COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00059480 I'l'iniiiHi I, i|iin!llllli!ilil!l! . Rp^i ^a^ Columbia ^mbtt^itp Sppartm^ ttt of #ttrgprg SttU mtmnrtal fttnft Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseonsurger01fowl A/ A TREATISE ON SURGERY BY GEORGE RYERSON FOWLER, M.D. BROOKLYN — NEW YORK CITY EXAMINER IN SURGERY, BOARD OF MEDICAL EXAMINERS OF THE REGENTS OF THE UNIVERSITY OF THE STATE OF NEW YORK ; EMERITUS PROFESSOR OF SUR- GERY IN THE NEW YORK POLYCLINIC; SURGEON TO THE METHODIST EPISCOPAL HOSPITAL; SURGEON-IN-CHIEF TO THE BROOKLYN hospital; SURGEON TO THE GERMAN HOSPITAL Containing 888 Text-Illustrations and Four Colored Plates, all Original VOLUME I PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1906 Copyright, 1906, by W. B. Saunders Company PRESS OF V. B. SAUNDERS COMPANY PM I l_ADei_PHIA TO MY WIFE WHOSE DEVOTION HAS ENABLED ME TO WRITE THIS BOOK PREFACE In presenting a new work on Surgery the author has endeavored to bring together the most recent and improved methods of surgical practice, and, with the aid of numerous cross-references, to arrange these in a form readily available to the student and practitioner. As a necessary preliminary to this, the so-called art of surgery, the effort has been made to set forth the fundamental principles underlying what is known as the science of surgery in both an interesting and an instructive manner. The study of inflammation from the surgical viewpoint is based on the tissue changes that follow the infliction of wounds. Contrary to the usual custom the subject of Surgical Bacteriology is introduced in connection with the etiology of inflammation, in which it is an important factor. The grouping of the topics differs somewhat from the arrangement usually employed, as will be seen by reference to the table of contents. It is believed that the study of the subject will, be facilitated by this method of classification. The section on Laboratory Aids in Surgical Diagnosis and Prognosis it is believed wall be specially valuable, owing to the increasing interest in hem- atology, urinology, and kindred subjects. The practical part of the work comprises a separate consideration of the injuries and diseases of each region. This, the anatomic method, it is hoped will appeal to the surgical clinician, particularly with reference to diagnosis. The section on Surgical Bacteriology is the work of Dr. A. T. Bristow, and the section on Laboratory Aids in Surgical Diagnosis and Prognosis that of Dr. F. E. Sondern. I wish to express my indebtedness to these gentlemen for their valuable contributions. The aid rendered by Dr. W. C. Wood in connection with the section on Injuries and Diseases of the Bones and Joints, by Dr. Russell S. Fowler in the preparation of the section on Bandaging and other portions of the text, by Dr. G. E. Buist in connection with the section on Surgical Anesthesia, and by Dr. T. B. Spence is gratefully acknowledged. My thanks are due also to my clinical assistants. Dr. J. E. Jennings, Dr. C. F. Buckky, and Dr. Carl Fulda, for efficient help in the work, and to my hospi- tal internes for the compilation of clinical material from the records of my hospital services. The final preparation of the manuscript as w^ell as the supervision of the passage of the sheets through the press is the work of Miss Annie T. Keyser, Editor and Proof Reader of Question Papers, New York State Education Department, to whose faithful, painstaking, and efficient cooperation in bring- ing out the book I am greatly indebted. VI PREFACE The illustrations are the work of Mr. F. A. Deck, to whose skill is due the aid that these furnish in the elucidation of the text. Finally, I wish to extend my acknowledgments to the publishers for their unremitting endeavors to make the work represent the highest ideal of the bookmaker's art. George Ryerson Fowler. Brooklyn, New York City January, 1906. CONTENTS GENERAL SURGERY Page Inflammation 1 Wounds 1 Inflammation in General 8 Etiology 14 General Diagnosis 33 Termination and Prognosis 38 Surgical Fever 39 Treatment 48 Injuries and Diseases of Separate Tissues 66 The Skin and Subcutaneous Connective Tissue 66 Blood-vessels 85 Lymphatic Vessels and Lymphatic Glands 107 Nerves '. . . . 114 Fasciae, Muscles, and Tendons 120 Bones 123 Joints 146 Gunshot Injuries 165 Acute Wound Diseases 177 Erysipelas 177 Erysipeloid 179 Hospital Gangrene 180 Malignant Edema; Acute Purulent Edema 181 Infectious Emphysema 182 Septicemia 182 Pyemia 184 Tetanus 187 Hydrophobia .' 190 The Chronic Surgical Infections 194 Syphilis 194 Tuberculosis 205 ■ Actinomycosis , 209 Tumors 214 Classification 214 Diagnosis 241 Treatment 242 vii Vlll CONTENTS Page Laboratory Aids in Surgical Diagnosis and Prognosis 243 Pathologic Examinations 244 Bacteriologic Examinations 247 Chemic Examinations 248 Examination of the Blood 248 Urine Analysis 259 ExaiTiination of Sputum 273 Examination of Gastric Contents 274 Examination of Feces 276 Examination of Aspirated Fluids 277 Surgical Operations in General 280 General Considerations 280 Common Dangers 281 Special Dangers 283 Post-operative Complications 284 Surgical Anesthesia 288 Local Anesthesia 304 Spinal Anesthesia 306 The General Principles of Operative Technic 308 The Separation of Tissues 308 Indications for Uniting the Tissues; Mechanism of Uniting the Tissues. 321 Operations on Individual Structures 327 Skin 327 Blood-vessels 336 Nerves 354 Muscles and Tendons 357 Bones 361 Joints 370 Amputations and Disarticulations 376 Foreign Bodies 383 Bandaging 388 REGIONAL SURGERY Surgery of the Head 429 Scalp 429 Cranial Bones 434 Brain 455 Soft Parts of the Facial Region 474 Soft Parts of the Nose and Nasal Cavities 495 Frontal Sinuses 514 Jaws , 519 Nerves of the Facial Region 540 CONTENTS IX Page Tongue 545 Soft and Hard Palate 558 Fauces, Pharynx, and Nasopharynx 566 Ear 578 Salivary Glands 586 Surgery of the Neck 594 Larynx, Trachea, and Hyoid Bone 594 Thyroid Gland 610 Esophagus 617 Lateral Region of the Neck 624 Cervical Vertebrae 641 Surgery of the Thorax 652 Soft Parts Surrounding the Chest 652 Bony Chest Walls 670 Lungs 681 Heart and Pericardium , 684 Index of Names 687 Index 693 A TREATISE ON SURGERY PART I GENERAL SURGERY SECTION I INFLAMMATION Inflammation, as viewed from the surgical standpoint, is that series of changes in the tissues which takes place as the result of injury plus infection. In the absence of infection and during the repair of an injury, however, the processes concerned are histologically identical with those concerned in inflam- mation. But the differences in degree and extent are such as to stamp the one as a pathologic process and the other as a physiologic process. The study of the phenomena will therefore naturally commence with the injury itself. WOUNDS A wound is the forced separation of any portion of the skin or mucous membrane so that the protective covering of the underlying tissues is destroyed and the latter exposed to the influence of the air and other extraneous matters. Classification and Mechanism.— Wounds of the external surface of the body involving exposure of the subcutaneous connective tissue are di'vided, according to the condition of the edge of the wound, into those possessing (1) well-defined edges; (2) lacerated solutions of continuity of the surface; (3) contused breaches of tissue. Wounds with well-defined and sharp edges are subdivided into incised and punctured wounds. Lacerated wounds occur where there is excessive tension on the skin by the application of a dragging force, or where the tissues are forced against some unyielding part, as, for instance, the skuU. Contused wounds are caused by contact of the body ■v^'ith an object having a broad surface, or by falls upon hard angular surfaces. Wounds resulting from the blow of a club, or from the entrance into the body of some missile (gunshot wounds), are familiar examples of contused wounds. In addition to these, wounds are spoken of as penetrating when the foreign bodv enters a cavitv of the body without emerging: as perforating when 2 ' ' 1 2 INFLAMMATION the foreign body enters and emerges. If some specific poison has been car- ried into the wound and has infected it, it is then spoken of as a poisoned wound. Wounds are likewise said to be septic or aseptic, according as they have been infected or not mth those organisms which excite putrefaction or other disorganization of tissue. Destruction of tissue to a greater or lesser extent characterizes all wounds. Symptoms. — A symptom common to all wounds is separation and gaping of its edges. This is caused by the presence of elastic fibers in the connective tissue and cutis, and emphasizes the elasticity'' characteristic of the uninjured skin. The degree of gaping depends on the number and direction of the elastic fibers, as well as on the depth of the wound. If the wound separates the tissues in a direction parallel to that of the elastic fibers, the gaping will be less than when these are separated in a transverse direction. Deep wounds gape more than superficial ones. The hemorrhage which accompanies a wound depends on the depth, length, and breadth of the wound, as well as on the size and condition of the divided blood-vessels. As a rule, this symptom is less marked in contused and lacerated wounds than in those with clean-cut and sharply defined edges. The symptom of pain is usually an immediate accompaniment of a wound, and results from the injury and irritation of the numerous fibers of sensor\' nerves in the injured tissues. It is of a sharp, burning character and radiates along the nerve-tn,mk or in the area of its distribution. The more rapidly and thoroughly the nerve-fibers are divided, the less, as a rule, is the pain. It may happen that no pain whatever is experienced, owing to the rapidity with which the wound is inflicted, or to mental excitement at the time of the injury. In clean incised wounds the wounded person may not be aware that he is injured until his attention is attracted by the presence of blood. Contused wounds are the most painful of injuries. Individual temperament also may modify the amount of pain. Courageous persons and those in a furious rage, on the one hand, and those exercising a quiet self-control, on the other, suffer the least, for these conditions act as restraining influences on the sensory cortical centers. Healing by Primary Intention, i.e., without Suppuration. — Wounds with sharph- defined edges and but slight separation may heal in a relatively short time, no essential change being discoverable in the wound and its sur- roundings. A very narrow blood-coagulum fills the interspace and causes agglutination of its edges, while the upper layers of this coagulum projecting just beyond the edges become dried and form a thin line or scab, hermetically sealing the wound. In the earlier stage of this reparatiA'e process the wound may be reopened by ver}' slight violence, but as organization takes place in the thin cement of blood-clot, union becomes firmer, until finally the narrow surface scab falls off, leaving a bluish or purple furrow covered with new and tender epidermis — the cicatrix. The period of time occupied by the healing process varies with the degree of separation of the edges of the original wound. Small incised and punctured Avounds that have not been exposed to irritating or septic influences may heal in the course of twenty-four hours. As a rule, however, from five to seven days are required before the falling of the crust announces the comxpletion of the healing process. Even considerable losses of substance in the skin, particularly if extending only to the rete Malpighii, may be completely repaired in a very short time; WOUNDS 3 the hemorrhage being very slight in these cases, the effused blood dries rapidly, and, under the protection of the crust thus formed, cicatrization is soon complete. Healing by Secondary Intention, i. e., with Suppuration.— In a ^^•idel^' gaping wound the extent of the injury and the size of the coagulum may prevent rapid drying. In the absence of preventive measures there are present all the conditions fa\-orable to the implantation and reproduction of septic organisms, namely, (1) organic tissues deprived of their protecting cuticle; (2) a favorable temperature (blood-heat) ; (3) moisture. In trivial incised wounds the surface of the coagulum dries cpickly, and septic organ- isms are thus deprived of that moisture which is absolutely essential to their growth; but in the case of large gaping wounds desiccation cannot take place rapidly; as a result bacteria quickly multiply therein, and decay and disorganization of tissue take the place of repair. Under these circum- stances in the course of twenty-four hours the wound is covered with a semi- liquid, foul-smelling layer of broken-down tissue swarming with the organisms of putrefaction. Peculiar changes due to a local sepsis or infection occur also in the neighborhood of the wound. A more or less broad zone of redness appears about the edges, together with increased heat and subsequent induration, and the patient complains of pain and a feeling of tension in the surround- ing tissues. These symptoms increase as putrefaction of the coagulum pro- gresses. In some contused wounds a foul-smelling, semiliquid mass exudes from beneath the lacerated edges, mingled with the debris of broken-down tissue. If improvement occurs, a yellowish-white and creamlike secretion makes its appearance over the edges of the wound about the fifth day, and the "laudable pus" of the older surgery is present. With the cessation of the so-called ichorous discharge the wound enters on the stage of suppuration. With the advent of suppuration there is a diminution of the redness, heat, swelling, and pain which are the classic symptoms of an inflammatory process. The length of time covered by the stages of suppuration varies with the depth of the wound, the extent of the laceration of its edges and the contusion of sur- rounding parts In an uncomplicated lacerated wound , from about the seventh day there is observed a mass of material of pinkish hue which forms beneath the layer of pus and rises from the depths of the wound. This consists of small papillae which continue to rise higher and higher until they fill in the entire ^^•ound cavity, so that its surface presents a granular appearance. The wound is then said to be "granulating," and the papillae are called "granu- lation tissue." The presence of granulations constitutes another stage in the process of repair. The parts surrounding the wound at this time return nearly or quite to their normal condition. Redness and heat disappear, and tenderness, with per- haps some induration, alone remains to indicate that the reparative process is still going on in the depths of the wound. As the cavity of the wound becomes filled with granulation tissue the latter, which up to this time has been more or less easily injured and has bled at the slightest touch, becomes to some extent solidified, loses its bright pink color, and grows pale. At the same time a process of shrinkage goes on, and in a corresponding degree the cavity of the wound markedlv diminishes. 4 INFLAMMATION AVhen the granulating surface is level with the surrounding surfaces, a nar- row strip of new epidermis begins to grow around the edges of the wound, and increases from without inward. One zone after another, growing concentric- ally, is added to the new tissue until, when they meet in the middle, the new epidermis comi^letely covers in the granulating surface and cicatrization is accomplished. The two processes of healing thus briefly described have been recognized for years, but it was not until John Hunter (1793) pursued his classic studies on the subject that these processes were fully recognized and distin- guished as healing by primary and by secondary intention. Healing by first intention seems almost a ph^'siologic process, inasmuch as it is the simplest and most direct method of repairing tissues lost or destroyed. In some of its stages it seems to be akin to the processes of restitution of epithelial tissues constantly going on as normal metamorphosis, if indeed it is not entirely identical with them. In the second method of I'epair, healing by second intention, the reproduc- tion of tissue in connection Avith suppuration is marked by the presence of true inflammatory conditions, the essential and characteristic symptoms of which have been knowTi since the days of Galen, namely, (1) redness (rubor) ; (2) local heat (calor) ; (3) swelling (tumorj ; (4) pain (dolor). To these is to be added (o) interference with the function of the part (functio laesa). Histology of the Healing Process. — Such a thing as immediate union after the infliction of a wound does not occur, if by this is meant the direct adhesion of the histologic elements of the parts, without further reparatii^e effort. Trabeculae form in the exuded fibrin, making up a fine network from which processes are sent out into the open blood-vessels and into the clefts or spaces between the tissues. In the cavit}" of the wound itself, however, there will be found, besides blood-corpuscles, small portions of necrotic tissue and coagulated fibrin. The blood-corpuscles are partly unchanged. Some, how- ever, have assumed a star-shaped appearance, while others are swollen and pale in color. The passage of the trabeculae of the coagulum into the mouths of the open blood-vessels leads to coagulation in the neighboring capillaries. In from twenty-four to forty-eight hours the red blood-corpus- cles have almost entirely disappeared. Those ^vhich remain have lost their color and have become diaphanous or finely granulated. The spaces now found in the network mark the site of former blood-corpuscles which have been destroyed. Simultaneously with the disappearance of the red blood-corpuscles, the so-called cells of new formation make their appearance. These are small round-cells with a clear nucleus, which in size and general appearance resemble the young cells of connective tissue as well as the colorless blood-corpuscles them- selves. These gradually fill up the gap in the wounded structures, and in addi- tion are crowded into the neighboring perivascular spaces. About the fourth clay blood-vessels in small loops pass from the edges of the wound, and meeting in the center anastomose or unite in the new cellular mass (Julian Arnold). These vessels are the result of a process of proliferation. A slight granular thickening on the wall of a capillary marks the point whence a new vessel is about to bud. This projects in a somewhat triangular shape, and is the so-called protoplasmic proliferation. The projection develops into a fine cord with a threadlike termination, becomes hollow at the base, and WOUNDS 5 blood enters it from the parent vessel. F)>- the uniori of these protoplasmic cords an arch-shajjed connection is established between two capillaries, con- stituting the so-called protoplasmic arch. In the beginning this contains blood only in the hollow base, but a process of canalization takes place in the inter- mediate portion and later complete conmiunication is established. These pro- toplasmic arches are at first homogeneous, but a nucleated structure subse- quently replaces the homogeneous connection, and they become lined with endothelium. Later, by a process of cleavage new cellular elements develop and new capillary vessels are formed from the condensed cellular bodies. This primary cellular layer is enlarged from within by the adjacent round-cells of new formation (formative cells of Ma re hand), which latter form the adventitia of the new vessels. Thiersch carefully injected tissues undergoing reparati\-e processes and microscopically examined sections of the same. He believed that spaces existed betAveen the connective-tissue new-formation cells and that the injected fluid passed into these from the blood-vessels ; on the basis of these experiments he assumed that there was' a system of intercellular canals communicating directly with the vessels whose function was to supply nutriment to the parts until new blood-vessels were formed. It is extremely difficult at the present time to decide whether such a system of plasma canals really exists or whether Thiersch's injections penetrated simply into the protoplasmic arches and the proliferations of the vessels of Arnold. The formative round-cells which fill the wound soon begin to undergo trans- formation. The intercellular spaces increase, and between them there grows a framework, partly striped, partly granular, which in all probability originates in the cells themselves. At a still later stage of development the striped appearance of the intercellular substance becomes more clearly defined, eventu- ally developing into fine fibers, between which are found spindle-cells, perhaps the remains of the masses of round-cells. With the disappearance of the round-cells and the appearance of the newly formed fibers the new tissue closely resembles 3'oung connective tissue. As cicatrization goes on, the spindle-cells, as well as the round or formative cells, vanish, some undergoing granular degeneration and absorption while others are either taken up again by the circulation, or, after reaching a certain stage of development, destroyed by cell action in the process. The shelter of the • epidermis is now needed to complete repair. On the surface of the built-up tissues a clot or crust consisting of broken-down blood-corpuscles, epithehal scales, and exudation forms, and beneath this new epithelium develops, which the rete JMalpighii of the adjoining skin furnishes. Its cells are increased by nuclear segmentation, and these new cells arrange themselves along the young connective tissue until they meet and finally cover in the surface of the wound. The histologic process which marks the healing of a wound by second inten- tion (healing by suppuration) is essentially the same. Here also after a few hours the round-cells appear. When brought in contact with the putrid blood, they rapidly perish and mingle with the foul secretions of the wound. ]\Iicro- scopically at this time the discharge during the first three days consists of por- tions of fibrin, red blood-corpuscles in different stages of decomposition, granu- lar detritus, bacteria, and, finally, of dead connective-tissue cells that undergo changes in c|uality and form the principal components of pus. From the 6 IXFLAM.MATIOX surface of the wound, however, while numerous connective-tissue cells arc being thrown off, new ones are being supplied to take their places, until the lowest layer, being gradually supplied with blood-vessels, remains to form the young connective tissue. This, with its numerous loops of vessels, each sur- rounded by a growth of the same connective-tissue cells, appears as a surface of light and irregular nodules, the granulations. The discharge of pus gradu- ally lessens. No disturbing influence interfering, the granulation tissue gradu- ally fills up the cavity, and its size is diminished also by a general shrinkage of the whole mass. Finally, as the wound surface becomes level A^ith the sur- rounding integument, cicatrization is completed by the renewal of the pro- tective epidermis, as before described. As a rule, the new epidermis forms a narrow zone about the edges of the wound, but occasionally little islets spring up at varying distances from the margins themselves, to become the centers of successive zones of new epidermis. The latter may originate from the cells surrounding the sweat-glands and hair-follicles, which, passing as they do deeply into the cutis, may have escaped injuiy, even in wounds involving considerable loss of substance. Again, it may occur during changes in dressings, or in some other way, that epidermal cells may be sown over the granulation tis.sue, trans- planted, as it were, from sound skin. It has likewise been suggested that a narrow epithelial strip may extend from the margin of the wound to the islets. Ho\\ever this ma}- be, it is not at all probable that these epithelial cells are formed from the round-cells of the granulation tissue. An additional division of the subject is made by some writers, the so-called "healing by third intention." In granulating w^ounds rendered aseptic and maintained so, direct union is said to take place, if, after the lapse of two or three days, or when the granulating process is well under way and there is but little or no secretion present, the granulating surfaces are brought into apposi- tion. The histologic process, however, differs in nowise from the foregoing. Septic conditions are replaced by an aseptic state, and the gap to be filled is simply lessened by mechanical means. The question of the origin of the connective-tissue cells during the heal- ing process has received a great deal of attention. It was formerly supposed that the spindle-shaped corpuscles, the only cells then knoA^Ti to exist as con- nective-tissue cells, were the progenitors of the round-cells. The origin of this belief seems to be the observation previously made that in fetal connective tissue spindle-cells developed from the round-cells lying in large numbers in the matrix. In 1863 Recklinghausen, in the course of experi- ments on the corneas of rabbits and frogs, found, in addition to the so-called fixed corneal corpuscles, small round-cells which possessed the peculiar property of changing their form and position in a manner entirely independent of one another. They bore a striking resemblance to the round-cells of pus, as well as to the Avhite blood-corpuscles. C o h n h e i m , in 1867, demonstrated the direct origin of the migrating cells from the blood. The mesentery of the frog was usecl for the experiment, and the white blood-corpuscles were obserA^ed to escape through the uninjured wall of the vessel into the perivascular connec- tive-tissue spaces (diapedesis). Thoma (1878) succeeded in demonstrat- ing in the exposed mesentery' of the dog (1) the dilatation of the vessels and the retardation of the blood-current; (2) the adhesion of the white blood-corpus- cles to the walls of the capillaries : (3) the passage of the corpuscles through the AVOUXDS walls of the vessels. The query as to whether all the pus present in a case of prolonged suppuration can be accounted for by C o h n h e i m ' s theory of diapedesis is an interesting one. There are to be accounted for, in addition, the round-cells, the newly formed blood-vessels, their walls first homogeneous and then nucleated, the young connective tissue, and the granulation structure. Do these all originate from the white blood-corpuscles ? While the adversaries of the exclusi\-e diapedesis theory asserted that corpuscles of connective tissue, as well as endothelial cells, underwent a contractile change of shape and division, C o h n h e i m and his followers combated this with the classic experi- ments with cinnabar. The blood of frogs was injected with cinnabar, the finely di^■ided particles of which were readih' absorbed by the white blood-corpuscles. This furnished a method of distinguishing them from other cell-elements for which they might be mistaken. The frog, after the injection, was injured, and at the site of the injury could be seen escaping the white blood-corpuscles inclosing the particles of cinnabar. The value of this experiment as conclusive proof of the theoiy of diapedesis is impaired, as is justh- remarked by Recklinghausen, on account of the well-known fact that the particles of cinnabar may escape directly into the tissues from the blood-vessels of frogs so injected and impart their stain to cells formed outside the vessels. Experimental research on animals and obser^'ations in man have thus far determined of inflammation as follows: That it consists in (1) dila- tation of blood-vessels; (2) increase in the 'permeability of the walls of the blood- vessels; (3) augmented supply of nutriment to the tissues; (4) migration of white blood-corpuscles through the vascidar loalls into the surrounding connective- tissue spaces. In addition, there also probably occurs (5) proliferation of pre- existing cells. Finally, under certain circumstances processes of degeneration and decomposition take place, resulting in more or less loss of tissue. This histologic definition of the process of inflammation corresponds through- out to the clinical picture. The local results of the morbid processes vary with their intensity and extent. In other words, the varieties of inflammation are due to differences in the factors thereof. In indi^'idual cases the four car- dinal symptoms of Galen, redness, heat, swelling, and pain, do not coexist in the same degree. The redness of the inflamed part is the consequence of the dilatation of the vessels, and results from a paralysis of the muscular coat. This is due to an immediate disturbance either of the cells in the muscle-fibers themselves, or of the vasomotor nerves supplying them. At the very outset this is the exclusive cause of the redness, but later on it is further due to the occurrence of a stasis in the capillaries which leads to local accumulation of red blood- corpuscles, and finaUy to a formation of new blood-vessels as well, provided the inflammation persists. Increased heat in the inflamed part is due to the increased amount of blood which the dilated capillaries supply to the tissues; in addition, there are probably some chemic processes to be taken into account (such as increased oxidation) , but to what extent it is difficult at present to decide. The swelling of the inflamed tissue depends on the same causes, and, in addition, on an increase in nutritive material supplied by the escape of the white blood-corpuscles from the capiflaries into the connective-tissue spaces, as well as on the proliferation of the connective-tissue cells themselves. 8 INFLAMMATION Pain felt at the seat of inflammation is to be referred to an irritation of the sensory nerves of the part and the amount of pressure exercised on them by the dilated blood-vessels and the products of inflammation. The \-arying character of the pain is caused in part by the varying force of the blood-current, in part by the occurrence of congestion in dependent parts, and to some extent by the resistance which the tissues offer to the increase of nutrient material and to the products of inflammation. INFLAMMATION IN GENERAL The reparative process already considered consists, first, of that in \A'hich the loss of the essential tissue elements is immediately replaced; second, of that in which the repair is accomplished by the slower and more tedious process of suppuration. In the first case the cellular material for repair is at once appropriated to its uses without waste, with the co-operation of the adja- cent vessels and without disturbance of neighboring structures. In the second, the putrid decomposition of the extravasated blood and the exposed tissues is followed by a copious outpouring of blood-plasma and white blood-corpuscles, which inundates the wound with formative material. Here, however, everything is exposed to putrefaction and decay, and the decomposed products of destroyed tissue rapidly cause tissues previoush^ healthy to become involved in the local death. These two processes correspond to two forms of inflammation, and have been called resi3ectively the regenerative and the destructive. Where the process involves, however, the formation of a new tissue which cannot be said to represent strictly the regenerative process, but substitutes for the lost tissues material which may be classed as superfluous, this is known as the pro- ductive form of inflammation. The exudative form is characterized by a predominating and persistent exudation of blood-plasma from the tissues, the migration of the colorless blood-corpuscles or leukocytes being less marked than in the other forms. The regenerative form of inflammation is that which occurs in every case of primar\^ union. It like^^ise concludes the process of destructive inflamma- tion whenever the latter tends to resolution, and invariabl^v furnishes the material for building up the cicatrix. The productive form of inflammation will be referred to in the discussion of diseases of separate structures as adhesive or hyperplastic. It not infre- cjuently accompanies the regenerative, or closes the destructive form. The exudative variety appears as the serous, serofibrinous, and sero- hemorrhagic. Finally, w^e recognize four varieties of the destructive inflam- mation, namely, the suppurative, the purulent, the gangrenous, and the granulating. These terms are applied according as one or the other of the conditions which they describe predominates. Sharply defined distinction between them cannot be made, however, because the suppurative may change to the purulent or the gangrenous, the granulating to the suppurative form, or vice versa. In fact, the four varieties are interchangeable. Exudative Inflammation. — The lowest form of the exudative inflam- mation is the serous. In the present state of our knowledge it is presumed that this form is the result of noxious agents whose influence on the vessels is neither of a verv intense character nor of long duration. Its most promi- INFLAMMATION IN GENERAL 9 nent characteristic is an increased secretion of fluid which distends the connec- tive-tissue spaces. This is foflowed by flat swellings of the soft parts, which, on palpation, feel dough}- and can be made to diminish or to disappear alto- gether by pressure. Should the serous exudation occur in the rete Malpighii, the epidermis is elevated at one or more points, and blisters or blebs result. When this form of inflammation attacks mucous membrane, the exudation becomes mingled with the mucous secretion and thins it, so that a mixture of the two or a seromucous discharge is the result. In serous and synovial cavi- ties the occurrence of this form of inflammation sometimes leads to enormous accumulations of fluid and occasional displacements of neighboring organs, as, for instance, in the chest when the pleural cavities are involved, or in a hydrarthrosis of the knee-joint with a resulting deformity. The term inflam- matory edema is sometimes applied to this form of exudative inflammation. It should not, however, be confounded with ordinary edema, the result of mechanical obstruction to the circulation. It may be difficult to discriminate between the t^^•o, but it should be borne in mind that the former is character- ized by the occurrence of fibrin in the exudation together with an occasional white blood-corpuscle, and is a true inflammation. In simple edema, however, the mechanical obstruction, while permitting the ingress of blood through the elastic capillaries, prevents its egress through the more readily collapsed veins. As a consequence of this passive engorgement, the serum of the blood escapes through the distended vessel walls into the surrounding connective- tissue spaces. The fluid which thus collects contains Ixit little fibrin. The difficulty of dis- tinguishing between these two conditions may be increased by the fact that \'enous obstruction may complicate the inflammation and give rise to passive edema in addition. Serofibrinous inflammation is a serous inflammation, which, occurring in serous or synovial cavities, is characterized by a deposit of fibrin on the walls of the cavity. Sometimes the fibrin is present in the form of flakes floating in the fluid effusion. Here the fibrin has become coagulated and is precipitated. How far the various agents that induced the inflammation in the first place contribute in the furnishing of a fibrin ferment is, in the present state of our knowledge, a matter of speculation. Serohemorrhagic inflammation is that variety characterized by the addi- tion, to a greater or lesser extent, of red blood-corpuscles to the serous effu- sion. The secretion of a serous or synovial cavity may thus be stained red, like blood. The contents of a bleb or blister sometimes in like manner becomes colored. OccasionaUy a condition is observed which simulates that just described. It consists of a collection of blood-corpuscles outside the vessels, and is due to an extensive obstruction of the blood-current, a stasis in a circumscribed capillary area. Here the vessels are crowded Avith red blood-corpuscles which, as the result of pressure, pass through the dilated vessels singly or in groups. This process is simply mechanical and passive, and is known as hemorrhagic diapedesis. In exudative inflammation there is generally an intrinsic tendency to recovery. A complete return to the normal is the rule. Even though large amounts of exudative material ha^-e been poured out into the connective-tissue spaces, this is soon taken up by the lymph-channels and no lesion demonstrable to the eye is left. It occasionally happens, however, particularly after inflam- 10 INFLAMMATION mations of large synovial closed sacs, as, for instance, that of the knee-joint, that a condition of recurrent or chronic inflammation supervenes and more or less of the secretion remains. In consec|nence of the access of new noxious agents, the exudative form of inflammation is sometimes converted into the suppurative or the purulent variety. From influences not at present well understood there may likewise occur a development of the adhesive or hyper- plastic form. Suppurative and Gangrenous Inflammations. — The most important form of inflammation from the standpoint of the surgeon is that known as the suppurative. Its peculiar and distinctive feature is the presence of pus. The most essential components of pus are pus-corpuscles and pus-serum. The former are for the most part the migratory white blood-corpuscles, reinforced by the proliferations of pre-existing tissue cells. Degeneration and decay seem to be necessary concomitants of pus-corpuscles. Subsequent to their escape into the perivascular spaces, they soon lose their characteristics as elements of the blood and differ essentially from those leukocytes still in the vessels. They are polynuclear. This at one time was supposed to be proof of the ability of pus-corpuscles to proliferate, but is now recognized as an evidence of degeneration. Their nuclei are pale, often hardly visible. The protoplasm is granular and contains drops of fat. Pus itself is a yellowish-white fluid of the consistency of milk or cream. Its specific gravity is about 1030. It is at first slightly acid, but afterward becomes alkaline by a process of decomposition in the course of which ammonia develops. When allowed to stand it separates into a sediment averaging from 10 to 16 per cent of the whole amount, and a clear supernatant fluid known as pus-serum. As a rule, pus is nearly odorless. The sediment consists of the pus-corpus- cles, pyogenic organisms, and fragments of broken-down tissue. Pus-serum is a pale, yellowish fluid corresponding to the blood-plasma which has left the vessels, from which, however, it often differs in chemic composition in addition to containing the products of the decomposition of tissues during the suppura- tive process, such as leucin and tyrosin. Oxygen and hydrogen are absent from pus-serum, but nitrogen and carbon dioxid are always present. The proportion of potassium and sodium salts is somewhat larger than in blood. Among the albuminous substances found in pus-serum may be mentioned paraglobulin, an albuminate resembling casein but not precipitated by rennet, serum-albumin, and myosin. In addition to the constituents of pus already mentioned, occur flakes of coagulated fibrin, red corpuscles, and the rhombic plates of cholesterin. The last is found only in pus which has been for a long time inclosed in the living body. Rapidly advancing inflammation produces not rarely complete stasis and coagulation of the blood in isolated capillars' areas, or even in the smaller arterial vessels. Under these circumstances, unless blood is supplied by coflateral branches, large portions of tissue are liable to die, and as a consequence we have local death or gangrene. At the margin of this dead tissue, and maintained by it, there is a zone of suppuration which circumscribes and isolates it, and the whole process constitutes what is kno^^^l as suppurative gangrenous inflammation. The extent to which tissues become necrotic does not always depend on the degree or intensity of the inflammation present, but rather on the pre- vious vitalitv of the structure involved. This is illustrated by the compara- INFLAMMATION IN GENERAL 11 live behavior of tendon and muscle. The former will slough readily from a slight inflammatory action, for, since it contains no blood-vessels, but onh' lymph-channels, the lymph-channels become easily obstructed and the tendon dies, as nutrition is thus cut off from it. The muscle, on the contrary, abun- dantly supplied with blood-vessels, resists the attack of the inflammatory process and survives. The progress which the inflammation makes in the healthy tissues sur- rounding its focus depends partly on their condition, partly on the force of the lymphatic current, and perhaps to some extent on the ameboid move- ments of the migrating cells. The latter, if H u e t e r ' s observations are correct, ma}-, by virtue of the organisms that they contain, become the bearers of infection. The passive methods of propagation are of the greatest importance, how- ever, in considering the spread of the inflammatory process. Advancing sup- puration frequently follows the line of the lymphatics, and consecjuently lymphangitis is the not infrequent precursor of suppuration. The quality of the surrounding tissues is likewise to be taken into account. I>oose tissues favor inflammation, solid structures resist it. Phlegmonous Inflammation. — Phlegmonous inflammation is charac- terized by the rapidity ■\\ith which it advances over large areas of flattened tissue. It may spread along the planes of connective tissue which lie between skin and fascia, or along the loose areolar tissue about the muscles, aponeuroses, or tendons. Phlegmons such as these are known as subcutaneous or sub- fascial. Phlegmons developing in special situations have been designated by special names, as, for instance, paronychia or panaris when they develop in the subcutaneous connectii-e tissue of the palmar surface of the fingers. Abscess. — Circumscribed collections of pus in large c^uantities are termed abscesses. A characteristic of abscess is the progress of pus in all directions from the original focus of infection with an inherent tendency to evacuate itself. This happens always along the line of least resistance. Hence abscesses either seek the surface or evacuate themselves into the cavity of some hollow viscus. It is notably easy to distinguish between phlegmon and abscess, although one condition may readily pass into the other, as, for instance, when a spreading phlegmon meets with a layer of more solid and resisting connective tissue, and, thus circumscribed, becomes practically an abscess; and vice versa, where an abscess slowly increasing meets 'uith a layer of loose connective tissue and lights up there a rapidly advancing phlegmonous inflammation. "^^Tiile, however, the phlegmon always presents the character of an acute inflammation, the course of the abscess may var\'' according to the susceptibility of the tissues attacked. Accordingly the abscess is distin- guished either as hot (acute) or as cold (chronic). The acute abscess is characterized by active hyperemia, marked local heat, and rapid destruction of tissue. The cold abscess, on the other hand, is accom- panied by ver}^ slight local rise of temperature, and a comparatively slow progress of the suppurative process. The latter may, indeed, come to a stand- still and remain in this condition for a considerable time. It is usualh' of tuberculous origin, and may be converted into an acute abscess if it becomes infected by the ordinary pus organisms. An abscess cavity is usually surrounded by a zone of granulation tissue, which, whether the abscess is emptied by artificial means or spontaneously, 12 , INFLAMMATION is the starting-point of the reparative process. This granulation tissue, by its augmentation, gradually fills up the cavity formerl}' occupied b}- the ])us. Sinus. — The final closure of an abscess may, however, be retarded by one cause or another. In such an event a communication is maintained between the surface on which the abscess discharges (be it skin or mucous membrane) and its old cavity, and the latter, narrowed doAvn by granulation tissue, is called a sinus. A sinus may also be caused by the burro^\•ing of the pus in different directions, a number of tortuous channels thus forming. Such a result is more likely to follow the spontaneous opening of an abscess, though it may happen after an insufficient or ill placed incision ; for an opening which does not give free drainage, A^'hether resulting from the natural process of ulcera- tion toward the surface (the so-called pointing of an abscess), or made by the surgeon's knife, will in all probability lead to the formation of a sinus. On the other hand, a free opening made so as to afford a ready exit to the contents of the abscess offers the best security against such a result. The cavity of an abscess, as it becomes filled up with granulations and cicatricial formation, gradually contracts until the external communication is narrowed down so as to admit a fine probe. This finally closes under favorable circumstances; but if at the bottom of the abscess cavity there remains a portion of necrosed tissue, a foreign body or necrosed bone, though the granulations close around it and contraction takes place, there will still be a sinus leading to the offending body, which will not close. About the mouth of the sinus grows a mass of granulations, rich in organisms, which presents a peculiar puckered appearance comparable to the anus of a fowl. Again, the cavity may fail to close from inability of its walls to collapse, as in an empyema or a bone abscess. A dis- eased condition of the walls of the sinus may also hinder complete healing. In the case of persistent sinus due to the presence of a foreign body, necrosed bone, etc., the removal of the irritating cause is essential to the closure of the sinus, together with the thorough cureting of its walls. Fistula. — Where an abscess opens into some natural cavity or hollow viscus, as, for instance, the rectum, vagina, or bladder, or into a natural canal, as the urethra or Stenson's duct, the resulting communication is called a fistula. Communications existing between normal cavities, as between the bladder and the vagina, are likewise called fistulas, and are known by special names which indicate the parts involved. Thus, a fistulous tract between the blad- der and the vagina is called a vesicovaginal fistula. These will be described under their appropriate names. Granulating Inflammation. — The formation of granulation tissue repre- sents a stage between suppuration and cicatrization. It is the first step, so to speak, in the replacement of the defect caused by the injur>^ and subsequent suppuration. There are other kinds of inflammation in Avhich the formation of granulations precedes rather than follows- suppuration, the latter occurring as a secretion from the granulating surface itself. The inflammation here seems to be due to some interruption of the normal course of the granulating process. Granulating inflammation is essentially chronic in its course, and occurs in individuals having those peculiar constitutional disturbances formerly com- prehended under the name of scrofula ; also in those suffering from syphilis, etc. Granulating inflammations, unlike the serous and suppurating forms, are not caused by common injuries involving the infliction of a wound and the INFLAMMATION IN GENERAL 13 entrance of air and dust, if, indeed, traumatism enters into their etiolo2;y at all. They are most likely to occur in yoiith and attack the medullary substance of bones, the lymphatic glands, tlu^ joints, or the surface of the skin. The differences between iiran\ilation tissue occurring in the border zone of an abscess and that resulting from a granulating inflammation are not at first ^\•ell marked. Both consist of newly formed vessels between which are fo\uul the small, round, fixed, connective-tissue cells and white blood-corpus- cles. Later on, however, the>- pursue a different course. The former shows an intrinsic tendency to cicatricial formation, while the latter seems predis- posed to prolonged suppuration; if repair takes place at all, it is long delayed. Abscesses occur as a sequence of the granulating inflammation; these may find their wav singly to the surface, or may unite to form one large abscess. Here again an apparent resemblance may be detected between this form and the common suppurative inflammation. It is, however, an apparent resem- blance only, for in the ordinary suppurative variety the granulating zone soon shows a tendency to contract and so close the cavity, but in the granulating inflammation the granulations appear pale or faded. They become yellow or gray toward the periphery and advance slowly into the surrounding con- nective tissue. They break down readily, and the pus which results easily undergoes putrefaction. The granulating, or rather ulcerative, process may extend in all directions, sinuses forming which lead along the connective-tissue planes, and, what is of most importance to the surgeon, to the original focus of inflammation (medullary substance of bones, etc.). The clinical characteris- tic of the granulating inflammation, therefore, is the fact that it does not lead to the formation of solid cicatricial tissue. On the contrary, after the pus evacuates either into the surrounding tissues or externally it continues to advance and to involve contiguous stimctures by a process of progressive ulceration. I'nder cer- tain circumstances this form of inflammation is characterized by a dry condi- tion of the parts rather than by the secretion of pus. Matters of a grayish- yellow color and of the consistence of soft cheese are found in the ulcerating tissues ; this process is known as the cheesy metamorphosis, and is some- times called cheesy inflammation. The albuminoid (nitrogenized) substances resulting from the breaking down of tissue seem to degenerate into a fatty substance which contains many living organisms. This cheesy metamor- phosis occurs particularly in lymphatic glands. In granulating inflammations, histologically we find small round-cells, some- times gathered in groups and often surrounding a large cell with many nuclei, the so-called giant-cell, which in turn is surrounded by a network of capillary vessels. These collections resemble the tubercles found in cases of diffused miliary tuberculosis, scattered in numberless masses throughout the internal organs. They were formerly belie^■ed to be identical with these tubercles, though local and less dangerous to life. Since the discovery of the tubercle bacillus by Koch, the presence or absence of this organism will decide as to the tuberculous character of the inflammatory process. 14 IXFLAMMATIOX ETIOLOGY OF INFLAMMATION Process of Putrefaction. — Putrefaction is the disintegration, in the presence of moisture, of organic nitrogenous matters, particularly the albu- minoids, into their constituent parts, the nitrogen uniting with the hydrogen to form ammonia, the carbon Avith the oxygen to form carbon flioxid. tho hydrogen with the oxygen to form water. During this process there is developed an intermediate class of compounds which resemble the vegetable alkaloids in their chemic composition and are powerful poisons. From the fact that certain substances of this class were first discovered in the dead body, they have been termed ptomains (-rw.aa, a corpse). The conditions necessar}- for putrefaction are the folio Anng: (1) heat of a moderate grade; (2) moisture; (3) certain agents competent to decompose organic matter when brought in contact with it and called, by the generic terms, bacteria, microbes, or microorganisms. As early as 1835 C a g - niard-Latour discovered in the fermentation of ^mie small globular structures, increasing partly by fission, partly by spores. Schwann, in 1837, by a series of experiments demonstrated the existence of microorgan- isms in the air which, when brought in contact with a proper nutrient medium, increase in number and produce the phenomena of putrefaction. He like- wise showed that these microorganisms are destroyed by heat. A year earlier (1836) Franz Schultze made a series of experiments whose object was to refute the doctrine of spontaneous generation, and showed that air passed through sulfuric acid becomes sterile. Subsequently Schroder and D u s c h showed that neither heat nor sulfuric acid is necessary in order to free the air from so-called zymotic agents, simple filtration through loose cotton being sufficient. This demon- strated the physical character of the germs. Pasteur's famous experiments (1861) still further simplified the matter. He showed that not only can air be deprived of its power of infection, but that the agents inducing the fermentative process are not conveyed through a fine glass tube if the latter is bent in a downward direction, though the air enters freely. In other words, these agents, though microscopic, partake more or less of the physical properties of dust and obey the law of gravitation. While, by the series of experiments abave alluded to, it was clearly demon- strated that fermentation and putrefaction are due to the presence and growth of microorganisms, it still remained to apply this knowledge to the relation of the process of putrefaction to inflammation. L e m a i r e . in 1860, studied the effects of coal-tar preparations on the healing process in the light of the Schwann-Pasteur theor\' as to the origin of wound putrefaction. The results, however, were neither satisfactory nor conclusive enough to attract more than passing notice. It was reserv^ed for Joseph Lister to prove the definite relations which existed between micro- organisms and inflammation, and to this now famovis surgeon belongs the credit of demonstrating beyond the shadow of a doubt that the presence and develop- ment of germ life in wounds is the cause of suppuration, and that the so-called wound secjuels. inflammation, septicemia, pyemia, er\-sipelas. etc.. are due to microorganisms. ETIOLOGY OF INFLAMMATION 15 Basing his theory on ihc^ Avell-known expenments of Schwann, S c h r o d (M- , 1 ) \i s (• h , and Pasteur, he reasoned that if he could protect fresh wounds from the putrefactive processes caused by the organisms of putrefaction shown to be present in the air, or could treat germs, which might gain entrance into the wound, so as to inhibit their growth, the interruption of the healing process by those accidents which were at once the scourge and opprobrium of surgen,^ could be prevented. To this end he labored assiduously, and finally developed a method of wound treatment which in its beginning was intended only for operation "\\ounds. The agent he mainly emploved was carbolic acid, at that time the best-known antiseptic. The sur- roundings of the intended wound, the instruments, the hands of the operator, the sponges and dressings, were all treated ^\"ith a solution of carbolic acid. The air of the operating room was filled with a nebulized spray of the same antiseptic. The successes attained by this method were remarkable, and. though at first sharply criticized, it was finally adopted by the profession throughout the world. As a result, large gaping wounds healed without suppuration and by first intention, and this became the rule rather than the exception when Lister's method was rigidly followed. Proof trod on the heels of proof until the era of antiseptic surgery was fairly established in the world's his- tory, and became unalterably associated with the name of Joseph Lister, to whom humanity owes a debt that it can never repay. AVhile Ij i s t e r was pursuing his experiments in the Royal Infirmary at Glasgow, other observers were following up elsewhere the discoveries of Schwann and apph'ing them to medical science. In 1868 C. H u e t e r, of Greifswald, in a case of hospital gangrene, observed many nests of microorganisms; K 1 e b s , in 1871, described growths found in the wound and its neighborhood in cases of septicemia and pyemia, and to these organisms he gave the name "microsporon septicum." He further suggested that these destroyed the tissues and induced suppuration, and by penetrating into the blood-channels and lymph-channels and being thus transported to different parts of the body, set up a similar process of suppuration. Then came Lister's announcement of the nonsuppurative course of wounds under carbolic dressings. This confirmed the relation of pathogenic organisms to wound diseases. The microorganisms may enter the wound either from the surface of the patient's bod}', from his clothing, or from contact with dust-laden and hence germ-laden air. Fluids brought in contact ^\ith the wound, if not sterilized, may also prove to be carriers of infection. The surface of the vulnerating body may infect the wound in the act of inflicting it ; so may the surgeon's knife, his hands, or those of an attendant, if proper and adequate precautions have been neglected. In short, infection may be conveyed to a wound by contact with any nonsterile substance. Common air is full of organisms. If a saucer of perfectly sterilized jelly is allowed to remain exposed but for a few minutes to permit the deposit of organic dust, though subsequently protected from contamination, it will in the course of a few hours show numbers of different colonies of germ hfe growing on its surface. Certain of these bacteria are sure to be putrefactive organisms or pus-producers, and they soon decompose the gelatin. These, when deposited by the air in an unprotected wound, produce 16 IXFLAMMATIOX the same phenomena of putrefaction and suppuration as well. The albu- minous secretions of the wound, its moisture, and the natural heat of the part furnish all the conditions most favorable to the multiplication of micro- organisms and the subsequent de\-elopment of putrefactive processes. Auto- infection may then take place from the putrid or decomposing secretions. The interesting question has arisen whether the fluids of the body in a nor- mal state do not themselves contain organisms, which, poured out with the blood, lymph, etc., in the wound and thus brought in contact with the air. multiply and so produce decomposition independent!}' of germ infection from without. Many interesting experiments have been made with the view of clearing up this point. Results widely cUffering have been obtained at the hands of equally competent observers, so that it is difficult to reconcile state- ments so at variance. B i 1 1 r o t h ' s and Bur don-Sanderson's experiment consisted in the rapid removal of portions of a sohd viscus of ani- mals and their immediate transference to heated paraffin which completely enveloped the mass on cooling. These underwent putrefaction at about the usual time. Xo provision was made against the contact of air with the tissues when in transit, however, and no matter ho^^■ quickly they might have been removed, infection was nevertheless possible. On the other hand, carefr.lh- conducted experiments in the hands of Pasteur, Koch, C h e y n e and others have pretty conclusively proved that, as a rule, the blood and tis- sues of a healthy body are free from microorganisms. Nevertheless the bodv may appear to be healthy and yet contain bacteria. Klebs, after he had made, with negatii-e results, quite a number of carefully conducted experiments on dogs, found microorganisms in an animal apparently in per- fect health. Investigation, however, revealed that this identical animal had been the subject of a former experiment in which injections containing zymotic organisms had been made into a vein. As a result the dog had suffered severely, but had apparently recovered. It may be fairly inferred that some of these organisms had remained in the body and thus caused an error in the .subsequent experiment. The obser\'ations of Klebs gave rise to the further suggestion that blood which has been infected may, even after the lapse of a considerable period, under proper conditions, such as the reception of an injury, give rise to the active processes described. Experiments made by C h a u v e a u bearing on this point are very striking. Male goats were injected ^rith cul- tures of microorganisms and the testicles afterward subjected to the subcu- taneous separation of the spermatic cord in such a manner as to rob them of their blood-supply. Rapid putrefaction followed, just as if the organs had been infected from without. Animals thus treated, but not injected with pathogenic organisms, suffered simply from atrophy. In another experiment the animal was subjected to the same operation on the left testicle, prior to inoculation, and on the right after inoculation ; the latter alone under- went sloughing and putrefaction. Occurrence and Spread of Microorganisms.— Death and decay are of daily and hourly occurrence wherever animal and vegetable life exist. In the frozen regions of the north, however, decay does not follow dissolution, for, of the three factors necessary- to reproduce microbic life, heat, moisture, and organic matter, the first is wanting, and therefore the process of putrefac- ETIOLOGY OF INFLAMMATION 17 iion is inlubitecl. Tho undecayed remains of Ion- extinct mammoths in bihena are examples ol this. So, too, in certain portions of the tropics, because of the extreme ch-yness of the air, rapid desiccation takes place and the dead body, deprived ot its moisture, simply mummifies. Here the second factor moisture, is absent. This desiccating process is sometimes taken advantage oi m preserving meats, as, for instance, the "jerked beef" of the plains Except under these exceptional circumstances, however, dead animals or vegetable tissues decay and become the birthplace of new germs of putrefac- tion to be taken up by the atmosphere as dust when the process of disintegra- tion has advanced far enough. This cannot happen while the decaying mass IS ma moist condition, but only after its evaporation and the conversion^of the dried and broken-doNMi tissues into dust, ^^•hich, disseminated through the air iurmshes constant accessions to germ life. ' At great elevations, therefore, beyond the level at which vegetative life can grow, and beyond the confines of crowded communities, it will be found that comparatively few microorganisms are present in the atmosphere The classic- experiments of T 3' n d a 1 1 , carried on in the Alps, show this to be true On the contrary-, it is found that in awampy regions where vegetation is con- stanth- undergoing putrefactive changes, and in large cities and thicldv populated portions of the country where more or less deca^-ing animal matter exists the conditions are favorable to the development and dissemination of o-erm'life^ These germs may be carried out to sea by the wind or transported on ships" and become foci of infection in distant regions. In general, howe^-er it mav be s^aid that on the high seas the air is practicallv sterile, being free from dust In pre-aseptic times surgical practice suffered greatly from a want of knowledge concerning the dissemination of wound infections. In improperly built, poorly ventilated, and unclean hospitals, where many patients with sup- purating wounds were crowded together, the putrefying wound secretions turmshed to the atmosphere an unlimited supply of germs. Deposited in connection with dust on instruments, dressings, and the persons of attendants these organisms were conveyed to fresh wounds, which, in turn, became infected, and furnished new sources of infection and reinfection: this consti- tuted a vicious circle of events. SURGICAL BACTERIOLOGY _ In the preceding pages reference has been made to bacteria, or oro-anisms microscopic m character (microorganisms), and the relation which these bear to the_ processes of putrefaction, and, through their irritating influences to the etiology of inflammation. Since .this subject constitutes the essential groundwork of modern surgical practice, it demands a fuller discussion in this connection. _ It has been happily stated that every operation in surgery is an experiment m bacteriology (Welch). It is, therefore, essential that the surgeon should ha^'e at least an elementary knowledge of the organisms which com- monly mfect wounds, in order to exclude them intelligently. Familiarity ^^dth laboratory methods will emphasize the precautions to be taken during an operation and wfll contribute to the employment of intelligent means for the purpose of securing asepsis or antisepsis. A single act of carelessness or over- 18 INFLAMiMATlON sijiht in the series of acts that make up an operation is sufficient to vitiate all the precautions that have been taken to keep the wound aseptic, and it is cer- tain that unless the surgeon understands the rationale of laboratory procedure he v-ill often defeat his own best efforts by mistakes which he would otherwise avoid. Unless the methods of the surgeon, together with all the paraphernalia of operation, are exact and precise, and competent to attain the ends sought, namely, perfect sterilization of the wound and its surroundings, the antiseptic and aseptic procedure will prove a snare and a delusion, for it will induce a false sense of security in the operation which may prove dangerous and even fatal to the patient. Bacteria. — Bacteria are unicellular vegetable organisms, multiplying by fission. They are the active agents in that process of degeneration in organic substances which we call putrefaction. They may increase and produce their characteristic phenomena of decay onh^ in dead tissues, whether plant or animal, in which case the}^ are called saprophytes; or they may require living tissue for their development, when they are called parasites. Finally, they may flourish under both conditions, when they are termed facultative parasites. As strict parasites, they may or may not be disease-producers. With regard to their shape, bacteria are divided into two classes: (1) bacilli, rod-shaped organisms, longer than broad; (2) cocci, the spheric forms. The bacilli, in turn, when curved are called comma bacilli. AVhen comma bacilli, increasing as they do by fission, are grouped end to end, forming a spiral, such a group is called a spirillum. The cocci are subdivided, also, according to their grouping, the different and characteristic forms of the various species depending on their methods of subdivision when undergoing fission. When subdivision takes place in one direction only, but that indifferent, we then have a number of cocci, either solitary or occurring in irregular groups, and to these the term staphylococci is applied. AVhen fission takes place in one direction only, but alwa3's in the same direction, the cocci are then asso- ciated in chains and are described as streptococci. If the cocci occur mostly in pairs, they are termed diplococci. A^-lien fission takes place in two directions, then the cocci occur in groups of four, and are called tetrads. When division occurs in three directions, the so-called packet shapes are formed, containing eight elements. These cocci are called sarcinae. Other subdivisions and varieties of bacteria occur and have been described and classified, but they have not as yet been shown to be important as disease-producers. With regard to the bacilli, it is to be noted that many varieties in the shape of rods occur. Some are scarcely longer than they are broad, as, for instance, Bacillus prodigiosus, which for this reason was for some time described as a coccus. Some rods have their ends well rounded, while others seem to be cut off sc^uare. The size and length of the rods may vary somewhat, e^-en in the same species, so that quite long threads may occur together with shorter rods. So also there may be a distortion of form in old and worn-out cultures, swellings and constrictions quite different in form from the original bacillus. Such forms are known as involution forms. Bacteria are further classified with regard to certain peculiarities in their growth, as liquefying and nonliquefying organisms, aerobic and anaerobic. KTIOLOGY OF INFLAMMATION 19 Tho li(i\icfyino; oro-anisnis liave the property of liqucfyino; c;clatin. This they do by secretini!; a pei)tonizing ferment. Anaerobic bacteria are those that grow only \\'hen oxygen is excliulcd from tlie nutrient niecUum. Aerobic bacteria grow only in the presence of oxj'gen, while facultative organisms grow either with or without oxygen. Some ana- erobes will tolerate this gas in minute quantities, while others reqviire its abso- lute exclusion in order to grow. Such are called strict anaerobes. All bacteria multiply by fission. The cocci ne^'er increase in an}' other wa}^ as far as A\"e know at present. An important modification of the process of reproduction, known as sporulation, occurs in many of the bacilli. When this takes place, the individual rods develop in their substance a small and highly refractive oval granule, Avhich, increasing in size, finally escapes from the parent cell. This is the spore, which in turn, under favorable circumstances, again changes its form and passes into a shape exactly similar to that of the parent cell. The spore ma}' be considered as the fruit of the original plant, and develops only imder circvmistances favorable to the growth of the parent cells. It is not, as was formerly supposed, a result of unfavorable environment. Spores differ from the bacilli in one ^'•ery important particular. They possess an extraordinary power of vital resistance far in excess of their originating rod forms. Many spores resist prolonged boiling, desiccation, and the action of chemic agents quite sufficient to insure the destruction of the plants themselves. It will be seen at once how important to the surgeon is a kno^\•ledge of this peculiarity of the spore.- All bacilli are not known to be spore-bearers, nor are any of the cocci. In the nonspore-bearing species cer- tain individual members of a group appear under the microscope to be slightly larger and more refractive than the others. There is reason to believe that they are more refractory also. These are supposed to take the place of the spores, and are called arthrospores. Sporulation in the spheric form, if it ever takes place, is thus accomplished. Ptomains. — In the life processes of animals we have, as a result of tissue metamorphosis, the formation of certain products such as carbon dioxid, urea, etc. So it is with the higher order of plants. They give out oxygen and absorb carbon dioxid as a result of their development and growth. Not dissimilar are the bacteria in that they, too, in the course of their life processes originate certain new substances as the result of the tissue changes which take place dur- ing the process of decomposition. These substances, as has been before stated, are called ptomains. There are both poisonous and nonpoisonous ptomains. In the pathogenic species of bacteria in many cases the specific ptomain which they originate is the active agent in the production of disease. This is notably true of tetanus, a bacterial disease in which the nervous phenomena are entirely due to the ptomain formed by the bacillus of tetanus. During the progress of wound diseases the high temperatures and the vascular paralys'es which occur are caused by the action of these poisonous substances in the circulation. Sup- puration itself can be produced by the ptomains alone of certain of the pus organisms. The blush of erysipelas is probably due to a vascular paralysis caused by the local action of a poisonous, alkaloidal substance formed by the Streptococcus pyogenes, and to the same cause are due the high tem- perature and other phenomena of fever. 20 INFLAMMATION Culture Methods. — Not until it was practicable to cultivate bacteria on artificial solid media was it possible to isolate and classify' the different varieties for obser^-ation and experiment. The world is indebted to Robert Koch for the media which are now used in all lal)oratories for the cultivation of these organisms. The fluid medium which is most generallv used is Koch's bouillon. The solid media are nutrient gelatin, nutrient agar, and coagulated blood-serum. The bouillon is made as follows: One pound of lean beef is fineh* chopped and added to one liter of water, then boiled for half an hour in a glass flask. The infusion is then filtered, neutralized b}' adding drop by drop a saturated solution of sodium carbonate, and again boiled for an hour to clear it. A 0.5 per cent solution of sodium chlorid is usually added. The bouillon is subseciuently poured into test-tubes which are sterilized after the following method, known as fractional sterilization : The tubes are first plugged with common non- absorbent cotton and subjected for one hour to a temperature of 150° C. in a hot-air sterilizer. The bouillon is then poured into the tubes, which are re-plugged and placed in a cage made of wire cloth, and this in turn is put in an Arnold steam sterilizer and exposed to flowing steam half an hour each day for three successive days. The object of this method of sterilization is to permit the spores which have resisted the first steaming to develop into cell forms during the intervals, and then to destroy them by the second and third sterilizations. This method is thoroughly effective. It is to be noted here that all cell forms of bacteria perish after an exposure of ten or fifteen minutes to streaming steam, and all pathogenic bacteria, with the exception of the anthrax bacillus, perish after exposure to a temperature of 80° C. (176° F.), yet there are spores which resist prolonged boiling, and it is to permit such spores to germinate into the less refractory vegetative forms that the method of fractional sterilization has been adopted. One exposure of an hour to wet steam under pressure (35 to 40 pounds per scjuare inch) t\111 destroy all spores, but as this requires special apparatus'' the method first described is that usually adopted. The nutrient gelatin is made as follows: An infusion of meat is made by adding to one liter of cold water a pound of well-chopped beef. This is placed on ice for twentj-four hours and the expressed and filtered infusion then cooked, filtered, and neutralized by the addition of a solution of sodium car- bonate, drop by drop. To one liter of this "flesh water" is added 10 grams (154 grains) of peptone and 0.5 per cent of sodium chlorid. Ten per cent of gelatin is then added to this mixture, which is boiled after the gelatin has been allowed to soak for a time. In order that the gelatin may be perfect^ transparent it is necessary' to clear it of insoluble precipitates, which, if not removed, would render it cloudy. This is done by adding the albumen of one egg to 100 grams (about 3 ounces) of cold water. This is gradually poured into the gelatin mixture, which is stirred constantly with a glass rod. The whole is then boiled for ten minutes, when the coagulum of the egg-albumen comes to the bottom of the vessel, together A^dth the insoluble residue which it is sired to separate from the nutrient medium. The gelatin thus prepared after filtration is poured into test-tubes to about one-third of their capacity. This must be done carefully "\nthout wetting the upper portion of the tube, other- wise the plug of cotton A^ill stick to the tube as the gelatin sets, and it ^^^.ll be ETIOLOGY OF INFLAMMATION 21 difficult to remove it. The tubes containing the gelatin are placed in a cage made of wire cloth, put in an Arnold sterilizer, and subjected to flowing .steam for half an hour; this is repeated three times at intervals of twenty-four hours, in the same manner as the bouillon. Too prolonged boiling, it is to be noted, will depri\-e the gelatin of its property of solidifying when cooled. The agar jelly is also made in a similar manner, except that a vegetable gelatin called agar-agar is substituted for the ordinary gelatin. This is the product of a species of seaweed in Japan and has a melting-point much higher than that of gelatin. It is to be added to the flesh peptone solution in the pro- portion of 1 to 2 per cent. This medium is more difficult to make than the ordinary nutrient gelatin, as it filters less readily and is consequently more troublesome to clarify. For filter- ing both gelatin and agar preparations it is desirable to use a hot-water filter. This is simply a double-walled copper receptacle shaped like a funnel and filled with water which is kept heated by a number of gas jets issuing from a circular hollow tube perforated for the jets and fastened in the ordinary way to a retort stand. The glass filter is slipped inside the hollow copper funnel, and in this manner the gelatin or agar is kept hot while filtration is going on. In the absence of such an apparatus the ordinary glass funnel may first be heated by boiling water, and after the agar or gelatin is poured therein its walls may be kept hot with cloths wrung out of boiling water and continually renewed. A modification of the ordinary nutrient agar may be prepared by the addi- tion of 5 per cent of glycerin. This is the so-called glycerin agar, and is a useful medium for the tubercle bacillus, which will not grow on the ordinary media. After the addition of the glycerin, which is often acid, the agar must be carefully neutralized as before. It is important that all the media should be neutral, as some organisms resent even a trace of acid. Human blood-serum is often used for the cultivation of organisms which refuse to grow on other media. It is usually obtained from maternity hospitals and is sterilized in what is kno^Mi as a blood-serum sterilizer. It is a useful medium for the diplococcus of gonorrhea, which will not grow on any other medium. The common potato is sometimes used as a culture-medium. To prepare it for use, the tubers must first be well scrubbed with a brush in a solution of bichlorid of mercury, 1 : 500, and then well rinsed in sterilized water. Potato cylinders may then be cut with an apple-corer and sliced obliquety to their axis in order to secure a broad flat surface for inoculation. This is the method of Bolton. These pieces are then placed in test-tubes, plugged in the ordinar}' manner, and sterilized as usiial. All these different media have their own peculiarities and indi^'idual uses in laborator}^ practice. For hospital use, the chief advantage of the bouillon is the certainty with which the sterility of sutures and ligatures may be tested. Dropped into a test-tube of bouillon, every portion of the material to be tested comes in contact with the bouillon, Avhich thus offers a more rigid test than solid media. More than one organism ma}' be lodged on a suture or ligature, and when these grow together in a fluid medium there is no way of isolating and sepa- rating the different species from one another. Thus no conclusions with regard 22 INFLAMMATION to the pathogenic power of different organisms coukl ]i()ssil)l\' be reached, unless we possessed some means of separating them and testing their properties indi^'idually. Before the introduction of sohd media this was a most (hfhcult and uncertain process. In 1881 Koch introduced Avhat is known as the plate method of isolation, which is as follows: Three test-tubes of nutrient gelatin ai'e used, numbered in rotation, one, two, and three. Heated until the gelatin is fluid, but at a temperature below 40° C. (104° F.), number one is inoculated with a minute quantity of the material whose organisms it is desired to isolate. This is done by means of a fine platinum wire in the end of a glass rod, the point of which being bent on itself forms a fine loop. To sterilize the ^xiTe, it is first heated to redness in a Bunsen burner and then made to take up in its loop a minute quantity of the material to be used for inoculation. The wire loop is then plunged into the first tube, the gelatin being Avell agitated. From tube number one, thus inoculated, a sowing is in the same manner implanted in tube number two, and in like manner number three is inoculated from tube number two, the wire being heated to redness before each sowing to insure its sterility. Now, it is evident that this is a process of dilu- tion, and that each successive tube will contain organisms rapidly diminishing in number. Three sterilized glass plates are then prepared and leveled. The contents of tube number one are poured on plate number one, and so on, so that finally we have three plates covered with a thin layer of solidified gelatin. In plate number one so numerous are the organisms which have been dif- fused through the gelatin that the colonies which start from each individual coalesce, so that they cannot be isolated, but in plate number two, after a time, numerous isolated points may be seen, each of which is a colony growing from a single spore or plant, and therefore an unmixed growth. In plate number three, as the individuals are far fewer, the colonies are more widely scattered, so that the whole plate may contain fewer than a dozen colonies. These plates are all, of course, protected from the atmosphere after sowing, so as to prevent the introduction of organisms from the air. This may be conveniently done as follows: Two circular glass dishes with straight sides about an inch and a half high are used, one just small enough to fit inside the larger dish. The plates, suitably elevated, are placed in the larger dish and covered by the inverted smaller dish. Sufficient water is then poured into the larger dish to make a water seal, and the plates are then left to develop their growth. Of course, the removal of the covering dish exposes the plates to the contamination of organisms floating in the air, and this method has been modified by Petri ^^ith a view to minimizing the chances of contamination. He pours the inoculated gelatin into three shallow circular dishes with straight sides and covers each dish with one similar, but a little larger. These little receptacles, about six inches in diameter, are known as Petri dishes. Most organisms grow m^ore or less rapidly at a temperature of 22° C. (70 F.), or that of an ordinary room. They all grow much more rapidly, however, at blood-heat, and some refuse to grow at any other temperature. It there- fore became necessary- to devise an incubator which could be maintained stead- fastly at the desired heat by means of a thermostat. Koch's device is simply a double-walled box or oven mounted on a standard. The space between the walls is filled with water, to which heat is communicated by a small flame under the bottom of the oven. Radiation is prevented by covering with KTIOI.OGV OF IXFLA.MAIATIOX 23 fVlt the outside of the oven. kSuch ovens usually have iloul)le doors, sometimes triple, the inner ones being of glass (Fig. 1). There is usually a water-gage at the side to show the height of the water between the double walls, and an orifice in the top through which a ther- mometer may be passed. There are numerous thermostats in use at present, all depending on the expansion of a column of mercury to regulate the flow of gas to the l)uruoi-, the mercury, as it rises, reducing the size of the aperture admitting the gas. increasing the size as it falls. The Dunham therinostat is represented in Fig. 2. It is usual to interpose a pressure regulator between the house s\stem and the thermostat in order to obviate the effects of Fig. 1. — Laboratory Incubator. changes of pressure in the mains (Fig. 3). The small jet at the burner is protected from accidental extinction b^'-a cone of mica. A hot-air o^'en is useful in a laboratory for the purpose of ciuicldy sterilizing the test-tubes ^^ith their cotton plugs previous to filling them -^Aith the various media. This is simply a box of Russian iron with double walls and suitable shelves. Heat is furnished by a nest of Bunsen burners underneath the bottom. A temperature of 150° C. for one hour will completely sterilize both tubes and plugs. Identification of Bacteria. — With regard to the naked-eye appear- ances of bacteria as they grow on the different media, these organisms differ ^ndeh^ In stick cultures some grow within the narrow boundaries of the stab, while others send out branching growths therefrom in great exuberance. 24 IXFLAMMATJON Fig. 2. — Dunham's Thermostat. Color is moreover an important jooint of distinction between different organisms, and has given rise to a classification in which these organisms are divided into chromogenic and nonchromogenic species. One produces a bright red growth, others a deeper shade; some, again, are orange, some }'ellow, and the organism of blue pus imparts a peculiar bluish-green tint to the agar. Color, howe^ver, is not a test of pathogenic power, many of the pathogenic organisms being nonchromogenic and a dirty \\hite. The odor of certain organisms is to some extent charac- teristic and furnishes a means of identification. Thus, Bacillus ureae has an odor like that of decomposing urine. The malignant edema l^acillus generates a putrid, offensive gas. Some organisms licjuefy gelatin and gi^'e a characteristic funnel shape to the area of lic[uefying gelatin stab cidture, and again the liquefying organisms differ widely in the rap- idity with which they bring about hquefaction. Microscopic Examination. — It is to be seen, therefore, that the organisms may differ in man}-- particulars, and that it is necessary to take all these into consideration before we appeal to the microscope for final adjudication. Indeed, were we to trust to the microscope alone for our means of identification, very few, if any, are the bacteria which we could identify. It is as necessary to know the behavior of organisms on cul- ture-media as it is to be able to recog- nize their forms under the microscope. Indeed, ^^■e gain more information as to the identity of a particular or- ganism by observing the peculiarities of its growth than we do b}' the microscope, which may simply con- firm our previous conclusion. Methods of Staining. — In the minute quantities which are required for the purpose of microscopic ex- amination all these organisms are colorless, chromogenic, or nonchro- mogenic. It thus becomes a matter of difficulty to see them well under the microscope, and hence for pur- poses of examination they are stained. We are indebted to W e i g e r t for this very great addition to the technic of the microscopic examination of these organisms. The anilin dyes yig. 3.— Moiterseur's pressure Regulator. are used because they are readily ab- sorbed by the protoplasm of the cells, the spores remaining unstained, except by the aid of special processes. -r Ll ^ -20 : -0- 20:- r ^^P ^^^^■^ ^^ irffl| ii li ^ qg^l tii^^^#«M^*25_J pi -UigSBes IIHaMil iHHI ■■■UBiHHI ETIOLOGY OF INFLAMMATION 25 Since W e i g o r t ' s discovery many methods of staining bacteria have been invented. Only three formulas will be ,2;i\'cn here, which will be quite sufficient for ihe purposes of the "general suro;eon. For a j2;eneral stain that known as the alkaline methylene-blue (Loffler) is probably the best. It is made as follows: To 30 c.c. of saturated alcoholic solution of mcthylono-blue add 100 c.c. of a solution of caustic potash. 1 : 10,000. This stain may be kept in a bottle through the cork of which has been thrust a dropping tube with rubber compressor. It is a most useful stain. In per- manent preparations, however, it will fade. In examining bacteria in pus, sputum, etc.. the dried albumin also takes the stain. This is often confusing, and it becomes desirable to remove the coloring in some way and yet leave the bacteria stained. Gram's method does this satisfactorih-. Some organisms, that of gonor- rhea, for instance, do not retain their color in Gram's stain, so that this method may be used for the purpose of differentiation. The Ziehl-Neelsen method removes the stain not onlv from extra- neous material, but from all organisms except Bacillus tuberculosis, so that this also is available for the purpose of differential diagnosis. In the method of Gram there are two solutions, a stain, and a decolorizing agent: Gram's Stain. Saturated aqueous solution of methyl-violet. Decolorizing Solution. lodin 1 part; potassium iodid, 2 parts; water, 300 parts. The preparation is first stained, then immersed in the decolorizing solution for a minute or longer, then cleared. The Ziehl-Neelsen formula for staining tubercle bacilli is as follows: Carbol-fuchsin. Fuchsin Ice Alcohol '.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'..10 c'c! When dissolved, add 100 c.c. of a 5 per cent solution of carbolic acid. All these stains require to be freshly made every now and then, as by long standing the}- deposit the dye in the walls of the bottle and so lose in efficiency. Method of Examination by the Microscope.— A minute quantity of the organism to be examined is taken up in the pre\-iously flamed loop of platinum wire and spread very thinly over a cover-glass (smear preparation) . If neces- FiG. 4. — Hot-air Sterilizer. 26 IXFLAMMATIOX san^,the smear may be still further attenuated by the addition of a loopful of sterilized ^A•ater. The preparation is then allowed to dry spontaneously. The cover-glass is then seized in a pair of forceps and passed three times through the flame of a Bunsen burner, smeared side up. If the alkaline blue solution is used a drop of this may be placed on a glass slide and the cover-glass then placed, smeared side down, on the drop of stain, so as to exclude air-bubbles. The sur- plus stain which exudes from the edges of the cover-glass is then to be blotted off by a piece of filter-paper placed over the slide and coA'er-glass, and gentlv pressed thereon. Sufficient stain will remain to keep the cover-glass fixed to the slide. A drop of cedar oil is then placed on the cover-glass and the specimen is ready for examination with the homogeneous immersion lens. In the Gram method, after the specimen has been stained in the methyl-violet solution and subsequently decolorized as before directed, the decolorizing fluid is to be washed off with sterilized water and the cover-glass placed on the slide and treated as before. There must always be some fluid between the slide and the cover- glass, but not sufficient in amount to float it. If during the examination the fluid evaporates, it must be renewed by placing a drop of water at the edge of the cover-glass, which will be drawn underneath by capillary attraction. Speci- mens when stained may be permanently mounted in Canada balsam after they have been dried. For staining tuberculous sputum, etc., the application of heat is necessary", if it is desirable to work expeditiously. This may be done in the following manner: The preparation liaA'ing been made and dried in the usual way, the cover-glass is flooded with the carbol-fuchsin solution and held over the flame until it boils vigorously for half a minute. The stain is then washed off and the slide is in like manner flooded with the decolorizing solution. If this is left too long in contact with the preparation, the bacilli themselves may be decolorized, especially if faintly stained. A little practice will teach the observer the proper interval, which is usually not over one minute, and sometimes less. The cover-glass held against a white surface should show but a trace of color. This rapid method is useful for diagnostic purposes, but the evaporation of the stain when boiled leaves unsightly crusts at the edge of the cover-glass, so that, for a permanent mount, it is better to leave the specimen overnight in a watch-glass filled vdih a cold solution of the carbol-fuchsin, the decolorizing method being identical with that first described. Common Pus Organisms. — It now becomes necessary to describe those organisms that the surgeon will encounter in wounds and in certain diseases which require surgical interference. First and most important are those that induce suppuration. They are the following: Staphylococcus pyogenes aureus, Staphylococcus pyogenes citreus, Staphylococcus pyogenes albus, Staphylococcus epidermidis albus (Welch), Streptococcus pyogenes, and, rarely, Bacillus pyogenes soli and Bacillus pyocyaneus. Under the microscope Staphylococcus pyogenes aureus, Staphylococcus pyogenes citreus, and Staphylococcus pyogenes albus do not differ from one another, nor could they be thus distinguished. When grown on nutrient agar, these varieties of staphylococci differ from one another in the color of the resulting growth, aureus being a golden yellow, citreus a citron yellow, and albus milk-white. It is to be observed, however, that sometimes the color is slow in appearing in the citreus and aureus, so that they may at first be mistaken for albus. With respect to the behavior in gelatin, all three organisms produce liquefaction ETIOLOGY OF INFLA.M.MA'I'IOX 27 tlioutih this is said to occur soincwliat nioi'c slowly in the citrous than in the other two. Plates of these or Fi^.a. "'S^ '^Uif Jft Fi^.4. Fig. 1. Bacillus Prodigiosus, Agar Culture. Fig. 2. Bacillus Pyocyaxeus, Agar Culture. Fig. 3. Tuberculous Sputum. Fig. -i. (ioxococci. Enclosed in Pus Corpuscles. ETIOLOGY OP INFLAMMATION 29 resembling; the o-onococcus takes the G r a m stain, or if it can be grown on the ordinary media, it is not the specific organism of gonorrhea, exen though it resembles the gonococcus in other particulars. The gonococcus stains somewhat slowly with the L 5 f f 1 e r stain ; more readily with the methyl-violet solution of the Gram stain. Specific Pathogenic Bacteria. — Lustgarten and others have claimed that syphilis is a bacterial disease, and different organisms ha\'e been described in this connection, but at present the matter is not sufficiently well settled to deserve more than passing notice in this place. So, too, with chancroid ; as yet no definite organism has been associated with either the sore itself or the resulting bubo. It seems probable, however, that in all these diseases bacterial infection plays an important part. Diphtheria may occur in wounds, and, as the surgeon is sometimes called upon to perform tracheotomy in the course of the disease, a brief description of the organism may not be out of place. The organism is a bacillus known as the Klebs-LbflEier bacillus, K 1 e b s having discovered it in diphtheritic membrane, its identification with the disease being completed by L o f f 1 e r . Its morphology is somewhat peculiar. It is sometimes c^uite straight, some- times curved, and in a single cover-glass preparation both forms may be seen; some are swollen at the ends, some in the middle. Often it stains irregularly. It does not form spores, nor are the rods eA^er seen in threads. It stains well with the L o f f 1 e r meth^dene-blue. With regard to its behavior in culture-media, it is aerobic, nonmotile, and nonliquefying. The Bacillus of Tetanus. — One of the most important of wound diseases with which the surgeon is confronted is tetanus, though its importance is derived rather from its fatal character than from the frecjuenc}" with which it occurs. Formerly this disease was attributed to wounds of nerve structures, but the researches of N i c o 1 a i e r , K i t a s a t o , and others have sIioaati that it depends on a peculiar bacillus called, from its discoverer, the bacillus of N i c o 1 a i e r . This organism is a rather slender rod, usualh' bearing a single spore at one end, so that the bacillus and spore resemble a drumstick. In pure cultures not only the drumstick, but separate spores also are found. This bacillus is a very strict anaerobe and must be cultivated in an atmos- phere from which oxygen is excluded. For the surgeon a convenient method of accomplishing this is as follows : Nutrient agar in a test-tube is melted and allowed to cool to 80° C. (176° F.). It is then inoculated in the usual manner with the secretion of the wound and kept at 80° C. for the space of twenty minutes. This temperature kills the other organisms which may be present, but does not affect the spore of tetanus, because of its high power of resistance. The agar is then allowed to cool, and after it has set, the remainder of the tube to within a sliort distance of the cotton plug is filled with liquid agar. This thick layer of superincumbent agar prevents the oxygen from gaining access to the inoculated la}'er at the bottom of the tube, in which the tetanus bacilli then develop in about forty-eight hours if placed in the incubator. The colo- nies have a peculiar shape as they grow, sending out long fuzzy prolongations from the parent colony, as represented in Plate II, Fig. 5. They never grow very near the surface of the agar. When cultivated in gelatin, the tetanus bacillus slowly liquefies the medium. It is a gas-producer to a limited 30 INFLAMMATION extent, and motile. This organism is not found in tlie blood nor in tissues remote from the wound. It must be recovered from the wound itself or from the immediate vicinit>'. Cultures exposed to diffused daylight soon lose their pathogenic power. This may account for the fact that some observers have failed to produce the symptoms of tetanus in animals by cultures not kept in the dark. The nervous symptoms of tetanus owe their origin to two extremely poisonous alkaloids, called tetanin and tetanotoxin, either of which when injected into susceptible animals causes the s}'mptoms characteristic of the disease. Besides these alkaloids, a toxalbumin has been isolated which is said to be still more poisonous. Some observers have claimed that the poisonous product of the tetanus bacillus is of the nature of a ferment. The Anthrax Bacillus. — This organism is of special interest to bacteriolo- gists because it was the first organism that was conclusively shown to be patho- genic. Koch demonstrated the relation between the anthrax bacillus and the disease of cattle called splenic fever by inoculating animals with pure cultures of the bacillus. Never before had any organism been grown on arti- ficial media, and it was from this time that the science of bacteriology began to have a firm basis. The anthrax bacillus is of interest to the surgeon because it produces in man the gangrenous spreading ulcer called malignant pustule. It is a rather long bacillus, with sf(uarely cut ends, is rarely seen isolated, but grows for the most part in long threads, usually twisted together in convolu- tions. It is a spore-producer when in contact with oxygen, is nonmotile, aer- obic, and slowly liquefies gelatin. In a long stab in gelatin or agar, the organism grows to the end of the stab, but more abundantly as it approaches the surface, sending out fuzzy prolongations sideways which are most abundant at the top of the stab and hardly visible at the bottom. In this respect it is the opposite of the tetanus bacillus, in which the reverse is true. The gelatin first com- mences to liciuefy at the top, as shox^m in Plate II, Fig. 5. In Plate II, Fig. 4, are shown the rods, some undergoing spore formation. This does not occur, it is to be remarked, in the living body, therefore in a cover-glass preparation of a suspected malignant pustule only the rods Avill be seen, never the spores. They resemble verv closely the rods of the hay bacillus, which is, however, motile. To observe this distinction it is necessary that the preparation should be examined unstained and unflamed. The organism of malignant edema somewhat resembles the anthrax bacillus, but is motile and a strict anaerobe, and ma\' thus be distinguished by cultivation. It is not likely to be met with, howe\'er, and has not been described among the organisms of wounds because its pathogenic power in man seems doubtful. All these organisms stain readily with L o f f 1 e r ' s stain. Bacillus tuberculosis (Plate I, Fig. 3).— In 1882 this organism was proved by Koch to be the specific cause of tuberculosis. It is found in the sputum of tuberculous patients, in tuberculous glands, in caries and in those joint affec- tions which are the result of tuberculous infection. It has also been shown to exist in great numbers in the diseased tissues in cases of lupus. This organism is a strict parasite and exists in the form of very fine rods, usually curved, with rounded ends. The organism stains with great difficulty, but when stained retains the color, resisting for some time the decolorizing agency of alcohol and nitric acid. The directions for staining have already been given in a pre- vious part of this section. When thus stained, all other organisms having PLATE 11 ^^■* ■^ 'Oi ^!^^-abj9 ^f<«| t '<.-'< V 1. Streptococcus Pyogenics. 2. Staphylococcus Pyogenes Aureus. 3. Bacillus Anthracis. 4. Bacillus Tetani. 5. Stroke Culture op Tetanus. 6. Culture of Malignant Edema. ETIOLOGY OF INFLAMMATION 31 boon (l(H'ok)rize(l h\- the action of tlie alcohol and nitric acid, the tubercle bacilli are seen as \Try small and slender red rods, with empt>' or unstained spaces in indi\'idual rods. These unstained spaces have been called spores by some writers, but spore-formation has not as yet been shown to exist in connection with the tubercle bacillus. The rods are extremely fine and slender, so that it takes some little practice to see them. They do not grow on ordinary gelatin or agar, but grow readily on glycerin agar in the incubator, not, however, at the room-temperature. The organism can be best obtained in pure culture from a nodule in a case of tuberculous meningitis or peritonitis, care being taken to avoid contaminating the cultures with surface organisms. If the peritoneum is used, the abdominal wall having first been opened to the transversalis fascia, the opening into the peritoneum should be made with a sterile knife and with appropriate precaution. A tubercle is then removed from the peritoneum, crushed on a sterile surface, and implanted on a slanting glycerin-agar tube. If contamination has not occurred, no growth will be apparent until the lapse of two weeks, when fine grayish-white points will be seen growing at intervals from the inoculated surface. These slowly increase until the surface of the agar is covered A^ith a dry yellowish- white growth, looking very much like bread- crumbs, scattered over the agar. As it is necessary to keep the tubes in the incubator for so long a period, either they must be sealed above the cotton plug with sealing-wax, or the air of the incubator must be kept moist by a vessel of water within. It is not always easy to discover tubercle bacilli in tubercu- lous joints. As many as twenty sections were made before the bacilli were discovered by one observer. R o s w e 1 1 Park, however, in a series of observations lasting over two years, was almost always able to find them. If not readily found ^^ith the microscope, the internal surface of the thigh of a guinea-pig or the anterior chamber of the eye of a rabbit may be inocu- lated with a bit of the tuberculous material from the joint. In about six weeks the animal will die of tuberculous infection. Unfortunate examples of autoinfection have followed operations for the relief of tuberculous affec- tions. A. T. B r i s t o w has observed two cases where tubercular nodules of the skin followed slight punctures in the course of operations on tuberculous patients. In a case where puncture of a joint of the thumb resulted in tuberculous synovitis, subsequent general infection followed and death occurred in a year and a half. A bacillus occurs about the genitalia which has been named the smegma bacillus, and which bears a remarkable resemblance to the tubercle bacOlus. It may occur in urine which is being examined for the tubercle bacillus and give rise to an erroneous diagnosis. The inoculation test would, of course, settle the c^uestion beyond a doubt. The Lepra Bacillus. — Leprosy is a disease which is but seldom seen in our northern latiiude. though on account of importation, cases are more common now than formerly. The organism of leprosy, the so-called lepra bacillus, very closely resembles that of tuberculosis, in regard to size, general appearance, and behavior when brought in contact with decolorizing agents. It is, however, somewhat smaller than the tubercle bacillus, with more pointed ends. It stains more easily than the bacillus of tuberculosis, but gives up its stain \^ith the same difficulty. For purposes of staining the same solutions may be used as with tubercle. This organism has never been successfully cultivated on artificial media. Its causal relation to leprosy has been definitely ascertained. 32 INFLAMMATION The Bacillus of Glanders. — ({landers, while primarily a disease peculiar to the equine race, nevertheless is not infrpquentl.v communicated from dis- eased animals to man. It is the result of the infection of the animal by the bacillus of glanders (L o f f 1 e r and Schiitz, 1882). This organism, too, bears some resemblance to the tubercle bacillus, but is shorter and thick-er! It stains with some difficulty, but easily parts with its stain in decolorizing fluids. It stains most readily in a hot solution of Loffler's alkaline blue, and grows fairly well on all media, best perhaps on glycerin agar. It is aerobic, nonmotile, and does not liquefy. Pure cultures of this organism may be obtained, if proper precautions are taken, from the interior of the so-called farcy buds or nodules. NON-BACTERIAL SUPPURATION Foreign bodies buried in the tissues, as well as mechanic and chemic irri- tation, have long been looked upon by surgeons as causes of suppuration. After Lister's demonstration of the germ origin of wound suppuration, however, many referred suppurative processes to the direct intervention of bacteria. Some, nevertheless, held that, while microorganisms were the accom- paniment of suppuration, they were not necessarily the cause of it. Experiments conducted with the view of settling the question were con- tradictory and misleading until, as familiarity with proper methods of technic increased, common sources of error were eliminated. These consisted princi- pally in attempts to cause suppuration by the introduction into the tissues of such substances as croton oil, mercury, and turpentin. The different results obtained by different observers were in part due to the fact that the injected animals used in the experiments did not always belong to the same species. Some animals are peculiarly susceptible to suppurative and analogous processes, while others possess a comparative immunity from them. Turpentin, for instance, will produce these in dogs but not in guinea-pigs. By far the most common and serious sources of error, however, arose from faulty aseptic technic. Experiments serving to show that suppuration could be caused by heat- sterilized pus, which presumably contained only the chemic products of pus organisms, were reported in 1878 (Pasteur). These were confirmed in 1885 (Petrour), the animals used being rabbits and guinea-pigs. Bouillon cultures of Staphylococcus pyogenes aureus, after being both heat- sterilized and filtered, produced suppuration (Christmas). The same results were obtained from injections of croton oil in the cellular tissues beneath the skins of rabbits (Councilman). Experiments conducted along the same line, with the precaution, however, of placing the croton oil in hermetically sealed sterilized glass tubes introduced beneath the skin of the animals and broken at different intervals of time after the wounds had healed, gave different results. In no case Avas real pus produced, but only a mass of puslike consistency. This is to be regarded as one of the changes that take place in fibrinous exudations as the result of the solvent action of living cells on tissues destroyed by the action of the chemic irritant (Cheyne). In this connection attention may be called to the property which chemic sub- stances possess of attracting or repelling certain kinds of organisms (chemo- GENERAL DIAGNOSIS OF INFLAMMATION 33 taxis). In the case of tlie chemic substances placed beneath the skin, both these and the resulting dead tissue exert a similar chemotactic action and attract the leukocytes. The introduction of calomel \\ill almost invariably produce a puslike matci-ial which, ho^^■ever, differs in several particulars from true pus: the cell nuclei arc single, cystic, and stain only feebly (Steinhaus). Finally, the i^roducts of decomposition produced by bacteria, as well as the ptomains of putrefaction, such as cadaverin, may produce pseudo-suppuration. Aseptic suppurative processes, or suppuratiA-e inflammation without the presence of bacteria, to which reference has been made, and with which the results of irritation with jequirity seed (B a u m g a r t e n) are to be classed, require further investigation and study. The fact, however, that they are germ-free is of interest to the surgeon, and with more extended knowledge of laboratory methods he will be able to distinguish between these and sup- puratiA-e inflammatory processes which depend on bacterial infection (see Surgical Bacteriology) . GENERAL DIAGNOSIS OF INFLAMMATION Objective Symptoms.— The classic objective symptoms, namely, redness, heat, and swelling, are usually perceptible, the first to the sense of vision (mspection), the second to touch (palpation), assisted bv thermometric mstruments, and the third to vision and touch. Inspection.— When the inflammation is deep-seated or but slightly devel- oped superficially, inspection may not reveal the presence of redness. '^ Swell- ing may also escape observation, particularly if the point of infiammation is covered by thick fascia. The redness of infiammation is to be differentiated from that produced by mechanic obstruction. The swelling may likewise prove a source of error in cases where it is due to the presence of a tumor. Here, however, the redness is of a bluish tint, and in cases of long duration the superficial vessels are more or less dilated. The redness of acute" inflammation IS evenly diffused, of rather light color, and without any appearance of rami- fymg vessels. Changes in color may be observed. Subcutaneous rupture of vessels and effusions of blood into the tissues, together with the subsequent breaking down of the red blood-corpuscles of the effusion, cause a staining of the tissues by the blood-pigment. This, combining with the inflammatorv redness, produces the peculiar tints of yelloAvish blue, bluish green, or even deep brown. In addition to the redness and swelling, inspection sometimes reveals the presence of pulsation, of blebs or bullae, of points of sphacelus, and of foreign bodies, facts -which are of diagnostic value. Inspection of corresponding healthy portions of the body should always be made, when possible, for pur- poses of comparison. In this manner slight departures from the normal which otherwise might have escaped notice are made apparent. Palpation.— When employed in the diagnosis of inflammation, palpation, as a rule, has for its primary object the discovery of that cardinal symptom of inflammation, elevation of local temperature. Exclusive of the so-called cold abscesses, the symptom is rarely so slightly pronounced as not to be dis- tinguished by the hand of the surgeon applied to the skin at the point of 34 INFLAMMATION inflammation. It is comparative!}' a rare circumstance, in acute and subacute inflammator}^ foci, that the local elevation of temperature is not sufficiently great to permit of a diagnosis on the strength of this symptom alone. The dorsal surface of the fingers of the examiner should be employed rather than the palmar, the latter, in doubtful cases, being nonsensitive to slight changes of temperature. Here a comparion of the point under examination with the corresponding healthy portion of the body will often prove of value. Palpation is further employed to determine the presence or absence of fluc- tuation. This symptom depends on the presence of fluid at the point of inflammation, either serous or suppurative. It is based on that physi- cal property of all fluids by reason of which they produce wavelike movements in the mass when disturbed, and thus transmit the sense of pressure from one side to the other. In the case of large accumulations, as, for instance, serous effusion within the peritoneal cavity, the wave can be distinguished by sight as weU as by touch, especially if the abdominal walls are thin. Fluid which occurs within inflammatory foci, however, is, as a rule, so covered by tense and unyielding tissues that these wavelike movements cannot be produced. Under such circumstances advantage is taken of another physical property of fluid, that of propagating pressure ec|ually in all directions. The finger being placed on each side of the swelling, alternate pressure will convey the sense of transmitted motion, always to the passive finger, no matter in which axis of the tumor the fingers are placed. In estimating the importance of this symp- tom in any given case the surgeon should not fail to appreciate the character of the tissues overlying the site of the supposed fluctuation. This is of special importance where large muscular masses, such as the quadriceps extensor of the thigh, intervene, most of the sensation which otherwise would be conveyed to the touch being lost, unless both fingers are firmly pressed deep into the tissues. The right index-finger may be i^laced at the margin of the suspected swelling and steady pressure made in such a manner as to increase the tension within the cavity containing the fluid. Pressure made at some other point of the swelling with the left index-finger will lift the other finger to the same extent to which the fluid is displaced. Should the right index-finger remain stationary or fail to feel the pressure when it is but slightly made by the left, then the pressure is not propagated by fluid and the examination is negative. All collections of fluid within the body cannot be demonstrated by means of palpation. This is true of accumulations of pus within cavities bounded by bony walls. Not only may cavities with rigid walls be situated in bone, but those having originally soft and yielding walls may become changed by inflammator}'- processes or long-continued pressure, so that the finger fails to make any impression. This is most likely to occur where collections of inflam- matory fluid become encysted. Subfascial phlegmons of an acute character also do not, as a rule, give rise to the sense of fluctuation on palpation, but rather appear to be a solid infiltration, until they find their way through the fascia, when a ver}^ distinct sense of fluctuation may exist at the opening, which also may be plainly felt. It frequently happens that fluctuation is felt when no fluid is present. This is called pseudo-fluctuation, and it depends on the failure to recognize the distinction between true fluctuation and elastic resist- ance. Faulty palpation is responsible for this error, which may be avoided GENERAL DIAGNOSIS OF INFLAMMATION 35 by strict adherence to the jjropcr metliod of conducting the examination. The sense of fluctuation conveyed by muscular tissue when largely developed is such as to deceive at times the most careful observer. So difficult is it to distinguish between the fluctuation of muscle and that found in collections of fluid in some situations, such as the thigh or the thenar eminences, that the result of an examination for fluctuation in these regions may be almost without value. Muscular fluctuation, however, it may he observed, always takes place across the axis of the muscle, never in the direction of the axis. Thus, if one index-finger is placed on the outer margin of the quad- riceps extensor and the other on the inner margin, a very distinct sense of fluc- tuation may be produced which is caused by the rolling of the fibers of the muscle on their axes. If, however, one finger is placed on the center line of the muscle belly and the other above or below, on the same line, so that the motion, if any, will follow the axis of the muscle, muscular fluctuation never takes place, as the fibers are unable to roll against each other as in the other case. Finally, certain solid tumors may simulate fluctuation. Of these, myxomas and sarcomas are to be particularly mentioned. These either contain in their tissues large amounts of nutrient fluid, or are peculiarh' rich in cellular elements or cystic formations. The history of the condition, together with the presence of some of the other signs of inflammation, will assist in the diagnosis. Palpation is further employed to determine how far the swelling extends and whether or not it is movable on the deeper parts (muscle, fascia, bone) ; in other words, its relation to surrounding parts. This point is specially impor- tant in establishing the differential diagnosis between an inflammatory swelling and the formation of a tumor. If the swelling, whether inflammatory or neo- plastic, is in the neighborhood of a large vessel, the pulsations of the arterv will be conveyed to the finger with more or less distinctness and may be visible to the eye. This is found to the greatest extent in aneurisms. Tumors with fluid contents, however, in the vicinity of large arteries transmit the arterial impulse very distinctly, provided there is much tension in the cyst or sac. Tumors of a soft or compressible character transmit pulsation less readily. Certain growths, such, for instance, as some of the sarcomas, in Avhich large nutrient vessels have developed also exhibit pulsation, even at a considerable distance from large trunks. Pulsation is also present in the brain when its bony incasement is removed, and may occasionally be detected in the medullary cavity of large bones. Friction sensations or sounds, as they are sometimes called, are conveyed through the palpating finger of the surgeon. These may follow injuries of different kinds, but are specially noticed in cases in which considerable blood is extravasated and coagulated in the connective- tissue spaces. There is also a peculiar crepitating feeling conveyed in cases in which serum is forced through elastic effused material. In serofibrinous exudations in synovial cavities, par- ticularly Avhere the walls of the latter are covered by a proliferation of tissue, these sensations of friction are also felt. The sense of hearing is not often employed by the surgeon for diagnostic purposes in inflammatory conditions. In instances in which there is a ques- tion of differential diagnosis of inflammatory conditions and aneurismal tumors, the stethoscope is employed. The conditions which produce the sensation of 36 IXFLAM.MATIOX friction above alluded to also produce audible friction sounds, but for the detection of these, even when aided by the stethoscope and its modifications, the sense of hearing is rarely useful. The sense of smell is likewise employed for diagnostic purposes in cases in which the odors are given off by gases having their origin in foci of putrefaction. Instrumental aids to diagnosis have long been employed by surgeons. First ainong them is the probe. This little instrument is intended to serve as a prolongation of the finger, and gives information to the surgeon of the condi- tion of structures which communicate Avith the air through either natural or artificial channels, but Avhich, by reason either of the narroAATiess of the channel or of its depth, are inaccessible to the touch. It is also used to determine the location and presence of foreign bodies, such as bullets, etc., and necrotic bone. In the treatment of old sinuses it is likewise useful to convey certain medica- ments within its tract, such as stimulating applications, caustics, etc., or a tampon of medicated gauze, or a drainage-tube. Exploratory puncture is of special importance in the diagnosis of certain inflammatory conditions, and of their products. This is generally accom- plished by means of the aspirator, though a deeply grooved needle called an exploring needle may often be used instead. By the use of this means the presence of liquids may be ascertained, together with their character. For diagnostic purposes the common hypodermic syringe may be used, the needle having been first sterilized by being passed through an alcohol lamp. It sometimes becomes necessary to employ mensuration for the purpose of establishing and recording differences in the circumferences and lengths of parts. As aids to inspection varieties of instrimients are employed. Of these, the laryngoscope, the rhinoscope, the ophthalmoscope, and the endoscope are examples. An important aid to diagnosis of which surgeons of the present day avail themselves much more frequently than did those of former times is the microscope. Its aid is constantly invoked to determine the nature of the products of disease, the malignancy or benignancy of neoplasms, and to assist in identifying the various bacteria of wound diseases. Finally, the thermometer and the sphygmograph are employed in estimating the extent of the partici- pation of the entire oi-ganism in the inflammatoiy process. The thermometer measures the variation of animal heat, the sphygmograph the changes in vas- cular tension. (For Laboratory Aids to Diagnosis see page 243.) Fever. — In ever}' acute inflammation, whether exudative or suppurative, more or less constitutional disturbances arise. Of these, the most important to the surgeon is fever. This scarcely ever commences earlier than twenty- four hours after the reception of the injury, is coincident with the beginning of putrefactive changes in the blood and the. secretions in and about the wound, and pursues a course parallel to these changes, rising or falling according as these processes are rapid and extensive or the reverse. If the latter are mod- erate in degree and extent, there may be simply a morning and an evening rise of temperature, with subsec^uent remissions. The occurrence of a sud- den chill followed by a considerable rise of temperature (103° F. or more) always indicates a profound degree of intoxication through influences more pro- nounced than those which produced the original fever. Coincidentally with the rise of temperature there occurs an increase in the GENERAL DIAGNOSIS OF INFLAMMATION 37 frequency and force of the pulse, as well as an acceleration of the respira- tions. There is a more constant relation between the temperature and the pulse, however, than between either of these and the respiration. The usual and typic symptoms of anorexia, impaired digestion, etc., occur- ring in other forms of fever, likewise exist in surgical fever. The aversion to meat is particularly noticeable. Even liquid food is taken but sparingly, as the digestion is much weakened, if not interrupted altogether. The urine is of a dark wine-color, due to the presence of urates in large cjuantities, and usually the daily quantity falls below the normal. While the total quantity of urine may be decreased, there is nevertheless an increase in the amount of pliosphates, urates, and particularly the potassium salts and urea, which indi- cates an increased metamorphosis and waste of tissue. The albuminates and their derivatives eliminated are derived from the tissues themseh'es. This to a certain extent explains the emaciation of fever patients. During this time the subjective symptoms are well marked. Thirst is excessive, restlessness is very great, and there may be delirium. With the occurrence of profuse suppuration from the wound, these symptoms gradually subside if the outpoured pus con- tains but few of the products of putrefaction (laudable pus of the ancients). On the third or fourth day the discharge of pus is well established, granulations spring up, and the wound is said to " clean off." At the end of about a week the temperature falls to normal, the tongue clears, moisture replaces the un- natural dryness of the skin, and convalescence is established. Subjective Symptoms. — In estabhshing the diagnosis in any given case too much reliance should not be placed on the patient's history as given by himself. In fact, the more the surgeon relies on the objective symptoms to the exclusion of the subjective ones, the less frequently will he be in error. This arises from the fact that patients are apt to exaggerate the importance of some symptoms and to belittle others, if not to conceal them altogether, as in affections of venereal origin. At the same time we cannot entirely ignore the patient's statements, unless there is good reason to believe that he is a malin- gerer. If the case in hand is of traumatic origin, an account of the manner in which the injury was received Avill ahvays be in order. Long voluntary state- ments should even here be discouraged as far as possible, and this portion of the examination should take the form of question and answer. Under other cir- cumstances, where the case is of a more chronic character, only the bare state- ment from the patient as to the part affected should be received, after which the examination should be categorical and physical. The form of the inc{uiry should be based on what the surgeon sees or feels when the affected part is presented to him. In general the age, occupation, and condition in life, whether married or single, are useful points A^Tith which to commence. Then follows an inquiry as to the time at which the patient first noticed the impair- ment of health. After this the s}'mptom or group of symptoms which first attracted the patient's attention is inquired into. Then comes the question as to the persistence or abatement of the symptoms and the occurrence of new ones. The patient should thus be carried through the course of the disease until the present time is reached. A series of short and sharp inquiries, made somewhat after the manner of an examining attorney addressing a witness, without waste of words or time, and directly to the point, may throw con- siderable light on the case. Under no circumstances should the patient 38 INFLAMMATION be permitted to go into long and tedious details, and when disposed to do so he must be brought back to the proper point in the examination by a well- directed question. The main points bearing on the case must be borne in mind, the patient being permitted to volunteer but very little, and the surgeon ask- ing as few questions as possible. The tact and knowledge necessary to carry on an examination of this kind can be obtained only at the patient's bedside or in the clinic. Fixed niles, though they are of great service, cannot be made for application to all cases. The beginner will be compelled rapidly to nm over in his mind what the condition before him may he, and, having grouped together all points, he will proceed to determine what it is. Knowledge of all the branches of medical science is of use to the surgical practitioner, and the information gained in the autopsy room is of the greatest possible value. In taking into account subjective symptoms, particularly that of pain, the surgeon will be careful not to give undue consideration to them. If careful examination does not reveal any good and sufficient reason for the exis- tence or the persistence of pain, the case should be carefully watched for objec- tive corroborative symptoms or for simulation. If the patient is a plaintiff- at-law, the surgeon will find it necessary to be more than ever on his guard. The same remarks apply to local points of tenderness. The surgeon should ahvays, in doubtful cases, after a patient has complained of a point of tender- ness, endeavor to verify or to disprove its existence by distracting his atten- tion from the point complained of, and then, without the patient's knowledge, applying as nearly as possible the same amount of pressure as before. Loss or impairment of function may be present as a subjective symp- tom, or its presence may be objectively demonstrated by special means adapted to that purpose, e. g., electricity, in loss of function of muscles. The loss will manifest itself in various ways, according to the part affected. A glandular structure may cease to furnish its normal secretion. An impairment of the special senses may also be properly included in the subjective symptoms. Finally, it should be borne in mind that but few diseases or inflammatory conditions have a mereh^ local importance. The local inflammation, for instance, may give rise to a general disturbance, as in traumatic fever, and vice versa, as in general tuberculosis. TERMINATION AND PROGNOSIS OF INFLAMMATION Inflammation may terminate (1) in resolution; (2) by healing and cicatri- zation; (3) in death. Termination by resolution takes place in the majority of cases of serous inflammation. The effused fluids undergo but slight changes, unless infection occurs, and are soon taken up by the lymphatics, the normal condition of the tissues being then restored, In cases in which healing by the formation of cicatricial tissue occurs, the course is that followed by all suppura- tive and some granulating forms of inflammation. In discussing the second manner of termination of inflammation it was formerly the custom to speak of it as terminating in suppuration. That this is illogical may be seen at a glance, because the suppuration does not terminate the process at all, but is simply an incident in its course. Both suppurative and gangrenous inflam- mation, after greater or lesser loss of tissue, proceed to cicatrization in a com- paratively short time. In cases of granulating inflammation, however, the TERMIXATIOX AXD PROGXOSIS OF IXFLAMMATIOX 39 repair proceeds much more slowly, and a tendency to recurrence is manifested. The granulating- tissue is dcstro}-ed as rapidly as formed under the influence of the pathosi-ciiic microoro-anisms. When healthy jjranulations form, cica- trization ma}' take place, the bacteria being prevented from coming in contact with sufficient pabulum on which to subsist, and licnce perishing. When caseation takes place, a healing reparati^'e process is impossil^le. It some- times happens that, within the area of a granulating inflammation, the organ- isms of suppuration penetrate, and an acute or a subacute suppurative process intervenes. The formation of pus leads to destruction of the diseased granulating tissue, the pus finds its way to the surface or is evacuated, and cicatrization occurs. The originally infecting pathogenic bacteria seem to be destroyed in the process. Whether lymphatic resorption of pus ever occurs, or granulating inflamma- tion undergoes repair without leaving cicatricial tissue behind, is uncertain. Death occurring from the direct effects of the presence of inflammation is of comparatively rare occurrence. AMien this does occur, it is usually the result of the sloughing away of the walls of a large vessel, death taking place from acute anemia (hemorrhage). But death occurs frequently from the more remote effects of inflammation, or from its indirect results. In the great majority of cases in which a fatal result follows, it is through the medium of an infection from the seat of inflammation, which occasions a disturbance of the entire organism. A familiar example of this general infection is found in traumatic fever. Although this is not particularly threatening to life, yet it may become so in cases in which the vital resistance is lowered by large loss of blood, pre-existing disease, or old age. When the reception of a wound gives rise to a fatal result, the immediate effects of the trauma being excluded, death is due to the supervention of one or the other of the wound sequels, or wound diseases. Granulating inflammation may prove fatal by infecting the entire body, as in miliary tuberculosis. Amyloid degeneration of the spleen, liver, kidneys, and blood-vessels of the intestinal canal may produce a fatal issue in a case of long-standing granulating inflammation of tuberculous origin. 'V\Tiile our best efforts are directed toward saving life, the restoration of the function of the part which is the seat of inflammation is also entitled to some considera- tion. This will depend to a certain extent on the part affected. W^hile mus- cular and glandular structures show, as far as their functions are concerned, but slight traces of inflammatory conditions, the same may not be said of the articulations. And these will, in turn, be profoundly disturbed in their func- tions according to the extent, duration, and character of the inflammation, as well as the particular joint attacked. SURGICAL FEVER In speaking of the participation of the entire organism in the inflammatory' process mention has been made of fever. This is the most important of the constitutional symptoms of inflammation. In the study of surgical fever it will be necessary, in order properly to appreciate all of its phenomena, to incpire into the physiologic regulation of the temperature of the body, and the principal factors concerned in this regulation. Of these the most important 40 INFLAMMATION are (1) the reception of oxygen b.y the blood-corpuscles, and the subsequent process of oxidation which takes place in the tissues and blood ; (2) the divi- sion of the appropriated nutrient materials into their final products of carbon dioxid, water, urates, urea, and the constituents of the bile; (3) the action of the muscles, when in a state of contraction as well as when at rest ; (4) the action of the glands, in which, during the process of secretion, heat is set free; (5)^ the action of the central nervous system. The most important ways by which heat is lost to the body are (1) through the skin ; (2) through the exhaled air; (3) by the secretions and excretions which leave the body, notably the sweat, urine, and feces. The blood is the balancing medium between production of heat and loss of heat. As the circulating fluid passes through the lungs it gives off a portion of its heat to the alveoli, and at the same time receives oxygen, which becomes a source of increased heat during the process of oxidation. Thence it passes through the systemic circulation, parting with a portion of its caloric in the capillaries of the skin, because of its proximity to the surrounding air. In the muscular system it is reinforced by the metamorphoses going on, only to part with the heat again at some other point. The blood therefore furnishes oxygen and nutrient material, the agents necessary for the active performance of the functions of the organs; and, in addition, it equalizes the warmth of the different organs, thus producing a uniform temperature. Inasmuch as the temperature of the surrounding atmosphere differs greatly under different circumstances, it becomes evident that a much greater loss from the body will take place at one time than at another. Though the temperature of the body will vary slightly under normal conditions, yet these variations are incompar- ably less than those which take place in its surroundings. It is therefore evi- dent that there must exist some means within the body itself of preventing at one time too great a production of heat, and at another too great a loss. In other words, there must be some physiologic processes instituted for the purpose of regulating the temperature of the body. The temperature of the body varies, within normal limits, between 98.3° F. and 99.2° F. Normal elevations of temperature are due to several circum- stances, such as the reception of food, movements of the body, and particu- larly vigorous and long-continued muscular exertion. To compensate for variations of temperature in the surrounding air, loss of heat by conduction and radiation is to a certain extent limited. Increase of the temperature in the surrounding air, which otherwise Avould lead to diminution of the loss of heat from the hving body, is balanced by a simultaneous dilatation of the arteries of the skin. This causes a much larger quantity of blood to flow to the surface and hence a larger quantity of caloric is parted with in a given time. The insensible perspiration, or transpiration, depending on increased flow of blood to the surface and an irritation of the sweat-glands, also tends to diminish the temperature by evaporation from the surface. Under certain conditions in which the atmosphere is charged with moisture accompanied by a high temperature (humidity) , greater suffering is experienced by the indi- vidual for the reason that the moisture from the surface of the body is pre- vented from evaporating; on the other hand, a dry hot air is easily borne. Under the influence of surrounding heat the body is rendered unfit for exertion for the reason that all unnecessary movements are restrained in the instinc- SURGICAL FEVER 41 ti\-e desire to prevent the production of more heat. When the surrounding air is cooler than the body, regulation of the temperature is accomplished by means of the contraction of the arterioles, whereby the amount of blood pass- ing through the capillaries of the skin is lessened, and the loss of heat decreased. The impulse to increased muscular exertion is felt which, by furnishing an increased amount of heat to compensate for that which is lost, o^'ercomes the sensation of cold experienced. Whether or not the lowering of the sur- rounding temperature leads to more rapid metamorphosis in the body when at rest, is an open question. Experiments on this point have given con- flicting results; on the one hand, careful observation seemed to show that, under the influence of a lower temperature, increased elimination of carbon dioxid took place, and at the same time an increased appropriation of oxygen, while seemingly eciually trustworthy experiments showed the reverse! As far as the increased elimination of carbon dioxid is concerned, a difficulty arises in that it is impossible to determine whether this is due to a more rapid metamorphosis and a consequent formation of this agent, or has its origin in a more rapid elimination of that which was already existing. Again, it has been shown that the quantity of carbon dioxid given off is not proportionate to the decrease of the surrounding temperature, and that the reception of oxygen and the elimination of carbon dioxid do not occur coincidentally with the rise and the fall of temperature. Liebermeister's observations in fever patients show that after cold baths there is a progressive fall in temperature for some time after the bath. The nerves of the skin play an important part in the regulation of the body-temperature. The irritation of the surface of the body "in consequence of changes of temperature external to the body induces reflex action along the paths of the vasomotor nerves. In addition, the existence of special heat- centers has been suggested, Avhich regulate the production of body-heat. Frac- tures of the middle and lower cervical vertebrae and contusions of the spinal cord in this region have been followed by rapid and extreme rise of tempera- ture. Experiments by N a u m y e r and Quincke on animals showed rapid rise of temperature after division of the spinal cord. This also follows separation of the medulla oblongata from the pons ^'arolii. I have seen it follow depressed fracture of the occipital bone with extensive laceration of the cerebellum. The latter observation suggests the presence of an inhibit- ing heat-center in the brain, while the former implies the presence in the cer- vical portion of the cord of inhibiting fibers from a center in the brain itself. E u 1 e n b u r g and B r o w n - S e q u a r d demonstrated on animals the fact that destruction of certain portions of the cortex cerebri resulted in a local rise of temperature, and, in addition, in a like effect on the muscles supplied from the centers destroyed. As the vasomotor ner^'es, both those which govern the constrictors and those which govern the dilators of the ves- sels, pursue almost the same course in the brain and spinal cord as the motor nerv^es, the effects obtained in these experiments, as well as in the case of contusions of the cord itself, may have been due to irritation or paralysis of these. A r o n s o h n and Sachs's (1884) experiments were instituted Anth the view of locating a heat-center near the corpus striatum. An increase of temi^erature followed the introduction of a needle at this point, in dogs and rabbits, but the same criticism will also apply to these experiments. 42 INFLAMMATION The existence, therefore, of either a heat-producing or an inhibitory center is not yet proved; according to our present knowledge, the vasomotor system of nerves alone serves to regulate the heat of the body. The febrile state is undoubtedly brought about by a disturbance of the balance existing bet^^'een the suppl}' and the loss of heat as it exists in the nor- mal condition. Whether a lessened loss, or an increased production, or both, constitute this disturbance, the effect is the same. An increase in the tempera- ture of the body, as a whole, occurs, and a condition of fever results. As to the first of these propositions, i. e., a lessened loss of heat, T r a u b e advanced the theory that a reflex spasm of the constrictor muscular apparatus of the superficial circulation resulting from vasomotor disturbances produced a dimi- nution of the amount of blood at this point, this necessarily leading to a diminished loss of heat from the skin, and causing the subjective sensation of chilliness and the objective rise in the temperature of the blood. C. H u e t e r ' s theory somewhat resembled this, except that the lat- ter attributed the narrowing of the lumina of the vessels to conditions existing in the blood, which lead to disturbances of function in circumscribed areas, the loss of heat in these being lessened, while in others an actual accumula- tion takes place. H u e t e r claimed that septic infection produced such changes in the blood itself that in these limited areas retardation or complete stasis took place, and that this was to be attributed to an adhesion of the white blood-corpuscles to the inner walls of the vessels, these blood-corpus- cles containing micrococci, which cause obstruction to the blood-current. Isolated and grouped micrococci likewise appear adherent to the walls of the vessels, obstructing the passage of the red blood-corpuscles. While it cannot be denied that in cases of pronounced or profound septic infection such conditions as H u e t e r describes may occur, yet it is scarcely probable that they are present in ordinary surgical fever. On the other hand, there would seem to be some foundation for T r a u b e ' s theory that accumulation of heat within the body, resulting from contrac- tion of the vessels of the skin, produces the general condition characteristic of the febrile state. For instance, during the stage of rigor, or even chill, the sensation of cold referred to the peripheral portions of the body is accompanied by a diminished loss of heat in the latter, and the objective symptom of rise of temperature. While this is apparently true of the initial stage of the febrile attack, it is likewise true that when the fever is once established the surface becomes actually hot, and gives rise to an increased elimination of heat. The thermometer placed in the axilla of a fever patient will rise more rapidly than one placed in the axilla of a healthy person. It should be borne in mind that, in surgical fever, at least in the majority of cases, the occurrence of an initial chill is either not marked or entirely wanting. L e y d e n has shown by calorimetric measurements carried on in patients suffering from remittent fever, that in the stage of fever there is actually a much larger amount of heat eliminated during the febrile stage than during the normal interval. These are confirmed by L i e b e r m e i s t e r ' s experiments, and by W a h 1 , Senator, and others. Neither T r a u b e ' s theory nor H u e t e r ' s modification is suf- ficient to account for the indubitable fact that in the febrile state there is an increased production of heat. That this results from an increased tissue SURGICAL FEVER 43 metamorphosis there can now be but httle doubt. L i c b e r m e i s t e r and Leyden lia\-c both shown that the ehmination of carbon dioxid with the exhaled air is much increased chiring the febrile state. The ciuan- tit>' inci'eases in direct proportion to the rise of temperature, but the increased elimination ceases or subsides more rapidly than the temperature. This is in part accounted for by the fact that the respirations become more shallow when the fever is at its height. In addition to this, it has been demonstrated that an increased amount of oxygen is consmned in the febrile state, and that consequently' an increased oxidation takes place. To this is to be attributed the presence of increased heat, Avhich raises the temperature of the body. Increased metaiiiorphosis in fever patients is hkewise shown by the greater quantity of urea eliminated, the increase of urea precechng the attack of fever. This would seem to suggest that decomposition of the albuminates takes place before the ele\'ation of temperature, and that this decompositiozi is not the result but rather the cause of the fever. Other constituents of the urine are likewise increased. How far the formation and secretion of water are increased or diminished in fever can scarcely be determined by experiment, from the fac't that water leaves the body through many channels. That which is separated by means of the kidneys is usually diminished, as well as that which is eliminated through the skin, as shown by the dry skin of fever patients. The amount of water eliminated by the lungs as well as the amount elimi- nated by the perspiration, particularly during the sweating state of the fever, is markedly increased, but this is compensated for by an increased production of water in the tissues. In the decomposition of nitrogenous as Avell as of nonnitrogenous substances water is formed by the addition of oxygen to the released hvdrogen. An augmentation of these processes during the febrile state would therefore lead to the greater production of water. This increased formation, however, does not apparently equal the demand on the part of the system for fluids to compensate for the loss occurring during the existence of the fever. Else how are we to account for the urgent thirst, the dry skin, the parched lips and tongue of fever patients ? Lavoi- sier's view that the oxygen combining with hydrogen is derived for the greater part from the carbohydrates of the fat explains the rapid disappear- ance of the latter during the febrile state or under circumstances involving the occurrence of profuse sweating. The relations existing between surgical fever and augmented meta- morphosis are important, and deserve special consideration. The connec- tion between the changes which occur in the wound and the patient's general condition is now well known. The most casual observer cannot fail to note that with the first occurrence of putrefaction in the wound, a rise of the gen- eral temperature takes place, and increases with the advance of an acute abscess, facts too well known to require more than casual mention here. These facts are suggestive of but one theory to account for their occurrence in connection with each other. The wound itself must contain the noxious agent which produces the rise of temperature, and this agent must be pyro- genic to the entire body. The question as to the character of the agents which serve as etiologic factors in the production of surgical fever has long been a troublesome one. 44 INFLAMMATION G a s p a r d in 1SS2, and subseqnently ]\f a g e n d i e , S e d i 1 1 o t , and others, demonstrated that injection of putrid material under the skin or into the veins of animals invariably produced fever. Endeavors to isolate an active principle of a chemic nature from the putrid material were only partially successful (Bergmann's sepsin). A fresh impulse was given to the investigation Avhen the role -which microorganisms play in the production of wound infection was properly understood and their presence demonstrated in the blood itself. The action of the bacteria on organic substances was already known. It remained only to appreciate at its true value the fact that the infectious agents or toxic principles, the so-called ptomains, depend on the vital processes of these microorganisms. Advanced methods in bacteriologic research and increased knowledge as to the pathogenic character of certain microorganisms have year by year con- firmed the opinion that the presence of bacteria in the tissues or the blood itself, or in both, produces not only inflammation but also fever. At the present day it is generally held that the rise of temperature following the inflic- tion of a wound depends on soluble poisons, the ptomains, which, acting as pyrogenic agents, exert a general influence on the body either through the nervous system or by way of the lymph-channels and blood-channels. These agents may exert their influence (I) by irritating the peripheral nerves, which in turn affect the central ner^'ous system by reflex action; (2) by being taken up through the last-mentioned channels, passing into the gen- eral circulation, and being transferred thence into the tissues of the body, where by their presence an increased metamorphosis is excited. It cannot be denied that such a thing as fever from reflex irritation may exist. Clinical observation supports this view. The condition kno^\-n as ure- thral fever has been so classed. Even in these cases it must be admitted that the microorganisms which invariably inhabit the meatus urinarius may have been of a septic nature and may have been carried b}^ the sterilized sound into the deeper parts of the urethra, there producing their appropriate phenomena. It is certain, however, that in the great majority of cases urethral fever can be prevented by the administration of a full dose of opium. It is also a clini- cal fact that the treatment of a stricture by gradual clilatation of the urethra will sometimes be followed by a chill subsequent to each introduction of the sound. But in the fever following wounds the course of the symptoms and the conditions present differ greatly from those mentioned above. In the case of wound fever the appearance of the fever is deferred for from twenty-four to forty-eight hours, while in the case of urethral fever the rise of temperature rap- idly follows the passage of the sound. This makes it very improbable that the two conditions originate in the same way. It has been suggested, however, that the toxic material develops earlier in one case than in the other, but that in both its influence is exerted reflexly through peripheral nerve irri- tation. Tetanus has been cited as a wound disease which has its origin in a peripheral nerve disturbance. However, in the light of modern research and the work of Nicolaier, Kitasato, and others, tetanus has been sho^vn to be due to a specific ptomain, the result of bacterial infection. Likewise if the nerve-trunks of a limb are resected, reflex disturbances being thi;s rendered impossible, suppuration artificially produced in the part deprived of innervation still produces all the phenomena of fever. On the other hand, SURGICAL FEVER 45 the injection of putrid material into the veins is invariably followed b}' similar febrile symptoms. There can be no question but that the central nervous system is more or less disturbed in the febrile condition. This is evinced by the muscular trem- bling that occurs during a chill, and by the convulsive attack which is so fre- quently the precursor of a febrile attack in children. The cerebral disturbance, the psychic irritation, and the excessive sensibility are all the consequences of the introduction into the blood of the p^rogenic agent. That the vasomotor nerves participate more or less in this general disturbance is shown by the alternate flushing and pallor of the surface and the varying sensations of heat and cold. These latter symptoms, however, are rather a part of the general effects of the morbific agent and not a cause of the fever, since it has not yet been shown that the vasomotor disturbances result in an augmentation of tissue metamorphosis and increased heat-production. It has already been stated that the muscles and glands are the chief sources of heat in the normal condition. Increased irritation of these structures was thought to be the source of the increased heat of fever. B e c q u e r e 1 , H e 1 m h o 1 1 z , B e cl a r d , L u d w i g S p e i s s , H e i d e n h a i n , and K r n e r , ho'\\'ever, made a series of thermo-electric measu.rements in animals in which fever had been artificially produced, and demon- strated that even in inactive conditions of the muscles heat production is increased, as shown by an elevation of temperature in the adductor muscles and in the blood of the common iliac vein, as compared with that in the left heart. The same increased heat production is believed to take place in the glands. In the case of the muscles this is thought to be due to the so-called " insen- sible innervation" the result of the irritation, and in the case of the glands to the irritation of the ner^'es regulating secretion. Neither direct irritation of the nerve-centers nor vasomotor disturbances are sufficient to account for the increased metamorphosis occurring in fever. As to the direct influence of the pyrogenic agent on the blood and tissues, there is during a febrile attack an evident increase in the coloring- matter of the urine, due to the augmented decomposition of the red blood- corpuscles. This destruction occurs to a still greater extent in highly septic conditions, and constitutes the so-called hematogenous icterus. The diminu- tion of fibrin is likewise noticeable. Boeckmann demonstrated by actual count the relative diminution of the red blood-corpuscles during the fcA'er stage of an intermittent fever, as compared ^vith the number existing in the interval. Certainly no nerve interference can be said to be possible here. "VMiat occurs in the blood without nerve influence can occur in the tissues to which the. pyrogenic agent is conveyed by the circulation. The character of this agent, as well as that of the tissues with which it comes in contact, antU govern in great measure the extent of the effect produced, just as specific phenomena are observed to follow the introduction of such soluble poisons as strychnin, curare, and ergotin in the muscular apparatus, and mercury in the glandular structures. The presence, on the one hand, of a ptomain or amor- phous ferment in the blood and tissues, and, on the other, of the bacteria themselves, wiU determine the extent and character of the changes produced in the organism. As far as the bacteria themselves are concerned, these, cir- 46 INFLAMMATION dilating in the blood, may accumulate in certain places, notably in the larger glandular organs, such as the kidneys, spleen, and liver, and also in the medul- lary structures of bones. The free supply of blood to these structures carries the microorganisms there in great numbers, Avhere either the retardation of the blood-current or the presence of a terminal circulation causes their accu- mulation. Increased metamorphosis results from the irritation Avhich their presence excites, and this, in turn, increases the production of heat. This fact explains the rise of temperature observed by H e i d e n h a i n and K o r n e r in the common iliac vein. Finally, the increased production of heat due to the inflammation itself is not to he lost sight of, for although it cannot alone explain the whole phe- nomena of fever, as suggested by Z i m m e r m a n n and by most of the older writers, yet its co-operative influence is not to be denied. It is scarcely probable that the multiplication of cellular elements and the increased move- ments of the leukocytes can be accomplished without the production of increased heat. Experimental research and clinical observation, therefore, justif}^ the fol- lowing definition: Fever is an increased tissue metamorphosis, the essential result of the influence of pathogenic bacteria. This influence may be exerted directly by the presence of the jnicroorganisms themselves, or indirectly by the products of decomposition and the presence of ptomains. In addition, there are present irri- tations of the sensory and motor nerve-centers, particularly of the vasomotor nerves, the disturbances of which cause temporarily decreased elimination and increased irritability of the nerves of the vessels. The Respiration and Pulse in Fever.— As fever represents increased tissue metamorphosis, it follows that there will be an augmentation in the pro- duction of carbon dioxid and a demand on the part of the system for more oxygen. This can be supplied only by more rapid respirations and an accele- rated circulation. The necessity for the latter is still further increased by a diminution in the number of red blood-corpuscles, the oxygen-carriers of the blood. The production of an increased amount of heat also increases the num- ber of respirations, together with the pulse-rate, this increase occurring inde- pendently of tissue changes. Irritation from want of oxygen likewise disturbs the centers of respiration and circulation. While either the want of ox^-gen or the increased heat may in some cases act as direct irritating causes, in other instances the direct action of the pyrogenic agent may be the stimu- lant to the nerve-centers. This is probable from the fact that other abnor- mal qualities of the pulse, such as dicrotism, may occur in fever. This phenomenon results from a relaxation of the wall of the vessel and a conse- quent decrease in arterial tension. Sphygmographic tracings in connection with animals which had inhaled nitrite of- amyl, or had been injected wdth atropin, showed dicrotic tracings. It has also been claimed by some observers that almost every form of fever produces characteristic and peculiar changes in the pulse, those produced by traumatic fever differing from those produced by erysipelas, those produced by intermittent fever differing from those pro- duced by remittent fever, all these in turn differing from one another and from the pulse observed in the exanthemata. In simple traumatic fever pathologic changes in parenchymatous organs are scarcely ever observed. In the fever of wound diseases, however, they SURGICAL FEVER 47 do occur, and will bo described in that connection. It is sufficient to mention here that these changes may depend on the presence of heat. But this fact will not of itself suffice to explain these phenomena. It has been observed that special and peculiar degenerations follow the administration of specific poisons, as phosphorus and arsenic. In the same manner the specific action of certain pathogenic bacteria may produce characteristic and peculiar lesions. This has been demonstrated by experiments made by Koch, C . V o i t , and others. Animals whose secretions after several days of hunger remained unaffected, were subjected to artificial heat. The decomposition of albumin- ous elements was not thereby affected. Resorptive or Aseptic Fever. — Traumatic or wound fever, as it is sometimes called, is caused, as has been shown, by a pyrogenic agent which has its origin in a wound whose secretions have undergone putrefaction and become putrid. This is to be distinguished from another form of fever pro- duced by the passage of dead tissue into the blood, the further destruction and oxidation of which occurs without the bacteria of putrefaction. This is known as aseptic fever, or the fever of resorption (Volkmann). It is anal- ogous to that which follows intravenous infusion of solution of sodium chlorid, transfusion of the blood of animals, and experimental fever resulting from intravenous injections of flour and water, etc. Like these, aseptic or resorptive fever is characterized by rapid onset and short duration, which distinguish it from wound fever proper. Volkmann pointed out the analogy existing between this fever and that which is observed to follow simple fractures, which results from resorption of effused blood in large quantities. The blood is overfilled with dead albuminous substances, originat- ing from the extravasated blood, its broken-down corpuscles and other detritus, and an increased process of oxidation is rendered necessary to dis- pose of it. The transformation of the albuminous substances which accumulate in the blood in aseptic fever is probably due to ferments already existing, and not introduced from without. Resorptive fevers and even death from exten- sive coagulation of blood in the vessels occurs after the injection into the veins of animals of Schmidt's fibrin ferment, a substance obtained from defibrinated blood itself. Some of the digestive ferments, such as pepsin and pancreatin, will likewise produce similar results. Whether the wound is acci- dental or operative, aseptic fever occurs when the blood escapes into the wound cavity, or when the particles of broken-dowTi tissue, with the effused blood, undergo resorption. It is claimed for these resorbed products that they are but slightly altered from their normal condition, not having undergone putre- factive or other changes, and that the fever resulting from their presence should not be confounded with febrile conditions associated with well-kno\Mi putre- factive changes and included under the general term of sepsis. The necrosis of tissue may be the result of the antiseptic agent employed as well as the result of the damage done to the tissues by the traumatism inflicted. Resorptive or aseptic fever may follow the injury within a few hours, and is usually of short duration, rarely lasting beyond the third day. The tempera- ture may rise from one to three degrees above the normal. This fever does not produce, as does septic fever, a profound impression on the sensorium, nor do the patients, as a rule, complain greatly of discomfort from its presence. 48 INFLAMMATION The appetite is not usually affected. These points, as well as the fact that it subsides at about the time when septic fever begins, distinguish it from the latter, into which, however, it may imperceptibly merge. It is questionable if the term "aseptic fever" is admissible as applied to this condition, for the reason that the changes described as occurring in the effused products of inflammation and the debris of the wounded surfaces, as compared with the changes of putrefaction, are differences of degree rather than of kind. TREATMENT OF INFLAMMATION The preventive treatment of suppurative inflammation consists in main- taining in an aseptic condition, as far as possible, the part injured or diseased. The curative treatment will include the employment of antiseptic measures. In the majority of accidentally inflicted wounds the germs of putrefaction gain admission to the effused kood and lymph, where, under the favorable influences of heat and moisture, and in the presence of a proper pabulum, thev proliferate. Under these circumstances a thorough disinfection of the parts will be necessary- in order to protect the patient from the effects of the noxious agents which have infected the wound. This process of disinfection consti- tutes the antiseptic treatment of wounds. Failure to establish or to maintain a rigidly aseptic condition in operation wounds may permit them to become infected to as dangerous an extent as those accidentally inflicted, and may require antiseptic measures in the after- treatment. Under some circumstances it may be difficult or impossible to accomplish even a relative asepsis. Probably such a thing as absolute asepsis is not attainable. On account of the minute character and general dissemina- tion of the germs of putrefaction it is beyond the possibilities of human skill and foresight to close effectually every channel to their entrance. But, fortu- nately, the serum of the blood is itself a germicide which will protect the tis- sues, and, unless too heavily invaded, will enable them to withstand the effects of lesser degrees of putrefaction and germ proliferation. Different tissues, as well as individuals as a whole, may possess varying powers of resistance, and the question of infection will depend on (1) a greater or lesser dosage; (2) the degree of local or general vital resistance. Finally, in some individuals, the victims of accidentally inflicted wounds or the subjects of cutting operations, the organism already contains noxious agents which may be transported to the wound and give rise to disturbances more or less pronounced, independent of local sources of infection. This, however, is comparatively rare. As a rule, the more rigid the enforcement of aseptic precautionary measures in operation wounds, on the one hand, and the earlier and more persistent the application of antiseptic measures in wounds that have become septic on the other, the better the results. Aseptic Operative Teclinic. — This consists in the employment of methods which will, as far as possible, sterilize the site of the wound and all articles which are likely to come in contact with it, together with the hands and person of the surgeon and his assistants. Experiments have sho^^TL that a large number of pathogenic bacteria have their habitat on the cutaneous sur- face of the body (C h e y n e). Others, which are less virulent, but which may become actively pathogenic under conditions of lessened local vital resistance. THE TREATMENT OF INFLAMMATION 49 such as Staphylococcus epidermidis albus (Welch), are also present, in addition to others that are positively harmless. Only criminal careless- ness will permit a surgeon to make an incision into integument which has not been deprived, as far as possible, of lurking sources of danger. No disinfec- tion or sterilization of instruments, care in the operative technic nor appli- cation of antiseptic dressings can compensate for failure in this respect. The Preparation of the Patient. — This consists in giving a general bath about twelve hours before the operation, and scrubbing that portion of the surface of the body in the neighborhood of the proposed operation which is likely to be exposed in the operating field, with a bristle hand-brush and strongly alkaline soap (sapo viridis of the Pharmacopoeia) and warm water. The parts are shaved, rinsed, and covered with a compress wetted Avith the borosalicylic solution of Thiersch (salicylic acid, 1 5 grains ; boric acid, 90 grains; water, a pint), covereci with oiled silk and bandaged carefully in place. The object of this application is the further separation of the dead epithelium; the power of salic3'lic acid in effecting this separation is well known. After the patient is anesthetized the compress is removed and the parts again washed with soap and water, a bunch of gauze being substituted for the brush. This second scrubbing is followed by rinsing with 95 per cent alcohol and then with ether, to remove the secretions of the glandular appa- ratus of the skin excited by the manipulation, which of themselves contain microorganisms. The skin is now freely moistened with a 1 : 2000 solution of sublimate in 50 per cent alcohol, which is allowed to dr}- on the surface. On parts already in an inflamed condition, and in connection with which it is difficult to employ the scrubbing process, solutions of carbolic acid, 2 to 3 per cent, because of their well-kno^^Ti power to penetrate through the epidermis into the cutis, may be applied, and the more vigorous cleansing measures postponed until the patient is anesthetized. The mouth, pharyngeal cavity, female genitals, rectum, and bladder require special care in the preparation. The mouth and pharyngeal cavities are cleansed for a day or two before the operation b}- frequent rinsings and garglings with a 1 per cent solution of chlorate of potassium or a wdne-colored solution of permanganate of potassium. The teeth are to be brushed vigorously with a stiff toothbrush and all tartar removed. I'lceration and suppurative conditions are to be allowed to heal, if possible. Carious teeth should be removed. The vagina should be douched for a day or two before the operation ^^ith a warm borosalicylic solution, or a 2 per cent carbolic acid solution, and tamponed with iodoform gauze. Immediately before the operation it should be cleansed ^ith gauze and soapsuds, and afterward irrigated. If putrefy- ing processes are present (e. g., breaking doA\Ti carcinoma of the cervix), the diseased tissues are to be curetted away and the surface cauterized with the thermocauter)\ In operations in and about the rectum the patient should be restricted to a fluid diet and the bowels kept free by salines, aided by enemas of glycerin and water, for a day or two beforehand. During the operation, after the lower bowel has been cleansed, the upper part of the rectum is tamponed with gauze. After the operation, unless some contrain- dications exist, bowel movements are to be prevented for several days or a week by the judicious use of opium. If cystitis is present, the bladder should be frequently irrigated with a 2 per cent solution of salicylic acid or the borosalicvlic solution of Thiersch (see above). 5 50 INFLAMMATION Provision against reinfection is made by covering the patient with a steril- ized sheet that has an opening admitting access to the field of operation, and, in addition, a number of sterilized towels are pinned carefully over the sheet. Unless the head is the part to be operated on, a towel should be placed upon it, turban fashion, to confine the hair. The Preparation of the Surgeon and His Assistants. — The outer street clothing of the surgeon and his assistants is removed, and a freshly laun- dered white linen suit substituted. After all other preparations are com- FiG. 5. — Schimmblbdsch's Sterilizer for Boiling Instruments in Soda Solution. pleted this is covered Avith a linen gown, steam-sterilized, the sleeves of which fit closely to the forearm and stop just below the elbow. The head is covered b}' a linen cap such as bakers wear, or an improvised turban made from a towel. No beard should be worn; at the most a mustache is permissible, and this is disinfected by a sublimate solution Fig. 6. — Scalpel Rack and Case. before each operation. The nostrils and mouth should be co\'ered with a mask of cheese-cloth to prevent the expulsion of infectious material in speaking, or accidentally coughing or sneezing. The hands, and particularly the sub- ungual spaces, are the constant habitat of pyogenic organisms and require special caie. The finger-nails should be kept closely trimmed. The hands must be scrubbed with a hand-brush and soap and running water for at least three minutes, particular attention being paid to the fmger-tips; the nail THE TREATMENT OF INFLAMMATION 51 spaces are finally rubbed with gauze moistened with a 1 : 2000 solution of sub- limate in 50 per cent alcohol and rinsed in a I: 2000 watery sublimate solution. They are then immersed in a 1: 2000 solution of sublimate to which has l)ecn added potassium i)ermano;anate to saturation, until they are deeply stained. The hands should not be scrubbed too vigorously, since the irritation thus pro- duced will lead to prompt reinfection of the surface from the passage of micro- organisms from the depths of the skin. This will be still further enhanced by slight abrasions. If the hands re- main stained with the perman- ganate sublimate solution, the surface is in a measure protected from reinfection from bacteria residing in the skin itself. After the operation is completed the stain is remo\'ed by immersing in a saturated solution of ox- alic acid. If the sapo viridis Fig. 7. — Arnold Steam Sterilizek. Fig. 8. — Hospital Steam-pressure Sterilizer, Instru- ment Boiler, and Water Sterilizer. of the German Pharmacopoeia is used, both before and after the operation, the hands will not suffer from eczematous eruptions. Or, the hands may be stained in a saturated solution of permanganate after they are scrubbed, and this removed at once by the oxalic acid solution (K e 1 1 y) . The oxalic acid itself is a potent factor in the sterilization. When the hands have been re- cently exposed to pus organisms, this course should be followed, and the hands restained in the permanganate sublimate solution above mentioned. Another 52 INFLAMMATION method is to Avash the hands with ether and alcohol after scrubbing, and to immerse them for five minutes in sublimate solution (F ii r b r i n g e r). Experiments have shown simple soap and water cleansing to be inefficient (Bole). The aseptic condition of the hands must be maintained during the operation by occasionally rinsing them, first in a watery sublimate solution, and then in alcohol. They are dried on a sterilized towel before being brought in contact with the wound. Disinfection of Instruments. — The simplest and at the same time the most trustworthy plan is to boU the instru- ments for five minutes in a 1 per cent so- lution of the alkaline carbonate of soda (sal. soda of commerce). They are after- ward placed in trays which have been boiled in the soda solu tion and filled with a cold boiled soda and carbolic acid solu- tion, 1 per cent, S c h i m m e 1 b u s c h (Fig. 5). In the absence of suitable trays the instruments maj^ be placed on steril- ized towels and covered with them. The latter method is preferred by many oper- ators. During the operation the instru- ments are rinsed, when soiled, in boiled water, or a 2 per cent carbolic solution. After use they are rinsed in the same solution, then in hot water, again boiled in the soda solution, scrubbed with soap and water, rinsed in hot water, and carefully dried. In order to withstand the damaging effects of this treat- ment the instruments should be made of metal throughout. After the other Pig. 9. — Small Steam-presscke Sterilizer AND Instrument Boiler. Fig. 10. — Wringer for Hot Towels, Gauze, Etc. instruments have been boiled the edged instruments should be placed in the boiler in racks (Fig. 6) to prevent their edges from becoming dulled by coming in contact with one another, and boiled for two minutes. THE TREATMENT OF INFLAMMATION 53 The Disinfection of Gowns, Sheets, Towels, Gauze, and Dressing Ma- terials.— This is best acconiphshcd by exposure to flowing steam, or steam \mder ten pounds pressure and upward, for forty-five minutes. A convenient apparatus for the former is the Arnold steam sterilizer (Fig. 7). In order to prevent the materials from becoming wet in the sterilizer by condensation of the steam thereon, they should be first warmed. For sterilizing on a large scale for hospital purposes the steam-pressure apparatus (Fig. 8) is to be used. A convenient coml)ination of steam-pressure sterilizer and instrument boiler for office use is shown in Fig. 9. For boiling instruments in soda solution and sterilizing gowns and dressing materials by steam at the same time the Fig. 11. — App\R«rs for Sterilizing Catgut by Boiling in Alcohol. A, fruit jar containing jelly jars filled with catgut; B, Dowd's condenser; C, water-bath; D, rubber corK connecting the jar with the condenser; E, tube extending from body of condenser through wluch the condensed vapSr of the alcohol flows back into the jar; F tubing connected with cold-water faucet O, outflow tube for water from the condenser; H, cotton-sealed receptacle for overflow of alcohol, 1, gas cork Sterilizer of S c h i m m e 1 b u s c h is convenient and efficient. Squares of gauze to be used in place of flat sponges in abdominal section, which require to be warm wdien brought in contact wdth the intestines, may be iDoiled in a 0.6 per cent solution of common salt (T a v e 1) and kept therein until read^' for use, when they are wrung out (Fig. 10). The Sterilization of Ligature and Suture Material.— This is of the first importance. Tn spite of the unfortunate experiences of ^' o 1 k m a n n , who observed cases of anthrax arising from infection of wounds by catgut, surgeons are loath to abandon catgut as a ligature material. It may be boiled in 95 per cent alcohol for an hour without impairing its strength, as I have 54 INFLAMMATION heretofore shown,* and h\boratory experiments made for me by Dr. H o d e n p y 1 prove that gut thus prepared is sterile even after previous infection with anthrax. Since the temperature reached by boihng alcohol (185° F.) can scarcely be deemed sufficient to effect sterilization alone, particu- ^^^^^^^^^^^^^^^^^ IH ■ ^^Mm |JH ■ H P ^fl ll ii Fig. 12. — Hermetically Sealed Bent Glass Tube Containing Sterilized Catgut. Fig. 13. — Breaking the Tube. larly when the catgut has been previously infected by anthrax, it must be assumed that in the method of boiling in alcohol the efficiency of the steriliza- tion must depend to a great extent on chemic processes occurring in connection with the heated alcohol. The use of catgut in my hands has been followed by the most satisfactory results in cases in which it has been buried in the tissues. It should never be used as a skin suture for the reason that it is almost impossible to disinfect the skin in its depths, and the catgut, though sterile, passing through this structure serves as a pabulum in the presence of which bacteria already pres- ent rapidly proliferate and produce irritation, and at times infection. An apparatus for ster- ilizing catgut by boiling in alcohol, which has the double advantage of safety and economy of alcohol, as originally suggested by me, has been devised by Dr. Dowd (Fig. 11). Cat- gut may be placed in bent glass tubes, which are filled with alcohol, hermetically sealed and exposed in an oven to a temperature of 185° F. (the boiling-point of alcohol) for an hour (Fig. 12). When required for use, the tube is simply broken (Fig. 13). Fractional steriliza- tion of catgut by means of dry heat in a hot- air sterilizer (Fig. 8) has been proposed. Slowly heating it to 140° C. and exposing it to this temperature for three hours is said to be efficient (R ever din, Boeck- mann). Another method consists in first immersing the gut in ether for * New York Medical Journal, Aug. 16, 1890. Fig. 14. — Removing the Catgut. THE TREATMENT OF IXFLAMMATIOX 00 two days (B r a t z) to remove the fat, and then in a 1:500 sokition of sublimate in alcohol for six hours, and thence transferring it to pure alcohol; or, after washing in ether for three or four consecutive days it may be permanently kept in a 1 : 500 ethereal solution of sublimate (S c h a p p s) . Alcohol 1000 parts, glycerin 100 parts, and sublunate 1 part, has been recom- mended as a preserA-ative medium (B r u n n e r). If stiff gut is desired, the glycerin is to be omitted (Bergmann). The iodin method consists in permanent immersion in a 0.33 per cent solution of iodin in alcohol. It is immersed one Aveek before using. Sterilization by means of combined heat and cumol (Johns Hopkins Hospital) requires a special apparatus, as well as some handling during the process. Kangaroo tendon and all other animal ligature material must be sterilized in the same manner as cat.gut. Silk, silkworm-gut, and like suture material may be conveniently sterilized by placing them in the steam chamber with the dressing materials, or preferably by boiling them for five minutes in a 0.6 per cent salt solution for each oper- ation (T a V e D . Dressing of the Wound. — Except for the purpose of washing away blood- clot, irrigation of the wound will not be required in aseptic operations. The wound should be kept as dr\- as possible (Landerer). T^Tien neces- sary-, a solution of salt in sterilized water, one dram to the pint, is to be used. The necessity for drainage in an aseptic wound is exceptional. It may be required, however, where there are large dead spaces which cannot be obliterated by deep sutures or by the pressure of the dressings, or where extensive dissec- tion has been made. Generally speaking, with entire arrest of hemorrhage and careful removal of all blood-clot an aseptic wound may be closed completely. The dressing of an aseptic wound consists in covering it vi'th simple sterile gauze in sufficient quantities to protect it properly, ai^plying a tliick layer of steam-sterilized nonabsorbent cotton, and securing the whole in place by a method of bandaging adapted to the part operated on. As rapid evapor- ation of wound secretions plays an important part in preventing putrefactive changes in aseptic wounds, impermeable coverings are not only imnecessar}^ but mischievous. ^Miere means for steam sterilization are not at hand, the gauze may be boiled in the 0.6 per cent salt solution and "^-nmg out as dr\^ as possible before being applied, large Cjuantities being employed, and the cot- ton omitted. "^Mien it is necessary to pert'orm the operation in a private dwelling-house, additional precautions are to be taken, in order to prevent infection from the patient's surroundings. These consist in clearing all furniture from the room. removing aU hangings, window curtains, etc., and thoroughly wetting the car- pet several times in advance with a 1 : 1000 sublimate solution. Woodwork and walls are to be washed and disinfected -^ith the same solution. Perma- nent fixtures are to be covered T^-ith sheets ^Ttmg out of sublimate solution. Doors opening into closets are to be closed and sealed by plugging the cracks and keyholes with cotton. A reasonably trustworthy aseptic immediate emdronment may be impro- \ased in private dwelling-houses, and this in the main with the means ordi- narily at hand, with the addition of a supply of sublimate tablets. Freshly laundered sheets may be used to cover a well-scinibbed domestic table to be used as an operating table, fixed articles of furniture or those too hea^w to be 56 INFLAMMATION removed from the room, and the patient after the anesthetization and final preparation. The immediate field of operation may be surrounded by towels first boiled in saline solution and then wrung out of a sublimate solution. Washing soda from the household supply will serve to make the solution for boiling the instruments, and soap from the laundry will answer for cleansing the patient's skin and the hands of the operator and his assistants. Gauze for sponging and wound-dressing purposes may be sterilized by boiling for ten minutes in T a v e 1 ' s solution made with sufficient accuracy by dissolving a teaspoonful of table salt in a pint of Avater. Clean sheets arranged in Roman toga fashion may be substituted for operating gowns. Utensils selected from the kitchen outfit for boiling the instruments and gauze, a fire in the kitchen stove, and a plentiful sujoply of boiled water will serve for the rest. The Antiseptic Treatment of Wounds. — Every Avound that has been exposed to infection must be treated antiscptically. Wounds already infected must be protected against infection by an antiseptic regimen. In accident- ally inflicted wounds the parts must be cleansed, foreign bodies removed, and bruised tissue likely to die cut away. The surroundings are to be shaved, scrubbed, and disinfected precisely as if no infection had taken place. The wound itself is to be irrigated with a 1 : 2000 sublimate solution and closed, drainage being provided for. An alcohol sublimate solution consisting of mer- curic chlorid, 1 part, and 50 per cent alcohol, 2000 parts, may be used with advantage at the first two or three dressings in suppurating wounds, the cavity of the wound being packed with gauze wrung out of this solution. Drainage. — This may be provided for (1) by leaving the entire wound, or at least the most dependent part thereof, open; (2) by enlarging wounds too small to permit of drainage (compound fractures) ; (3) by making counter- openings at proper points; (4) b}'' securing primary drainage and secondary suture, i. e., placing sutures in position, leaving the wound open, and packing it with iodoform or other antiseptic gauze, and in the course of twenty-four or forty-eight hours drawing its edges together with the sutures already placed (K o c h e r) ; (5) by using drains, either capillary or tube. Capil- lary drains, consisting of wicking, plain or wrapped in gauze, perforated oiled silk, or rubber tissue, or narrow strips of gauze, will conduct away serum if the wound is a recent one. Narrow strips of oiled silk or rubber tissue will -also be of service, under the same circumstances. For tube drainage fenestrated rubber or annealed glass is generally used. When extra rigidity of the walls of a rubber drainage-tube is required, the latter may be immersed for five minutes or more, according to the size, in commercial sulfuric acid (Ja- varro). In order to avoid the necessity for the removal of tube drains it has been proposed to employ those made of bone and subsequently decalcified (N e u b e r) or those of the long hollow bones of fowls (Mace wen, Tren- delenburg). Tube drains should be prevented from slipping too far into the Avound by a safet\'-pin placed across them at their point of exit. What- ever material is employed for facilitating drainage from a AAOund should be removed and dispensed with as soon as possible. Its presence exerts an irri- tating influence and excites secretion from the wound surfaces. All drains before being introduced into the wound should be sterilized by boiling. Antiseptic Dressing. — The antiseptic dressing of a wound demands that absorbent material impregnated with an antiseptic agent, and hence capable THE TREATMENT OF INFLAMMATION 57 of (lisinfectins^ septic discharges, be a])j)licd. Sterilized p:;anze wrung out of sublimate solution \vill answer in many cases. b)doform gauze treated in the same manner is ^•ery useful. Where dermatitis results from contact of sub- limate or iodoform, and where the toxic properties of the latter are to be feared, gauze wrung out of a mixture of oxid of zinc in sterilized water is to be substi- tuted. In chronic suppurating cases (ischiorectal abscesses, etc.) iodoform gauze wrung out of alcohol is very efficient. Disarrangement of the dressings b}'' the restlessness of the patient should he provided against by the applica- tion of proper splints, adhesive plaster, starched crinoline, or plaster-of-Paris bandages, in addition to the ordinary bandages. These ser\-e also as impor- tant additional means of securing prompt healing in parts otherwise freely movable,, by insuring rest. Moderate compression to overcome muscular spasm is useful in all dressings, and the influence of position in securing comfort and facilitating drainage is to be borne in mind. The indications for redressing a wound, exclusive of those which arise from accidental displacement or soiling from without, are as follows: (1) the occurrence of pain due to tension from sw^elling or accumulation of wound secre- tions ; (2) the appearance of discharge on the surface or at the edges of the dress- ings ; (8) the necessity for removal of the drain ; (4) the removal of the sutures ; (5) the rise of temperature after the first twenty-four hours, showing the occur- rence of systemic infection from the \vound as a septic focus. In order to recog- nize promptly the last-named indication the temperature should be taken every four hours during the first few da3^s. On removing the dressings the condition of the wound and surrounding parts must be carefully investigated. Tension on sutures is to be relieved by removal of one or more of these. Pent-up discharges are to be furnished exit by separating the wound edges. Slough or clots are to be removed by the curet. Inflamed or phlegmonous conditions in the neighborhood are to be relieved by reopening the wound, and by incisions in addition, and they, as well as the original wound, are to be treated by sublimate irrigation and tamponed with iodoform gauze A^Tung out of alcohol or w-et sublimate gauze. Compresses of the latter are to be applied as dressings, and daily or twice daily reappli cations of these practised until the symptoms disappear. When a simple serous or serosanguinolent discharge appears and no other symptoms are present indicating removal of the dressings, this, if it dries rapidly, may be covered by another sterile or antiseptic dressing. The drainage-tube may be removed on the third day, unless some positive indication for its further use exists. If there is any doubt as to this, it may be shortened at each dressing. The occurrence of stitch abscesses in skin A^hich has been cleansed with the most scrupulous (^are is to be attributed to the presence of Staphylococcus epidermidis albus of W e 1 c h . This observer found that after sterihzation of the surface the presence of this coccus could still be demonstrated by making cultures from sutures passed through the skin, or from excised portions of the skin. While ordinarily innocuous, under the influence of lessened local vital resistance, such, for instance, as the strangulation of tissues and the resulting necrosis from the pressure of a stitch-loop, or the presence of foreign bodies in the wound, it may become the cause of disturbance manifested by local- ized suppuration and elevation of temperature. No time should be lost in relieving the pressure ; the sutures should be removed and the infected tissues 58 INFLAMMATION through which they pass curetted to remove all necrotic tissue, with a sinus curet (Fig. 15). Each suture track should then be disinfected and packed with antiseptic gauze. The time for the removal of the sutures will depend on the exigencies of the case. They should not be permitted to bury themselves in the skin, except under exceptional conditions. Where no tendency of the wound edges to gape is present, they may be removed early. On the contrary, wounds involving the abdominal wall will require a longer support. Under circumstances in which it has been necessary to remove sutures on account of septic conditions, as well as when it has been necessary to omit these from the commencement, with the subsidence of the local inflanmiation and in the presence of healthy granulations, attempts to close the wound and hasten the healing process may be made by the use of either adhesive plaster strapping or secondary sutures. Care should be taken to pre^'ent rolling in of the skin edges. Finally, in summing up the indications for redressing a wound emphasis is to be placed on the dictum that, in doubtful cases, it is better to dress the wound once too often than once too seldom, and then perhaps too late. On the other hand, the general principles of c^uiet and infrequent dressings are to be borne in mind. While a careful watch should be kept for indications for removing the dressings, meddlesome and unnecessary interference does harm. The act of dressing should be carefully performed and all precau- tions taken to prevent further infection. Too much sponging and Aviping and even forcible irrigation is mischievous. "WTiatever causes bleeding from the wound is to be avoided. Losses of substance or severely contused conditions of the w^ound may lead to failure to approximate the wound edges. It should be tightly packed after being cleansed, if sepsis is suspected, or covered A\'ith simple sterile dressing if not. If an antiseptic condition is maintained, granulations gradually fill up the space. The discharge consists of plasma and a few migrating cells or leukocytes. The completion of the healing process is marked by the formation of a skin covering from the rete Malpighii at the margins. The occurrence of profuse granulations is to be met, if these are florid and due to the too rapid development of vessels, by the application of caustic substances, such as the nitrate of silver, or by removal by knife or scissors. If pale and flabby from an edematous condition, and particularly if a tubercu- lous infection is present, they must be curetted away, and stimulating and antituberculous remedies, such as combinations of naphthalin and iodoform, or Peruvian balsam, applied. In foul-smelling wounds with grayish, sloughy-looking surfaces the curet should be vigorously used, followed by the application of a 10 per cent solution of chlorid of zinc. This should be well rvibbed in and foUo^Aed by packing mth a stimulating antiseptic gauze (gauze treated AA'ith naphthalin and Peruvian balsam). The process of curetting and "scouring'" should be repeated, if necessary, at subsequent dressings. Fig. 15. Delatour's Sinus Curet. THE TREATMENT OF INFLAMMATION 59 7- lf\1 ^ One of the sequels of an infected wound is an opening or sinus leading from the surface to a suppurating cavity. The infected area is to be thoroughly curetted with the sinus curet (Fig. 15) and treated by stimulating and bactericidal agents, injected into its depths and incorporated in gauze and carried to the bottom of the sinus. Chlorid of zinc, followed by hydrogen peroxid, the latter principally for its mechanical cleansing properties, and, after irrigation, the introduction of Peruvian balsam incorporated in gauze fulfil the indications, as a rule. A persistently discharging sinus may be due either to the presence of necrosed bone or other foreign body or to septic conditions involving the walls. The former should be searched for and removed ; the latter should be met first by thorough curetting followed by injection of the sinus with a 95 per cent solution of car- bolic acid by means of a sinus syringe (Fig. 16). After the lapse of from one to two minutes the carbolic acid is dissolved and washed away with alcohol and the opening dressed with sterile gauze without drainage. Or, equal parts of carbolic acid and tincture of iodin may be injected and the parts dressed at once with sterile gauze. Antiseptic Agents. — Antibacterial or antiseptic agents are those drugs and appliances which either possess a de- structive (disinfectant, sterilizing) power or exert an inhibitory influence in their relation to microorganisms. Of the first of these, the most powerful is heat. This is applicable only to instmments, dressing materials, etc. Corrosive Sublimate (Mercuric Chlorid). — This bac- tericidal agent is most generally applicable to the require- ments of antisepsis in its relation to the body. The demon- stration of its bactericidal properties (K o c h) was soon followed by its introduction into surgical practice (S c h e d e ; Bergmann, 1878), and it almost completely replaced carbolic acid, which under the influence of Lister's teaching was theretofore the most universally employed an- tiseptic. It is usually emplo3^ed in solutions of from 1:1000 to 1 : 5000, though the weakest of these is irritating to the tissues in some situations (the eye and urethra). In joint cavities a 1:5000 solution is employed. The vaginal canal may be irrigated with a 1 : 3000 solution, and the uterine cavity as well, if proper provision for the return flow is made beforehand by thorough dilatation of the cervix. A solution not stronger than 1 : 20,000 is to be employed in the urethra in the beginning; as the sensitiveness lessens under frequent use and instrumentation, the strength may be increased. A sublimate solution is never to be employed in the mouth or rectmn for irrigating purposes on account of its toxic properties ; abdominal pain, tenesmus with bloody mucous stools, etc., follow. These symptoms may also occasionally follow absorption from wound surfaces, though they are rarely of so pronoimced a character. Such disagreeable symptoms as eczema, saliva- tion, and stomatitis may occur in sensitive individuals. These, as weH as the slight superficial necrosis which follows contact of the tissues ^dth the stronger (It Fig. 16.— Si nus Syringe. 60 INFLAMMATION solutions, may be prevented to a considerable extent b}' washing the latter a\\'ay subsequently with the sterilized normal salt solution. The presence of alka- line earths in common water interferes somewhat with the solubility of corro- sive sublimate, and for this reason the addition of some acid, such as tartaric, citric, or acetic acid, is useful. Ammonium chlorid (sal ammoniac) or sodhim chlorid (common cooking salt) will act as correctives in effecting the solution. In the case of any of these agents the amount employed should equal that of the mercuric chlorid. The beneficial results following the use of mercuric chlorid as a local application to infected wounds are greatly enhanced by the addition of alcohol to the solution (corrosive sublimate, 1 part, alcohol and water, of each 1000 parts). Experimental research confirms the results of clinical experience as to the value of mercuric chlorid and the other bactericidal agents in antiseptic wound treatment (H e n 1 e). Its availability, cheapness, and undoubted disinfectant properties have combined to render it the most popular agent of its class. Mercuric lodid. — This is a trustworthy antiseptic of the bactericidal closs, and is used more especially in operations on the eye. Its effects on polished instnunents are not so pronounced as those of corrosive sublimate. It is used in strengths varying from 1 : 4000 to 1 : 12,000. Its solubility in water should be aided by the addition of an equal portion of potassium iodid. The expense of its manufacture as compared with the expense of mercuric chlorid has been a bar to its universal employment. Carbolic Acid. — This is one of the inhibitory antiseptic agents, and is em- ployed in the strength of from 2.5 to 5 per cent. It possesses the property of decidedly penetrating the skin surface (Hueter), and for this reason, in connection vdth opium and sufficient glycerin to assure the solubility of the carbolic acid, is a useful application in inflammatory conditions of the sur- face, replacing the lead and opium wash of the older surgeons. To each pint of a 2.5 per cent solution one ounce of tincture of opium is added. It should be used with caution in young children and old persons. Its toxic properties are first manifested in connection with the kidneys, the urine becoming a dark olive-green or black. Nausea, vomiting, and a rapid and small pulse are the other symptoms, followed by coma and death. Carbolic acid may be found in the urine. It should not be used in cases in which chronic degenerative diseases of the kidneys exist. It is absorbed through both the lymph- channels and the blood-vessels; in the case of the skin it passes through the thin epidermis and into the vessels, hence its value in septic dermatitis and cellulitis. This also explains the fact that young children with very delicate epithelial covering, and old persons with atrophic skin are specially susceptible to its influence when it is used in this manner. The treatment of carbolic acid poisoning consists in suspending the use of the drug, stimulating with alcohol and camphor, the administration of 10- to 2d-gram doses of sulfate of soda (S o n n e n b u r g) if the urine remains dark colored, and the application of drv' cups in the renal region and intravenous saline infusion if suppression is threatened. Local troublesome eczema may follow its prolonged use as a wound dressing. Zinc Chlorid. — This is a very useful antiseptic, and Avas emijlo3'ed as early as 1866 (Campbell de Morgan) after operations for carci- noma. Later it was employed in the primar}^ treatment of compound frac- THIO TREATMENT OF INFLAMMATION 61 ture (L i s t c r , ^' o 1 k m a ii n), and as a })crmanent wound dressing (zinc chlorid lint and jute, 1^ a r d e 1 e b e n). It may be used in extremely septic Moiuids of long standing in a 10 per cent solution. In those in which less energetic measures are required, a 5 per cent solution will suffice. As a pernianont dressing it is irritating to the skin. Salicylic Acid. — This is one of the syntlictically produced antiseptics. It is used in strengths of from 1 :oO() to 1 : 100; its solution in water is aided by the addition of six times its weight of boric acid (Thiersch : sali- cylic acid 15, boric acid 90, water 500). It is nonpoisonous in these strengths, and is employed for irrigating purposes where sublimate solutions are unsafe. It is a useful application to the skin in preparing the latter for operation, because of the property which it possesses of separating dead epithelial scales from tlie surface. Iodoform. — The antiseptic properties of tliis agent are developed by the liberation of free iodin in the presence of the products of bacterial decomposi- tion (ptomains and toxalbumins) . When employed in cases in which sujopura- tion is not present it should be sterilized before being used. It is said to possess hemostatic properties. It is used principally in tuberculous disease, and as a mild inhibitor}^ agent to the growth of pyogenic organisms. A 10 per cent emulsion of iodoform in glycerin is used as an intraarticular and parenchyma- tous injection in tuberculous affections of bones and joints. It is slow in its action, owing to its insolubility. Its principal use is in the shape of iodoform gauze for tamponing cavities in the neighboi'hood of the rectum and -v'agina, particularly when free oozing of blood occurs from these, and as an antituber- culous application to the ^^■ound surfaces after resection and erasion of tuber- culous joints. Iodoform gauze is sometimes used to wall off septic intraperi- toneal areas from the remainder of the cavity of the abdomen, as in suppurative appendicitis. The toxic properties of iodoform are pronounced and the symp- toms of poisoning are of both a general and a local character. The former are the more important, and consist of headache, nausea, and vomiting; in more serious cases increased frecjuency of the pulse, rise of temperature, confusion of ideas, delirium, coma, and death follow. The symptoms and postmortem appearance resemble those of acute meningitis. Old persons and young chil- dren are peculiarly susceptible to its toxic influences. Withdrawal of the drug will usually arrest the early symptoms. The same general measures of treat- ment as in carbolic acid poisoning are used. The use of sodium chlorid in large quantities has been suggested as an antidote. Intravenous saline infusion should be emplo^'ed. Acetate of aluminum, a nonpoisonous agent, Is used as an astringent and mild antiseptic solution in certain phlegmonous affections requiring perma- nent immersion and irrigation. It is used in from 1 to 3 per cent solu- tions (B ii r o w). The following formula affords a ready means of making a 1 per cent B ii r o w ' s solution : Alumen 5 parts Plumbi acetas 25 parts Aqua 500 parts Creolin is used in the shape of a milky mixture with water in the propor- tion of from one to two parts in a hundred, as a substitute for carbolic acid. 62 IXFLAMMATIOX It is said to be nonpoisonous. Lysol belongs to the same class of coal-tar products as the last named, and is used in a similar manner. Thymol is ver}- insoluble, and does not find a wide range of usefulness. In the proportion of i : 1000 it is an agreeable addition to certain mouth-washes. It is nontoxic. Boric acid is the most frequently employed of the weak antiseptics. It is used principally for irrigating the bladder, cavity of the mouth, and rectum, and as an addition to solutions of salicylic acid (Thiersch's solu- tion). It is also extensively employed in the shape of boric acid ointment. In addition to the above, C[uite a large number of more or less useful anti- septic agents have been introduced, which may prove useful under special circumstances. Among these may be mentioned naphthalin, subnitrate of bismuth, oxid of zinc, hydronaphthol, aristol, dermatol, and subiodid of bismuth. Besides these, there are some which are supposed to exert a specific effect on the bacillus of tuberculosis, such as Peruvian balsam and cinnamic acid. The Selection of an Antiseptic. — No hard and fast rule can be laid do-^ai for the selection of an antiseptic for any particular case. It is far more impor- tant that the surgeon should be familiar with the uses of a few antiseptics than that he should attempt to limit with sharply defined lines the special uses of a large number. For the purpose of aseptic irrigation ordinary sterilized saline solution (0.6 per cent solution of sodium chlorid) is all that is needed. Solutions in varying strengths of sublimate, carbolic acid, zinc chlorid, salicylic acid, or boric acid are used in suppurating wounds and cavities. Iodoform is most advantageously employed in tuberculous cases, and Peruvian balsam and naphthalin in indolent granulating surfaces and sinuses. As for the rest, they are more or less useful when incorporated in hygroscopic cheese-cloth or gauze. Oxid of zinc and boric acid, alone or combined, are useful dusting-powders. Antiseptic Ointments. — These are but ver\' little used at the present day, except where sensitive areas about a wound are to be protected against irritating wound discharges or contact with antiseptic substances. Vaselin one part and paraffin two parts form the best base for an ointment. Salicylic ointment is made by adding one part of sahcylic acid to twenty-nine parts of the above base. Boric acid ointment is made by adding one part of the acid to ten parts of the same base. Salicylic cream is made by mixing one part of the acid to ten parts of glycerin. Carbolized oil in varying strengths (1:5; 1:10; 1:20) is likewise employed for the purpose mentioned, as well as for oiling the examining finger and instruments. Dressing Materials.— Cheese-cloth, butter-cloth, or absorbent gauze, introduced by Lister, is the standard dressing material. Any of the antiseptic substances may be incorporated in this. Except in cases of special susceptibility, the most generally useful antiseptic dressing material is gauze wrung out of a corrosive subhmate solution. In strictly aseptic operations steam-sterilized plain gauze suffices. The antiseptic gauzes furnished by the manvcfacturers should undergo a further process of sterilization in the steam sterilizer before being used. The sterilization of the manufacturer is not to be trusted; sufficient time usually elapses between the sterilization and the final use to permit reinfection. When practicable, heat should be used for the sterilization. THE TREATMENT OF INFLAMMATION 63 Iodoform gauze cannot be sterilized by heat owing to the decomposition of the iodoform. It should l>o A\runo- out of sublimate solution before being used. Peruvian balsam gauze is a useful means of conveying this medica- ment into sinuses, etc. Should a still greater stimulating effect be desired, naphthalin may be added to the balsam in the proportion of one dram to the ounce. The gauze is simply saturated with the balsam and the superfluous portion pressed out. It should be heat-sterilized before being used. In addition to gauze dressing materials, which are relatively expen- sive, cheaper dressings have been devised to serve in making up the bulk of large dressings. These consist of absorbent cotton (B r u n s ) ; jute (Mos'engeil); peat moss (Leisrink); peat (Neuber); forest moss (H a g e d o r n) ; sawdust (P i 1 c h e r) ; wood-wool and paper- wool (Fowler). These are made into cushions, and may be impreg- nated with antiseptic substances, but should be heat-sterilized before being used. Cotton batting furnishes a cheap and useful means for protecting dressings after they have been placed in position. In addition, it assists in the even distribution of pressure as applied by retentive bandages. It should be nonabsorbent for the reason that in this condition it is a more effectual bar- rier against microbic invasion, and it is to be heat-sterilized. The method of applying gauze dressings is as foUo^vs: A yard square of the material is applied in a cnmipled mass to the wound. This is repeated until several layers are placed in position, or the cushions of paper-wool may follow. Over the entire mass, particularly at the edges, is superimposed a thick layer of sterilized cotton wadding, the whole is secured in place ^\-ith turns of a roller bandage, the latter preferably of gauze also. Superficial wounds of the face may be treated without any dressing other than the apphcation of collodion mixed vdth iodoform, subnitrate of bismuth, oxid of zinc, or boric acid or salicylic acid. Any of these latter may be applied as a poAvder dressing to superficial granulating surfaces or excoriations. Local Antiphlogistic Measures.—There are certain local measures which, while in one sense acting to arrest septic symptoms, yet cannot be said to be directed against the cause of the inflammation in the sense of antisepsis. These symptomatic remedies are directed toward the arrest of spreading dermatitis and lymphangitis occurring in the neighborhood of infected wounds, which are not arrested by the remedies used in the wound itself or its im- mediate neighborhood. These consist of certain ointments and moist applica- tions. Zinc oxid ointment is most commonly employed. The ordinary mercurial ointment is sometimes used for this purpose. A 10 per cent mix- ture of ichthyol with lanolin is another useful remedy. The local use of ice is founded on rational therapeutic principles. It abstracts heat and locally diminishes the quantity of blood by contracting the vessels. It tends also to arrest the development of bacteria and lessens the pain, or abates it entirely. Its use, however, is restricted to ca.ses in which large dressings are not employed, as, for instance, inflamed joints. Here also its use islimited. In joints in which the capsule is superficial, such as the knee-joint, it is of great advantage, vrhile in the hip-joint it is entirely useless. The local abstraction of blood hi inflamed areas, formerly so much in vogue, is now substituted by position, particularly in the case of the extremities ; elevation of the inflamed parts answers all the requirements of local blood-letting. 64 INFLAMMATION So-called derivatives or measures of counter-irritation are used less fre- quently than in former times. Blistering and cauterization are still believed by many surgeons to be of service in chronically inflamed joints, particularly the knee-joint, when combined with fixation. Tenosynovitis and chronic inflammatory conditions else^vhere are ad- vantageously treated by massage. This consists of massage a friction (simple friction movements with the finger-tips), eflEieurage (rubbing with an ointment), petrissage (kneading with both hands at right angles with the long axis of the parts), and tapotement (beating the soft parts ^\-ith the ulnar margin of the hands or the closed fist). ]\Iassage is particularl}- useful in old cases of serous or serofibrinous inflammation and in cases of edematous swelhng and infiltration following such injuries as severe sprains, fractures, and dis- locations, and after the subsidence of suppurative inflammation. It is con- traindicated in acute inflammation, particularly where this disposes toward suppuration. It should not be employed in specific or granular inflammatory conditions, lest f\irther disseminations and propagation of pathologic ele- ments be favored by forcing these into neighboring lymph-channels. Steadily maintained equable pressure favors lymphatic resorption. The roller band- age is a most useful antiphlogistic measure. The elastic bandage of Martin or the material known as "stockinet" is a valuable means of accomplishing this pressure. Care is necessary in the application. The ease with which a very slight pressure will serve the purpose is quite surprising. Onh^ just enough pressure to hold the bandage in place is usually sufficient when the rubber bandage is employed. Elastic compression is employed with advan- tage as an adjunct method of treatment to massage. Warm baths are like- wise useful in the treatment of old inflammatory residua. These may be simply of v^ater of normal temperature, or certain medicaments and salts may be added to aid resorption. Some of the natural mineral s}orings, both thermal and salt, have a more or less well-founded reioutation in the treat- ment of this class of cases. Finally, certain local antibacterial meastires have, in recent years, been introduced for the specific local treatment of granulating inflammations. These will be considered under the head of the special diseases in which they are employed. The Constitutional Treatment of Inflammation. — AVhile the local treatment of inflammation demands our first and greatest care because of the now Avell-recognized causes of the processes which contribute largely if not ex- clusively toward bringing about the condition, yet the constitutional state should not be neglected. The local application of cold, while restricted in its use, serves at the same time as a general refrigerant measure. The application should be made as near the inflamed part as possible. Running water used at room-temioerattire, or cooled by the addition of ice, is the most useful. A convenient arrangement for the purpose is the ice-coil (Fig. 17). The administration of antipyretic drugs is to be discouraged, as far as possible, in the treatment of surgical infiammator}' fever. The use of cpinin, formerly so extensively employed, is now limited to tonic doses. The synthet- ically prepared coal-tar products used in general medicine are all more or less harmful in surgical practice, first, because they mask the real condition, and, second, because of their depressing influence. The specific or granulating THK TlfKAT.Ml'LN-r OF IXFI.A.MM Al'lOX 65 forms of indanimation arc not. as a rule, accompanied by very marked fel)rile disturbances, except possibly for a brief period at the commence- ment of the infective proc- ess. This is particularly true of syphilis. General mercurial treatment is in- dicated as soon as the diagnosis is established. No specific has been dis- covered for tuberculosis and leprosy analogous to that which we possess for syph- ilis. In the absence of this, e^'ery effort nmst be made to build up the tissues in a manner calculated to render the cellular elements resist- ant to the inroads of the specific bacillus on which the granulating inflamma- tion depends. For this purpose rich foods, strengthening wines, and, in the case of tuberculosis, residence in a favorable climate should be recommended. Fig. 17. — Ice-coil. SECTION II INJURIES AND DISEASES OF SEPARATE TISSUES THE SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE CONTUSIONS AND OTHER TRAUMATISMS Owing to the great elasticity of the skin, force appHed to its surface by a blunt instrument or object may produce a solution of continuity of the under- lying structures without producing separation of the skin itself. Crushing effects may also lead to rupture of vessels and extensive hemorrhage into the subcutaneous cellular tissue (hematoma) without apparent injury to the skin itself. The presence of long elastic fibers in the cutis and sulicutaneous con- nective tissue will reasonably account for this power of resistance to injury which the skin possesses. Ciaping of the wound when sharp-edged instruments are employed is also accounted for by this elastic property of the skin. The arrangement and extent of the fibers of the skin are not the same in all })ortions of the surface of the body. In the extremities they pursue a course almost parallel to the limb; on the trunk they are irregularly distributed as regards direction, ^\'hile about the palpebral fissure and margins of the oral opening they are disposed in a circular manner in accordance with the manner of disposition of the orbicular muscles. In fact, it is evident that the elastic fibers follow, to some extent, the direction of the muscular fibers of the part. The pectoralis major and latissimus dorsi show this plainly. The strictly longitudinal direction is not preserved in the case of the knee-joint and elbow-joint. Here the elastic fibers pass around the patella and olecranon in a concentric fashion. Gaping of Wounds. — The manner in which solutions of continuity in the surface of the skin will gape dejjends, therefore, on the location of the wound and the direction in which it divides these fibers. If it is on an extremity and passes at right angles to the direction of the elastic fibers, there will be the maximum amount of gaping; while if it passes in the same direction as the fibers^ the minimum amount will be produced ; in the latter instance but few fibers are severed , as compared with the former. The prox- imity of the wound to a gingh-moid joint ^vill likewise govern the amount of gaping. Tension on the convex side of the knee-joint or elbow-joint will tend to increase the separation of the wound edges. Wounds of the sole of the foot and palm of the hand are obser\'ed to gape but very slightly, for the reason that in these regions the fibrous structure of the connective tissue is so arranged as to form a dense attachment between the papillary body and the underlying aponeurotic structures. This will explain the difficulty which the surgeon experiences in turning back a flap in these localities as compared with one in other portions of the bodv. G6 SKIN AND SITRCITTANKOUS CONNECTIVP] TISSUE 67 The above considerations will enable^ the sui'geon to estimate in manv in- stances the amonnt of tension which it is necessary to make on the wound edges in order to bring about perfect approximation, as well as aid in the selection of a proper suture material. Abrasions of the Skin. — In abrasions of the skin involving but little more than the pai)illarv layer the reparative process takes place rapidly and patliologic inflammation does not occur. The injured layer of the rete Mal- pighii furnishes a few drops of blood and exudation, which, mingling together and undergoing coagulation, cling to the abraded surface. Evaporation of its watery elements leads to desiccation of the mass, and the typic crust or scab is formed. This serves as a means of protection to the underl}'ing wound surface, and its rapid change from a moist to a dry state keeps it from becom- ing a favorable pabulum for bacteria, so that suppuration is prevented. In this method of repair, called healing under a crust, there is complete deA-elopment of the epidermal layer beneath the incrustation, when the latter, left undisturbed, is permitted to fall off of itself. This healing is possible in a natural way only in case there is but a slight amount of primary wound secretions and in situations favorable to rapid desiccation. Attempts to imitate the formation of the crust by artificial means have been more or less successful in wounds extending into the subcutaneous cellular tissue and involving blood-vessels and lymph-channels. Thus, asepsis being assured, the wound has been hermetically sealed by means of collodion, with or -without the addition of iodoform (K ii s t e r), or some other antiseptic powder. The latter alone, provided it is sterile and the wound edges are brought into contact, is quite efficient. Tn fact, am^ occlusive method Avhich shuts out from the wound extraneous and irritating matters imitates the process of healing under the scab. Suppurative Inflammation of the Skin.— The skin may take on sup- purative inflammation from infection having its origin in a wound. This is superficial in character and comparatively harmless, involving only the rete Malpighii and the papillary body. Owing to the dense character of the parts involved, rapidly progressive suppuration is impossible. Suppurative Inflammation of the Subcutaneous Connective Tis= sue. — Here, without aseptic and antiseptic measures, phlegmonous conditions of a very severe character are easity produced. The arrangement of the elastic fibers in this situation, and the parallel direction of the lymph-current, form favorable conditions for the propagation of phlegmonous suppurative inflam- mation. It is not necessary, however, that phlegmonous inflammation of the subcutaneous connective tissue should have its origin in a Avound involving this structure. A microorganism of sufficient infecting power in the rete Mal- pighii, Avhich may have gained entrance therein by an almost microscopic breach of surface, may finally reach the subcutaneous connective tissue, where it propagates rapidly. So-called idiopathic phlegmonous inflammations are to he accoimted for in this manner. The more or less constant coexistence of lymphangitis with subcutaneous cellulitis renders it probable that the course of the infection is along the lymph-channels. The simultaneous in- volvement of the papillary layer and rete Malpighii with the subcutaneous connective tissue constitutes the condition known as erysipelatous cellulitis, or traumatic erj^sipelas. 68 INJURIES AND DISEASES OF SEPARATE TISSUES Losses of substance may occur in the skin in conseciuence of trauma, from sloughing as a result of the injur>', or in very high grades of phlegmo- nous inflammation. Destruction of the skin likewise follows as an effect of extreme heat and cold (burn and frost-bite) and as a result of ulceration. In the repair which takes place the first essential is the proliferation of healthy granulations. These subsequently, by a process of contraction, approximate to some extent the margins of the granulating surface, and in this way the defect is partially corrected by the neighboring structures. While under these cir- cumstances the displacement of neighboring tissues is of service in assisting to supply a defect caused by loss of substance, some very serious disadvantages ma}' subsequently follow, as Ave shall see further on. In addition to the attempt at closure of the defect by cicatricial shrinkage, the formation of an epider- mal layer is needed to complete the process of repair. This formation may take place rapidly or slowly, and the resulting epidermal formation may be a firm and solid layer, or may prove to be thin and defective, in which case further aid will be needed. This is furnished by either plastic procedures or skin transplantation (R e v e r d i n , Thiersch) (see page 328). THE CICATRIX AND ITS DISEASES Althougli the complete cicatrix is intended to serve the purposes of the normal structure which it replaces, it is never identical, either anatomically or functionally, with the normal structures. When recently formed, it may break down and take on inflammatory conditions, particularly if aseptic pre- cautions have been neglected during the healing process. Abscesses in scar tissue may result from the presence of foreign bodies, such as bone spiculae, or portions of ligature or suture material. Suppura- tion from the presence of infectious agents may occur in the newly formed tissue. Ulceration may result from mechanic causes, such as friction from the clothing. In the recent cicatrix this may heal readily, but, later on, when the rich blood-supply disappears, ulceratiA-e conditions heal but slowly. In addition, injury to the cicatrix may arise from its unyielding and inelastic character, solutions of continuity occurring more readily than in the soft and elastic normal structures. Pain from pressure on nerve-trunks may result from the pressure of dense and extensive scar tissue. This will be severe and persistent accord- ing as the nerve-trunk or its sheath is actually involved in the cicatrix, or as it results from simple pressure or tension consequent on the shrinking of the cicatrix. Cicatricial Keloid. — The causes of the degenerative changes in scar tissue, knoAATi as keloid, are obscure. Cicatricial keloid is characterized by increased vascularity of the scar, together with growth into the surrounding tissues, a tumor resulting A\-hich is verv hard and has a reddish color. Extirpation followed by primar\^ union, and even skin-grafting or transplantation, does not prevent recurrence. The disease, in this respect at least, resembles malignant dis- ease. Electrolysis (H a r d a w a y) and continued pressure b\' the elastic bandage (V e r n e u i 1) are recommended. Multiple scarifications made at intervals of a sixteenth of an inch from one another, crossed so as to form square or lozenge-shaped figures, deep enough to reach almost to the depth SKIX AXD SUBCUTANEOUS CONNECTIVE TISSUE 69 of the scrowth and long enough to reach just beyond its borders, should be tried, local anesthesia being enij)l()yed. The parts should be dressed at first with boric acid solution, and twice daily applications of mercurial plaster should be com- menced on the day following. The scarification is to be repeated until the growth disappears. Tlic application of the x-rays has been recently recom- mend(>d. Epithelioma of Cicatricial Tissue. — Recurrences in operation wounds following extirpation of malignant growths are not to be classed with the con- dition under consideration. True cicatricial carcinomas are to be divided primarily into two groups: (1) those having their origin in theretofore un- changed and typic cicatricial tissue; (2) those occurring in cicatricial tissue which has been the site of previously existing but benign ulcerative processes. The latter group includes the larger number of cases. The sites of old seton cicatrices, leg ulcers, bone fistulas and old urinary fistulas about the penis, scar tissue in the rectum and along the lower intestinal tract where chsenteric and old tuberculous and other ulcerative conditions have previously existed, and old parturient lacerations of the cervix uteri are favorite locations for the dis- ease. It may occur on the granulating surface of cicatricial tissue which has never been covered with normal epithelium. The disease develops, as a rule, where the greatest amount of tension exists in the scar, when efforts are made to reduce deformities due to the latter, and at the site of ulceration from injur}-. Applications to the latter of nitrate of silver or of other cauterizing agents may contribute toward the result. It inclines to spread on the sur- face, and rareh' passes into the depths of the tissues : when the latter condition occurs, an extremely malignant form of the disease is present. The treat- ment consists in early and radical extirpation. Amputation of an extremity offers a better prognosis than ablation of the ulcer and its surroundings. Primary- union should be obtained; existing defects should be corrected at once by accurate coaptation and plastic procediu'es when necessaiy. ULCERATION OF THE SKIN By ulceration is meant that process in which the tendenc}- to progressive suppurative destruction of tissue is greater than the tendency to granulation. The resulting condition is called an ulcer. Ulcers may be divided into three groups. The first includes those which arise from disturbances of the circu- lation. The second embraces those in which an ulcerative process is engrafted on a granular inflammation (syphilis, tulDerculosis, leprosy). The third is composed of cases in wliich an iflcerati^e condition supen-enes in certain neoplasms, notably those of a malignant character. In the first group the \'ascular error may be (1) a local anemia arismg from some intert'erence vrith the arterial current : (2) a local congestion due to intert'erence with the return circulation. A slight traumatism or an eczematous vesicle, through which irritating or putrefactive agents have entered, may give rise to an ulcer, repair or the formation of normal granulation tissue being rendered difficult by the disturbances of the circulation. Besides the ulcers which occur in conditions W enfeebled circulation and varices, varicose ulcers may arise from inflam- matory conditions involving the dilated veins themselves. Ulceration from Pressure ; Bedsores. — A necrosis of portions of tis- 70 INJURIES AND DISEASES OF SEPARATE TISSUES sue that have been exposed for a considerable time to pressure, occurring in those lying in bed, or in certain paralyses of cerebral or spinal origin in which the pressure is neither considerable nor prolonged, constitutes the classic type of ulcer known as bedsore or decubitus. The position of these bedsores will vary Avith the position of the patient. They are usually confined to the skin overlying projecting bony points. In the dorsal position the sacrum, coccyx, and tuber ischii are the most prominent points. The skin over the spines of the scapulae, the occiput, and, in the lateral position, the trochanter major and the malleoli may suffer. If the patient lies on the abdominal surface, bed- sores may appear on the anterior superior spinous processes of the ilium, chin, and forehead. Pressure of the bed-covering alone may produce bedsores, the extremity of the toes and the prepatellar regions suffering. Fever is a predisposing cause of bedsores; with the subsidence of the fever the ulcera- tion may take on a healthy action or heal entirely, only to recur upon relapse. The appearances present when a bedsore is about to occur are character- istic, consisting of a reddish discoloration of the skin at the point of pressure, followed by a bluish tint ^vhich afterward changes to browm or black. The resulting destructive process involves the entire thickness of the skin, and even the underlying structures to the bone. A suppurative and putrefac- tive process occurs coincidentally in some cases; in others, after a longer time more or less oval or round defects of tissue are produced, which, in some instances, are never restored, and in others occupy months in the healing process. The treatment of the class belonging to the first group of ulcers, arising from disturbances of the circulation (varicose ulcers), consists (1) in cor- recting as far as possible the disturbed conditions of the circulation on which the ulcer depends; (2) in affording even and firm support to the vessels of the part, in order to minimize as much as possible the tendency to stasis. Elevation of the limb, with the patient in the horizontal position, wheneA'er this is possible, is of material service in fulfilling the first indication, and systematic strapping and bandaging fulfil the second. In carrying out the latter, all antiseptic conditions should be complied with. Thorough shaving and scrubbing of the neighborhood, and irrigating with sublimate solution, should precede the application of the strapping. In case a hard elevated ridge circumscribes the ulcer, or a dense fibrous floor exists, it will be neces- sary first to incise these thoroughly in order that the vessels beyond and be- neath the area of the ulcer may be permitted to find their way into the latter and convey suitable nourishing material for the purpose of repair (L. A. S a y r e) . These incisions should be made about a quarter of an inch apart, in the direction of the long axis of the limb, and should penetrate well through the hard fibrous floor above mentioned. An anesthetic is not neces- sary, under ordinary circumstances, as the incisions can be rapidly made, and the parts, as a rule, are not very sensitive. Bleeding having ceased, whatever blood remains on the surrounding skin should be carefully wiped away by means of a bit of dry sterilized gauze, while any clots which cling to the edges of the incision or remain on the ulcerated surface should be left undisturbed. These blood-clots will form an arbor or trellis- work, through the medium of which the surrounding and underlying vessels, which now have access from the cut edges of the incisions, will penetrate and form new SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE 71 granulation niatprial. The circulation in the foot should be supported by either a snug flannel bandage or circular strips of adhesi\'e plaster, sys- teniaticalh' aj^plied. These may reach to ^\-ithin about two inches of the edge of the ulcer. The ulcer itself is to be strapped in so-called "basket strap- ping." This consists of strips of diachylon or resin plasters, cut in lengths about one inch less than will be sufficient to encompass the limb and not more than one inch A\ide. When practicable, it is better to cut the strips crosswise to the piece as it is furnished b}- the manufacturer. This facilitates their smooth application. Each strip, at the moment of application, is heated over the alcohol lamp. This sterilizes the surface which is to be applied to the ulcer, and at the same time increases its adhesiveness. The first strip is applied horizontally, and just overlaps the upper bound- ar}' of the flannel bandage; it encircles the limb. The next strip is placed verti- cally, or at right angles to the above, and is likewise placed at least two inches from the nearest border of the ulcer. The next strip is placed horizontally, and half overlaps the first. The next or fourth strip is placed verti- cally and half overlaps the second, or the vertical strip which has preceded it. The process is now continued in the same manner, alternate horizontal and vertical strips being applied until the entire surface of the ulcer is gradu- ally covered. (See Fig. 18.) The strapping is carried well Fig. is.— basket Strapping and Ulcer of the Leg. ab0\'e and bevond the mar- • ^ Bandage applied to foot and ankle; B basket strap- ping; O, portion oi ulcer remaining uncovered; D, incisions gmS of the ulcer. An antisep- through base and edges of ulcer. tic compress, made of crum- pled gauze and large enough to cover and overlap the plaster strapping, is now placed over the latter, and over all, including the flannel bandage of the foot, a roller bandage is firmly applied. Should no discharge or other evidences of dis- t'lrbances occur, the dressings should be allo^^■ed to remain for from ten to four- teen days; the patient, as a rule, is permitted to walk about. At the end of this time the bandage and plaster are to be slit up T^dth a pair of bandage scissors, care being taken in doing this to select a point suflficiently far from the site of the ulcer in order to avoid injuring this with the scissors. The bandages and plaster are now removed, the latter peeling off like the bark of a tree. Some tenacious secretion from the ulcerated surface will be found on the plaster, as well as on the neighboring skin. From the latter situa- tion it may be removed with a piece of sterilized gauze ; on no account should 72 INJURIES AND DISEASES OF SEPARATE TISSUES the gauze l^e permitted to come in contact with the nicer itself. In lieu thereof a gentle stream of a mild antiseptic solution (boric acid 1 : 1000) should be allowed to flow over the surface of the ulcer until it is thoroughly cleansed. A striking change will be found to have taken place in the ulcer. In place of the hard and elevated edge, A\hich will be found to have disappeared, there is a soft flattened margin, from which a white or pale l:)lue line of new epi- dermis is already forming. The hard and smooth floor Avill have given place to a bed of soft and healthy granulations. The incisions, where they cross the margins, gape widely and are filled with healthy granulations. The antiseptic solution is not to be dried from the surface of the granulation ; only the surrounding skin is to be dried. Precisely the same course is now fol- lowed as at first. It may happen that the first dressings will need replacing before the time specified above, owing to the occurrence of discharge through the bandage; it is rare, however, that a bandage cannot remain on at least a week. Two or three dressings, except in exceptionally large ulcers, usually suffice, when the epidermal layer is found to have completely co\'ered the granulating sur- face, and the cure is complete. The patient should thereafter, in order to escape relapse, wear a silk elastic stocking to support the circulation in the part, care being taken in the beginning to place a piece of soft linen or lint over the newly formed cicatrix in order that this may not become irritated and renewed ulceration occur. In case of the latter the skin-grafting method of R ever din or that of Thiersch should be employed. (Plastic operative procedures, skin transplantation, etc., will be described under the head of Operations on the Skin.) Although chronic ulcers of the extremity are far more amena]:)le to treatment now than formerly, there are still cases which are intractable, suggesting malignant disease. Still others extend deeply and involve the periosteum, necrosis resulting. In these cases, as well as in some instances which involve the entire circumference of the leg (cir- cular ulcer), other measures failing, the resort to amputation is justifiable. Treatment of Bedsores. — Early measures should be taken to prevent ulceration from pressure in the sick and disabled. This may be accomplished, in the majority of cases, by the judicious use of elastic cushions to distribute pressure, by occasional bathings with alcohol and water, and by the use of ring-shaped air or water cushions, when ulceration threatens or is in progress. An occasional change of position will likewise be useful. Allien ulceration occurs, this should be treated antiseptically, with 1 : 1000 sublimate solu- tion, after which the ulcerated surface should be powdered Avith naphthalin and iodoform in eriual proportions and dressed with antiseptic gauze. The resulting separation of sloughs may be hastened by the vigorous use of the curet. Health}- granulations follow as a result of this treatment, and, these once established, the use of iodoform gauze or Peruvian balsam and naph- thalin gauze as a dressing Avill result, in most cases, in final healing. Oc- casionally iodoform ointment or Peruvian balsam on gauze is found to be a useful dressing. \"arious astringents, such as nitrate of silver, chlorid of zinc, or preparations of lead, are also employed, as well as some of the mer- curial ointments, particularly a diluted ointment of the red oxid of mercury. An exceedingly valuable combination consists of 1 part of nitrate of silver, 5 parts of Peruvian balsam, and 20 parts of simple ointment. Sometimes SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE 73 considerable time may be sa^-ed by freslieniiig the edges of the ulcer, detach- ing the soft parts for some distance beyond the edges, and bringing the mar- gins in more or less close ajjproximation by silkworm-gut or silver wire sutures. After preliminary curetting and antiseptic treatment, filling the ulcer cavity with a blood-clot obtained by scarifying the granulations, and dressing by means of oiletl silk protective and antiseptic dressings (the so-called healing by organization of the clot, Schede), or sponge grafting, has proved of service. Finally, these ulcers, like those on the leg, may be treated by a circumscribing incision (Nussbaum), incision of the boundaries and floor, and by skin transplantation. EFFECTS OF HEAT AND COLD Certain physical and chemic disturbances occur alike as the result of ex- cessive heat and cold. The inflammatory conditions present are not essen- tial but accessory. These disturbances consist of changes in the skin and circulating channels, which vary according to the temperature and length of time of exposure of the part. Degree of Burns. — A momentary exposure to a temperature at or just below the boiling-point of water produces a simple paralysis of the con- strictor muscles of the smaller arteries, and a consequent overfilling of these. The increased quantity of blood which results from this occasions the red- ness observed under these circumstances; this is known as a burn of the first degree. Burns of the second degree are those in which blistering takes place, the j^arts being exposed for a greater length of time or to a higher temperature. Here there is an exudation of serous fluid into the tissues, and particularly into the rete Malpighii; portions of the epidermal la}-er are lifted up, constituting the covering of the blister. More lengthy exposure to the temperature of boiling water induces albuminous coagulation affecting the contents of the vessels, together with the serous fluid and albuminous substances of the tissues. Owing to this interference with the normal struc- ture, greater or lesser areas are deprived of nourishment, and hence necrosis of tissue constituting a burn of the third degree is the result. The dead tissue presents a '\\^hite appearance from coagulated albumin. In case of exposure to a stifl higher grade of heat, as, for instance, on the application of a glowing hot iron, the destro}'ed tissue may assume a blackish tint. Some authors make a fourth and even a fifth degree of burn. These are, however, simply the third degree exaggerated, and constitute charring either of the skin or of this and the muscular structures as well. Prognosis of Burns.— The involvement of large areas of the surface in burns of the second and third degree involves direct danger to life. Bums of the first degree in very young children ma}', even if of but limited extent, prove fatal. Still smaller areas of the second and third degree may also result fatally. Mere reddening of more than two-thirds of the body, or a burn of the first degree, in an adult may destroy life, while one-third of the surface burned to the second or third degree will almost inevitably- j^roduce death. Locality will to some extent govern the prognosis. A lesser area in the abdominal and thoracic regions is to be regarded more seriously than a larger extent of surface on the extremities. Death may result directly 74 INJURIES AND DISEASES OF SEPARATE TISSUES from shock. Overstimulation of the superficial sensory nerves may produce death by reflex cardiac paralysis (S o n n e n b u r g). After reaction, con- gestion of internal organs from vasomotor paresis may occur; it is probable, however, that excessi\'e destruction of the red blood-corpuscles and their conversion into small globules (M ax S c h u 1 1 z e) are more frecjuently the cause of blood-stasis in internal organs. The secondary dangers relate to prolonged suppuration, exhaustion, erysipelas, pyemia, septicemia, and tetanus. Perforating ulcer of the duodenum has been observed as a second- ary complication of burns. Edema of the glottis from scalds of the mouth is an occasional fatal complication. Excessive Cold, or Frost=bite. — When the temperature of the skin is con- siderably lowered, the constrictor muscular apparatus of the small arteries contracts. If this occurs suddenly, the blood is shut off from the respective areas of distribution, and a blanching of the surface is observed as a result of the local anemia. This is seen in the ear and nose when exposed to a low tem- perature. As a rule, however, this takes place slowly, and the flow of blood through the parts continues, though imperfectly. In affected regions re- mote from the center of circulation greater difficulty is experienced by the heart in forcing the blood into the larger veins, and hence in these parts (the hands and feet) the earliest and most destructive effects of frost-bite are ob- served. In the venous stasis which marks the first degree of frost-bite, the discoloration, unlike the redness in the first degree of bums and scalds, is of a bluish tint. This difference arises from the fact that, in the case of a burn, the redness is the result of an arterial flux, -while, on the other hand, the dis- coloration in the first degree of frost-bite results from venous stasis. The second degree of frost-bite is characterized by the formation of small vesicles. If the lowered temperature of the parts persists, the resulting stasis forces the blood-serum from the capillaries and smaller veins. This accumulates in the rete Malpighii, and, elevating here and there the horny layer of the epi- dermis, results in the formation of blisters. Unlike the vesicles resulting from bums, these are filled with straw-colored fluid or reddish liquid, due to the presence of red blood-corpuscles in greater or lesser number. In the third degree of frost-bite, like that of burn, more or less destruction of the skin by necrosis occurs. A persistent venous stasis is followed by gangrene, which differs in color from that following a burn. In the latter, the skin assumes a white appearance from albuminous coagulation, or a black hue from actual carbonization or charring. In the third degree of frost-bite the color of the necrotic portion is dark bro\^Ti. This arises from the fact that, owing to the venous stasis, a large amount of blood-pigment is i.mprisoned in the part as gangrene takes place. Later on, as putrefactive changes occur, this dark brown color deepens into black. Prognosis of Excessive Cold, or Frost-bite. — Excessive cold endangers life in proportion to the length of time of exposure and the extent of surface involved. Muscular rigidity alone ma}' produce death. The most important factor in producing immediate death, however, is the destructive changes which the blood-corpuscles undergo, exposed, as they are in venous stasis, for a long time to the effects of excessive cold. In consequence of these changes they lose their function as oxygen-bearers. It is probable also that when a large mass of blood-corpuscles thus altered is permitted to enter the general cir- SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE 75 dilation, the frozen part being too rapidly restored, the blood-corpuscles may accumulate in internal organs and exert a deleterious influence on the entire economy. This is a rational explanation of the fact that, in persons who have been exposed to excessive cold with resultant frost-bite, the frozen parts cannot be subjected to the action of heat without great risk, but must be treated rather by cold applications, such as friction with snow or ice-^\•ater in a cold room, the change to a warmer atmosphere being brought about gradually. Thus the whole mass of altered blood-corpuscles is not at once precipitated into the cir- culation, but rather admitted gradually. Inflammatory Conditions Following Burns and Frost=bite.— Burns of the first degree somewhat resemble in appearance an inflammation of the structures affected. But the differences become apparent when it is observed that the former disappear spontaneously after a very short time. In burns of the second and third degrees, however, opportunities are afforded for the entrance of microorganisms. In the former, if the vesicles are not disturbed healing may take place beneath the raised outer layer constituting the surface of the blister. Usually, however, these are ruptured, and more or less infec- tion takes place as a consequence, inflammatory complications following. In burns of the third degree the infection does not, as a rule, take place in the area of charred tissue, since here the usual and readiest channels of infection are closed, but from the margins of the burn, which, as a rule, are not carbon- ized, but the seat of a burn of the second degree. At this point a slowly pro- gressive suppurative inflammatory process goes on, the neighboring structures partaking of this to a greater or lesser extent; this is what is known as the suppuration of demarcation, and marks the site of the so-called line of de- marcation. By means of it the necrotic tissue is slowly lifted and separated from the living structures beneath. A phlegmonous inflammatory condition may replace the suppuration, in which case the line of demarcation is not formed at the site of the original injury, but an inflammatory necrosis may become associated with that arising from the burn; in this way larger areas of tissue become involved in the gangrenous process. With the early employment of antiseptic measures, however, the suppuration of demarcation is not always observed. The charred portion does not form a favorable soil for the develop- ment of bacteria, owing to the coagulation of its albuminous elements. If, therefore, the entrance of bacteria can be prevented at the margins, the entire separation of the necrotic portion may occur without any trace of suppuration. The white blood-corpuscles do not migrate ; new vessels are formed, and, the young vascular connective tissue crowding toward the necrotic tissue, an asep- tic granulation process takes the place of the suppuration of demarcation. Similarly, in the first degree of frost-bite true inflammatory conditions are not present. Even though increased heat is present as a result of reaction the arterial flux is soon replaced by the normal state. But the vesicles which form in frost-bite in the second degree may become the medium of infection and subsequent inflammation may occur, precisely as in burns, though not so readily nor to the same extent. The occurrence of chilblain or pernio, however, is common, particularly about the fingers or toes, as well as about the nose, ears, and lips. This is usually induced by the patient's coming too suddenly in contact with warm air after frost-bite, and is particularly liable to occur in children and feeble persons. 76 IXJUIUES AND DISEASES OF SEPARATE TISSUES Frost-bite of the third degree, however, offers the coiHlitions favoral^le to the rapid occurrence of infection, and hence of inflammation, rnhke a burn of the same degree, the tissues are filled with blood in a passive state, the albuminous elements are not coagulated, and the necrotic tissues offer the three cardinal conditions favorable to germ proliferation and putrefaction, namelv, warmth, moisture, and putrescible organic matter. The surrounding zone of venous stasis offers a fertile field for bacterial invasion and prolifera- tion, together with rapid death of the parts. These in their turn undergo putrefaction, and thus the progressive gangrene extends a considerable dis- tance beyond the apparent area originally involved in the frost-bite. Unless, therefore, an early antiseptic course is followed in the treatment, extensive and severe septic conditions may complicate the original frost-bite. Finally, a line of demarcation may occur here as in the gangrene following bums of the third degree, and the same process of elimination of the dead parts may take place. Bums of the second and third degrees involving movable parts are fre- quently followed by deformities resulting from subseciuent contraction and shortening of the cicatrix. These are particularly distressing when occurring in the facial region, wdiere they are greatly increased by the involvement of the platysma myoides, the anterior portion of the neck and the upper portion of the chest, and in the flexures of the joints. The Treatment of Burns and Frost=bite. — As far as the immediate treatment of bums and frost-bite is concemed, inasmuch as inflammatory conditions are not necessarily present, the employment of antiphlogistic agents is useless. The influx of blood to the parts in the burn soon disappears, and the coagulation and exudation are alone to be considered. In frost-bite, how- ever, the venous stasis is more permanent, and measures to support the venous circulation, if an extremity is affected, are indicated. In addition to this, chilblain or pernio, which may follow frost-bite of the first or second degree, is to be treated. This may amount to a chronic stasis, for which warm baths may be usefid to hasten the venous circulation. Again, friction with snow or ice-water will be found serviceable. Liniments containing oil of turpen- tin, diluted hydrochloric acid (4 : 100), or the applications of collodion are use- ful in this condition. A favorite stimulating application consists of tincture of cantharides one part, and soap liniment three parts (Wardrop). When itching or burning sensations are prominent symptoms, a 2.5 per cent solution of carbolic acid, to which is added tincture of opium in the proportion of an ounce to the pint, will i^rocure relief. In chronic cases in which the skin becomes thickened, equal parts of the tincture of iodin and glycerin may be employed. Oil of peppermint, pure or diluted with six times its bulk of glycerin, is also successfully used. In chronic cases, or those which have a persistent tendency to recurrence, the galvanic current has been advantage- ously employed. In the mild and superficial forms of ulceration which may follow chilblain, the employment of a carbolic acid or creosote ointment, or other combined antiseptic and stimulating application, \\\\\ be indicated. In cases of bums as well as in those of frost-bite, where the slightest vesi- cation occurs, the practitioner should bear in mind, as the first indication for treatment, the necessity for early aseptic and antiseptic measures. The ex- tent and severity of the resulting inflammatory complications will be in direct SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE 77 proportion to the amount of infection which occurs. Tlic old-fashioned methods designed to shut out tlic atmospheric air, such as dusting the parts with flour, or covering them witli ^-adding ^^•ith or without the employment of oil>- compounds, were useful in that they prevented to some extent bacterial infection and, by j^romoting rapid drying of the exudates, deprived the micro- organisms of material fa^'orable for their support and proliferation. The use of equal parts of lime-water and linseed oil (carron oil) also acted by affording protection. These may, however, be profitably replaced by antiseptic irriga- tion, followed by the application of antiseptic dressings, both to the vesicles which are still entire and to those which haxe been accidentally opened. Antiseptic powder dressings (iodoform, zinc oxid, bismuth subiodid, etc.) may be employed, with or without the addition of gauze material impregnated with the same. Supporting measures and remedies designed to relieve pain in se^'ere cases form necessary adjuncts to the treatment. In cases in which extensive and deep gangrenous areas are present, involv- ing, for instance, a considerable portion of a limb, removal by amputation will become necessar}\ The dissecting away of sloughs, in order to get rid of putrefying masses as rapidly as possible, is always indicated, and should be practised wherever feasible for this reason, as well as for the purpose of ob- taining access to the parts beneath for more thorough antisepsis. In making antiseptic applications to extensively denuded or large granulating surfaces the poisonous character of some of these agents should be borne in mind. When wet dressings are indicated the borosalicylic solution of T h i e r s c h (page 61) should be employed. For a dry dressing either salicylic gauze or oxid of zinc gauze is useful. With the clearing away of the vesicles and sloughs an ointment dressing best fulfils the indications. Boric acid ointment, or an ointment consisting of dried alum (50 parts to -150 parts of the vaselin and paraf- fin base, page 62), Peruvian balsam, ichthyol, and carbolic acid in proper proportion should be used. FURUNCLE, CARBUNCLE, ANTHRAX, AND GLANDERS Furuncle. — A furuncle or boil is a circumscribed inflammation of the skin, characterized by a typic course. It is caused by a coccus, probably Staphylococcus pyogenes aureus, which reaches the roots of the hair by pene- trating along the sheaths of the hair-follicles from the deep epidermal layer. Its appearance is, therefore, restricted to regions in which hair grows, and it attacks by preference those portions of the bod}' that are particularly ex- posed. Certain anatomic peculiarities will likewise predispose to the pro- duction of these cocci. In some indi^'iduals the openings of the sheaths of the hair-follicles are larger than in others, and in certain portions of the body the same difference exists. If the cocci do not penetrate be- yond the mouth of the follicle, only a pustule is formed. In the majority of cases, if they pass beyond the mouth of the foUicle, a true furuncle results. Inder these circumstances a violent inflammation follows, characterized by necrosis of the hair-follicle and the surrounding connective tissue. A cir- cumscribed red swelling of the skin appears, the center of which is occupied by the affected hair-follicle. A varying amount of necrosis follows, and con- stitutes what is known as the core. A furuncle may occasionahv invade the 78 INJURIES AND DISEASES OF SEPARATE TISSUES subcutaneous cellular tissue, in which case a phlegmonous inflammation may result. Carbuncle. — A carbuncle is a circumscribed inflammation of the skin occupying a larger area than the boil or funmcle, and results from the ex- tension of infection from one hair-follicle to a number of others in the neigh- borhood. Or it may, after commencing as a comparatively superficial in- flammation, extend to the subcutaneous connective tissue. It more com- monly attacks the thick skin at the back of the neck and in tlie upper dorsal region, in ^^'hich regions the hair-follicles are arranged in groups and their sheaths pass deeply into the subcutaneous connective tissue. The rigid connective-tissue fibers in these regions so interfere with the circulation on the access of inflammation that a venous stasis occurs. This gives to the swelling a bluish tint. The sloughing process begins in the subcutaneous connective tissue and extends thence to the surface, the latter breaking doAATi at several points at once and giving the mass a honeycombed appearance. The gluteal region may be attacked b}- carbuncle. Ilere the extension may be considerable in the fatty solid connective tissue of the part, and large fiat swellings may occupy comparatively large areas without producing a proportionate amount of elevation of the surface. Sloughy masses of con- nective tissue of considerable size are present in carbuncle in this region. In the cou.rse of diabetes mellitus carbuncles are liable to appear. A reasonable explanation for the frequent combination of diabetes and carbuncle has not as yet been found. Under these circumstances carbuncle not infrec[uently proves fatal. Carbuncle may likewise threaten life in compar- atively healthy persons who have no general disease. The prognosis is graver when it occurs in elderly people, and likewise when erysipelas or phlegmon arises as a complication. Death may occur from phlebitis and septic emboli (pyemia), or from exhaustion or septic pneumonia. Anthrax. — The occurrence of a carbuncular process about the lips, cheeks, and forearms or dorsum of the hands should at once excite suspicion of anthrax, a disease originating in oxen and sheep, and especially liable to occur in those handling the dried hides of these animals. This suspicion will be strengthened if the gangrenous process forms and spreads rai^idly. An examination of the affected tissue, if this disease is present, will reveal the presence of the anthrax bacillus (see page 30). Glanders. — This is a contagious disease occurring primarily in horses or in asses and mules. It is characterized in these animals by an ulceration of the mucous membrane of the nose, swelling of the submaxillarv glands, and suppurati^'e metastases in internal organs. It is capable of being trans- mitted to certain other of the lower animals, and to man as well. The in- fection usually takes place through some small abrasion, though this may occur through the hair-follicles. At the point of entrance of infection there appear small ulcers with sharp edges, which secrete a thin pus. These may be on any point of the skin usually exposed, or on the mucous mem- brane of the nose or on the conjunctiva. Extensive inflammation of the superficial structures first attacked, together with inflammation of the under- lying connective tissue, results. This inflammation may follow the course of the lymph-channels. Pustules or nodules appear, whicli break doAATi into ulceration and discharge pus; more or less extensive abscesses may follow, and SKIN AND SUBCUTANEOUS CONNl-XTIVE TISSUE 79 large vesicles coiuaiiiing- thick imicus-like pus may form. These vesicles and pustules, on discharging, break down w ith a tendency to phagedena, and are characteristic of the disease; they mark the occurrence of general infection. Similar lesions may occur in the respiratory passages, muscles, etc. l^ven the bones and joints may become iuA-olved. The specific microorganism (Bacillus mallei) somewhat reseml^les the Bacillus tuberculosis. It is some- times found in the blood, but oftener in the foci formed by the nodules. The Treatment of Furuncle, Carbuncle, Anthrax, and Glanders.— In tlie treatment of furuncle early and free incision is of the first importance. This permits antiseptic applications to the parts, particularly if followed at once by the use of the sharp spoon or curet in those cases in which necrosis has occurred. The application of a 5 per cent solution of carbolic acid or of a 1 : 1000 sublimate solution at once arrests the infection. Warm com- presses of either of these solutions, covered with either oiled silk or rubber tissue, are of service. If pointing has already occurred, free incision, followed by curetting and packing ^^dth gauze wet mth the subhmate solution, and covered with the wet compress and impermeable covering, is an admirable measure and calculated to afford immediate relief. In carbuncle a most vigorous course must be pursued from the ver}^ start in order to limit the infection and resulting slough as much as possible. A number of parallel incisions or free crucial incisions are to be made, or, better still, complete excision of the underlymg mass practised, the four cor- ners of the skm resulting from the crucial incision of the older authors being turned back in four flaps for this purpose (Riedel). By this means a dangerous inflammatory focus is removed, the local and general infection is arrested in its progress, and rapid healing follows. The resulting cavity is to be treated with pure carbohc acid, which, after the lapse of two minutes, is washed away with alcohol, and a packing or tampon of iodoform or sub- limate gauze apphed. A w^et compress of the latter, and a covermg of im- permeable material, as in the case of the furuncle, complete the dressing. A 50 per cent solution of zinc chlorid may be used in place of the carbolic acid, and gauze vrcung out of a 25 per cent solution of the latter in glycerm used as a dressing until the infection is arrested. Ordinary stimulating 'dress- ings T^nll then suffice. In carbuncles arising from anthrax infection the same vigorous meas- ures are employed. The thermocautery of Paquelin, how^ever, should be substituted for the carboUc acid or zinc chlorid application following either crucial incision or extirpation. A^ similar energetic procedure is indicated in glanders. The bacillus of this disease is readily killed by the application of heat, as well as by the sul^hmate solution. GRANULAR INFLAHHATION OF THE SKIN AND SUBCUTANEOUS CONNECinrE TISSUE Tuberculosis of the Skin.- This is by far the most common form of granular inflammation of the skin. It may appear in the form of (1) lupus; (2) tuberculous ulcer; (3) the so-called cadaver or anatomic tubercle. Lupus was formerly classed among the scrofulous diseases. In 1874 it 80 INJURIES AND DISEASES OF SEPARATE TISSUES was suggested that it was a local tuberculosis (Volkmann, Fried- lander). Soon after Koch's discovery of the Bacillus tuberculosis this microorganism was demonstrated in lupus. It is not always easy, however, to identify the microorganism. The disease attacks by preference young adults, though it may attack those in advanced years. It most frequently affects the skin of the face. Rarely it is found on the mucous membranes. Generally, when present on the latter structure, it advances from the direc- tion of the skin. Occasionally it is seen on the hand, forearm, arm, and breast. It may appear in more than one place in the same individual. The disease was formerly classed among the tumors, but its inflammatory character is manifest from the suppurative and ulcerative destruction of the granular masses. The tendency of the disease is to remain local; rarely, however, it may lead to general tuberculosis. The variety known as lupus vulgaris is most frequently seen on some portion of the nose or eyelids. The course of the inflammation is essentially chronic, making its fii'st appear- ance as brownish-red nodules which break down into ulceration and slowl}' coalesce. In the nose and eyelids the cartilages may become involved, and the nasal bony structure as well. As long as the skin structure alone is attacked there is a tendency on the part of the ulcerated surface to cicatrize, while at the same time in one or another direction fresh nodules make their appearance, which in their turn pass through the same processes. In this way a considerable area may become involved, in some portions showing the whitish scar tissue, in others the elevated nodules, while in others, again, an ulcerative destruction is in progress. The cicatrized surface is frequently covered with scales of thickened epidermis which repeatedly exfoliate. When the ulcerative process extends beyond the thickness of the skin and proceeds more rapidly than cicatrization, the disease is known as lupus exedens. In cases in which the granular proliferation is a marked feature, it is known as lupus hypertrophicus. The variety characterized by scaling of the epider- mal layer is known as lupus exfoliatus. All three varieties may be present in the same individual. The differential diagnosis of lupus and carcinoma of the skin is made by attention to the following points: (1) the peculiar condition of the ulcerated border and the nodules at and beyond this; (2) the tendency on the part of lupus to cicatrize in one portion, while fresh nodules break down in others, as compared, in carcinoma, with the progressive tendency to spread in all direc- tions. Some difficulty may arise in cases in which carcinoma develops at the site of an old lupus. This occurs rarely on the face, but may take place on the dorsum of the foot or hand. Lymphatic involvement may be present in either disease. Lupus exfoliatus may at first glance resemble a dry eczema, but it is to be differentiated from the latter by the fact that in lupus the scaly formation is formed on cicatricial tissue, while in eczema there is no cicatricial formation. The prognosis of lupus will depend on the extent of the surface in- volvement and the depth to which it penetrates. As before stated, it rarely gives rise to general tuberculosis, though this danger is not to be lost sight of. The functional prognosis, however, is important; extensive and extreme deformities may result from its presence, equaled only by the cicatricial shrink- ing resulting from burns. SKIX AND SUBCUTANEOUS CONNECTIVE TISSUE 81 The treatment of lupus, owing to the fact that the disease de]:)ends on a specific bacilhis, will be, as far as possible, in the line of radical measures to effect its complete destruction and removal. This is accomplished by means of the sharp spoon. The entire area involved is thoroughly scraped and stimulating applications employed in the after-treatment. A more satisfactory method, however, consists in total excision of the diseased area and the subse^iuent transplantation of strips of skin after the method of Thiersch (Senger). This, together with rhinoplastic and cheilo- plastic procedures, ^^ill be described in connection with special operative procedures. The use of the thermocautery and gah'anocautery has been advocated; the influence of heat, as in certain galvanocautery operations about the uterus (John Byrne), is believed to extend beyond the area of the part to which the cautery iron is actually applied, destro^-ing in the neighboring tissues the noxious agents which produce the disease. The use of the .r-ray, as well as of Finsen's light, has proved effective in lupus and in the superficial carcinoma for which it may be mistaken. These are like- wise recommended to prevent recurrence after radical operations for the cure of these conditions. Certain chemic corrosive substances, such as the zinc chlorid (10 to 20 per cent), may be useful in certain cases. Nitrate of silver is too superficial in its effects, and tincture of iodin, sometimes recommended, is applicable only to the most superficial varieties of the affection. The application of caustic alkalis, such as caustic potash, is to be deprecated for the reason that the resulting slough is moist in character, and hence forms a putrefying mass in which microorganisms proliferate and extend into the surrounding struc- tures, producing violent inflammation. The use of chlorid of zinc, carbolic acid, nitric acid, etc., by coagulating the albuminates, produces a dr\" eschar which is more easily maintained aseptic. This point may be borne in mind Adth advantage in the application of caustics in affections other than lupus. Tuberculous ulcer is the result of a breaking down of a tuberculous gumma. The latter affects primarily the subcutaneous connective tissue. The neck, chest, and extremities are favorite locations for its appearance. The gumma consists of a painless swelling of varying sizes, which pursues a chronic inflammatory course and shows constant tendency both to form granulation tissue and to break down easily into ulceration. The involve- ment of the integument gives this a bluish or a reddish tint just prior to ulceration. When this takes place, one or more small openings may lead down to the mass of granulation tissue beneath. The skin structure is loosened from the latter by a process of suppurative inflammation, and the ulcer pre- sents one or more openings in the skin, T\'ith overhanging, thin, livid edges. "\Mien these openings are enlarged, there may be seen througli them the irregiflar surface of the mass of granulation tissue beneath, presenting the classic picture of a tuberculous ulcer. This may occur at the site of a lym- phatic gland, in which case it is difficult to decide whether the gland or the skin and the underlying structure were the site of the primary' infection. The affection may be associated Avith tuberculosis elsewhere. The treatment consists in dissecting away the overh'ing skin, in curetting the granulation tissue, and in applying vigorously to the surface zinc chlorid in 10 per cent solution (L a n n e 1 o n g u e) . Camphorated naphthol (P e r r i e r) is 82 INJURIES AND DISEASES OF SEPARATE TISSUES strongly recommended as an antituberciilotic agent, as well as iodoform (Billroth, Mikulicz), and Peruvian balsam and cinnamic acid (L a n d e r e r). The so-called cadaver tubercle, or anatomic tubercle, is a granular inflammation occurring as a flattened nodule on the backs of the fingers and hands of anatomists and their assistants, and is now recognized as a distinctly tuberculous affection, though some doubt is still expressed as to its exclu- sive origin from tuberculous infection. Other agents, particularly ptomains, give rise to similar nodules. They resemble plaques of lupus hypertrophicus, and vary in size from a pea to an almond. They may occur in clusters or singly, and their favorite site is the dorsal surface of the metacarpopha- langeal joints. Erythematous patches and pustules may likewise appear. Though cadaver tubercle rarely becomes purulent, and scarcely ever gives rise to extensive inflammation of the connective tissue and of the lymph- channels and glands, yet the nodule should be thoroughly removed, either by excision or by application of the thermocautery. Syphilis of the Skin. — From -the viewpoint of the general surgeon, the two most important lesions of the skin occurring as the result of syphilis are (1) the syphihtic initial sclerosis ; (2) the syphilitic gumma of the sub- cutaneous connective tissue. The initial lesion of syphilis, as its name im- plies, is the first manifestation of the presence of the disease, as far as is at present knoAAOi. It occurs at the point where the infection makes its entrance, and occupies from ten to thirty days in its development after the date of infection. The sclerotic nodule, when first noticed, is usually about the size of a pea. The center of the infiltrated part breaks down into an ulcer, the edges of which, as well as the base, being formed of granulation material, retain their characteristic hardness. This constitutes the classic so-called Hunterian or hard chancre. It may happen that a soft chancre, or non- syphilitic venereal sore (chancroid), resulting from contact with indifferent or not necessarily specific organisms, may follow within a day or two after exposure, which, pursuing the course of such ulcer ujd to a certain point, may thereafter present the symptoms of genuine syphilitic chancre. Here the syphilitic local infection follows the usual course of incubation of from ten to thirty days, the indifferent or nonspecific infection producing its local effect at once. It may happen, on the other hand, that a primary sclerosis may occur, which never breaks down into ulceration, but, after running its course as a granulating infiltration, disappears. The location of the initial sclerosis varies, but, as a rule, it occurs on the genitals. Exceptionally, it has been found witliin the oral cavity, on the tonsils, and on the end of the nose. Nonvenereal syphilitic chancre may occur on the surgeon's fingers from abrasions arising from contact with the ulcerated initial sclerosis, or the lymph or blood of infected patients. The site of vaccination is likewise occasionally the seat of a syphilitic chancre, and the infection has been conveyed in ritualistic circumcision, .the source of the contagion here being mucous patches in the mouth of the operator, it being customary to place the infant's penis therein after the operation. Vaccino- syphilis can occur only when blood from a syphilitic subject is transmitted along with the vaccine virus. The gummas of the skin and subcutaneous connective tissue resemble SKIN AND SUBCUTANKOUS CONNECTIVE TISSUE 83 closely at first glance the initial infiltration at the point of infection. The latter, however, will be found to occupy the tissue of the skin almost exclusively, while the former may or may not invade the deeper structures. The gummas of the skin generally appear as a late manifestation of the disease. They may disappear by absorption without ulceration, or they may break down into ulceration, and by fusion with several in the immediate neighborhood form a spreading and creeping ulceration (serpiginous ulcer). The gummas extend- ing into the subcutaneous connective tissue or originating in it are liable to occur as large infiltrated areas, but undergo the same changes. Gummas of the skin and subcutaneous connective tissue affect particularly the forehead, neck, shoulders, and legs, named in the order of frequency of occurrence of the gummas. The treatment of a sore suspected to be the initial sclerosis of syphilis should be purely local. Under no circumstances should the practitioner be induced to treat constitutionally what may not prove to be a genuine syphilitic infection on the chance of its being such. By so doing he robs the patient of the only means of knowing whether or not he really has syphilis, b}^ pre- venting the occurrence of the secondary S3^philitic skin lesions, which are decisively diagnostic and final. The prevention of the occurrence of these does no real good, inasmuch as no harm can arise from their presence. Early excision has been practised with the vieAV of pre^^enting the constitutional de^-elopment of the disease, and some success has been claimed for this. In cases of supposed arrest of the disease by excision conclusive evidence that the disease ever existed is, of course, wanting. Then, too, the long delay in the appearance of the local lesion suggests that the primaiy sore is really only the local expression of a constitutional infection which has been undergoing a process of incubation in the interval. Such considerations have impaired the confidence of surgeons in primary excision of chancre for the prevention of syphilis. Therefore, in the treatment of chancre simple antiseptic dusting- powders, or some form of antiseptic dressing fulfil all the indications. Gummas of the skin and subcutaneous connective tissues occur among late lesions of the disease, and are to be treated on general antisyphilitic principles. In case ulceration takes place, excision or curetment is indicated, generally the latter. This is to be followed by the application of zinc chlorid in a 10 per cent solution, with after-dressings of sublimate moist gauze. Leprosy. — When Bacillus leprae invades the body, it manifests its pres- ence in a variety of ways. Early in the disease, months, and it is said years, sometimes elapse before the appearance of local manifestations. In the mean- while the patient suffers from general malaise, languor, chills, fever, and osteo- copic pains. The most prominent of the local symptoms are the lesions of the skin. These may be bullae, maculae, or tubercles. Based on these different manifestations, varieties of the disease have been described, such as tubercular, macular, etc. As all these lesions may, and usually do, appear in the same patient, there seems to be no good reason for making such distinctions. As a matter of fact, the first cutaneous manifestation of the disease is the appear- ance of bullae. As the deeper cutaneous structures become involved, maculae develop, of a red color at first (the lepra rubra of some authors), this fading later into a brownish hue. With the appearance of the maculae, symptoms of peripheral nervous disturbances show themselves, first, as hyperesthesia 84 INJURIES AND DISEASES OF SEPARATE TISSUES from irritation, and, second, as anesthesia from loss of function. As the disease advances, tubercles make their appearance on all parts of the body, most numer- ous, however, on the more exposed regions. These ma}' or ma}- not ulcerate, though they usually do. With the invasion of deeper structures, such as the sub- cutaneous cellular tissue, the muscles or bones, atrophy may take place, and, as the bones and joints are attacked, the fingers and toes drop off. Clreater mutilations may occur, even to the loss of hands and feet. In the skin of the face a peculiar hypertrophy with wrinkling takes place, gi^■ing rise to the peculiar facial appearance called leontiasis. These different lesions do not make their appearance in any regular order. They may exist together. The tubercles may predominate, in which case we have the so-called tubercular leprosy; or maculae and general anesthesia may be the characteristic features, in which case we have the anesthetic leprosy of some writers. It is evident that the disease is the same in all cases, and that the varieties which have been described depend really on the structure attacked by the bacillus, which is in every' case identical. This disease is not to be confounded with elephantiasis Arabum. The prognosis of leprosy is exceedingly grave. It is essentially an in- curable disease. The victim usually perishes of exhaustion, or of some second- ary wound disease, such as tetanus. There is a disease common to tropical climates called elephantiasis Ara= bum, or, from the frequency with which it is seen in the West Indies, Bar- badoes leg. It is not to be confounded with elephantiasis Graecorum, or leprosy, to which it is in no respect akin. It may attack any part of the body, but in the great majority of cases the lower extremities are the seat of the disease; next in frequency the genitalia, more especially the scrotum in the male and the labia majora in the female, are attacked. The disease is characterized by great hypertrophy of the skin and subcutaneous tissue. The sldn itself becomes fissured, roughened, and edematous, and hangs in enormous folds, giving to the limbs, when the disease occurs there, the ap- pearance of elephant legs. The hypertrophy is very great, so that a scrotum the seat of the disease has been known to weigh a hundred pounds. It com- mences like an erysipelatous inflammation, but constantly recurs, each attack leaving more and more thickening of the tissues. It is supposed to be due to obstruction of the lymphatics of the part, though the etiology of the disease is still obscure. In very numerous cases Filaria sanguinis hominis has been discovered in the blood, and to this parasite have been attributed the origin of the obstruction and the inflammatory lymphangitis which is uniformly present. Operative procedure offers the only hope of relief from the disease. When it occurs in the penis and scrotum, early amputation is largely successful. When the disease has appeared in an extremity, liga- tion of the femoral artery has been practised, with much less success, how- ever. The immediate result of the operation has been a prompt diminution of the size of the limb, but unfortunately improveinent has been but tem- porary. In early cases ligation of the external iliac artery gives better results (Hueter). Digital compression has been tried with some benefit, but early amputation offers the best hope of permanent reUef. INJURIES AND DISEASES OF BLOOD-VESSELS 85 INJURIES AND DISEASES OF BLOOD-VESSELS INJURIES OF ARTERIES In severe crush injuries to the limbs the vessels are ruptur(Ml or torn across, and in machinery accidents they are frequently twisted. Under these cir- cumstances the bleeding is comparatively slight. This is due to the fact that the internal and middle coats are more easily torn than the outer, and give wa}' first, thus occluding the lumen of the vessel. The occlusion results from the rolhng in of the middle coat or the retraction of it, and occurs in the fraction of a second. In case of a crush injury the adventitia or external coat is forced about the retracted ends of the middle coat; in case of a machinery accident, the member is usually forcibly twisted, and therefore torsion of the external coat still further supports the retracted ends of the internal and middle coats. Further, the elastic middle coat sends prolongations of its elastic fibers into the closely woven network of connective tissue which constitutes the external coat (B a 11 a n c e and Edmunds), so that a retraction of the middle coat involves some retraction of the external coat as well. The middle coat will likewise vary according to the age of the individual, and differences will be noticed in different portions of the same body ; consequently, the facihty with which the retracted middle coat closes the lumen of the vessel will vary. Contusion of the artery is sometimes occasioned by the striking and glancing off of a bullet or other missile. The artery, unless held firmly in position against a bony surface by overlying structures, will be pushed aside, though bruised by the contact. Under these circumstances the injury to tissue may be so great as to cause rupture of the vessel and so-called second- ary hemorrhage {vide infra). The catastrophe from this cause may be ex- pected in from eight to ten days after the injury. In other instances the supposed contusion turns out to be really a partial rupture of the artery, a portion of the intima giving way, this curling up and producing occlusion more or less permanent at this point. Gangrene of an extremity may occur as the result of complete or partial rupture or contusion. In case of partial rupture the thrombus which is formed is of irregular shape. This irregularity in shape leads to a further fibrinous deposit, and, as this occurs eventy and follows the shape of the original thrombus as a mold, it happens that the latter is continued almost indefinitely, in time occluding the entire trunk and its collateral branches. Thus the blood-supply of the part is cut off and more or less extensive gangrene results. Gunshot Injuries of Blood=vessels. — The proportion of injuries of large vessels, or those requiring the application of a ligature, to the total number of wounds received in battle, exclusive of those which prove immediately fatal from hemorrhage, is astonishingly small. This is the more surprising in view of the fact that, in the case of the old-fashioned unprotected spheric leaden missile, the smashing of bone, the splitting of the projectile into frag- ments, and the deformation of the bullet greatly contributed to increase the chances of injury of neighboring blood-vessels. The liability to the wound- ing of blood-vessels in this manner is lessened in the case of the modern high- 86 IXJURIES AND DISEASES OF SEPARATE TISSUES velocity and mantled projectile, the smaller size likewise contributing to the escape of the vessels. On the other hand, however, the high velocity, pointed form, and direct course of the projectile through the tissues increase the chances of direct injury to the vessels in its path. Death from external primar}^ hemorrhage is very rare; the same may be said of the necessity for immediate ligation of a large vessel. Recurrent and secondar}^ hemorrhages when caused by the modern projectiles are likewise uncommon, though the}' take place with sufficient frequency to keep the sur- geon alert as to the possil^ilities of their occurrence. Such injuries as con- tusions or lacerations without the invasion of the lumen of the vessel may occur, to be subsequently followed by ulceration in the case of the former, and b}' com- plete perforation in the case of the latter. The secondary' hemorrhage which results may occur in a few hours, or it may be postponed for from one to three weeks. It is most likely to occur in the presence of suppurative condi- tions; in fact, the latter are largely responsible at the present day for the occur- rence of secondary hemorrhage. On the other hand, even if aseptic healing takes place, various kinds of aneurisms may occur as a part of the after- history. Incised and punctured wounds of arteries have for their primary- symp- toms, except under the rare circumstances of a valvular opening in the OA^er- lying parts, active and idsible hemorrhage in an interrupted or per saltum stream varying in size and force according to the vessel involved and the size of the external Avound. The bright red color of the blood, as well as the jetting character of the stream, will serA'e to distinguish this from venous hemorrhage. In punctured wounds, in which the wound of the overlying parts is such as to produce a valvelike closure of the external opening, escape of the effused "blood is prevented, and this may collect around the injured arter\'. The pres- sure of the clot in case of small arteries causes spontaneous arrest of the hemor- rhage, but in large arteries a traumatic aneurism develops (see page 96). Lateral wounds of the arterial wall, as a rule, produce the most alarming hemorrhage. This is more particularly true when the wound is at right angles to the long axis of the A'essel. Here the elastic middle coat, the fibers of which have principally a longitudinal direction, retracts, and very active hemorrhage results from the wide gap in the vessel which this retraction produces. Complete transverse separation of an artery leads to a retraction of the ends thereof, on account of the marked elasticity of the middle coat, which produces a constant tension on the arterial tube, and a narrowing of the lumen, in addition, by the action of the constrictor muscular layer. The extent of the retraction will vary- according to the size of the vessel and the thickness of its middle coat. The arrest of hemorrhage, under these circum- stances, will be governed by these considerations, as well as by the character of the tissues AAithin which the vessel retracts. If these are large masses of muscular tissue, the spontaneous arrest will take place earlier, while if they are mostly masses of loose connective tissue, spontaneous arrest will be delayed. The retraction within large masses of muscular tissue tends to impede free escape of the blood, and, therefore, after the blood has left the vessel, coagula- tion is favored. When the hemorrhage takes place into loose connective- tissue planes, the accumulation of blood here will cause lateral pressure on the IXJURIES AXD DISKASKS OF BLOOD-VESSELS 87 tnmk of the divided vessel, and thus arrest ^vill be brought about. Finally, the failing power of the heart's action, \\hether from shock or from acute anemia, favors coagulation and lessens or arrests the hemorrhage. In the latter condition dea'tli may follow unless closure of the wound in the artery and infusion of saline solution are promptly performed. Spontaneous Arrest of Hemorrhage.— This, tho\igh it may appear to be complete, is not to be relied on as permanent. In the case of the large vessels, particularly in the course of a few hours, when the heart's action becomes more forcible, the obstructing coagula may be washed away by the increased flow of blood, and recurrent hemorrhage occur. The occurrence of secondary hemorrhage depends on septic inflamma- tory complications in wounds. Arteries which have been torn or laterally contused are particulariy liable to secondary- hemorrhage. Divided and ligated arteries are likewise hable to septic mvasion. and hence to the same compli- cations, though not in the same degree, as the foregoing. The damage done to contused and lacerated vessels is much greater than that which occurs after simple application of a ligature; hence, the local vital resistance is not lowered to the same extent in the latter case as in the former. Should the w^all of the vessel become so weakened as to be unable longer to resist the force of the arterial wave, it will give way under the pressure from within. Secondary hemorrhage occurs rarely before the fourth day and very seldom after the twelfth. ^Coincident ally \-ith the appearance of the process of repair as announced bv the presence of healthy granulations, the dangers from secon- darv hemorrhage disappear. As long as these granulations remain in a healthy condition, no further danger from this source is to be feared (see page 88). Subcutaneous Injury of Smaller Vessels.— Contusions produce more or less tearing of the smaller vessels, both arteries and veins, in the subcu- taneous connective tissue. As the blood escapes into the meshes of the latter, it coagulates and forms what is known as a hematoma. The more or less solid tumor thus formed will vary in size according to the extent of the extravasated blood. A familiar form oi hematoma is that found on the head of a new- bom child, in which, however, the blood usually remains fluid (cephalhema- toma) . A blow upon the head, causing rupture of the vessels of the scalp from impingement agamst the skull beneath, sometimes produces extensive hema- toma." The center of this is often found to be quite soft, partly because the connective-tissue fibers at this point tear, and partly because the central mass of the blood remams fluid. This, surrounded by the more solid and elevated margins, may give the impression of a depressed fracture of the skull, ^^^len the hemorrhage occurs hi otherwise healthy joints as the result of injun,', it is knov^-n as hemarthrosis. The swelling which follows a subcutaneous injur}' to the vessels slowly dis- appears, and coincidentally therewith there appears on the surface at first a blue or a bluish-red tint, followed later on by a greenish and a yellowish tint. The disappearance of the swelling is due to the resorption of the blood, and the discoloration is due to the coloring-matter of the latter. Avhich is set free by the destruction of the red blood-corpuscles in the extravasated blood preceding resorption. As time goes on, the discolored skhi resumes its normal appear- ance, the coloring-matter and serum being taken up by the lymph-channels. In the great majority of cases resorption of the extravasated blood takes 88 INJURIES AND DISEASES OF SEPARATE TISSUES place without leaving any trace of its presence. Occasionally, however, a con- nective-tissue proliferation surrounds the hematoma, and a cyst with serous contents is formed. In still rarer instances the so-called organization of the clot occurs, i. e., the surrounding connective tissue in its proliferation invades the clot, and repair takes place in this manner. As a rule, however, resorp- tion, and not cicatrization, constitutes the method of restoration. All hematomas, however, do not follow this favorable course. Bacterial infection, occurring either through the tightly stretched and poorty nourished skin, or along the sheaths of the hair-follicles, or having its origin in the blood itself, may produce a purulent condition of the mass. The suppuration may then assume a phlegmonous character, spreading into the surrounding connec- tive-tissue spaces and into the opened up lymph-channels, or may become localized and slowly point toward the adjacent surface, according to the more or less active infectious agency of the bacteria. In the treatment of hematoma two indications are present: (1) the pro- motion of al^sorption ; (2) the prevention of suppuration. The first is fulfilled by massage, which breaks up the clot and stimulates the absorbents. Thorough cleansing of the injured part and the application of an antiseptic moist dressing (sublimate, Thiersch's, or a carbolic solution) will meet the second indication. If suppuration has already occurred, or the ten- sion is considerable and massage too painful to be borne, free incision with antiseptic precautions must be made. The clot is to be turned out, the resulting cavity irrigated with sublimate solution, 1:2000, and subsequently packed with sterile gauze wet with hydrogen dioxid, the dressing being com- pleted by a wet sublimate compress. HEMORRHAGE This term is applied to an escape of blood from the vessels. It is more generally applied to an escape of blood to the surface or into a cavity of the body. The latter is known as concealed hemorrhage. The term extrava- sation or subcutaneous hemorrhage is employed to designate an escape of blood into the subcutaneous connective tissue. Hemorrhage may be divided into primary, recurrent, and secondary. The first immediately follows the reception of the wound. The second follows reaction from the shock or injury, and is due to the increased power of the circulation either displacing the coagula which have formed and which held the bleeding in check, or forcing the blood from wounds of the smaller vessels. Secondary hemorrhage may be due to a contusion or abrasion of the wall of the vessel which at first passed unrecognized, the wall subsequently giA^ing way. It may be due to an inefficiently applied ligature, or to a failure to apply a ligature to the distal end of a divided "vessel, w^hich on the establishment of the anastomotic circulation furnishes blood. Premature softening of an animal ligature may also give rise to secondary hemorrhage. Disease of the walls of the artery (page 93), septic processes (page 86), as well as cer- tain constitutional conditions, such as hematophilia, septicemia, pyemia, renal and hepatic disease, may give rise to secondary hemorrhage by inter- fering W'ith the plastic and proliferatiA^e changes necessary to the definite seal- ing of wounded vessels. IX.TT-RIES AND DISKASKS OF CLOOD-VESSELS 89 S}Tnptoms of Hemorrhage.— When death is threatened from hemor- rhage, the following ,s\inptom8, more or less pronounced, are present: (1) The external appearance of blood. This will vary according to the size of the injured vessel and the rapidity of the flow. It may be absent altogether, a sullieient quantity of blood escaping into one of the larger cavities to pro- duce syncope (concealed hemorrhage). (2) A peculiar hue of the surface. This is a combination of jjallor and lividity due to the fact that the flow of blood fi-om the vessel, ])articularly an arter}-, lessens the vis a tergo in the peripheral vessels, and a venous stasis is added to the otherwise pallid sur- face. (3) Coldness and a clammy condition of the surface. (4) Dilatation of the pupils and twitching movements of the eyeballs. (5) Sighing respirations and diaphragmatic breathing. (6) General restlessness, and the throwing about of the extremities, particularly the arms. (7) Involuntary evacuation of urine and feces. (S) Rapid and weak pulse. (9) Coma; more rarely con- vulsions. In addition to these, the patient complains of giddiness, oppression of breathing with occasional gasping efforts (air hunger), intense thirst, and disturbances of vision and hearing. Death may occur rapidly, or the lowering of the circulatory tension may give an opportunity for the formation of coagula at the point of injury; the bleechng may then cease. The patient rallies, but the increasing power of the heart's action forces away the clot from the interior of the injured vessel, and the patient relapses into his former condition. This may be repeated several times until fatal anemia of the important nerve-centers occurs. The rapidit}^ with which the symptoms of hemorrhage supervene varies in different individuals, and at different periods of hfe. A very small loss of blood ma}' produce fatal s}-ncope in weak or nervous individuals; on the other hand, robust or phlegmatic persons may suffer a considerable loss without showing pronounced symptoms. The more rapid the loss, the greater the danger. Women bear the loss of blood better than men. Children and aged people, as well as stout persons, do not bear the loss of blood at all well. Arterial hemorrhage produces greater depression than venous. If death does not occur, there is a reactionarj' stage. The occurrence of fever has been noted (hemorrhagic fever), but it is difficult to separate this from febrile disturbances due to septic changes. Convalescence is slow, and a condition of chronic anemia may last for a long time. (For treatment of hemorrhage, .see Operations on Blood-vessels, page 336.) LIGATION OF ARTERIES The most simple and trustworth>- method of closing an incised or punctured wound of an artery is by ligation. After ligation of an artery in con- tinuity certain changes take place in the neighboring circulatory appa- ratus. At the moment when the flow of blood in the tube is obstructed the current at once sets in the direction of the lateral branches which are given off nearest the seat of ligation, with an increased pressure. These lateral branches, in their turn, communicate with arteries given off from the arterial trunk beyond the place at which the ligature is applied, and thus the blood finally reaches its original destination, albeit by a more or less roundabout course. The completed circulation thus established is kno^Rii as the collateral cir- 90 INJURIES AND DISEASES OF SEPARATE TISSUES culation (Fig. 19). This anastomotic or collateral circulation is usually restored at once in every ligated artery, and makes for itself, according to the number of the collateral branches and the amount of the blood-pressure, more or less wide channels for carrying on the circulation. The combined area of the collateral branches equals that of the trunk which has been ligated, and the blood-supply normal to the part is finally furnished. The exception to the rule is found in cases in which diseased conditions of the arteries or infiltration of the surrounding tissues prevents a prompt enlargement of the anastomosing branches, and thus the blood-supply to the periphery is retarded or entirely prevented. Under these circumstances gangrene is the inevitable result. The Changes Which Occur in the Vessel. — When an artery with healthy walls is tightly con- stricted by a ligature secured by a knot, the two inner coats or tunics proper, the intima and media, give wa}^ and are separated by the pres- sure of the thread. The adventitia or external coat, however, remains intact, but is constricted in a narrow circle. The intima and media, mainly from their elasticity, retract or curl upon themselves as their division takes place, and, the longitudinal elastic tension on the arterial tube being relieved b}^ the division of the elastic middle coat, on which it depends, a separation of the divided ends occurs to a greater or lesser extent. The vessel just beyond the limit of the clot is constricted somewhat, this con- striction varying with the particular artery involved. The application of a ligature in such a man- ner as simpty to occlude, but not rupture any of the coats of an artery, two or more ligatures being placed side by side and tied by a so-called ''stay-knot" (see Fig. 128) for this purpose, has been proposed as a substitute for the ordinary method of ligation in which rupture of the two inner coatstakesplace(B a 1 1 a n c e and Edmunds). Changes Which the Blood Undergoes. — It was formerly supposed that the mere arrest of the blood at the point of ligation was sufficient to permit its coagulation, this arrest giving opportunity for the fibrinoplastin, or paraglobulin (Schmidt), and the fibrinogen to act on each other. Later researches, however, have shown that a third body of the nature of a ferment is needed. This has been shown to have its origin in the so-called "blood- plaques," the death and disintegration of which give rise to the ferment. The coats of the artery being ruptured, fibrin is first deposited on the damaged recurved tunics; the disintegration of the cell containing the fibrin ferment is thereby initiated. When the coats are uninjured, as may happen, either intentionally or otherwise, it has been asserted that clotting does not take place, particularly on the side above the ligature, nor where a collateral Fig. 19. — Schematic Representa- tion OF AN Artery Ligated IN Continuity. Showing the estabUshed col- lateral circulation and the forma- tion of the clot (after Hueter). INJURIES AND DISEASES OF BLOOD-VESSELS 91 branch of sullicient size exists (D e ii t and I) e 1 6 p i n c , Paul B r u n s). It has been maintained that the two opposing surfaces maybe made to cohere by nuiltiplication of tlie endothelial cells, without the formation of a clot (R i e - del). On the other hand, experiments made with reference to this point show that clotting always takes place, whether the tunics are ruptured or not, Furthermore, the presence of collateral branches of not inconsiderable size in the immediate neigh) )orhood does not interfere with the formation of a clot, the latter not infrecjueutly passing into these (B a 1 1 a n c e and Edmunds). The view that coagulation always takes place when the normal conditions of the vessel are interfered with sufficiently to prevent the blood-current from continuing its course through the same, even when the tunics are not ruptured, is probably the correct one (Michael Foster). Under these circum- stances a profound alteration in nutrition is established, the vasa vasorum become blocked, and a plastic effusion ensues as a result of the presence of the ligature, which acts as a foreign body. The effusion buries the loop of the ligature, this taking place sometimes as early as thirty hours after the operation. Simultaneously the opposed endothelial surfaces proliferate and adhesions form between them (B a 1 1 a n c e and E d m u n d s). The formation of the coagu- lum does not take place so rapidly with unruptured coats as with ruptured ones. This is due to the fact that the fibrin is not deposited until the occur- rence of the blocking of the vasa vasorum, the exudation of plasma, and the migration of the leukocytes. The coagulation, under conditions favoring its occurrence, may be initiated in an hour. It is not likely to be delayed beyond six hours. In small vessels the coagulation takes place up to the nearest collateral branch. In the large vessels this varies. The proximal clot is general^ the larger. Immediately above the ligature an apparent ampulla is formed (B r y a n t) . This enlargement in reality depends on a contraction of the vessel above the clot (W a r r e n) . The clot does not distend the vessel ; it fits the tube but loosely, and a space is frequently found between the clot and the surface of the tunica intima, though the clot is attached to the latter here and there. The Function of the Clot. — The clot takes no part in the process by means of which the obliteration of the vessel is produced. Its function seems to be threefold: (1) it acts as a cushion against which the impulse of the blood is received, and in this manner prevents any disturbance of the plastic pro- cesses which are in progress at the seat of the ligature; (2) it forms in this situation, as in other localities where processes of repair are going on, a trellis- work support to cell invasion, as the latter proliferates from side to side of the interior of the arterial tube; (3) it serves as nutriment for these cells. The Fate of the Ligature. — A ligature applied to a blood-vessel is always treated by the tissues as a foreign body and an attempt made at once on the part of the cells to absorb it. The material of which the ligature is com- posed will determine the success of this attempt. In the case of gold or plati- num mre, this remains permanently in an unchanged condition. Ligatures of silver, lead, iron, and other metals become absorbed sooner or later. AU animal and vegetable ligatures disappear in time, this var^-ing vdth the char- acter of the ligature material and the method of its preparation. 92 INJURIES AXD DISEASES OF SEPARATE TISSUES If no bacterial infection follows the operation the wound will unite by first intention, a mass of plasma-cells rapidl}^ surrounding the ligature. This collection of cells will be greater on the tissue than on the vessel side of the ligature. The plasma-cells, in attacking the ligature, provided it is of a material which will permit its absorption, such as catgut, kangaroo tendon, reindeer tendon, silk or Chinese twist, etc., penetrate into its interior as well, and its more or less rapid absorption follows. If there is an}- delay in the absorption, encapsulation occurs from the formation of connective tissue; the absorption is not on this account arrested, but goes on, although slowly, to completion. As absorption takes place, the ligature material is replaced by new connective tissue. In the case of animal ligatures the softening and absorption of the ligature occur earlier if suppuration takes place. T'nder these circumstances catgut, unless chromicized or otherwise hardened, may completely disappear in fourteen days. Good chromic gut, however, in a septic wound, may be relied upon to hold sufficiently long for all purposes of ligation; ordinaiy gut, prepared by boiling in alcohol, will, in general opera- tive work of an aseptic nature, be foimd to be entireh" trustworthy. But in hgation in continuity of large arteries near the heart, in which case special precaution is necessary, well-chromicized catgut ^^■ill be the safest to employ. The reparative process by means of which the final obliteration takes place does not differ materially, after the formation of the clot, from that which occurs elsewhere. The proliferation of the cellular elements of the intima leads to connective-tissue formation, the clot is inA^aded by the cell growth, and a regenerative or hyperplastic inflammator}- condition occurs, somewhat resembling that which marks the formation of callus after fracture of a bone (see page 130). If the Hgature does not occlude the arterv' at the time of the operation, or if it is of such material or the conduct of the wound is such as to lead to the too rapid softening of the ligature, or if the knot gives way too early, the circulation through the vessel may become reestablished. This may occur in cases in which the internal coat of the arter\- is not ruptured, and also where the external coat or adventitia is completely divided. Again, it may happen that a diaphragm forms between the ligated ends of the vessel, through which a central opening passes. Reestablishment of the circulation after a clot has formed may take place in one of three ways: (1) The central mass is divided by cell in\-asion in such a manner as to form spaces, which are bounded tOAvard the center of the clot by endothelial cells, and externally by the intima of the vessel, these constituting true blood-channels. If the force of the blood-current is sufficient, these may be so enlarged that they will be converted into one, the young and slender con- nections between the lining of the vessel and the central clot giving wa}-. In this way a peripheral reopening of the vessel lumen may take place. (2) The vessel may become peiwious by an opening forming through the center of the clot. If the development of connective tissue does not proceed in such a manner as to protect the cells or granular material of which the portions of the clot between the spaces are made up, these may be washed away and the former transformed into lacunae filled with moving blood, so that the circula- tion is accomplished through a kind of cribriform or sieve-like membrane, INJURIES AND DISEASES OF BLOOD-VESSELS 93 wliich takes the place of the oris:inal clot. (3) The connective-tissue develop- ment taking place more rapidly in the periphery than in the center of the clot, the latter of which is the natural course, true canalization of the clot may occur. DISEASES OF ARTERIES .Arteritis. — The influence of surrounding conditions of infection of arteries, or so-called perivascular suppuration, is such as to induce suppura- tive inflammation of the vessels of the arteries. The vessels of the connective tissue covering the artery, or the adventitia. are chiefly affected. The inter- ference with the nutrition of the artery is such as to lead to coagulation in the latter, particularly in the smaller arteries (intra-arterial thrombosis). Injury of the wall of the vessel, the re.sulting coagulation undergoing suppura- tion, is followed by thrombo-arteritis. Larger arteries do not suffer so readily from attacks of suppurative inflammation : they have been observed to resist for a Ions: time the influence of .suiTOunding septic conditions. Chronic arteritis is more frecpently observed than the acute form. The chronic form of the chsease (1) may result from previously existing degen- erative processes, or may accompany the latter; (2) may precede these degenerations and be the initial factor ui their production. The degenera- tiA'e processes wliieh mvade the arteiy. and wliich may be accompanied or fol- lowed by a chronic arteritis, are fatty degeneration and calcification of the intima. and amyloid degeneration of the mtima and media. The chronic mflammation of the arteri* known as endarteritis deformans is the most common form of the disease. It usuaUy occurs in persons beyond middle Ufe : it is veiy rarely observed m those under fifty. It begins iu the shape of small yeUowish spots on the iutima, and is suggestive of a fatty granular degeneration of the subendothehal layer. These spots coalesce and form placjues. which finally undergo calcification. Tins is the course usuaUy followed, but somewhat rarely the fatty softening proceeds to the formation of excavations filled with detritus, this, on accoimt of a fancied resemblance to retention cv'sts of sebaceous glands (the so-called atheromas), constituting the concUtion known as atheromatous degeneration. In chronic endarteritis the rigicUty of the waUs of the vessel is not due to an atheromatous condition, but rather to u^egular condensation and thickening. The elastic subendothe- hal layer is connected with a more or less soUd membrane in cases of calcifica- tion; the loss of elasticity due to this leads to dilatation of the arterial tube. with lengthening, and the production, sometimes, of a serpentine coiu-se of the arter}-. Tliis can be often observed m the supei-ficial arteries of old people, particidarly m the temporal and rachal arteries, occurring comcidentally with other senile changes and perceptible both by touch and b}' sight. The disease is_not confined to these vessels, however, but occurs thi'oughout the entire arterial system, mcluding the coronaiy arteries and the siulface of the mitral valve. There are two forms of surgical cUsease which foUow clu'onic endarteritis or are in close association with it. These are senile gangrene and aneurism. The first-named affection ^iU be discussed more fidly among the cUseases of the lower extremities, for the reason that it makes its first appearance, as a rule, in that locality. It may be said, however, that calcification of the arteries is m most instances the cause of senOe gano-rene; it mav be so considerable 94 INJURIES AND DISEASES OF SEPARATE TISSUES as completely to obliterate the lumen of the vessel, and thus the supply of blood is shut off from its area of distribution. Obstruction of smaller branches of the main trunk may result from the loosening of the calcified patches, which are carried as emboli by the blood-current until they reach the smaller arteries, where they lodge and obstruct the circulation. The occurrence of embolism is characterized by severe pains in the regions of the nerves supplied by the vessel involved. If the collateral circulation is insufficient, stasis occurs in the capillaries, the local temperature is lowered, and gangrene follows (embolic gangrene). Fig. 20. — Schematic Representation of the Different Forms of Aneurism (after Manteuffel). A, Sacciform aneurism; B, cylindriform aneurism ; C, fusiform aneurism; D, dissecting aneurism; E, the mechanism of the production of the diffuse form of sacciform aneurism through rupture of the elastic elements of the arterial coats; ¥, arteriovenous aneurism, showing a direct communication between the artery and the vein, with dilatation of the vein alone; G, arteriovenous aneurism, with dilatation of both artery and vein; H, arteriovenous aneurism with the formation of a sac between the artery and the vein. Aneurism. — Aneurism is a dilatation of the lumen of an artery filled with circulating blood. This definition includes dilatation limited to a portion of the artery, as well as the condition in which an enlargement of the entire arterial system of a part occurs (cirsoid aneurism). Aneurisms are classified on the basis of an invariable involvement, or otherwise, of all the coats of the vessel in the disease. The first-named con- dition is known as true aneurism, while the second is called false aneurism. True aneurisms are divided, according to their shape, into (1) sacciform; INJURIES AND DISEASES OF BLOOD-VESSELS 95 (2) cylindriforai; (3) fusiform (Fig. 20). These forms are nontraumatic in origin, ami are marked l)y a gradual dilatation of the vessel; the dilatation takes'ono or more of these shapes according as the entire circumference of the vessel, or onlv a i)ortion thereof, is involved. False aneurisms, or those in which ah the coats of the vessels do not take part in the enlargement, are usually the result of an injury involving partial division or destruction of the arterial wall. The mycotic form may also occur as a false aneurism. Occurrence of Aneurisms.— True aneurism occurs most freciuently in the decade between thirt}- and forty years of age, when structuraU-hanges in the arterial coats, due to syphilis, rheumatism, gout, and excesses in diet, are most common. It is very rare before puberty, and the frequency of its occur- rence gradually decreases after the age of forty, w^hen the heart's action grad- ualh- becomes weakened. Less than 19 per cent occurs in women (L ii t - tich). It is more common in cold than in hot countries. It occurs most commonly in the following vessels, mentioned in the order of frequency of occur- rence of the aneurism: The ascending and transverse portions of the thoracic aorta; the popliteal, carotid, subclavian, innominate, and axillary' arteries. Cirsoid aneurism occms especially on the scalp, and is usually congenital. Rarely, it occurs from some mechanic injury. Etiology.— Etiologically all aneurisms are either dilatation aneurisms or rupture aneurisms. All diseased conditions or injuries of the arteries by which the strength and elasticity of their walls are dimuiished, may give rise to either one or the other of these forms. These include the foUo\\-ing: (1) chronic endarteritis; (2) periarteritis with secondary- atrophy of the media; (3) contusions, wounds, and subcutaneous ruptures of arteries and their sequels (cicatricial weakening of the vessel wall) ; (4) degeneration of the vessel wall through infectious diseases (typhus, etc.). Sometimes a combination of circumstances operates to produce the aneu- rism, such, for instance, as the presence of primaiy ruptures of the media due to a diseased condition or traumatism, and a marked elevation of blood- pressure from some strong physical exertion or violent emotion, whereby the resistance of the arterial wall is overcome. Syphilis is a frequent cause of aneurism of the aorta. Aneurism arising from endarteritis may partake of either the sacciform, the cylindriform, or" the fusiform shape. In the first two the entire circum- ference of the vessel may be involved, while in the latter only a portion of this forms the aneurism. Where the diseased portion of the vessel, although occupying the entire circumference, is sharply limited in a longitudinal direc- tion the aneurism will be cylindriform (Fig. 20. B) : where the limits of the diseased portion are not so sharply defined, but merge gradually into the adjoining and less diseased portion, the aneurism will be fusiform (Fig. 20, C). Where dilatation takes place at a single point and but a portion of the circumfer- ence of the vessel is involved (E p p i n g e r). the aneurism will be sacciform (Fig. 20. A). In the more or less diffused forms the elastic elements of the arterial coats give way at numerous points in the same locality (Reckling- hausen) (Fig. 20, E). Endarteritis being a more or less widely diffused disease of the vessels, dilatation may occur at several points in the same vessel, or may be present in several vessels at the same time. 96 INJURIES AND DISEASES OF SEPARATE TISSUES Locality has some influence in the development of aneurisms. They have a special predilection for those portions of arteries where divisions of main trunks occur, as, for instance, the point of division of the innominate, of the common carotid, of the femoral where the profunda is given off, and of the popliteal where it divides into the anterior and posterior tibial. This seems to arise from the fact that a slight fusiform dilatation occurs at these points normally, and under pathologic conditions further enlargement occurs the more easilv. Aneurism is also more likely to occur where the artery is embedded in soft tissues with absence of firm external support. It likewise tends to arise where the vessels are exposed to injury at the points of flexion of the extremities. False Aneurism. — This includes all forms in which one or another, or all three of the coats of the vessel are missing from the wall of the aneurism. Traumatic aneurism is the most common variety of false aneurism. Traumatic Aneurism. — This may arise from simple contusion of the vessel through consequent perforation by necrobiosis, though M a c k o w ' s experiments tend to show that contusions undergo repair at first. Subsec^uent yielding of the cicatrix may give rise to aneurism. It is usually due, however, to partial division of the vessel. Complete division of an artery does not develop into aneurism except in the rare instances in which it arises from the presence of a diseased vessel lying in a dead space and being without adec|uate support, in an amputation stump, or from improper ligation or the premature giving wa}' of a properly applied ligature, and the subsequent canalization of a hematoma. The aneurisms arising from a punctured injury result from a gradual yielding of the thrombus which forms, and of the surrounding con- nective tissue, from intra-arterial pressure. Under these circumstances the sac which develops is made up, first, of the outer layer of the thrombus, and finally of the newly formed connective tissue, supported by the surround- ing soft parts. In subcutaneous rupture of a large artery there is more or less separation of the coats of the vessel in a transverse direction, and extensive extravasation of blood in the perivascular connective tissue of the sheath of the vessel, which finally forms the wall of the sac of the aneurism. In dissect- ing aneurism rupture of the intima and media takes place, with preser^^ation of the adventitia. The blood dissects its ^vay between the media and the adventitia, separating these from each other. In hernial aneurism the defect is in the adventitia, and the inner and middle coats are forced through the opening. Arteriovenous Aneurism (Fig. 20, F, G, and H). — This results from the simultaneous lateral injury of an artery and a neighboring vein, in which either a sac is formed in the connective-tissue sheath common to both, or direct agglutination of the artery and vein takes place at the point of injury. The wound of the artery and that of the vein, if directly in apposition, result in the formation of an arteriovenous aneurism or aneurism by anastomosis (Hunter) (aneurismal varix, varicose aneurism). This originates in stab or shot wounds, and abrasions by exostosis. In former times phlebotomy was a frequent cause. It has been obser^-ed in amputated stumps. In arterio- venous aneurism the arterial blood invades the vein and produces pulsation in the latter, with marked disturbance of the circulation, and pulsating dila- tations of the branches of both arten' and vein. INJURIES AND DISEASES OF BLOOD-VESSELS 97 Pathologic Anatomy, — True aneurism contains within its walls all the constituents of the normal arterial wall, only altered and attenuated. Strata of shell-like thrombi line the inner wall concentrically in large sacciform aneui-isms. Dissecting aneurism shows a defect in the intima; in hernial aneurism the defect is in the ach entitia and muscularis. lalse aneurism arises in the beginning from the fluid center of a hematoma; later the sac develops from the c()nno(•ti^■e tissue. The Symptoms of Aneurism. — The presence of a pulsating tumor is the most important symptom of aneurism. The tumor will vary in size from a millet-seed to an adult head. The pulsation can be distinguished by the eye; each systolic act of the heart causes the tumor to pulsate, relaxing at the diastole. A thrill or soft friction sensation is conveyed to the examining finger by the passage of the Ijlood over the rough walls of the sac. This latter symptom is heard, by the aid of the stethoscope, as a rough sound. Symp- toms arising from pressure on surrounding parts are the following: (1) pain from involvement of nerve-trunks and filaments; (2) obstruction to the return circulation, resulting, in the case of the extremities, in permanent edema and new connective-tissue growth, simulating elephantiasis; (3) erosion and destruction of neighboring bony and cartilaginous parts. Diagnosis. — When a pulsating tumor is present the following points must be borne in mind: (1) The pulsation is expansile, i. e., it is felt to take place in all directions. In this manner an abscess which may rise and fall from proximity to a large vessel may be differentiated from an aneurism. (2) Com- pression of the artery between the tumor and the heart causes lessening or disappearance of the tumor, and arrests its pulsation and the thrill or fric- tion sound. (3) In aneurism the pulsating wave in the peripheral por- tion of the artery is retarded as compared with that of the corresponding healthy vessel. In the sphygmographic tracing the curve is flattened and the point disappears. (4) The presence of a considerable amount of fibrinous coagulum within the sac may mask the pulsation. (5) Pulsation may occur in localities where contact with large vessels does not exist, as, for instance, the pulsation of the brain may become visible in case of a bony defect in the skull ; the exposed medullary tissue of the long bones in some instances is seen to pulsate; thyroid or other highly vascular tumors, and certain varieties of osteosarcoma, likewise present this symptom. The Terminations of Aneurism. — The spontaneous cure of traumatic aneurism occurs not infrequently. Stratiform deposits of solid masses of fibrin on the internal wall of the sac occur, the excavated portion, as well as the lumen of the vessel, becomes filled, and fibrinous contraction of the mass finally produces complete obliteration. Cure by nature's efforts, however, m aneurism depending on endarteritis is not to be expected. In the most favorable cases the dilatation may remain stationary. Between the progressive character of the endarteritis on the one hand, and the continued pressure of the blood-current on the other, steady increase of the dilatation is the rule. Structures other than the arterial walls may become involved in the disease. Large aneurismal dilatations of the aorta give rise to erosions of bony struc- tures; even the vertebral column is invaded, its medullary cavity opened, and the spinal cord exposed. Anteriorly the bony chest wall disappears over a considerable area and the pulsating mass is Adsible externally. Nerve-trunks, 98 INJURIES AND DISEASES OF SEPARATE TISSUES subjected to pressure, are disturbed in their function; violent pain or paralysis results. The aneurism may open externally, the overstretched skin ulcerat- ing rapidly ; fatal hemorrhage usually follows. Finally, a patient with aneurism is subjected to the dangers of embohsm. Treatment of Aneurism. — The indications for treatment include the fol- lowing: (1) The treatment of the arteriosclerosis, on which true aneurism depends, by the use of iodid of potassium, whereby it is hoped to arrest the progress of the disease. (2) The lowering of the blood-pressure, both the volume and the force of the blood-current that enter^^ the sac being thereby lessened, and rest in the recumbent position and fasting (Valsalva). The subjective symptoms of pressure and obstruction are relieved by these means. (3) Attempts to cause coagulation of the blood entering the sac. (For the operative treatment of aneurism see Operations on the Blood-vessels.) INJURIES AND DISEASES OF VEINS Incised and punctured wounds behave in a manner similar to that of arteries under the same circumstances. The walls of veins contain less elastic and contractile tissue, and consequently there is not the same amount of retraction of the vessel and contraction of its lumen as in the case of arteries. There is not, therefore, the same tendency to spontaneous arrest of hemorrhage in the case of an injured vein as in the case of an artery.- This is somewhat compensated for by the fact that there is not the same amount of intravascular pressure in the veins as in the arteries, and blood is not so rapidly lost from this source. In operation wounds, the arteries supplying the parts being closed by ligation, the hemorrhage from the veins becomes less troublesome, from the fact that the supply of blood is cut off. It is fortunate that this is true, for the reason that the efferent branches of the large veins have very extensive and firm connections to the surrounding structures, in order to meet fulty the demands made by constantly changing intra-arterial blood-pressure. These connections, each one of which is a- small vein, if supplied with blood with the same force of current as that which exists in the arteries w^oukl increase very greatly the difficulty of arresting venous hemorrhage. Although venous hemorrhage is not so serious an accident as arterial, yet, under certain circumstances, a large amount of blood may be lost in a short time. Position, for instance, has a very decided tendency to increase hemorrhage from a vein. Without depending on the arterial blood-pressure, hemorrhage from a subcutaneous vein with the body in the upright position, particularh^ if this vein is in a varicose condi- tion, will give rise to serious bleeding. The blood here escapes from the central end of the injured vein by the mere weight of the column of blood, in spite of the valvular apparatus of the veins which is intended to prevent reflux of blood. Aspiration of Air into Veins. — A special danger in connection with wounds in veins at the root of the neck and in the neighborhood of the superior opening of the chest cavity relates to the intravenous aspir- ation of air. Each expiratory effort retards the return of the blood from the head and upper extremity to the large venous trunk within the thorax, and tends to force it back toward the periphery. An injury to either of the jugulars, the subclavian, axillary, or subscapular veins, or the cere- IN.Tl'RIES AND DLSKASIOS OF BLOOD-VESSELS 99 bral sinuses, ivsults in a crowding out of tlie large mass of dark blood from the wound. As an inspiration takes place the thorax is expanded, and the vacuum thus produced is filled by the blood rushing into the intrathoracic vessels. Whatever fluid other than blood is brought within the range of influence of this suction will likewise pass in. The escape of blood from the wound in the vein is held temporarily in check by the inspiratory effort; at the same time., however, more or less air passes into the vein, producing, in its passage, a peculiar hissing sound which, once heard, is never forgotten by the surgeon. Small ([uantities of air thus aspirated may do no harm, but a large quantity may cause immediate death. The exact mechanism by which this effect is produced is still a matter of dispute. The air passes from the right ventricle into the pulmonary circulation in aeriform emboli, the result of a "churning" process which the mixed air and blood undergo in that cavity by the contraction of the heart muscles. The emboli fill the branches of the pul- monary artery, and, these being obstructed, stasis occurs, the left heart collapses from want of blood on which to contract, and fatal syncope residts from failure of blood to reach the cerebrum, while at the same time the right heart is paralyzed from inability to contract on the mingled mass of blood and air within its cavities. Although experiments on animals have repeatedly shown that quite large quantities of air can be injected into the veins without producing a fatal result, yet the fact remains that many patients have died from this accident, particularh^ during operations about the neck. The diagnosis between venous and arterial hemorrhage is, as a rule, easily made. The former flows in a rather continuous stream, while the latter is forcibly ejected in interrupted jets. The blue color of the venous blood and the red color of the arterial blood constitute a striking difference. Exception- ally, however, this differentiation is embarrassed by the fact that the dark color of venous blood becomes changed to a lighter hue by contact with the air; the presence of arterial blood flowing from divided arterioles in the skin in cases of punctured wound of a vein may likewise mask the real source of the more serious bleeding. Artificial arrest of hemorrhage from a vein is more rarely demanded than in the case of arteries of the same size. The reasons for this have been already mentioned. Circumstances frequently arise, however, which demand prompt action, both on account of the quantity of blood lost and on account of the dan- ger of aspiration of air. Prior to the introduction of antiseptic and aseptic operative technic surgeons aimed to avoid, as far as possible, the placing of ligatures on veins. Infection and suppuration of the resulting intravenous thrombus occurred frequently, and here, as in the case of decomposition of an intra-arterial thrombus, secondary hemorrhage was liable to follow. The detachment of portions of this septic clot, its passage into the circulation, and its transportation in the shape of emboli, occurred from veins as well as from arteries. On this account ligation of the veins was resorted to only in the most urgent cases. The introduction of the aseptic ligature, however, has changed all this, and at the present day the application of the ligature is practised on veins and arteries alike. The frequently recom- mended and as frequently rejected lateral ligation of veins has at last been placed on a firm scientific footing by the introduction of antiseptic pro- cedures. That the closure of veins without the formation of a clot may occur has been proved. 100 INJURIES AND DISEASES OF SEPARATE TISSUES Varix. — The condition known as varix consists of a dilatation of the lumen of a vein, and corresponds to dilatation of an artery, or aneurism. A funda- mental difference exists, however, in the method of origin of the two conditions. While the latter occurs either as the result of injuries to the arterial wall or from the presence of endarteritis, the former is the result of passive dilatation of the unchanged walls of the vein, which suffer by the accumulation of venous blood. The obstruction may be due to various causes, as follows: (1) occupations involving continuous walking or standing, the weight of the column of blood producing pressure on the lower extremities; (2) the pressure of the pregnant uterus and of large intra-abdominal tumors on the ascending vena cava; (3) physiologic conditions relating particularly to the distance of the parts from the heart, to which may be added abnormal conditions of these parts, as in fractures of the lower extremities followed by the formation of large masses of callus, the presence of bone tumors, etc. It may also be due to cardiac weakness and conditions involving obstruc- tion to the entrance of venous blood into the heart. Pathologic changes in the connective tissue surrounding the veins, the latter losing their support from without, also favor the origin of varix. Occurrence of Varix. — Varices occur more frequently in the lower extrem- ities than elsewhere. For the purpose of surgical study we may group all cases subject to this hemadynamic condition within the area of the lower half of the body, where the return flow of blood in the veins is rendered difficult. This will include the veins of the spermatic cord, the pampiniform plexus, the veins of the lower part of the rectum (hemorrhoidal), and those of the lower extremity. Varicose veins, as varices are sometimes called, undergo lengthening somewhat similar to that which occurs in arteries, in cases of endarteritis, and in aneurism. In the case of varix, however, this occurs to a much greater extent, the veins pursuing a tortuous course with numerous convolutions. Under the influence of constant pressure on the walls of the veins, in which elastic fibers exist to a much less extent than in arteries, these become thinned, together with the overlying skin, in the case of subcutaneous veins. These conditions are specially prevalent in the vessels of the thigh and leg. Below the ankle, as a rule, only a fine network of blue lines is seen. The veins of the gastrocnemius muscle are occasionally affected. Those which accom- pany the arterial trunks are comparatively exempt. The same may be said of the saphenous vein, the dilated veins occurring in the course of this trunk beingreally varices of the branches which join the saphenous near its upper limit. Diagnosis. — Pressure applied directly on the dark blue, cordlike eleva- tions and convolutions will cause a disappearance of the varices, while pres- sure, centrally applied, will cause them to increase in size. Prognosis. — This, as far as danger to fife is concerned, is favorable. Com- plications may arise, however, from the presence of varicose veins which may become sources of great inconvenience, and sometimes of real danger. Inter- ference with the function of parts, particularly of the skin, leads to the pro- duction of inflammatory and suppurative processes. Eczema occurs in the legs, particularly of elderly persons. Ulceration of the skin follows compara- tively slight abrasions; contusions give rise to sloughy conditions. Repair goes on verv slowlv under these circumstances. INJURIICS AND DISK ASKS OF BLOOD-VKSSELS 101 Complications of Varix. — Thr()nil)o,sis sometimes occurs as a result of retarded circulation in vai'ix, this in time leading to obliteration of the latter by a transformation of the clot into solid connective tissue. This change is proba- bly due, to some extent, to chronic inflammatory conditions in the neighboring tissues. The hart! mass thus formed is solidly attached to the walls of the vein, and to the touch simulates a small fibroma. This occasionally becomes the seat of tleposits of lime salts, constituting the so-called phlebolith, numbers of which may exist for years without serious inconvenience to the patient. Rupture of a varicose vein may occasionally threaten life from profuse hemorrhage. Patients with varicose veins should be taught provisional methods of arresting hemorrhage. Peptic changes in thrombi, followed by transportation of infectious emboli to distant parts, may occur. Septic metastases in the lungs and other parts (pyemia) constitute another danger- ous complication. The latter termination is fortunately rare, however, for the reason that the inflammation is usually limited to the perivascular spaces. Treatment, — This may be divided in a general way into palliative and curative. The former consists in supporting the parts surrounding the varices by properly applied bandages or their substitutes. Compression is secured by means of rubber bandages (Martin), bandages of "stockinet" mate- rial, and stockings made of silk with elastic threads interwoven. Operative measures will vary according to the location of the varices. These consist of ligation, with or without excision, as in varicocele, and in some cases of superficial varices of the lower extremities. In the latter cases, however, recur- rences are rather common. Injection of solutions of ergotin into the peri- vascular connective tissue has been followed by good results (Vogt). Car- bolic acid, sufficient to make a 2 per cent solution with the ergotin solution, should be added. Strict aseptic precautions should be obser^•ed, and the point of puncture made by the hypodermic needle protected by a drop of iodoform collodion. Ligation of the internal or long saphenous vein at the saphenous open- ing, in properly selected cases, constitutes one of the best operative procedures for varicose veins of the lower extremity (Trendelenburg). The ligature should be applied below the point where the superficial circumflex iliac and superficial epigastric veins join the saphenous (see page 351). Phlebitis. — Unlike the corresponding condition occurring in arteries, acute suppurative inflammation of the veins, or phlebitis, either alone or complicat- ing subcutaneous and subfascial phlegmonous inflammation, or as a result of these, is not uncommon. Plilebitis pure and uncomplicated occurs most frequently in the leg and thigh. When it occurs in the course of the subcuta- neous veins in the latter situation, the hard cordlike lines are quite easily dis- tinguished. This cordlike hardness arises less frequently from coagulation of the column of blood in the inflamed veins than from more or less dense cellular infiltration of the adventitia and perivascular connective tissue. Coagulation, however, does occur in phlebitis, and is the result of a deposit of fibrin on the diseased intima. Thrombophlebitis is that condition in which a suppurative inflammation situated peripherally to the subsequently inflamed vein causes a thrombosis in the latter, the phlebitis resulting. Here a minute thrombus forms in a capil- lary, and, charged with cocci, it is carried into the wall of the vein and 102 INJURIES AND DISEASES OF SEPARATE TISSUES becomes attached to it, where it forms the nucleus for further deposits of fibrin. These in their turn become the seat of renewed suppuration antl infect the wall of the vein. This thrombus may develop, by further deposit, to an extent sufficient to produce complete obliteration of the vein ; it may likewise extend into the next larger vein (I-lg. 21) or still further. During its existence the patient is exposed to all the dangers of pyemic invasion of remote parts. While the thrombi just described have their origin in septic inflammatory conditions, either from the bacteria producing the coagulation or from their influence on the leukocytes in setting free the fibrin ferments (see page 90), thrombi likewise occur, exclusive of these influences, in otherwise healthy veins. These coagulations occur as the so-called stagnation thrombi. This thrombosis rnay happen from any obstruction, as, for instance, a ligature applied so as to obliterate the lumen of the vein. The vein from the point of ligature to the next collateral branch is filled with blood (the valvular apparatus being insufficient to prevent this), which remains for a time in a liquid state. Finally coagulation takes place, beginning at the wall of the vein, and the resulting thrombus obliterates the lumen. The continued presence of the carbon dioxid, in all probability, is the disturbing agent of the leukocytes; the disturbances which follow result in the setting free of the fibrin ferment neces- sary to the production of coagulation. The produc- tion of stagnation thrombosis is not confined to cases of ligation of a vein, but may result from any cause which produces obstruction, such, for instance, as tumors of rapid growth, or the presence of two or more clots which invade the vein at different parts of its course. Thrombosis. — The retardation of the current of blood in the veins ma}' also produce thrombosis. This dilatation thrombosis occurring in varicose veins is the result of over-accumulation of carbon dioxid, and takes place more particularly in situations where the blood collects within the pouches formed by the valves of the -v'eins. Here, also, the disturbance or destruction of the leukocytes sets free the fibrin ferment and coagulation results. These valvular thrombi most frequently undergo fibromatous change and calcification (see PlileboHths, page 101). Finally, a thrombosis is ol)served ^dth advancing years after debilitat- ing diseases, to which the name marasmus thrombosis was given by V i r - chow. With the lessening of the cardiac impulse, the influence on the weakened circulation is such as to produce coagulation at certain points in the venous system. The diseases of greatest interest to the surgeon, which give rise to this condition, are particularly those which arise from infectious processes, as the traumatic septic fevers. In these, as well as in some other diseases resulting from infection, it is believed that the influence of the infectious agents in the blood is such as to set free the fibrin-forming fer- ment, which induces coagulation under circumstances favoring retardation of the blood-current. The thrombi which are thus produced are usually of the vahiilar variety at the start, but they may easily advance into the lumen of the vessel, or extend to the next collateral branch (extension thrombi). The Fig. 21. — Thrombosis from Small to Large Vein. INJURIES AND DISEASIOS OF BLOOD-VESSELS 103 favorite sites for these thrombi are the femoral, the profunda, and the common iliac vein. The large veins in the muscles of the thigh, as well as tlie network of veins in the lesser pelvis, are likewise occasionally involved. In the autops>' room are fr(>([U(nitl>' found venous thrombi which have occurred after death. These postmortem thrombi are easily distinguished from those occurring during life by reason of the fact that they are not closely con- nected to the vessel wall. (3n the contrary, they are either loosely connected to the intima or not connected to it at all; in addition, they are of softer con- sistency and darker in color than true thrombi. Where the latter occur shortly before death there is a possibility of error, but their lighter color will probably serve to aid in tlie discrimination. The longer the interval between the formation of the thrombi and the death of the patient, the more intimately adherent to the vessel wall will the former be found to be. The prognosis of thrombosis relates principally to the dangers which arise from the tendency of portions of the fibrinous mass to loosen and to be trans- ported to other parts ]:)y the circulation. These dangers are increased by the possibilities of septic conditions and suppuration, particularly in phlebitis from injury to veins. The danger of transportation of portions of thrombus arises particularly from the tendency on the part of extension clots to have their terminating extremities, where exposed to the current of blood in the collateral branches, detached and swept into the general circulation. These are carried in a centripetal direction to the right heart, unless they are arrested en route, where they pass into the pulmonary artery and are finally deposited into the lungs. The discussion of the disturbances which may result from displaced portions of thrombi vill be found in the paragraph on embolism. Venous Stasis and Its Consequences.— Obliteration of the lumen of a vein either by ligation or by pressure from neighboring inflammatory conditions or neoplasms, unless the collateral circulation is established at once, produces decided disturbances in the capillary area from w^hich the obstructed vein receives blood. The changes which occur, this description being based on observations of the process as it takes place in the web of the frog's foot on the stage of the microscope, are as follows: The smaller veins and capillaries become filled to their utmost capacity; the arteries continue to supply blood to these, its escape, however, being prevented by the obstruction. Each sys- tolic heart movement sends a wave of impulse into the already overfilled area, but in the intervals of diastolic pause between the heart-beats this wave of impulse recedes in the capillary area. The effect of this is to give a to-and-fro movement of the blood-corpuscles. This wave results from the fact that \vhen the increased tension on the somewhat elastic vessels is lessened by the relaxation of the heart muscle (diastole) , these force some of their contents back against the arterial column. After twenty-four hours or less of this fruitless effort on the part of the arterial current to force the blood through the capil- laries, the watery constituents of the blood are forced through the vessel walls and into the perivascular spaces. At the same time the red blood-corpuscles are forced through the avails of the vessels in greater or lesser quantity, and diapedesis of the red blood-corpuscles occurs (Cohnheim). Coin- cidentally the capillaries increase greatly in size. The escape of the blood- serum into the tissues resulting from the permanent pressure exerted by the arterial column causes the red blood-corpuscles to accumulate in a homogene- 104 INJURIES AND DISEASES OF SEPARATE TISSUES ous mass, in which the individual corpuscles can no longer be recognized. Those which have escaped through the vessel wall, however, may be seen lying in the perivascular spaces. The view that hemorrhage by diapedesis occurred was held by the older writers, but subsequently denied, the theory being rejected in favor of hemorrhage by rupture of the vessel as the exclusive method of escape of the red blood-corpuscles. If the pressure continues to obstruct the circulation, whether this occurs from the application of a ligature, as in Cohnheim's experiments, or from the pressure of a neoplasm or inflammatory processes, the senim is forced from the interior of the vessels into the perivascular spaces, and the condition known as edema results. The pressure being continued, the serum is forced into the rete Malpighii, and blebs or blisters may thus arise in venous stasis. The slightly reddish or deep straw color of their contents is due to the presence of greater or lesser numbers of the migrated red blood-corpuscles; in less severe cases the fluid is identical with pure blood-serum. In extreme and rapidly occurring cases of venous stasis the migrated red blood-corpuscles in the connective- tissue spaces may be grouped together; usually, however, they occur in this situation singly. Generally speaking, there is to some extent a collateral circulation established, which permits of a somewhat impaired but sufficient return of the venous blood from the affected area to the blood-current. The diagnosis of venous stasis resulting in edema is made by the presence of the characteristic objective sign of the latter, namely, pitting on pressure. The finger being pressed firmly against the soft swelling at the site of the edema, its removal will show the impression left in the tissues, which disappears again in a few seconds. By this manipulation the serum is pressed into the neigh- boring connective-tissue spaces, and perhaps also into the lymph- vessels. There may occur conditions of edema in which pitting is not produced, on account of extreme tension of the skin and connective tissue. The distinction between edema and inflammatory swelling will be made clearer by attention to the following points: In edema the fluid which accumulates in the tissue is light straw-colored serum in mild cases, and reddish colored in severe cases; in inflammation this fluid is plastic lymph in serous inflammation, and pus in suppurative inflammation. In edema the blood is at a standstill, while in inflammation it circulates through the dilated vessels. In edema the cellular elements found in the perivascular spaces are exclusively the red blood- corpuscles; in inflammation these cellular elements consist of white blood- corpuscles. In edema the swelling is marked by a local normal or sub- normal temperature; in inflammation the swelling is accompanied l)y a local elevation of temperature. Venous stasis in small as well as in large vessels may result from ob- struction. This occurs more particularly in inflammatory processes, the return circulation being interrupted in several veins at once, and thus the establish- ment of a collateral circulation is prevented. In small veins the obstruction may result from the filling of their lumina with white bloocl-corpuscles, the so-called white thrombus, or from the filling of these wath pus. Here the symptoms of venous stasis and inflammation occur conjointly. The most constant as well as the most important sequence of persistent venous stasis is that condition of the involved area of distribution known as gan- INJURIES AND DISEASES OF BLOOD-VESSELS 105 grene. Coagulation of the blood in extensive capillarv regions extending into the small arteries leads to the death of circumscribed areas, as, for instance, that of portions of the foot and leg after injury and thrombosis of the femoral artery. The gangrene which follows burns of the third degree is partly the result of venous stasis. The abundance of fluid in the parts, due to the increased quantit}^ of blood massed within the region implicated, together with the edematous condition present, shows a more or less strongly marked contrast to the gangrene which follows obstruction of the arterial trunks (embolic gangrene). Because of these differences the former is designated as moist and the latter as dry gangrene. Although hi the latter an edem- atous condition does not occur, yet this discrimination is not quite exact; while in embolic gangrene the peripheral portions are comparatively blood- less in the beginning, yet blood is finally supplied, sometimes in a very short time, and the parts are plentifully saturated with moisture. The in- vasion of the parts by micro-organisms is a very important part of the process in gangrene, and the appearance of these sooner or later not only originates and hastens the more or less rapid putrefaction of the devital- ized tissues, but produces gangrenous inflammation of the adjoining living structures. In the treatment of venous stasis the first care of the surgeon is to place the limb in which it occurs on a higher level than the horizontal, in order to aid, by force of gravity, the return flow of blood from the tissues, and to avert the more serious consequences which may result from this condition. Ever}' effort should be made to give the collateral channels time to dilate and thus perform vicariously the function of the obstructed veins. In this manner only can extensive gangrene and edema be prevented. Centripetally apphecl friction movements or massage may be useful, but care should be exercised in the application of this, for the reason that, though its usefulness in promoting reflux of blood and lymphatic absorption is well established, it may do harm, if applied in the immediate vicinity of the vein which is the seat of the throm- bosis, by forcing into the circulation loosened masses of coagula, dangerous embolism resulting. Gangrene following venous stasis is a most serious condition and demands the utmost watchfulness on the part of the surgeon. The fact should be borne in mind that early and extensive infection from exposure to bac- terial influence is very likely to occur. Early provision should be made to prevent this, and to hmit it if it has already occurred. The parts should be protected as far as possible by means of a 1 : 1000 solution of sublimate. The repeated application of crude pyroligneous acid (Sim- mons), from which the acetic acid of commerce is obtained, or diluted acetic acid, is useful as an antiseptic and stimulant application, particularly where the entire limb is involved. By these measures putrefaction may be some- times prevented, the dead mass becoming mummified. Immediately on the appearance of the line of demarcation separating the dead from the living tissues, and under some circumstances even before this, amputation of the limb should be performed. Patients not infrequently succumb to meta- static pyemia, in spite of every effort. Embolism. — Embolic processes, to which frequent references have been made in the preceding paragraphs in connection with the transportation of 106 INJURIES AXD DISEASES OF SEPARATE TISSUES corpuscular elements, portions of fatty or calcareous degenerated arterial intima, or of decomposed thrombi, may be divided for purposes of study into two groups. In the first of these the embolus originates from the left heart or some portion of the arterial trunk system; the second includes those cases in which intravenous thrombi furnish the material. Of the first-named group, surgically speaking, the most important conditions are those which include embolic gangrene of the lower extremities, particularly that of the toes, foot, and leg, the so-called senile gangrene. In the second group the emboli are derived from the small veins and are forced by the return circulation into the large veins, or are formed in the latter, and portions thereof are carried into the venous trunks. In either event they are usually carried to the right heart and thence into the pulmonaiy circulation. Here, as a rule, they lodge, though smaller emboli containing infectious material may pass through the puhnonarv' artery and its branches, and gain access to the general arterial circulation. The immediate result of the arrest of an embolus derived from an endar- teritis is the filling of the vessel in which it lodges, and which is thus plugged (obstructive embolus). The area of distribution of the obstructed vessel, in the absence of an immediate^ established collateral circulation, is at once deprived of its blood-supply. The failure of the collateral circulation may be due to an endarteritis deformans in the neighboring vessels which prevents them from supplying the requisite amount of blood, or to a weakened circula- tion in feeble individuals, or to both. Xecrosis of the starved-out area super- venes, and the condition kno-wai as embolic infarction follows. These infarc- tions are usualh' wedge-shaped, the base of the wedge corresponding to the first ramification of the vessels, while its point lies in the direction of the obstructed arterj^ (cuneiform infarctions). A capillary hemorrhage about an infarction sometimes occurs, and for a long time it was thought that this was the primary condition, and not the result of the embolic infarction. The true explanation of its occurrence is as follows: The anemic condition of the excluded area havmg existed for a short time, the capillaries in the neighborhood, in response to the augmented blood-pressure, dilate and send arterial blood into the former, through numerous anastomoses. The obstruction which the blood meets in its attempts to permeate the infarction leads to stasis within these dilated arterioles (hyaline thrombi, Recklinghausen), still further impeding its progress, and the red blood-corpuscles are forced through the wall of the vessel. These capillary hemorrhages are found in situations where the blood-supply is particularly rich and the freest anastomoses exist (lungs and spleen) ; on the other hand, where these conditions do not obtain, infarctions occur with- out capillary hemorrhages (kidne}^ and brain). In addition to the mechanic effects of embolism, this condition is hke- wise of importance in connection with the transportation and deposit of infec- tious material at the points of obstruction, or where emboU become adherent; here new colonies of bacteria develop in consequence. This, the infectious embolus, it is believed, becomes the bearer not onh- of pathogenic germs (see Pyemia) in the ordinary sense of the term, but likewise of the cell- elements of certain malignant tumors. LY-AIPHATIC VESSELS AND LYMPHATIC GLAXDS 107 INJURIES AND DISEASES OF THE LYMPHATIC VESSELS AND LYMPHATIC GLANDS Injuries of Lymph=vessels.— Any injury of the soft parts necessarily invoh-cs injur}- of the lymphatic vessels. The walls of these are so attenuated and their lumina so small as to escape notice. The escape of lymph is so slight that it is masked by the flow of blood. Some hours afterward, however, this is noticeable as a part of the wound secretion, which is composed of lymph, connective-tissue fluid, and blood-serum, originating from the vessels mvolved in the venous stasis. In some situations, however, such an amount of lymph ma}' escape as to constitute a genuine lymphorrhagia. notably in the axilla and inguinal region, where the principal lymph-vessels of the extremities join those of the trunk. Contusions in situations where the muscular structures are closely adja- cent to the skin may result in a rupture of a sufficient number of lymph- A-essels to constitute a subcutaneous lymphorrhagia. Most of the reported cases of this condition have occuiTed in the lumbar region, and have resulted from the contact of some hea\^' object with the body, the force being applied in a slanting chrection. As pathognomonic signs are to be mentioned the following: (1) well-marked fluctuation immediately occurs, and persists, inasmuch as the contents of the swelling do not become solidified; (2) the exploring trocar demonstrates the presence of a clear, shghtly yellow fluid; (3) jDain and febrile action are generally absent. The prognosis is favorable. The treatment consists in the apphcation of a pressure bandage. Should the condition persist and require operative mterference, especially careful aseptic measures should be taken, for the reason that even shght infection under these circumstances may lead to -widespread septic conditions. Injury of the Thoracic Duct.— The thoracic duct may be injured opera- tively in the neck, and by gunshot and stab wounds in this situation and in the thorax. Operative injuries are recognized by a copious flow of milky fluid during digestion, which coagulates spontaneously when exposed to the au-, and of clear fluid during fasting. Intrathoracic injuries of the duct usually lead to accumulations of chylous fluid in the pleural cavity, and are frequently fatal through inanition. The prognosis in operative cases is more favorable (14 recoveries in 15 cases, Allen and Briggs). The treatment consists in compression, which is usually successful. Ligation of the distal end may be attempted; a pair of valves on the proximal end stops the flow of chyle from that chrec- tion. A collateral circulation is usually established. Obstruction of the Thoracic Duct. — This may arise from the pressure of tumors from within, or from growths springing from the Avails of the duct. It may also have its origin in inflammatory' conditions of the duct leading to stricture, and in impaction of filaria. Thrombosis of the left innominate vein, or of the duct itself, and the backward pressure of blood in the sub- clavian vein in cases of tricuspid insufficiency, may also cause obstruction. When the obstruction is in the lower part of the duct, it is usuaUy compensated for by the establishment of a collateral circulation. This failing, general lymph- angiectasis may follow. Transudation of chyle or its escape from ruptm-e of 108 INJURIES AND DISEASES OF SEPARATE TISSUES the duct leads to infiltration of the tissues. Or, the chylous fluid may collect in the cavity of the peritoneum (chylous ascites) or in the pleural cavity. Normal lymphatic glands arc not, as a rule, visible in wounds or during operations, on account of their very small size. Under certain pathologic conditions, as, for instance, in the presence of certain neoplasms rec[uiring operative interference, these glands are removed when discernible. The part Avhich these structures play in the removal of effused blood after subcutaneous injuries is an important one. Red blood-corpuscles, in the course of this resorptive process, are carried by the lymph-current to the reticulum of the lymphatic glands and accumulate within them (vide infra). Inflammation of Lymph=vessels (Lymphangitis). — The relation of the lymphatic radicles to the pathologically altered current in cases of inflam- matory processes permits the admission into these of free bacteria, as Avell as of those inclosed in cells. The lymph-current may become obstructed in the radicles by the corpuscular elements added to the hmiph, or these may be carried on to the next adjacent lymphatic glands ; the latter condition occurs in the majoritA^ of cases. The blood-corpuscles carrv the infectious material, and act to obstruct the current. The role which they play in inflammatory^ pro- cesses is therefore a twofold one: (1) they may transport agents to distant parts; or (2) they may themselves become infected from contact with infec- tious material. Or, what happens more frec[uently, the nearest lymphatic glands become infected. Inflammation of the lymphatic channels speedily follows this infection, and lymphangitis is the result. If this occurs in the radicles, it is knoAMi as reticular lymphangitis, and if in the tnmks, as tubular lymphangitis. The first-named form of the disease consists of a cir- cumscribed patch of reddened and edematous skin, and is frec^uently seen in the neighborhood of a focus of infection (erysipeloid of R o s e n b a c h). which may persist and even be propagated after the entire disappearance of the primary- infection. This is the variety usually present in instances of some- what mild infection, though it may be seen in connection with a virulent infection as well, in which case it is soon followed by the tubular variety. In er\'sipeloid or reticular lymphangitis it has been thought that a specific spore- bearing organism, derived from decomposing animal matter, was the cause of the inflammation (R o s e n b a c h) . The presence of the bacteria, what- ever their form, within the lymph-channels, particularly those which cling to the walls of the radicles, produces coagulation and consec[uent formation of thrombi. These inclose bacteria which, in their turn, infect the thin Avails of the lymph-vessel, and through these the surrounding connectiA'e tissue. In this manner a reticular lymphangitis and cellulitis are combined; this is the form most commonly obserA'ed, and constitutes a form of er\'sipelatous inflammation; it is due to theiuA-asion of the lymph-channels, either from a Avouncl surface or through a sweat-gland or hair-follicle, by Streptococcus erysipelatis (see page 27). A more than usually A'irulent form of infection causes rapid spread of the inflammation, and a tubular lymphangitis is present. Here the thrombi, A\-hen superficially situated, ma}- be perceptible to the touch as a hard cord; the connectiA'e tissue of the sheath of the lymph- A'-essel becomes early infected and inflamed, and the red stripe or streak Avhich is then obserA-ed serA-es to identify positiA^ely the seat of the disease. A number of these thrombosed lymph-A-essels, Avith their accompanying periA^ascular stripes, LYMPHATIC VESSELS AND LYMPHATIC GLANDS 109 are observed ninnins; parallel to one another, and extending from the reticular form immediately adjacent to the primary focus to a considerable distance in a centripetal direction. In case a considerable number of lymph-channels are involved, lymphostasis occurs, and a certain amount of edema complicates the already existing inflammatory swelling. The formation of thrombi in lymph-channels differs essentiall}' from that which occurs in blood-vessels (page 102), dependent, as it is, on the inflam- mator}^ process itself, and resulting from the excessix^e entrance of bacteria within the lymph-vessels, whereby a rapid extension of the disease is caused. Despite this, however, these thrombi are more rapidly resorbed than those which occur as intra-arterial and intravenous thrombi, for the reason that they are in intimate relation, on all sides, with resorbing collateral lymph-channels. This is the usual method of their disappearance. Exceptionally suppurative inflammation and the formation of abscess occur; when this happens, the abscesses are usually seen in circumscribed areas, and quite commonly, singly as well. The strip of redness at the site of the lymphangitis enlarges, and finally a fluctuating swelling appears. It is questionable if so-called organiza- tion of these thrombi ever occurs. Certain!}' cicatricial development in the connective tissue along the hne of the previously involved h^mphatic vessel has never been demonstrated. The prognosis is not particularly affected by the formation of an abscess in the course of a lymphangitis, as compared with the dangers which arise from suppurative inflammation in wounds. On the contrary, a rather favorable influence may be exercised by the formation of abscesses under these circum- stances, as these are quickly circumscribed and form a ready means of elimi- nating the infective agents which ha^^e found entrance into the h-mph- channels. In the treatment of lymphangitis the one thing to be borne in mind is the fact that its extension depends on the combined presence of septic agents and open lymph-channels. The treatment, therefore, must be of the most rigid antiseptic character. Fortunately the open lymph-channels form a ready means for the introduction of antiseptic agents into the region of infection. When the wound cavity can be reached, if the disease is the result of a wound which has become infected, this should be thoroughly packed with gauze, saturated either ^^•ith a 2.5 to 5 per cent solution of carbolic acid, or vith a 1:2000 solution of corrosive sublimate in 50 per cent alcohol. The best application to the reddened patch of reticular lymphangitis, or the stripes of tubular lymphangitis, is a large compress wrung out of the carbolic acid solution. The addition of tincture of opium, in the proportion of an ounce to a pint, to the solution, and the application of an oiled silk covering to the com- press will be found useful. As soon as the more acute symptoms have sub- sided, the use of mercurial ointment along the lines of thrombi is indicated; in the reticular variety a 20 per cent mixture of ichthyol in lanolin is very use- ful, locally applied. Abscess cavities along the course of the l3'mph-vessels should be opened freely and treated antiseptically. No danger is to be apprehended from displacement of lymph thrombi. Even should this occur, they would be arrested in the nearest lymphatic gland. Inflammation of Lymphatic Glands (Lymphadenitis). — The rela- tions between the lymphatic vessels and the lymphatic glands are such 110 INJURIES AND DISEASES OF SEPARATE TISSUES as to render the latter liable to become involved in inflammatory condi- tions of the former. The extent to which this occurs, however, will be in inverse ratio to the intensity of the lymphangitis. The reason for this is obvious. With a high degree of inflammation thrombi form rapidly and the lymph-channels become early obliterated, while in a mild or lesser degree of infection the bacteria will reach the lymphatic glands without meeting Avith great obstruction. The physiologic function of the lymphatic glands favors- the accumulation within their structure of such matter of a foreign character, whether bacterial or corpuscular elements, as may find its way into the lymph- current. The extent to which this may become infected will depend on the intensity of the infection ; this may be of every grade of severity, the resulting inflammation ranging from a slight tumefaction and tenderness to a rapid breaking down and suppuration. Chronic enlargement and induration are not infrequently observed, this condition remaining for years without apparently affecting the health of the individual. The swelling which occurs in lymphadenitis is due to the migration of white corpuscles to the cortex of the gland, and the accumulation of lymph and the formation of thrombi in the gland structure. Besides this, there is a direct inflammatory proliferation of the lymph-cells, equivalent to the migration of the white blood-corpuscles, which are transformed directly into pus-corpuscles. Suppuration may follow, an abscess of the gland resulting. This may occur when there has been no suppuration at the point of original infection, as not infrequently happens in cases of infected wounds of the fingers. Again, granu- lating inflammation (syphilitic, tuberculous, etc.) may give rise to secondary lymphadenitis by infection Avhen no suppuration has occurred at the site of the inflammation itself. Suppuration of the glands may happen early, or a slow breaking down may occur. A single gland is rarely involved, usually the process including a con- glomerate mass consisting of several glands. The capsule of the gland is in- volved in the suppurative process, the latter passing thence to the surround- ing connective tissue (paradenitis), this being an incident in the course of an unusually severe lymphadenitis. This condition of paradenitis may mask the glandular inflammation to some extent, and may partake somewhat of the characteristics of a phlegmonous inflammation, particularly when it occurs in the loose connective tissue of the neck. Or, abscesses may occur in the tissue outside the gland, the latter, enlarged and infiltrated, lying in the cavity yet not itself involved in the suppurative process. Again, the gland may first become the site of suppurative inflammation to a limited extent, the pus from which finds its way into the connective tissue outside the gland, and collects there, and, by a process of ulceration, points toward the surface. If not evacuated, it finds its way out, and a fistulous communication is established leading into the gland. The skin about these fistulous openings is usually adherent to the gland structure underneath, and becomes extremely thin from atrophy due to pressure and the suppurative process going on in the deeper layers of the skin. It becomes quite blue in color, and is very likely to slough if it is made use of as a flap in the operation for the removal of these infected glands. The skin will be found to be loosened here and there from the underlying mass, the center of this undermined portion corresponding to the site of a fistula, of which there mav be several leading to the same mass. LYMPHATIC VESSELS AND LYMPHATIC GLANDS 111 In the treatment of simple lymphadenitis, in case the point of infection can be reached, the rational j^rocedure consists of the application of antiseptic measures in such a manner as to destroy the primary focus. As a rule, how- ever, this will not be discoverable. The treatment under these circumstances will, therefore, be very unsatisfactory. The injection of carbolic acid or of chlorid of zinc solutions into the inflamed glands has not been followed by very brilliant results. The same may be said of applications and injections of tinc- ture of iodin. As soon as an abscess forms it should be opened freely. As a rule, the entire glandular tissue, though diseased, is not involved in the suppurative process. If the abscess cavity is simply opened, under these circumstances, incomplete healing, or at any rate a very tedious convalescence, may be expected. The propei; course to pursue is to remove thoroughly, with either the knife or the curet, any portion of diseased glandular tissue within reach. The fistulas, which are so frequently observed after spontaneous or incomplete opening of an abscess from lymphadenitis, should all be thoroughly incised and the curet employed to curet out their walls, and diseased gland tissue as well. Skin which has been undermined is to be cut away. The curet is to be applied unsparingly until the connective-tissue covering is reached, when healthy granu- lations and complete healing may be confidently anticipated. This may be hastened and a better cosmetic result obtained by skin-grafting. Tuberculous Lymphadenitis.— The chronic granulating and caseating inflammations of the lymphatic glands which go to make up the general picture of tul^erculous lymphadenitis form one of the most important diseases to which these structures are subject. The infective agent almost invariably enters by way of the lymph-channels from some peripheral tuberculous focus. Tuber- culous lymphadenitis frequently follows the so-called scrofulous inflammations of the skin and mucous membrane, such as chronic moist eczema of the face and scalp, chronic catarrhal inflammation of the conjunctiva, the middle and external ear, the mucous membrane of the nose and jiharynx, etc. This accounts for the frequent occ\irrence of tuberculous inflammation of the glands of the anterior and lateral regions of the neck. The conjoint or sequential occurrences of these last-named conditions go to make up the state formerly known under the name of "scrofula." Glands in other regions of the body likewise become the subject of secondary tuberculous deposits, such, for instance, as those in the axilla which follow tuberculous affections of the skin, bones, and joints of the upper extremity and those in the inguinal region which follow like conditions in the lower ex- tremity, and the genital organs ; the glands situated in the ischiorectal region following tuberculous disease of the lower bowel, or of the skin in the anal region (see Fistula in Ano) ; the peribronchial glands in pulmonary tuberculosis, and the mesenteric and retroperitoneal glands in tuberculous enteritis. Lymphatic glands the site of tuberculous infection may either undergo rapid suppurative changes and cheesy metamorphosis, or may remain for a long time as soft semi-elastic swellings, which are freely movable under the skin. In the first named the products of suppuration collect in the capsule of the gland, a paradenitis follows, and the pus finally makes its way toward the surface, emptying itself through fistulous openings on the skin. The second breaks down late, if at all, and cheesy foci are likewise observed 112 INJURIES AND DISEASES OF SEPARATE TISSUES late in the course of the disease. The glands crowd closel}' together in this form and sometimes attain the size of a hen's or a goose's egg. On section they present a grayish diaphanous appearance; their structure breaks down easily under the finger, and somewhat resembles the contents of the medullary cavities of the long bones, although it is somewhat firmer. Microscopic examination of the first form shows infiltration of small cells, composed of migrating leukocytes and newly formed lymphoid cells. Between these areas of infiltration, foci of suppuration and cheesy degeneration are found. This is the variety which affects children principally. The second form, that in which an apparent quiescent state is maintained, is the tubercu- lous lymphadenitis of adolescence; this appears by preference in the cervical and axillary glands. As regards general or distant infection, the prognosis in the latter form is much more favorable than in the former. In the one the tuberculous agent is localized for a long time, perhaps permanent^, while in the other, or in that w^hich affects children, the early suppuration and caseation lead to disintegra- tion and ready transportation of infective agents to distant parts. Treatment. — As long as these glandular structures remain without break- ing down into suppuration or undergoing caseation, comparatively slight dan- ger attends their presence. The difficulty, however, is that the surgeon cannot tell just when either of these processes may be initiated, or what circum- stances will hasten their development. A strict surveillance should be main- tained, and, in case palpation reveals any tendency on the part of the glands to break down, they should be extirpated at once. Their long persistence in an apparently unchanged condition will awaken suspicion that the central portion is undergoing cheesy degeneration, in which case delay in effecting their removal may mean serious peril to the patient. In the very commencement of the infil- tration, injections of iodin may be used with advantage (iodin 1, iodid of potas- sium 4, water 100; Durante). The injections should be made daily. The dose employed is at first about 3 minims, the amount being progressively increased according to the size of the gland and the effect produced. Every portion of each gland should receive an injection in turn, until all portions of the structure have been treated. Or, injections of a 5 per cent solution of chlorid of zinc into the structure of the gland, particularly the periphery thereof, and the adjacent structures may be employed (L a n n e 1 o n g u e) . The amount used at each sitting will vary from four to six drops according to the size of the gland, at intervals of from three to five days, according to the pain and local reaction which follows These measures may be persisted in for several months, particularly if undoubted improvement follows their use. The best results are obtained by proceeding slowly and deliberately. Attempts to hasten the cure by the use of large or more concentrated solutions will, by exciting too great reaction, necessitate abandoning the treatment altogether. A careful watch must be kept for the breaking down of the gland, however, since the treatment may have been begun too late to prevent caseation. The use of ointments of belladonna, mercury, iodid of potassium, etc., or the older methods of painting with tincture of iodin, have now been quite generally replaced b}- injection methods or operative procedures. Internal medication in the shape of ferruginous tonics, cod-liver oil, etc., may result beneficially by improving the general health; this treatment, however. LYMPHATIC VESSELS AND LYMl'HATIC GLANDS 113 should not take the j)lacc of tho iiijoetion or operative treatment, but rather sup,, enient It. (For the technic of extirpation of tuberculous Ivmphatic frlamls, see Operations on tho Neck.) Syphilitic Lymphadenitis.— The infection of syphilis, like that of tuber- culous disease, gn-cs ri.se to f?ranular inflammation of h-m}ihatic o-land^ The ni-umal glands, situated as they are near the most common point of entrance of the mfection. are the first, as a rule, to be involved (see page 197) Other glands may likewise become involved, as, for instance, the epitrochlear and post-cervical glands. It very rarely happens that Ivmphatic glands affected by the syphilitic virus undergo either suppuration or caseous' degeneration Ihe diagnosis of syphilitic lymphadenitis will depend on the historv as to primary infection. In inquiring into this, the possibilitA' of nonvenereal infection with the syphilitic virus should be borne in mind ' The prognosis depends on that of the general infection. The glandular in^-ol^•ement is not such as to excite alarm. The treatment will coincide with the general treatment of syphilis (see page 199). The suppuratiA-e form of bubo follow- ing the venereal sore, known as the soft chancre or chancroid, does not depend on syphilitic infection, and. therefore, is to be treated as a simple sup- purative lymphadenitis. Leukemic Hyperplasia of the Lymphatic Qlands.-Chronic inflamma- tion, or chronic hyperplasia of the lymphatic glands, affecting almost equallv all parts of the gland, lymphoid cells, and reticular structure, accompanies the disease of the blood known as leukemia. This disease does not fall within the province of the surgeon, but is referred to in this connection for the pur- poses of differential diagnosis. The glandular swellings occur in the reo-ion of the neck, axilla, groin, and other regions to such an extent as to form tumor masses; the glands remain freely movable and discrete. Hvperplasia of the lymphoid tissues of the body generally takes place, this occurring as nodules m the mtestmes. lixer, and spleen. The latter mav be palpablv enlarged increase m the number of the leukocytes in the blood is the distinguishing characteristic of the disease, these sometimes equaling in number the red corpuscles, which latter are generally decreased. The course of the disease may be slow or rapid ; m the latter case an infectious process is suggested. .Inemia is a marked s}-mptom. The diagnosis depends on the blood-examination. Proportionate increase of the leukocytes in this disease presents a marked contrast to the absence of this symptom in the onlv affection with which it is likelv to be confounded, namely, Hodgkin's disease or pseudoleukemia (vide' infra) Othen^-lse the two have many points of resemblance. _ No surgical treatment is indicated in cases "of glandular enlargement occur- nng m the course of leukemia. In the present state of our knowledge the extirpation of these glands is as irrational as extirpation of the spleen once aclvocated m this disease. Besides the difficulties of arrest of hemorrhage, uhich IS speciaffy noticeable in leukemia, a positive contraindication is to be found m the fact that the disease on which the local conditions depends can be neither cured nor arrested bv this means. Progressive Multiple Hypertrophy of Lymphatic Glands (Hodgkin's uisease) ; Pseudoleukemia.— This disease, sometimes called malignant lymphoma (B 1 1 1 r o t h), occurs in adolescence and middle life, and is 114 INJURIES AND DISEASES OF SEPARATE TISSUES characterized by an enlargement of the lymphatic glands, first in the neck, and siibseciuently in the axilla and inguinal region. Other systems of lymph- atics become affected, and the disease may finally involve the lymphoid tissues generally throughout the body. It is observed more frecjuently in the female than in the male. Single glands frequently enlarggx to the size of an orange or the fist, constituting in the neck a characteristic deformity. Other and neighboring glands are afterward affected, these latter becoming attached to those first involved, as well as to the underlying skin, by a low grade of inflammatory action. The masses thus formed give rise to more or less circu- latory disturbances in the intracranial organs by pressure on the veins, as well as to dyspnea and dysphagia by pressure on the trachea and esophagus. The spleen has been known to be enlarged, and the tonsils and lymphatic appa- ratus of the intestine as well. Both the etiology and the essential pathology of this disease are very obscure. There can be no doubt that it is an infectious disease, but the special microorganism which produces it still remains undiscovered. The principal difficulty in the diagnosis of Hodgkin's disease is the lia- bility to mistake it for tuberculous lymphadenitis, which it may resemble very closely in the beginning of the attack, for leukemic hyperplasia of the lymphatic glands, and for sarcoma of the lymphatic glands. The rapid extension of the disease to other and distant groups of glands, with absence of suppuration and caseation, will assist in differentiating it from tuberculous lymphadenitis. In making this diagnosis aid may be obtained, where practicable, by the micro- scope, tuberculosis behig excluded in the absence of the characteristic bacillus. Lymphosarcoma may be excluded by the fact that in this latter affection there is an early tendency on the part of the disease to proliferate beyond the boundaries of the gland structure and invade the surrounding tissues. Large tumors thus developed cannot be traced by palpation to the lymphatic glandular tissue, while, on the contrary, in Hodgkin's disease the mass can almost invariably be so identified. Finally, in lymphosarcoma there is sooner or later an involve- ment of the skin in an ulcerative process. The prognosis is very unfavorable ; in its later stages it produces almost invariably a fatal result by the supervention of extreme anemia. The only treatment which, up to the present time, has seemed to have any influence on the disease is the administration of arsenic. In the few cases reported in which success has resulted from the use of arsenic the treatment was gener- ally commenced early in the disease, and was continued over a long period of time. From 5 to 10 drops of Fowler's solution (liq. potass, arsenitis, U.S. P.) or corresponding closes of arsenious acid may be emplo^'ed daily. Operative interference here, as in leukemic hyperplasia of lymphatic glands, is not to be recommended. The Rontgen ray treatment is said to have favorably influenced some cases. INJURIES AND DISEASES OF THE NERVES Contusions of Nerves. — In a severe case of contusion of a nerve the pathologic changes are quite similar to those which follow section. In cases of less severity there are points of difference which relate chiefly to existing con- ditions of the nerve itself. Thickening of the neurilemma at the point of injury, INJURIES AND DISKASKS OF THE NERVES 115 (•:iiis(h1 by a colloction of rouiid-cclls and spindlc-colls, occurs after contusion (E r b), which interferes with the process of re,2;eneration, and, in the course of a few days, the Wallerian degeneration sets in and the medullary substance degenerates; the axis-cylinder is also apparently implicated in the degenerative process (Tillaux). It is asserted that the axis-cylinder remains intact in both the central and the peripheral ends in slight injuries, in which paralysis is complete, though temporary (E r b), as in the so-called " Saturday- night paralysis." This is observed in persons who in the course of a debauch fall asleep in a chair with the arm resting across the back of the latter in such a manner as to cause long-continued pressure on the nerves in the axilla. The lesion probably invoh-es slight hemorrhage in the sheath. But few fibers are separated, and a large proportion of the disturbances are mechanical, involving simply a displacement of the semifluid contents of the tubules (Weir Mitchell). Here degeneration does not occur. Contusions of nerves may be slight or severe, and the symptoms arising therefrom will therefore vary. In fact, a contusion of the soft parts can scarcely occur without some nerve contusion resulting, but this relates to the branches of distribution, and not to nerve-trunks, which alone are included in the present consideration. In the milder cases no more serious symptoms ensue than some pain at the injured point, and tingling and benumbed sensations referred to the periphery, combined with real or imagined subjective sensations of heat. These symptoms pass away rapidly, as a rule; as, for instance, in the well-known accident in which the ulnar nerve is pressed against the inner condyle of the humerus by a blow on this part of the arm. They may remain, however, particularly the tingling, for several days. The symptoms may persist and chronic neuritis, with neuralgic and shooting pains, supervene; trophic changes are finally established. In more severe injuries complete paralysis and anesthesia of the parts supplied by the damaged nerve ensue. This condition may pass away rapidly, may remain for variable periods of time and still be followed by slow but decided improvement, or it may become permanent. Recovery, however, is the rule. Severe crushing of long portions of nerve-trunk, such as is sometimes seen in machinery and railroad accidents, explosions, etc., causes considerable and sometimes severe shock. This is characterized by a weak and small pulse, pallor of the surface, and cold skin and extremities. Slight disturbances of the sensorium are present; rarely complete loss of consciousness ensues. It is extremely difficult, however, under these circumstances, to determine how much of the shock is due to the nerve lesion and how much to the loss of blood which almost invariably accompanies these injuries. . The treatment of contusions of nerves consists in placing the parts at perfect rest ; if there is much pain, this should be relieved by an anodyne. Later on the paralyzed muscles and anesthetic skin should be galvanized or fara- dized, and massage or \dgorous friction applied. In case chronic neuritis supervenes the nerve may be exposed at the seat of injury, and if adhesions are found to be present these should be broken up by nerve-stretching (Bowl by). Other nerve injuries arise from pressure, such as crutch paralysis. This is liable to occur in those who are unused to these artificial aids to progression; 116 INJURIES AND DISEASES OF SEPARATE TISSUES it is rare to meet with examples of it among those who have been in the habit of using crutches. The symptoms are numbness and tingling in one or more fingers, followed by weakness and loss of power in the arm and forearm. Com- plete paralysis may follow persistent efforts to use crutches. The duration of the symptoms will depend on the extent of the mechanic disturbance of the nerve-trunk and the parts involved. The sensory symptoms occur first and are the first to disappear. The paralysis affects some muscles more than others, and hence some recover more rapidly than others. The final outcome of the condition is, as a rule, recovery. Pressure on the nerves during sleep gives rise to symptoms almost precisely like the foregoing. Here the prognosis does not seem to be so favor- able, for, while the sensory symptoms pass away early, the motor paralysis disappears more slowly, and may become permanent. The pressure from the too prolonged apphcation of an Esmarch' s elastic tourniquet during oper- ations on the extremities may cause paralysis: so, too, holding the arm in a forcible manner, or allowing it to rest against the hard and sharp corner or edge of an operating table during profound anesthesia, may give rise to similar loss of function. Compression by tumors, cicatrices, etc., as well as pressure in bony canals through which certain nerves pass, occasionally gives rise to similar paralyses. The treatment of pressure symptoms resolves itself, to a great extent, into a removal of the cause. Where other treatment is necessary, galvanism, friction, etc., are useful. If, in spite of treatment, the symptoms persist, showing the presence of adhesions, and perhaps some thickening of the trunk itself from chronic neuritis, free exposure of the nerve is indicated, which is to be freed from surrounding adhesions and stretched. Division of Nerves. — The first change noticed after division of a nerve is a retraction of the sheath and a spreading out of the myelin over the cut ends, which in a few days become united by a gray translucent tissue. The further changes depend on the distance to which the cut ends finally retract. The nerves possess some elastic fibers in the neurilemma, and the distance between the cut ends increases for several days at least. If a space of a fourth of an inch or more intervenes, or if this amount of nerve tissue is removed, regenera- tion is prevented unless the ends are brought together by artificial means. The encls being left separated for the distance mentioned, the space is filled by cellular granulation tissue containing vessels, which in turn becomes a fibrous cord devoid of nerve tissue. The ends of the nerves undergo degenera- tive changes in the meantime (G 1 u c k). These changes, however, differ in the two ends. In the case of the peripheral end the degeneration commences within a day or two of the injury, and continues until, within two or three weeks, the nerve has undergone complete atrophy. The degenerative changes are marked by destruction of the myelin, multiplication of the nuclei and their encroachment on the medulla, and loss of continuity of the axis-cylinder. In the central end the principal difference relates to the axis-cylinder, which remains intact. The nuclei likewise multiply and increase in size, but, in- stead of encroaching on the medulla, they remain flattened against the sheath of Schwann. An infiltration of white blood-cells into the nerve substance occurs. The upper end of the nerve becomes bulbous. This has been particularly noticed in stumps after amputation. These bulbs were INJURIES AND DISEASES OF THE NERVES 117 forniorly belic^vod to be eoniposcMl of simple fibrous tissue, but it is now known tfuit they contain new nerve-elements as well, or fully developed nerve-fibers which replace the altered distal portion of the cut nerve (H a y em). 'J'lie pain caused by a division of a nerve-trunk is inconsiderable ; the patient will usually refer to the skin wound whatever pain is felt. Numbness and tingling- cause more anxiety than the actual pain. In civil practice shock is not a prominent symptom of nerve division, although in military practice, in which the nerve is divided by a missile or projectile, the shock may be con- siderable. Loss of muscular power and of the sense of touch immediately supervene, and continue as long as the nerve remains divided. Sensation maj^ be affected in many ways; there may be loss of sense of touch and of temperature; analgesia, hyperesthesia and anesthesia, and various other abnormal sensations, such as prickling, tingling, numbness (paresthesia), etc., may be present. The thermal sense is generally lost in proportion to the loss of the sense of touch, and extends over about the same areas as the latter. It may be altogether absent. Patients exhibit no appreciation of heat and cold as applied to the surface in some instances in which complete anesthesia is not present. The anesthesia following a nerve injury varies in extent, and is quite difficult to estimate. The distance at which the two points of a pair of com- passes can be distinguished on the affected surface, as compared with the distance at which they can be distinguished on a corresponding portion of the body on the opposite side, is the best means of testing the tactile sense. The sense of locality may also be diminished or lost. Error may be avoided by light touches of the compass points arising from vibrations conveyed to surrounding and sensitive parts. The application of friction tests should be carefully applied for the same reason. In making the examination the condition of the skin should be taken into account. The hand of a working-man, for instance, in conditions of health is sometimes so insensitive as not to recognize contact of any kind. Complete and permanent anesthesia need not necessarily occur in the area of distrilDution of a sensory nerve, even in complete section of the nerve-trunk. In given cases it is difficult to determine in case of returning sensibility whether the improvement is due to nerve anastomosis or to true nerve regener- ation, and only an examination of the ends of the divided nerve can decide the question. It is probable that neighboring nerve branches, passing within the area of distribution of the affected nerve, convey sensation from that area. In recent cases and in indubitable retraction of the divided nerve ends the occurrence of sensation in the affected area can be attributed only to nerve anastomosis. The importance of differentiating these two causes of returning sensibility is apparent when the question of operative interference and its results is to be discussed. The reaction which the muscles affected show to the different electric currents will likewise govern the prognosis. The persistence of the reaction of degeneration for a period longer than six months, during which time the degenerative process is going on, and at the end of Avhich regenerative processes may be expected (W a 1 1 e r), will be usually followed by further changes of a decidedly hopeless character. 118 INJURIES AND DISEASES OF SEPARATE TISSUES Trophic changes are chiefly of a degenerative nature, though they may be combined with inflammatory conditions. All of the changes grouped under this head are not present, and some of them are of very infrequent occurrence. The trophic changes include the glossy and atrophied skin, almost devoid of wrinkles, and tapering fingers with curved nails, which may be quite soft or abnormally brittle. Eczematous as well as herpetic eruptions may occur. Ulceration and abscess and even gangrene may likewise be present. In parts where hair grows, changes in the latter are very common. There is either an atrophy of the hair-follicles and loss of hair, or the hair becomes very short and brittle. The sudoriferous glands also atrophy, and a dry condition of the parts results. Changes of temperature are observed, that of the affected parts becoming elevated, as a rule. Rapid atrophy and degeneration of the muscles occur. The muscles are transformed into fibrous tissue, and deprived of contractility and elasticity; fatty degeneration may be added to this. These changes come on gradually, the muscle wasting in bulk. Trophic changes of the bones are of comparatively rare occurrence. The changes are chiefly of an atrophic character. Shortening of the long bones has been observed. The arthritic changes may occur shortly after the injur}', or at a later period. One or more joints may be involved. In case but one is attacked, it is likely to be a large one. The joints become stiff, swollen, and exquisitely tender on touch and motion (Mitchell). Some cases are less severe and of a more chronic type. The exact pathology of these joint lesions has not as yet been determined. The possibility of obtaining restoration of function immediately on the completion of primary union is often disputed, but it occurs, though very rarely. If not more than a quarter of an inch intervenes between the nerve ends, and provided a large amount of cicatricial tissue does not intervene, restoration may take place, after intervals varying from nine months to a year and a half. Restoration has taken place after twenty-one months (B o w 1 b y). Treatment. — The most rational method of treatment consists in the immediate or primary suture of the nerve ends. The attempt should always be made to secure primary union. Even if this fails, the nerve is left in a much better condition for subsecjuent regeneration, by the prevention of excessive retraction, than would be the case otherwise. (For the technic of nerve suture, see page 354.) The operation of secondary suture is performed some time after the inflic- tion of the original injury, and is most commonly resorted to in cases in which no attempt has been made to secure primary union of the divided nerve. It may be attempted before the wound has entirely healed, or delayed after cicatrization is completed. The sole indications for its performance are the existence of symptoms which show that a nerve has been divided and has not united. Inflammation of Nerves. — Nerves are not particularly prone to inflam- mation, in spite of their delicate structure. The pain present in acute inflam- matory conditions is partly the result of an involvement of the nerves, and partly due to the pressure exercised by the products of inflammation. Large nerve-trunks are peculiarly insusceptible to acute inflammation in their neigh- borhood. Phlegmonous suppuration not rarely follows the connective tissue along a large nerve-sheath, without apparent disturbance of the nerve itself. INJURIES AND DIRKASES OF THE NERVES ■ 119 Suppuration of nerves is extremely rare, the immunity being most probably due to the fact that the laminated sheath presents an almost insurmountable barrier to the diffusion of pus into the interior of the fasciculi (C o r n i I and K a n V i e r). A suppurative inflammation involving destruction of a nerve- trunk with paralysis in the area of its distribution is luiknown. In inflammation of nerves the result of traumatism (traumatic neuritis) the new cell-formation is continued into the perifascicular connecti\'e tissue, and between the la^^ers of the laminated sheath of the nerve fasciculi. The laminae become separated, the fasciculi are compressed, and the nerve-fibers below the diseased spot undergo degenerative changes. The more chronic the inflammatory process, the greater is the tendency to the development of inflammatory products. In chronic neuritis, therefore, a general enlargement of the nerve due to the growth of tissue of new formation between the fasciculi is found. The compression exercised by the latter interferes with the nutri- tion of the nerve, and degeneration takes place precisely similar to the changes observed in the peripheral end after division. Neuritis is subdivided into the localized and spreading forms. The latter form is the more serious. Neuritis following an injury to a nerve is by no means a common affection. It results more frequently from contused and lacerated wounds than from clean incised ones. Septic conditions of w^ounds favor its occurrence. Symptoms. — Pain at the seat of injury, spreading along the sheath of the damaged nerve, and sometimes felt in the neighboring trunks, and fibrillar tremors or spasmodic movements of the muscles are the most common symp- toms. Paresis or paralysis and trophic changes in the area of distribution may occur. Sensitiveness to pressure and a hardened feeling along the nerve- trunk are sometimes observed. Extension of the symptoms occurs over a larger area as fresh nerve-trunks or branches are implicated (spreading neu- ritis). In this form the pain is more severe at the commencement, but sub- sides later on, owing either to a subsidence of the inflammation or to destnic- tion of the nerve-fibers. The prognosis of acute neuritis will depend on the extent of the damage inflicted, as shown by the severity of the symptoms. The length of the attack, as well as the final result, will vary. Recovery may follow or chronic neuritis may ensue. Chronic neuritis is marked by pain and tenderness along the affected nerve, followed b}'^ exacerbations of numbness and tingling pains in the per- ipheral distribution, dull aching pains increased at night, and sometimes hyperesthesia of limited areas of skin. Trophic changes occur. Some enlarge- ment and hardening along the affected nerve may be perceptible. The mus- cles to which the latter is distributed are at first the seat of twitchings; later paralysis with wasting occurs. Their electric reactions decrease at the same time. The disease may remain localized or spread, the tenderness in the originally affected nerve subsiding with the occurrence of destructive changes, while the nerves secondarih' in^'olved become in time inflamed, tender, and enlarged. Extension of the inflammation to the spinal cord (ascending neuritis) has been obser\-ed clinically as one of the sequences of neuritis, the symptoms pointing to inflammation and sclerosis of the cord. 120 INJURIES AND DISEASES OF SEPARATE TISSUES Treatment. — In the acute form complete rest, with apphcation of cold (ice-bags) or evaporating lotions, and opium for the relief of pain, are indi- cated. Leeches and cupping are also recommended. In the chronic form mercury or the iodid of potassium is to be administered internally, and ano- dynes employed. Counter-irritation is useful (thermocautery). Clalvanism and faradism ma}' also be employed with benefit. Nerve-stretching may be of service. In aggravated cases, with great suffering and a practically use- less limb, amputation may be resorted to. Even this may not avail, the pains persisting in the stump. INJURIES AND DISEASES OF FASCIAE, MUSCLES, AND TENDONS Injury and Inflammation of Fasciae. — The fasciae are distinguished by very wide variations in both extent and composition. Many of them are simple planes of connective tissue spread out beneath the integument or between muscular layers, such as the fascia of the neck, perineum, etc. These do not need special study here, inasmuch as the diseased conditions of the fasciae in these regions are almost identical with those of the subcutaneous cel- lular tissue already described (see page 66). The rigid fasciae, composed of solid transverse fibers, such as the fascia found in the anterobrachial region, the fascia lata of the thigh, and the palmar and plantar fasciae; present certain peculiar characteristics worthy of notice. Incised wounds of the fascia, if made in a direction parallel to the direction of the fibers, gape but slightly; on the contrary, if made in a direction to cross the fibers, they gape considerably. These points are to be borne in mind when making incisions for the purpose of evacuating pus or reaching an inflamma- tory focus in the palm of the hand or the sole of the foot. In the latter situa- tion, the fibers run in a longitudinal direction, and incisions in this direction gape but slightly. In the palm of the hand the fibers are placed trans^'ersely to the long axis of the part. Inflammation of Fasciae. — Fasciae and aponeuroses contain compara- tively few vessels, and are, therefore, but passive agents in inflammatory processes. They serve as barriers in limiting suppurative processes. In extensive phlegmonous inflammation, and in the burrowing of pus, this does not suffice, for the reason that weak points exist here and there, particularly at localities where blood and lymphatic vessels pass through. At these points pus and other septic products pass from one side of the fascia to the other. It is a noticeable fact, however, that while a subfascial suppura- tion is quite likely finally to find its way toward the surface, a subcutaneous phlegmonous inflammation, on the contrary, is usually limited, as to depth, by the fascia. This is due in part to the strong pressure exercised by the tense fascia in case there are accumulations of pus beneath. This circumstance likewise favors the absorption of septic material from subfascial suppuration, and increases septic fever. Inflammatory necrosis of fasciae is quite commonly observed, particu- larly where a phlegmonous suppuration invades both sides of the fascia. This tendency to sloughy conditions is also explained by the presence in its struc- ture of a relatively small number of blood-vessels. In case of extensive injury and loss of substance, laying bare areas of fascia, granulations spring up very INJURIES AND DISEASES OF FASCIAE, MUSCLES, AND TENDONS 121 slowly on the latter; vascularization of the fascia must occur before the latter is able to })ro(luce granulations. Injuries of Muscles. — In injuries of muscles the contractility of the latter play an important role. When the fibers are separated in a trans- verse direction, the wound gapes in proportion to the extent of the division. The application of force by a blunt instrument may result in a separation of the muscular fibers by driving them against the bone underneath, the skin and fascia escaping. Rupture of a muscle may likewise occur without the application of external force (see Injuries of Special Parts). The torn blood- vessels pour out a mass of blood, which fills up the gap between the injured muscular fibers. The connective tissue proliferates rapidly in the coagula and the latter are alosorbed, leaving a swelling of exce]3tionally firm consistency, the so-called muscle callus, or muscular cicatrix. In this, muscular fibers may finally develop. Inflammation of Muscles. — With the exception of some forms of so-called rheumatic affections of muscles (lumbago, etc.), inflammation of muscles is of rare occurrence. In certain conditions of deficient or erratic metabolism characterized by uricemia, infiltrations occur in the muscular and subcu- taneous connective tissue. There may be considerable interference with the function of parts controlled by the muscles involved, and pain and inability to relax these on motion. The involvement of nerves in the infiltration will lead to painful, paresthetic, and anesthetic areas. A peculiar variety of hyperplastic inflammation, characterized by the flnal development of genuine bony plates, affects muscular structures, and is known as myositis ossificans. The affection may be traumatic or nontraumatic. Heredity is supposed to influence its production. Osteomas and osteophytes sometimes occur simultaneously. The x-ray may be employed to assist the diagnosis. Treatment in the nontraumatic variety is generally useless. In traumatic cases complete excision may give relief (Keen). Phlegmonous inflammation f oho wing the plane of connective tissue be- tween the muscles (the paramuscular connective tissue) constitutes what is sometimes known as suppurative myositis. This affection originates, as a rule, in the bony or periosteal structures. While the sheath of the muscle may be invaded by phlegmonous inflammation, and in rare instances the intra- muscular connective tissue hkewise, the inflammation spreading between single bundles of fibers, it is very exceptional for the muscular fibriUae and sarco- lemma sheaths to become involved. It is not an uncommon thing to observe muscular structures intact in the midst of a perfect wreck of tissue, bathed in pus and surrounded by structures involved in suppurative destruction. Small abscesses may be found exceptionally on the belly of the muscles. In metastatic or pyemic infection abscesses occur near the insertion of certain muscles (flexor carpi ulnaris, quadriceps extensor femoris). In glanders, particularly in the slowly developing forms, multiple abscesses appear in the muscular structures. In syphilis a gumma of the muscular struc- ture may suppurate, producing abscess. The migration of trichinae into muscular tissue produces edematous swell- ings, but these are circulatory disturbances rather than the resiflt of inflamma- tory irritation. Sarcomas of voluntary muscles are somewhat rare. The majority of 122 INJURIES AND DISEASES OF SEPARATE TISSUES the cases have occurred in the muscles of the lower extremities. They may occur at any period of life from young adult age to sixty. A locahzed involvement of the sheath is first observed, the disease afterward extending to the belly of the muscle. The localized induration of a sarcoma of a voluntary muscle may be mistaken for a syphilitic gumma in a patient with a syphilitic history. Invasion of muscle from adjacent sarcomas, particularly of the peri- osteal variety, is common. It may also occur in sarcoma of the uveal tract following the involvement of the sclerotic, the disease finally infiltrating the muscles of the globe. Sarcomas of involuntary muscle-fiber are exceedingly rare. Those which affect the uterus have their origin in the endometrium. Injuries and Diseases of Tendons. — Subcutaneous contusions of tendons are of rare occurrence, owing to the solid consistency of these structures. Aside from incised wounds, the most common injury to which tendons are subject is rupture or the tearing off of the tendon at its point of insertion, by exces- sive contraction. This occurs more particularly in the great quadriceps exten- sor femoris at its point of attachment to the patella. In modem times not infrequently machinery accidents produce rupture of tendons in the hand and forearm. Incised wounds of tendons are of rather frequent occurrence. These are observed particularly about the anterior carpal region, arising from suicidal attempts to sever the vessels at the wrist. They are also observed rather frequently in domestic servants as a result of accidentally pushing the hand through the windowglass in cleaning. The posterior metacarpal region suffers among house carpenters, the injury being caused by edged tools falling from a height. The tendo Achillis is sometimes divided in the same way, the falling implement striking the tense tendon just as the individual is taking a forward step with the other foot. Immediate and accurate suture should always be attempted in order to restore the function of the divided tendon (see page 358). In subcutaneous tenotomy for the correction of deformities, particularly of talipes, a "splice'' of tendinous tissue unites the divided ends by means of connective- tissue proliferation. This proliferation originates in the con- nective-tissue covering of the tendon, a portion of which stretches from one extremity to the other after the division of the tendon proper (Adams). Increased vascularity of the vessels in this connective tissue occurs, but the extravasation of blood from the divided vessels of either the skin or the connective tissue between the divided ends is not essential and may be dis- advantageous to the reparative process. Tendons are not invaded by suppurative inflammation, owing to the comparative absence of blood-vessels in children, and their entire absence in adults. Pus-corpuscles may migrate into the nutritive channels, and blood- vessels may invade the tendon during the granulating process in the course of repair. This latter circumstance is rather unfortunate than otherwise, as the function of the tendon is likely to be interfered with by the adhesions which form as the result of this vascularization. Still worse, however, is the necrosis of tendon which occurs somewhat freciuently in the course of a phlegmonous inflammation in the paratqndinous structures. In manv localities genuine synovial cavities develop in the course of the INJURIES AND DISEASES OF BONES 123 paratendinous tissues, f<)i-inin<;- a true synovial sheath. The inflammatory processes miiy attack the synovial lining of the sheaths, constitutin«; the so-called tenosynovitis. This synovial inflammation is practically identical with that which occurs hi joints, and will be discussed in connection with these structures (see page 151). Treatment of Inflammation of Muscles and Tendons. — The preserva- tion of the function of muscles is of very great importance, and special care should be taken to prevent burrowing of septic material along the surfaces of muscles and tendons. To this end, early and free incision in spreading sep- tic conditions, whether of phlegmonous inflammation or of burrowing pus, must be made and efficient drainage provided for. Great damage may be inflicted on the function of muscles, even when these are not actually invaded by the inflammatory process, by considerable masses of granulations develop- ing between the bellies of the same, or about the tendinous structures. Cicatricial tissue forms, and this may prevent the contraction of the muscle. The interdependence of the muscular groups on one another, as well as the con- joint action of muscles of the same group, demands the utmost freedom of motion. Muscles of one group, if impaired in their function, limit the useful- ness of opposing muscles. Under these circumstances of impairment of function, due to the effects of intermuscular inflammatory conditions, much benefit may be derived from the employment of passive motion. This may be accomplished at first under an anesthetic, but subsequently the latter maybe omitted. Complete flexion and extension being accomphshed, the employment of massage, conjoined with systematic passive movements, constitutes the most efhcient means at our disposal. The so-called muscular rheumatism and erratic infiltration are like- wise very efficiently treated by massage and faradization. Articles of food con- taining notable quantities of the purin bodies, which are supposed to stand in a causative relation to the uricemia, are to be avoided, such as certain meats and fish, particularly salmon, the glandular structure of animals (sweet-breads, thy- mus, liver, etc.), pulse (peas and beans) and asparagus, coffee, Ceylon and India tea, and ale. The usual antirheumatic remedies are useless, and some of the most vaunted, such as salicylate of soda, are positively contraindicated. Motor paralyses are also benefited by massage. Although somewhat pain- ful in the application, there is no better method of treatment than massage for muscular hematoma and serous effusions within muscles. INJURIES AND DISEASES OF BONES Contusion.— Force directly applied to a bone is felt (1) in its periosteal covering; (2) in its cortical substance; (3) in its medullary substance. Slighter forms of contusion occur, particularly in bones superficially situated, such as the tibia, ulna, etc. In fracture from direct violence, contusion and fracture are combined. Fissure of a bone, in the direction of its long axis, occupies a ground midway between contusion and fracture. It does not interrupt the continuity of the bone. Occasionally these fissures assume a spiral direction, and have been designated spiral fractures (Fig. 22). They have been known to occur by indirect violence, the patients having been crushed, from above, beneath heavy masses of earth, etc. 124 INJURIES AND DISEASES OF SEPARATE TISSUES Contusion of bone is not, as a rule, an important form of injury. Extra- vasated blood is soon resorbed; a slight thickening may remain. Very rarely suppurative or phlegmonous inflammation follows. The infection producing this finds its way to the point of injury, either from the skin or through the medium of the effused blood. The latter view is supported by the occurrence of nontraumatic infectious osteomyehtis and of syphilitic affection of bones. Extravasation within the medullary cavity of bone still more rarely results seriously, though, in certain cases, inflammation and suppuration may develop. The course of the blood through the medullary tissue favors the arrest of corpuscular elements between the cells of the latter. (See Traumatic Inflammation of Bone, page 139.) FRACTURES Classification of Fractures. — Fractures of bones are divided into in- complete, complete, and comminuted; simple and complicated. The Relations of Direct and Indirect Force to Fracture. — Fracture may be the result of direct and indirect violence. In the former the force strikes the bone directly, while in the latter it is transmitted through some other portion of the skeleton. When an entire extremity is exposed to the force, it is simply a question whether certain ligaments are to be- come ruptured and a dislocation produced, or one or more of the bones are to give way. When indirect force produces the fracture, one portion of the extremity is fixed by muscular contraction, and, acting as the fixed arm of a lever, transfers the force to the bone, which gives way. Seat of Fracture. — The point of fracture, other things being equal, will be at the place of least resistance, and this, in its turn, will depend on the relation of the cortical sub- stance to the medullary and cancellated tissues. The middle of long bones marks the site of the first or diaphysial center of ossification, and at this point the cortical lamellae are strongest and the cancellated structure absent. In the di- rection of the epiphysis, where later ossification occurs, the cortical lameflae are much thinner, and cancellated tissue is abundant. The long bones, therefore, are more solid, though they are brittle at the middle, and the tissue at ^'tkactor"^'*'^ the extremities is loosely built up. In indirect force, there- fore, it is the upper or the lower third of the bone which yields, while in direct force, received in the middle, the latter gives way. In addition, direct force may produce a fracture wherever it is expended. The Character of the Force. — A classification of the causes of fracture, owing to their number, is almost impossible. Projectiles from the modern rifle, as a rule, pass directly through the bone; those from the old-time smooth-bore generally lodged withm the bone. A partially spent ball may likewise follow the latter course. In the case of the former a "punched out" effect is produced. The ball carries a portion of the bone ahead of it, as a solid punch would make a hole. This occurs more particularly in the diaphysis, where the effect is something like that which follows the passage INJURIES AND DISEASES OF BONES 125 of a l)all throus'i :^ wiiulow-pane. In the neighborhood of a joint the ciishion- Ukc structure of the c])iph>-sis may arrest the ball and cause its lodgment. In civil life falls are the most common cause of fracture. Here the force producing the fracture depends on the distance which the body falls, the weight of the body, and, in case of fracture of an extremity by indirect force, the^length of the lever through which the force is transmitted. Crush- ing beneath heavy objects (fallhig banks of earth) and muscular contrac- tion may also be mentioned. In the case of the latter the bony insertions of muscles are usually torn off. Exception- ally a long bone may be fractured by muscular force, as, for instance, in fracture of the humerus occurring in baseball pitchers. Direction of the Line of Fracture.— The hne of frac- ture may be longitudinal, transverse, or oblique. The first named is rare. Ouly a direct and very considerable force can produce a fracture of a long bone. A purely transverse fracture is also rare, for the reasori that the line of fracture will follow the direction of least. resistance, and this differs according to the arrangement of the lamellae. The latter, on transverse section, do not show the same degree of solidity at all points; the line of separation may show a zigzag line for this reason (dentated fracture). From the bottom of the dentations fissures may run in an oblique or longitudinal direction (Fig. 23), according to the direction of the lamellae, constituting a splintered fracture. Comminuted Fracture.— Where several splinters are loosened, or more than two fragments are found at the site of fracture, the latter is said to be comminuted. Brittle- ness of the bones, great velocity of the effecting force, machinery accidents, and crushing by means of a heavy broad surface, such as the wheel of a railway car, are the common causes of comminuted fracture. Incomplete Fracture.— The most common form of in- complete fracture is the subperiosteal fracture. These occur more particularly in rachitic children with thickened periosteum, the untorn periosteum retaining the fragments in position. Partial preservation of the periosteum also oc- curs in cases grouped under the head of epiphysial separa- tion. This is a true fracture, i. e., it is not a separation at the cartilage of the epiphysis, but of the bony structure at the very youngest layer of the diaphysis. It constitutes the most typic form of transverse fracture. It is not so common as was formerly supposed. Green-stick Fracture (Infraction).— The inherent elasticity of young bone permits more or less bending before fracture occurs. Bones of children vield somewhat in this way before breaking. This increased elasticity _ is compensated for, however, by the lessened diameter and diminished cohesive qualities. In this forcible bending of bones which are somewhat elastic, single lamellae give way and a sphntered effect, such as follows the forcible bending Fig. 2.3. — An Ob- lique Fracture WITH Dentated Surfaces, Splin- tering, AND Com- minution . 1, Oblique line of fracture with dentated surfaces; 2, 2, 2, 2, line of fis- sures ; 3, an isola- ted fragment con- stituting a commi- nuted fracture. 126 INJURIES AND DISEASES OF SEPARATE TISSUES of a o-reen twig, occurs (Fig. 24). Green-stick fracture differs from impacted fracture in that, while in the former some of the lamellae give way and others maintain their integrit^y, in the latter the entire thickness of the bone is trav- ersed by the line of fracture. In this sense, therefore, the fracture is com- plete, though at first glance there is no displacement apparent. This, how- ever, is delusive, as shortening of the limb occurs, and there is therefore a longitudinal displacement (see page 127). Complicated Fractures. — Comphcations of fractures refer principally to the soft parts. No fracture can occur without some injury to the surrounding parts. Those in which a wound affords a medium of communication l^etween the atmospheric air and the site of the fracture are known as compound fractures. The term "comphcated" is now applied more particularly to those in which important vessels and nerves suffer injury. Compound Fracture. — The compound variety is the most common of the complicated fractures. Here the communicating wound involves both skin and muscular tissue, except in situations in which the bone is subcutaneous. The wound in compound fracture may be caused by the missile or object which produces the fracture, as, for instance, the bullet in fractures from gunshot injuries, or the toe-calk or heel-calk of a horseshoe in fractures resulting from the kick of a vicious animal. Fractures from indirect force may also be compound, the bone being driven or pushed through. This variety may be properly termed a perforating frac- ture. Noncommunicating Wounds of the Skin in Frac- ture. — Simple wounds of the skin, though not so serious as those which extend to the site of fracture, are still worthy of note. Suppurative inflammation here may prove serious from close proximity to the bone lesion. During the after-course of a fracture a skin wound may arise as a complication, either from faulty dressing or, in case of delirious patients, from attempts to walk. In the former the dangers relate principally to infection from the neighborhood, while in the latter a true perforating fracture takes place. Rupture and contusions of vessels and nerves form special comphca- tions of fractures. In military life these result from gunshot wounds particu- larly, and in civil life they are more often observed in machinery and railroad accidents. Except under these circumstances they are rare. In case of recent fracture inspection in the majority of cases reveals a displacement of the fragment. The strain placed on the bone at the moment of giving way produces at first a bend in the same, owing to more or less flexibility present in all bones. The fracture occurring, the direction of force which produces the bend continues, and deformity at once results. This displacement usually consists primarily of an angular flexion in the long axis of the bone (Fig. 25, A). Contraction of muscles, the support given to fragments by surrounding structures, the weight of the portion of the body below the site of fracture, and the rebounding force may individually or col- FiG 24. — Green-stick Fracture. INJURIES AND DISEASES OF BONES 127 Icctixcly opci'ato to jirevnit aii,i;ul;ir (lis])lacenioiit in tiio long axis. Angular clis})hu'oniont failing to occur, other toi'nis replace it, as shown in Fig. 25. The characteristics of each (lisj)lacement may be seen at a glance. It should he remarked, in connection with the displacement shown at ]), that a lengthening of the limb does not occur, but that the separation of the frag- ments is due to muscular contraction, the bony prominence to which the mu.s- cles are attached being broken off. Impacted Fracture. — Among the peculiar forms of displacement, that in which impaction occurs is to be particularly noticed. Either by external force or by the weight of the falling body, one fragment is driven into the other, and an effect similar to a gomphosis is produced. Impacted fracture occurs Fig. 25. — Varieties of Displacement Occurring in Fractures. A, Displacement in the axis of the bone; B, lateral displacement; C, longitudinal displacement with transverse line of fracture and the overriding of the fragments ; D, longitudinal displacement with separation of the f ragnents ; E' and E-, the overriding of the fragments in oblique fracture (modified after Hueter) . particularly at the junction of the cancellous structure and diaphysis of the long bones, and is most frequently observed in the neck of the femur (Fig. 26). Rotating displacement is likewise observed. This results from the rotation of a fragment on its own axis, the fractured surfaces remaining in contact with each other. Overriding of Fragments. — A combination of two or more of these forms of displacement ma}' be observed. A displacement in the axis, a lateral displacement, and a longitudinal displacement with approximation of the fragments, constitute the form in which overriding occurs (Fig. 25, E^. Mechanism of Displacement. — Whatever displacement occurs, the prin- cipal factors in its production are (1) the character of the force; (2) mus- cular contraction. The primitive form, or that of displacement in the axis, is a 128 IX.I TRIES AXD DISEASES OF SEPARATE TISSUES familiar example of the first (Fig. 25, A), while the longitudinal displacement, with separation of the fragments (Fig. 25, D), illustrates the second. In addition to these, two other circumstances enter into the consideration, i. c, the weight of the body, which is to be considered in relation to the occurrence of impacted fracture, and the weight of the extremity beyond the seat of fracture, which may influence the occurrence of lateral and rotating displacement. Diagnosis of Fracture. — The signs of fracture are (1) deformity; (2) swelling, and perhaps contusion when the fracture is the result of direct force, and a wound in compound fracture; (3) pain and tenderness; (4) crepitus; (5) preternatural mobility; (6) loss of function. Any of these signs may be absent. In examining a suspected fracture we employ chiefly inspection and palpation. Inspection. — The deformity vrill depend on the extent and character of -'. the displacement present. In addi- \' tion to this, inspection reveals the character of the swelling, the extent of the extravasation of blood, and the condition of the skin at the site of fracture. Later on, the swelling, which in the beginning depended on displacement of the fragments and blood extravasa- tion, will be in a measure due to the formation of new tissue, bony and otherwise (see Repair of Bone, page 130). If the extravasation is superficial, the discoloration from changes in the blood-pigment will occur early; if deeply situated, the characteristic blue and yellowish- green discoloration will appear after the lapse of several days. In case a fracture extends into a joint the latter may become swollen from serous effusion or a genuine hemarthrosis may occur. Direct inspection of the injured bone may now be accomplished by the aid of the Rontgen or x-ray, both for the purpose of diagnosis in doubtful cases and as a guide for the manipulation in adjusting the fragments, the fluoroscope being employed for this purpose. A permanent record of the conditioii and relations of the injured osseous structures, as well as of the course and completion of the reparative process, is obtained by exposing a sensitized photographic plate to the .x-ray, with the injured part interposed, a shadow picture resulting (skiagraphy or radiography). As a part of the examination by inspection, mensuration is employed for the purpose of assisting in the immediate diagnosis and of ascertaining the extent of shortening present when restitution of the fragments is supposed to have been accomplished. In measuring the length of a limb and comparing it with that of its fellow, care should be taken to bear in mind differences which. mav exist \\ithin normal limits. Too much stress should not be laid on Fig. 26. -Impacted Intertrochanteric Fracture OF Neck of Femur. IX.IURIKS AXD DISEASES OF BOXES 129 slijiht differences, for tlie reason that, in addition to the inal:)ility to exckide normal discrepancies, tlie method cannot be appHcd with sufficient accuracy to exchide absokitely errors of a half inch or less. Palpation.— Although inspection will frequently be sufficient to establish the diagnosis, in doubtful cases it is often necessary to employ palpation as well. Tenderness is well marked at the line of fracture, and this is of special diag- nostic \alue if none exists elsewkere in the neighborhood. Crepitus, a peculiar grating sound and sensation heard and felt when the fragments moA-e upon each other, is elicited by grasping the seat of fracture with both hands, one above and the other below, and moving these in different directions. Slight rotation will often elicit crepitus. This sign is not of so much importance as was heretofore supposed by the older surgeons. It is quite frequently absent ; in impacted fracture it cannot be produced. In fracture with lateral displace- ment it is difficult to elicit it without first reducing the fragments, in which case, for purposes of diagnosis, it is not then necessary-. The same may be said of the longitudinal displacements. In all of these conditions its existence is not necessarv' for purposes of diagnosis. On the other hand, the attempt to demonstrate it is always a source of suffering to the patient and it may do positive damage, as, for mstance, in the case of an impacted frac- ture of the cervix femoris. Palpation likewise reveals the existence of preternatural mobility. The existence of a fracture undoubtedly permits a certain amount of abnormal movement, and this can be demonstrated by the same manipulations as are carried on in ascertaining the presence or absence of crepitus. This sign, kke that of crepitus, is absent in impacted fracture and m longitudinal displace- ments. In case the fracture is near a joint, it is exceedingly difficult to dis- tinguish between preternatural mobility and normal joint movements. The examination for both crepitation and preternatural mobility may well be omitted until measures have been taken for the application of proper treat- ment in the case. In some cases, such, for instance, as fractures of the internal epicondyle and the malleoli, sole dependence must be placed on the symptoms of swelling due to extravasation and pain at the site of the injur}-. As a funher aid in the diagnosis, palpation may detemiine the number, size, and shape of the fragments. In addition to this, later on in the case, it ^^ill likewise be employed to ascertain the extent of functional disturbance of neighboring structures, joints, etc. Anamnesis. — ^^\Tiile the historv- of the case as obtained from bystanders may be of some avail in assisting in the diagnosis, it should be borne in mind that statements made by the injured person are of but secondary- importance, and should receive but little consideration compared vdxh the objecti^■e symp- toms. L nder all circumstances involving doubt, if a reasonably well-founded suspicion of the existence of a fracture is entertained, the case is to be treated precisely as if the diagnosis were positively assured. It is always best to err on the side of safety, in the patient's interest. It is far better for both surgeon and patient that any number of cases in which a positive diagnosis cannot be made, and in which only a suspicion of fracture is entertained, be treated as fractures, even unnecessarily, than that a single case of fracture be allowed to go untreated until irreparable injury- is done. The differential diagnosis of fracture and dislocation will be treated of under the head of the latter. 10 130 INJURIES AND DISEASES OF SEPARATE TISSUES m 111 Course of Simple Fractures. — The reparative process in simple frac- tures includes (1) resorption of effused fluids and particles of destroyed tissue; (2) the formation of callus. The first named is sometimes accompanied by slight fever (aseptic fever of V o 1 k m a n n) and some lymphatic swelling in the groin or axilla. During the first few days albuminuria and the presence in the urine of debris from the destroyed red blood-corpuscles are occasionally observed (Riedel). Fat embolism, resulting from the break- ing up of the medullary substance and its absorption by the lymph-channels, from which it finds its way into the circulation, is sometimes obser\'ed in connection with multiple fractures or the crushing of a single large bone. The arrest of fat emboli in the pulmonary circulation leads to edema of the lungs and consequent dyspnea, which may terminate fatalh'. The fat globules obstruct the capillaries of the glomeruli and are excreted with the urine. The supply of fat may be intermittent and occur at different stages of the repair. Callus is formed principally by the periosteum and medullary tissues; the former, how^ever, plays the most important part in its production. During the first few days calcium salts are deposited between the ends of the fragments. In the meantime the torn periosteum becomes reunited and a ring of new formation occurs at the site of the fracture. This is the provisional callus (D u p u y t r e n) , and is formed by the innermost or osteogenetic layer of the periosteum (Oilier). At the same time the medullary substance forms the defini- tive callus (C r u V e i 1 h i e r). The Haversian canals likewise take part in the production of bone, and to a slight extent the cortical lamellae as well. The process of ossification commences in the newly formed tissue be- tween the fragments; this tissue, together with that fur- nished by the periosteum and medullary structure, becomes welded together in a solid mass, and the formation of cal- lus is completed.* The length of time which the entire process of repair occupies in man varies from three weeks to as many months. The average time is from five to six weeks. After the completion of the reparative process, regen- eration of the callus (L o s s e n) occurs. This consists in a gradual restoration of the callus to the condition of true bone. Sys- tems of regular lamellae are produced, and the dowel which divided the med- ullary cavity of the bone into two portions is replaced by true medullary substance. This process occupies a year or more. In fractures involving articular extremities the medullary callus is finally converted into true can- cellous structure. In fractures of the neck of the femur the reformed cancel- lous structure follows the lines best calculated to bear the weight of the body, as in the normal state. * The terms " provisional " and " definitive " callus are liere retained; the terms, how- ever, are not quite exact. Although the outer ring is formed somewhat earlier than the connecting dowel from the medullary substance, j^et both alike contribute to the final repair. am m Fic. 27.— Repair of Bone. 1, Periosteal cal- lus; 2, medullary cal- lus or dowel ; 3, loos- ened periosteum. INJURIES AND DISEASES OF BONES 131 The roi-niation of callus ami its final change to normal bone are anal- ogous to the process of repair in soft parts when union by first intention occurs. The histologic processes, consisting of cell infiltration, new formation of vessels, and condensation of newly formed tissue, are quite similar. The newly formed bony tissue is the result of the proliferation of existing osteoblasts.* The manner in which the periosteal and medullary newly formed tissue appropri- ate fioin the circulation the salts necessary for their proper construction is as yet unexplahied. A curious circumstance in connection with this matter is the fact that, under the influence of irritation, particularly that of hematic origin incident to extreme displacement or defective fixation of the fragments, the neighboring structures become the sites of deposits of callus. These deposits are instances of superfluous callus, for the reason that they take no part in either the temporary or the permanent fixation of the fragments. Excessive fonnation of callus is that condition in which an undue amount of reparative material is formed at the site of the fracture, and is considerably in excess of the requirements of definite repair. Excessive, like superfluous, callus is the result of undue mechanic irritation, such as improper coaptation or insufficient fixation of the fragments. It is formed principally from the osteo- genetic layer of the periosteum in transverse fractures. The circumference of the bone may be two or three times in excess of the normal, this being due in part to the displaced fragments, and in part to the necessity for a large mass of reparative material to form bridge-like masses of bone between lateral surfaces, in order to maintain the weight of the body in fractures of the lower extremity, on the completion of the process of repair (Fig. 25, C). In fractures with longitudinal separation of the fragments an excessive amount of callus at first develops in filling up the gap between the fragments (Fig. 25, D). In oblique fractures with overriding of the fragments (Fig. 25, E^ and E") the excessive callus is produced by both the medullary substance and the periosteum. Considerable impairment of function may result from the presence of excessive, as well as of superfluous, callus. The imprisonment of a nerve-trunk may lead to severe neuralgia and paralysis. This is illustrated in the case of the musculospiral nerve in fractures of a shaft of the humerus. Functional chsability of tendons and muscles may result from the relations which, these bear to excessive and superfluous callus. Ulceration of the skin at the site of the injur}' from friction of bandages or clothing may also follow excessive callus. Defective Fonnation of Callus; Pseudarthrosis. — Insufficiency of callus formation may be relative or absolute. The first named is due to local dis- turbing influences, while absolute defective formation of callus depends on general nutritive disturbances. The causes of relatively defective callus formation are the following: (1) Excessive splintering or crushing of the bone. Here it is impossible for callus formation to occur until vascularization of the separate fragments has taken place. Hence delay, varying from four to twelve weeks, occurs in this * AMiile it has been asserted that the leukoc}i:es form a new osteoblastic cell, this is probably not the correct view. The traumatic irritation reduces the bone to a condition analogous to that of young bone or identical with it. This is supported by the fact that, very frequently, cartilaginous tissue is found in the newly formed periosteal callus. 132 INJURIES AND DISEASES OF SEPARATE TISSUES class of cases. It is somewhat rare for complete failure of union to occur. (2) Impossibility of complete coaptation of the fragments on account of the presence of a parallel unbroken bone, as in the case of the forearm and leg. Here each end may form both a periosteal ring of callus and a medullary dowel, but these fail to reach each other and unite. Displacement longitudi- nally, with separation of the fragments, will, in like manner, act as a cause of failure of union. (3) The interposition of muscle, tendinous structures, etc., as well as the occurrence of profuse hemorrhage between the fragments, also leads to failure of union. (4) Too early movements of the fragments, either through the restlessness of the patient or through the use of defective retention apparatus, may result in the formation of a synovial sac at the site of the fracture. These are cases of pseudarthrosis in the proper sense, and are to be dis- tinguished from cases in which a simple movable connection between the frag- ments has taken place. Other local causes of pseudarthrosis and of movable connection between fragments of bone may occur without fracture, as, for i:istance, in loss of sub- stance from necrosis following suppurative periostitis and osteomyelitis. The general disturbances of nutrition which produce absolute failure of callus formation are included under the following: (]) Rachitis. This may simply retard the healing process, arrest it in its progress, or prevent it alto- gether. Antirachitic treatment is indicated. (2) General syphilitic infec- tion may lead to the replacement of the reparative process by a syphilitic induration. Antisyphilitic treatment will be required before the normal proc- esses of repair can proceed. (3) The presence of the cancerous cachexia, the condition of carcinosis, or the local occurrence of malignant disease. It is not always possible to determine whether or not the latter preceded and pre- disposed to the occurrence of the fracture or' not. (4) Scorbutus is said to interfere with the formation of callus. (5) Pregnancy, by withdrawing the lime salts from the maternal circulation in the course of the formation of the fetal skeleton, renders the formation of callus more difficult. (6) Chronic alcoholism also interferes with the reparative process in fracture. (7) An inhibition of the trophic nerve-fibers, due to injuries of the trophic centers after spinal injuries, or disturbances of them, interferes with the local nutritive processes and thus iDrings about failure or retardation of union. (8) Infection and excessive suppuration at the site of fracture may prevent the completion of repair. (9) The occurrence of an acute infectious fever, such as typhoid, may also be mentioned as tending to prevent union. The Course of Compound Fracture. — Provided an aseptic condition is maintained or an antiseptic state secured, compound fracture may undergo the process of repair in the same manner as a simple fracture. Not the severity of the injury itself but the absolute care which the surgeon bestows on the case and the relative susceptibility of the particular tissues involved will decide the question. The difficulties in securing an antiseptic condition are caused by the irregular shape and course of the v,^ound which leads to the bone, as well as by the layers of loose connective tissue beneath the skin and between the muscular aponeurotic planes throiigh which the wound passes, since these readily become the seat of extensive phlegmonous inflamma- tion. The medullary structure, particularly in young persons, is peculiarly INJURIES AND DISEASES OF BONES 133 prone to a high grade of plileomonous inflammation (acute septic osteomyel- itis), which, if the patient escapes with his life, will impair the usefulness of the limb through failure or insufficient union of tlie fragments. This is par- ticularly liable to occur in comminuted fracture, the supply of blood being cut off from the smaller fragments by the infiammator\- process, so that these undergo necrosis. These necrotic fragments ma\' become imprisoned in the callus, forming the so-called sequestra. Callus may form at some distance from the fracture, where the inflammation is not of so high a grade. Small fragments Nvhich have been cut off from the blood-supply, provided the case pursues an aseptic course, may be inclosed bv callus, and maintain their vitality. Prognosis in Compound Fractures.— The prognosis of fractures com- plicated with \vounds of the soft parts relates (1) to the danger to life; (2) to the integrity of the limb. Acute septic fever may destroy life in a compara- tively sliort time, or a fatal result may follow chronic suppurative fever, with amyloid degeneration of the alxlominal organs. The function of the limb may be temporarily or permanently impaired, or altogether destroyed. This may be due to influences affecting the bone itself or the surrounding parts. Of the former, may be mentioned the retardation of the consolidation of the frac- ture, the shortening of the limb in consequence of removal of sequestra or frag- ments at the time of injur^^ and the disturbances of growth before the full development of the skeleton. Suppurative inflammation of an adjacent articulation, and disturbances of functions of muscles and tendons in the neigh- borhood from acute and chronic inflammation of connective tissue planes, are instances of the latter. Molecular disintegration of the bony stmcture,' or caries, and death of the bone en masse, or necrosis, may occur. The first of these results from inflammatory granular proliferation, the second from suppurative inflammation. Treatment of Simple Fractures.— Reposition.— When displacement of the fragments is present, these must be "reduced," or reposition effected, general anesthesia being employed, if necessary, and measures taken to secure their retention as nearly as possible in the normal position. When no dis- placement is present, the latter alone will be necessary. The methods of reduction to be employed will vary according to the part injured and the char- acter of the displacement. Mechanic aids to reduction are seldom, if ever, employed at the present time, anesthesia having made them unnecessary. Extension and Counter-extension.— Force in the direction of the long axis of the limb, when peripherally applied, is called extension; the force which opposes this, or makes traction in the. opposite or central direction, is called counter-extension. When muscular resistance is too great to permit reduction by the exercise of the surgeon's unaided strength, an anesthetic should be administered. The latter should likewise be employed if consider- able pain attends the examination or the effort at reduction. Impacted Fracture.— It may be to the patient's interest not to reduce a fracture, as, for instance, when immobilization has taken place through impaction of the fragments, as in fracture of the cervix femoris in an elderly patient, and there is reason to believe that permanent union through the forma- tion of callus may follow, when otherwise this would be unlikely to occur. The so-called ''green-stick" fracture, however, though held firmly by the inter- 134 INJURIES AND DISEASES OF SEPARATE TISSUES denticulation of surfaces of the fragments, will require to be forcibly reduced in order that the normal axis of the limb may be restored. Certain ])ositions of the limb favor both reposition and retention. This is well illustrated in fractures of the clavicle and of the olecranon process of the ulna. Again, it may happen that the dislocated portion cannot be made to approach that which is still normal, in which case the latter must be made to acconmiodate itself to the former. Fracture of the upper third of the femur illustrates this. Reposition of fractured bony processes may be assisted by placing the joints in such a position as to relax the muscular structures attached to them. When a reduction is indicated, it must be completely performed before a retention apparatus is applied. One must not expect splints by pressure to complete a reduction that has been incompletely performed. Retention of the Fragments. — The fragments being restored to their normal position, it becomes necessary to apply such means as will overcome the tendency to redisplacement arising from involuntary muscular action, from vohmtary movements on the part of the patient, and from the weight of the parts. The apparatus used in simple cases consists of splints and retentive bandages. These are applied to the whole or a portion of the limb, should always include, when possible, the next adjacent articulation and suf- ficient of the circumference of the limb to provide against movements of the broken parts on each other, and should be made to fit the various in- equalities of the limb by systematic padding. Injurious constriction is to be guarded against on the one hand, and a too loose application of the splint on the other. As a result of constriction, gangrene from venous stasis, and loss of the limb may follow. Failure to guard against pressure on bony prominences sometimes leads to gangrenous ulceration at such points, which may extend to the periosteum and finally cause loss of bony substance. Too loose an application of the splint, on the other hand, while it does not lead to such disastrous consequences, gives rise to considerable pain, on account of the mobility of the fragments, and may be followed by the occurrence of deformity, if not by failure of union. Retention of the fragments may be accompUshed, under certain circum- stances, by means of permanent extension (Buck). This may also be employed as a measure of reduction by tiring out the muscles, as in certain fractures of the thigh. The extending force is usually applied below the seat of fracture; in some instances, where it is necessary to overcome the action of muscles and there is not sufficient space below the fracture to apply the plaster extension strips, these may be applied above (B a r d e n h e u e r). Very oblique fracture of the tibia and fibula low down in the leg, in some cases, can be retained in no other manner. When extension is substituted for splints, or used in conjunction with them, provision must be made for a counter- extending force. The elevation of the foot of the bed or the use of a perineal band fulfils this indication in fractures of the lower extremity. Weights, grad- uated to the requirements of the case, with a friction roller or pulley, or elastic extension is used, as, for instance, in fracture of the femur. After reduction and the apphcation of retentive apparatus, fluoroscopic inspection should be employed to verify the correctness of the apposition, and a skiagraph of the parts obtained for the future protection of the surgeon. INJURIES AND DISEASES OF BONES 135 Treatment of Compound Fractures. — The treatment of a fracture complicated with exposure of the fragments to the atmospheric air, is that of a simple fracture, with the addition of aseptic or antiseptic treatment of the wound of communication. 'J'horough disinfection of the parts must precede the rethietion. Some special difficnilties to be met, in addition to those usually encountered in ordinary wounds, may be mentioned here. A compound fracture may be infected through the medium of foreign bodies containing infectious material, or the source of infection may be the skin of the patient. On this account the latter must be at once thoroughly cleansed and shaved for a considerable distance around the wound. Most foreign bodies, even a bullet from a firearm, convey infection of greater or lesser degrees of harmfulness. The most harmful of foreign bodies, however, are the pieces of clothing, hair, straw, etc., which so frequently find their way into wounds of compound fractures. Digital exploration is advisable whenever possible and when the circumstances will permit thorough disinfec- tion of the exploring finger, for only by this means can certain foreign bodies be distinguished from the contused soft parts, and the extent of splintering and the presence of detached fragments be determined. A sterilized finger- cot of thin rubber placed over the exploring finger is a wise aseptic pre- caution. The removal of all loose bone splinters must be the next care. Though these do not necessarily become necrotic, still it is better to remove them when- ever possible, in order to prevent the irritation arising from their presence, as well as to facilitate drainage and to get rid of the medullary substance which may cling to them, and which undergoes putrefactive changes very rapidly. Large recess cavities in the depths of the wound serve as an indication for counter-openings for purposes of drainage. When these are made, they should be in a position where gravity will aid in affording exit to the wound secretions, and sufficient in number. It is a mistake to suppose that a single drain, in these cases, will serve the purpose. Every portion of the cavity, in all its recesses, must be thoroughly cleansed, irrigated with sterile saline solution, and either closed or packed with antiseptic gauze, according to the indications in each case. The antiseptic dressings are to be applied in each case in such a manner as to permit the employment of the necessary splints or other retentive apparatus. Very small punctures of the skin may, under certain circumstances, be simply cleansed as to surroundings and sealed with collodion, to which bismuth subiodid or iodoform has been added. A projecting point of bone should be removed before reduction, in order still further to lessen the chances of infection. The After=treatment of Fractures.— The fact that the injured part is, in a manner, hidden away from the surgeon's gaze, and that the frequent disturbance of the seat of fracture is but a meddlesome procedure and not calculated to further the patient's best interests, taken in connection with the fact that certain important deviations from the normal course of repair may arise and without due care be overlooked, renders it important that the following precautionary measures should be taken: 1. Inspection of the peripheral parts (the fingers and toes), in order to 136 INJURIES AND DISEASES OF SEPARATE TISSUES determine the presence of venous stasis, due to constriction from the bandage, or inflammatory swelling of the injured soft parts. This is evidenced by swell- ing and a bluish color. If pressure on a toe-nail or finger-nail produces a blanched appearance which is very slow in changing again to its former color, the dressings are to be removed immediately and reapplied more loosely. 2. The occurrence of pain is the rule during the first few days following the injury. This, however, is usually such as can be easily borne l^y the average patient. Should it, however, become excessive and progressively increase in severity, the dressings are to be removed and reapplied. In frac- tures of the leg special heed should be given to complaints of burning sensa- tions or pain in the heel, since an intractable pressure sore frecjuently develops at this point. 3. The indications arising from the temperature should be carefully weighed. The resorptive, or V o 1 k m a n n ' s aseptic fever, may exist during the first few days (see page 47) in simple fractures, having its origin in the sub- stances which pass into the general circulation from the place of injur}', such as disintegrated iDlood-corpuscles, the fibrin ferment of the blood, and med- ullary fat from the marrow of the injured bone. The aseptic fever of itself need give rise to no alarm. Should, however, a temperature of 102° to 103° F. be reached, it is an indication for an inspection of the parts and a renewal of the dressing. Inflammatory disturbances may, under these cir- cumstances, be found to be present, and the fever prove to be a septic or pyemic fever, with its focus at the point of injury. The ambulatory treatment of fracture of the lower extremity, enabling the patient to walk about with no other aid than that of the special splint applied, is sometimes attempted, with the expectation that the patient's general health will be conserved, the local processes of repair stimulated, and more rapid and firmer union secured. The method is not one of general applicability. In compound fractures freciuent inspection of the parts will be made necessary by the occurrence of discharge or elevation of temperature, as above described. Simple fractures with but slight or easily corrected displacement may be allowed to remain uninspected for a period averaging about four weeks from the time of injury, unless the dressings loosen and require removal on this account. In very oblique fractures it is wise to remove the dressings at the end of the second or during the third week, in order to be certain that the displacement has not recurred. Fractures in the neighborhood of joints in which there is practically no tendency to displacement, so that manipulation may be made, should be massaged daily from the commencement. In fact, any fracture of the extremities may be treated in this manner wdth advantage where the conditions present will permit it. In all cases, where practicable, the patient should not be confined to bed any longer than is necessary, but should be allowed to move about at the earliest possible moment. Treatment of the Functional Disturbances Following Fractures.— The disturbances of function which follow union of fractures consist in (1) edematous swellings due to circulatory changes in the parts; (2) the presence of the residuum of the extravasation; (3) adhesions in and about muscular and tendinous structures; (4) atrophy of muscles from nonuse; (5) interfer- INJURIES AND DISEASES OF BONES 137 ence with tlio movements of neighboring joints from excessive callus or hiflammiitory exudate; (6) undue shortening of the limlj; (7) vicious callus. The first four conditions named are benefited by massage, elastic Ijandages, passive movements, warm baths, electricity, etc. Interference with the movements of joints which cannot be remedied by passive motion will be described later (see page 161). Undue shortening of the limb is to be remedied by an extra thickness of sole on the shoe worn on the injured side. When partial union or delayed union is encountered, it is often well to use various orthopedic braces to protect the limb, to shorten the period of confinement, and to permit an improvement in the general health, which in turn will often promote more complete repair in the fracture. Un- united fractures are to be treated on the hues laid down in the section on operations on bones. Amputation for these complications is seldom resorted to at the present day. In case of joint disturbances of an intractable nature, particularly those of the shoulder-joint, resection may become necessary^ to restore the function of the limb. Osteoclasis, or refracture, may be necessitated by undue deformity, and resection of the callus in vicious- union in which the function of a neighbor- ing bone is interfered with, as, for instance, the radius and ulna in their func- tions of pronation and supination. GUNSHOT INJURIES OF THE LONG BONES The destructive effects of the old and new projectiles are alike severe, and in certain localities, as, for instance, the femur, the injury inflicted in some instances by the modern bullet is scarcely exceeded by that produced by the old spheric missile of former times. Owing to the great resistance which compact bone offers to the impact of projectiles, lesions of the diaphyses in gunshot mjuries are much more exten- sive than in the case of the epiphyses (see Gunshot Injuries of the Joints, page 147). In the case of the jacketed bullet of high velocity and at short range the bone is finely comminuted, and the debris from it is driven along the wound canal. Bony fragments are torn loose from the periosteum and increase the damage to the soft parts, the bone being fissured in its long axis in both directions. The wound of exit in the bone is much larger than that of entrance, showing the effect of resistance in causing an explosive reciprocal back-action on the projectile through which a part of its intrinsic power is con- verted into deformation (R e g e r). At longer range the missile is deprived of a part of its velocity before striking, as a result of which the perforating and explosive back-action effects are lessened and the shattering effect is increased. The fragments are larger and remain attached to the periosteum, and the fissures are longer. Under favorable circumstances, Q THE JOINTS ^'^^ tion-il .vmptoms. closelv resembles a septic arthritis. Tenderness and pam on motion, loss of function, and general sepsis are present. It is not eas> to dia-nose some of these periarticular inflammations. It may be noted that the° characteristic position assumed by the joint in question, when it is the he of a septic arthritis, is absent. This is clue to the fact that mtra-articu ar iension is not present to cause the position. The onset of these cases is also less abrupt, as the absorbing surface is less extensive. The treatment of these cases is incision and dramage : tliLS should be prompt, so as to protect the adjacent joint. The prognosis for a full recovery- of function is excellent. CONTRACTURE AND ANKYLOSIS Contracture.— A restriction of the normal range of motion in a joint con- stitutes a contracture. Cicatricial contractures arise from the action of more or less extensive cicatrices these usuallv resulting from bums and scalds and situated on the flexor aspect of the limb. The skin alone, or the skin and the fascia and muscles in addition, mav be involved in the cicatrix. The joint is not neces- sarily involved, though secondar^' changes, from pressure and position, may take i^lace in the articulation. . . . Myogenous and tendogenous contractures are consequent on mj lines and inflammation of the muscular apparatus. The muscles may be prevented from moving independentlv of one another, or they may be shortened from nutritive disturbances foUo^^ing rupture, or from cicatricial deposit toUow- ino- the accident, as. for instance, the wiy neck after a breech dehyer^'. FamiUar examples of tendogenous contracture are found m the contracted fin- gers so commonlv obser^-ed to foHow phlegmonous iiiflanmiation of the pahn ot the hand and invohing the sheaths of the flexor tendons. Neurogenous contracture develops after paralysis ot the motor nen'es, the mu-cles undersoing nutritive shortening. Pes paralyticus is the most important of the contractures in this group. Here the muscles that are para- Ivzed suffer from the continual tension to wliich they are subjected, wMe the muscles that stiU receive a proper nen-e-supply become permanently shortened bv a constant approximation of their points of origin and msertion. from ab- sence of an opposing force. Paralysis of a single nen-e trunk may comphcate the conditions. Neurogenous contractures of the hand and fingers are usually distinctlv defined. . ^ . ■ ■ • ^i ^ ;^;r.+ Arthrogenous Contractures.-This group finds its ongm m the jomt apparatus itself, and is of the greatest importance in its bearmg. especiaUy on the prognosis of arthritic inflammation. Etiologically. arthrogenous contrac- tures mav be divided into those which are congenital and those which are inflammator^^ The first named appear as contractures of the foot (<;ongenital clubfoot)- less frequentlv as contractures of the carpus (congemtal clubhand); finaUy, still more rarely' as congenital knock-knee, or genu valgum (see these deformities). . . , _^i \moncr the most important seciuels of arthritis are the arthrogenous contractures Thev form the great majority of cases of tins class coimng under obser^-ation; hence their hnportance. ^Mren due to the presence 160 INJURIES AXD DISEASES OF SEPARATE TISSUES of an acute synovial inflammation, on the disappearance of this in most instances they vanish in whole or in part. In other cases some disturbance of function, more or less permanent, results. The contracture due to tension of the joint capsule in larjje effusions within the joint is likewise, as a rule, onh' temporary. Granulating inflammation within the capsule, however, inter- feres greatly with the movements of the joint. Cicatricial contracture of the capsule prevents it from following the joint movements. In cases of osteo- arthritis the swelling of the bony substance likewise restricts the movements. Proliferation of the cartilaginous or synovial tissue will offer mechanic ob- stacles as well. The indurations remaining in the subsynovial connective tis- sue after suppurative inflanunation of the synovial membrane interfere more or less "^'ith the mobility of the joint. Fracture in the neighborhood of a joint or communicating with it, by an abundant formation of callus may restrict its movements very seriously. In the case of the elbow-joint, particularly, the deposit of callus in the capsule (the so-called ossification of the capsule) is of great importance. Projecting masses of callus having their origin in the torn periosteum, or in displaced centers of ossification in children, also hinder the mo^'ements of the joint. Finalh', hyperplastic synovial inflammation, giving rise either to vascular processes in two or more portions of the joint which become adherent, or to direct adhesion of two opposing surfaces, as in pannous synovitis, may seriously cripple the usefulness of the joint. Ankylosis. — This term means literally an angular, bent, or crooked joint. In this sense it may be applied to most contractures. It is properly applied, however, to joints w^hich are incapable of movements, whether in the flexed or in the extended position. False Ankylosis. — This term is applied to those cases in which joints, apparentl}' immo^'ably fixed, can be moved throughout the normal range, under an anesthetic. Muscular spasm of these cases is the cause of the rigidity. True Ankylosis. — This signifies a solid attachment of two articulating surfaces. Three varieties are distinguished: (1) the fibrous; (2) the cartila- ginous; (3) the osseous. Fibrous Ankylosis. — In this variety movements may be impossible^ or a certain amount of mobility may be present. The extent of motion will depend on the firmness of the tissue connecting the joint surfaces. This tis- sue is derived from either the synovial membrane or the connective tissue of the medullar}^ structure. In the first case it occurs in the shape of smooth projections from the border of the capsular insertion on the joint surfaces. Two layers of connective tissue, therefore, are present, each progressing over its corresponding articular surface. These may unite directly, the underlying cartilages becoming attached to each other through the medium of these layers of newly formed tissue. In cases in which the cartilage has been destroyed in consequence of an advancing granulating myelitis, the bony tissues them- selves are connected by means of this connective tissue, which, soft at first, may, in consequence of cicatricial contraction, become firm and fibrous. Cartilaginous Ankylosis. — The fibrous form may become converted into the cartilaginous by the development of cartilage in the connective tissue cover- ing the still intact joint cartilages. This variety may occur after granu- THE JOINTS 161 latiiiii; synovitis and snppurative conditions; it is most frequently observed, }u>\\ (^cr, after fractures communicating with the joint. Osseous Ankylosis. — Bony ankylosis may develop after either the fibrous or iho cartilaginous form. In the former case a cicatricial development of connective tissue occurs, the cartilage being destroyed in whole or in part by a granulating myelitis. This cicatricial tissue contracts and gradually ossifies in \-ery much the same manner as callus in union of fractures. In the latter case tlic cartilaginous strip, which still remains intact, ossifies. It is therefore evident that ankylosis appears first as fibrous; this may subsequently be converted into the cartilaginous and thence into the osseous, or may pass directly into the osseous. In either case the transformation is necessarily very slow, occupying years for its completion. Treatment of Contracture and Ankylosis. — While every effort should be made to preserve as far as possible the full range of movement in the limb, it will occasionally happen that, in spite of every precaution, ankylosis occurs. Under these circumstances it is imperative that the position of the joint should be such as to insure the greatest usefulness to the limb. In the case of the knee, this will be in an almost extended position, and in the elbow, at a right angle. The treatment of both contracture and ankylosis may be divided into (1) manual passive movements ; (2) manual correction under an anesthetic ; (.3) cor- rection by weight and pulley extension; (4) correction by instrumental means (pressure and traction) ; (.5) tenotomy ; (6) resection ; (7) osteotomy ; (8) amputation. Manual passive movements should be first attempted. Slight contrac- ture of short duration will frequently yield to these. Passive movements promise success when an increase in the range of motion is evident on measure- ment. When night pains follow the employment of passive movements, no improvement is to be expected, as a hyperplastic inflammation is being set up which tends to increase still farther the rigidity. They must then be employed less vigorously or give place to other methods. When they have failed, man- ual correction under an anesthetic may be resorted to, in which consid- erable tearing of the tissues results. This forced correction should not be applied to tuberculous joints until all active processes have ceased. Even then it may arouse a latent focus to renewed activity. This may or may not precede the third method, that of correction by weight and pulley extension. The latter is usually resorted to when the deformity results from excessive irritability of the muscular structures due to an active inflamma- tory condition. Correction by instrmnental means consists in the adaptation of appara- tus which accomplish the object by gradual pressure and traction, such, for instance, as in congenital clubfoot and knock-knee (see these deformities). Tenotomy or myotomy may be substituted for the above in cases in which the contracture is of tendinous or. muscular origin. It is employed also in cases in which it is necessary to remove resistance of tendons in order to per- mit other methods of treatment, e. g., extension by traction in ankylosis of the knee after section of the hamstring tendons. Resection of the diseased joint, or of such portions thereof as are necessary for the correction of the deformity, constitutes a very effective method of 12 162 INJURIES AND DISEASES OF SEPARATE TISSUES treatment. It is particularly useful in cases in which a newly formed joint may develop (see Resection of Wrist-joint, Elbow-joint, Shoulder- joint, etc.). Osteotomy. — Osteotomy is specially applicable to the hip-joint and the knee-joint. It is performed by saw or chisel, applied as near the apex of the deforming angle as possible and followed by a proper adjustment of the sawed surfaces. Amputation is a last resort. It is to be employed only when total loss of function or extensive ulceration occurs. This method, however, has been practically abandoned. Compound methods are frequently employed, as, for instance, tenotomy and correction under anesthesia, or osteotomy and subsequent mechanic treatment. Manipulation under anesthesia, tenotomy and myotomy (Phelps), and retention by means of plaster-of-Paris bandages are specially useful in congenital talipes. Some forms of fibrous ankylosis, as well as false ankylosis, may be treated by one or both of the first two methods, namely, instrumental correc- tion or tenotomy. Bony and cartilaginous ankylosis, however, and some forms of fibrous ankylosis will require resection or osteotomy. Movable Bodies in Joints. — These are the consequence either of in- juries or of arthritis deformans. When the result of injuries, portions of the articulating surfaces or interarticular cartilages are torn off. These may remain attached and become subsequently detached by sudden movements of the limb. They are rarely observed elsewhere than in the knee-joint or the elbow-joint. When the result of arthritis deformans, they may have their origin in the pediculated synovial villi. They may likewise be found in the sheaths of tendons which have been the seat of tendovaginitis, as ^^'ell as in bursae following bursitis. Here they occur as quite small rounded bodies which resemble grains of rice (oryzoid bodies) . Or, movable bodies the result of arthritis deformans, may occur in consequence of the pediculation of the free edge of cartilaginous and bony proliferations, which subsequently become torn off. Even after becoming loosened they ma}' continue to grow, receiving their nourishment from the synovial fluid. Diagnosis. — The symptoms of movable body in a joint depend on (I) the size of the body; (2) the particular joint involved. Large bodies give rise to much less disturbance than small ones. The latter, by becoming pinched between the articular surfaces, cause a sudden arrest of the movements of the limb, and more or less pain. The discomforts arising from pain in the joint are much greater in the case of the knee than in that of the elbow. In the case of the latter, the pain is, as a rule, not very severe; on the contrary, in the case of the former, it may be sufficiently acute to cause the patient to swoon. In many cases the movable body becomes fixed in some recess of the joint where it does not interfere with the joint functions, and thus all symptoms are absent for a long period of time. Palpation is employed to establish the presence of the movable body. This may be difficult, owing to the fact that in some localities thick overlying parts intervene. The patient will usually be able to locate the body when every effort on the part of the surgeon to do so has failed. The treatment consists in removal of the movable body by incision, after its presence and location have been assured positively (see Regional Surgery). THE JOINTS 163 Synovitis of the Sheaths of Tendons, Tendovaginitis, Tendosyno= vitis. — TentUnous sheaths are hncd with a synovial membrane which is identical in every particular with that which lines the interiors of joints. Analogous conditions involving the necessity of preventing friction exist in tendons and joints. Certain tendon-sheaths have direct communication with the joint (the popliteus with the knee-joint, and the long head of the biceps with the shoulder-joint). Tendovaginitis assumes the same forms as synovitis of the joints. If the disease is due to a direct injury, hemorrhage may accompany the effusion of serum. Fibrinous deposits in the sheath give rise to crepitating sounds which are quite characteristic. The affection has its origin in excessive strains on the tendons when certain difficult and unusual movements are executed. It is commonly seen about the wrist in tennis players from the use of the racket, and in plasterers from the use of the trowel. The fibrous type is best treated by immobilization and counter-irritation with tincture of iodin for several days. The serous variety, showing the swelling and not the crepitation, requires the use of splints and lotions. The few cases that are wholly or in part rheumatic in origin require constitutional medication as well. Suppurative Tendovaginitis.— Suppurative inflammation of the sheaths of tendons is almost exclusively observed in cases of septic wounds involving these sheaths. It may be exceedingly rapid in its progress, a septic infection at a phalanx reaching the forearm in twenty-four hours by this route. Nec- rosis of the tendon also occurs very rapidly under these circumstances. If the tendon escapes, granulations spring up, and both tendon and sheath become adherent in the resulting cicatrix. Early and free incision and antiseptic treat- ment are imperatively demanded. Tuberculous Tendovaginitis. — This occurs very rarely as a primary affection, but is the result of extension from neighboring diseased bones and joints. Papillary tendovaginitis is a hyperplastic inflammation of the sheaths of tendons. The papillae become separated from their attachments by con- strictioi^ forming the so-called oryzoid or rice bodies. They probably arise from the small synovial recesses which are found in the normal state closely attached to the tendinous sheaths. The extensor tendons of the fingers are most frequently affected. The bacilli of tuberculosis have recently been demon- strated in these rice bodies. An excision of the affected part of the sheath is the treatment advised for these cases. QangHons. — These are protrusions of the synovial sheaths through their fibrous coverings. They are, in fact, hernial pouches. A strain is a frequent cause. Clinically there are seen semispheric tumors of more or less density that do not involve the skin but move with the tendons. They have the same inflammatory actions as joints. They .are to be differentiated from chronic dropsy of the sheath both by the absence of fluctuation in the solid variety and by the correspondence of the swelling to the length and breadth of the sheath in the dropsical conditions of the tendons. When the tension is very great, fluctuation is absent in the gelatinous form as well. Some of these gan- glions though appearing near the tendon, when dissected out A\ill be found to arise by a pedicle from the joint, and are really protrusions of the joint synovial membrane. The acute cases are simply serous in character, as a rule, 164 INJURIES AND DISEASES OF SEPARATE TISSUES and require only subcutaneous puncture. Other cases of greater densit}' are of a serofibrinous t>pe and should be dissected out. Still others are tuberculous in character and progressive in their course, requiring a prompt radical excision before neighboring tendon-sheaths and joints are involved. Bursitis. — The bursae mucosae are lined ^^ith synovial membrane, which may become the subject of inflammation. This may be serous, serofibrinous, or, in the case of the prepatellar bursa, suppurative, as in joint synovitis. These bursae are sometimes situated near large joints, and inflammatory' processes may extend from one to the other, as, for instance, the bursa of the iliopsoas and of the hip-joint, and that of the subscapularis and of the shoulder-joint. Rarely a bursa may be the seat of a primarv- tuberculous synovitis. SECTION 111 GUNSHOT INJURIES Definition. — The term "gunshot injury" is usually applied to those in- juries caused by missiles propelled by means of a sudden violent expansive force. Besides injuries which result from projectiles discharged from some of the various kinds of guns and firearms in common use, those which result from missiles projected by violent explosive force other than that imparted to them by the aid of guns, such, for instance, as fragments of a shell, canister shot, and shrapnel bullets, as well as substances propelled by the explosion of military mines, are comprehended under the same term. In fact, any sub- stance driven with sufficient velocity, and hence violence, through the agency of an expansive force will produce injuries which to all intents and purposes are gunshot injuries. The great majority of wounds of this class coming under the care of the surgeon, however, are caused by bullets from such portable firearms as rifles, pistols, and muskets. The General Characteristics and Distinguishing Features of Qun= shot Injuries. — Every conceivable variety of injury capable of being in- flicted on the human frame by violently propelled obtuse bodies is embraced in gunshot injuries. The leading characteristic of these lesions is the constant presence of the features of either contusion or laceration, or of both, in connec- tion with the injur>\ The former may be present as a simple bruise of the surface from contact with a spent ball, or it may involve complete destruction of deep-seated structures or organs with very httle superficial injury. The elements of both contusion and laceration enter in the case of penetrating gun- shot wounds, though these may vary from mere division of the skin to the most extensive shot canals, or the shattering of the tissues with which the bullet may come in contact. The variations present in gunshot injuries in general depend on the following: (1) The physical qualities of the projectile. These relate to its form, weight, the material of which it is composed, its dimen- sions, volume and density. (2) The qualities which the missile derives from the arm from which it is projected, namely, its velocity and rotation. (3) Qualities imparted to the missile during its flight, such as the resistance offered by the air through which it passes, its passage through media of different densities or through resisting bodies, deviations from its normal course or from the direction of its longitudinal axis (ricochet shots), etc. (4) The heat devel- oped during the flight of the buflet, which has been supposed by some to affect the wound. In addition, the quality of poison added to the bullet, from which it is transferred to the wound, may have to be taken into account. (5) Con- ditions pertaining to the part of the body struck, such, for instance, as the relative position of the part struck to the missile (the angle of impact), the location of the injury, and the course taken by the projectile after it enters the body. (6) The entrance of foreign bodies into the wound, such as por- tions of clothing, gun wadding, splinters of wood, etc. 165 166 GUNSHOT INJURIES The Shape and Size of the Projectile. — In the case of the larger pro- jectiles the crushing effects and disturbances of neighboring parts are such that but slight influences are exerted by the forms of these projectiles on the character of the injuries that they inflict. On the other hand, the wounds made by the smaller projectiles, or those discharged from rifles, pistols, etc., present variations according as the bullet is spheric, of the combined cylindric and pointed arch form (the so-called cylindro-ogival), or cylindroconoidal. The diameter of the bullet likewise exercises an important influence on the character of the injury. In the case of the spheric bullet there is more or less of a diffused concussion effect radiating from the point of impact (Long- more). This effect is less marked in the pointed arch and cylindrocon- oidal forms, and progressively lessens as the diameter of the bullet is decreased. The latter circumstance, namely, the decrease in diameter, as well as the smoothness of surface, such as exists in the steel-mantled, nickel-mantled, and copper-mantled bullets, greatly increases the penetrative power of the projectile. The question of deformation of the projectile has a direct bearing on the character of the injury. The intrinsic tendency of the round bullet to deformation is slight, on account of its minimum amount of so-called "in- ternal energy"; in the modern oval and long bullet this tendency is greater and has necessitated the application of a jacket or mantle to prevent marked bending and splitting. These deformations are caused by the resistance met with in the tissues resulting in a reciprocal back action on the projectile through which a portion of its intrinsic power is converted into deformation and heat in such a manner that both effects are equal (Reger). The velocity being the same, in the case of the unprotected bullet the deformity increases with the resistance; in the case of the protected bullet the heat increases. Again, the resistance being equal and the velocity increasing, the deformity in- creases in the unprotected bullet and the heat increases in the protected bullet. The deformity of the projectile influences the effect of the bullet in a marked degree. The effects are more extended, and, as a result of an increase of the resistance and a decrease of the penetrating power, the deformity still further increases, so that the bullet either lodges in the tissues, or in emerg- ing, causes the most bizarre effects. This is specially true in cases in which the bullet has passed through other living bodies or through breastworks. If the deformed missile has sufficient energy remaining, it may still exert a radiating concussion (explosive effect). The effect known as mushrooming is a still more pronounced deforma- tion, and is more especially marked in the so-called Dumdum bullets. This effect may take place in jacketed projectiles that strike hard objects, either before or after they enter the body, or it may be produced by tampering with the jacket of the projectile. In the majority of cases gunshot wounds inflicted by the modern small- bore, elongated, high-velocity projectile have two apertures, one made by the entrance of the missile and the other by its exit. As a rule, the wound of entrance is smaller than the wound of exit. The wound of entrance is modified by the manner in which the missile comes in contact with the surface of the body. Changes of position with reference to the long axis in the case of the modern projectile cause the latter CHARACTERISTICS AND DISTIXGUISHIXG FEATURES 167 to strike more or less sideways, this " cross-hit " causing a wound which dif- fers materially from the small and smootli-edged ajjerture present when the intact ball strikes with its long axis directly at right angles to the surface. Cross-hits are the result either of the striking of the bullet on some object, such as a tree branch, stone, etc. (ricochet shots), or of its passing through several different media, or through bodies that resist its course more or less strongly. It is therefore a])parent that a ricochet shot, if it retains sufficient energy, may do a greater amount of damage than if it had struck in its long Fig. 28. — Bullet Wouxd in a Japanese Soldier Received while Lying Down. Photographed after the battle of Liao-yang. A furrow is made in the upper arm and a wound of entrance and exit in the forearm. diameter. Usually, however, the greater part of the velocity of the missile is lost either by its striking the object on which it ricochetted, or by the greater resistance which the air affords to its passage in its changed position, or by both, and, in addition, the influence of rotation imparted to it by the rifling in the barrel of the arm is lost ; the result is that the shot does much less damage than if projected from the same distance without meeting resisting or deflect- ing bodies on the way and striking in its long diameter. 168 GUNSHOT INJURIES The wound of exit is increased in size by the tissues driven out with the ball (fragments of bone, portions of muscular tissue, etc.), by the alterations in the direction of the long axis which almost invariably occur and which, when considerable, the power of rotation still being retained, may cause extensive destruction of both bone and soft parts, as well as by deformations of the projectile itself. Variations in the size and shape of the wound of exit also depend on the elasticity and mobility of the part. In organs in which Fig. 29. — Fragments of Mantles Removed from Bullet Wounds (after a photograph from the Medical Department of the Japanese Army). there is considerable fluid, such as the brain, the heart, the stomach and intestines, the hydrodynamic pressure effect influences the action of the pro- jectile in a marked degree; this effect serves also to explain the radiating concussion or explosive action of projectiles on the tissues in general. The hydrodynamic theory rests on the incompressibility of water and the re- sulting narrowing of the space through which the transfer of pressure in all Fig. 30. — Bullet Wound Received by a Japanese Soldier at the Battle of Liao-yang. The shot struck at the range of about 500 yards while the soldier was kneeling. The wound of en- trance is about normal in size ; the wound of exit is very large and illustrates the destructive effects of the modern projectile at short range. The bone was broken in this case. directions takes place. The more fluid present in the tissues or organs struck and the shorter the distance at which the shot is fired, the more intense the effect. For instance, a shot at close range may almost completely empty the skull of its contents. In addition to the increase in the effect due to increase in the fluid present and the velocity of the projectile, increase in the caliber and deformation of the latter heightens the damaging effects. CHARACTERISTICS AND DISTINGUISHING FEATURES 169 Experiments show that an 8 mm. steel -man tied projectile at 100 meters gives a hydrodynamic pressure of 6.4 atmospheres, while a projectile of 11 mm. at the same distance gives a pressure of 8 atmospheres (Kikuzi). Deformations of modern projectiles occurring after they enter the body arc due exclusively to impact against bone; in wounds of soft parts alone the form of the missile is not altered. In 4.5 per cent of all hits deformation takes (ilace (C o 1 e r and S c h j e r n i n g). A much larger proportion of hits of bone than the above percentage represents, however, actually takes place. In certain parts of bone which are harder than others, such, for instance, as the crest of the tibia, the linea aspera femoris, etc., more deformity of the missile takes place, while bullets lodged in the epiphyses remain comparatively intact. The extent of the injury is in direct proportion to the deforma- tion of the bullet. Wherever there is marked shattering of the projectile, there is extensive de- struction of bone and a corre- spondingly large wound of exit. When mushrooming of the modern projectile takes place as the result of disturbances of the mantle, the effects are in no way less than the wounds made by the old-time leaden mushroomed bullet. The soft tissues with which firearm projectiles come in con- tact are often greatly diminished in vitality, and more or less sloughing is likely to occur. In addition to this, their repair may be interfered with by infectious material carried in by the bullet, as well as by the presence of foreign bodies. In injuries of long bones, in case the diaphysis is struck, even at ranges of from 1500 to 2000 meters, there is a shattering of the bone as a constant effect. On the other hand, smooth bullet canals are found in the epiphyses even at as short a range as 200 meters (C o 1 e r and S c h j e r n i n g). The claims made th"at the modern small-bore high-velocity missile is a more humane weapon than the old large-caliber rifle with its bare leaden bullet, as based on the experiments of B r u n s and H a b e r t , are not borne out by the observations of C o 1 e r and Schjerning. The explanation of this discrepancy seems to lie in the fact that the former experi- menters, in order to overcome the difficulties inherent in making experimental shots at long range, shortened the distance and projDortionately reduced the Fig. 31. — Bullet Wound Received by a Japanese Soldier at the Battle of Liao-yang. The shot was received at a range of between 700 and 800 yards while the soldier was kneeling. The diameter of the wound of exit as shown is 3i inches. The bone was shattered. Ttie wound of entrance at the back of the arm is circular. 170 GUNSHOT IXJURIES charges, thereby reducing the rotatory velocity of the projectile. It may be confidently stated, however, that in the case of injuries of the soft parts alone the advantages are altogether in favor of the modern arm provided its projec- tile strikes the body with the mantle or jacket intact. Under these circum- stances, and in the absence of injury of the bone, smaller wounds of entrance and exit are made and less damage to the soft parts results. When but one aperture exists, it is fair to presume that the ball remains in the body. The presence of two openings, however, does not necessarily mean that the bullet has made its exit; only a fragment thereof may have escaped, or two shots may have been discharged from different directions, both projectiles remaining in the body. One ball may produce several wounds of entrance and exit, as in the case of a gunshot wound of the arm and chest, or of a flexed limb, or of both lower extremities struck by the same missile, the latter passing through one and lodging in the other. The missile may graze one part of an extremity, making a furrow, and penetrate or perforate another (Fig. 2S). Fragments of man- tle torn from the projectile may re- main in the tissues, the projectile itself escaping (Fig. 29). The circumstance of fracture of the bone adds greatly to the destructive effects of the shot, not only on account of the radiating con- cussion (explosive effect) of the ar- rested bullet, but also on account of the tearing and mangling of the tissues from the deformation which the bullet undergoes and from the disturbing in- fluences of the bone fragments. These sometimes occur in a most extraordi- nary degree when the shaft of the bone is struck, but in a less degree when the epiphysis is the part injured (Figs. 30 and 31). With loss of veloc- ity and of rotatory force before striking, such as occurs at long range, or at a shorter range in a ricochet shot, the iDullet may strike directly on a long bone, as, for instance, the tibia, and lodge in the limb, the bone escaping fracture. If to this are added the effects of a deformed bullet, the conditions present, as shown in figure 32, will obtain. A bullet that has ricochetted and become altered in shape by impact against the object which deflects it from its course, and finaUy strikes as a cross-hit, Tvall inflict such an injury as that shown in figure 33. In an engagement in which both rifle projectiles and shrapnel bullets are employed it is sometimes difficult to determine which wounds are inflicted by the latter and which by the former, especially under circumstances where Fig. 32. — BrLLET Wound of the Leg Received BY A .Japanese Soldieb at the Battle of LlAO-YANG. The wound of entrance as shown is 1^ inches long and i of an inch wide. The wound shows the usual appearance of a cross-hit (querschlager) from a ricochet shot with deformation of the bullet. SYAIPTOMS OF GUNSHOT WOUNDS 171 the best opportunities are afforded for ricochet shots, namely, with the men on the firing-lino either kneeling or lying down (compare Figs. 34 and 35). The Symptoms of Gunshot Wounds. — The more or less constant symptoms include (1) pain; (2) shock; (3) primary hemorrhage. The occasional symptoms are (1) lodgment of the bullet; (2) powder burns; (3) multiplicity of wounds. The symptom pain is an exceedingly variable one. Its intensity depends on the part struck and the circumstances under which the injury is received. Only the most vague recollection of the amount of pain suffered at the moment of being struck is recalled if the injury is inflicted during periods of excite- ment, as in a battle or in a duel. A condition of local anesthesia may l^e present alDout the injured parts. More or less shock is usually present. This, even in the case of the modern projectile, is usually sufficient to disable the injured one, in spite of the assertion to the contrary so frequently made. The dra\Mi or anxious facial ex- pression is a fairly good index of the gravity of the shock present. The sjnmptom of primary hem- orrhage, particularly of the inter- nal variety, may be sufficient to threaten life. In all probability the majority of deaths on the field of battle are due to injuries of blood-vessels in the interior of the trunk. Of fatal external hemorrhage or that which is ac- cessible to the surgeon, and which, seen in time, ma}' be ar- rested, such as occurs in injuries of the brachial and femoral arter- ies, the instances are rare (L o n g - m o r e , 3 per cent ; Otis, 0.05 per cent). Aside from the two classes of cases mentioned, in which death may take place at once, the primary hemorrhage from a gunshot wound is rather unimportant. Even when vessels of considerable size are injured by the small-caliber projectile the hemorrhage tends to spontaneous arrest. The occurrence of secondary hemorrhage may be due to some general cause, such as hemophilia, or the presence of constitutional conditions due to prolonged campaignmg (scurv}^, anemia, etc.) in military' practice. ]\Iore fre- quently, however, it is due to local causes, among which may be mentioned ulceration or the sloughing of the coats of a vessel from injury of the vessel, this injury involving only its outer coat, the remainder of the vessel givmg way Fig. 33. — Bullet Wound. Japanese Soldier Wounded at the Battle of Liao-yang. The soldier was shot at the range of about 200 yards while kneeling. The large wound of entrance suggests that the bullet was deformed before striking, or that it struck as a cross-hit. 172 GUNSHOT INJURIES several hours or days later. In former times it was most frequently due to the supervention of septic arteritis in a suppurating bullet track. It may be due to the continued pressure of a lodged projectile, or of a fragment of a projectile or l^one, the sharp or ragged edge of which in time causes erosion. The lodgment of the missile occurs with much less frequency in the case of high-velocity small-caliber projectiles than in the old-fashioned, large, smooth-bore guns, and in the pistol-l^all wounds of civil life. A missile from a modern small-caliJDer rifle seldom lodges in the tissues except when fired at long range, or when it meets with intervening objects which retard its flight and lessen its velocity. The presence of powder burns is observed in gunshot injuries occurring at short range and on exposed portions of the body, when the old-fashioned black powder is used. When the wound is inflicted by a revolver, the " pow- der brand" will bear a rather constant relation to the wound, according to ^ 1 ^%^ v'*- tM^C ^ r 1 jAl "If Is m Fig. 34. — Shrapnel Bullet Wound, Received by a Japanese Soldier at the Battle of LlAO-YANG. The wound of exit, 6 inches long by 4 inches wide, is shown in the illustration. The bone was shattered. the position of the hammer of the weapon when the latter is fired; these two wiU correspond to each other (Fish) . The degree of powder burn will be modified by the distance; a relatively short range will result in superficial burning of the tissues, and a range sufficiently long to enable the parts to escape the flame of the burning powder may yet be sufficiently close to permit grains of unburned powder to lodge in and beneath the skin, causing tattoo marks. These grains of powder may be the means of conveying septic infec- tion, particularly tetanus and malignant edema. The powder brand will be absent in the case of smokeless powder. The subject of multiplicity of wounds has already been referred to (vide supra). Multiple wounds occur much more frequently since the introduction of the modern small-bore rifle, and depend on the increased velocity and high penetration of projectiles from this class of firearms. The arms and chest seem to be involved most frequently in simultaneously inflicted multiple DIAGNOSIS OF GUNSHOT WOUNDS 173 wounds Either the uppcn- or the lower extremity, when flexed, offers oppor- tunity for the occurrence of multiple wounds from a smgle missile as a primary compUcation. The question of infection of a gunshot wound is of special importance That this may occur through the medium of an infected bullet has been placed bevond dispute bv the classic experiments of L a G a r d e , of the United States Army. That all bullets are not infected is true ; it is equally true that all infected bullets do not give rise to suppuration. In the case of the latter the question is simply one of the relations existing between the virulence of the infecting microorganism on the one hand, and the vital resistance of the patient on the other. The in- fection from clothing, portions of which may be carried in by the bullet, is of greater import- ance, since it is far more likely to occur than infection from the bul- let. Yet even this method of in- fection is not so common as would be supposed. Meddlesome fingering and probing, even under presumably aseptic conditions, are far more frequently respon- sible for subsequent suppuration in gunshot wounds than is either the^ bullet or the pieces of cloth- ing carried into the wound. Diagnosis. — The character of the wound of entrance, as well as of the wound of exit, if such is present, will settle the question of the infliction of the injury by a projectile from .a firearm. Difficulty will not infrequently be experienced, however, in de- termining the character of the missile, its caliber, etc. The typic smaH and clean-cut wound of entrance incidence with the surface is a right angle. Y^a 35 —Bullet Wound Received at the Range of ■ between 600 AND 700 Yahds while the Soldier WAS Lying. The illustration shows the wound of exit 3i inches long by 2 inches -nide (from a photograph taken under the auspices of the Japanese Army Medical Department after the battle of Liao-yang). results when the angle of ]\Iore or less pronounced incidence wiin xne suiiaue lo a. x^&^x^ ^..^.^. ^'-i.^ ^ ^ • -j deviations from this are observed with variations m the angle of mcidence, extension of the range, and reduction of the residual velocity of the projec- tUe from ricochet. Still more decided departures from the ^^^^mal aperture of entrance are observed as the result of deformations of the bullet from striking hard substances, such as rocks, etc. In the case of ^ ^P^e^ic bulle the wound of exit is larger than the wound of entrance, for the reason that the explosive effect which the invaded tissues manifest as a result o the hidro- dvnanfic force initiated bv the invading missile forces the overlying mteg- 174 GUNSHOT INJURIES iiment away from the supporting structures beneath, as the pressure takes place from Avithin outward, and an irregularly shaped and larger opening results. When the injury is caused by the cylindroconoidal or the cylindro- ogival projectile of moderate size, and this pursues a normal flight with prac- tically undiminished residual velocity and encounters soft tissues only, pass- ing through the latter almost unimpeded, it may be difficult to distinguish the wound of exit from that of entrance. Departures from these conditions, however, Avill give rise to varying appearances. Slight ragged and radiating slits from the margins are due either to the escape of small fragments of bone, of fragments of the mantle and lead kernel of the bullet, or to the loss of sup- port beneath the skin. Or a wound several times as large as the wound of entrance may be present, signifying the occurrence of a bone lesion. Dif- ferences in appearance between the wound of entrance and the wound of exit can be more easily recognized if the wounds are examined early; later on these differences are more or less obscured by the swelling. Indiscriminate probing is to be strongly condemned. Instances are few and far between in which the use of the probe is justified prior to a most care- ful and thorough aseptic preparation. The information thus gained cannot compensate for the risk of conveying infection from the superficial to the deeper portions of the wound, or of spreading infection that has been already conveyed. Fluoroscop}'^ and skiagraphy with the Rontgen ray have prac- tically replaced all other methods of diagnosing the location of lodged bullets and the extent of damage inflicted on osseous structures. Prognosis. — This will depend on (1) the parts of the body traversed by the projectile and involved in the injury; (2) the primary destructive effects; (3) the promptness with which early assistance can be given and the subsequent care of the case; (4) the type of arm employed. 1. It is estimated that of every 1000 casualties occurring in warfare, there are about 200 deaths on the field; and of the remaining 800, about 110 are wounds of the head, face, and neck; 154 of the chest, abdomen, and pelvis; 252 of the upper extremities, and 285 of the lower extremities (L o n g - more) . Gunshot wounds of the head, large vessels, spine, and viscera are the most serious. 2. The circumstances governing the destructive effects of projectiles have already been dwelt on. In further estimating the probable effects in the individual case the possible deformation of the bullet is of great importance. Some missiles designed for hunting purposes (express bullets) are purposely made to flatten or mushroom on impact, causing extensive mutilation of tis- sue. This object is effected by omitting the usual mantle or jacket covering of the lead core at the point or nose of the bullet. The same condition is obtained by tampering with the bullet, removing in part the mantle or covering therefrom. The favorite method of accomplishing this among soldiers is to grind away the point of the bullet by means of a rough stone. It is needless to say that this is a murderous practice, and opposed to international agree- ment as expressed at the Hague conference in 1899. The possibilities of a ricochet shot and consequent deformation from this cause are also to be taken into account. 3. The promptness with which early assistance can be given and the thor- oughness of the subsequent care of the case are important factors in estimate COMPLICATIONS AND GENERAL TREATMENT OF GUNSHOT WOUNDS 175 iny; tlu> iirognosis of o;unslK)t wounds. In civil life the hospital surgeon can usuall\' control conditions that are ideal in the care of gunshot wounds. In military practice the exigencies of active service make such demands on the surgeon as to render it impossible in most instances for him to do more at first than to ajiply a first-aid packet to an infected wound, and even this is most frc(]uently done by a hospital corps man or the wounded man's "bunkie." In the subsequent treatment the exigencies of military life recjuire tlie movement of the wounded so often that they are robbed of the necessary rest, and maintenance of aseptic conditions so essential to the best results is well-nigh an impossibility. 4. The type of arm employed governs the prognosis to a considerable ex- tent. It is unquestionably true that with improvements in the efficiency of firearms there has resulted a lower mortality, both immediate and remote. The very conditions that secure a higher velocity and longer range, likewise assure, on the whole, a more humane weapon, namely, smaller caliber, higher expansive character of the gases from exploded smokeless powder, and, above all, the armored or jacketed projectile. While it is true, as previously stated, that even with all of these favorable conditions present the most terrific de- struction may occur, it is also true that the reverse of these conditions favors still more destructive effects. Complications of Gunshot Wounds.— These are such as relate to wounds in general, and embrace inflammations, gangrene, secondary hemor- rhage, aneurism, hospital gangrene, pyemia, tetanus, erysipelas, etc. (see Acute Wound Diseases). In recent years these complications have become quite exceptional in their occurrence. (For gunshot injuries of separate structures see individual structures, and for gunshot injuries of regions see Regional Surgery, Vol. II.) The General Treatment of Gunshot Wounds.— In simple uncom- plicated gunshot wounds a sterile dressing and rest in the recumbent posi- tion usually fulfil all the indications. In military practice, before going into battle provision for the occurrence and the immediate protection of gunshot w^ounds is made by furnishing each soldier with a first-aid dressing consist- ing of antiseptic compresses protected by oiled paper, and bandages and safety- pins for securing these in position. This dressing is applied either by the wounded man himself, or, if the wound is in a part of the body which makes this impossible, by a member of the hospital corps, an officer or a comrade, either on the spot or at the dressing station ; the case is frequently not seen by a medi- cal officer until hours, and sometimes days, afterw^ard. The most that can be said of the first-aid dressing is that, when properly applied, which is not often the case, it serves to protect the parts against further infection. Suppurative conditions, when they occur, are to be treated on general principles. Every effort must be made, in military hospitals particularly, to keep down the num- ber of suppurative cases as much as possible, since sepsis, under the strenu- ous conditions of active military service, tends to spread with ever-increasing virulence. The question of the removal of lodged bullets is an important one. In military practice the cases are rare in which it is necessary to remove the bul- let at once, and even in civil practice it happens frequently that more harm may be done by persisting in an effort at removal than by permitting the 176 GUNSHOT INJURIES missile to remain. If time and environment permit, there is no objection to the removal of a bullet that is immediately beneath the skin, provided asep- tic precautions can be rigorously enforced; on the other hand, neither the surgeon in charge of an ambulance in ci\'il life, nor those engaged at the dress- ing stations in military service, should attempt the removal of lodged bul- lets. A bullet superficially situated and easily felt may be removed at the field hospital: the removal of those deeply situated and not definitely located should not l)e attempted until a field hospital on the line of communication or a base hospital is reached, where the .x-ray apparatus can be employed to assist in the search. Lodged projectiles that cause pain by pressure on a nerve-trunk, those that interfere with the function of a part, and those that lie at the bottom of an infected bullet track should be removed. Irregularly shaped fragments of bullets, pieces of shell and of the covering or mantles of projectiles, unless these lie in inaccessible regions, should be removed. Attention has been called to the occurrence of plumbism as a result of lodged leaden missiles (X i m i e r and Laval). This occurs with greater frequency in case of the lodgment of small shot, or of the separation of the bullet into fragments, particularly where these lodge beneath the peri- osteum or in the cancellous tissues, or in the medullar}^ cavity of bones. The symptoms disappear on the removal of the missiles. Lead intoxication, even in civil practice, is a very rare sequence of the lodgment of unprotected bullets; it will be rarer in the future in military practice, on account of the almost universal adoption of the mantled or protected bullet, and the infrequency with which this lodges in the tissues. SECTION IV ACUTE WOUND DISEASES ERYSIPELAS Erysipelas is an infectious progressive inflammation of the skin, with a clearly defined and circumscribed area. It is characterized by a redness of the surface, varying with the intensity of the inflammation, as well as with the location of the disease. In the scalp, the edges of the wound may be pale, wdth some serous infiltration at the commencement. Its circumscribed mar- gin distinguishes it from phlegmonous inflammation of the subcutaneous con- nective tissue, in which the redness gradually merges into the surrounding healthy parts. Where lymphangitis follows erysipelas, its well-defined edges are wanting, but in the former, red lines or stripes will be j^resent correspond- ing to the Ivmph- vessels. Increased heat and swelling are present. The former is demonstrable by means of the surface thermometer; the latter is inconsiderable, and ordinarily scarcely perceptible, except in localities where serous infiltration occurs (scalp, etc.). A burning sensation rather than pain is complained of. The disease, in its progress, varies as to rapidity. In advancing, the margin does not, as a rule, maintain a symmetric contour, but projections occur here and there, giving it an irregular outline. Locality seems to influence the more or less rapid progress of the disease. The direction taken is generally that of the lymphatic current, though exceptions to this are numerous. In erysipelas bullosum there occurs a profuse exudation of colored serum in the rete Malpighii, with the formation of vesicles. These occur after the stage of redness, about the second or the third day, and are not unlike the blisters following a burn. Suppuration may occur in these. Phlegmonous erysipelas is characterized by a suppurative process in the subcutaneous connective tissue, coincident with the inflammation of the skin. It constitutes a severe form of the disease. Gangrenous Erysipelas. — All the other forms may culminate in this, but the phlegmonous variety is particularly liable to merge into the gangren- ous variety. Blisters form from obliteration of the nutritive vessels, and bro^^^lish-red spots, which afterward change to black, appear. Necrosis of tissue and putre- factive changes soon develop. If phlegmonous cellulitis has not preceded the gangrenous form, it rapidly develops after the appearance of this form. The gangrenous condition shows the same tendency to spread as the others. In certain erratic or wandering forms, the disease spreads irrespective of direct continuity of tissue, attacking remote portions of the body either simultaneously or successivel3^ Clinical Course. — A rapid and continuous rise of temperature occurs. 13 177 178 ACUTE WOUND DISEASES A chill, except in very mild cases, usually precedes the disease development. Sweating is rare; a dry condition of the surface is present. Nausea and vomiting generally follow the chill. Except in ver}' scA'ere cases, these, as well as the chill, are not repeated. Anorexia is present. Diar- rhea is rare; constipation is the rule. The temperature curve is irregular but follows more or less the progress of the disease, as it attacks new tissue. Its duration is, on an average, about one week. Low morning temperature denotes the subsidence of the attack. High temperature both morning and evening gives a more favorable prognosis than high evening temperature alone. Complications. — Albuminuria to a moderate extent sometimes occurs, though it soon disappears. Bronchitis is a not infrecjuent complication, but pneumonia is rare. The serous membrane may be attacked, particularly the meninges, in erysipelas of the scalp. Pleuritis may follow er\'sipelas of the chest walls^ peritonitis that of the abdominal surface, and synovitis er}'- sipelas about joints. The mucous membranes may be attacked, with sub- mucous infiltration, particularly the nasal and faucial cavities in erysipelas of the face. Etiology. — The idiopathic origin of erysipelas has long been disproved. ''Catching cold" and mental emotion are no longer considered factors in the causation of the disease. Erysipelas is infectious in origin, contagious in char- acter, and both endemic and epidemic in its occurrence. It is most frecjuent in low, swamjDy localities, less so in elevated and dry situations. It is more prevalent in the months of December, February, and March. The contagiousness of the disease was known long prior to the discovery of the bacterial origin. Instruments, the surgeon's fingers, bed and bedding were known to convey the disease. Micrococci were found by both H u e t e r and Recklinghausen in blood taken from eiysipelas patients and from portions of skin removed postmortem, but it was not until methods of obtaining pure cultures were introduced that ordinary pus cocci were eliminated and the essential and characteristic organism, the Strepto- coccus pyogenes (see page 27), was isolated and demonstrated (1884). This demonstration was confirmed by successful inoculation experiments. Predisposition to Erysipelas. — This varies, as in all infectious diseases. It ma}^ be local or individual. Certain localities, notably the scalp, are espe- cially predisposed to its occurrence (see page 431). Operations for the re- moval of lipomas are also followed, in a certain proportion of cases, by ery- sipelas. The fatty tissue itself is not particularly liable to it, but the thin and atrophic skin covering lipomas seems to invite an attack. The predisposition of individuals is well known. It is more freciuently observed in weak persons with tender skins. For this reason blonds are more liable to be attacked than brunettes. In these, slight abrasions of the epi- dermis, and even normal furrows of the skin, as well as the open mouths of sebaceous follicles, may be the seat of invasion by the infectious agent. It is very doubtful if erysipelas can occur without invasion of the streptococcus from without. Except for the endemic occurrence of erysipelas, careful and conscien- tious application of aseptic precautions will prevent its development as one of the wound seciuels. Its epidemic occurrence should be taken into ERYSIPELOID 179 account, and. in its presence, operations, particularly about the head and neck, should be postponed. Erysipelas occurring in patients who are already debilitated from large losses of blood or other causes follo^^'ing major operations is of serious import. This is particularly true of the suppurative or phlegmonous form. In certain cases of inoperable sarcoma the neoplasm has been inoculated with Streptococcus pyogenes (P . B r u n s . W . B . C o 1 e y) . While en- couraging results have been obtained by the use of the toxic products of Streptococcus erj^sipelatis, mixed with those of Bacillus prodigiosus, in the hand.-? of the originators of the method, the latter may be said to be still on trial. C)n the other hand, death has followed the experiment (J a n i c k e , X e i s s e r) . The disease known as elephantiasis arabum is said to have its origin in repeated attacks of eiysipelas (see page 84). The erratic or wandering form of the disease fm-nishes, as a rule, a better prognosis than the other varieties. Treatment. — In the prevention of the cUsease the most rigid detaUs of asepsis are requisite (see page 48;. The necessity for tliis should impress itself on the surgeon's mind, particularly if he is compelled to dress non- infected wounds after bemg m contact with a patient who has er\'sipelas. All dressings that have been used should be burned, and towels, sheets, blankets, etc.. subjected to at least the boUing process in the laimdr\'. Instnmients should undergo the most rigid sterilization, and the free and liberal use of soap, hot water, and subhmate or carbolic solution on the part of the attendants should be enforced. Prior to the introduction of antiseptics into practice, the surgeon was almost helpless in the face of this formidable disease. Its rational treatment began ^^ith L ii c k e ' s recommendation of the local use of turpentin and H u e t e r ' s use of tar and of the subcutaneous mjection of carboKc acid at the marghi of the disease, at wliich point the streptococci proliferate most rapidly. The carbolic injections may be replaced by sublimate 1 : 5000, or salicylic acid solutions (Peterson). Multiple scarifications and incisions through the skin at the margin of the er^'sipelatous zone (K r a s k e , R i e d e 1), with the subsequent use of a 5 per cent carbolic or a 1 : 1000 sublimate solution (L a u e n s t e i n) m the shape of compresses, are valuable measiu'es. The addition of tmcture of opiimi in the proportion of two oimces to the pint to the antiseptic solution is of advantage. These solutions should be applied warm upon compresses either with or T\-ithout the lorelimhiari' incision of the skin, and the compresses covered with oiled silk. Where danger is to be apprehended from carboHc acid poisoning creolin may be substituted. ^ The fever should be combated by the usual antip^Tetic measures. Luke- warm baths and the cold pack may be necessary- in extremely high tempera- tinges; quuiin is useful in ordinary' cases. Supporting meastires should be employed and nourishing but easily digested food allowed. ERYSIPELOID Rosen bach has described, mider this name, a form of infectious derma- titis which is sometimes obser\^ed in persons, butchers, cooks, etc.. who have occasion to handle dead animals. The point of primary' infection is some 180 ACUTE WOUND DISEASES minute abrasion of the epidermis, from which point a bhiish-red infiltration gradually spreads, generally toward the trunk. The infection travels very slowty, occupying a week in passing from the finger-tip to the metacarpopha- langeal joint. The margin of the patch maintains the original liluish-red infiltration appearance, while the point originally infected and its immediate surroundings return to the normal. There are no constitutional disturbances; the disease is a purely local affair and has a self-limited course, lasting two or three weeks. The inflamed parts give rise to some burning, smarting sensations. The disease is of interest to the surgeon mainly because of the liabihty to mistake it for erysipelas. The etiologic factor in the disease is some specific infecting agent, supposed to be one of the thread-forming microbes. No treatment is necessary. The disease tends intrinsically to recovery. HOSPITAL GANGRENE This consists of a septic inflammation of the granulating surface of wounds in which there is a coagulative necrosis of the upper layer of the granulations, due to either an imperfect development of the vessels or an obstruction of their lumina by septic inflammatory processes, or a coagulation of fibrin in a layer of exuded blood-plasma. The resulting pellicle occurs in the shape of a firmly adherent thin parchment-like layer resembling diphtheritic deposits on mucous membranes ("wound diphtheria," Hueter). The dis- ease begins with small pointlike ecchymoses in the granulations; the latter turn to a dirty grayish-brown color. Fusion of the granulations occurs, minute abscesses form, and a true ulcerative process may be initiated. In the pulpy variety a profuse exudation occurs from the newly formed blood-vessels in the granulations. The latter become greatly swollen and grayish-white, ris- ing above the level of the skin like a mass of sponge. Finally these may cul- minate in the gangrenous form.. The inflamed structures become necrotic, putrefaction sets in, and sometimes the most rapid advance of the disease takes place. The destruction of the granulations opens up the way for renewed infection and the rapid breaking down of the tissues furnishes the bacterial agents of infection in large numbers. Clinical Course. — All of these forms may be observed on the same granulating surface. Slight hemorrhages may be present at one point, sup- purative destruction of the granulations at another, and a spongy elevation may appear at a third. Finally a gangrenous condition may supervene. As long as the granulations remain intact no lymph-vessels are opened, and con- stitutional symptoms are absent. With the destruction of the granulations, bacterial infection occurs and febrile symptoms appear. This may occur within the first twenty-four hours. The rise of temperature, although not high, is accompanied by a disproportionate depression of the vital powers. In this respect the disease resembles diphtheria of mucous membrane. The temperature, even in markedly septic and gravely depressed conditions, may remain normal or even become subnormal. Prognosis. — This is grave in proportion to the amount of depression and the extent of the local disturbances. In the gangrenous variety large vessels may be opened and fatal hemorrhage follow. Invasion of large MALIGNANT EDEMA; ACUTE PURULENT EDEMA 181 serous cavities or of joints by tli(> ulceration or gangrenous process involves great danger to life. I\ycniia may develop. Etiology. — The affection arises from infection of the granulating sur- face, either from contact with unclean dressings or from the air. In former times the disease occurred especially in military hospitals, from want of care in the selection and application of dressings; hence it was known as hospital gangrene. It occurs, however, in private as well as in hospital practice, if care is not exercised in wound dressing. The mass of microorganisms found locally and in the blood of the patient fixes the bacterial origin of the disease ; a specific germ, however, has not yet been discovered. It is probable that the gangrene which occurs in wounds may be caused by more than one micro- organism. In two instances of rapid gangrene occurring in my service in St. Mary's Hospital, Bacillus pyocyaneus was isolated in pure culture from tissues at some distance from the gangrenous area. Treatment. — This is to be conducted on the principles of asepsis and antisepsis, the former method to be used in the prevention, the latter in the cure. The use of carbolic moist compresses is indicated; these are to be renewed at least as often as once in six hours. A 5 per cent solution should be employed. At each change of dressing the softened granulations should be curetted away. In more severe cases an application of zinc chlorid, from 10 to 20 per cent in strength, is to be used, well rubbed in. In the gangrenous variety recourse should be had to the thermocautery for the purpose of com- pletely destroying the infected surface and its infectious agents. The effect of the application of the actual cautery to these gangrenous conditions of a wound is sometimes marvelous. Acid escharotics (chromic acid, nitric acid, etc.) are to be preferred to alkaline ones, such as caustic potash, etc., for the reason that the former have a more decidedly antibacterial effect. Hydrogen dioxid is useful in aiding the destruction of the dead organic matter (W a r - r e n) . Iodoform gauze saturated with hydrogen dioxid should be packed in all the recesses of the wound. MALIGNANT EDEMA (Pirogoff); ACUTE PURULENT EDEMA This form of gangrenous inflammation, sometimes kno^^Ti as gangrene foudroyante (M a i s o n n e u v e), is a most dangerous affection. It some- times accompanies severe injuries of bone and extensive contusions of soft parts, as well as less severe injuries, insect stings, etc. It is characterized by rapidly advancing septic inflammation of the subcutaneous connective tissue and the intermuscular planes, with rapid putrid decomposition and the for- mation of gases. The skin assumes a dirty brownish-red color, with distended veins filled with stagnating blood. The tissues are edematous and infiltrated with gases, which give rise to a crackling sensation on palpation. A thin ichorous discharge occurs from the wound ; this can also be pressed out of the edematous tissues into the wound cavity. The neighboring lymphatic glands become greatly swollen, and the general condition of the patient shows that the products of putrefaction are being rapidly disseminated through the sys- tem by the medium of the lymph-channels. The temperature rises rapidly; remission, as a rule, does not occur. Typhoid symptoms, such as blunted sensorium, dry tongue, tough, fetid mucus in the roof of the mouth, rapid and feeble pulse, and dilated pupils are present. In other cases jactitation 182 ACUTE WOUND DISEASES and delirium, followed by coma and involuntary evacuation of the contents of the bladder and rectum, precede the fatal issue. The patient is too apath- etic to complain of either pain or thirst. The sj'-mptoms may supervene within a few hours of the injury, and death may occur in from fort3'-eight hours to three or four days, an entire extremity in the meanwhile becoming involved in the disease. Etiology. — The affection is essentially the result of a putrefactive, process and is of undoubted bacterial origin. It probably depends on a bacillus found almost universally in common garden earth. Bacillus oedematis maligni (see page 30). Treatment. — Since the introduction of antiseptic methods of treatment this excessively dangerous disease is of much less frec^uency than hereto- fore. A most vigorous antiseptic course must be followed. While the use of free and extensive incisions may be of some service in mild cases, these cases are so few compared with those overwhelmingly malignant, that amputation will be the rule, rather than the exception. This should be performed promptly, and as high up as possible. INFECTIOUS EMPHYSEMA This is an emphysematous condition of the tissues of the body and is due to the presence of Bacillus aerogenes capsulatus. The microorganisms may gain entrance through an accidental or an operation wound and infect the surrounding structures. Their presence is followed by the formation of gas, which is marked by the occurrence of swelling and a crackling sensation on palpation. In this class of cases there is usually but moderate con- stitutional disturbance. In more severe cases the viscera are filled ^^^lth gas bullae and the blood T\'ith bubbles. In these cases it is supposed that the infection gains entrance from a perforative lesion of the intestinal canal. Treatment. — ^^^len the emphysema appears in the neighborhood of a wound the latter is to be considered as the starting-point of the infection and treated accordingly. In mild cases when the emphysematous condition is limited and shows no disposition to spread, and when constitutional symp- toms are absent, simple watching is all that is required. Upon the super- vention of symptoms of extension, or of constitutional disturbance, however, the treatment for an infected wound is to be instituted immediately. If the emphysema still persists or increases, in addition to thorough disinfection of the wound, incisions are to be made in the infected area and wet sublimate gauze is to be employed as a packing, compresses of this being applied as well. The milcl cases may recover without the reopening of the wound, and even the more severe forms, with simple yet efficient antiseptic treat- ment of the wound. SEPTICEMIA This is a form of systemic poisoning of bacterial origin in which living bacteria are found in the blood. While they are deposited in many cases in the liver, spleen, and kidneys, the disease differs, in typic examples, from pyemia, in that septic inflammation and the formation of abscesses in these organs do not occur. When the symptoms of sepsis as well as those of pye- mia are present the term septicopyemia is used. SEPTICEMIA 183 Clinical Course. — The disease is ushered in by a rise of temperature, this varyins: from 101° to 105° F. even within the first few days after the mjiirv. The occurrence of a well-marked chill is not common and is not re- peated if it does occur, the disease differing in this respect from pyemia. The pulse-rate is increased to 120 or more, and a remarkable condition of indifference and lassitude is present. The tongue is dry and leather-like and is protruded ^\•ith a hesitating and trembling movement over the parched lips. The skin is hot and dry, and is a dirty brownish color. In severe cases a pale yel- lowish hue of the skin is present, with dark purplish- red spots (petechiae). These point to a disintegration of the blood; the blood-corpuscles perish and the blood pigment is diffused into the tissue (hematogenous icterus). The walls of the vessels also undergo changes from the influences of the ptomains, and a hemorrhagic predisposition is present. The wound itself undergoes characteristic changes. The edges become shmnken, the granulations become flabbv and turn to a dirty gray, and thin and offensive discharge occurs. Anorexia is present; constipation is the rule, though in the severe forms profuse and not infrequently bloody diarrheic discharges occur. The respi- rations are rapid and superficial. The disease may last from five to fourteen days. Improvement is an- nounced by remissions of the fever, preceded by a more or less pronounced perspiration, the clearmg up of the intellect and deeper and less rapid respira- tions. The wound assumes a healthier aspect and granulations spring up. In fatal cases the apathetic state passes into coma, the temperature may drop below the normal, and the pulse becomes extremely rapid and feeble. Pathologic Anatomy. — Examination of the blood shows the destruc- tive effects of the bacterial infection on its corpuscular elements. The con- tents of the large venous trunks show incomplete coagulation; the blood is very dark, and tarlike. An acid reaction is sometimes observed. The spleen, liver, and kidneys are the seat of more or less turgescence. The serous membranes are sometimes more or less covered with ecchymoses and the cavities contain a small amount of brownish-red fluid. The fibrillae of the muscles are the subject of granular degeneration, as shoT^^l b}^ micro- scopic examination. They are a dark-brown color, particularly in the neigh- borhood of the wound. The condition of the blood is such as to produce rapid decomposition of the body after death. Etiology. — The disease was formerly regarded as autointoxication from the absorption of the products of a general proliferative process occurrmg in the wound. Attempts were made to isolate a chemic substance from the wound secretion (sepsin of Bergmann). Inoculation experiments with this, though fatal to the animals, did not reproduce the picture of the disease. Klebs, m 1871, demonstrated the presence of bacteria m septic wounds. By filtration of 1 he wound-secretion he also showed that the filtered liquid had but a comparatively slight degree of infecting power, wliile the filtrate itself produced a rapiclly fatal febrile condition, thus proxdng that the disease was one of infection rather than of intoxication. The experi- ments of Devalue (1872), however, settled the question. Inoculations from one animal to another showed that even the tenth animal died from septicemia. 184 ACUTE WOUND DISEASES The question as to the bacterial origin of septicemia was further studied by C . H u e t e r , whose results, however, were subjected to considerable criticism, though he undoubtedly discovered the presence of bacteria in septicemic animals as well as in man. His observations were confirmed in part by Birch-Hirschfeld and Koch. While certain microorganisms are found pathogenic to different classes of animals (bacillus of mouse septicemia of Koch, bacillus of hog cholera of Salmon and Smith, the micrococcus of rabbit septicemia, etc.), a separate form has not yet been discovered in man. Prognosis. — Prior to the antiseptic era, this disease was preeminently a fatal one. Together with pyemic and hospital gangrene, it swept away the great majority of patients who died in the surgical wards of hospitals. At the present time these three diseases are rarely observed, and only then when there has been a neglect to apply, or a failure to maintain the necessary asep- tic or antiseptic measures. Treatment. — In the very beginning of the disease, the changed condi- tions of the wound and the occurrence of a foul odor will arouse suspicion, and an energetic application of antiseptic treatment will be imperatively de- manded. This includes the opening up of the wound, the curetting away of decomposing shreds of sloughing connective tissue, thorough irrigation, and the establishment of counter-openings when necessary for purposes of efficient drainage. The interior of the wound should be well swabbed with a 10 per cent solution of zinc chlorid. When a joint is involved, the medullary tissue is finally invaded, and resection or amputation may have to be resorted to in order to save life. The internal treatment will include the use of quinin and alcoholic stimulants. Oil of turpentin has likewise been recommended. The inhalation of oxygen with the view of utilizing to the greatest extent the function of the red blood-corpuscles still available is indicated. PYEMIA This is an infectious wound disease produced by pyogenic organisms and characterized in its course by the invasion of distant tissues of the body by secondary foci of suppuration. The microorganisms are carried into the blood through the lymph-channels (H a 1 b a n), whence they are distrib- uted to the points where they lodge and proliferate and set up destructive changes. Isolated cases are observed in which a so-called spontaneous pyemia (cryp- togenic pyemia) occurs. These either occur from the passage of bactei'ia through the medium of the follicles of the mucous membrane lining the respiratory or digestive tract, or depend on a minute abrasion of the epidermis, without the development of a distinct local inflammation. Finally, a mixed infection may occur, the so-called septicopyemia. Either condition may precede the other, but the' term should not be used to apply to a distinct affection, for such does not exist. Metastases. — These are found most frequently in the lungs. Abscesses of various sizes are found, usually situated at the periphery. When adjacent to the pleural covering, a pleuritis occurs, which may result in serous, fibrin- ous, seropurulent, or even purely suppurative exudation. A diffused lobar pneumonic infiltration may take the place of the multiple foci and inclose a single metastatic abscess, or a gangrenous portion of the lung. PYEMIA 185 Next in frequency the liver, kidneys, and spleen are the seat of pyemic suppurative foci. The connective tissue and muscles, particularly the ten- dinous attachnionts of the latter, as well as the heart, brain, eyes, the syn- ovial lining of joints, and the serous membranes are attacked. Tlie knee-joint, hip- joint, and elbow-joint are the most frecjuently attacked. These may be simultaneously or successively invaded, and without due care the joint affec- tion may be mistaken for a rheumatic attack. The serous membrane may be attacked independently of neighboring structures or adjacent organs, as, for instance, tendinous sheaths, or these structures may suffer from extension, as the peritoneum in case of the liver and spleen, the pericardium in the case of the heart, the arachnoid in case of the brain, etc. Clinical Course. — Usually several days elapse between the reception of the injury and the occurrence of the primary suppuration. The onset of the disease proper occurs several days later. From the date of the injury to the commencement of the pyemic process, therefore, the earliest symp- toms will not occur within eight days, and they may be delayed for several weeks. The occurrence of metastases will be marked by a sharp chill, followed by a rise of temperature and local symptoms to indicate the points of secondary suppurative foci. The temperature, though it may reach 105° F., does not rise rapidly. The extent of the fever due to metastases may be masked by the previous existence of a surgical septic fever, or erysipelas. The occurrence of repeated chills and the increase of previously existing fever, which may assume a remittent or even intermittent type, will serve to identify the process when occurring in conjunction with local symptoms, such as cough with physical signs of circumscribed infiltration and softening, in case the lungs are invaded; local pain and tenderness in the case of the liver and spleen; pus in the urine in the case of the kidneys, etc. The disease is most likely to be mistaken for a severe malarial affection ; the sweating stage of the latter, however, is absent. The chills may occur coincidentally with each new deposit, and in the commencement of the disease each succeeding suppurative focus furnishes a more or less distinct exacerbation of the febrile symptoms. With the occurrence of a large number of metastases the chills become less frequent, the fever maintains itself at a higher grade, the vital forces give way, and the patient sinks from extreme and rapid asthenia. :\lany of the points of deposit may escape discovery altogether, particularly when in deep-seated joints, as the hip. This is due in some degree to the painless character of the suppurative process of the joints in this affection as compared with the process which occurs in traumatic cases. The other constitutional symptoms are such as obtain generally in febrile affections, including dry skin, the latter assuming a_ leathery character in cases of long duration, dry tongue, and vexatious thirst. Etiology.— Clinical observations point to the probability of a specific microorganism for this disease, yet efforts thus far have failed to isolate such. If the bacteria of common suppuration were alone involved in the causation, the disease, it is fair to assume, would be of far greater frequency. It has been asserted that an essential factor in the production of the disease is the absence of a protecting wall of granulation in primary suppurative foci, throm- bophlebitis resulting. Even this will not explain its infrequency; such gran- ulation barriers must be very often absent, as, for instance, in whitlow and its 186 ACUTE WOUND DISEASES fi-eqiient sequel, phlegmonous inflammation of the synovial sheaths of ten- dons. Yet even in preantiseptic times pyemia rarely followed these rather common conditions. That some specific morbific cause enters from without is rendered probable by the fact that the disease is of rather frequent occurrence in improperly treated and hence suppurating compound fractures, while in acute infectious osteomyelitis it is exceedingly rare. In both instances there is an acute suppurative inflammation and the medullary veins are equally exposed to the invasion of bacterial infection. The epidemic and endemic occurrence of the disease is to be taken into consideration in discussing its etiology. Its outbreaks in connection with crowded militar}' hospitals in times of war are matters of medical history. There are many reasons for believing that there is a specific poison at work under these circumstances, and that this is capable of being conveyed by the air as well as by contact. It was suggested by H u e t e r that this poison resides in a special microorganism which possesses peculiarly ener- getic powers of infection, but which, in its turn, is destroyed by the common pus cocci. R o s e n b a c h , however, concluded after patient observation that Streptococcus pyogenes and Staphylococcus pyogenes aureus produced pyemia. The metastases are accomplished through the medium of the blood-cur- rent, as well as through that of the blood-lymph. When the route is the blood, the lungs suffer mainly. The metastases, under these circumstances, are largely of embolic origin (V i r c h o w) . These emboli are infected with bacteria and again produce suppuration at the place of deposit. The loosening of a portion of clot and its migration to the right heart, and thence by way of the pulmonary artery to the respective lung, in case no bacterial infection or pus is likewise transferred, will produce simply a hemorrhagic infarction. Pyeinic foci occur in the liver, kidney, spleen, muscles, and subcutaneous connective tissue; in fact, the entire capillary area is exposed to infection. Bacteria alone, or carried along by pus-corpuscles, traverse the lymph-ves- sels and glands, and may pass even through the pulmonary circulation and thus gain access to the arterial current. In this manner the general invasion of joints, pleura, pericardium, and peritoneum is explained. Prognosis. — The disease once under way, its cure depends on an arrest of the metastases, and the subsequent discharge, resorption, or encap- sulation of already existing secondary foci. A pulmonary abscess may dis- charge into a bronchus; nephritic abscess may empty itself into the pelvis of the kidney and be discharged with the urine; those situated near the surface may make their way through the skin. The joint affections do not always suppurate, and hence resolution may likewise occur. Notwithstanding all these possibilities, recovery from the disease is rare; the affection always tends to a fatal termination. In proportion as the primary focus of suppuration is small and easily ac- cessible, permitting surgical treatment, will the prognosis be rendered more favorable. The ability of the patient to bear repeated deposits and renewed assaults upon his vital forces will also have a bearing on the prognosis. A condition of " chronic pyemia " may finally carr}- the patient off after a long and painful struggle. TETANUS 187 Treatment.— Under careful aseptic and antiseptic management of wounds this (list>asc> luis almost disappeared. Yet it is occasionally met with, under circumstances beyond the control of the surgeon. The primary focus of sup- puration must be at once attacked, in order to prevent further mfection. Free incisions and vigorous antiseptic treatment may suffice m mild cases. These failing if the suppuration is in a limb and important mternal organs are not in^•otved, amputation must be performed; extirpation of a suppuratnig tumor, and extensive incision of phlegmonous areas, are measures not to be considered as too radical when life is so urgently threatened. Lio-ation of the larger veins, when these are found to l)e the seat of thrombi, has been suggested (Klebs) ; favorable results of this expedient have been reported. i i i u When the joints involved show evidences of suppuration, they should be freelv incised, antiseptically irrigated, and drained. Abscesses in the mus- cular structures and in the parotid gland, which seems particularly liable to the infection, as well as those in the connective tissue, may be easily reached and freely incised. The pericardium may be aspirated (B. F. W e s t b r o o k) , and even incised and drained; the pleural cavity is capable of free drainage and antiseptic irrigation; the peritoneum may be incised and drained. In the meanwhile the patient's strength must be supported by every possible means, both dietetic and medicinal. Quinin, or the cinchona prep- arations with mineral acids, are useful. Alcoholic stimulants and malt liquors are particularlv indicated. Antipyretics of coal-tar origin, such as antipyrm, antifebrin, and phenacetin, should be used cautiously, if at all, on account of their depressing action. TETANUS This belongs to the class of wound infectious diseases in which the microbes or their ptomains affect the central nervous system. It is characterized clinically by spasm, either clonic or tonic, of definite muscular groups, ihose of mastication (trismus) and of the head and back (opisthotonos) are the most frequentlv affected. • t. +i Clinical Course.— The disease usually commences with some restless- ness on the part of the patient, and an anxious or pinched expression of coun- tenance, with elevation of the external angle of the eyes. There is some diffi- cultv in opening the mouth. In speaking, the patient keeps the teeth to- gether on account of the spasm of the masseteric and temporal muscles. Ihe muscles of deglutition next become affected, and finally the muscles of the back of the neck and the extensors of the spine. The opisthotonos which now occurs is characteristic; the body rests on the occiput and heels when the patient is in the dorsal position. The anterior trunk muscles may become affected, producing a position the reverse of opisthotonos, that of emprosthot- onos Contraction of the lateral trunk muscles produces pleurothotonos More or less rigidity of the affected groups of muscles persists (tonic spasm , though this is increased bv paroxvsmal convulsive movements (clonic spasm;. The svmptoms bear a striking resemblance to those of strychnm poisoning. The slightest peripheral irritation, even a draft of cold air, m severe cases, brings on aggravation of the muscular spasm and most excruciatmg pam Respiration is interfered Anth in proportion to the extent of mvolvement ot 188 ACUTE WOUXD DISEASES the respiratory muscles. The pains, which are sometimes most excruciatingly severe, usually follow the course of the nerves leading from the spinal cord to the affected muscles. The sensorium generally remains unaffected during the entire course of the disease. A profuse salivary secretion escapes from the mouth through the set teeth. The pulse in acute cases is rapid and feeble, and the temperature rises to 40° or 41° C. (104° to 106° F.). W under- lich has noted a postmortem temperature of 44.7° C. (112° F.). Pro- fuse sweating is a characteristic symptom. There is inability to take food and drink. In consecjuence of this, and of the intense pain and loss of sleep, there is rapid emaciation and loss of strength early in the disease. There is generally more or less cyanosis present, and, the diaphragm becoming involved, a spasm of this suddenly produces death. When death takes place from exhaustion, a profuse and clammy perspiration, coldness of the extremities, and weak, intermittent, and rapid pulse precede the lethal exit, which may occur in some cases in a few days. In cases which terminate in recovery, the muscles of mastication present m^ore or less stiffness for several weeks, which gradually subsides. Tetanus neonatorum. — This occurs in infants during the first week fol- lowing birth. It is almost invariably fatal, and that very shortly after the attack. The point of infection, as a rule, is the umbilicus. Trismus, associated with paralysis of the facial nerve (E . Rose, 1870), is a peculiar form of trismus folloAving injuries of the head, and par- ticularly of the facial region. It is sometimes called hydrophobic tetanus, from the fact that attempts to swaUow bring on the spasms. The prognosis is more favorable than in the other varieties. Rose's trismus may pass into a chronic or typhoid form of the disease, which is followed by death. Etiology. — The essential cause of tetanus is the Bacillus tetani of Nicolaier (1884), who discovered it in garden earth. Rosenbach demonstrated its existence in the wound secretions of tetanic patients. Sternberg in 1880 produced tetanus in a rabbit by injecting beneath its skin mud from the street gutters of New Orleans. The identity of these bacilh was established in Koch's laboratory (1887). A pure culture was obtained by Kitasato (1889). The ptomains of the bacihus are undoubtedly the toxic agents acting through the medium of the spinal cord. One of these, isolated from cultures of the microorganism, called ''tetanin" (Brieger), injected beneath the skin of animals, produced tetanic convulsions. Wounds of the hands and feet are said to invite the occurrence of the dis- ease. This is probably due to the greater exposure of these parts to the material containing the infective agent. Extirpation of the thyroid gland has been followed by tetanus (13 cases reported by Weiss). It occurs more frequently after partial than after total extirpation (Billroth), and is said to be due to the increased peripheral irritation caused by the application of a large number of ligatures. The colored races are attacked more frequently than the Caucasian race. The conditions of climate in southern regions favor reproduction of the bacillus. Conditions of soil also favor its cultivation and propagation. Incubation.— The period of incubation is extremely variable both in the lower animals and in man. This depends on (1) the number of bacilh TETANUS 139 introduced (Watson C li e y n c) ; (2) the location of the point of infec- tion and the anatomic characteristics of tlie surrounding tissues; (3) the capa- city of the different tissues to yield the ptomains under the influence of the bacillus. It is also probable that the degree of virulence of the Imcillus governs, to a certain extent, both the duration of the stage of incubation and the severity of the attack. Prognosis. — This will be governed by the type of the disease. The attacks characterized by an early and sudden onset and intense symptoms are more than likeh- to prove fatal. Later and slow development of the symp- toms and a less violent manifestation of the characteristic spasms may end in recovery. If the patient survives beyond the fourteenth day, recovery is the rule and death the exception. Even a chronic state may follow an acute attack; after a period of weeks or more, recovery may take place. Not less than 75 per cent of all cases prove fatal. Pathologic Anatomy.— The most constant pathologic lesions found are inflammatory softening of the gray substance of the cord and dilatation of the vessels. Hyperemia of the medulla oblongata and spinal cord is always present. An entire absence of gross pathologic changes is characteristic of the disease. Treatment. — The preventive treatment depends on an antiseptic regi- men in connection with all wounds, and the prompt removal of foreign bodies. Punctured wounds of the hands and feet are, as a class, more liable to be followed by tetanus than are incised wounds. As the bacillus of tetanus will not grow in the presence of oxygen, it is evident that a punctured wound quickly closed offers just the conditions appropriate for reproduction of the germ if it has been introduced into the depths of the wound. Wounds of this character, as well as those inflicted by toy pistols, the cartridges of which contain earth, should be laid freely open and thoroughly disinfected by a 1 : 1000 solution of corrosive sublimate and wet dressings of this applied. The efficiency of the sublimate solution is enhanced by the addition of alcohol (see page 60). Equal parts of 95 per cent alcohol and a 1 : 500 solu- tion of sublimate may be employed. This course is imperatively demanded in localities where tetanus is known to follow trivial wounds." Under no circumstances should a small opening be sealed by a dry dressing. Among the internal remedies employed in the symptomatic treatment of tetanus. Calabar bean, chloral, and opium are to be mentioned. Chloroform is largely used in the South in the hyperacute cases. Of these remedies. Calabar bean is of value in relieving the muscular contractions. It is to be given in doses of from one to one and a half grains of the extract every three or four hours. For subcutaneous use twenty drops of a 1 per cent solution of the extract is to be administered. Chloral acts by diminishing the reflex excitability of the_ nerve-centers, but it is not a curative agent. It relieves pain, however, and limits the spasms as well as wards off the comailsive attacks. It should be given to the extent of from 100 to 200 grains in twenty- four^ hours if necessary. It is sometimes thought advantageous to combine it with bromid of potassium. Chloroform may be administered by inhalations when required to reheve the excruciating pains and to relax the contracted muscles. Spasm of the glottis will sometimes prevent its use. Hypodermic injections of morphin every two or three hours have been employed. 190 ACUTE WOUND DISEASES Treatment by Tetanus Antitoxin. — Experiments made with the view of estabhshing in animals immunity from the disease have been carried on, and it lias been shown that the blood of animals rendered immune may have the effect, when injected into other animals, not only of rendering these im- mune, but of curing the disease when it is established. The blood-serum of such animals, when brought in contact with the poison outside the body, destroys its toxic properties (Kitasato, Behring). The horse is usually employed in the production of tetanus antitoxin. The dose of the latter and the frequency of the injection var}^ with the preparation used, the weight of the individual, and the urgency of the symptoms as well as the improvement noted. In hyperacute cases with a short period of incubation a large dose must be employed. Prophylactic doses are smaller and less frequently repeated. The average dose of the antitetanic serum furnished by the Health I^epartment of the City of New York is twenty centimeters. The injections are usually made under the skin of the back or thigh in cases not urgent. In hyperacute cases they may be introduced directly into a vein. Intracranial injections of from five to seven cubic centimeters into the frontal region of each hemisphere, after the skull has been perforated on both sides, have a still greater efficacy. The serum should be allowed to diffuse itself slo^\iy beneath the dura. As this method is not devoid of danger, it should be reserved for hyperacute cases, and for those in which no benefit is derived from the subcutaneous and intravenous use of the serum. The results follow- ing the use of intraspinal injections have been disappointing in my hands. Carbolic acid, injected beneath the skin in from ten to thirty drop doses of a 1 per cent solution, every three or four hours, has been used extensively in Italy (B a c c e 1 1 i) . It is of less value than the serum treatment. There is no objection to combining the two. The nutrition of the patient is to be maintained b}^ nutrient enemas, and by means of a tube passed into the stomach through the nostril, when swal- lowing is impossible. Chloroform may be given to effect this. The hydrate of chloral may be given in milk introduced in this way. It may also be given in nutrient enemas. Physical and mental rest must be enjoined. The patient should be placed in a dark, quiet room, and every possible source of excite- ment and noise avoided. HYDROPHOBIA This is a disease of man and certain other mammals, and, like tetanus, belongs to the class of wound infectious diseases. It arises from the bite of a rabid animal, the saliva being the infection-bearing medium. The virus of the disease may be transmitted to all warm-blooded animals. The disease in man is caused most frecjuently by dogs, both because of opportunity, and because the saliva of infected dogs is more virulent than that of other animals. By some it is believed, however, that danger of the development of hydro- phobia is always greatest when the bite is inflicted by a wolf. Clinical Course. — The first onset of the disease does not occur until after a comparatively long period of incubation. In rare instances this may be as short as fourteen days; it has been prolonged to twenty-tA^t) months. The younger the patient, the shorter the incubative period, as a rule. HYDROPHOBIA 191 This sta2;c of the disease is said to be lengthened by depressing influences. The heaiiug of tlie wound is generally uninterrupted. During the initial stage of the disease a reddening with burning and itching, and sometimes actual pain at the site of the scar, is observed. This may radiate along the course of the nerves of the limb. Anesthesia and hyperesthesia are also present at times. During this stage there are some ill-defined s>'mptoms, such as melancholia, irritability, and disturbed sleep, alternating with restlessness and short periods of joyous excitement. With the onset of active symptoms the characteristic symptoms of the disease make their appearance. These refer to mental excitement conjoined with spasms of the muscles concerned in respiration and deglutition. There is at first a sense of choking, which is soon followed by spasms of the lar\'ngeal muscles. A profuse salivary secretion is present, which becomes mingled with viscid, tenacious mucus from the fauces. Attempts to drink excite such pain- ful spasms of the pharyngeal muscles that the patient soon abandons the at- tempt, and cannot be induced to repeat it. Spasm of the glottis also takes place as a result of the effort to swallow. General tremors may occur, and even con- vulsions. The temperature is always increased to from 101° to 103° F. The pulse is not markedly increased at first, but later on becomes rapid and feeble, and sometimes intermittent. The skin is hot and dry; just before the fatal issue a cold and clammy perspiration may be present. Priapism and satyria- sis are observed. A most disturbing symptom, present from the first moment the disease is suspected to exist, and lasting to the very close, despite the most positive assur- ances and consolation, is the fear of impending death. The mental faculties are not, as a rule, impaired, though occasionally the patient has hallucinations of sound and hearing. Etiology. — It can no longer be doubted that hydrophobia is a disease of microbic origin, though its specific microorganism has not as yet been dis- covered. It seems now very certain that the \drus cannot be reproduced except Adthin the hving organism. The smallest amount of this introduced ^Aithin the body will produce the most serious consequences. The symptoms bear such a strong resemblance to those of tetanus that it is probable that the development of the disease is due to the action of the ptomains of the microbes on the nerve-centers. The specific virus seems to be generated within the glandular appendages of the mucous membrane of the mouth of the rabid animal, and is transmitted by the saliva. Only a certain proportion of persons bitten by rabid animals contract the disease, about one-fourth escaping (Renault). The route of entrance is usually a punctured wound made by the bite of a rabid animal, though the saliva deposited on an abraded surface may suffice for the inoculation. The microbe does not penetrate the uninjured skin or the mucous membrane. Prognosis. — The disease in man is invariably a fatal one. No case of recovery from genuine hydrophobia is authentically recorded. In the major- ity of cases death occurs during the first four days. It is rare for the patient to live beyond the second day. The length of time from the infection of the bite until death takes place is from the twentieth to the sixtieth day. Death, as a rule, occurs unexpectedly from either apoplexy or asphj^ia; 192 ACUTE WOUND DISEASES or rapid exhaustion may carry off the patient. A stage of paralysis may pre- cede death, the patient lying relaxed from two to eighteen hours. Pathology. — There are no gross pathologic changes in the disease. The scar, in some instances, may be red and somewhat swollen ; this is not by any means constant, however. The cerebral ganglia, particularly of the pneumo- gastric and trifacial nerves, and the spinal and sympathetic ganglia undergo certain distinctive changes, inflammatory tissue taking the place of the destroyed nerve cells. AA'ell-defined vascular lesions in the nerve-centers of the cord and medulla may be detected; these are less defined in the spinal cord, still less in other parts of the nervous system. An accumulation of leukoc3'tes around the vessels in the substance of the medulla and cord is usually found. There is well-marked hyperemia and edema of the substance and mem- branes of the brain, spinal cord, and medulla oblongata. Treatment. — When a person is bitten by an animal known or suspected to be rabid, inasmuch as the virus is slowly diffused in the system, no time should be lost in resorting to the most radical prophylactic measures at com- mand. These may be efficient, even if applied after several clays. Excision of the wound affords the best hope of preventing the disease. A tourniciuet should be applied on the proximal side of the wound, and in the absence of professional help, an attempt made to remove the virus by suction. The tis- sues in the immediate vicinity are to be dissected out, and the wound sutured. Cauterization of the wound may be most effectually performed with the actual cautery, the point of the Paciuelin cautery, if this instrument is employed, being thrust deeply into the wound. The parts are afterward dressed antisep- tically. Caustic potash, nitric acid, and nitrate of silver are less efficient. Statistics show that a large proportion of persons who have been bitten by hydrophobic animals escape infection when these measures of prophylaxis are employed. The inoculation test by which it may be demonstrated whether or not the animal is rabid is carried out by killing the latter at once, removing the medulla, and rubbing this up with sterilized salt solution. The emulsion thus obtained is injected into the subdural space of a rabbit. If the virus of hydrophobia is present, the inoculated animal will speedily develop the disease. The person bitten should be sent at once to a branch laboratory of the Pas- teur Institute, where immunization may be promptly carried out. Pasteur's Prophylactic Inoculation. — The varying periods of incubation in different cases suggest that this, the latent stage of the disease, depends either on the slow growth of the microorganisms, or on the fact that they reach the point where they exert their noxious influence very slowly in some cases, and more rapidly in others. The differences in this respect may depend on the fact that the tissues in which the virus was originally implanted permit reproduction of the microbe but slowly in some instances, and more rapidly in others. On the other hand, it was discovered by Pasteur that if the virus is introduced directly into the brain of the animals, a fixed period of incubation precedes the development of the disease. Subsequent inoculations are marked by a still shorter period of incubation. Pasteur made the additional important discovery that the virulence of the infected spinal cord in rabbits may be diminished progressively from the highest degree to the lowest or even rendered inert, according to the length HYDROPHOBIA 193 of time tho cord is kopt in a dryiiio- room, in a pure, dry atmosphere. This is accomplislicd in from sc\-en to eight days. I'\)iirteen days' drving will com- pletely- destroy all A'irulenee. l^y using the spinal cords of rabbits treated in this manner in varying strengths, commencing with the weakest and gradually approaching the strongest, he found that when the latter were reached, the animals did not respond to the inoculation. In other words, they became immune. After demonstrating the accuracy of these observations on dogs, Fasten r (July 5, 1885) applied the method to persons bitten by rabid ani- mals. The long period of incubation enabled him to apply the treatment to those who came from a distance, and during the first five years of its application nearly eight thousand persons who had been bitten bv supposed rabid animals were thus treated. Of these, only 0.92 per cent died, a most extraordinary savmg of human life, when compared with the fact that in former times 16 per cent died of hydrophobia, all those who were actually bitten by rabid animals, as well as those supposedly bitten, being taken into account. As those bitten by rabid wolves develop the disease much more certainly than those bitten by dogs, a crucial test of the method consisted in the prophylactic inoculation of this class of cases. Thirty-eight were submitted to the treat- ment, and of these only 7.89 per cent died. A collection of one hundred un- treated cases of persons bitten by hydrophobic wolves showed a mortality of 82 per cent (Pasteur). In view of the results obtained, the deadly character of the disease, and its probable development in those bitten by a hydrophobic animal, it is' recom- mended that all persons who have been bitten by animals suspected to be rabid be subjected to Pasteur's prophylactic inoculation. 14 SECTION V THE CHRONIC SURGICAL INFECTIONS SYPHILIS This disease has been kno^^-n since the very earliest times, if ^ve may judge from the fact that its symptoms are described in the ancient literatures of the earliest known races, such as those of China, Mexico, Peru, Greece, and Rome, and in sacred writings of the Hebrews. Renewed interest in the disease was awakened in the fifteenth century, coincidentally with the discovery of the con- tinent of North America, and on this account it has been supposed by some writers that the disease was introduced from this continent. It is probably true that the impulse given to traffic between nations by that discovery led to exten- sion of the disease. Communities theretofore immune became infected, and, as is usual where the soil on which specific infections are implanted is virgin, the epidemics of the disease were marked by exceptional se^'erity. At the present day it exists practically all over the world, particularly among those nations with great commercial activities, and in the crowded centers of trade. Rural populations are happily quite free from it. Syphilis is a specific infectious and chronic disease, limited to man, having its origin either from the contact of a sound indi^ddual with one infected ^vith the disease (acquired syphilis) or from heredity. The disease, beyond question, is to be classed with the infectious granulomas, and is caused by the introduc- tion of a specific microorganism into the human economy. The infectious agent is transmitted through the medium of fluids furnished by the pathologic tissues of infected individuals. A number of observers have claimed to have discovered a specific microorganism of syphilis. The latest of these, M a x Joseph and P i o r k o w s k i , isolated a bacillus which, when cultivated on sterilized placentae, closely resembled that of diphtheria. When it was transferred to artificial media and cultivated for successive generations, the size and form as well as the numbers and vigor of the bacilli diminished consider- abl}', these being restored by reinoculation on blood-serum. The disease is conveyed by inoculation through the skin or mucous mem- brane, or the \arus may exist in the embryo or be transferred through the pla- centa. The inoculation takes place most frequently from immediate, rarely through mediate, contact. In the vast majority of cases the disease is con- tracted during coitus and is therefore classed as a venereal disease. It may be contracted, however, by kissing a person infected with the disease, in examina- tions of syphilitics or in operations on them, or, rarely, by contamination from any article on which syphilitic virus has been spread. The last named is what is known as "mediate infection." The Course of Acquired Syphilis. — In the acquired form of the dis- ease the virus enters the organism at the point of infection and always begins as a hard chancre. This appears after a relatively definite and characteristic 194 SYPHILIS 195 intor\'al following the exposure to the virus and the reception of it. A so-called "primary incubation period," extending usually from two to four weeks, inter\-ones betwinni the reception of the virus and the appearance of the chancre, or initial lesion, as it is sometimes called. This is followed by the "secondary incubation" period, occupying from two to eight weeks, after which there develops the primary regionary lymphadenitis, then the secondary general lymphadenitis. Coincidentally w-ith the latter, in many cases, symp- toms which usher in the acute infectious diseases are observed, such as nervous disturbances, debility, anemia, elevation of temperature, headache, and pains in the extremities; less frequently i^eriostitis and prodromic papules. At the end of the second incubation period further evidences of constitu- tional syphilis appear. There is frecjuently more or less febrile movement pre- ceding the outbreak of the first exanthem, namel}^, the roseola. The heating of the surface may precipitate the occurrence of the rash, as, for instance, when a warm bath or excessive exertion immediately precedes the latter. The roseola makes its appearance in the majority of instances in from seven to nine weeks after the original infection. From this time on, the course of the disease is that of an irregularly relapsing chronic infectious disease. The re- lapses alternate with periods of more or less complete latency, as far as rasiy be judged by the symptoms. It is not to be supposed, however, that the dis- ease itself is not progressive, even during these periods of apparent quiescence. A gradual and continuous progression of the disease takes place from the moment the infection gains entrance, and no distinct line of demarcation can be made between the successive manifestations of the disease as they appear in any individual case. A general involvement of the lymphatic glandular sys- tem, the so-called "secondary lymphatic adenopathy," as distinguished from the primary lymphatic adenopathy, which occurs near the site of the chancre, marks the entrance of the toxic products of the latter into the general circula- tion, and, from this time on, the characteristic phenomena of the infection are observed as the evolution of the disease progresses. The red blood-cells com- monly decrease and the leukocytes increase. The general lymphatic involve- ment manifests itself by a somew^hat symmetric enlargement of the glands, thereby differing from the adenopath}^ near the site of the chancre, which is rather asymmetric. These phenomena, together with those already men- tioned, stamp this as a steadily progressive infection; the halt between the appearance of the initial sore or chancre and the occurrence of the skin erup- tions is more apparent than real. All the organs are more or less disturbed in their function. The spleen, liver, and stomach notably take part in these disturbances. The nervous sys- tem may suffer, as showm by the neuralgic pains along nerve-trunks and by the peripheral pains as well. Febrile disturbances are not uncommon (syphilitic fever) . There are pains in the bones and joints ; synovial effusions may occur. In severe infections the lassitude and depression are profound, with mental lethargy, followed by attacks of syncope and headache. All grades of severity of the disease may be observed, and the terms "benign" and "malignant" have been employed to designate these. These terms have but a relative significance, particularly the term known as benign, though all grades of malignancy also may be recognized. Benign Syphilis. — This includes (1) cases with mild and transitory symp- 196 THE CHRONIC SURGICAL INFECTIONS toms; (2) cases with relapsing or persistent superficial symptoms. Those cases with mild and transitory symptoms may present an apparent arrest of the disease after the appearance of a hard chancre and the presence of the characteristic local lymphatic glandular changes, the individual thereafter failing to react to the disease. As far as any outward sign of generalization of the latter may indicate, the patient is immune, and cannot thereafter be inocu- lated. Or, as more frequently happens, lymphatic glandular enlargement occurs in the occipital region or along the nucha, and later on along the sterno- mastoid muscle. The disease then progresses to the production of a macular skin eruption on the abdomen or over the chest, or both. With the subsi- dence of this exanthem the disease appears to terminate. A case may pursue the course above outlined with absolutely no treatment. The symptoms present, though typic, are of an astonishingly mild type. These cases differ from the foregoing in the degree of immunity exhibited. In the second group of cases, namely, those with relapsing or persistent superficial symptoms, the manifestations, both of the initial lesion and of the general disease, are in every respect typic, yet at no time scarcely more than an annoyance. The special features of this type are the persistency of the re- lapses and the mildness of the symptoms, the latter of which relate particularly to the superficial skin eruptions. The majority of cases of syphiUs belong to this group. There can be no doubt that, in the course of the natural history of the disease, in a large number of cases the destructive lesions neA^er develop. This will account for the so-called "cures" by infinitesimal dosage, mind cures, as well as for the ignored cases. Nevertheless, the fact should not be overlooked that the mildest cases in the beginning may become the severest in the end. Therefore there should be no relaxation in vigilance in respect to even the mildest cases. Malignant Syphilis. — This is fortunately a rare form of infection. The malignancy is probably due either to an extraordinary susceptibility of the individual to the disease, as occurs when the latter is introduced among a race or people for the first time, or to a lack of resistance to the infection and its rapid propagation in the tissues of the patient whereby the entire organism is overwhelmed by the virulence of the poison. The malignancy of this class of cases may be exhibited early in the case or soon after the chancre stage, and continue only through the exanthem period, this including the time when lesions of the mucous membrane and general en- largement of the glands occur (the secondary stage of R i c o r d) . Or, it may continue and manifest itself in connective-tissue hyperplasia, or gummatous deposits (^syphilomas), which constitute the late stage of the disease (the tertiary stage of R i c o r d) . In the mean^vhile the patient shows signs of a deterioration of the general system (syphilitic cachexia), with high fever, loss of flesh, and pains in various parts of the body — in fact, all the evidences of a profound systemic poisoning. Disturbances of the nervous system, such as aphasia, epilepsy, coma, and paralysis, have been observed. Degeneration takes the place of resolution in the case of the lesions. Ulcers, eruptive and gummatous, n;pia, and even gangrenous areas may occur at the site of the rather sparse lesions. Gummatous deposits undergo processes of disintegration, lead- ing to deep and gangrenous excavations where these can communicate ^Yith the surface. When restoration of these deposits takes place the implicated organs SYPHILIS 197 are greatly damaged. Exceptionally all these destructive manifestations ma}^ occur early in the disease (malignant precocious syphilis) . Finally, the fact cannot be too forcibly impressed that the different types of the disease, as expressed by the terms "benign" and "malignant," may be merged the one into the other. Chief among the causes for this interchange may be mentioned the influences of environment, constitutional conditions, and the effects of treatment. It has been customary to divide acquired syphilis into stages, namely, the primary, the secondary and the tertiary (R i c o r d) . This division, though artificial to a considerable extent, is convenient for purposes of clinical study and therapeutic considerations. The primary stage covers the two incubation periods before mentioned, namely, that which intervenes between the reception of the virus and the appearance of the chancre (the primary incubation period), and the interval between the appearance of the chancre and the occurrence of the characteristic exanthem, the roseola (the secondary incubation period). The secondary stage of the disease commences after an average interval of four or five weeks and is ushered in b}' the exanthematous outbreak of roseola (the macular syph- ilide). The tertiary period commences after the lapse of two years on an avei'age, and embraces what are known as the late manifestations of the disease, the gummas. The gummatous lesions may be absent, even in the cases un- treated; their presence is not to be expected in those who have been subjected to continuous mercurial treatment for two years. The Lesions of the Primary Stage. — After the primary period of incubation, this lasting from twelve to thirty clays (exceptionally even sixty days), the seat of inoculation undergoes certain characteristic changes which culminate in what is known as the initial lesion, primary sore, or .chancre. The chancre is usually single and painless and may be o^^erlooked owing to its situation (within the urethra in the male, and between the labial folds in the female, or in the mouth or throat). The primary adenopathy con- sists of an indolent enlargement of the lymphatic glands in anatomic relation with the primary sore (bubo) . The Lesions of the Secondary Stage. — These follow the secondary period of incubation in the primary stage (see page 195) . Sore throat, syphilitic roseola (macular syphilide) , and painless enlargement of the lymph-glands are the earliest manifestations usually observed in the secondary stage. The ante- rior and posterior chains of glands in the cervical region, the epitrochlear glands and those in the axillae and groins are, as a rule, easily palpated. Later on, and usually coincidentally with the disappearance of the roseola, another type of skin eruption makes its appearance, namely, the papular syphilide. Exceptionally, however, the latter appears before the subsidence of the roseola. The papular syphilide is a small, rounded, and distinctly indurated nodule of a brownish-red color. It usually appears first in the localities first affected by the roseola, namely, on the abdomen, chest, and back, and at a later period on the arms and thighs ; finally, on the palms of the hands and the soles of the feet. Or this order may be reversed. Coincidentally with the cutaneous eruption small superficial erosions appear on the mucous membrane of the mouth and pharynx (mucous patches). The favorite locations for these lesions of the mucous membrane are the sides of the tongue, the hning of the cheeks, the tonsils and 198 THE CHRONIC SURGICAL INFECTIONS pharynx, and the hps and angle of the mouth. Mastication is painful and the flow of saliva anno>-ing. About the time when the above symptoms decline, or about the third month, the symptom of the falling out of the hair appears. This may amount to only a general thinning of the hair, or complete absence of hair in patches may result (syphilitic alopecia). The hair in different locali- ties of the body may be affected, with the exception of the eyelashes; the latter are invoh'ed only through ulcerative action. The hair-follicles may be involved in an erythematous, papular, or pustular eruption, and scales or scabs appear on the scalp in conjunction -with the alopecia. This symptom of the falling out of the hair may last for a variable time. It disappears spontaneously in a short time, as do most of the symptoms of this period of the disease, even in cases that are not treated. Permanent baldness ma}^ result when the papillae are destroyed and the hair-follicles obliterated by the presence of ulcerative lesions ; this may also follow, to a greater or lesser extent, a simple erythematous or pap- ular eruption. After the disappearance of the first exanthems, the latter may reappear in different shapes and combinations (recurrent syphilides). A papular and a pustular eruption may appear either separately or in combina- tion, or these may occur with either a scaly or a pustulo-crustaceous erup- tion, or both. Other lesions occurring in this period, and somewhat allied to mucous patches, are the so-called condylomas or moist tubercles. These are situated in moist localities and on certain mucous membranes {e. g., in the larynx), about the anal aperture and on the genitals. In the latter situa- tions they appear as broad, flat warts with a purulent discharge (condylomata lata) and with a tendency to vegetate, though vegetating condylomas or papil- lomas are not necessarily of syphilitic origin. Finally, within the first or early in the second year there may appear small circumscribed and painless swellings under the skin, perceptible only to the touch (precocious gummas). These are of rapid growth, become adherent to the skin, and appear as inflamed indu- rations; the red color soon changes to a dull or coppery hue. Softening takes place; ulceration, however, is not the rule in cases subjected to treatment. As resolution takes place the gumma slowly disappears, leaving a peculiar copper- colored patch on the skin. If ulceration occurs, the softening begins early, fluctuation is felt, and the skin at the site of the gumma breaks down in several places. The points where softening first occurs coalesce rapidly, and an ulcer with a greenish base and with undermined, sometimes everted edges, results. Exceptionally, the development of precocious gummas may be slow and insidious. In other cases these lesions are accompanied b}^ severe neu- ralgic pains and excpisite tenderness of the tumors. The Lesions of the Tertiary Stage. — This stage of the disease may never be reached, even in untreated cases; in those that have been subjected to proper mercurial treatment for two years the so-called tertiary symptoms are practically wanting. The evolution of the disease at this stage is usually slow and insidious, and always erratic in its manifestations. The latter consist essentially of connective-tissue hyperplasia, or of masses made up of collections of small spheroidal and epithelial cells, and occasional giant cells (gummas). T'hese lesions are situated in the skin, deep in the subcutaneous connective tis- sue, in the mucous membranes and in other structures. The larger gummas consist of firm nodules with a cheesy or necrotic center and present a somewhat characteristic grayish-white appearance; they are inclosed in a rather ill- defined translucent capsule. SYPHILIS 199 No organ or tissue of the body is exempt from the infiltrations or deposits of these late manifestations of the disease, and the symptoms to which these latter give rise are as \-aried as are the functions of the parts attacked. In the skin patches serpiginous ulcers, rupia, and pustulo-crustaceous syphilides are observed. Ciummatous deposits, followed by ulcerations, occur in the subcutaneous connective tissue. These lesions, as a rule, leave pronounced, and sometimes characteristic, scars. Those occurring on mucous mem- brane, particularly that of the pharynx, increase rapidly and break down early, causing great loss of tissue. Necrosis of the hard palate and of the bones of the nose occurs, with interference ^^ith articulate speech in the case of the former, and facial deformity in the case of the latter. Syphilitic deposits may take place in the lungs, liver, kidneys, and heart — in fact, in all the internal organs. The central nervous system is attacked with relative fre- quency. The bones and joints, as well as the tendons, muscles, and bursae,do not escape. A cachexia which is out of all proportion in its intensity to the organic changes present develops (syphilitic cachexia). In favorable cases, or those in which the late symptoms just described yield to treatment, there occurs a tendency to a natural decline of the disease. This, however, may not occur until irreparable damage to one or more of the vital organs has been done, and permanent impairment of the health has taken place. Death as a direct result of the syphilitic infection, however, is not common, THE GENERAL TREATMENT OF SYPHILIS The self-limiting nature of the disease is now fully established. Women are particularly fortunate in this respect; in men also the disease occasionally runs its course to recovery of health without any treatment whatever. This circumstance has led to much heated discussion as to the proper methods to be employed to protect the patient against the ravages of the disease. The principal contention in this regard is in respect to the administration of mercury. Without entering into the merits of this discussion, it may be said that the experience of the profession for centuries has been in favor of this drug. Since the disease is one whose symptoms disappear spontane- ously in a large number of cases, it is no wonder that many vaunted cures have been urged. The use of mercury in one way or another, however, has been for centuries the chief reliance in the treatment of this affection, and is likely to remain so. With the sole exception of quinin in the treat- ment of malarial diseases, the influence of mercuiy on syphilis stands uniciue in the history of therapeutics. As the benefits to be derived from its use are fully realized, the only question today relates to methods of administration whereby the maximum amount of benefit may be derived A\'ith the minimum of harm. The objects of the rational specific treatment of syphilis are (1) to sup- press harmful symptoms already in existence; (2) to prevent the occurrence of the connective-tissue infiltrations and gummatous deposits of the later stage of the disease; (3) to prevent the spread of the disease by (a) inoculation and (/)) transmission to offspring; (4) to prevent damage- to important struc- tures and organs, and unsightly scars. The means to be employed for the attainment of these objects is the judicious use of the preparations of mercury 200 THE CHRONIC SURGICAL INFECTIONS and iodin. The term "specific" as applied to these remedies relates to their peculiar value in the control of the symptoms. But no one can say, in a given case, that the disease is cured, even after a prolonged exhibition of these remedies, for it will occasionally show fresh manifestations of its con- tinued existence after prolonged treatment and absence of all symptoms for years. The proper time to begin the systematic medication in syphilis is on the appearance of the general manifestations. The reasons for this are (1) that the diagnosis may be assured beyond a doubt; (2) that the pa- tient himself, on whom depends almost entirely the success of the treatment, may have convincing proof of his condition and persist in the treatment. Exceptionally, the treatment may be begwn earlier, but this is always at the risk of unnecessary treatment, or the loss of confidence, and hence interest, on the part of the patient. The Hygienic Treatment of Syphilis. — The importance of hygienic surroundings for the patient cannot be overestimated. Every effort should be made to maintain the general health at its very best, in order to diminish as much as possible the unfavorable character of the symptoms. It is unquestionably true that broken-do^\^l individuals in the declining years of life may acquire syphilis which will give rise to only mild symptoms, and that in spite of neglect and dissipation, while, on the other hand, young men in the best of health up to the time of infection suffer from a virulent form of the disease notwithstanding every care; yet these facts do not militate against the necessity for husbanding in every particular the vital resources of the patient. The precautions to be taken relate particularly to the ordinary rules of everyday life. Cleanliness of the body by daily bathing is important. No special dietary need be laid down for the syphilitic beyond what is required in usual health except that, during the existence of mouth or throat lesions, articles of food that may tend to irritate these should be avoided. Wine or beer in moderation may be allowed if taken only at meals; unless, however, the denial of these is a very great deprivation to the patient, it is safest, in order to avoid the possibility of alcoholic excesses, to enforce total abstinence. Acids may be allowed unless, under some special exigency, mercury is being pushed and salivation feared. When irritable conditions of the stomach and liowels supervene as the result of necessary medication, these may sometimes be avoided by a change in diet. This failing, corrective medication, such as the preparations of bismuth, bicarbonate of soda, and finally small doses of opium, may be tried before the antisyphilitic remedies are suspended. Cachec- tic states demand ferruginous and other tonics, change of air if these fail, and finally of occupation as well. Among the health resorts the Hot Springs of Arkansas have acquired a well-deserved reputation. A sojourn at any one health resort is not calculated to be of benefit. Due attention must be paid to the hygiene of the mouth. The teeth should be regularly cared for by a dentist, all ragged or projecting rough surfaces corrected and tartar prevented from accumulating. Mucous patches and resulting ulcerative conditions demand that the greatest care be taken to avoid irritating articles of food and drink, since, under the most favorable conditions, these lesions are frequently difficult of management. Smoking SYPHILIS 201 should be prohibited during the active existence of mouth lesions, and a syphilitic should not be permitted to chew tobacco under any circumstances. The tendency to the occurrence of superficial lesions (excoriations, con- dylomas, and ulcerations), in localities where the skin is thin and less resistant, and at the mucocutaneous junctions, demands that special precautions be taken as to cleanliness of the genitals and of the anal region. Washing the latter with soap and water after each defecation is not unwise nor uncalled for. The accumulation of moisture in these parts should be corrected by the use of some antiseptic drying powder, in addition to frequent bathing. The Specific Treatment of Syphilis. — This should never be com- menced until indubitable evidences of the existence of the disease are mani- fest (vide supra). The specific medicaments emplo}'ed in the treatment of the disease are practically limited to the preparations of mercury and iodin. The influence of the former is more especially exercised in the early stages of the disease, while the latter is particularly useful in the later manifesta- tions, or those dependent on gummatous deposits. More or less influence is exercised, however, by both drugs in all stages of the disease, and one may be employed to supplement the action of the other (the mixed treatment). There can be no question that the tonic effects of mercury administered to syphilitics rest on entirely competent clinical proof (K e y e s) . The drug should be given in sugar-coated granules of the protiodid (Gamier and Lamoureux's) in increasing per cliem allowances until the point of toleration (tenderness of the gums, colicky pains, etc.) is reached, care being taken that the patient's diet is such as not to provoke any of the sj'mptoms which it is expected that the mercury will produce, e. g., indiges- tion, diarrhea, etc. The full limit being reached, the "tonic dose" consists of one-half the per diem dosage required to produce the undoubted and un- desirable effects of the drug. Individual cases may be able to tolerate only a still smaller dose. Mercun,' may be employed either by internal adminis- tration, by external treatment, or by subcutaneous method. The protiodid is the preferable preparation for internal use. A preparation that is uniform in its effects, is properly protected against change by climate, and 3'et one that is promptty released from its protective environment to be acted on in the stomach, such as sugar-coated granules of a trustworthy manufacture, should be selected. These should be given after meals twice daily; they should be commenced \\i\\\ one granule at a dose and continued in an increasing dosage every fourth day by adding a granule at successive times of administration. That is to sa}", on the morning of the fourth day an extra granule is added ; on the fourth succeeding day an extra granule is added to the midday dose, and again on the fourth succeeding day an extra granule is added, this time to the evening dose. This is continued until the point of toleration is reached {vide supra). The latter varies in different indi- viduals. When the limit of dosage of the individual is reached, the question of continuing this, or of dividing it by two (the tonic dose), must be decided by the patient's condition. If the case is urgent the use of the protiodid may be continued, its use being combined with some preparation of iron to combat the tendency to anemia due to both the presence of the disease and the effects of such large doses of the drug, until either the urgent symptoms subside or 202 THE CHRONIC SURGICAL INFECTIONS the more pronoimced effects of the drug are obtained. A tonic dose should then be substituted for the full dose, and, unless a return to the latter is demanded by an outbreak of symptoms of an unusual character, it should be continued uninterruptedly for at least two years. During this time it may be necessary to alternate the tonic with the full dose many times. In case of the occurrence of an intercurrent malady the administration of the mercur}' may be temporarily suspended. After six months, if everything goes well, one-third of the original full dose, instead of one-half, may be considered as the tonic dose. When the dose has been satisfactorily adjusted to the requirements of the case, and two A^ears have passed, the treatment should be alternated with periods of rest of a month's duration. The drug should thus be given every other month for six months. At the end of this time treatment should be suspended pending further manifestations. If, at the end of another six months, the patient shows no further signs of the disease, he is to be con- sidered cured and may be allowed to marry. In the administration of mercury by the inunction method mercurial ointment is employed. From 30 to 60 grains is the daily dose for an adult. Mercurial vasogen is also employed. The ointment should be applied to por- tions of the body free from hair and should be well rubbed in once daily, at night if possible. A new location for the inunction should be selected each day until all of the available parts of the body have been employed for the purpose. The patient may make the inunctions himself, or the professional rubber may be employed. Another method of inunction consists in wearing a piece of flannel cloth on which mercurial ointment has been smeared (Teale). This is bandaged in position, and its location changed from time to time as signs of irritation appear. The hypodermic (intramuscular) use of mercury is occasionally re- sorted to, if a prompt effect is recpired, the use of mercury by the mouth impossible, or the inunction method undesirable. Indeed, this method may often be employed in obstinate forms of palmar and plantar syphihdes in which the other methods prove unavailing. The best preparation is the salicylate of mercury, twenty-four grains of which are mixed with one ounce of benzoinol. Thirty minims of this mixture, equal to one and a half grains of mercury, are injected twice a week in the upper and outer part of the buttock (Keyes), an extra long needle being employed in order to reach the gluteal muscles. The mixture should be well shaken before use, and the needle should be of extra large caliber in order to prevent clogging by the insoluble particles of the salicylate. The occurrence of salivation is rare in properly conducted cases. The nearest approach to this in cases in which the progress of the disease is care- fully watched and the dose of mercury properly adapted to its needs is the so-called "touching " of the gums as the full dose of the drug is reached. Should it be necessary to continue the latter, there is danger of salivation, and pre- cautions should be taken to prevent this. These consist in a proper care of the mouth, as to cleanliness, etc., and the avoidance of acids in the dietary. The further preventive treatment of salivation consists in the free employ- ment of baths and of diuretics, which encourages the elimination of mercury from the system. Chlorate of potassium in 2 or 3 grain doses repeated hourly. SYPHILIS 203 given in a demulcent, such as flaxseed or slippery elm l)ark tea, exercises a soothins; inflnonco on tlio mucous membrane of the mouth. \\'itli the full (Icxc'lopniont of sahvation the breath hoconies highly offen- sive, tlie tongue at first coated and then swollen, the gums puffed, spongy and bleeding, and deej) red or bluisli in color. A profuse flow of saliva occurs. Symptoms of gastric irritation supervene; diarrhea is present. The general adynamic condition is marked and the patient becomes mentally depressed. In the final stage ulceration of the inflamed mucous membrane and sometimes gangrenous conditions occur, the teeth loosen and may fall out, and necrosis of the adjacent bou}- parts takes place. Under these circumstances a mouth- wash consisting of a 1.5 to 2 per cent solution of carbolic acid, in which chlorate of potassium is dissolved in the proportion of 15 grains to the ounce, should l^e constantly used. Mixtures of borax and honey are also useful. For the so-called tertiary symptoms of syphilis, or the late manifestations of the disease due to gummatous lesions, the treatment is the combined use of mercury and iodid of potassium (mixed treatment), which should be alternated, as the effects of the mercury become evident, with the iodid alone. The latter should be given in doses of from 5 to 100 grams three times a day, according to the urgency of the sj'-mptoms and the toleration of the drug. It must l^e given in sufficiently large quantities of Vichy or hot milk to insure toleration by the stomach (from an ounce to half a pint, according to the dose of the iodid reached). In cases in which the iodid of potassium is not well borne, or, because of the large quantity of fluid necessary as the massive doses are reached, I have employed wdth satisfaction the preparation of iodin known as iodonu- cleoid. This is nonirritating to the digestive tract when given in powder or tablet form, and may be combined with mercuric chlorid, iron, strychnin, etc. The dose is the same as that of iodid of potassium. Syphilitic Reinfection. — One of the points upon which is based the belief of the curability of syphilis is the undoubted fact that the disease has been acquired a second time, the patient passing through its different stages twice. Inasmuch as the existence of the disease renders the patient absolutely immune from reinfection, as shown by numberless experiments, if reinfection occurs in the case of a patient who beyond question has suffered from the disease, the natural conclusion is that he had been cured of the disease. Hereditary Syphilis. — In this form of the disease the infection is derived from one or both parents, subjects of the disease in its active form. The chancre is absent, the disease usually exhibiting general manifestations from the commencement. When active infection unmodified l^y treatment exists in both parents, or in the mother alone, the child is almost certain to be diseased. On the other hand, when the mother is healthy and the father alone is a syph- ilitic, the child may or may not be born a victim of the disease. The possibility of the transmission of syphilis to the child m utero, particularly in the later stages of gestation, is doubted by many eminent syphilographers. If the chancre is acquired by the mother simultaneously with the occurrence of conception, she usually aborts. It is generally agreed that if the chancre is acquired by the mother after the seventh month of pregnancy the child is safe. To this rule, however, there are exceptions. As to the possibilities of infection, however, in the intermediate period, authorities are not agreed. It is more than probable that if the mother acquires a chancre at any time between 204 THE CHRONIC SURGICAL INFECTIONS the time of conception and the seventh month of gestation the child will be syphilitic. The question of the infection of the mother through the presence in utero of the product of conception derived from a syphilitic father {choc en retour of R i c o r d) is of interest in this connection. That this may occur is very probable, since it is more than hkely that the ovum becomes diseased through the spermatozoa, and that therefore the prolonged presence of the product of such a conception in the uterus may poison the mother. The experiment of attempting to inoculate an apparently healthy woman delivered of a syphilitic child conceived of a syphilitic father resulted negatively (C a s p a r y). This observation supports Colles' law, namely, that a nursing mother never accjuires a chancre of the nipple from her syphihtic offspring. Chancres of the nipple, however, are acquired by previously healthy wet-nurses from suckling syphilitic infants. The virulence of the infection in the child will depend on whether or not the mother has been subjected to treatment during the period of gestation and how much treatment she has received. All grades of virulence or of modifications of the infection by treatment are observed, from the still-born child or one born with the most unmistakable signs of congenital syphilis and doomed to early death, to the child born apparently healthy, but developing the evidences of the disease later in life. Finally, if a syphilitic mother has been under proper treatment for two or more years, or if four years have passed by with or without treatment, she may give birth to a healthy child. The presence of gummatous lesions in the parents is not inconsistent with the production of offspring free from the disease. The symptoms of hereditary syphilis are practically the same as those of the acquired form of the disease, with the exception of the chancre. Some of these, however, are accentuated in a peculiar manner in well-marked cases. The syphihtic dyscrasia is manifested in the small and puny body, the wrinkled skin and the pinched face (the "old man countenance "). Deformities of a varied character may be present. The macular syphilide and mucous patches about the anus and mouth are frequently observed at birth. Gummatous lesions in the viscera are not uncommon. In cases in which the virus has been modified by treatment during gestation the signs of inherited syphihs are not so marked, and the first suspicion of the existence of the disease may be awakened by the occurrence of digestive or nutritive disturbances, with the appearance, later on, of rachitic conditions, diseases of the bones and joints, lymphatic glandular enlargements, corneal lesions (keratitis), and skin affec- tions. Thinning of the walls of the skull (syphilitic craniotabes) and thick- ening of the ends of the bones at the epiphysial fine (syphilitic osteochondritis) may be present. The so-called Hutchinson teeth, generally considered as pathognomonic of congenital syphilis, consist of a narrowing and notched con- dition of the two upper central incisors. The treatment of congenital syphihs is by inunction. Mercurial ointment, made in half strength, should be used. A flannel belly-band, in which the ointment is well incorporated, should be worn twelve hours out of the twenty- four. The nutrition should be maintained at the very highest possible point, and as soon as the digestive apparatus will permit tonics, iron and cod-liver oil should be administered in addition. TUBERCULOSIS 205 TUBERCULOSIS ]W this term is meant tissue changes associated witli the presence of the tubercle bacillus. The latter is the sole cause of tuberculosis (Koch), though it is not always possible to demonstrate its presence in a tul^erculous focus! a fact readily explained by the biologic characteristics of the tuljercle bacillus. (For description of the tubercle bacillus, see page 30.) Of late the bacillary nature of the factor of tuberculosis has been called into question through the "demonstration of its polymorphous nature (X o c a r d and R o u X , M e t c h n i k o f f ,, and others), so that it is now classed among the hvphomvcetes (streptothrix, K r use). Under certain circumstances the localization and propagation of the tubercle bacillus in the living body resemble those of the actinomyces (Babes and L e v a d i t i). The numerous chnical similarities of tuberculosis and actinomycosis can be readily understood through this biologic similarity. The toxins produced by the tubercle bacillus are not yet clearly under- stood. The disproportion between the number of bacilli and the magnitude of the tissue changes induces the belief that there are specific bodies pro- duced by the bacilli which are capable of causing profound alterations. In addition to the effects of the toxins it is possible that chemic combin- ations are produced in the infected animal or human economy which are the result of tissue necrosis caused by the tubercle bacillus, and which vary in quantity and toxicity according to the constitutional or hereditary charac- teristics of the individual. The complex of symptoms known as tubercu- lous cachexia is. to a certain extent, the result of the action of these toxins. 1 ■ r • Clinically it is difficult to locate the point of entrance of the mfection ni individual cases, though numerous anatomic and experimental studies have clearly demonstrated the mode of entrance and the paths taken by the infection. The disease travels at first from the point of infection by means of the lymph-channels; later on, and especially in the case of infection of more distant organs, the blood-vessels must be regarded as conveying the disease (K 1 e b s). In this wav the cervical glands form the first point of arrest for bacUli entering by way of the mucous membrane of the mouth, the mesenteric glands the first point in intestinal infection, etc. The bronchial glands are infected through the lymphatics before the lungs necessarily become diseased. In all probability most forms of surgical tuberculosis (bones, joints, epididymis, etc., as well as visceral tuberculosis) proceed from a hematogenous infection (K 6 n i g), though in manv instances the primary focus cannot be determined. In many cases the introduction of the bacilli into the blood occurs in connection with a focus in juxtaposition with blood-vessels of small caliber into which perfora- tion may occur (W e i g e r t , O r t h , X a s s e), or the transition into the blood-current is accomplished by means of the lymphatics (B a u m g a r t e n). As a third source of hematogenous infection is to be considered a primary disease of the intima (tuberculous endangeitis) (0 r t h , S i g g , Strobe, Bend a). According to H i 1 d e b r a n d , this may result either from the transportation of an infectious embolus to some point where complete stenosis of the vessel does not occur from its arrest, as, for instance, at some point of bifurcation, tuberculous infection of the wall of the blood-vessel following, or 206 THE CHRONIC SURGICAL INFECTIONS from the entrance into the blood-current of only comparatively few bacilli which are deposited on the vessel wall, causing an infection at one or more places. The bacilli first develop at the point of infection, and are carried from there through the lymphatics to the neighboring tissues; then to the lymph-glands, and through these eventually to other points of the body. Unlike the point from which the infection of acquired syphilis gains entrance into the organism, the site of infection in tuberculosis does not necessarily involve either a demon- strable tissue defect or a tuberculous lesion ; even microscopically there may be no tuberculous change. Animals fed on tuberculous material developed tuberculosis of the mesenteric glands more readily than a tuberculosis of the intestines themselves. Pathologic Anatomy .^ — The irritation of the tubercle bacillus causes first a karyokinesis of the fixed cehs (J . A r n o 1 d), the connective-tissue cells and the living endothelium of the vessels, these changes occurring first in the cells inclosing bacilli (B a u m g a r t e n and others). The tubercle bacillus is mostly found lying in the interstitial connective tissue, singly or in pairs, or in small or even large colonies. The further changes which occur in the infected area consist of swelling of the connective tissue and endothelial cells ; according to V i r c h o w , it is the latter which are characteristic in the formation of a tubercle. The fibrous interstitial tissue thus formed is gradually absorbed through pressure from the proliferating cells until only a small reticulum (the fibrillary basement mem- i3rane) is left. The blood-vessels within the infected area become obliterated from the proliferation of their OT\m epithelium, and the site of the disease appears surrounded with a wall of epithelial cells showing centrally two, three, or many nuclei; this constitutes the transition stage to giant-cells. With the segmentation of the nucleus before cell division actually takes place, the development of the cells ceases (V i r c h o w , F 1 e m m i n g). The diminution of the vitality of the connective-tissue cells and the pro- gressive development of the giant-cells go hand in hand, and the latter becomes the precursor of the changes known as tissue necrosis and cheesy degeneration. The genesis of the giant-cells at the present time is unknown; Orth has shown, however, that the number of these cells is in inverse ratio to the extent and intensity of the infection, so that the observer is enabled to estimate, with certain limitations, the present state of the infection. According to the degree of cellular attraction exerted by the tubercle as a whole, and the bacilh in particular (positive chemotaxis), a more or less marked diapedesis of lymphoid cells from the surrounding blood-vessels occurs. This takes place coincidentally with the occurrence of fibrin in the tubercle (0 r t h), though to this rule there are exceptions. Destructive processes now super- vene. The tissue metamorphosis is terminated by either a slow or a rapidly spreading cell death; the lymphoid cells shrink, the nuclei disappear from the epithelioid cells, and the tubercle tissue breaks up in a finely granular detritus consisting of albumin and fat globules. Finally, cheesy degeneration occurs, and proceeds from the center to the periphery. In this way cavities are formed. Precisely the same series of changes takes place, whether the lungs, bones, lymph-glands, kidneys, etc., are attacked, the process differing only in extent and virulence. In the neighborhood of free surfaces or cavities, TUBERCULOSIS 207 such, for instance, as the skin, cavities lined with mucous membrane, the joints and vessels, a destruction of the covering membrane occurs secondarily to the progressive necrosis of the adjacent focus, and a tuberculous ulcer results. The peculiar undermining of the edges of these tuberculous ulcers is characteristic, and tlcpcnds on the power of the enveloping structure surrounding the tissues to resist the spread of the tuberculous process. Exuberant granulations may bar the latter and assume the size of a tumor (tuberculous granuloma), or healing may take place by cicatrization of the focus. The great bulk of the gummatous mass discharged from a tuberculous focus is made up of the degenerated tissue-cells ; only a comparatively small part con- sists of leukocytes. The characteristic features of tuberculous granulations are (1) their anemic and occasionally cyanotic appearance; (2) their edematous condition and vitreous luster; (3) their proneness to break down. When a tuberculous focus communicates with the external air by means of a canal, the latter is called a tuberculous fistula. Pending the definite cicatrization of the central focus these fistulas may repeatedly break open again after healing. In cases in which spontaneous cure takes place this occurs either by separation and elimination from the system .(sequestration) of the tuberculous products (granular detritus, degenerated tissue-cells, leukocytes and bacilli), by resorp- tion of smaller necrotic foci, or by encapsulation and cicatrization. Encapsu- lated foci sometimes pass into a further stage of retrogressive change, namely, that of calcification. Small bacillary foci may remain dormant for long periods of time, some- times for several years, without causing any subjective or clinically objective symptoms (latent tuberculosis). Either of their own accord or under the influence of some exciting cause, such, for instance, as the presence of other infectious diseases, disorders of nutrition, or traumatism, these become active, or by rupture and direct discharge into the circulation alarming symptoms from new bacillary foci are produced. The importance of these facts and their proper recognition relate particularly to the prognosis of the disease. Absolute cure of tuberculosis cannot take place until all bacilli have been eliminated from the body or are no longer viable. The relation between traumatism and local tuberculosis frequently becomes a question of medicolegal importance. While it is undoubtedly true that, in the large majority of cases, this relation does not exist, still the possibility of its occurrence demands consideration. If a patient is suffering from miliary tuberculosis, with baciUi circulating in the blood, and injury is inflicted at some part of the body, as a result of this the bacilli are deposited at the site of the locus minoris resistentiae and give rise to a so-called "local" tuberculosis. In this instance there must he established the evidences of a miliar}" tuberculosis. Or an already existing tuberculous focus may be injured simultaneously with a bone or joint, as a result of which fragments of tuberculous material are carried directly or by means of the lymph-channels into the blood-vessels and finally become localized at the site of the bone or joint injury. Here it is unlikely that the part affected by the injury should alone be selected as a place of deposit for the tuberculous tissue w^hich has become disintegrated and entered the circu- lation. Animal experiments have shown that traumatism does not favor the localization of tuberculosis. Finally, an old latent focus may exist at the point affected by the traumatism and again become active through the circulatory 20S THE CHRONIC SURGICAL INFECTIONS and structural changes caused hy the injury. This third possibiUty is the most hkely of all. It is in this class of cases particularly that a positive connection has been traced between tuberculosis and traumatism. The cases in Ciuestion, however, must be few and isolated. Treatment of Surgical Tuberculosis. — This must be both general and local. The first named includes dietetic and drug treatment. The second is subdivided into (a) methods to increase the local resistance and to assist connective-tissue proliferation; (&) methods to eliminate or destroy the bacilli. The general constitutional treatment is of the greatest importance in surgi- cal tuberculosis, and in many cases may overshadow^ all other methods. Chief among the measures imperatively demanded are climate and altitude, life out of doors in suital^le weather and an environment with plenty of sunlight (sun parlor) at other seasons of the year, a suitable mixed diet, cod-liver oil and sea baths. The chief benefit to be derived from these methods of treatment is in great measure due to increased respiratory movements, increased appetite, etc. In the absence of opportunities for bathing at the seashore, home baths with sea salt may be employed. These, however, are less satisfactory than batliing in the sea. Kapesser's green soap treatment consists in rubbing the patient from the neck to the knees with green soap two or three times a week, preferably in the evening. From 1 to 2 ounces are employed. The soap is washed off again with warm water after thirty minutes. The method has been found of great value, although its rationale is not clearly understood. The local treatment may be considered under three groups: (1) local conservative measures; (2) specific antibacillary treatment; (3) radical opera- tive measures. First among the local conservative measures to relieve pain and to facilitate cicatrization is to be mentioned immobilization of the parts by means of plaster-of- Paris. This should be employed wherever applicable, particularly in tuberculous affections of joints. In addition to the effects of simple im- mobilization, it is probable that the pressure of the bandage likewise brings about more or less pronounced venous stasis, on which the Bier treat- ment is based (vide infra). It has long been knowai that in pulmonary congestion, such, for instance, as occurs from certain forms of cardiac valvular disease, tuberculosis rarely occurs, and when present tends to heal in the presence of such pulmonary con- gestion (L a e n n e c , R o k i t a n s k y). These facts led to the introduction of the method of artificial hyperemia in the treatment of tuberculosis of the extremities and epididymis (A . Bier). The first effect of this treatment is the almost immecUate relief from pain. The curative results are to be ascribed partly to a bactericidal action of the blood itself, and partly to . the in- creased proliferation of the connective-tissue cells. The most brilliant suc- cesses with this method have been observed in cases of synovial tuberculosis with fungous proliferation. The hyperemia is secured by means of thin elastic bandages placed proximally to the site of the disease in such a manner as to obstruct the return circulation and yet not interfere with, the arterial flow. The limb beyond the diseased part is bandaged with a roller bandage (Fig. 36). The length of time for which the hyperemia is maintained varies in different cases from two to three hours to a day at a time. The method must be modified for individual cases. ACTINOMYCOSIS 209 Among the conservative measures for the treatment of surgical tuberculosis injections into the tissues and joints also deserve special mention. The in- jections employed up to the present time have been supposed to exert an anti- bacillary action. The drug employed most extensivel}^ is iodoform, either a 10 {)er cent iodoform glycerin (B r u n s) or the 10 per cent olive oil mixture (T r e n d e 1 e n b u r g). In the case of the iodoform glycerin, the marked action of the glycerin on the circulation, causing first exudation and then resorption, is not too greatly overestimated. Even in the case of the iodoform itself, the 7nodus operandi of which is supposed to depend on the liberation of iodin, it is now believed that the bactericidal action is not so important as its action on the tissues. It has been demonstrated that, under the influence of iodoform, fungous granulations disappear and cell ' proliferation is checked, healthy vascular granula- L ^ --"^^ -ij U^ ^^'^^^ tissue taking the place of the fungous gran- mS^^^^--^^^^ ulations. Tissue containing tubercle bacilli be- ImJ^^^^^v comes separated, and lastly a marked formation ^^HL^ j^Uk^ *^^ connective tissue occurs, terminating incicat- ^^% ,m^^^Sl^m rization (Baumgarten, M a r c h a n d , P . B r u n s , N a u- w e r k) . The 5 per cent iodin-potas- sium iodid injection (D ur ante) is ad- vocated b}^ some. PI , , 1 Fig. 36. — Bier's Method of Securing Temporary Passive Cox- noiornerapy gestion in the treatment of tuberculosis of a Part. (F i n s e n) and ra- diotherapy have been employed in tuberculous diseases. The use of these measures is purely empiric, and there is no well-defined theory as to their action. Radical operative measures constitute the most trustworthy and speedy method of dealing with surgical tuberculosis, whenever the focus can be read- ily reached and removed without causing serious disturbance of function. The benefit to the general health which almost invariably follows the prompt and thorough removal of the tuberculous tissue is marked and lasting. ACTINOMYCOSIS This is a chronic infectious disease which occurs in domestic animals and man and is caused by the ray fungus (Actinomyces bovis, H a r z). Bollinger, of iMunich, in 1876, first demonstrated the fungoid nature and pathogenesis of the just visible, yellowish, and more or less opaque granules characteristic of the disease, which are present in the lesions, in the contents of bone cavities, and in the discharge from fistulous tracts. These granules, varying in size from 0.15 to 0.75 mm. in diameter, were regularly found in the central softened area of new growths of the jaw and tongue of cattle, popularly known as "lumpy jaw," which had previously been regarded either as one of the forms of sarcoma or as tuberculosis. In the earlier stages of their development the granules are of the consistency of soft jell}', and of a grayish-white color. Later on they become more opaque and yellow, and finally, particularlv in cattle, the granule mav be the seat of a deposit of cal- ls 210 THE CHRONIC SURGICAL INFECTIONS cium salts (mulberry like granules). The botanist Harz found that the granules were made up of several patches and suspected that they represented the conidia form of a mold. The latter grows on the foodstuff of cattle, the infection taking place through the fodder. It is usually forced into the tissues by means of a foreign body. The parasite is identical in man and beast (W e i - g e r t , P o n f i c k). The fungus belongs in the same provisional group as the hyphomycetes, and is in intimate relation with the newer findings in the group of the tubercle bacillus (branching ray and club formation, F r i e d e r i c h , L e v a d i t i), to which it bears a close resemblance in its effects on the tissues. At first the granules consist of fine threads; later on these increase in thick- ness, become bulbous at their extremities (club-shaped or finger-shaped), and are arranged radially at the margins of the hyaline mass in which the threads occur. Masses of pus-cells are also present and make up a portion of the bulk of the granules. The fungoid patches contain threadlike branching mycelia of from ^ to 1 /J. in diameter and from 1 to 6 // in length, with a membrane which takes the anilin dyes but does not stain with methylene-blue. Simple double staining with hematoxylin and eosin, or by the method of Weigert or of Gram, is efficient. The mycelium is normally homogeneous; it is sometimes broken up into short or long rods and sometimes into bodies resembling cocci. In addition, cocci are present. These are sometimes arranged in rows, and at other times irregularly in the membrane. They are to be considered spores, since by growth from one or both ends true mycelia are formed. These spores, and perhaps the threadlike fragments as well, are the disseminators of the dis- ease. Hyphae with regular segmentation are formed in conidia spores in cul- tures only under the most favorable conditions. In the body, however, the ends of the mycelia usually, though not always, undergo degeneration, the membrane becoming gelatinous, so that the club shapes and pear shapes mani- fested on staining result. By rupture of the membrane finger forms occur. The radiating mycelia with the peripheral clubs make up the typic felt like patch of the fungus. After death of the fungus the club shapes may persist and may be found embedded in the cicatrix. Pathologic Anatomy. — The living fungus brings about changes in the tissues not unlike those produced by the tubercle bacillus. It becomes sur- rounded by round and eosinophile granules, and beyond these by granulation tissue frequently containing giant cells. The tubercle-like mass thus developed is made up of round and ei^ithelioid cells; this tubercle, however, does not undergo cheesy but hyaline or fatty degeneration. Fusion of two or more neighboring tubercles forms suppurating masses or abscess cavities; in this suppurative process no tissue is spared. Only in parenchymatous or very vascular organs an indurated area surrounds the connective-tissue processes. In connective tissue, however, the breaking down process goes on more rapidly and easily. The large amount of inflammator}^ tissue which forms a thick, tough, brawny infiltration in connection with the lesions is a special characteristic of the presence of this fungus. This is due to the irritation kept up by the para- site as a foreign body, as well as to the cell-destroying products of its metabo- lism. The granulation tissue is always marked by great vascularity and ACTINOMYCOSIS 211 UMidi'iicy to (Ict^X'iK'ration. Tlio yellow color is .sometimes present in the granu- lations. A\'hen infection takes place in subcutaneous areas, not infrequently small yellow nuiltii)le foci may be cliscerned through the intact epidermis. Clinically, however, only the actual identification of the fungus is of value in differentiating the lesions from those of tuberculosis and carcinoma. Mixed infections (streptococci and staphylococci) are not rare, these giving rise to marked fever. The central portion of the focus usually contains the fungus, where its presence may be detected by microscopic examination. It may be free or attached to the foreign body by means of which it gained access. Symptoms. — Actinomycosis is essentially a chronic disease, lasting for months or years. Clinically, the cases may be divided into those occurring in the region of the head, the thoracic region, the abdominal region and the skin. The Region of the Head. — In accordance with the usual mode of infection, namely, through the medium of foodstuffs, such as grain, etc., actinomycosis occurs most frequently in the neighborhood of the mouth. . The infection spreads from the oral cavity by penetrating the mucous membrane of the gums, sometimes through the cavities of carious teeth, and extends to the jaws and soft parts of the neck. Involvement of the tongue is rare either primarily or secondarily. In cattle the penetration takes place between a tooth and its alveolus. Swelling of one side of the face or an enlargement of the jaw ("lumpy jaw") usually occurs. This enlargement is most readily distinguished inside the mouth, where several fistulous tracts are also usually present, the discharge from which often contains the yellow, sulfurlike detritus characteristic of the disease. Tenderness on pressure is sometimes present, though pronounced pain is rare. Except in cases of mixed infection {vide supra), as a rule fever is absent. The tendency is always to progressive ex- tension of the infection, the routes taken being in the direction of the soft parts of the neck, the pharynx, the vertebrae, the thoracic organs, and the gastrointestinal canal. In cases of infection of the upper jaw there frequently occurs by extension actinomycosis of the base of the skull and of the brain. Retropharyngeal and spinal cord involvement has been observed. The lacrimal canal and eyelids may be involved. The Thoracic Region. — Involvement of the pulmonary organs may be either primary when due to inoculation by inhalation, or secondary when due to lesions about the lower jaw, more frequently the former. All the symp- toms of a chronic pulmonary affection are present, namely, cough, mu- copurulent expectoration, fever, and progressive emaciation. According to H o d e n p y 1 , either the mucous membrane of the bronchial tubes may be involved, giving rise to symptoms of chronic bronchitis, or interstitial , changes and abscess formation may occur with symptoms of bronchopneu- monia. Finally, miliary invasion of the lungs may take place, the s}'mptoms of which closely resemble those of miliary tuberculosis. Actinomycosis of the lungs is frequently mistaken for pulmonary tuberculosis. Extension within the thorax by way of the pharynx and esophagus has been noticed. Primary invasion of the mammary region has also been observed. The Abdominal Region. — Here the gastrointestinal canal is primarily involved, the actinomyces gaining access to the stomach and intestines along with the food and resisting the destructive effects of the gastric juice and bile. 212 THE CHRONIC SURGICAL INFECTIONS ^rho mucous membrane is penetrated and the submucous comiectivc tissue invaded, after which the mucosa may become involved to a superficial extent, or apparently escape entirely, the characteristic destructive jjrocess going on in the deeper structures. In the case of the intestine a small submucous tubercle appears which breaks down in the center and gives rise to a small ulcer. Exceptionally the latter may heal, leaving a pigmented and irregular cicatrix. The stomach and all portions of the small and large intestine, including the vermiform appendix, may be the seat of invasion. About one- half of the cases occur primarily in either the cecum or the appendix. The liver is frequently involved secondarily. Abscess of the liver, with rupture into the cavity of the chest, may occur. Extension posteriorly leads to in- volvement of the spinal column and invasion of the spinal canal; general metastasis may occur. The destructive process may extend anteriorly and externally and involve the abdominal wall. The onset in abdominal actinomycosis is frequently quite sudden, the symptoms being those of catarrhal gastrointestinal disturbances, namely, vomiting and either diarrhea or constipation. Or obscure abdominal pains may be present for weeks or months. The frequency of origin in the cecal region may lead to the diagnosis of chronic recurring or chronic relapsing appendicitis. This is strengthened by the later appearance of a tumor in this region. Or, a tumor finally appears in the neighborhood of the umbilicus. In any case the tumor presents a somewhat irregular outline. Pain is usually present at this stage. With involvement of the anterior abdominal wall the infiltrated area softens, fistulous openings form, and the surrounding skin presents a peculiar livid hue, described by some authors as bluish- violet, merg- ing into a bluish-gray (slate color) toward the margins of the infiltration. Actinomycosis of the Skin. — There are trustworthy observations showing that inoculations of the skin with resulting local actinomycosis may take place. This may occur from chaff (Ammentorp, Reboul), from splinters of wood in the case of farm laborers (E . M ii 1 1 e r), or from poultices (W. M ii 1 - 1 e r). The lesions closely resemble those of tuberculosis of the skin. The pyemia of actinomycotic origin presents an interesting picture. It constitutes the final stage of the chronic afebrile cases. In addition to the dissemination among the internal organs there occur multiple subcutaneous abscesses. The metastatic abscesses take place through the circulation. They may occur through rupture of a primary focus into a large vessel, such, for instance, as the jugular vein, of which there are five recorded instances (S i c k), or, the disease having extended from the lungs or intestine to the liver, the infection is transported by the hepatic vessels. Dissemination through the lymph-vessels does not take place. Diagnosis. — The diagnosis depends on the presence of the character- istic granules or colonies in the lesions or in the discharges from the sinuses lead- ing from the same. These are not always discoverable with the naked eye ; it is necessary to subject the suspected material to microscopic examination in order to distinguish the granules or colonies from necrotic tissue and col- lections of pus-cells, for which they may be mistaken. In pulmonary actinomy- cosis the fungus will be found in the sputum or in the discharges from fistulous tracts in the chest wall leading to the lesions. In examinations of the sputum care should be taken to differentiate the ray fungus from the common lepto- thrix of the mouth ; the filaments of the latter are frequently found adherent to ACTINOMYCOSIS 213 epithelial cells; they are larger, straighter, and thicker than those of the former, and they do not branch, as do tlie filaments of the ray fungus. The fact that dissemination by the lymph-vessels does not take place in actinoniA'cosis should be borne in mind as an aid in differentiating the disease. The finding of the fungus, however, is the only positive diagnostic point.* Prognosis. — The statistics compiled by S i c k , of Kiel, are exceedingly in- teresting in this connection. In cases in which extension to the base of the skull and brain took place this complication was observed six times out of 61 cases oc- curring primarily in the upper jaw, and ten times out of 525 cases occurring pri- marily in the lower jaw. In a general way, cases occurring in the lower jaw offer a more favorable prognosis than those in the upper jaw. Of the 525 cases above mentioned, aside from the 10 necessarily fatal cases in which propagation to the brain took place, 4 proved fatal by secondary lung invasion, 3 by retro- pharyngeal abscess, and 1 by spinal cord involvement. In addition, there was 1 fatal abdominal case and 6 cases of general actinomycosis. Of 27 cases of actinomycosis of the tongue, all were cured b}^ operation. The prognosis is equally favorable for circumscribed lip and cheek cases. Of 20 intrathoracic cases of pharyngoesophageal origin, 19 proved fatal. Out of 142 pulmonar}^ cases, 5 are alleged to have been cured. In two of these cases the diagnosis was not assured, and in the remaining, periods of time varying from six months to two years only had elapsed between the commencement of the symptoms and the date of the report. In view of the now well-known latency of the pulmonary cases which finally prove fatal this is manifestly too short a time on which to base a statement of cure. In all probability the affection as it attacks the lungs is an irremediable one, death taking place b}' cachexia and metastasis to the liver. In abdominal cases the prognosis is relatively better, especially if the abdominal wall is involved and the process extends anteriorly and outwardly. In ab- dominal cases extending posteriorly death takes place from abscess of the liver, rupture into the lung or spinal canal, and general metastasis. Invasions of the colon proved uniformly fatal. Ninety-three cases of actinomycotic appen- dicitis have been reported, 19 of which recovered. The rectum was involved in 13 cases, 7 of which proved fatal. In a total of 214 abdominal cases, only 47 recovered ; tliis does not include 30 cases which, according to the original report, were '^ recovering." In rare cases there is a tendency to spontaneous cure. Sick asserts that there are two or three well-authenticated cases of this character. Treatment. — The treatment is preferably surgical when possible. If the foci are situated where they can be safely removed, a cure may be confi- dently expected. Where complete removal cannot be effected, and this is the rule rather than the exception, free opening, partial excision, and the iodid of potassium treatment should be followed. The latter is used in a 10 per cent solution as an injection into the surrounding tissues, and internally in from 2 to 3 dram doses. The iodid of potassium does not act on the fungus, but on the tissues (Prue z , of Konigsberg). In desperate cases arsenic has been of value. For local use tincture of iodin, nitrate of sih'er in stick or 1 per cent ointment, boric acid, and concentrated alcohol are all of value. As in tuber- culosis, climate and out-of-door life exercise a favorable influence over the disease (H e u s s e r). ♦Reactions following tuberculin injections have been observed bj- Billroth, Eiselberg, and others. SECTION VI TUMORS CLASSIFICATION The etiology of tumors is unknown. \' i r c h o w has shown, however, that all the tissues in these new growths have a normal histologic prototype. Under these circumstances, therefore, the most natural and satisfactory method of classification for the study of tumors is based on their structural characteristics. The term tumor may be applied to the following abnormal conditions, arranged in four groups : 1. Connective-tissue growths, or tumors of connective-tissue origin. 2. Epithelial growths, or tumors whose essential feature is the presence of epithelium. 3. Dermoids, or tumors containing skin or mucous membrane in abnormal situations. 4. Cysts differ in many respects from tumors, though clinically they possess so many features in common that it is convenient to consider them in this connection. If the methods of classification of the zoologist are adopted, it may be said that each of these groups contains several genera and that each genus contains one or more species (Sutton). From the standpoint of the practical surgeon the effects of tumors on the individual are of the greatest importance; hence it is usual to designate them as malignant and innocent. Malignant Tumors. — Malignant growths possess the following charac- teristics: (1) they infiltrate the surrounding tissues; (2) they infect neigh- boring lymphatic glands; (3) they tend to recur after removal; (4) dissemi- nation takes place in more or less remote organs; (5) in their natural course they inevitably destroy life. The two genera of tumors to which the term malignant is applicable are the sarcomas and the carcinomas. Malignant tumors, wherever situated, tend to destroy life. The extent to which dissemination occurs is best illustrated in cases of melanosarcoma, in which secondary deposits occur in almost all the organs of the body, the tumors in the skin alone being sometimes numbered by thousands. The most decided examples of malignancy, however, are observed when tumors of this type occur primarily in nonvital organs and destroy life in a few months. Here death is due, not to interference with the function of the organ first attacked, but either to secondary deposits in remote and vital organs, or to combined septic and anemic conditions (cachexia). When a malignant tumor involves a vital organ, life is often destroyed before there has been time for dissemina- tion to take place. Environment. — The influences of environment are shown in the familiar 214 CLASSIFICATION 215 examples of cancer of the larynx, in which death takes place from suffocation or from septic pneumonia following ulceration, of death from starvation in cancer of the gastric orifices, and of death from renal disease in cancer of the prostate with m'iiiarv obstruction. The environment of a malignant tumor in its relation to treatment likewise exercises some influence on the life-destroying pro]ierties of the tumor, irrespective of the importance of the part attacked or the genus of the tumor. For instance, a periosteal sarcoma attacking the femur will, on recurrence, destroy life almost twelve times as quickly as a tumor with the same histologic characters situated on the tibia, both being submitted to amputation. From this circumstance Bland Sutton is led to suspect that variations in tissue actually constitute an altered environment. It is much more prol)able, however, that the differences in this instance are due to increased difficulties of relatively complete removal. i\Ialignant tumors rarely occur as multiple growths. Exceptions to this are found in sarcomas occurring in paired organs, such as the kidneys, adrenals, ovaries, and retinae of young children. A malignant tumor may arise in an organ already occupied by an innocent tumor, such as occurs when a carcinoma attacks the endometrium of a uterus, the seat of a fibroid. Separate organs that are a part of the same system msLY be attacked concurrently by a malignant and an innocent tumor, as, for instance, in the case of a mammary carcinoma and on ovarian adenoma. Innocent Tumors. — As differing from the malignant type of tumors, innocent tumors present the following: (1) they are inclosed in a capsule, as a rule, and when not so inclosed their manner of increase is by diffusion and not by infiltration or implication of the surrounding tissues, the latter undergoing no change; (2) they do not produce infection of the lymphatic glands; (3) there is no recurrence after complete removal; (4) dissemi- nation never takes place; (5) clanger to life arises only from mechanic causes or from accidentally produced septic conditions. Environment. — While malignant tumors destroy life whatever their situa- tion, the dangers arising from innocent tumors depend entirely on their environment and on irritating or disturbing conditions. For instance, a small nonmalignant growth situated in the spinal cord may cause death in a com- paratively short time; an enlarged thyroid may cause sudden and fatal suf- focation from pressure on the trachea (scabbard trachea) ; or a lipoma may become accidentally infected through a point of irritation arising from friction of the clothing. Innocent tumors, unlike malignant growths, are often multiple. There is a tendency in this direction in all benign tumors except myelomas. Two genera of innocent tumors maj^ present themselves simultaneously in the same individual, or an innocent tumor and a malignant tumor ma}' appear under the same circumstances. An innocent tumor may precede the development of a malignant tumor in the same organ for many years. Finally, the rarest of all combinations is the presence of an innocent tumor surrounded by a malignant growth. Structure of Tumors. — The usefulness of a classification of tumors based on the histologic features of tumors is emphasized by the fact that the histology and embryology of an organ point with comparative certainty to the various genera of tumors and cysts to which it is subject. Exceptions, how- 216 TUMORS ever, are to be noticed in the liability of the salivary glands to pure chondromas and of the ovary to dermoids. CONNECTIVE-TISSUE TUMORS The various genera of the connective-tissue group of tumors are included in the following: (1) lipomas; (2) chondromas; (3) osteomas; (4) odontomas; (5) fibromas and myxomas; (6) myelomas; (7) sarcomas; (8) neuromas; (9) angiomas; (10) lymphangiomas; (11) myomas. Lipomas. — A lipoma is a tumor composed of fat. The genus is limited to a single species. Its occurrence is more generalized than that of any other genus occurring in man, with the exception of sarcoma. It is found in the subcutane- ous and subserous tissues; beneath the synovial and mucous membranes; in the muscular tissues and intermuscular spaces; as parosteal growths and in connection with the sheaths of nerves and the cerebral and spinal meninges. Subcutaneous Lipomas. — The subcutaneous fat is the situation in which lipomas are most commonly found. In this situation they are irregularly lobulated, encapsulated, movable within the capsule, the latter being more or less adherent to the skin. They are usually single, though one or more may be found in different situations in the same individual. They are often sym- metric and tend to become pedunculated. They vary greatly in size, from a marble to a man's head. Exceptionally they attain an enormous size. They are confined for the most part to the trunk and the parts immediately adjoining the same. They are occasionally found on the hands and feet, where they are liable to be congenital. They are more frequent in the former situation, where they simulate compound ganglions. Those of the palm probably originate in the lobules of fat lying between the lumbricales. They may occur in a vascular form on the face (nevolipomas), where they are probably nevi undergoing cure by fatty degeneration. Calcification may occur in old lipomas through deposits of earthy salts in the fibrous septa. Subserous Lipomas. — These occur in the layer of fat on which the peri- toneum rests, and are of special interest to the surgeon, from the fact that they are likely to occur in the subserous fat at the hernial apertures and be mistaken for a hernia. They may actually give rise to hernia by protruding into the inguinal or femoral canals and dragging with them a process of peritoneum. The latter may subsequently become the seat of hernial contents. Hernia of the bladder is particularly liable to arise in this manner. Subserous lipomas sometimes appear as fatty hernias of the linea alba, near the umbilicus. They may grow between the layers of the mesometrium and simulate ovarian tumors. A lipoma having its origin in the fat behind the ensiform cartilage may occupy the lower portion of the anterior mediastinum, after having passed through the gap in the diaphragm in this locality. The subpleural fat is some- times the seat of a lipoma (R o k i t a n s k y) which may make its way on each side of the chest wall, forming an intrathoracic and an extrathoracic portion (G u s s e n b a u e r). Submucous Lipomas. — These are of exceptionally rare occurrence. They are found in children in the subconjunctival fat; on the hps; in the larynx on the aryteno-epiglottic fold (Holt, Sidney Jones); and beneath the gastric and intestinal mucous membrane. Subsynovial Lipomas. — Those occurring in the knee-joint are of the CLASSIFICATION 217 o-reate^t surgical importance. Thev occur in this situation most commonly alongside the patella, at the site of the alar ligaments. The so-called lipoma arborescens is said to be associated with rheumatoid arthritis. Intermuscular Lipomas.— The largest specimens of this variety are found in the int(>rmuscular strata of the anterior abdominal wall. They are also found l)etween the pectoral muscles, and between the muscles of the tongue. The so-called "sucking cushion/' a collection of fat between the masseter and the buccinator muscle, has been considered by some a lipoma. Intramuscular Lipomas.— These have been found in the deltoid, biceps of the arm, complexus, and rectus abdominis muscles. They have_ also been reported as occurring in a submucous uterine myoma (J . Smith, Periosteal Lipomas.— These are usually congenital, are of infrequent occurrence and have been found in almost all portions of the skeleton. They spring from the periosteum and generally contain traces of striated muscular "^Neurolipomas is a term applied to fatty growths springing from the sheaths of peripheral nerves. They are not usually diagnosed until after removal. Meningeal Lipomas.— These are found both within the spmal dura and outside it, between the layers of the dura at the base, and on the sac of the spina bifida in the lumbosacral region. _ The Clinical Features of Lipomas.— This genus of tumor is usually easily diao-nosed, though under some circumstances the diagnosis may be exceedingly difficult This is particularly true of the periosteal, perineurial, intramuscular, subserous, and meningeal varieties. In operating on tumors m the imddle line of the back special care must be taken to recognize those connected with the spinal dura. Treatment.— Although innocent in character, these tumors are not without harmful tendencies, and hence many of them will require ultimate removal. When single, they are likely to attain large proportions ; but when a number are present, this tendency seems to be absent. When so situated as to become irritated by the clothing, or by some particular occupation of the patient, their removal should be strongly advised. Chondromas.— These are tumors composed of hyahne cartilage, ihe genus contains three species, viz., (1) chondroma; (2) ecchondrosis; (3) loose cartilages in joints. . Chondromas, in their most typic condition, occur m relation to the epiphy- sial cartilages of the long bones in children and young adults. They are usually single, but may be multiple, particularly when they occur m the hands and feet. They are always encapsulated, painless, of slow growth, and firm to the touch, except when they have undergone, mucoid degeneration. They may undergo - calcification and they sometimes ossify. In rickety individuals they frequently occur from the presence of fetal cartilage (V i r c h o w). Their occurrence m the parotid, submaxillary, salivary, and lacrimal glands constitutes one of the most striking anomalies in connection with tumors. Small local outgrowths of cartilage are known as ecchondroses. ihey occur on the edges of articular cartilages, the laryngeal cartilages and the triangular cartilage of the nose. They are specially common m the knee-joint after the age of forty, and have been thought to have some connection with rheumatoid arthritis. They occur as sessile or pedunculated nodules, which 218 TUMORS may become detached and constitute a loose body in the joint cavity; or they may be still held by a slight fibrous attachment. Laryngeal ecchondroses are rare. They may grow from any of the laryn- geal cartilages, most frequently, however, from the posterior plate of the cricoid, though both surfaces may be involved and the cavity of the larynx encroached upon. They vary in size from a pea to a walnut. Those that project into the cavity of the larynx are covered with mucous membrane, which in excep- tional instances becomes ulcerated. Intralaryngeal projections give rise to obstructed breathing and aphonia. Ecchondroses springing from the triangular cartilage of the nose are occasionally observed, the treatment of which by removal is usually advised. Loose Cartilages. — Li addition to the detached ecchondroses already mentioned, pieces of hyaline cartilage are found in joints attached by narrow pedicles, or lying in depressions, from which they may become detached or dislodged. They vary in size and usually occur in flat discs. They may be single or multiple, and sometimes are found in the corresponding joints as well. They are believed to have their origin in enlarged synovial villi which undergo chondrification. Calcareous changes sometimes occur. The latter may take place without chondrification, or both changes may be absent, the loose body consisting simply of the enlarged and thickened villi. The treatment of chondromas consists in incising the capsule and shelling out the cartilage. When a large number are present on the bones of the fingers, amputation may be necessary. Loose bodies constitute one of the conditions present in so-called "internal derangement of the knee-joint," for which arthrotomy and removal of the loose body become necessary. As a rule, small bodies give rise to more trouble than the larger ones, and present greater difficulties of removal on account of the uncertainty of locating them exactly when the joint is opened. Osteomas. — These consist of ossifying chondromas, the growth of the osteoma taking place from the covering of hyaline cartilage of the tumor, pre- cisely as the growth of a long bone takes place from epiphysial cartilage. Two species of this genus are recognized, namely, compact osteomas and can- cellous osteomas. Compact osteomas are identical in structure with the tissue forming the shaft of a long bone. Their distribution is rather general, but they seem to occur by preference in the frontal sinuses, in the roof of the orbit, in the bony walls of the external auditory meatus, where they have their origin in the numerous centers for cartilage formation in that neighborhood, in the mastoid process and the angle of the jaw. They are usually sessile, and are sometimes composed of dense tissue of ivorylike hardness. Those occurring at the margin of the external auditory meatus may obstruct the latter and cause impairment of hearing. Cancellous Osteomas. — These resemble the cancellous structure of bone and usually possess a thick covering of hyaline cartilage. They occur generally in sessile growths, though they are occasionally pedunculated. They are of slow growth, but, though painless and benign in character, they may in time attain a size sufficient to cause pain or even imperil life by pressure on large trunks or important organs. They are often congenital and by some have been deemed hereditary. They are sometimes multiple and may develop CLASSIFICATION 219 symmetrically as regards situation in the individual. They have been known to attain large proportions and to become the seat of sarcoma. Exostoses. — Although these are not true bony tumors, l)ut rather bony outgrowths, it will be convenient to treat of them in this connection. They occur as exaggerations of the normal bony projections at the site of the attachment of tendons, such, for instance, as the adductor tubercle. This form of growth is frequently found in the tendon of insertion of the adductor magnus, where exceptionally it may become pedunculated and is sometimes covered by a bursa. Exostoses are rather frequently found on the bones of the face, par- ticularly on the nasal process of the superior maxilla. The so-called horned men of the West Coast of Africa are subjects of the latter deformity. The subungual exostosis is a small bony outgrowth, averaging about the size of a cherry pit, springing from the ungual phalanx of the great toe. It crowds its way through the matrix and appears as a dull red projection between the nail and the skin. Ulceration of the overlying soft tissues is liable to occur. These growths are the result of inflammatory processes having their origin in shoe pressure. Treatment. — Osseous tumors require removal wdienever they appear in accessible situations and interfere with the function of a part or press upon nerves. It is also advisable to remove them when they occur in favorable situations for osteosarcomas or chondrosarcomas of the extremities, e. g., the tibia, the femur, and the humerus. Odontomas. — These tumors arise from tooth-germs. The species in this genus is determined according to the part of the tooth-germ from which it springs, as follows: (1) epithelial odontomas; (2) follicular odontomas; (3) radicular odontomas; (4) composite odontomas. Epithelial odontomas spring from persistent portions of the epithelium of the enamel organ, and are usually found in the inferior maxilla. They occur as small multilocular cysts separated by thin fibrous septa, the cavities of which contain a brownish-colored mucoid fluid. Care should be taken to distinguish these growths from endotheliomas. Odontomas arising from the tooth follicle comprise the following: (1) Fol- licular odontomas (dentigerous cysts), or those tumors which represent an ex- panded tooth follicle. The cavity of the C3"st usually contains viscid fluid and the crown or the root of an undeveloped tooth. (2) Fibrous odontomas, which consist of a thickening of the connective-tissue capsule or tooth-sac, in which a developing tooth is embedded. The thickened capsule prevents the eruption of the tooth. They are often multiple and are usually attributed to rickets. (3) Cementomas. These usuallv result from an ossification of the thickened tooth- sac constituting a fibrous odontoma, the tooth becoming embedded in a mass of cementum. They occur very rarel}^ in man. (4) Compound follicular odon- tomas. These result from a want of uniformity in the. ossification of the cap- sule of a filDrous odontoma, whereby a composite character is given to the tumor. Small fragments of cementum, or dentin, and denticles or even per- fect teeth (T e 1 1 e n d e r , of Stockholm) are found in these tumors. They are rare in man. Radicular Odontomas. — ^These spring from the root after the completion of the crown of the tooth. The tumor usually consists of an outer layer of cementum and an inner layer of dentin, with a nucleus of calcified pulp. 220 TUMORS Compound Odontomas. — These are abnormal growths of all the elements of a tooth-germ, namely, the enamel-organ, papilla, and folhcle, and therefore consist of enamel, dentin, and cementum. The tumor usiiall}' springs from one or more tooth-germs. They occur in both the superior and the inferior maxilla, attaining the larger size in the former. Occurring in the antrum of Highmore, they are frequently mistaken for exostoses. The diagnosis of odontomas is of importance from the fact that considerable deformity and even excessive mutilation may result from their removal under the belief that malignant disease was present. This is particularly true of the fibrous variety, which is likely to be mistaken for myeloid sarcoma. The other varieties have also been mistaken for necrosed bone, for unerupted teeth, and for exostoses. Treatment. — Follicular odontomas may be successfully treated by the excision of a portion of the wall, the removal of the contained tooth if one is present, and the thorough curetting of the cavity. The latter is obliterated by granulations. Enucleation may sometimes be practised in this species and is usually necessary in the others. Dental Cysts. — A fibrous sac containing crystals of cholesterm is some- times found at the root of a dead permanent tooth. These cysts var\' in size from an apple seed to an Enghsh walnut. They spring from the roots of the teeth of both the upper and the lower jaw, and, in the former situation, may invade the antrum and simulate an abscess of that cavity. They are usually small and met with only accidentally in the removal of dead teeth. They may, however, give rise to a suspicion of their presence by their size or by the occurrence of suppuration. The treatment of dental cysts consists in the removal of the tooth roots and the curetting of the cyst wall. In the case of those which invade the antrum it will be necessary to remove a small portion of bone in order to afford easy access to the cyst cavity. The after-treatment consists in frequently irrigat- ing the cavity with an antiseptic solution and packing it with sterile gauze until it is obliterated by the process of granulation. Fibromas. — Tumors composed of fibrous tissue are very rare. Those formerly described as such, particularly the "uterine fibroid," are now knowm as myomas and fibromyomas. Tumors composed of closely applied, long, slender, fusiform cells are observed in the ovary, the uterus, the gums, the lar^mx, on the sheaths of nerves, and in the walls of the heart. Epulis is a term loosely appUed to various tumors occurring on the gums, some of w^hich spring from the tooth folhcle (see Odontomas), while others are not tumors in the true sense, but are the result of inflammatory action. The growth sometimes called "malignant epulis" is a spindle-celled sarcoma. Small pedunculated tumors occurring on the mucous membrane of the larynx, and ha\dng a fibrous nucleus, are rather frequently removed by laryngologists by meaiLS of intralaryngeal operations. Neurofibromas are encapsulated tumors springing from the sheaths of nerves. These growi:hs vary in size from a small pea to a hen's egg. They occur on almost any portion of the cranial or spinal nerves as smooth, fusiform, and mobile swellings. They are liable to undergo myxomatous changes, with the formation of cavities in the interior. This has led to a con- fusion in the use of terms in designating these growths, such as myxoma, myxofibroma, myxosarcoma, etc. They are easily enucleated. CLASSIFICATION 221 SI Myxomas. — These are tumors composed of soft jellylike material known as myxomatous tissue. It is identical with that which surrounds the vessels of the umbilic cord. The best example of this genus is the common nasal polypus. Aural polypi likewise consist of myxomatous tissue. Sutton describes a myxomatous tumor springing from the lumbar fascia which recurred after removal. He regarded it as a sarcoma which had undergone myxomatous degeneration. The few examples of tumor of the heart which have been observed have been recorded as either fibromas, myxomas, or fibromyxomas. Myelomas. — The tissue of these tumors is identical with that of the red marrow of young bones. The genus contains a single species, which is found only in connection with the cancellous tissue of bone. They are very vascular, and present on section a deep red color. They are characterized by the presence of numerous large multinuclear or giant cells, in a bed of round and spindle cells. They are found wherever red marrow exists, except in the vertebrae. They are rarely found in the patella or in the acromial end of the clavicle. They occur by preference in the upper end of the tibia, the lower end of the radius, the body of the lower jaw and the alveolar border of the upper jaw, and the sternal end of the clavicle. They are rarely seen in patients above twenty-five, and are of slow growth. A clinical feature of these tumors is the parchment-like crepitation present on palpation as the bony cap- sule becomes thinned by growth of the tumor. With perforation of the capsule pulsation may be present. While the vascularity of these tumors, as well as their occurrence in the long bones of young subjects, always excites a suspicion of malignancy, the absence of both infection of lymphatic glands and dissemination, as well as their non- recurrence if thoroughly extirpated before perforation of the capsule, stamps them as benign. Sarcomas. — Sarcomas may be defined as tumors of connective-tissue origin, the special clinical features of which are embraced in the term " mahg- nancy." Structurally, almost any kind of connective tissue, such as fat, bone, cartilage, and sometimes striated muscle tissue, may enter into their formation. The special histologic feature of sarcoma is the fact that the greater part of the tumor consists of immature connective tissue with a preponderance of cells over the intercellular tissue. In the absence of all knowledge at the present time as to the cause of these aberrant growths of connective tissue, the most convenient scheme for deter- mining the species is based on the prevailing type of cell present, or on the presence of pigment, as in melanosarcomas. The species having its origin in pigmented moles is called alveolar sarcoma. Each species may be subdivided into one or more varieties, with such qualifying names as lymphosarcomas, myosarcomas, chondrosarcomas, etc. iMf!M Fig. 37. — Round-celled Sarcoma. 222 TUMORS Round-celled Sarcomas. — This species is the most generalized tumor found in man. It may attack any portion of the body and occur in any tissue. It is found at all periods of life, even in the fetus in utero. It is very simple in con- struction, consisting almost exclusively of round cells, each of which contains a large, round, vesicular nucleus and a small proportion of protoplasm. The intercellular substance is very scanty, but is plentifully supplied with blood- vessels, which often appear as mere channels between the cells (Fig. 37). In the variety known as large round-celled sarcoma the cells are of unequal size, some of them being multinuclear and resembling myeloid cells. Lymphosarcomas. — This rare and excessively malignant species derives its name from the resemblance of its tissue to that of the lymph-glands. It occurs particularly in the mediastinum, in the connective tissue beneath the pleura and peritoneum, in the tonsils and at the base of the tongue, and in the testes. The cells are identical with those of the round-celled species but are contained in dehcate meshes (Fig. 38). Spindle-celled Sarcomas. — This species derives its name from the fusiform character of its cells. Hyaline cartilage is frequently found in this species, from which circumstance it is known as chondrosarcoma. In other examples the sarcomatous tissue apparently con- sists of slender cells with almost an entire absence of protoplasm. In others, again, the cells are large, distinctly fusi- form, and rich in protoplasm. They resemble the cells of young unstriped muscle-fiber ; occasionally transverse striae are present, as in young striated muscle-fiber. This variety is known as myosarcoma or rhabdomyosar- coma. In chondrosarcomas the presence of immature hyaline cartilage may be so pronounced as to confuse the diagnosis. This is particularly true when the cartilage is calcified or ossified; under these circumstances the tumor may be erroneously described as a simple chondroma. On removal, however, it recurs, and the recurrent tumor may show no evidence of cartilage but may conform to the structure of a pure spindle-celled or a round-celled sarcoma. Myosarcomas. — Strange as it may seem, these rarely make their appearance in connection with voluntary muscles, but occiu" by preference in the kidney, cervix uteri, testis, and parotid glands, situations in which, under normal con- ditions, no muscle-cells of the striped variety are found. They have also been found at the angle of the jaw, in connection with the periosteum of the orbit, on the scapula and the tuberosity of the ischium. Spindle-celled sarcomas occurring in the subperiosteal connective tissue of the abdomen and pelvis present some peculiar features, these consisting of an almost uniformly globular shape, large size, slow growth, and lesser malig- nancy as compared with the other sarcomas. These retroperitoneal sarcomas sometimes attain a large size; in a case operated on by the author the tumor Fig. 38. — Lymphosarcoma. CLASSIFICATION 223 weighed iii')war(l of 30 pounds. The}' have Ijeen most freqiientty observed in the perirenal tissues and between the layers of the broad ligament. The cells of spindle-celled sarcomas (Fig. 39) vary greatly in size and are prone to collect in bundles which form in different directions, so that when sections are made of the tumor mass the spindle shape of the cells is not uniformly preserved in the microscopic appearances, a circumstance which may easily lead to error in the histologic differentiation. When the so-called giant-cells are present, these are multinuclear (Fig. 40). Melanosarcomas. — This term is applied to sarcomas in which pigment occiu's. The greater majority of tumors containing pigment are sarcomatous in character. The amount of pigment present varies greatly. The pigment granules are found not only in and among the characteristic cells of the tumor and in those of the fibrous matrix, but also in the walls of the vessel. This species of sarcoma, as it occurs usually in the skin, has its origin in connection with pigmented moles. It is next most frequently found in con- nection with the matrix of the nail, or in the neighborhood of it, or even in the nail itself. It also has its origin in the ^^-^^"^^^^^^^^ pigmented skm about the genitals and y^^Z^^^'^-^^^^j, anus. ^^/'/r,~_ - 'r^^^-f-f^^'^, Wliile pigmented moles may remain //f^^/' ^'-^^x '''C -7.''',; ')l'^^ quiescent for years, it occasionally hap- .'i ''i-,^-"^' ■--"i--- -,:?r^^; ^i^^yH ^^ pens that, as life advances, ulceration accompanied by bleeding takes i^lace. Neighboring lymph-glands become the seat of secondary pigmented sarcoma- tous deposits, and the skin over these, becoming infected, breaks down, so that the fungous mass beneath is exposed. The latter gives rise to frequent hemor- rhage, which is fatal when it occurs in the neighborhood of large vessels. Dis- fig. 39.-Spindle-celled Saecoma. semination, which does not always take place, results in secondary deposits in the liver, lungs, kidney's, or brain. Lymphatic glandular infection, dissemination, and fatal secondary deposits in distant organs may occur from simple increase in size of the mole, without ulceration. Finally, in rare instances large quantities of pigment may be produced, apparently by the tumor, and fed into the circulation, to be eliminated by the kidnej^s as melanin, no secondary deposits of sarcoma taking place. Xodules of melanosarcoma arising in connection with the nails usually ulcerate quickly, and rapid dissemination and secondary deposits are the rule. The pigment in the primary nodules is sometimes very scanty; the secondary deposits, however, may contain a large amount. Melanotic tumors maj^ be either sarcomatous or carcinomatous in character; in either case the characteristic feature consists of the more or less pronounced pigmentation of the growth. Inasmuch as the pigment particles have their origin in the normal sources of pigment, melanomas are found most frequently in the uveal tract of the globe of the eye and least frequenth" on mucous membrane. Their occurrence in the skin depends on the presence ^; :~-5i>^>: 224 TUMORS of pigment in the rete miicosum, to which situation the pigment grainiles are ahiiost entirely confined in the white race. The comparatively greater fre- quenc}^ with which these growths occur in the neighborhood of the anus and external genitals, particularly in the labia majora, is accounted for by the greater amount of pigment in these situations. The pathologic connection between the presence of pigment matter and the occurrence of melanomas has not as yet been satisfactorily explained. The General Character of Sarcomas. — Sarcomas differ from all other connective-tissue tumors in the absence, as a rule, of a proper capsule, and the consequent ease with which infiltration of the immediately adjacent tissues and remote dissemination occur. The vessels supplying sarcomas may be very large and numerous, though the circulation itself is mainly capillary. When the growth occurs in localities where the blood-supply is abundant and the arterial anastomosis free, as, for instance, in the neighborhood of the knee-joint, the blood-supply to the tumor from the vessels of the part is correspondingly increased and the hemor- _,,^-^„ rhage is alarming in case of injury, ulcer- ^ffl^lr^^^^^ ation, or when attempts are made to dis- sect out the tumor. In the round-celled species, as well as in all soft and rapidly growing varieties, the circulation is specially free, as shown by the pulsation which is frequently pres- ent. Owing to the extreme tenuity of the vessel walls hemorrhage frecjuently occurs ^^^:^t^t-c>.-* ^f^ V j^^^****;^,^;^- withm the mass, after slight m uries. ^ ^.£&< 3^'S*^'^>*'' ^.j*-"' asations ot blood may take place m ^t%^'^'^~\J!^^^^' situations in which the previous presence p.^v_ . - - *''■'•' of a large growth may be easily overlooked. ^^-iT^^''^'^-^^ jifet Np-'5£^V^'»-^''' Under these circumstances large extra v- Fig. 40.-GIANT-CELLED Sarcoma. ^s, for instance, in the gluteal region, and the collection maybe incised as an abscess. The ever present and inevitable tendency of sarcomas to destroy life, as expressed in the term "malignancy," is displayed through (1) their ubiquitous distribution; (2) their infiltrating properties; (3) their tendency to penetrate between surrounding structures; (4) their dissemination. Distribution. — While sarcomas may occur in any portion of the body, owing to the widespread distribution of connective tissue, they are observed springing with greater frequency from subcutaneous tissue and fascia, peri- toneum, the testis and ovary. They are very infrequently found in connection with the spleen, bowel, or uterus, and occur as primary growths with great rarity in the organs which are usually first affected by secondary deposits, namely, the lungs and liver. Sarcomas of mucous membranes are rare as compared with carcinomas of these structures. They were formerly supposed to occur in the endome- trium of the uterus after full-term delivery or abortion (see Choriomas). Sarcoma of the vagina occurs in young children and in the middle-aged. Rare and exceptional instances of sarcomas springing from the mucous membrane of the alimentary canal have been observed. CLASSIFICATION 225 'I'lio infiltrating properties of .sarcomas are ol)sorvcd in a marked manner in localities whei-e i-aj)i(lly growing lympiioKarcomas occur adjacent to extensive jilanes of connective tissue, as, for instance, in the superior mediastinum, where the growth en\'elops trachea and bronchi and extends to the roots of the lungs, follows the aorta and other large vessels to invest the pericardium, and even in some instances invades the heart. Projections of the tumor also pass in an upward direction along the sheaths of the large vessels to the head and appear in the posterior triangles of the neck. In this extensive infiltration the veins are first com})ressed, owing to the thinness of their walls, and interference with the venous circulation ensues. In some instances the walls of the veins are infiltrated with the sarcomatous tissue. The larger arterial trunks, though completely surrounded by the growth, are not, as a rule, appreciably com- pressed, nor do they become infiltrated. The trachea and bronchi suffer from compression, their nutrition is interfered with, and erosion follows. The nutrition of the lung tissue suffers from interference with the blood-supply and pnevunonia and gangrene result. Difficulty of swallowing is not an invariable or marked feature in these cases, however, and neighboring lymph-glands may be completely invested by the growth without showing signs of infection. The tendency of sarcoma to penetrate between surrounding structures differs from its infiltrating properties as follows: while in the former the extension takes place by growth from the periphery and the invasion is an actual vital process, in the feature under consideration the tumor follows the lines of least resistance in its penetrating or burrowing tendency, the process being a purely mechanic one. In this manner the cavity of the cranium may be invaded by a sarcoma originally springing from the upper jaw, which, after filling the sphenomaxillary fossa, forces its way alongside the second division of the fifth nerve through the foramen rotundum. Joint cavities are exceptionally invaded by either of the processes of extension described. The synovial membrane seems to serve as a barrier in the case of the penetrating tendency of the growth, and the absence of venous channels in the articular cartilages removes the most favorable condition for infiltration. When joint cavities are invaded, it is through infection and implication of the synovial structures. Dissemination or metastasis is that property possessed by sarcomas of reproducing themselves in distant organs. This process takes place principally through the veins, the sarcomas being devoid of lymphatics. It consists in the grow^th of minute portions of the tumor into the vessels, w^hich become detached and are carried by the blood-current to remote organs. Here they are arrested by the capillaries, become engrafted, and grow as secondary tumors. Any organ of the body may become affected by sarcoma in this manner, and that, too, from a primary growth, w^hatever its location. If the primary tumor ■is situated in the area of the portal circulation, however, the liver will be the organ most likely to be secondarily affected; otherwise the lung is the organ in which secondary sarcomas are most commonly found. Finally, the secondary or degenerative changes to which sarcomas are subject are to be mentioned. These consist of (1) the formation of spurious C3'sts from hemorrhage within the growth, as already alluded to ; (2) liquefaction of the tissues of the tumor and myxomatous changes, the latter being rather common; (3) calcification in sarcomas of slow growth, particularly in those 16 226 TUMORS connected with bone ; (4) necrosis of the tumor. This is more frequently observed in the interior of very large tumors and results in the formation of a spurious cyst containing fluid and detached and necrotic portions of the growth. Angiosarcoma, a rare and remarkable growth depending on a cellulai- overgrowth in the sheath of the smaller vessels, and on microscopic examination resembling superficially the lobules of the liver, has been described by Z i e g 1 e r . Treatment of Sarcomas. — The successful treatment of sarcomas deinands early and extensive extirpation. Only considerations of safety should limit the extent of the latter. No operation should be undertaken unless it can be made to include every vestige of suspected tissue. When a limb is affected, amputation above the next joint should be the invariable rule. Even this may not be sufficient, as in the case of the upper third of the thigh. In the case of the arm, sarcomas of the humeral region, whether of the bone or soft parts, demand amputation of the entire upper extremity (W. W. Keen, R.S. Fowler). (See Interscapulothoracic Amputation (vol. ii). Sarcomas of the subcutane- ous connective tissue or fascial structures, when situated on a limb, are best submitted to amputation. When situated elsewhere, they should be removed as frequently as they recur. Inoperable cases may be submitted to injections of the toxins of Streptococcus erysipelatis and Bacillus pro- digiosus (C o 1 e y). Treatment by this method offers a slight hope, of which the patient should be given the benefit. Recurrences in regions inaccessible to further operation, particularly if the tumor is of the giant-celled variety, should also be treated by the toxins. Neuromas. — ^A neuroma is a tumor springing from the sheath of a nerve, the structure of the neuroma resembling the structure of the sheath. They are usually observed as neurofibromas and include the so-called subcutaneous painful tubercle. This is a small, shotlike, and excessively painful and sensi- tive body felt beneath the skin. It occurs most frec|uently in men. Excision is always followed by cure. The term neurofibromatosis is now applied to the following: (1) multiple neuromas; (2) molluscum fibrosum; (3) plexiform neuromas; (4) ghomas of the brain and spinal cord. Multiple neuromas are of but slight surgical importance, except in those cases in which the growths are sufficiently few in number to admit of excision. The same may be said of molluscum fibrosum, which sometimes appears in a mild form as a single pedunculated groAvth, particularly in the labium majus. Exceptionally it may spring from the tissues in and about the nipple. AVhen these occur in large numbers as sessile growths, they are not amenable to operative interference. A form of fibromatosis confined to a particular nerve or plexus is called plexiform neuroma. This may affect any portion of either the cranial or the spinal nerves. There is a general enlargement and elongation of the nerves distributed to a part. The skin becomes raised and thinned over the area and is often a bluish color. The mass presents a rather uniform appearance (Fig. 41, 4) with a baglike feel. Mobile and nonsensitive bodies feeling like worms when manipulated and varying in size are present in the interior. The connective tissue of the nerve sheath is greatly increased and converted into a gelatinous material, like that of the umbilic cord. The presence or absence of changes in the axis-cylinder is as yet undetermined. CLASSIFICATION 227 Gliomas of the brain and spinal cord are of but slight surgical interest, owing to the fact that their relation to the important structures hi which they occur usually renders successful operative interference out of the question. Angiomas. — The characteristic feature of this genus of the connective- tissue tyi)e of tumors is the abnormal formation of blood-vessels. Three species are included, as follows: (1) simple nevus; (2) cavernous nevus; (3) plexiform angioma. Simple Nevus. — This may occur as a simple discoloration of the skin, in var3'ing extent, and may affect any part of the body. These discolorations are commonly known as " port wine stains." The form known as telangiectasis consists of an abnormal collection of arterioles in the skin and subcutaneous connective tissue. It may be present at birth as a small red spot which may be easily overlooked. During the first few weeks of life the spot enlarges rapidly and a pulsating tumor of the subcutaneous connective tissue arises. A specially dangerous location for these growths is over the parotid gland, the vessels of which they may involve, so that extirpation of the gland may be ren- dered necessary. This, in infants, is a specially difficult and dangerous operation and is almost certain to be followed by facial paralysis of the corre- sponding side, owing to unavoidable injury of the branches of the seventh nerve. In the case of a young woman under my care an apparently innocent telangiectasis of the tragus and external ear assumed a most vicious and threaten- ing aspect during the third month of pregnancy. The skin finally gave way and a most profuse hemorrhage took place, necessitating simultaneous ligation of the temporal, facial, and external carotid arteries, the lat- ter bej'ond the occipital branch. In a subsequent pregnancy the phenomena returned, and it became necessary to remove the entire ear and ligate each vessel of supply separatel3^ A cure w^as thus ef- fected. This form of nevus has, with some appearance of probability, been ascribed to a hereditary pre- disposition. Cavernous nevus, or erectile tumor, occurs most frequently in the skin, where it forms a red or blue tumor elevated above the surface. Pulsation may be present. The cavernous structure consists of variously shaped spaces and sinuses together with some vessels. The tumor may be emptied of its contained blood, but if emptied it slowly refills. Caver- nous nevi, as a rule, are congenital. They may enlarge rapidly and attain a large size, particularly in the breast of either male or female, and may even threaten life. They occasionally occur in the tongue, where they cause but slight inconvenience, as a rule, except for the accidental injury and the con- mJ^m^ — 1 k"^^L%^ e — 3 n^^^KBip V m 1 fi 1 — 5 iJ Fig. 41. — Plexiform Neu- romas OF Arm (after Sutton). 1, Humerus; 2, mus- culospiral nerve ; 3, supina- tor longus muscle ; 4, neu- roma; 5, neuromas on the cutaneous branches of the musculospiral nerve. 228 TUMORS sequent alarming hemorrhage to which they give rise and which may finally necessitate excision of the corresponding half of the tongue. Cavernous nevi have been observed in the voluntary muscles, in the larynx, and, in a case of the author's, in the broad ligament. Small cavernous nevi have also been found in the liver. Plexiform angiomas are comparatively rare. They comprise the tumors formerly called "aneurism by anastomosis" and "cirsoid aneurism." In structure they consist of moderately enlarged vessels arranged parallel to one another. Either arteries or veins may predominate in their formation, or the tumor may consist of both in about equal proportions. A practical point in regard to telangiectatic, cavernous, and plexiform angiomas is the necessity for their destruc- tion or excision on the first appearance of signs of activity and growth, in order to prevent them from assuming threaten- ing or excessively dangerous proportions. Lymphangiomas. — There are three species comprised in this genus, namely, (1) lymphatic nevus; (2) cavernous lym- phangioma; (3) lymphatic cyst. Lym- phangiomas consist essentially of the structural formation of Ij^mphatics and bear the same relation to lymph-vessels as angiomas bear to blood-vessels. Pure lymphatic nevi are, as a rule, col- orless. They may, however, contain some blood-capillaries, in which case they ap- pear as pale pinkish patches slightly raised above the level of the skin. Occasionally they are multiple. Lingual lymphangi- omas occur as localized clusters of pap- illae consisting of dilated lymphatic ves- sels projecting from the mucous membrane of the tongue (macroglossia, Fig. 42). Cavernous lymphangiomas, as the name implies, are identical in struc- ture with cavernous nevi, their cavities, however, being filled with lymph instead of blood. Macroscopically they are not to be distinguished from lymphatic nevi. Lymphatic cysts are easily recognized congenital cysts occurring either as unilateral or as bilateral growths. They affect by preference the anterior triangle of the neck, though they may be found in the middle line or may extend into the posterior triangle. In some instances they extend into the axiha and superior mediastinum. The cyst may be unilocular or multilocular, with or without intercommunication of the loculi. They originate beneath the deep fascia, but portions of the tumor may become subcutaneous. If the overlying skin becomes stretched and thinned by pressure from within — a not uncommon occurrence — the tumor may exhibit marked translucency. Their resemblance to hydrocele of the tunica vaginalis in this respect has led to the appellation "hydrocele of the neck." These congenital cervical cysts have a special tendency to spontaneous Fig. 42. — Macroglossia. CLASSIFICATION 229 cffacpiiient, through cither atro])lii(' oi' inflammator}'- changes. In the latter case their disappearance is preceded by sudden increase in size, with the develop- ment of heat and tenderness. In the rare instances in which they ha\'e per- sisted until puberty and attempts have been made to emj)ty the cyst, symptoms of collaj^se have followed (B i r k e 1 1). Endotheliomas. — 'Jliis is a rare species of tumor, usually containing dilated lympliatics, and arising from the endothelium of lymiah-vessels, and blood- vessels. They may infrequently attain a large size, are liable to degenerative changes, and exhibit a tendency to recurrence after removal. They arise in connection with the gums, in the mammary glands, in the skin in association with moles and warts, in the pleura, and in the cerebral and spinal dura. Myomas. — Tumors composed of unstriped muscle-fiber are called myomas. They are of very rare occurrence, with the exception of uterine myomas, and are exclusively confined to localities in which iuA-oluntary muscle- fiber normally exists, such as the upj^er portion of the alimentary tract (the esophagus, stomach, and duodenum), the bladder, and the uterus. The similarity existing between unstriped muscle-fiber and the fusiform cells of sarcoma renders the differentiation difficult, and these difficulties are still further enhanced by the transverse striations sometimes observed in the spindle- cells of malignant tumors, and which are likewise obsers^ed in voluntary muscle in the embryonic stage. Tumors consisting of mature striated or voluntary muscle-fiber have not been observed. EPITHELIAL TUMORS In the study of epithelial tumors it is important to bear in mind that epithe- lium, the presence of which is the essential and distinguishing characteristic of this group, is widespread in its distribution and disposed in such a manner as to serve many and important functions. Wherever epithelium exists, whether as a protective covering, as in the case of the epidermis, or as the cellular lining of simple or complex glands or of their ducts, these epithelial tumors may arise. The three genera of this group of tumors are (1) papillomas; (2) adenomas; (3) carcinomas. Papillomas. — The inost familiar example of a papilloma is the common wart. Warts consisting of overgrown papillae ma}^ occur in crops on the hands of children or about the anus and glans penis of patients with gonorrhea. A skin wart which persists and increases in size, particularly when it contains pigment granules, may ultimately become the point of origin of a melanosar- coma. Solitary soft red warts of rapid growth simulate malignant tumors. The surface cells of skin warts are sometimes converted into cutaneous horns. The mucous membrane of the cheeks, nose, and larynx may be the seat of warty growths similar in structure to those which occur on the skin. In the larjmx they may produce suffocation. Villous Papillomas. — The favorite seat of these growths is the mucous membrane of the liladder. They are occasionally observed in the renal peh'is. They may be either pedunculated or sessile. Structurally they consist of a dehcate and very vascular connective-tissue bod}' covered with epithelium. They are usually single, but they may be multiple. They ma_v obstruct the ureter or urethra and not infrecjuently give rise to severe hemorrhage. Those occur- ring in the renal pelvis may exceptionally be associated with villous growths 230 TUMORS in the bladder. Ilceration of renal and vesical papillomas causes a close simulation of malignant disease in these regions. Intracystic villous papillomas are observed springing from the lining of cysts of the mamma (Fig. 43). These have the same structural characteristics as vesical papillomas. On section the cavity of the cyst contains a brownish colored fluid, the result of hemorrhage from the villous growth. When the cyst is formed of a galactophorous duct, this same brownish fluid may he discharged at times from the nipple. Psammomas are confined exclusively to the pia mater of the brain and spinal cord and are of slight surgical interest. Cutaneous Horns. — These ma}- form in situations where sebaceous glands exist (sebaceous horns); as wart horns on the penis or pinna; as cicatrix horns springing from a scar left by a burn; or as nail horns on the toes of bedridden patients and elderly unclean individuals. Fig. 43. — Intracystic Papillomas of Breast. Adenomas. — A tumor arising from the epithelial elements of a secreting gland is called an adenoma. The principle of its construction is typic of secreting gland tissue, namely, narrow channels lined with epithelium, with a connective-tissue basis containing blood-vessels. In some examples the epithe- lial element greatly predominates, while in others the disproi)ortionate amount of connective tissue present is suggestive of sarcoma (adenosarcoma). Adenomas occur as encapsulated growths in the mamma and liver, and in large secreting glands, such as the parotid and thyroid. In the glandular structure of the mucous membranes they occur as pedunculated growths. They occur singly or as multiple growths springing from the same gland. They vary greatly in size. They may be found in a child's rectum as jDedunculated growths as small as a pea ; in the breast of a woman thej' will occasionally grow CLASSIFICATION 231 to the sizo of a large cocoaniit. When multiple, they are likely to be small, while solitary growths arc frequently large. These growths do not affect lymphatic glands nor cause secondary deposits, and when thoroughly extirpated they do not recur. The dangers of their presence arise principall>' from mechanic disturbances. The frequency with which these tumors coexist with carcinomas in the same gland has given rise to the erroneous belief that they may be transformed into cancers. A cystic adenoma is present when the epithelium-lined spaces of the growth are filled with fluid. The latter, however, is identical with the normal secretion of the gland from which the growth springs. This variety is found most fre- quently in the mamma, where it is sometimes in communication with a galacto- phorous duct. Under these cirumstances the fluid can be expressed from the nipple and constitutes a valuable diagnostic sign. Fibroadenomas affect particularly the breast. They occur as almond- shaped growths affecting the upper, outer, and lower quadrants specially. Their size varies, but it is not rare to find them larger than an English walnut. They are most commonly found after the age of puberty. They are usually situated in the superficial portion of the gland, though they may be deeply placed. They are not infrequently multiple and it is not unusual to find both breasts the seat of these growths. Complex adenomas have been observed in the mamma, combining the fibrous structure of the fibroadenomas and numerous and large cysts. The latter are sometimes the seat of intracystic growths. The cyst, under these circumstances, corresponds to a dilated galactophorous duct. These tumors are distinctly isolated from the remainder of the gland by a capsule and may attain a large size. Sebaceous adenomas are growths springing from the sebaceous glands and presenting the usual clinical signs of wens. On section, however, they are found to be composed of lobules which represent an overgrowth of a sebaceous gland. These growths ulcerate frequently, the ulceration being accompanied by a fetid discharge; they then constitute one of the varieties of "fungous wen." Sebaceous cysts or wens are collections of sebum in sebaceous glands. They are generally believed to arise from obstruction of the orifice of the follicle and distention of the acini, an appreciable swelling resulting. This explanation, however, wih not suffice for even a majority of the cases, inasmuch as obstruc- tion is more frequently absent than present. The tumor comprises a capsule and its contents, the latter consisting of pultaceous material mixed with epithelial scales. Calcification sometimes occurs. The cysts may occur in the skin covering any portion of the body except the limbs, but their favorite location is the scalp and the external genitals. They vary in size from a pea to a small orange. The contents of these cysts are Hable to decomposition, when a peculiar and extremely offensive odor is evolved. Inflammatory conditions of the cyst wall also occur, particularly when the, cysts are situated in parts exposed to injury. When inflamed, they are a deep purplish-red color. Suppuration may take place. Simple incision, as a rule, does not suffice for a cure, a portion or all of the cyst wall remaining and leading to the formation of fistulas or the reproduc- tion of the entire tumor. 232 TUMORS Adenomas of the thyroid constitute the basis of one of the forms of goiter. The}' occur as encapsulated tumors in one or both lobes of the glaiul, vary greatly in size, and contain vesicles of the same character as the thyroid gland itself. Coalescence of the vesicles occurs coincidentally with the disappearance of the septa, and in this manner a cystic bronchocele is formed. The cavity of a cyst thus formed contains fluid, the result of intracystic hemorrhage. The fluid itself often contains cholesterin. Colloid material may be present (colloid struma) . Very rarely papillomas may be found springing from the walls of the cyst. A cystic bronchocele may attain large proportions, causing pain and giving rise to dyspnea from pressure on the trachea in cases in which the tumor descends behind the episternal notch. When the descent is in front of the sternum, the growth is sometimes very mobile. Adenomas of the liver when fully developed occur as spherically shaped and encapsulated tumors, varying in size from a hazelnut, when they are single, to a small orange, when they are multiple. They may be situated in almost any portion of the liver. They may be a bright green in color, due to the presence of bile, or a dull white. They are made up of sohd columns of cells at the periphery of the tumor with a lumen in the center. In a case operated on by the author the growth presented to the naked eye a striking resemblance to carcinoma. Prostatic adenomas consisting of enlarged glands in the prostate are of not infreciuent occurrence late in hfe. The organ becomes increased to two or three times its normal size, and this increase in size, when it occurs in con- nection with the collection of glands situated posteriorly to the verumon- tanum, may cause a projection into the lumen of the urethra. The patency of the vesico-urethral orifice is thus interfered with, and urinary obstruction with its attendant and consequent evils follows. Carcinomas. — Malignant neoplasms arising in epithelium are called car- cinomas, or cancers. A malignant tumor springing from a free surface covered with epithelium of the squamous or pavement variety is called an epithehoma. When the growth originates in the epithelium of a gland, it is known as glandu- lar carcinoma. In spite of the widespread distribution of the epithelial elements from which carcinomas arise, the disease shows a special predilection for certain localities, and is rarely found in others. The special histologic characteristic of carcinoma consists of the presence of columns of cells, which on section present under the microscope the appearance of a number of alveoli. The walls of these alveoli are composed of fibrous tissue in which blood-vessels and lymph- vessels ramify, and the spaces are filled with epithelium (Fig. 44). The cells comprising the columns par- take of the character of those from which the growth originates. The amount of fibrous tissue in the walls of the columns as seen under the micro- scope will vary greatly between the hard and the soft^variety. The Infiltration of Carcinoma. — The dangers arising from the presence of carcinoma, as well as the difficulties of dealing with it surgically, are greatly enhanced by the inability of even the skilled pathologist, with the aid of the microscope, to define the dividing line between the diseased tissues and the surrounding healthy structure. This infiltrating property of carcinoma leads to the rapid involvement of adjacent parts, whether skin, fat, mucous mem- CLASSIFICATION 233 l)rane, or bone, is a very common cause of death, and only too often proves an insnrniountable l:)arrier to successful surgical intervention. Glandular Infection. — The free distribution of lymph-vessels on the sur- face of the body and within the secreting glands which are derived from this surface forms the basis for a free communication between epithelial growths and the lymphatic glands, and for the conseciuent infection of the latter when carci- noma is present. Lymphatic glands thus infected may attain many times the size of the original growth. The readiness with which lymphatic glandular infection arises varies with the susceptibilities of the individual, as well as with the anatomic peculiarities of the part affected. A lack of knowledge of the extent of the lymphatic glandular infection renders the prognosis after operation very uncertain. Dissemination. — In addition to the infiltrating and lymphatic-infecting properties of carcinomas, their malignancy is still further emphasized by their proneness to dissemination. This dissemination occurs through the medium of secondary deposits which have their origin in minute portions of cancer tissue. They may find lodgment in any of the organs or tissues of the body, may be transported as emboli by the lymph- ,^ ^^^ vessels and blood-vessels and deposited ^^= '^ '^^ ^^^'^K in situations where in due course of time y<^^^^ ^H^^^^^^-. they proliferate; a tumor then arises, ^^^x which has exactly the same histologic ^^'^-"'''^ features as the primary growth. When ^ the dissemination is widespread, and p'f ^^ particularly when such organs as the ^- '^ globe of the eye, ovaries, brain, and ^ '^ vertebrae are the seats of secondary ^ '*,^^ deposits, it is an indication that emi- ^? "^^^ gration of the cancer emboli has taken ^^ place . through the general systemic circulation. Disseminated infection may also take place without the aid of lymph- ^ig. 44.-CARciNOMA^or the mammary vessels or blood-vessels, as in the case of diffused nodular carcinoma of the peritoneum. Under these circumstances the original focus of disease resides in an abdominal viscus, the implicated peritoneal covering of which gives way, so that the epithelial elements of the tumor are scattered about in the peritoneal cavity through the peristal- tic movements of the intestines, and the peritoneal fluid. Degenerative Changes. — The absence of a free blood-supply to epithelial growths leads to retrograde changes in carcinomas, the chief of which is that known as colloid degeneration. In colloid degeneration the epithelial cells making up the columns of the carcinomatous structure undergo certain changes which result in a jelly like transformation of the cells. These changes may take place so rapidly and completely in certain situations, such as the ovary, the stomach, and the breast, that cancerous growths in these organs are frequently referred to as "colloid carcinomas." The condition, however, is simply one of degeneration of the common type of glandular carcinoma. The infective properties of carcinoma are now fairly well established. This is not a matter of surprise when the readiness with which epithelial ele- 234 TU.MORS merits grow when accidentalh' engrafted is considered. The most important bearing which this infective character has in the work of the practical surgeon relates to the care that should be exercised in operations for the removal of carcinomatous growths to prevent the surfaces of the wound from being sown with the diseased cells. The Etiology of Carcinoma. — The special predilection of cancerous growths to attack those glandular .structures which have a more or less cUrect communication with the outer world, such as the mammae, the stomach and rectum, as well as those which arise directly from the skin surface, has suggested a parasitic origin for the disease. The subject is, however, stni under investi- gation, and must at the present time be considered sub jiidice. While there are reasons for believing that certain congenital local predis- positions to the disease exist (moles, nevi, fleshy warts, etc.), yet it should not be assumed that either these or chronic infiammator}^ lesions are the necessar\^ antecedents of cancer. Traumata have also been considered as being efficient causes of the affection. A careful study of the statistics, however, disproves this view ( W i 1 1 i a m s) . Epithelioma. — Squamous-celled carcinoma, or epitheUoma, occurs on sur- faces covered with stratified epithehum, particularly at those pomts where skin and mucous membrane merge into each other. FamiUar examples of the latter tendency are found in the Up, the vulva, and the anus. The disease arises as a prominent isolated growth resembhng a wart, as a small ulcer with well- defined and infiltrated margins, and as a fissure with more or less firm edges. The histologic characteristics of epithehoma are similar to those of glandular carcinoma, the surface epithehum mvading the growth, or the ulcer and its mfntrated margins, in the shape of columns, the ceUs of which retam to a greater or lesser extent the characters of the epithehum from which they sprmg. Epi- thehal pearls are formed by the comification of the flattened cells in rapidly growing cellular cones. Parts that are the seat of already existing disease are apparently more haJjle to be attacked by epithehoma. As examples of this may be cited the tongue (leukoplakia and old syphilitic ulcers), the \ailva (leukoplakia), and chronic ulcers of the leg. Disturbances of nutrition due to the presence of scars resulting from burns, as well as lupus scars, also appear to increase the liability to epithelioma. The more vascular the structures adjacent to a breaking do^\ai epitheli- oma, the more rapidly the infiltration and ulceration extend. Cartilage, for mstance, is quite exempt from invasion. Occasionally the fungous properties of the ulcer predominate, and the mfiltration and peripheral ulceration proceed more slowly. In whatever structure or situation the disease occurs, however, it rapidly destroys life. When the disease mvolves large blood-vessels, these are opened, and death from hemorrhage often takes place. In parts remote from large vessels, as in the breast, death occurs from septic and anemic conditions combined (cachexia). Death from inhalation pneumonia is not infrequent in cases in which the cancerous growth is adjacent to the air-passages and septic material is inspired. Lymphatic glandular infection is the most serious danger which threatens patients with epithelioma, because of the promptness with which this occurs, the size which the glands attain, and the difficulty in completely removing these. This is particularly true of cases of epithelioma of the tongue, the hp, the scrotum, and the penis. CLASSIFICATION 235 Dissemination. — The extent to which this occurs bears some relation to the seat of the tlisease. This is due in part to the fact that in some situations, as, for example, the larynx, life is destroyed before opportunity is afforded for dissemination. On the other hand, this does not hold good in other situations in which destruction of life is sometimes delayed, gland infection being extensive, yet dissemination quite exceptional, as, for instance, epithelioma of the scrotum. Treatment. — Clinical experience with epithelioma, as in the case of all forms of malignant disease, emphasizes the supreme importance of early and complete operative removal of all implicated structures. DERMOIDS The special and characteristic feature of the group of tumors to which the term "dermoid" is applied, as the name indicates, is the presence of skin and mucous membrane in the growth. In the neoplasms thus indicated the skin or mucous membrane is formed in situations where these structures do not exist under normal conditions. No other tissues enter into their composition. Four genera are assigned to this group, as follows: (1) sequestration der- moids; (2) tubulodermoids ; (3) hairy moles; (4) ovarian dermoids. Sequestration Dermoids. — These constitute the simple form of this group. As the name implies, they arise in isolated or sequestrated portions of skin, usualh" in the lines of embryonic coalescence. A dermoid may be a simple skin- lined recess ; the usual form, however, is that of a globular tumor with a central cavity the lining of which possesses the dermal elements of true skin. Dermoids of the Face. — These occur in situations representing the site of the facial fissures in the embryo. They are found most frequently (1) at the outer and inner angles of the orbit; (2) in the upper eyelid; (3) in the nasofacial sulcus; (4) as dermoid recesses or sinuses at the site of the inter- nasal fissure. Dermoids of the scalp occur most frequently over the anterior fontanel and at the occipital protuberance. In either of these situations they may be mistaken for wens or meningoceles. Dermoids have also been found connected with the dura mater, a circumstance which finds its morphologic explanation in the fact that the skin and dura remain practical^ in contact at the sites of the cranial sutures, even for a year or more after birth, particularly in the neighbor- hood of the bregma and inion, and a failure of ultimate separation as the bone fissure closes may give rise to a dermoid. Dermoids of the trunk occur strictly in the regions where the lateral halves of the body join each other, namely, on the line . commencing at the upper limit of the cervical vertebrae, extending along the middle line posteriorly, and thence through the perineum and upward anteriorly to the middle of the lower lip. Dermoids are rare along the dorsal portion of this line, with the exception of sacral cysts and coccygeal sinuses. The latter are recesses lined with skin and running almost parallel to the surface. The small external opening lies at the bottom of a so-called postanal dimple. Hair and dirt accumulate in the sinus and suppuration may occur. A sinus of this kind may be mistaken for an anal fistula. Dermoids of the thorax are very rare. They may occur either at the ante- rior aspect of the sternum or within the chest itself. Only the former are of 236 TUMORS surgical interest. They are situated near the junction of the manubrium with the gladiohis, at the site of a small dimple or recess in the skin sometimes found in this situation. A dermoid tlevelops, though rarely, in the episternal notch. Dermoids of the Scrotum, Testicle, and Labium. — Dermoids of the scrotum have been found in such close relation to the testicle that they have been reported as arising from the latter. It is probable, however, from a morphologic standpoint, that dermoids of the testicle are very rare as compared with those occurring in the scrotum. Dermoids of the labium are very common. In a case operated on by the author the growth, which externally was only the size of a small orange, was found to have burrowed deeply into the thigh. A similar case is mentioned by Sutton. Implantation cysts are of interest in connection with the study of dermoids. They result from the accidental im- plantation of portions of skin or of some of its elements (epithelium, hair-bulbs, etc.) into the subcuta- neous connective tissue, where they become engrafted and proliferate, a cyst resulting. These are sometimes called " traumatic dermoids." They may grow to the size of a hazelnut. Similar cysts of traumatic origin have been found on the iris and cornea. Tubulodermoids. — These arise in connection with one of the em- bryonic canals which fail to disap- pear normally at birth. Those which may remain more or less per- sistent after birth and which are of special surgical importance in this connection are (1) the thyroglossal duct; (2) that portion of embryonic intestine extending behind the anus called the postanal gut; (3) the bran- chial clefts. The thyroglossal duct is a median offshoot from the ventral wall of the embryonic pharynx, from which the isthmus of the thyroid is derived. In the embryonic state the duct extends as far upward as the base of the tongue and bifurcates laterally in the direction of each rudimentary lobe of the thyroid. Its persistence assumes a surgical interest in connection with (1) lingual dermoids; (2) median cervical fistulas; (3) accessory thyroids. Lingual dermoids arise in the tongue and occupy a central position in that organ, between the geniohyoglossi muscles. They originate in the lingual portion of the thyroglossal duct, the upper end of which has become obliterated. These tumors vary greatly in size; they may become large enough to interfere seriously with the taking of food. Median Cervical Fistulas (Fig. 45). — These originate as retention cysts Fig. 45. — Median Cervical Fistula Associated WITH A Persistent Thyroid Duct. CLASSIFICATION 237 formed in a persistent thyroid duct, or that portion of the thyroglossal duct below the hyoid bone. A median swelUng in the neck commonly precedes the occurrence of glairy or mucous discharge, after which there is a persistent sinus. The site of this sinus is often marked l)y a cordlike process extending up to the hyoid bone. The lower end of the fistula usually terminates in a thin- walled sac opening on the free surface of the skin. Upon dissecting out this sinus the upper end may be found to be obliterated and firmly attached to the hyoid bone. The sinus may also be bifurcated, following the course of the duct in the direction of the lobes of the thyroid. The lingual duct, or that portion above the h}-oid bone, may persist to the surface of the tongue (Fig. 46). Median and lateral accessory thyroid bodies may occur as remnants of the thyroglossal duct. Dermoids of the Rectum. — These occur in connection with the embyronic postanal gut, which also gives rise, in all prob- ability, to the congenital sacrococcygeal tu- mors occasionally observed. The variety of dermoid sometimes found between the hollow of the sacrum and the rectum (postrectal der- moids) , which may attain large dimensions and extend upward behind the pelvic peritoneum, also has its origin in this obsolete canal. These growths sometimes contain both teeth and hair and may open spontaneousl}' in the perineum. In addition to the above described postrectal dermoids, these growths have been found grow- ing from the mucous membrane of the rectum as pedunculated tumors (rectal dermoids). They may protrude from the anus and simulate either rectal polypi or hemorrhoids. They may contain hair and teeth; the former is in the shape of long locks. Dermoids in this situa- tion should not be confounded with ovarian dermoids, which sometimes open and discharge into the rectum. Branchial fistulas and cysts have their origin in either one or more of the four em- bryonic branchial clefts of the human fetus. The partial or complete persistence of one or more of these clefts results in congenital cervical fistulas (Fig. 47). These may open on the skin surface of the neck or in the pharynx; or they may exist as complete fistulas. The site of the external orifice is some- times marked Isy a tag of skin containing yellow elastic cartilage (con- genital cervical auricle, vide infra). The fistulas may be single or multiple and lined with skin or mucous membrane. They are occasionally the seat of suppuration with the formation of an abscess. The persistence of the portion of the cleft between the internal and the external orifice results in an unobliterated branchial space, a true retention dermoid cyst arising. This cyst may contain mucus if the external portion is obliterated, and the sac lined with mucous membrane continuous with that of the jjharynx; or if the internal segment of the cleft is obliterated, the sac being Fig. 46. — Median Cervical Fistu- la. (Diagrammatic, showing THE Relation of the Parts.) 1 , Hyoid bone ; 2, pyramid of thy- roid; 3, abscess sac; 4, foramen cae- cum; 5, lingual duct; 6, epiglottis; 7, thyroid cartilage; 8, thyroid gland; 9, trachea (from Sutton, after Mar- shall). 238 TUMOES continuous with the epitheUal structure of the skin, the cystic dilatation will be filled with epidermal scales, sebaceous matter, and cholesterin. In the ex- perience of the author the latter is the more common variety. Those obliterated external]}- but openino; internally may occur as diverticula of the pharynx. Cervical Auricles. — A hereditary influence is claimed for the origin of these appendages. Both structurally and morphologically the}' are identical with the normal auricle or pinna, and consist of yellow elastic cartilage and muscle fiber from the platysma, covered with skin. They may or may not be associated with cervical fistulas, but when present are always situated in the locations affected by the latter. A congenital fistula sometimes appears leading into the substance of the hehx (auricular fistula). These are deemed hereditary and may coexist with branchial fistulas. They are sometimes found in the lobule. Auricular dermoids arise in un- obliterated skin-lined spaces left be- tween the tubercles uniting to form the auricle. They sometimes occupy the groove between the pinna and the mastoid. Reduplication of the tragus some- times occurs (accessory tragus). It may occur as a conical projection or as a pedunculated process of skin covered with hair. It is occasionally associated with defects in the mandibular fissure. Moles. — The dermoid patches known as moles are pigmented and slightly raised above the level of the skin. They are usually covered with hair. They are very vascular and bleed easily if injured, or in case of ulceration, to which they are liable. The tissue immediately underneath moles is arranged in alveoli, such as are found in sarcomas occurring in connection with these growths (alveolar sarcomas). In fact, the surgical interest manifested in these usually innocent tumors is centered in the fact that later in life they are liable to become the starting-point of one of the most mahgnant forms of sarcoma, namely melanosarcoma. Moles may be single or multiple, they are sometimes very sensitive, particu- larly those which occur on the trunk. The}' may occur on the conjunctiva, where they are sometimes associated with the embryonic defect of the eyelid known as coloboma. Teratomas are certain irregular and conglomerate masses formed almost exclusivelv in connection with the vertebral column and skull, and containing Fig. 47. — Congenital Fistulas, showing Ori- fices OF Persistent Branchial Fistulas. A, Tympano-Eustachian passage ; B, opening close behind the angle of the jaw, and anterior to the line of the stern omast old muscle; this open- ing is sometimes found on a level with the lobule of the pinna and slightly posterior to it; C, this opening occurs very constantly in the situation here shown, i. e., on a level with the thyroid space, close to the anterior border of the sternomastoid ; D, this fistula usually opens near the sternoclavi- cular articulation; it may vary somewhat in its relations with the latter, but its position relative to the sternomastoid muscle is rather constant. CLASSIFICATION 239 the tissues and portions of viscera ]:)cloiiging to an immature and suppressed fetus. They occur in individuals otherwise normal and inchide conjoined twins, super- numerary limbs, and acardiac parasitic fetuses. They are mentioned in con- nection with the surgical study of tumors because of the liability of confound- ing irregularl}- shaped tumors with dermoids. CYSTS AND PSEUDOCYSTS Cystomas are tumors resulting from the abnormal dilatation of pre-existing tubules or cavities. They may be divided into (1) retention cysts; (2) tubu- locysts; (3) hydroceles. Retention cysts, as the name implies, result from the obstruction of the duct of a gland and the accumulation of fluid within the ducts and acini. When the obstruction is permanent, the gland atrophies and is replaced by fibrous tissue, of which the walls of the simplest form of cysts are composed. The purest form of cyst occurs in connection with hollow organs, the inner walls of which are provided with glands. In the case of the gall-bladder the obstruction may be due to impacted gall-stones, a pancreatic concretion, tumors, etc., and may occur in the cystic duct, in the common duct, in Vater's diverticulum, or in the wall of the duodenum at the site of the latter. When the obstruction is complete and permanent, the gall-bladder may atrophy if the obstruction is in the common duct, or become greatly distended with mucoid fluid, the result of cholecystitis, if the cystic duct is the seat of the obstruction (dropsy of the gall-bladder); suppuration may follow (empyema of the gall-bladder). Pseudocysts.— The conditions known as diverticula and pseudocysts are conveniently treated of in this connection. They include the intestinal, vesical, and pharyngeal diverticula, the hernial protrusions of synovial membrane from cavities of joints known as synovial cysts, and a similar condition occurring in connection with the synovial lining of a tendon-sheath, known as ganglion. Adventitious bursae are also to be classified with pseudocysts. (For intes- tinal, vesical, and pharyngeal diverticula see Regional Surgery, Part II.) Tubulocysts. — These occur in the so-called functionless ducts, such as the vitello-intestinal duct, the urachus, and the remains of the mesonephron (Wolffian body). Those of special interest to the general surgeon occur in con- nection with the above mentioned. (vSee Regional Surgery, Part II.) Synovial Cysts.— These may occur as (1) hernial protrusions of the lining of a joint; (2) bursae in the neighborhood of joints; (3) hernial protrusions of the synovial covering of tendons. The first have been frequently observed in connection with the joints of the hip, knee, ankle, shoulder, elbow, and wTist. Those which have aroused the greatest surgical interest have occurred in con- nection with the knee-joint, where they have been found in relation with the biceps, the semimembranosus, or the heads of the gastrocnemius muscle. Cysts have been found at some distance from the joints from which they arise, communication being maintained by a very narrow channel. They are liable to arise in tuberculous joints and are due to increased intra-articular tension, the synovial membrane being forced through weak spots in the joint capsule. Normal bursae in the neighborhood of joints may become enlarged and establish a communication with the joint cavity. Synovial cysts connected with the knee-joint are likely to find their way either to the pophteal space, to the 240 TUMORS middle of the calf just below the latter, or to the mner side of the leg below the head of the tibia. It may be said of these cysts in a general way as they occur in the other locahties named, that they will force their way as synovial i3rojgctions from the joints at the points where the latter are least protected by overlying mus- cular structures, and thereafter pass in the direction of least resistance along the intermuscular planes. Or they may be guided by the margins of a sharply defined tendinous structure, as, for instance, the long head of the biceps in the case of a synovial cyst of the shoulder. The cyst contents may be clear synovial fluid, or in the case of diseased joints it may be turbid and contain pus-cells; or true pus may be present. Ganglion. — The cyst wall of a ganglion consists of the synovial lining of a tendon-sheath which has escaped from its normal environment. In the variety known as simple ganglion the cyst appears as a rounded, elastic, sessile swelling. A rather common situation for these cysts is the back of the carpus. i\Iany of these, however, on dissection prove to be diver- ticula from a carpal joint, from which it is often exceedingly difficult to differ- entiate them. In addition to the above named familiar location, simple ganglions are met with in the sheaths of the long flexors of the fingers, on the dorsum of the foot, and on the outside of the ankle. The fluid contents resemble grape jelly. Compound Ganglions. — These occur more freciuently in connection with the flexor and extensor tendons of the carpus, more rarely on the tendons of the peronei. This variety of ganglion is of far greater surgical importance than the fore- going. Extension takes place for variable distances, and unexpectedly wide dissections are sometimes necessary in following the prolongations of the cyst, which may pass under the annular ligament, both anteriorly and posteriorly, to find their way into the palm or along the extensor tendons. Crepitation felt in these ganglions is due to the presence of so-called " melon seed" bodies. Both varieties are likely to recur after operation, even when every vestige in sight has been carefully dissected out. In the case of the simple ganghons, this is due to the fact that, though they burrow in and between the tendons, they really spring from the wrist-joint ; in the case of the compound ganglions, to the fact that many of them are tuberculous in origin, the most radical meas- ures sometimes being inefficient to destroy the extensive infective process, so that after repeated recurrences amputation becomes necessary. Bursae. — Bursal sacs may form in any part of the subcutaneous con- nective tissue w^here the overlying skin is subjected to intermittent pressure. They may occur in any portion of the body where muscles and tendons glide over osseous surfaces or in situations where the skin lies in close contact with bony prominences. They are normally present in certain situations, as, for instance, in front of the patella and behind the olecranon. Adventitious bursae, on the other hand, arise in situations where the results of pressure are a pathologic rather than a physiologic sequence of anatomic conditions, such as in clubfoot, bunions, etc. Subtendinous bursae sometimes communicate with the sheath of the tendon and occasionally with the cavity of a neighboring joint. Bursal sacs are thin walled with smooth inner surfaces, in which, as a rule. THE DIAGNOSIS OF TUMORS 241 epithelium is wanting. They contain a glairy fluid and sometimes loose bodies. Their formation is believed to be brought about Ijy the rupture of connective tissue between the movable overlying skin and the solid prominence beneath. This at first imperfectl}' isolated space finally assumes definite boundaries and the condensed connective tissue becomes a smooth sac wall. These sacs may occur in any situation where pressure is exercised, and hence bear a close relation- ship to the occupation of the individual. The most frequent forms are "house- maid's knee " "miner's elbow," and bunion. The first occurs in persons whose occupation or habit leads to more or less constant kneeling. The second is common in those whose occupation in close quarters, as in mining, leads to frequent blows on the elbows. The third usually results from wearing ill fitting shoes, and is the condition commonly observed over the enlarged head of the first metatarsal bone in hallux valgus. Bursae are subject to inflammatory conditions (bursitis), either acute or chronic. An acutely inflamed condition demands complete rest of the parts. Accumulations of fluid may occur, requiring either systematic pressure to produce absorption or incision for their evacuation. Suppurative changes are not uncommon. An inflamed bunion may involve the underlying joint and demand excision of the latter or even amputation of the toe. The thyrohyoid bursa, or that lying between the hyoid bone and the thyrohyoid meml^rane, is sometimes the seat of considerable enlargement and may require incision and drainage. THE DIAGNOSIS OF TUMORS Even the existence or the nonexistence of a tumor is sometimes difllicult of aflarmation. This is particularly true of neoplasms in the brain and spinal cord. Dr. Charles K . Mills, of Philadelphia, has recently called attention to the R o n t g e n ray method in the diagnosis of intracranial neo- plasms. Tumors of the abdominal and pelvic cavities sometimes require very close attention and careful watching to eliminate the possibility of an accumu- lation of intestinal contents, contractions of isolated portions of muscular structures (phantom tumor), the existence of normal and ectopic gestation, etc., as sources of error. In the case of neoplasms easily palpated, as well as in most of the more obscure examples in which both subjective and objective symptoms are sometimes contradictory and misleading, the question of differen- tial diagnosis wall frequently present many difficulties. The history, age of the patient and length of time of the existence of the tumor, its rate of growth, its gross physical characters and situation, its freedom of movement or attach- ment to surrounding and overlying structures, its relations to these, the question of lymphatic iuA^olvement or visceral complications, the presence of metastases, the microscopic characters of sections removed for examination in the differentiation of benign and malignant growths, the results of ex- ploratory operation and the outcome of therapeutic tests in the exclusion of syphilitic lesions — all these are of the greatest importance in connection with the diagnosis of neoplasms. 17 242 TUMORS TREATMENT OF TUMORS In a general wa}' it may be stated that the only trustworthy method of dealing with a tumor is to effect its removal or destruction. There can be no two opinions as to the advisability of promptly attacking any malignant growth, and removing it, together with as much of the surrounding structures as safety will permit. Amputation of a part involved in a malignant growth should always be given the preference over simple excision. Benign tumors may be removed whenever they become a source of annoyance, inconvenience, dis- comfort, or deformity. In the event of their becoming a source of ill health even to a slight extent, or a menace in the future, their removal is demanded. SECTION VII LABORATORY AIDS IN SURGICAL DIAGNOSIS AND PROGNOSIS The use of laboratory procedures as practical aids in the diagnosis and prognosis of disease is comparatively modern, and their value has become so important that a consideration of their significance and of the detail of their technic has earned a place in every text-book. Successful surgery demands prompt and accurate diagnosis, and to this end laboratory examinations frequently offer conclusive proof or corroborative evidence of much value. With the great advances in surgical skill and the consequent improved statistics of surgical procedure, the question of prognosis has also become more important, and laboratory aids form no mean part in reaching conclusions in this regard. The brilliant outcome of laboratory diagnostic methods in some cases may lead the novice to attempt to make a definite diagnosis with the microscope and test-tube at the expense of clin- ical methods. This is a grave error— the diagnosis must be made at the bed- side, and the results of laboratory work considered for what experience teaches they are worth, just as the clinical signs and symptoms are considered. Pathologic, bacteriologic, and chemic technic must be shorn of every detail not absolutely necessary, in order to commend itself to the busy practical worker, who is interested solely in the result, and not in the method of investigation. The surgeon seeks aid in diagnosis and prognosis; he is in- terested in the outcome of the laboratory help, and the methods that meet with his approval are those which are easily and quickly executed, often at the expense of absolute accuracy, as long as they are sufficiently precise to meet clinical practical purposes. The research laboratory worker should be a scientist; for him absolute accuracy is the keynote of success, without which his results merit no confidence. He must^ modify his absolutely accurate method, in order that it may appeal to the clinician as a practical procedure, the results of which justify the work required. This demand, being of comparatively recent date, has not had the attention from teachers that it deserves, as the following examples will illustrate : Teachers and text-books advocate the spreading on the thin microscopic cover-glasses of sputum, pus, blood, or any other substance which is to be dried on a carrier for subsequent staining. These small films of glass are difficult to handle, are easily broken in the manipulation of staining, washing, and drying, and present a limited surface for investigation. The microscopic slide should be used for this purpose. Its advantages are obvious. A chemic procedure often presents the details of complex graphic formulas of not the slightest interest to the practical worker, while the specific directions given for the test are so lax as positively to invite error. 243 244 LABORATORY AIDS IN SURGICAL DIAGNOSIS The following is a brief summary of the examinations useful in surgical diagnosis and prognosis, with a description of the technic in the more important ones : Pathologic examinations. Blood. Urine. Bacteriologic examinations. Chemic examinations. Specific examinations <| Sputum. Gastric contents. Aspirated fluids. PATHOLOGIC EXAMINATIONS The following remarks must necessarily be limited to the preservation and preparation of specimens for examination, whereas the descriptions of the different gross and microscopic pathologic tissue changes met with in surgery are detailed elsewhere. For more minute data of the latter the reader is referred to the many admirable text-books on pathology. Gross Pathology in surgical diagnosis, or what can be learned by inspec- tion, palpation, etc., belongs to the clinical consideration and can be dis- missed here. The gross consideration of pathologic specimens removed by operation is an important matter, and their proper manijDulation immediately after removal not only allows a more critical inspection, but also preserves them for future examination and demonstration. The old method of washing the specimen in running water to remove the blood and then preserving in alcohol, doubtless prevents decomposition, but shrinks and decolorizes it to such an extent that recognition is often impossible. The following procedure is therefore recommended : As soon as possible after the removal of the specimen, the small pieces for histologic examination should be excised and placed in their proper fixative, and then the whole specimen should be immersed in No. 1 Pick's solution without previous washing and before the surfaces have become dry. It is rarely necessary to make incisions, except in very large specimens. Open cavities should be stuffed with absorbent cotton to preserve contour. Closed cavities containing fluid may be aspirated and injected with the preservative. Cross-sections of tumors and organs, especially the kidney, usually show better if made after the specimen is taken out of No. 1 solution. No. 1 Pick's Solution: 50 grams artificial Carlsbad salts. 1000 c.c. distilled water. Dissolve, filter, and add 50 c.c. Schering's formalin. This solution should be freshly prepared for each specimen in ample amount. Specimens look grayish-red and should be kept in the solution from one to five days according to shape and size. They are then placed in 85 per cent alcohol from two to six hours, and the natural color returns. The specimen is now transferred to No. 2 solution in a large specimen jar, and after remaining there for a number of days it may be placed for permanent preservation in a smaller jar containing the same fluid. PATHOLOGIC EXAMINATIONS 245 No. 2 Pick's Sohitinn: 300 grams potassium acetate cryst. (c. p.). 1000 c'.c. distilled water. Dissolve, filter, and add (100 c.c. pure glycerin. For luuscvilar tissue reduce the amount of potassium acetate to 150 grams. If this method is carefully carried out, it is astonishing how well specimens are preserved in both color and contour. Pathologic Histology is often most important in surgical diagnosis, and frequently has a direct bearing on the prognosis. The successful outcome of the examination may be largely dependent on the prompt and proper care given the specimen, and for this reason it should be placed in the fixative as soon as possible after its removal from the body. The usual examinations for diagnosis are as follows: Small pieces of pseudoplasm excised for diagnosis. Small pieces excised from diseased tissue which has been removed by operation. When small pieces of pseudoplasm are excised for diagnosis, the method selected for preparing the specimen for microscopic examination will depend on the time available for this purpose. If the specimen is removed at the first stage of the operation, and the patient is kept under an anesthetic pending the result of the microscopic examination, or when rapid work is necessary for other reasons, the sections must be made with the freezing microtome. While the technic of frozen sec- tions has been much improved, the pictures which they present are satisfac- tory only when the structure is a clearly defined one, and continuous use of the method will demonstrate how frequently its results are unsatisfactory or meaningless. It is far preferable to use one of the embedding methods when time allows, as the sections are thinner and the microscopic picture is much more satisfactory. When the surgeon clearly understands the decided advan- tages of the latter method, the occasions for the use of the freezing microtome will be rare. . , , ,, Brief Instructions for Making Frozen Sections.— The simple table microtome with a strongly made freezing chamber, the vents of the latter being large enough to prevent clogging and back pressure, and the usual chisel-edged spade-like knife make a satisfactory apparatus. The so-called student's freezing microtome made by Jung, of Heidelberg, as shown m Fig. 48, is inexpensive and far superior to anything in the home market. It 'can be imported by any one of the supply shops. Compressed carbonic acid gas as a " freezing mixture" is convenient, rapid, certain, and cheap as compared with ether or rhigolene. The steel cylinder containing the hquid CO^ can be obtained in every city, and is usually loaned without charge to the - purchaser of the contents. As shown in the accompanying cut, the cylinder should be inverted and the outlet connected with the freezing chamber by means of heavj^ rubber pressure tubing wired to the nipples. The valve, which should be on a level with the freezing chamber, must be opened carefully, so as not to burst the rubber tubing. Permanent hospital equipments should not be made with iron pipe for obvious reasons. A small piece of the fresh specimen, not more than 4 or 5 mm. thick, is placed on the plate of the freezing chamber in a few drops of water and quickly 246 LABORATORY AIDS IN SURGICAL DIAGNOSIS frozen. After a few seconds, a numl3cr of sections are rapidly cut and removed from the knife by immersing it in water. A few of the best sections are placed for two minutes in 4 per cent formalin, for two minutes in 95 per cent alcohol, for two minutes in aljsolute alcohol, and then transferred to water. They are then stained with rnethylene-blue (saturated acjueous solution, half strength) for ninety seconds, washed in water, and mounted in glycerin. Thus the slide bearing a present- able section can be under the microscope within twelve minutes after the excision. More rapid methods are avail- able, but the results are usually most unsatisfactory. Brief Instructions for Making Embedded Sections. — Specimens embedded in celloidin or paraffin may be sec- tioned on one of the many microtomes in the market, the selection of the instrument depending largely on the amount of work to be done and on the expenditure. For diagnos- tic purposes, where the paraffin method is used, the stu- dent's microtome shown in Fig. 48, the use of the freezing chamber being omitted, is an excellent instrument and can be used for all purposes. The paraffin method usually leads to the best results, and the following description will be hmited to it:* A small piece of the tissue to be examined (about 1 cm. square, and 3 mm. thick) is placed successively in the following solutions: 6 hours or more 4 per cent formalin. 6 hours or more 80 per cent alcohol. 6 hours or more 95 per cent alcohol. 6 hours or more absolute alcohol 6 hours or more chloroform. 6 hours or more saturated solution paraffin in chloroform. 1 hour or more paraffin bath. Tii Fig. 48. — Freezing Microtome Made by Jung, of Heidelberg, WITH Liquid Carbonic Acid Gas Freezing Attachment. It is then embedded in paraffin, cooled, at- tached to the object- holder, and cut. The paraffin bath is better replaced by a small incu- bator kept at a steady temperature by a ther- mostat, according to the melting-point of the par- affin employed. The cut sections are placed on the surface of a dish of warm water, in order to remove all *For a more detailed account of this and other methods, the reader is referred to Mallory and Wright's "Pathological Technique," 3d edition, 1904. W. B. Saunders & Co., Publishers. BACTERIOLOGIC EXAMINATIONS 247 wrinkles, and the best ones are then attached to the microscopic sUdes, which hiu-e previously been coated with a glycerin albumen mixture (equal parts of white of egg' and glycerin thoroughly beaten and filtered, to which a few drops of carbolic acid may be added as a preservative). The excess is drained, and when the slide is dry, it is placed in the small incubator at about 58° C. for several hours. This will firmly attach the section to the slide. The paraffin is now removed by passing the slide through two or three changes of xylol, followed by absolute alcohol and then by 95 per cent alcohol. I^Iany simple and elaborate staining methods are now in use to serve par- ticular purposes, but for general histologic work the hematoxylin and eosin method serves most purposes. The section attached to the slide is now placed in water, and then stained from two to thirty minutes in Delafield's hematoxylin. Better results are oftentimes achieved by diluting this stain with water and staining the specimen for a longer period. Delafield's hema- toxylin solution is difficult to make, and that made by Grlibler can be purchased in anv supplv shop. After the specimens have been stained they are washed for several hours in frequent changes of water, or in running water for twenty minutes; they are then placed in a 0.2 per cent aqueous solution of eosin for about five minutes. This is followed by two or three changes of 95 per cent alcohol to remove the excess of eosin and for purposes of dehydra- tion. The specimen is now cleared in oleum origani and mounted in Canada balsam. As stated above, the microscopic pictures found in the different pathologic lesions are detailed elsewhere. BACTERIOLOGIC EXAMINATIONS These examinations form an important item in laboratory aids in diagnosis, and the heading is placed among these for completeness, but for details the reader is referred to the section on the subject. The bactenologic investiga- tions of practical value in clinical diagnosis are comparatively simple and should be in general use more than thev are. They consist chiefly m direct micro- scopic examination of secretions or excretions for bacteria, or, if the organisms are not present in sufficient numbers or the morphology is uncertain, m examination of cultures. Direct examinations are quickly made and the advantage of shdes instead of cover-glasses is again emphasized. For cultures, a small incubator heated by gas or electricitv should be employed. It is inexpensive, occupies but little room, and is easily cared for. If gas is used, a Dunham regulator (Fig. 2) is all that is required, the additional gas-pressure regulator being unnecessarv for clinical purposes. All varieties of culture-media may be ob- tained from any laboratorv, or from Parke, Davis & Co. Petri dishes for plate cultures are easily sterilized in the apparatus which every surgeon has m con- stant use. With the conveniences at home, the surgeon is likely to avail himself of them more frequentlv than if specimens are sent off to a laboratory. To cite a few pertinent practical examples: ]\Iiddle-ear secretion containing strepto- cocci is followed by mastoid involvement in over 90 per cent of the cases, whereas staphylococci, pneumococci, and colon bacilli show totally different figures. In other regions of the body a streptococcus infection usually calls tor more extensive surgical interference than the presence of other organisms. The value of a culture from the throat to differentiate the bacillus of diphtheria 248 LABORATORY AIDS IN SURGICAL DIAGNOSIS from streptococcus, and the necessity of a microscopic examination to dis- tinguish a gonorrheal ophthalmia from a benign one, need no more than brief mention. CHEMIC EXAMINATIONS The application of chemic analysis as a clinical laboratory diagnostic aid probably owes its delayed advancement to the time demanded by this work and the fact that the medical student was formerly not taught chemic technic to any extent. The great advances in recent years have brought about a necessary change, and a good chemic laboratory in the medical school is the result. Chemic methods of value to the surgeon are mentioned under the head of Specific Examinations. EXAMINATION OF THE BLOOD It is within comparatively recent years that hematology has emerged from its theoretic state into a science of practical utility to the clinician, and today it stands as a factor of prime importance to the surgeon in diagnosis as well as in prognosis. The technic of a thorough blood examination has also been simpli- fied to such an extent that it is within the reach of every one. If a blood examination is worth making at all, it is worth making not only well but thor- oughly, and the methodic worker is the one who does not overlook pathologic lesions not suspected by the cHnical history. For example, the mere leukocyte count of 45,000 has seemed to indicate an inflammatory process in the hver resulting in abscess. The surgeon about to operate and not satisfied with the appearance of his patient has the blood examined by an expert hematologist, with the result that a diagnosis of acute lymphatic leukemia is made, which explains leukocytosis, the patient's prostration, pain, temperature, and area of dullness, and practically excludes the presence of pus. TECHNIC OF EXAMINATION OF THE BLOOD A complete routine blood examination is urgently recommended in every instance, but some special work is reserved for special cases requiring the same. This is not the place for a detailed consideration of technic, but the subject will be briefly outlined.* Routine examination should include the following : Estimation of the amount of hemoglobin. Count of red corpuscles and leukocytes in 1 c.mm. of blood. Differential count of leukocytes and examination of stained specimen. Exceptional procedures are lodophilic reaction. Cryoscopy of the blood. Blood cultures. A number of these procedures are purposely omitted in the present study, as they belong to internal medicine rather than surgery. * The reader is referred to Cabot, "Clinical Examination of the Blood," or DaCosta, "Clinical Hematology." EXAMINATION OF THE BLOOD 249 Hemoglobin. — The estimation of the amount of coloring-matter is, from a scientific ])()int of view, the least satisfactory procedure in present day hema- tology, but it must be employed in the absence of better clinical means. Of the numerous methods in use, the ])are hemoglobinometer and the Tallqvist scale are worthy of mention. The Dare hemoglobinometer, as shown in the accompanying illustration, is the best instrument in use. The undiluted blood is drawn by capillary Fig. 49. — The Dare Hemoglobinometer. attraction between two glass plates which form a chamber of measured thick- ness. The color is then compared with the color plate, the two are matched, and the result read from a conveniently placed scale. The Tallqvist scale is not nearly so accurate as the above method, but is far preferable to no determination of hemoglobin at all. It consists of a series of standard tints representing a scale from 10 to 100 by tenths, and is used in Fig. 50. — Thoma-Zeiss Hemocytgmeter for Dilutions of 1 : 100 and 1 : 200. daylight. A large drop of blood is received on a piece of white filter-paper, strips of which accompany the color scale, and is then compared with the scale. In the estimation of hemoglobin the arbitrary normal is placed at 100 per cent, but our city dwellers rarely show this figure. The Fleischl appa- ratus, of which there are many in use, shows the lowest readings. Count of Red Corpuscles and Leukocytes. — The fresh blood is diluted in proportion of 1:100 or 1:200, the corpuscles in a given cubic space are counted under the microscope, and thus the number of corpuscles in 250 LABORATORY AIDS IX SURGICAL DIAGNOSIS 1 c.mm. is computed. For the purpose of dilution, the Thoma pipet made by Zeiss, as shown in the illustration, is the best one. The blood is drawn to the figure 1, and after the excess is carefully removed from the tip of the pipet, it is filled to the mark 101 with Toisson's solution, the resulting dilution being 1 : 100. Toisson's solution is made as follows: Methyl violet 5 B ' 0.012 Sodium chlorid 0.5 Sodium sulfate 4.0 Glvcerin, pure 15.0 Distilled water 80.0 After the dilution in the pipet is thoroughly mixed by means of the contained small glass ball, a number of drops are blown out and a small one is placed in the center of an absolutely clean Thoma-Zeiss containing chamber and quickly covered with the cover-glass of the apparatus, the presence of New- ton's rings indicating proper contact. The counting chamber having the B 0.10 Omm. !■ 11 1 Fig. 51. — Thoma-Zeiss Counting Chamber. A, Cross-section. B, Plan view. 1, Glass slide; 2, 2', tinted glass for support of cover; 3, cover-glass; 4, circular ruled glass disk. Actual chamber for blood is between 3 and 4. Elzholz ruling, as shown in Fig. 52, is preferable to that having the Thoma ruling, as both the red corpuscles and the leukocytes can be counted in the same specimen. A good plan is to count the red corpuscles in the small scjuares marked with dots in the illustration, and all the leuko- cytes in the entire ruled surface. The counting chamber is then cleaned and the procedure repeated. In this w^ay the red corpuscles in 120 small squares have been counted (for example, 1140), and the number in 1 c.mm. can be figured as follows : 1140 X (dilution) 100 X (cubic space of square) 4000 ^ (squares counted) 120 = 3,800,000 red corpuscles in 1 c.mm. of blood. The normal figures usually quoted are, males 5,000,000, females about 4,500,000, but perfectly healthy persons deviate from this rule. The leukocytes in the EXAMINATION OF THE BLOOJ) 251 equivalent of 7200 small squares have been counted (for example, 144), and the number in 1 c.mm. can be estimated as follows: 144 X 100 X 4000 ^ 7200 = 8000 leukocytes in 1 c.mui. of Ijlood. A table of 5000 blood specimens shows the following figures for healthy adults: Leukocytes in 1 c.mm. of blood from 5200 to 9600, the average })eing 0700. Differential Count of Leukocytes and Microscopic Examination of Stained Specimens..— 'iliis procedure is of the greatest importance in the diagnostic significance of hematology, and it is the feature which is most frequently neglected on account of its supposed difficulty and expenditure of time. As a matter of fact, the new staining methods and some experience make it the least tedious of the different steps in a routine blood examination. Fig. 52. — Elzholz Ruling of Counting Chamber. (Magnified 30 times.) Red corpuscles are counted in the squares marked with dots. Leukocytes are counted in entire ruled space. The smears are best made on slides instead of cover-glasses, and a Httle prac- tice results in thin and even specimens in which the corpuscles have not been injured by pressure. For the purpose of fixing and staining, these are placed for several minutes in a covered vessel containing Wright's stain, then removed and a drop or two of water added to dilute the stain adhering to the specimen. This is allowed to remain two or three minutes, and the specimen is then washed in water until it has a yellowish-pink color. The process of decolorization and differentiation is the objection to Wright's stain, but this can be avoided by making a mixture of Jenner's stain, 2 parts, and Wright's stain, 1 part. With this solution specimens are stained for 252 LABORATORY AIDS IN SURGICAL DIAGNOSIS several minutes, quickly washed in water, and dried with filter-paper. Micro- scopic examination of the slides shows the character of the red corpuscles, of nucleated ones if any are present, ])lasmodia, etc., and the differential count is obtained by noting the relative number of the different varieties of leukocytes, successively encountered by moving the slide with a mechanical stage; an actual count of 500 is usually sufficient. The table of 5000 examinations mentioned above shows a normal differ- ential count of leukocytes to be as follows : Leukocytes. Small Lymphocytes Large Lymphocytes Polynuclear Neutrophiles . Eosinophiles Basophiles Percentages. Low. 24.0 3.0 59.0 0.2 None High. 35.0 10.0 68.0 4.0 0.4 Average. 28.0 7.5 62.0 LO 0.2 Actual Number in 1 c.MM. Based on Average L e u k o - CYTE Count of 6700. 1,876 502 4,154 67 7 lodophilic Reaction. — In a number of pathologic conditions the pro- toplasm of the polynuclear cells has an affinity for iodin, and when stained Fig. 53. — Thatcher "Mosquito." with the reagent, shows an intense brown coloring with granules of even darker color, while the specimen without this affinity shows a slight yellow color only. The value of the reaction will be considered later. The test is applied as follows: A drop of the reagent is placed on the dry and unstained blood shde and a cover-glass applied. The specimen is examined under the microscope after a lapse of about three minutes. The reagent is easily made fresh for each examination by mixing 1 part of Lugol's solution with 2 parts of pure glycerin. Cryoscopy of the Blood.— The value of this procedure, as well as the technic of the same, will be detailed under the head of Urine Analysis. Blood=CUltures.— The direct search for bacteria in blood-smears is very rarely successful, and may be disregarded for practical purposes, but their EXAMINATION OF THE BLOOD 253 (Icinonstration bv cultuiv from the blood is of great importance especially in the matter of prognosis. The presence of streptococci makes the prognosis ex- ceecUno-ly gra^^^ while the presence of staphylococci is much more frequently olTowe^d b? recovery. Scrupulous care to prevent contamination of the culture is mperative, and many misleading results may be ascnbedto imperfect asepsis ThXnd of the elbow must be rendered thoroughly aseptic m the most stringen manner of the surgeon ; compression of the arm will distend the superhcia veins and render ^them more prominent. The hypodermic needle 0^^^^ previously sterilized Thatcher "mosquito," shown m Fig. 53, is now thrust into the vessel and the blood immediately flows into the receptacle. A previous small incision reduces to a minimum the hability to pick up organ- fsmsfrl the skin. One c.c. of blood is now added to 100--'^W "l^toT fluid culture-medium in a suitable flask, mixed, and placed m he incubator Three such flasks are usually prepared. Should a growth develop, the exac character of the organism is determined by transplantation and microscopic tm na ion, as detailed in the section on Bacteriology. The original use o fltiid culture-media will be found much more satisfactory than the use of solid ones, though plates made at once often give good service. CLINICAL SIGNIFICANCE OF BLOOD-CHANGES In the foflowmg enumeration the features of interest to the surgeon are given special attention, and topics belonging to general medicine ^^^ considered onlv if they are of value in surgical diagnosis and prognosis Two tables, however, are appended briefly enumerating the changes noted m blood diseases. Anemia and its Influence on Surgical Prognosis.-In view of the present state of hematology the arbitrary rule largely held, that no surgical procedure is to be undertaken when the percentage of hemoglobin is below oO, is in need of amendment. The determination of the amount of hemoglobin m those specimens poor in coloring-matter is very crude at best, and an opimon concerning the prognosis in any operation in a case of severe anemia is much better if based on the complete blood-picture, than if the necessarily crude estimate of the amount of hemoglobin alone is considered. The chlorotic giri with 30 per cent hemoglobin, 4^ miflion red corpuscles, a normal leukocyte count and a normal differential count, is certainly in a much better condition to wi'thstand an imperative operation than one having secondary anemia with 50 per cent hemoglobin, but only 2 million red corpuscles, a marked leukopenia, and a high relative lymphocytosis. ^..^.u^ Leul^ocytosis and Differential Count in Inflammation.— This is to the surcreon the most important feature in blood examination, and consequently deserves consideration at length. For a long time the number of leukocytes in a o-iven quantity of blood has been looked to as a guide for the exist^ence and severity of the inflammatorv process, with a view of determmmg the degree ot leukocytosis which shows inflammation without exudate or with serous noninfectious exudate, the degree with which a purulent exudate may be expected, and, finally, that which indicates a degree of systemic poison- ing that would make" any operative interference a hazardous Procedure. It was soon found that arbitrary limits could not be established, and that the presence of leukocvtosis was not invariable in suppurative conditions, partic- ularly in the fulniinating cases. This latter feature has been the greatest obstacle to progress, as it has discouraged observation. 254 LABORATORY AIDS IN SURGICAL DIAGNOSIS •2 go .2 « & .2 £d .. 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S n '7^ : m fO ■ G 43 ^ j:: J^ o o o o o o ^ o f^ -2o is oo o -- -213 O , •G .G ft ' ^ ^ G s r/J •rH 03 • F-* ■w ftf s ^ aj f-ibj ^ § ■S ^ tc 03 ^ tc 71 •r^ 03 c ft ft G -G .2 S ^ O •as o3 tc PI ft a. 2 •1-1 CO Ti o ^ o 03 -G S G ■ft^ 03 ,a o ^ '^ 2 03 pC S.2 >- c O .G W O.G ■^^ fee > 1"^, as tc 1/1 03 G X aj C3 aj ^ ft tH S J2 C3 JG +3 ft ^ s ft >: 03 ;>io3 aj Si -< fee EXAMINATION OF THE BLOOD APPROXIMATE DIFFERENTIAL COUNT OF LEUKOCYTES. 255 Leukocytes. ►J a 00 N < S o °3 OPQ n «-< •z o m 28% 35% 38% 7% 6% 6% 62% 58% 55% 1% , 1% 1% 0.2% 0.2% 0.2% h t; - Q < ^ 5 K w ^ 0. u; S P ^ H ^. H a O -^ «s K K W a 0- w o U) J:: 1-1 Small lymphocytes Large lymphocytes Polynuclear neutrophiles . Eoshiophiles Basophiles Myelocytes Eosinophilic myelocytes . . 42% 4% 50% 3% 0.2% 1% 4% 90% 4% 0.5% 2% 88% 5% 7% 0.2% 8% 3% 30% 6% 0.2% 45% 8% Leukocytosis is largely dependent on body resistance toward infection, and therefore the degree of increase can he no guide to the intensity of the 'pathologic process. Good resistance will produce pronounced leukocytosis even in slight infections, and poor resistance but little leukocytosis in slight infections, and possibly none at all in grave infections. No adequate clinical method exists by which this body resistance can be determined with sufficient accuracy to apply it as a factor in the leukocyte count, and this is the key to the disappointments encountered by the surgeon in utilizing these counts in diagnosis. It is also the reason why arbitrary leukocyte count standards indicating definite degrees of lesion cannot be fixed. At first a leukocytosis of 10,000 was looked upon as indicating the presence of pus, while more recently it has been stated that at least 35,000 leukocytes must be present before pus may be suspected, though pus is often present with much lower counts. It has been found, however, that the quantitative relation or differential count of leukocytes offers a better guide to the status of an inflammatory process than the mere presence of leukocytosis, with the additional advantage that it is not particularly influenced by body resistance. Furthermore the leukocytosis present with a given differential count is a direct indicator of body resistance. The particular point in question is the relative percentage of polynuclear neutrophiles. This percentage varies somewhat in health, as shown in the above table. Moderate fluctuations in the anemia accompany- ing most pathologic states as well as in the different stages of body resist- ance are also observed. These fluctuations, however, are within fairly narrow limits. A careful analysis of 1415 blood examinations in surgical cases shows three distinct blood pictures in inflammatory lesions, grouped as follows: 1. — A relative percentage of polynuclear cells below 70, with on inflam- matory leukocytosis of any degree, excludes the presence of gangrene or pus, at the time the blood examination is' made, and usually indicates good body resistance toward infection. Of the large number of instances, but two will be briefly mentioned, which will illustrate the point. No. 12,971. — A robust young woman. Red cells 4,900,000. Hemoglobin 82 per cent. Serous otitis media. Owing to extreme pain, condition of pulse, etc., acute mastoid disease suspected. Leukocyte count 28,400. Poly- nuclear cells 59.7 per cent. Clinical picture and leukocytosis would have 256 LABORATORY AIDS IN SURGICAL DIAGNOSIS indicated immediate operation, but the normal polynuclear percentage led the aurist to wait, and a prompt recovery without purulent exudate made opera- tion unnecessary. No. 13,610. — A boy, convalescing from severe attack of an acute infectious disease, presented a clinical picture of acute appendicitis and a leukocytosis of 25,100. While surgical interference seemed urgently indicated, the general condition made it a risk not to be incurred unless imperative. The polynuclear percentage of 63.5 induced the attending physician to wait, and while he spent anxious da^^s in which the clinical signs and blood picture remained stationar}-, resolution without pus or gangrene resulted, and the child was saved an opera- tion at a time when he was in very poor condition to stand it. 2. — An increased relative percentage of polynuclear cells, even with little or no inflammatory leukocytosis, is still an absolute indication of the inflammatory process, and the percentage is a direct guide to the severity of the infection. As above stated, in all the cases no pus or gangrene was ever observed with a polynuclear percentage below 70. In children, in whom the polynuclear percentage is norjnally lower than in adults, pus or gangrene has been observed with the percentage as low as 73. In adults a purulent exudate or a gangrenous process is decidedly uncommon with less than 80 per cent of polynuclear cells, and the probability of their presence increases with the percentage. Eighty-five per cent or over of polynuclear cells was never seen without a purulent exudate or gangrenous process irrespective of the leukocyte count. Ninety per cent of polynuclear cells has always indicated a very severe degree of cachexia, if the term may be used, and while one specimen of 95.2 per cent was seen where recovery followed operation, all other cases in which the percentage was over 94.5 resulted fatally. It is not wise to estab- lish narrow arbitrary limits, nor should this be attempted, but the above figures are based on the 1400 surgical cases studied in this way. This second type of increased polynuclear percentage is the most inter- esting one, as it particularly demonstrates the value of the advocated pro- cedure in cases that are usually in urgent need of operation on account of poor body resistance. The few cited cases will illustrate: No. 11,509. — A young woman in apparently good condition. Red cells 4,208,000. Hemoglobin 72 per cent. Severe pelvic cellulitis from strep- tococcus infection, and somewhat vague manifestations of an abscess, with a leukocyte count of 7200. Her serious condition could be explained clinically by the intensity of the inflammatory process, but the polynuclear percentage of 87 indicated the necessity for immediate operation, which revealed a large collection of pus. The operation was followed bv recovery. No. 12,331.— A rather feeble elderly lady. Red cefls 4,400,000. Hem- oglobin 70 per cent "^dth typic clinical evidences of appendicitis. The attend- ing physician and the consulting surgeon advocated operation, but the con- sulting physician advised waiting. Leukocytes 13.200. Polynuclear cells 82.4 per cent. ' Owing to the latter feature, the surgeon insisted on operating, and found a perforated gangrenous appendix and spreading general peri- tonitis. No. 13,702. — A young man apparently in good condition. Red cells 4,820,000. Hemoglobin 80 per cent; patient convalescing from an operation for purulent otitis media and mastoid involvement, began to have evidences of meningeal irritation, with but slight clinical manifestations of acute inflam- .,ao>I ,A ))i9iq Typic Blood Pictures in A. Normal blood. 1. Small lymphocyte. 2. Large lymphocyte. 3. Polynuclear neu- trophile. 4. Eosinophile. 5 Basophile. Red corpuscles all normal. C. Inflammatory leukocytosis with in- crease in polynuclear cells. Note large number of polynuclear neutrophiles. E. Chronic lymphatic leukemia. Note predominance of small lymphocytes. THE Following Conditions : B. Abnormal cellular elements found in blood. 1. Poikilocytes, microcytes and ma- crocytes. 2. Normoblasts. 3. Megaloblasts. 4. Myelocytes. 5. Eosinophilic myelocytes. D. Acute lymphatic leukemia. Note pre- dominance of large lymphocytes which stain rather poorly. F. Myelogenous leukemia. Note myelo- cytes and many nucleated red cells. PLATE 111 EXAMIXATIOX OF THE BLOOD 257 mation. Leukocyte count 11,900. Polynuclear cells 82.3 per cent. Im- mediate operation revealed large abscess, and patient subsecjuently died of meningitis. 3. — An increased relative percentage of polynuclear cells with a decided inflammatory leukocytosis. Most of the cases of inflammatory lesions, with or without purulent exudate, meet the specifications of this class. Here, as in the last series, the percentage of polynuclear cells was found to be an accurate guide to the status of the inflammatory lesion. The figures ciuoted above apply here as well. The body resistance toward the infection is a most miportant point, and the clinical manifestations are usually a good guide, but by no means an invariable one. Good resistance, marked leukocytosis; poor resistance, little or no leukocytosis, is the old rule. As stated above, the leukocytosis with a given percentage of polynuclear cells is one of the best indicators of this body re- sistance, when we accept the theory that the polynuclear percentage is the index of the degree of the inflammatory lesion. For example, a patient has an inflammatory lesion without purulent exu- date, and a polynuclear percentage of 75. If his leukocyte count is 25,000, the body resistance is much better than if the count is 10,000. Another case has an acute inflammation with abscess, and a polynuclear percentage of 84. If the leukocyte count is 30,000 the body resistance is much better than if the count is 15,000. The severely toxic patient with 92 per cent polynuclear cells is combating his disease with greater energy and success if he has 40,000 leu- kocytes in 1 c.mm. than if they are only 20,000; and should the leukocyte count be 7000, this is a clear indication of an absence of all systemic effort to overcome the infection. The following must be kept in mind: Few rules ever existed that have no exceptions. Inflammatory lesions belonging to the domain of general medicine, notaUij pneumonia, and severely toxic conditions such as scarlet fever show blood pictures which closely simulate those of surgical suppurative lesions. lodophilia. — This reaction, the technic for obtaining which has been detailed, is noted in the blood in all inflammatory lesions, and its presence as well as its intensity has been used as a guide to the character and severity of the inflammatory process. Personal experience teaches its inferiority as a guide to the degree and type of the inflammatory process as compared with the method detailed above. A distinct iodophihc reaction is always obtained in a pronounced leukocytosis, and may erroneously indicate a suppurative process, which error would be most likely in the class of cases enumerated in Group 1. Tuberculosis. — Lesions due to pure tuberculous infections, necrotic or otherwise, do not occasion a leukocytosis or change in the differential count, the blood usually presenting a picture of secondary anemia. If the tuberculous lesions are the seat of a mixed infection, the leukocytosis and differential count behave as they would if the additional microorganisms were present alone. It is often observed that tuberculous meningitis and tuberculous peritonitis seen in children present a leukocytosis and polynuclear increase, but the presence of a mixed infection to account for this is by no means excluded, though not invariable" found on examination. 18 258 LABORATORY AIDS IN SURGICAL DIAGNOSIS Malignant Disease. — It was hoped that the examination of the blood would present characteristics of pathognomonic value in the diagnosis of malig- nant disease, but up to the present this hope has not been realized. Carcinoma is usually accompanied by the evidences of a rather pronounced secondary anemia, and oftentimes on differential count, shows a leukocytosis and an increase in the percentage of polynuclear cells, which in the absence of a febrile movement is supposed to be of value in the diagnosis. When these features are found, they may be significant, but many cases of carcinoma fail to show them. It is believed that the leukocytosis and pohmuclear increase observed in these cases are due to a secondary infection, and thus may be a guide to the extent of the accompanying inflammation, but that they are no indication of the nature or severity of the primary lesion. Sarcoma is usviaUy accompanied by a secondary anemia also noted in carcinoma, and more frequently, but not invariably, shows a decided leu- kocytosis and polynuclear increase. The value and significance of these changes are believed to be the same as in cancer. In the differential diagnosis of gastric ulcer and gastric cancer the blood examination usually lends no conclusive evidence, but it is noteworthy that in ulcer a leukocytosis is rare, the secondary anemia seldom pronounced^ and a relative lymphocytosis common. In the differential diagnosis of obscure malignant disease and pernicious anemia, the following features are worthy of note, viz.: Pernicious Anemia. Carcinoma. Loss of red corpuscles greater than that of Loss of hemoglobin and red cells approxi- hemoglobin (low color index). mately equal, as in all secondary anemia. In number of nucleated red cells, megalo- If nucleated red cells are present, they are blasts always predominate. only normoblasts. Leukopenia common and differential count Leukocytosis common, and if present shows shows relative lymphocytosis. an increase in polynuclear percentage. Scurvy and allied conditions and pronounced jaundice are frequently associated with a marked reduction in the coagulability of the blood, which feature is of importance in contemplated surgical procedure. Determining the coagulation period is a rather tedious matter, and but little work in this direction has yet been done. The coagulometer of Wright is the best appa- ratus devised for the purpose. Acute Lymphatic Leukemia. — The general blood-picture in this disease has been outlined in the tables on preceding pages. In these cases a sudden increase in lymphatic tissue, interorganic hemorrhages, or both, with tem- perature and other clinical evidences, often closely simulate acute inflammatory lesions, and therefore are brought to the attention of the surgeon. Omission of a diagnosis by proper examination of the blood may lead to operative inter- ference for a supposed abscess, which can but hasten the invariably fatal out- come of this disease. While the leukocytosis encountered is usually much higher than that of inflammation, this may not be so, and a differential count is an absolute necessity in establishing the diagnosis. Chronic Myelogenous and Chronic Lymphatic Leukemia.— The gen- eral blood-picture in these conditions has been detailed in the tables. The only interest that they have for the surgeon is in the diagnosis of enlargements, glandular and otherwise, encountered in the body. Concerning the significance URINE ANALYSIS 259 of these diseases in surgical jtrognosis but little has been written, ])robably because operations are rarely undertaken. Personal observation of the writer is limited to parturition in two cases of the myelogenous form. Both had nor- mal confinements, one a brisk but short postpartum hemorrhage. A moderate febrile movement was noted in both during the postpartum period of several weeks, without sepsis or change in the blood-picture. The parturition did not seem to alter the general condition. As the diagnosis in both was not made until the time of parturition, no data are at hand as to the duration of the disease or the influence of the pregnancy on it. Both children were well nourished and perfectly normal. Hodgkin's disease or pseudoleukemia is of interest here on account of the differential diagnosis from 13'mphatic leukemia; the details of the blood-pictures have been enumerated. The differential diagnosis of pseudo- leukemia and lymphosarcoma is often difficult, but the latter is likely to show a greater degree of secondary anemia, less relative lymphocytosis, and frequently a leukocytosis with polynuclear increase. BIood=pressure. — The determination of the blood-pressure by means of the Riva-Rocci or similar apparatus has been found to be of considerable value, but it is a clinical rather than a laboratory procedure. URINE ANALYSIS In consequence of the increased value of this procedure during late j^ears, its technic has undergone change and improvement. At one time the clinician believed that, when he had found the specific gravity, had tested the urine for albumin and sugar, and had made a hasty microscopic examination of the sediment, he had exhausted all practical information to be obtained from this complex fluid. Today an examination of this kind is not considered sufficiently exhaustive to meet the exacting demands of the expert diagnos- tician. The general idea formerly held, that the presence of albumin indicates a nephritis, and that the finding of granular casts means the presence of chronic renal disease, must be alDandoned. Albumin may be found in the urine without a true nephritis, and, on the other hand, a nephritis does not necessarily mean that albumin is constantly present. The same applies to the presence of casts; many granular casts may occur in convalescing acute nephritis and perfect recovery result, and, on the other hand, cases of advanced but ciuiescent chronic nephritis may show no casts for long or short periods. In the following consideration of the subject the clinical significance of the latter to the surgeon is kept constantly in mind ; the portion belonging to general medicine is alluded to when it seems necessary, and the technic is elaborated only where experience teaches its advisability. The cardinal points in urine analysis are the selection of a proper specimen and a methodic routine anah'sis. In most instances a twenty-four hour speci- men should be insisted on, as it presents many significant points not learned in any other way, and careful instructions to begin and end the period of twentv-four hours with an empty bladder and to prevent loss at stool are usualh' necessary. If methodic routine analysis is not constant, important unsuspected conditions may be overlooked ; for example, owing to the omission 260 LABORATORY AIDS IX SURGICAL DIAGNOSIS of a test for glucose because the specific gravity created no susjjiciou in this direction, a case of postoperative cUabetic coma may be a disagreeable surprise. Before considering the typic and atypic pictures presented by the urine in the more important surgical diseases, there are a few general considera- tions which merit comment. THE QUANTITY OF URINE The normal cjuantity of urine is, generally speaking, from 1000 c.c. to 1200 c.c, though persons in perfect health regular!}' pass smaller or larger amounts, owdng to the fact that they habitually take smaller or larger amounts of fluid during the clay. Polyuria, or an increased daily amount of urine, may be due to phy,siologic or pathologic causes. Aside from the common pathologic causes, diabetes mellitus, so-called diabetes insipidus, neurotic diseases, that following acute feb- rile diseases, chronic nephritis of atrophic type, and other conditions belonging to general medicine, the causes which particularly interest the surgeon in diagnosis are (1) the polyuria clue to diuretics and the ordered intake of much fluid; (2) pyelitis from any cause; (3) a previously removed kidney; (4) compensatory polyuria due to occlusion of one ureter; (5) the polyuria seen with myelomas of bone and an excretion of Bence-Jones albumin . Oliguria, or the diminished excretion of urine, is noted in febrile diseases, cardiac insuf- ficiency, acute nephritis, and in many other conditions which belong to the domain of general medicine. The causes which interest the surgeon are (1) the post-operative oliguria, especially if hemorrhage has been profuse; (2) the oliguria noted immediately after the removal of one kidney, which is soon followed by a polyuria; (3) the fact that a unilateral painful lesion in or about the kidney, without obstruction to the flow of urine, may produce a decided reflex oliguria. This should be noted particularly. Anuria, or the absence of renal excretion, is an exaggerated form of oliguria, and is due to the same causes. ALBUMIN In testing for albumin the methods selected should be such that not only serum-albumin but also nucleo-albumin, albumose, and Bence-Jones albumin are revealed at the same time. Absolute accuracy in this regard calls for the use of many tests not feasible as a surgeon's routine procedure, but for general clinical routine work the use of two tests is advised — the heat and nitric acid test and the nitric-magnesium test. The heat and nitric acid test should be made as follows: A test-tube three-quarters full of perfectly clear filtered urine is inclined at an angle of 45 degrees, and the upper inch heated by means of a Bunsen burner or an alcohol lamp. A turbidity which develops on heating and continues to increase may be due to phosphates, serum-albumin, Bence-Jones albumin, nucleo- albumin, or albumose. If this turbidity disappears in a large measure or altogether when the boiling-point is reached, albumose or Bence-Jones albumin is present. When the specimen is boihng, a few drops of nitric acid are added, which will dissolve the phosphates and increa.se the turbidity due to serum-albumin. Comparison with the lower part of the test-tube containing URINE ANALYSIS 261 \hv uriiu' whicli has not been heated will show faint traces, especially if a black screen is held between the test-tube and the light . ( )n cooling, the turbidity due to nuu'in, albumose, or Bence-Jones albumin recurs. If a reaction other than that for serum-albumin has been obtained, it must be corroborated Ijy specific tests.* The nitric-magnesium test is a cold test, made by contact of the urine with the reagent. This may be made in any one of the many ways taught in the laboratory, but the albuminometer shown in the accompanying cut (Fig. 54) is a handy instrument for this test and can also be used for the numerous other contact tests made by the clinician. The clear glass instrument is pref- erable to one with a black and a white background painted on it. The clear filtered mine is poured into the large tube until this is about half full. The reagent is poured into the small funnel-end tube until this is not cjuite full. The latter makes its w^ay beneath the former and a clean line of contact results. Serum-albumin shows a turbidity at the junction of the urine and reagent . Mucin or albumose shows an opalescent, not clearly defined turbidity above the junction, in the urine. These reactions are more clearly seen by placing any black object behind the instrument. The nitric-magnesium reagent is made as follows : Saturated aqueous solution magnesium sulfate. .100 c.c. Nitric acid 20 c.c. The quantitative determination of albumin if absolute accuracy is essential, is a rather tedious laboratory procedure. For clinical purposes, however, this is rarely necessary, and the results obtained by use of the E s b a c h albuminometer (Fig. 55) meet most of the requirements. The method is very simple, and is briefly as follows : The tube, as shown in the illustration, is filled to the mark U with filtered urine, acidulated if necessary with acetic acid, and then filled to the mark R with reagent. It is closed with a rubber stopper, inverted twelve times, and set aside in a cool place for twenty-four hours in a vertical position. The amount of albumin is read from the scale, which indicates grams per liter, or parts per thousand by weight. The specific gravity of the urine should be not higher than 1010, and the amount of albumin present should not exceed 4 per mille (parts per thousand) by weight — if it exceeds this the specimen should be diluted with water. It is a good plan to make a preliminary examination in an ordinary test-tu]_^e to estimate approximately the amount of all^umin and exclude the presence of a considerable amount of albumose which is redissolved by heating the mixture. If considerable albumose is present, the method should not be used. Esbach's reagent is made as follows: Picric acid (c. p.) 5 grams Citric acid 10 grams Dissolved in distilled water 500 c.c. and filtered. * For a detailed description of these tests the reader is referred to Simon's "Clinical Diagnosis," 5th edition, 1904, or to some other good work on clinical chemistry. Fig. 54. — Albuminometer. 262 LABORATORY AIDS IN SURGICAL DIAGNOSIS GLUCOSE AND ALLIED SUBSTANCES In routine work these substances are likely to be recorded simply as sugar, whereas one or another of the usual tests for glucose also responds to other substances. This matter is of interest to the surgeon, as the presence of glu- cose in the urine is often the first sign he has of the existence of a complicating true diabetes. Gh^curonic acid and pentose are chiefly of interest, as these also respond to the copper test, and may mean only a slightly disturbed body metabolism. In testing for sugar in a routine way, two methods should be used, the cop- per test and the bismuth test. Fehling's solution is the copper test com- monly employed, but it is objectionable because it must be kept in two solu- tions and needs mixing up for use, whereas Haines's solution is an equally sensitive test, needs no dilution, and keeps for a long time. Haines's test is made as follows: A few drops of urine are added to a dram of reagent and boiled. If sugar is pres- ent the characteristic copper reduction takes place. Haines's solution is made as follows: Cupric sulfate (c. p.) 3.0 Glycerin, pure 23.0 Distilled water 250.0 Dissolve and add potassium hydrate, pure 11.0 The bismuth test needs no comment. Both tests are made more sensitive by placing the tubes in a water-bath after simple boiling shows no reaction. The quantitative estimation of glucose is usually made by means of the fermentation test or Fehling's test. The objection to the former is the time required, and to the latter the indefinite end-reaction. The Rudisch quantitative test is -7|« recommended on account of its simplicity and accuracy : 1 c.c. '5 |B of urine measured with a volumetric pipet is placed in a 500 c.c. -4 IB Erlenmayer flask and 100 c.c. of distilled water are added. -3fB j}-^ig jg placed on a tripod with a white background, and heated. On boiling, the reagent is added in small amounts from an ordi- nary or a Bincks buret, until the faint blue color does not dis- appear on two minutes' boiling. Each cubic centimeter of reagent used equals 0.0011 gram of sugar in 1 c.c. urine. The result multiplied by 100 gives the percentage, or the result Fig. 5.5.— Es- multiplied by the number of cubic centimeters of urine voided MmoMETlH. in twenty-four hours gives the amount in grams of glucose excreted in twenty-four hours. Example: 3000 c.c. urine voided in twenty-four hours. Test shows use of 23.2 c.c reagent. 23.2 X 0.0011 = 0.02552 gram glucose in 1 c.c. X 100 =2.552%. 0.02552 gram glucose in 1 c.c. X 3000 c.c voided =76.56 grams glucose excreted in twenty-four hours. The volumetric sugar test solution is made as follows: Cupric sulfate crj^st 4.78 grams Sodium sulfite cryst 50.0 grams Sodium carbonate cryst 80.0 grams Ammonia water (10%), to make 500 c.c. URINE ANALYSIS 263 In order to exclude glycuronic acid or licntose, which would also respond to the above tests, a fermentation test is made. If this is positive, glucose is present; if it is negative and the copper and bismuth tests were positive, glycvu'onic acid or pentose is present. For corroborative tests for these sub- stances the reader is referred to special works. UREA While the value of the knowledge of the daily excretion of urea has been the subject of much discussion, it is certainly true that a ciuantitative test for urea made on a single specimen passed at any time of day is an absolutely useless procedure. The really absurd record of grains of urea per ounce must be replaced by a statement of grams excreted in twenty-four hours, and even then the clinical value is not nearly so great as we formerly supposed. The text- book statement that a healthy male excretes from 25 to 40 grams of urea in twenty-four hours is also wrong. From 16 to 28 grams are much more correct figures, and from the surgeon's point of view an average of 16 grams should be considered the normal minimum. CHLORIDS In the efforts to determine renal functional ability by the new methods devised for this purpose the quantitative estimation of the chlorids in the urine has assumed new importance. In this connection it is well to state that the method by direct titration with decinormal solution of AgNOg is very faulty, and, in order to secure results which merit any consideration, the method by incineration or other more accurate procedure must be used. MICROSCOPIC EXAMINATION OF URINE The great value of the centrifuge for precipitation of the sediment, aside from its time-saving advantage, is established. While it w^ould be folly to belittle the information gained from the character of the epithelial cells in a urinary sediment, too zealous effort to establish the origin of individual cells or groups of the same must be discouraged, and the opinion as to the character and seat of a lesion is better if based on the many characteristic general, chemic, and microscopic features presented by the specimen. FUNCTIONAL DIAGNOSIS This name has been given to a variety of procedures the aim of which is to determine whether the kidneys are doing normal excretory work. j\Iuch of what has been advocated has proved decidedly useful, though not infallible. The most important procedures advocated at present are the following: Cryoscopy of the blood, to determine molecular concentration. Cryoscopy of the urine for the same purpose. Inducing artificial glycosuria, separate collection of urine from each kidney, and examination. Ingestion of anilin dyes for the same purpose. Thorough analysis of twenty-four hour specimen of urine, preferably repeated. 264 LABORATOKY AIDS IN SURGICAL DIAGNOSIS Cryoscopy of the Blood, to determine its molecular concentration, is accomplished by learning the depression of its freezing-point as com])ar('d with that of distilled water. The normal molecular concentration of the blood causes it to freeze at minus 0.56° C, the freezing-point of distilled water being zero. In renal insufficiency the solids which should normally be excreted are retained in the circulating blood in abnormal amount, increasing its molecular concentration and thus lowering its freezing-point. This procedure is of very decided value to the surgeon as an aid in diagnosis and prognosis, and merits the consideration on this side of the Atlantic that it enjoys in continental Europe. It is an important factor in the prognosis when a diseased kidney is to be removed ; it lends much weight in deciding whether a kidney should be removed or not ; it forms an important element in the prognosis after one kidney has been removed, and it is of decided value in estimating the functional ability in bilateral kidney disease, thus influencing the prognosis of any operative procedure on persons thus afflicted. A normal freezing-point of the blood indicates normal renal excretory ability; if one kidney is diseased or destroyed, the other is doing the compensatory work. A reduction in the freezing-point to minus 0.58° C. or minus 0.61° C. indicates that both kidneys are unable to excrete sohds properly. These data should be corroborated by all available methods, just as in other diagnostic and prognostic investigation. Cryoscopy of the Urine, to determine the molecular concentration of the twenty-four hour specimen, was at one time advocated as an additional guide in estimating functional renal ability, but experience teaches that the wide variations met in health and disease without renal insufficiency (minus 0.9° C. to minus 2.0° C.) make a trustworthy conclusion based on this procedure a difficult and scarcely feasible matter. This test, applied to specimens of urine separately collected from each kidney, furnishes much more satisfactory results that are of great help in determining which is the diseased kidney, and in estimating the degree of its functional impairment. The decreased molecular concentration noted in the specimen obtained from the diseased kidney is often much more marked than the decreased specific gravity and the lowered relative amount of urea and chlorids would lead one to believe. The ordered intake of an unusual amount of fluid before ureter catheterization makes the procedure less tedious to both surgeon and patient, but it jeopardizes the value of the subseciuent analysis and absolutely destroys the significance of cryoscopy of these specimens, as the healthy kidney may excrete water more rapidly than the cUseased one, though the latter is comparatively impervious to solids. Even the polyuria of neurotic persons, under the circumstances, should be inhibited as far as possible by a sedative or narcotic. (The technic of crvos- copy is detailed below.) Inducing Artificial Qlucosuria. — The method of inducing artificial glu- cosuria, separately collecting urine, and determining the percentage of sugar excreted by each kidney is also used as a guide to functional ability. Phlorid- zin, 0.005 gram, is given by hypodermic injection before ureter-catheterization. This method never gained popularity in America and no longer enjoys universal support abroad. Requiring the patient to ingest methylene-blue or other anilin dyes, and observing the time intervening before the color appears in the urine, as well as the intensity of the color, or separately collecting the urine from each kidney and afterward comparing the specimens, is another method URINE ANALYSIS 265 whu'li uMi. .. iiulicates the decree of functional ability. This method never had a scientihc basis and has been largely abandoned. Electric conductivity of the urine and blood has been advised as an additional means of estimating functional abilitv of the kidneys, but as the results are also based on molecular concentration, tJiev are for practical puroses identical with cryoscopy. Uro= toxic coefficent "(B ouch a r d) is not yet sufficiently precise to be recom- mended as a practical procedure, to say nothing of the difficulties attending the use of the method. Conclusions.— A perfectly normal urine, including normal daily excre- tion of urea and chlorids, justifies the conclusion that proper eUmination exists. If corroborati\'e evidence is desired for any reason, such as severe opera- tive interference, or if a previous renal lesion creates a doubt, cryoscopy of the blood should show normal figures. In unilateral renal disease indicating a nephrectomy the followmg steps to determine functional ability are indicated and materially aid in determinmg the advisabilitv of operation and the prognosis. If a twenty-four hour specimen of urine contains at least 16 grams of urea, and if the freezmg- point of the blood is normal (minus 0.56° C), it is evident that the sound kidney is capable of compensatory elimination and the diseased one can be removed with safety. Separate collection of urine from each kidney by ureteral catheterization or other means and the demonstration by cryoscopy, specific gravity, relative amount of urea and chlorids, that the diseased kidney is doing but little excretory work compared with the sound one, strengthens the above conclusion. A diminution in the daily excre- tion of urea below 16 grams, and any increase in the molecular concentration of the blood shown by a lower freezing-point (minus 0.58° C. to minus 0.61° C), indicates that both kidneys are unable to eliminate properly and that the removal of one is a far more serious matter. K li m m e 1 1 and others consider a daily excretion of urea below 16 grams, and a blood freezing-point of minus 0.59° C. absolute counterindications to nephrectomy, and show greatly improved statistics of renal surgerv in consequence. Technic of Cryoscopy.— Either the Beckmann thermometer or the Heidenhain modification may be used. Both are graduated in hun- dredths of a degree Centigrade and the graduations are wide enough apart to allow readings of 2^0 of a degree. Sufficient distilled water (10 to 20 c.c.) to cover the bulb of the thermometer is poured into a glass cylinder, and this cylinder is placed in another slightly larger one, so that an air space is made between the fluid and the freezing-mixture, which insures gradual cooling. The tubes are now put into the freezing-mixture of salt and ice and the ther- mometer into the fluid to be frozen, where it is held in place by a rubber stop- per which also carries a platinum stirrer, bent in such a way as not to touch the sensitive thermometer. The apparatus is most conveniently set up as shown in the accom- panving illustration (Fig. 56), so that, by loosening the set-screw of the ferrule on the rod of the stand, the whole apparatus can be elevated above the level of the freezing-mixture in the glass battery jar. Constant stirring with the platinum wire is necessary; the mercury in the thermometer rapidly falls considerably below the freezing-point, when it suddenly jumps up, and momen- tarily rests at the freezing-point, which must be accurately noted. It now falls slowly to the temperature of the freezing-mixture. Several precautions must 266 LABORATORY AIDS IN SURGICAL DIAGNOSIS J. (H be observed: (1) The freezing-point of distilled water as described above must be obtained before every examination. (2) The described jump of the mercury must occur if the technic is proper, when testing the water as well as when test- ing blood or urine ; if it does not take place, the specimen has not been properly stirred. (3) The bulb of the thermom- eter must not come in contact with the container or the stirring wire. (4) The LJ-shaped glass cylinder is preferable to a |_J -shaped large test-tube, as more thorough stirring is possible. The specimen to be examined is tested in the same way and the difference be- tween the freezing-points obtained indicates the molecular concentra- tion. For example, the freezing-point of distilled water under existing con- ditions of atmosphere and Beckmann thermometer is, we will say, 4.015° C, while that of a specimen of blood is 3.455° C: 4.015—3.455 =—0.56° C, the freezing-point of the specimen of blood. The blood is most conveniently obtained from one of the large veins at the bend of the elbow by means of an aspirator, or preferably by using Thatcher's ''mosquito," shown in Fig. 57. Technic in Examining Small Amounts of Urine as Obtained by Ureteral Catheterization. — As the collection of urine under the circum- stances is a tedious matter to both sur- geon and patient, the analyst must arrange to obtain his information from very small amounts. With care and practice it is surprising how much can be done with little urine, and 10 c.c. of urine usually suffices, though every ad- ditional drop makes the procedure an easier one. The specific gravity is first taken with a Westphal balance, and the whole is then centrifuged to obtain the sediment for microscopic examina- tion. After removal of the sediment, the whole may be accurately diluted with distilled water at a given temper- ature, and the amount is next divided for the tests for urea, chlorids, albumin, etc. Precision is essential, as errors are liable to be greater owing to the small amounts of the specimens used. Fig. 56. — Apparatus for Crtoscopt. URINE ANALYSIS 267 Hematuria, or the presence of blood in the urhie, is a frequent symptom, the cause of which the surgeon is asked to determine. Chnical methods have made great headway, and the present universal use of the cystoscope makes the diagnosis a much easier one than it was twenty years ago. The character- istics presented by the urine are, however, worthy of close attention, and while its critical examination will not reveal the seat of the bleeding in every in- stance, much information of value is always obtained. That the more arterial the color of the blood, the lower in the urinary tract is its origin, is an old rule. This holds good except in some cases of severe hemorrhage from renal neoplasm, and in that seen in renal traumatism. In vesical, prostatic, and urethral hemorrhage the blood usually shows immediate tendency to coagulation, whereas in renal hemorrhage it is more intimately mixed with the urine and coagulates only when the bleeding has been profuse. In hemorrhage from the renal pelvis due to calculus, etc., unless very profuse, the blood is intimately mixed with the urine, and is much brighter in color than that in the smoky hematuria of acute inflammatory lesions of the renal parenchyma. The microscopic ex- amination of the urine often shows evidences of the diseased condition which is the cause of the hemorrhage, and in this case it is reasonable to infer that the bleeding is of the same origin . Pyuria, or the presence of pus in the urine, is also a frequent symptom, the cause of which the surgeon is asked to determine. As in the case of hematuria, the cysto- scope and other clinical methods are of much value in the diagnosis. The methodic analysis of the urine is also an important feature, as shown below, and the structural elements accompanying the pus, as well as many general characteristics presented by the twenty-four hour specimen, usually justify an inference as to its origin. Pus of vesical or prostatic origin usually undergoes coagulation quite rapidly, while that from the kidney is more intimately mixed w4th the urine and remains diffused throughout the specimen. Post=anesthetic nephritis is today a much less frequent condition than it was fifteen years ago, an improvement which can doubtless be ascribed to the more careful use of anesthetics, quicker operating, the free administra- tion of water by mouth or rectum after operation, and proper early attention to the bowels. There are but few cases in which a faint trace of albumin with or without few hyaline or epithelial studded casts cannot be demonstrated after anesthesia, due to some renal hyperemia. Comparatively few cases present all the characteristic evidences of an acute toxic nephritis. Diminished quantity of urine, high specific gravity, high relative and low absolute excretion of urea and chlorids, the presence of albumin, often in large amount, with a profuse sediment consisting of blood, a few pus-cells, and all varieties of casts, are the prominent symptoms. If the patient's general condition is good, Fig. 57. — Thatcher "Mosquito 268 LABORATORY AIDS IN SURGICAL DIAGNOSIS post-anesthetic nephritis iisuaUy responds to treatment more quickly than in the case of nephritis as ordinarily met with in medical practice. Every surgeon of considerable experience recalls a case in which the use of an anesthetic was followed by an absolute anuria and death. Pathologic examination reveals an intense hvperemia, but this seems scarcely sufficient to explain the clinical condition, especially if the patient presented no evidences of a previous renal lesion. Acute and Chronic Nephritis and Its Influence in Surgical Prognosis. — This is a question which not infrequently confronts the surgeon, and while the clinical manifestations of this complicating disorder merit close attention, much information is obtained l^y laboratory methods. A thorough and pref- erably repeated examination of the urine, not omitting quantitative determi- nations of the daily amounts of urea and chlorids, offers a good guide to the status of excretory abihty. The more recently advocated cryoscopy of the blood can be warmly recommended, and if the freezing-point is found below minus 0.56° C, the prognosis of the contemplated surgical procedure becomes affected in direct proportion to the freezing-point depression. Chloroform employed as an anesthetic is less irritating to the kidney than ether, but any anesthetic agent is liable to produce some exacerbation of the renal inflamma- tion. Diabetes Mellitus and Its Influences in Surgical Prognosis.— The presence of true diabetes as distinguished from simple glucosuria, glucuronic aciduria, and pentosuria, always exerts a decided influence on the prognosis in contemplated operative interference. It is a serious error to judge the severity of this disease by the percentage of glucose, or the quantity of sugar excreted in twenty-four hours, as the most dangerous cases sometimes excrete a com- paratively small amount of glucose at the time. Careful examination for evidences of acid intoxication, as shown by the presence of acetone, diacetic acid, and beta-oxybutyric acid, must be made, as this constitutes the best guide in determining the prognosis. The patient who is excreting a large amount of glucose without acetone or diacetic acid in the urine, is a much better subject for the surgeon than the patient who shows but very little glucose with larger amounts of acetone, diacetic and beta-oxybutyric acids. Evidences of Toxemia, Before and After Operations.— A fairly constant train of symptoms is at times associated with surgical lesions which cannot be referred to the pathologic process, and is now ascribed to faulty metabolism or toxemia. The causative factor is unknown, but the clinical manifestations are, briefly, severe headache, malaise often amounting to somno- lence, and vomiting, usually with considerable nausea. It was originally be- lieved that all these symptoms were referable to some local disorder in the stomach or bowel, and while it is true that- the toxin may originate there, a cause for such development is not apparent. The evidences in the urine would tend to divide the cases into two classes: (1) A decided increase in the daily amount of uric acid, as shown by a lowered urea and uric acid ratio, and the presence of acetone, diacetic acid, and sometimes beta-oxybutyric acid. (2) A decided increase in the daily excretion of indoxyl sulfate and skatoxyl sul- fate, as shown by pronounced indican and skatol reactions in the urine and a lowered ratio of mineral and ethereal sulfates. A combination of both is, however, frequently seen, and, as a rule, the first described class presents the most pronounced sj^mptoms. URINP] ANALYSIS 269 Acute Cystitis. — The (lail>- amount of uriiic, (he density, and the daily excretion of solids are normal, and the amount of albumin present corre- sponds to what might be accounted for by the blood, pus, etc. A microscopic examination of the sediment shows blood, pus, mucus, and many epithelial cells referable to the bladder. At first the reaction is usually acid, but it may become alkaline with the addition of triple phosphates in the deposit, unless the colon bacillus is the causative factor, in which case it remains acid and has an offensive odor. Elements of other causative factors can also usually be demonstrated. Chronic Cystitis. — The urinary picture is much the same as in acute cystitis, but there is usually no blood present. If the lesion is tuberculous or due to the colon bacillus, the reaction is usually acid, but otherwise an alkaline fermentation develops in the bladder and many triple phosphate crystals will be found in the sediment, the specimen having a very offensive odor. A differential diagnosis of chronic cystitis and pyelitis with hyperemia of the renal parenchyma is not always easy, because a cystitis so frequently accompanies the pyelitis. Chronic Cystitis. Pyelitis with Hyperemia. Daily amount of urine . . Normal. Increased. Specific gravity Norinal. Lowered. Daily amount of solids . . Normal. Normal. Reaction Alkaline. Acid. Albumin According to amount of pus. More than pus would account for. Sediment Coagulates quickly. Diffuse, not coagulated. Renal elements None. Few casts, and epithelial cells from pelvis. Pus due to cystitis always shows many structural elements referable to the bladder, wdiile pus due to pyelitis shows but few epithelial cells at best. Acute Catarrli of tlie Renal Pelvis. — The urinary picture is somewhat different according as this lesion is due to a local cause or to an ascending infection. In the event of a local cause, such as calculus or pronounced crystal- line deposits, the daily amount of urine is decreased, there is corresponding concentration, normal daily output of solids, blood-cells according to the amount of local abrasion, few leukocytes, some mucus, characteristic groups of epithelial cells, and an amount of albumin and casts according to the degree of hyperemia of the parenchyma, some evidences of which invariably accom- pany the condition. In the event of an ascending infection, pyogenic, gonor- rheal, or colon bacillus, the urine, showing the evidences of the original bladder lesion, suddenly becomes scanty, with some increase in the amount of albumin, the presence of few casts, and, if one is fortunate enough to recognize them, epithelial cells referable to the renal pelvis, with a normal daily output of solids. In either case this condition does not last long; the evidences of the acute catarrh disappear or the picture soon becomes that of pyelitis. Pyelitis with Hyperemia of the Renal Parenchyma. — The daily amount of urine is increased, the specific gravity lowered, and the daily excre- tion of the solids is normal. The microscopic picture shows pus in addition to the elements found with catarrh of the pelvis. The pus usually also shows the characteristics of its renal origin, as detailed under the heading of Pyuria. 270 LABORATORY AIDS IN SURGICAL DIAGNOSIS Pyelonephritis. — The twenty-four hour specimen of urine presents features siniihir to those noted in pyelitis, with the addition of the elements referable to the lesion of the parenchyma, i. 1': OF URINARY PICTURE IN THE MORE IMPORTANT SUIIGICAL DISEASES OF THE URINARY TRACT. Daily Specific Daily Abnormal Constituents. Disease. Amount of UlUNE. Reaction. Amount of UnEA. Gravity. Albumin. Microscopic. Acute cj'stitis. Normal. Normal. Acid, occa- .sionly al- kaline. Normal. Equal to a m o u n t , pus a n d blood. Blood, pus, mucus, and many blad- der epithelial cells. Evi- dences of the causative factor. Chronic cystitis. Normal. Normal. Alkaline unless colon ba- cillus or tubercu- losis. Normal. Equal to amount of pus, etc. No blood, otherwise as above. Also bacteria, and if alkaline, triple phos- phates. Evi- dences of causative factor. Acute catarrh Decreased. High. Acid. Normal or More than Blood, pus, of renal pelvis dimin- blood and few pelvic with hyper- ished. pus would epithelial emia of the Usually account cells, few parenchyma. increased if stone. for. hyaline or epithelial casts. Hem- aturia with stone colic. Evidences of causative factor. Pyelonephritis. Increased, Low. Acid Normal if Consider- No blood, particu- unilater- ably more otherwise larly in al, other- than 23US, as above. tubercu- wise de- etc., would Larger num- losis. creased. Usually increased if stone. account for. ber of casts also granu- lar. In tu- berculosis and neo- plasm usu- al 1 y few blood-cells, occasionally hematuria. Evidences of causative factor. EXAMINATION OF SPUTUM Specimens must be considered both macroscopically and microscopically; the former ma}^ show a typic picture of pulmonary gangrene by the offensive odor and the presence of pieces of necrotic tissue, while the latter may give the 19 274 LABORATORY AIDS IN SURGICAL DIAGNOSIS first indications of pulmonary tuberculosis. The following conditions are those of chief interest to the surgeon : Hemoptysis due to perforating aneurism may present simply a large amount of arterial blood, with or without the history of a previous catarrhal condition due to pressure and necrosis. An eroded carotid artery rupturing into an open retropharyngeal abscess presents the same picture. Abscess of Lung. — The expectoration may consist solely of pus, with little or no odor, which is raised in very large amounts, often as much as a pint in twent3'-four hours, structural elements, blood-cells, elastic fibers, fat glo- bules, crystals of fatty acids, etc., also being found microscopically. Staining usually shows many nonpathogenic organisms in addition to pyogenic forms, chiefly the staphylococcus. Chronic lung abscesses present much the same picture, with the occasional addition of cholesterin as seen microscopically, but no blood. In abscess of the lung evidences of actinomycosis and echinococcus should always be looked for. Empyema Rupturing into the Lung. — The specimens as well as the sudden manner of expectoration resemble what is seen in abscess of the lung, and a differential diagnosis is oftentimes quite difficult. The amount of pus expectorated at one time is seldom as large as noted in abscess, but the daily amount may be larger. Echinococcus cysts in the liver sometimes perforate into the pleura and in turn into the lung. The sputum has a peculiar yellow color and the evidences of echinococcus are usually easily found. Neoplasm of the Lung. — The sputum is likely to contain small or large amounts of blood, and the presence of microscopic blood between the more profuse hemorrhages is a suspicious sign. Very rarely indeed sufficien«t tumor tissue is expectorated for diagnostic purposes, and a warning must be sounded against so-called "carcinoma cells." The characteristics found in the sputum in pulmonary tuberculosis, pneu- monia, bronchitis, etc., belong to the domain of general medicine. EXAMINATION OF GASTRIC CONTENTS When the modern methods of gastric analysis resulted in greater accuracy in the diagnosis of diseases of the stomach, it was believed that the two diseases which particularly interest the surgeon, namely, ulcer and cancer, could be posi- tively diagnosed at an earlier period in the laboratory than by clinical means. The absence of hydrochloric acid and the presence of lactic acid were con- sidered positive indicators of carcinoma, while the presence of an excessive amount of hydrochloric acid indicated ulcer. Time proved that this rule, like most others, had its glaring exceptions, and the opinion of today is that the result of the gastric analysis must take its place with, the clinical signs and symptoms, to be considered for what experience has taught it is w^orth. The procedure is as follows: The patient is given an E wal d test breakfast consisting of one baker's roll without butter, weighing about 35 grams, and 300 c.c. of water or weak tea without milk or sugar, on an empty stomach. One hour after ingestion the contents of the stomach are expressed by tube without the use of water. While a more elaborate examination may be useful, at least the following determinations should be made: EXAMINATION OF GASTRIC CONTENTS 275 Total quantity (normal, 40 c.c. to 200 c.c). Total quantity of filtrate (normal, 20 c.c. to 140 c.c.)- Free hydrochloric acid (normally present). Lactic acid (normally absent). Total acidity (normal, 1.5 to 3.0 grams per mille). Scheme "A Total hydrochloric acid (normal, 1.15 to 2.48 grams per mille). Scheme "E." Total free hydrochloric acid (normal, 0.09 to 1.9 grams per mille). Scheme"!)." Total combined hydrochloric acid (normal, 0.24 to 1.49 grams per mille). Scheme "C." Total acidit}^ due to organic acids and acid salts (nor- mal, 0.2 to 0.88 gram per mille). Scheme "F." Presence of free hydrochloric acid {vide infra) is most easily demonstrated with T 6 p f e r ' s test. The addi- tion of one or two drops of 0.5 per cent alcoholic solution of dimethyl-amido-azo-benzol to 'a small amount of gastric con- tents immediately produces a bright cherry-red color if free hydrochloric acid is present. This test is preferable to others on account of its delicacy and the stability of the reagent. Lactic acid if present in considerable amount will produce an orange color, but if any doubt exists the lactic acid can be removed b}' treating the specimen with ether before the test for free hydrochloric acid is applied. Presence of lactic acid in sufficient amount to be of clinical importance can be demonstrated by the Strauss test. The graduated separating funnel shown in the illustra- tion (Fig. 58) is filled to the 5 c.c. mark with filtered gastric contents, pure ether is added to the 25 c.c. mark and this is thoroughly shaken. After the liquids have separated the stopcock is ojDened, and all but 5 c.c. allowed to escape. Dis- tilled water is now added to the 25 c.c. mark, shaken, and followed by 2 drops of the reagent, consisting of a freshly made 1 to 10 dilution of tincture of ferric chlorid in water. The presence of lactic acid is show^n by a decided green color. Fig. 58. Strauss Graduated Tube FOR Lactic Acid Determination. SCHEMES "A." Total acidity. To 10 c.c. filtered gastric contents add 2 drops of 1 per cent alcoholic solution phenolphthalein (indicator). Titrate with yV normal sodium hydrate. For example, 7 c.c. iV N. NaOH used. 7 X 0.00365 = 0.0255 gram total acidity in 10 c.c. gastric contents expressed as HCl. 0.0255 X 100 = 2.55 grams total acidity per mille (per thousand). "B." Free acids and acid salts. To 10 c.c. filtered gastric contents add 2 to 3 drops 1 per cent aqueous solution sodium alizarin sulfonate (indicator). Titrate with -rt,- normal sodium hydrate. For example , 4.9 c.c. rb N. NaOH used. 4.9 X 0.00365 = 0.0178 gram total free acids and acid salts in 10 c.c. gastric contents expressed as HCl. 0.0178 X 100 = 1.78 grams total free acids and acid salts per mille (per thousand). ''C." Total combined hydrochloric acid. "A" as above 2.55 minus "B" 276 LABORATORY AIDS IX SURGICAL DIAGNOSIS as above 1.78 = 0.77 gram total combined hydrochloric acid per mille (per thou.sand) . " D." Total free hydrochloric acid. To 10 c.c. filtered ga.stric contents add a few drops 0.5 per cent alcoholic solution dimethyl-amido-azo-benzol (indicator). Titrate with tV normal sodium hydrate. For example, 3.1 c.c. tV X. XaOH used. 3.1 X 0.00365 = 0.0113 gram total free hydrochloric acid in 10 c.c. gastric contents. 0.0113 X 100 = 1.13 grams total free hydrochloric acid per mille (per thousand). "E." Total hydrochloric acid. "C" as above 0.77 plus "D" as above 1.13 = 1.90 grams total hydrochloric acid per mille (per thousand). "F." Total acidity due to organic acids and acid salts. "B" as above 1.78 minus "D" as above 1.13 = 0.65 gram total acidity due to organic acids and acid salts per mille (per thousand). Some experience is necessary to determine the proper end reactions in the above. EXAMINATION OF FECES The macroscopic as well as the microscopic examination of the stool offers corroborative evidence in diagnosis, oftentimes of the greatest importance. The following resume is limited to the features of particular interest to the surgeon. Macroscopic Examination. — Hemorrhage from the lower portion of the bowel may show unchanged Ijlood, while blood derived from the stomach or small intestine may be totally disintegrated and give the stool a dark brown or black color, a sticky character, and a very offensive odor. In obstruction to the outlet of bile the stool is clay-colored or grayish-yellow. In suspected cholelithiasis careful search should be made for concretions by stirring the feces with water and straining. Gallstones occur in all sizes, and usually consist of a mixture of cholesterin and bile pigment with salts. Pus and mucus derived from the lower portion of the intestinal tract are usually adherent to the fecal masses, but if derived from a higher portion, they are intimately mixed with the stool and m?.y not be apparent macroscopically. Abscesses rupturing into the intestine usually show an easily recognized mixture of pus and blood in the stool. Microscopic Examination. — The presence of ameba may corroborate a diagnosis of abscess of the liver. Evidences of parasites or specific bacteria often explain what seem to be obscure conditions. Intestinal ulcerations in the small gut need not be accompanied by diarrhea, but those in the large intestine are always accompanied by it. The amount of pus found in the feces is no guide to the severity of the ulcerative process. Intestinal tuberculosis usually shows the evidences of ulceration and tubercle bacilli are easily found. In referring tubercle bacilli found in the feces to intestinal lesions it must be remembered that swallowed tuberculous sputum may occasion the presence of bacilli in the stool. In examining feces for tubercle bacilli, the mucopurulent particles should be selected if they can be found. As smegma bacilli also occur in feces, the differentiation by alcohol must be made. Carcinoma of the Intestine. — If the lesion is situated in the upper portion of the intestinal tract, the stool may present pus and altered Ijlood intimately EXAMINATION OF ASPIKATi:!) FLUIDS 277 mixed with it, the odor usiuilly Ixnng very offensive. No sio;nificance can be attached to the "ribbonUke" appearance of the stool formerly considered pathognomonic. In carcinoma of the rectum small amounts of offensive blood, pus, and mucus are often voided with tenesmus without an admix- ture of feces, but the same occur in proctitis from any cause, though the offen- siA'e odor is not present unless there is a ruptured periproctic abscess. Tumor particles are seldom found, and a warning against the imaginary "cancer cell" is again sounded. Passage of masses of blood and mucus not offensive and without tenesmus is sometimes seen with intussusception. In seeking a cause for intestinal hemorrhage, that due to scurvy and allied conditions must be kept in mind. While the modern surgeon is interested in diseases of the liver and pancreas which alter the chemistry of the feces, the significance of this analytic work still belongs to the domain of general medicine. EXAMINATION OF ASPIRATED FLUIDS The chemic and microscopic examination of aspirated fluids is often of the greatest help in diagnosis, and careful work generally leads to the most gratify- ing results, which are of particular interest to the surgeon. Transudates are usually straw-colored serous fluids of noninflammatory origin, though they may be tinged with blood, and they are of interest here on account of the differential diagnosis between them and the serous exudate of inflammation. This differential diagnosis is to be based on the characteristic features shown in the following table: Transudate. Exudate. Specific gravity 1005 to 1020. lOlS to 1030. Coagulation Unusual except when blood Usually prompt and decided. present. Albumin 1 to 45 per mille liy weight. 40 to SO per mille by weight. Seromucin (on addition of acetic acid) None or traces. Pronounced reaction. Microscopically Few leukocj'tes and endo- Characteristics as detailed thelial cells from the serous under special headings and surface. cj'todiagnosis. Exudates are usually serous, hemorrhagic, or purulent in character, and all are of inflammatory origin. If purulent, inflammatory origin is obvious, while the serous or the hemorrhagic exudate must be distinguished from a similarly appearing transudate by the means detailed above. Cytodiagnosis or the microscopic study of the cellular elements not only aids in differentiating transudate and exudate, but promises to give much information as to the type and cause of the latter. The main feature is the predominance of the lymphocyte cell or of the polynuclear cell, and the presence or absence of other varieties of leukocytes. Owing to the recent development of this study the opinions are still divergent, but the follow- ing conclusions probably represent present-day belief. In acute inflammatory exudates in the pleura of pneumococcic or strepto- coccic origin the polynuclear leukoc^'te usually represents 90 per cent of the total count, while in the early stage of tuberculous pleurisy the polynuclear 278 LABORATORY AIDS IN SURGICAL DIAGNOSIS percentage is rarely 50, and as the disease jDrogresses the polynuclear cells diminish in numbers and the lymphocytes represent as high as 90 per cent of the differential count. In malignant disease of serous membranes the microscopic picture of the cellular elements in the exudate is often looked to for diagnosis. Many so- called characteristic features have been described and the differential diagnosis of cancer cells and endothelial cells is detailed by many. An erroneous diag- nosis of cancer of the pleura is, however, a serious matter, and as long as the so-called pathognomonic cellular indications are disputed, it is well to accept a diagnosis on this basis with caution. The finding of tumor particles, which can be sectioned, stained, and examined, naturally leaves no room for doul)t. The significance of cytodiagnosis in cerebrospinal fluid will be detailed under the head of lumbar puncture. Actinomycosis. — In purulent exudates with obscure etiology the char- acteristics of this fungus should be kept in mind when making the microscopic examination. Aside from the fungus, the specimens present nothing particu- larly worthy of note. Putrid exudates are obtained from the pleural cavity when hepatic or subphi'enic abscesses have perforated into this cavity, and are characterized by a brownish-green color and an extremely offensive odor. Chylous exudates are observed usually in the abdominal cavity, but their significance depends largely on the clinical factors, and this examination lends little or no aid in the diagnosis. Echinococcus Cysts. — The fluid obtained by aspiration is usually clear and shows numerous crystals of cholesterin in addition to the characteristic booklets on microscopic examination. Small shreds of the typic laminated membrane as well as scolices may also be found. Ovarian Cysts. — ^The obtained fluid is viscid in character, varies greatly in specific gravity as well as in amount of albumin present, and should respond to tests for metalbumin. The coagulable albumin is removed and the fluid filtered, when the addition of alcohol should result in a flocculent precipitate. Microscopically the specimens present red and white blood-cells, and occasionally cholesterin crystals and fatty granules. Cylindric ciliated epithelial cells from the lining membrane and colloid concretions are charac- teristic, but unfortunately not always present. The fluid obtained from cystic uterine tumors has a low specific gravity, is not viscid, and coagulates quickly, while that from parovarian cysts has much the same appearance but does not coagulate. Hydronephrosis. — The differential diagnosis of fluid aspirated from an ovarian cyst and that aspirated from a hydronephrosis usually offers no diffi- culty. The latter is quite watery instead of viscid, contains little if any albumin, and notable amounts of urea and uric acid can be demonstrated. While the microscopic examination ma}^ be unsatisfactor}^, it frequently presents undoubted renal elements. Hepatic Abscess. — In the microscopic examination of pus from this source a search for Amelia coli should not be neglected. The reminder that amebas are the cause of abscesses in other parts of the body may not be amiss. Lumbar Puncture. — The increased value of this procedure as a diagnostic factor is noteworthy. The chemic and bacteriologic examinations of the cere- EXAMINATION OF ASPIRATED FLUIDS 279 bvospinal fluid arc decidedly useful, and cytodiagnosis, while still a disputed sul)ject, promises some aitl. 'i'lie normal fluid is perfectly clear and colorless, has a specific gi-avity of about 1006, and contains approximately by weight 1 per mille of albumin. As the subject really belongs to general medicine rather than to surgery, with one exception the details have no place here. In apo- plex_v, and injiu'ies of the skull extending through the dura mater, the blood may make its way into the lateral ventricles and appear on lumbar puncture, while extradural head injuries never present bloody cerebrospinal fluid. SECTION VIII SURGICAL OPERATIONS IN GENERAL GENERAL CONSIDERATIONS Eveiy surgical procedure is productive of more or less risk to the life of the patient, and no operation should be entered upon without clue consideration of the dangers which it entails, as far as the patient is concerned, to say nothing of the influence which the operation may have on the art of surgery itself or on the surgeon's reputation. Bearing this in mind, the surgeon will carefully weigh the benefits to be derived from the operation against the risks to be taken in order to secure these benefits, and he will see to it that a life is not unnecessarily placed in peril, or that unjustifiable risks are not taken, even at the patient's own request, for the correction of trifling conditions. On the other hand, the practitioner who hesitates, in the face of grave surgical emer- gency, to assume the responsibility which the circumstances demand, and to act promptly, as far as he is able, in order to saA^e a life, will bring reproach on himself and opprobrium on his profession. For purposes of consideration from the present standpoint surgical opera- tions maybe divided into (1) imperative operations; (2) operations of necessity; (3) oi^erations of utihty; (4) operations of expediency; (5) multiple operations; (6) unjustifiable operations. Imperative Operations. — In this class may be placed those operations that are universally acknowledged as of urgent and immediate necessity, and in which the life-saving character of the procedure depends on the promptness of the execution. As instances in this connection may be cited the folloAving: abdominal section for gunshot and stab wounds involving the integi'ity of the intestinal canal or causing concealed hemorrhage; the ligation of arteries not accessible for the provisional .arrest of hemorrhage; amputation for the removal of an extensively mangled and useless limb in which crushed nerve-trunks tend to increase shock, as well as amputation for the arrest of hemorrhage. Operations of Necessity. — In this class may be mentioned those operations for the removal of malignant grow^ths and other neoplasms, as well as for con- ditions which, though urgently demanding surgical interference, permit time and opportunity for due preparation. Operations of Utility. — In this class of cases an effort is made to correct conditions which tend to prevent the patient from entering into the ordinary pursuits and enjoyments of life, even if they do not threaten or shorten his existence. As familiar instances of this class of operations may be noted plastic procedures for harelip and cleft palate; tenotomies and bone resections for clubfoot; operations designed to correct deformities which are the result of paralyses and contractures arising from diseases of the central nervous 280 COMMON DANGERS OF SURGICAL OPERATIONS 281 system, as well as those due to injury; operations for the permanent fixation of Ihiil joints (see Arthrodesis, page 372); tendoplasty for transferring a portion of the muscular force from active to paralyzed parts. Operations of Expediency. — These are the so-called cosmetic operations, and are usually designed, as the name implies, to improve some unsightliness in the personal appearance of the patient. An instance of a purely cosmetic operation is that for projecting or protuberant ears. Certain operations in this class, while they are performed primarily for cosmetic purposes, yet serve a further and useful end, c. g., the operation for ectropion of the eyelid, in which, in addition to the improvement of the patient's appearance, there is a restora- tion of the protective function of this structure to the globe. Multiple Operations. — Operations on the pelvic floor of women who have borne children come more particularly under this head. In the majority of cases of parturient injuries the conditions demand for their relief several independent operative procedures, particularly if these are performed some time after delivery. These include curettage of the uterus for the chronic endometritis which is commonly present, trachelorrhaphy for the lacerated cervix uteri, and perineorrhaphy. In more aggravated cases, or those of long standing, anterior and posterior colporrhaphy may be necessary. Further, prolapse and retrodeviation of the uterus, as well as infections of the adnexa, may be present and demand hysterorrhaphy for the first named and oopho- rectomy' and salpingectomy for the second. Finally, the presence of aggravated hemorrhoids is not uncommon in this class of cases. All of the above operations may be necessary in the same patient, and it becomes a question of judgment in each individual case as to how many and which of them shall be performed at one sitting. Whenever several operations are performed on a patient at the same seance, care should be observed to conduct the several procedures in the order of their cleanliness. For instance, an operation for hemorrhoids should not precede an abdominal section. This rule does not always hold good, however. If a peritoneal suspension of the uterus or a salpingo-oophorectomy precedes a trachelorrhaphy, dragging on the uterus in the performance of the latter may nullify the hysterorrhaphy, or, in the case of the adnexal operation, cause the slipping of a ligature and the occurrence of concealed hemorrhage. Unjustifiable Operations. — No self-respecting surgeon will perform an operation for the removal of healthy ovaries, the ligation of the Fallopian tubes, and similar procedures intended to prevent conception in a woman capable of bearing children; nor will he perform an operation designed to alter the per- sonal appearance of an individual for the purpose of disguise or to enable him to escape punishment for crime. COMMON DANGERS OF SURGICAL OPERATIONS Excessive fear is to be mentioned in this connection. That the mental condition bears some relation to the occurrence of shock there can be no doubt, since it has been shown that stoically inclined individuals, and those hopefully inclined, as well as children and the insane, other things being equal, suffer comparatively little from shock. 282 SURGICAL OPERATIONS IX GENERAL The administration of a general anesthetic gives rise to certain imme- diate and well-defined risks, which should always be taken into account in this connection. These relate particularly to the effects of the anesthetic agent on the heart and respiratory apparatus, as well as to the dangers arising from mechanic causes, such as jaw spasm with the forcing back of the tongue so as to obstruct the glottic opening, which occurs in the case of ether anesthetization particularly, and the lodgment of foreign bodies, as false teeth, chewing- gum, vomited matter, etc., in the respiratory passages. Violent struggUng on the part of the patient at the commencement of chloroform anesthetization leads to a most pronounced and rapid effect of the drug, and if its administration is persisted in under these circumstances, it may cause fatal narcosis. Want of proper care and watchfulness on the part of the anesthetist may also easily permit the latter to occur. The avoidance of hemorrhage constitutes the most imperative duty of the operating surgeon. The careful and systematic clamping of each ordinary sized bleeding vessel as it is encountered, prompt finger pressure, and a properly directed effort to secure the bleeding point in the case of injury to a larger branch or main trunk form a very important part of the training of the skilled operator. While the loss of some blood is unavoidable during an operation, the aim should be to minimize this loss as much as possible consistent with the proper conduct of the operation, since, without due regard to this rule, the dangers from shock are greatly increased and the healing process is retarded. A considerable loss of blood extending over a longer period of time is better borne by the patient than the same cjuantity escaping by a sudden gush from a large trunk. Failure to institute prompt measures to compensate for the loss of blood when this is excessive may sacrifice the patient's life, even after arrest of bleeding is promptly and properly secured. The dangers of hemor- rhage do not cease with the completion of the operation; the patient must be watched for subsequent bleeding up to the time when definite healing of the ligated vessels may be expected to occur (see page 88). Shock. — This term is used to designate an extreme functional depression, first, of the nervous system, and, second, in consec^uence of the first, of the circulatory system, resulting from an injury or occurring as one of the effects of an operation. Young children, the aged, and weak individuals suffer most from shock. Children, however, recover most readily from its effects. Excessive weakness of the heart's action is the predominating feature in shock. The symptoms of shock and excessive loss of blood combined, as they some- times are, with the effects of over or prolonged anesthetization, make up a clinical picture of a patient critically ill from the effects of an operation. If a patient is suffering from shock as the result of an injury, none but the most imperatively demanded operations, such, for instance, as that recjuired for the arrest of hemorrhage, or for the relief of some condition on which the continuance of the shock depends, should be undertaken. If shock comes on in the course of an operation, the latter should be concluded as c|uickly as pos- sible; in some instances it will be necessary to suspend it entirely. When the patient once rallies from shock, the improvement is continuous, and in some instances rapid. The terms " delayed shock," " secondary shock," and "imperfect reaction from shock" are misleading, and relate to conditions arising independently of the original shock, such as concealed hemorrhage SPECIAL DANGERS OF OPERATIONS 283 (see page 89), rapitlly developing and virulent septic infection, fat embolism, pulmonary edema, renal insufficiency, etc. Shock may be (|iiickly recovered from if no vital organ is seriously involved in the injury or operation, or if the source of the depression is not persistent and continuous, such, for instance, as the presence of a mangled limb with crushed nerve-trunks, etc. In fatal cases the temperature becomes subnormal and death takes place from combined cardiac and respiratory failure. In the prevention of shock the patient's mental condition should be taken into account, antl, as a part of the preparation for the operation, every encouragement given him as to its outcome. Nervous patients are benefited b}' a few days' preliminary rest in bed. Opiates and bromids may be given as indicated. A oV-grain dose of strychnin may be given after anesthetization, if indicated. During the operation the patient should be kept warm, and, in long operations, artificial heat should be applied. Loss of blood must be avoided and operations brought to a close as quickly as possible. The preliminary injection of cocain into a nerve-trunk of a part operated on inhibits the transmission of afferent and efferent impulses and tends to lessen operative shock (C r i 1 e). Treatment of Shock. — The patient's head is to be lowered, and artificial heat applied to the whole body by means of hot-water bags, or, better still, the patient may be wrapped in blankets wrung out of hot water. An intravenous infusion of from 800 to 1200 c.c. of saline solution (1 dram of common table salt to a pint of sterilized water at 115° to 120° F.) should be given. Pending preparations for this, the saline solution is to be injected into the loose connec- tive tissue behind the breasts (see Hypodermoclysis, page 352). High enemas consisting of a quart of hot saline solution, 3 ounces of black coffee, and 2 drams of whisky should be given. Strychnin should be administered carefully (not more than two ^Vgrain doses). Oxj^gen is to be administered. Nitro- glycerin and amyl nitrite are contraindicated in shock on account of the vasomotor dilatation which they induce. Ergot, on the other hand, is said to possess distinct value in this connection. I have employed it with apparent advantage. It is to be given hypodermically in the shape of either ergotol in 30-minim doses repeated every half hour, or solutions of the aqueous extract. SPECIAL DANGERS OF OPERATIONS These relate chiefly to the locality in which the operation is performed and its proximity to certain important nerve-trunks and large vessels. Prolonged operations on the intracranial contents^ or in the area of important and extensively distributed sensory nerves, such, for instance, as the fifth or tri- facial nerve, either b}^ direct means or by reflex inhibitory effects, greatly augment the dangerous effects of shock. The entrance of air into veins, though a rare circumstance, is an accident against which the surgeon should be on his guard, particularly when operating in the lateral region of the neck. In the event of a wound of a large A'ein in this locality the opening in the vessel is kept patent by the cervical fascia, while the vacuum produced by the inspiratory effort causes the air to rush in. The accident has occurred most frequently in connection with the internal and external jugular veins and the subclavian. It has happened. 284 SURGICAL OPERATIONS IN GENERAL however, in the case of the cerebral sinuses, and the facial, axillary, sub- scapular, thoracic, and femoral veins (for Air Embohsm see page 98). The dangers of hemorrhage are enhanced when the operation is con- ducted in the neigh])orhood of the large vessels. These dangers arise, not only from the risks of wounding the main trunk, but from the fact that wounded branches bleed more freely under these circumstances and a large amount of blood is lost in a short time. Patients with hemophilia ("bleeders") are the most unpromising of all subjects for operation. Scarcel}' anything has been brought to light concerning the pathology of the disease and almost as little success has attended efforts to cope with the bleeding which occurs in its victims. This may result from the most trivial injury and may be initiated by a diseased condition, such, for instance, as occurred in a patient under my care in the German Hospital, in whom the ruptured vessels at the site of a perforation of the vermiform ap- pendix gave rise to a hemophilic bleeding, which all efforts, including exposure of the source of the hemorrhage and topical pressure, failed to arrest. In the treatment of hemorrhage in a hemophiliac where direct pressure can be made, this offers the best chance of arresting the bleeding. In addition, the common styptics, adrenalin chlorid solution (1 : 1000) by subcutaneous and intra- venous injection, heat, cold, the actual cautery, the rectal administration of gelatin solutions (5 per cent), and the internal administration of chlorid of calcium and ergot should be tried. POST-OPERATIVE COMPLICATIONS The most important immediate post-operative complications are the fol- lowing : Excessive Retching. — This may become a source of anxiety on account of the possibility of cerebral hemorrhage due to the straining efforts in patients with atheromatous vessels. Lavage with saline solution is of service. It sometimes becomes necessary to administer a hypodermic injection of morphin to quiet the reflex disturbances. Recurring hemorrhage from the slipping of a ligature, or from a vessel which was injured near the close of the operation and w^hich failed of ligation, is an occasional complication at this stage (see Treatment of Hemor- rhage, page 336). More or less complete suppression of urine (anuria) and disten- tion of the bladder from retention of urine are to be guarded against. Fluids given freely to drink, saline irrigation of the rectum, copious enemas of saline solution, dry cupping of the renal region to relieve the congestion of the kidneys on which the suppression depends, and, if this fails, wet cupping of the same, hypodermoclysis, and, finally, intravenous saline infusion, are the measures to be resorted to in cases of anuria; in cases of retention careful catheterization should be performed. Acute Post=operative Dilatation of the Stomach. — This has been observed as the result of a more or less complete prolapse of the small intestine into the lesser pelvis. The pressure of the mesentery, particularly of the superior mesenteric artery, thus arising causes compression and obstruction POST-OP KUATIVl': CO.MPLICATK^N.S 285 of the iluoilcnmu, Avilli con.scHiuciiL dilatation of the latter and finally of the stomach as well. The predisposing causes are said to be the weakening effects of general anesthetization and too co])ions purgation preceding the ojjeration. The condition can occur only with the patient in the dorsal i)osition. The symptom dominating the clinical picture of this post-operative com- plication is \()niiting, which is often very abundant and persistent, and usually biliary; more rarely brownish-gray or blackish. Intractable constipation is usually present; flatus is generally obstructed; thirst is urgent; the pulse is increased in freciuency; the temperature remains normal. The patient's appearance is that of one critically ill. The diagnosis is confirmed by the demonstrable ]:)resence of gastric dilatation. The treatment consists in placing the patient in the al)dominal position (flat on the abdomen) at once upon the appearance of symptoms of duodenal compression (jM u 1 1 e r). Lavage may also be practised. The more remote complications include delirium tremens, sepsis, peritoni- tis, tympanites, and pneumonia. Delirium 'tremens is a form of mental disturl^ance in which muscu- lar tremors are a characteristic feature. It occurs in persons habitually intemperate in the use of alcohol. It may follow^ an operation or any form of injury. The type of the disease is milder, as a rule, than that which develops Avithout injury. The attack is sometimes preceded by restlessness and tremu- lousness, and is ushered in by insomnia and delusions of persecution and of the presence of reptiles, animals, and insects which inspire fear and horror. If the patient is not restrained, he wifl attempt to escape from these by flight, entirely insensible to the pain of an injury or of the part operated on. In some cases there is marked and rapid loss of strength. The attack may pass off suddenly after a long sleep. Death may take place from prostration or suddenly from heart failure. The treatment of delirium tremens consists in warding off an impending attack by means of stimulants in small quantities, and the administration of capsicum and digitalis. Sleep should be secured by chloral hydrate and the bromids. During the attack the patient should be protected from doing him- self harm by a restraint sheet and wristlets. Malt liquors should be given ad libitum. Opium should be reserved for cases in which restraint to the extent of preventing displacement of splints or dressings is difficult or impossible. Septic inflammation is the most important of the post-operative sequels, and its advent should be most carefully watched for by a frequent inspection of the temperature record. If it occurs, its further progress should be guarded against by thorough disinfection of the wound, the sutures being remoA-ed for this purpose, if necessary (see page 58). In abdominal cases the surgeon will be on his guard particularly against the occurrence of peritonitis. Tympanitic distention is sometimes the cause of considerable discomfort and will require for its relief either the use of the rectal tube or enemas containing turpentin or lac asafetida. Post=operative pneumonia may be the result of exposure of the patient while under the anesthetic, either when he is on the operating table or subse- quently. It has likewise been attributed to the refrigerant action of the ether when this has been employed as the anesthetic agent. In the hypostatic form it arises from keeping the patient constantly in the dorsal decubitus. Septic 286 SURGICAL OPERATIONS IX GENERAL pneumonia results from the inspiration of septic agents during the anesthetiza- tion, and from the passage of septic material into the air-passages from the nasal, nasopharyngeal, and buccal cavities after operations in these regions. In the latter case it may be followed Vjy gangrene of the lung. Prophylaxis consists in (1) employing due care not to expose the patient unnecessarily while under the anesthetic; (2) keeping the patient's head turned to one side during the anesthetization in order to favor the accumulation of mucus, etc., in one or the other of the lateral portions of the pharynx, whence it may be readil}" removed by a strip of gauze leading out of the corresponding corner of the mouth, or by sponging; (3) taking measures to establish and maintain aseptic conditions of the parts after operations on the mouth, throat, and nose (see page 49); (4) alternating the position of the patient during convalescence between the lateral and the dorsal. The treatment of post-operative pneumonia embraces dry cupping, a pneumonia jacket (oiled silk lined with cotton batting), and systematic change of decubitus. Ten-grain doses of carbonate of ammonia in half an ounce of equal parts of mucilage of acacia, spearmint water, and syrup, given every two hoirrs, alternated with 10-grain doses of chlorid of calcium, are of service. (For Gangrene of the Lung, see page 682.) Causes of Death Following Surgical Operations. — Death following a surgical operation may arise from hemorrhage, from shock, or from these two combined; or from these with the addition of prolonged or too profound narcosis; or from entrance of air into the veins; or from overstimu- lation of the heart arising from the absorption of several doses of drugs at once administered hypodermically during shock. During and after anesthetization the foundation may be laid for a fatal post-operative pneumonia {vide supra). Suffocation arising from inspiration of vomited matters while the patient is still unconscious may prove fatal. Death may occur from acute dilatation of the stomach (vide supra). Uremia following anuria in those with diseased kidneys may destroy the patient. Infections from pus organisms may give rise to lethal pyemia and septicopyemia (see pages 182 and 184;. The special infection of tetanus is quite uniformly fatal. Delirium tremens following a long debauch may be fatal. Death may be due to some organic disease of a vital organ; to pulmonary thrombosis; to extension of infection and complicating inflam- mations of newly involved tissues or organs; to perforative peritonitis resulting from rough handling of the intestines; to post-operative peritonitis due to imperfect asepsis; to intestinal obstruction caused by angulation at the site of adhesions following an abdominal section; or to senile asthenia aggravated by surgical interference in those both aged and infirm. Acute cardiac dilatation may cause death in a totally unexpected manner, and at a period so remote from the operation as to arouse some doubt as to the connection between the two. In six cases occurring in my experience death took place at periods varying from ten to sixteen days after the operation. The latter had been succeeded by an absolutely uneventful course up to the occurrence of the acute dilatation. In none of the cases had a heart lesion been made out before the operation. In three of the cases the patients were awak- ened from sleep by the faint sensation which, in two of the cases, preceded death by less than a minute. It is estimated that in none of the six cases did the patient live longer than a minute after the first symptom. In tho.se POST-OPERATIVE COMPLICATIONS 287 attacks which occurred while the patient was awake the first impulse was to ask for a drink of water, but before this could be given the jjatient's alarming aijpearance. attracted attention to the pulse, which was found to be weak and fluttering.* * The following is a sumniarv of the cases: one case of amputation of the shoulder- joint; death on the sixteenth day after operation and after complete healing; the patient was being con\eyed home in a carriage when attacked. One case of abdominal hysterec- tomy; death on the eleventh day while the patient was uneventfully reco^•ering from the operation. Two cases of appendectomy; death in the one case on the eleventh day and in the other on the fifteenth day. In the first case the patient died while on the Ijedpan; in the other case the patient was awakened from sleep by the faint, sinking sensation. One case of operation for radical cure of hernia; patient attacked on the fourteenth day in the night and had time only to whisper faintly a message for his family when he breathed his last. One case of nephrolithiasis which had gone on to the thirteenth day without the slightest deviation from the normal, after the recovery from the anesthetic: the patient asked the nurse for a glass of water in a faint whisper, and died before it could be handed to her. The youngest patient was thirty-two, the oldest was se^-enty. In all of the cases there was the predominating feature of an absolutely uncomplicated and ap- parently safely established convalescence up to less than two minutes before the patient's death. In the three cases in which autopsy was permitted the left ventricle was found somewhat thinner than the average normal ventricle; the heart's action had been arrested in ventricular diastole: the remaining portions of the organ, as well as all the other organs of the body, were found to be in a healthy state. SECTION IX SURGICAL ANESTHESIA Surgical anesthesia is of two kinds, general and local. The first named is sometimes called narcosis. For ordinary surgical purposes general anesthesia must be produced. The ideal production of general anesthesia without narcosis has yet to be reached. The indications for the use of anesthetics are various. The suscepti- bility of the individual to pain, the length of time the proposed operation is to occupy, the amount of pain, the necessity for restraining the patient's move- ments during the operation, must all be taken into account. Some operations may be quite prolonged and yet comparatively fi-ee from pain; hence continu- ous and prolonged anesthesia is not rec^uired. Again, an operation may give rise to the most exquisite pain and yet be of such short duration as scarcely to justify the employment of a general anesthetic. Were it not for the fact that there is a lurking danger attendant on every occasion where an anesthetic is employed, anesthesia could be induced with propriety for all operations, including those causing even the slightest pain. Surgical anesthesia is also induced for the purpose of producing relaxation of muscular structures, as, for instance, in the reduction of dislocations and for the adjustment of the displaced fragments in fractures. Finally, it is almost impossible to make a diagnosis m some cases without the aid of anesthesia. The Physiologic Action of Ether and Chloroform. — The anesthesia obtained by the use of these agents results from the direct influence of the drug on the nervous system, as shown b}' Bernstein's experiments on frogs. The frogs were successfully chloroformed after the aorta had been severed, all blood withdra-wm and its place supplied by sodium chlorid solution. Further experiments by Bernstein demonstrated that portions of the central nerv^ous system excluded from the circulation are not influenced by the anesthetic, as sho^\Ti by the fact that under these circumstances the peripheral portions supplied by these centers do not lose their reflex irritability. In another experiment the femoral arterv^ was ligated, after which it was found that both limbs alike were affected by the influence of the anesthetic. Early in the administration of ether there is a cardiac and a vasomotor stimulation; later this is followed by depression and fall of blood-pressure. The action of chloroform on the heart is as follows : it acts directlj' on the heart muscle, steadily and strongly depressing and paralyzing it or its contained ganglia; to this depression is due the early fall of blood-pressure occurring in chloroform narcosis. While the pupil may become temporarily dilated slightly beyond the normal during the early stages, it becomes contracted below the normal as the anes- thesia advances. A return to the normal requires that more of the anesthetic be administered, but a sudden dilatation imperatively demands its immediate withdrawal. 288 THK Sia.KCTIOX OF AN ANKSTHKTIC 289 The Selection of an Anesthetic. — The anesthetic agents usually em- ployed at the present day are nitrous oxid, ether, and chloroform. These should be obtained in as pure a state as possible. Tests are given for ascertaining tlieir purity, but ])ractically the surgeon is at the mercy of the manufacturer, and should thei'(^fore supph' himself from one of standing and reputation. Nitrous oxid is the safest general anesthetic at present known. In ex- perienced hands its use is practically without risk. Any danger that may attend its use in unskilled hands is eliminated l)y administering it with oxygen. Under these circumstances the dangers are but infinitesimal. Unfortunately, nitrous oxid is both inconvenient and inapplicable for most surgical operations, though it may be employed for those of short duration. Sulfuric Ether. — Of the anesthetic agents suitable for prolonged adminis- tration ether is the safest, and, unless directly contraindicated, should be invariably employed. Its great advantage is the stimulating effect which it produces on the circulation. Even the sitting posture is not liable to result in circulatory respiratory depression while the patient is under its influence. It shoukl therefore be the routine anesthetic for general surgical work. The contraindications for the use of ether are extreme emphysema, chronic hronchitis with expectoration and dyspnea, and advanced pulmonary phthisis. In the case of very old persons and in those extremely obese, as well as in very young children, ether is not generally employed. It may, however, be employed in old persons in whom the arteries are not markedly atheromatous, and in young children, and even in infants. In the case of the latter, however, the open method should be used. Though albuminuria, nephritis, and uremia have been known to follow the use of ether, it is now generally believed that these sequels may follow, although perhaps not so frequently, when chloro- form is administered in equal amounts, and that they do not follow either anesthetic as frequently as is generally supposed unless renal disease exists beforehand. It may be observed, however, that the kidneys play a large part in the elimination of the anesthetic agent, and if diseased, may fail to perform their function, or become congested through the necessarily increased activity of the vessels, suppression following. Chloroform is used in operations on the palate, tongue, jaws, mouth, nasal cavities, nasopharynx and pharynx, on account of the difficulties arising from attempts to anesthetize the patient with ether mingled with a large amount of au-. When the actual cautery is to be used in these regions, even when ether might otherwise be employed, chloroform must be substituted, on account of the inflammability of the vapor of the former. Under all circumstances, how- ever, unless the use of ether is strongly contraindicated, anesthetization by this agent should be first obtained and chloroform employed only during the actual performance of the operation. In cases in which there is a fixed condition of the abdominal walls, as, for instance, in connection with general peritonitis from perforation, and intestinal obstruction with respiratory difficulty, chloroform may be used preliminarily to etherization. Finally, when it is shown by actual trial that ether is badly borne, either through uncontrollable coughing, embarrassed breathing, deep cyanosis, or prolonged tonic spasm, chloroform may be temporarily substituted. When the patient is fully anesthetized by chloroform, however, it will frequently be 20 290 SURGICAL ANESTHESIA found that these conditions have disappeared and that ether may be admin- istered. In stenosis of the larynx and trachea chloroform may be employed with advantage, as it is less likely to irritate and produce spasm of the glottis. The Preparation of the Patient for an Anesthetic— It not infrequently occurs that the condition of the patient is such as to prohibit the employment of an anesthetic. Each organ should be carefully examined beforehand, as far as possible, but particular attention should be paid to the heart and vessels, lungs and kidneys. The digestive organs should not be overlooked. The intestinal canal should be emptied by a purge administered the day previous, and thereafter only food allowed which shall leave the mini- mum amount of residuum in the bowels. ^leat broths and such food fulfil this indication. No liquid food is to be permitted for at least four hours before the operation, and solid food should be omitted, wherever practicable, for eight hours previous. If this rule has been transgressed, in emergency cases where food has been recently taken, lavage may be practised. The reasons for with- holding food are (1) the presence of food is provocative of vomitmg, with re- sulting dangers of inspiration of vomited food; (2) excretion of ether takes place by the gastric and intestinal mucous membrane, and arrest of digestion and the production and absorption of toxic products occurs in consequence. Except in emergencies, the examination of the heart and lungs should be made on the previous day. The patient is thereby made more comfortable by the assurance that these are in a healthy condition. This likewise gives the surgeon an opportunity to postpone the operation, in case these organs are not found normal, without unduly exciting the fears of the patient. This examination should be made, if possible, by the person who is to administer the anesthetic. In emergency cases the examination may be made just before commencing the administration of the anesthetic. The examination of the kidneys is most important. Not only should the presence or absence of albumin in the urine be determined, but tube casts should be eliminated as well. The examination of the urine for urea is, however, of far more importance than the test for albumin or even a micro- scopic examination for casts. It is now well known, in cases of renal disease, that the appearance of both albumin and casts may be, and often is, inter- mittent. The crucial test of the sufficiency of the kidneys is the amount of urea that they eliminate. Under ordinary circumstances a healthy man should excrete in twenty-four hours from 240 to 420 grains of urea, a w^oman somewhat less. No one can safely be given a general anesthetic when the total urea falls below 100 grains, and a total quantity of 200 grains should put the surgeon on his guard. The total quantity passed in twenty-four hours should also be ascertained, the specific gravity learned, and on the basis of this, an estimate of the daily excretion of urea made. A ready method of ascertaining the total amount of urea in twenty-four hours, which is approximately correct, is as follows : ^Multiply the fluid ounces passed in twenty-four hours by the last two figures as expressed in the specific gravity; this gives the total amount of solids in grains. Divide the result by 2, and this will give the amount of urea in grains. Example: Total quantity 50 oz., sp. gr. 1018; 18 X 50 = 900 -^ 2 = 450 (B a r 1 1 e y). In fact, the necessities of a life insurance examination are insignificant as compared with the demands of a properly conducted inquiry before administering an anesthetic. EFFECTS OF ETHER 291 Just before the commencement of the anesthetic the administrator should examine the patient's mouth for false teeth or other objects which may become cli.sijlaccd and obstruct respiration. The nose and throat may be cleansed with ad^•antago with a warm normal salt solution. In debilitated patients the pre- liminary administration of an enema consisting of half a pint of saline solution with two ounces of brandy is of service. Effects of Ether. — These are usually divided into four stages. In the first stage, if the patient experiences suddenly the irritating prop- erties of the vapor, there will be closure of the glottis, repeated acts of swal- lowing, cough, and a sense of suffocation. There are certain sensory disturb- ances, such as flashes of light and exaggeration of sounds; singing in the ears and hammering noises are experienced ; pricking sensations may be felt throughout the body. The pulse is accelerated and the pupils are large and mobile. Loss of consciousness marks the commencement of the second stage. Just as this condition supervenes, however, m some cases, a period of excitement occurs, in which the patient may shout, sing, or make vigorous struggling efforts with the arms and legs. When these are only slight, they should not be restrained. Tonic convulsive movements are observed in some cases; in others the muscular contractions are clonic. Tremors may be present (ether tremor). ]\Iucus and saliva are sometimes freely secreted. The pupils are mobile and somewhat dilated. The pulse is full and bounding. The features are flushed and the conjunctivae injected. The breathing is often irregular and some- times restrained or even suspended. The latter may be corrected by per- mitting the patient to breathe a little air. As the respirations become more and more regular the muscles acting on the jaw, as well as those of the larynx, which are sometimes thrown into a state of spasm, become relaxed and slight stertor is present. In the third stage the respirations become regular and stertorous, the extremities flaccid, and the cornea insensitive. The respiratory efforts are increased in frequency and are forcible and distinctly audible, particularly if mucus is present in the fauces and larynx. j\Iasseteric spasm occurs now and again, necessitating the pushing of the jaw forward. This, with irregularities in breathing, indicates that the patient is passing back into the second stage. The pulse is slower than in the second stage but is still more rapid than normal. The pupils are of moderate size or slightly dilated. Both eyeballs may be fixed in the horizontal plane or both may slowly move. There may be loss of associated movements, one eyeball being fixed while the other slowly moves ( W a r n e r) . The fourth stage of etherization is the stage of danger, and should never be reached. In it respiratory failure occurs; the pupils become more dilated; pallor gives place to a dusky hue of the surface ; the eyelids are slightly sepa- rated; the pulse becomes less forcible and sometimes slower. With the occurrence of respiratory failure the stertor first ceases and then the breathing efforts become less and less forcible, shallow, and slower; in some cases the breathing is jerky, intermittent, and gasping. If one or more of the phenomena above described occur in connection with a sensitive conjunctiva, they are due to causes other than an overdose of ether. 292 SURGICAL ANESTHESIA The invariable rule should be to watch the patient carefully, both during- and after the anesthesia. Methods of Administering Ether. — Two systems of administering ether are recognized, ^'iz., the open and the close. When the open system is employed, a plentiful supply of air is allowed with the ether. In the close system the suppl}' of air is restricted, the patient breathing to and fro into a rubber bag or other ether device attached to the face-piece of the inhaler. Open System of Administration. — While ether may be administered by means of an improvised inhaler cone consisting of a towel and newspaper folded together and fashioned into proper shape, with a sponge or bundle of gauze forced into the opening left at the apex of the cone, yet it is desirable to furnish as large an evaporating surface as possible, and at the same time permit the free ingress and egress of air. This may be accomplished by A 1 1 i s ' s inhaler (Fig. 59). The apparatus is to be placed over the face and the patient told to breathe deeply, in order to gain his confidence. The ether is then to be dropped on the inhaler in a steady succession of drops scattered over the margins of the evaporating surface of the inhaler. As the effects of the anes- Fig. 69. Fig. 60, Figs. 59 and 60. — Allis's Ether Inhaler. Showing fenestrated metallic frame with a muslin roller in course of application, and the inhaler complete with cover. thetic become manifest, the entire area is moistened, after which the ether is allowed to run in a small stream until the muslin material of the inhaler be- comes well saturated, in which condition it is to be maintained until the patient is thoroughly anesthetized. This method of gradually increasing the strength of the ether vapor prevents the feeling of suffocation commonly experienced when some of the other forms of inhaler are used, and permits the larynx to become accustomed to the vapor, whereby the respiratory rhythm is but little, if at all, interfered with. The administration should be rapidly pushed as the patient becomes semi- unconscious, it being borne in mind that at every free and deep inspiration almost the entire bulk of ether is removed from the inhaler. It is therefore incumbent on the administrator to keep up, without intermission, a constant supply of ether to the inhaler, every portion of the evaporating surface being kept equally moist, until the patient is completely under its influence. In this INIETHODS OF ADMINISTERING ETHER 293 numiier the minimum amount of ether is used, and the patient anesthetized in from three to five minutes. The stage of excitement is very much shortened anil may not occur at all. The" objections urged against the open system by some surgeons are (1) tlie larger quantities of ether needed to secure and maintain anesthesia; (2) the difficulty of anesthetizing alcoholic subjects; (3) the waste of ether and the presence of the vapor in the room; (4) the more prolonged stage of excitement when })resent ; (5) the greater risks of bronchial and pulmonary affections. Close System of Administration.— This system is largely used abroad, particularlv in Great Britain. In Clover's inhaler (Fig. 61) the face- piece fits the face accurately and the patient breathes backward and for- ward into the attached rubber bag, the ether being contained m a spheric-shaped reservoir placed in the body of the instrument. This Fig. 61. — Clover's Ether Inhaler. reservoir is surrounded by water to prevent the apparatus from becoming too cold. There are no valves and no provision for the ingress of fresh air. The apparatus is fitted closely to the face and the rubber bag attached while the patient is making an expiratory movement. This fills the rubber bag with expired air, which the patient breathes for half a minute before the ether vapor is turned on. No fresh air is permitted until signs of cyanosis appear, associated with stertorous breathing, or there is impairment of respiration or circulation. When it is necessarv to admit fresh air, the inhaler is removed for two or three breaths. When fufl surgical anesthesia is established, the minimum amount of ether vapor is permitted to pass to the face-piece, and air is admitted m suf- ficient quantities to prevent cvanosis. The object of the administration is to give as little air as possible short of producing actual cyanosis. The less air given, the less ether will be required. The more air the patient is permitted to breathe, the more ether will be required to maintain surgical anesthesia. 294 SURGICAL ANESTHESIA r m s b y ' s inhaler, as improved by H e ^v i 1 1 , has an arrangement to permit the giving of air with the ether vapor in varying proportions; or either all air or all ether may be inhaled. The ether ls poured on a sponge, the metal compartments containing it being fitted with a removable water chamber to prevent the sponge from becoming too cold (Fig. 62). In using Ormsby's inhaler the sponge is first wrung out of warm water, the water chamber removed and immersed in hot water for a few minutes, and then replaced. Half an ounce of ether is poured on the sponge, and, with the air- stop open, the inhaler is gradually brought toward the patient's face. The patient is encouraged to breathe deeply. Clover's inhaler is undoubtedly the best of the close inhalers for inducing anesthesia, while r m s b y ' s has some advantages over C 1 o v e r ' s in maintain- ing the anesthetic effect. The latter, however, is more economic in respect to ether. The use of r m s b y ' s inhaler is attended by more struggling while the patient is being anesthetized, but is well adapted for administering ether after precedent anesthesia by ni- trous oxid. The Semi-close System. — This is a compromise between the open method, with its waste of ether and difficulty of anesthetizing alcoholic and vigorous sub- jects, and the close method, with its complicated appa- ratus and asphyxial tenden- cies. The success of the open method shows that anesthetization can be accomplished even with the constant free access of fresh air. The admission of sufficient air to carry the ether vapor, yet not enough to dilute the latter unduly, is desirable. Lrkewise, it is of advantage both in the saving of ether and in the keeping of the evaporating surface warm, to find some means whereby the full force of each expiration is not exerted to drive the expired air, with a certam amount of ether vapor, directly from the inhaler into the room. In accomplishing this, the retention of the expired air in the inhaler for a time is necessar\^, but the evils of this are minimized by the constant accession of fresh air which is mingled with the previously expired air as it is reinhaled. An inhaler devised with the above objects in view (Fig. 63, A) consists of a flattened cylinder of metal, with one end closed. An opening on each side near the closed end serves for feeding the ether on the evapoiating surface. The latter consists of upholsterer's curled hair. The openings likewise serve the purpose of admitting sufficient air to reinforce the expired air to a sufficient extent. The size of these openings may be regulated as required. Two metal gutters are placed on the inside of the inhaler to catch whatever superfluous ether may be poured into the inhaler and lead it to a smaU vent hole as a telltale on each side of the inhaler. While using this inhaler the patient's head is turned to one side, in order to permit the mucus and saliva to accumulate in the lateral portion of the pharynx,. Fig. 62. — Ormsby's Ixhaler. A, Rubber bag; B, sponge; C, adjustable cap for regulat- ing the admission of air; D, tube for conducting air above the sponge; E, metal face-piece T\-ith vdre cage for sponge; F, in- flatable cushion for face-piece. METHOD OF ADMINISTERING CHLOROFORM 295 and the iiassago of these through the glottic ojjening, with the attendant risks of inhalation i)neumonia, is thus avoided. The patient breathes through the inhaler for a minute. This serves to impart confidence and at the same time warms the inhaler. Ether is then placed in small quantities on the evaporating surface through the slot which is uppermost, the quantity being gradually increased as the second stage is reached, until finally a small stream keeps the evaporating surface thoroughly charged with the anesthetic agent. I'his is con- tinued until the patient reaches the third stage, or that of surgical anesthesia. The curled hair possesses advantages over the sponge, cotton, and gauze materials usually employed, in that its meshes do not become easily clogged and hence comjiaratively impermeable. It is likewise easily sterilized by boiling in water and may be used over and over again. Method of Administering Chloroforni. — Here also a special appara- tus is advantageous, though the agent may be administered by means of Fig. 63. — Anesthetizing Outfit. A, Semiclose ether inhaler; B, dropper bottle for ether; C, Esmarch chloroform mask; D, dropper bottle for chloroform ; E, screw-gag; F, lever-gag; G, tongue-forceps; H, needle threaded with silk suture for securing the tongue; I, hypodermic syringe and medicine glass; J, ethyl-bromid tube; K, measuring glass and hypodermic tablets. a folded napkin or handkerchief. The mask of Esmarch, consisting of a wire frame, shaped to fit the face, covered with a merino material, is the best devised (Fig. 63, C). A modification of this by S c h i m m e 1 b u s c h permits the ready change of the woven material used as an evaporating surface and also presents the advantage of being capable of being folded. As in ether, the administration of chloroform should be begun by placing the mask over the face and bidding the patient breathe deeply a few times. Then only a drop or two should be placed on the apparatus by means of the dropper bottle (Fig. 63, D), the stopcock of which should be graduated so as to permit slow dropping only. Each part of the mask should receive a drop of the chloroform in turn, the anesthetizer thus keeping up a constant supply. Chloroform should always be kept in a well-stoppered dark bottle, in order to exclude the white rays of light, under the influence of which it is decomposed into hydrochloric acid, chlorin, free formic acid, etc. 296 SURGICAL ANESTHESIA The position of the patient should always be the recumbent one in chloro- form narcosis, with the head lowered; it is even recommended that the body should be placed at an angle of 45 degrees, the head depending. The preliminary hypodermic injection of morphin (Nussbaum) is recommended, in order to lessen the amount of chloroform or ether required. As a stimulant to the respiratory centers atropin is also recommended to be given hypodermically. The preliminary hypodermic injection of spartein and morphin as a cardiac tonic is recommended (Langlois; Maurange). The anesthetizer should not permit his attention to be diverted while carefully watching the patient's condition. He should constantly keep his finger on the temporal or facial artery, carefully watch the patient's breathing and the corneal and pupillary reflexes, as well as the color of the skin. Special Dangers from Ether Narcosis. — The dangers from ether inhal- ation are mainly those arising from asphyxia, and not, as a rule, from heart failure, though the latter may occur. For this reason, though the heart is not to be neglected, the greatest watchfulness is to be kept over the respira- tions. Usually there is some warning of danger during ether narcosis, symp- FiG. 64. — Junker's Inhaler Arranged for Administering Chloroform through the Nose. A safety-pin is passed across the nasal tube to prevent the latter from slipping too far in. toms of asphyxia coming on gradually. The first appearance of these should be met promptly by withdrawing the ether, and permitting the patient to breathe air for a while until the cyanosis ceases. The operator may note the dark color of the blood in the operation wound and notify the anesthetizer of the fact. In case of weak or failing respirations, artificial respiration should be resorted to (Sylvester's, see page 300). In case of coincident cardiac failure the method of stimulating the heart recommended in Chloroform Narcosis should be resorted to (see page 298). The After=effects of Ether. — The most common immediate after- effects of ether are nausea, retching, and vomiting. These are far less likely to occur if the patient's stomach is entirely empty at the time of the administration. This, together with the use of the purest ether, reduces these symptoms to a minimum. Sometimes the nausea and vomiting come on just as the patient is recovering consciousness. More commonly, however, they take place while he is unconscious. These symptoms are rarely the cause of anxiety to the surgeon. Bronchitis, pulmonary edema, and pnevunonia occasionally occur after etherization (see page 285). When they take place, it is not always clear that THE EFFECTS OF CHLOROFORM 297 the other is to be held res))()nsil)le. Then* occurrence is to be provided against, however, by a proper examination of the chest organs, and by a postjionement of the operation, whenever possible, in those suffering from bronchial catarrh or other abnormal conditions of the respiratory organs. Other precautionary measures are (1) keeping the patient's head turned well to one side during the administration in order to avoid inhalation of mucus and saliva; (2) avoiding all unnecessary exposure to wet coverings, drafts, etc., while the patient is on the operating table and after he has been removed to his room. Ether has been accused of causing albuminuria, nephritis, and uremia. It is now believed that these conditions rarely occur except in cases in which they have been present beforehand. Mental disturbances, choreiform move- ments, hemiplegia from cerebral hemorrhage, and jaundice are likewise to be mentioned as rare sequences of the use of ether. The Effects of Chloroform. — The phenomena of chloroform anesthesia are very similar to those of ether. During the first stage, however, the sense of suffocation, swallowing, coughing, and holding the breath are, as a rule, absent. This is owing to the fact that the vapor of chloroform is more pleasant to inhale than that of ether. During the second stage mental excitement and struggling are somewhat less common than when ether is administered, particularly where the open method of administering the latter is employed by those unaccustomed to its use. In muscular and alcoholic male subjects, as well as in hysteric and excit- able women, there is more or less rigidity, with attempts to rise to the sitting position, incoherent gesticulations, etc. Tonic spasm and irregular breathing may occur in some subjects in this stage; these pass away, however, and the advent of regular respirations, with slight snoring, marks the third stage of anesthesia. In the commencement of the second stage the pulse is accelerated, but as the third stage is approached it becomes normal. The pupils are, as a rule, mobile and more or less dilated, and react sluggishly, if at all, to light. As the anesthesia deepens they tend to become smaller and more fixed. The Third Stage.— As in the case of ether, the third stage of the effects of chloroform marks the presence of surgical anesthesia. The respirations, how- ever, are more quiet, though in plethoric, flabby, and obese subjects there may be more or less stertor, and some rigidity of the jaw muscles. Except in this class of cases it is not necessary, as a rule, to keep the jaw pushed forward m order to maintain free respiration. Indeed, at times the breathing may be so quiet under chloroform as to awaken anxiety. The circulation is more sluggish under chloroform than under ether. In the third stage the pulse may become even slower than the normal. In some " cases in which it was comparatively feeble in the first and second stages it is found to grow stronger in the third stage. The behavior of the eve reflexes is almost identical with that under ether anesthesia. The pupil i^ moderately contracted and averages somewhat smaller than in etherization. The pupil is an important guide in the admmis- tration. When it is verv small, the patient is not well under the chloroform, and when it is somewhat dilated either the anesthesia is dangerously deep, or the dilatation is of reflex origin and is associated with a light anesthesia. The 298 SURGICAL ANESTHESIA lid reflex is abolished and continues so as long as the patient remains in the third stage. The muscular system is completely relaxed under full cliloroform an- esthesia. The color of the face is at first heightened; afterward there is a tendency for it to become paler than the normal, particularly when the patient is coming out from the anesthetic and when vomiting is about to occur. The temperature is always reduced. Special Dangers from Chloroform Narcosis. — The majority of fatalities in chloroform narcosis occur early in the administration, i. e., in the second stage and at the commencement of the third, and in muscular and alcoholic subjects, as well as in hysteric and excitable patients. Evidence of great mental excitement, when present, indicates caution in the administration. This, together with irregular and shallow breathing, is to be met by a plentiful dilution of the chloroform vapor with air. Prolonged tonic spasm is a particularly dangerous feature. The general contraction of all the muscles of the body forces the venous blood to the right heart, from which it is prevented from escaping by the embarrassment of the pulmonary circula- tion incident to the want of fresh air. The right heart, being incapable of emptying itself, is unable to contract and becomes distended; unless the con- ditions are quickly relieved the patient dies from acute cardiac dilatation. The administration must be suspended and the patient made to breathe by forcible and intermittent pressure on the base of the thorax, or, if necessary, by artificial respiration. Aid in "breaking" the spasm of the respiratory muscles is sometimes afforded by forcibly dilating the sphincter ani. Clonic movements affecting the arms, whereby the latter are jerked more or less rhythmically toward the median line of the body, are due to spasm of the pectoral muscles. These should be regarded as strongly indicating the necessity for air (Hewitt). Cardiac failure may result from an overdose of chloroform, or it may occur quite independently of this, as shown by the fact that sudden syncope arises, in some instances, at the commencement of the inhalation, due in a measure to excessive fright and apprehension. Such sudden deaths oc- curring at the commencement of the operation were not unknown prior to the introduction of anesthetics. The freedom of ether, as well as of nitrous oxid narcosis from these fatalities is due to the fact that ether stimulates the heart and thus counteracts the depressing effects of the mental emo- tion, and nitrous oxid serves to overcome fear by quickly abolishing con- sciousness. Fatal syncbpe may arise in connection with vomiting, or efforts at vomit- ing, due to faulty or too sparing administration. The presence of undigested food is specially liable to lead to this complication. Asphyxia! complications leading to acute cardiac dilatation have been already alluded to {vide supra). Many of the cases of death under chloroform attributed to pure cardiac failure are probably due to a feeble, fatty, or dilated heart, the action of which is still further hampered by minor degrees of respira- tory embarrassment . Treatment of Dangerous Chloroform Narcosis. — The supervention of dangerous symptoms in chloroform narcosis must be met by withdrawing the anesthetic, lowering the head, elevating the lower extremities, drawing TREATMENT OF DANGEROUS CHLOROFORM NARCOSIS 299 the tongue forward, and making artificial respiration. The Sylvester method is the preferable one. The dashing of hot and cold water alter- natel}' on the chest and abdomen is recommended by some, but is of doubtful utility. The same may be said of hypodermic injections of the various drugs recommended. These cannot be absorbed while the circulation is enfeebled, and there is danger that their repeated administration may lead to the absorp- tion of an overdose when the heart's action is restored by other measures. This should be borne in mind when such powerful alkaloids as strychnin, cocain, digitalin, and atropin are used. The following points should be considered when these drugs are employed in dangerous chloroform narcosis : (1) Strychnin is a most powerful stimulant to both the heart and the respiratory centers. To be efficient it must be given in large doses in watery solu- tion, from 4o to yV of ^ g^^^^ being required in the case of an adult. Its effect on the respira- tion is first observed ; that on the heart occurs more gradually. (2) Cocain is a stimulant to the res- piration and may be given advan- tageously in combination with strychnin. These alkaloids given conjointly exercise a more power- ful influence than either given separately (Wood). From half a grain to a grain may be admin- istered in an emergency. (3) Digi- talis is indicated preliminarily for those with a weak heart, and it may also be given in cardiac failure under the anesthetic. (4) Atropin is a useful stimulant to the res- pirations alone. Its use is more frequently indicated in ether than in chloroform narcosis to -,-L, of a 2-rain is the dose. These From J-g- Y^ of a grain is the dose, drugs may be given hypodermi Fig. 65. -Sylvester's Method of Artificial Res- piration (Expiration). cally, though their effect will not be apparent unless the circulation is reestablished. For this reason their administration should not be repeated frequently nor at too short intervals, lest the patient be overwhelmed by the final absorption of an accumulated dose. While these drugs are being prepared and administered, a heated compress or a hot-water bag should be placed over the pericardial region. At the same time the diaphragm may be stimulated to contraction through the phrenic nerve by placing one pole of a faradic battery in the epigastric region and the other at the outer border of the sternomastoid muscle at its lowermost por- tion. This should not take the place of the work of making artificial respira- tion nor be permitted to interfere with it. 300 SURGICAL ANESTHESIA Artificial Respiration. — This is employed more frequently for the re- storation of patients suffering from dangerous surgical narcosis than in any other connection. It should be commenced as soon as respiration actualh^ ceases, as shown by the absence of all thoracic and abdominal movements, the absence of evidences of air passing from the mouth or nose, and the signs of deepening cyanosis. Sylvester's Method. — The head and neck should be fully extended, the former hanging over the end of the table; the tongue is well drawn forward to prevent possible obstruction to the entrance of air. The arms are grasped at the elbows and pressed firmly for about two seconds against the sides of the chest (Fig. 65). If this does not cause an expiration, the pressure should be made below the costal margins in the direction of the dia- phragm. The arms are now brought upward to each side of the head, inspiration being ef- fected by thus increasing the capacity of the chest through the action of the pectoral muscles on the upper ribs (Fig. 66). These movements are kept up at the rate of about fifteen times a min- ute. With the occurrence of spontaneous efforts at breathing, care must be taken to supplement rather than substitute the normal respiration. The artificial move- ments are occasionally suspended in order to judge of the efficiency of the normal efforts. Laborde's method of rhyth- mic traction of the tongue is sometimes successful in restoring the respiratory reflex. The tongue is grasped by forceps and alter- nate traction and relaxation made about twenty times a minute. This is kept up for at least half an hour, unless respiration is es- tablished in the meanwhile. This method may be employed alone or in conjunction with other methods. Intralaryngeal insufflation consists in forcing air from a bellows into the lungs through an intubation attachment (F e 1 1 - ' D w^ y e r method). Provision is made for the escape of the expired air through a branch tube. A modification of this apparatus consists of the substitution of a graduated pump for the bellows, and the addition of a mercurial manometer and auto- matic cut-off for preventing the backward leakage of air. This improved apparatus is also arranged for administering oxygen or an anesthetic while artificial resj^iration is being carried on (]\I a t a s). Fig. 66. -Sylvester's Method of Artificial Res- piration (Inspiration). PRIMARY anesthesia; I'liECEDENT ANESTHESIA 301 Primary Anesthesia.— It has been suggested that advantage may be taken of a period of rather complete anesthesia which is said to intervene between the connnencement of the a(hriinistration and the occurrence of the stage of excitement. The patient is requested to hold up his arm and main- tain it in that position as long as he possibly can. When it is no longer vol- untarily held, a very short operation, such as an incision for an abscess lasting for not more than ten seconds, may be performed. It is not always possible positively to identify this stage, if, indeed, it is of constant occurrence. On the other hand, some surgeons assert that there are certain dangers, particularly those resulting from sudden shock, which arise from the attempt to proceed with an operation of any kind before the patient is fully anesthetized. Many European surgeons, however, prefer to operate as soon as the stage of ex- citement is over and l^efore complete relaxation is established. Precedent Anesthesia.— The use of anesthetic agents which produce rapid yet transient anesthesia has been advocated for the purpose of abolishing the stage of excitement incident to the employment of ether, as well as of lessening the length of time occupied in producing anesthesia, and hence the amount of ether used. The agent of this class in most common use is nitrous oxid, or laughing gas. Chlorid of ethyl and bromid of ethyl have also been employed. Nitrous oxid possesses the advan- tage of not inducing a stage of excitement ; the agent it- self is practically without taste or smell and is abso- lutely nonirritating to the respiratory tract; hence its administration excites no resistance on the part of the patient. The necessary apparatus, however, is somewhat bulky and complicated. Nevertheless, there can be no question that in experienced hands the use of nitrous oxid precedent to ether has great advantages, in selected cases, over the employment of ether in the usual manner. Chlorid of ethyl (T u 1 1 1 e) and bromid of ethyl (Fowler) are equally efficient, and less expensive as to the cost of both the agent and the necessary apparatus. The absence of excitement cannot always be assured, and the odor, particularly in the case of bromid of ethyl, induces repugnance, and hence, in some instances, resistance to its use. In order to obtain the best results from chlorid of ethyl it is necessary to use a special inhaler, the agent being sprayed on the inhaler until the effect is obtained. In the case of bromid of ethyl the amount necessary to induce anesthesia, from three to four drams for an adult, is placed on a closed ether inhaler, and, all air being excluded, the pa- tient inhales this for about one minute, or until the pupils are widely dilated or Fig. 67. — Ware's Apparatus for the Opex Admixistratio.v OF Ethyl Chlorid. 1, Funnel-shaped rubber face-piece; 2, tube over the end of which two layers of gauze are stretched; .3, neck of the face- piece into which the end of the tube with its gauze covering is forced. 302 SURGICAL ANESTHESIA the usual signs of surgical anesthesia are present. Sulfuric ether is then sub- stituted for the bromicl of ethyl. Anesthesia by Means of Nitrous Oxid. — This agent is largely employed by dentists in tooth extraction. Its use is usually restricted to opera- tions of short duration, though it has been employed in operations of an hour or more in length. It requires special skill in its administration and a special and somewhat complicated apparatus as well. For painful redressings, when the patient dreads them, and when ether or chloroform cannot be repeatedly used for passing urethral sounds, etc., it has been employed with advantage. It enters the blood bv diffusion throu2:h the thin walls of the Fig. 68. — Ethyl Chlorid Tube. alveoli of the lungs. While its anesthetic properties are manifesting themselves, the patient's respirations become labored and stertorous and finally very shal- low. A cyanotic hue spreads over the surface, and it is not until this occurs that complete anesthesia is established. The latter lasts but a moment or two after the agent is withdrawn, which must be done before respiration ceases altogether, else the danger-line is reached. Paul Bert (1875), by mixing together 80 volumes of nitrous oxid and 20 of oxygen, succeeded in obtaining an anesthetic agent the great advantage of which consists in the fact that all the reflexes necessary to life are present, while complete anesthesia is established, the normal condition returning as soon as the inhalation is suspended. The general introduction of this mixture is very much embarrassed by the compli- cated and cumbersome ap- paratus necessary for its use. Ethyl Chlorid as a General Anesthetic. — The employment of this agent for the purpose of general anesthesia is indicated in minor operations of short duration. It may be administered with the patient either in the horizontal or in the sitting position. It is said that, with the exception of nitrous oxid, it is the least dangerous of general anesthetics, and that neither cardiac, respiratory or renal affections, nor pregnancy contraindicates its use. It may be administered to old and young alike. It is pleasant in its effects and rapid in its action. Anesthesia is preceded by an analgesic stage, lasting for a fraction of a minute; this is followed by tonic contractures, increased frec{uency of the respirations, and moderate dilatation of the pupils. Short operations may be performed in this stage. The third stage, or that of profound anesthesia, is Fig. 69. — Daniels's Modification of the Clover Ether In- haler, FOR Ethyl Chlorid Administration. DISTURBANCES OF THE NORMAL COURSE OF ANESTHESIA 303 reached in from a quarter of a minute to a minute later, according to the age of the patient and the method employed. In full anesthesia the muscles are relaxed; the respirations are deep and regular, with snoring in some cases; the conjunctival reflex is abolished and the pupils somewhat dilated. From 1 to 5 c.c. of ethyl chlorid are necessary to produce the third stage; 1 c.c. given about every minute thereafter suffices to maintain the anesthetic effect. Either the close or the open method may be employed, preferably the latter by those not accustomed to its use. W are's apj^aratus is the simplest (Fig. 67) for open administration; the ethyl chlorid is sprayed on the gauze from the ethjd chlorid tube (Fig. 68) as reciuired. For the close method Daniels's modification of the Clover portable ether inhaler is useful (Fig. 69). The ethyl chlorid is placed in the graduated glass ^•ial, and the latter connected with the tube and stopcock of the nitrous oxid attach- ment of the apparatus by means of a piece of red rubber tubing. The flow of ethyl chlorid is regulated by the stopcock. Only a pure article should be employed. The preparation known as "kelene," the ethyl chlorid of B e n g u e , or that of H e n n i n g , of Ber- lin, may be used. Disturbances of the Normal Course of Anesthesia.— The distur- bances of the normal course of anesthesia may be divided into those which occur during the period of excitement and those wliich occur during the period of relaxation. Among those which occur in the first period are to be noted uncontrollable and violent struggling and vomiting. Violent struggling is attended by some dangers, particularly in cases where chloroform is employed and in alcoholics. In this class of patients there is sometimes alarming cyanosis, demanding immediate withdrawal of the anesthetic. The suggestion to administer to alcoholics hypodermically a full dose of morpliin fifteen or twenty minutes beforehand is a valuable one. It renders the patient much more amenable to the anesthetic agent. Nausea and vomiting also occur before the patient is fully under the in- fluence of the anesthetic, particularly if he has partaken of food or drink during the preceding few^ hours. This vomiting may become a source of grave danger on account of the passage of the vomited matter into the air-passages, produc- ing suffocation. On the occurrence of this complication the patient's head should be turned to the side so as to facilitate the expulsion of food from the fauces and mouth. If this does not suffice, the index-finger is to be forced over the back of the tongue, bent like a hook, and used to withdraw any mass of food lying in the fauces. The stomach being once emptied, the anesthetic may be proceeded with. The occurrence of deep anesthesia will serve to assist the retching which sometimes follows the emptying of the stomach. In case suffocation threatens during vomiting, tracheotomy should be at once resorted to. The inspired portions of food will usually be coughed out of the tracheal wound. A condition of asphyxia is sometimes observed to come on without any preliminary vomiting. It is noticed that the patient makes vigorous efforts at breathing but no air enters the glottic opening. The patient's face be- comes bluish-red and finally deep purple or dark blue. As anesthesia ad- vances, the muscles of the tongue become paralyzed, and this organ sinks, from its own weight, so as to occlude the chink of the glottis. Under these 304 SURGICAL ANESTHESIA circumstances the fingers of the anesthetizer, placed behind the angles of the jaw on each side, flex the head sharply backward and at the same time force the lower jaw anteriorly, so as to cause its lower incisors to project as far as possible beyond the incisors of the upper jaw. The anterior insertion of the geniohyoglossus is thus forced forward and the tongue must necessarily follow. K a p p e 1 er seizes the body of the hyoid bone and drags it anteriorly, to- gether with the base of the tongue. If this maneuver fails to lift the tongue away from the glottis, this may be effected by grasping it with the tongue forceps (Fig. 63, G), or an ordinary pair of dressing or hemostatic forceps. If it is necessary to continue the lifting of the tongue, less injur}- will be in- flicted if a thread is passed through the organ, made into a loop and held by the anesthetizer. The thread should be passed crosswise to the tongue near its dorsal surface, at a point behind the attachment of the frenum, in order to prevent dragging on the latter. Sometimes, even in spite of this, it will be necessarj^ to press the tongue downward and forT\-ard, by the aid of the finger placed in the mouth. When masseteric spasm is present, the jaws should be forced apart by a screw-gag (Fig. 63, E), and a lever mouth-gag (Fig. 63, F) introduced to hold the lower jaw do-um. The arrested ingress of air and ether vapor incident to the blocking of the upper air-passages by the base of the tongue is frequently due to the combined effects of masseteric spasm and involuntary efforts at swallow- ing. Forcing open the mouth by a gag, so as to put the muscles freely on the stretch, relieves the spasm, interrupts the swallowing act, and gives access to the cavity of the mouth for the purpose of either depressing or drawing forward the tongue and clearing the fauces of mucus or saliva. Anesthesia in Face Operations. — Full surgical anesthesia is first estab- lished, after which the pharynx is cocainized. Two full sized drainage-tubes are passed through the nares to the level of the epiglottis and allowed to project beyond the nose a sufficient distance to permit the administration of the anesthetic away from the field of operation. The mouth is then widely opened, the tongue drawn out, and the pharynx packed with large pieces of gauze. If the base of the tongue is carried well forward an air chamber is formed, with which the rubber tubes and the larynx communicate. A Junker inhaler (Fig. 69), or other apparatus for vaporizing the anesthetic agent, may be connected with one of the tubes. ^yhen this method is employed, the patient may be placed in the position best suited to the operative technic, regardless of the flow of blood. The flow of mucus usuafly incident to operations within the cavity of the mouth is absorbed by the gauze (C r i 1 e). LOCAL ANESTHESIA This is best effected by the use of cocain hydrochlorate. LocaUy applied this drug produces anesthesia, and, in addition, a condition of anemia due to contraction of the arterioles. The mucous membranes are promptly rendered anesthetic; the intact skin, however, is not affected by the drug. Personal idiosyncrasy is an important factor in its use. In those specially susceptible to its effects a few drops of a 4 or 6 per cent solution in the eye or nasal passages, or ^ of a grain administered hypodermicaUy, may produce alarm- LOCAL ANESTHESIA 305 ing depression. Experiments on animals show lliat the fall of blood-pres- sure following such nianii)ulations as ordinarily produce shock, abdominal section and manipulation of the intestines, manipulation of the larynx, stimu- latiim of the vagi, etc.. is inhibited by the effects of cocain (C r i 1 e). In the surgery of the immediately accessible mucous membranes, e. g., the nasoi)har\-nx, larynx, urethra, bladder, etc., solutions of from 4 to 6 per cent are necessary. In order to secure the anesthetic effects of cocain in tissues other than mucous membranes it is necessary to luring the drug in contact with these either through the use of hypodermic injection or by prolonged contact through wounds or incisions. The Sterilization of Cocain Solutions.— This is best accomplished by repeatedly heating the solutions to a point just below the boiling-point (fractional sterilization) . Boiling injures the anesthetic qualities of the cocain. The Local Infiltration Method (H a 1 s t e d , S c h 1 e i c h).— This consists in mjecting a 0.1 per cent solution into the substance of the skin. The resulting elevation of the epidermis is called a wheal. The first wheal is made by introducmg the needle in a slightly ol^hque du-ection for a short dis- tance only. The needle is then advanced and a small quantity again injected. Successive wheals are thus formed in the area to he incised. In operations involving deeper parts these must be cocainized in the same manner. In larger areas, in order to avoid the toxic effects of the drug, edema of the parts obtained by the injection of normal salt solution will produce anesthesia in these. Perineural Infiltration.— This consists in infiltration of the tissues about the nerves supplving the parts to be operated on, proximal to the point of intended operation '(Halsted, Oberst). A constrictmg bandage is placed about the parts a short distance above the seat of operation (Corning). The anesthetic effects are enhanced and the toxic effects lessened by the retention of the solution in the tissues for from half an hour to an hour.^ The constriction should be just sufficient to arrest the volume flow of blood in the vessels. The tissues about each nerve supplying the parts are infiltrated. The mjected solution should be retained for at least half an hour, by keeping the bandage on for that length of time. Intraneural Infiltration.— The nerve-trunk is first exposed by the ordinary infiltration method, and then injected with from 0.25 to 0.5 per cent cocain solution. The first injection is made beneath the sheath of the nerve; the substance of the nerve is then injected (C r i 1 e . 31 a t a s). _ Not only does the injected cocain render the operation painless, but the physiologic ''block" produced arrests all afferent unpulses and thus prevents shock. The preliminarv' injection of a dose of morphin (i to i of a grain) is recom- mended in all cases of cocain anesthesia. Eucain /?, the hydroclilorid of benzoyl, is sometmies used as a sub- stitute for cocam. on account of its much less pronounced toxic properties when large quantities are to be employed. It can be sterilized by boUmg and its solution will remam unchanged. For the bladder or urethra 4 per cent solutions are emploved. Solutions of from 1 to 2 per cent are employed for perineural and intraneural injections. The resulting anesthesia is more rapidly produced but is less lasting than cocain anesthesia. 21 306 SURGICAL ANESTHESIA Tropacocain Hydrochloric!. — This is derived from a special variety of coca plant found in Java. It is said to be less toxic than cocain and to pro- duce a more rapid and trustworthy anesthesia. Nirvanin. — This is a synthetic product. It is freely soluble in water. When used on sensitive mucous membranes, such, for instance, as the conjunc- tiva, a temporary irritation precedes the anesthetic effect. The anesthetic effect is in proportion to the sensitiveness of the surface to this precedent irri- tation. It is specially adapted for subcutaneous use, the resulting anesthesia being complete and prolonged. It is used in from 2 to 5 per cent solutions. The solution may be boiled without injury to the drug. Its toxic ciualities are said to be less than those of cocain and eucain. Antiseptic properties also are claimed for it. Orthoform. — This synthetic compound occurs as a white and very light powder. Its slight solubility in water renders it useless for subcutaneous administration. Its employment is limited to applications to painful lesions of the skin and mucous membranes. It is used as a dusting-powder or in a 10 or 20 per cent ointment. It may be given internally in doses of from 74^ to 15 grains for the relief of gastralgia. Loss of sensation occurs in from three to five minutes following its application to an ulcerated surface or an open wound, and lasts, according to C h e a t h a m , for from thirty hours to three or four days (P a 1 1 o n). Its value as a dusting-powder is enhanced by its drying action. Finally, it may be applied freely and for protracted periods without fear of toxic effects. Aneson. — A watery solution of acetone chloroform is known by this name. Its anesthetic effect is more Ciuickly produced than that following cocain, but is less pronounced. It is used in 1 or 2 per cent solution for application to the conjunctiva and the nasal, pharyngeal, and laryngeal mucous membranes. The solutions are said to be antiseptic and hence sterile. It may also be used subcutaneously. It is said to be both nontoxic and nonirritant. Ethyl Chlorid (Kelene). — The local anesthetic effects of ethyl chlorid are due to the intense cold produced. It is furnished in hermetically sealed tubes (Fig. 68) with a screw cap covering a fine point. The liquid is expeUed from the latter by the warmth of the hand, in a fine stream, which is directed on the surface to be anesthetized. Temporary congelation occurs, as evinced by the white solid appearance of the anesthetized spot. The anesthetic effect ceases in a few minutes. Its inflammability necessitates caution in its use near an open flame. Liquid Air. — This has been used as a local anesthetic in the shape of a spray. As in ethyl chlorid anesthetization, the anesthetic effect depends on congelation. A slight tingling accompanies the process. In order to obtain the best results the parts should be frozen solid. The freezing effect produced lasts for about twenty minutes and is succeeded by hyperemia. It is some- times used to alleviate neuralgic pains. It has also been employed to abort furuncles, buboes, etc., and has been applied at intervals of three or four days as a stimulant to chancres, chancroids, and indolent ulcers. SPINAL ANESTHESIA This is more properly termed "spinal analgesia," since only the sensation of pain is abolished by its use. The effect is obtained by the injection of cocain SIMXAL ANESTHESIA 307 into the siibchiral space in the lower dorsal and upper lumbar regions of the cord and Cauda equina (Corning). Pure crystallized h}'drochlorate of cocain is sterilized by exposure for fifteen minutes to a dry temperature of 300° F. and kept in sterile tubes until needed. The dose varies from -} to H- grains accord- ing to the effect desired. Complete analgesia of the entire bod}', except the head, may be obtained by this method. In exceptional cases the scalp to the vertex also becomes analgesic. A glass hypodermic syringe with asbestos piston is easily sterilized by boiling and is the best instrument to employ. The edges of the beveled point of the needle should be ground off to prevent punching out a portion of the skin. The injection may be made with the patient sitting, or, better still, lying on the side with the back curved. The needle is introduced between the third and the fourth lumbar ver- tebra. Its entrance into the subdural space is announced by the escape of a few drops of cerebrospinal fluid. The cocain is dissolved in 30 minims of sterile water, the syringe attached to the needle, and the solution slowly in- jected. The needle puncture is sealed with a drop of collodion. Or the cocain may be placed dry in the syringe barrel, the latter screwed in place, and sufficient cerebrospinal fluid withdrawn to effect the solution of the cocain, which is then injected. The analgesic effect is obtained in from five to ten minutes. Exceptionall}^ a longer time is required. The abolition of sensation usually commences in the feet and gradually extends upward. The average height reached is the level of the umbilicus. "With larger quantities of the solution greater diffusion is obtained, but the use of larger doses of the drug is followed by alarming symp- toms of faintness, nausea and vomiting, and signs of collapse. On the other hand, larger dilutions of a safe dose may lead to faihu-e. The effect lasts from forty-fiA'e minutes to three hours. All operations on the lower extremities, genitals, anal region, bladder, and groins (hernia, etc.) may be performed under spinal analgesia. Ovariotomy, hysterectomy, appendectomy, gallbladder operations, and even operations on the thorax have been performed by this method. The last-named operations, however, are not advisable, for the reasons above given. The method should not be used as a routine procedure and can never replace ether and cliloroform. The toxic effects of cocain (great depression, profuse sweating, etc.), as well as the symptoms due to increased tension (intense head- ache), are common. Besides these, the nausea and vomiting are frequently persistent, together with relaxation of the sphincters and cramps in the limbs. Overaction of the heart and precordial distress are not uncommon. Old and somewhat feeble patients, in my experience, suffer less from these s}'mptoms than the young and vigorous. Spinal cocainization should be reserved for those individuals in whose cases, on account of the presence of either heart disease, pulmonary disease, or renal disease, a general anesthetic is contraindicated. SECTION X THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC THE SEPARATION OF TISSUES Tissues are separated or divided for either diagnostic or therapeutic pur- poses. Exploratory incisions are employed for reaching deeply placed dis- eased foci for purposes of inspection and palpation. Indications.— d J The separation of the destroyed tissues from the intact tissues in recent injuries; (2) the fash- ioning of irregular wound surfaces for coaptation; (.3) aid in the search for foreign bodies; (4) the exposures of bleeding vessels for purposes of ligation; (o) the introduction of drainage-tubes; (Q) the evacuation of the products of inflammation (pus and other debris); (7) access to inflamed structures for the removal of infected tissues, blood- clot, etc., and the appUcation of anti- -eptic remedies; (8) the extirpation or destruction of tumors; (9) the removal of parts hopelessly infected or diseased; nOj plastic procedures and the correc- tion of deformities; (11) hgation of blood-vessels in continuity; (12) trans- fusion; (13) the expsoure of underlying uarts to be operated on, as in trephin- ing; (14) abdominal section or celiot- omy; (1.5) herniotomy. Means Employed. — The following are the pjrincipal means employed for -eparation of the tissues: (1) cutting instruments; (2) blunt instruments, including the elastic and wire ligature; (3) cauterization; (4) puncture; (5) the sharp spoon or curet. Cutting Instruments. — lliese include the scalpel and its modifications, the scissors, for separation of the soft parts, and the saw, the chisel, the cutting forceps, and the drill, for the osseous and cartilaginous .structures. The scalpel (Fig. 70) is employed for free-hand incisions and dissections of the soft parts. The blade should be solidly attached to the handle, as in the case of those with hard-rubber handles in which the handle is vulcanized 308 70. — Scalpels. TIIK SEPARATION OF TISSUES 309 on the stem of tho ])la(lo (Tiemann); citlior this, or the entire instrument should be forged in one piece. The blade may be narrow and pointed for puncturing and short incisions, and broad and convex, or "bellied" on its cutting-edge, for long incisions and extensive dissections. Scalpels with slightly concave blades (hollow ground) are preferable. The handle should afford a firm and easy grasp for the thumb and fingers and the extrem- ity of this part of the instrument should have a "fish tail" shape for blunt dissection. A double-edged scalpel is useful in certain plastic operations. Knives with stout handles which may l)e grasped with the entire hand are pro- vided with short heavy blades for operations on bones and joints and with long blades for amputations. The bistoury (Fig. 71) is another modification of the scaljjel. It may be straight or curved and pointed or blunt. In the separation of tissues from without inward, it is necessary in some localities, on account of the loose connections of the skin to the underlying structures, to make tension on the tissues in order to facilitate incision. The skin may be put on the stretch (1) by the thumb and finger-tips of the surgeon's left hand; (2) by the hands of the surgeon and his assistant; (3) by the flexion or extension of joints, and rotation and ex- tension of the head in operations about the neck. After the skin has been incised, the underlying structures are steadied by anat- omic or thumb forceps (Fig. 72), held by the surgeon himself, by his assistant, or, bet- ter still, when the latter is well trained, by both. Different forms of fixation forceps have been devised for special operations, such as the double tenaculum forceps (Fig. 73) for grasping tumors and steadying the same during enucleation, and the ring-bladed or fenestrated clamp (Fig. 74), for grasping soft parts which would otherwise tear if grasped by tenacula, such as hemorrhoids during extirpation. The different methods of holding the scalpel are shown in Figs. 75, 76, and 77. The surgeon's own tact and ingenuity will suggest to him the conditions to which these positions are best adapted. Incisions from Within Outward. — These are made either with a probe-pointed or a sharp bistoury ; when emplo^^ed to enlarge or to expose the extent of a fistulous tract, a curved blade answers best. When a pointed bistoury is used for this purpose, it is prevented from penetrating beyond the fistula or sinus by the preliminary introduction of a grooved director as a guide (Figs. 79 and 80). Except under these circumstances and in special cases, such as external urethrotomy and perineal lithotomy, the surgeon Fig. 71. — Bistouries. 310 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC should depend on his knowledge of anatomy and execute incisions in a free- hand manner. Separation of the Tissues by Means of Scissors.— The blades of the scissors should be properly fitted and well sharpened, in order that Fig. 72. — Anatomic or Thumb Forceps. the incision should be as clean as possible; at the best the tissues are more or less pinched and contused by the opposing blades. The steadiness with which the parts are held by the scissors as they are incised constitutes an advantage in the use of this instrument. They should not be employed where Fig. 73. — Double Tenaculum Forceps. the vitality of the structures is already impaired and gangrene or sloughing is to be feared. The hand, in grasping the scissors, covers more or less the field of operation and obstructs the view. This is obviated somewhat by scissors curved on the flat (Fig. 81, A). In prolonged operations, as, for instance, in removing multiple lymphomas from the cervical region, the alternate use of the Fig. 74. — Ring-shaped Pile Forceps. knife and scissors lessens the fatigue incident to the continuous use of one instrument, inasmuch as different sets of muscles are employed for each. Besides straight scissors and those curved on the flat, there are other shapes which may be advantageously employed, e. g., angular or those curved on the side (Fig. 81, C). TTTE SEPARATION OF TISSUES 311 The Separation of Bone.— This is accomplished l\v means of the saw and its modilications, chisels, cutting forceps, and drills. Saws are made with solid broad blades for sawing squarely across the bone (Fig. 82). A narrow Fig. 75. — Method of Holding the Scalpel for a Long Sweeping Incision. Fig. 76. — Method of Holding the Scalpel for Dissecting. Fig. 77. — Scalpel Held Like a Violin-bow. blade fixed in a frame is useful in making irregularly shaped cuts (Fig. 83). The chain saw and the wire saw are used in separating bone from within out- ward (see page 312). 312 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC Fig. 78. — Method of Holdixg Bistouhy. Cutting upward as in opening an abscess. In commencing the section the saw should be drawn at first across the bone from the heel to the point of the instrument in the direction toward the operator, in order to secure a groove for the subsecjuent strokes of the instrument. This preliminary backward stroke can be made more steadily than a for- ward stroke over the smooth bony surface, so that the operator is thus enabled to place the groove at the proper point, the saw sub- sequently following the groove in completing the section. The chain saw (Fig. 145) is made of a numl^er of links con- ^^^^Vji ^^Bi^ltT nected together like the links of ^^BFJ^mwf^ mH^^^ ^ ^ chain, the teeth being set upon "^^^ ^Ji^l^^\mmlt% fmmm the links. A handle is attached to each end, the saw being moved by pulling on one or the other handle. The wire saw of G i g 1 i (Fig. 147) has largely taken the place of the chain saw. It is made of piano wire with roughened surfaces. It is more easily introduced and occupies less room when in position than the chain saw. It is com- paratively inexpensive and is much more readily cleaned and rendered aseptic than the latter in- strument. The trephine (Fig. 84) is a tubular shaped instrument with saw teeth, designed for re- moving button - shaped sections of bone. It is almost exclusively used for the vault of the skull. A pin is projected beyond the instrument for the purpose of steadying the latter until a groove is formed by a series of rotating movements. Fig. 79. — Cuttixg Upward on a Grooved Director. Fig. so. — Grooved Director. Care should be taken that the point of the pin does not project far enough to perforate the bone before the groove which is to serve for the sub- THE SEPARATION OF THE TISSUES 313 sequent guidance of the instrument is sufficiently deep for the purpose. Though the conical and grooved sides of the trephine of Gait (Fig. 85) are designed to prevent a too sudden com])l('ti()n of the section and consecjuent injury of the dura, in the case of the skull this should not be trusted too implicitly. The in- strument should be occasionally removed and the debris cleaned away for purposes of examination. The sound obtained by tapping on the button of l^one at different points with the handle of the in- strument will reveal any part which may have been cut through in advance of the rest, in which Fig. 81. case the trephine should be tilted away from that point. Drills are used for perforating bone for suturing and for exploratory pur- poses (Figs. 86 and 87). In applying the drill the handle of the instrument is grasped in the palm of the hand, the index-finger passing alongside the -A, Scissors curved on the flat; scissors; C, angular scissora. B, .straight Fig. 82. — Broad Saw. instrument and steadying the latter until its point is engaged. A crochet needle will be found useful in passing the suture. F 1 u h r e r has com- bined a drill and crochet needle in the same instrument (Fig. 87). Fig. 83. — Frame Saw. In recent years the surgical engine, modeled on the lines of the dental engine, has been employed for gaining access to the cavity of the skull and for sawing 314 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC and perforating bones in other situations. The electric surgical engine consists essentially of an electric motor, a flexible cable for transmitting the power, and various circular saws, burrs, and drills, together with proper chucks, and Fig. 84. — Roberts's Aseptic Trephixe. 1, Removable block and center-pin; 2, trephine complete. clutches for securing these to the cable, and handles for guiding the application of these to the work in hand. The best of these is that devised by D o y e n , and made by C o 1 1 i n , of Paris (Fig. 88). Chisels are used for cutting away portions of bone where the saw cannot be applied. They are made indifferent shapes and sizes, according to the var- ious rec{uirements (Fig. 89). They are used in connection with the mallet. The wooden mallet of the cabinet- maker is the best for the purpose. A little practice will enable the oper- ator to fix his attention on the prog- ress made by the edge of the instrument, rather than on the head of the latter where blows of the mallet are to fall. Rongeur forceps are used for round- ing off or smoothing rough surfaces of bone left after sawing (Fig. 90, A). Cutting forceps (Liston's, Fig? 90, B) for severing small bones are used where the latter are inaccessible to the saw. Those supplied with hollow blades are used as a punch in removing bone (Fig. 91). When the cutting forceps are used for the division of bones like the metacarpal, a preliminary Fig. 85. — Galt's Trephine. THE SEPAKATION OF THE TISSUES 315 groove made with the points of the forceps on one or more sides of the bone will prevent extensive splintering. The sharp spoon or curet (Fig. 92) is used for removing diseased tissues from surfaces by scraping movements. It is used for clearing away the infected walls of abscess cavities and sinuses, and the soft and broken-down parts of diseased foci in bone and other structures where a formal dissection is im- practicable or where the conditions are such as to render unnecessarv the removal of the entire part involved. These curets are made in different sizes; Fig. 86. — Bone Drill, with Hollow Handle to Contain- Different Sizes of Drills. some models have an u'rigating attachment to facilitate washing away the debris that results from the scraping. Separation of Tissues by Means of the Ligature and by Heat. — The simplest method of dividmg tissues b}' these means consists in applying a ligature to the pedicle of a soft tumor, the latter becoming necrotic and falling off. The application of the ecraseur is another example of the principle of this method. The instrument may be armed with a chain or firm steel wire (Fig. 95) ; the latter is preferred in removing nasal and aural polypi. The ligature is sometimes employed when no pedicle exists, e. g., in angioma of the skin, by transfixing the margins of the base with two or more needles carrying a thread in such a manner as to form a series of loops beneath the skin surrounding the Fig. S7. — Fluhrer's Crochet Drill. base. By tightening the loops of thread, the base is constricted, a subcu- taneous pedicle formed, and the ch'culation in the growth cut off. Elastic threads may also be employed for this purpose. The use of the elastic ligature has its more frequent apphcation in the cure of fistula in ano. It has likewise been used in effecting lateral anastomosis of contiguous bowel loops (M c G r a w). The galvanocautery loop is useful in a certain class of cases. The ap- paratus consists of a loop-carrier, somewhat like an ecraseur, wliich is armed with a loop of platinum wire. The latter is heated by a current of electricity supplied by the street current or a suitable battery. A galvanocautery knife ma}' also be used, as weU as a dome-shaped instrument for cauterizing flat surfaces. In addition to the hemostatic properties of the galvanocautery. an aseptic effect is obtained by its use. Recurring or secondary hemorrhage in tissues previously acted on by the cautery is troublesome to deal with on 316 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC account of the difficulty of grasping and securing the vessels. Wounds made by cauterization do not admit of primary union. The thermocautery of Paquelin (Fig. 96) is more restricted in its application than the galvanocautery ; for instance, it cannot be employed as a hot ecraseur. Fig. 88. — Doyen's Surgical Engine. 1, Electric motor; 2, cable for transmitting the power together with handle and chuck for securing the instruments; 3, larger saws; 4, small saw secured to chuck with guard ring in position; 5, burrs; 6, mortise burrs; 7, drill; 8, chuck shown separately; 9, handle with guard to prevent injury of the dura and saw arranged for section of the bones of the skull; 10, guard rings for the smaller saw; 11, instrument for measuring the thickness of the cranial bones after a small opening has been made. It has, however, the advantage of being simpler and less expensive, shaped pointed or flattened dome instrument may be used at will. A knife- THE SKPARATIOX OF THE TISSUES 317 Cauterization by Means of Chemic Substances.— These are divided into alkaline and acid substances, and the salts of various metals. The substances belonging to the former group that are in most common use are Fig. S9.— a, Maeewen's tapering chisel; B, Macewen's beveled chisel; C, hght tapering chisel ; D, hollow chisel or gouge. caustic potash and Vienna paste (potassa cum calce, U. S. P.). It consists of equal parts of potassa and lime. These unite with the water of the tissues and chssolve the albuminous bodies. Consequently their action is rather widely Fig. 90. — A, Rongeur forceps; B, Liston's bone-cutting forceps. diffused. Alkaline caustics produce a moist eschar which favors the develop- ment of bacteria and consequent septic processes. Then use. therefore, is greatly limited. 318 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC The acid caustics include nitric acid, hydrochloric acid, and chromic acid. These form, with the coagulated albumin of the tissues, dry eschars. The germicidal effects of the acids and the fact that the action of these does Fig. 91. — Keen's Gouge Forceps. not extend deeply into the tissues, constitute very decided advantages over the alkaline caustics. The salts of certain metals are also employed. Nitrate of silver, sulfate of copper, chlorid of zinc, and compounds of arsenic are useful. These act bv Fig. 92. — Volkmann's Bone Curet. precipitating albuminous substances. Nitrate of silver combined with chlorid of silver to modify its action has but a superficial effect; its use is restricted to the destruction of too rapidly proliferating granulations. Chlorid of zinc Fig. 93. — Brtjns's Bone Curet. produces a much more intense effect, and the resulting albuminous coagulation is aseptic to a high degree. It may be applied in the shape of a paste (equal parts of chlorid of zinc and flour with sufficient water to make a paste), when Fig. 94. — Irrigating Curet. it is desired to produce a deeply destructive effect. It has comparatively slight effect on the unbroken skin. Caustic arrows are designed to produce separation of parts by their eschar- THIO SEPAllATION OF TIIIO 'I'IS.SUKS 319 olic (effect. 'I'liov contsist of ,stri})s of heavy linen dipjjed in a strong solution of chloiiil of zinc. 'The blade of a scalpel is passed flatwise through the base of the tumor to be removed, in a ratUating manner, and the arrows are j^laced in the incisions. The part becomes necrotic and falls off. 'J"he process of separation is an exceedingly painful one. Puncturing and Aspiration. — These methods are employed for the purpose of removing fluids from a dis- eased part. The puncture made under these circumstances is only of a temporary character. A narrow-bladed scalpel may be employed for the purpose, but a trocar and can- nula are preferable (Fig. 97); or the latter, when pointed, may be employed alone. The puncture made, the trocar is withdrawn and the fluid allowed to flow through the can- nula. In performing the puncture the index-finger is held as a guard at the proper point to prevent the trocar from penetrating too deeply. A straight trocar and cannula ( l*'ig. 97, A) are usually employed, but it may be an advan- tage to use a curved instrument (Fig. 97, B) , as, for instance, in puncturing the bladder above the pubic symphysis. The pointed cannula or hollow needle is sometimes used, but it has the disadvantage of placing an unguarded point in the cavity to be emptied. To obviate this, the dome trocar and cannula of Fitch is used (Fig. 98). The diameter of the cannula will vary with the requirements of the case. For fluids of a thin character a small instrument will suffice, but those that are thick and viscid or that contain flakes of lymph will require a cannula with large caliber. Fig. 95. — Piano-wire ecraseur. Fig. 96. — Thermocautery. A, Hollow handle containing absorbent cotton — saturated with benzene; B, removable cap; C, con- necting tubing; D, rubber bulb; E. secondary bulb guarded by netting; F alcohol lamp and cap; G, knife-shaped cautery jjoint; H, pointed cautery point; I, dome-shaped cautery point; J, extension at- tachment to be used with the shorter cautery points. In case the instrument becomes obstructed, a proper sized wire is passed through it while in situ to clear it. Aspiration is accomplished by attaching a suction apparatus to the cannula. 320 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC The aspirated fluid may go directly into the barrel of the syringe, as in Dieiilafoy's apparatus; or by exhausting a bottle attached to the cannula, the fluid may be draAATi into the bottle instead of into the barrel of Fig. 97. — A, Straight trocar and cannula; B, curved trocar and cannula. the syringe (P o t a i n). Puncture for diagnostic purposes is best performed by an ordinary hypodermic syringe (Fig. 99). Fig. 98. — Fitch's Dome Trocar and Caxxula. A, The point exposed for introduction; B, the blunt cannula or dome protruded to guard the point after introduction. The operation of puncturing should be performed with all aseptic precau- tions. In withdrawing the cannula the vacuum in the syringe or bottle Fig. 99. — Collin's Gl.^ss Syrixge with Solid Metal Piston. should be preserved in order to prevent the entrance of air, as well as to guard against contact of the overlying structures with infectious material from the diseased part which otherwise would remain in the point of the instrument. INDICATIONS FOR UNITING THE TISSUES 321 INDICATIONS FOR UNITING THE TISSUES; UNITING THE TISSUES MECHANISM OF To secure union of divided structures is the first aim in this connection. 'rh(^ ]ireHininarv conditions necessary for this are (1) prevention of high grades of inflammation; (2) effective and permanent coaptation of the wound edges. The first condition is fulfilled partly by careful aseptic treat- ment of the wound itself, and partly by the application of aseptic principles in the introduction of the sutures, or the employment of other retentive means. Formerly the existence of contused wound edges was considerefl a con- traindication to the use of sutures. If the requirements of a rigid asepsis or antisepsis are met, however, it is possible to obtain primary union, even in these cases. But if the crushed tissues are beyond the hope of recovery, either the attempt to apply the suture or the effort to secure coaptation of the edges otherwise must be abandoned, or the crushed tissues must be first removed. In case of extensive and deep wounds, particularly those which have been accidentally inflicted, there will probably be a large amount of wound secretion, and drain- age must be provided for. A fenestrated drainage-tube of rubber may be passed the entire length of the wound, projecting at one or both ends. In the latter case the patency of the tube may be assured by "flushing" with a stream of antiseptic solution without removing the tube until it is permanently withdrawn. Finally, accidentally inflicted shallow wounds of limited area may be drained by means of a twisted strip of iodoform or other sterile gauze. The large majority of operation wounds made imder proper conditions of asepsis may be closed without drainage. The protection of the line of suturing is of impor- tance. This is usually accomplished by means of a simple gauze dressing. A narrow strip of silver foil affords protec- tion, and at the same time furnishes the base for antiseptic compounds formed by the action of the wound secretions on the metal (H a 1 s t e d). Gaping of the wound edges, due to the elasticity of the tissues, is overcome by permanent coaptation. In order to accomplish this, more or less strain is placed on the structures sutured. In case of large wound defects or in tissue naturally unyielding this may be more than they can bear, and there occurs a "cutting through" of the tissues, the latter being forced against the rigid and unyielding thread. Separation of the sutured line takes place and the suture material becomes buried in the tissues. This may also happen from tying the sutures too tightly or from excessive swelling. The Interrupted Suture. — This consists of a single thread passed by means of a needle through iDoth wound edges and then tied, the latter being at the same time adjusted in their proper relation to each other (Fig. 100). The needle emplo3'ed may be either curved or straight, according to the re- quirements of the case. The Hage dorn needle (Fig. 101) is flattened and has a 22 Fig. 100. — Inter- rupted Suture. 322 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC lance-shaped point . The wound which it makes lies in the same direction as the line of tension when the sutm-e is tightened, hence its edges tend to come together rather than gape, as is the case when the ordinary needle is used. Practically, however, any well-polished and properh^ shaped needle will answer the purpose. For suturing the peritoneum round wire needles are employed. For suturing other soft tissues, needles with cutting-edges are used. A straight needle may be employed on convex portions of the body, while in concave portions the curved needle is more useful. As a rule, the latter can be used in both, hence this form of needle is most freciuentty em- ployed. The curved needle may have different degrees of curvature, those rep- resenting from one-third to two-thirds of a circle being most commonh'^ used. In addition, needles have been devised for special operations, such as cleft palate, etc. In perforating the tissues the thumb and finger may be used for grasping the needle, or preferably, and for aseptic reasons, one of the many varieties of needle-holders may be employed (Figs. 102, 103). The needle forceps are particularly useful in deep sutures, or when the density of the latter is such as to require considerable force to drive the needle through them. In passing the needle through the skin surface there is less risk of conveying infection to the depths of the wound if the perforation is effected from beneath to the surface, instead of from the outer surface of the skin on one side and from Fig. 101.— 1, The Hagedorn needle; 2, the Hagedorn needle modified by twisting so as to permit it to be grasped with a hemostatic forceps. Fig. 102. — Richter's Needle-holder. beneath on the other. The amount of infectious material in the substance of the skin is almost incredible (W e 1 c h), and passing a needle from the surface into the wound depths favors infection of the latter. In passing the needle in this manner it is convenient to place a needle on the thread at both ends; and to avoid the annoyance of having the second needle become disengaged from the thread while the first is in use, it may be threaded with a " hitch" or bight (Fig. 104). Where the parts to be united consist of several distinct layers of tissue, as, for instance, in abdominal section in which peritoneum, muscle and fascia. MECHANISM OF UXITIXG THE TISSUES 323 and skin are to be united each to its own structure separately, layer sutures are employed. These cannot be removed, and hence are called buried sutures. For this purpose either catgut or kangaroo tendon may be used. These are sometimes prematurely absorbed and permit separation of the suture line. If of nonabsorbent material, they may become a source of irritation to the tissues. The employment of the removable layer suture obviates these disadvantages. With the thread (crin-de-Florence or silkworm-gut being preferred) armed with a needle at each end, each layer is secured separately by passing the needles from the depth of the wound toward the surface. As each successive la^'er is included in the loop the needles are reversed as regards position before being passed through the next layer, the two legs of the suture crossing each other between the separate layers until the skin surface is reached Fig. 103. — The Richter Needle Forceps Modified. A, The cam and "pick-up" device shown in detail. (Figs. 105. 106, 107). The sutures are here secured in pairs by "bolsters" of rubber tubing (Figs. 108, 109). Buried sutures are also employed to obliterate so-called dead spaces, as, for instance, those cavities in the thick fat layer of the abdominal wall of very- obese individuals left after operations for the radical cure of ventral or umbilic hernia. For accurately coapting the skin edges either the interrupted suture or the continuous suture may be used. The latter may be employed in a simple over-and-over manner (Fig. 110). or the intracuticular suture, in which the needle is passed on the raw edge of the skin, parallel to it, mav be used (Fig. 111). The best form of the continuous superficial suture is the chain-stitch. (Ford). The needle is passed as in the ordinary interrupted or glover's 324 THE GE:XERAL PRI^XIPLES OF OPERATIVE TECHXIC suture. Instead of allowing the suture to cross the wound edges at a more or less acute angle, however, the needle is passed beneath what would ordinarily Fig. 104. — M e t h o d OF Securing a Strand of Silk- worm-gut TO THE Needle. The end of the strand which has been passed through the eye of the needle is passed a second time from the same side as at first. The resulting "hitch " or bight is then drawn tight. Fig. 105. — The Removable Later Suture. Method of application with one needle. Schematic, represent- ing a cross-section of the abdominal wall. 1, 1, First layer, consist- ing of skin, fat, and superficial fascia; 2, 2, second layer, consisting of transversalis muscle, and transversalis fascia; .3, .3, third layer, con.sisting of peritoneum ; 4 4, 4, 4, dead spaces between the planes of the layers; .5, gap representing the wound to be closed; the end of the thread at .5 is armed -with a needle and finally passed through the first layer at 6 from within outward to complete the suture. Fig. 106. — The Re.movable Layer Suture. A Simultaneous coaptation of the edges and plane surfaces of the layers of the abdominal wall ; B, the manner of passing the suture ends through the lumen of the rubber "bolster when thick- walled tubing is employed. Fig. 107. — The Removable Later Sutltre. Method of application with two needles. The relative position of the needles is reversed as each layer is secured, the threads crossing each other as this is done, taken by the suture. The arrows show the directions MECHANISM OF UNITING THE TISSUES 325 Fig. 108. — The author's figure of 8 removable layer suture, applied to the oblique appendicitis incision, showing the sutures passed through all the layers, including the skin, and the bolsters in position. The dotted lines in the upper right-hand corner show the method of passing the suture through the lumen from each end of the bol- ster. Fig. 109. — The author's figure of 8 removable layer suture, applied to the ob- lique appendicitis incision sho^^-ing the su- tures drawn sufficiently taut to approxi- mate the edges of the incision in the deep structures. The edges of the skin are shown wider apart than they actually occur, in order to demonstrate the approximation. Fig. 110. — Continu- ous Suture. Fig. 111. — The author's figure of 8 removable layer suture, showing the bolsters set, the sutures tied, and the skin edges in course of closure by the intracutieular suture. Fig. 112. — Continu- ous Chain-stitch (Ford's). 326 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC be the overlying portion and the stitch (h-awn taut with this l_\'ing j)arallel to the wound edges. The needle may be passed one or more turns l)eneath the loop. Several turns should be made at the termination of the suture line in order to secure the suture (Fig. 112). (Special sutures will be descril)C(l in the part on Regional Surgery.) Coaptation by Means of Adhesive Plaster. — This is a somewhat unsatisfactory procedure, only the superficial edges of the skin being brought together. It cannot supplant the use of sutures, though it is sometimes em- ployed as a substitute for superficial sutures. When it is thus used, narrow spaces should be left between the strips to permit the escape of secretions from between the skin edges. SECTION XI OPERATIONS ON INDIVIDUAL STRUCTURES OPERATIONS ON THE SKIN OPENING OF ABSCESSES Abscesses may arise in the subcutaneous connective tissue, or mav invade this region from the deeper parts. In modern surgical practice it is deemed best to empt}^, curet, and otherwise treat antiseptically suppurating foci as soon as their presence can be demonstrated. This may involve incisions through fascia and muscular structures, as well as through the skin. The method usually employed in opening an abscess of the sul^cutaneous connective tissue is that known as transfixion. A curved pointed bistour}' is passed with its edge upward through the abscess cavity and the incision effected by a simple stroke outward. By this means the length of the incision can be governed with greater certainty, the incision is made with greater rapidity and hence is less painful. Its length should correspond to the diameter of the abscess cavity if the latter is not more than tw^o inches in diameter. After free incision vigorous curettage, thorough antiseptic irrigation, and "scour- ing" of the abscess cavity by means of dry aseptic gauze should be employed. In an abscess of more than two inches in diameter a smaller opening or more than one opening (counter-opening) may be made. After irrigation and curettage one or more drainage-tubes are introduced. In making a second opening the edge of the first may be grasped by a dissecting forceps to steady the collapsed abscess wall; or the forceps may be pushed through the first open- ing to a point opposite, the blades separated, and the parts thus steadied while the second incision is made. A finger is to be introduced and the size and shape of the cavity ascertained; this can then be curetted intelligently. Antiseptic irrigation can be carried on at the same time if the irrigating curet is emploved (Fig. 94). When, either through spontaneous opening of an abscess or through an insufficient artificial opening, the drainage is incomplete, this should be reme- died by introducing a probe-pointed bistour^^ through an already existing opening and withdrawing it vertically, at the same time enlarging the opening. The abscess cavity should then be treated as if now opened for the first time. Undermined portions of skin should be opened up freely, and in some instances may be excised with advantage. PLASTIC OPERATIONS ON THE SKIN Plastic operations are resorted to for the purpose of artificially restoring lost portions of the body by means of living tissues. The skin forms the most essential material for plastic operations on the surface of the body, by reason of its rich supply of arteries and capillaries. 327 328 OPERATIONS ON INDIVIDUAL STRUCTURES Heteroplastic operations consist in replacing defects by means of tissue derived from sources other than the intUvidual in whom the defect occurs. This includes transplantation from man to man, or from a lower animal to man. Attempts in this direction are sufficiently encouraging to justify a still further trial of the method. Autoplastic operations consist in replacing defects by means of tissue taken from the same individual. They are indicated in defects resulting from (1) congenital cleft formations (harelip, cleft cheek, palatal fissures, exstrophy of the bladder, etc.; (2) injuries; (3) thermic and chemic destructive action; (4) chronic ulcerative processes, particularly those arising from varicose veins; (5) the removal of diseased conditions (carcinoma, lupus, syphilitic and tul)er- culous ulcerative processes); (6) the removal of benign tumors, angiomas, etc. ; (7) cicatricial displacement leading to disturbances of shape and function of parts. The indications may be further divided into those of a cosmetic and those of a functional character. It may happen, as in the case of ectropion of the eyelid, that both cosmetic and functional considerations enter into the question. In the case of injuries the plastic replacement should be attempted at once by means of the part which has been removed. Portions of the nose, fingers, the tongue, etc., should be immediately replaced and sutured in position. The ends of the middle and ring fingers have I been successfully replaced seven hours »: after they had been cut off (F i n n ey). In case the injury is accompanied by ; more or less crushing or other destruc- tion of the parts, replacement cannot be successfully accomplished. ^ (Plastic operations will be further Fig. 113.-RELAXING Incision. discussed in Regional Surgery.) In ulcerative processes from syph- ilis, tuberculous disease, etc., the local focus must be first healed. In carcin- omatous and other tumors in w^hich the diseased tissues have been removed, the plastic operative measure best adapted to the case may be proceeded with at once. General Methods of Plastic Operations. — Two essential methods are employed. The first consists in the utilization of tissues from the immediate neighborhood; the second in their transplantation from a distant part. The first may be again divided into those methods in which the tissues used to replace the defect are brought into position by sliding or lateral displacement, and those in which flap formation and torsion of the pedicle are distinguishing features. Replacement by means of lateral displacement may sometimes be ac- complished without the introduction of new tissue. This may be aided by the loosening of the skin structures by means of a dissection carried along the plane of the subcutaneous connective-tissue space, or by the employment of relaxing incision (Fig. 113) made parallel to the intended line of sutures, or by both. The gaps left by these relaxing incisions are permitted to heal by granulation. A method of closing a rectangular shaped defect is shown in Fig. 104. D i e f - fen bach's procedure for closing a triangular shaped defect is shown in Fig. OPKKA'l'IONS ON THE SKIN 329 115. Tlu> motluxl of DiMTrnbaeh avus improved by B ii r o w (Fig. ^^* Flap Formation with Torsion.-The advantages of this method are as follow. (1) it adn.itsof ahnost universal apphcation; (2) the flaps can be ace uratelv adapted to the defects; (3) tissue free from disease can be Fig. 114.— Closing Kect.vngul.vk Gat. selected for the purposes of the repair; (4) by proper care in Pl-^f |;^ P^^^^^^^^^^ the nutrition of the parts may be more certainly assured. When the rans planted portion is takenfrom a distant part, the former is approximated to the place of defect; under these circumstances torsion of the pedicle may or may not be employed. ▼7 \^T' Fig. 115. — Closing Triangulak Gap. The free transplantation of large flaps dissected from the skin and subcu- taneous tissue is occasionaUy employed. There is a greater habihtr of death of the flans in this method. , , i ,■ i • i • Death of transplanted portions is less likely to follo,v the method ot shdmg than any other. In flap operations mth torsion the flap must be sufhciently Fig. 116.— Burg w's Modification of Dieffenbach' Method. narrow else the twist ^vhich it receives may result in undue pressure on the ve sT'ot supply and the occlusion ot them. The most '"n^rtant j^ec^utron. are the following: (1) The pedicle is to be situated m a ^-eg-on ><>- "^^^ supply of vessels pass to the portion to be transplanted; (2) the formation of 330 OPERATIONS OX INDIVIDUAL STliUCTURES the flap must be accomplished with the greatest care, the edge of the scalpel being directed awcaj from the skin, particularly when dissecting near the pedicle itself, in order not to injure the vessels in the latter; (.3) an accurate isolation of the pedicle is necessary, in order to permit torsion without folding; (4) the stem must be sufficiently long to permit an easy twist. The last is further provided for by extending the incision which marks one boundary of the pedicle somewhat further than the incision which marks the other Ijoundary, so that there is a long and short edge to the pedicle, the long edge representing the edge from which the twist is turned. The raw surface of the flap must fit closely on the properly prepared surface of the defect, and the edges of the former are to be accurately sutured to the latter. If the transplanted portion is intended to replace cicatricial tissue, the latter must be dissected entirely away, in order to obtain a normally vascularized surface for the reception of the flap. Aseptic measures must be employed. Plastic procedures are most successful when there is a rich supply of arterial and capillary vessels, as, for instance, in the facial region. In regions in which the vessels are less plentifully supplied it is sometimes of advantage to loosen the flaps from the subcutaneous connective tissues, and they are thus nourished by a pedicle at each end, gauze dressing or oiled silk protective being packed beneath it. At the end of a week or when a profuse granulating surface has been obtained one of the pedicles is severed and the edges of the flap and defect are freshened. This is called transplantation of a granulating flap. It is sometimes employed in operations for exstrophy of the bladder. Elastic and cicatricial shrinkage of the flap invariably occurs. The former takes place at once and amounts to about one-third of the entire area of the flap. It is to be compensated for by an increase in the dimensions of the transplanted portion over the size of the defect. Cicatricial shrinkage is to be guarded against by bringing the raw surfaces as accurately as possible into opposition, so that primary union rather than the filling of an intervening space by granulation is thereby secured. In rhinoplasty the newly formed part must at first be largely in excess of the original, in order to allow for the shrinkage which occurs in the course of a few months. Secondary shrinkage of the flap is prevented to a great extent by reinforc- ing the latter by means of the cicatricial tissues about the defect. For instance, in the case of a defect of the anterior portion of the nose, the skin at the root of the latter is circumscribed by a horseshoe-shaped incision, loosened and turned downward, its wound surface corresponding to that of the flap taken from the forehead (see page 510). The underlying periosteum may sometimes be employed as a portion of the transplanted structures. In the operation of uranoplasty this is imperative (L a nge nb e c k), and also where cicatricial tissue must be utilized, the vessels between the cicatrix and the periosteum being carried along with the flap. The flap should empty itself of blood before it is sutured in place. This prevents the formation of coagula which tend to retard the new circulation in the flap. A pale flap is more favorable than a congested one. In the former the supply of blood will probably be reestablished in a few hours; in the latter, retarded return flow- and stasis quickly threaten the integrity of the flap. The restoration of normal conduction of sensation occurs in the course of OPERATIONS ON THE SKIN 331 time, though at hrst the sensation nia}- be referred to the jDoint from which the transplanted portion was taken. Reverdin's Method. — This consists in the implantation of complete^ se})a rated small Hat portions of epidermis which form islands on the granulating stirface of the defect. These soon become sttrrounded by a zone of proliferat- ing epithelium. The transplanted epidermis is not very durable. The outer- most layer is cast off, giving every appearance of failure, yet sufficient epithelial structtire remains from which further proliferation occurs until the entire sur- face is covered. The fla])s should be of skin only and not more than three- eighths of an inch in diameter. If larger pieces are used they should be elliptic shaped in order better to close the defect. Still smaller pieces may be obtained by picking up a fold of the skin with mouse-tooth forceps and snipping them off with scissors; a large number of these may be scattered over the surface of the defect. A special instrument may be employed (Fig. 117). Autoepidermic Skin=grafting. — This may be employed to fill in an ulcerateil surface or a defect in which repair is under way by granulation. The method is based on the fact that the newly developed epithelial cells are very active in growth at the edges of a granulating ulcer or defect. The surface to be grafted is prepared by gentle curetting where the granulations are weak and flabby ; hemorrhage is arrested by firm pressure. The thin blue line of epithelial cells that has formed along the edge of the defect is dissected up and small pieces about one-eighth of an inch square cut off and placed with their raw surfaces clown on the granulating sur- face. The operation is pain- less. Each graft is covered with a small piece of oiled silk and dry sterile gauze dressing is applied (j\I c C h e s n e y). Thiersch's Method. — This consists in shaving long strips of the thick- ness of only a portion of the skin from the outer surface of either the arm or the thigh, preferably the latter, b}' means of a razor, and transferring these directly to the surface prepared for their reception. It is applicable alike to chronic ulcerated surfaces and to defects left after the removal of large tumors, par- ticularly those of the breast. In the case of the former, the granulating surface should be brought into as health}' a condition as possil^le. In the case of the latter aU hemorrhage must be arrested before the grafts are placed in position. The grafts must be of uniform thickness and have even edges, in order that there may be no gaps between for cicatricial tissue to form. Parallel incisions mark- ing the lateral boundaries of the strips to be taken may be made from one to two inches apart, according to the reciuirements of the case, these passing onlv partly through the skin. The skin is now put on the stretch. (Figs. 118 and 119.) Pressure by some hard substance on the skin surface just in advance of the razor sometimes answers a good purpose. In the case of the arm, the sur- geon's hand encircling the parts will make sufficient tension. The strips are cut Fig. 117. — Combixed Mouse tooth Forceps and Scis- sors FOR SkIX-GKAFTIXG AFTER MeTHOD OF ReVER- DIX. 332 OPERATIONS ON INDIVIDUAL STRUCTURES by a sawing movement of the razor, held flatwise. 'Fhe field of operation should be kept moistened with a sterilized normal salt solution; no antiseptics are used. The grafts are applied at once to the defect or ulcerated surface, care being taken that their edges do not roll under, and are covered with strips of sterilized oiled silk protective arranged in "basket strapping" fashion, with narrow intervening spaces for drainage (Fig. 120). Gauze dressings wrung out of the sterilized normal salt solution are applied and this is again covered with pro- tective or rubber tissue; a layer of cotton and a roller bandage complete the dressing. Fig. 118. — McBurxey's Skin-stretching Hooks. The dressings should be changed in from one to three days. If any portions of the grafts have perished, they should be trimmed away with sharp scissors in order to prevent infection of the remainder. Moist dressings are to be reapplied at intervals of forty-eight hours until healing takes place. The success of the method depends mainly on obtaining grafts of even thickness and with clean-cut edges, rendering the parts from which these are taken, as well as the surface to which they are to be applied, aseptic, and Fig. 119. — Cutting a Skix-guaft. securing firm contact betw^een the surface of the grafts and that of the ulcer, with no blood between; finally, on the early removal of such portions of grafts as fail to take. The Oilier method of skin grafting differs from that of Thiersch in that the former aims to obtain a graft as thick as possible without including the subcutaneous tissue, while the latter makes the graft as thin as possible. All fat must be carefully removed from its raw surface. Its area must be at least OPERATIONS ON THE SKIN 333 one-sixth larger than the surface to be covered, and in adjusting it in place, its edges must l)e accurately- coai)tated to the raw edges of the defect. No sutures are emplo>'ed. 'ilie parts are dressed with moist dressings. The After = treatment of Plastic Operations.— An irrigating fluid should be cmpkn'od which does not coagulate the albuminous substances on the surface of the flap or defect. A 0.6 per cent solution of sodium chlorid answers the purpose best. Dressing, as well as gauze sponge material employed about the operation, should be wrung out of the same. The site of the operation should be carefully covered in by narrow strips of oiled silk protective, arranged as in "basket-strapping" (page 332). Over this is placed a goodly supply of aseptic gauze, and the whole covered with sterilized cotton and held in place by a roller bandage. On redressing, after three to five days, care should be taken llllllilili llilllllli llllllilili llllllilili lllllilll llllllilili ■ ■ II f ■I 1 hiiiiiiin ■ j= ■ i miiiiin II 1 iliriiiip ■ 1 ^^^^H Fig. 120. — Basket Strapping Dressing for Skin-grafting. not to disturb the transplanted portions of tissue. The moist dressing should be continued and changed every second or third da}'. False or cicatricial keloid, which sometimes develops between the flaps, is said to be prevented by keeping up moist dressings until the healing is completed (^I c B u r n e y ) . THE REMOVAL OF TUMORS OF THE SKIN Those having a narrow base or pedicle, particularly when small or of but moderate size, are best removed by putting the pedicle or base on the stretch and severing with the curved scissors. Some nevi pigmentosi may be treated in the same manner. Cauterization of warts and nevi is now an obsolete procedure. Congenital capillary and capillar}^ venous tumors are best treated by extirpation with the knife. The hemorrhage requires special care in its 334 OPERATIONS ON INDIVIDUAL STRUCTURES management. The dilated veins usually reach through the sul)cutaneous con- nective tissue to the fascia, and it is therefore best to carry the incisions directly to the latter structures. The vessels leading to the diseased portion should be grasped by the fingers of an assistant and held until secured by the hemostatic forceps. Ligation of the base may be combined with extirpation. The employment of the ligature alone is objectionable on the score of excessive pain and sepsis. Small angiomas may be destroyed by means of the thermocautery, or the gal- vanocautery loop. The platinum wire of the latter is led around the base in the subcutaneous connective tissue as an encircling suture. Small angiomas also maybe attacked by electrolysis. This is accomplished by passing needles, insulated for a greater or lesser distance, into the tumor in a direction parallel to the surface and attaching these to the poles of a galvanic battery, the current being allowed to pass through them; or one needle may be employed, the other pole of the battery being attached to a sponge electrode placed in the neighborhood. To save repeated puncture with a single needle, a number of these may be fastened to a handle (Fig. 121) to which is attached a wire connected with the l^attery. The method by the injection of water at a high tem- perature for the obliteration and cure of vascular non- malignant neoplasms consists of the injection of water at a temperature of from 190° to 212° F., or sufficiently hot to coagulate the blood and the albuminoids of the tissues ( W y e t h) . A metal syringe is employed and the amount of water used and the temperature are governed by the character and size of the growth, and by its situation. Capillary nevi, or "mothers' marks," should receive small injections under slight pressure and at a temperature not above 190° F. Care should be taken not to scald the skin. A slight blanching of the latter in the area of each injection suffices and is a signal in all cases to cease at once injecting in that area. The injections are repeated at intervals of a week, according to the effect produced. In cirsoid aneurism and large cavernous nevi the water should be kept at the boiling-point, and large quantities (up to five or six ounces in some instances) used. A general anesthetic is necessary. Peripheral compression should be used to prevent embolism. Vaccination of an angioma is a very uncertain procedure; the injection by means of perchlorid of iron solution is mentioned only to be condemned. Venous angiomas or cavernous tumors are best circumscribed by incision and are rapidly extirpated. Varices are treated of on page 100 and cirsoid aneurism on page 94. Atheromatous cysts or wens may perforate the skin, either through a suppurative process or otherwise, atheromatous fistulas resulting. The suppurative form may result in epithelial carcinoma. In extirpating these cysts care should be taken to preserve the sac intact in order to facilitate its entire removal. A horseshoe-shaped incision should be made well beyond the Fig. 121. — Steven- son's Instru MENT FOR ElEC TROLYSIS. OPERATIONS ON THK SKIN 335 limits of the tumor, partially surrounding the same. B}^ turning up the jioi'tion of skin inclosed in the incision as a flap to which the tumor is at- lacluHl the entire growth may be dissected from the flap and the latter replaced. Congenital dermoid cysts may be dealt with in the same manner. In these cases a deeply placed i)edicle is often found containing the \'essels of supply. Lipomas are extirpated by two converging incisions (elliptic incision). In some localities, e. g., the neck and shoulders, these growths cannot be dis- tinctl,v defined and the removal must be more or less arbitrary. The sim])le character of these tumors should not impel the surgeon to relax his ^-igilance in the application of aseptic measures, for the reason that erj^sipelatous inflam- mation is particularly lial^le to follow their removal. In elephantiasis arabum excision of the hypertrophic portions, when possible, is preferable to the long incision formerly emplo}-ed. ^Vhen the scrotum is the part attacked, extirpation may be indicated. Amputation should be reserved for cases in which an extensive and incurable ulceration is present, or suppuration of a, large joint occurs. Malignant Tumors of the Skin. — Three absolutely positive indica- tions always exist and must be rigidly followed in operating for these growths: (1) The operation must be performed as early as possible; (2) the extirpation must be as complete as possible; (3) the next adjacent lymphatic glands, if it is possible to identify them, must be removed at the same operation. As to the first: In cases of doubt it is better to remove an innocent tumor than to permit the development of advanced carcinoma. As to the second: Thorough extirpation demands the free use of the knife, rather than caustic applications. The most deplorable errors, as well as the most common on the part of the practitioner, consist in the occasional touching of commencing epith- elioma of the skin with nitrate of silver. Should the prejudices of the patient prohibit the employment of the knife, the use of the Paquelin cautery offers the next best means at our command. Pastes of zinc chlorid, arsenic, etc., are occasionally successfully employed. A removal or destruction of all the diseased tissue, together with half an inch or more of surrounding healthy tissue, constitutes the only means of avoiding recurrence of the disease. As to the third: Unfortunately, when secondary glandular involvement is present in carcinoma, the prognosis is exceedingly unfavorable. ]\Iany of the diseased lymphatic glands are so deeply situated as to escape recognition and extirpation. Every swollen gland in the neighborhood should be removed. Diligent search should be made for diseased Ij^mphatic glands deeply situated. In late cases and in persistent regionary recurrences operative procedures of a purely palhative character are justifiable. There is a limit to these, however, particularly where great risk to life is involved. But curettage and energetic antiseptic treatment, including the use of the thermocautery, or of a 10 per cent solution of zinc chlorid, followed by dusting with iodoform to meet the indications of hemorrhage and sepsis, are almost always justifiable. The above remarks apply likewise to other forms of malignant disease of the skin, particularly that exceedingly malignant form known as melanotic sarcoma. 336 OPERATIOXS OX IX DIVIDUAL STRUCTURKS OPERATIONS ON BLOOD-VESSELS THE ARREST OF HEMORRHAGE Hemorrhage is distinguished according to its source as arterial, venous, and capillary or parenchymatous. The methods employed to arrest hemorrhage are either direct or indirect, according as they act immediately at the place of bleeding, or through distant parts. The procedures are also classified as provisional and definite. The importance of saving as much blood as possible during operative procedures is verv'- generally recognized, not only for the immediate, but for the ultimate prognosis. On the completeness with which all bleeding is arrested before the wound is closed, as well as on the efficiency of the measures taken to prevent recurring and secondary hemorrhage, will depend, to a great extent, prompt healing of the wound and rapid recover}' of the patient. For spontaneous arrest of hemorrhage see page 87. Provisional measures for the arrest of hemorrhage are indicated Fig. 122. — Petit's Screw Tourniquet. under circumstances where means and appliances for its definite arrest are not at hand, or where, if they are at hand, their application would consume valuable time and risk the patient's life. They consist in procedures having for their object the interruption of the blood-current between the heart and the bleeding point. This is accomplished by (1) digital compression ; (2) forced positions of joints; (.3) pressure by means of specially contrived apparatus (arterial compressors, or tourniquets; . In digital compression a point should be selected where the artery can be pressed against a bone. In the lower extremity the femoral artery can be readily pressed against the horizontal portion of the pubic bone just below Poupart's ligament. In the upper extremity the brachial arter\' can be pressed against the humerus along the inner margin of the biceps muscle. With the arm abducted, the axillary artery can be pressed against the head of the humerus. The common carotid arterv^ may be pressed against the carotid tubercle (the anterior tubercle of the transverse process of the sixth cervical OPERATIONS OX T^T.OOD-VESSELS 337 A'ertebra). In this latter procedure, however, free anastomosis with the artery of the other side, as well as with the subclavian branches, very quickly restores the circulation bej'ond the point of pressure. The radial artery may be pressed against the radius and the posterior tibial against the inner surface of the os calcis. In thin individuals the aorta may be pressed against the lumbar ver- tebrae in hemorrhage from the internal iliac. In forced jDositions of joints the arrest of hemorrhage may be accomplished without special apparatus and without anatomic knowledge. Extreme flexion of the elbow-joint and of the knee- joint will bring pressure to bear respectively on the brachial and popliteal arteries. H3'perexten- sion of the hip-joint will bring the femoral artery to bear strongly against the horizontal ramus of the pubic bone so as to ob- struct its lumen almost ■ com- pletely. The clavicle may be made to approach the first rib, so that pressure is brought on the subclavian artery, by ex- treme adduction of the arm to the anterior surface of the thorax, and at the same time the acro- mion is forcibly crowded down. Pressure by Means of Spe- cially Devised Apparatus. — The term "toui'niquet" is now applied to all apparatus devised for the arrest of hemorrhage. The old-fashioned screw tourni- quet (Fig. 122) is now employed only to fulfil special indications (arterial compressors designed for special classes of cases will be treated of in Regional Surgery). The Spanish windlass (Fig. 123) is of value in hemorrhage from the vessels of the extremities, from the fact that it may be readily im- provised. A handkerchief is tied loosely around the limb and a stone or other hard object is placed over the A'essel and beneath the handkerchief. A cane, bayonet, sword, scabbard, drumstick or similar object may be emploj^ed to twist the handkerchief until the bleeding is arrested. The pressure is l^rought to bear on veins, nerves, and lymphatics as well as on the artery, and for this reason the use of the windlass should not be long continued. Bloodless Operations by means of Esmarch's Elastic Compression. — This is applied principally to the extremities and is intended to secure 23 Fig. 123. — Spanish Windlass. 338 OPERATIONS ON INDIVIDUAL STRUCTURES a completel}^ exsanguine condition of the portion to be operated on. The limb is elevated for a few minutes in order to empty the large venous channels into those of the tnmk and is then tightly bandaged in a spiral manner from below upward by means of a rubber bandage. The turns of the bandage, with the exception of the first two, should overlap each other but slightly (Fig. 124). The bandage should be continued some distance beyond the point of proposed Fig. 124. — Esmarcii's Bandage Applied. Showing method of application without overlapping. The last three turns serve as a tourniquet. operation. Here a few circular turns of the bandage are made, these are Hfted forcibly away from the limb and the remaining portion of the roller forced beneath them at the site of the main vessel of the limb. The spiral turns are now unwound, at a point conunencing from below (Fig. 125). A tourniquet consisting of a narrow band of rubber with hook and chain fastening is Fig. 125. — Esmabch's Bandage, Showixg Ease of Remov.vl of the B.axdage. sometimes employed to secure the vessels immediately alcove the termination of the bandage before removing the latter. Ur a hard roller of muslin may be laid over the vessel and secured bv a few turns of the rubber bandage (Fig. 126). The procedure serves only a temporary purpose. As soon as the constrict- ing band is removed, not only does the blood flow from the larger vessels, but OPERATIONS OX BLOOD-VESSELS 339 there is a relatively greater amount of parenchymatous oozing. This is due to a paralysis of the muscular aj^paratus of the vessels in consequence of the com- pression, which is complete antl continued in proportion to the length of time the compression is kept uj). It may therefore happen that the patient loses as much blood as would have been lost if no preliminary application of the rubber bands had been made. Paralysis of an extremity has also been charged to the use of E s m a r c h ' s bandage from compression of nerve-trunks, as well as sloughing of flaps in amputation cases. In spite of the alleged disadvantages of E s m a r c h ' s procedure it is of great value. It permits rapid operative work, particularly in seques- trotomies, resections, amputations, etc. Special care should be exercised in its application. If the constricting band is applied too loosely, the venous return flow is interfered with, while the supply of blood is not interrupted ; hence a large amount of venous blood msiy be lost. On the other hand, a too tight constriction endangers the nerve-trunks. In case of the removal of a large portion of the body, such as a limb, the saving of blood by forcing it from the Fig. 126. — Esmarch's B.vxdage, showixg Hard Roller ix Positiox over the Vessel axd .Secured BY THE Last Few Turxs of the Baxdage. The roll in front is the loose bandage unwound from the limb, gathered in a roll, and placed for conve- nience of disposition beneath a few loosely applied turns. limb to the trunk and into the rest of the circulation constitutes of itself a very great advantage. All vessels that can be identified should be ligated before the removal of the constricting band. The application of compresses wrung out of hot water sen'es to check the capillary hemorrhage. - The presence of malignant disease, putrefaction, or suppurative conditions in the limb is a contraindication to the use of the Es march compression bandage. Infectious material may be forced into the lymph-vessels in this manner and distributed over the entire body. Prophylactic Hemostasis. — This may be obtained by (1) digital com- pression by a trained assistant; (2) tourniquets and compressors applied from the surface; (3) temporary compression through an open wound after exposure of the vessel, by means of encircling tapes or bands, or instruments specially devised for the purpose (C r i 1 e) ; (4) preliminary ligation of the main arterial trunk (see page 345). 340 OPERATIONS OX IXDIVIDUAL STRUCTURES Permanent Arrest of Arterial Hemorrhage. — This is accomjjlishoil by forcipressure, followed either by torsion or by application of the ligature. Under certain circumstances it may be necessary to rely entirely on the forceps. The habits and fancy of the operator will usually govern his selection of arterv^ clamps or hemostatic forceps. The ring-handle instrument of Pean and its modifications are employed by most surgeons (Fig. 127), while the slide catch or torsion forceps are preferred by others. In any case the ends of the blades or jaws should be so shaped as to permit the ready sliding of the loop of the ligature therefrom. The forceps should be loosened and removed l^y an assistant before the first portion of the knot is fully tightened, in order that the Fig. 127. — Varieties of Hemostatic Forceps. constricted portion of the vessel may adapt itself in shape to the final grasp of the ligature. In case of emergency a tenaculum may be employed to lift the bleeding vessel away from the tissues. If this method is used, ligation of the vessel must at once foUow. If the hemostatic forceps are employed, these may be left until the close of the operation. The knot may be the usual square or reef knot; a "granny knot" with three turns serves equally as well. In ligation in continuity the " stay knot" of B a 1 1 a n c e and Edmunds is employed (Fig. 1 28) . Ligature Material. — Since the introduction of aseptic surgery catgut has almost entirely replaced silk as a ligature material. Both ends are cut short and buried in the tissues. The ligature material is destroyed if the wound OPERATIOXS ON BI.OOD-VESSELS 341 follows an aseptic course, living tissue being proliferated into the dead but aseptic substance of the catgut. If septic conditions supervene, the ligature material as well as the portions of tissue constricted may be cast off. Silk, if only the smallest or finest sizes are vised, and if this is made thoroughly aseptic, may, if it is specialh^ desirable to employ it as a ligature material, also be cut short and left in the tissues. If primary union is obtained its presence in the tissues may do no harm (Kocher, Hals ted). Nevertheless it remains as a foreign body, and hence, as a ligature material, it falls short of the requirements of ideal surgery. Torsion may be sometimes employed. It is accomplished by grasping the vessel by two forceps and twisting it several times on its own axis between the forceps. The lumen is closed by a rolling together of the intima. The method is applicable only to the smaller vessels and has been but little used since the introduction of absorbable ligatures. Acupressure consists of pressure exercised on the vessel l^y means of a long needle passed through the tissues. The procedure has practically fallen into disuse. The suture ligature, or circumsuture, is employed if the wounded vessel is situated in tissues where it is inaccessible, as, for instance, when a vein is wounded by the puncture of a needle in suturing a wound, or if it is situated in tissues from which the points of the artery forceps repeatedly slip off. A full curved needle threaded with catgut is used. This is passed through the tissues in which the bleeding vessel is situated and at a short distance from the latter, in such a manner as com- pletely to circumscribe the vessel. It is then drawn tightly and secured l^y a knot. f^^ i28.-The stay- Suture of Arteries. — In the case of small wounds of ^^'o^ °^ ^^'^- LANCE AND Ed- large arteries, in which ligation of the vessel is contrain- munds. dicated, the opening in the latter may be sutured. A round intestinal needle and fine chromicized catgut should Ije used. All the coats of the vessel should be included in the sutures. A second row of sutures, including the sheath and the overlying tissues, is to be applied. During the operation the wounded portion of the vessel should be kept free from blood by digital compression. The contraindications to suture of arteries are (1) large transverse wounds of the vessel; (2) lacerated wounds; (3) contused wounds, e. g., gunshot wounds. An atheromatous condition of the vessel does not necessarily furnish a contraindication to the procedure. Suture of the arteries is not likely to find favor among practical surgeons for the following reasons: (1) Circumstances rarely arise demanding its employ- ment to the exclusion of other means of securing hemostasis; (2) there is a not unfounded fear of thrombus at the seat of injury; (3) the dangers of aneurism due to subsequent yielding of the scar in the vessel are not to be lost sight of. Arterial Invagination. — In this operation the proximal end of the artery is invaginated into the distal end, where it is secured by firm catgut sutures (J. B. Murphy). Temporary occlusion of the vessel is first obtained. The distal end of the artery is incised longitudinally for a short distance and the sutures are preliminarily applied to facilitate the invagination (Fig. 129). The method may be used in cases in which arterial suture is contraindicated and ligation in continuity undesirable. 342 OPERATIONS OX INDIVIDUAL STRUCTURES Arrest of Parenchymatous Hemorrhage.— Simple pressure of the wound surface by accurate suturin.ii; and the ajiplication of dressing usually suffice to arrest this form of bleeding. Other methods consist of the application of compresses wrung out of hot water, or, better still, hot saline solution. Ice, ice-water, or the ethyl chlorid spray should never be used in hemorrhage com- plicated by shock. The actual cautery long antedated the use of almost all hemostatics. When this is enijjloyed, it should be used at a red rather than a white heat. The thermocauter^^ (page 316) or the galvanocauter}^ (page 315) has now almost entirely replaced the cauter\' irons of the older surgeons. Tamponade. — Continuous oozing of blood from large wound surfaces, and even bleeding from vessels of considerable size, may be arrested by the applica- tion of an antiseptic tampon. The tampon should be of one strip, rather than of a number of small pieces, in order to avoid overlooking one or more of the latter on removal. If no contraindication to its use exists, e. g., in the case of children, old persons, and those that are the subject of renal disease, iodo- form gauze may be freely used. Other^-ise zinc oxid gauze, or even plain sterile gauze, is to be employed. If blood finds its way to the surface the pack- ing is to be removed and replaced by fresh gauze. Unless some indication arises for its removal it is to be allowed to remain fortv-eight hours, at the end Fig. 129. — Murphy's Method of Arterial Ixvagixatiox. of which time, in the majority of cases, the bleeding vessel wiU have become obUterated. If oozing persists, the bleeding surface may be moistened for a short time with adrenalin chlorid solution, 1 : 1000, and repacked. If the bleeding space is large a " chemise tampon" may be employed. This consists of a spread out scpare of iodoform gauze of sufficient size, to the center of which a silk ligature is secured to facilitate its removal. This is spread out on the wound surface and the pouch thus formed is tightly packed with gauze. The silk ligature is brought outside and the projecting ends of the pouch gath- ered up and secured by a tape or narrow strip of gauze. The Graduated Compress. — Where the bleeding occurs from a definite area the tampon is applied in the shape of an inverted cone, the apex of which is made to rest on the bleeding point. Deep suturing by means of the buried catgut suture is sometimes of use in the arrest of otherwise intractable bleeding. A round needle should be employed in order not to provoke further hemorrhage, and several layers of sutures may be applied, if necessary', care l^eing taken to include any bleeding points discoverable. OPERATIONS OX BLOOD-VESSELS 343 Styptics. — Of the numerous styptics formerly employed, the solution of the scsiiuiehloricl of iron is almost the only one now used. Even this is more often abused than rationally employed. The iron salt incorporated in dry cotton is to be preferred to the moist application. The active principle of the suprarenal capsule (adrenalin) is a valuable local hemostatic agent. It is employed in the shape of adrenalin chlorid solu- tion, 1 : 1000. Care should be exercised in its use, since the l:)lanching of the tissues is marked and may become excessive, leading to sloughing. Oil of turpentin is useful as a styptic after excision of the tonsils. Fer- ripyrin, a combination of chlorid of iron and antipj^rin, in 20 per cent solution has recently been used with success in epistaxis (J u r a s z). Antipyrin has l^een found to possess valuable hemostatic as well as anti- septic properties (Park). It should be used in 5 per cent solution. Gauze wrung out of this solution may be bandaged on bleeding sur- faces or packed in cavities such as the nasal cavity. It may also be used in the form of spra}' with an atomizer. Hemorrhage in Hemophiliacs or "Bleeders." — The surgeon is occasionally called upon to operate on patients who are the subjects of hem- ophilia, as well as to arrest hemorrhage in these from wounds accidentally in- flicted. In addition to the styptic measures already mentioned, inhalations of carbon dioxid gas and the internal administration of calcium chlorid in from 30- to 60-grain doses four or five times a day are to be employed. SaUne infu- sion is contraindicated, but copious rectal enemas of hot saline solution should be used. When the bleeding has been arrested the patient should be placed on a nutritious diet and preparations of iron, such as Blaud's mass, or the tincture of the chlorid should be given. Operations on hemophiliacs should be avoided as much as possible, and when not absolutely necessary they should be postponed for a few days to permit the preliminary administration of calcium chlorid. Arrest of Venous Hemorrhage. — Bleeding from veins as well as from arteries occurs in the larger operations. The dread formerly entertained of the occurrence of suppurative phlebitis after ligation of large veins has entirely given way to the confidence felt in aseptic and antiseptic measures. Whenever venous channels are opened during operation, they may be ligated with the same confidence as in the case of arteries. The necessity for ligation of veins arises more frequently in operations on the lower extremity than elsewhere, owing to the fact that numerous varices are here present; in amputations particularly, dilated veins are found in the muscular structures. Simple pressure in cases of superficial veins, when wounded, will generally arrest the hemorrhage, e. g., rupture of varicose veins. A compress and a well applied bandage usually fulfil the indications in these cases. Air Embolism. — In the anterior region of the neck special dangers may arise from injuries to the veins, particularly to the external jugular. This danger refers to the aspiration of air. This may occur likewise in wounds of the internal jugular, the superior vena cava, the innominate, the subclavian and the axillary veins. The wide-open mouths of these vessels and the blood- stream flowing toward the heart favor the entrance of air through a wound in the vein, when an inspiration occurs. A peculiar gurgling or hissing sound 344 OPERATIONS ON INDIVIDUAL STRUCTURES is heard as the air rushes in. The symptoms wiU depend on the amount of air which enters. If small in quantity, no harm beyond labored breathing and rapid heart action may result. If a large quantity enters, death may occur at once, the air collecting in the right side of the heart and preventing the con- traction of the right ventricle. The accident occurs more frequently in surgical operations than under other circumstances. The treatment consists in instant compression on the cardiac side of the injured vein and the flooding of the field of operation with sterile water until the vessel is secured. Inhalations of oxygen should be given, compression should be made on the chest wall to favor forced expiratory movements, electricity should be applied over the heart, and the limbs should be bandaged. In operations about the lower and anterior part of the neck a competent assistant should stand ready to make compression between the point where a large vein is endangered and the heart, in order that aspiration of air may be avoided in case the vein is wounded. When large venous channels are discov- ered to be involved in the neoplasm during its removal, these should be divided between two ligatures preliminarily applied. Lateral Ligation of Veins.— Small lateral injuries of veins, or an injury of a small vein at the point where it joins a main channel, may require the application of a lateral ligature. Under aseptic conditions small wounds of the largest vein may be dealt with in this manner. Under these circum- stances the repair takes place without thrombus and the lumen of the vein remains patent. The wound in the wall of the vein is grasped with a hemo- static forceps and tied. Large wounds of the veins, in cases in which it is undesirable to ligate the latter, are best dealt with by suturing. In the case of a deep and inaccessible vein the hemostatic forceps may be permitted to remain in situ for several days (forcipressure). Suture of Veins.— This operation is particularly indicated in Avounds of large veins. The wounded portion of the vein is isolated by temporarily constricting it on each side. Sutures of silk or fine chromicized catgut are employed. If the latter material is used a second row of perivascular sutures is applied (Senn). Approximation of the intima is not essential to success (S c h e d e). Silk sutures, when used, are always cast off in a direction away from the lumen of the vessel. The dangers of thrombus formation from this cause are therefore but slight. Complete transverse separation of large veins requires that both ends be ligated. LIGATION OF ARTERIES IN CONTINUITY Indications.— The indications for ligation in continuity are (1) those arising from injury; (2) those arising from inflammatory processes; (3) those arising from tumor formations. In all procedures except that of B r a s d o r , the ligature is applied between the heart and the point of injury or disease, the blood-supply of the part being thus restricted. Complete arrest of blood-supply is prevented by the collateral circulation. In case of injury (punctured wounds, gunshot wounds, and contusion of arteries) the ligature is to be placed as near as possible to the point of injury, and above and below the latter. If necessary, the wound of the soft parts is to be enlarged to accomplish this, but when this can be accomplished only with great. OPKRATIUXS OX BLOOD-VESSELS 345 difficulty and the case is urgent, ligation at a distance from the bleeding point is indicated. In localities in which the collateral circulation is rapidly estab- lished, ligation in coiuiiniity may be followed l)y ligation at the point of injury. Arterial secondary hemorrhage furnishes an indication for ligation in continuilN'. Secondar}- hemorrhage rarely occurs under aseptic conditions. It is generally due to either contusion of the arterial coats, these subsequently giving wav, or septic inflammatory changes in the vessel or surrounding ])arts, or both. It is also known as "septic after-hemorrhage." It is to be dis- tinguished from recurring hemorrhage which occurs within five or six hours after the injury, instead of as many days. In recurring hemorrhage the wound is to be reopened and the source of the bleeding sought. In septic after-hem- orrhage, however, the condition of the tissues at the site of the original wound is such as to preclude, as a rule, a search for the bleeding point. The vessel must be ligated at a distance. Ligation in con- tinuity is also indicated in certain cases of trau- matic aneurism {ride infra). Prophylactic ligation in continuity is in- dicated where an operative procedure is about to be instituted, in which it is more than likely that the arterial trunk must be divided. This may likewise be employed to prevent great loss of l3lood during the operation (extirpation of tongue, resection of the superior maxillary bone, etc.). Exposure of the vessel, and the placing of a ligature in position ready to be tightened in case of emergency, may also be practised. Provisional arrest of the blood-supply of parts involved in proposed operations by tem- porary occlusion of the main tiimk is of value at times. The best instnmient for this pur- pose, the jaws of which should be guarded by niliber, is that de^lsed by C r i 1 e , of Cleveland (Fig. 130). In the absence of this, a traction loop or a piece of tape passed about the vessel with the ends carefully twisted and clamped may be used. Even the slightest injury to the vessel must be avoided lest coagulation of the blood take place, the resulting clot being subsequently displaced and produc- ing serious disturbances, particularly in the case of the carotid arteries. From the theoretic standpoint, and in the absence of sufficient operative experience to confirm the experimental observations made, the propriety of applying the method in the last-named situation is questionable. Ligation in Continuity for Aneurism.— This is indicated by func- tional disturbances due to the presence of the tumor, growth of the latter with attenuation of its walls, and threatened spontaneous rupture and consequent fatal hemorrhage. Ligation of the trunk above and below the sac and extirpation of the latter, the old operation of An t y 1 1 u s, is the simplest method of treating aneurism. ^Yhen the aneurism occupies the greater portion of the artery, the method is not applicable. Even after successful ligation above and below the aneurism difficulties mav be- met with in extirpation of the sac. Under these circum- Crile's Clamp ; 2, Rubber Tubixg for Slipping OVER THE Ends of the Clamps; 3, Clamp Applied to Artery. 346 OPERATIONS ON INDIVIDUAL STRUCTURES stances large branches may exist in the sac and fatal hemorrhage follow the attempt to remove the latter. Ligation in continuity between the aneurism and the heart, the opera- tion of Hunter, is the best known and most commonly practised of the operations for the cure of this disease. The retardation of the flow of blood in the sac leads to coagulation, and obliteration of the sac follows. This opera- tion is successful in a certain proportion of cases. If the collateral circulation is established before obliteration of the aneurismal sac occurs, pulsation returns after some days. On the other hand, sudden interruption of the l)lood- current, particularly in elderly persons with endarteritis (see page 93), may lead to gangrene of the extremity. Peripheral Ligation. — Where the central portion of the artery is not accessi- ble and Hunter's operation cannot be performed, peripheral ligation may Fig. 131. — Matas's Operation for the Cure of Axeurism. A, Showing the process of obliteration of the orifices of the aneurismal sac in a sacculated aneurism ; B, the obliteration of the orifice completed. be resorted to (Bras dor). It is used almost exclusively for the cure of aneurism of the innominate artery. The ligature is applied to either the right common carotid or the subclavian. As no branches are given off from this point of the aneurism, the formation of a thrombus advancing from the site of ligation will lead to obliteration of the sac. Incision of the sac and subsequent ligation constitute a very bold pro- cedure. The index-finger seeks the point of ingress of the blood and is made to act as a plug to the vessel, being withdrawn only at the moment of drawing a ligature taut about the artery. It is rarely indicated except in those cases of aneurism of the external iliac in which the tumor reaches to the common iliac and precludes the use of the operation of H u n t e r . It is too dangerous for general application. Matas's Method of Arteriorrhaphy for the Radical Cure of Aneurism. — In this operation the sac is obliterated by a plastic procedure and the com- OPERATIONS OX BLOOD-VESSELS 347 niunication hetwetni it and the artery closed, while at the same time an attempt is niaile to preserve the lunu^n of the artery. 'Hie stei)s of the operation include (1 ) prophylactic hemostasia, which may be accomplished by means of a C r i 1 e ' s clamp or a silk traction loop, applied, when necessary, to the distal as well as to the proximal pole of the aneurism, as, for instance, in aneurisms in the cervical region ; (2) exposure of the sac by a free incision parallel to the long axis of the tumor; (3) opening of the sac and evacua- tion of its contents; (4) closure of the arterial orifice or orifices by means of sutures so placed as to effect broad apjjroximation of the serous surfaces of the margins of the openings; (5) removal of the clamp or constricting loop and test of the sutures; (6) obliteration of the aneurismal sac. In the case of a sacculated aneurism the operation is comparatively simple. The orifice of communication between the artery and the sac is closed either by interrupted sutures or by a continuous suture of chromicized catgut (Fig. 131). Fig. 132. — Matas's Operation for the Cure of Aneurism. A, Showing the method of closing the orifices and constructing a new arterial channel in a fusiform aneu- rism ; B, removal of the guide. In fusiform aneurisms the procedure is somewhat more complicated. Here two large openings are present, the space between them representing the continuation of the floor of the parent artery. This space must be preserved, if possible, in order to aid in the construction of a new arterial channel. This is effected, where the flexible character of the sac will permit, by lifting two lateral folds of the sac and bringing them together by suture over a soft rubber guide, in the same manner as that adopted in W i t z e 1 ' s method of gas- trostomy. The sutures are all placed while the guide (a soft rubber catheter of proper size) is in position (Fig. 132, A). The sutures are all tied with the exception of the two middle ones. These are drawn to one side and the catheter withdrawn (Fig. 132, B). The remaining sutures are now tied. "Where the condition of the vessel walls will not permit the lifting of these to form lateral folds for suturing over a guide, as is not infrecjuently the case in aneu- 348 OPERATIOXS OX INDIVIDUAL STRUCTURES risms of pathologic origin, the orifices are closed by one or more tiers of sutures extending along the space representing the floor of the parent vessel and includ- ing both openings (Fig. 133). After all of these procedures obliteration of the remaining portion of the cavity of the aneurismal sac is effected by approximating its walls by succes- sive layers of sutures. The skin edges are then sutured and the dressings applieci in such a manner as to fill the hollow on the surface left by the oblitera- tion of the aneurismal sac. In the after-treatment of all cases of obliteration of the main vessel of supply of an extremity the latter should be kept elevated to favor the return circulation and the temperature maintained by loosely bandaging with cotton batting and bv applying artificial heat. Other Methods of Treating Aneurism.— Digital and instrumen- tal compression may be applied whenever the position of the aneurism permits the application. These methods are de- void of danger but excessively painful. To be effective the compression must be kept up for several days. Disappear- ance of pulsation and induration of the sac are the indications for its cessation. In case of digital compression relays of assistants are necessary. In instrumental compression the point of pressure must be occasionally changed. These are lim- ited in their application, but in individual cases have given favorable results, par- ticularly in the lower extremities. Few patients, however, have sufficient forti- tude to endure the pain of their appli- cation. To assist this, hypodermic injec- tions of morphin may be given. Chemical means calculated to bring about coagulation of the blood have been recommended. These, as, for instance, the injection of the solution of the ses- quichlorid of iron into -the sac, cannot be too strongly condemned. Galvanopuncture consisting of the introduction of two fine needles as electrodes into the sac, and the coagulation of the blood by the passage of the galvanic current, as well as acupuncture, or the introduction of several needles into the sac, the needles remaining there for several hours in order to favor coagulation, has not been sufficiently long on trial to determine its advantages or dangers. The introduction of foreign bodies into the cavity of the aneurism in order that the blood may coagulate around them has been recommended. For this purpose horsehair, catgut, and fine silver steel and copper wire have been employed. A number of yards of the material is introduced through a cannula (Moore). The wire after insertion may be connected with the anode of a galvanic battery (Corradi). There are two dangers to be apprehended from this procedure: (1) fatal hemorrhage may result from the puncture by Fig. 133. — Matas's Operation for the Cure of Aneurism. Showing the orifices in the aneurismal sac in process of obliteration by suturing. OPERATIONS ON BT.OOD-YICRSKLS 349 the cannula; (2) at the very bcfiinniiii^ of the o])eration small clots may be swept away, and, in the shape of emboli, jiroduce disturbances at a distance. Nevertheless the method is worthy of trial in inoperable cases. The method of " needling" (]\I a c e w e n) aims at the formation of a white thrombus on the innc>r surface of the sac. Long steel needles are introduced and gently manipulated so as to produce irritation of the entire lining. Several needles may be used at each sitting and the operation may be repeated until the thickening of the walls of the sac is evident. Injections of ergot in cases of aneurism in the manner recommended in varices has l)cen suggested (L a n g e n b e c k). The acjueous solution is injected by means of a hypodermic syringe around the outside of the wall of the sac. The ergot produces contraction of the muscular apparatus of the vessel. The method is applicable only in the earliest stage of the disease ; as the latter progresses, the muscular fibers disappear. Ligation in continuity in the treatment of neoplasms has not been very successful. In the case of the external carotid the addition of excision of the branches of the vessel on both sides (Dawbarn) promises to become a valuable resource in the treatment of malignant disease occuri'ing in the area of supply of this vessel. The lingual arteries have been tied in carcinoma of the tongue (D u m a r q u a y). Ligation of the femoral artery has been employed in elephantiasis arabum (Carnochan). Hueter's suggestion of ligature of the exter- nal iliac in the same class of cases has likewise been followed. The rationale of the method is not clear. In a young man in whom I ligatecl the external iliac for elephantiasis arabum affecting but one extremity the method proved successful. After twelve years the patient still remains free from the disease. Methods and General Technic of Ligation in Continuity. — The selection of the proper site for placing the ligature was formerly considered of the greatest importance. It was deemed necessary, in order to secure a long coagulum, to place the ligature as far as possible from a branch of the vessel as was consistent with the purpose for which the ligature was employed. The occurrence of suppu- ration, almost a necessary sequence of the operation and an accompaniment of the process of separation of the ligature in preaseptic days, in the case of a short coagulum was not infrequently followed by secondary hemorrhage and the necessity for a repetition of the ligation. These precautions are superfluous when the aseptic ligature and aseptic wound treatment are employed. lender these circumstances the size of the thrombus is of but little importance. In addition to the requisite anatomic knowledge, it will be found useful to identify the vessel by its pulsation whenever possible. It is likewise necessary before applying the ligature to make digital compression at the point at which the occlusion is intended to be made. If pulsation ceases in the area intended to be deprived of supply, the operation is to be proceeded with; other^dse not. In making the necessary incision for ligation of the vessel, care must be taken not to draw the skin away from the line of the vessel to one or the other side. The incision, as a rule, is made parallel to the long axis of the vessel, though there are several exceptions to this rule (see Regional Surgery). The skin, subcutaneous connective tissue, and fascia are separated by the incision, the different structures being steadied by the anatomic forceps. In making the dissection, the muscular structures should be spared as much as possible. 350 OPEEATIOXS OX IXDIVIDUAL STRUCTURES In reaching the sheath the exact location of the vessel is ascertained by feeling for its pulsation with the point of the finger. In case pulsation is absent the artery is identified as a flat cord with a solid feel; the vein which accom- panies it appears soft, while the nerve has a more solid but roundish feel. The relation which these bear to each other must also be borne in mind. In order to avoid injury to the vessel in opening the sheath the latter is grasped by the anatomic forceps, lifted away from the vessel, and opened by an incision parallel to the arterial wall. The sheath is now separated from the vessel by means of the blunt end of the scalpel or a probe, each edge of the incision being steadied in turn by the anatomic forceps for that purpose. This being accomplished a blunt aneurism needle (Fig. 134) armed with a double ligature is passed around the vessel. A bent probe with an eye may be made to answer the purpose. The instrument should always be passed from the direction of the vein, in order to avoid injury to the latter. The arterial wall must not be grasped by the forceps, else injury to this 1 ^ >^ may result. It is well to ligate at IH ^H two points and divide the artery ^H ^H between these; the gaping lumen of ^H ^H the vessel will positively identify it. ^H ^H In tying the ligature it is not ^H ^H always necessary to apply a surgi- ^H ^H cal knot. The ordinary flat knot ^H ^H will answ^er. The turns of the knot ^m ^M are directed to the arterial wall by ^m ^M the tips of the index-fingers. The ^M ^m first turn is to be drawn moderately ^1 ^M tight; it is not necessary that the ^H ^H operator should feel the giving way ^^ ^^ of the middle and inner coats of the vessel, as was formerly taught. The second turn should be only suffi- ciently drawn to secure the first turn against slipping. A third turn affords additional security. For the larger vessels sterilized silk is preferred to catgut by some surgeons, through fear of a too early loosening of the latter. Catgut boiled in alcohol (page 53) will last sufficiently long for any vessel. The ends of the ligature are cut off about one-eighth of an inch from the knot. The wound is sutured in its entire length and dressed aseptically. OPERATIONS ON VEINS Lateral ligation of veins has been already described. Transverse ligation in continuity of large veins is somewhat more difficult than in the case of arteries. With care, however, it may be accomplished. Smaller veins may be ligated as readily as arteries. Fig. 134. — Aneurism Needles. a, Straight; 6, left; c, right. OPEEATIOXS ON BLOOD-VESSELS ■'ol Ligation in continuity of vein, i, sometimes mdioated and practised in c^ e-< of varices. Ligation of tlie internal saplienous vem ( f r e n d e 1 e n - bur") just below the point where the superficial circumflex >hac, the su,>erfici 1 eri-aic and the superficial pudic veins join the vessel near the saphenous oSn" and ligation of the external saphenous itt the middle hne of the pos- terior a°pect of the left leg just before this vessel pierces the deep asc.a to join he poplfteal vein, are employed for the cure of varicose yems of the thigh and lel When the superficial epigastric and superficial pudic vems are mvolved tiresp ve«el= should l>e ligated separately. . \lultiple Ligation.-The multiple ligation of vems commumcatmg with V ices with formal excision of the latter. Ls often practised wuh adyan- a"e Ivulsion of the vein, i. c. its removal by traction after its hgation throu^lf two small openings placed some cUstance apart is sometmies pra ti- caMe The so-caUed " earter-operation" consists of a circular mcis.on of the tab whch dhides all "the superficial strxictures, inclucUng the vems. which ^er are hVated at both di^ided ends. The method, if emplo.ved at all. should be reserved^lnr the most aggravated and mtractable cases Venesection.-TMs Uttle operation, formerly so frequent y emplojed, is now but rarelv called for. The median basiUc vein at the l,end of the elbow usuall chosen. The parts should be prepared in an aseptic manner and a bandTg appLl sufficiently tight to restrict the return flow of blood, but it must noUntertere with the circulation through the vessel, as shown by the puke at the writ The supei-ficial veins become filled. The escape of blood b favored b vo uman -rasping movements of the hand. When sufficien blood has escaped, he con5ri° ting bandage is removed and an aseptic gauze bandage apphed. Trans Usion.-Blood taken from the circulation of one mchvidual and imroduced too that of another in case of excessive hemorrhage has been practi- callv abandoned m favor of mtravenous normal saline mfusion. This resrUt has been brought about, first, beca.u»e of the difficidty of obtammg blood in sufficien" quanUtv: secoM. from the delay mcident to the operation thircl, on a foimt of the i-isks from thrombosis and emboUsm when the direct method is em,Z4d. and the fever and hematuria when the mdirect method is used. intravenous Saline Infusion.-Tlii, operation is usually performed either Aroi"h the mecUan basilic or the mecUan cephalic, at the bend of the W. A constricting bandage is placed on the upper part oft^e a™ to re °ram the flow of btood from the Umb. The vem is bared and cleared for Iboutl toch, and two ligatures passed, one above the pomt of mtenc ed open- tt the vein and one below (Fig. 13.5). A sUghtly curbed cannub .s now mroduced throu^-h a small valve-shaped opemng made m the ^em bj a smp wi^ !he polmrd-scissors. the infusion fltud being ahowed to Aow while th.^ bein.. done in order to gtiard against the emrance of air. The upper hgature t now ti^hteMd around the caiSirUa to hold the latter in place^and to prevent LCeiweU while the lower Ugature closes the vein below. The oonstncting banda°'e Ls now removed. If gra^-ity is employed the reser^w contaming the Musion fluid should be held about three feet above the patient's chest. Or tt'a^^amus show^ in figure 135 may be used. A 0-6 per cent^so ution of chloric! of sodium should be employed at a temperature ""^^ m cl lorid one S z u m a n n ' s transfusion solution consists of slx parts of sodium chlond. one w of carbonate of soda, and one thousand parts of stenle wa er. In case o emergencv a transfusion fluid can be rapidly extemporized by dissohtnga level 352 OPERATIONS OX IXDIVIDUAL STRUCTURES teaspoonful of table salt in a pint of l:)oiled water. The solution should be strained or filtered. This solution, used at a temperature which the hand will bear without discomfort, will answer every practical purpose. The quantity will vary with the recjuirements of the case; from two and one-half to three pints is the usual ciuantity. Care is to be exercised not to inject too much in cases in which secondary hemorrhage is to be feared (^I i k u 1 i c z). Intravenous infusion is employed as follows: (1) for replacing lost fluids following severe hemorrhage; (2) for the restoration of heat to the body in surgical shock and analogous conditions; (3) for the removal of toxic substances by provoking diuresis in cases of renal insufficiency. It has also been used in illuminating-gas poisoning combined with venesection. Under these circum- stances it is difficult to apportion the credit for the favorable outcome in success- ful cases. The contraindications to intravenous infusion are (1) the presence of infective emboli liable to A B Fig. 13.5. — Intravenous Saline Infusion. A, The lower ligature is tied and the upper ligature is in place ready for tying. The valve-shaped opening in the vein is shown ready to receive the cannula. B, Flask containing the saline solution. This flask is an ordinary wash-bottle, the long glass tube of which is connected to the infusion cannula and the short glass tube to a rubber bulb with valves. By pumping air into the flask above the solu- tion the latter is forced into the veins. be forced into the circulation by the operation; (2) the presence of advanced dropsy; (3) marked cardiac insufficiency; (4) cyanosis, or pulmonary edema. The most frec^uent employment of intravenous infusion in surgical practice is in combating shock accompanying or following operations. It is in this class of cases that the higher temperatures are employed. The use of strychnin may be combined with that of the saline infusion when indicated. The strj^chnin is introduced along with the saline fluid by injection from a hypodermic syringe through the rubber tube of the apparatus. This should be done very slowly. Adrenalin chlorid in 1 : 1000 solution may be employed in the same manner. From 10 to 15 minims of the latter may be thus introduced and repeated every few minutes while the infusion is progressing, until its effects in increasing the blood-pressure are manifested (C r i 1 e). Subcutaneous Infusion or Hypodermoclysis. — From one to two pints of the saline fluid may be introduced l^eneath the skin in cases in which OPERATIONS OX BLOOD VESSELS 353 the indications for infusion are less urgent, or for the purpose of supplement- ing an intravenous infusion when this has been given. From one to three pints of the saline infusion may also l^e given hy the rectum for the latter pur- pose. By these means the necessity for a second intravenous infusion may sometimes be avoided. For subcutaneous or intracellular infusion any large hollow needle will answer. This and a clean douche bag, an ordinary Ijulb syringe, or an irrigator to which the necessary rubl^er tul^ing can be attached constitute the requisite apparatus. The infusion is made beneath the breasts. Should it become necessary to repeat the infusion, the interscapular region or the inner surface of the thighs should be selected. Autotransfusion consists in the temporary displacement of the l^lood in the direction of the essential vital organs in cases of excessive loss of blood in wliieh death is threatened from embarrassment of the general circulation. One of the methods of effecting the displacement of the blood is to incline the patient at an angle of 45 degrees by raismg the foot of the bed. By this means the force of gravity is made available and the action of the heart operates to force the blood in the direction of least resistance, namely, in the direction of the cardiac and respirator}' centers. Another method is to hold the limb in a verti- cal position until it is practicall}' deprived of its blood, when a constricting band is placed at its base to prevent the blood from reentering when the limb is lowered. A still more etficient method is to bandage the limb from below upward, its blood being rapidly forced out in this way. A limb may be kept deprived of blood in this manner for two hours with safety ; in case of neces- sity, the limbs can be alternately bandaged or constricted. Autotransfusion is of great value as a temporary' resource. It should be employed only after the hemorrhage is arrested. It should not take the place of intravenous saline infusion, but may be used to gain time to make the latter available. General Treatment of Hemorrhage. — Internal medication is of prac- tically no value in the arrest of hemorrhage. Ergot, of so much value in post- partum hemorrhage from inertia of the uterus, is of no use in surgical hemor- rhage except in cases of capillar}' oozing, and in these, except in the cases in which the bleeding area is not accessible, the method of tamponade may well replace it. It may be advantageously employed, however, in combating the shock resulting from hemorrhage, the caliber of the capillaries being dimin- ished by its action as a vasomotor constrictor, and the heart better enabled to control the general circulation (Livingstone). Oil of turpentin is employed by some surgeons in five-drop doses, given in emulsion and repeated every hah-hour. Its action is not assured and it is liable to produce strangury. Acetate of lead, the dilute or aromatic sulfuric acid, and similar drugs formerlv believed to increase the coagulability of the blood, are no longer employed. Stimulation is to be avoided as long as bleeding continues or is likely to recur. Once, however, the hemostasis is effective, stimulation is to be pushed by hot diluted alcoholic drinks, hot enemas of saline solution and whisky, and the hypodermic use of digitalis and strychnin for the purpose of bringing about reaction and combating excessive prostration. At the same time the heat of the body is to be restored by hot-water bottles applied to the extremities, and, if necessary, to the tnmk as well. A hot-water bottle applied to the precordia sometimes answers a good purpose. In carrying out these measures care should be taken not to burn the patient. 24 354 OPERATIONS OX INDIVIDUAL STRUCTURES OPERATIONS ON NERVES Suture of Nerves. — This is required in complete accidental division of nerve-trunks. This injury occurs at points where nerve-trunks are super- ficially situated, such as the median nerve above the wrist or the ulnar nerve in elbow- joint resection. Contusion of a nerve may recjuire removal of the con- tused portion and the suturing of the nerve-ends. In the earher attempts to suture nerves the method employed was that of transfixion of the entire nerve with interrupted sutures. The employment of a nonabsorbable suture led to frequent and mischievous suppurative inflam- mation. The use of catgut or other absorlDable suture material, and improve- ment in the technic consisting of the suture of the neurilemma of the divided ends rather than the entire thickness of the nerve-trunk (W e b e r), together with H u e t e r's further modification of perineural suture (Fig. 136, suture of the connective tissue of each end), marked a very decided advance in the surger}^ of the nerves. Accurate approximation and healing without suppuration assure excellent results, in a large proportion of cases (about 67 per cent, P. Bruns, 1884). Secondary Nerve-suture. — In cases in which nerve- trunks have been divided and the stumps buried in a mass of cicatricial tissue with loss of function, these may be dissected from their cicatricial surroundings and sutured. If the nerve-ends are readily approximated, H u e t e r ' s suture or Weber's neurilemma suture may be applied. If there is considerable tension on the nerve-tnmk in re- placing it, it will be necessary to apply the transfixion suture of the entire thickness of the nerve-trunk. The results of secondary suture are very encouraging (24 successful cases out of 33, P. Bruns). One case was operated on nine years after the original injury, with a sue- Though there are reports of extraordinarily rapid restoration of function, this varies, as a rule, from three months to two years. Neuroplastic Operations.— In cases of marked retraction of the nerve stumps or loss of substance preventing ready approximation of the same, Letievant (1872) proposed to turn down a flap attached by a pedicle from one nerve stump, and to attach this to the other. The most brilliant success in the employment of this procedure was achieved by T i 1 1 m a n n s , in a case of division of the ulnar and median nerves (1882). Another ingenious operation, also introduced by L e t i e v a n.t , consists in suturing the central end of one nerve-tnmk to the peripheral end of an adjacent nerve, when two neighboring nerves are injured. In cicatricial union of ner\^es, without restoration of function, a longitu- dinal incision is made through the middle of the mass of scar tissue, extending well into the healthv nerA-e substance (Fig. 137, A). This is then converted into a transverse line and secured by suture (Fig. 137, B). In this manner, ner\'e-tissue is brought in contact with nerve-tissue (Bruns, 1893). In cases of nonunion with bulbous central end, in order that a large amount of the length of the nerve may not be sacrificed in getting rid of the f1 ■ Fig. 136.— Perineu- cessful result. EAL Suture. OPERATIONS ON NERVES 355 - Fig. 137. — Bruns's Method of Nerve-suture. A, Longitudinal incision through cicatrix extending into normal nerve; B, incision shown in A, united trans- versely. latter, tliis is s])lit well beyond the bulbous extremity, and the distal end trimnietl to a wedge shape. The latter is then sutured into the split of the central end, as shown in Fig. 13(S (li run s). In order to i)reA-ont tlio sutured ])()rtion from being compressed by the newly formed connective tis- sue, it has been proposed to slip a decalcified bone tube over the nerve before suturing; or the tube may be split and passed arountl the nerve after suturing. Strangulation of a nerve from its embedment in a mass of cicatricial tissue or callus sometimes leads to impairment of function, without coincident injury to the nerve itself. The nerve should be liberated and enveloped in a T h i e r s c h skin-graft (G 1 e i s s) to prevent repetition of the accident. After all operations of nerve- suturing the position of the parts should be carefully attended to. The limb should be placed so as to bring as little tension as possible on the sutured nerve. As soon as healing has taken place electricit}' and massage are useful adjuncts to treatment. Transplantation of Nerves.— G luck in 1880, after P h i 1 i p a u x and V u 1 p i a n ' s experiments (1870) in trans- plantation of nerves in dogs, attempted to place the operation on a surgical basis and made some ex- periments for that purpose. This implantation of completely separated portions of nerves has never been successful in man, though it has been perfectly accomplished in some of the lower animals. Neurotomy and Neurectomy. — Intractable neuralgia sometimes assumes such importance as to demand division of the nerve for its relief. Otherwise inoperable but excessively painful tumors also require division of the sensory nerve supply- ing the organ involved, e. g., division of the lingual nerve in inoperable carcinoma of the tongue. For- merly motor nerves were occasionally divided in cases of intractable painful convulsive movements in the region supplied, e. g., division of the facial for tic douloureux. The opera- tion of nerve-stretching has now quite superseded nerve-section in these cases. Simple division, or neurotomy, is found to be quite insufficient to meet the requirements of permanent interruption of function in sensory nerves. For this reason the operation of neurectomy has taken the place of that of neu- rotomy. Without this, the violent pains which originally demanded the oi3era- tion soon return. The object of neurectomy is to excise a portion of the nerve, Fig. 13S. — Nerve Stump United BY Wedge Method. 356 OPERATIONS ON INDIVIDUAL STRUCTURES in order to prevent reunion of the cliA'ided ends. Idie removal of at least two inches has been shown by experiment to be necessary in order to insure against reunion. These operations are usually performed for intractable trigeminal neuralgia; it is manifestly impossible to remove two inches from any of the branches of the fifth pair. All that can be done, under these circumstances, is to remove all of the nerve accessible ; this will usually include the trunk to the extent to which it passes through the bony canal, from its exit from the skull to its peripheral distribution. More recently the cavity of the skull has been invaded (see Intracranial Neurectomy, page 541). Crushing of the Divided Central End of the Nerve.— This has been suggested to prevent a return of the neuralgia by arresting nerve regeneration. There is danger of inflammation progressing in the direction of the brain or spinal cord (ascending neuritis) occurring as a result of this procedure. Quite as effectual and far safer is the application of the thermocautery to the central end of the divided nerve. Relapses of intractable neuralgia following neurectomy are not always due to reunion of the divided nerve-ends. The development of a neuroma on the central end, or the unfavorable influence of the cicatrix, in a certain proportion of cases, will account for the recurrence. Further, some of these cases have a central origin, the paroxysms depending on some peripheral irritation which is conducted along the intact nerve. The latter being divided, the paroxysms cease for a time only. The condition of these sufferers will sometimes demand repeated operation even though but temporary relief is obtained. Extirpation of Tumors of Nerves.— Neuromas are found most fre- quently in amputation stumps, forming bulbous enlargement of the cut ends of the nerve-trunks. Since the introduction of aseptic wound treatment, however, they have been less frequently observed. They produce exquisite pain and prevent the wearing of an artificial limb. They are dissected out after the cicatrix has been split, the nerve-trunk on which they are situated being divided as far away from the stump as possible. Neurofibromas may occur singly or in groups. When they occur singly, the tumor is usually situated on the lateral aspect of the nerve-trunk. The nerves of the skin of the lower extremities are more frequently attacked. These growths are exceedingly painful and require removal. This should be done without division of the nerve, particularly in the case of important nerves. Multiple neurofibromas, particularly the form known as plexiform neuro- fibromas, except when they occur on the extremities, or on the skin of the tnmk, are not amenable to operative treatment. Myomas of nerves are the most important nerve tumors that come under the notice of the surgeon. They are soft masses consisting of semifluid mucous tissue, the size of a child's head; when large', they are usually situated in the course of large nerve-trunks and have a feeling of pseudofluctuation. In some instances the large ones pass over the convex surface of the tumor, but few nerve-fibers invading the tumor; in other cases the latter seem to be a portion of the tumor itself. Paralysis of the nerve-trunk from which they spring is not common, the nerve-fibers seeming to preserve their conductivity in spite of their apparent involvement in the tumor. In the removal of these growths such nerve-fibers as are distinctly isolated may be preserved; otherwise the trunk must be divided at the limits of the tumor and the continuity of the former restored by a neuroplastic operation (see page 354). OPIOIIATIONS ON IMUSCLK.S AND TIONDONS 357 Ncrve=stretching lias l)oen successfully omj^loyed in cases of neuralgia in which huniUcs of nerve-hhers arc bound down to the surrounding connective tissue by cicatricial attachments. The strong tension made on the nerve, under these circumstances, results in the stretching and the loosening of these adhe- sions. The method has also been employed in certain forms of neuritis; it has been followed fre(|uently by temi)orarv relief, and occasionally by cure. In convulsi\'c tic douloureux stretching of the motor portion of the seventh ncv\Q has also been successful. This is not a trustworthy method of treatment in intractable neuralgia, prompt relapse following any improvement obtained. It is now virtually abandoned in tetanus, tabes dorsalis, epilepsy, and degen- erated processes in peripheral nerves. Slight tension on a nerve increases the reflex excitability (S c h 1 e i c h), while decided stretching is followed by a temporary diminution of the excita- bility, or this may be abohshed altogether (Valentine). The jDaralysis which follows nerve-stretching usually rapidly disappears. Nerve-stretching may be useful, therefore, when a nerve is in an excessively excitable condition, or when the symptoms are due to an inflammatory fixation or constriction of the nerve at some part of its course. It has been shown (P. V o g t) that the stretching of a nerve-trunk is follow^ed by dilatation of the vessels of the nerve. This may give rise to beneficial nutritive changes. In most instances the operation is applied to the large nerve-trimks supply- ing the upper and lower extremities. The nerve is exposed, isolated, and a band of gauze made by folding several thicknesses together which are passed beneath the trunk. This is formed into a loop by tying its ends together and is attached to a Chatillon spring balance scale. The tension is then applied and the amount of strain put on the nerve noted. Breaking Strain of the Principal Nerves in the Body.— The breaking strain of the principal nerves in the body is as follows (T r o m b e 1 1 a) : Great sciatic, 183 pounds Internal popliteal, 114 " Anterior crural, 83 " Median, 83 " Ulnar and radial, 59 " Brachial plexus in the neck, 48 to 63 " " " axilla, 35 to 81 In applying the tension the strain must be divided, by proper division of the force, as nearly as possible between the central and the peripheral portion of the nerve. So-called "dry stretching" of a nerve consists of making tension on the nerve by means of forcible changes in the position of the parts. It is used principally in connection with the sciatic nerve. (See Regional Surgery.) OPERATIONS ON MUSCLES AND TENDONS Suture of Muscles and Tendons.— Subcutaneous ruptures of muscles generally unite without operation. Open section of muscles, however, usually demands suturing. Silk is generally preferred for this purpose; the elasticity of the muscular tissue and its tendency to contract contraindicate the use of catgut. When employed for suturing muscles or tendons the silk should be as fine as possible, the suture should not be drawn very tight, and the knot ends should be cut as short as possible. 358 OPERATIONS ON INDIVIDUAL STRUCTURES the muscle Traumatic Separation of Tendons. — This is of much greater frequency than tlie above, owing to the more exjDosed situation of the tendons. The divided ends recede at once to a considerable distance in the sheath. If permitted to remain, they become attached to surrounding structures and the function of is lost. Suture of Tendons. — The tendon should be exposed by a curved incision so as to avoid a continuous cicatrix between the skin and the tendon. The sheath of the tendon is split in order to secure the retracted ends. These are then brought into position and secured by sutures of fine aseptic silk. In broad tendons several sutures should be applied. Whenever possible the ends should lap over each other, as the peritendinous con- nective tissue is much more A^ascular than the tendon itself. The slight shortening which results does not interfere with the future usefulness of the ten- don. The wound is closed and a fixed dressing applied to support the parts in a relaxed position. Tendoplasty. — This procedure is employed when, either from destruction of a portion of a tendon, or in cases of old injury, there is an inability to approximate the retracted ends. A flap is formed from one end of the divided tendon, turned down and sutured to the other stump (Fig. 139). If necessar}^, in order to fill a greater defect, a similar flap may be taken from the other extremity also (Fig. 140). Threads of catgut and aseptic silk have been made to stretch across from one stump to the other in cases in which it was impossi- ble to bring these together. The implanted material is healed in, and, in case the wound pursues an aseptic course, becomes gradually absorbed and is replaced by connective tissue. A piece of tendon transplanted from a lower animal will, if the operation is successful, behave in the same manner. Lengthening Contractured Tendons. — A longitudinal incision is made in the middle line of the tendon, from each end of which a cross-cut is carried to the edge of the tendon in opposite directions. The tendon is then separated, lengthened, and sutured as shown in Fig. 141. Another method consists in making two parallel incisions in the tendon, each two inches ^^°; i40.— Double ° . J^ . . ' rENDOPLASTY. long, one l^eing three-eighths of an inch higher up on the tendon Flap taken from than the other. The opposite ends of these incisions are carried lon^ (Trn'ka)°^ *^'^" to the edge of the tendon (Fig. 142). By traction the cen- tral portion is straightened out and the tendon is lengthened by an amount equal to the length of the incisions. Vicarious Tendoplasty. — Failure to identify the retracted central end of a tendon constitutes one of the indications for this procedure. The peripheral Fig. 1.39. — Method OF Tendoplasty. OPERATIONS OX .MUSCLES AND TENDONS 359 inriTtiiniiiviDTii: end is identified and freshened. The tendon of an adjoining muscle is now spUt. one half of its tissue utilized for attachment to the injured tendon, the other half retaining its normal connection. In in- jury of the tendon of the extensor longus pollicis or that of the extensor brevis pollicis, the tendon of the extensor carpi radialis longior may be split longitudinally, a flap turned down and sutured to the peripheral stump of the injured tendon (Schwartz). In cases of old injury of the muscles and tendons of the forearm in which the retracted ends cannot be brought together the extensor communis digitorum may be split and a flap of the muscle itself turned down and attached to the peripheral tendinous stump (S crib a). Tliis method may also be employed in certain cases of talipes. The divided peroneal tendons may be united to the tendo Achillis to assist the action of the latter in paralytic calcaneus. In paralytic valgus the extensor proprius hallucis is frequently un- affected and may be employed to substi- tute its action for that of the paral- yzed tibiahs muscle by cutting away the sheaths of both ten- dons which run side by side, scarifying and sutm'ing them for an inch or more, the foot being strongly mverted so as to shorten up the tendon of the tibialis anticus and pull down the tendon of the extensor haUucis (P a r r i s h , 1892). Or. the tendon of the extensor proprius hallu- cis and the anterior tibial tendon may be divided, the proximal end of the former being sutured to the distal end of the latter; the distal end of the extensor polUcis is united to the conmion extensor of the toes. Suppurative Inflammation in Sheaths of Tendons. — Rapid uifection may take place by this means. The sheath must be opened up freely by means of the probe bistoury and thoroughl}'' irrigated by means of an anti- septic solution; otherwise the necrotic changes wiU destroy the tendon itself, or its function will be impaired by the formation of adhesions between the tendon and the sheath. If. in order to reach a deep abscess, it becomes Fig. 141. — Lexgthzxtxg a Texdox. A, Method of dividing the tendon; B, method of reunit- ing the tendon. Fig. 142. — Texdoplastt. 360 OPERATIONS ON INDIVIDUAL STRUCTUKES necessary to pass through a mass of muscular tissue, this may be advan- tageously accomplished by first passing through it a l)lunt probe or director and then the closed blades of a dressing forceps, which should be open when withdrawn, llie hemorrhage which follows incision of the muscle is thereby avoided. In following up burrowing pus the uterine repositor (Fig. 165), used as a director or probe, is introduced in case the finger fails to reach the extreme limits of the pus cavity, and the screw on the handle turned until the extremity of the instrument marks externally the point where the counter- opening is to be made. The skin and fascia are now incised, and the director and dressing forceps relied on for the rest. Myotomy and Tenotomy. — The essential indication for these operations is the existence of contracture of muscular or tendinous origin, such, for instance, as section of the sternomastoid for wry-neck (page 651), the tendo Achillis in paralytic talij^es equinus (see Regional Surgery), as well as various contractures of cicatricial and arthritic origin. Prior to the introduction of anesthesia, tenotomy, which is always the preferable procedure when practi- cable, was somewhat indiscriminately performed; at the present time its employment is more restricted. In contractures of the knee-joint, and par- ticularly in the early treatment of clubfoot, forcible restitution under anesthesia and retention by proper means (see Regional Surgery) have to a great extent replaced tenotomy. The methods of lengthening contracted tendons already described have still further narrowed the field of simple transverse tenotomy. Subcutaneous Tenotomy. — To S t r o m e y e r and D i e f f e n Ij a c h we are indebted particularly for the development of this method of tenotomy (1840-1850). By means of this procedure much less risk of suppuration in the wounds was incurred. At the present day, however, the employment of aseptic precautions renders open tenotomy an almost dangerless procedure and per- mits its employment in situations in which injury to important structures may follow the subcutaneous method, e. g., to the subclavian vein in section of the sternal attachment of the sternomastoid, and to the external popliteal nerve in division of the tendon of the biceps flexor cruris. An anesthetic should always be employed in myotomy and tenotomy. Otherwise involuntary contraction of the muscles may embarrass the operator. The muscle should be put on the stretch as much as possible. The tenotome (Fig. 143) is introduced flatwise, passed immediately behind the tendon, and the latter is divided from behind forward by short sawing movements of the instrument, the operator's left thumb pressing on the tendon from without. The operator is thus enabled to determine when the edge of the blade approaches the skin, and to avoid cutting the latter. The tendon will be felt to give way, if forcible restitution of the parts is made at the same time ; some- times this occurs with a snap or jerk, due to rupture of the last few fibers. The tenotome is then withdrawn and the wound closed by the thumb until a com- press of antiseptic gauze is applied and secured in place by a roller bandage. Operations for the Removal of Tumors of Tendons. — No definite rules can be laid down for the removal of these tumors. Fibromas may usually be enucleated by splitting the muscle in the direction of its fibers. In sarcomas the most careful dissection wdll not give immunity against recurrence. Ganglions spring from the sheaths of tendons and may be treated success- ori'.HA'riONS ox HONKS 361 fully (lurin,<2; the first few weeks of their existence' by means of massage or meiliodicalh' applied pressure. 'Hie old method of rupturing the sac by a sliai'i) blow wilh the back of a book not infreciuently fails and is a barbarous procedure. Subcutaneous incision and the pressing of the contents into the surrounding conned ive tissue, from which they are absorbed, is preferable. 'riu> wall of the sac may 1)6 scarified from within at the same time. Pres- sure by means of a compress and bandage is then ai)plipd. Aseptic incision, followed by extirpation of the sac wall, if carefully performed, is the ideal Fig. 143. — Tenotomes. method of dealing with these tumors. Even if small portions of the sac wall are left behind, recurrences are rare. ^lovable bodies occurring in tendinous sheaths, as well as in bursae, may be removed by incision. In the case of the latter, extirpation of the entire sac wall may be indicated on account of the usual coexistence of hyperplastic synovitis, in connection with which some semisessile rice bodies are usually found to exist. This, however, is not practicable in the case of tendinous sheaths. OPERATIONS ON BONES The Division of Bones.— Bones are divided either by fracture, osteo- clasis, sawing, chiseling, or cutting. Fracture may be accomplished by the hands, when the solidity of the structure is not too great to permit the employment of this method, or the conformation of the parts such as to render it impracticable (e. g., insufficient leverage, or the interposition of thick muscular structure preventing a firm grasp). Under the latter circumstances osteoclasis or instrumental fracture is indicated. The most perfect instrument for the purpose is shown in Fig. 144. Division of Bone by Sawing.— Saws of different patterns have been devised. The most practicable of these are the broad saw (Fig. 82), the frame saw (Fig. 83), the kevhole or metacarpal saw (Fig. 148), the chain saw (Fig. 145), the wire saw of G i g 1 i (Fig. 147), and the trephine (Fig. 84). For ordi- nary amputations either of the two first named answers. In resections_ m which it mav be desirable to change the direction of the blade m order to give a certain conformation to the sawed surface, the frame saw with a mechanism 362 OPERATIONS OX IXDIVIDl'AL STRUCTURKS for accomplishing this is useful. The metacarpal saw (Fig. 148), or keyhole saw as it is sometimes called, is useful when it is desirable to introduce the Fig. 144. — Rizzoli's Osteoclast. instrument through a small opening or to saw on a curved line. A modifica- tion of this instrument for purjDOses of subcutaneous osteotomy is that known as Adams's saw (Fig. 149). Fig. 145. — Chain Saw. The chain saw is led around the bone by means of the chain saw carrier (Fig. 146) or a large curved needle. A loop of silk is first drawn around and Fig. 146. — Chain Saw Carrier. to this the saw is attached. The wire saw of G igli has largely replaced the chain saw. Pinching in the furrow and consequent breakage of the chain or OPERATIONS ON BONES 363 the wire saw mav 1)o best avoided by holding the handles of the instrument wide apart in the manipulation, the saw thus describing a very obtuse angle. In the manipulation of the broad and the frame saw the heel of the mstru- ment should be first applied to the bone and the act of sawing commenced by a slow and stcadv drawing movement and strong pressure. For the rest of the Fig. 147. — The Gigli Wire S.i.w. manipulation the usual to-and-fro movements are executed. The assistant who steadies the parts to be removed should do this in a manner which will tend slio-htlv to separate the sawed surfaces, in order to prevent the saw from becomino- pinched. Too great force applied in this direction, however, should be avoid^'ed. else the bone will be prematurely broken before it is sawed com- pletely across. Fig. 148. — Met.\carp.\l Saw. In former times great stress was laid on the occurrence of necrosis as the result of sawing the bones. The influence of sepsis and consequent mflam- matorv conditions were not properly appreciated. It is now known that the nutrition of bone is not easily destroyed by this means, if septic comphcations are avoided. Fig. 149. — Adams's Saw. Division of Bones by Chiseling.-Chisels are made either tapering or wedo-e-shaped (M a c e w e n, Fig. 89), with beveled edges, or hoUowed out^on one surface (gouges) . The latter may sometimes be used as hand gouges. The usual method of usmg the chisel, however, is in connection with the mailet (Fio- 150) which is preferablv made of lignum-vitae or other hard wood. 364 OPERATIONS OX IXDIVIDUAL STRUCTURES Where a simple straight cut is to be made, particularly in the cancellous struc- ture of bone, as in supramalleolar osteotomy (M a c e w e n), the wedge- shaped or tapering chisel is to be preferred. To prevent "binding/' as the instrument advances into the depths of the bone, a more bluntly shaped instrument is at first emploj'ed; this is subsecjuently followed by one less blunt, and finally by a comparative^ slender instrument. In cutting away portions of bone the beveled chisel is to be used. It is held at a ver}' obtuse angle to the bone, in order to cut away wedge-shaped pieces. The V-shaped groove which is thus produced may be "sciuared" at each margin of the cut before completing the section. The chisel must not be held Fig. 150. — Bone Chisel axd Mallet. too firmly, else a portion of the force of the blow will be lost. Neither must it be held too loosely, or it may deviate from the course intended. When thin slices are to be removed parallel to the surface, the bevel side of the instrument is to be placed next to the bone. With the acquirement of skill in the manipulation of the chisel and mallet the surgeon will be enabled to substitute these for the trephine almost entirely (see page 444). Division of Bone by Cutting Forceps. — Though bone in its very young state and in certain pathologic conditions may be divided by means of the knife or scissors, bone-cutting forceps are usually employed for this purpose. These are made in several patterns, those of L i s t o n and L u e r (see page 317) Fig. 151. — The Sharp Spoox. being the best known. The first named have plain cutting-edges which meet instead of passing each other, as in the case of scissors. L u e r ' s forceps are also known as the rongeur. A well-made L i s t o n forceps may be advantageously substituted for the metacarpal saw in dividing such small bones as those of the metatarsal and metacarpal regions, as well as in making the section of the ribs in Estlander's operation of thoracoplasty. The rongeur forceps (Fig. 90, A) may be used as an adjunct to other bone-cutting instruments, as, for instance, in cutting away the small toothlike projections left on sawed or chiseled bones. The sharp spoon (Fig. 151) is also employed in cutting bone, somewhat in the same manner as the hand gouge. It is much more effective than the latter, OPinjATIoXS oX BOXES 365 however. It has been improved so as to permit of simiihaneoiis cutting and irrigating; (Fig. 94). Coaptation of Bone by Operati>e Weans. — Laterally placed openings, as, for in.^tance. tho.se produced in the operation of sequestrotomy (j^age 369), will not permit approxima- tion of the edges of the opening. In certain joint resections, in which transverse sections of the bone have been matle. it may be undesirable to promote union of the sawed surfaces directly (subperiosteal re- section). The simple application of a retention ban- dage, and perhaps the application of extension, is here indicated. In cases in which imion is desired and the fixed dressings are not sufficient to insure coaptation of the fragments, operative fixation is indicated. In ac- complishing tills the method of mortise coaptation is sometimes employed (Fig. 152). Bone Suture. — This, when properly applied, will accomplish all that can be accomplished in operative fixation of the fragments. It should replace the meth- ods of clamping, the use of metal plates, rods, and steel screws, and pegs of metal and ivory, etc. The follow- ing points should be borne in mind: (1) The entire limb, except the site of the operation, must be care- fully bandaged with a sterile bandage in order to main- tain asepsis durmg the operation; (2) the incision should be no larger than necessary and the parts must be carefuUy manipulated in order to prevent further devitaUzation. Forcible protrusion of the bone from Fig. 152. — Mortise Coaptatiox of Boxe with Ivort Pegs. Fig. 153. — Bevel-gear BoxE Drill. the depths is to he discouraged; the operator should work by the sense of feel- ina; as much as possible. Fig. 154. — Jeweler's Drill. The instmments reciuired are (1) a proper drill (Figs. 153 and 154); (2) a hook for drawing the suture through the holes; (3) several stout strands of silkworm-gut to serve as "leaders," or light copper wire for the same purpose; 366 OPERATIONS ON INDIVIDUAL STRUCTURES Fig. 155. — A, Faulty Method of Applying the Bone Suture; B, Correct Method (after Wille). (4) forceps to twist the wire and a wire cutter. A narrow and pointed meta- carpal saw may be needed. In the application of the wire the following points in the technic must be observed in order to obtain the best results : 1. The shorter the distance be- tween the drill holes consistent with securing a firm hold on the fragments, the less will be the chances of subse- quent displacement. 2. The line of traction or the bind- ing force of the suture must be placed as nearly as possible at right angles to the line of fracture. This is easily accomplished when the drill holes are properly placed (Fig. 155, B). In oblique fractures this will naturally remove the drill holes from the mid- dle line of the bone (Fig. 156, A); otherwise the very undesirable effect shown in Fig. 157 will be produced. In very obliciue fractures there may not be room enough for the drill holes, in which case a wire sling may be placed tightly around both fragments so as to bring the binding force in the proper direction ; grooves are made in the bone with the metacarpal saw in which to engage the wire (Fig. 156, B). Another method of securing a very oblique fracture is shown in Fig. 158, A. The fragments are brought into align- ment and both drilled vertically in the center of the fracture surfaces. The silver wire is now passed to its middle behind the bone, and its "bite" caught by a hook or leader passed through the holes. The wire, doubled upon itself, is drawn through on the withdrawal of the hook. By dividing the loop thus formed, after it is drawn through, two separate and permanent binding sutures are formed (Fig. 158, B) (Wille ; H e n n e q u i n) . Operations on Bones after Frac= tures. — Some of the procedures dis- cussed in the foregoing may be neces- sary after fracture. In addition, some special operations are required, particu- larly in fractures complicated by an externally communicating wound (compound fracture, accompanied or other- wise by extensive comminution). In extensive extravasations, even in subcutaneous fracture, it will occa- sionally be necessary to make an incision and turn out the clot. This should Fig. 156. — A, Proper Method of Applying the Bone Suture in Oblique Fracture; THE Drill Holes are Placed in such A Manner that the Wire Suture is AT Right Angles to the Line of Frac- ture; B, Sling Suture Applied to an Oblique Fracture (after Wille). OPERATIONS ON BONES 367 Fig. 157. — A, Faulty Method of Applying the Bone Suture IN Oblique Fracture; B, Mechanism of Possible Dis- placement of the Fragments in Faulty Method of Bone Suture in Oblique Fracture (after Wille). be resorted to only in extreme cases, such as urgent hemarthrosis of the knee- joint comphcating fractures of the patella. Ordinarily in blood extravasations about fractured bones, unless the supervention of high fever and increasing sensibility of the part leatl- ing to a suspicion of sejisis demand interference, it is better to wait patiently for nature's efforts at resorp- tion. If incision is made, the most rigid aseptic pre- cautions and antiseptic treatment are necessary. In comi^ound fractures, in addition to the indica- tions offered by the reciuire- ments of aseptic and anti- septic measures, drainage, and the removal of foreign bodies, it may become necessary to remove isolated portions of bone. Under these circumstances every effort must be made to preserve as much of the periosteum as possible. In separating the fragments from the periosteum the elevator (Fig. 159) will be found useful. In oblique fractures, not com- minuted, one of the fragments may project from the wound and require removal in order to effect reduction. So-called ^tf^^ \ ( ^"fP^ ^ diaphysial resection should not be ^Bil^ JV k^ ^^'^^- -■ A resorted to, on account of the large de- fect remaining, except under the most urgent circumstances. In case of frac- ture extending into a joint the projec- tion of a portion of the latter through a wound of the soft parts may require re- section. Operations for Ununited Frac- tures. — The conditions existing under these circumstances vary considerably and methods of treatment must be adopted in accordance with the require- ^ ments of individual cases. Delayed Union. — Percussion of the soft parts over the seat of fracture (Thomas) by means of the handle of a percussion hammer, a rubber faced mallet, or other instrument, the parts being protected from direct injury by a folded compress, will fulfil the indications in a certain proportion of cases. A daity seance, or thrice weekly seances of from five to ten minutes, until decided reaction is established, should be prescribed; if necessary, ether may be Fig. 158. — A, Method of Securing the Frag- ments of an Oblique Fracture in Posi- tion BY Means of a Loop Suture Passed through Both Fragments; B, the Loop Suture Divided and the Two Halves of the Loop Twisted Together (after Wille). 368 OPERATIONS OX INDIVIDUAL STRUCTURES administered. The liml) is kept in a fixed bandage in the intervals. When consideral)le tenderness and some swelling have supervened, a plaster-of-Paris bandage should be applied so as to maintain exact inm-iobilization for three or four weeks. This failing, rubbing the fragments together under an anesthetic may be tried. Needling after the method of .^ t a r k e (the introduction of a stout needle or an awl, and its manipulation aljout the ends of the fragments in order to produce effusion) may accomplish the object. Ah of these methods failing, a condition of pseudarthrosis exists, for which the following methods of treatment have been resorted to, in addition to those above described: 1. Implantation of Ivory Pegs. — In this operation two small incisions are made, one above and the other l^elow the seat of fracture, and a conical ivory peg driven into each of the fragments a short distance from the seat of fracture. Reposition and retention follow. If the procedure is accomplished without aseptic precautions, union may be secured, but at great risk from septic con- ditions. If strict aseptic precautions are observed in the treatment, the chances of success are remote, owing to the very slight reaction which follows. 2. Resection of the Fractured Surfaces. — This method, combined with bone suture following the resection, is comparatively devoid of danger under aseptic conditions and offers the advantage of inspection and recognition of the conditions present, such as the interposition of soft parts, as well as the opportunity for the removal of these. The ends of the fragments are exposed, Fig. 159. — Periosteal Elevator. a cuff of periosteum turned back from each, the surfaces of the former sawed off so that they will make proper support for each other, and the cuffs of peri- osteum sewed together with catgut. A fixed dressing is applied, the external wound, if asepsis has been preserved, being closed. Bone suture may be added to the periosteal suture. Whatever method may be indicated in individual cases, the periosteum must be preserved. The slight production of callus from the medullary tissue is insignificant, compared with that furnished by the periosteum. Bone Transplantation. — In cases in which pseudarthrosis is due to a long defect from considerable loss of osseous substance, after necrosis for instance, bone transplantation (N u s s b a u m) is indicated. By means of the chisel a piece of bone, still attached to its periosteum, is loosened and brought around so as to bridge over the gap. The pedicle of periosteum is twisted upon itseh. Or, a bone flap may be obtained by splitting an adjoining bone and bringing this, still attached by its periosteum (the muscular and fascial attachments of the latter being preserved as well), into position so as to fiU the gap. The bone flap thus transplanted must accurately fill the defect. The method is not applicable to pseudarthrosis without l^ony defect. Operations in Inflammation of Bone.— Immediately on the recur- rence of suppuration, incision and drainage are indicated. In case of sup- purative foci in the medullary canal, the bone is to be chiseled away in order opi;i;a'I'I()Ns on bonks 569 lo ostalilish (lraiiiai;(\ or tlio .softened corticiil lamella may be ]ierforated with 1 he |)(iiiits 1)1' a closed anatoiiiic forceps. The sharp spoon is applied, all granu- latina; material scrapetl away, and gauze drainage employed. In acute sup- purative myelitis incision and drainage will frequently give better results, if applied sulhciently early, than extensive resection or removal of the entire bone. When delayed, howe^'er, sequestra and an involucrum form and require the operation of sequestrotomy. Myelitis granulosa differs from acute suppura- tive myelitis by producing suppuration more slowly. The slow formation of the resulting abscess usually delays operative interference. When these abscesses arc situated centrally, their situation is first determined by exploratory drilling; the opening thus made is subsequently to be enlarged by means of the chisel and mallet . Sequestrotomy. — Sequestra involving the cortex only may be removed as soon as formed ; those involving the entire thickness of the bone should be per- mitted to remain until an encasement of new bone has formed about the diseased portion, unless profuse suppuration which threatens life compels interference. E s m a r c h ' s bandages should be applied. The fistulous opening leading down to the diseased bone is enlarged by means of the probe-pointed bistour\\ The site of the cloaca is now investigated. This is enlarged by pushing back the periosteum and chiseling away its edges with the gouge and mallet. Two Fig. 160. — Sequestrum Forceps. cloacae situated near each other may be connected. If the examination dis- closes an entirely movable sequestrum, this may be removed at once by means of the sequestrum forceps (Fig. 160) or the elevator (Fig. 159). Or the seques- trum may be removed after being divided. This failing, a large portion should be chiseled away to permit the passage of the detached portions. The ingenuity of the surgeon will be able to overcome the mechanic difficulties; as little as possible of the involucrum of new bone should be sacrificed, though equal care is to be exercised in the removal of all diseased bone. A repetition of the operation is frequently necessary. The incised soft parts are sutured and the cavities drained after thorough antiseptic irrigation. Insufflation of iodoform powder or of salicylic acid is sometimes practised with benefit. Excavation of Bone; Evidement. — This operation is employed in the treatment of caries resulting from myelitis granulosa. The focus of inflam- mation and suppuration is to be sought for through the fistulous canals, if such exist, and made accessible for purposes of thorough removal by means of the sharp spoon of all products of disease from the medullary canal, as well as the broken-down osseous structures. Small foci are sometimes scattered through the otherwise healthy appearing marrow; only complete removal of this will insure a complete cure. In some instances nothing but the sheet of cortical substance and the articular extremities of the bone are left. It is sometimes supple- 25 370 OPERATIONS ON INDIVIDUAL STRUCTURES mented by the application of the actual cautery to the .site of the primary focus. If the cortical lamellae are affected, evidement may not suffice, and partial or total resection, or, in the case of short bones, c. g., the metatarsal and meta- carpal bones, extirpation may be necessary. If a joint is found to be invaded, this, too, must be attacked. After resection the sawed surface is to be carefully examined and all suspicious looking points scraped out with the sharp spoon. Evidement and sequestrotomy are frequently combined, as in tuberculous ostitis, though amputation must frequently replace both these and resection, as, for instance, when several bones and joints of the tarsus are simultaneously involved, when general miliary tuberculosis or amyloid degeneration of internal organs is threatened. In elderly persons, in ^\ hom the periosteum rarely regener- ates bone, amputation is to be preferred, as a rule, to the more conservative procedures. Operations for Tumors of Bone. — The variety of osteoma which is attached to otherwise healthy bone by a narrow base or pedicle (exostosis) is removed by being completely exposed and either sawed off or chiseled away. In exostoses having a broad base, the mallet and chisel are employed. It is sometimes necessary to make a transverse section of the bone itself, in order to remove the growth comjDletely. Chondromas. — These may spring from the cortical lamella or from the medullary cavity. They are usually adherent by a broad base. The former, as a rule, may be removed by the knife. The latter are either lifted out of the medullary substance, or resected, as in osteoma. Complete removal is not always necessary. A removal of a portion of the tumor sometimes results in ossification of the remainder, particularly when the tumor springs from the medullary cavity. In the case of an important bone partial removal should be tried before resection or amputation is resorted to. Malignant disease of bone is represented by sarcomas and secondary carcinomas. The most common^ observed are the sarcomas, originating either in the medullary structure, in the periosteum, or in the immediately adjacent soft parts. The operative indication for these conditions is amputation or disarticulation. The bone that is the seat of the disease, together with its attached soft parts, must be entirely removed. Even this does not give immunity against recurrence. The prognosis in the sarcoma of pregnancy is much more favorable. Recurrence, except in subsequent pregnancy, is not frequent. In epulis at the alveolar processes of the jaw resection of the portion of jaw gives favorable results. Fibromas of bone are comparatively rare and indicate extirpation of the tumor. Echinococci of bone are exceedingly rare; they require incision and extirpation of the sac. OPERATIONS ON JOINTS Operations on Joints after Injury. — Puncture of the capsule is sometimes required in hemarthrosis, particularly in that of the knee-joint occurring in fracture of the patella, the repair of the latter being facilitated thereby. Usually, however, the effused blood is resorbed without difficulty. In hydrarthrosis puncture of a joint is more frequently required. The opera- tion should always be performed under the most stringent asepsis. If there is not much tension present, the left hand of the operator forces as much as OPERATIONS OX JOINTS 371 possible of \ho (luiil in the joint toward the i)lace of intended puncture. The trocar employed should he suflici(>ntly large to permit the free passage of thick- ened synovia. If antiseptic irrigation of the joint is indicated, this can be accomplished through the trocar, solutions of carbolic acid (1 : 40), corrosive sublimate (1 : 2000), or salicylic acid (1 : 200) being employed. The irrigating fluid is forced into all parts of the joint by external manipulations and the joint thoroughly washed out l)y repeat(Mlly filling and emptying it. Incision and Drainage of Joints. — These two procedures combined are most frequently indicated by the occurrence of suppuration of joints after traumatism and infection, suppuration from any other cause (pyarthrosis from polyarthritis, synovitis, gonococcus infection), or from an extension of an acute osteomyelitis to an adjacent joint. In granular synovitis (tubercu- lous) the procedure is useless. The first incision must be sufficiently long to pemiit digital exploration of the joint. Other and smaller openings (counter-openings) may be made when the condition of the joint is ascertained. The exploration should take cognizance of the condition of the cartilages with reference to the presence of necrosis; of the bone with reference to the presence of fissures or splintered fragments, sequestra, etc.; it likewise determines the most available points for locating the counter-openings. Dressing forceps introduced into the joint and their l^lades then separated form the best guide on which to make the incisions for the counter-openings. They are likewise utihzed by being passed through the incision for the purpose of drawing the drainage-tube into position. In large joints and extensive suppuration through-and-through drainage is best, a long tube being led through the whole joint cavity. The attempt to drain a joint b}' means of a rubber drainage-tube introduced through the cannula employed in making a puncture is not to be recommended. Incision alone may be employed for diagnostic purposes, but should be restricted to conditions in which strict asepsis is possible and where the incision may be utilized for therapeutic purposes. The operation is also indicated for the removal of joint villi and free movable bodies in the joint. Resection of Joints. — The general indications for resection of joints are as follows: 1. Compound dislocations. Here the choice will be between removal of splintered portions, reduction of the dislocation and drainage, or primary resection. The circumstances in each case must be carefully taken into account, particularly with reference to the establishment and maintenance of aseptic conditions. 2. Extensive and severe suppurative conditions consequent on in- jury. Resections performed under these circumstances are either inter- mediate or secondary, according to the period of time intervening between the injury and their performance. 3. Suppuration occurring in connection with tuberculous synovitis and myelitis. While it cannot be said that every tuberculous focus in joints demands operative interference, owing to the fact that the suppurative process tends to limit the specific infection, greater security against general infection is obtained, other things l^eing equal, by resection of the parts containing the tuberculous focus. Even after apparent recovery in cases not operated on, recurrence is to be feared. 372 OPERATIONS ON INDIVIDUAL STRUCTURES 4. Granular synovitis without suppuration, nonoperative treatment proving unavailing, furnishes an indication for resection. The presence of granular myelitis is an indication for early resection, a l:)etter functional result following this than when the interference is delayed, inasmuch as the sheaths of the tendons are still unchanged and the nutrition of the muscles comparatively unimpaired. Arthrectomy {vide infra) is followed by prompt and satisfactory results, in cases of synovial tul^erculosis, pure and simple. 5. Contractures and ankylosis, in case nonoperative treatment is of no avail, may be submitted to resection. In ankylosis a most positive indication is offered by a functionally useless position of the parts, e. g., a knee-joint in the flexed position, or an elbow-joint in the extended position. Old disloca- tions, if they cannot be reduced in the ordinary' manner, require resection, both to increase the range of movement and to relieve functional dislocations arising from pressure. Arthrodesis, designed to produce a rigid condition of the joint in certain muscular paralyses and flail-like joints (infantile paralysis), involves resection of the joint surfaces (seepage 373). The justification for the performance of resection for the sole purpose of restoring function to otherwise useless parts is to be sought for, in each individual case, in the desire on the part of the patient to have his condition improved, and in a prior understanding as to all possible results of the operation itself. Immediate resection is rarely performed in grave injuries. The oppor- tunities of coml^ating sepsis justify waiting for shock to subside. Primary resection is performed after the shock of the injury has subsided and before septic complications set in. This period covers from twenty-four to forty- eight hours after the injury. Intermediate resection is preferred after septic complications have set in and while these are in existence. By facilitating drainage and rendering accessible remote suppurating foci and collections of pus, resection in this period assists in overcoming sepsis. Secondary resec- tion is performed after sepsis subsides. Its uses are to remove diseased bone; to overcome deformity; to relieve extreme pain or loss of function in a part. It may likewise be necessary because of the presence of persistent sinuses. Partial Resection. — ^lany surgeons prefer partial resection. This may be indicated in certain acute joint injuries under conditions where an aseptic wound course may be confidently expected. Even here, the projecting artic- ular extremity of the bone into the cavity, as, for instance, the presence of the lower extremity of the femur after removal of the head of the tibia, and of the humerus after removal of the ulna, may interfere with free drainage and aseptic treatment. Partial resection is not admissible as an intermediate or secondary operation and it is usually contraindicated in granular synovitis and myelitis. In the majority of instances it will therefore give way to total resection. Erasion or arthrectomy (V o 1 k m a n n) is a variety of partial resection. It consists in opening the joint and cutting or scraping away all diseased tissues, these including both the synovial structures and the joint ends themselves. It is particularly applicable to the cases of tuberculous joint disease of childhood in which the granulating inflammation takes its origin in the synovial structure and is limited to that membrane. In this class of cases total resection, by interfering with the epiphysis, restricts the relative growth of the corresponding OPERATIONS ON J(HNT,S 373 liiiil). Special caro must bo exercised in selecting cases for erasion, in order that promiit and ri'ix'ated i-ccuitcmicc may be avoided. The General Technic of Joint Resection. — Incisions in the soft parts are usually made in the longitudinal axis of the limb and are so located as to avoid injury to temlinous and muscular structures. This rule may be deviated from at times in cases of granulating synovitis and myelitis, and particularly in resection of the head of the humerus and of the femur. The parts are incised by a knife with a broad blade and a large handle. Large nerve-trunks and important blood-vessels are to be avoided. The drains are so located as to reach the deepest portion of the wound cavity and are placed in a position in which gravity will assist in carr3dng off the wound secretions. When the resection is performed for granulating synovitis and myelitis, the capsular covering is necessarily sacrificed. Where the capsule is healthy, one or two longitudinal incisions are to be made in the synovial membrane; this is dissected loose and turned aside to permit the sawing away of the bone underneath (subcapsular resection). Further, subperiosteal resection is likewise to be employed wherever practicable. In the latter the periosteal covering is to be incised and turned back in the shape of a cuff to the extent of the intended removal of bone. The adjoining muscular and tendinous structures should be pre- served in their attach- ment to the periosteum as far as possible. In cases of old inflammation this is comparatively eas- ily accomplished. In re- cent injuries, old luxa- ^ig. 161.-Lionwaw Forceps. tions, and ankylosis cases it is not possible, oftentimes, to make a completely subperiosteal resection. In these difficult cases it is occasionally possible to lift a layer of the outer lamella of the bone with the periosteum. When it is borne in mind that subperiosteal resection preserves the branches of the rete arteriosum of joints, prevents suppuration in the synovial sheaths of the tendons, as well as in the connective-tissue planes in the neighborhood of the joint, and secures the formation of new articular extremities, the necessity of adopting it in every case in which it is indicated or possible is apparent. Every strip of perios- teum capable of being utilized should be preserved. Bony prominences which serve as attachments for muscles may be chiseled off and left attached to the latter. The metacarpal saw (Fig. 148) is a very useful instrument for dividing the bone in resection of joints. Where sufficient retraction of the soft parts can be secured, either the broad or the frame saw (Figs. 82 and 83) is advantageously employed. The chain saw (Fig. 145) is not often used on account of the difficulty of carrying it around the joint extremities. In very young children the soft bone may be cut with a stout knife. It is sometimes an advantage to grasp the end of the bone about to be sawed off by means of the lion-jaw forceps of Ferguson (Fig. 161). The extent of the removal of bone will depend on the conditions present. 374 OPERATIONS ON INDIVIDUAL STRUCTURES In typic resection enough is removed to take away the joint cartilages. The extent of the resection also differs in different Iwnes (see Regional Surgery). In the case of the knee-joint a rigid though straight liml) is aimed at. In the upper extremity a mobile connection in the joint is desirable. In the first instance, therefore, the simple sawing through of the line of fusion, or near the same, is sufficient. In osteotomy for the correction of contracture and anky- losis the bone is sawed or divided by the chisel two-thirds through and the remainder fractured. In the case of the elbow-joint, either the fused portions are at first separated and then isolated and removed, or the ankylosed portion is removed in a wedge-shaped piece. Resection of Joints for Tuberculous Synovitis and Myelitis. — In civil practice joint resection is more freciuently required for tuberculous affections than for traumatism. Here the resection must include the capsule, which is always diseased, as a routine measure. In fact, under these circumstances the operation becomes a typic extirpation of the entire diseased joint ; this includes the removal of the entire synovialis, the sawing off of the joint ends and the articular cartilages, and the apphcation of the sharp spoon to any suspicious point in the cancellous or medullary structure. In order to gain free access to the parts, large transverse incisions are made. In some localities it may become necessary to divide tendons in making these incisions, in which case these must be sutured at the close of the operation, in order to preserve their functions. In granulating myelitis the periosteum is not always involved ; even considerable of the cortical lamella may be preserved, in which case the operation is completed by evidement (see page 369) . Hemorrhage from the can- cellous or medullary tissue is sometimes troublesome. In rare instances it may become necessary to apply the thermocautery for its arrest. Drainage of the medullary cavity, if deemed necessary, is secured by carrying a drain from the latter and either leading it through the external wound, or chiseling an opening in the cortical layer at a convenient point and thence through a separate incision in the soft parts. The employment of drainage is not always necessary, particularly if suppurative processes have not invaded the tuberculous affection. If the operation has been thoroughly done, the prognosis is generally favorable, provided the patient is free from general infection. Recurrence may take place after the healing has been completed, or the wound surfaces them- selves may become infected. The latter condition is known by a yellowish- brown and flabby appearance of the granulations lining the cavity and fistulous passages. As soon as these symptoms are observed, immediate steps should be taken to correct them. The sharp spoon or thermocautery is to be applied and the fistulous tracts opened up freely, if necessary to gain access to the infected granulations. These should be thoroughly curetted and the sinus injected with pure carbolic acid, followed at the end of a minute with 95 per cent alcohol. If the curetting has been thoroughly done and further packing of the sinus omitted, prompt healing follows in many cases. The After-treatment of Resection Wounds. — The parts are to be enveloped in copious dressings of aseptic gauze. If drainage has been employed, these should be specially thick in the neighborhood where the tubes emerge. The large and dense dressings, reinforced by thin basswood or pasteboard splints, which should extend beyond the next adjacent joint and be secured in position by starched gauze (crinoline) bandages, first wetted and then applied, OrKRATIOXS ON JOINTS 375 Avill secure suflicient immoljilization of the parts for the first few weeks at least, without the aid of plaster-of- Paris. I'he ordinary rules governing redressing should 1)0 followed (see page 57). If all goes well a large resection wound may heal by primary union, except, in cases in which drainage is employed, the ]ioints where the drains emerge. Even in the knee-joint no more time is occupied in uncomplicated cases than is necessary for recovery from a fracture. As the wound approaches complete healing, the surgeon's chief efforts should be directed toward securing the desired functional result. In the lower extremity solid union is to be obtained, and \\\\\\ this in view a fixed form of dressing, such as will permit the application of aseptic measures and at the same time completely immobilize the parts, is to be applied. The bracketed splint (Fig. 162), employed in connection with a plaster-of-Paris bandage, serves the purpose admirably. In the case of the upper extremity, if a subcapsular and subperiosteal resection has been possible, not much difficulty will be experienced in obtaining an artificial joint (nearthrosis). The new bone is molded into shape and even articular extremities may form. Passive motion in the normal range of the limb will assist in the molding process. The synovial membrane resumes its function. Fig. 162. — Bracketed Plaster-of-Paris Splixt for Use after Resection of the Kxee-joint. In due time active movements supplement those of a passive character. Atrophy of the muscles resulting from nonuse is to be treated first by the galvanic current, and subsequently by faradization. When it is found impossible to preserve the synovial capsule and periosteum, an artificial joint may still be secured. The perisynovial connective tissue seems to assume the function of the synovial membrane. Aseptic healing materially aids in producing a nearthrosis, even where no passive movements are made. But flail-like joints may result from excessive mobility, the joint permitting movements in all directions like a flail. This condition may arise from injury to unportant muscles by the incisions, defective preservation of the periosteum, severe and prolonged suppuration, the removal of too much bone and excessive passive movements during the after-treatment, and in- sufficient stimulation of the muscular apparatus, paralysis of the latter from nerve injury, and paresis of the same from want of use. In the case of the elbow-joint a flail-like joint is of not infrec|uent occurrence after resection for tuljerculous disease. Under these circumstances it is recommended to attempt to secure bony ankylosis in a proper position (Billroth). 376 OPERATIONS ON INDIVIDUAL STRUCTURES Solid or ankylotic union must be secured at the knee and ankle; and even at the hip it is not a great disadvantage. Good functional results have been obtained, however, with an artificial hip-joint. Whether solid union is intended or not, in case of its occurrence the limb is to be placed in a position most convenient for use, i. e., the elbow at a right angle and the knee in the extended position. During the period of childhood every effort should be made to preserve the epiphysial cartilages in resection of the joints. Injury of these structures, with the enforced rest necessary in resection, leads to lessened longitudinal growth of the bone and consequent relative shortening of the liml). Operations for the Removal of Joint Tumors. — Movable or free bodies in the joints (page 162) are now generally removed by means of incision of the joint (arthrotomy). This operation, in preaseptic times an exceedingly dangerous one, is now performed aseptically with the best results. The methods formerly in vogue, e. g., the subcutaneous opening of the capsule and the forcing of the body out of the joint into the perisynovial connective tissue, from which point, after the wound in the capsule was healed, it was removed by open incision, the pinning of its free border to cause its adhesion, etc., are no longer necessary, provided a rigid enforcement of aseptic principles accompanies open incision and immediate extraction. Difficulty is sometimes experienced in locating the movable body. If the symptoms are sufficiently urgent, exploration of the joint is indicated, or even resection may be resorted to. Sarcoma, having its origin in the medullary structure, is the most impor- tant form of tumor of joints. While amputation above the joint has been resorted to, the operation of choice is disarticulation at the joint next nearest the body. Recurrences are not uncommon even then. Resection is absolutely excluded. Sarcoma of the synovial membrane is very rare. It tends to recurrence, as sarcomas elsewhere, and reciuires the same radical treatment as that springing from the bone itself. Lipomatous and large papillary pro- liferations of the synovialis are benign growths and do not necessarily demand interference. Extirpation of the growths is indicated, however, if their pres- ence gives rise to functional disturbance. AMPUTATIONS AND DISARTICULATIONS Amputation and disarticulation differ from each other in the method of separation of the bones. The first has been termed amputation in conti- nuity, the latter amputation in contiguity. Both are employed to follow the same general indications. Indications. — Conservative surgery has -very greatly restricted the indi- cations for amputation and disarticulation. The following formal statement of these can therefore have but a relative value: 1. Cases of Injury. — Removal of the extremity is indicated in the com- plete crushing of a portion of the extremity, as in severe machinery accidents, shell explosions, etc. ; in rupture of important vessels and injury of large nerve- trunks; in unsuccessful ligation of artery or vein or both; extensive rupture of tendons and muscles, in which the dangers attending the attempt to save the limb are very great and the usefulness of the limb itself but problematic AMPUTATIONS AND DISARTICULATIONS 377 at best. The crushing of bones and joints alone does not necessarily indicate removal of the limb; resection at joints and in continuity will frequently pre- ser^•e an extremity thus injured. But this, combined with extensive injury to the muscles, tendons, vessels and nerves, such, for instance, as usually happens -.when a railwa}' car passes over the limb, presents almost an absolute indication for amputation or disarticulation. This should be performed as soon as the patient rallies sufficiently from the shock to bear the anesthetic (primary amputation). 2. Acute Inflammation. — Removal of a limb may be indicated by the occurrence of acute intiannnatory processes, when these cannot Ije controlled by antiseptic measures and the septic conditions are such as to threaten life. Again, when the local inflammatory processes are such as to render the extrem- ity functionally useless, an indication exists for its removal. 3. Chronic Inflammation. — Tuberculosis of bones and joints furnishes b}^ far the greatest number of cases in this class. Removal of the limb may be necessar}^ to prevent general infection, or to rid the patient of a member practi- cally useless, which is weakening him and exposing him to the unfavorable influences of intercurrent or secondary affections (e. g., amyloid disease of internal organs). While resection of joints offers a conservative method of treatment in many of these cases, those in which tuberculosis of the lungs, kidneys, or bowels exists do better with amputation. Cases of extensive tuber- culous disease of the wrist-joint, knee-joint, and ankle-joint require amputa- tion rather more frec[uently in adults than in children, resection failing. 4. Extensive destruction of tissue other than that mentioned as result- ing from mechanic disturbances may require removal of an extremity. In this class belong cases of gangrenous inflammation from extensive burns and frost-bite of the third degree, as well as senile gangrene and gangrene from venous stasis. Further, hospital gangrene and malignant edema are to l^e mentioned. 5. Tumors. — Malignant tumors of the soft parts, such as sarcomas of the skin and epithehal carcinomas, as well as benign tumors which tend to ulcerate or involve new portions of surface, such as elephantiasis, and are not amena- ble to other treatment, require amputation or disarticulation. Malignant tumors of bone demand removal of the extremity rather than resection. Methods of Amputation and Disarticulation. — Three methods of sep- aration of the soft parts are employed, namely, circular incisions, flap ampu- tation, and oval amputation. None of the methods about to be described can be said to possess such decided advantages as to be employed to the exclusion of the others. The method is to be selected with a view (1) to the anatomic peculiarities of the region involved in the disease or injury ; (2) to the character of the tissues, their freedom from disease or the extent of injury in which they are involved. It sometimes happens that the crushed and mangled tissues occupy but one side of the limb, and a large amount of healthy structure must be sacrificed if a circular amputation is insisted on. But if the flaps are fash- ioned in unequal lengths, or an oval amputation is selected, the healthy structure may l^e preserved. Circular incision is the simplest of all methods of amputation. The skin is divided at one level, a cuff turned back, the muscles divided to the bone, and a cuff of periosteum fashioned by peeling this from the bone. The soft parts are now retracted and the bone divided. In making the circular incision the long 378 OPERATIONS ON INDIVIDUAL STRUCTURES amputating knife is grasped by the hand with its edge up. First the knife and forearm of the operator are carried under the hmb, and then the knife over the hmb in the position shown at " 1 " (Fig. 163). The heel of the blade is passed well into the soft parts of the limb and the knife swept around, assuming the different positions shown in the figure (Joseph D. Bryant). Slight to-and-fro sawing movements aid in the section. In dissecting up the cuff of skin the edge of the scalpel must be directed away from the skin, in order to avoid injury to the vessels in this structure. A short cut on the posterior surface of the limb, made parallel to the long axis of the latter, facilitates the turning back of the cuff and affords a favorable point from which the drainage-tubes emerge. In case of difficulty in turning back the cuff, from the presence of cicatricial contraction, a similar vertical incision may be made on the anterior surface, the circular incision thus being converted into two quadrangular lateral flaps. The circular method is particularly applicable to the lower third of the leg, the lower third of the thigh, and the middle of the fore- arm. Where the skin and fascia are closely at- tached, there is no objec- tion to including the latter in the cuff. The nutrition of the skin is thus better secured. The length of the cyl- inder or cuff of skin will depend on the size of the limb. The incision through the skin should be placed at a distance below the proposed divi- sion of the bone corre- sponding to about one- fourth the circumference of the limb at that point. In making this incision the left hand of the operator should be placed above the hne of section and the skin drawn in an upward direction. This compensates for the tendency of the skin to retract. Flap Amputation. — Two methods are here employed. In the first the flaps are made by incision, while in the second they are made by transfixion. While the first has the advantage of permitting an accurate fashioning of the flap as to size, it has the disadvantage of producing a steplike shape to their surfaces, owing to the varying degrees of retraction of the different layers of muscular structures. The method of transfixion avoids this. The blade of a long amputation knife is passed through the limb at the base of the proposed flap, with its edge directed toward the apex of the latter. The knife hugs the bone at first, and with steady drawing movements the flap is formed, the edge being gradually directed anteriorly in the case of the anterior flap, and poste- riorly in the case of the posterior flap. By this method the muscles, l^eing made Fig. 163. — How to Carry the Knife Around the Limb in Am- putation (after Bryant). AMPUTATIONS AM) DISAUTICULATIONS 379 tense in front of the knife, are divided more evenl}'. Care must be exercised not to make tlie flaps too long and narrow. ^Examinations of old stumps show that the muscular tissues atrophy and that finally the ends of the bones are covered onty by the integument and fascia. In amputation through healthy structures, therefore, the method of skin flaps will suffice, but in amputation through infiltrated or otherwise altered structures a larger blood-supply is assured to the skin by including the muscular and fascial structures in the flap. The employment of methods of unequal flaps, as, for instance, in the opera- tion in the loAver third of the leg, knoAvn as T e a 1 e ' s , or that of one large curtain-shaped flap, as in the amputation of the thigh through the condyles (C a r d e n) , will depend partly on the parts involved in the operation, and partly on the injury or disease for wdiich the amputation is performed. Oval Amputation. — This method does not possess a wide range of applica- tion, yet it has some advantages in special cases. Where large muscular masses are to be divided, the individual groups are retracted in varying degrees, as in other methods. In oval incision the point of the oval is placed anteriorly wdiere the retraction is the slightest, while the base is located at the point where the retracted muscular structures surround the bone accurately; a more even wound surface is thus produced. By this method the cicatrix can be made to assume a certain position, which is sometimes desirable, e. g., on the dorsum, in amputation of the fingers, in order to assure the preservation of the tactile sense on the end of the stump, as well as at the palmar surface. Choice between Amputation and Disarticulation. — When the choice lies between amputation and disarticulation, the following considerations should be borne in mind: Disarticulation is simpler; it requires only a knife for its performance; it does not open the medullar}- cavity and hence there is less risk of suppurative osteomyelitis; there are fewer structures opened up, the parts about joints being comparatively thin. On the other hand, these operations require greater anatomic knowledge and technical skill; portions of the synovial membrane are likely to be left behind and become subsequently hiflamed; in case suppuration takes place, necrosis of the articular cartilages is liable to occur; the stump surface is ver}' broad and requires large skin flaps to cover it in, which are not easily obtained in the region of joints; a number of tendons are divided, and the sheaths of these give ready access for suppurative processes to reach the tissues above the point of operation. In addition, the field of disarticulation must necessarily be a restricted one, demanding, if placed arbitrarily above amputation in the choice, the sacri- fice in man}" instances of healthy structures. While, therefore, there are some advantages in disarticulation as compared with amputation, the latter under aseptic conditions wall, as a rule, be the preferable procedure. Under certain circumstances, such as in Symes's amputation of the foot, the two are combined. The sawing off of the prominent portions of the articular surface in knee-joint disarticulation has also found favor. General Rules for the Performance of Amputation. — The incision in the soft parts should be made in healthy tissue, when possible. When tissues are devitalized by the presence of acute injuries, cicatricial conditions or edema, care must be exercised that the slightest possible traumatism is inflicted during 380 OPERATIONS OX INDIVIDUAL STRUCTURES the operation. If suppuration is already present, vigorous antiseptic measures must be instituted. The separation of the muscles is to be effected by long and decided strokes of the amputating knife. The intermuscular connecti^'e-tissue sj^aces must not be opened up more than is necessary. Before the bone is sawed through a cylinder of periosteum must be peeled off from the part to be removed and pushed back with the soft parts of the stump. In some localities, as, for instance, the lower third of the tibia, and the femur, the deeper muscles and the periosteum are together detached from the bone with advantage. Careful retraction of the soft parts by means of a broad bandage or the fingers of an assistant, whenever practicable, is necessary in order to avoid injury of these by the saw. Splintering the bone, when the saw is nearly through, is to be carefully avoided by proper support of the part to be removed. Likewise, pinching the saw is to be guarded against (see page 363). When two bones are to be sawed through, both may be sawed simultane- ously until the larger of the two is divided about one-third of the way through; section of the smaller one is then to be completed, final division of the larger one following. The somewhat roughened point which marks the site of the completion of the work of the saw is rounded off with a rongeur (Fig. 90, A). Hemostasis in Amputation and Disarticulation. — Exsanguination is to be accomplished preliminarily by elevation of the limb, and the application of a roller bandage or of Esmarch's rubber bandage. Compression, either by the fingers or by means of a Pet it's tourniquet or the rubber bandage, secures against active hemorrhage during the operation (see pages 336 and 338). The separation of the extremity being accomplished, the larger vessels are secured by hemostatic forceps (see page 340) before the tourniquet or constricting band is removed; the latter is then temporarily relaxed and the smaller vessels secured. Catgut is to be employed for ligatures. Parenchymatous oozing is to be arrested by means of a large compress or towel wrung out of hot sterilized water. In cases in which the vessels are the seat of atheromatous changes, floss silk (B a 1 1 a n c e and Edmund s) may be applied; portions of the sur- rounding soft parts may be included by a circumsuture (see page 341). Vessels lying closely on the bone, as well as those difficult to grasp from any reason, may also be dealt with by the circumsuture. Drainage, Suture, and Dressing after Amputation. — When drainage is employed, two or more rubber tube drains are to be placed between the sutures. These should be sufficiently long to insure" efficient drainage of the wound surfaces of the stump. The tubes are secured from slipping inside the wound cavity by a safety-pin. Where septic conditions are already present, vigorous antiseptic irrigation by means of a 1 : 2000 solution of mercuric chlorid should be employed and the suturing omitted altogether. The drainage is secured by lightly packing the wound with gauze wet with a 1 : 2000 solution of mer- curic chlorid in 50 per cent alcohol (equal parts of a 1 : 1000 solution of mer- curic chlorid and alcohol). The dressings are applied in such a manner as to make but slight compression AMPUTATIONS AND DISARTICULATIONS 381 the stump. A compress of heat-sterilized gauze should be applied over the line of sutures, ()^'er this a number of two-3^ard square sterile gauze com- presses, either heat-sterilized or wrung out of a 1 : 1000 freshly made sublimate solution, crum])led and evenly distributed over the parts, are placed. Finally, a covering of heat-sterilized nonabsorbent cotton batting, secured l^y roller bandages, completes the dressing. Sliding of the dressings is prevented by including the next adjacent joint in the dressings, applying a light splint to maintain this in position, and, just before applying the last turns of the roller, passing a broad strip of adhesive plaster down the limb parallel to its long axis, across the face of the stump and up on the other side. Undue retraction of the soft parts, which occasionally occvirs in .amputations of the thigh, may be prevented by preliminary division of the lower attachments of the muscles (D a w b a r n), or by a traction strip of plaster, arranged stirrup fashion and attached to a weight and pulley extension. The stump is placed in an elevated position to favor the return of blood from it, and steadiecl by long sand pillows, placed on each side to aid in pre- venting the painful muscular contractions which occur during the first few days. Sequels of Amputation. — The sloughing of the flaps in cases of endar- teritis cannot alwa}'s be avoided. It is specially liable to follow amputation for senile gangrene. The employment of insufficient flaps, or their subsequent sloughing from any cause, notably the "buttonholing" of these during the operation, may lead to conical stump. This may also result from intermus- cular suppuration, as well as from contracted and elastic conditions of the soft parts, and from growth of the bone in young subjects. Conical stump may sometimes be prevented, when threatened by retraction of the soft parts, by the application of a broad strip of adhesive plaster applied stirrup fashion, and weight and pulley extension. When due to growth of bone, reampu- tation or subperiosteal resection of the bone is necessary. This may also be required l)y extensive sloughing of the flaps. Attachment of the cicatrix of the skin to the sawed surface of the bone, formerly a very annoying sequel, is not so frequently observed as it was before the aseptic era. Eccentric pains referable to the fingers or toes of the amputated member are sometimes very annoying. These gradually dis- appear. Cicatricial constriction of the nerve ends must be guarded against by removing considerable portions of the nerve-trunk and securing rapid and aseptic healing. The formation of neuromas is to be guarded against in the same manner. These latter produce violent pains and require excision. Finally, necrosis of the sawed surfaces pf bone may occur later on, due to suppurative periostitis and myelitis. The sequestra are to be removed from the direction of the stump. It is needless to say that, with aseptic and antiseptic methods, this is a rare sequel. Common Amputation Errors. — Sloughing, or suppuration, or both, may occur if the flaps are made from tissues damaged b}' injur3\ In malignant disease, failure to remove the parts well beyond the limits of the disease will result in a return of the disease in the stump. In senile gangrene it will not suffice simply to remove the gangrenous parts. The adjoining tissues, though not actually invaded, possess but a slight 382 OPERATIONS OX INDIVIDUAL STRUCTURES degree of vital resistance, owing to either insufficient vascular sup]:»ly or trophic disturbances of nervous origin, such as perforating ulcer of the foot, and are ready to break down under the influence of the disturljanccs ]jroduced by the knife. In the dry gangrene present in R e y n a u d' s disease amputation of the diseased fingers or toes is frequently followed by destruction of adjoining tissues, which may live if left undisturbed. Septic conditions, however, are rare, under these circumstances. The failure depends on the fact that the surgeon's knife cannot remove the vasomotor spasm, on which the gangrene depends. In amputation for chronic joint disease it is an error to make the flaps from edematous tissues, or those riddled with sinuses or the site of suppurative inflammatory processes. Under these circumstances the absence of the neces- sary recuperative power will frustrate the healing of the amputation wound. Long disuse of a limb lessens the healing powders of its tissues. This is particularly true of limbs that have been long confined in splints, tightly bandaged, or kept in an elevated position. In selecting the site of an amputation, failure to take into account the patient's recuperative powers may result in disaster. Primary healing should always be secured, if possible, in a patient already greatly weakened by disease or loss of blood, even if more of the limb is sacrificed than, under other circum- stances, would seem to be necessary. At the same time the increased immedi- ate risks of high over low amputations should be borne in mind. To cut the flaps too short, and to be compelled to adjust these forcibly over the l)one, is to invite final exposure of the latter, either from swelling and retraction, or from sloughing. The latter may likewise occur from rough handling of the flaps, separating the muscular tissues from the skin portion of the flaps w^hile exposing the bone, or interfering unnecessarily with the blood-supply at the base of the flap. In addition to want of aseptic care in the operative technic itself, sup- purative inflammatory processes may result from injury to the soft parts by the teeth of the saw in dividing the bone; from forcing sawdust from the bone into the muscular structures; from including large masses of tissue in the ligatures; from permitting portions of tendons to project from the wound surfaces; from splintering the bone and leaving partially detached fragments behind ; finally, from closing the wound before the bleeding has been thoroughly arrested and from too great tension on the sutures. Failure to dissect out the main nerve-trunk from a long flap or to sever it at least an inch proximad to the level of the bone, in a circular amputation, may result in painful stump from involvement of the nerve in the cicatrix, or subsequent regeneration of the divided nerve (so-called stump neuroma). SECTION XII FOREIGN BODIES Foreign Bodies and Their Effects. — Foreign bodies may become lodged in certain parts without injury to the tissues, such, for instance, as the esophagus, nasal cavity, auditory meatus, salivary ducts, larynx, trachea, vagina, and urethra. These will be considered in detail in connection with the diseases and injuries of these parts. Foreign bodies in the tissues enter through solutions of continuity. In punctured and incised wounds the presence of a foreign body may result from the breaking off of the instrument itself, as, for instance, when a knife- blade becomes imbedded in the skull. Very brittle material forced into the tissues, such as glass, may also break off and remain as a foreign body. The question of infection from the foreign body is an important one. In case this occurs suppuration necessarily follows and the foreign body is loos- ened and cast off with the pus ; or it may be forced to the surface by the granu- lations which follow the suppurative inflammation. Wooden splinters invad- ing the fingers, on account of their irregular surfaces most frequently follow this course if not promptly removed. In cases in which infection does not occur the foreign body, by contact with sensitive nerve filaments, produces more or less irritation and pain and requires removal. Bullets and other lead projectiles may be clean of themselves, but infection occurs along their tracks from the presence of other foreign bocUes, bits of clothing, etc., which have been carried into the tissues with the bullet. It is a mistake to suppose, however, that infected projectiles driven into the body by the explosion of gunpowder cannot carry infection on their own surfaces independently of that which they receive from passing through the clothing (La Garde, U. S. Army). Though bullet wounds may be aseptic, this does not result from disinfection of the projectile by means of burning powder or from the passing of the projectile rapidly through the air, but rather because it was surgically clean beforehand. Migration of foreign bodies may occur, as in the case of heavy lead balls in the substance of the brain and in the loose perimuscular connective tissue. In the first-named situation this migration is excessively dangerous. Slender and pointed foreign bodies, particularly needles, are sometimes driven onward by muscular contractions until they migrate to parts far distant from the point at which they entered. Serious consequences may follow their passage through important parts. Solid products of living tissues may act as foreign bodies, such, for instance, as biliary calculi, vesical calculi, etc., which, by processes of ulceration, have left the viscus in which they originally formed and have become imbedded in the surrounding tissues, producing abscesses and fistulous openings. Finally, the effects of foreign bodies will vary according to the mechanic, 383 384 FOREIGN BODIES chemic, or bacterial influences incident to their presence. They may likewise form the nucleus of calculi, when surrounded by physiologic secretions from which salts may be deposited (vesical and salivary calculi). Diagnosis of Foreign Bodies.— When foreign bodies are superficially placed, their presence may be determined by the elevation of the overlying tissues. When they are situated in deep cavities or wounds, reflected light may be employed for diagnostic purposes. In the case of foreign bodies which arrest the Rontgen ray the presence of these may be determined by the shadow which they cast on the fluorescent screen; the portion of the body in which the foreign body is believed to have lodged is placed be- tween the vacuum tube of the x-ray apparatus and the examiner. For purposes of permanent record the sensitized plate is employed in place of the fluorescent screen. This is after- ward developed, as in ordinary photography. In employing palpation care should be taken to avoid pushing the for- eign body still further into the tissues or other point of lodgment. When satisfactory evi- dence is not obtained by means of the finger, which is always to be preferred when avail- able, instruments called probes are to be called into requisition. The wound may be enlarged to permit the passage of the finger. In cases in w^hich the foreign body has been driven into the tissues with great force, as, for instance, a bullet, palpation may reveal th.e missile lodged at some distant point. In cases in which the bullet has followed the contour of the bony thoracic wall a line of tenderness may indicate its path. Probes. — These are employed for diagnostic purposes, l^oth in searching for foreign bodies in the tissues, and in cavities as well (e. g., the bladder, etc.), and for determining the condition of bone at the bottom of suppurative fistulas ■connected with the osseous structure, as well as that of the w^alls of natural Fig. 164. — Telephone Probe. A, Receiver; B, flexible metal band for attaching receiver to the operator's head ; C, flexible conducting cords ; D, electrode to be placed in the mouth or rectum; E, screw connection for attaching probe; F, insulated portion of probe; G, noninsulated portion of probe. Ri:.MO\'AL UF FORKIGX BODIES 385 canals (<\ (/., lacrimal canal, esophagus, urethra, etc.). Bougies or .sounds for special purposes will be tlescribetl in their appropriate places. In acklition, specially constructed probes are used to follow sinuous tracks (vertebrated probe of Squire), and instruments of greater or lesser length with plain (not enameled) porcelain tip (Xelaton) for the exploration of gunshot wountls. In the case of the latter the porcelain tip receives and retains the lead marking made b}- contact with the bullet. In this connection is also to be mentioned the telephone probe (G i r d n e r) for the detection of metallic foreign bodies in the tissues (Fig. 164). In using this instrument the alumi- num bulb, D, is placed in the patient's mouth or rectum, the receiver, a, is held to the operator's ear, while the probe, fg, is passed into the wound in search of the bullet or other metaUic foreign Iwd}-. When the latter is touched, a peculiar grating or clicking sound is heard in the receiver. If the canal leading to the foreign body is tortuous and the probe cannot be made to follow this, a long steel needle is substituted for the probe and search made by passing this directly to the suspected locality. The probe or needle used for exploring should be insulated except at the tip, in order that the examiner may not be misled as to the depth at which the respon.se to metalHc contact is given. Probes should be made of either virgin silver, copper, aluminum, or other flexil)le material, in order that they may be fashioned to follow the course of the fistulous track or wound. They are sometimes used as a guide in makino- 1^ Fig. 16.5.— Elliot's Uterixe Repositor Adapted as a Guide ix M.uiixG Couxter-opexixgs. counter-openings. The uterine repositor of Elliot (Fig. 165) has been adapted to this latter purpose (H u e t e r) hy introducing it wliile straight and curvmg it in the required direction by turning the milled screw-head at'ter it has reached the termination of the fistulous track to be opened. The employment of probing as a means of diagnosis is frequently very unsatisfactor\-. The extremity of the probe can distmguish only a sohd foreign body from the soft and yielding tissues. In the case of soft foreign bodies which are lodged in fibrous or othei-wise unyielding structures it is quite useless. TMien a hard foreign body is lodged in unyielding tissue, e. g.,a splinter of glass lying against a phalanx, or a soft foreign body lies in yieldmg tissues, such as ,a bit of clothmg in muscular structures, the difficulties are ahnost insur- mountable. The only trustworthy form of probe yet devised is that em- ployed for the detection of metallic foreign bodies (see telephone probe). Next to this is the porcelain-tipped probe of Xelaton {vide supra). Remo\'al of Foreign Bodies.— When accessible, foreign bodies should be removed at once, in order to escape possible septic infection. TMien deeplv placed, their removal is not always an urgent necessity. The damage done by extensive exploratory procedures should be balanced against the possibly shght harm which may result from their contmued presence in the tissues. Life may be threatened to such a degree as to demand that an attempt at extraction be 26 386 FOREIGX BODIES made. In furtherance of this, trephining, tracheotomy and laryngotomy, cys- totomy, urethrotomy, or gastrotomy may be indicated in individual cases. In case a foreign body is lodged in the skin or muscles, the ordinary dressing forceps or the dissecting forceps are usually sufficient for its removal. When convex surfaces of a foreign body present themselves, the forceps will slip, however, and even tend to drive it stiU more deeply into the tissues. This is particularly true when the foreign body is lying in a canal or cavity such as the urethra or nasal cavity. Under these circumstances a fenestrated spoon-shaped instrument, or a curet of proper size, is to be preferred. This is to be passed behind the foreign body and the latter scooped out. as it were. In the class of instruments which operate b}' being first passed behind the foreign body belong G r a e f e ' s coin extractor (Fig. 366) and the umbrella probang of S a y r e (Figs. 368 and 369). (The removal of foreign bodies from special parts will be considered in Regional Surgery.) The removal of small and superficialh' placed iron splinters from the globe of the eye has been accom- plished by means of a powerful magnet (Hirschberg). Firearm Projectiles. — ^These are either cylindric, cylindroconic, elliptic, or acorn-shaped. The shape, however, after the discharge of the arm and entrance of the ball into the tissues, changes according to the density of the latter and to some extent according to the character of the rifling of the bore of the firearm. Where but one opening exists, the ball is, as a rule, retained in the tissues. Exceptions to this, however, are to be noted in cases where the ball enters the csLvitj of the mouth or is swallowed, or enters a viscus, as the stomach, and is vomited, or the intestinal canal or esophagus and finds its way extemall}^ through nomial channels. Again, a portion of clothing may be driven ahead of the ball in the case of a partially spent ball, and, not perforating the clothing, be removed from the wound of entrance by efforts made in undressing the patient. A careful examination of the clothing will eliminate the possibility of being misled by this. The passage of a ball by the same force along a natural canal after it is driven into the tissues is of rare occurrence. The existence of two openings denotes the occurrence of a complete perforation, as a rule, and the escape of the projectile, provided the occurrence of two shots or the existence of the fragment of a divided projectile can be excluded. The wounds of entrance and exit differ from each other in most instances. The former is somewhat larger, more rounded and blackened and contused, as well as inverted. The latter is smaller, more oblong, and resembles a cleft with rather clean-cut and everted edges. Instances occur, however, in which these appearances cannot be relied on. Recent gunshot wounds should be examined at once on account of the absence of swelling and sensibility. The strictest antiseptic precautions should be obser\'ed, whether the finger or the probe is employed. If hemorrhage is to be feared from the proximit}' of large vessels to the track of the bullet, the exploration may be omitted entirely until proper preparations have been made for its removal. The advisability of making an attempt at removal of the bullet will depend on(l) whether or not it can be positively located; (2) the character of the tissues in which it has lodged. In case it cannot be discovered by the finger or probe, or the x-ray, it will usually be good surgery to permit it to remain FIREARM PROJECTILES 387 undisturbed. The occiuTence of jihleginonous inflammation in case septic mate- rial has been carried along with the liall will disclose its presence. If none such occurs, in the great majority of cases no harm will result from its retention. Exceptions to this are to ])e noted, however, in cases in which grave functional disturbances occur from the presence of the missile in the brain, bladder, large joint cavities, etc. Fig. 166. — Tiemann's Bullet Forceps. The removal is accomplished by instruments specially designed for the purpose. The most practicable of these are the Tiemann bullet forceps (Fig. 166). The instrument shown in Fig. 167 likewise serves a useful purpose. In case no other foreign bodies, such as bits of clothing, etc., are carried into the tissues the wound will pursue, as a rule, an aseptic course. It is not possible, however, to determine this positiveh', and it will therefore be best to Fig. 167. — ^Bullet Forceps with Spoon-shaped Jatvs. drain the track of the l^ullet as a routine method of treatment and to adopt the most stringent antiseptic measures in the after-treatment. The treatment ma}' therefore be summed up as follows: (1) removal of the infected foreign bodies; (2) cleansing of the accessible portion of the bullet-track; (3) drainage; (4) under certain circumstances dilatation or incision of the buUet-track, and counter-openings for through-and-through drainage. SECTION XIII BANDAGING Materials. — Bandages are made of various materials according to the uses to which they are put. Bleached and unbleached muslin, linen, crinoline, Liverpool cloth, gauze and cheese-cloth, flannel, rubber, and various other materials are used. Uses. — Bandages are used to retain dressings, as in case of wounds; to retain splints, as in fractures and dislocations ; to make pressure, as in the pal- liative treatment of varicose veins and also in the treatment of tuberculous joints (Bier's method) ; to immobilize the parts, as in fractures, in which case plaster-of-Paris, paraffin, glass, starch or some other agent that quickly hardens is worked into the bandage; to arrest hemorrhage. Classification. — Bandages are divided as follows: (1) the simple or roller bandage, which maybe a single or a double roller; (2) compound ban- dages, which are also known as many-tailed bandages, and slings; (3) immobi- lizing bandages, commonly made of crinoline or other large meshed material into which plaster-of-Paris or starch has been incorpor- ated. The form of ban- dage most frequently used is the roller bandage, which may be made of any of the materials above mentioned. Strips of the selected material are cut, varying in width and length according to the locality to be bandaged. These strips are rolled up into a cylinder and constitute the roller bandage. This rolling may be done by hand or by means of a special machine devised for the pur- pose. If by hand, there are certain rules .which, if adhered to, make the task an easy one. One end of the strip is first folded on itself a number of times until a small cylinder is formed. This cylinder is grasped by the right hand, the forefinger on one end, the thumb on the other, and while so held, revolved by the fingers of the other hand so as to roll around it the rest of the strip, which is guided by the left hand (Fig. 168). A simpler method and one which must be used if the width of the strip does not permit of its being grasped by the forefinger and thumb, is to start the cylinder as before, but instead of grasping it by the forefinger and thumb, to place it on the anterior surface of the thigh and roll toward the knee, tension being made on the 388 Fig. 168. — Rolling Bandage by Hand. GENERAL RULES 389 Fig. 169. — Hand Rollek-bandage Machine. strip at the same time and care taken that each revolution of the latter accu- rately overlies the preceding one. If a machine is used, one end of the ban- dage is fastened by tension to the revolving spindle of the machine, and this, l)oing turned by a crank, rapidly rolls up the strip. The proj^el- ling force of these machines may be the hand (Fig. 169), or the foot (Fig. 170). Also a machine may be so constructed as to roll a cylinder the width of the bolt of material, which ma}- subse- quently be cut into as many roller bandages as desired. For purposes of facilitating the description of the applica- tion of a roller bandage, the roller is divided into two parts. Thus, the free end is known as the initial extremity, the in- closed end as the terminal extremity, while all that portion between these two points is called the body of the bandage. There are also the external and internal surfaces. The double roller, less frequently used now than formerlv, is made by sewing together the initial extremities of two single rollers. Compound bandages and immobilizing bandages will be treated of later. Dimensions. — The width and length of a bandage vnH vary ac- cording to the part to which it is applied and also accorcUng to the purpose for which it is used. In bandaging the fingers and toes, the inch-wide roller is to be -preferred. In length tliis bandage varies from three to five yards, according to the variety to be used. The most useful bandages for the head and for the extremities in cliildren are two inches -^nde and from four to seven yards long. Bandages two and a half to three inches wide and six to ten yards long are used for bandaging the extremities in adults and for thigh and groin bandages. In bandaging the trunk a roller four to six inches wide and six to eight yards long is most frequently used. General Rules. — There are a few simple ndes to be observed, the application of which in applying iDandages will aid the beginner to master the art Fig. 170. — Foot Roli.er-b.\xd.\ge M.^chixe. 390 BANDAGING Fig. 171. — Bandage Scissors. more quickly. First, as to holding the bandage: It is best to grasp the roller tightly between the thumb and the finger, and to rest it in the hollow of the hand so that it will unroll easily. The internal surface of the roller bandage is the one that is external when it is applied to the part, and the external surface becomes internal. Second, in apphdng a bandage to an extremity, always cause the bandage when applied anteriorly to run away from the median line of the body. This should be borne in mind in reading descriptions of methods of bandaging. The turns should always be applied smoothly and with even pressure. In case of an extremity the roller should be applied from the toes or fingers, as the case may be, in an upward direction. Third, see that the part is in the position it is to retain after the bandage is applied, otherwise there may re- sult pressure effects from the sub- secjuently altered position. If l^leached muslin bandages are wrung out of warm water, this will be found to facilitate their application. This rule is par- ticularly useful in bandaging fingers. Fourth, in fastening a bandage use safety-pins or needle and thread, not plain pins; or tear the end longitudinally, knot to prevent tearing, encircle the part in opposite direction with the torn ends, and tie. Fifth, in removing bandages either cut or unwind them. If the bandage is to be cut, there are special scissors made for this purpose. These have a blunt point on one blade of the scissors which prevents the blade from injuring the patient while they are being used (Fig. 171). If a bandage is to be unwound, the unrolled portion should be loosely collected in the hand in a mass as the unwinding proceeds and the mass passed from one hand to the other, a rapid and neat removal of the bandage being thus effected. The removal of the plaster- of-Paris bandage will be discussed further on. Varieties of Roller Bandages. — In roller bandages a number of "turns" are used. It is quite neces- sary to understand the nature of these turns before using them in any special bandage. Circular, spica, and spiral turns are used, together with several other varieties, and the bandage is known as a circular, a spica, or a spiral bandage, according to the kind of turn employed. Circular Bandages. — A circular bandage is made up of a number of circular turns, each turn accurately overling the turn preceding it (Fig. 172). This bandage may be used to retain dressings on small wounds of circular portions of the body, as the head, upper arm, and neck, and for purposes of coaptation. Oblique Bandages. — An oblique bandage is one in which the turn runs obliquely around a part without overlapping (Fig. 173). It is useful in apply- ing temporary dressings. Spiral Bandages. — In a spiral bandage the turns surround the part in a Fig. 172. — Circular Bandage. VAlilKTlKS Ol" JiULLKK BANDAGES 391 spiral manner, each turn covering in one-half or more of the preceding turn. This form of bandage can be used on parts of the body which do not increase rai)idly in circumference, as the finger, chest, and abdomen. Reversed Spiral Bandages (Fig. 174). — When the part of the body to be bandaged increases rajiidly in circumference, as in the case of the forearm of a well-nourished person, it is impracticable to continue the use of spiral turns, since they soon assume the shape of a simple oblique bandage and be- come easily disarranged ; what is more import- ant, they do not exert even pressure. To over- come this when a mus- lin bandage is used, the Fig. 173.— Oblique bandage is folded ob- lic^uely on itself, or reversed, in such a manner as to cause it to conform to the shape of the part. In making these reverses the forefinger of the left hand is placed on the previously applied turns to hold them in place and the head of the roller is turned toward the operator in such a manner that the slack of the bandage is turned or folded obliquely on itself, the part being thus fitted ANIJAGE. ^^BMk^y' ^T" ^^H^^^^ / ^ V Fig. 174. — The Reversed Spiral Ban'dage. snugly (Fig. 174). As many of these reverses are applied as required, care being taken that the points of the reverses are in alignment and that they are smoothly applied; also that they do not lie over bony prominences, as the crest of the tibia, for here they may give rise to pressure effects. When a bandage is made of yielding material, the reverse may be made by simply changing the direction of the bandage in an alternating manner so as to 392 BANDAGING form a short figure-of-8. For instance, in bandaging the leg, instead of permitting the turns to pass at right angles to the limb, the turns are placed obliquely, the direction of the obliquity alternating at each turn. As the bandage passes in front of the limb it is directed obliquely upward; after it passes to the back of the limb and as it approaches the front from the other side, it is directed obliquely downward (Fig. 175). Spica Bandages. — Spica turns are those which cross each other in the form of the capital Greek letter "lambda," thus A, and a bandage made up for the most part of these turns is called a spica bandage. They are useful in retaining dressings on the shoulder Fig. 211) and groin (Fig. 224) and also in exerting firm pressure. Figure- of -8 Bandages. — These bandages are made up of figure-of-8 turns, and are most frequently em- ployed in the neighborhood of joints. A turn is first taken above the joint, and then another below it, a figure 8 being thus formed. The joints over which such turns are used are the ell^ow, wrist, knee, and ankle (Figs. 216, 217, 229, 230). Recurrent Bandages. — Recurrent bandages are made up of turns which extend back and forth over a part until it is covered, these recurrent turns being secured by spiral turns. The bandage is used to cover in the ends of fingers or toes, and in the dressing of stumps (Fig. 176). Pressure Bandages. — In cases where pressure is indicated, as in vari- cose conditions of the extremities, the treatment of tuberculous joints by blood stasis, to control effusions in joints and in the soft parts, and to control hemorrhage, the pressure ex- erted by the muslin roller is insuffi- cient unless applied so tightly as to produce serious injury to the soft parts. For these purposes a bandage is needed which will combine elasticity with strength. Again, the amount of elasticity depends on the condition for which the bandage is employed. Bandages of stockinet, flannel, and rubber will be found to meet all the various indications. The flannel bandage is made and applied in the same manner as other roller bandages. It is useful in preventing and limiting the progress of effusions and also as a primary roller under the plaster bandage. In babies, and persons of irritable skin, so-called canton flannel may be employed. Stockinet and Japanese crepe are expensive but extremely useful materials of which bandages for the treat- ment of varicose conditions may be made. They exert the needful amount of -^ Fig. 175. — Spiral. Bandage with Alternat- ing Obliquely Directed Turns (Short Figure-of-8). The dotted lines represent the direction taken by the next turn of the bandage. VARIKTIKS OF ROLLER UAXDAGES 393 uniform pressuri' niul do not irritate the skin. The thickness, length, and width of the rubber bandage vary with the purpose for which it is employed. For simple pressure in cases of varicose veins, a thin bandage is used. For rendering an extremity bloodless (E s m arch) a thicker one is required. When the latter is not at hand, two thin rubber l^andages rolled together answer the purpose. When employed to render a part bloodless, the rubber bandage is started at the distal end of the extremity and ascends with firm pressure in spiral turns. Each turn meets, but does not overlap, the pre- ceding turn (Fig. 12-1). When a level has l^een reached well beyond the site of the proposed operation, a few circular turns are made. These circular turns are lifted up over the course of the main artery by the fingers of the left hand, while the fingers of the right hand thrust what remains of the body of the bandage vertically under these circular turns, and so effectually shut off all lilood-supply. The spiral turns are now un- wound and this part of the bandage placed loosely around the extremity at the level of the circular turns (Figs. 125 and 126). Care is taken not to place the circular turns at a point where they will cause serious pressure on important nerves. It is of extreme importance that no bandage of this kind be used in cases in which there is danger of pressing either tumor or septic products into the circulation. In such cases the bandage must be placed above the limits of the disease. The rubber tourniquet is a narrow, thick band having a chain attached to one end and hooks to the other, by which it may be secured; it is sometimes used to secure the tourniquet effect in place of the final circular turns. Tourniquets are also used for the immediate control of hemorrhage in accidents to the extremities. The chief use of the rubber bandage is in the treatment of varicosities of the lower ex- tremity. It is applied with even pressure, begin- ning at the base of the toes, and in case of vari- cosity of the leg ending just below^ the knee. Should the varicosity also be present on the thigh, the bandage is continued upward to the groin. Reversed turns are not necessary, as the elasticity of the bandage allows it to conform to the shape of the extremity. It is fastened by means of two tapes attached to its distal end. These tapes are wound around the extremity and tied. While not a strictly curative measure, it relieves those cases for which it is indicated. The daily contact of the rubber will produce eczematous condi- tions in some individuals. To avoid this a thin flannel bandage is applied next the skin. The bandages should be removed at night when the patient has resumed the recuml^ent position, and reapplied in the morning before he arises. After removal they should be rinsed in lukewarm water and hung up in folds to dry. For use in the Bier treatment of tuberculous joints a much shorter ban- FiG. 176. Recurrent Bandage OF Stump. 394 BANDAGING dage can be employed. Half a dozen circular turns are all that are necessary. As this method is employed in children, whose skin is particularly prone to irrita- tion, and as the rubber is to be kept applied for several hours at a time, it is well to protect the skin by the application of a few turns of a canton flannel bandage. The amount of compression necessary to produce venous stasis must be judged by the effect on the limb. A bluish "marbled" appearance is to be produced. The arterial blood-supply is not to be arrested. The parts below the diseased area are to be sup- ported by a snugly applied roller bandage (Fig. 209). Permanent Fixation Ban= dages. — The ordinary roller ban- dage, while it fixes the parts at the time it is applied, soon be- comes loosened if the parts are moved. In cases which require absolute rest, therefore, we are obliged to incorporate into the bandage some material which will make it stiff, so as to secure im- mobilization of the parts and dur- ability of the bandage. The uses of such bandages are manifold. They frequently take the place of ordinary splints. For purposes of stiffening, soluble glass, paraffin, starch, and plaster-of-Paris are most frequently employed. The starch bandage is made by soak- ing large meshed material in a strong solution of starch, then spreading it flat to dry. Ban- dages of various widths are made of thin material. When ready for use, the starch bandage is (lipped in hot water for a few minutes or sufficiently long to allow the water to penetrate the innermost parts of the bandage. It is wrung out almost dry and apphed as any other bandage. It soon dries, forming a firm protective splint, but it is neither so hard nor so durable as the plaster-of- Paris roller. It has the advantage, however, of being much lighter, and is therefore to be preferred in simple injuries of the upper extremity which require fixation, but the patient should be instructed to take special precautions against further injury. It may be removed by cutting with a knife, or with scissors if only a few layers have been used, or by unrolling. Fig. 177. — Plastek Roller-bandage Machine. PERMANF.XT FIXATION BANDAGES 395 Method of Preparation of Plaster-of-Paris Bandage. — An opcn-meshed niatiuial, such as "cross barred" crinohne, is selected lor the bandage. This is cut the proper width and length, and rolled. This rolling may be done by- hand or in any one of the numerous bandage boxes made for the purpose. As the bandage is being rolled, fine plaster-of-Paris (dental plaster) is rubljed in if the operation is carried on by hand; or allowed to fall in the turns of the bandage if a special machine is used (Fig. 177). When a bandage of the required length and width has thus been prepared, a small rubber elastic is snapped around it to keep it from unrolling, and it is wrapped in oiled paper or placed in an air-tight can to prevent the plaster from becoming moist and cak- ing, which it is quite likely to do unless kept in a dry place. Made in this way, these plaster bandages may be kept indefinitely. Should they become damp at any time, they may be put in an oven and dried. When they are required for use, the oiled paper is removed from a sufficient number of bandages of the proper width. These are placed on a table with a basin containing hot water. Table salt, in the proportion of one heaping teaspoonful to two quarts, added to the water is useful in hastening the hardening, but causes brittleness of the plaster cast after setting. Zinc oxid added to the water is also useful in facilitating the setting. The member to which the plaster is to be applied is to be thoroughly cleaned and shaved. It is now covered with a thickness of sheet wadding, applied as a roller bandage. Extra layers of cotton are placed over bony prominences, such as the olecranon, patella, and crest of the tibia. This is to prevent local gangrene of the skin overlying these points, from excessive pressure. In place of sheet wadding a thick canton flannel roller may be used. Whatever is used, its purpose is to transmit the pressure of the plaster equally, and to prevent direct pressure on the skin. Care must be taken not to cover the bony prominences with too much cotton in the endeavor to pro- tect them, lest the purpose of the fixation bandage be nullified by allowing the parts to move inside it. Sometimes a plaster-of-Paris bandage is applied, allowed to harden, and then cut along each side and removed. It is then padded with cotton and reapplied as a removable plaster-of-Paris splint. In such cases sheet wadding or a canton flannel roller is not to be applied primarily, as an exact cast of the parts themselves is desired. To protect the skin from irritation and to facilitate the removal of the cast, vaselin is thickly coated over the entire surface which is to come in contact with the plaster. When the skin and bony prominences are protected, two of the bandages are placed in the basin of hot water. These are left immersed until the water has penetrated to the core. The surplus water is expelled by squeezing the bandage by pressure on its sides. In order to save time, as one is taken from the basin another is placed therein until the required number is reached. The general rules which govern the application of other bandages apply also to the plaster roller. It is applied evenly, smoothly, and with uniform pressure. Those parts which are subjected to the most strain, as the elbow, knee, ankle, and other joints, are reinforced by supplementary^ turns of the roller. The number of layers applied depends on the purpose for which the bandage is emplo3'ed. Simply to retain a dressing in place, two or three layers are all that are necessary. On the other hand, six to eight layers are necessary to insure immobility of joints. In the ambulatory treatment of fractures of the lower extremity (see page 136) more layers will be required than in case the patient 396 BANDAGING is to rest quietly in bed. If the bandage is used over a wound, as in compound fracture, a window or a fenestra may be cut through the entire thickness of the bandage. Should very large fenestrae be required, pieces of soft iron may be bent into the shape of the Greek letter i2 and used to reinforce the bandage. These fenestrae should be cut after the plaster has hardened, so as not to impair its strength. In order to produce a nice finish, the last plaster roller applied may have a selvage. This is so applied as to cover the raw edge at each suc- cessive turn and leave the selvage exposed. Dry plaster may be nibbed in after the bandage is complete. The parts must be kept perfectly quiet in the re- quired position all through the application of the bandage and long enough aftenvard to allow the wet plaster to harden. Removal of the Bandage. — In the case of the extremities, the line where the bandage is to he cut should be on the external surface, but many circum- stances will govern this point, so that no hard and fast rule should be laid down. There are many appliances specially devised for the removal of plaster-of-Paris splints, such as knives and saws of different shapes (Fig. 178). A strong straight -bladed resection knife or a shoemaker's knife answers the purpose. The cut is to be made obliquely rather than at right angles to the surface. A Fig. 178. — Removal of Plaster Splint with Plaster Saw. weak solution of acetic acid (common vinegar) is painted along the proposed line of incision. This softens the plaster and makes it easier to cut. The bandage, or cast, as it is more commonly called, should l)e removed in one piece to avoid any unnecessary disturbance of the parts. \'inegar may be used to remove any plaster which has adhered to the hands. Water, to which either granulated sugar or molasses has been added, is also useful in removing plaster from the hands. Dangers of the Plaster-of-Paris Bandage. — The dangers attending the application of an ordinary bandage are multiplied in the case of the plaster-of- Paris bandage. This is specially true in cases of recent fracture which have been immoblized in this way. At the first sign of superficial venous stasis the bandage is cut completely open from end to end; should the blood stasis not be relieved by this, the bandage must be entirely removed. All cases should be watched for the first few days following the application of the bandage. The danger of gangrene is always present. Compound Bandages. — These are usually made of unbleached muslin, cut in various ways to fomi the shape of the part of the body to which they are to be applied. There is a great number of these bandages, but few of them COMPOUND BANDAGES 397 are reall}^ useful. Their true range of usefulness is limited to the hurried first dressing done on the battle-field. As a rule, they afford neither the comfort nor the security of the well-applied roller bandage. The sling is one of the most frequentl}' used of the compound bandages. It is made in three ways. Two of these are for the upper extremity and one for the lower. The former is a single triangle of muslin, or a yard square of muslin folded diagonally to form a triangle. The apex of the triangle is applied under the elbow, the half of the triangle which is next the body goes over the opposite shoulder, the other half of the triangle goes over the shoulder of the affected side. The ends of these two halves are knotted at the back of the neck, enough traction being put on each end to insure that the body of the triangle affords equal support for the entire length of the forearm. To afford additional secu- rity the two sides of the sling may be sewed or pinned together, parallel to Fig. 179. — T-bandage. Fig. 180. — Double T-bandage. the forearm and just above it. The apex of the triangle is pinned to the front of the sling. The second form for the upper extremity is used as a sling for the upper arm. It is of use only when the patient is in bed. A strip of muslin as broad as the arm is long and about three feet in length is used. One end is pinned along the median line of a previously applied bandage of the chest. The other end is passed between the body and the arm, partly sur- rounding the latter, and brought back to the starting-point, where it is pinned or sewed fast. It should be applied with just enough tension to support the arm comfortably. For the lower extremity a sling may sometimes be used with advantage in fractures of the femur. A long board splint, 10 inches broad and long enough to extend from the axilla to below the heel, is well padded and secured to the chest and pelvis by bandages or adhesive plaster. One of the long sides of a broad strip of muslin is tacked to the uppermost edge of that portion of the splint corresponding to the leg and thigh. The body 398 BANDAGING of the strip is then passed under the leg and thigh and fastened to the first edge, the whole thus forniino; a convenient sling. The single and double T-bandage are both frequently used, the first to hold perineal dressings in place in the female, the second, in the male. These are called perineal T-bandages. They are made of a broad strip of muslin sufficiently long to encircle the pelvis. This is called the body of the bandage. To this is attached a narrow strip at the center of the I^ody of the bandage to form the single T (Fig. 179). In case a double T is required (Fig. 180) two strips are fastened a short distance to each side of the middle of the body of the bandage. T-bandages may be made of varying breadth and length of body and strips Fig. 181. — The Chest "T "-binder. SO as to conform to different parts of the body. Examples of this are found in the chest T, the abdominal binder, and the breast binder. In applying the chest T, the body of the bandage, 10 or 12 inches broad, surrounds the chest, while the vertical straps pass from behind over the shoulder and are fastened in front (Fig. 181). The plaited abdominal binder is from 12 to IS inches wide and in length one and one-half times the circumference of the body. It is securely pinned in front with safety-pins and made to fit snugly by taking plaits on each side (Fig. 182). Straps of muslin are passed from behind forward over the perineum and fastened posteriorly and anteriorly to prevent any slipping of the bandage. These are called perineal straps. These are both fastened with safety-pins so as to admit of easy removal when soiled. COMPOUND BANDAGES 399 The breast binder (Fig. ISo) is a modification of tlicT-lKindago of the chest. Fig. 182. — The Plaited Abdominal Binder. It consists of one piece of doubled muslin made into an armless jacket. In Fig. 183. — The Breast Binder. 400 BANDAGING applying it, the portions which correspond to the straps of the T-bandage are fastened over each shoulder with safet3^-pins. The ends of the body of the Fig. 184. — The Triangle of the Groin. bandage are then secured to each other in front. A nice fit is obtained by tak- ing plaits wdth safety-pins on each side. I'lG. 185. — Hernia Bandage. Single and douljle T-bandages may be used to retain dressings on different parts of the head and face. RETRACTORS 401 A variety of T-bandagc known as the triangle of the groin is often useful. The vertical strap of the single T is made broad and triangular, the base of the triangle being attached to the body of the bandage. The portion of the body ■with the triangle attached is placed over the dressing to be retained. The ends of the body of the bandage are then fastened, while the apex of the triangle is drawn across the perineum to be attached to the bodv behind (Fig. 184). A useful hernia bandage is made by lengthening this bandage so as to encircle the body twice, attaching the initial extremity of a roller 3 inches wide to the apex of the triangle and using this as a spica for the thigh and groin (Fig. 185). The four-tailed bandage is a light and effective dressing for fracture of the lower jaw with slight displacement, and is also used to retain dressings in the region of the chin. A strip of bandage 4 inches broad and 3 feet long is Fig. 1S6. — Four-tailed Bandage for the Jaw. employed. Each end is split in two and torn longitudinally until within 4 inches of the middle of the bandage. This four-inch square is called the body of the bandage. The center of the body is applied to the symphysis of the jaw^ The upper two of the four tails are carried directly backward to beneath the inion and are there draw^n taut and knotted. The four loose ends are then tied tightly together and the superfluous ends cut away (Fig. 186). Retractors. — These are bandages made by splitting strips of muslin six or eight inches wide into two or three tails, according as they are to be used for retracting the soft parts around one or two bones. A many-tailed bandage is sometimes used to retain the dressings of an abdominal wound and to exert even pressure as the fluid is withdrawn in para- centesis abdominis. The body portion of the bandage occupies a little more than one-half of the circumference of the abdomen, the tail strips being supplied by tearing or splitting the remainder from the ends. The bandage is secured 402 BANDAGING in position by crossing the tail strips, drawing upon them until the bandage fits snugly and pinning the end of each separately at the sides (Fig. 187). Adhesive Plaster. — Two varieties are furnished for the use of the surgeon, namely, the officinal resin plaster and that known as rubber plaster or surgeon's adhesive plaster. Fig. 187. — Many-tailed Bandage for the Abdomen. The appearance of the bandage before appHcation is shown in the upper right-hand corner of the illustration. Uses. — Adhesive plaster is sometimes used to approximate the edges of superficial wounds, and occasionally the skin edges of deep wounds, when it is desirable to avoid the use of skin sutures. When used for this purpose, it should Fig. 188. — The First Pieces of Dressing of an Abdominal Section Held in Place by Adhesive Plaster and Tapes. be sterilized by passing the strip, cut ready for use, with its back down across the flame of a spirit lamp. Care should be taken not to apply the plaster too hot. When resin plaster is used, it will be necessar}^ to heat it in order to make it adhere. When rubber plaster is used for purposes other than the above, it ADHKSIVK PL AST FOR 403 will not i-ociuire hcatiiig. In uppl3ing the plaster to the edge of a wound a space should be left between the strips for the escape of discharges. It is sometimes necessary to secure dressings and bandages from slipping by the use of adhesive plaster. This is most freciucntly used in this connection for retaining the first pieces of dressing in position in the case of an ab- dommal section (Fig. 188). When bandages are liable to slip, as, for instance, m the thigh, a strip of adhesive plaster laid over the bandage on the inner and outer side is useful in holding the bandage in place. Fig. 189.— Stirrup of Adhesive Plaster to Prevent the Foot from Assuming the Equinus Position. A, A, Padded foot-pieces; B B adhesive plaster straps; C C bandages securing foot-pieces in position; D, D, bandages securing upper ends of adhesive plaster straps. i uu. Adhesive plaster is useful for retaining a graduated compress in position, and for exercising direct pressure as a local therapeutic measure, as in strapping a testicle and the female breast. It is likewise employed to secure the immobili- zation of parts, as in fractures of the ribs and sprains of joints, and to prevent the foot from assuming the equinus position when patients are long confined to the bed (Fig. 189). In the ambulatory treatment of ulcer of the leg adhesive plaster is useful to relieve the hyperemia of the parts. Resin plaster is to be preferred for this purpose. Fig. 190. — Buck's Extension. One of the most important uses of adhesive plaster is to furnish a means of making extension on an extremity for the purpose of maintaining the frag- ments m position after a fracture. It is most frequentlv emploved for thts purpose in fractures of the femur (G u r d o n B u c k). The adhesive plaster IS cut so as to provide both longitudinally and obliquelv placed strips (Fig. 190) 404 BANDAGING The parts to which adhesive plaster is to be appHecl should first be cleansed, and, if hairy, they should be shaved. In removing rubber plaster the latter may be loosened by the application of alcohol or benzin. The streaks of gum left at the site of the edges of the plaster may be removed by the use of the same agents. In making a second application of plaster care should be taken to avoid, if possible, the site of the formerly applied strips. Head Bandages. — Fronto-occipital Bandage (Fig. 191). — Roller two inches wide, four yards long. Application: Fix the initial extremity of the bandage beneath the inion with the index-finger of the left hand. Carry the roller across the parietal bone of the left side to the forehead, around the forehead, then over the right parietal region to its starting-point. Repeat this, taking care that each turn accurately covers the preceding turn. Com- plete by fastening under the inion. Oblique Bandage (Fig. 192). — Roller two inches wide, four yards long. Application: Fix the initial extremity of the bandage by means of one Fig. 191. — Fronto-occipital Bandage. Fig. 192. — Oblique Bandage. or two fronto-occipital turns. From the occiput, pass the roller obliqueh^ over the first parietal eminence to the forehead, make a fronto-occipital turn, ending at the forehead, pass oblicjuely over the second parietal eminence to the occiput, then make a fronto-occipital turn. Continue these turns in the order named, making each oblique turn over the lower two-thirds of the preceding turn. Complete the bandage by a fronto-occipital turn. Recurrent Bandage (Fig. 193). — Roller two inches wide, seven vards long. Application : ]\Iake one or two fronto-occipital turns to secure the initial extremity of the bandage. Beginning at the central point of the forehead, make a reverse and. carry the roller directly backward in the median line over the vertex to just below the inion; at this place fold the bandage on itself and HEAD BANDAGES 405 carry it forvv^ard to the left of the first turn, so that it overlaps it by two-thirds. Rojieat these recurrent turns between the occiput and the forehead until the Fig. 193. — Recurrent Bandage, or Capeline of the Head. Fig. 194. — V-bandage of Head and Chin. Fig. 195. — Barton's Bandage. whole of the left half of the skullcap is covered. Then secure these by a fronto-occipital turn. Forehead and Chin (Fig. 194). — Roller two inches wide, seven yards long. 406 BANDAGING Application: Fix the initial extremity of the bandage by one or two fronto-occipital turns. From below the inion pass below the right ear around the side of the jaw to the chin, across the anterior surface of the chin, along the left side of the jaw, and below the left ear to below the inion; then make a fronto-occipital turn. Alternate these fronto-occipital turns with the oc- cipitomental turns. Instead of passing from the occiput to the chin, the second turn may pass from the occiput to the upper lip, if so indicated. This bandage is known as the forehead and upper lip bandage. If the second turn passes around the neck, it is known as the forehead and neck bandage. Or, the second turn may cross any part of the nose, and the bandage is then called forehead and nose bandage. Occipitofacial.— Roller two inches wide, four yards long. Applica- tion: This bandage consists of two turns which are identical with the first Fig. 196. — Modified Barton's Bandage for Lower Jaw. two turns of G i b s o n ' s bandage {vide infra). The intersections are fastened by means of safet3^-pins. Barton's Bandage (Fig. 195).— Roller two inches wide, seven yards long. Application: With the index-finger of the left hand fix the initial extremity of the bandage to the vertex of the head in the middle line. Pass down over the left parietal bone to the starting-point. This forms turn number 1. To form turn number 2, continue from the starting-point over the temporal bone of the left side, down the side of the left cheek in front of the left ear, under the chin, up the side of the right cheek in front of the right ear, and over the right temporal bone to the starting-point. To form turn number 3, continue from the starting-point over the left parietal bone to below the inion, below the right ear around the right side of the inferior maxilla to the front of the chin, passing around the anterior aspect of the chin to the left aspect of the inferior maxilla, II 10 AD 15 AND AG KS 407 over this and below the left ear to just below the inion. These three turns repeated a number of titnos in the order given constitute Barton's bandage proper. In the modified Barton's bandage (Fig. 196), after the third turn, there is added a fronto-occi})ital turn. The points of intersection of the various turns arc secured by means of safety-pins. Gibson's Bandage (Fig. 197).— Roller 2 inches wide, 7 yards long. Application: Fix the initial extremity in front of the ear, carry the roller beneath the jaw, up on the other side and over the fronto-parietal region to the place of beginning. After making three such vertical turns a reverse is made a little above the ear and three horizontal turns are made sur- rounding the head. A reverse is then made in front at the root of the nose and the bandage carried backward over the head to the nucha, where it is again reversed and three or more turns are made around the front of the chin. Fig. 197. — Gibson's Bandage. Safety-pins should be placed on all the intersections to prevent the bandage from slipping. The points of reverse and intersection of the bandage are secured with safety- pins. One or two final vertical turns add to the neatness of the chin portion of the bandage. Oblique Bandage of Jaw (Fig. 198).— Roller two inches wide, seven yards long. Application : Fix the initial extremity by means of one or more fronto- occipital turns. If it is intended to cover in the left side of the jaw, the bandage is passed from right to left; if the right side, from left to right. From the occiput, pass below the ear, under the chin, and bring the bandage up over the opposite angle of the jaw, thence carry it over the side of the face just posterior to the external angular process of the frontal bone and in front of the ear of the same side to the vertex. Carry the bandage across the vertex behind the ear of the opposite side to the point at which it first passed under the chin, continue around under the chin as before, this time, however, placing the turn so 408 BAXDAGIXG as to overlap the posterior two-thirds of the previous turn. Continue these turns, each turn overlapping the posterior two-thirds of the previous turn, until the Fig. 198. — Obliuue Bandage of Angle of the Jaw. Fig. 199. — Combined Head, Neck, and Figure-of-8 of the Axilla. ■ space between the external angular process and the ear is completely covered in ; the oblique turns may include the ear, if so indicated. Then carry to above the HEAD BANDAGES 409 opposite ear, reverse, make two or three fronto-occipital turns, and fasten. The obhque turn may be apphecl on both sides, one alternating with the other. This l)andao;e may be comliined with the forehead and neck bandage and with the figure-of-S of the neck and axilla {vide infra). Combined thus and taking in with its oblique tin*ns both sides of the head and omitting the ear, it makes the best bandage known for securing dressings after operation on the neck (Fig. 199). ^ Single Eye Bandage (Fig. 200). — Roller two inches wide, four yards long. Application: Fix the initial extremity by one or two fronto-occipital tui-ns. If it is desired to cover in the left eye. the turns should pass from right to left; if the right eye, vice versa. From the occiput, the roller pa.sses below the lobe of the ear to the cheek, upward over the cheek to the glabella, thence obliquely over the frontal and parietal region of the opposite side to the occiput. Fig. 200. — Single Eye Baxdage. Fig. 201. — Double Ete Baxdage. This forms turn number 1. A fronto-occipital turn is now made. Turn number 2 is identical with turn number 1 . except that it ascends and overlaps the latter by one-third its width. It will be found more comfortable for the patient if the second turn and subsecpent turns cover in the ear instead of passing below it, as in the case of the first turn. These turns are repeated, alternating with the fronto-ocdipital turns until the eye is entirely covered in. A few fronto-occipital turns complete the bandage. The ear is pro- tected from pressure by cotton. Double Eye Bandage (Fig. 201). — Roller two inches wide, six yards long. Application: The initial extremity is fixed by one or more fronto-occipital turns. Then from the occiput the roller passes imder the lobe of the first ear to the cheek, upward upon the cheek to the glabella, covering in the first eye, and thence obliciuely across the opposite frontal and parietal region to the occiput. A fronto-occipital turn is now made. From the occiput, the 410 BANDAGING roller now travels up over the parietal and frontal regions to the glabella, then over the second eye obliquely down the cheek beneath the lobe of the Fig. 202. — Bandage for Supporting Tampons in Anterior Nares. Fig. 203. — Figure-of-8 Bandage of the Neck and Axilla. ear to the occiput. A fronto-occipital turn is now made. The turn covering in the first eye is now repeated, two-thirds of the previous turn are covered in, BANDAGES OF THK TRUNK AND EXTREMITIES 411 tluMi a fi-onto-occipital turn is taken and the turn covering in the second eye is rt'pcated, and so on, each eye turn ascending by two-thirds of the width of the i)receding turn and alternating with a fronto-occipital turn. 'I'hese are continued until the eyes are completely covered in. Bandages of the Trunk and Extremities.— Figure-of-8 of the Neck and Axilla (Fig. 203).— Roller two inches wide, four yards long. Application: Fix the initial extremity of the bandage by one or two circular turns around the neck, not too tightly applied. According to the axilla to be included, pass the roller ol^liquely across the corresponding shoulder under the axilla, and back again obliquely over the same shoulder, crossing the first oblique Fig. 204. — Spiral Bandage of the Chest. F"iRST Method. Fig. 205.^ — Spiral Bandage of the Chest. Second Method. turn. Now take a circular turn around the neck. Alternate the circular neck- turns with the turns passing under the axilla and crossing over the shoulder. Each succeeding turn overlaps the preceding one by two-thirds its width. A circular turn around the neck completes the bandage. '' Spiral Bandage of the Chest (Fig. 204).— Roller three inches wide, eight yards long. Application : The initial extremity of the roller is fixed by means of one or two circular turns around the chest at the level of the xiphoid cartilage. The roller then gradually ascends the chest by means of spiral turns, each turn covering in tv^^o-thirds of the preceding one, until the level of the axillary fold is reached. Here one or two circular turns complete the bandage. 412 BANDAGING Another way of completing the bandage is to make one circular turn at the level of the axillary folds, pass under the axilla to the posterior aspect of the chest, thence obliquely to the opposite shoulder, over this to the anterior aspect of the chest wall and diagonally down over the turns of the bandage to the xiphoid cartilage, where the bandage ends. This last oblique strip is secured by pins to each spiral turn of the bandage (Fig. 205). Or, the spiral turns may be supported by shoulder-straps pinned in front and behind (Fig. 206). Anterior Figure-of-S of the Chest (Fig. 207).— Roller three inches wide, eight yards long. Application : Two or more circular turns are first made around the chest at the level of the axillary folds. From a point commencing Fig. 206. — Spiral Bandage of the Chest. Third Method. at the center of the sternum, the roller is carried over one shoulder to its posterior aspect, through the axilla of the same side to the anterior aspect of the chest, diagonally across the chest to the other shoulder, then over the other shoulder to its posterior aspect, through the axilla to the anterior aspect of the chest, and diagonally across it to the starting- point, thus forming a cross over the sternum. These turns repeated a number of times complete the bandage. Or, the circular turns may alternate with the figure-of-8 turns. The turns may be placed so that each will exactly cover in the preceding one or overlap it by a portion of its width. Finally, the bandage is secured by a pin through the intersection of the turns over the sternum. JANDAGE^. OF THIO TRUNK AND EXTREMITIES 413 Fig. 207.— Oblique Bandage of the He.ad and Anterior Figure-of-8 of the Chest. Fig. 208. -Posterior Figure-of-8 Bandage of the Chest. 414 BAXDAGING Posterior Figure-of-8 of the Chest (Fig. 208). — Roller three inches wide, eight yards long. Application: The initial extremity of the bandage is fixed between the scapulas at the level of the axilla, and the roller carried over one shoulder to its anterior aspect, through the axilla of the same side to its posterior aspect, and thence to the starting-point. The roller is then carried in a similar manner around the other shoulder, and these turns are alternated first around one shoulder and then around the other until the roller is finished. The bandage is pinned at the point of intersection between the scapulas. Breast Bandage (Fig. 209). — Single roller three inches wide, eight yards long. Application: Starting from the scapula of the affected side, carry the roller over the shoulder of the opposite side to the anterior chest wall, Fig. 209. — Bandage Sling for the Breast. Fig. 210. — Double Breast Bandage. and thence under the affected breast and obliquely along the lateral and pos- terior chest wall to its starting-point. Repeat this turn in order to secure the initial extremity. This is turn number 1 . Turn number 2 is an oblique one, starting from the initial extremity over the scapula of the affected side and going completely around the body just under the affected breast. These two turns are alternated, each covering in its corresponding preceding turn by two- thirds its width, thus gradually ascending and covering the breast completely. To support both breasts the bandage is repeated on the opposite side (Fig. 210). Ascending Spica of the Shoulder (Fig. 211). — Roller three inches wide, eight yards long. Application: Fix the initial extremity of the roller by means of one or two circular turns around the arm of the affected side at the level of the axillary fold, or at a short distance below it. Carry the bandage BANDAGES OF THE TRUNK AND EXTREMITIES 415 directty across the anterior aspect of the chest to the axilla of the opposite side, under the axilla to the posterior aspect of the chest, and across this to the starting-point. jMake a circular turn around the arm at the starting-point and then a second turn around the chest, similar to the first, but ascending and covering in two-thirds of the previous turn, except at the opposite axilla where the turns exact l.v overlap each other. The chest turns are alternated with the circular turns around the arm, each chest turn ascending and covering the preceding turn by one-third of its width. In this manner the shoulder is ascended by spica turns until it is completely covered. The bandage is com- pleted by a circular turn around the arm and there fastened. Descending Spica of the Shoulder.— Roller two and a half inches wide, seven yards long. Application: Fix the initial extremity of the bandage by means of one or two circular turns around the arm at the level of the Fig. 211. — Ascending Shoulder Spica. Fig. 212. — Velpead's Bandage. First Turn. axillary fold or at a short distance below it. Carry the roller over the shoulder and the anterior surface of the chest as high up as it can be made to go, thence around the axilla of the opposite side, around the posterior aspect of the chest and over the shoulder to the starting-point. Here a circular turn is taken. These turns are alternated, each chest turn descending by one-third the width of the preceding turn until the shoulder is completely covered. The bandage is finally completed by a circular turn around the arm. Velpeau's Bandage (Figs. 212, 213, and 214).— Two rollers, three inches wide, eight yards long. Application: The arm of the affected side is drawn across the chest, the palmar surface of the fingers resting on the point 416 BANDAGING of the sound shoulder, with a layer of cotton between. The initial extremity of the roller is placed over the scapula of the unaffected side, and the roller carried over the point of the opposite shoulder, thence down across the outer and then the posterior surface of the arm of the same side and under the elbow to the anterior chest wall to the axilla of the unaffected side and thence to the starting-point, the first turn being thus completed. This turn is repeated in order firmly to fix the initial extremity of the roller. After this second turn is completed, the roller is carried directly around the body, passing over the elbow of the affected side near its point, thence to the axilla of the sound side, and thence to the starting-point over the scapula of the sound side. These turns are alternated, each succeeding turn overlapping the previous one by two-thirds Fig. 213. — Velpbau's Bandage. Second Turn. Fig. 214. — Velpeau's Bandage Completed. its ■v\ddth, the shoulder turns gradually approaching the base of the neck, and the turns crossing the elbow gradually ascending to the shoulder, until the last turn passes across the wrist and is secured behind. Figure-of-8 of the Elbow (Fig. 216). — Roller two inches wide, four yards long. Application: Place the elbow in the position in which it is to remain and pass two circular turns around the flexure and tip of the olecranon. Circular turns are now made alternately above and below the joint until the latter is completely covered, each turn covering in two-thirds of the preceding one. Or, fix the initial extremity of the bandage by one or more circular turns a few inches above the joint. Return obliquely to the starting-point and BANDAGES OF THE TRUNK AND EXTREMITIES 417 make a circular turn. Alternately make a circular turn above the joint gradually approaching the tip of the olecranon from both directions; finally Fig. 216. — Figure-of-8 of the Elbow. complete by a circular turn directly around the flexure and covering in the olecranon. 28 418 BANDAGING Figure-of-8 of the Hand and Wrist (Fig. 217). — Roller, one, two, or three and a half inches wide, two yards long. Fig. 217. — Figure-of-S of the Hand and Wrist. Application: Fix the initial end of the roller by one or two cir- cular turns at the wrist. Carry it obliquely across the dorsum to the base of the index-finger or little finger, make one circular turn, followed by one half turn around the hand at the metacar- pophalangeal articulation, and re- turn to the wrist. After complet- ing a circular turn at the wrist, again carry it obliquely to the base of the index or little finger, and proceed as before. The turns are continued, each overlapping the pre- ceding one by two-thirds its width, until the dorsum of the hand is completely covered. A circular turn at the wrist completes the bandage. Figure-of-8 of the Hand and Wrist (Palmar Application). — This is applied in the same manner as the preceding, except that the oblique turns cross the palm instead of the dorsum of the hand. Reversed Spiral of Upper Extremity (Fig. 218). — Roller two and a half inches wide, seven yards long. Application: Fix the initial extremity of the ban- dage by means of one or two circular turns around the wrist; cross the back of the hand obliquely to the level of the last phalan- geal joints, where a circular turn is made ; then by means of spiral or reversed spiral turns ascend the hand to the me- ^ 1^^^ tacarpophalan- Hj^ H^l geal joint of the ^^H^^^l thumb; pass ob- mB^^^^ liquely to the w^ wrist and take a circular turn at this point; then back obliquely to take a circular turn around the body of the hand. Make three or more of these figures-of-S and finish bv a circular turn at the wrist. Ascend the forearm by means of Fig. 218. — Bandage for Wrist, Forearm, and Elbow. Fig. 219. — Spiral of the Finger. BANDAGES OF THK TRUNK AND KXTKEMITIES 419 spiral and reversed spiral turns mil 11 the elbow is reached. If it is desired to keep the arm flexed, cover in the elbow by a series of figure-of-8 turns while in flexion; if, however, the arm is to be kept extended, continue the spiral and reversed turns over the elbow and up the arm. The bandage is completed by one or two circular turns at the level of the axillary fold. Care should be taken here, as elsewhere, not to allow the reverses to press over bony prominences, as, for instance, the ridge of the ulna; also to keep the reA'erses in line. Spiral of the Finger (Figs. 219 and 220). — Roller three-quarters of an inch wide, three yards long. Application : The initial extremity of the roller is secured by two or three turns around the middle phalangeal joint. The bandage is carried in a spiral manner to the base of the finger, each turn covering one-half of the preceding turn. A circular turn is made at the base of the finger, and the bandage carried by means of spiral turns to its starting-point at the middle pha- langeal joint. From the posterior surface of the joint a recurrent turn is now j^assed directly over the tip of the finger to the ante- rior surface of the joint. The fin- gers of the operator's left hand hold the extremities of this turn taut and in position while a second turn is passed back over the inner half of the finger-tip to the starting-point of the first. This is also held in place while a third and final turn is passed over the outer half of the finger- tip to the anterior surface of the joint. A circular turn secures the ends of the three loops, the ban- dage being then carried to the distal extremity of the finger by means of spiral turns. At the extremity another circular turn is taken, which secures the parts of the loops extending to the right and left side of the finger-tip. Finally, by means of spiral turns the base of the finger is reached and the bandage fastened either by splitting longitudinally for a distance of six or eight inches, knotting the bandage to prevent further sphtting, and tying the ends directly around the base of the finger; or by splitting for a distance of ten or twelve inches, tying at the base of the finger and carrying the superfluous ends around the wrist once or twice in opposite directions, and finally tying. This last effectually prevents the loosening and falling off of the bandage. The reversed spiral of the finger is applied in the same manner as the spiral, with the exception that reversed spiral turns take the place of spiral turns. Fig. 220-— Spiral 5AXDAGE OF FiXGER. Method. Second 420 BANDAGING . \ ^^^^^H 1 i i '^^^^B ^. Fig. 221. — Spica of the Thumb. Spica of Thumb (Fig. 221). — Roller one inch wide, three yards long. Application: Fix the initial extremity at the wrist by one or two circular turns. Carry the roller over the dorsal aspect to the tip of the thumb and there make a circular turn; then return to the wrist and make a circular turn around the wrist. The roller is again carried across the dorsal aspect of the thumb and a sec- ond circular turn is made around the thumb, this last overlapping the first in the direction of the base of the thumb by two-thirds of its width. This procedure is continued until the thumb is cov- ered. A turn around the wrist completes the bandage, W'hich is then fast- ened. Spiral turns may be used around the thumb in place of cir- cular ones. A few recurrent turns may be first placed over the tip, if it is desirable to inclose it in the bandage. Any of the above described spiral or reversed spiral bandages of the finger may be applied to the thumb. Demi-gauntlet (Dorsal) (Fig. 222). — Roller one inch wide, four yards long. Application: Fix the initial extremity at the W'rist by one or two circular turns. Carry the roller obliciuely across the back of the hand to the base of the thumb ; here make a circular turn and return to the wrist. ^lake a circular turn at the wrist and then carrj' the roller obliciuely across the back of the hand and the base of the index- finger, there making a circular turn, and return to the wrist. So continue until the base of each finger has received in due order the same circular turn. Complete a few figure-of-S turns of the hand and wrist. Demi-gauntlet (Palmar).— Same as the preceding, except that the oblique Fig. -The Demi-gauntlet Bandage (Dorsal). BANDAGES OF TIIK TUUNK AND ICXTREMITIKS 421 turns from the wrist to the base of the finger are passed over the palmar instead of the dorsal surface. The Gauntlet (Fig. 223).— Roller one inch wide, three j-ards long. Application: Fix the in- itial extremity by means of one or two circular turns at the wrist. Cari-y the roller by an obliciue turn to the tip of the thumb and cover the latter by spiral or re- versed spiral turns. The ban- dage is then carried back to the wrist and a circular turn made around it, then carried to the index-finger, which is bandaged in the same manner as the thumb. In like manner the remaining fin- gers are covered, the bandage be- ing completed by a few circular turns at the wrist and there fast- ened, or a few additional figure- of-8 turns may be passed around the hand and wrist for further security. Ascending Single Spica of the Groin (Fig. 224).— Roller three inches wide, eight yards Fig. 223. — The Gauntlet. long. Application: Fix the initial extremity of the bandage by means of one or two circular turns just above the level of the iliac crests. If the right grom is the one to be covered in, the roller should run anteriorly from left to right, and in the reverse direction in the case of the left groin. Carry the roller from the summit of the ihac crest oppo- site the groin to be bandaged, obliquely across the anterior sur- face of the abdomen to the outer side of the thigh of the affected side at the junction of its middle and upper third. A circular turn and a half is now made around the thigh at this point, the roller finally emerging on the inner side of the thigh, whence it is carried obliquely across the front of the latter, crossing the first oblique part as low down as pos- sible in the middle line of the thigh, thence over the groin to Fig. 224. — Ascending Single Spica of the Groin. 422 BANDAGING Fig. 225. — Descexdixg Single Spica of the Groin. the lateral aspect of the ilium of the same side, then around posteriorly in a slightly oblique direction to the iliac crest of the side from which it started. A circular turn is now made around the body just above the iliac crest as in the first turn which secured the initial extrem- ity. The spica turns are alter- nated with the circular turns around the body, the circular turns around the thigh each ascending one-third of the width of the bandage and the spica turns also ascending one-third of their width. In this manner the upper third of the thigh and all of the groin is completely covered in. The circular turn around the body, or that around the thigh, or both, are sometimes omitted. The spica turns should cross each other exactly in the middle line of the thigh and groin. If, in bandaging the right thigh, the bandage is started around the body from right to left, instead of from left to right, the roller will be carried obliquely across the groin from the lateral surface of the iliac crest of the affected side to the internal aspect of the thigh at the junction of its middle and upper third. Here a circular turn and a half is made. The roller, emerging on the outer side of the thigh, is carried across the anterior surface of the thigh, crossing the first ob- lique part in the middle line of the thigh as low down as possi- ble, and is carried obliquely across the anterior surface of the abdomen to the iliac crest of the opposite side, and thence circu- larly around the body to its starting-point. If, in bandag- ing the left groin, the roller is started from left to right, the above description also holds good for that side. Descending Single Spica of Groin (Fig. 225). — Roller three inches wide, eight yards long. Application: The descending spica of the groin is Fig. 226. — Ascending Spica of Both Groins. BANUAGKS OF THE TRUNK AND KXTIIKMITIES 423 applied in the same manner as the aseen(Un<^ spica, and consequently the same des{'i'i])ti()n and rules hold good for both, with the exception that, whereas in the case of the ascending spica the first spica turn is placed at the junction of the middle and upper third of the thigh, and the subsecjuent spica turns ascend from that point one-third of their width, in the case of the descending spica the first spica turn is ))laced as high as possible and the subsequent spica turns descend one-third of their width until the junction of the middle and upper third of the thigh is reachetl. Ascending Spica of Both Groins (Fig. 226). — Roller three inches wide, ten yards long. Application: Fix the initial extremity of the bandage by means of one or two cir- cular turns around the body just above the level of the iliac crests. The roller runs from left to right or from right to left according to the thigh which is to receive the first spica turn. From the iliac crest of one side, the roller is carried obliquely across the anterior surface of the abdomen and groin to the external surface of the oppo- site thigh at the junction of its middle and upper third. Here make a circular turn and a half, emerge from the inner side of the thigh ob- liquely across the first ob- lic{ue part in the middle line as low down as possible on the thigh, ascend obliquely to the lateral surface of the ilium of the same side, thence obliquely around the body posteriorly to the opposite iliac crest. Now carry a cir- cular turn around the body ending abov^e the iliac crest opposite the groin yet to be encircled. Proceed obliquely across the back ■ to the lateral aspect of the iliac bone of the opposite side and thence obliquely over the anterior surface of the groin of that side to the interior surface of the thigh at the junction of its middle and upper third. Here make a circular turn and a half, and, emerging on the external surface of the thigh, ascend obliquely over the anterior surface of the groin, crossing the first part of this spica turn in the middle line of the thigh. Carry the roller on obliquely over the anterior surface of the abdomen to the opposite iliac crest. Here make a circular turn around the body. These turns are repeated in order, first a circular one around the body, then a spica turn around one groin which Fii -Double Descen'dixg Spica of Groix. 424 BANDAGING Fig. 228. — Volkmann's Block. emerges from the outer side of the thigh after surrounding it by a circular turn, then a circular turn around the body until both groins and the upper thirds of both thighs are completely covered in, the circular turns around the thigh ascending one-third of their width, and the spica turns of both groins ascending likewise one-third of their width. Either the circular turns around the body or the circular turns around the thighs or both may be omitted. The bandage is fast- ened at its intersections at the back over the anterior surface of the abdo- men and also at the spica intersec- tions on the thigh and groin. Descending Spica of Both Groins (Fig. 227). — Roller three inches wide, ten yards long. Application: The descending spica of both groins is applied in the same manner as the ascending spica, with the exception that the oblique turns in the de- scending spica begin to cross high up and descend to the junction of the middle and upper third of the thigh by one-third of the width of the roller. Otherwise the bandage is applied in the same manner. In applying the spicas of the groin the patient should be raised from the table and supported on a V o 1 k m a n n ' s block (Fig. 228) . In the absence of the latter, an inverted basin an- swers the purpose. Figure-of-8 of Knee (Fig. 229). — Roller three inches wide, six yards long. Application: Fix the initial extremity of the bandage by means of one or more circular turns a short distance below the knee- joint. Carry the roller obliquely across the popliteal space, the first oblique turn crossing the middle line to the inner surface of the thigh. Here make a circular turn, followed by a second which overlaps the first by two-thirds of its width and ap- proaches the knee-joint by one- third of its width. Again cross the popliteal space to the circular turns below, and here make another cir- cular turn which ascends toward the knee-joint by one-third of its width. Continue to make circular turns above and below the knee, the upper ones gradually ascending until the knee is entirely and securely covered. Spiral of the Foot. — Roller two inches wide, five yards long. Applica- FlG. 229. FlGURE-OF-S OF THE KnEE. BANDAGES OF THE TRUNK AND EXTREMITIES 425 Fig. 230. — Figure-of-S of THE Foot and Ankle. tion : Fix the initial extremity above the internal malleolus with the finger- tips of the left hand. Carry the roller around the ankle aiiteriorly to "the point of commencement, crossinp; the initial extrem- ity and then fixing it. The roller now crosses the instep to tiie base of the toes. Here a circular turn is made, and, succeeding this, spiral turns ascend the foot and instep as far as the conformity of the parts permit. The roller is then carried to the ankle; a few circular turns are here made, and the terminal ex- tremity fastened. Figure-of-8 of Foot and Ankle (Fig. 230).— Roller two inches wide, five }'ards long. Applica- tion: Fix the initial extremity of the bandage as in applying the spiral of the foot. Carry the roller obliquely across the instep to the base of the toes. Here make a circular turn. Return to the outer malleolus atid make a circular turn around the ankle. Continue these turns, one around the ankle, then one around the foot, the ankle turns gradually descending until the foot, instep, and ankle are cov- ered. Then complete by a circular turn around the ankle, and fasten. Reversed Spiral of the Foot. — Roller two inches wide, five yards long. Application: Same as the spiral bandage except that the spiral turns of the foot and instep are replaced by reversed spiral turns. Spica of the Foot (Fig. 231).— Roller two inches wide, five yards long. Application: Fix the initial extremity as in applying the other foot bandages. Carry the roller obliquely across the instep to the lateral aspect of the foot, along the lateral aspect to the posterior surface of the heel low down, thence along the lateral aspect of the foot obliquely across the instep, crossing the corresponding oblique turn to the other side of the foot in the median line. This completes the first spica turn. Repeat these spica turns, ascend- ing by one-third the width of the bandage each time, until the foot and ankle are covered in. Then complete by circular, spiral, or spiral re- versed turns around the ankle. A few spiral or reversed spiral turns applied around the instep before beginning the spica, and similar turns about the ankle on completion of the spica, add to the neatness of the bandage. The spica Fig. 2.31.-SPICA of the Foot. p^^^^g gj^^^j^ ^^^^.^^^ ^^ -^ ^j^^ median line. Recurrent of Foot. — This is simply one of the usual bandages of the foot among whose turns are included recurrent turns to cover in the toes. 426 BANDAGIXG Serpentine of the Foot (Fig. 232). — Roller two and a half inches wido, seven yards long. Application: The initial extremit}' of the bandage is fixed in the same manner as in the case of other bandages of the foot. The roller is carried obliquely across the instep to the base of the toes, where a circular turn and a half is made, bringing the roller to the middle line anteriorly. Now carry the roller obliquely to the outer edge of the sole uncier the hollow arch of the foot to the interior lateral aspect of the heel low down, thence obliquely up over the posterior aspect of the heel to the external malleolus. Here make a circular turn around the ankle. This is turn number one. Then obliciuely across the instep to the base of the toes, the roller naturally coming to the internal aspect of the base of the toes, whereas in turn number one it came to the external aspect. Take a circular turn and a half around the base of the toes as in turn number one. Thence obliquely over the instep to the internal edge of the sole of the foot, on around beneath the hollow arch of the foot obliquely to the external lateral aspect of the heel low do^^^l, thence obliquely up over the posterior aspect of the heel to the internal malleolus. Now make a circular turn around the ankle. This is turn number two. Turn number three is simply a circular turn around the instep and point of the heel, its edges being held and covered in by a repeti- tion of turns one and two, so that the heel is completely covered. Turns one, two, and three are repeated until the parts are covered. A few spiral turns above the malleoh complete the bandage. Combinations of Spiral, Reversed Spiral, Spica, and Figure-of-8. — Recurrent and serpentine bandages of the foot may be used as indications for them arise in individual cases. It is sometimes necessary in strapping the joint to carry spiral or reversed spiral turns above the ankle. This may also he done to add finish to a bandage. If it is not necessary to cover in the heel, the circular turns of the heel and instep should be omitted. If the toes are to be covered, recurrent turns may "be introduced. This bandage is the best of the foot bandages, as it is easy to apply and stays firmly in place. Reversed Spiral of Lower Extremity (Fig. 233) .—Roller two and one-half inches wide, seven yards long. Application: One of the foot bandages is first applied, except that, instead of ending the bandage at the ankle, the Fig. 232. — Serpentine of the Foot. BANDAGES OF TIIK TRUXK AND EXTREMITIES 427 Toiler is oarriod up the lee; by means of spiral or reversed spiral turns according to the sluipe of the linib, until the knee is reached. The bandage may be ended here with a few circular turns, or, witli the leg in the extended position, it may be continued on up the thigh to the groin, and either end there, or a spica of the groin may be added for additional security. If it is desirable to leave the l)atient's knee in a flexed position, a figure-of-8 bandage of the knee may take the place of the spiral or nn-ersod spiral turns covering in that region. Fig. 233. — Reversed Spiral of Lower Extremity. Figure-of-8 of Leg (Fig. 234). — Roller two and one-half inches wide, seven yards long. Application: If the leg is fairly well molded, this is the best bandage to use. First apply one of the foot bandages. Then ascend the leg by means of spiral or spiral reversed turns until the lower part of the calf is reached. Here the figure-of-8 turns begin. The bandage is carried obliquely upward and around to the median line posteriorly, whence it is carried obli- queh' downward and around to the front of the leg, crossing the starting turn as near the median line as is permissible Avithout bringing too much pressure over the long ridge of the tibia. These figure-of-8 turns are repeated, gradually ^H ■ H Fl ^^^^H WM HF^ J : 1 ^^W WTu J ' ' ' ' ; 1 i 1 ■ ^^ •-■ . ^ j ^^^^^^^^H /-^- _ ~ ^^^^^^1 K^^ .^ ^^gUM ■ Fig. 234. — Figure-of-8 of Leg. ascending the leg until the calf is covered. The bandage is completed by one or more circular turns around the leg just below the knee. Spica of Great Toe (Fig. 235). — Roller one inch wide, five yards long. Application: This is applied in a manner similar to that employed in the spica of the thumb. The initial extremity of the roller is fastened by one or two circular turns around the ankle. The bandage then crosses the instep of the foot obliquely from the internal malleolus to the outer side of 428 BANDAGING the great toe. A circular turn is taken around the toe as near the tip as possible and the roller carried from the inner side of the toe obliquely across the instep, crossing the first oblique part as near the end of the toe as possible to the hiternal malleolus. Here a circular turn is made. If desirable, the tip may be covered in by a few recurrent turns. The spica turns are repeated, ascending toward the base of the toe each time one-third the width of the bandage until the toe is completely covered. Serpentine of Great Toe. — Roller one inch wide, six yards long. Application: The initial extremity of the bandage is fastened by means of one or two circular turns around the ankle. The roller is then carried obliquely across the instep to the outer edge of the sole, then ob- liquely under the sole to a point just posterior to the thenar eminence. It is here brought to the inner edge of the foot, thence across the anterior surface of the base of the toe to its tip. Here a circular turn is made and a few recurrent turns may be added. From the tip the roller crosses the anterior surface of the base of the toe to its tip. Here a circular turn is made and a few recurrent turns may be added. From the tip the roller crosses the anterior surface of the base of the toe and thence obliquely across the base of the other toes to the outer side of the foot at a point opposite the hypothenar emi- nence. It passes the hollow obliquely just behind the thenar eminence to emerge at the inner edge of the foot, thence oblicjuely across the instep to the exterior malleolus. Here a circular turn around the ankle is made. These serpentine turns are repeated, each overlapping the preceding one to a slight extent until the toe is completely covered. Fig. 235. — Spica of Great Toe. PART II REGIONAL SURGERY SECTION XIV THE SURGERY OF THE HEAD THE SCALP The thinner portions of the cranium, as, for instance, the temporal regions, are covered with a rather thick cushion — the temporal muscle ; but with this exception the bones of the skull are practically unprotected. The epicranial structures are stretched across the skull in such a manner that force applied affects soft parts and bone alike. The elasticity of the cranial vault is such, however, that, on account of its peculiar conformation, it may return to its normal shape after quite a severe blow and only a contusion of the soft parts result. Simple contusions of the scalp are usually of but slight importance and require no treatment; the extra vasated blood is, as a rule, rapidly resorbed. The slightest abrasion of the integument, however, should be treated antiseptic- ally because of the readiness with which inflammatory infection takes place in this region. Hematoma of the scalp results from rupture of one or more vessels of con- siderable size. The subcutaneous and subaponeurotic varieties are recognized. In the first named variety a fluctuating swelling surrounded by an indurated border is present. Owing to the soft and apparently depressed center, this condition is sometimes mistaken for a fracture of the skull. This mistake may be avoided by noting the fact that the indurated margin is above the level of the surrounding bone, and, in addition, that it pits on pressure. In the second variety, namely, that which occurs beneath the aponeurosis of the occipitofron- talis muscle, the effusion of blood may separate the latter from the bone for a large area, giving rise to bulging at the supraorbital ridges and in the occipital region. In the treatment of a large hematoma it may become necessary to resort to incision and evacuation of the clots and fluid blood, with subsecjuent drainage. Wounds of the scalp gape considerably, provided they penetrate to the bone and are transverse; otherwise they do not. This is due to the peculiar anatomic structure of the connective tissue between the scalp and the pericranium, the bony elastic fibers of which permit the retraction of the edges in both directions by the action of the occipitofrontalis when the entire 429 430 THE SURGERY OF THE HEAD thickness of the scalp is traversed by the wound. Sharp pointed instruments, easily penetrate to the bone, but rarely pass through it, unless directed with great force. The treatment of incised wounds of the scalp requires on the part of the surgeon the arrest of hemorrhage as his first care. The vascularity of the parts- is such that considerable blood may be lost before spontaneous arrest takes place. The rigid fibers of the aponeurotic connective tissue in the scalp, like the walls of the bony canals, prevent retraction of the divided arteries and narrowing of their lumina. Artificial means for the arrest of hemorrhage are therefore quite necessary in this region. The application of a ligature in the ordinary manner is often impracticable, and if coaptation and suturing do not suffice, a ligature must be passed through the scalp by means of a needle in such a manner as to surround the bleeding point (circumsuture), and must be tightly tied. This suture may be so applied as to avoid puncturing the skin, and thus there is no risk of infection from that source. Oozing from the edges of the wound after suturing may usually be arrested by a snugly applied bandage holding the dress- ings in position. The solid bone beneath admits of the application of considerable pressure. Contused wounds, though pro- duced by a blunt object, because of the tense state of the scalp and the presence of the smooth bony wall of the skull in close proximity, resemble incised wounds at their edges. The rupture of the vessels, however, is quite irregular or ragged, thus favor- ing coagulation of blood and sponta- neous arrest of hemorrhage. It was formerly the custom to per- mit such wounds to close by granula- tion, on account of the fear of exten- sive suppurative inflammation of the scalp. With aseptic or antiseptic wound treatment, however, contused and lacerated wounds, after their edges have been trimmed with the knife or scissors, may now be sutured at once. Avulsion of the Scalp. — This usually occurs in women from machinery accidents, the long hair becoming entangled between the belt and the pulley of shafting or of a machine. The avulsion may be partial; usually, however, the entire scalp is torn from the head, leaving the pericranium exposed. All or portions of the ears and upper eyelids, as well as the integument and subcutaneous connective tissue of the back of the neck, and portions of the temporal muscles, may be included in the avulsion (Figs. 236 and 237). The cranial bones may be denuded of periosteum in places. The degree of shock present and the amount of blood lost vary greatly. Death may result from Fig. 236. — Avulsion of the Scalp. these causes alone, usually takes place. Where the periosteum is torn off, exfoliation of bone^ THE SCALP 431 Treatment. — These accidents most coininonly occur in anemic and poorly nourished factory operatives. The loss of blood, together with the prolonged drain on the system incident to the constant oozing of serum from so large a granulating surface, demands that the period of healing be shortened as much as possible. For this reason the surgeon should not await the results of nature's efforts before interfering, but, on the recover}' of the patient from the shock, he should at once commence the treatment by skin-grafting. The method of Thiersch should be employed. The strips are to be taken from the outer portions of the thighs as long as these regions are available; sub- sequently they may be taken from the legs and arms. In the beginning the strips should be placed adjacent to the skin edges, and successive strips placed in position from time to time, with as little time intervening as pos- sible. Care should be taken not to imperil the vitalit}^ of the strips by too tight bandaging. This is particularly likely to occur beneath the circular or occipitofrontal turns of the head bandage. Simple loosening of the scalp without avulsion may occur from force applied in the same manner as in the case of a\nilsion. the force, however, stopping short of actually tearing away the scalp. This is fol- lowed by extensive hematoma of the scalp. Moderate compression by means of a bandage usually suffices in the treatment. Inflammation Following In- juries of the Scalp. — The tissues of the scalp are not specially disposed to inflammation. "N^Tien an inflam- matory process follows an injury, in the case of the skin covering, it as- sumes an erysipelatous character ; in the connective tissue it is phleg- monous. In preaseptic times the former was of very frec^uent occurrence after sutured wounds of the scalp; now, however, it is comparati^'ely rare. A special feature of erysipelas attacking the scalp should not be lost sight of. The redness observed in other localities as one of the symptoms of erysipelas is here replaced by a pale edematous swelling which spreads to the lower margins of the scalp. This is probably due to the fact that the tension of the tissues of the scalp pressing on the bony wall beneath prevents the overfilling of the capil- laries. For this reason an edematous, puffy state of the scalp, accompanied by a rigor and elevation of temperature, should be looked on with suspicion as the possible initial stage of an attack of erysipelas. The special danger to be apprehended from erysipelas of the scalp is the occurrence of traumatic meningitis (see page 457). The cortex of the brain may finally take part in the inflammatory process (encephalitis, see page 458). A fatal termination is the rule in these cases, delirium and coma supervening. Fig. 237. — Avulsion of the Scalp. 432 THE SURGERY OF THE HEAD A fatal septic meningitis may also follow a phlegmonous inflammation of the connective tissue between the aponeurotic structures of the scalp and the cranium. Here the direct communication between the veins in this region and those of the diploe, and between the latter and those of the cerebral membranes, favors infection by thrombosis. The thrombi, after putrefying and softening, ma}' become displaced and finally be transported to distant parts, causing a fatal pyemia. The occurrence of phlegmonous inflammation is recognized by the extreme edema, the scalp pitting on pressure and giving rise to acute tenderness and severe pain accompanied by high fever. Fluctuation is not usually present. Phlegmonous inflammation and erysipelas may be combined here as else- where. "\Mien the erysipelas reaches the lower margin of the scalp the skin becomes reddened. Phlegmonous inflammation is soon followed by suppura- tion. In the early stages the two cannot be differentiated. Treatment of Wounds of the Scalp. — The importance of a strict antiseptic procedure in cases of scalp wounds cannot be overestimated. Est lander has shown by a careful study of the subject that in preantiseptic times the mortality from this class of injuries was 23 per cent. With antiseptic wound treatment this mortality has been reduced to 1.5 per cent. While the general rules governing the treatment of wounds will here apply, there are some special points to be noted in this connection. In the first place, a large area of the scalp in the neighborhood of the wound must be carefully shaved. With- out this 25recaution it is next to impossible to cleanse the scalp so thoroughly as to prevent bacterial infection. Moreover, exact coaptation of the edges of the wound, as well as the accurate ai^plication of dressings, is impossible in the presence of the hair. All traces of dirt are to be removed by the brush, soap, and hot water, and copious irrigations practised before suturing. As a final measure, germicidal solutions employed for irrigation are to be washed away by means of sterile water or a sterilized normal sodium chlorid solution. The best suture materials for this purpose are horsehair and crin-de-Florence or silkworm-gut. The interrupted suture should be used. In cases in which there is considerable oozing from the skin edges, the suture should always include the entire thick- ness of the scalp. If the injury is the result of an accident and the case comes to the surgeon's hands shortly after the accident, and if no special infection is suspected, wounds involving the entire thickness of the scalp may frec^uently be entirely closed without risk. But, as a rule, drainage should be provided for. This may consist simply in leaving the lowermost angle of the wound open for a c^uarter of an inch or more. In large, flaplike wounds resulting from glancing blows-, in which infection is always to be suspected, the center of the place of attachment of the flap is to be selected and a counter-opening for drainage made at this point. Narrow strips of oiled silk protective make an excellent drain in these cases. Wounds made in the course of an aseptically conducted operation are always to be closed without drainage. ■WTien dressings are applied to wounds of the scalp they should include the entire head after the wound and neighborhood (which should also be shaved) have been completely covered by separate pieces of sterile gauze. A recurrent THE SCALP 433 doul)l(> voWvv oi- capoliiio baiuhigc (see page 404) to secure the dressings in place, and a bandage of starched crinoline, thoroughly wetted and stjueezed out before being applied, serve to conijilete the dressing. The starched crinoline, on dry- ing, will hold the dressings firmly in position, even in the most restless patient. This is a commercial article and is sold in the dry-goods stores for dressmaking and tailoring purposes. Dextrin and glue enter into its composition. Careful therniometric observations will warn the surgeon of the super\-ention of a septic condition. Er^-sipelas and phlegmonous inflammation should be recognized early, and on their occurrence prompt measures of treatment should be instituted (see Treatmentof Erysipelas, page 179). In case of phlegmonous or suppurative inflammation the dangers of pyemia and septic meningitis are imminent ; free incisions should be made, followed by the vigorous application of the sharp spoon to clear out suppurating foci. The wounds are subsequently to be packed with gauze wrung out of 1 : 2000 mercuric chloric! solution in 50 per cent alcohol. It is also useful to cleanse the wound thoroughly with a 5 per cent zinc chlorid solution and pack it afterward with gauze wrung out of the same. Even in those cases in which most or all of the scalp has been torn off l^y machinery accidents a favorable result may be expected. The large granulating surface, after it has assumed a healthy aspect, should be covered in b>- the application of strips of skin transplanted after Thiersch's method (see page 331). Tumors of the Scalp. — Atheromas or sebaceous cysts of the scalp, sometimes called wens, are the tumors most commonly found in tliis location. They differ from dermoid cysts in that the latter are always congenital and limited to certain localities, while the former occur almost exclusively in adults and on almost any portion of the scalp. A differential diagnosis of these tumors will be facilitated if their location is taken into consideration. The favorite sites for dermoid cysts are, in order of frecjuency of occurrence of the cysts, the external portion of the supraorbital arch, the point where the sagittal and coronal sutures join, the site of the anterior fontanel, behind and in front of the auricle. Dermoid cysts, when uncomplicated by bony defects, as well as sebaceous cysts, are to be extirpated when, because of their size or from any other cause, they become sources of discomfort. The best method of accomplishing this is to make a semicircular incision at the base, turn back a flap which shall include the entire cyst and its contents, and then dissect the cj'st from the flap. In this manner the cj^'st does not, as a rule, rupture, and. w^hat is of greater im- portance, the entire sac is removed. Dermoid cysts in the neighborhood of the fontanel are frec^uently complicated by an opening into the cranial cavity, which necessitates extreme care in their removal. Aneurism of the Scalp. — This may appear either in the shape of a circumscribed saclike dilatation of a portion of a single vessel, or a diffused cylindric dilatation of a number of the arteries of the scalp. The first is usually due to injury of the wall of the vessel, and not infrequently develops in the recent cicatrix after a punctured or glancing wound. Extirpation is the only resource. Care should be taken not to mistake a highly vascular sarcoma of the scalp for an aneurism of this kind. Sarcoma of the dura which has per- forated the bone may likewise simulate aneurism. Cirsoid or racemose aneurism occurs almost exclusively in the arteries 29 434 THE SURGERY OF THE HEAD of the scalp (see page 94). These are mcreased in both circumference and length, the latter circumstance producing a serpentine course and wormlike appearance, which are cjuite characteristic of the disease. Its origin has been attributed to congenital conditions (capillary angioma), to vasomotor paralysis, and to injury. Varices of the scalp have also been observed (cephalohematocele of S t r o m e 3' e r), and venous cysts situated on the line of the sagittal suture and communicating directly with the longitudinal sinus. In the treatment of cirsoid aneurism many difficulties present them- selves. Injections of solutions of perchlorid of iron have been tried with fatal results from too extensive coagulation and extension of this to one of the smuses. The application of caustics has been followed by fatal hemorrhage on separation of the slough. Ligation of the external carotid artery of both sides has been followed by recurrence, owing to the free anastomosis of the arteries of the scalp with the vertebral from the subclavian through the circle of Willis to the frontal, supraorbital, and internal carotid and facial branches. Dieffenbach proposed repeated excision of fusiform portions of the scalp, each w^ound as it is made being grasped by clamp forceps or the finger of an assistant, hemorrhage being thus held in check until the application of close and accurate suturing. The wound having healed, a second portion is to be ex- cised, and so on, until a sufficient amount has been removed to cure the disease. Total extirpation of the entire aneurismal area followed by immediate cor- rection of the defect by skin transplantation holds out the best hope of cure. An elastic tourniquet should be passed around the head to hold the bleeding in check during the operation (see page 339, Prophylactic Arrest of Hemor- rhage). In cases of extensive involvement of the scalp, on account of the danger of death from hemorrhage, the method of total extirpation at a single sitting is an exceedingly hazardous one. Lipoma of the scalp occurs only in the low occipital region. Fibromas are limited, as a rule, to the frontal region, and are usually the result of hat pres- sure; they occur as hard and painful tumors. Fibromas are sometimes simu- lated by sebaceous cysts which have undergone calcification. Sarcoma of the scalp is an exceedingly rare affection. It has been ob- served most frecjuently in the occipital region. Recurrence in the cicatrix after removal is the rule. Carcinoma may occur as rodent ulcer or as proliferating epithelial carcinoma, is usually confined to the frontal region, and may appear at the site of a suppurating sebaceous cyst. THE CRANIAL BONES Contusions of the cranial bones as described by the older surgeons and considered as indications for trephining because of resulting necrosis are at the present day admitted only as possibilities. FRACTURES Fractures of the cranial bones constitute 2.75 per cent of all fractures (G u r 1 1) . The bony walls of the cranial vault are more or less compressible THE CRANIAL BONES 435 in both tlio fronto-o(Tii)ital and the l)ipan(>tal diameter. The vertical (Uameter ran also be shghtl^- altered by pressure without fracture. Experiments have 8hc)\Nn that the bone almost hivariably gives wav in the line of pressure { e transA-crse pressure gives rise to a transverse fracture and longitudinal' pres- sure to a longitudinal fracture. Fractures of the cranial bones may be the result of direct or indirect force • fractures from dn-ect force are the more common and their mechanism is very simple. Fractures from indirect force result from the transference of the force to the skull through the medium of the vertebral column, as, for instance when the patient falls from a considerable height and strikes on the feet One or more fractures of the base may follow, these radiating from the foramen magnum. Or. if the fall is on the vertex, the compressibilitv of the skull in this direction is easily exceeded, but the diploe acting somewhat as a buffer protects the vault and the force is transferred to the more ri-id and unvielding base, which is usually fractured at a point opposite the^ place of Wpact ihese iractm-es are called fractures bv contrecoup. Fractures by contrecoup were formerly believed to be very common and were thought to be the result of vibrations passing around the cranium and meetmg at the pomt at which the fracture occurred. Thev are now believed to be due to changes in the shape of the skull through the compressibilitv above referred to, the pomt opposite that at which the blow was received alt'erino- in shape to a less extent than the rest of the bony casing, and hence giving m av Even perforatuig forces ma.' produce a second fracture opposite the point of entrance of the bullet or other missile, the latter not reaching the pohit at which the second fracture is found. Fractures of the skull assume various forms, according to the degree of force and the shape of the impinging object. A sharp-edged or pointed object ..-ill be hkely to produce a splintered or comminuted fracture; one of a somewhat larger surface, a star-shaped or stellated fracture; while a stOl broader surface, such as the pavement, commg in contact ^ith the skull mav produce one or more simple fissures. These fissures may be very extensiv^, taking a course cir- cumferentially, transversely, or longitudinallv, and dividing the^cranial encase- ment into two portions. At the moment of their occurrence they gape con- sic erabl}' but close agam, imprisoning portions of the aponeurosis and even ot hair when the fracture is complicated by an external wound (compound frac- ture) The basilar artery has been found thus imprisoned. When the bone is torced inward to a greater or lesser extent this constitutes a depressed fracture I he entrance of the vulnerating object, such, for instance, as a bullet or a knife- blade, gives rise to a penetrating or punctured fracture. The latter is alwavs a compound complicated fracture and comminuted as well. All fractures of the cranial vault, including simple fissure, stellated fractures, and depressed fracture^ of greater or lesser extent, may be complicated bv an external wound (compound fracture). Certain fractures of the base maV also be com- pound, such, for mstance, as result from perforation of the roof of the orbit as well as those m which a fracture of the vault complicated with an external wound extends to the base. While a fracture of the vault may extend to the base, yet by far the greater number of combmed fractures of the base and vault take the op]3osite course, i.e., the fracture extends from the base to the vault A fracture oi the anterior fossa communicates with the air through the nasal cavity and 436 THE SURGERY OF THE HEAD a fracture of the middle fossa through the auditory canal. This i)articular feature of these fractures is frequently overlooked. They constitute a most dangerous class of hijuries. In comminuted fractures the tables of the skull do not partake of the splinter- ing process to the same extent. This occurs most freciuently at the internal table because of the fact that the greater number of skull fractures are produced by violence originating from without. In cases in which the force is applied from within, as, for instance, where a buUet passes entirel}' through the skull, while the point of entrance will show the greatest amount of splintering at the mternal table, the point of exit will reveal exactly the reverse. It therefore must be apparent that the formerly accepted theory, that the brittleness of the internal table accounts for the more general occurrence of splintering at this point, is incorrect. In the usual form of injury from without inward, the inter- nal table is splintered more than the external table, simply because the latter is affected only by the force which is applied, while the former suffers from this plus the effect of the external table driven against it. Fracture of the internal table may occur, the external table escaping. This is due to the curved shape of the cranial vault. The molecules of the bony structure are condensed on its convex surface, while the force, transmitted to the concave or inner surface, produces separation there. After the fracture of the internal table the outer unbroken table returns to its normal position. Traumatic separation of the sutures of the skull occurs, with or without fracture. Separation without fracture takes place almost exclusively at the base. Extensive fissures of the vault may communicate with one or more sutures, the line of force following the latter for a greater or lesser distance, subsequently leaving this sometimes at a right angle and ending on the surface at a place quite remote from the point where it began. Fractures of the base are almost necessarily of the fissured variety, except those in which the cavity of the skull is invaded directly, as by a bullet or other foreign body. These fissures may pass in almost any direction or invade any locality. The wings of the sphenoid bone and the pyramids of the petrous portion of the temporal bone may be considered as two systems of braces which cross the base of the skull in a transverse direction. Fissures of the base pass in a direction either in front of or behind these. Transverse fissures are more common than longitudinal ones, for the reason that a much greater force is recjuired to produce the latter. In the posterior fossa the fissure frequently involves the edge of the foramen magnum, crossing the latter, as it were, and passing in the direction of the lambdoidal suture. Or, it may cross the sella turcica of the sphenoid and reach the middle fossa, thence turning in the direc- tion of the squamous portion of the temporal bone and the greater wing of the sphenoid. Again, a short longitudinal fissure may communicate with the transverse fissure, pass into the anterior fossa, and invade the ethmoid bone at its horizontal plate, passing to the crista galli.. Finally, the fracture not in- frequently passes along the anterior edge of the petrous portion of the temporal bone and crosses the tympanum. Diagnosis of Fracture of the Sl' ])acking with compresses of iodoform gauze. Contusion and Laceration of the Brain. — These are not infrequent accompaniments of injuries of the cranial bones and are to be classed with the most important of the complications of these lesions (see page 455). In cases in which compound fracture with depression occurs to an extent sufficient to permit brain matter to escape, the latter exudes as a pulpy mass more or less mixed with blood. Clinical Course of Simple Fractures of the Skull. — Uncomplicated fractures of the skull pursue the same uneventful course as simple fractures elsewhere. A noticeable feature is the small amount of callus produced during the processes of repair. This is to be ascribed to the immobility of the fragments and the consequent very slight irritation present. This also explains the absence, as a rule, of symptoms of cerebral irritation such as would follow the presence of deposits of new bone on the inner sur- face of the cranial bones. Cases occur, however, in which disturbances of function result from the formation of bony deposits in this location; operative procedures are necessary for the relief of these. Complete regenera- tion following losses of bone, either from accidental mjury or from the use of the trephine, almost never occurs. The dura mater here assumes the function of a periosteum, though but to a minor extent, as shown by the fact that excessive formation of callus under these circumstances is almost unknown. In simple uncomplicated fractures of the cranium repair takes place Avithout any treatment other than the protection afforded by the unbroken scalp. Minor disturbances of the cerebral tissue likewise require no further care aside from that embraced in the expectant plan. Should symptoms of concussion persist, however, beyond those of a simple and temporary "stun," stimulating treatment should be instituted, such as application of artificial heat, the administration of hot alcoholic drmks m small quantities, by the mouth if the patient can swallow, otherwise through the rectum. Hypodermic injections of camphorated ether, inhalations of aqua ammoniae to stimulate the heart, and shiapisms to the surface of the extremities are also useful. The hypodermic injection of yto ^^ ^ grain of sulfate of atropm to increase the arterial pressure, and inhalations of nitrite of amyl to lessen the resistance to the passage of blood through the smaller vessels and capillaries, are also useful. Under no circumstances should ice or cold water be applied to the head during this stage. As soon as reaction is established all stimulating measures should be aban- doned; with excessive reaction a new line of treatment is indicated. Fuhness of the cerebral vessels, as indicated by the flushed face, congestion of the conjunctiva, and throbbing of the temporals, is to be met by the application of the ice-cap or ice-cold compresses. At the same time, the administration of an active cathartic, such as a powder containing 10 grains of powdered jalap, is a useful adjunct to the local treatment. The treatment of compression of the brain \Yi\\ depend on its causes. If due to clot, this should be turned out and the bleeding vessel tied if necessary. Tin: CKA.XIAL BOXKS 443 If tlie result of abscess, this should be evacuated. The cause being removed, the brain usually recovers its functions. As a rule, ligation of the vessel after remo^■al of the coagulum is not necessary; the hemorrhage will be found to have ceased. Should it persist, however, removal of a sufficient amount of bone to enable the vessel to be reached will be indicated, and may be effected in a rapid and satisfactory manner liy means of Keen ' s gouge forceps (Fig. 91). Clinical Course of Compound Fractures of the Skull. — In the absence of infection, union of a fracture of the skull complicated by an external wound progresses m all essential particulars precisely as union of a simple fracture. This is particularly true if primary' union of the soft parts takes place. WTiere union by secondar}' intention occurs, the reparati^'e process goes on rapidly and cicatrization is soon accomplished. The occurrence of septic infection, how- ever, exposes the patient to grave special dangers, such as erysipelas and phlegmonous inflammation, which may lead to meningeal and cerebral compli- cations. Suppurative osteomyelitis of the diploe and general pyemic itifection may also follow. It was formerly thought that fractures of the skull gave rise to a special danger from metastatic abscesses. It has been sho^Aii, however, that there is no greater tendency to this complication in these fractures than in injuries else- where. Pachymeningitis. — The dura mater is not readily disposed to inflamma- tion, owmg to its structure. Hence inflammation of this membrane is not a common result of head injuries; when it does occur, it is usually hmited to the place of mjury. Suppuration between the dura and the internal surface of the skull, however, as well as between the peri cranium and the external surface, leads to necrosis; this occurs the more readily when considerable splintering takes place. This suppurative process becomes the more dangerous from the ten- dency to septic phlebitis and thrombosis of the vems communicating through the dura with those of the pia mater, arachnoid, and encephalon. In the case of the first named, a leptomeningitis develops (see page 458). Though the manner of mfection described is m aU probabilit}' the most common, it is not to be denied that suppurative mflammation of both the external and the internal surface of the dura may occur, infection of the arachnoid and pia mater and consequent leptomeningitis arismg from contact through the lymph and blood- vessels. The vascularity of the last-named membranes tends to rapid spread of inflammation. Er\'sipelas may affect the arachnoid and pia mater through the medium of the lymph-channels or blood-vessels. Again, infection may occur from the foreign body which produces the mjury. or from portions of head covering or from the hair itself (see Traumatic Menmgitis. page 457). Suppu- rative meningitis is to be considered an absolutely fatal affection. Treatment of Compound Fractures of the Skull. — The first care of the surgeon should be to protect the wound itself ^^ith a gauze compress AATimg out of 1 : 1000 mercuric chlorid solution of sufficient size to fill the wound com- pletely. Next the entire scalp must be shaved and cleansed, first with soap and Avater followed by alcohol, and subsecjuently A^ith ether: lastly -^ith a 1 : 2000 mercuric chlorid solution m 50 per cent alcohol. The wound itself is now to be cleared thoroughly of all macroscopic dirt and disinfected Anth the above mentioned mercuric chlorid solution. Stress is here laid on these precautions, though they are described elsewhere, their importance being enhanced hi this 444 THE SURGERY OF THE HEAD connection by the .e;rave complications which follow failure to exercise from the very beghming the greatest possible care in the treatment of this class of injuries. The wound should be sufficiently enlarged to permit proper exploration and the removal of foreign bodies. Ocular inspection should be practised. It is not sufficient to ascertain that a simple fissure exists; hair is sometimes imprisoned in the latter and must be removed. A knife-blade or other pointed instrument may have been driven through the skull and broken off below the level of the bone. The further operative procedure will be guided by the condition found on exploration. If blood oozes in considerable quantities from the fissure, the cavity of the skull is to be entered by removal of sufficient bone for the purpose. Fig. 238. — Application oi Chisel and Mallet to the Skull in Depressed Fracture. The skull is exposed through an "X" incision. The dotted lines are intended to show the method ot making a large opening in the skull when this is required for purposes other than the removal of the iragments in depres.'sed fracture. Fragments of bone detached from the pericranium and dura are to be removed. Although the importance of depressed portions of bone in producing symptoms, of compression has been very much overestimated, they should nevertheless be brought up to their proper level, for the reason that foreign bodies, hair, as well as loose spiculas of bone, may have been carried do\\Ti with the edge of the depressed bone. Drainage of the parts is also thus greatly facilitated. A time-saving method of elevating the fragments consists in chiseling away v^dth a chisel and mallet (Fig. 238) a portion of the undepressed bone at the margin of the depressed portion to an extent sufficient to permit introduction of the elevator (Fig. 239) . With the back of the latter resting on the solid edge of the intact bone and its point beneath the fragment, a powerful lever is formed THE f'RAXIAL BOXES 445 and the depressed bone is lifted into position (I'ig. 240). It will rarely be neces- sary to remove fraji'nients permanently in cases in Avhich an asejitic course is expect chI; e\-en wlum these are lilt(>(l away for purposes of thoroup;h cleansing, they may be frequently replaced with advantage (Oilier, Mace wen). When the uijury to the cranial bones is quite extensive, and particularly when the wound has been exposed to possible infection for a long time before coming Fig. 239. — Elevator for Elevating Fragmexts in Fracture of the Vault of the Skull. nnder the surgeon's care, the fragments, if detached completely, may be removed. It will scarcely ever be necessary to employ the trephine in cases of depressed fracture. The chisel and mallet, if properly employed, will always fulfil all the indications with less destruction of bony tissue and considerable saving of time. Even fissures are to be treated operatively in order that the best results Fig. 240. — Elevation of Fragments. may be obtained. The beveled edge of the chisel is applied toward the surface of the skull and held in such a manner that the corner of the chisel cuts away the edge of the fissure at an angle. By cutting away both edges in this manner a V-shaped groove is formed which enters the diploe. Drainage of the latter is thus provided for. and all foreign bodies, hair, etc., which may have entered when the fissure gaped Avidely are thoroughly removed. The V-shaped gouge 446 THE SURGERY OF THE HEAD may be advantageously employed for this purpose. Projecting edges of bone which prevent elevation of the fragments ma}' also be chiseled away with advantage. The operative procedure being completed, the wound itself claims attention. This should be treated on general antiseptic principles if infection has occurred. The use of an antiseptic irrigating fluid is rather to be deprecated and is con- traindicated if there exists a wound of the dura. If it is employed it should be subsequently washed away with a sterilized salt solution. In place of the irrigating fluid, gauze sponges wrung out of a 1 : 1000 mercuric chlorid solution, a 2.5 to 5 per cent solution of carbolic acid, or a 5 per cent solution of zinc chlorid may be employed, if decided septic conditions are already present. In case of Fig. 241. — Removing a Portion of the Skull with the Gigli Wire Saw. injury of the brain substance, the last named is considered to be particularly efficacious (Socin). The question of drainage is an important one. The ideal method is to close the wound completely, but this presupposes an aseptic condition of the parts, of which the surgeon cannot always be certain. The gauze drain a^tII fulfil all the indications, if the simple leaving open of the most dependent portions of the wound is not deemed sufficient. If all goes well and no drain has been employed, the wound need not be disturbed for a week or ten days. If a drain has been introduced, this should not remain longer than twenty-four or thirty-six hours, at the end of which time, in the great majority of cases, the wound after being redressed may remain undisturbed for the period of time occupied by the healing process. THE CRANIAL BONES 447 In fractures at the base purely surgical measures are restricted to those which proA'ide ai2;ainst infection through the nasal cavit}' m fractures of the anterior fossa, and through the auditory canal m case there is escape of cerebro- spinal fluid, hi fractures of the middle fossa. The external auditory canal is cleansed with soap and water and a cotton probe, thoroughly washed (not forcibly- irrigated) with an antiseptic solution (the borosalicylic solution of Thiersch), and lightly packed \\ith cotton or gauze wrung out of a mercuric chlorid or carbolic acid solution. The nasal cavity is not so readily protected. This should be washed out with a boric acid solution and the anterior nares lightly packed. Pluggmg the posterior nares pro- duces considerable irritation and increased flow of mucus, which latter offers a still greater opportun- ity for putrefactive changes and hence sepsis. In addition to these measures the patient is to be placed under conditions which shall insure the greatest possible Ciuietude, and the ice-cap applied. The administration of a calomel and jalap purge and the subsequent administration of remedies to control pain, etc., are indicated. The bromids may be tried; the use of opium is not contraindicated and in some cases is useful. In extreme restless- ness and delirium doses of y-^o of a grain of hydro- bromate of hyoscin given hypodermicalh' will be found useful. Trephining. — The application of the trephine is not so frequently required m fractures of the skull as heretofore, its place being supplanted by the mallet and chisel (Fig. 238) and the Luer or Keen gouge forceps (Fig. 91). In traumatic epilepsy and in brain tumors and brain abscesses the trephine is useful in making the first perfora- tion in exploratory operations. The method of drilling holes at proper dis- tances and dividing the intervening spaces with the G i g 1 i wire saw also has its advocates (Fig. 241). The incisions necessary" to bare the sur- face of the skull in nontraumatic cases should be U-shaped, the base of the flap being preferably toward the base line of the skull. In cases of frac- ture of the vault an X-shaped incision is employed in order to permit extension of the incisions in all directions in following up lines of depressed fractures (Fig. 238). The pericranium should be lifted with the flap by means of the periosteal elevator (Fig. 239). Either Gait's conical trephine (Fig. 85), the aseptic hand trephine (Roberts, Fig. 84), or the aseptic brace trephine (Fig. 242) may be employed. The latter with its guard rings insures rapid and safe perforation of the cranial cavity. The method of its application is readily shown in the figure. Several widths of guard rings are furnished (Fig. 242. D). The widest of these, which permits the crown of the instrument to make a simple Fig. 242. — The Aseptic Brace Trephine. A A, Brace; B B, handles; C, pin detached ; C, upper sur- face of pin showing clutch; D, guard rings detached; E, crowTi, with guard ring in position; F, stem. 448 THE SURGERY OF THE HEAD groove, is first employed. This, together with the pin, which up to this time has served as an axis on which the crown rotates (Fig. 242, C), is removed, and a narrower ring permitting a still deeper groove is substituted. A turn or two of the brace suffices to bring the trephine to the full depth permitted by the guard ring. As the operator has no fear of unexpectedly perforating the cranial cavity, these movements ma}" be executed boldly and rapidh*. The guard rings are changed in a few seconds and the operator has the satis- faction of knowing, first, the exact depth which has been reached; and, second, that the groove is the same depth in its whole extent — advantages which give him greater confidence in his manipulation. The awkward and strained movements which involve considerable muscular exertion, as in the use of the hand trephine, are avoided. Each time the guard ring is changed for a narrower one, the button of bone is tapped with the handle of a scalpel or the elevator to ascertain if it is yet loosened. Osteoplastic resection of quadrangular plates of bone (J. Wolf f), though an ideal procedure, is difficult in its technic. Three sides of the square are grooved to the entire thickness of the bone by a narrow chisel, the scalp not being turned back, but simply incised, and the grooves cut at the bottom of the openings made by the incisions, the edges of the latter being retracted for the purpose. The fourth side of the cjuadrangle is broken across by prying up the piece; it, together with the flap of the scalp which remains attached to it, is raised up like a trap-door. The same procedure, with an omega-shaped flap of scalp and bone (W a g n e r) , permits a more ready fracture of the base of the bony portion of the flap, the latter being narrower in proportion to the area of the remainder of the flap. Indications for Trephining. — In addition to enlarging openings in the skull to facilitate the elevation of depressed portions of bone and the removal of fragments (which, as before stated, is best accomplished by chiseling), it becomes necessary to trephine for the removal of foreign bodies. Many of these, however, such as smooth pieces of metal, small pistol balls, etc., remain in the cranial cavity without apparent detriment, provided the patient recovers from the first effects of the injury. Instances are recorded of pistol balls that remained in the cranial cavity for years and w^ere found postmortem, the patients dying from diseases having no connection with the presence of the foreign body in the brain. Large bullets, however, and rough foreign bodies do harm. In exploring for these, after the dura mater has been trephined and incised a light aluminum probe is introduced and permitted by the force of gravity to find its way along the supposed bullet track (Fluhrer). Incision of the brain may also be practised for the purpose of further explora- tion. The telephone probe (G i r d n e r) w^ill be found to be a useful instru- ment in locating metallic foreign bodies in the brain as elsewhere (Fig. 64). The Rontgen ray should be used when available. The treatment of compression arising from hemorrhage from the middle meningeal artery has already been dwelt on. In cases in which no fracture occurs and yet the suspicion exists that rupture of the vessel has taken place from a blow on the side of the head, the bone having from its elasticity sprung back to its normal position without fracture, trephining and ligation of the artery at the point where it passes to the lateral wall of the cranial cavity are indicated. The anterior branch of the middle meningeal artery can be con- THE CRAXIAL BONES 449 veniently located as follows : Two lines are drawn at right angles to each other. Tiie one is vertically placed and is located an inch and a half in front of the external auditory meatus; the other is horizontally placed one inch above the edge of the zygoma. The point at which these lines cross each other represents the center of the middle meningeal area. In applying the trephine at this point the extreme thinness of the bone should be borne in mind. A U-shaped flap, which includes in its thickness the skin and temporal muscle, large enough to expose the middle meningeal area, is turned back and a large button of bone is removed; after the clot is turned out the vessel is exposed and secured. The opening, if not already sufficiently large to enable the bleedmg point to be reached, may be rapidly enlarged by means of Keen's gouge forceps (Fig. 91). Sometimes the bleeding point can be identified by turning back the dura by means of a spatula. If it is found that the anterior branch is not injured, the source of the bleeding must be sought in the posterior branch by applying the trephine over the parietal prominence. These failing, ligation of the external carotid artery is indicated. In cases of brain abscess, secondary trephmirig is indicated, to permit the evacuation of pus and drainage. Even the occurrence of suppurative menmgitis and cortical encephalitis A\'ill permit the application of the trephine, smce no better antiseptic or antiphlogistic measure offers. If performed sufficiently early, this may yet prove a rational method of meeting the indications in these otherwise almost necessarily hope- less cases. In focal suppurative encephalitis or brain abscess the diagnostic acumen of the surgeon is taxed to the utmost to determine, first, the existence of an abscess, and, second, its location (see Cerebral Localization, page 466). The trephine opening havmg been made at the place to which the symptoms pointed as the probable seat of the abscess, even after the use of the explormg needle and syringe no pus may be found. The great mortalit}' of abscess of the bram. on the one hand, and the fact that 50 per cent recover if success follows the effort to locate the same, on the other, will impel the surgeon to persist m his efforts when the symptoms are at all well marked. The sense of fluctuation is not always available in this situation ; absence of pulsation, though suggestive, is not to be relied on. Foreign bodies, producing symptoms of irritation of the brain, may recjuire the operation of secondary trephmmg. Broken-off knife-blades have been thus removed after the lapse of years. The occurrence of paralysis, epilepsy, and mental disturbances with a history of head injury constitutes an indication for trephining. The site of the injury is usually selected for this purpose. H u e t e r mentions an instance in which a paralysis of seven years" duration was relieved by trephining at the site of injury. A hyperostosis, together A\ith portions of lead from a pistol ball, was removed. In epilepsy following cranial injury a certain small number of mild cases are improved l\v simple excision of the cicatrix in the soft parts. Tenderness of the scar is usually present here. But by far the greater number of cases relieved by trephining are those having depressed portions of bone and thickening at the site of the injury. The pro- liferation may not always be demonstrable until a button of bone has l^een removed. Though many of the successes reported have been l^ut temporary. 3-et the impossibility of cure b}' other means fully justifies the attempt at cure ly\^ operative means, when a clear history of injury can be obtained (see Surgical Epilepsy, page 471). 30 450 THE SURGERY OF THE HEAD GUNSHOT INJURIES OF THE HEAD The traumatism of the bullet in this region differs from that arising from any other cause, for the reason that, no matter how apparently slight the injury, the element of concussion always enters largely into the case. The symp- toms therefore are those of concussion (even if the bullet does not enter the head), followed by those of fracture, and finally, in severe cases, of laceration of the brain. The first effects of concussion in gunshot injuries of the head are manifested in the oblongata; the respiratory center is at once inhibited or aVjsolutely paralyzed. The physical influence of the bullet on the encephalic contents is a hydrodynamic one (K r a m e r and H o r s 1 e y) . Other centers likewise suffer, their functions remaining suspended until the general effects of the concussion have passed off. In moderate concussion the heart's action may be retarded; in severe concussion, accompanied by lacera- tion of brain tissue, it will be accelerated from paralysis of the vessels and loss of vascular tone. The missile from a modern rifle will rarely lodge in the cranial cavity, but the ordinary pistol bullet will often do so. Where the bullet enters and emerges the wound is called a perforating wound; where the bullet enters but does not leave the cavity of the skull, it is called a penetrating wound. The secondary symptoms of gunshot injuries of the head are of so varied a character as to be entirely untrustworthy in locating the bullet. In conducting the examination of a case of gunshot injury of the head, when a fractui'e is found but no evidence of perforation exists, the possibility of the bullet's having entered the cranial cavity between a depressed fragment and the adjoining sound bone, the former having sprung back from its natural elasticity, should be borne in mind (B e r g m a n n). Or a portion of a bullet may pass in this way, the remaining portion lodging beneath the scalp (case in my ovm practice). Another fallacy may arise from a separation of the bullet into two portions, one portion escaping through an opening of exit, the other remaining. A\Tien the bullet enters from the direction of the cavity of the mouth it may lodge in the nasal fossa or in one of the accessor}^ sinuses. It may glance off from the bony structure of the base of the skull at the back of the pharjTLX and finally lodge in the ca%dty of the mouth. Or. it may pass either into the esophagus and be swallowed, or through the glottic opening, lodging finally in the larATix, the trachea, or the bronchus. In gunshot injuries of the facial region the bullet may pass from below through the accessory sinuses and reach the cranial cavity; or it may stop short of the latter, in which case the missile may usually be traced by the telephone probe and its removal effected. Occasionally a case is observed in which a would-be suicide places the muzzle of a pistol to the ear, in the belief that access to the cranial cavity is more easily effected by this route. In a case of this kind, during my service at the Methodist Episcopal Hospital, an injury of the internal carotid artery in the carotid canal occurred, the walls of which had been crushed in by a bullet, the presence of the latter, however, preventing hemorrhage. Upon removing the missile a violent hemorrhage took place, necessitating ligation of the common carotid arterv. THE CKAXIAL BONES 451 The fallacy arising; from the simultaneous reception of other injuries which subseciuently "•ive rise to symptoms of intracranial disturbances should not be lost sifi'ht of. The bullet may penetrate the skull and \-et not pass through the dura mater. The missile may be found resting on the dura, or lodged between the dura and the inner table of the skull at the site of the wound, or at a point more or less remote from the original point of entry. This may occur in the case of a "spent ball," or one that has lost most of its projectile force immediately after entering the skull. In these cases the bullet may not be accessible to the probe, and may be discovered only by the Rontgen rays or after trephining. The dura mater may be injured by the splintered fragments of the skull, the latter being driven into the substance of the brain, the bullet assuming an extradural location. The missile may pass but a short distance into the brain substance, where it may be identified after trephining and enlarging the opening in the dura. When both tables are broken the greatest amount of damage is inflicted on the inner table; this is according to T e e v a n ' s law, that the fracture com- mences in the line of extension rather than in the line of compression, the internal table receiving the force of the bullet, plus the force conveyed by the outer to the inner table. In perforating wounds the force at the point of exit is applied from within and the outer table is more extensively splintered. Hence, the wound of exit is larger than that of entrance, A bullet in its passage through the skull produces radiating tears of the brain, substance, these being more marked in the gray than in the white substance (T i 1 1 m a n n s). In addition to the missile and bone splinters, portions of hair, etc., may be present in the brain substance. The probable direction taken by the ball, as based on the position in which the firearm was held at the time of the shooting, should be considered, as well as an inspection of the opposite side of the head made for the presence of bulging or other evidences of fracture. The ball may strike the opposite side of the wall at right angles to the surface or within 15 degrees of it and lodge at the point of impact (Ruth). Fluhrer, Delbet and D a g i o n claim that a ricochet takes place in some cases, the deflected bullet taking a secondary course in the cranial cavity. According to R u t h , when deflection does occur, it is almost invariably at right angles of more than 90 degrees to the angle of incidence. In probing for a bullet lodged in the cranial cavity the instrument used should ha^'e a spheric tip, and in order to minimize the friction arising from its contact with the collapsed bullet track and to insure that all resistance to be appreciated by the hand manipulating the probe is communicated from its tip, the tip should be mounted on a slender shaft. For the larger sized missiles a probe tip one-fourth of an inch in diameter will suffice for bullets from .32 caliber up, and one three-sixteenths of an inch in diameter will follow the track of a bullet from one of the smaller firearms. The extreme limit of force em- ployed in the case of the first named, in order to guard against driving the tip of the probe into the brain substance or between the convolutions, is from two and one-half to three ounces (R u t h) . In order to determine the exact amount of force employed, the graduated pressure probe may be employed (Fig. 243). The handle of the instrument is hollow and slides on the stem against the 452 THE SURGERY OF THE HEAD pressure of a spiral spring. An indicator on the stem and a scale marked in fractions of an ounce on the handle serve to record the force existing. As long as the probe is following the bullet track, the pressure to propel it is conve3'ed through the medium of the spring, and this is recorded. As soon as the limits of the spring have been reached, as shown by the indicator, the danger-point has been reached and the probe must be partially withdrawn and its course changed. The stem of the instrument is insulated with a coating of rubber and has a connection by means of which it can be attached to a telephone receiver and used in connection with the Girdner apparatus (Fig. 164). As soon as the tip of the instrument comes in contact with the bullet, a distinct click is heard in the receiver. In the treatment of gunshot wounds of the head the first care of the surgeon will be to bring about reaction, and in case of respiratory failure, to make artificial respiration. In the meanwhile the head is to be shaved and every aseptic preparation made. The scalp is to be turned back to expose the opening, the latter enlarged, splintered bone removed, hemorrhage arrested, and the dui'a examined. If the bullet lies on the latter, it is to be removed wdth the dressing forceps. If there is an opening in the dura, the bullet is to be sought for beneath this. The direction from which the shot was fired having been ascertained, the surgeon will be in a position to calculate the probable direction which the bullet track takes in the brain. If the bullet is located near Fig. 243. — Graduated Pressure Bullet Probe for Braix. the wound of entrance, it is to be removed with forceps. If located nearer the opposite side, a trephine counter-opening is to be made, and, with the probe held in position by an assistant, the surgeon may explore through the counter- opening, passing through the brain substance a fine steel needle with the sharp point ground off. When the proper direction is ascertained and the exact location of the bullet identified, it may be removed through an incision. It should always be borne in mind that the surgeon may do more harm by ill directed efforts to locate and remove the bullet than will probably result from the presence of the latter. Many surgeons are contented with clearing away the bone splinters and foreign debris at the wound of entrance and instituting tube drainage along the wound track. If the graduated pressure probe with telephonic attachment fails to locate the missile, the operative effort should terminate with the introduction of a soft-rubber drainage-tube and the dressing of the wound ; further interference should be postponed until localizing symp- toms arise. Bullets frequently become encysted and give rise to no further trouble. NONTRAUMATIC INFLAMMATION OF THE CRANIAL BONES Acute infectious osteomyelitis and tuberculous inflammation of the bones of the skull may iDoth occur. The last named, though of infrequent occurrence, is not bv anv means so rare as the former. In tuberculous THE CRANIAL BOXES 453 inflammation of the cranial bones the apphcation of the trephine in such a man- ner as to remove one or more buttons of bone, and in an area sufficient to include healthy bone as well, is preferable to curetment, in order to secure a permanent result . S}philitic caries and syphilitic necrosis of the skull are rather more frequent than tuberculous disease of the cranial bones. The}' occur in con- junction with the breaking down of a syphiloma or syphilitic gumma. The external coverings of the skull may ulcerate first, showing a necrotic external table, or the gumma may break down in the substance of the bone and reach the inner table. The latter condition is one of caries, and the former a necrosis, both of which may occur at the same site. Under an antisyphilitic regimen the smooth, white, external table of the skull, which appears at the bottom of the syphilitic ulcer, is gradually replaced by little islands of granulations which spring up from the underlying diploe and find their way to the surface of the outer table. Occasionally the bared portion of the outer table is lifted up en masse by the underlying granulations. In cranial bones bared by accident or in the course of plastic operative procedures the same process of repair occurs. This process, formerly known as insensible exfoliation, is now known to be result of the tendency of the granulations to dissolve the bone. Exfoliation of the entire tliickness of the skull may also occur as a result of syphilitic necrosis, in which case pulsation of the brain may be recognized after separation or removal of the seciuestrum. Syphilitic osteoma results from a sclerosed condition of the bones of the skull in which the syphilitic deposit, instead of proceeding to suppuration and softening, pursues the opposite course. Suppurative inflammation of the medullary substance of the bones of the skull occurs almost exclusively in connection with diseased conditions of the mastoid and will be described in connection with inflammations of the ear (see page 583). The ridgelike prominences wliich are sometimes obserA-ed along the lines of the sutures and are easily felt by the fingers are due to rachitic disease of the cranial bones. Likewise the persistence of open fontanels is of rachitic origin, showing an irregularity in the development of the cranial bones which pro- liferate from the suture lines. Craniotabes is a condition observed in rachitic children in which limited areas in the cranial bones undergo softening and absorption. Such spots yield under the pressure of the finger and feel like wet parchment. They occur most frequently over areas subjected to pressure, like the parietal and occipital regions, but they occasionally appear in the frontal bone. Rachitic softening of the periosteum also occurs, which on slight injury leads to extravasations of blood between the bone and the periosteum resembling a cephalhematoma of the newborn. TUMORS OF THE CRANIAL BONES Tumors of true congenital origin must be very rare, as none are on record. Cephalhematoma, however, resulting from prolonged pressure on the head during labor, is not uncommon. This differs from the so-cafled caput suc- cedaneum, which, while of similar origin, consists of a general edematous swelling from venous stasis. Cephalhematoma, on the other hand, consists of 454 THE SURGERY OF THE HEAD an extravasation of blood between the pericranium and the bone. Extra- vasation between the cranial l^ones and the dura mater has been found in the cadaver of the newborn, simultaneously with cephalhematoma. If the effused blood of a cephalhematoma is not resorbed in the course of a few weeks, the elevated periosteum proceeds to the formation of new plates of bone and a parchment-like crepitation is felt beneath the palpating finger. These bony plates may persist and finally inclose the fluid in a true cyst with bony walls. The treatment of cephalhematoma in cases in which no perceptible diminu- tion occurs under the use of evaporating lotions continued for a fortnight, consists in evacuating the contents by means of a puncture with a thin-bladed scalpel, under strict antiseptic precautions. The fluid will be found to be chocolate-colored and devoid of fibrinous clots. Aspiration of the fluid is also recommended. Finally, free incision may become necessary in order to effect a cure. Firm compression by means of semielastic bandages should follow either puncture or aspiration. A conve- nient pressure bandage may be made from ordinary domestic flannel, the strips being cut on the bias. Cranial pneumatocele is a name given to a diffusion of air between the pericranium and the bone. The air finds its way into this abnormal position usu- ally through some defect in the cancelli of the mastoid portion of the temporal bone. Owing to the fact that the air is filtered through cavities lined with mu- cous membrane, bacterial infection and inflammation do not necessarily follow. Acts of sneezing may be the exciting cause of the condition. By firm ban- daging the air can sometimes be forced from its position, escaping through the Eustachian tube. ITsually, however, recurrence takes place. Where, as some- times occurs, the entire scalp becomes "ballooned," evacuation by means of the trocar may be necessary. The repeated injection of tincture of iodin has proved successful and should be tried. Chondroma of the cranial bones is a very rare affection. Osteoma of the frontal sinuses is described elsewhere (see page 518). Syphilitic osteoma has been already discussed (see page 453). Sarcoma of the cranial bones originates from the diploe. It usually pro- ceeds toward the surface. Those sarcomatous growths which involve the dura generally have their origin there. The prognosis is very grave and extirpation is usually followed by recurrence. The orbit is frequently the seat of sarcoma (Fig. 244). The nasopharynx is also a favorite location, whence the growth may extend to the nasal fossa and into the pharjoix, or perforate the base of the skull. Sarcomas arise in the mucoperiosteal structures in this locality. Their growth is accompanied by intense headache and sometimes by profuse epistaxis. Fig. 244. — Sarcoma of the Orbit. THE BRAIN 455 THE BRAIN Contusions of the Brain.— The.se are the result of external violence transmitted from tlie skull to the brain, the skull itself being simultane- ously injured. Direct injury without involvement of the skull takes place exceptionally at the apex of the orbital cavity; it is possible, however, for only very small objects to enter at this point without injurv' to the bone. Sudden changes in the shape of the skull, the latter returning at once to its original shape, fractures, and other injuries of the bony capsule, may produce solutions of continuity of the brain ti.ssue. Contusions are more frecjuenth^ observed than incised or lacerated wounds, owing to the nonresisting character of the brain substance, which transmits the vulnerating force in all directioiLS. The extent of the damage inflicted will vary from merely punctate hem- orrhages in one or more areas to the crushing of an entire lobe with pulpifica- tion of the brain substance in which fragments of bone may be embedded, and extensive hemorrhage. Or, extensive ruptures located in different areas of the brain (multiple lacerations of the brain) may be present. Contusions occur with the greatest frequency at the base; in spite of this the pons varolii, crura cerebri, and medulla oblongata often escape injury. Contusions and lacerations of the brain follow a course corresponding to the extent of the damage inflicted. The symptoms ma}^ be transient, recover}^ taking place in a few days, or permanent lesions may result in more or less permanent impairment of function, ^lany weeks or even months may elapse before the paratyses and psychic disturbances disappear. In other cases abscesses of the brain may follow. In cases in which recovery has apparently taken place impairment of memor}' may exist, and psychic disturbances, epilepsy, etc., develop. Again, in the unfavorable cases the paralyses may be permanent, encephalitis and cerebral softening from fatty degeneration of the vessels finally destroying the patient. Slight contusions of the surface may result in but little apparent disturbance of the functions of the brain. But grave symptoms may arise from severe contusions and lacerations. The latter, occurring at the base in the posterior fossa, are almost without exception immediately fatal on account of the im- portant ner\'Ous centers essential to life that are involved in the injur\^ SUght contusions and lacerations occurring anteriorly may interfere simply with the functions of the optic and olfactory- nerv'es. Disturbances of the motor oculi and abducens may also follow. One of the symptoms peculiar to laceration of the brain is the tendency of the patient to lie on the affected side, with the knees drawn up and the head and shoulders depressed. This peculiar position, in which nearly all of the flexors of the body take part, has never been satis- factorily explained. After recover\' from the immediate effects of contusion and laceration of the brain, certain symptoms of a more or less chronic character occur. These include paralysis of both motion and sensation in the upper and lower extremi- ties. Other important symptoms are the following: Amnesia, or loss of memory-; aphasia, or incoordination in speech; and agraphia, or inability to express language in writing (see Cerebral Localization, page 466). Repair takes place through the medium of the connective-tissue elements 456 THE SURGERY OF THE HEAD and vessels of the pia mater. Regeneration of nerve-cells, and probal^ly of nerve-fibers, does not take place (T s c h i s t o w i t s c h) . The process of repair may occupy weeks, or even several months. In cases which survive the immediate effects of the injury degenerative processes ("yellow soften- ing") may occur, ha^'ing but few or no symptoms at first and proving suddenly fatal at the last (traumatic late apoplexy). Wounds of the Brain. — Wounds of the brain are to be distinguished, for purposes of study, from contusions of the brain, in that, in the former the lesions take place in conjunction with closed (simple) fractures and similar injuries, wdiile in the latter the injury of its encasement is an open one, or one which effects a communication between the exterior surface and the brain. They may be classified as contused, punctured, and lacerated. Wounds of the brain may occur from force bluntly applied, from sharp objects, or from both coincidentally applied, as, for instance, when a blunt object produces a fracture of the skull, a splintered fragment causing a wound of the brain. Or, a sharp object may produce a contused wound of the brain, the outer bony structure neutralizing the force at the diploe and the splintering of the latter causing the brain injury. If the patient survives the immediate effects of the injury (shock and hemorrhage) the future course of the case will depend more on the occurrence of infection than on all other circumstances combined. With the invasion of the traumatic area by pus microorganisms suppurative inflammation develops and encephalomeningitis results. This is usually progressive in character. Exceptionally, in cases in which opportunity for drainage is afforded through the existing wound, the infectious inflammatory process may remain localized and healing take place. Or, with the arrest of free escape of pus from the damaged area retention occurs and an abscess results (acute traumatic corti- cal abscess, K r o n 1 e i n). Intracranial Hemorrhage. — The predominating symptoms in cases of intracranial injuries are those arising from the escape of blood from the vessels. Extradural Hemorrhage. — This may take place with or without fracture of the skull. It usually occurs from rupture of one of the branches of the middle meningeal artery, the blood escaping between the dura and the skull. Local compression of that part of the brain lying near the artery will be the first symptom, and diminution or loss of power on the opposite side of the body will follow. The most important feature is the occurrence of a well-marked interval of intelligence, after the first concussion, between the reception of the injur}^ and the supervention of symptoms pointing to pressure on the brain svibstance, such as interference with motion or speech if the effusion of blood is opposite a portion of brain presiding over these ; or hemiplegia, stupor, coma, and irregu- lar and automatic movements. In addition to the above, there will be con- traction of the pupils, followed in the later stages by- dilatation. When the compression is local, the pupil may be dilated and immovable. In a right- handed person aphasic symptoms occur in injury of the left side. The pulse is slow and full at first, but becomes more rapid as compression increases. The breathing, at first quiet, becomes stertorous, and convulsions may occur. The hemorrhage may cease spontaneously, the dura, as it is crowded away from the skull by the effused blood, making pressure on the point of rupture. Mental THIO BRAIN 457 disturbances will persist, however, until the clot is resorl)cd, and traumatic (Jacksonian) ej)ilepsy may result from the irritation arising from the presence of the scar. Subdural and Subarachnoid Hemorrhage. — Bleeding in these situations is often combined, and when the hemorrhages occur separately it is impossible to differentiate them clinically. In most instances the arachnoid is torn and the effusion of blood takes place in both the subdural and the subarachnoid space. Exceptionally, a true subdural hemorrhage is caused by injury of one of the sinuses of the dura mater, or by a coincident rupture of the middle meningeal artery and dura just after the vessel enters the skull at the foramen spinosum. A true subarachnoid hemorrhage may follow rupture of the vessels of the pia mater without a tear in the arachnoid. If the escape of blood from the injured vessel is rapid, and this is usually the case, symptoms of pressure appear quickl3^ The lucid interval so character- istic of extradural or subcranial hemorrhage is absent, the symptoms of con- cussion merging into those of compression. In the exceptional instances in which the hemorrhage takes place slowly, the cerebrospinal fluid is gradually displaced by the effused blood, and symptoms of disturbance of brain functions are delayed in their appearance. In subdural hemorrhage the blood tends to gravitate in the direction of the basal ganglia, and pressure in this locality gives rise to general compression, rather than to special symptoms, the respiratory center becoming involved early. Intracerebral Hemorrhage. — Nevertheless, hemorrhage from the vessels of the pia takes place in cases of contusion and w^ounds of the brain. It is impossible to differentiate clinically this variety and the jd receding except by operation. Intraventricular Hemorrhage. — Hemorrhage into the lateral ventricles can take place only as the result of very extensive injuries; hence it is of rare occurrence. Coma sets in early and a rapidly fatal termination follows. (For foreign bodies in the brain, see page 449.) The Diagnosis of Brain Injuries. — This is based almost exclusively on the localized cerebral symptoms (Cerebral Localization, see page 466). Special difficulties in the interpretation of these are present, however, due to the following: (1) the manifestaton of concussion and compression masking the other symptoms; (2) the presence of multiple and differently located lesions; (3) complex symptoms resulting from extensive injuries com- bined with intrameningeal hemorrhages; (4) the presence of localized injuries which give rise to no topical symptoms; (5) the rapid supervention of in- fection with its accompanying s3miptoms (see Traumatic Meningitis; also Fractures of the Skull). Traumatic Meningitis. — This is alw^ays the result of infection, most frecjuently from the presence of Streptococcus pyogenes and Staphylococcus pyogenes aureus (Mace wen). Infection takes place almost exclusively from the external surface of the body. It may follow directly after the injury (early meningitis) or develop later (late meningitis). The first occurs in connection with the reception of the injury or in the course of the healing of the wound. The late form may appear weeks or even months afterward; its occurrence is favored by the presence of splinters of bone, foreign bodies, and other sources of irritation. The pia mater and arachnoid are more com- 458 THE SURGERY OF THE HEAD monly involved (leptomeningitis) ; in these the spread of the infection is rapid. Traumatic inflammation of the dura is comparatively rare and is usually limited to the place of injury (see page 443). Symptoms. — In cases of early meningitis the symptoms are usually masked by those of the injurv, and in late cases it is difficult to distinguish them from those due to complicating inflammatory conditions, such as suppurative en- cephahtis, abscess of the brain, etc. In cases in which it is possible to separate the symptoms, these will include chills, fever, headache, nausea and vomiting, contracted pupils, restlessness followed by delirium, and stupor succeeded by coma. Encephalitis is always an accompaniment of suppurative meningitis. Under these circumstances the inflammation follows the pia and affects only the superficial portion of the convolutions. The extensive character of the inflammation here contributes largely to the fatal result. In addition to cor- tical encephalitis there occurs a suppurative inflammation of the deeper por- tions of the brain, circumscribed in character, constituting abscess of the brain (see page 460). Diagnosis of Meningitis and Encephalitis. — The occurrence of intra- cranial inflammation, particularly of a suppurative character, is accompanied by a sudden rise of temperature, and the onset of severe cephalalgia at or near the seat of injury. A chill may or may not precede the temperature eleva- tion. In examination of the wound care should be taken to exclude erysipelas of the scalp and phlegmonous inflammation between the aponeurosis of the scalp and the pericranium, by ascertaining the presence or absence of the characteristic edematous swelling of the one, or the combined tenderness and swelling of the other, if, indeed, these have not preceded the intracranial inflammatory involvement. The symptoms of the one may overlap those of the other. The next characteristic symptom is gradual loss of consciousness. This course marks a rapid involvement of the cerebral surface and the cortex of the hemispheres. Cases less rapid in their development show paralysis of the side opposite the injury and convulsive movements. When the dura is exposed through an opening in the skull, it has been suggested that increase of the pulsation of the brain is a sign of commencing intracranial inflammation. The accumulation of serum or pus, however, increasing the tension and forc- ing the dura against the edges of the opening, will lessen the visible pulsations. This latter symptom is not trustworthy, particularly in focal suppurative encephalitis (brain abscess), for the reason that the latter has been shown to be present in conjunction with pulsation ; on the other hand, a number of conditions may exist, exclusive of brain abscess, which lead to absence of pulsations. The occurrence of convulsive movements of the ocular muscles indicates the existence of a basilar meningitis. The fever of meningitis and encephalitis is usually of a continuous charac- ter; variations, if any occur, are not extreme. If repeated chills occur, or well-marked exacerbations of fever are observed, pyemia is indicated. Death may take place in twenty-four hours from the commencement of the attack or be postponed for several days. Meningitis of traumatic origin and cortical encephalitis cannot clinically be separated from each other; hence, the symptoms in the above description have been grouped together. THE BRAIN 459 Abscess of the brain is marked by a slow development, the symptoms pointing to disturbances of function of separate portions of the brain and localized headache. In the beginning the fever is not very decided, chills are absent, and morning remissions are the rule. Twitchings or convulsive movements in either the upper or the lower extremity of the opposite side ma}'' occur; peripheral paresis or paralysis of an entire extremity or of sepa- rate groups of muscles of the same sjde is observed (see Cerebral Localiza- tion, page 466). The symptoms are progressive in character until the sup- purative focus enlarges sufficiently to reach the surface, when it either passes beyond the established boundary wall and infiltrates the surrounding brain tissue, or a violent septic meningitis sets in. In either case, death soon fol- lows (see Abscess of the Brain, page 460). In differentiating meningitis and cortical encephalitis on the one hand, and abscess of the brain on the other, the time of the occurrence of the symptoms should be considered in their relation to the injury. An inflammation which occurs during the first week usually indicates the former; a later and gradual development, the syhiptoms being of the character above described, is indicative of the pres- ence of cerebral abscess. Should the case be seen sufficiently early an ex- ploratory operation is indicated in view of the hopelessness of this class of cases when purely expectant treatment is followed. The prognosis of traumatic meningitis is always unfavorable and the treatment in the main unsatisfactory, owing to the opportunities offered for the spread of the infection on account of the anatomic structure of the pia mater, its extensive ramifications and the rigid bony encasement of the inflamed parts and consequent early pressure on vital organs. The efforts of the surgeon will be directed mainly to its prevention by the exercise of a most thorough and rigid aseptic regime in connection wdth all cases of compound fracture of the skull or wound of its coverings. With the first sign of infection the wound should be opened up freely and the surrounding tissues drained. If meningitis develops, prompt measures must be taken to limit the infectious process by giving exit to pent up secretions, removing blood-clots, and instituting drainage. To accomplish this the opening in the skull must be enlarged if necessary, and the dura incised to expose the pia mater as much as possible. Hernia Cerebri (Acquired Encephalocele).— By this is meant the escape or protrusion of brain substance from the cavity of the skull. It occurs most frequently in connection with gunshot wounds and compound fractures with loss of bony tissue. It may follow extensive operative attacks on the skull (craniec- tomy, etc.). The immediate and instantaneous occurrence of gaping of a simple fissure may permit brain substance to escape when this takes place in connection with a tear in the dura mater. Syphilitic caries and necrosis rarely give rise to it. Hernia cerebri may be primary or secondary. In the primary cases the brain substance may pour out at once. It is usually accompanied bj" a flow of cerebrospinal fluid, which may continue for several hours. In cases of secondary hernia cerebri the protrusion may occur in the first week following the injury or it may be delayed for several weeks (cerebral prolapse). Here the portion of brain not separated at the time of injury is gradually protruded from the opening in the dura and skull. The cause of the protrusion is an abnormally high intracranial pressure due to the inflammatory processes and 460 THE SURGERY OF THE HEAD their products (exudates, pus, etc.). In cerebral prolapse the protruding mass slowly increases in size until it attains the size of a walnut or is even larger. Distinct pulsation is usually present. The mass soon loses the normal ap- pearance of the lirain surface, if this has not been destroyed at the time of the injury, and becomes dark or black and softened and necrotic. The diagnosis may be usually made on the gross appearances. In case of doubt microscopic examination should be made. Extensive granulations due to ulceration of the surface of the brain may cause a fungous and bleeding mass (hemorrhagic granuloma) to protrude from the wound and simulate hernia cerebri {vide infra). The prognosis will depend on the amount of brain substance extruded, the importance of function of the part lost, and, above all, the occurrence or non- occurrence of infection. Death usually takes place from septic encephalo- meningitis, a cerebral abscess developing behind the protrusion. In the absence of infection the mass is cast off, the remaining portion shrinking until it disappears in the cranial cavity. Treatment. — Shaving off the prolapsed mass with or without subsequent cauterization is recommended. Attempts to cover in the prolapsed mass by a plastic procedure, consisting of transplanting a flap attached by a pedicle, have succeeded (Adams, K o c h e r). Hemorrhagic Granuloma. — This is also due to infection arising usually from the presence of splinters, foreign bodies, or other sources of irritation occurring in an open wound of the skull. The granulations spring from an ulcerated area on the surface of the brain. The protruding mass may be the size of a walnut or larger. It is soft, pulsating, bends readily, and may contain small suppurating foci. Microscopic examination may be necessary to distinguish it from hernia cerebri (vide supra). Its removal, together with splinters of bone, foreign body, or necrotic tissue that may be present, is usually followed by cure. Abscess of the Brain. — Abscess of the brain arises from (1) traumatism (traumatic abscess of the brain) ; (2) disease of the ear (otitic brain abscess) ; (3) infections from the nasal cavity ; (4) infectious processes on the skull (osteitis, caries, etc.) ; (5) metastasis from a distance (metastatic brain abscess). Traumatic abscess may be divided into the acute and chronic forms. The acute form is due to an open injury of the skull, usually a depressed frac- ture with injury of the brain. The pia mater is also more or less infected, as a rule (leptomeningitis, see page 458). The latter, if it assumes the diffuse purulent form, will usually prove rapidly fatal. In more favorable cases the infectious process is limited to the seat of injury. The wound of the scalp presents the characteristic appearances of infection, and the usual constitutional manifestations of sepsis are present. Treatment. — Removal of depressed portions or splinters of bone, foreign bodies, such as hair, pieces of the vulnerating object, etc., and thorough dis- infection of the surroundings (see page 432), should not be overlooked in the prophylaxis. Efficient drainage should be provided for. The simple lifting up of a neglected depressed fragment which has prevented the escape of pus has saved many lives after infection had occurred. Even with traumatic men- ingitis present (see page 457) the case is not necessarily hopeless. The removal of infected diploe, exposure and incision of the pia mater, with the THE BRAIX 461 evacuation of purulent material and thorough drainage, may save the patient. Chronic Traumatic Abscess of the Brain. — The chronic form may follow the acute as a result of the extension of the infection in this direction. An acute abscess lasting for from three to five weeks may be said to have become chronic. The pus caA-ity is usually seated in the medullar}- substance and tends to point either toward the surface through the cortex or. in the case of abscess of the frontal and parietal lobe, toward the lateral ventricle. In the case of abscesses wliich tend to peri'orate the cortex, the presence of adhesions at the site of the original injur}- and infection may prevent purulent extravasation beneath the pia mater. The lodgment of foreign liodies carr\-ing infection into the brain substance is the usual cause of their occurrence. Brain abscess which occurs at points comparatively remote from the original point of infection, with intervening normal brain tissue, are probably due to thrombo- phlebitis of a sinus. A chronic abscess is usually lined with a yellowish- white capsule, made up of a layer of connective tissue (the pyogenic membrane of the older writers), and may remain encapsulated for a considerable time, this sometimes extend- ing over a period of months, or even years, and involving a whole lobe or even an entire hemisphere without producing definite symptoms; extension of infection usually takes place, however, each step in its progress being marked by a fresh attack of encephalitis and the formation of new and adjacent foci. Exceptionally, in favorable cases these become included in the original ca^-ity. In the absence of a well-defined capsule a rapid increase in the size of the abscess takes place: this, occurring in the direction of the cortex and before adhesions form at the site of the pia mater, leads to diffuse and rapidly fatal meningitis. From three to six weeks are recjuired for the development of the capsule. Symptoms. — In chronic traumatic abscess of the brain the primary cerebral symptoms var}- in different cases from those apparently due to concussion to well-defined focalized manifestations according to the site of injury. In a typic case these subside, and the patient apparently recovers. The latent period which foUows may be marked by exacerbations of fever, some confusion of thought, mental irritability, irrational acts, headache, and diz- ziness. After the latent period the secondary symptoms appear. These also var\- greatly. There is usually fever, though this is not a pathognomonic symptom, since it may occur in diffuse meningitis. The occurrence of a chill is not a constant symptom. The headache, which is referred to the injured region, usually becomes intensified, jDarticularly m certain movements of the body. Neuralgic pains in the distribution of the fifth ner^-e are present, as a rule, and constitute a ver\- suggestive symptom in this connection. In- crease of the symptoms is due to variations in cerebral pressure, and increase of fever is coincident with extension of infection and the occurrence of fresh suppuration. The symptoms subside and reappear until the so-caUed terminal stage is ushered in. With the advent of this extension cerebral edema occurs, and death takes place from this cause or from rupture into a ventricle. Diagnosis. — This must rest largely on the histor\- of apparent recover^' from the injur\-. the intervening latent or semilatent period, the super^'ention 462 THE SURGERY OF THE HEAD of the secondary symptoms, and, finally and chiefly, the localizing mani- festations (see page 466, Cerebral Localization). The appearance of pus flowing from a fissure, or from between two fragments, in cases in whicli the wound remains unhealed, together with a septic condition of the latter, will demand investigation. Pyemia is to be excluded if chills are absent or in- frequent and atypic, and if there are no other manifestations of this condi- tion present, as joint involvement, etc. Treatment. — The invariably fatal termination to which chronic trau- matic abscess of the brain leads, unless evacuated, imperatively demands operative interference. In doubtful cases presenting evidences of a grave intracranial condition, it is better to make an exploratory investigation than to defer interference until there is but slight or no hope of the patient's recovery. Drainage must be obtained at all hazards. This may follow on the removal of a fragment of bone. If evidence of pus is not obtained by this procedure, or its escape is not deemed sufficiently free,- the ojoening in the skull is to be enlarged. The dura must be incised if this is tense, or pressed outward, or if pulsation is absent. The dura may be discolored or gangrenous in appearance. If these signs are not found, and if there are no evidences of an abscess on opening the dura, the cerebral tissue itself should be thoroughly explored. Otitic Cerebral Abscess. — Abscesses of otitic origin follow chronic otitic suppuration in the vast majority of cases. The infectious process usually has its origin in caries of the attic, the suppuration extending thence through the roof of the tympanic cavity. Or, the suppurative process may spread to the mastoid antrum. In the latter case the pus accumulates in the mas- toid cells, with possible perforation of the outer bony layer, or an extradural abscess may form from infection of the lateral sinus. The suppuration may extend beneath the tentorium and form a cerebellar abscess. With symptoms of mastoiditis present in a case of abscess of the brain of otitic origin, there- fore, either an extradural abscess from infection of the lateral sinus or a cere- bellar abscess exists. In the absence of mastoiditis the suppuration focus is most likely to be found in the temporal region. Both conditions may coexist, however. Diagnosis. — The signs of intracranial suppuration (remittent temperature variations and increased intracranial pressure) are present in otitic abscess, whether situated in the cerebrum or the cerebellum. In suppurative mas- toiditis with intracranial complication the attacks of fever are intermittent and of short duration and the period of freedom longer. Intracranial sup- puration gives rise to headache and vomiting from increased and varying intracranial pressure. The headache is subject to evening exacerbations, with rise in the temperature. It may be. increased by percussion on the affected side. An attack of vomiting may be produced by a sudden change in the position of the patient. Choked disc, also due to the latter, is present, and is a valuable diagnostic sign. Distinctly focalizing symptoms are absent in the great majority of cases. Treatment. — The abscess cavity must be evacuated and drained. In the case of abscess in the temporal lobe, this may be reached through the antrum and tympanic cavity (8 c h w a r t z e and S t a c k e). Or, the suprameatal fossa and squamous portion of the temporal bone may be exposed by turning THE BRAIX 463 up a flap between the middle and the posterior vertical line of K r 6 n 1 e i n (Fig. 245). These lines of incision are joined by a third commencing at the top of the tragus and crossing above the i)inna. A rectangular opening is made in the bone corresponding to the exposetl area. This opening, extended anteriorly, will expose the neighborhood of the Gasserian ganglion ; if extended backward, the groove for the transverse sinus can be reached. It will also permit exploration of the usual site of otitic cerebellar abscesses. The opening in the abscess, if such already exists, is to be dilated bluntly and a drainage-tube introduced. Drainage should be maintained long enough to insure complete emptying. If cerebral prolapse occurs, lhis is due either to a reaccumulation of pus, or to a collection of cere- ^ brospinal fluid in an ad- jacent ventricle. In case of the latter lumbar puncture is recommended (K r o n 1 e i n). Cerebral Abscess of Nasal Origin, — TMs is caused Ijy suppuration in the upper nasal spaces and their accessory cavi- ties. The infection may reach the brain by per- forating the walls of either the frontal, the sphenoidal, or the max- illary' sinus, or from the ethmoid cells, or it may follow the vessels (throm- bophlebitis) . The collec- tion of pus may be extra- dural, or a true abscess of the brain may be pre- sent. Thrombosis of the cavernous sinus or lepto- meningitis may occur. Rarely, the temporal lobe is involved. Symptoms. — T h e s e . are wearmess, restlessness, headache, mental apathy, and vomiting. Choked disc is present. Focalizing symptoms are absent except in cases of large abscess producing pressure on the motor centers. Treatment.— The frontal sinus should be opened, its pcsteriorwaU removed, if this has not been already destroyed, the dura opened if necessary-, and the frontal lobe explored. Tube drainage should be employed. Cerebral Abscess Developing from Disease of the Skull.— Cerebral abscess mav arise from osteomyelitis or caries of the bones of the skull, of traumatic, tuberculous, or syphilitic origin. Fig. 245. — Rroxleix's Craniocerebral Topographic Lines. 1 1 Base line, passing through the infraorbital ridge and the •superior border of the audit or v meatus; 2, 2, superior horizontal line, passing through the supraorbital ndge parallel to the base hne; 3. .3, anterior vertical hne, parsing from the middle of the zygomatic arch perpendicular to the base hne; 4. 4, middle vertical line, passing from the head of the inferior maxilla (immechately m froiit of the tragus) perpendicular to the base hne: 5, .5, posterior vertical hne, passing from the posterior palpable margin of the mastoid process perpendicular to the base hne; 3. 6, line of fissure of Rolando (see p. 467) ; 3, 7, line of fissure of Syh-ius. 464 THE SURGIORY OF THE HEAD Metastatic Cerebral Abscesses. — These arise most frequently from infected emboli originating in intrathoracic suppurative disease (gangrene of the lung, old empyema, etc.). The emljoli follow the most direct route from the aorta, namely, through the left carotid and one or more of its terminal branches, finally lodging in the fossa of Sylvius. They are usually multiple, and the prognosis is, therefore, unfavorable. They may be simple, however, and hence efforts at operative relief are not excluded. Infectious Sinus Thrombosis. — This may arise from any infectious inflammation of the soft parts of the head and face (erysipelas, anthrax, etc.); from severe infections of the adjacent cavities (oral, buccal, nasal, or pharyn- geal) ; or from infectious processes in the bones (caries of the temporal bone from ear disease, periostitis of the jaw from a carious tooth, etc.). Its most common origin is in a suppurative mastoiditis following disease of the ear. In this connection it occurs with greatest frequency on the right side, is most commonly observed in male subjects, and is practically limited to the middle period of life. It usually develops by continuity to the wall of the sinus and there is a resulting thrombophlebitis of the latter. It may, however, extend from a thrombophlebitis of a vein in the primary focus. When extending directly to the sinus from disease of the mastoid, the inflammatory process as it reaches the sigmoid fossa invades the sigmoid sinus, whence the infection spreads, extending in many cases to the lateral sinus and sometimes to the internal jugular vein, or even to the superior vena cava. The thrombus breaks down and a purulent collection takes place within the sinus. More or less widely scattered embolic infection from attached fragments of the thrombus is the rule (see Pyemia, page 184) . Metastatic abscesses may occur in the brain. When thrombosis of the two petrosal sinuses is present, this usually coexists with the sigmoid affection. The disease as it attacks the cavernous sinus is generally bilateral. Symptoms. — The symptomatology of infectious sinus phlebitis is that of pyemic infection, plus disturbances of brain function (see page 466, Cerebral Localization). Headache is an early and important symptom. Dizziness and vomiting are present. The fever is usually intermittent. The tempera- ture, however, ma}- sink to the normal or may even fall below it. Edema in and about the mastoid region, and tenderness over the jugular vein, together with the presence of a hard cord, are diagnostic in cases originating in mastoid- itis. Pressure on the nerves which accompany the sigmoid sinus through the foramen (pneumogastric, spinal accessory, and glossopharyngeal) may occur and cause symptoms of compression and paralysis. Repeated chills usher in the pyemic condition in the course of two or three days. The latter is marked by the occurrence of pulmonary complications (abscess and gangrene of the lungs). Such small emboli as pass the larger pulmonary capillaries lodge in the other organs (liver, spleen, kidneys, joints, sheaths of tendons, etc.) and cause characteristic symptoms, the most strik- ing of which is jaundice, which develops coincidentally with enlargement and tenderness of the liver. Septic endocarditis may occur as a complication. Thrombosis of the petrosal sinuses causes no special local symptoms. Thrombosis of the longitudinal sinus may cause edema of the scalp and dilatation of the superficial veins. Thrombosis of the cavernous and trans- THE BRAIX 465 verse sinuses may cause exophthalmia from retrobulbar edema, and edema t)l' the upper lid. Xerve pressure will cause neuralgia in the ophthalmic division of the trigeminus; isolated paralyses of the eye muscles give rise to abnormal positions of the globe and contracted pupils and ptosis. Total ophthalmoplegia may be present. Amaurosis may result from optic nerve pressure. Diagnosis. — This depends on the local and general symptoms combined. The disease is most likely to be mistaken for typhoid fever, malaria, and miliary tuberculosis. Septic endocarditis occurring independently, and the presence of a cerebral abscess, may complicate the diagnosis. The history of a recent aural suppuration, and the presence of mastoiditis followed by edema, infiltration, or subperitoneal pus formation in the neighborhood of the mastoid, and later by tenderness and thickenuig m the course of the jugular vein on the corresponding side, serve to distinguish the affection as it exists m the sigmoid smus. Edema of the eyelid and within the orbit and symptoms of nerve pressure in this neighborhood point to involvement of either the cavernous or the transverse sinus, or of both. The prognosis m cases of even moderate severity of mfection is unfa^or- able, in the absence of operative treatment. Early diagnosis and prompt operative mterference govern the outlook for recovery more than all other considerations combmed. Treatment. — Prophylaxis demands the careful treatment of cases of aural suppuration, early openmg of the mastoid m doubtful cases, and the antiseptic treatment of aU mfections withm the area from which they can be transmitted to the cranial ca^'ity. Infection of the sigmoid sinus demands the following: (1) Opening of the mastoid and thorough removal of the primary focus. (2) Exposure of the smus and its explora- tion by pimcture. If JBuid blood fails to follow the punctiu'e. the sinus is thrombosed. (3) Evacuation of the sinus through a half-inch vertical incision and the removal of the clot with forceps or a small sharp spoon to an extent sufficient to insure disintegration of the remainder and efficient drainage. If the upper two-thu'ds of the sinus can be evacuated and effici- ently drained, this may be deemed sufficient. (4) If a decomposed throm- bus extends below the openmg in the sinus, drainage must be obtained at a lower point and the jugular vein ligated in a healthy portion of the vessel low do\Mi m the neck and excised. If the vein is palpably affected, pre- limmar\' excision is indicated, both for prophylactic and aseptic reason. In hgating the vein the procedure is similar to that for ligation of the caro- tid artery (see page 632). The vein should be ligated m two places and excised for its entire length between the ligatures. Intracranial Tumors.— Of the mtracranial tumors most freciuently observed, 23 per cent are tuberculous gro^^■ths, 13 per cent gliomas, 13 per cent sarcomas. 5 per cent hydatids. 4.6 per cent cysts. 4 per cent carcmomas, 3.6 per cent gummas, 2.2 per cent gliosarcomas. and 2 per cent myxosarcomas.* Of these. tubercrJous growths are most frequent m early life, while the mahg- nant forms are more common from the twentieth to the fortieth year. As a rule, to which, however, there are exceptions, tumors of a mahgnant *These figures are taken from AMiite and Bernliardt's statistics as tabulated by Seguin and Weir ("'American Text-Book of Surgerj""). 31 466 THE SURGERY OF THE HEAD character, as -well as tuberculous lesions, tend to infiltrate the surrounding tissues. Benign growths are either inclosed in a well-defined capsule, as, for instance, in the case of cysts, or have distinct boundaries which separate them from the neighboring structures. Only those tumors of the brain which possess a surgical interest \\ill be considered in this connection. The inquiry A^ill be limited, therefore, to those situated in the motor area and the adjacent regions (central con\-olutions). T-ess than 25 per cent of brain tumors are accessible to operati\-e interference (0 p p e n h e i m) . Symptoms of Tumors of the Brain. — The clinical symptoms of those tumors included in the present study will comprise the following: (1) gen- eral brain symptoms or those caused by compression of the brain; (2) local symptoms. Of the general symptoms, the most important, on account of its frequenc}', is headache. It occurs early, is constant and severe, and is migrainelike in its dull and bormg character. It is likely to be accompanied by nausea and voixdting. When the tumor is superficially situated, the head- ache may correspond to the site of the growth; generally, however, it is dif- fused. The next most important general symptom in this connection is vomit- ing. This usuahy occurs without effort and from an empty stomach (men- ingeal or cerebral vomiting). Finally, choked disc, or stasis of the visible veins in the fundus of the eye, when present, is of the greatest importance, it is absent, however, in about 40 per cent of cases of tumor in and about the central fissure. It may be due to obstruction in the circulation caused by increased tension of the cerebrospinal fluid, or it may arise from direct pres- sure on large venous tnmks. When unilateral the tumor, as a rule, is situated m the opposite hemisphere. Usually, however, it is bilateral. It does not interfere with vision until secondary- changes in the optic nerve take place. Of the local sj^mptoms, localized convulsions are of the first importance, particularly when these have been preceded by disturbances of sensibility or of muscular sense. The convulsions are at first tonic, then clonic in character, and usually begin in some definite group of muscles. As a nde, they follow a fixed sequence in the manner of their extension (see page 468, monospasm). The occurrence of unconsciousness is marked in proportion to the severity, extent, and length of the convulsive seizures and the frequency of their re- currence. Finally, the paralyses which eventually follow, while but temporary at first, soon become permanent (see page 468, monoplegia), and the spasms of the affected muscles cease except for the occurrence of slight twitchings during the seizure. CEREBRAL LOCALIZATION In this connection the symptoms arising from interference with the functions of the cerebral organs, either from injury or from tumor formation, will be considered. It is obvious that these symptoms can be of service only when the lesion occurs in a part of the brain the physiology of which is known. In the surgical sense the most important region of the brain is that known as the motor area. This includes the central portion of both central convolutions, the paracentral lobule, the operculum, and the foot of the third frontal convo- lution. The fissure of Rolando, from its proximity to this area, serves as a guide to the surgeon for the location of those portions of the area whose func- THE BRAIN 467 Fig. 246. — Motor and Sensory Centers op the Brain. tions have been demonstrated to exist. These are as follows: (1) the motor center for the leg; (2) the motor center for the arm; (3) the motor center for the head (Fig. 246). In all prol)al)ility these re- gions are also the seat of cutaneous sensil)ility and of muscular sense. The Fissure of Ro= lando. — According to Thane, this fissure com- mences at a point 55.7 per cent of the distance between the glabella and the inion, measured on the median line. It runs downward and forward at an angle of about 67 degrees, with an average length of 3| inches. The following is a ready method of locating the fissure (Fig. 247): (1) Draw a line from the glabella to the inion with an anilin pencil, and mark a point half an inch behind the midway point of this line; this represents the commencement of the fissure; (2) select a piece of stiff paper or light cardboard 4 inches square, fold it diagonally on the line AC, bringing the edge AD to corre- spond with the line AC; (3) place the card with the point A at the com- mencement of the fissure, and the edge AB on the middle line, when the folded edge AE will mark the site of the fissure sufficiently near for all practical jour- poses (C h i e n e). Lesions of the Motor Area.— It is impossible in any given case to exclude participation of the medullary substance in injuries of the cortical area. Further, cortical lesions may be so slight or involve so unimportant a focus as to give rise to no focalizing symptoms; on the other hand, these may be so extensive as to cause total destruction of both central convolutions. Finally, as more fre- quently happens, there may be partial destruction of both central convolutions, in which case the focalizing symp- toms are both definitely expressed and characteristic. The most important of these are monospasm and monoplegia. Fig. 247. — Chiene's Device for Locating THE Fissure of Rolando (Reduced Size). 468 THE SURGERY OF THP: HEAD Monospasm, or convulsive movements limited to a single group of muscles, is a symptom of value in the diagnosis of lesions of the motor area. 'J'hese movements are caused b}' mechanic irritation arising from the presence of foreign bodies, tumors, etc. They are at first tonic and then clonic. The convulsion always begins in that group of muscles in whose center the irritation occurs. In the case of a tumor, extension of the convulsive movements, cor- responding to the area involved, takes place with its growth. The convulsion may affect first the face, then the finger, hand, arm, leg, foot, and toes; or in the reverse order (Jacksonian epilepsy). The convulsions are succeeded by permanent monoplegia, later by combined monoplegia; finally, with de- struction of the motor centers, complete hemiplegia develops and the convul- sions cease. Contractures occur (combined paralysis and rigiditj^ in the groups of muscles, the former seat of the convulsions, together with pain, paresthesia, and dulled sensation from involvement of the sensory area. This transition from monospasm into localized paralysis constitutes a most important diagnostic sign. The monospasm alone may be due to pressure on the motor area by a lesion situated in one of the neighboring lobes, either the frontal, the parietal, or the temporal. In the case of a subcortical tumor the effect is the same. Monoplegia, or paralysis of a single limb, may occur as a pure symptom, or the paralysis may affect the upper and lower extremity simultaneously. The interposition of the arm center prevents simultaneous occurrence of symptoms referable to the leg and head centers without involvement of the former. A pure monoplegia is most frequently observed in connection with lesions of that portion of the leg center represented by the upper third of the anterior central convolution and the paracentral lobule. In the case of monoplegia of the arm the lesions have been found in the cortex of the middle third of the central convolution and in the adjacent sulci. Lesions of the leg and arm centers are the favorite starting-point for Jacksonian epilepsy. Lesions of the Parietal Lobes. — These do not give rise to distinctly focalizing symptoms for the reason that the functions of this part of the brain are but little known. "\^Tien on the left side and partly on the angular gyms', optic and sensory aphasia, with disturbances of reading (alexia, or word blindness), probably caused by the intermption of connectmg tracts between the visual center in the occipital lobe and the speech center in the left temporal lobe, have been observed. Muscular sense may also be inter- fered with. Remote effects of tumor pressure on neighboring centers (motor area, sensory area of the cortex, posterior section of the internal capsule, and the occipital lobe) ^^■ill cause corresponding focahzing symptoms. The frontal lobes are the seat of the mentality. Lesions of these are fol- lowed by weakness of memory, apathy, and similar aberrations of the mental state. An ataxic gait may be present (L . B r u n s ' s frontal ataxia) , with weakness or paresis of the trunk muscles. These are due to a lesion of the tnmk center in posterior portions of the first frontal convolution. Encroachment on the motor area by the growth of a tumor will cause temporary monospasm and monoplegia, and growth in the direction of the base causes symptoms of loss of smell (anosmia), disturbances of vision, optic nerve atrophy, exophthalmos, etc. Choked disc is a later manifestation. Hysteric con\ailsions or genuine THE BRAIN 469 epilepsy may develop. Finally, there may be tiirniii^ A B Fig. 260. — Malgaigne's Operation for Harelip. A, The incision ; B, sutures introduced. Simon's Operation (Fig. 263). — In this operation the h shaped line, when the flap and freshened edge are united, forms a very complete correction of the deformity. The cicatricial contraction is distributed over three separate lines and the minimum amount of shrinkage at the vermilion border occurs. This operation is most useful in harelip of the third degree. A B Fig. 261. — Mirault-Langenbeck Operation for Harelip. A, The incision; B, the sutures introduced. Choice of Operation. — In newborn children and during early infancy and early childhood, other things being ec{ual, the operation which involves the least loss of blood should be chosen. In harelip of the third degree it sometimes becomes necessary to equalize the openings in the nostrils. When necessary, this can be done after complete THE SOFT IWRTS OF THE FACIAL REGION 489 hoalinii- and contraction of tlio jxirts by dotachiiip; the cartilaginous septum at the floor of the nasal cavity and carrying it toward the wider nostril, a place for its reception having been previously freshened. It is here sutured and the side from which it was displaced kept plugged A\-ith antiseptic gauze until union occurs. The Operation for Double Harelip.— Time for Operation.— Strong and vigorous children may be operated on at any time. In weak children the operation may be delayed. Even in these, however, failure to maintain the nutrition of the child may neces- sitate an early operation. Disposition of the Intermaxillary Bones. — In cases in which the projection is but slight or entirely absent the labial clefts may be closed at once. But usually the intermaxillary bone will be found to be a serious obstacle in the way of restitution of the parts. In favorable cases, AA'ith slightly marked prominence, the removal of the labial cleft ex- ercises a favorable influence over both the cleft and the prominent bone; the latter gradually recedes to its normal position and unites with the alveolar process. A con- siderable prominence, however, will prevent union when the soft parts are brought over the bone. Under no circumstances must the intermaxillary bone be removed. The functional and cosmetic effects are such as to demand its retention. In order to FiG. 262. — Golding-Bird's Opera- tion FOR Harelip. A B Fig. 263. — Simon's Operation. A, The incision ; B, the sutures introduced. effect its reduction, fracture and the crowding backward of the vomer have been employed ; this method is applicable only after ossification of the vomer has taken place. The method of excision of a triangular portion of the vomer close behind the intermaxillary bone (B 1 a n d i n) is to be preferred. This should be done through an incision made along the edge of the vomer, the mucoperios- 490 THE SURGERY OF THE HEAD teal covering being lifted with a slender elevator and a A-shaped gap made by sharp scissors. A further modification of B 1 a n d i n ' s operation consists ill niakmg a simple vertical section of the bone. This is done subperiosteally also (Fig. 264). The anterior portion is now forced backward, the lateral surfaces overlapping each other and becoming united (Rose). The Operation. — The skin overlying the intermaxillary- bone is pared at its margins so as to leave a cjuadrangular space ^A^ith three ■wound surfaces. Then, from the outer edge of each cleft a flap is formed, the lines of inci- sion being similar to those em- ployed in M a 1 g a i g n e ' s operation (Fig. 260) ; each of these flaps is left attached to the lip by a pedicle. The re- mamder of the outer edge of each cleft is freshened by re- moving the margins by a ver- tical cut. The flaps taken from the outer edge of the clefts are now apphed to the horizontal wound surface of the central portion ; the thm extremity of each flap is trimmed so as to meet in the middle line when the clefts are closed (Fig. 265). All tension is to be relieved b}- thoroughly freeing the lip and cheek from the bone. After=treatment of Harelip Cases. — The edges of the wound are to be thoroughly dried and penciled \^ith a mixture of collodion and subiodid of bismuth. Or simple occasional cleansing may be employed. Xo further Fig. 264. — The Portion In( llded ix the Solid Lines IS Removed in Blandin's Operation. The Dotted Line Represents the Site of the Incision in Rose's Operation. 1, Vomer; 2, premaxillary bone ; 3, upper lip; 4, alveolar process of upper jaw. A B Fig. 265. — Operation for Double Harelip. A, The incision ; B, sutures introduced. dressing is required. Strict attention on the part of the nurse is necessary to prevent the child from crying. The cavity of the mouth should be cleansed occasionally with a weak boric acid solution. Bits of absorbent cotton tied on a stick and dipped in the solution are best for this purpose. If the bowels do not move after the first da}', a suitable purge should be given. The first defecations will be dark colored as a result of the blood swallowed. THE SOFT PARTS OF THE FACIAL REGION 491 Removal of the Sutures. — The sutures should be removed at the end of a week. Union is usuahy found to be complete. If the union is only partial, the vermilion border, at least, is generally found to be united; the remainder of the cleft will unite by granulation, which may be assisted by strapping with adhesive plaster. In case of complete failure a second operation should be performed after from four to six weeks. Hemorrhage is the chief danger from the operative procedure itself. Bron- chopneumonia constitutes the chief after-danger. Congenital Fissure of the Cheek. — This is observed (1) as a vertical cleft : (2) as a horizontal cleft ; (3) as an angular fissure. Vertical fissure arises either from defective union or from total failure of one lateral plate to join the midfrontal process. In the most aggravated cases the fissure reaches to the lower eyelid, constituting one of the forms of colo- boma palpebrae, the conjunctiva being connected with the mucous membrane Fig. 266. — Fissure of the Cheek, Fissure of the Upper Eyelid, axd Auricular Appexdages. of the edges of the cheek cleft and through the latter with that of the enlarged oral orifice. The cleft may continue through the upper eyelid to the forehead or it may be connected with the nasal cavity. Horizontal fissure of the cheek is the result of a failure on the part of the edges of the highest branchial arch to unite. An enormxous enlargement of the mouth (macrostoma) is formed; the mouth may reach from ear to ear. Skm appendices in front of the auricle are sometimes seen in connection with tliis deformity (Fig. 266). Angular fissure is sometimes observed. Ferguson records an instance in which the cleft extended from the left angle of the mouth to the base of the lower jaw. It occurs occasionally on both sides and simultaneously with other cleft deformities, as well as with congenital hypertrophy of the tongue (macroglossia). Exceptionally the edges of the cleft appear in fissure of the cheek as scar 492 THE SURGERY OF THE HEAD tissue. In the majority of instances of the deformity the angle of the cleft is attached to the gums by a connecting bridge or frenum; more rarely to the hard i)alate. Treatment. — The edges of the fissure are to be freshened and the opposing surfaces brought together and united by sutures. In the case of horizontal cheek clefts with macroglossia the verinilion border of the cleft is to be dissected loose throughout its entire length, the incision commencing at a point on the upper lip where the angle of the mouth should be, and terminating on the lower lip about one-eighth of an inch nearer the median line than the above point (Fig. 267, A). The strip is then released by cutting directly upward through the lower lip, when it is shortened sufficiently to allow accurate adjustment in the formation of a new angle of the mouth. The strip is now' secured in posi- tion with fine silk sutures and the gap in the cheek sutured (Fig. 267, B). Congenital Anomalies of the Eyelids. — Complete absence of the eyelid is of rare occurrence. Imperfect development of the lid resulting in a fissure (coloboma) is occasionally observed. In some instances the entire thickness of A B Fig. 267. — The Operation for Cleft Chicek and Macrostoma. The vermilion strip is sutured in position and the gap in the cheek closed. the lid is wanting (Fig. 266), while in others a membranous intermediate portion occupies a part or all of the gap in the lid. Both the upper and the loA\-er hd on one or both sides may be affected, or both upper lids or the upper lid of one eye may be involved. Coloboma of the eyelids may exist alone or it may occur in conjunction with other malformations of the eye, harelip, and clefts of the cheek, nose, hard and soft palate, and pharynx. The treatment consists in paring the edges of the fissure and unithig the freshened surface by sutures. Congenital Fistulas.— These are observed in the face, on the bridge of the nose, in the median line, at the lower extremity of the nasal septum, on the lower lip, in front of the ear, and behind the lobe of the ear. They can usually be traced ■v^ith a fine probe for a distance of from half to three-fourths of an inch beneath the skin, the fistula apparently terminating in a cavity. They may lead from the nose to the base of the skull (C r u v i e 1 h i e r, K 1 e b s) ; from the termination of the nasal septum to the nasal cavity (R u y s c h) ; or from just behind the ear to the cavity of the mouth (Rose). The entire THE SOFT PARTS OF THE FACIAL REGION 493 fistulous track may be lined Avith epidermis (Beely). Their place of exit on the skin is occasionally the seat of an intractable eczema. "When the canal beneath the skin can be accurately followed, extirpation is indicated. This may be facilitated by leaving a probe in situ while the dissec- tion is being made. Fistulas of the Lower Lip. — These are usually accompanied by a strongly prominent lower lip, on the vermilion border of which appear two shallow dimples. At the base of each of these near the median line the opening of a fistula is found, the size of the head of a pm, from which more or less watery salivalike fluid exudes. The canals diverge, as a rule, and can be followed by a probe a distance of from three-fourths of an inch to one and one-fourth inches, ending in a blind passage. At the lower portion of their course and in the thick part of the hp they approach the mucous membrane of the mouth. The fistulous opening is surrounded by muscular tissue, which becomes narrow, or gapes, A^th movements of the parts. A snout-shaped lip is sometimes formed by a doA^mward and outward lengthening of the lip. The' condition may be associated with other facial deformities, notably harelip, as well as malformations m other and remote parts. Heredity hke- wise enters into the causation. Defective embryonal development of the furrows on either side of the intermaxillary or thin portion of the mandibular process, together A^ith o^'e^growth of the latter in cases of snout-shaped projec- tion of the lip, originates the deformity. Should the prominent lip or persistent secretion demand it, a wedge-shaped portion including the fistulous canal may be excised. Auricular Appendages. — Congenital tumors m front of the ear, varying in size from a lentil to a pea, are sometimes obser\'ed projectmg above the surrounding level, the so-called auricular appendages (Fig. 2661. These appear in some cases to be simply reduplications of the skin, while in others a decidedly cartilaginous structure is found in the interior. Occasionally they are attached by a narrow pedicle. They occur on one side, as well as symmetrically on both sides. Sometimes there is a simultaneous malformation of the external ear, in which case the appendages take on a larger form. They may be simply snipped off Anth the scissors. A small vessel may reciuire the application of a suture. Stomatoplastic Operations. — These operations differ from cheiloplasty in that they aim at correcting congenital mouth formation rather than replace- ment of parts lost by injur\' or disease. The conditions most frequently requiring their performance are (1) macrostoma; (2) microstonia; (3) ectropion of the lips. Macrostoma. — In case of congenitally large mouth the plastic operation for forming a new angle of the mouth described in connection with horizontal fissure of the cheek (vide supro) is to be preferred to the usual procedure of freshening the edges of the angle of the mouth and uniting the same by sutur- ing. There is usually no tension on the parts and union is rapid and complete. Microstoma is seldom congenital. Its most common cause is cicatricial contraction of the mouth foUoxAing disease or mjur}'. It is corrected by making an incision for the necessars^ distance beyond the angle of the mouth and lining this ■v^ith mucous membrane from the cheek, which is loosened for this purpose. In order to prevent the incision from granulatmg together from 494 THE SURGERY OF THE HEAD the angle in^vard toward the median Hne, the incision is prolonged as a Y placed horizontally at the angle and the mucous membrane of the cheek loosened more extensivel}^ at this point. The triangular-shaped flap of mucous membrane is sewed to the new angle. Or the older method of R u d t o r f f e r may be tried. This consists in perforating the cheek at the point where the neAV angle is to be formed, and passing through the opening a metallic wire. When cicatrization of the opening is complete, the usual incision is made from this point to the already existing oral opening and covered with mucous membrane after Dieffenbach's method. The difficulty in obtaining cicatrization of the opening through ^^'hich' the wires are passed constitutes the chief objection to this method. The patient wears an oval double-faced ring, made of hard rubber, for an hour or more each day in order to prevent recontraction. Ectropion of the lips, or eversion from cicatricial contraction of the mucous membrane lining the lip, in its complex forms is to be corrected by V-shaped excision of the cicatrix and Y-shaped union of the gap (vide infra) . In other and more severe cases cheiloplastic procedures are indicated. Separat- hig the labial edges from the cicatricial tissue, raising them to the proper level and filling the gap by a flap with a pedicle, ^^^lll prove successful in a certain number of cases. Meloplastic Operations. — Operations designed to correct defects in the soft parts of the cheeks are less frequently required than plastic operations in other portions of the face. The skin of the temporal region and of the forehead is most frequently utilized for this purpose, where the loss of sub- stance is complete. Schimmelbusch's operation is to be employed after removal of the entire cheek. The first flap is reflected upward from the neck, and, ^vhen in position, its skin surface replaces the buccal mucous membrane. The second flap is taken from the scalp, and, when turned downward, its rav/ surface is presented to the raw surface of the first flap, its outer hairy surface replacing the beard. The pedicles are divided in four weeks. In partial defects flaps with small pedicles are successfidly employed on account of the rich blood-supply. When in the extirpation of a growth the mucous membrane cannot be spared, this structure is not easily replaced; the buccal surfac^e of a skin flap is likely to undergo cicatricial contraction. In cicatricial lockjaw folio-wing noma the cicatrix must be divided, and, in order to prevent recontraction, the defect filled with double skin flaps, one integumentary surface facing the buccal cavity and the other presenting externally (Gussenbauer). Blepharoplastic Operations. — Cicatricial deformities of the eyelids con- stitute the most frequent indication for these operations; they are some- times resorted to after the extirpation of morbid gro^vths. Ectropion, or a turning outward of the lid, is the most common of these; the lower lid is most frec^uently affected. A condition of entropion attends cicatricial contraction of the conjunctival surface of the lids. The first step in the correction of ectropion is the separation of the everted conjunctiva from the underlying cicatricial tissue. The edge of the eyelid is then restored to its normal position. In partial ectropion a simple V-shaped incision made by dissecting up the triangular-shaped flap, sliding it in an SOFT PARTS OF THE NOSE AND NASAL CAVITIES 495 upward direction, and suturing this so as to form a Y-shaped line of union, after restoration of the hd to the proper level, suffices (Fig. 268). Complete ectro- 1 ^^^^^^Hnrv ~^ Y > Fig. 268. — Operation for Simple Ectropion. A, The incision; B, the Y-shaped Une of union. pion is best remedied by making the incision along the tarsal margm, dis- secting the conjunctiva loose, restoring the edge of the lid to the proper level, and suppiymg the then existing defect by a flap from the temporal regions (Fig. 269). The trans- planted portion must be at least t\\ice as large as the defect to be corrected. The use of R e - V e r d i n transplanted flaps or the method of Thiersch like- ^^ise gives good results. All methods are followed by slight relapses in a certain proportion of cases. These are to be cor- rected by subsequent, though less formidable, operations. In ectro- pion of the upper lid the same procedures suffice, the lines of the incision being reversed. Fig. 269.-Fricke's method of blepharoplastt. Ectropion of both lids is sometimes treated bv tarsorrhaphy, the lids bemg sewed together over the globe after correction of the defects, until complete healmg has taken place. THE SOFT PARTS OF THE NOSE AND NASAL CAVITIES The onlv injuries of the soft parts of the nose requiring special notice are those v.-hich involve the alae. Portions of the latter, though entirely separated, should be at once replaced after careful cleansing; they occasionally unite, even some hours after the injury. If they fail to do so. certain plastic operations are indicated. Fractures of the Nasal Bones.— These are always the result of direct 496 THE SURGERY OF THE HEAD Fig. 270. — Asch's Open Scissors. The best expedient, if spon- violence. The fragments are displaced in the direction of the nasal cavity. These, if permitted to remain, lead to a saddle-shaped deformity of the organ. In addition to the cosmetic effects, certain functional disturbances, such as embarrassment of respiration, loss of sense of smell, etc., follow. The indica- tions, therefore, are to replace the fragments as soon as possible. This is best accomplished by a pair of dress- ing forceps introduced in the nos- tril, first on one side and then on the other, the fragments on the outside being supported with the thumb and finger of the other hand. By pressure made upward the displaced fragments are forced into position. The sep- tum, if displaced, is to be straightened forcibly by grasping it with the dress- ing forceps and making pressure in the proper direction. Retention of the fragments, after reduction, sometimes requires nothing more than simple packing of the nostril ^^dth antiseptic gauze. This sometimes produces so much irritation as to lead to its abandonment, taneous retention does not occur, is to pass a needle, grasped in a stout forceps, by drilling move- ments through the fragments from side to side. A narrow piece of adhesive plaster is now passed over the bridge of the nose and made to include the two ends of the needle. The latter may be ■\\ithdra'v\Ti at the end of a week or ten days (Mason). Sometimes as a result of traumatism, but more frequently from abnor- malities of growth (Harrison Allen), deviations of the septum are observed. The deviation may affect the cartilaginous septum alone, or the vomer may likewise be involved. No difficulty should be experienced in diagnosing these deformities; only the most superfi- cial observation could possibl}' mistake them for new growths. The treatment consists in thoroughly dividing all adhesions to the turbinates, and making two inter- secting incisions at the point of greatest convexity of the deformed septum by means of the open scissors (A s c h. Fig. 270). The finger is then introduced into the obstructed side and the four segments of cartilage made by the intersecting incisions broken at their bases by forcing them into the concavity. The septum is then straightened by powerful compression forceps (Fig. 271) and a snugly fitting vulcanized tube splint (Fig. 272). In case the vomer is prim- arily at fault, this may be corrected by dissecting the upper lip from the alveolar side and detaching the anterior portion of the vomer with the attached cartilaginous septum from the superior maxillary bone by means Fig. 1. — Compression" Fohcki-s for Stkaightexing THE Septum. Fig. 272. — Asch's Vulcan- ized Tube Splint. SOFT PARTS OF THE NOSE AND NASAL CAVITIES 497 of the bone-cutting forceps. The entire septum is then crowded over to its normal position and there maintained by the suitable packing of the formerly narrowed nares (L o s s e n). Epistaxis. — This may occur from external injuries or from injuries of a vessel frequently found at the anterior portion of the cartilaginous septum, which is easily invaded by forcible attempts to remove crusts from the nasal cavity. Acute and chronic inflammatory conditions, ulcerative conditions of the mucous membrane, tumors, etc., and finally defective cardiac action, as well as hemophilia and the beginning of typhoid fever, give rise to alarm- ing hemorrhages. The treatment consists in the application of cold, either externally by means of ice over the bridge of the nose, or the use of ice-water snuffed up the nose or injected by means of a syringe. In mild cases deep inspirations will sometimes suffice to arrest the bleeding. By this means the mucous membrane is emptied of its blood by aspiration, and at the same time the blood which has escaped from the vessel is forced against the open point and coagulation favored. This failing, plugging of the anterior nares with non- absorbent cotton is the next step to be taken. These plugs should be forced as deeply as possible into the nasal cavity b}' a screwing movement. Hemor- rhage may now persist from the posterior nares, in w^hich case it ■wall be neces- sary to resort to the plugging of both posterior and anterior nares. This may be accomplished, in case of emergency, by the use of a soft-rubber catheter, which is passed through the anterior nares, grasped with a pair of forceps as it emerges from behind the u\aila, after which it is dra^m over the back of the tongue and thence out of the mouth. Here a doubled strand of strong thread about a foot long is tied to it. In the middle of this, a firm wad of common cotton (nonabsorbent) is tied. The catheter is now withdra\^TL by dra^^ing on the end projecting from the anterior nares, the forefinger of the left hand at the same time guiding the cotton plug attached to the string over the base of the tongue and up behind the uvula until it is safely lodged crosswise, at the posterior nares. The end projecting from the mouth is permitted to remain for the purpose of withdrawing the plug when necessary. The double strand which projects from the anterior nares is separated, a tightly rolled wad of cotton placed outside the nose and between the strands, and the latter tied over this, to serve as a plug to the anterior nares. If a Bellocq's cannula is at hand, this may be advantageouslv emploved (Fig. 273). Rubber balloons, on the principle of Barnes's uterine dilators, have been suggested, these being filled ^^ith air or ice- water, after introduction. Passing a fold of gauze or linen, covered with vaselin, well into the nasal cavity and packing this with cotton, answers as well, and can be improvised in cases where this would suffice. Rhinoscopy. — Inspection of the nasal cavities is required for the exact diagnosis of foreign bodies, acute and chronic inflammatory conditions, and tumors. In order to accomplish this the parts must be dilated and illumi- nated. Direct inspection through the nostrils in front is called anterior rhinos- copy ; where a mirror is placed in the fauces and rays of light are reflected on this, illuminating the parts and at the same time reflecting their image in the mirror, the manipulation is known as posterior rhinoscopy. 33 498 THE SURGERY OF THE HEAD Anterior rhinoscopy is made by dilatiiijij tlie flexible portions of the nos- trils by means of a suitable speculum, and illuminating the cavity by means of hght reflected from the surface of a concave mirror. A convenient form of self-retaining speculum for this purpose is shown in Vig. 274. Forcible Fig. 273. — Bellocq's Cannula with the Spring Carrier Projected. elevation of the tip of the nose, in conjunction with the use of the speculum, permits accurate inspection. Turning the patient's head from side to side will facilitate the examination of the different parts. Posterior Rhinoscopy. — This is more difficult than the anterior method. Fig. 274. — Self-retaining Nasal Speculum. Fig. 275. — Nasal Ele( tuic Light Specu- lum. A mirror is placed in the pharynx, from w^hich light is reflected into the pos- terior nares; the palate must remain completely relaxed and the tongue depressed. The palate can sometimes be controlled b}' the patient if he is directed to say "Eh" with a strong nasal sound. If after a few patient Irials SOFT PARTS OF THE XOSE AND NASAL CAVITIES 499 the uvula is still found to be irritable and disposed to drag up forcibly against the surface of the mirror, the parts may be anesthetized ^^■ith an application of a 10 or 20 per cent solution of cocain. Before resorting to this, which is very disagreeable to the patient, an attempt may be made to steady the Fig. 276. — French's Pal.\.te Hook. soft palate by means of a palate hook. The most efficient of these hooks is that devised by Dr. T, R. French (Fig. 276) . The tongue is to be kept out of the way by means of a tongue depressor. In depressing the tongue care should be taken to drag it forward at the same time, rather than permit it to be forced back against the fauces; the latter produces gag- ging. In order to be able properly to diagnose mor- bid conditions about the posterior nares. the sur- geon should familiarize himself with the appear- ances of the parts in health (Figs. 277.278). Foreign Bodies in the Nose. — A foreign body in the nose is of rather common occur- rence among children, as the result of either mis- cliief or accident. In the act of vomiting, portions of the contents of the stomach find their way into the nose through the posterior nares. Soft arti- cles of food in this local- ity are easily expelled; the stones of fruit which have been swallowed, or other ingested articles. however, ma}' give rise to considerable irritation. Children often place beans, peas, and buttons in the nose, in play, though anxious mothers sometimes imagine that their children ha-\'e placed a button or some other foreign bodv in the nose when this is not reallv the case. Fig. -Posterior Rhixoscopic Examination-. 500 THE SURGERY OF THE HEAD The presence of a foreign body in the nose at once produces a more or less profuse seromucous discharge ; this soon becomes mucopurulent or even bloody if ulceration results. The diagnosis should be made between foreign bod}- producing irritation and ulceration and syphilitic nasal disease. Carcinoma and sarcoma may give rise to the same symptoms. The escape of flocculent or cheesy masses with the discharge is characteristic of foreign body (B o s w o r t h). When ulceration is present, it is neither progressive nor extensive; necrosis is very rare. If the foreign body is well forward it may produce deformity. Instrumental examination should be preceded by cocain anesthesia. A thorough preliminary wash- ing of the nasal fossae with a mild alka- line solution will enhance the anesthetic effects of the cocain. Chloroform may be administered to young children. The probe will usually detect readily the pres- ence of the foreign body. Previous un- successful attempts to remove the foreign body may have denuded the turbinated bones of their coverings. The probe com- ing in contact with bare bone ma}' mis- lead the surgeon. Inspection by anterior rhinoscopy may assist. The treatment is very simple. An ordinary wire curet of the proper size will serv'e to dislodge almost any foreign body that can be crowded into the nose (Fig. 279). This may sometimes be improvised from an ordinary' hairpin. If clirectly \\ithin reach, the foreign body may be grasped with a pair of forceps. If lodged far back, a finger passed from the pharynx into the posterior nares ^^ill assist in steadying the object while it is being extracted with the loop of the curet. Inflammation and Tumors of the Covering of the Nose.— The presence of short connective-tissue fibers between the skin and the periosteum and peri- chondrium of the nose is unfavorable to the development of phlegmonous inflam- mation of the nasal covering. Erysipelas, however, develops readily; the Fig. 278. — Rhixoscopic Im.4ge. The illustration is shown larger than normal in order to bring out the parts in detail. Fig. 279. — Small Wire Curet. broad follicles with open mouths favor acne and pustulous affections and the infection of erysipelas enters and extends rapidly. Acne rosacea is a hyperplastic process, consisting of a proHferation of the skin tissue, with development of blood-vessels. It is generally a bright red or bluish color. Uneciual development leads to a warthke or uneven appear- ance in some cases. It is popularly associated with the abuse of alcoholic stimulants, though it does not necessarily arise from this cause. It occurs more particularly in middle age and late in life. Removing the skin from the entire nose and replacing this by Thiersch's skin transplantation. SOFT PARTS OF THE NOSE AND NASAL CAVITIES 501 or permitting the space to fill up with granulation tissue, though a severe remedy, is the only resource in the most severe cases. Fusiform excision frequently repeated, and the suturing of the edges of the gaps, may be resorted to in less severe cases. Solutions of the aqueous extract of ergot and carbolic acid (aqueous extract of ergot, 1 ; distilled water, 10; carbolic acid, 10) injected in small quantities into the skin and beneath its surface have been used with some success (R i e s m y e r). Lupus. — This commences in the hyperplastic granulating form and after- ward passes more deeply, finally involving the cartilages, and ulcerating. It may spread over the entire surface of the organ, reach the nasal bones, and extend laterally to the nasal processes of the superior maxillary bones. The septum suffers in the general destruction and the tip of the nose becomes depressed in consequence. Excision and skin transplantation after T h i e r s c h is the best remedy (see page 331). Rhinoscleroma is a dis- ease characterized by an ex- tremely chronic inflammation of the coverings of the nose. The nasal mucous membrane, as well as that of the phar\mx and larjmx, may be involved. It sometimes produces great de- formity. It is marked by the occurrence of hard grayish-red nodules covered with normal epidermis, the tissue of which is infiltrated with round cells. These are the sites of numer- ous large lymphatic vessels. Ulceration may occur in the large nodules. A specific bacil- lus has been shown to exist in the disease (Finch) and pure cultures of this microorganism Fj^. 280.-Rhinophyma, before Operation. have been obtained (P a 1 1 a u f and Eisenberg). The disease has been produced in the lower animals by inoculation (Stepanow). Free excision, in the early stages, is the only remedy. Rhinoph5rma. — This is a name applied to an elephantiasis-like thickening of the skin of the nose, in which all of its structures take part. Large soft nodules frequently appear on the alae nasi (Fig. 280). Distinct enchondromas have been found in this situation. The treatment consists in reflecting the skin covering from the nodules and remoA'ing these, the skin flaps being afterward trimmed and replaced. The removal of V-shaped longitudinal strips the entire thickness of the skin serves to reduce the nose in size (Dieffenbach). In extreme cases the entire integumentary covering of the nose may be dissected away and its place sup- plied by Thiersch skin grafts. The result as shown in Fig. 281 was obtained bv a combination of these methods. 502 THE SURGERY OF THE HEAD Tumors of the covering of the nose occur in the shape of atheromas, fibromas, and adenomas of the sweat-ghmds. The most important tumor in this region, however, is epithelial carcinoma. The latter occurs usually as a flattened ulcer and differs from acne and lupus in selecting primarily by preference the alae of the nose. It is peculiar in that it rarely passes from one side to the other; as a rule, it extends outwardly and in an upward direction. It usually remains limited to the integument for a considerable time. The lymphatics become invoh-ed late in the affection; therefore early extirpation affords a favorable prognosis. In addition to lupus and carcinoma, syphilitic ulceration and destruc- tion of the nose may occur. In the differential diagnosis the history and the results of microscopic examination must here be the main reliance. Inflammations of the Mucous Membrane of the Nose.— Chronic hypertrophic rhinitis, the thickening being particularly over the inferior turbinated bones, polypi, and ulceration may result from repeated at- tacks of catarrhal inflammation of the mucous membrane lining the nose. This inflammation may extend to the frontal sin- uses (page 515) and to the an- trum of Highmore (page 528). Ozena results from an ab- normal secretion from the mu- cous glands, the peculiar char- acteristic of which is a tendency on the part of this secretion to undergo rapid putrefactive changes. It is not infrequently associated with chronic atro- phic rhinitis. The nasal cavi- ties are abnormally large in this affection, the nasopharyn- geal region and orifices of the Eustachian tube being visible in exceptional instances. The disease may be preceded by the hypertrophic form. More or less impairment of hearing is associated with atrophic rhinitis in about two-thirds of all the cases. A pharyngitis sicca may be associated with ozena and atrophic rhinitis. In addition to the putrid odor, the charac- teristic feature of the affection is the presence of dried crusts on the mucous surface. This is also observed in pharyngitis sicca. The causes of ozena are obscure. It occurs most frequently in so-called scrofulous subjects. Syphilitic disease of the nose should not be confounded with it. Here there is a puriform discharge with putrid odor, rather than a putrefaction of the secretion combined with the accumulation of crusts. The pressure arising from these crusts, as the secretions dry on the surface of the mucous membrane, is said to give rise to disturbances of the circulation in the parts and consequent atrophy (Bosworth). Fig. 281. -Rhinophyma. The Appearance Presented AFTER Operation. SOFT PARTS OF THE NOSE AND NASAL CAVITIES 503 The treatment consists in a thorough removal of the crusts; spraying or syringing the mucous membrane with a cleansing alkaline and antiseptic solu- tion, *such as bicarbonate of soda, gr. ij; borate of soda, gr. ij; carbohc acid, gr. ij; glycerin, dr. ij; water, oz. j (Do bell); this is followed by such applications as will stimulate the secretion of mucus. Of these may be men- tioned a 0.5 per cent solution of salicyhc acid; a 2 per cent solution of chlorate of potash, or a pledget of cotton saturated with a 20 per cent solution of chlorid of zinc to which sufficient hydrochloric acid has been added to make a clear liquid. In case difficulty is experienced in loosening the crusts by means of the spray apparatus, pledgets of cotton, upon a probe and saturated with the cleansing agent, are to be passed through the nasal cavities to effect their dislodgment. The dailv application of simple cotton plugs, to excite the secretion of mucus, has' been advocated (Gottstein). These may be combined with stimulating medicaments by incorporating certain po\\ ders in the cotton (Woakes). lodol, boric acid, or aluminum acetotartrate are very use- ful, applied in this manner. The treatment, however, involves considerable discomfort to the patient. Ulceration of the mucous membrane frequently results from acute and chronic rhinitis and from too persistent efforts to dislodge dried secretions. These frequently show but slight disposition to heal. By resisting the tenip- tation to remove the crusts frequently, and occasionally applying white precipitate ointment, or oxid of zinc ointment, the healing process is soon completed. Syphilitic rhinitis in the newborn may be associated vith ulceration. This differs from that resulting from the common form of rhinitis in that the syphilitic form is associated with periostitis and perichondritis as well, which can be demonstrated by palpation from without, the external osseous covering also being invoh^d. The treatment is that of congenital syphilis in general, namely, appropriate doses of gray powder or inunction of blue ointment. Syphilitic affections of the nose will be discussed on page 508. The ulceration of farcy or glanders sometimes occurs in the nose; it is very frequently fatal. It is usually multiple, occupies both nares, and is accompanied by swelling of the skin of the face and scalp, vith marked infiltration of the subcutaneous cellular tissue. The occurrence of these symptom.s in conjunction with high fever and the presence of suppurative ulceration of the nares should always excite suspicion of farcy. Bacterio- logic examination will assist in the diagnosis (see page 32). It is suggested, in case the diagnosis can be made sufficiently early, to expose the nasal, cavities by means of B r u n s ' s osteoplastic resection (page 507) and arrest the propagation of the infection by the application of the actual cautery. Tumors of the Mucous Membrane of the Nose. — Tumors which spring essentially from the nasal mucous membrane are comprised in the classes loio^-n as mucous polypi, papilloma, and the rarely encountered epithelioma and fibrosarcoma. Tumors which invade the nasal cavity from other regions will be considered in connection with the surgerA' of those regions (tumors of the upper jaw, of the pteiygopalatine fossa, and of the base of the skull). The mucous polypi are the most frequently seen of all tumor formations of the nose. They result from repeated attacks of rhinitis; they have also been observed in connection with tumors springing from the upper jaw and the base of the skull. 504 THE SURGERY OF THE HEAD Mucous polj'pi are of a soft consistency, almost gelatinous at times, and a pale grayish-yellow color, not unlike the ocean polypi. Microscopicalh' they consist of a development of the mucous glands and submucous connective tissue; the cells are few in number and are surrounded by an almost homo- geneous matrix. Pathologically, they are benign adenornyxomas of the mucous membrane. The great majority of these tumors take their origin from the mucous membrane covering the turbinated bones, particularly the middle and nasal meatus. Less frequently the}^ originate from the free posterior edge of the septum and hang down behind the soft palate. Rarelj' they are found to spring from the mucous membrane covering of the ethmoid bone. Their growth, except in the case of those at the posterior edge of the septum, tends at first to bring them forward toward the anterior nares. Subsequently, they grow posteriorly and may even appear at the posterior nares or in the pharyn- geal cavity. In this location a digital examination mil reveal their presence. The anterior extremity of a polypus, if well forward in the nasal cavity, is prone to ulceration. As a result of constant irritation and chronic inflammatory action, the tumor may become more or less indurated and thickened. Under these circumstances, also, hemorrhage is of occasional occurrence. Mouth-breathing results from an occlusion of the nostrils from the presence of polypi, and as a result of chronic thickenings. This, in its turn, may lead to diseases of the pharynx, larynx, bronchi, and lungs. Asthmatic troubles are also, in some instances, traceable to intranasal disease. The sense of smell is weakened and the formation of vowel sounds greatly impaired ; to the latter, a nasal sound is added. Large polypi occupying both nasal cavities may produce marked deformity of the face. In the diagnosis of polypi care must be taken not to mistake for these growths the chronic hypertrophic conditions of the mucous membrane covering the turbinated bones, particularly that covering the anterior edge of the inferior turbinated bone. The grayish color of the latter compared with the bright red color of the former, together with the fact that polypi are usually more or less pedunculated while simple hypertrophies are sessile, wdll serve to distinguish the one from the other. Papilloma is a comparatively rare affection of the mucous membrane. It consists of a warty growth, situated, in the case of the soft variety, which is the more common on the inferior turbinated bone; the hard papil- loma occurs near the mucocutaneous junction and ma}^ spring from the septum, floor, or inner surface of the ala. It is usually sessile in character. It gives rise to no particular disturbance until it has attained a considerable size. Hemorrhage may occur if erosion of the growth takes place. The treatment consists in extirpation with the cold snare, with or Avithout the application of the galvanocautery to the base. In case of very large papilloma an external operation (W a r cl , V e r n e u i 1) , such as tem- porary resection of the nose (B r u n s , page 507) , may be necessary. The Operative Treatment of Nasal Polypi. — The only successful means of dealing with these growths is their extirpation. The use of the forceps for this purpose has now ver}^ largel}^ given way to that of the cold wire snare ecraseur, J a r v i s (Fig. 282). This, or one of its modifications, is mounted with fine unannealed steel piano wire, which gives it a certain amount of stiffness and enables the operator after a little practice, to place the loop in any desired location or position. This being accomijlished, the encircled portion of the SOFT PARTS OF THE NOSF AXD NASAL CAVITIES 505 tumor is severed from its attachment. Instruments designed to accomplish the tightening of the loop A\ith but a single movement of one hand are pref- erable. The galvanocautery loop (M i d d e 1 d o r p f and V o 1 1 o 1 i n i is now seldom used by operators of experience. This cauterization, as well as the barbarous procedure, formerly practised, of removal of a portion of the turbinated bone attached to the growth, is imnecessary. Cocain anesthesia should always precede the operation for rem^oval of polypi. A freshl}^ made 20 per cent solution, thrown into the nose b\ means of a spra}- apparatus, should be used; this produces insensibility both rapidly and completely. Large growths are difficult to cocainize, but by persisting, anesthetization may be finally accomplished. A portion of the growth being removed, a fresh supply of the cocain solution should be introduced. It is not always possible to encircle the entire growth at the first attempt. The loop should be passed between the septum and the growth with its lo^^'er border below the level of the tumor, when it should be turned to a horizontal position (inasmuch as in the great majority of cases the grovi;h is attached to the middle turbinated bone), and by gentle manipulation slipped in an upward direction until as much of the growth as it is possible to grasp is judged to be within its opening. The loop should now be forcibly tightened, the instrument being held steadily; the process is really a cutting one. If an exostosis of the septum pre- FiG. 282. — Jarvis's Sxare. vents the proper introduction of the wire loop, this should be removed (vide infra) . Several sittings, as a rule, are necessary, and in order to guard against further growth the case should be kept under observation for several months. Osteoma. — AA^iile it is not a specially rare occurrence for bony tumors that have their origin in other parts to invade the nasal cavity, a growth of this nature occurring primarily in the latter region is of infrequent occurrence. These tumors are among the nasal growths first described by the earliest T\Titers on medicine. Their etiology is obscure. They occur early in life, say from the age of fifteen to twenty; a case making its first appearance at forty-five is recorded, however (Tillmanns). The male sex seems to be attacked by preference. External deformity is usually noticed before the occurrence of nasal stenosis, owing to the fact that the osseous growth has its origin in the upper portion of the nasal cavity, and extends toward the face rather than in a do^mward direction toward the lower meatus. The orbit may be invaded, the tumor extending through the ethmoid cells. Pain may be present, due, in great part at least, to pressure on some of the sensory nerves. Epistaxis is not of frecjuent occurrence. Any discharges from the nose that take place are due to ulceration or necrotic changes in the tumor. The latter may lead to external fistulous openings. 506 THE SURGERY OF THE HEAD These growths have their origin in the periosteum and general!}^ spring from one of the accessory sinuses. The ethmoid cells give rise to them in the majority of instances, though they may spring from the septum or in- ferior turbinated l)ones. Their surface is irregularly lobulated and covered with mucous membrane. Their external bony surface is compact, while the interior is composed of cancellous tissue. The osteomas are sometimes distinguished as the hard and the soft variety, though this division is misleading from the fact that they are all hard to the touch. The division is based on the relative amount of compact and cancellous tissue which goes to make up the tumor. Osteoma can be mistaken only for osteosarcoma. The history of the growth, and, in case of doubt, the removal of a portion for microscopic examination, will determine the cpestion. The treatment consists in extirpation. An external opera- tion, in order to reach the place of attachment of the growth, will usually be necessary {vide infra). This must be planned in accord- ance with the demands of indi- vidual cases. Osteomas, attached to the septum or inferior turbi- nated bone, may occasionally be reached and removed by means of the nasal saw without external operation. Enchondroma. — This is a very rare affection, if the term is re- stricted, as it should be, to the large, round, nodulated tumor which presents all the clinical fea- tures of fibroma, but which on removal is found to contain hya- line cartilage. The nasal cavi- ties do not present favorable con- ditions for the development of cartilaginous tissue. The symp- FiG. 283.— Skin Incision for Splitting the Nose. ^OmS are SUch aS are met with in fibroma, namely, nasal stenosis and mucopurulent discharge; the latter may be offensive as the result of retention. The slow growth of enchondromas, their great density, immobility, pinkish-yellow color, and nodulated appearance, together with their loca- tion, which is usually the point of junction of the septum with one of the alar cartilages, serve to distinguish them from the nasal gro^^■ths and from deviations of the septum. They usually occur in young subjects. The method of removal is to be determined by the size and situation of the growth. Either the cold snare, the curet, or the gouge may be employed. They show no tendenc}' to recurrence. Osteoplastic Resection of the Nose. — The complete removal of intra- nasal tumors may demand the exposure of these, together with the nasal SOFT PARTS OF THE NOSE AND XASAL CAVITIES 507 The simplest of these operations con- FiG. 284. — Langenbeck's Line of Incision for Osteoplastic Resection of the Nose. cavities, through an external operation. sists in splitting the nose in the me- dian line (Fig. 283), from one or the other nasal orifice to the nasal bones. Though the deformity following this operation is not great, it does not give access to any point be}-ond the anterior nasal fossae. Langenbeck's operation consists of a temporary resection of the bony lateral wall of the nose. The incision is commenced in the median line slightly above tlie root of the nose and is carried directly downward in the median line, reaching to the ala. Another incision, commencing at the inner cavities of the eye and extend- ing do\Mi'ward, parallel to the first and corresponding to the posterior border of the nasal bone, likewise extends to the ala nasi. These two incisions are joined by a horizontal one at their lower extremities (Fig. 284). Bv means of a pair of bone- cutting forceps the bone is di\'ided along the vertical lines of incision and the osteocutaneous flap turned upward. Oilier' s Operation. — The design in this operation is to detach the bony framework of the nose from the face and turn it downward. Two inci- sions, one on each side of the nose and at its junction with the cheek, are made. These extend to the alae of the nose. A shghtly cur\'ed trans- verse incision connects them above (Fig. 285). By means of a thin- bladed narrow saw, section of the bone and septum is made along the same Imes. The nose, thus freed from its attachments, is tilted do's^m- ward on the face. This operation gives access to the nasal cavities and nasopharyngeal space. Bruns's Operation. — In this pro- cedure the first incision is commenced immediatelv below the outer margin of the nostril on the sound side, and is carried in a horizontal line directly T, r,^^ r^ , r T r^ across to from half to three-fourths of xiG. 2«5. — Olliers Line OF Incision FOR Osteo- ... .... plastic Resection of the Nose. an mch DCVOnd the OUter Imilt of the 508 THE SURGERY OF THE HEAD Fig. 286. — The Line of Incision for Bruns's Osteoplastic Resection of the Nose. other nostril. This is carried directly down to the bone, but does not invade the cavity of the mouth. A second horizontal incision is made across the bridfj;o of the nose at its narrowest part, from one inner canthus to the other. These two incisions are joined by a third, vertically placed, at the junction of the nose and cheek (Fig. 286) . A thin-bladed saw is now in- troduced at the point of commence- ment of the first incision and made to enter the nasal cavity. The first section made by the saw is through the anterior nasal spine and septum; the instrument is then carried around the entire extent of the original lines of incision. The free end of the saw plays in the nasal cavity throughout the entire extent of the section of bone; its tilted position makes a bev- eled cut. The bony section is con- fined entirely to the superior maxilla, the anterior portion of the inferior turbinated bone, and the bony sep- tum, the latter being divided last from below upward by means of a pair of bone forceps. The entire nose is now turned to one side (Fig. 288). The best of these operations is that of B r u n s . It is comparatively easy of performance, and by means of it wide access is gained, not only to the nasal passages, but to the nasopharynx as well. In all of the operations of osteoplastic resection of the nose, when the indica- tions for which the operation was per- formed have been accomplished, the parts are restored to their normal posi- tion and there sutured. The position of the head during these operations is of importance. That of Rose, with the head in a dependent position over the edge of the table, has some advantages (see page 534 ) . Plug- ging the posterior nares, to prevent the blood from passing into the larynx, or preliminary tracheotomy and the use of Trendelenburg's cannula, may also be employed. Syphilitic Affections of the Nose. — The osseous and cartilaginous structures of the nose are preeminently disposed to syphilitic affections. A Fig. 287. — Osteoplasty after Bruns. Showing the skull lines of section. SOFT PARTS OF THE NOSE AND NASAL CAVITIES 509 favorite starting-{)()int for these is the i^eriosteiun of the septum, though the alae nasi and anterior edge of the septum may become affected. In the latter case a poricliondrial infiltration first occurs, followed by suppurative destruction of the cartilages. The foci of infection on the bony septum frequently lead to perforation of the latter. The spread of the destructive process leads to a sinking in of the entire nasal bony framework, producing a characteristic deformity. This sunken appearance of the nose may vary from a slight depression of the bridge to a complete flattening. The bony framework of the nose is occasionally the seat of necrosis in laborers employed in chemical factories in which potassium salts, arsenic, and corrosive sublimate are made. The skin of the nose is rarely the seat of S3^philitic affections; if these occur at all, it is late in the destructive process, and they are the result of ex- tension from within, particularly from the septum. Syphilitic disease of the nose is to be treated, at first, on an antisyph- ilitic basis. Subsequently when the destructive process has terminated, plastic operative procedures are indi- cated to overcome existing deformities (vide infra). Tuberculous Affections of the Nose. — Subperichondrial abscess of the nose may occur in strumous children. These occur bilaterally, as a rule, the swelling closing the nos- trils like a tumor of the septum. Fluctuation is easily discovered and a free incision will give exit to the pus. As a rule, perforation of the septum has taken place, but the peri- chondrium closes this in and the opening is not permanent, as in syphilis, pus, but is sometimes light and viscid. Tuberculous ulceration and granulating proliferative processes may attack the nose, the latter process occurring particularly at the septum. Fig. a — Bruns's Method of Osteoplastic Resection of the Nose. The evacuated fluid is not always RHINOPLASTY This operation is performed for deformities that are the result of the fol- lowing : 1, Destruction of a portion or all of the bony framework of the nose and adjacent osseous structures. Complete destruction of the bony framework usualh' results from syphilis, and rarely from tuberculous disease. Loss of portions of the nasal bony structure is due to suppurative processes following injuries. Depressed fractures, giving rise to the deformity kno\\Ti as "saddle nose," also require a rhinoplastic operation. 510 THE SURGERY OF THE HEAD 2. Partial loss of both bone and soft parts, caused by sj'philis, lupus, and carcinoma. It may likewise follow injuries. The procedure, under these circumstances, is kno^^Ti as partial rhinoplasty. 3. Complete loss of the organ resulting from saber cuts, shell and gunshot H Fig. 289. — Konig's Osteoplastic Rhinoplasty. A, The upturned tip of the nose restored by a transverse incision ; the lines for the osteoplastic bridge and the integumentary flap appear on the forehead; B, the osteoplastic bridge in place; C, the flap with pedicle, taken from the forehead, sutured in position. Fig. 290. — Partial Rhinoplasty. A, Rectangular flap from healthy part of nose ; B, rectangular flap from healthy part of nose covering the defect. wounds, etc. The operation intended to correct the resulting deformity is known as complete rhinoplasty. Operation for Saddle Nose.— The underlying principle of these oper- ations is that of transplantation of a flap consisting of both bone and skin SOFT PARTS OF THE XOSE AND XASAL CAVITIES 511 * Fig. 291. — Busch's Method of Rhixopl.\stt. Flap used to cover the defect when the septum and the tip of the nose are absent. taken from the forehead to fill the gap in the bridge of the nose that has re.sulted from freeing the tip and restoring it to its proper position (Konig). The bony portion of the flap furnishes a rigid support to prevent the soft parts from again collapsing. In K o n i g ' s original operation a transverse incision is employed to free the upturned tip and permit its re- storation. The resulting gap, which opens into the nasal cav* ity, is filled with an osteoplastic flap, the base of which is at the root of the nasal bridge. This flap is about two and one-half inches long and three-eighths of an inch wide. It is formed by two vertical parallel incisions extending from the root of the nose and united at their upper ex- tremities (Fig. 289). The inci- sions are carried directly to the bone. A narrow groove corre- sponding to the incisions in the soft parts is chiseled in the bone, extending to the diploe. The outer surface is now separated from the diploe, with a flat chisel, do^^TL to its base, broken across at this point, and, together with its skin covering, inserted so that the latter presents to the nasal cavity. The lower edge of the inverted flap is slipped under the skin edge of the lower margin of the original transverse incision and there sutured. The outer or raw presenting surface of the bony portion of the flap is covered by a pediculated flap fashioned from the skin of the forehead. This is brought do^^^l into position by reversing its sur- face through a half tudst at the base of the pedicle, and sutured in place. The gaps in the forehead are closed at once as much as pos- sible. The pedicles are divided when union has taken place. The protuberances left by the pedicles of the reversed flaps, together with the remaining openings in the soft parts in the same situation, are corrected at a subsequent operation. Israel and H e 1 f e r i c h employ a curved incision with its convexity upward to free the top, make the bone flap less Fig. 292. — Partial Rhinoplasty. Method of correcting a defect of the ala nasi. 512 THE SURGERY OF THE HEAD Fig. 293. — Parti.^l Rhinoplasty. Another method of correcting a defect of the ala nasi. than one-fourth of an inch wide, clo.se the .2;ap in the forehead by suturing, and leave the outer presenting surface of the inverted flap to cicatrize. When healing has taken place, the unsightly lump at the base is dispo.sed of by mak- ing flaps from the skin beneath the turned over base of the flap and bringing tliese over to recover the new nasal bridge, whose cicatricial covering is dissected away for that purpose. S c h i m m e 1 b u s c h formed a flap of skin and bone with narrow pedi- cle and broad base, and closed the forehead defect by sliding large cur\-ed flaps. The flap is not tran.s- planted until its parts are well con- solidated, this usually occupying a period of several weeks. Several operations are reciuired to give a good result, which, however, is finally obtained (see Complete Rhino- plasty) . Attempts to transplant detached plates of bone from the tibia, decal- cified bone, etc., are not successful for the reason that the posterior surface is exposed in the nasal cavity and leads to suppuration and loss of the bony plate. In comparatively slight deformities in which restoration can be effected without opening the nasal cavity they have succeeded (Lexer). The subcutaneous injection of parajfin has been followed by thrombosis accidents resulting in total blindne.ss. D a w b a r n operates for the correction of nasal bony defects as follows: Dentist's gutta-percha is softened over an alcohol lamp and molded over the nose until it fits the deformity and corrects it. It is then hardened by cooling. The patient is then anesthetized and each nostril packed with gauze well back to pre\'ent blood from flowing into the phar\'nx. A knife is then inserted into the nostril and the skin and perios- teum stripped from the nasal bone on the side of the deformity as widely as possible, care being taken to avoid the infraorbital vessels. In the case of a centrally placed or bilateral deformity it is necessarv to enter both nostrils. The cavity thus formed is packed until bleeding is arrested, when the molded piece of gutta-percha is slipped in through the incision Fig. 294. — Pai;tial Rhinoplasty. K6nig'.s operation for correcting a defect of the ala na.si by transplanting a piece from the auricle. SOFT PARTS OF THE NOSE .VXD NASAL CAVITIES 513 until it occupies the site of the deformity and corrects it. The piece of giitta-pcrcha is held in place by a small roller bandage compress on each side of the nose, and a strip of surgeon's plaster. D a w b a r n claims that gutta-porcha does not produce irritation, remains unchanged, and. even if suppuration takes place, this soon subsides, and the gutta-percha heals in. Fig. 295. — ScHiiiitELBUscn's Complete Rhixoplastt. A. Osteoplastic flap detached from the forehead. 1, 1, Areas of skin removed to permit the sliding of the lateral flaps in position. The dotted lines about the re- mains of the alae nasi show the site of the incisions for the formation of the newcolmnna. B. The osteoplastic flap covered "with Thiersch skin grafts and reversed. The newly formed columna is shown in position. 2. 2, Lat- eral skin flaps approximated. C. Osteoplastic flap sutured in place and the pedicle severed. The stump of the pedicle Ls sutured to the freshened edges of the defect in the glabella region. Partial Rhinoplasty. — Partial de- fects are best corrected by oblic^uely placed and pediculated skin flaps taken either from the forehead or from some other adjacent structure, according to the location of the defect (Fig. 290), care being exercised to have these sufficiently large to provide skin to line the edge of the newly formed ala nasi. The new de- fect is closed, except the opening left for the replacement of a part of the pedicle where the latter is subsequently detached. Complete Rhinoplasty. — K 6 n i g ' s method of transplantation of an osteoplastic flap from the forehead is modified and adapted to complete rhinoplasty. The flap of the skin and bone is cut one and one-half inches vdde. inverted at its base at the root of the nose, and placed temporarily over the defect. After several weeks it becomes thorouglily consolidated by the 34 514 THE SURGERY OF THE HEAD reparative process. It is then divided longitudinally in three sections with a fine saw. The middle section serves for the new bridge of the nose. The lateral sections are separated from their connections above, but still remain attached at the lower end. These are turned doA\Tiward and outward at an angle so as to form a bon}^ tripod to support the tip of the new nose. The outer surface is freshened and covered by skin from the lateral margins of the original defect (Rotter). Or S c h i m m e 1 b u s c h ' s plan of dividing the bone in the center and utilizing each half to form bony walls for the new nose in its entire length may be followed. In this method a large flap is taken from the forehead in the same manner as in the operation for saddle nose. The base of this flap before it is inverted is from three-fourths of an inch to an inch wide and its upper end from two to two and one-fourth inches wide. The defect in the forehead is closed at once by a plastic proce- dure (Fig. 295, A). After the separation of such necrotic portions of the bone as fail to survive (usually from four to eight weeks afterward), the granulating surface of the flap is covered by Thiersch's strips. When the heal- ing of these is completed, the flap is sawed lengthwise to the depth of its bony portion so that it can be shaped like a double-pitched roof (Fig. 295). The flap must now be reversed. This is done by loosening the pedicle so that a half-turn can be made in it. By this maneuver the normal skin aspect of the flap looks outward, and the Thiersch-covered side presents inward, or toward the nasal cavity. The edges of the defect, both bony and soft, are now freshened, and to these the freshened edges of the bony flap are adapted and sutured. Where sufficient tissue is present, a new columna may be formed (Fig. 295, B). In order to obviate the tendency of the new bony lateral walls to spread, and at the same time to provide for the normal depressions on each side above the nostrils, a silver wire is passed through from side to side and twisted over pieces of rubber tubing. Finally, when union of the flap is assured, the pedicle is severed. Reposition of the stump left is effected by suturing it to the freshened region of the glabella. The construction of a sep- tum is useless as far as aiding to maintain the shape of the tip is concerned. A celluloid support or silver double tube answ^ers the purpose much better. Eventually this need be worn only at night. THE FRONTAL SINUSES These are accessory to the nasal cavity, with which they communicate through the infundibulum. They are situated one on each side of the nasal spine, between the two tables of the frontal bone, and are separated from each other by a thin bony partition and from the cranial cavity by a thin bony wall which is continuous with the internal table of the rest of the skull (Fig. 296). They are absent at birth, but appear in early childhood. Up to puberty they remain of small size, when they enlarge coincidentally with recession of the brain. They are lined with mucous membrane which is continuous AA'ith that hning the nasal cavity through the infundibulum. Injuries. — These are usually the result of direct violence, such as knife thrusts, sword cuts, projectiles, flying fragments, horse kicks, blows of the fist, falls on the face, and the hke. The resulting lesions are generally those of THE FRONTAL SINUSES 515 fracture, either a simple fissure with or ^^•ithout indentation, a compound comminuted fracture, or a punctured fracture. These injuries occur almost invariabh' in the anterior wall. Fractures of the cranial wall are quite generally fatal. Hematoma of the sinus usually coexists. The symptoms are either local or cerebral, or both. Epistaxis and pain are practically the only symptoms present in simple fracture. The epistaxis may be absent in compound fracture. The lining membrane of the injured smus is sometimes detached. The escaping secretion may simulate brain substance. Subcutaneous opening of the sinus may lead to adjacent subcu- taneous emphysema (pneumatocele). Infection of the injured parts readily follows exposure of the cavity of the sinus, and abscess, periostitis, necrosis fistula, and intracranial complications may result. In the absence of in- fection, healing is the rule. Hemorrhage from the sinus in simple fracture may sometimes be detected by rhinoscopic examination. Sinusitis with empyema of the frontal sinus may follow undetected fractures or simple contusions. Treatment. — In all open injuries an- tiseptic irrigation and drainage must be practised. The possibility of intracra- nial complications should be borne in mind. The opening should be enlarged, the sinus thoroughly cleansed, spiculas of bone and foreign bodies removed, the cranial wall examined for possible injury, and the cavity drained. In very extensive wounds a subsequent plastic operation may be re- quired. Pneumatocele is best treated by the application of a bandage and compression. Fig. 296. — Horizontal Section through THE Frontal Sinus. 1, Frontal bone; 2, frontal sinus; 3, frontal aperture ; 4, frontal septum ; 5, crista. INFLAMMATION OF THE FRONTAL SINUS (FRONTAL SINUSITIS) This may be either acute or chronic. The acute form generally results from a coryza, particularly in epidemic influenza. Symptoms.— These include headache, sometimes accompanied by fever, vertigo, vomiting, etc. Ocular symptoms observed are lacrimation,"^ photo- phobia, colored vision and spectra. There is a sense of pressure, with the occasional occurrence of edema of the upper eyelid and exophthalmos. The smus outlet may become obstructed, by edema, in which case the escape of the secretions by way of the nose is prevented and accumulation takes place. In the majority of cases the onset is sudden and the course of the disease brief; it usually terminates in the first week in evacuation, \\ith subsidence of the symptoms. In a certain proportion of cases the disease "becomes chronic. Periostitis of the walls of the sinus, particulariy of the orbital wall, may occur. Ulceration and necrosis of the bony wall ensue with resulting infection of the orbit, or the latter may occur Anthout previous organic changein the bony wall. Intracranial lesions may follow eariy in the case and occur in the same manner, in both instances the infection taking place from thrombophlebitis of the veins which traverse the walls of the sinus. Intracranial infection may be followed 516 THE SURGERY OF THE HEAD by extradural and intradural abscesses, meningitis, encephalitis and cerebral abscess, thrombosis of the superior longitudinal sinus, etc. Chronic frontal sinusitis, as a rule, is a sequel of the acute affection. It may, ho^ve^'er, be due to an extension of an ozena or to traumatism. The frequency with which chronic sinusitis follows the acute disease is due to the fact that the anterior ethmoid cells are usually invoh'ed; with the subsidence of the acute inflammation of the sinus the ethmoiditis frequently remains as a source of infection. One frontal sinus may infect its fellow with or without perforation of the septum. Chronic frontal sinusitis may terminate in dilata- tion of the sinus or destruction of its bony Avails and abscess. The symi)toms may continue as in the acute stage (headache and reflex ocular disturbances) or they may subside altogether. Dilatation may develop in a short time or it may occupy years. The sinus may attain the size of a pigeon's egg or it may have a capacity of several ounces. The orbital wall usually yields first, though the entire bony capsule may suffer, molecular absorption of bone taking place in both instances. Distention of the sinus may also occur through accumula- tion of mucus (mucocele) or mucopurulent material. In about 75 per cent of the cases of mucocele the outlet of the sinus is closed. Termination by ulceration of the lining membrane of the sinus, followed by caries or necrosis of the sinus wall and abscess, is nearly twice as common as the dilating variety. The manifestations of the disease may not occur for a long time (after the first year in one-sixth of 100 cases, K i 1 11 a n), the infection following a persistent anterior ethmoiditis. Sequestra form in cases of necrosis. The orbital wall is affected in about two-thirds of the cases, the cranial wall and the frontal wall being affected about equally in the remaining cases. As in acute sinusitis, a considerable percentage of cases of infection of the orbit and encephalon occur without demonstrable lesion of the bony wall. Cerebral abscess is the most commonly produced lesion in these cases. The symptoms of the destructive and purulent fonn of chronic sinusitis vary greatly. Pyorrhea nasalis may be abundant and fetid. Pain is often a prominent feature. Orbital abscess may occur. Swelling of the lids and displacements of the globe produce diplopia. Fistulous openings may follow spontaneous rupture. Optic neuritis may occur as a complication. The symptoms of intracranial infection closely resemble those which follow dis- eases of the middle ear. In the diagnosis of suspected chronic dilating sinusitis (the "latent sinu- sitis" of some authors) cocainization of the middle turbinate and the use of a nasal specuhim with blades adapted to the examination of the middle meatus will be of service. As a routine procedure, however, the general surgeon will resect the middle turbinate and pursue the investigation with either the probe or the cannula. The dangers arising from the use of the probe must be borne in mind ; at least two fatal cases are on record due to perforation of the cranial floor by the instrument. As soon as the bent end of the instrument is an inch above the anterior process of the middle turbinate it should be within the sinus (Fig. 297). The Rdntgen rays may be of service in localization of the probe. A sudden gush of pus may follow the introduction of the probe into the outlet of the sinus. This may be due to the evacuation of an empyema of the sinus, or there may be anomalies of the ethmoid cells, the pus coming from an anterior ethmoiditis. These two affections frequently coexist. If THE FRONTAL SIXUSES 517 pus does not follow the introduction of the probe, a fine cannula should be substituted and air forced in with the view of forcing out the pus. Tender- ness is also an important diagnostic symptom, and when this is conjoined with orbital cellulitis, the diagnosis is placed beyond a doubt. Chronic em- pyema of the frontal sinns may lurk beneath the clinical picture of trigeminal neuralgia. A further diagnostic sign is a crackling sound produced on pres- sure, due to attenuation of the sinus walls. If exploration with the probe fails, the surgeon should make an exploratory- puncture from without rather than assume the risks of a puncture from the direction of the nasal cavity. The operation may be both exploratory- and curative. Simple dilatation is recognized by the local deformity and displacement of the e^e, the usual absence of pain, the slow progress of the case, and the parchmentlike crack- ling on palpation. Ulceration is announced by circumscribed periostitis, abscess, perforation, fistula, or caries. Cerebral complications 'nill give rise to characteristic symptoms. In exploratory^ operations it should be remem- bered that cerebral complications occur \^ithout perforation of the sinus waU. In doubtful cases it will therefore be necessary- to expose the dura, and even to incise this if it shows evidence of in- fection, and to explore the cortex. Treatment. — Acute frontal sinusitis requires, as a rule, only expectant treat- ment, such as rest in bed. diaphoresis, warm applications to the brow, inhala- tion of hot steam, politzerization and cocainization of the nose, and the ad- ministration of such remedies as phe- nacetin, salol. etc. If relief is not ob- tained, the middle turbinate should be resected and the sinus irrigated with warm saline solution. If the symptoms still persist and the encephalon is threat- ened, the sinus should be laid open from without. It may be necessary to enter the cranial cavity through the frontal wall to gain access to an abscess of the frontal lobe and effect its drainage. In chronic frontal sinusitis it has been recommended to resect the middle turbinate as a routine procedure (Hajek). This operation of turbin- ectomy is tantamount to a radically curative operation prior to the occur- rence of destructive lesions. Xotliing is to be gamed by it after suppurative compHcations have occurred. It is performed \\"ith the cold snare; one-third of the bone is removed. For the first one or two weeks after its performance an increased amount of secretion occurs, after which time mucus alone is discharged, which discharge finally ceases after a month or two. The method has only a limited range of apphcation. and that in the hands of the expert rhinologist. It is inadequate to meet the indications in severe cases. The operation of choice consists of an exploratory opening of the sinus, followed by simple irrigation if the bone is healthy and the mucosa free from polypoid hypertrophies. The irrigation is repeated daily (K u h n t) . In Fig. 297. — Sagittal Section" theough the Froxtal Sixrs. Showing the probe passed into the sinus from the middle meatus (after Lichtwitz). 518 THE SURGERY OF THE HEAD suitable cases extirpation of the mucosa is the preferable operation (K o c h e r). This may be accomplished after entire removal of the anterior ^^■all through verti- cal and horizontal incisions (N e b i n g e r, P r a u n) ; or after removal of the orbital wall (J a n s e n) ; or by opening the sinus through the frontal wall, temporary resection of the corresponding nasal bone with the breaking up of the infundibular cells to insure a permanent communication and free drainage by way of the nasal fossa (K i 1 1 i a n). A narrow briclge at the orbital margin is preserved to prevent disfigurement (Fig. 298) . This form of intervention also gives- access to the ethmoid labyrinth. In operations on the frontal sinus from without the posterior nares should be plugged, the incision made through the eyebrow, an exploratory puncture made through the incision, and the sinus entered by either removal of the walls or a temporary osteoplastic resection of the same. Resection of the nasal bone and division of the nasal process of the superior maxillary bone are accomplished through a prolongation of the original inci- sion. A chisel is used in the last step men- tioned, and a small portion of the frontal bone is likewise divided. Diseased ethmoid cells are removed with bone forceps and the curet and a communication established be- tween the sinus and the nose. A'o irriga- tion is permissible until two or three weeks have elapsed (W inkle r) . Foreign Bodies. — In the majority of cases foreign bodies in the frontal sinuses have consisted of projectiles, chiefly from old-fashioned firearms. These may heal in the sinus and remain indefinitely, but, as a rule, a fistula results. Sinusitis is invaria- bly set up. Metallic foreign bodies are easil}' discoverable at the present day by the use of the Rontgen rays. There are a number of ancient cases recorded in which animate foreign bodies have gained access to the sinus, mature insects or larvae having reached there through the nasal cavities. Tumors of the Frontal Sinuses.— Of the benign growths of the frontal sinuses osteoma is the most important. Polypi and cysts are regarded as essential features of chronic inflammation. Even osteomas are held by some to be of inflammatory origin. They may be attached to the bone by a broad base or pedicle or embedded in the mucous membrane, or they may lie loose in the cavity of the sinus. They are essentially confined to the period of child- hood and adolescence. The nucleus and pedicle are cancellous. They may attain the size of an orange, separating the walls of the sinus and encroaching on the cranial cavity and the orbit. The functional disturbance is slight in this slow gro^Adng tumor, though exceptionally ocular disturbances, compression, etc., are produced. They may be complicated with sinusitis; they may simulate dilating sinusitis, so that an exploratory puncture may be necessaiy for the differentiation. Fig. 298. — Frontal Sinus, the Ante- rior AND Inferior Walls of which have been removed, with the Exception of a Narrow Bridge Corresponding to the Orbital Margin. O. B., Orbital bridge (after Killian). THE JAWS 519 The treatment of osteoma is ininiediate extirpation under the most careful asepsis. Of malignant growths orighiating in the frontal sinus, sarcoma is alone to be considered. In the recorded cases the disease advanced rapidly and invad(>d the contiii-uous cavities early. Carcinoma has never been kno'\\Ti to originate in the frontal sinus and c\-en seconcUa-y invasion is of extremely rare occurrence. THE JAWS Fractures of the Superior Maxillary Bone.^These arise principally through direct violence, as, for instance, a blow from a bludgeon or a stone, a kick from a vicious horse, suicidally ■ffiflicted gunshot injuries from the direc- tion of the cavity of the mouth, etc. Fractures of the alveolar processes were formerly quite common, arising from the use of the old-fashioned lever or "kev" used in tooth extraction. Occasionally complete separation of both upper jaws from their surroundings and attachments has been observed. Fracture of the body of the jaw, beyond a simple fissure in the wall of the antnnn, is somewhat rare; the processes, as a mle, receive the force of the blow. Transverse fracture of both bodies of the upper jaw may be produced, never- theless, by a blow received on the face just below the nasal bones, and a vertical fracture, running through the median suture of the palate and separating the two superior maxillas, may result from a blow on the chin. These fractures are not dangerous in themselves, but complicating con- ditions that threaten life ma}- occur. The first in importance of these is hemorrhage from the internal maxillary artery. This is most likely to occur in gunshot injuries. The next most important compHcation is injury of the infraorbital nerve, producing paralysis in the distribution of the nerve. Intractable neuralgia may likewise follow transverse and oblicjue fracture from final involvement of the nervc-tnmk in the callus. Suppurative inflammation of the antrum may also occur in comphcated and compound comminuted fractures. In the treatment of fractures of the alveolar processes but little difificulty is experienced in replacing the fragments, since these are usually displaced in the direction of the oral cavity. They become easily displaced again, however, from the movements of the tongue, and measures must be taken to retain them in position. This is best accomplished by wiring the teeth of the fractured portion to adjoining teeth that are firmly fixed. On no accomit should the fragments be removed without a thorough trial of conservative measures, including the interdental splint (see page 522). Fractures of the body of the bone reciuire no treatment of themselves, yet the comphcations may be of sufficient gravity to demand interference. This is specially true of injury of the internal maxillary artery. Ligation of the conmion carotid artery is useless, owing to the free anastomosis of the internal maxillary with vessels supplied by the vertebral arteries. Partial or temporary resection of the upper jaw will gi^-e access to the bleeding point, and permit the application of the ligature, thermocautery, or tampons. Paralysis folloT\'ing nerve injury may disappear without treatment. In in- tractable neuralgia from pressure of callus t1ie removal of the latter by chisel 520 THE SURGERY OF THE HEAD and mallet is indicated (for the Treatment of Suppurative Inflammation of the Antrum, see page 529). Luxation of the Malar Bone. — This can occur only from the aiDpli- cation of great force. The bone ma}' be loosened from all its connections with the upper jaw and frontal and temporal bones. Replacement and re- tention of the displaced bone in position are accomplished without difficulty. Fractures of the Inferior Maxilla.— Fractures of the lower jaw, like those of the upper jaw, may involve the alveolar processes or the body of the bone. The remarks already made in connection ^\■ith the fracture of the alveolar processes of the upper jaw will apply to those of the lower jaw as well. In fracture of the body of the lower jaw the line may pass transversely so as to separate the whole of the ascending ramus. Fracture of the condyle, as well as of the coronoid process, may also occur. Owing to the pro- tection afforded by the parotid gland and masseter muscle, fracture of this portion by direct force is rare. Fracture by indirect force, the latter being transferred through the mandibular arch, is likewise rare, the latter structure, being less resistant than the ramus, giving way first. Fracture of the coronoid has been observed as the result of muscular action. This fracture unites only by fibrous tissue, the strong vascular tendon of the temporal muscle, which does not produce bony callus, replacing the periosteum at this point. It is diagnosed by palpation with the finger in the mouth. Pain will be felt on pressure and displacement of the process will be observed. Transverse or oblique fractures result either from direct force, as gun- shot wounds or blows from a horse's shoe, or from indirect force, as compres- sion by falls on the chin or simultaneous pressure at both angles of the jaw. They occur at the weakest portion of the bone, i. e., in the region of the bicuspid or first molar tooth. Both artery and nerve are torn; hemorrhage, however, is rare, but there is usually loss of sensibility in the front teeth and the skin covering the chin. The displacement of the fragments is peculiar. The fracture occurs at one side of the median line, a shorter fragment corre- sponding to the injured side, and a longer fragment corresponding to the un- injured side. The muscles which close the jaw (temporal, masseter, pterygoid) are attached to the former, while to the latter are attached those which open the jaw (mylohyoid, geniohyoid). The shorter fragment is dra^ATi upward, approximating the attached teeth, while the longer fragment is dra\\Ti dowTi- ward, separating the teeth attached to it from those of the upper jaw. In addition, the shorter fragment is drawn toAvard the median line by the action of the pterygoids. Occasionally the bone gives way in two places, the central portion being dragged doA^^lward by the mylohyoid muscles. In addition to the typic displacement, splintered fragments may be displaced in various directions. The disturbances of function are marked. Mastication is impossible, the mouth remains partly open, the saliva dribbling. Speech is diflficult, owing to inability to form the labial and sibilant sounds. Swallowing is also A^ery much embarrassed. The fracture is usually complicated "with a wound of the mucous mem- brane and sometimes with a wound of the external soft parts as well. Infec- tion from the mouth is common and septic bronchitis and septic pneumonia may occur from the passing of the inspired air over the putrid Avound secretions. TIIK JAWS 521 The diagnosis does not prosont marked difficulty unless there is very great obliquit>' of the lino of fracture, in which case the mobility of the fragments can he demonstrated only by grasping the bone with both hands. Treatment of Fracture of the Lower Jaw. — The mouth is to l)e irrigated frec^uently with a boric acid solution or permanganate of potash, and in the intervals a pledget of cotton saturatetl with a 3 to 5 per cent solution of chlorid of zinc should be kept applied to the wound in the mucous membrane. The food must be liquid and always followed by irrigation and renewal of the chlorid of zinc pledget. Feeding is best car- ried on by means of a rubber tube and funnel. If there is a complicat- ing external wound, a drainage-tube maj^ be inserted, or if necessary an opening may be made for that pur- pose. If the fragments can be held in place by simple approximation of the lower to the upper teeth, measures to maintain this approximation are in- dicated. A Barton bandage or one of its modifications is usually em- ployed (Fig. 195). In order to secure direct upward pressure on the mandible the following device is useful : A strip of tin 5 inches wide in front tapering to 3 inches posteriorly, with the anterior end bent upward to form a projecting shelf, is fitted to the head, to which it is secured by a circular plaster-of-Paris bandage. The anterior curved end projects from the forehead and strips of adhe- sive plaster pass from the shelf do^Miward and backward beneath the jaw, exerting traction up- ward and forward, this o^'ercom- ing the posterior displacement (K n a p p) . Or the head may be encased in a plaster-of-Paris cap in which two projecting iron arms are incorporated, the latter serving as points of support for the strips of adhesive plaster that pass beneath the mancHble (Fig. 299). The Interdental Splint. — When this method of treatment can be made available, it is by far the best method for fractures of the mandible. The Fig. 299. — Apparatus for the Treatment of Fracture of the Lower Jaw. Fig. 300. — The Articulator. 522 THE SURGERY OF THE HEAD patient's mouth and teeth are carefully cleaned beforehand. It may be neces- sary to administer a general anesthetic. An impression is taken as for upper and lower dentures, no attempt being made to reduce the fragments. The method of procedure is as follows: The ordinary modeling cups of the dentist are filled with yellow beeswax; the latter is gradually heated over an alcohol flame and worked with the fingers until it is soft. Impressions of the upper and ^^^^^^^K' r 'Vf-v,.^ ^^^^1 ^^^^^' ^^^ ^--y^^i ■ I ^^^^^^^^^1 Hr^ ^^m ^K^^^^ ^^^^^^^^^^^^^^^^^^H ^HH Fig. 301. — Plaster-of-Paris Models of Upper and Lower Teeth Molded in the Articulator. A, Cast of fracture of the lower jaw; B, the same after the site of the fracture has been sawed across and the normal relations of the parts restored. the lower teeth are taken and the wax allowed to harden. A plaster-of -Paris cast of the upper jaw is then made and this is secured by means of plaster cream to the upper arm of an articulator (Fig. 300). In the same way a cast of the lower jaw is made, the site of the fracture recognized and marked, and the cast sawed in two at that point in a line corresponding as nearly as possible with the fracture. The two pieces of the cast of the lower jaw are now brought into their proper relation so that the lower and upper teeth articulate normally; they are then fast- ened together by means of plaster cream on the lower arm of the articulator (Fig. 301). On this model of the reduced frac- ture an interdental splint of vulcanite (Fig. 302) is made by a mechanical den- tist. The splint is trimmed so as not to impinge on the gums. In placing the splint in position it is first adjusted to the upper teeth; the teeth of the lower jaw are now forced into the recesses made for them on the corrected model, the displacement thus being rectified. Suitable bandages (Barton's or a modification thereof) are apphed so as to hold the lower jaw firmly in place against the splint. The latter is worn for from thirty to fifty days. The interdental splint is suitable for the treatment of fractures through the dental arch. Various slight modifications of its form may be rendered necessary Fig. 302. — Interdental Splint of Vul- canite. THE JAWS 523 for feeding purposes so as to take advantage of any gaps in the teeth that may exist. In fractures in the region of the molar teeth special care must be exercised not to separate the jaws any wider than is absolutely necessary in the applica- tion of the splint, lest failure of the front teeth to articulate when the healing is completed result. Here the portion of the splint interposed between the teeth should be as thin as is consistent with strength, for it is e^'ident that the greater the separation of the jaws, the greater will be the stress on the posterior fragment. The thin gold splint of Ottolengui (Fig. 303) answers the purpose best under these circumstances. If the fracture is in front of the bicuspid teeth, a short splint or a simple capping of the lower teeth in cases where there is little de- formity will fulfil all require- ments. In cases of double fracture an interdental splint is indis- pensable; if one break is at or near the angle, the splint should be as thin as possible so as to avoid increasing the deformity at this point. Roberts's Method. — A den tal splint is made, as in the method last described. This is held in position by one or two loops of silver wire, the ends of which are passed through the soft parts close to the anterior and posterior surfaces of the body of the jaw, by means of a needle, and secured externally by being twisted over a roll of gauze covered by rubber tissue, or a piece of heavy rubber tubing. Necrosis of splintered fragments may require subsequent removal union previously obtained is not generally disturbed by such removal. Matas's Adjustable Metallic Interdental Splint. — This apparatus is designed with the object of immobilizing the broken fragments of the jaw without restricting its movements as a \vhole, so that it permits the mouth to be opened and closed at will. It is specially adapted for compound fractures of the symphysis and body of the jaw. It consists of the following parts: 1. A detachable dental plate or mouth-piece, made of block tin (Fig. 304). This is hollowed to fit loosely over the crowns of the teeth. Its edges form two flanges which project downward, the one on the outer or buccal side ex- tending to the neck of the teeth, while the one on the inner or lingual side is longer and almost touches the gums when applied. Two partial sections of the splint are made approximately on a level with the bicuspids; they include the width of the splint to its outer rim. These sections are for the pur- FiG. 303.- GoLD Interdental Splint (.after Otto- lengui). For use in cases of fracture posterior to the last molar. A, The splint; B, the splint shown in place on the plaster model. The 524 THE SURGERY OF THE HEAD pose of increasing the inflexibility of the splint, thus facilitating its adaptation to different forms of the lower dental arch. The hollow groove or gutter in the splint can be filled with dental wax; this serves to hold loose teeth in place, to reduce the mobility of the splint to a minimum, and to overcome the difficulty of ()]:>taining a uniform compression caused by the vertical irregu- larities of the teeth. The splint is made in three sizes. Fig. 304. — Matas's Adjustable Splint for Fracture of the Lower Jaw. A, Upper ^^ew; B, lower view, showing partial sections cut in the soft block-tin mouth-piece to facilitate adaptation to different forms of the lower dental arch (after Matas). 2. An adjustable chin-piece made of perforated aluminum, shaped to fit the contour of the lower jaw, and secured to the lower arm of the clamp by a thumb-screAv (Fig. 305). In order to prevent injurious pressure on the skin, the chin-piece is padded with cotton wadding or felt covered with gauze smeared with oxid of zinc ointment. 3. A clamp which holds the mouth-piece and chin-piece to- gether. This consists of an upper and lower arm connected to- gether by a joint, and capable of adju.stment by means of a screw attached by a swivel joint to the uj)per arm (Fig. 305). The pressure required to hold the in- terdental splint and chin-piece firmly in position when applied is obtained by this screw. Where extensive comminution is present, the block-tin inter- dental splint may be used with- out the clamp and chin-piece, the latter being substituted by a molded chin splint made of coarse flannel thoroughly soaked in plaster cream, and held in place by a plaster-of -Paris or a starch bandage. After reducing the fracture and restoring the contour of the dental arch, preferably under an anesthetic, the splint is fitted to the arch of the teeth by molding Avith the fingers. If the dental wax is used, this is softened in hot Fig. .305. — Matas's Adjustable Splint for Fracture OF the Lower Jaw. 1, Block-tin interdental splint; 2, clamp adjusted and tightened with a screw ; 3, chin plate of aluminimi, which can be moved backward and forward and secured by the screw 4 (after Matas). THE JAWS 525 water and spread over the gutter surface of the splint; the sphnt is then apphed and held in place until the dental wax cools. The clamp is attached Fig. 306. — Matas's Adjustable Splint for Fracture of the Lower Jaw. Shown on the adult skull. A, Front view; B, lateral view (after Matas). to the splint after the latter has been adjusted to the jaw, by means of a hook at the tip of the clamp, which fits in a groove or slot in the center of the inner surface of the splint. If great swelling takes place, or necrosis of the skin of the chin is threatened, the pressure of the screw must be relaxed from time to time. Freciuent irrigation of the mouth must be practised. Dislocations of the Lower Jaw. — A meniscus separates the two articular surfaces of the temporomaxillar}^ articulation, constituting what is called a "double joint." The opening and closing of the mouth, the forward and backward move- ments of the jaw, as well as those made in grinding, and marked by a simultaneous back- ward movement of one condyle and a forward movement of the other, are performed through the medium of this interarticular cartilaginous plate. In spite of its apparent great freedom of motion dislocation occurs in but one direction, namely, forward (Fig. 308), and then usually by forcible efforts at opening the mouth (gaping) . During this act the condyle, Fig. 307. — Matas's Adjustable Splint for Frac- ture of the Lower Jaw. The splint is adjusted in position. The apparatus is held in place by a Gibson or Barton bandage (after Matas) . 526 THE SURGERY OF THE HEAD with the meniscus, is forced on the articiihir eminence, and, in case tlie poste- rior wall of the capsule gix-es way, the condyle with the meniscus is carried in front of the articular eminence, from which position tiie masseter is unable to extricate it by attempts at closing the mouth. Lax conditions of the capsule, either congenital or acquired through nutritive disturbances, predispose to the accident. In such cases clicking sensations referred to the joint and due to abnormal movements of the meniscus (a form of subluxation) occur. External force, such as a blow on the teeth when the mouth is wide open, may give rise to the dislocation. Habitual Dislocation. — After a dislocation has once taken place, the condition may occur from slight causes. This is due to the formation of a broad cicatrix during the process of healing of the torn capsule. 1 1 ■ 2 in^^Jl ^ ^^^B J, M » ' f - /^^tf^H i^wF ^ 1^ i^^ti ^/^KK ^ 1 ^V^' -^ ^^^^«f-'' . '■ ^ ^ Fig. 308. — Dislocation of the Mandible. Method of reduction by a pry made of a piece of splint material covered with a bandage. Dislocation of the jaw is very rare in children. This is due to the fact that the articular eminence is absent, and hence there is no obstruction to the sliding movements of the meniscus when this is thrown forward as the mouth is widely opened. S3maptoms. — The open mouth, dribbling saliva, and projecting front teeth form a characteristic clinical picture. With the index-finger introduced into the external meatus auditorius the normal depression felt when the mouth is opened is found to be greatly exaggerated. The prominence of the coronoid process is carried anteriorly and is felt below the middle of the zygomatic arch. Treatment. — Reduction is accomplished by pushing both coronoid proc- esses below the articular eminence. The thumbs of both hands are placed THE JAWS 527 with the palmar surfaces downward on the lower molars of each side, the points of the fingers resting on the lower edge of the bod}- of the jaw, and the two little fingers meeting beneath the point of the chin. The back molars are pressed downward, and at the same time the point of the chin is elevated by the two little fingers. Or, a pry may be improvised from a common desk ruler, or piece of splint material covered with bandage muslhi (Fig. 308). In some cases it may be necessar}- to make pressure on the coronoid process from within the mouth. In old cases Stromeyer's forceps, constructed so as to grasp the lower molars and the chin, afford a longer leverage for the manipulation. In cases otherwise irreducible, open incision and removal of the obstruction to reduction, or resection, may be performed. Unilateral dislocations of the lower jaw are ver}' rare. They are reduced without difficulty by the manipu- lations already described. In an intractal^Ie case of habitual dislocation of the lower jaw I succeeded in correcting the tendency to recurrence by the following operation: The parts were exposed through an incision, the temporomandibular articulation opened at the site of the external lateral ligament, a portion of the latter removed so as to shorten the ligament, and the eminentia articularis chiseled aw^ay. The external lateral ligament was then sutured and the external wound closed. Inflammation of the Gums. — Subperiosteal or alveolar abscess, the result of caries of the teeth, may advance from the alveolus and find its way beneath the gum. These suppurative processes should ])e o]^cned early and treated by an antiseptic mouth-wash. Metastatic (pyemic) abscesses may result from their presence. Their recurrence, or the persistence of a fistulous opening, usually requires the removal of the offendmg tooth. If this is neglected, the pus may finally burrow beneath the periosteum and other fistulous openings form; or, the pus may continue to burrow, reaching the region of the angle of the jaw, or that of the symphysis menti in the inferior maxilla, or the infraorbital region in the superior maxilla, pointing externally. This development of suppurative periostitis of the jaw is accompanied by swelling of the soft parts, pain, and occasionally high fever. Multiple pyemia may develop as a consequence, or life may be threatened, in the case of the upper jaw, by an extension of inflammation along the nerves to the base of the skull. Usually, however, the affection pursues a favorable course. Free incision and antiseptic treatment promptly relieve the symptoms, but a fistula leading to the carious root of a tooth or to a necrosis of the alveolar process is left. The tooth must be extracted and all diseased portions scraped away. In more extensive necrosis of the jaw sequestrotomy is necessar}', the fistulous opening being utilized for a portion of the incision for this purpose, if it is found impracticable to remove the sequestrum from the inside of the mouth (intrabuccal sequestrotomy), a procedure always desirable, on account of the cosmetic effect. This will be facilitated by waiting until the sequestra have become loosened, free drainage and antiseptic treatment being employed in the meanwhile. The cutting of a wisdom tooth in adults may be so painful as to recpire an incision at the hands of the surgeon. Gingivitis. — This is an affection in which the edge of the gum surrounding the tooth is inflamed and sometimes ulcerated. It originates from septic inflammation arising from decomposition of food. It appears as an epidemic 528 THE SURGERY OF THE HEAD affection, occasionally several children in the same family being attacTced, The affection readily yields with the use of an antiseptic mouth-wash, such as permanganate of potash or chlorate of potash. Cleansing the ulcerated edges with absorbent cotton dipped in a 2.5 per cent solution of carbolic acid is useful, in conjunction with the above. The affection should not be confounded with scurvy. Lead Poisoning. — This gives rise to a peculiar grayish-blue discoloration of the gums. I'lcerative destruction of the gums is observed as a result of mercurial stomatitis. Deposits of tartar may also give rise to inflammation and ulceration of the gums. Necrosis of the Maxillary Bones. — In addition to necrosis resulting from suppurative periodontitis already mentioned, which gives rise more commonly to small sequestra, the two following diseases, though rare, con- stitute much more serious affections. Phosphorus Necrosis, — Employees of match factories, prior to the en- forcement of certain hygienic rules, suffered from this disease. The etiology of the affection is obscure. It appears to be due to the exposure of carious teeth to the fumes of the phosphorus, though a bacteriologic origin has been suggested, the phosphorus in some unknown manner favoring the development of the fungi. The sequestra separate very slowly, and new bone forming over the diseased osseous structure, if exposed to the phosphorus fumes, in its turn becomes diseased. The processes are exceedingly putrid; septic bronchitis and pnetmionia may supervene, or even general infection ensue. Early antiseptic treatment is imperative. Necrosed portions of bone are to be removed. This more frequently involves a resection of the entire bone than a sequestrotomy. If the periosteum is preserved or an in- volucrum of healthy bone has formed, reproduction of the entire bone may take place. Acute Infectious Osteomyelitis. — This occurs exclusively in the lower jaw, as it alone possesses a medullary cavity. It is an exceedingly dangerous affection, though of slow development. It may follow the exan- themata of children. The treatment consists in early and free incisions. Edema of the glottis and subsequent suffocation may occur after inflammation of the soft parts. Intrabuccal sequestrotomy should be performed, whenever practicable, to avoid extensive cicatrices on the face. If external incisions cannot be avoided these should l^e placed along the line of the jaw. Necrotic Caries. — This attacks by preference the superior maxillary bone at the infraorbital ridge, and the malar bone. It is usually of tubercu- lous origin. The treatment consists in the vigorous application of the sharp spoon or the removal of small secjuestra. An ugly depressed scar results; this may lead eventually to ectropion, and require the operation of blepharo- plasty (see page 495). Inflammation of the Antrum of Highmore. — Inflammation of the antrum, or maxillary sinus, occurs either from extension of catarrhal rhinitis through the lower nasal duct, from frontal sinusitis, ethmoiditis, various nasal obstructions, such as nasal polypi damming up the secretions in the middle meatus (C r y e r) and enlarged middle turbinates, from extension of inflammation from periodontitis, particularly of the posterior molars, or from suppurative periostitis of the walls of the superior maxillary bone. The dis- THE JAWS 529 f^ase occurs only in adult life; the antrum is not developed in childhood.* The right side is affected in 75 per cent of the cases. Five cases out of 140 were bilateral (C line). Hydrops of the Antrum.— This arises from a serous inflammation of the lining of the antrum; this latter is the most common of the affections of this cavity. The opening conununicating between the antrum and the nasal duct is small and easily closed b}- a slight inflammator}- swelling, an accumulation of the products of inflammation resulting. The portion of the maxillary \\-all corresponding to the canine fossa becomes bulging, and even the entire half of the face may become unduly prominent. The con- dition may simulate malignant disease of the superior maxillary bone. In the latter, however, the tumor develops through the palate and nasal fossa, while in the former these structures are the least affected. In malicrnant dis- ease the bony wall of the canine fossa is converted into a softmass; in hydrops this usually becomes thinned so that palpation discloses the so-called parchment crepitation. If the bone preserves the normal consistency or becomes thickened by inflammatory irritation, this crepitation niav be absent. Other causes of hydrops of the antrum are said to be abnormal growths of a wisdom tooth (McCoy), polypi and mucous cysts, or cystic degeneration of the mucous membrane (A d a m s , W e r n b e r). Suppurative inflammation may develop from a simple hydrops or from suppurative inflammation of the adjacent molars. The occurrence of suppura- tion is marked by pain, fever, and edematous swelling of the cheek. The disease may terminate in perforation of the bony ^vall of the antrum, particu- larly at the inner portion of the infraorbital ridge, or the periosteum of the antrum may become attacked and necrosis result. Treatment.— Acute cases of simple serous inflammation of the antrum usually subside \Althout operation. Operative measures are demanded, how- ever, both in chronic serous inflammation and in suppurative inflammation. If crepitation is present, an incision may be made at the thinnest part as an emergency measure. This can almost alw^ays be accomplished from within the mouth by passing the blade of a stout knife from the direction of the gums. If a carious tooth or the roots of a tooth are present, the extraction of these will usually open the way into the antrum. If not, a hole may be driUed into the cavity from the bottom of the tooth socket and the contents evacuated. For the radical cure of suppurative inflammation of the antrum the fol- lowing operation best fulfils the indications: The nasal passages are first thoroughl}- cleared of polypi, turbinate hypertrophies, and other causes of obstruction. A curved incision is made at the site of the root of the corre- sponding bicuspid tooth in such a manner as to reflect a flap from the gin- givolabial fold of mucous membrane and expose the anterior wall of the antrum at this point. The latter is then perforated and access gained to its cavity. The opening is enlarged sufliciently to permit the introduction of a curet, and the entire cavity is thoroughly curetted. The nasal cavity is then entered on a level with the lowest point of the antral cavity by per- * Rudaux ("Ann. d. mal. de I'oreille et du lanTix," Sept., 1S95) reports the case of an intant three weeks old, in whom empyema of the antrum was due to the presence of a prematurely developed tooth in the floor of that cavity. The presence of the latter at tins early age, it is presumed, was likewise the result of a premature development. 35 530 THE SURGERY OF THE HEAD forating the inner bony wall from the direction of the latter. This opening should be enlarged by the removal of sufficient bone to allow for subsequent contraction. The mucous membrane flap at the site of the original opening is sutured in place. The subsequent treatment consists in frequent antiseptic irrigation from the direction of the nasal cavity. This is to be continued until the puru- lent discharge into the nasal cavity ceases. The free communication between the latter and the cavity of the antrum insures against a relapse. Malignant growths of the antrum of Highmore occur, both as sarcomas and as carcinomas. Neuralgic pains referred to the teeth at the com- mencement lead to the extraction of the latter. Symptoms of inflammation of the antnnn appear, with mucopurulent discharge from the nose. Swell- ing of the soft parts of the superior maxillary region occurs, with reddening and soft edema. Implication of the skin of the cheek finally takes place. The globe is displaced by the crowding upward of the orbital plate (see Fig. 309), with resulting exophthalmos. Occlusion of the tear duct leads to overflow of tears on the cheek (epiphora). The anterior wall becomes thinned from expansion of the walls of the cavity. The nasal fossa is encroached upon and respiration thereby obstructed. In some cases the alveolar border is depressed. Ulcer- ation of the part projecting into the nasal fossa gives rise to frequently recurring hemor- rhage. Finally, the growth makes its way through the posterior wall and invades the zygomatic and sphenomaxillary fossa, thence passing into the temporal fossa; or it may pass through the sphenomaxillar}- fissure to the orbit, or through the sphenoidal fissure or the foramen rotundum into the middle fossa of the cranium. The mucoperiosteum of the antrum is a common situation for periosteal sarcomas. The disease is most frequently observed in youth and before middle life. Sarcoma as it springs from a tooth follicle is confined exclusively to children. The germ of the first permanent molar is a favorite situation for these growths. Primary epithelioma as it affects the antrum is a rare and insidious dis- ease occurring in patients past middle life. It commences with pain in the upper jaw, followed by a fullness of the parts, edema of the lids, and braA^Tii- ness of the skin of the cheek ; the latter finally breaks do^^'n into an ulcer. The growth extends into the orbit and along the pter\-goid muscles. The lymph- atic glands of the neck are invoh'ed late in the disease. Metastases to internal organs are rare. The treatment demands complete resection of the upper jaw (see page 537). Contracture of the Lower Jaw ; Lockjaw. — This is freciuently due to inflammatoiy conditions in the neighborhood of the mandibular arch and the lower portion of the ascending ramus. Lockjaw of arthritic origin is extremeh' rare. Fig. 309. — Sarcoma of the Antrum. THE JAWS 531 The inflammatory conditions giving rise to acute lockjaw are (1) periostitis: (2) paradenitis following inflammation of the lymphatic glands in the submental and submaxillary region, and of the submaxillar}- sahvary gland; (3) parotitis; (4) aggravated forms of acute tonsillitis with involvement of the peritonsillar connective tissue; (5) osteitis of the lower jaw from any cause: the immobility of the jaw ceases, however. -^Ith the subsidence of the inflammation in the majority of cases. The cicatricial form of lockjaw constitutes a more frequently observed and most intractable form of contracture. This results from the presence of solid cordlike bands of cicatricial tissue following destructive ulcerative changes (noma) which have their origin, as a rule, on the buccal mucous membrane. The acute inflammatoiy suppurative conditions above alluded to may. though rarelv. result in the formation of cicatricial tissue and give rise to cicatricial lockjaw. Bony fusion i synostosis i of the temporomandibular articulation has been observed, though, as before stated, the arthritic form of contractm-e in tliis joint is rare. This articulation, however, is not exempt from the diseases which attack other articulations. Disease of the coronoid process may also give rise to lockia^v. Treatment of Lockjaw. — This -^111 var\- T\ith the origin of the condition. The preventive treatment consists in placing a cork between the teeth, fu'.st locating it between the incisors, then between the canine teeth, and finally between the molars. In the beginning of contracture of inflammatory' origin, including that due to the development of cicatricial tissue, this method may be tried. The operative treatment consists first in attempting to separate the jaw by means of wooden wedges, the patient being placed under an anesthetic. This failing, intrabuccal or subcutaneous division of cicatricial bands may be tried. Usually, however, it will be better to dissect away the cicatricial tissue and supply its place by an attached skin flap from the cheek, passed through a slit in the cheek. The base of the flap is subsequently separated and the slit closed. The formation of an artificial joint in front of the point of cicatricial or bony contracture (E s m a r c h . "W i 1 m s) is a procedure which may be resorted to with advantage. About hah an inch of the bone is removed and mobihty established through subsequent passive movements. This is preferable to Rizzoli's operation of simply sa-^ing through the mandibular arch, for the reason that the latter operation is freciuently followed by reunion of the frag- ments. In convulsive or spasmodic lockjaw operative treatment is of no avail. The older operations of myotomy and tenotomy for this condition should be abandoned. Resection of the condyle is indicated m contractures originating in disease of the temporomaxiUari- articiflation. Diflicidty is usually experienced in remo^-ing the head of the bone from the glenoid fossa. In cases of disease of the coronoid process the latter may become welded to the upper jaw by bony proliferation: this may be di^'ided by the chisel and maUet or narrow saw. Benign Tumors. — The maxillar\' bones, from their pecvihar formation, the processes of dentition, the presence of the antrum, and irritations arising in the oral ca-\-ity. are specially disposed to tumor formation. 532 thf: surgery of the head Subperiosteal abscesses, "when not opened, give rise to a separation of the periosteum, the latter forming a new bony layer. The symptoms of crepita- tion may be present, or the tumor may assume a solid consistency. This constitutes the so-called subperiosteal cyst of the alveolar process. The pus which originally filled the cyst changes to a clear m\icous fluid, Avhich, from the presence of crystals of cholesterin, sometimes looks like butter. These cysts sometimes attain the size of a hazelnut and empty their contents into the antrum. Extraction of the roots of carious teeth is usually sufficient for a cure. If not, the bony wall of the cyst must be incised. Fibromas. — These are of rare occurrence. They develop at or about the twentieth year of life in strong and healthy individuals and sometimes attain the size of a walnut. Their favorite location is the alveolar processes of the canine teeth. Thej^ are generall}' of osteal origin, though they uislj spring from the periosteum. They are usually of almost bom' hardness. The}^ are best treated by resection of the alveolar process from which they spring. Recur- rence after complete removal is not observed. Odontomas. — These are ]3eculiar growths which appear in young in- dividuals. They consist of cystic formations surrounded by bony walls, arising from either tooth germs or the teeth. The cysts contain either a number of teeth, or one giant tooth, the result of the fusion of the germs of several teeth, or fibromatous or chondromatous masses may inclose displaced tooth germs. Their usual location is the neighborhood of the last molar. The treatment is by extirpation. Osteomas of the Maxillary Bones. — These sometimes attain a very large size. They are exceedingly benign, becoming troublesome only by their per- sistent but slow growth, and the great deformity which they produce. The globe may be displaced forT\'ard, and cerebral disturbances may follow their in- vasion of the base of the skull. Visual disturbances are not observed as a result of stretching of the optic nerve, from the fact that this takes place very slowly. Adenomas and chondromas of the maxillar}- bones occupy a midway ground between benign and malignant growths. They are much rarer in their occurrence than sarcomas and carcinomas. Malignant Tumors. — These consist of sarcomas and carcinomas. Of these, the former are the more frequently obser^-ed. The superior maxilla is not infrequently the seat of periosteal sarcoma. It often arises from the mucoperiosteal structure of the gums, though the most common situation is the antrum, in which case it causes considerable enlarge- ment of the body of the bone, encroaching upon the nasal fossae and the orbit, displacing the globe; and occasionally depressing the alveolar border. It may perforate the posterior wall of the antnun and enter the sphenomaxillary, zygomatic, or temporal fossa. It may enter the orbit from the direction of the sphenomaxillary fissure, or, finally, reach the cavity of the cranium through the foramen rotundum or the sphenoidal fissure. It ma}- perforate the antnim at its anterior wall and involve the soft parts of the face. Projections into the nasal fossa are liable to ulcerate and giA'e rise to sanious discharge and hem- orrhage. Sarcomas involving the germ of the first permanent molar may occur in childhood. The disease is rare in infancy, however, occurring most fre- quently after the fifteenth year. As a rule, the sarcoma is of exceedingly rapid groAvth. THE JAWS 533 The nuicoiis membrane of the soft and hard palate may be the seat of sarcomas, which may be mistaken for adenomas or endothehomas. Melanotic sarcoma in this region is very rarely seen. Sarcoma of the Alveolar Process; Epulis. — This originates from the external periosteum of the alveolar process. Epulis is characterized by a peculiar color, a mixture of blue, red, and brown. This is due to a brown pigmentation. Epulis is the only instance of pigmented sarcoma that is not exceedingly malignant. Microscopically the tumor is characterized by a very great number of giant-cells. Some specimens of the growth consist exclusively of giant-cells. Epulis resembles, except in color, the ordinary fibroma of the gums. While the latter, however, may be removed by a simple incision involving only the gums, the former requires, in order to prevent recurrence, removal of a portion of the alveolus as w^ell. If permitted to extend, the disease spreads in all directions and may finally require for its cure partial or complete resection of the upper or the lower jaw. Sarcomas of the body of the jaw are of far greater malignity than the foregoing. They are observed usually between the fortieth and the fiftieth year of life. The disease appears most commonly in the body of the upper jaw as soft tumors of rapid growth. Microscopically they consist of small round cells in a scanty stroma. The antrum, orbital and nasal cavities are speedily invaded, and finally the ethmoid and base of the skull become involved in the disease. As they extend outwardly the skin of the facial region becomes involved, break- ing down into ulceration. The lower jaw may be attacked by sarcoma, where the latter may attain large proportions. It is less frequently observed here than in the superior maxilla, however. When it springs from the outer surface of the ramus it may be mistaken for a tumor of the parotid. The growth extends somewhat symmetrically. Cystic sarcoma also is found in this locality. Lymphatic glandular involvement is rare, and occurs at a late period and from septic processes, if at all. Sarcoma of the jaw is liable to recur, even after the most careful resection of the bone. Exceptionally, in the case of the lower jaw, removal of the bone from the temporomaxillary articulation to the symphysis menti is followed by cure. Carcinomas attack the alveolar processes of both jaws, particularly the lower. They may occur primarily from the gums, or secondarily from the adjacent soft parts. They are essentially a disease of advanced life. They tend to break down rapidly into ulceration, the teeth are loosened early and drop out, and the entire growth soon assumes the appearances of a foul ulcera- tion W'ith hard edges. The lymphatic glands at the angle of the jaw become involved early in the disease. The only disease wdth which carcinoma is at all likely to be confounded is epulis. The latter, however, does not ulcerate early unless from being acci- dentally bitten. Lymphatic involvement is not the rule in epulis. The body of the upper and lower jaw is rarely attacked by primary car- cinomas. ^Malignant growths in this location belong, probabh' with rare exceptions, to the small-celled sarcomas. The absolute differential diagnosis depends on microscopic examination. 534 THE SURGERY OF THE HEAD Patients with malignant disease of the jaw usually fall first into the hands of the dentist, and the disease is sometimes far advanced when it comes under the observation of the surgeon. Comparatively few cases are operated on early, and even these show marked tendency to rapid recurrence. Only the immunity, which rare and isolated cases enjoy, from a return of the disease justifies the surgeon in yielding to the importunate demands of the patient for operative interference. RESECTION OF THE LOWER AND UPPER JAWS This may be partial or total. In the former, removal of the processes or portions of the body of the bone is accomplished. In total resection all of the lower jaw, or half of the upper jaw, with its attached palate and malar bone, is removed. The inferior maxillary bone is seldom entirely removed. Performance of the operation with the patient only half anesthetized, in order to prevent the blood from finding its way into the air-passages and produc- ing suffocation, has been recommended. Preliminary tracheotomy with the Fig. 310. — Rose's Dependent Head Position. use of the tampon cannula (T r e n d e 1 e n b u r g) (Fig. 311) or a folded napkin crowded into the pharynx and occluding the glottic opening (N u s s - b a u m) has also been employed for the same purpose. Nasal intubation and the tamponing of the pharynx (C r i 1 e , see page 304), or the slow raising of the patient to the sitting position after anesthetization (French), is preferable to either of these. Rose's dependent head position may also be employed with advantage (Fig. 310). Resection of the Alveolar Processes. — Benign growths situated anteriorly, and even epulis, may be removed through the mouth without external incision. The operation is commenced by the removal of the teeth corresponding to the alveolar processes to be resected. L i s t o n ' s forceps (Fig. 90, B) in the case of the lower jaw, and the chisel and mallet in the case of the upper jaw, are to be employed in making the necessary rectangular in- cisions. These incisions limit the part to be removed at each extremity of the growth. The portion between the rectangular incisions is freely separated from the lip and removed by means of the cross-cutting forceps (Fig. 312). In Til 10 JAWS 535 carcinoma or sarcoma a free removal must be practised. In the case of the lower jaw it is best to remove the (Mitire thickness of the body of the bone for a considerable distance beyond lli(> limits of the disease. Resection of Half the Lower Jaw.— 1die corresponding median incisor is extracted. The incision should, as far as possible, be placed below the bonier of the bone so that the resulting scar may be hidden. The lower lip is divided in the median line and the incision is carried downward to a Fig. 311. — Trendelenburg Cannula with Attachment for Administering Chloroform. point below the level of the symphysis menti. The incision is then carried along just below the lower border of the bone as far as the angle, and then upward behind the posterior border of the ascending ramus to within | of an inch of the lobe of the external ear (Fig. 313). The facial artery is divided and both ends at once secured. The incision terminates below the edge of the parotid gland, and the most important branches of the facial nerve are preserved. The tissues of the face and the masseter muscle are dissected Fig. 312. — Cross-cutting Forceps. away from the bone or tumor, and the jaw sawed through at the symphysis with either a small frame saw or the G i g 1 i wire saw. The tissues forming the floor of the mouth are divided by carrying the knife along the inner sur- face of the bone, care being taken to preserve the sublingual gland. The bone is now grasped by the lion forceps (Fig. 161) and the internal pterygoid muscle brought into view; the latter must now be detached. The jaw is now forced downward, the soft tissues held out of the way by means of retractors, 536 THE SURGERY OF THE HEAD when the coronoid process is brought forward. The temporal muscle, which completely surrounds the latter, is now separated from the bone. It is some- times extremely difficult to do this, owing to the unusual length of the process, or the fact that it is crowded against the malar bone by the bulk of the tumor. Under these circumstances it may be necessary to cut off the coronoid with bone forceps. After clearing the coronoid the jaw is still further depressed from before backward in order to throw the condyle forward ; the parotid gland and masseter are held out of the way by means of retractors. As the coro- noid becomes prominent the joint capsule, together with the ligaments and insertion of the external pterygoid muscle, alone remains to be divided. The first named may be divided by the knife, but the others are torn through in crowding the bone out of the glenoid cavity by forcibly depressing it. The muscular fibers are not to be divided with the knife, though the inferior dental nerve may re- quire section, in order to prevent it from being dragged out of its bony canal. In executing the movement which depresses the jaw and forces the condyle for- ward, care should be taken not to rotate the jaw outward, else the internal maxillary artery will be torn or divided and give rise to troublesome or even severe hemorrhage. If rotation is avoided, the periosteum usually separates from the bone and both it and the artery are left behind intact. All hemorrhage is to be ar- rested, and the oral cavity iso- lated from the remainder of the wound by a row of sutures unit- ing the edge of the mucous mem- brane of the cheek with that of the floor of the mouth. A row of external sutures is now applied, between which small openings for drain- age are to be left. A drainage-tube is to be placed in the lower angle of the wound; this passes into the mouth and drains the oral cavity. Antiseptic dressings apphed externally and frequent irrigation of the mouth constitute the after-treatment. This procedure may be modified or varied on account of the growth of the neoplasm at the central portion of the inferior maxillary arch. Resection of the bone at this point involves the separation of the geniohyoglossus muscle of each side, which will permit the root of the tongue to fall backward and suffocation to occur. This is to be prevented by passing a silk Hgature through the tongue. This part of the operation is given in charge of an assistant, and the tongue fastened by a strip of adhesive plaster to the cheek for the first few Fig. 313. — External Incision for Resection of Half of Lower Jaw. THE JAWS 537 days afterward. The head of the patient is held bent slightly forward as he lies on his side during the after-treatment, and on the first sign of suffocation the tongue is drawn forward. Some discomfort arises from the failure of the teeth to approximate nor- mally in mastication. In time this will be partially obviated by growth of new bone. A skilful dentist may be able to construct a frame of gold or silver wire for the purpose of maintaining proper separation of the remaining por- tions of the jaw, in order that the teeth may articulate properly wdth each other. Removal of the entire lower jaw may be necessary in phosphorus necrosis. Under these circumstances the operation should be performed both sul)periosteally and intrabuccally. In young subjects reproduction of the entire lower jaw may occur. If some months are permitted to elapse between the removal of the two halves (or the removal of the two jaws, as it is some- times called), the periosteum becomes thickened and serves as a support for the portion last operated on. Resection of the temporo= maxillary articulation is rarely required except for ankylosis of the jaw arising from inflamma- tory conditions in the neighbor- hood, or irreducible dislocation of the lower jaw. The head of the bone is exposed by an inci- sion extending from the anterior margin of the zygomatic arch downward and H inches in front of the auricle. The soft parts are crowded away from the neck of the bone, the latter divided with the chisel and mallet, and the head of the bone removed. The proximity of the internal maxillary artery prohibits the use of the saw or bone-cutting forceps. A movable articulation is to be secured by early, per- sistent, and methodic movements of the jaw. Resection of the Upper Jaw. — This is indicated in cases of malignant disease where the latter is limited to the upper jaw, and to gain access to nasopharyngeal tumors (temporary osteoplastic resection). Operation (Fergusson, Weber) .—The incisor teeth of the correspond- ing side are extracted. The incisions commence by dividing the upper lip in the median line. The incision continues on around the ala and thence on the side of the nose to the inner canthus of the eye (F e r g u s s o n). From this point it is carried along the infraorbital margin (Weber) and to the malar bone if necessary (Fig. 314). The flap thus marked out is dissected from the Fig. 314. — Lines op Incision for Resection of the Upper Jaw. 538 THE SURGERY OF THE HEAD Fig. 315. — Resection of Half of the Upper Jaw. Dissection of the flap from the bone. Fig. 316. — Lion-jaw Forceps Grasping the Resected Portion of the Upper Jaw. THE JAWS 539 bone (Fig. 315). A narrow saw is passed into the nostril and the alveolar process and hard palate are divided. The saw is now reversed and the nasal process of the bone divided in a direction upward and outward. The point of the saw is now carried along the thin floor of the orbit to the malar process or to the malar bone itself, if necessary, which is then sawed through. In benign tumors the orbital plate may be spared. These bone sections are completed with the bone-forceps. The mucous membrane of the roof of the mouth is now incised as far back as the soft palate in the line of the bone section. The bone is grasped with the lion forceps (Fig. 316), forcibly pried away from the ptery- goid process and palate bone, and detached with the scissors from its remaining attachments to the soft parts (orbital fascia, infraorbital nerve, and soft palate). Hemorrhage is arrested by the ligature, the thermocautery, and packing with antiseptic (zinc oxid) gauze. The edges of the soft parts are adjusted by interrupted sutures of silkworm- gut. Septic complications are to be combated during the after-treatment by swabbing out the wound cavity with a 5 per cent solution of zinc chloric! at the first four or five re- clressings. Daily redressings, spray- ing with hydrogen dioxid, and irri- gating the parts with a 1 : 1000 solu- tion of permanganate of potassium or Thiersch's solution are neces- sary. The dentist's art will materially aid in supplying the lost parts, both for cosmetic and functional pur- poses. Visual disturbances may occur from displacement of the globe. Simultaneous removal of both superior maxillas has been per- formed for rapidly growing sarcoma, extending from one jaw to the other. This may be accomplished by means of the Lizar-Velpeau incision (Fig. 317) applied on each side. The entire facial soft structures of each side, including the upper lip, are dis- sected loose from the bone and turned up as one flap. Or. the Fergusson- Weber incision already described may be employed, applied on both sides. In this case two facial flaps are formed. The hard palate need not be divided. The .saw is applied so as to divide the frontal process of one malar bone; thence it passes through the corresponding orbital plate and across the root of the nose; finally, it divides the orbital plate of the other side and the remaining malar bone. Removal of both superior maxillas in two sittings is sometimes indicated in cases of phosphorus necrosis. The portion most advanced in disease is first removed. After several months the remaining jaw is removed. Fig. 317. — The Lizar-Velpeatt Incision Applied TO Both Sides for the Simultaneous Re- moval or Both Superior Maxillas. 540 THE SURGERY OF THE HEAD THE NERVES OF THE FACIAL REGION The nerves of the facial region are affected with neuralgia in the following order of frequency: (1) supraorbital; (2) inferior maxillary; (3) infraorbital; (4) frontal; (5) lingual. Tic douloureux, or neuralgia of the fifth nerve accompanied by muscular spasm of the affected region, may be a symptom of peripheral nerve lesion, this being situated, as a rule, in a cicatrix of the alveolar margin. It is par- ticularly liable to occur in the eruption of the lower wisdom tooth. In case the point of original injury and the (;onsequent cicatrix can be determined, resec- tion of the parts is indicated (see page 545). Simple division of the branches of the trigeminus (neurotomy) at the point where they leave the bony canal is useless; relapse occurs in the vast majority of cases. In this connection, therefore, only those methods which are calcu- lated to afford some hope of permanent relief will be considered. Neurectomy of the Infraorbital Nerves and Superior Maxillary Nerve. — This nerve is attacked either at its place of exit at the infra- orbital foramen, in the infraorbital canal, or at the foramen rotundum in the sphenomaxillary fossa, beyond the ganglion of Meckel. The infraor- bital foramen corresponds to the upper limit of the canine fossa and is on a vertical line dra^vn directly upward from the fissure between the first and the second superior molar. A curved incision is made, parallel to the infraor- bital margin and just below the latter; this separates the fibers of the orbi- cularis palpebrarum. On reaching the deeper portions of the canine fossa the fibers of the levator anguli oris are encountered, passing in a vertical direction. This muscle may be separated in the direction of its fibers, if not too thick; otherwise the latter may be divided. The leash of nerves arising from the division of the nerve-trunk as it emerges upon the face is now to be identified and dissected from the flap. The foramen may be readily found by following the nerve branches in a central direction. A ^-inch trephine is now applied to the wall of the antrum of Highmore with its edge just below the foramen, or the wall may be chiseled away. Access is thus gained to the an- trum. A V-shaped piece is to be chiseled away from the margin of the orbit at the site of the foramen, the nerve-trunk loosened, and j inch or more removed at this point. To resect the superior maxillary nerve the trunk is followed along the infraorbital canal, the walls of the latter being chiseled away for that purpose. A head band mirror reflecting light into the antrum, will be useful at this stage of the operation. The posterior wall is perfor- ated with a |-inch trephine, with its point withdrawn, and the sphenomaxil- la.T}' fossa entered. Hemorrhage is to be arrested by pressure and section of the nerve made by means of double curved scissors close to the edge of the foramen rotundum. The resected portion of nerve is withdra^nl and the thermocautery applied, if the hemorrhage persists in the fossa. This serves, also to effect destruction of the ganglion of Meckel, and the palatine nerves passing thereto. The cavity is to be packed and the external Avound par- tially closed by suturing. Method by Means of Temporary Resection of the Malar Bone.^ — This method, introduced by Liicke, of Strasburg, is as foDows: An incision is made from the middle of the external orbital edge do\Miward and THE XERVES OF THE FACIAL REGION 541 toward the median line, terminatinji: near the root of the third molar. This is carried down to the bone. The malar bone is freed from periosteum at both its anterior and its posterior surface, and a chain saw passed. The bone is now di\-ided from behind, forward and inward. A second incision begins at the lower angle of the first, is carried to the lower edge of the malar bone, and thence to the junction of the zygomatic arch and the temporal bone. The zygomatic arch is separated by means of a chisel or the cutting bone forceps. The insertion of the masseter at the malar bone is detached, when the entire flap, consisting of bone and soft parts, is turned upward by means of retractors. By displacing outwardly the temporal muscle, the infraor- bital fissure is reached and resection of the nerve performed at this point. On account of injury of the masseter, which interferes afterward \\'ith opening the mouth, it has been proposed (L o s s e n , B r a u n) to carry the horizontal incision of L ii c k e above instead of below the malar bone. A^'ulsion of the nerve may be performed (T h i e r s c h), or twist- ing and avulsion combined fB r a u n). through either of these incisions. Neurectomy of Second and Third Divisions of the Fifth Nerve with Avulsion of the Qasserian Ganglion.— An omega-shaped incision is made having its base at the zygoma and measuring a distance marked by a line dvsLwnn. from the external angular process of the fron- tal bone to the tragus. The curved upper portion reaches to the supra- temporal ridge. An osteoplastic resection of the bone is made by chisel- ing a groove on the same lines, the bone breaking at the base of the omega and the soft parts serving as a hinge to the trapdoor-like flap which is turned down. The dura and brain are raised from the floor of the middle fossa of the skull by retractors, and both the foramen rotundum and ovale exposed, together ^dth the second and third divisions of the fifth nerve. By forcing back the dura at the front where the second and third divisions of the fifth nerve pass through the foramen rotundum and the foramen ovale, these branches are divided close to the bone. The central ends of the divided nerves are grasped by forceps and excised or a\ailsed to a point beyond the Gasserian ganglion. The osteoplastic flap is now replaced and united by sutures (K r a u s e , Hartley). Various modifications of the above method have been introduced. The best of these is that of intracranial neurectomy de\dsed by A b b e , in which a vertical incision over the middle of the zygoma and the remoA^al of sufficient of the temporal bone to give access to the site of the Gasserian ganglion replace the omega-shaped osteoplastic flap of Krause and Hart fey. The second division is resected at the foramen rotundum and the third division at the foramen ovale. In order to prevent reunion of the divided nerve-trunks a piece of sterihzed rubber tissue is implanted over the foramen ovale and the foramen rotundum after resection of the nerves (Fig. 318). The following points should be borne in mind in conducting the operation: (1) The incision should be of sufficient length to permit easy retraction of its edges. (2) The soft parts, including the periosteum, should be well cleared to and somewhat below the level of the zygoma. (3) The preliminary trephine opening should be immediately opposite the foramen ovale. This will be on a line drawn vertically from just in front of the condyle of the lower jaw. (4) In enlarging the opening with the gouge forceps this should be confined as much 542 THE SURGERY OF THE HEAD as possible to the squamous portion of the temporal bone. Encroachment upon the area beyond this is sometimes followed by troublesome hemorrhage from the vessels in the diploe. If this is unavoidable, however, the flow of blood may be usually arrested by grasping the edge of the bone at the site of the bleeding by a rongeur forceps and crushing the diploe. (5) In separating the dura from the base this should be done by the finger. The separation should be carried on systematically and continuously without regard to the hemor- rhage until the finger encounters the flattened out trunk of the third division, which is usually easily recognized by the touch at the foramen ovale. The brain is then lifted from the base of the skull by the retractor (either Hartley's or the one shown in the illustration, see Fig. 318), the blood cleared away by rapid sponging, and the parts thoroughly packed with iodo- form gauze. This is removed and replaced at intervals of five minutes or less until the bleeding ceases. (6) The third division at the foramen ovale is first caught up by a blunt hook and drawn out as far as possible. The nerve is then grasped by a narrow bladed forceps on the foramen side of the hook and divided between the two, as close to the ganglion as possible. By traction on the peripheral stump by means of the forceps, from an eighth to a quarter of an inch of the nerve-trunk is dragged out of the foramen and removed. The second division at the fora- men rotundum is dealt with in the same manner. (7) Under no circumstances should the pressure exercised b}" the retractor in lift- ing the brain from the base of the skull be kept up for more than two or three minutes at a time, on account of the damaging effects of the compression on the cerebral substance, and of the prolonged displacement of the cerebrospinal fluid. The respiratory center is especially likely to be unfavorably influenced by the latter, as shown by the shallow breathing of the patient. Neurectomy of the Inferior Dental Nerve.— The nerve is to be reached at its entrance into the bony canal. The nerve lies about in the middle line of the jaw, except in old people, when it lies more inferiorly. It enters the bone about I of an inch above a line drawn from the point of the projecting angle of the jaw to the center of the receding angle within the cavity of the mouth. In order to expose the nerve a flap is formed, with its base upward, its sides corresponding to the anterior and posterior edges of the ramus of the jaw. The masseter attachment, together with the periosteum, is separated and the sur- face of the bone exposed. A portion of the bone is chiseled away, or the trephine is applied and a button of bone removed ; the bone is further chiseled Fig. 318. — Abbe's Intracranial Neurectomy. THE NEUA'KS OF Till'] FACIAI. IIEGION 543 away in an upward direct ion. Tlie norA-e can scarcely be separated from the artery, and tlierefore both are generally severed. A j)iece of the nerve is resected and the hemorrhage arrested by pressure. II' the themocautery is employed hi the section, hemorrhage is avoided (H u e t c r). The fhi}) is replaced and sutured. Methods without Chiseling the Bone. — An incision is made along the posterior edg(> of the ramus of the jaw down to the periosteum, which is lifted. The internal pterygoid insertion is divided with scissors. The spine of Spix is identified by means of the index-finger, and with the latter as a guide the nerve is hooked at the point at which it enters the inferior dental foramen. The nerve is drawn out into the external wound without being divided, after which an inch or more may be resected. Or the same result may be obtained b}' an incision along the angle of the jaw (S o n n e n b u r g). In the first mentioned method the cosmetic effect is inferior to that of the second. On the other hand, in the two last mentioned methods the divi- sion of the pterygoid constitutes an objection from the point of view of function. In some cases in which intractable neuralgia persists after resection of the inferior dental nerve, it will be necessary to reach the third division of the fifth pair at its exit from the foramen ovale, or this may be performed at the outset. Intrabuccal Methods. — The mouth is opened widely and the coronoid process identified. The mucous membrane is incised at tliis point from above downward, the soft parts pushed away from the bone, and the spine of Spix felt for with the index-finger. The nerve is then hooked up and resected. Only a small portion can be removed by this method, and a pocket for the accumulation of pus is left. Method by Temporary Resection of the Lower Jaw. — The jaw is exposed by an incision commencing in front of the mastoid and extending first down- ward along the sternomastoid to the cornu of the hyoid bone, and from here upward and forward until it reaches the point of insertion of the masseter. The bone is divided just posterior to the last molar by means of a G i g 1 i saw, the internal pterygoid muscle severed, and the two halves of the jaw reflected; the cavity of the mouth should not be opened. The process of Spix is now to be identified; just below this short spine and posterior to it the nerve enters the dental canal. Here it is hooked up and secured by passing a thread around it. It is now divided close to the bone and drawn out with the thread so that it can be followed up to the foramen ovale. The chorda tympani is to be avoided. After section of the nerve at the foramen ovale it will be found still held by its gustatory branch passing to the tongue. The point where the chorda tympani joins the gustatory should be identified and the latter severed move this. The jaw is to be wired and the wound closed except where the wire emerges. In order to secure proper articulation of the teeth the services of a den- tist should be employed to make an interdental splint before the section of the jaw is made. This is to be employed in the after-treatment. Method by Temporary Resection of the Malar Bone (S a 1 z e r).— A curved incision with its convexity upward extends along the entire length of the malar bone. The skin, fascia, periosteum, and temporal muscle are divided. The bone is divided at each end and the temporal muscle loosened 544 THE SURGERY OF THE HEAD from the skull. The flap, consisting of the skin, muscle, and bone, is now- retracted downward. The nerve is separated from the middle meningeal artery, divided close to the foramen and a portion resected. The coronoid process of the inferior maxilla is kept out of the wa}" by opening the mouth widely. The vessels in the pterygoid fossa lie beneath the field of operation, and the external pterygoid muscle is uninjured. The parts are to be replaced and sutured as in L ii c k e ' s operation (page 540). Method without Bony Resection. — The incision is carried in a curved direction from f of an inch above the angle of the jaw to a point in front of the facial arter}'-, where the latter crosses the bone. The parotid gland is loosened from the parotido-masseteric fa.scia and retracted in an upward direction. . The internal pterygoid muscle is separated at its insertion at the angle. The guide to the nerve is the spine of 8pix (U 1 1 m a n n). Neurectomy of the Supraorbital Nerve. — Neuralgia of this nerve occurs next in frequency. It is sometimes the result of an inflammatory swelling of the periosteum lining the short canal in which it lies at the supra- orbital ridge. An incision is made, following the line of the supraorbital ridge. The skin and orbicularis palpebrarum are separated from the bone, as well as the external portion of the superior tarsal cartilage. By pushing back the fat and connective tissue in the orbit the roof of the latter is brought into view. The nerve is now isolated from the adipose and connective tissues, when a piece If inches long may be removed. The wound may be sutured in its entire length; primary union is the rule. Intraneural injections of osmic acid have been employed in intract- able facial neuralgia (Bennett). Temporary relief may be some- times obtained by this method, lasting for months, and exceptionally for longer periods of time. The method is indicated in the aged and in those in poor physical condition. A general anesthetic may be administered, or local anesthesia may be secured, and the branches of the fifth nerve exposed. In the case of the supraorbital nerve the incision is made over the supraorbital notch and parallel with the eyebrow. The infraorbital is reached most easily by a curved incision at the site of the infraorbital foramen. To avoid de- formity, however, the nerve should be reached, whenever possible, by forcible retraction of the upper lip, incision of the mucous membrane of the mouth and dissection of the structures covering the superior maxilla. The mental branch of the inferior dental is reached at the mental foramen by retraction of the lower lip and an incision through the mucosa. The nerve is elevated by a blunt hook, and from 5 to 15 minims of a freshly prepared 1.5 per cent solution injected directly into the nerve by means of an ordinary hypodermic syringe and fine needle. The solution is injected in several places, in order to be certain that every portion of the nerve is reached, and finally a small quantity is injected between the nerve and its sheath in its bony canal (J. B. Murphy). The modus operandi of the procedure is not definitely understood. It should not be employed in neuralgias of nerves with important motor functions. Neurectomy of the Lingual Nerve. — Except for the purpose of relieving the pains of inoperable carcinoma of the tongue, this nerve rarely requires division, compared with the frequency with which the second and third divisions of the trigeminus are operated on. THE TONGUE 545 For neuralgia the lino;ual nerve may be readily reached by an incision at the lateral edge of the tongue. C . H u e t e r was compelled to perform a neurectomy of the lingual for intractable neuralgia following a wound of the tongue by a common table fork. In carcinoma of this organ, however, the nerve must be I'eached at a higher point. This may be accomplished by the same incision recommended for neurectomy of the inferior dental, and by chiseling away a portion of the receding angle of the inferior maxilla until the spine of Spix is reached. The nerve is here hooked up and resected. Neurectomy and Stretching of the Facial Nerve.— Painful spasm of the face (tic douloureux) sometimes i-equires operative interference. The disease is characterized by continuous convulsions of the facial muscles of one side. In some cases the spasm is of reflex origin and depends on in- creased sensibility of the branches of the trigeminus. Resection of the nerve is necessarily followed by paralysis of the facial muscles of the corresponding side. Stretching of the nerve is the preferable operation and should be first tried. The nerve may be reached through an incision at the anterior edge of the sternomastoid insertion. The body of the parotid gland is drawn toward the front by blunt retractors; the styloid process is the guide to the nerve at its point of exit from the stylomastoid foramen. Hueter's Method.— The lobe of the ear is separated from the facial skin by a vertical incision 2 inches long at the posterior edge of the ramus of the jaw. The parotid fascia is divided and the parotid gland separated, care being taken not to invade the region behind the ramus, where the external carotid artery may be wounded. By careful dissection the mferior I3 ranch is reached first, which, though very small, may be recognized by its curve as it passes anteriorly. Following this the superior branch is found, passing almost hori- zontally and meeting the first at an acute angle. The main trunk is now followed to the stylomastoid foramen. The nerve may be stretched, without being followed to the foramen, from the point of union of the upper and the lower branch. The paralysis which follows stretching may be recovered from; the original spasm frequently returns at the same time. Mimic spasm consists of continuous convulsive movements of the facial muscles of one side, particularly of the orbicularis palpebrarum. A more or less constant wuiking occurs. The con^^dsions are usually of reflex origin and depend on an exaggerated irritability of the sensitive branches of the tri- geminus nerve, which are usually ^'ery sensitive to touch, as weU as painful. Pressure on a sensitive branch at its place of exit at once arrests the spasm. Surgical treatment will sometimes give relief. This consists in a neurectomy of the branch involved. THE TONGUE Examination of the Oral Cavity.— The ordinary tongue depressor is used by da^dight for purposes of inspection. For examination in a dark room, or at night, the combined tongue depressor, candlestick, and reflector, or the electric light tongue depressor, is useful (Figs. 319 and 320). The cheek may 1)e retracted by the finger placed in the angle of the mouth. Special oral specula are rarelv necessary- for purposes of examination. 36 546 THE SURGERY OF THE HEAD Palpation of the organs behind the hne of the teeth (tongue, hard and soft palate, and tonsils) is of value in cases of suspected syphilitic, tuberculous, or carcinomatous disease of these organs, and should never be omitted. Lacerated wounds of the tongue from violent contact with the edges of the teeth occur during careless mastication, from falls on the chin Fig. 319. — Combined Tongue Depressor, Candlestick, and Reflector. with the tongue projecting between the teeth, and in epileptic convulsions. Punctured wounds occur from the presence of bone splinters, bits of glass, needles, etc., in the food. Gunshot wounds of the tongue may occur in con- nection with simultaneous injury of the bone, or the missile may enter the cavity from the suprahyoid region, the head being forcibly extended. Burns and scalds of the tongue are comparatively^ fre- quent but not likely to be severe. Treatment. — These in- juries of the tongue are neither difficult of maii- agement nor dangerous to life. The hemorrhage, which may be considera- ble, is usually arrested by a few deep sutures. Pain, which may be severe, is to be allayed by small pieces of ice in the mouth. Suturing is facilitated by passing a loop of thread through the organ at its tip and pulling it forward. In consequence of the rich blood-supply, healing usually takes place by primary union. Inflammatory edema usually marks the limit of the reaction following traumatism of the tongue. The vital resistance of the organ is very high, and hence marked septic processes, such as phlegmonous inflammation, or sup- puration extending beyond the wound surfaces themselves, are rare. In slight Fig. 320. — Electric Light Tongue Depressor. THE TONGUE 547 injuries healing may take i)Iacc without any apparent reaction whatever. In those rare cases in which the swelling in traumatic glossitis is such as to em- barrass respiration, scarification may be necessary, the branches of the lingual nerve at the lateral aspects being avoided, and the knife being entered slowly and superficially to avoid the branches of the lingual artery. Ulceration occurs on the lateral aspect of the organ from contact with the sharji edges of a tooth, ajid disappears on the removal of the latter. A simple localized glossitis may arise from the same cause. Chronic Glossitis.— This includes a number of affections, the im- portant characteristic of which is a change of form and overgrowth of the epidermis, or keratosis, l^pithelioma is prone to develop during these changes. Leukoplakia (leukokeratosis) is a name given to the white patches on the tongue and buccal mucous membrane, the result of keratosis or corni- fication. The disease has its origin in a long-continued chronic glossitis. The gouty and rheumatic diathesis, irritative changes from syphilis, and smoking arc thought to favor the development of the affection. S3aiiptoms. — The patient frequently is not aware of the presence of the disease in the beginning until the peculiar appearance of the tongue is dis- covered by accident. As the disease advances there may be burning or smart- ing when hot or highly spiced food is taken. Later on, the comification becomes thick and unyielding and gives rise to considerable discomfort and to more or less interference wdth the movements of the tongue. The sense of taste is affected in proportion to the thickening of the coating and its area. The affection is found on the buccal mucous membrane, and particularly on the lining of the lower lip and near the angles of the mouth. The patches vary from time to time in size and shape, and in their location on the tongue as well. Of the varieties of leukoplakia the most important are (1) so-called syphili- tic psoriasis; (2) smoker's patch; (8) simple psoriasis; (4) ichthyosis, an advanced stage of the affection in which the papillae are greatly hypertrophied, giving the tongue a warty appearance. The diagnosis is usually not difficult. The chronicity of the affection, its almost exclusive occurrence in male adults, and the bluish-white tint of the patch are sufficient to distinguish it. The prognosis is unfavorable for complete cure. In addition, the cUsease offers a predisposing cause of cancer. The latter may develop after the leuko- plakia has been in existence for many j^ears. The treatment consists of abstention from all foods and drinks which tend to produce irritation. The use of tobacco, particularly chewing tobacco, must be forbidden when the patches are spreading. Alcoholic drinks, if taken at all, must be largely diluted. Leukoplakia of syphilitic origin is not usually benefited by antisyphihtic treatment. It is a postsyphilitic, not a syphilitic, manifestation. Alkaline mouth-washes, such as a 20-grain solution of bi- carbonate of potash, give the greatest relief as a rule. Solutions of chlorate of potash, and hydrogen dioxid are useful. Syphilitic cases are benefited most by applications of a 10 grain to the ounce solution of chromic acid. A mouth-wash of the same in about one-fifth of the above strength may be used. The patches may also be touched with a 10 per cent solution of potassium iodid. Cold cream containing borax or eucalyptus acts favorably by pro- 548 THE SURGERY OF THE HEAD tecting the surface. All sources of irritations within the mouth, such as ragged or decayed teeth, should be removed. If ulcers or fissures form, total excision of the affected parts is to be recommended. In advanced cases, and because of the dangers of the supervention of malignant disease, destruc- tion of the cornified area with the thermocautery is advisable (V o 1 k m a n n). Tuberculous ulceration of the tongue may accompany pulmonaiy tuljerculosis or occur jjrimaril}-. It is usually situated at the tip near the lateral margin and is more frequently observed in men than in women. It may l^e mistaken for carcinoma. Extirpation is indicated in both cases. The diagnosis may be established by microscopic examination of a portion removed for the pvirpose. Lupus of the tongue is verv rare. Abscesses of the tongue are usually the result of a breaking down of gummas. They are situated in the median line, and as a rule pursue a chronic course. If far advanced, the usual anti- syphilitic treatment of iodid of potas- sium must be supplemented by incision and curettage. Nonsyphilitic phlegmon (erysipelas of the tongue) is comparatively rare. It is sometimes ushered in by chills and vomiting. The sweating may be consid- erable, as in traumatic glossitis, and fin- ally subside, or eventuate m abscess. Early openmg of the latter is indicated. Scarifieation is useful in any event. Deformities of the Tongue. — The most important of these is the congenital giant growth (macroglossia). This oc- curs (1) as a fibromyoma, the muscular structure and connective tissue being ab- normally developed; (2) as a lymphan- giotna, the vessels proliferating into the spaces. The tongue may be so large as to project from the mouth from want of space, and hang down as a dry, fissured, or ulcerated mass, which bleeds easily (Fig. 321). The incisor teeth become loosened and crowded forward to a horizontal position. An acquired similar condition following erysipelas of the tongue suggests an analogy to elephantiasis following erysipelas of a lower extremity. The treatment consists in excision of wedge-shaped por- tions at successive sittings, to avoid profuse hemorrhage. Pressure by means of flat-bladed forceps behind the uicisions will control the bleeding uiitil deep sutures can be taken. Puncture by means of the thermocautery has been used successfully (H e 1 f e r i c h). Congenital ankyloglossia or tongue-tie is a very rare condition. When present, it is due to a defective development of the tongue, rather than to an excessive development of the frenum. The condition will, with rare excep- tions, correct itself with the growth of the child. Where the tongue-tie indubitably interferes with sucking, it may be corrected by lifting the tongue Fig. .321. — ^Macroolossia. THE TONGUE 549 with the index-finger and cutting the tense fold of mucous membrane close to the floor of the mouth with blunt scissors. Excessive bleeding is to be prevented by putting the child to the breast at once. Fatal hemorrhage has occurred after division of the frenum. Death from asphyxia, due to tongue-swallowing (Petit) and macroglossia, has also followed this operation (Sedillot, Bollinger). Bifid or split tongue consists of a longitudinal fissure which divides the forepart of the tongue into two unequal parts. The split may extend a con- siderable distance toward the root. It may be associated with a cleft lower lip, with arrest of. development of the lower jaw, and cleft palate or harelip. The opposed surfaces may be pared aiid brought together with sutures. Acquired ankyloglossia is the result of cicatricial thickening of the frenum following ulceration occurring in the course of the eruption of the incisors. The mucous membrane on each side of the frenum becomes irritated by con- tact with the sharp edges of the teeth as they first appear. Later on, as the teeth advance, the pressure ceases and the ulceration heals, leaving the frenum contracted. The treatment is the same as in congenital tongue-tie. Cancer of the Tongue. — This occurs most frequently after the fortieth year. Among 4600 cases of cancer collected byJessett, over 8.7 per cent w^ere cases of cancer of the tongue. This relative frequency is explained by the exposure of the tongue to "\^arious sources of. irritation. The proportion of men to women attacked is 85 per cent. This is attributed to the habit of smoking, though the role which the latter plays in the causation is probably exaggerated. Its occurrence is commonly ascribed to friction against a carious tooth with rough edges. The most common location for its fi.rst appearance is on one or the other side of the tip ; it is occasionally observed on the dorsum, but it is never found in the median line of the organ. Leukoplakia, syphilitic ulcer, and ichthyosis are noted as of rather frequent occurrence precedent to epithelioma of the tongue. Lymphatic glandular infection occurs early, dissemination is not common, and death frequently takes place within a year. The disease occurs in the ulcerative and the infiltrated forms. The former involves rapid destruction, while the latter is characterized by the appearance of nodules varying in size from a pea to a hazelnut, which appear deeply embedded in the muscular substance of the organ along its lateral margins. These finally ulcerate, after which the progress is very rapid, the dis- ease extending in all directions. Symptoms. — There is a large increase of the saliva from reflex irritation of the salivar}^ glands. Decreased mobility of the tongue, difficult degluti- tion, and embarrassment of speech are prominent features. Pain is -marked. It occurs early in the disease, is radiating in character, and is propagated from the lingual branch of the mferior maxillar}' division of the fifth nerve to the other sensory branches of this division (auriculotemporal and inferior dental). A'iolent pains are complained of in the external auditory meatus and the temporal and submaxillary regions of the affected side. The patient is liable to fatal hemorrhage from the lingual or carotid arters^, or life may be destroj'ed by septic pneumonia, asjohyxia from edema of the glottis, the pressure of massive cervical glands on the trachea, or from septico- anemia, exhaustion, and semistarvation combined. 550 THE SURGERY OF THE HEAD The prognosis is doubtful at best. It is most favorable if removal is accomplished before lymphatic involvement. The mortahty after operation is 10 per cent, the causes of death being hemorrhage and septic pneumonia. The liability to recurrence is very great. The latter takes place in the stump or in the cervical glands withhi a year. In cases otherwise inoperable neurec- tomy of the lingual nerve will relieve the pain and excision of both external carotids and their branches (D a w b a r n) may serve to hold the disease in check. Diagnosis.— The character of the pains and their distribution are of diag- nostic importance. The ulcerative variety may be mistaken for syphilitic ulcer and the infiltrated variety for gumma. In the former, induration of the lingual substance will be less marked than in carcinoma; in the latter, the nodules will occupy the median portion of the tongue and there will be an absence of the characteristic pains. If no impression is made on the growth in fourteen days by the internal adminis- tration of iodic! of potas- sium and inunctions of mercurial ointment, car- cinoma is to be suspected and a section removed for microscopic examina- tion. Tuberculous ul- ceration rarely occurs without the presence of other tuberculous foci. The Operative Treatment of Carci= noma of the Tongue. — The exceedingly rapid course which carcinoma of the tongue pursues, as well as the early lym- phatic involvement, de- mands prompt operative interference. Above all things, the appHcation of nitrate of silver or other caustic substances is to be avoided. Such apphcations involve loss of time and favor further growth by their irritating effects. When the disease is superficial and situated near the tip of the tongue, a large cuneiform piece may be excised. The entire organ should be drawn well forward by two stout ligatures passed well back at the base (Fig. 322). The part to be removed is grasped by forceps, the frenum divided, the entire tongue brought well forward, and a V-shaped piece excised. On account of the tendency to focal proliferation, the limits of the portion to be excised should be first marked out on the mucous membrane of the dorsum of the tongue with a scalpel, from a fourth to three-eighths of an inch of healthy tis- sue being included. The gap left after the excision should be sutured at once. If a large portion is to be removed the sutures may be passed preliminarily. Fig. 322. — V-shaped Excision of Tip of the Tongue. THE TONGUE 551 In tlie average case, liowevcr, nothing short of extirpation of half of the tongue will suffice in indubitable cancer of the organ. In still more advanced cases, with extensive ulcerative carcinoma, or deep nodular infiltration, total extirpation will be required. When the floor of the mouth is involved and lymphatic glandular involvement present, the operation nuist be extended so as to include these. In cases otherwise inoperable the removal of a portion of the lingual nerve will serve for a time to arrest the pain. Excision of the external caro- tid artery on each side for the purpose of inhibiting the growth of malignant disease in the area of distribution of this vessel has been followed by en- couraging results in the hands of the originator of the method. Prof. D a w b a r n. The Hemorrhage.— When the whole tongue is to be removed, one or both lingual arteries may be tied primarily. When carcinomatous glands in the neSv are to be removed, this should be done before the tongue is excised, and the Unguals tied at the same time, provided the wound in the neck does not communicate with the cavity of the mouth. Otherwise the Unguals should be tied as they are divided, owing to the septic complications which are likely to ensue and the consequent dangers of secondary hemorrhage. Asphyxia from the passage of blood into the trachea is one of the dangers to be feared. Whitehead prevents this by placing the patient in a semisitting position with the head held forward. The Trendelen- burg position, as adopted by Keen for laryngectomy, or Rose's hanging head position for cleft palate operations, serves a useful purpose in severe cases. The venous oozing is increased by these measures, however. In the majority of cases the patient may be placed on the side with the angle of the mouth firmlv pressed down by an assistant. Preliminary tracheotomy, or, better stih, iaryngotomy (Bond, Butlin), should be performed when the entire tongue is to be removed. Whitehead's Operation for Extirpation of Half of the Tongue (Modi- fied).— The mouth should be washed out with antiseptic solutions for a few days prior to the operation and all loose or carious teeth removed. The head should be somewhat elevated on a sand-bag and turned to one side. Whitehead operates with the patient's head elevated and bent for- ward. The mouth is held open by a self-retaining mouth-gag. Chloroform should be administered by means of a Junker's inhaler with a nasal tube. A stout ligature is passed through the base of the tongue on the sound side and another through the tip on the diseased side (Fig. 323). The opera- tor grasps the latter and the former is given in charge of an assistant. When the disease does not encroach upon the floor of the mouth, the tongue is - split at once along the raphe to the base by first cutting through the mucous membrane on the upper and lower surfaces and then forcibly tearing the two halves apart. The diseased half is extirpated by first dividing the attachments to the floor of the mouth, then the anterior pillar of the fauces, and finally making a transverse section well behind the limits of the growth. ^ The lingual artery "is secured either before or after the transverse incision is completed. When the disease encroaches upon the floor of the mouth, the frenum is first cut through well in front of the limits of the growth. The incision is now extended along the tongue laterally, still well outside the diseased area, until 552 THE SURGERY OF THE HEAD the anterior pillar of the fauces is reached, when the latter is divided. The diseased half is now brought Avell forward, the tongue split in the middle line, and the muscular structures on the floor of the mouth cut through. When the floor of the mouth is deeply affected, the sublingual gland is removed. The lingual arter}- is secured, and, finally, the half of the tongue removed by a transverse incision with the scissors. In order to control the bleeding from the floor of the mouth gauze sponges are pressed on the wound surface and counter-pressure made with the hand beneath the chin. After the vessels are secured and the mouth cleansed the latter is sponged out with a zinc chlorid solution (40 grains to the ounce). The mucous membrane on the dorsum of the tip is secured to that on the under surface by sutures, in order to prevent the tip from being bound down in the floor of the mouth. Fig. 323.^ — Whitehead's Operation for Excision of One-half of the Tongue. Showing Junker's inhaler in use. The tube leading to the nose should be longer than that shown in the illustration. The patient is placed in bed with the head turned toward the affected side. As soon as he recovers from the anesthetic he is propped up in bed and allowed to sit up in a chair as soon as practicable. The mouth should be frequently irrigated with a boric acid or permanganate solution and sprayed with hydro- gen peroxid. To assist in carrying off the secretions Trendelenburg carries a large drainage-tube through the floor of the mouth. Whitehead's Method for Extirpation of the Entire Tongue. — The tongue is brought well forward and secured by a ligature passed through its tip. The organ is then separated from the floor of the mouth by blunt scissors, and the anterior pillars of the fauces are divided. The lingual arteries are secured. A ligature is passed through the glosso-epiglottidean fold behind the point of transverse section, to secure the stimip and draw it forward, if necessary, after the tongue is removed. The extirpation is now completed. THE TONGUE 553 The parts are thoroughly cleansed by swabbing with a 1 : 1000 solution of bin- iotlid of mercury and painted with an iodoform styptic varnish. This is made by substituting for the spirit ordinarily used in the preparation of friar's balsam a mixture of 1 volume of ether and 10 volumes of turpentin, to which iodoform is added to saturation. The patient is fed as freely and as early as possible, the varnish being ap})lio(l at least once daily. The ligature at the base of the tongue is either fastened to the teeth or kept hanging out of the mouth by the weight of a pair of forceps, and is usually removed at the end of twenty-four hours. When the floor of the mouth is extensively diseased, the method of median section of the lower jaw will be useful. The soft parts are incised vertically and cleared away from the jaw in front and an inch or more on each side. The bone is divided at the symphysis and the two halves forcibly separated. The tongue is now secured, drawn strongly forward, and readily ex- tirpated, together with the dis- eased structures in the floor of the mouth. The bone is replaced and sutured with silver wire, drainage provided for through the floor of the mouth, and the soft parts united with sutures. Billroth performed a temp- orary resection of the median portion of the lower jaw. When the disease extends from the base of the tongue and in- volves the surrounding structures, the organ cannot be protruded. In order to obtain ready access and get well beyond the disease, one of the extrabuccal methods must be adopted. The simplest extrabuccal method is that of splitting the cheek. The inci- sion is carried through the entire thickness of the cheek from the angle of the mouth back to the masseter (Fig. 324). If the access gained is still insufficient, and particularly if infiltrated glands are present in the neck, the incision should be carried across the angle of the jaw and thence curved so as to pass down the anterior margin of the . sternomastoid, and the jaw divided at the level of the last molar (L a n g e n - beck). The anterior portion of the jaw is retracted firmly forward and the posterior portion is retracted outward, as wide a gap as possible being made between the two portions. After the removal of the involved- glands, the tongue itself, and the surrounding implicated structures, the divided jaw is wired together. In some cases of extensive involvement it may be advisable to dissect out the glands, and as much as possible of the branches of the external carotid artery on each side, and then to dissect out the tongue and adjacent diseased structures at a subsequent operation. Fig. 324. — Splitting the Cheek for Extirpation of THE Tongue. 554 THE SURGERY OF THE HEAD Kocher's Method. — The advantages of this method are (1) it gives ready access to the parts; (2) it permits simultaneous removal of aU of the tissues in the floor of the mouth and the glands as well; (3) it permits preliminary ligation of the lingual and of the external carotid artery when necessary; (4) the pharynx can be plugged after preliminary tracheotomy, this, together with the efficient drainage which can be obtained, constituting a safeguard against septic bronchitis and pneumonia. A preliminary tracheotomy is performed, and the chloroform thereafter given through the Trendelenburg cannula (Fig. 311). Or C r i 1 e ' s method of administering chloroform through nasal tubes and tamponing the pharynx may be employed. The incision commences just below the lobe of the ear, extends along the anterior border of the sternomastoid to the middle of the latter; thence to the mid- dle line of the neck and finally upward to the border of the lower jaw (Fig. 325). The flap is dissected up and kept well retracted by being sutured to the cheek. All glands beneath the upper portion of the sterno- mastoid and under the angle and body of the jaw are removed. The anterior border of the sterno- mastoid is bared to the sheath of the large vessels, and the greater cornu of the hyoicl bone and the anterior belly of the di- gastric laid bare. The mass of glands is now raised and the posterior belly of the digastric and the stylohyoid exposed in the posterior and lower portion of the wound. The submaxil- lary salivary gland is dissected up as far as the border of the jaw and removed with the lym- phatic glands. The facial vessels are hgated while the submaxillary gland is drawn upward; the lingual artery is ligated as it passes beneath the hyoglossus muscle. The mylohyoid muscle and its mucous membrane covering are cut through close to the bone and the tongue drawn out through the opening. The attachments of the tongue to the hyoid bone are now separated, together with all infiltrated tissues. If the entire tongue is to be removed, the opposite lingual artery is to be ligated through a separate incision (see Ligation of the Lingual Artery, page. 558). If the carcinomatous infiltration involves the pharyngeal walls, these can be reached through the same opening. The periosteum in front of the masseter and pterygoid muscles is detached from the jaw, the bone sawed through and drawn well forward, in order to gain more room. The bone is afterward wired. The wound is left open for drainage. The Trendelenburg tube is Fig. 325. — Line of Incision fob Kocher's Operation FOR Cancer of the Tongue. A second incision may be carried in the direction of the dotted line to facilitate the removal of infected glands. THE TOXGUE 555 replaced by an ordinary tracheal cannula wliich is worn until the A\'Ound is well granulated. The pharynx is packed with zinc oxid gauze and the patient fed with a tube at each change of dressing, at which time also the parts are cleansed with hydrogen peroxid and irrigated with permanganate of potassium solution. Nonmalignant Tumors of the Tongue.— These occur very infrequently, as compared with malignant growths. Tumors of embryonic origin resem- bling sacrococc3^geal and similar tumors are sometimes fomid in the tongue. Lipomas. — These are usualh- single, situated on the border or tip, or on the dorsal aspect, with the overlying mucous membrane smooth. They are of slow growth and produce but slight inconvenience except when they attain sufficient size to be caught between the teeth. "Wlien occurring in the depth of the substance of the tongue, they may protrude beneath the latter; the golden yellow color shining through the mucous mcmljrane serves to distinguish it from so-called ranula. Multiple and diffuse lipomas have also been observed. Fibromas. — These are observed most frequently on the dorsum and may occur as multiple growths, with varying distances between the growths. They commence in the substance of the tongue, but finally project from the surface after assuming a polypoid form (fibrous polypi of the tongue) . They resemble fatty tumors in this region, except that the}- lack the yellowish hue peculiar to lipomas. They become irksome in the course of time from interference with speaking and eating. Fibromyomas and rhabdomyomas occur as circumscribed growths in the substance of the tongue. The latter are non-encapsulated, and may attain the size of a pigeon's egg. In consistency and color they resemble the normal structure of the tongue. Cartilaginous and osseous tumors occur either as congenital chondromas and osteomas, or develop after birth as mixed tumors containing cartilage, bone, fibrous tissue, and fat. Amyloid tumors are non-encapsulated am}-loid masses occurring at the base of the tongue in patients d}ing of diseases in which amyloid degeneration occurs. Cartilaginous and bony nodules are sometimes found in the waxy substance. The treatment of the foregoing consists of the enucleation through a single incision of those growths which are deeply situated. Polypoid growths are removed simply by cutting through the pedicle. ]\Iultiple and diffuse lipomas occurring in elderly individuals, and giving rise to no special inconvenience, should not be interfered with. Angiomas. — These occur on the tongue in the same forms as elsewhere, the varieties including (1) arteriovenous aneurism; (2) aneurism by anas- tomosis or cirsoid aneurism ; (3) capillary nevi ; (4) venous nevi. Arteriovenous aneurism may result from a wound and is recognized by its pulsation and thrill. In aneurism by anastomosis the tumor is more or less definitely circum- scribed and the vessels possess a distinct wall. The growth may occupy the front half or one of the lateral halves of the tongue (Fig. 326) or appear in the situation of a ranula. The tumor may be emptied by pressure, but it refills when the pressure is relieved. Pulsation is more or less marked. Hemorrhage does not usually occur. Capillary nevi may be congenital or acquired. When congenital, they 556 THE SURGERY OF THE HEAD Fig. 326. — Cirsoid Aneurism of Toxgue of Twenty Years' Standing in a Woman Forty Years of Age. are often multiple and occur on other parts of the body as well as on the tongue. They may be continued into the mouth as a simple port wine stain on the face. In the acquired form the}^ have been ob- served in pregnant women and in others also. The}' appear as bright red tumors varying in size from a pin's head to a split pea. Arterial hemorrhage occurs, especially on eating. Venous Nevi (Cavernous Tumors). — ^'enous angiomas are, as a rule, congen- ital. They may be single or multiple, and are generally situated on the dorsum of the organ in the anterior half. They project slightly and their dull bluish or hvid color shows through the thinned mucous membrane; small varicose vessels and vascular areas appear on the mucous membrane. This variety of angioma sel- dom attains a large size, is painless, as a nile, and does not usually give rise to great inconvenience. Profuse hemor- rhage may occur from accidental injur}'. Lymphangiomas may begin T\dth what appears to be a simple ne^iis; with the steady advance of the l}-mphan- gioma marked macroglossia may ensue. Lingual angiomas, like similar vas- cular tumors elsewhere, occasionally be- come parti}' obliterated by fatty degen- eration. The diagnosis of angiomas of the tongue is made on the same basis as vascular tumors in general, namely, the color, consistency, diminution in size on pressure, and rapidity of return to their original dimensions when the pressure is relieved. An arteriovenous aneurism may give a histor}' of an injur}'; the presence of a thrill is characteristic. In cirsoid aneurism large tortuous A'essels are present. Capillar}- nevi of congen- ital origin are similar to the common "birthmark" seen on the skin. Accjuired capillary nevi exhibit a tendency to bleed, particularly in the case of women during pregnancy. Venous cavernous nevi are usually situated on the anterior half of the tongue; small varicose vessels and vascular spots are obser^-ed on the mucous membrane covering the nevus. Treatment of Angiomas of the Tongue. — In cases showing a tendency Fig. 327. — Cirsoid Aneurism of the Tongue. Showing swelling in the neck when the tongue is retracted into the cavity of the mouth. THE TONGUE 557 to progressi^'e growth early operation is indicated. Small nevi may be de- stroyed with the galvanocautery or thermocauter}-; two or three applica- tions may be needed. The hemorrhage is slight if a dull red heat only is employed. Removal en masse by means of an elastic or other ligature is liable to be followed by septic pneumonia. Excision of a wedge-shaped piece, the incision passing beyond the vascular area, is the operation of choice. The vessels can be usually secured in the healthy tissues and oozing arrested by deep suturing. The cut surfaces may be touched with the cauter}' or the entire excision ma}- be performed Avith the latter. In large and diffuse caver- nous tumors, cirsoid aneurism, and arteriovenous aneurism electrolysis at several sittings may be tried. Preliminary ligation of the Unguals should be practised before either electrolysis or excision in this class of cases. Papillomas are among the most common nonmalignant tumors of the tongue. They are not limited to the papillar}^ area of the organ, but are some- times found on the under surface. The entire fungiform papillae of the tongue may become inA'olved in a warty enlargement. A peculiar form of sublingual growth, the product of an inflammatory process due to irritation, is kno\\-n as Riga's disease. It occurs on either side of the frenum in young children from contact with the sharp incisor teeth. The treatment is by excision. Sessile warty growths which form on patches of leukoplakia commence as an apparent thickening of the surface of the latter. Later on they assume a more decidedly warty character, and finally, if left untreated, become in- durated about the base, a condition indicating the cancerous nature of the affection in this stage of its development. In the diagnosis of papillomas care should be taken to differentiate the disease from warty s}'philitic growths, or condylomas, particularly in children and young adults. A 10 grain to the ounce solution of chromic acid causes a syphilitic gro'U'th to disappear rapidly, while a true papillary growth is unaffected by the application. If accompanied by chronic superficial glossitis in a male between thirty and sixty, the differential diagnosis from epitheliomas is not so eas}-. The presence of ulceration, and of induration about the base, is of importance as showing the presence of malignant disease. If the latter has indubitably supervened, the microscope will aid in the differentiation. The treatment of papillomas consists in their early removal, particularly in persons over thirt}'. The base should be included in two elliptic incisions extended deeply into the substance of the tongue and the growth removed with some of the adjoining healthy tissue. The gap left is closed by sutures. If ulceration and an indurated base are present, the operation should be as if for epitheliomas, even if the microscopic. examination is negative, since the latter may fail to discover the difference in the period of transition from a -benign to a malignant growth. Caustics should never be used on these growths. Destruction l^y means of the galvanocautery is inferior to excision. Hypertrophy of the Blandin-Nuhn gland beneath the tip of the tongue has been occasionally observed. Ligation in Continuity of the Lingual Artery. — A cushion or block is placed beneath the patient's shoulders and the head turned slightly toward the opposite side. The incision is commenced slightly to the outer side of the sympliA'sis menti and about j of an inch above the body of the hyoid bone. With its convexitv downward it is carried for about two inches along 558 THE SURGERY OF THE HEAD the border of the jaw, reaching to a point just in front of where the facial artery crosses the latter. Its center is just above the greater cornu of the h}'oid bone. After separation of the skin, platysma, and superficial fascia, the subniaxillarv gland comes into view. This is to he separated from its surrounding connective-tissue attachments and retracted upward, the lower edge of the incision being retracted downward at the same time (Fig. 328). The two bellies of the digastric muscle now come into view. The hypoglossal nerve and ranine vein are exposed by depressing the digastric at the point where its two bellies meet, with a blunt tenaculum. By retracting the nerve Fig. 328. — Ligation of Lingual Artery, showing Hueteh's Triangle. and vein in an upward direction the trigonum linguale (H u e t e r) is formed. The artery lies at the lower portion of this triangle, beneath the thin hypo- glossus, which muscle is divided in a horizontal direction. At this point the vessel changes its direction from the horizontal and assumes a vertical course to enter the tongue; it is usually accompanied by a small vein. The operation is performed most frequently for disease of the tongue, preliminarily in complete extirpation for carcinoma, or to restrict the circu- lation and thus limit the nutrition of diseased portions of the organs, as, for instance, in hemihypertrophy. THE SOFT AND HARD PALATE THE VELUM Wounds of the soft palate are not usually followed by septic inflamma- tory processes. Cicatrization of wounds of the velum sometimes leads to interference with speech, and whenever possible primary union should be secured by suturing. Foreign bodies are usually removed without difficulty. Primary inflammation of the soft palate is not common, but it usually THE SOFT AND HARD PALATE 559 Fig. 329. — Whitehead's Gag. takos moro or loss part in that arising; in the adjacent parts. Phlegmonous inflammation in the peritonsillar connective tissue (quinsy), as well as diph- theria of the tonsils and pharynx, may extend to the soft palate. Syphil- itic ulceration may occur, and, by cicatriza- tion, necessitate a subse- (juent plastic operation. The uvula may become the seat of edematous swelling from slight causes and be considera- bly lengthened. Fissures of the Soft Palate. — C on g en i t a 1 fissure of the soft palate constitutes one of the forms of cleft palate. It occurs almost exclusively in the median line. The uvula is usually involved in the fissure. The margins of the fissure, A^'hen com- plete, terminate at an acute angle at the posterior edge of the hard palate; the latter may be invaded for a short distance. Incomplete fissure extends only a part of the way; the uvula alone may be in- volved (bifid uvula). Acquired Cleft of the Soft Palate. — Unhealed wounds of the soft palate may result in a cleft, this varying in form and extent. This condition is also due to con- stitutional syphilis, and presents. Fig. 330. — Brophy's Mouth Speculum. Fig. 331. — Brophv's Mouth Speculum Applied. Patient in the dependent head position of Rose. under these circumstances, the rather constant and characteristic form of an oval or oblong shape due to the fusion of several openings resulting from gummatous infiltration, with varying degrees of destruction. The ulceration 560 THE SURGERY OF THE HEAD frequently extends from the posterior surface of the ^-ehim to the adjacent pharyngeal walls; fusion occurs and the margins of the remains of the soft palate are dragged to each side, greatly enlarging the fissure. Disturbances of speech and deglutition are marked. Fig. 332. — Cheek Retractor. The treatment of congenital cleft of the soft palate is by staphylorrhaphy. Acquired clefts of traumatic origin may be similarly treated where there is not great loss of substance. Those due to syphilitic infection are best treated by an obturator or artificial velum (K i n g s 1 e y , Suersen). Operation of Staphylorrhaphy. — The operation is divided into (1) paring the margins; (2) dividing the muscles to relieve tension; (3) introducing the sutures. Fig. 333. — Staphylorrhaphy. Paring the Edges. Paring the Margins. — A suitable gag or mouth speculum is introduced (Figs. 329 and 330). A cheek retractor is of service (Fig. 332). The dependent head po.sition of Rose is the best (Fig. 331). One edge of the fissure is grasped by a tenaculum or mouse-toothed forceps and a thin and narrow- THE SOFT AND HARD TALATE 561 bladed bistoury is passed throii2;h just in front of the angle and at a little distance from the margin. By gcntlv sawiu"; movements the incision thus Fig. 334. — Staphylorrhaphy Scissors for Dividixg the Levatores Pal.^ti. commenced is carried parallel to the margin until tlie tip of the uvula is reached (Fig. 333). This is repeated on the other side. The two incisions are then united at tlie bottom of the angle b_y a curved cut made by a sweeping movement of the knife, the paring being re- moved in one piece. Dividing the Muscles. — If this is done before intro- duction of the sutures, a sickel-shaped knife (L a n g e n- beck's) is passed through the cleft, its point introduced over the hamular process, which can be felt b}' the point of tlie finger in close relation to tlie last upper molar, and the section made while the corresponding portion of the velum is made tense. Or, the double curved scissors may be employed for this purpose (Fig. 334). These incisions divide tlie levatores palati. If tension still exists, the pala- topharvngei may be di^'ided simply by cutting across the posterior pillars with blunt scissors. Introducing the Su- tures. — A small half-circle needle grasped by a needle holder serves best, when it can be emplo^'ed. A needle with the eye at the point ma}' be passed armed with a ''car- rier," i. e., a double thread (Fig. 335), the "bight ' or loop Fig. of which is left in the gap. A single thread is then introduced from the other side, its free end passed through the carrier and the latter withdrawn, carrying with it the single thread which is to remain as a suture (Fig. 336). An ordinary needle, if small and well curved, may be employed when armed with a carrier. A good quality of silk is the best suture material. Fig. 335. — Needle Armed with Car- rier. 336. — Passing the Sutures IX Staphylorrhaphy (Dia- gram.matic). THE HARD PALATE Slight injuries of the mucous membrane covering the hard palate arising from foreign bodies in the food are unimportant. Those which involve the 37 562 THE SURGERY OF THE HEAD entire thickness, as, for instance, when they are caused by the fall of a child with a pencil or toy in its mouth, or perforation occurs by a pistol ball, are of greater importance. \^Tien the latter in\olves a suicidal attempt, there is accompanying extensive contusion of the surrounding soft parts. Suppuration of the antrum of Highmore may follow the last named injury. There may be some limited necrosis, but the sequestra easily separate and the opening finally closes. Extensive destruction of bone may lead to a per- manent communication between the cavity of the mouth and the nasal cavity in case of median situation of the opening, and between the cavity of the mouth and the antrum of Highmore in case of lateral situation. Suppurative periostitis occurs as an extension of a similar condi- tion from the alveolar processes in phosphorus poisoning. When sequestra are separated they should be removed from the direction of the gums, but not by an incision in the median line, lest a permanent opening be left in the roof of the mouth communicating vrith the nasal fossa. The exfoliated por- tions are usually replaced by new bone formation. Syphilis of the palate appears almost exclusively in the shape of gummas, the nodule of which is strictly limited to the median line or raphe of the palate wliere the two palatal processes of the superior maxillary bone join the septum. A bony ridge marks the site of the syphilitic infiltration if the diseased condition is arrested by appropriate treatment. Otherwise the entire thickness of the bone becomes affected, more or less of the bony vault is destroyed, and with the final cicatrization small or large openings are left. These may be distinguished from those due to injury by the fact that they are situated in the median line and are oblong in shape, while those from injury vary in situation and are usually round. Congenital Cleft of the Hard Palate. — This may be partial or com- plete. It is always associated with cleft of the soft palate. The cleft may pass to one side of the vomer; more commonly, how^ever, it passes directly in the median line, leaving the palatal edge of the vomer free. It is frequently, though not invariably, associated with harelip. The latter may be single or double. In complete cleft of the hard palate the fissure is V-shaped, with the opening of the angle posteriorly situated, and with the anterior portion and the alveolar processes intact. In complete cleft the fissure passes to the alveolar processes in front and in some instances involves it. The latter con- dition alwaj^s obtains when double harelip is present, on account of the for- ward displacement of the premaxillary bone. The functional disturbances in the newborn resulting from cleft palate relate principally to interference with suckling. As a rule, the infant will require to be artificially fed. A feeding bottle with, a large nipple to close the gap, or a specially constructed nipple with a rubber shield, may be used. Malnutrition is not uncommonly present in spite of these appliances. Defects in speech in older children are next in importance. As the child learns to talk it will be found that these are present, generally speaking, in proportion to the extent of the cleft. In cases uncomplicated by harelip labial sounds are usually enunciated without difficulty; those requiring pressure of the tongue against the hard palate and of the velum against the posterior phar^mgeal wall are lost. Even under the most favorable conditions of a short cleft the impairment of speech, consisting of a broad nasal sound, is noticeable. THE SOFT AXD HARD TALATE 563 Unfortunately, in the majority of cases the habits of speech first formed cUng to the patient, even after the most successful operative closure, or the applica- tion of an obturator and artificial soft palate. The continued impairment is due in part to absence of development of the levator palati and palatophar\-n- geal muscles, and in part to early acciuired habits of speech. These are more difficult to overcome after operative closure than in case of application of an obturator and artificial soft palate, for the reason that division of the muscles to relieve tension on the approximated edges of the cleft in the soft palate is usually necessary, this involving permanent impairment of these to a greater or lesser extent. When an obturator and artificial velum are properly fitted, the muscular apparatus of the soft palate is brought into use. With careful training by means of selected vocal exercises the muscles develop, and at the same time faulty habits of speech are corrected. The lodgment of particles of food in the nasal cavities, leading to catarrhal inflammation of these, constitutes a further indication for operative correction of the defect, or the application of a proper prosthetic apparatus. Treatment. — Opinions differ as to the age at which operative measures should be instituted for cleft palate. In view of the fact that faulty habits of speech, once acquired, are very difficult to overcome, Wolff, of Berlin, advised operative interference in early infancy. His method was to loosen by means of the chisel the remains of the hard palate adjoining the alveolar processes, and to force these toward the median line until the previoush- freshened margins of the cleft palate came into apposition (osteoplastic closure). The gaps left by this median displacement of the lateral portions of the hard palate were left to heal by granulation. The cleft in the soft palate was closed by the usual staphylorrhaphy (see page 560). By operating in this manner before the child learned to talk, it was thought that one of the causes of permanently defective speech, namely, habit, would be overcome. In order to avoid the necessity for di\asion of the muscles. howe\'er, operation in the earliest period of the infant's life is demanded. It is surprising to what an extent the muscles attached to the soft palate make tension upon and separate the edges of the cleft in this region during the act of crying, even in an infant only a tew weeks old. If this eariier period of life is chosen for operation, however, the latter must necessarily involve a liigher mortality, since very 3'oung infants succumb more easily to the combined effects of shock ancl loss of blood than those farther advanced. This consideration is somewhat compensated for by the fact that the operation may be performed on the former without the administra- tion of an anesthetic. The method of osteoplastic closure of the cleft by forcing together both the lateral portions of the hard palate and the alveolar processes (B r o p h y), the gaps left by section of the former being thus avoided, succeeded the method of Wolff. This can be done -v^ith comparative ease in ver\- young infants. The resulting narro^\-ing of the face disappears in time. The edges of the cleft are first carefully freshened in their entire extent. The superior maxillas are perforated on each side just above the alveolar processes at the gingivobuccal fold and two stay wires of silver passed above the plane of the cleft. The ends of these are passed through carefully fitted lead plates placed between the cheek and the gum. The maxillas are now forced together, the special 564 THE SURGERY OF THE HEAD compression forceps of h r o p h y or other mechanical means being employed if necessary. If the bone does not yield readih-, it may be weakened just above the level of the stay sutures by one or more short incisions with a stout scalpel. When approximation is secured the raw edges of the cleft are imited by a row of fine silk sutures. ]\Iore or less blood may be swallowed b\' the ])atient during the operation, and the fever following the digestive disturbances and absorption may inter- fere with the healing process. Every care should be taken, therefore, to a^-oid the swallowing of blood by keeping the parts carefull}^ sponged and the phar\'nx clear. The administration of an emetic, followed by a simple purge, is an additional safeguard against failure from this cause. Occasional cleansing of the mouth with a boric acid solution, particularh" after food has been taken, should be practised. The operation of uranoplasty, as applied to older children and adults, is performed as follows: The mouth is carefully cleansed, ether administered, and the patient placed in the dependent head position of R o s e (Fig. 331). After the patient is fully anesthetized the administra- tion of the ether is carried on through the Junker inhaler (Fig. 323). A .suture is passed transversely through the dorsum of the tongue behind the frenum and given in charge of an assistant. The largest sized combined oral speculum and tongue depressor (Fig. 330) that the oral opening will accommodate is introduced. Or the rack-and-pinion mouth-gag may be employed (Fig. 337). The edges^ of the cleft are carefully freshened, as in staphylorrhaphy (Fig. 333). The mucoperiosteal coverings of the hard palate are now thoroughly separated from the bone in all directions by means of the raspatory (Fig. 338). In carrj-ing out this step of the operation care should be exercised not to contuse the freshened edges of the soft parts of the cleft. The elevator should be kept close to the bone and the process continued until the entire hard palate is denuded. A traction suture is now passed througli the velum on each side and each half drawTi strongly forward and toward the opposite side, while the finger palpates the site of the levator palati and palatophaiyngeal muscles of the corresponding side to determine the amount of tension ])resent. Usually these ^\ill recjuire division (see Staphylorrhaphy, page 560). The fact that these have been thoroughly divided will be determined by the palpating finger. The ability to approximate the edges of the mucoperiosteal flaps is now tested. In cases in which a high arch or vault exists the edges will fall to- gether easily. In a low or flat vault the edges will fail to approximate, and Fig. .337. — Rack-and-pixiox Mouth-gag. THE SOFT AND HARD PALATE 565 a relaxing incision parallel to the alveolar margin on each side must be made. These incisions must not be made longer than is necessary to effect approxi- mation, lest the blood-sii])ply be interfered with and sloughing of the flaps ensue. In the application of the sutures ])r()\ision must be made for removing all ])()ssil)le strain from the line of union. The relaxation sutures intended to accomplish this are of sih'er wire, are passed through the flaps about half-way between the freshened margin and the edge of the relaxation incision of each side, and are secured b>' being passed through a narrow and thin lead plate and clamped with perforated shot. When the edges have been accurately adjusted by means of the relaxation sutures they are united by a row of fine silk sutures. The lateral gaps are packed with sterile gauze! In order to prevent the child from reaching the line of sutures and separat- ing them with the tip of the tongue the latter may be secured by a suture to Fig. 33S. — Raspatories for Uranoplasty. the lower gingivolabial fold for the first few days, in cases in which the lower front teeth are absent. Careful antiseptic cleansing should be carried out in the after-treatment. The palatal sutures may be removed from the eighth to the tenth day. The Non-operative Treatment of Cleft Palate.— The apphcation of a prosthetic apparatus involves considerable expense and is beyond the reach of poor patients. It cannot be advantageously applied until the permanent teeth have erupted. Constant care is necessary to cleanse the apparatus properly and prevent damage to the teeth to which it is attached. The latter should be regularly inspected by a competent dentist. To offset these dis- advantages, it may be said that the functional results are far superior to those obtained by any operative procedure performed after the patient has learned to talk, provided pains are taken to train the vocal organs properly after its. application. 566 THE SURGERY OF THE HEAD THE FAUCES, PHARYNX, AND NASOPHARYNX THE TONSILS The tonsils are vestigial structures, endowed with a low power of vital resistance and with numerous recesses which invite the presence of agents of infection. For these reasons they are very Uable to become the seat of inflammatory processes. Acute Tonsillitis. — This occurs m connection with acute catarrhal pharyngitis. The attack may resemble erysipelas of the skin; in fact, facial erysipelas may be accompanied by a hyperacute inflammation of the mucous membrane of the oral, nasal, and phaiyngeal cavities. Follicular Tonsillitis. — This may follow an attack of acute catar- rhal tonsillitis. It usually pursues a chronic course, with occasional acute exacerbations. The tonsils swell considerably and project from be- tween the faucial pillars. The contents of the crypts accumulate and are either removed by coughing or become desiccated and form concretions (ton- sillar calculi). Decomposition of the accumulated secretions sometimes gives rise to a foul breath. Hypertrophic tonsillitis results from either acute catarrhal tonsillitis or follicular tonsillitis. Repeated attacks of the former, a long continuance of the latter, or a mixture or alternation of the two, induce connective-tissue hyperplasia and enlargement of the tonsils to the extent of a tumor as large as the end of the thumb or larger. Phlegmonous tonsillitis (peritonsillitis) is a phlegmonous inflamma- tion of the peritonsillar connective tissue. The connective tissue of the tonsil proper is composed of short and rigid fibers and is but little prone to phlegmonous inflammation. The infectious agents of a catarrhal or fol- licular tonsillitis may pass to the connective tissue between the tonsil and the faucial pillars and set up a phlegmonous suppurative inflammation. Diphtheritic Tonsillitis. — This form is characterized by the forma- tion of a pseudomeml^rane on the surface. The false membrane consists of layers of micrococci, fibrinous filaments, pus corpuscles, and epithelium. The pellicles, the coalescence of which makes up the bulk of the false membrane, develop first in the depths of the tonsillar crypts as the result of the presence of the special bacillus of the disease (K 1 e b s - L 5 f f 1 e r). The pres- ence of this bacillus may be demonstrated by bacteriologic examination for diagnostic purposes (see page 29). Ulcerative conditions of the tonsils are observed. These are (1) syphilitic; (2) carcinomatous; (3) tuberculous; (4) lupous. Those due to syphilis extend to the velum and pharyngeal mucous membrane; those of a carcinomatous nature are to be differentiated by the microscopic section; tuberculous ulceration is usually accompanied by general tuberculosis, in addition to which the bacillus tuberculosis may be found by microscopic ex- amination. Symptoms. — Swallowing is greatly embarrassed in phlegmonous tonsillitis, rather less so in the acute catarrhal form, still less in the follicular and least of all in the hypertrophic form. Respiration may be interfered with, notably THE FAUCES, PHARYNX, AND NASOPHARYNX 567 in the phlegmonous variety. 'Hie infiannnutory process may extend to the mus- cular attachments of the inferior maxilla and produce inflammatory lock- jaw. Inspection, in the acute catarrhal form, shows the tonsil to be evenly reddened and slightly enlarged. In the follicular variety yellowish-white spots are seen in the crypts of the swollen organ; slight reddening is present. In hypertrophic tonsillitis the tonsils project like tumors from between the pillars of the fauces, the latter, however, remaining distmct. The tonsils may be so large as to come in contact with each other by their inner surfaces. In phlegmonous tonsillitis also the projection is considerable, but the organ, instead of becoming prominent between the pillars of the fauces, as in the hypertrophic form, carries the palatoglossal pillar along with it toward the uvula. In the latter form the mucous membrane is thickened, intensely red, and covered with glairy mucus. In diphtheritic tonsillitis the false mem- brane first appears as a grayish veil covering the tonsils near the lower infected crypts; later on, this assumes a characteristic white appearance. General febrile disturbance occurs in acute catarrhal tonsillitis. This, and in addition enlargement of the submaxillary lymphatic glands, is also present in both phlegmonous and diphtheritic tonsillitis. Disturbances of function are present to a greater or lesser degree in hyper- trophic tonsillitis. There is a nasal sound to the speech from rigidity of the velum and separation of the nasal cavity from the pharyngeal cavity. Impairment of hearing may result from occlusion of the pharyngeal orifice of the Eustachian tube either by the swollen tonsil or by the accessory mflamma- tion of the pharyngeal mucous membrane. Mouth-breathing may become habitual ; snoring while asleep occurs from the vibrations in the tense velum. Prognosis. — This is always grave in diphtheritic tonsillitis, either by exten- sion to the pharynx, larynx, and nasal cavities, or by general infection. Phlegmonous tonsillitis may cause death by extending along the planes of con- nective tissue and giving rise to suppurative pleuritis, or edema of the glot- tis; finally, suppurative erosion of the carotid artery and fatal hemorrhage may occur. Usually, however, the focus of suppuration points, and if not incised finally breaks through the thinned mucous membrane, and rapid recovery ensues. Recurrences are liable to take place. Treatment. — Usually only the phlegmonous and hypertrophic forms come under the surgeon's care. The first demands early incision, this being repeated from time to time until either the suppurating focus is reached or subsidence of the inflammation follows the antiphlogistic effects of the local depletion ; the relief of tension and diminution of pressure bj^ division of the peritonsillar structures is also of service, even though no pus escapes. Deep suppuration will sometimes find its way to the bottom of an incision and dis- charge. A narrow-bladed bistoury is used, and a puncture is made which should be enlarged should pus flow alongside of the knife. Incisions should be made in a vertical direction and care be taken that they are not too far outward, in order to avoid wounding the internal carotid artery. Tonsillotomy is performed for hypertrophic tonsillitis. The simplest method of performing this operation is to grasp the tonsil with a tenaculum forceps held in the corresponding hand of the operator, draw it toward the median line, and amputate it b}^ a quick stroke of the probe-pointed bistoury 568 THE SURGERY OF THE HEAD from above do^^Tlwa^d. Should the surgeon not be ambidextrous he mav remove the left tonsil first, grasping it by the tenaculum forceps held in his left hand. He then stands behind the patient, the head is bent backward, and with the tenaculum forceps in his left hand, he uses his right for the cutting. In the latter case he makes the incision from below upward. Care should be taken to make the incision as close as possible to the palatoglossal fold and not to drag the tonsil too far from its bed between the pillars of the fauces, else danger- ous hemorrhage may occur from injur}- to the tonsillar branch of the facial arter}- or to the large branch of the ascencUng pharyngeal from the ex- ternal carotid which takes the place of the tonsillar branch of the facial when the latter is absent. The external carotid arter}- can scarcely be injured in this operation; it lies at least three-fourths of an inch from the base of the tonsil. Special instruments ftonsillotomesj have been devised for the operation. Overestimation of the difficulties of the amputation and fear of injur}- to the carotid arter}- led to their introduction. While this fear is groundless, still the removal may be facilitated by the use of the instnunents particularly in the case of children, and where a general anesthetic is not given. The best of these is that sho\\-n in Fig. 339. The ring-shaped extremity is slipped OA-er the organ and adjusted T\-ith the index-finger of the left hand, the middle and ring fingers depressing the tongue at the same time. B}- a single movement the tonsil is Fig. 339. — Toxsillotome. seized by the fork of the instnmient. elevated and made tense, and amputated by the heretofore concealed blade. Pencihng the mucous membrane of the phar}-nx and ton.sils T\-ith a 10 or 20 per cent solution of cocain hydrochlorate will usually produce a sufficient ane.sthetic effect. ()r general anesthesia may be established by means of ether, in which case the upright position (F r e n c h ' .s) or the dependent head position of Rose may be employed. Hemorrhage is generally arrested by gargles of ice- water; this failing, pledgets of cotton wet ^nth spirits of turpentin should be held firmly applied to the bleeding surface. The tonsillar arter}- proper passes to the tonsil along the front of the levator palati muscle, and as the latter forms a portion of the poste- rior surface of the soft palate, pressure from behind forward against this struc- ture is indicated. Latent tuberculosis of the tonsil, manife.sting its pre.sence by hypertrophy of one or more of the lymphoid organs in this region, has been obser\-ed CD i e u 1 a f o y). The bacilli may remain latent for a long time, recover}' finally taking place, an indurated fibrous condition of the tonsil remaining. Or the bacillus may find its wa}- into the hmaphatic vessels, giving rise to enlarged submaxillar}- and cervical lymphatic glands. Pulmonar}' tuberculosis may finally result. Malignant Tumors. — Malignant disease of the tonsil when primary. THE FAUCES, PHARYNX, AXD XASOPHARYXX 569 usually occurs as sarcoma; this has been observed in patients under twenty. A rapidly growing tumor involves the tonsil and may be readily mistaken in the beginning for simple hypertrophy. Attempts to remove it by ordinary methods, however, will reveal its true nature, and be followed b>- a sharp hemorrhage from the enlarged tonsillar artery. Epithelial carcinoma is usually an ex- tension of the disease either from the soft palate or the tongue, usually the former. It may begin on the pharyngeal surface, extend to the oral surface, to the pillars of the fauces, and to the tonsil, breaking do^^-n rapidly into ulceration. The cervical glands become involved early. I have observed it to be a primary disease in one case. External Pharyngectomy.— This operation is incHcated in malignant tiunors of the tonsil and faucial pillars or of the phar^Tigeal wall. The patient is prepared beforehand by thoroughly cleansing the buccal and pharvngeal cavities. The patient's head is placed on a block, well extended, and turned toward the opposite side. An incision is made from the lobe of the ear along the an- terior edge of the stemomastoid muscle to a point three-fourths of an inch below the level of the hyoid bone. A second incision commences half-way between the angle of the jaw and the point of the cliin and is earned down- ward and backward to meet the lower angle of the first incision. The triangu- lar-shaped flap thus marked out is dissected up and includes the tissues doW to the sheath of the muscles. Upon retracting the flap, the angle of the jaw, portions of the parotid and .submaxillaiy glands, the stylohyoid muscle, the posterior belly and a portion of the anterior belly of the cUgastric. together with the omohyoid muscle, are brought into xievr. A portion of the hyoglossus is visible just below the angle of the jaw. To increase the working space the hyoid attachment of the styloh^'oid. as well as the posterior belly of the digastric, may be severed. Further room may be obtained by excision of the submaxillar}- gland. Finally, under certain circiunstances section of the inferior maxilla may be necessaiy in order to gain access to the parts involved in the disease (Billroth. Che ever), in which case a prelmiinan- impression of the teeth should be taken, and an interdental splint made so that these may be preserved in their proper articulation wliile the bone is uniting. The hyoglossal nen-e is avoided, the stemomastoid. the stylohyoid and the posterior belly of the digastric, as well as the important vessels and nerves of this region, are bluntly retracted well do^mward and backward, the mylo- hyoid being drawn anteriorly. The forefinger and middle fingers of the left hand are passed into the mouth, a gag having been previously introduced, and the parts crowded dovsmward and outward. The phar\-nx is now opened and the diseased parts extirpated. The thermocauter^- applied both from the ca\-ity of the mouth and from the external wound may be used at this stage in cases in which there is extensive disease of the faucial pillars and velum as well. The above procedure furnishes a means of gaining ready access to the parts ^-ithout sacrificing any important vessels or ner\-es of this region. The employment of the thermocautery facilitates the final extirpation of the gro^^•th. ^^-ithout entrance of blood into the pharynx or larynx, and furnishes protection against cancerous infection of the wound as well. 570 THE SURGERY OF THE HEAD If section of the jaw has been made, the bone is to be wired and the inter- dental sphnt finally applied. Under these circumstances a drainage-tube is to be passed into the pharj-nx from the upper and posterior angle of the wound when the latter is sutured, and the patient fed through this. During the first four days the after-treatment consists in flushing the parts every t\\"o hours with a 2 per cent solution of permanganate of potassium Fig. 340. — Exterx.vl Pharyxgectomy. 1, Hyoglossus muscle; 2, retracted posterior belly of the digastric muscle; 3, stylohyoid muscle di^•ided at its lower attachment at (4); 5, mylohyoid muscle retracted anteriorly; 6, body of mandible. through a catheter passed through the corresponding naris. This is followed by a solution of hydrogen peroxid applied by the same route. The diet should be limited to sterilized milk. A decided and persistent rise of tem- perature Avill rec|uire the api^lication of a 5 or 10 per cent solution of chlorid of zinc to the parts once or twice a day. Septic pneumonia is to be feared, as in all extensive operations about the mouth and upper respiratory passages. FOREIGN BODIES IN THE FAUCES AND PHARYNX Predisposing Causes. — These may be classified according to the regions in which the conditions exist as follows (Poulet): (1) the mouth and pharynx : loss of teeth, facial paralysis, neoplasms, and nervous spasm; (2) affections in the vicinity: infiammatory swellings in the neck and resulting changes in the course of the alimentary canal; (3) affections of the walls : constrictions and paralytic dysphagia ; (4) predisposing physi- THE FAUCES, PHARYNX, AXD NASOPHARYNX 571 ologic causes : these include the natural irregularities of the pharynx which tend to the arrest of difficult substances there. The particular location of the foreign body is freciuently determined hy the anatomic structure of the parts. Objects Taken with the Food.— The most common of these are small fish-bones. They are most frequently lodged in the lingual tonsil, where they are sometimes difficult of detection. The symptoms are pricking sen- sations and sometimes pain, which the patient finds difficulty in locating. The patient may insist that the fish-bone is lodged in the vault of the phar}-nx, when inspection reveals it projecting from the surface of the lingual tonsil, the bone being forced upward by the tongue against the mucous membrane of the nasopharynx with each act of deglutition. The fish-bones may also be lodged in the faucial tonsil, the posterior pharyngeal wall, the pyriform sinuses, or the entrance to the esophagus. If possible, the search should be conducted by the aid of direct or reflected sunlight. Their extraction is usually easily accomplished with properly cur\-ed forceps. Sharp and Angular Objects.— These consist of pins, needles, etc., placed in the mouth, whence they make their way into the fauces or pharynx. Small sharp bodies give rise to pain on attempts at swallowing, coughing, retch- ing, etc. They may be embedded in the tissues and either become encapsu- lated or give rise to inflammation and suppuration. Or, if sharp, they may migrate and appear beneath the skin of the neck without producing suppura- tion. Excessive hemorrhage may necessitate ligation of the common carotid artery. These objects may make their way into the Eustachian tube, finally emerging through the external auditory canal. The removal of this class of foreign bodies is usually easy, though in isolated cases it has been necessary to perform external pharyngotomy. Smooth Round Bodies.— These are rarely arrested in the fauces or pharynx, but pass at once into the esophagus and lodge at the prominence of the cricoid cartilage. Failing to enter the esophagus or lodge at the orifice, they are found in one of the lateral pharyngeal sulci (pyriform sinuses). The symptoms are difficulty in swallowing, cough, and certain reflex convulsive movements of the fauces. If the larynx is involved there may be loss of voice. Impaction of this class of foreign bodies is rare. The foreign body is to be located by inspection by means of direct and reflected light. Digital examination may aid in the diagnosis and is frequently instrumental in dislodging the object directly or by the reflex vomiting which it excites. Large Objects Irregular in Shape.— False teeth fixed on a plate which have dropped into the pharynx during sleep constitute the type of this class. This accident may also happen during the administration of an anesthetic, as the result of a fall, or while drinking from a large vessel. Large and irregular pieces of bone taken with the food are rather common. They lodge either in the orifice of the esophagus or in one of the lateral pharyngeal sulci. In cases of large irregular objects, death may result from suffocation on account of the difliculty of removal. A foreign body lodged in the orifice of the esophagus may give rise to S3'mptoms demanding tracheotomy. Finally, foreign bodies in the fauces and pharynx may be the unsuspected cause of pain on swallowing, progressive emaciation, attacks of hemorrhage following ulceration, and perforation of the posterior laryngeal wall. The phar3'ngeal wall may be perforated and the cer^4cal vertebrae eroded. 572 THE SURGERY OF THE HEAD Living Objects. — These are rare, though among the older writings there are recorded instances of all sorts of small living animals finding their way into the fauceS; pharynx, and esophagus (P o u 1 e t) . INFLAMMATION OF THE PHARYNX Acute Pharyngitis. — Acute inflammation of the pharynx alone is a com- paratively rare disease. It may occur in connection with an acute inflamma- tion involving the soft palate, uvula, and the pillars of the fauces (acute fauci- tis) . Acute inflammation of this region usually occurs in those already suffering from a chronic catarrhal inflammation of the fauciai region, some slight ex- posure establishing a locus minoris resistentiae , as the result of Avhich bacterial invasion, particularly streptococcus infection, occurs. Other predisposing causes are digestive disturbances, constitutional SA'philis, rheumatism, and tuberculosis. Acute faucitis also occurs at the commencement or in the course of scarlet fever, measles, smallpox, erysipelas, and typhoid fever. It is some- times epidemic. The disease frequently commences as a rhinopharyngitis. The larynx may be affected because of contiguity. Symptoms. — A peculiar scratching sensation, followed by discomfort in swallowing and finally by pain, is complained of. There is sometimes a decided rise of temperature; a chill rarely precedes the latter. Headache, earache, tinnitus, and impairment of hearing may be present. Purulent otitis media may be a sec{uel. Speech becomes painful and difficult. A grayish viscid mucous, followed by a mucopurulent secretion, is present. Neuralgic pains in the ear through Jacobson's tympanic branch of the glossophar}-ngeal are sometimes complained of. Local examination reveals a velvetlike appear- ance and redness of the mucous membrane from hyperemia, and later on swell- ing of the mucosa. Sometimes a paretic condition of the soft palate exists Hyperesthesia is frequently marked. In mild cases resolution occurs in from two to four da^-^s. Some congestion and scanty tenacious discharge may con- tinue for a time. Treatment. — This, in the commencement, is largely medicinal (the use of diaphoretics, antipyretics, etc.). Duciuesnel's aconitin (gr. 5-^ every hour until the constitutional effects of the drug are obtained) is recommended (B o s w o r t h) . Salol is also valuable (Jonathan Wright). Inha- lations of the steam of hot medicated solutions (tincture of benzoin, one dram to the pint) are very soothing. When the secretion appears, an astringent gargle or spray of chlorate of potassium and carbolic acid (2 per cent of the former and 1 per cent of the latter), or direct applications on cotton of 2 per cent solutions of chlorid of zinc, alum, tannin, etc., in glycerin are to be em- ployed. Ear symptoms demand early attention. Inflation of the middle ear (Valsalva's or Politzer's method) should be practised. In case of catarrhal or purulent collections in the tympanic cavity, paracentesis of the drum membrane should be promptly performed. Prophylactic treatment consists in attention to the general health, the wearing of proper woolen under- clothing, daily tepid or cold baths, and the avoidance of wet or chilled feet. Subacute catarrhal pharyngitis is best treated locally by means of the daily application of a 2 to 10 per cent solution of iodin and iodid of potassium,, with 1 per cent of carbolic acid. THE FAUCES, PHARYXX, AND XASOPHARYXX 573 Phlegmonous Pharyngitis (Erysipelas of the Pharynx). — This is of undoubted bacterial oriiiiii. The microorganisms probably enter through some slight traumatism of the upper epithelial layers. It occasionally occurs in connection with acute infectious diseases. Infection of the deeper layers of th(^ mucosa and sul)niucosa results in a grave form of the disease (acute in- fectious phlegmonous pharyngitis). Symptoms. — The attack is sudden and violent and is sometimes accom- panied by a chill. Considerable rise in temperature with rapid pulse is observed. Deglutition is difficult and painful. The throat is at first dry, afterward there is a tenacious secretion. The tongue is coated and the breath offensive; salivation may occur. The mouth is opened with difficulty on account of the spread of the inflammation to the tissues about the temporomandibular articulation. The peritonsillar tissues are particularly affected. The post- nasal space may be in^•aded, producing obstruction. Dyspnea may result from extension and edema of the glottis. The submaxillary salivary and lymphatic glands are sometimes swollen and tender. The inflammation maj' subside in from four to fourteen days, or suppuration may occur. In the latter case the symptoms are greatly aggravated. Spontaneous rupture of the abscess may result in the passage of pus into the trachea. The pus may find its way into the esophagus, or burrow- along the connective-tissue planes into the tongue and the mediastinum, or externally beneath the deep cervical fascia and into the submaxillary glands. Erosion of the great vessels may occur. General septic infection may take place. Treatment. — A general tonic form of treatment, with stimulants, Avhen indicated, should be followed. The local use of a 5 or 10 per cent solution of cocain may be employed before taking food. It may be necessar}' to resort to rectal alimentation. Hot antiseptic gargles and hot fomentations of carbolic acid applied to the neck in 3 per cent solution, are indicated. Free incisions should be practised as soon as fluctuation is detected. Even if the suppura- tive process is not reached at the first attempt, relief is afforded through drain- age of the infiltrated tissues. The pus frequently finds an exit subsequently through the incisions. The cut is commenced laterally and made obliquely toward the median line. Frequent gargling A^dth a hot antiseptic solution (2 per cent solution of boric acid) should follow the operation. Tracheotomy must be resorted to if edema of the glottis occurs. If suppuration finds its way ex- ternal'}-, incisions in the lateral region of the neck must be made. Ulcerative Pharyngitis. — This occurs as an ulceration of the super- ficial epithelial layers and lymphoid follicles. It frequently occurs in hos- pital attendants, pathologists, and medical students (hospital sore throat). It is marked by sore throat, high. fever, and prostration. It is usually of -short duration. The treatment consists in the use of antipyretics (phenacetin) , gargles of a mild antiseptic solution (permanganate of potassium), and the occasional application to the ulcers of tincture of iodin on a small cotton swab. Gangrenous Pharyngitis.— This is essentially a septicemic process which may superA'ene upon scarlet fever, diphtheria, measles, typhoid fe^'er, smallpox, and phlegmonous pharyngitis. Black or greenish-blue spots appear. The breath is horribly fetid. The temperature is at first high; it may be- come subnormal. The prognosis is necessarih' very unfavorable. The treat- ment consists in supporting measures and the local application of cleansing and disinfecting measures. 574 THE SURGERY OF THE HEAD TUMORS OF THE NASOPHARYNX Lymphoma (Adenoids).— This is essentially a disease of childhood. It consists of a hypertrophy of the l}-mphoid tissue (phar}-ngeal tonsil) in the vault of the pharynx. It develops in infancy, is frecpently congenital, and ma}- be hereditary. Inflammatory conditions are frequently the exciting cause. Nasal stenosis from hypertrophic rhinitis or deflected septum, or both, may be present. Symptoms. — The leading symptoms are (1) excessive mucopurulent discharge; (2) an altered character of the voice from loss of the nasal sound, m, n, and ng being sounded as b, d, and g; (3) chronic otitis; (4) mouth- breathing and deficient air-supply; (5) a broadened and flattened contour at the root of the nose and a semi-idiotic facial expression. The hard palate is raised to an abnormally high level and the dental arch is narrowed. The transverse nasal vein crossing the bridge of the nose is sometimes enlarged (Spicer). In addition to these, there is disturbed sleep, headache, and in certain cases cough and asthma. Diagnosis. — This is made by digital exploration and posterior rhinoscopic examination. In making the digital examination the lower portion of the septum is first identified and this traced until the growth is felt. Contraction of the muscles of the ]:)harynx should not be mistaken for the growth. The posterior rhinoscopic examination is con- ducted with the tongue depressed and the palate relaxed. Cocain anesthesia will assist in the exami- nation. Treatment. — The use of as- tringent sprays will lessen the dis- charge, and perhaps slightly lessen the size of the growth. A combination of carbolic acid and tannic acid (carbolic acid, 1 grain; tannic acid, 40 grains; glycerin, 4 drams; water, 3| ounces) is useful for this purpose. The galvano- cautery is advocated by some. Complete extirpation by operation is the best method of treatment. This is best accomplished by means of the cutting forceps (Fig. 341), aided, when necessary, by the cutting curet (Fig. 342). The child is anesthetized and placed in the dependent head position, if chloroform is employed ; or secured to a chair and placed in the upright position if ether is employed (French). A mouth-gag (Fig. 337) is introduced and a palate retractor used as rec{uired. The mass of tissue must be completely removed. Hemorrhage is free at first, but ceases when the lymphoid tissue is remoA-ed and pressure applied. If necessary', the posterior nares may be plugged. Fibromas. — These are sessile growths at first, though they may finally become pediculated. They usually occur in males at about the age of puberty. The growth springs from the periosteum of the basilar process of the occipital bone and from the body of the sphenoid bone. S5rmptoms. — Repeated attacks of epistaxis, sometimes violent in charac- ter, usually occur early in the case. As the growth increases in size the pos- FiG. 341. — Cutting Forceps for PlEmoval of Adex oius. THE FAUCES, THAKYXX, AND .XASOFHAKYXX 575 terior nares become occluded and bilateral nasal stenosis results. This is foUowctl by a characteristic facial expression. This expression increases until the broatlcning and flattening of the face become a well-marked facial tleformity. Finally, the pressure of the growth from behind, and perhaps invasion of the antrum and ethmoid cells, causes protrusion of the globe (exophthalmos). A discharge of tenacious mucus or mucopus in the fauces and of a watery secretion from the nasal cavity occurs. This may he tinged with blood. Dyspnea from mechanic obstruction due to extension of the growth downward may take place. Diagnosis. — This is made by digital and posterior rhinoscopic examina- tion. The examining finger sometimes causes hemorrhage. The growth is dense to the touch. Inspection reveals an irregularly rounded growth of a light pinkish color. The bilateral stenosis is diagnostic. Prognosis. — This is grave in proportion to the invasion of surrounding vital parts, and the dangerous nature of the operative procedures necessary for their extirpation, when they have attained large proportions. The tumors sometimes disappear by sloughing. Treatment. — When of moderate size the growth may be removed by repeated applications of the galvanocautery, or at a single sitting by means of Fig. 342. — Cutting Curet for the Removal of Adenoids from the Nasopharynx. A, Gottstein's curet ; B, sharp ring-shaped curet. the cold wire snare (Jar vis, Fig. 282). Piano wire (No. 5, or even larger) should be employed. The section should be made very slowly, to avoid hemorrhage. For larger growths separation of the two halves of the superior maxilla after sawing through the hard palate (see page 577) or tem- porary osteoplastic resection of the upper jaw may be required. Myxofibromas. — These spring from the openings of the posterior nares. They occur more frecpently in females than in males, and are generally observed between the ages of fifteen and thirty. The growth is generally nonvascular. Symptoms. — The tumor is of comj^aratively rapid growth and gives rise to progressive unilateral nasal stenosis. There may be some hypersecretion. The voice is deprived to some extent of its normal nasal resonance and articula- tion is interfered with by the impingement of the growth on the soft palate. The growth may attain considerable size without giving rise to marked symp- toms. Diagnosis. — A myxofibroma is to be differentiated from a fibroma by its grayish-red appearance, greater mobilit^^ and the absence of marked vas- cularity. Epistaxis does not occur and facial deformity is wanting. Myxo- fibromas occasionallv recur after removal. 576 - THE SURGERY OF THE HEAD Treatment. — These tumors are usually easy of removal by means of the cold wire snare introduced through the nose, or they may be twisted off b}; the polypus forceps. Their removal may be facilitated by incision of the soft palate. The parts should be cocainized beforehand. Chondroma. — This is exceedingly rare in this region. Its removal may be accomplished by temporary removal of half of the nose, division and separation of the upper jaw, or temporary resection of the latter. Sarcoma. — This is of comparatively rare occurrence. The disease is observed as rounded masses, sometimes encapsulated, springing from the deeper layers of the mucous membrane that covers the basilar process of the occipital bone, the body of the sphenoid bone, the soft palate and pharyn- geal wall, extending sometimes to the upper cervical vertebrae and invading the nasal cavity, orbit, zygomatic fossa, and anterior portion of the base of the brain. The growth increases more or less rapidly in bulk, and the pos- terior portion of the brain may be invaded by involvement and perforation of the basilar process. It may occur at almost any time of life. Symptoms. — The symptoms are those of nasopharyngeal tumors in gen- eral, with the addition of the presence of a seromucous, ichorous, and offen- sive discharge, which vitiates the inspired air, impairs digestion, and thus leads to deterioration of the general health. Interferences with swallowing and breathing from mechanic pressure occur as the growth enlarges. Hear- ing is impaired by encroachment of the tumor upon the orifice of the Eustachian tube. Epistaxis occasionally occurs. Diagnosis. — A grayish-yellow lobulated tumor with a soft pultaceous feel is present. The thin, watery, ichorous, and offensive discharge should always excite the surgeon's suspicion. The only certain means of diagnosis consists in the removal of a piece for microscopic examination. Prognosis. — This is unfavorable. Small round-celled tumors grow rapidly as compared with the spindle-celled variety, but death finally takes place, either from the growth or from the operative attempt for its removal. A single authenticated instance of cure is recorded (Bosworth's). Treatment. — Extensive radical operative procedures are generally useless. They frequently fail even to alleviate the sufferings of the patient, and many patients die on the table, or shortly after the operation. Wliile still of moderate size, the cold wire snare is most applicable for its removal, as in fibroma. Wide access to the growth may be obtained by incising the palate. In larger growths, provided adjacent vital parts have not been invaded, the surgeon is sometimes justified in consenting to radical operation, though not always in advising it. In advanced cases involving the antrum, orbit, zygomatic fossa, or spheno- maxillary fossa, he should refuse to interfere in this manner. Carcinoma. — The occurrence of carcinomatous deposits in the nasophar^mx is less frequent than the occurrence of sarcoma. The symptoms and clinical course are similar to those of sarcoma. Microscopic examination, if a portion is removed for the purpose, will establish the diagnosis. Secondary involve- ment of the glandular and other tissues of the neck occurs early in the disease. The youngest patient recorded was thirty-seven; the oldest, seventy-five. Treatment, to be of any service, must be instituted early in the case and be radical in character. THE FAUCES, PHARYNX, AND NASOPHARYNX 577 Operations for Gaining Access to the Nasopharynx for the Removal of Tumors. — The Nasal Route. — ^The incision i« made slightly to one side of the middle line of the nose. The lateral nasal cartilage and the nasal bone are divided on the same line. If more room is needed, the nasal process of the superior maxilla is divided from below upward, just in front of the lacrimal sac, the root of the nasal bone chiseled across, and the corresponding side of the nose thrown upward (Kocher). Or, the nasal cavity may be exposed by detaching the nose and turning it upward. Two incisions are made, one on each side of the nose, commencing at a point just internal to the lacrimal sac. These are carried downward to the junction of the ala nasi of each side with the lip, and are thence extended into the nasal cavity by cutting through the nasal bones and the nasal process of the maxilla. Finally, the septum is divided and the nose turned up (Lawrence). The Palatal Route. — In this method the hard and the soft palate are divided and a portion of the former removed. A median incision is made down to the bone in the hard palate, and extended so as to bisect the soft palate and uvula. The mucoperiosteal soft parts are detached and turned aside, a trans- verse cut on each side facilitating this. The hard palate and a portion of the vomer are chiseled out in the shape of a quadrilateral piece of bone, and the posterior part of the nasal cavity and the nasopharynx exposed (N e 1 a t o n , Gussenbauer). Annan dale operated as follows : The mucous membrane of the lip is freely detached at its reflection on the jaw and the lip turned upward so as to expose the anterior nares. The bony septum of the nose is divided at its attachment to the superior maxilla with cutting forceps. A gag is now intro- duced and an incision is made in the median line of the hard palate down to the bone. An incisor tooth is extracted, a metacarpal saw introduced in the naris, and the hard palate sawed through the median Hne. If necessary, the soft palate is also divided. To gain additional room, the Hp and cheeks may be detached at their reflection on the gums, and both halves of the upper jaw chiseled through transversely outward and backward from the anterior nares (Kocher). The two halves of the upper jaw are now drawn apart with sharp hooks, the mucous membrane of the floor of the nose divided, the vomer drawn aside, and the projecting turbinated bones excised. The tumor is now completely exposed and removed through the gap. Ligation of both external carotid arteries should precede the operation on the jaw. The Maxillary Route. — The method of osteoplastic resection of the upper jaw gives good access to tumors attached to the basilar process of the occipital bone and its neighborhood. Both external carotid arteries may be ligated preliminarily. The operation is the same as for typic resec- tion of one-half of the upper jaw, except that the soft parts of the face are not detached from the bone after the skin incisions are made. The frontal process of the malar bone must be divided through a separate incision. The separated half of the jaw is to be turned back with the attached soft parts. After removal of the tumor the parts are restored and the soft parts sutured. In all operations of the kind described the venous hemorrhage is sometimes excessive. Kocher recommends that a sixth of a grain of sulfate of morphin be given half an hour before the operation, and a minimum amount of chloroform administered through a tracheotom^- tube, with the patient sitting upright. 38 " " 578 THE SURGERY OF THE HEAD For operations in the nasopharynx French recommends that the patient be secured to a chair, the back of which is lo^\•ered, and that ether be administered. The chair is then carefully raised until the patient is in the upright position, when the operation is proceeded with. THE EAR Only those common affections of the ear coming under the observation of the general surgeon will be considered in this connection. Injuries of the Auricle and Cartilaginous Auditory Meatus. — Incised wounds of the auricle are usualh' followed by retraction of the skin layers, leaving the cartilage more or less exposed. Wliile there is no objection to suturing both the cartilage and the skin, carefully applied fine silk sutures at the skin edges alone will suffice. Care should be taken in applying the dressings to maintain the proper shape of the parts, or serious deformity may result. Even if but a slight connection of skin is maintained between the partially severed portion and the auricle, the attempt should be made to restore the former, since parts even completely severed have reunited when promptly replaced. An unsightly slit is sometimes left in the lobule by the tearing out of an earring. This also happens from slow ulcerative action, the weight of the earring slowly separating the lobule. Freshening the surfaces of the gap and suturing give uniformly good results in the so-called coloboma of the lobule. Frost=bites of the auricle are of not infrequent occurrence, through which small portions of the upper border are lost. Attempts at plastic replacement have not heretofore met with very encouraging success. Othematoma of the auricle is a peculiar affection occurring particularly in the insane. It consists of an isolated subperichondrial effusion of blood near the free edge of the auricle, at either its anterior or its posterior wall, a fiat convex swelling resulting. Coagulation does not take place, in this re- spect the effusion resembUng cephalhematoma. In the insane the presence of an othematoma is frequently made the basis for accusations of maltreat- ment against those in charge. It is due, in. all probability, to vasomotor disturbances. Treatment by massage should first be tried. This failing, aseptic incision and drainage will result in prompt cure, the loosened peri- chondrium very readily reattaching itself to the cartilage. Injuries of the Bony Parts of the Ear.— Isolated fractures of the bony auditory meatus sometimes occur from forcible impact of the con- dyle of the lower jaw, the result of a fall on the chin. In fractures of the base of the skull in the middle fossa the fissure passes to the apex of the petrous portion of the temporal bone and thence to the lateral wall of the skull. The usual signs of fracture of the base of the middle fossa, with rup- ture of the membrana tympani, ?'. e., hehiorrhage from the ear and the escape of cerebrospinal fluid, are present. In the differential diagnosis of fractures in this region and injury to the drum membrane alone, the amount of bleeding, together with the presence of sugar in appreciable quantities in whatever serous oozing is present, is to be considered. In case of compound fractures, even considerable quantities of brain matter from the lateral lobes of the cerebellum may escape wdthout marked disturbance, owing to the ab- sence of important function in this locahty. Injuries of the petrous portion of the temporal bone by direct force, e. g., by projectiles, give rise to compound Til 10 i:ak 579 fractures, as well as to fatal hemorrhage cither from the internal carotid artei'v as this vessel passes through llic cai'olid canal, from the transverse sinus, or from the middle meningeal artery from extension of the fissure to the upper margin of the sciuamous portion of the temporal bone. Careful packing of the wound will usually suffice to arrest the hemorrhage, if this comes from the sinus. In some cases of rupture of the internal carotid not proving immediately fatal, the corresponding common carotid artery has been successfully ligated. In others, howcA^er, this has failed, even when supplemented by ligation of the other common carotid. The uncertaintv of this procedure is explained by the freedom of the arte- rial cerebral circulation through the circle of Fig. 343.-Tubular Ear Speculum. Willis, as derived from the terminals of the vertebrals when the common carotids are ligated. In cases of secondary hemorrhage, therefore, following injury in this region, as well as in cases of hemorrhage resulting from erosion of the internal carotid occur- ring in the course of caries of the petrous portion of the temporal bone, the preferable course is to pack the canal A^ery tightly with iodoform gauze. In order to guard as much as possible against septic meningitis and en- cephalitis in injuries in this locality, every aseptic precaution, including anti- septic irrigation and sterile protective dressings, should be taken. Both the facial and the auditory nerves may be injured in fractures of the petrous portion of the temporal bone. These injuries are surgicallv ir- reparable. Spontaneous restoration of function may take place, however. Foreign Bodies in the External Auditory Canal.— Children often introduce such articles as peas, beans, and buttons into the external audi- tor}- meatus. The for- eign bodies most fre- quentty found in adults are cotton plugs, placed in the ear with the delusive belief that these will prevent "catching cold," the presence of the cotton being forgotten. The cerumen and cotton com- bine to form a dense hard mass completely filling the canal. Plugs of cerumen having their origin in excessive secretion of cerumen from chronic inflammation of the ceruminous glands may give rise to the symptoms of true foreign bodies in the ear, the mass obstructing the canal and producing impairment of hearing; in some cases they may cause annoy- ing and persistent tinnitus. Fig. 344. — Electric Light Otoscope. 580 THE SURGERY OF THE HEAD Foreign bodies and masses of cerumen are usually easily discovered by inspection, the auricle being retracted so as to straighten the canal by grasping it at its upper edge. If the foreign body is small, it may be necessary to use an ear-speculum (Fig. 343). The common tubular ear speculum made of metal, with the interior polished to improve the illumination, serves an ex- cellent purpose. The electric light otoscope is a very useful instrument for examining the deeper parts of the canal and the drum membrane (Fig. 344). In the case of the common tubular speculum the patient is seated with the ear to be examined opposite a window, and the light reflected with a head band mirror. If the direct rays of the sun are used or an artificial source of light is employed, the polished interior of the tubular speculum is somewhat dazzling to the examiner, and the instrument with dull finish, or one made of hard rubber, is to be preferred. In examining for foreign bodies the sur- geon should not be misled by the brownish layers of cerumen lying against the walls of the auditory meatus. In the case of a foreign body the inspection will sometimes reveal whether or not a space is left between the latter and the wall of the meatus, into which an instrument may be introduced for the purpose of effecting the extraction from within outward. A probe, if employed at all, should be used with the greatest care. Its use without the aid of the speculum gives but very little information, since its contact with the bony walls closely covered with skin and periosteum will greatly resemble the touch of a foreign body. Foreign bodies should always be removed, for, though exceptionally they may remain innocuous for a time, they will eventually set up irritation, and finally suppuration, which will extend to the tympanum and impair the func- tion of hearing, and lead to destructive changes in the bone itself ; the latter may even threaten life by setting up meningitis. It is as dangerous, how^ever, to attempt to extract these bodies roughly without proper illumination as it is to permit them to remain. Removal of Foreign Bodies from the External Meatus. — Small foreign bodies w^hich do not completely fill the meatus are best removed by forcible syringing with a large sized piston syringe with ring pieces for firm grasping (Fig. 345). The syringe is worked with the right hand, the left grasping the auricle and retracting it upward and backward so as to straighten the canal and give free access and exit to the lukewarm water employed. In the case of foreign bodies deeply placed the wire curet or a fenestrated ear spoon sometimes accomplishes the purpose with facility. If a space exists between the foreign body and the meatus, it will usually be found in the direc- tion of either the upper or the lower wall. A small hook introduced flatwise and then turned so as to engage the foreign body is often successful. An extracting instrument may be improvised from a hairpin. Whatever form of instrument is employed it must be introduced with strong pressure against the wall of the meatus or canal, so as to gain as much room as possible, as well as to lessen the friction as it glides past the foreign body. Foreign bodies swollen by attempts to flush them out with water, or from secretions excited by their presence, may be reduced in size by contact with glycerin for some hours. The instrument may then be introduced alongside the softened cortical layers. Softened beans will sometimes split longitudinally and admit of easy extraction. In the case of nervous children, and in anv case in which much pain is caused THE EAR 581 by the inaiii])ulation, the patient should be anesthetized. Hard impacted foreign bodies may even require temporary- loosening of the auricle and cartilag- inous meatus through an incision made from behind. This usually permits direct access to the foreign body. Such incisions should be made Avith every aseptic precaution, since suppuration in this locality may involve destruction of the membrana tympani. Ceruminous plugs are best removed by forcible syringing. In case these should ])rove obstinate they may be softened by the previous application of a weak solution of carbonate of soda in water and glycerin. Inflammation of the External Ear.— The usual inflammatory affections of the face and scalp, such as eczema, impetigo, etc., attack the auricle. Erysipelas gi\-es rise to the formation of vesicles at the upper edge of the auricle. Se\'ere phlegmonous inflammations, however, are rare, on account of the absence of loose connective tissue. Furuncles are also rare, on account of the superficial location of the hair-follicles. Lupus may extend from the cheek to the ear. This usually occurs in the exfoliating form of the disease. The cicatricial atrophy may result in the disappearance of nearly the entire auricle. Lupus of the lobule has been described as an isolated disease in which the whole substance of the lobule is converted into pale red tissue. In some cases the disease is arrested only by the removal of the lobule. Otitis Externa. — Ex- ternal otitis appears in the following forms: 1. Eczema of the ex- ternal auditory meatus, occurring specially in strumous children and accompanying eczema of the skin of the external ear. The vesicles discharge a serous fluid, a part of which escapes from the ear while some remains and dries in hard crusts -on the walls of the canal. 2. Furuncle. — This commences with swelling of the skin lining the external auditory meatus, and develops with violent pains as the thin skin is tightly stretched on the underlying perichondrium and periosteum. The "local symptoms partake of the character of periostitis. There is diffuse swelling with absence of localized elevation corresponding to the site of infected seba- ceous glands or hair-follicles, so characteristic of the affection as it occurs else- where. The furuncular character of the lesion, however, is established by the occurrence of an isolated connective-tissue necrosis , unless this is anticipated -by early and free incision, which always gives prompt relief. Furuncles should be incised early. The curved and pointed bistoury, or the tenotome, best serves the purpose for the incision. If an abscess of the ear drum or a collection of pus behind the tympanum, as shoAMi by a bulging of the latter, occurs, the puncture is best made with the point of a cataract needle. Illumination, both for the purpose of cUagnosis and for the guidance of the instrument in case of puncture, is here absolutely necessary. 3. Traumatic suppuration following injuries or due to the presence of foreign bodies. Fig. 345.— Eab Syringe. 582 THE SURGERY OF THE HEAD 4. Secondary suppuration consequent upon suppurative perforation of the memljrana tympani as a result of otitis media. Otitis media, which, with otitis interna, belongs essentially in the domain of the otologist, will be only superficially considered here. Not only is the drum membrane perforated, but the mastoid cells are also affected. The resulting caries is not necessarily tuberculous, though it may be of this character if the original suppuration in the tympanic cavity Avas tuberculous. The latter, however, is usually metastatic, and occurs especially after measles and scarla- tina. Finally, a true tuberculous myelitis may occur in the mastoid process without preceding disease of the middle or external ear. Tumors in the Region of the Ear.— Deformities of the Auricle. — So-called polypi of the external auditory meatus are A^ery frequently made up of granulation tissue originating in the suppurating surfaces of an external otitis, or in cases of otitis media, from the mucous membrane of the tympanic cavity. In the latter case the tumor grows through a large defect in the membrana tympani and projects into the external auditory meatus. Some- times this granulation tissue becomes covered with a layer of epidermis, and the name of granuloma is given to the resulting tumor. These growths occasionally persist in this shape for a long time after the suppuration Fig. 346-. — Wilde's Aural Polypus Snare. has ceased, and from the fact that they finally become pediculated the name of "aural polypi" is more or less justified. They are even said to have become finally the seat of angiosarcomas. * When these granulating masses are sessile and soft, they are to be treated by scraping and cauterization; when solid, they will require excision. Those belonging to the pediculated variety are easily and satisfactorily removed with Wilde's snare (Fig. 346). Removal of the granula or polypus, however, will not improve the hearing in cases in which the growth follows otitis media, since the preceding suppurative process in the ixiiddle ear has already done its damaging work. Both benign and malignant growths occur at the auricle and in its neigh- borhood. Dermoids are found springing from the upper branchial cleft ; their favorite location is either in front of the auricle or behind it. They are less frequently found at the upper or the lower portion of the latter. They vary in size from a hazelnut to a hen's egg. Those of smaller size, and particu- larly those lying in front of the auricle, are usually very superficial and are often mistaken for simple atheromas. Those extending into the deeper struc- tures are somewhat difficult of removal. Auricular appendages have already been referred to in the section on tumors. They are connected with the processes of development, and occur Til 10 FAR 583 not iiifiv(iu(>iill>- will) inacrostonia. 1liey are generally found at the anterior edge of tlu> tragus. In addilioii to (hose containing a nucleus of cartilage, others have been found with a small ()])cning corresponding to an inversion of the epidermis. These skin-covered remnants of cartilage have also been found over the sternomastoid (L o s s e n). They Iku'c been found springing concurrently from both sides. 'Jdiey may be easily and safely removed. Angiomas occur as congenital tumoi's at the auricle and may give rise to dangerous symptoms in connection with pregnancy (see page 227). Of benign tumors, atheromas, enchondromas, and fibromas are only occasionally found in this region; they rarely develop to an excessive size. The last named, together with a condition a]iproximating elephantiasis, attacks by preference the lobule. Epithelial carcinoma sometimes attacks the auricle. It occurs as a flat ulcer and may linall}- destroy the auricle. It develops gradually, the destruc- tive process^ is slow, and the prognosis in case of early and wide extirpation is comparatively good. Lymj^hatic glandular involvement takes place in the parotid, region, behind the angle of the jaw, and at the anterior edge of the sternomastoid. Efforts to correct the deformity following amputation of the ear by plastic operations (otoplasty), as well as those designed to supplement congenital defects, have met with but indifferent success. While efforts to replace the lobule by skin flaps from the neighljorhood are fairly successful, the compli- cated shape of the auricle has heretofore defied, to a great extent, the liest efforts of plastic surgery. ]\Iore or less improvement, however, may some- times be obtained. Projecting ears, in which the auricle projects abnormally, may be cor- rected by the removal from the auricle of an elliptic shaped portion of proper dimensions. The sutures are so placed as to include both skin and cartilage on the outer aspect, and the skin alone on the inner aspect. ^ Mastoiditis. — This is usually due to an extension of infection from the middle ear. Primary mastoiditis is rare. The pathologic changes consist of thickening of the lining membrane of the cells of the mastoid, followed in some cases by a deposit of new bone, which may finally lead to complete obhteration of the cells. In other cases necrosis occurs, with the formation of a sequestrum. Or, gradual disintegration may occur, with discharge of detritus and pus through the external ear. When the evacuation takes place externally, this may occur either behind the ear, into the external meatus, or into the digastric fossa. When internally, the fluid finds exit either through the roof of the antrum or through that of the tympanic vault, into the middle cranial fossa or into the posterior cranial fossa along the groove which lodges the lateral sinus (sinus thrombosis, see page 584). The external discharge of pus does not relieve the case of its dangers, particularly in children, since intracranial infection may subsequent!}- take place through the incompletely ossified sutures. Invasion of the cranial cavity may lead to diffuse septic meningitis (see page 457) or to a circum- scribed inflammation and epidural abscess. Finally, the intracranial con- tents may become infected through the free anastomosis of the vessels of the parts, and thrombosis of the lateral sinus (see page 464) or abscess of the brain substance follow (see pages 459, 462, and 586). 584 THE SURGERY OF THE HEAD The symptoms of mastoiditis arc intense pain over the mastoid, which is most severe at niglit, more or less constitutional disturbance, and tenderness on deep pressure, particularly over the posterior margin of the canal. A pre- vioush' existing aural discharge is diminished or ceases altogether. In children tumefaction behind the auricle may be present. Perforation of the cortex is announced by the presence of a purulent material between the overlying soft parts and the bone. Invasion of the cranial cavity is accompanied in the case of sinus thrombosis by sudden elevation of temperature, followed by a decided fall in temperature; the temperature curve becomes irregularly intermittent thereafter. The symptoms of general sepsis are present. Septic emboli may become lodged in the viscera, particularly in the lungs. If the lateral sinus is the seat of thrombosis, the latter may extend into the internal jugular vein, with tenderness and tumefaction along the course of the latter. In cases of diffuse septic meningitis there is intense headache, intolerance of light, constant high temperature, and nausea and vomiting. The pulse is generally rapid when the meningitis is basilar, which condition is usually the case in otitic meningitis. Local paralyses, particularly those involving the distribution of the third and sixth nerves, appear early. Rigidity of the muscles of the neck is an early and characteristic s3aiiptom. In cases of localized menin- gitis the constitutional symptoms are less severe, the headache localized, the paralytic symptoms delayed in their appearance, and the vomiting, intolerance of light, and rigidity of the muscles of the neck absent. Treatment. — Whether or not an aural discharge is present, free drainage through the canal should be insured by incising any bulging segment of the drum membrane. This is followed by irrigation with boric acid solution and the application of ice, if the case is not advanced. The presence of the Streptococcus pyogenes in the discharge constitutes an indication for im- mediate opening and drainage of the mastoid, even in the absence of definite symptoms of mastoiditis. The presence of this microorganism in the dis- charge resulting from an exploratory puncture of the ear drum likewise indi- cates the operation. Even in the absence of a streptococcus infection efforts to abort the attack should not be continued, at the very outside, beyond forty-eight hours from its commencement. The mastoid cells should be freely opened and the infected area exposed by removal of the entire cortex and drainage of the middle ear through the opening secured. Trephining the Mastoid; Antrectomy. — The incision commences at the top of the auricle in the line of the hair, and is curved first backward, then backward and doAvnward, and finally downward and forward to terminate at the posterior part of the apex of the mastoid (Fig. 347, 1 to 2). The in- cision is carried directly do^■v^l to the bone. If the aponeurosis of the sterno- mastoid comes into view at the lower angle of the incision, it is to be detached from the bone by means of blunt scissors, the instrument hugging the bone closely while this is being done. In children the stylomastoid foramen, owing to the undeveloped condition of the mastoid process, is laterally placed, instead of lying on the under surface of the base of the skull, so that deep dissection carried below a point on a level with the middle of the meatus exposes the facial nerve to injury. The bone is thoroughly cleared; the auricle is detached l3y blunt dissection, and, together with the skin lining, the meatus is pushed well forward and held tup: ear 585 by a retractor. If a sinus the result of a spontaneous rupture is present, this is enlarged and followed; it will generally lead to the mastoid antrum. If no sinus is present, the upper limit of the external auditory canal is located; under no circumstances must the opening in the bone bo carried above the level of this point. The cortex over the antrum, the level of which corresponds Fig. 347. — Lines of Incision for Mastoiditis, Brain Abscess, and Sinus Thrombosis. 1 to 2, Incision for mastoid operation; 2 to 4 and 2 to 5, incisions for brain abscess; 3, line of incision for sinus thrombosis. with the upper half of the orifice of the external meatus, is removed with the chisel. The junction of the antrum with the middle ear corresponds with the posterior half of the segment of the orifice of the external meatus above mentioned. The further application of the chisel is made so as to deepen the Fig. 348. — Mastoid Chisels. opening, a bony funnel being formed. The larger pneumatic spaces are soon opened, and the antrum reached at a depth varying from an eighth to three- fourths of an inch. Occasionally it is obliterated by hypertrophic sclerosis. As the cancellous structure is reached the gouge is substituted for the chisel and worked as much as possible with the hand, the use of the chisel being 586 THE SURGERY OF THE HEAD avoided. Entrance to the antrum is known by the fact that a probe, sUghtly bent at its tip, passes into the middle ear. The antrum and passage to the middle ear are now thoroughly curetted. If granulation tissue is present the curetting should be carefully proceeded with; this sometimes springs from the dura lining the cerebellar fossa and covering the sigmoid sinus, and projects into the mastoid cells. All pus and debris being cleared away, the bony cavity is packed with sterile gauze and the upper portion of the wound sutured with silkworm-gut . Injury to the lateral sinus is best avoided by keeping well forward toward the auricular attachment, and above the level of the lobe of the ear. If the dura of the middle cranial fossa is exposed, the remainder of the chiseling must be done at a lower level, in order to reach the mastoid antrum. Hemor- rhage from an injury to the lateral sinus can be controlled by tamponing with iodoform gauze, the operation being completed by enlarging the opening in the opposite direction. In children the mastoid cells are but imperfectly developed, almost the entire process being occupied by the antrum. Great variations exist in the adult mastoid process, in 20 per cent of which there is an absence of pneu- matic cells; in 38 per cent the opposite condition obtains, i. e., the absence of diploe. In some cases the upper half of the mastoid process is pneumatic, the lower half containing diploe. In the absence of the antrum, or when no pus is present in this cavity, the apex of the mastoid and the vertical group of cells should be explored. When the latter are well developed and become infected, perforation is liable to occur on the inner side of the apex, followed by suppuration in the digastric fossa and under the sternomastoid muscle. In cases of long-standing discharge, with extensiA^e disease in the tympanum, and particularly where previous operations have failed, the auricle should be temporarily detached, and, in addition to the outer wall of the antrum, the upper and outer portion of the bony meatus and the remains of the membrana tympani and ossicles should be removed (S t a c k e). Abscess of the Brain. — This may give rise to no characteristic symptoms, except constant headache, progressive weakness and dullness of intellect, until it has attained sufficient size to press on some portion of the motor area. The temperature may remain normal or become but slightly elevated. In- vasion of the motor tract will give rise to definite localizing symptoms in many cases (see page 467). It should be borne in mind that two or more intracranial complications of otitic origin may be present at the same time. Steatomas of the mastoid consist of epithelial collections in the cells. They may excite hyperjDlastic inflammation, sclerosis, and obliteration of the trabeculae, in some cases converting the mastoid antrum, tympanic cavity, and external bony canal into one cavity, with sclerosis of the mastoid cortex. THE SALIVARY GLANDS Injuries of the Parotid Gland. — ^These may result from blows, stabs, or gunshot wounds; they may also occur in the course of operations. Healing usually takes place promptly. The occurrence of a salivary fistula is generally THE SALIVARY GLANDS 587 preceded by the accuinuUilion of saliva beneath the suture hue. Pressure on this, abstinence from cliewing and talkino-, and a fluid diet taken in small quantities, usually suffice to prevent a fistula. Even when the latter occurs it is not usually persistent. Injuries of the Parotid (Stenson's) Duct.— Fhese usually result from sword' slashes or stal) wounds, and occasionally from operation wounds. The flow of sali\'a from the wound usually announces the nature of the injury. This mav be verified by passing a probe from the normal orifice in the mouth to and out of the wound in the cheek. If the wound of the cheek is a penetrating one and the external portion heals, the centrally placed divided end is kept patent by the saliva flowing into the mouth. If the wound is nonpenetrating and allowed to heal as such spontaneously, a salivary duct fistula is sure to follow. Treatment. — In order to prevent a fistula of Stenson's duct in non- penetrating wounds of the cheek primary union must be secured; the duct itself must be sutured separately with fine catgut. The sutures should not encroach upon the lumen of the duct. In penetrating wounds the skin alone is sutured, the saliva being allowed to flow into the mouth through the wound in the mucous membrane. In contused and lacerated wounds involving Stenson's duct, in which primary union is improbable, an immediate communication should be made in order to secure an internal salivary fistula; the latter will serve all the purposes of a normal duct. In the after-treatment of injury of the parotid duct the secretion of saliva and movements of the jaw should be restricted as much as possible. A permanent fistula of Stenson's duct results when the wound heals with fusion of the mucous membrane and skin at the site of the injury, or when the peripheral portion of the duct is occluded and the central portion termi- nates externally. Loss of substance of the duct itself is also sometimes present. Undermining of the surrounding parts takes place in some cases and the saliva discharges by several small openings. The fistula is usually situated in the buccal division of the duct. The diagnosis is generally made by the cUscharge of saliva upon the cheek, and in some cases it may be verified by probing. Treatment.— When the proximal end is still pervious, cauterization with the solid stick of nitrate of silver or the use of the actual cautery should be tried. If the peripheral end is impermeable to probing and an injec- tion of a colored solution from the oral opening fails to appear at the fistulous opening, a spontaneous cure is not possible, and operative measures must be resorted to. The simjDlest of these is to convert an external fistula into an internal one. The cheek is perforated somewhat obliquely by a trocar passed from the cavity of the mouth to the site of the fistula. A small drainage- tube is passed along the canal thus formed, its inner end projecting into the cavity of the mouth; its outer end is cut off obliquely so as to receive the saliva, which it conducts into the mouth. The tube is removed in about ten days. A substitute for the occluded peripheral portion of the duct having been thus formed, the fistula either closes spontaneously or is cauterized or sutured (K a u f m a n n). The method by double puncture consists in first excising the fistula for half the thickness of the cheek, and passing a silk ligature through the remaining portion so as to include about | of an inch of tissue. The ligature is tied tightlv from the inside of the mouth. The included bridge of tissue 588 THE SURGERY OF THE HEAD sloughs and an internal opening of the fistula is provided (D e g u i s e). The external wound is sutured. These measures failing, the central end may be dissected out and implanted into the mucous membrane (Langenbeck). In the absence of sufficient length of the duct to accomplish this a new duct may be formed from the mucous membrane (N i c o 1 a d o n i, B r a u n). Foreign bodies sometimes find their way into the salivary excreting ducts. A bristle from a tooth-brush, small fish-bones, and hairs have been found in Stenson's duct. Large foreign bodies, such as the cereals, seeds of fruit, etc., are much more frequently found in the submaxillary duct. Inflammatory conditions, or, if the foreign body is not forced out, abscesses and fistulas follow. Sometimes the foreign body is not discovered until an incision is made for the relief of an abscess. The treatment consists in removal of the foreign body by forcing it toward the orifice, or exposing it by an incision through the mucous membrane. If the foreign body has found its way to the submaxillary gland, the latter may become so altered by inflammatory conditions as to recjuire removal. Salivary Calculus. — Salivolithiasis is of relatively infrecjuent occur- rence. It occurs most often between the ages of twenty and forty. Men are more often affected than women. Sali^'ary calculi are most frec|uently found in Wharton's duct, though they likewise occur in the submaxillary gland, in the sublingual duct, and in the sublingual gland. The calculi vary in size from a grain of sand to a split pea, or even a hazelnut. More than one may be present. In composition they usually consist of calcium carbonate with the addition of calcium phosphate, soluble salts, and organic matter. The essential pathologic factors in the etiology of salivar}^ calculi are foreign bodies (particles of food, fragments of tartar from the teeth, etc.) and bacterial infection. The symptoms vary with the size of the calculus, its location, and the occurrence of suppuration. In the absence of the latter but slight discomfort may be present. Retention of saliva lasting for several hours after a meal, accompanied by pain and discomfort ("salivary colic"), is characteristic of a calculus in Wharton's duct. A hard nodule in the floor of the mouth, with difficulty in chewing, swallowing, and speaking, is usually present. If suppuration occurs, the abscess frequently discharges into the mouth, the calculus escaping at the same time ; the latter is rarel}^ discharged through the normal orifice of the duct. The stone may give rise to pressure necrosis and escape through the opening thus made. With the occurrence of suppuration the corresponding gland becomes infected, giving rise to a j^ainful swallowing. Phlegmonous cellulitis of the neck, resembling L u d w i g ' s angina, may supervene. Spontaneous external discharge of supi^urative collections may lead to salivary fistula. The diagnosis may often be confirmed by probing the duct. The affection is to be differentiated from inflammation of the duct, from alveolar abscess, particularly in cases in which the abscess develops about the submaxillary gland, and from syiDhilitic and tuberculous disease, actinomycosis, and mahgnant disease. The a;-ray may be useful in the diagnosis. The treatment consists in evacuation of the abscess, removal of the calculus, and, in the case of the submaxillarj'^ and sublingual gland, the removal of these if a number of calculi are present and are difficult to remove, or the gland is the seat of miliary abscesses. Simple infection of the gland is not an indication for its removal. When the stone is situated in the duct, it should be removed THE SALIVARY GLANDS 589 thnnio'h the mouth; if in one of the siilivary glands, it must he attacked from the outsid{\ Inflammation of the Salivary Gland (Sialadenitis). — This is usually caused by infections from the cavity of the m(jutli. Acute i^rimary inflam- mation of the salivary glands is rare with the exception of the acute epidemic form (mumps). This affection derives a surgical importance from the orchitis which ckn'clops as a complication, and for which no satisfactory explanation has been given. Atrophy of the testicle occurs in about one-third of the cases (Kocher). Abscess occasionally forms. Oophoritis, mastitis, vulvovagin- itis, prostatitis, and cystitis are other complications of surgical interest. Acute secondary sialadenitis results from foreign bodies, calculi, and septic con- ditions following injuries. It is not an infrecjuent complication of typhus; it also occurs in other infectious febrile states (scarlet fever, pneumonia, variola, pyemia, septicopyemia, etc.). It likewise develops after operations, particularly abdominal section (not necessarily operations on the ovaries, as was formerly believed). Here, as in the case of the febrile conditions, it is also due, in all probability, to infection from the mouth, since it has been shown (P a w 1 o w) that, after abdominal section, as in the febrile state, there is a cessation or diminution of the salivary secretion. To this is to be added, as increasing the locus minoris resistentiae, the drvness of the mucous membrane of the mouth. The symptoms of parotitis are fever, swelling of the gland, radiating pains, and tenderness. The sw^elling is first seen below the angle of the jaw, but finally extends from the middle of the cheek to the mastoid and lower temporal regions. The lobule of the ear becomes prominent and is elevated ; the appear- ance is characteristic. The parts are intensely tender, especially when attempts are made to move the jaw, and the radiating pains become intense. The skin becomes red and edematous and the superficial veins are dilated. The hearing may become affected by compression of the external auditory canal. If the symptoms continue to increase beyond the third or fourth day, suppuration will probably occur. Extensive abscess formation may be present without palpable fluctuation, on account of the unyielding overlying fascia. Perfora- tion may occur into the external auditory canal and purulent otitis media result. Burrowing may take place behind the pharynx and esophagus and into the mediastinum, rupture finally taking place into the air-passages. In- fection may travel along the vessels and nerves and reach the interior of the cranium. Cerebral complications may also arise through the medium of venous thrombi. Thrombosis of the jugular vein and sigmoid sinus may occur. Involvement of the submaxillary gland is comparatively rare, and ex- tensive suppuration here is the exception .rather than the rule. ^^Tien this does occur, it resembles in its course L u d w i g ' s angina. Sialadenitis affecting the submaxillary and sublingual glands occurs in nursing children. Suppuration is the rule, the pus escaping through the ex- cretory ducts and breaking through the skin and escaping externally. The treatment of inflammation of the salivary glands consists in prophy- lactic cleansing of the mouth of a patient who has undergone an operation, or of one seriously ill with a febrile affection. The boric solution, with the addi- tion of thymol, gaultheria, and tincture of myrrh, applied with gauze, is useful. With the development of the disease ice is to ]3e applied to the parts for two or three days. If no improvement follows this treatment, and the ^•iolent symp- 590 THE SURGERY OF THE HEAD toms persist, a free incision should be made through the fascia and the gland further exposed b}^ blunt separation with a grooved director, or the blunt blades of an artery clamp. In making the incision in the case of the parotid gland the facial nerve is to be avoided. Diffuse suppuration and perhaps necrosis may be revealed. The parts are to be curetted, carefully cleansed, and a drainage-tube and an iodoform gauze tampon introduced. Early operative interference, in these cases, gives the best results. The sialadenitis of nursing children is to be treated by incision and drainage. The "inflammatory tumor" of Kiittner is a chronic interstitial in- flammation of the submaxillary salivary gland. The gland increases in size to a hen's egg, or becomes larger, and is more or less adherent. Tenderness is not marked. The swelling is difficult of difTerentiation from malignant tumors occurring in this region, and for this reason, as well as the fact that this tumor tends to extend to the surrounding tissues, excision is advisable. Inflammation of the principal excretory ducts of the salivary glands (sial= odochitis) has been observed in the duct of the parotid more frequently than in Wharton's duct. Injuries and carious teeth are said to be the causes. The chief symptoms are acute retention of saliva, the formation of a salivary tumor, with cessation of the latter coincidental with an increased flow of saliva as the obstruction is overcome. The retention is clue to a flbrin- ous plug. The orifice of the duct is red and projecting, and pressure along its course will express a drop of pus or a fibrinous plug. A permanent dilatation of tlifi duct may follow and the gland itself may become involved. The treat- ment should be primarily directed to the removal of the cause. The occa- sional passage of a probe and the injection of an antiseptic solution afford relief. The disease is not usually amenable to curative treatment except by the operation of splitting up the duct, which should be performed when the attacks of retention are painful and frecjuent. TUMORS OF THE PAROTID AND SUBMAXILLARY GLANDS In addition to salivary cysts, chondroma, adenoma, and sarcoma, or combmations of these, are observed. Those of the parotid gland are the most frequent. Chondroma. — The cartilage of the first branchial arch lies at the site of the subsecjuently developed parotid, and fetal cartilaginous structure is inclosed during the formation of the gland (L ii c k e , Cohnheim). Chondroma of the submaxillary gland results from proximity of the second branchial arch. These tumors are globular in shape and present nodulated surfaces. Their growth is very slow and painless. After being in existence for years they may take on rapid growth, the tumor being thus converted into an adenosarcoma; simultaneously the growth softens and becomes the seat of pain. After attain- ing a considerable size the tumor breaks down, with ulceration of the surface and hemorrhage. The branches of the seventh nerve become involved in the growi^h and facial paralysis occurs. The patient dies either from exhaustion from repeated hemorrhages or from septicemia. Sarcoma of the Parotid Gland. — In all probability many of the growths in this region that were formerly described as sarcomas sprang from the lymph- atic vessels as endotheliomas. Sarcomas appear as oval shaped, smooth, and elastic swellings. When composed of immature hyaline cartilage (chondrifying; THE SALIVARY GLANDS 591 sarcoma) they are of slow ma of the neck. A compromise course which assists materially in shorten- mg the healing process is to perform a low tracheotomy and suture the original wound at the angles. The wound may traverse the tissues so as to seA'er the attachments of the epiglottis and open the pharynx, in which case the patients must be fed by means of an esophageal tube. Wounds of the larynx and trachea may lead to cicatricial stenosis and require the permanent use of a tracheal cannula. In stab wounds the weapon may penetrate the posterior wall of the upper air-passages, when the esophagus will also be opened. In punctured wounds emphysema is likely to occur and may be prevented or remedied by tracheot- omy below the point of puncture. The emphysema soon disappears by resorption of the infiltrated air. Rupture of the tracheal mucous membrane with infiltration of air into the connective tissue of the neck sometimes occurs from forcible shouting efforts. When this forms a saclike cavity on the side or in front of the trachea'' it may simulate goiter. ' Foreign Bodies in the Air=passages.— Irregular or spasmodic action of the muscles engaged in the act of swallowing is the usual cause of passage of portions of food, and particularly fluids, into the trachea. The sensitiveness of the glottis is such as to impel an act of coughing as soon as fluid comes in contact with that structure, which results in the removal of the latter. Suffocation may result from the passage of vomited matters as well as of artificial teeth in surgical anesthesia. The space between the true vocal cords and the ventricular bands is a favorite place for the lodgment of pointed and angular foreign bodies, such as pins, fish-bones, etc. These may be removed by means of cur^^ed forceps with the aid of the laryngoscope. The further progress of the foreign body tends in the direction of the right bronchus, from the fact that the latter is almost a continuation of the trachea and has a larger lumen. Small and smooth foreign bodies taken in the mouth by children at play sometimes pass into the larynx and produce suffocative svmptoms. These shortly disappear on account of the forcing of the foreign body either upward into the ventricle of the larynx or dovnwa'rd into the trachea." In the former situation its presence may be easily recognized by means of the laryngoscope, and sometimes even in the latter situation, where, if not attached, \t may be seen moving up and down with each act of respiration. Auscultation over the trachea will also give the physical signs of obstructed entrance and exit of air m case a foreign body with rough surface has lodged against the tracheal wall. In case the foreign body has lodged in a bronchus, the respiratory movements of that side of the chest are lessened, and' the respiratory murmur found, on auscultation, to be notablv weakened or absent altogether. The pectoral fremitus is also lessened. Interlobular emphysema, which may extend to the neck, has also been observed. 596 SURGERY OF THE NECK Treatment. — As soon as it is positively determined that the foreign body has passed beyond the glottis a tracheotomy must be ]:)erformed. If the body is not coughed out through the tracheal opening, the latter will afford facilities for its subsecjuent dislodgment. If this fails, aTrendelenburg cannula may be introduced, the thyroid cartilages split (thyrotomy), and the foreign bocly removed. Or, the patient being guarded against further downward passage of the foreign body by the presence of the cannula, attempts may be made to remove it through the glottic opening with the aid of the lar}'ngoscope. If the lodgment is in one of the bronchial tubes, the case becomes greatly complicated. Here the tracheotomy wound will serve to facilitate the ex- ploration, and may also serve to increase the ease of expulsion later on, should the foreign body become loosened by suppurative changes in the immediately adjoining tissues. If the foreign body chances to be metallic and hollow, as, for instance, a detached tracheal cannula, its presence and location may be determined by means of the telephone probe. Its removal will be greatly facilitated once its exact location is determined. With the tracheotomy wound located as low as possible, the foreign body may sometimes be reached with properly bent forceps. I once succeeded in thus locating and removing a tracheal cannula which had become loosened from its shield and had passed into the left primary bronchus. Finally, efforts at loosening and other measures failing, an attempt may be made to reach the site of the incarcerated foreign body, if in a primary bronchus, by means of resection of the chest wall behind. This operation was devised by me and carried out under my direction in the dead-house at St. Mary's Hospital by Dr. E . Arthur Parker, who was at that time my House Surgeon, on May 27, 1891. The experimental procedure demonstrated that the operation could be carried out without injury to important structures.* Gauze tamponade, without suture of the bronchus, tube drainage, and partial closure of the external wound meet the indications in the after-treatment. Failure to remove the foreign body is usually followed by grave septic pneumonia in the respective portions of the lungs. Angular shaped or pointed objects may perforate a bronchus and cause suppurative mediastinitis. Perforation of the aorta or of the pulmonary artery may occur. The esophagus may be invaded ; passage of food into the air-passages and fatal pleuropneu- monia follow. Laryngoscopy. — The reciuisites for an ordinary examination of the in- terior of the larynx are (1) a good light, the strong white light of a kerosene lamp answering the purpose admirably; (2) a perforated concave reflector three to four inches in diameter with a focal distance of from six to eight inches, and an apparatus to secure it to the head (Fig. 350); (3) laryngoscopic mirrors of v8.rious sizes (Fig. 351). * At my request, Dr. Parker has furnished me with the follomng report of the experimental procedure from notes and a sketch made at the time: A foreign body (a cork from a medicine bottle) was introduced through a tracheotomy opening and forced into the left bronchus by means of a stout wire. The left arm was drawn forward to gi^-e additional space between the scapula and the spine. A "double door" incision was made to include the second, third, and fourth ril^s, and the latter divided as near the spine as pos- sible, and near the posterior border of the scapula. The included sections of ribs were re- moved and the pleura incised. A tenaculum was passed through the wall of the bronchus and into the cork, thus fixing the latter securely. An incision was then made over the cork in the lone; diameter of the bronchus, and the cork easily extracted. THE LAllY.VX, TUACHKA, AND llVoJI) BONE 597 The room is darkenod aiul the patient .seated witli the lamp on a table and behind his left shoulder. 'J'he operator places the reflector on his head and Fig. 350. — Laryngoscopic Head Band and Reflector. adjusts the latter so that the perforation in its center, his own eye, and the back of the patient's larynx are in line (Fig. 352). In Collin's reflector Fig. 351. — Laryngoscopic Mirror. (Fig. 353) both eyes are emplo^'ed. The surgeon draws the tongue forward by grasping its tip, slipping being prevented by the interposition of a single thick- FiG. 352. — Laryngoscopic Ex.a.mination. The reflector and mirror in position. ness of a coarse napkin or towel. The image mirror must be warmed Ijefore introduction to prevent condensation of moisture from the patient's breath on 598 SURGERY OF THE NECK Fig. 353. — Collin's Electric Light Reflector. its surface, and consequent blurring. The fauces may be advantageously sprayed with a 10 to 20 per cent solution of cocain to overcome troublesome irritability of the parts. The rays of light are caught on the reflector from the lamp behind the patient's shoul- der and reflected on the surface of the mirror held over the glottic opening, in which is seen the re- versed reflected image of the parts below (Fig. 354). When the pa- tient makes such sounds as "ah" and "air" the vocal cords are readily seen in different posi- tions, and upon deep and forced inspiratory efforts the tracheal rings, and under favorable cir- cumstances the bifurcation of the trachea, are brought into view. Inflammatory Obstruc= tions of the Larynx and Tra= chea. — Catarrhal inflammation in its severest form may lead to serious obstruction through ser- ous infiltration of the submucous connective tissue, and demand tracheotomy. The mucous mem- brane covering the false vocal cords and ar^^epigiottic ligaments are most fre- quently the site of this submucous infiltration. Two roll-hke masses result from edema of the long mucous folds of the latter, which upon inspiration are sucked in toward the central portion of the glottis and obstruct it. They can be felt by palpation from the mouth. There is no obstruction to expiration. Edema of the glottis may result from an exten- sion of traumatic inflammatory edema of the pharyngeal mucous membrane. The treatment consists in scarification of the edematous tissue, and finally trache- otomy. Diphtheritic inflammation produces stenosis of the larynx and trachea by both submucous infiltration and pseudo- membranous deposit. The glottis itself, the narroAvest portion of the air-pas- sages, is the part which when encroached upon demands operative measures of re- lief. In these cases intubation of the larynx is frequently performed with benefit (O'Dwyer). The percentage of recoveries is about the same as in tracheotomy, with the added advantage that there is Fig. 354. — The Larynx as seen in the Laryngoscopic Mirror. The illustration shows the parts larger than normal in order to bring out the details. THE LARYXX, TRACHKA, AM) IIVOII) JJOXFO 599 no wound lo hcconic iiircctcd willi the ' produce obstruction. If the arytenoid cartilages are involved there will be pain on deglutition. Syphilitic Laryngitis. — This occurs as a gummatous infiltration and perichondritis, with or without ulceration. In sj^philitic perichondritis the cricoid especially is attacked. Variolous and typhoid laryngitis is a metastatic inflammation which produces uleeratiA-e destruction of the mucous membrane. In the first named the dangers of obstruction are due in the beginning to inflammatory swelling of the mucous membrane and later to perichondritis. In tj^phoid ulceration obstri.iction rarely occurs until later, or during convalescence, when cicatri- cial contraction may follow the healing of the ulcer; or the obstruction may be due to perichondritis. Inflammatory thickening of the vocal cords (chorditis vocalis inferior hypertrophica), due to chronic catarrhal inflammation of the inferior or true vocal cords, may produce a stenosis sufficient to necessitate tracheotomy. Tracheotomy. — The term laryngotomy is applied when an opening is made from without into the larynx; laryngotracheotomy when the opening is made in the cricoid cartilage and the adjoining tracheal rings; tracheotomy when the trachea is opened. Generally speaking, however, these are all in- cluded under the latter term. The operation is indicated by the presence of a narrowing of the normal lumen of the tube sufficient to interfere with respiration and endanger life. It is also appHed as a preliminary operation in laryngo- tomy, laryngectomy, and other operations about the upper air-passages and pharyngeal and oral cavities. Among the acute obstructions requiring the operation as an emergency procedure may be mentioned (1) croup and diph- theria; (2) inflammatory affections and edema of the larynx; (3) foreign bodies in the larynx; (4) bilateral abductor paralysis; (5) spasm of the larynx (occa- sionally in children, rarely in adults). It is also employed in syphilitic and tuberculous disease of the larynx to give the parts rest; in tumors of the larvnx and for the removal of foreign bodies from, the trachea and bronchial tubes. In croup and diphtheria, and in abductor paralysis, the mistake of delaying the operation too long should not be made. To be of benefit it should be performed while there is yet hope of sa^-ing the patient's life, and not post- poned until euthanasia constitutes the only indication in the case. The anesthetic employed should be chloroform whenever practicable. This is usually safe in the case of children; ether is very irritating to the mucous membrane of the air-passages. In adults cocain (4 per cent solution) may be injected under the skin at the site of the cutaneous incision, the local anesthesia thus obtained lasting for from ten to tweh'e minutes (B o s - wort h) , and being efficient for all the structures except the mucous membrane. Finally, in the case of very young children, when struggling may be prevented by wrapping the child in a blanket, and of older children who are 600 SURGERY OF THE NECK Fig. 355. — French's Combined Hemostatic Forceps and Retractor. practically already anesthetized by carbon dioxid poisoning, anesthesia may be omitted altogether. Choice of Operation. — Under circumstances of extreme emergency the trachea ma>' be opened by a single cut, or rapid tracheotomy (D u n h a m), without reference to the presence of large veins or the thyroid isthmus. The trachea and larynx are steadied laterally by the thumb and finger of the left hand, or a large tenaculum hooked deeply and firmly into the cricoid or cri- cothyroid membrane. Though a plexus of veins lies on each side of the line of incision, A^et not infrecfuently a large vein or two, increased in size by ob- structed breathing, crosses the trachea. The only normal artery likely to be met with is the cricothyroid, and this is placed so high (at the lower border of the thyroid cartilage) as to be practi- cally out of the way in almost all of the operations of choice. An occasional arterial abnormality, the arteria thy- roidea ima, is met with; it rises from the arch of the aorta and passes directly upward in the middle line to the lower border of the thyroid. In a low or infrathyroid tracheotomy the innominate artery may be endangered. In young children the thymus gland may be an obstacle. In spite of these latter objections and of the fact that the trachea in children is more deeply placed and smaller in diphtheria cases, in which it is desirable to place the tube as far away as possible from the pseudomem- branous exudation, as well as in cases of malignant disease in which the can- nula must be permanently worn, the low operation should be performed. Where the isthmus can be severed between two ligatures, the tube may be placed at its site. In an emergency reciuiring rapid tracheotomy, and under circumstances which de- mand prompt interference on account of threatened suffocation, the most super- ficial portion of the tube is chosen (laryngotracheo- tomy) . The Operation.— The patient, if a child, is wrap- ped in a blanket which is snugly pinned so as to confine the arms at the lateral portions of the body; they should not be crossed over the chest. He is placed on the table so that a good light may be obtained. The parts to be operated on are brought into prominence by a hard pillow made by wrapping a wine bottle in a towel, or some similar de\dce. The instruments required are a scalpel, half a dozen artery clamps (French's clamps are the most convenient), four small retractors (Fig. 356) (two sharp and two blunt), two pairs of thumb forceps, a grooved director, a strong and well curved tenaculum for fixing the trachea (Fig. 357), curved and straight blunt pointed scissors, an aneurism needle, and curved and Fig. 356. — Pilcher's Retractors. TI IK LAKVXX, TUACHKA, AXD HYOII) BOXE 601 Fig 357. — Combined Grooved Director AND TeXACULUM. ?trai^-ht needle:?. iSilk ami eutgut arc also needed lor .sutureand ligature purposes. An assortment of tubes must be at hand. The one best adapted to the case is prepared, with tapes attached, and placed con^■enientl>' near. The other in- struments are i^laced in the order in which the}- are to be used. A median incision is made from the lower edge of the cricoid cartilage downward for from an inch and a half to two inches, in- cluding the skin and superficial fascia; the anterior jugular veins, one on each side of the larynx and trachea, pass downward and are joined by a transverse tmnk just above the sternum. The lateral ribbon-shaped muscles (the crico- thyroid above and the sternoth}Toid below) are separated by the handle of the scalpel and drawn apart by small blunt retractors, so that the deep fascia is brought into view. The latter divides into two layers to inclose the isthmus of the thyroid, which is recognized b}- its pinkish red appearance, resting on the second and third rings of the trachea. The deep fascia is carefully nicked just below the lower border of the isthmus and divided on a grooved director, the incision baring the rings of the trachea with some loose connective tissue in front. A stout tenaculum is now inserted, point upward, at the lower border of the isthmus into the trachea to steady the latter while it is being incised. Whenever possible, a loop of strong silk is passed through each edge of the tracheal incision for purposes of retraction. As large a tube as can be passed without crowding should be used. Various tracheotomy tubes have been devised; the best is that known as the Cohen model (Fig. 358). It is flattened from side to side, so that its introduction is facilitated and the tendency of the posterior wall to bulge forward, as a consequence of wide separation of the edges of the di^•ided tenaculum rings, is lessened. A pilot trocar aids in the introduction in emergency cases and during the after-treat- ment, but if the loops of thread above men- tioned can be placed in position and retained, this, as well as tracheal dilators, can be dis- pensed with. The wound is closed by inter- rupted sutures, except at the point where the tube emerges, and dressed with iodoform gauze. The tube is secured in place by tapes about the neck and covered by a number of tliick- nesses of gauze saturated with a steriHzed normal salt solution. The atmosphere of the room is kept moist and at a temperature of at least 80° F. In croup and cUphtheria cases a watchful care is to be exercised to prevent the tube from becoming blocked by pieces of false membrane. The inner tube is to be re- moved and cleansed from time to time. In an emergencv both tubes are to Fig. 358. — Cohen's Tracheotomy Tubes. 1, Outside tube and obturator; 2, obturator; 3, inside tube; a, cross-sec- tion of the tube. 602 SURGERY OF THE NECK be removed at once and the patency of the opening maintained by the loops of thread. The tul^e should be dispensed with at the very earliest possible moment. In suprathyroid tracheotomy the incision commences opposite the middle of the thyroid cartilage. The isthmus is loosened by the handle of the scalpel and crowded down- ward, where it is held by a small Ijlunt retractor while the trachea is steadied l)y a tenaculum and the first two or three rings incised. In laryngo- tracheotomy the incision is carried upward in- stead of downward, dividing the cricoid cartilage and the cricothyroid membrane. This operation is rarely required except for exploratory purposes, and in case the isthmus is placed abnormally high and is very broad. Cricothyroid laryngotomy is an exceedingly simple operation and hence is some- times employed w^hen the emergency of the case de- mands a speedy opening of the windpipe. The in- cision is confined to the cricothyroid membrane. A tube introduced at this point is not well toler- ated and but a limited space is afforded for its in- troduction, so that only a small tube can be used. The After Course and Treatment in Tracheo- tomy Cases. — When the operation is performed for the relief of stenosis due to diphtheritic conditions of the larynx or trachea, in addition to meeting the immediate indications for the prevention of suffoca- tion and removing whatever diphtheritic membrane may be detached or detachable, the procedure permits the application of proper local remedies to the diseased area. The tracheal wound also gives ready exit to loosened portions of pseudomembrane, which are propelled upward by -acts of coughing. This loosening is hastened by inhalations of steam. The stream of steam from a croup kettle (Fig. 359) or from a com- mon teakettle with a tube ex- tension on the spout, is directed so as to be inhaled through the cannula. The addition of gly- cerin to the boiling water is said to hasten the separation of the diphtheritic deposit by pro- ducing a serous transudation of the mucous membrane (P. Voigt). The entire effort must be directed toward preventing the drying of the secretions of the larynx and trachea. By the flapping noise the practised ear will at once detect when a portion of diphtheritic membrane is loosened but cannot escape. Under these cir- cumstances the curved intracannular forceps (Fig. 360), which should always be at hand, are to be used. They are passed through the cannula, the jaws opened, Fig. 359. — Ckoup Kettle. Fig. 360. — Ixtracaxxular Alligator Forceps. THE LARYNX, TRACHKA, AM) IIVOII) ]U)NE 603 and while a eou^hiii;;" el't'ort is made the jaws are closed and llie instrunient with- drawn. This may be frequently repeated, but if it is found that the loose piece is not caught after several trials, the entire cannula should be removed, when the mass A\ill almost immediately follow. If not, the forceps should be carried through the wound to the interior and further efforts made. I'he inner tube may be removed occasionally for purposes of cleansing. During the intervals a compress made of a num])cr of thicknesses of gauze, and moistened with a sterilizcMl salt solution, should ])e kept over the cannula. The Treatment of the Wound. — Complete aseptic regime cannot be maintained in the treatment of the wound. A piece of iodoform gauze may be placed between the shield of the cannula and the wound surfaces, and changed frequently. In nondiphtheritic cases the wound usually heals with- out complication. Infection of the wound is very likely to follow in cases of diphtheritic inflanunation of the trachea. The infected wound surface is to be treated with gauze compresses wrung out of a 5 per cent carbolic acid solu- tion or disinfected with a 5 or 10 per cent chlorid of zinc solution. Phlegmonous inflammation of the connective tissue of the neck may occur. This is an ex- ceedingly serious complication and is to be met by the frequent application of compresses dipped in sokitions of corrosive sublimate, 1 : 2000 in 50 per cent alcohol, or the carbolic acid and opium lotion (see page 160). Diphtheritic ulceration of the anterior tracheal wall may arise in con- sequence of severe diphtheria of the mucous membrane and of the wound. A tracheal stenosis may arise from this cause, necessitating in very rare instances a second tracheotomy. Or, the tracheal wound may fail to close and a subse- quent plastic procedure become necessary. Diphtheritic Paralysis. — Motor paralysis of the muscles of the palate and sensory paralysis of the nerve-fibers at the entrance of the larynx permit fluids to pass through the glottic opening and out of the tracheal wound. The diet therefore should be restricted to sterilized milk. Should the patient's nutrition suffer because of inability to swallow sufficient milk, the stomach, tube should be emjDloyed or nutrient enemas administered. Paralysis of the vocal cords sometimes remains after severe laryngeal diphtheria, with resulting aphonia. Spontaneous recovery usually takes place, as in other paralyses of diphtheritic origin. Electric applications to the mus- cular apparatus of the larynx are useful in obstinate cases. Ulceration of the trachea from improperly curved tubes occurs in a certain l^roportion of cases. The resulting hemorrhage is sometimes sufficient to cause obstructed breathing. The introduction of a tampon cannula (Trendelen- burg's, page 535) will arrest the bleeding. The preventive treatment con- sists in removal of the cannula as early as possible. Granulomas sometimes form at the edges of the tracheal wound and in the tube track. When within the trachea, they mark the site of pressure ulcers. When in the latter location, they may cause suffocative attacks after the removal of the tube and the closure of the external wound, by being drawn in with the inspired air. The granulomas may be destro^'ed by nitrate of silver or chromic acid, the cannula being replaced until smooth cicatrization of the sm-faces has been secured. Attacks of suffocation are sometimes observed after removal of the tul)e, when no discoverable cause for these is present. They are due to psycliic 604 SURGERY OF THE NECK causes and paralysis from long inactivity of the posterior cricoarytenoid muscles. The patient should be encouraged to make long and forcible inspiratory efforts. Electric treatment is also useful. Permanent Removal of the Tube. — In diphtheria cases the cannula can generally be dispensed with after the fifth day. If, upon dispensing with the tube for a short time, the oljstructed breathing recurs, the tube should be replaced and another trial made on the following day. A compress placed over the wound for a few seconds while the patient is directed to make forced inspiratory and expiratory efforts will assist in restoring the func- tion of the muscular apparatus of the glottis, when the difficulty is due to inactivity of this. When tracheotomy is performed for foreign bodies, it may not be necessary to employ a cannula; at the most this will be required only for a day or two after the removal of the foreign body. In stenosis from tumors or cicatricial bands, unless the cause can be removed by other operative procedures, the tube must be worn for life. Under these circumstances the track of the tube becomes covered with mucous membrane from within outward, and by a layer of epidermis from without inward, the two layers meeting. After preliminary tracheotomy the cannula can be removed as soon as the operation is over, as a rule, or it may be left in place for a short time to prevent blood and wound secretions from entering the air-passages. In acute cases the wound heals rapidly after removal of the tube. In those who have worn a tube for a long time a minute fistulous opening may remain after its removal. Persons who are compelled to wear a tracheal cannula permanently should ])e taught how to remove and cleanse the tube. It is better for these patients to wear a hard vulcanized rubber tube of solid construction to avoid accidents arising from corrosion of the metal tube at the point where it is soldered to the shield. Intubation of the Larynx (O'Dwyer). — This operation has largely replaced tracheotomy in cases of diphtheria. It is also employed in stenosis of the larv^nx from causes other than malignant disease. As in the case of trach- eotomy, it should be performed early in order that the greatest benefit may be derived from its use. It has the disadvantage of rec|uiring special instruments for its performance, whereas in tracheotomy the urgently demanded relief can be obtained by means of instruments usually at hand. This disadvantage is offset, however, by the fact that it entails neither loss of blood nor shock, and can be speedily performed. The instruments as ordinarily supplied are (1) a set of tubes with obturators, adapted to the ages between one and twelve years; (2) a metal gage to aid in the selection of the proper tube; (3) a mouth-gag; (4) a tube intro- ducer; (5) a tube extractor (Fig. 361). Operation. — The child is held upright on the lap of an attendant, with its head resting on the latter's left shoulder, so that the body, head, and neck are in a straight line. The arms are held securely against the patient's body. The mouth-gag is inserted in the left angle of the mouth as far back as possible between the teeth, and the latter forced apart as far as possible. The proper sized tube is attached to the introducer by its obturator, a piece of thread attached to the tube by passing it through a hole provided for the purpose, and THE LARYNX, TKACllKA, AXU HYUIU BONE 605 the thread wound around the Httle finder of the risi^ht hand of the operator. This thread is to facihtate the immediate withdrawal of the tul)e shoukl it become improi)erly lodged. The introducer is grasped in the right hand whik^ the tip of the left index-finger is passed to the epiglottis, identifying it. The latter is raised so as to uncover the glottic opening, and the tube is passed, guarded liy the index-finger. As the tul)e glides over the now vertically placed ejiiglottis and enters the glottis, the guiding index-finger is shifted posteriorly toward the pharyngeal wall, where it prevents the tube from slipping into the esophagus. The proper position of the tube being assured, it is at once driven home and at the same time released from its obturator and the introducer by |H ^Hl ^^^^^^^^^^^^^^B ^1 ■^B ^^1 ^^K^y 1/ j^^^^^^^^^^^B B W^ t/m ^R «'i v^^^^^^^^^^^i I ^p^l^ ■ ^ m "B| . L 9^ 4 ' ' ."" ' v*^ . ^M ^»##iiiiii ) i J W!^ Fig. 361. — O'Dwyer's Intubation Instruments. A, Tube with obturator; B, tube; C, obturator; D, metal gage; E, mouth-gag; F, introducer; G, ex- tractor; H, silk cord. pushing forward the slide on the latter with the thuml) of the right hand. The introducer with the attached obturator is now withdrawn. The left index- finger then identifies the tube in position, and, if not placed well down in the glottic opening, it is pressed home by the same finger. The gag is then re- moved. If the breathing is relieved, the gag is again introduced and the tube steadied with the finger as before, while the thread is withdrawn. In case the tube is expelled by the subsequent coughing efforts, a larger one should be introduced. The removal of the tube, which is usually safe after from three to nine days, is effected l^y a maneuver similar to that by which it was introduced. The child is held in the same manner, the gag introduced, the top of the tube identi- fied bv the left index-finger, and the extractor introduced. The blades of the 606 SURGERY OF THE NECK latter are released by a device on the shank worked by the thumb of the hand which grasps the instrument as the point of the latter passes into the lumen of the tube. The spread-out blades of the extractor engage the tube and the latter is withdrawn. The following precautions must l)e observed: (1) The operator should be- come thoroughly familiar with the mechanism of the instruments, and, if possi- ble, practise the operation upon the cadaver; (2) the finger should not be held too long over the glottis lest suffocation take place. The dangers of the operation are the following: (1) Membrane may be pushed ahead of the tube and produce obstruction. This will necessitate with- drawing the tube immediately and waiting until the loosened membrane has been expelled before reintroducing it. (2) Failure to remove the thread may lead to the swallowing of the latter, followed b}^ the tube itself. Should this occur, another tube must be introduced at once. The swallowed tube will be expelled with the bowel movements. Tumors of the Larynx and Trachea. — Papilloma. — This is a connective- tissue new formation (fibrosarcoma) with a broad base and fissured surface. The smaller growths occur isolated or in groups at the free edge of the anterior commissure of the vocal cords. Large growths occupy by preference the aryepiglottic ligaments and occasionally the posterior surface of the epiglottis. These occur generally in children. Pediculated fibromas originate from the free edge or lower surface of the vocal cords. The first named usually give rise to progressive aphonia at the commencement; later on they may increase in size sufficiently to cause dyspnea. The pediculated fibromas may give rise to suffocation early in their history. Sarcoma of the larynx is rare, and when it does occur it springs from the lateral wall. Myxoma, angioma, and adenoma of the lary'nx are verj^ rare. Enchondroma of the thyroid and cricoid cartilages is also very rare. Large intralaryngeal growths of benign origin are l^est dealt with by laryngotomy. Tumors of the trachea are exceedingly rare, except the granuloma due to the use of a tracheal cannula. Sarcoma and submucous fibrosarcoma have been observed. Cancer of the Larynx.— This is the most important of the mahgnant growths. It occurs both as a primary affection and as an extension of disease from carcinoma of the tongue, fauces, and esophagus. It is essentially a disease of adult life. It may arise in the mucous membrane of the ventricles, vocal cords, or ventricular bands (intrinsic cancer) ; in the aryepiglottic folds, or the covering of the arytenoids, or the interarytenoid fold (extrinsic cancer). The first named is papillomatous in character, almost alwavs occurring as a warty growth. Lymphatic glandular infection and dissemination are uncommon. On the other hand, in the extrinsic variety the disease extends rapidly and infects the lymph-glands promptly. The clinical importance of the distinction is further emphasized by the fact that implication of the surrounding parts occurs far more freciuently in the extrinsic than in the intrinsic variety, and operative interference (excision of the corresponding half of the larynx, or thyrotomy and thorough removal of the soft tissues) gives far better results in the intrinsic form of the disease than in the extrinsic. Indeed, in the majority of cases of the latter, as well as in those cases of the former too far advanced for thyrotom}-, the only hope of saving the patient from death from TlIK LARYXX, TI{A( 'II lOA, AXD 11 VOID BONE 607 suffocation ivsulcs in Iruflicoloiny. 'I'hc slight tendency to involvement of the thyroid cartilage^ in the intrinsic form of the disease, and the low mortality following thyrotomy as comi:)ared with that following complete or even partial laryngotomy, have gi^•(Ml a h()i)eful impetus to the effort to diagnose the disease early by the i-emoval with the intralaryngeal forceps and the microscopic examination of portions of all suspicious growths in the larynx occurring in middle-aged adults. The laryngoscoiw is to be employed in the diagnosis of tumors of the larynx. The small benign growths are best removed l)y intralaryngeal operations at the hands of skilled laryngologists. In malignant disease, the tliagnosis being established early by microscopic examination of portions re- moved by the laryngologist, either thyrotomy or partial extirpation of the larynx is indicated {vide supra). If the growth has extended to the pharynx or wppvv poi-tion of the esophagus, operation is not admissible. Laryngeal Stenosis of Cicatricial Origin. — Ulcerative processes, of which that arising from syphilitic laryngitis is the most common, are the most frequent causes of this condition. Next in frequency is typhoid ulcer- ation. The causes which produce primary inflammatory stenosis rarely produce cicatricial stenosis. Traumatism may cause stenosis of the larynx, such, for instance, as follows ulcerative or suppurative conditions due to the pressure of angular foreign bodies, or wounds from pointed foreign bodies. Gaping transverse incised wounds which heal by the formation of dense cicatricial tissue, and fractures of the larynx in which the fragments remain unreduced, will also give rise to stenosis. The diagnosis of stenosis is based on the history of the case, the peculiar whistling noise accompanying the respiratory movements, and the dyspnea. Laryngoscopic examination will reveal the location and degree of the affection. The treatment -consists in attempts at dilatation through the glottic open- ing, or a tracheotomy wound if this operation is demanded, preliminary incision of the cicatricial tissue being practised when necessary. The dilatation is best carried on by the use of intubation tubes, progressively increasing sizes of these being introduced and worn. Recurrence is the rule, however, both in dilatation and in resection of the larynx, cicatricial tissue taking the place of that removed in the latter. In cases otherwise irremediable an intubation tube if possible, or, this being impracticable, a tracheal cannula must be per- manently worn. To improve the speech a separate tube which passes upward toward the glottis and is attached to the tracheal cannula is to be employed (Richet). The instrument resembles the artificial larynx of Gussen- b a u e r . This device is also to be employed in cases in which collapse .of the laryngeal framework follows removal of diseased cartilages. Laryngotomy. — In former times laryngotomy was frequently resorted to for the removal of foreign bodies lodged above the true vocal cords, in cases where the symptoms were not sufficiently urgent to demand tracheot- omy. The perfection of intralaryngeal methods and the introduction of cocain anesthesia have restricted the indications for this operation to cases in which intralaryngeal methods of extraction have failed, and to cases of fracture of the larynx in which fragments of cartilage project into the lumen. The complete separation of the two halves of the larynx after total 608 SURGERY OF THE NECK lan-ngotomy, or laryngofissure, as it is sometimes called, leads to changes in the voice, the two ])ortions failing to resume their exact original relative positions. Thyrotomy has replaced, to a great extent, laryngotomy. It is indi- cated in cases of impacted foreign bodies in the glottis and benign tumors not amenable to intralarvngeal methods of removal. Preliminary tracheotomy and the introduction of a tampon cannula are necessa^3^ If possible, this should be done three or four weeks beforehand. Operation. — An incision is made from the pomum Adami to the crico- thyroid memljrane. The point of the knife enters the cavity of the larynx through the membrane and separates the latter from the thyroid cartilage by a transverse cut in both directions. This avoids injury to the cricoid artery. The sternothyroid muscles are separated; the cricothyroid of each side is to be preserved as far as possible. One blade of heavy blunt scissors is introduced into the cavity of the larynx between the vocal cords, and the thyroid cartilage split along the median line from below upward and from within outward. Where the cartilage is ossified, bone cutting forceps must be used. If the cartilage is sufficiently flexible, in order to secure accurate reposition and avoid changes in the voice it is advantageous to preserve the uppermost edge intact (C o a t e s). The cricoid preserves the relation of the two halves sufficiently well, as a nile, however. After complete separation, if more room is necessary, the thyrohyoid ligament is to be divided transversely, after which the th^^roid cartilage may be widely separated by means of retractors. A small opening will be sufficient for the removal of a foreign body, but more space will be rec|uired for the extirpation of a tumor. In replacing the parts care must be exercised lest the vocal cord of one side is placed on a lower level than the other. The cartilage, as well as the overhang parts, must be accurately sutured; a tracheal cannula is to be left in place for a few days to prevent emphysema of the neck from air forced between the sutures into the connective tissue. Extirpation of the Larynx (Laryngectomy).— This operation is some- times performed for malignant disease of the larynx. The operation is to be preceded by low tracheotomy, performed, if possible, two or three weeks beforehand, and the introduction of the tampon cannula at the time of the operation. Operation. — An incision is made from the hyoid bone to the edge of the cricoid. From each extremity of this incision a transverse cut is made in the direction of the anterior edge of each sternomastoid muscle. The two quad- rangular flaps of skin are turned back and the separation of the larynx effected from below upward (Billroth) as follows : The trachea is separated from the cricoid cartilage by a transverse cut, and the larynx drawn forcibly ujjward and fon\-ard by a strong tenaculum. This gives access to the posterior wall of the larsmx, from ^^-hich the esophagus is to be separated. The separa- tion is continued posteriorly and laterally from below upward, the growth, which usually occupies the region of the arytenoid cartilages, separating with the larynx. If it invades the pharyngeal wall, this is to be removed as far as necessary'. In separating the larynx from the thyroid body the knife must be kept close to the former, in order to avoid injury to the superior thyroid artery as it passes from above to the inner edge of the lobe. Finally, the THE LAUYXX, TRACliKA, A.\l) HYOID BONE 609 larynx is separatcel from its attachments to the tongue. In small growths the separation may be made at the th3Tohyoid memljrane, the epiglottis re- maining intact. In more extensive growths the epiglottis also must be re- moved, in which case the final separation takes place at the deep muscles of the tongue. It may also be necessary, if .such a radical procedure is indicated, to remove portions of the underlying muscles (sternohyoid, sternothyroid, and thyrohyoid). Here both the superior and the inferior thyroid artery must be divided and ligated. 'rhe hemorrhage may l)c troublesome if it becomes necessary to remove portions of the thyroid gland; the ascending palatine artery ma}" be injured in the removal of portions of the pharyngeal wall. Partial lateral excision of the larynx, one half being preserved (I^ i 1 1 r o t h , Max S c h e d e , H a li n), has been perfoi'med when the disease has been ap]5arently limited to one side. The th}-roid cartilage is separated in the median line, as in thyrotomy, and one lateral half of the larynx removed from below upward. The epiglottis can usualh' be pre- served. Partial Laryngectomy (Cohen). — The posterior third of the thyroid cartilage has been found remarkably free from disease in epi- thelial carcinoma. Inasmuch as this portion of the cartilaginous frame- work of the glottis serves for the at- tachment of certain muscles which are of importance in the act of swal- lowing (inferior constrictor, stylo- pharyngeus, and palatopharyngeus) the importance of the preservation of this is manifest. The steps of the operation are carried out as in total extirpation, except that the thyroid cartilage is split each side of the median line and along the line of at- tachment of the inferior constrictor muscle to the cartilage. The entire larynx with the exception of this portion of thyroid cartilage, including the interior of the glottis itself, comes awa}' in one piece. In the first case of epithelial carcin- oma of the larj^nx operated on after the method proposed by Prof. Cohen, in my service at the ]\Iethodist Episcopal Hospital, the patient lived twenty- seven months, finally dying of the recurrence of the disease in the cicatricial tissue and skin surface. After-treatment. — The parts about an ordinary tracheotomy tube, if this is used in the after-treatment, are to be packed carefully with iodoform gauze. Or the tampon cannula may be worn. The trachea is to be protected against the entrance of wound secretions, in order to avoid septic bronchitis and pneumonia. Feeding is carried on in the beginning b}' means of the stomach tube. The wound is partially sutured above and the cavity from which the larynx has been removed packed with oxid of zinc or plain sterile gauze. Dailv repacking and antiseptic irrigation are necessary'. The wound 40 Fig. 362.- P ark's Modification of Gussenbauer's Artificial Larynx. 610 SURGERY OF THE NECK gradually retracts to a narrow opening above the tracheotomy tube. The latter is to be eventually transferred to this and the low tracheotomy wound permitted to heal. Before final contraction of the parts above the stump of the trachea occurs an artificial larynx is to be fitted (G u s s e n b a u e r , Fig. 362). The speech thus obtained is such as can be easily understood, though it is absolutely monotone. The vocahzing portion of the apparatus obstructs the breathing as soon as mucus collects upon it, and patients must be taught to remove it for purposes of cleansing. Without it, conversation can be carried on in a whisper, the consonant sounds being formed by the closing of the exter- nal opening and tlie forcing of the air through the pharyngeal, oral, and nasal cavities. When eating, the patient replaces the vocalizing apparatus by an obturator which closes the upper or chimney portion of the artificial larynx (P . B r u n s) and prevents food from being forced into the tube. He soon learns to substitute the base of the tongue for the removed epiglottis and dispenses with the obtura- tor entirely. When one lateral half of the larj^nx is removed, the use of an artificial lar}-nx may not be necessar}^ (]\I a x S c h e d e) . Mortality. — The immediate mortality following total laryngectomy is about 40 per cent. Of those who recover from the operation itself, about 50 per cent die of septic bronchitis or pneumonia during the first two or three weeks. Re- currence takes place at periods varv'ing from nine months upward (H a h n). One case, when last heard from, had gone four years without recurrence. Recurrences are regionar\', as a rule. The mortality following extirpation for sarcoma is somewhat less, and recurrence is less likely to occur. The immediate mortality following partial (one-sided) extirpation is less than that following total laryngectomy. The average length of time before recurrence takes place in both partial excision and total excision varies with the extent of the disease and the ability of the operator to extend the extirpa- tion of surrounding tissues beyond the limits of the growth. As in malig- nant disease elsewhere, early interference is always to be strongly urged. THE THYROID GLAND Injuries of the thyroid gland occur almost exclusively in connection with self-inihcted suicidal w^ounds. The injur}" inflicted on other parts is usually more important than that of the thyroid, though the hemorrhage may be abundant, particularly in the somewhat rare instances in which the lateral lobes are reached by the incision and the thyroid arteries divided. The isth- mus may be injured in the operation of tracheotomy, and in diphtheritic cases may become the site of infection. Thyroiditis, or non-traumatic inflammation of thyroid tissue, is very' rare in healthy glands. It usually ends in formation of abscess. Pyemic infection and metastatic inflammation of glands that are the site of goiter may occur in connection with multiple pyemia and certain infectious fevers. The treatment is that of suppurative inflammation in general. Goiter (Struma, Bronchocele). — Goiter may be denominated a true adenoma of the thyroid gland, though the term has been applied indiscrimin- ately to all tumors of this structure. The different varieties of goiter may be THE THYROID GLAND 611 classified as folknvs: (1) hypertrophy of the gland; (2) fetal adenoma; (3) gelatinous or intraacinous adenoma (Wolfler). The first consists in a unit'onn iiuTcase in the gland tissue, is soft to tlie feel, and may be vascular and compressible. The second follows formation of gland tissue from the remains of fetal structure in the gland and is usually observed as one or more fine and movable nodules, varying in size from a hazelnut to an orange. The third consists in an increase in size of the acini, these being apparently dilated by the accumulation of colloid material and the growth of the intra- acinous tissue. Cystic goiter is a result of further liquefaction of this colloid material; irregularly dilated acinous spaces filled with straw-colored semi- lic{uid occur at one or more points in the tumor. Mucous cysts are sometimes found in the so-called accessor}- thyroid glands. These latter consist of dis- placed portions of thyroid tissue, the displacement occurring during fetal life. They are found in the neighborhood of the hyoid bone, where the mucous cyst is most frequently found, at the base of the tongue, behind the j^harynx and esophagus, and behind the sternum. Vascular goiter may deserve clinical recognition as a distinct variety, though pathologically it is an undue dilatation of the vessels, especialty the arteries, which may occur in any of the forms of thyroid adenoma. It is charac- terized by distinct pulsation and a perceptible bruit, heard through the stethoscoiDe. It may preserve the form of the gland or Ijecome crescentic in shape. Finally, we may distinguish clinically fibrous, calcifying goiter, and ossi- fying goiter. These terms signify certain changes which any of the varieties of goiter may undergo in course of time. Causes. — The disease may occur at any time of life and sometimes develops during pregnancy (hypertrophy of the gland). It occurs more f requently . in females. It has been observed to develop after malaria, diphtheria, and typhoid fever. It may be either sporadic, endemic, or epidemic. It occurs endemically in certain mountainous districts on the continent of Europe and in the lowlands of rivers as well. These districts have a special geologic forma- tion, the w^aters from which consist largely of magnesia (Grange). It has been noticed to occur epidemically in schools and garrisons (W a r r e n). The special cause has not been discovered. Grange, followed by L ii c k e and V i r c h o w , attributed the disease to a special miasma, while B i r c h e r claimed to have discovered a special microorganism in the waters of the districts in w^hich it is endeixiic. The growth of goiter is extremely slow. Occasionally an acute form is observed (vascular goiter) ; it may C|uickly prove fatal from pressure effects on the trachea. In goiters of slow growth, sudden death may also occur from asphyxia, from paralysis of the posterior crico-arytenoid muscles due to pres- sure on the recurrent laryngeal nerve. When the goiter has advanced sufficiently to cause stenosis and consequent d3'spnea, the further growth is greatly accelerated b}' congestion in the venous channels. This is shown by the decided diminution in size of the enlargement within a few hours after a tracheotomy, a long tube being used. Finally, an inflammatory swelling of the goiter (striunitis, K o c h e r) may produce a dangerous degree of tracheal stenosis. The inflammation may occur in connection with infectious diseases in septicemia and pyemia or it ma}^ arise 612 SURGERY OF THE NECK witliout discoverable cause and follow febrile catarrhal conditions of mucous membranes. If not arrested early by the application of antiphlogistic remedies and the injection of a 5 per cent solution of carbolic acid (K o c h e r), extensive sujipuration and gangrene may occur. The Relation of Goiter to Cretinism. — Cretinism is characterized by idioc>' and imjierfect development of the bones, particularly those of the skull. ]ioth affections are found in the same localities and sometimes in the same intlividuals. In addition to this, it has been shown by statistics that half the number of cretins in these districts originate from parents who have goiter. Exophthalmic Goiter (Graves's Disease).— This is a sporadic form of the disease ciuiraeterized by a peculiar coml)ination of palpitation of the heart (tachycardia), exophthalmos, and thyroid enlargement. The condi- tion is supposed to have its origin in local nerve irritation giving rise to perverted function and finally to toxic effects from altered thyroid secretion (Green- field, Mandiy. Temporary enlargement of the thyroid gland bears a certain relation to the female sexual life and appears at the time of menstruation. It depends on some obscure vasomotor influences. Embolic distribution of portions of goiter, these prohferating in the thyroid veins, particles ]3eing swept in the blood-current and producing tumors at dis- tant points, particularly in the medullary tissue of the bones of the extremities (W . M ii 1 1 e r , Neumann), has been observed. The diagnosis of goiter is not difficult, as a rule. It is to be differentiated from all other tumors in this region by the fact that it moves up and down with each act of swallowing. The only other tumor which presents this symptom is a hydrops of the thyrohyoid bursa mucosa. Nor is it difficult to differentiate the different varieties, both pathologically and clinically. Disturbances of function are not in proportion to the size of the goiter. Large growths may give rise to very shght disturbances and small growths to pronounced symptoms. Disturbances of deglutition are rare, except in cases where the disease attacks displaced portions of thyroid tissue behind the pharynx or esophagus (Czerny, Kocher). Disturbed respiration depends on the relation which the mass bears to the trachea. This may also occur in those cases in which the affection is present in a portion of thyroid situated behind the sternum. These so-called "plunging goiters" make a rapid downward move- ment behind the sternum during an act of inspiration and compress the trachea, to reappear during expiration. Goiters which grow backward easily compress the trachea from the fact that from one-fifth to one-third of the periphery of the tube is uncovered by cartilage behind; respiration is interfered with early in these cases. Lateral compression of the trachea between the enlarged lobes also interferes greatly with respiration, producing the so-called "scabbard trachea." The Treatment of Goiter. — The external apphcation of tincture of iodin, as well as of ointments of iodid of potassium formerly much in vogue, is now very generally deemed useless. The internal use of iodid of potassitun has much to recommend it. It should be continued for months, being inter- rupted only because of intolerance of the drug, as shown by the symptoms of iodism. A certain degree of success is obtained by the use of injections of tincture TIIK THYROID GLAND 613 of iodin (1> u t o n and 1. ii c k c). From 10 to 15 drops of the tincture is injected, with antisejitic j^recautions, into the tumor every tliird or fourth day. The accidental entrance of the injected tincture into a large blood-vessel is followed b}' alarming symptoms of dizziness and fainting. This is to be guarded against by first introducing the detached needle and directing the patient to make movements of swallowing. If a large vessel has been entered, the drops of blood will follow one another in quick succession through the needle, and another place must be selected for the injection. The barrel of the syringe, previously charged, may then be screwed fast to the needle and the injection made. Strumitis terminating in suppuration occurring as a result of the injec- tion is due to uncleanly manipulation. The method is applicable only to simple hypertrophic goiter. It is useless in goiters that have undergone fibrous, calcifying, or ossifying changes; it is contraindicated in the gelatinous variety and is highly dangerous in vascular growths. The injection of alcohol (Schwalbe) is inferior to that of tincture of iodin. Injections of arsenic have not fulfilled the expectations of its originator. In Graves's disease a solution of extract of ergot to which carbolic acid has been added, injected into the connective tissue of the anterior region of the neck and not into the goiter itself, has been followed by favorable results (C a g h i 1 1). In cystic goiter, where a single C3^st can be isolated and emptied by the trocar and cannula, this may be follow^ed by an injection of from 15 to 30 drops of tincture of iodin. As this form of goiter is usually a further stage of develop- ment of the gelatinous or intraacinous variety, there is considerable danger of setting up acute suppuration. The occurrence of this M-ill necessitate incision or extirpation. The Operative Treatment of Goiter. — Treatment by setons has been aban- doned. Attempts at cure by electrolysis are unsafe and have proved to be of but slight benefit when employed. Opening cystic goiters by the use of chlorid of zinc paste is mentioned only to be condemned. Incision is indicated in suppurative inflammation and possibly in some cases of cystic goiter. To avoid dangerous hemorrhage the opening may be carefully made with the thermocautery. Even with this precaution there may be serious hemorrhage from the presence of vascular tissue in the cyst wall itself. The bleeding may be controlled by passing acupuncture needles across the base of the tumor and appljdng a constricting ligature beneath these. Where the cyst is quite superficial, it may be opened under asepsis with the knife, and the sac wall and skin stitched together. Extirpation. — Owing to improved methods of hemostasis and asepsis, the radical cure of goiter by extirpation has become an established operation. It is to be recommended in progressive cases in which iodin injections have failed, and may replace incision in cases of cystic goiter demanding interference. Total extirpation of the thyroid gland is contraindicated b}^ the prol^ability of the occurrence of cachexia strumipriva. The operative methods available are (1) excision; (2) enucleation; (3) resection. Excision (K o c h e r).— Disfiguring may be avoided by the use of the transverse curved or " collar " incision, with the concavity directed up- ward (Fig. 363). This is carried across the most prominent part of the swelling. The skin and platysma are divided and branches of the anterior jugular vein cut across between two ligatures. The fibers of the sternolaryngeal muscles, 614 SURGKRY OF THE NECK Fig. 363. — Kocher's Curved (Collar) Incision FOR Goiter. sometimes greatly thinned, are exposed and separated vertically- or diA'ided in the line of the skin incision. When necessary, the anterior edge of the cor- responding sternomastoid is nicked, when the tumor is freely exposed. When the tumor is large and it is (lesiral^le to avoid extensive division of the muscles, the angular incision is to be employed (Fig. 365). This begins over the prominence of the sternomas- toid at the level of the thyroid carti- lage and extends almost transversely in the direction of the skin-creases as far as the middle line of the neck, and thence vertically downward to the suprasternal region. In deeply situ- ated goiters it is prolonged on to the manubrium sterni. The skin and platysma are divided in the transverse portion of the incision. The superficial fascia is now divided. The anterior jugular vein is divided between two ligatures. The anterior border of the sternomastoid is exposed at the outer extremity of the horizontal incision and thoroughly freed and drawn aside with blunt retractors. The fascia at the middle portion of its horizontal incis- ion is retracted and the fibers of the sternohyoid and sternothyroid ex- posed. The two sets of sternolaryn- geal muscles lying on each side are now separated in the vertical portion of the incision, freed, lifted up by passing the finger beneath them, and partially or completely divided and retracted by blunt hooks. The thin layer of connective tissue which constitutes the outer capsule of the gland is now carefully divided and stripped to each side by blunt dissec- tion; any veins which pass from the capsule to the goiter are divided be- tween two ligatures. The capsule and overlying muscular structures are re- tracted, the finger passed around the outer edge of the tumor, and the latter carefully detached until the finger reaches the posterior surface. The tumor is now drawn forward and the principal vessels hgated. The Fig. 364. — Goiter. Curved Incision. CLES Exposed. Mus- THE THYROID GLAND 615 relations of the recurrent laryngeal nerve to the inferior thyroid artery are such as to endanger this, unless the artery is carefully isolated and insjjected before tying. Unless the operator is enabled positively to identify the nerve, only a provisional ligature should be applied. The further isolation of the tumor is now proceeded with. The large inferior thyroid vein or its branches is put upon the stretch and divided between two ligatures. The superior thyroid artery is exposed l^y blunt dissection above the isthmus. The dissection is carried upward along the inner border of the upper horn, which is lifted carefully forward, and a ligature passed beneath the superior thyroid vessels, which are tied and divided. The isthmus is now care- fully isolated and a strong silk ligature passed by means of a large aneurism needle, or Thiersch's ligature carrier and spindle, and tightened while the isthmus is being divided. The goiter is now lifted away from the trachea, to which its posterior border is still at- tached. In detaching the tumor from the trachea at this point, the recurrent laryngeal nerve is in danger of being injured in spite of every care. In order to guard against this, it is better for the surgeon to cut through the tumor parallel to the surface of the trachea, leaving behind a portion of the in- ternal capsule. If the nerve has not been included in the ligation of the inferior thyroid, the tumor can now be completely removed. Otherwise another ligature must be applied and the first removed, after which the re- maining attachments may be divided. The thermocautery may be employed to effect the separation of the goiter at the isthmus, the silk Hgature being dispensed with. Enucleation (Porta, Soc- i n). — This is applicable where single, large colloid or cystic nodules are to be removed. In these cases it is a simpler procedure than excision and possesses the additional advantage of preserving the healthy thyroid tissue. The tumor is to be exposed as in K o c h e r ' s operation, after which the healthy thyroid (internal capsule) over the nodules is incised and the latter shelled out. The hemorrhage is sometimes severe. To prevent this, the main vessels may be ligated preliminarily. Resection of Goiter {M i k u 1 i c z). — This consists of resecting the diseased part of the gland. It can be only exceptionally applied, and should be resorted to only in cases in which the nodules are small and prominent and easily separa- ble, or in cases of diffuse colloid degeneration in which the mass is not easily lifted forT\'ard for purposes of excision. Ligation of the vessels on one side should precede the resection in these cases. The thyroid tissue is sometimes very brittle and pressure forceps applied as angiotribes cut into it and cause Fig. 365. — Goiter. Angular Incision. 616 SURGERY OF THE NECK severe hemorrhage. The wound tlocs not heal so readily as in typic excision on account of the large stumps of ligated tissue which become necrotic. Enucleation Resection (Kocher). — The goiter is exposed as before, ligation of the main vessels, however, being omitted. The tumor is drawn forward and the isthmus ligated and di\'ided. Access is gained to the nodule through the cut surface of the divided isthmus. The gland capsule is separated by blunt dissection and ])ressure forceps appUed in an upward and downward direction. The tissues included in the forceps are then ligated, the forceps being gradually loosened as the Ugatures are tightened. It may be necessary to repeat this maneuver in the neighborhood of the upper and lower poles. The posterior wall of the capsule is now incised vertically and the parts beyond the ligatures enucleated. In closing the wound after thyroidectomy the head should be flexed slightly forward, the divided portions of the sternolaryngeal muscles united by chromi- cized catgut, and the external skin wound closed by the intracuticular or the chain suture. When extirpation of goiter is performed on account of great difficulty of breathing, general anesthesia should be avoided, when possible. Local cocain anesthesia aided by morphin narcosis is to be preferred in such cases (K o c h e r). Summary of important points in the operation of thyroidectomy: (1) Avoid resort to general anesthesia, as a rule. (2) Emplo}' cocain and mor- phin whenever practicable. Among other advantages there is less danger of hgating the recurrent laryngeal nerve; the patient should be asked to count aloud when the attempt is made to secure vessels in the neighborhood of the nerve. (3) Sensitive patients with healthy chest organs may have ether or chloroform, if they urgently insist on it, during the operation. (4) Avoid anti- septics. Strict asepsis is to be established and maintained during the operation. (5) Make all incisions free, and, as far as possible, in the direction of the natural creases. (6) !\Iake a timely and careful ligation of the vessels before division, thus insuring against excessive loss of blood and injury of the recurrent laryn- geal nerve, whose location is masked by the flooding of the field of operation, and secondary hemorrhage. (7) The sternolaryngeal muscles and their nerve- supply should be considerately treated and disturbed as little as possible, else sinking in of the neck will follow. When necessary to divide the muscles, this should be done near their upper insertion. The occurrence of cachexia strmnipriva (Kocher), or myxedema, following total removal of goiter is characterized in the beginning by a sensation of general weariness and a sense of weight and coldness in the extremities. The movement of the limbs becomes slow and heavy and the speech is clumsy. The skin becomes bloated in appearance, particularly in the face, and this, together with the pallor and dullness of expression, gives an idiotic appearance to the patient. Mental powder and energy are lessened, and patients are unable to continue their former occupations. The young are stunted in their growth. A general condition of hydremia is present, the skin and mucous membranes becoming markedly pale. The skin is everywhere edematous. The proportion of red corpuscles is lessened in the majority of cases. The im- pulse in the vessels is remarkably lessened. The entire clinical picture resem- bles the condition described as "cretinoid disease" (Gull), "myxedema" (Ord), and "pachydermatous cachexia" (Charcot). The resemblance is Till': ESOPHAGUS 617 still further augmented l\v the fact that the decrease in size of the thyroid gland is a marketl and permanent feature in myxedema. Typic cachexia strumipri\'a occurs only after extirpation of the entire thyroid gland. It follows the operation about twice as often in males as in females. The occurrence of tetany has also been observed to follow total extir- pation of the thyroid (W e i s s , B i 1 1 r o t h , M i k u 1 i c z). Paralysis of one recurrent laryngeal nerve from injury or contusion of the nerve during the operation not uifrcquently occurs. Hoarseness follows, and deglutition may be erratic on account of paresis of the epiglottis, particles of food passing into the glottis. Paralysis of the corresponding vocal cord is revealed by the laryngoscope. The breathing is not disturbed unless the paral- ysis is bilateral, the accident is sometimes unavoidable. It is to be noted that the condition is sometimes present before the operation, and the latter may relieve it. In any event, the voice usually improves, though laryngo- scopic examination still reveals paralysis of the vocal cord. Sarcoma of the thyroid gland sometimes develops, partly in old goiters, partly in normal tissue! It is characterized by rapid and enormous increase in the'size of the gland. Carcinoma occurs either in the medullary form with development of large soft masses in the tumor, or in the scirrhous form, in which there is shrinkage of the connective-tissue stroma, induration, and gradual decrease in the size of the growth. It is a disease of great rarity, except in districts where diseases of the thyroid are prevalent. It occurs between the ages of forty and fifty. In the early stages of the disease it may greatly resemble an ordinary^ goiter. The steady increase in the size of the gland, its nodulated outline, the occurrence of pain, and paralysis of the recurrent laryngeal nerve as infiltration proceeds, together with a certain fixity of the gland, constitute the characteristic symptoms. Disturbances of respiration and radiating pains are said to be pathognomonic of fibrous carcinoma or scirrhus of the thyroid gland. Dissemination takes place rarely, unless the condition known as general thyroid malignancy, described by C o h n h e i m , constitutes an expression of such dissemination occurring in connection with the very eariiest stages of over- looked cancer of the thyroid. In the condition in question, tumors structurally identical with the thyroid gland are formed in the bones in individuals affected with enlargement of the gland. These growths appear more frequently in women than in men. Cases have been reported in which tumors were found on the bones of the skull, for which they seem to have a predilection. They have also been found in the following situations, mentioned in the order of frequency of occurrence of the tumors: the femur, clavicle, sternum, and vertebrae. The growths may attain a considerable size, and in some instances pulsation has been a marked feature. Operative treatment in these secondary tumors, when they have appeared in accessible situations, has been followed by satisfactory results. THE ESOPHAGUS Injuries.— Of injuries of the esophagus the majority are incised wounds; gunshot wounds are observed next in frequency and punctured wounds least of all. The first occur almost exclusively in connection with suicidal attempts. 618 SURGERY OF TIIK NECK The prognosis in this class of cases, other things Ijeing equal, is in proportion to the extent of the separation. Tracheotomy is at once performed and the wound in the esophagus closed with chromicized catgut. The patient is fed by means of a stomach tul^e. In transverse separation of the larynx and esophagus the wound may gape widely in spite of every effort, a permanent fistula becoming established. A plastic operation may be necessary to cure the defect. Punctured and shot wounds of the esophagus alone are rare. The latter is usuall}- injured from the side. In all of these cases the swallowed food escapes through the wound for a short time only, the latter finally closing by granulation and cicatrization. In order to prevent phlegmonous inflammation of the con- nective-tissue planes of the neck from lodgment of food in the wound track the patient should be fed by the stomach tube until granulations are formed. Transverse rupture of the esophagus from forcible efforts at vomiting has been observed (B o e r h a v e). Death usually follows from mediastmitis. Injuries from swallowing caustic substances derive their chief surgical importance from the cicatricial stenosis of the tube which subsequently follows. In the case of acids the immediate treatment consists in the adminis- tration of harmless alkalis, such as chalk or lime water; and in the case of alkalis, vinegar or fniit acids. Instrumentation of the Esophagus. — The use of the esophageal bougie is of service in the diagnosis of diseased conditions of the esophagus. By means of it, altered conditions of the wall of the esophagus may be quite satisfactorily made out. The stomach tube is employed for purposes of artificial feeding. The instrument is best made of thick-walled rubber tubing, with a smooth-edged extremity, or a lateral velvet-edged opening near the end. Before introducing the stomach tube the distance from the lips to the hypo- chondrium should be measured, in order to avoid introducing the tube too far. In the normal esophagus the tube is arrested at a point directly behind the cricoid cartilage, at which point the latter approaches the vertebral column. In order to overcome this resistance the larynx is drawn forward by placing the tip of the index-finger of the left hand in the depression between the epiglottis and the tongue, and drawing the parts forward through the medium of the glosso-epiglottic ligament. Simply bending the finger sharply against the base of the tongue usually suffices, the point of the tube being at the same time directed toward the posterior pharyngeal wall and passed downward. The patient is then directed to make efforts at swallowing. The tube passes without further resistance into the esophagus. For purposes of artificial feeding, the tube is connected to a glass funnel. The fluid must be introduced slowly, other- wise efforts at vomiting will be provoked. In cases of injury of the pharynx and esophagus, and after certain operations about the neck (extirpation of the larjmx, etc.), the frequent introduction of the stomach tube may do harm. Retention of the tube in situ by means of a safety-pin passed through its wall, to which a tape is secured and passed around the neck and tied over the dress- ings, is here indicated. The stomach tube is also used for washing out the stomach (lavage), the fluid which has been introduced being withdrawn by simply lowering the glass funnel to which it is connected just before it is empty. The tubing which con- nects the funnel to the stomach tube being longer than the portion which occupies THE ESOPHAGUS 619 the esophagus, a siphon effect is produced and the stomach is promptly emptied. It may be refilled and emptied in this manner as often as required. When the patient resists, as the insane, a proper sized tube may be passed through the nasal cavity and thence to the stomach. In children a gag may be used. If this is not at hand, the operator may avoid injury of his finger from the little patient's teeth by forcing the lip in with the finger. The patient then l)ites his own hp. Foreign Bodies in tlie Esophagus.— Round, smooth foreign bodies that have been swallowed usually find their way without difficulty into the stomach, and, in the course of time, are passed per anum. When retained, however, their retention is due to convulsive contractions of the tube, the foreign body being arrested either behind the cricoid or at the car- diac orifice. In children pieces of coin, buttons, etc., are swallowed and lodged in the esophagus. Pins carelessly held between the teeth sometimes find their way into the mouth and are swallowed. Imperfectly masticated pieces of meat, bones taken with the food, and, finally, artificial teeth have been lodged in the esophagus. These latter may produce fatal suffocation by pressure on the trachea. One- fourth of the fatal cases of foreign bodies in the esophagus perish from asphyxia (K 6 n i g) . Wounds of the esophagus from pointed and angular foreign bodies are particularly dangerous. Pins and needles may perforate the tube, migrate from muscular action, and enter a large vessel (aorta, carotid), causing death from hemorrhage. Those perforating low down may enter the heart. A bronchus may be invaded. They may appear beneath the skin of the neck and be removed by a simple incision. Artificial teeth on plates with pro- jecting angles, bits of glass, pieces of bone, etc., wound the tube in their passage downward and produce ulceration or necrosis from pressure. The wall of the esophagus is per- forated, food enters the periesophageal connective tissue, and extensive and fatal suppuration frequently follows. The mediastinal space, or the pleural cavity, may thus become the seat of suppurative inflammation. The trachea may be invaded, an esophageotracheal fistula resulting, with fatal termination. The diagnosis of foreign bodies is to be based on the his- tory, the existing difficulties of swallowing, and particularly the results of exam- ination by means of the esophageal bougie. It sometimes happens that the foreign body has passed into the stomach and the symptoms are due to injuries inflicted during the passage. MetaUic foreign bodies, if not completely em- bedded, may be located by means of the Rontgen rays or the telephone probe. Treatment.— Large masses of meat, etc., as wefl as smooth bodies, are to be pushed into the stomach by means of a whalebone bougie with a piece of com- pressed sponge attached. This instrument may be used for both propulsion and extraction. When Fig. 366. — Graefe's Coin Catcher. 620 SURGERY OF THE NECK for the former, it is passed down to the mass and there allowed to swell and fill the entire esophagus. When used for extracting a foreign body, it is passed below the latter, and, after swelling, is withdrawn. All pointed and angular bodies must be removed from above. Fish-bones, unless very large, seldom do harm after reaching the stomach, the gastric juice attacking and softening them. While most swallowed coins will pass through the entire intestinal tract without doing harm, yet it is best to extract them when possible. The instnmient of G r a e f e is useful for this purpose (Fig. ■jjl'l,l:u:i};!..ll"niun::uin,ujLnnini,.,ni.mmimnr, ^ Fig. 367. — Flexible Esophageal Forceps. MrH^^MMMHWHWaiaBiflHBiHiii Fig. 368. — Umbrella Probang Closed for Introduction. Oh« OriiMAiiiHMHaiHiiMiiteAiiiMlllaliM^^ Fig. 369. — Umbrella Probang Open for Extraction. Fig. 370. — Esophageal Forceps, Blade Opening Laterally. Fig. 371. — Curved Alligator Forceps. 366). The basket attachment should be as wide as the esophagus will admit. The flexible esophageal forceps is also a useful instrument (Fig. 367). The umbrella probang (8 ay re, Weiss, Fig. 368) serves for the extraction of fish-bones, etc. It sometimes happens that, by means of this instrument, a fish- bone may be loosened and placed longitudinally in the esophagus, passing sub- sequently to the stomach. For foreign bodies high up, forceps with blades opening laterally are to be preferred (Fig. 370), for the reason that this form will accommodate itself best to the longest diameter of the esophagus. In extracting foreign bodies from the esophagus the index-finger of the left THE ESOPHAGUS 621 hand should be passed to the base of the tongue ready to steady the foreign body as it enters the pharynx, and prevent it from falling into the glottic opening. Cocainization of the accessible parts will assist in the manipulation. The grasj)ing and extraction of a metallic foreign ])ody may be accomplished under the guidance of the .r-ra.ys. (For cutting operations for the removal of foreign bodies, see Esophagotomy.) STRICTURES, TUMORS, AND DIVERTICULA OF THE ESOPHAGUS Strictures arising from syphilitic and tuberculous ulceration are exceed- ingly rare. Esophagitis in the proper sense scarcely ever exists. Cicatricial strictures are commonly a late effect of swallowing caustic fluids. A slough is cast off and gradual condensation of the resulting cicatrix produces stenosis. Weeks and in some cases months may elapse before s3'mptoms of obstruction appear. Epithelial carcinoma is a frequent cause of stenosis of the esophagus. It usually occurs at the level of the cricoid cartilage. The next most frequent points of attack are near the cardiac orifice, and at the point where the tube is crossed b}- the left l^ronchus. It is most common iDetween the ages of forty and sixty. Of the cases, 75 per cent occur in men. Lymphatic glandular infection occurs at the root of the neck, in the mediastinum, or in the lumbar region, according to the point of location of the disease. The disease is insidious in its first symptoms, but runs a rapid course, death resulting from inanition due to obstruction, from septic pneumonia and pleurisy following perforation of the trachea, or from mediastinal abscess and perforation of the pleura or of the pericardium. Two or more points of stricture may be present from longitudinal extension of the disease. The diagnosis is established with the aid of the whalebone bougie a boule. If ulceration has taken place, evidences of this may be present on the bougie when withdrawn. Fibromas and myxomas may grow from the mucous membrane and become pediculated from acts of swallowing (polypi of the esophagus). They occur by preference behind the cricoid cartilage. Deglutition is interfered with, and respiration as well, particularly when the polypus, being forced upward, lies across the glottic opening. These growths are best dealt with by being hfted up in the act of vomiting, after an emetic has been administered, and seized with forceps and severed by means of the galvanocautery loop. If removed with the scissors, the pedicle must first be ligatecl to avoid troublesome hemorrhage. Compression of the esophagus may result from the pressure of tumors from without, particularly in cases of carcinomatous goiter. Diverticula are mainly of congenital origin and may bear some relation to congenital fistula of the neck (B a r d e 1 e b e n). They develop, or may even originate, late in life. Anatomically they may consist of both mucous mem- brane and the muscular coat, or the former may, hernia-like, pass through an opening in the latter. Dilatation of the esophagus (ectasia) may take place in connection with stricture from any cause or independently of this. Spasm of the cardiac orifice having its origin in reflex neurotic disturbances or occurring as a hysteric manifestation may give rise to either of these conditions. Finally, diverticula may arise from traction on the esophagus from without from en- larged lymphatic glands (traction diverticula) or from pressure from within (propulsion diverticula, Z i e m s s e n). 622 SURGERY OF THE XECK The accumulation of food in the esophagus and its rejection undigested resuh from increase of capacit}- of the pouch. When sufficiently marked to attract attention, the whalebone bougie a boule will establish the diagnosis. Small diverticula may produce no inconvenience for a long time. Their tendency is to increase, however, and inability to obtain sufficient nutriment may render starvation imminent. Under these circumstances gastrotomy should be performed and the cardiac orifice thoroughly and efficiently overdilated to overcome the tendency to spasm (M i k u 1 i c z). The opening in the stomach wall is then closed. Exceedingly good results have followed this procedure in the hands of its originator. When symptoms of stricture of the esophagus arise as a part of the com- plexus of s3'mptoms constituting the condition known as hysteria (hysteric dysphagia), the occasional passage of the bougie for its moral effect is usually sufficient for cure. The Treatment of Stricture of the Esophagus. — The preventive treatment of cicatricial stenosis, consisting of the systematic introduc- tion of an esophageal sound or bougie, should be instituted in about the third week after the accident of swallowing caustic fluids. At first daily seances, followed by weekly and finally by less frequent ones, are indicated, as in urethral stricture. The case comes to the surgeon, however, only after difficulty in swallowing is experienced. Small bodies (kernels of nuts, lemon seeds, etc.) may lodge at the point of stricture and produce ulceration, neces- sitating esophagotomy. Gradual dilatation (T r o u s s e a u) is carried on by means of the bougie a boule. Gradually increasing sizes are employed three or four times a week when the parts are irritable, and daily when the parts are tolerant or the symp- toms urgent. In adults sizes from 35 to 40 (French) may be reached, after which the largest size possible is to be passed occasionally to insure patency of the lumen, the stricture tending to constant recontraction. In cases of cicatricial stricture a temporary gastrotomy should be per- formed and an effort made to pass an instrument from lielow. If successful, Abbe's bowstring method of dividing the stricture should be em- ployed {vide injra). In case of failure to pass the stricture with the smallest instrument, a permanent gastric orifice should be established for feeding purposes (see Gastrostomy). External Esophagotomy. — When the stricture is situated in the cervical portion of the esophagus and is accessible from without, it may be divided from the latter direction, and narrow circular strictures may even be excised (resection of the esophagus, Billroth). Dilatation must be subsequently employed to prevent recontraction. Internal Esophagotomy. — Strictures of the thoracic portion not amen- able to gradual dilatation have been subjected to incisions from within, and for this purpose esophagotomes (M a i s o n n e u v e , Sands, Mac- kenzie) are employed (Fig. 372). Here also recontraction must be pro- vided against by the occasional subsequent introduction of a dilating instru- ment. In performing the operation care must be taken not to cut through the wall of the esophagus. The latter is simply nicked at one or more points to permit the introduction of dilating instniments. The exact status of the operation has not yet been determined. THE ESOPHAGUS 623 Abbe's method of treatment consists in performing a gastrotomy and pass- ing one eml of a string from the opening in the stomach through the esophagus and out of the mouth by means of a gum elastic catheter or other instrument that will pass the stricture. The string is then made tense and drawn rapidly back and forth until the stricture is divided. The gastrotomy wound is then closed. Recurrence is prevented by the frecjuent introduction of esophageal bougies. Intractable strictures require the establishment of an esophageal fistula in the cervical region, if the}^ are situated sufficiently high up, or gastrotomy. In the former case the esophagus is opened low down in the neck and its mucous membrane sutured to the skin; or it ma}' l^e completel}' di^•ided and secured by suturing into the external opening (esophagostomyj. (For making an arti- ficial mouth at the stomach, see Gastrostomy.) In carcinomatous stricture the treatment resolves itself into operative methods designed to prevent the patient from starving to death. Further, the withdrawal of food from the natural passage and^the substitution therefor of artificial feeding through an esophageal fistula, or a gastric mouth, will retard the progress of the disease by remo^ang the irritation arising from the attempt to force food through the narrowed lumen of the tube. Attempts at dilatation are ahsohdely coiitra indicated. The Operation of External Esophagotomy. — The indications for the Fig. 372. — Roe's Modification of Mackenzie's Esophagotome. operation have already been discussed (viz., foreign bodies, strictures, and possibly diverticula). When a large foreign body is situated high up in the tube and can be felt from without, this may form a sufficient guide for the incision. Or, when practicable a curved sound may be introduced and the parts made prominent by pressure from wdthin. The left side is to be selected for the opening, on account of its greater accessibility. It is covered almost entirely b}" the trachea on the right side. When necessary, as,' for instance, when a left-sided goiter complicates the case, the opening ma}" be made on the right side. The incision is made along the anterior edge of the stemomastoid muscle. The platysma myoides and superficial fascia are divided, and by retracting the inner edge of the stemomastoid outward and the sternothyroid inward, the omohyoid is exposed. If necessar}^, this may be divided. If the operation is performed on a level with the larynx, after the thyroid fascia is divided the gland itseh is drawn inward. The inferior thyroid artery, if necessar}'', may be divided between two ligatures. It lies on the longus colli at this point. The carotid arter}' is drawn outward with a blunt retractor. The esophagus and lateral edge of the trachea are now exposed. Care must be taken at this point not to injure the recurrent lar}'ngeal nerve, which passes between the esophagus and the trachea toward the outer aspect of both organs. The esophagus is recognized by its pale red color and longitudinal muscular fibers. If a sound has been pre^^ously introduced as a guide, the tube may be opened upon this. It is difficult to open it in the coUapsed state. Tliis opening is to be made on its 624 SURGERY OF THE NECK lateral aspect and should be large enough to introduce the index-finger; it may be enlarged subsequently, if necessary. If the operation is performed for the removal of a foreign body, the esophagus may be closely sutured with fine chromicized catgut, Ixit the remainder of the wound is to be left open to avoid infiltration, should tlie esophageal sutures give way. If for stricture, this may be dilated, or, if this is intractable or carcinomatous, the mucous membrane is to be stitched to the skin (esophagostomy), and a permanent opening estab- lished for purposes of artificial feeding. Resection of the esophagus (esophagectomy) was suggested by Bill- roth (ls7()j after experiments on animals. Later, Czerny (1873) per- formed the operation for annular carcinoma in the cervical portion of the esophagus in a woman of fifty -one. The patient was able to take food through the opening left, Ijut died from local recurrence fifteen months later. j\I i k u 1 i c z has reported 10 cases. Rose operated successfully in 1887. THE LATERAL REGION OF THE NECK A line drawn from the mastoid process to the inner third of the clavicle limits the area in this region within which punctured, incised, and gunshot wounds endanger life. Here, passing in a vertical direction, are found the carotid artery, internal jugular vein, and, more deeply placed, the vertebral artery and the pneumogastric, sympathetic, and phrenic nerves. Just above and partly behind the clavicle are placed the subclavian artery and vein, and above is the brachial plexus. It is a matter of surprise how frequently the vessels in this region escape in cases of punctured and gunshot wounds of the neck. This is due to the elasticity of their walls. The latter, however, may become contused, in which case a slough occurs and fatal hemorrhage frequently follows. Contour shots in this neighborhood ai'e not uncommon, a sudden turn of the head at the moment when the ball strikes accounting for these. In suicidal wounds of this region the larynx usually receives the greatest inju^^^ The weapon may, however, reach the anterior edge of the sterno- mastoid muscle and even open the common carotid artery. Operation wounds occasionally divide the platysma, omohyoid, digas- tric, and stylohyoid muscles. These, however, are not of special importance; even partial or complete extirpation of the sternomastoid does not produce serious functional disturbances. Rupture of the sternomastoid muscle in the child during delivery some- times produces torticollis (wryneck or caput obstipum of the newborn). Hemothorax, pneumothorax, and pyothorax may result from punctured wounds afTecting the lower portion of the neck, the projecting portion of the pleura in this region being involved. Deforming Cicatrices of the Neck. — These result from extensive burns. While they may be sometimes obviated in a measure b}^ means of early aseptic treatment and skin transplantation, they are frequently unavoidable. In addition to the cicatricial contraction of the skin and subcutaneous connective tissue, the platysma myoides and its connections are affected, the deformit}^ extending beyond the parts originally involved in the burn to the lower lip and angles of the mouth (Fig. 373) and eye. The treat- ment consists in dissecting away the entire cicatricial mass when practicable THE LATERAL REGION OF THE NECK 625 and siii)i)lyin,ii; its place witii transplanted pediculated flaps. When this is not feasililo, tiie cicatricial band is to be completely divided, the position of the head corrected to h>'i)crextension, and a flap of skin with pedicle transplanted to fill the defect (B 1 a s i u s). Or, the method by double j)ediclc may be em])loyed. This consists in raising the flap of healthy adjoining skin, leaving it attached by both ends, but loosening it entirely in the middle and passing a strip of oiled silk beneath it to prevent reunion to the parts beneath. When a granulating surface has been secured on the raw surface of the flap, this is severed at one end, deprived of its granulating surface by paring, and the gap left by the division of the cicatrix and reduction of the deformity filled with the flap (Croft). Fixation apparatus is to be ap- plied to keep the parts at rest and maintain the head in posi- tion. Injuries of Cervical Nerves. — Injuries of the cer- vical sympathetic nerves may result in paralysis of the vaso- motor supply, as shown by flush- ing, or a red blush on the cor- responding side of the face (see Cervical Sympathectomy) . The pneumogastric nerve may be injured by operations about the neck. Death usually follow^s within a few days, though recoveries after this accident have been reported. In one case excision of a portion of the pneu- mogastric nerve in a patient was not followed by serious disturb- ances, other than paralysis of one vocal cord (Billroth). Interference with respiration, however, is the rule. Injury of the phrenic nerve results in paralysis of half of the diaphragm, and life is endangered, in spite of the fact that the other half of the diaphragm and the other respiratory muscles continue to act. The spinal accessory nerve may be injured during operations for the removal of tumors lying between the external edge of the sternomastoid and the anterior edge of the trapezius. The function of the sternomastoid is not greatly interfered with, and the levator anguli scapulae supplies to some extent the place of the trapezius. Division of individual branches of the cervical plexus is not followed by serious results on account of their free communication with branches of the fifth cranial nerve above and the brachial plexus below. Injuries of the recurrent laryngeal nerve have been discussed in connection with excision of goiter. The hypoglossal nerve may be injured during operations about the angle 41 Fig. 373. -Contraction of Cicatrix and Platysma Myoides Following Burns. The lower lip and angles of the mouth are practically ob- Uterated. Dr. Everson's case 626 SURGERY OF THE XECK of the jaw, the injury resulting in paralysis of one half of the tongue. Upon projecting this organ it is found to point toward the uninjured side, this para- doxic symptom being due to the action of the geniohyoglossus muscle, the radiating fan-like fibers of which, shortening onl}^ on one side, cause the healthy side of the tongue to approach the point of insertion of the muscle in the middle of the jaw. The symptoms of injury of the brachial ])lexus in the neck will var\^ accord- ing to whether the roots of the median, radial, or ulnar nerves are involved. The Treatment of Intractable Facial Paralysis by Nerve Anas= tomosis. — Experimental ol^servations and operations in man have sho^^^l that cortical impulses may be made to reach a group of muscles from which the normal neural connections have been cut off. Even in the case of mixed nerves both motor and sensoiy functions have been restored. Well authenticated instances are not wanting in which an anastomosis between a paralyzed nerve and a neighboring healthy nerve has resulted in a cure of the paralysis. The distressing conditions present in facial pa ralysis may be remedied in some instances by establishing an anastomosis between the peripheral por- tion of the seventh nerve and either the spinal accessor}- neiwe, the hypoglossal ner\' e, or a motor branch from the cer^dcal plexus. In case the spinal accessory is selected for the purpose, emotional movements of the face are accompanied by disfiguring movements of the shoulder (Gushing). The operation is usually indicated in paralysis secondarv' to middle-ear disease, operations, injuries, and fractures of the base of the skull. In cases of stab wounds in which the nerve is known to be cut across, and in which pri- mary suture is impossible, the operation should be performed at once. In other cases electric treatment and massage should l^e persevered in for at least six months, at the end of which time, provided the presence of muscular fibers on the paralyzed side of the face can be demonstrated by electricity, the operation should be performed. The operation of choice consists in implantation of the facial on the hypo- glossal ner\-e (facio-hypoglossal anastomosis, B a 1 1 a n c e and Stewart). The hj-poglO'Ssal ner\'e is exposed above the posterior belly of the digastric. The incision is planned so as to include the peripheral portion of the seventh nerve, and the twelfth nerve at the point mentioned. The facial nerve is most easily exposed by incising the posterior border of the parotid gland (Gush- ing). The hypoglossal should be very carefuUy manipulated during the oper- ation, lest paralysis of one side of the tongue foUow; the least possible amount of suture material should be used. Only the nerv'e-sheath should be included in the sutures. Noticeable improvement may be expected at the end of three months. This should be assisted by electricity and massage. Injuries of the Vessels. — In punctured, incised, and gunshot injuries of the large arteries of the neck and their- branches (iimominate, subclavian, and common carotid) the hemorrhage usually proves fatal before the arrival of surgical help. In provisional arrest of hemorrhage from the carotid the tnmk of this vessel may be pressed with the finger against the transverse process of the sixth cervical vertebra (Ghassaignac's carotid tubercle). Bleeding from the collateral current is to be arrested by pressure either immecUately above the wound or in the wound itself. The subclavian may be pressed from behind the clavicle against the first rib in lean individuals THE LATERAL REGION OF THE NECK 627 after depressino; the shoulder; in stout persons and when the shoulder cannot be sufficiently depressed, this may fail. The hemorrhage may then be arrested by making pressure from before backward so as to compress the artery against the middle scalenus muscle and the transverse process of the seventh cervical vertebra. This failing, the method of strongly adducting the arm and placing the elbow in the epigastrium and the hand on the opposite shoulder may be tried. By this maneuver the cla\'icle is brought firmly down on the first rib and the vessel compressed between the two l^ones. Finally, direct pressure may be made upon the artery by the finger through an incision made in the cervical fascia. If hemorrhage persists from a wound of the carotid after the latter is firmly compressed against Chassaignac's tubercle, the bleeding comes through the vertebrals, which cannot be compressed by manual pressure. With temporary arrest of the bleeding the patient's head is, to be lowered, if he feels faint or the pulse is greatly weakened, and bandages applied to the extremities to force the blood into the trunk and head (autotransfusion). When the patient rallies, the wound is to be explored and both ends of the vessel secured by ligature. If this is found to be impossible, ligation in continuity is to be resorted to. After the permanent arrest of the hemorrhage, should the patient's life be threatened from acute anemia, infusion of salt solution should be employed (see page 351). Incised wounds of large venous trunks, particularly of the innominate and internal jugular veins, are almost invariably fatal, both from loss of blood and from entrance of air. In gunshot and punctured wounds gaping is not so great, at least in case of the jugular vein, and compression may be effected by placing the finger directly in the wound until a graduated compress can be applied. If the hemorrhage recurs, the parts must be explored and the vein ligated both above and below the wound. If the wound of the vein is small and involves only one wall, lateral ligation is indicated. Of the superficial veins, the external jugular is most easily injured, particularly in operations in this region. To avoid entrance of air it should be ligated before division. If not easily discern- ible, it may be brought out prominently by pressure immediately above the clavicle. Inflammations in the Lateral Cervical Region. — Inflammatory con- ditions m the cervical region spread easily on account of the loose layers of cellular tissue which connect the muscular tissue and organs in this locality. Abscesses may arise from different neighboring organs, such as the parotid gland, the submaxillary gland, and the cervical vertebrae (migrating ab- scesses) . Those arising from the glandular structures are more superficial and may be opened early, so that diffuse phlegmon of the neck is prevented. Those arising from the cervical vertebrae are more deeply placed, and are scarcely recognized until they appear at certain points. Lymphadenitis of the lateral cervical region is a very common affection. The affection may. be divided into that having a tuberculous origin with cheesy infiltration, and the true inflammatory variety arising from septic infection and proceeding rapidly to supiDuration. In both varieties the immediate source of infection is the lymph-cun-ent. Tuberculous lymphadenitis is characterized by its chronic course and by 628 SURGERY OF THE NECK the fact that several neighboring ghmcls are simiiltaneou.sly attacked. The affection is not infrequently bilateral. Either the swollen structure of the gland becomes tlie seat of a slowly developed cheesy infiltration, or suppurative changes occur in it, the capsule being perforated and the connective tissue surrounding the gland becoming involved (paradenitis). Even under these circumstances the course of the affection is slow and rarely ends in destruction of the entire gland. The entire organism may be endangered by tuberculous infection, either from the cheesy glandular infiltration, or from the bacilli present in the fistulous tracks which lead to broken-down foci within the glands. Should a fair trial of intraparenchymatous injections of iodin fail (see page 112), early and radical extirpation of diseased glands, particularly when these have become the seat of cheesy metamorphosis, or of suppurative changes, is indicated. Septic Lymphadenitis. — The infection originates in the buccal or pharyn- geal ca^■ity, and attacks, as a rule, but a single gland. The inflammation usually pursues an acute course, ending either in early resolution or in suppura- tion. In the latter case the capsule is perforated and suppurative paradenitis or even phlegmonous inflammation of the neck ensues. When arising from glands just beneath the superficial fascia, this form is comparatively harmless; it points early and is easily managed by incision. When originating from glands more deeply situated or extending to the area of the middle cervical fascia through the medium of the perforating lymph-channels of L u d w i g (Lud- wig's angina), the suppurative process may follow the sternothyroid muscle to the space between the anterior surface of the trachea and the depressors of the hyoid bone (the pre visceral space of Henle), or along the inner surface of the sternomastoid, or the perivascular connective tissue of the large vessels, to the anterior mediastinum (suppurative mediastinitis). Under these circumstances the affection is accompanied by high fever and other alarming symptoms of a septic character, and sometimes passes entirely beyond surgical control. If the area of the deep cervical fascia is invaded, it may reach the retrovisceral space between the esophagus and the vertebral column, in which case a fatal result almost invariably follows. In addition to high fever and marked pain, difficulty in swallowing is complained of. Therefore, in the treatment of septic lymphadenitis, the more deeply phlegmonous par- adenitis penetrates, the more urgent the necessity for early interference. The suppurating focus should be exposed by careful and formal dissection, as for the removal of a deep tumor from this region, injury of the vessels being avoided by separating natural lines of cleavage by means of the blades of anatomic or hemostatic forceps. The search must be persisted in until the source of the .suppuration is reached. Congenital Hydrocele and Other Cystic Tumors of the Neck.— Con- genital hydrocele of the neck is a cystic formation found most frequently be- tween the hyoid bone and the mastoid process, and also in the region of the external carotid artery and supraclavicular fossa. The tumor increases gradually in size and is the result of accumulation of secretion from its walls, lined with layers of pavement or of ciliated epithelium. These walls represent unobliterated portions of the branchial clefts (branchial cysts). They may extend to the styloid process, to the hyoid bone, to the anterior pharyngeal wall, or even to the anterior mediastinum. The contents of these cysts may be light- THE LATERAL REGION OF THE NECK 629 colored and serous, or inucuslila', eontainiii.i;- crystals of cholesterin. The atheromatous cysts soin(>1iin(»s found in immediate connection with the sheath of the carotid artery j)rol)al)ly belong to the same class. These may also contain cartilage (auricular teratomas of V i r c h o w). Treatment. — A certain degree of success follows the method of emptying the cyst and injecting tincture of iodin or Lugol's solution. The injections may be repeated several times, if necessary (Es march). Incision and drainage may also be employed {B a r d e 1 e b e n). Extirpation of the sac, however, is the most trustworthy method of cure, though the operation is difficult and not unattended with danger. Congenital fistula of the neck results from failure of closure of a branchial cleft (branchial fistula). This may be bilateral (18 out of 82 cases, according to G . F i s c h e r) . It may be hereditary. The fistula is usually situated at the lower third of the anterior edge of the sternomastoicl muscle, near the sternoclavicular articulation. It usually takes a direction upward and toward the median line and sometimes communicates with the pharyngeal cavity. The inner wall of the fistula is lined with ciliated epithelium (R o t h). These fistulas have been successfully treated by injections of tincture of iodin (Rehn and Serres). The galvanocautery has been recommended (G . Fischer). Excision of the fistulous track has been successfully per- formed (H u e t e r). Median congenital fistula of the neck (tracheal fistula) has been ob- served. Though this is said to occur only in women (B a r d e 1 e b e n), I have seen it in both sexes. The fistula passes directly backward to the trachea, without invading it, however. Branchiogenous carcinoma, or carcinoma having its origin in the epithehal structure of unobliterated branchial clefts, has been observed (V o 1 k - m a n n , P. B r u n s). Congenital Cystic Hygroma. — This is a multilocular cystic formation which sometimes originates in the submaxillary region. It may extend over the entire lateral and anterior region of the neck. The surface of the tumor is lobulated, the lobes corresponding to the indi\adual cysts. The contents are serous and yellowish in color or brownish from admixture with decomposed blood. The inner wall is lined with a layer analogous to the epithelium of lymph-vessels, and the cyst cavities can sometimes be demonstrated as com- municating with the lymph-spaces of lymphatic glands (W i n i w a r t e r , Wagner and others). H u e t e r proposed the name congenital l5rmph- angiectasis, and Wagner congenital lymphangioma. The growth some- times forces its way through the intramuscular spaces until it reaches the vertebral column. Its presence may cause interference with respiration. Treatment. — Temporary relief may be obtained by puncturing several of the cysts and emptying them of their contents. Injections of tincture of iodin are contraindicated because of the ramifications of the growth and the probable occurrence of deep-seated and perhaps violent inflammation. Isolated and superficial cj'sts ma}^ be extirpated. Blood cysts, apparent^ arising as a congenital formation, may develop later in life. They communicate with one or more veins of the lateral region of the neck. H u e t e r extirpated one of these tumors, which proved to corre- spond in situation to the internal jugular vein. These C3"sts contain partly liquid 630 SURGERY OF THE NECK and i)artly coagulated l)lo()d. The walls are sometimes covered with blood- clot in process of organization. In the treatment of these cysts injections of tincture of iodin arc contraindicated on account of the danger of their entering the veins and reaching the right heart. In extirpating the tumor care must be taken not to injure the cyst wall, as hemorrhage from the communicating veins may be dangerous. Echinococci of the lateral region of the neck are rare. Two cases suc- cessfully operated on are recorded (Hueter). Cystic goiter has been already discussed (see page 611). Noncongenital hydrocele of the neck (]\I a d e 1 u n g) probably arises as a cyst of the thyroid isthmus or of the third lobe, sometimes called the pyramid. Hydrops of the Thyrohyoid Bursa. — This is a dropsy of the bursa which exists between the lavers of the thyrohyoid membrane in the space where these are separated from each other. A flattened and fluctuating tumor may develop from accumulation of the secretion of the bursa, probably induced by infection. The skin becomes thickened and reddened and the adjoining connective tissue is infiltrated, resembling L u d w i g ' s angina. The center of the latter, how- ever, always lies near the angle of the jaw. The treatment consists in free incision and subsec^uent open dressing of the wound, the latter being allowed to heal by granulation. TUMORS OF THE SKIN, MUSCLES, AND VESSELS OF THE NECK Angiomas, nevi pigmentosi, atheromas, lipomas, papillomas, and fibromas occur occasionally in the skin of the neck. Neoplasms of the cervical muscles are rarely observed. The fusiform swell- ing of the sternomastoid, occurring at delivery and followed by wryneck (see page 650), is sometimes mistaken for a tumor. Sarcoma having its origin in the connective tissue of the sheath of the muscles is rare in the lateral cervical region, as compared with its occurrence in the posterior cervical and scapular regions. Syphilitic gummas of the sternomastoid have been observed. Aneurism of the large vessels in the lateral cervical region is not infre- quent. The disease attacks the vessels most frequently (1) at the bifurcation of the common carotid into the external and internal carotid; (2) at the division of the innominate artery into the right subclavian and right common carotid. Other portions of the vessels may also be attacked, though less frec^uently. The presence of a cervical rib (an abnormal lengthening of the transverse process of the seventh cervical vertebra) is said to be an occasional cause of subclavian aneurism at the point where the vessel passes over the process (G.Fischer). The diagnosis of aneurism is based on the symptoms already described (see page 97). The bruit can be made out in the pulsating tumor by both auscultation and palpation. Aneurism of the vertebral artery may be mis- taken for that of the common carotid. Compression of the latter against the transverse process of the sixth cervical vertebra will aid in the differentiation. The carotid artery has been erroneously ligated for vertebral aneurism (G.Fischer). In the treatment of aneurism of the lateral cervical region reliance must be placed on ligation in continuity, for only by means of this operative pro- cedure can a cure be hoped for. THE LATERAL REGION OF THE NECK 631 The rare occurrence of a communication between the common carotid artery and the internal jii^i^ilar vein is to be here noted. Tumors of Lymphatic Origin. — Simple chronic as well as tuberculous l5rmphadenitis gives rise to intlammatory enlargement of the lymphatic glands of the neck, the latter attaining the size of the fist or becoming even larger. The superficial cervical glands may be affected, viz., (1) the submaxillary, situated beneath the body of the lower jaw in the sub- maxillar>' triangle and closely adherent to the submaxillary salivary gland; (2) the suprahyoid, situated in the middle line of the neck on the mylohyoid muscle and between the anterior bellies of the two digastric muscles; (3) the lateral cervical, placed in the course of the external jugular vein between the platysma and the deep fascia Involvement of the deep cervical glands in- cludes (1) the chain beneath the sternomastoid and on its anterior edge, and intimately attached to the sheath of the carotid artery and the internal jugular vein above the bifurcation of the former, the upper deep cervical or supra- carotid glands; (2) the lower deep cervical glands, clustered around the lower part of the internal jugular vein and extending to the supraclavicular fossa; (3) the supraclavicular group. The latter is continuous externally with the axillary and internally with the mediastinal glands. In addition to these, the occipital glands, which lie between the superior posterior edge of the sternomastoid and the trapezius, and the posterior auricular group may be involved. Finally, a prevertebral group, situated at the anterior surface of the cervical vertebrae, and an internal carotid group, extending along the internal carotid artery to the base of the skull, may be included in the classification, though these are usually inaccessible operatively. These same glandular groups may be the seat of infection from primary carcinoma with resulting secondary carcinomatous infiltration, or simple inflammatory enlargement may result from the ulcerative changes occurring in malignant disease within the area of communication of the respective groups. It is best, however, not to trust to the latter possibility, but to regard all glandular enlargements in the neighborhood of cancerous disease as being essentially malignant in character. The following table shows the relation of the respective groups of glands to the periphery (Treves): Region. ( Posterior part. Suboccipital and mastoid (posterior auricular) glands. Scalp \ Frontal and parie- Parotid lymphatic glands ; superficial cervical glands. ( tal portions. Bkin of face and neck. Submaxillary, parotid, and superficial cervical glands. External ear. Superficial cervical glands. Lower lip. Submaxillary and superficial cervical glands. Buccal cavity. Submaxillary and upper set of deep cervical glands. ~ ■Gums of loiver jaw. Submaxillary glands. rp J Anterior portion. Suprahyoid and submaxillary glands. 1 ongue ^ Posterior portion. Upper set of deep cervical glands. Tonsils and palate. Upper set of deep cervical glands. p. ( Upper part Parotid and retropharyngeal glands.. Pharynx | Lower part. Upper set of deep cervical glands. Larynx, orbit, and roof of mouth. Upper set of deep cervical glands. ,- Retropharyngeal glands ; upper set of deep cervical AT 7 f ' glands. J\ asal fossa. -. g^j^g lymphatic vessels from the posterior part of the (, fossa enter the parotid lymphatic glands. 632 SURGERY OF THE NECK True lymphomas form a part of the disease known as leukemia (lymphatic leukemia), an affection belonging to the domain of internal medicine. The disease is characterized b>' the }:)resence of tumors varying in size and occur- ring simultaneously in the cervical, axillary, and inguinal regions. These tumors differ from the enlarged glands resulting from tuberculous infection by being softer; the separate glands in lymphatic leukemia may also be isolated, whereas, in tuberculous lymphadenitis, the glands are massed together by inflammatory condensation and infiltration of the periglandular connective tissue. i\licroscopic examination of the blood will assist in the diagnosis, though the proportion of white blood-corpuscles is sometimes increased in general tuberculous lymphadenitis. Sarcoma of the cervical glands is almost without exception a primary manifestation. These growths occur particularly in the upper deep cervical group, attain a large size, and destroy life either by compression of the trachea or by paralysis of the pneumogastric nerve. The large vessels of the neck are greatly distorted. Sarcoma may also occur in this region, having its origin in the connective tissue surrounchng the vessels and muscles. Extirpa- tion, unless attempted early in the case, is usually impracticable. Therefore treatment by means of injections of sterilized cultures of the Strepto- coccus erysipelatis and the Bacillus prodigiosus (B r u n s , C o 1 e y) is to be attempted (see page 226). Ligation of tlie Common Carotid Artery. — Indications. — (1) Hemor- rhage; (2) aneurism; (3) operation on tumors; (4) neuralgia of the trigeminus (G . Fischer); (5) aneurism of the innominate artery (Bras dor's oper- ation). In cases of hemorrhage the ligation may be either preventive or cura- tive. In operative attacks on tumors the ligation may be either temporary and provisional or permanent. It has been suggested to ligate the common carotid artery in neuralgia of the trigeminus with the hope of benefiting the disease through the central nutritive changes that follow. The mortality following the operation varies with the conditions present. When the vessel itself is healthy and no serious affection is present, as, for in- stance, when the operation is performed for neuralgia of the fifth nerve, the mortality amounts to 5 per cent. The mortality of all cases of ligation of the vessel is about 40 per cent. Both common carotids have been ligated success- ively (32 cases). In one case an interval of five years elapsed between the operations. In this case the patient lived forty-six years, and at the post- mortem it was found that the collateral circulation was carried on more by the ascending cervicals than by the vertebrals (Roth). The most successful eases are those in which several weeks intervened between the operations. In one instance, both carotids were ligated simultaneously (Valentine M o 1 1). The attempt proved unsuccessful. Functional disturbances are present, as a rule, even in one-sided ligation, when the collateral circulation is established and recovery takes place. These include mental impairment and paralysis of the peripheral nerve distribu- tion. In fatal cases due directly to the ligation foci of cerebral softening are found. In double ligation these disturbances are most marked. The Operation. — The point of election is at the level of the cricoid cartilage and above the omohyoid muscle. Below this, the vessel is comparatively inaccessible, and above it, the bifurcation is encroached upon. The patient. THE LATERAL REGION OF THE NECK 633 is placed on his back, the shoulders supported on a hard pillow, the chin drawn up, and the head turned slightly toward the opposite side (Fig. 374). The Fig. 374. — "Dissecting Room Position" for Opebations on the Neck. position of the cricoid cartilage is ascertained and a three-inch incision made in the line of the artery with the center on a level with the cartilage. The skin Fig. 375. — 1, Ligation of the Common Carotid Artery above Omohyoid; 2, Ligation of Subclavian Artery. and platysma are incised, the deep fascia divided along the anterior edge of the sternomastoid, and the latter followed until the omohyoid muscle is made out. 634 SURGERY OF THE NECK The superior border of the omohyoid muscle is then well exposed and identi- fied. The sternomastoid is retracted outward and the omohyoid downward (Fig. 375). The carotiel tubercle is now sought for and the vessel detected by its pulsa- tion. The sheath of the vessel is opened on the side toward the median hne, the descendens noni nerve avoided, and the vessel cleared from the sheath on the inner side first, the edge of the incision in the sheath being steadied with strong forceps. The outer side is then freed. For releasing the artery from the sheath a curved blunt instrument, such as an unthreaded aneurism needle, is to be em- ployed. It is important that the process of clearing the artery from the sheath should be carried out with great care and that it should be thoroughly done. The ligature should be passed from without inward. The descendens noni Fig. 376. — 1, Ligation of the Internal and External Carotid; 2, Ligation of the Common Carotid below the omohyoid; 3, ligation of the innominate. The sternomastoid is here shown divided. This is not always necessary, but if ready access is not obtained, both this and the sternothyroid and sternohyoid may be cut. nerve and the pneumogastric have been accidentally included in the ligature, and the artery has been transfixed by clumsy manipulation. Ligation of the External and Internal Carotid Arteries.— Ligation of the external carotid artery for aneurism is less frequently indicated than ligation of the common carotid. Hemorrhage from the branches of this vessel can be generally controlled by ligation at the point of injury. Bleeding from the internal maxillary and its branches may, however, indicate ligation in continuity of the external carotid. The collateral circulation is very quickly re- established by the free communication of its branches (facial, lingual, superior thyroid, and occipital) with the corresponding arteries of the opposite side, as well as with branches of the internal carotid, particularly the ophthalmic THE LATERAL REGION OF THE NECK 635 Ligation of the external carotid is most frequently performed in the course of operations for the removal of deeply placed tumors. I haye found preliminary ligation of the vessel beyond the facial and occip- ital branches of ath'antage in controlling the hemorrhage from the middle meningeal branch in intracranial neurectomy of the trigeminus in intractable neuralgia (see page 541). Operation. — A line drawn from the external auditory meatus to the side of the cricoid cartilage marks the line of the artery with sufficient accuracy. An incision two and a half inches in length is made on this line, with its center resting on the greater cornu of the hyoid bone. The vessel is reached by baring the anterior edge of the sternomastoid muscle, retracting the latter outward, identifying the greater cornu of the hyoid bone, and after the posterior belly of the digastric at the upper angle of the wound and the hypoglossal nerve at the lower angle are located, by exposing the artery between the origins of its superior thyroid and lingual branches. After the artery is cleared the aneurism needle is passed from within outw^ard, care being taken to avoid the superior laryngeal nerve, which curves behind the artery at this point. In order to minimize the risks of secondary hemorrhage it has been advised to secure the superior thyroid, lingual, and ascending pharjmgeal branches ( J a c o b s o n) . This, however, is usually very difficult; moreover, as has been shown (Harrison C r i p p s), the fear of secondary hemorrhage is not well founded. The internal carotid artery very rarely requires ligation. Hemorrhage from the vessel in the carotid canal, erosion of the vessel from disease of the bone, wounds of the vessel (Lee), and traumatic aneurism (B r i g g s) constitute the principal indications. The vessel has also been tied for secon- dary hemorrhage following removal of the lower jaw (Sands). The col- lateral circulation is almost immediately restored through the branches of the vessel of the opposite side in the circle of Willis and the vertebrals. The common carotid has been ligated by mistake for the internal carotid (B r o c a). Operation. — The line of the artery is practically the same as that of the external carotid. The latter vessel is first exposed and then drawn imvard with a small blunt hook. The digastric muscle is drawm upward, when the internal carotid is brought into view. The latter vessel is secured at its commencement close to the bifurcation. The needle is passed from without inward, and the same care is taken to avoid injury to the internal jugular vein and the pneumo- gastric nerve as in ligation of the common carotid. Ligation of the Innominate Artery.— The only indication for liga- tion of the innominate artery is aneurism of this vessel at the point of its division into the right common carotid. The operation was first performed by Valentine M o 1 1 , of New York, in 1818. Though aneurism of this vessel is not rare, in a large proportion of cases the diseased condition occupies the entire area of the arter\\ Among the 24 reported cases ( A s h h u r s t) but one proved successful, that of S m i t h , of New^ Orleans (1864). M i t c h e 1 Banks's case survived fifteen weeks. Death takes place from secondary hemorrhage from the peripheral end, the powerful collateral circulation through the common carotid, subclavian, and vertebral preventing the formation of a firm clot (L e F o r t). In S m i t h ' s case this also occurred, though the right common carotid was simultaneously ligated. The patient was saved by prompt 636 SURGERY OF THE NECK ligation of the vertebral artery. In future cases the aseptic procedure may obviate this danger. The operation is ver}^ difficult of performance. Operation. — The skin incision commences at the left sternoclavicular articulation, and follows, with a sliglit curve downward, the upper edge of the sternum until the light sternoclavicular articulation is reached. This is met by a vertical incision three inches long which follows the anterior edge of the sternomastoid muscle. The superficial fascia is divided in the same lines. The flap is dissected up and the sternohyoid and sternothyroid muscles divided close to the sternum. In order to gain more room the sternomastoid may be partly cUvided, care being taken to avoid injuring the anterior jugular vein. If met, it is to be divided between two ligatures. The deep cervical fascia is now incised in the direction of the original wound and the common carotid sought for and its sheath opened as low dowm as pos- sible. This vessel is now^ traced downward until the bifurcation of the innomi- nate is reached. The vessel usually lies behind the right sternoclavicular articulation, in the mass of fat and connective tissue extending downward to the anterior mediastinum and upward to the trachea and esophagus. In fol- lowing the arterA' downward, when it is situated low down, the head should be slightly flexed and the search aided by a head-band reflector (J a c o b s o n). The innominate vein and pnemnogastric nerv^e should be drawn outw^ard and injury- to the pleura avoided by keeping the needle closely applied to the artery. The needle is to be passed from without inward and slightly from above down- ward. Special difficulties are met when the j^arts surrounding the vessel are matted together by adhesions. The operation may have to be abandoned on account of extensive disease of the artery, in which case Bras dor's opera- tion of ligation of the right common carotid and subclavian should be substi- tuted. In order to avoid secondary- hemorrhage, the common carotid and A'ertebral should be ligated at the same time. Sterilized floss silk or chromicized catgut should be employed as ligature material. Ligation of the Subclavian Artery. — Ligation of this Aessel may be demanded by certain injuries and diseases of the upper extremity, tumors of the axiUa and operations for their removal, and by hemorrhage. The vessel has also been ligated in cases in which chstal ligation is employed in innominate and aortic aneurism, as a preliminary step in excision of the scapula, and in amputation of the entire upper extremity. The mortality is almost 50 per cent (W . Koch). Though the cause of death in most of the fatal cases has been due to the condition for which the ligature was applied, yet the ligation itself is not without danger. In case the wound suppurates, suppurative pleuritis may cause death. The pleura may be injured and pneu- mothorax result. The vessel may be exposed and secured in its second portion, where it lies behind the scalenus anticus; in its third portion between the external edge of the scalenus anticus and the outer border of the first rib ; and, finally, below the c\2i\ic\e at the upper portion of the anterior thoracic wall. The first- named situation is very unfavorable on account of the proximity of numerous and large branches (vertebral, internal mammary, thyroid axis, and the supe- rior intercostal), the necessity for division of the scalenus anticus muscle and the consequent risks of injuring the phrenic nerve and the internal jugular THE LATERAL REGION' OF THE NECK 637 vein, and the dangers of injury to the j^leura, with which the artery is in contact below. The third part is the most fa\-oral)le point for a})phcation of the hga- ture. Here the artery is more superficial and does not send off any branches ; as far as present surgical experience extends, it is the only justifiable point to apply a ligature except when the operation is performed in cases of tumors of the axilla (secondary carcinomatous deposits involving the vessel and demand- ing its resection). This artery was first successfullv ligated bv Post , of New York (1817). Operation. — The patient's head is turned toward the opposite shoulder and the neck is slightly flexed laterally. The corresponding arm is drawn downward and the shoulder depressed. The skin of the posterior triangle of the neck is drawn downward and an incision three inches in length is made through the skin and platysma down on the clavicle. The external jugular vein is avoided by this maneuver. When the traction is withdrawn, this incision should extend from the trapezius to the sternomastoid. To this may be added a short vertical incision. The deep cervical fascia is now incised in the length of the original w^ound. If the external jugular vein comes into view, it is to be displaced outward and di^dded between two Hgatures. The omohyoid muscle is retracted upward and outward. The edge of the scalenus anticus muscle is now sought for and the finger passed along its edge until the tulaercle of the first rib is identified. The brachial plexus is identified with the finger as it passes from above downward and outward, limiting the supraclavicular fossa above. The vessel itself is identified by its pulsation as it rests on the bone. The artery is now cleared by careful dissection and an un- threaded aneurism needle passed from above doT\mward and from behind forward. The index-finger serves as a guide for the passage of the needle and at the same time protects the vein from injury. Care is necessary- not to wound the pleura. The needle is now threaded and withdrawn. The vertebral artery is accessible for about an inch and a cparter of its length. It can be reached only just below the transverse process of the sixth cervical vertebra and before it enters the canal of this process. It was first tied by M a i s o n n e u V e (1852). The first successful case is that of Smith, of New Orleans {vide supra). Alexander, of Liverpool, Hgated the verte- bral in 36 cases of epilepsy. Of these, 33 recovered from the operation. The strong collateral current from the vessel of the opposite side through the basilar artery usualh" renders the operation useless. The artery is reached by an incision three inches in length, commencing at the clavicle and extending along the posterior border of the sternomastoid. The transverse process of the sixth cervical vertelira is the guide to the vessel. It is usually necessary to divide a portion of the clavicular attachment of the sternomastoid. The vertebral vein lies in front of the artery. On the left side the thoracic duct may be endangered. Stretching of the Brachial Plexus.— For intractable neuralgia of the arm the brachial plexus has been stretched at the points where its roots leave the intervertebral canals. The incision begins at the middle of the sternomastoid, extends downward for about two inches, and terminates about an inch and a half from the posterior edge of the latter muscle. The external jugular vein is to be compressed above the clavicle b}' an assistant. The transversalis coUi crosses the plexus horizontaUy in the lower third of the 638 SURGERY OF THE NECK wound. I'hc plexus is lifted b}' means of a blunt hook and freed by the index- finger, isolated, and stretched in l)()th directions. Stretching of the cervical plexus is indicated in neuralgia in the occip- ital, auricular, and supraclavicular regions. Branches of the cervical plexus may be reached by an incision along the posterior edge of the stemo- mastoid; from the middle of this muscle upward the branches are followed behind the muscle to their points of origin from the plexus. Great care is necessary to avoid injury to the internal jugular vein. Intraspinal Nerve Stretching and Neurectomy. — The posterior or sensory roots of spinal nerves have been stretched, as well as divided and resected, for persistent neuralgia (Dana, Abbe, 1888). Portions of the arches of the vertebrae are removed and the dura exposed for two inches. The latter is not opened. The intervertel^ral foramina are explored by a curved blunt hook ancl the nerves stretched, divided, or resected. The results of the operation thus far have not been very satisfactorv'. Neurectomy of the Spinal Accessory Nerve. — Clonic spasm in the area of distribution of the spinal accessory has been treated by neurectomy of this nerve. The point where the nerve passes into the sternomastoid corresponds to almost the exact middle of this muscle (i. e., half-way between the mastoid process and the inner extremity of the clavicle). The posterior edge of the muscle is exposed and the nerve sought for at the point where it passes from within outward to the sternomastoid ancl thence to the trapezius. The nerve is resected here without difficulty. The results of the operation have thus far been satisfactory. Operations for the Removal of Tumors of the Neck. — The extirpation of tuberculous lymphatic glands is indicated for the jorevention of general tuberculosis. Early operation is preferable, not only because of the greater pro- tection afforded but on account of ease of performance as well. In late cases the glands become attached to important surrounding parts. Curved incisions should be employed, wherever practicable, a flap being turned back to give access to the underlying parts and the glands isolated wdth the thin wedge- shaped handle of the scalpel, rather than with its blade. The closed blades of a curved blunt scissors will be found very useful. The suprahyoid groujD is removed without difficulty. The only vessel rec|uiring ligation is the small mylohyoid artery. The submaxillary lymphatic glands are more difficult of extirpation. The facial artery is frequent!}' in- jured. This group may extend downward to the lingual artery and outward to the external carotid. The submaxillary salivary gland is frecjuently involved in the mass and is removed as well. Extirpation of the upper deep cervical or supracarotid group is still more difficult. Fortunately, in most cases the connective tissue is not very intimately adherent at the posterior aspect" of the group or in the direction of the vessels. Ligation of the common carotid artery is seldom necessary, though its wall is freciuently exposed. The edge of the knife should never be directed toward the vessels. The lower deep cervical glands are exceptionally difficult of removal by reason of their intimate relation with the internal jugiilar vein and their fre- quent adhesions to it. The portion involved in the latter is to be left till the THE LATERAL REGION OF THE NECK 639 last; then, if the vein is injured, th(> wound in the latter can be grasped by hemostatic forcejis and a lateral ligature applied. The occipital and supraclavicular groups are usually easy of extirpation. Cdands lying on the internal carotid artery and those constituting the prever- tebral group are exceeding!}' diilicult of removal, and the impossibility of reach- ing all of the diseased glandular structures nullifies the entire operation. In case these glands have suppurated, complete removal may be impossible, lender these circumstances the abscess cavity is to be evacuated and its walls curetted, vigorously ruljbcd with iodoform gauze, and only partially closed. Carcinoma and Sarcoma. — The justifiability of removal of malignant tumors of the neck wdll depend on whether or not they are movable on the underl^-ing parts. The absence of mobilit}^ on the vertebral column, or only a slight mobility, as a rule is a contraindication to extirpation. Their size and location must also enter into the question. Before exposing the growth it is not always possible to decide as to the practicability of removal. Sometimes the tumor is not attached to the carotids, but only lies against them or the internal jugular vein. Where the vessels are displaced by the growth, they will often be found intimately adherent to it. In case of doubt the operation should always begin by exposing the common carotid artery below the tumor and passing a provisional ligature around the vessel. By adopting this precaution excessive hemorrhage may be prevented. When portions of the carotid artery or the internal jugular vein are involved in the growth and reciuire removal, this must be accomplished between two liga- tures. When the vein is accidentally wounded low down, instant digital com- pression must be made to prevent entrance of air. The bleeding point is then to be grasped beneath the compressing finger by broad-bladed hemostatic forcej^s, and the vessel secured hj a ligature. It is still an open cjuestion as to whether or not the operation is to be abandoned W'hen the pneumogastric is involved. Instances of complete division of this nerve are recorded in which the patient survived. If the operation is to be proceeded with, no portion of the tumor is to be left behind. The necessity for abandoning the operation before com- pletion is always an unfortunate circumstance, for the reason that septic con- ditions usually supervene and rapid growth of the remaining portion always occurs. The removal of a growth that has begun to break down should not be undertaken. The inevitably fatal result may sometimes be postponed, how- ever, by removing septic foci with the sharp spoon and packing with iodoform or other antiseptic gauze. Even after apparent complete extirpation and perfect healing recurrence is the rule and immunity the exception. Branchial Fistula. — Congenital fistulas of the neck result from incom- plete closure of the branchial clefts (see page 237). In the great majority of cases they arise from the fourth branciiial cleft, in wliich case the external opening is situated just above the sternoclavicular articulation, and on either the outer or the inner edge of the sternal portion of the sternomastoid muscle. When they arise from the upper clefts, the external opening is found on a level with either the cricoid cartilage or the thyroid cartilage and at the inner edge of the sternomastoid. When found high up, congenital ear fistulas (Hensinger) or atresia of the external auditory canal, as weU as mal- formations of the external ear, may coexist (V i r c h o w). 640 SURGERY OF THE NECK In about one-third of the cases the fistula is double-sided. In the one-sided cases it is most frequently found on the right side. It may be complete or incomj)lete. The fistulous canal is lined with mucous membrane ; its external opening is usually very small and is marked by a slight elevation or a reddish ring of mucous membrane. The secretion from the canal may amount to only a slight moisture ; generally there is a scanty, stringy, saliva-like fluid, which, under some circumstances, may become purulent. Fetal cartilage may be found in the depths of the fistula. When the fistula is complete, it leads under the skin in the direction of the greater cornu of the hyoid bone, and thence beneath the lower margin of the inferior maxilla to open in the pharynx in the neighborhood of the tonsil. The canal is wider than either of its openings and a dilated portion is sometimes found near the external opening. When incomplete, it ends blindly a short distance above the aperture, and from retention of secretion it may lead to the formation of a small cyst. Females are affected oftener than males. Hereditary influences are some- times observed. Ascherson records eight cases occurring in three genera- tions of one and the same family. The treatment of complete fistula is very unsatisfactory, owing to the difficulty of destroying the mucous lining. Cauterization, as well as the injec- tion of iodin, gives but indifferent results. Excision of the fistulous track is usually impracticable, and if successful leaves an amount of scarring as objec- tionable as the fistula itself. Incomplete and shallow fistulas may be dissected out without difficulty. Cervical Sympathectomy.— This operation has been recommended for glaucoma and for Jacksonian epilepsy (Alexander; Jonnescu). The incision is the same as for ligation of the carotid artery.* The superior ganglion is first sought. The internal jugular vein, pneu- mogastric nerve, and internal carotid artery are identified in turn and drawn anteriorly; the sternomastoid is retracted posteriorly. The cervical sym- pathetic cord is differentiated from the pneumogastric and superior laryngeal nerves, and traced upward until the lower border of the ganglion is reached. This appears as a reddish-gray fusiform swelling on the cord about 3 centi- meters in length, lying posteriorly to the commencement of the internal carotid and on the rectus capitis anticus major muscle. The ganglion is carefuUv cleared and secured by catch forceps, and slow and careful traction is made until its upper border appears, when the cord above is severed. Sometimes the cord and ganglion come away by avulsion. The cord is now .traced downward until the middle ganglion is reached. This is situated opposite Chassaignac's tubercle in front of or on the inferior thyroid branch of the subclavian and about on a level with the omo- hyoid muscle. The ganghon is detached from its cardiac filaments and the cord below the ganglion traced downward. The inferior ganglion is in relation to the superior intercostal branch of the subclavian artery, and in order to reach it with safety the skin incision is ex- tended and the artery exposed in its first portion. On the left side the ganglion * B r a u n , of Gottingen, operated by an incision placed posterior to the sterno- mastoid. He found difficulty in locating the upper ganglion, and, because of the difficul- ties and dangers, abandoned the attempt to remove the lower ganglion. THE CERVICAL VKRTl^BRAE 641 lies behind the sulx'laAian and on ihc inner side of the intercostal artery. On the ri<2;ht side the artery is Ijehind the muscle, and the ganglion is in relation with the inner edge of the latter, and lies Ijetween the base of the transverse process of the last cervical vertebra and the neck of the first rib. Here the greatest care is required to avoid injury to the vessels and to the phrenic nerve as it passes in front of the subclavian to the inner side of the scalenus anticus. Once the ganglion is identified it is forced upward by gentle traction and separated from the cord Ijelow by avulsion. In case the operator succeeds in identifying the ganglion readily on the first side attacked, both sides may be operated on at the same sitting. Visual disturbances due to interference with the sympathetic supply to the ciliary muscle are more or less pronounced and in some instances irremediable and permanent. In four cases in which I operated for epilepsy all recovered from the opera- tion. In the first case the patient died in the status epilepticus before the second operation could be performed. In the other three cases both sides were operated on at the same sitting. In the first of these no benefit was derived. In the second the patient, an exceedingly sensitive youth, was cured, but he committed suicide in the following year in a fit of mental despondency incident to erratic and intractable visual disturbances following the operation. The fourth case could not be traced beyond three months after the operation, up to which time he had had no return of the convulsions. THE CERVICAL VERTEBRAE Injuries of the spine in general, like those of the skull, derive most of their importance from the associated injury of the contained nerve centers and tnmks. In addition to this, the function of the spine as a support to the head is interfered with. Fracture of the Cervical Vertebrae.— The body of the vertebra is broken in a little more than one-half of the cases; in the remainder the arches are broken (Gurlt). Fracture of the arches is more frequent above the middle of the cervical region, and fracture of the bodies below this point. Simultaneous fractures of two or more vertebrae occur not infrec|uently. The axis is more frequently broken than the atlas, and the odontoid process is some- times broken alone. The body of the axis is most frequently broken about a fourth of an inch below the neck of the process. Fractures of the spinous processes occur, particularly of the seventh. In fracture below the fourth cervical vertebra the paralysis wall usually affect both arms. The anesthesia may be asymmetric at first; the asymmetry, however, soon disappears as degenei-ative changes progress. A hyperesthetic area may be noted in the parts supplied from immediately above the injury on account of irritation of the latter. Owing to the length of the course of the involved nerves within the spinal canal, the area of both motor and sensory paralysis will be lower than the point of injury to the cord. A differential diagnosis of fracture and dislocation is frequently impossible. In cases of fracture of the odontoid process, the head is held rigidly fixed, and, when accompanied l)y displacement, the lar^mx is unduh^ prominent; the voice sounds may be altered. The posterior wall of the pharvnx may be pushed 42 642 SURGERY OF THE NECK fdnvai'd 1)}- the (lis])lacod A-(>rtt>ljra. Crepitus may ])c felt and pain and ten- derness present in the occiput and neck. Prognosis and Complications of Injuries of the Cervical Vertebrae. — Both fracture and dislocation of the bodies of the cervical vertebrae are neces- sai'il>' attended by a high mortality, owing to the almost inevitabh' accompany- ing injury of the s])inal cord and the consequent severe disturbance of function. These functional disturbances decrease somewhat in importance the lower down in the spinal column the injury occurs. They retain a very serious import, however, even low down in the lumbar region. Injuries below the fourth cervical ^•ertebra ma}' paralyze the respirator}^ muscles with the exception of the diaphragm (distribution of the phrenic nerve). Severe injury above the fourth vertebra may produce immediate death from complete paralysis of respiration. Even with preservation of the phrenic nerve death usually takes place in a few days, the patient dying of suffocation from final failure of the diajjhragm to act. Injuries sufficiently low down to leave all the respiratory nerves intact are still usually followed by a fatal result from paralysis of the remaining motor nerves, as well as of the sensory nerves. When the injury occurs above the fourth cervical vertebra and the cord is damaged, the injury may prove immediately fatal; or the patient may survive for a few hours, or, in the majority of cases, for a fortnight at the most. Ex- ceptionally, patients may survive for a longer period (Shaw's case for fifteen months and Hilton's for fourteen years). It is not possible to determine at the commencement whether or not lacera- tion of the cord has taken place. In cases of contusion of the latter the paralysis may be complete at first, subsequently improving. Treatment should therefore be instituted in such cases and continued as long as the patient remains alive. Most frequently, however, the cord is lacerated, as revealed by the autopsy. Even when the cord escapes laceration, contusion of this structure, hemor- rhage, and laceration of the roots of the spinal nerves lead to inflammatory softening of the cord, which finally extends to the uninjured portions. This is announced by a rise in temperature, which sometimes occurs suddenly; it is sometimes preceded by an abnormally low temperature. Treatment of Fractures of the Cervical Vertebrae. — The spine should be gently straightened, the patient placed on a water-bed, and every precaution taken to prevent bedsores. The bladder should be emptied every six or eight hours. Where there is palpable deformity, attempts should be made at rectification. This should be attempted by extension and counter-extension, the patient lying on his back, and manipulation at the site of fracture. The chin and collar portion of S a y r e ' s suspension apparatus may be used for extension, and counter-extension maintained by raising the head of the bed, a rubber sheet being used with boric acid sprinkled on it to prevent friction. Resection of the spine, or laminectomy, has been frequently resorted to of late years, either as an immediate or as a secondary operation. Postmortem examinations have shown that even where the cord is not lacerated, pressure from displacement may produce irremediable softening in from twenty-four to forty -eight hours. The mortality after laminectomy is 48 per cent (W h i t e). The immediate operation is indicated particularly where fracture of the arches can be made out. The operation may still be of service when the body is broken and displaced, the compression being due to coincident displacement of THE CERVICAL VKUTKBUAE 643 tlK> laniiiuu\ Wlicn ixM-foinuMl as a sccoiulary operation, it is indicated by failure of imi^rovement in the ])aralysis at the end of six weeks, with persistent s])read of l)e(lsores, incontinence of urine and cj'stitis (L a u e n - stein). The indications for operative interference in injuries of the osseous framework of the spine areas foUows; (1) in compound fractures for the ^enlo^•al of foreign bocUes and fragments of l)one; (2) in injuries of the arches and spinous processes, with lesions of the cord, when bony fragments are driven against the theca and are liable to produce further injury at every movement; (3) in the rare cases where the symptoms are mainly due to thecal or perithecal hemorrhage pressing upon the cord; (4) in pach}-meningitis and perimeningitis following an injury; (5) in cases where the cauda equina is pressed upon, recover}^ maj^ follow the relief of pressure by operation. (For the operation of laminectomv, see Vol. II, page 2.) DISLOCATIONS OF THE CERVICAL VERTEBRAE These are more frequent than fractures in the cervical region, on account of the greater flexibility of this portion of the spinal column. Combined disloca- tion and fracture occurs, however, the bony insertions of the strong liga- mentous structures giving wa}'. Under these circumstances the fracture is unimportant as compared with the dislocation. Mechanism and Varieties of Dislocation.— With the exception of the movements of the atlas and axis, the movements of the cervical spine are comprised in those of flexion or bending forward, extension or bending back- ward, and abduction or lateral bending, the head approaching the shoulder. In the latter movement, when extreme, there is also flexion, these two move- ments combined comprising rotation. Dislocation in Extension. — Extension movements are more limited than those of flexion, owing to the tilelike arrangement of the vertebral arches. Extreme extension to the point of dislocation, therefore, presupposes compres- sion and final crushing of the arches, and after this, of the cord as well. Cases of this description are rarely seen clinically, death taking place almost immedi- ately. Flexion Dislocation. — In extreme flexion the arches are carried away from each other, the two articular processes of the upper vertebra moving upward on the two articular processes of the lower vertebra, being restrained only by tension of the ligamentum subflava. The posterior edge of the upper vertebral body is lifted away from the posterior edge of the one l^elow. With the yielding of the ligaments between the arches and the posterior portion of the intervertebral disc, and, perhaps, the tearing away of the bone (avulsion), the articular processes of the upper vertebra leave those of the lower vertebra, and the former is dislocated forward, its articular processes resting in front of those of the lower. Reduction is then opposed because the articular pro- cesses of the upper vertebra become locked in front of those of the lower, from which position they must be released before both pairs of articular processes can be brought again into normal relations with each other. Falls from a height, the patient striking on the head, and the falling of hea^^ masses of earth and the like on the head, are the most common causes of flexion dislocations. Many of these accidents are followed b}' instant death 644 SURGERY OF THE NECK from paralj'sis of respiration or prove fatal before surgical assistance can be summoned. The symptoms of flexion dislocations are usuall}- well marked and unmis- takable, though transverse fracture of a cervical vertebra with anterior dis- placement may simulate flexion dislocation. The head is bent forward, the chin approaching the sternum. The neck muscles are spasmodically con- tracted and bulge on each side. There is a sudden interruption of the line of the spinous processes corresponding to the forward recession of the upper vertebra, and the spinous process of the latter cannot be felt. Deglutition is interfered with and the projecting body of the dislocated vertebra can be felt under the pharyngeal mucous membrane posteriorly. Paralysis to a greater or lesser extent is alwa^'s present from encroachment upon the lumen of the spinal canal, this varying, however, both in degree and in extent. Finally, cases occur in which recoil takes place. In the cervical region these are believed to be commoner than cases of persistent displacement (T h o r b u r n). The injury to the cord may be quite as great as when per- manent displacement is present. The treatment consists in an immediate attempt at reduction, the risks of the procedure having been previously explained to the patient or his friends, as well as the further fact that even should reduction be successful a fatal result may yet occur from damage already inflicted on the cord. Simple traction in the longitudinal axis is successful in many cases, all the ligaments being torn. This latter, however, makes traction all the more dangerous, slight overtraction resulting in complete separation of the already injured cord. Converting the flexion dislocation into a rotation dislocation and then reducing this (H u e t e r) is effected as follows : The head is carried strongly toward one shoulder, and by rotating movements the opposite artic- ular process is disentangled from its locked position with that of the one below and replaced in its normal relation with the latter. The head is now abducted in the opposite direction and the same maneuver repeated, the other articular process being dislodged and finally reduced. Rotation Dislocation.— With combinations of flexion and abduction, the articular process of the upper vertebra may rest in front of the corre- sponding articular process below on the side toward which abduction is made, while the other two articular processes bear their normal relation to each other. Under these circumstances a rotation dislocation is said to have occurred. This form of dislocation is most commonly produced by a fall on the head, the weight of the trunk falling to either one side or the other and bending to the corresponding side the cervical portion of the spinal column. The dis- location usually occurs either between the fourth and the fifth vertebra or between the fifth and the sixth vertebra. The symptoms are not so marked as in flexion dislocation. The head is inclined to one side toward the shoulder. The neck muscles corresponding to the side on which the dislocation has occurred are someAvhat prominent. The chin is not markedly rotated toward the opposite side, as in active or physiologic abduction of the head. In thin persons the shght displacement may be felt on palpation. A prominence, more marked on one side than on the other, can be felt on the posterior pharyngeal wall. Paralytic symptoms are not so prominent in this dislocation as in that last described. In most THE CERVICAL VERTEBRAE 645 instances, howovov, the roots of the spinal neT•^'(■s at lliis ])art, particularly those of the brachial plexus, are more or less contused, and ])ain in the distri- bution of these, together with formication and paretic conditions, is present. Hemorrhage, compression, or concussion of the cord may likewise occur, though rarely. The treatment consists in immediate reduction, not only to correct the position of the head, but to restore the function of the nerves distributed to the arm and to avert progressive disturbances in the cord itself. Reduction by traction is positively eontraindicatecl. The dislocation must be reduced in the way it occurred. The position of superabduction is the cause of the hooking of one articular process in front of the other, and the head must be brought back in this position. The manipulation consists in first forcing the head in a further position of abduction, or toward the side to which it already tends; this releases the articular process. The head is then rotated so that the ear of the same side moves toward the front, the ear of the opposite side moving backward. In the after-treatment of dislocations of the cervical vertebrae the head must be secured in the median position. In cases of rotation dislocation a simple pasteboard cravat answers the purpose. In cases of flexion dislocation the destruction of the ligamentous apparatus demands more trustworthy means. Here the plaster-of-Paris bandage is to be added, which should encase both shoulders as well. The patient should be placed on a water-bed to prevent bedsores and the results of the paralysis treated symptomaticallv. The Atlas and Axis. — These occupy a special position, both anatomi- cally and clinically. Flexion and extension are accomplished through the atloido-occipital articulation and rotation through the atlo-axoid articulation. These are protected by very strong ligaments, which, when ruptured, permit dislocation, with resulting pressure on the spinal cord and instant death. This occurs in official hangings, in which the body, falling from a sufficient height, is suddenly arrested by the rope encircling the neck. The ligament behind the odontoid process gives way and the cord is crushed by the backward movement of the process. Fractures of the atlas and axis are speciaU}^ danger- ous from proximity of the medulla oblongata. In suicidal hanging in the majority of cases the rope slides upward and constricts the pharynx, as well as the large venous tnmks, carotid artery, and pneumogastric nerve. Neither the spinal cord nor the vertebrae are injured. Dislocations of the odontoid process sometimes occur with fatal results from lifting children by the head in play. Dislocations between the atlas and the axis are rare (8 out of 73 cases of dislocations of the cervical verte- brae, B 1 a s i u s). Fracture of the odontoid process is somewhat rare; the process is more resistant than the arch and the transverse ligament which secures it (S t e p h e n Smith). The accident is almost necessarily fatal. INFLAMMATORY AFFECTIONS OF THE CERVICAL VERTEBRAL COLUMN Practically, these may be divided into those which affect the articulations of the oblique or articular processes, and those which affect the body of the vertebrae. Inflammation of the Lateral Articulations. — This is usually of rheu- matic origin. The inflammation rarely passes beyond the stage of serous 646 SURGERY OF THE XECK effusion. It occurs more frequently in children than in adults. Pain is re- ferred to the region of the articular processes and is always unilateral. Tender- ness is present. The head is abducted toward the diseased side (infianunatory torticollis), in order to relax the synovial membrane. The treatment consists in the application of warm moist compres.ses. Later, a jjastcboard and starch bandage dressing to restrict movements and gradually restore the head to its normal position is applied. In chronic cases the application of the actual cautery (thermocautery) may be of service. It may be necessar}^ to employ forced passive motion later on, if adhesions restrict the movements of the head. The prognosis is u.sually good, though moderate wryneck or caput obstipum has resulted from the affection. Spondylitis in the Cervical Region. — Inflammation of the bodies of the cervical vertebrae belongs to the large group of affections known as Pott's disease. The intervertebral discs take only a small part in the affection. The disease is essentially a granular (tuberculous) myelitis of the vertebral bodies, including the cancelli, the cortical lamellae, and finally the periosteum and the surrounding tissues. Abscess forms in the vertebral body and the pus makes its way in various directions (migratory abscess). The inflammation is almost exclusively of infectious origin, the bacillus being deposited by the blood in the abundant medullary tissue of the growing bone; hence its more frecjuent occurrence in childhood. The middle portion of the cervical column is attacked with greatest frequency, as a rule, though opinions differ on this point. Taylor asserts that the sixth and seventh cervical vertebrae are more liable to the disease than all the other vertebrae of the spinal column. Kyphosis or permanent curA^ature occurs here as in other portions of the spine attacked, and is due to the fact that the vertebral body, after conden- sation of the cancellous and cortical substance, sinks anteriorly under the in- fluence of the weight of the head. The curve is more uniform and convex than in kyphosis in the dorsal and lumbar regions, owing to the normal curve of the neck, which, being placed with its concave surface directed anteriorly, con- stitutes a lordosis. Scoliosis, or lateral curvature, is rare in the cervical region, unless the focus of the disease occupies but one-half of the vertel^ral body. Under these circumstances a variety of inflammatory caput obstipum is present. The spinal cord escapes injury from the fact that the disease tends to extend anteriorly rather than toward the vertebral canal. Resulting abscesses also incHne to pass anteriorly; exceptionally, however, they may follow the root of one or the other lamina or arch and jorogress laterally, in which case the}^ may follow the roots of the brachial plexus and point in the supraclavicular region, or even in the axilla. When pointing anteriorly from the lower cervical vertebrae they find their way into the posterior mediastinum and thence into the pleura, or into a bronchus, causing death. From the middle cer-vical region they reach the posterior pharyngeal wall, forming a retropharyngeal abscess. With the exception of the rather rare form of the latter resulting from phleg- monous inflammation of the submucous tissue, or suppurating lymphadenitis of a retropharyngeal lymphatic gland, retropharjmgeal abscess arises almost exclusively from Pott's disease in the cervical region. The projection of the abscess into the cavity of the pharynx produces disturbances of deglutition at first, and finally disturbances of respiration. THE CERVICAL VERTEBRAE 647 Treatment. — Tlio al)scoss sliould be emptied early. This may be done through a siiiall incision, in onler to avoid entrance of pus into the glottic opening, or the abscess may be incised freely with the head in the dependent head position of Rose (see page 534). The walls of the abscess contain the constrictor muscles of the pharynx; hence, their elasticity is such as to lead to rapid emptying and collapse. This favors early resolution, the healing process frequently being completed in a remarkably short space of time. In the further treatment of Pott's disease in the cervical region it will be necessary to apply some form of support for the head and vertebral column. Fig. 377. — Jury Mast. Fig. 378. — Anteroposterior Support with Head-piece. This may be accomplished by the use of a jury mast attached to a plaster-of- Paris jacket (Fig. 377), by an anteroposterior support with head-piece (T a }' 1 o r , Fig. 378), by a padded leather collar (Thomas, Fig. 379), or by a brass wire collar (B u r r e 1 1 , Fig. 380). The two latter are rendered more efficient by being attached to an anterolateral support. Or V o 1 k m a n n ' s method of extension in the recumbent position may be employed (Fig. 381). Caries sicca of the medullarv structure of the atlas and axis, particu- larly of the latter, may occur. The inflammation soon attacks the neighboring joints and synovitis ensues. The affection is more connnon in adults and in old 648 SURGERY OF THE NECK people than in children. Caries with suppuration is uncommon in this region, even in cases where the autopsy reveals extensive destruction of osseous and Fig. 379. — Padded Leather Collar. Fig. 380. — Bcrrell's Brass "Wire Collar. ligamentous structure with fusion of all the parts concerned. The affection is difficult of recognition in the early stages, the symptoms resembling those of Fig. 381. — Volkmann's Method of Extension in the Recusibext Position. suboccipital neuralgia. When softening of the ligamentous structures has taken place, the attitude of the patient, as he grasps the head to support it- THK CKKVK'AL VERTEBRAE 649 whilo in the act of lyinij; down or rising-, is characteristic and striking. Sudden death may occur from (hslocation ((> out of 10 cases, R u s t). Extensive par- alysis may occur. Progressive myelitis may occur from gradual)}' increasing pressure on the cord and death take place from this cause. Treatment is not instituted, as a rule, until after softening of the ligaments has taken place. Tiie indications are to support the head, either by means of V o 1 k m a n n ' s extension in the recumbent position (Fig. 381) or by means of j\I a t h i e u ' s cuirass, or one of the head supports already described (Figs. 379 and 380). If abscesses form they are to be opened early. Bony ankylosis of the upper cervical vertebrae is occasionally found in dissecting-room sul^jects. The affection is thus far unknown clinically. TUMORS OF THE CERVICAL VERTEBRAL COLUMN Certain congenital clefts of the cervical vertebral arches occur (spina bifida). Cysts with transparent contents occupy these clefts, which communi- cate with the enlarged central canal of the spinal cord, and through this with the cerebral ventricles. When a broad communication with the fourth ven- tricle is present, the case presents a combination of occipital encephalocele and spina bifida. The occurrence of a cervical rib has been mentioned in connection Avith aneurism of the subclavian. A genuine exostosis of this al^normal cervical rib has been observed (Holmes C o o t e). An accidental bursa mucosa may form over one of the spinous processes of the cervical vertebrae, ]3articularly of the seventh. This occurs as a slightly elevated convex sAvelling filled with a small amount of serosynovial fluid sur- rounded b}^ somewhat dense walls. It usually arises by pressure from carry- ing burdens upon the neck. Those greatly thickened must be treated by extir- pation. The milder forms may yield to puncture and injection of tincture of iodin, or, this failing, free incision and drainage must be practised. Sarcomas may develop in the cervical vertebral bodies primarily either in adults or in children. This, however, is a rare occurrence. They are most frequently observed as a secondary invasion of the disease and in adults rather than in children. In some instances of supposed primary invasion the original site of the disease has been overlooked. The tendency of the growth is to extend anteriorly toward the pharyngeal wall rather than laterally or posteriorly toward the spinal canal. The disease may likeAvise spring from the periosteum behind the muscular wall of the pharynx and esophagus. The first symptom usually noticed is some difficulty in swallowing. Palpation of the pharyngeal wall reveals the presence of a small tumor, which may be mis- taken for an abscess. Sarcomas of the vertebral column grow rapidly and are accompanied b}' most agonizing pain. When they grow in an ante- rior direction, they may cause death by starvation or suffocation. If the growth spreads laterally, the sheath of the carotid artery is involved, and death may take place from pressure on the pneumogastric nerve. In view of the utter hopelessness of these cases from the operative standpoint, treatment by the mixed toxic products of the Streptococcus er\'sipelatis and Bacillus prodi- giosus may be tried (C o 1 e y , see page 226). Carcinoma. — Dissemination of carcinoma elsewhere, particularly in the breast, leads to deposits in the spinal column. The cervical vertebrae may 650 SURGERY OF THE NECK become the seat of such deposits. The suffering is most intense, and if the patient lives long enough, suffering may be followed by paraplegia. TORTICOLLIS (WRYNECK, CAPUT OBSTIPUM) These names signify an alxluctory contracture of the cervical vertebral col- umn, in consequence of which the axis of rotation of the head is obliquely placed and the chin is rotated toward the opposite shoulder. The affection may be of cicatricial, articular, muscular, or central (cortical) origin. The first has already been discussed (page 624). The articular variety was mentioned in connection with inflammation of the joints of the cervical vertebrae, as well as in connection with unilateral spondylitis of the latter. Wryneck of muscular origin is most frecjuently observed after breech presentations in newborn infants. It results from partial rupture of the fibers of the sternomastoid, and its common cause is traction on the after-coming head. It may be observed immediately after birth, but usually its manifesta- tion is the occurrence of a fusiform swelUng, consisting of a mass of so-called muscular callus, in the course of the sternomastoid muscle when the child is several weeks old. Tliis may be mistaken for a fibroma or an enchondroma. Tills traumatic muscular hyperplasia usually disappears with treatment, after which shortening of the muscle resulting from cicatricial contraction, and perhaps from a voluntary malposition of the head in efforts to relieve pain, occurs. A peculiar complication observed in cases of long standing is an arrest of development of the corresponding side of the head. This is probably due to pressure on the vessels and nerves of the affected side. This as}mimetry usually disappears in the course of time after correction of the deformity. Wryneck of Central Origin (Spastic Torticollis, Tic Rotatoire).— Tills affection is a neurosis and has its seat in the brain cortex. It is to be defined as a disturbance in the motor area regulating movements of the head. Symptoms of neurasthenia, and more rarely those of hysteria or mental disease, may coexist. It is most commonly observed in middle-aged persons with either an inherited neurotic taint or an acquired tendency to nervous disease. I have seen two cases occurring in young girls as the result of injury (falling fonx^ard and striking on the coronal suture of the opposite side). It is occasionally oliserved as an occupation spasm. The symptoms consist in a mor- bid contraction of certain muscles of the neck, which is slight at first, of short duration, and easily overcome by the patient. Later it increases in severity and the clonic contraction is converted into a tonic contraction. As a rule, the rota- tors of the head are affected. The sternomastoid of one side and the muscles of the back of the neck on the other side are usually affected. Exceptionally one sternomastoid and the muscles of both sides of the neck are in"\'olved. Still more rarely one sternomastoid and the cervical muscles of the same side are implicated. Occasionally the muscles of the mouth, face, shoulder, and arm take part in the contractions. The vital prognosis is good, luit the outlook from every other viewpoint is unfavorable. True congenital wryneck of intrauterine origin has been described (G . Fischer). Spasmodic and paralytic wiyneck have also been described. Torticollis has been observed in children after typhoid fever. The affection has been attributed to shortening of the platysma myoides. THE CERVICAL VERTEBRAE 651 Compensatory scoliosis in the cervical region occurs in connection with scohosis in the dorsal region. Treatment. — Wryneck of muscular origin is best treated by section of the sternomastoid muscle. While orthopedic apparatus serve a useful purpose in maintaining a correction obtained by o])eration, unless the latter has been pre^•iousl^- performed they are of little or no avail. In the rare cases which come to the surgeon before shortening from contracture or defec- tive growth of the muscle occurs, a pasteboard collar, plaster-of-Paris ban- dage, or other means designed to prevent the development of the deformity may be of service. The operation is to be performed under an anesthetic. Either subcutaneous division of the muscle at its sternal and clavicular attach- ments or open section may be made. The latter is the safer and more efficient method, but is open to the objection, particularly in female patients, that it leaves a prominent scar in an undesirable location. When the former is employed, the tenotome is introduced behind the muscle and the section made from behind forward. W^hen, as is usually the case, the entire width of the muscle is to be divided, it will be, as a rule, necessary to introduce the tenotome a second time, the portion which is most shortened being divided first. An assistant forces the patient's head toward the opposite shoulder, in order to put the muscle on the stretch, and the operator presses his thumb over the point to be divided so as to feel when the fibers give way and thus avoid injurv'^ to the skin. Aseptic dressings and plaster-of-Paris bandages are applied after correction of the deformity. The question of the application of one or another of the forms of orthopedic apparatus to maintain correction is to be decided after the healing of the wound. In severe wrvmeck, as well as in milder cases of long standing, the latter Avill usually be necessary. In milder cases plaster- of-Paris dressings suffice for the after-treatment. The treatment of spastic torticollis is almost exclusively operative. Anti- spasmodics, hydrotherapy, massage, electricity, and cauterization have been used without success. Rigid orthopedic fixation appliances are useless, as far as effecting a cure is concerned. Elastic traction of the head toward the sound shoulder has been successfully used (H o f f a). Stretching or resection of the spinal accessory nerve controls only a part of the affected muscular area and leads to recovery in only one-fifth of the cases and improvement in two-fifths, leaving two-fifths without any benefit whatever. Section of the upper cervical nerves (Gardner, G i 1 1 e s , Keen) has been introduced as a substitute for division of the si3inal accessory. A combination of these procedures (K o c h e r , Richardson, Walton) gives loetter results. In Kocher's operation all the muscles that are involved are divided. This will include, as a rule, the sternomastoid of one side and all the cervical muscles of the other side. In the division of the latter the obliciuus capitis inferior must not be overlooked. The movements of the head are surprisingly little affected by these extensive myotomies, and whatever impairment does take place is only temporary. Relapses may occur and require repeated division of the muscles until the disease is cured. Gymnastic exercises are to be em- ployed for a considerable time after healing. The operation is not only palliative, but also curative. The cure is accom- plished by the rest given to the irritable center by division of the muscles, the impulses being no longer effectual and resisted. In this way the ec|uilibrium is restored (F . d e Q u e r v a i n). SECTION XVI THE SURGERY OF THE THORAX THE SOFT PARTS SURROUNDING THE CHEST The skin and muscular structure of the chest wall are seldom injured alone. Among the exceptional injuries in this class are to be mentioned gunshot wounds in which the ball passes for a short distance beneath the skin and then emerges, producing a wound which closely resembles that formerly made for the intro- duction of a seton, called a seton gunshot wound. The so-called contour shots are also produced in this way. In the latter class of cases the ball strikes the elastic ribs at a tangent and is deflected outward from the ribs and the intercostal muscles, either issuing again after pursuing a short course or re- maining. Occasionally a ball will strike near the sternum and pass around the corresponding half of the chest, emerging near the vertebral column. It is difficult to comprehend the precise mechanism of this injury. Experiments show that a bullet, traversing apparently in a circular direction for about one- fifth of the circumference of the thorax, can have its course changed into a straight line hdng outside of the thorax, by sudden rotation of the vertebral column and elevation of the arm (Simon, 1871). Hemorrhage from wounds of the chest wall is not usually troublesome. The subclavian artery is the only vessel of importance likely to be injured. Bleeding from this artery may be arrested provisionally by pressure above the clavicle (see page 626). Permanent hemostasis is secured by ligation at the point of injur}', or in continuity (see Ligation of the Subclavian). The long thoracic branch of the axillary artery passes almost vertically downward on the lateral chest wall, somewhat anterior to the axillary line. This, together with the external mammary (superior thoracic) branch, may be injured and rec|uire ligation. Penetrating and Perforating Wounds of the Thorax.— Gunshot wounds constitute the type of this class of injuries. Many of these when inflicted by bullets of the larger calibers prove fatal almost immediately, on account of injury of a large vessel. When both lungs are injured, fatal double pneumothorax develops early. Death may take place from hemorrhage. When but one lung is injured, dyspnea, though urgent at first, is relieved by compensatory expansion of the uninjured lung. Pneumothorax is sometimes prevented by outward prolapse of the injured portion of lung into the wound of the soft parts by violent coughing efforts; more rarely, in shot wounds by the forcing of the pleural surfaces temporarily on each other in the passage of the ball. The existence of old adhesions may also prevent its development. Pyothorax is difficult of prevention on account of frecjuent infection from paz'ticles of clothing carried along with the bullet in its passage. Septic pneumonia and even gangrene of the lung may follow. 652 THE SOFT PARTS SURROUNDIXG TIIK CHEST 653 These complications usually end fatally. Death may also occur from septic l^ronchitis, edema of the hmg, exhaustion from prolonged suppuration and discharge from the bullet track, and paralysis of the diaphragm. When the lower portion of the chest is traversed by the missile and free drainage is established, spontaneous recovery may take place. When the hemorrhage is due to injury of the smaller vessels of the lung substance, the pneumothorax will usually arrest it. Ice compresses to the chest wall may be employed if the l^leeding persists. Resection of portions of one or more ribs for the purpose of tamponing with gauze and thus assuring collapse of lung may be performed to arrest the hemorrhage. Opium should be given, and the most perfect quiet of body and mind enjoined. If hemorrhage from the intercostals is troublesome and tamponing fails to arrest it, splintered fragments of rib may be removed and the vessel included in a suture ligature (circumsuture). Fatal hemorrhage may occur in injuries of the internal mammary arter}^; the bleeding may take place into the pleural cavity and hence be overlooked. In such a case, if the source of the hemorrhage is dis- covered, the wound must he enlarged, a portion of costal cartilage resected, and both ends of the vessel secured. This last is rendered necessary by the free anastomosis of this vessel with the deep epigastric. If foreign bodies that have been carried along with the missile can be easily reached, they should be removed. Deep probing for these will be likely to do more harm than good. Loose splinters of bone are to be removed, and the ends of sharp angular fragments resected or rounded ofT with the rongeur. The parts are to be very carefully and tentatively irrigated with Thiersch's borosalicylic solution. If the irrigating fluid reaches a bronchial tube, as evinced by the paroxysms of coughing and suffocation, it must be abandoned at once. If the prolapse of lung is slight, the granulations in the wound will cover it in. If considerable, the prolapsed part may be hgated and cut away or re- moved "v\'ith the thermocautery. The occurrence of suppurative pleurisy or empyema demands free drainage, with perhaps resection of one or more ribs. Copious aseptic dressing materials are to be apjDlied and held in place by wide roller bandages. The tight application of broad strips of adhesive plaster encircling the chest will tend to prevent the development of subcutaneous emphysema. Opium is to be given to allay pain and insure c^uiet. Support- ing measures are indicated. With the introduction of the modern small-caliber mantled projectile of high velocity as a weapon of war the mortality from this class of injuries has greatly diminished. As a result of the smaller size of the bullet and the diminished resistance of the tissues traversed the destructive effects are reduced to the minimum. In the absence of wounds of the heart and great vessels complete and permanent recover}' from penetrating and perforating wounds of the chest is not unusual, as shown by the most recent experiences in active military service (M a k i n s). Inflammation of the Soft Parts of the Chest Walls. — Suppurative inflammation following gunshot wounds of the chest easily takes on a phleg- monous character, from infection of the large and loose planes of connective tissue which surround the muscular lavers of the thoracic wall. Gunshot 654 THE SURGERY OF THE THORAX wounds of the upper dorsal region at the inner margin of the trapezius and latissimus dorsi are usuall}' followed by a suppurative process with a constant tendency to extend in a downward direction, and consequent pocketing of pus until the sacral region is reached. Repeated incision, drainage, and antiseptic irrigation are indicated. Subpectoral Phlegmonous Inflammation ; Subpectoral Abscess. — This is a diffuse suppurative inflammation of the cormective tissue behind the pectoralis major muscle. It is usually the result of a streptococcus infec- tion, transmitted through the supraclavicular and infracla^dcular h-mphatic channels. The infection is derived from Avounds in the neck or on the cor- responding side of the chest ; a slight abrasion of the skin may be the atrium of infection. There may be a histor}^ of a strain or blow. A suppurative collec- tion sometimes takes place behind the pectoral muscle from abscesses within the chest which perforate the chest wall, or it may result from necrosis of the ribs, of tuberculous origin. Besides the usual general symptonxs of phlegmonous inflammation, the patient complains of pain over the corresponding pectoral region, particularly when the arm is moved so as to bring the pectoralis major muscle into play. The swelling may be so diffused beneath the muscle as to render its recognition difficult. Tenderness, however, may be pronounced. The skin overlying the pectoralis major muscle remains unchanged, except in the rare instances in which the muscle is involved by an exceptionally virulent infection, in which case edema, and, finally, an inflammatory' redness will be obser^^ed. In rare instances the jDhlegmonous character of the inflannnation may give place to a localized process, a true abscess resulting. The suppurative process tends to pass in the direction of the outer edge of the pectoralis major and the Ij'mphatic glands at this point become infected; infection of the axillary glands may also occur. The presence of pus will be announced by a soft swelUng, "u-ith tenderness, and later on by involvement of the skin. Spontaneous eA'acuation may occur at this point. In neglected cases general sepsis, and even metastatic pyemia, may occur. Treatment. — Early operative interference is imperative. An incision should be made to the outer border of the pectoralis major muscle, and the site of the suppurative process sought by passing the end of an arteiy forceps or other blunt instrument beliind the great pectoral muscle. Thorough curetting of the debris of broken-down tissue found to be present, cleansing with an antiseptic solution, and tube drainage are indicated. Infected subpectoral and axillar}' glands should be dissected out. In cases of spontaneous evacuation a discharging sinus is liable to remain. These sinuses are sometimes persistent in spite of frequent curettings ; excision of the entire suppurating tract maybe recpired before heaUng can be secured. When the muscle itself becomes involved and a circumscribed abscess tends to point anteriorly, the latter may be evacuated by a direct incision. More or less impairment of the movements of the shoulder-joint may result from interference with the free play of the pectoralis major muscle. The proper treatment for this condition is massage and passive and active move- ments of the joint. Nonsuppurative Mastitis; Mastitis of the Newborn. — A pecuhar form of distention of the breast occurs in newborn infants of both sexes, from THE SOFT PARTS SURROUNDING THE CHEST 655 which a niilklikc Ihiid somcluncs exudes. It is doubtful, however, if this is a tru(> mastitis. Mastitis in the Male. — A nonsuppurative mastitis is sometimes ob- served in male \'ouths between the ages of twelve and sixteen years. Mastitis adolescentium seems to bear some relation to sexual devel- opment. Slight contusion may be an exciting cause. The affection appears as a painful, and perhaj^s tender, swelling of the gland; a colostnimlike fluid may sometimes Ix^ pressed out of the latter. The condition is analogous to menstrual irritation of the mammary gland in young females. Gynecomastia is an abnormal development of the mammary glands in the male. It is sometimes accompanied by atrophy of the testicles. Chronic mastitis or interstitial paradenitis is a diffuse proliferation and condensation of the connective tissue l)ctween the lactiferous ducts and the acini. The condition attacks women of forty and upward and seems to bear some relation to the menopause. It is usually bilateral. Care should be taken not to confound the disease with fibrous carcinoma or scirrhus, in the cases in which the disease is unilateral, and in wdiich marked cicatricial contraction (cirrhosis of the mamma) has occurred. Treatment. — Extirpation of the breast is the only safe remedy. In view of the tendency toward malignant disease any persistent induration which wdthin a few weeks does not show signs of retrogression under massage and inunctions of a 10 per cent ichthyol lanolin mixture should become the subject of at least exploratory incision and microscopic examination. To wait until the glands are involved is, in many instances, to doom the patient. Painting the breast with tincture of iodin and injections of iodin solutions have been recommended. Tuberculosis of the mamma is very rare. But a single case in which the diagnosis was established has been reported (P o i r i e r). Syphiloma of the breast is of doubtful occurrence. Suppurative Mastitis. — Suppurative inflammation of the mammary gland is almost exclusively confined to nursing women. It occurs, though rarely, in newborn children of both sexes, when it is not infrequently the result of violent efforts on the part of the nurse or the midwife to force milk from the breast of the infant. It may occur as a metastatic inflammation during the first few days following delivery, and under these circumstances it bears the same relation to injuries of the parts involved in the delivery as do puerperal metritis and parametritis resulting from septic infection. This is favored by increased functional activity. The inflammation develops most frequently during the third and fourth weeks following delivery, and under these circumstances it is usually due to infection from fissured or abraded nipples, or abrasions or eczematous condi- tions about the base of the nipple or areola. The infection occurs in the con- nective tissue surrounding the excretory ducts and the lobules of the gland. The lymphatic spaces surrounding the ducts are particularly liable to infection. The inflammation may radiate from the nipple to the outlying glandular struc- ture and an abscess form on the periphery of the gland. As soon as the sup- purative inflammation extends beyond the limits of the gland and invades the loose connective tissue separating the latter from the pectoralis major muscle, 656 THE SURGERY OF THE THORAX it assumes a phlegmonous character and retromammary phlegmon is added (paramastitis, P) i 1 1 r o t h). The symptoms of suppurative mastitis will var}- with the extent and viru- lence of the infection. A small focus of infection situated in the gland itself may give rise to but a slight elevation of temperature, while a retromammary phlegmon may give rise to the most serious disturbances. In the latter variety the absorption of the septic products of inflammation is favored by the pressure of the overlying swollen gland. In extensive suppurative inflammation con- fined to the breast itself, the marked development of lymphatic vessels during lactation favors absorjDtion of inflammatory products. The axillary, and more rarely the subclavian glands are affected, though these rarely suppurate. Prognosis. — The usual tendency of suppurative mastitis is toward recovery, though suppurative fistulous tracts may persist for a long time. These may communicate with the lactiferous ducts and both milk and pus discharge from the orifices (lacteal fistula). The principal obstacle to healing is defective drainage, particularly in cases of retromammary phlegmon. Under these circumstances new abscesses form constantly, until the entire gland and retro- mammary tissues are infiltrated and riddled with discharging fistulas. Treatment. — The preventive treatment consists in cleansing the nipple with an antiseptic solution after each time of nursing. Already existing fis- sures and abrasions are to be touched with either sulfate of zinc or nitrate of sih-er. At the commencement of the inflammation the breast should be covered with compresses wrung out of a 2.5 per cent solution of carboHc acid, covered with oiled silk and cotton batting, and the breast bandaged in suspension (Fig. 209). Nursing should cease at once and the breast should be kept free from secretion by use of the breast-pump. As soon as suppuration occurs, free incision is indicated. Occasionally pointing occurs late and appears in the shape of a slightly softened and particu- larly tender spot in the swollen gland. Here a skin incision, followed by blunt boring with a director or dressing forceps, will finally reach the suppurating focus. Incisions should always be made in a direction radiating from the nipple, in order to avoid cutting across the lactiferous ducts. In case retromammary phlegmon has occurred the patient must be anes- thetized and the suppurating focus behind the gland sought for and incised from the peripher\^ of the gland, but not through its substance. Any openings already made in the breast may be utihzed in the search, but the incision which gives free access to the retromammary tissues must be made through the soft parts of the chest wall in a position to give the readiest access, the influence of position in its relation to free drainage being also borne in mind. Extensive streptococcal infection vrith multiple small foci of suppuration scattered throughout the breast, these finally coalescing to form abscess cavi- ties of various sizes, is sometimes observed. There is marked constitutional disturbance present, and often great prostration. Ablation of the entire organ is usually necessar}', in these cases, in order to arrest the systemic infection. Sometimes more or less comparatively healthy skin can be saved to hasten the heahng process. In cases of multiple mammary fistulas in which, through neglect early in the case, multiple foci of suppuration have formed and the function of the gland is practically destroyed by cicatricial contraction and obliteration of the lactif- THE SOFT PARTS SURROUXDIXG THE CHEST 657 croiis ducts and acini, and in wliich the fear of supervention of fibrous carci- noma (scirrhus) may be reasonably entertaincMl, extirpation of the mamma is to be resorted to. The treatment of lacteal fistulas consists in frecjuent cauterizations with nitrate of siher. They may persist because of the presence of pus and infected granulations. Tiiorough curetting is to be employed in these cases. Neuralgia of the breast (mastodynia) probably depends upon nerve pressure in the course of chi-onic interstitial mastitis. It is sometimes difficult to differentiate between neuralgia of the breast and intercostal neuralgia. In severe cases, when the usual general measures of treatment of neuralgia have failed, amputation ma}' be resorted to. NONMALIGNANT TUMORS OF THE MAMMARY GLAND Congenital supernumerary mammary glands (polymazia) are analogous to the lacteal glands of mammals. In some cases two or more distinct nipples and areolae appear on a single gland. Supernumerarv' glands have been observed in the axilla and on the outside of the thigh (R o b e r t). This abnormality has been observed in the male sex (Sanderson). Giantlike growth of the mammary gland occurs at the period of adoles- cence. Both mammae are usually involved. The size and weight of the breasts may be enormous. Internal and external use of iodin are recommended. Extirpation may be resorted to in extreme cases. Adenomas. — These constitute a common form of tumor of the breast. The}- occur principally in young W'Omen of from sixteen to twenty years of age. They are situated away from the nipple and most freciuently near the lower edge of the pect oralis major muscle. These tumors rarely exceed an egg in size, averaging the size of a hazelnut. They are of a consistency harder than that of the breast ; transitory- forms doubtless exist between adenoma and fibroma (Billroth). Adenomas increase in size temporarily at menstruation. They are of slow growth and are situated at varying depths from the surface. The treatment consists of extirpation. The benign character of the growth, when assured by microscopic examination, gives immunity from recurrence. On the other hand, the possibihties of carcinomatous and sarcomatous develop- ment from adenoma and adenofibroma of the breast are such as to justify the remoA'al of the tumor in every instance. Fibromas and lipomas of the mamma are rare. The variety of the latter wliich makes its appearance behind the breast (retromammary Hpomas) should be mentioned. Fibroma may develop from adenoma or independently; lipomas, as well as pure fibromas. are seen most frequently in the male breast. Enchondromas with partial ossification have been reported (Cooper). Atheromas are occasionally seen at the areola and nipple. Cysts of the Mamma. — Cystic dilatation of the lacteal ducts, with milky contents, is called galactocele. True cysts, multiple or single, with firm walls (fibrocystoma), or in conjunction with malignant disease (cystocarcinoma) are observed. Simple cysts with clear contents are not uncommon. Some- times the contents are of the consistency of butter (butter cysts). Deposit of calcareous and other salts in the cysts following thickening of the contents of the latter constitutes the so-called mammary or lacteal calculi. The treat- ment of benign cvsts is puncture and subsequent injection of tincture of iodin, 43 658 THE SURGERY OF THE THORAX If they persist, they should be removed. Echinococcus cysts have been observed. Malignant Papillary Dermatitis (Paget's Disease of the Nipple).— This consists of an abnormal development of the interpapillary processes, with frecfuent ol^literation of the papillae. It affects almost exclusively the nii)ple and surrounding areola of women in the cancerous age, and is usually followed, in the course of two or three years, by carcinoma of the breast. Its existence may extend over a period of from ten to twenty years. Etiology. — The disease is probably cancerous from the outset, though its malignanc}' is claimed by some to be a secondary phenomenon resulting from constant irritation and infection. Symptoms. — The aj^pearances are those of a moist eczema. The nipple and areola present a raw, granular surface, from which a clear viscid fluid exudes. The edges of the affected area are well defined; in old cases there is considerable infiltration. Tingling and burning are present. The disease may be mistaken for ordinary eczema of the nipple. The latter, however, is usually bilateral and lacks the sharply defined border of P a g e t ' s disease as well as its excessive rawness. Finally, carcinomatous nodules, appearing first in the lactiferous ducts, and retraction of the nipple, occur in P a g e t ' s disease. Treatment. — As soon as the diagnosis is assured, the entire breast is to be removed. While the disease may last for a long time wdthout manifest deteri- oration of the health, it will sooner or later prove fatal unless operative treat- ment is resorted to. MALIGNANT TUMORS OF THE BREAST These are far more frequent than benign (82 out of 100, Bill- roth). Sarcomas. — These are of rare occurrence compared with carcinomas of the breast. The presence of cystic spaces in these growths has given rise to the term "adenosarcoma." Both the round-celled and the spindle-celled variety may occur. HyaUne cartilage and even bone may be present. The round- celled variety grows rapidly, particularly in nursing women. The spindle- celled variety grows more slowly. The disease develops between the twentieth and the thirtieth year. A moderately hard and painless tumor is present. Secondar}^ lymphatic glandular involvement occurs late, if at all. When the growth breaks clown it may simulate a myxoma. The actual occurrence of the latter as a primary form of the disease is probably extremely rare, though a myxosarcoma characterized by the presence of striated muscle elements is described (Billroth). Melanosarcoma is the rarest of all mammary tumors. So-called " cystic sarcoma" is that form in which various sized cystic spaces develop, these originating probably from the lactiferous ducts and acini in the immediate neighborhood of the growth. Sometimes a peculiar leaf-like proliferation is present in one of the cysts (phylloid cystic sarcoma). Carcinoma of the Mamma. — The favorite starting-point of cancer of the breast is in the acini; exceptionally it occurs in the ducts. Acinous carcinoma is the most frequent as well as the most dangerous variety of mammary cancer. It may attack any portion of the glandular structure, but it affects the base of the nipple by preference, w^here it induces THE SOFT PARTS SURROUXDIXG THE CHEST 659 early retraction. In other portions of the gland, a.s involvement of the skin takes place, retraction of the latter follows. The growth is devoid of a capsule on section and indefinitely infiltrates the entire gland. A roughened, leathery sensation is imparted as the growth is incised after removal, and the cut .surfaces present the appearance of an unripe pear. Sections under the microscope present the usual appearances of alveolar spaces filled with epithelium, representing the columns of cells characteristic of carcinoma. The columns are arranged in the lobules of the gland and are embcddeil in tlense fibrous tissue. Isolated collections of cells may be identi- fied well beyond the apparent limits of the tumor. The proportion of fil^rous tissue will varv greatly, and on the amount of this tissue present will depend the solidity of the growth. In the variety commonly called " scirrhus " the fibrous tis.-;ue is proportionately abundant (fibrous carcinoma); the growth proceeds slowly and contraction of the gland takes place, the breast being markedly lessened in size. Car- cinoma sometimes arises in a supernumerary' mammar}' gland in the axilla. The age for the appearance of acinous carcinoma of the breast is between the fortieth and the fiftieth year, but cases of patients between thirty and forty are not uncommon. It is rare before thirty and after seventy. About one per cent of the cases occur in the male. Blows, overlactation, and preexisting mastitis, particu- larly where suppuration has oc- curred, may be considered as taking part in the etiology. Rarely both breasts are concur- rently attacked. The tumor appears insidious^ and is of slow growth, except dur- ing lactation, when it grows very rapidly. It is painless at first and rarely as.sumes large dimensions; one larger than the fist is uncommon. Infiltration occurs early, particularly in cases in which the fibrous tissue is less abundant. The pectoral fascia and pectoral muscle become invaded, the channels of infec- tion being the lymphatic vessels which pass transversely through the latter (H e i d e n h a i n) . Lymphatic glandular infection occurs early; this and the lessening in size of the breast, when taken in conjunction with the presence of a tumor, consti- tute the most valuable diagnostic signs of carcinoma of the breast. The glands at the free border of the pectoralis major are first affected, those in the axiUa follow, and finally those above the cla^-icle become involved. The skin becomes invaded, causing dimpling or puckering; in some cases it becomes involved in the shape of smaU nodules which appear like duck-shot or split peas in the substance of the skin (lenticular skin involvement, see Fig. Fig. 3S2. — SciRRHrs Carcixoma ix the Male Breast. Four years' duration. Inoperable. Death in five months with lung involvement. (Patient of Dr. Walter C. Wood.) 660 THE SURGERY OF THE THORAX 383). Ulceration is preceded b}' a brownish or a bluish appearance of the skin. The destructive process may proceed rapidly and deeply in some cases (Fig. 383). In others the growth proceeds more slowly and the tumor projects above the surface in the shape of a fungating mass. Pain is not usually a prominent feature until the later stages of the disease are reached, and some patients are free from it altogether. Dissemination takes place, as a rule, following the lymphatic glandular Fig. 38.3. — Advanced Carcinoma of the Breast. Showing the ulcerated and excavated mammary gland, carcinomatous infiltration of the chest wall and of the deep cervical glands of both sides, lenticular recurrences in the skin, and extreme edema of the lower part of the arm, forearm, and hand from pressure of enlarged glands on the vessels in the axilla. infection. The secondary deposits take place in the viscera, especially in the lungs and liver, but they may take place in any organ. Hydroperitoneum follows secondary deposits in the liver, pneumonia and pleurisy those in the lungs and pleura, mental disturbances and coma those in the brain, and para- plegia, preceded by intense suffering, those in the vertebral column. Deposits in the bones are sometimes followed by spontaneous fracture, even in patients who are bed-ridden (fracture by muscular action). Extensive dissemination in the chest wall produces extreme induration in the skin, due to the invasion THE SOFT PARTS SUUUOUXDIXG THE CHEST 661 of the lymphatics of this structure; the latter becomes coarse in appearance and hard and unyielding (cancer en cuirasse). Progressive emaciation may be a marked and early feature ; yet in a certam proportion of the cases this is not present until the disease is ^vell advanced. It is quite common for the patients to be up and about until vcyx late in the disease. - , i Lymphatic edema is an occasional complication of cancer ot the breast. It is due to the pressure of infected and infiltrated lymphatic glands and secon- dary nodules on the main lymphatic channels in the apex of the axilla, or close to the chest wall in Mohrenheim's fossa. It usually involves the entire upper extremity, commencing, as a rule, in the neighborhood of the shoulder and even involving the scapular region. The connecti\e tissue is infiltrated with Ivmph and the skin is firm, bra^^•ny. and unyielding. The movements of the joints are interfered with and the limb becomes a burden to the patient (Fig. 383). This condition is usually present as a late complication in the natiiral historv of the disease, or it may occur in late operative cases irrespective of whether the axillary glands have been removed or not. It may simulate the dissemination in the 'skin kno^^-n as "cancer en cuirasse." The dropsical condition of the arm which sometimes follows the complete operation for can- cer of the breast and which is due to cicatricial interference with return circu- lation should not be mistaken for hTuphatic edema. In the former the skin will pit on pressure, while in the latter the skin, instead of pitting, will be firm and unyielding. In some instances, however, the condition present is due to a combination of the two causes. ^Yhen pain is present, it is due to pressure on the nerve-tmnks bv the enlarged glands, or to secondary growths. Carcinoma of the ducts occurs just before, at, or after the menopause. The growths arise in the dilated ducts or " mvolution cysts" so frequently pres- ent in connection with atrophy of the glandular structure due to the climac- teric period. The dilated ducts or cysts are occasionally the seats of new growths such as papillomas and carcinomas. Dilated terminal ducts, and particularlv the ampullae or lacteal sinuses, are the favorite locaUties from which these sro^^i;hs spring. The tumor usually occurs singly, is of slow growth, varies'^in size from an English walnut to a goose-egg. and when situated near the skin presents some discoloration suggestive of melanosarcoma. The grovrth lacks the hard fibrous feel of the acinous variety. An abundant dis- charge of dark thin fluid from the nipple is usually present. The lymphatic glands are rarely infected, dissemination scarcely ever occurs, and recurrence following the removal of the entire breast is uncommon. The prognosis of carcinoma of the breast is always unfavorable if the disease is allowed to pursue its natural. course. The average duration of life AAithout operation is twentv-two months (combined statistics of Wini- warter. Fischer, and" E s m a r c h) . Death takes place from ulcera- tion, sepsis, hemorrhage, and exhaustion. In addition to the breast and sub- pectoral and axillary lymphatic glands, the retromammary- fascia and fat, which connect by numerous lymphatic channels ^"ith the breast, the sheath and substance of the pectoralis major muscle, the intercostal muscles, perios- teum, ribs, pleura, and lung become afi^ected. Numerous nodules also appear in the skin of the thoracic wall, both laterally and po.^teriorly. Finally, secondary deposits occur in the brain, vertebral colunm. the bones, etc. 662 THE SURGERY OF THE THORAX Scirrhus of the breast in males has been noted in 7 out of 252 cases of the disease (Billroth). The other varieties of malignant disease are also rare here. The treatment of malignant tumors of the mamma consists in total removal of the diseased breast and of all neighboring lymphatic and other sus- piciously affected structures. The condition of pregnancy is not to be con- sidered a contraindication to operation. The existence of lymphatic involve- ment may not be demonstrable until after the parts are exposed by turning back a flap of skin. It is not enough simply to enucleate the individual glands; the entire fatty and connective tissue, the lymphatic glandular contents of the axillary cavity, the loose connective tissue between the latissimus dorsi and the Fig. 384. — The Radical Operation for Carcinoma or the Breast. The lines of incision for amputation of the breast for carcinoma. 1,1, Elliptic incision surrounding the breast; 2, a.xillary incision; 3, incision made in formation of flap for closing the gap left after re- moval of the breast (Warren) ; 4, incision for removal of supraclavicular glands. (The final disposition of flaps A and B is shown in Fig. 389.) pectoralis major muscle, the glands and connective tissue lying beneath the latter muscle and passing from it to the mamma, and, finally, except in the very beginning of the disease, the pectoralis major muscle, and if necessary the pectoralis minor as well, must be completely extirpated. These structures should all be removed in one piece, in order to prevent the wound from becoming infected by the division of tissue invaded by the disease or by lymphatic vessels containing cancer cells, as well as to effect complete removal of all cancerous tissue (H a 1 s t e d) . The Radical Operation for Malignant Disease of the Breast (Will y Meyer; Halsted; Warren). — This operation aims at complete removal of the gland, the immediately underlying muscular parts, and the THE SOFT TARTS SURROUNDING THE CHEST 663 glandular and fatty contents of the axilla. The incisions will necessarily vary with the location of the tumor. In the majority of cases the following method, developed by Willy M c y e r , may be followed : The patient's arm is held by an assistant either at riglit angles with the body, or alongside the head. The first incision commences at the humeral attachment of the pector- alis major, and is carried by a gentle sweep around the outer border of the breast and finally around the lower border. The second incision commences at the middle of the anterior axillary fold and is carried around the upper and inner margin of the organ, meeting the first incision at its terminal point. A flap is now marked out on the outer side of the pectoral region by dividing the skin above the middle of the first incision and carrsdng the cut at right angles to the latter, then curving it until it becomes parallel to the level of the lower Fig. 385. — The Radical Operation for Carcinoma of the Breast. Dissection of the integument with "undercutting " in an oblique direction. margin of the wound and finally terminates at a point a little below it (J. Collins Warren, Fig. 384). This flap is to be afterward utilized in closing the gap. In case of lymphatic involvement in the cervical region an additional incision is made, which is commenced at the middle of the second incision and carried across the clavicle and along the posterior border of the sternomastoid. The surrounding skin is to be dissected freely in all directions, including the axilla, so as to remove as much of the surrounding fat as possible with the breast. WTiere the incisions lie adjacent to the latter, the method of "undercutting" in an oblique direction facilitates this step of the operation. The dissection should expose the cephalic vein and the clavicle; the fat overlying the pectoralis major muscle, as well as that covering in the 664 THE SURGERY OF THE THORAX axilla back to the latissimiis dorsi and nmning doAMi on tho lateral chest wall, should be allowed to remain and come awa}- with the breast, jjlandular struc- tures, and fat in the final removal. The lower border of the pectoralis major is now identified, and the course of the cephalic vein as it lies between the pectoral muscle and the deltoid determined. The forefinger of the left hand of the operator is now introduced from below so as to isolate the humeral insertion of the pectoralis major, and the latter divided close to the bone by stout blunt scissors. If a portion of the attachment is allowed to remain, it is likely to slough. The muscle is now further loosened until its clavicular attachments are reached. An assistant now holds the muscle and breast toward the median line while the operator identi- fies the pectoralis minor muscle and raises it on his fingers and divides it (Fig. Fig. 386. — The Radical Operation for Carcinoma of the Breast. Exposure and division of the humeral attachment of the pectoralis major muscle. 386). The triangular shaped space lying behind the latter muscle and bounded internally and posteriorly by the chest wall (M o h r e n h e i m) is thus exposed. In this space are to be found the vessels and nerves of this region and the glandular structures most frec|uently infected. The thin layer of fascia overlying the vessels is now divided. The vein is to be first identified and the utmo.st pains taken not to injure this, as the glandular structures, as well as the fatty and loose connective tissues, are carefully and systematically dissected (not torn) away. The arterj' will always announce its presence by its pulsation, and the nerv^e cords of the brachial plexus, from their larger size and hard feel, are more or less constantly in evidence. But the vein is easily ob- literated by slight pressure in the course of the manipulation and hence may be inadvertently injured. THI-: SOFT I'AHTS surrouxdint; the chest 665 The entire glandular and fatty contents of the axilla and Mohrenheini's fossa are dissected loose except where they join the breast and pectoralis major muscle. In this dissection the latissimus dorsi muscle is exposed before the fat layer is finally cut throufjh. The remaining; attachments of the pectoralis major (clavicular, sternal, and costal) are now di\'idpd in succession, the entire mass turned in an outward and downward direction, and the removal elTected by completino; the section on the outer niaro;in of the breast through the re- maining attached fat layer. The vertical incision may be utilized in the search for infected glands in the clavicular region and extend up on the neck in clear- ing out any suspicious growths in the supraclavicular region. In patients whose condition will not permit a greatly prolonged operation Fig. 387. — The Radical Operation for Carcinoma of the Breast. The muscles divided and the mass retracted, exposing the a.xilla and giving ready access to Mohrenheim's fossa. it is better to accept the remote risks of a subseciuent recurrence from cancerous infection occurring during the operation than to court the immediate dangers of fatal operative shock. Under these circumstances the operation may be considerably shortened by first removing the breast and then the pectoralis major muscle. The pectoralis minor is then divided (vide supra) so as to give ready access to Mohrenheim's fossa and enable the operator safely to clear this and the axillary region of suspicious appearing tissues in a comparatively short space of time.* The divided pectoralis minor muscle may be sutured ^^'ith * Theoretically the dissection of the breast from tlie muscle is objectionable from the fact that the presumably infected lymph-channels lying behind the breast are opened up This is no more true, however, than in the case of the removal of the axillary gland.s and those lying on the edge of the great pectoral muscles, when these are indubitably infected. 666 THE SURGERY OF THE THORAX catgut. It always unites and resumes its function. The latter, however, is not of great importance, and the muscle may be removed as a routine procedure along with the pectoralis major. Where a still more conservative course is indicated, and in exceptionally early cases, simple removal of the breast and extirpation of the axillary glands may suffice. In this class of cases the elliptic incision with extension of the same to the axilla may be employed (Fig. 390). In closing the wound the axillary flap is first forced well up in position by a pad of sterilized gauze in the axilla, so as to elevate the fornix of the latter as much as possible and obliterate the "dead space" which otherwise would exist, the arm being brought down to the side at the same time. In aseptic cases no Fig. 388. — The Radical Operation for Carcinoma or the Breast. Exposure and division of the pectoralis minor muscle. drainage is recpired. The thoracic wound is closed as completely as possible. If a gap remains, this may be filled with Thiersch transplantation strips immediately, or when granulation is well under way. Where Warren's flap is employed excellent approximation can usually be obtained. It should be placed in position and sutured with as little tension as possible, in order to avoid endangering its vitality (Fig. 389). Failure to observe this precaution not infrequently leads to gangrene. In Halsted's original method the steps of the operation are mainly in the reverse order from those just detailed. These include the following: (1) The reflection of a triangular shaped skin flap (Fig. 391) . The fat layer at the site of this flap is dissected back to the lower margin of the pectoralis major muscle. (2) The pectoralis major muscle is severed first at its costal and then at its clavic- THE SOFT TARTS SrURorXDlXO THE CHEST 667 \ilar insertions, and finally at its luim(>ral attaclnnent. (3) The whole mass thus far loosonc^l is strii->pe(i from the thorax and from the peetoralis minor muscle. Fig. 3S9. — The Radical Operatiox for Carcixoma of the Breast. Mode of closing the wound when Warren's flap is employed. FlQ. 390. — Elliptic Incision for Simple Removal of the Breast and Extirpation of the Axillary Glands. (4) The pectoralis minor muscle is cleared and divided across near its middle, and the tissues near its coracoid insertion, together with the loose connective tissue lying under the muscle itself, are dissected away. (5) The subcla\dan 668 THE SURGERY OF THE THORAX vein is exposed at its highest point, and the contents of the axilla, including the loose tissue above the vessels and about the brachial plexus of nerves, carefully dissected (not pulled) away. After the vessels and nerves are cleared the lateral wall of the thorax is stripped, and finally the posterior wall of the axilla. The Fig. 391. — Halsted's Radical Operation for Carcinoma of the Breast. Showing the hnes of incision and the reflection of the flap. Fig. 392. — Halsted's Radical Operation for Carcinoma of the Breast. The mass turned back. mass is now held only at the posterior line of incision (Fig. 392). This is severed by a few strokes of the knife. In closing the wound it is important to apply the triangular shaped flap closely to- the fornix of the axilla by a mass of gauze crowded well up in the axillary space. This obliterates the dead space and lessens the amount of THK SOFT PARTS SURROUXDIXC THE CHEST 669 cicatricial tissue I'ornunl, thcrehy ix-ducin"!; to a iniiiinmm the sii])sequcnt dis- ability of the arm. When the subcla\iau artery and vein ])ass tln-ough the glandular growths and are intimately attached thereto, they have been extirpated with the latter between two ligatures. This condition is rarely encountered, however, for the reason that it is present only in those advanced cases in which operation should not be undertaken. In cases otlierwise favorable for oj^eration the lymphatic and fatty structures in the axilla can usually be dissected from the blood-\-essels and nerves. Glandular in^•olvement in the supraclavicular region renders the prognosis unfavorable. Whatever method of operation is adopted the skin incisions must be made wide of the diseased area and so placed as to afford ready access to the entire mammary region, and b}' extension to the axillary, infraclavicular, and sub- pectoral regions as well. In making the deeper dissections the blood-supply should be taken into account and the vessels which supply the gland divided and clamped early, in order to avoid constant repetition of this portion of the technic. Bleeding points are to be secured at once ; if the clamp forceps become so numerous as to be in the way, the vessels are to be ligated with catgut before completion of the operation. Hot towels applied for a few seconds will arrest the parenchymatous oozing. Complete hemostasis must be assured before the wound is closed. Strictly aseptic conditions obviate the necessity for drainage-tubes. Copious gauze dressings are to be applied, covered by sterilized cotton, and held in place by a snugly fitting chest binder with hollow places cut under the arms. The arm is wrapped in sterilized cotton and bandaged. For the first few days the arm is placed over the chest and there secured by a few turns of a broad roller bandage. If all goes well, the dressings are not disturbed for a week, at the end of which time the sutures are removed. The prognosis after operation will vary with the stage of the disease at which interference is undertaken. Death resulting from the operation itself is rare in ordinary uncomplicated cases. Before the introduction of aseptic methods the mortality was 25 per cent. Healing takes place in about fourteen days. Recurrence of the disease is to be expected in late cases within the first three months. The immunity from regional recurrence, or the appearance of the disease in remote parts of the body will be in direct proportion to the advances made by the disease at the time of the operation, and the complete- ness of the latter. Prompt recurrence may follow an incomplete operation, even when undertaken in the very earliest stages, while a complete operation may afford comparative or complete immunity when the disease is well ad- vanced. In a recurrence the lymphatic glands are usually involved in advance of the cicatrix. Next in frequency the skin is attacked in the shape of scattered lenticular indurations. These should be promptly removed. Keloid develop- ment in the cicatrix, or at the site of suture punctures, is to be looked on with suspicion. If a year elapses without recurrence, the prognosis is thereafter favorable. The movements of the arm are generally more or less interfered ^nth at first, particularly that of abduction. If this interference is due to shortening of the cicatrix at the site of the incision which crosses the front of the axilla, a plastic operation may be indicated. Usuall}-, however, this part of the incision can be 670 THE SURGERY OF THE THORAX Clinked sufficiently in an upward direction to avoid this sequel. Early and per- sistent passive and active movements will usually lead to restoration of function in time. All tendencies toward recurrence should be promptly met b}' further operations, though the prognosis is graver under these circumstances. The average duration of life after operation, in cases in which recurrence takes place, is thirty-four months, a distinct gain of at least a year over cases which are permitted to pursue their natural course. These figures are taken from the combined statistics of Winiwarter, Fischer, and E s m a r c h . They w^ere compiled by these authors before the introduction of the more radical procedures now employed. While it is true that slightly greater risks are taken with the latter, more benefit in the way of greater immunity from recurrence is derived in cases that recover. In cases of inoperable carcinoma of the breast the treatment consists of efforts to restrict the septic processes by antiseptic applications, and possibly of the removal of broken-dowTi portions by the sharp spoon. Opium, adminis- FiG. 393. — Line of Incision for the Removal of Nonmalignant Tumor of the Inferior Quadrant OF THE Breast. tered both internally and locally (acjueous extract of opium, 1 part, simple ointment, 20 parts), is to be used to allay pain. The application of styptics may be necessary to arrest hemorrhage. Nonmalignant growths may be isolated and removed as elsewhere, need- less sacrifice of mammary tissue and mutilation being avoided. In cases of fibromas which, as a rule, are situated on the outlying portion of the breast, the skin incision should be made in the sulcus between the lower margin of the breast and the skin of the chest wall, the parts lifted, and the tumor removed from that direction (Fig. 393). The precise location of this incision will neces- sarily vary with the location of the tumor. THE BONY CHEST WALLS Fractures of the Ribs. — Fractures of the ribs are very rarely seen in children, owing to the great elasticity of the chest walls. Later in life the boii}^ THE BOXY CHEST WALLS 671 portions of the ribs become more brittle, and the costal cartilages also lose their elasticity by partial ossification. The false ribs are much less liable to fracture tlian the true ribs, owing to their cartilaginous connections, until late in life, when the latter undergo calcification and give way upon the application of greater force. The repair of fractures involving the cartilages takes place as follows: The perichondrium furnishes a ring of Ijone which surrounds in a ferulelike manner the ends of the fragments. The fractured surfaces do not unite. According to G u r 1 t , fractures of the ribs represent 17 per cent of all the fractures in the body. The form of fracture varies with the \Tilnerating force. Splintered fractures result from direct force, such as that inflicted by small mis- siles, while transverse fractures follow indirect force, such as forced compression of the chest in an anteroposterior direction, when several ribs may be broken simultaneously; these usuall}^ give way in the axillar\' line. The eleventh and twelfth ribs are rarely broken, on account of their loose connections, and the first rib escapes because of its short arch and broad transverse section. The remain- ing ribs (second to eighth) suffer the most frequently. The ribs on one side give way only with the lateral application of the force. When this is appHed in an anteroposterior direction so as to force the sternum toward the spinal column the ribs on both sides of the chest may A'ield. The fragments may be displaced inward, rarely outward. Usually, however, owing to the elasticity of the chest wall, the fragments resume their normal position. Incomplete fracture is rather commonly observed, the inner lamella being the portion bent, wliile the external lamella is broken. This may occur in 3"oung and middle-aged persons from elasticity of the chest walls, and in the aged from senile atrophj-. Dislocations of the costal cartilages sometimes occur after the application of comparatively shght force, on account of the arrangement of the articulations of these with the ribs, this amounting in many instances to a simple cleft sur- rounded by a strijD of synovial membrane. Complications. — Compound fractures are rare. In gunshot fractures, where these are penetrating or perforating, the skin injury- as well as the fracture is unimportant compared with the damage done to the pleura, lung, etc. Severe contusions, or even lacerations of the lung substance may occur in the young, without fracture of the rib, the rupture of smaU capillaries giAlng rise to hem- orrhage in the alveoli and small bronchi. According to K 6 n i g , this injury is more likely to occur if the glottis is closed when the force is applied to the chest waU. In laceration of the lung by fragments of a broken rib these are forced through both layers of the pleura. Here hemorrhage may occur into the cavit}' of the pleura (hemothorax) and into the alveoli and smaller bronchial tubes as well. It is removed from the latter situation by coughing. Its presence in the pleural cavity will be announced by a progressively ascending line of dullness. During expiration air is forced from the alveoli and broncliial tubes into the pleural cavity (pneumothorax) ; a highly tympanitic percussion note is present above the area of dullness. As the canity of the pleura is filled with air and blood, the lung is compressed and the hemorrhage is arrested. Air that has passed along the pulmonary tract is not so likely to be followed by suppuration of the contents of the pleural cavity as that which enters through a wound in the chest waU. In the former instance the air is more or less freed 672 THE SURGERY OF THE THORAX from irritating matters in its passage. The bloocl in the pleural cavity is gen- erally absorbed readily; the wound in the lung heals usually by first intention, precisely as an aseptic wound of the external skin does when its edges are held in close apposition. If the dyspnea becomes urgent, the contents of the pleural cavity may be removed by means of the aspirator. This should be delayed sufficiently long to permit perfect hemostasis at the site of the wound of the lung. The intercostal arteries may be injured in cases of fracture of the rib, l^ut the hemorrhage from this source is not, as a rule, serious. The long thoracic arter\- may be injured by a fracture of the rib and may require ligation. The internal mammary is more liable to be injured by stab wounds. Emphysema of the connective tissue occasionally occurs when fracture of a rib and injury of the lung occur simultaneously, the pleural cavity being first filled with air, which subsequently finds its way into the loose connective tissue around the ribs, finally reaching the subcutaneous connective tissue. The accumulation in the pleural cavity, by compressing the lung, usually arrests quite promptly the escajDc of air, except in cases in which this is prevented by adhesions between the costal and the pulmonar}' surface of the pleura. Unless arrested the emphysema may reach the neck and head, and finally invade the entire subcutaneous connective tissue of the body and the connective tissue of the lungs and mediastinal space, death taking place from mechanic obstruc- tion of the circulation and dyspnea. Diagnosis. — Displacement of fragments is comparatively rare. Localized pain is a constant symptom. Cough and bloody expectoration may occur in contusion of the lung with or without fracture of the ribs. Palpation may disclose crepitation, but this sign is more frequently obtained by auscultation. Tenderness at the injured point may be elicited by pressure on the sternum. Deep inspiration usually increases the pain, though this is not always the case. When the pleura is injured, pleuritic friction sounds may be heard on ausculta- tion. This may occur in only partial fracture, the inner surface of the rib giving way, while the outer surface remains intact. Treatment. — Simple fracture of the ribs is to be treated by opiates to relieve the pain, and by strapping the corresponding half of the chest by means of adhesive plaster. Marked outward displacement of the fragments is to be corrected by pressure from without. Permanent inward displacement is rare; it may be corrected by passing a sharp hook behind the fragments and making traction. If suppurative changes take place in the contents of the pleural cavity (pyothorax, or traumatic empyema), free incision, with, perhaps, resection of a rib to facilitate draining, should be performed. Compression of the chest wall by means of an elastic bandage is useful in cases of slight emphysema. Punctures and incisions are admissible only when a slight area of emphysema exists. Caries of the Ribs. — A number of affections w^ere formerly included under this name. At the present time these are classified as (1) granular myelitis of tuberculous origin; (2) traumatic suppurative periostitis occurring in connection with compound fractures (gunshot injuries, etc.); (3) suppurative periostitis from phlegmonous inflammation of the soft parts of the chest wall; (4) syphilitic disease of the ribs; (5) typhoid infection of the ribs. Granular Myelitis. — Contrary to the usual rule governing this affection, THE BOXY CHEST "WALLS 673 tuberculous inflammation of the l)onc in this region is less frequently observed in children than in adults. It nia}' appear even in advanced age. A cold abscess gradually develops, sometimes behind the mamma; the resulting fluc- tuating tumor may resemble cystic sarcoma of that organ. In other cases it passes in the direction of the pleura (subcostal abscess) and may be mistaken for empyema. It may invade the pleural cavity, in which case there may be caries of the rib, complicated with .suppurative pleuritis. The favorite seat of this affection is the lateral aspect of the chest wall, though the posterior and anterior portions may ])e attacked. The middle ribs are most frecjuently afi"ected. Granular perichondritis of the costal cartilages leading to extensive destruction is sometimes observed. It occurs more fre- Cjuently in children than in adults. Suppurative periostitis may follow infection of wounds of the ribs and soft parts, and may result as well from phlegmonous inflammation of nontraumatic origin. The probe may .detect bare bone when fistulous openings exist. The inflammation is usually only superficial and rapidly disappears after free incision, scraping of the rib with the sharp spoon, and antiseptic treatment. Syphilitic disease of the ribs is sometimes observed. A gununa develops first. This softens and breaks down. It is difficult, in man}^ cases, to differen- tiate at this stage between this condition and true caries. The history- of the case must be taken into account, and other manifestations of syphilis sought for. Antisyphilitic measures may here be employed for both diagnostic and therapeutic purposes. Typhoid infection of the ribs has been observed. The resulting lesion may assume the characters of osteitis and periosteitis, or osteomyehtis. Treatment of Caries of the Ribs. — Prompt resection of the affected bone is indicated, not only with the hope of preventing general tuberculous infection, but in order to avoid the development of suppurative pleuritis. Granular perichondritis is best treated by exposing the affected area and gouging away the diseased cartilage. Healing by organization of a blood-clot under a dressing of oiled silk or iiibber tissue (S c h e d e) should be obtained, if possible. Heal- ing by granulation is ver^,^ tedious and frequently fails altogether, the diseased condition constantly extending, in spite of every effort. Abscess of the chest walls originating in perforation of a sup= purating cavity of the lung is sometimes obserA-ed. It is most fre- cpently situated on the upper portion of the anterior surface of the thorax, usually at the first or second intercostal space. Adhesions generally occur before perforation takes place; the fistulous opening leads directly into the lung cavit}'. As the latter usually conmnunicates with a bronchial tube, air may escape with the pus. Billroth has described a peculiar suppurative process developing between the costal pleura and the bony chest wall (suppurative peripleuritis). Its origin is imknoA^m and it is verA' likely to be confounded with empyema. Neuralgia of the intercostal nerves belongs to the domain of general medicine. X u s s b a u m , however, once cured an intractable case of this kind by nerve stretching. Tumors of the Ribs and Thoracic Region. — The costal cartilages are almost absolutely exempt from neoplasms. Chondroma of the Ribs. — Tliis is of frequent occurrence in otheiT\'ise 44 674 THE SURGERY OF THE THORAX healthy persons. It is observed between the twentieth and the fortieth year. It springs from the bony and not from the cartilaginous portions of the ribs, is of slow growth and painless. Early successive invasion of more than one rib is the rule. The direction of the growth is generally outward and rarely toward the pleural surface. In larger growths the pressure on the skin and friction of the clothing may lead to ulceration, and death may result from breaking down of the tumor and consequent septicemia. Myxomatous de- generation may also occur and even transition to sarcoma take place (C . H u e t e r) . Secondary nodules are liable to occur in the lungs or other internal organs, these having an embolic origin. In view of these unfavorable tendencies in advanced chondroma the treat- ment should consist in early extirpation. Owing to the absence of pain as a s^miptom, surgical aid is not sought, as a rule, until the growth has attained a large size. In early operations the growth can be removed without opening the pleural cavity. Late interference, when undertaken at all, necessitates most desperate operative attempts. Sarcoma. ^ — This attacks the ribs much more rarely than chondroma. Angiosarcoma is the usual variety. It may occur late in life, in w^hich case operation is scarcely "justifiable. When the heads or necks of the ribs are attacked, the disease may invade the intervertebral foramina and compress the cord. Carcinoma. — This is found only as a seeondar}^ growth in cases of carci- noma of the manmia. THE STERNUM Fracture. — Splintered fractures may occur in gunshot injuries or from other projectiles. Transverse fracture may follow the application of great force, the fragments becoming considerably displaced. In this class of injuries the manubrium is held securely in position by its attachments to the first rib, while the body of the sternum is displaced. This separation of the body of the sternum from the manubrium has been called a dislocation; this name, how- ever, is incorrectly applied. The injury partakes of the character of a dias- tasis. The same may be said of separation of the ensiform appendix. Frac- ture of the sternum may occur in connection with dislocation of the upper dorsal vertebrae. The treatment consists in elevating the depressed portion by manipulation with the fingers. This failing, it may be lifted into position by means of a strong hook. Serious functional results are not common even if the displace- ment is not corrected. Dangerous traumatic suppuration following ginishot wounds may occur behind the sternum and invade the anterior mediastinum (anterior medias- tinitis). The suppurative process may extend to the pleura and pericar- dium. The treatment of anterior mediastinitis, both when it results from the cause just mentioned and when it arises from suppurative processes originating in the lateral cervical region and extending beneath the sternothyroid muscles into the anterior mediastinal space, is trephining the sternum. The opera- tion, however, is not performed with a trephine but with a chisel. Syphilitic caries of the sternum is relatively frequent. Tuberculous caries is not rare and occurs by preference at the manubrium and upper THE BONY CHEST WALLS 675 portion of the body of the sternum. Thorough division of all fistulous tracts, scraping slwhx all diseased tissue with the sharp spoon, trimming away the infected lining of the sinuses, and thorough antisepsis, will prevent septic conditions in the anterior mediastinum and may result in cure. Typic re- section of the diseased portion of the sternum has been successfully performed in recent times, owing to the advantages of asepsis and antisepsis. In syphil- itic cases antisyphilitic treatment should supplement the operative procedure. Sarcoma of the sternum is observed. It develops as true sarcoma of the bone or originates in the connective tissue of the anterior mediastinal space. A large soft tumor is formed, which gradually destroys the sternum and finally invades the skin. Destruction of the upper portion of the sternum also attends the development of aneurism of the ascending portion of the arch of the aorta. Chondroma of the sternum is comparatively rare. Resection of the entire sterniim has been successfully performed for osteoid chondroma (Konig). The justifiability of operative interference in sarcoma of the sternum must rest on the possiliilities of removal of the entire disease. Congenital fissure of the sternum is mentioned as a curiosity. The physiologic action of the heart can usually be studied through the skin which fills in the hiatus. EFFUSIONS INTO THE PLEURAL CAVITY AND THEIR SURGICAL TREATMENT Effusions into the pleural cavity may result from the lodgment of foreign bodies, from injury to the pleural membrane by a fractured rib, from the pre- sence of malignant growths, from circulatory disturbances (hydro thorax), and from simple pleuritis. Hydrothorax is a simple noninfiammatory water}- effusion into the pleural cavity and is due to circulatory disturbances following diseases of the heart and kidney, and to changes in the blood itself. The accumulation usually takes place in both sides of the chest and may threaten life by suffocation. It may be removed by aspiration. In simple pleuritis with effusion, if two-thirds or more of the cavity of the pleura is occupied by the serous exudation, the pressure of the accumulated fluid will be such as to prevent the absorbent vessels from disposing of the fluid. Here a portion or all of the fluid may be withdrawm by simple aspiration. Septic and tuberculous inflammation of the pleura may follow similar affections of the pulmonary tissues. Empyema. — A suppurative pleuritis is knowm as empyema. Staphylo- cocci and streptococci are usually found in the pus. Ordinar}- catarrhal bron- chitis may furnish the microorganisms which, through involvement of some of the alveoli, may lead to infection of the pleura and consecjuent suppurative pleuritis. A serous effusion from idiopathic (primary) pleuritis may become infected by the pneuococcums of a coincident pneumonia. Or, bacterial infec- tion maj^ occur in a carelessly performed exploratory' puncture, and empyema result. Gangrene of the pleura has been observed in connection with general pyemia. Two or more separate ca'sities may be present at the same time (encysted pleuritic effusion and encysted empyema). The fluid in one ca\aty may remain serous and be absorbed, while that in the other mav become infected and 676 THE SURGERY OF THE THORAX undergo suppuration. These cavities may be separated from each other by adhesions between the visceral and the costal reflections of the pleura. The gonococcus of N e i s s e r may diffuse itself and give rise to inflam- matory conditions in the pleural cavity, as well as in other serous cavities (M a z z a). It is probable that the Bacterium coli commune, the migrating character of which has been established beyond doubt (W y s s , T a v e 1), is occasionally the infecting agent. The occurrence of a perforating gastric ulcer in the upper and posterior stomach wall may give rise to subphrenic abscess, the pus making its way along the muscular planes of the diaphragm, finally emptying into the pleural cavity and there exciting a septic pleuritis. The prognosis in simple pleuritis with effusion is always favorable. Aseptic aspiration, even if only a portion of the fluid is removed, is always followed by recovery. In septic pleuritis recovery usually follows appropriate surgical treatment. In cases in which the effusion is of tuberculous or can- cerous origin, and in pyemic gangrene of the pleura, the prognosis is most grave. Delay in operative interference in septic and suppurative pleuritis may lead to mpture into a bronchus and evacuation of the cavity by coughing. Cure occasionally takes place in this manner. This method of evacuation is fraught with danger, however, since the discharge may be so profuse as literally to drown the patient in his own pus. The persistence of a seropurulent fluid in the pleural cavity is known as chronic empyema. There is progressive thickening of the pleura due to the deposition of successive layers of fibrin, compression of the lung until the latter occupies but an extremely small portion of the corresponding half of the thoracic cavity, and the formation of dense adhesions which imprison the lung and prevent its expansion. The Surgical Treatment of Pleuritic Effusions. — If, after a reason- able trial of salines and hydragog cathartics, a simple serous effusion is not removed, operative measures must be resorted to. When the effusion is puru- lent from the commencement, the employment of such measures is but a waste of time; the longer the operative interference is postponed, the greater the difficulties encountered, owdng to the thickening of the pleura and the forma- tion of adhesions in securing expansion of the lung after evacuation of the fluid. Simple Puncture and Aspiration. — This is indicated as follows: (1) In cases of rapid accumulation in which great dyspnea arises from compression of the lung, before compensatory expansion of the other lung can take place. (2) In cases of slow accumulation in which absorption is prevented by pressure, -two-thirds or more of the corresponding half of the thoracic cavity being -occupied by the fluid. If the serous effusion is due to the presence of tubercu- lous disease, the improvement will be only temporary. (4) In doubtful cases ior purposes of exploration. AVhen the effusion is large, the pleural cavity can be punctured at different places. In encysted or encapsulated effusions, the fluid developing between different layers of adhesions, or where the cavity of the pleura is divided into several compartments by adhesions between the interior of the chest wall and the pulmonary pleura at different points, repeated punctures may be necessary THE BONY CHEST WALLS 677 before locating the fluid. The latter may also occupy several separate spaces (multiple encapsulation). In ordinary cases the puncture is usually made in the lateral thoracic region on the axillary line, and in either the fifth, the sixth, or the seventh intercostal space. A puncture on a line with the angle of the scapula is safe on either side. A slight incision in the skin may be made if the operator so fancies. If this is done, cocain anesthesia should be employed. Usually, in large effusions, the intercostal spaces are prominent and the puncture is easily made. The point of the left index-finger is pressed firmly in the intercostal space to steady the trocar and prevent it from gliding off on the surface of the rib as the patient makes a quick respiratory movement at the contact of the instrument. The latter should hug the upper edge of a rib to avoid the intercostal artery. When, from any reason, it becomes necessary to puncture in the lower intercostal spaces, the point of the trocar must be directed obliquely upward to avoid injury to the diaphragm, and to the liver on the right and the spleen on the left side. During the operation of tapping, the fluid should be permitted to escape only slowly, in order to avoid circulatory disturbances in the heart and large vessels, the formation of coagula on the walls of the latter, and the loosening and subsequent passage of these into the pulmonary arteries. These pre- cautions are doubly necessary in left-sided effusions, the heart being displaced to the right (dextrocardia). Hence, these disturbances are more likely to occur if the heart is suddenly permitted to resume its normal position. The flow should be interrupted from time to time by compressing the tube or by placing the finger over the open end of the cannula. When the aspirating trocar is used, air is effectually prevented from enter- ing and the flow is continuous, the lung expanding to replace the evacuated fluid. WTiether the tapping is performed with an ordinary trocar or with an aspirating apparatus the lumen of the instrument may become obstructed by flbrinous material and require clearing by means of a blunt probe or a wire. In pleuritic effusions complicating well-marked tuberculous disease of the lungs aspiration should be delayed until demanded by purulent changes in the fluid, as shown by exploratory puncture, considerable displacement of the heart, and marked increase in the ch^spnea. Incision (Thoracotomy). — This is indicated (1) in cases in which there are constantly recurring effusions that are nontuberculous and nonmalignant ; (2) in cases of primary septic or suppurative pleuritis and in cases of septic infection of previously existing serous effusion. It may also be resorted to in cases in which repeated tapping has failed. It is rarely employed at the present day except in children. The operation is made in the localities indicated for tap- ping. The skin incision is made over an interspace and the muscular tissues and serous membrane divided in turn. The fluid must not be permitted to flow away too rapidly. Where the effusion is large and recent, it is better to remove a portion of the fluid first by slow tapping, or aspiration. In effusions of long standing, as well as in "empyema of necessity," w^here the pus from a pj'-othorax has found its way beneath the thoracic muscles, this precaution is not necessary. The incision is made about three inches in length in a longitudinal direction in the midaxillary line at the upper border of the sixth or seventh rib. Incision is usually supplemented by tube drainage. Irrigation of the chest cavity should not be employed. In recent cases of empyema in young children recov- 678 THE SURGERY OF THE THORAX ery has sometimes been quite raj3id under this treatment. When the hmg is collapsed from compression, as well as from cicatricial contraction, the cure is tedious, from failure of obliteration of the suppurating cavity. In young subjects the obliteration sometimes takes place at the expense of the chest wall, the latter collapsing from above downward, and lateral curvature of the spinal column (scoliosis) results. As a further effect of this collapse of the chest Fig. 394. — Position for Operations ox the Chest Walls and on the Pleura, Lungs, etc. wall the intercostal spaces are narrowed and the elastic drainage tube is com- pressed. Metal tubes are unsatisfactory, and the best result under these circumstances is obtained by resection of a portion of one or more ribs. Resection of a Portion of Rib. — This is usually the procedure of choice in adults and is frequently necessary in children. Where considerable dyspnea is present, and the voluntary muscles of respiration are brought into play to assist in breathing, a general anesthetic should be avoided and the operation per- FlG. 39.5. COSTOTOME. formed under local anesthesia (cocain). Some surgeons advise that aspiration be employed the day previous to the operation, to permit the use of a general anesthetic. The patient should be placed supine, or nearly so, in order to permit free expansion of the sound lung (Fig. 394). The incision should expose the sixth rib in the midaxillary line so as to permit the removal of an inch or more of the rib. The latter is divided by the costotome (Fig. 395) in two thp: bony chest walls 679 places about one inch apart, and the intervening piece grasped by the bone forceps and finally freed and removed. By proceeding in this manner the investing periosteum is removed with the section of rib, and the narrowing of the opening by the rapid formation of bone prevented. The intercostal artery will require ligation at each side of the incision. Thoracoplasty. — Plastic operations on the chest wall are employed as secondary procedures in cases of empyema in which the collapsed lung is pre- vented from expanding by the presence of dense adhesions and thickened pleura; and in cases in which partial expansion takes place, the rigid chest wall failing to collapse sufficiently to effect its proper approximation to the lung. It is indicated as a primary operation in old cases of empyema in which the above conditions are revealed at the outset by the resection of a portion of rib. Estlander's operation consists of the removal of portions of the second, third, fourth, fifth, sixth, and seventh ribs. These may be reached through three transverse incisions, two ribs being removed through each incision. Or, a vertical incision or a U-shaped flap maj^ be used. In order to prevent repro- duction of the ribs, which would defeat the object of the operation, namely, the permanent collapse of the chest wall, the periosteum must be removed with the ribs. Irrigation of the cavity is usually safe in cases in which this operation is indicated. The incisions are closed ^^■ith silkworm-gut and cavities are drained by a large tube. Small cavities may be packed with antiseptic gauze. Schede's operation is designed to accomplish the same object as E s t - lander's, but in a more radical manner. By means of this procedure, not only the ribs with the periosteum are removed, but the thickened parietal pleura and intercostal muscles as well. The operation is to be reserved for that class of cases in which the pleura is greatly thickened, and in which the removal of portions of the ribs alone will not suffice to secure collapse of the chest wall to fill the space formerly occupied by the fluid. The operation is performed as follows: The bony chest wall is bared by reflecting a modified U-shaped flap in an upward direction. The incision marking out this flap commences in front at the outer edge of the pectoral muscle, on a level with the fourth rib, passes downward to curv^e at the level of the tenth rib, is carried thence to the midaxillari' line, from which point it again curves and passes to the posterior scapular line, thence continuing upward along a line midway between the vertebral border of the scapula and the spinous processes to the level of the second rib (Fig. 396). The arm is elevated so as to reach the tubercles of the upper ribs that are to be removed. The incision is carried down to the ribs throughout its entire length, the soft parts turned upward, the scapula displaced and the ribs successively divided, first along the costochondral articulations and then at the tubercles, and this portion of the chest wall removed in one mass, including the pleura and intercostal muscles. The flap is then replaced with its raw surface resting against the visceral layer of the pleura and sutured with silkworm-gut. Drainage is provided for by one or more drainage-tubes. Pleurotomy with detachment of the visceral layer of the diseased pleura (pulmonary decortication. D e 1 o r m e , 1S94) is employed for the purpose of releasing the lung from its environment of thickened and adherent pulmonary pleura. An incision is made through the visceral pleura and the opening thus made extended by merely separating the investment 680 THE SURGERY OF THE THORAX of the lung or by both separating and cutting away the pleura. Good results have been obtained by this procedure, even in cases in -which the lung failed to expand at first. Fig. 396. — Lines of I^.cision' fob Schede's Opeeation of Thoracoplasty. Fig. 397. The Author's Lines of 1s( i traumatic infiam- uuition of, 474 Facultative parasites, IS Fasciae, diseases of, 120 inflammation of, 120 injuries of, 120 Fauces, 566 ^ foreign bodies in, 570 Feces, examination, 276 in intestinal carcinoma, 276 tul)erculosis, 276 ulcerations, 276 macroscopic examination, 276 microscopic examination , 276 Female genitals, care of, before operation, 49 Ferment, fibrin, 47 Ferripvrin in hemorrhage, 343" Fetal adenoma of thyroid gland, 611 Fibrin ferment, 47 Fibroadenoma, 231 Fibroc3'stoma of breast, 657 Fibroma, 220 of bone, operation for, 370 of breast, 657 of cheek, 477 of esophagus, 621 of jaw, 532 of nasopharynx, 574 of scalp, 434 of tendons, removal, 360 of tongue, 555 pediculated, of larynx and trachea, 606 Fibromyoma of tongue, 548, 555 Fifth nerve, neurectomy of second and third divi- sions, with avulsion of Gasserian ganglion, 541 Figure-of-S bandage. 392 anterior, of chest, 412 of elbow, 416 of foot and ankle, 425 of hand and wrist, 418 palmar appHca- tion, 418 of head, neck and axilla, 409 of knee, 424 of leg, 427 of neck and axilla, 411 posterior, of chest, 414 Finger, spiral bandage of, 419 reversed, 419 Firearm projectiles, 3X6 Fissure of cheek, angular, 491 congenital, 491 liorizontal, 491 v(M-ticai, 491 of Kolando, localization, 407 ('hiciie's device, 467 of soft palate, 559 congenital, 559 of sternum, congenital, 675 Fistula, 12, 140 auricular, 238 branchial, 237, 629, 639 congenital cervical, 237 of facial region, 492 of neck, 629 esophageal, 623 esophageotracheal, 619 lacteal, 656 median cervical, 236 of breast, 656 of lower lip, 493 of neck, 629 of Stenson's duct, 587 tracheal, 629 tuberculous, 207 Fitch's dome trocar and cannula, 319 Fixation Isandages, perma- nent, 394 FlaiHike joints, 375 Flannel bandage, 392 Flap amputation, 378 granulating, transplanta- tion of, 330 Floating kidney, urine in, 270 Fluctuation in diagnosis of inflammation, 34 Fluhrer's crochet drill, 313 Fluids, aspirated, examina- tion of, 277 FoUicular odontomas, 219 compound, 219 tonsillitis, 566 Food, withholding, in pre- paring for anesthesia, 290 Foot and ankle, figure-of-8 bandage, 425 combinations of spiral, re- A-ersed spiral, spica, and figure-of-8 bandage, 426 recurrent bandage, 425 reversed spiral bandage, 425 serpentine bandage, 426 spica bandage, 425 spiral bandage, 424 Forceps, alligator, 620 intracannular, 602 anatomic, 310 bullet, with spoon-shaped jaws, 387 cross-cutting, 534 Forceps, cutting, 314 division of bone by, 364 esophageal, 620 hemostatic, varieties, 340 Keen's gouge, 318 lion-jaw, 373, 539 liiston's bone-cutting, 314 ring-shaped pile, 310 rongeur, 314 sequestrum, 369 tenaculum, 309 thumb, 309 Tiemann's bullet, 387 Forehead and neck ban- dage, 406 and nose bandage, 406 and upper Hp bandage, 406 bandage of, 405 Foreign bodies, 383 effects, 383 in air-passages, treat- ment, 596 in bronchus, 595 in chest, 653 in esophagus, 619 in external auditory canal, 579 in fauces, 570 in frontal sinuses, 518 in larynx, 595 in meatus, removal, 580 in nose, 499 in parotid duct, 588 in pharynx, 570 in soft palate, 558 in submaxillary duct, 588 in trachea, 595 migration, 383 palpation in diagnos- ing, 384 probes in diagnosing, 384 removal, 385 Rontgen ray in diag- nosing, 384 tracheotomy for, 604 Forest moss, 63 FormatiA-e cells of March- and, 5 Four-tailed bandage, 401 for jaw, 401 Fowler's Hnes of incision for resecting ribs in pleurec- tomy, 681 Fractional sterihzation, 20 Fracture, 124 after-treatment, 135 ambulatory treatment, 136 character of force, 124 classification, 124 comminuted, 125 comphcated, 126 704 INDEX Fracture, compound, 126 delayed union, treatment, 367 direction of line of, 125 dislocation combined with, 148 division of bones by, 361 from direct violence, 123 functional disturbances after, treatment, 136 green-stick, 125 impacted, 127 implantation of ivory pegs, 368 incomplete, 125 mechanism of displace- ment, 127 noncommunicat ing wounds of skin in, 126 of alveolar processes, 519 of base of skull, 436 of cer\ical A'ertebrae, 641 laminectomy in, 642 resection of spine in, 642 of cranial bones, 434 of hyoid bone, 594 of lower jaw, 520 interdental splint in, 521 Matas's splint in, 523 Robert's method of treating, 523 of nasal bones, 495 of odontoid process, 641, 645 of ribs, 670 of skull, 434 cerebral complications, 438 Cheyne-Stokes respira- tion in, 440 compound, 443 compression of brain in, 439 contusion of brain in, 442 hemorrhages from sin- uses of dura mater in, 441 laceration of brain in, 442 pachymeningitis in, 443 trephining in, 447 indications for, 448 of sternum, 674 of thyroid cartilages, 594 of upper jaw, 519 operations on bones after, 366 overriding of fragments, 127 perforating, 126 Pott's, 149 relations of direct and in- direct force to, 124 resection of, 368 Fracture, rotating displace- ment, 127 seat, 124 simple, course of, 130 treatment, 133 spiral, 123 splintered, 125 subperiosteal, 125 ununited, operations for, 367 Frame saw, 311, 313, 361 Freezing microtome, 246 French's combined hemo- static forceps and re- tractor, 600 palate hook, 499 Frontal sinus, inflammation of , 515. See also Fron- tal sinusitis. sinuses, 514 carcinoma of, 519 cysts of, 518 foreign bodies in, 518 injuries of, 514 malignant growths of, 519 osteoma of, 518 polypi of, 518 sarcoma of, 519 tumors of, 518 sinusitis, 515 chronic, 516 turbinectomy in, 517 Fronto - occipital bandage, 404 Frost-bite, 74 inflammatory conditions after, 75 of auricle, 578 of first degree, 74, 75 of second degree, 74, 75 of third degree, 74, 76 Frozen sections, instructions for making, 245 Functional diagnosis, 263 disturbances after frac- tures, treatment, 136 Furuncle, 77 of external auditory mea- tus, 581 Fusiform aneurism, 95 G alt's trephine, 313 Galvanocautery loop, 315 Ganglia, central, lesions of, 469 GangUon, 163, 240 compound, 240 of tendons, removal, 360 simple, 240 Gangrene, 10 after venous stasis, 104, 105 drv, after venous stasis, 105 emboHc, 94, 106 Gangrene, hospital, 180 moist, after venous stasis, 105 of lung, 682 senile, 93, 106 Gangrene foudroyante, 181 Gangrenous erysipelas, 177 inflammation, 8, 10 suppurative, 10 pharyngitis, 573 Gaping of wounds, 66, 321 Gastric. See Stomach. Gastrotomy, temporary, in cicatricial esophageal stricture, 622 Gauntlet bandage, 421 Gauze, disinfection of, 53 dressings, method of ap- plying, 63 iodoform, 63 Peruvian balsam, 63 Gelatin, nutrient, method of making, 20 Genitals, female, care of, before operation, 49 Giant-cell, 13 Giantlike growth of breast, 657 Gibson's bandage, 407 Gigli wire saw, 312, 361, 362 Gingivitis, 527 Glanders, 78 bacillus of, 32 ulceration of, in nose, 503 Glioma of brain, 227 of spinal cord, 227 Glossitis, chronic, 547 Glottis, edema of, 598 Glucose, quantitative esti- mation of, 262 Glucosuria, 262 artificial, inducing, 264 bismuth test for, 262 Haines's test for, 262 Rudisch quantitative test, 262 Glycerin agar, 21 Goiter, 610 cystic, 611 embolic distribution, 612 enucleation of, 615 resection of, 616 excision of, 613 exophthalmic, 612 extirpation of, 613 fibrous, calcifying, 611 growth, 611 ossifying, 611 relation to cretinism, 612 resection of, 615 vascular, 611 Golding-Bird operation for single harelip, 488 Gonococcus of Neisser, 28 Gonorrhea, diplococcus of, 28 INDEX 705 Gonorrhoal arthritis, 15-1 Gowns, disint'oction of, 53 Graefe's coin catcher, 620 Gram's stain, 25 Granny knot, 340 Granulating fhip, transplan- tation of, 330 intianimation, 12 proliferative processes of nose, 509 synovitis, 151 wound, 3 Granulation tissue, 3 Granulations, profuse, 5S Granuloma, hemorrhaa;ic, 460 of auricle, 5S2 of tracheal wound, 603 tuberculous, 207 Graves's disease, 612 Green-sticlc fracture, 125 Groin, ascending single spica bandage of, 421 descending single spica bandage of, 422 triangle bandage of, 401 Groins, both, ascending spica bandage of, 423 descending spica ban- dage of, 424 Grooved director, 309 Gross pathology in diagno- sis and prognosis, 244 Gumma, 197 of skin, 82 of subcutaneous connec- tive tissue, 82 precocious, 198 svphilitic, of sternomas- ' toid, 630 tuberculous, 81 Gums, carcinoma of, 482 inflammation of, 527 lead poisoning of, 528 metastatic abscess of, 527 multiple pyemia of, 527 subperiosteal abscess of, 527 Gunshot injuries, 165 complications, 175 contour, 652 cross-hit, 167 definition, 165 deformation of projec- tile, 166 diagnosis, 173 general characteristics, 165 hemorrhage, 171 infection, 173 lodgment of missile, r72 multiplicity, 172 mushrooming, 166 of air-passages, 594 of blood-vessels, 85 of chest, 652 46 Gunshot injuries of chest, suppurati\'e inflam- mation after, 653 of esophagus, 617 of head, 4^50 prol>ing for bullet, 451 ' of joints, 147 of long bones, 137 of tongue, 546 pain, 171 plumbism, 176 powder burns, 172 prognosis, 174 removal of bullets, 175 seton, 652 shape and size of pro- jectile, 166 shock, 171 symptoms, 171 treatment, 175 wound of entrance, 166 of exit, 168 Gussenbauer's artificial larvnx. Park's modifica- tion, 609 Gynecomastia, 655 Habitual dislocation, 150 Hagedorn needle, 321 Haines's test for glucosuria, 262 Halsted's operation for car- cinoma of breast, 666 Hand and arm sling, 417 and wrist, figure-of-S ban- dage of, 418 palmar application, 418 Hanging, suicidal, 645 Harelip, 484 after-treatment, 490 choice of operation in, 488 double, disposition of in- termaxillary bones in operation for, 489 operation for, 489, 490 time for operation, 489 first degree, 485 functional disturbances in, 485 operative treatment, 486 anesthetic in, 486 general technic, 486 second degree, 485 single, Golding-Bird ope- ration for, 488 Malgaigne's operation fo^r, 487 methods of operation in, 487 Mirault - Langenbeck operation for, 487 N^laton's operation for, 487 Harelip, single, Simon's operation for, 488 third degree, 485 Head, actinomycosis of re- gion of, 211 bandages, 404 capeline l)andage, 405 gunshot wounds, 450 probing for bullet, 451 oblique liandage, 404 recurrent l)andage, 404 surgery, 429 Healing bv primary inten- tion, 2 by secondary intention, 2, 3 ' by third intention, 6 process, histology of, 4 with suppuration, 3 without suppuration, 2 Heart, 684 dilatation, acute, as cause of death after ope- rations, 286 in chloroform anes- thesia, 298 examination of, in pre- paring for anesthesia, 290 failure in chloroform nar- cosis, 298 wounds of, 684 Heat and nitric acid test for albumin in urine, 260 effects of, 73 of inflammation, 7 Hemarthrosis, 87, 146 puncture of capsule in, 370 Hematoma, 66, 87 of scalp, 429 Hematuria, 267 due to atrophic kidney, 272 Hemianopia in lesions of the base, 470 Hemocvtometer, Thoma- Zeiss", 249 Hemoglobin, estimation of, 249 Dare's instrument for, 249 scale, Tallqvist's, 249 Hemoglobinometer, Dare, 249 Hemophilia, hemorrhage in, 343 operations in, dangers, 284 Hemoptysis due to perforat- ing aneurism, sputum in, 274 Hemorrhage, 88 adrenalin in, 343 antipvrin in, 343 arrest of, 336 ro6 INDEX Hemorrliage, arrest of, by digital compression, 336 b}^ forced positions of joints, 337 by pressure by means of specially devised apparatus, 337 provisional measures, 336 spontaneous, 87 arterial and venous, dif- ferential diagnosis, 99 permanent arrest, 340 bv acupressure, "341 bv circumsuture, "341 bv forcipressure, "340 by invagination, 341 by ligature, 341 by suture, 341 by torsion, 341 avoidance of, in opera- tions, 282 capillary, 106 concealed, 88, 89 ferripyrin in, 343 from carotid artery, ar- rest of, 626 from sinuses of dura mater in fracture of skuU, 441 from subclavian artery, arrest of, 626 from wounds of chest, 652 graduated compress in, 342 in bleeders, 343 in hemophiliacs, 343 in operations, dangers, 284 intracranial, 456 extradural, 456 intracerebral, 457 intraventricular, 457 subarachnoid, 457 subdural, 457 of wound, 2 oil of turpentin in, 343 parenchymatous, arrest of, 342 primary, 88 recurring, 88 after operations, 284 secondary, 87, 88 spontaneous arrest, 87 styptics in, 343 subcutaneous, 88 suturing in, deep, 342 symptoms, 89 tampon in, chemise, 342 tamponade in, 342 treatment, general, 353 Hemorrliage, venous, 98 and arterial, differential diagnosis, 99 arrest of, 343 Hemorrhagic diapedesis, 9 fever, 89 granuloma, 460 Hemorrhoitl forceps, 310 Hemostasis in amputation, 380 in disarticulation, 380 prophylactic, 339 Hemostatic forceps, varie- ties, 340 Hemothorax, 624 Hepatic abscess, Ameba coli in, 278 Hernia bandage, 401 cerebri, 459 of lung, 684 Hernial aneurism, 96 Herpes labialis, 476 rhagades, 476 Heteroplastic operations, 328 Highmore, antrum of, epi- thelioma of, 530 hydrops of, 529 inflammation of, 528 malignant growths of, 530 sarcoma of, 530 Histology, pathologic, in diagnosis and prognosis, 245 Hodgkin's disease, 113 blood examination in, 259 Hordeolum, 475 Horns, cutaneous, 230 sebaceous, 230 Hospital gangrene, 180 sore throat, 573 steam-sterilizer, 53 Hot abscess, 11 Hot-air sterilizer, 25 Housemaid's knee, 241 Hueter's method of neurec- tomy and stretching of facial nerve, 545 Hunterian chancre, 82 Hunter's operation for aneu- rism, 346 Hutchinson teeth, 204 Hyahne thrombi, 106 Hydrarthrosis, 151 puncture of capsule in, 370 Hydrocele of neck, 228 congenital, 628 noncongenital, 630 Hydrocephalus, 473 internal, 470 Hydrochloric acid, free, presence of, in gas- tric contents, 275 total free, in gastric con- tents, test for, 276 Hydrocliloric acid, total, in gastric contents, test for, 276 Hydronephrosis, fluid ob- tained in, 278 urine in, 270 Hydrophobia, 190 inoculation test, 192 Pasteur's prophylactic in- oculation, 192 Hydrophobic tetanus, 188 Hydrops of antrum of High- more, 529 of thyrohyoid bursa, 630 tuberculous, 151 Hydrothorax, 675 Hygroma, congenital cystic, of neck, 629 Hyoid bone. 594 fractures of, 594 Hyperplasia, congenital, of hps, 477 ftukemic, of lymphatic glands, 113 syphilitic renal, simulat- ing malignant growth, urine in, 270 Hyperplastic inflammation, 8 in bone, 138 polypan arthritis, 155 synovitis, 151, 155 papillary, 155 Hypertrophic rhinitis, chronic, 502 tonsiintis, 566 tonsillotomy in, 567 Hypertrophy of Blandin- Nuhn gland, 557 of hTnphatic glands, pro- gressive multiple, 113 of thyroid gland, 611 Hypodermoclysis, 352 Hypoglossal nerve, injuries of, 625 Hysteric dysphagia, 622 Ice, local use, 63 Ice-coil, 64 Ichthyosis of tongue, 547 Iliac artery, external, liga- tion of, in elephantiasis arabum, 349 Impacted fracture, 127 treatment, 133 Imperative operations, 280 Implantation cysts, 236 Incised wounds, 1 of arteries, 86 of esophagus, 617 of tendons, 122 of venous trunks of neck, 627 Incision and drainage of joints, 371 in pleuritic effusions, 677 INDEX 707 Incomplete fracture, 125 Inculiator, laboratory, 23 Infarction, cuneiform, 106 eml)olic, 106 Infectious embolus, 106 emphysema, 182 osteomyelitis, acute, of cranial bones, 452 of jaw, 528 sinus thrombosis, 464 Inflammation, 1 adhesive, S after injuries of scalp, 431 cheesy, 13 diagnosis, 33 difterential count of leu- kocytes in, 253 diphtheritic, of larynx and trachea, 598 etiolog}^ 14 exploratory puncture in diagnosis of, 36 exudative, S fever in, 36 fluctuation in, 34 gangrenous, S, 10 granulating, 8, 12 heat in, 7 hyperplastic, 8 in bone, 138 in general, 8 in lateral cer\'ical region, 627 inspection in diagnosis of, 33 loss or impairment of function in, 38 mensuration in diagnosis of, 36 nontraumatic, of cranial bones, 452 of soft parts of facial region, 475 of antrum of Highmore, 528 of auricle, 581 of bone, operations in, 368 of covering of nose, 500 of external ear, 581 of fasciae, 120 of frontal sinus, 515. See also Frontal sinusitis. of gums, 527 of joints, 150. See also Arthritis. of lateral cer-\-ical articu- lations, 645 of hinph vessels, 108. See also Lymphangitis. of lymphatic glands, 109. See also Lymphadeni- tis. of medullary tissues, 139 of mucous membrane of nose, 502 of muscles, 121 Inflammation of nerves, 118. See also Neuritis. of pharynx, 572. See also Pharyngitis. of salivary gland, 589 of soft palate, 558 parts of chest, 653 of tendons, treatment, 123 pain in, 8, 38 palpation in diagnosis of, 33 periarticular, 158 phlegmonous, 11 subpectoral, 654 probe in, 36 productive, 8 prognosis, 38 purulent, 8 redness of, 7 regenerative, 8 septic, after operations, 285 serofibrinous, 8, 9 serohemorrhagic, 8, 9 serous, 8 suppurative, 8, 10 gangrenous, 10 in sheaths of tendons, 359 of chest, after gunshot wounds, 653 of cranial bones, 453 of skin, 67 of subcutaneous con- nective tissue, 67 swelling of, 7 symptoms, objective, 33 subjective, 37 termination, 38 traumatic, of soft parts of facial region, 474 treatment, 48 constitutional, 64 preventive, 48 tuberculous, of cranial bones, 452 Inflammatory affections of cervical vertebral col- umn, 645 conditions after burns and frost-bite, 75 edema, 9 of tongue, 546 necrosis of fasciae, 120 obstruction of larynx and trachea, 598 processes in bone, 138 tumor, .590 Infraction, 125 Infraorbital nerves, neurec- tomy of, 540 Infrathvroid tracheotomy, 600 Infusion, intravenous saline, 351 subcutaneous, 351 Inhaler, AUis's ether, 292 Clover's ether, 293 Daniels's modifica- tion, 303 Junker's chloroform, 296 Ormsljy's, 294 Initial lesion of svphihs, 82, 197 Injuries and diseases of separate tissues, 66 gunshot, 165. See also Gunshot injuries. Innervation, in.sensible, 45 Innominate artery, hgation of, 635 Insensible innervation, 45 Instrumentation of esoph- agus, 618 Instruments, disinfection of, 52 Insufflation, intralaryngeal, in dangerous anesthesia, 300 Intercostal arteries, injury of, in fracture of rib, 672 nerves, neuralgia of, 673 Interdental splint in frac- tures of lower jaw, 521 Intermuscular lipomas, 217 Interrupted suture, 321 Intestinal tuberculosis, feces in, 276 ulcerations, feces in, 276 Intestine, carcinoma of, feces in, 276 Intra - arterial thrombosis, 93 -Intracannular alligator for- ceps, 602 Intracuticular suture, 323 Intracvstic villous papil- lomas, 230 Intramuscular lipomas, 217 Intraneural injections of os- mic acid in facial neural- gia, 544 Intraspinal nerve stretch- ing, 638 Intrathoracic aneurism, 683 Intravenous saline infusion, 351 Intubation of larynx, 604 dangers, 606 precautions, 606 removal of tube, 605 Invagination, arterial, 341 Murphy's method, 341 Involucrum, 140 lodin method of sterilizing catgut, 55 Iodoform. 61 gauze, 63 poisoning, treatment, 61 lodophilia, 257 lodophilic reaction of leuko- cytes, 252 708 INDEX Irrigating curet, 318 Ivory pegs, implantation of, in pseudarthrosis follow- ing fracture, 36S Jacksonian epilepsy, 472 Jarvis's snare, 504 Jaundice, blood examina- tion in, 258 Jaw, 519 adenomas of, 532 benign tumors of, 531 carcinoma of, 533 caries of, necrotic, 528 chondromas of, 532 fibromas of, 532 four-tailed bandage of, 401 lower, acute infectious osteomyelitis of, 528 contracture of, 530. See also Tetanus. dislocation of, 525 habitual, 526 fractures of, 520 interdental splint in, 521 Matas's splint in, 523 Roberts's method of treating, 523 habitual dislocation of, 526 median section of, in cancer of tongue, 553 modified Barton's ban- dage for, 407 resection of, 534 entire, 537 half, 535 lumpy, 211 necrosis of, 528 phosphorus, 528 oblique bandage of, 407 odontomas of, 532 osteomas of, 532 osteomyelitis of, acute in- fectious, 528 periostitis of, suppurative, 527 sarcoma of, 532 tumors of, benign, 531 mahgnant, 532 upper, fractures of, 519 resection of, 537 Jeweler's drill, 365 Joint disease, Charcot's, 152 Joints, contracture of, 159. See also Contracture. contusions of, 146 diseases of, 146 drainage of, 371 erasion of, 372 flail-Uke, 375 gunshot wounds of, 147 incision and drainage of, 371 Joints, inflammation of, 150. See also Arthritis. injuries of, 146 movable bodies in, 162 treatment, 376 operations on, 370 after injury, 370 resection of, 371 after-treatment, 374 for tuberculous mye- Htis, 374 synovitis, 374 general technic, 373 immediate, 372 intermediate, 372 partial, 372 primary, 372 secondary, 372 subcapsular, 373 subperiosteal, 373 sarcoma of, treatment, 376 wounds of, 147 Jugular A'ein, external, in- juries of, 627 Junker's chloroform inhaler, 296 Jury mast, 647 Jute, 63 Keen's gouge forceps, 318 Kelene anesthesia, 306 Keloid, cicatricial, 68 Kettle, croup, 602 Kidney, actinomycosis of, urine in, 270 atrophic, hematuria due to, 272 calculus in, urine in, 271 cysts of, urine in, 270 examination of, in pre- paring for anesthesia, 290 floating, urine in, 270 hyperplasia, of syphilitic, simulating malignant growths, urine in, 270 malignant tumors of, urine in, 270 parenchyma of, pyelitis with hyperemia of, urine in, 269 pelvis of, acute catarrh of, urine in, 269 polycystic degeneration of, urine in, 270 subcutaneous traumatism of, urine in, 272 tuberculosis of, urine in, 271 Klebs-Loffler bacillus, 29 Knee, figure-of-8 bandage of, 424 housemaid's, 241 Kocher's curved incision for goiter, 613 Kocher's operation for can- cer of tongue, 554 for torticollis, 651 Koch's bouillon, method of making, 20 Konig's osteoplastic rhino- plasty, 513 rhinoplasty, 511 Kronlein's craniocerebral topographic hues, 463 Kyphosis, 646 Labium, dermoids of, 236 Laboratory aids in sur- gical diagnosis and prog- nosis, 243 incubator, 23 Laborde's method of trac- tion of tongue in danger- ous anesthesia, 300 Lacerated wounds, 1 of tongue, 546 Laceration of brain in frac- ture of skull, 442 Lacteal calculi, 657 fistula, 656 Lactic acid, presence of, in gastric contents, 275 Laminectomy in fracture of cervical vertebrae, 642 Langenbeck's cheiloplasty, 483 osteoplastic resection of nose, 507 Laryngeal nerve, recurrent, injuries of, 625 paralysis of, after thyroidectomy, 617 stenosis, 607 Laryngectomy, 608 mortality from, 610 partial, 609 Laryngitis, syphilitic, 599 tuberculous, 599 typhoid, 599 variolous, 599 Laryngofissure, 608 Laryngoscopy, 596 Laryngotomy, 599, 607 cricothyroid, 602 Laryngotracheotomy, 599, 600, 602 Larynx, 594 adenoma of, 606 angioma of, 606 artificial, Gussenbauer's, Park's modification, 609 carcinoma of, 606 diphtheritic inflammation of, 598 enchondroma of, 606 excision of, partial lateral, 609 extirpation of, 608 fibromas of, pediculated, 606 INDEX 709 I>ar\iix, I'orc'i.iin Ixidics in, infiainniatory obstruction of, 59S injuries of, subcutaneous, 594 intubation of, 604 (lanii'tTS, 606 precautions, 606 removal of tube, 605 myxoma of, 606 papilloma of, 606 sarcoma of, 606 stab wounds of, 595 stenosis of, 607 suicide wounds of, 595 tumors of, 606 Laudable pus, 3 Lavage of stomach, 618 Law, Colles', 204 Layer suture, 323 removable, 323, 324, 325 Lead poisoning of gums, 528 Leg, Barbadoes, 84 figure-of-8 bandage of, 427 Leontiasis, 84, 477 Lepra bacillus, 31 rubra, S3 Leprosy, 83 Leukemia, 113 acute lymphatic, blood examination in, 258 chronic lymphatic, blood examination in, 258 myelogenous, blood ex- amination in, 258 lymphatic, 632 Leukocytes, counting, 249 differential count, 251 in inflamination, 253 iodophilic reaction, 252 microscopic examination of stained specimens, 251 Leukocytosis, 253 Leukokeratosis, 547 Leukoplakia, 547 Ligation in continuity be- tween aneurism and heart, 346 for aneurism, 345 in neoplasms, 349 of artery, 344 indications, 344 methods and general technic, 349 of lingual artery, 557 of veins, 351 multiple, of veins, 351 of artery, 89 changes which blood undergoes, 90 which occur in ves- sel, 90 Ligation of artery, fate of ligature, 91 function of clot, 91 in continuity, 344 indications, 344 methods and general technic, 349 of common carotid artery, 632 of external carotid ar- tery, 634 of external iliac artery in elephantiasis arabum, 349 of femoral artery in ele- phantiasis arabum, 349 of innominate artery, 635 of internal carotid artery, 635 of subclavian artery, 636 of vertebral artery, 637 peripheral, in aneurism, 346 Ligature, elastic, 315 fate of, in ligation of ar- tery, 91 lateral, of veins, 343 material, 340 sterilization of, 53 Line of demarcation, 75 Lingual artery, ligation in continuity, 557 dermoids, 236 nerA'e, neurectomy of, 544 Lion-jaw forceps, 373, 539 Lipoma, 216 intermuscular, 217 intramuscular, 217 meningeal, 217 of breast, 657 of cheek, 477 of scalp, 434 of tongue, 555 periosteal, 217 subcutaneous, 216 submucous, 216 subserous, 216 subsynovial, 216 Lips, adenoma of, 477 atheroma of, 477 carcinoma of, 479 cheiloplasty in, 482 congenital hyperplasia of, 477 • malformations of, 484 ectropion of, stomatoplas- tic operations for, 493 fistula of, 493 mucous cysts of, 477 scrofulous edema of, 477 tumors of, 477 Liquid air anesthesia, 306 Liston's bone-cutting for- ceps, 314 Liver, adenomas of, 232 Lizar-Velpeau incision for simultaneous removal of both superior nuixillas, 539 Localization of brain areas, 466 Lockjaw, 530. See also Tetanus. Lordosis, 646 Liicke's neurectomy of superior maxillary nerve, 540 Ludwig's angina, 628 Lumbar puncture, 278 Lumen of vein, obliteration of, 103 Lumpy jaw, 211 Lungs, 681 abscess of, 681 sputum in, 274 cavities in, operations on, 682 echinococcus of, 683 empyema rupturing into, sputum in, 274 examination of, in pre- paring for anesthesia, 290 gangrene of, 682 hernia of, 684 neoplasm of, sputum in, 274 resection of, 683 sarcoma of, 683 Lupous ulceration of ton- sils, 566 Lupus exedens, 80 exfoliatus, 80 hypertrophicus, 80 of auricle, 581 of facial region, 476 of lobule of ear, 581 of nose, 501 of tongue, 548 vulgaris, 80 Luxation of malar bone, 520 Lymphadenitis, 109 of lateral cerAdcal region, 627 septic, of lateral cervical region, 628 syphiUtic, 113 tuberculous, 111 of lateral cer^dcal re- gion, 627 _ Lymphangiectasis, congeni- tal, of neck, 629 Lymphangiectatic cysts of cheek, 477 Lymphangioma, 228 cavernous, 228 congenital, of neck, 629 of tongue, 228, 548, 556 Lymphangitis, 108 reticular, 108 tubular, 108 Lymphatic adenopathy, sec- ondary, in syphilis, 195 cysts, 228 710 INDEX Lymphatic edema in carci- noma of breast, 661 glands, diseases of, 107 inflammation of, 109. See also Lymphade- nitis. injuries of, 107 leukemic hyperplasia of, 113 progressive multiple hypertrophy of, 113 tuberculous, of neck, extirpation of, 638 leukemia, 632_ acute, blood examina- tion in, 258 chronic, blood exami- nation in, 258 nevi, 228 vessels, diseases of, 107 inflammation of, 108. See also Lymphan- gitis. injuries of, 107 Lymphoma, malignant, 113 of nasopharynx, 574. See also Adenoids. of neck, 632 Lymphorrhagia, subcutan- eous, 107 Lymphosarcoma, 222 Lymphostasis, 109 Macewen's chisels, 317 needling in aneurism, 349 Mackenzie's esophagotome. Roe's modification, 623 Macroglossia, 491, 548 Macrostoma, 491 stomatoplastic operation for, 493 Macular syphilide, 197 Malar bone, luxation of, 520 Malgaigne's operation for single harelip, 487 Malignant disease, blood ex- amination in, 258 edema, 181 Mallet, bone, 363 Mamma. See Breast. Many-tailed bandage, 401 for abdomen, 402 Marasmus thrombosis, 102 Marchand's formative cells, 5 Massage, 64 a friction, 64 Mastitis adolescentium, 655 chronic, 655 in male, 655 nonsuppurative, 654 of newborn, 654 suppurative, 655 Mastodynia, 657 Mastoid chisels, 585 steatomas of, 586 Mastoid, trephining, 584 Mastoiditis, 583 Matas's operation for aneur- ism, 346 splint in fractures of lower jaw, 523 Maxilla. See Jaw. Maxillary nerve, superior, neurectomy of, 540 by temporary re- section of malar bone, 540 resection of, 540 McBurney's skin-stretching hooks, 332 Meatus, auditory, cartilag- inous, injuries of, 578 external, eczema of, 581 furuncle of, 581 removal of foreign bodies from, 580 suppuration of, 581, 582 Mediastinitis, anterior, 674 suppurative, 628 Medulla oblongata, tumors of, 470 Medullary tissues, inflam- mation of, 139 Melanosarcoma of breast, 658 Melanotic sarcoma, re- moval, 335 Meloplastic operation, 494 for cicatricial lockjaw, 494 Schimmelbusch's, 494 Meningeal lipomas, 217 Meningitis, traumatic, 457 Mensuration in diagnosis of inflamrpation , 36 Mercuric chlorid, 59 iodid, 60 Metacarpal saw, 361, 362 Metamorphosis, augmented, and surgical fever, re- lations, 43 cheesy, 13 Meyer's operation for car- cinoma of breast, 663 Microorganisms, occurrence and spread, 16 Microscopic examination of bacteria, 25 of stained specimens of leukocytes, 251 of urine, 263 Microsporon septicum, 15 Microstoma, 477 stomatoplastic operations for, 493 Microtome, freezing, 246 Migration of foreign bodies, 383 Mimic spasm, 545 Miner's elbow, 241 Mirault-Langenbeck opera- tion for single harehp, 487 Mirror, laryngoscopic, 596 Moist gangrene after venous stasis, 105 tubercles, 198 Moiterseur's pressure regu- lator, 24 Moles, 238 Molluscum fibrosum, 226 Monoplegia, 468 Monospasm, 468 Mosquito, Thatcher, 253, 266 Moss, forest, 63 peat, 63 Motor area of brain, lesions, 467 Mouth, care of, before ope- ration, 49 dermoid cysts of, 593 speculum, Brophy's, 559 Mouth-breathing, 504 Mouth-gag, rack-and-pinion, 564 Movable bodies in joints, 162 treatment, 376 Mucocele, 516 Mucous cysts of accessory thyroid glands, 611 of Hps, 477 membrane, sarcomas of, 224 of nose, inflammations of, 502 tumors of, 503 ulceration of, 503 tracheal, rupture of, 595 patches of acquired sy- philis, 197 Multiple hypertrophy of lymphatic glands, pro- gressive, 113 ligation of veins, 351 neuromas, 226 operations, 281 pyemia from suppurative periostitis of jaw, 527 Murphy's method of arter- ial invagination, 341 Muscle - fiber, involuntary, sarcomas of, 122 Muscles, callus of, 121 diseases of, 120 inflammation of, 121 injuries of, 121 of neck, sarcoma of, 630 tumors of, 630 operations on, 357 sternomastoid, rupture of, 624 syphilitic gummas of, 630 suture of, 357 voluntary, sarcomas of, 121 Mushrooming, 166 INDEX 711 Myelitis, acute suppurative, treatment, 369 granular, of ribs, 672 granulosa, 141 tuberculous, resection of joints for, 37-1 Myelogenous contractures, 159 leukemia, chronic, blood examination in, 258 Myeloma, 221 Myoma, 229 of neryes, remoyal, 356 Myosarcoma, 222 Myositis, 121 ossificans, 121 suppuratiye, 121 Myotomy, 360 M^'xedema, 616 Myxofibroma of nasopha- rynx, 575 M}^oma, 221 of breast, 658 of esophagus, 621 of larynx, 606 Nares, anterior, bandage for supporting tampons in, 410 Nasal bones, fractures of, 495 cayities, soft parts, 495 electric light speculum, 498 septum, deviations, 496 speculum, 498 Nasopharynx, 566 carcinoma of, 576 chondroma of, 576 fibroma of, 574 lymphoma of, 574. See also Adenoids. myxofibroma of, 575 operations for gaining ac- cess to, for removal of tumors, 577 sarcoma of, 576 tumors of, 574 Nausea and vomiting in anesthesia, 303 Nearthrosis, 375 Necessity, operations of, 280 Neck and axilla, figure-of-8 bandage of, 411 carcinoma of, operation in, 639 cicatrices of, deforming, 624 cvsts of, atheromatous,629 " blood, 629 deforming cicatrices of, 624 echinococci of, 630 fistula of, congenital, 629 glands of, carcinoma of, 631 Neck, glands of, removal, 638 sarcoma of, 632 hydrocele of, 228 congenital, 628 noncongenital, 630 hygroma of, congenital cystic, 629 lateral region, 624 abscess of, 627 aneurism of, 630 inflammations in, 627 lymphadenitis of, 627 paradenitis of, 628 septic lymphadenitis of, 628 spondylitis in, 646 tuberculous lymph- adenitis of, 627 lymphangiectasis of, con- genital, 629 lymphangioma of, con- genital, 629 lymphatic tumors of, 631 lymphomas of, 632 muscles of, sarcoma of, 630 tumors of, 630 operation wounds of, 624 sarcoma of, operation in, 639 skin of, tumors of, 630 surgery, 594 teratoma of, auricular, 629 tumors of, cystic, 628 hTTiphatic, 631 operations for, 638 venous trunks of, incised wounds of, 627 vessels of, injuries of, 626 tumors of, 630 Necrosis, 138 inflammatory, of fasciae, 120 of hard palate, 562 of jaw, 528 of tendon, 122 phosphorus, of jaw, 528 syphilitic, of cranial bones, 453 tuberculous, 138 Necrotic caries of jaw, 528 Needle, Hagedorn, 321 Needle-holder,Richter's, 322, 323 Needle-holders, 322 Needles, aneurism, 350 Needling in aneurism, 349 Neisser, gonococcus of, 28 Nelaton's operation for sin- gle harelip, 487 Neoplasms, ligation in con- tinuity in, 349 of lung, sputum in, 274 Nephralgia and allied con- ditions, urine in, 272 Nephritis, acute, influence in surgical prognosis, 268 chronic, influence in sur- gical prognosis, 268 post-anesthetic, urine in, •267 suppurative, urine in, 272 Nerve anastomosis in in- tractable facial paraly- sis, 626 crushing of divided cen- tral end, 356 dental, inferior, neurec- tomy of, 542 facial, neurectomy of, 545 paralysis of , intractable, nerve anastomosis in, 626 trismus associated with, 188 stretching of, 545 Hueter's method, 545 fifth, neurectomy of sec- ond and third divisions, with avulsion of Gas- serian ganglion, 541 hypoglossal, injuries of, 625 laryngeal, recurrent in- juries of, 625 paralysis of, after thy- roidectomy, 617 lingual, neurectomy of, 544 maxillary, superior, neu- rectomy of, 540 by means of temporary resection of malar bone, 540 resection of, 540 phrenic, injuries of, 625 pneumogastric, injuries of, 625 spinal accessory, injuries of, 625 neurectomy of, 638 stretching, intraspinal, 638 supraorbital, neurectomy of, 544 Nerves, breaking strain, 357 cervical, injuries of, 625 cicatricial union, 354 contusions of, 114 diseases of, 114 division of, 116 inflammation of, 118. See also Neuritis. infraorbital, neurectomy of, 540 injuries of, 114 anesthesia after, 117 intercostal, neuralgia of, 673 myomas of, removal, 356 of facial region, 540 operations on, 354 12 INDEX Nerves, pressure on, during sleep, 116 strangulation of, 355 stretching of, 357 suture of, 354 primary, 118 secondary, 118,354 transplantation of, 355 tumors of, extirpation, 356 Neuralgia, facial, intraneu- ral injections of osmic acid in, 544 of breast, 657 of intercostal nerves, 673 Neurectomy, 355 Abbe's intracranial, 541 and stretching of facial nerve, 545 Hueter's method, 545 of inferior dental nerve, 542 intrabuccal meth- ods, 543 method by tempor- ary resection of lower jaw, 543 method by tempo- rary resection of malar bone, 543 method without bony resection, 544 methods without chiseling bone, 543 of infraorbital nerves, 540 of lingual nerve, 544 of second and third divi- sions of fifth nerve with aA^ulsion of Gasserian ganglion, 541 of spinal accessory nerve, 638 of superior maxillary nerve, 540 by means of tem- porary resection of malar bone, 540 of supraorbital nerve, 544 Neuritis, 118 acute, 119, 120 ascending, 119, 356 chronic, 119 spreading, 119 traumatic, 119 Neurofibroma, 220 removal, 356 Neurofibromatosis, 226 Neurogenous contracture, 159 Neurolipoma, 217 Neuroma, 226 multiple, 226 plexiform, 226 Neuroplastic operations, 354 Neurotomy, 355 Nevi, capillary, of tongue, 555 cavernous, 227 lymphatic, 228 of facial region, 477 pigmentosi, removal, 333 simple, 227 venous, of tongue, 556 Newborn, mastitis of, 654 syphilitic rhinitis in, 503 Nicolaier, bacillus of, 29 Nipple, chancre of, 204 Paget's disease of, 658 Nirvanin anesthesia, 306 Nitric-magnesium test for albumin in urine, 261 Nitrogen, injection of, into pleural sac, 683 Nitrous oxid anesthesia, 289, 302 Noma, 475 Nose, abscess of, subperi- chondrial, 590 bony defects, Dawbarn's operation for, 512 coA'ering of, inflammation of, 500 tumors of, 500, 502 destruction of, 502 enchondroma of, 506 erysipelas of, 500 foreign bodies in, 499 granulating proliferative processes, 509 lupus of, 501 mucous membrane, in- flammations of, 502 tumors of, 503 ulceration of, 503 osteoma of, 505 osteoplastic resection, 506. See also Osteoplastic re- section of nose. papilloma of, 504 polypi of, 503 cocain anesthesia in re- moval, 505 saddle, operation for, 510 soft parts, 495 svphilitic affections of, 508 ulceration of, 502 tuberculous affections of, 509 ulceration of, 509 ulceration of glanders in, 503 Nutrient gelatin, method of making, 20 Oblique bandage, 390 of head, 404 of jaw, 407 Obstructive embolus, 106 Occipital lobe, lesions of, 469 Occipitofacial bandage, 406 Odontoid process, disloca- tions of, 645 fracture of, 641, 645 Odontoma, 219 compound, 220 follicular, 219 epithehal, 219 fibrous, 219 folHcular, 219 of jaw, 532 radicular, 219 treatment, 220 O'Dwyer's intubation in- struments, 605 method of intubation of larynx, 604 Oil, carljolized, 62 of turpentin in hemor- rhage, 343 Ointment, boric acid, 62 zinc oxid, 63 Ointments, antiseptic, 62 Oliguria, 260 Ollier's method of skin- grafting, 332 operation of osteoplastic resection of nose, '507 Operations, causes of death after, 286 complications after, 284 dangers, common, 281 special, 283 general considerations, 280 imperative, 280 in general, 280 midtiple, 281 of expediency, 281 of necessitv, 280 of utiHty, 280 preparation of patient, 49 of surgeon and assis- tants, 50 unjustifiable, 281 Operative technic, aseptic, 48 general principles, 308 Oral cavity, examination, 545 Orchitis, 589 Ormsby's inhaler, 294 Orthoform, 306 anesthesia, 306 Osmic acid, intraneural in- jections, in facial neural- gia, 544 Osseous ankylosis, 161 tumors of tongue, 555 Ossifying goiter, 611 periostitis, 138 Osteitis, rarefying, 145 Osteoarthritis, 157, 158 Osteochondritis, syphilitic, 204 INDEX 713 Osteoclasis, 137 Osteoclast, Kizzoli's, 362 Osteoma, 21 S cancellous, 21S compact, 21S nasal, 505 of frontal sinuses, 51S of jaw, 532 syphilitic, of cranial bones, 453 Osteomalacia, 144 Osteomyelitis, acute, 140 infectious, of cranial bones. 452 of jaw, 52S suppurative, 139 syphilitic. 142 Osteoplastic resection of nose, 506 Bruns's method, 507 Langenbeck's meth- od, 507 Ollier's method, 507 rhinoplasty, Konig's, 511 Osteopsathyrosis, 145 tabetica, 145 Osteotomy. 162 for correction of contrac- ture and ankylosis, 374 Othematoma of auricle, 578 Otitic cerebral abscess, 462 Otitis externa. 5S1 interna, 5S2 media, 5S2 Otoplasty, 5S3 Otoscope, electric light, 5S0 Oval amputation, 379 Ovarian cysts, fluid ob- tained in, 278 Ozena, 502 Pachydermatous cachexia, 616 Pachvmeningitis in fracture of skull. 443 ' Paset's disease of nipple, 658 Pain in inflammation, 8 Palate, hard. 561 cleft of. 562 » functional disturb- ances in newborn , from, 562 , uranoplasty in, 564 necrosis of, 562 [ suppurative periostitis i of, 562 syphilis of, 562 hook, French's, 499 sarcoma of, 533 soft, 558 cleft of, 559 staphylorrhaphy in, 560 fissures of. 559 congenital, 559 Palate, soft, foreign bodies ' in, 558 inflammation of. 558 svphilitic ulceration of, ■ 559 velum of, 558 wounds of. 558 Palmar application of figure- of-S bandage of hand and wrist, 418 demi - gauntlet bandage. 420 Palpation in diagnosis of foreign bodies, 384 of inflammation, 33 Paper-wool. 63 Papillary dermatitis, malig- nant, of breast, 658 synovitis, 152 tendovaginitis, 163 Papillomar 229 nasal, 504 of larvnx and trachea. 606 I of tongue, 557 I viUous^ 229 I intracystic, 230 Papular syphilide. 197 Paracentesis of pericard- iiun, 685 I Paradenitis, 110 interstitial, of breast, 655 I of lateral cer-\-ical region, ! 62S Paralvsis, crutch, 115 diphtheritic, 603 facial, intractable, nerve anastomosis in, 626 trismus associated with, 188 of recurrent laryngeal nerve after thyroidec- tomy, 617 of vocal cords after laryn- geal diphtheria, 603 Saturday-night. 115 Paralytic wryneck, 650 Paramastitis, 656 Parasites, IS facultative, IS Parasynovitis, treatment, 157 Parenchyma, renal, pj-ehtis with hyperemia of, urine in, 269 Parenchymatous h e m o r - rhage. arrest of, 342 Parietal lobes of brain, lesions of, 468 Park's modification of Gus- senbauer's artificial larynx, 609 Parotid duct, fistula of. 587 foreign bodies in, 588 injuries of, 587 gland, adenoma of. 591 adenosarcoma of, 591 Parotid gland, chondroma of, .590 extirpation of. 591 injuries of, 586 sarcoma of, 590 telangiectases of, 591 tumors of, 590 Pasteur's prophylactic in- oculation in hydrophobia, 192 Pathogenic bacteria, speci- fic, 29 Pathologic examinations in diagnosis and progno- sis. 244 histology in diagnosis and prognosis. 245 Peat. 63" moss, 63 Peh'is. renal, acute catarrh of. urine in. 269 Periarticular inflammations, 1.5S Pericardiotomy. 685 followed by drainage, in pyopericardiimi, 685 Pericardium. 684 dropsy of, 685 paracentesis of, 685 wounds of. 684 Perichondritis, granular, of ribs. 673 Periosteal elevator, 367 lipomas. 217 sarcomas. 145 Periostitis. 138 fibrous. 138 ossifying. 138 serous. 138 suppurative. 138 of hard palate, 562 of jaw. 527 of ribs, 673 s}-philitic, 142 Peripheral Hgation in aneu- rism, 346 Peripleuritis, suppurative, 673 Peritonsillitis, 566 Pernio, 75 treatment, 76 Peruvian balsam gauze, 63 Pes paralyticus, 159 Petit's screw tourniquet, 336 Petri dishes, 22 Petrissage, 64 Pharyngeal cavity, care of, before operation, 49 Pharyngectomy, external, in malignant tumors, 569 Pharyngitis, 572 acute. 572 catarrhal, subacute, 572 gangrenous. 573 phlegmonous, 573 acute infectious, 573 714 INDEX Pharyngitis sicca, 502 ulcerative, 573 Pharynx, 566 erysipelas of, 573 foreign bodies in, 570 inflammation of, 572. See also Pharyngitis. Phlebitis, 101 Phlegmon, nonsyphilitic, of tongue, 548 Phlegmonous erysipelas, 177 inflammation, 11 subpectoral, 654 pharyngitis, 573 acute infectious, 573 tonsillitis, 566 Phosphorus necrosis of jaws, 528 Phrenic nerve, injuries of, 625 Piano-wire ecraseur, 315 Pick's solution, No. 1, 244 No. 2, 245 Pilcher's retractors, 600 Pirogoff's edema, 181 Plaster, adhesive, 402 coaptation by, 326 resin, 402 rubber, 402 surgeon's, 402 uses, 402 Plaster - of - Paris bandage, dangers, 396 method of preparation, 395 removable, 395 removal, .396 Plastic operations on chest, 679. See also Thor- acoplasty. on skin, 327 after-treatment, 333 autoepidermic, 331 basket-strapping for, 333 flap formation with torsion, 329 general methods, 328 lateral displacement of tissues, 328 Olher method, 332 Reverdin's method, 331 Thiersch's method, 331 Plate method of isolation, 22 Pleural sac, injection of nitrogen into, 683 Pleurectomy, total, 680 Pleuritic effusions, 675 encysted, 675 incision in, 677 resection of rib in, 678 simple puncture and as- piration in, 676 thoracotomy in, 677 Pleuritis, simple, with effu- sion, 675 Pleurotomy with detach- ment of visceral layer of diseased pleura, 679 Plexiform angiomas, 228 neuroma, 226 Plexus, brachial, stretching of, 637 cervical, branches of, di- vision of, 625 stretching of, 638 Plumbism in gunshot in- juries, 176 Pneumatocele, cranial, 454 Pneumectom}^ 683 Pneumogastric nerve, in- juries of, 625 Pneumonia after ether an- esthesia, 296 post-operative, 285 septic, following wounds of the thorax, 652 post-operative, 285 Pneumopyopericardium,685 Pneumothorax, 624 Pneumotomy, indications for, 682 Podagra, 154 Pointing of abscess, 12 Poisoned wound, 2 Poisoning, carbolic acid, treatment of, 60 iodoform, treatment of, 61 lead, of gums, 528 Polyarthritic synovitis, 153 Polycystic degeneration of kidney, urine in, 270 Polymazia, 657 Polypanarthritis, hyperplas- tic, 155 Polypi, aural, 582 fibrous, of tongue, 555 nasal, 503 cocain anesthesia in re- moval, 505 of esophagus, 621 of frontal sinuses, 518 snare, Wilde's aural, 582 Polyuria, 260 Pons, tumors of, 470 Port wine stains, 227 Post - anesthetic nephritis, urine in, 267 Postmortem thrombi, 103 Post - operative complica- tions, 284 Postrectal dermoids, 237 Potato as culture medium, 21 Pott's disease, 646 fracture, 149 Powder grains in face, 474 Precedent anesthesia, 301 Precocious gummas, 198 syphilis, malignant, 197 Pregnancy, sarcoma of, 370 Pressure bandages, 392 blood-, 259 on nerves during sleep, 116 ulceration from, 69 Probang, umbrella, 620 Probe in inflammation, 36 telephone, 385 Probes in diagnosis of foreign bodies, 384 Probing for bullet in cran- ial cavity, 451 Productive inflammation, 8 Projecting ears, 583 Propulsion diverticula of esophagus, 621 Prostatic adenomas, 232 Provisional callus, 130 Psammoma, 230 Pseudarthrosis, 131 implantation of ivory pegs in, 368 Pseudocysts, 239 Pseudoleukemia, 113 blood examination in, 259 Psoriasis, simple, of tongue, 547 syphilitic, of tongue, 547 Ptomains, 19 Pulmonary decortication, 679 edema after ether anes- thesia, 296 Pulse and respiration in fever, 46 Puncture and aspiration in pleuritic effusions, 676 exploratory, in diagnosis of inflammation, 36 lumbar, 278 of capsule in hemarthro- sis, 370 Punctured wounds, 1 of arteries, 86 of esophagus, 618 of tongue, 546 Puncturing, 319 Purulent edema, acute, 181 inflammation, 8 Pus in urine, 267 laudable, 3 organisms, 26 Putrefaction, process of, 14 Putrid exudates, 278 Pyelitis with hyperemia of renal parenchyma, urine in, 269 Pyelonephritis, urine in, 270 Pyemia, 101, 184 actinomycotic, 212 cryptogenic, 184 metastasis in, 184 multiple, of gums, 527 spontaneous, 184 Pyemic abscess of gums, 527 Pyonephrosis, urine in, 270 Pyopericardium, 685 INDEX 715 Pyothorax, 624, 672 Pyuria. 267 Racemose aneurism of scalp, 433 Rachitic rosary, 144 Rachitis, 144 Rack - and - pinion mouth- gag, 564 Radicular odontomas, 219 Ranula, 591 acute, 592 Rarefying osteitis, 145 Raspatories for uranoplasty, 564 Rectal dermoids, 237 Rectum, care of, before ope- ration, 49 dermoids of, 237 Recurrent bandage, 392 of foot, 425 of head, 404 of stump, 393 laryngeal nerye, injuries of, 625 paralysis of, after thyroidectomy, 61 7 syphilides, 198 Recurring hemorrhage after operations, 284 Red corpuscles, counting, 249 Redness of inflammation, 7 Redressing wound, indica- tions for, 57 Reflector, Collin's electric light, 597 Refracture, 137 Regeneration of callus, 130 Regenerative inflammation, 8_ Regional surgery, 429 Reinfection, syphilitic, 203 Removable layer suture, 323, 324, 325 Renal. See Kidney. Resection, diaphysial, 367 enucleation, of goiter, 616 in fractures, 368 of alveolar processes, 534 of both superior maxillas in two sittings, 539 upper maxillas, simul- taneous, 539 of callus, 137 of entire lower jaw, 537 of esophagus, 624 of fractures, 368 of goiter, 615 of half lower jaw, 535 of joints, 371 after-treatment, 374 for tuberculous myelitis, 374 synovitis, 374 general technic, 373 Resection of joints, immedi- ate, 372 intermediate, 372 partial, 372 primary, 372 secondary, 372 subcapsular, 373 subperiosteal, 373 of lower jaw, 534 of lung, 683 of rib in pleuritic effu- sions, 678 of spine in fracture of cervical vertebrae, 642 of sternum for chon- droma, 675 of superior maxillary nerve, 540 of temporo - maxillary ar- ticulation, 537 of upper jaw, 537 osteoplastic, of nose, 506. See also Osteoplastic re- section of nose. Resin plaster, 402 Resorptive fever, 47 Respiration and pulse in fever, 46 artificial, in dangerous anesthesia, 300 Laborde's method, 300 Sylvester's meth- od, 300 Cheyne-Stokes, in frac- ture of skull, 440 Retching, excessive, after operations, 284 Retention cysts, 239 of urine after operations, 284 Reticular lymphangitis, 108 Retractor bandages, 401 cheek, 560 Retractors, Pilcher's, 600 Retropharyngeal abscess, 646 Reverdin's method of skin- grafting, 331 Rhabdomyomas of tongue, 555 Rhabdomyosarcoma, 222 Rheumatism, acute, 153 Rheumatoid arthritis, 152 Rhinitis, chronic atrophic, 502 chronic hypertrophic, 502 syphilitic, in newborn, 503 Rhinophyma, 501 Rhinoplasty, 509 Busch's method, 511 complete, 510, 513 Konig's method, 513 Schimmelbusch's meth- od, 514 Konig's, 511 Rhinoplasty, partial, 510, 513 Rhinoscleroma, 501 Rhinoscopy, 497 anterior, 498 posterior, 498 Rib, cervical, 630, 649 exostosis of, 649 resection of, in pleuritic effusions, 678 Ribs, angiosarcoma of, 674 carcinoma of, 674 caries of, 672 chondroma of, 673 fractures of, 670 granular myehtis of, 672 perichondritis of, 673 sarcoma of, 674 separation of, from ster- num, 681 suppurative periostitis of, 673 syphilitic disease of, 673 tumors of, 673 typhoid infection of, 673 Richter's needle - holder, 322, 323 Riga's disease, 557 Rizzoli's osteoclast, 362 Roberts's method of treat- ing fractures of lower jaw, 523 trephine, 314 Rodent ulcer of face, 478 Roe's modification of Mac- kenzie's esophagotome, 623 Rolando, fissure of, localiza- tion, 467 Chiene's device for, 467 Roller bandages, varieties, 390 Rongeur forceps, 314, 317 Rontgen ray in diagnosis of foreign bodies, 384 Rose's dependent head posi- tion, 534 Round-celled sarcomas, 222 Round-cells, formative, 5 Rubber bandage, 393 plaster, 402 tourniquet, 393 Rudisch quantitative test for glucosuria, 262 Rupture aneurisms, 95 of sternomastoid muscle, 624 of tendons, 122 of tracheal mucous mem- brane, 595 of varicose vein, 101 Sacciform aneurism, 94 Saddle nose, operation for, 510 716 INDEX Salicylic acid, 61 cream, 62 Saline infusion, intraven- ous, 351 Salivary calculus, 588 glands, 586 inflammation of, 589 Salivolithiasis, 588 Sandelin's cheiloplasty, 483 Saprophytes, 18 Sarcinae, 18 Sarcoma, 221 blood examination in, 258 central, of bone, 145 character, general, 224 degenerative changes, 225 dissemination of, 225 distribution, 224 giant-celled, 222 infiltrating properties, 225 intraocular, 477 melanotic, removal, 335 metastasis of, 225 of alveolar process, 533 of antrum of Highmore, 530 of bone, 145 operation for, 370 central, 145 of breast, 658 cystic, 658 phjdloid, 658 of cervical vertebral col- umn, 649 of cranial bones, 454 of eye, 477 of frontal sinuses, 519 of glands of neck, 632 of involuntary muscle - fiber, 122 of jaw, 532 of joints, treatment, 376 of larynx, 606 of lung, 683 of mucous membranes, 224 of muscles of neck, 630 of nasopharynx, 576 of neck, operation in, 639 of orbit, 454 of palate, 533 of parotid gland, 590 of pregnancy, 370 of ribs, 674 of scalp, 434 of sternum, 675 of submaxillary gland, 591 of synovial membrane, treatment, 376 of tendons, removal, 360 of thyroid gland, 617 of tonsils, 569 of vagina, 224 of voluntary muscles, 121 periosteal, 145 round-celled, 222 Sarcoma, secondary changes, 225 spindle-celled, 222 tendency to penetrate be- tween surrounding structures, 225 treatment, 226 Saturday - night paralysis, 115 Saw, Adams's, 363 broad, 311, 313, 361 chain, 312, 361, 362 frame, 311, 313, 361 GigU wire, 312, 361, 362 metacarpal, 362 Sawdust, 63 Sawing, division of bone by, 361 Saws, 311 Scabbard trachea, 612 Scalds of tongue, 546 Scale, Tallqvist's hemoglo- bin, 249 Scalp, aneurism of, 433 cirsoid, 433 racemose, 433 avulsion of, 430 cirsoid aneurism of, 433 contusions of, simple, 429 dermoid cysts of, 433 dermoids of, 235 fibroma of, 434 hematoma of, 429 hpoma of, 434 loosening of, without avulsion, 431 racemose aneurism of, 433 sarcoma of, 434 surgery of, 429 tumors of, 433 varices of, 434 venous cysts of, 434 wounds of, 429 inflammation after, 431 Scalpel rack and case, 50 Scalpels, 308 Scar tissue, abscess in, 68 Schede's operation of thor- acoplasty, 679 Schimmelbusch's complete rhinoplasty, 514 meloplastic operation, 494 sterilizer, 50 Schmidt's fibrin ferment, 47 Scirrhus of breast, 659 Scissors, Asch's, 496 bandage, 390 curved on the flat, 310 Scoliosis, 646 compensatory, 651 Scrofulous edema of lips, 477 Scrotum, dermoids of, 236 Scurvy and allied conditions, blood examination in, 258 Sebaceous adenomas, 231 cysts, 231 Sebaceous horns, 230 Sections, embedded, in- structions for making, 246 frozen, instructions for making, 245 Senile gangrene, 93, 106 Septic arthritis, acute, 152 inflammation, post-opera- tive, 285 lymphadenitis of lateral cervical region, 628 pneumonia, following wounds of the thorax, 652 pneumonia, post - opera- tive, 285 synovitis, acute, 156, 157 wounds, 2 Septicemia, 182 Septicopyemia, 182, 184 Septum, nasal, deviations of, 496 Sequestra, 140 Sequestration dermoids, 235 Sequestrotomy, 369 Sequestrum forceps, 369 Serofibrinous inflammation, 8, 9 • Serohemorrhagic inflamma- tion, 8, 9 Serous inflammation, 8 periostitis, 138 Serpentine bandage of foot, 426 of great toe, 428 Serpiginous ulcer, 83 Serum, blood-, human, as culture-medium, 21 Seton gunshot wound, 652 Sheets, disinfection of, 53 Shock, 282 Shoulder, ascending spica bandage of, 414 descending spica bandage of, 415 Sialadenitis, 589 Sialodochitis, 590 Silk, sterilization of, 55 Simon's operation for single harelip, 488 Sinus, 12 curet, Delatovir's, 58 frontal, inflammation of, 515. See also Frontal sinusitis. syringe, 59 thrombosis, infectious,464 Sinuses, frontal, 514. See also Frontal sinuses. of dura mater, hemor- rhages from, in fracture of skull, 441 Sinusitis, frontal, 515. See also Frontal sinusitis. Skin, abrasions of, 67 actinomycosis of, 212 INDEX 717 Skin, contvisions of, GG epidermal layer of, forma- tion, 68 gunnna of, 82 inflammation of, granular, 79 suppurative, 67 injuries of, 66 losses of substance in, 68 of face, powder grains in, 474 of neck, tumors of, 630 operations on, 327 plastic operations on, 327. See also Plastic Opera- tions on Skin. suppurative inflammation of, 67 syphilis of, 82 traumatism of, 66 tuberculosis of, 79 tumors of, removal, 333 ulceration of, 69 wounds of, noncommuni- cating, in fracture, 126 Skin-grafting, 327. See also Plastic operations on skin. SJvin-stretching hooks, Mc- Burney's, 332 Skull, bones of, 434. See also Cranial bones. diseases of, abscess of brain developing from, 463 fracture of, 434 base, 436 cerebral complications, 438 Cheyne-Stokes respira- tion in, 440 compound, 443 pachymeningitis in, 443 compression of brain in, 439 concussion of brain in, 441 _ contusion of brain in, 442, 455 laceration of brain in, 442 trephining, 447 hemorrhages from sin- uses of dura mater in, 441 Sling, 397 arm and hand, 417 bandage, for breast, 414 Smear preparation, 25 Smegma bacillus, 31 Smoker's patch, 547 Snare, Jarvis's, 504 Wilde's, 582 Snowball crackling, 146 Soft palate, 558. See also Palate, soft. Sore, primary, of acquired syphilis, 197 throat, hospital, 573 Spanish windlass, 337 Spasm, mimic, 545 Spasmodic wryneck, 650 Spastic torticollis, 650 Speculum, Brophy's mouth, 559 ear, 580 nasal, 498 Spica bandage, 392 ascending of both groins, 423 of shoulder, 414 single, of groin, 421 descending, of both groins, 424 of shoulder, 415 single, of groin, 422 of foot, 425 of great toe, 427 of thumb, 420 Spinal accessory nerve, in- juries of, 625 neurectomy of, 638 anesthesia, 306 cord, gliomas of, 227 Spindle-celled sarcoma, 222 Spine, resection of, in frac- ture of cervical vertebrae, 642 Spiral bandage, 390 of chest, 411 of finger, 419 of foot, 424 reversed, 391 of finger, 419 of lower extremity, 426 of upper extremity, 418 fractures, 123 Spirillum, 18 Splint, interdental, in frac- tures of lower jaw, 521 Matas's, in fractures of lower jaw, 523 Roberts's, in fractures of lower jaw, 523 SpUntered fracture, 125 Split tongue, 549 Splitting cheek in cancer of tongue, 553 Spondyhtis in cervical re- gion, 646 Spoon, sharp, 315 diAasion of bone by, 364 Sporulation, 19 Spreading neuritis, 119 Sputum, examination of, 273 in abscess of lung, 274 in empyema rupturing in- to lung, 274 in hemoptysis due to per- forating aneurism, 274 in neoplasm of lung, 274 Squamous-celled carcinoma, 234. See also Epithelioma. Stab wounds of larynx and trachea, 595 Stagnation thrombi, 102 Stain, alkaline methylene- blue, for bacteria, 25 Gram's, 25 port wine, 227 Ziehl-Neelsen, for tuber- cle bacilli, 25 Staining methods, 24 Staphylococcus, 18 epidermidis albus, 26 pyogenes albus, 26 aureus, 26 citreus, 26 Staphylorrhaphy, 560 dividing muscles, 561 introducing sutures, 561 paring margins, 560 Stasis, venous, 103 gangrene after, 104, 105 Stay knot, 340 Steatoma of mastoid, 586 Stenosis, laryngeal. See also Stricture. Stenson's duct, 587. See also Parotid duct. Sterilization, fractional, 20 of catgut, 53 apparatus for, 54 iodin method, 55 of cocain solutions, 305 of ligature material, 53 of silk, 55 of suture material, 53 SteriUzer, Arnold, 53 hospital, 51 hot-air, 25 Schimmelbusch's, 50 Sternomastoid muscle, rup- ture of, 624 syphilitic gummas of, 630 Sternum, 674 caries of, syphilitic, 674 tuberculous, 674 chondroma* of , 675 fissure of, congenital, 675 fracture of, 674 resection of, for chon- droma, 675 sarcoma of, 675 separation of ribs from, 681 trephining, 674 Stevenson's instrument for electrolysis, 334 Stitch abscesses, 57 Stockinet, 64 Stomach, carcinoma of, blood examination in, 258 contents, examination of, 274 718 INDEX Stomach contents, free acids and acid salts in, test for, 275 hydrochloric acid in, "275 lactic acid in, 275 total acidity due to or- ganic acids and acid salts, test for, 276 test for, 275 free hydrochloric acid in, test for, 276 hydrochloric acid in, test for, 276 dilatation of, acute post- operative, 284 lavage of, 618 tube, 618 ulcer of, blood examina- tion in, 258 Stomatoplastic operations, 493 for ectropion of lips, 494 for macrostoma, 493 for microstoma, 493 Strain, breaking, of prin- cipal nerves, 357 Strangulation of nerve, 355 Strapping, basket, in ulcers, 71 Strauss graduated tube for lactic acid determination, 275 Streptococcal infection of breast, 656 Streptococcus, 18 pyogenes, 27 Stretching, intraspinal nerve-, 638 nerve-, 357 of brachial plexus, 637 of cervical plexus, 638 Stricture, carcinomatous, of esophagus, treatment, 623 cicatricial, of esophagus, 618, 621 frorri tumors or cicatricial bands, tracheotomy tube in, 604 of esophagus, 621 Abbe's method of treat- ing, 623 Struma, 610 Strumitis, 611 Stump, recurrent bandage of, 393 Sty, 475 Styptics in hemorrhage, 343 Subcapsular resection of joints. 373 Subclavian artery, hemor- rhage from, arrest of, 626 hgation of, 636 Subcutaneous connective tissue, granular in- flammation of, 79 gumma of, 82 injuries of, 66 suppurative inflam- mation of, 67 hemorrhage, 88 infusion, 352 injuries of larynx and trachea, 594 of smaller blood-ves- sels, 87 lipoma, 216 lymphorrhagia, 107 painful tubercle, 226 tenotomy, 122, 360 traumatism of kidney, urine in, 272 Subluxation, 148 Submaxillary duct, foreign bodies in, 588 gland, adenoma of, 591 adenosarcoma of, 591 chondroma of, 590 extirpation of, 591 sarcoma of, 591 tumors of, 590 Submucous lipoma, 216 Subpectoral abscess, 654 phlegmonous inflamma- tion, 654 Subperichondrial abscess of nose, 509 Subperiosteal abscess of gums, 527 cyst of alveolar process, 532 fracture, 125 resection of joints, 373 Subphrenic abscess, 676 Subserous lipoma, 216 Subsynovial lipoma, 216 Subtendinous bursae, 240 iSubungual exostosis, 219 Sucking cushion, 217 Suff'ocation after removal of tracheotomy tube, 603 Sugar in urine, 262 Suicidal hanging, 645 Suicide wounds of larynx and trachea, 595 Sulfuric ether as anesthetic, 289 Superfluous callus, 131 Supernumerary breasts, congenital, 657 Suppression of urine after operations, 284 Suppuration, non-bacterial, 32 of demarcation, 75 of external auditory mea- tus, 581 Supraorbital nerve, neurec- tomy of, 544 Suprathyroid tracheotomy, ^ 602 Surgeon and assistants, preparation, 50 Surgeon's adhesive plaster, 402 Surgical bacteriology, 17 epilepsy, 471 fever, 39 and augmented meta- morphosis, relations, 43 respiration and pulse in, 46 infections, chronic, 194 Suture after amputation, 380 bone, 365 buried, 323 chain-stitch, 323 continuous, 323 interrupted, 321 intracuticular, 323 layer, 323 material, sterilization, 53 of arteries, 341 of' muscles, 357 of nerves, 354 secondary, 354 of tendons, 358 of veins, 344 primary, in division of nerves, 118 removable layer, 323, 324, 325 removal of, time for, 58 secondary, in division of nerves, 118 Suturing, deep, in hemor- rhage, 342 protection of line of, 321 Sweat-glands, adenoma of, 477 Swelling of inflammation, 7 Sylvester's method of arti- ficial respiration in dan- gerous anesthesia, 300 Sympathectomy, cervical, 640 Syncope in chloroform an- esthesia, 298 Synovial cysts, 239 membrane, sarcoma, 376 Synovitis, 151 acute, 151 septic, 156 serous, 156 chronic, 151 serous, 151 etiology, 153 granulating, 151 hyperplastic, 151, 155 papillary, 155 hyperplastica granulosa, 141 metastatic suppurative, 155 INDEX 719 Synovitis of sheaths of ten- dons, 163 pannosa, 155 papillary, 152 polyarthritic, 153 septic, 157 serous, 154 suppurative, 154 tuberculous, 151, 153, 155, 157 resection of joints for, 374 Sj'phihde, macular, 197 papular, 197 recurrent, 198 Syphilis, 194 acquired, 194 initial lesion of, 197 mucous patches of, 197 primary incubation pe- riod, 195 sore, 197 stage, 197 secondary incubation period, 195 stage, 197 tertiary stage, 198 benign, 195 hereditary, 203 initial lesion, 82 maUgnant, 196 precocious, 197 mediate infection, 194 of hard palate, 562 of skin, 82 secondary lymphatic ade- nopathy in, 195 treatment, 199 general, 199 hygienic, 200 specific, 201 Syphilitic affections of bone, 142 of nose, 508 alopecia, 198 bubo, 197 cachexia, 196, 199 caries of cranial bones, 453 of sternum, 674 craniotabes, 204 disease of ribs, 673 fever, 195 gummas of sternomastoid, 630 laryngitis, 599 lymphadenitis, 113 necrosis of cranial bones, 453 osteochondritis, 204 osteoma of cranial bones, 453 osteomyelitis, 142 periostitis, 142 psoriasis of tongue, 547 reinfection, 203 Syphilitic renal hyperplasia simulating malignant growth, urine in, 270 rhinitis in newborn, 503 ulceration of nose, 502 of soft palate, 559 of tonsils, 566 Syphiloma, 196 Syringe, Collin's, 320 ear, 580 sinus, 59 Tabetic arthritis, 154 arthropathy, 152 Tallqvist's hemoglobin scale, 249 Tampon, chemise, in hemor- rhage, 342 Tamponade in hemorrhage, 342 Tampons in ant. nares, ban- dage for supporting, 410 Tapotement, 64 T-bandage, double, 398 of chest, 398 single, 398 Teeth, Hutchinson, 204 Telangiectasis, 227 of parotid gland, 591 Telephone probe, 385 Temperature of body, phy- siologic regulation, 39 Temporo-maxillary articula- tion, resection of, 537 Tenaculum forceps, double, 309 Tendogenous contractures, 159 Tendons, contractured, lengthening, 358 diseases of, 122 fibroma of, 360 ganglions of, 360 incised wounds of, 122 inflammation of, 123 injuries of, 122 necrosis of, 122 operations on, 357 rupture of, 122 sarcoma of, 360 sheaths of, suppurative inflammation in, 359 synovitis of, 163 suture of, 358 traumatic separation, 358 tumors of, operations for, 360 Tendoplastv, 358 double, 358 vicarious, 358 Tendosynovitis. See Teno- synovitis. Tendovaginitis, 163 papillary, 163 suppurative, 163 tuberculous, 163 Tenosynovitis, 123, 141, 163 Tenotomes, 361 Tenotomy, 360 subcutaneous, 122, 360 Teratoma, 238 auricular, of neck, 629 Test, bismuth, for gluco- suria, 262 for free acids and acid salts in gastric con- tents, 275 for total acidity due to organic acids and acid salts in gas- tric contents, 276 of gastric contents, 275 for total combined hydro- chloric acid in gastric contents, 275 for total free hydrochloric acid in gastric contents, 276 for total hydrochloric acid in gastric contents, 276 Haines's, for glucosuria, 262 heat and nitric acid, for albumin in urine, 260 nitric-magnesium, for al- bumin in urine, 261 Rudisch quantitative, for glucosuria, 262 Testicle, dermoids of, 236 Tetanus, 44, 187, 530. See also Lockjaw. antitoxin treatment, 190 bacillus of, 29 cicatricial, 531 meloplastic operation for, 494 hydrophobic, 188 incubation period, 188 neonatorum, 188 treatment, 189 Tetany after thvroidec- tomy, 617 Tetrads, 18 Thatcher mosquito, 253, 266 Thermocautery, 316 Thermostat, Dunham's, 23 Thiersch's method of skin- grafting, 331 Thoma-Zeiss counting cham- ber, 250 hemocytometer, 249 Thoracic duct, injuries of, 107 obstruction of, 107 region, actinomvcosis of, 211 Thoracoplasty, 679 Estliinder's operation , 679 Schede's operation, 679 Thoracotomy in pleuritic effusions, 677 720 INDEX Thorax, 652. See also Chest. Throat, hospital sore, 573 Thrombo-arteritis, 93 Thrombophlebitis, 101 Thrombosis, 102 dilatation, 102 infectious sinus, 464 intra-arterial, 93 marasmus, 102 Thromljus, extension, 102 hyaline, 106 postmortem, 103 stagnation, 102 valvular, 102 white, 104 Thumb forceps, 309 spica bandage, 420 Thyrohvoid bursa, 241 hydrops of, 630 Thyroid, adenomas of, 232 and cricoid cartilages, en- chondroma of, 606 cartilages, fracture of, 594 gland, 610 accessory, mucous cysts of, 611 adenoma of, 232, 611 carcinoma of, 617 enlargement of, tem- porary, 612 hypertrophy of, 611 injuries of, 610 malignancy, 617 sarcoma of, 617 Thyroidectomy, summary of important points in, 616 tetany after, 617 Thyroiditis, 610 Thyrotomy, 608 Tic douloureux, 540 rotatoire, 650 Tiemann's bullet forceps, 387 Tissues, granulation, 3 indications for uniting, 321 mechanism of uniting: 321 ^' separate, injuries and dis- eases of, 66 separation of, 308 by means of ligature and heat, 315 of scissors, 310 incisions from within outward, 309 indications for, 308 means employed for, 308 Toe, great, serpentine ban- dage of, 428 spica bandage of, 427 Tongue, 545 abscess of, 548 aneurism by anastomosis, 555 Tongue, angioma of, 555 arteriovenous aneurism of, 555 bifid, 549 burns of, 546 cancer of, 549 asphyxia in, preven- tion, 551 hemorrhage in, 551 Kocher's operation for, 554 median section of lower jaw in, 553 splitting cheelv in, 553 Whitehead's operation for extirpation of entire tongue in, 552 for extirpation of half of tongue in, 551 cirsoid aneurism of, 555 deformities of, 548 depressor, electric light, 545 dermoids of, 236 edema of, inflammatory, 546 erysipelas of, 548 fibroma of, 555 fibromyoma of, 548, 555 gunshot wounds of, 546 ichthyosis of, 547 lacerated wounds of, 546 lipoma of, 555 lupus of, 548 lymphangioma of, 548, 556 nevi of, capillary, 555 venous, 556 papilloma of, 557 phlegmon of, nonsyphih- tic, 548 polypi of, fibrous, 555 psoriasis of, 547 syphihtic, 547 punctured wounds of, 546 rhabdomyoma of, 555 scalds of, 546 spht, 549 tumors of, amyloid, 555 benign, 555 cartilaginous, 555 cavernous, 556 osseous. 555 ulceration of, 547 tuberculous, 548 warty growths of, 557 wounds of, punctured, 546 Tongue-tie, 548 TonisiUitis, acute, 566 diphtheritic, 566 foHicular, 566 hypertrophic, 566 tonsillotomy in, 567 phlegmonous, 566 Tonsillotomes, 568 Tonsillotomy in hyper- trophic tonsillitis, 567 Tonsils, 566 carcinomatous ulceration, 566 epithelial carcinoma of, 569 lupous ulceration, 566 malignant tumors of, 568 external pharyngec- tomy in, 569 sarcoma of, 569 syphilitic ulceration of, 566 tuberculosis of, 568 tuberculous ulceration of, 566 ulcerative conditions of, 566 Torticolhs, 624, 650 congenital, 650 Kocher's operation for, 651 of central origin, 650 of muscular origin, 650 paralytic, 650 spasmodic, 650 spastic, 650 Tourniquet, 337 Petit's, 336 rubber, 393 Towels, disinfection of, 53 Toxemia before and after operations, 268 Trachea, 594 diphtheritic inflamma- tion, 598 fibroma of, pediculated, 606 foreign bodies in, 595 inflammatory obstruc- tion, 598 papilloma of, 606 pediculated fibroma of, 606 scabbard, 612 stab wounds of, 595 subcutaneous injuries of, 594 suicide wounds of, 595 tumors of, 606 ulceration of, from im- properly curved trache- otomy tubes, 603 Tracheal fistula, 629 mucous membrane, rup- ture of, 595 wall anterior, diphther- itic ulceration of, 603 wound, granulomas of, 603 Tracheotomy, 599 after-course, 602 after-treatment, 602 anesthetic in, 599 choice of operation, 600 IXDKX 721 Tracheotomy, cocain in, 599 cricothyroid, 002 for foreiijii hodios, 004 infrathyroid, (iOO preliminary, 004 rapid, 000 suprathvroid, 602 tube. 001 Cohen's, 601 in stenosis from tumors or cicatricial bands, 604 permanent removal, 604 suffocation after re- moving, 603 Traction diverticula of eso- phagus, 621 Tragus, accessory, 238 Transfusion, 351 Transplantation, bone, 36S of granulating flap, 330 of nerves, 355 Transudates, examination of, 277 Traumatic abscess of brain, 460 chronic, 461 aneurism, 96 dermoids, 236 empyema, 672 erysipelas, 67 inflammation of soft parts of facial region, 474 meningitis, 457 separation of tendons, 35S Traumatism of skin, 66 subcutaneous, of kidney, urine in, 272 Trendelenburg cannula, 534 Trephine, 312 aseptic brace, 447 Gait's, 313 Roberts's, 314 Trephining in fracture of skull, 447 indications for, 448 mastoid, 5S4 sternum, 674 Triangle bandage of groin, 401 Trigonum linguale, 558 Trismus associated with facial paralysis, 188 Trocar and cannula, 319 Fitch's. 319 Tropacocain hydrochlorid anesthesia, 306 Trunk, bandages of, 411 dermoids of, 235 Tubercle, anatomic, 82 bacilli, Ziehl-Xeelsen stain for, 25 cadaver, 82 moist. 198 subcutaneous painful, 226 Tuberculosis, 205 bacillus, 30 47 Tuberculosis, Ijlood examina- tion in, 257 intestinal, feces in, 276 latent, 207 of manuna, 655 of skin, 79 of tonsils, 568 pathologic anatomy, 206 renal, urine in, 271 treatment, 20S Tuberculous affections of nose, 509 arthritis, 152 cachexia, 205 caries of sternum, 674 endangeitis, 205 fistula^ 207 granuloma, 207 gumma, SI hydrops, 151 inflammation of cranial bones, 452 laryngitis, 599 lymphadenitis. 111 of lateral cervical re- gion, 627 lymphatic glands of neck, extirpation of, 638 myehtis, resection of joints for, 374 necrosis, 138 spondylitis, 646 synovitis, 151 resection of joints for, 374 tendovaginitis, 163 ulcer, 81, 207 ulceration of nose, 509 of tongue, 548 of tonsils, 566 Tubulocysts, 239 Tubulodermoids, 236 Tumors, 214 benign, 215 influence of environ- ment, 215 cavernous, treatment, 334 classification, 214 connective-tissue, 214 diagnosis, 241 epithehal. 229 erectile, 227 inflammatory, 590 malignant, 214 influence of environ- ment, 214 structure. 215 treatment. 242 Turbinectomy in chronic frontal sinusitis. 517 Turpentin. oil of. in hemor- rhage. 343 Typhoid infection of ribs, 673 laryngitis, 599 Ulcer, 69 basket strapping in, 71 miprop- tracheo- Ulcer, gastric, blood ex- amination in, 258 rodent, of face, 478 serpiginous, S3 tuberculous, 81, 207 varicose, 69 Ulceration, carcinomatous, of tonsils, 566 diphtheritic of anterior tracheal wall, 603 from pressure, 69 in cicatrix, 68 intestinal, feces in, 276 lupous, of tonsils, 566 of glanders in nose, 503 . of mucous membrane of nose, 503 of skin, 69 of tongue, 547 of tonsils, 566 of trachea from erlv curved tomy tubes. 603 syphilitic, of nose. 502 of soft palate, 559 of tonsils, 566 tuberculous, of nose, 509 of tongue. 54S of tonsils, 506 UlceratiA-e pharyngitis, 573 Umbrella probang, 620 Unjustifiable operations, 2S1 Uranoplasty, 564 application of sutures, 565 raspatories for. 564 Urea in urine, 263 Ureteral catheterization, technic in examining small amounts of urine as obtained Ijy. 266 Urethral fever, 44 Urinary tract, infection with colon bacillus, urine in, 272 Urine, albumin in. 260 analvsis. 259 blood in. 267 chlorids in. 263 cryoscopy of. 264 electric conducti\itv of, 265 glucose in, 262 in acute catarrh of renal peh'is. 269 in acute cystitis. 269 in chronic cystitis. 269 in colon bacillus infection of urinary tract. 272 in cysts of kidney. 270 in floating kidney. 270 in hydronephrosis. 270 in malisnant tumors of kidney, 270 in nephralgia and allied conditions, 272 722 INDEX Urine in polycystic degener- ation of kidney, 270 in post-anesthetic neph- ritis, 267 in pyelitis with hyperemia of renal parenchyma, 269 in pyelonephritis, 270 in pyonephrosis, 270 in renal actinomycosis, 270 calculus, 271 tuberculosis, 271 in subcutaneous trauma- tism of kidney, 272 in suppurative nephritis, 272 in syphilitic renal hyper- plasia, simulating ma- lignant growth, 270 microscopic examination, 263 pus in, 267 quantity, 260 retention of, after opera- tions, 284 sugar in, 262 suppression of, after oper- ations, 284 technic in examining small amounts, as ob- tained by ureteral cath- eterization, 266 urea in, 263 Urotoxic coefficient, 265 Uterine repositor, Elliot's, 385 Utility, operations of, 280 Vagina, sarcoma of, 224 Valvular thrombi, 102 Varices of scalp, 434 Varicose aneurism, 96 ulcers, 69 veins, 100 rupture of, 101 Variolous laryngitis, 599 Varix, 100 aneurismal, 96 Vein, jugular, external, in- juries of, 627 Veins, aspiration of air into, 98 diseases of, 98 injuries of, 98 ligation in continuity of, 351 lateral, 344 multiple, 351 lumen of, obliteration of, . 103 operations on, 350 suture of, 344 Veins, varicose, 100 rupture of, 101 Velpeau's bandage, 415 Velum of soft palate, 558 Venereal sore, non-syphili- tic, 82 Venesection, 351 in wounds of heart and pericardium, 685 Venous and arterial hemor- rhage, differential diag- nosis, 99 angioma, treatment, 334 cysts of scalp, 434 hemorrhage, 98 arrest, 343 nevi of tongue, 556 stasis, 103 and its consequences, 103 gangrene after, 104, 105 Vertebrae, cervical, 641. See also Cervical vertebrae. Vertebral artery, ligation of, 637 column, cervical, bursa mucosa of, 649 carcinoma of, 649 congenital clefts of, 649 inflammatory affec- tions of, 645 sarcoma of, 649 tumors of, 649 Villous papilloma, 229 intracystic, 230 Vocal cords, paralysis of, after laryngeal diphthe- ria, 603 Volkmann's block, 424 bone curet, 318 method of extension in recumbent position, 647 Vomiting and nausea in anesthesia, 303 Ware's apparatus for open administration of ethyl chlorid, 303 Warty growths, sessile, of tongue, 557 Water, injection of, at high temperature, in tumors of skin, 334 Wens, 231 removal, 334 White corpuscles. See Leu- kocytes. thrombus, 104 Whitehead's gag, 559 operation for extirpation of entire tongue in can- cer, 552 Whitehead's operation for extirpation of half of tongue in cancer, 551 Wilde's polypus snare, 582 Windlass, Spanish, 337 Wire curet, 500 saw, GigU's, 312, 361, 362 Wood-wool, 63 Wound diphtheria, 180 Wounds, 1 antiseptic dressing, 56 aseptic, 2 classification and mechan- ism, 1 contused, 1 diseases of, acute, 177 drainage of, 56 dressing of, 55 foul-smelling treatment, 58 gaping of, 66 of edges, 321 granulating, 3 gunshot, 165. See also Gunshot injuries. healing by primary inten- tion, 2 by secondary intention, 3 by third intention, 6 histology of, 4 origin of connective- tissue cells during, 6 with suppuration, 3 without suppuration, 2 hemorrhage of, 2 incised, 1 lacerated, 1 mechanism and classifica- tion, 1 penetrating, 1 perforating, 1 poisoned, 2 punctured, 1 redressing, indications for, 57 separation of, 2 septic, 2 symptoms, 2 Wringer for hot towels, gauze, etc., 52 Wrist and hand, figure-of-8 bandage of, 418 palmar applica- tion, 418 Wryneck, 624, 650. See also Torticollis. ZiEHL - Neelsen stain for tubercle bacilli, 25 Zinc chlorid, 60 oxid ointment, 63 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE Ui - ^1 CZa (962) 50M 1 li A treatise on suroery ■■■III L__ 2002103265'