COLUMBIA IIBRARIFS OrfSlIC 1:,y'- ■ .'<,'.' '< ' : N' ' w-iX;,','' v<'.:Vr;> ^KC~ t0'fV:[_ B;;' 'k'u ■■ ■ ■ ■ '■■ H[n'' i.'>.V,'''- /■■•'•' ' ■• ^Hjj IB^-:'V^ ^' ■■ 1 Is ; v \ ^- ■'•. ~ . ^\,■'^■^■'^|^• -.^ , V *,' .'. A!^Vsr'N>;''.^''. Columbia ©nitif rsfftp intlieCftpaflrtogork THE LIBRARIES iHebical %ihvavp Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/iconogramscollecOOgard ICONOGRAMS ICONOGRAMS A Collection of Coloi-fd I'l.-ites From Prof. BOCKENHEIMER'S Atlas dkr Chirurgischkn Haltkrankhkiten" ILLUSTRATING Interesting Surgical Conditions EXPLANATORY TEXT WITH Special Reference to Diagnosis and Treatment ADAPTED AND REVISED IIV FAXTON E. GARDNER, M.D. Lecturer in the New York Polyclinic Medical School, etc. NEW YORK REBMAN COMPANY HERALD SQUARE BUILDING lU-145 WEST 3Gin STREET Copyright by Rebman Company, 1913 New York All rights reserved Gil 6l FOREWORD. This Atlas is not a text book, still less a series of extensive mono- graphs. No claim is made that any subject has been exhaustively covered. The sole aim of the text is to set forth, in as concise a form as pos- sible, the essentials of diagnosis and treatment, and, by comparison with the plates themselves, to establish in the reader's mind an asso- ciation between the objective aspect of a condition and the two points just referred to — which association cannot but be helpful when a simi- lar case occurs in actual practice. As a basis the plates in Bockenheimer's Atlas of Clinical Surgery have been used. The order of the plates has not been changed. Con- siderable thought was, however, devoted to this point. At first it was believed that another grouping of the figures (by anatomical regions, for instance) might prove more didactic and thus enhance the practi- cal value of the book, but, after several attempts, it was found that no arrangement was perfect — each one proved artificial in some respects and had its drawbacks as well as its advantages. The idea was then abandoned. The text has been completely remodelled. Things move rapidly nowadays in medicine. There is no subject on which the past five or six years have not brought some enlightenment; a few have, indeed, been absolutely revolutionized. The rewriting has been done from the standpoint of American methods, reference to which is, unfortunately, very scant in most Continental treatises. No theorizing has been indulged in, except when a direct relation to diagnostic or therapeutic principles was involved. In a book of this kind, comparison of different plates with each other is always very fruitful. This is the reason why all references to plates have been printed in bold type, by which means their im- portance is clearly and duly emphasized. CONTKXTS TUMORS. Figs. 1 to 54. CARCINOIMA. Figs. 1 to 23. pace Fig. 1. Rodeut ulcer -^ Fig. 2. Carcinoma of the skin of the forehead. ... 5 Fig. 3. Carcinoma of the lip ^ Fig. 4. Carcinoma of the nose 6 Fig. 5. Cai'ciuoma of the lip and lupus 9 Fig. 6. Papilloma of the tongue 10 Fig. 7. Papilloma and carcinoma of the tongue. ... 10 Fig. 8. Carcinoma and leucoplakia of the tongue. . . 10 Fig. 9. Ulcerated carcinoma of the tongue 10 Fig. 10. Carcinoma of the hreast 18 Fig. 11. Carcinoma of the male hreast. . • 18 Fig. 12. Carcinoma of the nipple 18 Fig. 13. P.iget's disease 19 Fig. 14. Cancer "en cuirasse." 19 Fig. 15. Cancer "en cuii-asse." 19 Fig. 16. Carcinoma mastitoides 20 Fig. 17. Carcinoma of the scalp 20 Fig. 18. Carcinoma of the scalp. Sebaceous cysts. . . 21 Fig. 19. Carcinoma of the penis 22 Fig. 20. Carcinoma of the skin of the leg (burn). . . 24 Fig. 21. Carcinoma of the hand (wart) 24 Fig. 22. Carcinoma of the hand (scar) 24 Fiff. 23. Melanotic cnrcinoinn 25 SARCOMA. Figs. 24 to 35. Fig. 24. Lymphosarcoma of the neck Fig. 25. Epii)haryngeal sarcoma. . Fig. 26. Angiosarcoma of the cheek Fig. 27. Sarcoma of the face. . Fig. 28. ^lelanosarcoma of the scalp Fig. 29. Sarcoma of the breast. . Fig. 30. Cystosarcoma of the breast Fig. 31. Multiple sarcoma of the skin vii 30 32 35 36 36 33 38 38 PAGE Fig. 32. Sarcoma of the linmerus 40 Fig. 33. Sarcoma of the forearm 44 Fig. 34. Chondromyxosarcoma 45 Fig. 35. Epulis 46 MIXED AND BENIGN TUMORS. Figs. 36 to 54. Fig. 36. Angioma of the tongnie 47 Fig. 37. Cystic fibroadenoma of the breast 48 Fig. 38. Cutaneous horn. Adenoma sebaceum. ... 50 Fig. 39. Endothelioma of the face 51 Fig. 40. Mixed tumor of the parotid 53 Fig. 41. Carpal ' ' ganglion. " 55 Fig. 42. Acute purulent bursitis 56 Fig. 43. Hygroma 56 Fig. 44. Cystic goiter 58 Fig. 45. Papilloma of the skin 61 Fig. 46. Dermoid cyst of the forehead 62 Fig. 47. Dermoid cyst of the prepuce 62 Fig. 48. Dermoid cyst of the neck 62 Fig. 49. Fibroma of the sheath of a tendon 64 Fig. 50. Multiple chondroma of the fingers. . . . -. 66 Fig. 51. Hemorrhoids 67 Fig. 52. Fibrolipoma 68 Fig. 53. Subcutaneous lipoma 69 Fig. 54. Symmetrical lipomata 69 MISCELLANEOUS LESIONS. Figs. 55 to 83. SCABS AND FISTULJE. Fig. 55. Granulating wound and epidermic grafts. . . 75 Fig. 56. Fistula due to insufficient drainage 75 Fig. 57. Congenital fistula of the neck 76 Fig. 58. Keloid after vaccination 79 Fig. 59. Keloid after laparotomy 79 MUSCULAE CONTEACTIONS AND BONY DEFORMITIES. Fig. 60. Dupuytren's contraction 81' Fig. 61. Cicatricial retraction of finger 82 Fig. 62. Ulnar "claw hand." 82 viii PAOE Fig. 63. Isehemic retraction of iiinsclos of tlio foro:inii. . 82 Fig. ()4. Hallux valgus and lianuner toe 87 Fig. 65. Racliitis 88 Fig. 66. Pseudarthrosis 90 N.'EVI, VASCULAR AND LYML'HATIV LESIONS. Fig. 67. Pigmentary n;T3Vus 9" Fig. 68. Pigmented niisvus and neurofilironiatosis. . . 92 Fig. 69. Neurolibroinatosis of the seal)) 92 Fig. 70. Acne rosacea and rliinopliyiua 95 Fig. 71. Elephantiasis of tlu' ])enis 96 Fig. 72. Elephantiasis of the fnot and varicose ulcer. . 97 Fig. 73. Detachment of the skin 99 Fig. 74. Othematoma 99 Fig. 75. Cutaneous angioma 101 Pig. 76. Vascular nixivus 101- Fig. 77. Spontaneous hemorrhages. Hemophilia. . . . 104 Fig. 78. Gunshot injury of the arm 106 Fig. 79. Traumatic asphyxia 107 Fig. 80. Cavernous angioma 101 Fig. 81. Cutaneous and subcutaneous angioma. . . . 101 Fig. 82. Arterial aneurysm 108 Fig. 83. Varices of the leg HI INFECTIONS. Figs. 84 to 131. ACUTE PYOGENIC PROCESSES. Figs. 84 to 114. Fig. 84. Acute purulent thrombo-phlebiti; Fig. 85. Subcutaneous abscess of the breast Fig. 86. Puerperal mastitis Fig. 87. Furuncle Fig. 88. Furunculosis Fig. 89. Carbuncle Fig. 90. Erysipelas of the face. . Fig. 91. Hemorrhagic bullous erysipelas. Fig. 92. Erysipeloid Fig. 93. Subepidermic whitlow. . Fig. 94. Subcutaneous whitlow. . Fig. 95. Osteal and articular whitlow. ix 122 123 124 125 125 125 129 131 133 133 133 134 PAGE Fig. 96. Tendon-sheath suppuration 1.34 Fig. 97. Interdigital whitlow 135 Fig. 98. Paronycliia 138 Fig. 99. Ingrowing toe nail , . . . 139 Fig. 100. Corns and bunions 140 Fig. 101. Gangrenous phlegmon 141 Fig. 102. Acute suppurative cervical adenitis. . . . 143 Fig. 103. Purulent alveolar periostitis of the lower jaw. 145 Fig. 104. Chronic osteomyelitis of the lower jaw. . . 154 Fig. 105. Acute osteomyelitis of the scapula. . . . 155 Fig. 106. Chronic osteomyelitis of the humerus. . . . 155 Fig. 107. Acute osteomyelitis of the tibia. Total necrosis of the dia]3hysis 156 Fig. 108. Generalized infection .157 Fig. 109. Gaseous gangrene 163 Fig. 110. Bubo 166 Fig. 111. Gonorrheal arthritis of the wrist. . . . . 168 Fig. 112. Malig-nant pustule (early stage) 172 Fig. 113. The same (later stage) 172 Fig. 114. Cervical adenitis 174 CHRONIC INFECTIONS. Figs. 115 to 131. Fig. 115. Actinomycosis of the cheek 175 Fig. 116. Actinomycosis of the neck. 175 Fig. 117. Marginal glossitis 177 SYPHILIS. Fig. 118. Syphilitic chancre of the tongue 178 Fig. 119. Gumma of the tongaie 182 Fig. 120. Gummatous ulcer 181 Fig. 121. Gummatous abscess. 181 Fig. 122. Gummatous osteitis 182 Fig. 123. Gummatous ulcer 181 TUBERCULOSIS. Fig. 124. Tuberculous cervical adenitis 192 Fig. 125. Multiple tuberculosis of joints 199 Fig. 126. Purulent tuberculous arthritis. . . . . . 199 Fig. 127. Fibrous arthritis. Ankylosis 200 Fig. 128. White swelling of the knee 200 X PAGE Fig. J 29. Tuherculosis of the testicle 202 Fig. L'!0. Tuherfulo.sis of the hand 201 Fig. I'M. S|)ina veiitosa 201 GANGRENES. BURNS. Figs. 132 to 141. Fig. 132. Moist gangrene of tlie foot 209 Fig. 133. Dry gangrene of tlie arm 209 Fig. 134. Gangrene of the skin and fascia 209 Fig. 135. Carbolic gangrene 211 Fig. 136. Burns 217 Fig. 137. Frostbite 220 Fig. 138. X-ray burn 219 Fig. 139. Perforating nicer. R.^yxaud's disease. . . 215 Fig. 140. Diabetic gangrene 212 Fig. 141. Gouty arthritis 222 MALFORMATIONS. Figs. 142 to 150. Fig. 142. Eucephalocele and rachischisis 227 Fig. 143. Spina bifida. Myelocele 229 Fig. 144. Spina bifida. Myelocystocele 230 Fig. 145. Multiple congenital cystic lymphangioma. . . 235 Fig. 146. Teratoma of the face 237 Fig. 147. Persistency of the omphalo-mesenteric duct.. 239 Fig. 148. Fetal umbilical hernia 240 Fig. 149. Amniotic constrictions of the fingers. . . . 242 Fig. 150. Acromegaly 242 TUMORS Figs. 1-54 A.— Carcinoma— Figs. 1-23 B.— Sarcoma— Figs. 24-35 C— Mixed and Benign Tumors — Figs. 36-54 Bockenheimer, Atlas. Tab. I. U U Rebman Company, New-York. CARCINOMA Figs. 1 to 5, inclusive, depict types of cutaneous carcinoma affecting the face. Cancers of the face are of great importance, because of their frequency. The nose, eyelids, cheeks, temples and forehead are the most common sites, while the chin and ears are least affected. In youth, these tumors are very rare ; when they occur, they are malig- nant degenerations of a xeroderma pig-mentosum (a disease described by Kaposi, and developing in the first years of life; characterized by multiple pigmentary spots on the parts exposed to sunlight, and atrophy of the skin. Epitheliomatous degeneration is common). In older people (fortieth to seventieth years), cutaneous carcinoma of the face is frequent and develops from pre-existing warts, cutaneous horns, adenomata {see Fig. 38), dermoid or sebaceous cysts (for a similar condition originating in a wen, see Fig. 18), or on a ground prepared by chronic irritations of the skin (erysipelas, eczema, sebor- rhea, excessive exposure to rough weather, sailor's skin). In old country people the flat carcinoma, of the types shown in Figs. 1 and 2, is of common observation, being, as it is, favored in its development by early wrinkling of the skin, uncleanliness and senile seborrhea, causing an accumulation of dirty scales on the skin. When these epidermic scales are scratched, superficial, easily bleeding sores are formed, which, however, heal quicklj^ as long as they are not cancerous. Fig. 1 shows a so-called "Rodent ulcer," that is, a flat, very superficial, cutaneous cancer, in a tyjiical situation on the face; still clear of the subjacent tissues. Rodent ulcer, which, of course, may be observed not only on the face, but in any point of the skin, presents itself at first as a hard, flat, reddisli nodule wliich, when scratched or broken, forms a shallow ulcer with little tendency to heal. Of slow growth, and never attaining a conspicuous size before several, and often many, years, it generally remains a long time unnoticed by the patient, especially as it causes no inconvenience or pain. Wlien it presents itself as a growing superficial ulceration, this usually has a circular shape with hard, slightly raised edges of overlapping 3 thinned epidermis ; while the floor of the ulcer is, for the most part, soft at first, and the whole growth is movable over the deeper structures. It is characteristic of these cutaneous carcinomata that plugs the size of a pin's head can be squeezed from the yellow surface of the ulcer ; microscopic examination shows these to consist of broken-down, fatty, cancer cells. The ulcer is often covered by a scab, so that the diagnosis is only possible after its removal. As the tumor extends there appear radiating contractions of the surrounding skin and con- sequent deformity (of the eyelids, for example). The original circular shape is then often lost, and the outline becomes irregular (Fig. 2). At first superficial, the tumor may after some years extend to the deeper parts and cause extensive destruction; for instance, of the bones of the face (Fig. 4). This deep extension is especially seen in parts where the subcutaneous fatty tissue is not developed (the tem- ples, bridge of the nose and zygomatic arch, etc.. Figs. 2 and 4) ; and it is also evidenced from the beginning by the decrease in mobility of the tumor over the subjacent structures. However, the tendency to deep extension is very little marked : but the extension in surface is practically unlimited, old ulcers sometimes attaining a huge size. On account of the spontaneous cicatrization, which may take place at different parts of the ulcer or over its whole surface, although it is not permanent, these growths were formerly wrongly placed in the group of benign tumors under the name of cancroid. Certainly metastases are by no means as frequent as in other cancers; the gen- eral condition of the patient for years remains unimpaired while the ulcer is but slowly expanding; recurrence seldom takes place after complete removal ; so that, as a rule, ulcus rodens is not possessed of the high malignancy of the cancers of mucous membranes and glandu- lar organs. It is, however, an unquestionably malignant lesion. Its microscopic structure is that of baso-cellular epithelial cancer. The appearance of rodent ulcer is typical and, oftentimes, the diagnosis is not difficult, provided care is taken thoroughly to remove the overlying scab to bare the real surface with its slightly raised and everted epidermic edge. However, particularly in the region of the chin, an extragenital syphilitic chancre, especially if modified by local caustic applications, might show a certain resem- blance, but the early adenitis and the demonstration of the spirochetse pallidse would clear up the doubt. A tertiary gumma or an atypical lupus iniglit also be mistaken for a rodent ulcer. The notion of age is very important, ulcus rodens being a disease of elderly people. In all doubtful cases, microscopical examination of an excised fragment is the quickest and best way to settle the question. Transient epidermization can generally be promptly obtained in small flat ulcers by antiseptic dressings. A permanent healing is, however, not to be obtained by this means, ;mil under the scar, columns of epithelial cells keep on proliferating. Treatment Early excision, about half an inch beyond the ulcer in healthy tissues, and of suflicient depth, is the treatment preferred and almost exclusively advocated by uuiuy surgeons; and was in fact, success- fully applied in the case shown in Fig. 1. The defect was repaired by a pedunculated flap taken from the left side of the forehead, where the loss of substance was covered with Thiersch grafts. Rodent ulcers are frequently situated in the vicinity of structures important to consider for cosmetic results (eyelids, nose) : the gap created by the surgeon is often surprisingly large, owing to the ten- dency rodent ulcers seem to have to draw tissues toward them, so that a plastic repair is by no means a simple task in many cases. This is why many dermatologists prefer treatment by scraping with the sharp spoon, followed by cauterization with acid nitrate of mercury, and subsequent applications of X-rays. Such a treatment gives excel- lent results {She r well) provided it be very thorough. If incom- plete, it simply accelerates the progression of the ulcer. It can be carried out under local anesthesia. Good results have been reported from the use of radium (Abbe). X-ray treatment alone is also effi- cient, especially the single dose method {Mackee) in which the ulcer- ative type requires about 1\\ Ilolzhnecht units, and the nodular form iibout 114 of the same units. Finally, caustic pastes, tabooed by sur- geons, have given favorable results in the hands of dermatologists {Robinson, Pusey). Fig. 2 shows an advanced carcinoma of the skin of the fore- head with irregular borders. The growth has already extended to the bones. The upper eyelid and the ocular conjunctiva are also involved. This is a case of the rare form of cancer of the skin first described by von Bergmann, which in its early stages appears in the form of small multiiile nodules and may therefore be mistaken and treated for tuberculosis cutis (lui)us). The raised, irregular, hard edges of the 5 Tilcer point to the correct diagnosis, wliich in doubtful cases should be cleared up by removal of a piece for examination. Previous treatment with X-rays had caused a rapid extension of the carcinoma, so that the patient came to the clinic in an inoperable condition. When carcinoma of the face extends through to the dura mater, the patient may die of meningitis ; operation is contraindicated and the palliative treatment alone comes under consideration. This treatment consists in disin- fection by antiseptic dressings with potassium permanganate and hydrogen peroxide. Later on, cauterization with the actual cautery,. or cautious fulguration (sparking with the high frequency current) may make the condition less unbearable for a time. Fig. 4 shows a cutaneous cancer with extensive deep growth, hav- ing destroyed the bony framework of the nose and the ethmoid cells. This form of cancer in its early stage consists of subcutaneous nodules covered by unaltered skin. The skin gives way when the nodules break down and a very extensive and deep cancerous ulcer results. This may be mistaken for a gumma, but the latter is not so ragged and has a yellow core. (Cf. Fig. 120.) The presence of epithelial plugs is also characteristic of this form of carcinoma. Microscopical examination, the Wassermann reaction and antisyphilitic salvarsan treatment will decide the diagnosis in doubtful eases. The papilloma- tous forms (Fig. 4), which often give rise to deep cutaneous cancer through their rapid growth and metastatic formations, must be re- garded as extremely malignant tumors. In all cases of extensive carcinoma of the face the patients may die- from septic pneumonia when the destructive process reaches the buccal cavity. Permanent results may sometimes be obtained after radical opera- tions which often necessitate removal of diseased bones, but these of course are very disfiguring. Inoperable cases may be somewhat relieved by the palliative treatment already mentioned. Fig. 3 shows a carcinoma involving the whole lower lip. Cancers of the lip resemble cancers of the skin in form and structure, for they have the structure of squamous-celled epithelioma and tend to cornification. Theirs is intermediate between the com- paratively low malignancy of cutaneous cancer and that — very high — of lingual carcinoma. They arise as cauliflower-shaped, polypoid tumors on the mucosa of the lip or as deep, ragged ulcers. Both these principal varieties are found in cancers of all mucous raem- Bockeiilicimcr, Atlas. Tab. II. U RchiiKin Company. New-York. hr;iiios cdvi'i-cd with ciiitlicliiiiii (cliccks, toiiniu', jioiiis, etc.). This is well slmwii ill Fig. 3, \\ln'i(' (l('c|) ulcerations alternate witii |i;ipill()iii.il(iiis growths. In sciiiic p.-irts llici'e are soal)s on tlie surface of tlie ulcers; in others isolated, yellow, epithelial i)lu.u;s. CarcinoMiii of the upper lip is very I'ai'c. A few cases have heen IMlhlislu'd ill wiiicli Mirh ;i c'l l-cilKilii.-i dc\'el(ipcd al'icr (Hie of the lower lip, in a syimiiet rical position. Carcinoma of the lower lip is almost exclusively a disease in the male sex, and seemingly more frerpient in smokers, although the part played by tobacco, admitted by a iiia.jority of writers, is stoutly denie(l liy others. Labial leucoplakia, similar to that observed on the tongue {Cf. Fig. 8), and closely allied, as is the later, to syphilis (see page 8), may degenerate into cancer. Antecedent tul)erculous disease also seems to be a cause favoi'ing the development of cancer. (Fig. 5 is an example of this mixed condition.) Cancer of the lower lip often begins at the junction of the skin with the vermilion border of the lip, generally between the midline and the angle of the mouth, as a small, hard nodule at first covered by mucous membrane. The latter soon becomes broken and the nodule grows, infiltrating the surrounding tissues rapidly, while the mucosa breaks down more and more, and thus is formed an ulcer. The whole of the lower lip may be gi-adually destroyed (Fig. 3)- Scabs and crusts form at several places on the ulcer, and when separated cause bleeding. In its early stages the cancer is only an ulcer with hard, raised edges and a crateriforni floor, but later ]iaiiillomatous proliferations spring from this floor (Fig. 3). The more the carcinoma extends, the more it implicates the underlying liones and the mucosa of the cheeks and floor of the mouth, so that all these structures may be completely destroyed. The exudation of growing cancer of the lip gives rise to marked cachexia, gastritis and enteritis, and the secre- tion maj^ reach the lungs and cause death from septic ]meumonia. In such inoperable forms the submaxillary and submental regions are usually lilleil with hard, fixed glands. UilJcnndal Dkiynosis Although these advanced runiis. which are often neglected, espe- cially in country people, are umnistakable, there may be difficulty in diagnosing a cancerous nicer in the early stage, when it is most important. The irregular, ragged surface of tlie carcinoma is in 7 marked contrast to the smooth, raised surface of a primary syphilitic sclerosis, far from uncommon on the lip. The comedo-like epithelial plugs which are pathognomonic of squamous-celled epithelioma can be extruded from it by pressure. The submental and submaxillary glands are involved early in both cases, and as there are no character- istic clinical symptoms in either case sufficient to differentiate the adenitis, scraping of the surface of the ulcer and a dark field illumin- ator search for sinrocheUe, or the excision of a piece of the tumor for miscroscopical examination, are imperative. This procedure is to be preferred to a test course of antisyphilitic treatment, because it wastes no time, a precious advantage when dealing with malignant growths. An ulcerated gumma of the lip may resemble a carcinomatous ulcer. Here also, if anamnesis and a positive Wassermann reaction are not suthcient to clear any doubts, histological examination must be resorted to. The difficulty is still increased by the close relations between syphilis, leukoplakia and cancer and the existence of hybrid forms. In a general way, gummata are covered with a special, tenacious, yellowish deposit and do not exhibit the hardness of cancerous formations. Primary tuberculosis of the lip, or the extension of a tuberculous ulcer of the buccal or lingual mucosa, is rare on the lip. The irregu- lar edges are not raised and remain soft. The surface of the ulcer has the anemic, reddish-gray color of all tuberculous ulcers; and at the periphery, there maybe some small, non-ulcerated tubercles. The ulcer bleeds easily, is generally covered with a single large scab ; no plugs can be expressed from it. Glandular enlargement is frequently .absent : when it exists, it is soft and involves but few lymph nodes. An ulcerated cavernoma (cavernous angioma) may look some- what like cancer, but the young age of the subject and the coexistence of other anomalies of the blood-vessels is conclusive. The induration of fissures of the lips resulting from chronic «czema heals quickly under appropriate treatment. Much depends on an early diagnosis, because a small tumor may be •easily removed by a cuneiform excision, while large growths neces- sitates difficult plastic operations; the results are much less certain, and the disfigurement is much more marked. This removal must always be preceded by a thorough cleaning of the submental ^nd submaxillary glands. In extensive tumors, from half an inch 8 Bockenheiraer, Atlas. Fig. 5. Carcinoma labii inferioris — Tuberculosis cutis. Rebman Companj', New-York. to an inch of lienltliy tissue sliould he removed heyond the margin of tlie growtli, and tlie n('i,u:hl)orin.u- i^irts suspected of disease, such as hones and huccal mucous meml)rane, sliould also he excised. In the case represented in Fig. 3, the extensive defect was repaired by douhle clieilo])lasty aiiil a cure was ohtained. Fig. 5 rcprofiils a large cancerous ulcer, niiij:iiiatin,i,' t rom tuberculosis of the skin, iinolvin.e; half the lower lip. Such an association is not very rare; and most of the destructive forms of lupus described under the name of lupus vorox seem to depend on it. The hard, raised edjjes of the ulcer divested of mucous membrane are characteristic. The floor of the ulcer is irregular and ragged and beset Avith yellowish epithelial plugs. Cancerous ulcers developing on a previous tulierculosis of the skin have a great tendency to bleed. In contrast to hypertrophic lupus, which gives rise to soft, fungoid, slow-growing tumors, the hardness and rapid growth of Inpus- carcinoma is characteristic. Excision of the carcinoma, removal of the glands, and rejiair of the defect by Dicffciiharli's cheiloplasty led to a cure. Fig. 5 also shows a charactoiistii' jucture of different forms of cutaneous tuberculosis (lupus) of the face. Lupus appears most frequently in this situation, usually begins on the nasal mucosa,, and extends over the face in the shape of a butterfly. The sharp, irregular outline on the forehead, neck and behind the ears is char- acteristic. The disease begins with small reddish-brown, opple-jcUi/ like nodules situated in the cutis and causing exfoliation of the epidermis (lupus exfoliativa) ; these become confluent and form flat, reddish-gray, easily bleeding ulcers (lupus exulcerans), which after healing leave radiating cicatrices, often after considerable destruc- tion of tissue. (Fig. 5, ear). After a time papillomatous jirolifera- tions of soft and spongy consistency may arise, especially about the ear (lupus hypertrophieus). These three forms are often present in the same patient. The characteristic lesion of lupus i> the liiir/ of sniall apple-jcUf/ tubercles at the i)eriphery, while the center has already healed. If tho.se elements are found, the diagnosis is certain, unless we are deal- ing with some mixed lesion. Tieiitmail The treatment of siikiU, wcll-circumscrilied lupic lesions may be surgical excision followed by simple suture or plastic repair. 8crap- 9 ing, scarifications, cauterization (thermocautery, hot air) and appli- cations of strong caustics have been less used since phototherapy (Finsen) and radiotherapy have given brilliant results. These are now the real methods of treatment. Radiotherapy is more within the reach of all practitioners than is phototherapy. Freezing with a stick of carbonic acid snow has sometimes' been employed with good success {Pusey) on small nodules or patches. The general dietetic and hygienic antituberculous treatment is a great help; and injections of tuberculin (TE) in small doses, to avoid general reaction, may prove useful in refractory cases. Figs. 6 to 9, inclusive, represent epithelial newgrowths of the tongue. To be compared with Figs. 36, 117, 118, 119). Fig. 6 shows a flat papilloma which was removed with the sharp spoon. (About the nature of papilloma, see page 61.) Fig. 7 shows on the left half of the tongue an extensive papil- loma, and on the right a superficially ulcerated carcinoma. Fig. 8 shows a deep carcinoma developing under a patch of leucoplakia: it is not jet ulcerated and is characterized by its hardness and irregular outline. This central location is exceptional. Fig. 9 represents the most common form of cancer of the tongue: a carcinomatous ulcer of the side of the tongue with ex- tensive destruction, leucoplakia and glandular metastases. Cancer of the tongTie is seen almost exclusively in men after the fortieth year. Alcohol and particularly tobacco favor its develop- ment. The lesion shown in Figs. 8 and 9 and called leucoplakia plays an interesting part in the production of ling-ual cancer. Leucoplakia is a hyperkeratosis of mucous membranes, particu- larly frequent on the tong-ue and on the buccal mucosa, but which has also been observed in other mucosfe, e.g. bladder and glans penis (see page 20). It forms hard, white, opaline patches consisting of horny epithelium and raised above the surface of the adjacent mucous membrane. The nature of leucoplakia is uncertain. For- merly, it was considered as a special disease in itself (buccal psoriasis) : more recently, chiefly under the influence of Fournier 10 Bockenheinier, Atlas. Tab. IV. Fig. 6. Papilloma linguae. Fig. 7. Carcinoma et Papilloma linguae. Fig. 8. Carcinoma linguae incipiens. Fig. 9. Carcinoma linguae exulceratum. — Leukoplakia. Rebman Company, New- York. aud his pupils, it has liecii coiisiikTi'il as a pnrasyiihiliti<; keratosis — that is, an affection of sypliilitic orit/iu. Iml, not (if syphilitic nature — devfloiiinn" inulor tlic cornhiiHMl iiitluciirc df syphilis and tol)acco. Tlii.v view is iiiiw liclil li\ liic iiiajmily (if sypliilologers. A third opinion contends that IIh'ic aic Iwi. kinds dl' Iciicoijlastic lesions: first, genuine leiicophihin. liypi'ikcratosi.v of unkiiovvn origin, hut having nothing to do with syi)liilis; second, pseudo-lciicoplakia, much more frequent, which is the so-called i)arasyphilitic "leucoi)]alva" of syphilologers. Tiiis tliird ojiinion seems tlie most rational, but, practically, tlie ]ioint is not of nnich iini)ortance, l)ecause, he it pseudo- leucoplakia or genuine leucoplakia, all these patches of hyperkera- tosis have an unfortunate tendency to undergo malignant epithelial degeneration. In fact, cancer is the natural outcome of leucoplakia of long standing; and lingual leucoplakia is found in the antecedents of one-half of the cases of lingual cari-iiKniia. The surface of the patch, at first smooth and painless, after a time becomes fissured, especially after excessive smoking, and the lesion becomes deeper and sometimes exceedingly painful. The treatment of leucoplakia consists in the avoidance of tobacco, alcohol aud spicy food, and in the removal of patches, either with the knife or with the thermo or galvano-cautery. This is possible only when the patches ai-e not too extensive. Simple cauterizations which do not destroy the leucoplakia patch are worse than useless, because they merely irritate and tend to promote malignant degenera- tion, without being able to cure. Besides leucoplakia, jagged carious molar teeth also act as ex- citing causes of cancer of the tongue, which explains the almost exclusive occurrence of cancer in the posterior part of the side of the tongue. Lingual carcinoma appears in two forms, according as it arises from the superficial miicnus membrane or from the fjlandular epifkeUu)n. The first form rosemlilcs a flat cutaneous carcinoma and soon gives rise to a small ulcer with hard, raised edges (Fig. 7, right half), the fissured surface of which has a yellowish or dirty-brown appear- ance. Although the carcinoma is only superficial, the .submaxillary glands are soon affected, owing to the alnindant l>nii)hatii's of the tongue. Deep carcinoma begins as iiard nodules over which the mucous memlirane remains intact for a long time. After the breaking down of the nodules and destruction of the mucous membrane, an extensive crateriform ulcer is formed with hard, irregular edges aud deep^ 11 fissures in the center. This often reaches as far back as the epiglottis. Numerous epithelial plugs can be expressed from the floor of the ulcer, and often from the papillomatous proliferations. The patients suffer great pain from the irritation of free nerve endings in the floor of the ichorous ulcer, and, in untreated cases, usually succumb within a year from glandular metastases extending along the carotid to the supra-clavicular region (as was the case in the patient repre- sented in Fig. 9). Early diagnosis is, therefore, of the greatest possible importance. Diagnosis The superficial carcinoma (Fig. 7) is recognized by the character- istic features of flat cutaneous carcinoma and differs from syphilitic chancre (see Fig. 120) by its sharp, hard edges, the irregular floor of the ulcer with epithelial plugs, the absence of spirochetse pallidss in the scrapings examined under the dark-ground illuminator. As long as a flat carcinoma of the tong-ue is covered with mucous mem- brane it may in its earliest stages be mistaken for papilloma (Fig. 6), especially in the rare cases where it lies more in the center of the dorsal surface of the tongue. Papillomata, however, generally appear as multiple, soft elevations the size of a pin's head, so that the surface of the tongue may appear dotted with small points, or may assume a lobulated form; or there may be fungiform sessile tumors, like stalactites, which often form high projections and have a warty appearance (Fig. 7). A flat carcinoma and a papilloma of this kind may occur independently without microscopic transition into each other. Small papillomata cause the patient hardly any incon- venience and can be removed with the sharp spoon or Paquelin's cautery. Larger papillomata should be excised (Fig. 7, left half). A small carcinomatous ulcer of the edge of the tongue is liable to be mistaken for ulcerations caused by the irritation of broken teeth (dental ulcers), especially when it is situated opposite a sharp tooth; however, the cancerous ulcer continues to grow after removal of the offending tooth. Larger ulcerations which result from the breaking down of deep carcinoma may be confounded with a gumma on superficial examina- tion. The latter, however, is almost always situated in the center of the tongue or in its anterior part, and has the characteristic dirty- yellow, gummatous core, which can be removed without bleeding (Fig. 119), in distinction to the easily bleeding reddish-brown pro- liferations of carcinoma. Moreover, the pain radiating to the ear 12 which is constnntly present in larp;e oarfinomnta is alisont in jjurnjna; also tlie glandular metastases and the leucoplaUia. Tn cases of small, non-ulcerated tumors, tlie diagnosis is more diriicuH ami iiiay again liesitate l)et\veen a cancer and a gumma. Here the Was^ermaiin reaction is of little helji when negative; it simply increases the suspicion of cancer witliout proving anything; a test course of aiitisy|iliilitic t rcalmi'iit wastes tdn inin-li precious time so that //' tlie iHitinntsis Is rmlln Impossible h// c/iininl means, excision of a jiiccc ami immediate hislnhir/ical examination i)y a corn- competent j)atluilogist is justilied, Init only if radical removal is to follow without delay, should malignancy be proved (as unfortunately happens practically in all "suspicious" cases); else such excision has all the inconveniences of partial ablation in cancer. The diagnosis is also difficult when, as in Fig. 8, a hard, carcino- matous nodule develops under a patch of leucoi)lakia. The irregular, deep, hard infiltration and the rapid increase point to a commencing new growth, which should always be removed before it breaks through, especiall\ as when there is lencoiilakia over the nodule, malignancy must always be suspected. Semi-chronic abscesses of the tongue, V'^u]] result iVdiii injury by foreign bodies (steel pens, etc.), and form hard lumps in the sub- stance of the tongue, are characterized by the early painfulness on IDressure. Actinomycosis causes a more diffuse, woody infiltration of the whole tongue and very soon interferes with its motion. Treatment Tlio treatment of lingual carcinoma is always total removal of the tongue and its lymph glands. Partial excisions are always iusulticient, even in the rare cases of seemingly well localized lesions of the anterior half, and excision of the tongue without the lymph glands should never be performed. The best surgical technique for the removal of the tongue is that in which, as a preliminary step, all the lymph glands of the sub' maxillary and submental regions are cleaned out and both lin- gual arteries are ligated. This step is wholly aseptic, 'flic extirpa- tion of the tongue is effected a few days later. It is almost bloodless, owing to the previous ligation of the lingual arteries, and, the tongue being already markedly shrunken, its removal is nmch easier. There is less chance of being compelled to tlivide the lower jaw, either in the midline or laterally; however, such a division remains necessary if the carcinoma extends far back. 13 Even after extirpation of extensive portions of the tongue the patients, after a few months, can make tliemselves well understood. Permanent cures are, however, unfortunately rare, even after radical operations performed before any hardened lymph nodes can be felt in the submental region, so that some surgeons content themselves with the local palliative treatment of carcinoma by applications intended to relieve pain. X-ray, radium, and high frequency treat- ment does not yield results in lingual carcinoma. Early and extensive removal is the only hope, and it is none too promising. The treatment of cancer of the buccal cavity, which often develops from leucoplakia, with the same symptoms and objective aspect as lingual carcinoma, is carried out on the same principles. The closure of extensive defects of the cheek is no easy task in most cases. A mucous lining must be provided for the buccal side. Cicatricial retraction often hinders almost completely motion of the lower jaw; section of the ramus of this bone at the time of operation prevents this cicatricial ankylosis (Bodine). Figs. 10 to 16, inclusive, show a number of types of carcinoma of the breast. (Other lesions of the breast, see Figs, 29. 30, 37, 85 and 86.) Of the carcinomata of glandular organs those of the female mam- mary gland are among the most common (they take the third place). A division into soft, many-celled, rapidly growing tumors of which the medullary cancers represent the most malignant, and slow- growing scirrhous forms with few cells, is of clinical importance. The exciting causes include inflammatory irritation, puerperal interstitial mastitis, eczema of the nipple, antecedent benign tumors (fibro-adenoma, cysts), injuries, mechanical irritation, frequent par- turition with prolonged suckling of infants. Cancer of the breast is attributed by the laity to injuries (blows), but these are often too recent to be accepted as an etiological factor, considering the slow growth of the carcinoma. The activity of the gland in lactation is a predisposing cause of cancer. Only 10 per cent, of the cases of breast carcinoma are seen in sterile women. The weakening action of pregnancy and lactation is well shown in the type known as carcinoma mastitoides (Schur- man) or mastitis carcinomatosa {V olkmann) (see Fig. 16), which is the most malignant form of all. Women are most often affected at the menojoause (fortieth to 14 Bockcnheimer, Atlas. Tab. V. Fig. 10. Carcinoma mammae — Lympliomata carcinomatosa. Rebman Company, New-York. fifty-fifth years), and come to tlie surgeon with nodules in tlie l)reast wliich liavo l)een hitherto ])ainh>ss and are only ar-fidentally ohserved. Tliese nodules very soon I'diin .-i iii;iliu!iaii( u'rowtli ol' lianl I'Diisisteney and irregular surface. The most iiii|Hirlaii1 siiiii ol' a nialiL;iiaiit jiew growth is the absence of any demarcation or encapsulation. The tumor cannot, like all benign luiiiors, lie separated rroin the mannnary tissue and moved freely, hut is fixed iinmovaMy in the glandular tissue, with ill-defined boundaries, and is nncluireil in the meshes of the mammary tissue by numerous offshoots. The nodules, wliirh at first ajtpear liarmless, thus soon show their malignity. Progressively the tumor sends its destructive extensions in all directions into the neighboring tissues, without limit or restraint, and reaching the surface adbei'es to the skin and causes dimpling of the skin, retraction and fixation of tfie nipple. Finally, it gives rise to a liard inflammatory infiltration of the whole of the overlying skin. At the same time the tumor extends deeply and soon intiltrates the lymphatics beneath the pectoralis major muscle and also the regional lym])hatie vessels and glands of the axilla (Fig. 10), which are usually affected about a year after the formation of the nodules in the breast, and take the form of hard, solid, painless lumps, which are often difiticult to feel in corpulent women. Extensive glandular involvement gives rise to radiating pain and edema of the arm (supra-clavicular glands). Although the cancer usually arises as a single nodule, there are cases in which several nodules develop simul- taneously (Fig. 10) and extend through the whole breast to the axilla (Fig. 10). The prognosis is unfavoiable in these cases, and in disease of both breasts (Fig. 15). Cancer is very frequently situated in the upiiei- and outer quad- rant of the breast, especially on the left side. The tumors situated in the outer half of the mamma towards the axilla, wrongly called paramannnary earcinomata, are really glandular cancers, for they originate in the offshoots of the mamma, which extend toward the clavicle, stei'num, axilla and twelfth rili in the form of long, thin cords. Cancer of the breast, like all cancers rich in cells (acinous, tubu- lar), grows rapidly, es]ieci;illy during pregnancy, and causes destruc- tion of the skin. A cancernns ulcer results, characterized like cutane- ous carcinoma by its liai-d. laised, tixed borders, crateriform base and sanious discbai-ge. A liaiil inlilti-ation develops around the tumor, which is usually liiinly iidlinent t' old i)eople, and in cases where organic metastases ai-e pi-esent. X-ray treatment is good in the post-operative period, but cannot cure cancer without operation. A carcinomatous nodule ma.v disin- tegrate and disapjiear under its influence, and sui-face epidennization occur, but the canccr(nis pi-ocess continues in the deeper tissues. The 17 same is true of radium and fulguration. Nevertheless, X-rays, fulgu- ration, scrapings, cauterizations are useful in the palliative treat- ment of inoperable cancer. No cancer serum has as yet gone beyond the experimental stage or given durable results. Fig. 10 shows an acinous carcinoma forming several nodules in the breast, already infiltrating the skin. The axillary glands are felt as hard, fixed, indolent lumps, and a chain of nodules can be easily traced from the mammary gland to the axilla. The nipple is retracted and fixed, and the whole breast is diminished in size. Opera- tion was performed in the i;sual way. The patient was already emaciated. Fig. 11. A single cancerous nodule in a male breast. The skin has broken down and shows a cancerous ulcer with hard, raised, jagged edges, which has destroyed the nipple. The floor of the ulcer is irreg-ular and the whole tumor is fixed to the pectoral muscle. At the edge of the ulcer the skin is radially contracted and shows iso- lated cancerous nodules. The axillary glands are hard, visible and hardly movable. In spite of the small size of the tumor, there was already cachexia. After removal of the mamma with the pectoralis major and the axillary glands the wound, which could not be com- pletely clofeed by suture, as is frequently the case in women, but almost the rule in men, was repaired by Thiersch {see Fig. 55) grafts. Cancer of the male breast (about 1 per cent, of all mammary carcinomata according to Schuchardt) generally arises as a small, hard nodule (scirrhus) in the neighborhood of the nipple and gives rise to a typical cancerous ulcer. The tumor occurs between the fortieth and seventieth years. Fig. 12 shows a very rare case of carcinoma arising from the nipple (squamous-celled epithelioma). This is more common in men than in women. It begins as a hard infiltration of the nipple, in the same way as does incipient carcinoma of the navel. The nipple is much retracted and the whole areola is transformed into a rigid wall. A cancerous ulcer soon develops which destroys the nipple and areola. At first there is no connection between this cutaneous cancer and the mammary gland. The treatment consists i)! early extirpation of the mammilla with 18 I^nrkcnlipiincr, Atlas. Tab. VII. I"itr. 12. Carcinoma maiiiiiiillac. Ri'lnii.iii Comp.iiiy, Ncw-\'ork. Bockcnheiiiicr, Atlas. Tab. VIII. Fig. 13. Carcinoma mammae — Pacret Disease — Eczema cliroiiiciim mammillae. Rcbman Company, iNcw-York. ockenlieinu'i, Atlas. I'iy. 14. C-'aiiiiKima niaiiimae - Disscminalioiics. 'bni.tii ('(iinp.iuy, Nc\v-\'ork. iockciihcimcr, Alias. Tab. X. Kebinan Company, New-York. the subjacent iii.iinin.ny tissue, by means of an oval incision with subsequent suture. KecuiTence is rare after early treatment. In doubtful cases with induration of llic maininilla excision should always be pcrforinod. Fig. 13. Paget' s disease, nr chronic eczema of the nipple, wliicli is rofrac'lory lo all trfalinciit. Tlii' (■(•zciiia lii'i;iiis on tliu nipple and .uTadually extends to the areola and surrounding skin. Retraction of the nipple and dra.irs'ing i)ains are caused by the pres- ence, under the nipple, of carcinouia (cyiiuder-epithelioma), which at first has no connection with the nipple, but later on may become attached to it. The mammarj'^ gland in this ease shows hard infil- tration around a nodule. In the normal parts of the skin there are small dimples. Obstinate eczema of the nipple accompanied by a tumor in the breast, with infiltration of the axillary glands and early cachexia, make the diagnosis clear and indicate removal of the whole mammary gland with the axillary glands. In cases of chronic eczema of the nipple resisting all treatment, excision of the mammilla is advisable. Out of 884 cases of mammary carcinoma in v. Bergmann's clinic there were only seven typical cases of Paget's disease. Two of the author's cases showed cancer of the mammary gland without connection with the eczematous ni])]ile. Fig. 14. This is a case of tubular carcinoma with cutaneous dissemination which has extended in all directions and spread over the thorax. The development of nodules in the skin occurs early. These appear at first as punctiform, bluish, glistening elevations, which increase in number and size and coalesce, forming a kind of cuirass inclosing the thorax in a rigid mass {"Cancer en cuirasse"). These cases are inoperalile. Fig. 15. This is a case of inoperable cancer "en cuirasse," in whi<'h both mamma> are affected with carcinoma. On the right side there has been a recurrence of the growth in the scar soon after opera- tion, where a soft, fungating, easily bleeding ulcer is seen. In the surrounding skin there are several isolated nodules. The left mam- mary gland is involved in a hard, immovable, carcinomatous infiltra- tidii. Tlie transmigration (if a caicinoma from one side to the other is possibly cx]iliiIiH'd liy the ]>ersistence of congenital lyiiii)liatics. 19 Fig. 16. At first sight this appears to be a pyogenic inflamma- tion. (Compare with Figs. 85 and 86.) However, the bluish color, the retraction of the nipple, the hard, immovable breast forming a large tumor, and the extensive metastases in the axillary and supra- clavicular glands lead to a diagnosis of carcinoma. Volkmann has named this not very rare form of cancer mastitis carcinomatosa and Schurman carcinoma mastitoides. That we have here to deal with an affection of the lymphatics (lymphangitis carcinomatosa) is shown by the jDunctiform red spots between the two breasts, the larger punctiform or circular spots below the clavicle and the changes in the region of the neck. The latter is of a blue color and the seat of a hard infiltration, which is not inflammatory, but due to lolugging of the lymphatics with cancer cells, and consecu- tive edema. This form of cancer is hardly seen except during preg- nancy or lactation, when there seemingly exists a special vulnerability of the breast cell. Therefore this acute form of carcinoma is seen more frequently than the other forms in young women ; and in not a few instances, it is bilateral. The last three plates (Figs. 14, 15 and 16) show the terrible effects of advanced cancer of the breast, so that the necessity for the earliest possible diagnosis and radical removal by operation must once more be set forth emphatically. Fig. 17 shows a rapidly growing tumor developed, in a man aged 37 years, on a congenital n«vus. Degeneration of such a nsevns, of an old sear, ulcer, wart, sebaceous cyst (Fig. 18) or mole, is the origin of all cancers of the scalp, which are very rare. Papilloma, sarcoma and melanoma are other possible evolutions. The cutaneous covering of the nsevus was quickly destroyed and the tumor was formed by cauliflower growths separated by deep fissures. The ulcerated surface was covered with sanious secretion, so that the naked-eye appearance was not sufficient to establish whether the case was one of sarcoma or carcinoma. However, the malignant character was not doubtful, on account of the rapid growth, the cachexia and the lymph-gland metastases, which soon extended along the large vessels of the neck down to the supra- clavicular fossa. These lymphatic metastases favo.r the diagTiosis of carcinoma as against that of sarcoma. This case was inoperable. A less advanced tumor, without any 20 B keiiliciiiRT, Atlas. % Fig. 16. Carcinoma mammae. — Lymphangitis carcinomatosa. :bnian CoTuiiaiiy, Ncw-Yoik. Bockenheimer, Atlas. Tab. XII. U < u palpable lymph glands, would iciiuiic a wido excision of the tmiior and oi' tlie ikwus. ( Koi- tiie treatment of iiM'vi, xr Figs. 67, 68, 76 and page 1U4). As soon as cliaiiiii's uf any kind apitear in a na'vus, it is important to remove it forthwith. It is best to excise all pig- mentary urcvi because they are too often the startinir ])nint of fatal melanotic growths (see Figs. 23 and 28)- Fig. 18 si lows a carcinoma of the scalp originating in a seba- ceous cyst. Ordinary, non-dege7ierated, sebaceous eysts are scat- tered over the whole scalp. Beginning as small nodules inlaid in the skin, these eysts slowly grow into large tumors with a broad base and smooth surface. They are fixed to the skin, but easily movable over the subjacent bone, and have a doughy consistency often re- sembling fluctuation. If this mobility of the cyst over the subjacent tissues ceases and the originally soft tumor becomes a hard nodule with an irregular, rough surface, malignant degeneration is to be suspected; apart from the occurrence of calcification in its walls, in which, moreover, the spherical, smooth surface is generally preserved. This suspicion becomes a certainty wlieu the skin gives way and there appears a rapidlj'' growing nodular tumor characterized by multiple lobulation and secreting a fetid discharge. Such a carci- noma resembles in many ways an ulcerated sarcoma (Fig. 33), and often causes severe pain owing to inflammation around the tumor. Cachexia occurs early, and the patients are usually of advanced age. The digTiosis of carcinoma depends on the characteristics men- tioned above and later on the hard multiple glanclular enlargement, which affects the whole nape of the neck. This usually occurs late and is not so hard in sarcoma. Treatment This consists in extirpation of the carcinoma, and involves re- moval of part of the external table of the skull on account of the tumor being fixed to it. The extensive space left by removal of the tumor can be sutured after making two long lateral incisions over both ears and undermining the scalp. The spaces left by the lateral incisions can be repaired by Thiersch grafts. The glands in the nape of the neck must also be removed. On account of the early apjiearance of glandular metastases the excision of especially indurated sebaceous cysts is indicated. More- over, as there is always a possibility of malignant degeneration, it 21 is advisable to remove every sebaceous cyst by dissecting it out, so as to avoid recurrence. Fig. 19 shows the ordinary clinical appearance of carcinoma of the penis. Carcinoma of the penis begins on the glans or in the coronary sulcus as a squamous-celled epithelioma, generally between the fiftieth and seventieth year. Predisposing causes are all chronic irritations of the region ; for instance, congenital phimosis with pre- putial concretions, leucoplakia preputialis (white, glistening patches similar to leucoplakia of the tongue and cheek, see page 8), warts, long-standing tuberculous and syphilitic ulcerations. Old fistulae, which occur especially in eunuchs after removal of the scrotum, testicles and pendulous part of the penis, near the symphysis or perineum, also predispose to carcinoma. "Chimney sweep's cancer" is a cutaneous cancer observed on the scrotum and is due to the irri- tation of soot and dirt. The usual form of penile carcinoma is that represented in the figTire, a warty carcinoma which destroys the prepuce a2id soon forms a cauliflower growth. Between the separate hard nodules destitute of skin appear crateriform excavations which are characteristic. Epithe- lial plugs can be expressed from the growth, and in other parts the surface is cornified. Thus, continuous growth alternates with per- manent disintegration. The rapidly developing nodules often cause exhausting hemorrhage, while the breaking down of the carcinoma gives rise to a fetid sanious discharge. The borders of the growth are hard, raised and prominent. The whole penis may be transformed into a large tumor, which may extend to the scrotum, testicles and pelvis. The growth may destroy the urethra and cause much pain on micturition. A more rare form of carcinoma arises as a small ulcer, generally on the corona glandis. . It is hidden by the resulting phimosis, but its characteristic hard borders can be felt distinctly and there is a sanious secretion. The inguinal glands are affected early and point to the diagTiosis of carcinoma. The growth at first causes the patient little" inconvenience, but quickly leads to severe cachexia, so that the patients often present themselves with extensive metastases of the inguinal and retroperitoneal glands, and are in an inoperable con- dition. A saying of Kauffmann's, "In old men with phimosis and offensive discharge the possibility of cancer is always to be borne in mind," merits special consideration. 22 Bockciilicimcr, Atlas. Fig. 19. Carcinoma penis — Leukoplakia. Kcbinnn Company, Nc\v-\'ork plugs. A cauliflower tumor grows, which soon becomes fixed to the fascia (Figs. 20 and 22). Warts, old-standing ulcers of the leg and lupoid changes in the skin also lead to carcinoma of the extremities. Eczema of the skin occurring in chimney-sweeps and workers in paraffin has often led to multiple carcinoma of the extremities and scrotum. Fig. 20 shows a papillary carcinoma of the skin of the leg arising from the scar of a burn. The smooth, partly white and partly brownish, shiny scars of the burn are seen over the whole leg. The carcinoma has extended above and below and has extended around the whole circumference of the leg. The soft, cauliflower prolifera- tions have given rise to severe hemorrhages. From the depth of the growth oozes a sanious discharge. The borders of the tumor are very hard and raised, and are immovable over the fascia. The inguinal glands were' already involved. Amputation was performed through the thigh, and the inguinal glands were removed. Though adenitis, in cancer of limbs, may, -perhaps,' not be a formal contraindication of operative inference, it considerably increases the chances of a recurrence. Therefore, here also, as in all cases of tumors, an early diagnosis is essential. As soon as a chronic ulcer of the leg begins to show marked induration of the borders and proliferation, the suspicion of carcinoma is justi- jied, and it is best to remove the whole ulcer as soon as possible. For X-ray carcinoma, see Fig. 138 and page 219. Fig. 21 shows a carcinoma in a common situation, the back of ihe hand, arising from a wart and forming a characteristic carcino- matous ulcer. As the growth was still movable over the fascia, and there were no glandular enlargements, it was excised and the gap repaired by a pedunculated flap from the forearm. The rapid growth of these small tumors with hard borders makes early diagnosis and removal necessary, so as to avoid recurrence. Compare with rodent ■ulcer of Fig. 1. Fig. 22 shows a very extensive carcinoma arising from the scar of an injury two years before. In this case the irregular, wall-like, 24 Tab. XV. U u Rebm.-iii Company, New- York. Bockenheimer, Atlas. Tab. XVI. Fig. 23. Melanocarcinoma cutis ex verruca. Rebman Corapan}', New- York. hard, irroijnlar honlors are very marked. The floor of tlie ulcer is in some places coniilied and is covered with crusts and sanious secretion. The carcinoma has already extended through the fascia to tiie bones, interfering with the function of the liand. Tlie glands of the elbow and axilla are li.ird ;iiiil nndul.ii-. The r.ipid growth of the tumor has led to severe caclicxia. Tiiis was treatcil liy amputation through the arm and i*emoval of glands, and calls for the same remarks as Fig. 20, about early excision of a scar showing suspicious symptoms of de- generation. Fig. 23 shows a tumor arising from a pigmentary wart of the sole of the foot, the aivcohir structure on microscopic examination showing it to lie a melanotic carcinoma. (Com])arc Fig. 28, Melanosarcoma.) Malignant melanotic tumors (sarcoma, endothelioma and. more rarely, carcinonui) occur most frequently in the skin and adjacent mucous membranes, and in the choroid and iris. In the skin, they arise from pig-mented benign tumors, fiat, pigmentary Jiicvi, and from warts subjected to repeated irritations. Warts on the sole of the foot, the toes and the fingers often degenerate in melanosarcoma. A tumor develops, black, hlui.'^h. or hroioiish-yelloiv in color. The skin soon becomes iilcerated, the tumor breaks down and a deep, ragged, black or blue ulcer is jiroduced. A melanosarcoma remains soft. A melanocarcinoma produces an ulcer with hard edges. All melanotic tumors are extremely malignant because they ]irop- agate and disseminate with the utmost rapidity. Suudl black nodules appear in the neighboring skin; soon the lymphatics are involved, cachexia develoi>s and a miliary crop of small growths is found at the autojisy in must organs, i)articul;irly the lirain. the hnigs and livei'. Some of the growths are full of pigment as in the mother tumoi-; others, younger, do not yet contain any, and are white or pinkish on section. The dcjiosit of melanin in the growth is, there- fore, secondary. ^felanocarciimmata may l)e seen in cliililren as multiple growths in the skin in connection with xeroderma jiigmentosum. (See jiage 1 ^. The rapid growth and frequent hemorrhages lead to severe anemia. The appearance of melanotic growtlis is so typical that no con- fusion is possible. 25 The best treatment is prophylaxis, which consists in the precau- tionary removal of pigmentary nsevi, warts, especially those that are subject to constant irritation. Eepeated cauterization of nsevi and warts is to be condemned. Once a melanotic tumor has developed, a radical operation may be performed, if the tumor is situated on a limb and the regional glands are not yet involved. But, in spite of this (in the case repre- sented in Fig. 23, amputation of the leg and removal of the inguinal glands), early recurrence is the unvarying rule. No kind of new growth possesses as high a dissemination power as malignant melanoma. 2G Bockenheimer, Atlas. Tab. XVII. Fig. 24. Lymphosarcoma colli. Rebman Company, New-York. SARCOMA Figs. 24 to 35, iiulusivc, i('i)iosc'iit different types of sarcoma. Sareoiiiata (thus named from tlioir llcsliy a|}|icaraiicc nii mm;- tion) are tumors developed from connoclive cells and which, there- fore, may originate in any organ containing connective tissue, that is, practically everywhere in the body. Owing to the often very rapid growth, the newly formed cells do not attain complete maturity, so that the sarcoma consists of imperfectly developed connective tissue. In its early stages it often resembles, microscopically, inflammatory granulation tissue, but by its rapid growth it soon assumes the character of a malignant tumor. The bulk of the sarcoma is formed of various connective tissue cells, "while the interstitial fibrous tissue is scanty. There is in sarconta an abundant formation of neiv blood-vessels, which is characteristic; so that any new growth accompanied by a marked collateral circulation or possessing itself a great vascularity is very likely sarcoma. The transition of fibroma, especially of such as arise from the connective tissue of fascia, and of other connective tissue tumors, e.g., chondroma, into sarcoma has been demonstrated. Patients often attribute these growths to various injuries, but there is no direct proof of this, though Phelps, Coley, Segond admit the possibility of a causal relation between both. Pure sarcomata are classified according to their microscopic structure into round-celled, spindle-celled and giant-celled sarcomata. Those formed of various tissues are known as lympho-, myxo-, fibro-, chondro-, angio-, and glio-sarcomata. Pigmentary or melanotic sar- comata are placed in a special group. Clinically, sarcomata are best divided into soft, many-celled, quickly growing, very maligTiant, easily recurring medullary sar- coma (usually small, round-celled sarcoma) ; and hard, few-celled, slow-growing, less malignant forms (spindle-celled and giant-celled sarcoma). In the first form the soft consistence is due to the richness in cells and the scanty development of interstitial tissue. As com- pared with carcinoma, sarcoma is more circumscribed and is at first almost completely encapsulated, with borders as soft as the rest of the tumox". 27 Frequently, owing to hemorrhages and softening in the interior of the sarcoma, cystic cavities are formed which can be recognized by the presence of fluctuation (Figs, 25 and 30). Sarcomata situ- ated under the skin gradually destroy and break through the latter and proliferate on its surface in various forms. Fleshy reddish- brown parts alternate with yellowish-white, pulpy parts in these tumors. There are usually blood extravasations, both old and recent. The whole tumor has the appearance of a fungoid mass (Figs. 26, 27, 29 and 33). After a time these superficially proliferating growths break down and become septic, so that the characteristic appearance of the sarcoma is lost, and, on the scalp and extremities, for example, it cannot be distinguished from an ulcerated carcinoma. As the sarcoma usually breaks through the skin and proliferates on the sur- face, so may it extend into all the deeper tissues, so that fijially an enormous tumor is formed which may destroy the bones (Figs. 25, 27 and 33). The second form, the slow-growing, few-celled tumors, resemble fibroma and often represent transitional forms (fibro-sarcoma). The- latter sometimes occur as multiple nodules in the skin. Sarcoma often occurs in robust people in middle life (between 30 and 50). Sometimes it is congenital or appears in infancy (kidneys and testicles), or soon after puberty (mammary gland). The earlier the tumors appear, the more malignant they are, as a rule. Multiple- sarcomata are seen in the skin as pigmentary sarcomata (Fig. 31) and in the bones. Soft sarcomata lead to metastases much more frequently than hard forms. Metastatic deposits are formed by growth of the tumor into the large veins and the formation of emboli, which are carried to the lung, spleen, liver and brain. Dissemination by way of the lymphatics is usually absent. The latter, however, are certainly often involved, especially in ulcerated sarcoma, in melanotic forms and in osteosarcoma. Sarcoma is accompanied by a thermic ascension, either general or local, or both, due to the resorption of toxins. In many cases the body is so quickly filled with metastases that the patients soon succumb from severe anemia and toxemia. Unfor- tunately, they often do not apply for treatment before metastases^ render the condition hopeless. Differential diagnosis Sarcoma may be mistaken for a benign tumor, for a gumma, for a carcinoma. The latter is a hard tumor, while sarcoma is gen- 28 erally soft; however, il does not iiiiitter if a mistake be made in this direction, since both conditions call for the same radical surreal treatment. The other mistakes aic iiKirt' serious: a bciii,i;ii tumor is dis- ting^nished by its slow evolution; but, in doubtful oases, it would be most unwise to delay making a diafrnosis till the latter has become evident. Exploratory incision with dii-cct iiis])ectioii, and excision of a piece for inunediate microsco])ical examination is the best procedu7'e, care being taken not to submit the tumor to unnecessary manipulation. It goes without saying that such a partial excision with microscopical examination is only for those organs the conservation of which is important (a limb for instance). In others, such as the breast or the skin, immediate complete excision of all suspicious tumors is indicated. A gumma may be mistaken for sarcoma ; but here the ante- cedent history, the Wassermann reaction and the quick influence of salvarsan treatment help clear up all doubts. In former times, the mistake seems to have been frequent. Esmnrch claims that many growths were extirpated as sarcoma that might have been cured by autisyiihilitic treatment. A local hyperthermia, cvideiircd by the color of tlie skin and the sense of touch, and an abundant development of collateral venous circulation, ma])ping out a bhiish network under the skin (see Figs. 25 and 32), are always particularly suspicious symptoms when an underlying newgrowth is felt by palpation. So is the uitli- draival of only pure blood fro)ii a fimior liy exploratory puncture. Trrahnciit All tumors in which there is a suspicion of sarcorrta must be removed as early and as radically as possible. lUnsi rvative ojierations have no i)lace in the treatment of ordinary spindle or round-celled sarcoma except as stated I)elow, even if the latter seems still to be encajisulated. Sarcoma of the limbs demands exarticu- lation or amputation high up above the newgi'owth. Recurrences is very frequent; it is almost without exception in the soft varieties. The harder a sarcoma, the fewer, and the less embryonic in nature the cells it contains, and the less malignant the tumor; so that in the very hard varieties of l)one sarcoma, conservative ojierations (e. //., resec- tion) sometimes give permanent results. Bloodgood goes so far as to say that giant-celled iione sarcoma is not a maligmmt tumor, and that it can be cured permanently by 29 resection or scraping followed by treatment of the cavity with boiling water. This opinion is accepted by many surgeons, and there is no doubt that this hard giant-celled variety is at least comparatively benign. Many cases have been treated by the X-rays. While some authors contend that the X-rays transform the embryonic cells of sarcoma into adult tissue, and, therefore, sarcoma into fibroma, others say that the action is only superficial and similar to that caused by an intercurrent erysipelas, which often brings about a temporary shrink- ing of sarcoma. It is interesting to note, in this respect, that Coley, treating inop- erable cases of sarcoma by injections of a mixture of toxins of the microbe of erysipelas and of the Bacillus prodigiosus, claims to have obtained remarkable results (sometimes permanent cures) in about 10 per cent, of cases. He also advises injection of the mixed toxins after operation as a prophylactic against recurrence. Coley always begins by operating largely, and uses toxins alone only when opera- tion is refused. Fig. 24 shows an extensive tumor involving the whole right side of the neck, and made of several nodular, irregular formations. The skin is broken in one place, in other places it is thin and bluish- red in color. There is a fistula discharging a sanious secretion. This tumor is a lymphosarcoma. The region of the neck, where lymphatics are abundant, is the seat of predilection of three different malignant processes involving the lymph glands. 1. Lymphadenoma (also called malignant lymphoma, Hoclgkin's disease, pseudoleuhemia) . 2. Lymphosarcoma, sarcoma of the lymphoid cells of the lymph glands. 3. Sarcoma of the connective tissue of the same lymph glands. The latter two are often not distinguished from one another. A hard, diffuse, nodular tumor quickly develops from a group of small, hard, movable glands and shows its malignancy, especially in young individuals, by the continual formation of fresh nodules at the periphery, which coalesce with the main tumor and cause it to attain a considerable size. The imlimited growth into the neighboring tissues is characteristic. The capsule of the gland is quickly broken through, a fact which does not happen in other lymph gland tumors of the neck. The cervical fascia is destroyed and the sterno-mastoid BO muscle invaded. Tlie skin is at first reddisli, then l)luisli-re(l or liviil; it tliou hoconios tliin .-ukI .i;;ivos way over tlic tumor. The oxposeil parts oi' llif Imniir rai)i(lly lircak down while tlie sarcoma grows into the do('i)cr pails, especially into the internal jugular vein, giving rise to fatal organic metastases. Tlie vagus nerve and tiie common carotid also become cnsheathcd in, and may be destroyed by, the tumor. Dyspnea and dysjihagia may be caused by pressure on the larynx and esopliagiis. This occurred in tlio case represented in Fig, 24. The tumor extends downwani intu the inediastinum and may even destroy the vertebra". Dioynosis ami Traitim iil To recognize that a tuiiKH' of the neck is made of lymph glands is not difficult. Its situatiun in regions where lymph glands normally exist, and the palpation of rounded nodules is sufficient. To decide what is the nature of the condition is not so easy. Lymphosarcoma is distinguished from other lymph gland tumors of the neck hif its rapid f/rou-(h in all directions, its breaking tlirough to the exterior and its fungating masses. But, in the earlier stages, it has no patho,gnomonic symptoms, and microscopical examination itself may be inconclusive, so that the nature of the alTection can only be suspected. Lymphad(iii>)ua {Ifn/hil.'ni's disease), which usually begins in the neck, consists of small. iiiiilti|ile, encapsulated nodules, which do not break down nor extend iiiin the neighl)oring organs. There are gen- erally also giandiilai- enlargements in the axilla?, groins and medi- astinum, and eliaiiges in the s]ileon and bone-marrow. TiihirciiIiHis f/lin/ils lesemble llnilgkin's disease so nnwh that many of the eases rei)orted as l)eing the latter have lieen found either to be purely tuberculous or, at least, to contain tuberculous lesions. The confusion is not possible when there is a history of several years' duration, other symptoms of scrofula, and groups of glands of dilTer- ent consistency, some hard, some soft, some Huctuating. Hut the diagnosis is exceedingly dinicult — in fact, sometimes not possiiile — when there are but I'i'w hard, movable glands invniveil. SyphiUlic aldii/ls are at lirst hard, lalei- on soft ; but are not so extensi\'e, and there are other symptoms, which soon clear the diag- nosis. Branchiogenous ((ircinnnia ^^' rnniiiiii;' a liinidr wliicli is at first iiiovalilc over llic iiiidcrix iiii;' ti>>ii('>. I.alcr on IIh' skin d('S(|nainates and hoconios red, liliii>li (ir li\id, then Innwncr after rcpoatod liemor- jia.n'cs, and may linnll>' iili-crate. The <\<\\\ dv-cr iiiuincntary sarconiata is liluish black". (Figs. 23 and 28.) Besides the ulceration oi tiie no' lie seen. Cachexia, however, kept on progressing till death. The skin III' the whole hody between the nodules is often of a dirty sallow cohir (Fig. 31). Small spots and elevations on the skin point to the develo))ment of fresh sarcdinatuus nodules. Multiple hemorrhagic sarcoma appears in the form described above, but first of all on the lower extremities, in the form of reddish nodules which often cause much itching. Tumor formation goes hand in hand with edematous iufiltratimi which extends over the whole leg and prevents the patient from walking. Desquamation of the skin on the surface of the nodules occurs along with coruification of the e]udermis. Cicatrices form in the skin from atrophy of the nodules. Other regions of the body are unaffected, except the peripheral jiarts of (he iip]ier extremity, 'i'liere is no enlargement of the lymi)hatic glamls. The disease runs a proiiicssive course, and in sjiite of th& spontaneous resolution of some df (he tnnmrs. linally causes death by marasmus. The average duiatitm is about 5 years, Init some cases lin\-e been followed for 20 to .">() years. ^Microscopic examination siiows a pure sarcoma with abundant blood-vessels, which often gives rise to organic metastases. As tlii;* form occurs often in old peojile, arteriosclerosis may, perhaps, play a part in the origin and course of the disease. 39 Differential diagnosis and Treatment Primary multiple sarcomata must not be mistaken for secondary sarcomatous growths in connection with a primary cutaneous sar- coma or a sarcoma of the internal organs. So a careful search must always be made for a possible primary tumor. The tumors of myco- sis fungoides are more likely to be mistaken for sarcoma, as they also develop from red, uneven spots, and form granulation tumors of a brownish-red color which in the later stages tend to ulceration and cachexia ; but mycosis fungoides is of much slow6r growth than sarcoma and there generally coexist in different parts of the body of the same patient the three different stages of mycosis fungoides, namely, the premycotic itching patch, the infiltration and, finally, the fungating lesion. The association of these three types of lesion is characteristic. Syphilitic and tuberculous granulomata can hardly be taken for sarcoma on careful examination. Carcinoma of the skin is clinically so different from multiple sarcoma that no hesitation can arise, except for the melanotic form, which can be distinguished only by microscopical examination. Preventive treatment of multiple sarcoma consists in the removal of all nasvi which begin to take on rapid growth. In already existing multiple pigmentary sarcoma excision is generally useless, and should only be performed when the tumors are very few in number if not single, and the blood-vessels free from melanin. After excision of multiple sarcomata, especially melanosarcomata, death often fol- lows from rapid dissemination and organic metastases. Hence the X-rays, large doses or arsenic (internally or subcutaneously) have been employed for multiple cutaneous sarcoma, in the same way as for mycosis fungoides. They have given temporary improvement. A permanent cure, however, is not to be expected and the prognosis of these multiple sarcomata is always bad. Fig. 32 shows a peripheral sarcoma of the upper end of the humerus in a young individual. The soft tumor has extended under the skin, in which the brown coloring and extensive network of dilated veins are very marked. The lower borders of the fusifonn tumor are irregular and send processes here and there into the muscles. The tumor has destroyed the head of the humerus and has broken through into the joint, in which there is an effusion. The function of the joint and upper arm is destroyed. The supra-clavicular glands are enlarged. Posteriorly 40 lab. XXIV. Fig. 32. Sarcoma liumcri |-icriplicricum. ibniaii Comp.iny, New-York. the linnor hns oxtoiidcil In tlic sc.-ipul.-i rci^inii. Tlic X-r;iys sliow complete destruction of (he ii|>i>cr |i.iii of liic ImnnTiis. I)i)ii(' sarcoiiiii is one ol' tiic nm>t inipDrl.-int, ;in(l l'rc(|U('iit varieties (if sai'conia. ( )sleo-sareoniata are l)e.st divided into peripheral and central; the latter may arise from the cortical, sponyy or medullary ])ortions. Division into periosteal and myelog-enous tumors is clinically impos- sible, and the word mycloiienous may be rejilaced l)y osteal. Tumors wliicb appeal- clinically tii be pci'iosteal often arise from tlie super- licial layers ol' tlic cnrtcx. Tlic X-rays enable easily to divide them into peripheral and central tiiiiiors; tbis leaves npeii the possible orijrin of the sarcoma from any jiart of the bone, and this can only be conclusively settled by section of the bone after removal. This classi- fication is all the more rational because sections of specimens which were clinically regarded as i)eriosteal sarcomata show that these arose from small foci in the medullary cavity. Periosteal tumors may extend into tlie medullary cavity and so sinuilate osteal tumors. In extensive tumors tlie origin of the tumor from any definite ]iart of the bone cannot as a rule be established. Both forms have special seats of predilection: in the long bones, the neighborhood of the epiphyses e.g. tlie upper end of the humerus (Fig. 32), the lower end of the femur, especially the internal con- dyle, the head of the tibia, the lower end of the radius; the Hat bones, especially the scapula and bones of the skull. Both forms also grow in a globular type involving the whole circumference of the bone and tinally its whole thickness. They aii]iear at ]niberty and during the whole period of growth, generally in young and rolnist individ- uals. Both kinds soon lu-eak through their own cajisule and that of the bones and then extend sometimes into the neighboring joints, often into the muscles, especially the muscular insertions into the bones, and into the veins, eventually forming enormous tumors which break through the skin and protrude as riingoid masses. The sn])erlicially situated tumors have a teinleiicy to ri-i'i|iieiil lieinorrliage and destruc- tive inflammation. Microsco]iically, spuidle ccUk are often found in ix I'lpheiul aar- coma, and rj'xnit cells in centred sarconin. The other forms of sar- coma cells are also ]iresent. The X-rays, in peripheral sarcoma, show little cliaime in the cor- tex. In central tiiinors. es|iecially those arisiiii;' IVoni the iiiediillary cnvity, they often show spherical transpareiil .-paces in the interior, II while the cortex is very thin and excavated — forming a shell — in the same way as in bone cysts, osteomyelitic abscesses, isolated tubercu- losis and gumma. Dingn osis In the early stages the diagnosis of osteo-sareoma is difficult. The peripheral tumors are naturally easier to recognize, as they present a rapidly growing mass, firmly attached to the bone, with irregailar boundaries toward the muscles. Eheumatic pains and effusion into the joints frequently occur when the tumors are situated near the joints. The nearer the sarcoma comes to the skin the easier it is to palpate the superficial tumor masses, which infiltrate the soft tissues, and consist of cells only without bony infiltration. Sivelling of the cutaneous veins occurs early from pressure of the tumor on the ves- sels, while the skin becomes reddish brown, thin and almost trans- pjarent, especially when the tumor is adherent to it. These two feat- ures are clearly visible in Fig. 32. Slow-growing central sarcomata can at first be diagnosed only by the X-rays, later on they present themselves as hard spheroidal swell- ings like billiard balls. The more they extend and approach the skin, the thinner becomes their bony shell, which finally gives the sensation of parchment crepitation, first described by Dupuytren. Central tumors are often first diagnosed by the. occurrence of spontaneous fracture. Extensive forms, which assume a more spindle-celled for- mation are easy to recognize. Through growth of the txmior into the joints and muscles, typical functional derangements are produced, and separation of the epiphyses. Metastases in the lungs develop early. Disintegration of the tumor cells gives rise to fever, espe- cially in rapidly growing, small, round-celled sarcomas. Parostecd sarcoma is easily mistaken for pei'ipheral sarcoma, and is often impossible to disting-uish by the X-rays. It is often of very soft consistence, and was formerly called encephaloid. Chondrosarcoma only occurs in the neighborhood of the joints and forms irregular nodular tumors (Fig. 34). Sarcoma situated near the large vessels and pulsating with them may be mistaken for aneurism, but the X-raj's will assist the diagno- sis. Central sarcomata have been wrongly considered as aneurism of the bone, owing to their vascularity and their reddish-brown color on section, which is due to frequent hemorrhages. Myelomata are multiple, occur chiefly in the vertebrje, and albu- mose is found in the urine. 43 Metastatic carclnoiua, which (iccui'^ f,-|icci;illy in tliu neck nl' the femur after mammary carfiiioina in wdhicm. ;iii<1 in tlie head of the humerus after rnrcinonia df Ihc lliyroid ;4l;in(l ( /■. Eiselsherg), must be diagnosed l)y Ihc ]M-iiii;iry -inwlh. Osteo-sarcoma may i)()ssii)|y ht' inistai\t'ii I'or arthritis, rheuma- tism, osteomyelitis, syphilitic and tithcrciiloiis [jrocesses; but in most cases the dia.i>nosis can l)o made l)y careful clinical analysis, by the history of tlie case, l)y the X-rays, by anti-syphilitic treatment, and in osteomyelitis by searcli for hemolysin (Brack, Michaelis, Schultze). Uninterrupted increase of a diffuse e. The movements of the knee .joint are very limited. No s'landular or organic metastases were found. This tumor, when removed, was found to be a chondromyxosarcoma. Choiidrosarcomafa are situated on or neai' joints. Most fre- cpiently they arise from the head of the tibia or the upper end of the humerus, also from the lower end of the radius. They may also origi- nate from previous diondromata of the phalanges, metacarpal and metatarsal bones. They generally form large, nodular, liard tumors consisting of hyaline cartilage, osseous, mucoid and sarcomatous tis- sue and contain cystic cavities due to softening and hemorrhage. They then resemble in appearance benign, cystic chondrofiliroma. They often form rajiidly growing tumors which destroy the bones and joints and give rise to sarcomatous metastases containing no cartilage. Their prognosis is, therefore, very bad. In young indi- viduals they cause disturbance in gi-owth (shortening, etc.). S])on- taneous fractures are frequent in the forms which show an abundant development of sarcomatous tissue and much cystic degeneration. Chondrosarcoma may also develop in chondroma arising from carti- laginous exostoses, which are due to arrested develoimient of the skeleton and disturbances in growth. These tumors are so tyjucal that they cannot be mistaken for other growths when they have attained a certain size. On the contrary, when small, their nature may be suspected, but rarely decisively allirmed, as they then much resemble exostoses. All exostoses and chondromata which show signs of rapid growth must be removed. In sarcomatous tumors, removal of the growth may be attempted, if the neighboring parts are not too involved. In large tumors, amjuitation. and chiefly exarticulntion. are necessary. •I.") Fig. 35 shows a soft tumor, the size of a cherry, arising from the alveolar border of the first right bicuspid tooth, in a young woman, and which has grown rapidly during pregnancy. On the surface is a pin point ulceration from which frequent hemorrhage has occurred. This tumor is an epulis, which name has been given to sessile or pedunculated fibrosarcomata with numerous spindle and giant cells, arising from the periosteum or alveolar connective tissue of the upper and lower jaw. They are hard or soft according to their histological constitution, with a smooth surface covered by mucous membrane, of rounded form and the size of a walnut. In women they grow rapidly during pregnancy. They seldom ulcerate. In children and young people they occur equally in both sexes. They often arise in the spaces between the teeth, and then bear the imprint of the neighbor- ing teeth on their surface. They sometimes develop from the lateral surface of the alveolus and then grow over the teeth, usually the molars, which they may loosen. They are very vascular and bleed easily, but cause no other trouble. These tumors, although sarcomatous, have usually a good prog- nosis, for their growth remains circumscribed, rarely involves the bone and gives rise to no glandular or organic metastases. They only assume a malig-nant character by their frequent recurrence after in- complete operations. Diffci Diagnosis and Treatment Polypi of the gums {gum boils) arising from alveolar fistula and bad teeth do not attain the size of epulis. The flaccid fibromata of the gum seen in leontiasis ossea do not form globular tumors, and are only slightly vascular. Carcinoma occurs at a later age, seldom arises from the alveolar border, and can easily be recognized by its hard borders, fissures, and metastases. Epulis sliould never lie simply snipped off ivitli scissors. The ad- joining part of alveolar border should always be chiselled away. This was done in the case represented in Fig. 35. After such a removal, recurrence is rare : on the contraiy, it is frequent after simple ex- cision of the growth without bone removal. 4fi Roc iheimer, Atlas. Tab. XXVII. U in. n Company, New-\'ork. MIXED AND BENIGN TUMORS Fig. 36' slii>\vs ,111 ciiciii-ulalid cavernous hemangioma of the tongue developed, after puherly, from a previous coui>'enital siiiiijle lieiiiaii.:;ionia, a sli.^litly raised red spot whieh often remains un- nolieed. This is tlie most common secpieTice. Siieli a cavernous an- gioma may also oecnr as a cong-enita! tumor wliieii l)ecomes fully de- veloi)ed in adolescence or sometimes later, and extends more deeply than simple hemangioma into the mucous membrane and sub-mucous tissue. The tumor consists of new blood-vessels, especially capil- laries, and cavities lined by endothelium and filled with blood. Cavernoniata, as a rule, present themselves as bluish, glistening tumors with several small nodular jirojections on the surface. The mucous membrane in the region of the tumor is so thin that a dark fluid nuiss appears to be seen through it. Apart from this charac- teristic a])pearance, the softness of the tumor, and the fact that it can be emptied bj' pressure and made tense by bending the head are noteworthy features. The growth consists of cavernous tissue, such as is found normally in the corjiora cavernosa penis, and on this ac- count the name erectile tumor has been applied to it. Besides the superficial growth there is also a deeper one into the mucous mem- brane, so that the wliole tongue, the floor of the mouth, the soft palate, the lips and the cheeks may be involved. Eventually the tumor may implicate the whole side of the face and extend through the orbit to the brain. In other cases the tumors are encapsulated. Sometimes there are multiple encapsulated cavernomata lying close together, but without any direct connection. Tumors which, starting from the buccal mucous membrane, come to bulge under the skin of the face, give rise to thinning and a bluish glistening coloration of the latter. Apart from the deformity large cavernomata are dangerous, as they may rupture and cause ]irofuse and sometimes fatal hemorrhage (as often occurs in cavernomata of internal organs, alimentary canal and liver). Sometimes ulceration occurs at the points of rupture, which may cause gciicral scjilii' iiifcctidii. and in tlic Inugui' acute glossitis and edema of the glottis. iKor other lesions of the tonj;ue, see Figs. 6, 7, 8, g, 118, 119, 120. 47 Differential Diagnosis Cavernous lymphangioma (see Fig. 145) is composed of larger protuberances and has a greenish surface. Moreover, lymphan- gioma, though diminished hy pressure, remains independent of the circulation and is not increased by bending the head, stooping or coughing. As the result of inflammatory changes, hard nodules form in these tumors, which are disseminated in the soft parts. Sarcoma of the tongtte is rare and can generally be recognized by its smooth surface and rapid growth. Retention cysts of the mucous membrane of the tongue are smaller, circumscribed, and have a uniform surface. On the other hand, they are also covered by thin, bluish, glistening mucous membrane. Treatment Cavernous hemangiomata can be extirpated if they are encapsu- lated. Diffuse forms may be incised and scraped, after which the big vessels are ligated, and the inside of the cavity treated by boiling water or the cautery and packed. If there is a recurrence, the pro- cedure must be repeated. Inoperable tumors are best treated with injections of alcohol, or with Payr's magnesium. Both methods aim at thrombosis, after which shrinking of the tumor takes place. Injections must be made deeply under the mucous membrane to avoid necrosis, and are not absolutely devoid of danger. For the treatment of simple heman- gioma, see p. 104. Fig. 37^ shows the right breast of a woman (at the menopause) much more projecting than the left. The upper half of the right breast is involved in a tumor, the irregular surface of which can be, recognized by the bulging of the skin. The skin is thin and reddened. The tumor, which was at first remote from the nipple in the inner and upper quadrant of the breast, has grown toward the nipple with- out causing retraction. It is completely encapsulated, freely movable, and of moderately hard consistency. It was removed through a ra- dial incision, together with the adjacent mammary tissue, and micro- scopical examination confirmed the clinical diagnosis of cystic fibro- adenoma already established by the above-mentioned signs. Real adenoma and piire fibroma are rare in the breast. Myxoma, angioma, chondroma and mixed tumors are very rare. Fibro-ade- iCompare with Figs. 10-16 (eaveinonia of the breast), 2g- wouion, as a slow-,u;rowin.i!:, nodular tninor, so well encapsulalcij tli.il if is IVccly movable witliin the l)r('ast. Tumors of this t>|u' inc r.irdy niiiltipie and seldom aifeet both breasts. \\'h('n IIh'it is ,111 aliuinl.iiit development of connective tis- sue the tumors are lirm; when cystic cavities develop they are soft and fluctuating {cystic fihto-adenoma). The tumor desci'ibed as cystadenoma papilliferum, or intracanali- cular lihroma, which is formed by connective tissue processes covered by ei)ithelium projecting into the cavity of the cyst, belongs to the grou]i of benign mannnary tumors. In older women, especially at the menopause, small multiple cystadenomata occur chiefly in the region of the nipple, without causing retraction; sometimes in both breasts. These feel like solid tumors owing to their thickened walls. The name of clironic cystic interstitial mastitis has been given to these tumors by Ku)iig, and that of " ci/stic disease of the breast" by many authors. The benign nature ol' those tumors is shown l)y the fact that they ordinarily cause neither glandular nor organic metastases. On the other hand, these tumors, especially cystic fibroadenoma, after slow increase in size may become enormous growths, as large as a man's head, and then cause much inconvenience by their weight, and also radiating pains in the arm. Moreover, there is a possibility of a transformation into carcinoma or sarcoma, so that here again (see ji. 14) we must be doubly certain before we affirm the non-malig- nancy of any given case, and it is better to err on the side of radical interference than on that of too much exjiectancy. Iliffi n nli.ll lllaiiiiasis Chronic interstitial mastitis may give rise to a nodular inliltra- tion of the mammary glami, but tliis disajipears under treatment by cleansing the iiipjile, injection of alcohol into the nodules, and sus- pension of the breast; in distinction to the steady growth of tumors. l>ut there ai'e luany doubtful cases, and this diagnosis is very dillicult. Cysts orcnr rliiell>- ill the iieiiilil lorjicu m 1 (if the nipjile, from which a brownish lluid can be expressed. When they appear under the skin they can be recognized by their bluish, glistening surface. Galactocele begins develojiing dni-ing a lactation period and has, when large, a special doughy cousistemy. Incision discloses mas.ses of cheesy material. 49 Carcinoma of the breast is characterized, as already said (page 13), by its hardness, its infiltration into the tissues, retraction of the nipple and dimpling of the skin. However, a few cases of metastatic carcinoma in the breast {e.g., a metastasis from a chorioepithelioma observed by the writer) are encapsulated, movable and of slow growth as a benign tumor. Such rare occurrences could be suspected only by the knowledge of the primary growth, and correctly diagnosed only by microscopical examination. The latter, made by a competent man, is the last and final resort for the diagnosis of breast tumors, and must be performed in all un- certain cases. If the immediate examination of frozen sections at the time of operation is conclusive (which unfortunately is not al- ways the case) the surgeon has a safe criterion to guide his further course. Treatment Early removal of all chronic nodular formations in the breast is advisable. They should be exposed by an incision radiating from the nipple (but avoiding it) and extirpated with the adjacent mammary tissue. Large tumors can be removed subciitaneously by raising the breast through a curved incision at its lower border so that, after healing, the scar is hidden under the breast which overhangs it. In very extensive growths, especially cystic fibroadenoma and multiple cystic disease of the breast, the whole gland should be re- moved. But it is not necessary to remove the pectoral muscles, or thoroughly clean the axilla, so that the unpleasant after effects of radical amputation of the breast (edema of the arm, interference with the function of the latter) will not be so marked. Fig. 38 shows a slightly curved cutaneous horn about three-fifths of an inch long, in an old countrywoman, in the zygomatic region, with all the characteristic features. The skin at the base of the growth is scaly and somewhat reddened. The same figaire also shows multiple pin point adenomata of the sebaceous glands. Cutaneous horns occur more frequently in old people (senile kera- toma), and in those subject to exposure (sailors, etc.). They develop on preexisting sebaceous and dermoid cysts and warts, and are ob- served on the eyelids, nose, lips, cheeks and ears, also on the scalp and genital organs. They are seldom multiple. They generally form sessile, freely movable, curved or spiral striTctures which have an ir- regular, grooved, yellowish-brown surface and a horny consistency. 50 E kenlieimer, Atlas Tab. XXIX. n.iii Comp.iny, Ncw-^■oI■k. Tlieso honi.aii rdriii.itioiis. wliicli iii;iy iitt.iin a lenfj;tli of two inclies or nioro, are forinctl \>y a in-olil'i-ratioii of tlic horny layer of tlie epi- derniis. The pai)ilhi' are also k'ii,i;tlioiKHl, wliirli accounts for tlie soft consistency of the inner core. Ihjj, rrnliiit Itiiiniio.ti.t iiiitl rrcihiiiiil In young people iimltiple nirxi willi cornification dccin-, l>iif these have a wider hase, and a flatter ami iiniro prickly siufacc As about 10 per cent, nf ciilancniiN Ikhiis degenerate iiitn carci- noma (see page 1), excision l)y \\\r knife with a ring of healthy skin is indicated. Eccurrence takes place after removal l)y simple liga- ture. Adenoma of the skin develop.s from the sebaceous glands or from the sweat glands {adenoma sebaceum, adenoma sudoriparum). Both conditions are rare: adenoma sebaceum seems fairly frequent in England. Adenoma sebaceum consists in small translucent tumors, im- bedded in the skin : of pin point to small pea size, round, movable, enca]isulated and circumscribed, which usually occur on the flush area of the face, often in women, young or old, and is very often associated with telangiectases. The consistency of the tumors is quite firm. This lesion is benign, does not involve the lymphatics and does not recur after removal. It is u.sually congenital. Adenoma sudoriparum (multiple benign cystic epithelioma, Puscii) is still rarer; the tumors are much like those of adenoma se- baceum, but generally slightly larger. The surface is quite smooth and glistening: the tumors look a little like vesicles. It is also a eon- genital lesion. Any large adenoma of the skin should be extirpated. Smaller, pin-point size lesions may be treated by the X-rays. This was done in the case rejiresented in Fig. 38, and the small tnindv-; dis-:i))penred to a great extent. Electi'olysis is also a suitable met hod. Fig. 39 slidws a horseshoe sliapecl endothelioma "f the zygo- matic re,nion. in an old wouiaii. Tlie tumor is situated in the skin and has grown out of it. It is uiovalile over the sulija<'eut tis.sues. The bonlei-s are ret^ular on all si(h's. The skin over the tumor is reddish brown like sarcoma, \-ei-y tliin, and canuol he j-aised IV(UU the tumor. It shows numerous line ramifying vessels. In the middle of the horseshoe is an ulcer which resembles a rodent ulcer. There are thus points of resemblance to both carcinoma ami sarcoma. The soft borders and consistency, the circumscribed form, and the ab- sence of glandular involvement, show the benign nature of the tiamor. In endothelioma of the face the occuri'ence of small multiple cysts in the cutaneous covering is more common than ulceration. Excision of the tumor was performed and the defect was repaired lay a plastic operation. Microscopic examination showed the growth to be a plexiform hemangio-endothelioma. The group of tumors linked together under the name of endothe- lioma is far from being homogeneous; its histology is exceedingly complex and unsettled, and the very existence of a group of tumors to which the name endothelioma would properly belong has recently been questioned. The opinions heretofore most generally admitted maj'' be sum- marized as follows : Endotheliomata (Golgi) arise from the endothelium of the blood- vessels and lymphatics, which, according to Borst, consists of speci- ally modified connective-tissue cells. Owing to the double nature of the endothelium, it is not surprising that those who regard endothelial cel-ls as epithelial cells give the name of endothelial cancer to the tumors arising from them, while others, who regard endothelial cells as connective-tissue cells, call these tumors endothelial sarcoma, plexi- form angiosarcoma {Waldeyer) and angiosarcoma {Kollaczeh). If we hold with Borst that endothelium cells are but connective- tissue cells, which may assume all kinds of modifications, it follows that tumors of varied structure may arise from the different varieties of endothelium. According to cases, these tumors bear a resemblance to fibroma, sarcoma or carcinoma (but without cornification). Thus we avoid the endless number of names given to these tumors, and clinically have only the term endothelioma, to be further analyzed microscopically as hemangio-endothelioma and lymphangio-endotheli- oma. In these two great groups we can still divide cases into alveo- lar, plexiform or vascular, according to their microscopic structure. Clinically, endothelioma may appear in the most varied forms and be mistaken for fibroma, adenoma, sarcoma and carcinoma (more par- ticularly the first two), from which it may be distinguished only by microscopical examination. Endothelioma may arise from all kinds of endothelium and is most frequently observed in the skin of the face, the mucous membrane of the mouth and pharjmx, the bones of the face and skull, the perito- neum, the pia mater of the brain and spinal cord, and the parotid gland. (See Fig. 40.) 52 Bockenheimer, Atlas. Fig. 40. Endothelioma parotidis — Tumor mi.xtus. Rebman Company, New- York. Occurring at any age, it forms encapsulated, generally slow-grow- ing, comparatively benign tumors which seklom cause glandular or organic metastases, but have a tendency to local recurrence. As the sha])e. surface and consistency of the tumor may assume all possible varieties, the clinical signs of endothelioma are very in- delinite. The sha])e is often irregular, especially in endothelioma of the face (Fig. 39, horseshoe shape). The surface may be smooth, uneven or uhcraled. The consistency may be hard, soft or cystic. Sometimes the tumors are very vascular and the epidermis takes the reddish-brown coloration whicli is seen in sarcoma (Fig. 40) at other times they ai-c ]ioor in vcssi'Is. Although they are at first en- capsulated they nuiy later on give rise to a diffuse infiltration of the tissue along the endothelial clefts, and then have irregular boun- daries. Trcatmoit Ea>l,ij e.rcisioii is indicated, as transformation in ra])idly growing tumors is possible. In the ditTuse forms, which represent nialig-naut tumors like carcinoma and sarcoma, extensive operations are neces- sary. When multiple nodules develop in the extremities amputation is sometimes necessary. Metastases in the lymi)hatic glands, which appear in the form of soft nodules, should also be removed. Fig. 40 shows a mixed tumor of the parotid which slowly de- veloi^ed during three years in a woman aged 30. Profuse salivation, and latterly rapid growth of the tumor, led the patient to seek advice. The skin is freely movable over the tumor and shows a fine network of vessels. The tumor lies under the fascia and has sjjread to the anterior and lower region of the ear. The surface is irregular; the consistency of the posterior jiortion, where the surface is uneven, is hard ; that of the anterior portion, where the surface is smooth, is soft and fluctuating. The tumor does not project into the buccal cavity; it is freely movable over the subjacent parts, and there is no glandu- lar enlargement. The tumor was extirpated with its capsule, and tlio facial nerve avoided. Part of the parotid gland was left behind. On section, carti- lage, cysts, calcification, and iii)rous and sarcomatous tissue were found. Mixed tumors occur frequently in the parntid. less often in the other salivary glands. These mixed tumors, which also occur in the breast, kidneys and testicles, are regarded as endotheliomata (see 5.3 page 49) by some authors, while others hold that they arise from epi- thelial and connective-tissue cells. On section, they show a very variegated structure, in which are found parts resembling carcinoma and sarcoma, mucoid and calcified tissue, cartilage bone, cysts. The presence of cartilage, which, to the feel, is the most characteristic element, coupled with the often slow growth, is responsible for the nam« enchondroma often given these tumors. Parotid tumor occurs more often in young individuals, and ap- pears as an encapsulated, smooth or nodular tumor, movable over subjacent parts, lying imder the fascia, and covered by intact non- adherent skin. The rare tumors which lie above the parotid fascia probably originate in aberrant parotid rudiments. The consistency of parotid tumors may be stone hard, hard, soft or cystic, according to their composition, and may diiTer in different parts of the same tumor. At first they increase slowly, but may suddenly take on rapid growth, break through their capsule, infiltrate the surrounding parts like malignant tumors, and finally perforate the skin and ulcerate. In such cases there are glandular and organic metastases. Tumors arising from the anterior part of the parotid cause swell- ing of the cheek; those arising from the posterior part of the gland raise up the external ear. Large tumors may extend toward the chin, the nape of the neck and the clavicle. In a few cases, the growth bulged exclusively toward the faucial region (Mixter) and could be extirpated through the buccal cavity. Small tumors cause hardly any pain, but sometimes salivation. Extensive tumors may give rise to pain in the ear, deafness and facial paralysis. Differential Diagnosis The more common cartilaginous tumors with uneven surface are easy to distinguish from other growths, but the soft tumors with smooth surface may be mistaken for salivary cysts, cavernous angi- oma, lymphangioma, lymphadenom^a, lipoma, fibroma, myxoma, sar- coma and carcinoma. As all of these tumors call for extirpation, an exploratory incision which will become the first step of a radical in- terference, is justified in all doubtful cases. Treatment Mixed tumors should be extirpated as early as possible on account of the possibility of their taking on malignant character. Both be- nign and malignant recurrence may take place from the remains of 54 Bockenheimer, Atlas. Tab. XXXI. r ■T0*^- Rebman Company, New- York. the capsule after removal of tumor. The capsule must, therefore, be completely removed during extirpation, which, however, is always a very diflicult and delicate procedure owin.ij- to tlie more tlian inti- mate aiintomical relations between the parotid tissue and the facial nerve. The latter must not be sacriliced except when the major interest of radical removal makes it imperative (malignant tumors). Even when care is taken to avoid large bvanclies of tlie nerve, when part of the gland is unaffected and can be h'ft beliiml, facial i)aralysis is frequent on account of si retelling duiing operation, or of infiltration of the sheath of the nei-ve by bluod. |>ut if the nerve has not been divided, jiaralysis is only temporary. In tumors of the subnuixilhn-y gland, very siniilai' in nature to those of the parotid, the whole gland should always be. removed. This procedure presents no special difficulty as to technicpie. Fig. 41 shows a so-called "ganglion," that is, a i)eriarticular cyst, developeil in a hernial protrusion of the synovial membrane of a joint (more particularly of the wrist and hand) through an interstice l)etween adjoining bundles of fibres of the capsule. The case shown in Fig. 41 is in a ty[)ical situation. It was observed in a young girl,, and was a recurrence of a previous forcibly broken cyst. Extirpa- tion of the ganglion resulted in cure. The unilocular cyst contained colloid matter. The presence of septa gave evidence of an earlier multilocular structure. Ganglions most often oceur on the dorsal surface between the extensor carpi radialis and extensor indicis, less commonly on the palmar side near the flexor car])i radialis (especially in jnanists) : also on the dorsum of the foot at the joints of the cuboid bone and in the neighborhood of the knee joint. According to the theory most connnouly accepted, ganglions are only retention cysts in a protrusion of the synovial cavity which has secondarily become isolated, or is connected with the articular cavity only by a nuire or less slender ]iedicle. According to another theory colloid degenei'ation of the joint capsule and the lu'i-iarticuhir con- nective tissue gives rise iirsl to multilocular, then unilocular cy>ts. Ganglions of the tendon sheaths develop in the bmsa' normally ex- isting between two tendons where they cross eacli other. They occur cliietty in the shealhs of the llexor tendons over the uietacai-po-iiha- laugeal joints, and cause neuralgic pain by pressure on the digital nerves. They often occur after rowing and fencing, i.e., from trau- matic causes. Spherical ganglions occur most commonly on the dorsal aspect of the hand in young women, and resemble exostoses on account of their hardness. They often cause neuralgic pains and slight trouble in the movements of the joints. Ganglions are of slow growth, the skin is unaltered and movable over them; the surface is smooth or slightly wrinkled. The con- sistency is hard in small ganglions, soft and fluctuating in larger ones. In pedunculated ganglions there is slight mobility over the joint. Differential Diagnosis In the knee joint they may be mistaken for affections of hursce; in the foot, for ganglions of the tendon-sheaths. Tuberculous teno- synovitis is distinguished by its nodular surface," its fusiform shape following the direction of the tendon, and sometimes by the fine grat- ing sound it gives on motion or pressure. Treatment The only treatment to be recommended is extirpation of the cyst and its pedicle imder strict observance of all rules of asepsis, for ganglions often communicate with the joint, or are only separated from the latter by a thin membrane. The time-honored method of bursting the ganglion by violent pressure of both thumbs or a blow with a wooden hammer, and then compressing with a bandage often leads to recurrence. So do sub- cutaneous discision, puncture, injection of alcohol or simple incision. All these methods are nowadavs obsolete. Fig. 42 shows an acute purulent inflammation of the prepa- tellar bursa. Fig. 43 shows a chronic inflammation of the same bursa, attended by the development of the cystic formation commonly called hygroma. The lower half of the pretihial bursa is also in- volved. Bursitis is acute or chronic, purulent or nonsuppurative. Acute bursitis supervenes especially after injuries of the region, or after neighboring inflammations (furuncles, lymphangitis, ery- sipelas). In serous bursitis (rheumatism) the skin is unchanged. In puru- lent bursitis, it is red and edematous far beyond the limits of the in- 56 Bockenheimer, Atlas, Tab. XXXII. Fig. 43. Hygroma genus multiloculare. Rebman Company, New- York. flamed hurs.i. Siiii)iiii';iti(iii .ilsn may cxU'iid l)eyon(l those limits and cause a dirfiisc plilci^iiKui. 'I'lic iimvements of the neij^hhoring joint are painful and limitccl and there is iiip^li fever. Under the movahle skin, in the case of snperlicial l)urs;r {e.g., the prepatelhir), a hemi- si)herieal, tense, sometimes fhictuatins-, slisjlitly movalile swollin,!!: witii a smootli sni'face can 1)0 felt, limited to the anatomical ))osition of the hursa (Fig. 42). Hygroma is n'ci-v i^cncrally an occiiiKitniiKil (liscasc, liecauso re- peated contusions and chronic irritation are the most important etio- logical factors. Hygroma of the prepatellar hnrsa is well known among persons who have to work in the kneeling position (as was tlie case with the man whose knee is shown in Fig. 43) : hence the name of "hoiisemniirs hiice." The "miner's elhoir," hygroma of the olecranon bursa, and the rider's hygroma, on the internal aspect of the internal condyle of the femur, are other frequent jiroofs of the same causal relation. It would be easy to multiply examples: there is not a trade requiring constant pressure and rubbing over a special point of the body that does not supply instances of the developinent of bursa? in this same traumatized point and of subsequent hygroma. Plygroma may also develop in adventitious bursa? developed with- out occupational trauma, for instance, on the toes over a corn or bunion, or in any other point where the skin passes over a prominence of bone subjected to pressure. \'illous jiroliferations and rice-like bodies are often observed in the walls of chronic hygroma. When rice-like bodies are found, the case is generally considered as tuberculous. The skin covering a hygroma is movable over the tumor, but rough and thickened, owing to the rejieated irritation. The hygroma forms a tumor of varying size (some as large as a child's head) and liarfhiess according to the thickness of its walls, but always too tense ill glrc real /hut iiiilidii. The hygroma is sphei'ical when developed in a niiilocular, regular bursa; it is nmltilocular and irregular in sliape (Fig. 43) when in a large bursa. It causes no ]iaiTi, aiid no functional dislurbnnce exce]it by its vol- ume; wlii'Ti large, il liimlcrs m(i\'cmenl. In tlii' case ol' "miner's elbow," there may li(> disaliilily or ueurali^ic pain from pressure on the ulnar nerve. DilJinnlial JUainiosis The different forms of bursitis 7uay be mistaken for arthritis of the adjacent joint, owing to limitation of movement, e.g., suV)deltoid 57 and sub-trochanteric bursitis. The strict localization of the affection to the anatomical position of the bursse should make the diagnosis easy. Multiple bursitis is chiefly observed in tuberculosis, syphilis, gonorrhea and gout, and inquiries must be pushed in the direction suggested. Treatment Acute bursitis requires early incision to stop the progress of the condition and its extension to the adjacent structures. Acute serous bursitis is apt to undergo spontaneous resorption, which may be has- tened by compression. Tapping and injection of a few drops of car- bolic acid or alcohol will, at times, prove useful. For chronic hygroma, the only treatment to be recommended is total extirpation, when feasible (sometimes the cyst is too large, or has too intimate connections with a joint, and part has to be left be- hind) ; or, when total excision is not possible, incision, scraping and sivabbing with carbolic acid, alcohol or tincture of iodine. When treating a hygroma, always remember the possibility of communica- tion with a joint. The bursitis shown in Fig. 42 was incised. All three bursas — sub- cutaneous, subfascial and subaponeurotic were full of pus and in communication with each other. The hygroma shown in Fig, 43 was extirpated. The two bursfe were in communication. - Fig. 44 shows a tumor the size of a walnut, in an old woman. Its situation in the isthmus of the thyroid gland is evidenced by its ascen- sion during swallowing. Its rounded form and regTiIar outline and consistencjr show that it is a cyst. The lesion is therefore a cystic goiter. Goiter is endemic in some countries (Switzerland), but sporadic cases are fairly frequent everywhere. Its real cause is unknown, though many are the hypotheses that have been made on this point. Pathologically, the goiter may be follicular, colloid, vascular, cys- tic or fibrous. These different varieties may all be found together in the same tumor. The characteristic feature of all thyroid tumors is ascension with the larynx during deglutition. The simplest form of goiter is follicular hypertrophy. The gland is slightly enlarged and studded with small, hard nodules which may persist indefinitely, undergo resorption, or more frequently, increase in size and lead to colloid or cystic degeneration. ■ 58 a disease of elderly and old people. It is a nodnlar, \cry hard ami ra]>idly growing tumor which soon infiltrates all the tissues of the neck and promptly leads to paralysis of the vocal cords, to glandular metastases and cachexia. A sud- den, rapid growth, in did iicdplc. in ;in old standing goiter is always suggestive of malignancy. 50 Sarcoma of the thyroid is a rare affection occurring in young people. The infiltration is diffuse, but the consistency is soft. Sar- coma may break through the capsule and give rise to severe hemor- rhage. Syphilitic gumma of the thyroid gland is probably not as rare as the scarcity of observations would lead us to believe, but the clinical history is little known, and barring anamnesis, a positive Wasser- mann reaction and the influence of specific treatment, there are no diagnostic elements. Tuberculosis of the thyroid gland may also assume a nodular form, not unlike follicular goiter, but the cases well studied are not numerous enough to enable one to give a clear description. Aberrant goiters, when connected with the thyroid by a palpable pedicle, are easily recog-nized; But when free, they may be mistaken for lymphoma, adenitis, sebaceous or dermoid cysts or malignant tumors. Retrosternal goiter is a mediastinal tumor, and as such may be mistaken for any of the other kinds, particularly aortic aneurysm. Exophthalmic goiter {Graves' disease) is characterized by symptoms of hyperthyroidism (tremor, palpitations, highly nervous condition, etc.) associated with bulging of the eyes and hypertrophy (always moderate in pure cases) of the thyroid gland. The train of symptoms is sufficiently typical to allow the diagnosis to be made: but symptoms of hyperthyroidism may sometimes appear in cases of long-standing goiters. Treatment Incipient follicular hypertrophy can be happily influenced by io- dine preparations or thyroid extract (administered with caution, lest we produce symptoms of hyperthyroidism). In localized lesions, cysts or nodes, the remainder of the gland being sound, enucleation is indicated. In more diffuse forms, in colloid degeneration particularly, par- tial thyroidectomy by the Mayo suhca,pstdar technique is the best operation. Total thyroidectomy is not physiologically permissible, as it is followed by post-operative myxoedema, akin to congenital myxcedema, sometimes associated with cretinism, observed in coun- tries where goiter is endemic. An entire lobe is generally left, that is, the more affected lobe and the isthmus are taken away. The subcapsular technique wards off the danger of post-opera- tive tetany due to the removal of all parathyroid glandules situated 60 Bockenheimer, Atlas. Tab. XXXIV. Fig. 45. Papilloma cutis inflainmatorium. Rebmaii Company, New-York. licliiiid tlif lliyroiil lolics, and tlic aiiatdinii-al (lisposilioii of wliicli is vai-ial)l('. Should all iiaratliyroids 1)0 iiiadvertt-iitly rt'iiioved, totally may i>c prevented by imniodiate iinpUiiitdtioii into tlio al)dominnl wall of one or two of the excised parathyroids; or it may be cured l)y sul)- cutaneous injectiou of an extract of paratliyroids or by the use of calcium lactate {Beehc, McCdlliiiii). Transplantation of thyroid frafpnciils has also boon attomptod for the cure of myxcedema. In Graves' disease, when the hygienic treatment fails, o])orative measures are indicated. In not too severe cases ligation of the thy- roid arteries (up to three) often brings about marked relief and lessens the hyperthyroidism. It can be done quickly under local anesthesia and in severe cases may be a i)reliminary step, preceding by a few days partial thyroiilectomy, which is then indicated. There are no cases in which post-operative toxemia can be so hyperacute. Therefore the operation must be done under local anesthesia, as quickly and as gently as possible so as not to squeeze thyroid secre- tion into the circulation. The results are excellent when the danger- bus post-operative period can safely be tided over, and no class of patients are moi-e grateful to the surgeon who has cured them \Crile). Therefore it is important not to delay surgical interference too long, and not to dally with ineffectual internal remedies until the patient is in a hopeless condition. Fig. 45 shows a so-called "papilloma" of the skin. It is a small tumor freely movable over the underlying parts, of rather soft con- sistency, and covered with warty projections. It has been frequently cauterized: hence the abrasion of the surface, and the inflammation of the surrounding skin. The surface is covered with a yellowish, fetid secretion, and between the villous projections are deep depres- sions caused by ulceration, so that the appearance in some places is almost that of carcinoma, but the borders are not hard. In the past, the name "papilloma" has been used to designate various growths of the skin, consisting of hypertrophied papillae covered with epithelium (warts, nsvi, condylomata). It was even claimed that true papilloma, as distinguished from paiiillomatous formations, was a special type of fibro-opitholial tumor. Nowadays the tmn papilloma of tlu' skin is ol)solete; at least in so far as the skin and cxtcinal niiicuus nicnibranos (see iiapilloma of Iho longno. Figs. 6 and 7) :n'c cnnrci ihmI. it is adniiltod that the (il so-called "papillomata" are not tumors in the usual sense of the word, but simply papillary and epithelial hypertrophies developed under the influence of repeated irritations, chiefly of an infectious nature, in regions that are warm and moist; hence the frequencj^ of these lesions around the mucocutaneous junctures of the genitals (venereal warts). Similar growths may be observed on internal mucous membranes (larynx, intestines, bladder). On account of their vascularity, they bleed very easily, and hemorrhage is one of their chief symptoms. In the bladder, villous tumors sometimes degenerate into carcinoma or recur as carcinoma after excision. Treatment The best treatment of papilloma is excision. Papillomatous tumors of internal organs, especially the bladder, are very well re- moved by sparking with high frequency currents (Beer, Keyes Jr.). External "papillomata" may be destroyed with the galvanocautery or strong caustics. Mild cauterizations only irritate the lesion. Figs. 46, 47 and 48 show three cases of dermoid cysts. Fig. 46 shows a dermoid of the forehead, where it is often observed, either above the root of the nose, in the inner angle of the ej'-e, or laterally near the glabella (fissural dermoid cyst). The skin is movable over the tumor, which was observed in early youth, and shows a small white scar left by a former insufficient operation. The surface of the tumor is smooth and hemispherical. At the periphery there are raised bony walls. The tumor slowly attained its present size after the former operation and then remained stationary. There is no diminution on pressure over the tumor. It is of doughy con- sistency and but slightly movable over the subjacent bone. I Fig. 47 shows a dermoid of the prepuce, situated symmetrically on both sides of the raphe, and present since birth. The skiii is so thin that the contents can be seen through it. The tumor has caused phimosis and balanitis. Fig. 48 shows a dermoid of the neck in the position of the second branchial arch. Symmetrical dermoids in the middle line may occur above or below the larynx. Dermoids of the floor of the mouth may cause bulging of the submental region. The tumor has the size of a hen's Qgg, a smooth surface, a doughy, semi-fluctuating consistency. 62 Bockenliciiiicr, Atlas. Tab. .\XX' Fig. 46. Dermoid — Recidiv. Fjo-. 47. ncnnnid Phimosis. Rebnian Company, New- York. Bockenheiraer, Atlas. Tab. XXXVI. Fig. 48. Dermoid — Cystis. Kebman Company, New-York. It is not adlierent to sul)jaceiit parts nor to tlie unaltered skin. It dated hack to int'aiicy: it lirst jirew slowly, later l)ecaiiie stationary, and caused no inconvenience apart from the disfigurenient. True dermoid cysts are formed by invagination of the epihiast only, while compound dei-moid cysts {Tenituntu, Fig. 146) include all tliree embryonic layei's. Dermoid cysts occur (uily wlirii-. in I'mlnynnic lilc, there were folds, furrows or recesses, or in i)laces where origans are developed by invagination of the epiblast. The latter mode explains dermoids in the vertebra! canal, cranial, thoracic and abdominal cavities, retro- peritoneal tissue and kidneys. The former mode of development accounts for tlie (issnral dermoid cysts in the regions of the head, of the face (Fig. 46), in the neck, at the umbilicus and in the coccygeal region. Dermoid cysts of the testicles and ovaries, on account of their complicated structure, are not ]inrc dermoids. Pure dermoids are unilocular or nuiltilocular cysts, the external walls of which consist of connective tissue, and are connected with the surrounding tissues while the internal surface resembles skin (hence the term dermoid), and presents papilla^, squamous epithelium and hair. Those dermoids which contain bone, cartilage and teeth are formed at a very early embryonic period, before differentiation has taken place. The contents of the cyst consist of a yellowish-white, caseous, odor- less, fatty mass, mixed with numerous hairs, the appearance of which varies according to the situation of the dermoid (in the region of the eye, eyelashes, etc.). The contents are rarely serous or hemorrhagic. In the cutaneous or subcutaneous tissue the cysts form spherical or hemisi)herical tumors with a smooth surface and tallowy con- sistency. They are covered liy intact skin, and are often attached to the bones. The superficial dermoids usually occur in youth. They are slow-growing and ])ainless, and about the size of a walnut. Some- times fistuhie form, from which hairs protrude. Diiujnosis The dia.gnosis of superficial dermoids is easy to estal)lish by the above signs. But, according to the region of the body in which they are situated, even superficial dermoids may be mistaken for other conditions, sncli as sebaceous cysis, for instance, but the contents of the latter are yellow and foul smelling. Lipomata are not congenital and are generally lobiilnted. f)3 A cyst in the location of that shown in Fig. 46 might be diagnosed encephalocele; but the latter attains a much larger size and diminishes on i^ressure (see Fig. 142 and page 2;J1). Also in the same case, owing to the scar of the previous operation, an epidermic inclusion cyst might be thought of ; however, the latter is not congenital, develops only after a trauma, and, on microscopical examination, its walls contain only squamous epithelium without any sebaceous or sweat glands. A dermoid cyst of the neck (Fig. 48) may be mistaken for a tubercidous adenitis, a branchiogeiious cyst, a thyro-glossal cyst (see Fig. 57, median fistula of the neck). None of these conditions, how- ever, has the doughy consistency of a dermoid cyst. Dermoids of the umbilicus, on account of their special hardness, may be mistaken for malignant tumors, but they are of slow growth and circumscribed. Dermoids of the abdominal walls are often mis- taken for sarcoma and fibroma, but the latter increase in size while dermoids remain stationary. Deeply situated dermoids of the various cavities and organs, which often are noticed only by accident, cannot as a rule be dis- tinguished from other tumors. Treatment Extirpation of the whole cyst is necessary, as recurrence takes place if any part is left behind. Commencing carcinoma has been observed in the inner surface of the cyst wall (Wolff). Extirpation was carried out in the three cases represented. Fig. 49 shows a fibroma of the sheath of the flexor tendon of the finger, the yellowish-white surface of which shows through the skin. The skin is slightly movable over the hard nodular tumor. The tumor itself is movable over the subjacent structures, and remains unaltered in position on moving the finger, which fact shows its inde- pendence from the tendon itself. Fibromata of tendon sheaths are rare on the whole, and are due to traumatic causes. After injuries and stretching of tendons similar growths occur, sometimes multiple; they are due to proliferation of the cellular tissue. In Dupuytren's contraction (Fig. 60) nodules also develop in the palmar aponeurosis, which somewhat resemble fibro^nata. Thickenings which occur in tendons and tendon sheaths, and lock tire movements of the fingers in certain positions, are not true fibromata. 64 BuckL-iiliL-iiuL-r, Atlas. Tab. XXXVII Rcbinan Company, New- York. Fil)i-oina is ;i licnimi '■iiiiiicctivc-fissiii' tmiior, cunsistiiifx of con- uective-tissiic rdls, HliiilLii-. inlcr cclluljir substiinf-e and a variable amount of bluud vessels and l\ inplialics. Wlien tlie matrix is hard and abundant, with slight develojiment of spindle-cells, the fibroma is hard, wliilo soft fibi-oiiia is foi-inocl by s])nn,i>y tissue witli minifrous blood-vessels. Those fibromata which consist of librous connective tissue with few nuclei are also termed fJesmoids, esiiecially when they occur in the fascia of tlie abdominal walls, while the term fibrosarcoma is aiijjlied to tumors which consist of irregularly arranged spindle cells with little intercellular substance, and sliow deuciiei-ative changes and an absence of mature tissue. 'J'ransitional forms from fibroma to fibrosarcoma and sarcoma are especiallj' observed in the tumors occurring in fascia. Mixed foi-ms are often found, such as fibro-liporaa, fibro-myoraa, fibro-adenoraa and fibro-myxoma. Cystic formation is also seen in fibromata. Fibromata occur in all situations where fibrillar connective tissue is present — in the cutaneous and subcnlaneous tissue (back and thigh), in intermuscular, intertendinous (Fig. 49), submucous and subserous tissue (alimentary canal, uterus, larynx). They may also develop in fascifB and aponeuroses, nerve sheaths and pei-iosteum {uaso-phani)igeal tumors, Fig. 25, and epulis, Fig, 35), and also within the internal organs. Filn-eids of the uterus are the most fre- quent of all. Fibromata form circumscribed tumors of fii'm consistency and smooth surface, often encapsulated, slow-growing, sessile or peduncu- lated (tibrolipoma pendulum, Fig. 52). Pedunculated submucous fibromata often occur in the larynx in singers. Fibroid tumors may occur at any age; they are seldom congenital. After metaplastic changes (ossification) they may become hard. In the skin and sul)cutaneous tissue they have a yellowish-white surface (Fig. 49). On section they show stratification and a glisten- ing appearance like tendon tissue. Diffrrnificil ilUifiiiosix niiil trral iiuiil Superficial hard liliroiiiata ol' llie skin and siilicutaiieoiis tissue are easily recognized by their form, consistence, clear demarcation and solitary appearance. It is oidy transitional forms between fibro- sarcoma and sarcoma that ])resent any difficulty. T)ee]i fibromata which oflen attain a large size (c.p.. in the abdominal cavity) are recognized by llieir iiddular siirfai-e. hardness and ciicapsulatiou. 65 Treatment Treatment is excision of the tnmor with its capsule. For the removal of deep fibromata extensive operations are necessary. Some- times they are so firmly attached to the neighboring tissues or organs that a portion of the latter must be removed with them. In other cases, they can be shelled out without difficulty (enucleation of uterine fibroids). Fig. 50 shows a case, observed in a young man, of multiple chondroma of the fingers, which had been present since childhood. The nodular tumors are situated in the phalanges and metacarpal bones, and have caused thinning and reddening of the skin by pres- sure. The X-rays showed the origin to be in the medullary cavity. The tumors on tlie first, second and fourth fingers were incised and scraped. The little finger was removed with its metacarpal bone, on account of the multiplicity of the tumors. Although cartilaginous tumors are pathologically divided into two groups: (1) ecchondroma, or hyperplastic proliferation from pre- existing cartilage, which only occurs in places where cartilage is usuall}^ present; (2) lieteroplastic cartilaginous growths, or enchon- droma, which occur in places where cartilage is not normal])^ pres- ent, these two foi'ms are often impossible to distinguish clinically. We therefore include both forms under the name of chondroma. The tumors either consist of the different forms of cartilage, or else they are mixed (cliondro-myxoma, chondro -lipoma, or chondro- sarcoma). Cystic degeneration may also occur in chondroma, and by liquefaction of cartilaginous tumors large cysts may form in the long bones. True chondroma may occur in the soft parts from aberrant pieces of cartilage in the neighborhood salivary glands, neck, ear, lungs, trachea, mammary gland. The mixed tumors occurring in the testicles and salivary glands, which develop cartilaginous tissue through metaplasia, are not true chondroma. Congenital chondroma and chondroma develoi^ing in infancy, according to Virchow, are due to disturbances in the development of bone during the period of growth, and arise from islands of cartilage left in the diaphysis. Rickets appear to play a certain role in this connection owing to the irregnilar ossification of the epiphyseal car- tilages. In some cases there appears to be a hereditary tendency ta the formation of chondroma. 66 Bockenheimer, Atlas. Tab. XXXVIII. Fie. 51. Hamorrhoides et Fibromata ani. Rebman Company, New- York. Tine (•Itoiirlroma. or ciiclinniliotn;!, (l('Vf'ln])s from tlio poriosteum or inciliilla, most coiiii liy in tlic |ili;il;iiif>-('.s ;iiul mt't;ic;iri);il or meta- tarsal bones; it is usually multiple. Cases of isolated cliondroma also occur in the u]ii)pr oud of the humerus, the lower end of the radius, the head of the lilii.i, flic iidxic hones and the scapula, often com- bined willi cartila.uinuus exostoses (ossified ecehondromata Avith a cartilaginous covering). Chondroma forms slow-growing, hard, nodular, circumscribed tumors, whicli may cause pressure atrophy of neighboring parts (Fig. 50)- Alulliplc tumors, especially in the hands, cause consider- alilc (Icfoi'inity li\ disturbance of growth (shortening and twisting). Spontaneous fractures may occur from destruction of the cortex, in tumors growing from the medullary cavity. The softer forms of chondroma, less comnimi than the hard, must be regarded as malignant, because they take on an infiltrating growth, extend to the veins and give rise to metastases. {Chondro- sarcoma.) Diffcniiiiiil didgiwsis Central medullary chondroma has to be dia.gnosed from osteo- myelitic abscesses and from central sarcoma. The former, on X-ray examination, show thickening of the pei'iosteuni ; the latter can often only be distinguished by operation, as the X-ray appearances are very similar in chondroma and sarcoma (when the chondroma is single). Large chondromata of the head of the tibia or ujiper end of the humei'us, and generally speaking peripheral chondromata are easily recogTiized by their nodular surface and typical hard consistency. Multiple hard tumors are always suggestive of chondroma. Treatment Any isolated chondroma should always be extirjiated, as it may develop into sarcoma. IMultiple tumors (case of Fig. 50) may be incised and scraped. If rapidly growing recurrence takes place, resection or amputation must be performed. Fig. 51 shows around the anus yellowish nodular hemorrhoids, which, owing to the concomitant moist eczema and rciieatcd ulceration and inflanunatory changes, have undergone iibrous changes and somewhat resemble fibromata. Tu one place there is a typical bluish, glistening hemorrhoidal iiodiilc 67 Hemorrhoids, the most common surgical condition of the anus, are external or internal, according to their location. External hemorrhoids are those developed from the inferior hemorrhoidal plexus. Constipation and pelvic congestion are two favoring factors in their development. They form bluish, com- pressible, nodular, sessile or pedunculated growths covered by thin skin and situated around the anal orifice. When turgid and iniifimed they cause much itching, pain and tenesmus, while the nodules bleed easily and thrombophlebitis is frequent. The latter and the moist eczema bring about the changes shown in Fig. 51. Multiple internal hemorrhoids of the lower part of the rectum bleed easily without being inflamed and are often accomj^anied by a slight mucous prolapse. Diagnosis When situated high up in the rectum, a proctoscopic examination is necessary. For ordinary cases, digital examination is generally sufficient for the diagnosis. Condylomata acuminata, frequent in the anal region, might be mistaken for hemorrhoids only on superficial examination. The cockscomb-like vegetations are too characteristic. The same may be said of condylomata lata. Genuine anal fibroma is rare, solitary and pedunculated. Carcinoma of the papillomatous type is recognized by its early ulceration with hard borders and irregular outline, and surface bleed- ing to the slightest contact. In all cases of hemorrhoids, a digital exploration should be made for carcinoma. The treatment of hemorrhoids consists in cleanliness, antiphlo- gistic measures during the periods of inflammation, and removal of the nodules if they are too troublesome, either by the clamp and cautery method (applied in the case of Fig. 51) or by a bloody opera- tion if there is a complete ring of sessile tumors. Anal dilatation is the first step in all operations for hemorrhoids. Figs. 52 to 54, inclusive, show three types of lipoma. G8 Bockenheimer, Atlas. Tab. XXXIX. Fig. 52. Fibrolipoma subcutaneum pendulum. Rebman Company, New-York. Fig. 52 shows a pendulous fibro-lipoma in a middle-aged woman. The skin is somewhat reddened, but non-adlierent. The tumor is smooth, moderately hard in consistency and moval)le over the f:i~i'i,i. Its base is broad, on account of its small size. Fig. 53 shows a sub-cutaneous lipoma Hie size of the fist in a common situation in a middle-aged woman. The puckering of the skin is clearly seen. These puckcrings (white spots in the figure) are also found in the breast, and are due to processes of the lipoma ex- tending into the latter. Fig. 54 shows symmetrical lipomata in the region of both parotids, in the upper eyelids, and in various parts of the neck (both sides of submaxillary region and sublingual region) in an old man. The painless tumors had not increased in size for some years. Their lobular surface and their consistency distinguish these solid tumors from symmetrical cystic formations in the salivai'y glands, which cause similar swellings in the face and neck. (See about lymph- angioma and Miliulicz' disease, page 2.36.) The disease is distin- guished from sim^jle adiposis by consisting of multiple, separate, encapsulated tumors. There were no other lipomata in other parts (in distinction to cases in which lipomata occur over the whole body). Lipomata are tumors formed of fatty tissue, and have, therefore, the yellowish-white color, soft consistency, and lobular structure of fatty tissue. The individual fat lobules are separated by more or less strongly developed connective-tissue septa, and the whole tumor is demarcated from the surrounding tissues bj^ a thin capsule. Lipo- mata are of soft, often pseudo-fluctuating consistency; in rare cases they are harder, because they contain more connective tissue. They are slow-growing, globular tumors, which sometimes attain an enormous size, and are usually supplied by a single vessel at their base. They are generally sessile. In large tumors the skin is often drawn so as to form a broad pedicle. Narrow pedunculated lipomata (Fig. 52) are rare. Lipomata are essentially benign tumors, which neither recur, nor give metastases, nor undergo malignant changes. Besides the fat, which differs from ordinary fatty tissue only in that the globules are sliglitly larger, there may be other constituents, hence the varieties fibro-lipoma, myxo-lipoma, angio-lipoma, chondro- G9 lipoma. Cystic degeneration may give rise to so-called oil-cysts in the interior of lipomata. The etiology of lipoma is unknown. That it is a true tumor is shown by its persisting in severe emaciation. Thus are multiple lipomata distinguished as a nosological entity from obesity, though, clinically, it may be difficult in some cases to know which of the two conditions we are dealing with. That repeated irritations may act as a predisposing cause is demonstrated by the development of lipomata on the back of carriers and on the forehead of persons who wear hard hats. Pregnancy may give a sudden impetus to the growth of stationary lipomata. Developmental and trophic disturbances undoubtedly play an im- portant part in the production of multiple lipomata, which are usually symmetrical (Fig. 54). Symmetrical lipomatosis has been described as a separate morbid process. Multiple lipomata may be connected with nerves or with lymphatic, glands, which sometimes have been found within them. The connections with nerves explain why those multiple lipomata are often painful [Dercum has described a variety under the name of adiposis dolorosa). Congenital lipoma is found especially in spina bifida of the myelo- cystocele variety (usually myxolipoma, Fig. 144). Lipomata are most often found in the subcutaneous tissue (Figs. 52, 53 and 54), where they appear as soft, encapsulated tumors with a lobulated surface, covered by non-adherent skin. The skin over the tumor becomes dimpled when i^inched up, owing to its connection with the tumor by connective tissue (Fig. 53). The seats of predilection for subcutaneous lipomata are the back, nape of the neck (fatty neck), axilla, shoulder, upper arm, thigh, buttocks and scrotum. In the limbs lipomata become less and less frequent as the region becomes more distant from the attachment to the trunk. Subfascial lipomata are much less common. They may occur under the fascia of the forehead (where they may be mistaken for dermoids, see page 63) and under the palmar fascia. Intermuscular lipomata occur behind the pectoralis major and in the tongaie. In the knee joint arborescent lipoma occurs, which has the typical struc- ture of fatty tissue, and is connected by some authors with tubercu- losis of the knee, healed or of very low virulence. Lipomata may also arise from the submucous and subserous tissue (gut and larynx) ; subperitoneal lipomata may give rise to hernia through the linea alba. Subserous lipomata also sometimes appear in the inguinal 70 Bnrkenlu'iiiier, Atlas. V'\g. 53. Upiima (.iillii>uiii subcutaiicuni. Rcbm.m Company, Ne\v-\'ork. Bockenheimer, Atlas. Tab. XLI. Fig. 54. Lipomata subcutanea symmetrica. Rebman Company, New-York. and foiiioral caiiiils; in the oiiK'iitum and inosontery ; in tlic retro- peritoneal tissne, and in tiie ,n-iandiiiar orf^an.s (l)reast and kidney). Ail lij)oniata, especially suhcntaneous, suhfascial and inter- muscular, have a tendency to send processes into the surrounding parts. The cliarncU'rislic rc.-iluics of li|i(iiiia. fidiii the staiHlpoiiit of diagnosis, are the t>uft, ptniudo-jlmtnatuui consiatciuti and the lobu- lar surface with i)uckering of the skin. Fihromala are harder; sebaceous cysts are round, smooth and more tense; cijst.s and hyrjromata are perfectly smooth; dcnnoids have a special doughy consistency. Adenitis has small, hard nodes, unless already suppurative and does not much resemble lipoma. The fatty accumulations seen after long suppurations, for in- stance in the perirenal capsule (lipomatous perinephritis) are not true lipomata. Nor is diffuse lipomatosis (obesity). Trcntiiunt The treatment of lipoma is cxtirindion of the tumor and of all its processes. This was applied to the three cases represented in the illustrations: several sittings were necessary for the case represented in Fig. 54. In cases of lipoma of the limbs (such as that of Fig. 53) c-are must be taken, because, despite its encapsulation, the tumor may have sent processes in all directions, eusheathing the big blood ves- sels and nerves, which it is important not to wound. Adiposity of the abdominal walls has recently been treated sur- gically. Kelly advocates removal of large masses of fat by wedge- shaped excisions before laparotomies. This facilitates the work of the surgeon, insures better repair of the abdominal wall and lightens the patient. 71 MISCELLANEOUS LESIONS Figs. 55-83 A.— Scars— Fistulae— Figs. 55-59 B.— Deformities Due to Contractions of Muscles or to Fractures— Figs. 60-66 C.-Naevi-Figs. 67-69 D.— Lesions of the Lymphatic and Vascular Sys- tems—Figs. 70-83 Bockenheimer, Atlas. Fig. 55. Granulationes et Transplantationes. Rebman Company, New- York. SCARS FISTULAE Fig. 55 shnws ;i granulating wound li'l'l !'>' Hh' extirpation of the rig-ht breast, and three epidermic grafts that have been trans- planted thereon. After extirjiatioii of the lireast, an attempt sliould always be made to close the wound by sutures, but these sliould not be tied too tightly, especially in the center of the wmmd, where there is much tension, as they arc liaMe to tear tliiiniiili tiie tissues and cause sloughing. Fig. 55 shows the i-eddi.sii-l)rown holes of the sutures, which have led to partial closure of the wound in the middle. The remainder of the wound can be left to heal by granulation, and TJiierscli's grafts may be applied. A wound is ready for epidermic grafts when it is covered with red, vigorously sprout'uig granulations. When the granulations are still yellowish (as on the axillary side in Fig. 55), it is still too early. Balsam of Peru, either pure or mixed with oil, is a very good di-essing to promote granulation. When the whole surface of the wound is covered with red, ex- uberant granulations, these are scraped off with a sharp spoon, and the bleeding surface compressed with hot compresses soaked in saline solution until all blood oozing has been absolutely checked: this is essential to success, as oozing would raise the grafts from the surface of the granulations; the largest possible epidermic grafts are then applied, each one overlap])ing the preceding, and covered with sterile rubber tissue soaked in saline solution [no iDitiseptics in the whole process of skin grafting). Scarlet red salve (5-8%) is very efficient to hasten the epidermi- zation of granulating surfaces of all kinds (ulcers, partially success- ful grafting operations). Fig. 56 shows a fistula due to iiisiifjicifiif tlrdiinit/c of a kidney. As a result of incision of a ])arane])liritic abscess, a tistula has remained, which, in spite of drainage, ]iackingand repeated scrapings, has not healed. The surrounding skin is inflamed and edematous. The granulations at the o]>ening of the fistula are unhealthy, dirty- hrown and pui'ulent. Shreds of tissue with a I'etid odor are dis- charged from the fistula. 75 Such an appearance of the fistula and its surroundings is typical of all cases where the external opening is too small, so that an abscess in connection with it is not sufficiently drained, or where necrosed pieces of tissue in the deeper parts are cast off and act as foreigTi bodies {e.g. bony sequestra in coxitis, etc. Figs. 95 and 96). Similar fistulse, with an offensive sanious discharge, sometimes result from tampons, drains, or instruments being left behind after opera- tions. Hence veiy simple and important rules of caution. In pyogenic lesions which have been insufficiently incised, the pres- ence of unhealthy, purulent granulations shows that the pus has not a free outlet, or that the lesion is extending. '^Vhen a local pyogenic lesion gives rise to general pyaemia the wound shows similar changes, but the granulations, besides having a dirty yellow appearance, are quite dry. Treatment .Treatment must be directed to the cause of the fistula. The latter should be laid open freelj^, and foreign bodies or pieces of necrosed bone removed, after which healing will take place. Such cases are not suitable for the Beck bismuth paste method (see page 192). In the case represented in Fig. 56, the kidney was found to be almost completely destroyed by suppuration. Healing quickly took place after removal of the kidney. Fig. 57 shows a median fistula of tlie neck in a girl aged 19. The fistula first appeared at the age of 15, and was treated by injection and incision, without any result. A drop of secretion is seen at the orifice of the fistula. Radiating cicatrices are also visible. The fistu- lous track could be felt as a cord as far as the hyoid bone, but its further course could not be made oiit by injections of fluids. The foramen cfecum was deep. After an incision around the opening of the fistula together with the scar tissue, the track was dissected out. The center of the hyoid bone, through which the track penetrated, was removed, so as to push the extirpation up to the base of the tongTie. Microscopic examination showed squamous epithelium in the lower part of the fistula and ciliated, cylindrical epithelium in the upper part. Fistulce of the neck are median or lateral. They may be complete; blind internal or blind, external. Those we are considering now all result from an arrest in the 76 I'.nckciilu'iiiipr, Atlas. Tab. Xl.lll. Fig. 56. Fistula c.\ corpoix- alieiio. Kcbiiian Company, New-York. Bockcnheimer, Atlas. Tab. XI lY. bJ3 Rebman Company, New- York. development of tlie cervical region, anrl, therefore, are oil congcuital; but some are complete at the time of birth, wliilo others (as was tlie case in the jiatient of Fig. 57) hecome complete oiih/ hij the secondary opening to the skin of a 1)1 ind internal fistuhi. The outer opening of fistula? of the first variety always corresponds in position to a point where during development there ivas a transitory orifice: the outer opening of fistula? that liave hecome secondarily complete does not necessarily, and in fact, in most cases, does not, correspond to such a point. Median /isliila of the neck is due to the persistency of the thyro- glossal duct, which in embryonic life leads from the foramen crecum at the back of the toniQ:ue to the middle lobe of the thyroid gland. In most cases; when complete, it belongs to the class of fistuhp that have become secondarily complete, which fact explains wjiy they are not noticed before a certain age. Lateral fistidce of the neck were formerly attributed to imperfect closure of the second branchial cleft, when the existence of genuine clefts was admitted: now that we know that there are no real clefts, but simply thinnings between the thickened branchial arches, lateral fistula? are ascribed to anomalies in the evolution of the sinus prce- cervicalis. Heredity is an important factor, found in 25% of the cases. Median fistula? o])en in the midline between the hyoid bone and the sternum : those opening low have been considered as tracheal fistuljp, but there is not a single well-authenticated case to prove the exist- ence of a tracheal communication. There are no median supra-hyoid fistulfe, and embryology shows that there can be none. Lateral fistula? generally open along the inner liorder of the sterno- cleido-mastoid muscle, usually about an inch above the sterno- clavicular joint, and more frequently on the right side. Bilaterality is fairly frequent (22%). The outer orifice is generally button shaped, partly cutaneous, partly mucous (sometimes purely cutaneous and difficult to see). Sometimes its lips are glued together by secretion; sometimes a free drop of secretion exudes from it (Fig. 57). Tf there is much secre- tion the skin very likely is eczenuitous. The tract itself may be felt by palpation as a hard, round cord, as thick as a quill pen, directed upward and inward toward the greater comu of the hyoid bone in case of lateral fistula; straight upward toward the body of the hyoid bone in case of median fistula. In the latter case, the tract passes behind or through the hyoid bone and 77 ends at the foramen ccectwi of the tongue. The tract of lateral fistula3 passes below the facial nerve, before the glosso-pliaryngeal nerve and stylo-hyoid ligament, between the external and internal carotid arteries (that is, between the vessels and nerves of the second and third branchial arches). The upper part of the tract is some- times, if not always, innervated by the glosso-pharyngeal nerve. The internal orifice of lateral fistiilfe is found in a constant position in the tonsillar region. The direction of the tract may be further ascertained by probing : this, however, is generally disagreeable and painful to the patient, and the probe can hardly ever be passed above the level of the hyoid bone; which fact does not prove that we are dealing with a blind external fistula, but that there are kinks in that portion of the tract, because if we inject milk or hydrogen peroxide stained with methylene blue {Lynch's method) or sapid solutions, we can often demonstrate the existence of the internal orifice. Narrow fistulse cause little trouble to the patient, but in wide, lateral fistulae accumulation of food may cause inflammation and abscess. Carcinoma may arise from fistute and cysts of the neck; it is called branchiogenous, as it is derived from the epithelium of the branchial clefts. In most cases, the history of the case, the appearance of the open- ing and the anatomical relations of the tract are so striking that the diagnosis is made without any hesitation whatever. Fistulae arising from tuberculous or inflammatory processes differ both in their external appearance. and in the course of the fistulous track. In doubtful cases microscopic examination may be made, which will show the epithelial lining absolutely characteristic of a congenital tract. Treatment Injections with the object of causing obliteration of the fistula are absolutely useless, and so is incision and scraping. The only rational treatment is total extirpation of the fistulous tract through a long incision, bearing in mind the anatomy of the region and the very important connections of the upper part. In lateral fistula it is best to remove the internal orifice together with the tonsil. In median fistula, it is sometimes necessary to remove the middle part of the hyoid bone, in order to follow the track to the foramen caecum. Ee- currence is unavoidable if the smallest part of the fistulous track is left behind. Microscopic examination of both median and lateral fistulae shows squamous epithelium in distal sections, cylindrical 78 Bockenheimer, Atlas. Tab. XLV. X Rebman Company, New- York. epithelium in ])roxiiii;il sections. The presence of lymphoid tissue in tlie wall of tlie listula is cliaracteristie. Figs. 58 .111(1 59 icpicsciit two fasos of tiic iiyp('rtro|)hic lesion of scars known as keloid. Fig. 58 shows a kcldid which arose on a vaccination scar, in a young girl, and recurred extensively after extirpation. It appears as a large flat growth with radiating processes; smaller nodules are scattered in the neighlidilKMMl. Fig, 59 shows a liig noduhir keloid developed, in a woman of twenty, in the scai' of a laparotomy. Each suture hole has hecome the seat of a nodule. In the lower part are seen hard, cauliflower-like nodules, freely movahle and covered with epidermis. Keloids, the etiology of which is still little known, are character- ized by the formation of homogeneous, fibrous nodes in cicatrices; which nodes consist of hypertrophic scar tissue with thickened blood- vessels. The chief part of the growth consists of dense, hyaline, often interlacing bundles of connective tissue, while cells and elastic fibers are few in number. The papillary bodies are unchanged, but lying under them are nodules or lamelhT, more or less rich in cells. In the lamellar form (Fig, 58) there are radial processes at the periph- ery which are often prolonged as fine processes into the skin. A l-eloid is a painless tumor of hard consistency, with a smooth, glistening surface, of reddish (Fig. 58) or yellowish white color (Fig. 59). It is situated in the skin, at the site of a former scar, and movable over the underlying structures. After it has reached a certain size, it remains stationary. Barring their unsightly appearance, keloids cause no incon- venience. They are absolutely benign lesions; cancerous degenera- tion is seen only after ulceration. Only if the keloid is very large, and from its situation exjiosed to repeated pressure and irritation, does pain sometimes occur. Keloids are more common in young women. Scars of burns, ulcers and vaccination are more liable to undergo keloidal evolution. The role of infection is not definitely established. There seems to be a local or general predisposition in the individual affected. Some races (negroes and other dark races) have a special tendency to keloid formation. Certain jiails nf the body are more affected than others: shoulders, face, abdomen, ear. ;9 Diagnosis The appearance is typical and the diagnosis simple. Mei*ely hypertrophied scars, snch as are seen after large infected wounds, and wounds that have been drained for a long time, are not real keloids: they are usually very tender and nearly always flatten out in the course of a few years. But sometimes it is difficult — and maybe the question has but an academic interest — to say where scar hypertrophy stops and where keloid formation begins. Treatment It is best to avoid operations, as cauterization and scraping simply increase the keloid, and extirpation, with or without plastic repair of the defect, is almost uniformly followed by a recurrence often larger than the first lesion. (This happened in the case of Fig. 59-) Long continued compression, especially of young scars exhibiting a ten- dency to keloidal hypertrophy, has a certain prophylactic value. Electrolysis or injections of a 10% solution of fibrolysin (thiosi- namin) sometimes cause improvement. This latter method was applied to the case represented in Fig. 59 and a partial disintegration was obtained; but later on recurrence took place. ' Bier claims good results from passive hyperemia, and Kromayer excellent results from the use of the quartz lamp in keloids. X-rays, particularly with the single dose method {Mackee) are very efficient. 80 Bockenheimer, Atlas. Tab. XLVI. Fig. 60. Contractura aponeurosis palmaris (Dupuytren). Rebman Company, New- York. DEFORMITIES DUE TO CONTRACTIONS OF MUSCLES OR TO FRACTURES Figs. 60 l<> 63, iiielusive, .show acquired deformities of the hand, ilnc to coiit raction (or bettei' retiactioii) of various aiiatoiiiieal organs (Figs. 60, 61, 63) or to paraUfsis of muscles (Fig. 62) due to nerve injury. Fig. 60 shows a ease of Ditpui/ticii's contraction of the palmar aponeurosis in a man of 50. As is usually the case, the fourth and fifth liiii;ers are more })articu]arly affected. The little finger is mark- edly tiexed and only tlie last phalanx can 1)e freely extended. The first phalanx of the fourth finger is immobilized in flexion, and the second begins also to feel the effects of the fibrous retraction. There is a very slight incipient involvement of the third finger. Neverthe- less, the condition, which had existed for several years, caused so little trouble that operation was refused. Dupuytren's contraction (or, better, reiractiou) is a clironic shrinking of the palmar aponeurosis, i.e., the triangular fibrous struc- ture that continues the palmaris longus muscle, spreads over the palm and sends processes to the in-oximal phalanges of all the fingers, and is also connected with the skin: At first, nodules develop in the ajioneurosis and skin. Later these nodules become cord-like thickenings, which are found not only in the ijalm, but even more commonly on the second, third, fourth and fifth fingers. Contraction of the cords gives rise to an abnormal position of the fingers, immobilization in flexed position of the first and second phalanges, while the terminal jihalanx remains movable. The thumb generally is unaffected; the contraction is often sym- metrical. It ])rogresses slowly, so that after some years the finger is completely doul)led on itself into the palm and cannot be extended. There is generally some power of extension left in the middle and terminal ])halanges, l)ut as motion is painful, it is avoided by the patient. The nature of Ditpiii/freii's contraction is unknown. It occurs almost exclusively in men, and hence a traumatic influence was admitted by Dupui/trrii. At any rate it is often found in men in whom the palm of the. hand is exposed to continued pressure (i^ost-ofKce 81 clerks, from stamping, liunters and gun-bearers, carpenters, etc.). The influence of trauma is not accepted by all : nor is tbat of gout. A trophic nervous origin is the hypothesis most in favor now, because the contraction is often symmetrical and equally developed on both sides, and it sometimes coexists with conditions manifestly of nervous origin (e.g., Recklinghausen's disease, for which see Figs. 67, 68, 69). Fig. 61 shows a hard, slightly movable scar, extending from the palmar aspect of the last joint of the middle finger to the center of the palm: this scar resiilts from an incision made for suppuration of the tendon sheath (see Fig. 93)- The flexor tendon is destroyed, the finger is half flexed and stiff, without any power of motion. Both the retraction of the scar and the destruction of the tendon contribute to the faulty position of the finger. Fig. 62 shows the "claw hand" attitude observed in injuries of the ulnar nerve. In this case, the cause was a blow on the ulnar side of the wrist-joint, which, perhaps, directly contused the ulnar nerve, and, in addition, caused a hemarthrosis of the joint which pressed on the same nerve. When a nerve supplying part of the muscles of a given anatomical region is injured, these muscles are paralyzed, and their antagonists immediately become preponderant, and produce in the region affected (this is particularly plain in the limbs) a deformity, always the same for the same nerve; thus the typical deformity of ulnar "claw hand" (Fig. 62) is due to the paralysis of the interossei muscles, whose function is to flex the first phalanges : consequently in ulnar ' ' claw hand," we find the first phalanges of the fourth and fifth fingers hyper extended, while the second and third are flexed. The other fingers are not in claw position, although their interossei are paralyzed, because their lumbricales (supplied by the median nei've) are still active. In the case of Fig. 62, there was slight swelling on the back of the wrist joint, chiefly on the ulnar side. Fluctuation was jsresent. The sign of "snowball crunching" indicated the presence of hemar- throsis. Motion in the joint was limited and painful; it was in slight flexion (the natural position of the wrist joint in case of intra- articular effusion), but could easily be extended. Fig. 63 shows a very important type of retraction of the flexor muscles of the forearm, that consecutive to too prolonged ischemia 83 Horkpiilu'i'incr, Atlas. Tab. XLVII. Rebiiian Company, New-N'ork. Bockenheimer, Atlas. Tab. XLVIII. U Rebman Company, New- York. of the same muscles. Tlie practical importance of this condition lies in the fact that it maj'' he foreseen and foretold in some cases where it is hardly avoidahle, and is avoidahle, in a great majority of in- stances, throni^h the ohservance of simple rules of caution; while, once it is established, it is hardly curable. It can only be partly impi-oved hy surgical interference and patient after-treatment. This post-ischemic retraction was first described by Volkmann under the name of ischemic iiaralysis; it was later studied by Lexer and other German authors. Of late years, American cases have be- come quite frequent. Thomas has well studied the implication of nerves in this condition, and American surgeons {Freeman, Hunting- ton, Poivers) have been conspicuous in the development of surgical methods of treatment. These ischemic contractures are myogenous and appear when the blood supply of the muscle has been cut off for too long a time: this induces a special degeneration of the muscle fibers, which is followed hy sclerosis and retraction. Muscular tissue stands ischemia less well than the skin, hecause the arteries of muscles are terminal. The causes of muscular ischemia are manifold, but are met only in traumata of the limbs. It may be an injury to the main artery, a complete laceration with hematoma, or simply an abrasion of the intima in one point followed by thrombosis and obliteration of the artery, or too tight a constriction hy a tourniquet, or long exposxire to cold; but by far the most frequent cause, the one that has most practical importance, and the only one known to tl\e authors who first described ischemic contracture, is the application of too tight a bandage around a fractured limb. Fractures of tlie upper limb, and particularly of the lower end of the humerus, are those after which ischemic retraction has been most often seen. Next come fractures of the bones of the forearm. Out of about 200 published cases only one pertains to the lower limb ; and strange to say it is the original case from which Volkmann indi- vidualized the type of ischemic "paralysis." The predominance in the upper limb is explained by the lesser bulk of the muscles in that region, and the frequency with which the flexors of the fingers are aflfected is quite naturally explained by the fiat surface of the forearm and the rigid frame constituted by the two bones of the forearm on which the flexors are directly applied. The more common occurrence of ischemic contracture in younger individuals is due to the greater comjiressibility of their muscles and vessels. In oi'der to produce contracture, the ischemia must be 83 marked enotigh to cause irretrievable lesions, but not sufficient to cause gangrene. The latter condition is wkat happens in older persons (whose blood vessels are sclerotic), either as a result of strong pressure, or of obliterative thrombosis after slight pressure. Un- fortunately, it seems much easier to obtain the necessary clegTee for ischemic contracture unwillingly under a bandage applied for a frac- ture than to gauge it accurately in experimental work. Up to the present time, ischemic retraction, fairly frequent clinically, has not been reproduced experimentally. A few hours after the application of a bandage around a fractured limb, the patient begins to feel great pains and numbness of the fingers. These become blue, swollen, incapable of active motion, wliile passive motion is painful. The lingers are flexed. If the bandage is then removed, the skin appears white, while the muscles feel as hard as board and are incapable of motion (hence the appellation "paral- ysis" given at first). If the lesions are not yet too marked, recovery may take place. But if the bandage has been left too long, the muscles become the seat of a very painful swelling, rapidly developing soon after it is removed; the fibers are dead and later are replaced by fibrous tissue, which forms hard lumps in the muscular body, and progressive retraction sets in. The skin of the fingers gradually becomes yellowish-white like parchment. The swelling of the fingers is followed by shrinking. First of all the fingers, then the metacarpal bones, and finally the wrist become fixed in a position of flexion. The fingers are eventually so strongly flexed that the hand becomes use- less. The movements of the wrist are also very limited, and the muscles of the forearm -become atrophied and are covered by pale skin. Sensory disorders may occur from ]Dressure of the shrunken muscles on the nerves, and the implication of nerve trunks in the sclerotic masses is always marked in severe cases. But this nerve involvement, although important and calling for a particular treat- ment in many cases, is always secondary in Volkmann's contracture. The disease has no tendency whatever to spontaneous improve- ment. Only an energetic and patient treatment can give hopes of a partial cure. Diagnosis of deformities due to muscular action in the upper limis Each one of the types shown is sufficiently characteristic to avoid mistakes. Dupuytren's contraction is seen in middle aged or elderly people, develops sloivly and gradually, and there are palpable nodes and 84 ihickenings in the p.-ilinnr .ipnupurosis. Fihiomafa or rj/sts of the tendon sheatlis (see Fig. 49) are easily dilTerentiated from tliese tliicl:s, l)ecause they are j^enerally single, well limited, and round in shai^e, while the process in Dii/Jitifticii'N contraction is diffuse. Cicatricial contractions .nc .ilways easily diajj^iosed, owinj? to the history of I lie disease and liie presence of an always very visible scar. The only point is to determine how much the scar is at fault, and how much the tendon. A)ikylosis of the finijer joints, such as is ol)servehh). X-ray exam- ination in these cases is invalual)le; it ought to be performed in all cases of ])ressure symptoms on the nerves of limbs. Trail niriit of i)iii.. liiliMi.tinnc> cruris ulriubqiic. Rebnian Company, Ne«•-^■orl^. especially tlie frontal and parietal eminences, the bones are thickened and prominent, givin.i": the so-called "Olinnpic fomhedfl" The cranial sutures and fontanelles remain open far k)nger than normal; the upper and lower jaws are iiM-e.irularly develo|)cd and flattened and the implantation df tin. Wr\U is ai.noniial and irrc-ular. The weight of the hudy causes l)eudiug of the softenet n\' tlir pseudartliroses were due to the fact that the aceeiitcd trmluR'nt iIhI not bring the two frag- ments in exact apposition ; that, if the extreme abduction treatment is applied, coaptation is obtained, and i)ony union follows, even in old people. This emphasizes the necessity, in cases of non-united fractures, of carefully analyzing- all data, and of ascertaining: ail local con- ditions, before we have a right to attribute non-union to a .sreneral cause. In this respect X-ray examinations are invaluable. Simple delayed union may be accelerated by passive hyperemia, Bier's blood injection between the frag-meuts {Kiliani, Lyle), and, perhaps, by the internal administration of calcium salts. Carrel's recent work shows that l)one reparation may be consider- ably hastened by the direct application on the line of fracture of pulp of glandular parenchyma, chiefly of the thyroid gland. Non-union depending on local conditions calls for a correction of the latter: interposed soft parts must be removed, bone ends must be freshened and brought in correct position, and maintained there, either by a plaster of Paris cast, or by plating. The operative treatment of fractures has been much advanced in late years; Lane's plates (or better, the modified vanadium steel plates of Sherman), when properly used, give excellent results in ununited fractures, or in those in which the displacement cannot be corrected by the other methods of ti'eatment. A strict asepsis- is necessary; hence the operative treatment of fractures is not applic- able in ca.ses of non-union in infected compound fractures of long standing. In old fractures, and in those near joints, resection may become necessary to insure reduction. When syphilis is suspected, mixed treatment or salvarsau should be administered. 91 NAEVI Figs. 67, 68 and 69 show naevi and a condition of cutaneous nerves sometimes found in conjunction with them. Ncevi are developmental defects of the skin characterized by an excessive growth of pigment {figinentary ncevi, Figs. 67 and 68) or of vascular tissue {vascular ncevi, Figs. 75 and 76). Fig. 67 shows a large pigmentary hairy nsevus, wliich was present at birth and increased in size till the age of puberty. The borders are smooth, but the central parts are warty {ncevus verrucosus). The color is blackish brown in the center and brown at the periphery. Fig. 68 shows a slightly pigmented nsevus extending over most of the forearm, with a bluish-red, irregular elevation in the center. This nsevus was present at birth. Small pigment spots were scattered over the whole body. The bluish-red elevation in the centre was formed by a fibroma of the sheath of a large subcutaneous nerve. In addition, there were fibromata along the course of the principal nerves of the arm (neuro-fibromata) (on the upper arm and the axilla, of the size of a walnut) and multiple cord-like formations {plexiform neuroma) could be felt under the nsvus. There were also small soft nodules in the skin (fibromata mollusca). All these forma- tions had appeared later than the na?vus, but had been present many years. Fig. 69 shows a similar condition in a girl aged 20. The whole of the right half of the scalp, the right side of the forehead and the ear are the seat of a lobulated growth (elephantiasis nervorum) fixed on the head like a cap. The growth was congenital, and on its surface are numerous pigTnent spots and soft, small, pain- less tumors (fibromata mollusca). Numerous cord-like formations were found in it by palpation (plexiform neuroma). This is a typical location for the disease; the nape of the neck and the back are also affected. !)2 i;i>fl])lyiug lotio alba 05 is useful. Telangiectases are treated as will be said later (page 102). X-rays favorably influence the hypertrophy of the skin and sebaceous follicles. However, when rhinophyma has attained the development shown in Fig. 70 decortication of the nose with the knife is the only treatment. Owing to the very abundant blood supply of the region, and the hypertrophy of the epidermis, the wound heals very promptly, the scarring is trifling and results are excellent. Fig. 71 represents a case of elephantiasis of the penis, in a man of 40. Elephantiasis (or pachydermia) is a chronic, diffuse hyperplasia of the skin and subcutaneous tissue due to persistent obstruction of the lymph channels. In the case shown in Fig. 71, the obstruction had been caused by bilateral extirpation of the ing-uinal glands. The swelling had begTin soon after the operation and had progressed slowly, the chronic course being interrupted several times by acute exacerbations, which subsided after a few days' rest in bed. The thickening of the skin was not uniform, but lobulated. It felt soft and spongy. In such cases there is a marked fibrosis of the subcutaneous tissue and dilatation of the blood and lymph-vessels, the latter being the primary factor. The skin was pigmented and the scrotum covered with crusts, and there were numerous depressions, as in rhinophyma. There was no pain. In tropical countries, elephantiasis results from a specific cause, namely, the blocking of lymphatics by the filaria sanguinis honiinis and kindred parasites. In our climate, elephantiasis is not a specific disease, but only a symptom, which depends on manifold causes; chronic edema, or eczema, recurrent erysipelas, syphilitic and tuber- culous lesions, varicose ulcers, phlebitis and thrombosis of veins, and pyogenic infections of the skin. We have already mentioned double extirpation of the inguinal glands (Fig. 71)- A double radical opera- tion for hernia has sometimes had the same result. The legs are the parts most frequently affected; next come the male and female genitalia. In prostitutes, the labia, clitoris and perineum sometimes become affected with elephantiasis from gonor- rheal discharges and syphilis. The tissues feel at first soft, but afterward become firm and elastic. Parts having undergone pachydermic alterations are more liable than healthy tissue to intercurrent infections. Eepeated attacks of 96 Bockciiliciiiier, Atlas. Tab. L\'. I i.^'. 71. I:lcplianti;-isis penis l\iiipliaiigiectalic;i. RcliMi.iii Company, Ncw-N'ork. Bockenheinier, Atlas. Tab. LVI. fig. 72. Ulcus cruris varicosum — Elephantiasis, Pachydermia acquisita. Rebman Company, New-York. lyiiil)liaiisiti.s are oominon, after eacli of wliich tliere is an increase of tlie elei)liantiasis. lOczema, bulla\ pif^niented spots, scabs and crusts, condylomatous or papillomatous proliferations, or, finally, ulceration, may occur on the surface. Ulceration causes intolerable sufferinp:: otherwise, the condition is painless and causes inconven.- lence only by its weight or when it prevents walking on account of its size. Diagnosis It is hardly necessaiy to dwcli on tlio differential features existing between ordinary ek'iihantiasis and the so-called " vlrpUantiasis nervorum" of von Rcckliiighintsen's disease (Figs. 68 and 69). The other symptoms of the latter condition, fibromata, neuromata, dissem- inated pigment spots, do not leave room for any hesitancy. In partial giantism there is an overgrowth of all the tissues, including the bones, dating back to early infancy. The recognition of the cause is important. The diagnosis of endemic elephantiasis is settled by the detection of the parasite in the blood taken at night. Treatment All lesions of the inguinal glands, especially if bilateral, must receive prompt attention in order to avoid lymphatic oljstruction. All conditions enumerated above, susceptible of leading to pachy- dermia, must be carefully treated. Recent and light cases may be improved by elevation, massage and compression. More extensive eases have to be treated by cunei- form excision. This was performed in the case shown in Fig. 71. Fig. 72 shows an elephantiasic thickening of the toes developed in connection with a varicose ulcer of the log. The toes are enor- mously thickened and constricted in places; the whole foot is also enlarged and the arch of the foot is obliterated. The thickening of the foot continually increased and extended to the ankle. Frequent attacks of erysipelas aggravated the affection. The varicose ulcer is situated on the inner side of the leg, at its lower third, and extends nearly over the whole circumference. Varicose ulcers occur generally in old people of the poorer classes, who cannot take proper care of their varices and have to do much standing; uncleanliness makes matters worse. All diseases of the nervous system and arteriosclerosis may cause the development 97 of trophic ulcers (see Fig. 138), wliicli are not unlike varicose ulcers^ but are still more refractory to treatment than the latter. Varicose ulcer of the leg is characterized by its irregular, slightly raised edges, while the surrounding parts may be covered with scat- tered, flabby granulations, crusts and blood-scabs (Fig. 72). Around the base of the ulcer are fine, bluish, dilated veins, from which fre- quent bleeding takes place. The ulcer is often connected with a rup- tured varicose vein. In small ulcers temporary healing may take place, but the scar is very thin, generally pigmented, and gives way again on the slightest cause ; after which no further healing usually takes place, but the ulcer continues to extend. The whole neighborhood of the ankle joint, and even the whole leg, may be involved in ulceration, which often has a sanious discharge. In extensive ulcers there is generally severe pain and the leg becomes more or less useless owing to the extent of the ulcer and the elephantiasis. Differential diagnosis Large ulcers with sanious discharge may suggest carcinoma, owing to their hard borders, but in carcinoma there are always irreg- ular, hard-tumor masses in the whole extent of the ulcer. The possi- bility of transition of an ulcer of the leg into carcinoma must be borne in mind (see Fig. 20)- In doubtful cases, always excise a piece of the indurated edge for microscopical examination. Gummatous ulcer, frequent on the leg, is more regular, often circular, and has a punched-out appearance. The base of the ulcer is smooth and covered with a tenacious, yellowish, fatty core. The ulcer is generally less extensive and there is no bleeding. Anamnesis and the Wassermann reaction may clear up the diagnosis. The tibia may show some of the characteristic features of gummatous osteitis. Tubercular ulcers are rare on the leg. However," their thin, undermined edges, and particularly anemic appearance are sufficient to enable one to recognize them without difficulty. Treatment Inveterate varicose ulcers are difficult to heal, owing to the gen- erally very poor condition' of the circulation in the limbs affected. Rest in bed, with the foot elevated, is absolutely necessary. An enormous number of substances have been extolled as dressings. The best are styrax, balsam of Peru and especially scarlet red salve (see page 73). 98 Bockenheimer, Atlas. Tab. LVII. Fig. 73. Detachment of tlie Skin. Rebman Company, New-York. Sinn oraffnig (see Fig. 55 .in,! pajye 7:3) may be resorted t.. Jn obstinate cases, Morcschi lias ailvu.-ated a circumferential incision of the skin and subcutaneous tissue of tlie le^ above tlie ulcer. Excision of the wliole ulcer with repair of the defect l)y means of the skin flap has also been done. Oporativo treatment of tlie varices (for which see Fig. 83 and pn-c 1].!) i< ,,rteii necessary to bring about the cicatrization of an ulcer. Fig 73 shows a detachment of the skin, lliat is, a sul)cutaneous separation of the skin from the subjacent structures, with the special variety of effusion dcstq-ibod by Morel LacalK-e under the name of traumatic effusion of serosity. Jt is tlie result of a blow on the left elbow, which acted tuugeutmllii, so that the skin was not injured, but slid on the resistant underlying fascia; the connective tracts uniting the skin to the fascia were torn and with tliem innumerable lymph vessels, from which exuded the clear, yellowish fluid, which was evacuated by tapping a few days after. The absence of blood showed that no important blood vessels had been torn. If any blood vessels have been torn in such an injury, the result is an ordinary hematoma, which promptly undergoes spontaneous resorption, while those lymph effusions persist indefinitely with slight variations from day to day. The above-described mechanism explains why such a condition is more frequent in the thigh on account of the tough fascia lata, and on the abdomen. A carriage-wheel passing over the thigh gives the ideal condition for its production. The effusion causes a fluctuating bulging of the skin, which never becomes very tense. There is no discoloration of the skin. This, with the indefinite persisfenci) and the fact that the effusion develops slowly, and not immediately, differentiates lymph effusions from hematomata. The treatment is repeated aseptic tapping followed by com- pression. Incision ought to be resorted to only in case of suppuration. Fig. 74 shows the mixed blood and lymph effusion in the auricle known as othematoma. In the auricle (as sometimes in the nasal septum) we find the condition already stated as essential (see above) for the production of such collections, namely, a tense structure (iiere, the cartilage), over which the skin can slide when struck tangentially. 99 othematoma occurs especially in tlie upper half of the auricle, and is found in the mentally affected as the result of ill-treatment by blows on the ear, etc. ; in workmen who carry on the shoulder loads which graze the ear ; in carpenters through carrying planks ; in butchers through carrying troughs, etc. It is also a common injury in boxers {caulifloiver ear results from repeated othematomata) and in acrobats. It generally causes little trouble. As already stated about Fig. 73 (page 97) blood effusion is indicated by the rapid development of a tense, dark-blue swelling, which, after a time, subsides. Lymph effusion is indicated by a swelling which does not develop till some time after the injury and has little tendency to subside; the skin is not discolored. Lymph effusion in the ear is nearly always slightly mixed with blood, and always forms a tense swelling, in distinction to lymph effusions in other parts of the body (page 97). Blood and lymph effusions in the auricle may undergo chronic inflammation, which first causes thickening, later on atrophy and necrosis of the auricle, with considerable mutilation. If the skin is much abraded, the effusion may become septic, with consequent de- struction of the cartilage. Differential diagnosis Cavernous angioma, which often occurs in the upper part of the auricle, somewhat resembles hematoma. However, angioma is con- genital ; it can be reduced by pressure and has a special bluish colora- tion (see Figs. 36, 80 and 81). Other vascular anomalies (such as nt' the liinh can he iin|»roveil and the ]);itient made (luitc c-onit'ortalile liy tlie application of flannel bandages from the toes upward {Murtiii's ruiiiier bandage is liable to cause eczema) or Ity tlie wearing (when not in bed) of well-made elastic stockings. Surgical treatment is called for when the varices keep growing, circulatory disturbances art- vciy marked, valvules iusutlicient and the nutrition of the limb seriously impaired (ulcers, etc.)- Simple ligation of the saphenous vein is useless; the most radical operation is removal of the whole saphenous vein through a uuml)er of incisions, each segment of the vein being pulled out through the incision immediately above. Partial resection of the vein is some- times sufficient. Elastic bandages should be worn for some time after the operation. Extirpation of secondaiy varices due to thrombosis of the deeper veins is useless. Fig. 83 also shows a flat foot, a condition frequently associated with varices, either because both depend on a congenital dystrophy of the tissues, or because the falling of the arch of the foot entails poor circulatory condition and venous stasis in the lower limb. 113 INFECTIONS Figs. 84-131 I.— Acute Pyogenic Processes— Figs. 84-114 II.— Chronic Infections— Figs. 115-131 A.— Actinomycosis— Figs. 115-117 B.-Syphilis-Figs. 118-123 C. — Tuberculosis— Figs. 124-131 PYOGENIC INFECTIONS The entriuice of l)actoi'iii in tlic hoily iimiicdiately starts a wondei'- ful defensive process, the chief ap:ents of which are tlie leucocytes of the blood. Metchnikoff has demonstrated the importance of phago- cytosis and Ehrlich has explained the complicated processes that lead to antibody formation and immunization, by liis side-chain theory. Clinically, when l)aeteria begin to develop in a given point, the inflammatory reaction which is tiie outward manifestation of the defensive process is evidenced by four cardinal symptoms: Redness, heat, sivclling and pain. The first tivo are due to the active hyper- emia, the blood being called in greater abundance by chemotaxis to the part. The swelling is due to the transmigration (diapedesis) of leucocytes through the walls of the caj^illaries, favored by' the slowing of the blood stream. The pain, i:)ul sating in character in many in- stances, is due to the increased tension in the tissues. It is directly proportional to the rigidity of the tissues. This is why the pain is marked in dense tissues, while, whei'e the connective tissue is lax, there may be enormous edema with but little pain. The exudation is at first serous and formed exclusively by leuco- cytes and clear seinim; later, when the fight between leucocytes and invading micro-organisms has resulted in the death of many of both, it becomes cloudy owing to the formation of pus corpuscles. A pus corpuscle is a leucocyte that has engulfed one or several microbes and has died from its victory. It then becomes a foreign body and has to be cast off. "When there are but few microbes and but little pus is formed, the latter may be absorbed by other phagocytes of the body, and no collection ensues. This termination by resolution is the most favorable. It is frequent in normal, healthy subjects, in case of low virulence infections. The pus formation is a fairly accurate gauge of the manner in which the defensive process is successful. Numerous pus cells give a creamy, thick jdus and indicate a successful resistance of the ana- tomical elements against infection; the latter will become circum- scribed, and the only result will be an abscess. When few pus cells are present after the septic process has lasted a little time, it means that the I'esistance is unsuccessful, either because the attacking organ- isms are very virulent or the doFending leucocytes are weak. When ii: sero-piirnlent fluid or only turbid serosity is found on incision, it generally foretells a grave infection, a diffuse phlegmon. If tlie latter is not stopped in its progress, the result is the invasion of the blood stream : generalized infection, septicemia or pyemia^ The lymphatic channels play also a very important part in the extension of infection. The strength of the resistance depends on the general health of the body: old, feeble and diseased individuals (e.g. diabetics) are less capable of combating bacterial invasion. In these cases, infec- tions that TTould be trifling in a normal body may become severe or even fatal. The virulence of the invading microbe depends to a certain extent on its nature : there is no pathogenic microbe that cannot form pus : the pneumococcus, gonococcus, colon-bacillus, Eberth bacillus, pyo- cyaneus, tubercle bacillus, are frequent pus producers ; but the most important pyogenic organisms, from the surgical standpoint, are the staphylococci and streptococci. Staphylococcic infections are very common (furuncles, carbuncles, osteomyelitis, etc.) and generally lead to circumscribed purulent in- flammations. Streptococcic inflammations are generally more severe in type, more diffuse, and may lead to general infection. Mixed infections are not rare, but there always is a predominant microbe. This first stage of inflammation — pus formation — is destructive in character, not only of leucocytes and microbes, but also of surround- ing connective tissue elements, which undergo necrosis. - Necrosis is not much marked in circumscribed abscesses; it is considerable in diffuse i^hlegToons, where most of the tissues bathed in the turbid serosity may become necrotic, so that these diffuse processes are accompanied by much sloughing. Wlien the destructive stage has come to an end, the repair process begins. The fixed connective tissue cells proliferate and form granu- lations (in abscesses, the so-called "pyogenic" membrane), the in- flammatory area becomes isolated and demarcated; the necrosed tissue is cast off with the pus, and the wounds eventually heal by scar tissue, which, is but a later evolution of the vascular granula- tions. During this stage of reparation, the clinical symptoms grad- ually subside; all this is much hastened if the pus has been evaciaated outside the body. The elimination of pus is effected by gradual involvement of tissues and rupture in cases left to spontaneous evo- lution; but it may be brought about much more quickly by a free incision, which saves all the time that would be required for the iGeneral infection, see page 157. 118 spontaneous ulceration from witliin outward of tlie structures over- lying the pus, and, finally, the skin. Aside fi'oiu llic local symptoms of iiitlanimation, enumerated above, there is a general reaction showed by a more or less con- sideraltle rise in tcniperature. The fever is due to the action of toxalbumins (toxins) secreted by the bacteria, liberated by them into the blood stream, and influencin.c: the thermic centers of the brain. Besides these exotoxins, there are insoluble endotoxins, which remain fixed to the body of the bacteria themselves. Another general reaction common to all bacterial infections is the increase in the number of leucocytes in the circulating blood, or IcKcocytosis. This is the response of liematopoietic organs, spleen and J)one marrow, to meet the demand for leucocytes to destroy bac- teria. So constant is this leucocytosis in surgical infections that a lilood count is now a routine procedure in the examination of such cases. The leucocytosis is also, to a certain extent, a gauge of the intensity of the defensive pi-ocess. Every pyogenic infection, however slight it may seem, requires watchful treatment, because unexpected and unpleasant surprises are always possible. Cases are frequent where an apparently trifling septic wound has resulted in a fatal septicemia. Under ordinary conditions, and with appropriate treatment, the prognosis is favor- able in inost pyogenic infections: but, nevertheless, these remain one of the big factors of post-o]ierative mortality, perhaps the biggest, despite the progress of surgical technique. To limit the infection and to favor the natural defensive process is the alpha and omega of surgical treatment of suppurative conditions. General treatment consists in a substantial diet and tonics. Sera and vaccines, which are useful in chronic conditions and medical septicemifP, are not — barring a few exceptions — of much value in sur- gical acute infections, nor are, probably, colloidal metals (collargol, electrargol, etc.). Nucleinic acid (20 c.c. in 200 c.c. of saline solution) has found favor in Germany. Local measures' are rest, dressings and hyperemia. It was Bier who, running against all jirinciples formerly admitted, drew the atten- tion to the fact that hyperemia and its consequences, far from being I liiunclimi^ with iilitliyiil iir tiii'iciirial ointment, and iodine preparations may hasten tlic risdlutiiiti i>f :i iiciM-=,ii|iiJiu;itivo iiifi-ct inn, piirticularly adenitis. This is but one kind of hyperi'inia treat luoiit. 119 harmful and having to be restricted and kept under control, was indeed the very effort of the organism to bring about a cure : hence his method of passive hyperemia, which has been enthusiastically received by some, wrongly applied to all sorts of cases, among which, of course, some where it was not indicated, and subsequently con- demned as worthless, as a "double-edged" sword, as impairing th^ nutrition and delaying the absorption of bacteria and bacterial toxins. Certainly passive hyperemia, improperly apijlied, may do harm, but this is no fault of the method. Nor is it just to decry it, because it has not fulfilled the expectations of those who asked of it what it could not give. Passive hyperemia is not supposed to take the place of all other methods of treatment of pyogenic infections; it is only one of several means, and one which, when employed correctly, in proper cases, is undoubtedly benetieial. However, we shall add that, generally speaking, we have seen much better results in subacute and chronic than in acute inflammatory processes. But the subject of hyperemia in the treatment of acute infections goes far beyond the question of passive hyperemia, which is only a particular (and not the natural) mode. Active hyperemia is the natural defensive process, and many of our methods are only means of inducing it. Thus the swabbing of an infected surface with tincture of iodine is nothing but hyperemia ; so is the touching of a small boil with carbolic acid ; so is also the use of moist, tvarm., antiseptic dressings or of hot antiseptic baths, one of the most efficient treatments at our disposal. Ice bags are injurious, though they may relieve pain, because they hiake the blood-vessels contract and retard hyperemia. Rest favors hyperemia by slackening the circulation. Elevation of the limb is useful only to r-elieve the pain and has no curative value. It goes without saying that all sources of irritation (foreign bodies, stones, etc.) must be removed. When pus has formed and collected, it must be evacuated by an incision sufficient to insure free drainage and no retention. For- merly long incisions were the only ones considered as worthy of the name of "surgical." A judicious application of Bier's method enables us to shorten the incision in many eases. A notable instance is given by finger suppurations. The scar retraction shown in Fig. 64 is due in part to the long incision, formerly so much in honor. An infinitely better result is oljtained nowadays by multiple small incisions alongside the tendon, and hyperemia {Klapp's method). The time for incision in circumscribed abscesses is when the pus 120 has collected. In difTuso processes, it must l)e niiide witliout delaj'v as it is the only means of clieckiiiij further i)rof?ress. Early incision is also indicated when the inflamed tissue is encased and, so to speak, straii^uhited in a touf,di inextensihie sliealh, liecause tlie pain is then very severe and incision aiTords a sure and prdiiipt relief (e.g., treatment of ei)ididymitis hy Hagner's method). "When liie incision cannot be done rapidly without anesthesia, or under superficial anesthesia by freezing, it is best to i-esort to general narcosis, unless the abscess is situated in a part where regional (conduction) anesthesia is possible; because local infiltration anes- thesia is unsatisfactory in inflamed and edematous tissues. All connective tissue septa within the abscess cavity must be broken. Retention of pus increases the virulence of the bacteria and the danger of absorption (see general infection, ])age 157). InsulficieDt drainage leads to fistulaj such as tliat of Fig. 55. The drainage of abscesses is done best with rubber tubes, if the discharge is profuse; by a cigarette drain if the same is scanty. Various dressings can be applied on infected wounds or those resulting from the incision of abscesses. A hot tvet dressing covered ivith impervious material, such as oiled silk, is only a way of inducing hyperemia, as already stated, and belongs to the early, pre-incision,. stage of treatment. A wet dressing covered imth absorbent cotton, but tvithout impervious fabric, dries up soon and powerfulh^ draws pus by capillarity; it is the best dressing to apply just after the incision when there is much pus. A dry dressing is the l)est to promote cicatrization: it is the kind to apply when the discharge becomes scanty. If it adheres to the surface of the wound, it must not be stripjied off violently, but first soaked with hydrogen peroxide or a solution of sodium perborate, which makes its removal easy. "When no more discharge exudes, the wound may be ]iacked with gauze to allow it to close from the botioin upward. Superficial closure over an imperfectly drained cavity leads to the formation of sinuses such as that represented in Fig. 55. Granulation tissue should be controlled in its growth by fre(|Uont applications of silver nitrate. Innnobilization of the part must be continued till all signs of inflannnation have subsided. After healing, massage and electricity are indicated, accordiii.i;' to the sitiuilioii and nature of ilic alTcetion. Vi\ Fig. 84 shows an acute purulent throtnbo-phlebitis affecting a varicosity of the saphenous vein, which develoijed after pregnancy. There is a patch of diffuse redness with yellowish nodules indi- cating the development of abscesses in the infiltrated and thrombosed vein. This is a not infrequent complication of the condition shown in Fig. 83 (seepage 112). Inflammation of veins, or phlebitis, may be seen after many pyo- genic affections (lymphangitis, furuncle, carbuncle, erysipelas, vari- cose ulcer of the leg). Antecedent pathologic changes of the venous walls (varices most commonly) make them more liable to infection. In some cases the contamination comes by contiguity from a neighboring sujDpurative process. In every pyogenic infection micro- scopical purulent thrombi are found in the small venous radicles. In larger veins, periphlebitis develops first and then the vein itself is involved : e.g. involvement of the lateral sinus in otitis media, of the facial vein and cavernous sinus in furuncle of the face. But, more frequently, the phlebitis is a result of a blood in- fection. Anatomically, phlebitis is invariably accompanied by the forma- tion of a thrombus, which, in the cases now under consideration, is always septic. (Aseptic thrombosis is possible after surgical opera- tions, particularly on the abdomen.) If the virulence of the microbes is not too great, and the resistance power of the tissues good, the thrombus does not go to pus formation. The result is the plastic form of phlebitis, seen particularly in the femoral vein of women as the result of puerperal parametritis, and known under the name of phlegmasia alba dolens (painful white leg), which describes the car- dinal symptoms of the condition. If the virulence is great, purulent degeneration of the thrombus sets in : the thrombus disintegrates and by repeated embolisms causes a general, usually fatal, pyemia, with formation of multiple abscesses. Thus infection of the portal vein gives rise to pylephlebitis and multiple abscesses of the liver. Non-suppurative phlebitis is heralded in by a local thermic ascension, in the part affected, as well as by fever. The part (leg generally) becomes ,s«'o??e«, white, painful, so that motion is im- possible. The edema is hard. The thrombosis may be so extensive as to cause gangrene of the extremities. The veins are felt as thick, hard cords (not to be manipulated roughly). Purulent thrombo-phlebitis, if superficial, gives the ordinary symp- 123 Bockenheimer, Atlas. Tab. LXVII. Fig-. 85. Abscessus subcutaneus. Rebman Company, New-York. toms of iiiilaiiuiiatioii, rodiies.s, .swelling and edeiiui of llie skin and subcutaneous tissue, pain, fever and chills. These last symptoms are much more markeci, nTid iiiiiy hn the only symptoms, in deep- seated purulent i)lil('l)itis. A .hi 1 1 .ilter an operation for a septic condition (otitis media, mastoid, for instance) is always an ominous symptom, claiming immediate attention. In non-fatal eases of thromho-phjebitis, resorption of the throm- bus takes place, the cells of the endothelium of the thrombosed spot proliferating and invading the clot. This explains why there always remains, in those cases, a thickening of the vein, which often goes to complete occlusion. Hence the post-phlebitic chronic congestion, which, in the lower extremities, leads to deficient nutrition (ulcer, eczema, elephantiasis, equiuus club-foot). Thrombi may become transformed into hard, painful phleboliths, by deposit of calcareous salts. The thrombosed veins, that are felt as thick, hard cords, along the anatomical course of veins, diflferentiate thrombo-phlebitis from lymphangitis. "When those cords cannot be felt, in deep situated lesions, the diagnosis of thrombo-phlebitis from other pyogenic infections becomes often very obscure. The two dangers of phlebitis are embolism (hence very important and obvious rules of caution) and generalized infection. Em- bolism is the mechanism of generalized infection, but it has also special dangers of its own. Treatment Complete immohility and rest are essential, and practically con- stitute all the treatment of non-suppurative phlebitis. Suppurative phlebitis calls for incision: there need be no fear of hemorrhage: thrombosed vessels do not bleed. Ligation proximal to the diseased segment, or resection between ligatures, is indicated to ward ofif an impending generalization (jugular vein in otitis media, facial vein in furuncle of the lip, pelvic veins in puerperal septicemia). After subsidence of all symptoms, gentle massage is indicated to improve the circulatory conditions in limbs that have been the seat of thrombo-phlebitis. Fig. 85 shows a subcutaneous abscess surrounding the nipple, shortly after childbirth. The portal of entry of bacteria was a crack of the nijiple. The skin around the latter is bluish-red and swollen. 123 Fluctuation indicates the presence of fluid in the subcutaneous tissue. Despite the apparently slight extent of the abscess, there were well- marked general symptoms. The abscess healed quickly after in- cision. Acute abscesses must be distiug-uislied from cold abscesses, that is, from all purulent collections resulting from the liquefaction of infiltration deposits in chronic infections (tuberculosis, syphilis, spo- rotrichosis, etc.). The rapid evolution and the cardinal symptoms of inflammation make this distinction easy. Siiperficial abscesses are easily detected by fluctuation. The purulent nature of deeper collections is established by exploratory puncture. Incision and drainage is the only treatment. Fig. 86 shows another sujipurative condition of the breast, due also, as are the most frequent inflammations of that gland, to the puerperal state. TMs condition is of more moment than the one shown in Fig. 85. It is an intraglandular infection, a mastitis, situ- ated in the outer and lower quadrant of the organ. (This location is the most frequent, owing to the dependent position of this seg- ment and consequent congestion.) ,The inflammatory sjTnptoms are very marked. The skin is reddened, tense and infiltrated ; the whole of the outer and lower part of the mamma is hard and painful. No fluctuation anywhere. There were the usual general symptoms, fever and malaise, and radiating pains in the arm. In some cases, purulent mastitis causes an acute suppurative lymphangitis with involvement of the axillary glands. Differential diagnosis Mastitis, that is, abscess of the breast itself, must be distinguished from superRcial abscesses in the region of the nipple (Fig. 85) : the latter are well circumscribed and do not cause deep infiltration. Also from the deep retro-mammary abscesses ; there may be some un- certainty in the diagnosis when inflammation of the mamma exists at the same time. A phlegmon of the retro-mammary bursa raises the whole gland from the thorax; the skin is iisually intact; palpation of the breast causes no pain, while pressing the breast against the thorax is very painful. The pus bulges in the fold under the breast. There is generally an acute axillary adenitis and pain on moving the arm is more marked than in ordinary mastitis. Chronic mastitides, either simple, or tuberculous, or actino- mycotic, or syphilitic, do not have the acute course of puerperal 124 [inckciilii-imcr, Atlas. Fig. 86. Mastitis pucrperalis punilciitn. Ri'hin.iii ("niiip.niiy, NcwVoik. Bockenheimer, Atlas. Tab. LXIX. Rebman Company, New- York. mastitis and the aiiaiiim'sis is difTereiit. It is imicli liarder to differ- entiate tliese various types of chronic lesions between themselves than from acute pyogenic inflammations. Nor does mastitis neona- torum or the similar congestive condition observed at puberty give cause to any confusion. However, it may sometimes be attended by superficial abscess formation. One form of acute cancer of the breast (Fig. 15), the mastitis carcinomatosa of Vitllnixnni, or (((niiwinn iiiaslitoides, somewhat resembles mastitis, inasmuch as it also develops during tiie lactation period. However, the malignancy is so evident that the dia.gnosis is easy if only one thinks of that form of cancer, as one always sliould do. Galadocelc and milk abscess have a special doughy consistency and disappear after removal of the milk by a breast pump. Treatment Treatment of puerperal mastitis is incision in a radiating direc- tion. All recesses should be opened and connective tissue septa broken : free drainage should be insured. Xaturally, the breast is of 'no further use for nursing at the present time. Bier's suction cups are very useful in the treatment of su})- purative mastitis. Aspiration of the pus, with the application of passive hyperemia, often spares the necessity of making a large in- cision, which will leave an unsightlv scar. Fig. 87 shows a furuncle with lymphangitis in one of tlie most common locations, the nape of the neck; Fig. 88 a ease of furuncu- losis in a young child ; Fig, 89 a carbuncle of the nape of the neck in a man of 40. All these lesions are staphylococcic infections of the pilosehaceous system. The bacterial invasion occurs through the duets of the sebaceous glands. Even slight friction is sufficient to cause staphylococci, which are always present on the skin, to enter the sebaceous ghmds, where they find more favorable conditions for their growth than on the surface of the skin. In uncleanly jiersons pustules often occur on the skin, each one pierced by a hair. This purulent inflammation of the sebaceous glands is called folliculitis. (In the eyelids folli- culitis of the eyelashes forms hordeolum, or stye.) Folliculitis is cured by e])i]ation of the hairs, and may l)e avoided by cleanliness. The inflammation may extend beyond the sebaceous gland and 125 cause inflammatory infiltration of the skin and a furuncle (boil) develops. The pathological process consists in hyperemia and exuda- tion, with redness and hard swelling of the skin, followed by necrosis ■of the tissue in the center of the infiltration; afterward regener5,tion by the formation of granulation tissue. Furuncles occur especially in parts which are exposed to irri- tation — the nape of the neck, the wrist joint, the buttocks, the thigh and the face. They often develop secondarily to cracked conditions of the skin caused by eczema, excoriations, etc. In diabetics, fur- uncles are very common owing to the dry condition of the skin and the scratching produced by pruritus, also to the body being especially vulnerable to bacterial invasion. For this latter reason, carbuncles in diabetics are still more common than furuncles. Furuncles may also appear in all cases where the bodily resistance is impaired — in children, old people, and the tuberculous. Then, either they are few in number or there is an outbreak of furuncles over the whole body, iurunculosis (Fig. 88), in which most of the furuncles are not as well developed as when there are but a few of them (Fig. 87). In furunculosis of children, and in many aborted boils of full-grown people, the process consists in the formation of multiple, small nodu- lar infiltrations in the skin, in which there is no central necrotic core, but a small abscess. This is seen in a few of the larger boils in Fig. 88. The clinical appearance of furuncle is typical. From a small punctiform redness develops a hard, redder, painful nodule imbedded in the skin, and which extends at its periphery and also deeply toward the fascia. The epidermis is at first intact, but afterward ruptures at the apex of the projecting furuncle, exposing a yellow- ish centre, which becomes more and more demarcated from the hard, red infiltration. In this way a round, crateriform ulcer is produced with a central yellowish core (Fig. 87). Sometimes a hair is situated in the centre of the furuncle. Large furuncles are extremely painful owing to the inextensibility of the inflamed tissues and the resulting high tension in the central parts. Motion exaggerates the pain, so that patients instinctively immobilize the region (stiff neck in furuncles of the nape). General symptoms are marked in large furuncles. They subside when the central core becomes loosened by suppuration. The cavity is then quickly filled by granulation tissue, which may form a cicatrix in a few days. The hard infiltration remains for a long time and generally causes unpleasant itching of the skin. The scar, which is 12G Bockenheimer, Atlas. Tab. LXX. Fig. 8Q. Carbunculus. Rebman Company, New- York. always liypcviroiiliic in all iiiflaiiniKitni'v processes, may also cause troulilo. Carbuncle is but an aKH'l"i"ii-'i'iitioii t)L' I'uruuck'S, resulting rroin the iutVctiou of several sebaceous glands and differing only by its greater extent, both in surface and doptli. Tt also differs in being frequently a streptococcic condition. The skin gives way in several ])laces and there are several yellow cores. Connnencing as a small, red nodule, it quickly develoi)S into a hard infiltration, extending to the fascia, and may eventually attain the size of a hand, and cause more or less diffuse inflammatory infil- tration of the neighboring jjarts. Lymphangitis and adenitis are gen- erally present. The affection is accompanied by severe pain, high fever and rigors. Furuncle can develop into carbuncle, especially when the core has been forcibly expressed. Carbuncle of the nape of the neck may attain an enormous size and spread from ear to ear. In diabetics, carbuncle causes extensive necrosis and is a serious aft'ection. Complications may increase the severity of furuncle. There is always lymphangitis, especially in the extremities, and often lym- phadenitis. Early implication of the lymphatics signifies extensive inflammation and virulent bacteria. Several furuncles are sometimes found close together, either from simultaneous infection of several sebaceous glands or from secondary infection from the primary furuncle. This often occurs after the application of plaster or other measures with the object of "drawing out" the furuncle. Such cases must be distinguished from primary carbuncle (Fig. 88), which, as already said, is also an agglomeration of furuncles, but of a distinct type. Extensive furunculosis may be fatal from exhaustion. It may also lead to jiurulent thrombo-phlebitis and general sepsis. Furuncles of the lip or carbuncle of the face may cause menin- gitis by thrombo-phlebitis of the facial vein and cavernous sinus and general pyemia may be caused by thrombo-phlebitis of the jug-ular vei)!. Renal abscess and osteomyelitis (see page 147) are other possible complications. Lymphangitis, as sliowii in Fig. 87, appears as red. dift'use patches, which soon develop into irregular red cords extending from the periphery to the root of the limb. The number of those red cords, which are smalh'r than the cords of thronilio-iiliI(>bitis, diminishes in 127 the upper part of the limb, till finally there is only one reaching the regional glands, which are swollen and tender. The cords themselves are slightly raised above the level of the skin, tender on pressure, and abscesses frequently develop within and around them. Diagnosis The acuminated, localized swelling of an ordinary furuncle can hardl}^ be mistaken for any other affection. Furuncles originating in the sweat glands are often described as a separate condition {hydradenitis or hidrosadenitis). The distinction has practically no importance. The sweat gland furuncles are par- ticularly frequent in the axilla. Metastatic furuncles are associated with other pyogenic infections. Acne is sometimes associated with furuncular lesions, and might somewhat resemble furunculosis in its attenuated form. But the pres- ence of comedones and the painlessness of lesions help settle the diagnosis. Anthrax (malignant pustule) differs from carbuncle in the pres- ence of small vesicles filled with turbid fluid and early central necrosis of the skin, and in the absence of cores (see Figs. 112 and 113). In doubtful cases a bacteriological examination must be made. All constitutional disturbances (diabetes, anemia) should receive proper treatment, the diet should be invigorating, and the skin kept very clean. Old-fashioned poultices are to be rejected, as they favor auto- inoculations in the neighboring skin. On the contrary, hot antiseptic dressings are beneficial (hyperemia). Small furuncles may sometimes be aborted by pulling out the cen- tral hair and swabbing the resulting hole and the apex of the furuncle with pure carbolic acid. Incision does not materially shorten the duration of a boil, but markedly decreases the pain. When, therefore, it becomes likely that . a furuncle will suppurate, there is no reason to delay free incision, so as to give complete relief of tension. This is done after careful disin- fection of the skin, under local anesthesia for simple furuncles, under general anesthesia for carbuncles, in which the crucial incision must be deep. The core of a furuncle should never be forcibly expressed. 'The best way to hasten healing in a carbuncle is to remove all the inflammatory mass. Protecting the surrounding skin with fatty 128 Bockenheinier, Atlas. Tab. LXXI. Fig. 90. Erysipelas erytliematosum. Rebman Company, New- York. ;mtisei)tic ointnionts is j^ood. Tlie thermocautery was formerly much used iu tlie treatment of carbuncles. It has no special advantages. Furunculosis has heen treated internally with yeast preparations, and more recently with .stajiliylococcic vaccines (stock or autogenous), which give good results in acne. Fig. 90 shows a typical case of erysipelas of the face, which originated from a fissure on the nose. Erysipelas is tlie stre])tococeus infection of the .skin. The strep- tococcus of erysipelas, formerly thought a distinct species, is very likely the Streptococcus pyogoics. While in lymphangitis the deeper and larger lymphatics are in- fected, in erysipelas the smaller lymphatic spaces of the skin and subcutaneous tissue are plugged with streptococci. A similar con- dition may occur in the superficial layers of the mucous membranes. Erysipelas may occur wherever there is a solution of continuity in the skin — after sci'atches and excoriations, after all injuries and operation wounds. Spontaneous or "medical" erysipelas is most often seen on the face, and the portal of entry is an excoriation of the skin or of the nasal mucosa. It generally begins in the inner canthus. It may also be combined with various pyogenic affections — - whitlow and phlegTiion. Conditions which give rise to constant irri- tation of the skin, such as lupus, tuberculous fistula, ulcer of the leg, foreign bodies, etc., may also give rise to erysipelas, which is then often relapsing. Eelap.sing erysii^elas of the face and leg may cause elephantiasis, flattening of the nose and considerable deformity. Lastly, erysipelas may arise iu general streptococcic infection, and is then always comljined with other pyogenic conditions — abscess, phleg- mon, etc. Some subjects seem to have a particular predisposition to erysipe- las, so that they will coTitract the disease whenever exposed to the infection. The common form of erysipelas, which consists in a red elevation of the skin, is called erythematous erysipelas (Fig. 90). In bullous erysipelas the skin is covered with vesicles (Fig. 91 ). In hemorrhagic erysipelas there is hemorrhage in the skin (Fig. 91). In the great majority of ca.ses erysipelas ends by resolutioji, but sometimes it may cause cutaneous abscesses, and in the form of gangrenous, phleg- monous erysipelas may give rise to ulceration and extensive destruc- tion of the skin. 129 The clinical symptoms of erysipelas are characteristic. The dis- ease usually commences by a chill, high temperature (104°-106°) and redness of the skin. There is itching and tension in the skin, and tenderness on pressure. There is considerable constitutional disturb- ance, owing- to high fever, headache and vomiting, which continue while the disease progresses. The affected skin is red, tense, some- what glistening and slightly raised above the level of the rest of the skin. The borders are well defined, distinctly raised and zigzag (seen in Fig. 90, especially toward the scalp and the neck), so that the exten- sion of erysipelas, especially on the face, haS' been compared to lam- bent flames. When the disease spreads over the whole body, it is spoken of as migratory erysipelas. In places where the skin is loosely attached (eyelids, scrotum), there may be considerable swelling and edema, as may be seen in Fig. 90. The eyelids were so swollen that the patient could hardly open them. Then the temperature falls suddenly, the redness ceases to extend,, and the skin, after slight desquamation, resumes its normal condition in about a week from the onset of the disease. In relapsing ery- sipelas the whole process is considerably shorter and may not take more than one or two days. Erysipelas of the mucous membranes is generally difficult to recog- nize, except when it is an extension from erysipelas of the skin. The mucous membrane is swollen, edematous, sodden and of a deep-red color. Constitutional disturbance is generally severe. Erysipelas of the buccal mucous membrane may occur after tooth extraction with dirty instruments. It may cause death by meningitis or edema of th& glottis. Diagnosis Erythematous erysipelas is so characteristic that it can hardly be mistaken for other affections. The advancing, irregular, raised edge and shiny surface are enough to differentiate it from other in- flammatory conditions. Eczema itches and burns much more than erysipelas. Lymphangitis is a diffuse redness without raised border, or hard cords going directly to lymph glands. Fulminating gangrene (see Fig. 109) is sometimes called by Continental writers "bronzed erysipelas," but there is no similarity whatever between this condition and ordinary erysipelas. Bullous, erysipelas might be more confusing. 130 kenheimer, Atlas. Tab. LXXII. 3maii Company, New-York. Fig. 91. Erysipelas bullosum hamorrhagicum. Diffuse suppurative cellulitis quickly leads to infiltration and pus I'onnatioii. II' tlicrc arc any aliscfsses in (M-ysiiielas, they always remain very small. Anthrax ^'nu he conruscd willi luilldus ("i-ysi)iclas (sec Fig. 91 and page l'A'2) mucli nKirc than with the I'lmniKHi crythcniatous form. Treatment Erysipelas is a contagious disease until after tlic period of desquamation. The patient should be isolated and the room disinfected after recovery. The best local apjilications are 0.5% carbolic oil or 10% ichthyol. Drawing a circle with tincture of iodine beyond the raised border is but one way of inducing active hyperemia and establishing a ring of leucocytic infiltration, which acts as a barrier against the- peripheral spreading. Serum therapy, extolled by some, gives uncertain results; in theory, it does not seem rational, since repeated attacks of erysipelas^ though lessening the symptoms, do not confer any immunity against infection. An intercurrent erysipelas often has a beneficial influence on a pre-existing disease of the skin. It also sometimes brings about the regression of malignant tumors, chiefly sarcoma. Hence the use of toxins made by Coley in the treatment of sarcoma, to which reference has already been made (see page 30). Inunctions of colloidal silver ointment have been foimd beneficial in streptococcic infections. Fig. 91 shows a case of hemorrhagic bullous erysipelas of the arm consecutive to a horse bite. Around the three superficial abra- sions due to the teeth the skin is dark red, and there are annular extravasations of blood. There are also several vesicles filled with turbid fluid, in which streptococci were found. There is extensive diffuse reddening, especially on the forearm, and a brownish coloration due to numerous extravasations of blood from the smaller blood-vessels situated around the lymphatic vessels. In the upper arm there is a macular and cord-like reddening due ta lymphangitis. The axillary glands are much swollen and painful; the swelling of the forearm was so extensive that a deep phlegmon- was suspected, which suspicion was all the more justified because- 131 wounds caused by bites from animals or men tend to become severely infected, but the symptoms quickly subsided after suspension of the arm and the constitutional disturbance always remained mild. In the place where the erysipelas was hemorrhagic and bullous, there occurred a superficial phlegTnonous inflammation, which led to gan- grene of the skin. Diagnosis Anthrax also commences with redness of the skin and the for- mation of vesicles (Fig. 112), fever and rigors, and may, in its early stage, be confounded with this form of erysipelas. But the redness is not so extensive in anthrax, nor so rapidly developed. Anthrax always causes early gangrene of the skin. In doubtful cases anthrax bacilli must be looked for in the contents of the vesicles. In the ease shown in Fig. 91, which resulted from a horse bite, there was a suspicion of glanders. But, in the latter the redness is punctif orm or macular ; the vesicles are larger and purulent, and soon rupture, giving rise to gangTenous ulcers, and the hadlhis mallei is found. Subcutaneous phlegmons, caused by virulent streptococci, may exhibit an erysipelatous redness of the skin, but this only occurs in the region of the phlegmon, and does not extend so rapidly as erysipelas. Vesicles may also form on the skin in virulent strepto- coccic infection. Phlegmons due to gas-forming bacteria (e.g. malignant edema, Fig. 109) cause rapid redness and swelling of a whole limb. In- crease of jjressure in the tissues from the formation of gas also leads to the development of vesicles, but these are very large and often raise the epidermis over the whole part affected (Fig. 109). In these severe forms of lahlegmon there are sigiis of general infec- tion from the beginning — chills, delirium, diarrhea, dry tong•^^e, and bacteria in the blood. In all the above-mentioned cases the clinical pictures may be very similar, and the diagnosis should always be established without delay by bacteriological examination. A correct diagnosis is all the more important because the treatment is not the same in the different affec- tions. In erysipelas, anthrax and glanders conservative measures are indicated, while streptococcic phlegmon requires early incision to prevent general infection, and in gas-phlegmon very extensive in- cisions, or even early amputation of the limb, are necessary to save the patient's life. 133 Hockcnliciincr, Alias. Tab. I.XXIII liy. 92. lii\sipcloid. Krbinan Coinp.Tiiy, New- York. i Bockenheimer, Atlas. Tab. LXXIV. Fig. 93. Panaritium subepidennoidale. Rebiiian Company, New-York. Fig. 92 shows a case of an al'fi'ctinn very similar to erysipelas, and called chronic erysipelas or erysipeloid. It is a bacterial infec- tion of the skin, of a very harmless nature, niayhe caused by the staphylococcus albus, which has sometimes been found in it. The case was observed in a cook, a few days after handling game. This is the common etiolosy, as erysipeloid generally occurs after injuries to the fingers, especially by fish and game. It is, therefore, more common in venders of fish and game, cooks, butchers, curriers, etc. SometiiBes the injured spot is invisible, as the redness and swell- ing generally ap]iear a few days after the injury. In otlier cases foreign bodies are found in the skin. The affection has been observed in surgeons after operating upon infected ])ersons; it is more common in the autumn. It begins with redness and swelling of the fingers. Like erysipelas, the redness has sharp, irregular borders. The redness spreads slowly but continuously over the whole finger, and may extend to the next finger and as far as the wrist. At this point the inflamma- tion stops. There are no constitutional symptoms; no fever nor chills. The patients only complain of itching and a feeling of tension in the skin. In some cases there is lymphangitis, generally on the extensor surface, as far as the axilla. In rare cases adenitis with high temperature has been noted. The sym]itoms generally subside in a week, but relapses are common. Supi^uratiou has never been observed. Erysipeloid differs from erysipelas in its chronic, apyretic course, paler color and demarcation at the wrist. Treatment consists of ointments, rest and support on splints. Figs. 93 to 98, inclusive, show the in-ineipnl types of the sup- purative conditions of the different tissues of the finger grouped together under the name of panaris, felon or whitlow. Whitlows are most frequent in workingmen owing to the numer- ous cracks and fissures of their skin. It often occurs after punctured ■wounds, which directly inoculate bacteria (staphylococci or, more rarely, streptococci) in the finger. It is far from rare in surgeons. The most superficial whitlow is the subepidennic (Fig. 93). But the most common, and the most important to know, is the suhcu- taneous variety (Fig. 94), because from this, if improperly treated, derive all the other, deeper, and more severe types. The anatomical disposition of the subcutaneous tissue of the 133 fingers is peculiar : vertical connective-tissue septa separate the fatty tissue into a number of distinct compartments. If bacteria gain an entry into one of these, the inflammation naturally is at first circum- scribed : there is hyperemia, exudation and tissue necrosis : the latter occurs rapidly owing to the impairment of nutrition from the great pressure in the inflamed area enclosed within inextensible walls. In this way a necrotic core is formed, as in furuncle. If properly drained at that time, no further damage ensues ; but if not, the pus burrows in the direction of least resistance. The tendon sheath is bathed in pus, finally involved and perforated. The result is a tendon-sheath suppuration (Fig. 96). Going still deeper, the pus may involve the periosteum of th& phalanges, the bone, and the finger joints {osteal and articular whitlow. Fig, 95). The clinical symptoms vary in severity in proportion to the depth of the pathological changes, and the virulence of the bacteria. In subepidermic whitlow (Fig. 93), a purulent vesicle develops, gen- erally on the dorsal surface of the finger, with slight redness of the surrounding skin. The raised epidermis sometimes shows several yellow spots, where the pus breaks through. Pain and functional disturbance are slight, the inflammation remaining local. Lymphan- gitis is rare, there is no tendency to spread, and but little or no 'constitutional disturbance. In subcutaneous whitlow it is quite otherwise (Fig. 94). The whole finger is red, swollen, flexed and extremely painful, especially at one spot. This greatest pain on pressure in one spot is often the only symptom pointing to the primary seat of infection, as in horny-handed workmen, the latter is often very difficult to see. In a few cases only, the skin gives way and a yellow core becomes loose and cast off, after which healing takes place by granulation tissue. More usually, as the hard skin of the palmar surface of the fingers prevents escape of pus, the latter takes paths of less resistance. The vertical connective tissue septa, mentioned above, guide it toward the peritendinous zone, where it may spread along the whole length of the tendon. It may also reach the loose connective tissue on the dorsal surface, and give rise to marked redness, swelling and edema, while inflammatory signs may be slight or absent at the primary focus of infection on the flexor surface. There is some lymphangitis of the hand and forearm, a moderate fever (102°) and constitutional disturbance. 13-i BockciilR-iiiRT, Atlas. Tab. I. XXV. \-\g. 94. Paiiariliiim subculaiicuin l-\•nlpllallL;ili^ acuta. Rcbm.Tii Coiiiiwiiy, Nc\v-\ork. Bockenheimer, Atlas. Tab. LXXVI. Fig. 95. Panaritium ossale et articulare. Pebman Company, New- York. An intcrcstiii.n' \-ai-icty nl' sulicutiiiicdiis whitlow i> interdigilal whitlow, sliowu in Fig. 97. It is a snln-ntaueous suppiiratiou Ito- twccn tlio laeiaearpal i)une.s; in the ac;tual case, between the tliunih anil inilicatoi" finger. Redness and edema are marked on the dorsal surface, and, as pus is i)resent in more considoi-alilo f|uaiitify than in ordinary suhciilaueous felon, fluctuation, wliich is laic in the latter, is ]>r('S(Mit. The syinptuiiis arc Jimst severe in tendinous whitlow (Fig. 96)- There is more swelling of the finger, and tlie participation of the tendon sheath is evidenced by the flexion of the finger. Tiiere is )>aiTi (in pressure along the whole tendon sheath, and usually over the whole ])alin. Movement of the tendon causes great pain, and extension is almost impossible. Lymphangitis and erysipelatous reddening often extend far beyond the seat of infection. There are chills and fever (104°), sleeplessness, and considerable mnlaise. If the tendon sheath of the thumb or little finger is infected, the pus may extend along the course of these sheaths as far as the wrist; whereas, su])puration in the tendon sheaths of the second, third and fourth fingers does not extend beyond the metacarpo-phalangeal joints, where these tendon-sheaths end. In the wrist the tendon-sheaths widen and lie so close together that suppuration may extend from one to the other. In this way, infection of the tendon-sheaths of the thumb may result from that of the tendon of the little finger; and inversely, infection of the little finger may come from the thumb. This has been called V-shaped whitlow. It is obvious that infection of both tendon-sheaths causes more severe symptoms — high fever and much constitutional disturb- ance. The thumb and little finger are flexed, swollen and very pain- ful on pressure. The pus often breaks through the sheaths and spreads between the muscles of the forearm up to the elbow joint. In other cases the wrist-joint is infe(>ted. Such cases may give rise to general sepsis. V-shaped whitlow is recognized by its severe clinical symptoms and typical appearance. In the early stages there is often i)ain. red- ness and swelling in the palm, or on the flexor surface of the wrist. When suppuration has existed for some time and become extensive it seeks a way to the surface. Thus fistuhT are formed along the- tendon-sheaths, discharging much pus, and often exj losing the greenish-yellow remains of the necrosed tendon (Fig. 96). The orifices of these fistuhx.' are surrounded bv flaiiliv, unhealthv uranu- 135 lations, which, as mentioned before (Fig. 56), indicate necrosis in the ■deeper parts. In periosteal and osteal whitlows, which generally occur at the ends of the fingers, the periosteum and bone are surrounded by pus and destroyed. In the terminal phalanx total necrosis may occur. A fistiila forms and discharges the fetid, slimy pus characteristic of necrosed bone. Frequently dead bone is eliminated (Fig. 95). Parts of the skin may become necrosed, so that, eventually, the whole finger-joint may be lost. Beginning with sharp pain, the acute stage gradually becomes more chronic, and in this stage bone involvement may be overlooked. In the first and second phalanges there is often infection of the joints, either secondarily to periostitis, or directly from the surface. Articular whitlow generally manifests itself by chills. The joint is fixed in a position of flexion and is very painful on movement. The capsule and ligaments are soon destroyed, and erosion of the cartilage causes grating on motion. Articular whitlow may also give rise to general sepsis. 3iagnosis Tuberculous and syphilitic inflammations are more chronic and cause less pain and fever. They do not heal after incision, but require specific treatment. It is not always easy to diagnose the stage of the whitlow. Patients of the working-class generally come so late for treatment that there is often infection of the tendon-sheath, periosteum and joint. In other cases the pain is so severe as to suggest tendinous whitlow, while it is only subcutaneous. A correct diagnosis can often only be made after incision. Treatment All whitlows require early incision. In subepidermic whitlow the purulent bulla must be opened, its edges pared off, an antiseptic dressing applied, and the arm suspended in a sling. Subepidermic ' whitlow may cause infection of the deeper tissues, and there is also the danger of erysipelas. Hence, do not consider it too lightly. Subcutaneous whitlows should be incised as soon as possible, under an anesthetic. Schleich's infiltration anesthesia does not work well in inflamed tissues, but regional anesthesia is very prac- tical on the fingers. However, general anesthesia should be resorted 136 Bockenheimer, Atlas. Tab. LXXVII. Rebman Coniiiany, New- York, to in all cases wlioro the oxtoiit of the suppuration is not clear. Do not let yourself be inttu('nce))urati()n arc not fit foi' anibulatoi'v treatment. 137 Fig. 98 shows a type of subepidermie whitlow, having special features on account of its location; it is the peri-ungual ivhitloiv or paronychia. The skin is bluish-red and tender to the touch. The nail bed is red, infiltrated, and painful on pressure. Paronychia may result from punctured wounds, tearing of the nail, foreign bodies or manicuring with dirty instruments. There is often suppuration around the nail, which is raised from its bed, may become quite loose, and generally falls. In severe cases there is much pain, fever and lymphangitis. Syphilitic chancre of the finger often resembles paronychia. It begins with redness and hard infiltration, which develops into an unhealthy ulcer with flabby granulations. This is followed by painful infiltration of the lymph vessels and glands. This form of chancre is very chronic and painful (thus differing from most other chancres). Syphilitic chancre shouFd be borne in mind in every case of chronic paronychia which is refractory to treatment. It is especially com- mon in medical men and midwives. Tuberculous infection of the nail bed may also occur among physi- cians and nurses. This begins as a dark-red infiltration of the skin. Nodules then develop and break down into an ulcer with flat, irregu- lar borders. The tuberculous granulations are grayish-red and bleed easily. This affection is very chronic. The nail may be lost and replaced by thickened tissue in both tuberculous and syphilitic paronychia. In some cases the whole finger may be destroyed. The diagnosis of tuberculous paronychia can sometimes only be settled by microscopic examination, or by inoculation to the guinea pig. The diagnosis of syphilitic chancre is confirmed by finding the spirochceta pallida in scrapings. If the inflammation is not around the nail bed, but under it, we are dealing with the condition called suh-ungual iv-hitloiv. Owing to pressure of the nail, the virulence of the infecting bacteria is in- creased, so that the inflammation rapidly spreads and soon leads to necrosis of the tissues. Sub-ungual whitlow causes severe pain and lymphangitis. It is often overlooked, as the changes under the nail are not at first visible, and the first sign is usually a yellow color- ing seen under the nail. The diagnosis is suggested by the severe pain elicited by pressure on the nail. As the pus cannot break through the nail, it extends deeply and may cause necrosis of the ter- minal phalanx by infection of the periosteum. Corns and exostoses may also develop under the nail and cause inflammation with severe pain. 138 liockeiiliciiiicr, Alias. Tab. LXXVIII. Rcbnian CoiitiMiiy. Nc\v-Voil<. Trcatmnit ]*;ii'f)iiyclii;i rci|uii-('s early iiicisidii licforc llic |iiis lias loosened the nail; this is tlic only ciiancc nl' .->avini;- (lie lallcr, an' the iiiiifr hoidor of tlio storno-mastoid muscle. Extensive cases ic<|uiii' rumitci- iiici>iuii>. In Ludniff's angina, tlie thermocautery is usetul. No I'uhher drains must be left in contact witli tlie 1)1^ l)lood-vesselM of the neck, for fear of pressure ulceration. Jjari^e incisions in the nock heal very well and often leave only surprisingly small scars. Woody ])hlegmon sometimes requires multiple incisions. In all cases of cervical cellulitis in wliicli there is nnich inliltration of the floor of the mouth, with diHicully in lucathinn- ,ind swallowing, preliminary tracheotomy is advisable, as death might occur from sudden edema of the glottis during anesthesia. Fig. 103 shows a purulent alveolar periostitis of the lower jaw, witli fonnation of a subcutaneous abscess, which is the usual termina- tion (Panilis). This comjnon condition is caused by lesions of the gum (tooth extraction with unclean instruments), fractures of the jaw, dental caries or fistula. Infection of the periosteum of the alveolar portion of the lower jaw gives rise to a circumscribed subperiosteal accumulation of pus, which descends to the sulmiaxillary region and lies over the fascia, covering the submaxillary gland. The signs of pui'ulent inflammation are most apparent in this region, while symptoms at the seat of infec- tion are often slight. The symptoms commence with fetor of the breath, fever and chills, and inflammatory infiltration in the submaxillary region. Soon after- ward the ])resence of fluctuation indicates abscess formation, after which the symptoms somewhat abate. In most cases the suppuration is circumscribed, but sometimes it is diffuse and causes considerable infiltration of the soft parts, swelling, and redness of the side of the face. There is often in those cases trismus and edema of the buccal mucosa, with difficulty in mastication and often dysjmea. In these diffuse forms there are severe constitutional symptoms — chills, high fever, headache, etc. Although the circumscribed form is not dangerous, the diffuse foi'7n may be quite serious. es]iecially when imiiroperly treated. If incision is too long delayed. ,is \va> tlic case in the patient shown in Fig. 103, the bone may be denuded of periosteum for a cojisiderable length, or there may develop osteomyelitis of the jaw (Fig. 104). In the u]i]ior jaw, infection of the periosteum may also (^ause 145 subperiosteal suppuration, wliich here does not meet with such favor- able anatomical conditions for propagation to the subcutaneous tissue as in the lower jaw. Small abscesses caused by morbid conditions of the teeth may burst into the mouth and cause no trouble, but more virulent infections may cause osteomyelitis of the iipper maxilla, which rapidly spreads to all the bones of the face, and often causes death by general j^yemia. In these cases there is infiltration of the upper part of the face, edema of the eyelids, high temperature, chills, headache, etc. In abscesses due to alveolar jDeriostitis, staphylococci are gen- erally associated with some of the putrefactive bacteria of the buccal cavity. Hence the fetid, dirty, reddish-brown pus, mixed with broken-down tissue that is generally found on incision. Diagnosis Subcutaneous abscesses due to alveolar periostitis of the lower jaw are distingiiished from cervical lymph gland suppuration by the history, the finding of a purulent peridental focus in the mouth, and the fact that the swelling of cervical phlegTnons is all below the lower border of the jaw, while that of periosteal abscess is situated higher and encroaclies upon the face. (Compare Figs. 102 and 103). Parulis of the upper jaw may be mistaken for antral suppuration, but transillumination of the antrum will show that the latter is intact. Acute osteomyelitis of the lower jaw begins with more marked symptoms. Actinomycosis is, on the contrary, chronic and painless from the outset, and first infiltrates the floor of the mouth. Treatment Mild cases of periostitis can be treated by the hyiDeremia method (hot fomentations, figs boiled in milk applied on the gum), but too much time must not be wasted. Many cases can be incised through the gum. Only when things have gone very far, and there is distinct subcutaneous abscess must an external incision be made, because with the latter there is sometimes a risk of permanent external fistula. Of course, the treatment of the tooth, either conservative if it is worth while trying, or avulsion, is of prime importance. However, it is best not to do anything to the tooth during the acute stage of the peri- ostitis. 346 Figs. 104 t" 107, inclusive, reprosciit v,n-ii>ns ty|ic< ol' osteo- myelitis III' (iirt'ciciit hones; either acute I Fig. 105) m' chronic (Figs. 104, 106, 107). The term osteomyelitis is aiiplied to pyoi^enic jitTections of hone in general, while in the stricter sense these are divided into purulent periostitis, osteitis and osteomyelitis. Since all three parts of the bone are generally the seat of suppuration and clinically the process can only be localized to the bones as a whole, and ns the majority of cases begin with infection of the bone-marrow, the ii;ime osteo- myelitis is rational. Infection of the bones may result, by continuity or contiguity,, from lesions of the soft parts, compound fraciines, operations (this was common after amputations in the pre-antiseptie days) ; after pyogenic affections of the neighhoring parts (subcutaneous abscess, whitlow, otitis media). In the latter cases the periosteum is first infected, the cocci then invade the Haversian canals in the cortex and contaminate the medullary cavity. Infection may also, and in fact does more frequently take place through the blood ; the medulla is then first infected, and the suppura- tion spreads to the cortex and periosteum, finally appearing as a sub- cutaneous abscess. As in all pyogenic infections, the great majority of eases are- caused by the staphi/lococcus pyogenes aure)(s; while the staphylo- coccus albus, the pneumococcus, the streptococcus and the Eberth bacillus are less frequently found in the pi;s. In all pyogenic affections in which microbes circulate in the blood — and this does not only include such septicemic diseases as typhoid fever, pneumonia, or scarlet fever, but many, if not all, so-called "local" infections (see page l.")?), furunculosis, whitlow, tonsillitis, otitis media — the bone marrow is infected by cocci, but the power of resistance of the body is generally sufficient to withstand the actions of the latter, which remain harmless till the defensive process is weakened for some reason, such as a fracture, overexertion, ex- posure to cold, etc. Osteomyelitis may thus occur after injury to a bone, even after a slight contusion. In this case the resulting effusion of blood favors further growth of the cocci and leads to infection. Therefore, accoi-ding to circumstances, suppuration of the bones may develop sometimes directly after, and sometimes a long time after septic conditions in other organs of the body ; again, according to the number and virulence of the bacteria, it may take an acute or chronic form, with correspondingly violent or mild symptoms. As usual, the- 14r process begins at the seat of infection with hyperemia and exudation; then occur suppuration, degeneration and regeneration; these processes assuming a special type corresponding to the structure of the bone. Thrombo-phlebitis may develop and give rise to metastatic infection by embolism in other parts of the body (bones, endocardium, meninges, etc.). As the great majority of cases arise from blood infection, it is clear that the bones most' liable to infection are those which are most richly supplied with blood-vessels, especially during their period of groivth, when they are most vascular. The diaphyses of the long bones are thus most often affected at their junction tvith the epi- physes. The lower ends of the femur and radius and tibia, and the upper ends of the humerus and tibia, are the places of predilection. Osteomyelitis is less common in the short and in the flat bones. It is also rare after the thirtieth year. According to the statistics of Garre, in 20% of the cases several bones are affected simultaneously. The symptoms of acute osteomyelitis are more severe than those of any other pyogenic affection. The deeper the infection, the greater is the virulence of the bacteria. Bacteria in the bone-marrow are under greater pressure than in any other tissue, and this increases their virulence. In young individuals osteomyelitis often begins sud- denly after an injury, with high fever, chills, pains in the joints and severe constitutional disturbance. Pain on pressure on a localized point of the bone, or on movement, and loss of function are suggestive of an affection of the bones. Serous effusion soon takes place in the nearest joint. Changes first appear under the skin when pus collects under the periosteum. The subperiosteal abscess appears as a sharply defined fluctuating swelling with hard borders, and the skin over it is tense and reddish-blue. If the subperiosteal abscess bursts, it gives rise to intermuscular and subcutaneous infiltration, with red- ness and swelling of the skin, and edema of the soft parts ; the regional IjTQphatic glands are swollen and painful. Although operation often only reveals a subperiosteal abscess, especially in children, in cases of hematogenous origin the cortex and medulla of the bone are also affected. Involvement of the cortex is shown by the presence of yellow spots on the surface, which corre- spond to small holes discharging pus. After removal of the cortex, the infected medulla shows reddish-brown or yellowish spots, which may lead to the formation of a circumscribed abscess, or to diffuse suppuration in the medullary cavity. If the condition is not recog- nized early and the spread of infection checked by operation, separa- 148 tion of the epiphyses or infeditm of llie joint may occur, or general sepsis with death in a few days. Jii extensive disease the whole hone is whitisli-yellow ; wliite from hloodlessness due to thrombo-phlebitis, and yellow from pus formation. Numerous pits are seen from which pus has been dist*harc:cd under llie periosteum. The amount of necrosis i-orresponds to the degree and extent of infection. In subperiosteal necrosis the destroyed cortex and medulla may regenerate without loss of substance, especially when the pus has been given an early outlet. If the cortex has been for some time the seat of extensive purulent inflammation, necrosis must result with the formation of a sequestrum. According to the extent of the inflammation, this necrosis will be limited to part of the bone or involve the whole thickness and length of the bone (Fig. 107)- In disease of the cortex the sequestrum is generally lamelliform, slightly corroded and pitted; in disease of the medullary cavity the sequestrum is, to a certain extent, a cast of the cavity, and trough- shaped. The sequestrum in osteomyelitis is large and continuous, thus differing from the sequestra in tuberculous bone disease, which are generally multiple, small and much corroded. Complete necrosis of the diaphysis occurs in acute cases which have been operated upon too late and in chronic cases. The sequestrum becomes separated from the healthy bone by a zone of inflammatory demarcation, more or less rapidly according to its size. In extensive necrosis the demarcation process may last for months, so that patients who escape death from general infection may succumb from exhaustion, albuminuria or amyloid degeneration of the kidneys. Spontaneous expulsion of the dead bone should be assisted by operation (sequestrotomy). The regenerative or osteoplastic process goes hand in hand with the degenerative. The suppuration not only causes necrosis, but also irritation, which stimulates the osteogenic activity of the periosteum. This results in thickening of the cortex at the seat of necrosis ; and in cases of total necrosis, complete repair of the destroyed bone (at least in young subjects). This irregular formation of new bone is sometimes called the "sequestral capsule." There are numerous boles in this capsule where the periosteum has been destroyed. From these holes ]ius is discharged from the zone of inflannuatory demar- cation; and eventually the sequestrum, after passing through one of these apertures, is eliminated through a fistula in the skin 149 (Fig. 107). The X-rays are useful in showing the extent of necrosis, and also separation of the epiphyses. The whole process of degeneration and regeneration takes much longer than in suppurative diseases of the soft parts, and the acute stage is followed by a chronic stage after the pus has been evacuated spontaneously or by operation. However, an acute relapse may occur at any time during the chronic stage, especially after improper treat- ment, or after a trauma. Besides acute osteomyelitis, there exists a form which is chronic from the outset. In these cases there is often a history of previous acute inflammation of the bone, and the condition is really a mild recurrence, often at the age of puberty, or later in life ; hence bones which have been previously affected with os.teomyelitis must be deemed as loci minoris resistentice and protected against injury and overexertion. The clinical symptoms in these cases often resemble those of chronic rheumatism, but the pain is localized to one bone, or some- times a definite part of a bone. There is often a history of pyogenic disease in youth, and scars and fistulas may be found in the bone concerned or in others. The affected bone is often very tender to pressure at certain points. In the course of time it becomes thick- ened, and the diaphysis lengthened. The growth in thickness may be enormous at the seat of disease, both the periosteum and cortex sharing in the hyperplasia. The changes in chronic osteomyelitis are as follows: Sometimes there is a small sequestrum in the interior of the bone, showing in an X-ray picture as a clear spot surrounded by bony proliferation, some- times a circumscribed abscess in the medullary cavity, shown by the X-rays as a round space surrounded by bone. If bony proliferation is absent the X-ray pictures resemble those given by tumors or cysts in the bone. The diagnosis of chronic osteomyelitis, therefore, may be difficult when there is no history or evidence of former osteomye- litis. Pain on pressure suggests the infectious nature of the disease. If large portions of the cortex and medulla are affected by chronic osteomyelitis the result is large sequestra, which seek a way to the surface in spite of the considerable formation of new bone. In these cases we find numerous holes in the bony capsule, subcutaneous abscesses and fistulse (Fig. 106) ; while the whole bone is thickened, and the X-rays show changes in the periosteum, cortex and medulla. A third form of chronic osteomyelitis is limited to the periosteum, under which a hyaline sero-mucoid fluid develops, forming a sharply 150 doliiKMi, (liictuatiiiK swelling witli li.ird lidrdors. Tliis liiis hecii c-alled albuminous periostitis, but is a form of osteomyelitis. Staphylococci are present in the fluid. All these chronic forms are due to infection by staphylococci of slight virulence. Howovor, every chronic osteomyelitis may become acute, especially when tlic hones are exposed to the eifects of over- exertion, injury or mnssai^c (wroiift' diaiiiiosis or ostcopalhic Ireat- ment). In the lons>- bones, both acute and chronic osteomyelitis may cause disturbance in s'J'owth, shortenini>- or lengthening of the limb, spon- taneous fractures and pseudarthrosis. Chronic osteomyelitic fistulfe may sive rise to carcinoma (see page 23). Although the great majority of cases of acute and chronic oste- omyelitis affect the long bones, both forms may occur in the short and flat bones; in the skull, after compound fractures, incised and punctured wounds ; in the scapula, pelvic bones and vertebrae ; in the bones of the face, after tooth extraction. As the cortex is thin in these bones, there is greater destruction. Osteomyelitis of the cranial bones may spread through the diploe to half the skull, form large sequestra of the inner table, and epidural abscess. In the scapula the whole bone may be destroyed by multiple abscesses and sequestra, necessitating complete removal of the bone (Fig. 105). In osteomye- litis of a facial bone, infection may involve all the bones of the face,, causing extensive destruction and consequent deformity. Osteomye- litis of the cranial and facial bones may give rise to meningitis. In streptococcic osteomyelitis the pus is thinner and very abun- dant, and the disease is more severe, like all streptococcic infections. In these cases the skin usually shows erysipelatous reddening. Osteomyelitis due to tyjihoid bacilli or pneumococci can be dis- tinguished from the other forms only by the history and bacterio- logical examination. Diagnosis Acute osteomyelitis, at the onset, may be mistaken for any gen- eral infectious disease causing high fever. The only diagnostic sign is then the finding, of tender points in the juxta-epiphf)seal region of bones. Searcli nmst always be made for these points in obscure febrile conditions of childi'CMi. A deep diffuse phlegmon r(^senililes osteomyelitic abscess. Incision is the best way to clear up the diagnosis. Propulsion of 151 bones from below upward is painful in osteomyelitis; and not in abscess independent from the bone. The chronic forms may be confused with tuberculous or syphi- litic osteitis. Tuberculous bone disease generally affects the epiphyses, while osteomyelitis attacks the dkiphyses. Osteomyelitic fistula has hard borders and bright red granulations, and passes directly to the bone, while tuberculous fistula has yelloiv, slimy granulations, irregTilar borders and an irregular course through the deep parts (Figs. 125 and 130). In osteomyelitis the pus is reddish brown, in tuberculosis it is thin and greenish yellow. In doubtful cases an incision will decide the diagiiosis; in osteomyelitis the periosteum and cortex will be found thickened and the sequestrum- large and continuous ; in tubercular bone disease there are multiple, small corroded sequestra. In other words, osteomyelitis tends to hyperostosis ; tuberculosis only to destruction of bone without regeneration. Besides, osteomyelitis generally has had an acute onset; and, if dating back to childhood, causes much more marked disturbances in tlie skeletal growth. Syphilitic osteitis is recog-nized by the anamnesis, the Wcisser- manii or luetin reaction, the pains more intense during the night, and tlie X-ray findings, showing a diffuse thickening of all layers of the bone, and a uniform dark shadow with irregular borders, cor- responding to the periosteum; while, in osteomyelitis, dark shadows together with clear spaces are shown, corresponding to sequestra and abscesses respectively. If fistulre form in syphilitic bone disease they present the characteristic sharp borders and prolific granulation tissue around them (Fig. 122). Osteitis deformans {Paget' s disease) is characterized by affecting the whole extent of both tibias, and by the early appearance of marked curvature. Sarcoma and bone-cysts may also in some cases be difficult to distinguish from chronic osteomyelitic abscess, even by the X-rays. However, the raj^id increase in case of sarcoma soon dispels any doubts, and an exploratory incision is always justified. Treatment Acute osteomyelitis calls for early incision and opening of the bone-marrotv canal, where lies the primary focus of infection. This is done with a concave chisel; the bone marrow is scraped out: this 153 Bockenheimer, Atlas. Tab. LXXXII Fig. 104. Osteomyelitis maxillae inferioris. Febman Company, New- York. does not impair the iiutriliuii dT tlie bone. Tlie wound is drained and loosely packed. Complete immobilization is necessary. In chronic osteomyelitis it is best to wait till the sequestrum is completely loosened and now bone has begun to form around it (X-ray examination) before performin": sequestrotomy. If there ai'e sub- cutaneous abscesses these must be opened. As small sequestra and abscesses often cause considerable pain, in some cases the indication is to chisel open the bone, even if the X-rays show no changes. The operation is then troublesome, as the small sequestrum or abscess is often situated deep in tlie middle of hardened sclerotic bone. Fistula? in chronic osteomyelitis must be freely opened up and the exiiberant bone removed. The cavity remaining in the bone after chiselling must be left open and drained till healing takes place from the bottom. Imme- diate plugging of the bone cavity with Mosetlg 's iodof orm-wax mixture renders good service when all sequestra have been removed and the cavity is clean. Even when the filling mass is subsequently expelled, it has the advantage of making the dressings easy and painless (Honians), while removal of a packing from a granulating trough in. a bone causes much l)leeding and sulTering. Therefore, as soon as the cavity is well granulated, it is scraped, disinfected with peroxide- lotion, dried with Hollander's hot-air apparatus till all oozing is absolutely checked, and filled with a mixture of iodoform, glycerin and spermaceti. Whenever possible, the periosteum should be imited over the plug and a covering of skin made over the cavity. Strict asepsis is necessary. When the whole diajihysis of a bone lias been destroyed, bone' transplantation may be indicated. Thus the fibula may be used to- replace a missing tibia (Mc?Jiceii), or a segment of rib to replace the- lower jaw, or splinters of bone laid in the empty periostic sheath of a humerus. In the first place, the fibula hypertrophies and assumes the function of the tibia; in the latter cases, the transplanted fragments serve only as a temporary support and a stinnilant to new bone for- mation, and slowly undergo resorption. Frequent recurrences in chronic osteomyelitis, with emaciation, albuminuria, amyloid degeneration, etc., necessitate amputation. Contractures must be treated by oxtonsion on a splint, ov when thev cannot be extended, by resection. In flat bones subperiosteal removal of the whole bone is often necessary (e.g. scapula, see page 155). This may be followed by complete regeneration and restoration of function. In osteomyolitis of the cranium sequestra and epidural abscesses must be evacuated 153 through a large trephine hole, which can afterward be repaired by bone grafting. Fig. 104 shows chronic osteomyelitis of the lower jaw in a girl of 19. It developed after a tooth extraction. It may also result from neglected cases of suppurative alveolar periostitis (Fig. 103). A painless, diffuse swelling of the lower jaw slowly developed. The skin gradually became tense, red and edematous : a fistula was pro- duced ; it was opened up ; the discharge decreased, but the fistula did not close, because necrosis had occurred. Radiographs showed a diffuse swelling of the bone. A special occupational necrosis of the lower jaw is of very par- ticular interest, namely, phosphorous necrosis (phossy jaw). It occurs in workers in white jDhosphorus, the vapor of which causes "ulceration of the gums, from which buccal germs invade the peri- osteum and bone. The whole of the lower jaw becomes greatly swollen. The teeth progressively loosen and fall, while the gums are ulcerated and fetid ; many patients succumb to pneumonia or general sepsis. The bone becomes both sclerosed and brittle. After some years (if the patient survives, the mortality is as high as 60%) total necrosis occurs with a row of fistulas along the border of the jaw. As phossy jaw cannot be prevented, even with the best care of the mouth, most countries (the United States recently) have prohibited the use of white phosphorus in the manufacture of matches. A similar condition observed in workers in mother of pearl is much less severe ; it undergoes spontaneous resolution, if the patients change their occupation. Chronic osteomyelitis of the lower jaw, wliich is much more fre- •quent than the acute form, must be diagnosed from actinomycosis (Fig. 116). In the latter the swelling is situated in the floor of the mouth and in the muscles and only later on extends to the bones. In the stage of painless swelling, chronic osteomyelitis may re- semble cystic adenoma of the jaw. Malignant tumors are easily ex- -cluded by their rapid growth. The treatment is early incision ; later on, extraction of sequestra. In phossy jaw partial resection is useless, and owing to the total ■character of the necrosis, subperiosteal resection of one or both sides of the jaw should be performed. After this, regeneration of the jaw 2nay take place if the periosteum has been preserved, and relapses 154 Hockciiheimcr, Atlas. Tab. LXXXllI. Fig. 105. Osteomyelitis sca|nil;ie acuta. Kcbman Company, Ncw-N'ork. Bockenheimer: Atlas. Tab. LXXXIV. Fig. 106. Osteomyelitis humeri clironica. Rebmo.n Company, New- York. are avoided. In all cases of total resection of the jaw hone ^ral'tiuj (see page 153) should be resorted to. Fig. 105 shows a case of acute osteomyelitis of the scapula devel(ii)('d a few days after au injury. A swcHin.u' nijpearcd over the whole scapular res'ion as far as the supra-clavicular fossa, accom- panied by fever and chills. The skin became red and mottled, and a large fluctuating subcutaneous abscess developed. The function of the shoulder-joint was abolished. An incision was made and pus evacuated; the bone at the seat of injury was infiltrated with pus. Plealing took place without any necrosis. In osteomyelitis of the scapula, especially when due to blood infec- tion, an abscess usually forms at the anterior border of the scapula, as the osteomyelitic focus in this mode of infection is situated in the body of the bone. The pus is at first limited by the subscapularis muscle; on the other hand, the jiressure of the muscle causes rapid extension of suppuration in the medulla of the bone. The abscess may thus not be recognized till it breaks through into the axilla. An early symptom of osteomyelitis of the scapula is painful effusion into the shoulder joint; on this account it may be mistaken for an affection of that joint, the true seat of disease only being revealed after incision. In doubtful cases the anterior surface of the scapula should be exposed by an incision in the axilla. In most cases of osteomyelitis of the scapula, the wound does not heal after incision of the abscess; the occurrence of multiple abscesses and necrosis is un- avoidable, owing to the extension of suppuration through the medulla of the bone. For this reason the disease may last for years. In these cases, and also in acute cases where incision shows extensive destruction of the bone, subperiosteal total extirpation of the scapula is indicated, taking care to preserve the muscular attachments and the important nerves. (This is generally indicated in acute osteo- myelitis of the flat bones, which often gives rise to early general infection.) After total extirpation of the scapula relapses are avoided, and complete regeneration of bone with normal function is l")0ssible {Bockoiheimer). Fig. 106 shows a painrul chih-shaited swelling of the left humerus, which gradually developed at the age of puberty, in a patient who had frequently suffered from tonsillitis in childhood. The patient 155 attributed it to over-exertion at liis work as a blacksmith. A year after the onset, a fistula opened at the posterior and external side of the arm, with hard borders and red granulations at its orifice. A probe passed down the fistula discovered rough bone, denuded of periosteum. Subcutaneous abscesses formed at the front of the arm, where the skin was thin and reddened. Examination by the X-rays showed a sequestrum, along with new bone formation. Chronic osteomyelitis of the diaphysis of the humerus was diagnosed. An incision was made down to the bone in the lower third of the outer side of the arm, avoiding the radial nerve. The periosteum was de- stroyed at one place and a hole was found leading to a sequestrum,^ which was removed by carefully chiselling the bone ; the cavity was scraped and plugged, and the fistulous track with its hardened walls excised. The subcutaneous abscesses were opened and scraped. The arm was immobilized for a long time. Healing took place after some months, and the patient was told to choose a lighter occupation in. order to avoid recurrence of the disease. Fig. 107 shows acute osteomyelitis of the tibia in a child, aged 9 years, which began with severe pain in the leg and knee joint, accompanied by high fever and chills. There was no history of a previous attack. A few days before, the child had received a blow on the tibia. In spite of the severe clinical symptoms and the marked swelling of the knee-joint, operative treatment had been neglected, and an incision was made only when a subcutaneous abscess devel- oped. Although the acute symptoms subsided after this, the swelling^ in the leg persisted and the wound discharged fetid pus. In a few months almost the whole shaft of the tibia became necrosed. In Fig. 107 the yellow, dead bone and the open medullary cavity with slimy gTanulations are clearly seen. Between the necrosed and the healthy bone are granulation tissue and pus. As the leg had not been properly fixed, a fracture occurred at the lower part of the tibia. The general condition was poor. The X-rays showed that the seques- trum extended further down and that a thick, bony capsule had already formed behind and at the side. The wound was enlarged downward, the necrosed bone removed,, the cavity scraped and packed, and the leg immobilized in correct position on a splint. Such extensive necrosis could have been avoided by early chisel- ling of the bone and proper after-treatment. 156 Bockenheimcr, Atlas. Tab. LX.XXV. Pie. 10/. Osteoinvelitis tibiae — Necrosis totalis. Rcbman Comp.iiiy, Ncw-N'ork. Bockenheimer, Atlas. Tab. LXXXVI. Fig-. 108. Infectio peneralisata. Rebman Conipan}^ New- York. Fig. 108 shdws ;i metastatic abscess of the thigh, one of several developed in the course of an acute generalized infection arising from a subcutaneous whitlow, whicli was insuflieieutly incised and drained, and which spread to the adjoining tendon-sheath and joint. The temperature rose to 106° F., with chills; it remained high for a few days and. then became remittent during the formation of several metastatic abscesses, whidi i-e(|iiire(l incision aiid contained tliin pus with but few staphylococci. There also were other general symptoms: dry tongue, jaundice, subdelirium and diarrhea. The wound in the finger was dry and un- healthy: the finger was exarticulated, and it is noteworthy that bac- teria which had been found in the blood prior to this operation were after it no longer detected therein : a direct proof of the origin of the virulent microorganisms, confirmed, besides, by the improvement in the general condition and the checking of further local inflammation. Under the influence of stimulating treatment and repeated saline in- jections recovery took place in a few months: but for a long time afterward the pulse remained rapid. In every ])yogenic condition there is a slight degree of general infection: even in apparentlj' benign and localized lesions such as furuncle, staphylococci may be found in the blood. This explains the occasional occurrence of osteomyelitis after such affections, and the often existing disproportion between the local inflammation and the general imiiairment of health. So that, strictly speaking, there is no really localized infection: but the general involvement is usually not sufficient to be recognized clinically. All pyogenic microorganisms may l)e the source of a general in- fection: pneumococcus, Ehertli bacillus, colon bacillus, staplnilococ- CHS and streptococcus. From the surgical standpoint the last two are by far the most important. Among putrefactive bacteria, the proteus vulgaris is the one most frequently at fault: it causes a special type of sepsis, but it is seldom alone: it generally is associated with the staphj'lococcus or strei)tococcus. It would lie very interesting to lie able to distinguisli in general infection what is due to the bacteria themselves and what is due to their toxins. There is always simultaneous bacteriemia and toxi- neniia; but toxins are not easy to detect in the blood owing to the tendency they have to become combined with organic protective substances. 157 The part played by the blood in general infection is pre- ponderant; dissemination takes place by small bacterial emboli (this must be distinguished from propagation by purulent thrombi in suppurative phlebitis) ; but we now begin to appreciate that the lymph stream also often has an important role, and that many metas- tatic deposits, formerly unhesitatingly labelled hematogenous are really lymphogenous in origin. The more rapidly virulent bacteria invade the blood, the more severe the symptoms. In very grave cases, the temperature rises to 104° or 107° ; such cases generally cause death in a few days with- out clinically appreciable metastatic abscesses. But this does not necessarily mean that there are no anatomical metastases; indeed, small foci are frequently found post mortem, especially in the kidney. There is even a form of general infection, well studied by Brewer, Cotton, Cunningham, in which small miliary abscesses in a kidney are the only anatomical lesions of a general sepsis that usually proves fatal unless nephrectomy is hastily performed. In less severe forms, the thermic ascension becomes intermittent after the initial high ascension; maybe because microbes enter the blood only inter- mittently, or because there are fewer of them. When the body de- fenders conquer the bacteria and their toxins, and sufficient anti- bodies have been formed, the temperature falls. When the invaders gain the upper hand, the temperature rises. If the outcome is going to be fatal, the longer the process goes on the more frequent are the chills and the shorter are the intermissions, so that finally a stage of continuous high fever is reached, as in those cases, already referred to, where no remissions occur from the outset. But, if the organism is victorious, the infection expands its energy in the formation of metastatic abscesses in those parts of the body which are specially adapted to absorb bacteria, render them harm- less, and finally destroy them (subcutaneous tissue, serous cavities, peritoneum, pleura, joints). Staphylococcic general infection has a marked tendency to cause metastatic abscesses (95% of cases), while the initial focus is circum- scribed. Streptococcic infections, on the contrary, as a rule have no localized initial focus, and in their spread keep the same character of diffuse processes, as they hardly ever cause metastatic abscesses. Streptococcic infections are more regularly fatal than staphylococcic, precisely on account of that same character. The rare cases of streptococcic general infection that end in recovery are those which lead to the formation of pus collections. 158 Clinically, ^oiicral iiirccliun i.s urdiiiarily acute, rarely chronic. Acute general infection may be i)rimary or secondary, mild or severe. The severity depends on the number and virulence of the invading niicrol)es, and on the defensive power of the body. The severest forms develop so (|uickly after the local infection that the latter remains in the background; the portal of entry may even be unrecognized and the general infection seem spontaneous; this must occur most fre- quently after lesions of the internal mucous membranes. Severe forms are fre(juently seen in i)hysicians who prick their fingers dur- ing an operation or an autopsy (streptococcus) : they also result from infection by putrefactive bacteria (proteus) or a symbiosis; both these kinds of microorganisms. In the great majority of cases, however, general sepsis is of grad- ual onset, and arises from a local primarj' focus; but it has often reached an advanced stage before it is recognized. It may occur after a progressive extension of the suppuration in the primary focus, but also may arise ivithoid further extension of the latter, a fact of prime importance, always to be borne in mind. In the hyperacute forms, the symptoms appear suddenly, while, in milder cases, there is a premonitory stage with general disturb- ances (insomnia, loss of appetite, headache, pain at the seat of infec- tion). A frequent small pulse points to the onset of general infection, even before the great thermic ascension. This occurs suddenly (102° to 106°) with chills. As already stated (see page 158), the fever may remain continuous (hyperacute cases) or become inter- mittent or remittent, to become again continuous in cases tending toward a fatal outcome, or to subside in those terminating in recov- ery. All varieties in the temperatui-e chart may be seen. Every fresh infection of the blood is heralded in by a rise of teniiierature. For example, after an extremity has been amputated for progressive suppuration, the tenqierature falls; but it may rise again after a time, showing that the organism was already saturated with bacteria and their toxins and that the operation came too late to save life. However, under those restrictions, a fall in tem[)erature after ex- tensive surgical interference is always a hopeful sign. Hypothermia, sometimes observed in very severe cases, is a very grave omen, as it indicates the utter collapse of the organism and complete toxemia. It is noteworthy that the pulse in remittent fever remains small and raj)id during and after the fall of temjierature, and during con- vale.scence. This shows how mucli llu' heart is affected in general sepsis, even in curable foi-ms. 159 The respiration is rapid and shallow: it may become stertorous when coma sets in, near the end, in severe cases. The tongue in general infection shows characteristic changes ; at tirst smooth, dry, salmon colored, it later becomes rough, fissured and brownish black. In severe cases the teeth also are dry and coated with sordes. The conjunctives are yellow, and in severe cases the jaundice (hematogenous icterus) may be general. There is profuse sweating and uncjuenchable thirst. These symptoms are the only ones in case of general sepsis of internal origin (e.g. after pylephlebitis), but when the portal of entry is a preexisting suppurating wound, the latter exhibits local changes, the appearance of which is fairly characteristic : the wound becomes painful and edematous; the granulations look unhealthy and flabby; the discharge of pus is much lessened and replaced by a scanty, dirty, often fetid secretion; the surface of the wound becomes dry and often covered by a diphtheroid membrane (Fig. 101). Pns reten- tion, necrosis, extension of suppuration, lymphangitis and adenitis are often concomitant signs. In infection by putrefactive bacteria (Fig. 109) there are bullae in the infiltrated skin and crepitation due to the formation of gas, and bubbles of gas in the secretion. In order not to overlook these signs, suspicious wounds must be fre- quently dressed. Another frequent sign, more common in advanced stages, is septic secondary hemorrhage in the wound, one of the most dreaded scourges of preantiseptic surgery, and which is due to vas- cular degeneration. The gastro-intestinal canal is severely affected: there may be hematemesis, bilious vomiting and uncontrollable diarrhea. The skin is pale and cold and may present various types of erythema, scarlatiniform, morbilliform, erysipelatous, or vesicular eruptions and purpura. Almost all the internal organs are saturated with bacteria and their toxins. Hence the nephritis (evidenced by albu- minuria and casts), the meningitis, pleuritis, pericarditis and endo- carditis that are seen- so frequently. Nephritis is even constant. The spleen is enlarged, and so may be the thyroid gland. In the advanced stages, the patients become subdelirious, then delirious, finally, and generally, unconscious. Just before the end, if not comatose, the patient may have maniacal excitation followed by collapse. In streptococcic general infection, there is nearly always suppu- ration in the joints : in staphylococcic, in the bones. Bacterial emboli carried to the capillaries can and do disseminate the infection to all ,160 organs of tlio limly (particiiljirly the luiig-.s, liver, lioart and kidiiej-s). Embolus ol' tlie ceiilral arlcry of the retina causes i)ano|)lillialinia. Even if the involvement of the central organs escapes clinical de- tection at first, overshadowed as it is by the more noisy and tlireat- ening signs of generalized infection, it may become prominent after- ward, after an apparent cure, and residual foci of old septicemise, long quiescent, arc fi'cqiifiiily the cause of grave trouble subsequently (supimrativc nephritis, ciiddcarditis, ])l(Mirisy, or pneumonia). Multiple metastatic abscesses, as already said, are much more frequent in staphylococcic infectious: they may remain cold and painless and (•inilaiii hut few haetoria, as was the case in the abscess shown in Fig. 108. The chronic forms of sepsis, which occur after long-standing fistula;, suppuration and necrosis (particularly osteomyelitis) are characterized by their gradual development and mild symptoms. Many cases, however, are fatal from heart failure or albuminuria {amyloid degeneration), or a chronic form may become acute. In chronic cases, the remission periods are long, and metastatic abscesses are tlie rule. Recovery may take place after removal of the primary cause, Init convalescence is very slow. Prognosis It depends on the general condition of the subject. Young and robust individuals may survive acute forms; older, weakened, dia- betic subjects do not, barring exceptions. It depends also on the nature of the infecting host. Streptococcic infections are the most redoubtable of all: staphylococcic infections are more likely to end in recovery. Pneumococcie infections are the mildest of all. It clinically depends on the type of the disease: hyperacute eases, with continued fever, are always fatal ; subacute remittent cases, with abscess formation, are less serious; chronic cases recover, unless so much time is wasted before the necessary surgical interfer- ence that irretrievable damage is done to the internal viscera. Abscess formation is always a hopeful sign; so is generally a decrease of the number of bacteria circulating in the blood, with this qualification, that in some cases such a decrease is followed by an increase in the clinical severity of the toxic symptoms. Always remember, after recovery, the possible existence of en- capsulated metastatic foci or inconii>lotoly healed septic infarcts. liU Diagnosis The clinical picture of general infection, though many-sided, does not generally leave room for doubt, especially if there is a known primary focus. Direct demonstration of the bacteria in the blood, by blood culture, clinches the diagnosis. Streptococci are more easily demonstrated in the blood than staphylococci. Blood cultures, and the different agglutination reactions, estab- lish the nature of the infection, and differentiate typhoid fever, pneu- monia, miliary tuberculosis, all diseases which closely resemble gen- eral infection, because, in fact, they are general infections, but caused by .other microbes than those at fault in the two great ty^ses of sur- gical sepsis. Acute rlieum,atism is soon recognized by its exclusively articular involvement, and its changeable localizations. Severe erysipelas may somewhat resemble general infection: sometimes the diagnosis is only a distinction without much differ- ence, because there is often general infection in those severe cases. Everything that promotes the strength of the body is indicated (nourishing diet, tonics), as is the stimulation of faltering organs (caffeine, strychnia). Saline infusions restore tone to the circula- tory system and effectively help in the elimination of toxins. No antipyretics should be given, as they are useless, and simply depress the heart. The high temperature is best reduced by tepid or cool sponging. Locally, if there be a wound, frec[uent dressings are necessary: no antiseptics should be used. Hot wet dressings induce active hyperemia of the part. Alcohol or ether dressings have been sometimes very efficient in grave infections of the limbs. All retention of pus should be sup- pressed. In iDrogressive infection of the limbs amputation should not be too long delayed. In impending general infection from thrombo-phlebitis, ligation, or even excision, of the veins should be resorted to (see page 123). Metastatic abscesses must be opened early, according to the rules governing incisions of abscesses in the region where they are situ- ated. Joint resection is often necessary. The serum treatment of general sepsis has been considerably improved during recent years. However, the results are not always 162 Bockenheimer, Atlas. Tab. LXXXVII. Rebman Company, New- York. as sntisfnotory ;is ooul