^ THE ff, O LIBRARIES ^ u Health sciences LIBRARY Digitized by tine Internet Arcinive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/sciencepracticeo01gant ''m. .rai,: ^^fS^PV'^" e;A^^'?'^''^S'R^'f<; ^mm f^W/vB^^AMlUKiMKJuvl^l '^'^Y^H '/^.^ra.''?;.. THE SCIENCE AND PRACTICE OF SURGEEY. " The greatest error of all the rest is the mistaking or misplacing of the last or furthest end of knowledge : for men have entered into a desire of learning and knowledge, sometimes, upon a natural curiosity and inquisitive appetite ; sometimes to entertain their minds with variety and delight ; some- times for ornament and reputation ; sometimes to enable them to victory of art and contradiction ; and most times for lucre and profession ; and seldom sincerely to give a true account of their gift of reason to the benefit and use of men : as if there were sought in knowledge, a couch whereupon to rest a searching and restless spirit, and a terrace for a wandering and variable mind to walk up and down with a fair prospect ; or a tower of state for a proud mind to raise itself upon ; or a fort or commanding ground for strife and con- tention ; or a shop for profit and sale ; and not a rich storehouse for the glory of the Creator, and the relief of man's estate." — Francis Bacon. THE SCIENCE AND PRACTICE OF SURGERY WITH ONE THOUSAND AND NINETY ILLUSTRATIONS ON WOOD, MOSTLY NEW AND ORIGINAL. FREDERICK JAMES GANT, E.R.C.S. SENIOR SIJEGEON TO THE EOTAL FEEE HOSPITAL. LATE PRESIDENT OF THE MEDICAL SOCIEl'Y OF LONDON. FORMERLY STAFF CIVIL SURGEON TO HER MAJESTY'S MILITARY HOSPITALS, CRIMEA AND SCUTARI. AUTHOE OF "THE PRINCIPLES OF SUEGEKT : CLIITTCAL, MEDICAL, AND OPERATIVE." THIRD EDITION. REVISED, AND MUCH ENLAEGED THROUGHOUT. VOL. I. LONDON : BAILLIERE, TINDALL, AND COX, 20, KING WILLIAM STREET, STRAND. [PARIS: BAILLIERE. MADRID: BAILLY-BAILLIERE.] 1886. a/ PRINTED BV WILLIAM CLOWES AND SONS, LIMITED, LONDON AND BECCLES. PREFACE TO THE THIED EDITION. The favourable receplioil of the previous edition, in this country, in America, and India, has induced me to spare no effort that may render a Third Edition more worthy of the position which this work has hitherto held in the judgment of the Profession. Pursuing the original design I had in view, I have endea- voured to produce a more correct and complete representation of Surgery, in its widest acceptation ; and as based upon a sound and enlarged exposition of Pathology — supported by the appli- cations of Anatomy and Physiology. The arrangement of the work, which is simple and compre- hensive, remains unchanged. The Introduction presents an ele- mentary exposition of Modern Surgery, as a Science and an Art. Then follows the Primary Division into General and Special Patho- logy : the one comprising Diseases of Nutrition, of the Blood, and of the Nervous System ; the other being a Histological associa- tion of Diseases and Injuries, as affecting Textures and Textural Systems ; and Topographical, as pertaining to Organs and Regions. Beginning with the Head, and proceeding downwards in the Body, this latter subdivision includes every branch of Surgical Practice. But each chapter bears the fruit of careful revision, and of renovation from numerous additional sources of original observa- tion, including my own further experience. The primary importance of Diagnosis, in relation to the treat- ment of the various forms of Injury and Disease, has induced me to notice more particularly their differential characters, especially VI PREFACE TO THE THIRD EDITION. with regard to conditions which are seemingly alike ; and the variations to which the same disease is subject, in its course and terminations, will further indicate the diagnosis under these circumstances of apparent differentiation. In connection with Treatment ; the conditions — local and constitutional, which should determine operative interference, and guide the Surgeon in the choice of alternative procedures, or in the adaptation of methods to circumstances, and the resources of experience for encountering the difficulties, or the accidents, which may be met with in performing operations, have aliki; undergone mature reconsideration. Careful attention also has been given to the particulars which should be observed in the various manipulative procedures of Surgery, and in the applica- tion of Apparatus, so conducive as these details are to a successful issue in many cases. The chapters relating to Surgical Anatomy have been extended. A descriptive view of the Arteries, in their normal and abnormal distribution, conveys that kind of practical knowledge which the Student must carry with him in following the Opera- tions for Ligature, with reference to Aneurisms especially, where- in the guidance of Anatomy is more essential. Such knowledge, at hand, will further enable the Surgical Practitioner to modify the usual operations as occasion may require, in their application to different portions of the Arterial System, and to anticipate varieties which may be found in the normal distribution of the Arteries. So also the Anatomy of the Bladder, Prostate Gland, and Urethra, as described from a Surgical point of view, has numerous practical' bearings ; whether in the clinical examina- tion of these organs, or in guiding the hands of the Practitioner when performing any of the various precise operations which pertain to Urinary Surgery. Nearly all along the line of Pathology, inspection will dis- cover some positive advance in the frontier of the Science, and not unfrequently corresponding achievements in the Art of Surgery — supplemented by the further teachings of experience. New and important Surgical operations are thus fully described, both with regard to their design and performance. Some subjects have been dwelt upon more fully, and treated at greater length, in this edition, according to their more recent development in Surgery. The chapters which have thus ac- quired a not unduly prominent position, relate chiefly to Inflam- PREFACE TO THE THIRD EDITION. Vll mation; Tumours, as including the Sarcomata; WoudcIs, and Antiseptic Treatment ; Neuro-patliology and Surgery ; Aneu- risms, and the Ligature of Arteries ; Diseases of Bones, and of the Joints ; Excisional Surgery, and Osteotomy ; Injuries of the Head, and Brain-Surgery ; Diseases of the Breast ; Abdominal Surgery, including Intestinal Obstruction ; Surgical Diseases of the Kidneys ; and Diseases of the Genito-Urinary Organs. The special section on Antiseptic Surgery comprises a review of its principles, practice, and results,— with regard to Wound- treatment and Operations, and in Hospitals, British and Foreign ; the claims of Antiseptic measures are also discussed, and illus- trated, as compared with the preseptic influence of Hygienic conditions ; but for an authoritative expression of the Germ- theory, and description of the various forms of Micro-organisms, with their relation to the production of Septic and other Diseases — under the title of " Bacteria in Surgery," I am indebted to Mr. Watson Cheyne, of King's College Hospital. Abdominal operations for the cure or relief of otherwise incurable diseases of the Viscera, and of the Kidneys, constitute two entirely new chapters in this edition, and have received that large share of attention which may be commensurate with their practical importance, and as viewed in the light of Modern Surgery. In connection with Diseases of the Genito-Urinary Organs, Urinary Diseases, Deposits, and Calculi, with their Treatment, constitute a somewhat special feature in this work on Surgery. Cystotomy, as practised under various conditions, and the removal of Vesical Tumours, have been ranked among the ac- knowledged resources of operative interference, in the treatment of Diseases of the Bladder ; and the whole subject of Stone in the Bladder, Lithotomy, and Lithotrity, has, I hope, been placed abreast of recent progress in this department of Surgical Practice. My object has been to introduce into this edition a concise account of all those changes and additions which have gained an important and established position, whether in the Science or in the Practice of Surgery ; including, therefore, whatever will place the Surgeon on the vantage-ground of real progress in the knowledge of both. Change alone is not always advancement in knowledge of any kind. Surveying the vast yearly accumula- tion of lore in the Mart of Surgical Science and Art, we must not be allured too readily by the tempting solicitation of the vendor VIU PREFACE TO THE THIRD EDITION. Avho, like the magician in the Oriental tale, offers "new lamps for old," seeing that the newest thing is not always the truest thing in the history of Surgery. But the Author of a System of Surgery should be more than an Historian of things, both old and new. His Avork should be a continued expression of a calm and critical judgment, in the selection of that which shall be appropriate for a full and clear exposition of whatever subject he may be describing or discussing; in determining also the relative merits of evidence, and in the solution of various debatable questions, the same judicial dis- crimination must be exercised ; and generally in exhibiting a reliable and usefully complete view of the present state of Surgery. However imperfectl}'' this ideal may have been realized, I trust that the original observations and experience gathered from the labours of others, among British, American, and Foreign confreres, are duly acknowledged throughout the Work. As in the former edition, the chapters on " Diseases of the Eye," the " Ear," and the '' Teeth," have been undertaken respec- tively by Mr. Henry Power, Senior Ophthalmic Surgeon to St. Bartholomew's Hospital ; Mr. W. Laidlaw Purves, Aural Surgeon to Guy's Hospital ; and Mr. Charles S. Tomes, F.R.S., Examiner in Dental Surgery to the Royal College of Surgeons. "Diseases of the Throat and Larynx " are again represented by the large experience of Dr. Morell Mackenzie ; and in like manner Mr, William Adams has dealt with " Deformities." The chapter on " Diseases of the Skin," which, in the previous edition was contributed by the late Sir Erasmus Wilson, F.R.S., has been entirely rewritten, in accordance with modern pathology and therapeutics, by Mr. Malcolm A. Morris, Surgeon to the depart- ment of Dermatology in St. Mary's Hospital. The concluding chapter, on " Diseases of the Female Genital Organs," has been renovated by the more important advancements in this department of special experience ; Dr. Robert Barnes having thus again contributed his valuable aid. Lastly, I must not omit to mention the kindly assistance I have received from my colleague, Mr. William Rose, by his revision of " Cleft Palate and its Treatment." A special description of the " Sphygniograph "and its applica- tions to various clinical investigations in the hands of the late lamented Dr. Mahomed, remains intact. All these valuable contributions, although amounting to only two hundred and thirtj^-three pages of the whole Work, cannot PKEFACE TO THE THIED EDITION. IX fail to render it a more complete expression of British Surgery, and more generally useful. One hundred and twenty-one new wood engravings have been introduced, chiefly of a clinical or of an operative character, and selected for the most part from cases in my own practice, making a total of one thousand and ninety illustrations, the great majority of which are peculiar to this work. Of eight hundred and forty -nine new engravings in the previous edition, the greater proportion of the pathological series were selected, by permission, from the rich collections in the Royal College of Surgeons, and most of the Metropolitan Hospital Schools, with not a few from the Royal Free Hospital, gathered from the large assortment of cases which, in the course of more than thirty years, have passed through my hands, as Surgeon to that Hospital. The renovation of the Text throughout has involved a not inconsiderable extension of both volumes, jointly to the amount of four hundred and seventy-one pages, but commensurate only with Surgery in its present acceptation. Unrestricted by any conventional limitations with regard to the Science and the Art, this work may be thus better fitted for the guidance of the Surgeon, and under the varied circumstances experienced in the course of practice ; but these professional requirements will also best fulfil the true educational wants of the Student in Surgery, by supplying an adequate course of preparation for the duties and responsibilities he must undertake as a Surgical Practitioner, and which will enable him to give a reason for the faith that is in him. It will be his special privilege to enjoy the luxury of practising a beneficent Art, which strikes its roots deep into the Sciences of Pathology, Anatomy, and Physiology, and which thus gives the Surgeon an intelligible, and often a positive, assurance that he can follow his profession with success. FREDERICK JAMES GANT. London, February, 1886. CONTENTS OF VOL. I. INTRODUCTION. Modern Surgery as a Science and a Scientilic Art. A primary division of Medi- cine. Pathology, and the intimate relations of Anatomy and Physiology, Biology, Physics, and Chemistry. The relative importance of Diagnosis — its Methods, Physical, Stractural, Chemical, and as connected with Pathological Anatomy by Post-mortem Examination ; Etiology ; Prognosis, and Modes of Dying. Their relation, severally, to Treatment ; General Indications. Re- parative or Eestorative Power ; and its Operation in the Organism. Conser- vative Surgery, and Medicine. Plastic Surgery. Pathology in the plan and performance of Surgical Operations. Conditions Favourable and Unfavourable for Operation. Pathological Condi- tions; constitutional and local. Hygienic Conditions : Diet; Ventilation and Sunlight; Atmospheric Space in Wards of Hospitals, Civil and Military; Drainage; Prevention of Contagion or Infection; Antisepticism. Preparation of Patient for Operation. Arrangements — The Room, Table, Instruments, Assistants. Anaesthetics — Historical notice. Chloroform — its Physiological Action. Phenomena or Symptoms. Contra-indications to the employment of Chloroform, and exceptional Operations. Administration of Chloroform, and signs of Ansesthesia. Inhalers. Death from Chloroform — by Asphyxia, Car- diac Syncope, Coma, persistent Sickness. Treatment of an overdose. Sulphuric Ether. Other Anaesthetics — Nitrous Oxide or Laughing Gas ; Ethidene Dichloride ; Bichloride of Methylene ; Chloral. Local Anaesthesia. Freezing — by frigorific mixtures, ether-spray. Dangers attending, or consequent on, Surgical Operations. Dressing of the Wound, and Constitutional After-treat- ment. Results of Operation — Temporally, Permanent. Modes of Unsuccessful Results. Statistics in Surgery. PABT I. GENERAL PATHOLOGY AND SURGERY. DISEASES OF NUTRITION. PAGE Chapter I. — Inflammation. Nutrition . . . . • ' • . . .48 Growth and Development ...... 49 Hypertrophy and Atrophy. Repair . . . . .51 luflammatiou • . . . . . • 52 Xll CONTENTS. r.VFi,AMMATiON' — continued. Textural Changes, and State of the Circulation aiirl Blood -Vessel Signs ...... Redness, Heat, Swelling, Pain, and tlicir Patliolocry . Relative Diagnostic- Valao .... Functional Symptoms ..... Constitutional Symptoms — Inflammatory Fever , Temperature ...... I'nlse-tracings ..... Urine ....... Blood — Vital and Chemical Changes Pathology of Inflammatory Fever Causes ...... Exterual and Internal Exciting and Predisposing Operation of Inflammation — Local and Constitutu)iial Course and Terminations .... Resolution ...... Productive Course .... Products, and their Development. Consequences Pathology of Effusion — Pyogenesis Signs of Effusion .... Suppuration and Abscess . Fistula and Sinus . . . Hectic Fever. Pathology Destructive Course ... Ulceration .... Mortification ... Signs. Fever. Pathology Treatment ...... Local ...... Removal of Causes .... Removal of Pathological Conditions Constitutional Remedial Measures Of Inflammation in its Course and Terminations Varieties of Inflammation, and their Treatment 53 58 59 5!» 63 fi4 fi4 69 77 7s 82 84 85 85 87 88 88 88 89 95 100 100 104 106 109 110 111 112 113 114 114 115 120 133 142 Cri.Ai'TKK II. — TuMOuus OK MouBiD Gro-\vths. General Pathology . ..... 145 Vital, and Histological Characters ; relation to Embryology . 146 Etiology — Pathogeny or Genesis ; and in relation to Healthy Tissues 149 General Principles of Treatment ..... 150 Special Tumours . . . . . . .150 Cysts — Simple. Prolil'eroiis ..... 151 Cystic Tumours ...... 156 Connective-Tissue Tumours ..... 161 Fatty Tumoui' — Lipoma ..... 161 Fibro-cellnlar Tumour ..... 164 Painful Subcutaneous Tubercle. Neuroma . 165 Glioma. Myxoma. Lymphoma. Cylindroma. Psammoma 167 Fibrous Tumour . , . ... 168 Fibro-calcareous. Fibro-cystic . . . 170 Fibro-nucleated and Recurrent Fibroid Tumours . 170 CONTENTS. Xlll Tumours or Morbid Growths — continued. Cartilaginous Tumour — Encliondroma . . . 172 Fibro-cartilaginous. Ossific . . . 174 Myeloid, or Fibro-plastic Tumour . . . 174 Vascular or Erectile Tumours — Angioma . . 176 Nsevus — Telangeiectasis .... 179 Aneurism by Anastomosis . . . . 181 Osseous Tumours — Exostoses .... 182 Embryonic or Rudimentary Conuective'Tissue Tumours . 182 Sarcoma ....... 183 Round-celled . . . . . . 188 Spindle-celled . . . . . .189 Giant-celled ...... 190 Mixed-celled . . • . - . . 190 Plexiform ...... 191 Epithelial-celled Tumours . ■ . . . . 191 Glandular Tumours — Adenoma ■ . . . 191 Paiailloma' — Corns. Horns. Warts. Condyloma . . 192 Cancer . . ..... 192 Encepbaloid ...... 194 Varieties — Villous. Melanotic. Fungus Hsematodes 197 Scirrhus ....... 198 Varieties — Osteoid .... 198 Colloid— Varieties . . . . .199 Cyst-Formation ..... 199 Situations . . . • . .200 Causes . . . ■ • • 201 Effects of Cancer, Local and Constitutional . . 203 Co-existing Diseases .... 205 Course . . . . . . -206 Ulceration and Ulcer .... 207 Terminations . . . . . . 207 Recurrence, and Secondary Cancer . . . 209 Treatment . . . . • .210 Operations ...... 213 Epithelial Cancer . • • ■ • • • 215 Columnar-celled .... 222 Chapter III. — Degenerattons. General Pathology and Treatment Special Degenerations . Fatty . . . . Pigmentary Fibrous . . . . Amyloid . . . Granular . . . Calcareous . 224 225 225 234 235 236 238 239 Chapter IV. — Ulceration and Ulcers, Gangrene and MoRTiriCATioN. Ulceration . . . . . • . . . . 241 Healthy Ulcer . . . . . . . 245 Inflamed Ulcer ........ 247 Eczematous Ulcer . . . . . . • 248 I. h XIV CONTENTS. PAGE Ulceration and Ulceks, Gangrene and Mortification— cow tinued. Irritable Ulcer ...... . 248 CEdematous Ulcer ..... 249 Indolent and Varicose Ulcer . . . 249 Phagedaenic Ulcer . . 252 Hsemorrhagic Ulcer .... . 253 Scorbutic Ulcer ..... 253 Scrofulous or Strumous Ulcer . 254 Cancerous Ulcer ..... 255 Lupoid Ulcer ..... . 255 Eodent Ulcer ..... 256 Syphilitic Ulcer .... . 257 Gangrene and Mortification .... 257 Signs ...... . 257 Causes — External. Internal . . ; 259 Fever ...... . 266 Treatment ...... 268 Amputation .... . 269 DISEASES OF THE BLOOD. Chapter V. — Scrofula. Eelation to Tuberculosis Pathology of Tubercle . General Syniptoms . Special Forms . Causes . . . . Hygienic Conditions Treatment . . . . Scurvy and Purpura Cuaptee VI. — Eheumatisji and Gout. Rheumatism Symptoms and Diagnosis . Pathology Treatment . Gout. . . . . Symptoms and Diagnosis . Pathology , Treatment ; . 272 273 274 275 280 281 281 283 287 287 288 289 292 292 293 295 DISEASES OP CONTAGIOUS ORIGIN. Chapter VII. — Syphilis. Local Syphilis ..... Chancre, and its Diagnosis Chancroid, or Local Contagious Ulcer Diseased Conditions of Chancre and Chancroid Ulcer Bubo, and its Diagnosis , Syphilitic or Indurated Chancroidal . . . . ■ Constitutional or Secondary Syphilis . Skin-Diseases . . . . Eoseola ..... CONTENTS. XV Syphilis — continued. Lichen .... Tubercular Eruption . Lepra .... Psoriasis Vesicular Eruptions Pustular Eruptions Ulceration of the Skin Diseases of Mucous Membranes Ulceration of Tonsils Syphilitic Iritis Chronic Enlargement of Testicle Diseases of Bones, and Periosteum Tertiary Symptoms Congenital, Hereditary, or Infantile Syphilis Vaccine- Syphilitic Inoculation Diagnosis of Constitutional Syphilis . Blood-pathology of Syphilis Unity or Duality of Syphilitic Virus . Treatment ..... Local Syphilis Constitutional Syphilis . . Congenital, Hereditary, or Infantile Syphilis Syphilieation . Chaptek VIII. — Erysipelas. Simple Erysipelas . Phlegmonous Erysipelas Blood -pathology Causes . Infection External Predisposing . Prognosis Treatment . Erysipelas of New-born Infant Chapter IX. — Pyemia and Septicemia. Symptoms . . . . i Secondary Abscesses .... Septicaemia ...... Pathology ..... Suppurative Phlebitis ; Lymphatitis, Arteritis Thrombosisj and Eibrin Itifection . Leucocytosis ..... Germ Origin .... Septic Animal Matter .... Causes — Predisposing. Exciting Prognosis ...... Treatment . . . 311 311 311 312 312 312 313 313 314 315 315 316 317 319 322 328 323 324 326 326 331 337 338 340 342 346 346 346 349 351 351 352 354 355 357 358 359 359 363 363 364 365 366 367 367 Chapter X.— Hospital Gangrene. Signs . Origin and Coui'se 368 368 XVI CONTENTS. Hospital Gangrene — continu Causes .... Local and Constitutional Origin Infection and Contagion Treatment Chapter XI. — Poisoned Wounds. Hydrophobia Treatment . Snake-Bites .... Treatment . Insect-Bites Dissection-Wound Malignant Pustule — Charbon Treatment . Glanders .... Treatment . . ;57i 371 . 872 374 . 375 378 . 381 381 . 382 383 . 384 385 . 385 386 DISEASES OF THE NERVOUS SYSTEM. Chapter XII. — Shock, of Injurt. Symptoms and Diagnosis . Causes . . . • Terminations Inflammatory Traumatic Delii'ium- Nervous Traumatic Delirium Prognosis Treatment . . . . -Prostration with Excitement Chapter XIII. — Tetanus. Symptoms and Diagnosis . Varieties Pathology Causes .... Course, and Terminations . Prognosis Treatment Chapter XIV. — Delirium: Tremens. Symptoms . Pathology Causes Terminations Treatment Chapter XV. — Hysteria. Symptoms and Diagnosis Local Affections . Causes — Constitutional and Social Treatment 388 388 390 390 391 391 392 393 395 396 399 400 401 401 404 405 406 406 406 409 410 417 419 CONTENTS. PAET II. SPECIAL PATHOLOGY AND SURGERY. Division I. INJURIES AND DISEASES OF TEXTURES. SKIN AND SUBJACENT TEXTUEES. p. Chaptee XVI. — WoxjNBS — Incised Wound. Wounds of Aetoeies and Veins. Incised Wound ... ... Traumatic or Surgical Fever Eeparation ...... Immediate Union . . . . Primary Adhesion .... Suppurative Granulation and Cicatrization . Healing under a Scab .... Modelling Process .... Treatment ...... Antiseptic Wound-Treatment Antiseptic Dressings . . ... Theory of Antisepticism . . . ' Results ..... In Hospitals, British and Foreign Bacteria in Surgery .... Wounds of Arteries ..... Signs . . . . . Constitutional Symptoms of Haemorrhage — Eeaction Hsemorrhagic Diathesis— Hsemophilia . Eeparation ...... Modes in Various Forms of Wounds Treatment ...... Astringents ..... Cauterization ..... Compression ..... Ligatnre ..... Acupressure ..... Torsion . ..... Wounds of Veins ...... Constitutional Treatment of HEemorrhage, Arterial or Venons Transfusion of Blood .... Entrance of Air into Veins .... Chafiee XVII. — Contusion. Contused and Laceeated Wounds. Punctueed Wounds. Contusion ......... 485 Signs ........ 486 Course ......... 487 Treatment . , . , . , . , 487 . 421 422 . 422 423 . 423 427 . 428 428 . 428 438 . 437 443 . 445 445 . 454 462 . 463 463 . 464 466 . 466 468 . 469 469 . 469 470 , 474 477 . 478 IS 480 . 480 483 XVlll CONTENTS. Contusion, etc. — continued. Contused and Lacerated Woands . Characters ...... Gangrene — Traumatic. Inflammatory. Spreading Reparation . . . Secondary Inflammations Prognosis .... Treatment Ampntation Punctured Wounds . Characters .... Course .... Prognosis . . . . Ti-eatment Chapter XVIII. — Gunshot "Wounds. Structural Conditions Signs .... Projectiles .... Consequences . . Prognosis .... Treatment . Ampntation Excision Antiseptic Chapter XIX. — Morbid Cicatrices. Deficient Cicatrix ..... Excessive, and Exuberant — Cheloid Cicatrix . Depressed and Adherent Cicatrix . Painful Cicatrix ..... Ulceration — Growths and Desrenerations of Cicatrix 488 4«8 489 491 494 494 494 496 497 497 498 498 499 500 502 505 507 508 508 513 514 516 519 519 521 52L 522 Chapter XX. — Burns and Scalds. Burns and Scalds .... Characters .... Causes ..... Course and Terminations Prognosis .... Treatment .... Of Cicatrix Lightning .... Frost-bite ..... Chapter XXI. — Surgical Affections of the Textures. CeUnUtis ..... Symptoms and Diagnosis . Treatment .... Carbuncle or Anthrax Treatment .... Boil or Furunculus Delhi Boil ..... Chilblain .... Lightning, Frost-bite. Skin, and Subcutaneous 522 522 523 524 527 527 528 530 531 533 533 534 534 535 536 537 538 CONTENTS. XIX Surgical Affections of the Skin, etc. Whitlow or Paronychia , Onychia .... In-grown Toe-nail Corns .... Perforating Ulcer of Foot . Horns .... Warts .... Elephantiasis — Leprosy Elephantiasis Arabnm Tubercular Disease of Foot Fungus Foot — Mycetoma Guinea-Worm -continued. 539 540 541 541 542 543 543 544 546 548 550 552 MUSCLES AND TENDONS, Chapter XXII. — Sprain. Eupture. Myositis. Myalgia. Tumours. Sprains or Strains .... ... 553 Eupture of Muscle and Tendon ..... 553 Eeparation .... ... 554 Treatment ........ 555 Displacement of Tendon ....... 556 Hernia of Muscle ..... , . . 556 Inflammation of Muscle . . . . . . .557 Myalgia ......... 558 Tumours ...... .... 558 BUES^ AND SHEATHS OF TENDONS. Chapter XXIII. — Inflammation. Ganglion. Inflammation of Bursse — Bursitis .... Of Bursse Patellae ..... Of Bursse in other Situations ..... Bunion ....... Teno-synovitis — Acute and Chronic Ganglion ....... 560 561 561 562 563 564 NEEVES. Chapter XXIV. — Injuries. Neuritis. Neuralgia. Injuries ........ Nerve-suturing .... Consequences .... Neuritis ...... Neuralgia ...... Sym' toms and Diagnosis . Causes ...... Treatment ..... Operations — ^Neurotomy and Neurectomy Nerve - stre tching On Particular Nerves Symptomatic Painful Nervous Affections Tumours 566 567 569 569 570 570 571 572 572 574 575 578 581 XX CONTENTS. ARTEKIES. Chapteu XXV. — Aneurisit. Structural Conditions Circumscribed — True Aneurism Diffused— False Aneurism Fusiform or Tubular Aneurism Dissecting Aneurism . Signs ..... Diagnosis .... Causes . Course .... Terminations .... Spontaneous Cure — Modes Prognosis .... Treatment .... Rest ..... Compression Modes .... Ligature Modes .... Consequences — Treatment Manipulation Distal Compression, or Ligature Galvano-puncture . Injection Amputation Treatment of Traumatic Aneurism Aneurismal Vaiix and Varicose Aneurism Signs .... Causes . . Treatment 582 582 582 583 583 584 585 58G 588 589 589 593 593 593 595 595 599 600 G02 607 608 609 610 611 611 613 613 614 615 Chapter XXVI. — Aneurism of Special Arteries. Ai"ch of Aorta ....'.... 616 Symptoms ........ 616 Diagnosis ........ 618 Treatment ........ 619 Aneurisms at Eoot of Neck ...... 619 Diagnosis .... .... 619 Spbygmographic Tracings of Pulse ..... 622 Treatment . . . . . . . .624 Innominate Aneurism . . . . . . 624 Aneurisms of Eight Carotid and Subclavian Arteries . 628 Carotid Aneurism ....... 628 Subclavian Aneurism ...... 628 Aneurism of Carotid Artery ...... 629 Wounds and Traumatic Aneurism .... 632 Aneurismal Varix ....... 632 Aneurism of Internal Carotid ...... 633 Extra-cranial ........ 633 Intra-cranial ....... 633 Wounds, and Traumatic Aneurism, of Internal or External Carotids 636 Aneurism of Subclavian Artery ..... 636 CONTENTS. XXI Aneurism of Special Arteries — continued. Wounds and Traumatic Aneurism Aneurismal Varix ...... Aneurism of Axillary Artery .... Wounds and Ti'aumatic Aneurism . = Aneurism of Brachial, Eadial, and Ulnar Arteries Wounds and Traumatic Aneurism Aneurismal Varix, and Varicose Aneurism Aneurism of Abdominal Aorta ..... Aneurisms of Iliac Arteries — Common, Internal, and External Aneurismal Varix . . .... Aneurisms of Gluteal, Sciatic, and Pudic Arteries Wounds, and Traumatic Aneurism, of Gluteal Artery Aneurism of Common Femoral Artery . . Wounds and Traumatic Aneurism .... Aneurismal Varix, and Varicose Aneurism Aneurism of Femoral Ai-tery — Deep and Supei'ficial Femorals Wounds and Traumatic Aneurism Aneurismal Varix, and Varicose Aneurism Aneurism of Poijliteal Artery .... Wounds and Traumatic Aneurism Aneurisms of Tibial Arteries — Anterior and Posterior Wounds and Traumatic Aneurism Aneurismal V^arix, and Varicose Aneurism •. 640 640 640 642 643 643 644 644 644 646 647 648 648 650 651 651 ' 654 654 654 658 659 659 659 Chapter XXVII. — Ligature of Arteries. Ligature of an Artery in its continuity Ligature of an Artery at the seat of Wound Ligature of Innominate Artery Surgical Anatomy . Varieties ... . , Operation .... Ligature of the Common Carotid Artery . Surgical Anatomy . . . , Varieties .... Opei-ation .... Collateral Circulation Ligature of tlie External and Internal Carotid Arteries Surgical Anatomy . ... . . . Varieties . . . ... . . _ Operation . Ligature of the Lingual Artery ..,.,. Surgical Anatomy ....... Varieties . . . . , - Operation . . . ..... Ligature of the Superior Thyroid, Facial^. Temporal, Internal Maxillary, and Occipital Arteries .... . . . Ligature of the Subclavian Artery ...... Surgical Anatomy . . ..... Varieties . . . . , . . , Operation . . . ... Collateral Circulation . Ligature of the Vertebral Artery . . 660 662 663 663 663 664 665 665 666 666 667 667 667 668 668 669 669 669 669 669 670 670 673 674 675 675 xxn CONTENTS. Ligature of Arteries — continued. Ligature of the Internal Mammary Artery- Ligature of the Axillary Artery Surgical Auatomy Varieties . Operation . . , . Collateral Circulation . Ligature of the Brachial Artery Surgical Anatomy . Varieties , Operation .... Collateral Cii'culation Ligature of the Eadial Artery . Surgical Anatomy Varieties Operation Ligature of the Ulnar Artery . Surgical Anatomy Varieties Operation Collateral Circulation . Ligature of the Abdominal Aorta, and of Iliac Arteries — Common, Ex- ternal, and Internal . Surgical Anatomy . Varieties . Operation — External Iliac . Collateral Circulation ,, Internal Iliac . J, Common Iliac Collateral Circulation „ Abdominal Aorta . Ligature of the Femoral Artery— Common and Superficial Surgical Anatomy Varieties Operation — Common Femoral Artery Collateral Circulation „ Superficial Femoral Artery Collateral Circulation . Ligature, of tbe Popliteal Artery . Surgical Anatomy . Varieties . . . • Operation .... Ligature of the Anterior Tibial Artery Surgical Anatomy . Varieties . , . . Operation .... Ligature of the Posterior Tibial Artery Surgical Anatomy . Varieties .... Operation .... Peroneal Artery , CONTENTS. XXlll Chaptee XXVIII. — Diseases of Aeteeies. Arteritis ....... . 706 Symptoms ....,, 706 Terminations ...... . 707 Treatment . . . . ... 707 Degenerations ...... . 707 Cartilaginous — Acute Endarteritis 708 Atheromatous — Chronic Endarteritis . . 708 Ossification ...... 710 Senile Gangrene . . . . . . 713 Symptoms ...... 713 Treatment . . . ... . 714 VEINS. Chaptee XXIX. — Injuries. Vaeicose Veins. Phlebitis. Varicose Veins or Varix , . . . . . 716 Operations ...... 719 Phlebitis . . . . , . 720 Symptoms ...... 720 Terminations ...... . 721 Treatment ...... 721 Thrombus ...... . 722 Transformations . . , . 725 Embolism . . . . ■ . . 725 Phleboliths or Vein- Stones .... 729 LYMPHATICS AND GLANDS. C HAPTEE XXX. — Lymphatitis. Tumours. Lymphatitis — Inflammation of the Lymphatics Symptoms ..... Diagnosis ..... Treatment ..... Adenitis — Inflammation of the Lymphatic Glands Varicose Lymphatics .... Enlargements and Tumours — Lymphoma . 729 729 730 731 731 732 732 BONES. Chapter XXXI. — Fractuees. Fracture ....... . 735 Structural Conditions ..... 735 Signs . . , . , . 736 Diagnosis ....... 737 Causes . . • . . 738 Reparation . ...... 739 Treatment ...... . 743 Compound Fracture ...... 750 Structural Condition, and Diagnostic Characters . 750 Course ....... 751 Reparation . . . . . . 751 Prognosis ....... 753 Treatment . . . . . . 753 Amputation . . . 756 XXIV CONTENTS. FuACi'UHKs — continued. Complicated Fractures ..... Treatment ...... Diseased Callus, and Deformed Union Treatment ...... Operations . . . . Ununited Fracture, and False Joint. Disunited Fracture Treatment ...... Operations . . . . . 759 760 7G0 7G1 762 762 765 766 Chapter XXXII. — Specul Fractukes. Fractures of the Facial Bones „ „ Nasal Bones . Septum Narium . Malar Bone Zygoma . . . Upper Jaw- Lower Jaw Hyoid Bone . . . Eibs, and Costal Cartilages Stei-num Clavicle . . , Scapula Humerus . Intra-capsnlar Extra-capsular Great Tuberosity . Compound, of Upper End Ulna — Processes Compound, of Elbow. joint Radius and Ulna Compound, of Fore-arm Radius — Lower End . Head, and Neck, of Radius CarjDal, Metacarpal Bones, and I'ingers Compound Innominate Bones Sacram Coccyx Femur Intra-capsular Extra-capsular Trochanteric Compound ' Patella ComiDound . Tibia . Fibula Near Ankle-joint Compound, of Leg, and Ankle-joint Tarsal, Metatarsal Bones, and Toes Compound . CONTENTS. XXV Chapter XXXIII. — Diseases of Bone; Ostitis, or Inflammation of Bone Scrofulous Ostitis . Syphilitic Ostitis Periostitis .... Endostitis . . ... Osteitis Deformans Suppuration .... Osteo-myelitis . . . Diffuse Periostitis . ... Periosteal Abscess — ^Acute. Chronic Circumscribed Abscess of Bone Caries Operations Necrosis ..... Partial Necrosis Necrosis without Suppuration . Oijerations for Necrosis Rachitis, or Rickets Mollifies Ossium Fragilitas Ossium Hypertrophy and Atrophy . Tamours Exostosis Enchondroma . ■ . Fibrous Tumour . - . Cysts Cystic Tumours Hydatid Cysts Sarcomata .... Round-celled. Spindle-celled . Giant. celled — Myeloid Sarcoma . Recurrent Osteoid . Cancer — Interstitial ,, Periosteal - . „ Osteoid Pulsatile Tumour, and Osteo-Aneurism Diseases of Particular Bones . * 838 839 840 840 842 842 844 844 847 848 848 851 853 854 858 860 866 868 871 874 874 876 876 878 879 879 879 880 880 881 882 883 883 884 884 887 JOINTS. Chapter XXXIV. — Injuries. Sprains. V*''ounds. Dislocations. Sprains or Strains ...... Wounds ........ Dislocation ....... Structural Conditions ..... Signs . . . Diagnosis . . . . . Causes ....... Reparation . , . . Treatment . . . . . . Comipound Dislocation ...... Structural Condition, and Diagnostic Characters 889 889 891 891 892 892 893 894 895 900 900 XXVI CONTENTS. Injuries. Sprains. Wounds. Dislocations— confinued. Course, and Terminations .... . 901 Prognosis 901 Treatment . . 901 Amputation ...... 902 Complicated Dislocations ..... . 903 Treatment • 904 Unreduced Dislocation and False Joint . 904 Treatment 906 Congenital Dislocations ..... . 908 Chapter XXXV. — Special Dislocations. Dislocations of the Lower Jaw .... . 909 Congenital . . . . 911 )) )) Spine ..... . 911 ,, ,, Ribs ..... 913 » n Clavicle .... . 913 Sternal End . 913 Scapular End . 915 )( )j Scapula ..... 916 >• ») Shoulder-joint .... . 917 Subglenoid .... 917 Subclavicular . 918 Subspinous . . . . 918 Unreduced .... . 920 Compound . . . . 923 Complicated Forms . . 923 Congenital . . . . 925 » )t Elbow-joint .... . 926 Radius and Ulna .... 926 Ulna ..... . 928 Radius . . . . . 928 Unreduced .... . 931 Compound . . . . 933 Congenital .... . 933 It i) Inferior Radio-ulnar Articulation . 933 jj >j Radio-carpal Articulation . 934 Injuries allied to Dislocation 935 Compound . . . . 936 Congenital .... 936 )) j Carpal Bones .... . 936 >> ) Metacai-pal Bones . . . . 936 )j J rhalangeal Bones — Thumb . 937 Compound .... 939 Congenital .... . 939 )> )> Pelvis ..... 939 Coccyx .... . 940 >j » Hip-joint . . . . . 940 On the Dorsum Ilii . . 940 Into Great Ischiatic Notch 941 Unreduced . 945 Into Obturator Foramen 950 Upon the Pnbes . 952 CONTENTS. XXVH PAGE Special Dislocations — continued. Unreduced ..... 953 Anomalous Dislocations .... 954 Complicated . . . . . . 957 Congenital ..... 958 Dislocations of the Patella ..;.... 958 ,, j, Knee-joint ...... 960 Derangement of Semilunar Cartilages . . 962 Compound Dislocation .... 963 Congenital ...... 963 „ ,, Fibula ...... 964 „ „ Ankle-joint ...... 964 Compound ..... 967 ,, „ Astragalus ...... 967 Unreduced ..... 969 Compound ...... 969 „ ,, other Tarsal Bones . ; , . 970 „ „ Metatarsal Bones ..... 971 ,, „ Phalangeal Bones ..... 972 Chapter XXXVI. — Diseases or Joints. Synovitis — Acute, Chronic, Hydrops Articuli . . , . 973 Gonorrhoeal ....... 976 Pysemic ....*... 977 Septic ........ 977 Chronic Ehenmatic Synovitis or Arthritis ..... 981 Ataxic or Charcot's Arthropathy . . . . . 986 Scrofulous Synovitis . . . . . . . 987 Scrofulous Disease or Caries ...... 989 Acute Articular Ostitis — Epiphysitis . . . . . 996 Ulceration of Articular Cartilages ..... 996 Anchylosis, or Stiff Joint ....... 999 Peri-articular Stiffness .*..... 1000 Examination of Joints ....... 1001 Joint-rigidity, without Anchylosis ..... 1001 Nervo-muscular Physiology of Joints ..... 1002 Loose Cartilages ....... 1007 Tumours ......... 1009 Neuralgia ........ 1009 Chapter XXXVII. — Diseases or Paeticular Joints. Diseases of the Hip-joint ....... 1010 Scrofulous Disease — Morbus Coxarius .... 1010 Diagnosis ........ 1016 Treatment ....... 1019 Chronic Eheumatic Arthritis — Morbus CoxEe Senilis . . . 1022 Neuralgia ........ 1022 Disease of the Sacro-iliac Joint ...... 1023 Diagnosis ........ 1023 Treatment . . . . . . . . 1026 Disease of Shoulder-joint ...... 1026 XXVlll CONTENTS. Ch.vi>ter XXXVIII. — Deformities. Deformities of Face and Neck Wry-neck or Torticollis . Congenital Strabismus or Squint Deformities of tlie Arm and Hand Contraction of Fingers Congenital Contraction of Fingers Deformities of the Leg Knock-knee Bowed or Bandied Legs . Contraction of Knee-joint Talipes or Club-Foot . Talipes Equinus Talipes Varus Talipes Valgus Flat or Splay Foot Talipes Calcaneus Varieties of Club-Foot Contraction of Toes 1020 1029 1030 1031 1032 1033 1034 1034 1034 1035 103G 1037 1037 1041 1045 1046 1047 1047 1050 THE SCIENCE AND PEACTICE OF SUE&EEY. INTRODUCTION. MODERN SURGERY AS A SCIENCE AND AN ART. Surgery is that primary division of Medicine whicli lias for its object the cure or the relief of morbid conditions of the body, in a corre- sponding division of Pathology. But the line of separation is arbitrary, conventional, and indefinite. Firstly, as to the nature of the morbid conditions, or Surgical Pathology. All injuries, malformations, and deformities, congenital and acquired, and all diseases affecting extexmal parts, are usually ^.Hotted to Surgery. Secondly, in respect to the kind of Treatment, or the means of cure or relief. Surgery comprises all operations effected by instruments, manipulative procedures, and the employment of mechanical ap- pliances ; but it also has recourse to the administration of medicinal agents, and to hygienic measures. Surgical Pathology is both Greneral and Special. General Surg-ical Pathology comprises the different forms of Injury and Disease which are common to all parts of the body ; and these morbid conditions, illustrating the laws of Pathology, are the primary source of guidance in all surgical practice. As general forms of Injury — Wounds, Fractures, Dislocations, and Aneurisms, may be naturally associated ; and especially in virtue of the various laws whereby these lesions undergo Reparation, through processes which are more or less clearly referable to modifications of healthy Nutrition. But this department will be more conveniently considered in connection with the particular Textures injured. As general conditions of disease — Inflammation, Morbid Growths or Tumours, and Degenerations, may also be referred to aberrant modifi- cations of Nutrition; namely, to Accelerated, to Reproductive, and to Declining Nutrition ; while Ulceration, and Gangrene or Mortification, represent textural Death. Certain Blood diseases, Contagious diseases, and general diseases of the Nervous System, further illustrate the laws of Pathology. VOL. I. B 2 THE SCIENCE AND PRACTICE OF SURGERY. Special Surgical Patliolosjy may be subdivided into injuries and diseases of tbe Textures and Textural Systems — e.g., the Skin and tlie Vascular System, and those which, with malformations, pertain to Organs and Regions — e.g., the Organs of Special Sense, and of Repro- duction. The latter subdivision, as a mode of classification, makes no pretension to any scientific distinctions ; it is simply an anatomical or a topographical arrangement of morbid conditions. In i-elation to Anatomy and Physiology, the truth has become fully recognized that disease is not an independent entity in the body, as if foreign to the healthy organism ; but that Pathology represents only viodes of living and modes of dj-ing ; although the line of ti-ansition from healthy to diseased states, in regard to structure and function, is indefinite, and variable in the history of every indiA'idual existence. But the student must ascend to yet higher ground than this in his contemplation of modern Surgery as a Science. Animated, or rather inspired, by a far more comprehensive spirit of inquiry, than that which relates to the human species alone, John Hunter's view of Pathology was an extension of a colossal Physiology, and a corre- sponding Anatomy, embracing the whole living creation. It was from this vast range of Biolog'ical Science that Hunter sought to interpret the structural conditions and the phenomena of life in any one species ; and thus, for example, to enlighten our otherwise isolated knowledge of human anatomy, physiology, and pathology; — of man, structurally and functionally, in the states of health and disease. From this elevated point of view we must look, to justly appreciate the Hunterian conception, and its influence on the British School of Surgery. Sub-* sequently, it became apparent how largely and intimately the Sciences of Physics and Chemistry enter into this system of Biology ; and thence we might trace the grand contributions of the Continental Schools, more especially, and particularly in Germany and France. Here, then, we discern the three primary elements of modern Scientific Medicine. The more immediate sense, however, in which. Modern Surgery claims the rank of a Science, is by virtue of the progress of Pathology ; — of that Science which teaches the nature of all the abnormal or diseased changes which the li^nng organism is liable to undergo ; the causes of such conditions ; their vital course, terminations, and conse- quences. In this country, the section of Pathology which relates to Surgery first assumed a representative position, mainly by the labours of Sir James Paget, as recorded in his renowned " Lectui^es," and " The Pathological Catalogue of the Museum of the Royal College of Surgeons ; " "vvhile, in Germany jDarticularly, Surgical Pathology has been developed chiefly by the genius of Vii^chow and Billi-oth. Regarded as a scientific Akt, the Practice of Surgery has a corre- sponding derivation from Science — in the guiding knowledge of patho- logical conditions, the applications of anatomy and physiology, and of physics and chemistry. But this compound Scientific Ar-t is supple- mented by the resources of simply empii-ical experience. The pathology of injuries and diseases, taken individually, em- braces: (1) the particular structural condition presented, its signs and symptoms, and its diagnosis or detection and discrimination fi'om other conditions ; (2) its cause or causes, or etiology, and the operation of the morbid condition itself ; (3) its course, termina- MODEEN SUKGERY AS A SCIENCE AND AN ART. 6 tions, and conseo[iiences, and the prognosis or foreknowledge of these events. The treatment in any case may be operative, or medicinal, or both. The comparative importance of the three divisions of investigation respecting injury or disease, and of the whole of this pathological knowledge in relation to treatment, may be estimated as follows : — ■ 1. Diagnosis is primarily necessary, in order to discover the par- ticular structural condition, and extent of the injury or disease, when capable of being so defined, and its distinction fi'om other conditions. To make this discovery, the concomitant effects of the morbid con- dition are taken as Signs or Symptoms of its existence. The relative diagnostic value of such evidence will depend upon, and vary with, its more or less constant aud exclusive conjunction with the morbid condition. Accordingly, a Symptom, or as the etymological meaning of this term would express, a coincidence or co-occurrence, is less characteristic and distinctive than a Sign, the latter being that by which anything is known or recognized. Methods of Diagnosis — (1.) By conihination of Sym,ptoms or Signs. Any sign peculiar to a morbid condition is named pathognomonic. But the co-existence, or at least the consecictiveness of symptoms, — - any one of which would be equivocal, if taken by itself, — constitutes a weight of evidence, greater in, the aggregate than that which the several items of evidence would represent by being merely added together. This augmentation of collective evidence is by virtue of a law of mental association, and not a property of numbers or of any kind of magnitude. If in one balance of a weighing scale were placed a weight of five pounds, and in the other a weight of one pound, the balance is as five to one. Other weights of one pound each being successively added to the one-pound scale, would severally tend to equalize the balance; and five such weights would equal a five-pound weight ; but five separate pounds weight, so to speak, of evidence, taken together, preponderate over a single five-pound weight of adverse evidence. In the diagnosis of the diffei'ent general forms of Injury — -already mentioned — the discrimination of Fractui'e from Dislocation and other conditions, affords an instructive illustration of the equivocal value of sigus and symptoms, taken singly and separately, but of their conclu- siveness, when considered collectively, in determining the diagnosis of this injury. Let me first briefly enumerate the signs and symptoms of Fracture, say in either limb ; and then proceed to the Diagnosis ; as hereafter stated in the course of this work. Fracture is attended with mobility of the broken portions of bone, and crepitation, a rough grating sensa- tion, felt and heard when the broken surfaces are gently moved in contact. Usually the normal outline of the limh is altered, by the displacement of the fractured ends of bone, a deformity which the experienced eye will frequently recognize at a glance ; and there is more or less elevation or depression, also occasioned by the displace- m.ent, prior to swelling, at the immediate seat of fracture. Shorten- ing of the limh, in some degree, takes place, when one of the single long bones is broken ; this sign arising from the involuntary contrac- tion of the muscles which act on the lower fragment. Lastly, pain, and inability to use the limb, are functional symptoms, which the 4 THE SCIENCE AND PKACTICE OF SURGERY. patient experiences, and which may be included in the evidence obtained by the surgeon in his examination. Proceeding' to analyze the diaf/nostic value of these signs and symptoms, as the evidence of Fi-actuve, they may severally be estimated as follows : — The pain may be insignificant at first, before swelling supervenes ; and the power of motion is retained in the case of impacted fi^acture, or where one only of two companion bones is broken, the other acting as a splint. With fi-acture of the radius, in the forearm; or of the fibula, in the leg; the ulna or the tibia thus preserves some of the motions of the limb, although the special functions of either broken bone are lost. But if the functional symp- toms of pain and loss of voluntary power attend the injury, they may each arise from other causes than fracture ; as from dislocation, a bruise, or an attack of rheumatism, which thus far may simulate fractiire. The physical signs of Fracture, taken singly, are some- times absent. Mobility, in the case of impacted fracture ; crepita- tion, also, in such case, or if there be much displacement, or if soft tissue of any kind intervene between the fragments, or if some days have elapsed since the accident. The deformity of the limb, and the elevation or depression at the immediate seat of injury, may be "wanting ; as in impacted fracture, and in fracture without displace- ment ; and these signs are less pronounced than usual, when one only of two companion bones is broken, the other resisting and sup- porting as a splint. Shortening also is less marked or absent in all such cases. The most difficult case is this : a fracture of one of two companion bones in the leg or forearm, in a muscular subject, and when considerable swelling has supervened. There is no shortening, and no deformity as from fracture, no crepitation can be felt, and mobility of the broken portions is obscured by the swollen cushion of soft tissues around the seat of fracture. " Where is the surgeon," says Boyer, " who has not hesitated sometimes to deliver an opinion in cases of this description ? " On the other hand, if the signs of Fracture be present, they may, severally, arise from other causes ; with one exception, — namely, mobility in the continuity of a bone. This can arise only from, fracture. Crepitation attends the play of the tendons in their sheaths, in connection with inflammation ; although the creaking, jerking crepitation thus produced, differs fi-om the rough grating of broken bone. The altered contour of the limb, and of the part at the seat of supposed fracture, and the shortening of the limb, might arise from various other conditions ; a previous fracture, interstitial absorption, or other disease of the bone, or from de- foiTtnity, congenital or acquired, as rickets or mollities ossium. In the proximity of a joint, these signs may be due to dislocation ; but the presence of crepitation, and of mobility, are the turning points of the diagnosis. It appears, therefore, that no physical sign taken singly, except one — mobility — is pathognomonic of Fracture, and that any one sign may be absent ; but that all these signs taken collectively, deter- mine the diagnosis of this kind of injury. Functional symptoms, singly or combined, are insufl&cient ; yet their concurrence will con- firm the diagnosis. (2.) Diagnosis — JBy Exchision of Allied Injuries or Diseases. — MODEEN SUKGERY AS A SCIENCE AND AN ART. 5 Where the injury or disease nnder consideration is one of several which are liable to occur in the same region, the diagnosis or dif- ferentiation may be conducted on the principle of exclusion ; by con- sidering each such possible condition with regard to its signs and symptoms, until that condition only remains to which the signs and symptoms correspond. But in this process of exclusion, the diagnosis is still determined by the combination of evidence already explained ; each possible form of injury or of disease being in turn rejected, but that one to which the concurrence of evidence points. Where, indeed, the majority of the signs appertaining to any morbid condition are present, it will rarely be requisite to confirm the diagnosis by eliminating the possibilities of other conditions for which it might perchance be mistaken. To illustrate the method of exclusion : in the diagnosis of Tumours, Cancer and Sarcoma can be distinguished only by the balance of associated symptoms in favour of either morbid growth — as affecting the mammary gland, for example. Disease of the hip-joint may be recognized in like manner, when possibly simulating dislocation on the dorsum ilii ; and so on with regard to other affections of the hip, which bear more or less resemblance to the disease in question. These, and many other illustrations of Diagnosis, partly by exclusion, will be found in the course of this work. The surest ground of diagnosis is Pathological Anatomy, as directly manifesting during life the existence of morbid conditions ; by the physical, the structural, and the chemical changes, which the different textures or organs, and the fluids, affected, have undergone. Thus, in the diagnosis of the general forms of Injury or of Disease : — the physical characters of Wounds are distinctive of these injuries, as represented by the terms incised, contused and lacerated, and punctured wounds ; the physical signs of Fracture are equally diagnostic, — in the altered length and shape of the limb, and the alteration at the seat of injury, with the presence of ci'epitation and mobility at that part ; the signs of Dislocation also are characteristic ; and the same may be said of most other injuries ; while, among diseases, the significance of physical diagnosis is illustrated by that of Tumours ; as with regard to their various differences of shape or surface-character, consistence, size, and mobility. By an appeal to structural characters appertaining to the textural elements of Morbid Products of Ifutrition, — the cells and fibres, or other organized contituents of such Products, as found in the dis- charges from natural passages, it may be possible — under examination with the microscope — to determine their nature ; whether as to pro- ducts derived from the mouth, oesophagus, stomach, or intestines, the lungs, kidneys, urinary bladder, or urethi'a, the uterus, or vagina ; or as yielded by the skin, or procured by subcutaneous puncture. This turning out of the interior of the body, or gathering" from its surface, supplies the materials for all that minute inspection which is associated with the achievements of microscopic examination. Among tunioui's or morbid growths, for instance, the diagnostic value of structural charac- ters, and as compared with physical diagnosis, is forcibly illustrated by the differentiation of the recurring varieties of non-malig-nant tumours, from the typical forms of such tumours. Thus, the fibro-nucleated tumour — a recurring growth, and the ordinary fibrous tumour, joossess 6 THE SCIENCE AND PRACTICE OF SURGERY. the same physical characters, — those of a hard, elastic, lobnlated tnmour ; but the recurring form i-epresents only a rudimentary con- dition of fibrous tissue, — consisting of fine filaments infiltrated with an abundance of well-defined oval nuclei ; whereas, the fibrous tumoar consists simply of developed fibrous tissue. These two structural con- ditions can be readily distinguished under the microscope, and by merely puncturing the tumour with a grooved needle, this method of Diag- nosis is made available in clinical examinaticm. Its critical value lies in the fact, that tumours which otherwise present the physical charac- ters of identity, and would thus be mistaken, have yet a widely different vital history and therapeutic importance. An oi^dinary fibrous tumour, never recurring, admits of removal by the knife as a certain cure ; but a fibro-nucleated tumour recurring, is so far allied to a cancerous growth, and when remoA^ed, springs up again and again, so that in spite of surgical interference, it not unfrequently runs its course to a fatal termination. The same diagnostic superiority of structural characters, might be further exemplified by the recurring fibroid, as compared with the fibrous tumour, in relation to their vital history and treatment ; while something might be said to reclaim the value of the sti'uctural method of Diagnosis with regard to cancer-growths. But, if the microscopic examination of organized products has yielded important diagnostic results in relation to Surgery, how fruitful has been this method of diagnosis in its extension to crystalline forms. "No one will dispute the value of the knowledge thus acquired respect- ing Urinary Deposits. Overlooking the varieties observed in the crystals of each kind of deposit, certain well-defined forms may be regarded as typical, and representing the morbid conditions of urine in which they are found ; such crystalline deposits supply conclusive or corroborative evidence of the diseases with which they are more or less constantly and exclusively associated. The rhomboidal prisms of uric acid; the octohedral and dumb-bell crystals of oxalate of lime; and the prismatic, foliaceous, penniform, or stellate crystals of phos- phatic deposits ; will severally suffice to identify the morbid conditions of urine, which physical characters, and even chemical tests, perhaps, will not so surely determine. Organized forms occurring in the urine, may supply evidence equally trustworthy ; casts of the uriniferous tubules, with blood and pus-corpuscles, presenting their characteristic appearances under the microscope, in connection with acute desquama- tive nephritis. Or, the artificial production of certain organized forms in urine, after its emission, may be the means of diagnosis ; as by the yeast-plant in the urine of diabetes mellitus. • Chemical diagnosis seems to contend with the structural method, for "superiority, in regard to its scientific exactitude. Destined, probably, hereafter to become the most minute method of detecting and discri- minating the essential changes which constitute morbid conditions, chemical diagnosis has already thrown a vivid and penetrating light on certain classes of diseases which appertain to Surgery. Urinary Pathology, forming a neutral ground for research, has been cultivated by the lalaours of Prout, Bence Jones, Golding Bird, Lehmann, Julius "Vogel, Neubauer, Owen Rees, Lionel Beale, Thudichum, Pai'kes, W. Roberts, Hassall, G. Harley, and other physicians ; but Urinary Deposits have to be examined also by surgeons, if they would practise their art in the light of modeiTi progress. All the various morbid MQDEEN SURGERY AS A SCIENCE AND AN ART. 7 conditions of the urine are of diagnostic importance in the treatment of surgical diseases, and relative to the favourable circumstances for surgical operations and their after-treatment. This source of g'uidance is often the key to the successes and failures of surgical practice in different hands. Albuminuria is specially sigaificant. The escape of albumen in the urine and the retention of urea in the blood, — the daily loss of so much nutriment in one of its highest forms, and the accompanying ureal blood-poisoning, — constitute a process so destruc- tive, that, if overlooked, it would undermine any good results in the * whole range of operative surgery. Sugar in the urine, when symptomatic of diabetes mellitus, is scarcely less unfavourable ; and bilious urine, in connection with jaundice, cannot be regarded as propitious for operation. Phosphatic urine, as dependent on chronic cystitis, is specially ominous in the treatment of stone in the bladder, as to the relative safety of lithotrity and lithotomy. Now, the chemical tests for these, and all other morbid conditions of the urine, have been reduced to practical forms so simple and conclusive, as to be readily available to every one engaged, and almost under any pressure of time, in Surgical Practice. Diagnosis may be confirmed by the functional disturbances, which, as symptoms, accompany the particular injury or disease ; also by con- necting either condition with its cause or causes ; and by the character- istic effects of the operative or medicinal treatment employed. Por example, pain, and inability to use a limb, are symptoms in aid of the physical diagnosis of Practiire or Dislocation, although the same symptoms may occur from even a sprain, without either such injury ; and the functional disturbances arising from the pressure of a Tumour on surrounding parts are similar, with reference to Tumours of very dissimilar nature. In further aid of diagnosis, the external cause of an injury or disease, may be taken into account ; the crushing violence to which a limb has been subjected, being presumptive evidence of a commiruuted fracture ; or the direction in which force has been applied, will perhaps indicate the form of a dislocation. Lastly, the effects of treatment may confirm our diagnosis ; as when, in the reduction of a Dislocation, the sensible snap of coaptation announces the replacement of the articular surfaces ; or, the non-recurrence of a Tumour, after extirpation by operation, is evidence in support of its non-malignant nature. Medicinal agents afford, occasionally, diagnostic testimony, by their definite and specific effects ; as by the influence of mercury in syphilis, quinine in ague, and sulphur in the cure of itch. But it is only by careful and repeated clinical observation of the physical, the structural, and perhaps the chemical conditions, — which are the more constant signs of disease or injury ; by a similar observa- tion of the functional alterations, as coincident symptoms ; the associa- tion of causes, and the effects of therapeutic measures ; and by connecting all this evidence, gathered during life, with the pathologico-anatomical alterations — as demonstrated by the scalpel, the microscope, and per- haps by chemical appliances — after death, and in all stages of these alterations, that we can rationally hope to establish the most exact and earliest Diagnosis. This connection, oft-recurring, at length begets self-confidence ; so that with the accumulation of such experience, our diagnosis, although determined during life, and therefore by evidence not infallible, yet 8 THE SCIENCE AND PRACTICE OF SURGERY. having been repeatedly verified by post-mortem examination, has now become proportionately exact. The most remarkable result of Diagnosis thus worked out has been the onah/sis of comjponnd diseases. Morbid conditions which were formerly regarded as simple, have been discovered to be compound — to consist of several diseases, which may, or may not, be associated ; each of which presents its own individual pathological history, and has its own peculiar treatment. One of the most striking illustrations of this diagnostic analysis is afforded by our present differentiation of joint-diseases. The term " white swelling," which was formerly in vogue, is now known to have included at least three diseases of dis- similar chai-acter — scrofulous caries, synovitis, and ulceration of the articular cartilages, this analysis having been clearly established by the diagnostic investigations of Sir B. Brodie. Under the old term, amaurosis, several distinct diseases of the retina have been discerned. Again, in the province of medicine ; continued fever, by the clinical and jMst-mortem investigations of Sir "William Jenner, has been resolved into ty]3hus and typhoid ; exanthematous diseases as distinct as small- pox and measles. More recently also, the term phthisis pulmonalis, which in the time of Louis signified exclusively tubercular disease of the lungs, is now being resolved into other diseases, by the peneti-ating analysis of modern diagnostic investigation. It is needless to point out how much all this advancement of Diagnosis has reformed, and is still changing, the old Nomenclature of diseases and the old Noso- logy or classification of diseases. In the investigation of Disease or Injury, the true relationship of Anatomy and Physiology thereto, should be clearly understood. Anatomy presents the normal standard of comparison, Avith regard to all changes of structure, and possibly teaches their interpretation ; thus enlightening the knowledge of Pathological Anatomy, in the investigation of the structural conditions of disease. The twofold guidance of Physiology in the study of Pathology is similar ; normal states of life being the standard wherewith to compare, and whereby possibly to interpret, functional disturbances; but never to predicate the knowledge of a single fact in their clinical investigation. As representing the science of life, Physiology and Pathology are one, and continuous ; but the formative facts of Patho- logy can be gathered only by independent observation. In this sense, but in this sense only, the investigation of Disease must rest on its own basis. The independence of Pathology — in recognizing facts of its own kind, was first propounded by Dr. W. H. WaLshe, in a highly original address, on " The Logical Applications of Physiology to Pathology " (1849). This relationship " denies that Physiology (vital, chemical, or physical) is the basis of Pathology, in the sense that acquaintance with the one secures, by involution, acquaintance with the other. It denies that Physiology is the basis of Pathology in the sense that, given the recognized healthy life of an organ, the conse- quences of the derangements of that life can by any forms of reasoning, inductive, deductive, analogical, or other, be positively predicated pHor to actual experience of their character and habitudes. It affirms, on the contrary, that from observation, interpretation, numerical com- parison, and classification of those derangements themselves (Collated, of course, with healthy conditions), are their natures and laws alone to be established. MODERN SURGERY AS A SCIENCE AND AN ART. 9 " Take the instance of an aged person, the neck of whose femur suddenly snaps; Physiology might certainly justify us in the positive affirmation, that inability to use the limb for progression would follow this accident ; it might, by diligent consideration of the precise lines of action of the various connected muscles (admitting this knowledge to be perfect in its way), make a correct assertion, prior to experience, as to the unnatural direction the limb would assume. But all this is merely mechanical ; it is the sort of inferential power which would indeed prove Physiology to be the formative basis of Pathology, were man a mere machine. But he is not simply a machine ; his femur cannot be broken without vital action being disordered ; and the sum total of physiological knowledge could never have established, prior to actual experience, the vital consequences, local and general, of that simple injury. No; scarcely, I affirm, could it have supplied even a solitary link of the great chain of impressions which, originating in the disruption of a few minute nerves, vessels, and bone lamella, may eventually make themselves felt in every fibre and every function of the frame." 2. Etiology comprises the knowledge of causes, and their operation, in the production of injury or disease. Such causes may be external to the body, as external violence in the production of injury, or exposure to cold in inducing disease ; or, they may be internal, by the excess, deficiency, or perversion, of structure and function. Both classes of causes may be either predisposing, or immediate and exciting, in their operation. Sometimes, the former occurs after the latter mode of causation, as when an individual undergoes fatigue or privation, after exposure to an infectious poison. Then, that weakening of the system cannot be said to predispose, but it is aptly named the determining cause. An innate power of resisting the supervention of morbid con- ditions, explains why the same cause does not invariably produce its reputed effect in different indi\aduals, or in the same individual at different periods of life ; this uncertainty being due to different degrees of resisting power. But the influence of habitual toleration will also much affect the operation of causes, whether external or internal. Either kind of cause may be self-sufficient, but both kinds fre- quently co-operate, or operate in succession; the internal cause more commonly predisposing, the external, when sufficiently aided thereby, immediately inducing disease or injuiy. Thus, a fall which does not produce a hernial protrusion in one case, immediately does so in another, owing to weakness of the abdominal wall at the seat of rupture, as the structural predisposing condition to this lesion ; and a posture which does not cause an apoplectic seizure in one case, immediately does so in anothei', owing to the blood-vessels of the brain having become brittle from calcareous degeneration. Causes are also distinguished as local and constitutional. The former term requires no definition ; the latter signifies such conditions of disease as have a systemic character, and a correspondingly wide- spread influence in the production of local manifestations. Snch are principally diseases of the blood, of the nervous system, or of nutrition. Local causes may give rise to constitutional diseases ; and conversely, any constitutional cause must give rise to, and be mani- fested by, some local affection or affections. Thus we often speak of 10 THE SCIENCE AND PRACTICE OF SURGERY. the constitutional origin of local disease, a general and most important doctrine of etiology, originally taught by Abernethy. In connection with the study of Etiology, many causes, whether constitutional or local, relate to the individual condition of the patient; as modified by age, sex, temperament, mental or moral states, occupation, habits of life, social condition — including marriage, here- ditary history, and the hygienic influences of locality and climate. The same considerations w-ill also more or less guide the surgeon's judgment in the Diagnosis, and the Prognosis, of many forms of disease and injury. The detection of internal causes, whether local or constitutional, may be regaixled as an extension of diagnosis ; but the operation of these causes, through functional disturbances, comprises the further study of Pathology. Diseases, which were formerly regarded as of local origin, and to be removed by topical applications, have been traced back to their constitutional origin in the blood-forming pro- cesses ; of which such diseases are only manifestations, and are accordingly submitted to constitutional treatment. It has been thus that our knowledge of scrofulous affections has been expanded ; that many skin diseases, and ulcerations of mucous membranes, diseases of the eye, the bones and joints, of the testicle, and other parts, have also been referred to constitutional syphilis ; Avhile the pathology of gout and i-heumatism has been equally fruitful in the interpretation of many otherwise anomalous local affections. Nor has the pathology of the nervous system been unproductive in the same direction ; and thus we now recognize hysterical affections of the joints, and other parts of the body, as distinguished from inflammatory disease ; a discrimination which has saved many limbs that, doubtless, were formerly sacrificed by an erring surgical interference. On the other hand, the local origin of constitutional disease embraces the causative relations of injury, and local disease, to morbid states of the system. In relation to the nervous system, the vital history of injury comprises the phenomena of shock, reaction, prostration with excitement or trau- matic delirium, and tetanus. The doctrine of constitutional irritation, originally established by Travers, was a fertile source of inquiry for subsequent clinical observers ; and the history of shock has been further elucidated by the investigations of Farneaux Jordan and Le Gros Clark ; while the phenomena of tetanus, by the original researches of Lockhart Clarke, have been connected with certain definite struc- tural changes in the spinal cord, — a hypersemic state of the blood- vessels with exudation, and disintegrative softening of the gray substance of the cord. The vital history of local disease, in relation to disorders of the nervous and vascular systems combined, — another illustration of the same pathological law,- — has equally engaged the attention of clinical observers. Thus, we have come to acquire our present knowledge of the pathology of inflammatory fever, as pro- ceeding fi'om a focus of inflammation in whatever part may be affected ; and the development, subsequently, of hectic fever from prolonged suppuration, and gangrenous typhoid fever from mortification of the part or local death. All this advancement has been the w'ork of many contributors whose labours cannot be here adverted to. There is yet another law respecting the operation of internal causes which merits more than a passing notice ; it is the causative MODERN SURGERY AS A SCIENCE AND AN ART. 11 relation of local diseases, — that oue morbid condition of a part, may give rise to the same, or to another, morbid condition in another part, continuous, contiguous, or remotely situated in the body. In- flammation exhibits abundant illustrations of these modes of opera- tion as an internal cause. The continuous extension of inflammation is witnessed in its progressive spreading in the skin or mucous membrane, as in erysipelas, and the sore throat of scarlet-fever. Con- tiguous extension is illustrated by secondary ulceration of the articular cartilages, consequent on caries of the subjacent bone, or on synovitis. So also ostitis may proceed from periostitis ; cellulitis from inflam- mation of the skin ; and conversely. Taking internal organs from the head dowpwards-; meningitis is succeeded by cerebritis ; scrofu- lous and purulent ophthalmia, by inflammation of the cornea and deeper textures of the eye ; laryngitis, by oedema glottidis ; gastritis, enteritis, cystitis, and metritis, each probably, by peritonitis. The transference or metastasis of inflammation to a distant part is ex- emplified by the supervention of orchitis from the sudden suppres- sion of gonorrhoea. I^ervous and muscular affections, of a sym- pathetic kind, might also be mentioned, as a large and most in- teresting class of manifestations, in all organs and regions of the body, more or less remote from their internal causes ; some such ^yffections depending on a cause of irritation in the trunk of the nerve affected, or centrally, in the brain or spinal cord ; or, proceed- ing fi^om the transference of an impression from one distant nerve to another through the medium of the central nervous axis — ^reflected sympathetic affections. Space will not permit me to enter further into this important view of internal causes. Originally, I believe, investigated by Dr. Whytt, the subject was ably elucidated by Sir B. Brodie in his " Local Ifervous Affections," a work which almost more than any other has influenced the practice of Modem Sargeiy ; and yet further light has been thrown thereon, by the researches of Professor Hilton, in his admirable Lectures on "Pain and Rest." To complete this general view of diseases in their causative re- lations to each other, I may just notice the association of diseases — their co-operations and orders of succession in the body. Consti- tutional morbid conditions frequently co-exist. This combination of rq.orbid states of the blood and nervous system is exhibited by fever, in every variety. Among blood diseases ; erysipelas, which occurs not unfrequently in surgical practice, may co-exist with typhus, pr with typhoid fever, with smallpox, or with syphilis — primary or secondary. Local morbid conditions frequently co-exist ; as in the association of inflammation with every kind of injury — wounds, burns, fractures, dislocations, etc." As illustrating the order of suc- cession perhaps most commonly met with ; a (local) suppurating wound induces (constitutional) blood-poisoning or pyaemia, and this disease is reflected by the formation of (local) secondary abscesses in various parts of the body. Primary syphilis in its relation to the blood, and thence to secondary syphilitic affections, is another familiar example of the same order of succession. Among diseases of the nervous system, we observe tetanus arising from some local injury, and then reacting upon that part, causing it to assume an unhealthy condition. After a sti^angulated femoral hernia, for which I operated, no bad symptom ensued for a week, then tetanus super- 12 THE SCIENCE AND PRACTICE OF SURGERY. Tened, and tie wound immediately re-opened and became distinctly gangrenous. But I can only glance at the "svhole of this inquiry, which I hare endeavoured to develop in my '• Pnnciples of Surgeiy." 3. Prck3X0SIS is a department of clinical knowledge, which, com- pared with modem Diagnosis and Etiology, is far less advanced. To foretell the coni^se and terminations, and the eventual consequences of any given disease or injury, is generally far more difficult than to discover the morbid condition itself, and its causative relations. At the same tinie. the practical impoitance of this foreknowledge ia relation to Treatment cannot be doubted ; whether we look to the prevention of impending complications, of a fatal issue, or of the consequences which may follow even in the event of recovery. To this end. the old *' pi-ognostics " of symptoms being " good " or " bad " according to the suggestions of empirical experience, affords no better knowledge than can be acquired by observant nurses no less than by practitioners. On the other hand, the intelligible guidance of Patho- logy has hitherto failed, in most cases, to cast more than a dim and uncertain light on our prognostications. Why is this f There are two unavoidable difficulties to be overcome. The "natural history" of disease has been watched but little, and recorded less; this deficiency in our knowledge being the result of our having to treat disease, as well as to observe its progress ; so that its vital history is continually modified by the intei-vention of our medicinal agents and operative procedures. Then again, individual peculiarities of con- stitution, age, sex, social position, and many other cii-cum stances, have to be taken into account, and the influence of which in this or that case, may defy calculation. Certain general principles only seem to be trustworthy : the persistence or not of causes in their operation, as the immediate ground of Prognosis ; with the kind and extent of structural alteration which the organ or part has undergone, and the influence of which is somewhat proportionate to the period during which the disease or injury has continued, unless as a chronic l£«ion to which the system has become habituated. Beyond this source of foreknowledge, the nature and the importance of the furvdional disturbances will indicate the probability of recovery, or of a fatal termination. Thus, to prognosticate the approach of death, the knowledge of Pathology iruJicates the various modes in which Disease or Injury may terminate fatally ; and Physiology enables the clinical student to interpret and appreciate the functional disturbances, as symptoms, which betoken each mode of dying. This scientific foreknowledge contrasts with the empirical prognostics known only as " bad " symptoms. Death may begin in various ways : (1) fi'om cardiac syncope, or from asthenia — a sudden arrest, or a gradual failure of the heart's action ; (2j Coma or loss of brain-functions, and paralysis ; (3j! Asphyxia or Apnoea — failure of respii-ation ; (4; Necrsemia, from suppressed excretion, or blood-poisoning ; (5) Atrophy or general wasting, — acute, or chronic — as marasmus. These several modes of dying may lead to each other. Beginning therefore in any one way, death results from the association and co-operation of the rest. Or again, two or more modes of dying may commence indepen- MODERN SURGEEY AS A SCIENCE AND AN ART. 13 dentlj, yet at tlie same time, and lead to the supervention of the rest more speedilj; just as a fire, lit in two or more places at once, sooner consumes the whole combustible matter. Thus, from fatty degeneration of the heart and kidneys, asthenia and nrsemia, begin- ning together, co-operate, and rapidly extend their fatal influence. Physiology explains these pathological combinations. The six functions — circulation, innerTation, respiration, excretion, digestion, and nutrition — together form a circle^ as it "were, consist- ing of so many links. By the failure of any one such function, the rupture of any one link, the bond of life is broken, and death begin- ning thence, as the starting-point, entails, sooner or later, the failure of the remaining functions. If more than one such link be snapped at once, the circle falls to pieces sooner — death ensues more speedily. In whichever way death begins ; in order to prognosticate the fatal termination of a disease or injury, it is necessary to know and be able to appreciate the particular functional disturbances as symptoms which characterize each mode of dying. (1) Death by cardiac syncope or fainting, by arrest of the heart "s action, and consequent cessation of the blood's circulation, is mani- fested by sudden pallor, and immediate insensibility ; the individual falls down with a gasp, the respiration has ceased, and all is over. This mode of dying is particularly an instance of sudden death, and the shock of severe injury a good illustration of its cause. Paralysis of the heart is immediately induced, w^hereby this organ loses its vital irritability ; or tonic spasm may occur, whereby it refuses to undergo relaxation, and remains contracted. Asthenia denotes the gradual failure of the heart's action, and of the circulation. This state is preceded by symptoms of similar character and import, but of some duration. Pallidity gradually overshadows, with coldness of the extremities ; the heart's beat is feeble, the pulse languid, intermittent, now slow, now quick, and the mind clouded. Occasionally a temporary reaction prevails, even as the glow of burnt embers reviving from time to time. Death is almost imperceptible ; or, in some cases, life is suddenly extinguished. Death slowly accruing from fatty degeneration of the heart is pre- ceded by these symptoms, although the act of death itself is generally sudden. (2) Death by coma implies the cessation of the cerebral functions. Insensibility, and loss of voluntary power, are therefore the primary symptoms. The heart still retains its contractile power, and the pulse-beat fails not. But it is slower and fuller than usual. These symptoms may occur quite suddenly and overwhelmingly, as from depressed fracture of the skull, or from knock-down apoplexy. They may, however, supervene slowly, and by instalments. Obscurity of the mental faculties, with partial paralysis and perversions of the special senses, singing -in the ears, flashes of light before the eyes, are then the primary symptoms. In either case, the loss of the cerebral functions does not MU. Insensibility and paralysis are not of themselves fatal prognostics. They become so only in proportion to the loss also of involuntary excito-motion, and especially as regards the act of respiration. With overwhelming coma, the breathing is much embarrassed and stertorous; and besides this most perilous condition, all other 14 THE SCIENCE AND PRACTICE OF SURGERY. functions depending on involuntary excito-motion fail. The pupils dilate, and refuse to obey the stimulus of light ; deglutition is not excited by the presence of food in the fauces ; vomiting cannot be aroused by the most powerful direct emetics; the sphincter muscles yield, so that the urine and fa3ces escape. All these symptoms ai-e pi-emonitory of a fatal issue. Their significance lies in the fact, that ■with the general failure of involuntary excito-motion, respii-ation is involved ; and this function is essential to life. Paralysis arising from disease or injury of the medulla ohlongdta is equally fatal, by apnoea ; but this mode of dying contrasts with that beginning in the spinal cord — i.e., by the failure of its functions. In the former, respiration is necessarily stopped ; in the latter, the act of breathing may remain unimpaired. Physiology readily inter- prets the different prognostic importance of these two cases. The -medulla oblongata is that nervous centre by the integrity of which respiration is sustained, and failing which, it ceases. More-" over, if the pneumogastric, or great afferent nerve of respiration be injured, the respiratory act ceases, or becomes insufficient to maintain life ; and the same result attends any impediment to the course of reflex nervous influence from the medulla oblongata through the efferent nerves of respiration — the phrenic, intercostals, and spinal accessory. Paralysis arising from disease or injury of the spinal cord is fatal only in so far as it implicates these efferent nerves. But if not surely fatal, such paralysis acquires an ominous character, when, besides the loss of sensibility and voluntary power, the damage done to the spinal cord precludes involuntary excito-motion also. For then, the vesical and anal sphincters ceasing to contract, involuntary micturition and defecation render life miserable and undesirable. Not only so ; the excrements are now worse than excrementitious — ■ the urine is rankly ammoniacal and fetid, the faeces are decomposed and putrid. Both are poisonous ; the one inflaming the bladder and excoriating the skin over which it dribbles, the other generating gas and inflating the intestines. Add, thereto, failure of the circulation in the paralyzed limbs, which become cold, livid, and ill- nourished. These are, indeed, symptoms of death, by paralysis, beginning in the spinal cord. Excepting this mode of dying, both that by coma and by cardiac syncope, or asthenia, derive their fatal import from the more or less urgent asphyxia consequent on the failure of one or other of the conditions essential to respiration. By cardiac syncope, the heart suddenly fails to propel the blood through the lungs, and an expiratoiy gasp succeeds ; in asthenia, this requirement gradually fails. By coma, the nervous requirements of the respiratory act are wanting. (3) There is yet another mode of dying 'by asphyxia, or apnoea, pi'operly so called : — when any mechanical obstacle prevents the free admission of air from without, through the larynx and air-tubes, to the air-cells ; or when, if air be thus freely admitted, it is impure, and therefore chemically unfitted to aerate the blood. In either case asphyxia ensues. But its symptoms vary with circumstances, and chiefly according to the suddenness and urgencj^ of this state. Sudden and complete asphyxia, as by strangulation, immediately MODERN SUBGEEY AS A SCIENCE AND AN ART. 15 provokes violent, but voluntarj, efforts to regain breath. If the struggle proves unsuccessful, what then happens ? During this short and sharp, but ineffectual struggle for breath, the pulmonary capillaries refuse to transmit venous blood. It therefore accumulates in the right half of the heart, and in the systemic veins; hence the surface of the body, particularly of the face and neck, having first exhibited a red hue, has now become livid, and the veins are turgid. The eyes are bloodshot and lustrous, and the tongue protrudes. The natural temperature of the body begins to decline ; the surface becomes cold and clammy. More perilous events press on. The brain, ever foremost in its demand for arterial blood, fails first ; subsequently the heart loses its contractile power. It flaps and flutters more and yet more feebly and imperceptibly. The cessation of respiration, insensibility, and the stagnant circu- lation, proclaim that life is virtually extinct. Nevertheless, the presence of black blood in the veins of the cerebro-spinal axis excites involuntary contortions, and during this apparent agony the semen is ejected. But involuntary excito-motory power declining, the sphincter muscles relax, thus allowing the contents of the bladder and rectum to escape. One or two slow, writhing movements, and the body hangs lax and lifeless, beyond the possibility of revival. Such are the chief symptoms that accompany and indicate sudden and complete asphyxia. It is otherwise with asphyxia slowly induced, as by pneumonia. The demand for air not being refused abruptly, time is allowed for the system to adapt itself by a compromise to the deficient supply. The ordinary symptoms of asphyxia are therefore less marked. There is not the sudden fight for breath; for respira- tion continues, although laboriously and with a sense of oppression. The sertti-wenows blood is permitted to pass through the pulmonary capillaries, whence it circulates through the body. Consequently the systemic veins are not so conspicuously bloated, yet the face has a dusky hue. Stupor and delirium, rather than insensibility, accom- pany this state, and the heart's action is enfeebled more by the mechanical impediment of pulmonary congestion, than by a deficient supply of arterial blood to its muscular substance. If, indeed, the patient outlives his pneumonic attack, there is hope that the con- solidated lung or lungs may permit sufficient aeration of the blood to sustain life in a quiescent and inactive state during convalescence. The system has gradually become accommodated to a I'educed respi- ration — asphyxia to a degree which, if caused suddenly, would have been fatal. The respiratory condition is that of a reptile, yet without any urgent symptoms of asphyxia. This systemic accommodation to deficient respiration is well shown in the course of many chronic lung-diseases. In advancing phthisis, for example, asphyxia slowly progresses without urgent' symptoms, by almost imperceptible degrees of toleration. (4) Death beginning in the blood, or by necrcemia, is naturally associated with that by asphyxia. The symptoms, however, are different and sufficiently characteristic. They imply the fatal failure of all the vital powers. The cerebral functions are oppressed, and, as it were, smothered. Involuntary excito-motory power is eventually overcome. Muscular strength sinks into helpless weakness. The heart loses its contractile power, and thus the force of the circulation 16 THE SCIENCE AND PRACTICE OF SURGERY. declines, the pulse hecomina: very rapid, althouefh ineffectual. The power of excretion is exhausted, so that effete matters natui~ally elimi- nated, by the skin and kidneys more especially, are now retained in the blood. Livid congestions and bloody extravasations are thus pro- duced. The skin acquires a dusky or livid hue, petechias or patches of ecchymosis appear, the conjunctiva? are bloodshot, and the fauces congested, the tongue gets dry and brown, and blackish encrustations or sordes beset the lips and teeth ; a cold, clammy sweat, often foetid, bedews the whole surface of the body, and the temperature declines from the first accession of this typhoid state ; the urine becomes scanty, high-coloured, and ammoniacal, and a putrid diari'hoea may occur, the discharges are often involuntary, while utter prostration, muttering delirium, convulsive twitching of the limbs or subsultus tendinum, and hiccuppy respiration betoken the approach of death. The symptoms of Becrjemia are those -which precede the fatal termination of blood-disease from the retention of excrement it ious matters, as in urtemia from the retention of urea ; but they are witnessed also in blood-poisoning by pyemic infection or septic8Bm.ia, and in the course of infectious or contagious fevers. (5) Starvation, or Inanition — Acute Atrophy, as I have termed it — is another mode of dying related to the last in this way : — Both have reference to the blood as the source of all their symptoms ; but in necrfemia the blood is poisoned by the addition of some noxious matter ; vrhereas in starvation it is deprived of its healthy constituents. The symptoms denoting this deprivation are briefly these, and occur in order as follows : — Gnawing pain is experienced in the epigastrium ; relieved, how- ever, by pressure. In a day or two it passes off, being followed by an empty sinking feeling in the same part. Unquenchable thirst succeeds, and continues as the most tormenting symptom. The eyes look -n41d and lustrous, the facial expression is anxious and pallid. General emaciation begins to be perceptible. A remarkable foetor is exhaled from the skin, which exudes also a brownish and faint- smelling secretion. The muscular strength now fails rapidly, and the individnal prowls about with a tottering gait, and speaks with a small and feeble voice. Generally an overclouding torpor prostrates the emaciated victim ; but frequently this apparent corpse revives towards the last in a state of wild delirium. Finally, death releases, either imperceptibly, by relapse into torpor ending in the sleep of lethe, or life ceases suddenly in a convulsive paroxysm. By Chronic atrophy — Marasmus — I mean that mode of dying in which the vital power of nutrition fails first, and the whole body Avastes slowly. It occurs most commonly in advanced life, and is indeed the usual mode of dying in old ag'e ; it might, therefore, be termed death by senile atrophy ; but chronic wasting may possibly occiir at any period of life, owing to the premature decline of assimi- lation — premature old age. Death beginning in this way is always equivalent to that by age. Unfortunately, however, our knowledge of all these changes is still incomplete, and the pathological history of this natural decadence has yet to be wiitten. Regarding ckronic atrophy as that " degeneration of the body " by which life declines and ceases in the order of Nature, Paget adds, in one of his most suggestive reflections, " It could not be without interest to watch the MODERN SURGERY AS A SCIENCE AND AN ART. 17 changes of the hodj as life naturally ebbs — ahanges bj which all is undone that the formative force in development achieved, by which all that was gathered from the inorganic world, impressed with life and fashioned to organic form, is restored to the masses of dead matter; to trace how life gives back to death the elements on which it had subsisted ; the progress of that decay through which, as by a common path, the brutes pass to their annihilation, and man to immortality." The symptoms of this natural decadence are thus described by Dr. Day : " Under the influence of senile marasmus, the desire for food is almost lost ; after partaking- of it, a feeling of more or less weight and pain is experienced in the region of the stomach, and vomiting- not unfrequently supervenes. There is seldom any unpleasant taste in the mouth, and the tongue either remains unchanged, or is of a bright red colour and dry. l!^o hardness or swelling is perceptible in the abdominal region, nor is it tender on pressure. The evacu- ations from the bowels are dry, hard, and scanty, and there is frequently great constipation. The least exertion is followed by extreme depression, emaciation increases, and the pulse becomes very small and weak. At length the patient takes to his bed, from a feeling' of intense debility. Then we usually observe, if not earlier, more or less febrile irritability towards evening. The palms of the hands and the soles of the feet burn, and the cheeks flush ; the powers of life are gradually and almost imperceptibly extinguished, and at last, without a struggle, 'the dust returns to the earth as it was, and the spirit to the God who gave it ' " (" Diseases of Advanced Life "). As the student yet lingers at the bedside over the living human body, to watch all the wondrous phenomena it presents in its multiform diseased conditions, — its innumerable modes of living and the modes of dying ; and, as he has then revealed to him g'liuTpses of that higher life, — the innermost workings of the soul, as a Trior al agent, when almost dissociated from its co-operation with physical forces ; under these privileged circumstances of observation, he will more fully realize the superiority of his clinical study of life over that of the pure anatomist and physiologist in their view of the body only through the course of its development and the evenly balanced condition of health ; and, in his position oi final intercourse with nature, he is favoured with something- like an experimental demonstration of that life which is to come, beyond this brief tenure of our earthly existence. Physical Science knows no instance of annihilation, but only of the transforma- tion of force, and thus the death of the body is but a ripple in the stream of our life. At whatever moment this may occur is merely incidental — " If it be now, 'tis not to come; if it be not to come, it will be now ; if it be not now, yet it will come: the readiness is all." Such, then, are the chief aspects of modern Surgery as a Science. Let me now turn to its practice as an Art. Thus regarded. Surgery, like most other Arts, may be practised in either of two ways — Em- pirically, by experience alone, or as a Scientific Art, by the guidance of the Science pertaining to it. In its full signification, this Ai't em- braces the scientific, as distinguished from the empirical, practice of diagnosis, etiological investigation, prognosis, and treatment. In its common acceptation, the art of treatment is more especially considered ; VOL. I. c 18 THE SCIENCE AND PRACTICE OF SURGERY. and from this point of view, the aspects of modern Surgery are singu- larly intc'i'esting. 4. Treatment derives its Indications from each of the three fore- going heads of inquiry respecting morbid conditions. Diagnosis fixes the essential nature of the moi'bid condition, and thus not unfrequently indicates the requisite remedial measures, particularly as to surgical operations, manipulative procedures, and mechanical appliances ; etiology supplies the knowledge of causes, which, if they be still in operation, must be removed; and prognosis determines the remaining indications of treatment. A considerable portion of surgical treatment yet remains empirical ; but it is now generally felt and acknowledged to be so far aimless, and as often therefore unsuccessful. Such treatment of injury or disease is like trying to hit a mark blindfolded. It can, indeed, only be regarded as a temporary resource, accepted by the practitioner under the pres- sure of his natural anxiety to relieve human suffering in any possible way, but as often little better than nothing until enlightened by Pathology. As thus directed, however, Treatment acquires three primary Indications of the highest importance. In proportion as the natural course of any morbid condition is towards an unfavourable issue, the Surgeon thence discovers the earliest occasion for interference, and the unfavourable conditions to be removed ; while, in proportion as the natural course is towards recovery, it indicates the least amount as well as the Tcind of surgical assistance requisite, from time to time, to conduct the case to this happy issue. Treatment in accordance with the natural course of morbid con- ditions towards recovery, is evidently responsive to the requirements of a 8 elf- Restorative or Reparative Poz^*er, which is inborn and inherent in the living body. The existence of some such power has been recog- nized by clinical observers from the earliest period, but the practical acknowledgment of its varied operation and resources in the treatment of diseases and injuries, forms the most prominent aspect of modern Surgery as an Art. A less definite recognition of tbis power had prevailed from the time of Hippocrates downwards ; it was the archceus of Van Helmont, the anima of Stahl, the vis medicatrix natures of Cullen ; but the original observations of Hunter on Reparation, in the healing of wounds, and after other injuries, first gave this distinctive character to modern surgical treatment. The Restorative Power is manifested, partly in its resistance to external causes of disease, as the influence of cold; but principally, in the processes of nutrition, and other functions, vp hereby structures, when disorganized, are recovered to or towards a healthy state, and readjusted. In relation to the recovery of parts injured, it may be termed the Reparative Power, which is exhibited in all the various processes of reparation, with regard to wounds, fractures, dislocations, and other injuries. Treatment which shall be responsive to the requirements of this two- fold power of restoration or reparation, I have long since designated " Conservative," whether in Surgery or Medicine, as denoting its preservative efficacy, the timeliness and moderation of its remedial assistance. {Med. Times and Gaz., 1864—65.) A few leading illustrations of the power of Reparation, in its various manifestations, as so many laws of Pathology, will inculcate MODERN SURGERY AS A SCIENCE AND AN ART. 19 tlieir bearing in the Conservative practice of Surgerj. And firstly, the law of Reparation by Adhesion, in the Healing of Wonnds and other injuries. The older surgeons, in their treatment of Wounds, never attempted to solicit " anion by the first intention," without any intervening blood or lymph ; nor did they venture to invite union by " adhesive iaflammation," or simply "primary union," tbrough the medium of plastic lymph, as it is now understood. Believing also, — as John Bell records, — that wherever a bone was laid bare, it mast exfoliate ; until they saw exfoliation take plape, they would not permit such a wound to heal. Thus, they would not lay down th.e skin in a wound over the shin-bone ; and if there was a lacerated scalp, they cut the torn piece off. And so too in operations and their after-treat- ment. If they extirpated a tumour, they cut away also all the sur- rounding skin. If they trephined the skull, they always scalped the patient ; and in amputating a limb, they cut by one stroke down to the bone, or after the flap-operation, they dressed the stump and flap as separate wounds. These references to the past will sufiice to illus- trate the great change which the Practice of Surgery has undergone by virtue of a distinct recognition of the Reparative power in even one of its almost innumerable modes of manifestation. Subcutaneous reparation is another law of Pathology, like that of primary adhesion, the recognition of which is due to Hunter; and this law also has conferred an equally conservative character on a scarcely less notable extent of modern Surgical Practice. The wide difference, — both in point of time and safety, — between the healing of an injury under the circumstances of exclusion from, or exposure to, the atmospheric influence, has led to the important practical distinc- tion of wounds, as being open or subcutaneous ; and the same law lies at the bottom of our distinction of simple and compound fractures and dislocations. Hence it has become the primary principle of treat- ment with regard to all these lesions and injuries generally, to convert them from the condition of open into that of subcutaneous lesions ; whether in the form of wound, fracture, dislocation, or other injury. The further development of this principle from the subcutaneous reparation of tendons, is exemplified by the practice of tenotomy. Introduced by Stromeyer, in 1831, the subcutaneous division of tendons has become the established treatment of deformities depending on muscular contractions ; and in the hands of Scarpa, Dieffenbach, Lonsdale, Little, Tamplin, W. Adams, and other surgeons, tenotomy has created that department of practice known as Orthopsedic Surgery. Enlarging oar view of the Reparative power, we observe in the treatment of Aneurism, as now understood, only so many imitations of the modes of natural cure, by the formation of clot and obliteration of the aneurism. As one such imitation, we have the Hunterian application of ligature to a sound portion of artery, at some distance on the cardiac side of the aneurism, just to take off the force of the arterial current, and thus induce coagulation in the sac ; a mode of cure which has since been fulfilled also by temporary compression, and for which Surgery is indebted principally to the Dublin school. Distal ligature, or compression, would obtain the same result in the sac, by imitating occlusion of the vessel as occurring from the impac- tion of a piece of clot, dislodged from the sac into the artery below ; and manipulation of the aneurism, as proposed by Sir W. Fergusson, 20 THE SCIENCE AND PRACTICE OF SURGERY. would efPect this dislodgment by a manual procedure, which is, how- ever, attended with considerable peril. Then again, galvano-puncture, and injection, are procedures designed to induce coagulation, somewhat as in the event of inflammation affecting the sac — another rare mode of spontaneous cure. Not to amplify these illustrations of modern surgical treatment, as responsive to the resources of Nature, medical ti'eatment also has undergone a similar advancement, at least to the acknoivledgment of their curative efficacy. Few surgeons there are who will not, each from his practical experience, concur in the convictions expressed by an eminent American writer. Dr. Jacob Bigelow, in his treatise on " Nature in Disease " : " It is difficult to view the operations of Nature divested of the interferences of Art, so much do our habits and par- tialities incline us to neglect the former, and to exaggerate the import- ance of the latter. The mass of medical testimony is always on the side of Art. Medical books are prompt to point out the cure of disease. Medical journals are filled with the crude productions of aspirants to the cure of disease. Medical schools find it incumbent on them to teach the cure of disease. The young student goes forth into the world believing that if he does not cure disease, it is his own fault. Yet, when a score or two of years have passed over his head, he will come at leng'th to the conviction that some diseases are con- trolled by Nature alone. He will often pause at the end of a long and anxious attendance, and ask himself how far the result of the case is different from what it woiild have been under less officious treatment than that which he has pursued ; how many, in the accu- mulated array of remedies which have supplanted each other in the patient's chamber, have actually been instrumental in doing him any real good ? He will also ask himself whether, in the course of his life, he has not had occasion to change his opinion, perhaps more than once, in regard to the management of the disease in question, and whether he does not even now feel the want of additional light ? " The term " Conservative Surgery,". as originally understood, when introduced by Sir W. Fergusson in 1852, was restricted to operations for the preservation of some part of the body, which would otherwise have been inconsiderately and unnecessarily sacrificed. The perform- ance of some operation of removal having become necessary, in conse- quence of an incurably diseased or injured state of a part; a lesser and limited operation, the extirpation of that part alone, may then be sufficient, instead of an operation involving also any portion of the sound organism. With regard to two, or more, practicable opei^tions of removal, this consideration of anatomical preservation may guide the Surgeon's choice. For example, excision of an incurably diseased joint may be performed, instead of amputation of the limb. Thus, observes Sir W. Fergusson, " a compromise may be naade, whereby the original constitution and frame, as from the Maker's hand, may be kept, as nearly as possible, in its normal state of integrity." This, then, is Preservative Surgery. Surely, however, it may be said, that is simply the object of all true Surgery — the preservation of limb and life. Why, therefore, designate it by the superfluous prefix — Con- servative ? "A rose by any other name would smell as sweet; " and Surgery will be equally saving, whether called conservative or not. Yet, on looking back to the gloomy records of the past, to the reckless MODERN SURGERY AS A SCIENCE AND AN ART. 21 amputations and mutilations wMcli were then practised, it was not, perhaps, without a significant reason that the true character of Surgery should have been recalled, and a rallying standard erected, for a time at least— the standard of Conservatism. Is any such admonition still necessary ? But the Surgeon should have and hold in view the preservation of function^ and not merely that of the anatomical integrity of the part, — ■ so far as pathological conditions permit, — in operation. The saving of a limb in a useless state would be no triumph of conservatism in Surgery. I'hus, as the result of excision of the knee-joint, I have seen the limb reduced several inches in length ; partly owing to the free operation requisite to remove the whole of the diseased portions of tibia and femur, and partly as the consequence of diminished growth of the limb, after removal of the whole of the tibial epiphysis, in a young subject. A limb shortened by half the length of the leg, cannot afford a better support, when the remainder must be supplemented by some artificial contrivance, than can be obtained by means of an artificial leg, after amputation. In thus estimating the relative value of two operations, from a conservative point of view, the comparative risk to life they entail must, in all cases, be also taken into account. Allied to the conservative or preservative character of Modern Surgery, as displayed in operations whereby the removal of some por- tion of the body is effected ; another aspect of Surgery has assumed an equal prominence — its reparative character, as exhibited in the design of the various operative procedures for the restoration of parts lost, whether in consequence of injury or disease, or for the construc- tion of parts wanting by congenital malformation. Thence the origin of " Plastic Surgery." Enlightened by physiology in the fact that each individual part of the body has its own sepai^ate vitality, and by pathology in the additional fact, that the whole organism is ever ready to re-acknowledge any outlying, or even detached portion, by processes of reparative union ; Plastic Surgery has responded to these overtures of science by the contrivance of some operation of anatomical repair, in almost every region, nay, in almost every hole and corner of the body. Thus, rhino-plastic operations have been devised for the repair of structural deficiencies in the nose, these original specimens of sur- gical reparation being connected with the names of Gasparo Taglia- cozzi of Bologna, in the sixteenth century, and Carpue, who introduced the Indian Operation, in 1814 ; since which period, Plastic Surgery has visited the lip and palate, in the operations for hare-lip and cleft-palate ; while the genito-urinary organs have become the scene of busy repara- tive procedures for the cure of rectal, urinary, and uterine fistula, by closing up these communications between adjoining passages, so as to regain their continuity ; and extroversion of the bladder has been met by various constructive procedures. The principle of surgical repara- tion has lately undergone a remarkable extension, and acquired a new signification. Plastic Surgery had availed itself of portions of integu- ment borrowed, but not detached, from adjoining parts. But the physiological fact known to John Hunter, that detached portions of the body may be re-united or even transplanted, had been witnessed in such instances as where a bit of the nose or a finger-end, accident- ally cut off, was thus restored ; and the additional fact of subsequent growth was not unknown ; yet the principle involved in these remark- 22 THE SCIENCE AND PRACTICE OF SURGERY. able phenomena remained Avithout much suggestive application in the practice of Surgery. This double law of independent vitality and growth has recently received a most i-emarkable and fruitful illustra- tion in the practice of shin-grafting^ as originated by M. Riverdin; particles of skin being implanted on a granulating surface, that each may reproduce integument from itself as a centre, and thus complete the cicatrization of a large or slow-healing nicer. Some most remarkable results have been achieved by this method of reparation, the introduction of which into this country is due to Mr. G. D. Pollock, 1870. Pathology in Surgical Operations. — In the plan and performance of Surgical Operations, the Guidance of Pathology supplements and completes that of healthy Anatomy. It is only under the circumstances of disease or injury, and life combined, — in one word, Pathology, — as superadded to Anatomy, that the operating surgeon interferes. He is never called upon to touch the body in its healthy and dead anatomical conditions. Surgical Anatomy, properly so called, is found to be modified throughout by constant association with pathological conditions, in the performance of any operation. Such an association therefore will tend to correct the ijurely Anatomical impressions of the Student, and to safely guide the operating Surgeon. Certain Operations are only apparent exceptions to this otherwise unexceptional law in Operative Surgery. It may be that the seats of operation and of disease or injury are not identical ; that our operation is somewhat removed from the diseased or injured locality. Such are amputations, and the ligature of arteries for aneurism. But even under these circumstances, pathological anatomy can alone determine whether or not we operate clear of the disease and amid healthy tissues ; whether, for example, the bone and soft parts left after amputation are healthy, and whether we cast our ligature around a healthy portion of artery. This negative application of pathological anatomy is obviously of the highest importance in respect to the successful results of surgical opei^tions. On all other occasions, the physical properties and relations of parts disclosed during an operation are then so changed by disease as sometimes scarcely to admit of recognition; and thus it is that anatomy phis certain pathological alterations, or the p)atlwlogico- anatomical conditions of the body, are those with which the operating surgeon is concei-ned. Guided by this a priori principle, we can predicate those patho- logical conditions which from their nature must chiefly influence the performance of surgical operations ; alterations of certain physical properties, more especially of colour, consistence, and elasticity ; also modifications of shape and size, with those affecting the situation, position, and relation of parts. Such peculiarities altogether change the scene with which the mere anatomist is familiar. ]S"or are these the only circumstances that overshadow the appear- ances to which he is accustomed. Whoever has observed the arm of a dead subject as it lay extended over the side of a dissecting-table, must have been struck with the well-marked bicipital depression, especially visible on a thin subject. If injected, the brachial artery can almost be distinguished as a prominent line throughout its course. Apparently, a single incision would bring one down upon MODEEN SURGERY AS A SCIENCE AND AN ART. 23 the vessel, and so it does. The skin, gluey and adhesive, hangs upon the knife ; nor does the incision gape ; the arterj is soon exposed, not being overlaid by the contracted biceps, and only, perhaps, obscured by the turgid vein on its inner side. Contrast all this with the same proceeding during life. We observe no such well- defined groove to guide our incision ; the skin yields before the knife with a crimp and elastic resistance ; the wound gapes ; the swollea and vibratile belly of the biceps muscle, especially if amply developed, overlays the artery, while the vein, perhaps not so turgid, immediately conceals it. More or less hemorrhage will also further obscure the vessel, which can only be recognized by its beautiful fawn colour and its pulsating under the finger. I have purposely excluded the brachial plexus of nerves from this sketch, in order more clearly to contrast the dead with the living. This illustration will apply, mutatis mutandis, to operations for the ligature of other arteries ; and the experience of every practical Surgeon will supply him with the more extended application of the same principle to all other surgical operations. We must, therefore, acknowledge also the guidance of living conditions in the performance of surgical operations. The condition of life modifies certain physical appearances, and chiefly those aifected by pathological anatomy. Thus, the colour, consistence, elasticity, and even the size and shape of the various parts of the body, their situa- tion, position, and relation to contiguous parts, are presented to the Surgeon, when modified by the twofold conditions of Disease and Life combined. Pathology, — conjoined with Anatomy, — is, therefore, our guide during surgical operations. In proportion as we are familiar with pathological conditions, by so much are we enabled to foresee, and to provide for, the peculiar appearances and conditions which the knife discloses, and to recognize them as they are successively presented in surgical operations. Guided by this anticipatory knowledge, our operations are no longer discoveries made by dissection, but planned and m,etJwdical proceedings, conducted on known principles ; in fact, an Art, based on the science of Anatomy supplemented by Pathology. The twofold Principle I have advanced will be further elucidated by tracing the combined influence of disease and life on the scenes of the chief Operations of Surgery. And here the results of inflamma- tion, meeting us so constantly, first invite attention. The swelling that accoTnpanies an effusion of serum, or pus, in the event of suppuration, deepens and displaces those tissues amid which it infiltrates. Their physical properties are soon chang'ed. Cellular tissue, so abundant, assumes the appearance of wet tow ; muscle becomes soddened and discoloured ; the larger blood-vessels perhaps alone escape, appearing dissected out and isolated froni their adjoining- tissues. Or, the fibrin effused solidifies, and its more or less complete organization ensues. If the latter change, then induration and sub- sequent contraction of the tissues affected, together present pathological conditions which contrast with those arising from the mechanical agency of fluid. If gangrene supervene, then we observe the gradual loss of all the physical properties peculiar to each living tissue, as severally they are consigned to the uncontrolled dominion of chemical 24 THE SCIENCE AND PRACTICE OF SURGERY. forces. Observe the skin darkened or black, and also the inter- mediate tints of tissues between it and bone, whitened and rough. Moreover, the tissues resign their consistence and elasticity as they impei'ceptibly lose their organization and i-eturn to a liquid form. I ■would not locate these changes, because with unimportant diflFerences they may occur in every region with which the opei-ative surgeon is concerned. If we re^aew the history of other products not due to inflammation, we observe them disturbing the relation of parts surrounding their locality, and by pressure gradually obstructing and even obliterating hollow organs in their vicinity. The clinical history of all tumours or swellings exemplifies these mechanical results ; but grou-ths more especially", by their gradual and unlimited enlargement, jiroduce such displacements. This circumstance chiefly determines the necessity for extirpating tumours which are otherwise harmless in their local and constitutional consequences. I would not allow such benign growths, as fatty or fibrous tumours, to remain too long imbedded ; for, although the general health may continue uninfluenced thereby, they may yet by their gradual enlargement so far encroach on adjacent and important parts as eventually to render their own removal difl&cult, if not impracticable. This indication more espe- cially refers to tumours situated in regions where vital structures are crowded together. Such are the face and neck, where the presence of large vessels, nerves, etc., complicates the removal of tumours. Under these circumstances I have removed more than one tumour, which, although of innocent tendency, would soon have passed beyond the ramus of the jaw posteriorly, and had already encroached on the cavity of the mouth. This condition would suggest the early extirpation of tumours, benign in themselves, when lodged in the sides of other cavities ; as, for example, the abdomen and joints. Thus placed, they might by pressure and inward progress eventually endanger life, if their removal were attempted at a later period. I^ext, inspect certain regions of the body, in which the relation of their pathology to surgical operations being more special is even more conspicuous. Observe aneurisms, — say one of. the axillary artery. The mere anatomist would suppose that the subclavian artery in the outer third of its course would offer no special obstacles to its easy deliga- tion. On the dead subject but few exist. The operator observes the depression over the vessel, in the situation supposed, above the clavicle. He makes his incision along that bone ; he veiy soon recognizes the subclavian vein below, branches of the brachial plexus above ; and the shoulder being now depressed, he at once passes a ligatui'e around the artery. But with the shoulder elevated by an axillary aneui-ism, and the artery above having a corresponding depth, the vein turgid from obstructed return of blood, and more so under chlorofoi'm, the sterno-mastoid and omo-hyoid muscles swollen, with perhaps also a portion of the trapezius ; these modify- ing conditions of disease and life combined, all conspire to render this operation perhaps the most difficult in surgery. They tried the skill of a Liston and a Dupuytren ; the former of whom at first ligatured the lower cord of the plexus instead of the artery; the latter, at the end of one hour and forty-eight minutes, only MODEEN SURGEEY AS A SCIENCE AND AN AET. 25 Succeeded in casting a ligature around the fourth cervical nerve ! Need I say more for the influence of aneurisms on adjacent parts during life ? Turning to hernial tuviours, as I would term them for my present purpose, how significant is the relation of Pathology to Operative Surgery ! The mere anatomical knowledge of the so-called " cover- ings " of hernise will avail hut little when tested by an operation on the living body. I can understand the coverings of a piece of intestine when thrust in the direction of a hernia through the crural or inguinal apertures in the dead subject. We might then dissect and display the superimposed layers of tissue thus artificially made tense. We might successively remove the skin, superficial fascia, inter- columnar and cremasteric fibres, with perhaps also some cellular tissue and the fascia transversalis from off the sac of peritoneum, successively covering a portion of intestine thus protruded through the internal inguinal aperture. But I cannot understand how all this applies to a recent oblique inguinal hernia, and still less to one of former date ; for then the external and internal inguinal apertures are found so approximated, and the " coverings " enumerated so matted together by constant pressure, as to have altogether effaced their mere anatomical characters and relations. In like manner, what are the "coverings" of femoral hernia? One stroke of the knife might bring us down upon the sac, through skin and fasciiB — super- ficial, cribriform, and transversalis ; where is the septum crurale ? It therefore appears that Anatomy can be used only as a diagram for the study of hernige, and that, like other pathological conditions, we must rely on the knowledge of hernia themselves to direct us during operations for their cure. In short, we can no longer put our trust in Anatomy alone, but may rely with confidence on Pathology as our guide. Looking around the urinary Madder and neighbouring organs, we again discover the intimate relations of Pathology to surgical operations. The thin scrotal skin and tuuica vaginalis may easily be transfixed with a common needle, and one might therefore suppose that the fluid of a distended hydrocele would always be readily detected and evacuated. Apart from pathological experience, no one could have predicated from mere anatomical knowledge that the tunica vaginalis may itself become so thick and dense as not only to disguise the fluctuation and translucency of hydrocele, but to yield before the point of a trocar with the resistance of thick pasteboard. Should the testicle require removal, how much are our incisions modified and the adjacent parts endangered by the enormous bulk to which this organ and its coverings sometimes attain ? The urethra and fellow testis might be wounded by a bare turn of the knife. Anatomy per se can only furnish our landmarks under these circum- stances, and we must trust to our actual experience of such tumours and in their removal from the living body. Again, the every-day operation of catheterism cannot be learnt ou the dead subject. The parts are then so peculiarly flabby, and the urethral passage so adhesive to even a well-oiled catheter, as to com- municate no sensation of that grasp of the instrument which an operator experiences during life. If, indeed, the urethra be indurated 26 THE SCIENCE AND PRACTICE OF SURGERY. and contracted witli stricture, then certainly we can learn nothing but the direction of the passage by practising on the dead body. In passing an instrument, the Surgeon's hand should be tempered by the vital conditions of the urethral canal, — its muscular irritability, its nervous sensitiveness, and perchance its disposition to bleed ; coupled with the various states of organic induration and contraction met with at the seat of stricture. Should retention of urine demand relief, additional pathological knowledge may be needed. The variable size, shape, and consistence of the prostate, and even its relative position to the neck of the bladder, as altered by disease and examined during life, will further determine our pathway, — per urethram, or per rectum, — when guided no longer by pure Anatomy and lost to sight. Approaching the bladder, and inspecting the scene of other opera- tions designed to gain an entrance thereto, we find, wherever we seek admission, that our procedures should be governed by Anatomy, modified by the twofold conditions of disease and life combined. Is it our intention to remove a calculus by the lateral or Cheselden opera- tion ? Then what availeth it us to know that our incision through the skin may also divide the superficial perineal branches of artery and nerve, and will inevitably sever the inferior haemorrhoidal ? No anatomical knowledge, however exact, could foretell how far distant the artery of the bulb may be from the margin of the triangular ligament which is not seen ; nor can we discern the transverse arteiy and muscle, and still less perceptible are a few fibres of the levator ani. Yet such are some of the misleading details of Anatomico-Surgical works respecting "the parts cut in lithotomy," or "the structures divided in this operation." All we know, or care to know, is, that as our first or pei'ineal incision was directed by anatomical considerations, so also that a trifl.ing stroke or two with the knife is continued until, guided upwards by the point of our left forefinger, it enters the groove of the staff just in front of the prostate gland ; the knife being then carried onwards through this body into the bladder, is followed by the finger ; which, at once a protector of the rectum, a blunt gorget, and searcher, is required to discover the pathological conditions of the prostate and bladder, as it dilates the former and explores the latter, for the situation of the stone. Just before sliding the closed blades of the forceps over the finger, as the guide thereto. The foregoing illustrations afford sufficient evidence of what Pathology can do for the performance of Surgical Operations. Without the knowledge of Anatomy, attired in the garb of disease and life, neither safety nor success can be attained in the planning and performance of Surgical operations. " The operator, — I would say, without this knowledge, — is seen agitated, miserable, trembling, hesi- tating in the midst of difficulties, turning round to his friends for that support which should come from within, feeling in the wound for things which he does not understand ; holding consultations amid the cries of the patient (before the days of chloroform), or even retiring to consult about his case, while he lies bleeding, in great pain and awful expectation." But the old carpenter style of Operative Surgery, derived merely from the dissecting-room, is passing away ; it belonged to a period when Surgery ranked with the mechanical arts, and shared their honours. MODERN SURGERY AS A SCIENCE AND AN ART. 27 !N"o less important in Operative Surgery is tlie knowledge, partly Pathological, to which I would next direct attention, as mainly deter- mining the success of operations. Conditions Favourable and Unfavourable for Operation. — The selection of cases fitted for Operation should always most seriously engage the Surgeon's consideration. The Conditions Unfavourable for any Surgical procedure being known, all other conditions may be presumed to be favourable. Unfavourable conditions comprise : (1) certain states of the Patient's Health, constitutional, and local in regard to the seat of disease or injury, — in short, certain Pathological conditions ; (2) the Hygienic circumstances by which he is surrounded. Constitutional conditions unfavourable for Operation, relate both to the mind and body. Persons who are naturally of an irritable and anxious, or of a desponding, mind, cannot sustain a surgical operation so well as those of a tranquil and cheerful disposition. This rule holds good also in the case of persons who, from temporary circumstances, may be men- tally affected in like manner. And especially unfavourable, is any despondency respecting the issue of the operation itself. This adverse influence affecting the patient's bodily health, before and after the operation, will be alone sufficient to undermine the result of any skill on the part of the Surgeon. On the other hand, the sustaining influence of hope is well exhibited by the fatal effect produced when it is suddenly withdrawn. Sir A. Cooper tells the story in his Lectures of a poor countryman in Guy's Hospital, who, lying in bed previous to a capital operation, was asked by a student what part of the country he came from ; "Cornwall," he replied. Then said his inten'ogator, "You will never see Cornwall again." IS'or did he; the man never rallied. An instance of such heartless or thoughtless indiscretion, suggests the kind of address and tact, animated by honest sympathy, with which the true Surgeon will manage his patient's mental disposition, ever fairly supporting hope as the well-spring of life. Conditions of bodily health, of a constitutional character, unfavour- able for Operation, are numerous. They relate to all the organs of the body, and vary in importance according to the physiological agency of the organs in maintaining life. Thus, the nervous system, the heart, lungs, digestive organs, and excretory organs, especially the kidneys and skin, have severally to be considered, and from a twofold point of view. Firstly, organic conditions must be considered, as affecting the general health, and thence the life, of the individual, when subjected to any particular surgical operation ; and secondly, they should be regarded in relation to reparation, or the reserve- power of nutrition requisite after any operation of magnitude, and which necessarily also entails an ordeal of some duration for the system to undergo, before the health can possibly be re-established. Age, or Period of life, has a very significant relation to the proba- bility of recovery after surgical operation, no less than from any injury of equal severity. Extreme periods of life, — infancy or childhood and old age, are about alike unfavourable for operation, as affecting the nervous system — by shock, and the circulation — by haemorrhage. But old age, or an approach thei'eto, is more especially adverse, owing to 28 THE SCIENCE AND PRACTICE OF SURGERY. the degenerations of textural structure which the vital organs have naturally undergone in the course of this period of life. Nutrition is inactive, and repai-ation accordingly is defective ; hence the special liability to secondary h iijniorrhage — the vessels being insecurely closed, and to pyaemic infection — the wound remaining open ; or exhaustion ensues fi-om the prolonged process of repair, and thus the patient is apt to sink even during convalescence. Bad subjects for surgical operation are those persons who, if not old in years, are yet, in appearance, old — prematurely — for their age. Certain types of this description are vividly portrayed by Sir James Paget in his highly suggestive " Clinical Lectures and Essays " : " They that are fat and bloated, pale, with soft textures, flabby, torpid, wheezy, incapable of exercise, looking older than their years, are very bad. They that are fat, florid,' and plethoric, firm-skinned, and with good muscular power, clear-headed, and willing to work like younger men, are not indeed good subjects for operation, yet they are scarcely bad. The old people that are thin, and dry, and tough, clear-voiced and bright-eyed, with good stomachs and strong wills, muscular and active, are not bad ; they bear all but the largest operations very well. But very bad are they who, looking somewhat like these, are feeble, and soft-skinned, with little pulses, bad appetites, and weak digestive power; so that they cannot, in an emergency, be well nourished." Previous habits of life are connected vsdth some such bad subjects for surgical operation. Habitual intemperance, in the use of stimulants, is specially unfavourable ; whether the individual be a confirmed drunkard, or an habitual soaker, who never appears to get drunk. The latter are, indeed, worse subjects for operation than the former. On the other hand, teetotalers, as being more often reclaimed drunkards, are also by no means good subjects. "Of such people," observes Sir James Paget, " I have no good opinion when they come to be the subjects of surgery; for they seem to retain the bad liabilities of the intemperate long after they have given up their bad habits." They readily succumb to shock or haemorrhage, or die from traumatic delirium — resembling delirium tremens. Habitual over- eating — another mode of intemperance — is scarcely less important, although perhaps less generally prevalent, relative to the risks of life from surgical operation. Among the " upper classes," not a few persons are thus bad subjects, — having their blood surcharged with unassimilated food, especially of an azotised character ; and this evil condition reaches its maximum in the retention of excrementitious matter, from the want of bodily exercise, or when relieved only by " carriage-airings." Some such persons have a gouty diathesis or tendency, and their urine is constantly depositing the cayenne pepper- looking particles of lithic acid or a pinkish sediment of lithates. Hence, the risk of internal inflammation after any operation ; a sudden attack of pleurisy, pericarditis, or meningitis, resulting apparently from deficient excretion. I proceed to notice, more particularly, various constitutional and organic conditions. The state of the nervous system is a primary consideration. When itself naturally irritable, or when in an irritable state for the time being, this condition is peculiarly unfavourable for surgical operation. It seems to be associated vsdth a weak circulation ; and the patient — especially if habitually intempei-ate — is prone to traumatic delirium, or MODEEN SURGERY AS A SCIENCE AND AN ART. 29 apt to sink from exhaustion, soon after any severe surgical procedure. But the judicious administration of opium with wine, brandy, or other stimulants, will often succeed in preparing the patient for operation, and carry him or her through the critical period subsequently. Chloroform, besides preventing pain, has a specially beneficial in- fluence in irritable nervous persons, subjected to operation for surgical disease, or when the circulation is depressed by the shock of injury. Hysteria does not render the patient liable to any special risk ; the sensibility to pain not being attended with any notable excitement of the circulation or fever, and the povrer of repair is unaffected by the constitutional peculiarity. But there are some hysterical subjects in whom, Tvith a feeble circulation, and defective digestion and nutrition, the loss of blood and the liability to imperfect repair or protracted recovery may be of more serious consequence than the beneficial effect of an operation. Certain blood-diseases prohibit any operation, otherwise than one of immediate necessity for the preservation of life ; as hernia or tracheotomy. Thus, any operation of choice should be postponed when the patient is labouring under erysipelas or pyeemia. Other diseases, less properly blood conditions, have not a fatal tendency, yet their existence is adverse to the successful result of an operation. Such are scrofula, and the contamination of the system by malignant disease. In the latter case, an operation will be almost surely followed by a return of the disease, in situ, or its development in some distant part. Diabetes mellitus predisposes the patient to gangrenous or sloughing inflammation, or the repair of an operation- wound is delayed by tedious ulceration. Carbuncle often occurs in conjunction with saccharine urine. Heart disease, and particularly fatty degeneration of this organ, should make the Surgeon consider the necessity or the advantage of any operation attended with much loss of blood or shock to the nervous system. Consequently, when the pulse is habitually feeble, irregular, and perhaps slow, the patient breathless on slight exertion, and marked with the arcus senilis ; these symptoms co-existing, almost surely indicate fatty degeneration of the heart, and should warn the Surgeon that he has a bad subject to deal with. Lu7ig disease does not seem to have so important a relation to surgical operations. This may, perhaps, be explained by the fact that after any severe operation, the patient being confined to bed, there is no special demand on the function of the lungs as the organs of respiration. As double organs also, one may be more or less diseased and incapacitated, and the other fulfil a double or compensa- tory function, and especially in the case of old-standing disease. Phthisis is an exceptionally unfavourable condition, and particularly if this disease be in an active state or in an advanced stage. The operation for fistula in ano, a disease often co-existing, should not be performed under these circumstances. The Digestive Organs play a most important part with regard to the result of surgical operations, and disorders or derangements of these organs demand the most careful consideration. Obviously this is due to the necessity arising aEter any operation of magnitude, for an extra supply of nutritive material to meet the demands of the reparative process, a supply which implies an active state of the 30 THE SCIENCE AND PRACTICE OF SURGERY. digestive organs incompatible with any kind of indigestion. Irritable dyspepsia, and hepatic derangement, terms not very definite, but sufficientl}^ familiar in practice, represent the conditions which are most adverse to surgical procedures. The Kidneys and Shin, as excretory organs, have a grand relation to surgical operations by purifying the blood of noxious matter, the retention of which would inevitably spoil the material requisite for reparation. Disease of the kidneys, in the various forms of degenera- tion, accompanied with albuminous urine, and the retention of urea in the blood, constitutes the most unpropitious condition under which a patient can be subjected to operation. The wound is apt to undei'go diffuse inflammation and sloughing, while the patient sinks rapidly from the exhaustion of blood-poisoning. This seems to arise from the local products of inflammation, thus induced, becoming absorbed, and which accumulating in the blood, soon overwhelm the system beyond the endurance of life, when already oppressed by the ura3mic poisoning. In this condition also, both kidneys are diseased, so that there is no chance of any relief by one organ compensating for the functional deficiency of the other, as in the case, sometimes, of the lungs. The state of the skin must also be taken into consideration before undertaking any operation. A cool, moist, soft, perspiring skin is no less conducive to success, than a free secretion of healthy urine. Chronic diseases of the skin, such as lepra or psoriasis, involving a large extent of the cutaneous surface, had better be treated before proceeding to any surgical operation which can be postponed. Pregnancy does not prohibit any surgical operation, excepting in so far as this state may thereby be itself affected. In the case of a lady advanced in pregnancy, 1 have removed a large slough from the abdominal wall by incision, without disturbing the course of pregnancy ; but, on another occasion, in the same person, the removal of necrosed bone from the scapula, under the influence of chloroform, was followed by a miscan-iage' the next day. Idiosyncrasy, or some unknown constitutional condition peculiar to the individual, may prove singularly prejudicial to the success of even a trifling operation. Thus, in one case, after removing a small fatty tumour from the abdominal wall, on the following day the adjoining integument presented a sphacelated black patch, with an abundant, thin suppurative discharge from between the lips of the incision. Local conditions unfavourable for operation relate to any diseased state of the part itself, which will tend to produce an unsuccessful result. Thus, acute inflammation of a joint, for example, would probably be adverse to excision ; and a sloughing condition of the parts involved in the flaps of an amputation, would defeat the purpose of this opera- tion. Cancer, or disease of a malignant nature, should never be removed, unless the whole disease can be freely extirpated. Any portion beyond the reach of operation will necessarily cause a return of the disease, in situ; an important consideration, in addition to the question of probability as to the development of cancer in some distant part. Hygienic Conditions. — Besides the state of health, constitutional and local, by which a patient may be in an unfavourable condition for operation; the hygienic circumstances in which he is placed, both MODERN SURGERY AS A SCIENCE AND AN ART. 31 before and afterwards, will much afEect the probability of success. Adverse hygienic conditions comprise chiefly : Defective Diet, in quality, quantity, or in both respects ; Overcrowding of the sick and wounded, especially those having open and suppurating wounds, or Deficient Ventilation, associated with which is the Exclusion of Sunlight; Defective Drainage; Atmospheric Conditions; Exposure to Contagious or Infectious matter, by dressings or inhalation, as in the propagation of Hospital gangrene and erysipelas. Some of these adverse circumstances, relative to operation, require further considera- tion, beyond what ordinary experience would suggest. Deficient Ventilation. — The minimwm space allotted to patients in the Surgical Wards of an Hospital should be 1500 cubic feet of air to each person. And this quantity must be accompanied with change of air also, by proper ventilation. In different Hospitals, the number of cubic feet of air per bed varies considerably. Civil Hospitals range the highest ; in England, the wards of Hospitals with relation to the number of beds, are calculated to allow an amount of space varying from 600 to 2000 cubic feet per bed, and in London the allotment is increased even to 2500 cubic feet ; in the Hospitals of Paris it is less • — 1700 cubic feet. Military Hospitals, in general, have not been arranged on the same liberal scale ; 800, 700, or even 300 cubic feet of air for each patient having been deemed sufiicient, the army regulations thus being a provision for overcrowding. But, more recently, this hygienic defect has been reformed. Thus, in the Herbert Hospital at Woolwich, the allotment of space per bed is 1200 or 1400 cubic feet. A surgical ward for twenty patients should measure 80 feet long by 25 feet wide, and 16 feet in height ; thus allowing about 1600 cubic feet per bed. Each bed or patient should have a surface area not less than 8 feet wide and 12 feet long ; cubic space over the bed would be an insufficient provision. Consequently, the arrangement of beds should allow at least 3 feet between each on either side, and 12 feet between foot and foot. In the event of infectious disease, further isolation of each patient will be advisable, and either or both adjoining beds should be left unoccupied. Atmo- spheric impurity, whether proceeding from the person or the excre- tions, diminishes as the square of the distance. In open localities, or iu the country, less than the average cubic space per patient is requisite than in towns and crowded districts. Hence, the advantage of an Hospital built in detached sections, as New St. Thomas's, and of Cottage Hospitals ; also the greater comparative salubrity of huts or tents in the Military Hospital system, — an advantage which I experienced with regard to patients in the wooden huts on the heights of Balaklava above the sea, and which was also strikingly exhibited in the Franco-Prussian War. In private practice, the aerial conditions of our London squares are more favourable than in narrow old streets; while in poor districts, the dense neighbourhood, small and ill-venti- lated rooms, overcrowded and badly drained tenements, represent the consummation of unfavourable atmospheric conditions. Sunlight has a decidedly beneficial infl.uence, which should not be overlooked, in relation to the general health, and thence to recovery after surgical operations ; excepting when the supervention of inflam- matory fever would indicate the propriety of excluding any source of disquietude, or, again, after ophthalmic operations, where the stimu- 32 THE SCIENCE AND PRACTICE OF SURGERY. latino- action of light would be directly injurious to tlie eye. The sanitary influence of solar light is refei-able not only to the light and heat, but also to the chemical rays which are known to be associated ; and this compound emanation has a potent action on all vitality. In the vegetable kingdom, the blanched appearance of plants reared in dark localities, contrasts sadly with the brilliant tints of flowering plants grown under sunshine ; and among aniraals, similar peculiai-ities with regard to colour are observable in different localities or climates, fi'om the white polar bear of northern latitudes, to the gay plumage of birds in tropical countries. In the human species, colour is developed by solar light, as shown by the inhabitants of different climes, and by the influence of each returning summer ; but the pallid appearance of the artisan in dark workshops, or of ofiice-clerks, compared with the ruddy brown hue of the countryman, presents not only a striking con- trast of apparent health, — the anaemic and enfeebled state of the one is no less unfavourable for sui'gical operations. This anaemic condition is due, partly at least, to the habitual absence of sunlight in certain occupations. The production of pigmentary matter, whether in the cuticle, or as the colouring matter, haematin, of the red corpuscles of the blood, is affected by solar light. Hence the importance of ample sun-lighting, by the arrangement of windows in the wards of Hos- pitals, or in the bedrooms of private patients, especially with regard to recovery after the loss of blood incident to many surgical operations. Defective Drainage, in its causative relation to the generation of typhoid fever, is now generally acknowledged, and the noxious in- fluence of decomposing animal or vegetable sewage-matter, in surgical practice, is too well known to need further notice. Atmospheric conditions exercise an unfavoui-able influence on opera- tions — not merely when occurring as epidemic disease, but in virtue of different meteorological states, as to temperature and moisture. Cold winds, especially from a north-easterly direction, in spring, depress the circulation ; and the sudden change to cold, wet weather, in autumn, is thus also prejudicial. Under these circumstances, erysipelas often prevails ; but perhaps no class of pre-existing diseases are so directly affected by such seasons as affections of the genito- urinary organs. Very hot weather, according to Sir B. Brodie's experience, is most unpropitious for any surgical operation — that can be postponed. Exposure to Contagious or Infectious Matter. — Among the characters of Modern Surgery, as an Art, Preventive treatment has acquired a position of great importance. The human body is encompassed by many external causes of disease, which may be not only of a palpable kind, but exist as subtle influences, wafted about in the air or im- pregnating the water, by either of which media they may find an entrance through any breach of the cutaneous surface, and must gain admission in the act of breathing or the reception, of food. Other such agents there are in the recognized form of virus, ever ready to be communicated fi-om one affected human being to another, or from the bodies of animals through poisoned wounds. Here, then, are so many sources of contagion or infection ; the latter term sometimes being restricted to the reception of the morbid influence through the medium of the atmosphere, or by means of any other intermediate substance, called fomites. Certain diseases of contagious or infectious MODERN SURGERY AS A SCIENCE AND AN ART. 33 character more especially pertain to Surgery ; principally erysipelas, pysemia, and Hospital gangrene. Yet these diseases are preventible, chiefly by cleanliness in dressings, and clean or fresh air, the latter requirement having reference to free ventilation, and isolation of the patient or patients affected. Antisepticism may be regarded as dis- infection in the treatment of wounds, not primarily poisoned ; the object being to prevent the putrefaction of any animal fluid, as blood, liquor sanguinis, or pus, in contact with an open wound, and the consequent systemic infection known as pyasmia or septicsemia ; the one disease signifying, literally, purulent infection of the blood, the other, that infection which arises from the inti'odliction into the blood of decomposing* animal matter, septic matter, of any kind. Hence the so-named antiseptic dressings, in all their variety ; for the experimental investigation of which, with regard to carbolic acid in particular, Surgery is principally indebted to Sir Joseph Lister. Diseases which arise from the local introduction or inoculation of any virus, as in Syphilis, are far more of a preventible nature than amenable to any known curative treatment. Preparation of Patient for Operation. — It is scarcely necessary to observe that, on the ground of personal liberty of the subject, and- legal liability of the Surgeon, the consent of the patient, and of his or her immediate relatives, should iirst be obtained before proceeding to any surgical operation. But this rule will as necessarily admit of exceptions, according to the mental capacity, or the age of the patient, and the more or less urgent nature of the case proposed for operation. If the patient be sensible, of sound mind, and mature age ; and he resolutely and persistently refuse to allow an operation of urgency to be performed ; and if, moreover, his determination be backed by that of an immediate relative, as his wife ; the Surgeon will have no alternative but to give up the responsibility of the case. Thus, I have seen a man die from strangulated hernia, in spite of my earnest and repeated remonstrances to him, and to his wife, as the strangula- tion proceeded to a fatal termination. On the other hand, if the patient be insensible, or imbecile, or in the case of a child or infant, and in the absence of immediate relatives or parents, the operation being an urgent one, the Surgeon will be free to act according to his own judgment. The preparation of the patient, mentally and bodily, will consist in inspiring him with cheerful hope, and in bringing his bodily health to a quiescent condition, especially observing that the actions of the digestive organs, and of the skin and kidneys, are healthy, when time can be allowed for any such preparation. This tranquil, even state of mind and body, is that best fitted for operation. But, when no time can be permitted for any constitutional preparation, as after most severe injuries, the patient must be at once submitted to opex^ation. Arrangements for Operation. — The arrangements requisite for the efficient and convenient performance of surgical operations, relate to the Room, the Operating-table, Instruments, with other Appliances, and Assistants. The Room, of convenient size, should admit a good light, an over- head or sky light being very desirable for most operations ; it must be adequately warmed in cold weather, or for the performance of VOL. I. D 34 THE SCIENCE AND PRACTICE OF SURGERY. operations wherein the abdomen is opened and the viscera exposed, as in opei-ating for strangulated hernia and in ovariotomy ; but there should also be the means of free ventilation or change of air about the patient, when under the influence of ether or chloroform. Besides the requisites of light, teiuperature, and air, an ample supply of "water, Avarm and cold' must be at hand. The Operating-table must be strong, and firm-standing (not moving on castors), of convenient height, and width only of the body, covered with blankets overlaid with india-i-ubbei" sheeting, and provided with pillows. The tables constructed for operation, as used in Hospitals, are fitted with a mechanism for raising the head and shoulders to any requisite height ; and flaps are provided for leaving the legs unsup- ported, as for amputation, or when the nates are placed so as to rest over the end of the table, as for lithotomy, and other perineal opera- tions. A low, firm stool will be a requisite accompaniment for these operations, to seat the operator in cutting for stone, or an assistant in holding the leg for amputation. Au Operating-chair, instead of a table, is necessary for case^ wherein the patient is seated ; as possibly may be more convenient in operations about the face, the extraction of nasal polypi, or for cleft-palate; also for other operations, as amputation at the shoulder-joint, and tapping the abdomen. The chair itself, firm-standing, and high-backed to svippoi't the head, much resembles a dentist's chair. These arrangements respecting the room and table should be seen to by the Surgeon himself, when not reg-ularly provided as in an Hospital ; but the remaining pro- visions, as to instruments and assistants, must always be personally superintended. The Instruments necessary should be well selected with regard to the nature and possible complications of the operation ; and for con- venience, they should be arranged on a small table or tray, in the order in which they are to be used, and placed near the Surgeon, so that he can help himself to any instrument he may require, or have it handed to him immediately by an instrument-assistant. The collection of instruments, however few, had better be covered with a towel, to conceal them from the eye of the patient when brought into the room. Sponges, of various sizes, clean and compressible, with lint and plaster, will always be provided by any well-trained nurse ; but here again, the Surgeon had better see that these appliances are at hand. Any splint or other accessory requisite for application after operation, and previously prepared by the nurse or an assistant, should also be inspected. A tray containing sawdust or sand may be placed on the floor so as to catch the blood ; but this has a repulsive appearance, and it is more agi-eeably substituted by a piece of maroon-coloured oil-cloth under the table. The operator may be conveniently dressed, in an easy-fitting, long-cut alpaca coat, or dressing-gown. The Assistants should be in number sufiicient, but not superfluous, and each should have an allotted duty to perform, orderly and silently ; under the directions of the Surgeon, as occasion may require in the course of the operation. Thus, for a capital operation, as amputation, joint-excision, or lithotomy, four, or not less than three assistants, will be required ; one, specially to administer chloroform ; then, in the first-named opei-ation, another sometimes to command the main artery ; MODEKN SUEGERY AS A SCIENCE AND AN ART. 35 fi, third to hold the limb in position ; aud a fourth to take charge of the flaps, and ligature the vessels as thej are seized by the Surgeon. A fifth assistant might hand the instruments ; but they are often taken up most readily by the Surgeon from the table near to him. Anesthetics. — The greatest gift of God to man, through Natural Science, is, perhaps, the discovery of means for the prevention or the abolition of bodily pain. This exemption approaches the realization of that blissful hereafter, one of the Divine promises of which is, that then " there shall be no more pain." Glimpses of the truth as now made kilown had appeared in various ages ; but it was not until the year 1800 that Sir Humphry Davy, having himself experienced relief from pain while breathing nitrous oxide gas, suggested the possibility of employing the influence of this agent for the same purpose in surgical practice. After the lapse of nearly half a century, in 1844, the same idea occurred to Dr. Horace Wells, a dentist in Hartford, America, who underwent the extraction of a tooth without pain after inhaling the gas, and he administered it with the same effect to several of his patients ; but, finding the practice uncertain, he soon abandoned it. About the same time. Dr. W. T. G. Morton of Boston, in America, who had previously been a partner with Wells, sought of his own accord, without it would appear receiv- ing any suggestion from him, to discover an efficient anesthetic ; and having experimented upon himself and the lower animals, he exti'acted a tooth painlessly from a patient, under the influence of sulphuric ether by inhalation ; this event taking place on the 30th of September, 1846. He then publicly exhibited the efficacy of this agent at the Massachusetts General Hospital; and thenceforward anaesthesia in surgery became an established blessing to mankind. It was not long ere this invaluable discovery was recognized, and followed up by farther investigation in this country; which resulted in the introduction of chloroform, and its employment instead of sulphuric ether. The latter agent is still extensively used as an anaesthetic in America ; but in Europe, chloroform is generally preferred to it, or was so, at least, until quite recently. Disguised under the name "chloric ether," in which it exists diluted with spirit of wine, this agent was employed by Dr. Morton in his first experiment upon him- self ; and it is a fact, not perhaps genei-ally known, that it was also used in the same form, in preference to sulphuric ether, by Mr. Lawrence, at St. Bartholomew's Hospital, in the summer of 1847. It was in the autumn of 1847 that Dr. Simpson, who was engaged in a series of experiments with various narcotic vapours, employed for the first time the active principle of chloric ether, at the suggestion of Mr. Waldie, of the Apothecaries' Hall of Liverpool : and finding that pure chloroform had certain advantages over sulphuric ether, he zealously recommended it to the Profession, and it has since been generally used. The advantages alluded to in favour of chloroform are, that it is a more potent anaesthetic, its inhalation causes less bronchial irritation, its odour is more agreeable, it is less volatile, thereby rendering its administration more easy ; and lastly, the vapour of chloroform not being inflammable like that of ether, it is fitted for operations by artificial light. Chloroform, — This anesthetic agent will be briefly considered in regard to : — its physiological action ; the phenomena produced by 36 THE SCIENCE AND PRACTICE OF SURGERY. inhalation ; the question of its contra-indication in certain diseased conditions of the system; the method of administration; death from chloroform ; and the treatment of an over-dose. Physiological Action. — The action of chloroform on the ftinetions of the nervous system is such as to render it exactly suitable for the pur- poses of surgical practice. Chloroform is a narcotic, and like most medicinal agents of this class, it produces temporaiy excitement, followed by suspension of the functions of the nervous centres ; but it affects them not simultaneously, but in a certain order. The hrain is the first to evince loss of power, in the failure of sensation, including consciousness, and voluntary motion ; the spinal cord, or rather the whole cerebro-spinal axis, secondly, soon loses the reflex function of involuntary exeito-motion so far as regards the voluntary muscles, which lie perfectly relaxed and passive. This combined state of in- sensibility to pain, paralysis of muscular action, voluntary, and involun- tary with regard to the voluntary muscles, presents a condition most favourable for the performance of surgical operations. On the other band, tbe involuntary action of the muscles engaged in respiration remains, and the action of the heart, as dependent on the ganglia of the sympathetic nerve, continues. Thus then, while the whole physio- logical condition of the nervo-muscular system suits the convenience of the Surgeon, and the patient is rendered insensible to pain ; those dependent functional actions are retained which are essential to life. Certain other important advantages attend the inactivity of the cerebro-spinal centre. The shock of injury, which would be increased by the additional violence of surgical operation, is diminished under the influence of chloroform ; thence, the contractile power of the heart, as affected by the action of the brain and spinal cord upon the cardiac ganglia thi'ough the medium of the pneumogastric and sympathetic nerves, is unreduced by such violence, thus averting the tendency to cardiac syncope and death during operation ; and lastly, in the absence of faintness, the vessels bleed freely, and by at once declaring those which require ligature, the liability of secondary hcemorrJiage is prevented. Moreover, the mental tranquility secured before operation by the pro- spect of immunity from suffering, is a condition highly favourable to recovery afterwards. With regard to muscular action, anaesthesia sheds a relaxing influence of special advantage in all those operations where any such action would interfere with, the requisite procedures ; as in joint-excisions, amputations, ligature of arteries, herniotomy,' colotomy, and other operations of abdominal section, and in operative procedures on the genito- urinary organs and rectum. Fhenomena or Symptoms produced by the action of chlorofonn. — After inhalation for a time, varying considerably in different in- dividuals, but generally of longer duration in adults who have been accustomed to the free use of narcotics, and shortest in children, symptoms of excitement are manifested by various ejaculations, and by muscular rigidity and movements requiring some restraint ; but this state is soon and suddenly succeeded by complete relaxation and insensibility, accompanied with deep, heavy respiration. Or, without any previous stage of excitement, the patient may at once pass into a state of tranquil sleep. The suspension of reflex action is denoted by the absence of unconscious winking when the eye-ball is touched with the tip of the finger, as a stimulus ; a state commonly regarded as MODERN SURGERY AS A SCIENCE AND AN ART. 37 insensibility of the conjunctiva. The heart's action, and pulse, at first quickened a,nd more forcible than natiiral, subsides under the influence of chloi'oform, and becomes slow and feeble or scarcely perceptible. The respiration also becomes feeble and imperfect, and the blood proportionately venous ; a state approaching or bordering on asphyxia. Snoring or stertorous breathing is soon induced, passing into complete obstruction to the entrance of aii' into the chest, although the respiratory movements of the thoracic walls still con- tinue. Occasionally, without any premonitory stertor, the breathing becomes more or less suddenly obstructed, and a livid tiu-gescence overspreads the face. Death is imminent where inhalation is carried to this degree as regards either the circulation or respiration ; and whether as the result of administering a highly concentrated vapour, or of long- continued inhalation. There are instances occasionally of persons who, from some peculiar idiosyncrasy of constitution, are incapable of being affected by chlo- roform ; they are proof against its angesthetic influence. Thus, I have known four ounces of chloroform administered to a lady, by inhalation, without producing the slightest effect. Gontra-indications to the employment of chloroform. — Certain con- stitutional conditions and organic diseases, are said to prohibit the use of chloroform, or to require extreme caution in its administration. The influence of shock has already been adverted to, in speaking of the physiological action of chloroform. Pain is not a stimulant but a depressant, and therefore the performance of an operation during the continuance of shock, and without chloroform, would increase the collapse ; and, moreover, as already explained, the influence of this agent protects the action of the heart from the tendency to cardiac syncope, resulting from the pain incident to an operation. Hence, operations may be safely performed, under the influence of chloroform, during the shock of injury; thus overturning the old rule of postponing operation, amputation for example, until the patient has recovered from the state of collapse. The system may be at once relieved from the injurious presence of a mangled limb, or life preserved where it would be hopeless to wait for returning consciousness. But, during shock, it is unnecessary to give chloroform to its fall extent; but only so far as to deaden sensation in the incisions or painful part of the operation. Epileptic persons may be subjected to the influence of chloroform inhalation, administered cautiously, however, considering their liability to suffer from congestion of the brain. Hysterical persons are said to be subject to laryngeal spasm, during inhalation. Disease of the Heart does not absolutely contra-indicate the adminis- tration of chloroform, but only that it be given with extreme caution ; watching the pulse especially, and the breathing. In fatty degeneration of the heart, the sedative influence of chloroform is liable to suddenly arrest the action of this organ with instant death. In valvular disease there is less danger. Disease of the Lungs is not specially obnoxious to inhalation. In phthisis, not far advanced, no difficulty arises ; but with bronchial irritation, troublesome cough is apt to be produced. Disease of the Kidneys, resulting in degeneration of these organs, 38 THE SCIENCE AND PRACTICE OF SURGERY. ^nd the retention of urea in the blood, is a condition decidedly nn- favourable for the administration of chlorofoiTn. Congestion of the brain being superadded to the uraemic-poisoning, may induce epileptic convulsions, with lividity of the face, stertorous breathing, and coraa. All Surgical Operations alloAV of the employment of chloroform, excepting a few in which the assistance of the patient is required, and in operations attended Avith copious haemorrhage into the mouth. In some cases, however, pain may be prevented to a great extent, by giving chloroform during the earliei' or more snpei-ficial parts of the operation. Age is no objection to the employment of chloroform ; infants and octogenarians taking it with safety. Administration of Chloroform. — Prior to giving chloroform, the patient should be directed to omit taking food for four or five honrs, as the presence of any food in the stomach is apt to canse tronblesome vomiting during inhalation. The patient lying recumbent with the head and shoulders just comfortably elevated on a pillow, he should not be allowed to raise himself in any struggling excitement, or be raised, into the sitting posture whilst under the influence of chloro- form, lest cardiac syncope take place. Any tight band round the neck or waist should be loosened, the breast had better be exposed, and care should be observed not to subject the thorax, or the abdomen especially, to any compression, as the respiration becom.es principally diaphragmatic. Chloroform may be administered simply on lint or a handkerchief, or by means of an inhaler of some kind. The former mode is in general use, it being equally safe, provided only two precautions be observed ; the chloroform must not be given too suddenly, or the vapour breathed in too concentrated a state without a free admixture of air. The mode of administration is simply this : a piece of lint or a handkerchief folded two or three doubles, and about the size of the hand, is sprinkled with a drachm or two of chloroform, measured from a graduated bottle ; it is then held near the nostrils, but so as to admit a free admixture of air with the first few inhalations ; after the lapse of about a minute, a towel may be placed over the face of the patient and the hand of the chloroformist to enclose the vapour, still observing to admit the air freely under one comer or one-half of the towel. This is continued, interrupted perhaps by the temporary excitement and struggles of the patient, until the arm falls involuntarily and relaxed when raised, and the eyelid ceases to move when the conjunc- tiva is touched with the finger. During the course of inhalation, the chloroformist should have his other hand on the pulse, carefully feeling its force and fi'equency, while at the same time he unceasingly watches the breathing. If at any moment, earlier or later, during inhalation, the pulse sinks to a feeble, slow beat ; or if the breathing becomes strongly stertorous ; immediately discontinue the administration of chloroform ; and for the relief of the respiration, at once seize the tip of the tongue, with forceps or the fingers, and draw it firmly forwards out of the mouth, until the tendency to obstruction has subsided. The breathing returns with perfect freedom, and the over- shadowing lividity of the face disappears. Chloroform can then be cautiously re-applied, if necessary. MODERN SUEGERY AS A SCIENCE AND AN ART. 39 Inhalers of various kinds have been devised for the purpose of regulating the proportion of chloroform and the admixtui'e of air. Snow's inhaler, or Clover's chloroform apparatus, may be employed ; and the latter is spoken of very highly by those who have used it, as being most efficient. But simplicity with efficiency is always a great recommendation, and thus the administration of chloroform by means of a piece of lint or a handkerchief can be accomplished at once, when any form of inhaler may not be at hand and would have perhaps to be fetched from a distance of some miles. Even in Hospitals, inhalers are not commonly employed. In point of safety, the two methods of chloroform administration are equally available, provided only that a free admixture of air be attended to. I have seen chloroform given in some thousands of cases without an inhaler, daring nearly forty years, — ever since its introduc- tion, and both in Hospital and private practice, with only three deaths, or even an appi'oach to a fatal termination, when the requisite precau- tions for safety have been observed. Death from Chloroform. — During inhalation, death may occur from the failure of either of the organs which constitute the tripod of life ; by asphyxia, by cardiac syncope, or by coma ; through failure of the respiration from insufficient aeration, or by laryngeal obstruction ; cessation of the heart's action ; or congestion of the brain. Asphyxia is indicated by the ordinary symptoms : lividity and targescence of the face, violent respiratory efforts, and cessation of the pulse, and of the heart's action. These symptoms may arise simply from depi'ivation of air resulting in a highly venous state of the blood ; but stertorous or snoring breathing is superadded, when the asphyxia arises from laryngeal obstruction. The cause of this obstruction is generally attributed to a " falling back of the tongue," thus mechanic- ally obstructing the entrance of air through the larynx. But Lister has specially investigated the question, and he finds that the obstruction arises from an approximation of the apices of the arytgenoid cartilages towards, or to, the base of the epiglottis ; the stertorous breathing resulting from the vibration of the corresponding portions of mucous membrane, the posterior parts of the arytseno-epiglottidean folds. Traction of the tongue firmly forwards abolishes the obstruction and stertor, not by any mechanical action on this part of the larvnx, for the base of the tongue and hyoid bone remain unmoved in position. It would appear that such traction operates by reflex action through the medium of the nervous system, but whether by inducing or relaxing muscular contraction in the larynx, is uncertain. Cardiac Syncope always occurs suddenly. The patient, after a few inspirations, suddenly becomes pale and faint, the pulse beating almost imperceptibly for a few moments, and then ceasing, although the respiration may continue ; death taking place by paralysis of the heart. This organ may itself be healthy, but more frequently it will be found to have undergone fatty degeneration. To prevent the liability to a sudden arrest of the heart's action, it is proposed by Mr. Schafer to administer atropin, hypodermically, which apparently counteracts the cardio-inhibitory influence of chloroform. This must be done before giving the ana3sthetic, for when the circulation stops, absorption is impossible; and as the 40 THE SCIENCE AND PRACTICE OF SURGERY. liability to syncope cannot be foretold, the antidotal effect of atropiu should, he says, never be omitted. Covia presents the same appearance as asphyxia, but without failui'e of the heart's action. The face becomes livid, the breathing stertorous, and the body convulsed ; the heart continuing to beat up to the last, as death results from congestion of the brain. This mode of death occurs mostly in epileptics, and in persons affected with uraemic blood-poisoning from old-standing renal disease. These three modes of death are referable generally to the incautious administration of chloroform ; whether as regards an excess of chloro- form in propoi'tion to the admixture of air, or the prolonged inhalation of this anfesthetic agent. Persistent Sickness is another occasional cause of death ; but it occurs afteo' the administration of chloroform, and seems to be a con- sequence of some idiosyncrasy of the individual. I have only known one case, death having occurred from the exhaustion of continued sickness for four days after amputation of the thigh for encephaloid cancer of the knee-joint, in the person of an otherwise apparently healthy young woman. In another case, after excision of the knee for scrofulous disease, in the person of a young woman, sickness set in and continued for a week, but it was subdued by the hypodermic injection of morphia, while life was sustained by nutritive enemata. The after effects of chloroform may, however, relate to the lungs or to the brain ; congestion of one or other of these organs being attended with the unfavourable or even dangerous symptoms of a tendency to asphyxia or perhaps pneumonic dyspnoea, or of headache, tending perhaps to apoplectic coma. Treatment of an Overdose of Chloroform. — The indication to be fulfilled will vary according as the symptoms, or apparent mode of death, arise from asphyxia, or from cardiac syncope ; the object being to re-establish the respiration, or to stimulate and restore the heart's action and the circulation. But in either case, the following directions should be carried out immediately : — The administration of chloroform must at once be discontinued. Firm traction of the tongue must be immediately had recourse to, this being effected by seizing the tip of the tongue with fingers or forceps and drawing it well forward out of the mouth. Air must be allowed to circulate freely around the patient, by opening the nearest window and the withdrawal of bystanders. The chest, exposed and free of constriction, should be whipped or flagellated with a wet towel in order to stimulate reflex respiratoiy action. This failing, artificial respiration should be resorted to ; the best mode being compression with the hands just below the sternum, by a sort of sharp concussive jerk, followed by relaxation for expansion of the thorax, while the tongue is still drawn out of the mouth. Electricity may be employed as the last resource, by applying one pole of a galvanic battery over the spinous processes of the upper cer- vical vertebrae and the other to the precordial region, so as to stimu- late the respiratory and cardiac ganglia. Friction of the extremities, and bottles or cans of hot water to the feet, may also be used, to promote the general circulation. These means of resuscitation should be continued perseveringly MODERN SURGERY AS A SCIENCE AND AN ART. 41 ■while any sign of vitality remains, for it has happened that a patient irrecoverably dead, to all appearances, has thus at length been restored to life. Sulphuric EtherhaiS regained its original celebrity as an anassthetic in America, its re-introduction into surgical practice having been accomplished mainly by the late Dr. Mason Warren, of Boston ; and it seems not nnlikely to be again brought into general use in this country. The advantages which may be fairly claimed for ether instead of chloroform are : the greater safety of that agent, — fewer deaths having occurred from its administration, and the less tendency to vomiting under its influence, — a decided superiority in many opera^ tions. Ether excites the heart's action, and its administration is, therefore, especially favourable in operations for injury attended with much shock, or in persons with a weak heart, having a tendency to syncope. But the inhalation produces more or less considerable bronchial irritation and mucous secretion, which impairs the safety of this anaesthetic in cases having such predisposition, and in advanced life. Owing to the volatility of ether, and the explosive nature of its vapour, it cannot be used conveniently in operations with the cautery, about the mouth. Anhydrous ether produces insensibility nearly as quick as chloroform, thus being equally eligible in this respect. It can be administered most readily, without much loss of vapour, by nieans of an inhaler in the form of a funnel-shaped receiver, fitted to the mouth and nose, and provided with a small air aperture at the top. A piece of flannel is placed in the inhalei', and then saturated with a measured quantity of well-washed ether from a graduated bottle. From four to six ounces or more will be required to induce and maintain insensibility in a long operation ; persons who have been habituated to alcoholic stimulants taking the largest quantity. The symptoms of anaesthesia, under the influence of ether are similar to those induced by chloroform, but the stage of excitement is perhaps more marked, especially in those -who have drank hard. During the ensuing relaxation, whatever surgical pro- cedure may be necessary is performed. Another method of administering ether consists in fixing a balloon of caoutchouc to the inhaler; so that the same air shall be rebreathed, saturated with ether. This — which may be termed the close method of administration — speedily induces a state of partial asphyxia in the patient, owing to the influence of the expired air, combined with the anaesthetic action of the ether. It was Originated by Dr. Ormsby of Dublin, and adapted by the late Mr. Clover. The alleged advantage is — not only the economy of saving a portion of the ether, which is wasted by the volatile nature of this anaesthetic, as otherwise administered ; the tendency to bronchitis and pulmonary conges- tion, due to the coldness of the inspired air, by the rapid evapora- tion of ether, may be also prevented. But, in thus averting the danger of asphyxial complications, ensuing from the ordinary — or open method of -giving ether, we encounter the risk of partial asphyxia — unrelieved by the stimulant influence of this agent, in maintaining the action of the heart. It would seem, that without gaining any positive advantage with regard to asphyxia, the close method of respiration destroys or neutralizes that beneficial action which specially renders ether preferable to chloroform as an anaesthetic. 42 THE SCIENCE AND PRACTICE OP SURGERY. A mixture of ether and chloroform is now commonly employed^ ■with a proportion of alcohol to blend the two anaesthetics, Th^ action of ether as a cardiac stimulant will thus overcome the sedative influence of the chloi'oform. The proportions suitable for this pur- pose, seem to be 3 of ether, to 2 of chloroform, with 1 of alcohol ; or 1, 2, 3, taking these agents in their alphabetical order — this combined anaesthetic being sometimes spoken of as the ACE mixture. Nitrous Oxide Oas has again been placed in the list of anaesthetic agents, chiefly by the advocacy of Dr. Evans, an American dentist in Paris. The action of this gas is speedy, but of questionable safety if continiied longer than a few rninutes, and of transient duration, sensi- bility returning almost immediately after the inhalation ceases. It is, therefore, specially adapted for operations of almost momentary pain, and which are not succeeded by immediate after-pain. Hence, tlje value of nitrous oxide gas in dentistry ; while it is less serviceable in general surgery. The symptoms produced depend sornewhat qn the admixture of atmospheric air with the gas. Mixed with air, nitrous oxide is highly stimulating ; exciten^ent is rapidly induced, and of that lively and agreeable kind which originally suggested the name qi " laughing gas." Unmixed with air, its inhalation is attended with no stage of excitement, but a state of profound coma is soon presented ; and this being due to the almost asphyxiated condition of the patient, it is accompanied with turgid lividity of the face, and staring expansion qf the nostrils. These alarming symptoms pass off with equal rapidity, when inhalation is discontinued, leaving generally no feeling of nausea or other discomfort. The gas may be con- veniently inhaled from an india-rubber bag or balloon, of snfiicient size to contain the quantity requisite for producing insensibility ; and the dose can be repeated by refilling the bag from a cast-iron stock- bottle, provided with a stop-cock, the gas having been rendered portable by condensation in the liquid form. Sometimes, nitrous oxide gas is given to rapidly induce anesthesia, followed by ether, to maintain the state of insensibility, in any operation of longer duration than a few minutes. Ethidene-Dichloride, as an anaesthetic — has received the sanction of Mr. Clover's large experience for its advantages in almost every case requiring longer aneesthesia than that produced by nitrous oxide. His "usual plan of giving it is by first getting the patient nearly uncon- scious by means of the nitrous oxide gas, and then gradually adding the vapour of ethidene. The general features of an administration are, that the patient falls asleep, without moving a limb; a little con- vulsive twitching is seen, and then stertorous breathing ; the pupils at first dilate, about the same time that stertor commences ; a very little air is now given at every third or fourth respiration, and the pupil contracts. The quantity of ethidene is regulated according to the condition of the pupil or the unsteadiness qi the patient, the pulse usually remaining much less affected th^n when the same narcosis is pi-oduced by chloroform. The dreams are usually pleasant, often of rapid travelling or of music, and if one whistle or sing, it often guides the dream in this direction. The patient, within two minutes of being in the most profound sleep, if it have lasted only a short time, will get up and walk steadily. The anaesthesia generally continues some time after consciousness returns, and the patient awaking almost MODERN SURGERY AS A SCIENCE AND AN ART. 43 as from natural sleep, speaks clearly. The non-interference "with muscular co-ordination is equally striking in the act of talking. Vomiting has occurred in about one-third of the cases of major surgery, and in about one-twentieth of the minor cases. It is more likely to occur if the rapour have been strong enough to excite swallowing. Without exception, the vomiting has ceased sooner than it usually does after chloroform. Ethidene sometimes depresses the heart's action, and on three occasions it was necessary to lower the patient's head, and induce artificial respiration. By this means, recovery has been easily effected." Mr. Clover has adininistered this anaesthetic in 1877 cases ; of which 287 have been major operations in surgeiy. (Brit. Med. Journ., May 29, 1880.) Bichloride of Methylene and Chloral Hydrate are ansegthetic agents which have more recently been added to others already noticed — nitrous oxide gas, sulphuiic ether, and chloroform. For this addition we are indebted to the experimental researches of .Dr. B. W. Richardson. Bichloride of Methylene, compared with chloroform, has certain alleged advantages ; anaesthesia is rapidly induced, and it can be main- tained for any length of time, without also any muscular excitement or rigidity, recovery is rapid and complete, and without any unpleasant after-symptoms. Sickness, however, is not less liable to occur f rona the influence of this agent when continued beyond a few rqinutes. In point of safety, it seems to be about equal to chloroform. According to Dr. Richardson's estimate, up to October, 1869, bichloride of methy- lene had been administered to between six and seven thousand persons with only one fatal termination. It occurred in a patient of Mr. Can- ton's, on whom he was about reluctantly to operate at Charing- Cross Hospital, for advanced malignant disease of the upper jaw. The patient, a man thirty-nine years of age, was previously iexhausted, bodily and mentally, by great suffering of three months' duration, the apparent date of the disease ; one nostril was closed by the tumour, thus obstructing respiration, and the patient was subjected to the influence of the bichloride in a sitting posture. One drachm and a half, in separate quantities, had been administered, when the man's head fell back, the pulse became feeble, and then ceased. There was no accompanying stertor nor lividity of countenance, ^he horizontal position, artificial respiration, and galvanism, failed to restore life. Other fatal paseg have since occurred. Mr. Rendle, of Guy's Hospital, observes that the rapid action of bichloride of methylene, — in twenty or thirty seconds, — and the rapid recovery from its influence, are apparently due to its great volatility and solubility, enabling a large quantity to reach and escapp from the nerve-organs at once ; while its sg-fety is referable to its rather stimulant action on the heart, and to its speedy elimination. The bichloride, being very volatile, should ibe kept in a well-stopped bottle, placed in the dark, and inverted under water. Mr. Rendle's inhaler consists of a leathern receptacle, dome-shaped, and perforated for the admisgion of air ; having also an accurately fitting mouth and nose piece. This inhaler is lined with a loose flannel bag, fastened round the mouthpiece by an elastic band. A drachm dose of the bichloride of methylene is scattered over the interior of the flannel bag ; the vapour should then be administered cautiously, with a sufficient proportion of air not to induce anaesthesia under one or two minutes ; and as sensibility returns in only a few 44 THE SCIENCE AND PRACTICE OF SURGERY. minutes, the effect of the bichloride may be maintained by giving another drachm, if necessary, observing to discontinue the inhalation immediately, in the event of dangerous symptoms, — namely, cessation of the pulse and respiration, Tvith turgid lividity of the face. This anaesthetic agent is employed chiefly in operations on the eye, as at the Ophthalmic Hospital, Moorfields, and in the Ophthalmic Wards at Guy's Hospital ; also in Ovariotomy, by Sir Spencer Wells, at the Samaritan Free Hospital, where"! have seen it used very satis- factorily. In general surgery, to save time, bichloride of methylene is sometimes administered in order to rapidly induce anaesthesia, which is then continued under chloroform. Chloral Hydrate is, by some observers, said to possess powerful ansesthetic properties ; others deny that it is an hypnotic or angesthetic, but regard it as a powerful excitant. I have found its action to be very uncertain. From an elaboi^ate " Report on the Action of Anaesthetics, by the Scientific Grants Committee of the British Medical Association,"* we learn two conclusions of practical importance, with regard specially to Chloroform and Ethidene : that in their administration, it is necessary to watch the effect of the ana?sthetic, not only on the pulse, but also on the respiration, with regard to abnormal increase of the respiratory movements, as well as sudden stoppage of the breathing ; and, that after their administration, owing to the tendency of these agents, particularly chloroform, to reduce the blood-pressure .suddenly, when the influence of the ansesthetic has been discontinued, it is equally necessary to watch the pulse, for indication of this occurrence, both during the time the agent is given, and for some time after the patient has recovered from its more obvious effects. Local Axsisthesia. — The application of cold to a part of the body, in order to reduce the temperature of that part to a frost-bitten con- dition, is a mode of angesthesia which mav be advantageously employed in certain surgical operations. It is eligible in all super6cial and limited operations, in regard both to their extent and the time requisite for their performance. Such are, the avulsion of a toe-nail, puncturing abscesses, slitting up fistulse, and the excision of small tumours. Freezing of the part operated on may be effected either by the application of a frigorific mixture, as introduced by Dr. J. Arnott, or by the ether-spray, devised by Dr. B. W. Richardson. The frigorific mixture of pounded ice and salt is easily made, and answers admirably. This mixture is put into a muslin bag, and applied to the part, being raised in a minute or two to see whether the desired effect has taken place. The skin almost immediately loses its colour and becomes white, a change the more observable when previously reddened by inflammation ; but this blanching of the skin is no sign of freezing having occurred ; soon, however, a dead white, opaque spot appears, quickly spreading over the cutaneous surface, and then the part is frozen and anaesthesia produced. The integument cuts hard, like parchment, and the blood is singularly florid. Reaction speedily sets in, the part bleeds fi'eely, and often becomes very painful. But no constitutional disturbance accompanies, or ensues fi'om, this freezing of a part of the body. I have seen or known only one case of any un- favourable consequence. The patient, a healthy, florid young woman, * Journal, December 18th, 1880. MODERN SURGERY AS A SCIENCE AND AN ART. 45 had sat and seen me remove one of her great toe-nails, looMncr at the operation with perfect indiJfference ; but when reaction took place, she suddenly fainted, and again and again, until the syncope was alarming. The Ether-sprcLy is another means of freezing a part and inducing local anaesthesia ; but in this method it is effected by evaporation of ether thrown upon the surface in the form of a fine spray from a little apparatus contrived by Dr. Richardson for the purpose. It offers a more ready method for the convenience of siirgical practice, as it may always be kept at hand ; whereas ice canuot always be obtained. Unfortunately, so far as my experience has gone, the apparatus, simple in itself, usually seems to be out of working order when wanted. Dangers attending, or consequent on. Surgical Operation. — The perils pertaining to operation are principally as foUows : — (1) Hsemor- rhage,primary and secondary; (2) Shock; (3) Exhaustion; (4) Tetanus; (5) Traumatic Delirium ; (6) Delirium Tremens ; (7) Inflammation and Inflammatory Fever, Suppui^ation and Hetic; (8) Gangrene, — inflam- matory, traumatic, spreading traumatic ; Contagious or Hospital Gangrene ; (9) Erysipelas ; (10) Pygemia. Of these different con- tingencies, some are coincident with, others consequent on, -the operation. They will all be fully considered in various chapters of this work. Dressing of the "Wound, and Constitutional After-treatment. — The dressing of a wound made by surgical operation is the same as that of an Incised Wound, or Amputation- Stump ; and the dressings \vill vary with the supervention of Inflammation, and its consequences - — Suppuration, Gangrene, and Ulceration. The Constitutional After- treatment must have reference to the various states of the system ; as "with regard to Shock, or Tetanus ; or, as resulting, for example, from Inflammation — namely. Inflammatory Fever, Hectic, and Gangrenous- typhoid febrile disturbance. All these states also are considered in their appropriate chapters. Results of Operation. — The object or purpose of any Surgical pro- cedure should be viewed with regard both to its temporary and its permanent results. An operation may be successful from the one point of view, but not from the other. The unsuccessful results of any Surgical procedure may, perhaps, be reduced to three general heads : — (1) A return of the original condition for which the operation was performed ; (2) the substitution of some new condition, not better, or worse, than the first; (3) the inducement of disease in some distant part of the body. Of the two first modes of unsuccessful results, such instances may be cited as, after amputation of a limb, the return of gangrene in the stump ; after excision of a joint, the substitution of a useless limb. The thii^d mode of unsuccessful result is illustrated, after ligature of an artery for aneurism, by the development of aneurism in another part ; or after the excision of cancer-growth, the development of internal cancer. Statistics in Surgery. — To properly estimate the facts gained by observation, whether in the Science or the Arf of Surgery, we must count them. The impressions of experience so called, respecting pathology and treatment, are too vague and indistinct for any trust- worthy conclusions. Accuracy of observation is essential to reliable results, and the number of observations taken is also a very important 46 THE SCIENCE AND PRACTICE OF SURGERY. consideration. Hence, the value of Statistics, or the Numerical method of inquiry ; which, by the process of counting, imposes a rigid check upon any dissimilarity of the facts thus enumei-ated by units, and estimates their evidential signiBcance by their number, — • absolute, or relative to other series of facts with which they niay be compared and weighed. It is sometimes said of Statistics, that any- thing can be proved by figures, for or against a. given question at i.ssue. The fallacy of this assertion is demonstrated by the very process of counting, as the cori-ective of erroneous data. The numerical method may, indeed, seem dry and unattractive to persons of an imaginative disposition, for its inherent exactitude imposes on such, persons a disagreeable restraint. But, as men of Science, and Students or Practitioners of an Art involving the tremendous issues of life and death, truth should ever be our first consideration. And, for the fruits accruing fi'om well-assoi'ted collections of facts, and their comparison, I may point to the very important results which have thus been achieved in many departments of Surgery, as ei^hibited in the coui-se of this work. PART I. GENEEAL PATHOLOGY AND SURGEEY. DISEASES OF NUTEITION. CHAPTER I. INFLAMMATION. When the Student has acquired a preliminary knowledge of Anatomr and Physiology, and begins to read the first lines of Surgery, he I'easonably expects to find some decided and constant evidence as to the utility of those preparatory Sciences, in this new stage of his professional education ; that they have indeed their applications and bear fruit in both the Science and Practice of SUrgery. Anatomy and Physiology, he knows, relate to the structure and functions of the various organs and parts of the body in health ; and he now learns that disease is not an entity, but only a state or states of existence — structurally and functionally ; that health and disease are but relative terms, expressive of normal and aberrant modes of living and dying, — in the course and terminations of the same existence, and which together I'epresent the Science of Biology, so far as may be made known in the life of man. The latter, or aberrant states of structure and function — constituting what is called Pathology, or the knowledge of Disease, forms the more immediate scientific basis of Surgery, and ofliers, therefore, a direct source of guidance in its practice as an Art, for the prevention and treatment of morbid conditions. But, in the description and investigation of these conditions, as set forth in works on Surgery, does the Student find connecting references to the structure and functions of the body in health : or is the pathology, and thence the rational practice of Surgery— the Science and the Ai't, virtually divorced from the teachings of Anatomy and Physiology ? It is upon the assumption of at least some such deficiency, among others, that this work on Surgery proceeds. Read in the Kght of physiological interpretation, the general condi- tions of Disease, in Inflammation, Morbid Growth or Tumour-pi'o- duction, and Degeneration, are seen to have a running relation between them, as aberrant modifications of Nutrition — referable to the Accelera- tion, the Reproductive increase, or the Retrogressive failure of this 48 GENERAL PATHOLOGY AND SURGERY. physiological process in textural life ; while Ulceration and Gangrene signif}^ the molecular, or the accumulative, death of Texture. Inflammation may be defined to be a local modification of Nutrition ; consisting, essentially, in an increased textural productiveness and destruction of texture, and acceleration, therefore, of the nutritive pi'ocess ; resulting in an accumulation of mixed, organized mattei", — partly, of products having an imperfect structural homology or re- semblance to healthy conditions of texture or textural elements, and partly, of debris or waste of the textures involved. In connection with this process of accelerated and imperfect nutrition, the local circulation of blood, and the containing vessels, undergo certain changes ; an increased flow or determination of arterial blood to, and in, the capillary vessels, at the seat of inflammation, stagnation and accumulation or congestion of blood in the capillaries of the inflamed part, the veins transmitting the increased current of blood through collateral capillaries, with enlargement of all the vessels concerned ; vascular changes which are accompanied with an effusion or exudation of organizable plasma or liquor sanguinis. The condition of the local circulation in the capillaries is known as the stasis of the circulation in an inflamed part. This complex process has the most comprehensive significance, both pathological and practical ; having relation to all Injuries, Diseases, and Surgical Operations. Hence, a due knowledge of Inflammation and its consequences, is of primary importance in the study of Surgery. The pathology of Inflammation is most appropriately introduced by a brief consideration of the physiology of healthy Nutrition, — in the maintenance of the structural integrity of the body, and the modifica- tions of this process in growth and development. The deviations from nutritive maintenance by increase or diminu- tion, known as Hypertrophy and Ati'ophy, will be noticed in this connection, and the Reparation of texture, also, in relation to the process of Nutrition ; these deviations from the normal Nutritive process being more or less intimately associated with the pathology of Inflammation. NuTEiTiox is that process, wherein the blood or its constituents as nutritive material — liquor sanguinis, plasma or blastema — is converted into the various textures and organs of the body ; thereby restoring or repairing the loss or waste of their structure, which continually accom- panies the exercise of their respective functions. The changes which the nutritive material undergoes are of two kinds : — chemical, in respect to its composition, plastic or formative, as productive of structure ; analogous but opposite changes taking place in the course of decomposition and destruction of the textures. The process of Nutrition maybe traced, to some extent, in certain tissues, which, being situated on the surface of the body, are open to observation. Epidermic tissues, namely, scarf-skin or cuticle, nails and hairs, are thus patent. The cuticle, for example, is a layer of cells overlaying the vascular and sensitive true skin. From the latter, a thin, and nearly transparent, serous fluid perpetually exudes, and in this, as a nutritive plasma or blastema, the cuticular cells are formed. Let a portion of cuticle be removed by a blister or a slight burn ; the exposed surface is found to be constantly bathed with this fluid. If lightly sponged dry, the surface immediately perspires, as it were, INFLAMMATION. 49 and moistens again. The cells, first formed in this fluid, are soft and round, as seen iinder the microscope, in newly formed cuticle. They are also soluble in acetic acid. They give place to similar cells under- neath, and as the first formed pass upwards from the true skin, they become dry, hard, and flattened, and acquire the characters of ordinary scaly epithelium ; which eventually disintegrates and desquamates from off the surface of the body. A chemical change also accompanies the maturation and destruction of cuticular cells ; in this stage, they are insoluble in acetic acid. This twofold process — formative and destractive — is ever going on ; the cuticle being produced, and reduced more or less perceptibly by the decay, death, and shedding of the cuticular cells ; they having previously served their function of protecting the subjacent true skin. Molecular disintegration and death, by the constant exercise of function, may be inferred, if not seen, to be proceeding in all other tissues. But constant waste, thus induced, implies constant repair, and the reparative material can only come from the blood. This vital fluid must, therefore, present an appropriate composition for the repair of each component tissue of the body, and must also be supplied in adequate quantity thereto, as all the tissues are alike undergoing incessant destruction. Assuming this twofold condition of quality and quantity of blood, due to the tissues severally ; they, on their part, select and secrete or separate from the blood-vascular system, as the common reservoir, that kind and quantity of plasma which is appropriate for their individual nutritive maintenance. The blood is thus left reduced in quantity, and moreover, deprived of those constituents which have entered into the formation of the tissues. But, as each tissue draws its own particular nourishment, the residual mass of blood, in circula- tion, becomes relatively adapted, in quality, for the proper nourish- ment of other tissues, of dissimilar composition. The tissues, severally, in their functional relation to blood-elaboration, may therefore be regarded as excreting organs. The blood is renewed in quantity, and further maintained in quality, by the co-operation of other functions,— digestion, excretive secretion, and respiration; while its circulation is regulated by the agency of the nervous system. Again and again is this fluid, replenished and renovated, distributed to every part of the body, each tissue claiming and retaining that quantity of the common pabulum which may be necessary, and selecting those ingredients which enter into its own formation, to repair its waste and thus maintain its substance. Growth and Development. — It will be obvious that any increased nutritive demand, beyond that of mere maintenance, as by Growth, necessarily implies at least an increased supply of blood to the part undergoing this change, and perhaps also a different quality of blood to meet any such additional requirement. Indeed, ever moving and vibrative as are the leaves of an aspen tree even on a breathless summer's day, so likewise oscillatory is the nice adjustment and equilibrium of nutrition. The balance of maintenance could never be continued fi-om hour to hour, scarcely from minute to minute, -without a varying capacity in the circulatory system to satisfy VOL. I. E 50 GENERAL PATHOLOGY AND SURGERY. evei"-vavying demands. This provision is brought into action by nervous influence. It is now known, originally by the experimental researches of M. Claude Bernard, that the circulation of the blood is influenced by vaso-motor nerves — nervi-vasorum — forming a "wide expanse of the nervous system, distributed to the blood-vessels, principally to the ai'teries, and extending even to their ultimate ramifications. This vascular system of nerves is derived, in part, directly from the sympathetic or ganglionic system, as from the splanchnics, which are the vascular nerves of the abdominal viscera ; and in part, indirectly, by communicating branches between the sympathetic cord and the anterior roots of the spinal nerves, as the source of nerve-supply to the blood-vessels of the extremities, upper and lower. But, "while the vaso-motor sj'stem of nerves thus proceeds from the sympathetic, its pi-imary origin is in the cerebi-o-spinal system ; isolation of any portion of the sympathetic, by division of its spinal communicating branches, being attended with paralysis of its vaso-motor functions. There is also, apparently, an excito-motory centre, presiding over the whole vaso-motor system of nerves ; for the motor influence of these nei'ves on the blood-vessels can be elicited by stimulating afferent spinal nerves, being therefore reflected by that centre, through efferent sympathetic vascular nerves. The situation of the centre here refeiTed to is intracranial, — the vaso-motor influence ceasing when the spinal cord is divided immediately below the medulla oblongata, and thereby causing paralysis of the whole vascular system. The most important results respecting the physiology of the vaso-motor system of nerves, as shown by the effects of their stimulation or their division, are thus summarily stated by Dr. Burdon Sanderson: — That section of a vascular nerve produces congestion of all the tissues to which it is distributed; that excitation by the interrupted current, or by mechanical means, produces constriction of the minute arteries pre- sided over by the irritated nerve, and consequent anaemia ; that excitation of a sensory nerve produces increased activity of the capillary circulation in the part in which the nerve originates ; and that all arteries exhibit alternating states of contraction and dilata- tion, their I'hythmical movements being entirely independent of those of the heart and the respii-ation, and ceasing when the vessel is paralyzed by division of its nerves. In addition to this indirect influence of the nervous system on nutrition, — through the nervi-vasorum, affecting the dilatation of the blood-vessels, there may also be a direct influence on the nutritive process, through an intimate relation of nerve-filaments, — trophic nerves, with the structural elements of at least some of the textures and organs of the body. Thus, experimental observations by Meissner have indicated the existence of trophic nerve-filaments in the fifth cranial nerve ; for, when the sensory root or part of this nerve is divided, except the inner fibres, the eye-ball remains uninflamed, — its nutrition is undisturbed, although there is complete loss of sensibility and the globe be subject to any external irritation ; but division of the inner fibres alone, while it leaves sensibility unaffected, is followed by inflammation of the eye-ball. Apparently, therefore, the sensory part of the fifth nerve contains, not only sensory fibres, but also trophic fibres, which directly influence the nutrition of the eye-ball. INFLAMMATION. 51 This inference is confirmed by the analogy between nutrition and secretion. The intimate relation of terminal nerve-filaments with secreting cells in the salivary glands, would seem to indicate a dii*ect nervous influence on the secretion of saliva ; and consequently a similar influence on the analogous process of nutrition. Development contrasts with growth, in representing the quality, as well as quantity, of structure produced. But the two are concurrent and co-equal manifestations of the formative power, in healthy Ifutrition. Any departure from, this concurrence of development and gTowth, results in malformation. Thus, development may he arrested, while growth proceeding, is relatively abnormal. In the formation of the heart, the ventricular septum may be left incomplete, but the muscular walls of the ventricles continue to gTow, until the heart resembles, in size, the organ at a much later period of development. On the other hand, development being normal, growth may be abnormally excessive, as when the growth of the skeleton — itself fully developed in all its bones, at length attains to the stature of a giant. In this summary of the process of ISTutrition, we observe a co- operative relation subsisting between its essential conditions : — textural changes ; and the blood, in quality and quantity, as repre- senting the nutritive material; accessory to which are the blood-vessels which convey the blood to the part nourished ; and the nerves in connection therewith, which further regulate the supply. The acces- sory character of the two latter conditions is also evinced by the fact of N^utrition taking place in comparatively avascular textures, and those which are destitute of nerves ; as cartilage. Thus, then, is Nutrition maintained : and we also observe in these conditions adequate provision for the extra demands of Growth and Development, whereby blood is duly determined to textures or parts undergoing this twofold physiological change. Hypertrophy and Atrophy denote, respectively, an increase or a diminution in the growth of any texture or organ, above or below the normal standard of its nutritive maintenance. This deviation from the condition of healthy nutrition so far relates to the quantity of organized material of which the part consists ; as indicated by aa increase or a diminution of weight, coupled generally with a cor- responding alteration of size ; except in cases where the change is interstitial,^hypertrophy then resulting in condensation, atrophy, in rarefaction, say of the osseous texture. In either case, however, the quality of the structure remains unchanged. But, not unfrequently, this alteration is combined- — a developmental metamorphosis then co-existing. With hypertrophy, development may proceed equally, or advance disproportionately ; the overgrown part thus having an equal, or acquiring even a higher, degree of organization, as in the gravid uterus ; whereas, with atrophy or wasting of a part, the developmental condition is often reduced — degeneration of structure takes place, as in voluntary muscular tissue. Either state — hypertrophy or atrophy, is immediately referable to opposite degrees of nutrition in the part affected ; but these apportion- ments of the nutritive process commonly depend on corresponding differences in the exercise of function, above or below the average 52 GENERAL PATHOLOGY AND SURGERY. demand, in co-operation Avitli other parts of the system. Certainly, these changes in the quantity of structure of which any organ or texture consists, are attended with an inci-eased manifestation, or an impairment, of its functional power. A few examples will suffice to illustrate this general view of these two deviations from normal nutrition. The cuticle of the hand grows thicker and harder, or becomes hypertrophied, under circumstances of extra-functional use, for the protection of the subjacent true skin ; as when the hand which had been previously unused to labour, is thus employed. When the laboui' is discontinued, the cuticle becomes atrophied, and returns to its foi-mer thinner and softer condition. The hypertrophic change is evinced in thickening of the muscular coat of the bladder, owing to constant retention of urine from stricture of the urethra or enlargement of the prostate, coupled with the expul- sive efforts in micturition, to overcome this obstruction ; and in stricture of the intestine, the portion of gut above acquires an hypertrophic thickness. If an artificial anus be formed, the portion of intestine below, falling into functional disuse, becomes atrojihied. Of companion organs, disuse of one beget.s hypertrophy of the other, as shown by the enlargement of one kidney from disease of the other organ ; or an ununited fi-acture of the tibia being accompanied with thickening of the fibulge. Atrophy may occur quite independently of any previous hyper- trophy ; as witnessed in the diminution or disappearance of parts disused. Thus, parts which were functionally active before birth, but the functions of which cease subsequently, undergo atrophy ; the umbilical arteries and vein, the ductus arteriosus, and the thymus gland, alike waste away after birth. Inactive muscles waste ; and the end of a bone in a stump becomes pointed — the limb having been amputated. The immediate cause of atrophy in other cases is refer- able to a diminution of one or more of the conditions upon which nutrition depends. Thus, a deficient supply of blood, as arising fi-om some occasion of pressure upon the blood-vessels ; or any of the other causative conditions which may give rise to gangrene. Defective inner- vation also tends to the atrophic change: by paralyzing the contraction of the smaller arteries, and resulting in congestion, or by directly impairing nutrition through the failure of trophic nerve-influence ; instances of which may be noticed in local muscular paralysis, from injury to the nervous centres, or to a nerve-trunk, and which is followed by rapid wasting of the muscles aifected, before their functional inactivity could have caused atrophy. Hypertrophic overgrowth of any texture or organ of the body, indicates the existence of a reserve-poicer of nuti'ition to fit its structure, both in respect to quantity and quality, for the extra-functional de- mands imposed on the part by the varied circumstances of its life — as including the contingencies of disease. But the compensatory resources of this formative reserve-power are manifested also by processes of Mepair, for the reproduction of parts destroyed by injury, or dis- organized in consequence of disease (see Wouxds and Fractures). Inflammation is another local modification of Nutrition, the same elements co-operating as in that process. This modified process can be observed when it takes place in textures on the surface of the body, as the skin ; and it is best illustrated when occasioned simply by a INFLAMMATION. 53 burn or other injury, rather than when induced by the operation of a blood-poison, as in erysipelas, boil, or carbuncle, which are specific and complicated illustrations of inflammation. (1.) Textural changes. — The twofold nature of the textural changes in Inflammation, is the same as in healthy ISTutrition ; but the textui-al productiveness, and the destruction of texture, are both increased ; and thus the process proceeds more rapidly. The destructive part of this process arises from defective maintenance of the natural tissue-elements, their nutrition being diminished or even suspended, with consequent (fatty) degeneration and disintegration of texture. And the products are not only increased in quantity, they are imperfect structural con- ditions of textural elements, by various degrees of arrest of their development; such as .pus-cells and exudation- corpuscles with coagu- lated fibrin, granular matter, and serum ; while the debris or waste matter of the texture is apt to accumulate. In virtue of its increased productiveness, inflammation differs from nutritive maintenance, and is allied to growth ; but in virtiie of its rapidity, the process is so hurried on, that more is accomplished in a given time, and consequently the products are imperfectly developed. Accelerated Nutrition would therefore, I think, be an appropriate name for Inflammation, as at once expressing its nature and distinctive character. JExperimental investigations have been instituted, chiefly by Pro- fessors Cohnheim and Strieker, with regard to the changes which the textural elements undergo in inflammation. I^on-vascular tissues are best adapted for the observation . of such changes — apart from the blood-vessels and circulation ; as the cornea of the frog, cartilage, and tendon, under the influence of irritation by caustic or a seton-thread. But vascular tissues, as connective tissue in the frog's tongue, muscle, mucous membrane, and gland tissues, especially that of the liver, have also been submitted to similar examination. The general results have been — that the textural changes represent degeneration, disintegration, and destruction of the natural tissue elements, coupled with increased activity of cell-life, in the proliferation or germination of protoplasm or of cells, which multiply either by cleavage or by endogenous ger- mination. Whether this increased textural productiveness be due to the direct stimulant action of the liquor sanguinis eifused from the capillary blood-vessels, or be referable to nerve-influence, may be regarded as an open question. Strieker's experiment would indicate the stimulant influence of inflammatory effusion. Inflammation having been induced in the eye of a fi'og, the cornea of the other eye was excised and inserted beneath the membrana nictitans of the inflamed eye ; and from contact only with the effusion, or by its imbibition, the excised cornea underwent the same textural changes as in the unexcised source of inflammation. (2.) State of the circulation of blood, and of the blood-vessels, in rela- tion to, and in, the part inflamed. — This element of inflammation necessarily pertains to vascular textures ; nevertheless, comparatively avascular textures, such as cartilage, which are nourished by imbibi- tion, are affected by the circulation of blood in the adjoining texture, whence they derive their nutritive material as the source of supply. The blood current to, and from, an inflamed part, through the arteries and veins respectively, is increased in quantity, force, and 54 GENERAL PATHOLOGY AND SURGERY. rapidity ; so also it would appear to be pi'imarily increased in the capillaries of the pai't, but secondai'ily it becomes stagnant, a condition known as the stasis of the circulation in those vessels. The arteries, veins, and capillaries all apparently become enlarged. Enlargement of the arteries, with increased flow of arterial blood through them, constitutes determination of blood ; enlargement of the capillaries, with slow movement or stagnation and accumulation of blood in them, constitutes congestion of blood and stasis ; the enlarged veins transmitting the increased current of blood, through collateral capillaries. Or, the state of the circulation in an inflamed part may be thus expressed — General dilatation of all the vessels, capillary, arterial, and venous; with a central focus of stagnant blood (stasis), a surrounding zone of slow movement (congestion), and a circum- ferential area of rapid movement (determination). In Inflammation, the presence of determination of blood, subse- quently of congestion, and the co-existence of both these vascular con- ditions, are facts which have been more or less established by the following experimental observations : — • (a.) Arterial and Venous Circulation. — The arteries towards an in- flamed part throb with increased pulsation, while the veins therefrom are turgid. It might appear that the former are beating with blood apparently rebounding fi^om some obstruction in advance, and that the latter become turgid with stagnant blood. But experimental observa- tions demonstrate the accelerated rapidity and force of the blood's motion to, and from, an inflamed part. Let an artery toward a part inflamed be divided, and the blood is seen to be ejected to a much greater distance than that from an arteiy of the same size and distance from the heart, but not contiguous to an inflaimed part. This increased propulsion was noticed by Dr. John Thomson, when the arteries of a finger were di\'ided in Avhitlow, and when those of the prepuce, much inflamed, were cut in the operation for phimosis. More exact, because comparative and otherwise complete, was the observation of Mr. Lawrence. One hand of a patient being inflamed, venesection was perfoiTued, at the same time, and in a similar manner, in both ai'ms : the vein, from the inflamed hand yielded about three times more blood in a given time than the vein from the uninflamed hand. The blood's motion from the jDart Avas increased. Enlargement of the arteries leading' to an inflamed part, in the human subject, is rendered probable by Hunter's well-known experi- ment on a rabbit. Hunter froze the ear of a rabbit, and thawed it again ; acute inflammation began, with increased heat, and considerable thickening of the part. The rabbit was killed when its ear was at the height of inflammation. The head was then ejected, and the two ears were removed and dried. The uninflamed ear dried clear and trans- parent ; its vessels were distinctly seen ramifying through its substance ; but the inflamed ear dried thicker and more opaque, and its arteries were considerably larger. (&.) Capillary Circulation. — The state of the capillary circulation in inflammation has been observed in the transparent parts of certain of the lower animals, chiefly in the web of the frog's foot, or in the mesentery of that animal, and in the bat's wing. Conclusions drawn from such data relative to the human organism, are inferential only, INFLAMMATION." 55 the physiological and structural conditions being dissimilar. Yet these inferential conclusions represent the remainder of what is known respecting the nature of inflammation, in the human subject. Determination and Congestion of blood co-exist at the seat of inflam- mation. Dr. C. J. B. Williams was one of the earliest observers who demonstrated this conjunction of increased and diminished motion of the blood in the capillary vessels in inflammation ; and also that the resulting compound state of the capillary circulation may originate either in determination or in congestion, or in the concurrence of both simultaneou sly . To illustrate the origin of inflammation by the concurrence of deter- mination of blood and congestion, Dr. Williams adduces experimental observations on the web of the frog's foot, under the microscope. " If," says he, " a strong irritant, as a gi^ain of capsicum, or a minute globule of essential oil, be applied to the -vveb, all its blood-vessels speedily become enlarged ; those most irritated are very large and red, and the blood in them is stagnant and coagulated ; contiguous vessels are also very large, but less red, and the motion of the blood in them is slow, Fig. 1.* Fig. 2.* and often in pulses or oscillations ; whilst in vessels beyond, the en- largement of the capillaries is less considerable, but that of the arteries is obvious, and the cuiTent of blood is very rapid." f This descrip- tion has more recently been confirmed essentially by Dr. Burdon Sanderson, and other observers ; — that, in inflammation, the vascular phenomena consist of "increased activity of the capillary circulation in the affected part, followed by diminished circulation;" or con- versely, that the vessels may become contracted, in the first instance, followed by dilatation ; this difference depending on the kind of irritant employed, as a solution of ammonia, while a. solution of caustic soda, produces dilatation succeeded by contraction, and croton oil seems to have a variable effect on the vessels, sometimes producing the one, sometimes the other. The general enlargement of the capillary vessels is well shown in the bat's wing ; where, as compared with their natural condition, before irritation (Fig. 1), the vessels have become dilated to nearly twice * (Wharton Jones.) f " Principles of Medicine," Edit. 3rd, 1856, p. 323. 56 GENERAL PATHOLOGY AND SURGERY. Fig. 3.* theii" diameter, and many more have become A^sible within the area of the focus of irritation (Fig. 2). The cessels having undergone dilatation, they generally also become lengthened and tortuous, and sometimes present fusiform or saccu- lated enlargements, as the result of their weakened and inelastic state from over-irritation, in an advanced stage of inflammation (Fig. 3). In any healthy, or temporary, determination of blood, as that of blushing, the smaller arterial and the capillary vessels are uniformly dilated, and thus transmit an increased afflux. Their partial dilatation, — fusiform or sacculated, is apparently so far distinctive of inflamma- tory or persistent determination of blood. This state of the vessels, as originally noticed by Kolliker and Hasse, in inflammatory red softening of the brain, would seem to be a manifestation of the general tendency to degeneration in the textural elements of an inflamed part ; giving rise to an aneurismal or varicose condition of the vessels, similar to that which occurs in larger vessels — arterial or venous, whereby they yield, here and there, to the cun-ent of blood. Yet the partial dilatations, thus induced, are not peculiar to inflammatory hypersemia, being found — according to Virchow's observations — in other dis- eases attended with a degenerative laxity of the vessels. The blood con- tained in the vessels undergoes certain changes, the red corpuscles being im- pacted, accompanied with an increased production, apparently, of the pale corpuscles, which also appear to be more adhesive, and cling to the sides of the vessels. But the capillary cir- culation of a warm-blooded animal, as in the bat's "wdng, when thus sub- jected to irritation, does not exhibit any increased proportion of white corpuscles, according to the observations of Wharton Jones and Paget ; and in the frog, that condition is found at an early period of life, — during rapid growth, or it may be due to an ill-nourished state of the animal, thus arresting the development of the white corpuscles into the red. In the human subject, the alleged increased production of these corpuscles seems very doubtful ; for, whether by examination of the blood drawn from an inflamed part, during life, or by inspection of the vessels after death, the results of Paget's numerous observations were to the same effect, — that the same proportion of white corpuscles exist in the vessels, and in the blood, of an inflamed part, as in other parts of the body. Lastly, the investigations of Dr. Hughes Bennett respecting leucocythemia or white-celled blood, supply the additional evidence, — that even with an excessive proportion of these corpuscles in circulation, there is yet no predisposition to inflammation, nor to any aggravation of this process. The leading vascular change in inflammation — acceleration of the capillary circulation — is referable to an impression received by the cen- tripetal nerves of the injured part, and reflected by the vaso-motor * (Paget.) INFLAMMATION. 57 centre througli the centrifugal nerves to the vessels. This physio- logical explanation rests on the observations of Lndwig and Loven ; in curarised rabbits, excitation of the central end of a divided nerve in the external ear, or of the dorsal nerve in the foot, was noticed with regard to its effects on the corresponding artery ; and similar experi- ments on the sciatic nerve of the frog, relative to the circulation in the web of the foot, were conducted by Strieker and Eiegel, and repeatedly verified by Dr. Sanderson. On the other hand, the direct influence of irritation upon the walls of the vessels, is shown by Cohnheim's ex- periments, in which, dilatation of the vessels and acceleration of the blood-stream were produced in the tongue of the frog, when the lingual artery and vein were alone left undivided ; and also after removal of the brain and spinal cord. The retardation of the blood-stream and stasis of the circulation in the focus of inflammation, result from some change in the vitality of the vessels, and is not owing to any abnormal tendency in the corpuscles to cohere, and thus become impacted. For, Ryneck's experiments have shown that stasis occurs in the vessels of the frog's web, when injected with milk instead of containing blood ; but that when the vitality of the vessels was destroyed by the injection of powerful irritants, no stasis could then be produced. Emigration of blood-corpuscles througJi the walls of the Capillaries. — In the course of Inflammation, the passage of blood-corpuscles through the walls of capillary vessels seems to have been originally noticed by Dr. W. Addison (1842), and more completely described by Dr. A. Fig. 4.* Waller (1846) ; but this remarkable fact first attracted attention by the observations of Professor Recklinghausen (1863), Professor Strieker (1865-6), and specially by the investigations of Professor Cohnheim (1867) and Dr. Prussak ; more recently confirmed in this country by Dr. B. Sanderson. Experimental observations upon the transparent parts of animals, as the foot-web, or the mesentery of the frog, or the tongue of that animal, have been the source of our knowledge in this important physiological inquiiy. The process of emigration in the ■passage of white corpuscles, or leucocytes, is as follows : — The corpuscles having accumulated within the capillary vessels, those which lie on the interior of the vessel begin to sink into the capillary wall, pre- senting button-shaped projections externally (Fig. 4) ; gradually en- * Mesentery of living Frog. — a. Vein. hh. Adjoining connective tissue per- meated by colourless corpuscles, which have migrated from the vessel, c. Centi'al column of red corpuscles, jj^j. (Cohnheim.) 58 GENERAL PATHOLOGY AND SURGERY. larging in the shape of pyriform bodies, the imbedded corpuscles pass through the wall, but are still adherent by their pedicles ; lastly, becominsr detached, the passage is completed, and ^he corpuscles — which have thus emigrated from within — are each free outside the vessel. The red corpuscles may emigrate in like manner, though less abundantly. The cause of this migratory process seems to be. that the cells possess an inherent vital activity — that of pi'otoplasm. and resembling the mobile power of arruehce ; and that the capillaiy walls also possess the same contractile power of protoplasm, in addition to their vital capacity for proliferation, as evinced in the ramifying formation of new vessels, and. moreover, the physical properties which had long since been known. Thus, then, the capillary vessels and the blood-corpuscles, white and red. are apparently alike endowed with the power of amceboid activity : and thence the emigration of the cor- puscles in the process of Inflammation. In tracing the process of Inflammation, it is diflBcult to determine the order of succession in the changes which essentially constitute this pi"0cess. The question of priority, therefore, on the part of the textures or blood, is doubtful. Whether an increased textural pro- ductiveness, and consequent demand for nutritive material, induces an exti'a flow of arterial blood towai'ds this focus of accelerated nutrition ; or whether a determination of blood solicits the formative power of the textures to more active, albeit abortive operation ? The latter view, originally advocated by John Hunter, long held undisputed acknowledgment in the schools and in medical literature ; befoi"^ the textures were discovered, so to speak, by Bichat, and before the grand and fertile theory of cell-development introduced by Schwann and Schleiden. But the independent vitality of the textures in relation to the blood, a physiological doctrine probably entertained by Haller, was subsequently extended to pathology by Hebrenstreit, Burdaeh, Alison, and others ; while, in respect to Inflammation espe- cially, this docti'ine is strehuously advocated with great originality of argument by Virchow,* and exclusively adopted by Mi-. Simon and other pathologists in recent works. That the determination of blood is not the essential constituent of inflammation, would appear, as Paget remarks, from the lower organization of its products, com- pared with that of an hyperti'ophied part, — although there is an increased supply of arterial blood in both these modifications of !Xutrition. For the discussion of any other doubtful points respecting the intimate nature of Inflammation, and more particularly as investigated in animals, the reader is referred to abundant sources of interesting information in the writings of Wilson Philips, Kaltenbrunner, Gerber, Gendrin, Muller, Lebert, Rokitansky, Alison, Henle, Macartney, Addison, Travers, Gulliver, Wharion Jones, C. J. B. WilHams, Bennett, Paget. Lister. Beale, Virchow. Billroth. Cohnheim, Strieker, Waller, Prussak, Eindfleisch, Remak, Buhl, Recklinghausen, Arnold, Samuel, Simon, and'Burdon Sanderson. Si^n^. — The local signs of inflammation — as enumerated from rime immemorial — are redness, heat, swelling, and pain ; the first three being objective phenomena, pain a subjective symptom ; and there is also some functional distui'bance or loss of functional power * •' Cellular Pathology." Trans. F. Chance. INFLAMMATION. 59 in the part affected. In proceeding to consider the relative value of these indications as evidence of inflammation, the general principle of diagnosis should here be remembered ; that no one or two signs alone are sufficiently distinctive, — being" possibly absent in some cases, or present in connection with other morbid conditions ; but that, taken collectively, they afford aonclusive evidence that the process of inflammation underlies their manifestation. (1.) Redness is a sig-n of inflammation, owing to the determination of arterial blood ; but the development of this sign will be propor- tionate to the number of capillary vessels pervading the part, and the extra flow of blood through them ; coupled perhaps with infiltration of the textures with colouring matter, from disintegration of the red corpuscles. The colour, a florid hue, varies according to the arterial or venous character of the blood, and as shaded by any intervening texture ; or it may be entirely unseen through the depth of integu- ment concealing the engorged vessels. Various shades of redness are met with in different inflammations : a bright crimson hue in acute inflanimation ; a darker or purple tint in the chronic form ; a damask redness in erysipelas, or a brownish lividity in phlegmonous erysipelas ; a yellow redness when associated with jaundice j a copper hue in syphilitic inflammation ; a purplish lividity, deepening into black, whenever inflammation becomes gangrenous. The vascular engorgement, or hypersemia, presents different shapes, according to the peculiar anatomical arrangements of the capillaries in the texture or part. Hence punctiform, stellate, arborescent, maculiform, or spotted, and uniform blush-redness, are frequently recognized, as in the skin and mucous membranes which are open to inspection. The redness may be circumscribed, as in phlegmonous inflammation ; or diffused, as in the erysipelatous. Heemorrhagic redness, arising from the interstitial extravasation of blood, in the form of spots or petechia, may be an accidental coincidence with, or result from, inflammatory engorgement of the capillary vessels ; but increased redness from this source will be readily distinguished from that of inflammation, the one remaining under pressure with the finger, the other disappearing when the engorged vessels are thus emptied. Persistent redness, such as I have described, is the earliest an- nouncement of inflammation, and also its most certain indication, being invariably present even when unseen, a sign of no other kind of hypersemia, and the measure of its own. The exceptional case of a growing part, e.g. new bone, or the gravid uterus, having similar redness, scarcely invalidates the general fact that this sign is, other- wise, peculiar to inflammation. Nor does its exceptional absence in extra- vascular tissues, e.g. cartilage and the cornea, affect the other- wise, general constancy of this hypersemia. Even in such cases the adjoining textures exhibit its characteristic appearance, as by a zone of redness around the cornea, in corneitis, and increased vascularity of the adjoining bone, in inflammation or cartilage. In either case, the seat of hyperaemia coincides with the capillary plexus which is subservient to the healthy nutrition of the part inflamed. Redness from, the development of new vessels in an inflamed part is not an early occurrence, but a consequence of the process of in- flammation. (2.) Reat is another local sign, partly due to the determination 60 GENERAL PATHOLOGY AND SURGERY. of blood ; as siich it is proportionate thereto, and to the number of vessels through which the extra supply of arterial blood is passing. But the increase of temperature will be perceptible only according to the superficial situation of the inflamed part, and the facility with which heat is transmitted through any intervening textures. Is heat generated by inflammation ? The flow of artei-ial blood, and therefore of red blood-corpuscles charged with oxygen, may pos- sibly generate heat. Yet the experiments of John Huntei- show that the temperature of an inflamed part never rises more than two or three degrees, and scarcely, if ever, above the average heat of arterial blood — say, from ninety-eight to one hundred degrees Fahr. On the other hand, the experiments of Becquerel and Breschet, and the more recent "thermo-electric" observations of Mr. Simon * and Dr. E. Mont- gomery are apparently conclusive on this point — that an inflamed part is no mere passive recipient of heat, but is itself actively calorific. For among the observed results are these : — " That the arterial blood supplied to an inflamed limb is less warm than the focus of inflammation itself. " That the venous blood returning from an inflamed limb, though found less warm than the focus of inflammation, is warmer than the arterial blood supplied to the limb ; and, " That the venous blood returning from an inflamed limb is warmer than the corresponding current on the opposite side of the body." Granting, then, that the inflammatory process unquestionably involves a local production of heat, " to interpret this fact," adds Mr. Simon, " is perhaps, in the present state of physics, not possible." Whatever be the source of increased heat, it dbntinnes with the inflammation, unlike the transient warmth of blushing, or other non- inflammatory determination of blood. Respecting its diagnostic value, the increased heat arises at the same time as the redness ; it is an equally early, if not an equally sure sign of inflammation. (3.) Swelling. — The persistent or inflammatory deterruination of blood is accompanied with the appearance of liquor sanguinis, i.e. of coagulable lymph or fibrin, and serum, — constituting what is known as e fusion or exudation. This, by its accumulation in the part, and augmented by increased textural productiveness, or proliferation of tissue, coupled with the emigration of blood-corpuscles, gives rise to swelling in a greater or less degree, unlike the issue of that temporary distension of the vessels, which ordinary determination of blood denotes. The presence of fibrin is characteristic of inflammatory effusion, as distinguished from that produced by venous congestion ; unless in cases of great intensity and duration, when there niay be a slight admixture of fibrin with the serum effused from the congested vessels. The engorged vessels themselves occasion some degree of swelling of the part ; an increase proportionate to the vascularity of the part, and to the degree of turgescence of its vessels. Full-blooded internal organs become most swollen in this way, such as the lungs, liver, spleen, and kidneys when inflamed. Associated with the swelling thus produced, the blood may be effused or extravasated, actual * " System of Surgery." Edited by T. Holmes. Vol. i. " Inflammation," by J. Simon, p. 42. INFLAMMATION. 61 liemorrhage taking place ; or sometimes the exudation of colouring m.atter only, from, disintegration of the red corpuscles. At a later period haemorrhagic effusion may occur from ruptui-e of the yet tender new vessels formed in organized fibrin. But, generally, from a persistent increased flow of blood, the sur- charged vessels would appear to be gradually relieved by elf usion of the liquor sanguinis. Virchow * regards the fibrin, not as an exuda- tion or effusion from the vessels, bat as an educt from the vessels, in consequence of the activity of the histological elements themselves. Professor Bennett f suggests that the tissues attract the fibrin, which, however, pre-exists in the blood. The situation, size, shape, consistence, and physical characters generally of the swellings will, for the most part, depend on the kind of structure in which it takes place. Liquor sanguinis is readily effused into the constituent cellular texture of the organ, or part inflamed, and therefore most readily into the substance of loosely parenchymatous organs ; frequently, more- over, the most vascular, such as those just enumerated. Lymph and serum overflow into cavities, e.g. into serous membranes and syno\na] sacs. These and similar structures solicit the overloaded vessels to relieve themselves, and their size becomes enlarged, in a con-espond- ing measure, by inflammation. Witness hepatized lungs from pneu- monia in its second stage ; immense enlargement of the liver fi^om chronic inflammation ; enormous increase of the spleen, forming the aguecake by an analog'ous process ; and the large size to which the kidneys attain by chronic nephritis and Bright's disease. Phlegmo- nous erysipelas — engaging, as it does, the subcutaneous cellular tissue deeper and deeper — is characterized by considerable swelling. Witness the opposite result in tight, unyielding textures — such as effusion beneath fasciae and in fibrous textures generally, and an abscess formed in the substance of bone, but unattended with any perceptible swelling, and suspected only by the intense and unremit- ting pain it occasions. Certain textures allow of an intermediate amount of swelling between the extremes presented by cellular and fibrous tissues. Such are the degrees peculiar to the skin and mucous membranes. Of the latter I may mention pulpy thickening of the large intestine in cases of chronic dysentery ; while swelling, in some measure, of the skin is one feature of most of its eruptions, however otherwise diversified their appearance may be — as rashes, scales, papules (pimples), vesicles, pustules ; and most conspicuously is this the character of solid tubercular swellings, such as occur in secondary syphilis. The shape of inflammatory swelling is also a mixed result, princi- pally due to the kind of structure into which effusion takes place ; partly, however, to the kind of matter effused. If thin serum, the swelling will be fluid, fluctuating, and diffused ; if coagulable lymph be poured out, it will be more solid and circumscribed. But the lymph may not underg'o coagulation, — remaining in a fluid state, commingled vrith the serum, for some days, even after death, provided it be con- tained within the body. Under exposure to the air, coagulation speedily takes place. I shall not attempt to describe the various * " Cellular Pathology," p. 162. t " Cliu. Lectures on Medicine," 1858, p. 133. 62 GENERAL PATHOLOGY AND SURGERY. degrees of density or consistence which inflammatory swelling pre- sents, as resulting from the combined influence of the kind of matter effused, and that of the receiving structure. These alterations may be of two kinds : softening, chiefly in connection with acute inflammation, and induration, chiefly in consequence of chronic inflammation. The diagnostic value of inflammatory swelling is not equal to that of redness. It is necessarily a later sign than redness, which always precedes effusion by an irapoi-tant and often appreciable period of time. Iritis is announced by injection of the ciliaiy arteries and a zone of redness around the iris, before the perilous effusion of lymph. Erysi- pelas spreads with a red blush before the disorganizing engorgement of the subcutaneous cellular tissue. Regarded as a sure sign, although some degree of swelling invariably follows inflammatory determination of blood, and although the nature of an obscure swelling is assured, if not by its physical properties, at least by puncture, and if necessary by further examination of the material of the swelling with the microscope ; yet these guarantees of identity are the only unequivocal, advantages of this sign. Unlike redness, it is no measure of the degree of inflammation. The most intense may produce a trivial swelling in an unj'ielding texture, and a ti-ivial degi-ee of inflamma- tion will soon exhibit considerable swelling in a loose tissue. Subject to these disqualifications, swelling is the more valuable sign, practically speaking, of inflammation. It can be discovered when the redness cannot be seen. In all superficial textures and parts, swelling can be readily detected. The skin, cellular texture^ muscles, periosteum, bone, blood-vessels, and lymphatics, and the component tissues of the joints, severally present each a characteristic swelling when inflamed. Certain internal organs are also open td examination, e.g. the pelvic viscera, excepting the bladder. Thus, inflammatory enlargement of the prostate, or the uterus, and thicken- ing of the rectum, can be felt, and possibly seen. Certain other organs are, indeed, beyond the reach of vision and the direct applica- tion of the hand, yet the ear can then detect effusion and swelling by means of percussion, as of the liver, gastro-intestinal canal, and spleen ; and this may be aided by auscultation, as of the heart and lungs. (4.) Pain. — Observe the influence of swelling. No sooner has the first contribution toward swelling been made by persistent distension of the vessels of the inflamed part, than pain, or at least exalted sensibility — tenderness — is induced by the blood's influence on the nerves of that part. The degree of pain from this cause will be regulated by both the elements which determine the amount of hypergemia — that is to say, will be propoi-tionate to the determina- tion of blood, and the vascularity of the part ; but the number of sensory nerves affected will further apportion the degi^ee of pain. As swelling ensues from effusion, the same conditions which represent the degree of tension, will also measiu^e the intensity of the pain. Thus a more solid, and therefore circiimscribed effusion of coag-ulable lymph, underneath an unyielding texture, such as a fibrous membrane, e.g. the fascialata, or a fluid similarly circumstanced, as an abscess in the substance of bone, are aggravating conditions inducing the most severe and unremitting pain ; while a fluid, serous effusion into a loose texture such as the cellular tissue, say of the armpit, allows of a- INFLAMMATION. 63 considerable accumulatioQ without much pain, and will then be more tolei'able. Pain is also attributed to structural change in the nerve- fibrils of the inflamed part. The character as well as the degree of pain accompanying inflam- mation, is equally diversified. A burning pain in erysipelas, whence the popular name of this disease — St. Anthony's fire ; a scalding pain in inflammation of the rectum, during evacuation of the faeces. Chronic rheumatism and lumbago are attended with the. dull aching pain of inflamed fibrous and muscular tissues ; gout, with a wrench- ing pain ; abscess in bone, with an unremitting burrowing pain ; inflammation of the dental periosteum, or periodontitis, with a throb- bing pain. In other parts this character of pain is the known fore- runner of suppuration. Parts endowed with but little sensibility in health, generally become acutely sensible when inflamed ; as fibrous textures and bone, including the teeth ; the intestinal canal in enteritis, the pleura and peritoneum respectively, when inflamed. Parenchymatous organs likewise acquire exalted sensibility, as mani- fested by the heavy, oppressive pain of pneumonia. Organs of special sense are for a time quickened by inflammation, and convey their own sensations but too keenly. The ear becomes too susceptible of sound, and iritis begets intolerance of light. The pain arising from inflam- mation may extend to parts distant, but continuous with the seat of origin ; as from a whitlow, the pain passes up the finger and hand, thence perhaps up the forearm to the shoulder. Ophthalmic pain may involve the brow. Reflected pains in distant parts are not uncommon symptoms of inflammation. Pain in the inner side of the knee may emanate from inflammation of the hip- joint ; in the glans penis, from cystitis ; in the testicle, from nephritis ; under the right shoulder-blade, from hepatitis ; and under the left scapula, from gastritis. Reflex motions are often excited in like manner ; sneezing, by catarrh ; coughing, by bronchitis and pneumonia ; vomiting, by gastritis ; and (reflex ?) micturition, by cystitis. The diagnostic value of pain is comparatively little. The pain of Inflammation being chiefly due to swelling, is scarcely an earlier sign. It is also the most uncertain sign ; pain may be absent in true inflam- mation, and present without ; and is rather a measure of the kind of swelling than of the degree of inflammation. By itself, therefore, pain has little diagnostic importance. (5.) The function of the organ or texture affected, undergoes cer- tain changes, which constitute additional local symptoms of inflamma- tion. They may be described in general terms, as exaltation of function, followed by its depression, and various perversions of function having an intermediate character. Thus, with inflammation of the brain ; delirium, increased sensibility, and convulsions, are succeeded by stupor and paralysis. Inflammation of the spinal cord presents similar symptoms ; excepting, of course, any modifications of purely cerebral functions. With nephritis, the secretion of urine is first increased, then diminished ; and so with regard to other secreting organs. In pneumonia, dyspnoea represents increased respiratory effort, but this is attended with imperfect aeration of the blood and the retention of hydro-carbonaceous matter. Accumulation of ex- crementitious matters in the blood is the most serious consequence 64 GENERAL PATHOLOGY AND SURGERY. of inflammation affecting any specially exci'eting organ ; as tho kidneys or skin. From Inflammation, as a local morbid process, which I have desig- nated Accelerated Nutrition of the part affected, "vve pass to its ac- companying constitutional disoi'der, a febrile condition of the whole body. Constitutional Symptoms — Inflammatory Fever. — The phenomena of this fever are briefly these : — The heart's action is excited, the pulse becoming more forcible and frequent than usual, and in some cases less compressible, while the temperature rises, perhaps to 10° F. above the normal heat of the blood, — as determined by the clinical ther- mometer placed within the axilla or the month of the patient, for two or three minutes ; the skin is diy and hot, alternating with chilliness or even shivering, the ui'ine scanty and high-coloured, the tongue dry and furred, the bowels probably constipated, and the fseces di-y and hard ; thirst and inappetency, weakness with general nervous excite- ment, — restlessness, sleeplessness, or delirium, and hurried respii-ation, are also primary phenomena. Thus, the vascular, secretory, and nervous systems, are together engaged in a constitutional disorder — symptomatic of the local inflammation, and hence sometimes named Symptomatic Fever. When the nervous phenomena predominate, as delirious excitement, soon succeeded by exhaustion in broken-down constitutions, it has been named Irritative or Nervous Fever. In a typical case of inflammatory fever, — as arising from com- pound fracture, without much hgemorrhage, — the patient, if otherwise sound and strong, exhibits the following symptoms, of which the clinical description given by Mr. Simon is true to life : — Before twenty-four hours have elapsed from the time of injury, the patient's general system begins to be thus affected. He feels hot, or alterna- tively very hot and chilly. His skin and lips and mouth are diy. He passes urine in less quantity, but of higher colour, than usual. His pulse is quickened. A sense of general disorder gains upon him. He becomes restless and intolerant of disturbance. Signs of drought increase with him. His urine becomes scantier and more coloured. His skin feels hotter to the surgeon's hand, and his pulse, whether full or hard, is quicker and stronger than before. He craves more and more for water. His face has a flushed, anxious look. He is thoroughly uncomfortable ; feeling distressingly hot, but at intervals feeling touches of chilliness — sometimes even of such cold that he shivers with it. His sleep is troubled and unrefreshing ; or, as night comes, he gets delirious. His tongue, besides being dry, is furred. If his bowels act (which commoni}' they are inapt to do without laxatives) the excretions are morbidly offensive. Gradually these symptoms give way : in proportion as the injured limb ceases to be tense, and passes into suppuration, the skin and mouth become moist again ; the excretions lose their concentrated character ; the hard pulse softens, and the heart's action becomes quiet ; the nervous system is no longer restless ; the look of trouble passes from the countenance ; and the patient can again take solid food. On Temperature in Disease, and the Clinical Hiermometer. — In the process of Inflammation, the generation of heat m.ay be termed a " product," just as the collection of lymph and white blood- cells, whether known as effusion or suppuration, are also products ; accruing INFLAMMATION. 65 from those textural changes, involving the blood, which constitute a localized acceleration of nutrition, and which, in the increased produc- tion of heat, is still not inaptly designated Inflammation. But this increased production of heat in the part, becomes a more exact si^n of the degree of inflammation, in proportion as any rise of temperature can be accurately measured. Then again, heat from the part, passing by successive increments into the blood in circulation, and thence raising the temperature of the whole body, is assuredly the most tf-sen- tial element of inflammatory fever. Yet here also, the value of this element, as a symptom of the degree or intensity of the fever, must be estimated by measurement. And in febrile conditions generally, not to mention most other forms of disease or injury, the temperature of the part or of the body has become a cardinal consideration. Accordingly, in the clinical observation of inflammatory fever, for example, the question of temperature is now commonly determined by means of a delicate thermometer (Fig. 5), the use of which has entirely Fig. 5. |uii|iiii|iui|iiii|i[ii|iiii|Uii|iiii|iii||iii|| nii| i uni i ii|Mn|iiiii i ii i ii i ii | iiii|ii i i|ji i | i i ii[ii n | >, 'JO s -l loo i no ^ superseded the far less exact appreciation of temperature by the sense of touch. The straight instrument figured, is self-registering, by Ftg. fi. OECEM BEgl 9. 10. II • 12.13. !iTiianB3nw3iTiraFTiranirai.'.Bdnii3iiB3r E M.EM. EM -EM-EM. EM. EM. EM. E ME means of a small line of mercury, as an index, detached from the main column in the stem. This thermometer is commonly used by VOL. I, F 66 GENERAL PATHOLOGY AND SURGERY. introduction into the mouth, rectum, or vagina. A curved ther- mometer at the bulb end, is better adapted for the axilla. Hoio to use the Thermometer. — Before introducing the instrument, the index must be set, or brought down below the graduated part of the stem. Holding the bulb end of the instrument in the hand, by a rapid swing — not shake, of the arm, the index may thus be placed for registration, or another such movement may be required. Then passing the bulb end into the month, under the cheek, until nearly the whole stem is buried, the mouth is closed ; and the instrument is kept there for a period of some minutes — not less than four or live. On withdrawing it, the mercurial column rapidly falls, but the index remains in situ, and the top of this line, namely, the end farthest from the bulb, indicates the highest degree of temperature registered. A non-registering thermometer must be read before it is removed. In the axilla the space must be closed up. For this method of observation, " Temperature Charts " have been constructed, to accurately record the temperature of a patient, at the two most significant periods, morning and evening, in the course of every twenty-four hours. The state of the Respiration, and of the Pulse, each with regard to one important element — its frequency — is taken in conjunction with the Temperature. The chart on page 65 (Fig. 6) represents the rise and fall of tem- perature daily, morning and evening, in a case of traumatic inflam- matory fever, from compound fracture of the leg, under my care in the Hospital. After the fever-curve in this case, the influence of disturbing causes in producing an increase of tempei'ature, is indicated also by the rise which occurred from readjustment of the splint, and when suppuration commenced. For the record of observations in ordinary cases, a tabular view will perhaps suffice, as in the following Hospital form : — No. in Register SURGEOX Ward House Surgeox_ Dresser Name Disease Date. Hour. Temp. Pulse. Resp. Remakes. Date. Hour. Temp. Pulse. Resp. Remarks. But the characters of the Pulse afford no less faithful indications as to the state of the circulation; and here the invention of the Sphygmo- o-raph has at length supplied the most exact and intelligible evidence ; for with this instrument the pulse wave writes, and records, its own testimony. Pulse-tracings must, however, be read and interpreted INFLAMMATION. 67 aric^Tit by tte clinical observer. The use of the Sphygmograph m the investio-ation of disease is not generally understood ; and as Dr. MahonTed has made tbis instrument and its applications the subject of special study, I am indebted to him for the following description. On the Pulse in Dis- ease, and the Sphygmo- graph. • — " Various forms of Sphygmographs have been contrived, but none ever obtained recognition as an instrument likely to be of use in clinical medicine, till M. Marey produced his, which, with some modifications, is the one now in general use. His instrument was port- able, could be applied without much difiiculty, and yielded valuable in- formation with regards to the circulation. The chief fault about this instru- ment is the inability to vary or gauge the amount of pressure applied to the artery, and required to develop the pulse. Various methods have been sug- gested by which to regu- late and measure pressure. That I have employed is at once accurate and simple. Fig. 7 is a draw- ing of this instrument, from which a general idea of it can be obtained, while Fig. 8 is a sectional diagram to illustrate the arrangement of the levers and the method of measuring pressure. The instrument consists of a brass framework attached to ivory bars and is strapped upon the arm, which reposes on a double inclined pad 68 GENERAL PATHOLOGY AND SURGERY. or splint. The framework supports the spring which presses npon the pulse and the system of levers, by which the movements imparted to the spring by the pulse are magnified and conveyed to the writing lever, which inscribes them upon a slide, moved past its extremity by clockwork. To the fi"amework also is attached a small brass box containing the clockwork ; along a groove in the top of this box the slide, on which is stretched smoke paper, travels. " The mainspring of the instrument a (Fig. 8) is attached to the framework by a hinge-joint H, and is free at the other end, which is applied to the pulse. To the centre of this spring is attached a small block c, which is received between the bifurcated extremity of the short intermediate lever B, and which is attached to the block by a pin which forms its centre of movement. The free extremity of this lever is turned upwards at a right angle, and ends in a sharp knife edge, upon which rests the long writing lever d. The centre of movement for this lever D is a pin, which passes through it and into the framework of the instrument at the point F. The screw E passes through the intermediate lever b, close to its free extremity, and rests upon the spring which presses upon the pulse. The movements of the pulse are imparted directly to the spring A, from the spring to the screw e, which rests upon it, by the screw to the intermediate lever B, and from the intermediate lever to the writing lever D. " The writing lever D thus forms a lever of the third order, and though working at a mechanical disadvantage with regard to power, it gains in rapidity and extent of movement ; the small movement imparted to it bv the intermediate lever B, close to its fulcrum F, is greatly magnified by the very great proportional length of the whole lever, and the consequently much greater excursion of its free or writing extremity. By the screw E, the short intermediate lever is kept in contact with the writing lever, the distance between the writing lever and the spring varying with the depth to which the spring a presses into the soft parts, and therefore with the degi^ee of pressure employed and the amount of fat in the subcutaneous tissue. " The pressure of the spring upon the artery is varied by turning the thumb-screw at the side of the instrument, and thus causing the eccentric G to revolve above the spring a. The longer the radius of the eccentric at its point of contact with A, the greater the pressure upon the spring, and therefore upon the artery. The amount of this pressure is indicated on a dial plate, seen at the side of the instrument, and measured in ounces of Troy weight. The pressure employed to obtain a perfect tracing should always be recorded, and the pressure required to completely compress the pulse and arrest the movements of the lever may also be noted. " It is unnecessary to detail at length the method of applying the instrument ; sufiice it to say that the arm should be placed on a double inclined pad, the angle of which should be about 135°, the instrument strapped on to it, care being taken to apply the ivory pad at the extremity of the spring over the centre of the radial artery, where it lies on the inner side of the styloid process, and is crossing the anterior ligament of the wrist-joint. The proper pressure to employ is that with which the greatest height of upstroke can be obtained. The upstroke should be uninterrupted and the apex sharp, forming an acute angle with the downstroke, any variation from this being due INFLAMMATION. 69 (except in very rare instances) to an imperfect application of the instrument. The paper on which the tracing is taken should be double enamelled, and enamelled on both sides. It is most easily smoked by burning a small lump of camphor, the size of a pea. After the tracing has been obtained, it may be varnished by passing the slip of paper through a simple spirit varnish, made by dissolving one ounce of gum benzoin, or Burgundy pitch, in eight ounces of methylated spirit.* " The tracing obtained by this instrument fi-om a normal pulse reveals the fact that the pulse felt by the finger is not merely a simple movement of expansion and contraction of the artery, produced by each contraction of the heart, but is composed of three factors, the part played by each of these varying under different circumstances of disease. They do not depend, however, for their existence on any peculiar or complicated condition of the circulation in the human body, but merely on the ordinary laws of hydrodynamics, and are invariably Fig. 9- — Formation of False Wave. (a.) Tidal wave b. (b.) Tidal wave b + percnssion wave A. (c.) Tidal wave B + percnssion wave A + dicrotic wave c. produced when fluid is pumped, in an intermitting stream, forcibly and suddenly through an elastic tube. The development of each varies with conditions which can be experimentally ascertained and varied at will, so that a pulse of any character can be obtained by regulating the conditions accordingly. " The simplest pulsatile movement that can be conceived in an elastic tube is the mere passage of a wave of fluid through it, causing more or less sudden expansion, and a gradual collapse of the tube, as it passes through it ; such a wave is the foundation of the pulse, and has been called the ' Tidal ' wave (Fig. 9a). If the impulse imparted to the fluid is more sudden, an element of percussion or shock will be introduced (Fig. 96), giving an abrupt and vertical upstroke, from the * The instrument and all necessary appliances can be obtained of Messrs. Kroline and Sesemanu, 8, Dnke Street, Manchester Sqnare. Price seven guineas. 70 GENERAL PATHOLOGY AND SURGERY. jerking up of tbe lever by tbe sudden expansion of tbe artery. Owing to its acquired velocity, tbis movement of the lever is rather greater than the corresponding movement in the arterial wall which produced it, and on reaching its highest point, it falls suddenly by its own weight, till it is again caught and perhaps slightly raised by the tidal wave A, whicb is now only reaching its maximum of distension. " The third element is that of elastic recoil, and is produced by the contraction of the elastic wall of tbe vessel or tube, which occurs immediately on the termination of contraction or systole ; this is called the ' Dicrotic ' wave (Fig. 9c). The elastic wall of the vessel is over-distended during systole, owing to the acquired velocity of the blood, which is considerable on account of its great inertia and the force of the ventricular contraction ; and immediately systole ends and the acquii'ed velocity is exhausted, the over-distended elastic wall Fig. 10. — Dep'rees of Dicrotism. (a.) Dicrotic^ (b.) Fully dicrotic. (c.) Hyperdicrotic- springs back and originates a new wave, which is prevented passing backwards by the closure of the aortic valves which it produces, and therefore passes forwards, imparting a fresh impulse or wave to the blood-stream, called the dicrotic wave, or diastolic expansion. A small secondary wave of somewhat similar production to the last is occa- sionally seen in the remainder of the downstroke, being apparently a slight oscillation, before an equilibrium, is attained between the blood-pressure within the tube and the elastic pressure of its walls. " Various degrees of dicrotism occur, to which terms have been applied indicating the relation of what is known as the Aortic notch to the respiratory line of the ti-acing. The Aortic notch, sometimes called the dicrotic notch, is the notch immediately preceding the dicrotic wave, or diastolic expansion (Fig. 10, c.) It is so called because it is coincident with the closure of the aortic valves, and INFLAMMATION. 71 indicates tlie termination of systole ; the portion of the pulse wave preceding it coincides with systole, that following it with diastole. The Bespiratory or base line of the tracing is the line drawn through the lowest points of the upstrokes (Fig. 10, A b). It should be straight in a normal tracing, but it varies if the amount of blood in the vessels, or arterial tension, varies. Thus, if during the tracing a deep inspiration be made, the blood tension is reduced, owing to the suction action of the thorax, and there is a fall in the respiratory line, while by complete expiration the tension is increased, and an elevation occurs in the respiratory line. So in some cases of disease, when there is severe dyspnoea, and dilatation of the right side of the heart, there is a constant variation in the respii'atory line with each movement of respiration ; it is then called ' undulating.^ " To return to the degrees of dicrotism. If the dicrotic notch c is. well marked, but its lowest point does not reach the respiratory line, the pulse is called ' dicrotic,' or sometimes liypodicrotic, but this term tends to confusion (Fig. 10a) ; if the notch c reaches to the level of the respiratory line A B, the pulse is called fidly dicrotic (Fig. 106) ; lastly, if the notch c sinks below the level of the line A B, it is then called ' hyperdicrotic ' (Fig. 10c) . "Briefly, then, the Percussion wave is due to shock or sudden impulse, and is produced by sudden and forcible contraction of the heart. It may occur in a very exaggerated degree and form the most striking feature in the tracing (Fig. 11a), owing to an excited action of the heart ; or it may be transmitted much more rapidly than the tidal wave, so that the two become distinctly separated from each other (Fig. 11&). This occurs in conditions of high tension, with excited and forcible action of the heart, as in early stages of Bright's disease. The Peecussion wave is Increased iy Diminished by 1. Forcible contraction. 1. Feeble contraction. 2. Sudden contraction. 2. Gradual contraction. 3. Large volume of blood. 3. Small volume of blood. 4. Fulness of vessel. 4. Emptiness of vessel. " The Tidal wave is the true pulse wave, and indicates the passage of a volume of blood through the arteries, pumped into them by each contraction of the heart. It resembles the passage of the tidal wave or ' bore ' up a river ; hence its name. It is transmitted more slowly than the percussion wave, or rather attains its maximum intensity more gradually ; hence their separation in the tracing. Though they usually commence to distend the artery together, the percussion wave necessarily attains its maximum intensity instantaneously, it being only a shock, while the tidal wave does so more gradually (Fig. 11a). Sometimes a considerable interval elapses between them (Fig. lib). Frequently they are inseparable, the percussion wave not existing, or else being emerged into the tidal (Fig. lie and e). The Tidal wave is Increased hy Diminished by 1. Slow and prolonged contraction. 1. Quick and short contraction. 2. Large volume of blood. 2. Small volume of blood. 3. Emptiness of vessels. 3. Fulness of vessels. 4 Diminished outflow, or slow capillary 4. Increa=ed outflow, or rapid capillary circulation circulation. 72 GENERAL PATHOLOGY AND SURGERY. " The Dicrotic wave is the wave of elastic recoil, dae to the con- traction of the aorta. It occurs during the diastole of the heart. It may reach almost as high as the tidal and percussion (Fig. lie). The Dickotic wave is Increased hy Biminifihed iy 1. Sudden contraction. 1. Gradual contraction. 2. Emptiness of vessels. 2. Fulness of vessels. 3. Inci-eased outflow, or rapid capillaiy 3. Diminished outflow, or slow capillary circulation. circulation. 4. Elasticity of aorta. 4. Rigidity of aorta. 5. Relaxation of mnscular coat. 5. Contraction of muscular coat. " The Sphygmograph will indicate and explain the meaning of all Fig. 11. — Extreme Developments of each Wave. [_ (a.) Exaggerated percussion. (6.) Ditto. (c.) Exaggerated dicrotic. (d.) Exaggerated tidal. (e.) Ditto. A = Percussion. B = Tidal, c = Dicrotic. the terms usually employed in describing the pulse. Thus, the puLse may be ' hard ' or ' soft ; ' that is, require much or little pressure. It INFLAMMATION. 73 may be 'sudden' or 'gradual,' namely, having a well-marked per- cussion wave or none at all ; ' large ' or ' small,' according to the size of the tidal wave and height of upstroke, which will depend on the volume of blood sent into the vessels by each systole, on the emptiness or fulness of the vessels during diastole, and on the con- traction or relaxation of the muscular coat of the arteries. Should they be contracted, the terms ' wiry ' or ' contracted ' are applied to the pulse. The pulse is called ' flickering ' when the systoles are feeble and unequal, the tidal waves being therefore unequal in volume and perhaps in rhythm; or 'undulating,' from an undulation in the respi- ratory line ; ' dicrotic,' if the dicrotic wave can be felt. Irregularities in rhythm are also particularly well shown, and their cause, whether purely cardiac or dependent to some extent on the respiratory move- ments, indicated. There is one character of the pulse, however, which is perhaps the most important of all to recognize, and which the Sphygmograph does not indicate, namely, that of ' persistence.' By this is meant the ability to feel the artery during the diastolic period, owing to its prolonged distension and overfulness, due to contracted arterioles or impeded capillary circulation, whichever may prove to be Fig. 12. — To arauge High Tension. (a.) Line from apex of up- stroke to bottom of aortic notch. (h.) Line from bottom of notch to base line. the true cause of what is known as ' high tension.' Although this particular character is not shown by the Sphygmograph, and can only be felt by the finger, nevertheless others which are always associated with it, are most perfectly indicated by the instrument, and comprise the signs of 'high tension.' It is as a measure of 'arterial tension' that the Sphygmograph is perhaps of the greatest value, and a few words on the indications of the degree of tension existing are necessary. "By the term 'high tension' a condition is meant in which the arteries are fuller than natural. It produces increased resistance to the heart's contraction, and increased pressure on the arterial walls. If such a condition be chronic, it produces hypertrophy of the left ventricle and thickening of the heart, as in chronic Bright's disease, and is also the immediate cause of atheroma, aneurism, apoplexy, albuminuria, and other conditions. The most constant indication of this condition is prolongation, or undue sustension of the tidal wave. This can be gauged as follows : — Let a line be drawn from the summit of the often upstroke to the bottom of the aortic notch (Fig. 12a, A c) ; 74 GENERAL PATHOLOGY AND SURGERY. if any part of the tidal wave rises above this line, forming a curve with its convexity upwards, the tidal wave may be said to be undulj-- sustained, and the arterial tension to be high. The next important sign of high tension is the height of the line drawn from the bottom of the aortic notch to the base line (Fig. 126, c d). The longer the line, the higher the arterial tension, and vice versa. "In high tension the percussion wave is usually well marked, and separated from the tidal wave (Fig. lib). Sometimes it is absent, from failing power and feeble contraction of the heart (Fig. lie). High tension may exist with the muscular coat of the arteries con- tracted or relaxed; the upstroke may therefore be short or high. It Fig. 13. — Variations in Arterial Tension. (a.) High. Chronic Bright's disease. Pr. 5 oz. (p.) Medium. Normal. Pr. 3 oz. (c.) Loiu. Normal. Pr. 3 oz. (d.) Very Low. Typhus. Pr. 1 oz. usually requires considerable pressure to develop the pulse, but not invariably ; this depends upon the strength of the heart and the force of its contractions. " The other extreme of tension is gauged by the dicrotic wave, the size to which it is developed, the shortness of the line c D (Fig. 126), or its entire absence ; the pulse being fully or hyperdicrotic (Fig. 10&, c). In addition to this, the percussion wave is generally absent, and the collapse of the tidal wave sudden, the angle formed by the upstroke and downstroke being very acute. This sudden collapse is due to the emptying of the artery being sudden and not gradual. " The degrees of tension which are commonly met with are very various ; four types may be given : — The extreme high tension of Bright's disease (Fig. 13a) ; the medium or normal tension of a INFLAMMATION. 75 healthy pulse of good tone (Fig. 13b) ; the low tension often found in healthy persons, with bad tone and relaxed vessels (Fig. 13c) ; the extremely low tension of the hyperdicrotic pulse of fever (Fig. ISd). To these might be added the pulse of empty arteries, as in free aortic regurgitation. " From this consideration of the pulse in general, let us return to that of Inflammatoiy fever, which is of considerable interest, and affords valuable assistance in the prognosis and treatment of the case. In simple inflammatory fever of the sthenic type, although the temperature may be high, the pulse is one of rather high tension ; this is also the case with erysipelas in some cases, and these are Fig. 14. — High Tension Pulses in Traumatic Fever. (a.) Second day after ovariotomy. 1. 100. Pr. 2 oz. (p.) Third day after excision of breast. Pr. 3 oz. (c.) Scalp wound. Pr. 2 oz. (d.) Severe contusions and frac- tured thigh. T. 103-8. Death next day. Pr. 2 oz. generally of a mild nature. In inflammatory fever of an asthenic type, and occurring in debilitated subjects, the pulse may be one of low tension and considerably dicrotic ; this is especially the case if there be any tendency to pyaemia, when the pulse is almost invariably of low tension and very dicrotic. So, in low forms of asthenic erysi- pelas, the pulse is often hyperdicrotic, and these cases especially require free stimulation. With pulses of high tension in inflammatory fever, depletion and antiphlogistic treatment may almost invariably be employed ; it is the ' hard ' pulse which the old practitioners regarded as the infallible indication for bleeding. " If, however, the pulse in inflammatory fever be one of low 76 GENERAL PATHOLOGY AND SURGERY. tension, stimulants and a generous regimen are required. Fear also may be entertained of pyeBmic infection ; absorption probably takes place more readily in this condition than in high tension. Further indications may be afforded by the amount of pressure required to develop the tracing, and the presence or absence of well-marked per- cussion showing the strength of the heart and its mode of contrac- tion ; a sloping upstroke and a rounded top being the infallible indications of a failing heart. " There is no rule as to the nature of the pulse in inflammatory fever, erysipelas, or pyaemia ; either high or low tension may occur in either of these conditions. Roughly speaking, however, it may be said that high tension is most likely to be met with in inflammatory Fig. 15. — Low Tension Pulses in Pytemia. (a.) Pyaemia. Pr. 2 oz. (b.) Puerperal pyaemia. Pr. 3 oz. (c.) Pyaemia after amputation of thigh. Death two days after- wards. T, 103-5. Pr. 2 oz. fever, and low tension in pyemia. The tracings in Fig. 14 give types of degrees of high tension occurring in inflammatory fever in different individuals, and from various causes; while those in Fig. 15 give types of low tension occurring in pyaemia. The last tracing in Fig. 14 gives the form of pulse immediately preceding death, when the tension has been high throughout, namely, a short and rather sloping up- stroke, with a slight rounding of the apex, and a want of sharpness or rounding off of the angles about the tracing ; while the last tracing in Fig. 15 exhibits the form of pulse preceding death, the tension having been low throughout the illness. In this case the pulse is hyperdicrotic, w^hile the upsti'oke is also short and a little sloping." The Urine, in Health and Disease. — The urine in disease undergoes alterations which can be estimated only by observing the characters and composition of the urine in health, as the representative and ex- INFLAMMATION. 77 ponent of blood-conditions in health. The student, therefore, will do well to start with this physiological knowledge before proceeding to the description oi febrile urine. Healthy Urine. — Physical Characters. — A fluid, clear, of a bright amber colour, peculiar aromatic odour, and specific gravity or weight, varying from. 1'015 to I'OSO, the average being 1'020, when cold. The quantity secreted varies from 30 to 80 fluid ounces in twenty- four hours, the average being about 52 ounces. Slightly acid, except after food, when it becomes neutral or alkaline, during digestion in the stomach — chymification. Chemical Composition or Constituents — qualitative and quantitative. — Mean or average in twenty-four hours, for the adult male : — Grains. Urea . 512-40 Uric aoid .... 8-56 Phosphoric acid . 48-80 Oxalic acid .... 1-42 Sulphuric acid .... . 31-11 Hippuric acid .... . 34-50 Chlorine . 126-76 Extractives, e.g. creatine and creat nine, and colouring matters . 15400 Soda . 125-37 Potash . 58-21 Ammonia . . . . . 8-58 Lime ...... 3 55 Magnesia . . . . . 3 09 Iron ...... . undetermined Mucus (adventitious) 7-00 m . , ^ Solids ...... T°*^W Water . 1123-35 Grains weight. 52 1^ Ounces measure In estimating the quantity of any urinary constituent excreted in twenty-foar hours, the weight of the body and activity of the functions must both be compared therewith. Thus the excretion of only 150 grains of urea, in a person whose weight is 80 lbs., would be a healthy proportion ; but if the weight be 170 lbs., that quantity would be very disproportionate, and indicate a diseased condition of serious or fatal consequence. The physiological origin of the urinary constituents is represented in the following tabular view, taken from Dr. Golding Bird's well- known work, edited by Dr. Birkett : — 1. Organic Products. 1st. Ingredients characteristic of the secretion (Urea, uric acid, creatine, creati- produced by the destructive assimilation of tissues < nine, colouring and odorous and separated from the blood by the kidneys. | principles. „,,- Tij T J ■ ■ ^^ s- (In addition to the above, hip- .T, ? ; Ingredients developed principally from ^^^ acid, lactic acid; acci- the food during the process of assimilation. j ^^^^^^ constituents. 2. Inorganic Products. I Sulphates, phosphates, chloride of sodium, and all soluble salts taken with the food, and often undergoing decomposi- tion in the system. 78 GENERAL PATHOLOGY AND SURGERY. 4th. Saline combinations chiefly generatedJSnlphates. during the process of destructive assimilation. (Phosphates. 3. Ingredients derived from the Urinary Passages. 5th. Mucus of the bladder. 6th. D(ibris of epithelium. 7th. Phosphate of lime. Febrile urine exhibits physical characters and cheniical peculiarities of diagnostic importance. At first, it has a deep red colour, strong urinous odour, super-acid reaction, high specific gravity ; and the «|uantity secreted in a given time is diminished. These alterations are chiefly owing to a reduced proportion of water, rather than of solid constituents in the urine, which has thus become concentrated. But the inorganic salts, especially the chloride of sodium, are diminished, both absolutely and relatively ; while uric arid and the urates are increased. Even when urates ai-e not deposited, there is always an excess of uric acid. Urea is increased in some cases, and probably diminished in others. The greatest quantity present would appear to be in meningitis, and an excess is found during exudation; but urea is diminished during resorption, in pneumonia, pleurisy, and in acute rheumatism, especially if accompanied with endocarditis. Extractive matter is generally increased, and lactic acid is often present. Occa- sionally, a small quantity of albumen is found, but only for a short time. As inflammatory fever declines, the urine deposits a lateritious brick-dust, coloured sediment, more or less abundant, consisting of urate of ammonia. The quantity of sioeat is much diminished during inflammatory fever, but its chemical composition at that time is not well understood. Ulcers, also, which have been discharging freely become dry. The flow of saliva is less free, and the tongue furred. This appearance arises from a material of whitish yellow or brown colour and firm consistence, overlying the posterior and middle portion of the tongue on its upper aspect, and adhering closely. It cannot be removed altogether by scraping, but as the fever declines it is shed spontaneously. If, says Dr. Thomson, this fur arose from the nature of the saliva secreted, then, instead of being found only on the upper, middle, and posterior parts of the tongue, we should find it incrusting the whole internal surface of the mouth. It is probably secreted from the papillae to which it adheres. A similar appearance arises from irritation of the stomach, without any fever at all. Discrimination, therefore, is neces- sary, by considering whether other symptoms occur. Blood. — The blood undergoes certain very important alterations in inflammation, and which are of two kinds, — namely, in respect to its vital properties, and therefore as affecting its coagulability and coagu- lation ; and in respect to its chemical composition. The resultant blood-condition affords another and very significant symptom of inflammatory fever, and which can be readily ascertained, when neces- sary, by drawing off a sample, say a few ounces, from the general mass of blood, as supplied by venesection. (a.) The altered vital properties of the blood comprise — an increased tendency to coagulation, and to the separation and contraction of the flbrin in a free state. The phenomena known as the huffy coat and sizy blood are thus produced. These appearances can be understood by INFLAMMATION. 79 comparing the cbariges which take place, as observed in the coagula- tion of healthy blood. Let a pint of fresh-drawn blood be exposed in a shallow basin ; im- mediately a vapour, having a faint odonr, arises, which (halitus) was first noticed by Haller. In about four minutes a pellicle appears at the edge of the vessel, soon extending over the surface of the blood and down the sides of the vessel. It pervades the whole mass in about eight or nine minutes. The fluid blood is thus converted into a jelly. But in a variable period, from seventeen to twenty minutes, or much later, this jelly begins to shrink away from the sides of the basin, and the colourless, transparent serum exudes — a process which, continuing for several hours, or even days, at length leaves a blood-red clot, floating about in limpid serum. And what is this clot ? The fibrin of the liquor, sanguinis, which has spontaneously solidified into fine homo- geneous filaments, interwoven like felt, and which has caught and involved the red corpuscles. They also have spontaneously aggregated, their disc-shaped surfaces cohering side by side, and forming rouleaitx, like piles of money, which connected themselves into an irregular net- work ; the shrinking of this fabric, intertwined with that of the fibrin, expressed the serum, and thus aided the solidification of the clot. Two constituents, therefore — the fibrin and red discs — together sponta- neously aggregate to form the clot, which consists of woven filaments involving the net of red discs. The expressed serum is structureless. The pale or colourless corpuscles are irregularly distributed through- out the clot and serum. These changes are represented in the following table : — Fluid Blood. ) ^^^1"°^ ^^°^"^^^ { ISn." 7 Clot. ) Coagulated Blood. „ ^ , ° ( Fibrin. 7 Clot. ] Oorpuscles. > I If the blood, freshly drawn as we have supposed, be inflammatory, its coagulation then presents a clot, the upper portion of which is pure fibrin, of a tawny-yellow colour, and known as the huffy coat. This, therefore, consists of a portion of fibrin, which has coagulated apart from the mesh formed of red discs. And what is the immediate cause of this kind of clot ? Obviously, that the red discs separated and subsided from the liquor sanguinis before the fibrin began to coagu- late. ■ How does such isolation arise ? Possibly in either of two ways, or by a concurrence of both. The fibrin may coagulate so slowly as to allow time for the blood-discs to separate and subside. But Dr. Stokes watched the coagulation of inflammatory blood in twenty-seven cases. In fifteen of them the bufEy coat formed ; in the remaining twelve it did not. In four of these twelve samples of ordinary coagulation, it began only at the end of eight minutes after venesection, and in other three of this series not until after twenty to forty minutes had elapsed, making a range between the two extremes of from eight to forty minutes. This delay of coagulation gave ample opportunity for the red discs to escape from the fibrin during its solidification ; yet they did not subside, and the usual red clot formed. On the other hand, in twelve of the fifteen samples of buff-forming coagulation, the yellow clot of pure fibrin formed in only five minutes, and in the remaining three it was delayed only to ten minutes ; so that, during this com- 80 GENERAL PATHOLOGY AND SURGERY. paratively short period of five or ten minutes, the red particles had separated and settled down, leaving the buff-coloured fibrin free and floating. Slow coagulation, therefore, does not explain the production of the buffy coat. The only other active element in coagulating blood is the mesh- forming discs ; and how do they behave in freshly drawn inflammatory blood ? They individually possess undue power of aggregating (H. Nasse), and the net thus wrought has also undue power of contracting (W. Jones), whereby the serum is more effectually expressed from its meshes. This fabric, therefore — the component particles of which have individually greater specific gi"avity than the serum — has now even greater weight, bulk for bulk, and being formed earlier than usual, subsides in the serum before the fibrin has fairly solidified, or perhaps before this more essential element of the clot has begun to coagulate. John Hunter seems to have anticipated this view of buffy blood, and Schroeder Van der Kolk, with other observers, has corroborated it. Combining all these observations— formation of the buffy coat seems to imply an increased separation and contraction of fibrin in a free state, rather than its increased power of separation and contrac- tion, and that the blood-discs are the initiative and active element in the process of buff -forming coagulation. Slow coagulation of the fibrin will, however, favour this result, by allowing more time for the gregarious blood-discs to flock together and exercise their function as a contracting mesh. If, therefore, the blood be artificially preserved in a fluid state, by adding serum to above its normal proportion, thereby delaying coagulation, the red discs aggre- gate and subside, and the buffy coat is thus presented. Px'obably both the causes I have mentioned concur to produce this result, and that as they prevail more or less during the act of coagulation, so is the buffy coat of pure fibrin more or less completely established. The earliest intimation that blood is about to undergo this kind of coagulation, is the appearance of a violet tint, not unlike the bloom of black Hamburg gi-apes, on the surface of the exposed blood. This appearance was, I conceive, noticed by Hunter, and regarded by him as due to the red particles shining through a thin layer of buff'-coloured lymph, just as blood in the veins gives a similar tint when viewed through the skin. The tint will therefore vary as the layer of fibrin becomes thicker. Coagulation proceeding, if the mesh of red particles separate and subside from the fibrin, but yet slowly and incompletely, and if the free fibrin but imperfectly solidifies and conti-acts, then a loose sizy clot is produced, resembling a solution of isinglass, attached to the sides of the vessel, and scarcely trembling when shaken. If, again, the separation and contraction of pure fibrin be more complete, a flat, yellow buff-coloured cake is produced, swimming in serum ; but the under portion of this clot is red as usual by admixture of the red discs. If, again, the separation and contraction of fibrin be still more complete, the fully formed, solid, and buff-coloured clot is presented, withdrawn from the sides of the vessel, and probably concave or cupped on its upper surface ; the lower portion of this clot having formed more slowly, has contracted more strongly and drawn down the central part of its upper aspect. The blood, or rather the clot, is buffed and cupped. Even in this case the red particles and fibrin INFLAMMATION. 81 do not completely separate. In thirty samples of buffed blood, care- fully inspected by Dr. Richardson,* he never failed to find red discs in the lower portion of the clot, and in many instances this red lower portioa had the consistence of ordinary coagalum. The diagnostic value of these appearances is not absolute. In- variably present with inflammation, they are also present in other conditions affecting the blood. Coagulation exhibits the buffy coat notably in pregnancy, and other conditions attended with an excess of fibrin in the blood; and both the buffed and cupped appearance may proceed from slow coagulation, without any change in the constitution of the blood itself, as when this fluid is drawn quickly, in a full stream, and received into a narrow deep vessel. Conversely, exposure, as by a trickling stream, into a shallow vessel, hastens coagulation, and thus prevents these results. (6.) Besides these deviations in the process and product of healthy coagulation, inflammatory blood is found to have undergone certain alterations of chemical composition. Its constituents, no less than their properties and endowments, are perverted. Becquerel and Rodier enumerate the following alterations in the blood of acute phlegmasiae : — 1. An increased proportion of fibrin. 2. A decrease of globules. 3. A decrease of albumen of the serum. 4. An increase of fatty matters. 5. A decrease of soda and soluble alkaline salts. In point of practical interest, the importance of all these chemical changes appears to concentrate in the influence they exercise on the separation of the fibrin, and its coagulation in a free state. Alkaline salts in excess are well known to retard coagulation, and a decrease of the soda and soluble alkaline salts will have the opposite effect. Less time than usual is then allowed for the blood-discs to subside, and so far the formation of the baffy coat is not promoted. An increased proportion of fatty matter will probably favour the early separation of pare fibrin, by inducing it to rise with such matter to the surface of the blood drawn, and leave the red discs below. A decrease of the albumen of the serum will have a similar effect, by directly diminishing the specific gravity of this fluid, so that the blood-discs sink more readily. The mean specific gTavity of the serum in the phlegmasia generally, is estimated by Becquerel and Bodier at 1027'0 ; and although, according to Nasse, that is about the average in health, yet the specific gravity of serum in inflammations frequently declines below the mean of 1027. And this is due to the proportion of albumen being reduced below the healthy average of 80 parts in 1000, to 73"35, and even as low as to 64"84. It was formerly stated by Gendrin that the albumen rose to about twice its proportion above the standard of health. The decrease noted is in a direct ratio to the increased proportion of fibrin. So also the blood-discs decrease in quantity proportionately to the increase of fibrin (Simon), and this reduction will facilitate their complete separation — the more so, since, by undue aggregation of the * " The Cause of the Coagulation of the Blood," p. 335. VOL. I. G 82 GENERAL PATHOLOGY AND SURGERY. discs, their combined specific gi-avity prepouderates even jnore than thej do individually. Lastly, the increased proportion of fibrin above the average of two to two and a half parts in 1000 of blood, conti-asting as it does with the reduced proportion of blood-discs, is the culminating point in favour of a clot being formed of pure fibrin ; and this increase, and corresponding formation of the butfy coat, was noticed by Andiul and Gravarret to rise as high as ten parts in 1000 of blood drawn, in acute articular rheumatism, and in pneumonia. The source of this additional proportion of fibrin is doubtful. Simon sugg-ests that the blood-discs ai-e transformed into 6brin. and in conformity with an acknowledged physical law, that as textures waste in pi^oportion to their functional activity, so therefore the blood- discs disintegrate more abundantly in inflammation — owing to their function as beai^ers of oxygen to the various textures being overtaxed, in the more frequent ti-ansmission of these discs through the lungs, by accelei'ation of the blood's circulation. The flotilla of oxygen- laden cells perishes from overpressed service, and their wrecks are converted into fibrin. Simon's statement that the discs decrease in quantity proportionately to the increase of fibrin, harmonizes Avith his theory : but, against it, Becquerel and Rodier urge that this destructive change ought to take place whenever the circulation is accelerated, and therefore whenever fever exists. Yet an increased proportion of fibrin is not found in other fevers accompanied Avith an accelerated circulation. Is the excessive fibrin transformed albumen ? Probably similarity of composition allows of such transformation ; and certainly, as the albumen diminishes in quantity, so does the proportion of fibrin in- crease. Of this metamorphosis we know neither the cause nor the mechanism, observe Becquerel and Rodier. Summarily, the coagulation of inflammatory blood — when drawn and fresh — amounts generally to this : the blood-discs, having an undue tendency to aggregate, and the net they form an undue power of contracting, more speedily sink in serum, normally of less specific gravity than the discs individually, of still less than the shrunken net uf discs ; and that this separation of the discs (before coagulation of the fibrin) is facilitated by their reduced number, and by diminished specific gravity of the serum itself. The fibrin, itself increased in quantity, then coagulates free of blood-discs, at least in its upper portion, and rises to the surface of the serum, its ascent being probably aided by admixture with the free and floating fat. Pathology of Inflammatory Fever. — The alterations of the hlnod, in connection with inflammation, proceed apparently from the persistent local determination of blood, coupled with the inci'eased productiveness and destruction of the textures. The increased jDroportion of fibrin, and the increased tendency to coagulation and to separation and con- traction of the fibrin in a free state forming the buify coat, ;ire both commonly proportionate to the extent of the inflammation, and its duration in an active state. Under similar circumstances of nutrition, the same blood-conditions are induced in a greater or less deg-ri-e; as during prt-gnancy, Avhen the uterus is growing ; and the bnff'td appear- ance of the blood is readily induced by inflammation in fast-p rowing INFLAMMATION. 83 childi'en, in whom also the plastic products are then unusually copious. Other writers believe — and Mr. Simon ranks himself most unreservedly among them — " that the blood yields more fibrin, not in proportion as it is ripe and perfect, but rather in proportion to quite opposite con- ditions ; that an increased yield of fibrin corresponds not to the rise, but to the decline, of albuminous material ; that its relations are not with repair, but with waste ; that its significance is that of something intermediate between life and excretion." (1.) The Fever of inflammation was formerly supposed to arise from the increased proportion of fibrin in the blood, or hyperinosis, as the cause of febrile excitement of the circulation, and the other functions involved. Hunter advocated this interpretation of inflam- matory fever, and he gave cases which, as tested by venesection, seemed to support it. But the recent results of chemical analysis indicate that inflam- matory fever may possibly be absent with hyperinosis, or present without it ; and they certainly prove beyond doubt that the degree of inflammatory fever cannot be measured by the amount of hyperinosis. MM. Becquerel and Rodier estimate the increase of fibrin in various diseases to range from the healthy average of three to ten parts in one thousand of blood; and that a slight increase from three to five takes place in chlorosis, in certain cases of scurvy, more especially when it assumes the chronic form, during pregnancy also, and in erysipelas of the face ; yet surely the two first-mentioned diseases are not inflam- matory, nor are the ordinaiy constitutional symptoms of pregnancy those of inflammatory fever. On the other hand, a diminished pro- portion of fibrin below the averag'e of three in one thousand was noted in scarlet-fever, small-pox, and measles ; but the ordinary type of these fevers is inflammatory in a high degree. Lastly, when present, the degree of this fever does not correspond with the amount of hyperinosis. A great increase of fibrin up to ten in one thousand was noticed in acute articular rheumatism, in pleurisy, and pneumonia; and a proportion varying from five to ten was also found in peritonitis, bronchitis, and severe erysipelas of the face — diseases which are accompanied with at least as high a degree of inflammatory fever as pleurisy or pneumonia. (2.) The foregoing facts and considei'ations compel us to attribute the accompanying inflammatory fever to some other source than the blood ; and the only other bond of sympathetic connection between the heart and inflamed part is the nervous system. Many years since, Abernethy * suggested this channel of communi- cation, and subsequently, Travers pointed out the agency of the nervous system, and drew the distinction between nervous excitement alone and inflammatory fever. Although he attributes this fever to excitement of the circulation from hyperinosis, yet he observed that the first morbid impression was upon the nervous system, and trans- mitted by the nerves of the part injured or inflamed to the nervous centre, and thence to the organs of circulation. In proof thereof, Travers urges the priority of nervous excitement in the development of inflammatory fever. " The premonitory symptoms, viz. headache, lassitude, disquietude, nausea, chilliness, and rigor, are indications of the more or less troubled condition of the nervous centres ; to these * " Constitutional Origin of Local Diseases," 1824, p. 3. 81 GENEEAL TATHOLOGY AND SURGERY. the alterations in the measure and force of the circulation, the perma- nent and sensible changes upon the internal and external surfaces, and their secretions, succeed — viz. quick pulse, hot skin, dryness of the mouth and fauces, furred tongue, vitiated and scanty secretions." * (3.) But the chemically changeful state of the textures, and thence f the blood in circulation, -vvith the evolution of heat, are the essential constituents of inflammatory fever ; and its symptoms are those of this more active change and increased temperature. There is, observes Mr. Simon, an accelerated devitalization and destructive ti-ansforma- tion of organic material, which infects the blood through the venous and lymphatic outflow ; the general mass of blood, thence receiving corresponding increments of heat, and an unwonted afflux of chemi- cally changing' material, thus in its turn undergoes similar changes, chemical and calorific ; and this process is then extended, through the circulation of the blood, to all the textures in the body. Every tissue, according to its chemical mobility, participating in the excitement, thus reflects in a lesser degree the disorder of the inflamed part, and contributes its share to that overproduction of waste material and of heat which characterizes inflammatory fever. As the blood gets hotter and hotter, more and more do the symptoms of fever become developed ; as the blood subsequently gets cooler, so do they decline. The " crisis " of febrility consists in a rapid, and generally continuous, rise of tem- perature ; the " lysis," in a slow, and usually intermittent, return to the normal standard. Certain of the phenomena which precede and accompany inflam- matory fever are difficult of explanation. I allude more particularly to inappetency and thirst. Healthy hunger and thirst are now generally allowed by physiologists to be sensations expressing corre- sponding requirements of the system, rather than proceeding from conditions of the stomach. " These sensations," observes Dr. Carpenter, " bear no constant relation to the amount of solid or liquid aliment in the stomach, whilst they do correspond with the excess of demand in the system over the supply afforded by the blood ; and they abate by the introduction of the requisite material into the circulating blood, even though this be not accomplished in the usual manner by the ingestion of food or drink into the stomach." f Agreeably to this physiological provision, inflammatory fever should be attended with hunger, rather than inappetency. Albumen is the pabulum most extensively demanded by the tissues for their support, and its propor- tion in the blood declines considerably during inflammation ; yet this deficiency is accompanied with the loss of appetite. Again, the secretions are suppressed, and water, therefore, retained in the blood ; yet this excess is attended with incessant thirst. The rise of temperature — to perhaps 107° Fahr. — during inflam- matory fever may be due, partly, to suppression of the perspiration, whereby heat is retained which would otherwise pass off by evapora- tion from the skin ; and the excited nervous system probably con- tributes to the actual production of heat. But the principal source of increased heat would appear to be the chemical changes in the textures of the inflamed part. Causes; External and Internal, — Exciting s^nd Predisjoosing. — In * " Physiology of Inflammation," 1844, pp. 62, 63. t " Principles of Human Physiology." INFLAMMATION. 85 common with most diseases, the etiology of Iiiflamm.ation relates to causes without and within the body ; and the latter, at least, may have either an immediate, or a predisposing causative influence. The External causes of inflammation are manifold, but they may all be comprehended under four heads : — (1) Mechanical injury or ii-rita- tion, as wounds, fractures, dislocations ; or foreign bodies, introduced into the organism, as grit, portions of clothing, a splinter of wood, a bullet, and parasites, animal and vegetable ; (2) Heat and Cold ; (3) Chemical agents which decompose or kill living animal matter, as strono- acids, caustic alkalies, chloride of zinc, and other escharotics ; (4) Vital iiTitants, or animal and vegetable poisonous matters, and some mineral poisons ; as the venom of noxious animals and plants, cantharides, mustard, capsicum, essential oils, arsenic, etc. Internal causes may be either of an exciting character, in having an immediate action ; or predisposing in their operation. Exciting internal causes comprise the blood, textures, and excre- tions of the body, severally, under peculiar circumstances ; and morbid products, organized and unorganized. Blood extravasated is a foreign body. So also are the various textures, when dying or dead ; in the form of slough of the soft tissues, sequestrum of bone. The various excretions, as urine, f^ces, bile, are irritants to the organs which naturally contain them, if such matters be in a state of decomposition ; or if, being themselves healthy, they are extravasated ; as urine into the scrotum, feculent matter into the peritoneum. These excretions are peculiarly obnoxious to cellular texture and serous membrane. Lastly, morbid products are apt to excite inflammation. Of deposits, softened tubercle does so in the lungs and other parts ; of growths, cancer especially has this effect, the ichorous discharge more particularly being irritating. Calculi are familiar examples of unorganized products exciting inflammation in organs where they occur. For example, a stone in the kidneys provokes nephritis ; in the bladder, cystitis. All exciting causes of inflammation, in regard to their modes of action on the part aif ected, may be referred perhaps to two types : the stimulant kind, like heat, which acts as an excitant of textural changes in the nutrition of the part ; the depressive kind, like cold, which acts as a textural depressor. Predisposing internal causes include all those conditions which, co-operating locally, would constitute inflammation ; or which, as systemic conditions, incline towards inflammation. The body is thus rendered susceptible to the influence of exciting causes. But the pre- disposition differs relatively, according to the nature of the cause which excites inflammation. For example, an excited state of the vascular system favours the production of inflammation from local irritation ; whereas, a depressed state of the vascular system favours the develop- ment of inflammation from exposure to cold. It is not easy to refer an inflammatory predisposition to any one element of inflammation ; but an approach to certain illustrations of their respective influences is exhibited by the inflammation of different parts, wherein one or other of these elements predominate. Tissues in a devitalized state, and ready to die under the' action of stimulants or depressors, are prone to inflammation, and thus a comparatively under-nourished part, which has been subject to 86 GENERAL PATHOLOGY AND SURGERY. former injury or disease, is ever liable to an inflammatory attack, wlien this " weak part " is provoked by some slight external cause, — tis when an old cicatrix, or a rheumatic joint, is exposed to cold or heat. But tissues whose reproductive power is greatest, and which are commonly also most vascular, are equally predisposed ; as, for example, the skin compared with fibrous or tendinous structures; or tissues whose pro- ductive power is tempoinirily exalted, as during the growth of the body in childhood and youth. The more vascular organs are similarly inclined ; the lungs, for example, as compared A\'ith most other organs. On the other hand, a deficient supply of blood to a part inclines to inflammation by textural starvation ; as in incipient senile gangrene. The condition of the blood is specially influential ; poorness of blood — spansemia — depending on a deficiency of animal food, is apt to induce inflammatory affections of low type, by defective nutrition ; i-heumatic and gouty inflammations are ever impending when an excess of lactic or of lithic acid, respectively, is in circulation ; the retention of urea in the blood, as in Bright's disease of the kidneys, leads to inflammation of the serous membranes ; and suppressions of the excretions in general, have other inflammatory tendencies ; Avhile the introduction of irritant poisons into the blood gives rise to inflammation in different organs, — arsenic gaining' admission through an ulcer, leads to gastritis, and blistering by cantharides produces bloody urine. It would seem that at least some such inflammatory affections are natural efforts to eliminate the poisonous matter from the system. Thence the predisposing influence of constitutional conditions generally, most of which are blood-diseases manifested by various local inflammations, and. ever ready to recur ; as secondary syphilitic diseases of the skin and other parts, scrofulous affections of the bones, skin, and other textures. Other blood-conditions predispose, as unquestionably, to local inflam- mations ; but they require for their development the co-opei^tion of external exciting causes — contagious matters — in each case peculiar, relatively to the special condition of blood, which is thereby brought into action. All the infectious and eruptive fevers are of this kind. The intimate relations subsisting between blood-conditions and the textures, individually, is evinced in the selective or secretive affinities of different textures, giving- rise to inflammatory affections peculiar to each tissue. Thus, the skin selects an infectious blood-poison, such as that of small-pox or measles, and produces a specific eruption ; and the fibrous tissue, in the form of ligaments or fascia, for example, eliminates the rheumatic materies morbi from the passing blood- streams. Even more definite selective power is manifested by corre- sponding portions of the same texture, on either side of the body ; thus producing symmetrical inflammatory affections ; as witnessed in many scrofulous ulcerations and their resulting mapped-out cicatrices, also in syphilitic eruptions, and in chronic rheumatic arthritis of the same joints, as both knees, and both elbows. Predisposition through the influence of the nervous system is evoked by nerve injuries, the operation of which in producing peri- pheral inflammation is thus generalized by Simon : — A part deprived of sensibility becomes specially incapable of protecting itself against mechanical and chemical irritants, and accordingly inflames — e.g. the urinary bladder, subject to the action of retained urine, in paralysis. A part injured in respect of its innervation, is likely to suffer some INFLAMMATION. 87 circulatorj disorder, with, corresponding disturbance of natural temperature, and proneness to inflammation. The co-operation of all these elements will render the predisposition complete, and almost give rise to inflammation. Thus, the functional activity of any organ implying the concurrence of all the conditions essential to nutrition, in excess, such activity is accompanied with a proportionate proclivity to inflammation ; as in the mammary glands, after parturition when lactation commences, and during its continuance; or the ovaries at the period of menstruation. The operation of inflammation itself is both local and constitu- tional. Locally, inflammation operates by extension, continuously, in the texture or organ affected ; contiguously, to parts adjoining ; or, by transference (metastasis) to a part remote from that originally affected, the primary inflammation then subsiding. Continuous extention is witnessed in the progress of inflammation along the skin or mucous membrane, as in erysipelas, and the sore- throat of scarlet-fever. Contiguous extension is illustrated by ulceration of the articular cartilages of any joint consequent on caries of the adjoining head of bone, or on synovitis. Thus also ostitis supervenes on periostitis ; cellulitis on inflammation of the skin, and conversely. Taking internal organs, from the head downwards : meningitis is succeeded by cere- britis ; scrofulous and purulent ophthalmia, by inflammation of the cornea and deeper textures of the eye ; laryngitis, by inflammation of the subcellular texture and oedema glottidis ; gastritis, enteritis, cystitis, and metritis, respectively, may extend to the peritoneum, giving rise to peritonitis. The transference of inflammation is exemplified by orchitis super- vening on the sudden suppression of gonorrhoea. Such, then, is the general operation of Inflammation locally ; con- stitutionally, its operation was traced in the origin and development or the pathology of inflammatory fever. Septic and Infective Infla'mmation. — Organic matter, when dead, and in a fluid state especially — such as blood, pus, or albuminous serum, is apt to undergo putrefaction or septic decomposition, under the influence of atmospheric air and warmth ; and when this septic change is associated with inflammation, the concuri-ence may be denominated septic inflammation ; furthennore, as the septic matter enters the circulation of the blood, by absorption through the blood- vessels, or by the lymph-stream, the whole system is infected — in the form of septicaemia ; thereby showing that the inflammation is infective, as well as a septic putrefaction in conjunction with the ordinary textural changes of inflammation. But, it would be obviously an unpathological connection to study septic infection as part of the history of Inflammation in general ; or even to associate it with the inflammatory process, as arising fi'om injury of the texture or organ which may be undergoing the changes constituting that process. Traumatic inflammation often runs its course quite independently of any septic change ; e.g., in cutaneous and sub- cutaneous lesions — as erythema from burn, in contusion, sprain, simple fracture, and simple dislocation. Septic putrefaction and its systemic infection may indeed be superadded to Inflammation and its 0» GENERAL PATHOLOGY AND SURGERY. accompanying fever, in connection with open lesions — exposed to the influence of atmospheric air, as wounds, compound fracture, and compound dislocation. Course and Terminations. — luflammation may proceed to either of foui' Terminations : Resolution, or disappeai-ance ; Effusion, or lymph- production ; Suppuration, or pus-formation ; Ulceration and Mortifica- tion, or death of texture. Excepting the first of these terminations, that of I'esolution or simply cessation of inflammation, the line of de- marcation between each of the remaining thi-ee modes of termination, is indistinct, and they are common!}" more or less combined. A more definite line of distinction maj" be drawn between them, by regarding the course of inflammation in reference to its two principal constituent elements ; increased productiveness, and increased destruc- tion, of texture. . According as one or other of these predominates, so may we associate therewith the remaining terminations of in- flammation respectively ; as effusion, and suppuration ; ulceration and gangrene. (i.) Eesolution. — Inflammation may subside and terminate without any permanent structural result. This is i'esolution ; a termination of inflammation by the concurrent cessation of all the elements of this process ; and consequently, the cessation of its local and constitutional manifestations. Nothing definite is known of the process by which the part retui'ns to a healthy state ; nor of the order in which the I'estorative changes take place — whether in the textural elements, or in the vessels and in the circulation, begins the resolution of inflammation, or that both concur, simultaneously, in undoing this aberration of nutrition. The redness fades away, the part recovers its health}" temperature, slight swelling if perceptible subsides, and exalted sensibility or pain ceases ; while any inflammatory fever jDasses off. (ii.) P?-o^Mc^u-e«as3es of round cells, set in a fibrous matrix ; but the latter, undergoing a hyaline transforma- Fig. 57. ■ tion, compresses the cell-masses into cylinders — the tumour thus becom- ing a cylindroma. The cells them- selves assume a polygonal form' ; and the blood-vessels in the matrix often partake inthehyaline transformation. As modifications of Sarcoma may be mentioned, melanotic ov pigmented sarcoma, and liemorrliagic sarcoma. These conditions represent: the one an association of black or brownish pig'ment, chiefly within the cells ; the other, an admixture of blood from extravasation, in a sarcoma of high vascularity. Either condition may occur in connec- tion with a round-celled or a spindle-celled sarcoma ; modifying its structural and physical characters accordingly. Soft sarcomata are more often haemorrhagic and blood-stained ; the tumour being con- verted perhaps into a blood-cyst, and losing its original characters. Melanotic sai'coma occurs usually in the skin — as malignant mole ; or in the eyeball, originating in the choroid coat. Some such sarcomatous tumours have been described as melanotic cancer ; and hemorrhage with protrusion from a sarcoma has been designated fungus haema- todes, and as occurring in the course of encaphaloid cancer. Treatment. — Tumours which possess the characters relating to their growth, that distinguish the Sarcomata, and which are more or less prone to recur, after removal, cannot be treated with much pro- spect of permanent cure. Early and free excision affords the only hope — by complete extirpation of the tumour. In a more advanced stage, amputation, quite above the seat of the tumour, will be neces- sary, — when this is practicable. But, although the recurrence of the disease, in the locality of operation, ftiay thus be prevented ; the rapid dissemination of the growth in the system, in the course of perhaps only a few weeks, may render operative interference abortive for the prolongation of life, Epitheliil-celled Tumours. The Adenomata or Gtlandulab Tumours, consisting of Gland-tissue, may grow in any Glandular organ or secreting tissue ; and thence the more common forms known as Adenoma of the Mamma, and of the mucous membrane, — including out-growths or polypi. Some adenoid tumours also are of a mixed character ; consisting partly of gland- tissue with the proper structure of some heterologous Growth; thus pro- ducing Adenoma-sarcomata, and other compound Glandular Tumours. * Giant-celled sarcoma. (Virchow.) 192 GENERAL PATHOLOGY AND SURGERY. Some of these differentiations from the normal type of Adenoma, — a non-malignant gland- tissue tumour — border on Cancer, not only in their structural affinity as Epithelial-celled Growths, but in their malignant characters. Papillary Growths, in the forms of Corns and Warts, etc., are noticed in connection with Sargical Affections of the Skin (Chap. XXL). The fjeneral characters of Papillary Growths are these. They are all growths of the papillae, or villi, of the skin, or mucous membrane, respectively, in the part affected. Fx^om the interior of serous or synovial membranes, analogous growths may be produced ; as in the form of polypoid development of synovial fringes, which may ulti- mately become detached, and changed into false cartilages in the joint. Mucous and serous or synovial papillary growths are soft and moist ; whereas epidermic papillary growths, as corns and warts, are usually hard and diy ; sometimes, howevei", soft, as soft warts and condyloma, pi'obably owing to the moisture from secretions in the part whence they grow. The structure of Papillomata is simply that of connective tissue, more or less vascular, overlaid with the epidermic or epithelial cells, peculiar to the skin or mucous membrane. They are thus over- growths, or out-growths, rather than Tumours — as discontinuous formations in the texture of the part. Growing in various situations, almost any portion of the skin, or in the tracts of mucous membrane, may be the seat of papilloma. Epidermic growths, in the form of corns and warts, appear mostly on the feet and hands, respectively ; warts also, on the mucous membrane of the external genitals. Horns are sometimes produced on the head or face ; or from the matrix of a toe-nail, as a vei-tical elevation of the epidermic layers forming the naiL Mucoiis papilloma are met with on the lips, tongue, and soft palate, and in the larynx ; in the rectum or higher up the intestine; in the bladder — as non-malignant villous growth ; in the vagina, or at the orifice of the urethra. Sometimes, the conjunctiva, and more often, the mucous membrane of the auditory canal, gives rise to small papillary growths. Condyloma or mucous tubercles are apt to form on various parts of the buccal mucous membrane ; but more especially around the anus, or on the scrotum, or the external labia in the female. When of genito-anal origin, they are the product of irritation from venereal secretions ; but similar soft, opaq-ne- white, mucous cushions may appear on other parts of the cutaneous surface, the skin being readily converted into mucous membrane by moisture and warmth, — as on the inner aspect of the thigh, in the gi'oin, or the axilla. Warts also are probably the result of various irritant matters ; they are found on the hands of girls who may have fallen into the evil habit of masturbation ; and the dissecting- room wart arises from frequent contact with decomposing animal matter. Cancer comprises three typical species : Encephaloid, Scirrhus, and, perhaps. Colloid ; with many sub-varieties ; distinguished chiefly by shades of difference in their general characters of colour, con- sistence, shape, size, and mobility. Epithelial cancer, as another form of this Growth, is taken separately. Structural Conditions, and Diagnostic Characters. — The three species of cancer present under the microscope the same cell (Fig. 58). This, TUMOURS OR MORBID GROWTHS. 193 Fig. oi y^y^-^}^ at first colourless and pellucid, consists of a delicate envelope, con- taining a large clear nucleus or two, sometimes more, within each of which is imbedded one or two nucleoli, also large and clear. Such is the " cancer- cell." (Bennett.) But is this cell pecu- liar to, and characteristic of, cancer ? In considering the diagnosis of cancer, I shall have occasion to recur to this question. The cell is of large size, varying from -g-^ to xwo" ^^ ^^ ^'^^^ in diameter ; and it assumes various shapes ; either round, more usually caudate or spindle-shaped ; and it presents other forms by out-growths in one or more directions (Fig. 59). These cells are de- posited in a filamentous stroma "^' '* or mesh work, which has a vari- able alveolar arrangement and closeness of texture (Fig. 60). This intercellular stroma is pro- bably, in most cases, nothing more than the fibrous tissue of the textures, amid which the cancer-cells are infiltrated (Fig. 61). At the same time, it may contain some cells, round and spindle-shaped, indicative of new fibroid formation. But another intercellular substance — gelatinous, translucent, and amber- col oiired - — may be present in more or less abundance, and this is probably Fig. 60.t Fig. 61.§ peculiar to cancer, — the colloid species, or variety. This colloid matter * Cancer-cells a, from scirrhus of the mamma. Transparent cells h, seen after the action of acetic acid. 250 diam. (Bennett.) t Cancer-cells in the most advanced stage of development. (Ibid.) X Section showing the arrangement of cells and fibrous stroma in scirrhus of the mamma. (Ibid.) § Stroma of soft cancer, with partial infiltration of cells. (Rindfleisch.) VOL. 1. 194 GENERAL PATHOLOGY AND SURGERY. is itself structureless ; but many of the suspended cancer-cells are of large size, owing to their distension with the gelatinoas intercel- lular matter. Some such distended cells present a linear concentric marking. The leading species of cancer are further allied by possessing a similar chemical basis ; namely, chiefly albumen, associated with fibrin, gelatine, osmazorae, fat, certain salts, — such as the phosphates and carbonates of lime, with the carbonates of soda and magnesia, the oxide of iron, and water. But the results of chemical analysis hithei'to made are not very reliable. Species. — As the proportion of cells, or of intercellular matter, prevails, so do we recognize Encephaloid, or cancer, par excellence, aboanding with cells ; and therefore soft, opaque, and of a dead white or fawn colour. Hence the terms cerebriform or medullary, applied to this form of the disease ; and — the cellular or special element of cancer predominating — encephaloid yields on pressure an abundant quantity of "" cancer-juice," which resembles milk or cream. ScirrJms, on the other hand, is far vaove fibrous, and therefore hard and craggy ; semi-transparent in a thin section, and of a bluish- white or fawn colour; comparatively little "cancer-jaice " is exuded on pressing the cut surface of the fibrous stroma, and this little rather resembles thick grupl than cream, or it may be a small quantity of thin yellow serous fluid exudes ; but the fibrous stiT)ma itself contracts, whereby the cut surface speedily assumes a concave aspect, unlike the section of any other tumour, which remains level or becomes slightly convex at its margin. Colloid — in contrast with both the foregoing — is gelatinous, owing to the predominance of the gelatinous, intercellular matter, and in which the cells are suspended, the whole being infiltrated through a delicate fibrous stroma, with large alveoli ; it appears, therefore, either as a trembling mass, or a glairy fluid, dimly transparent, and of a greenish-yellow^ colour. This condition of cancer is not now recog- nized as a species, but simply as a variety of encephaloid or scirrhus, in consequence of a gelatinous transformation of a degenerative character. Cancer is essentially an infiltrating growth ; but while this pecu- liarity almost constantly prevails in scirrhous and colloid cancers, encephaloid becomes encysted, about as frequently as it remains free. A very thin, yet distinct fibro-cellular capsule may invest this typical form of cancer, and from which thin partitions pass into the tumour thus defined, intersecting its substance, or investing its several lobes. Generally speaking, this capsule is not adherent to the surrounding textures ; it furnishes a matrix in which numerous and tortuous blood- vessels ramify, previous to entering its prolongations and the inter- cellular fibrous stroma.\. The vascular network thus distributed around the alveolar spaces, seldom passes inwards among the contained cells. Encephaloid is, indeed, always abundantly vascular, as com- pared with scirrhus and colloid, both of which are relatively destitute of blood-vessels. The section of encephaloid is therefore often blood-stained, in the form of spots or patches of extravasated blood, contrasting with the white cancer-substance. Lymphatic vessels have been shoAvnby injection in medullary cancer, according to the observa- tions of Schroeder Van der Kolk, with regard to sjiecimens of this TUMOURS OR MORBID GROWTHS. 195 Fig. 62.* species in the stomach and liver. The lymphatics accompany the blood-vessels in the intercellular stroma, bat they enter the alveoli, as the -observations of Cornil and Ranvier have shown. IS'erves probably exist in the substance of a cancerous tumour; for pain is felt in scirrhus, and less so in encephaloid cancer, when cut into during a surgical operation. This sensibility may be due to the nerves of the part, involved in the cancer- growth. But the question of nerve supply, in point of origin, pro- portion, and distribution, has yet to be demonstrated anatomically, by dissec- tion. Twrnoiitr. — The investing capsule, when present, gives a definite outline to an encephaloid tumour — i-ound, oval, spheroidal, or lobed, which contrasts with the irregular and unbounded out- line of scirrhus and colloid, the infil- trating course of which is very rarely circumscribed. The boundary of either of these species of cancer is perceived rather by their degree of consistence, as compared with that of the textures around the seat of infiltration. The greater vascularity of en- cephaloid, coupled with its capsular and therefore more isolated condition, in many cases, are circumstances favourable to a corresponding* rapidity of g'rowth, and evolution as a Fig. 63.t Fig. 64. t distinct tumour ; consequently this, the typical species of cancer, fre- quently attains an enormous size and protrudes (Fig. 62) : whereas * Encephaloid Cancer. Advanced stage. (Oliver Pemberton.) t Scirrhus of both breasts. Removal of both. Death, from convalsions, one month after operation, lloyal Free Hospital. (Author.) X Scirrhus of breast, from same case. Section showing contraction of nipple. 196 GENERAL PATHOLOGY AND SURGERY. scirrhus, being differently circumstanced in these respects, remains smaller, rarely acquiring a larger size than an orange, and this rendered indistinct by infiltration of the surrounding textures. It shrinks yet smaller by their condensation and absorption, as its abundant fibi'oas stroma, continuous with parts around, draws texture after texture within the claws, as it were, of the infiltrating mass (Fig. 63). Infil- tration penetrates onwards, while contraction pulls backwards ; so that there is a double action at work — like the pulling on of a glove (Fig. 64). Colloid cancer, although ill-provided with blood-vessels for rapid growth, is scarcely restrained by a contracting fibrous stroma, and — in this particular resembling encephaloid — it spreads to an indefinite size, but not as a distinct tumour. The circumscribed, or non-circumscribed, condition of cancer much affects its mobility as a distinct tumour. Encephaloid is often dis- tinctly movable in the organ or textures in which it is imbedded; while scirrhus and colloid can be moved about, only as a diffused mass in connection with those textures to which the cancer has con- tracted adhesion by infiltration. Snch are the chief peculiarities respecting the shape, size, and mobility of the three typical species of cancer — in addition to their individual properties of consistence (and colour) ; and by the concur- rence of which characters they can be recognized during life. The three species — encephaloid, scirrhus, and colloid — may possibly co-exist and be combined in the same growth. Of this association I once saw a remarkable example in the post-mortem examination of a patient who bad been under the care of one of my colleagues at the Royal Free Hospital. The abdominal viscera were literally agglomer- ated into an enormous mass of cancer, which consisted of the three cardinal species above mentioned. A beautiful wax model is preserved in the museum of the hospital. Then again, these species of cancer may succeed each other, as well as co-exist, in the same individual. Yet, with all this fraternization, they never lose their individuality ; they never become transformed. Diagnosis of Cancer. — ]^o sufficiently exact structural differences have as yet been detected, by which to distinguish these species of cancer-growth ; we are, therefore, compelled at present to rely solely on their physical characters to determine the question of their {differ- ential) diagnosis, so far as these characters can be recognized through superimposed integuments. This conclusion refers only to the comparative value of structural characters ; for many other circumstances associated with cancer — its seat, character of the pain, influence of the growth on surrounding parts, — by infiltration and lymphatic infection, — the supervention of ulceration and the form of ulcer produced, I'ate and duration of growth, its recurrence as secondary cancer, locally, or in distant organs, and the circumstances of age, sex, previous diseases of the individual, and hereditary taint — combine to regulate the diagnosis. All these elements will be more conveniently considered in the Vital History of Cancer. But the structural individuality of cancer-groivth, as a distinct kind of growth, is itself uncertain. The supposed characteristic " cancer- cell " is occasionally absent in tumours, otherwise cancerous ; while similar cells may be found, and as often — according to Foster — in TUMOUES OR MORBID GROWTHS. 197 other morbid growths, and even in healthy tissues, and are, therefore, not peculiar to cancer. These two propositions, taken together, apparently negative the value of the " cancer-cell," as the most exact ground of identification. Excluding, however, those forms of growth — the recurrent Sarcomata — which simulate cancer in their maliguancy, but which do not present the cells of cancer ; and excluding also those exceptional morbid growths and healthy tissues with which similar cells are found ; this structural element is the most unequivocal sign of the presence of cancer. But the locular arrangement of the cells within the meshes of the filamentous stroma, constitutes an alveolar structure, which is almost equally peculiar to cancer, and characteristic therefore of it as a Morbid Growth. Often have I thus clearly demonstrated the nature of a cancer- tumour, by puncture with a grooved needle and submitting the material withdrawn to a microscopic examination. In relation to the cells of healthy tissues, the cells of cancer are of the epithelial type ; and there is evidence also that they may be transformed epithelial cells. Thus cancer-growth originates most frequently in tissues adjoining to epithelium ; as in the gland-tissue of the mamma, the mucous membrane of the stomach and intestine, and in the skin. The earliest stage of cancer-growth in some gland- tissues is found to be an excessive production of epithelium ; and the cancer-cells resemble the form of epithelium in the part, — the cells of cutaneous epithelioma, for example, being squamous. But cancer is produced also, although less commonly, in tissues quite removed from any form of epithelium ; as in bone, and in the lymphatic glands. 1 would appear, therefore, that cancer-cells m.ay be evolved from other than epithelial cells ; from connective-tissue corpuscles, in accord- ance with the observations of Virchow and Rindfleisch, possibly also from the hepatic cells, and other corpuscles ; while Billroth with Waldeyer would refer the cells of cancer exclusively to an epithelial origin. Varieties. — Many varieties of cancer have been described, which are worthy of notice, not because they possess any essential importance, but owing to the uncommon appearances they .present, at least on examination as pathological specimens, and which may help to verify the Surgeon's diagnosis, after removal by operation. Like the typical forms of cancer, their varieties also are, in most instances, occasioned by different proportionate quantities of their constituent elements — the cancer-cells and fibrous stroma, or of the blood-vessels. Some of them, however, are occasioned by morbid changes of structure ; de- generation, and the consequences of inflammation. They are all, severally, distinguished and recognized by their physical characters, which have suggested appropriate names ; although such designations are now rarely used. The varieties of Encephaloid are thus named : — " Hsematoid " cancer is a modification of encephaloid, in which the brain-like character is associated with an unusual amount of vascularity, the vessels sometimes interlacing so as to constitute a dense and somewhat spongy network, without, however, the peculiar structure of erectile tissue. " Fungus hsematodes " is rather an advanced stage of encephaloid, than a variety of this species of cancer. It represents the occurrence of interstitial haemorrhage, which either infiltrates the whole mass, or forms 108 GENERAL PATHOLOGY AND SURGERY. Fig. 65.* irregular acenmulations of blood in its substance ; and ulceration of the integuments taking place, a fungoid bleeding growth protrudes. "Villous" cancer is a term somewhat expressing the appearance presented bj this form of encephaloid. It is very vasculai-, and apt to bleed copiously. This and its other characters are well marked when the disease occurs on the mucous membrane of the urinary bladder. It is described by Rokitansky as " dendritic vegetation ; " an excrescence consisting, in its stem, of a fibroid membranous structure, on which the branches and villous flocculi are borne, as larger and smaller pouch- like and flask-shaped buddings, or sproutings of a structureless hollow tissue. " Melanotic," or melanoid cancer (Fig. 65), is, with very rare excep- tions, medullary cancer modified by the presence of black pigment in its elemental structures. This is a species of degenera- tion; besides which, en- cephaloid is subject to fatty and calcareous de- generations. Other mor- bid chang'es are suppura- tion and sloughing, which it is very liable to undergo. The v&rieties of Scir- rlms are — " Hsematoid " scirrhus, a condition of rare occurrence ; but when it does happen, its pecu- liarities are of the same kind as those of the hsematoid variety of encephaloid ; differing only in being less fully developed. (Walshe.) " Osteoid " cancer, or ossifying fungus growth (Mliller), occurs as a tumour, consisting chiefly of bone, but having on its surface, and in the interstices of its osseous parts, an unossified fibrous constituent, as firm as fibrous cartilage ; after a time similar growths ensue in parts distant from the seat of the first formed, and not on bones alone, but also in the celhilar tissue, serous membranes, the lungs, lymphatics, etc. It would appear to be the calcareous or osseous degeneration of scirrhus, or of medullary cancer, with which it not unfrequently co-exists. Uninterrupted gradations may be traced between the osteoid variety and these typical forms of cancer. Scirrhus is subject to other species of degeneration, and to morbid changes in common with encephaloid. Ulceration is more frequently observed in the course of scirrhus. Colloid cancer is singularly exceptional in not presenting varieties, properly so called. Nevertheless, the quantity of fibrous stroma, or of * Advanced carcinoma of the mamma, — exhibiting a prominent, fungoid, and bleeding mass. (Cruveilhier.) TUMOUES OR MORBID GROWTHS. 199 colloid matter, may respectively predom.iiiate. If the form.er, then this species assumes the appearance of a very tough, white, fascia-like mass, in which are small i-eparate cysts or cavities, filled with the colloid substance. In the opposite extrem.e, large masses of colloid matter appear to be only intersected by fibrous w^hite cords or thin membranes, arranged as in areolar tissue, or in a wide-meshed network. Another vai'iety refers to the quality of the colloid matter, rather than its quantity. It may be, or become, white and pearly, or opaque. I once met with a remarkable specimen of colloid cancer, in a female patient at the Royal Free Hospital (1862), and which I carefully examined. Most of the abdominal and pelvic viscera were aifected with this disease ; namely, the stomach ; the intestinal canal, which was beset ex- ternally, here and there, with pedunculated masses of colloid, somewhat resembling plums on their stalks : two colloid masses were imbedded in the spleen ; the pancreas was w^holly converted into the same gelatinous substance, enclosed in loculi ; the bladder was distended with a trembling mass, which rolled out like a jelly, leaving the mucous membrane pulpy, ragged, and bloody. The siibstance of the uterus and ovaries was infiltrated with drops of colloid, together forming a mass which seemed to be incorporated with a similar con- dition of the I'ectum. The gelatinous matter thus extensively diffused, was in some parts white, and of brilliant pearly transparency, looking like colourless and clarified jelly throughout the panci'eas, white and ofiaque in the spleen and uterus; while it presented its usual amber colour and transparency in the other organs I have specified. This opacity of the colloid matter was probably due to molecular disinte- gration. Cyst- FORMATION. — I have yet to notice cyst-formation in relation to cancer. This production, if not one of accidental association, represents an actual substitution of cysts for cancer-growth, and at the expense of its own structural elements. Thus cysts may either be formed with cancer ; or from and out of the cancer-structures, by their erring development and growth. Sir James Paget's work contains the best summary of this subject, of which the following is an abstract : — (1.) Respecting cysts accidentally associated with cancer, but of independent formation. Scirrhus of the mammary gland may occupy a portion of it only, in the rest of which many cysts may be formed, that are in no sense cancerous ; or, the chief lactiferous tubes may be dilated into pouches or cysts, contiguous to, but quite independent of, the neighbouinng cancer-growth. Such a cancer may nevertheless in its course enclose these cysts, and they remain for a time imbedded in its substance. The ovary may be the seat of cysts, and also the seat of cancer ; the two growths thus accidentally associated, will probably become connected, although of independent origin. Further than this, cancers may grow from the walls of common cysts, i.e. of cysts which have not origi- nated in cancer-structures. Medullary cancer, especially the villoiis form, sometimes grows from the walls of cysts which have themselves no cancerous appearance. (2.) Cysts derived from cancei'-structures — by theii' erring develop- ment and growth — constitute a series parallel with that of the cysts barren and prolifex^ous, which form in innocent tumours, or in the 200 GENERAL PATHOLOGY AND SDRGERY. natural textures. Cancer-cysts Laving this origin, are, therefore, either baiTen or proliferous. Of the barren species are : — Cysts filled with serous fluid, variously tinted. Serous cysts are often boi-n in cancers, especially in those of the medullaiy type, which grow quickly, or to a great size. One or many such cysts may be present on the surface or in the substance of a cancer. Sometimes a single cyst of this kind enlarges so as to surpass the bulk of the cancer, exceedingly perplexing the diagnosis. Sometimes many cysts are present, as if the tumour were entirely composed of them, with cancerous structure only in their interstices. Sanguineous cysts are born as often as serous, in medullary and other cancers. The imprisoned blood undergoes changes in respect of colour and consistence, thereby diversifying considerably the ap- pearances presented by cancers containing these cysts. Colloid cysts, i.e. cysts containing a glairy jelly — not cancerous — niay likewise be developed in cancer- growths, by conversion of their structural elements. The proliferous cysts which originate in cancers, bear on their inner surface cancerous growths — thus coiTesponding with the glandular growths which spring from the interior of cysts in the mammary and thyroid glands. These endogenous growths are often found in the alveoli of colloid cancer. Clusters of clavate, or flask-shaped villous processes, resembling those formed in the early stages of " dendritic vegetation " of villous cancer, spring from the wall of the alveolus. The origin and modes of development of these cysts — simple and proliferous — have been traced by Rokitansky, and shown to correspond with those of all other cysts ; the only difference being the source of the cyst-formation — here a cancerous element, while in respect of all other cysts it is an element of some natural tissue. Situation. — The preference of Cancer for different tissues and organs, varies with each species of growth ; and according to the following order of liability with regard to each species. (1.) Encephaloid cancer — the most malignant species — selects first, in order of frequency, the testicle ; next, the bones, and particularly the femur ; the intermuscular cellular texture of the limbs ; the eyeball or orbit ; the breast ; the walls of the chest, or abdomen ; the lym- phatics. Moreover, encephaloid " occurs in organs in which no other cancer, least of all scirrhus, ever occurs, — as in the liver, the kidneys, the lungs, the testicle, the lymphatic glands." (Rokitansky.) Encephaloid cancer is not usually solitary. It commonly co-exists in many textures and organs. Melanotic cancer — mostly a variety of encephaloid, by pignaentary degeneration of its cells, and the most common of all melanotic tumours — is prone to grow first, in or beneath pigmentary moles (Paget) ; or selects first the liver (Rokitansky) ; but it may occur " in the brain and about the nerves ; at the eyeball, in the lungs, thyroid gland, liver, spleen, kidneys, bones, lymphatic glands, ovaries, in and beneath the intestinal mucous membrane, between the mesenteric layers, in the skin and subcutaneous areolar texture, upon serous membranes, ia the dura mater, upon and within the heart." This variety of cancer occurs as secondary formations, in very many textures and organs, simultaneously. I TUMOURS OR MORBID GROWTHS. 201 Villous cancer — another variety of encephaloid — is produced, according to Rokitansky, exclusively upon membranes ; more espe- cially upon mucous membranes, and most of all that of the male urinary bladder, near the opening of either ureter ; next to this the mucous membrane of the stomach, and in particular the pyloric por- tion. It has been observed suspended by a pedicle from the internal membrane of the rectum, and even from that of the gall bladder. Secondly, it is very apt to grow extensively from the internal wall of ovarian cysts — cystocarcinoma — where it is recognized as villous cancer by its copious accompaniment of medullary sap. In these cases, it is often concurrent with cancerous infiltration of the lym- phatic glands about the lumbar vertebrae, and with, peritoneal cancer — representing villous cancer upon a serous membrane. It has been observed also upon the dura mater ; occasionally upon the general integument ; and perhaps in bone. Lastly, it occurs in parenchyma- tous organs. (2.) Scirrhous cancer selects first the breast in the proportion of 95 per cent. (Paget.) Next in order of frequency, the stomach; perhaps still more frequently, in this organ (Rokitansky); then, according to the last-named authority, the colon in its sub-mucous cellular tissue ; more rarely in the vaginal portion of the titerus ; tipon serous mem- branes, and in the snb-serous areolar tissue. Again, as an expansive degeneration of the omentum, and of the mesentery; in the salivary glands; in the fibrous tissue of the bronchi. In several of these, as well as in other structures, — for example, the ovaries and the brain, — there occur " cancerous growths of embryonic composition, and in all likelihood of fibro-cancerous (scirrhous) nature." To this list may be added cancer-growths secondary to scirrhus, and which, in proportion as they are consecutive, incline more and more to the condition of encephaloid ; for example, of the lymphatic glands, the bones, muscles, skin. Scirrhous cancer is not unusually solitary. (3.) Colloid cancer selects the stomach and large intestine, the serous membranes, and particularly the peritoneum. In other textures and organs this species is mostly secondary ; as in the lymphatic glands, the lungs, the ovaries, the bones, the breast ; " and in rare cases, the kidney, uterus, and liver " (Rokitansky) : to which I may add, the pancreas, spleen, and urinary bladder. Colloid cancer is usually solitary. Vital History of Cancer. — Causes. — Age has no definite influence on the production of Cancer ; the three species having been known to originate at every period of life. Even during intra-uterine life, scii'rhus in the heart was found in one case. At birth, meningeal cancer, and instances of cancer aifecting other organs, have been found. In infancy, childhood, maturity, middle age, the decline of life, and extreme old age — even at ninety-tlrree — cancer is liable to occur. But certain periods of life are prone to cancei'-growth, as indicated by its mortality ; the tenth to the fifteenth year is least liable, the thirty-fifth to the eightieth year, and perhaps to a later period, is most liable, the tendency increasing with each succeeding decennial period. There seems to be a more rapidly increasing tendency after thirty and on- wards for some years, as compared with the same number of years before that period ; the proportion of deaths, in both sexes, from the 202 GENERAL PATHOLOGY AND SURGERY. age of thirty to fortj increasing to six times more tlian botween twenty and thirty. Sex much affects the liability to cancer. Thus, from forty to fift}' years, in females, the mortality increases sixfold ; whereas, in males, the number of deaths increases only two and a half times. Sex in relation to Species. — Scirrhus is more common in tlie female, as affecting the breast ; enceplialoid occurs more commonly in the female, as affecting the uterus ; but exclusive of this organ, men are more liable than women ; colloid is of about equally frequent occur- rence in both sexes (Lebert) ; but epithelial cancer is most frequently met with in the male. Age in relation to Species. — Enceplialoid occurs more often in infancy and youth ; scirrhus in adults, it being uncommon befoi-e puberty or even the thii'tieth year ; colloid in adults only, or exces- sively rarely, if ever, before the thirtieth yeai'. Hereditary tendency. — Evidence in this direction may be resolved into two general facts. In some families cancer is known to have occurred in more than one individual. Mr. Sibley traced it among cancer patients at the Middlesex Hospital, in one case of every nine; Sir James Paget, in one of every six cases. Mr. Arnott and Mr. De Morgan each had charge of members of a family in whom disease was thus exhibited ; the father and his relatives were healthy, the mother died of cancer of the breast, two of her sisters of phthisis, and one of dropsy. Of six daughters, five had cancer of the breast, the youngest was still healthy, and the only son died of phthisis. On the other hand, to give some force to such observations, some entire families are exempt from the disease. Hereditary tendency in relation to Species, is about equally in- fluential in the production of scirrhous and medullary cancer. Constitutional tendency to cancer can only be inferred — yet the in- ference is strong — from the apparently negative relation of this disease to any external causes. The various presumed external causes of chronic maladies shall continue in operation in many individuals, for a length of time, with every degree of intensity and in all possible modes of combination, tcithout producing the slightest manifestation of cancer ; and cancer exercises its most fearful ravages in persons who have never been influenced by any such causes. Excluding, there- fore, external causes, some internal and individual, or constitutional, tendency must have been in operation. Thus, medullary cancer occurs mostly in persons of apparently scrofulous diathesis, although 89 per cent, seem to have good general health at the commencement of the disease ; and in scirrhus, at its first appearance, this proportion rises to 95 per cent. (Paget.) It is difficult to trace the histological generation of Morbid Growths, but should future observation show that the production of Cancer-growth is connected with emigration of the pale corpuscles of the blood, that connection would indicate the constitutional origin of its textural development. On the other hand, there are reasons for believing that cancer, like syphilis, is primarily local, and only secondarily constitutional. Yel- peau is, perhaps, the leading authority who supports this position ; and the reasons which have been adduced may be thus summaril}- stated : (I.) Cancerous tumours spring iip in individuals who have always TUMOURS OR MORBID GROWTHS. 203 enjoyed perfect health, and who, to all appearances, are perfectly well at the time of the occurrence of the disease. (2.) These tnmoars are not unfreqiieatly the result of some local injary or irritation. (3.) Primary cancer-growth is always solitary ; never multiple, although sometimes rapidly disseminating, as secondary cancer, and thus co-existing' in different parts. (4,) The constitutional health does not, in the majority of cases, appear to suffer until some months have elapsed ; when, as the lym- phatics or glands become implicated, or neighbouring tissues invaded, signs of cachexia set in. (5.) If the disease be removed before neighbouring parts have become contaminated, the health, if it have suliered, often improves materially, (6.) The patient remains free from any recurrence of the disease for a considerable period, in the great majority of cases. (7.) In some instances, no recurrence whatever takes place, the disease being eradicated from the system, which could not be the case if it were constitationaL (8.) Recurrence having taken place soon after an operation, it is almost invai'iably either in the cicatrix or in its immediate neighbour- hood ; owing to cancer-cells which had been widely infiltrated escaping removal, and subsequently developing into a new tumour. Were the disease constitutional, recurrence would be as likely to take place in other parts, or in internal organs, as it does when the operation has been too long delayed. (9,) The same tendency to recurrence after removal, and even to secondary deposit in distant organs, is observed in respect to other tumours which are incontestably, primarily local — e.g. myeloid and other sarcomatous tumours, and which only become constitutional in their more advanced stages, and in a secondary manner. External causes. — Injury, or irritation, is not found to have more than a limited influence on the production of cancer. Thus, scirrhiis of the breast seems to have some such origin in less than one case in six ; medullary cancer, however, twice as often — one in three cases ; colloid is doubtful in this respect ; but epithelial cancer has a traumatic origin most frequently — one in two cases. (Paget.) The causative influence of injury is evinced when cancer-growth is the immediate consequence. Instances of this kind are more often met with in the history of medullary cancer. Or again, a broken tooth scratching the tongue or cheek, may induce epithelial cancer in either of these parts ; the friction of a clay-pipe, constantly used, may affect the lip in like manner; and the irritation of soot in contact with the scrotum or prepuce appears to induce the well-known chimney-sweeper's cancer of those portions of integuments. Effects of Cancer. — (a.) Locally. — Pain may be regarded as an effect, produced, apparently, by compression of the nerves in, and around, the cancer-growth ; by separation of their fasciculi and fibrils with interstitial deposit ; and, in the case of scirrhns, by dragging of the nerves as the growth contracts. Pain is, therefore, due rather to a mechanical operation of the tumour, than arising from any vital endowment of the growth itself, which is in fact comparatively desti- tute of nerves. Enceplialoid cancer, in particular, is of this character; 204 GENERAL PATHOLOGY AND SURGERY. the tumour scarcely seeming to be sensitive, when cut into during a surgical operation for its removal. ScirrJius, however, seems more especially to give rise to pain from ivithin itself, the pain radiating thence along the nerves. The kind and degree of pain vary considerably. Lancinating pangs, particularly when the tumour is handled, are commonly experienced in scirrhus. A hot dart, molten lead, and other such expressions are also used to denote both the character and severity of the pain in this species of cancer. The pain of eneephaloid is generally less severe ; and colloid is comparatively painless. In cases taken indiscriminately the pain differs : a dull aching sensation, a feeling of weight and cold- ness, distressing itching, represent these varieties. The pain varies also in point of date, duration, and constancy. Thus it is not generally of early occurrence : being absent in most cases of scirrhous breast, for the first year or year and a half. Its dui'ation is temporary ; occurring from time to time, as when the breast is handled. And cancer, not uncommonly, runs through its whole career without any pain. It is absent in about one-fifth of the cases, inckiding all organs and localities. (Walshe.) The pain is usually proportionate to the rapidity of growth ; becoming inore severe and persistent when the tumour is inflamed or ulcerating or about to slough, and acquiring the hot burning or scalding- character. The Lymphatic vessels, and glands, proceeding from the seat of cancer-growth become implicated at an earlier or later period, and in various degrees, according to the species of cancer. Scirrhus, espe- cially, is thus infective, as shown by the axillary glands when the breast is the seat of disease ; Eneephaloid has the same influence in a lesser degree ; Colloid, more slowly, and in the least degree ; but Epithelial cancer is very constantly infective, in about the proportion of one in two cases, although the glands are not involved to so great a distance from the seat of disease, as in the other species of cancer. The results of Paget's obseiwations, respecting the decidedly infective character of epithelial cancer, are at variance with those of Lebert and Hannover. Cancerous lymphatic glands present more or less enlargement and induration, without any adhesion, or discolouration of the skin, at first. But the course of their disease is similar to that of the primary cancer- growth. Derangements of function a,re produced, some of which are irritative ; as pleurisj and hydrothorax by mammary cancer, peritonitis by ovarian cancer, vaginal discharge by non-ulcerated scirrhus of the uterus. Other derangements are Tnechanical ; as effusions by the compression and obstructions of blood-vessels, spontaneous fracture with cancer of bone, stricture of the urethra or bowel, pressure on the brain, spinal cord, or nerves, inducing paralysis, partial or complete, pressure on the optic nerve or from within the eyeball, impairing or destroying- vision . (6.) Constitutional effects, — The functions of the various parts of the body, other than of the part affected, may continue uninterruptedly for a longer or shorter period as cancer advances. Thus then the genreal health remains unimpaired, independently of the local disease. Conversely, the groivth of cancer is inversely proportionate to the TUMOUKS OR MORBID GROWTHS. 205 general health ; being temporarily arrested, if it remains unaffected or is maintained, and coming into activity as it declines. Consequently, with advancing age, there is, so far, a greater liability to cancer ; and particularly of the uterus, during the decline of generative power. In like manner the functional vigour of any part of the body apparently protects that part against the production and growth of cancer; whereas the decline of such vigour has the opposite tendency. Thus, pregnancy and lactation protect the uterus and breasts, respectively ; while the cessation of those functions is favourable to cancer-growth in these organs. The supervention of either of the functions referred to, is, however, sometimes accompanied with a rapid extension of the disease, or the tumour may remain unaffected by these local changes. Cachexia is the term used to denote all those functional derange- ments, chiefly of the circulation, nutrition, and innervation, which together represent the constitutional condition. Feverishness, loss of appetite, nausea and vomiting, distressing thirst, imperfect digestion, obstinate constipation or diarrhoea, ^^progressive emaciation with peculia?' yelloiD salloivness,'' muscular weakness, sleeplessness, and melancholy: such are the leading phenomena of this condition. They are somewhat proportionate to the amount and diffusion of cancer-growth in the system, and hence are more pronounced when it appears in different parts sucessively, as secondary cancer, and as affecting- especially the great internal organs, which minister to the nutrition of the body. Cachexia is most marked in scirrhus, or in eneephaloid at an early period of the disease, and least in colloid cancer. Much has been urged for and against the reality of cachexia as a constitutional symptom of cancer. I think the truth may be thus expressed ; that an individual affected with cancer often presents a pallid, or perhaps yellowish and emaciated appearance, but that this state is not peculiar to cancer disease. The patient may look very ill and worn, just as in any other chronic disease ; and that no such state can be recognized as the cancerous cachexia. This acknowledgment, however, amounts only to the fact, that in regard to cancer, as of nearly all diseases, no one symptom is pathognomonic, but that the diagnosis must be determined by the concurrence of symptoms, — co-existing or successional. Co-existing Diseases. — Diseases of various kinds may co-exist with cancer, without apparently influencing it, or being influenced by it. Thus, Bright's disease of the kidney has no effect on the course of cancer, which may proceed favourably, even to withering and complete cicatrization, independently. Extensive skin-disease, syphilis, caries of the spine, fatty and cirrhosed liver, may severally co-exist. " But," observes Mr. Moore, " exanthematoiis fevers are unknown in the cancer wards of the Middlesex Hospital, excepting erysipelas, which is not less common in such patients than in others. Erysipelas sweeping over a cancerous ulcer will sometimes efface its specific characters, rendering it a healthy, granulating, and cicatrizing sore. In a few days, or weeks at most, the original kind of ulcer has reappeared. Hospital gangrene, occasionally, has a similar temporary effect, and ultimately the same result. Apoplexy and heart-disease seem to have some protective influence against the production of cancer. Tubercle appears to be nO less manifestly incompatible with cancer, while yet related to it." Traces of old tuberculous disease are remarkably common in the bodies of 206 GENERAL PATHOLOGY AND SURGERY. persons dying with cancer, and in 34 per cent, of tbeni phthisis exists in the family ; yet tlie two diseases are never found in active growth together in the same person. Active tubercle co-existing, supplants as it were cancer, which may wither and even cicatrize as the patient is rapidly dying of phthisis. CouusE. — In the vitalhistor^'of cancer, certain aspects of its progress are particularly worthy of observation. Bate of Growth. — Encephaloid cancer takes the lead, gi-owing generally to some dimensions in a short time, or even with vast rapidity. Scirrhus grows more slowly ; colloid, with a medium degree of rapidity. Duration of Groivth. — Scirrhus is of the longest mean duration, averaging three or four years ; encephaloid is of shorter mean duration, averaging about two years ; colloid holds a middle place also in this respect. But the suspension of cancer-growth for a time, the tumour remaining stationary, is not uncommon. This period may extend even to years. Thus, scirrhous cancer has been kno^\^l to renaain quiescent for ten or twelve years ; medullary cancer, in like manner, and perhaps more frequently, for n, period of twelve and fifteen years. Sex appears to have but little influence on either the rate or duration of growth. Age seems to have some influence ; the progress of cancer, generally, being more rapid in the young, and chronic in old persons. Arrest and Decay. — These changes consist in a cessation of growing, and a desti'uction of the proper structural elements of the tumour. Cells and nuclei break up, oil-globules and graniiles are substituted, by a degenerative transformation. The chief element in a icitliering cancer is fat, contrasting with the general emaciation of the body. Scirrhous cancer-growth is thus arrested, in rare instances ; and even more rarely, the remnant cancer may become calcified. Softening — which contrasts with the hard withering of cancer — takes place, principally, in encephaloid, itself soft cancer. It is transformed into matter having a creamy or milky appearance, very slightly viscid, and the consistence of soft cheese or thin pus. This is the further result of fatty degeneration, which has passed into caseation ; the fatty matter having become less oily and more piiltaceous. The proportion of milky opaque fluid, yielded on gentle pressure, indicates the progress towards this change. As affecting" colloid cancer, softening represents, not perhaps any further change in its already jelly-like matter, but the breaking down of its containing stroma, with rupture of the loculi and escape of their contents. The commencement of softening, in any species of cancer, is either at the circumference or centre of the tumour ; and in a single spot, or in several spots, simultaneously. Age seems to have no definite relation to these changes. In old persons, the aiTest of cancer is not an uncommon event. One such case, under the care of Mr. Cooke in the Cancer Hospital, was that of a healthy-looking woman, with a ruddy complexion, and aged eighty-two. Scirrhus of four years' duration existed in her left breast, and she had been an out-patient just twelve months. Another instance, in the University College Hospital, was that of a woman aged seventy-seven. The disease had existed for seven or eight years, but was progressive durino- the last eight or nine months. TUMOURS OR MORBID GROWTHS. 207 ' Teemuvations. — (a.) Hesolution and Ahsorption\s one mode of spon- taneous cure. This would appear to be synonymous with Atrophy, — as the result of withering and induration of the cancer, coincident with fatty, and perhaps calcareous degeneration of its structure, until the tumour has partly or entirely disappeared. Both the ordinary species of cancer-growth have been known to undergo spontaneous cui-e in this way. But such instances are very rare, and exceptional. Thus, scirrhus of the breast disappeared in a lady whose other breast had been extirpated for this disease. In this case, scirrhus was found in several of the abdominal viscera ; the patient having died of asthma not long after the subsidence of the breast-cancer. An encephaloid cancer of the eye of an infant ultimately disappeared, and was followed by dropsy and atrophy of the eyeball. (&.) Suppuration is another mode of spontaneous cure. A man had, a large scirrhous tumour removed from his back. The disease returned. !N"o operation was again performed ; but subsequently violent inflammation supervened, an abscess followed with profuse suppurative discbarge, and then re- covery, (c.) Mortification may extirpate a cancer, though rarely. The whole tumour is eliminated by sloughing in a mass. None of these modes of spontaneous cure, however, have proved of permanent duration. Cancerous Ulceratiooi and TJlce^-. — The former consists in the mole- cular disinteg-i^tion or destruction of the structural elements of the textures, as in ordinary ulceration, preceded, however, by interstitial infiltration circumferentially ; thus differing from ordinary ulcera- tion. And the infiltrating cancer-elements, although' themselves dying", seem to exercise a destructive influence over the proper textural elements. Species of Cancer, in relation to Ulceration. — Cancer-growth mani- fests a tendency to ulceration, in different degrees, according to the particular species. Scirrhus is inherently disposed to underg'o this change, and which is exhibited in either of two ways : by softening and disintegration of the cancer-substance, leading* to discharge through ulcerative destruction of the integument ; or, by cancerous infiltration with adhesion of the integument to the tumour, resulting in ulceration. Two modes of ulceration, therefore, may be recognized, — the deep or excavating, and the superficial or erosive ; the former presenting' an ulcer which has characteristic appearances — those of the scirrhous ulcer ; the latter, an ulcer having no specific characters. Mechdlary cancer evinces less tendency in its substance to ulceration, and com- paratively little disposition to infiltration of the integximent ; but the tumour growing more rapidly than scirrhus, the skin, subject to the mechanical influence of mere bulk,, yields partly by tension and attenu- ation, and partly by common inflammatory ulceration, or perhaps sloughing, the aperture thus formed ha\"ing the characters of an ordinary ulcer indisposed to heal. The growth protrudes as a fungoid mass, which is liable to repeated attacks of inflammation, with suppu- ration, ulceration, or sloughing. Haemorrhage also occurs, from time to time, or interstitial extravasations of blood into the cancerous mass. Consequently, a protruded encephaloid cancer appears in the form of a softened and bleeding exuberant growth — fungus htematodes. Diminished in bulk occasionally by ulceration or sloughing, further protrusion takes place, so as to overlie and become adherent to the 208 GENERAL PATHOLOGY AXD SURGERY. margin of the ulcer, which then appears everted. Colloid cancer 13 indisposed to ulcerate, although freely infiltrating ' the suiTounding textures. Epithelial cancer is very prone to ulceration, as will be described in connection with Fig. 66.* this species. The ulcer resulting from the process of infiltration, and destruction of texture, presents certain appearances which are most characteristic in the scirrhous ulcer (Fig. 66). Of variable size and shape, the edges, at first per- haps thin, irregular, and level with the surrounding sui*f ace, or sunken, undermined, and inverted, become thickened, elevated, and everted — a con- dition commonly observed. The bordering skin acqiiires a bluish-red, or brown tint ; and the surface, excavated and irregular, presents large prominent granulations, or a base of slough and blood. A thin, greenish, fetid, and acrid discharge — ichor — oozes from the ulcer. Other changes may occur which more or less ob- scure these appearances, but they ai'e chiefly exceptional or accidental. Hsemoi-rhage, for example, may be profuse, and particularly from the ulcer of encephaloid cancer. The capillary vessels are the usual source of this hemorrhage ; but it sometimes proceeds from erosion of the larger vessels, or from rupture of varicose veins communicating with the ulcer. An admixture of melanotic matter may occur, as seen also in the ulcer of encephaloid cancer. Then again, a cancerous ulcer is liable to those pathological processes which afiect an ordinary ulcer; as inflammation and phagedena. A cancerous ulcer enlarges slowly or rapidly, both circumferentially and in depth, the whole area of the textures being infiltrated with cancer- elements. Consolidation increasing, the ulcer becomes firm and fixed, both in its margins and base ; scii-rhous ulcer especially acquires these characters, like this species of cancer in the course of its growth. Hardness and immobility, therefore, superadded to the appearances of margin and surface already described, render the cancerous ulcer more peculiar. Cicatrization and Cicatrix. — Paradoxical as it would seem that any process of healing should take place in a cancerous ulcer — itself inherently destructive and texturally indisposed to heal — nevertheless, cicatrization supervenes occasionally. Unlike that of an ordinaiy ulcer, this cicatrization rises over the prominent granulations and dips into the hollows of the ulcer. In the majority of cases, the process and its result are only temporary ; as when erysipelas sweeping over a * Scirrhous ulcer of the breast ; with slough in the base. (T. W. Nunn.) TUMOURS OR MORBID GROWTHS. 209 Fig. 67. cancerous ulcer renders it a healthy cicatrizing sore, for a time. But, in some cases, the healing is established, and a sound cicatrix has formed. This has occurred in the ulcers of both scirrhous and en- cephaloid cancers. Of such unusual permanencj, a case is related bj Nicod, and several others were observed by Bayle. The Cicatrix of a cancerous ulcer is, in some respects, peculiar. It is extremely thin, of a red or violet colour, and often traversed by large vessels. Contraction is restrained by the firmly adherent skin around, the cicatrix is thus rendered very tense and even more attenuated, and disposed to ulcerate again. Recurrence of Cancer, locally. — This is a very common event in the vital history of cancer, whether after its separation spontaneously, or removal artificially by the knife. The period of recuiTence is generally early : in scirrhous cancer, under six months in the great majority of cases (Lebert) ; in encephaloid, about seven months as the average (Paget) ; in colloid, a period of uncertain duration; and in epitlielial cancer, the period of immunity may extend to months or years. As a general rule, the rapidity of recurrence is proportionate, not to the previous duration, but to the rate of growth, of the primary cancer. Local reproduction takes place under different circumstances, which are classed, by Dr. Walshe, as follows : — (a.) The process of cicatrization may not distinctly com- mence, or be interrupted at an early stage, and fungating growths spring frotm some part of the ulcer or wound. (6.) A perfect cicatrix forms, and after a vari- able lapse of time, a tumour grows in the subjacent tissues, presses outwards the newly formed scar, destroys it, and ap- pears externally with the characters of cancer, (c.) In the cicatrix itself, repro- duction may occur, by the development of tuberiform cancerous growths (Fig. ^7). (cZ.) The lymphatic glands, near to the original cancer-growth, may become the seat of recurrent cancer; as often witnessed after the removal of scirrhus, which primarily affected the breast. Recurrent cancer is said to grow more rapidly than the primary cancer, but certainly this is not the rule in regard to scirrhus. Less pain and exhaustion attend the recurrent disease, whether sciirhus or encephaloid, than the primary growth. Dissemination of Cancer in the System. — Secondary Cancer. — One general law respecting the dissemination of cancer in the system, would seem to be this ; — it is regulated, in some measure, by the retention of cancerous matter within the body, or its discharge ex- ternally through the integuments by ulceration or through some natural passage. Cancer of the uterus with free discharge per vaginam, is followed by secondary cancer in not more than 25 per cent. ; whereas deep-seated cancer of the breast produces secondary cancer in 79 per cent. In calling attention to this important general * Eeturning scirrhns in the breast, after operation; presenting a series of nodules in and around the cicatrix. One in the centre has ulcerated. (Cruveilhier.) VOL. 1. P 210 GENERAL PATHOLOGY AND SURGERY. fact, Mr. Moore justly adds, there are covered cancers, though very- few, which remain solitary to the end of life, and there are cancers on free surfaces which do become disseminated. Primary and secondaiy cancer must not be confounded with the simultaneous dissemination of cancer, or the production of more growths than one, in different parts, at the same time. The total absence, probably, of functional symptoms at an early period is apt to mislead, e.g. in cancer of the brain, lungs, liver, and stomach, organs of leading functional impoi'tance. Thus cancers which are apparently successive may really be simultaneous. The relative tendency of the three species of cancer to affect the system secondarily, differs with respect to each. Encephaloid and scirrhus seem to dispute the first place in this aspect of their vital history. But colloid undoubtedly has here the lowest rank, as also in the other characters of malignancy. Species and shaped secondary cancer. — Encephaloid is produced in the majority of cases ; Scirrhus far less frequently, and even rarely, although perhaps always secondary to scirrhous cancer of the breast (Paget) ; Colloid has not yet been found, in any case recorded. (Walshe.) The nodular form is that which secondary cancer usually assumes, especially in the liver, lungs, and bones. In a cicatrix, as after excision of a cancerous breast, this form of secondary cancer is very common. N'odules or button-like tubercles appear, which spread and coalesce ; or a hard ridge forms in the line of cicatrix. In either case the colour, whitish at first, deepens into a purplish-red hue. In proximate lymphatic glands, secondary cancer produces — and probably at an early period — tenderness, enlargement, and induration, increasing even to bullety hardness. Termination by Death. — This, the natural and most frequent issue of cancer, takes place in various ways, which may be concurrent or suc- cessive, (a.) By the constitutional influence of the disease on nutrition and blood-production, as manifested by cachexia ; the proper cancerous death, (h.) The direct inflaence of the disease, locally, on various functions, e.g. of the liver, stomach, oesophagus, intestines. (c.) Haemorrhage, internally or externally, e.g. Cancer of the uterus. {d.) Exhaustion from pain and discharge, e.g. Cancer of the uterus, (e.) Mortification, e.g. cancer of the limbs. (/.) Intercurrent diseases, generally of the inflammatory class, e.g. pleurisy, or pneumonia, by cancer affecting the ribs and lungs, (g.) Substitute diseases, e.g. phthisis supplanting cancer ; tubercular deposit in the lungs, for ex- ample, being pathologically equivalent to the cessation of cancer- growth in some other part of the body. Treatment. — Naturally incurable and fatal as cancer is generally, it may, as we have seen, undergo certain structural changes of a self-curative character, the purpose of which it should be the aim of therapeutics — medical and operative — to imitate. To establish this correspondence between the treatment of injuries and diseases and the processes of Pathology, in respect to their natural courses and ten- dencies, is one of the leading features of modern Surgery ; and this relation of art to the indications of nature, is better illustrated by the treatment of Cancer than by that of any other Morbid Grrowth. (1.) Arrest of Cancer, and Hygienic and Medicinal Treatment. — The TUMOURS OR MORBID GROWTHS. 211 natural arrest and decay of cancer consists in the cessation of growth, a.nd the disintegrative destruction, of its proper structural elements ; changes which are accompanied with, and denoted by, ivithering of the Tumour. This course and termination are observed mostly in the career of scirrhus, as witnessed best in the puckered-up chronic mammary cancer and shrivelled breast of old women. No known medicinal treatment seems to insure this result; although iron, bark, cod-liver oil, the anodyne influence of opium, and such other agents as, apparently, improve nutrition, may prove auxiliary. But hygienic measures, especially in the shape of a generally nutritious and easily assimilated diet, and a. cheerful, hopeful tone of mind, will be most efl&cacious. The growth of a cancer-tumour is inversely propoi-tionate to the arrestive influence of the general health. Thus, when the body is well nourished, the tumour starves. Local applications are advantageous resources occasionally. Any temporary supervention of inflammation may be treated accordingly, by a few leeches or a light poultice. Pain recurring or persistent, and affecting the general health, is often mitigated by a belladonna plaster, or by conium or opium ointment. A scruple of the iodide of lead in a drachm of glycerine, mixed with an ounce of unguentum opii, is recom- mended by Mr. Moore. Gently rubbed over the tumour two or three times a day, it reduces any swelling, as well as relieves pain. Soap plaster, used simply to protect, not to compress, the integument, is also calculated to retard the progress of the growth. Compression may control pain, but its efiicacy in repressing growth is doubtful. First tried at the Middlesex Hospital many years since, it was unfavourably reported on by Sir Charles Bell ; subsequently highly extolled by Recamier — who stated that 30 per cent, of his cases were cured — and advocated bj Dr. Walshe — it has, nevertheless, not found much favour in this country. Compression is best effected by means of the air-cushion and spring, devised by Dr. Neil Arnott. Pres- sure varying in force from two and a half to twelve or sixteen pounds can thus be brought to bear on the tumour. (2.) Sloughing and Emicleation. — (a.) By Cauterization. — This method of treatment is warrantable only in cancer which is already ulcerated, and has acquired adhesions beyond the fair reach of the knife. Cancerous glands, as an extension of the disease, are not so con- veniently removed by the application of caustic. But they, and the textures around the slough, mostly become notably diminished in size; an important fact with reference to the glands, compared with their progressive enlargement after removal of the primary tumour by ex- cision. Velpeau's observations seem to confirm this difference in favour of treatment by caustic. It may be followed by successful results, but of temporary duration ; a few weeks only — if the disease be incompletely extirpated, or lasting until after the wound has healed ■ — if a healthy granulating surface was obtained. Eventually, in either case, cancer reappears, in situ, and runs its course with rarely an exception to a fatal termination. As compared with removal by the knife, the advantages of cauteri- zation are — the bloodless character of the operation and, consequently, less exhaustion, and the less liability to erysipelas or pyeemia ; the disadvantage is, the pain, severe and persistent. Various caustics have been employed ; the concentrated mineral 212 GENERAL PATHOLOGY AND SURGERY. acids, sulphuric or nitric, or the solid caustic alkalies, — potash or lime, and various clilorides, that of zinc especially. Of all these, the glacial sulphuric acid mixed with powdered saffron, forming a black paste, is preferred by Velpeau, particularl}^ in fungoid and bleeding cancers. The caustic alkalies combined, form the well-known Vienna paste. The chloride of zinc mixed with flour readily forms a paste by deliquescence. If a liquid caustic be used, the surrounding skin should be protected by a bari-ier of gutta-percha or other similar material attached to the skin. If chloinde of zinc be used, the skin, which resists this agent, must previously be destroyed by sulphuric or nitric acid. The depth to which the action of any such agent extends, and the destruction of the tissues accordingly,'will depend on the strength and quantity of the caustic employed. But the result can only be roughly estimated. The slough produced varies in appearance with the kind of caustic employed ; a dry, hai'd, contracted blackish eschar, resulting from the application of a strong mineral acid ; a wet, pulpy slough, from chloride of zinc. It separates after a time, a few days to a month, disclosing a healthy granulating surface, but perchance, of prodigious depth and extent. Other modes of applying caustics have, therefore, been devised. The repeated introduction of chloride of zinc through incisions daily made deeper and deeper, affords a precaution for limiting the slough to the depth and extent of the cancer. This plan of treatment was first practised in this country by Dr. Fell, of the United States ; a report of which Avas drawn up by the Medical Staff of the Middlesex Hospital, in 1857. Another mode is to under- mine a cancer with caustic, introduced through nari'ow passages pierced with a seton needle. Of all these caustics, my own experience inclines to the chloride of zinc, which I first saw used by Mr. Listen, many years ago, and the efficacy of which has since been attested by its results in some cases. In the ulcerated stage of cancer, disinfectants become requisite, for the double purpose of cleansing the sore, and of counteracting- the effects of that peculiar foetor which would otherwise encompass the patient in a self-created poisonous atmosphere. Charcoal or yeast poultices, and lotions of chloride of lime or carbolic acid, are thus beneficial. I can speak favourably of the latter poultice and lotion. They were remarkably efficacious in the case of a large cancer spring- ing from the arm and involving the shoulder. Ulceration having commenced in front of the axilla and subsequently in other parts of the tumour, the odour would have been intolerable to the patient but for these appliances. (6.) Congelation.— Ulae continued application of intense cold, is another means of destroying a cancer. Used in conjunction with caustic, congelation mitigates the pain, without diminishing the cauterization. Freezing is, alone, far less effectual. When most successfully practised, its destructive action extends not deeper than an inch ; the only advantage then being the freedom from pain during .and even after this process. As a method of treatment for cancer, it was introduced by Dr. James Arnott. Pounded ice may prove sufficient ; but a mixture of ice, salt, nitrate of potash, and hydro- chlorate of ammonia, will freeze more thorough Ij-. The frigorific mixture should be circumscribed by gutta-percha or other pliant TUMOUKS OR MORBID GROWTHS. 213 material, fasliioned into a bowl around the part, with a tube to drain off the fluid as the mixture melts ; and the process must be continued for some hours. (3.) Excision, or amputation, for the immediate removal of cancer, is the treatment most worthy of consideration. Granting the local origin of cancer, and thence the subsequent infection of the system ; excision — as distinguished from 2iUj -process of removal — is indicated, and at the earliest possible period. Hence also amputation, where practicable, may be preferable to excision — a partial operation, which may not thoroughly extirpate the disease. The delay of either opera- tion will assuredly allow the infiltrating course and adhesions of cancer to ensue, thereby rendering it locally impracticable or constitutionally useless. These pathological considerations suggest certain general reasons in favour of both excision and amputation, and their comparative advantages. (i.) Extirpation of the disease, entirely and permanently. This is very rarely accomplished. (ii.) Temporary removal of the disease, and thence a proportionate restoration of ease and health. This immunity is always gained. The period of non-recurrence varies ; perhaps less than one, it averages two years. Early performance of the opei'ation may prolong this period to ten, fifteen, or twenty years. Such prolongation has been observed particularly in scirrhus affecting the breast. The experience of Velpeau and of Sir B. Brodie concur as to the long period of immunity which may be enjoyed. (iii.) Prolongation of life. Comparing the duration of life in cases without operation, and after, Sir James Paget states that, in the former case, the average period scarcely exceeds two years ; whereas, in the latter, it extends to about twenty-eight months. Mr. Moore goes much further, observing that in seventy-eight cases of cancer affecting the breast, not operated on, the average duration was 32'25 months ; and in fifty-seven such cases the average was 53"2 months. Any estimate of this kind is liable to a twofold error ; the selection of cases for operation is generally those most favourable to life, and the probable mortality of the operation itself. The latter varies from five to ten per cent. ; and albuminuria peculiarly predisposes to a fatal issue. The species of cancer affects the estimate as to the average pro- longation of life, with and without operation. Thus, in Scirrhus, the I'elative periods may be stated as fifty-two months against forty-eight months, or even a still more advantag'eous difference (see Cancer of Breast) ; in Encephaloid, thirty-three months against twenty months ; in regard to Colloid, the difference is undetermined ; but, in Epithelial Cancer, the relative periods are, with operation, fifty-seven months, without operation twenty-seven months, or less than half the duration of existence granted by surgical interference. The conditions of cancer, or the cases which are respectively favour- able and unfavourable for operation, may be stated, approximately, as follow ; cancer of the breast being taken as the type : — (a.) Favourable iov o-^erdition. — (1.) A single tumour, not diffused, and whether in the nipple, on the surface, or in the substance of the breast. (2.) When the nipple alone, or some very limited portion of the skin, is drawn in towards the subjacent tumonr. In either case, 214 GENERAL PATHOLOGY AND SURGERY. the integument not being widely infected but simply dimpled, the breast may be removed. But the disease is apt to return in and around the cicatrix. This took place in the case of a scirrhous breast which I removed in the condition described, a small portion of skin not larger than half a crown being attached to the gland. (8.) Ulceration of a cancerous tumour does not preclude opeitxtion, if in other respects the case is suitable. (4.) The glands having become diseased to an extent which does not interfere with their removal, is a condition propor- tionately favourable for excision of the primary tumour. But the state of the glands cannot be exactly determined, otherwise than in the course of the operation, and if then found to be cancerous, they also must be removed ; not necessarily, however, at that time, if such an enlarge- ment of the operation might be perilous. Subsequently, and as soon as the health permits, the cancerous glands should be excised. (5.) Ampu- tation of a limb is justifiable, although the glands show some harden- ing or doubtful enlargement. This rule applies both to the encephaloid and epithelial disease. (6.) Hereditary tendency, strongly manifested, does not entirely prohibit operation. In a family, of which six members were the subjects of cancer, one sister underwent excision of the breast in 1845, and another in 1846. Both remained well, until in each, with a recent recurrence of the disease, a second opei'ation was performed in 1856 — eleven and ten years after the primary operation. In 1859 both patients were alive. (7.) Recurrent cancer may be removed under the same restrictions, as with reference to a first operation. (8.) Age does not prohibit the removal of a growing cancer. (fe.) tfnfavourable for operation. — (1.) Certain constitutional con- ditions — e.g. cancer co-existing, especially in some internal organ, or marked cancerous cachexia, albuminuria or other grave organic disease. (2.) Diffused cancer and persistent oedema. But the latter condition is significant only when circumferential ; oedema remote, depending on obstruction to the circulation at the seat of disease, e.g. oedema of the hand from cancer of the arm, is not itself a prohibitive condition. In such case, I have seen the swelling subside and return ; apparently with varying states of the circulation as connected with the growth of the cancer above. (3.) Adhesion, if at all extensive, either of the skin, or subjacent textui'es, is decidedly prohibitive of operation. (4.) Ulcer- ation, otherwise than to a very limited extent and depth, is equally so. (5.) Cancerous tubercles in the skin over a cancer, is a condition even more unfavourable for operation. Over a mammary cancer, increasing thickness of the skin, its widespread adhesion, and enlargement of the pores, constitute a decisive contra-indication. (6.) The glands having become diseased to an extent which interferes with their removal, pro- hibits also removal of the primary tumoui*, either by excision or ampu- tation. (7.) Rapid growth, in any way, is decidedly unfavoui^able for operation. Hence most encephaloid cancers are better left alone, unless in a very early stage. (8.) Cancers, the relations of which to important parts around cannot be foreseen, are better not meddled with. Thus circumstanced, are cancers beneath the scalp, which often implicating the bone, penetrate the skull ; cancer of the eye, which often involves the ojjtic nei've ; cancer of either jaw, particularly the upper, where it is apt to protrude into the maxillary sinus or the ethmoid cells ; and cancers about the root of the neck. I once assisted my colleague Mr, de Meric in removing an encephaloid cancer sitiiated TUMOURS OR MORBID GROWTHS. 215 about tbe sixtli rib, below the fold of the pectoral muscle on the right side. The tumour was not larger than an orange, the skin unbroken, and it seemed movable on the rib. Yet, on commencing the opera- tion, the hemorrhage was alarming, the rib gave way, and any further attempt was at once discontinued. The man, of florid complexion, became blanched with almost fatal syncope in a moment, and rally- ing only for a short time, he died of intei-nal hiemorrhage ; a warning in all such and similar cases. Epithelial Cancer. — Epithelioma. — One variety of cancer I have reserved for special description ; because, although in many points allied to encephaloid and somewhat to scirrhous cancer, it neverthe- less presents very cbaracteristic appearances, and possesses much surgical interest. I allude to epithelial or squamous-celled cancer, as affecting the skin ; with which may be pathologically associated, cylindrical or columnar-celled epithelioma, as affecting the mucous membrane. The latter variety will be noticed subsequently. Structural Condition, and diagnostic Cliaracters.—Th.\& variety con- sists essentially of cells or scales, resembling those of scaly epithelium, infiltrated among the component elements of the skin or mucous mem- brane, or sometimes among the textures of internal organs. Whatever poi'tion of the skin or mucous membrane may be thus affected, the epithelial cancer-cell or scale has very much the same characters (Fig. 68). It is flattened, of an irregular outline, with usually a pro- FiG. 68.* longed diverticulum at some point of its margin, and of a variable size, averaging y^ of an inch in diameter. It contains pale molecular matter, converging towards a central nucleus, which is clear, bright, and well defined, round or oval, and very small in comparison with the cell ; more uniform also in its shape and size. This nucleus is usually single. It may contain two or more minute granules, but rarely a bright distinct .nucleolus. The cells of Epithelial Cancer nearly resemble the large," Tound, well-defined, and clearly nucleated cells of Alveolar Sarcoma • "so named by Billroth, from these cells being infiltrated in a well-marked alveolar fibrous stroma or openly reticulated cellular texture. Associated with these cells, are what Paget calls " brood-cells," or endogenous cells. They present many varieties of appearance, which may be regarded as the results of one or more nuclei, enclosed within cells, assuming, or tending to assume, the characters ol: nucleated cells. The " globes epidermiques " of Lebert (Fig. 69) — " laminated cap- sules," Paget — are the most singular and characteristic structures of epithelial cancer, yet not peculiar to this disease ; nor are they, ap- parently, special structures, for they consist of epithelial scales. These * Epithelial cancer-cells or scales in various forms. Magnified 350 times. (Paget.) 216 GENERAL PATHOLOGY AND SURGERY. Fig, 70 f capsules are very large and spherical cysts, containing granular matter, nuclei, and roundish epithelial cells, clustered so as to almost appear as if fused together ; the peri- Fig. 69.* phei-al portion consists of epi- thelial scales, superimposed in successive layers, thus form- ing a laminated capsule. Such are the structural elements of epithelial cancer. They are found infiltrated — principally in the substance of the skin or mucous mem- brane — but not uniformly dif- fused throughout the component textures of the part affected ; with more or less fibroid stroma, forming a network between the cells, but not having the open, alveolar arrangement for the reception of cells in groups, which dis- tinguishes otherspecies of Cancer- Growth. Section shows the in- filtration, and micro- scopic examination will confirm the nature of the growth (Fig. 70). Its physical characters, on section, are also characteristic. The substance is of a grey- ish-white colour, and hard or fii'm but fri- able, andpressure yields only a little cancer- jviice, but a thicker, yellowish, cheesy matter curls out. The cancer-cells may predominate in the corium, forming a swelling very slightly elevated above, or imbedded below, the proper level of the integument, and the depth or thickness of which is much less than its dimensions laterally; or these cells may predominate in the papillae, presenting a prominent warty or exuberant out-growth ; or, the sub- iategumental texture maybe their chief seat, forming a deeper-seated, flat, or rounded mass. Of these varieties, the first two may be named the superficial or oat- growing ; while the third is the deep-seated form of epithelial cancer. Paget believes that either of these principal varieties may occur in any of the usual seats of this disease, but that they are not both equally common in every such part. The superficial, and especially those which have the characters of warty and cauliflower-like out-growths, are most frequently found on mucous membranes, especially of the genital organs ; those also on the extremities and the scrotum have usually a * Object to the left, a single globe epidermique. (Lebert.) Object to the right, formation of a laminated epithelial capsule, by endogenous development of nuclei into nucleated cells, their detrusion, and concentric lamination. (Rokitansky.) t Epithelioma of skin, showing the interpaplllary processes of epidermis pene- trating inwards. (J. Coats.) TUMOURS OR MORBID GROWTHS. 217 well-marked warty character, and are rai-ely sub-integumental. The deep-seated are more frequent in the tongue than elsewhere. It must not be forgotten, however, that these distinctions are more apparent than essential. Their value consists in reference to the earliest and most exact diagnosis of this disease, in whichever form it may chance to make its first appearance. For subsequently, and especially when ulceration has commenced, an epithelial cancer which was superficial or exuberant, is prone to extend into deep-seated parts ; and one at first deeply seated may grow out exuberantly. Moreover, when ulceration is progressing', a greater uniformity of external ap- pearance is found ; because, in general, while all that was superficial or exuberant is being destroyed, the base of the cancer is constantly extending, both widely and deeply, into the sub-integu mental tissues. Respecting, then, the earliest appearances of epithelial cancer, the following" are most diagnostic. 1. Of the superficial or out-groiving, prior to ulcei-ation, they are these : — (a.) An outspread swelling arises — say on the lower lip, labiu.m- pudendi, or scrotum ; and an unnatural firmness or hardness of the Fig. 70a.* affected skin is perceptible ; but the superficial dimensions much exceed the thickness of this swelling. Its outline is round, oval, or sinuous ; and its surface, sometimes nearly smooth, is more often coarsely granulated — like that of a syphilitic condyloma — deriving this ap- pearance from the enlarged and closely clustered papillae. Generally, the surface is moist with an ichorous discharge ; it may, however, be covered with a scab, or encrusted with a soft substance, consisting of detached epithelial scales. In most cases, the part is unduly sensitive, and injected with blood. If the papillae become infiltrated, they con- stitute the cauliftoU'e7--\\]sie mass so characteristic of the ordinary form of epithelial cancer (Fig. 70a.). This mass looks very vascular, is * Epithelial cancer of hand ; showing the papillary character, from specimen in the Museum of St. Bartholomew's (Ser. x. i. 6). The history of this case is in Pott's Works by Earle, iii. 182. The patient was a gardener, who had been employed in strewing soot for several mornings. The disease was of five years' duration. (Paget.) 218 GENERAL PATHOLOGY AND SURGERY. moist with ichor, and covered with pasty cakes of epithelial scales, which beset the interstices of the enlarged papilhv. (6.) Occasionally, the shape of an out-growing epithelial cancer is that of a sharply bordered circular or oval disc, upraised a little above the level of the adjoining skin, or mucous membrane, and imbedded to about the same depth below it. The sui-face of this disc — usually flat or slightly concave — is granular, spongy, or irregularly cleft ; and its margins are surrounded with healthy texture, which becomes raised and often slightly everted by their enlargement— e.gr, many epithelial cancers of the tongue. (c.) Sometimes, epithelial cancer grows out in the form of a cone. (d.) Lastly, the out-growing form of this disease maybe a narrow- stemmed, and possibly pendulous, growth from the skin. These and other shapes of superficial epithelial cancer resemble somewhat the appearances presented by warty and condylomatous growths ; but they differ essentially in respect of their minute struc- ture ; — being infiltrations of the skin and papillfe with epithelial cancer-cells ; whereas the structure of warty growths remains healthy, however strange may be the appearance they assume, (2.) Beep-seated epithelial cancer is generally (a) an advanced stage of the superficial ; for by progressive infiltration, the subcutaneous or sub-mucous tissues are invaded; (6) but this variety of the disease may occur primarily, although comparatively rarely. " Thus," ob- serves Paget, " the first formation of epithelial cancer may be in masses of circumscribed infiltration of the tissues, beneath healthy skin or mucous membrane. This condition is more frequent in the epithelial cancers that form, as recurrences of the disease, near the seats of former operations, or as secondary deposits about the borders of primary superficial growths." Situation. — Epithelial cancer selects either the skin or subcutaneous texture ; or the mucous membrane ; and of these textures the portions most liable are ranged by Paget in the following scale of frequency. First, its chosen seat is the lower lip, at or near the junction of the skin and mucous membrane; then the prepuce (glans, Rokitansky), scrofwm of chimney-sweeps ; the nymphfe, the tongue ; occasionally in very many parts ; as at the anus, interior of the cheek, upper lip, mucous membrane of the palate, larynx (trachea, Rokitansky), pharynx and " cardia ; " neck and orifice of the uterus (stomach, Rokitansky), rectum, and urinary bladder ; skin of the perineum, of the extremities ; the face, head, and various parts of the trunk. In yet more rare in- stances, as a primary disease, it occurs in other than integumental parts ; as in the inguinal lymphatic glands, in bones, in tissues form- ing the basis or walls of old ulcers. Rokitansky has met with epithelial cancer only once in a parenchyma, namely, in the liver, and then encysted in a capsule of fibro-cellullar tissue. By extension from its original seat, this growth may involve many deeper textures ; fasciae, muscle, bones ; and as a secondary disease it may, but very rarely, supervene in internal organs — the lungs, liver, heart, spleen, or kidneys. Epithelial cancer, as a primary disease, is usually solitary. Occa- sionally, two or more co-exist, and even in the same part, as on the prepuce and glans. Eventually, secondary epithelial cancer-growths form in the tissues surrounding the primary and parent growth. TUMOURS OR MORBID GROWTHS. 219 Origin. — Predisposition to the production of epithelial cancer in- creases, as age advances, the proportionate liability rising with each decennial period. This becomes more apparent when compared with the number of persons living at each successive period ; so that if the frequency of occurrence between 20 and 30 years be represented by 12, that between 40 and 50 years is equal to 100. Billroth estimates the period of greatest liability to be from the fortieth to the sixtieth year, rarely later; but sometimes the disease appears in childhood. With regard to the part alfected, Sir J. Paget believes that the mean age of occurrence is lowest in the sexual organs, and highest in the integu- ments of the head, face, eyelids, and upper extremities. Males are more often attacked than females ; in 105 cases affecting parts common to both sexes, 86 were in men, 19 only in women. Hereditary predis- position would seem to be traceable in members of the same family; or where scirrhous or encephaloid cancer has affected some, other members have been the subject of the epithelial disease. External Causes. — Previous injury of the part is more often predis- posing in regard to the production of epithelial cancer than of perhaps any other kind of tumour, excepting melanotic cancer of the skin. But the injury is generally some slight and oft-repeated damage, as by frequent blows or friction, thus amounting to prolonged irritation. The habitual smoking of a clay pipe, as affecting the lip, and the irritation arising from soot lodged in the crevices of the scrotum, are familiar examples of the external causes of epithelial cancer. It is often seen to proceed from a crack or fissure, to appear in the form of a small hard knob, lump, or scabbing waii:. Some chronic morbid condition of a part may become the seat of the disease ; as a cicatrix, especially when exposed to injury ; or, it has been known to supervene on a patch of old-standing cutaneous eruption — apparently chronic eczema, in the neck ; a case of this kind being recorded by Mr. H. Morris (Med.- CJiir. Trans., vol. Ixiii.). Course. — Epithelial cancer is constantly progressive, but its rate of progress varies from time to time, and according to the part affected. The disease may run its course in a year, or continue for three, five, ten years, or longer. Sometimes advancing slowly, in a year it gains only the fraction of an inch on the part around ; or spreading rapidly, in a few months it invades to the extent of several inches. This pro- gress is perhaps now and then interrupted by partial cicatrization — when ulceration had supervened. But the average rate of progress is less than that of any other species of cancer-growth. And, with reference to the part affected, epithelial cancer advances more slowly in the scrotum and lower limbs ; more rapidly, and with great malignancy, in the mouth, tongue, and penis. The deep-seated form of growth is also more malignant than the superficial or out-growing. The ulcerative stage of epithelial cancer is that in which the disease is commonly seen ; and the usual state of ulceration observed is that of progressive destruction of the central and superficial parts of the cancer, with more than co-extensive growth of the marginal and deeper parts, thus constituting the type of the "cancerous ulcer." It is important, therefore, to be able to discern the first aspect of ulceration — both as regards the superficial and the deep forms of epithelial cancer, respectively ; and then, the characters of the com- plete ulcer. '2'20 GENERAL PATHOLOGY AND SURGERY. (1.) Ulceration of superficial or oiit-growing' epithelial cancer, pri- marily appears as either a diffuse excoriation of the whole surface of the cancer, except its borders; or else a shallow ulcer limited at first to some fissure where the disease commenced. The discharge from this excoriated or ulcerated surface dries into a thin scab, or a thicker and darker crust ; which conceals for awhile the ravages of ulceration, still slowly extending beneath, — downwards and outwards. (2.) Ulceration of deep epithelial cancer begins in one of three ways : — In some cases, the superimposed skin or mucous membrane having becomes adherent and thin, cracks ; and this condition may remain stationary for a long while, in the form of a dry dark crevice ; but usually ulceration, commencing from this point, extends into the mass of the cancer. In other cases, the substance of the cancer having become inflamed, it softens, suppurates, and discharges its contents through an ulcerated opening, or a long rent ; leaving a cavity which speedily assumes the characters of an ulcer, and extends peripherally. In a third series of cases, and, perhaps, especially in secondary for- mations, and in those under the scars of old injuries, the cancer protrudes through a sharply bounded ulcer in the sound integument or scar, growing exuberantly, with a soft shreddy surface, like a medul- lar}- cancer, or with a firmer, warty, or fungous mass of granulations. Dissimilar as are the earliest aspects of ulceration in both forms of epithelial cancer — out-growing and deep — they gradually assume a uniformity of appearance which is very characteristic. (3.) Complete Ulcer. — An excavated sore, of a round or oval shape, presenting a roughly granular surface, which has a brick-dust red colour, and oozes a stale-smelling discharge. This surface bleeds easily, although not freely. The textures surrounding its base and borders become indurated and rigid, as they progressively become more and more infiltrated with cancer-cells. The ulcer thus acquires a remark- able degree of immobility, and its margin pi'otrudes in the shape of a thick everted ridge, well defining the boundary of the ulcer. Infil- ti-ation increasing, the marginal ridge forms an irregular nodular belt, which overhangs the base of the ulcer, and gives an undermined ap- pearance to its everted borders. If the papilke of the surrounding skin are more particularly the seat of cancerous infilti-ation, then a warty rather than a nodular belt springs up around the ulcer. With all these signs of progressive infiltration, followed by ulceration, the work of 'destruction is not stayed below the base of the already excavated sore. It spreads deeper and deeper, sparing no texture, not even large arteries, which hold out against the invasion of most other forms of ulceration, if indeed they do not escape altogether. But arteries of the first magnitude yield to the unsparing ravages of epithelial cancer. Pain, varying in kind and intensity, such as burning or neuralgic pain, attends the course of ulceration. The lymphatic glands are in- fected at an early or later period, according to the rapidity of the disease ; and involving the proximate glands, which become enlarged and somewhat indurated, the disease extends to other glands, yet not so far as in other species of cancer. Thus, when the hp is the primary seat of disease, the cervical glands are secondarily affected ; while the lumbar glands show the extension of disease from the penis or scrotum. TUMOURS OR MORBID GROWTHS. 221 Internal organs are far more rarely infected than from any other species of cancer. Cachexia is neither early nor well marked ; nor in any way peculiar. The average duration of life is from two years to two and a half ; although life is not nnfrequently prolonged to three or four years, or to a more distant period, — unlike the usaal course of other cancers. Here, also, the part affected will regulate the prognosis. Epithelial cancer in the limbs generally runs its course to a fatal termination more slowly than when the lower lip or the tongue is the primary seat of disease. The age of the patient, at the commencement of the gTOwth, scarcely influences the duration of life. Treatment. — The guiding indications of treatment in respect to epithelial cancer are two ; one or other of which is always practicable. (1.) To superinduce inflammation and sloughing, thus destroying the cancer. This may be accomplished by caustics, such as those already mentioned for the destruction of cancer generally ; the strong mineral acids, caustic alkalies, and chloride of zinc. But it must be confessed that this method of treatment is not more successful in the one case than the other. In one instance, of an epithelial cancer of the entire circumference and nearly the whole length of the vagina, I repeatedly applied the strong fuming nitric acid by means of a glass brush ; but without apparently any effect, for better or worse. (2.) Removal of the cancer is the most effectual treatment. This may be accomplished by excision,, ligature, or amputation. The former method is, generally, most eligible; care being taken to cut sufficiently wide for the entire extirpation of the growth. It will be necessary to include any neighbouring lymphatic glands which have decidedly become secondarily affected by the cancerous infiltra- tion. But the strong infiltrating tendency of epithelial cancer renders its effectual removal by excision doubtful. Removal by ligatoi'e, or the ecraseur, is the alternative method ;: wherever excision is imprac- ticable, or would be imprudent, or inefiBcient. Amputation is necessary, primarily or secondarily, in certain cases. It may be so, in the first instance, owing to the extent of the disease, or its locality, as when situated on the leg, or the arm, near the trunk. Of the latter urgency for amputation I had an instance in the case of an epithelial cancer just below the shoulder-joint. The patient died, after the operation, of Hospital gangrene. Secondary amputation is unavoidable in any case of recuri'ent cancer ; caustics, excision, liga- ture, or even primary amputation, as the case may be, having failed, perhaps successively, to extii^ate the primaiy disease. Recurrence of the disease after apparently complete removal by operation is, I believe, the rule, without exception. And the epithelial growth returns sometimes in the cicatrix, sometimes in the lymphatic glands, when previously healthy ; or occasionally in some distant part or internal organ. The period of recurrence varies considerably ; being very early, or much longer after operation, — a year and a half, possibly to five years, or an indefinite time. But the prolonga- tion of life is a very advantageous consideration. The average duration after operation is nearly five years, — thereby granting a period about twice as long as without operation, or an additional two years and a half, as the advantage gained by timely surgical interference. 222 GENERAL PATHOLOGY AND SURGERY. Cylindrical oe Columnar-celled Epithelioma. — This variety of Epithelial Cancer is so named from the shape of its essential cell- element — columnar epithelium, as distinguished from squamous epithelium in the other form of Epithelial Cancer. Columnar epithelioma affects some portion of mucous membrane. The growth consists of irregular tubules, lined Avith columnar cells, forminof one or more layers within the tubules ; between which there is a variable amount of connective tissue — an intra-tubular stroma. The arrangement of the epithelium may so neai-lj^ resemble that of normal gland-tissue, as to render it most difficult to distinguish a columnar-celled epithelioma from the structure of a columnar-celled adenoma. Hence, the epithelioma in question has been sometimes misnamed adenoid or glandular cancer (Fig. 706). This growth may occur in various parts of the whole tract of mucous membrane ; it is especially the cancer of the gastro-intestinal mucous membrane, and is produced in the rectum particularly, as the most common situation; sometimes in the ducts of secreting glands, as of the pancreas ; but it may appear also in the uterus, or within the nasal fossai, or the antrum. The growth increasing, forms a more or less raised tumour, whitish — or dark red, when highly vascular — and of soft consistence; it pre- sents a granular or papil- Fio. 706.* la-ry surface ; or, with soft and long processes, it has more of a villous character. Usually diffused, the tumour is sometimes sharply defined and encapsuled — in facial columnar epithelioma. It gradually infiltrates adjoin- ing textures, thus attaining perhaps to a considerable size, and tends to ulcerate early. In the face, the tumour may thus appear through an ulcerated opening in the skin. The bones become eroded, without any osteophytic reproduction. Bat, the general character of infiltration," and destructive tendency, ally columnar epithelioma to the squamous or cutaneous form of epithelial cancer ; and, indeed, it is thus allied to Cancer, in any form, and to Sarcoma. When ulceration has supervened, the pristine appearance of the tumour is more or less effaced ; the growth being lost in the extensive ulcer. In the course of growth, the lymphatic glands may become infected, although this is not a marked feature in the vital history of columnar epithelioma ; and facial epithelioma of this kind — according to Billroth's observation— is never attended with lymphatic infection. But, secondary formations in internal organs are_ not uncommon, especially in tlie liver, as the disease becomes disseminated. _ The Treatment is the same as for squamous or cutaneous epithelioma ; and early operative interference is more hopeful, when the disease occurs in a locality which admits of its complete removal, as in the face. * Adenoid cancer of rectum. Mag. 200 diam. (Billroth.) ( 223 ) CHAPTER Iir. D E G E N E E A T I N S . To clearly understand the significance of the term degeneration, it is necessary to bear in mind the nature of healthy nutrition, of which physiological process, Degeneration is only another modification, — concluding the Pathology of N"utrition. The functions of the various organs and parts of the body, in health, are so adapted or adjusted as to constitute an evenly balanced livino- organization. And this co-operation is continued throughout life, in health. But the activity of all the functions — nutrition, for example — varies considerably during the successive periods of existence. After birth and with an independent existence, during infancy, youth, and adolescence to maturity, the function of nutrition is yet more one of growth and development. During mature manhood or womanhood, this function is simply one of maintenance, to repair the muscular waste of the body consequent on the functional exercise of its various members and organs. Lastly, as age approaches, and during decrepitude, the nutritive power of the body proportionately declines. Waste is still repaired ; but the textural structure repro- duced is an imperfect representation only, not a copy, of either its original or mature condition ; it is a retrogression of textural structure, effected by a degenerative modification of nutrition. Degeneration is, therefore, only the concluding stage of the natural course of healthy nutrition, and as the retrogression of textural structure extends more or less throughout the body, and certainly pervades vital organs, the whole organism slowly and gradually retrogrades or reverts to the unorganized matter whence it came. Earth returns to earth, ashes to ashes, dust to dust. To die by degeneration is, therefore, as natural as to live by growth and development, and by the subsequently adapted maintenance of nutrition, — such as may be requisite during the period of mature life. The process of nutrition is, indeed, the consummation and resultant of all the other organic functions ; and when in the order of nature they decline, nutrition declines also into degeneration, which it then represents. But this ultimate inodifica- tion of nutrition is sufficient for life as age advances, all other functions declining at the same time, and in due proportion. The senile retrogression of textural structure, thus effected, cannot, in any sense, be designated a diseased condition, nor the result of any moi'bid process. IS'or again, when degeneration, natural to advancino- and advanced life, occurs prematurely , can it tJien be regarded as a morbid process of nutrition, issuing in a diseased condition of textural structure. It is only premature old age ; but the individual overtaken by degeneration is the subject of defective nutrition, and in this sense only, retrogression of textural structure by degeneration ranks, and may be classed, with morbid pix)ducts of IS'utrition. Degeneration, whether senile or premature, is a form of Atrojpliy ; but it is so by a deterioration of structural quality, not by a mere diminution of quantity. And be it observed, this structural deterio- ration is effected by the retrogression or falling back from a higher 224 GENEKAL PATHOLOGY AND SURGERY. condition to a lower or more elementaiy gi*acle of textural structure, or even to an altog-etlier structureless condition. It, moreover, takes the place of or substitutes the proper elements of the original texture, which disappear. This retrogression and substitution of textural structure, are the essential chai-acteristics of Degenerative transformation. By substitu- tion, it is distinguished from the transformation of texture resulting simply from Disintegration. Causes. — Analogy and facts alike concur to render the conclusion highly probable that degeneration, as being a modification of nutrition, is caused primarily by an appropriate blood-disease, in regard to each kind, of Avhich it is the local and anatomical manifestation. On the other hand — as Paget observes — degeneration, like simple atrophy of quantity, may arise from local causes, and apparently the same such causes ; namely, diminished supply of arterial blood, as by partial closure of the chief nutrient artery of the part ; or by abroga- tion or suspension of function. Furthermore, both degeneration and atrophy occur commonly in old age, but possibly prematurely ; both also may occur simultaneously in one and the same texture, under precisely the sanie conditions ; and a cause of atrophy in one case may cause degeneration in another. In relation to disease, both may co- exist, as in inflammation ; or the disease, so called, may be only de- generation, as in simple softening of the brain or spinal cord, and the liquefaction of inflammatoiy exudations during the suppurative process. General characters of Begeneration. — In relation to healthy con- ditions of texture, the general characters of Degeneration are fully and clearly expressed, as originally stated by Sir James Paget : — (1.) The new material is of lower chemical composition, i.e. less remote from inorganic matter, than that of which it takes the place. Thus, fat is lower than any nitrogenous organic compound, and gelatine lower than albumen, and earthy matter lower than all these. (2.) In structure, the degenei'ate part is less developed than that of which it takes the place : it is either more like inorganic matter, or less advanced beyond the form of the mere granule, or the simplest cell. Thus, the approach to crystalline form in the earthy matter of bones, and the ciystals in certain old vegetable cells, are character- istic of degeneration ; and so are the granules of pig-ment and of many granular degenerations ; and the globules of oil that may replace muscular fibres or the contents of gland-cells, and the crystals of cholesterine that are often mingled with the fatty and earthy deposits. (3.) In function, the part has less powei' in its degenerate than in its natural state. (4.) In its nutrition, it is the seat of less frequent and less active change ; and without capacity of growth, or of development. General Treatment. — The pathological indications of treatment, in regard to degeneration, are two : — (1.) To elevate the condition of degeneration to some higher state of textural structure. This indication cannot be fulfilled by any known Hygienic or Therapeutic measui-es. The practicability of effect- ing recovery from degeneration would seem to be inconsistent with the vital incapacity of a degenerate part for growth or development. (2.) To counteract any further degeneration in an already degene- rate part, or its extension to texture contiguous. This indication DEGENERATIONS. 225 may, perhaps, be accomplislied by Hygienic and Therapeutic measures, either of which are general or topical. It would appear that what- ever influence, of a preventive tendency, any such measures may have, their action is mainly through the medium of the blood, by raising its quality and promoting its circulation. Sygienic measures, of a counteractive character, have reference to the functions concerned in blood-production. Diet, selected with regard to the particular form of degeneration, pure air, friction of the skin, shampooing, baths warm or cold, regular exercise, and other means of promoting excretion, are thus highly important. Medicinal measures, within the present range of therapeutics, are less obviously counteractive of degeneration. Iron, cinchona bark, the mineral acids, and other tonics, may have some beneficial influ- ence, by improving the quality of the blood and invigorating* the circulation; while aperients, diaphoretics, and diuretics increase and regulate the excretions of the bowels, skin, and kidneys. Some such resources are found in convenient, and apparently inimitable com- binations, in the various natural chalybeate and saline mineral waters ot Vichy, Wiesbaden, and other Spas. In such resorts, persons of a " broken or worn-out constitution " — subjects of degenerative changes of structure — experience a temporary revival of their faiKng powers, if not a permanent I'estoration to health. Rarely will any topical applications prove beneficial ; degeneration of any kind, and perhaps afiiecting internal organs, can scarcely be influenced by such treatment. Special Kinds of Degeneration. — Pathologists differ as to the number and specific distinctions of the various kinds of degeneration. As this branch of Pathology stands at present, I would propose the following arrangement: — (!) Fatty degeneration; (2) Pigmentary; (3) Fibrous ; (4) Amyloid ? Waxy, or Lardaceous ; also, Mucous and Colloid degenerations; (5) Granular; (6) Calcareous, osseous, or mineral degeneration. Normal tissues, no less than the products of Inflammation, and Tumours or Morbid Growths, are subject to these degenerative trans- formations ; the whole of this pathological histology supplementing and completing our knowledge of Diseases of Nutrition. Such know- ledge will often throw light upon the diagnosis of structural modi- fications of Morbid Products, which have undergone degenei'ative metamorphosis from their normal type. But the special forms of degeneration are little amenable to any treatment beyond the general indications already noticed. (1.) Fatty degeneration presents certain general, yet distinctive characters — structural, physical, and, it may be, chemical. Examina- tion with the microscope shows minute granules in the very substance of some structural element ; be it a cell — in its contents, or in the place of its nucleus ; if a primitive fibre — in its substazice ; if a simple membrane — in its substance : thus, in all cases substituting, at least in part, the original structural element, which has undergone this degenerative metamorphosis. These granules are particles of fat or oil ; for being highly refractive, they are bright and glistening ; they are soluble in ether ; and they tend to coalesce into distinct drops of oil. Proportionately as the oil-grannies usurp the place of an elemental VOL. I. 226 GENERAL PATHOLOGY AND SURGERY. structure, its proper substance disappears. For example, a cell having become full of oil-particles, — a grauule-cell, its walls disappear, leaving only a granule-mass ; and these granules are apt to coalesce into drops of oil. The interstitial tissue of the texture usually undergoes fatty de- generation simultaneously. And the disposition of these oil-granules is peculiar and significant. They are arranged, as Vii'chovv observed in the liver, in the course of the capillary blood-vessels, which become thickly studded with particles of oil, as if deposited from the blood. The general physical characters of a texture whose structural elements have undei'gone fatty degeneration are these : — The texture is softened, or if soft in its healthy condition, it has now assumed a doughy consistence, which retains any impression or mould given by the fingers, as if it were soft putty ; but this fatty texture is friable, greasy, burns readily and with a bright flame, and yields, by analysis, an unusual quantity of fatty matter. It has also acquired a dirty- brown colour, here and there mottled with a dead-leaf or wash-leather colour ; these patches corresponding to the most advanced stage of fatty degeneration. (a.) Muscular texture in the state of fatty degeneration well illus- trates these physical chai'acters ; while the coexisting changes of minute structure are also well defined, and they are characteristic of this degeneration. I select the muscular textui-e of the heart, for its fibres being striated, they resemble and represent those of voluntary muscle. The fatty degeneration of this oi-gan is also a most impor- tant question in the practice of Medicine and Surgery ; and, I may add, in relation to Medico-legal Inquiry re.'^pecting the (natural) causes of sudden death; e.g. from the administration of chloroform. The history of our present exact knowledge respecting fatty de- generation of the heart proves beyond a doubt that this condition of its muscular texture was for a long time confounded with the mere interstitial deposit of fat in the muscular substance of this organ. For the physical appearances of both these conditions are .similar. They are those which I have just described, and they contrast with the healthy characters of muscular texture. Portions of the heart, commonly of the left ventricle, have acquired a mottled yellowish appearance, chiefly visible on the interior or the external surface of the ventricle, immediately underneath the endocar- dium or pericardium. When viewed more closely, these spots present wavy transverse lines. Each spot is not abruptly defined, but tinted off into the adjoining healthy texture. If degeneration be incipient, these spots are yellowish brown ; if advanced, they have assumed a dead-leaf colour. The muscular texture is no longer fibrous, but friable ; and if the deg'enerative transformation be extensive, involving a considerable portion of the whole substance, the heart will have acquired a doughy softness, which retains any impression given by the fingers. The organ is palpably greasy, and its texture burns readily, and with a bright flame. Chemical analysis has shown that, in connection with this degeneration of texture, the quantity of fatty matter, and the proportion of olein to margarin, is much increased.* * See "A Chemical Investigation of the Pathology of Fatty Degeneration," hj Mr. J. Peel. Appendix to " Address in Medicine," by Dr. E. L. Ormerod. Brit. Med. Journ., 1864. DEGENERATIONS. 227 Both ventricles are more sabject to this degeneration than the auricles ; but, although rarely, the muscular substance of the whole heart may undergo the same change. Degeneration is more ad- vanced in proportion as its extent is limited, — to perhaps only a few fasciculi. The foregoing physical appearances had long since been observed by Laennec, and previously by Dr. A. Duncan, in 1816, and would even seem to have been known to Lancisi and Morgagni ; but many such observations referred to fat, merely accumulated, on the surface of the heart, and deposited interstitially amongst its fibres. It was reserved for the microscopic researches of Rokitansky, Drs. C. J. B; Williams and Peacock, and more especially for those of Sir James Paget, Drs. Ormerod and Quain, to fully demonstrate the changes of structure which the muscular fibres themselves undergo in fatty Fig. 71. Fig. 72. FrG. 73. degeneration. By comparing the textural elements of muscle in a healthy state, these alterations of structure will be more clearly appre- ciated.. The annexed figures represent the appearances of healthy muscular fibres taken from the hearts of a bullock and sheep, which I examined. Half a dozen fibres are presented in Fig. 71. The transverse striae are well shown, and also the fibrillse projectino- from the end of each fibre. Similar appear- ances are seen in the fibres from the sheep's heart (Fig. 72). In fatty de- generation of the muscular fibres, as observed' in the human subject, the earliest stage exhibits characteristic alterations. The fibrillae evince a disposition to dis- integrate, as shown by their readily split- ting longitudinally and transversely (Fig. 73, a and 6. Wedl). The transverse stri^ become less distinct, and oil-particles visible — within t\\e sarcolemma of the fibres, and externally — besetting the fibres, a condition represented by the fi.bre to the right of h (Fio-. 73) ; 228 GENERAL PATHOLOGY AXD SURGERY. but this is not an essential condition. The former may be termed intra oil-partieles, to distinguish them from the latter, between the fibres, or inter oil-particles. The intra oil-particles appear, firstly (Fig. 74 and 75), as minute granules, arranged transversely, as it were, across the direction of the fibres ; thus corresponding to the sarcous elements whose place they occupy, and substitute, but from which they are readily distinguished by their bright glistening appearance, being highly refractive, and by their solubility in ether. Subseqiiently, in a more advanced stage (Fig. 70), or simultaneously in other adjacent fibres, the transverse striae have entirely disappeared ; the intra oil-particles have no definite aiTaugement ; each fibre consists of oil-partieles confusedly aggregated together, presenting, a dim molecular aspect, in this respect somewhat Fig. 76 t Fig. 7-4.* Fig. 75.* resembling the healthy appearance of unstriated organic muscular fibre. The bright glistening appearance of the aggregated oil-particles, and their solubility in ether, are still characteristic marks of dis- tinction. Ultimately, the oil-particles have coalesced into distinct drops of ojl (Figs. 77 and 78), some of which adhere to the interior of the sarcolemma, which still remains unbroken and enclosing them. The large oval nuclei, which are perhaps peculiar to the muscular fibres of the heart, have become obscure, or altogether disappeared. But no fat-particles or drops are commonly found between the fibres, and the absence of any interstitial fat is conspicuous, unless, the * Fatty degeneration of muscular fibres of heart in cattle, exhibited by the Smithfield Club as prize specimens of breeding and feeding, 1857. — The Author. t Another prize speciniea ; the hest sheep, of any long-woolled breed, one year old, showing more advanced fatty degeneration of muscular fibres of the heart. — The Author. DEGENERATIONS. 229 sarcolemma has partially disappeared in the course of degeneration, or has been ruptured in displaying the fibres with needles. In contrast with this degeneration, I have here represented the appearance produced by disintegration of the sarcous elements in the muscular fibres of the heart (Fig. 79) ; showing the entire _ absence of transverse striae, unaccompanied by the substitution of oil-particles. This transformation resulted from malnutrition, induced by dense thickening of the cardiac reflexion of the pericardium consequent on pericarditis, as represented in Fig. 19, page 92. Fatty degeneration is regarded as a chemical transformation. It is alleged that this conclusion might be inferred from the fact, that in fatty degeneration of striated muscular fibre the oil-particles are primarily arranged in the same manner as the proper structural constituents, or sarcous elements of the fibrils, whose place they Pig. 77.* Fig. 79. Fig. 78.t occupy. It is urged as a more direct proof, by Dr. Qnain,J sup- ported by Dr. C. J. B. Williams, § Paget, || Bennett,^ and by other distinguished pathologists, that fatty matters are produced during the spontaneous decomposition of nitrogenous substances, as the for- mation of adipocire in muscular tissue; instances of which are given by Virchow.** Then again, muscular tissue is converted into adipocire when macerated in water for some time ; and this artificial production of fatty matter in muscular tissue was originally adduced by Dr. Quain, and since by the above-named pathologists and others, in confirmation of the chemical theory of fatty degeneration, by which muscle and other textures are transformed into fatty matter within the living body. But the carefully conducted experiments of Mr. Peel and Dr. Ormerod lead to the conclusion that, in the production of adipocire * The hest Devon ox, above three years old, showing most advanced fatty dege- neration of musenlar fibres of the heai't.- — The Author. t Muscular fibres of human heart, in most advanced fatty degeneration. (Wedl.) + Med.-Chir. Trans., vol. xxxiii. p. 140, etc. § "Principles of Medicine," 1856, p. 449 et seq. II " Snrgical Pathology," 1853, vol. i. % " Principles and Practice of Medicine." ** "Archiv," B. i. p. 167. 230 GENERAL PATHOLOGY AND SURGERY. from mnscle, the fatty matter is " not a newly formed substance, but a new arrangement of the old materials, a saponification of the fat already existing." Hence, that the chemical theory of fatty degeneration is fallacious, and that the increased production of fatty matter is a vital change, — that degeneration is a physiological or pathological process. This would seem to consist in an incomplete oxidation of the fat ; or of the nitrogenous elements, — this defect in the destructive changes of the nutritive process resulting in a residuum of carbonaceous or fatty matter. Thus, the sarcous elements of muscle are converted into oil-particles. The oxidation of tissues is diminished in connection with anaemia, or by deficient supply of arterial blood to the part. Thus the muscular tissue of the heart undergoes fatty degeneration commonly in consequence of atheromatous and calcareous degenera- ;tion of the coronary arteries — impeding the cardiac circulation. Fatty degeneration is apt to arise' in connection with a general increase of fat in the body ; a fact adverted to by Dr. T. K. Chambers,* as a casual coincidence in the human subject; and I have shown this connection in over-fed prize cattle,t and thence the fallacy of the principle of the English system of fattening cattle. Fatty infiltration — a spurious form of degeneration — occurs more often than true degeneration ; fat-cells or drops of oil being deposited between the constituent elements of a texture — as between the fasci- culi and fibres of muscle, instead of within, and in the place of, the ultimate elements. The one is an interstitial deposit of fat, the other an intra-substitute conversion. The functional disuse of muscles is eventually followed by fatty infiltration of their texture ; as may be found in cases of paralysis ; or in tbe muscles of a limb disused from anchylosis of a joint, or after excision. But the interstitial and intrastitial transformations frequently coexist ; probably from the deposit compressing the blood-vessels, thus inducing atrophy and degeneration of the structural elements. When occurring in muscle from paralysis, the deficient innervation is probably, at least, a co- operative ca,use of degeneration from malnutrition. (6.) The blood-vessels are prone to fatty degeneration, which is then known by the name of atheroma. The larger arteries are not unfre- quently beset with flattened and slightly elevated patches on their inner surface, but underneath the thin lin- ing membraiie. The atheromatous matter is yellowish, opaque, of cheesy consistence, yet friable ; and it con- sists of oil-particles with crystals of cholesterine (Fig. 80, Gulliver), which partially occupy the place of the middle muscular coat. Eventually, a further deposit ensues, consisting of minerg-l salts — probably phosphate and carbonate of lime, by which the atheromatous matter becomes hard and *" On Corpulence," 1850, pp. 120, 121. t " Evil Eesults of Overfeeding Cattle." 1857. + Tatty particles, oil-drops, and grannie-cells, v^ith crystals of cholesterine; from broken-down atheroma of an artery. (Bennett.) Fig. 80.] v^--t DEGENERATIONS. 231 Pig. 814 brittle, and the patches assume the character of calcareous or bony plates, but with a very imperfect imitation only of the structure of bone. The inner lining" membrane may then give way, and the degenerate portion of artery having lost its elasticity, is disposed to yield to the pulsating throbs of the arterial wave-current, and expand into an aneurism. This series of degenerate transformations is especially apt to occur in some portion of the arch of the aorta; and in one remark- able case of aneurism of the transverse aorta, which I examined for my colleague, Dr. Cockle,* a no less remarkable condition co-existed : — the whole thoracic aorta was converted into a continued series of bony plates, forming a bony tube, which condition terminated abruptly at the aortic aperture in the diaphragm. The histological characters of fatty and calcareous degeneration of the larger arteries were discovered by Mr. Gulliver ; f but the smaller blood-vessels, arteries, veins, and capillaries are also liable to a certain transformation, respecting' which two opposite views are held. The smaller blood-vessels (Fig. 81) may become studded with fatty granules, at first thinly and irregularly scattered, subsequently more thick set; or the oil-particles may aggregate into patches, sometimes oval or round, gene- rally of an irregular shape ; and these aggregated granules are apt to coalesce into drops of oil. Now, the question is — Are these granules outside the vessels, or in the substance of their walls ? Patches of granules w^ere described and figured by Dr. J. H. Bennett § in 1842, and attri- buted to fatty degeneration of exudation- matter, thrown out from the vessel. In 1849, Mr. Paget || also described the same appearances, but attributed them to fatty degeneration of the vessels themselves. These latter observations referred to the smallest cerebral vessels, in connection with apoplexy, ;and softening of the brain, respectively. He desci-ibes the fatty granules as being situated " beneath the outer surface " of the vessels. That in small arteries of g^ of an inch in diameter, the granules are formed in the more or less developed muscular or transversely fibrous coat ; in veins, the corresponding layer, immediately within their external fibro-cellular nucleated coat; in vessels, whether arteries or veins, whose walls consist of only a simple pellucid membrane, bearing nuclei, the substance of this membrane is the first seat of the fat deposit. As this degeneration proceeds, the portion of * Case read before Med. Soc. Lond., 1862. t Med.-Chir. Trans., vol. xxvi. p. 86. X Fatty degeneration of blood-vessels, illustrated by the cerebral vessels of an aged individual who died of apofilexy. — a. Ultimate capillary, h. Larger vessel. c. Small artery, with fatty particles scattered over its surface. (Wedl.) § Edin. Med. and Surg. Journal, vols. Iviii. and lis. II Medical Gazette, vol. xiv. 232 GENERAL PATHOLOGY AND SURGERY. vessel thus affected undergoes chang-es of structiire, the nuclei and fibres disappeai'ing, until at length blood-vessels of -^^jj of an inch in diameter appear like tubes of homogeneous pellucid membrane, studded with oil-particles, in its substance. By this change, the proper structure of the vessels wastes, and eventually disappears, giving place to the fatty g'ranules. Alterations of shape, also, are not uncommon. Usually, the outer layer of the wall is lifted up by one or more clusters of oil-particles, and the outline of the vessel becomes tuberous. Sometimes aneurismal dilatations form. This fatty degeneration of the smaller blood-vessels occurs most frequently in arteries of yi^ of an inch in diameter; veins of the .same size, or smaller, are next in order liable ; and capillaries, least so. Rupture is apt to ensue, with haemorrhage ; and thus cerebral haemor- rhage is often produced, accompanied with previous chronic softening of the surrounding brain-substance. A similar degeneration of the blood-vessels of the lungs has been observed by Dittrich, and in branches of the pulmonary artery, accom- panied with tuberculous disease of the lung, by Dr. R. Hall.* The placental blood-vessels often exhibit a similar transformation ; and those of tlie eye, in connection with arcus senilis. (c.) Fatty degeneration of the cerebro-spinal substance, and of nerve-fibres, is unquestionable. The brain or spinal cord may thus liquefy or soften, partially, or throughout its whole substance, with breaking up of the nerve-fibres, and the cells of the grey matter ; and the production of abundant granule-cells or masses, and free-floating granules — from fatty degeneration, and disintegration, of the cells of the neuroglia or delicate connective-tissue of the brain. (Virchow.) These changes are collectively denominated by Paget " liquefactive degeneration; " and it presents the various colours of cerebral soften- ing, — white, yellow, or red, according to the absence or presence of hyperaemia, with perhaps extravasation of blood and pigment-staining, more or less superseding the yellowish fatty transfoi-mation of the bmin-substance. And this arises from obstructed circulation through the substance of the organ ; as from embolism or chronic inflammation. Atrophy of nerve-fibres is thus described by Waller : — At first trans- verse lines appear in the intra-tubular substance, indicating its loss of continuity ; then it is apparently divided into round or oblong coag'ulated masses, as if its two component materials were mingled ; they are converted into black granules — resisting the action of acids and alkalies ; and finally, these granules are slowly and imperfectly eliminated. (d.) Besides fatty degeneration of textures, the healthy integrity of which is most essential to life, this transformation may occur in perhaps any other texture. In the air-vesicles of the lungs, and in the bronchi (Bennett f) ; in the cells of the liver — hepatic cells — con- stituting fatty degeneration of that organ ; in the shut sacs of vascular glands, as those of the spleen (Bennett) ; in the pancreas (C. J. B. Williams J) ; in the kidneys, as first shown bj' Bowman ; and generally in the ducts of all glands which are lined with epithelium. The stomach, intestine, and urinary bladder, are probably not exempt ; their fatty degeneration being a further illusti-ation of this process, * M^i.zfhir. Rev., October, 1855. t Op. eit., p. 234. - '• -, ^ " Principles of Medicine," p. 448. DEGENERATIONS. 233 chiefly as regards organic nmscalar fibres. By a similar transforma- tion of the uterine substance after parturition, this organ regains its former dimensions, or nearly so. The placenta often passes into fatty degeneration — so named by Dr. Barnes, and originally figured by Dr. J. H. Bennett, in 1844,* who regards the fatty molecules and granule- cells, not as produced by a transformation of the placental tissue, but of exudation-matter, or by that of extravasated blood. " The yellowish or fawn-coloured deposits may be infiltrated throughout the tissue of the placenta over a greater or less space, or they may occur in isolated spots forming nodules. They are generally somewhat indurated, and give rise to the idea that they are coagulated fibrin. I (Dr. Bennett) have frequently examined them, and traced all the changes intermediate between a coagulated exudation, or extravasation of blood, and the ultimate conversion of the foreign matter into a mass of molecules filling" up the intervascular spaces. Similar observations have since been made by Drs. Hanfield Jones f and Cowan. ;J: In many cases the fatty material may be seen forming a layer separate from the vessel, and inside the limitary membrane of the villus." § (e.) Bones are liable to fatty degeneration of their texture ; a con- dition corresponding to the "mollities ossium" of most English authors. The characteristic properties of the osseous texture in this state are — • its softness and brittleness, pale yellow colour, oily greasiness, and lightness ; the texture being that of a spongy bone deprived of its earth, and soaked in soft fat, while the original size and shape of the bone remain unaltered. Hence the name — Eccentric Atrophy of Bone — proposed by Mr. Curling, as suggesting one of the most striking characters of this transformation. Oil, not fat-cells, fills the cancelli, and is even found in the lacunge and canaliculi. (Virchow.) Combined with this oil, Bennett describes numerous cells, each of which vaines in TTOU nucleus, also varying much in size, and occasionally showing various stages of division and of endogenous development. The production of this cell — as in most of the so-called fatty degenerations of texture, according to the same observer — is attributed to an exudation fvoui the blood-vessels, mingled with more or less of the coloured corpuscles, in which new cells az^e developed, combined with fatty tran.sformations of the albuminous and fibrinous materials ; thus differing from the structural condition of bone known as- " i^chitis," which, although also accompanied with softening, is regarded as aiTCSted development of bone with increased growth of cartilage-cells. (Kolliker.) (See Mollities Ossium, and Rachitis.) ( /.) Cartilage is prone to true fatty degeneration ; oil-particles, and \)j. coalescence, oil-drops, substituting the contents of the cartilage- cells ; during which transformation the nucleus vanishes. Oil-particles may likewise beset the intercellular hyahne basis ; which, together with the cell-contents, acquire a marked opacity. " Arcus senilis " consists of oil-particles in the substance of the cornea, near the iris, forming a marginal ring round it. This fatty degeneration was discovered and originally described by Mr. E. * " Treatise on Inflammation," plate, Fig. 10. t British and Foreign Med.-Chir. Rev., vol. ii. p. 354. X Edin. Med. and Surg. Journal, April, 1854. § " Principles and Practice of Medicine," 1859, p. 238. 234 GENERAL PATHOLOGY AND SURGERY, Canton.* Its significance extends far beyond the organ of vision, whose function i-emains unimpaired ; for, unless consequent on inflam- mation of the eyeball, arcus senilis is the pathologico-anatomical indication of many other and most important co-existing fatty de- generations, — of the ophthalmic artery, of the mnscles attached to the eyeball, of the heart ; and, in fact, a degenerative tendency throughout the body. Thus, a well-marked arcus, in both eyes, is the surest external and visible sign, during life, of internal and unseen fatty and other degenerate conditions of organs, discovered after death. Arcus senilis was present in about nine-tenths of the cases m which Dr. C. J. B. Williams had reason to infer the existence of fatty de- generation of the heart. And although commonly seen, as the tei-m implies, only in advanced life, the arcus in earlier years is, apart from local disease of the eyeball, a sure indication of premature old age. The lens is sometimes transformed into fat (Dairy mple, Lebert), con- stituting soft cataract. (g.) New Products — i.e. false tissues, deposits or exudations, and growths — are by no means exempt. A pleuritic false membrane, foi- example, may be converted into fatty matter. Of deposits, pus-cells are especially prone to fatty transformation of their contents, forming granule-cells, known as exudation-corpuscles ; thus also tubercle- corpuscles disintegrate, in the softening of tubercle. Among growths, cancer is apt to become studded throughout its substance with oil- particles, free, and in the cells, which are then no longer distinguishable as "cancer-cells." Eventually the cell-walls disappear, and the whole or portion of the growth which has thus degenerated, becomes a con- fused mass of fatty matter, with the remnants of cells. It is worthy of note, that the fatty matter may appear in yellow masses, not un- like softened or yellow tubercle, and. that this resemblance explains some instances of the so-called co-existing admixture of tubercle with cancer. Secondary changes in fatty degeneration. — The fatty matter — originally, perhaps, in the fluid state of oil- — may undergo inspissation, and become converted into an almost diy mass, having a cheesy con- sistence, or friable, and opaque, with a yellowish colour ; this change being known as caseation. It may be consequent on the fatty degene- ration of any tissue or new product ; but especially in cells of all kinds ; as pus-corpuscles, forming the caseous matter in a chronic abscess, or in the cells of tubercle, forming yellow cheesj" tubercle. Any such caseous matter consists of disintegrated cells, and fatt}^ matter, with crystals of cholesterine. Caseation may itself be followed by lique- faction of the inspissated fatty matter ; a further change designated softening; and thus the cheesy residuum breaks down into a thin, yellow, opaque fluid — puriform in appearance, but consisting of granular debris, oil, and cholesterine. Another change may super- vene on caseation, by the interstitial deposition of saline matter — chiefly phosphate and carbonate of lime, constituting calcification, or the calcareous degeneration of the previous fatty transformation. This has already been noticed in connection with atheroma of arteries. (2.) Pigmentary is akin to fatty degeneration ; the material in either case being essentially carbonaceous ; in the one, oil-particles or drops ; in the other, pigment-particles or granule-masses of pigment : * " Observations on Arcus Senilis," Lancet, 1850-51. I DEGENEEATIONS. 235 but the origin of this pigment-matter is different in different cases ; and its pathological significance is therefore equally diverse. Pigment-matter may represent the colouring matter of the blood, or of the bile ; and these being distinct sources, refer to morbid con- ditions of origin, as distinct. The particular colour of the pigment deposit — commonly black, sometimes red, brown, green, or yellow — does not enable us to determine with precision the question of origin. Whichever may be the colouring matter — haemoglobin or biliary, the process of degeneration may consist either in its abnormal secretion from the blood-vessels, by the cells of the part affected ; or the escape of the colouring matter by transudation through the vessels, or their rupture, owing to chronic congestion. Haemoglobin may be liberated from the red corpuscles either by transudation or rupture of corpuscles, — within or without the vessels ; or the cells may have themselves transuded by migration. The change into pigment is a chemical transformation. Carbonaceous matter introduced into the body, and deposited in the textures, is obviously not pigmentary degeneration. Such is the black matter found in the lungs and bronchial glands of colliers and others who habitually inhale smoke. The colour of this matter is not discharged by hydrochloric acid or by chlorine ; a point of distinction between it and the pigment of morbid origin, which disappears under the influence of these chemical agents. Other kinds of pigmentation must also be distinguished from degeneration ; the greenish-yellow or black discolouration, resulting from extravasation of blood, as witnessed in the chameleon-hues produced by contusion ; and the pigmentary discolouration with heemoglobin from disititegration of the red corpuscles of the blood in gangrene. Nitrate of silver stains the tissues, and its prolonged administration internally imparts to the skin a leaden hue. Gas-staining also may occur, from decomposition reacting on the colouring matter of the blood in the tissues ; sulphu- retted hydrogen thus producing the greenish -black patches on the liver and other organs, so often seen in post-mortem examinations. Pigmentary degeneration occurs frequently in the mucous mem- brane of the stomach and intestines of old persons, and is recognized by slate-coloured discolouration of this texture. So also in cases of dysentery. Of new tissues, intestinal cicatrices not unfrequently present the same appearance. Deposits of tubercle eventually become surrounded with black pigment-matter. New growths may be infil- trated with this matter, as commonly occurs in encephaloid cancer ; or pigment may be deposited by itself, and accumulate in the form of a distinct tumour, as melanosis. (3.) Fibrous degeneration would appear to be an evolution of one structural constituent of the transformed texture — the fibrous element — at the expense of another constituent, which itself has undergone degeneration and disappeared ; leaving its surviving companion more conspicuous, and the representative of the originally compound texture transformed as if entirely by degeneration. Muscles are the chief seat of this fibrous transformation, and especially the voluntary muscular texture. In the course of that general and natural wasting of the body which denotes old age, the voluntary muscles especially become paler and more fibrous, as seen after death ; though softer, because less contractile, during life. This 236 GENERAL PATHOLOGY AND SURGERY. senile atrophy is characterized by wasting of the muscular fibres, while the interstitial fibro-cellular tissue thus becomes more apparent, forming a condensed sinewy texture, instead of muscle. As felt during life, the tendons seem to have encroached upon and substituted the muscles. By this shrinking, and by that consequent on the dis- appearance of subcutaneous fat, the rounded outline of youth is lost in the shrunk shanks of the lean and slippered pantaloon. Apart from this textural transformation incident to age, it is ques- tionable whether fibi-ous degeneration occurs otherwise than by the deposit of interstitial exudation-matter. The musculai" texture is still a chosen seat. Of voluntary muscles, those of the limbs may acquire a fibrous condition, as the result of chronic fascial rheumatism ; the intercostal muscles and diaphragm also, in chronic {pleurisy; while fibrous degeneration of organic muscular texture is exemplified by that of the heart after endocarditis or pericarditis. Membranous textures likewise are peculiarly liable to this change, apparently by interstitial deposit. Hence, probably, the opaque white tiiickenings of serous membranes which are seen as patches in the cardiac reflexion of the pericardium, in the valves of the heart, in the pleui-a, in the peritoneum, especially over the liver, and in the arachnoid. Other accredited examples of fibrous degeneration are certain indurations produced by interstitial fibrinous effusions, as in the interstitial cel- lular tissue of parenchymatous organs — the liver, kidneys, spleen, or lungs — constituting cirrhosis ; or in the sub-mucous or subcutaneous cellular texture ; the latter, so-called degeneration, being that in- duration of this tissue which is occasionally witnessed in a newly born infant. Fibrous degeneration, or induration of parenchymatous organs, takes place at the expense of their proper structure, which ati-ophies and partially disappears. (4.) Amyloid, waxy or lardaceous degeneration, is probably allied to, if not a variety of, the fibrous degeneration. The texture afi^ected acquii-es considerable firmness and density, is somewhat transparent and lustrous, and of a yellow or yellowish-brown colour, which in many cases contrasts with the colour of the original texture — rendered paler, however, by compression of the blood-vessels with the amyloid matter. The cut surface is not unlike that of firm bacon, or wax. The liver, the kidney, or the spleen, having acquired these cha- racters, is then said to be in a state of waxy degeneration. An organ, from amyloid degeneration, becomes much enlarged, and heavier; its substance is firm, and feels elastic through the capsule ; but it retains an even surface, — without nodular enlargement, as from a projecting cyst or solid tumour. The whole, or a portion only, of an organ may be thus affected ; but often several organs have undergone the amy- loid transformation of texture. And perhaps no tissue in the body is free from the liability to this change — commencing generally in the smaller arteries and capillaries of the part involved. The essential structure of the tissne or organ atrophies ;■ — the secreting cells of the liver or kidney, and its malpighian bodies, wither ; at the same time these cells present a remarkably pale and transparent appearance, as they become insignificant. The corpuscles of the spleen, both in its parenchyma and malpighian bodies, shrivel, and have also a similar appearance. DEGENERATIONS. 237 Amyloid degeneration is apparently due to interstitial exudation- matter. This material is unorganized ; it is itself translucent, but presents a dull surface, at first of a greyish tint, afterwards perfectly colourless ; it belongs to the albuminoid group of organic chemical compounds, bat its precise composition and chemical relations are unknown. If deposited in a free state, amyloid matter appears in the form of "corpora amylacea," bodies which are concentrically laminated, like starch-granules ; as found sometimes in the nerve-centres. Pure amyloid matter assumes a blue colour by the action of iodine ; and this fact, first observed by Virchow,* led him to conclude that the waxy material in question was similar to starch, and therefore hydro-car- bonaceous. He accordingly named it " animal amyloid." Meckel regards the amyloid matter as fatty, and especially cholesteinne ; he therefore retains the name, lardaceous or cholesterine disease : but Friedreich and Kekule f have ascertained that the composition, of the purest amyloid matter obtained from the spleen closely resembles that of the albuminous principles ; and this conclusion is confirmed by the independent analysis of Schmidt. J Yet the chemical reaction of amy- loid being unlike that of albuminous matter, the material itself is so far peculiar. There seems to be an intimate connection between amyloid de- generation and previous suppuration, of long duration, in some part of the body. This may be accepted as a patliological or clinical fact, according to the original observations of Dr. W. Howship Dickinson, without adopting his theory, — that the constant discharge of pus, as a richly albuminous, alkaline fluid, leaves a relatively increased propor- tion of dealkalinized fibrin in the blood, which is deposited in various organs and textures. The material of amyloid degeneration is thus regarded as " dealkalinized fibrin," rather than a form of albumen. But the same kind of degeneration may be associated with albuminuria, scrofula, rickets, syphilis, and other cachectic diseases. Ordinary albuminous matter is rendered yellow by iodine ; and this reaction explains the different shades of colour produced, when a texture is submitted to the influence of iodine, — as a test for amyloid degenera- tion. The blue and yellow colours present the resultant colour — green ; its shade, however, varying with the different proportions of the nor- mal albuminous and amyloid matters. Thus, there are cases, observes Yirchow, where throughout the whole extent of the digestive tract, from mouth to anus, the small arteries of the mucous membrane are affected with amyloid degeneration. The intestines are pale grey, translucent, and may have a slightly waxy appearance. Apart from microscopic examination, the nature of this change might not be dis- cerned. But the iodine test supplies a ready method of detection. Brush a little iodine upon such mucous membrane, and a number of densely aggregated yellowish or brownish-red spots are soon seen to start up, leaving the intervening mucous membrane merely yellow. These points are the amyloid degenerate villi. Waxy and fatty degenerations are frequently combined, as in the liver and kidney respectively ; but a series of analyses, chiefly by Dr. * " Archiv f. Path. Anat.," Bd. vi. ss. 135, 268, and 416. t Ibid., Bd. xvi. s. 50. X " Annal. d. Chemie und Pharmacie," Bd. ex. s. 250. 238 GENERAL PATHOLOGY AND SURGERY. Drummond, and collected by Gairdner,* has elicited this important genera] result : — that the human liver in the state of waxy degenera- tion contains considerably less fat and water, and a greater amount of solid constituents, than in the healthy state. Mucous and Colloid Degenerations — so called, result from the trans- formation of normal tissue albumen. Mucin is precipitated from mucus or synovial fluid, by the action of acetic acid, appearing in the form of a white, stringy or membranous deposit, which is insoluble in an excess of acetic acid ; alcohol and chromic acid also give a turbid deposit of mucin ; whei-eas, colloid material, although allied to mucin, is not precipitated by acetic acid, nor affected by the other reagents. Bat both substances swell up in water, and become gelatinous. Either such transformation of albuminous matter often occurs within epithe- lial cells, as in the catarrh of mucous menibranes, or in a colloid ovarian cyst, or in cysts of the thyroid gland — colloid goitre ; but a mucoid transformation may also occur in the intercellular substance of con- nective tissue, including bone and cartilage. These textures are thus converted into a gelatinous material, and acquire a remarkable softness. Hence, the softness of the costal cartilages in advanced life, from mucoid degeneration of their intercellular matrix. Tumours generally are liable to mucoid and colloid changes in their substance — cellular or intercellular ; thence constituting varieties of fibroma, sarcoma, and carcinoma. Such tumours as myxoma, and colloid cancer, are nor- mally formed of similar mucoid, or gelatinous matter. Associated with colloid, is the vitreous transformation — waxy deg'eneration of Zenker. Thus, musciilar fibres swell, and become transparent; presenting trans- verse and longitudinal fissui-es. The vitreous substance is stained with carmine, and swollen by the action of acetic acid. This morbid change may be found in typhoid fever; and a similar change occurs in the epithelial cells of mucous membranes affected by diphtheria. (5.) Granular degeneration is manifested by an albuminous matter — granular, i.e. structureless, and, it is said, deposited interstitially ; but superseding the proper structural elements of the textures, which atrophy and disappear. Thence the original texture becomes con- verted into a granular mass. With this degenerative transformation, the texture loses its cohesion, and also acquires an oj^aque yellowish colour. It is apparently identical with what Bennett denominates '' mo'ecular albumen," and a variety of "albuminous degeneration." I am inclined to regard this degeneration as being, more correctly speaking, a disintegration of the structural elements of the oritrinal texture, without the deposition of any new granular or molecular albuminous matter. It chiefly affects the fibrous textures or fibrous new formations ; either of which by their disintegration would yield this kind of matter, and present the physical characters of yellowish opacity and want of cohesion already noticed. This granular trans- formation of texture is often the result of chronic inflammation, or con- sequent defective nutrition. As arising from fever, granular degenera- tion is synonymous with the " cloudy swelling " — so named by Virchow, in which the cell-elements of various organs and textures are enlarged, and their contained protoplasm has become granular. This change is most marked in the liver, kidneys, lungs, and in the muscular texture of the heart and in the muscles generally. The organs, thus affected, * Monthly Journal of Medical Science, May, 185i. DEGENERATIONS. 239 are increased in size, but their consistence is friable from disintegra- tion. Proceeding from acute pyi^exia of blood origin, this textural degeneration is found mostly in typhus and typhoid fevers, rheumatic fever, py99mia, and erysipelas. (6.) Calcareous degeneration — the lowest form of all — approximates organized textures to unorganized concretions. The new matter con- sists of phosphate of lime and magnesia, and carbonate of lime. This matter may be deposited interstitially in the origiual texture, the structural elements of which, having atrophied, are gradually super- seded ; thus completing that substitution of texture which constitutes a degenerative transformation. Rokitansky regards calcareous de- generation as a chemical precipitation of the apparently new mineral matters from their natural combinations with the animal matters of the texture. This view is analogous to what I have denominated degeneration by the absorption of one structural constituent of a com- pound texture, and thence the evolution of another such constituent. Whatever may be the essential nature of the process, it may be induced by chronic inflammation or other cause of diminished nutrition in the part affected, but commonly results from a general senile failure of nutrition. As proceeding, occasionally, from a blood-condition, it depends on an increased proportion of saline matter — resulting probably from absorption in the course of bone-disease, as extensive caries or osteomalacia; the surcharged proportion of saline constituents in the blood being deposited in other textures or organs — as in the connective tissue of the lungs, kidneys, liver, stomach, and intestines. Calcareous degeneration takes place in tissues of simple organiza- tion and of low vitality in respect of blood-supply and nutrition'. For example, in fibrous textures, in cartilag'e and tibro-cartilage, and in bone ; the mineral transformations of these textures constituting that natural petrifaction whereby, as age advances, the body is slowly yet surely reduc.ed to its primitive earth. But this degeneration is not unf requently secondary to some other ; commonly consequent on the fatty metamorphosis, and of the arteries, principally. Atheroma in the coats of these vessels, or in the valves of the heart, is followed by calcareous degeneration, so that both become associated in the same portion of texture ; as was noticed in connection with fatty degenera- tion. The calcification of nerve-texture is seldom met with in the human species. Of deposits, tubercle is most liable to calcify, as in the pulmonary texture, and the tuberculous matter deposited in the bronchial and lymphatic glands. This chang'e would seem to arise from absorption of the animal or albuminous matter of the deposit, and precipitation of the associated mineral constituents. The same change may occur in inflammatory exudations on serous membranes, forming osseous-like or calcareous plates, as on and in the pericardium — of which I have met with a remarkable specimen — and in parenchymatous organs, forming calcareous concretions. Morbid growths of all kinds are liable, and some are prone, to calcification ; fatty tumour, some- times fibrous, or cystic tumour; cartilaginous tumour, very commonly ; cancer, not unf requently. And in all such cases, this degeneration arrests the further progress of growth, and is a natural mode of cure. Regarding Degeneration, of whatever kind, as a process resulting in the transformation of the structural elements of textui-es and orsrans, 240 GENERAL PATHOLOGY AND SURGERY. this process may take place in apparently three different ways, repre- senting as many modes of degenerative transformation. This change of textural structure may issue from (1) the deposi- tion of new matter, which directly substitutes the proper structural elements of the texture undergoing degeneration, they having dis- appeared ; or (2) degeneration may proceed from chemical transfor- mation of the proper structural elements, or again, from similar ti'ansformation of exudation-matter, interstitially deposited. These modes of degeneration are illustrated by fatty degeneration. Pig- mentary degeneration, properly so called, I have restricted to the de- position of pigment-matter from the blood or from the bile. Fibrous degeneration, in its typical form, I have regarded as (3) the evolu- tion of fibrous tissue, by the atrophy and disappearance of another and more essential structural constituent of a compound texture ; as in muscle, the muscular fibres disappearing, this change evolves and exhibits their interstitial connective tissue, which becoming condensed, readily assumes the character of fibrous tissue. The actual conversion of muscle into fibrous tissue is the received view of tibrous degeneration. Obviously, however, this change cannot be effected by conversion of the muscular fibres, — for they have partially or entirely disappeared ; but it may occur from the more or less complete substitution of interstitial exudation-matter, which assumes the fibrous character. This is the acknowledged mode of amyloid degeneration, and the new matter interstitially deposited seems to be chemically allied to that of fibrous degeneration in having an albuminous nature, while structurally it differs in being granular or structureless. Granular degeneration is also said to take place by the deposition of new matter interstitially ; as another form of albuminous material, which gradually usurps the place and substitutes the structural elements of the original texture, and thus completes this degenerative metamorphosis. I have regarded it as a process of Disintegration of the structural elements, without the deposition of any new matter ; and that the granular matter is formed chiefly by the breaking down of textures originally fibrous, or by that of fibrous new formations. Calcareous degeneration is an analogous process ; being either a chemical precipitation of saline matters from their associated albuminous matters, or possibly the deposition of new calcareous matter, interstitially, with absorption and disappearance of the albuminous matter. These Transformations — degenerative and disintegrative— of tex- tures, original and adventitious, are represented in the following table : — RETROGRESSION OF THE STRUCTURAL ELEMENTS OF TEXTURES. (1.) By the deposition of new matter — a. Directly substituting the original structural elements, which have themselves disappeared. Fatty and Pigmentary degenei-ations, respectively. h. Interstitially deposited, and accompanied with the absorp- tion and disappearance of these elements. Fibrous, including amyloid or waxy degeneration. Granular degeneration. Calcareous degeneration. ULCERATION. ^41 (2.) By clieniical transformation — a. Of the original structural elements. Fatty degeneration of muscle. (Dr. R. Quain.) h. Of interstitial exudation-matter. Fatty degeneration, in many cases. (Dr. J. H. Bennett.) (3.) By atrophy of one structural constituent of a compound texture, and the evolution thereby of another constituent. (The author.) Fibrous degeneration of muscle. (The author.) (4.) By disintegration — (The author.) a. Of the original structural elements. Granular degeneration, so named, of fibrous textures. b. Of interstitial exudation-matter. Grranular degeneration, so named, of fibrous new for- mations. By chemical precipitation, — analog'ue of disintegration. Calcareous degeneration, so named. (Rokitansky.) Retrogression of textural structure, by Degeneration — morbid, only when it occurs prematurely — represents, as I have said, the falling back from a higher condition, to a lower or more elementary grade of textural structure ; and which substitutes the proper con- stituents of the original texture. This retrogression and substitution are the essential characteristics of Deseneration. CHAPTER TV. TJLCEBATION AND ULCERS, GANGRENE AND MORTIFICATION. Death of any part of the body, as contrasted with its nutrition, is essentially a disintegration of the constituent elements of structure and resolution into molecular matter ; the destruction of the oi'ganiza- tion which resulted from development ; the falling to pieces of that which the formativa power had constructed. Disintegi^ation, like Degeneration, therefore denotes both a process and its result in the destruction of structure. Disintegration is related to Degeneration : the latter presupposes the former, but conversely, the former does not necessarily presuppose the latter ; for Disintegration may occur independently, without any preceding Degenerati< m of texture. Ulceration, and Mortification including Gangrene, are essentially processes of Disintegration and textural death. But the pathology of these processes, and their difference in degree only, should be clearly understood. Ulceration is a disintegrative process, essentially ; generally also of inflammatory origin. The molecular matter resulting from ulcera- tion may disappear in either of two ways : — VOL. I. K 242 GENERAL PATHOLOGY AND SURGERY. Firstly. By discharge, in the liquid form ; thus leaving a chasm or ulcer- Secondly. By absorption through the lymphatics and veins jointly, especially the former vessels ; thus leaving a chasm or ulcer. Possibly, both modes of removing the disintegrated textures co- operate in ulceration. Observe a case of common ulcei'ation. The shin having come into collision with some blunt obstacle, receives a tolerably severe bruise. What probably happens ? The bruised portion of integument becomes inflamed ; in the course of a few days a small piece separates and comes away, leaving a chasm, from which more or less discharge of some kind issues ; in fact, the skin, with perhaps the subjacent cellular tissue, has slowly undergone " solution of continuity," and an ulcer is formed (Fig. 82). Its formation and extension are termed ulceration. The balance of evidence is, I think, decidedly in favour of the removal of the disintegrated matter by discharge. This matter can, indeed, be seen to come away occasionally ; the molecular matter accu- mulating in the form of minute sloughs, whenever disintegration pro- ceeds too rapidly for its discharge in the liquid form ; and again disappearing as molecular matter, when disintegration and discharge proceed evenly. In caries or ulceration of bone, the pus discharged, contains in solution nearly two and a half per cent, of phosphate of lime, instead of the mere trace found in the discharge from soft tissues, — a signiBcant fact first noticed by Bransby Cooper. Hunter originated the doctrine of " ulcerative absorption " — a doc- trine which eventually took firmer root than perhaps any other of Hunter's views. " When," says he, " it becomes necessary that some whole living part should be removed, it is evident that nature, in order to effect this, must not only confer a new activity on the ab- sorbents, but must throw the part to be absorbed into such a state as to yield to this operation ; " and among the circumstances which lead to absorption. Hunter enumerates " death of the part." Now, the possibility of dead tissue being removed by ulcerative absorption is demonstrated by the appearances which necrosed bone presents when a portion has been exposed, and the remaining portion for a time surrounded by living textures. For example, the shaft of the femur having become necrosed, the sequestrum loosens and even- tually separates, or is easily taken away with the forceps. If, during the process of separation, part of the sequestrum has been exposed, that portion is seen to be smooth and polished, while the remaining portion which has been enclosed in new bone is seen to be worm- eaten, obviously, under these circumstances, from absorption. So also dead bone, artificially inserted into living bone, is in time partially absorbed. But, in the process of ulceration, the conditions are unfavourable for the removal of the disintegrated textures by absorption. The veins proceeding from an ulcerated part are obviously much congested in certain cases, and therefore do not allow of that free pas^^age of blood which venous absorption implies. A common varicose ulcer of the leg is a good illustration ; and, as regards the lymphatics, ulcera- tion may occur in a texture destitute of these vessels, or at least in which they have hitherto been seai'ched for unsuccessfully. Ulcera- tion of the cornea is a familiar example. Its conclusiveness is impaired ULCEKATION. 243 by ila.e presence of lympliatic vessels in, or immediately beneath, the conjunctiva. Again, Mr. Gaskell * originally brought forward certain facts which, are inconsistent with the theory that ulceration is absorp- tion by the lymphatics. Thus, ulceration does not appear to be most common where the lymphatics are most freely distributed. They are more numerous and of greater size in the jejunum than in the ileum, yet ulceration is rarely found in the former poi'tion of intestine. The lymphatics are freely distributed on the siu'face of the body, yefc spreading ulceration does not extend so readily on the external surface as a little below. Lastly, absorption readily takes place from the surface of serous membranes ; nevertheless, theii* inflammation is rarely followed by ulceration. The independence of ulceration and absorption, whether by the veins or lymphatics, is, I think, further established by another species of evidence. " If," as Key remarks,! " the formation of an ulcer be an act of absorption, the parts that are removed in the formation of a chancre are so disposed of ; the lymphatics, in forming a chancre, carry into the system tissues tainted by the syphilitic viras, and must therefore, in every instance, contaminate the whole mass of circulating* fluids. A bilbo, therefore, ought to be one of the earliest accompani- ments of chancre. Whereas, during the ulcerative stag-e of chancre, the glands in the groin usually remain free from infection ; it is when the ulcerative stage is at an end that the gland enlarges and bubo forms. In other w^ords, when the lymphatics are most actively engaged in producing the ulcer, and in carrying the poisoned mass into the gland, the latter exhibits no sign of irritation ; but when the lymphatics are inactive, the gland begins to enlarge." Furthermore, if ulceration implies absorption, contamination of the system should always follow a chancre, unless, indeed, we assume that the syphilitic poison may be received into the mass of circulating fluids, without necessarily causing constitutional disease, — an admission which we are not warranted in making. Duly considering the anatomical facts which I have adduced, namely, the condition of the veins in certain cases of ulceration, and the absence of the lymphatics in other cases ; also, the fact that con- tamination of the blood is neither a constant sequent of primary syphilitic ulceration, nor, in its oi'der of sequence, consistent with the hypothesis of absorption ; the fair inference is, that ulceration may begin and continue without absorption. Goodsir maintains, or did maintain,;]; that tilceration is a process independent of the vessels, both veins and lymphatics, they being " passive agents, mere ducts for conveying away the products of action. " A rapidly extending ulcerated surface appears, as if the textures were scooped out by a sharp instrument. The textures are separated from the external medium by a thin film. This film is cellular in its constitution, and so far it is analogous to the epidermis or epithelium." It is alleged that this cellular layer possesses the peculiar (vital) power of disintegrating the subjacent texture, and that by virtue * " Jacksonian Prize Essay," 1837. MS. Eoy. Coll. Surg. Eng. t Med.-Chir. Trans., vol. xix. p, 141. X " Anatomical and Pathological Observations," by J. Goodsir and H. D. Good- sir, 1845, p. 14 et seg. 244 GENERAL PATHOLOGY AND SURGERY. thereof, so far from ulceration denoting a diminution of the formative power of the part, progressive ulceration represents its undue activity. " The apparent diminution is a consequence of the extremel}" limited duration of existence of the cells of the absorbent layer, which die as rapidly as they are formed, disappearing after dissolution partly as a discharge from the surface, but principally through the natural channels Ijy which the debris of parts which have already performed their allotted functions are taken up into the organism. *' In this view of ulceration there is substituted, for the hypo- thetical active or aggressive power of absorption ascribed to the veins and Ivmphaties, a power which is known to exist in the organic cell durino- the progress of its growth ; and the ultimate removal of the matter from the scene of action is ascribed partly to the formation of discharge, partly to the yet unexplained, but at the same time undoubted, and in all probability passive, agency of the returning circulation." Defeneration precedes the disintegration, when consequent on in- flammation. The degeneration connected vpith inflammation, unat- tended with ulceration, is usually fatty. Thus it takes place in muscles, as sho^\'TL by Yirchow's observations, and perhaps in muscular tissue of the involuntary order, e.g. the heart, as in a case of fatal traumatic pericarditis examined by Paget ; in bones, in the liver, and the kidneys, as shown also by Virchow ; in the cartilages, as noticed by Redfern ; and in the cornea, by Strube. Calcareous de- generation may be the prior textural change. It takes place in chronic rheumatic arthritis ; wdth inflammation of the laryngeal cartilages ; and the formation of imperfect dentine, with inflammation of the tootb-pulp, is, perhaps, another illustration. Cell-iv filtration of the surrounding tissue, Avith hypertemia, usually also precedes the enclosed disintegration of tissue. (Billroth.) The proper discharge from an ulcer — the product of ulceration, not that of a granulating sore — is ichor, the nature of which is not well imderstood. Ichor is usually a thin sanious fluid, colourless or slightly yellow ; structureless, but mixed with exudation, pus, and blood corpuscles, and with tbe disintegrated matter or debris of the textures. Its chemical composition, as to the essential constituents of this fluid, is unknown. Its chief property is corrosiveness. The operation of ichorous discharge thus maintains and extends ulceration, — partly by acting as a solvent of the already degenerated textui'e elements, and partly as an irritant, by inducing inflammation and degenerative dis- integration of texture. Diagnostic Characters of Ulcers. — An ulcer difl^ers widely in appear- ance. Ulceration forms a chasm of very variable extent and depth, from the slightest abrasion of the integument to the deepest cavity down to and into the bone ; its shape circular, crescentic, or irregular ; it is found less frequently bare, than accompanied with sloughy por- tions of tissue, or with granulations of some description, overspread- ing the vrhole or part of the surface. The circumferential margin of the ulcer varies in thickness, and in direction ; being tm-ned inwards and perhaps undei^mined, everted, ii-regular, or tolerably even ; it may be hard or soft ; its colour and that of the surface may be red, dusky brown, livid, or otherwise shaded ; while the ichor or discharge varies HEALTHY OE TYPICAL ULCER. 245 Fig. 82. greatly in qiiantitj and qnalit j from the typical characters already stated, through every description of mixed discharge, replaced by healthy pus. The integument around may be healthy, inflamed, in- durated, oedematous, or show pigmentary discolouration. Causes. — All these diiferent appearances proceed, generally, from constitutional conditions, as scrofula, scurvy, syphilis ; bnt, occasion- ally, they are produced by external causes acting locally on the part ; as by friction, continued pressure, filth, or various topical applications and dressings of an irritant character. Two classes of ulcers, therefore, each including subordinate varieties, might be recognized with reference to their etiology ; but, practically, it would be difficult to draw this line of distinction. The course of ulceration is either that of progressive extension, in surface and depth ; or that of healing by suppurative gi^anulation and cicatrization, as the mode of reparatiom (See Reparation by Granu- lation in Contused and Lacerated Wounds.) Treatment. — Two general indications may be mentioned for guid- ance in the treatment of all ulcers ; namely, to arrest disintegration, and to induce reparation. The measures, both local and constitutional, which may be appropriate for the fulfilment of these indications will be learnt in the treatment of the various species of ulcers. The following species present, perh-aps, the most distinctive characters : — (1.) Healthy or typical Ulcer. (2.) Inflamed. (3.) Irritable. (4.) (Edematous. (5.) Indolent, and Varicose. (6.) Phaged£enic. (7.) Htemor- rhagic. (8.) Scorbutic. (9.) Scrofulous. (10.) Cancerous. (11.) Lupoid. (12.) Rodent. (13.) Syphilitic. (1.) Healthy or Ttptcal Ulcer may be con- sequent on a wound or other injury, or the sepa- ration of a slough ; and the open sore thus formed, in a healthy person and itself in a healthy state, will be known by certain characters. Of variable extent, depth, and shape, the surface is uniformly mammillated with small florid gi^anulations (Fig. 82), which, however, do not bleed readily and are not painfully sensitive. YLe?t\Xhj pus, opaque, yellowish, and of creamy consistence, mor« or less in quantity, bathes the granulating sur- face. The Tnargin of this ulcer shelves gently down to its base, and is scarcely perceptibly harder than the adjoining healthy skin. The new skin, corresponding to the margin, has an opaque white colour, and its formation is preceded by a linear translucent film of cuticle, which, veiling the subjacent gTanulations, has a bluish-white tint. The granulations immediately within this line are more florid than those nearer to the centre of the ulcer, because more vascular where the cuticle and skin around are being formed. The histological or textural condition consists of an abundant emigration of cells, infiltrating the connective tissue around the ulcer, and at the base of the granulating surface, where these wandering 246 GENERAL PATHOLOGY AND SURGERY. cells become granulation-cells, some of which pass ofE as pus-cells. There is also an increased development of vascular loops, especially in the papillae around the margin of the ulcer, where the gimnulations are most vascular and florid; and the papillce a,re themselves enlarged. Around the margin of the ulcer, the epidermis is thickened, and perhaps indurated, forming a somewhat raised border, shelving down to the thin bluish-looking line of circumferential new cuticle (Fig. 83). The surface ha^nng reached the level of the skin, by granulation, and the formation of pus — superfluous organizable material — having ceased ; cicatrization proceeds inwards by the continued formation of marginal skin, preceded by cuticle, and thus, at length, exhibits the characters of healthy cicatrix, in the recent state. (See also Repara- tion by Granulation.) Treatment. — Little or no positive treatment is requisite, a healthy ulcer healing spontaneously, provided any circumstances adverse to Fig. 8?.* the process of reparation be excluded. Rest, position, to prevent tension and any undue determination of blood, and protection of the surface by water-dressing, are sufiicient. STxin-Grafting may be here noticed ; a principle of treatment due to M. Reverdin, whereby the cicatrization of a granulating surface may be completed, and in a much shorter period than from the cir- cumference alone ; as when the ulcer is of lai^-e size,, or indolent ; or in order to prevent contraction of the cicatrix, as after burns, which would result in deformity and func-tional inutility of the part. But, it is essential that the ulcer be a healthy granulating surface, and which has commenced to cicatrize. Any ulcer induced, or maintained, by constitutional disease, is inherently unfit for skin-gi-afting. The procedure of skin-grafting is as follows : — A very small por- tion or particle of healthy skin is excised from some part of the body, as the thigh, and transplanted by laying it on the surface of a granu- lating ulcer, as on the leg ; the particle of skin being there retained with a fine strip of adhesive plaster, or perhaps better, simply by over- laying it with a small piece of wet lint. The excision is ea.sily accom- plished by raising the bit of skin up with fine forceps, and paring it off with a scalpel (Fig. 84), or snipping it off with sharp scissors ; or an instrument, combining forceps and scissors, has been devised for * Cutaneous ulcer of the leg. Section magnified 100 diam. (After Forster.) — a. Tiie cutis, h. The sm-face of the ulcer, c. The thickened and raised boi-der of epidermis. INFLAMED ULCER. 247 Fig. 84. this purpose. In removing the particle of skin, its deptli should not extend into the subcutaneous fat, or produce hardly an appear- ance of blood from the spot. The surface of the granulations may be freshened with the point of the knife, and so as to imbed or graft the transplanted portion ; but it is better merely to lay the particle of skin down, on its under surface, there retaining it in easy contact with a very narrow strip of plaster, ov a layer of lint. Several bits of skin may be thus grafted, according to the size of the ulcer. The changes which any such reproductive centre undergoes are, according to my own observations, apparently as follows : — The particle remains stationary or dormant for a few days, possibly even for some weeks, before beginning to grow ; it may perhaps die away and nearly disappear as a thin, bluish-white point ; then, if examined with a magnifying glass, a network of vessels will be seen in, and as a zone around, any cutaneous centre about to grow. The particle assumes an opaque white appearance, and loses its vascularity; it enlarges with a thin, semi-transparent, fringed border, preceded by the vascular zone, and increases also in thickness, thus growing both circumferentially and in substance fi-om below. These changes of character are more observable in the reproduced portion of skin, the original centre remaining thinner and more transparent. Any such islet does not extend indefinitely, probably not to a larger size than a fourpenny piece or a sixpence. The areas of cicatrix, thus formed, meet tog'ether, or extend into the margin of the ailcer, and at length the surface becomes covered and cica- trization is completed. Skin- graf ting- sometimes succeeds or fails ; and when practised in the same individual, at the same time, and in the same manner, on the same ulcer, some engrafted centres prove reproductive, others die out. Whether the resulting cicatrix may be as sound as that pro- duced by ordinary cicatrization, is a question not yet determined. (2.) Ikflamed Ulcer.- — A departure from the healthy type of ulcer; the usual signs of inflammation are characteristic. An area of redness with some swelling around the ulcer are more or less con- spicuous appeai'ances, while a burning heat and aching pain are experienced,, particularly when the part is pendent, as the shin — a common situation for an inflamed ulcer. The granulations have a rose-red rather than a florid colour, or they may be absent and the surface of the ulcer overspread with a thin ash-grey slough ; the suppuration is scanty, thin, and perhaps tinged with blood. As in- flammation subsides, the cuticle peels olf or desquamates for some distance round the ulcer. When, in the course of an inflamed ulcer, sloughing becomes the prominent feature, and the ulceration enlarges in this manner, it may be properly named, — a slougliing ulcer. This condition of sore accompanies inflammatory fever, an ulcer '248 GENERAL PATHOLOGY AND SURGERY. previously healthy then becoming inflamed ; or it may be produced by external violence or consequent on local irritation. Treatment. — Any cause or causes in operation Avill, as usual, primarily direct the treatment, namely, their removal. Then, i-eraedial measures are those appropriate for inflammation. A. poultice, or a cold evaporating' lotion, if more agreeable, and pei-haps the local absti'action of blood hj a few leeches applied in the neighboui-hood of the ulcer ; with rest and an elevated position of the part ; and, finally, water-dressing as the sore assumes a healthy character, and undergoes the process of healing. Bandaging the limb may, at this period, be useful to support the weakened vessels of the part ; and thus prevent any liability to the continuance or recurrence of a low state of inflammation ; a very troublesome chronic condition, which is apt to follow an acutely inflamed ulcer. The constitutional treat- ment should be more or less depletory, by a combination of saline aperients, diuretics, and diaphoretics, aided by a moderated diet. Subsequently, when the ulcer may have assumed a chronic form of inflammation, the general health will need to be supported by tonic and stimulant treatment, including dietetic resources. Eczematous Ulcer, so called, is simply a variety of the inflanaed ulcer; the surroanding skin presenting the usual red appeai"ance, with the punctiform and vesicular chai'acter of eczema. When the vesicles burst, the surface becomes raw, and exudes a yellowish, serous dis- charge, which is very acrid and irritating. This species of inflamed ulcer may occur in debilitated subjects — young or old ; but it is liable to be provoked by some irritant dressing, even of an antiseptic kind, when probably the constitutional predisposition to eczematous inflam- mation coexists. The treatment should hare regard to the constitutional condition ; by the administration of such tonics as quinine and iron, with careful attention to diet, and the state of the digestive organs. Sometimes, a scrofulous or gouty tendency will indicate the appropriate course of treatment. Topical measures comprise various stimulant, astringent, and sedative applications to the ulcer, and siirrounding area of eczema: as by painting the surface with a strong solution of nitrate of silver ; or dressing it with boracic ointment ; while, the distressing heat and itching may be allayed by means of conium or belladonna extract, in the proportion of a drachm to the ounce of ointment. Scrupulous cleanliness must be observed in dressing the ulcer. (3.) Ikeitabli: Ulcer. — This variety of ulcer is to be distinguished from an inflamed ialcer, with which it might be confounded. Painful to a degree, even of a neuralgic character, the other and more peculiar signs of inflammation, particularly circumferential redness and swell- ing, are wanting. The granulations are imperfect or absent, reddish here, tawny there ; but they are very painful and sensitive to the touch, and readily bleed on slight pressure or the application of a stimulant dressing. The discharge is thin and sanious ; and the edge of the ulcer, irregular, sharp, and abrupt, evincing no disposition — not to say an obstinate indisposition — to commence cicatrization. Commonly situated on the shin or lower part of the leg, an irritable sore or fissure of the anus also not unfrequently occurs, which well illustrates the pain and other characters of this variety of '.ulcer. It is generally connected with some disturbance of the diges- (EDEMATOUS ULCER. 249 Fig. 85. tive organs, and with constitational irritation as distinguished from inflammatory fever. More rarely, some cause of local irritation may co-operate ; as the passage of the f^ces and the contraction of the sphincter ani muscle with regard to irritable ulcer in ano. TreatTYient. — The removal of any cause in operation is the primary consideration. Hence the rectification of the constitutional disorder, as by saline purgatives and mercurials to influence the secretion of bile. Then opiates, occasionally, will do much to allay the general irrita- bility. Of topical applications, nitrate of silver freely applied is the most efiicacious. Lead and opiate lotions may be recommended. Rest of the part is necessary or advantageous, as in the treatment of other ulcers ; and thus, division of the sphincter ani muscle by incision through a fissure of the anus, will relieve pain and facilitate granula- tion in that situation. In any case of irritable ulcer, as healthy granulations spring up, the pain subsides ; and the cicatrix fonned is not more than ordinarily sensitive. (4.) Q^^DEMATOUS Ulcer. — In this variety, sometimes named the weak ulcer, the gTanulations are large, pale, translucent, and flabby, sometimes cropping up as large gelati- nous masses above the level of the sore (Fig. 85). The discharge is watery, and the margin has no disposition to commence cicatrization. Indeed, the granulations are apt to slough. This condition arises in connection with a weak circulation, or malnutrition ; or it may arise from some local cause of defective nutrition, or proceed from the soddening of an ulcer by continued poulticing or other prolonged applica- tion of moisture and warmth. Treatvient. — Any constitutional or local cause having been removed, an cedematous ulcer soon becomes converted into a healthy granulating surface. Local treatment is often remarkably curative. An elevated position, astringent lotions, as of sulphate of zinc or copper, or nitrate of silver, and the support of a bandage, will probably succeed in redticing the granulations to the level of the ulcer, when exuberant, and strengthen their vitality, thus favouring cicatrization. But in using these appliances, it is important to remember the perishable nature of cedematous granulations. Consequently, the astringent solutions should be weak, either of the sulphates being used in the proportion of about two grains to the ounce of water. And the bandage miist be applied with even and gentle pressure. In conjunc- tion with local measures, a tonic and nourishing plan of general treatment will aid in imparting a healthy character to the ulcer. The mineral acids especially, with cinchona or cascarilla bark, may be given, to remove the constitutional condition, on which the unhealthy state of the granulations often depends. (5.) Indolent, or Callous, and Varicose Ulcers.— A deep and, perhaps, large excavation, presenting a flat surface,— without granu- lations, of a dusky or pale colour, scarcely sensitive to the touch nor disposed to bleed, and having a firm, hard base adherent to the sub- 250 GENERAL PATHOLOGY AND SURGERY. jacent fascia (Fig. 86). A thiu offensive discharge exudes. The edges are everted, thick, and callous, and of an opaque-white colour, owing to accumulated epidermis ; the surrounding integument to some distance is congested, of a dusky hue, and pigment-stained, thickened, hardened, and bound down to the textures beneath. Such an ulcer is obstinately indisposed to heal. It is commonly situated on some part of the leg. An ordinary — non-specific — indolent ulcer does not seem to be dependent on any constitutional disorder ; but it is apt to occur in weakly, ill-nourished, and perhaps ill-fed persons. The varicose ulcer is a variety of indolent ulcer, and so named from its connection with the varicose condition of the adjoining veins. Resembling generally an ordinary indolent ulcer, it differs in certain tolerably distinctive characters. Situated on some part of the leg, commonly on the inner side towards the ankle, and single ; in the recent state it is of small size, ovoid shape, and with its long axis in ^ eg the direction of the limb ; without granu- lations and firm, a bluish-purple colour of the base and more so of the margin and adjoining integument will be noticed, and the ulcer is not uufrequently painful and sensitive. Inflammation and sloughing, or other conditions, may temporarily veil these appearances; but the tortuous, knotty enlargement of the venous trunks, or the more diffused mottling of smaller varicose veins, with, perchance, a brownish-red pig- ment-stained skin around the ulcer, is still a characteristic accompaniment. In the progress of varicose ulcer, an occasional event of practical importance is venous hemorrhage ; arising from the ulceration having penetrated an enlarged vein, it may occur suddenly and copiously. Treatment. — An indolent ulcer cannot cicatrize so long as it and the surrounding integument are both bound down ; the margin being upraised and retracted, and the base depressed. Accordingly, pressure and stimulation together, represent the plan of treatment. The nitrate of silver freely applied to and around the ulcer, or the con- tinued application of zinc ointment, with tolerably firm bandaging, may bring it into a healthy condition. But in this kind of ulcer par- ticularly, iodoform has a most beneficial influence, apparently as a stimulant. The yellow crystals maybe sprinkled on the surface of the sore, or applied iu the form of an impregnated gauze. It is apt, how- ever, sometimes to induce symptoms of poisoning by iodine, especially in childhood, or when the surface is extensive. The effects of this agent must, therefore, be watched, and it may have to be discontinued, as it has occasionally proved fatal. A more even and constant pres- sure is secured by strapping the limb with strips of linen spread with soap-plaster, mixed with a little adhesive plaster to fix it. Drawn around the limb, from the side opposite the sore, each strip in succes- sion should partly overlap the preceding one, and the ends be crossed obliquely ; thus forming a compact casement, and which should extend two or three inches above and below the sore. This is known as INDOLENT AND VAKICOSE ULCERS. 251 Baynton's method of strapping. The strips should be changed every other day, to remove the discharge ; but when the integument has became softened and loosened, so that the sore is beginning to heal, the strapping may be allowed to remain for a week at a time. At length, simple di^essing, and the support of a roller-bandage, will com- plete the cure. The india-rubber bandag-e, introduced by Dr. Henry Martin of Boston, is specially serviceable, in affoi'ding an even and maintained support to a varicose ulcer. Blistering circumferentially, softens and loosens the integument, and may thus tend to facilitate cicatrization. The actual cautery is recommended by Billroth, to induce purulent inflammation, or to destroy the callous edges entirely. A warm-water bath, according to Zeis's practice, has proved very efficacious in softening the dry hardened borders of the ulcer. Incisions have been recommended to allow the granulations to contract ; and, in most obstinate cases, transplantation of a portion of adjoining healthy integument, sufficient to close in the ulcer, may be tried, with the view of forming a substitute cicatrix. Of these resources, I am decidedly in favour of blistering. Opium seems to have some special influence in rendering the granulations florid, and promoting the healing of an indolent ulcer. It is therefore advisable to keep the system under this influence by the repeated administration of opium, in small doses. At the same time, the aid of stimulants, tonics, and a general diet should not be overlooked. When an indolent ulcer has healed, the thin and tense cicatrix may be protected and supported with a pad of lint and bandage, worn as long as may be necessary. The varicose ulcer is amenable to the same plan of treatment ; but the varicose state of the veins, as the apparent cause in operation, is an additional and the special object of treatment. An elevated position of the limb to relieve congestion, and an elastic bandage or stocking to equally support the vessels, will prove sufficient for this purpose, in most instances. When the ulcer has healed, it may still be necessary to wear an elastic stocking, as a preventive measure. In more obstinate cases, and with the view of a permanent cure, oblitera- tion of the veins must be resorted to. Curved incisions may be made, free and deep, on either side of the ulcer-margin, according to the method which Mr. Gay originated, and whereby a twofold principle is fulfilled : the destruction of any circumferential or smaller veins, and relief of the tension of the contracted and indurated skin. Ulcers of from one to twenty years' standing have thus been induced to heal, and with a permanently firm cicatrix. But the larger veins may require obliteration. Of the various m.eans devised — and noticed in connection with Varicose Veins — the safest and most successful, in my experience, is that by siibcidaneeus section of the veins ; with the precaution of a twisted suture, for compression, on either side, to stop any communication with the circulation. A hare-lip pin is passed underneath the vein, and another at a point about an inch distant. Care must be taken that the vessel be not transfixed, a misadventure easily avoided by dipping the pin, and readily discovered by the escape of a drop or two of venous blood. If the vein be transfixed, the pin should be withdrawn and introduced at another point. A ligature of silk or fine whipcord passed round either pin in a figure-of-eight fashion, will com- 252 GENERAL PATHOLOGY AND SURGERY. Fig. 87.*- press the vessel sufficiently to cut off all communication with the venous blood in either direction, and thus isolate the portion of vessel between the pins. Division of the vessel in that situation subcutaneously, as recommended bj Mr. Lee, will then more thoroughly insure its oblitera- tion. (See Veins.) Several such interceptions may be necessary at different points in the course of the saphena vein ; in which case the highest pair of pins should be introduced first. The pins must be allowed to remain for about a week or ten days, unless the superven- tion of ulcerative suppuration should indicate the necessity for with- drawing one or more of the pins at an earlier period. I do not find the tendency to slight ulceration of sufficient importance to require the precaution generally recommended, that of protecting the skin with a piece of bougie before applying the ligature ; for the thread should not be twisted around the pin with any degree of tightness which might strangu- late the skin, and thus necessitate the removal of the suture in perhaps two or three days — before the vein had become obliterated permanently. But having snipped off the pointed end of the pin with small cutting pliers, a strip of oiled lint should be wound underneath both projecting ends, to protect the skin, as some swelling ensues. After this operation, in no case have I seen any perilous consequence, such as phlebitis or pyaemia, but diffuse or erysipelatous inflammation ensued for a while, in one case. In some instances, after the lapse of a year and a half or two years, occlusion of the vein has still been com- plete, a permanently successful result which has allowed of active exercise with comfort ; in other cases, the varicose condition has returned, as the only unfavourable issue ; while in yet a few, it has remained on the removal of the pins, and a repetition of the operation has altogether failed. Venous hsemorrhage, occurring in the course of a varicose ulcer, may be arrested by a compress of lint, secured by a bandage, over the aperture in the vein which has given way ; and by elevation of the limb. (6.) PHAGED2ENIC Ulcee. — Essentially a spreading ulcer, it is characterized by dusky red discolouration and swelling, with perhaps acute pain around the ulcer ; a greyish, glutinous or slimy slough, which exhales a peculiar fetid odour, occupies the surface of the sore, and the edges, sharp, irregular as if worm-eaten, and undermined, fall away rapidly ; thus enlarging and deepening the area of the ulcer (Fig. 87). Sloughing may predominate in such tilceration, and hence sloughing and phagedfenic ulcers are not uncommonly associated. Sooner or later, constitutional disorder ensues ; irritation rather than inflammatory fever, with great weakness and exhaustion. Allied as this ulcer is, in its local and constitutional characters, * Phagedsenic ulcer. Eoyal Free Hospital. (Author.) H^MORKHAGIC ULCER — SCORBUTIC ULCER. 253 to Hospital gangrene, it would seem that phagedena arises from an external cause, — contagious matter applied to a sore ; the constitu- tional disorder being secondary and symptomatic, although in its turn affecting the ulcer. On the other hand, habitual deprivation of food, the abuse of stimulants, or living on spirits, and, perhaps, overcrowd- ing, with destitution, seem also to give rise to phagedaeua. Treatment. — To arrest the rapidly spreading ulceration, a free appli- cation of strong nitric acid, by means of a glass brash, is most effectual. Followed by poultices, the slough, thus formed, is detached, exposing probably a healthy surface, which has acquired a healing' character. Re-application of the acid may be necessary, or the continued applica- tion of yeast, charcoal, or chlorinated poultices may be sufficiently stimulant and cleansing ; and, at the same time, disinfectant. Opium, administered in small and repeated doses, so as to keep the system under its influence, is most potent in allaying* the irritative fever; while the strength of the circulation and healthy nutrition are restored by quinine, the mineral acids, and a generally nourishing diet. (7.) Hjimorrhagic Ulcer. — Any variety of ulcer may assume this character, but some more particularly — e.g. the irritable, phagedgenic, varicose, cancerous, and, perhaps, lupoid ulcers — by the penetration of a blood-vessel ; and the scorbutic ulcer, by passive heemmorhage owing to the blood-condition. N^ot unfi-equently, an ulcer oozes blood about the catarnenial period, and especially in women suffering from amenor- rhcea ; the hgemorrhag-e then being vicarious menstruation. An ulcer thus acquires a blooiiy, clotted appearance. Treatment. — Arising from such various causes, a hgemorrhagic ulcer is a contingency rather than any special variety of ulcer, and should be treated accordingly in connection with whatever ulcer it may be associated, by reference to the particular condition, local or constitutional, which causes the haemorrhagic character. (8.) Scorbutic Ulcer. — rAlthough scurvy in itself, observes Mr. Busk, cannot be said to be attended with any peculiar form of ulcera- tion, ulcers or sores of any kind already existing from other causes assume, in consequence of the scorbutic taint, a more or less peculiar character, and Avhen thus modified have usually been termed " scorbutic ulcers." It is the effusion of a semi-plastic fibrous material — the same as that which causes the spongy swelling of the o-ums, etc. — on the free surface of sores or ulcers, which gives them the peculiar aspect termed scorbutic. Ulcers of this kind are distingnished by their livid colour, and irregular tumid border, around which no trace of cicatriza- tion is evident ; whilst the surface of the sore is covered with a spongy, dark-coloured, strongly adherent, fetid crust, whose removal is attended with free bleeding, and is followed by a rapid reproduction of the same material. This crust, in bad cases, as remarked by Lind, attains to a " monstrous size," and constitutes what has been named by sailors "bullock's liver." Treatment. — Regarding a scorbutic ulcer as but a manifestation of the blood-disease — scurvy, the appropriate treatment is that which pertains to this disease ; and having regard to its apparent dietetic cause, namely, the deprivation of fresh vegetables, remedial measures will consist, chiefly, in their restoration. Hence the well-known efficacy, preventive and curative, of potatoes and of lemon or lime juice. This dietetic treatment may be aided, medicinally, by the 254 GENERAL PATHOLOGY AND SURGERY. mineral acids and bark ; and, as a topical application, a lotion of dilate nitro-muriatic acid has an astringent and cleansing effect on the ulcer. (9.) Scrofulous or Strumous Ulcer. — Consequent on the ulcera- tion of a scrofulous tubercular swelling, or the opening of a scrofulous abscess, the ulcer is remarkably indolent, yet its characters are unlike those of the ordinary indolent ulcer. Large, pale, flabby gi-anulations, sometimes exuberant, form the surface of the sore, with a thin puriform discharge ; the margin is thin, livid, and undermined, sometimes pre- tending to heal by incrustation of the discharge. The characters and tendency are those of an ordinary oedematous ulcer; but a scrofulous ulcer is even less disposed to heal soundly. A scrofulous cicatrix appears drawn, puckered, and incomplete. Small bridges form across _ „_ the ulcer, underneath which a probe can be passed readily, in and out, here and there (Fig. 88). Nature does but "skin and filra the ulcerous spot." The co-existence of indolent glandular swellings and abscess, in other parts, will complete the diagnosis. Scrofulous ulcers are most frequent in the neck, groins, cheeks, scalp ; and about the knee, ankle, wrist, and elbow. They are often niimerousand clustered. The immediate cause in operation would appear to be a blood -disease, the nature of which how^ever is un- known. But whatever impairs the nutritive qualities of the blood and its circulation, predisposes to scrofula. Hence deficient or defective food, in- sufficient ventilation, want of cleanliness and excretion, poor clothing, cold, damp, and even dark localities, with other hygienic conditions of similar import, are the nurseries and nurses of this blood-disease. Individual predisposition, as usual, plays its part ; for among a family of children in precisely the same hygienic circumstances, one becomes scrofulous, while the rest remain free. Treatment. — In addition to the removal of any adverse hygienic condition, iron, bark, and cod-liver oil are calculated to strengthen the circulation and improve nutrition. The digestive organs will also require watchful attention. A stimulating plan of treatment with moderate pressure on the ulcer is appropriate, as for an oedematous ulcer. Thus, nitrate of silver or sulphate of copper, and bandaging, are beneficial as topical appliances ; but the more important part of the treatment is constitutional. The scar of a strumous ulcer is unsightly, and may occasion defor- mity, either by contraction, or, more commonly, by overgrowth, and the formation of bars raised in radiating lines, or networks, or tongues of skin. In such cases, observes Sir James Jfaget, excision of the scar may be necessary ; but in many instances a great portion of the excess of scar can be removed by repeated slight blistering, a^nd with time nearly the whole will level down. In a superficial scrofulous ulcer on the hands or feet, excessive growth of the papillce at the base or borders of the ulcer, gives a CANCEROUS ULCER — LUPOID ULCER. 255 remarkably warty character to tlie ulcer ; wliicli often remaining after cicatrization, leaves a coarse, nodular patch of skin, with opaque, thick cuticle. In this particular resembling a papillary epithelial cancer, the diagnosis of this form of scrofulous ulcer may be determ.ined, by the absence of hardness in the granulations or the base, of a sinuous or upraised border, and of rapidity of progress ; and by the presence of more than one, perhaps many such ulcers. These warty strumous affections may be cured by repeated applica- tions of iodine-paint. (10.) Cancerous Ulcer. — Already described in this work, as part of the general history of cancer, the characters of a cancerous ulcer are here alluded to as compared with those of a lupoid ulcer. The scirrhous ulcer is most distinctive. Beginning in the skin and extend- ing down to deeper textures, or commencing subcataneously — in a cancerous mass, and extending upwards to and involving the skin — the ulcer, formed in either way, presents an irregular cavity, the surface of which is covered with large, hard granulations, discharging a thin, peculiar-smelling ichor; the edges are elevated, thick, and everted, with much circumferential induration. (See Tumours.) The neigh- bouring lymphatic glands are, or become, indurated, and enlarged. The ravages of this ulcer are unlimited. Treatment. — See Cancer. (11.) Lupoid Ulcer. — Commencing as a fissure or soft wart, the ulcer formed is an excavated hollow, having, commonly, no granula- tions, the edges sharp and worm-eaten, with no induration around. The lymphatic glands are unaffected. But this ulcer, also, spreads and spares no texture. It is the true Lupus Exedens, or the disease known also as " noli me tangere," owing to the frightful appear- ance which is at length exhibited. This disease commences in the earlier half of life, sometimes in childhood, very rarely after middle age ; and females are rather more liable to it than males. It is allied to scrofula. As contrasted with a cancerous ulcer, the differential characters, above stated, were early impressed on my mind by two well-marked cases which I observed when a student at the University College Hospital. The one, an elderly woman — under the care of Mr. Morton — had a large cancerous ulcer of the leg, which presented the appear- ances I have described; the other, a middle-aged man, an ostler — under the care of Mr. Liston — had a large lupoid ulcer of the cheek, with the appearances already noticed, — namely, opposite to those of a cancerous ulcer. Treatment. — Various powerful escharotics have been tried with the view of arresting the progress of a lupoid ulcer, and converting it into a healing condition. Caustic potash is very serviceable, as it readily unites with the tissues. Chloride of zinc, mixed with flour and form- ing a paste by deliquescence, was used in Mr. Liston's case. The intense pain, for a time, which followed its application, would nowa- days be subdued by the continued influence of chloroform. Subse- quently, poultices help to bring away the slough. Further extension of the ulcer may be thus arrested, and the cavity evince a tendency, at least, to heal. This favourable change took place in the case alluded to, and I have since met with similar instances. Cicatrization may ensue. Iron, bark, and cod-liver oil, with other means of improving 256 GENERAL PATHOLOGY AND SURGERY. nutrition, have a decidedly beneficial influence. The disease seldom returns in the cicatrix, but lupoid nodules often reappear in the imme- diate neighbourhood. These admit of early excision, as a preferable mode of removal to the more wide-spread destruction i-esulting from cauterization. (12.) Rodent Ulcer. — Vai-iously named, as Rodent Cancer, Can- croid Ulcer, or Lupus Exedens, the nature of this ulcer is disputed. Thiersch, of Erlangen, originally described the disease as " flat or superficial epithelial cancel'," and Dr. C. Warren, of Boston, regards it as a modification of epithelial cancer, but distinguished as the small-celled and non-infiltrating form, and the progress of which is very slow. The growth, as rodent epithelioma, is said to originate from the external root-sheath of the hair-follicles — the involuted layer of the rete mucosum.* On the other hand, Mr. Jonathan Hutchinson and Sir James Paget have failed to find in rodent ulcer any of the structui^al elements of cancer, epithelial or scirrhous. It consists of fibroid tissue, with numerous nucleated exudation-cells ; and the latter observer considers the growth to consist of granulation- tissue. There can be no doubt, however, of the affinity of rodent ulcer and epithelioma, both in their clinical and histological charac- ters, to which Lebert drew attention, under the name of Cancroid. j,^^ gg But, Dr. George Thin {loc. cit.) expresses his belief, as the result of careful examination, that the disease is an "adenoma of the sweat glands." Commencing as a troublesome pimple, situated generally near the nose or inner angle of the eye, this may disappear and return, during a period of some months or years ; at length, a small, super- ficial ulcer forms, having a raised and hardened margin, set in healthy tissue (Fig. 89). Pro- gressing slowly, as a fretting ulceration, it spreads to the nose or eyelid, yet sparing the eye until a later period ; extending in depth, the ulcei'ation destroys the nose and bones of the f;)ee, nassing backwards even to the pharynx, and thus forming a hideous chasm, overspread with a greyish pul- taceous matter. Similar ulcers are said to have occurred on the breast, and external genitals, but such cases are doubtful. Rodent ulcer rarely appears under forty years of age ; and both sexes are about equally liable. No kind of treatment has any curative efficacy. At an early period, * " Eodent Tjlcer," by W. Tilbtu?y Fox, M.D., and T. C. Fox, M.B. Trans. Path Soc, Lond., vol. xxx. t Eodent ulcer. Hospital of Pennsylvania. From cliromo-lithograph in " International Cyclopaedia of Surgery." — " Tumours ; " an excellent article by H. T. Butlin. GANGKENE AND MOKTIFICATION. 257 the part may be excised ; or cauterization, with fuming nitric acid, may have some beneficial influence in temporarily arresting the spread of ulceration. Any portion of loosened bone had better be removed, iu order to preserve a cleaner surface, and which lies perhaps beyond the reach of detergent washes. From the carious cavity of deep ulceration I have removed, with forceps, several large portions of loosened bone, blackened, sodden, and fetid; or entire bones, as the ethmoid, save the cribi-iform plate, with the vomer, or the maxillary antrum and the palate bone. No hemorrhage attends such procedures. (13.) Syphilitic Ulcer.— Primary, secondary, and tertiary syphi- litic ulcers form part of the general pathology of Syphilis. Mortification. — The transition of ulceration to mortification, as ah'eady noticed, will have suggested their mutual relation. As pro- cesses, they differ in degree, but are one in kind. The former may be exaggerated into the latter, and this again may subside into that. Ulceration and mortification are convertible by gradations of the same process, disintegration of structure ; the one, molecular, as a liquid discharge ; the other en masse, presenting accumulations of disinte- grated matter. Thus, during ulceration, ever and anon some tem- FiG. 90.* porary cause may accelerate the process; a larger portion of tissue undergoes disintegration than can pass away as discharge ; a portion of such matter then appears as slough, instead of having disappeared imperceptibly — molecule after molecule — in ichorous solution. It is as if the "flow " of a tidal stream washed up more material than the returning " ebb " can well recover — the line of coast shows the remain- ing debris. Even so, the surface of an ulcer may present a rim of slough, and from time to time, another and another, as the margin of the sore recedes and extends. Signs. — Gangrene, or the incipient stage of mortification, exhibits certain characteristic appearances. The skin is livid or has a black hue, shading off to a reddish brown around the dying part. Its con- sistence is changed ; becoming soft, with considerable swelling and pitting on pressure, while the cuticle is raised into vesicles containing a yellowish serum, or phlyctense — large blebs or bladders, full of bloody serum. The part is, in fact, altogether sodden and succulent, from the infiltration of the constituent cellular texture with serum. This condition is the humid gangrene of French authors, the hot of German writers, and the aciite of our own school (Fig. 90). Or the part may be hard, shrunken, and dry ; an opposite condition, known as * Traumatic humid gangrene. (After Liston.) VOL. I. S 258 GENERAL PATHOLOGY AND SURGERY. dry, cold, or chronic gangrene (Fig. 91). la either state, the sensi- bility of the part is diminished, and its temperature reduced. The odour of gangrene is peculiar and pungent ; it becomes fetid Avith the evolution of gas by decomposition, which, inflating the cellular texture, much increases the swelling ; and owing to the admixture of gas and serum, it then has the additional character of crackling under gentle pressure, or of fluctuation like a collection of pus, if the deeper textures be thus distended. The part is irrecoverably dead ; mortifi- cation having advanced to its second and furthest stage — the condition of sphacelus. The textures, in this condition also, may be dry and shrunken ; as in senile gangrene which has advanced to sphacelus. In either case the part is insensible and cold. The anatomical condition of sphacelus is somewhat peculiar. The cuticle, removed perhaps in parts, readily separates, or slides off, — in humid g'angrene, and the subjacent skin, of a brownish-black colour, may have become dry and coriaceous, from exposure, — having a Fig. 91.* mummified appearance. This state of the integument is always seen in the dry condition of gangrene. Disintegration of the soft textures prevails more or less uniformly, with various shades of discolouration, from an ash-grey or dirty brown, to olive green or black. In humid gangrene, the broken-doT\Ti textures are succulent with bloody or brownish serous fluid, and may crackle under the fingers, from com- mingling of the gases generated by decomposition. The bones have undergone but little change, otherwise than appearing dry and blood- less, their periosteum being detached ; but the articular cartilages and tendons are dull and slightly softened. The blood-vessels alone may have escaped destruction. Thus, phlegmonous erysipelas may have laid bare several inches of the femoral artery, by sphacelus of the integuments, and yet that vessel remain intact. The blood also — stagnant and coagulated therein, after death — may remain fluid and circulating during life; or, coagulation having taken place, the* vessel will be impervious, and perhaps to some distance above the seat of sphacelus. Hence the absence of hgemorrhage during amputation in such cases. When the blood has become stagnant, it is the seat of the earliest change in the course of textural disintegration and de- composition. The blood-corpuscles are thus destroyed; and the * Senile dry gangrene. (After Liston.) GANGRENE AND MOETIFICATION. 259 red corpuscles yielding up their haemoglobin, this molecular matter transudes through the vessels, staining their coats with a pinkish- red hue, — unlike any form of vascular hvperfemia, and chiefly producing the various discolourations of the soft textures, by changes in the transuded colouring matter. Causes — External and Internal; and their Operation. — The patho- logy of ulceration and mortification being essentially the same, their etiology also is the same. External causes are of three kinds : physical — as mechanical violence and injury, heat, cold, electricity ; chemical decomposing agents ; and vital, as animal poisons introduced into any living texture. Either of these external causes may immediately kill the part, or kill, if the tissue be vascular, by inflammation supervening and terminating, perhaps speedily, in ulceration or in mortification. (1.) Violence or injury of any kind may give rise to gangrene, which is thence denominated traumatic. It is thus distinguished from gan- grene arising from any internal, and commonly constitutional disease — e.g. a blood-condition; and which, as a local manifestation of that disease, is thence named idiopathic gangrene. This distinction is noticed, more particularly, in connection with contusion and contused wounds. Of traumatic causes, pressure or contusion, directly applied, severely although momentarily, as by a squeeze, kills the part immediately. A finger caught in the hinge of a door may thus be squeezed to death. Pressure, continued, although less severe, excites gangrenous inflam- mation. In either case, mortification is limited to the part injured. Indirect contusion or concussion, as by a fall, produces either gangrene or gangrenous inflammation; and the mortification will be more extensive, although still co-extensive only with the part injured. But the damage done to the smaller blood-vessels by concussion, may be far more extensive than could have been anticipated. Sir B. Brodie relates a very instructive case. A poor boy, in jumping over a ditch, fell with considerable force upon his feet, producing a com- pound fracture of the leg above the ankle. Although the external wound was trifling, the foot and leg evidently sustained a great shock. Four days after, the limb had undergone mortification as high as the knee, and it seemed to be extending to the thigh. Amputation was performed near the great trochanter. The limb was very carefully dissected. Arteries of the largest size, and their companion veins, Avere quite pervious. In fact, no injury whatever of these vessels could be discovered; but the cellular membrane, the muscles, and, in short, all the structures, seemed to be more or less disorganized. There were spots of ecchymosis in the large nerves ; the periosteum w^as universally detached from the fibula, and very nearly so from the tibia. Pressure or contusion — applied directly or indirectly — chiefly injures the capillary vessels and smaller arteries ; but traumatic gangrene more frequently arises from injury to larger-sized blood- vessels. Considerable haemorrhage takes place, causing gangrene, partly by pressure of the blood extravasated amonsf the textures, partly or principally by cessation of the supply of blood requisite for nutrition. Wounds implicating the larger blood-vessels, compound fracture, and dislocation, especially operate in this way. Gangrene 260 GENERAL PATHOLOGY AND SURGERY. is not necessarily limited to the immediate and apparent seat of injury ; it may exteud — e.g. up a whole limb, but still only as high as the cause in operation. Heat, cold, and electricity require no further considei-a- tion as causes of mortification, than that they operate, either by killing outright, or by inducing gangrenous inflammation ; cold, however, not seeming to have the power of killing a part at once. A frost-bitten or frozen portion of the body is not irrecoverably dead. (2.) Chemical decomposing agents, on the other hand, mostly take effect by kilHng immediately — decomposing the living tissues with which they come in contact. Such are caustic alkalies, the concen- trated mineral acids, and other escharotics. (3.) Animal poisons inti'oduced into the body, ai-e genei-ally less immediately killing to the part — i.e. they induce gangrenous inflam- mation. Bites of venomous serpents represent this class. Internal causes are perversions of the constituent elements of nutrition. Blood of a certain "quality," suitable to each part for its nourishment, and a certain "quantity " of this blood supplied to and circulated through the part ; " an appropriate physical and structural condition of the part itself ; " and some kind of " nervous influence ; " — these are the internal conditions which, when perverted, become internal causes of mortification. (1.) Blood-conditions, by altei-ations of quality, are eminently con- stitutional causes. Their pathological nature is but little understood ; but their local manifestations in gangi-ene, having characteristic appearances, are well known. Some of these blood-conditions were alluded to, in speaking of the varieties of ulcers as depending on constitutional causes. Other such causes more especially give rise to mortification, in various remarkable foi-ms. Thus are produced carbuncle, boil, and the carbuncle of plague; phlegmonous erysipelas, bloody small-pox, malignant scarlatina; glanders, ergotism, scorbutic sloughing, noma or cancrnm oris, the phagedsenic and sloughing buboes of svphilis. Other diseases of, or involving, the blood evince a tendency to gangi^ene ; as manifested in iira^mia, diabetes mellitus, septicaemia, typhus, and other fevers. Of these gangrenous diseases, those which fall within the province of surgical treatment will be described under the titles refen-ed to. As an example of pure gan- grene, from blood-disease, the following may be here noticed : — Ergotism results in gangrene of the toes or the fingers, from eating bread made with the ergot of I'ye. The symptoms ai-e peculiar; red- ness and heat, with a tingling itching or crawling sensation in the skin, or sometimes a burning pnin, succeeded in a few days by a sensation of cold, then loss of sensibility, and the part becomes black, hard, dry. and withered, — an extreme form of dry gangrene. But a humid and putrid gangrene has been known to occur. The toes are more commonly affected than the fingei's ; and the gangrene may spread up the foot and leg, even to tlie thigh, so that both lower extremities, black and dry as charcoal, and shrivelled, have resembled the remains of Egyptian mummies. The fever attending this gangrene is more or less pronounced, and sometimes accompanied with much delirium. Separation of the dead parts may be attended with an excruciating burning pain, followed perhaps by a distressing sensation of cold. An acute ami a chronic form of the disease have been recog- nized ; the former being distinguished perhaps by severe general GANGRENE AND MORTIFICATION. 261 cramps, and death ensuing in from four to eigbt days; while, in the latter, the patient usually survives, though vrith the loss of toes or fingers. According to Duhamel's memoir in the Royal Academy of Sciences, 1748, in 120 cases, not more than four or five recovered. Post-mortem examination shows congestion of the brain, liver, and lungs; the blood also, apparently, has undergone some change, pre- disposing to haemorrhage. This morbid blood-condition, whatever it may be, is probably the essential cause of gangrene ; although contraction of the smaller arteries may have some co-operative influ- ence. Both these pathological changes are produced by a diseased state of the rye-grain — known as ergot, or spurred rye — when eaten as bread. In this state, the grain is of large size, has a black X!olour, and horny consistence. But a similar diseased state of wheat may be equally pernicious. The gangrene induced by such food is peculiar to wet seasons and certain localities. First described with accuracy by Dodard, as having occurred in France, 1G30, ergotism is uncommon in Germany, Italy, or England. Mortification arising from any blood-disease spi'^ads without limita- tion, as to its extent. (2.) The quantity of blood supplied to and circulated through any part depends upon, and is regulated by, the heart's mechanism and action, the state of the blood-vascular system — arteries, veins, and capillaries — and the physical condition of the blood itself, chiefly in respect of its spissitude and adhesiveness. These conditions are severally, and collectively, more or less causes of mortification. Of diseases and malformations of the heart, their influence in rela- tion to mortification is impressively illustrated by a probably unique casC:, — gangTene of both feet in a boy (like Fig. 91), arising from dilatation of the auriculo-ventricular opening, and of the auricle and ventricle, ,oa the right side of the heart. Double amputation, which I performed by modifications of Hey's and Chopart's operations, was followed by speedy recovery, with sound stumps ; but death ensued from cardiac and pulmonary conditions, — j^eriearditis, capillary bx'onchitis, and pleurisy.* Ancemia, with weakness of the heart's action, is a rare cause of gangrene. Both feet, as the parts most distant in the circulation, are specially liable to be affected. This antemic gangrene occurs some- times in young chlorotic females ; the premonitory symptom* being fatigue, fainting fits, and rigidity of the hands and the feet. In one case, Billroth noticed that the tip of the nose first became gangi'enous. (a.) Arteries are liable to undergo changes of structure, which are particularly worthy of notice surgically. Ossification or calcareous degeneration of the larger arteries, with fibrous thickening of the smaller ones, is accompanied with a more or less inelastic and contracted state of the vessels, thus leading to coagu- lation of the blood, in tubes which have become too narrow and rigid for the transmission of that fluid, and in quantity adequate to meet varying demands. This condition represents the changes of structure concerned in producing " senile " gangrene,^a diy form of mortifica- tion, commonly aifecting the foot, when the arteries of the leg have undergone these changes. Some slight injury, followed by low inflammation, is usually the immediate or exciting cause in such * Trans. Qlin. Soc, 1872. • 262 GENERAL PATHOLOGY AND SURGERY. cases. Traumatic gangrenous inflammation is, in fact, engrafted on the state of the arteries, as a predisposing condition. Mortilication, commencing genei-ally in a part most distant from the heart, as the ball of the great toe, and thence spreading upwards, gradually assumes the appearance of a black slipper on the foot. (See Fig. 91.) Arteritis — inflammation of an artery — is a far less frequent cause ; it acts in a similar manner, and may induce gangrene of the same character, or more dry and h'orny. Fibrinous coagulum may form as a thrombus Avithin an artery, either by the deposition of fibrin around a calcareous projection from the interior, or in a sacculated dilatation of the vessel ; in either way the clot, gathering moi-e fibrin, advances into the artery, so as at length to entirely plug up the canal. Or, instead of arterial thrombosis, the coagulum may not have formed in the artery where it is found im- pacted, but have been washed from the left ventricle of the heart and carried thence by the current of blood to that vessel ; such a clot being known as an embolus, and an ai-tery thus impacted with clot, as embolism. The gangrene arising from either of these modes of arterial occlusion may be dry or moist, according to the rapidity and complete- ness of clot-formation or impaction. Eupture of the internal and middle coats of a large artery, by violence, will also induce coagulation ; the loose portion folding inward across the stream of blood. There are two specimens of this lesion in the Museum of St. Bartholomew's. Mortification is liable to supervene. Aneurism is another cause ; partly by interrupting the free flow of arterial blood through the aneurismal artery, and partly, by pressure on adjacent veins, obstructing the return of venous blood. Popliteal aneurism will thus induce gangrene, which soon passes into sphacelus. Presstire on a main artery may also induce gangrene in the part supplied — distal in the course of the circulation. A tumour may act in this way ; or the surgical application of a ligature have the same effect ; compression of the artery impeding, or cutting off, the supply of arterial blood. Wound of a main artery acts in two ways. A punctured wound is sometimes an immediate cause, by loss of blood ; gangrene taking place in the extremities. Sir B. Brodie mentions the case of a drunken man, who was bled profusely, and both feet became gangrenous in a few- hours. A contusion or bruise may lead to sloughing of the ve.=sel, after some days have elapsed ; this being" attended with hsemorrhage and false aneurism, followed by mortification. Laceration of the vessel may, in like manner, have the same issue. In either case, the integu- ments may have escaped injury. Simple fracture, and perhaps simple dislocation, will thus lead to mortification, occasionally ; compound fracture and dislocation, far more frequently. In any case of interrupted or arrested supply of blood through a main artery, the sudden even more than the persistent operation of such cause, will tend to induce gangrene ; by not allowing time for the substitution of a collateral cii'culation. It is highly important to observe the partial extent to which gan- grene spreads, in connection with all these vascular lesions, as con- trasted with gangrene arising from any constitutional cause. Unlimited in that case, it is here limited in extent to the source of gangrene, and GANGEENE AND MORTIFICATION. 263 probably restricted to less than that extent, by the enlargement of branches coming from the artery above the seat of injary, which supply a collateral and compensatory circulation of blood. Thus limited is the gangrene arising from the ossification of arteries, or senile gan- grene; from arteritis; from thrombosis, or from embolism; from partial rupture of an artery ; from aneurism; from wound of an artery, whether punctured, contused, or lacerated ; and from ligature. But, then, the limitation connected with some of these causes — the point to which o-angrene may extend — can scarcely be determined during life. This is the practical ground of distinction between senile gangrene, arising from ossification of the arterial vessels, and traumatic gangrene ; and in favour of the latter, the limitation of which can be more definitely predicated. Failing this foreknowledge, the Surgeon must wait the "line of demarcation," drawn by nature. (b.) Veins are less liable to become causes of mortification ; obstruc- tion to the return of venous blood from any part of the body, having a less important relation in this respect, than obstruction to the supply of arterial blood. Gangrene arising from venous obstruction is always the humid or moist condition ; more or less fluid being retained, and infiltrating the part. PMehitis induces coagulation of blood within the vein or veins in- flamed, and this obstruction is attended with cedematous swelling of the limb or part below. The swelling becomes tense and persistent, a condition bordering on gangrene. Phlegmasia dolens, in w^hich the iliac and femoral veins, the main venous trunks of the limb, are inflamed, thus perils the leg below. Fibrous obliteration of a venous trunk is another such cause, once in a way, of tense anasarca. In a case reported by Dr. J. W. Ogle,* the entire vena cava was filled with firm, fibrinous, indurated material, and was shrunken and reduced to the state of a dense thick cord. This condition appeared to be of long duration, as the contained material was with great difficulty separable. A considerable quantity of soft recent fibrin blocked up the left external iliac vein. PMeboliths or vein-stones, not unfrequently formed within various veins, more particularly the iliac, have a similar tendency to produce venous obstruction. An ossified calcareous deposit, of unusual size, that occupied the common iliac vein, is described by Dr. Ogle fas having measured about two inches in length, and tapering to its extremities from the middle part, which was between one quarter and one half of an inch in thickness. Fortunately, however, in most instances, w^hen venous obstruction has been gradually established, an adequate compensation is provided, by the contemporaneous enlarge- ment of other veins, through which the blood flows without impedi- ment. The sufficiency of this provision to prevent anasarca is shown in cases of old-standing, yet complete, obliteration of the inferior vena cava. Such cases are described by Matthew Baillie J and Mr. James Wilson. || Aneurisrnal varix and varicose aneurism, resulting from a com- munication between an artery and a companion vein, as from un- skilful venesection at the bend of the elbow, is attended with venous * Trcms. Path. Soc, London, vol. vii. t Ibid. X Trans. Soc. for Improvement of Med. a«d Chir. Knovjledge, vol. i. p. 127. II Ibid., vol. iii. p. 65. • 264 GENERAL PATHOLOGY AND SURGERY. engorgement, persistent and increasing, and cedematous swelling of the limb below, threatening gangrene. Prolonged pressure on a large vein, itself in a healthy state, is an extraneous canse of obstruction to the return of venous blood. Tumours may thus, indirectly, have this effect in relation to mortifica- tion. But, usually, pressure produces an entire arrest of the circula- tion, arterial and venous ; as by the application of a tight bandage at the elbow, after venesection, causing gangrene of the hand ; the con- striction of paraphimosis leads to gangrenous inflammation of the prepuce; and a hernial stricture induces gangrene of the included bowel or omentum. On any exposed part of the body, the influence of prolonged pressure is witnessed in the formation of ulcers, as bed-sores. The limitation of gangrene is no less characteristic of that which arises from obstruction in the course of a large vein, than from obstruc- tion of a main artery ; the gangrene, in either case, extending possibly up to, and probably within, that situation. Thus hoth classes of causes, those pertaining to the arteries and those pertaining to the veins, concur ; and differ from any constitu- tional cause, in relation to gangrene. But the limitation dependent on some venous causes, like that dependent on certain arterial causes, can scarcely he foreseen. Diseased conditions of veins are more often perplexing in this respect, as com- pared with any tendency to gangrene of traumatic origin from injury to a large vein. (c.) Capillaries. — Compression of these vessels is followed by gan- grene of the part, if thereby deprived of a due supply of blood. Inflammation, therefore, with lymph-production, and compression of the capillary vessels, reacts destructively upon the textures. More- over, inflammatory products, for the most part, are inherently short- lived. And especially during suppuration, the surrounding textures are dying, disintegi'ating, and being absorbed to make room for the new pi oduct — pus ; destruction and production here usually keep- ing pace. Hence the formation of abscess necessarily presupposes the death and absorption of the textures around ; and co-extensively with the foimation of pus, which now occupies their place. Sometimes, they die faster than absorption can remove them, and then their mortification — as sloughing of the soft textures or a sequestrum of dead bone — becomes plainly visible. Certain conditions predispose to gangx'enous inflammation. Blood- poisons are constitutional causes of this kind ; as in the production of carbuncle and boil, phlegmonous erysipelas, and the other forms of gangi'enous inflammation, already mentioned in connection with the constitutional causes of mortification. Intensity of inflammation has a similar tendency. And lastly, the vascularity of the texture affected ; a comparatively avascular tissue readily becoming gangrenous, and especially if looseness of texture permit the accumulation of serum, as the cellular tissue in erysipelas ; but any texture will be perilled under the pressure of effusion beneath an unyielding investment, as the tendinous expansion of the occipito-frontalis muscle. (3.) Physical and structural conditions of the part relative to mortification in g-eneral. Of physical properties ; an uvTjieldinri fascia or aponeurosis, e.g. GANGRENE AND MORTIFICATION. 265 the fascia lata, predisposes subjacent textures to gangrene, by pressure in the event of any effusion of blood or serum therein. Looseness of textui"e also predisposes to this issue, by favouring an interstitial accumulation of blood or serum. Traumatic gangrene is determined, partly, by these physical conditions impeding the nutrition of the part; although mainly, by the insufficient circulation of blood depriving it of adequate nourishment, and by the damage which the textures have, directly or indirectly, sustained by violence. Structural conditions predispose to mortification ; the. proportion of blood-vessels having this relation. Both extremes meet. Thus, comparatively avascular textures have a tendency to gangrene ; e.g., the liability of cellular texture to slough, from any cause. Highly vascular textures also have a similar tendency, apparently by favouring the intensity of inflamma- tion and effusion ; e.g., the skin as compared with fibrous or tendinous textures, which often resist sloughing' long after the integument has disappeared in consequence of an extensive burn. Predisposition to gangrene from textural conditions is most con- spicuous when they are co-operative causes. Cellular texture, for ex- ample, being comparatively avascular, as well as liable by its looseness to become the seat of interstitial effusions, most readily sloughs. Causes of Ulceration. — By some variation in the degree of any cause of Mortification, this process of mass-disintegration subsides into that of molecular disintegration. Ulceration is mortification by small instal- ments. Consequently, similar conditions of texture predispose thereto. Thus, with regard to vascularity ; the less vascular textures are prone to ulcerate, as well as mortify, — e.g. cellular texture and cicatrix tissue ; in this respect agreeing with the liability of the higlily vascular skin, and mucous membrane, to inflammation and thence to ulceration. The comparative liability of different textures to ulceration and mortification, is well shown in the natural process by which a dead limb is gradually separated from the living tissues ; they detaching themselves fi'oni the dead. All, excepting the cellular texture and tendons, are severed by ulceration forming a fissure, which is pro- gressively incisive down to and through the bone. The dead skin, vessels, muscular tissue, and bone are severally detached evenly, by ulceration ; but the cellular texture and tendons die for some distance upwards within the stump, and are separated irregularly, by sloughing'. (4.) Nervous influence, of some kind, plays an important part in mortification and ulceration. For example, injury to the spine has been followed within twenty-four hours by mortification of the ankle (Brodie) ; and the tendency to ulceration in such a case, or of the cornea in connection with facial paralysis, is equally remarkable. A preparation in the Museum of St. Bartholomew's Hospital is thus referred to by Sir James Paget : — A central penetrating ulcer of the cornea formed in consequence of destruction of the trunk of the trigeminal nerve by the pressure of a tumour near the pons varolii. The whole nutrition of the corresponding side of the face became impaired, the patient had repeated attacks of erysipelatous inflamma- tion, bleeding from the nose, and at length destructive inflammation of the coats of the eye, and this ulceration of the cornea. An instance of ulceration and reparation, alternating with the operation and removal of the occasion of pressure on a large nerve, came under Mr. Hilton's observation ; and it affords a clinching proof that the 266 GENERAL PATHOLOGY AND SURGERY. death of tissues may arise from defective nervous influence. A man was admitted into Guy's Hospital Avith fracture at the lower end of the radius; it reunited with an excessive quantity of new bone, and the median nerve suffered compression. Ulceration of the thumb, fore and middle fingers, ensued, which resisted various treatment, and was cured only by so bending the wrist that, the muscles on the palmar aspect being relaxed, the pressure on the nerve ceased. Theii the ulcers healed and remained well ; but as soon as the man began to use his hand, pressure on the nerve was renewed, and ulceration of the parts supplied by them returned. Considering the whole internal etiology of mortification and ulcera- tion practically, the most important general fact is the co-operation, usually, of two or more causes, in either mode of textural death ; whereby it is difficult to determine the share due to each internal condition, more especially in conjunction with the operation of external circumstances, such as moisture, temperature, etc. Tlie Fever of Mortification. — Coincident with mortification, as the local disorganization, the constitutional disorder at once commences. Its phenomena or symptoms are generally more insidious, but not unlike those of Pygemia, though differing in degree. The patient has a wild apprehensive look, with great restlessness; the features and manner at length become somewhat composed, and the face assumes a pallid hue. In some cases, the tunicse conjunctiva?, and the skin over the whole body, acquire a peculiar yellow colour. Utter prostration of mind and muscular power gradually supervenes, and a quivering subsultus tendinum steals over the body. The pulse is now very feeble, rapid, and irregular, feeling like a fine rough wire drawn under the finger, and perhaps scarcely to be distinguished fi-ora the vibrating subsultus of the adjoining tendons. The secretions are soon perverted. The skin, at first hot and dry, is afterwards bathed with a cold, clammy sweat. The urine, fetid and scanty, may be suppressed. A brown, rough, dry tongue with black sordes encrusting the lips, is accompanied with nausea and a putrid diarrhoea. The powers of organic and of animal life failing, involuntary excito-motions prevail ; spasms and convulsions shake the moribund frame, while coma ends in death. Post-mortem examination reveals no appreciable morbid conditions, although Billroth states that, in some cases, putrid abscesses have been found in the lungs. Or, the mortification ceases to spread. The reddish-brown tint of the skin bordering the dead part, and which has hitherto spread in advance, gets brighter and more circumscribed ; accompanied with some swelling or tension, increased temperature and tenderness, pricking or burning pain,- — these changes denoting an inflammatory afflux of blood around the seat of mortification. In contrast with this activity of the circulation, the dead part presents the blackish hue of sphacelus ; it is soft, or mummified, according' to the more or less succulent state of the textures, in the latter condition also appearing somewhat shrunken below the level of the living part ; and it always feels cold, and is insensible to the touch. A white raised line — the "line of demarcation" — forms in the living skin immediately adjoining the dead ; it melts into a gi-ove by ulceration, which extend- ing deeper and deeper, as a fissure, successively passes through tissue after tissue, and at length converging, completely detaches the whole GANGEENE AND MORTIFICATION. 267 of the dead part (Fig. 91). Pending this course of severance fi'om the living organism, adhesive inflammation precedes the line of nlcera- tion, and, corresponding to it in length and depth, seals the blood- vessels ; thus efllectnally excluding any further communication with the dead tissues, and preventing their absorption for the time to come. The typhoid fever immediately begins to subside, and ultimately ceases. In exchange, some degree of " inflammatory fever " accom- panies the concurrent process of ulcerative separation and plastic closure of the vessels. After the detachment of the dead part, the sur- face left is a healthy granulating ulcer ; and the process of granulation more or less completely restores the loss sustained by mortification. Such is a descriptive outline of the origin, course, and termination, fatal or favourable, of the constitutional disorder proceeding from mortification. Arising -with spreading" gangrene, it ceases when the dead part is detached from the living body. Respecting the obvious dependence of this fever on mortification ; these two general facts, taken conjointly, seem to warrant the conclusion that absoi'ption of the dead tissues as the connecting link is the immediate cause of the fever. The presence of g'as, as decomposition supervenes on sphacelus, is probably a co-operative cause, subsequently, by its direct influence on the nervous system. The following" significant case occurred in the practice of Sir B. Brodie: — "I was called," said he, "to see a gentle- man who appeared to be actually on the point of death. His extremi- ties were cold, his pulse barely perceptible. It was doubtful whether he was sensible or not. Below the right hypochondrium there was a considerable tumour, the skin being of a dai'k red colour, on the verge of mortification. On examination with the fingers, I perceived a sort of emphysematous crackling, and an imperfect fluctuation. Having made a free incision, I discovered, underneath the discoloured skin, what might be called a quagmire of slough. A small quantity of putrid matter escaped ; but there escaped also such a quantity of noisome and offensive gas, apparently sulphuretted hydrogen, that I could scarcely bear to remain in the room. The stench pervaded the whole house, and even could be perceived in the garden round it. Within two minutes after the performance of this operation, so trifling in appearance, so important in reality, the patient looked up, and said quite distinctly, 'What is that you have done which has made so great a difference in my feelings ? ' At the same time the pulse returned at the wrist ; and from that moment he recovered, without any further unfavourable symptoms. After a few days, sloughs came away, probably of muscle, cellular membrane, and peritoneum, in a con- fused mass ; and with them a gall-stone of moderate size, explaining, to a certain extent at least, the origin of the disease." In this case " a quagmire of slough " remained for a few days after incision, yet without constitutional disturbance ; and the almost instantaneous relief afforded by the escape of fetid gas is scarcely to be explained by supposing that absorption of dead tissue was as suddenly arrested ; rather, this sudden relief suggests that an over- whelming poison was removed by the discharge of gas, resulting from decomposition of dead tissues, a poison which had previously operated chiefly throug"h the iiervous system. But this gas is only present in advanced sphacelus, and cannot therefore be the immediate cause in operation in the first instance. 268 GENERAL PATHOLOGY AND SURGERY. The fair conclusion is, that absorption of dead matter primarily, nervous sympathy secondarily, and ultimately both together, induce and maintain the typhoidal fever which proceeds fiom mortitication. Treatment of Mortification. Taking a compi-ehensive retrospect of the pathology and etiology of (ulceration and) mortification, the Indications of Treatment are four :— (1.) To remove the cause or causes in operation, and thus arrest the progress of death. (2.) To remove the dead part — e.g. a slough, a sequestrum, a limb ; and the proper time for such surgical inteii'erence. (3.) To solicit the natural separation of the dead part, with re- parative closiu-e of the blood-vessels ; and then the reparative process of granulation and cicatrization. (4.) To control the constitutional disorder, consequent on mortifi- cation. (1.) The first indication of Treatment — that of removing the cause or causes of mortification — requires no further explanation than by reference to the causes themselves, whether they be external or internal. Thus, any occasion of pressure, as by a tight bandage, must be removed; or ossification of the arteries in the legs must be managed, by reference to the pathology of this internal cause, as a persistent condition, iu senile gangrene. (2.) Removal of the dead part by operation, and the proper time for such surgical interference. The earliest opportunity for fulfilling this indication, with due regard to the non-recurrence of gangrene in the part adjoining, may be a highly important question for the Surgeon's consideration. Thus, the removal of a loose slough of soft textures or a seques- trum of bone, cannot admit of any such doubt ; for there and then, mortification has become defined. The amputation of a limb will, however, be a question having reference to the spreading of gangrene, and the probability of its ■recurrence in the stump. The consideration which partly determines this question is, the constitutional or the local origin of the gangrene. In the former case, spreading ivithout limitation as to its extent, amputation must be postponed tintil the "line of demarcation" has formed; in the latter, limited in its extent to the source of gangrene, and probably restricted to within that boundary, by the establishment of a collateral circulation, from above to below, amputation may be performed ^r{o>' to the formation of the line of demarcation. Thus, in traiimatic gan- grene from whatever cause, — contused or lacerated wound, compound fracture or dislocation — amputation is determined, not by svaiting for the limitation of sloughing, but by the extent of injury as its source. But in certain of these naturally limited gangrenes, the limitation cannot he foretold, simply because the exact situation of the causative condition cannot be diagnosed. Of arterial conditions ; such are ossi- fication of a main artery or arteries, leading to senile gangrene ; arteritis, indefinite in a lesser degree, as to its extent ; embolism ; and partial rupture of an artery without any external w^ound. Of venous GANGKENE AND MORTIFICATION. 2'69- conditions ; such also are fibrous obliteration of a large vein ; pble- boliths or vein-sfcones impacted ; and phlebitis, indefinite as to its extent. Hence, in all these cases, arterial and venous — the treatment appropriate for the particular causative condition having failed — amputation must be deferred until such time as nature has indicated, by the formation of the line of demarcation, that limitation which cannot be foreseen. The venous conditions referred to seldom, if ever, necessitate amputation. On the other hand, the line of demarcation can be foretold, in other cases of definitely local origin. Such are aneurisms, spontaneous and traumatic, and wounds of a main artery; aneurismal varix, and vari- cose aneurism ; and any occasion of prolonged pressure, or ligature, on a large artery or vein. Hence in all these cases — 'arterial or venous — the treatment appropriate for the particular causative condition having failed, amputation may be resorted to before the formation of the line of demarcation had indicated the actual extent to which the gangrene will spread. Generally speaking, the rule for amputation may be thus stated, in all cases of local origin ; idiopathic gangrene, however caused, suggests the postponement of amputation until the limitation of gangrene is declared by Nature ; whereas traumatic gangrene, however caused, suggests amputation more immediately, this anticipation of Nature by Surgical Art then being justifiable. Two exceptions are urged by Erichsen — namely, gangrene from frostbite, and that from severe burns. In these injuries, he considers it better to wait for the forma- tion of the line of separation, and then to fashion the stump throug-h or just above it, as the circumstances of the case require. In Spreading traumatic gangrene, the question of amputation is to be determined rather by the consideration that a constitutional cause is in operation. Operative interference, therefore, should be deferred, pending the formation of the natural line of demarcation, — as was directed by Sharp and Pott. The contrary rule is, however, main- tained by Larrey, and some other modern Surgeons of large experience ; that in this condition, if life be in danger, amputation should be performed, although gangrene may yet be spreading. (3.) Solicitation of the natural separation of the dead part, with reparative closure of the blood-vessels ; and the healing process of granulation and cicatrization. Constitutional gangrene, or gangrene arising from local conditions the exact situation of which cannot be diagnosed, may, in either case, have compelled the delay of amputation until the line of demarca- tion takes place ; but Surgical Art should solicit this limitation, and thus also, if possible, restrict the extent to which the gangrene might otherwise have spread. By maintaining the temperature of the part not yet mortified, the local circulation may become diffused sufficiently to sustain its vitality ; whereby the line of demarcation between the living and the dead portions will be declared. Hence, the preventive value of cotton wadding, with which material the limb should be deeply enveloped. This padding need not be reapplied for some days ; the gangrenous part being covered with lint soaked in a solution of permanganate of potash (Condy's fluid), a chlorinated, carbolic, or other antiseptic lotion. Concentrated solutions of carbolic acid, e.g. 5ii. to 1 lb. of olive oil, are apt to induce symptoms of 270 GENERAL PATHOLOGY AND SURGERY. poisoning, indicated by olive-green urine. (Billroth.) A poultice of powdered charcoal answei-s the double purpose of an antiseptic and moist warm dressing. In senile gangrene, the line oP demarcation having formed, and sepai-ation of the dead part slowly taking place, reparative closure of the blood-vesels "will be promoted by a light poultice or epithem of moist spongio-piline, to encoui-age adhesive inflammation. When the soft textures are thus safely detached, the bone may be sawn through, and the otherwise natural amputation completed by this amount of surgical interference. Granulation and cicatrization supervene as in the healing of a healthy ulcer, although perhaps more slowly than usual. Simple water dressing, or some gently stimulating lotion, will therefore generally prove sufficient in the way of topical treatment. Balsam of Peru, pure or diluted, with an equal part of yolk of egg, is highly recommended as an application in these cases. Remembering the persistent cause of gangrene, namely, ossification of the ai-teries, exposure to cold must ever be avoided, and the circulation in the legs cherished by the patient wearing thick woollen socks, flannel drawers, and other such warm clothing, (4,) Constitutional Treatment , — Prior to closure of the vessels, the constitutional disorder consequent on gangrene — the typhoidal fever — -requires supporting measures ; an easily assimilated diet, comprising proportionately more animal food, malt liquor, and alcoholic stimu- lants, will prove most beneficial. Of medicinal stimulants and tonics; the sesquicarbonate of ammonia and chlorate of potash, with cinchona bark or cascarilla, forms a combination which is, I think, more lauded in the books, than suggested by pathology or sanctioned by expe- rience. Opium is, generally, a remedy of great value, apparently by subduing the pain and nervous excitement ; and by promoting the capillary circulation, thus aiding the process of separation. It should be administered in small but repeated doses, to the amount of two to four grains in the twenty-four hours, and increased as the system is brought under its influence ; but opium is contra-indicated or must be discontinued, whenever it disturbs the digestive organs or occasions headache. The hypodermic injection of morphia may, however, not be obnoxious, Inflammatonj fever, in some degree, accompanies occlusion of the vessels during the separation of the gangrenons part ; opium may, therefore, still be continued to suppress nervous excitement and the heart's action, while it perhaps sustains adhesive inflammation. The stimulant and tonic plan of ti'eatment should be moderated during this period, and resumed dui-ing convalescence. White Gangrene. — The association of a livid or black discoloura- tion with gangrene is so invariable, that to speak of gangrene as distinguished by the white appearance of the part thus affected, seems anomalous. And, indeed, this is a very rare affection ; appa- rently of neurotic origin. Commencing svith. neuralgic pains in the course of the nerves leading to the part about to become gangrenous, any portion of the body may be the seat of white gangrene, but usually one of the lower limbs. After the lapse of some weeks or months, a circumscribed, and somewhat circular spot appears, of a dull white colour, and the GANGRENE AND MORTIFICATION. 271 integuinent assumes a drj, parcliment-like character, Sucli a spot may be an mch or two in extent ; bat the area does not enlarge. At length, a red line of demarcation forms, and the white portion of skin is detached, and shed. Sometimes this gangrene extends deeper, invading the subcutaneous textures, even down to the bone. The duration of the disease will differ, according to the depth of the dying part, — from a period of weeks to months. The ulcer left, heals by granulation, which proceeds almost equally with the separation of the dead patch of integument. Unlike senile gangrene, not only in colour, white gangrene occurs also in childhood, and especially in weakly constitutional conditions. The disease sometimes recurs. It differs again from traumatic gangrene, produced by such violence as shall directly kill the part affected ; in that case, the colour is white at first, from compression of the vessels ; but this appearance is speedily exchanged for the lividity of congestion. No special plan of treatment has hitherto proved efficacious. The predisposing constitutional debility would indicate tonic measures, probably iron and quinine — having regard to the neuralgic character of the neurosis. In women, amenorrhoea or dysmenorrhoea suggest the same course of remedial resources. The disease, if not thus averted, may be conducted to a favourable issue, by the detachment of superficial sloughs ; when, however, this gangrene progresses deeper and deeper, the limb or life may be sacrificed. DISEASES OF THE BLOOD. CHAPTER V. SCROFULA, By tbe term Blood-disease, I mean a disease in which some alteration of the blood is the primary affection, as from a poisoned wound ; or is the central condition, although the blood-forming organs, and all the textures, in the processes of assimilation, primary and secondary, and thus the whole body, may be engaged in the disease. The latter will be considered first, as representing blood-diseases of a constitutional character, essentially. Their affinities and differences are of great practical importance. Scrofula should be distinguished from Tuberculosis ; for these diseases do not appear to be identical, as some pathologists have main- tained, and even still allege. I endorse the Yiew held by Sir James Paget, that this is therr relation — "the scrofulous constitution implies a peculiar liability to the tuberculous diseases, and that they often co-exist. But their diffei'ences are evident, in that many instances of scrofula (in the ordinary meaning of tbe word) exist with intense and long-continued disease, but without tuberculous deposit ; that as many instances of tuberculous disease may be found without any of the non-tuberculous affections of scrofula ; that, as Mr. Simon has proved, while diseases of ' defective power' may be experimentally produced in animals by insufficient nutriment and other debilitating influences, tuberculous diseases are hardly artificially producible ; and that nearly all other diseases may co-exist with the scrofulous, but some are nearly incompatible with the tuberculous." The dis- sociation of these two diseases is further indicated by the observa- tions of Villemin * to the effect that not only do a considerable number of tuberculous, including phthisical, patients show no vestige of scrofula, but that scrofulous children are no more liable to become tubercular than others ; and Grancher also denies any such predis- position. Kiener f gives the history of eighty-seven cases of scrofu- lous disease of the bones and joints, with only six deaths from tuberculosis of the lungs or cerebral meninges. On the other hand, among the patholgists who incline to the identity of Scrofula and Tubercle may be mentioned Lugol, who affirms that " the natural death of the scrofulous is by consumption ; " while Hamilton, Euehle, and Rindfleisch, concur in the intimate * L' Union Medicale, vol. xxxi., 1881. t Ibid. SCROFULA. 273 association of these diseases. Mr. F. Treves, in an e]a"borate treatise,* maintains " that scrofala and phthisis are identical in their nature, but that phthisis is by no means a common complication, either immediate or remote, of the former disease. They are due to the same morbid process ; phthisis may be regarded as scrofula of the lung, in like manner as a scrofulous lymphatic mass may be regarded as phthisis of a gland." The interchangeable relations are thus ex- pressed : " (1.) The manifestations of scrofula are commonly associated with the appearance of tubercle ; or if no fully formed tubercle be met with, a condition of tissue obtains that is recognized as being- preliminary to tubercle. Anatomically, therefore, scrofula may be regarded as a tuberculous or tubercle-forming process. (2.) The form of tubercle met with, in scrofulous diseases is usually of an elementary and often of an immature character. Whereas in diseases called tuberculous clinically, a more perfect form of tubercle is found in the form of grey granulation or 'adult tubercle.' (Grancher.) (3.) Scrofula therefore indicates a milder form or stage of tuberculosis, and the two processes are simply different in degree." hioculatioji has been appealed to for th.e settlement of this vexed question. That tuberculosis may be produced by inoculation is now generally admitted, and that the products of scrofula are not inocu- lable, has also been maintained; but that scrofula is the soil, tubercle the seed, according to the views of M. Rendu, and that it is especially, if not exclusively, upon the soil of scrofula, the infective tubercle can take root and grow. Thus, some pathologists, with Villemin, main- tain, " that tubercle alone gives tubercle by inoculation." But Cohn- heim affirms that the products of tubercular and scrofulous disease are almost equally active on innoculation ; either of them thus producing the other form of the disease. Other pathologists have worked in this direction of inquiry ; .notably, Wilson Fox, Burden Sanderson, Klein, Klebs, Schiiller, Deutschmann, Hueter, Wagner, Kiener, and Creighton. PatJiology. — Tubercle — so named, as appearing in the shape of roundish little masses — -is only a degenerate condition of lymph-deposit, resulting probably from chronic inflammation, and such also is the patho- logy of scrofulous matter. Tubercular deposit may be found in either of two form.s : as miliary tubercle, in the form of greyish-white, semi- transparent, and firm granulations or granular bodies, about the size of a millet-seed ; or, yelloic, opaque tubercle, in larger masses, of soft and friable, or caseous consistence. The generally acknowledged relation of these two forms of tubercle is, — that the miliaiy represents thetvpical and primary condition ; and that the yellow is a secondary transforma- tion, resulting from softening of the miliary deposit. The enlargement of any such deposit may arise from the accumulation of cells around a starting-point ; but the larger deposits of yellow tubercle accrue from the infiltrating conglomeration of the grey granulations. In either form, tubercle consists, structurally, of cells — apparently lymph- corpuscles, infiltrated into a delicate stroma, or into the interstices of the tissue, in which it occurs. The deposit is avascular ; although some capillary vessels of the texture invaded, may permeate between the cells. Yellow, softened tubercle consists chiefly of molecular matter, with broken-down cells, — from disintegration of the miliary * " Scrofula, and its Gland Diseases," 1882. VOL. I. T 27 i GENERAL PATHOLOGY AND SURGERY. tubercle. This transformed tubercle is sometimes spoken of as scrofu- lous matter. With the debris of tubercle is associated degenerated epithelium-cells, pigmentary matter, cholesterine, and tlie remains of whatever tissue may have been the seat of deposit. And, owing to the relation of the two forms of tubercle, — as primary and secondary conditions of the same cell-deposit, both may be combined. Thus, corpuscular or miliary tubercle sometimes contains molecular or yellow tubercular matter ; the former passing into the stage of central softening and transformation. Both conditions of tubercle, especially the yellow variety, are liable to undergo a calcareous degeneration ; the cell-element disappearing with the substitution of inorganic, saline matter, chiefly phosphate and carbonate of lime ; whereby the deposit is reduced to hard, chalky matter, sometimes named the cretaceous tubercle. Rokitansky, differing from other pathologists, maintains the independence of miliary and yellow tubercle, anddenies the ti-ansform- ation of the former into the latter ; but he describes an atrophic change in grey granulations, — the withering up into hard, horny, fibrous masses. Formerly, it was thought that tubercle was some specific kind of deposit ; the expeiimental observations of Villemin, and those of Lebert, having originally demonstrated that tuberculosis can be trans- mitted from the human subject to the lower animals, by inoculation with tuberculous matter. This i-esult was confirmed by Mr. Simon, and by Dr. Marcet, who found that sputa-containing tuberculous matter, was thus inoculable. But, the more recent experiments by Sir Andi^ew Clark, Dr. Burdou Sanderson, and Dr. Wilson Fox, have further shown that tuberculosis can also be induced by the inoculation of non-tubercular morbid matter. The specificity of tubercle having been thus dispi-oved, it is now understood to signify simply a form of lymph-cell deposit, of abortive character ; there being no power of reproduction in stich product, but an inherent tendency to degenera- tion and disintegration. It may be regarded as merelv a perverted condition of the normal nutritive plasma or lymph, of lower vitality and capacity of organization. In the course of further degenerative transformation, as softened tubercle, it cannot be disting-uished from the caseous degeneration of other inflammatory products, including that of pus in a residual abscess. The cretaceous return to inorganic matter completes the parallel in the histological history of tubercle. The relation of scrofulous lymph-deposit has also been noticed ; and its pathological individuality is no more tenable than that of tubercle. But, their manifestations as diseases are widely different. I proceed to describe the various morbid affections kno'vvn as scrofulous. General Symptoms. — Scrofula exhibits itself locally by " malnutri- tion and chronic inflammation." This inflammation is scarcely ex- pressed by pain or heat, or redness, but rather by swelling, more or less considerable and doughy, slowly enlarging, and tending to sup- pni'ation ; yet scrofulous suppuration is unwilling, so to speak, and the pus a mixture of curd and serum. Should a scrofulous abscess point, the skin thins, but gradually, and assumes a purplish tint ; an irregular rent follows after some time, and the flaky matter rolls out. Perhaps this aperture gets blocked up and imperfectly closed ; the matter reaccumulating, again to be discharged, and so on from time to time. Or the aperture may remain free, with puffy everted edges, SCEOFULA. 275 of a pnrplisli colour, and tlie discharge continae — now thick, now thin. The scrofulous ulcer, which eventually results, is equally indolent. It persists, with a thin, livid, undermined margin, large, pale, flabby granulations and a gleety discharge ; although sometimes pretending to heal, by this discharge crusting over its surface. Should cicatri- zation ensue, the scrofulous cicatrix appears drawn, puckered, and incomplete. Small bridges form across the ulcer, underneath w^hich a probe can be passed readily, in and out, here and there. Special Forms. — Scrofula is essentially a " pervading " disease. It blossoms and bear fruit chiefly in the lymphatic glands, in the skin and cellular texture, mucous membranes, bones and joints, eyes, salivary glands, tonsils, ears, breasts, and in the testicles. Then, again, various parts are rarely affected siniultaneously, but con- secutively ; the scrofulous affection "migrating" from one texture or part to another texture or part. Their order of priority cannot be stated with accuracy. In most textures, the disease evinces a marked tendency to spread, as in scrofulo-derma and caries ; but in some the scrofulous affection is more pronounced than in others. Lymphatic glands, so called, appear to solicit the deposit of scrofu- lous matter. At first soft and fleshy, these glands enlarge and harden ; portions of each gland are observed to have altogether lost their flesh colour, and acquii-ed a degree of transparency, and a tex- ture approaching to that of cartilage. At length, a soft, white, or yellowish, curd-like substance is deposited. Glandular tumours, thus formed about the neck and groin, sometimes attain an enormous size ; in the latter situation, being perhaps half as large as the head of a new-born child. An enlarged scrofulous gland is not necessarily impervious — at lesat, mercury can be injected in many instances. Scrofulous glands are remarkably indolent, but eventually they soften and discharge the peculiar pus — flaky and ichorous, perhaps creta- ceous matter; or they remain as soft and spongy tumours, beneath a thin, silky cuticle, which frequently breaks and oozes ; or they waste, and are at length represented only by a few bands of condensed cellular tissue attached to the cicatrized integument. Mr. Treves' treatise contains an excellent account, from original investigations, of the nainute changes of structure which the glands undergo. Lymphatic vessels are said to be rarely the receptacles of scrofulous matter, biit there are such instances on record. Chronic enlargement with suppuration of the lymphatic glands is one of the earliest and most characteristic manifestations of scrofula. In childhood, therefore, these glands may be found as just described, in various stages of scrofulous inflammation and suppuration. Tet this is a rare event in children under two years of age. Cullen men- tions a case in which the disease broke out at the very early period of three months. Taking the other extreme, Thomson found the mesen- teric glands affected with scrofulous inflammation in persons of very advanced age. In various parts, also, of the body, the lymphatic glands may become scrofulous. Those in the neck — glandulce concatenatcB — are perhaps most frequently affected. This enlargement of the cervical glands is apt to arise from slight and transitory injuries and affections of the hairy scalp, ears, eyes, nose, and more particularly from slight 276 GENERAL PATHOLOGY AND SURGERY. and tempoi'ary affections of the teeth, gums, and other parts "within the mouth. Decay of the first teeth is often the immediate cause of scrofulous glanthilar swellings in the neck, hut their eruption, seldom or never. The axillary and crural glands are less frequently affected than those of the neck. The mesenteric glands are very liable to undergo scrofulous inflammation, constituting that formidable disease, tabes mesenterica, by arresting the absorption and passage of chyle through those glands, and thus inevitably depriving the ■whole body of its nutriment. A tumid abdomen, with progressive emaciation, begets suspicion of this disease ; while detection of the mesenteric mass, by palpation and percussion, will go far towards confirming our diagnosis, JBut we look for the concurrence of some other expressions of the scro- fulous diathesis. Age, also, should be taken into account ; although, in this respect, Thomson found the mesenteric glands affected in children two years old, in persons between twenty and thirty, and in those who had passed their sixtieth year. The cellular texture is peculiarly liable to exhibit scrofulous swell- ings, bordering on suppuration or actual collections of matter. In the subcutaneous cellular tissue, scrofulous gummata or small nodules are apt to form, closely resembling scrofulous glands in appeai^nce. They often appear very suddenly ; and from the absence of pain and discolouration, they may exist a long time without being perceived. They are usually of an oval figure, and seem to be pro- duced bj' the effusion of a fluid into the interstices of the cellular texture ; they are very variable in their size, being one day more prominent and tense, and the next more flaccid. Subcutaneous abscesses may form, and are usually numerous. When a lymphatic gland suppurates and bursts, a fistulous sore is the result ; but abscess in the subcutaneous cellular texture commonly tenninates in an open scrofulous ulcer. In the sheaths of muscles, large chronic abscesses sometimes gather insidiously, containing the pus which characterizes scrofulous sup-, puration. The sTcin is more than liable — it is prone — to scrofulous eruptions and ulceration. Its wrinkled seams and puckered scars are familiar to common observation. And these vestiges are not unfrequently " sjon- metrically " disposed on either side of the body. An instance of remarkably symmetrical scrofulous scars on the neck and fore part of the chest, occurred in a patient of mine at the Royal Free Hospital. In the raiddle line, a vertical scar extended downwards to the sterno- clavicular articulation, terminating in a kind of root, and upwards to the OS hyoides. From thence a branch scar passed upwards and back- wards to the angle of the jaw, on either side ; and from this again, on either side, another seam extended upwards to the_ mastoid pi^ocess, and downwards on the sterno-mastoid muscle. Either axilla was the seat of a horizontal seam, which discharged a small quantity of scrofulous matter. According to the special experience of Erasmus Wilson, cuta- neous scrofula is presented in two conditions — that of tubercles, and that of ulcers. Scrofulous tubercles are small, purplish or livid, indo- lent tumours.. They soften internally and discharge an imperfect pus, remain open or fistulous for a long time, and on disappearing, fre- quently leave hard knots in the skin. They appear on the neck and face, and near ulcers resulting from inflammation of the lymphatic SCROFULA. 277 glands. "When sucb. tubercles have partially discharged their contents, a crust of inspissated matter forms, which being rubbed off occasionally, exhibits an open sore, with an ichorous discharge, and no disposition to heal. Eventually an ugly cicatrix or scar marks the site of these sores. Usually but one scrofulous tubercle arises ; sometimes a group of three or four close together, which may have a circular arrangement, enclosing an area of thin, shining, livid or purplish skin. Rings of this kind occur chiefly on the back of the hands and feet. They are very intractable. The characters of the scrofulous ulcer need not be repeated. An irregular, livid, and puckered scar is its remnant. Such cicatrices are seen mostly in the neck, near enlarged glands, and in the neighbour- hood of joints. Inflammation of the niatrix of one or other of the 7iails is not un- common, more particularly in young persons having the scrofulous diathesis. Scrof ulo-derma ungueale, so named, begins by inflammation of the skin immediately round the edges of the nail about to be affected ; then follows considerable swelling, with vivid redness of the end of the finger, extending even to the bone, and presenting the appearance of a clubbed finger. The nail is shed, disclosing an angry raw surface, upon which, from time to time, there reappears a rugg'ed, ill-formed, and imperfect nail. Fungous granulations and unhealthy pus continue for perhaps many months. Other cutaneous manifestations of scrofula are noticed by some writers. Porrigo favosa, larvalis, and furfurans ; eczema impetiginodes and rubrum, in their chronic forms ; lichen ; and that variety of lupus which appears as small, red, button-like, indolent tubercles, chiefly on the lips and nose, occasionally on the genitals. These tubercles excoriate and run into eroding ulcers, with pale, shining, spongy granu- lations and encrusted margins ; or perhaps this work of destruction is concealed by a thick incrustation, which every now and then drops off, exposing its subjacent ravages. The osseous system and th.e joints seem to invite scrofulous inflam- mation — in this respect somewhat contrasting with the indisposition evinced by these structui-es towards the syphilitic poison, unless rein- forced by mercury. The bones and joints, then, are more conspicuous in the histoiy of scrofulous manifestations. In the extremities of long bones, or in the bones of the carpus and tarsus, their cancellated portion is specially liable to undergo scrofulous caries. Sometimes this species of malnutrition runs its coui'se within the shaft of a long bone, but generally speaking, as I have said, in the neighbourhood of joints. The latter are secondarily invaded, caries so placed then being- denominated "scrofulous disease of the joints." In the career of scrofula, inucous membranes are not exempt from harm, particularly if its blood-associate, tuberculosis, be considered an ally. The ejes, ears, nose, upper lip, tongTie, tonsils, salivary glands, larynx, and genital mucous membrane, severally exhibit scrofulous inflammation ; yet this is not altogether limited to the mucous mem- brane in connection with these parts. Scrofulous ophthalmia is a variety of conjunctivitis, characterized by great intolerance of light ; so that the child (for this affection occurs mostly in young subjects) seeks a dark room, or bui-ies its head in the bed-clothes, and screws its brows together with screaming agony 278 GENERAL PATHOLOGY AND SURGERY. on any attempt being made to examine the eyeball. From habitually endeavouring to exclude the light, the corvugator and orbicularis muscles become hypertrophied, eventually giving a remarkable heavi- ness of expression. When the eyelids are separated, a copious flow of tears trickles down the cheeks, excoriating the face. The eyeball is now involuntai'ily upturned to avoid the light, a patchy redness is observable on the conjunctiva, and vesicles or pustules are seen here and there at the margin or on the sui-face of the cornea. These pus- tules burst and expose small ulcers. Frequently an interstitial deposit overshadows the whole cornea, which thus becomes thickened and opaque (pannus), 'projecting also, so that the eyelids cannot be closed. This is one destructive sequel, and should ulceration of the cornea not terminate comparatively favourably, in specks of opacity, perfoi-ation of the anterior chamber will be inevitable, the aqueous humour is dis- charged with prolapsus of the iris, and the eye collapses. Fretting ulceration of the Meibomian glands, attacking the margin more especially of the eyelids, and known as ophthalmia tarsi, is a frequent concomitant of scrofulous ophthalmia; or this diseased con- dition extends to the iris, giving rise to scrofulous iritis. But there is nothing peculiar about this variety of iritis, taken per se ; and indeed it is only as one of a series of local manifestations that we venture to designate it " scrofulous " iritis, and refer the Avhole series to one and the same constitutional cause in operation. The organs of hearing do not escape. Otorrhoea, the purulent dis- charge being fetid and abundant, is a very common affection ; or, chronic suppuration perforates the tympanum ; the ossicula crumble, loosen, and are washed out by the discharge. The nose assuredly enjoys no immunity. Habitual swelling, ulcera- tion, and fetid discharge from the pituitary membrane — ozaena — may or may not be accompanied with cai'ies and discharge of portions of the spongy bones. The upper lip is commonly tumid, protuberant, and chapped. Fissures also and ulcerated spots are seen on the tongue. Xodules, moreover, superficially imbedded in the substance of this organ are said to arise in most instances, and to present the following characters. They vaiy in size fi'oni a small shot to that of a horse-bean ; are painless, unless subjected to fii'm pressure, which occasions a pricking sensation. The superimposed mucous membrane i^eddens, soon breaks in the centre, and forms an ulcer, which spreads and destroys by sloughing ex'osion ; accompanied with mvich pain, profuse salivation, fui-red tongue, and fetid breath. If cicatrization ensue, hardness still remains ; fresh nodules also form in other parts of the tongue. The gums may present a red line, sharply defined, along the edge, opposite the incisor and canine teeth. (Ruehle.) Chronic and considerable enlargement of the tonsils, with perhaps indolent ulceration, is another outbreak of the scrofulous diathesis ; so likewise is swelling of the sub-lingual, sub-maxillary, and occasionally the pai'otid salivary glands ; but these affections alike owe their signi- ficance to the invariable co-existence of other local diseases of more unequivocally scrofulous origin. Chi'onic laryngitis may be due to this constitutional cause. The vocal cords become thickened ; the voice therefore is hoarse or squeak- ing, ajid the breathing embarrassed ; a tickling cough from time to SCEOFTJLA. 279 time ejects a slimj, not frothy, expectoration, streaked with blood perhaps ; or the sputa are muco-purulent. In either case the breath- ing is relieved bj this expectoration ; but eventually ulceration of the rima glottidis renders its closure imperfect, the act of coughing incom- plete, and expectoration therefore difficult ; so that the respiration is yet more oppressed. Should ulceration of the epiglottis supervene, there will be considerable difficulty of deglutition. In the genital mucous membrane, scrofula is manifested by profuse chronic urethral discharge ; or, by the leucorrhoea and catarrhal vulvitis, which occur in female children. Tubercular cystitis is also met with, as a rare affection. A certain mammary tumour was first described by Sir A. Cooper. "In young women," says this author, "who have enlargement of the cervical glands, I have sometimes, though rarely, seen tumours of a scrofulous nature form in their bosoms, confined in most cases to a .single tumour in one breast ; but in one case two existed in one breast, and one in the other. They are entirely unattended with pain, are distinctly circumscribed, are very smooth on their surfaces, and scarcely tender to pressure. They are very indolent, but vary with the state of the constitution, diminishing as it improves, and increasing as the general health is deteriorating. They can only be distinguish-ed from simple chronic inflammation of the breast, by the absence of tender- ness, and by the existence of other diseases of a similar kind in the lymphatic glands of other parts of the body. They produce no dangerous effects, and do not degenerate into malignancy." Lastly, a peculiar enlargement of the testicle, or rather, of the epididymis, is worthy of special notice among the local manifestations of scrofula ; and it particularly exhibits the usual characters of stealthi- ness and slow development. A small nodule, consisting of yellow friable matter deposited within the tubules or ducts, appears generally at one end of the epididymis ; little pain or tenderness attends this structural change, and it may progress without complaint. Another and another such nodule forms on the surface of the testis, h"t generally connected with the epididymis, which becomes beset with three or four small tumours. Thus the testicle itself feels enlarged and irregular at an early stage of this disease. It has been stated by Mr. Curling, that scrofulous matter is also deposited within the body of the testis, in the form of pearly or greyish bodies, of the shape and size of millet-seeds — e.gr. grey granular tuber- cles, which I suppose this description denotes. That these tubercles have a linear arrangement, like strung beads, less abundant and less regular in the anterior part of the organ than towards the rete testis, whei^e they are closely set, and sometimes confluent; and that they undergo transformation into a yellow friable cheesy substance, which at a later period softens, and is often broken up into a curdy purulent fluid, the gland-structure being" absorbed to give place to this tuber- culous matter, But, if tubercles are deposited within the testicle itself, this structural change signifies little in reference to the diagnosis of this disease, for the testis is often masked by small local effusions of fluid in the tunica vaginalis, the surfaces of which are partially adherent. Now, the epididymis may remain nodose for many months ; the nodules qiiiescent, or enlarging very slowly, and becoming painful. At length one declares itself more than the rest, attaches itself to the 280 GENERAL PATHOLOGY AND SURGERY. skin, Avliicli then assumes a purplish discolouration, ulcerates, and dis- charges a cardy purulent matter — the substance of the nodule. Other nodules undergo successively this process of disintegration, softening, and evacuation ; but, unlike healthy abscesses, they do not heal. Fis- tulous openings obstinately continue to exude a mixed discharge — now curdy, now serous, now seminal ; and in this advanced stage of the disease, destruction of more or less of the gland-substance is inevitable. According to Sir B. Brodie's observations,* occasionally one testis is completely disorganized ; more frequently the organ is only partially destroyed, and a considerable portion of the glandular structure re- mains unimpaired. Sometimes the disease is confined to one testicle ; sometimes both are similarly involved. By this process of disorganization and protracted discharge the testicle is drilled and worm-eaten, as it were ; so that eventually the organ collapses and shrivels up, a fi'agment only of its former self. There is seldom, therefore, any protrusion of gland-substance through the fistulous sci'otum ; on the contrary, in a favourable case the aper- tures gradually become inverted and depressed, leaving, after the lapse of time, a puckered cicatrix, adherent to the remaining portion of the gland, as a lasting record of all this mischief. Scrofulous affections seldom co-exist, in an active state ; one mani- festation of Scrofula seeming to be antagonistic to the development of another at the same time. Thus, from the records of the Margate Infirmary, we learn the remarkable result, that in 509 cases of Scro- fula, occurring in both sexes, only 56 patients presented concurrent scrofulous affections, — excluding cases where of two such affections, one was the cause of the other, as an ulcer of the foot and inguinal adenitis, and instances also of a remnant and an active disease co-exist- ing. With regard to the concun-ence of Scrofula and phthisis. Dr. AValshe observes, " The external lymphatic system on the whole rarely undergoes tuberculization in the phthisical state. An antagonism, not absolute, but tolerably well marked, seems to exist between the external and internal tuberculizing processes. I have known the cervical and axillary glands, greatly enlarged in phthisical people, rapidly fall to the natural size without suppuration or symptom of any kind, while pulmonary tuberculization rapidly advanced." Blood-pathology . — Nothing definite is known respecting the com- position of the blood in scrofula. The blood is said to be rich in its amount of fibrin, but thin, of inferior plastic quality, and poor in its proportion of red corpuscles ; such is the result of analysis by Andral and Gavarret : that the solids of the serum are increased, and the blood-globules diminished, was the result of Dr. M. Glover's analyses; and so on I might enumerate the conclusions of many other distin- guished chemists. Causes. — Temperament. — Certain bodily organizations evince a tendency to scrofula, and beget a suspicion that it will declare itself in some wav, sooner or later. Individuals thus constituted are ever verging on this morbid condition, with threatenings of its outbreak here or there ; but it must be confessed that no one temperament alone possesses the scrofulous character. It is the tendency of those whose circulation is habitually weak — are leucophlegviatic — who have flabby m.uscles, a dull muddy complexion, large heads, pigeon breasts, tumid * London Med. Gaz., vol. iii. SCROFULA. 281 bellies, and large joints ; but then the strumous tendency is manifested in those persons also who, with a more active circulation, are rather of the sanguine temperament, have firmer muscles, a clear, transparent, ruddy complexion, which readily assumes a purple or livid hue by exposure to cold. The circulation, although active, is susceptible. Chilblains, therefore, not uncommonly occur in children of this tem- perament ; while their yellow or reddish hair, large lustrous blue eyes, crimson-patched cheeks, and pouting upper lip, are associated with that lively, impiTlsive, affectionate, and precocious disposition which so often raises hopeful expectations never to be realized. In contrast, however, with this organization and with these mental endowments, the same strumous tendency may be evinced in the highest degTce by those who, without any marked character of circula- tion, are habitually subject to biliousness. In such persons the liver seems to be their weak point. Sluggish, yet enduring power is theirs also ; and hair approaching black in colour, a dark olive or yellowish complexion, and dry skin, are aptly associated with a gloomy, often resolute, and reflective disposition. Theirs is the melancholic tempera- ment. These are the chief signs of the scrofulous diathesis, although it may appear also in persons of the nervous temperament ; and, indeed, the same tendency can be induced in those who are congenitally most indisposed to it when subjected to circumstances favourable to its development. Hygienic Conditions. — Whatever impairs the nutritive qualities of the blood and its circulation may produce scrofula ; therefore, deficient or defective food, indoor life, insufficient ventilation, want of cleanliness and excretion, poor clothing, cold, damp, and even dark localities, with other circumstances of similar character, are the nurseries and nurses of this blood-disease. At the same time, individual pi^edisposition, as usual, plays its part ; for among- a family of children in precisely the same hygienic circumstances, one becomes scrofulous, while the rest escape. Phthisis begets scrofula, and this disease transmits its own tendency, from parents, or either parent, to offspring. And the inter- changeable nature of these diseases is shown in altered hereditary pre- disposition ; phthisis in one generation appearing as scrofula in the next, succeeded by phthisis again in the third. Sometimes an intermediate generation is passed over, the individiials being free from either disease. Scrofula makes its appearance in early life ; although sometimes not until old age, as "senile scrofula," to which Sir James Paget* and Dr. Bourdelais have drawn attention. Exciting causes sometimes evoke the constitutional disposition, and especially in the production of glandular afi:ections. The irritation of teething may thus give rise to enlargement of the cervical lymphatic glands ; and a current of cold air often induces tonsillitis. Treatment. — Preventive measures are far more efiicacious than remedial treatment. They consist in the anticipation or timely removal of the predisposing hygienic conditions just adverted to ; any inborn predisposition by temperament being beyond prevention. Due atten- tion to food is primarily important. In the absence of more precise knowledge respecting the blood-condition in scrofula, it is impossible to direct and regulate the diet chemically. Experience, however, suggests a light nutritive diet, and not to overload the stomach by a * "Clinical Lectures and Essays," 1875. 282 GENERAL PATHOLOGY AND SURGEEY. heavy meal. Stimulants may be necessaiy to assist digestion, but tliey should be indulged in sparingly. The pampered scrofulous child of affluent parents is as badly ofE as the ill-fed child of the poorest. The bowels, which are very apt to be costive, or at least irregular in their action, will requii-e the assistance of gentle aperients, such as rhubarb or the confection of senna. Not less important is daily exercise in pure air, and ablution not only to cleanse the skin, but to invigorate the circulation and promote excretion. Hence, sea-bathing may prove very beneficial. Friction with the horse-hair gloves and belt, or a rough towel, and warm clothing, with flannel next the skin, are likewise salutary. But, a Avarm, dry, light locality for habitation, in a well- ventilated and well-drained dwelling, constitute the hvgienic surround- ings which are most preventive of scrofula. The latter, especially, is a hard prescription for the poor to cany out. Among, however, the many blessings bestowed on them in this vast metropolis, by the imperishable philanthropy of Mr. George Peabody, a yearly decreasing predisposition to scrofula will perhaps be the greatest boon. Curative ti-eatment implies the same continued attention to the removal of any causes provocative of this disease. The hygienic con- ditions of diet, exercise, air, ablution for cleanliness and invigoration, clothing, and climatic influence, are still of paramount importance. But certain medicinal agents, principally iron, iodide of potassium, bark, and cod-liver oil, have an acknowledged therapeutic value. Iron may be given in the form of viniim ferri, the ammonio-citrate, the citrate or the sulphate of iron ; the latter of which preparations I prefer, as it improves the blood more effectually. This is denoted by a notable ari'est or diminution of any scrofulous deposit in the glands or other parts of the body. Iodide of potassium has a beneficial influence on scrofulous deposit, apparently by promoting its absorption ; but I must confess that this influence seems to me overrated. Iodide of iron is unquestionably remedial, but this is probably due to the iron rather than the iodine. Perhaps, therefore, the therapeutic value of iodide of potassium in scrofula, may be attributed to the latter ingredient ; an explanation in harmony with the generally accredited efficacy of other preparations of potash in this disease. Cod-liver oil must be regarded rather as a food than a medicine ; by supplying the diminished amount of fat in the blood, relative to the fibrin. It certainly has a most marked influence on scrofulous mal- nutrition. Cinchona bark, whether in the form of decoction or tincture, or quinine, is highly serviceable as a tonic in sti^engthening the circulation, and thence indirectly improving nutrition and all other functions. But it has no special influence on scrofula, and mast be regai-ded as an adjunct to other medicinal measures. I am thus accustomed to prescribe the sulphate of iron in doses of three to five grains, w4th one or two grains of the disulphate of quinine, three times a day ; coupled with a teaspoonful of cod-liver oil. Local treatment has some e^eei on t\ie clironic enlargement of glands, and of other parts, arising from scrofulous deposit. Applications of the compound tincture of iodine, or the stronger iodine-paint, may be advantageously aided in their stimulant operation by the pressure of strapping Avith soap plaster, or bandaging. Usually, however, these glandular enlargements will not subside, at least under topical treat- SCURVY AND PURPUEA. 283 ment. Cautery-puncture answers the purpose of destroying the gland-tissue, especially when in a state of caseous degeneration and discharge, it is beyond hope of recovery ; or the effete material may be turned out by incision, and scooping with a Yolkmann's spoon. But a mass of glands had better be excised; an operation whereby I have removed a conglomerate bunch of axillary glands, in three cases, with a completely successful result. When ahscess forms, and dis- charges subsequently as an ulcer, these results must be treated accord- ingly. Much has been said about the virtues of caustic potash and other barbarous modes of apparently punishing a scrofulous abscess or ulcer ; but there need be nothing peculiar in their local treatment, and it should ever be remembered that constitutional treatnaent can alone have any curative efficacy in scrofula. Operations for scrofulous conditions of the bones, joints, or other parts, should be determined by the same consideration. Constitutional treatment will often succeed in averting the necessity for excision or amputation ; a highly important consideration, since any local form of a constitutional disease is always an unfavourable condition for opera- tion, and the removal of the part affected can in no way cure that disease as the primary cause. Hence, also, the postponement of such operation may not unfrequently be justiBable; and until the local condition becomes more defined, or its progressive extension renders operative interference imperative, whether with regard to the part affected or its reactive influence on the general health. Scurvy and Purpura. General Symptoms. — Scurvy and Purpura are alike manifested by hgemorrhages into many textures, occurring at the same time or in succession; and it will be readily imagined that these hfemoiThag-es take place with greater facility in some textures than in others. Into cellular tissue, for example, blood is very apt to escape. Such spon- taneous hgemorrhages result from alterations which the blood itself has undergone. ScuEVT. — Symptoms. — The symptoms of scurvy may be well illus- trated by a supposed case. A sallow and dejected-looking man, whose strength has been gradually failing, becomes the subject of haemor- rhages of a peculiar kind. The gums are turgid, spongy, and rotten ; they ooze blood on the slightest pressure ; the teeth loosen in their sockets and drop out. This fungous condition of the gums ceases abruptly at the reflexion of the mucous membrane to the lips, which are extremely pale ; so also are the tongue, fauces, and inside of the cheeks. In some rare instances, however, the lividity extends nearly all over the hard palate. Red or livid spots are found on various parts of the body, principally on the legs, together with bruised-looking patches, of a yellowish-green colour, swollen and as hard as brawn. Extensive effusions of fibrin rather than pure blood, forming very hard, broad, and painful swellings, are found imbedded in the deep cellular texture and between muscles. Over these fi^brinous mats, the skin sometimes retains its natural colour, but usually appears bruised, is always thickened and brawny, and adherent to the subjacent textures. Swellings such as these occur particularly in the thighs and legs, but most com.monly in the hams, occasioning stiffness and contraction of 284 GENERAL PATHOLOGY AND SURGERY. the tnee-joint. Nodes also arise from this effusion taking place between the bones and their periosteal investment ; the tight swellings formed thereby giving great pain upon the slightest motion, even by turning in bed. None of these effusions, Avhether of fibrin or blood, ever suppurate ; nor do the nodes just mentioned, however large their size, ever cause the bone to exfoliate. The dark livid or purple colour of scurvy overshadows any skin- eruption, wound, or ulcer, which may chance to be pi-esent during this disease. A dark gruuious coagulum juts out fi"om the surface of an ulcer ; and this — which, owing to its appearance, has been named by sailors bullock's liver — often attains an incredible size in the course of a single night. To conclude the catalogue of hismorrhagic lesions, repeated issues of blood from the nose are common, blood may be coughed up or vomited, lost by the bowels, and perhaps passed with the urine. Scurvy is apt to prove fatal suddenly, from exhaustion. This re- markable feature in its career, with others of instructive moment, were exemplified in an equally remarkable manner during Lord Anson's expedition, 1740-1744. The narrative states : — " Many of our people, though confined to their hammocks, ate and drank heai-tily, were cheer- ful, and talked with much seeming* vig-our and in a loud, strong tone of voice ; yet, on their being the least moved, though it was only from one part of the ship to another, and that in their hammocks, they immediately expired ; others, who confided in their seeming strength, and resolved to get out of their hammocks, died before they could reach the deck. It was no uncommon thing for those who could do some kind of duty and walk the deck, to drop down dead in an instant, on any endeavour to act with their utmost vigour ; many of our people having thus perished during the course of this voyage." Pdepcjra. — Similar Symptoms characterize Purpura, but there is not the same marked dejection and feebleness, nor are the gums always fungous. Extravasation of blood occurs in the form of small, round, purple spots, rather than party-coloured blotches. These spots of blood are scattered in almost every texture. According- to Sir Thomas Watson's experience, they are not peculiar to the skin, nor to the sub- cutaneous tissues, but occur occasionally upon all the internal surfaces also, and within the substance of the viscera. For example, on the mucous membrane of the mouth, throat, stomach, and intestines ; on the pleurge and pericardium, in the chest ; on the peritoneal investment of the abdominal organs ; in the substance of the muscles ; and even upon the membranes of the brain, and in the sheaths of the larger nerves ; and they may be accompanied with large extravasations of blood in most of the vital organs of the body. Such lesions are neces- sarily perilous. Bateman states that he witnessed three instances in which persons were carried off, while affected with purpura, by htemorrhage into the lungs. Watson saw two post-mortem examina- tions, in both of which a considerable quantity of blood was found spread over the surface of the brain, between its membi^anes ; and in one of these cases blood was extravasated also into the cerebral substance, with extensive laceration. Blood-patJiolog y . — Scurvy and Purpura are plainly blood-diseases. The hlood itself spontaneously exudes, and appears as a bruise, yet without any bruising force having been applied. This haemorrhage and SCUKVY AND PURPURA. 285. eccbymosis takes place in many textures, and visits one after another. The whole organism, in fact, becomes leaky, yet without the blood- vessels themselves being in any diseased state. Scurvy. — To what morbid condition of the blood must scorbutic hemorrhage be ascribed ? The blood has undergone remarkable and significant changes of colour ; from the florid red of health, it has assumed a dark brown or green tint ; it appears, also, only half coagulated, the supernatant serum being of a livid colour. Again, the red corpuscles are observed by Drs. Ritchie and Buchanan to have become irregular in their outline, their discs more flattened, and more disposed to cohere together and aggregate into large insulated masses, than the corpuscles of healthy blood. These peculiar appearances are denied by other observers, who regard them either as inconstant or altogether absent. Dr. Garrod, for instance, affirms that recent ex- aminations have shown the blood not to be in a dissolved state, as was formerly supposed, but that the globules are normal in appearance, the clot firm and frequently bujffed and cupped. The balance of evidence, however, preponderates in favour of the peculiar colour and fluidity of the blood, and the collapse of the red corpuscles. The chemical constitution of scorbutic blood is doubtful. In the present state of Chemical Pathology, according to one authority, jtotash is deficient. Dr. Garrod's analyses led him to con- clude that the proportion of this alkali is reduced. Other authorities — Becquerel and Rodier — find the proportion of soda increased in scorbutic blood, aud that oi fibrin diminished. Treatment. — Scurvy. — The preventive and curative treatment of this disease is alike dietetic. It is an undoubted fact that certain articles of diet possess anti- scorbutic properties. Lemon-juice is the grand an ti- scorbutic, whereby thousands of persons have been rescued, who otherwise would inevitably have perished from scurvy. 1457 cases of scurvy were sent to Haslar Hospital in the year 1780. Subsequently, in 1795, lemon-juice was provided by order of the Admiralty, through the representations of Sir Gilbert Blane and Dr. Blair. Then only one case of scurvy appears in the hospital returns for 1806 ; and for 1807, one. Potatoes, whether in a raw state or cooked, are equally anti-scorbutic. Many other ai"ticles of diet, more or less in use, are enumerated by Dr. W. Budd, and their anti-scorbutic properties compared. So far, the prevention of scurvy is practicable. But this kind of knowledge is empirical; we are ignorant (as Dr. Budd justly remarks) of the essential element common to the juices of anti-scorbutic plants,' and in which their efficacy resides. Therefore, one plant cannot be substituted for another — prior to actual experience of its anti-scorbutic value — with the sure and certain prediction that it will pi'ove equally efficacious, or more so. And why are we still ignorant of this "essential element," and incapable, consequently, of substituting an untried for a known anti-scorbutic ? Because the blood-condition essential to scurvy is yet unknown, and that some- thing, by virtue of which various plants are anti-scorbutic, is there- fore equally unknown. Accordingly, the prevention of scurvy can be determined only by the results of actual experience. Mark the further consequences of this empiricism. If potash were 286 generaij pathology and surgery. assuredly known to be the thing in question, it could be procured in almost any emergency from the ashes of any plant or of any wood, and especially, as Dr. Garrod has suggested, from that ubiquitous weed, tobacco, which is rich in potash. In the present state of knowledge, the commissariat of an army, a navy, or commercial marine — ever liable to be placed in straitened circumstances with regard to all food — ai'e in the dark on this most critical point. In encampments-far from home, during sieges and long voyages, the allowance of lemon-juice has perhaps long been exhausted, and fresh vegetables are a dream ; when, therefore, under these adverse circumstances, scurvy stealthily threatens, with pallid hue and dejected mien, the light of Pathological Chemistry would supply an unerring guide in search of that yet unknown soniething — be it potash or what- ever else— by which the impending scourge would assuredly be averted. It might be possible, by a simple process perhaps, to extract that needful something from an abundant source at hand, in a locality otherwise well-nigh barren and desolate. To conclude, on behalf of the prevention of this disease ; any new and tintried kind of food cannot be suhstihded, in an emergency, for another less plentiful ; and, should all food run short, then the essen- tially anti-scorbutic constituent cannot be extracted from substances pei'chance close at hand, in which, like a precious pearl, it remains undiscovered, while scurvy is already overshadowing its victims. Empirical experience is our only i-esource under these circum- stances, and the rules which it authorizes for our guidance are neces- sarily of a very general character. They are enumerated by Dr. Budd as follows : — Firstly. Anti-scorbutic properties reside exclusively in substances of vegetable origin. Secondly. These properties are possessed in very different degrees by different families of plants ; least so by the farinaceous, as wheat, oats, barley ; most so by the succulent, as the aurautise, comprising oranges and lemons ; lastly, by potatoes. Thirdly. The anti-scorbutic property is impaired by the action of strong heat ; nevertheless, boiled potatoes are anti-scorbutic (Dr. W. Baly) ; impaired, also, by vinous fermentation, but improved probably by acetous fei^mentation. To show the difficulty of determining the essential treatment of scurvy empirically, I might add, in striking contrast, the conclusions of Sir R. Christison in favour of azotized substances, and of animal origin, perhaps exclusively, such as milk. Purpura. — A.lthough resembling scurvy in appearance, the curative treatment of purpura, by abstinence, pui-gation, and venesection, as recommended by the late Dr. Parry, of Bath, is altogether at variance with that which is so efficacious in cases of scurvy ; and points, there- fore, to some essential difference between these two diseases, otherwise allied. The manifestations of both are unquestionably of blood-origin, yet essentially different in this respect ; and not until Chemical Patho- logy has determined the blood-condition peculiar to Purpura will it be possible to interpret rightly the whole etiology of this disease. Its rational preventive and curative treatment will follow. ( 287 ) CHAPTER VI. EHEUMA.TISM AND GOUT. Rheumatism. — Symptams and Diagnosis. — Rheumatism is manifested by an inflammation affecting some portions oi fibrous tissue ; the liga- ments and tendons around the joints are more commonly selected, sometimes the aponeuroses or the fascise, less freqaently the periosteum or perichondrium, and veiy probably the pericardium and endocar- dium. Other textures may be affected, apparently by the continuous extension, of rheumatic inflammation ; as in the case of fibro-serous membranes, like the pericardium, or the synovial membranes in connection Tvith capsular ligaments. The larger joints are most liable to rheumatism, as the knees and elbows, the shoulder and hip joints. But exposure increases this liability, as with reg-ard to the ankles and wrists. Among the smaller joints, those of the fingers are more often affected than those of the feet. Rheumatic inflamma- tion is specific. It is denoted, just as common inflammation is expressed, by redness, heat, pain, and swelling ; but rheamatic inflammation is distinguished by not tending to the effusion of plastic lymph, nor to suppuration and gangrene ; unless, indeed, some other texture besides fibrous tissue shares the inflammation; as synovial or serous membrane, when its products are the same as those of ordinary inflammation. Around joints, the deposits are often ossific. Fever. — This local condition is preceded by and accompanied with inflammatory fever, in perhaps its highest degree, — contrasting, there- fore, in every way with fever of the typhoid type. After certain premonitory symptoms, — the individual having, for some time past, looked pale and depressed, felt chilly, and very sensitive to atmospheric changes ; a shivering attack is succeeded by burning heat of skin, with a strong, rapid, hard pulse ; headache without any delirium, excepting when pericarditis or endocarditis ensues ; drenching acid perspirations, and scanty, high-coloured, turbid, acid urine ; — these are the chief phenomena of rheumatic fever. And this fever not only precedes the local inflammation, but possibly runs its course without any such manifestation. Sometimes, the two commence together; or the local inflammation, as of the joints, precedes rheumatic fever. In this fever, the pulse rises to 90, 100, 110, or highei^, but remains strong and full ; and the temperature rises also to a varying average of from 101° Fahr. to 103°, — between the fifth and ninth day, with evening increments to perhaps 104°, in severe cases ; there is, however, no constant proportion between the frequency of the pulse, and the increasing temperature, sometimes a marked disproportion. The fever having been continuous, or sometimes of an exacerbating* or remittent character, begins to decline in about ten days, and gradually subsides in from that to three weeks; leaving the joints still painful and swollen. Strong predisposition to rheumatism, and repeated attacks, may lengthen the period to four, five, or six weeks ; but the fever, whether as regards its severity or duration, is not commensurate with the intensity and extent of the local symptoms. Rheumatism — like other inflammatory affections — may be either 288 GENERAL PATHOLOGY AND SURGERY. acute or clironic ; the latter being consequent on the former, or occurring quite independenth'. In chronic rheumatism the pain is less intense, it has a wearing, heavy character, and may or may not be relieved by pressure, movement of the part, or by friction and warmth ; the swelling has given place to stiffness, and any heat or redness may be scarcely perceptible ; nor is there any notable febrile disturbance. And actite rheumatism presents two important varieties ; according to the seat of inflammation — the kind of texture affected. In fibrous rheumatism, the pain is very intense, but attended Avith only a little puffy swelling, great heat, yet often little redness of the part. The fever is well marked. In synovial rheumatism, there is less pain, but far greater swelling, — obviously from effusion into the joint. The febrile disturbance is less pronounced. This variety of the disease may be named, more pi'operly, rheumatic gout. Blood-pathology. — Rheumatic inflammation, whether exhibited by the joints, the fasciae, or the heart, is evidently due to the operation of some morbid blood-condition ; and for two reasons more especially. The very fact of the same inflammation affecting, possibly, " many parts " — e.g. many joints — simultaneously, points to the blood as its common cause. So also does the "metastatic" character of this in- flammation. Passing from one joint to another — from the shoulders to the elbows, or from the knees to the ankles, perchance back again to the joints first affected, and probably thence migrating to the heart ; these and similar alternations of the same form of inflammation betoken some morbid condition of the blood, which, as a reservoir supplying in common all parts of the body, is turned on, as it were, more abundantly (by inflammation), now on this part, now on that. The " symmetrical " distribution of chronic rheumatism,* in many cases, affecting as it does corresponding parts of either half of the body, is further evidence of there being a blood-disease in operation ; while such distribution exhibits also the elective power of similar portions of the same texture. But although the blood, vitiated in some way, is determined to the fibi'ous texture, by virtue of its elective power, we cannot say what particular ingredient, normal or foreign to the blood's composition, is appropriated thereby. The texture undergoing rheumatic inflamma- tion selects something — but what ? — from the blood. Judging by the acid state of certain secretions — perspiration, saliva, and urine — during an attack of acute rheumatism, it would appear that an acid of some kind prevails in rheumatic blood ; and, first suggested by Prout.f other authors — Todd, Fuller, C. J. B. Williams, Headland, etc. — have since concurred in believing that this acid is lactic acid. It is urged that as the perspiration contains lactic acid, with lactates of soda and ammonia, and that exposure to cold, checking this secretion, is well known to be frequently followed by an attack of rheumatism, that therefore this disease is due to an accumulation of lactic acid in the blood. But then, sufficient exposure to cold ought invariably, to have this effect ; or — making* allowance for individual peculiarities of constitution — at least in many instances such would be the effect of exposure. Moreover, the not unfrequent spontaneous * Med.-Chir. Trans., 1842, Dr. W. Budd. t " Stomach and Eenal Diseases," 184S, p. 84. RHEUMATISM. 289 origin of rheumatism in hospitals, where patients are protected from exposure, is irreconcilable with the theory in question. Again, it is alleged that primary mal-assimilation — dyspepsia, in fact, of some kind — produces lactic acid in excess, which accumulates in the blood. But this theory also is not consistent with observation, so far as the absence of any symptoms of indigestion is significant. Neither has it been demonstrated that lactic acid accumulates in the blood, as the product of secondary textural mal-assimilation ; for chemical research has failed to discover any abnormal quantity of this acid in rheumatic blood. And this fact equally tells against the supposition of its accumulation by primary mal-assimilation, or by suppressed excretion of the perspiration. Nor does uric acid superabound in rheumatic blood. Grarrod's chemical analyses * establish this negative fact. In truth, rheumatic blood is decidedly alkaline. In acute rheumatism, the most notable alteration in the constitu- tion of the blood, is the relatively increased proportion of fibrin, 10 or even 13 parts in 1000 ; above the average of 2, or at the most 3, parts in 1000 of healthy blood. Oattses.— Exposure to cold or damp, and especially vicissitudes of temperature and moisture combined, undoubtedly provoke rheuma- tism, whatever may be the peculiar predisposing blood-condition. Sometimes, hereditary predisposition can be distinctly traced. The period of life is also influential ; rheumatism very rarely occurring before the age of fifteen years, and chiefly from then to thirty ; less frequently between thirty and forty, aud as life advances. Both sexes ai'e perhaps equally liable, under similar hygienic circumstances. The prognosis of acute rheumatism is generally favourable, so far as coucerns the joint-aifections ; but in a large proportion of cases, cardiac disease co-exists, or supervenes, — whether in the form of pericarditis or endocardiac valvular disease, although sometimes not declared for months, or even years, after the attack of rheumatic fever. Fibrous rheumatism is, I believe, more apt to be accompanied with some cardiac affection than the synovial form of the disease ; and in youth, the special tendency to cardiac complication should be remembered, in judging of the probable issue, whether during an attack of rheumatic fever, or as remotely contingent. Treatment. — Preventive. — The essential morbid condition — which in those subject to rheumatism, is ever in operation as the cause predis- posing thereto — being unknown, the evolution of rheumatic symptoms, from time to time, cannot be averted 5 and as if to show how com- paratively unimportant, apart from this knowledge, is that of knowing the exciting and reputed cause of rheumatism, it is useless to avoid exposure to cold, for that alone will never evoke the disease, and if the blood be charged with the unknown poison, it will arise spontaneously. Curative Treatment. — The same want of exact knowledge as to the nature of the rheumatic blood-poison, renders our remedial measures proportionately aimless. Whatever it be, there is probably, as with other blood-poisons, a natural tendency to elimination from the system by one or more of the excretory organs. Hence, it is not surprising that experience should sanction the employment of medicines affecting the liver and intestinal canal, the kidneys and skin. * Med.-Chir. Trans., vol. xxxvii., 1854. VOL. 1. U 290 GENERAL PATHOLOGY AND SURGERY. In acute rheumatism — Avith high inflammatoiy fever — it may be necessary, in the first place, to reduce the genei'al circulation by systemic blood-letting, venesection. Usually, however, a cholagogue dose of calomel, and an aperient saline, will prove sufficiently depletory, and remove also any source of irritation from the intestinal canal. But such measures are preliminary only. Then, the colchicum and alkaline treatment is generally the most effectual anti-rheumatic. Bicarbonate of potash, in large doses — two scruples or half a drachm— combined with the wine of colchicum in doses of ten or twenty minims, may be administered every four hours. The joint-affections may thus subside within an averag'e period of ten days, and the urine becomes alkaline. Sometimes, the colchicum producing sickness and purging, it must be discontinued, or moderated ; but it is desirable to keep the urine alkaline for two or three days after the joint-symptoms have subsided. This plan of treatment is certainly successful in many cases. In pro- portion as syyiovial symptoms predominate, or mix themselves distinctly with the fibrous — observes Sir Thomas Watson-^in proportion as the disease approaches in its characters to gout, you may expect to be successful with colchictim . Dr. Garrod, who originated the potash treatment in large doses, affirms that it greatly diminishes the tendency to pericarditis and endocarditis. Nitrate of potash — still in large quantity, half an ounce to three ounces a day— is the favourite salt with some practitioners ; acetate of potash with others. The late Dr. Golding Bird trusted to the latter, given in quantities of half an ounce, much diluted, in divided doses, during the twenty-four hours. In three days only, it has been known to overcome the pain and in- flammation, leaving the joints still swollen but placid. Or, the following combination may be recommended : — Nitrate of potash, one drachm ; acetate of potash, three drachms ; water, eight ounces : an ounce to be taken every two. three, or four hours, according to the urgency of the symptoms. An agreeable alkaline solution may be given in the form of bicarbonate of potash, or of soda, a scruple to a drachm, every three or four hours, in half a bottle of soda or seltzer water ; or in an effervescent citrate of ammonia, or potash draught. (Tanner.) Iodide of potassium finds favour with yet other men of experience, Surgeons chiefly, and lemon-jnice has been advocated by Dr. Owen Rees. Both the latter agents answer better in the less acute form of rheumatism. All these agents are probably eliminative, principally through the kidneys. My colleague Dr. Sainsbury has supplied the following note respecting another therapeutic agent of more recent use :-— " Of late years, in the treatment of acute aii;icular rheumatism, the use of the drugs salicine, salicylic acid, and salicylate of soda has become almost universal. It is claimed for these bodies that, as Rossbach puts it, they act as specifics to the disease— just as quinine does in malaria, or iodide of potassium in the later stages of syphilis. In addition to this speci6c action in rheumatic fever, they all three act as antipyi'etics in fever generally, though as to their precise value relatively to other antipyretics, in particular to quina, authorities are not quite agreed. Salicylate of soda, being more soluble than salicylic acid and less unpleasant, is the more commonly employed. Salicine appears to be the least active of the three prepai^ations, " The mode of administration is to rapidly saturate the system with RHEUMATISM. 291 tbe salt, ten to fifteen grains being given hourly, or twenty to thirty grains every two hours. The susceptibility in each case must guide the administration, and the above doses are, as Ringer recommeiids, to be increased, failing an effect. Should toxic symptoms appear — noises in the ears, deafness, headache — the dose may be diminished or temporarily suspended. After the acute attack has been subdued, the drug is still to be continued, in smaller doses, for another ' ten days or a fortnight.' (Ringer.) It is important to remember that other forms of so-called rheumatism of chronic or subacute course, affecting muscles, joints, and tendinous structures — in fact, just those forms which wander now into the surgical and now into the medical out-patient department — that such do not appear to be specifically affected by the salicylic-acid treatment. Rheumatoid arthritis belongs to this group." Calomel and opium, quickly pushed to slight salivation, is another plan of treatment. It would seenn to be preferable in cases having a tendency to cardiac inflammation. Opium is, perhaps, most remedial in all cases of acute fibrous rheumatism. Sir Dominic Corrigan has great confidence in its efficacy. Beginning with one grain, repeated at short intervals in the twenty-four hours, he gradually increases the quantity up to an average of twelve grains during that period ; and continues it until the disease declines. In chronic rheumatism, the compound powder of ipecacuanha (Dover's Powder), guaiacum, sulphur, and sarsaparilla have reputed efficacy. It would be useless to extend the list. But Dr. Aitken, in his work on Medicine, gives two formulas which are very generally ordered by medical officers of the Army and Navy, to relieve the pains in old chronic rheumatism. One combination of remedies, known as the '' Chelsea Pensioner," is this — pulv. guaiaci, Ji- ; pulv. rhei, 5ii. ; potass, bitart., sulp. sublim., aa 5i- ; pulv. nucis moschatae, Jii. ; mel., lib. ; to be well mixed. Two large spoonfuls may betaken night and morning. The other formula runs as follows : — ^Pulv. sinap., sulp. sublim., aa ^iii. ; pulv. guaiaci, '^^ss. ; pulv. rhei, potass, nitratis, aa grs. xlv. ; to be well mixed, with honey, treacle, or glycerine, in the form of an electuary ; of which a teaspoonful may be taken every other night. A teaspoonful of the powder in milk, is an equivalent dose. Local treatment can scarcely be of any avail for a disease v^^hich, apparently, naturally expends itself by inflammation of whatever part or parts may become affected. Assuredly no repressive application can be salutary. Warm fomentations are calculated to lead the in- flammation, as in all other cases, to issue by resolution. Alkaline fomentations, and especially with an alkaline and opiate solution, are found to be even more conducive to this termination. Dr. Fuller, who strongly advocates such an application, usually employs a solution of carbonate of potash or soda, about half an ounce, in nine ounces of hot water, adding six drachms of liquor opii sedativus. Flannel steeped in this hot lotion is wrapped round the inflaiued joints, and then encased with thin gutta-percha. Blistering, in the neighbourhood of the joints inflamed, was proposed by Dr. Dechilly, as a method of entirely local treatment for acute rheumatism ; the discharge of serous fluid, thus induced, being regarded as a mode of eliminating* the blood-poison. Some apparently successful results have been obtained. Whatever topical applications may be used, the patient 292 GENEKAL PATHOLOGY AND SURGERY. should lie enveloped in blankets, instead of linen next the skin ; for certainly, the risk of cardiac inflammation occurring^, is thus consider- ably reduced, and in the event of this complication, its severity is miti- gated. Chronic rheumatism, attended with thickening and stiffness of the joints and f ascite, may be somewhat ameliorated by Avarm baths, vapour baths, shampooing, or frictions. The Turkish bath will thus prove beneficial, provided thex'e be no heart affection of consequence. Gout. Go IT is a blood-disease allied to rheumatism, but differing in its pathology and treatment. General Sym'ptovis and Diagnosis. — This disease is manifested by an inflammation affecting the joints, very commonly the first joint, or hall, of the great toe. Commencing, usually, when the individual about to suffer has retired to rest, and has enjoyed some hours perhaps of sleep, he is awoke with fixed pain in one of his feet, — mostly, as I have said, in the ball of the great toe, but sometimes affecting the heel, instep, or ankle. With this pain, cold shivering is generally experienced, succeeded by heat, as the pain, boring, grinding, and wrenching, fastens more and yet more firmly on the spot of its election. " Place your joint in a vice," said a witty Frenchman, " and screw the instrument up until you can endure it no longer. That will represent rheumatism. Then give another tAvist, and you will somewhat realize gout." The skin over this part is acutely tender, red, tense, and shining, encircled by some oedema, and by converging turgid veins. Much restlessness and excitement supervene. In vain the sufferer seeks to relieve himself of the weight of the bedclothes upon the part inflamed ; in vain he shifts his foot from place to place in search of a cool and easy position. The pain, remorse- less, grapples yet more tightly. At length, in the course of twenty- four hours or so, it loosens its hold gradually, perhaps suddenly. The sleepless excitement also then subsides, and the victim enjoys some temporary repose. He wakes again to undergo punishment. The toe-screw is reapplied, it may be with a turn or two less ; and day by day a slighter punishment is inflicted, until at length the full penalty has been paid. The cuticle peels off the part affected, for gouty in- flammation ends by resolution ; it never terminates by the effusion of plastic lymph, suppuration, or gangrene. In these respects, this in- flammation and that of rheumatism are similar. Eventually, after frequent attacks of gouty rheumatism, the cellular texture around the joint usually becomes pervaded with a deposit of urate of soda, forming concretions, at first pultaceous, then "chalk-stones," of perhaps considerable size. The nodular, distorted, and stiffened fingers and toes of chronic gout is a matter of common observation. The skin over these nodules being stretched, at length breaks, and the chalky concretions are laid bare. Urate of soda has been found infiltrating all the textures of one or several joints, in synovial membrane, cartilage, the heads of bone, and ligaments ; and usurping their place, the articulations are irreparably destroyed. Premonitory symptoms refer to the functions of the stomach and kidneys, more especially. Dyspepsia, denoted by inappetency, eructa- tions, heartburn, and acidity of the saliva ; together with scanty urine, GOUT. 293 clear, high-coloured, and containing less than the average amount of uric acid or none at all ; these symptoms portend a fit of the gout. An intolerable lowness of spirits, with general restlessness and peevishness, are not nnfrequently additional warnings. Blood-pathology. — Chemical analysis demonstrates tlie presence of an excess of uric acid,vf itln no other change, in the blood. The absolute test of " blood-disease " having been thus supplied in this instance directly, it supersedes the occasion of any other evidence. According to Dr. Garrod's original observations, the blood in gout always contains uric acid in abnormal quantities and in the form of urate of soda, which, salt can be obtained from it in a crystalline state.* It arises, apparently, from mal-assimilation, — primarily, of albuminous food in the course of digestion, or secondarily, in the metamorphosis of muscular texture. Or, it may denote simply an excess of animal food over the wants of the system. And the fact first disclosed by Garrod's analyses of the blood, coupled with the know^n phenomena of arthritic inflammation, inducing the formation of urate of soda concretions, and abundant deposit of urates in the urine, constitute a series of facts, which plainly declare the pathology of this disease. An attack of gout is an effort of nature — of the restorative power — to expel a poison, uric acid, from the blood. Sir Thomas Watson well describes this struggle. " Morbific matter (it may well be called a poison) is gene- rated, or detained, under certain circumstances, within the body, and silently collects in the blood ; until, after obscure threats, perhaps, and prelusive mutterings, it explodes in the foot ; and then the bodily economy, like the atmosphere after a thunderstorm, is for a while unusually pure and tranquil." Or, gout may engage many joints at once, or flit from one to another; or wander about, disturbing the heart, the lungs, and the bi'ain. Hence palpitation and syncope, dyspnoea, disturbed vision and hearing, with cerebral commotion, bordering on apoplexy and paraly.sis. This is known as irregular, lurking, or masked gout. Sometimes, however, having settled in the foot, it suddenly disappears, and migrates to the stomach, heart, or brain ; retrocedent g'out as it is then called, being unlike the i^etreat of an ordinary foe, an assault on the very fortress of life. Less perilous migrations are witnessed, when gout betakes itself to the urethra, occasioning" a scalding discharge ; to the testicle, constituting one form of orchitis; to the eye, giving rise to ophthalmia. All these manifestations of irregular and migratory gout should be borne in mind, otherwise the disease in some form might be over- looked. In whatever shape gout may have appeared, whether regular, disguised, or migratory, its decline is marked and measured by a flow of urine, surcharged with uric acid, thus relieving its accumulation in the blood. This appears in the form of a pink deposit, often abundant, and consisting of lithate of soda, mixed with more or less urea and phos- phates. Sometimes, when the gouty attack is asthenic — attended with a weak circulation, and general feebleness — this critical discharge con- tains a larger proportion of phosphatic deposit, imthe form of a whitish powder ; or which may alternate with the pink-coloured lithates. The urine, thus charged with the morbific matter, is also notably * Med.-Chir. Trans., 1848. 294 GENERAL PATHOLOGY AND SURGERY. increased in quantity. During the attack, the lithates and phosphates are proportionately retained in the blood, although the urea and sulphates are sufficiently eliaiinated. And before the attack, nearly all the solid constituents of the urine will be found deficient ; uric acid, urea, extractives, and phosphate of lime. After an acute attack of gout, the patient is more than relieved from his previous dyspeptic and other symptoms ; both mind and body seem to be renovated. Detection of Uric Acid in the Blood. — The ready method proposed and practised by Dr. Garrod for this purpose, and for which the abstraction of only a very small quantity of blood is requisite, he thus describes as the " uric-acid thread experiment : " * "Take from one to two fluid drachms of the serum of blood, and put it into a flattened glass dish or capsule ; those I prefer are about three inches in diameter, and one-third of an inch in depth : to this add ordinary strong acetic acid, in the proportion of six minims to each fluid drachm of serum, which usually causes the evolution of a few bubbles of gas. When the fluids are well mixed, introduce a very fine thread, consisting of from one to three ultimate fibres, about an inch in length, from a piece of unwashed huckaback, or other linen fabric, which should be depressed by means of a small rod, as a probe or point of a pencil. The glass should then be put aside in a moderately warm place until the serum is quite set and almost dry ; the mantel-piece in a room of the ordinary temperature, or a book-case, answers very well, the time varying from twenty-four to forty-eight hours, depending on the warmth and dryness of the atmosphere. " Should uric acid be present in the serum in quantity above a certain small amount, it will crystallize, and during its crystallization Avill be attracted to the thread, and as.sume forms not unlike that pre- sented by sugar-candy on a string. This may then be examined by a linear magnifying power of about fifty or sixty, procured with an inch object-glass and low eye-piece, or a single lens of one-sixth of an inch focus answers perfectly. The uric acid is found in rhovibs, the size of the crystals varying with the rapidity with which the drying of the serum has been effected and the quantity of uric acid in the blood." The serum procured by the application of a blistering agent, will also give evidence of the presence of uric acid in the blood. An amount of ui'ic acid equal to at least 0'025 grains in 1000 grains of serum, in addition to the trace existing in health, must accumulate before this experiment gives indication of its presence. Premonitory symptoms, however, coupled perhaps with the signal given by this test, announce that gout is impending. Hygienic Causes. — Certain habits of life predispose to gout, and certain other habits of an opposite character have an opposite ten- dency. Indulgence in animal food more particularly, and stimulating drinks ; generally, in point of fact, what is called " rich living," together with a sedentary, idle life ; these are the acknowledged parents of gout; while moderation in the " pleasui'es of the table," even abstinence, with a life of active exercise, has no such oflfspring. Luxury and ease have long since been mistrusted as unqualified advantages compared with the apparent hardships of earning daily bread, by daily labour ; so much so, that Abemethy's pithy advice, * " On Gout and Ehenmatic Gout." GOUT. 295 " Live on sixpence a day, and earn it " — pointing, as it does, to the two elements, food and exertion, in relation to gout — has passed into a proverb. Tet, under these circumstances, there are not a few that suffer from gout, among the toiling classes, and especially those -vvhc labour and wait for success, with that " hope deferred which maketh the heart sick.'* At the same time, the constitutional tendency from hereditary predisposition must not be overlooked. Gout commences more frequently towards middle life — from thirty to fifty, though the diathesis may be manifested much earlier, and even before puberty. When once the disease is established, gouty attacks recur with increas- ing frequency, and perhaps at almost periodic intervals. Men are said to be more commonly affected than women, but this proclivity may not be true apart from habits of life favourable t-o the diathesis. TreatmenL — Preventive. — The regulation of diet according to exer- cise — of bodily supply to expenditure — is the preventive measure sanctioned by experience. But experience is insufficient for practical purposes. It affords no clue to the right understanding of the physio- logical relation subsisting between food and exercise, nor of the pathological relation between these hygienic requirements, and which guides the rational prevention of gout. Physiological Chemistry having first demonstrated the fact that all kinds of animal food, more especially, farnish uric acid in their transit through the body, by indig-estion, or by metamorphosis of the muscular textures, it becomes obvious that the balance between the production and elimination of uric acid can alone be adjusted and regulated by a supply of animal food in proportion only to the textural waste from bodily exercise. Then, Chemical Pathology contributed the additional and com- plemental fact, that ui'ic acid existing as urate of soda in abnormal excess in the blood, is the viaferies morhi of gout. Consequently, the preventive measure which should be directed against such accu- mulation is this : — To allow only that jparticular amount of animal food which, with daily exercise in proportion, will preserve the blood free from iiric acid, beyond the trace existing in health. Tables for the calculation of diet with relation to exercise, are given in works on Physiology and Hygiene (see " Practical Hygiene," by E. A. Parkes, edited by Francois de Chaumont, 1883, p. 119). But no better rule — observes Dr. Garrod — can be laid down for the prevention of gout, than that which Sir William Temple recommends — "A simple diet, limited by every man's experience to his own easy digestion, and thereby proportioning as near as can be the daily repairs to the daily decays of our wasting system." Experience, indeed, supplements the teaching of science with much valuable knowledge for the treatment of gout, as in regard to the prevention or cure of most other diseases. Thus, the diet should be further regulated by the avoidance or moderated allowance of many articles of food which, in some way or other, favour the formation of lithic acid. Certain forms of animal food are more digestible than others. Sydenham — himself a martyr to gout — makes- the following selection :• — mutton, well-kept beef, poultry, white kinds of fish, as cod, sole, and whiting ; but, the exclusion of salmon, veal and pork, cheese, salads, and all highly seasoned dishes, and rich sauces. Pastry, I am sure, is also specially noxious. Such vegetables and fruits are to be 296 (iENERAL PATHOLOGY AND SURGERY. avoided, as coiatain much saccliarine matter. Wines, beer, and alcoholic liquors, are all apt to disao^ree ; but especially port and Burgundy, while dry sherry — as Amontillado or Manzanilla — and the Rhine wines, may be taken in moderate quantity. Tea and coffee often prove detrimental ; whereas, boiled milk, water, soda and seltzer water, may be drank freely. Respecting the salutary efficacy of moderate and regular exercise, the same authority leaves no doubt as to his decided opinion : " For although," says he, "the pain and the great inaptitude for motion may seem to contra-indicate that I'emedy which I have so much extolled — exercise — it must still be undei^one. At the beginning of a fit it may appear impossible for the patient even to be can-ied to his carriage, much less to bear the motion of it ; yet if he make the attempt, in a short time he will feel as little pain when driven in his coach, as when seated in his elbow-chair at home. And again, in regard to the kind of exercise, riding on hoi'seback, unless forbidden either by old age or a calculus, is by far the best. Indeed, I have often thought, that if any person knew a remedy of Avhich he wished to make a secret, equally efficacious in govit as i^gular riding on horseback, he might make a fortune." Guided by the pathology of gout, we are led to rationally administer certain medicines in aid of our hygienic preventive measures. Alkalies — of which the bicarbonate of potash is perhaps the most efficacious for prolonged use — may be administered daily, to neutralize any fresh accession of acid ; and colchicnm, as a diuretic, will aid the elimination of ui^te of soda by the kidneys. The mineral waters of Yichy, Wiesbaden, and other places of known repute, owe their virtue chiefly to similar qualities. To illustrate the prophylactic management of gout. Dr. Garrod relates a case, on the authority of Sir H. Halford, in which colchicum with quinine taken in moderate doses daily, gave immunity for two years, when previously scarcely two months elapsed without an attack. Curative Treatment. — Having due regard to the origin of the gouty diathesis — by mal-assimilation, primarily or secondarily — hy- gienic measures are also curatively important. A reduced proportion of animal food is obviously the leading curativ©^ measure, and active exercise daily to increase the elimination of any excess is equally necessary. The effect of increased bodily exercise may be to increase the destructive metamorphosis of the highly nitrogenous textures, i.e. muscle, and thus directly increase the production of uric acid ; but this may also react beneficially in subsequently coiTecting the mal- assimilation. No remedial measui"es are at present known for directly correcting mal-assimilation in respect to uric acid. Uric acid passing off in the urine as urate of ammonia, the latter is liable to be decomposed by the action of any free acid present in the urine ; and uric acid being insoluble, it appears as a deposit of reddish-yellow sand, consisting of crystals, which may aggregate and form a calculus. The administration of alkalies to nejitralize the. acidity of the urine is indicated, of which bicarbonate of potash is, perhaps, the best for oft-repeated use. Other alkalies employed for this purpose are the bicarbonate of soda, the acetates, tartrates, and citrates of s'^da and^ potash, phosphates of soda and ammonia, and GOUT. 297 borates of soda and potash. Hence the therapeutic efficacy of vaiious mineral waters, to which gouty patients resort : the waters of Yichy, Homburg, Wiesbaden, Carlsbad, Kissengen, and Ais-la-Chapelle. The removal of any source of acidity is also indicated ; but this refers chiefly to hygienic considerations. Thus, Avlth regard to food — as already noticed — the vegetable acids, or that -which will form them, as sugar or starch in the food, should, in Dr. Benoe Jones's opinion, be prohibited. On the other hand, free perspiration should be promoted, to eliminate the acids of the sweat, the retention of which would precipitate uric acid in the urine, and thus lead to the formation of calculus. Warn\ clothing, warm bathing, friction with horse-hair gloves and belt — an excellent stimulant — and diaphoretics, are there- fore most efficacious adjuncts in the treatment of the gouty diathesis. The Turkish bath is often very salutary ; provided that the patient subjected to this ordeal, is not affected with any important structural lesion of the heart or kidneys. Urate of ammonia being soluble in urine at the temperature of the body, its solution is secured, provided only that that fluid be not over- charged. Dilution of the urine will best prevent supersaturation and deposit. The free use of aqueous drinks or soda water, is calculated to fulfil this indication, and thus probably prevent the formation of a urate of ammonia calculus. Diuretics, which increase the secretion, will also aid the dilution of the urine ; and in both ways tend to eliminate lithic acid or lithates from the system. The wine of colchicnm, in doses of ten minims and upwards three times a day, prescribed with the carbonate of potash to keep the lithic acid in combination — the resulting lithates being further held in solution by the administration of diluents — will to- gether carry off the morbific matter, and soothe the irritability of the bladder which accompanies its discharge. Lithia water may be drank with probably great benefit ; acting as a solvent of lithic acid, besides rendering the urine neutral, and having a diuretic or eliminative influence. Saline aperients seem to aid this desirable insult. Any prolonged subjection to such a course of elimination, r-equires also the simultaneous action of small doses of blue pill, apparently to maintain the secretion of bile, which otherwise being" retained as compared with the secretion of urine, would disturb the balance of their constituents in the blood. Local applications may be resorted to for the relief of pain. Thus, various anodyne lotions are us,ed i such as that recommended by Dr. Garrod, — a solution of atropine, two to three grains in a weak mixture of spirit and water. An inflamed joint is enveloped in lint, saturated with this lotion ; evaporation being pr-evented by a covering of oiled silk. Or the tincture of aconite may be equally soothing. The hypodermic injection of morphia — a third of a grain of the hydro- chlorate — also affords relief. Of coarse the part affected should be rested, and placed in an elevated position, — when the patient is not in bed. And, as any exposure to cold might be followed by the dangerous symptoms of retrocedent gx)ut, the pai't should be wrapped in flannel or cotton- wool. In chrome gout, certain remedies — beyond the preceding general course of treatment — are more especially of vak^e. Then it is, that the iodide or bromide of potassium allays pain, and subdues the local 298 GENERAL PATHOLOGY AND SURGERY. inflammatory swellings ; guaiacum is beneficial in the more asthenic condition of the disease ; while quinine, iron, and ai'senic tend to sustain the strength, in the course of repeated attacks. At the same time, mental tranquillity, and freedom therefore frora the excitement and depression of a busy life, with often its contingent anxiety, will do much toAvards keeping the gouty diathesis in subjection. But this part of our programme may be recommended under circumstances which render such advice difficult for the patient to follow. DISEASES OF CONTAGIOUS OKIGIN. CHAPTER YII. Bt tlie general term Contagion is meant the communication of Disease, either bj external contact with morbid matter, perhaps of an imper- ceptible kind, or through the inhalation of such matter in the atmo- sphere by the act of breathing-in, which is sometimes distinguished as Infection. The disease produced by the former mode of contact is not necessarily constitutional, but, possibly, merely a local affection ; e.g., Itch, as contrasted with secondary or constitutional Syphilis. Certain Diseases of the Blood, which come within the province of Surgery, are naturally associated, as being Contagious, or the offspring of Contagion ; Syphilis, Erysipelas, Pyaemia, Hospital Gangrene, Hydrophobia, Snake-bites, Malignant Pustule, and Glanders. Of these diseases, the first four are derived from the human species, the remaining four from animals. This distinction allows a corresponding division of the whole class. Syphilis. Syphilis is essentially a blood-disease, produced by the introduc- tion of a specific virus or poison into the general circulation. Its introduction, by local contact or by inoculation, is attended with certain tolerably definite manifestations in the skin or mucous mem- brane of the part, and in the proximate lymphatic glands, in the form of chancre and bubo, respectively, — constituting primary or local syphilis ; while the consequent blood-disease is manifested by certain tolerably definite inflammatory modifications of nutrition in the skin, mucous membranes, eyes, testicle, periosteum, bones, and other parts, — constituting secondary or constitutional syphilis. But the term Syphilis is also understood to signify an entirely constitutional disease ; the term Chancre being restricted to the primary lesion or ulcer at the point of inoculation of the virus, which, followed by lymphatic absorption, in the form of bubo, gives rise to systemic infection or Syphilis. The so-called Chancroid, or simply Local Contagious Ulcer, would thus be distinguished from Chancre, by the absence of systemic infection. Gonorrhoea has long been recognized as an entirely distinct disease, arising from the contagion of another species of virus, which produces an inflammatory discharge from the urethral mucous mem- brane, of a contagious character, but which does not infect the system. These three diseases, Syphilis, Local Contagious Ulcer, and Gonor- 300 GENERAL PATHOLOGY AND SURGERY. rhoea, alike arising from impure sexual intercourse, are included under the common term — Venereal Disease. Prhnary and Local Venereal Ulcers. — (1.) Chancre, and its Diagnosis. — Chancre is a primary si/philific soi-e or ulcer. After exposure to contagion or inoculation, a period of incubation ensues, daring which nothing is discernible, and the individual thinks himself well. The duration of this period varies, averaging from two to three weeks, and being I'arely under a week (H. Lee), but, perhaps, extending to five or six, and very rarely to eleven weeks. (Bumstead.) Then the primary manifestation of syphilis begins. Commencing with a trifling itching, affecting usually some spot in the furrow at the base of the glans penis, near the frsenum, or it may be on the prepuce or the skin of the penis itself; there soon appears, as the initial lesion, a small pimple, whose summit speedily becomes a vesicle, containing a thin transparent fluid-lymph, or becoming thicker and opaque — in fact, purulent — when subject to imtation. The vesicular stage of chancre is seldom met with. I have seen it only twice. This vesicle or pustule bursts and forms an ulcer. If the syphilitic virus be introduced through a crack or abrasion, >vhich may happen in the act of inter- course or have existed previously, the chancre forms an ulcer, without any incipient pimple or vesicle ; obviously because the cuticle there raised by secretion, was here removed. The primary syphilitic ulcer may appear in either of two forms, (a) A superficial erosion, flat or elevated, when the subjacent in- duration has taken place. The shape of this Fig. 92.* sore is circular, but sometimes irregular ; and it has a smooth or polished surface, of a red or greyish colour, overspread with a discharge consisting of lymph-globules and epithelium scales. Or, (6) the ulcer presents a small circular cnp-sJiaped cavity (Fig. 92), having a smooth, red interior, without granulation, and discharging a thin serous fluid, or glazed with a little adhesive lymph, and set in apparently healthy texture. About the end of the first week, and never before the third day, chancre becomes indurated, and circumscribed, like a split pea, by an effusion of plastic lymph beneath its base, and around the ulcer ; its colour now having a fawn hue, or assuming various shades of brow'n or red, according to the secretion. A single exception is met with in chancre on the glans penis, which rarely acquires indura- tion. It is here simply a spot denuded of cuticle, and having a red, moist, glistening, flat surface, (c) Occasionally, no ulcer is produced, nor perhaps any discoverable breach of surface ; but induration appears in the forni of a hard knot or tubercle, imbedded, and covered with epithelial scales. Diagnostic value of Induration. — When confined to the base of the ulcer, induration of an elastic, cartilaginous hardness, and terminating abruptly, was regarded by Hunter as characteristic of true chancre. Yet he acknowledged that this indurated base is not peculiar, being common to other indolent ulcers. When affecting the texture around, as well as the base of the ulcer, M. Ricord f regards cartilaginous * Eoyal Free Hospital, f " Lectures on Chancres," trans. C. F. Maunder, 1859. SYPHILIS. 301 indaration, thiis disposed, as absolutely pathognomonic of ^^ infecting chancre," or that species which accompanies and denotes constitutional syphilis. This kind and form of induration is, indeed, the local ex- pression, hj chancre, of the syphilitic blood-disease, — the first secondary symptom. The latter doctrine is supported by the authority of Pro- fessor Bumstead, of Ifew York, and Mr. H. Lee, and is now generally accepted. On the other hand, the fact should not be overlooked that precisely the same condition of induration may be produced artificially, by irritating applications ; such as kali pnrum (Hennen), corrosive sub- limate (Acton), and better still, says Ricord, by chromate of potash, nitrate of silver, or the nitric and sulphuric acids ; " so as to deceive even the most careful and experienced practitioners." The duration of chancre, as an open ulcer, is commonly a period of some weeks ; it continues often until after the appearance of secondary symptoms, and being thus indolent and indisposed to heal, it then cicatrizes slowly and pei-haps imperfectly ; or the sore may reappear. Induration remains for a longer period, usually for at least two or three months ; especially when the chancre is situated in the furrow at the base of the glans penis. As instances of extreme per- sistence may be mentioned induration of two and three years, in several cases known to Bumstea.d ; nine years, in a case seen by Piiche ; and thirty years, in one instance, according to Ricord. On the other hand, induration may disappear before the chancre heals, leaving a perfectly soft base to the cicatrix. This occurs particularly in the parchment form of hardness, around a superficial chancre ; the deposit being limited to the mucous membrane, without involving the sub- cellular texture, it is soon resolved. The termination of chancre is not attended with any loss of sub- stance, and thus there is no marked cicatrix. When situated on the skin, as the outer aspect of the prepuce, a brown or dusky-red dis- colouration often remains, which, however, at length fades away into a white colour. Chancre is generally solitary; although sometimes more than one such sore may be produced. It is protective against the recurrence of a similar sore, conferring a relative, but not an absolute, immunit7 against subsequent attacks. Thus, inoculation with the secretion of chancre fails to reproduce chancre in the same person, or in another person already affected ; in other words, chancre is neither capable of a%fo-inoculation, nor of ^eie?'o-inoculation ; the reason of non-repro- duction being, apparently, that the system or constitution is already under the influence of the syphilitic virus — syphilis is established. Whenever the discharge from an indurated chancre proves to be in- oculable, it never begets a similar sore, but only a pustule, and then some slight erosion or ulceration. The failure of reproduction may, therefore, be regarded as diagnostic evidence that the ulcer is a chancre. But it should be observed that no one character of chancre is invariably constant, nor peculiar to this species of ulcer, and, therefore, not absolutely pathognomonic ; neither its period of incubation, its circular shape, its induration, its indolence, nor its protective power, aud non-inoculable nature. Taken collectively, however, and in con- junction with an indurated or a bullety-hardened enlargement of the neighbouring lymphatic glands, forming a multiple indurated bubo, 302 GENERAL PATHOLOGY AND SURGERY. the ulcer is then recognized as a chancre. The co-existence of secondary symptoms in constitutional syphilis, will of course strengthen the diagnosis. (2.) Chancroid, or the Local Contagious Ulcer. — Commencing as a pustule, which bursts, or occasionally as an open sore, the ulcer formed has a circular shape, as if punched out (Fig. 93) ; but the base pre- sents a cellular or honej-combed, worm-eaten appearance, and is covered with a greyish-yellow membranous secretion, consisting of disintegrated texture and pus-globules ; and the margin of the ulcer is a little undermined and vertical, instead of sloping inwards to the base, as in hard chancre. No induration ensues, so that when the prepuce, for example, ^^^- 93.* is retracted, the ulcer bends upon itself, instead of rolling over en viasse, like the in- durated chancre ; and on raising the sore between the thumb and finger, it feels quite soft and doughy, its edge and base moving easily, and a little pus oozes out ; it is a soft and supptirating ulcer, the " soft chancre," or the " simple, non-infecting chancre," so named by Ricord. Attended with some loss of substance, the ulcer heals by granulation, gene- rally in a shorter period than chancre, and cicatrization leaves a depressed and per- manent scar. This soft, suppurating sore has no period of incuba- tion ; it appears from two to four, rarely five days, or within a week, after exposure to contagion. Chancroid is much more common than chancre ; perhaps in the proportion of 4 to 1, though some say 3, or only 2 to 1. It may be solitary, but is often multiple ; and it affords no protection against recurrence, conferring no immunity whatever for the future. The ulcer is reproductive by inoculation, and the reproduced sore can be propagated in like manner. Hence, this fact supplies a diagnostic test of chancroid ; or, as often happens accidentally, the purulent secre- tion affects contiguous parts. The ulcer is sometimes associated with a soft and suppurating enlargement of a neighbouring lymphatic gland, as in the groin— a suppurating bubo. The possible co-existence of chancre and chancroid — the indurated and the soft, suppurating ulcer — or of either species with gonorrhoea, must not be overlooked. And the co-existence of the two species may occur in the same sore — a suppurating ulcer, with an indurated base, an auto-inoculable discharge, and which is capable of communicating * Chancroid ulcer on penis ; and ulcer of chancroidal bubo. (Author.) SYPHILIS. 803 syphilis to an uninfected person. Such is the mixed chancre of Rollet and the French school. The consequent bubo may be both indurated and suppurating. Mixed chancre is produced bj double inoculation, occuring' perhaps at the same time ; as in sexaal intercourse, when a healthy man has connection with a woman having both a chancre and a chancroid ; or the inoculation of either species may be engrafted upon a pre-existing ulcer of the opposite species. In either case, when fully developed, m.ixed chancre can be propagated, in both its kinds, by successive inoculation from one person to another. But prior to full development, when double inoculation has occurred, chancroid first appears, which by contagion will only reproduce itseH ; and towards the close of ulceration, whichever kind of sore lasts the longest, it will reproduce itself only. Chancroid may be contracted by an individual aiSected with secondary or tertiary syphilis ; and the ulcer then retains its identity of character, and runs its course. An apparent interchange of the two kinds of ulcer is liable to happen, temporarily, from various accidental circumstances; so that the chancre, even when indurated, may perchance suppurate for a while, owing to some cause of irritation ; and the soft sore may, for a time, become somewhat hardened by irritation, although it still discharges a purulent fluid. But, when the disturbing cause is removed, either kind of ulcer re-assumes its original and distinctive characters. The conversion of indurated chancre into the soft chancroid ulcer, would seem to be an admitted possibility, according to the view advocated by M. Clerc, and other observers ; that the soft sore is a derivative from hard chancre, as resulting from the transmission of the syphilitic virus through the system of a person who had already undergone syphilitic infection. This relation of chancroid to chancre would be analogous to that of the varioloid eruption to variola, or of the false to the true vaccine pustule. Diseased Conditions of Chancre, and Chancroid ZTZcer.— -Either of these specific ulcers may assume the characters of some ordinary form of ulcer, under circumstances referable to the state of the general health, and that of the digestive organs in particular^ Thus, the ulcer may become irritable, or painful and disposed to bleed ; if inflamed, the usual appearances of this kind of ulcer are presented. Phagedcenic chancre appears as an irregular sore, with sharp, undermined edges, and a worm-eaten surface, covered with a white or black slough ; serpiginous phagedaena is a variety distinguished by the creeping character of the ulceration, its unlimited extent and duration ; and sloughing or gangrenous phagedaenic chancre has the mixed characters which its name implies. The three last conditions of ulceration are very destructive, especially the latter variety. When affecting the prepuce, this part becomes greatly swollen, brawny, and dusky red ; but the phimosis or contracted state of the preputial orifice, conceals the ravag'es beneath ; a black patch appears, and sloughs, disclosing the glans, or if the foreskin be split up with a bistoury, the phagedeenic ulcer is discovered, and perhaps only a remnant glans. The existence of chancre, as an ulcer having any distinctive characters, has been altogether denied by many observers of known 304 GENERAL PATHOLOGY AND SURGERY. accuracy and large experience. First: Rose* (1817), whose experience in the liospital of the Coldstream Guards i-anged over a large number of cases, admitted that although there are many symptoms common to chanci-es, they are not entirely peculiar to them. Hennen f (1829) acknowledged with regret that there are " not any invariable character- istic symptoms by which to discriminate the real nature of the primary sore;" and, having witnessed many instances of self-deception, in attempting to diagnose a sore for the cure of which mercury is indis- pensable, from one of a different nature, he repudiated the pretensions of those who assume-to themselves the possession of a iachis eniditus by which they can distinguish this kind of chancre. Recurring to the diagnosis of chancre, rather than the kind, Mr. Bacot's experience J (1829) led him to affirm, that chancre may present every variety of appearance to which a breach of surface is subject ; and Colles § (1 837) stated, " as the result of long, attentive, and anxious observation," that primary venereal ulcers present an almost endless variety of character. To this effect also were the observations of Wallace || (1838) ; for, says he, neither the mode of origin, nor the form, nor the colour, nor the size, nor the number of the ulcers of primary syphilis, are pathogno- monic. Acton 5r (1851) avowed it was incontrovertible, that other sores, not of a specific nature, may assvime all the aspect of real chancres; and Labatt** (1858), considering the great variety of appear- ances presented by primary ulcers, experienced the difficulty of classi- fying them, and confessed that hitherto every such attempt had ended only in disappointment. Mr. H. Lee recognizes four different morbid pivcesses and corre- sponding forms of Primary Syphilis : — First. The inoculated part may become affected with the adhesive form of inflammation, in which lymph is poured out either in the substance or on the surface of the part. Second. The inoculated part may, within a few days of the application of the poison, be affected with siippurative inflammation. Third. The lymphatics may assume an active share in the morbid process, and taking up some of the infected parts, and with them portions of the syphilitic poison, produce an acute inflammation of a lymphatic gland. This form of the disease is termed idcerative in- flammation. Fourth. The morbid action may terminate in ^mortification. Of this there are two practical subdivisions : — (a) Death of the whole infected part, which is then thrown off as a slough ; (b) Dissolution and death of a part only of the contami- nated structure, leaving a part still infected. Situation. — The external parts of the genital organs are obviously the common situation. of chancre, and some parts are more especially liable. Thus, in the male, that portion of the penis is commonly the seat of chancre, which having been exposed in sexual intercourse, is apt to retain any secretion with which it came in contact. Hence, the * Med.-Chir. Trana., vol. viii. p. 358. t " Milit. Surgery," p. 525. J "Treatise on Syphilis," p. 149. § " Prac. Obs. on Venereal Disease," p. 75. II " On Venereal Disease," p. 84. IF " Diseases of Urinary and Generative Organs," p. 380. ** " Obs. on Venereal Diseases," p. 48. SYPHILIS. 305 furi'ow between tlie glans and prepuce, and perhaps near the freenum, is the most frequent situation ; but chancre may form on the inner surface, or at the margin of the prepuce, or on the frgenum ; sometimes on the glans, or at the orifice of the urethra, or perchance on the skin of the penis. Urethral chancre is, however, not unfrequently met with ; the chancre being situated immediately within the orifice of the urethra, or higher up in the canal. In the one case, it miy easily be seen on just everting the lips of the urethral aperture ; in the other case, it can be felt as a more or less nodulated induration of the urethra when pressed between the thumb and finger. Chancres thus situated have been found by Ricord to extend along' the whole canal up to the bladder, in rare cases. Urethral chancre emitting its discharge from the external orifice, may be mistaken for gonorrhoea ; but, while their diagnosis cannot be determined by the variable appearance of the discharge, inoculation will evince its true nature ; a chancre being' pro- duced if the matter be syphilitic, and not by gonorrhceal discharge. The presence of a nodulated induration in the urethra will corroborate the diagnosis. In the/emaZe, also, the external genitals are the common situation of chancre, as just within the labia minora ; less frequently on the mucous membrane of the vagina, or on the os uteri, or within the cervix. Examination will readily discover a chancre when situated externally; but the speculum must be used to detect the presence of a vaginal or uterine chancre. In certain unnatHral situations, chancre may occasionally be found ; as at the anus, or on the lips of the mouth ; suspicious of practices which need not be named. Bubo, and its Diagnosis. — Bubo is a generic term, signifying a swelling of the lymphatic glands, and specially those of the groin (/JovySwv, the groin), of an inflammatory character, acute or chronic, and with or without suppuration. It may arise from any cause of local irritation, affecting the lymphatic vessels continuous with the glands, producing sympathetic bubo ; or proceed from the absorption of poisonous matter, or virus ; or it may depend on constitutional causes, as scrofula. (1.) Syphilitic or Indurated bubo denotes absorption of the syphilitic virus from the primary sore, which, on its way to the blood through the lymphatics, irritates the neai'est lymphatic glands — commonly the inguinal — whereby they become swollen and hai-d, and perhaps suppurate. Compared with chancre, bubo can scarcely be called a primary symptom, for although the time of its accession after chancre is uncertain, it is always somewhat later. On the other hand, it has been held that bubo may possibly arise from direct absorption, without the previous formation of chancre ; that bubo may thus be the only primary symptom. Such, buboes, therefore, have been named " primary buboes," and by the French, " bubous d'emblee." But the existence of non- consecutive bubo, as indicative of true syphilis, is inconsistent with the present state of knowledge ; although a simple inguinal adenitis may arise without any appreciable lesion of the genitals. Indurated bubo begins at a period of about eleven days (RoUet), and never later than two weeks (Ricord), after the commencement of chancre ; or, usually, at a somewhat earlier date, the time when induration of the base of the chancre takes place. (Bumstead.) It VOL. I. X 306 GENERAL PATHOLOGY AND SURGERY. appears as a hard, bulletj, and scarcely painful swelling of the lymphatic gland, nearest to the spot whence the poison was absorbed ; the lymphatics themselves proceeding to the enlarged gland, share this inflammatory induration, and sometimes feel like hard whipcord. Along the back of the penis, such cords may be felt leading to the groin, where generally, just above Poupart's ligament, lies the swollen, bullet-like gland. In the female, if a chancre be situated on the fore part of the vulva, this swelling is found at the external abdominal aperture; if situated posteriorly, then betwixt the labium and the thigh, inflamed lymphatic vessels lead to a swollen, hard gland in the groin. Commonly, as Bassereau observes, more than one gland is affected, forming a multiple bubo, of small olive-shaped or globular tumours, having a cartilaginous hardness, and which are freely mov- able upon each other, being unattached to surrounding tissues, or to the overlying integument ; and this little mass corresponds in direction to the inguinal fold. Almost painless, or only slightly tender, it does not interfere with walking. Sometimes the bubo is situated on the opposite side of the chancre ; or both groins may be affected, presenting double inguinal bubo. Chancres within the urethra, on the perineum, the anus, the mouth or neck of the uterus, the lower part of the abdomen, or the buttocks, are equally associated with inguinal bubo. But, when the vessels of absorption pass through other than the inguinal glands, the bubo will be situated elsewhere. Thus, Hunter saw a syphilitic bubo far down on the thigh. The course of indurated bubo is slow ; reaching its full develop- ment in a week or two, its ultimate duration varies from several weeks to five or six months (Bumstead), or may be prolonged even to a period of years. (Ricord.) Like chancre, it is thus essentially indolent and usually more persistent. It terminates by resolution : suppuration is a rare event, having occurred in only sixteen out of 383 cases, according to Bassereau, while Fournier met with only two in 265 cases. This species of bubo almost invariably follows a chancre, itself indurated; follows it, observes Ricord, as a shadow follows a body; and the constancy of this sequence is attested by Fournier's report, that 265 cases of chancre were succeeded by bubo in 260, and in only three of these was the absence of induration from the outset certain. This constancy of connection with indui-ated chancie con- firms the diagnosis as to the natui'e of the bubo. But, occasionally, induration may arise from some other disease ; thus far simulating syphilitic bubo. Scrofulous enlargement of the inguinal glands exhibits a somewhat hard and indolent swelling; the accompanying constitutional condition and history are, however, distinctive of scrofula. Cancerous enlargement of the glands will probably be con- nected with cancer of the penis. (2.) Injiammatory Bubo. — Arising from any cause of lymphatic irritation, and commonly from gonorrhoea, this species of lymphatic glandular enlargement is then named simple adenitis or sympathetic bubo ; but as proceeding from chancroid ulcer, by the abscjrption of its virus, it may be designated chancroidal bubo, being in fact a chan- croid of the lymphatic gland affected; or it is also known as virulent bubo, owing to the contagious character of the pus produced. Beginning usually within a fortnight after the appearance of SYPHILIS. 807 chancroid on the genitals, one gland only, or sometimes more, presents a swelling in the groin, but the enlarged gland is somewhat soft, never indurated, and decidedly painful, so that the patient walks with a limping lameness ; differing in all these particulars from indurated bubo, in connection with chancre. This state may last for an indefinite period, as an indolent bubo ; and then sabside by resolution, when resulting from simple adenitis. Or, the gland enlarging, it engages the fascia and skin, whereby the tumour becomes adherent and fixed. Suppuration may then ensue from simple inflammation ; and chancroidal bubo always proceeds to this issue. The integument acquires a purplish-red hue, and a stretched, shining appearance, while the cuticle is shed in receding circles, and the cutis becomes thinner. At some softer point, fluctuation can be felt, the thin skin cracks, and matter exudes from the interior of the gland, and from around ; or the circumferential abscess bursts first, a few days before that within the gland. The ulcer formed assumes all the characters of chancroid (see Fig. 93) ; its interior being overlaid with a greyish-yellow membranous secretion, its margin undermined and vertical or everted, while the pus from within the gland is auto- inocalable, — any abrasion of the surrounding skin thus reproducing a chancroid ulcer, or inoculation can be artificially effected. Chan- croidal bubo may be thus distinguished from the bubo of simple adenitis, and from the indurated bubo of syphilis, — -in the rare form of its suppuration. Associated causes will confirm the diagnosis. Thus, simple adenitis may arise from the local limitation of gonorrhoea, balanitis, vulvitis, herpes, eczema, or other inflammatory affections of the genitals ; or from a crack or abrasion in seminal intercourse ; from over-sexual indulgence ; or from muscular exertion, as in walking, dancing, or rowing ; and occasionally, from the presence of a chancroid or a chancre, acting as a source of local irritation, not of absorption. (Bumstead.) On the other hand, chancroidal bubo is connected with a causative chancroid; as indurated bubo is with indurated chancre. The ulcer of chancroidal bubo may acquire all the characters of some common ulcer ; as the indurated and indolent, the irritable, the inflamed, the phagedcenic, the serpiginous form of phagedena, or the sloughing pha- gedcenic. The three latter forms of ulcer, originally chancroidal, are more or less destructive ; the ulcer sometimes increasing to an enormous size, extending inwards over the perineum, or upwards perhaps as high as the navel, or downwards on the thigh, while its depth may there threaten the femoral artery. Diagnostic value of Inocidation.— Does inoculation supply the posi- tive test of Syphilis ? The answer to this question will be yes or no, according to whether or not the so-called chancroid ulcer be acknow- ledged as a species of chancre. The failure of inoculation to reproduce a chancre upon a person already affected, affords only a negative result, as the evidence of pre-existing systemic infection, i.e. of Syphilis ; and reproduction of the ulcer by inoculation indicates its locally con- tagious nature, i.e. its chancroidal character, as disting'uished fi*om chancre. Bearing in mind this negative and positive result of inocula- tion, we are prepared to understand, and to reconcile, the apparently contradictory results of observation respecting the question at issue. The virus or pus from a supposed chancre, or a suppurating bubo, being introduced beneath the skin of any part by a lancet charged 308 GENERAL PATHOLOGY AND SURGERY. therewith, produces another such chancre, — passing through the stages of a pimple, a vesicle or pustule, to the perfectly formed ulcer. Thence, in like manner, another such chancre may be produced. This power of reproduction was known to and used by Hunter, as a test of syphilis. But opinions have ever been divided respecting the diagnostic value of inoculation, just because the chancre and the chancroid ulcers may have been indiscriminately used in the cases submitted to this test. Evans, Bell, Sperino, and other observers have alike insisted on the value of reproduction by inoculation, in order to determine the specific nature of a supposed chancre ; and Ricord, who almost accords to '• induration " the rank of an absolute sign of the " infecting chancre," yet acknowledges that the individuality of this ulcer, as a distinct species, "exists neither in its form nor in its floor, nor in an absolute manner in any one of its external characters ; irs nature is in the pus which it secretes. Inoculation is the pathognomonic character of chancre, and which alone suffices to establish the diagnosis." But it is now known that Ricord's observations had reference to " simple chancre," aZias chancroid, or the local, contagious, and soft, suppurating ulcer. That, comparing the indurated and systeinic-infecting, true chancre with this chancroid ulcer, as to the results of inoculation, in forty-foiir inoculations of the latter, on individuals ah-eady affected, there were forty-four reproductions of the original kind of ulcer; but that in fif ty-fiv^e inoculations of the former kind, — chancre, — there were fifty-five sterile results ! Consequently, the answer of Inoculation as a diagnostic test, is ; of chancroid, positive, — that it is auto-inoculable ; of chnncre, neqatire, — that it is not auto-inoculable. And this negative result of inoculation is so far available in the diagnosis of Syphilis. It is, therefore, probable that the supposed instances of positive result adduced bv Dr. Sperino, were from simple suppurating sores, with some amount of accompanying induration. In ninety-nine cases of in- durated chancre, in only one instance did inoculation succeed upon the patient who thus had the disease, and that was within a very short time after contagion. Such is Fournier's experience. Puche could produce auto-inoculation in only 2 per cent. Poissou obtained a similar proportionate result in fifty-two cases of trial ; and Laroyeune was unsuccessful in every one of nineteen cases. Bumstead observes that the failui-e of inoculation is fav^ourable to the supposition that the sore is a chancre. In the earliest stage of chancre, before its specific action upon the patient's constitution has been developed, the result of inoculation may be a specific hardened sore, accurately resembling the original. So far jMr. Lee concedes the positive value of this test. But that as soon as the specific adhesive inflammation has once taken place in a patient, his system is no longer in the same condition as before ; he is no longer capable of being inoculated, and inoculation, if attempted, in the vast majority of instances, entirely fails. M. Clei'c's observa- tions (1855) lead to the conclusion that even the initiatory sore of syphilis is non-inoculable, in most cases. • The diferential nature of chancre and chancroid can, however, be readily discovered by inoculation. The power of reproduction is inborn in chancroid, and available, therefore, as the test, from the very first formation of lymph, when the chancroid is yet a pustular pimple. Inoculation is the earliest, and the most infallible, criterion of chancroid. CONSTITUTIONAL OR SECONDARY SYPHILIS. 5^09 What if this method of diagnosis be postponed to a later period ? Even then the open suppurating buho is a chancroid, and its pus will produce another such ulcer by inoculation ; not the pus secreted in the cellular tissue around the suppurating gland, but that which issues from the gland itself. Here, then, is an additional positive test, diagnostic of chancroid from the negative answer of hancre. Inoculation should be avoided whenever the patient's constitutional condition is broken down, or the ulcer of a phagedsenic character; the site chosen should be some portion of integument not liable to phage- daena, as the skin on the chest ; and the inoculated point should be freely cauterized with nitric acid, as soon as the diagnosis of a resulting chancroid is determined. The little operation is thus described by Prof. Bumstead : — Take a clean lancet, moisten its tip with the purulent secretion, and enter the point perpendicularly with a slight impulse, not deeper than to the vascular layer of the skin ; the instrument is then turned once round on its axis, and withdrawn, and any remains of the pus upon the blade is smeared over the orifice of the puncture. jSTo after care is required. Duration of Specificity. — Chancre retains its specific nature for a considerable period, frequently weeks, sometimes months, — in one of my own cases, probably eight months, during which time the sore can communicate the disease to an unaffected person. This period of " stattt quo specific," thus of uncertain diiration, extends to when the ulcer cleanses itself, begins to throw out healthy granulations, and to cicatrize from its circumference. These, therefore, are the signs of the loss of contaminating power. Bubo, however large, which has arisen from a chancre when about to heal, is simply a swelling of the lym- phatic gland, which, as Ricord observed, fails to supply virulent matter in the event of suppuration. Chancroid, or the soft, suppurating ulcer, mostly cicatrizes in the course of a few weeks ; but the period of repair may be prolonged much beyond, the sore retaining* its virulent specificity of local contagiousness up to the last moment of its exist- ence ; while, indeed, cicatrization is proceeding at the circumference, the pus is specific in the centre of the iilcer, and may propagate chancroid in a neighbouring part, or in another person. But different modes of therapeutic treatment will affect the duration of specificity, and must be taken into account. The mei'curial and non-mercurial methods of treatment have a different influence on chancre, in this respect, and unfavourable to the former method, in its prolonging or not curtailing the period before healing, — that period beiug taken as the indication of continued specificity. Thus, to com- pare the large collections of cases by Sir James M'Grigor and Sir William Franklin.* In 1940 chancres collated indiscriminately, and which healed without mercury, the average period was, without bubo, twenty-one days ; with bubo, forty-five days ; whereas, in 2827 chancres, including a large proportion of indurated sores treated with mercury, the average period prior to healing was, without bubo, thirty-three days ; with bubo, fifty days, — a longer continuance of the specific nature under the influence of mercury. Syphilis — Secondary or Constitutional. — The blood having become infected with the syphilitic virus, after the appearance of chancre with induration, in the course of a month or six weeks, or a longer period, * " Mjlit. Surg.," by Hennen, 2nd edit., p. 545. 310 GENERAL PATHOLOGY AND SURGERY. a constitutional disturbance — the syphilitic fever — ensues, in a degree more or less marked. According to the observations of Dr. Guntz, the period of its accession varies to within fifty and sixty-five days, in the natural course of the disease, unaffected by treatment ; but that no fever appears within or even bej'ond that period, wlien, from imme- diately after infection, tlie patient has been brought under the influence of mercury, used internally or externally. The symptoms of febrile disturbance are tho.se of oi"dinary pyrexia ; some acceleration of the pulse, a dry, hot skin, and furred tongue ; succeeded by great debility, wandei'ing pains, and gradual emaciation, with the wan sallowncss of syphilitic cachexia. Occasionally, Guntz has known a violent rigor or shivering fit to precede the symptoms. The temperature always rises considerably, perhaps to 103i° F., in the first twenty-four hours ; then, on the second day, it falls much lower, followed perhaps by evening exacerbations daily, for a long time. With the accession of .syphilitic fever, various inflammatory modi- fications of nutrition are developed, which have a tolerably regular order of sequence, in different parts of the body. As manifestations of the blood-disease in opei-ation, they ai'e " secondary," or even " tertiary " to the chancre and thence the bubo, which, proceeding from the original source of infection, constitute "primary " syphilis. The slow-healing power of the primary ulcer, and of the bubo, when, as a rare event, it suppurates and forms an ulcer, somewhat suggest the prevailing character of these secondary manifestations. From the first moment of the pus-forming pimple, the whole career of .'iyphilis is one of disintegration of the tissues, with an abortive effort of the repai-ative power b}^ plastic lymph-forming induration. Dis- integTation, by desquamative or other destructive eruptions of the skin ; disintegi'ation, by corroding ulceration of the tonsils, tongue, lips, palate, and perhaps the nose ; disintegration, by iritis, with molecular lymph ; disintegration, by iri*eparable destruction of the texture of the testis ; disintegration, by cariies and necrosis. Premature baldne.ss, fretting ulceration around the roots of the finger and toe nails, and a wan cachectic pallor, bespeak the consummation of syphilitic decay. During the course of secondary syphilitic manifestations, certain facts respecting the accession of rigors and rises of temperature merit attention. In the eruptive stage, the pyrexia is sometimes associated with repeated rigors, as noticed by Laucereaux ; and they may assume an intermittent character — quotidian, tertian, or double tertian. But this intermittent type of febrile disturbance is met with generally in the later stages of syphilis, when deep cachexia has supervened. The temperature rises, perhaps, from time to time, coincident with the extension of skin-eruptions. In the later stages, when syphilitic affections of the bones and joints have ensued, the observations of a committee of inquiry on temperattire * led to some notable results ; that in the febrile disturbance which usually accompanies, and is pro- jjortiouate to the amount of joint or periosteal affections, nocturnal exacerbations occui% the temperature rising fi'om one to four degrees, with an equal morning fall. The association of rheumatoid symptoms with an equal outbreak of macular or papular eruption is accompanied with fever, but not with the oscillation of temperature. Iodide of potassium affects the fever remedially, the temperature being reduced * Tram. CUn. Soc, 1870. Keport by C. Baumber, A. B. Duffin, Berkeley Hill. CONSTITUTIONAL OE SECOND AKY SYPHILIS. 311 within three days after its administration in sufficient doses. In pyaemia, the oscillations of temperature much resemble those noted in syphilitic rheumatoid affections. Comparing (Secondary) Syphilis in all its various forms, with similar diseases arising from other causes, their resemblance is often remarkable, and their appearances differ rather in degree than in kind. Probably, therefore, none of the local manifestations of (constitutional) syphilis, as secondary symptoms, are singly characteristic ; but a con- currence of such symptoms — simultaneously or consecutively — may be diagnostic. The descriptions given in Mr. Lee's elaborate treatise, with regard to syphilitic eruptions, for the most part amply confirm this general proposition. (1.) Skin-diseases. — Similar eruptions — exanthematous or rashes, papular or pimples, tubercular, squamous or scaly, vesicular and pus- tular — arise alike, as manifestations of constitutional syphilis in the skin; and also under other circumstances. But, as modified by this disease, they are named Syjphilo-dermata, or Syphilides. Roseola or rose-rash. — The eruption which usually first succeeds the syphilitic fever, is of a rose-red colour, not raised above the surface of the skin, disappearing on pressure, and returning as soon as the pressure is removed. It arises in the form of more or less rounded patches, giving a mottled appearance to the skin ; when examined closely, each patch is seen to be made up of a cluster of papillee, more injected than natural. This eruption sometimes vanishes within a few days. If it persists, the papillae forming each patch generally become visibly enlarged, and the colour of the eruption gradually changes to a copper hue. This colour is commonly present in all syphilitic eruptions which remain for any length of time without suppuration or ulceration ; but it is not peculiar to (secondary) syphilitic eruptions, it is not patlio- fjnomonic. It is, observes Erasmus Wilson, commonly met with in chronic eruptions .of other kinds- — for example, in acne ; and non- syphilitic eruptions often possess more of the dull and muddy copper colour which is generally supposed to be characteristic of syphilis, than syphilitic eruptions themselves. Moreover, when present in un- doubtedly syphilitic skin-diseases, it does not supervene until their decline. The eruptions which follow this first efflorescence on the skin, exhibit a variety of appearances. Lichen, a papular eruption. — The papillae of the skin are enlarged separately, in the form of hard elevations having a copper colour, which terminate by desquamation or resolution. These elevations may be scattered irregularly over the body, or collected together into groups. Tubercular eruption. — Effusion of plastic lymph having taken place, it becomes organized, as in the papiilar eruption, but now in the form of small and tense conical eminences, covered with a red shining" cuticle ; which gradually acquire a copper tint, and shed their shining silvery scales of cuticle. The tubercles may be scattered singly over the surface, or aggregated into groups. Lepra, a scaly eruption, commences, like the mottled skin of roseola, by the injection of circular groups of papilla. The papillae are at first separate, but soon the whole circular patch becomes equally involved ; an effusion takes place into the substance of the skin, which then 312 GENERAL PATHOLOGY AND SURGERY. presents a small flat elevation, the edges of which ai-e sometimes raised higher than the centre. A copper colour, of a more or less decided hue, overspreads the eruption, but it is often partially masked by a thin layer of cuticle, which is shed in thin white shining scales, as in common lepra. Numerous patches, all perfectly circular, may form on any part of the body. Patches of syphilitic lepra sometimes much I'esenible flattened syphilitic tubercles. l^soriaais — another scaly eruption — appears in the foi-m of oval or irregular patches, slightly elevated above the surface, 'i'hey are not depressed in the centre, and ai-e often traversed by ci-acks or fissures. A copper or brown colour is often observable, but covered with epithe- lial scales of various degrees of thickness. This disease is much more persistent than syphilitic lepra. It occurs on the palms of the hands and soles of the feet, or oii any part of the body. Vesicidar eruptions, as manifestations of constitutional .syphilis, are similar to, if not identical with, vesicular eruptions not of syphilitic origin. Thus, in point of their origin only, we recognize sypldlitic herpes, eczema, and pemphigus or pompholyx. In all, an effusion of serous fluid raises the cuticle into vesicles, or blebs — bullae, which are simply large vesicles such as form in the last-named form of eruption. But the diagnostic characters of syphilitic vesicular eruptions are even less peculiar than those of the eruptions already noticed. l-'ustidar eruptions constitute also an analogoiis class to the non- syphilitic. They, like eruptions generally, may arise from the trans- formation of ottier eruptions, in the course of syphilis. Thus, the papular may change into the vesicular, and this pass into pustular. The proper pustular eruditions of .syphilitic origin ai-e divided bj Cazenave * into thi-ee kinds : — (a.) Psydraceous pustules, which are either small and narrow, or of large size, elevated, and round. They have a hard base, and are sur- rounded by a copper-coloured areola. The pustules are of a dull reddish hue, and are developed in successive crops ; showing examples of the disease in its origin, maturity, and decline. Their progress is slow, and the accompanying inflammation moderate. In some cases, however, it destroys the true skin, and leaves a small, white, circular scar, depressed in the centre, and not lai-ger than a pin's head. This form chiefly occurs on the face and forehead, where it somewhat re- sembles acne rosacea, but it may ajipear on every part of the surface. The pustules dry into a small greyish scab, which separating, may leave either a cicatrix or some injection of the skin. On the limbs, p.sydraceous pustules are of the size of a lentil, but slightly elevated above the surface, with a hard base ; and they contain a very small quantity of yellowish-white mattei", contrasting with the copper-coloui-ed elevation on which it rests. They are not followed by ulcers ; a thin scab forms on them, which is succeeded by a scar, or sometimes by a livid discolouration, or a small chronic induration. (b.) Impetigo, preceded by slight malaise. — This eruption com- mences with redness of the affected parts ; then small collections of purulent matter form irregular-shaped patches, more or less confluent, resting upon surfaces of a coppery-red colour, which are soon covered by scabs irregular in shape, harder, darker coloured, and more adherent than those of non-syphiiitic impetigo. Beneath these scabs are ulcera- * "Diseases of the Skin/' by Burgess. CONSTITUTIONAL OR SECONDARY SYPHILIS. 313 tions, followed by scars, varying in shape and extent. This eruption more frequently occurs on the face, but it may affect any part of the surface. It sometimes appears on several parts simultaneously, but it has no tendency to spread. It is always secondary. (c.) Ecthyma. — The pustules are still larger, — the size of a shilling, or more isolated, and few in number ; chiefly occurring on the limbs, and especially the legs. Commencing as large livid spots, the epi- dermis becomes raised over a considerable portion of each spot, by a greyish, sero-purulent matter, which increases slowly, and is always surrounded by a broad copper-coloured areola, unlike the violet-red of non-syphilitic ecthyma. After a few days, the pustales having broken, scabs form, which are of a circular shape, dark and hard ; gradually increasing in thickness they fissure at their edges, and are very adherent and persistent. On separating, they expose deep round ulcers, with sharp-cut hard margins of a purple colour, whilst the bottom is greyish. They have little tendency to enlarge. The scabs generally re-form, and repeatedly, until the ulcers heal; leaving' circular and lasting cicatrices. This is the most common species of syphilitic pustular eruption, and that which is usually met with in new-born children. Here, the jiustules are broad, superficial, flat, of an oval shape, and in great numbers ; the scabs are dark and thick, and conceal small ulcers underneath. The countenance of the patient has quite a peculiar appearance ; it is drawn in, and marked with numerous wrinkles, like that of an old person ; the skin has an earthy hue, the body is emaciated, and exhales a most disagreeable odour. Ulceration of the Skin in constitutional syphilis, may be either a sequel of some kind of eruption, or it may arise independently; the syphilitic blood-disease always predisposing to disintegration of texture. But the characters of any such ulcer can scarcely be reg'arded as jieculiar to syphilis. Ulceration of the skin in connection with disease of bone about the skull, is specially noticed by Mr. Lee, with reference to its apparent cause — irritation — rather than as arising from the direct influence of the syphilitic poison. The importance of this diagnosis, in relation to the appropriate treatment, is obvious. (2.) Diseases of Mucous Membranes. — Sore-throat ranks among the earlier and less equivocal secondary symptoms. It may appear in one of three forms, according to the stage of the disease, (a.) Tonsillitis, in the foi'm of erythema; a -diffuse, purple redness of the arches of the palate and the tonsils, with some swelling, giving to the mucous membrane a velvety appearance. This may be attended with ulceration, more or less superficial ; the surface then looking red and glistening, as if from an abrasion of the mucous membrane ; or it is covered with a pellicular film, of a dirty- white or greyish-yellow colour. This ordinary soi-e-throat is met with in an early stage of syphilis, — from three to eight weeks after chancre. Apart from other symptoms, — usually an erythematous eruption of the skin, or roseola, — the throat affection might be mistaken for a common catarrhal ton- sillitis. (6.) Chronic congestion of the tonsils, which may be slighth' reddened, or have an ash-grey colour, and are much. swollen and con- solidated ; the tonsils appeai^ing as two fleshy bodies, roundish or per- haps somewhat taberculated, and projecting across the throat, so as to almost close the passage. This chronic enlargement of the tonsils 314 GENERAL PATHOLOGY AND SURGERY. occurs at the fully developed stage of the secondary symptoms, or may be an early tertiary symptom. It bears a resemblance to scrofulous tonsillitis, but the co-existence of other manifestations of Syphilis is diagnostic, (c.) Beep ulcer of the tonsils. This form of ulceration is preceded by, and accompanied with, comparatively little pain, red- ness, or swelling ; but the appearance presented is peculiar, and known, more especially, as " the ulcerated throat " of Syphilis. It is an advanced secondary, or perhaps tertiaiy symptom; and may result from ulcei'ation of a gummy nodule, or diffuse gummy inBltration. The ulcer formed is circular and excavated, with a sharp and pro- minent, not to say everted, margin. ' The bed of this ulcer is sloaghy and yellowish, the surrounding mucous membrane dusky red. But even these appearances are not distinctive of syphilis, and original observers, such as Rose * and Carmichael,f concur in mistrusting " the ulcerated sore-throat." Certainly, the excavated ulcer of Hunter is not consequent on the indurated chancre only ; and we must acknow- ledge, with Carmichael, that affections of the throat are too indistinct to afford any certain diagnosis. Fissures of, and milky staiyis on, the tongue and inside the lips are more pathognomonic, but the former must be distinguished from those cracks which accompany irritable dyspepsia, and the latter — opaque "white spots — resemble aphthous spots. More doubtful are tnucous tubercles situated on various parts of the buccal mucous membrane, as the tongue, lips, palate, and tonsils. "J'hese tubercles are of a w^hitish colour, and may be seen also on the skin, in the form of pale, soft little cushions, bedewed with mucus; the skin surrounding each tubercle appearing puckered around its margin. Such tubercles — condylomata— are commonly found in secondary syphilis, grouped around the anus or on the scrotum ; also, fretting along the margin of the external labia in the female; perhaps on the perineum, inner aspect of the thighs, and on the groins. Some- times these tubercles occur in the axillae (E. Wilson) ; and, in fact, vs'herever ordinary tubercles are warm and moist, they frequently become mucous tubercles, skin readily assuming the appearance of mucous membrane. But mucous tubercles are not necessarily syphilitic. Wilson notices the transition of roseola into lichen, of the roseola eruption into such tubercles, and that the conversion of lichen into them is by no means uncommon; yet. roseola and lichen are not necessarily syphilitic eruptions. Ulceration of the nasal mucous membrane, that of the hard and soft palate, of the pliaryax opposite the mouth, and of the larynx, is liable to occur in secondary syphilis. These iilcerations are frequently ac- companied with caries of the nasal bones, of the hard palate, even of the vertebrae behind the pharynx, and necrosis of the laryngeal cartilages. The breath and discharges are .singularly fetid. Is any such ulceration peculiar to secondary syphilis ? Colles acknowledges his inability to determine whether an ulcer in the nose be venereal or not. The appearances of scrofulous ozaena closely i-esemble those of venereal ozcena. Colles describes an ulcerated opening situated on the septum nasi, about a quarter of an inch from its anterior extremity, this ulcer being uniformly circular, and as large as the surface of a * Med.-Chir. Trans,, vol. iii. t "Essay on Venereal Diseases," p. 6i. CONSTITUTIONAL OK SECONDARY SYPHILIS. 315 split pea ; but Tie adds that a similar aperture may be found in persons who certainly never had any venereal affections, and that it may remain for years, at least for eight or ten years, in cases under observation. Extensive ulceration of the pharynx, as well as ulceration of the nasal mucous membrane and caries of the nasal bones, were noticed by Carmichael to be frequently associated with the primary phagedaenic ulcer, but that similar ulceration of the pharynx arises in constitutional conditions assuredly not venereal. Chronic laryngitis, and ulceration of the rima glottidis, denoted by a broken voice, impulsive coagh and foul expectoration, may be a manifestation of advanced and grave secondary syphilis. Portions of the laryngeal cartilages — e.g. the cornua of the thyroid cartilage, in an ossified state — are occasionally coughed up. But syphilitic laryngitis presents nothing peculiar in its characters, from first to last, whereby it can be distinguished from chronic laryngitis under other circumstances. The symptoms just mentioned might follow laryngitis, from a common cold. (3.) Syphilitic iritis was overlooked by Hunter, in his observations of the course of the venereal disease ; but although iritis is undoubt- edly a frequent form of secondary syphilis, it cannot be distinguished from arthritic iritis ; and resembles scrofulous iritis, in so far as regards the appearance of the eye itself. " Although," observes Law- rence, " the effusion of reddish, brownish, or brownish-yellow lymph on the iris in the adult, clearly shows the case to be syphilitic, I have seen analogous appearances in several instances, both of young children and infants, in whom no suspicion of syphilis could be entertained." The symptom in question is not peculiar to syphilitic iritis. I^or is "displacement of the pupil upwards and inwards" a characteristic appearance. It has been seen in chronic rheumatic iritis ; and still more frequently in scrofulous sclerotitis, without iritis. Moreover, it is present only occasionally in syphilitic iritis. This symptom, there- fore, is inconstant as well as equivocal. Indeed, all the special symptoms accorded to syphilitic iritis are unreliable, excepting the tawny or rusty colour of the iris near its pupillary edg'e, a condition present in most syphilitic cases, and almost exclusively in them alone. (4.) Chronic enlargement of the testicle occurs late, if at all, in the course of syphilis, and cannot be distinguished from scrofulous enlarge- ment of this organ. The physical characters which the testis assumes in these two diseased conditions are very similar. In both cases, the enlargement may commence in the epididymis— sometimes in syphilitic, genei-ally in scrofulous disease. In both cases, this swelling subse- quently engages portions of the testis itself, the intervening portions remaining free and healthy; so that sometimes, by careful manipula- tion, nodules can be felt in the substance of the organ, through the tunica albuginea. At length the whole testicle becomes considerably enlarged, and feels hard and heavy. Then the scrotum may become inflamed and adherent, eventually undergoing ulceration, accompanied with protrusion of the testicle. In one such case, having excised the organ, on section, the appearances were those of a scrofulous testis. The epididymis was filled with a yellow friable matter, which, under the microscope, was seen to consist of imperfect broken cells and granules ; while nodules of this substance were deposited here and there throughout the testicle, itself otherwise healthy, the reddish-grey 316' GENERAL PATHOLOGY AND SURGERY. colour of its tubuli serainifcri contrasting with the yellow nodules. The man bore the mark as of a chancre at the coi-ona jrlandis, which he says occurred about two years ago, and that the testicle began to etdarge nine months prior to the operation. Judging merely from the condition of the organ itself, in this case, it would have been almost impossible to have pronounced its enlargement syphilitic ; and, indeed, the most accurate diagnosticians have acknowledged the resemblance of scrofulous and syphilitic disease of the testicle. Under whatever circumstances chronic enlargement of the testis takes place, the symptoms are precisely' the same, observ'cs Sir B. Brodie.* Dupuytren. also, Avas led to this conclusion hy his observations.! Simple glandular enlargement or hypertrophy, and atrophy, of the testicle, are also noticed by some authors. The lymphatic glands, in various parts of the body, are liable to become enlarged, and their indurated enlargement, especially on the occiput and back of the neck, is regarded by Ricord, I believe, as diagnostic of secondary syphilis. But this condition is attributed, by other writers, only to disease of the parts in communication with such glands. (5.) Diseases of the hones, periosteum, fascice, and ligaments are possible manifestations of constitutional syphilis, advancing from the surface to deeper textures Within the body; but this is a neutral ground, shared by the mercurial poison — prolonged raercurialization, b\- scrofula also, and by rheumatism. The question of syphilitic origin is open, therefore, in every case, to investigation, probably afterwards to doubt. A truly syphilitic 7iode, for example, is usually considered to signify merely chronic enlargement of the bone itself. A hard swelling forms, without any redness of the skin in the first instance, nor for some time; eventually it becomes red and acutely painful. The syphilitic virus appears to select certain bones, or portions of bones, for the production of nodes ; they are mostly subcutaneous, as the inner aspect of the shaft of the tibia, the subcutaneous portion of the ulna, the sternum, clavicle, and cranium ; rarely also, I have found the seat of election to be the humerus, just above the inner condyle, or the crest of the ilium. These portions of bone more especially form nodes, which become inflamed. Nodes arising from periostitis are softei', and. e"vadently inflamed from their commencement. They are also more acute. These distinctions are true, and yet the hard chronic node is no criterion of secondary syphilis. This kind of node seldom, if ever, appears, excepting when mercury has been used, and coming, as it does, late in the career of syphilis, has pea-haps been preceded by more than one salivation. Issuing from the mixtui'e of mercury and syphilis, one cannot say how far a chronic node is due to one or the other. Carmichael's expei-ience led him to regard this symptom as "equivocal and uncertain." Colles notices " a general nodose affection of the bones," which is liable to be confounded with so-called syphilitic nodes, and he draws some distinctions. J Caries and necrosis are no less doubtful evidence of constitutional syphilis. Spongy softening of the bones, denoting caries, may happen in * Land. Med. Gaz., vol. xiii. p. 221. f " Clin. Chir.," t. i. p. 100. X " Practical Obs. on the Venereal Disease," p. 185. CONSTITUTIONAL OR SECONDARY SYPHILIS. 817 an advanced stage of secondary syphilis, and has its chosen seats ; these being chiefly those where nodes are prone to form — on the tibia, ulna, clavicle, sternum, and, above all, the nasal bones and cranium. But whatever bone or bones undergo carious softening, there is nothing characteristic of syphilis. Mercury as well as syphilis may be at work ; and indeed we rarely, if ever, find caries in syphilitic cases, excepting where mercuiy has been freely used. None of the cases of syphilis which, came under the observation of Guthrie,* in the York Hospital, were accompanied with caries ; and such was also the experience of Ilose,t in his series of cases, upwards of 120 in number, and where he was able to ascertain that the patients remained free from syphilis for many months afterwards, or if secondary symptoms returned, caries was not one of them. Necrosis, in constitutional syphilis, is equally often the offspring of mercury. Synovitis, of rare occurrence in the course of Syphilis, is attended with the usual pain and swelling into, and partly around, the svnovial capsule of one, and sometimes several joints ; but seldom resulting in ulceration of the cartilages. The knee-joint is mostly affected, occa- sionally the elbow or ankle. Tertiary Syviptoms. — All the foregoing diseases can scarcely be designated secondary. Some of them, as the pustular eruptions of the skin, and the deep circular ulcer of the tonsils, and more particularly disease of the testicles and of the bones, are tertiary, as compared with others previously described in the series. So also are certain ulcer- ations affecting the nose, lips, and roots of the nails. A tubercular nodule may form on the ala of the nose. It is a hardened copper-coloured mass, varying in size from the eighth of an inch and more ; persistent perhaps for many months, then ulcerating and destroying the nasal cartilages, and possibly extending further. Cracks on either lip may appear, and remaining for weeks or months, ulcerate extensively. Ulceration about the roots of the nails, onychia, may occur, having a brown or black colour, surrounded by a deep copper-red margin, and attended with a most offensive discharge. The fingers, toes, or both, though commonly the former, may be thus affected. In either case the ulceration is very obstinate, and the nails loosen, or fall off. The hair may become dry, withered, and faded in colour; cracked or split at its extremities, and be shed or easily combed off, abiindantly, even to baldness. If the bulbs are affected, the hair is not repro- duced, and the baldness is permanent, a condition known as alopecia. It may be partial or entire ; and affect the beard, eyebrows, and eye- lashes. In one case, recorded by Vidal, the hair over the whole body came off. Skin-diseases or SypJiilides. — In addition to the pustular eruptions, which, especially in the form of ecthyma, may occur as tertiary symptoms, rupia is another such eruption, but peculiar to this stage of syphilis. Commencing as pustules, the size of a pea, to as large even as a penny, and surrounded by a dusky red areola, the pus is often mixed with disintegrated blood-corpuscles, forming bloody pustules. In a few days, the pustule discharges or dries into a crust, as if about to heal ; but ulceration spreads beneath, circumferentially. The pro- gress is slow, yet persistent. Suppuration continuing under the scab, * Med.-Chir. Trans., vol. viii. p. 560. . . f Itiid-, p. 422. 318 GENERAL PATHOLOGY AND SURGERY. it becomes raised by the formation of a second scab, of somewhat larger extent, as the ulceration spreads ; until, by a succession of similar upliftino: scabs, a prominent, conical encrustation is produced, consisting of concentric laminge, and marked like an oyster-shell, but having a dark brown, blackish, or sometimes a greenish colour. The shape of this encrustation is characteristic, and scarcely less so, its size, — reaching perhaps to an inch in height, while the area may be much enlarged by the confluence of several pustules. Sometimes, a bullous ring arises around the conical shell, and the matter discharging and drying, the extent of the scab is thus rapidly increased. At length, the encrustation loosens ; so that under slight pressure, matter oozes around; and when completely detached, an indolent ulcer is presented, having a sharp margin. The ulceration is still disposed to spread laterally, though not in depth. More rarely, the scab remaining on, cicatrization takes place beneath ; and when the covering falls oi¥, a somewhat depressed, irregular cicatrix is seen, of a purple hue, but which ultimately becomes white. Giimmy Tumours are met with, consisting of cell-proliferation and degenerative transformations of connective tissue; having a yellowish- white appearance on section. They are of variable size, — from a hemp- seed to a chestnut, but with an ill-defined outline, being perhaps thinly encapsuled, yet continuous with adjoining textures. The consistence of these tumours is tolerably distinctive — hence named gummy ; they yield a soft or firmer resistance to the touch, or having undergone atrophy and conversion into caseous or perhaps calcified matter, the little mass becomes a harder lump. Sometimes a gummy tumour is slowly absorbed, leaving a fibroid cicatricial remnant; but, commonly, when subintegumental, ulceration or sloughing of the skin or mucous membrane supervenes, and discloses an ash-grey, sloughy lump — as of matted cellular texture, the integumental aperture having irregular, undermined edges or flaps, with surrounding bluish discolouration. Ulcerated subcutaneous gummata are thus met with on the scalp, back of the neck, thighs, and other parts. The structure of gummy tumour indicates a concentric development, and tendency to degeneration. The external portion consists of small, round granulation-cells, and a deeper layer of fibro-cellular or fibroid texture, sometimes reticu- lated ; this peripheral portion is slightly vascular, and is alone the seat of proliferation and growth ; the central portion is undergoing disintegration and degeneration, in the form of granular matter, with fat-particles and cholesterine. This central degeneration and death, with peripheral cell-development of a low type of connective tissue, is characteristic of gummy tumour. The parts in which such tumours may be found are very widespread : — in the skin or mucous membrane, or seated in the sub-cellular tissue, and at length forming tertiary ulcers, as on the tongue or soft palate, or in the pharynx and larynx ; in fibrous membranes, as the periosteum, or in bones, appearing as nodes ; while, in the connective tissue of muscles, gummy tumours are not uncommon, as obscure growths ; and in organs, more particularly in the liver, lungs, spleen, brain, spinal cord, and nerves, kidney, testicle, and breast, pancreas, stomach and intestines, heart and arteries, these formations constitute chiefly the syphilitic affec- tions of internal organs which have been specially investigated by Lancereaux, Dr. Wilks, and other pathologists. Fibroid induration CONSTITUTIONAL OE SECONDARY SYPHILIS. 319 occurs in the course of advanced sjpliilis, as a cicatricial remnant of gummy tumour, or as an independent formation. Commonly affecting fibrous textures, such iadurations are found in the periosteum, but most distinctly in muscle, and in the capsule of internal organs. The liver or the spleen presents fibroid indurations externally, in the form of opaque, thickened, puckered depressions of the capsule, with similar indurations of the septa and trabecular structure, — accompanied perhaps with dense adhesions of the peritoneum ; while the substance of the organ is often beset with gummy lumps. The diagnosis of these affec- tions is often obscure ; but they are fully considered, as pertaining to organic or visceral syphilis, in works on Medicine. Lastly, a wan, yellowish hue overshadows the skin in an advanced stage of the disease, which is designated the syphilitic cachexia; but this may denote a mercurial deterioriation of the blood. CoNGEiSfiTAL, HEREDITARY, OR INFANTILE Syphilis. — The term in- fantile syphilis is not intended to signify primary syphilis in an infant, communicated at birth, from a primary sore or chancre existing in the person of the mother. The disease referred to is truly constitutional syphilis inborn, and transmitted as an hereditary infection, from the mother at the time of conception or during the period of intra-uterine life. But constitutional syphilis in the mother, in the father, or in both parents, is not necessarily transmitted to the offspring ; who may indeed be singularly free from any manifest constitutional syphilitic taint, or any other evidence of impaired constitutional vigour — as scrofula. Syphilitic infection of the oviim appears so to lower its vitality, as to entail many morbid consequences. Abortion may ensue, at a vari- able period of pregnancy, the ovum never reaching maturity. Several consecutive miscarriages may thus take place, until the maternal or paternal state of infection is rectified or eradicated ; when the mother will probably retain the foetus for the full period of pregnancy — nine months, and then give birth to a living child. From the time of birth, the infant may exhibit symptoms of secondary syphilis, and present a cachectic, weakly, dwindled, and, as it were, aged appearance. Or, free from any secondary symptoms at birth, they supervene in a variable period — a few weeks, commonly between the second and eighth week — or, possibly, not until adult age. But after the eight month, Trous- seau affirms that the disease very rarely appears. The mode of communication would appear to take place in either of four ways, or in their combinations : — (1) From constitutional syphilis in the father, and without communicating any apparent infection to the mother ; (2) from constitutional syphilis in the mother ; (3) from both parents ; (4) from systemic infection of the mother, through a primary sore — a chancre contracted during pregnancy — the embiyo having been quite healthy at the time of conception. And the liability of the foetus to infection is much greater during the earlier period of pregnancy than in the later months ; an analysis of eleven cases by Diday tending to the conclusion that, after the end of the seventh month, syphilis acquired by the mother is not transmitted to the offspring. But neither pai-ent may exhibit any symptoms of syphilis, the disease having been latent for perhaps a period of many years. (Bumstead.) The important relation of these modes of transmitting syphilis to 320 GENERAL PATHOLOGY AND SURGERY. offspring will be obvious, both in regard to treatment and to medico- legal inquiry. The power of communicating the disease to offspring, from a consti- tutionally syphilitic parent, seems to decline in the course of time, and is perhaps at last ei-adicated. Thus, a man having had secondary symptoms, may afterwards beget a healthy child, his wife also remaiiiintr free from any coustitutional taint of the disease. But re-infection is possible. Eleven such cases occurred in the practice of the late Mr. Gascoyen.* Many other questions pertaining to hereditary syphilis remain open to doubt, and are disputed. Firstly, whether a mother, pregnant with a syphilitic foetns, the offspring of a father having the constitutional disease, can be infected through it without hei\self having had primary syphilis? Ricord answers this question in the affirmative, and the possibility of this mode of maternal infection is supported by a large amount of evidence collected by Mr. J, Hutchinson. Secondly, whether a wet-nurse, having the constitutional disease, can infect the child she suckles, through the medium of the milk ? Yes, says Ricord ; no, says Acton. Thirdly, conversely, whether a syphilitic child can infect a healthy nurse ? No, say Ricord and Acton. But Hunter and Law- rence relate cases in which several nurses have been thus infected, in succession ; and two of whom transmitted the disease again to their own offspring. Evidence in support of the affirmative of both the two latter questions, may be found in " Ranking's Half-yearly Abstract," vol. iv. As to the mode of communication by suckling; any crack or abrasion on the nipple, or on the lip or mouth of the child, will facilitate the transmission. But, according to Dr. Colles, mere contact, without any excoriation, will suffice. Symptoms. — Congenital syphilis is not indicated by any constant and peculiar symptoms taken singly, but collectively they are diag- nostic. The order of development is uncertain. The cachectic, wasted, and withered condition of the child usually attracts attention. The face has a muddy tint, or there is a tawny-coloured patch in the place of either eyebrow, from which the hair has fallen ; the skin is loose and wrinkled, especially around the eyes, mouth, and nose, which also has a flattened appearance ; and the expression is remarkably old-looking, giving to the visage of the infant a monkey-like aspect. The voice or cry is cracked, like the sound of a penny trumpet, as Dr. Farre observes. Secondary symptoms are manifested by the skin, and mucous membranes — especially of the nose and mouth. Congestion of, and offensive muco- purulent discharge from, the nasal mucous membrane, are accompanied with a puffed appearance of the nose, and constant snuffling breathing, as a chronic catarrh, existing from birth, or soon supervening. The tnoutli may exhibit around the lips radi- ating cracks or fissures, with spots of ulceration, and milk-white patches naay be found on the palate. Cutaneous ertiptiuns appear, before birth — the infant presenting some such eruption from birth, or not until some weeks have elapsed — usually three or four. Certain parts are affected more particularly ; the mouth and anus, the nates or scrotum, the palms of the hands and the soles of the feet. Hence, observation should always be directed to these parts, in examining an infant supposed to be the victim of hereditary syphilis. The congenital * Med.-Chir. Trans,, vol. Iviii CONSTITUTIONAL OR SECONDARY SYPHILIS. 321 eruption may be recognized in the form either of raucous patches, of a spongy, oozing character, especially besetting the angles of the mouth and perhaps the fauces, or gathered around the anus ; elsewhere the eruption may be that of roseolous spots, which come and go ; or the cracked appearance of psoriasis may be presented, more especially in the inelastic skin of the palm of the hand and sole ot the foot ; some- times the eruption takes the form of flat, squamous tubercles ; or vesicles or bullae, known as pemphigus, which dry into scales or scabs. A brownish-red, coppery colour, of or around these eruptions, is more characteristic. Iritis is not uncommon ; this affection occurring in about five or six months after birth, and being attended with an abundant effusion of lymph, occluding the pupil so that the sight is generally lost. Interstitial corneitis usually appears, but at a later period, — ^between the eighth and fifteenth years. Syphilitic periostitis and caries are comparatively rare ; but sometimes the bones lose their epiphysial connections. The teeth, both temporary and permanent, are affected in the tertiary or later form of congenital syphilis. Ac- cording to Mr. J. Hutchinson's original observations, certain carious or ill-developed appearances are presented. The temporary teeth are cut early, have a bad colour, and are liable to"a crumbling decay. The upper central incisors usually undergo this destructive change early, and always first ; then follow the lateral incisors, which become carious and are Fi<^- ^^• shed ; lastly, though rarely, the canine teeth wear away, so as to assume a flat- /^"^^m^-^k.^^^^^'^ /^r^ ^--^^^'"^^ tened, tusk-like character (Fio:. 94). \ /TrT^^ri^aViNvk / The teeth represented are the upper set ^^ ■<»— ^>^ — \y of a syphilitic child, aged nearly three years. Owing to early decay of the incisors, the syphilitic child remains edentulous from an early period, in regard to these teeth, and has a remarkably unsightly appearance in the laugh, of childhood, until the permanent ones are cut. The permanent teeth, are more peculiarly affected ; chiefly the upper incisors, and first the central ones. They are discoloured, short, peggy, ^^'^- ^^• rounded at the angles, standing apart with inter- s^Daces, or converging ; and marked, on their margin, with a deep broad notch (Fig. 95, show- ing two upper and four lower permanent incisors, recently cut, in a girl, the subject of inherited syphilis) . They readily disintegrate, crumble, and wear down. After the period of infancy, the individual peculiarities of physio- gnomy and appearance of the skin, by which the subject of inherited taint may be recognized, are, as Mr. Hutchinson observes, the conse- quences of specific inflammations which the patient has undergone at former periods ; e.g., the synechiee and lustreless iris of iritis, the malformed teeth of periostitis of the alveolus and dental sacs, the protuberant forehead of hydrocephalus, the flattened nose of snufiles, the pale, earthy, opaque skin of cutaneous eruptions. If in infancy the child escapes some such inflammatory affections, their consequent peculiarities of appearance will be wanting in the picture of after years. Growth and development are often arrested. As some com- pensation to the innocent victim of this inherited disease, it is probable VOL. I. Y 322 GENEKAL PATHOLOGY AND SURGERY. that he cnjojs some protected immunity to fresh syphilitic infection, or that the acquired disease would then liave a milder character in a constitution which has once paid the penalty. The prognosis of congenital syphilis may be determined mainly by the more or less early supervention of the symptoms of the disease. A withei'ed tawny-faced infant at birth, and affected with snuffling and nasal discharge in the course of a day or two, will probably die. The difficulty of suckling such an infant, — for the act of suckling is imper- fectly performed, the supply of milk from the diseased mother may be poor and scanty, and the substitution of a healthy wet-nurse would be obviously improper — the difficulty of weaning the infant to food suitable to its weak digestion and assimilation, and the oppressed respiration under which the child labours, are all veiy unfavourable to the reno- vation of nuti'ition and ultimate recovery. Whereas, when ihe infant remains free of syphilitic manifestations after birth for a period of two months or longer, and is then affected with symptoms, — when the syphilis is hereditary rather than congenital, it is probable that nutri- tion will have become sufficiently established for the child to outlive the disease, and perhaps also the liability to its return. But the mortality from congenital syphilis is far higher than that from the acquired disease. Bassereau is led to bslieve that in at least one-third of the congenital cases, death e«sues within a few months after birth. Post-mortem examination discloses morbid conditions of certain internal organs, more especially ; which, however, do not seem to possess any special practical importance. They comprise chiefly the appearances of broncho-pneumonia — death having often resulted from this pulmonary affection ; indurated deposits in the lungs, of a yellow colour and elastic consistence, which are probably gummy tumours, — the small cells found in these deposits being characteristic, and different from those of tubercle and cancer ; a degenerate and softened state of such tiimours may present the appearance of purulent infiltration or abscesses in the lungs; a so-called suppuration of the thymus gland, often found after death, is probably of a similar nature ; syphilitic peritonitis has been noticed by Sir James Simpson ; and lastly, the albuminoid liver, a degeneration of very common occurrence in congenital syphilis. First noticed by Gubler (1848), and afterwards minutely described by Diday, this albuminoid degenera- tion may be recognized — as Sir William Jenner observes — by certain characters; the liver is large, smooth, hard, heavy, pale, and semi- transparent, and infiltrated with a matter something like glue. The Treatment of Congenital Syphilis will be mentioned in con- nection with the general Treatment of Syphilis. Vaccino-Syphilitic Inoculation. — A most important social question is, whether a true chanci'e — an infecting syphilitic sore — can be com- municated by vacciiaation, through the vaccine virus ? Dr. Viennois, in 1860, brought forward cases, apparently, of such syphilitic trans- mission; other cases subsequently occurred under M. Trousseau, in the Hotel Dieu ; and, since, at Rivalta, an overwhelming demonstration occurred, one child, thus infected, having re-transmitted the disease to another child, and thence, through both, to forty-five other children, and to 'twenty other mothers or nurses ! In this country, the observations of Mr. Thomas Smith and of Mr. Jonathan Hutchinson* have since * Med.-Chir. Trans-, vols. Hv. and Ivi. CONSTITUTIONAL OR SECONDARY SYPHILIS. 328 borne corroborative testimony as to the possibility of vaccino-sypliilis. Bat in the event of transmission to a third person, by vaccination, Mr. James R. Lane * disputes the possibility of infection having occurred some time hefore the intermediate individual has manifested constitutional symptoms. Waller, of Prague, affirms that the blood of a syphilitic individual is contagious. Diagnosis of Constitutional Syphilis. — The presence of constitu- tional syphilis, as manifested by secondary symptoms, is determined solely by the calculation of probabilities ; and this is the basis of diagnosis in respect to all diseases, excepting- the few that are abso- lutely determined by pathognomonic signs. The diagnostic value of any one symptom is represented by the constancy of its presence and association with the same disease, and by the early period of its occurrence. But the co-existence, or at least the consectdiveness, of symptoms, any one of which is equivocal, per se, constitutes a weight of evidence greater in the aggregate, than that which the several items of evidence would represent by being merely added together. To illustrate this force of concurrence, by the evidence of secondary symptoms, I shall pass over the order of priority of these symptoms ; thus overlooking the relative value of each, as an early symptom. Ko one secondary symptom is sufficiently constant or peculiar to syphilis, to make their order of succession a question of much practical interest. But the fact of these symptoms being concurrent in the same person, outweighs their inconstancy. Let the weight of aw^i-syphilitic proba- bility be represented by 5 ; then any one of the five usual secondary symptoms maybe absent, or, if present, may point perhaps to constitu- tional syphilis, perhaps to the mercurial crasis, perhaps to both ; per- haps to neither of these blood-diseases, but proceed from other causes. Thus, the skin-eruption having a coppery hue ; the excavated ulcer of either or both tonsils ; iritis ; enlarged testicle ; node, caries, necrosis ; are severally equivocal symptoms of constitutional syphilis ; but taken collectively, or at least as consecutive symptoms, they outweigh the sup- posed anti- syphilitic counterpoise. Constitutional syphilis is diagnosed by an overbalance of probabilities in its favour — this overbalance being due, not to the actual diagnostic value of each symptom or probability, but to their concurrence. In like manner, other circumstances may tend to corroborate our diagnosis. The fact of primary syphilis, present or antecedent, has its weight — the weight of an additional probability, concurring. We look for the remains of a presumed chancre or chancres, and probably, also, the vestiges of a bubo or buboes. The diagnosis of constitutional syphilis — thus clearly illustrating the diagnostic value of concurrent symptoms — is the species of evi- dence on which rests the diagnosis of most other blood-diseases ; and, indeed, of diseases generally, the evidence of which is symptomatic. Blood-pathology of Syphilis. — Syphilis, secondary or constitutional, so called, is essentially a blood-disease ; the evidence being, partly, the " number of textures " affected with some form of malnutrition- — as of the skin, mucous membrane, iris, periosteum, bone and testicle ; partly, the "migratory" character of these local affections — from skin to mucous membrane, to the iris, thence to the testicle, or to periosteum and bone ; and partly, the " symmetrical " character of some such * " Lectxires on Syphilis." 324 GENERAL PATHOLOGY AND SURGERY. local afEections ; occasionally, also, their " serpiginous," or creeping nature, as phagedjenic ulcerations of syphilitic origin. But the last two characters would seem to indicate some determining power in the fexfu7-es, respecting the particular locality and form in Avhich a par- ticular blood-disease shall manifest itself. Lastly, syphilis is capable of being propagated by "" inoculation,"' thereby introducing the mo^eries morhi into the blood. The blood-pathology of syphilis shares the obscurity of other blood- diseases with few exceptions. The microscope exhibits nothing re- markable ; chemical analysis, at present, brings nothing to light. The potent virus works unseen, being known only by the commotion it occasions. As %vhen a diver has disappeared beneath the surface, we M'atch the troubled waters, without seeing his operations in the deep ; so likewise the s^-philitic virus having dived into the blood, we know nothing of its doings there, only that it throws up some eruption on the skin or mucous membrane. Moreover, as the debris and bubbles thrown up by a diver cannot be di?-tinguished from the commotion pro- duced by some monster sporting in the deep; so also the scales and pustules of syphilis are subsequent and equivocal signs of the kind of poison at work. But the vii-us has not hitherto been detected in the blood ; nor does inoculation with syphilitic blood manifest any charac- teristic result-s — unless Waller's experimental observations as to its con- tagious character, should prove to be correct. A primary syphilitic sore — a chancre — was unquestionably produced in the person of Dr. Barg-ioni. who submitted himself to inoculation with the blood of a syphilitic patient, by Professor Pelizzari, in 1862. Ricord failed to discover inoculable pus in the blood, even in veins nearest the chancre. M^E. Ricord and Grassi first noticed " a decrease of the globular element in the blood of persons affected with syphilis arising from the simple or non-infecting chancre;" and indurated chancre also is apparently followed by a diminished proportion of globules, while the albumen increases. Causative relation of Local to Constitutional Syphilis ; and the Unity or Duality of the Syphilitic Virus. — Of the two forms of Local Syphilis which have been designated Chancres, opinions differ respecting their causative relation to Constitutional Syphilis. It would be impossible within the limits of this part of the work, to discuss the evidence and arguments pertaining to this vexed question. Ricord and his school maintain that only one form of local syphilis — the indurated chancre — is the source of systemic infection, that it is the infecting sore, and that it invariably produces constitutional syphilis ; but that the non-indurated or soft chancre is always a local disease, and never followed by secondary affections. Hence, indurated chancre is the only form oi primary syphilis; and, indeed, that the supervention of induration is the first manifestation of systemic infection — the first secondary symptom. According to other authors, the term syphilis signifies an entirely constitutional disease, not to be distinguished as primary and secondary ; the term chancre being restricted to the initial local lesion of syphilis, whereby the virus is introduced or inoculated. If, therefore, indurated chancre be the only species of ulcer which is followed by syphilis, it thus differs essentially from soft chancre ; the one being the only form of local, or primary, syphilis ; the other, distinctively named chancroid, CONSTITUTIONAL OR SECONDAEY SYPHISIS. 325 being only a local contaCTioiTS ulcer of venereal origin. Hence the Dualist theory, in regard to the production of these two diseases. First proposed by Bassereau (1858), a former pupil of Ricord's, this theory has been advocated by several eminent supporters ; RoUet, Cullerier, Bumstead, H. Lee, and others, and is still gaining adherents. But Dualists strenuously maintain the unity of the syphilitic virus. On the other hand, some observers, scarcely less distinguished, maintain that while the indurated chancre possesses the greater power of producing constitutional syphilis, and is thus the most frequent cause, yet that soft chancre — chancroid — may also, occa- sionally, have this relation. Hence, that chancroid may be regarded as a form of local, or primary, syphilis. This is known as the JJnicist theory ; or the reference of these apparently different diseases to one common causative origin. Velpeau, Devergie, and Cazenave, more prominently represent the school of Unicists. My own experience inclines to the latter view of the relative infecting character, of hard and soft chancres, and thence to Unicism. Inoculation throws some light on this question. The general i-esults of inoculation in regard to syphilis, may perhaps be stated as follows : — (1.) That a chancre always produces a specific virus. (2.) That all chancres — hard and soft — are capable of being j)ropa- gated by inoculation, (3.) That inoculation with the serum or lymph from an indui'ated sore will only produce a chancre, and that an indurated one, when the system is unaffected. During, therefore, only the earliest stage of such chancre — i.e. prior to induration, which may be regarded as the first secondary symptom, (4.) That an indurated sore being irritated may become a suppu- rating sore -, and that matter so obtained, may, by inoculation upon the individual from whora it is taken, produce a soft sore — i.e. the suppurating indurated sore is auto-inoculable. (H. Lee and Boeck.) (5.) That inoculation from an indurated sore— the system being unaffected— is invariably followed by secondary affections, (6.) That inoculation from a soft chancre is less certainly pro- ductive of secondary affections, (7.) Secondary syphilis may be propagated by inoculation. The propagation of the constitutional disease through the seminal fluid of a syphilitic man, by habitual intercourse with a woman, is doubtful. (8.) But, that inoculation from secondary syphilis is inoperative on the individual himself, or upon another individual having secondary syphilis. (9,) That the secretion of other specific diseases existing in syphilitic subjects (including the specific syphilitic pustule, and the sores which result from it), ha.s no power of imparting constitutional syphilis. (H. Lee.) (10,) That the natural secretions of glands in syphilitic subjects, when those glands are not themselves specifically diseased, have no power of imparting constitutional syphilis. (H. Lee.) If any of these propositions be erroneous, the error arises not simply from the difficulty inherent in the investigation of inoculation, but also from the difiiculty of rightly estimating the mass of, ap- pai'ently, contradictory evidence on this subject. 326 GENERAL PATHOLOGY AND SURGERY. The modus operandi of chancre in producing systemic infection, is doubtful. The lymphatic or absorbent vessels were formerly regarded by Hunter, and his school, as the only medium of tninsmitting the syphilitic virus. Independently of the experimental facts adduced by Segfalas and Magendie, in evidence of the veina also being absorbent.s, there are two general facts which, apparently, disprove the absorbent function of the lymphatics, in the production of syphilitic systemic infection. (1.) That in those cases in which the irritation of the IjTuphatics is greatest, and where, therefore, we have the best evidence that the morbid matter has entered them, there is very seldom any secondary syphilitic affection. (2.) That the best-marked cases of systemic affection are as i^i^ly preceded by any very evident signs of inflammation of the lymphatic glands. In the first class of eases, moreover, the progress of the syphilitic virus may be ti^ced along the l.ymphatic vessels as far as the first lymphatic glands in their course, but never beyond. In any part of this course, the poison may be arrested and produce a hard knotted cord or i-ouud induration, or even a fresh chanci-e ; but there is no proof that the virus is con- veyed unchanged through these glands ; on the contrary, the vessels beyond are never affected, and bubo never forms in the glands next in order. Thus, chancre on the penis or vulva induces bubo of the gland in the groin, above Poupart's ligament, but does not affect the vessels and glands within the abdomen ; chancre on the finger affects the gland on the inner side of the biceps muscle just above the elbow, but not the axillary glands. Duly weighing these facts, and the analosry of the syphilitic virus with other poisons, in producing systemic infection, Mr. Lee is inclined to believe that the syphilitic virus is communicated directly to the blood, through the nutritive changes of the part around a chancre, or point of inoculation. Treatment. — Frimary and Local Veyiercal Ulcers. — The first con- sideration in the treatment of syphilis is the question of the prevention of s_ystemic infection. (1.) Chancre. — The early destruction of chanciT, within the first four days after contagion, and thence the prevention of systemic infection, was known as the abortive treatment of syphilis ; that primary syphilis being thus anticipated, the secondary or con- stitutional form of the disease would not follow. Accordingly, cauteri- zation and excision of the chancre have both been advocated and practised ; the former preventive measure especialh^, by Ricord and Sigmund of Vienna, and I'eported to have proved successful, for the prevention of infection, in some thousands of cases. But, considering the long period of incubation of the syphilitic virus, — two to three weeks as the average time, from the very beginning of which absorp- tion must have proceeded — and the fact also, that when chancre is produced, the system has already become infected, it will be obvious that any local treatment which shall be preventive or abortive of sj'philis must be extremely improbable or even impossible. Destruc- tive cauterization has jDroved unsuccessful during the incubatory period, — as early as four or five days after the sexual intercourse ; and, as applied within only a few hours after the development of chancre, it has failed to avert the constitutional disease. In a case by Diday, the chancre having appeared a month after intercourse, CONSTITUTIONAL OR SECONDARY SYPHILIS. 32 abortive treatment was tried within six hours ; the sore healed ia three days, yet secondary symptoms supervened in three weeks. The reputed eificacy of abortive treatment, relative to chancre, is also denied by Professor Bumstead and Mr. H. Lee, and it is now generally discredited. Former cases of supposed success were probably those of the locally contagious, soft suppurating nicer. (2.) Chancroid, the Local Contagious Ulcer. — The period for the production of this nicer after contagion is of short duration ; from two to four days, or within a week. Preventive cauterization must, therefore, be had recourse to within that time. Subsequently, how- ever, the same treatment is available to prevent the propagation of chancroid ; and for the destruction of bubo, which becoming a sup- purating ulcer, has the same contagious character. Cauterization, to be effective, must be, not a slight superficial application, which only destroys the sui-face of the ulcer, but cauteriza- tion, deep, broad, and destructive. We are dealing not merely with a poisoned wound, but a reproductive poisoned wound. The escliarotics most reliable are therefore the mineral acids, sulphuric and nitric, chloride of zinc, potash and lime combined in the form of Vienna paste, peruitrate of mercury, and the actual cautery. Nitrate of silver has the dangerous reputation of being sufficiently caustic, because some chancroid sores heal after its application. Of the other agents, sul- phuric acid, mixed with finely powdered charcoal — the carbo-sulphuric paste, as originally employed by Ricord — is a very effectual caustic. Chloride of zinc and flour, in equal parts, forming Canquoin's paste, is also very serviceable, and was first advocated by Rollett and Diday. Either of these caustics may be used with a glass rod, or a glazed crockery spatula. The caustic must be applied over the whole sore and around, so as to include the infected peripheral zone of tissue beyond it. The effect of cauterization should be limited within due bounds, if necessary, by means of some antidote ; as a solution of carbonate of potash, after an acid caustic, or an acid, such as vinegar, to restrain an alkaline caustic. But the caustic or paste may be left on the ulcer, where with the slough it forms an adherent scab, and the sore heals underneath. Or, where a caustic paste has done its work, in a period of about two hours, it may then be removed, and water- dressing or dry lint substituted, the latter being preferable ; thus simply to protect the surface fi'om the risk of contact with any adjoin- ing chancroidal ulcer. Destructive cauterization is impracticable, observes Professor Bum- stead, when the chancroid cannot be fully exposed ; as in consequence of phimosis, or concealment within the urethra, os uteri, or other inaccessible situations. It is inadviissible with regard to ulcers situated directly over the urethra, either in the male or female, owing to the risk of opening" this passage ; so also in chancroids of the deeper portions of the vagina, where the walls are in contact 'with the bladder, rectum, or peritoneum ; in sores upon the margin of the urinary meatus, lest cicatricial stricture should result ; lastly, wherever the presence of other ulcers in the neighbourhood, which cannot be sub- jected to the same treatment, would thus expose the surface, after separation of the eschar, to re-inoculation, as in the case of chancroid upon the margin of the prepuce, with phimosis concealing a chancroid within. 328 GENERAL PATHOLOGY AND SURGERY. Excision is rarely so successful as cauterization. Even when per- formed freely enongh to insure extirpation, and witli the precaution of removing any contagions matter, the wound is liable to become re- inoculated, forming a larger contagious sore than the original one. Hence, removal with the scissors or knife is eligible only in certain parts ; as in the case of chancroids fretting the margin of the prepuce or the border of the labile of the vulva, where the instrument can be carried sufficiently wide of the ulcers. The fresh surface should then be touched with caustic, to form a protective eschar. P/imosi.s%. complicating sub-pi'eputial chancre or chancroid, may be a congenital malformation, or acquired by induration or inflammatory engorgement. Destruci ive cauterization can be of no use, when chancre, thus enclosed, has become indurated, systemic infection having already taken place ; and with cliancroid, the phimosis being of an inflamma- tory character, any such treatment might induce gangrene. But the part should be regularly cleansed, by syringing the prepuce with tepid w^ator, or with a weak astringent solution, as the nitrate of silver, live or ten grains to the ounce. The operation for phimosis — that of slitting up the prepuce — in order to make any direct application to the chancroid, would be an improper procedure, from the liability of thus converting the Avound into a larger chancroid ulcer, cases of which have happened. It will be observed that the abortive treatment of chancroid, chancre not being thus controllable, has regard not only to the in- dividual affected ; it is also the surest preventive measure, socially considered, by extinguishing the source of contagion. As a public preventive measure against the propagation of primary syphilitic infection, the " Contagious Disease Act " for the periodic inspection of different classes of the community, was instituted ; — a similar legislative enactment to that which is in operation in France. As might be anticipated with reference to a procedure of such nature, its expeiiency has been strenuoush'' advocated from a sanitary point of view, and an extension of the Act urged, by numerous scientific supporters ; and it has been equally denounced, on moral and social grounds, by irreconcilable opponents. The Government wisely de- clared its intention of abiding the result of the most complete inquiiy, and a Royal Commission, appointed for this purpose, reported in favour of the beneficial operation, both sanitary and morally, of the Act in question. But the provisions thus made for the prevention of syphilitic infection, have since been practically repealed^, with regard to the '■ compulsory examination " of women, by an adverse vote of the House of Commons (1883); thereby dispro^nng the proverb, that "in the multitude of counsellors there is wisdom." The curative local treatment of chancre, as a specific sore, is best accomplished by mercury. It may be applied in the form of mercurial ointment, spread on lint, and laid on the sore ; or as a lotion — the lotio nigra, consisting of calomel and lime water, in the proportions of 3i. to _^vi. ; or, by calomel fumigation, locally applied, as suggested by Mr. Lee. Five or ten grains of calomel may be volatilized over an ordinary fumigating lamp, and the ulcerated part should then be held directly over the vapour, until the white powder is fully deposited on the sore, where it must be allowed to remain. Chancroid having been destroyed by free cauterization, it becomes CONSTITUTIONAL OR SECONDARY SYPHILIS. 329 a simple healing ulcer, whicli needs only the protection of "water- dressing. Various lotions, of a stimulant or astringent charactei*, may, however, sometimes be used with advantag-e ; as the diluted nitric acid, 51. to .^viii. of water, or a weak solution of sulphate of copper, grs. V. to ^^i. ; tannic acid, 9i. to ^^i., is another good formula, or perhaps the aromatic wine, ^i. to ^^iii. of diluent, as employed by French surgeons ; while nitrate of silver, grs. xv. to ^i., is much recommended by Rollet. Disinfectant and cleansing washes may be substituted, as. occasion requires ; a chlorinated solution, ^i. to ^ii- of water ; or a solution of carbolic acid, ^ii. to Oi., which Professor Bumstead prefers. The varioiis forms of ulceration which both chancre and chancroid may assume, as already noticed, will require modifications of treat- ment accordingly. Thus, the inflamed and the irritable sores are to be treated by the same measures which would be appropriate for similar ulcers otherwise arising. Inflamed and suppurating indurated chancre is a rare variety, but an inflamed and indurated chancroid — the phleg monoid form, so named by Ricord — is not uncommon ; in either condition, the inflammatory' character must be met by the application of cold lotions, or poultices, and other antiphlogistic measures. Phagedrenic ulceration comparatively seldom attacks chancre, and is connected with secondary symptoms of the most severe and intract- able character ; in the form of rupia, chronic periostitis and ostitis, .sloughing ulceration of the throat and nose. Phagedsenic chancroid is not infrequent. In either case, the ulceration may have the creeping- and persistent form of serpiginous phagedsena, spreading to an un- limited extent. Treatment comprises free cauterization with strong nitric acid, or the actual cautery; opium, tonics, and a supporting diet ; a temperate, quiet life, and fi^esh air. Hicord speaks highly of the potassio-tartrate of iron, and so also does Mr. Lee, both as a tonic and local application. A mixture of half an ounce of this salt to three ounces of water may be taken thrice daily, in doses of a tablespoonful, an hour after meals ; and a solution of twenty to forty grains to the ounce of water, applied to the ulcer as a dressing. Permanganate of potash, a drachm and a half to the ounce, is recommended by Hinkle. Iodoform, powdered on the ulcer, has also a marked effect. The co-exi.st- ence of phimosis, with sub-preputial ulceration, frequently occurs ; and then the foreskin must be slit up. to reach the part affected. Sloughing or Gangrenous chancroid is not uncommon, and more rarely chancre is thus affected. The part is struck with pain, and the ulcer, when Adsible, appears of a greyish hue, deepening into gTeenish black, surrounded by a dusky-red inflammatory areola. The dischai'ge is thin and fetid. Sometimes, this destruction en masse, supervenes on the molecular disintegration, and worm-eaten appearance, oi phage- dcena ; giving to the ulcer a mixed character. Depending on an enfeebled constitutional condition, the treatment consists in the free application of nitric acid to the ulcer ; but the general health must be renovated by quinine, perchloride of iron, and opium, with such food as the patient can digest, — often the main difficulty to be overcome. Bubo. — (1.) Indurated Buho, or abuUety, hard, and indolent swelling of one or more lymphatic glands, commonly in the groin, is generally the consequence of a previously indurated chancre, with accompanying systemic infection. No preventive treatment, therefore, can avail to 330 GENERAL PATHOLOGY AND SURGERY. avert the development of this kind of bubo, when, at least, the causa- tive chancre has nndero;one induration, — as the earliest manifestation of constitutional syphilis. Curative measures relate to the treatment of (constitutional) syphilis, under the influence of which treatment the bubo may gi-adually subside and disappear by resolution ; mean- while occasioninjs^ little inconvenience. (2.) Soft, and Suppurating Bubo is usually the consequence of a similar kind of ulcer — chancroid ; and both having simply a locally contagious nature, this bubo is amenable to topical treatment accordingly. Prevention may be ac- complished by the early destruction, or abortive treatment, of the original chancroid, in the manner already explained. Curative indi- cations comprise — the resolution of inflammation, if possible, in order to prevent suppuration ; or in that event, the treatment of abscess, and of the resulting ulcer. Inflammation may be subdued by rest in the recumbent posture, cold lotions, local blood-letting, counter-irritation, or compression ; aided by a somewhat lowering general treatment, by saline purgatives and reduced diet. Leeches should not be applied except in this early stage ; since any forma- tion of matter near the surface might inoculate the bites, which would thus be converted into chancroids. Each bite had better be covered with collodion and a bit of adhesive plastei', as a protective from any adjoining source of contagion, if one such point happens to become a chancroid. Of counter-irritants ; iodine paint may be used, or a strong solution of nitrate of silver, 5iii. to Ji. of water, with the addition of TTl.xx. of strong nitric acid, as recommended by Sir H. Thompson ; others prefer blistering, or even the actual cautery, as employed in French hospitals, by means of a pointed iron at a white heat, applied to numerous points over the bubo. Compression can be effected by a pad of compressed'sponge and spica-bandage, afterwards moistened with warm water to cause the sponge to swell under the bandage. Ricord's pad for buboes offers another resource. But I have rarely found any repressive measures succeed among the large number of out-patients at the Royal Free Hospital. Suppurating bubo should speedily be advanced by poulticing, and opened without delay ; before the formation of sinuses, which would undermine the thin, bluish integument, leaving it indisposed to cicatrize. The abscess is readily slit open with a curved, sharp-pointed bistoury or scalpel; observing to make a free incision, and in the vertical rather than in the horizontal direction, as the former cut allows a gaping outlet for the escape of matter when the thigh is raised. Any sinuses should then be followed up with a director, and laid open. If the glands at the bottom of the cavity appear isolated or pedunculated, they had better now be removed, in.stead of being extruded by a tedious ulceration. This may be done vntln the knife or scissors, or by touching the little mass freely with a stick of potassa fusa. The latter is also preferred by some Surgeons for opening the abscess, when it appears likely to become sloughy, as thus a cleaner and more thoi'oughly exposed cavity will be formed. Hsemorrhage is seldom much, and is easily arrested. The ulcer of the opened abscess always assumes a chancroidal character, and secretes virulent matter. A poultice is applied, or strips of wet lint, to the bottom of- the cavity, and the sinuses ; subsequently this dressing should be exchanged for the lotions applicable to chancroid, or in its varied conditions of in- CONSTITUTIONAL OR SECONDARY SYPHILIS. 331 flammation or pLagedeena. During the cicatrization of a healtliy sore, this process of healing will often be promoted by the support of a compress and spica-bandage, and in all cases bj keeping the patient at rest. ISTo particular constitutional treatment is required, and mercury would certainly be prejudicial. In the rare event of indurated bubo having suppui^ated, the local treatment is the same ; but the constitutional influence of mercury or other general treatment may be employed with advantage. Constitidional Syphilis. — Preventive treatment still claims our first consideration. After the development of chancre, and before consti- tutional syphilis is manifested by any secondary symptom, except, perhaps, induration of the chancre, there is yet an intervening period of blood- incubation— extending over about a month or six weeks, more or less, during which the development of constitutional syphilis may be intercepted. Otherwise, the blood will assuredly declare its noxious influence on nutrition, in due time ; by some secondary disease of the skin, by sore-throat, iritis, and so forth. The impending evil is sure to supervene, in sonie form ; the storm is sure to burst. There follows the indurated or infecting chancre, says Ricord— a blood diathesis pregnant with misfortunes and tempests. An infallible explosion of constitutional affections will ensue. But if some such manifestations are inevitable, in the natural course of systemic infection, all experience concurs, I believe, in the possibility of averting them by medicinal intervention. By what particular pre- ventive measures ? Here opinions differ widely. Mercury has long been, and is still generally, credited with the most potent prophylactic influence. The symptoms of its protective opera- tion, constituting mercurialization, and the modes of administering mercury, will be noticed presently, in connection with the curative efficacy of this medicinal agent. It appears indisputable, that if mer- cury be not pi-eventive of systemic infection, no other known medicinal agent possesses such influence in any perceptible degree. The chief difficulty. attending investigations with reference to this question, is first to determine the natural course of local syphilis, in its different forms — whether or not systemic infection would assuredly supervene ; and thus, with corresponding certainty, to estimate the positive and negative results of mercurialization, or of other supposed protective measures. Bemedial Treatment. — In the ti-eatment of Syphilis, the practitioner will do well to remember the now generally acknowledged fact in its pathological history, that this constitutional disease—like some others — evinces a strong tendency to seZ/-recovery. 2Iercury holds the first place, and iodide of potassium the second, in the present anti-syphilitic materia medica. It would be impossible and useless to enumerate all the various remedies for eonstittitional syphilis, which have been tried and failed, more or less entirely. Such are sarsaparilla, guaiacum, opium, conium, ju.niper, sassafras, dulcamara, etc. Mercury seems to produce a systemic condition which is antago- nistic to, and incompatible with, constitutional syphilis, in most of the forms of its manifestation. And, indeed, this positively reme- dial operation of mercury is rendered equivocal only by the fact, that the natural tendency of syphilis to recovery cannot be i^latively estimated. 382 GENERAL PATHOLOGY AND SURGERY. The symptoms of the systemic inflaence of mercury, and of its suffi- cient operation reniedially, are, a slight tenderness of the gums adjoin- ing the teeth, with, perhaps, a slightly increased flow of saliva, foetor of the breath, and a coppery taste in the mouth. But this degree of salivation must be maintained, until any secondary symptoms, whether as regards the skin, the throat, or the eyes, have entirely subsided ; including also induration of the primary sore. Not until then can mercury be safely discontinued, with a view to the non-recuri-ence of secondary symptoms. The administration of mercur}- is a matter of equal importance, and scai'cel}" less so, the kind of mercurial preparations employed. It may be introduced into the system, through the gastro-intestinal mucous membrane, by pills or solution taken internally ; or through the skin, by the rubbing in of ointment — inunction: or by exposure to vapour, known as fumigation, or the mercurial bath ; or by inhalation. Sig- mund advocates hypodermic injection. Blue pill — pilula hydrargyri — from three to five grains, two or three times a day ; or calomel, a grain or more, in the form of a pill, and taken as often ; have long been favourite forms of administering mer- cury. But these preparations are apt to produce irritation of the gastro-intestinal canal, and the liver, by their continued use — occa- sioning bilious diarrhoea and sickness, long before their beneficial operation on the system can take place. Their introduction is, in fact, thus intercepted, and the mercury is said to ■■' run off by the bowels." A small proportion of opium — say, a quarter of a grain — combined with each pill, will tend to make the blue pill or calomel settle on the stomach. The iodide of mercury, combined with opium in the form of a pill, is the preparation which I have long been in the habit of pre- scribing. It is less irritating to the stomach, and equally remedial. The Uqii07- hydrargyri hicliloridi, in half-drachm doses, more or less, is a convenient form of administering mercury internally; but I use it rather to sustain the systemic influence of the iodide. ^Mercurial inunction supplies a more sure method of affecting the system, without any collateral disturbance of the digestive organs. It consists in rubbing in a small quantity of some mercurial ointment on the inner or thin-skinned aspect of the thighs, every night. A drachm of the blue ointment, unguentum hydrargyri, may be thus continued nightly, until the gums are touched, and the secondary symptoms evi- dently subsiding. The ointment mu.st be rubbed in until it disappears, and then the greasy surface should be left unwa.shed. This, however, is a laborious and dirty ordeal, an additional penalty for any one to pay besides having syphilis. Hypodermic injection has been tried, in the form of the bichloride of mercury, one-eighth to one-fourth of a grain, to fifteen minims of water, as a dose. But although this method of administration was adopted by Sigmund in two hundred oases of Syphilis, the liability to abscess from the injection of a powerful irritant is a considerable disadvantage, Mercurial ftimigation may be preferable as a more cleanly and equally eSicacious mode of introducing mercury through the skin. It consists in exposing the surface of the body, enveloped in a blanket up to the chin, to the fumes of some mercurial powder, which is heated until it rises in the form of vapour, and which can be advantageously CONSTITUTIONAL OR SECONDARY SYPHILIS. 333 associated with steam, as a vapoui^ bath. For tHs purpose, an appa- ratus has been contrived bj Messrs. Savigny. A more ready con- trivance is a half brick, heated to a dull redness, on -which the powder is placed, and set in a pan containing a little water. Calomel is the mercurial preparation generally employed; and fifteen or twenty gTains, the quantity usually sufficient, will undergo volatilization, entirely, in fifteen or twenty minutes. The patient is then put to bed, so that the particles of calomel shall not be wiped off the surface of the body. This mode of introducing mercury is highly recommended by Mr. Lee, who observes that, in his experience, neither of the other modes removes the symptoms so readily as calomel fumigation ; none is attended by so little mischief to the patient's constitution ; and none is followed so seldom by a relapse. He extends it, as I have already mentioned, to the local treatment of primary sores ; and by means of a tube and mouth-piece, the vapour of calomel can be conveyed to the throat, for the treatment of secondary syphilitic ulceration affecting that part. Mercurial inhalation can be administered by a simple and efficient form of inhaler, which is easily constructed ; a common earthen tea- pot, to the spout of which is attached a tube of vulcanized india-rubber, about a foot long, and provided with a bone mouth-piece, in shape like the amber of a meerschaum pipe. A scrapie of calomel is placed in the teapot, and the little hole in the lid which allows the escape of steam is stopped with a peg of tightly rolled paper, — better than wood, which yields and loosens in driving it in. The pot thus equipped is ready for use. Resting on an iron tripod stand, the bottom of the pot is exposed to the flame of a spirit-lamp, placed sufficiently near, so that the flame shall expand under the whole bottom. In two or three minutes, the calomel begins to pass into vapour, and, the lid having been raised for a moment to ascertain that fact, the patient is told to inspire through the mouth -piece, at the same moment closing his nostrils between his thumb and forefinger, and then to expire through the nostrils ; and so on alternately, breathing in a naturally free and easy manner. After about ten or fifteen minutes, all the calomel will have been inhaled as vapour, save a small quantity which adheres as a thin, white film to the interior of the pot and tube. In two cases wherein I have resorted to the inhalation of calomel vapour for the treatment of secondary syphilis, with ulceration and sloughing of the throat — the teapot inhaler I improvised having been used — the following facts are worthy of notice for g'uidance in general. (1.) In both cases, previous treatment by mercury, and iodide of potassium, administered by the mouth, had been tried, successively, and failed; and, in one case, it was impossible thus to continue the treatment, these medicinal agents being absolutely rejected by the stomach with nausea, and constantly recurring sickness. (2.) The gradual process of inhalation, — ten or fifteen minutes, and the quantity used, twenty grains. (3.) Explosive coughing after inhalation, — vari- able in period of sequence, in its degree, and duration, but subsiding spontaneously and permanently. This might be moderated by reduc- ing the quantity of calomel to, say, half — ten grains, while the same beneficial influence might be gained by repeating the inhalation. (4.) Slight salivation, in about forty-eight hours, and disappearance of the secondary symptoms ; ulceration of the throat, especially. (5.) Com- 334 GENERAL PATHOLOGY AND SURGERY. pared with mercurial inunction, and with the mercurial bath ; the inhalation of calomel vapour is more speedy and efPectual, in its systemic influence, than the one, and far more so than the other. (6.) As to safety ; in one of the two cases, the patient died, some days after in- halation, from bronchitis and pneumonia, but this patient had a very feeble venous circulation, and his constitution had been worn out by an Indian climate, and gz-eat intemperance, more than by constitutional syphilis. In the other case, the pulmonic effect of the inhalation was inconsidei-able, and the process was repeated on four different occa- sions, without any danger. The balance of evidence, from these two cases, is, therefore, in favour of inhalation ; and relatively also to mercurial inunction, and the mercurial bath.* Excessive mercurialization produces symptoms which it may be con- venient here to notice. They are ; profuse salivation, swelling of the salivary glands, gums, tongue, and face, ulceration of the mucous mem- brane, loosening of the teeth, and even necrosis of the jaws. Diarrhoea, with bilious evacuations. Certain varieties of skin-diseases, e.g. mer- curial eczema. Periostitis and ostitis, otherwise than connected with the mouth. Low fever with great prostration or mercurial erythism. Nervous affections — e.g. neuralgic pains, partial paralysis, or mercurial tremor, sometimes complete paralysis and death ; usually observed in those subject to the action of mercurial fumigation. The therapeutic use of mercury in relation to Syphilis has been the subject of keen discussion, by partisans of the " mei^curial " and "non-mercurial" methods of treatment. A just estimate of this question is presented by Dr. Nevins, in the following series of conclusions ; and which will enable the practitioner to form a right judgment as to the administration of mercury, in the treatment of Syphilis. 1. That every form of Syphilis has been, and nnay be cured, with- out Mercury. 2. That in some forms of Syphilis, Mercury is not only useless, but injurious, when given so as to affect the constitution. 3. That in those cases in which it is admissible, its beneficial influence may be obtained from much smaller quantities than were formerly given. 4. That some of the symptoms and effects formerly attributed to Syphilis were due to Mercury itself. 5. That although all the forms of Syphilis may be cured without it, yet its judicious administration materially hastens the cure, in many forms of the disease. 6. That the occurrence of secondary symptoms is much less liable to happen after the administration of Mercury than if the disease has been cured without it. 7. That the liability to secondary symptoms being in great measure proportionate to the duration of chancre, and Mercury having the power of shortening the period of specificity, its employment to expedite the healing of the sore is most advisable. 8. That in hard chancre, the administration of Mercury is most essential ; whereas in the soft, suppurating ulcer — chancroid — Mer- cury is less useful, or positively injurious. * Summary of a Paper read before the Harveian Society, London. CONSTITUTIONAL OR SECONDARY SYPHILIS. 335 9. That its employment ought to be suspended when there is a suppurating bubo. 10. That in syphilitic eruptions of a papular or scaly form, Mercury is beneficial ; whilst in those of an ulcerative character, as ecthyma or rupia, it is injurious. 11. That the benefit of Mercury is not proportional to the degree of salivation induced ; and that, except as evidence of a constitutional effect, this result is undesirable. Iodide of potassium. — Not to be trusted for the prevention of con- stitutional syphilis, iodide of potassium ranks next to mercury as a curative agent ; and especially in some forms of the disease, and in a certain constitutional condition, whether natural to the individual .or morbid, where the action of mercury cannot be borne. It may be stated generally, that in the forms of skin-eruption accompanied with plastic induration, in the earlier period of constitutional syphilis, and in young and vigorous subjects, mercury is most curative ; whereas, in pustular eruptions, enlargement of the testicle, periostitis and ostitis, and any tertiary affections, in the later periods of syphilis, and in debilitated, cachectic subjects, iodide of potassium is the more remedial. But, perhaps, it may be added that its effects are less permanent than those of mercuiy, and thus the disease is liable to recur. Iodide of potassium is given in doses, usually from three to five grains, carried up to perhaps half a drachm, thrice daily, and combined with cinchona bark, cascarilla, or other vegetable tonic; this adjunct generally being- requisite under the circumstances of suppuration or ulceration, wherein the iodide is prescribed. This medicinal agent was, I believe, originally brought into use for the treatment of constitutional syphilis, by Mr. Samuel Coopei*, Mr. Morton, and other Surgeons at University College Hospital, about the time when I was a Student in that Institution ; and it has since found much favour with the Profession. I have pre- scribed it with marked advantage in some thousands of cases, principally at the Royal Free Hospital. Iodide of mercury has considerable repute with many continental surgeons ; a grain being given in a pill three times a day, and gradually increased to three grains. Or, this combination may, probably, be effected in the system, by the concurrent administration of iodide of potassium or iodide of sodium, while mercury is introduced through the skin ; thus obviating any irritation of the digestive organs which might be excited by giving the iodide of mercury itself. Sarsaparilla has far less influence on constitutional syphilis than was formerly supposed, within my recollection. Its therapeutic value would seem to be restricted to the more asthenic or later secondary, and tertiary symptoms, and as occurring in debilitated subjects ; the same circumstances which render iodide of potassium preferable to mercury. Or, again, mercury having produced a new series of symptoms simulating the syphilitic, sarsaparilla will then be remedial ; or it may come into use at a subsequent period, to remove the seq^uel ' "'^H'^l'^M^^ V^'^'^ in the first instance, though / ''"'^'' ' '" if the disease is allowed to go on, they ultimately may penetrate into the circulation and cause death. This di.scase varies much in malig- nancv, and this may depend either on diffei-ent degrees of virulence of the bacillus (for it has now^ been proved that the virulence of this organism may be diminished in various ways), or it may depend on the patient being a more or less favourable soil for its growth. That the bacilli often are growing with difficulty in cases of malignant pustule, is evident from their appearance corresponding to the appear- ance presented by them when gi-own on an unsuitable artificial soil. Glanders is another disease which has been proved to be due to a micro-organism — a bacillus. This bacillus is very small, and is present in large numbers in the nodules and ulcers. It can be cultivated outside the body on coagulated blood-serum kept at the temperature of the body, and aLso on boiled potatoes under the same conditions, and when again inoculated into hoz'ses and other animals produces the same disease. Erysipelas is caused by the growth of a micrococcus in the lymphatic vessels and tissue-spaces of the skin and subcutaneous tissue (Fig. 108). This micrococcus grows chiefly in chains. It is found at the spreading margin of the erysipelatous redness, and in the healthy * Bacillns anthracis in blood-vessels. BACTERIA IN SURGERY. 457 "tissues beyond. If a section is made tliroiigli the skin at the margin of the redness, the lymphatic vessels will be seen to be blocked by masses of these organisms, mixed with leucocytes. The micrococci will often be observed to penetrate into the tissue. They rapidly spread and as rapidly die, so that if the part of the Fig. 108.* skin which has been af- fected, with erysipelas a day or two previously be examined, no micrococci will be seen. These micro- «te^ ■•"*. , .2^_- "^-^ cocci can be cultivated l. " ""'\')/i '"''•'t on gelatinized, peptonized '%:•.•;■ .'* ' meat infusion, potatoes, -/ ^^ ^ i^'y" etc., but grow very slowly ^^ '^ ^ •• unless kept at the tern- ^\ ^ ""n^ perature of the body. ' "" .. • When inoculated into the ^ ear of a rabbit, they cause "^ ;- an erysipelatous redness, spreading from the point of inoculation, and if this skin is examined the same appearances of blocking of the lymphatics with micrococci will be observed as in man. The cultivations have also been inoculated into man, in a number of instances, with success. This has been done under the idea that lupus, rodent ulcer, and various cases of cancerous disease were improved after an attack of erysipelas, and in such cases the cultivations of these micrococci have been used for the production of the erysipelas, and, as I have just said, with success. Tubercular diseases may also be looked on as undoubted bacillary Fig. 109.t diseases, though here, probably, other ^ factors come largely into play. ~l /^' The bacillus of tubercle (Pig. 109) "is ' ~ r: one of the few which are recognizable ' ^ _, ~^ by the use of the microscope alone, as it is distinguished by its reactions with aniline dyes. It is always present in tubercular affections ; it can be cultivated on coagulated blood-serum kept at the temperature of the body, and when the cultivated bacilli are injected into animals, the 7^^ \ '^^"l 7 ^ C/ same result follows as when tuber- ~ ' '-^^ - cular material itself is introduced. It is also found in small niimbers in lupus nodules, and in scrofulous dis- eases (enlarged glands, white swell- ing, caries, etc.). In these instances of local tuberculosis, the bacilli are * Section of skin at the spreading margin of the redness in erysipelas. (From a photograph by Koch, x. 700.) A lymphatic vessel is seen containing micrococci, which are also spreading into the tissues aronnd. t Bacillus of tuberculosis in giant cell. 458 SPECIAL PATHOLOGY AND SURGERY. very few in number compared with their numbers in other cases, and further, in many cases, they seem to be undergoing degeneration as if they were growing with difficulty. What the various conditions necessary for the development of a local tuberculosis are, it is difficult to say, but there seems no doubt that the bacillus is the one essential element. A very interesting case bearing on this matter was recently published by Dr. Tscherning in Copenhagen, and may be i-eferred to here. Marie P , set. twenty-four, cook in the house of the late Professor H , Avas of a thoi-oughly healthy and strong constitu- tion. She had never suffered from scrofulous afPections, and there was nothing of the kind in her family. Professor H died at the end of July of the year of very acute phthisis, and his sputum contained large numbers of tubercle bacilli ; indeed, towards the end of his life it seemed almost a pure cultivation of tubercle bacilli in pus. A few days before his death, Marie P cut the palmar surface of the 6rst phalanx of her middle finger Fig. 110.* slightly with a portion of a vessel containing the sputum. Fourteen days later, she came to Dr. Tscherning with what seemed a commencing whitlow. Under treatment, the acute symptoms subsided without the occurrence of suppuration, leaving a small nodule in the subcutaneous tissue as large as half a pea. For a few weeks there was around this nodule a little oedema, and the noduleitself wassomewhat tender. At the end of August, an incision was made, and this swelling, which lay between the sheath of the tendon and the skin, was removed with a sharp spoon. The wound healed by first intention. For a time, mattei'S were improved, but when the patient was again seen in the beginning of October, she complained of pain in bending the finger. The skin and subcutaneous tissue were somewhat swollen, as well as the neig'hbouring part of the palm. In the middle of November, a marked swelling of the sheath of the flexor tendon was evident; the finger was comparatively useless, and there was considerable pain and tenderness. Further, two swollen glands wei'e felt above the elbow, and two also in the axilla. On November 21st, these four glands were removed, the finger was ampu- tated at the metacarpo-phalangeal joint, the incision was prolonged upwards in the palm, and the tendon, with its sheath, was removed and all apparently diseased tissue scraped out. The wounds healed rapidly, and when the patient was seen in the middle of January, she was apparently in perfect health, without any return of the affection. Examination of the diseased structure showed the presence of tubercle bacilli. Here is a distinct instance of a local tuberculosis — what would be termed a scrofulous affection, resulting in a healthy person from inoculation of tubercle bacilli. Leprosy is another disease which, there can be no doubt, is due to * Bacillus of leprosy in large cells, from a leprous nodule. BACTEKIA IN SURGEKY. 459 Fig. 111.^ bacilli, althoiigli absolute proof of this has not yet been furnished- There is always found, in the lesions of leprosy, enormous numbers of small bacilli (Fig. 110), which can be distinguished from others by their staining reactions. These are present from whatever part of the world leprous tissue is obtained, and they are never found in any other disease. They have not yet been cultivated, nor can the disease be reproduced in the lower animals, but, judging' from analogy, there can be little doubt that in these bacilli we have the cause of the disease. Actinomycosis is a surgical disease aifecting the tongue, jaws, glands of the neck, etc., which has been lately described, and which is appa- rently due to a fungus always present in the affected parts. This fungus has not yet been classified, nor has the matter been thoroughly worked out, but there is little doubt that the fungus is the cause of the affection. In syphilis a bacillus has just been discovered, apparently on good authority, but the research has not yet been piiblished. The whole history of the disease, however, renders it highly probable that its cause also lies in one of these minute organisms. Diphtheria is a disease the pathology of which seems to be very complicated, but which also appears to depend on bacteria. A variety of micro-organisms have been described as the cause of diphtheria, but as yet the result of these investigations is not sufl&ciently definite. Perhaps the best research is that by Loffler, published in the second volume of the reports of the Sanitary Institute of Berlin. He describes two forms of diphtheria — one the diphtheritic sore-throat, which often accompanies epidemics of scarlet- fever, one member of a family being- affected with scarlatina, another with diphtheritic sore-throat ; and the other diphtheria proper, unassoci- ated with scarlatina. Characteristic of these two forms, he finds two different kinds of bacteria. In diph- theria proper he finds a bacilkis enlarged at one end (club-shaped), which differs fi'om other bacteria in its mode and conditions of groAvth, and which produces a sort of diphtheritic affection when inoculated on the mucous membranes of guinea-pigs. It apparently is not present in all cases of diphtheria, and was in one case found in the mouth of a healthy child. In the other form of diphtheria he found a micro- coccus, which in all its characters closely resembles the micrococcus of erysipelas, and there are various facts which render it probable that many of these cases are in reality only erysipelas of the mucous membrane of the throat. Gonorrhoea is also probably due to a micrococcus. If gonorrhoeal pus is examined after being stained in a suitable manner, it will be seen to contain large numbers of micrococci, which are flattened on their opposed surface, and are more especially found in connection with the epithelial cells (Fig. 111). These have been cultivated, and * GonorrhcEal pus, showing micrococci in an epithelial cell. 460 SPECIAL PATHOLOGY AND SURGERY. Fig. 112.* it is stated that their injection into the urethra has produced gonorrhoea. The precise connection between these mici^ococci and gonorrhoea has hai'dly been sufBciently Avorked out, though here, again, thei'e can be no doubt that "vve have to do with a disease essentially due to micro- organisms. Contagious ophthalmia is probably also due to the same or similar micrococci. Perhaps one of the most impor- tant facts, from a surgical point of view, is the relation of these micro- organisms to inflammatory affec- tions. In all acute abscesses (Fig. 112), even befoi-e they are opened, micrococci are present. In most suppurating wounds micrococci are found. In chronic abscesses there are no micrococci. What is the relation between the micrococci and Fro. n.S.+ the inflammation ? In a paper published in the British Medical * Pns of acute abscess, showing micrococci and pus-cells. t Section of kidney, showing in the uiDper corner a mass of micrococci, a clear necrotic ring, and a layer of inflammation. In the centre is the further stage of the process; the inflammatory cells and the micrococci have now infiltrated the necrotic ring, and an abscess is the result. (For further details, sqq Brit. Med. Journ., September and October, 1884.) BACTERIA IN SURGERY. 461 Journal for September and October, 1884, to which. I must refer the reader, I came to the following conclusions: — Micrococci are always present in acute abscesses, and are probablj the cause of them. In some cases thej are the primary cause of the inflammation and sup- puration, as in pyaemic abscesses (Fig. 113) ; generally, however, they begin to act after inflammation has been previously induced as the result of injury, by absorption of chemically irritating substances fi-om wounds, by cold, etc. There are several different kinds of micrococci associated with inflammation. The micrococci cause suppuration by the production of a chemically irritating substance, which, if applied to the tissues in a concentrated form, causes necrosis of the tissue, but, if more dilute, causes inflammation and suppuration. Suppura- tion may, however, occur, in the case of wounds, from other causes. Thus croton oil causes suppuration, and, in fact, any irritating sub- stance continuing to act for a suflicient length of time will do so, whether that substance be produced by micro-organisms or artificially. Tension in a wound may also cause suppuration, but it is, perhaps, most frequently aided by the growth of micrococci. Somewhat similar views have since been put forward by other authorities, and my opinion that there were several kinds of micrococci associated with inflammation, which 1 formed more as a result of reasoning than of direct observation, has since been fully verified. Rosenbach has found four different kinds of micrococci in pus, which he calls staphylococcus aureus, staphylococcus albus, according- to the colour they produce on cultivation ; a third forms delicate colonies, and a fourth grows in long chains instead of in masses. Passet found, in addition, one producing a citron colour (staphylococcus citreus), and two gTowing in waxlike drops, which he calls staphylococus cereus albus and flavas. Many of these produced abscesses when injected into rabbits, guinea-pigs, and mice. The relation of osteomyelitis to micrococci has also been- pretty thoroughly worked out, but it seems that this micrococcus, instead of being peculiar to osteomyelitis, as was at first supposed, is really the staphylococcus aureus. This organism is always present in acute osteomyelitis ; it can be grown on gelatinized meat infusion, producing there an orange-yellow colour, and when injected into the veins of rabbits, if the bones have been previously broken or bruised, it causes inflammation and necrosis of the injured bone. The connection of septicaemia and pyasmia with micro-organisms is undoubted, but the precise state of matters in the human subject has not yet been determined. The following is probably pretty near the truth. "We may look on septicaemia in man as connected with micro- organisms in three ways. In the first place, as we have seen, micro- organisms growing in the fluids in a wound may produce substances which, when absorbed, give rise to fever, and, in large quantities, to death. The absorption and fever cease when granulation is complete, but if from any cause granulation is imperfect and absorption can con- tinue to occur, the fever would continue, and we should have a form of septicEemia. Most probably, however, in most cases the organisms are growing not only in the wound, but also in the tissues in the neigh- bourhood, and, growing there, pour their ptomaines into the blood. In a third form, the organisms grow in the blood itself, and cause the symptoms. The micro-organisms concerned are generally micrococci, but in some cases, especially in puerperal septicaemia, bacilli have 462 SPECIAL PATHOLOGY AND SUKGERY. been found. The growth of organisms in the blood is the common cause of septicaemia in the lower animals, and in the case of rabbits, guinea-pigs, and mice, the relation to micro-organisms of various kinds has been thoroughly worked out on the principles formerly laid down. In the case of pyjemia, the organisms, which are always micrococci, grow in the blood and tend to form colonies in the blood. These colonies, when they have attained a certain size, stick in the capillaries and set up abscesses — the secondary abscess of pytemia. Apparently, hoAvever, it is not a mere matter of plugging of capillaries, for then miliary abscesses would occur everywhere. These organisms seem to grow by preference in certain organs and tissues. Koch found, in the case of mice, that pyeemia could be induced by the injection of a particular micrococcus ; that this micrococcus tended to grow in groups, adhering to the red blood-corpuscles and causing them to stick together and to the walls of the blood-vessels, and setting up abscesses in the tissue around. Spreading gangrene, phagedtena, soft chancres, etc., are no doubt also due to micro-organisms, but they have not yet been worked out. It may be useful to those who wish to demonstrate these organisms to give shortly one method. Make a 1 to 10,000 watery solution of caustic potash. Take of this 100 parts, and add of a saturated alcoholic solution of methylene blue 30 parts. Stain sections in this, place them afterwards in distilled water, absolute alcohol, and oil of cedar, and mount in Canada balsam. For pus, dry a thin layer on a cover- glass, pass it three times pretty rapidly through a gas flame to fix the layer, float on the surface of the above solution for an hour or so, wash in water, dry, and mount in Canada balsam. It is not possible to give full details of the methods of staining and cultivation here. I hare mentioned them in one of the Health Exhibition Handbooks, to which 1 must refer those who wish to go further into the subject. Wounds of Arteries and Veins. These Lesions are conveniently taken next in order to Incised Wound. Wounds of Arteries. — A wound of an artery, like that of any other texture, may be incised, or lacerated; either of which lesions may be partial or complete. Incision, partially extending through the calibre of an artery, and practically equivalent to a punc- FiG. 114. tared wound, varies in direction; being longitudinal, oblique, or transverse, and these are im- portant practical distinctions (Fig. 114) ; so also is the vari- ation in size of an aperture, which may be of any circum- ferential extent, short of com- plete division of the vessel. Laceration, partially extend- ing through the coats of an artery, is limited to one or more of its three coats ; the external, and WOUNDS OF ARTERIES. 463 more or less oE the middle coats, may be torn through, leaving only the thin, inner one entire : or, the two inner coats are severed, leaving only the thick external cellular coat untorn. This latter condition of lacei-ation is effected by the surgical application of a ligature. Lastly, all three coats are torn through, if the laceration be complete ; but the external cellular coat and cellular sheath, being tougher than the two inner coats, are drawn out from off them, which also retract ; thus forming a canal of loose cellular tissue. The Signs of any such wound of an artery are Ticemorrhage, the blood having a florid red colour, and jetting out from the vessel, per saltum, with each beat of the heart ; not escaping in a continuous stream of purple or black blood. The force, and in a degree, the rapidity of the jets are regulated by the size of the artery, or of the aperture in it, by its proximity to the heart, and by the heart's action ; also by the presence or absence of certain conditions which retard or favour the free flow of blood through the vessel. Thus, pressure on the proximal portion of artery retards, while a dependent position favours, the haemorrhage. The blood coming from the distal portion of vessel is dark, and runs in a trickling stream, excepting from certain arteries, the palmar and plantar arches, which when wounded, jet arterial blood from either extremity of the vessel. Causes and Effects of Woimds of Arteries. — An artery may be incised or cut with a sharp instrument, punctured with a pointed one, contused or lacerated by a blunt one, or wounded by force of a bruising or wrenching kind. The operation of any such lesion locally, is to produce aneurism, if the blood be imprisoned in the textures ; constituting traumatic aneurism — diffused, or eventually perhaps circumscribed. Its formation will be specially described in connection with aneurism. Constitutionally regarded, whether arterial haemorrhage takes place externally, or internally, as into one of the great cavities of the body, its effects are manifested by syncope or fainting, more or less complete. And this may occur either by failure of the heart's action — cardiac syncope, and thence of the circulation, or as loss of consciousness — cerehral syncope ; or both modes of syncope may be produced. The symptoms of syncope are further evinced by a feeble or imperceptible pulse, with pallidity and cold clamminess of the surface, and lividity of the fingers, toes, lips, and eyes ; in this condition, the countenance assumes a leaden and clayey hue, with a haggard and alarmed, anxious expression, — such as is presented in the picture of a person who is assassinated ; and after a few oppressive sighs or gasps, with convulsive twitchings of the limbs, death may take place immediately. Or, if the heemorrhage be less considerable and sudden, the symptoms of syncope are less marked ; the patient turns pale and chilly, faint and sick, but soon becomes restless, and tormented with a raging thirst. If this state continue, the respiration becomes oppressed ; the patient restlessly throws his arms up and from side to side, or suddenly lifts his head from the pillow, as if for relief, in panting for bi-eath ; the pulse flutters and intermits, as the breath is drawn in long, convulsive sighs ; and thus asphyxia proves fatal, if death do not occur suddenly from cardiac syncope. These constitutional effects, and the probability of death resulting, are proportionate to the quantity of blood lost ; not necessarily by its escape from the body, but even when lost to the body 464 SPECIAL PATHOLOGY AND SURGERY. as blood in circulation. Providentially, however, the imminent peril of continued haemorrhage is lessened by cardiac syncope ; suspension of the circulation tends to arrest the escape of blood from the artery, and by thus favouring the formation of an occluding clot, it tends also to arrest the haemorrhage. Reaction after loss of blood is the return of the heart's action and the circulation. This state is denoted by symptoms of vascular and nervous excitement, which, after considerable loss of blood, constitute hcBinorrhagic fever. The pulse becomes rapid, but feeble or jerking, and irregular, loose, or thready also in proportion to the antemic con- dition of the blood-vessels. With returning warmth of surface, the face flushes, and the eyes acquire a lustrous brilliancy, while a restless excitement supervenes, bordering on delirium, and which perhaps terminates in death by coma and convulsions. Or the reaction may be intermittent ; pallidity and syncope recurring, followed by some return of the circulation. Age much affects the issue. In youth, the rallying power is greater, though the tolerance of hsemorrhage is less, the loss of a small quantity of blood, as from a leech-bite, sometimes proving fatal to an infant ; in advanced life, reaction is less vigorous, and as the reproduction of blood is also less active, recovery will be more and more doubtful, death perhaps ultimately taking place from exhaustion, or from some secondary affection of a typhoid character. Arterial heemorrhage is of greater consequence than venous. After death, the appeai-ances presented are remarkably anaemic ; the surface generally blanched, of a yellowish-white, semi-transparent cast, but the finger-nails, toes, and lips are congested and livid. Secondary htemorrhage is so named where the bleeding occurs, or recurs, after an interval of a few hours, more or less, subsequent to the vascular lesion. (See Ampdtatioxs — Stump.) The Hcemorrhagic Diathesis, also named Haemophilia, signifies a constitutional predisposition, whereby the slightest breach of surface — a scratch or a prick — is attended with a perj^istent oozing of blood ; the blood-vessels apparently possessing no contractility, and the blood no power of coagulation. From Wachsmuth's observations, it would seem that an exalted vitality of the blood, and a delicate organization of the capillaries, are the essential causative conditions. But the bleed- ings may occur spontaneously ; preceded sometimes by symptoms of plethora. Thus, in childhood, from various parts of the mucous membranes, spontaneous haemorrhages are apt to occur ; from the nose, mouth, intestine, or lungs. In cases of traumatic origin ; division of the frfenum linguae, or lancing the gums, has thus proved fatal ; and death has often resulted from the extraction of a tooth, bleeding from the socket — despite plugging — having continued for days. The opening of an abscess is no less dangerous ; and even a leech-bite, or vaccination, have their hcemorrhagic liabilities. In- terstitial haemorrhages or ecchymoses, in the connective tissue of various parts, or forming blood- turn ours, are not uncommon — w^hether arising spontaneously, or from slight injury. The joints are fre- quently the seat of extravasations into the synovial capsules ; forming intractable swellings, simulating rheumatism ; and which seem to control temporarily the tendency to h^mon^hage elsewhere. The knee-joint is commonly thus affected ; and relapses are frequently met with. WOUNDS OF AKTERIES. 465 This diathesis is always congenital, and usnally hereditary, although it may, it is said, be declared for the first time in adult life. But, according to Dr. Wickham Legg, as an authority, cases of this late appearance of hemophilia are unreliable ; the htemorrhagic diathesis rarely manifests itself at birth ; yet generally during the fi^rst year of life, sometimes, however, not until the commencement of the second dentition. HEemophilia must be distinguished from other constitutional conditions giving rise to haBmorrhage ; as witnessed in persons who are weak and flabby, and who easily bruise from trifling- injury, with perhaps considerable ecchymosis ; or again, as occurring in various blood-diseases, vsuch as scurvy, albuminuria, and jaundice. Privations seem to induce the heemorrhagic tendency in hsemo- philia, but it is often manifested in otherwise healthy constitutions, and apart from any adverse hygienic circumstances. The individuals subject look in good health. The predisposing influence of sex is shown by the fact, that males are far more fi'equently "bleeders" than females. Of 650 attested cases, 602 were in males, and only the small proportion of 48 in females. The average proportion appears to be about 11 to 1. In male children, the haemorrhages begin earlier and are more fatal. But marriage on the male side does not appear to transmit the diathesis. On the other hand, the children of women who are bleeders, almost invariably inherit the htemor- rhagic tendency. And in bleeder-families, males, who themselves are unaffected, rarely beget the diathesis, by marriage with women from other families ; whereas, the children of women, themselves unaffected, in such families, are very often heemorrhagic. The extraordinary procreativeness of non-bleeder brothers and sisters, is a remarkable element in the consanguinity of bleeder-families ; the births — accord- ing- to Immerraan's computation — amounting to nearly twice the general average. In haemophilia, if the bleeding be spontaneous, as often manifested by epistaxis, it may be periodic. Women — when the subjects of this diathesis — are seldom so liable to the typical haemor- rhages of " bleeders ; " but exhibit the same tendency by monorrhagia, and floodings after parturition. lHo race is exempt from the hgemor- rhagic diathesis ; and Jews are very prone to it. Persons born with this heredity seldom outlive it ; for if they do not succumb to repeated bleedings in earlier years, they never lose the tendency to hgemorrhage. This leaky state of the capillary system is but little amenable to any remedial treatment. The usual means for the control of oozing hemorrhage — to be noticed in connection with wounds of arteries — are here of very little avail. Styptics or astringents, when they can be applied, have scarcely any effect ; and being apt to induce inflam- mation, and sloughing, the bleeding recui-s from the fresh surface. The actual cautery is, therefore, even more hazardous. But, the per- chloride of iron, administered internally, is perhaps the most efficacious blood-stauncher. Compression is more effectual than stjptic appli- ances, especially when the haemorrhage is traumatic. The same liability to sloughing restricts the eligibility of compression, in the treatment of haemophilia. The persistent bleeding following tooth- extraction may perhaps be controlled by carefully plugging the alveolus ; or the tooth extracted will best fit the socket, the jaw being firmly secured by a chin-bandage around the head. Cold is the most YOL. I. 2 H 466 SPECIAL PATHOLOGY AND SURGERY. effectual resonrce in the ba^morrliagic diathesis, for restraining^ some local oozings of blood ; as by means of the ice-bag, or by irrigation. As the last resource in protracted or repeated bleedings, the patient may be rescued from otherwise fatal exhaustion, by the transfusion of blood from a volunteer life-giver. The hiemorrhagic diathesis prohibits any avoidable surgical pro- cedure, attended with a breach of surface, or subcutaneous vascular lesion. The general health of an indi\-idnal who is thus predisposed to bleeding, may be renovated by a nutritious, and easily assimilated diet; coupled with the administration of iron and cod-liver oil; and residence, if possible, in a temperate climate. Marriage cannot be sanctioned, especially on the female side, with regard to persons who inherit the boemorrhagic diathesis; or if themselves unaffected, belong to a family of "bleeders." Repakation of Wounds of Arteries. — If the artei-y be healthy, any lesion is uniformly disposed to heal by coagulation of the blood and the formation of a clot or clots so placed as to arrest the haeraor- rhage; a temporary provision, followed by primary adhesion, or, pos- sibly, adhesive inflammation, w4iereby the vessel is permanently secured and obstructed. But tbis process of coagulation and adhesion is modified chiefly according to the kind of wound — incised or lacerated, either of which may also be a partial or complete division of the artery. Then, again, the dii*ection of the wound more particularly modifies the process of healing. (1.) An incised and partial division, or 2l funchired wound, of an artery is the simplest instance. (See Fig. 114.) If the direction of the cut be longitudinal or oblique, it will close more readily than a transverse incision, the edges of which gape and do not fall into apposition. The elasticity of arterial issue longitudinally makes all the diiference, and in favour of that direction, aided also, in this case, by the circular contractility of the artery. The line of incision remains closed ; blood escaping coagulates betwixt the vessel and its sheath, forming a com- press, assisted by any corresponding coagulum which may have formed outside the sheath. The relative positions of the apertures in the artery and its sheath are displaced somewhat by the formation of the intervening portion of clot-compress, thus further tending to aiTest haemorrhage. But this clot-compress is a temporary provision only. Adhesion soon follows in the line of incision, the edges being in contact. A transverse cut, partly through the circumference, of an artery (see Fig. 114), opens, the vessel contracting longitudinally by virtue of its elasticity. Adhesion cannot ensue. The aperture is closed by the effusion and organization of lymph ivitliin the artery, which thus becomes impervious and obliterated. Lost, however, for ever as a blood-conveying tube, haemorrhage of perhaps fatal character is arrested. Nature is still victorious. The size of the vessel will some- what affect the issue, which is otherwise in favour of a longitudinal incision. An artery like the temporal, with a longitudinal slit, heals without obliteration. An artery of larger calibre, and similarly wounded, becomes impervious and obliterated. And the ultimate success of Nature's effort is apt to be marred, even when the wounded vessel remains pervious ; for the internal and middle coats not adhering firmly, this defect predisposes to aneurism. WOUNDS OF ARTERIES. 467 Fig. 115. (2.) Complete division of an artery by incision is healed by a modi- fication of the same process — clot-formation, but not as a compress, being tlie temporary provision, and lymph-effusion permanently plugging up the vessel. Immediately after its division the artery retracts by its elasticity — longitudinally into its sheath, which thus projects loosely ; and the mouth of the vessel contracts, even to a pinhole opening, owing to its muscular contractility — circularly. The retracted portion thus contracted has a conical shape, like that of a Florence oil-flask or French claret-bottle (Fig. 115). Contractility may be sufficient to close the vessel and prevent further haemorrhage. In this way small arterial branches spontaneously cease to bleed in an open wound exposed to the air, or the action of cold water ; but the artery having retracted, coagulation is induced within the loosely projecting filamentous sheath, which entangles the blood as it flows ; and this event may be aided by cessation of the stream, owing to failure of the heart's action — cardiac syncope — another resource of Nature for the temporary arrest of hsemorrhage. The extent to which a divided artery may retract — as favouring coagulation — will vary with the more or less yielding attachment of surrounding tissues, and with their retractibility in connection with the artery. Thus, an artery situated in loose connective tissue, will retract more freely than when set in dense cellular or fascial texture ; and in the substance of muscle, the retraction of the vessel appears to be less, owing to the surrounding texture at the cut sur- face, retracting to perhaps the same extent or even causing the end of the artery to project. Coagulation proceeds con- centrically. The clot, at first pervious and transmitting a small central stream of blood, soon forms a solid mass, which, still enlarging, passes np the bore of the artery for a short distance in the shape of a small cone. This portion — internal coagulum or houcJion — and that within the sheath — external coagulum or couvercle — together form a clot, in shape like a glass stopper fitted into a decanter, to which the whole is compared by Professor Gross. The shape of Nature's product is not quite so finished off, for a small portion of the clot is insinuated between the sheath and artery beyond the point of retraction, thereby compressing the arterial aperture, while a still larger portion of an irregular shape projects beyond the aperture of ihe sheath. The whole clot is, however, continuous, and with these little offsets still bears the resemblance suggested. (See Fig. 115.) The permanent closure of the vessel is effected by the effusion of plastic lymph. Like coagulated fibrin, its organization consists, essentially, of fibrils ; but those of plastic lymph result from the elongation and attenuation of cells into fibres, in various stages of development. Corresponding in situation to the clot, i.e. at the aperture, around it slightly, and extending into the vessel, the lymph intervenes between it and the clot, which it gradually replaces. During this 468 SPECIAL PATHOLOGY AND SURGERY. Fig. 116. change the clot varies in appearance, being partly lymph, and partly ordinary coagulura. The lower end of a divided artery is closed up much in the same ■way. According to Guthrie's observations, it retracts and contracts less than the cardiac end ; and the internal coagulutn is altogether absent, or very imperfectly formed in many instances. Consequently, secondary hfemorrhage is more liable to occur from the distal end of an artery, in the course of repair after division. (3.) A lacerated wound of an artery, ii partial, may extend thi'ough the external and middle coats, leaAang only a thin undivided inner membrane, which still continues the channel of communication. Htemorrhasre is imminent. Or the laceration may extend through the inner and middle coats, leaving the outer cellular coat entire. Haemor- rhage threatens, or gangrene may supervene. But if the two inner coats be cat rather than torn, reparation generally takes place and secures the vessel. Such is the kind of injury purposely inflicted by the Surgical application of a ligature, which leaves the external coat undivided ; and although itself noxious, as a foreign body in the very pathway of reparation, the artery becomes sealed with plastic lymph, plugged up also with coagu- lum, and obliterated. The details of this process, thus artificially induced by Surgical interference, will be described in connection with the treatment of haemorrhage. (4.) Complete laceration of an artery — all the coats being torn through — heals without hgemor- rhagp, or scarcely any. The process is the same as that which takes place after division of an arteiy by incision. But the cellular sheath and outer cellular coat are drawn off the two inner coats, which retract. Consequently the clot that forms within the projecting portion of loose sheath is larger than when the vessel is simply cut across ; presenting a bulb-shaped extremity, which may extend to half an inch or an inch in length. Hsemorrhage is thus prevented, as witnessed in many cases where a limb has been torn off, with scarcely the loss of any blood ; the arteries being plugged. This appearance is well shown in Fig. 116, which represents a popliteal artery and vein in a remarkable case, both vessels having been ruptured by a violent twist of the knee-joint. Gangrene of the leg ensued, for which I amputated above the knee ; with, however, a fatal result. Treatment. — Arrest of heenaorrhage is the first indication of treat- ment. Small arterial vessels spont ineously cease to bleed, almost im- mediately. Thus, if the vessels be divided entirely acro.^s — complete incision — as in most wounds, their cut extremities retracting and con- tracting soon offer adequate resistance to the es'-ape of blood. This natural provision will be insured by exposure of the wound to cool air, or a stream of cold water squeezed from a sponge. Gentle pressure with the sponge will readily discover whether there be still any oozing from the bleedmg points. Larger-sized arteries bleed in jetting streams WOUNDS OF ARTERIES. 469 of florid blood, and the further resoioi^ces of Surgical treatment are forthwith necessary to meet sach heemorrhage. Thej comprise : — (1) Astringents, including Cold, and Styptics ; (2) Cauterization ; (3) Compression; (4) Ligature; (5) Acupressure; (6) Torsion. (1.) Astringents. — Gold may be applied in various ways; in the form of a stream of cold water, or by exposure to cool air, or by means of an ice-bag, or as ice-water. Cold applications are most eligible for the arrest of general bleeding from a large surface, or in the event of per- sistent oozing hemorrhage; and where the bleeding proceeds from an internal cavity, as the mouth, rectum, or vagina, when it may be arrested by the injection of ice- water. After a wound has been closed and dressed, the recurrence of hemorrhage can often be stopped, either by a continued or a dropping stream of cold water by means of irrigation, or by the application of an ice-bag. Styptics are various astringent agents ; such as styptic colloid, tincture of the perchloride of iron, Ruspini's styptic, oil of turpentine, solution of alum, tincture or infusion of matico. These agents are used by means of a brush or a fold of lint soaked in the styptic, and applied to the bleeding surface. Other styptics m.ay be administered internally ; as gallic or tannic acids, lead, opium, or turpentine. All such agents are appropriate under similar circumstances of hgemorrhage to those for the employ- ment of cold. But external styptics are apt to induce a thin layer of slough, and thus prevent or intercept primary union. And internal styptics are hardly prompt enough in their action. Solid opium, given in a full dose, is accredited with the virtue of arresting any oozing of blood from a number of small vessels, after wound or operation. The hsemorrhagic diathesis also may perhaps be controlled by oil of tur- pentine. (2.) Cauterization may be effected by the actual cautery, or hot iron — the most ancient resource in surgical haemorrhage, or by the potential cautery, in the form of potassa fusa or nitrate of silver. The actual cautery usually consists of an iron rod, having a conical-shaped or button extremity, the other end being set in a wooden handle. The iron is heated in the fire to a black heat, rather than made red-hot, and the point is then applied, almost momentarily, to the bleeding vessel, which causes a hissing sound, and produces an eschar, or slough, of the burnt textures. Other forms of actual cautery are sometimes employed; a porcelain instrument heated by gas, or plati- num heated by means of the galvanic battery, the galvanic cautery. Paquelin's the rmo- cautery (Fig. 117) is the most handy and useful instrument. Cauterization is most serviceable when the haemorrhage proceeds from one or more arterial points, and in an otherwise inac- cessible situation. But on the detachment of the eschar, in about a week, bleeding is liable to return. (3.) Compression — mediate, as it is sometimes termed, when not directly applied to the bleeding vessel — may be effected either by the finger or a tourniqicet, placed over the parent arteiy, at the most eligible spot betwixt the wound and the heart. Pressure thus applied is only a temporary resource. Immediate compression is effected by pressure directly applied over, or to, the bleeding vessels. Direct pressure may be made over the seat of the bleeding vessels by a pad of dry lint or other material, secured in position with sufficient firmness by a roller-bandage. A wound having been thoroughly cleansed and closed, 470 SPECIAL PATHOLOGY AND SURGERY. haemorrhage can thus be arrested ; and after amputation, the flaps of the stump can be compressed with a broad pad above and below, retained by the turns of a bandage. Cavities admit of being plugged with a pledget of lint or piece of sponge, saturated perhaps with some styptic solution ; as in bleeding from the nares, rectum, or vagina, or from the orbit after removal of the eyeball, or from the socket of a tooth, Fig. 117. in the rare case of continued bleeding after tooth-extraction. Direct pressure can be brought to bear, even more effectually, by means of a graduated compress, applied to the bleeding vessel. This form of compress consists of a series of pads of dry lint, from the smallest pledget which is placed on the bleeding point, over which another is laid down, and as many more, each of increasing size, as will reach about the level of the surface ; thus making a conical-shaped compress, the apex resting upon YiG 118 the wound in the vessel (Fig. 118), and the whole being secured by a bandage. In ap- plying the first plug of lint, the cavity must be well sponged out, while the main artery is commanded above, that the bleeding vessel may be fairly seen, before laying down the compress. It represents the clot-compress of nature. The graduated compress should be allowed to remain until the wounded vessel has become closed without the risk of haemorrhage recurring ; the requisite period varying from about a week to a fortnight. This mode of direct compression is specially applicable to the wound of a single artery, and which cannot be secured otherwise ; but direct com- pression, in either of the ways described, is suitable only, or chiefly, for the control of small arteries, and where the support of bone affords counter- pressure. (4.) Ligature. — The ligature is a Surgical appliance in imitation of WOUNDS OF ARTERIES. 471 Fig. 119. a lacerated wound, partially extending through the coats of an artery, i.e. through its two inner coats, which are thin and fragile, leaving the thicker and tougher outer coat and cellular sheath untorn. The effectual operation of this appliance is compression of the vessel to induce coagulation of the blood stagnant above and below the ligature, and the effusion of plastic lymph, from the divided coats, to perma- nently occlude the vessel in both directions ; sloughing of the included ring of outer coat and cellular sheath being rendered necessary to detach the ligature. The details of this reparative process, thus induced artificially, are these : — The included portion of extei'nal cellular coat and sheath, having undergone continued compression, sloughs, and is detached with the thread, in a period varying from twenty-four hours or so to about three or four weeks, chiefly according to the size of artery. Hasmorrhage would then be in- evitable ; but, pending the detachment of this slough-ring, effusion of plastic lymph, from the vasa vasorum, takes place, whereby the two inner coats, divided, become ad- herent across the area of the vessel, just above and below the ligature. At these points they curl inwards when divided, and, converging, meet together. This condition was well seen in a femoral artery and vein (Fig. 119), which I examined five days only after it had been ligatured when the thigh was amputated. A process of organization, therefore, above and below the ligature, accompanies the destruction and detachment of the ring of external coat embraced by the thread. Thus, the artery is securely sealed. Accessory, but incidental only, to the prevention of hasmorrhage, are certain changes whereby either portion of the artery adjoining the ligature is obliterated. The vessel having ceased to convey blood when the ligature was applied, its walls slowly con- tract, and thus tend to reduce the size of the vessel, or even to close the canal, — just as when, at birth, the blood-stream is diverted from the umbilical arteries ; and concuiTcntly, the blood stagnant above and below, to the nearest collateral branch, has gradually undergone coagulation in the shape of two conical clots, the bases of which accurately plug the artery on either side of the thread. The apex of the clot on the cardiac side tails off, usually opposite the first collateral branch above, through which the stream of blood, now diverted from its course, is carried off from the main. The distal clot is always less defined. This double clot-formation in, and plugging of, the artery begins in a period varying from one to eighteen hours, after the stag- nation of the blood, as induced by the ligature. At first either clot has the appearance of ordinary coagulum, especially at the base ; sub- sequently it becomes mottled with paler spots, and its substance porous, and ultimately acquires a buff colour, firm consistence, and fibi'ous texture ; some adhesion also takes place between the clot and the walls of the vessel. In the course of this transformation of the clot, the 472 SPECIAL PATHOLOGY AND SURGERY. red corpuscles wither and disappear ; but the white corpuscles elongate into fusiform cells, or become stellated, and anastomosing, form a network, which pervades the whole substance of the clot, thus con- verting it into a tibro-cellular texture. Blood-vessels, proceeding from the Ijmph immediately above and below the ligature, shoot into the base of either clot, and gradually extend towards its apex. But, according to the observations of Stilling and Weber, the new vessels are formed in the clot independently, and then become continuous with the vasa vasorum. Finalh', these organized fibrous clots are incorporated with the lymph at their base, which has acquired a similar structure ; the coats of the unused portions of artery degene- rating, also assume a fibrous character ; and the whole is converted into a small, fij*m, impervious, fibrous cord, extending usually to the first collateral branch above and below. Nature ha\ang safely severed the artery, under compression by the ligature, and securely sealed either end, has now obliterated the portions useless as a blood-conveying tube. All these changes take place probably more rapidly on the distal side of the ligature. Certain advantages, and disadvantages, attend the use of the ligature. Appropriate for the arrest of hsemoiThage which would otherwise be persistent or recurring and perilous, the objections to ligature are : — the production of a slough or sloughs of arterial texture, according to the number of vessels ligatured — and thence the liability of secondary hgemorrhage ; the introduction of a foreign body, or as many foreign hodies, into the flesh-wound — a condition which, in conjunction with that of the arterial slough-rings, is antagonistic to the process of healing by primary adhesion ; and that suppuration consequently, and the sloughs, are provocative of pysemia. The efiicacy of ligature in the treatment of hsemorrhage from wounds of arteries, or from flesh- wounds, and in relation to pyaemia, is to be estimated by all these considerations ; and thence the questionable value of this method of treatment as compared with that of " acupressure," which was proposed to supersede it. More recently, the use of the ligature has been redeemed by the kind of material employed ; the old hempen or silk thread having been exchanged for a material — such as carbolized catgut — which can be absorbed, and with impunity, as an antiseptic substance. Certain particulars are of great moment in the application of a ligature ; the observance of which a due knowledge of the process which is thus induced for the arrest of haemorrhage, can alone insure. It is in this light that I specially here advert to them. But they have reference also to the value of ligature, as a method of treatment ; for they determine the probability of haemorrhage recurring or super- venicg, and also of the healing of a flesh-wound by primary adhesion when an artery or arteries are thus secured. The practical particulars having this twofold significance are these : — A ligature should be applied so as to cut through the two inner coats of the artery, leaving only the outer more-resisting cellular coat and sheath. Hence the ligature must be a small, round, and strong thi'ead — fine silk twist waxed, hempen thread, whipcord, or catgut, being found to answer best. Applied with suflBcient tightness for this purpose ; and also to induce sloughing of the outer coat by strangulating compres- sion. Applied transversely across the diameter of the vessel, observing WOUNDS OF ARTERIES. 473 to press the loop down well upon the vessel, with each forefinger, so as not to include the point of the forceps ; and then, in tightening the loop, to press the threads in like manner, downwards, adjoining the loop, that its hold may be retained ; tying them with a reef-hnot (Fig. 120). failing these precautions, with regard to the vessel, the ligature may shift its position, and loosening, hsemorrhage recurs or supervenes when adhesion is not yet sufficiently advanced to safely seal the vessel. For the same reason, a ligature should be applied so as not to include any extraneous texture — a bit of muscle, a vein, or nei've ; for then the twofold effect on the artery enclosed may not be produced, or sloughing may proceed more speedily in the extraneous Fig. 120. Fig. 121. texture than in the arterial coat, the liga- ture become loosened, and haemorrhage occur. Inclusion of a nerve - filament causes also great pain at the time, and for a considerable period in some cases. Bleeding points may be temporarily se- cured by the application of catch forceps, which when closed, retains its hold (Fig. 121). Several such forceps may be used to stop the hsemorrhage from an extensive wound, while the main vessel is being tied. This most useful instrument, devised by Sir Spencer Wells, is often employed in the course of various surgical operations. An imbedded artery may be inaccessible without including some other texture. In the most inaccessible situations — as when, by amputa- tion, the anterior tibial artery is divided at its origin and deep in the muscles between the heads of the tibia and fibula — it is absolutely necessary to " dip " for an artery so placed. When the vessel is set in condensed tissue, it may be equally difficult to seize with forceps. A curved needle armed with a ligature is in this way carried round the vessel, and the thread tied as usual, but including as small a quantity of extraneous texture as possible (Fig. 122). Or Bigelow's artery- forceps for securing a deep vessel is here most serviceable. On the other hand, the ligature should not be applied to any 'projecting portion of the artery ; the vessel being there denuded of its own nutrient vessels (vasa vasorum), plastic lymph is not effiised, and 474 SPECIAL PATHOLOGY AND SURGERY. when the slouch-ring separates, haemorrhage is inevitable. Regarded as a, foreign body, antagonistic to healing by pi'iniary adhesion, one end of the ligature is usually cut off close to the knot on the artery, leaving only the other end to command the noose, and thus reducing the quantity of foreign body in the wound by one-lialf. The ligature or ligatures may be brought to one or other angle of the wound, and there fixed by a small piece of plaster, thus also limiting any defective adhesion to the narrow track occupied by the thread or threads. Duly observing all these suggestions of pathology, the constructive part of the process — adhesion — will generally accompany the destruc- tive — sloughing — with even progress ; ^'^' ~" permanent closure of the vessel accom- panying the separation of a ring of slough with the ligature. The security o"f the vessel is safely ascertained by gently twirling the thread between the thumb and finger. A yielding sensa- tion shows that Nature has done her work, and that the ligature detached can be withdi-awn without the risk of hsemorrhage. This, however, cannot be expected, nor should the experiment be tried, before sufficient time has elapsed — the period varying from twenty-four hours to as many days or more, chiefly according to the size of the artery. Carbolized catgut, or the same material, as a chromicized ligature, possesses the advantage of being absorbed or dissolved ; and both ends of the ligature may, therefore, be cut off short. The noose usually holds securely for some days, as secondary hemorrhage rarely occurs, from even a large-sized artery, the brachial or the femoral. Carbolized silk — in the form of " Chinese twist " — may answer equally well as an antiseptic ligature ; but this material is more apt to imbibe any de- composing organic matter or pus ; and therefore the ligature is less likely to be absorbed — remaining as a foreign body, although it may become encapsuled with fibrous tissue — and thus rendered inert. The ligature should not be waxed, which would preclude its absorption. Ligature of an artery in its continuity, is fully described under Ligature of Arteries. (5.) Acupressure was proposed by Sir James Simpson as a sub- stitute for ligature. It is essentially the " temporary metallic com- pression " of an artery, and it may be accomplished in either of three ways :—(!.) By passing a long needle twice through the flaps or sides of a wound, so as to cross over and compress the mouth of the bleed- ing vessel or its tube ; just as in fastening a flower in the lapel of our coat we cross over and compress the stalk with the pin which fixes it, and therefore pass the pin twice through the lapel. In this method a long needle is introduced from the cutaneous surface, and its extremi- ties left out externally. In both the other methods a common sewing- needle, threaded with iron wire, is used. The needle is introduced on the raw surface of the wound, and is therefore placed altogether internally or between the lips of the wound. The wire is only for the purpose of withdrawing the needle when no longer required. (2.) In * From Esmarch. WOUNDS OF ARTERIES. 475 one of the metliods referred to, tlie needle is dipped down into the textures a little to one side of the vessel, then raised np and bridged over the artery, and finally dipped down again into the textures on the other side. This method, therefore, is the same as the first, but that the needle is applied altogether on the raw surface of the wound and over the arter}--, which it compresses. (3.) The third method consists in passing a needle under the vessel, transfixing the textures once. A loop of wire is passed over the poiat, and fastened round the eye end by a single twist, thus compressing the artery and some surrounding tissue between the needle and the ■wire. This method Sir James Simpson advocated as that which would probably be most frequently practised (Fig. 123). Occlusion, after acupressure, consists, essentially, in the formation Fig. 123.* of a conical clot, adjoining' the transverse line of acupressure, or needle; this clot increases in length, extending up probably to the first collateral branch of artery, and it increases also in calibre, so as to completely occupy the bore of the vessel at, and for some distance adjoining, the line of acupressure. Thus the artery is plugged (Fig. 124). This clot soon undergoes structural changes ; becoming fibrinous in its distal portion, partly fibrinous, eventually perhaps entirely so, in its proximal portion, and there adherent to the interior of the artery. Further changes I have not yet traced. But it would seem highly probable that the occluded portion of artery atrophies, and degenerating into a fibro- eellular cord, as after ligature, thus becomes permanently oblite- rated. In conjunction with this series of changes, as affecting the * Occlusion of arteries ; the femoral arteries, after Acupressure, and Ligature • — in double amputation — each twenty -four hours. (Author.) t Occlusion of femoral artery after Acupressure — in amputation — five days. (Author.) Trans. Clin. Soc, 1871. 476 SPECIAL PATHOLOGY AND SURGERY. blood in the artery, and eventually the vessel itself, there are, how- ever, no changes at the seat of acupressure — no division of the inner and middle coats of the artery, and their invei^sion or reduplica- tion, and no subsequent deposition of lymph with adhesion of the divided coats of the vessel ; the integrity of the artery remains un- affected by the compression of acupressure, temporarily applied, the needle serving the purpose merely of preventing the escape of blood as primary hgemorrhage, while, by arrest of the passage of blood, coagulation may be induced, and thus secondary htemorrhage prevented when the needle is withdrawn. A firm, fibrinous, and adherent clot was found to have formed within five days, and in a main artery — the femoral. In treatment by acupressure, therefore, the proper period for the safe withdrawal of the needle may be inferred to be at that period, if not earlier; without liability to the occurrence of secondaiy haemor- rhage. In one fm-m or other, acupressure is said to be superior to ligature, both with regard to the improbability of secondary hcemorrhage, the probability of healing by adhesion, and the improbability of purulent, or other septic infection of the blood — pycemia. (a.) Respecting hcemorrhage after amputations, in eleven cases of acupressure only one was followed by secondary hsemorrhage ; whereas in eleven cases of ligature, four of secondary haemorrhage occuiTcd, of which two were fatal. Such were the comparative results after ampu- tations at the Carlisle Hospital (Hamilton's Report). In other words, in that institution, secondary haemorrhage from ligature and from acupressure was as four to one in eleven cases. The more recent report is that of Professor Pirrie,* who, with Dr. Keith and Dr. Fiddes, has more especially practised and advocated this mode of arresting arterial haemorrhage. The former enumerates his experience in important cases, of which records have been kept, as comprising the following operations : — Eleven cases of amputation of thigh, four of amputation of leg, two of amputation of arm at the upper part of the surgical neck of the humerus, one of amputation at ankle-joint, one of Chopart's amputation, two of amputation of the whole of great toe, twelve of excision of mamma, six of excision of elbow- joint, one of excision of knee-joint, one of excision of an erectile tumour, one of excision of tumour on cbest, one of excision of tumour on thigh (wound eight inches long), one of excision of head of fibula, three of excision of testicle, one of hgemorrhage from sloughing of hand, one of wound of hand, one of wound of upper part of forearm with great haemorrhage, one of wound of radial artery, and one of wound of hand attended with great hgemorrhage; in all fifty-one cases, and in which he has acupressed 185 vessels. (6.) Respecting the probability of adhesion taking place between the surfaces of a wound, the arteries of which are secured by acu- pressure ; it is alleged that the needles are, as foreign bodies, merely temporary, while their material is less irritating than that of ligatures ; and that they are not intended or allowed to produce sloughing of the compressed arteries, whereby foreign bodies of worse character, in the shape of slough-rings of the cellular coats of these vessels, are produced and remain between the raw surfaces — with, moreover, suppuration. * Brit. Med. Journ., 1867. •WOUNDS OF ARTERIES. 477 Fig. 125. W^s (c.) Hence, also, tHe ^-eater probability, apparently, of pycemic infec- tion siiperveniiig after ligature. And certainly the observations of Professor Pirrie are here to the point, not a single instance o£ pygemia having occurred in his experience where acupressure has been employed by himself or his Hospital colleagues at the Aberdeen Hospital. Granting the advantages of acupressure, as compared with (the old form of) ligature, it has fallen into general disuse ; and in favour of antiseptic ligatures. (6.) Torsion of cut arteries is another method of arresting heemor- rhage, which may be regarded as an imitation of another natural process of cure. Torsion is effectual by laceration of the two inner coats of the cut end of a bleeding artery, the outer coat remaining as a loose filamentous sheath, which, entangling the blood and forming a peg, is equivalent to an accidentally complete laceration. This procedure, originally noticed by Galen, was revived about 1828 ; in Prance, by Amussat, Velpeau, and Thierry ; and in Germany, by Fricke. In this country, recently, torsion has been practised more generally, and it seems to be attracting increasing attention. Arteries of small size had long since, occasionally, been commanded by a pinch and twist with the forceps ; but large arteries, as the femoral, brachial, ulnar, and radial, have been effectually secured by torsion, in amputa- tions of the thigh, arm, and forearm, as previously practised by Amussat and Velpeau. Occlusion by Torsion has been specially investi- gated by Mr. Cooper Forster, whose observations are published in the Trans. Clin. Society, 1870. My own observations in one case, death taking place in 'thirty-six hours, were communicated to the same Society, in 1871. Occlusion consists in the following changes : — At the seat of torsion, the two inner coats of the artery are torn across, and reduplicated up the vessel, perhaps in the form of a complete funicular sheath, one-fifth of an inch in length; and at the upper or smaller opening of this reduplica- tion, or funnel, a conical blood-clot forms, occupying the bore and extending up the vessel (Pig. 125). The twisted condition of the artery, itself usually a persistent change, and the reduplicated sheath of the two inner coats, above, acting as a valve, are quite suflScient provision against the recurrence of hasmorrhage at the time of opera- tion and subsequently ; but there is also the supervention of clot- formation from this sheath, and extending further up the bore of the vessel. Different modes of torsion have been recommended, and are practised. The artery may be drawn out for about half an inch by one pair of serrated forceps, and its attachment seized by another pair of serrated forceps ; the free portion is then twisted off by about a dozen turns of the former instrument, the method of Amussat (Fio-. 126) . Or, the end of the vessel may be simply twisted several times, without detaching * Occlusion of brachial artery after Torsion — in amputation — thirty-six hours. (Author.) 478 SPECIAL PATHOLOGY AND SURGERY. Fig. 126. it, as recommended by Yelpeau and Fi-ieke. This is the method I ordinarily practise, not unfi-equently, instead of emplo^'ing antiseptic catgut ligature to any artery, of whatever size. Torsion- forceps are now in general use ; an instrument furnished with ti-ansversely serrated points, and closed by a slide when the end of the vessel has been seized (Fig. 126). Comparison of Ligature, Acupressure, and Torsion. — The occlusive process, in the changes which the artery and contained blood undergo by ligature, acupressure, and torsion, may be thus summarily stated : — Firstly, in all three, conical clot-formation and pluggin;; of the vessel, adjoining the line of compression, or of twist; and, in acupressure, this is the only provision agaiust the supervention of hcemorrhage, ■when the surgical appliance, the needle, is T\'ithdrawn. Secondly, in both ligature and torsion, division of the inner and middle coats of the artery, transversely, at the line of opera- tion ; followed by lymph-deposition and sealing of the vessel. This is the only additional pro- vision against the supervention of hsemorrhage, when the ligature separates ; but in torsion, the twist of the vessel is persistent, and re- duplication of the divided coats, probably in a funicular form, acts also mechanically as a valve, against the occurrence of heemorrhage. In relation to the treatment of hcemorrhage, the formation of a clot-plug might seem an insuf- ficient provision to prevent its recurrence, when the needle is withdrawn after acupressure, so that secondary haemorrhage would then take place; yet the results of experience, already referred to (p. 476), have shown that th:'S single provision is sufficient, without the ad- ditional security of lymph-deposit and sealing of the vessel, as at the line of ligature or of twist ; or the extra and mechanical security afforded bj' the persistency of the twist, and the funicular valve of lining membrane. But assuming the liability to the occurrence of secondary hgemorrhage to be about equal after either of the three methods of surgical treatment, the tendency to primary tioiion of the flesh-wound, and the' prevention of 2:)ycBmic infection of tlie system, must be very dif- ferent. Torsion has decidedly the advantage over either ligature or acupressure, in regard to both these very important considerations. The twisted poi-tion of an artery not being killed, as its subsequent adhesion shows, no sloughing of the end of the vessel ensues — when this portion is allowed to remain in the wound ; yet this event neces- sarily and intentionally ensues after the application of ligature, or .accidentally by prolonged acupressure ; and no other foreign body is allowed to remain in the wound, for however short a period, to possibly provoke, suppuration, as after both these methods of treatment. Wounds of Veixs. — The same forms of injury may occur as those to which arteries are liable, and they having been already sufficiently described, need not be repeated. WOUNDS OF VEINS. 479 The Signs of any sucli wound are venous haemorrhage ; the blood of a purple or hlack colour, aud flowing in a continuous stream, unlike the jetting of florid red blood from an artery. The size of the stream soon diminishes, and heemorrhage may be arrested, by collapse of the thin walls of the veins ; while any return flow from the cardiac end of the vessel is stopped by the valves, unless when the bleeding proceeds from valveless veins, as those of the portal system. Veins of the largest calibre, as the internal jugular, subclavian, axillary, and femoral, con- tinue to bleed copiously ; but the stream is intermittent during inspiration, and accelerated by expiration. The force and, in some deo-ree, the rapidity of the stream are regulated by the size of the vein, or of the aperture in it, by the heart's action, and its effect on the flow of venous blood ; and by the presence or absence of certain conditions which favour or retard the free flow of blood through the vessel. Thus, pressure on the vein between the aperture and the heart, a dependent position of the part, and muscular action in the coui'se of the current, favour the haemorrhage ; while the opposite conditions retard it. Causes, and Effects of Wounds of Veins. — Like an artery, a vein may be incised or cut with a sharp instrument, punctured with a pointed one, contused or lacerated by a blunt one, or injured by force of a bruising or wrenching kind. The operation of this lesion, locally, is sometimes to induce inflammation of the vein — phlebitis, if the wound be an open one, or to produce a collection of venous blood — blood-tumour, if the fluid be imprisoned in the textures. This con- dition will be described under Contusion. Constitutionally, whether venous hEemorrhage takes place externally, or internally into one of the great cavities of the body, its effects are manifested by syncope ; either by failure of the heart's action — cardiac syncope, and thence of the circulation, or by loss of consciousness — cerebral syncope ; or by both these effects, and their fatal termination if the haemorrhage be sufficiently prohmged. I am not aware of any observations respecting the pulse and temperature, as affected by the loss of venous blood ; when, for instance, venous haemorrhage, sometimes to a large amount, has occurred from the rupture of a large varicose vein in the leg. The tendency to syncope, and the probability of death resulting, are pro- portionate to the quantity of blood lost ; not necessarily by its escape from the body, but even when lost to the body as blood in circulation. Such consequences are less apt to ensue from venous than from arterial haemorrhage ; but another constitutional disturbance is specially liable to occur from an open wound of a vein, and more so, the larger the vessel. Air is apt to enter the circulation, attended with a whirling, bubbling, sucking, or lapping sound ; the individual feels death-struck, he moans and breathes heavily, becomes very faint, and probably dies, in a few minutes, or, at the most, in a few hours. Reparation. — Wounds of Veins heal by processes apparently analo- gous to those whereby similar Wounds of Arteries are repaired. Treatment. — The arrest of venous haemorrhage maybe accomplished, by an elevated position of the part, and the pressure of a compress secured by a few turns of a roller. Cold or astringent lotions are also of some service. Ligature should be avoided, as being apt to induce phlebitis. But this resource may be necessary in the case of a large vein, or if the vessel be so situated that pressure cannot be applied. 480 SPECIAL PATHOLOGY AND SURGERY. The treatment of inflammation of a wounded vein will be con- sidered under tlie head of Phlebitis ; and the remedial measures appropriate to the formation of a blood-tumour, in connection with Contusion. Constitutional Treatment of HiEMORRHAGE. — Arterial or Venous. — After the loss of any considerable quantity of blood, whether by accident or surgical operation, the patient should be laid in the recum- bent position, to prevent syncope ; and afterwards, rest in this position will be favoui-able to the Aveak circulation. The circulation should be restored, in the first instance, by the judicious administration of stimulants and warmth, as in the case of Shock ; but subsequently, nourishing food will be required, especially in the liquid form, to regain the blood lost, and the bulk of the circulating fluid. In the chronic anaemia resulting from severe haemorrhage, iron and quinine lend their aid, as the most effectual tonics ; though this condition often lasts perhaps for life, as an incurable cachexia. Transfusion of Blood. — This operative procedure offers an ultimate resource, justifiable only in extreme haemorrhage; not, however, to be delayed until the patient is dying, nor declined on that account, re- coveries having occurred when the patient was lying in articulo mortis. The operation consists in the injection into a large-sized vein, at the bend of the arm or instep, of a variable quantity of blood— six to six- teen ounces — freshly drawn from the vein of a healthy man or woman. Under circumstances of emergency, transfusion may be effected by means of an ordinary glass syringe, fitted with a stop-cock, and a cannula. A clean glass vessel is used to receive the blood, this vessel being rather deep to retard coagulation ; and both it and the injecting syringe are warmed up to blood temperature, 98°. The patient's vein having been opened by an incision just large enough to admit the can- nula, and the blood having been drawn from the arm of another person into the vessel, the injecting syringe is then filled with blood, and the nozzle being inserted into the cannula, the vital fluid is passed into the circulation, in a slow and equable stream. In this procedure, three other particulars must also be observed : — that the blood injected does not approach to coagulation ; that no bubbles of air be thrown in ; and that the vein be not injured by the cannula. It is to prevent coagulation and the admission of air, that certain forms of direct transfusion ap- paratus are preferable to the common glass syringe. If blood cannot be procured, warm water may be injected. The results of transfusion have been successful, occasionally, in saving life, for a time, at least, or even to complete recovery. First practised by Dr. Blundell in cases of flooding after child-birth, this method of restoration has since been resorted to in extreme surgical hsemorrhage ; notably in a case by Mr. Lane, where a boy was thus rescued, and who after an hour or two sat up in bed with no return of the bleeding. Dr. Roussel, of Geneva, has more recently practised transfusion with, much success. The principles he has inculcated, with reference to the safe and efficient performance of transfusion, and the apparatus he has devised for this purpose, merit more particular attention than seems to have been hitherto given to what he has written on the subject. Recognizing the objections to which the method of indirect trans- fusion, as already described, is liable; Roussel strongly advocates WOUNDS OF VEINS. 481 transfusion by tlie direct metliod — on the principle of fhus " uniting two cii'culations hj a simple closed and direct channel." * The indispensable conditions of a good transfusion, according to this authority, are : (1) that the blood be of the same animal species and from the same organic source ; from man to man, fi'om vein to vein. (2) That it should continue to be vital and unaltered in its most intimate composition, not having been subjected to contact with the air or any other modifying materials ; and that it should have lost neither its motion, nor its temperature, nor its gases, nor its density. (3) That the quantity to he transfused, and the rapidity of its flow, should be subject to the discretion of the operator. (4) That the operation should be conducted without danger to either subject. Roussel's " method of direct transfusion consists : (a) in joining the vein which is to supply the blood to that which is to receive it by a conducting tube, which is continuous, direct, and filled with water, consequently void of air, some time before the opening of the vein. (h) On opening this vessel in a cushion of water, that is to say, pro- tected from the air, by means of a lancet, in such a manner as to procure a sufficient jet of blood, by a simple puncture, as in bleeding. Thence phlebitis is avoided, which would be produced by the intro- duction and ligature of a cannula in a vein." To avoid any alteration in the temperature of the blood, the water which fills the apparatus up to the moment of transfusion, and in which it has been immersed, rinsed, and softened, should be at from 20° to 25° (Centigrade). A little bicarbonate of soda may be added to the water, to cleanse the interior of the apparatus thoroughly. In urgent cases, cold water, quite clean, may be used, without any in- jurious result ; the water serving only to drive out the air contained in the transfuser. The person about to receive blood being in an anoemic state, the veins of the arm, or leg, are empty, flattened, colourless, and invisible through the skin. ]S"o vein, therefore, in this state, can be opened as in ordinary venesection. But the opening may be made by incising a fold of the skin, in the direction of the vein, so as to expose it clearly; the vessel is caught up with a tenaculum, or fine forceps, and then opened, in an oblique direction, with small curved scissors. A small angular flap is cut, just sufficient to admit of the pliant cannula ; and this is fixed in position by the finger of an assistant, laid upon the flap of vein. After transfusion, this flap falls back into its place, and closes the vein. When the vein is so obscure as to necessitate a longer incision, the integumental wound may be closed by a wire suture, or a suture-pin passed through the skin, to insure exclusion of the air. The vein chosen is usually one in the arm — the median basilic ; but the saphena, in the leg, may sometimes be preferable, — that vessel being further distant from the heart and lungs, these organs are less apt to be affected by the jet of transfused blood. If transfusion be performed for excessive haemorrhage consequent on amputation, one of the veins in the stump might be selected for the introduction of the cannula. Roussel's Transfuser is here represented (Fig. 127), showing also * " Transfusion of Human Blood," by J. Eoussel, with Preface by Sir James Paget. 1877. VOL. I. 2 I 482 SPECIAL PATHOLOGY AND SURGERY. the apparatus adjusted, to the arm of the blood-receiver — below, and the arm of the blood-donor — above. '"The successive steps of direct transfusion, as thus perfomied, are : (1) Place the cupping-cup over the turgid vein of the blood-giver; adjust the lancet, 1 ; pump, 2, in the tepid Avater. (2) Introdnce the cannula, 3, filled with water, into the vein of the blood-i-eceiver. (3) Depress the lancet rapidly into the turgid vein ; shut off stop-cock of the water-aspirator, 5 ; expel through the escape cannula, 3, blood mixed with water. (4) Open the communication by stop-cock, 3, of cannula, into the vein of the blood-receiver, and transfuse pure blood in uninterrupted doses of one-third of an ounce. (5) After trans- fusion of the necessary quantity of blood, close the wound of each subject, with light compress and bandage. ((3) Wash the transfuser at once in warm water, before any coagulation of remaining blood therein." The quantity of blood transfused will vary with the condition of the recipient — and perhaps of the blood-giver. Ordinarily, the amount required will be between 200 and 300 grammes of blood — about 6 ounces; and administered slovply — not more than between 60 to 80 grammes per minute, not to obstruct either the heart or lungs, and gradually restore the functions of life. A successful transfusion, in skilful hands, will occupy from eight to ten minutes, to supply a bloodless subject with sufficient blood to restore life. The phenomena manifested by transfusion are remarkable for their physiological significance ; and should be observed, in order to appreciate the recovery of the patient, and the symptoms of apparent danger. " During the performance of the operation, the blood-receiver remains quite calm ; if he was previously in a state of syncope, the action of the heart and lungs now recommences; the face and the chest regain their natural colour, and are bedewed with a gentle * 1. Lancet, with cupping-cup. for blood-receiver, with stop-cock. 6. Balloon to regulate cupping-cap, 2. Balloon-pnmp of transfuser. 3. Cannula 4. Water-aspirator. 5. Stoia-cock of same. "WOUNDS OF VEINS. 483 perspiration, beginning at the roots of the hair. All np the arm, as high as the axilla, the vein is seen to rise and fall, as it were, by pulsation, with, each movement of the balloon-pump. The patient experiences the sensation of a warm current in his arm, which soon spreads to the chest, the face, and head, extending indeed over the whole body. The pulse and respiration have become full and strong. Towards the end of transfusion, perhaps, there may be a slight diificulty in breathing, some cyanosis, and a nervous excitement. When the arm is bandaged, and the patient in bed, a shivering fit will probably ensue, and a stimulant should be administered. The rigors — com- mencing in about twenty minutes, and lasting for half an hour — are consequent on the assimilation, as it were, of the new^ blood ; the vaso- motor system distributing throughout the whole system the blood which has just distended the veins. The shivering is followed by free perspiration, and a general rise of temperature, during which the patient falls asleep. He sleeps for an hour or two, his face becoming more animated, the pulse and respiration strong. The temperature, which during the rigors had fallen at the surface, so as to concentrate and rise in the rectum, gains its equilibrium and normal condition. On awakening, the patient experiences an urgent desire to micturate and defijecate, followed by great craving for nourishment. The urine shows no trace of blood or albumen — if previously free from either ; but it is abundant, pungent, light coloured, and charged with normal salts. The bowels are freely open, and any old faecal accumulations are evacuated." Subsequently, the patient alternately takes nourish- ment, and sleeps, until, with a free respiration, and full pulse, a warm and moist skin, and complete consciousness, recovery is established. Transfusion with arterial blood has been tried ; but as the blood is injected into a vein, it should be taken from the venous system, and is thus suitable for contact with the veins and right cavities of the heart. Arterial blood would only retain its characters during one circuit of the circulation ; and venous blood speedily becomes arterial, in passing through the lungs. The results of transfusion (venous blood) are notable, and en- couraging. From the time of Blundell — 1820 — to 18/5, this procedure has been resorted to in at least 80 cases of women dying from flooding after parturition ; in 30 cases of wounds in war, or of surgical wounds ; in 50 cases of anaemia from disease ; in 20 cases of typhus, cholera, hydrophobia, and other conditions of exhaustion ; and in 10 cases of blood-poisoning from asphyxia, or other causes : making — observes Roussel— a total of 200 authenticated cases of patients who have been rescued from death, in a period of fifty years, — -by the philanthropic generosity of persons who have given them their blood, and by the skill and confidence of Surgeons, in the life-r"estoring process of transfusion. Entrance of Air into Veins. — The fatal result or the extremely perilous symptoms arising from the forcible introduction of air into the veins of animals, had long been known ; and was at length made the subject of experimental observation by Morgagni, Valsalva, Bichat, and ISTysten. But, in Surgical Practice, the accident first occurred in the experience of M. Beauchesne in 1811, during an operation for the removal of a tumour from the lower part of the neck. It was necessary to disarticulate and raise the clavicle ; and while this was being done. 484 SPECIAL PATHOLOGY AND SURGERY. the patient became faint, exclaimed, " I am dyini?," and expired in less than a quarter of an hour. Dissection revealed a small wound in the internal jugular vein at its junction with the subclavian, and the entrance of air through that wound caused the fatal result. The accident has since happened in the practice of Mirault, Clemot, Roux, Majendie, Castara, Dupujtren, Delpech, Begin, B. Cooper, Warren, Mott, Stevens, and other Surgeons, both in Europe and America. A Commission of the French Academy was appointed to investigate the subject ; and the names of Majendie, Amussat, Wattmann, and Cormack, are distinguished for the light their labours have thrown on the pathology of the entrance of air into veins. Symptoms. — The local phenomena consist in a peculiar sound, of a hissing, gurgling, lapping, or sucking character, produced by the entrance of air, with the appearance of bubbles about the wound in the vein. The constitutional effects are equally remarkable; the patient is suddenly seized with great oppression in breathing, and extreme faintness, convulsive struggling, and a horrible feeling of terror and impending danger, inducing him to exclaim that he is dying. A churning noise is heard in the heart, synchronous with the ventricular systole ; and the hand applied to the chest, perceives a peculiar bubbling, thrilling, rasping sensation, produced by the air and blood being whipped together within the ventricle. The heart's action becomes extremely feeble, and the pulse almost imperceptible. When only a small quantity of air has entered the circulation, the symptoms may pass ofE and the patient rally. A larger admission of air speedily causes death, during the convulsive struggling, or without convulsions, as if by simple syncope. The period at which death occurs varies, from a few moments or minutes, to several hours. When the patient survives, some hours elapse usually before consciousness and strength are restored. In some cases, after recovery from the immediate eifects of the accident, death has ensued from pneumonia. The mode of death seems to be essentially asphyxia, by the impaction of air-bubbles in the capillaries of the lungs, mechanically obstructing the pulmonary circulation ; thence arresting the systemic circulation, and the supply of arterial blood to the brain, followed by syncope. But the heart's action continues, after respiration has ceased ; and at last failing from want of its necessary stimulus, arterial blood, this organ is the uUimum, m,oriens. Cause. — Air is liable to enter the veins only during each act of in- spiration ; and in consequence of a tendency to the formation of a vacuum within the thorax, more particularly in the pericardium, during in- spiration. Thence a sucking action, or " venous inspii^tion," in the veins within and near the thoracic cavity ; extending to where the coats of the veins collapse. This area is limited to that part of the root of the neck and axilla where the venous flux and reflux of blood are perceptible, and the space in which it occurs has been called " the dangerous region." Various circumstances favour the admission of air into an open vein : — 1. The site of the wounded vein being in the dangerous region. 2. Canalization of a vein ; owing to its coats having become thickened by morbid deposit, or adherent to condensed, consolidated surround- ing textures, or by the spasmodic contraction of muscles : either of these three conditions having the effect of converting a vein into a CONTUSION. 485 rigid, Tincollapsing tube. 3. Traction on the vein. 4. A stretched position of the part operated on. 5. Partial division of a vein. 6. The position of the vein in the wound ; a vein cut in the corner of a wound being apt to gape, as Dupuytren's case demonstrated. 7. Deep inspiration. Treatment. — Preventive measures consist in making pressure on the cardiac side of the wound, during operation in dangerous localities ; and keeping the part in a relaxed position, thus to prevent the veins being drawn open. Any vein of considerable size, and especially in which the venous pulse is perceptible, should be avoided as much as possible. Feeble inspiration is desirable, and this is best secured by the influence of chloroform ; tightly bandaging the chest to prevent deep inspiration, as some have recommended, is a perilous precaution. Curative ti^atment comprises the fulfilment of the following indica- tions : — 1. The wound in the vein should be immediately closed, by compression between the thumb and finger ; the urgency of the symptoms not allowing of any delay for the application of ligature. 2. To maintain an adequate supply of blood to the brain, for the prevention of death by syncope ; the patient should be placed recumbent, with the head low, and pressure should be made on the axillary and femoral arteries, so as to direct the circulation towards the brain. 3. To maintain the action of the heart by artificial re- spiration, — employing galvanism preferably to any mechanical method, which might aid the accidental readmission of air into the wounded vein. 4. To promote the removal of obstruction in the pulmonic capillaries, also by artificial respiration. 5. After recovery, to treat the tendency to inflammation of the lungs. CHAPTER XVII. CONTUSION. CONTUSED AND LACERATED WOUNDS. PUNCTUifED WOUNDS. Contusion. — Contusion is a forcible disintegration of the soft textures, suhcutaneously , the skin remaining unbroken ; whereby the textures, thus injured, are protected from the action of the air. This kind of lesion, therefore, is the connecting link between other subcutaneous lesions, by laceration, as simple fracture and dislocation, and openly lacerated, or contused wounds, compound fracture and similar dis- location ; the turning point being exclusion from, or exposure to, the action of the air. Subcutaneous laceration of the soft textures is necessarily attended with some haemorrhage, also beneath the skin, but which extends inwards according to the depth of the contusion. The degree of laceration is proportionate to the force applied exter- nally, and to the molecular cohesion of the textures affected ; the quantity of blood effused is regulated, partly by these circumstances, but chiefly by the vascularity of the textures ; while the effusion is finally determined by the resistance offered by the textures which, with the blood accumulated, together act as a compress upon the 486 SPECIAL PATHOLOGY AND SURGERY. lacerated vessels. The vessels become more or less occluded with fibrinous clots ; or this state of thrombosis may perhaps be induced by contusion of the walls of the vessels, Briicke having shown the influence of a healthy state of the walls in maintaining the fluidity of the blood within the vessels. Sigiis. — The blood, diffused into the textures interstitially, and especially into the cellular tissue, is said to be extravasated ; instead of being discharged out of the body as in ordinary haemorrhage. Any portion of the blood which has accumulated in the cellular tissue under the skin, is made visible through the integument ; and hence the ap- pearance of a livid or black discolouration, the ordinary appearance of bruise, as seen in the first instance, accompanied with more or less swelling ; presenting the characters of the " black eye " produced by a blow. If only a small quantity of blood be extravasated, the appear- ance is designated ecch'jmosis. The pain of contusion is of a dull, heavy, aching character ; or a vibrating sensation, extending perhaps far beyond the part, when a large nerve is more especially affected ; as the ulnar nerve at the elbow. Blood extravasated in considerable quantity may still present the appearance of bruise, but have also the fluid and fluctuating character of an abscess. A hard circumscribed boundary can also perhaps be felt. Puncture with a grooved needle will determine a doubtful diagnosis. The discolouration of contusion bears a general resemblance to gangrene, but the temperature and sensibility of the part are retained, at least in a higher degree than in that condition. When extravasation of blood has taken place, deeply, and possibly into internal organs, it is declared by functional disturb- ances of a less definite character, and which of course vary with the part to which the contusion extends. Compression of the brain, for example, niay arise from cerebral contusion and extravasation. • Causes of Contusion. — External force, in the shape of crushing pres- sure or a blow, may directly produce contusion ; or the force may be applied indirectly, at some distance from the part affected, as by a fall on the feet, bruising the legs. But the state of the textures very much predisposes to this kind of lesion. The elastic firmness and comparatively bloodless condition of the flesh of a prize-fighter, who has undergone " ti"aining," contrasts favourably with the flabby, bloated face of one who is " out of condition," as that of the intempei"ate debauchee, which is ever bordering on ecchymosis. Concussion often accompanies contusion ; parts distant being shaken, as well as the part at the immediate seat ol: injury being crushed, by the violence of the force applied. Hence, concussion is more often produced in contusion from indii'ect violence. Thus, the minute vessels may be concussed or shaken far beyond the range to which actual contusion extends. A fall from a height on the feet, causing contusion, may be attended also with concussion of the vessels, even up to the trunk ; as denoted by interstitial spots of extravasated blood, in a case recoi'ded by Sir B. Brodie. Concussion of the nerves, apart from actual contusion, is also an important distinction, which Billroth notices, in relation to parts distant from the immediate seat of injury. For example, dangerous symptoms may be produced simply by con- cussion of the cardiac and ptilmonary plexuses of nerves, in connection with contusion of the thorax. And reflex actions of the concussed nerves may possibly have their additional effects ; as witnessed in the CONTUSION. 487 syncope or faintness iadnced by a blow on tbe epigastric region of tbe abdomen. The consequences of concussion, ratber than contusion, affecting tbe nerves, are uncertain ; resulting in various forms of paralysis, botb motor and sensory, witb atrophy and degeneration of tbe muscles involved. The operation of contusion locally is identified witb tbe course of this lesion ; while its effects constitutionally are those which arise from other forms of Injury, and Hemorrhage ; but tbe syncope arising from contusion is due more to the injury, itself possibly extensive and severe, than to the extravasation of blood. Therefore, the shock of injury, as manifested by the nervous system, predominates, rather than collapse ; or tetanus may supervene. Course. — Tbe natural course of Contusion is twofold ; inclining, on the one hand, to suhcutaneous reparation ; on the other, to sloughing, the formation of an open wound, and repair by the pi-ocess of suppura- tive granulation. Thus, no perceptible alteration may take place in a contused part, the bruised appearance remaining for a variable period ; but absorption supervenes, and the originally purple or livid discoloura- tion of a bruise gradually fades away into a brown, and thence into a greenish or yellowish hue, the latter often continuing for weeks or months. Blood extravasated in considerable quantity may also remain stationary for a while, as a bag of fluid. Over prominent parts, as tbe crest of the ilium and tbe great trochanter, I have seen large tumours of this kind produced by heavy falls. Grenerally, however, any such collection of blood undergoes changes of consistence ; becoming thin and serous, and enclosed in a fibrous cyst ; or thick and dark like treacle, constituting a sanguineous tumour — hgematoma; or with coagulation, organization of the clot may result, by the development of new blood-vessels. In either of these reparative alterations, the blood-corpuscles disintegrate to some extent ; and hence, apparently, tbe changes of colour, followed by absorption ; and it can scarcely be doubted that tbe damaged structural condition of the tex- tures is more or less reinstated. But the intimate nature of all these reparative alterations, after contusion, requires further investi- gation. Lastly, the most obvious change may be destruction, prevail- ing over any reparative effort ; tbe blood, acting as a foreign body, induces inflammation, the products of which, commingling, form a bloody purulent fluid, extravasated amid the disintegrated textures. Gangrene is imminent, an event the more apt to ensue according to the severity and extent of contusion ; and gangrenous disintegration of the textures may appear in tbe form of sloughing, or as traumatic gangrene, thus converting the subcutaneous lesion into an open lacerated wound. Sometimes the extravasated blood rapidly passes into decomposition, accompanied with the symptoms of pyemic infec- tion. Haemorrhage, superadded to tbe blood originally extravasated, is another adverse issue, but even less common, unless in internal organs. Reparation by tbe process of suppurative granulation will be de- scribed in tracing the course of a contused or lacerated wound. Treatment. — The earliest occasion for interference is determined, not by tbe presence of contusion, which is naturally disposed to undergo reparation ; but it depends on tbe degTee of contusion and tbe quantity of blood extravasated. A slight eccbymosis disappears spontaneously ; a more severe bruise may need help. 488 SPECIAL PATHOLOGY AND SURGERY. The indications are, in the first instance, to stop any further ex- travasation, and then to promote absorption, without any breach of the integument. Compression, by the application of a bandage, may per- haps, therefore, have a doubly good effect. Various topical applications have reputed efficacy. Arnica, I think, possesses some virtue. The tincture diluted, in the proportion of an ounce to half a pint of water, is perhaps more efficacious than spirit lotion, or any other cold evapo- rating fluid. Leeches are not mei'ely useless to withdraw the blood, congealed and infiltrated ; but by admitting air, and thus inducing decomposition, they are positively noxious. Moreover, they are apt to excite sloughing of the skin. When the blood is in a fluid state, it may be drawn ofE by means of the aspirator ; but the cavity is apt to refill again and again ; as in a case of extensive contusion of the back, from which I thus removed ten to fifteen ounces of sanguineous fluid several times. Should suppuration or gangrene threaten, — whether from the blood acting as a foreign body, from the severity and extent of the contusion, or from both these conditions co-operating, — then, indeed, incisions, early and free, are imperative, to give vent to blood and pus, which would otherwise rapidly putrefy, and to prevent sloughing, or its progress. In short, any attempt to aid absorption would now be inappropriate, and the rule of treatment should be to anticipate if possible, or at least accompany, the work of desti'uction, and forthwith remove its results. Accordingly, in the event of trau- matic gangrene, amputation may become justifiable, as an extreme and rare resoui-ce. Contused and Lacerated "Wouxds. — These forms of Injury, although nominally distinct, in regard to the kind of force by which they are produced, are essentially the same. A contused or a lacerated wound is a sudden disintegration of the soft textures, with exposure to the action of the air. In the latter respect, wounds of this kind differ from contusion — a subcutaneous lesion ; and in virtue of the former particular, they differ from compound fracture and compound disloca- tion, wherein the lesion itself is not exclusively laceration of the soft textures, these parts being involved only by the injury. The characters of a lacerated wound are peculiar. It presents a torn, irregular surface or cavity, with more or less surrounding swelling and discolouration, owing to effusion of blood beneath the skin, or ecchymosis. Haemorrhage from the wound itself is inconsiderable, the vessels being lacei-ated. With these external appearances^ the degree of pain experienced would seem to be inversely proportionate to the extent and depth of the laceration; for this kind of injury implies a corresponding destruction and death of the textures. The pain is heavy and aching. The structural alterations produced by laceration, and thence the characters of a lacerated wound, are somewhat modified by the extensibility, elasticity, contractility, and other properties of the textures. The resulting appearances are most conspicuous when a limb is drawn off, as by machinery ; or abruptly struck off, as by gun- shot injury. Some textui^es are comparatively unyielding, and their torn extremities hang out of the stump ; others break off short within the general mass. Thus, the skin being tough and elastic, it either yields higher than the included textures, or it retracts, exposing them ; the muscles protrude and are everted; the tendons resisting with greater tenacity, tbey hang out of the stump, or giving way higher up, CONTUSED AND LACERATED WOUNDS. 489 they are pulled out of their sheatlis ; nerves, for tlie most part, break off at the surface; the vessels, especially arteries, possessing coasider- able elasticity, are di-awn out to some length, their inner and middle coats yielding, while the external coat is prolonged over them ; and as their torn ends retract, they become less pendent and exposed than any other part of the stump ; lastly, the bone having broken off abruptly, it forms the most prominent point. The stump, therefore, presents an irregular conical form, with the truncated bone as its apex. Causes of Lacerated WoiDid. — -The force applied may be chiefly lacerating, as when a leg' is crushed by a railway carriage passing over the limb, or an arm is torn between two revolving cog-wheels ; or the violence may be chiefly contusing, as the kick of a horse, or the action of a cannon-ball or other projectile. Some wounds are both lacerated and contused ; the bites of many animals, as of a dog, cat, or fox, having this mixed character; tusk or horn wounds, as by the goring of a boar or a bull, produce similar lesions, but more in the form of punctured wounds. In any case the part is damaged beyond, and perhaps far beyond, the apparent extent of injury. The constitutional effects of the contused or lacei'ated wound are those already noticed with reference to other forms of Injury, and Haemorrhage ; but the syncope arising from such lesion is due more to the injury, itself possibly extensive and severe, than to the ex- travasation of blood. The shock of injury is ahvays severe, some- times overwhelming ; tetanus also is apt to supervene, especially after any such wound of the hand or thumb, of the sole of the foot, or of the toes. Locally — the textures, disintegrated by violence, inevitably die to a greater or less extent. This event, which is strictly speaking traumatic gang'rene, on however small a scale, takes place in one of two ways, or both may co-operate. Severe contusion or laceration kills the part out- right ; or it does so indirectly, by damaging the blood-vessels some distance off, in which case mortification is occasioned by a deficient supply of blood to the part. In both cases, gangrene is immediate, or at least immediately commences ; it evinces no tendency to sjn^ead beyond the seat of injury, and, in due time, is defined by sloughing, or by " a line of demarcation " when the injury is more extensive. The appearances and textural changes may be gathered from Billroth's observations. Completely crushed skin presents a dark- blue violet appearance, and feels cold ; or, at first there may be no alteration, but in a few days it becomes white and insensible, later it assumes a greyish hue, or when quite dry, a brownish-black colour-. The healthy skin is bordered by a rose-red line, which shades off into diffuse redness ; this is the reaction redness about the wound, marking the line of the living skin, which only begins where the blood still flows through the capillary vessels. In muscles, fasciae, and tendons, this appearance is far less pronounced at first ; and how far they will be detached is uncertain. The process of separation comprises the following textural changes : — At the line of junction of the dead with the living tissue, the circulation is arrested by coagulation of the blood in the adjoining capillaries, and nutrition ceases ; cell-infiltration and the formation of vascular loops lead to the development of granu- lation tissue, from the surface of the living tissue below ; and then, by the solution of the granulation tissue into pus, its cohesion and 490 SPECIAL PATHOLOGY AND SURGERY. continuity with tlic dead tissue ceases, and the parts are detached (Fig, 1'28). Tliis suppurative separation in connective tissue takes place in all other tissues, bone not excepted. But more often the gangrene of a contused woiind is of an inflam- matory character, and occurs at a somewhat later period — in the course of a few days — as follows : — Course. — Gangrenous inflammation supervening, in the progress of a contused wound, the textures or a part which may not liaA-e been killed more immediately by the injury, die subsequently. Yet here, also, the gangrene is limited to the seat of injury, and is defined by sloughing. Gangrene may, indeed, supervene on a contused or lacerated wound, without any apparent or notable inflammation, and extend far beyond the seat of injury; a whole limb speedily falling into gangrene, which spreads vapidly and is not determined by a line of demarcation. This, I'iG. !_.. which has been named spreading traumatic gan- grene, is ti-aumatic only in having arisen from injury as the immediate or exciting cause ; but its spreading and un- limited character points to some blood-condition, in operation, as the essen- tial cause. In fact, this gangrene is the local manifestation of a con- stitutional condition, rather than the consequence of a local cause in operation. Its pathological significance is corroborated by two facts — that the contusion or laceration is quite subordinate in extent to the supervening gangrene ; and that it occurs in those persons especially who have albuminuria, a state of urine indicative of the retention of excrementitious matters, chiefly urea, in the blood. Either form of gangrene — traumatic or inflammatory — is always humid or moist, unlike the dry species of which senile gangrene is the representative. When a part is killed immediately, the appearances are those of the most severe contusion or bruise ; when less immediately completed, as by injury to the blood-vessels, the symptoms are the same, but proportionately more gradual ; and wdien gangrenous in- flammation supervenes, the symptoms are those of inflammation rapidly passing into gangrene. But w^hen spreading traumatic gan- grene takes place, the phenomena are those of a severely poisoned wound. Gangrene is announced by great tension and livid or purplish-black discolouration, which although most conspicuous about the seat of injury, extends rapidly upwards and downwards ; its progTess being preceded by a slighter oedematous swelling and greenish-yellow discolouration. This in advance, is a dying part ; that in the rear, is already dead. Emphysematous crackling, under * Diagram of the process of detachment of dead coDnective tissue in a contused wound. Upper, or contused, dead portion, showing blood-vessels occluded by coagu- lation ; lower portion, the living tissue, is the seat of cell-infiltration, principally at the janction of the living with the dead tissue. 300 diam. (Billroth.) CONTUSED AND LACERATED WOUNDS. 491 pressure with, the finger, soon leaves no doubt that death and decom- positiou go hand in hand. This may be regarded as diiSuse cellulitis, involving the other soft textures; and spreading readilj in the eon- tinuiby of the cellular tissue, — subcutaneous and intermuscular, and with the rapidity due to blood-poisoning, a whole limb falls into the state of humid gangrene within perhaps twentj-four hours. But the rapid decomposition, as indicated bj emphysema, is an equally charac- teristic feature of this constitutional gangrene. The accompanying constitutional symptoms are those of typhoid blood-poisoning ; and the disease g'enerally terminates fatally in a very few days, or not later than whenever the gangrene shall have spread to the trunk. Reparation. — In favourable contrast with any tendency to death, the wound may evince a disposition to heal by primary adhesion ; or, any irrecoverable part having sloughed and separated, the exposed surface heals by suppurative granulation. But this process of reparation is best seen on the clean surface of an open or gaping incised wound. The process is then as follows : — The local circulation is temporarily suspended, and the blood in the superficial vessels becomes stagnant, and coagulated up to the nearest branches. Any oozing haemorrhage is thus stopped. During the fii'st day or two, a reddish-yellow serous fluid exudes from the surface of the wound, which, containing pale blood-cells and a fibrinous matter, sets into a thin, yellowish-white or greyish film, rendering the appearances of the subjacent tissues indistinct. Thus the whole surface becomes glazed over. Symptoms of inflammation may, perhaps, precede and accompany this exudation; some redness, puffy swelling, heat and tenderness, just around the margins of the wound. But, in a healthy state, this inflammatory character passes off. A period of inactivity or calm succeeds, lasting from one day to ten or more, but which varies with each particular texture in the wound ; fat being tardy in its revival, as compared with the more vascular skin, or muscular texture, and bone, especially the compact portion, remaining longest dormant. Some further oozing" of the serous fluid may, however, continue during this period of incubation, — in which, as the brooding time for g'ood or evil, observes Sir James Paget, the mutual influence of the injuiy and the patient's constitution are often manifested. At leng-th, a distinct afflux of blood takes place, but Avith sluggish circulation, in the margins and surface of the wound. Reparative lymph begins to flow, abounding with emigrated white blood-cells, which mingles with or displaces the film which had hitherto glazed the wound. This lymph undergoes the same process of organization as in healing by primary adhesion, namely, self-development into fibro-cellular tissue ; but in the form of granulations. I^umerous minute bright-red points, or nodules, spring up from the surface of the wound, as seen on an open amputation- stump ; appearing first on the margin of the skin and the general muscular surface, while the bone-end or its compact disc remains yet covered only with the yellowish- white lymph-film. These rosy nodules or granules are yoixng granulations. The deepest granulation-cells are most advanced ; they are spindle-shaped, or elongated nearly into fibres (Fig, 129. Bennett). The superficial ones remain in a rudi- mental state, and at length acquire the character of epithelial cells. In the development of granulation tissue, the histological changes have been traced more closely than in the formation of fibro-cellular tissue 492 SPECIAL PATHOLOGY AND SURGERY. under other circumstances. According to Paget's observations, the nucleus of the granulation-cell takes the initiative. Becoming more distinct, clearer, and brighter, as if a vesicle tensely filled with a pel- lucid substance, it assumes an ovoid form, and presents one or two distinct nucleoli. Meanwhile, the cell acquires a distinctly granular appearance, and the cell-wall getting thinner, elongates at one or both ends, thus producing caudate or spindle-shaped cells, as in the general development of connective tissue. At the same time, fibrilla- tion of the intermediate protoplasm producing the characteristic wavy bundles, completes the formation of this tissue. Capillary blood-vessels spring from below, forming loops — as also seen in the figure. Each new vessel is constructed by the outgrowth of two pouches from a parent vessel. The pouches, crammed with blood-corpuscles, shoot upwards, and cur^ang inwards, never fail to meet exactly in apposi- tion, neither segment overshooting. They coalesce by absorption of the partition at the junction of their closed ends, thus completing a Fig. 129. vascular loop; through which the blood, diverging from the main current and rejoining it, is continuously propelled. If, in the con- struction of any such vascular arch, the pouches burst, the process is then completed by the propulsion of the blood-corpiiscles, the current of blood from the parent vessel being dii-ected so skilfully as to channel a curved passage through the fibro-cellular tissue. Another method of vascular formation in granulations, has been observed by Billroth. Spindle-shaped cells lying parallel, leave a narrow interval or canal between them ; this forms the channel for the blood-stream, the attenuated cells forming the wall of the vessel, while some of the cells loosen from the wall and are converted into blood-corpuscles. The arrangement of the blood-vessels in granulations is that of a net- work, consisting of loops having a vertical direction towards the surface, with communicating lateral branches, and which are more numerous near the superficial gi'anulation-cells. In their structure, the vessels consist of a thin, transparent membrane, with imbedded nuclei, some of which have a longitudinal, others a transverse direc- tion, in the wall of the vessel. Nerves and lymphatics do not apparently enter the substance of granulations. The process of development having finished, healthy granulations CONTUSED OR LACERATED WOUNDS. 493 are seen in the shape of small conical papillee, of a glistening red colour when free from pus. The pus-ceUs in suppurative granulations are either degenerate or immature granulation-cells. If the former, pus represents the superficial portion of organized granulation material, which, having lived its time, passes off, just as epithelial cells are de- tached. If immature granulation-cells, pus represents the superfluous portion of organizable material, which never reaches maturity. This is the more probable interpretation, considering the structural similarity or identity of pus-cells. As immature granulation-cells, pus ceases to be secreted when the granulations come to the level of the skin, for then, the wound or chasm being filled up, no more organizable material is needed. Sometimes during the granulating process, granulations from op- posed surfaces meet together. They may then unite; this conjunc- tion being designated " secondary " adhesion, to distinguish it from adhesion primarily, as between the surfaces of an incised wound. But it takes place in the same way, by the development of fibres out of nucleated cells and the interchange of capillaiy blood-vessels through this medium of communication. The contractile force of granulations is supplemental to reparation in bringing down the marginal skin to their own level and diminishing the area of the wound. Thus, then, by their actual growth and possible coalescence, aided by their contrac- tion, granulations and skin at length become even. Cicatrization commences, its purpose being to cover the granulations with skin. At the margin of the wound or ulcer, the granulations become flattened, and cease to secrete pus; appearing as a red, dry, smooth boi-der, about half a line in breadth ; this is followed by a translucent, bluish-white bordei-, — the cuticle, in advance of the opaque- white true skin. Converging at the rate of about half a line daily, the surface gradually gets covered. Sometimes little islands of cuticle form, here and there, on the granulation surface, which coalesce, and thus shorten the process of marginal cicatrization. But these isolated centres or patches of epidermis appear only where correspond- ing portions of the cutis with rete malpighii have remained unde- stroyed, on the surface of the wound or sore. (Billroth.) I^ewly formed and healthy cicatrix is thin and red, with a stretched, shinino- aspect, and not so supple and elastic as true skin ; somewhat de- pressed, sometimes elevated, but always attached more or less firmly to the subjacent tissue. It contracts for a long while, and perhaps with considerable force, especially after burns, thus becoming smaller in area, particularly if the surrounding skin be loose or redundant. In the course of months or years, the cicatrix acquires a pearly white colour, and becomes more supple, elastic — from the development of elastic tissue — -and movable as part of the integument, ISTature has healed, and almost effaced the wound. But a cicatrix always remains permanently, being more or less visible for life ; it never wears out altogether. It is less vascular, and less sensitive than the adjoinino- skin. Resembling true skin in its fibro-cellular structure, with elastic fibres, its papilla, and the cuticle, are reproduced, but cicatrix ne^er acquires its glandular elements, neither in the form of sweat-glands nor sebaceous follicles ; and it remains destitute of hairs. Accidental complications — both local and constitutional — may occur in the course of a contused or lacerated wound. Secondary 494 SPECIAL PATHOLOGY AND SURGERY. hfemorrliage is a])t to happen when the sloughs or gangrenous portion separate ; and wlien, occasionally, a large-sized artery is thus laid open, in about a week or ten days, or from the suppuration of a thrombus or tibi-inous plug, at a later period, the loss of blood may be of serious consequence. Bleeding granulations sometimes prove troublesome. The liability to tetanus occurring, even Avhen the Avound is granulating, should not be overlooked ; and especially as arising from exposure of the surface to a current of cold air. Professor Agnew, of Philadelphia, mentions the case of a man, who having a lacerated wound of tbe hand which had nearly healed, was attacked with tetanus, from travelling in a tram-car with his hand resting on the ledge of an open window. The attack passed off after several weeks. In another case, indirect exposure to cold induced the disease, and which was speedily fatal. A contused wound of tbe hand was granulating well, and the patient's health was excellent ; when, from standing on the deck of a feiTy-boat on a cold, raw day, he became chilled; and the same evening, tetanus supervened, and death ensued. These cases are very suggestive of a precaution in the dressing of such wounds. Professor Agnew remarks, " I view with horror the Surgeon ■who dresses a healins; wound while a drauo-ht of cold air is blowino* O O C) upon it. Progressive suppuration may take place from a contused or lacerated wound; the pus undei-mining the intesument, extending along the sheaths of tendons, and burrowing deeply between the muscles. The part becomes swollen and sodden, and the granulations pale and oederaatous ; the pus also has a sanious, fetid character, and is exuded through fistulous openings. This state of the part is more often met with when the hand or foot, or a lartre joint, was the starting-point of the suppuration, in a lacerated wound of either such part. The con- stitutional condition is no longer that of traumatic febrile disturbance, as in connection with the original wound, nor of the typhoidal character vrith gangrene, nor the collapse from secondary haemorrhage ; but hectic emaciation ensues, and exhaustion. Various secondary inflammations may proceed from a contused or lacerated wound. Lymphatitis, phlebitis, erysipelatous inflammation, and sometimes hospital gangi-ene, thus arising, offer no special pecu- liarities of practical importance. Septicfemia or pytemic infection may also be noticed as occasional consequences. The Prognosis of Contused and Lacerated Wounds maybe gathered, as with regard to other injuries, from a due consideration of their nature and course. It is less favourable than that of an Incised Wound, owingr to the kind of structural disorganization in contusion or laceration. For gangrenous disintegration of the textures, in a greater or less degree, is inevitable ; or gangrenous inflammation, with slough- ing and suppuration. The extent of the lesion will, therefore, much affect the issue. Spreading gangrene is an adventitious condition, but it is the most unfavourable consequence of contusion or laceration, as implying the co-operation of a constitutional cause. Healing by primary adhesion is exchanged for the slower and perhaps less effectual process of suppurative granulation; yet the latter being another mode of Reparation, it must be regarded as an eventiially favourable element in the prognosis of the lesion under consideration. Treatment. — In all superficial wounds — contused or lacerated — and CONTUSED OR LACERATED WOUNDS. 495 especially of vascular parts, as the scalp, the chance of primary aclh.csion taking place, to some extent, is not improbable, and it may be solicited with, good prospect of success. In the first instance, therefore, the treatment should be the same as for an incised wound. Foreign bodies, such as grit or portions of clothing, having been removed by a wet sponge or stream of water, replacement of the torn textures, and their retention in position by the usual surgical appliances, are the immediate rules of treatment to be observed. The prevention of decomposition is a consideration of primary consequence, both with regard to healing of the damaged textures, and to any liability of septic infection. Ac- cordingly, an important principle of treatment consists in the exclusion of air, and the continued application of cold. This maybe carried out in various ways ; by immersion of the part in cold water, by irrigation, or by wrapping the part in lint, and applying an ice-bag. These pre- ventive measures have been practised chiefly in Germany ; Professor Baum, of Gottingen, having used the bath, and with excellent effect in some cases, while Professor Billroth often employs it, thouo-h he does not regard this or the other such methods as surely prophvlactic of decomposition. In France, irrigation is especially approved by some Sui'geons. I have also used it with complete success ; particularly in the case of a smashed hand, which seemed hopelessly lost. The tem- perature of the water-bath should be moderated according to the feelings of the patient ; and this mode of treatment may be continued for a week or ten days, the part being cleansed from pus, which does not itself freely escape, and the water being changed so as to keep it quite fresh. If the cuticle of the part be thick and unyielding, as in the hand of a labourer, any continued soddening will, perhaps, be at- tended with a tense, burning sensation, quite unendurable. Lubrication with oil, or the addition of a handful of salt to the water, is said to afford protection against this contingency. The healing by granulation is slower in a wound unrler water and the influence of cold ; but when the treatment is discontinued, in time, the pale and infiltrated granulations, cedematous with the water, become ruddy and firm, and the wound soon begins to contract and cicatrize. Generally, however, carbolic- acid di-essings and syringing seem to have the advantage over cold- water treatment, in being equally protective against atmospheric influence, without further endangering the vitality of the already disorganized part, by the prolonged application of cold. But the disintegrated textures inevitably die, to a greater or less extent. Hence, in the event of primary adhesion having failed entirely, and in all deep and extensively contused wounds, it becomes necessary to actually encourage and aid the process of sloughing, in order to brino- into operation that of healing by granulation. The separation of sloughs will be favoured by warmth and moistxu'e, in the shape of a light poultice or spongio-piline epithem. At this time secondary hemorrhage is liable to occur, if an artery of any considerable size was involved in the contusion or laceration. Any collection of matter should be let out, or a free vent may be given by a counter-openino-, and discharge facilitated by the temporary introduction of a drainage- tube. Otherwise the reparative process needs little assistance ; posi- tion, rest, and protection from the action of the air by dry lint dressing, over a piece of protective, will suffice for the granulating of any healthy wound. 496 SPECIAL PATHOLOGY AND SURGERY. Beep and extensively contused or lacerated wounds of either lirrib are conditions which, in rehition to profuse suppuration or gangi*ene, must be considered both with regard to the preservation of the limb and the life. Amputation. — The propriety of amputation has regard to both these issues, which will be more advantageously considered in con- nection with compound fracture and dislocation. If gangrene be allowed to supervene, life is endangered ; if the limb be removed before the supervention of gangrene, it may have been sacrificed by such untimely interference. The compromise of these two considerations is better determined by pathology than by empirical experience : — (1.) If the tvlwle substance of a limb be involved by the injury, gan- grene is inevitable ; amputation, therefore, is imperative to intercept this event, and thus preserve life. (2.,) If, however, the injury be less extensive, and gangrene not inevitable ; what then ? Various patho- logico-anatomical conditions — less than the whole substance of a limb being involved — are defined in surgical works : respecting which forms of injury experience is said to justify amputation, in the first instance, considering the probable supervention of gangrene. But this event can never be foretold with absolute certainty in different conditions of injury ; the resources of reparation and the reserve constitutional power of different individuals being unknown. Having regard, there- fore, to the preservation of the limb — in cases short of its irreparable destruction — the actual supervention of gangrene is the only ground of assurance as to the urgent necessity for amputation. This compromise between limb and life may be thus stated : — whenever a limb is destroyed, by injury, and life would be perilled by the inevitable supervention of gangrene, (primary) amputation is im- perative ; whenever a limb is not entirely destroyed, the rule should be, to give the limb its chance of recovery, by waiting for gangrene ; but in that event (secondary) amputation becomes necessary, and further delay would peril life, without the compensating probability or pos- sibility of preserving the limb. Duly weighing both these conditions, the Surgeon will ever be prepared to estimate the urgency of amputa- tion in any particular form of contused or lacerated wound — otherwise than Avhen destructive of the whole substance of a limb. The time also, as well as the conditions, for the performance of amputation is a very important consideration. Amputation for injury, in general, is commonly divided into Primary and Secondary ; the primary being that which is performed during the first twenty-four or thirty-six hours, — before inflammation has commenced ; the secondary being amputation performed after that period, — after the supervention of inflammation, and, at a later period, suppuration. Amputations performed in the intervening period, between twenty-four hours and inflammation, are sometimes designated intermediate. With regard to contused and lacerated wounds, the proper time for amputation under different circumstances, as expressed by the terms primary and secondary, has reference to the performance of the operation before or after the occurrence of gangrene ; in accordance with the rules already laid down. Part for Amputation. — In the event of gangrene, the seat of amputa- tion, or the portion of limb to be removed, should not be determined PUNCTURED WOUNDS. 497 bj waitinof for the formafcion of the line of demarcation between the living and dead parts. Amputation must be pex-formed at once, and suflBcientlj high above the seat of injury to prevent the recurrence of gangrene in the stamp. The foregoing considerations relate ex- clusively to purely traumatic gangrene. Spreading traumatic gangrene being the local manifestation of some morbid condition of the blood, its supervention would be so far less likely to be intercepted by the primary amputation of the injured part. On the other hand, gangrene appearing in the stump, would frustrate the intention of the operation with regard to the preservation of life. When spreading gangrene has supervened, the Surgeon is placed in this dilemma in regard to the part for amputation : — -if the operation be performed without waiting for the line of demarcation, gangrene will probably reappear in the stump, and death ensue ; if the operation be postponed, for this pur- pose, the gangrene spreads rapidly up to the trunk, and then death is inevitable. Considering that the injury is the exciting' cause of this gangrene, amputation had better be performed at once, and at some height above the apparent seat of injury. But, in selecting a sound part of the limb, and not merely that which may recover itself as a stump, it must ever be remembered, that while the damage done by contusion or laceration, is more extensive than may appear on the surface, the destruction wrought by spreading gangrene, especially in the cellular texture, has even a wider rang^e up the limb, than as declared by any discolouration of the skin. The safest parts for amputation are, pro- bably, at the shoulder-joint, when the arm is involved ; and in the upper third of the thigh, when the leg is affected as far as the knee. The after or constitutional treatment is fully considered in connec- tion with the general pathology of Gangrene. Punctured Wounds. — A punctured wound is a more or less con- tused and lacerated wound; varying in depth, but of greater extent in this direction than superficially. Structures may thus be injured far beyond what appears to be the extent of injury, by the aperture in the integument. Other kinds of Wound — the incised and the purely contused or lacerated — may indeed be complicated by their depth ; a punctured wound is characterized by this additional element. Thus, penetration of an artery and the formation of traumatic aneurism may complicate a punctured wound in any part. Penetration of the brain complicates a punctured wound of the skull ; and similar injury of the lung or heart, or of one or more of the abdominal viscera, may complicate a punctured wound of the thoracic or abdominal cavities respectively. The external characters of a punctured wound are comparatively un- important, and not characteristic. Varying in size, from a pin's point .to a bayonet-thrust or an aperture of larger size, its shape differs with the form of the penetrating instrument ; the margin of the aperture is irregular and the surrounding integument bruised, if the wound was produced by the penetration of a blunt-pointed instrument ; and this laceration and contusion are the more conspicuous if the weapon was of increasing size from the point upwards, as a bayonet. The heemor- rhage cannot be estimated by the quantity of blood which escapes externally. The" narrow track of a punctured wound and laceration of the textures, rather impede the escape of blood, and are favourable to the formation of traumatic aneurism. If the wound extend into an VOL. I. 2 k 498 STzriii. ?i.rH::i>:-T avi* sxtbiGsss. infer ; - ^ ^ take place j^ more ■b^ r-d fn>ni the aperture CEtc : ' pa rficidar parts, per- - ^ :^ : the function of - ; , - ihe genexal pai::;- -~ : _ ::: ;:i "„ rre omitted. Bacl 5£; ;:--;-. :-:- , . ; / - - .^-^^.^ ^ the 17- - - ■ ^: :f - :; he -fnt. -— t- 1 ^nd -Z.Z im- r b]ood- raniis is rntnaHy - = :^ nor -1 ~sh ble : -i^-ion. ' T almost ^ a simi- : lording ■j^Lpoitaaice InTitrv to -djmiaxaem, is axi et-entnaMy fiwourahle puxcxrEED womsDS. 499 Treatment. — The first indication is to arrest haemorrliage. wkich. ob\"ionsly claims immediate attention when it occurs in any considerable qnantitv. Pressare. by means of a compress, will generally prove sufficient, nnless a large artery be pnnctured, when it will be necessary to ligature the vessel above and below the aperture, by catting down in the track of the wound., if it can possibly be thus secured. The removal of any foreign body is another obvions indication, whenever it can be safely fulfilled. A portion of clothing may have been thrust so deeply into the wound, and possibly into some internal organ, that its presence cannot be ascertained with certainty, nor its removal effected with safety, and without unwarrantable mutilation. Secondary haemorrhage may occur in the course of som.e days — ^when either, or both ligatures separate. The question of again securing the artery by double ligature, in situ, or of ligaturing the main artery — high up, will then have to be considered. As a rule, the punctured artery being in a healthy state, the former procedure should be adopted ; the wound leading to the vessel may be enlarged, the coagola turned out, and the vessel exposed, so that it can be clearly tied above and below the bleeding aperture : the vessel should then be divided between the ligatures — if this had not been done on the first occasion, thus to release the artery from any strain and disturbance dtiring the process of occlusion. When, however, the part is deep, the surrounding textures infiltrated, or sloughing has supervened, and especially if the artery itself is found to be diseased, — under these exceptional circumstances, the high ligature may be resorted to. But certain objections to this procedure should not be overlooked : the liability of haemorrhage re- curring by regurgitation from the distal side of the puncture, and that the process of occlusion takes place less readily in that portion of the vessel ; besides which, high ligature may fail to control the source of haemorrhage — as when the superficial femoral being stopped, the pro- funda still supplies blood below, or owing to some occasionally irre- gular origin of the bleeding artery. The possibility of gangrene of the limb, consequent upon ligature of the main artery, must also be taken into account. Temporary compression might, therefore, be more advantageous. Guided by the processes of reparation, healing by primary adhesion should be attempted in all cases of punctured wound ; but the prospect of success will depend on the comparatively simple character of the wound, by the less circumferential contusion, the absence or removal of any foreign body, and the arrest of haemorrhaare. railing in most cases to induce adhesion, the process of suppurative granulation is the alternative to be solicited, as in the usual treatment of a contused or lacerated wound. A neetZ?e-punctured wound, although trivial in itself, is apt to pre- sent some difficulty in the extraction of the foreign body ; the needle being driven in entirely, or having broken off, leaving a portion imbedded. This complication may be increased by the locality of the needle ; when near to large vessels and nerves, as in the axilla, and movable in cellular texture ; or impacted in a large joint, as the knee ; or thrust into or under the sheaths of tendons, as in the fineers and toes. I have experienced more or less difficultv in removing a needle from either of these situations. The point, or the end of the broken portion, may perhaps be near the puncture- wound, and it can 500 SPECIAL PATHOLOGY AND SURGERY. sometimes be detected by the pain produced on slight pressure over the spot, or a pointed projection under the integument may be felt ; but the needle easily shifts its position, and thus evades seizure with a fine pair of forceps. Careful dissection, with light sponging, will at length, expose a black point, which when seized with the forceps is found to be metallic, and then the foreign body is readily extracted. Needles which have been swallowed, migrate through the coats of the stomach or intestine, and work their way into all parts of the body, at last perchance coming to the surface in some quite unsuspected situation. Under any circumstances of doubt, if a needle be impacted, or have come to the surface, its presence may be declared by the magnetic method, devised by Mr. John Mai'shall ; the suspected part is brought under the influence of a powerful magnet for a quarter of an hour, then, on suspending over it a polarized needle, some deflection would indicate the presence of iron. CHAPTER XVIII. GUNSHOT WOUNDS. Gunshot Wounds. — Of Complicated Injuries, none are more interest- ing and important than Gunshot Wounds. But they chiefly concern the Military Surgeon, although the general Surgeon is occasionally called upon to undertake the charge of such injuries in civil practice. It will, therefore, be doubly necessary to fully consider the guiding elements of their pathology and treatment. Gunshot wound is, essentially, a contused and lacerated wound ; but varying in extent and depth. The latter element is always a critical consideration. Other kinds of wound — -the incised, and the purely contused or lacerated — -may, indeed, be thus complicated ; but a gun- shot wound is usually characterized by one or other of these additional elements. Structures may thus be injured far beyond what appears to be the extent of injury, in connection with the apertui-e or apertures in the integuments. If any part, as a limb, be shot away entirely, as by a cannon-ball, the extent of injury is more openly declared. Thus, also, penetration of an artery, with the formation of traumatic aneurism, may complicate a gunshot wound in any part. Penetration of the brain complicates a gunshot wound of the skull ; and similar injury of the lung or heart, or of one or more of the abdominal viscera, complicates a gunshot wound of the thoracic or abdominal cavities in either such case. Compound Fracture or Compound Dislocation not unfrequently complicate the more severe forms of gunshot injury. The course of a ball in the body is determined by its shape and velocity. The round musket-ball — formerly in use and propelled with a velocity which scarcely reached eighty yards, revolving, also, on its axis, at right angles to its transit — was turned aside by the slightest obstacle. On striking the body, the resistance offered by clothing, or, on penetrating the skin, by a bone, and, indeed, the GUNSHOT WOUNDS. 501 different resisting media of different structures, would deflect the ball from its course, and make it assume a circuitous and perchance most extraordinary route ; ultimately lodging in the body in many cases. I^owadays, the cylindro-conoidal rifle-bullet, generally used, and pro- pelled with a velocity true at 1000 yards or more, pursues its course straight through the body, and out again, in most cases. An apparent deviation is sometimes due to the Surgeon omitting to view the patient in the position he was when the ball entered ; and occasionally, though rarely, a real deviation, possibly a circuitous course, is caused by an accidental concurrence of circumstances, especially when the velocity of a conoidal bullet has become diminished. Of the various textures, none suffer so much damage as bone by the penetration of a conoidal bullet. Piercing and passing through the soft parts, it splits and comminutes any bone in its way, producing fissures which extend into neighbouring joints ; the greater destructiveness of this shaped projectile resulting from its wedge-like action, and the peculiar resistance offered by the osseous texture. The bullet itself becomes somewhat changed in shape ; its apex being flattened and reverted, if it strikes point-blank ; or planed from its apex towards its base, when it strikes parallel to its line of flight. Foreign bodies, of various kinds, are often lodged in a gunshot wound, and not unfrequently lie deeply buried ; thus constituting another complication. The lodgment of any foreign body is determined by its shape and velocity, chiefly by the latter circumstance. A conoidal ball, with a considerably reduced speed before entering the body, will lodge, more or less deeply ; while a round ball, although at full speed, having taken a circuitous route in the body, may become expended, and thus effect a lodgment. Bullets scattered from canister or spherical case, are liable to lodge ; owing apparently to disturbance of their course in the primary discharg-e, and secondarily, by explosion of their containing- case. Grape-shot lodge occasionally, and possibly after a very devious course in the body. More rarely, a cannon-ball lodges, and remains concealed. A ball weighing 8 lbs. was buried in the thigh, and dis- covered only by amputation. (Guthrie.) In another case, a ball weighing 5 lbs. was found also in the thigh by amputation. (Larrey.) Penetrating fragments of shell, if projected edgeways, almost invari- ably lodge, and are frequently concealed; of which some remarkable instances are mentioned by Professor Longmore. In exceptional cases, a small scale may be detached from a leaden bullet, and this lodges in the wound. Such portions may occur, irrespective of the shape of the bullet, from a cylindro-conical as well as from a round bullet ; and instances of either kind came within the experience of the last-named authority during the Crimean War. In gunshot wounds of the skull, a ball impinging obliquely is especially liable to be split ; one fragment penetrating the cranial cavity, and the other lodging under the scalp, or flying off. Cases of this kind are mentioned by Larrey, Hennen, and Guthrie ; and some half-dozen in- stances are recorded in that most valuable repertoire of American experience, " The Medical and Surgical History of the War of the Rebellion," by Assistant- Surgeon George A. Otis, under the direction of the Surgeon-General, Joseph K. Barnes. 1870. (Part I. vol. ii.) Other hinds of foreign bodies, and of various shape, as a gun- wad, 502 SPECIAL PATHOLOGY AND SURGERY. f^rsbvel, bits of wood, portions of clothing, etc., are not unfrequently found, or remain deep in a gunshot wound. ; any such substance being additional to the projectile, or the only extraneous substance. In the discharge of fire-arms, or of cannon, certain substances are apt to be thrown off accidentally, and may be found imbedded in a wound thus produced ; as when a fragment of a copper cap is blown off, or a piece of fuse. Gunpowder is sometimes driven into the skin, as by ex- plosions in blasting or the discharge of blank cartridges ; and, in civil practice, similar accidents occur, fi-om the explosion of a powder-flask, or of a gun in the act of loading. A portion of the body of another individual close at hand, may be struck off by gunshot injury and driven into the one who is the subject of examination. Any such fragment is thus introduced by indirect participation in the gunshot injury. A double tooth, belonging to a comrade, was found imbedded in the eyeball, in one case ; a portion of the jaw of a corapanion was driven into the palate in another case ; while, in a third case, a piece of the skull was found impacted between the eyelids, the fragment having been shot off the skull of a soldier close by. And, generally speaking, the fragment comes from a corre- sponding region of the body struck by the shot. Signs. — The external appearances produced by gunshot wound will depend on the size of the projectile and its velocity. Number of Aperhires. — A small penetrating* body, as a bullet, pro- duces — (a.) An aperture of entrance, and, if the ball lodges, this is the only aperture. But the ball may have passed round and out at this aperture ; or it may have rebounded, owing to the elasticity of the part struck, as the cartilages of the ribs ; * or, having lodged tem- porarily, it may have been withdrawn in a pouch of clothing. f There being only one aperture is, therefore, no sure sign that the ball has lodged. (6.) Two openings — one of entrance, another of exit — are pro- duced if the ball penetrates with sufficient velocity to pass through the limb or body, (c.) Moi'e than one, perhaps several openings of entrance are produced occasionally. Thus, a bullet having first struck any hard resisting object, and split into pieces, two or more portions may recoil and wound a bystander ; producing as many entrance- apertures. In one such instance, a ball split into five pieces by first striking against a rock ; and all five portions entered the body of a soldier a few paces off. But the number of openings are not necessarily the same as that of the balls which ^erae/ra^e. For example, of three balls, two may have the same aperture of entrance, and of exit also. This coincidence happened in the case of a youth who was shot through the abdomen ; " that three balls went through him was evident, for they afterwards made three holes in the wainscot behind, but two very near each other." (Hunter.) (d.) More than one, perhaps several openings of exit are formed in some cases. Thus, a bullet having struck a ridge of bone and split into pieces, two or more portions may pass through ; producing as many exit-apertures. In one instance, a 'ball having split into two pieces by striking against the sharp crest of the right tibia, both portions passed through the calf of that limb, forming two openings of exit, and then each entering the other calf, produced five openings altogether. J A portion or portions of a split ball may * Guthrie, 2nd edit., p. 19. f Clin. Chir., Dupuytren, torn. ii. p. 426. X Ibid., p. 428. GUNSHOT WOUNDS. 503 lodge. Instances of this kind are recorded, where the ball had struck the edge of the patella, or the spiue of the scapula.* In like manner, when several halls, say three, have entered, one or more maj lodge. There being an aperture of exit is, therefore, no sure indication that one or more balls, or a portion of one, has not lodged ; nnless, in the latter case, the entire ball can be found. And, moreover, the number of exit-apertures are not necessarily the same as that of the balls which entered, or of the portions into which any one ball may have split, (e.) Several openings, both of entrance and of exit, may be produced, and by a single ball. In one case, a ball passed through the hand, then the skin of the groin, and next the left buttock ; thus causing six open- ings. (Larrey.) In another case, six openings also were caused by a single ball having passed through both thighs and the scrotum. (Guthrie.) Appearances of the Entrance and Exit Apertures respectively. — They are tolerably distinctive (Fig. 130). The aper- Fig. 130. tare of entrance is a small, nearly circular opening, or, as produced by a conical ball, it may be linear or crucial, or variously shaped ; its margin is inverted, slightly torn, and sur- rounded with an areola of purple ecchymosis. The aperture of exit is larger and more irre- gular, its margin everted and more lacerated, showing the subcutane- ous fat, and with less sui'- rounding ecchymosis. Not unfrequently, there is no actual aperture, but a reddish discolouration of the integ'ument, the tough and elastic nature of the skin having offered sufficient resistance to prevent the formation of a second opening ; in which case, the ball can be felt lying under the skin, at a point about opposite to the entrance-aperture. These differential characters depend chiefly on the diminished velocity' of the ball after its passage through the substance of a limb or the body. Consequently, the appeai^ances of the entrance-opening vary somewhat in different cases, chiefly according to the speed of the ball ; and its features may resemble those of the exit-aperture. A larger penetrating- body than a ballet, and one of an irregular form, as a small piece of shell, produces an opening similar to that of a bullet ; but it is more lacerated and less circular, of small size also as compared with the fragment, this peculiarity resulting fi'om the slanting' direction in which it penetrates. Generally there is no exit-aperture ; such a pro- jectile lodges, owing to its comparatively less momentum. A still larger penetrating body and of an irregular shape, as a larger fragment * " Obs. in Milit. Hosp. in Belgium," by T. Thomson. '504 SPECIAL PATHOLOGY AND SURGERY. of shell, produces an aperture yet moi'e lacerated, and of even smaller size as compared with the fragment. It also not nnfrequently lodges. A large-sized projectile, as a cannon-ball, may penetrate and pass throiiah the body, producing an entrance and an exit apertui-e, which resemble those caused by a smaller projectile, as a bullet ; only that the characters of either aperture are presented on a much larger scale. If, however, such a projectile as a cannon-ball strikes one of the extremities, it carries away the entire limb, as if transversely amputated; leaving a contused stump, purple and pulpified. The stump is less abruptly truncated and more lacerated, if the ball impinge with diminished velocity, as when bounding along the ground it strikes off a limb. In both these forms of cannon-shot injury, the ball im- pinges in a direct line. If a cannon-ball strikes the body in a slanting direction, thus brushing the surface, and especially if, when moving vpith a greatly diminished velocity, it rolls over the part ; in either case, the skin may not be broken, its elasticity apparently preserving that texture entire, and scarcely any discolouration marks the course of the ball. But the gravest subcutaneous disorganization of other textures is produced ; even to the pounding of muscles, vessels, nerves, and bone, or of the viscera. Such internal lesions, unaccom- panied by any corresponding external signs, were formerly known as " wind-contusions," and attributed by French authors to the " vent de boulet." Hcemorrhage of an arterial character may attend a gunshot wound ; and sometimes proves fatal almost instantaneously. A gush of arterial blood is seen, and then and there a pallid corpse. Generally, however, the accompanying laceration secures the vessels, as already described (Chap. XVI.), and prevents the escape of any considerable quantity of blood, at the time of injury. The shape of the projectile will modify in some degree the amount of laceration, a sharp-pointed or angular missile cutting rather than tearing the textures; but the velocity of the missile is more effective; for a ball moving with great rapidity is more cleanly incisive, whereas a slow-moving ball lacerates and closes the vessels in its course. Haemorrhage will be more or less free, accord- ingly. Partial division of an artery is attended with profuse bleeding, as retraction cannot take place. Puncture by a spiculum of bone, occasionally, will cause primary h£emorrhage; but a bullet may pass between an artery and vein in contact, as the femoral vessels, without opening either vessel, their elasticity apparently preserving them intact. The pam of a gunshot wound is worthy of notice as a symptom. In the first instance, it is either like the sharp stroke of a cane, or a dull heavy blow; differences due, perhaps, to the degree of contusion. The pain may be referred to a part remote, more or less, from the seat of injury. This want of localization, coupled with the inconstant and in- definite character of the pain itself, evinces its \-aieYiov diagnostic value as a symptom, compared with the signs already described. For a short time after the injury, the sensibility of the part is numbed ; pain succeeding, and with increasing intensity as inflammation and tension supervene. The symptoms connected with the penetration oi particular parts — perchance the viscera — are specially significant, in virtue of the func- tion of the part, which is thus injured ; but as not pertaining to the general pathology of gunshot wounds, they are here omitted. GUNSHOT WOUNDS. 505 Causes ; or Kinds of Projectiles in Gunshot Wounds, and the Effects of these Injuries. — The shape of projectiles used in warfare presents several varieties, the chief of which are spherical, as cannon-balls, grape, musket-shot, and shell ; cylindro-conoidal, as balls belonging to rifled cannon and rifled muskets ; irregular, but generally bounded by linear and jagged edges, as fragments of shells and splinters, chain and bar shot. In point of size, projectiles vary from a rifle-bullet to the largest sized cannon-ball or shell. The shot used in civil life are usually of smaller size ; as the bullet of a fowling-piece, or of a i-evolver or pistol ; and game-shot of various sizes. The material and density of projectiles are less various ; being either lead, as the common bullet, glass, as some hand-grenades, or cast iron, as cannon-ball or shell and all other missiles. The momentum of a projectile is represented by its weight and velocity. The velocity of difi^erent kinds of projectiles varies consider- ably. According to a table published in 1851, the common musket- bullet moves at the rate of 850 miles per hour, the rifle-ball of that date at 1000, and the 24 lb. cannon-ball at 1600 miles per hour. But the musket-ball then could not be depended on to hit an object beyond 80 yards, and the rifle not further than 200 to 250 yards; while, at a later period, the Enfield rifle was sighted to 900 yards, and the short Enfield to 1100 yards ; and now, the Snider and Martini- Henry breech- loaders are true at certainly 1000 yards. The kind of motion imparted to different projectiles, and thence their course through the air, is a difficult question, which can only be analyzed and determined mathematically, and is, in fact, a very im- portant branch of dyna-mics. Different kinds of motion have to be considered in combination, and as resulting from the propulsive force, subject also to the law of gravity. A ball discharged from the old smooth-bore musket has a double motion ; it revolves on its axis at a right angle to the line of flight. A ball discharged from a rifle-bored musket or rifle has also a double motion, but of a different kind ; it revolves on its axis in the line of flight. The angle at which a pro- jectile strikes may be said to be accidental in many or most cases, and unconnected with the missile itself or its motion. Striking frequently at or nearly a right angle, one kind of missile — the shell — exploding on the ground, scatters its fragments upwards, and thus any such fragment will strike probably at an acute or obtuse angle. The penetrating power of a projectile is determined mainly by its shape and velocity. The cylindro-conoidal form is very pene- trating, in virtue of its mechanical advantage as a wedge. Thus, supposing one of the old musket-bullets to strike a limb at 80 yards, and an Enfield rifle conical bullet of the same weight at 800 yards ; the rate of velocity being equal in either case, the injury from the latter shaped ball may be expected to be much greater that that from the former. The influence of velocity is well known, and shown by the different effects of the same kind of missile according to its speed. A spent cannon-ball, rolling or bounding along the ground — ricochetting — may carry away a limb; whereas the same ball at full speed would level a line of men. But the former injury, occurring possibly when the cannon-ball is rolling along so slowly, as apparently to have no more force than a cricket-ball, shows also the influence of weight as an element of the momentum. Density is an important consideratioa 506 SPECIAL PATHOLOGY AND SURGERY. respecting the power of penetration. For example, the projectiles and charges being of the same weight, when lead is used, the penetration at 800 yards is one-third greater from the Whitworth than the Enfield rifle ; but, if a less yielding material be used, as when lead is mixed with tin, its penetration is as 17 to 4, at 800 yards. (Longraore.) The amount of injury produced will vary, therefore, according to the density of the material of which the projectile consists, — other con- ditions being equal. This has been demonstrated by the experimental observations of Dr. Knester, of the Berlin Augusta Hospital. Thus, a hard bullet penetrates deeply, but with comparatively less injury to adjoining parts ; whereas, a soft bullet is apt to spread out, — when it impinges on bone, or in its course through the textures, and produces a larger aperture of- exit, with surrounding laceration. In estimating the destructive power of different rifles, the hardness or softness of the leaden bullet must, therefore, be taken into account. The Martini-Henry bullet is hard, consisting of twelve parts of lead, with one of tin. The Chassepot bullet is made of soft lead. The hind of motion has certainly some relation to the penetrating power of any projectile. If spinning, like a top, at a right angle to the line of flight, as a bullet discharged from the old smooth-bored musket, the projectile is easily turned aside from its course ; whereas the screw motion of a ball discharged from a rifle-bored tube, coinciding with the line of flight, is very penetrating. Lastly, the angle at which a projectile strikes must affect its penetration. A right angle will be more effectual than an acute or obtuse angle, the impinging body having a tendency to glance off in striking at the latter angle. Small shot, such as are used in civil life, seldom penetrate deeply, unless when discharged at a short distance, and entering in a mass, they thus resemble a bullet, or even a larger ball, according to the charge. When scattered and spent by a longer range, shot of small size are often found to have entered only skin-deep ; but to have been deflected, probably, in all directions. Other bodies are sometimes associated with projectiles as indirectly causing wounds, additional, perhaps, to gunshot injury. Such missiles may be stones, splinters of wood or pieces of iron from gun-carriages, portions of clothing or coins, and fragments of bone from a wounded comrade. Having bor- rowed their motion from the projectile itself, of whatever kind — per- haps a ball already spent — any such body strikes with a proportionately diminished impetus, and with different degrees of effect under various circumstances affecting its own displacement, shape, and so forth. The effects of a gunshot wound, locally and constitutionally, are quite analogous to those of a punctured wound, or of any contused and lacerated wound. Parts are damaged far beyond the apparent extent of injury. Thus, the textures are killed to a greater or less extent along the track of the wound, and a corresponding tubular slough is eventually formed. Shock, rather than syncope from sudden hgemor- rhage, is the primary constitutional disturbance. This sloughing is more extensive, and the shock more overwhelming and prolonged, when caused by projectiles of modern design; their more deadly character being due to their greater power of penetration. Considerable importance has been attached to shock, in the sense of concussion of the whole body, by a heavy projectile, as a cannon-ball. But this can happen only when the velocity of any such projectile is so much reduced as to give time, in striking, to overcome the iuertia of GUNSHOT WOUNDS. 507 rest in the body. A cannon-ball at full speed may carry away a limb witliout knocking down the individual, who falls simply by the sudden shock of injury to the nervous system. Tetanus is of common occur- rence. But its frequency has varied much in different campaigns, and under different climatic influences. In the Peninsular War, it was estimated to occur in about 1 case in every 200 wounded ; in the Schleswig-Holstein War, 1 in about 350 cases. In the Crimea, tetanus appears to have been a rare event. Alcock's estimate of 1 case in every 79 wounded is too high. After naval engagements, the mortality has often been high. Sir G. Blane states that, after Rodney's action, out of 810 wounded 20 were attacked with tetanus, being 1 in 40. But sudden change from heat to cold is the most frequent cause of tetanus among the wounded. This was observed after the battles of Moskowa, Bautzen, Dresden, Chilianwallah, and Ferozepore. The above statistics include the proportion of cases of tetanus arising from all kinds of wounds, besides gunshot. Course. — The vital career of a gunshot wound is analogous to that of a punctured wound, or of any contused and lacerated, wound. Gan- grenous inflammation invariably supervenes, perhaps extensively, along the track of the wound ; and thus textures which may not have been killed more immediately, die subsequently. The total result is repre- sented by the slough which forms. About the fifth day of a gunshot wound, this slough begins to loosen from the margin of either aper- ture, if two exist, and the line of demarcation between the living and dead tissues is clearly visible ; about the tenth day, the slough or sloughs may be seen hanging out of the openings, and come away in the dressings. A tubular casting of slough had hitherto intervened between the living tissues surrounding the track of the wound, and prevented its union by adhesion. Suppurative granulations supervene, and the wound heals, or should heal, from within outw^ards. Pending this process of reparation, tension is often extreme and extensive, and suppuration equally profuse and diffused. Secondary hgemorrhage is not an uncommon event. It occurs most frequently on the sixth day. (Baudens.) Arteries which did not bleed primarily, or which were only slightly grazed, may now burst forth. Or a spiculum of dead bone, during the course of suppuration, is occasionally the cause, by penetration of an artery. Any secondary hemorrhage, if not suddenly fatal, may be uncontrollable, from its depth or in a disorganized part, or ultimately fatal in an individual already reduced by suppura- tive discharge. An unextr acted hall plays a singular part in the subsequent history of a gunshot wound. Constant suppuration, and exfoliation if the ball be lodged in bone, are consequences which might be expected. But the ball may move from its first lodgment and travel to some distance, in a devious course, and ultimately find an exit or still remain in the body. Various functional disturbances arise during these peregrina- tions. Again, the ball may become encysted in dense fibro-cellular tissue, and then being stationary and isolated in a sac, it occasions little or no inconvenience. Or, a long canal-like cyst may form, in which the ball, although imprisoned, moves freely up and down. Apart from this general vital history, a gunshot wound extending into any internal organ, exhibits a series of phenomena peculiar to the particular organ implicated ; and thence the completion of the vital 508 SPECIAL PATHOLOGY AND SURGERY. Fig, 131. hisfcorv of this form of iTijuiy, as occurring in different parts of tlie body, belongs to Special Pathology. Prorjnosls. — The prognosis of Gnnshot Wound is partly analogous to that of any other contused or lacerated Avound. The kind of structural disorganization is significant, as leading inevitably to slough- ing and suppuration. The presence of ?in j foreign body in the wound has a similar import. But the extent and the depth of a gunshot wound will much affect the tissue. The prognosis is specially un- favourable according to the number and functional importance of the parts injured, as complications of the wound. Injurj^ to large blood- vessels, nerves, or an internal organ, are thus, severally, unfavourable conditions ; and proportionately to the functional disturbances thence arising. Compound Fracture and Compound Dislocation are obviously most serious complications of gunshot injury. The subsequent course of the wound in its undei'going reparation by suppurative granulation, is an eventually favoitrable ground of prognosis. Treatment. — Iminediately after a gunshot wound, certain require- ments demand instant attention, as to hsemorrhage, position, and shock. (1.) Arterial hcemorrhage, whether in the form of a jetting stream or a rapid dripping of blood, mnst be arrested forthwith. Abundant venous heemorrhage is scarcely less perilous. If a limb be the seat of injury, a tourniquet should be applied, so as to command the main vessels. The same rule holds good when the limb is struck off, as by a cannon-ball ; a tourniquet should be applied above the stump. A convenient form oi field-touvni- quet is here represented (Fig. 131). In the absence of this instrument, a substitute may be readily made, by means of a stone about the size of an egg, rolled in the middle of a pocket-handkerchief and placed over the main artery ; the ends of the handkerchief being drawn around the limb and secured in a knot, and then twisted up tightly with a piece of stick or the hilt of a sword passed under it. A compress and an elevated position of the limb are more suitable when the haemorrhage is purely venous. The part may be covered with cold wet lint, as a soothing- application. If the head or neck be wounded, hEemorrhage, whether arterial or venous, must be arrested by pressure ; and cold applied. (2.) Attention to position is important. A limb should be laid in an easy position ; and fixed during the removal of the wounded person to hospital, in order to prevent any disturbance of the injured part from shaking or from spasmodic action of the muscles. Tims, a rifle may be used as a thigh-splint (Fig. 132) ; and a sword-scabbard, as a splint for the leg ; or two bayonets, fixed together at their reversed ends, Avill answer the same purpose. This precaution of fixing the limb, will be the more necessary when compound fracture or dislocation com- plicates the injury. If the chest be shot through, the patient should be laid on the injured side and cold applied. If emphysema occur, or if air escape freely through the wound, a broad rib-roller should be applied. If the abdomen be wounded, the patient should be laid on the injured side; or, if the wound be central, on his back, with the GUNSHOT WOUNDS. 509 knees drawn up over a pillovv or knapsack. Any portion of protruding intestine or other viscera must be g-ently cleansed with water and at once returned. (3.) Shock, or sometimes Jicemorrliagic collapse, may be most peri- lous ; and brandy, wine, or other stimulant must be administered to preserve life. Cold water may be given freely to allay the parching thirst which speedily ensues from loss of blood. The subsequent indications of treatment comprise — the permanent arrest of hfemorrhage ; extraction of foreign bodies ; the manage- ment of inflammation, and sloughing ; and the conditions requiring amputation. (4.) HcemorrJiage. — The permanent arrest of heemorrhage may first demand attention. If artei'ial, the application of a double ligature to the wounded vessel may be necessary ; the wound being sufficiently enlarged perhaps by an incision for this purpose, and the vessel secured at not less than half an inch outside the course of the wound, that it shall be unaffected by sloughing of the textures, which would lead to secondary hemorrhage. Whenever, therefore, the bleeding artery cannot be tied, with this precaution, owing to the depth of the wound, Fig. 132.* the main trunk must be ligatured. Yet this procedure should not be lightly entertained, considering the liability of thus inducing gangrene in a limb otherwise injured; as by ligature of the subclavian, or of the femoral artery. And, moreover, secondary haemoiThage not un- frequently occurs. Temporary compression of the main trunk might answer the purpose. But it is seldom requisite to have recourse to ligature of even the wounded artery for primary haemorrhage after gunshot injury. When a limb is torn off, leaving a stump, the lacerated vessels soon cease to bleed. Venous haemorrhage must still be arrested by pressure, and elevation of the limb. The application of a roller- bandage is advocated by Hamilton as a very effectual means of pre- venting extravasation of blood and serous effusion. But it should not be continued after inflammation has set in — say, not beyond the first twelve or twenty-four hours. Other indications for interference with the wound are best de- termined by examining the patient in the position, as nearly as it can be ascertained, in which he was relatively to the projectile that struck him. In any other posture, the apparent course of the ball in the body, and thence also the probable extent of injury or the parts implicated, would be modified by muscular action and by the various degrees of elastic retraction of the wounded textures. The relative situations of the rent in the clothing and the entrance-opening in the flesh, should also be compared. * From Esmarch. 510 SPECIAL PATHOLOGY AND SURGERY. (5.) Foreign Bodies. — To defect any such, substance, the finger is the best searcher or probe. Various forms of gunshot probe have been devised; an instrument provided with a bulb-end being the most serviceable. In case of doubt or difficulty of examination as to the lodgment of a leaden bullet, Nelaton's probe, having a bulb of un- glazed porcelain (Fig. 133), should be introduced ; and if, in firmly touching the foreign body, its point receives a metallic mark, as shown when the probe is withdrawn, this instrument will thus offer the requisite facility and certainty of diagnosis. In the well-known instance of Garibaldi, it will be remembered that a ball was detected with this instrument by Nelaton, after search had been otherwise made, repeatedly in vain. But it may happen that the probe I'eceives a lead-mark from a streak left on bone by the deep graze of a bullet ; and thus the hard substance of bone has actually been mistaken for a bullet. A probe should be introduced lightly, or dropped into the wound, not to miss the track of the ball ; any thrust of the instrument might make a false passage ; but if in the right course, the probe can be advanced almost by its own weight towards the i)all, ■while the Surgeon endeavours to overcome any hitch, by. adapting the position of the part so as to restore the track. The finger or a probe Fig. 133. will glide almost readily in the course which the missile has taken ; the tissues having been thrown down in this direction, as grass falls before the wind. Enlargement of the Entrance- Aperture. — A slight incision is some- times absolutely necessary for the removal of a hullet or other foreign body ; but the rule of practice which formerly prevailed of invariably enlarging the aperture by incision and to some considerable extent was an error; suggested by the false pathology of thus converting a supposed "poisoned" wound into a simple incised vround, and of giving free vent to the noxious discharge. Any foreign body, of irregidar shape, e.g. a fragment of shell, more generally needs release to effect its dislodgment and extraction ; the circumstances in this case at once showing the necessity, and regulating the extent, of incision. But, unless for an obvious purpose, the ride should be to avoid making any enlargement of a gunshot wound, as being an extension of the original injury. To remove a hidlet some form of bullet-extractor is generally requi- site or advantageous. The most convenient form is here represented (Fig. 134). The sharp points of this instrument will readily seize a ■leaden bullet. Any kind of forceps is somewhat objectionable, owing to the dilatation of the textures in using the instrument. A bullet lodged in hone may be extracted by an elevator, aided by gouging away any overhanging portion of bone. An}^ other foreign body, as a por- tion of clothing, which might be mistaken for some natural texture, should be searched for with the finger and removed by manipulation rather than with forceps, which, are apt to seize both indiscriminately. Examination of the dress will probably show whether a portion w^as carried with, the shot into the wound. It should, however, be remem- bered that any such fragment may have been withdrawn in undressing GUNSHOT WOUNDS. 511 Fig. 134.* the patient. Foreign todies are eligible for removal, according to tlie patency of their situation, as their presence can then be ascertained with proportionate certainty ; but the relation of surronnding parts will affect the safety of an operation for extraction. Thus, when situated beneath the skin, although perhaps at some distance from the entrance-aperture, a bullet is readily detected and removed by an incision, longer than the apparent size of the ball, care being taken to steady the ball lest it slip away out of reach. The bullet is usually found to be more or ^ less battered and mis- shapen, also tightly con- stricted and held fast by diverted threads of muscular, fibrous, or cel- lular texture ; the mis- sile, thus imprisoned, cannot be raised from its bed, and must be set free by touches with the knife, before it can be extracted, without fur- ther laceration of the textures and unneces- sary pain. A conoidal ball generally lies with its long axis sideways beneath the integument, and should be extricated in that direction. On the other hand, when the foreign body is situated deeply, and possibly already out of a^ /^^>> reach, its detection is lY |] less certain — unless it ftl jj be a leaden bullet, the V — ^ presence of which may be recognized by means of Welaton's probe ; and its extraction, in any case, by operation, will be less safely accomplished. The annexed form of bullet-forceps, Savigny's (Fig. 135), is especially serviceable for deep wounds. The blades unlock, and can be introduced separately, or used as a scoop. Cozeter's bullet-scoop (right object in Fig.) enables the Surgeon to fix the bullet by means of a screw. But when the foreign body is so placed that it cannot be distinctly localized, or should it be inaccessible surgically, the better rule of practice is to abandon any further search, as well as any attempt at operative interference. This injunction becomes absolute in the case of a foreign body lodged in any internal organ. Sometimes a counter -opening affords a more ready access to the ball ; and then, when extracted, the missile should be carefully * Luer's bullet-extractor, which was used generally in the Franco. German War. (Weiss.) 512 SPECIAL PATHOLOGY AND SURGERY. examined", to ascertain whether it has been chipped, by -coming in contact with the bone, and that the fragment is probably left in the body; or whether, judging from its misshapen, although unbroken appeai-ance, the ball has struck bone, directly or obliquely, this relative direction giving a further indication as to the amount of injury which the bone has sustained. Certain difficulties attend both these questions. A conical ball is i-arely split ; and unless the ball retain its regular shape, or if disfigured, unless it be much reduced in size and weight, there will be great difficulty in detei-mining whether any portion has been knocked off. If, however, a piece has been left, bone must have been struck ; and the fragment will be diverted from the course of the ball, so as perhaps to elude any further seai'ch. The misshapen appear- ance of the ball may also show that bone has been struck ; but only when it is flattened at its conical point, or deeply fun-owed on one side, can the inference be warranted that the missile impinged directly, in such case pi-oducing fracture with extensive comminution ; whereas, an oblique stroke, grazing the bone, may not cause fracture, or if so, without comminution. In connection with this examination of the ball, the possibility should not be overlooked that similar alterations of size and shape may have been produced by impingement against some hard substance, before entering the body ; as by striking a button, or a sword, upon the person of the wounded man. In com- minuted fracture, any loose fragments of bone should be removed. Gu7ipoivde7- grains, scattered beneath the skin, appear as black specks, and are perceptible to the touch ; they may be picked out with the point of a probe, though rather firmly imbedded. If allowed to remain, these granules induce some redness and swelling, followed perhaps by suppuration and their discharge. But, usually, a pointed marking- remains — the part is tattooed. The grains can be disinterred only by incision with a sharp-pointed bistoury, and even then the stain left is never effaced. An ordinar}- gunshot wound, having one or two, possibly more, openings, with an intermediate line of texture about to slongh, is a kind of lesion which requires little or no external dressing. The aper- tures may be protected from exposure to dirt by corresponding pieces of wet lint, or when fresh water cannot be procured, as perhaps at sea, simple cerate on lint will be a sufficient substitute ; but any restrictive dressings, which would preclude the escape of sloughs and the discharge of pas, are altogether at variance with the suggestions of pathology. An irregular and lacerated wound, as by a piece of shell, may need such dressings, but merely so as to adjust and retain the textures in position. Or, during a journey by land, as when recently wounded men are transferred to some distant hospital, their wounds, tender and irritable, may be protected; a broad compress of cotton or other soft padding, applied over the dressing, and lightly retained by plaster, will prevent any chafing of the clothes or other injury, and also afford great comfort. (G.) The accompanying inflammation and tension with severe pain are perhaps best moderated by warm- water fomentations ; but the choice of warm or cold and evaporating applications, must be guided by experience and trial in each case, and especially by the sensations of the patient, rather than by any pathological consideration at present known. Early and free incisions may be requisite to relieve tension and GUNSHOT WOUNDS. 518 ttence the accompanjin^ constitutional disturbance, and to give free vent to matter which otherwise accumulating would burrow and dis- organize the part. This relief of tension will also limit the sloughing. The irrigation of cold water has sometimes proved verj beneficial, apparently in cleansing the wound of any excessive discharge, or decomposing texture, and thence also in the prevention of pyemic infection. Subsequently, the process of healing by gi'anulation and cicatrization guides and regulates whatever slight assistance may then be necessary on behalf of reparation. Of the untoivard events to which a gunshot wound, in general, is liable ; secondary haemorrhage is one. It is especially apt to occur when the sloughs loosen and separate — about the fifth or sixth day ; but it may happen during a period from that time up to the twentieth or thirtieth day, when any ligatures separate, and commonly about the fourteenth day. At those times, therefore, the application of a tourniquet around the limb, in readiness to be tightened at a moment's notice, will always be a judicious precaution, but only as a temporary measure to arrest the haemorrhage. Ligature of the bleeding vessel or vessels is imperative, and without delay. This should be done in situ, if possible; or when impracticable, then by ligaturing the main trunk ; or tliat failing to command the hgemorrhage, amputation is the only resource. A general oozing of blood, or "parenchymatous hsemorrhanre," may be subdued by dilute solutions of perchloride or per- sulphate of iron, or other astring'ents. Any loose fragment or speculum of dead bone, as an accidental cause, should be removed ; although, sometimes, not without the danger of provoking erysipelas. The pi-o- bability of gangrene supervening, and thence the propriety of amputa- tion, and the question whether it should be primary or secondary, are subject to the same or analogous considerations as with regard to con- tused and lacerated wound, and to compound fracture or dislocation. (7.) Amputation. — When a limb is the seat of gunshot injury, requiring amputation, the evil consequences of delay are vividly portrayed by Sir Charles Bell, in the following course of such cases : — " In twelve hours, the inflammation, pain, and tension of the whole limb, the inflamed countenance, the brilliant eyes, the sleepless and restless condition, declare the impression the injury is making on the limb and on the constitutional powers. In six days, the limb, from the groin to the toe, or from the shoulder to the finger, is swollen to half the size of the body; a violent phlegmonous inflammation, with seroiis effusion, has taken place in the whole limb, and abscesses are forming in the great beds of cellular texture throughout the whole extent of the extremity. In three months, if the patient have laboured through the agony, the bones are carious, the abscesses are inter- minable sinuses, the limb is undermined and everywhere unsound, and the constitutional strength ebbs to the lowest degree." Keeping in view a clinical history such as this. Surgeons are now generally agreed on the great advantage of primary, instead of secondary, amputation, in gunshot injury, an advantage which is fully borne out by statistical results ; but the only question has been the kind or class of cases requiring amputation. The following conditions of gunshot injury may be enumerated, as those which justify amputation, according to the " Report of the United States Commission," 1864. (Hammond's Military Essays.) VOL. I. 2 L 514 SPECIAL PATHOLOGY AND SURGERY. (1.) Cases where a limb is nearly or completely carried away, leaving a ragged stump, with laceration of the soft parts, and projection oi: the bone. (2.) Cases in which the soft parts of a limb are extensively lacerated or contused, the principal arterial and nervous trunks destroyed, and the bone denuded or fractured. (3.) Cases in which a similar condition exists, without either fracture or denudation of the bone. (4.) Cases of compound and comminuted fracture, particularly those involving joints. (5.) Cases in which the ball does not actually penetrate the joint, but in which, the bone being struck above or below, the fracture extends into the joint. (6.) Respecting the lower limb : — Compound fractures of the middle and lower part of the thigh, occasioned by gunshot, require amputation. In the upper two-thirds of the thigh, with similar gunshot injury, the mortality following amputation has been so very great, that army Surgeons have generally abandoned the operation. On the other hand, this experience should be supplemented by the counter-fact that such injuries rarely recover. Six cases, however, in the upper third of the tliigh, are reported to have occurred during the Crimean War. (Longmore.) We may therefore join issue with the Surgeon-General of the United States Army, in the conclusion that such cases must be left to the judgment of the Surgeon. (7.) Gunshot wounds of the knee-joint demand amputation. Ex- cision has not been attended with favourable results. The conditions of gunshot injury to the lower limb, which do not necessarily require amputation, are : — (8.) Fractures in the middle of the leg, unless tlie arteries are destroyed, or the injuries involve the neighbouring joints. (9.) In the case of the ankle-joint, if the posterior tibial artery and nerve have escaped injury, and if the bones be not extensively com- minuted, an attempt may be made to save the limb. (10.) Respecting the tipper limb : — In gunshot injuries of the shoulder and elbow joints, provided the main blood-vessels and nerves are not involved, excision may be practised with a fair prospect of success. Thus, in 14 cases of excision of the shoulder- joint, by M. Baudens, as performed for gun- shot injury, 13 were successful. During the Crimean War also, Mr. Thornton states, that of 12 cases of shoulder-joint excision, 2 only were fatal; and in 17 of the elbow-joint, only 2; while 5 partial excisions of the joint were all of them successful. In the Russian army, we gather from the report by Messrs. Mouat and Wyatt, that of 20 elbow- joint excisions, 15 recovered. (11.) Gunshot wounds penetrating the wrist, unless accompanied with great laceration, do not necessarily demand amputation, (12.) Gunshot wounds between the phalanges of the fingers or toes, may also be exempted. (13.) Before proceeding to any amputation on account of gunshot injury, great care should be taken to discover whether the patient may not be otherwise mortally wounded. In duly considering whether amputation should be primary or GUNSHOT WOUNDS. 515 secondary — to give tte limb its chance — the large proportion of un- favourable or fatal results of secondary amputation, must ever be taken into account. During the siege of Sebastopol, there were 3000 ampu- tations, among 80,000 wounded Russians. Of the primary amputations of the upper extremity, of the lower and middle third of the thigh, of the leg, and foot, about one-third recovered ; but of all the secondary amputations, more than two-thirds died. These results are more than corroborated by those in previous wars. Thus, primary amputation was successful in three-fourths of the cases, under Larrey, during- the H"apoleonic Wars ; whereas, of 300 secondary amputations, reported by Faure, after the battle of Fontenoy, 30 only were successful. In the Peninsular War, the loss after secondary amputations of the upper extremity was, as compared with the primary, as 12 to 1 ; and of the lower extremity, the loss was three times as great. As the result of a very complete statistical inquiry, Dr. Stone, of the Bellevue Hospital, New York, arrives at two conclusions : — That, with regard to the upper extremity, primary amputations are to be preferred, both in military and civil practice, being more successful than secondary in both ; and that in the lower extremity, primary amputations are three times as successful as secondary, in military practice. (N.T. Jotirnal of Medicine.) Comparing amputation, both primary and secondary, with no amputation — an attempt to save the limb — it would appear that the risk of failure or the relative mortality is at least equal ! This conclusion is supported by Bilguer, and by Malgaigne's experience in Poland, where — in an army of 80,000 — after amputation of the lower extremity, not one case survived. Immediate amputation — • without any delay, if possible — offers the advantage of performing the operation in the absence of shock. This favourable opportunity would appear to be due to the elation of the soldier " while in heat and mettle," as Wiseman suggested ; and the beneficial influence of this state has been recognized by Pare, Larrey, John and Charles Bell, Hennen, Guthrie, and other Surgeons of experience ; and which was verified by not a few instances during the Crimean campaign. Hamilton concedes the advantage of immediate amputation in some cases of severe injury to a limb ; as when there is uncontrollable or recurring hgemorrhage, or if there be intense or irrelievable pain, from displaced spicule of bone which cannot be extricated ; and that this early period of operation will always be suitable for all the smaller amputations, as of the fingers and toes. Intermediate amputation — in tbe period between that which is either primary or secondary — is now generally acknowledged to be the most unfavourable time ; that interval not being safer than within the first twenty-four or thirty-six hours, when shock has passed off — the period for primary amputation ; but which is succeeded by congestive infiltration or acute inflammation ; and the consequences of which in suppuration and exhaustion are apt to render secondary amputation so disastrous. The seat of amputation should always be guided by the cardinal rule of preserving as much of the limb as possible, having regard to the nature and extent of the injury, not only for the formation of a more useful stump, but also in relation to the safety of life. The nearer to the trunk, the greater the danger of amputation for gun- shot injury, in common with other injuries, and especially when the lower extremity is submitted to the operation. Thus, amputation 516 SPECIAL PATHOLOGY AND SURGERY. through the thigh, in its upper third, is most fatal ; the death-rate rising to S6 per cent., or even higher. This "was alike the experience of English, French, and Russian Surgeons, during the Crimean War ; and it was confirmed by the results in the American War. Amputation through a joint, rather than in the continuity of a long bone, has yielded more satisfactory- results, both in regard to the stump, and the comparative mortality. The former is certainly a more convenient operation, where time is precious to the operator, as in service on the field- And looking at the results collected by Dr. Stephen Smith, it appears that in 86 cases of amputation at the knee-joint, 49 recovered, and 37 died, showing a mortality of only 43 per cent. ; as compared with 64 per cent., after amputation in the thigh, during the American War, The method of amputation — whether by the circular operation, or by flaps — -is a question worthy of consideration, principally with reference to circumstances, relative to the operator and the patient after operation. Thus, in amputations on the field, and performed necessarily under the pressure of time, flap amputation is mox'e expeditious ; but if time permit, and the patient is likely to be con- veyed to some distance soon after operation, circular amputation Avill be preferable, considering that heavy, and perhaps swollen flaps, shaken by the motion of carriage, are apt to loosen and become gan- grenous. This difiiculty was experienced during the Crimean cam- paign, among the cases of amputation subjected to journey by land, and even when the patients were conveyed by sea, in the transports to Scutari. The general treatment, hygienic and medicinal, in relation to gun- shot wounds, is the same as, under similar circumstances, with regard to other contused or lacerated Wounds, Compound Fracture, and Dislo- cation. Hygienic measures are chiefly important, and they claim special attention in Military Camp Hospitals ; where, ovving to the contingencies of warfare, regimen, ventilation, and general cleanliness are more than usually liable to be defective. When antiseptic precautions and appliances are practicable, under the circumstances of Military Surgery, Professor Esmarch, of Kiel, gives the following directions for their efficient employment ; which, having regard to the importance of accuracy and fulness of detail in this method of Wound-treatment, I venture to append, in extenso, from that author's " Surgeon's Handbook on the Treatment of Wounded ia War" (trans, by H. H. Clutton, 1878). " The Listerian Pi'inciple of Antiseptic Dressing aims at keeping from the wound all sources of putrefaction, hovering in the air and clino-ino- to every object, or at rendering them harmless by antiseptic means, which should not, however, excite the wound to a septic suppuration. " (1.) Firstly, for Operations: the skin around the seat of operation, and everything which comes in contact with the wound, the hands of the operator and of the assistants, the instruments, etc., after previous careful cleaning with soap and brush, are disinfected by washing with a strong (5 per cent.) solution of carbolic acid. " (2.) During the whole operation, and at every change of dressing, the air in the neighbourhood of the wound is perpetually filled with a fine mist of a weak solution (2| per cent.) of carbolic acid. This is GUNSHOT WOUNDS. 517 accomplished by means of the carbolic-spray producer. During lengtby operations and dressings, the spray can be momentarily interrupted, if the wound is in the mean time guarded by being covered with a linen rag soaked in a weak solution of carbolic acid. " The sponges which are used at the operation must, after they are thoroughly cleaned and boiled, be kept in the strong carbolic solution, and before as well as during the operation, be squeezed out in the "weak solution. " To thoroughly clean bath-sponges, they must be first repeatedly squeezed out in hot water, then dried, and beaten with a wooden stick until they no longer contain any sand. Sponges which have been used, are freed from grease in a hot concentrated solution of soda. They are placed for twenty-four hours in a solution of permanganate of potash — 1 to 500, and again washed in clean water; then they are soaked in a 1 per cent, solution of the commercial salt of sub-sulphite of soda, to which is added 8 per cent, of the pure concentrated hydro- chloric acid, until, in about a quarter of an hour, they have become "white ; and lastly, they are again washed in clean water until they are entirely scentless. They must be kept in a strong (5 per cent.) solution of carbolic acid. Before being used, they are laid in a weak solution (2^ per cent.) of carbolic acid, and while in use they are constantly cleaned in this weak solution. " In the place of the sponges, the antiseptic balls can be used. They are balls of salicylic wool, salicylic jute, or salicylic charpie, tied up in salicylic gauze. " (3.) Wounds which have already been exposed to the air, and operation-wounds which at the operation have come in contact with infectious matter, must, before the application of the dressing, be disinfected by washing with the strong (5 per cent.) solution of carbolic acid ; this does not retard healing by first intention ; if sup- puration has already set in, a stronger disinfection "with 8 per cent, solution of chloride of zinc is required for thoroughly washing out the wound. " (4.) Every bleeding point is to be carefully ligatured with carbo- lized catgut, and the ends of the latter are cut oS close to the knot. After some time they are completely dissolved in the interior of the wound and absorbed. " To render the catgut antiseptic, it must lie for at least two months in a carbolic emulsion — 1 part of crystallized carbolic acid dissolved in 10 per cent, water, and 5 parts of olive oil, at a low temperature and without being shaken. On standing, a part of the watery solution separates from the emulsion, into which the catgut is not allowed to sink. To prevent this, a small stone or bead is placed at the bottom of the glass, and over this a glass plate, upon which the catgut rests. The latter begins to swell, becomes opaque, soft, and slippery, but later it again becomes transparent and as firm as silk. " (5.) The wound is carefully seivn with silver wire, or carbolized silk — uncoloured silk, which has lain for half an hour in a mixture of melted wax and carbolic acid. " (6.) Brainage'tubes, well perforated, and carbolized by being kept in a strong solution of carbolic acid, are passed into the deepest parts of the wound; and a careful compression is made upon the cavities of the wound by carbolized sponges, or pads of carbolized gauze, wool, 518 SPECIAL PATHOLOGY AND SURGERY. salicylic wool, or jute. These are tlie means used to prevent the reten- tion of the secretions of the wound. " (7.) In immediate contact ivith the sicrface of the wound is laid a piece of protective-silk, steeped in a weak carbolic solution, which protects the wound against the direct influence of the carbolic acid, and at the same time when the dressing is changed, it indicates by an alteration in colour — dirty-grey, from sulphuret of lead — whether decomposition has taken place. " Protective-silk is a fine green oiled silk, made waterproof with copal varnish, which contains lead, and overlaid with a fine layer of a mixture of 1 part of dextrine, 2 parts of starch, and 16 parts of a watery solution of 5 per cent, carbolic acid. This, together with the germs of putrefaction, which, perchance, are sticking to it, is again washed by dipping it in a weak carbolic solution immediately before its application to the wound. " (8.) Over the protective, a layer of carbolized gauze in eight folds is laid, which extends beyond the edges of the wound more than a hand's breadth ; between the seventh and eighth fold is placed a piece of mackintosh or varnished silk paper, which prevents the secretion from the wound penetrating directly thi-ough to the upper surface. The whole is fastened on with gauze-bandages. " The antiseptic gauze is prepared in the following manner: — Cotton gauze, cither bleached or unbleached, but containing no starch, is first placed for some time in a double-walled tin vessel, heated by boiling water or steam ; then by means of a large syringe it is sprinkled with a hot mixture of 5 parts of resin, 7 parts of paraflBn, and 1 part of crystallized carbolic acid, and must remain for twenty-four hours under a heavy sheet of lead in the hot tin case, so that it may be equally penetrated throughout with the mixture. The gauze is then taken out, and carefully kept till required for application in a wrapping of parchment or varnished paper. " (9.) The dressing must be renewed in the same way, as often as the secretions of the wound appear at the edges of the dressing, at first once or twice a day, later on every two or three days, and at last much less frequently. The dressing is to be changed as quickly as possible. The neighbourhood of the wound is cleansed with the irrigator and cotton wadding soaked in the weak carbolic solution. The cavity of the wound is not needlessly washed out. Only when the silk has become discoloured must it be disinfected afresh with the strong carbolic solution. " The drainage-tubes are changed after some time, or replaced by thinner ones, and as soon as possible left out altogether. " (10.) If it is undesirable or impossible to renew the dressing fre- quently, the double antiseptic dressing is applied ; the deeper layer of which consists of protective, and a compress, soaked in a solution of carbolic acid, which is fixed by a gauze-bandage. Over this come then the dry layers and the sheet of mackintosh. The deeper layer can remain for weeks, and is only moistened at each dressing with the carbolic solution. " (11.) In default of Lister's dry antiseptic gauze, Bardeleben's moist carbolic dressing can be used. Over the protective are laid many folds of gauze which has first lain for twelve hours in a strong car- bolic solution, then been squeezed out and kept in a fresh 1 per cent. MORBID CICATRICES. 519 solution of carbolic acid. As soon as tlie secretion from the wound penetrates anywhere to the surface, new layers of the moist gauze are put on." Other antiseptic appliances, which are noticed by Professor Es- march, do not differ in their preparation, or the particulars relating to their application, from the methods commonly employed in this country. CHAPTER XIX MORBID CICATRICES. Morbid Cicatrices are either failures of reparation in the healing of Wounds and Ulcers, or various conditions of its results, in the form of faulty cicatrices. They comprise : — (1) Deficient Cicatrix ; (2) Excessive Cicatrix ; (3) Depressed and Adherent Cicatrix ; (4) Pain- ful Cicatrix; (5) Ulceration, Growths, and Degenerations of Cicatrix. (1.) Deficient Cicatrix. — A thin, flat, shining, reddish, easily wrinkled and cracked scar remains, after the imperfect healing of a weak ulcer or scrofulous sore. Such a result de- Fig- 136.* pends obviously on deficient reparative power of cicatri- zation. Treatment. — Pencilling with nitrate of silver, sul- phate of copper, or other stimulant application, and protection of the surface from any external occasion of inflammation or injury, constitute the most pro- bably successful topical treatment. At the same time, the general health must be improved as far as possible, thus having regard to the constitutional causative condition. (2.) Excessive and Ex- uberant Cicatrix — Cheloid or Keloid Cicatrix. — An opposite condition to the preceding; this form of cicatrix is thick, more or less projecting, irregular, dense, and perhaps adherent. Con- traction of such a cicatrix is not an uncommon character, and the force thus exerted may be so powerful and long continued, as to pro- duce great displacement and deformity. This result usually follows cicatrization after a burn, particularly if it be deep and extensive. * Eoyal Free Hospital. (Author.) 520 SPECIAL PATHOLOGY AND SURGERY. Cheloid cicatrix is "well defiBcd, gradually rising, with a rounded border, and a smooth, level, or slightly convex (Fig. 136), or sometimes centrally depressed surface. Its substance is always tough and firm, becoming more so as it grows older. At first, u.sually more vascular than even a recent healtby scar, and having a floi-id or purple tint ; it gradiially becomes paler as it becomes harder, and at length resembles healthy exubei-ant skin. In point of structure there is nothing peculiar ; compact fibro-cellnlar tissue more or less completely developed or de- generate, and slightly vascular, is covered with a thin cuticle. The size of a cheloid growth is generally distinctive ; rarely more than half an inch in thickness, or more than half an inch in any direction beyond the extent of scar in which it gix)ws, the growth thus differs fi'om a fibrous growth of skin which it nearly resembles. Exuberant cicatrix mav arise from some local cause of irritation during cicatrization, or some more obscure cause of a constitutional character. The latter Avould appear to be the origin of this cicatrix ; considering its infre- quency as compared with the frequency of wounds and scars, and that many such growths may appear in the same individual, and reappear in the scars of wounds made for their removal. It occurred as the result of confluent small-pox, in a remarkable case under my observa- tion ; the face presenting a seamed cicatrix, having a trellis- work appearance. Cheloid cicatrix may supervene on a completely formed healthy cicatrix, and even long after it has remained so ; it grows slowly, and generally, after a long duration, ceases to enlarge or diminishes, and it is liable to degeneration and ulceration. Treatment. — Strong stimulants, applied repeatedly, have some effect in dispersing an excessive cicatrix ; apparently by inducing or favouring degenei'ation and disintegration of the already imperfectly- developed fibro- cellular tissue, and thus facilitating its absorption. Further growth may at least be retarded or prevented in like manner. Iodine paint and mercurial ointments will perhaps prove the most effectual of these applications. Adhesion of the cicatrix to subjacent textures and to bone, is best overcome by subcutaneous division, as was, I believe, originally recommended by Hancock. A cicatrix, hitherto intractable, will, when thus detached, contract, and not unfrequently close in rapidly. Contraction of the cicatrix, as after a burn, is more preventable than curable. Mechanical restraint by some form of con- trivance adapted to the situation and extent of the ulcer, and applied as soon as the eschar is detached, will perhaps prevent the effects of contraction. Counter-extension, by similar means, in the direction of contraction, will less surely overcome its effects. But it may be necessaiy to continue such resistance for weeks or months ; often taxing the ingenuity of the Surgeon, and trying both his perseverance and that of his patient. In accordance with pathology, the general principles to be here observed are the following :- — " That scar-tissues seem rather to adapt themselves by changes of nutrition to the external forces brought to bear on them, than to be merely stretched by them ; that, in however long a time, the natural course and tendency of scars is to soften down to a greater resemblance to the natural parts in both structure and relations ; and that they are of low vital power, apt, therefore, to waste or ulcerate quickly under irritation, friction, or pressure, and are thus removable by absorption." (Paget.) Cheloid cicatrix is removable only by excision, complete extirpation MORBID CICATRICES. 521 being necessary, and not even then a guarantee of non-recurrence ; but a recurrent growth of this kind is not more intractable than the orio-inal one. The tendency to recurrence was evinced to a remarkable degree in the person of a florid young woman, who had a cheloid growth over the sternum, to the extent of about four inches. (See Fig. 136.) 1 excised this portion of integument, cutting quite wide of the disease, but it returned in the cicatrix within a month, and appeared also in the scars left by the button- sutures used to approximate the edges of the wound. Two similar excisions subsequently were fol- lowed by the same result. Indeed, the growth was more exuberant, if not more tender or itching, after each such operation. When the first removal has failed, I think it better to leave the growth alone ; as cheloid often tends to die out. Plastic operations, planned according to the particular case, are available for the cure either of excessive or of cheloid cicatrix. The chief general rules for such operations may be thus stated : — That if the scar is to be removed, so as to bring healthy structures together for union in its place, no portion whatever of its substance should be left; that scar-tissues should not be used for the formation of flaps, or relied on for any speedy or sound union ; that if the scar or pai*t of it is to be included in any flap for sliding or transplanting, all the borders and surfaces of such flap intended for union should, if possible, be of healthy structure, and not themselves parts of the scar ; and that flaps should not be dependent on scar-tissues for their supplies of blood. (3.) Depressed and Adherent Cicatrix. — As the result of cicatrization in a scrofulous ulcer, especially, the scar is not unfrequently marked by a depression, which is adherent to the subjacent part. Mr. W. Adams has applied his well-known ingenuity to remove this deformity by the following operative procedure : — All the deep adhesions of the scar are set free, by subcutaneous division with a tenotomy knife, introduced beyond the depression. Then the cicatrix is raised, and the pouch everted and turned inside out, thus forming a prominence. This is maintained by means of two hair-lip pins, transfixing the base of the cicatrix, for three days. On removing the pins, the everted scar, which has become swollen and succulent, subsides to the level of the surrounding skin, without regaining adhesion. Some successful results, or at least improvement of appearance, have followed this operation. (Brit. Med. Journal, 1876.) (4.) Painful Cicatrix. — Commonly arising from adhesion of the subjacent nerves to the skin or bone, and not attributable to bulbous enlargement of their cut extremities ; the cicatrix of any wound may thus be painful, although most frequently that of a stump after ampu- tation. Usually, the cicatrix-tissue is sound, but the nerves are subject to constant irritation or inflammation, varying with the mobility and movement of the part. Neuralgic pain, of an excruciating and paroxysmal character, is due rather to some constitutional cause affecting a cicatrix, still healthy in itself. This condition may super- vene long after the cicatrix is completely formed, and has loosened from any subjacent adhesions in the natural coui^se of healing. Treatment. — Free subcutaneous section is almost sure to prove remedial, when the pain arises from adhesion of the cicatrix. It is readily accomplished by introducing a tenotomy knife from the centre of the part, which usually remains open as an intractable ulcer, and 522 SPECIAL PATHOLOGY AND SURGERY. sweeping round the cicatrix, to beyond its circumference. In this way I succeeded in permanently curing a painful, adherent cicatrix over the projecting head of tlie astragalus, after Chopart's operation. I found it necessary, however, to remove a portion of the bone, in order to bring the margins of the ulcer together ; and to divide the tendo- Achillis in order to prevent retraction of the stump and tilting forward of the astragalus, as was the case before the operation. The result was that the pain ceased and the ulcer healed over the stump, the tendon was lengthened by gradual extension of the foot after operation, and the man walked well on the flat of the stump to the ground. This result was the more noteworthy, considering that, as a crucial experi- ment, I had previously divided the tendo-Achillis AAathout any effect on the cicatrix. After amputation in the upper third of the leg, I have had recourse to subcutaneous section of the cicatrix, when adherent to the tibia. Neuralgic pain can only be cured, if at all, by consti- tutional treatment ; chiefly by quinine, and careful regulation of the bow'els. The topical application of aconitina will often temporaril}- allay this pain ; a gx'ain of the best preparation of the alkaloid to a drachm of lard, in the form of an ointment applied from time to time. (5.) Ulceration^ and other morbid changes, groivths and degenerations, affecting cicatrix-tissues, follow the same pathological laws as in other structui'es ; and are amenable to the same treatment, accordingly. CHAPTER XX. BUENS AND SCALDS. LIGHTNING. FROST-BITES. Burns and Scalds. — Structural Conditions, and Diagnostic Characters. — Formerly, burns were classified according to their different degi-ees of structural disorganization, as represented by inflammation, suppuration, sloughing, and ulceration. Fabricius Hildanus, Boyer, and Dr. J. Thomson observed only three degrees of disorganization ; Heister and Callisen recognized a fourth ; but Dupuytren * was dissatisfied with this ground of classification, which regarded only the intensity of the burns, while the nature of the parts affected, the textures injured or destroyed, were altogether disregarded. He therefore superadded this kind of classification, by distinguishing burns according to their various degrees of depth, from the surface inwards to deeper parts. Firstly. Erythema, or simple reddening of the skin. Secondly. Vesication, the cuticle being raised in blebs, filled with serum. Thirdly. Incomplete destruction of the skin. Fourthly. Complete destruc- tion of the skin, extending down to and involving the subcutaneous cellular texture. Fifthly. Conversion into eschars of muscles, nerves, vessels, and other soft tissues to within a variable distance from the bone. Sixthly. Charring and complete disorganization of the whole substance of the burnt part. Obviously, this classification recognizes not only the various degrees of disorganization, beginning with ery- * " Le9ons Orales de Clin. Chir.," 1832, tern. i. p. 423. BURNS AND SCALDS. 523 thema and ending with chaiTing ; but the various kinds of tissue, or anatomical differences, are also recognized as grounds of distinction. Thus may be euumerafced burns of the skin, and those involving the cellular texture, the muscles, nerves, vessels, and so forth. The distinctions laid down by Dupuytren, although still generally accepted, are, I conceive, practically useless. Deep burns, to the fourth, fifth, and sixth degrees, extending successively thi-ough tissues having very different anatomical characters, are not attended with correspondingly different degrees of shock; they undergo the same process of reparation by sloughing and suppurative granulation, and with equal probability of recovery. It should also be observed that, as the textures successively destroyed by deep burns serve very different functions in the animal economy, the relative importance of such burns is not proportionate to the ])]iysiological character and importance of the parts destroyed. Nor, again, is the Surgeon concerned with the pathologico-anatomical differences of burns. He estimates not the effects of heat on the body by observing the different degrees of dis- organization produced in the various textures — that this eschar is yellow and hard, and that is black and brittle — as the geologist or mineralogist would examine specimens of igTieous rocks. Superficial burns are most important, and in proportion to the extent of surface affected, but not necessarily destroyed structurally. The more superficial the burn, the more the skin alone is affected, if only extensively, the more urgent will be the constitutional disturb- ance, and the more dangerous is the burn. A negi'o employed at the Bains Yigier, in Paris, wishing on one occasion to warm his limbs, which were benumbed with cold during a rigorous winter, immersed himself in a bath heated to a high temperature. In a short time he experienced a general feeling of uneasiness, with acute pain in the skin. He was immediately withdrawn and carried to the Hotel Dieu, where he expired in thirty-six hours ! It is reasonable to suppose in this case, that although the water was heated to a high temperature, yet it was not at the boiling point, and that it acted only as a general rubefacient, without raising or destroying the cuticle ; and yet here was a burn of only the first degree, but very extensive, and therefore accompanied with a shock to the nervous system, so sudden and overwhelming as soon to have proved fatal. Deep burns, when not superficially extensive, are of comparatively subordinate importance ; their significance having reference generally to the remote consequences of such burns, by exhaustion from sloughing and suppurative discharge. Causes, and their Effects locally and constitutionally. — Heat applied to the body is necessarily the cause in all cases ; but it may have been either by fire, as by the clothes catching fire, the explosion of gun- powder or other explosive compound ; or by means of a hot or scalding- fluid, as boiling water or molten lead. The lesions produced in the former way are commonly designated burns ; in the latter way, scalds. This distinction is of practical consequence; burns not unfrequently resulting from the more prolonged application of heat, are deeper lesions, but perhaps of less superficial extent ; scalds resulting from the more momentary application of heat, are more superficial, but gene- rally they affect a larger extent of integument. Any adhesive fluid, as boiling oil, is a more persistent cause, and boiling perhaps at a higher 524 SPECIAL PATHOLOGY AND SURGERY. tempei'ature than water, it affects the tissues to a greater depth, as well as superficially. Some such fluids, clinging to the skin, run over a yet greater extent. Thus, then, scalds may be even more severe than burns, by the duration of the cause ; the amount of lesion, superficially and in depth, being perhaps equal. Explosive compounds are destructive, not only as causing bums of considerable extent, but also by the mechanical violence of their explosion, producing wounds which might be called burnt wounds, contused and lacerated. Grains of gunpowder, grit, mud, or other material may, moreover, be introduced as foi-eign bodies into snch Avounds. Wounds of this kind were well marked in the persons of the unfortunate victims of the " Clerkenwell Explosion," admitted under my care into the Royal Free Hospital. In all cases, the wounds were not only lacerated, and ingrained with dirt, as if portions of flesh had been gouged out by extremely forcible splashes of mud ; but the surface of these wounds and surrounding integument were apparently burnt and contused by the concussive atmospheric force of the explo- sion. All the wounds sloughed for some time, with a yellow, and freely suppurating surface ; healing very slowly by granulation. The cicatrix contracted, and assumed a seamed, puckered appearance, notably in the wounds of the neck ; just like the cicatrix presented by the healing of a burn. Burns and scalds immediately induce pain and shock, both of which are more or less severe according to the superficial extent of lesion. The symptoms of shock, affecting the nervous system and circulation, are the same as those arising from any other injury. But it is accompanied with congestion of internal organs ; the brain, lungs, and mucous membrane of the gastro-intestinal canal. The duration of collapse is variable, averaging about forty-eight hours — two days. Course and Terminations. — (1.) Shock, or Congestion, iproves fatal in many cases within the first two days ; and indeed, of all the fatal cases of burn, a great majority die in this period. Mr. Erichsen collected 50 fatal cases, and Mr. T. Holmes 75 such cases of burn ; the former, with a view of determining the organs most frequently affected in each degree and period ; the latter, with the special view of determining the mode and cause of death. Of the whole 125 cases, 35 died on the first or second day ; but as the great majority of those who are burnt to death are not examined, the proportion is much greater than this. Thus, of 119 other cases brought to St. George's Hospital, 79 died in this period. In 16 — Erichsen's proportion — of the 35 cases, the brain and its membranes were found congested, with more or less serous effusion into the ventricles or arachnoid, in 15 cases. The brain in the other case was not examined. In the remaining 19 cases, the brain was examined only in a few, but in 1 only was it healthy in respect of structure and vascularity. The thoracic viscera were congested in 8 of the 16 cases, and in 6 of the 19 cases ; the congestion having passed into demonstrable inflammation in 1 of the former, and in 3 of the latter ; thus making thoracic congestion in one-half the cases examined. The abdominal organs were somewhat less frequently congested; in 12 of the 16 cases, in 3 only of the 19. The mucous membrane of the pharynx and larnyx is extremely liable to be con- gested, apparently owing to the inhalation of flame or heated air during the accident ; of the 19 cases collected by Mr. Holmes, which died in BURNS AND SCALDS. 525 tHe first two days, some appearance of this kind was found in 13. The congestion in the pharynx very generally ceases abruptly at the com- mencement of the oesophagus ; in some rare cases passing down into the stomach. (2.) Reaction and Inflammation constitute the next, or second period ; extending from the end of the second day to the end of the second week. During this period, 25 out of the 50 cases died ; and 29 out of the 75 cases ; or 54 out of 125. The brain, lungs, and intestines are the viscera principally affected ; laryngeal cases usually die earlier. In the 25 cases, the brain was affected in 14 ; 11 being simple conges- tion, and 3 serous effusion. Of the 29 cases, the brain was not examined in the great majority ; in 3 it was congested, with effusion into the . ventricles or arachnoid ; but there was no evidence of true inflammation in any case. The lungs are more frequently affected. In the 25 cases, these organs were congested in 10 cases, and inflamed in 5. Of the 29 cases, inflammation of the lungs or pleura had occurred in 7 (in one of which, however, it probably existed before the accident), and con- gestion was noted in 5 others. The abdominal viscera— liver, spleen, or kidneys — are perhaps never affected as a consequence of burns, except by pyeemia. But the mucous membrane of the gastro-intestinal canal is usually inflamed, and probably ulcerated ; with, in some cases, evidence of peritonitis. Inflammation followed by ulceration of the duodenum is a notable occurrence, in the second period of burn, to which Mr. Curling first drew attention. In the 25 cases, ulceration of this portion of intestine was found in 6 ; in the 29 cases, in 4 of them; making a total of 12 such cases out of 54. In 3 more of the latter series, enlarged glands were found, in 1 of which cases the glands of the whole intestinal tract were enlarged. The duodenal ulcer is sharp-edged, and tolerably circular, as if a portion of the mucous membrance had been cut out ; it is very indo- lent, and usually situated just below the pylorus. Often there are two or three close together. Generally, the burn is on some part of the chest or abdomen. The earliest known period of duodenal ulceration is the fourth day ; on the fifth day, it was noticed in two cases, and in one on the sixth. It usually occurs about the tenth day. This ulceration is unaccompanied by general inflammatory symptoms, or by any special symptoms. Persistent vomiting and bloody diarrhoea are the most reliable. Perforation of the bowel may ensue, and death take place suddenly from haemorrhage, or from acute peritonitis. In one case, however, after death from other causes, at the end of eight weeks, a recent cicatrix was found in the duodenum. (3.) Suppuration and Exhaustion, or Inflammation still prevailing, represents the third period ; extending from the end of the second week to the termination of the case. The proportion of deaths at this period was 9 in the 50 cases — less than ^, and 27 in the 75 cases — more than |. Brain lesions are accidental, being limited to infantile convulsions and pyaemia. The lungs or pleurae are far more frequently congested or inflamed, and this condition is the cause of death. Thus, in 6 out of 9 cases examined in Mr. Erichsen's table, lesions of the lungs and pleurae were noted. In 4 of these, the appearances were distinctly in- flammatory ; in the other 2 there was congestion with effusion into the pleurae. Out of 27 of Mr. Holmes's fatal cases — during this period —the lungs were affected in 10, in 8 of which inflammation was the 526 SPECIAL PATHOLOGY AND SURGERY. principal cause of death. Here, generally, the burn is situated on the chest. The symptoms — physical examination being precluded — are sufficiently marked ; pain and oppression of breathing, hacking cough, and bloody expectoration. The gastro-intestinal mucous membrane is less frequently congested or inflamed, but ulceration of the duodenum is still not uncommon. Out of the 27 fatal cases refen-ed to, in 6, open ulcers were found in the duodenum ; iti 1 a similar ulcer had cicatrized, and in 1 the whole mucous membrane of the small intes- tines was inflamed but not ulcerated. In the other 9 cases referred to, no ulceration of the intestines was discovered. In 1 case only of Mr. Holmes's series, the jejunum and ileum were ulcerated, the duodenum being intact, Eeparation. — Burns and scalds heal by the same process of repara- tion as similar lesions otherwise caused. But some features in their career are peculiar. Ery- thema, produced by a burn or scald, tends to subside, like any other simple cutaneous inflam- mation; resolution taking place with desquamation of the cuticle. Vesica- tion also is resolved and terminates in like manner. Deeper bui'ns involving, successively, the skin, subcellular tissue, and other adjacent textui'es, are followed by sloughing, with the formation of eschars, abundant sup- puration, and then the healing process of granu- lation and cicatrization. But the granulations are exuberant, and the cica- trix is contractile. At first thin, of a purplish colour, and shining, stretched appearance, it immediately begins to contract, and contx^action continuing for some months, with great and increasing force, the cicatrix gradually assumes a seamed and puckered appearance ; drawing together the surrounding parts, and ultimately producing strange deformity. Thus, remarkable distortions of the face and neck (Fig. 137),or of the joints, are produced; and numerous remarkable deformities in all other parts of the body have not unfrequently been met with. Tetanus, pygemia, erysipelas, and other affections may be omitted in estimating the causes of death as from burn; they being, rather, acci- dental concomitants. The period of death varies. The most fatal period is, perhaps, the first week after the accident. Erichsen found that in 50 fatal cases, 33 terminated before the eighth day; 27 of these dying before the fourth day. Of the remaining 17 cases, 8 died in the second week, 2 in the third, 2 in the fourth, 4 in the fifth, and 1 in the sixth week. BUKNS AND SCALDS. 527 Prognosis. — The chief considerations whicli determine the prognosis of burns and scalds, are the more or less superficial character of the lesion and its extent, its situation, duration of the cause, and the age of the patient. The first two of these indications were sufficiently noticed in connection with diagnosis ; a superficial hvii extensive bum is far more unfavourable than a deeper and limited one. Hence, many- scalds are more fatal than burns. These indications, however, have reference to death principally by shock or congestion, in the first period, after burn; or by reaction and inflammation, in tbe second period. The depth of a burn — as compared with a scald — is significant with reference to suppuration and exhaustion, terminating fatally, in the third period. Deep burns are also unpropitious with regard to the part affected ; distortion and loss of function supervening. The situation of a burn more especially indicates the probability of visceral congestion. Thus, bums on the chest or abdomen are especially dangerous, in relation to congestion of the lungs or gastro- intestinal mucous membrane, respefctively. Burns of the scalp are not so ominous of cerebral congestion ; but tbey are specially unfavourable as regards the liability to erysipelas. The duration of the burning cause is unfavourable so far as it implies a considerable depth of burn and consequent exhaustive discharg'e. Age has scarcely any relation specially to the prognosis of bui'ns. Children are peculiarly liable to the danger of (secondary) visceral affections, cerebral, thoracic, and abdominal ; and more easily succumb to their influence than adults. Extreme age is, of course, always comparatively unable to resist the shock, and consequences of injury. . Treatment. — (1.) Shoch and the tendency to Congestion require immediate attention. Wine, brandy, or ammonia are the stimulants commonly administered to induce reaction. Warm tea may be suf- ficient, if the patient be young and the burn slight. Laudanum, in favour with some Surgeons, is, I think, undesirable, as being conducive to congestion. The patient should be wrapped in a warm blanket ; or immersion in a warm bath has been recommended, which also cleanses the surface of any charred portion of the clothes. (2.) Reaction, occa- sionally excessive, must be moderated by any gentle depletory measures, otherwise than by loss of blood. Mild purgatives, and the withdrawal of stimulants for a time, will generally reduce any undue reaction, as measured by the pulse and heat of the skin. It should ever be remem- bered that any temporary tendency to inflammatory symptoms readily subsides into a congestive tendency, affecting the internal organs. (3.) Suppuration and exhaustion are specially inevitable in the course of deeper burns ; although some exhaustion supervenes in all burns. The strength of the circulation should therefore be retained for this period, and maintained when it arrives. Stimulants are again required, with tonics, and the generous diet suitable in cases of profuse and prolonged suppurative discharge arising fi'om any cause. Local Treatment. — The primary indication is to protect the surface from exposure to the action of the air. Increased and continued pain and shock will thus be prevented. For this purpose, various topical applications have been employed. The degree or depth of burn will, I think, best determine the choice. Erythema, or vesication, cannot require any application more than simply protective. Collodion, mixed with castor oil, two parts 528 SPECIAL PATHOLOGY AND SURGERY. to one, may be brushed lightly over the surface ; or gutta-percha col- lodioD, undiluted, may be used. Two or three coatings will perhaps be necessary. Some tingling pain, which aggravates the Wrning sensation, soon passes off. " Carron oil," consisting of equal parts of linseed oil and lime water, also answers admirably. Lint, dipped in this thick, yellow, pultaceous fluid, forms a covering, at once exclusive of atmospheric influence and enaoUient. Deeper burns, destroying the cuticle, skin, and so forth, thus presenting an exuding surface, are perhaps more advantageously covered with some absorbent material. Flour, dredged over the sui-face, soon forms an encrusting artificial skin. This need not be removed until loosened by increasing dis- charge and separation of the eschar. The removal of this crust by the Sui'geon Avould be attended with great pain, and damage to the surface about to heal, and would aggravate the constitutional disturb- ance. But the possibly irritating character of this kind of dressing, ,and the impossibility of removing it, without these evil consequences, are serious objections to any such application. Cotton wadding wi-apped around the part forms a good protective covering, and aids in restoring the temperature of the part, a consideration of importance in proportion to the extent of surface involved; but this appliance alone is objectionable for the same reason as the flour-dressing. Carron- oil dressing, enclosed with cotton wool, will generally be found the best application. If the burn be extensive, one limb or part should be dressed at a time ; while the remainder of the body is still covered up. The ulcer formed by the detachment of the eschar, must be treated agreeably to the general directions already given with regard to Ulcers. Water-dressing, or a weak solution of nitrate of silver, will then be appropriate, according to the state of the granulations. Pencilling the marginal granulations with nitrate of silver or sulphate of copper, may be necessary, to repress their exuberant growth, and favour cica- trization. But of all stimulant applications, boracic acid is, I think, the best. By powdering the surface with the iDoracic crystals, the slow- healing ulcer from a burn may assume a healthy appearance, and heal most rapidly. I have seen a surface on the back of nearly a foot square, cicatrized completely within a fortnight. No dressing, in the whole course of treatment, should be reapplied unnecessarily; its removal being attended with great pain, and much increasing the constitutional disturbance. One of my earliest recollections as a student, was that of witnessing the shrieking of a patient during the dressing of a large burn over the thorax and abdomen, the muscles quivering and bleating by exposure to the air. Contraction of the cicatrix is the grand difficulty to be prevented or overcome. In anticipation of this event, Dupuytren recommended attention to position and the application of extension by counteracting mechanical contrivances, as soon as the eschar had become detached and during cicatrization. But any such adjustment of splints and bandages or other apparatus, will generally prove effectual only for a time ; the cicatrix contracting when left free, and at length presenting its usual appearance and the accompanying deformities. Billroth recommends extension, with continued pressure, by means of a compress on the cicatrix ; thus promoting the natural tendency of the contractile tissue to become atrophied, as in the treatment of strictured urethra by gradual dilatation. BURNS AND SCALDS. • 529 Operations are practised with the view of overcoming contraction. Division of the cicatrix has often been tried, but with little permanent success. Complete division is necessary, both as regards the extent and depth of the cicatrix ; any subjacent bridles must also be freely divided. All contraction having been thus overcome, extension should be main- tained mechanically during granulation and cicatrization in. the lines of incision. With every precaution, however, the new intervening cicatrix-tissue is apt to acquire the same evil disposition. I have had recourse to this operation in many cases, and repeatedly in the same case ; but with no more successful results than in the hands of other Surgeons. Removal of the cicatrix offers the advantage of getting into healthy or non-contractile tissue ; but the extent of surface, or the part affected, may render this kind of operation impracticable. Thus, the cicatrix can be excised, when of limited extent, as in the form of a contracted band. Or, destruction by sloughing may sometimes be resorted to ; this mode of removal being effected by means of a clamp-instrument, and which is especially eligible when the cicatrix presents in the form of a web, thin, and perhaps extensive. In the management of webbed fingers, for example, the clamp is applicable. It was introduced by Brodhurst in 1861, and has since been employed by Tamplin, W. Adams, and other Surgeons with successful results. In aid of either mode of dealing with the cicatrix, tenotomy may prove serviceable when tendons are involved. Another method of treatment consists in the transplantation, or perhaps the sliding, of a flap of healthy skin into the gap made by division and extension of the cicatrix, or the surface formed by ex- cision. Very happy results have been attained by Teale, Miitter, and James in thus ovei-coming the deformity occasioned by burns of the face and neck. Eversion of the lower lip into the chin, a disfigure- ment attended with slobbering peculiarly revolting, may be remedied by Teale's operation. The everted lip is divided into three equal parts, by two vertical incisions, each three-quarters of an inch in length, and carried down to the bone. These incisions are so placed that the middle or intervening portion occupies one-half of the lip. From the lower end of either incision, another is carried upwards to a point one inch above the angle of the mouth. The two flaps, thus indicated, are freely and deeply dissected up. The alveolar margin of the median portion is then pared. The lateral flaps are raised, united by twisted sutures in the middle line, and supported as on a base by the median flap, to which they are also attached by a few points of suture, leaving a triangular even surface to granulate. Gradual extension of the cicatrix from the sternum, and elevation of the chin, can be accomplished by means of a screw collar devised by Mr. James. Skin-grafting, according to the method of M. Reverdin, offers another resource — after division of the cicatrix, with extension — when the exposed surface has assumed the condition of a healthy granulating ulcer. The grafts, growing and spreading over the surface, may coalesce, or join the marginal cicatrization (Fig. 138). Care must be taken that the surrounding- skin be healthy, or the new cicatrix will partake of the contractile character of the burn-cicatricial tissue. Hence skin-grafting will generally be more successful after excision, than when the cicatrix is merely divided into healthy tissue ; unless VOL. I. 2 M 530 SPECIAL PATHOLOGY AND SURGERY. in the case of a bridle, wliicli, when severed, presents a sound surface, by extension. A cheloid or exuberant cicatrix should be dealt with in like manner, with a view to skin-grafting ; — by free excision, to provide a henlthy granulating wound. Diseased conditions of the cicatrix have received sufficient attention in this work, among Morbid Cicatrices, in general. Erichsen notices J, ,00 pai'ticularly a projecting red and glazed £^:.,.. ' ' cicatrix,lookingasif composed of amass fc^:.-^ :..■.•..:.::•:::,:;:::;„. ^ ^£ fm-^gfj^Jng gpailulationS SmOOthcd down and lightly skinned over. This warty cicatrix — observable after burns about the neck and chest, more espe- MFH&SBSIiBK^^^ cially — resembles cheloid growth, but is remarkable as being the seat of in- tolerable itching, not relieved by any external application. Large doses of jKmmM liquor potassiB mitigate this distressing ^^^^Km symptom. But, if small and narrow, the cicatrix maybe dissected out; if large, it does not admit of removal without risk of considerable hsemor- rhage, as the structure, though fibroid, is very vascular. Amputation is an operative resource unavoidable in certain external cases. Complete destruction, by charring, of the whole substance of a limb leaves no alternative; or, as a secondary operation, it may become advisable under circumstances, locally and constitutionally, analogous to those resulting from other forms of injury. Lightning produces effects in the direction of its course through the part struck, resembling the appearances of any ordinary burn ; but the shock may suspend the functions of the nervous system, partially or generally, without any marked appearances of burn, and may thus also kill instantaneously. A stroke of lightning affecting the brain, knocks down the in- dividual with loss of consciousness ; lasting from a few minutes to a longer period, in one case an hour and a quarter. Recovery shows that paralysis was suddenly produced, partially or completely ; and this state may continue for an indefinite period, The special senses are variously affected ; loss of sight, smell, hearing, and taste ; or, more rarely, exaltation or perversion of these functions have occurred. Haemorrhage from the mouth, nose, or ears sometimes happens ; and abortion in some cases, A remarkable effect is said to be produced occasionally ; the formation of an image, as if photographic, of neigh- bouring objects on the body, even on parts covered with clothes. Every degree of hum may be produced, and perhaps in the same person, from the slightest singeing of the hair, reddening or blistering of the skin, to the deepest charring. The course of lightning through the body is sometimes marked by reddish-brow^n lines on the surface, having a starred and radiated appearance. In any case, the clothes are more or less rent and burnt. Other incidental injuries have been found, but rarely ; such as wound, or fracture, particularly of the skull. The tongue was mutilated in four out of six cases of injury recorded by M. Bondin. The prognosis, guided by the same considerations as with regard to FROST-BITE. 531 Burns, is generally more favourable respecting the local lesion, which is often comparatively trivial, and also in respect to shock. But the sabsequent paralysis or other functional disturbance maybe a specially unfavourable condition, as consequent on a stroke of lightning not immediately fatal. Some persons seem to have 'premonitory symptoms of the approach of a thunderstorm. One such individual, within my own knowledge, a remarkably robust young man, is invariably troubled with extreme nervousness, headache, and an indescribable dread, compelling him to go to bed some hours before any apparent approach of a storm. How far this might be an unfavourable state of the nervous system is unknown. After death by lightning, certain appearances are worthy of notice. The attitude of the body may be that in which it was when strnck, or the body may be thrown to some distance from the spot. Rigor mortis, occasionally absent, is commonly present, and well marked, or even to an intense degree of rigidity, resembling the condition of a person frozen to death. The blood, sometimes coagulated, is usually singularly fluid, and continues in this state. Decomposition is some- times speedy, but often delayed. The clothes are generally burnt or rent, even when the body is intact. The Treatment of suspended animation from a stroke of lightning consists in artificial respiration, with warmth and stimulants to restore the circulation. Frost-Bite. — Cold, intense or long continued, produces effects analogous to those of heat. It may kill the part directly, a local destruction analogous to charring, and accompanied with depression of the nervous and vascular systems, analogous to shock ; or the part dies by the speedy supervention of gangrenous inflammation, a process of destruction accompanied with inflammatory reaction as the constitu- tional disturbance. Unlike heat, cold more frequently kills by its direct operation ; presenting the condition known as frost-bite. This local effect, moreover, frequently exceeds in importance the general depression of the system. The parts most liable to be frozen are the feet and hands, or the ears and end of the nose, which are most pro- minent and exposed to cold. But the cold which can be borne with impunity may be many degrees below zero, when the air is dry and still ; a cold atmosphere with moisture or the slightest wind will speedily freeze a part exposed thus to a further and sudden reduction of temperature. The symptoms of frost-bite are loss of sensation and power of motion in a muscular part ; and, the cii'culation becoming arrested, a remarkable pallor overspreads the surface, deadening into a stone colour, with stifiiness increasing to hardness, and even brittleness of the part, when quite dead. The constitutional disturbance arises principally from general ex- posure of the body to cold, under the circumstances of frost-bite. Langour, and an overpowering sleepiness, ending in stupor or coma, invariably supervene during prolonged exposure to severe cold, and may thus cause death, the part itself dying with the general failure of life. The whole body becomes frozen by more continued exposure, and thence the condition known as " frozen to death." A part frozen or frost-bitten is not irrecoverably dead. A whole limb may have become perfectly insensible and cold as ice, white and 532 SPECIAL PATHOLOGY AND SURGERY. transparent like marble, incapable of being bent without breaking ; and yet not absolutely dead. The combs of cocks and the ears o£ rabbits were frozen by Hunter, but these parts afterwards recovered. Leeches and frogs have been placed in the same state, and then re- stored to life. Cold-blooded animals, and parts of warm-blooded animals, when frozen, are, therefore, not dead, but asleep as it were, and can be aroused ; even as a seed is ready to sprout, awaiting cir- cumstances favourable to life. How long a frozen part may retain its susceptibility of life is uncertain ; but this is certain, that, unless re- action be gradual, the returning flow of blood is apt to become excessive — to pass into inflammation, speedily ending in gangrene. While, therefore, gradual and moderate elevation of temperature induces salutary reaction and restoration, sudden or immoderate accession of warmth will inevitably excite gangrenous inflammation. Both these unfavourable circumstances concurred after the battle of Ejlau ; and their disastrous effect is clearly shown by the record of Baron Larrey. During the three or four exceedingly cold days which preceded this battle (the mercury having then fallen to ten and even fifteen degrees below the zero of E«'CLE or AyxHEAX. — Commencing as a hard, vesicular or pustular nodule, this soon enlarges into a flat, oval or cii-cular, some- what spongy swelling, having a bi'awny circumscribed border ; the whole swelling being of a dusky, reddish-brown colour, and very painful, — burning, contracting, or throbbing. The size of this swelling varies from half a crown to that of a dinner-plate, and it varies also with the progi-ess of the inflammation. At length the skin over the flat surface yields in yellow or ash-coloured sloughs at numerous points, * Trans. 2Ied.-Chir. Soc, Edin., vol. i. CAEBUNCLE OE ANTHEAX. 535 forming as many small apertures, tlu'ougli which, a greyish or yellowish, sloughy and purulent, fetid discharge oozes, or starts up on the slightest pressure around; exhibiting a cribriform appearance never to be forgotten when once seen, peculiar to carbuncle. As sloughing of the skin advances, the apertui'es run together and coalesce, the cribriform surface disappears, and discloses the subjacent cellular texture, a quagmire of slough. Carbuncle is commonly situated about the shoulders or on the nape of the neck, where if large it gives a remarkable breadth to that part. Occurring sometimes on the lower part of the back or sacrum, it may form on the front of the chest or abdomen, occasionally on either extremity, and very rarely on the fore- head or face. One on the nose, seen by Sir B. Brodie, gave the most singularly hideous appearance, completely disguising any lineaments of the human face. Fortunately, carbuncle is usually solitary. Fever oi the typhoid character precedes and accompanies the swell- ing, and it becomes more marked as sloughing ensues. But there is also a notable derangement of the liver and other digestive organs, indicated by a yellowish complexion and brown furred tongue. The causes of carbuncle are, as to their essential or pathological nature, obscure. It is a disease of advanced years, or it appears in those whose constitution has broken down prematurely. It is also induced by habitual free living, without exercise. It is associated, not unfrequently, with diabetes mellitus or albuminuria ; and swellings of a carbuncular character are not uncommon in some infectious diseases, as typhus and typhoid fevers, and plague. Course and Terminations. — -Generally, the slough of cellular texture having been thrown off or removed, the cavity, often of considerable size, slowly heals by suppui^ative granulation ; and the patient's health isultimately regained, a marked improvement having taken place when the slough was detached. But the brawny induration remains for some time, and a puckered cicatrix permanently. Sometimes, however, the sloughing deepens as well as enlarging superficially ; and involving important parts beneath, or overwhelming" with prostration, thus proves fatal. A large carbuncle situated on the nape of the neck is especially perilous. Rarely, a carbuncle subsides siiddenly, and the person rapidly sinks, death occurring apparently from septicfemia. A remarkable instance of this kind is related by Sir B. Brodie in his well-known " Lectures." Carbuncle on the face is apt to speedily induce meningitis, attended with delirium, and death results from effusion in three or four days; a case or two of this kind having happened in Billroth's pi^ctice. The prognosis, in different cases, will be guided by the foregoing considerations. Treatment. — Preventive measures are said to be occasionally suc- cessful. In the earliest stage of the disease, while yet only " a small pointed vesicle on a hard, brawny base," observes Mr. Erichsen, its further progi-ess may often be completely arrested by opening the vesicle and rabbing its interior with a pointed stick of potassa cum calce or nitrate of silver. Later still, he has often seen the extension of a carbuncle prevented, and a cure effected, by covering it with a square of soap-plaster spread on thick leather, with a hole in the centre for the exit of discharge. I have had no experience of a carbuncle in this stage, nor of the preventive treatment accordingly. In 536 SPECIAL PATHOLOGY AND SURGERY. considering the appropriate curative treatment, the preservation of as much integument as possible, by the limitation of sloughing, with the relief of pain and constitutional disturbance, are primarily im- portant; and the discharge of slough subsequently is equally so. Early relief of tension fulfils the former indications, an outlet fulfils the latter. Timely, free incisions fulfil both. A crucial incision, carried through the slough and the surrounding induration, as Sir B. Brodie recommended, answers admirably. The period for making this double incision must be determined by due observance of both the purposes in view; always inclining to the considei>ation of reliev- ing tension. A free application of potassa fusa, after the bistoury, was advocated by the late Professor Miller, in order to at once form an eschar and thus limit sloughing. Poulticing until the slough is discharged, with the use of carbolic, chlorinated, or other antiseptic solutions, and then dressing according to the state of the ulcer, are the only applications ordinarily reqiiired. Subcutaneous section, as proposed by Mr. French, is another method of treatment, on the same principle ; the mass being divided crucially, or in various directions, in order thus to facilitate sloughing and discharge through the openings in the integument. A poultice is applied for this purpose. On the other hand, compression has been advocated, in the direction from the cu'cumference to the centre of the carbuncle ; a layer of soap-plaster on leather, having a central aperture, is applied, and then cross-strips of adhesive strapping. Lastly, non-interference is recommended by some Surgeons of experience, as a general rule, and especially by Sir James Paget. In his highly suggestive " Clinical Lectures and Essays," so many valuable observations are urged, and so persuasively, to show the inutility or positive harm of any active treatment genei^ally, that I should at once perhaps be converted from the error of my ways, if only I had seen as many illustrative cases. The constitutional treatment, medicinal and dietetic, much resembles that of phlegmonous erysipelas. Early recoua'se to stimulants, tonics, and a generous diet ; but with special attention to the state of the liver and digestive organs. Yet here w^e encounter the chief difficulties. Inappetency, nausea or actual sickness, and mal-assimilation, all conspire to defeat our alterative mercurials and effervescing salines, as well as our endeavours to coax the stomach with digestible and nourishing food. If any other disease, to wit, diabetes or albuminuria, be associated with carbuncle, such complication will further embarrass the treatment. According to Su" James Paget's large experience, comprising not less than two hundred cases of carbuncle, the con- stitutional treatment requisite is very simple : no special recourse to stimulants and tonics, with a supporting diet; but principally fresh air, without confinement to bed, and opiates to procure sleep or allay pain. Cerebral symptoms, ai'ising from facial carbuncle, must be met by the application of ice or cold lotions to the head, and mild con- stitutional measures repressive of inflammation. The mortality of ordinary carbuncle is about two per cent. ; a lower death-rate than in perhaps any other disease of equal extent and severity. Boil or Fdrdxculus. — In some of its external chai-acters, Boil con- trasts with Carbuncle. It is an inflammatory swelling, of a conical shape, softening as it maturates, but set in a hard base ; of a purplish- red colour, and exquisitely painful and sensitive. Its size is much more BOIL OR FURUNCULUS. 537 moderate than carbuncle, never perhaps exceeding the smallest swelling of that kind, about half a crown. Its smaller size and conical shape are diagnostic, even in an early stage. Enlarging slowly, matter forms at the apex of the cone, tipping it with a yellow colour ; this point bursts and discloses a subjacent slough or core of cellular texture. But the cribriform, flat surface of carbuncle is never seen, — another diagnostic difference. Like carbuncle, a boil is commonly situated where the skin is thickest ; on the back of the neck, the shoulders, or the buttock, the latter being a favourite spot of election ; occasionally in the armpit, or on the thigh. They always seem to choose the most troublesome situations. To increase the torment, they seldom come singly, but are gregarious or successive. Fever islmess, generally of a more sthenic character than with car- buncle, accompanies the formation of boils. The causes also, so far as they are known, somewhat differ from those of carbuncle. Usually occurring in earlier life, boils are also connected with a plethoric state of the system ; but they may denote an enfeebled condition, or they may appear in the sequel of febrile diseases. Their fitful character is often far less explicable. Active exercise by persons of sedentary habits, sea-bathing, the spring-time of the year, or some epidemic influence, will, perhaps, severally suffice to bring out a crop of boils. The treatment is that of carbuncle on a small scale. A poultice or warm fomentation, to promote suppuration and detachment of the slough, should be followed, if the latter does not take place, by a sufficient incision for expulsion of the core without any thumbing or squeezing. With water-dressing, the little granulating wound will then look after itself. Constitutional measures must have reference either to the plethoric or debilitated state of the system. Alterative mercurials and saline aperients, followed by liquor potassag and other alkaline treatment ; or quina, iron, and nitro-muriatic acid, the acid-tonic treatment. At the same time, a well-regulated diet, and state of the digestive process, must not be overlooked ; in weakly patients, the assimilation of nutri- tious food being promoted by a course of cod-liver oil. The BelM-hoil — so named, is not a ti-ue furuncular inflammation, but a morbid growth, affecting the skin and subcutaneous tissue, which subsequently ulcerates ; but is unattended, until ulceration has commenced, with any inflammation. Such is the definition given by Assistant-Surgeon Fleming, with regard to this " boil," in the Report of the Army Medical Department (1868). Nor is this affection pecu- liar to Delhi, but is common to other parts of India ; as occurring in Scinde, Lahore, and in many other localities. It appears to proceed from exposure to water ; and is probably due to the invasion of some species of parasitic organism — a distoma or other trematode worm, in an embryonic condition. According to the observations of Surgeon- Major Smith, and which are recorded in the same Report, the para- sitic origin of Delhi-boil is corroborated by the remarkable fact — that scarcely a single dog belonging to the British troops, when stationed at Delhi, escapes contracting the disease on the tip of the nose. " It commences — in the human subject — like a mosquito-bite, the little red spot increasing slowly in size, with a well-defined border, and raised above the surrounding skin. The growth continues to spread for two 538 SPECIAL PATHOLOGY AND SURGEEY. or three weeks or longer, and as it progresses it becomes more elevated and covered with tortuous dilated vessels. A vesicle at length forms at the summit, which discharges a pale-yellowish serous jfluid. Ulcera- tion then begins, and proceeds centrifugally until the whole growth is destroyed. The ulceration sometimes even extends to the neighbour- ing structures, and if the ulcer is situated near the eyes, nose, or lips, those parts will almost surely be destroyed or materially injui*ed, not excepting the cartilages of the nose. Dui-ing the growth of the tumour it has a transparent and shining aspect, and if examined with a lens, exhibits one or more yellowish spots, deeply seated about the centre of the tumour. If one of these spots be separated with a needle, a small circular yellowish body with a glistening capsule may be easily removed." Treatment is more promising in the direction of prevention, than of cure, until the growth is reduced to the condition of a simple ulcer. Chilblatn. — This is a local inflammation of the skin, of an asthenic type; and subject, sometimes, to regular recuii'ing attacks of congestion. It occurs in three degrees : — -(1) Simple congestion, attended by great itching, alternating with periods of extreme tenderness to external pressure ; (2) in the form of vesication ; (3) death or slonghing of the affected portion of skin, and perhaps of the subcellular tissue, forming an ulcer of an indolent character. The Symptoms of chilblain are obvious, in connection with each of these forms of this affection. Congestive purplish redness, with a tingling, itching, or burning heat or pain, which comes and goes, and some degree of swelling which has a shiny appearance. Recurrence of the symptoms seems to be determined by circumstances affecting the circulation, as exposure of the part to the warmth of a fire, or of a periodic character, as the stimulant effects of daily meals. The vesicated and ulcerated forms of chilblain present appearances which are sufficiently indicated by these terms. Certain parts of the body are most commonly affected ; the feet, hands, or both ; more rarely, the lobes of the ears, or even the end of the nose. The causes of this affection may be said to be, sudden variations in the external temperature, and in connection with the predisposing con- dition of a weak circulation. Hence, chilblain is liable to occur in persons of the leueophlegmatic temperament, or of a scrofulous consti- tution. Age has decidedly some influence ; it happens most frequently in young persons or children, and of both sexes ; and in adult females more often than in men. This liability generally passes off towards manhood ; and chilblains ai^e rarely met with in men over forty years of age, though in weakly women they may recur throughout life. Local causes affecting the free circulation in the part, should not be overlooked ; such as tight gloves, elastic bracelets and garters, or tight shoes, and the sitting posture, long continued, in cold rooms, and with the legs pendent, — as in the mistaken discipline of many a schoolroom. Treatment. — Preventive measures will consist in promoting the general circulation ; by an even temperature, particularly as regards sleeping and sitting rooms in cold weather, warm under-clothing, socks and gloves, with regular exercise ; and the removal of any restraint to the circulation in the exposed parts of the body. A generous diet, with small stimulant doses of opium and quinine, may likewise prove salutary. In the event of any chill, affecting particularly the feet and WHITLOW OR PARONYCHIA. 539 Fig. 139. hands, the circnlation should be restored very gradually by friction and warmth. Curative treatment must depend on the state of the part. When chilblains are unbroken, the congestive inflammation may be brought to resolution, by daily frictions with stimulating embrocations, as of camphor or tincture of iodine, and soap liniment. The old-fashioned remedy, brandy and salt, should not be despised. Intolerable itching sometimes admits of relief by lead-lotion, or opiate ointment. Vesicated chilblains may be protected by a coating of collodion and castor-oil varnish. Ulcerated chilblain must be treated by poulticing rendered stimulating by admixture with spirits of wine, or turpentine, until any slough separates ; and then the dressing may be resin ointment, or other topical appHcations, as for any other weak or indolent ulcer. Whitlow or Paeoxtchia. — An asthenic inflammation of the dense fibro-cellular tissu.e forming the pulp of the finger or thumb ; this part becomes acutely painful, tense and hard, swollen so as to give a globular appearance to the end of the finger, and of a reddish colour. The inflammation and swelling are always diffuse — unlike phlegmon ; and it tends also to suppuration and sloughing of the cellular texture, thus also differing in its termination (Fig. 139). Necrosis of the ungual phalanx is not an uncommon event, in prolong'ed cases. Whit- low occurs spontaneously in persons of a naturally weak or of a debilitated constitu- tion, affecting both young and old, and either sex. Occasionally, it seems to have an epi- demic character, appearing in many persons without any traumatic cause ; and perhaps at certain seasons, as in the spring. But it arises frequently from some local irrita- tion, as a puncture, scratch, or inoculation with some poisonous matter. Hence, it is more frequently met with in connection with certain occupations, as in cooks, washerwomen, and grooms. Whitlow involving the sheath of the tendons, is a more severe form of this affection. It is attended with greater swelling of the whole finger, spreading to the hand, which becomes much puffed and enlarged. Violent throbbing in the finger, and shooting pain up the arm, are soon • experienced ; but the redness is not intense, and the end of the finger, particularly if the cuticle be thick, and the palm of the hand hardened by work, may assume a dull- white appearance — soddened, perhaps, by poulticing*. Some inflammation of the lym- phatics, denoted by red lines extending up the arm, not unfrequently accompanies this form of whitlow, and with much low feverishness or constitutional disturbance. Diflhise suppuration takes place in the sheath of the tendons, speedily involving the palm, and may even spread up the forearm, under the annular ligament. The swelling has an elastic character, but distinct fluctuation is obscure. Sloughing ensues, not only of the cellular texture of the finger and hand, but also of the tendons and palmar fascia. Necrosis of the phalanges results ; or a matted state of the part, with a rigid and contracted state of the finger and perhaps of the palm, rendering the hand useless. 540 SPECIAL PATHOLOGY AND SURGERY. F:g. 140. Treatment. — An incipient whitlow may sometimes be subdiied by the prompt employment of repressive measures; by leeching, poulticing, and an elevated position of the hand. In the simple form of whitlow, a crucial incision into the pointed swelling of the pulp of the finger, should be made at an early period ; or even snipping the vesicated summit will give great relief. In the tendinous form of whitlow, an early and free longitudinal incision, in the middle line of the finger, must be had recourse to, for the relief of tension and swelling. The digital arteries and nerves are thus avoided, and the sheaths of the tendons should not be opened extensively, thus to prevent sloughing and consequent i-igidity of the finger. Suppuration or abscess in the palm must also be relieved by timely incision, observing not to wound the superficial palmar arch, which about corresponds with the middle indentation across the skin of the palm. Then well soak the finger and hand in warm water, and envelop the whole with a poultice. The nail, growing and elongating, appears large ; it often loosens, and should then be removed by evulsion with a small pair of sequestrum- forceps, or with Hilton's nail-forceps, which holds more firmly and with less damage to the matrix. As a foreign body, the nail would be a source of continued invitation. Any ad- herent portion need not be removed, but may be pared and scraped to relieve tension. A new nail will form, if the matrix be healthy ; probably taking a period of five or six months before it is completely restored. In tendinous whitlow, when the inflammation has siibsided, a paste- board splint will be advisable, to prevent con- traction. Necrosis of the ungual phalanx necessitates the extraction of this dead portion of bone ; leaving the pulp end of the finger and nail, which eventually form a somewhat hooked ex- tremity, tolerably sensitive and useful, and not so unsightly as a truncated end. Amputation will be unavoidable, in the event of more ex- tensive destruction, involving the middle or the first phalanx. And it is better to operate rather, apparently, too high, than too low for the sake of preserving the useless remnant of a finger; any portion of the thumb, however, will be most useful. The general health must be renovated by tonics and diet. Onychia is a form of ulceration, which commences about the matrix of the finger-nail. It usually arises from a pinch or crush of the finger-end, bruising the matrix or loosening the attachment of the nail. Shortly after this injury, the finger-end swells, and fluid is effused beneath the nail, which loses its natural colour, and becomes thin and flattened at the end, or more rarely curled up laterally. As the nail continues to grow, it turns upward, and exposes beneath it a very foul, fetid, and painful ulcer; while the finger-end becomes enlarged and bulbous, the integument hardened, shining, and of a livid red colour (Fig. 140). This affection occurs mostly, according to Mr. Thomas Smith's observations, in children under ten years of age ; but is by no means common. It is little prone to spontaneous INGROWN TOE-NAIL — 'COENS. 541 recovery; proceeding, perliaps, to necrosis of the ungual phalanx. The disease is sometimes named onychia maligna, as a specific ulceration. Treatment is, firstly, evulsion of the nail ; and this is accomplislied either by tearing it o^ff as a whole, by seizing it with a strong, narrow- bladed pair of sequestrum-forceps, or with Hilton's instrument ; or, by dividing the nail with a naiTOw-bladed pair of scissors, run up to the root of the nail, and then everting each half with, the forceps. Both. scissors and forceps must be applied with a firm hand. Local anaes- thesia will suflBce to completely deaden sensibility, the pain otherwise being excruciating. Pounded ice and salt mixed in a bladder is con- venient for this purpose, or Dr. Richardson's ether-spray answers equally well. Water- dressing or carbolic lotion may then be followed by arsenical solution, one or two drachms of the liquor potass^ arseni- calis to an ounce of water. Chlorate of potash and tonics, especially bark, complete the treatment. Syphilitic onychia, as a secondary affection, has already been noticed. Ingrown Toe-nail. — This is a not uncommon condition, among especially the working-classes ; it may occur on either side of the great toe-nail, but nxore frequently on the outer side. It is attended with considerable pain in walking, and gives rise to fungoid and sensitive granulations, overspreading and concealing the ingrowth, accompanied with a thin, fetid discharge. This condition is caused, apparently, either by overcrowding the toes in a narrow, hard boot, thereby thrust- ing the adjoining integuments over the side of the nail ; or, by the toe-nail having been pared away too deeply at the side, thus allowing the integument to overlap ; in either way, the nail grows into and includes itself in the overhanging fold of integument. Treatment con- sists in removing any cause of pressure, as a tight or hard-toed boot , and then endeavouring to correct the faulty growth of the nail. The pressure of the integument on the nail may be relieved by neatly inserting shreds of oiled cotton wool into the cleft by means of a probe or the back of a scalpel-blade. Then, when sufficiently separated, in the course of some days, the margin of the nail can be gradually raised ia like manner, until the natural state of the part is restored. Scraping the edge of the nail very thin sometimes affords sufficient relief ; or, by notching the free edge down to the matrix, the strip of nail, as it grows, may gradually overlap the body of the nail, and thus bring relief. An obstinate or deep ingrowth can only be cured by evulsion of the nail, as in the treatment of onychia. After any such mode of cure, the fungoid gi-anulations subside, or they may be repressed by pencilling with nitrate of silver or sulphate of copper. Zinc ointment may be applied during the healing. Corns. — -Local hypertrophy of the cuticle forms the common corn ; a flattened or conical swelling, hard or soft, often acutely painful — varying in this respect, according to pressure on the part, the state of the health, and even the weather. Such cuticular out-growths occur commonly on the feet, usually on the outer aspect of the end of the little toe ; or between the toes, and then always as a soft corn, ap- parently from maceration of the cuticle by warmth and moisture. Occasionally, corns form on the hands, and more rarely over the pro- minences of the elbows or knees. They are produced by intermittent pressure or friction on some naturally prominent part, as on the little 542 SPECIAL PATHOLOGY AND SURGERY. toe, by wearing a tight, hard boot. Eventually, beneath an old com, a bursa is apt to form, which, becoming inflamed from time to time by pressure, greatly aggravates the pain and inconvenience in walking. Suppuration is liable to ensue. Treatment. — Relief is obtained by simply removing the cause of pressure — wearing a loose shoe or slipper, or protecting the corn by means of a circular plaster of thick leather, having a hole in the centre over the corn. The common " corn-plasters " are thus used. Pencil- ling with nitrate of silver induces desquamation, and thus thins down the corn. Paring or scraping down the corn, previously macerated in warm water, will also ease the pain, as occasion requires. Extraction of the centre or core of the corn is the ordinary practice of chiropodists. But the full-groAvn corn often returns. Inflammation and suppuration must be treated on ordinary principles. Perforating Ulcer of the Foot. — Under this title has been de- scribed a narrow sinus, which forms, occasionally, in the foot — rarely in the hand — and which usually extends from the centre of a large corn directly down to bone, the latter becoming exposed and carious. Cloquet first noticed this form of ulcer in 1837. Nelaton describes it as commencing in a sero-purulent bleb on a thickened pad of the foot. This, when opened, discloses the subjacent dermis of a rose colour, and highly sensitive ; the spot ulcerates downwards into the cellular texture, thus forming a fistulous track, which deepens. But, usually, the track would appear to originate as a simultaneous, although gradual, disintegration of texture throusrhout the whole thickness of the part, from the skin to the bone. Sometimes, the orifice of this sinus is beset with an excrescence or exuberant granulations — like an ulcer ; but commonly appearing as a small opening, and with little or no discharge, the part is painless, unless under motion or pressure, and the track is obstinately indisposed to close. If closing for a time, it is apt to reopen again. The foot m.ay remain unaltered in appear- ance, although sometimes it becomes livid and swollen ; and it is often bathed with sweat, of an offensive nature. These characters of the part affected are associated with a considerable loss of temperature, and of sensibility — the foot, and even the leg, feeling cold and numb ; but usually without any notable loss of motor power. Ultimately, thei^e is some wasting of the leg, and perhaps the supervention of a chronic eczema ; thus plainly declaring the failure of nutrition. The chosen seat of perforating ulcer is over the metatarso-phalan- geal articulation, of the gr^at toe, or perhaps of the little toe. Less frequently, it forms in the heel. Commonly single, there may be two or three such ulcers on the foot;; or both feet may b,G affected, and symmetrieally> Women are fa*- more subject to the disease than men ; and it may be met with in children, seeming sometimes to evince an hereditary tendency. In a ease related by Nelaton, the patient was one of six brothers, of whom two were affected, and another had died of the com.- plaint. The six were alternately the subjects of it; the first, third, and fifth being free, the second, fourth, and sixth were attacked. The causation of this ulcer is primarily referable to pressure, or other injury of the part ; but the local malnutrition would indicate a marked predisposition to necrosis of tissue, apparently from deficient innervation, vaso-motor and trophic. This is coupled with angesthesia. WAETS OR VERRUCA. 543 Thus, tlie sensory and nutrient fibrils of the supplying nerves are diseased ; the motor fibrils being comparatively healthy. The evi- dence in favour of this neuro-etiology rests on both clinical and histo- logical observation. In some cases, symptoms of nerve-lesion appear long before the production of the ulcer ; and a similar ulcer often forms in connection with loco-motor ataxy, and other diseases of defective innervation. But the elaborate investigations of Mr. Savory * and Mr. Butlin, have demonstrated certain morbid changes in the nerves, traceable to the sensory and nutrient fibrils ; and consisting especially in thickening of the endoneurium, which normally is much thinner than the medullary sheath of the motor fibrils. The pressui^e thus exercised on the other fibrils is conceived to be the immediate cause in operation. The treatment of perforating ulcer hitherto has proved most un- satisfactory. Obviously, not amenable to topical applications, as for local lesions, what can the Surgeon do but cut the knot of difficulty by amputating the whole of the part affected ? Gouging out any bone which has become involved, cannot be curative ; nor will amputation of the foot probably suffice ; the only further resource being to carry the ablation higher up, beyond the region of anaesthesia, by sacrificing the leg ! Mr. Hancock, in his work on the Foot, narrates cases of successful amputation ; on the other hand, experience records cases, and not a few, where the disease reappearing in the stump, the opera- tion has been abortive, and has even baffled repeated amputation. Regarding the ulcer as an expression of nerve-lesion, itself of un- certain extent— perhaps even of central origin, and which is provoked by motion or other local irritation ; the only rational suggestion, at present, is the palliative of prolonged rest. Horns. — Remarkable forms of out-growth, consisting of fibrous or fibro-cellular texture, have been known to occur on various parts of the body, particularly the head or face ; and springing from the various sebaceous cysts, unruptured, or ruptured spontaneously or by accident. Such a horny excrescence has a crooked, tapering form, and a yellow ish- brown colour. It may be met with in middle age or advanced life, though very rarely. Similar kinds of out-growth may arise from the matrix of one of the toe-nails, especially the great toe ; extending from one to four inches in length, tapering at the point, and curved spirally like a ram's horn. This is simply a vertical elevation of the epithelial layers forming the nail. Excision completely from the base of the horn is the only cure. Waets or Veeruc^: are collections of overgrown cutaneous papillae, either completely ensheathed by an excessive production of scaly epithe- lium, or with the papilla isolated, each having only itg own natural cuticular sheath. They may form in various parts of the body, a common situation being the hand and fingers. Warts may arise spontaneously, apparently, or be congenital, or perhaps hereditary; but usually they proceed from some source of local irritation, as dirt or discharge, or from the handling of animal matter, in cooking or dissec- tion. They occur more often in children, and in girls who have the evil habit of masturbation, though the presence of warts on the hands should not alone beget an unworthy suspicion of such practice. Venereal warts, excrescences, or vegetations well illustrate the origin * Med.-Chir. Trans., vol. Ixii. 544 SPECIAL PATHOLOGY AND SURGERY. of warty growths from irritative discharge. Such and similar warts are undoubtedly contagious. Common warts come and go, sometimes, in an unaccountable manner. Treatment. — Escharotics may succeed in removing these often ob- stinate out-growths. The strong acetic acid, applied by means of a glass brush, or rod, is the most efficacious. Excision witla the knife or curved scissors, is the only other mode of cure. Htemorrhage from venereal warts is always free and persistent, but the oozing of blood may be stopped by swabbing with percbloride of iron tincture diluted, or bv light searing vsath Paquelin's cautery. But I have known these warts to be reproduced in the corona glandis, after thorough removal bv circumcision and touching the corona with the actual cautery. Elephantiasis. — This term has been used to signify at least two different diseases : the elephas of the Greeks, — known also as leprosy or lepra in the Old and New Testaments ; and the elephantiasis Arahum, as more commonly referred to. The one is a constitutional disease ; the other a local affection, seated either in the leg, and then known as Arabian elephantiasis — the Elephant-leg, or leg of Bar- badoes ; or in the scrotum — forming the elephantiasis scrotal tumour or Egyptian sarcocele, tropical bucnemia, spargosis, etc. Er,EPHAXTiASis Gr^C'ORUM. — Lepro.sy is described by Dr. Vandyke Carter, as making its first appearance in the form of a circular spot, having a raised margin, not scaly, and a depressed atrophied centre, which is insensible; this spot is also remarkably indolent, but of a spreading" character. This " leper-spot " is said Fig. 141.* to have the same relation to the development of leprosy that chancre — as the local or primary lesion — has to secondary or constitutional syphilis. But it would seem that the nerves of the leper-spot are primarily and essentially affected; and that the disease thence spreads along the course of the nerves, which become infiltrated with a peculiar deposit, so that they may acquire twice their natural size. My friend Dr. Druitt, who, during his late resi- dence in Madras, particularly studied Elephan- tiasis, thus observes of this deposit : — " It seems to invade the nerves as soon as they pierce the fascia, and they can often be felt under the skin, as rounded cords, perhaps nodulated ; deeper trunks are affected later. The consequences of this nerve-disease are the same as when nerves are irritated by injury, i.e. loss of sensation in the skin — lepra ancBsthetica ; atrophy of the skin, which loses its hair ; biillse of pemphigus, which often lead to deep ulcers ; atrophy of the muscles, and of the bones, beginning with those of the last joints of the fingers or toes. The bones first become thin and slender, then absolutely vanish by absorption, so that the finger-nails may be found on the ends of the metacarpal bones, the parts between them having disappeared (Fig. 141). This process of mutilation is often hastened by abscess and necrosis of the bones." The same author describes * Disease cf six years. Age, 20. Showing absorption of phalanges, second row, with portions of first and third ; leaving nails. Ansesthetic Leprosy. Native of Macao, China. (From case by A. F. Anderson, M.D., Singapore.) ELEPHANTIASIS GRJECORUM. 545 " the most hideous form of leprosy as the so-called tuhercular — lepra tuberculosa (Fig. 142) — in which there is an eruption of rounded, flat- tened patches on the eyebrows, ears, and surface generally, giving in bad cases an extraordinary animal aspect to the face ; the forehead swollen, the hairless eyebrows protruding, the ears projecting forward and of enormous size, the upper lip pouting and swinish, the nose first flattening and then falling in." These three forms_ of leprosy —skin, nerve, and tubercular leprosy — are often combined in the same person. Then, indeed, being afflicted with a spotted skin-eruption, or with crops of tubercles, disfiguring the features to a degraded expres- sion, while the arms and legs are crippled, the fingers and toes raw with fetid ulcers, affecting also other parts, and the ^^^- ^^^-^ body emaciated to a living skeleton — the confirmed leper was ever shunned, save by Him whose com- passion embraced all man- kind. Dr. Anderson, of Sin- gapore — whose original observations on Leprosy, as prevalent in the Straits Settlements of China, are illustrated by the photographs, some of which I have represented — gives the following de- scription of the disease, in its origin and course of development : — " The symptoms seem to have commenced very gradu- ally, and almost imper- ceptibly, with a prickling sensation in the face, which continued for some time without attracting much attention ; after a variable inter- val, the skin became tense and shining, beginning usually in the lobes of the ears, and extending to the sides of the face and nose. The lobes of the ears became pendulous, the alee of the nose enlarged and thickened, the nipples lengthened and flabby, and gradually the whole external surface of the person is covered in the one variety with tubercular nodules — L. tuberculosa, and in the other with a dry, scaly skin — L. aneesthetica. The tubercles are not very prominent nor well defined ; they are more diffused, and present more the appearance of an abnormal and irregular thickening of the entire skin, particularly over the face and abdomen. There is little pain or uneasiness, except in some cases, where there is a good deal of pruritus. The aspect of the face is much altered : there is a peculiar anxious expression, due not so much to the effect of pain as the deposit, causing distortion in the features ; the voice is changed, * Disease of one year. Age, 58. Face presenting the nodulated and otherwise characteristic appearance of contirmed leprosy. Native of Macao. Typical case of Tubercular Leprosy. (From Anderson.) YOL. I. . 2 N 546 SPECIAL PATHOLOGY AND SURGERY. having a hai'sli, rongli sound ; there is increased discharge from the nostrils, and, in fact, the whole mucous membrane is more or leas affected. A symptom of the disease, hitherto unnoticed, is a peculiar odour emitted fi'om the person affected, which is as distinct as that fi"om sraall-pox or typhus fever. The ulceration commences in the tips of the eai-s. then follows the toes and fingers, the nose, and other por- tions of the body ; these ulcet^tions are frequently unaccompanied by pain, even though sloughing takes place ; in others, again, the pain is very severe, especially at night ; nocturnal pains are also common in the bones. The whole system participates in the morbid symptoms ; the digestion is impaii'-ed, the nervous force deficient, and the circu- lation weak. Anaesthesia was never a very prominent symptom ; it occasionally existed, but limited to the extremities and over portions of the abdomen. When the ulcei-ation has progi^essed so far as to pi"event locomotion. diaiThoea takes place, emaciation follows, and, although the appetite is generally good to the last, the patient gradually sinks until worn almost to a skeleton, when death comes to give relief." The causes of leprosy are but Kttle understood. As a constitu- tional disease it may be ranked with scrofula and syphih's. It seems to be hereditary, although not manifested perhaps until adult life, from twenty to thirty years of age. The disease is probably con- tagious ; and it may be communicated by various articles of food, milk in particular, and especially the milk of the buffalo. Climate appears to have no restrictive influence on the development of leprosy, for it is found in cold latitudes, such as I^orway, as well as under the Equator ; but, owing probably to habits of life, as with regard to uncleanliness under a hot climate, the disease has ever prevailed in Eai^tern countries. From the period of the Middle Ages, leprosy has died out in tliis country ; having appeared in Scotland after it was extinct in England, and was last seen in Shetland. (Edin. Med. Journ., 1831 ; '* Histoiy of Lepers^" etc., by Sir James Simpson.) Treatnient. — ^Although leprosy is a very cJironic disease, continuing perhaps for many years, it does not seem to have any inherently fatal tendency, — the poor sufferer dying at last rather from some contingent affection, such as diarrhcea or albuminuria. On the other hand, the disease responds hardly to any remedial measures. Druitt informs us that at present there are three medicinal agents under trial, — the gurjun oil, recommended by Dr. Dougall ; the chaulmoogra oil, which Dr. Bhau-Dagi advocates : and the Xeradee muttoo. They are all oleo-resinous drugs ; and, mixed Tvith lime water, are used as embroca- tions, and administered internally, in the cases of lepi-osy at Madras. Bnt, according to the experience of Dr. Van Someren, of the Leper Hospital, and the opinion also of Dr. Macrae, cleanliness and a good diet are more efficacious than any other treatment. Elephantiasis Aeabum. — Sigfis. — In the form of the Elephant-leg, Arabian Elephantiasis is very readily recognized, from its remarkable resemblance to the foot of the elephant, and the marked difference of the diseased appearance from that of any other morbid condition. The human leg is converted into a greatly enlarged, hard, tuberous, thick- skinned mass, the integument often marked by transverse folds, and the whole having a dark colour and a broad base, like the foot of the animal with which it is compared (Fig. 143). Sometimes the pachy- ELEPHANTIASIS AEABUir. 547 dermatous surface is fissured, or beset -vrith small, pearly crusts : and it is liable to ulceration, spreading both in depth, and breadth.. The elephantine integament gradually loses its sensibility. Thus, in the developed state of this disease, the appearances are quite character- istic. In the early stage, the signs are those of chronic inflammation of the skin and subareolar texture ; the foot is reddish and tender, encased with a semi-solid oedema, which renders any movement of the part stiff and painful. But ^vhat is more significant, in some cases, is the appearance of reddish - purple, Fro. 143.* branching streaks, in the course of the lymphatic vessels, coupled with ten- der swelling of the proximate lymphatic glands ; as if a cer- tain amount of lym- phatitis and adenitis were associated with the oedema. Tben, also, there is more or less febrile disturb- ance in connection with the otherwise local affection of the foot and leg. The structural conditions in the de- veloped form of ele- phant-leg may be comprised under the general term hyper- trophy of the skin and its papillae, with the cuticle and the subcutaneous cellular texture, resulting from infiltration with a peculiar fibroid matter of a firm, inelastic character. Thus, the skin may become increased in thick- ness to haK an inch or more, and the papillse tufted ; the epidermis is simply thickened, and almost inseparable from the cutis : but the areolar texture under the skin is also the seat of the fibroid deposit, acquiring the same dense, inelastic consistence. A section from the surface presents a whitish, fibroid texture, associated perhaps in the areolar spaces with a thick gelatinous matter. Deeper still, the muscles are found to be atrophied or wasted, and to have undergone a pale-yellowish softening, — in short, fatty degeneration. The blood- vessels are thickened and enlarged, so as to bleed freely durin? life ; the nerves, enlarged in size, have a flattened, compressed appearance: and even the bones may h.ave become enlarged in circumference and * Typical case of Elephantiasis of leg ; showing also the same disease affecting scrotum, earlv stage. From photograph, of Elephantiasis Arabom, in a native of India, (W. Pye, F.E.C.S.) 548 SPECIAL PATHOLOGY AND SURGERY. denser in texture, or hvpertrophied. Bnt the most noteworthy change may be the hypertrophic condition of the lymphatics, associated per- haps with a beaded varicosity of these vessels. They are distended with a milky, lacteal fluid, like chyle. Microscopic examination shows that the fibroid deposit consists of immature fibres, combined with an abundance of lymph-cells, in various stao;es of development into fibres. Taking the clinical appearances of lymphatitis in concction with this increased production of lymph-cells, it would seem that such may be the essential and initial change in the pathology of elephantine disease; giving rise to a species of fibroid hypertrophy of the pai't affected — allied to a fibrous tumour of the skin and subareolnr tissue. In relation to the influence of climate, it should be observed that this form of elephantiasis is common in Eastern countries, such as Arabia, India, Asia, and Africa, but is rarely seen in any part of Europe. It is a disease more often of early or adult life than of old age; and it occurs more frequently in males than females. The course of this disease presents few changes to be noticed. Remaining probably for life, an elephant-leg may undergo no further enlargement during many years ; or it may grow steadily until it attain an enormous bulk and weight, amounting perhaps to fifty, seventy, or even one hundred pounds. But beyond the encumbrance thus oc- casioned, the general health is little disturbed, until ulceration takes place, anl a draining purulent discharge, under which the patient may sink exhausted. In regard to the treatment of elephantiasis, but little can be done. The appropriate remedies for chronic inflammation are the most hopeful. Thus, in an early stage, topical bleeding by leeches or scarification may have some beneficial effect. But as the solid oedema supervenes, this miist be reduced, if possible, by stimulant applica- tions ; as by encasing the leg with a blister, or by painting with iodine pigment, repeated occasionally. The combined advantage of pressui'e with stimulation may be tried by means of strapping with the em- plastrum ammoniacum cum hydrargyro ; and the various preparations of iodine and mercurial ointments maybe employed by inunction. An irritant plan of treatment has, however, the disadvantage of perhaps jirovoking ulcei-ation of the leg, the ulcer being obstinately indisposed to heal. Compression of the limb, simply by bandaging, might there- fore be more judicious. And, in any case, an elevafed position, for the relief of tension, should not be overlooked. These local measures may be aided by the constitutional influence of mercurials. No satisfactory results have hitherto attested the efficacy of thus attempting to arrest the growth of elephantiasis. It has been proposed to ligature the main artery of the limb — the femoi-al, in order that, by withholding the supply of blood, the hypertrophied part may cease to grow, and become atrophied. Bnt the free collateral circulation, owing to the enlarged state of the blood-vessels throughout the limb, would alone render the propriety of this operative procedure very doubtful. In the few instances where it has been resorted to, the results, I believe, have not been very encouraging. Tubercular Disease of the Foot. — Under this ambiguous title as to the pathology of the morbid condition, an affection of the foot has been described from the physical characters it presents ; chiefly, that of considerable swellinsr — to double or treble the natural size, or even TUBEKCULAR DISEASE OF THE FOOT. 549 Fro. 144.* lai'ger, and which is beset with tubercular prominences ; this condition being limited to the foot, as by a line of demarcation, without involving the leo- (Fig. 144). The colour of the skin remains unchanged. In time, the prominences become ulcerated ; the ulcers having hard, elevated margins, and tbe surface discharging a sanious fluid. Sinuses lead down deep into the substance of the foot. Only one foot is affected. The disease commences in the form of one or more hard lumps, the foot enlarges slowly, and the toes spread out, with the development of the tubercular appearance. It may continue for years, without any pain or constitutional disturbance ; until ulceration having supervened, the general health becomes impaired, and ultimately death, ensues from exhaustion, or not unfrequently from diarrhoea. Section of the foot shows some re- markable morbid changes, varying in different cases. Sometimes, the bones and soft parts are converted into a uni- form gelatinous mass. Or, the muscles being healthy, the bones present a honey- combed condition. But, invariably, numerous minute tubercles, like fish roe, are found between the muscles, extending from the bones to beneath the integument ; and nodules oF this material, often having a black colour, are encompassed with pus ; these nodules lying amid the soft parts, and also within the honeycombed cavities of the bones, especially in the os calcis and astragalus. Osseous spiculee are often found near the larger tarsal bones. The diseased condition always terminates at the ankle* joint. Tubercular disease of the foot seems to have been first noticed by Garrison- Surgeon Godfrey. {Lancet, June, 1846.) Subsequently, in 1854, Dr. Ballingale described the disease in the Transactions of the Medical and Physical Society of Bombay ; and, in 1859, Mr. Eyre, of the Madras Medical Service, again drew attention to this singular affection, with, a series of 114 cases. {Indian Annals of Medicine a,nd Surgery.) The disease is also specially referred to in Hancock's work on the Human Foot. From this source I have gathered the particulars of the above description. Dr. Godfrey's observations show that either foot, right or left, is about equally liable to this disease ; that class and occupation have no apparent predisposing influence ; and that, while the age of the subjects ranges between twenty and sixty years, the period between twenty and thirty is the time of life when it most frequently occurs. With regard to sex, males are far more liable than females, in the proportion of 114 to 4. A similar affection of the hands is noticed by Dr. Bidie, as occurring among fishermen on the north-east coast of Scotland. * Tubercular disease of foot, in female. Eoyal Free Hospital. (Author.) 550 SPECIAL PATHOLOGY AND SURGERY. Treatment has not proved successful, when directed by any constitu- tional view of an affection, which seems to be quite local. According to Dr. Aitchison's experience, the actual cautery is the most beneficial appliance. Under this treatment, the sinuses gradually became obli- terated, the thickened and tuberculated. skin resumed a healthy state, the ulcers cicatrized, and cure resulted in a month ; and without any return of the disease some months afterwards. Otherwise, the only remedy, to save the life of the patient, is amputation ; Chopart's operation being eligible when the astragalus and os calcis remain sound, but amputation higher up — in the leg — in generally requisite. In twenty-two cases submitted to operation, of which the permanent results were known. Dr. Godfrey found the other foot sound, and the patient's health good, after a period of some years had elapsed. Fungus-disease — Mycetoma, — Allied in appearance to the tubercular disease, fungus-disease of the foot, and occasionally affecting the hand, was originally described by Dr. H. Vandyke Carter, of Bombay ; his communications being published in the Transactions of the Bombay Medical and Physical Society, for 1860, and the two following years ; a case also is given, by the same author, in the Transactions of the Pathological Society for 1864 ; while, " all the essential pRrticulars " relating to this disease, are recorded by Dr. Carter in the British and Foreign Med.-Chir. Eevieiv, 1863, vol. ii. I have selected the latter, therefore, as an authentic description of the symptoms and pathology peculiar to mycetoma. " The disease makes its appearance by a small flattened, indolent tumour or lump, firm to the touch, little painful, and of slow growth. In the course of a few months, raised soft spots, or blebs, or vesicles, arise, which soon burst, and let out the fungus-particles ; sinuses thus are formed, and persist until all are expelled ; meantime the swelling enlarges, or fresh ones appear, and so the disease progresses. The commencement is often on the sole of the foot ; or in the hand, one finger may be first attacked." Thence, the foot or hand becomes much swollen, of a dark colour, and studded with numerous sinuses. The swelling is more or less globular, and involving the whole foot, or one side or part only ; the sinuses are numerous, and often clustered together about the sole, ankle, or dorsum of the foot, some being simple openings, others raised upon soft elevations or presenting a pouting edge. The appearance of the most recent is characteristic ; having a circular form, from one-third to half an incb in diameter, and gradually deepening towards the central aperture, from the re- moval of successive layers of cuticle ; white patches are frequently seen around. The size to which the swelling may attain varies ; in advanced cases, its circumference may be eighteen inches or more, and the foot is then hugely misshapen. Seldom does the disease extend upwards beyond the ankle or wrist; and it bears some resemblance to a chronic scrofulous affection. From caries, the disease may be dis- tinguished by the size of the foot, its globular form, and the number and appearance of the sinuses ; with the absence of a corresponding degree of constitutional disturbance, pain, or hectic, and the patient is generally of a scrofulous or syphilitic taint. But the character of the discharge is always distinctive. The fungus-particles blocking up the apertures of the sinuses, or washed away in the sanious fluid, have a blackish colour, or are pale and soft (Fig. 145), looking like mustard MYCETOMA. 551 or poppy seeds. Under the microscope the fungi are foand to be vegetable forms of growth, three varieties of which are described by Dr. Carter. A further description is given of the mycelium in a case of fungus-foot, by Dr. Tilbury Fox. {Path. Trans., 187L) Section of a foot thus afliected, shows also characteristic appear- ances. " The skin is greatly thickened, and the bony, muscular, and fibrous textures seem^ blended and intermixed with a glairy or tenacious slough-like material, of reddish or greyish tint ; globular masses of fungi also, are seen scattered about, which are either yellowish and of Fig. 115.* cheesy consistence (the so-called tubercles ?) or deep brown or black, and much firmer. The collections of fungi are lodged in spherical cavities hollowed out in the osseous cancellous tissue, or in the soft parts, frona which loculi, branching tubular canals pass off, frequently inosculating, and terminating either in closed expanded extremities or on the surface of the sinus-apertures (Fig. 146). ^'■'^- 1^6.t These canals, like the loculi, are lined through- out by a membrane easily separated from the bone or blended with the softer tissues, and they also con- tain fungus-particles im- bedded in the soft glairy material ; the function of these canals evidently being to conduct the fruits ? the textures and possibly under unyielding fasciae ; the latter symptom— faintness, arises partly from shock, by the pain of tension, and partly from the loss of blood in circulation, by its extravasation. Below the seat of aneurism, the limb assumes the same condition and appearance as when the aneurism was primarily diffused. The functional symptoms of aneurism are pain, loss of muscular power, and venous congestion ; or there may be special functional disturbances in connection with internal aneurisms. These do not occur until a rather late period of aneurism, and do not accompany it throughout its career. Diagnosis. — The physical signs of aneurism, already described, may themselves be absent ; as when consolidation in the sac has taker place. Or, if these signs be 'present, they may arise from other causes, other pulsating tumours. Such are vascular or erectile tumours, and certain tumours of a highly vascular character, as encephaloid cancer. The diagnosis will be determined by comparing the signs of these tumours with those of aneurism. Thus, an erectile tumour is soft and com- pressible, but slowly regains its former size when left free. And pulsation may be felt, but indistinctly, or of a throbbing character in the arterial variety of this tumour, and accompanied with a blowing bruit. An external erectile growth is further characterized by having a bluish or purple-red colour. From a consolidated aneurism, the growth is sufficiently distinguished by its erectile 1-4* character. Encephaloid cancer presents a tumour of soft consistence, and may be so vascular as to pulsate indistinctly, but it is not compressible. The situation of either an erectile or encephaloid tumour away from an artery, as in connection with boue, may leave no doubt as to the diagnosis from aneurism ; whereas, when such a tumour is h\ contact with an artery of sufficient sizeforaneurismal enlargement, the distinction may be impossible. A vascular, pulsating tumour may be unconnected with a large artery, and connected with some other structure — say, a bone — and yet, from their proximity, it may be most diffi- cult to distinguish between a pulsating tumour thus situated and an aneurism. This perplexity is expe- rienced when the iliac bone is the seat of a pulsatile tumour, — close to which lies the external iliac artery. (See Aneurism of Iliac Arteries.) Then, again, a non-pulsatile tumour or an abscess seated on an artery pulsates, and thus simulates aneurism (Fig. 154). In the instructive specimen here represented, a firm tumour encloses the left common carotid artery ; and in which the internal jugular vein and pneumo- gastric nerve are imbedded and compressed. Thrombosis had taken place within the vein, thus further obliterating this vessel. But the pulsation of any superimposed mass is not expansive and uniform over its whole surface, but merely a heaving up of the supposed aneurism ; the tumour does not subside if pressure be made on the artery above, although the pulsation ceases ; and it cannot be emptied by direct * Eoyal Coll. Surg. Mus., 1741. (Hunterian.) 586 SPECIAL PATHOLOGY AND SURGERY. pressure. It should, however, be remembered that these negative signs are equally true of aneurism which has undergone consolidation. In some doubtful cases, the tumour can be lifted off the artery ; thus plainly declaring its independence. There are also frequently present the characteristic signs of the particular kind of tumour or swelling. Diffused aneurism, unaccompanied with the pronounced signs of the circumscribed form, is more likely to be mistaken for a tumour. Or, when about to burst externally, having a small area of fluid tension, and red or purple discolouration of the integument, it thus far resem- bles the pointing of an abscess. A suppurating aneurism is occasion- ally met with, combining the characters of an abscess ; increased swelling being attended with more or less fluctuation, acute pain, heat, and redness of the integument. These symptoms are partly due to surrounding cellulitis. But an abscess may have communicated with an artery, by an ulcerative opening in the walls of the vessel ; thus converting the abscess into an aneurismal sac, as in the well-known case of pseudo-carotid aneurism which Liston opened for an abscess, by an error of diagnosis. From the pain of rheumatism, aneurismal pain may be distinguished by its intermittent character, and the presence of physical signs ; coupled, generally, with the number of pai'ts affected in the case of rheumatism. Neuralgic pain has also its differential, although less distinctive, characters. The history of aneurism will further aid in determining its diagnosis. If the tumour be circumscribed, by conversion from diffused aneurism, there will be the antecedent transition changes from that condition. If diffused, by conversion from circumscribed aneurism, there will be antecedent transition changes from that condition ; if originally dif- fused, there will be the antecedent fact of traumatic origin. Causes, Effects, and Course of Aneurism. — Aneurism commonly arises from an internal cause ; namely, a diseased or atheromatous con- dition of the artery, by fatty degeneration into oil-particles, with crystals of cholesterine, and subsequently calcareous degeneration ; affecting the middle or muscular coat of the vessel. In the fatty or atheromatous stage of degeneration, the inner aspect of the artery presents slightly elevated patches, yellowish and opaque, underneath the thin inner membranous coat ; in the calcareous stage, it becomes inelastic and brittle, and the patches assume the character of bony plates, consisting of mineral salts, the phosphate and carbonate of lime, but having little or no osseous structure ; lastly, the inner coat or lining membrane gives way, or disappears. The atheromatous portion of artery having lost its elasticity, and perhaps being partially ruptured, is disposed to yield to the pulsating action of the arterial wave-current, and expand into an aneurismal sac. Hence, the formation of idiopathic Aneurism, which is primarily circumscribed, and secondarily only becomes diffused, by rupture ; or eventually perhaps again circumscribed, by fibrinous con- solidation. Billroth notices inflammatory softening of an ariery as a rare cause of aneurismal enlargement ; thus far regarding aneurism as an occasional consequence of arteritis, and when of an acute and idiopathic character. The number of aneurisms which are liable to form, simultaneously or successively, in the same individual, is mainly determined by the extent of the degenerative changes. Fatty and calcareous de- generation not unfrequently affects a large extent of an artery, as the ANEUEISM. 587 aorta, or many arteries, as both popliteals and other vessels. Thence the production of more than one, and even numerous aneurisms, in the same person. Many illustrative cases are on record ; some of them by the older Surgeons. Donald Monro found six aneurisms in the same person ; three of the right femoral artery, one of the left femoral, and one of either popliteal artery. In another case, there was an aneurism of the femoral artery, and three more in the cavity of the abdomen. These instances are quite surpassed by others on trust- worthy observation. Sir A. Cooper found seven aneurisms in one individual; Pelletan counted sixty-three in one man alone, varying in size from that of a filbert to half a hen's egg; and, Jules Cloquet contributes a crowning illustration. A crop of some hundreds of aneurismal tumours, ranging from the size of a hemp-seed to that of a large pea, studded the whole arterial system. Predisposing Causes vary in their nature and degree of influence. Age is important, but apparently only as connected with those degenera- tive changes which the arteries, in common with many other textures, undergo as age approaches. Thus, according to the observations of Sir A. Cooper and Lisfranc, aneurism is most frequent about the middle period of life, or between the ages of thirty and fifty ; whereas ten years on either side of these ages makes a very favourable difference — tinder twenty, and after sixty, the disease being exceedingly rare. Certain Mood-diseases seem to have some predisposing influence. Syphilis, gout, and rheumatism have this reputation. Climate appears to possess an inexplicable predisposition ; aneurism being far more common in cold than in hot countries. The immunity of the East Indies contrasts favourably with the climate of Great Britain and Ireland. Occupation has an unquestionably important influence, and especially in connection with previous habits of life. Thus, any violent exertion, and by persons who are habitually sedentary, is conducive to aneurism. Hunting, pedestrianism, rowing and other athletic sports, may therefore have this tendency. Such pursuits seem to favour the production of aneurism, by repeatedly exciting a powerful action of the heart and compression of the arteries, in muscular exertion. Sex is thus associated with predisposing" causes ; aneurism occurring more frequently in men than women, in about the proportion of 8 to 1, according to Hodgson's table ; or nearly 11 to 1, in the cases of surgical aneurism, 154, collected by Lisfranc. The liability of different arteries to aneurism has been shown by Lisfranc to vary in the following order of frequency, as gathered from 179 cases, all spontaneous, but exclud- ing those of the aorta: — Popliteal artery, 59 ; femoral, in the groin 26, at other points 18 ; carotid, 17 ; subclavian, 16 ; axillary, 14 ; external iliac, 5 ; brachio-cephalic, 4; brachial, common iliac, anterior tibial, of each, 3 ; gluteal, internal iliac, temporal, of each, 2 ; internal carotid, ulnar, peroneal, radial, palmar arch, of each, 1. The external causes of aneurism relate to injuries of various kinds affecting the arteries, as an external wound, a fracture or dislocation, opening an artery ; or, a strain, blow, or bruise, inducing sloughing of the vessel. Hence the formation of traumatic Aneurism ; which is primarily diffused, and secondarily only becomes circumscribed, in favourable cases. The relations of origin and structural condition, in respect to Aneurism, are clearly represented in the following Table : — 588 SPECIAL PATHOLOGY AND SURGERY. Aneurism. Origin. r Idiopathic < \ Trau raatic Circumscribed — primarily. Diffused — secondarily. Diffused — primarily. Circumscribed — secondarily. The mode of origin in no way affects the signs and the diagnosis of Aneurism — there the structural conditions, circumsci'ibed and diffused, are the grounds of distinction ; but the etiology of Aneurism affords the most significant indications as to treatment. This will appear presently. While, therefore, I recognize the perceptible distinctions, circumscribed 'and diffused Aneui-ism ; I would supplement this dia- gnosis, by associating therewith that condition of the artery, whether of disease or injury, which is suggested by the origin of the aneurism, as idiopathic or traumatic. The effects and the Goitrse of Aneurism have both local and consti- tutional I'elations. Locally, circumscribed Aneurism produces pressure- effects. The sac of blood, fluid or semi-solid, pulsating and gradually enlarging, exerts a constant, expansive, and increasing circumferential pressure ; Fig. 155.* producing various functional disturbances and alterations of sti'ucture in surrounding parts, as ex- hibited by the pressure-effects of popliteal aneurism (Fig. 155). The current of blood, through the artery, being more and more obstructed, Ftc. 156.t or altogether inter- cepted, the veins be- come turgid, and oedema supervenes ; this venous congestion being increased, per- haps, by direct com- pression of the large companion veins of the artery, as the aneu- rismal sac or tnmour enlarges. The nerves become flattened into ribands, occasioning intensepain, of an ach- ing character or shooting along the nerves, but intermittent according to the variable conditions of the circulation and the adjoining relations of the aneurism ; or eventually, partial paralysis ensues ; the muscles waste, and the bones erode, without, however, the accompanying formation of pus, as in caries (Fig. 156). The bursting of circum- scribed aneurism, and its conversion into the diffused condition, takes place in two ways. By sloughing and rupture of the skin, or of the mucous membrane in certain internal aneurisms ; or by fissure of a serous membrane, if the aneurism burst into the peritoneum, the * From Sir A. Cooper. t Aueurism of abdominal aorta, at bifurcation. Destruction of bodies of verte- brae, leaving inter-vertebral fibro-cartilages. Univ. Coll. Mus., 2741. ANEURISM. 589 pleura, or pericardium. As in the pointing of an abscess, when and where an anearism has yielded and is about to burst externally, an area of inteo-nment becomes thinned and has a purplish hue, and a fluid tension can be felt there, — premonitory of what will suddenly happen. The haemorrhage, taking place externally or internally, is sometimes suddenly fatal, or it recurs again and again, and thus at leno-th proves fatal. Various special functional disturbances may be produced, according to the particular seat of aneurism. Thus, aneurisms of the aortic arch give rise to aphonia and cough, by pressure on the left recurrent laryngeal nerve ; or to dyspnoea and dysphagia, when the trachea and oesophagus are compressed. With diffused Aneurism, the functional disturbances — consequent on the circumscribed condition — may persist, or be relieved, temporarily or permanently. Yet with pro- gressive enlargement of the diffused tumour, other functional disturb- ance and alterations of surrounding parts supervene. Gonstitutionally, the influence of Aneurism varies with its structural condition. If cir- cumscribed, the tumour may induce some degree of inflammatory or sympathetic fever, arising from the local irritation ; but this is suc- ceeded by exhaustion, from prolonged pain and sleeplessness. If the aneurism be diffused, the same constitutional disturbances ensue ; and, when circumscribed aneurism becomes diffused, this alteration of structural condition is accompanied, as already stated, by more or less shock, which is due both to the sudden and severe pain, and to the equally sudden haemorrhage or loss of blood in circulation, the latter being attended with faintness or the symptoms of syncope. Terminations. — Aneurism may undergo reparation, or spontaneous cure, as it is termed ; or burst, and eventually prove fatal by syncope, from haemorrhage, externally, internally, or in both directions. Death may, however, result from fuuctional disturbance, induced by pressure, involving some important organ ; as in aortic, and other internal aneurisms. Less common modes of death occur, from gangrene — • consequent on pressure or rupture of the anenrismal sac ; or from embolism by the transmission of blood-clot. (1.) Circumscribed Aneurism is naturally disposed to undergo spontaneous cure. The essential nature of this process is coagulation of the blood, within the aneurismal sac ; for although coagulation therein may occur naturally under four or five different contingent circumstances, as modes of cure, they alike tend to thus obliterate the aneurism. The principle oi cure will be readily understood. Aneurism arises whenever the force and velocity, or the im^petus of the blood's motion through any given artery, is no longer counterbalanced by the elasticity and contractile force, or the resisting strength of the walls of that vessel. Coagulation of the blood within the aneurismal sac tends to restore this resisting strength, and is therefore propor- tionately conducive to the cure of aneurism. The details of this pro- cess are briefly these: — The blood continuing to flow thi-ough the aneurism, leaves upon the interior of the sac a thin layer of coagulum, upon which another is superimposed, and so on, forming a concentric laminated coagulum; the outermost portion of which, attached to the sac, acquires considerable firmness and resisting strength. This con- sists of distinctly laminated fibrin. (See Fig. 151.) It eventually becomes somewhat friable, and resembles boiled beef in colour. The portion of coagulum next in order has the consistence and appearance 590 SPECIAL PATHOLOGY AND SURGERY. of damson cheese ; while the innermost portion, in contact with the flowing blood, is semi-fluid, like currant jelly. I prefer this homely description of aneurismal clot appearances to the terms used by Broca ; the outermost or stratified and decolourized fibrin being called active, and the inner, passive clot-formation. By this successive deposition of coagulum the sac is gradually filled up to the level of the artery, which still remains pervious, the surface of coagulum exposed to the current of blood acquiring a smooth and membranous appearance. In a large artery, through which the blood flows with most force, coagulation within the sac alone may be the Avhole extent of spontaneous cure. Its external signs are : — gradual solidification , of the aneurism ; less and less forcible expansion ; the pulsation becomes that of a solid tumour ; and, lastly, the swelling cannot be reduced by pressure applied to the artery above, or by compressing the aneurism. In aneurism of an artery of the second or third magnitude, through which the cui'rent of blood flows less forcibly, coagulation advances from the sac into the vessel, which gradually becomes plugged up, above and below, with a coagulum, extending to the next important branch above and below the aneurism. This advance of coagulation is accompanied with the cessation of pulsation. Eventually the aneurism contracts and dwindles into a comparatively small solid swelling ; while the artery, to some extent, above and below it, is converted into an impervious fibrous cord. During this process of obliteration, compensation has been gi-adually made for the loss of the original supply of blood through the artery. The collateral branches above the unobliterated portion of artery enlarge with the additional flow of blood through them, and becoming equal to their extra duty, at length convey as much, or even more, blood than the aneurismal artery formerly supplied. The circulation is adequately restored, and nutrition efficiently sustained, by this com- pensatory supply of blood — the collateral circulation. Remembering the internal cause of idiopathic aneurism, the in- elastic or partially ruptured condition of a degenerated portion of artery, as already explained, and also the physiological fact that the coagulation of blood is favoured by rest, we at once perceive how any- thing which retards the flow of blood through an aneurismal sac tends to restore its resisting strength, and is therefore proportionately con- ducive to the cure of aneuiism. The same effect is produced by any- thing which otherwise favours coagulation of the blood within the sac. Firstly. The flow of blood may be retarded by a less forcible pro- pulsive power of the heart ; in which case coagulation is possibly induced without any co-operative condition incidental to the aneurism itself. The sac is gradually filled iip to its brim ; then, possibly, the artery is plugged, and finally obliterated. This is the usual mode of spontaneous cure. Such cases are recorded by Stanley,* with regard to an enormous aortic aneurism, which had become firmly consoli- dated ; by Petit,t respecting right carotid aneurism; by Baillie,J as to aneurism of both carotids; and by Desault,§ in connection with * " System of Surgery," edited by T. Holmes, 1862, vol. iii. p. 365. t " Acad. Roy. des Sciences de Paris," an. 1765. X Trans, of a Society for the Improvement of Med. and Chir. Knowledge, vol. i. p. 119. II Journ, de Med. de Paris, torn. Ixxi. p. 430. ANEURISM, 591 aneurism, of the popliteal artery, wMcli not unfrequently undergoes spontaneous cure at the distance of this vessel from the impulse of the heart's action, in the course of the circulation. Secondly. The flow of blood through an aneurismal sac may be retarded by a piece of clot dislodged from the sac, and washed into the mouth of the distal portion of artery, or impacted within it some distance off ; embolism thus taking place. This condition may be followed by gangrene, from sudden occlusion of the artery, without the simultaneous provision of a collateral circulation. Thus for aneurism by a natural mode of cure, another evil would be substituted. Thirdly. A piece of clot may be floated down to the aneurism from one higher up, or the retarded flow of blood above may induce coagulation in the lower sac. Fourthly. The flow of blood may be retarded by the aneurism over- lapping and compressing the portion of artery immediately above or below itself. This natural mode of cure has unquestionably happened in a few cases. It was known to Hunter, who witnessed it in more than one instance. Hodgson * gives the particulars of a case in which the femoral artery was obliterated above an aneurism of this vessel by compression between the sac and the femur. The aneurism remained stationary for twelve years, when it began to enlarge, and was attended with a dull pain after violent exercise. Then the tumour gradually increased ; and twenty years after its commence- ment, had attained an immense size, but no longer possessed any of the characters of aneurism. It had a firm fleshy feel, and was without pulsation. Eventually, sloughing exposed the interior of the sac, yet without hgemorrhage taking place. On post-mortem examination, the femoral artery above the sac was found obliterated to the extent of three inches. Obliteration from pressure of the aneurism heloio itself is a similar mode of spontaneous cure occasionally discovered. It is admirably illustrated by a specimen in the Museum of St. Thomas's Hospital. An aneurism of the femoral artery, just below the j^rofimda, descended in the form of a large long sac for several inches below its communi- cating opening, and completely compressed the artery, which was full of clot even into the ham.f Hodgson J met with a case in which the left subclavian artery, having a small aneurism at its origin, was obliterated by the pressure of an aneurism of the aortic arch. Fifthly. Coagulation of the blood within an aneurismal sac may be induced otherwise than by any occasion of a retarded flow of blood. Adhesive inflammation possibly, and certainly sloughing, obliterates the sac, and leaves the artery impervious. If obliterated by slouo-h- ing, the sac discharges a quantity of coagulum, which, extendino- as a firm plug for some distance into the artery, closes it. No heemorrhao-e ensues. An aneurism of the femoral artery, in one instance, and a popliteal aneurism in another, were thus cured. (Hodgson.) Guthrie § saw three cases of inguinal aneurism attacked with slouo'hino-, and one of them recovered. Several remarkable instances of spontaneous cure by closure of the * " Diseases of Arteries and Veins," p. 107. t " System of Surgery," Chelius, trans. South, 1847, vol. ii. p. 206. + Op. eit., p. 110. § " Diseases and Injuries of Arteries," p. 96. 692 SPECIAL PATHOLOGY AND SURGERY. sac alo7ie are recorded in Mr. Hodgson's work.* Not only anenrisnifl of the aorta, but also those of smaller arteries, e.g. the brachial and anterior cerebral, were thus effectually closed, without any obliteration of the aneurisraal artery. For similar instances, Avhere the aneurisms were due to unskilful blood-letting, the reader is referred to the works of Scarpa,t Petit. + Foubert,§ and Saviard.|| In an aneui'ismal dilatation of the whole circumference of an artery Fusiform or Tubular Aneurism— the cure by coagulation is just possible, only modified in a remarkable manner to meet the exigencies of the case. In one case, recorded by Sir A. Cooper, the femoral artery, from its origin to the extent of more than three inches, was dilated into a sac, wliicb was lined throughout with very firm layers of coagulum, having a fleshy appearance. But this deposition did not completely obstruct tbe passage through the sac ; for an irregular canal, in some places larger than the natural bore of the artery, still remained through its centre. The coagulum that formed the imme- diate boundary of this canal was more condensed than any other portion of the whole, and had a membranous appearance. Here, then, -while coagulation had effectually strengthened this important artery, its continuity was preserved by an adequate channel through the coagnlum. Only so much, and no more, coagulum had formed as was absolutely necessary to accomplish this twofold purpose. Aneurism sometimes terminates safely in another Avay; but, not implying the favourable course and tendency of this disease, it must be reo-arded rather as an accidental mode of recovery, by an einl occur- rence, than as a mode of natural cure, although no assistance is given by art. I allude to the bursting of an aneurism under a tight fascia, or other resisting structure, and compression of the sac and artery, even to obliteration, by the extra vasated blood. One example of this kind is related by Sir A. Cooper. An aneurism of the femoral artery, -just below Poupart's ligament, having burst, the thigh became enor- mouslv swollen. For three days afterwards, pulsation was perceptible over the aneurism. Then, however, it ceased, and the size of the limb be^an to diminish. At the end of four months, the aneurismal swell- ino- had considerably subsided ; the patient could use his limb, and in less than six months he quitted the ho.spital. Subsequently he died from the rupture of an abdominal aneurism, and ^o.5f-?nor/er>z, examina- tion showed that the femoral artery w^as obliterated by the pressure of the large quantity of blood effused. Another mode of accidental recovery through a circumstance itself morlid, is by the pressui-e of an aneurism of a neighbouring artery, or by that of a tumour not aneurismal. Liston mentions the instance of a subclavian aneurism, which on dissection was found solidified by the compression of another aneurism springing from the innominate artery. (2.) Dijfused Aneurism, when it remains in this condition, runs the course already indicated by its operation as an internal cause of local and constitutional disturbances. The tumour progressively enlarging even to an enormous size, and ultimately bursting, externally, inter- * " Diseases of Arteries and Veins." 1815. t "Treatise on Aneurism, " trans. Wishart, p. 351. + " Mem. de I'Acad. Roy. Sci. de Paris." 1735. II " Mem. de I'Acad. Eoy. Chir.," t. ii. p. 535. § " Joum. des S9aTans." 1691. ANEURISM. 593 nally, or in bofh direcfcions, tlie career of such aneurism tends inevitably to further and fatal hgemorrhage. Duration of Aneurism. — This would seem to be regulated chieflj bj the force of the circulation, the proximity of the aneaiism to the heart, the size of the neck of the sac, and its direction relatively to the current of blood, and by the coagulating power of the blood. Rest, and the mode of treatment, will further affect the duration of aneurism. But the course of all aneurisms is generally slow ; extending to a few months, a year, or possibly several years. In one extreme case of femoral aneurism recorded by Hodgson, the period of its duration was twenty years. Prognosis. — The prognosis of Aneurism shoiild be determiaed mainly by a due consideration of the persistency, or otherwise, of its causes. Degeneration of structure, affecting the coats of an artery, implies the loss of that adequate resistance and resiliency to the current of blood, which having given rise to Aneuiism will also perpetuate it. The extent to which degeneration usually affects the arterial system, more than one artery being the seat of this destructive change, is an additionally unfavourable consideration. Hence, a single idio- pathic aneurism always sug'gests a suspicious prognosis. Traumatic Aneurism sug'gests an unfavourable prognosis, only in proportion as the aneurismal swelling is progressive. The conditions which mainly regulate the duration of aneurism are obviously important, as persistent causes in regulating its dilatation and progress. In so far as these conditions are discoverable during life, their consideration will com- plete the prognosis. Special aneurisms are subject to particular conditions which determine the Surgeon's judgraent respecting their course and issue, as in the case of internal aneurisms. Treatment. — Remedial measures — hygienic, medicinal, and opera- tive — should be entirely responsive to the natural or spontaneous cure of aneurisin. The ordinary mode in which natui^al care takes place is by retardation of the current of blood through the aneurismal artery, sufficiently to induce coagulation and the deposition of lami- nated fibrin within the sac. i. As conducive to this end, the primary indication of treatment is rest, prolonged rest, of mind and body. Position is an important adjunct, by taking off the force of the arterial current. The recumbent position will be most suitable for aneurism in any part of the body, the patient not being allowed to raise himself once from the bed during a course of many weeks. Gradual starvation and depletion, to diminish the quantity of blood in circulation, and to reduce the force of the heart's action, have some remedial influence ; but only within judicious limitations. The pulse should be maintained a little above 60, and at an equable rate. Farinaceous, rather than animal food, a sparine- proportion of liquids to the smallest quantity which can be tolerated, and total abstinence, if possible, from stimulants ; such are the chief features of the diet to be observed. That which was recommended by Bellingham answers to this description. It consisted of two ounces of bread-and-butter for breakfast, two ounces of bread and the same quantity of meat for dinner, and two ounces of bread for supper, with a little milk and water, occasionally, sipped in small quantities. Depletion by watery purgatives is preferable to blood-letting ; and should the latter be resorted to, it is, in Sir Thomas Watson's VOL. I. '> o 594 SPECIAL PATHOLOGY AND SURGERY. judgment, remedial only so far as it reduces any excessive force of the circulation. The small and repeated bleedings practised by Valsalva, may be beneficial in some cases ; but certainly not when pushed to the extreme he recommended; syncope, whea the patient attempted to stand, or even on rising in bed. Laxative aperients have also the advantage of preventing any straining effort in deftecation. Respect- ing medicinal measures for controlling the heart's action, I have no authentic information to offer. Aconite — Fleming's tincture — in doses of two or three minims, may be given every three or four hours, watching its effects. Narcotics may be administered to relieve pain and procure sleep, and thus maintain a tranquil state of the patient. Iodide of potassium has found favour with some practitioners, especially in cases of internal aneurism — intra-thoracic and abdominal. Commencing in five-grain doses, the iodide may be carried up to thirt}^ g-rains, thrice daily. Having succeeded in lessening the force of the circulation, suffi- ciently to diminish the expansive pulsation of the aneurism, are there any known means of directly favouring the coagulation of blood, and the deposition of laminated fibrin, within the sac ? By increasing the quantity of fibrin in the blood and its tendency to coagulate — in short, by improving the plasticity of the blood itself, this indication may be fulfilled. Animal food, therefore, should now be substituted for fari- naceous, and in larger quantity ; but the same restriction, or nearly so, should be observed with regard to liquids, and particularly stimulants. This combination of measures, for lessening the force of the general circulation, and then supplying the fibrinous material for coagulation, constitutes the regime originally proposed by Valsalva and Albertini, and known also as the internal method of treatment. Pathologically correct in itself, it was wrong only in the extreme degree to which he carried it in practice ; but recently, the same method has been rectified and ably advocated by Mr. Jollilfe Tufnell,* and is specially commended by Mr. Holmes. f I have practised it, in conjunction "with the treatment of external aneurism by compression, in cases of popliteal aneurism. Certain local applications externally are said to aid the coagulation of blood within the sac, but their efficacy is doubtful. Ice enjoys the repute of being thus beneficial ; its constant or repeated application is, however, apt to endanger sloughing of the integuments. Its occasional use may relieve pain. But, for this purpose, the belladonna plaster, or an embrocation composed of equal parts of oil and of the strong tincture of aconite, form topical appliances Avhich, according to Mr. Erichsen's experience, afford much relief. ii. Mechanical, and Operative, resources ; obediently to fhe first mode of natural cure. In the event of an endeavour to reduce the force of the general circulation, and thus to favour coagulation in the sac, having proved unsuccessful ; recourse must be had, without further delay, to such local measures as may retard the force of the arterial cuiTcnt through the aneurismal artery, exclusively. Mechanical appliances for this * " The Successfal Treatment of Internal Aneurism." 1864. Also Med.- Chir. Trans., vol. Ivii. (1874). t "Lectures on the Surgical Treatment of Aneurism." Royal College of Sur- geons. Pub. in Lancet, 1872. ANEURISM. 595 purpose favourably contrast with any cutting operation. The former mode of treatment anticipates the necessity for oblitei'ating the aneu- risraal artery, and avoids also the danger consequent on any operative procedure for securing the vessel. (1.) Compression of the artery above the aneurism. This plan of mechanical treatment should be gaided by two principles. It is un- necessary to entirely arrest the stream of blood through the artery above the aneurism, and therefore unnecessary to obliterate the vessel by inflammation, in order to effect a cure. It is only requisite to lessen the force of the stream, and temporarily ; in order to give a fair start to the deposition of laminated fibrin, and contraction of the walls of the sac, and so at length regain the balance of resistance naturally offered by the artery to the pulse-wave of blood passing through it. A degree of compression just suflB,cient for this purpose, and applied intermittently for a few hours daily, will represent the kind and amount of assistance necessary ; instead of complete occlusion and by continuous pressure, which might lead to obliteration of the artery. This, the old method of compression, as employed by Dubois and Pelletan, has been judiciously superseded by the more conservative modification introduced by the Dublin school, and with which the names of Bellingham, Hutton, Tufnell, and Carte are principally associated. Compression is the means employed in either case ; but the old method was simply blind empiricism, the modern one is a strict imitation of the mode of natural cure. More recently, under the influence of chloroform, the requisite degree and duration of compres- sion has been maintained — or "rapid" pressure effected — in cases where this method of treatment would not otherwise have been tolerated. Thus, Mr. Mun'ay, of I^ewcastle, originally had recourse to anaesthesia, in conjunction with compression, for the cure of an abdominal aortic aneurism, and with a successful result in five hours ; and Mapother, of Dublin, cnred an ilio-femoral aneurism in like manner, — compression of the common iliac having been maintained, under chloroform, for four hours and a half. InstriiTnental Compression. — Various forms of Instruments have been devised for com- pressing an artery, above the seat of aneurism. The compressor used may be in the shape of the horse-shoe or Signoroni's tourniquet (Fig. 157) ; or that invented by Carte (Fig. 158), the advantage of which is that it provides an elastic and yielding pressure, instead of the unyielding force of the screw. Tufnell's compressor is constructed on the same prin- ciple, the pressure being maintained by a truss-spring. Other forms of instrument are more or less used : Hoey's clamp ; and Dr. P. H. Watson's weight-compressor. Before applying any compressor, the limb should be evenly bandaged, to prevent congestion of the vessels, as much as possible ; and the irritation occasioned by the pad of the instrument may be much prevented, by shaving and powdering the integuments of the part. Two instruments are often applied in different parts, alternately, in order to remove the pressure Fig. 157. 596 SPECIAL PATHOLOGY AND SURGERY, from the same situation. Thus, for the treatment oP popliteal aneu- rism, a compressor in the groin, and another in the middle of the thigh, raaj be altei-natelj tightened aud relaxed, as the pressure becomes painful to bear. But in transferring the seat of operation from one artery to another — from Fig. 158. the common to the super- ficial femoral, the col- latei'al circulation is also altered, — a disadvan- tage compared with the " one-arterj system of pressure," to which Mr. Walker, of Liverpool, has specially called at- tention. The degree of compressing force ap- propriate should be esti- mated by its effect in controlling the pulsa- tions in the aneurism ; it being only necessary to suspend them, with- out entirely arresting the transmission of blood. The total dura- tion of intermittent com- pi'ession requisite, may be determined by its ef- fect in promoting coagu- lation and consolidation of the tumour ; the period necessary for this purpose varying con- siderably, from a few days to some months. In 26 successful cases, collected by ^Lv. J. Hutchinson,* this period ranged between 60 hours and eight months ; its averag'e duration being 19 days. I have failed in arresting the enlargement of popliteal aneurism by compression, after a trial for two months ; and then having had recourse to ligature of the femoral artery, an uninterrupted recovery ensued in three weeks. iS^o medicinal treatment is indispensable to the completion of the process of cure, when thus induced by compression. If, notwithstand- ing the precaiition of shaving and powdering the part, pain be occa- sioned by the pad in such degree as to disturb sleep, then indeed opiates may be administered; but, in most cases, this inconvenience will be anticipated by proper management of the instrument. It is well to try it on gently at first, and augment the pressure by little instalments ; also to shift the pad a little, and, as Tufnell suggested, to lighten it slightly, so that when the patient has fallen asleep, the pressure may be renewed without awakening him. This plan of treatment being a faithful imitation of the process of natural cure by retardation of the passage of blood through an aneurism, it is not sur- prising to find that the anatomical condition induced is the same as that resulting from the unaided process. In both cases, the aneurism is solidified and pai'tly absorbed, leaving the artery pervious ; while * Med. Times and Gazette. ANEURisir. " 597 collateral branches proceeding from the parent trunk are enlarged, thereby contributing to. maintain the circulation and. nourishment of the limb below the seat of aneurism. Thus, during compression of the femoral artery, for popliteal aneurism, three arteries are observed, to undergo enlargement ; one passing over the centre of the tumour, another externally, over the head of the fibula, and a third, internally, along the inner margin of the patella. This observation, originally due to Tufnell, is corroborated by Mr. Erichsen. The statistical results which appear most worthv of credit, with respect to compression as practised in England, are those collated by Mr. Hutchinson from the Metropolitan and Provincial Hospitals. Of 70 cases, 46 were popliteal aneurism, and in 24 of them this treat- ment was successful. The remaining 22 cases had reference to the treatment by ligature of the femoral artery, as compared with com- pression. The experience of the Dublin schools is far more favourable. Of 25 cases collated by Bellingham,* in 1 only was the ligature sub- sequently resorted to. The only disqualification of instmmental compression for the treat- ment of aneurism is its impracticahility in certain parts of the body. It is almost necessarily restricted to the treatment of femoral and popliteal aneurisms. Direct compression of the aneurism was formerly practised, with the view of opposing the expansive force of the current of blood and consequent enlargement of the sac. But pressure thus applied, not being desigmed to check the force of the current through the aneurisraal portion of artery, was an unpathological mode of treatment ; and, more- over, it was apt to cause inflammation and sloughing of the sac. This modification, therefore, which was first employed by Bourdelot, and adopted by Guattani, Heister, and other Surgeons, not unsuccess- fully, at length gave way to compression on the cardiac side of the artery. Digital compression, or pressure Avith the fingers, may be con- veniently applied to aneurisms in situations ineligible for instrumental compression. They are chiefly those of the axillary, subclavian, and carotid arteries. In these situations, pressure with the fingers on the cardiac portion of the aneurismal artery, will aid the natural process of cure by retarding the flow of blood through the sac. The requisite continuance of compression is provided for, by having a sufficient number of assistants ; each, in turn, taking charge of the vessel before the previous one withdraws his finger, and observing to apply only that degree of pressure which controls the pulsations in the aneurism. In some situations, where the artery lies deep, or is not accessible, as in the third part of the subclavian, pressure may be effected by means of a hammer furnished with a spring pad. A quarter of an hour to twenty minutes will be about the time each assistant can maintain digital compression without fatigue, but by the addition of a three or four pound weight on the finger, steady pressure may be continued for as long again. Having maintained compression, in this way, for a few hours, the patient may be advantageously allowed a period of intermission, followed by its reapplication, and so on alternately. The total duration of these periods necessary to complete the cure, varies of course in different cases. In 19 cases successfully treated by digital * " Observations on Aneurism." 598 SPECIAL PATHOLOGY AND SURGERY. pressure, the average number of hours was not more than 4H ; spread, however, over a variable period of time, owing to intermissions of the pressure. Whereas, according to the most favourable reports of those who are greatly interested in the treatment by instrumental compression, the average duration of treatment by that method was 20j days in each case.* Digital compression, for the cure of aneurism, is of recent date as compared with instrumental compression. In 1846, Professor Vanzetti first attempted it for the care of a popliteal aneurism, at the Hospital of Karkof, in Russia. The case was deemed unsuccessful after only two days' treatment, and forthwith a ligature Avas resorted to. The particulars were not published until 1858. f Meanwhile, in 1848,J Dr. Knight, of jSTewhaven, United States, for the first time, success- fully employed digital compression, as the sole means of cure, in a case of popliteal aneurism, and which had resisted compression by every kind of instrument. At the end of forty-eight hours' pressure, thus applied to the femoral artery, the tumour in the ham had become one- third smaller, hard, and pulseless. The treatment was then discon- tinued, and four months subsequently the tumour could scarcely be felt. Encouraged by this and similar cases, digital compression has since been on its trial, and this method now bids fair to rival instru- mental compression. It is more simple, comparatively painless, a more speedy cure, equally effectual, and as permanently so. Compression by flexion is another, and even yet more simple, method of pressure ; but limited in its applicability to aneurism situated in the flexure of a joint — the knee or the elbow, or in the groin, where this method was once tried by Gurdon Buck and with success ; the latter case, however, being one of i^eturning pulsation in the sac of a femoral aneurism, after compression. The cure of popliteal aneurism may be effected, simply by flexing the leg on the thigh and securing it in that position by a bandage, previously rolled round the limb from the toes upwards to prevent congestion. The degree of flexion requisite is an acute angle in the first instance ; or better, a right angle only, at first, and gradually diminished. The duration of genuflexion necessary can scarcely yet be averaged. In the first case of idiopathic aneurism on record as thus treated, that by Mannoir, of Geneva (1857), a successful result was attained in a period under three weeks ; and in the second case, by Mr. Ernest Hart,§ the cure was considerably advanced after the first day, and complete on the fourth ; on the seventh day the patient was moving about. In a case by Mr. Shaw,|| the cure was far more protracted, the cessation of pulsation not having been observed until the thirteenth day ; but in this instance the tumour was of larger size. In 57 cases of flexion, collected by Fischer up to 1869, nearly all being those of popliteal aneurism, 28 were successful — in 8, however, of these flexion having been combined vsdth other modes of treatment — and the remaining 29 were failures. There does not appear, as yet, sufficient evidence to determine the permanence of the cure resulting from this method of compression. The causes of death, which have to be encountered, are — gangrene of the limb, suppuration or rupture of the sac. Many cases are reported in which flexion has * " System of Surgery," edit, by T. Holmes, vol. iii., "Aneurism." t Annali Univ. di Med., 1858. ;*: Trans. Amer. Med. Assoc, 1848. § Med.-Chir. Trans., vol. xlii. 11 Ibid. ANEUEISM. 599 been successfully used in conjanction with pressure; one by Mr. Pemberton,* another by Mr. A. Pritcbard.f Esmarch's bandage and elastic coil were first applied by Staff Suro-eon Dr. W. Eeid, in a case of popliteal aneurism. (Lancet, 1875.) The bandage having been removed, the ligature, above the seat of aneurism, was continued for fifty minutes ; and in that short period consolidation had taken place, so that pulsation had entirely ceased. But as a security. Carte's compressor was used for about forty-eight hours. The result was permanent. This method of compression would seem to be a combination of means to arrest the circulation, both direct and collateral, with relation to the aneurism. Speedy coagulation or passive clot-formation may occur, rather than the slower production of laminated fibrin. Small-sized aneurisms, there- fore, would appear most suitable for the trial of compression in this way; and obviously, it is applicable only to external aneurisms in eligible situations. (2.) Ligature. — (a.) Ligature of the aneurismal artery on the cardiac side, but at some distance fi'om the sac, and in a sound portion of artery. This is the Hunterian operation for Aneurism (Fig. 159, middle figure). The application of a ligature to any part of an aneurismal artery, divides the vessel when the ligature separates ; thus per- Fig. 159. manently intercepting the trans- mission of blood through the artery, itself perhaps a main trunk. This treatment, there- fore, should be an ulterior re- soui'ce to temporary compression, in any form ; obliteration of the vessel not becoming necessaiy until after temporary compression — preceded by hygienic (and medicinal) measures, for retard- ing the general circulation — has failed. Ligature on the cardiac side of an aneurismal artery, as a surgical procedure, is another illustration of treatment in accordance with the mode of natural cure by retardation of the current through the aneu- rismal artery ; but it is a further concession of such assistance. I have, therefore, postponed the consideration^ — as in practice, the application — of compression by ligature, until after that of other handy modes, without any surgical operation, have been tried and found wanting. Then, if the heart be competent to withstand the obstruction to the circiilation consequent on the operation, and no internal aneurism complicate the case, — under these favourable circumstances, obliteration of the aneurismal artery, by ligature, is a justifiable resource. There are, however, certain tmfavotirable, if not positively contra- indicating, circumstances with respect to this ulterior measure. Atheromatous or calcareous degeneration of the artery at the seat of ligature would be a decidedly adverse condition. But this can scarcely be discovered prior to operation. A rapidly enlarging aneurism is * Lancet, 1859, vol. ii. t Brit. Med. Journ., 1861. 600 SPECIAL PATHOLOGY AND SURGERY. unfavourable, as evincing an indisposition to the deposition of laminated fibrin. Then again, a very large ancm-ism is unpropitious, as threaten- ing gangrene of the limb ; an event almost inevitable, if the circu- lation were suddenly cut off by ligaturing the arterj^. Inflammation of the sac will be unfavourable, by possibly proceeding to suppuration ; and suppuration itself would be a positively forbidding condition, by rendering the result of ligature abortive. The Hunterian operation, first performed in December, 1785, con- sists in applying a ligature on the cardiac side of the aneurism, to a sound portion of the artery ; and thei-efore at some distance above the aneurism. For popliteal aneurism, tlie superficial femoral artery is ligatured, where this vessel is crossed by the sartorins Fig. IGO.* muscle, in the middle third of the thigh. The force of the current of blood having been thus reduced, coagulation within the sac is promoted, yet without cutting off the supply of blood entirely. A sufficient quantity is transmitted for the process of coagulation, by collateral branches issiiing from the artery above the ligature (Fig. 160, a) and communicating with the vessel below, but above the aneurismal sac ; while there is also a sufficient quantity of blood transmitted onwards, and by collateral branches which become adequately enlarged, for the maintenance of the limb below. Meanwhile, coagulation and the deposition of laminated fibrin is proceeding in the aneurismal sac, and it extends into the artery as high, perhaps, as the ligature ; both the sac and this portion of the artery thus become consolidated ; the ligature separates, in the usual manner, bj sloughing of the ring of artery within the noose, and the divided ends of the vessel are simultaneously sealed with plastic lymph. This takes place in a period ranging from ten days to a month ; but varying chiefly according to the size of the artery, and the plastic power of the individual. Of 54 cases recorded by Crisp, in which the femoral artery was ligatured, the average period for the sepa- ration of the ligature was 18 days. Finally, the con- solidated aneurism and artery are partially absorbed, so that the latter withers and degenerates into a fibrous cord. The limb, nourished by the collateral circula- tion, may nevertheless become somewhat ati'ophied. (&.) Anel's operation, 1710, contrasts with the Hunterian, in its ultimate purpose, more than as an operative procedure. The operation proposed by Anel was to ligature the aneurismal artery, on the cardiac side, but close to the aneurism. (See Fig. 159, left figure.) The aneurismal blood escaping through the distal portion of artery, the sac would, it was thought, collapse, and thus the tumour disappear. For this purpose, the blood must remain fluid in the aneurism, instead of undergoing coagulation and the deposition of laminated fibrin, with occlusion of the sac, followed by the absorption of both, the tumour disappearing * From Liston. ANEURISM. 601 in that way. Althougli, then, these two operations are somewhat similar, they differ widely in their ultimate purpose as to their modes of cure. Moreover, Anel having performed his operation once only, and for traumatic aneurism of the brachial artery at the head of the elbow, he never himself repeated it, nor advocated its repetition, in similar cases. He apparently regarded his operation as applicable only in that particular case ; unlike Hunter, as a conception ruling the treatment of a large class of cases. It is, however, with reference to idiopatliic aneurism — as implying a diseased state of the artery — that the operations of Anel and Hunter notably contrast, and when compared with the old operation which had been designed for the cure of such aneurism. The old operation, or that of Antyllns, consisted in extirpating the aneurism. An incision was made throughout the whole extent of the aneurismal sac, in order to scoop out the coagulum and expose the two orifices of the artery, leading into the sac ; immediately above and below those points a ligature was passed round the vessel, securing it in both directions. But an unsound portion of artery was thus selected — that immediately above and below the sac, which participated in the degenerative change of structure that originally gave rise to the aneurism. Hence, secondary hfemorrhage, perilous or perhaps fatal, generally occurred when either ligature separated, and as often necessi- tated amputation ; while invariably, the large wound of the aneurismal operation healed tediously and often precariously to life by exhausting suppurative discliarge. In Hunter's operation, a sound portion of artery was selected, thus avoiding these evil consequences. This operation, therefore, at once superseded that of Antyllus, and Anel's also — ^the ligatiire having been applied equally close to the aneurism in that operation. But the principle of Hunter's operation, in relation to the natural cure of aneurism, differed even more essentially from both these operations ; in the assumption that it was necessary only to reduce the force of the circulation by applying the ligature at some distance from the aneurism, for the j)rocess of natural cure to super- vene, instead of entirely arresting the current of blood through the aneui'ism by ligaturing the adjoining portion of artery. The revival of the old operation by Mr. Syme, was attended with some notably successful results, in certain exceptional cases : aneurisms of very large size, in the carotid artery, the axillary, and the external iliac. This procedure may, I think, be regarded as specially appro- priate when the aneurism, although idiopathic, has become diffused — the sac having burst. Signs after Ligature, by JSunters Operation. — Certain alterations in the signs of aneurism attend or follow the Hunt^erian operation of ligature. The aneurism ceases to pulsate and partially subsides. These changes taking place immediately the ligature is drawn tight, are valuable signs of its successful application. The circulation of blood being' proportionately arrested in the limb, it becomes numb and cold, and its muscular power is diminished. But, usually, near the seat of ligature, the jDart is perceptibly warmer, and moistened with perspiration. As the collateral circulation is established, these im- mediate effects disappear; the temperature of the whole limb may rise above that of the other, a tingling sensation is experienced — formication, as if, insects were crawling within the flesh, and the sense 602 SPECIAL PATHOLOGY AND SURGERY. Fig. 161. of weakness is only that of heaviness. The aneurismal tumour, in the course of twenty-four hours, continues to diminish, but acquires a hard, ehistic tension, and is perhaps sh'ghtly pulsatile ; returning, however, to a passive state, as the tumour undergoes absorption, and gradually disappears. After-treatment. — The treatment after this operation should he directed to avert the temporary tendency to gangrene, pending the establishment of an adequate collateral circulation. Hence, the circu- lation and temperature of the limb must be maintained. A thick wrapper of carded wool answers most effectually, aided by a suit- able elevation of the limb to relieve congestion. The diet should be moderately nourishing and stimulant, which, with the judicious administi-ation of opium, will tend to sustain the process of cure. Co7isequences. — Certain tinfavourahle consequences and evil results are liable to ensue from this applica- tion of the ligatui'e for aneurism, (1.) Pulsation inay continue or return in the aneurismal sac. The small stream of blood con- veyed by collateral branches into the artery below the ligature, and thence into the sac, depositing the laminated fibrin, is not a pulsatory current. If, however, these feeding vessels are larger than suf- ficient for this purpose, pulsation continues, or soon returns ; if they enlarge immoderately, then aLso pulsation returns. Any regmrgitation of blood into the sac, from below, and therefore in opposition to the current, need scarcely be taken into account. If it occur, it will cause gradual enlargement of the /> III aneurism without pulsation ; simulating the gradual increase of a malignant tumour. Rarer causes are these : — Any condition of the blood which, delaying or hindering coagulation, disposes it to remain fluid in the sac, will favour the continuance of pulsation. A vas aberrans may exist, which communicating directly, or indirectly, with the aneurism, thus con- tinues its pulsation. An instance of this kind occuri'cd to Sir Charles Bell.* He ligatured the femoral artery for popliteal aneurism. The patient died a week afterwards from erysipelas ; and it was then discovered that the femoral artery was double, and that the vas abeiTans had continued to supply blood to the aneurism in the ham, after the operation. Yet in this case, the sac had become completely consolidated ^vith coagulum, and in the short period of one week. The preparation is in the Museum of University College, London; and the instructive lesson it conveys will be further impressed by the engraving (Fig. 161). Other contingencies, by which the pulsation of an aneurism continues after the application of a ligature, relate to the operation. The ligature may not have been applied to the aneurismal artery : or having been applied thereto, the noose may have been tied obliquely, instead of transversely, then shifting its * Lond. Med. and Physical Journ., vol. Ivi. ANEURISM. 603 place and loosening its hold, the pulsation continues, or returns, soon after the operation. Of all these causes of pulsation after the Hunterian operation for aneurism, that arising from an undue collateral circulation, as explained, is by far the most common. But its relative frequency in different arteries is remarkable. In carotid aneurisms it is most frequent. Of 31 cases, in which the carotid artery was ligatured for aneurism, pulsation continued or returned in 9 ; whereas of 92 cases of inguinal aneurism, in which the external iliac artery was ligatured, pulsation returned in 6 cases only. In axillary and popliteal aneurisms, respectively, recurrence of pulsation is an exceptional event. It should be remembered that a slight thrill may very frequently be felt in an aneurism, on the second or third day, after the applica- tion of a ligature by the Hunterian method. This, however, is a favourable occurrence, as it bespeaks a feeding stream of blood for coagulation in the sac ; and it supervenes with about equal frequency in all aneurisms, irrespective of any particular portions of the arterial system, and the distribution of vessels accordingly. The thrill, thus arising, soon subsides — with consolidation of the sac. Returning pulsa- tion, on the other band, if it occurs, usually begins at a much later period, not until a month or six weeks have elapsed^ and continvies for some time. Returning pulsation is seldom persistent, and rarely terminates fatally. Of 26 cases in which pulsation I'eturned, 3 only were fatal, and then not owing to this event, but by sloughing of the sac. (2.) Secondat-y Aneurism , or aneurism reappearing by redilatation of an aneurismal sac, which had previously undergone consolidation and absorption, is a very uncommon event. This must not be confounded with returning pulsation. Mr. Erichsen believes there are only two unequivocal instances on record, both of which were in the ham; the original tumour having disappeared entirely, this seeondaiy disease made its appearance after the lapse of six months in one case, and after four years in the other instance. More frequently, after ligature, an aneurism may gradually become enlarged, without pulsation, in consequence of a reflex current of blood through the distal portion of the artery. Secondary Aneurism, in the sense of another distinct aneurism arising close to the former one — double aneurism, in fact ■ — is quite another matter. Treatment of Pulsation^ Continuous or Beturning. — This, of course, must have reference to the cause or causes of the pulsation. Arising, in most instances, from an undue collateral circulation communicating, directly or indirectly, with the sac, the pulsation will cease as the deposition of laminated fibrin proceeds therein. The process of natural cure rights itself. Failing this result, the balance between the deposi- tion of fibrin and the supply of blood may be slowly gained, or regained by sufiiciently elevating the limb ; while the pulsation can be directly restrained by moderate pressure on the aneurism, with a compress and roller, evenly applied. These resources not proving effectual, the coagu- lating power of the blood deserves consideration ; but our knowledge respecting its operation within the body is at present very limited. Here then pathology fails to guide the treatment. The presence of a vas aberrans is discovered at the time of operation, by ascertaining whether the ligature entirely controls the pulsation of the aneurism. 604 SPECIAL PATHOLOGY AND SURGERY. If not, the tributaiy vessel should be souglit. It will not be far off, aud it must be secured bj anothei* ligature. In like manner, the aneurismal artery is identified by trying the pulsations of the sac, when the supposed aneurismal vessel is commanded above ; but this should be done before the ligature is applied. Lastly, applicatiou of the ligature transversely round the artery will avoid any chance of pulsa- tion continuing or returning, as occasioned by shifting of the noose. Extreme cases, which baflfle all these resources and precautions, necessitate further operative proceedings. ReappUcation of the ligature may have to be resorted to ; either lower down the artery — nearer the sac, as aa approach to Anel's operation ; or by opening the sac, turning out the clots, and tying the artery immediately above and below — the old operation of Antyllus. I kuow of no data for determining the Surgeon's choice, but the latter operation, Avhereby Nature's work of coagulation and consolidation is undone, should be resorted to reluct- antly. Amputation is the very last resource. (3.) Gangrene of the limb proceeds from causes of an opposite character to those which induce pulsation in the aneurism, after the Hunterian operation. The latter are conditions which favour an undue collateral circulation through the sac ; the conditions to which I now allude retard any collateral condition. Firstly, an aneurism itself retards the current of blood through the artery, and operates also by compressing the neighbouring vessels ; thus preventing the transmission of arterial blood, and the return of venous blood. Gangz-ene threatens. The application of a, ligature to the aneurismal artery is an additional obstruction, rendering the condition more perilous ; and if the collateral circulation be interrupted by the large size of the aneurism compressing the neighbouring vessels, then gangrene ensues. Secondly, surgical mismanagement of the limb, after operation, by inattention to position and temperature, secondary liJEmorrhage, or the presence of any morbid condition which lowers the vitality of the limb, will severally tend to induce gangrene. It supervenes in a jseriod varj-ing from the third to the tenth day ; but in rare cases, not until the third week. (Porter.) Treatment. — So far as gangrene is due to the ligature, it cannot be prevented ; but if due principally to interruption of the collateral circulation by pressure of the sac, this source of obstruction can be removed by the old operation of cutting dow^n upon the sac, laying it fi'eely open, and turning out the clot. At least two such successful cases, both of popliteal aneurism, are on record ; one by Lawrence,* another by Benza. Other preventive measures, topical, dietetic, and medicinal, have already been noticed in reference to the appropriate treatment after ligature. With gangrene, as with recurring pulsation, amputation of the limb is our last resource ; and the operation must be performed above the situation of the ligature. (4.) Suppuration and sloughing of the sac is attended with the usual symptoms of inflammation— heat, pain, and throbbing. At length the integuments give way, purulent matter is discharged, and portions of clot escape, having various degrees of consistence and shades of blood- red colour. Then haemorrhage of fluid arterial blood occurs, either with a fatal gush, or recurring in small but increasing quantities. Which form of hsemon-hage shall take place is apparently determined * Lond. Med. aiid Physical Journ., vol. Iv. ANEURISM. ■ 605 "by the degree to whicli consolidation of tlie aneurism lias advanced ; and thereFore, in a measure, by the time of its occarronce after lio-a- tare. The amount of hgemorrhage is regulated in like manner, it being most free and nnintei"rapted in the event of pulsation continuing* or* returning. An abscess commencing external to the sac, and opening into it, runs the same course; or suppuration may begin, both in the sac and the cellular texture around, afterwards forming- one abscess. The causes of suppuration and sloughing of the sac, and of hemor- rhage thence arising, in the course of aneurism, are any conditions unfavourable to the vitality of the sac. Hence, the large and increasing size of an aneurism, and the imperfect coagulating power of the blood therein, have this tendency. So also any external injury to, or irritation of, the sac. Considering these and other similar accidental circumstances, the period after ligature when suppuration may supervene is, obviously, very uncertain. It may happen at any time in the subsequent course of the aneurism. The average time is, perhaps, between the third and eighth weeks, but in a case of carotid aneurism recorded by Sir A. Coopei", suppuration occurred at the eighth month after operation. Comparatively few cases terminate fatally ; probably not more than one in four, and then, generally, by haemorrhage. Treatment. — This will be guided by the state and result of suppura- tion. In the first instance, the sac should be treated as an ordinary abscess ; only that when an incision is made, it should be free enouo-h to turn out the whole of the clot. I did this with a successful result in the case of a popliteal aneurism, the sac having suppurated after ligature of the femoral. Any remaining portion of coagulum is likelv to putrify and become a fetid, purulent discharge ; but when removed entirely, the sac is in a condition to heal from the bottom by granula- tion. Hcemorrh'age, of course, is imminent. A tourniquet, therefore, loosely applied to the limb above, will be a judicious precaution which can be brought into use at any moment. In the event of hieraorrhao-e, loss of blood may be temporarily stayed by a compress of spono-e well placed at the bottom of the sac, over its mouth ; and of sufficient size to be secured in position by a roller, evenly applied. Then comes the question of \\o^ to permanently arrest the hsemorrhage. The diseased state of the artery immediately above and below the sac, in idiopathic aneurism, forbids the application of a double ligature in sitic,as by the old operation. Ligature of the artery higher up than was performed prior to suppuration, would probably be the turning-point for the commencement of gangrene. In this dilemma, the Surgeon may advantageously wait and see what J^ature can accomplish, as the healing process of granulation closes over the arterial aperture in the sac ; guarded always by the compress, and during its reapplication occasionally, by tig'htening the tourniquet. This faithful following up of Nature's operation having failed, our only resource is amputation. (5.) Secondary hcemorrhage from the operation- wound, after lip-ature by the Hunterian method, is an event unconnected with the course of Aneurism. It is a failure of the operation ; and, as it arises from sloughing of the included portion of artery before the preparatory closure of either or both ends of the vessel has taken place, the 606 SPECIAL PATHOLOGY AND SUKGERY. hsemorrhage occurs whenever the ligature separates. The average time was the eighteenth day, in fifty-tour cases, recorded by Dr. Crisp, of ligature applied to the femoi-al artery. It is more likely to occur, the nearer the artery is to the heart, the central force of the circulation. The treatment in this case is not presumed to be restricted by any- diseased state of the artery, at the seat of ligature. Consequently, the reapplication of tivo ligatures, one to each end of the artery at the point of division, Avill most probably prove effectual ; the former operation-wound having been sufficiently reopened for this purpose. Temporarily, the hosmorrhage may be arrested or checked by plugging Avith sponge or lint. In the event of double ligature, in situ, having failed, ligature of the main trunk — higher up, must be resorted to. But this resource may prove ineffectual ; either by regurgitation from the distal end of the vessel, in the lower operation-wound, or from even the higher ligature failing to command tlie source of the haemor- rhage, owing to an irregular origin of the bleeding artery. The pos- sibility, at least, of gangrene supervening is, however, the chief risk to be encountered ; and I should, therefore, be inclined to try com- pression of the main trunk, before ha^^ng recourse to ligature of that vessel. Amputation is, of course, the final resource in any case ; but this procedure would be more judicious than risking any probability of gangrene,' for then the limb must be amputated, and under more adverse circumstances. Statistical Results. — Ligature for Aneurism shows a considerable mortality. In 256 cases of this operation on the larger arteries, the deaths were about 22 per cent. This was shown by Dr. Crisp's tables. The result of investigations by Porta is even more startling. In 600 cases of ligature for diseases and injuries indiscriminately, the mortality rose to 27 per cent. Then again, as compared with covi- pression, the balance is decidedly in favour of the latter mode of treatment. Thus, according to Norris, of 188 cases of ligature for femoral and popliteal aneurisms, 142 were cured, 46 died, 6 limbs were amputated ; in 10 suppuration of the sac supervened, and in 2 gangrene of the foot ; giving a total of deaths about 1 to 4, and failures I to 3. Whereas of 32 compression cases, also of femoral and popliteal aneurisms, collected by Bellingham, 26 were cured, in 1 liga- ture was resorted to after compression had failed, in 2 amputation became necessary, in 1 death occurred from erysipelas, in 1 from chest-disease, and in 1 instance the pressure was discontinued. The failures of compression were, therefore, only as 1 to 53 ; and the deaths only as 1 to 16. Even where compression itself fails, it most advantageously prepares the way for success by ligature. Thus, ac- cordins: to Mr. Hutchinson's Report, in 22 cases of ligature of the femoral artery, previously treated by compression, 2 only died of gangrene ; whereas, in only 10 such cases, without preparatory com- pression, 3 deaths occurred from this cause. Obliteration of an Artery tcithout Division. — Since the period of John Hunter, whose method of operation, on the femoi-al artery for the cure of popliteal aneurism, originally consisted in the compressing applica- tion of a ligature or ligatures, without any division of the coats of the vessel, this principle of treatment has, from time to time, attracted attention ; the object being the consequent preservation of the con- tinuity of the artery, thus to prevent the risk of secondary haemorrhage. ANEURISM. 607 Various procedures and. contrivances have been devised for this pur- pose. Thus, temporary compression of the exposed artery, as by means of Assalini's compressor, Crampton's pr esse- art ere, or Porter's wire-compressor, improved by Stokes, an instrument whereby acu- pressure is effected; or ligature has been used, but made of silver wire, or consisting of some animal substance, such as chamois leather, introduced by Dr.Phjsick, of Philadelphia; buck-skin thread, employed by Dr. Jamieson, of Baltimore ; or moistened catgut, which was the material, as first suggested by Sir A. Cooper, and subsequently pre- ferred in Porta's practice. Animal ligatures are cut off short, and left in the wound, which heals over them ; any such ligature is better tolerated as a foreign body, and it may possibly become absorbed, leaving the external coat of the artery undivided, but the vessel oblite- rated. GarhoUzed catgut — a more recent appliance, in accordance with Lister's antiseptic principle of treatment — seems to answer even better ; the wound almost always healing by primary union, and burying the ligature. More recently, cliromicized catgut has found favour, as a more reliable ligature, in the hands of Dr. Macewen, of Glasgow, and was specially commended by Sir Joseph Lister — as the result of ex- perimental observations, brought before the Clinical Society (1881). Mr, Barwell speaks highly of the ox-aorta ligature, — the middle coat, prepared in a fresh state, by steeping it in a three per cent, solution of carbolic acid. This material is too elastic to bear a reliable knot, and maybe absorbed too rapidly to prove secure. It should, therefore, be stretched to half longer than its own lengtli. When dried, it becomes brittle, but is easily rendered pliant, by soaking in the carbobc solution, before being used. (Med.-Chir. Trails., 1878-79-80-81.) Arteries of the largest size, as the common iliac, external iliac, femoral, common carotid, and brachial ai^teries, have been deligated with animal liga- tures ; as by Porta and Bickersteth, both of whom used catgut. The results of this method of treatment, by ligature, have been encouraging ; that — as Mr. T. Holmes has shown — arteries may be tied and obliterated, but without their continuity being interrupted, thereby affording much security against secondary haemorrhage ; while the wound heals by primary union. On the other hand, failures in both respects must not be overlooked ; the artery becoming divided, as after ordinary ligature, and the wound opening up with abscess and discharge. (Hu-mphrj, Brit. Med. Journ.,1874! ; Woods, La?icet, 1875; T. Bryant, Trans. Clin. Soc, 1878.) iii. Manipulative and Operative resources, corresponding to the second mode of natural cure — i.e. retardation of the passage of blood, throug'h the aneurism, by obstruction of the distal portion of artery ; a piece of clot being dislodged from the sac and washed into the mouth of the distal portion, or becoming impacted within it, some distance off. (1.) Manipidation. — This plan of treatment was introduced by Sir W. Fergusson. It consists in so thumbing the aneurism, as to dislodge a piece of clot into the distal portion of artery. The manipulative pro- cedure designed for this purpose is thus described : * "The patient was seated in a chair, and I placed the flat end of my thumb on the aneu- rismal tumour so as to cover the prominence. I then pressed, until all the fluid blood had passed from the sac, and I could feel that the upper side of the aneurism w^as pressed against the lower. I now gave a • Med.-Chir. Trans., vol. xl. 608 SPECIAL r.VTHOLOGY AND SURGERY. rubbing motion to the thumb, find felt a friction of surfaces within the flattened mass. The movements were little more than momentary, but they were such as I had preconceived." Two cases of subclavian aneurism were subjected to this treatment; neither Avas unequivocally successful, and both were attended with very alarming symptoms at the time of manipulation. In the first case, the aneurism never ceased to pulsate, and, after eight mouths, terminated fatally by rupture of the lower and back part of the sac. The axillary artery was found to be firmly plugged with fibrin. In the second case also, the aneurism continued, but the pulse ceased at the Avrist. At the end of two years, and after hard work as a sailor, the aneurism itself had disappeared. In both cases, giddiness and faintness were immediately produced by the manipulation; and in the second case, these symptoms were succeeded by hemiplegic paralysis of the left side,, from which, how- ever, the patient recovered in two months. So far the results of treatment by manipulation were not very en- couraging. More disastrous cases occurred in the hands of Esmarch,* and Teale,t of Leeds. Both were carotid aneurisms. On the other hand, an aneurism of the right subclavian artery, thus treated by Mr. R. Little,J proved quite successful, although not without the dis- advantage of temporary parab'sis of the arm. Two successful cases in aneurism of the lower extremity, one of the femoral artery, treated by Dr. G. E. Blackman, of Cincinnati, § and the other of the popliteal artery, by Mr. Teale,|| are, I believe, the only additional results, at present, in favour of this method of treatment. (2.) Compression, or Ligature, of the distal portion of an aneurismal artery represents other methods of imitating the second mode of natural cure ; although the obstruction, as thus effected, is not by the impaction of a piece of clot in that portion of the vessel. The operation by liga- ture of the distal portion is principally associated Avith the names of Brasdor and Wardrop. (See Fig. 159, right figure.) Whether the arterial current be obstructed by ligature, or simply by compression of the arteiy, at that part of its course, in either case the principle is to retard the stream of blood through the aneurism, and thus induce the deposition of laminated fibrin with consolidation of the sac. For this purpose, it is necessary that there shall be no arterial branch between the aneurismal sac and the ligatui'e, which would lessen the obstruction offered to the current of blood on the distal side of the sac. Carotid aneui-ism alone fulfils this requisite condition for the success of distal ligature or compression. The immediate effect of distal obstruction is to turn the full force of the arterial current into the sac ; which being distended, may at once yield and burst with fatal htemorrhage. Should this issue not occur, the collateral branches of artery from the main trunk above the aneurism, will probably have time to enlarge sufficiently to relieve the ten-sion of the sac, and to carry on the circulation for the maintenance of the limb ; a small feeding stream of blood passing down also to the sac, which becomes solidified and obliterated by the process of natural cure. But this happy issue is very precarious and doubtful. Accord- ing to the results of 27 cases collected by Mr. Erichsen, 20 terminated * " Archiv. Path. Anat. tind Physiologie," 1857. t Med. Times, 1859, vol. i. % Ibid., 1857, vol. i. § N. Y. Journ. Med. Science. 1857. Il Op. cit. ANEURISM. 609 fatally soon after the operation, and in tlie other 7 cases, although, the patients survived the effects of ligature, the disease remained nncured. iv. Certain Operative procedures, of a physical or chemical cha- racter, correspond to, if they do not imitate, the fifth mode of natural cure ; that by inflammation of the sac, and its consequences. Galvano- puncture has been practised for the purpose of inducing coagulation of the blood, en masse, within the sac. Two needles, insulated by gutta- percha coating, and connected with the wires of a galvanic battery, are introduced into the sac, in opposite directions, until they nearly touch, and fibrin becomes deposited around one of the poles, or needles. The action of the battery should be continued for about ten minutes, and repeated several times. In connection with subclavian aneurism, I have mentioned the particulars of a case in which I employed this method of treatment. Under this galvanic influence, a soft clot may form which partially fills the sac ; but acting as a nucleus it may induce the deposition of laminated fibrin, and at length occupy the whole sac. Or, a large but loose clot having formed, in the first instance, it may settle down, and thus the sac become consolidated. Or lastly, the current of electricity excites inflammation of the sac, rather than coag'ulation of its contents ; and this may be followed by coagulation, or by suppu- ration with sloughing of the sac and its obliteration. These are successful issues. But there are cases, and not a few, of an opposite kind. The clot liquifies, pulsation is re-established, and the disease resumes its course. This relapse, after galvano-puncture, is probably due to the mode of coagulation thereby effected ; the mass of blood setting suddenly into a semi-solid state, instead of consolidating by the gradual deposition of laminated fibrin. Then again, in the event of inflammation supervening, sloughing is mostly accompanied with haemorrhage which may be fatal to the patient's limb or life. Apart from any adverse issue, the pain occasioned by galvano-puncture is always hard to bear, in some cases intolerable ; and the administration of chloroform would probably be injudicious. Galvano-puncture is of comparatively recent date. First introduced by Mr. B. Phillips, in the year 1832, it was subsequently followed up by Listen, Gerard, and Keate ; but with so little success that it fell into disuse. A few years later, however, this proceeding was practised by Petrequin and Burci with more success, and thence its revival as an occasional expedient. It is justifiable only, or chiefly, in cases of internal aneurism, or of aneurism at the root of the neck ; in fact where compression, ligature, or any other method of treatment has failed, or is impracticable. The statistical results hitherto recorded are very unfavourable. According to Bonnet, up to July, 1851, 23 cases of aneurism had been subjected to this treatment ; 8 were of the brachial artery, 7 of the popliteal, 2 of the subclavian; 1 of each of the following arteries — ophthalmic, temporal, carotid, thoracic aorta, ulnar ; and 1 unknovm. Of these, 13 cases were unsuccessful, and although 9 were reported as successful, 7 of them were due rather to compression and the appli- cation of ice, or to inflammation and suppuration of the sac, than to galvano-puncture. It failed, therefore, in no less than 20 cases out of 23 ; leaving only 2 favourable results, excluding the unknown case. Subsequently, out of 50 cases collected by Ciniselli, 23 were cured, VOL. I. 2 E 610 SPECIAL PATHOLOGY AND SURGERY. Fig. 162. 20 were not cured, and 7 were fatal. In the case of subclavian aneu- rism to which I have alluded as having occurred in my own practice, the effect produced was slight and only temporary. Mr. Holmes concludes, respecting this method of treatment, that " its use is not so dangerous as to render further trials of it inexpedient," and he antici- pates that it may be so far perfected as to become " a safe and. regular plan for the treatment of thoracic, subclavian, and other forms of aneurism." The injection of coagulating agents has been practised, like galvano- puncture, with the view of inducing coagulation, en masse, within the sac. Various such agents have been tried. The least hazardous, and the most efficacious, appears to be a weak solution of perchloride of iron, used in small quantity. A solution of 20° Beaume is the highest degree of strength recommended by Yalette ; and twenty drops only to every lOOth of a pint of the blood in the sac is the quantity permitted by Broca. The safest instrument for injecting is a small glass syiinge, furnished with a screw-piston, and a fine-pointed nozzle — the hypodermic syringe (Fig. 162). This instrument may be graduated, so as thus to regulate the quantity of fluid injected by means of a sliding piston ; but a screw-acting piston answers the purpose more exactly, one turn of the sci-ew corresponding to a minim of the solution. Before introducing it, the circulation through the artery should be suspended by compressing the vessel carefully on either side of the aneurism. Then the point should be thrust perpendicularly into the aneurism, until a drop or two of arterial blood escaping, shows that it has penetrated. The instrument may be directed to different points within the sac, and a drop or two deposited successively, forming as many centres of coagulation. On withdrawing the instru- ment, a tarn of the piston, backwards, will prevent any of the solution escaping under the integument. Taking all these precautions, as to strength and quantity of the solution, and its injection into the sac alone, coagu- p-n-^v lation may proceed to consolidation and cure. But the ^''5~^ process may stop short of this issue ; or inflammation be excited in the sac, which, owing to the highly irri- tating character of the solution, will probably result in suppuration and sloughing, with fatal haemorrhage, or by extending to the sur- rounding integuments, may end in gangrene of the limb. Thus, then, the probable consequences of this treatment restrict its eligibility ; while the kind of coagulation induced, en masse, disqualifies it propor- tionately, for the cure of aneurism. Then, again, the requisite com- pression of the artery on the cardiac and distal side limits the appli- cability of injection to aneurism in certain situations only. Internal aneurisms are excluded ; and external aneurisms — those of the ex- tremities — are open to far preferable methods of treatment — compres- sion or ligature. Injection seems to have been practised indiscriminately, or at least without regard to the situation of the aneurism. Originally suggested by Monteggia (1813), injection was tried, with different coagulating agents, by Vilardebo, Wardrop, Leroy d'Etiolles, Pravaz, and Petrequin. ANEUKISM. - 611 Aneurisms in every part of the body have been subjected to this treat- ment ; those of the innominate artery by Barrier ; of the subclavian by Petrequin ; of the carotid by Diifour; and of the popliteal artery by Wiepce, Minor, Isaacs, and Lenoir. Aneurism of all-sized arteries has been injected, from that of the supra-orbital artery, by Raoult and Deslongchamps, to the aorta itself, by Syme. The sum total at present exceeds thirty cases. But their results have not been sufficiently analyzed to draw any numerical conclusion for, or against, this kind of treatment. Injection succeeds in so far as it induces coagulation, rather than excites inflammation and its consequences. Such also is the favourable modus operandi of galvano-piinctnre. "Various substances have been introduced into aneurisms, for the purpose of mechanically inducing coagulation, as the current of blood passes through the sac, — just as solidification of the fibrin is produced by whipping blood in a basin, with a bundle of twigs. Thus, Mr. Moore originally employed a coil of iron wire, which having been passed into the sac of an aortic aneurism, produced a large amount of loose coagulum ; but the result was fatal, from inflammation of the sac. Catgut and horsehair have since been tried ; with no better success, and always with the same risk. Ergotin has been injected hypodermically by Langenbeck, with the view of exciting contraction, of the sac. Boujean's watery extract of ergot was used, — fi'om one to three grains dissolved in three proportions of spirit and glycerine. This may be repeated, according to the pro- gress of consolidation, in two or three days. A small radial aneurism was thus cured, by a single injection, in one day. Amputation. — In but few cases of Aneurism will primary ampu- tation be justifiable, rather than having recourse to the trial at least of treatment by compression or ligature. The exceptional cases are chiefly these : (a) when gangrene is imminent ; owing to the large size of an aneurism, or rupture of the sac having occurred, an aneurism has become extensively diffused ; the existence of gangrene will, there- fore, of course render amputation imperative ; or (6) the co-existence with aneurism of such pressure-effects as would leave a useless limb — after other treatment ; e.g., the destruction of the knee-joint from popliteal aneurism. Then again, the co-existence of an internal aneurism with an external one — say, of the popliteal artery — would afford sufficient evidence of a general degeneration of the arterial system. Under these circumstances, my own experience is decidedly in favour of amputation, rather than that the patient should undergo all the risks of failure, or of danger, contingent on compression or ligature, and then be subjected to amputation, in a less favourable state than before the general health had been thus reduced. The question of secondary amputation — after other treatment for aneurism, was considered in connection with the consequences of Ligature. Treatment of Traumatic Aneurism, — The requisite operative pro- cedures here are also governed by the pathology of this lesion. In the first instance, traumatic aneurism is always a diffused and more or less pulsating collection of blood, communicating with an artery ; this escape of blood having taken place, by a puncture or laceration, more or less complete, of the vessel; and with, or without, an external wound of the integuments. Hence, a punctured wound, or division, of an artery may give rise to traumatic aneurism ; or this 612 SPECIAL PATHOLOGY AND SURGERY. lesion may be produced by contusion, a wrench, a fracture or disloca- tion, involving an artery. Such being the essential condition of traumatic aneurism, if the tumour bo also enlarging, if it be diffused and dif using, the immediate and total arrest of the hfemorrhage is necessary. For this purpose, no partial arrest of the current through the wounded artery, no mere retardation of the passage of blood, will suffice, as for idiopathic aneurism, in its early or circumscribed state. The whole force of the circulation through the artery must be taken off, ere the haemorrhage "will cease, and the diffused aneurismal tumour cease to spread. Ligature, therefore, of the artery above and below its wounded point is the treatment indicated. This, however, is easier said than done, in most cases. A free incision into the tumour will expose the half- coagulated blood and commingled textures, when the mass can be readily turned out ; the recurrence of hosmorrhage during this pro- cedure being guarded against, by an assistant compressing the artery on its cardiac side, and as near the tumour as is practicable. Having sponged the bottom of the cavity thus made, the bleeding orifice may be seen at once, or it will be discovered by a spirt of blood, when com- pression on the artery above is slightly, and momentarily, relaxed. This is the point for which the Surgeon seeks. The vessel must then be secured, by tying it on either side of the aperture ; or if divided, by tying both ends. Here especially, difficulty is encountered ; owing perhaps to the locality of the artery, and also to its disorganized, although not degenerate state, as in idiopathic aneurism. Failing to effectually control the heemorrhage, plugging of the cavitj', from the bleeding aperture outwards, will be necessary to completely arrest it. And this additional safeguard is unobjectionable, as the wound can only heal, for the most part, by granulating from the bottom. If a traumatic aneurism has become circumscribed, thei-eby evincing a decided tendency to natural cure, then indeed the lesion so far resembling an idiopathic aneurism, it may be tx'eated accord- in o-ly, by merely retarding the force of the circulation through the aneurismal artery. Compression, therefore, of the artery above the aneurism, or perhaps direct compression ; and ligature on the cardiac side only, and at some distance from the tumour — i.e. the Hunterian operation — are both eligible resources. If the circumscribed aneui-ism be of small size, compression alone may prove sufficient to retard the passage of blood ; or that failing, the Hunterian operation will probably loe an effectual check. This operation is often far more conveniently performed than any application of a ligature near the tumour. Thus, in the palm of the hand, where it would be difficult and hazardous to apply a ligature on either side of an aneurismal tumour, the brachial artery has been ligatured for a small circumscribed traumatic aneurism over the ball of the thumb, and cure was accomplished. The application of a ligature, still on the cardiac side alone, but near the aneurism, is not forbidden by any structural condition of the artery. This procedure — Anel's operation — is appropriate, provided only that the force of the circulation through the aneurism can thus be sufficiently retarded. But if the aneurism be, or become, of large size, although circumscribed, the force of the current preponderates over the arterial resistance, and the balance cannot be sufficiently restored by a ligature at any part of the artery, on its cardiac side ANEURISM. 613 alonie. The treatment accordingly is again restricted to double ligature — one on either side of the bleeding aperture — by the operation already described ; the old operation of Antyllus, as for diffused traumatic aneurism. The treatment of traumatic aneurism unaccompanied by an ex- ternal wound, will be considered in connection with Complicated Fracture, and Dislocation, respectively. Aneurismal Varix and Varicose Aneurism. — Structural Conditions. — An opening between an artery and a vein, in contact, whereby a direct communication with the two vessels is established, constitutes Aneurismal Varix (Fig. 163). Through this opening, the current of arterial blood, being the more forcible, passes, in part at least, into the opposing current of venous blood. Under favourable circumstances — to be presently explained — an indirect communication is established, by the formation of an intervening circumscribed false aneurism ; this condition constituting Varicose Aneurism (Fi^. 164). It is so named Fig. 163.* FiG. 164.t from the varicose condition of the vein, with which the artery thence communicates. But the vein is varicose also in Aneurismal Varix. Signs. — The same signs accompany either of these lesions, and they are very significant. Take, for example, a communication of the brachial artery and median basilic vein, occasioned by unskilful vene- section ; whereby both these vessels are punctured, as they cross at the bend of the elbow. The superficial aperture in the vein and skin may soon be healed, but the deeper aperture in the vein and that in the artery remain open. The current of arterial blood, being partly diverted from its course, is less forcible below the seat of injury, reducing the pulsation at the wT?ist to a feeble thread; and as the jetting stream passes through the median basilic vein into the veins of the forearm and arm, they become distended and tortuous, or varicose. The median vein, more especially, assumes an eel-like appearance down the forearm ; while the median basilic and median cephalic, the radial and ulnar veins, with the basilic and cephalic veins at the bend of the elbow, also exhibit in various degrees the force of the arterial * From Listen. f Ibid. 614 SPECIAL PATHOLOGY AND SURGERY. current; thej all become enlarged and varicose. Aneurismal Varix simply, is formed as the result of the puncture of both vein and artery ; or, the jet of arterial blood passing- into the vein, may buiTow for itself a cavity in the intei-vening cellular tissue ; forming a circum- scribed false aneurism, as the medium of an indirect communication between the two vessels, and constituting Varicose Aneurism. In either condition, the varicose state of the neighbouring veins connected therewith, is the earliest and most characteristic appearance. The aneurismal swelling is wholly, or partly, formed, as the case may be, of enlarged and tortuous veins. And these veins, vpith or without the circumscribed aneurism, pulsate in unison with the arterial pulse ; their pulsation being distinctly visible, perceptible also as a tremulous thrill, and audible as a soft, burring sound. Moreover, the whole swelling can be emptied by pressure upwards in the course of the veins, or it subsides and regains its former dimensions, when pressure is made on the artery. An elevated position of the limb will have the same effect. In the event of a circumscribed aneui-ism having formed, between the aperture in the artery and that in the vein, this portion of the swelling is at first soft and compressible, bat it acquires a firmer and less elastic consistence, by the gradual deposition and consolidation of fibrin within the sac. If allowed to progressively enlai^ge, the skin shows the tint of venous obstruction, by assuming a livid hue ; while the whole limb, downwai-ds from the seat of injury, becomes swollen, oedematous, feeble, numb, and cold, even threatening gangrene. Causes. — The communication between an artery and a vein is com- monly of trauvtatic origin ; as that produced by puncture in unskilful venesection at the bend of the elbow, or a lesion from the thrust of a sharp instrument, or a ball in gunshot wound, passing between an adjoining artery and vein. But an opening may result from a diseased condition of the vessels, the lesion having an idiopathic origin ; as in the bursting of an ordinary aneurisna occasionally into a neighbouring vein. The determining cause of Aneurismal Varix simply, or the formration of Varicose Aneurism, has reference to the anatomical re- lation of the arteiy and vein. Whenever the two vessels are in contact, a direct communication may be produced — giving rise to Aneurismal Varix; whenever the vessels are not in contact or in apposition, an indirect communication is established, by the formation of an inter- vening circumscribed false aneurism — constituting Varicose .4we7vhich the organ has passed in former years, and survived. The treatment of Thrombosis and Embolism will, of course, be as LYMPHATITIS. 729 widespread as tteir pathology, chiefly in connection with wounds of arteries and veins, and of arteritis and phlebitis, so named, Phleboliths, or Vein- stones. — Concretions are not unfrequently formed within various veins, more particularly in the iliac and its branches. Consisting of fibrin, which at length calcifying forms concretions, these bodies are of a roundish shape, and the size of a pea or bean ; they are either free, or attached to the interior of the vessels, cropping in and gathering more fibrin around themselves as the stream of blood eddies slowly by. One such body, situated in a principal vein, as either common iliac, might become a cause of serious obstruction to the return of blood from the whole lower extremity. The diagnosis would be difiicult or impossible, the occluding con- cretion being discovered only after death. Fortunately, however, when venous obstruction is gradually established, an adequate compensation is provided by the simultaneous enlargement of other veins, as col- lateral channels, for the return of blood. The obscurity of diagnosis, and this compensatory circulation, render vein-stones of little pi^actical interest. LYMPHATICS AND GLANDS. CHAPTER XXX. lymphatitis. — adenitis. tumours. Lymphatitis. — Inflammation of the Lymphatics, Lymphangitis, or Angeioleucitis. — Structural Conditions. — The walls of the lymphatic vessels, when inflamed, are thickened and softened, the surrounding Cellular tissue is infiltrated with fibrinous exudation, and the capillaries are injected. Similar exudation mingling with the lymph within the vessels, forms a rosy clot, obstructing their interior. Suppuration often ensues, limited as an abscess, or a chain of abscesses along the course of the vessel ; or as diffuse infiltration. The Symptoms are refei'able both to the vessels affected, and to the part. Inflamed lymphatics present purplish-red linear streaks, tortuous and intersecting, forming an arborescent appearance, not necessarily continuous with the source of inflammation, but running up to the neighbouring lymphatic glands, which become swollen and painful. These red lines are firm, rather than hard or some- what cord-like under the finger, and beset with a spongy swelling — the surrounding infiltration. A hot, burning pain, and tenderness on pressure, also corresponds with the course of the vessels. These symptoms are more marked when the superficial lymphatics are affected, and may be scarcely perceptible when the deeper lymphatics are principally the seat of inflammation. In the limbs, the superficial 730 SPECIAL PATHOLOGY AND SURGERY. lymphatics on the flexor aspect are most affected ; the vessels being" seen coursing up the front of the forearm and inner side of the arm to the axillary glands, or along the inner side of the leg and up the thigh to the inguinal glands. Beyond these glands, lymphatitis rarely extends, in the limbs. Suppuration is made known by the usual symptoms of abscess, or by those of diffuse suppuration, in the event of this condition prevailing. Considerable oedema of the part — possi- bly a whole limb — supervenes, as the vessels become occluded ; and this symptomatic condition is more intense with inflammation of the deeper lymphatics. The general symptoms will be those of inflamma- tory fever, soon exchanged for prostration, or sinking into the collapse of pyaemic infection. - Diagnosis. — As distinguished from pJilehiiis, lymphatitis may be recognized by the absence of the cord-like and knotted character of the purplish streaks, and by the presence of swollen lymphatic glands, to which they lead. The arborescent appearance also presented by inflamed lymphatics diifers from the distribution of the veins, or the more common limitation of inflammation to a single vein, as the long sapbena ; when, however, a plexiform arrangement of small varicose veins is affected, this differential character is lost. In the capillary or subcutaneous form, lymphatitis might be mistaken for erysipelas ; but the uniform blush of redness — unlike the. ramified streaks of ordinary lymphatitis — has a pale rose colour, and is unaccompanied Avith cutaneous stiffness or tension, the boundary also of the patch of redness is less abru ptly marked ; yet in both diseases, the inflammation has the same continuously spreading or diffuse character. Considered etiologically, capillary lymphatitis is always traumatic; originating from a wound, however trivial, or a mere friction of the skin, without breach of surface; whereas erysipelas, when of traumatic origin, pro- ceeds always from some open lesion. Erythematous inflammation of the skin is characterized by the numerous patches of redness presented, in various parts of the body, and which have not the diffuse form of capillary lymphatitis. Causes. — Usually arising from some form of injury — a wound, or friction, or from the absorption of some poisonous matter, as by a dissection-wound — the external and local cause of lymphatitis is fre- quently a trifling lesion. Some constitutional condition would appear to prevail in other cases ; and this, probably, is of the erysipelatous nature. In persons of a broken constitution, and those who are in a low state of health, inflammation of the lymphatics readily occurs, and often, from scarcely perceptible external causes ; the pressure of a tight boot, inducing a few reddish streaks on the inner side of the leg and thigh, with swelling and tenderness of the inguinal glands ; or a slight abrasion on the hand being followed by similar inflam- mation of the lymphatics along the inner side of the arm, extending to the axillary glands. The association of erysipelatous patches with the linear streaks of lymphatitis, would bespeak a constitutional condition of that kind. Course and Terminations. — (1.) Resolution takes place not unfre- quently, even in those who seem most susceptible of the disease. The reddish streaks fade away, and the oedema subsides. (2.) Or, in- flammation haA'ing ceased, indurated cords may remain, with brawny INFLAMMATION OF LYMPHATIC GLANDS. 731 swelling, for some time. (3.) Suppurative lym.p}iatitis often leads to the formation of abscesses in the surrounding cellular texture, and possibly sloughing. (4.) PjEemic infection is a frequent conse- quence, proceeding, probably, from the direct transmission of pus from the interior of the vessels. Treatment. — The application of a few leeches, along the course of the vessels, may be appropriate in the absence of an erysipelatous tendency ; but warm fomentations, elevation of the limb, and rest will always be suitable, and generally prove sufficient to reduce the inflammation. Alkaline salines and other mild depletory measures are auxiliary at an early period. Abscesses should be opened without delay, and chronic oedema is best overcome by careful bandaging and blistering, or the application of mercurial ointment. Stimulants will soon become requisite in the course of this disease. Wine, brandy, and ammonia must be freely administered ; the latter, I think, has a depressing influence, when continued for any length of time ; and any stimulant supplies only a prop, to be withdrawn in proportion as nourishing food can be taken and assimilated. The treatment of pyaemia, as a consequence of lym- phatitis, presents nothing peculiar. Inflammation of -LrMPHATic Glands. — Adenitis. — Structural Con- ditions. — Inflammation of the lymphatic glands differs in no important particular from that of the lymphatic vessels. Their structural re- semblance explains this pathological affinity, for these glands each consist of lymphatic vessels in the form of a network, connected by cellular tissue into a dense mass, enclosed in a cellular capsule. The lymphatics, entering a gland and forming the network, are again collected into lymphatic trunks issuing from the gland. Capillary blood-vessels ramify on this network of lymphatics, and are thus brought into an intimate relation with them, anatomically and physio- logically. Inflammation of the lymphatic glands is attended with some thickening of the conglomerated vessels, and in61tration of the interstitial cellular tissue with fibrinous exudation and cells, but seldom with any permanent obstruction of the interior of the vessels. Sup- puration not unfrequently takes place, forming an abscess, either centrally in the substance of the gland, or in the external and sur- rounding cellular texture. The symptoms are simply those of ordinary inflammation ; the gland becomes swollen, hard, and painful, with, perhaps, a blush of redness and heat in the superimposed integument. Induration is less notable, owing to the naturally firm consistence of the lymphatic glands ; but they may acquire even a bullety hardness, as the inguinal glands in connection with an indurated syphilitic sore. Softening often suc- ceeds in ordinary adenitis ; and with suppuration, the usual symptoms of abscess supervene. QEdema commonly occurs in the part below, and proportionately as absorption becomes obstructed. The consti- tutional disturbance is the inflammatory type of fever, and often more acute than with inflammation of the lymphatic vessels. Causes. — Usually ensuing as a continuation of inflammation along the lymphatics, adenitis sometimes arises independently, from an injury, or from absorption of noxious matter, not affecting the inter- mediate vessels. A sprain or an ulcer may thus induce inflammation of the glands distant from the seat of either ; as the inguinal glands, 732 rSPBCUJL PATBCHjOGfT ASD SCBGERT. vlien fke fool a..— Structural Conditions. — In fracture of the patella, the line of fracture is generally traus- ^ verse, and across the middle (Fig. 327), or some- '"' '' times the upper rim only of the bone. Longitudinal fracture may occur ; or comminution more frequently, the bone being starred and broken into three toler- ably equal pieces. More or less laceration and open- ing of the synovial capsule has been known to accompany simple fracture, as shown by a specimen in the Museum of the Royal Free Hospital. The upper fi^agment is drawn upwards, by contraction of the quadriceps extensor muscle ; the lower fragment, fixed by the ligamentum patellse, remaining stationary. The Signs of fracture are sufficiently obvious ; a depression or interval, into which the finger readily sinks, between the two frag- ments, and more perceptibly when the joint is flexed ; mobility of the * Eoy. Coll. Surg. Mus., 543, Transverse fracture of patella. Incomplete osseous union. 824 SPECIAL PATHOLOGY AND SURGERY. fragments, and probably some crepitus, when the limb is extended. Pain may be inconsiderable, but marked inability to raise the limb, in addition to the above signs, can never be overlooked (Fig. 828). Fracture of just the upper rim, without any rupture of the aponeurotic capsule of the joint, -will probably render these signs obscure. In one such case, and since, a second case, the patella seemed to me of the usual shape and size ; no interval could be detected, the small crest-piece of bone not being drawn upwards, but slipping down into the concavity between the condyles of the femur, and even behind the patella, itself apparently entire ; and thus the fragment could not be readily moved laterally, nor brought into contact with the rest of the bone. But there was the usual powerlessness, or nearly so, in the patient's endeavour to lift his leg. Ccmses. — Muscular action is the most fi*equent cause, producing transverse fracture. A person falls backwards, the knee is bent, and the patella snaps — as the tendon of the quadriceps extensor might be ruptured— by the sudden strain thrown on that muscle in the effort to i^egain the upright posture. But the fall is completed because the patella gives way, and the bone is not broken by falling on it. This accident happens more commonly in men, and in adult life than child- hood. In like manner, after fracture of one Fig. 328.* patella, the other is more liable to be broken by muscular action ; increased strain being thrown on the quadriceps muscle of the other leg, in any similar effort of self-pre- servation. Both patellae have been known to snap simultaneously. Direct violence, as by a fall on the knee, is the occasion of longitudinal, and, more especially, of com- minuted fracture. According to Hamilton, such force will genei'ally produce transverse fracture ; but muscular action invariably having this effect, the greater proportion of, if not all, transverse fi^actures are thus pro- duced. Considerable swelling* speedily en- sues from effusion into and around the joint, in connection with fractured patella, whether produced by muscular action or by direct violence ; and this is associated, in the latter case, with marked discolouration. The signs of fracture are thus more or less obscured. The mode of union in fracture of the patella would appear to be of two kinds, ligamentous and osseous; the difference depending probably on the less or more complete contact of the fi^agments, during the process of union. Hence the probability as to the one or the other taking place will vary according to the direction of the line or lines of fracture, whereby the fragments are subjected to displacement by muscular action — that of the quadi-iceps extensor, or perhaps by an altered position of the limb. Ligamentous union usually takes place in transverse fracture ; with rare exceptions, where osseous union may occur, nearly complete contact having been maintained. Union by ligament wall form even when separation of the fragments extends to an inch and a half ; beyond this distance, thickened aponeurotic * After Fero-usson. FRACTUKE OF THE PATELLA. 825 Fig. 329.* fascia serves as. the only bond of connection. Thus the fragments may remain severed to an extent of four or five inches, and often become enlarged (Fig. 329). Osseous union, apparently, takes place more frequently in longitudinal and in comminuted fractures of the patella, the fragments remaining in apposition. Hamilton has recorded two such cases : one of longitudinal fracture across one corner of the patella ; and the other, a transverse fracture near the middle of the patella, with a longitudinal fracture near its inner margin, constituting a comminuted fracture. Sir A. Cooper also succeeded in obtaining bony union in some longitudinal fractures. The proof of this mode of union having occurred in these cases, and in my own experience, has rested on two facts : permanent appo- sition of the fragments, without any increased separation taking place eventually, as after ligamentous union ; and the absence of any mobility be- tween them. Specimens of bony union, in fracture of the patella, would be more conclusive evidence ; and this is supplied by a specimen of such union after transverse fracture, marked E. A. (594), in the Museum of the Royal College of Surgeons, Dublin. Incom- plete ossific union had taken place in the preparation figured 327. ISTecrosis of the patella may ensue, after trans- verse fracture with ligamentous union ; owing apparently to deficient vascular supply to the fragment affected. Treatment.— In the treatment of fractured patella, the reduction of the upper fragment is effected by position of the limb, so as to relax the quad- riceps extensor muscle, thus bringing the fragments into apposition. The limb should be extended, and flexed on the abdomen, until the frag- ments would naturally fall together ; and this position is main- tained by a sufficiently elevated inclined plane on which the limb rests, and which is provided with a foot-piece. Any swelling or distension of the synovial capsule — any synovitis, consequent on the injury, having subsided, aided by an evaporating lotion, the fragruents can then be brought into absolute contact. When, therefore, the swelling has diminished in the course of three or four days, during which period no reparation could have commenced, the fracture may be readily, and painlessly, retained in position by the application of a bandage immediately above and below either portion of the patella, encircling the limb and splint in a slightly figure-of-eight form, and tied together at the sides. This splint may be furnished with a hook above and below the popliteal space, to catch the turns of the bandage, and thus bring further pressure to bear upon the fragments (Fig. 330). * St. Bartholomew's Hosp. Mus., 3, 28. Two patellae from the same person. Transverse fracture in both, separation to the extent of five inches, and connection only by a thin fibrous membrane. Enlargement of all the fragments. 826 SPECIAL PATHOLOGY AXD SURGERY. Sometimes the additional security of a compress, or a. semilunar cap of gutta-percha, just above the upper fragment may be necessary, with a counter- cap below the lower frag- ment, to steady it iu position. The band- age should be tight- e ned daily as the swell- ling subsides. Broad strips of plaster, over- lapping each other, might be used instead of the bandage, but this retentive appliance cannot be tightened Avithout reapplication and disturbance of the fragments. An unusually large amount of fluid eiiusion into the synovial capsule, forming a tense and almost globular swelling, may be aspirated ; and thus the patellar fragments can be brought together. In such cases, I have resorted to this expedient, and with success. Various other apparatus have been contrived, but they are all alike in principle, and none of them succeed in bringing about union better than the above described. Malgaigne's hooks are a contrivance whereby the fragments can be forcibly drawn together, and retained, by steel claws thrust into them, or just above and below them. If there be no risk of penetrating the joint with this instrument, violent synovitis is not unfrequently in- duced. I have never thus used the clamp in my own practice ; but in one case particularly, having been asked by a Surgeon to see a frac- tured patella which was subjected to its gi'asj^, I found a huge globular knee, pierced by the claws of the instrument, and surrounded by a gutter of pus. IsTor is this instrument necessary, if the position of relaxation be duly observed. Malgaigne, I learn from Mr. W. Adams, has used hooks in only fourteen cases out of a large number of fractured patellte ; exceptional cases attended with unusually wide separation of the fragments. The hooks will be found very serviceable, and safe, for fixing the semilunar caps of gutta-percha, instead of being thrust into the bone; my own method of employing this instrument (Fig. 331). Comparing the two retentive appliances, it may be fairly said that the bandage in a moderately figure-of-eight form is at least equally efficacious, and invariably safe ; whereas the hooks are unnecessary, and not unfrequently perilous. With the simple, efficacious, and safe plan of treatment I have described, union will be so far secure in a month or six weeks as to allow the patient to move about, guarded by a back splint, and FRACTURE OF TH^ PATELLA. 827 starched bandage. It is not advisable to have recourse to this sub- stitute apparatus at an earlier period ; simply because the yielding ligamentous union should not be strained by any muscular action in using the limb, or the chance of osseous union be frustrated. Even after some six weeks have elapsed, the ligamentous band continues to yield ; and in the course of as many months may present an interval between the fragments of several inches, resulting in a tottering movement of the joint forwards, whenever the patient stands or walks. For permanent support, I have used with advantage another simple contrivance ; a laced elastic knee-cap, having a leathern receptacle to compress the patella. In one case, a gentleman, of powerful muscular development and accustomed to a sporting life, was thus enabled to go about, without any further separation of the fi-agments. This apparatus should be worn until the union has become firm and unyielding, in a period from three to six months. But in thus taking care of the fracture, the tendency to anchylosis of the joint, from inflammatory effusion, must not be overlooked. Hence, passive motion should be used judiciously, in time to prevent this result. The union-results of this mode of treatment — by position and ban- dage-retention — have been, in my own practice at least, most satis- factory. In four cases, selected as having been authenticated by notes carefully taken by Mr. John B. Foster, formerly House Surgeon at the Royal Free Hospital, the principal points of interest and im- portance were the following : — (1.) The fracture in all four cases was transverse, and occurred in the left patella. (2.) Three of the frac- tures were caused by muscular action, the fourth by direct violence. (3.) The ages of the patients were fifty-six, forty-nine, forty, thirty- three. (4.) The periods when union was found to be firm, and the support of a back splint in starch used only as a precaution, were ten weeks, six weeks, eight weeks, six weeks. (5.) The extent of separa- tion between the fragments, originally, and at the end of these periods, was as follows : — Original separation, in all the cases, two inches, slightly more or less. Union-separation : one-fourth of an inch, contact, one-fourth of an inch, one-eighth of an inch. But there are not a few cases in which the fragments having united by a ligamentous band, leaving an interval between them of half an inch, the band subsequently becomes stretched to the extent of two or three inches ; and in other cases, no union whatever takes place, — there is an ununited fracture of the patella. Under these circumstances, the operation of wiring the two portions of the patella together, has been occasionally practised. This procedure was originally devised by Dr. John Rhea Barton, more than fifty years since ; but the case in which he resorted to it proved fatal. The operation was revived by Prof. E. S. Cooper, of San Francisco, in 1861, and with a successful result ; this w^as followed by Logan, of Sacra- mento ; and afterwards by Dr. Hector Cameron, of Glasgow, in 1877 ; since which period, wiring the patella has been tried by a few Surgeons, both in this country and on the continent. But the operation has especially attracted attention since the employment of antiseptic pre- cautions, after the Listerian method. More recently, the same method of treatment has been practised as a primary operation — in recent fracture of the patella. Sir Joseph Lister has himself set the example in a few such cases ; seven of which he brought before the Medical 828 SPECIAL PATHOLOGY AND SURGERY. Society of London (October, 1883). And if the pi-actice of wiring a fractured patella lias been encouraged by the confidence reposed in the almost absolute safety of Antiseptic Surgery ; so also, as involving the opening of one of the largest joints in the body, this operative procedure has come to be regarded as a critical test of the " system," when strictly carried out. The results of about twenty cases Avhich have thus been subjected to operation, would atfoi-d some evidence at least for determining the safety and efficacy of wiling the patella, as a method of treatment ; but the issue of some such cases, in regard to limb and life, cannot be ascertained with cei-tainty. Meanwhile, there are certain considerations which may aid in directing the Surgeon's judgment respecting this question. On the one hand, the old method of treatment, by retention, or approximation, of the fragments together — without opening the joint, and thus converting the injury into a compound fracture of the worst description — has all the guaranteed safety of " subcutaneous " surgery. There is no record of a single case in which death has occurred from simple fracture of the patella, and as treated on this pi'inciple. Can as much be said in favour of wiring the patella, even under the strictest antiseptic precautions ? Then again, in the event of the not unfi'equent ligamentous union only of the fragments, leaving, or resulting in, an interval of some extent between them, the joint is not much weakened, nor the limb disabled. In a case where the upper fi'agment was drawn quite above the condyles of the femur, the patient (who had not previously been under my care) assured me that he could walk a distance of many miles daily without any inconvenience, until he had then broken the patella in the other leg. Duly weighing these facts — as to the safety and efficacy of the old method, even when apparently resulting in failure — my own judgment decidedly inclines to the treatment of simple fracture of the patella by bandage-retention of the fragments, in the manner already described ; and I think that loiring, if practised at all, should be reserved for those quite exceptional cases in which the fracture remains 'ununited, as the final result. Wii'ing is easily performed. An incision — longitudinal or trans- verse — lays bare the fragments ; the edges should be pared, if necessary, to expose fresh bone ; they are drilled in two places, exactly opposite each other in either fi'agment ; and taking care not to penetrate the cartilaginous surface of the patella — so that the sutures shall be extra- articular. Silver wires are then passed through the holes, and tightened, thus placing the fragments in contact. The incision-wound being closed with fine wire sutures, the patellar sutures are clipped off above the level of the integument. A drainage-tube is inserted through the outer part of the joint — to secure a dependent opening. The limb should be put up in a back splint and elevated. Antiseptic gauze- di'essing is then applied. When osseous union has taken place, the sutures must be removed; and as, if all goes well, the wound will have soundly healed, this necessitates reopening it sufficiently to snip the wires and extract them fifom the patella. This concluding part of the operation was, therefore, modified by Van der Meulen, of Utrecht. {Lancet, January 3rd, 1880.) Before closing the wound, the wire suture having been twisted, the ends may be cut off short, and the twist hammered dow^n — thus leaving a foreign body beneath the integu- FRACTUEE OF THE PATELLA. 829 ment, which, however, may remain quiescent. In a case of recent fractured patella, at the age of forty-five, bony union and perfect motion were obtained after four months. Professor Volkmann has devised an analogous operation to that o£ wiring the fragments, but differing in two important particulars. The portions of the patella are maintained in contact by means of silver wire, passed subcutaneously through the extensor tendon and liga- mentum patellae. He has thus succeeded in obtaining osseous union in several cases. Compound fracture of the patella rarely occurs alone. It is almost necessarily comminuted, with great injury to the joint ; and results from direct violence of severe character, as some crushing force, or gunshot wound. On the other hand, the joint may be opened, but not otherwise injured ; as by an incised wound, with an axe, hatchet, or other cutting* instrument ; or by a lacerated or a gunshot wound. Treatment. — Special attention has been given to compound fracture of the patella, with an analysis of 69 cases collected in an elaborate paper, by Mr. Alfred Poland (Med.-Ghir. Trans., 1870), from which, I think, the following indications of treatment may be safely estab- lished. In compound fracture, uncoviplicated with fracture of the articular ends of bone forming the knee-joint, preservation of the joint, without or with anchylosis, should always be tried, in the first instance. The operation of wiring the fragments together, under anti- septic precautions, is, I think, here especially applicable. The wound is to be accurately closed with sutures. In the event of suppuration, free incision must be made, and a drainage-tube used. If the fracture be much comminuted, the removal of any loose fragments is always advisable ; but attached fragments had better be left, to regain adhesion, perchance, or be thrown off during suppuration. Failing to save the joint in a state of useful anchylosis, excision should be had recourse to, secondarily, that by sacrificing the joint the limb may still be preserved. The complication of fracture — when the articular end of the femur or of the tibia, or of both bones, is involved — must be submitted to primary excision of the joint ; but extensive crushing of the bones of the joint is the only condition which renders amputation justifiable; and, of course, it is the only resource, sm a, secondary opera- tion, whenever excision has failed. Bony union seems to be a not uncommon mode of repair in com- pound fracture of the patella, and especially when comminuted. BesuUs. — The total number of cases collected by Mr. Poland is 85 ; 69 being compound fracture of the patella alone, and the remain- ing 16 complicated with fracture of the other bones in the joint — ^a distinction not observed by Dr. G. Bouchard, of Paris, who had pre- viously written a valuable paper on this injury. Of the 69 uncomplicated fractures, the results were as follow : — ■ In 8 cases of fracture, with incised wound, the recoveries were 5 without anchylosis, 1 with complete anchylosis ; and the deaths 2, no operation having been performed. In 40 cases, with lacerated wound, the recoveries were 10 without anchylosis, 5 with partial and 11 with complete anchylosis, in 1 the condition was uncertain, and 4 were submitted to secondary amputation ; the deaths were 8 without any operation, and 1 after secondary amputation. In 21 cases, with gunshot wound, the recoveries were 3 without anchylosis. 830 SPECIAL PATHOLOGY AND SURGERY. Fig. 332.* Fig. 333.t 3 with partial and 7 with complete anchylosis, in 4 the condition was uncertain, and 1 was submitted to secondary excision ; the deaths wei-e 1 without any operation, and 2 after primary excision, by removal of the shattered patella. Of the 16 cases of fracture, com- plicated with fracture of the other bones of the joint, the recoveries were 2 without anchylosis, 2 with partial and 2 with complete anchylosis, and 1 was su.bmitted to primary excision, 2 to secondary excision — 1 being the removal of a ball from the head of the fibula — • and 1 underwent primary amputation ; the deaths were 1 without any operation, 1 after primary excision, 3 after secondary excision, and 1 after secondary amputation. Thus, in the total number of 85 cases, the recoveries were 65 : 20 without anchjdosis ; 10 with partial, and 21 with complete anchylosis ; in 5 the condition was uncertain ; after excision, primary, 1 ; secondary, 3 ; after amputation, primary, 1 ; secondary, 4. The deaths were 20 : 12 without any operation; after excision, primary, 3 ; secondary, 3 ; after amputa- tion, secondary, 2. The total relative mortality was less than 1 in 4. Fractuees of the Leg. — (1.) Feactdee of the Tibia AND FlliULA, OK OF EITHER BONE SINGLY. — Structural Conditions. — (Fig. 332.) The direction of fracture is usually transverse in the upper part of these bones, especially the tibia (Fig. 333) ; or it may be comminuted, and extend into the knee-joint (Fig. 334); in the middle or lower part, the fracture is com- monly oblique (Fig. 335), or transverse ; or perhaps less frequently commi- nuted. These differences are dependent on the causes of fracture, above and below. Displace- ment varies with the line of fracture. Angular displacement occurs with transverse fracture, the ends of bone remaining, partly at least, in contact. This displacement is produced by the flexor muscles of the calf drawing the bones backwards, aided by the weight of the leg, and pei'haps the tilting forwards of the ends of the upper fragments by the quadriceps extensor, inserted into the tubercle of the tibia. Longitudinal dis- placement, with the oblique fracture, is produced by the muscles of * Fractures of Tibia and Fibula. Diagram showing situations and lines of fracture ; chiefly from specimens in the Museum of St. Bartholomew's Hospital. — Tibia. — 1. Head, comminuted into knee-joint (St. George's Mus., 1, 199). 2. Below- head (Univ. Coll. Mus., 255). 3. Upper third. 4. Middle third. 5. Lower third, and below head of fibula. 6. Above ankle-joint, and the same in fibula. 7. Internal malleolus, and lower end of fibula, or Pott's fracture. 8. Lower end of tibia, into ankle-joint (St. Bart. Hosp. Mus., C. 22). Fibula. — 5, 6, 7, as in tibia. (Author.) t Univ. Coll. Mus., 255. FRACTURES OF THE LEG. 831 the calf drawing the lower fragments backwards and upwards, as in the specimen figured. Rotatory displacement of the lower fragments may be occasioned by inversion or eversion of the foot. Fracture of the tibia or fibula, singly, is attended with less dis- placement ; either bone acting as a splint to the other, and especially the massive tibia in relation to the fibula. Signs. — The signs with fracture of both bones are most marked. Deformity is presented corresponding with displacement ; an angular projection forwards will be ob- FiG. 334.* served in transverse fracture, high Fig. 335.t up ; a depression on the subcu- taneous surface of the tibia, in oblique fracture, lower down. Mo- bility and crepitus are easily pro- duced on handling the fragments ; and the outline of the leg is seen to be altered, the shafts of the bones above and below the seat of frac- tiire forming an angle ; with some shortening also in oblique fracture. Pain, as in other fractures, is oc- casioned by any movement, and marked powerlessness of the limb cannot be overlooked ; the leg can be moved about loosely as a flail below the fracture, and lies helpless in any position in which it is placed. Fracture of the tibia or fibula, singly, is attended with the same signs, but less pronounced than in the case of both bones ; the sound bone supporting the fractured bone. Fracture of the tihia presents the more obvious signs. On tracing down the bone, some irregularity will be discovered, and some mobility and crepitus of the fragments may be elicited. Fracture of the fihula in its upper two-thirds is obscured by the peroneal muscles, which overlie the bone in this portion of its extent. By following the fibula with the finger, from below upwards, the signs of fracture may be rendered perceptible. Causes. — Direct violence seems to be the only cause of fracture of these bones in their upper part. Any crushing compression, as by a wheel passing over the leg, or a jam between the bufliers of railway carriages, may thus be the occasion of fracture; both bones being broken at the same height, and transversely or comminuted. Gunshot injury acts in like manner. Indirect violence is, probably, the more common cause of fracture lower down. A fall or leap from a heio-ht, * St. George's Hospital Museum, 1, 199. Comminuted fracture of the head of the tibia, into the knee-joint. Bony union has jDartially taken place between the contiguous margins of the fragments, one of which is wanting. This extensive injuiy was produced by direct violence, in the person of a drayman, whose knee was jammed between a lamp-post and the wheel of his cart. Death ensued from suppuration and haemorrhage. t St. Bartholomew's Eiosi^ital Mus., C. 110. 832 SPECIAL PATHOLOGY AND SURGERY. Fig. 336.* the person alighting on his feet, breaks the tibia obliquely ; and the iibula next sustaining the shock, gives way; Fracture thus seldom occurs at the same height in both bones ; either bone yields at its weakest point — the tibia about the junction of its lower third, the fibula near its upper end. (See Fig. 332.) Union by bone usually takes place in about six weeks or two months ; in fracture of the fibula, a shorter period, three or four weeks. Some deformity, from overlapinng and short- ening, to about half an inch in extent, is apt to result, in perhaps not less than half any number of cases when carefully examined. Commonly, the upper fragment overrides the lower, and — observes Hamil- ton- — -oftener a little upon the inner than upon the oiTter side. The natural axis of the limb is not un- frequently changed ; the lower part having fallen backwards, or inclining inwards, occasionally out- wai'ds (see Fig. 335), or forwards. In the result here represented (Fig. 336), angular displacement inwards has taken place to an extent which shows the ex- treme deformity that may occui" from inattention in the course of treatment. Treatment. — The fragments having been brought into apposition by moderate extension, aided by suf- ficient flexion of the knee, and of the thigh on the abdomen, the leg may be laid in Mclntyre's double- inclined plane splint, properly padded, or that ap- paratus as modified by Liston (Fig. 337). This position of the limb overcomes displacement of the upper and lower fragments, as arising' from muscular action ; but displacement of the lower fragment, owing to any dropping of the leg, is still further counteracted by supporting the foot in a short sock with a tape attached to the toe, which is wound round a brass button over the end of the foot-piece of the splint. A roller is then applied around the foot and this portion of the splint to maintain Fig. 337. extension, and continued around the leg and splint, upwards to the lower part of the thigh, or interrupted, if the fi"acture be compound. Mclntyre's double-inclined plane may be fixed by a vertical iron support under the foot, which is screwed to a flat board, itself placed underneath the mattress of the bed on which the patient lies. A cradle is placed over the leg to raise the bed-clothes. A more com- * St. Bartholomew's Hospital Mus., C. 97. FRACTURES OF THE LEG. 833 fortable arrangement, and equally efficacioas, ia relation to the union of fracture, is to suspend and swing the limb in a case of tin or wood, secured by cross straps ; the limb being suspended by a chain from two pulley- wheels which run upon a horizontal bar, supported by a light iron frame. Such is Salter's cradle-swing apparatus (Fig. 338). A double motion is thus allowed : a lateral swing, for ease of position to the body ; and a motion in the axis of the limb, for the prevention of longitudinal displacement of the fragments, by any downward shift of position telling in that direction. Various other apparatus have been designed for the adjustment of fractures of the leg. A fracture-box, consisting of three splints— a leg-rest with foot-piece, and two supporting side-pieces Fig. 338. — may be used and swung in like manner. Or, the limb having been flexed, and the fracture reduced, a well-padded external splint, corresponding in shape to this attitude, is applied ; the splint extending from just above the knee, and having a side foot-piece ; a short splint is placed on the inner side of the leg, reaching from the bend of the knee to just above the inner mal- leolus ; the whole is then secured by a roller-bandage, and the limb laid on its outer side, with the body also inclining to that side. This method of treatment was originated by Pott, and it is strongly advocated by Hamilton ; for the alleged reasons, that displacement, with ultimate deformity, is thereby prevented — particularly as resulting from an inclination of the lower part of the leg backwards — and thus also a tendency to ulceration of the heel. But I have never experienced any diffi- culty or unsatisfactory result, which could be fairly attributed to Mclntyre's splint, in the treatment of ordinary fractures of the leg ; and the results have been, in many cases, most satisfactory, — no deformity being perceptible to the eye, nor could any irregularity be felt on passing the finger along the tibia. The wire side-splints — devised by Bauer — form a very simple and efficient apparatus, padded with cotton wadding. They can be readily adapted to the form of the leg, and thus keep the fragments well adjusted. But I would recom- mend the additional prolongation of both splints around the sole of the foot, forming a foot-piece (Fig. 339). A roller-bandage, carried up the leg, will secure the whole in position. Plaster of Paris splints, as modified by Mr. Croft, answer the same purpose. Two side splints are used, instead of one encircling the limb, as in the ordinary " immovable apparatus." Each splint consists of two pieces of flannel, cut to the form of the limb, — conveniently from the patient's stocking, and of sufficient width to leave an interval of half an inch between them, before and behind. The inner piece of flannel is overlaid by the outer piece, soaked in wet plaster of Paris the consistence of cream. These VOL. I. 3 H 834 SPECIAL PATHOLOGY AND SURCJERY. splints are applied in a moist state, and moulded to the limb ; and are then retained in position by a muslin roller-bandage. The interval between the splints allows of the relief of tension, by slitting up the layer of muslin bandage in front, the intermediate layer behind form- ing a hinge for the readjustment of the splints. Another muslin roller is then applied. Fracture, very oblique, or comminuted, may occasion some difhculty as to the retention of the fragments in apposition. It is here that division of the tendo-Achillis — Laugier's proposal — seems a justifiable procedure, with the view of correcting the displacement arising from muscular contraction. This resource certainly proved effectual in one case under my care, where the tibia Avas broken just above the ankle-joint, attended with marked retraction of the foot, and threatened protrusion of the upper end of the fracture. Erichsen divided the tendon, apparently with less success, in two cases. (2.) Fracture of the Lower Exds of the Tibia and Fibula, ok of EITHER Bone singlt. — Structural Conditions. — Five forms of fracture are liable to occur near the ankle-joint: — (1) fi-acture of the lower end of the tibia, obliquely from without downwards ai:d inwards, and of the fibula, about three inches above the ankle (Fig. 340) ; (2) fracture of the fibula about three inches above the ankle, with the tip of the Fig. 340.* Fig. 341.t internal malleolus of the tibia, this double fracture constituting Pottos Fracture, a very common form (Fig. 341) ; (3) fracture of the fibula two to three inches above the external malleolus, with rupture of the * St. Bartholomew's Hospital Museum, C. 18. 1 Ibid,, C. 22. t Ibid., C. 137. FEACTURES OF THE LEG. 835 internal lateral or deltoid ligament ; (4) fracture of the internal malleolus of the tibia ; (5) fracture of the articular end of the tibia, involviug the ankle-joint (Fig. 342). Displacement in these fractures varies : in fracture of the Tibia and Fibula, the upper fragment of the Tibia usually projects inwards, and both fragments of the Fibula also in that direction ; in fractures of the Fibula and inner malleolus of the Tibia, or of the Fibula alone, with rupture of the internal lateral ligament, the same displacement of the fibular fragment occurs — i.e. inwards towards the tibia; in fracture of the internal malleolus of the Tibia, displacement of this fragment is still inwards. Dislocation takes place, not unfrequentlj, in connection with each of these fractures, and with that in particular of the inner malleolus alone ; which, I believe, seldom happens without, and from, dislocation of the tibia outwards. Respecting fractures of the fibula, Hamilton writes : " In all the fractures which have been produced by falls on the bottom of the foot, and in all except one produced by a slip of the foot, the accident was accompanied with a dislocation of the ankle ; the foot being turned outwards." The exceptional case was doubtful. Signs. — Deformity is presented, corresponding to the displacement of one or both fragments, with, perhaps, dislocation ; and mobility, with crepitus, are discovered on handling the part. Fracture of the lower end of the tibia obliquely, and of the fibula, produces a notably increased breadth of the ankle-joint, between the malleoli, with some eversion of the foot, and obliquity of its axis, the toes being turned outwards and the heel inwards. Fracture of the lower end of the fibula, and of the internal mal- leolus, or Pott's fracture, is accompanied with a very notable eversion of the foot (see Fig. 341) ; the sole being turned somewhat upwards, as well as outwards, so that the outer edge is directed upwards, and the inner side downwards, on which the patient rests. Thus, Sir A. Cooper, describing his own case, observes : " I broke my right fibula by falling on my right side, whilst my right foot was confined between two pieces of ice; and I could with difficulty support myself to a neighbouring house by bearing on the inner side of the foot." Causes. — Indirect violence is certainly the more common cause of these Fractures ; either by a fall or jump fi'om a height, breaking the tibia, and fibula secondarily ; or by violent eversion or inversion of the foot, breaking the fibula, with the internal malleolus, or rupturing the deltoid ligament; or snapping off the inner malleolus alone. The relative frequency of the two latter modes of indirect force has been doubted ; most surgical authorities regarding violent eversion as the more frequent; but Dupuytren found inversion to be the ordinary occasion of fracture. Thus, in 200 cases of broken fibula, 120 were produced by inversion or twisting the foot inwards, and 60 only by eversion or rolling of the foot outwards ; the remaining 20 arising from direct violence applied to the bone itself. Union of fracture — not involving the ankle-joint — takes place readily ; and without any appreciable displacement, under proper management and supervision. Treatment. — In all these Fractures, Mclntyre's double-inclined plane splint, or Listen's modification of that apparatus, will be found a most efficient means of retaining the fragments in position ; and the 836 SPECIAL PATHOLOGY AND SURGERY. more so proportionately to their mobility. The trough ia which the leg rests steadies the upper fragments ; the foot-piece counteracts any tendency to twisting of the foot inwards or outwards ; and the sock supports the heel. Any marked tendency to eversion of the foot, as in Pott's fracture, may be more effectually restrained by Dupuytren's splint : a short, straight splint applied to the inner side of the leg, from the knee to the foot (Fig. 343). A pad should be doubled just opposite the inner Fig. 343. Fig. 344.* malleolus, and a roller wound round the foot and splint in a figm^e-of- eight form, thereby drawing the foot inwards over the thick pad as a fulcrum, and the roller is then continued upwai'ds to the knee to steady the splint. Some tendency to anchylosis of the ankle-joint must be met by timely recourse to passive motion, and relapsing swelling may require the support of a bandage for a considerable period. Gortipound Fractures of the Leg, and of the Ankle-joint. — In the former situation, compound fracture of the Tibia and Fibula, or of the Tibia alone, happens more frequently than similar injury of any other bone. It was, therefore, selected as the typical form of such Injuries in describing Compound Fracture generally (Chap. XXXI.). Its Pathology and Treatment are there considered. In relation to the ankle-joint, com- pound fracture presents no differences of practical importance. The same considerations guide as to the pre- servation of the limb, excision, and amputation. Fractures of the Tarsal, Meta- tarsal Boxes, and Toes. — These bones are liable to both Simple and Compound Fractures, and with the usual signs of such injuries. The Astragalus is very seldom fractured, without fracture of other • St. George's Hospital Mus., 1, 247. Fracture of the astragalus, separating the superior third from the remainder of the bone. The lower fragment is partially dislocated. All the ligaments of the ankle-joint are torn, excepting the internal lateral, which is attached to the periosteum, as the only connection between the bones of the leg and the foot. This rare fracture was caused by direct violence, an omnibus wheel passing over the foot. Amputation, and recovery. (See also Brit. Med. Journal (1862), part i. p. 328.) In another case, with fracture of the astragalus, the foot, and therefore the os calcis, was dislocated backwards and inwards, with some rotation (St. Thomas's Hosp. Mus., B. 29). FEACTUKES OF THE LEG. 837 tarsal bones. The line of fracture may be transverse, or longitudinal, or perhaps horizontal (Fig. 344), sometimes attended -with comminn- tion ; and with, or without, impaction of the fragments. Usually, the injury is complicated with dislocation of the foot outwards, or inwards, and with fracture of the fibula. Grenerally also, the dislocation is compound. The signs will be some crepitation and mobility of the fragments on flexing and extending the foot, backwards and forwards ; but there may be no displacement — the bone being held in position betwixt the malleolar arch and the calcaneum, although sometimes the upper fragment is driven up and wedged between the ends of the tibia and fibula. As accompanied with dislocation, the additional signs of that injury will of course be presented. Causes. — Indirect violence seems to be the more common cause of fracture through the astragalus ; in 10 cases collected by Dr. B. Monahan, 9 occurred by a fall from a height on the feet, 1 only from direct force, crushing the foot. Treatment must be guided by the amount of injury. Thus, the reduction of displacement can sometimes be accomplished, and then maintained in a Mclntyre's splint ; but excision of a displaced fi'agment will be necessary, •'' ^^- ^^'^• when it cannot be reduced and kept in posi- tion ; and amputation of the foot is the only resource of treatment for a crushing injury. Compound fracture of the astragalus, with perhaps protrusion of a displaced fragment, may be produced, partly by the displacement, but principally by the violence of the injury. This condition of fracture generally admits only of amputation. Fracture of the os calcis presents particulars worthy of notice. The bone is broken trans- versely, or comminuted occasionally, with per- haps impaction ; and the line of fracture may be either behind the lateral ligaments, or throug'h the hody of the bone (Fig. 345). In the former situation, there will be some displacement, the posterior fragment being drawn upwards by the muscles of the calf ; in the latter situation, this fragment is retained in position by the lateral ligaments and the strong interosseous ligament. The Signs of this fracture vary accordingly. Marked flattening of the heel on its plantar aspect, or even a depression upwards, and projection of the fragment posteriorly, with mobility and crepitus, denote fracture behind the lateral ligaments ; of which injury I have had one well-marked case. Comparative absence of these signs, and particularly of the deformity of the heel, denotes fracture more anteriorly, or that across the body of the bone. Catises. — Direct violence is, probably, the only cause of fracture ; as by a fall from a height, the person alighting on his heels, or by a cai't-wheel passing over and crushing the foot. Very rarely, the os calcis may be broken transversely, by the powerful action of the muscles of the calf, in jumping or falling on the toes. Twelve such cases are i-ecorded; 8 having been collected by Malgaigne, 2 by South * St. Bartholomew's Hosp. Mus., C. 126. 838 SPECIAL PATHOLOGY AND SURGERY. in Chelius's Surgery, and 2 by B. Cooper in his edition of Sir A. Cooper's work. Treatment consists, as usual, in the adjustment of the fragments, "with relaxation of any opposing muscular action ; and their retention in position. A gutta-percha or pasteboard splint must be contrived according to the fracture ; and, when necessary to place the leg in the flexed attitude, with the heel drawn up, this position may be main- tained by the apparatus used for rupture of the tendo-Acliillis. Or, the tendency to displacement and the more severe contusion may require the support of a Mclntyre's splint, used as a double-inclined plane. In this, and other fractures of the tarsal bones, passive motion should be employed in time to prevent anchylosis. Compound fracture generally allows only of excision or amputation. But — as in regard to the hand — the removal of any portion of the foot should be guided by great circumspection and judgment ; having due regard to the extent of the injured part, and the preservation of this valuable member. CHAPTER XXXIII. diseases of bone. Inflammation of Bone. Bone, or the Osseous tissue, with its investing Periosteum, and the En- dosteum or Medullary Memhrane of long bones, are, severally, subject to Inflammation. But the pathology of Inflammation as affecting each of these structures is intimately associated, and they are commonly affected simultaneously, or consequently. It will, therefore, be more natural to describe in order, first, the structural alterations pertaining to Ostitis, Periostitis, and Endostitis, and then their diagnostic characters, causes, consequences, and treatment. (1.) Ostitis, or Inflammation of Bone. — The cellulo-fibrous net- work — the organic basis of the lamellee in the compact and cancel- lated structui'e of Bone, with the vascular network ramifying in the Haversian canals and cancelli, is alone the seat of inflammation ; the inorganic matter, superadded to the fibrous network in the process of ossification, not being subject to any perversion of nutrition or other vital change. The blood-vessels become enlarged — as shown by Yon Bibra — giving an injected red appearance to the portion of bone undergoing inflammation ; and the fibrous matrix, probably, passes into a state of fatty transformation, as in inflammation of most other textures. The inorganic or earthy matter undergoes merely a disintegrative separa- tion from the fibrous matrix with which it was intimately connected, but retains its chemical composition, and is then absorbed. Such are the earliest structural and chemical alterations in the inflammation of bone. A change of consistence — softening — accompanies this fatty OSTITIS, OE INFLAMMATION OF BONE. 839 Fig. 346.* liquefaction of the organic matrix and unloosening of the inorganic matter. But the Haversian canals, lacunse, and canaliculi soon become the seat of disintegration and absorption, -whereby these natural cavities are rendered more conspicuous under the microscope ; or, opening into neighbouring cavities, iiTCgular spaces are formed. The compact structure thus acquires a rarefied or porous character, presenting the appearance of cancelli ; while the cancellated portion is exaggerated ; as in the neighbourhood of necrosis or death of bone, when consequent on inflammation (Fig. 346). Within these spaces the fattT matter and earthj salts — detritus of the osseous tissue — accumulate ; and the products also ot inflammation are deposited. They consist of plastic lymph, with emigrant pale blood-cor- Fig. 347.t puscles, or pus ; the one kind of deposit resulting in induration and hypertrophy of the bone (Fig. 347), the other in increased softening and disorganization. In the medullary texture, many of the new cells are of large size, and contain several nuclei — like myeloid corpuscles in growing bone, and the fat-cells lose their contents. The description of these changes belongs to the conse- quences of Ostitis. Scrofulous ostitis structurally resembles simple inflammation of bone ; the osseous substance being disintegrated and absorbed. Thence the bone is light, soft, and oily. But the rarefied cancelli or spaces in the compact texture are filled with peculiar pro- ducts ; a red jelly-like matter, or occasionally, a deposit of tubercle. The former is always diffused. The accompanying chemical changes — according to Dr. Black's analyses — consist in a considerable in- crease of fat in the diseased bone, a large diminution of the salts of lime, a diminution of the organic matrix, and an increase of the soluble salts. Asso- ciated with these destructive alterations, minute projections of bone from the walls of the cancelli evince an attempt at osseous repro- duction, thus corresponding to the induration or sclerosis which results from simple inflammation of bone. Tubercle in bone maybe either diffused or circumscribed ; the latter form being comparatively rare. Diffused tubercle occurs commonly in the shaft of long bones, or in the bodies of the vertebrse, and more often of the dorsal or lumber region of the spine. It occupies the cancelli, and appears as a nodulated, or granular, yellowish mass of soft consistence ; extending frequently along the whole length of the * St. Bartholome-w's Hosp. Mus., 1, 132. Necrosis of -wall of femur, near the lesser trochanter, with rarefaction of the cancellous structure between it and the great trochanter. t Ibid., A. 3. 840 SPECIAL PATHOLOGY AND SURGEKY. shaft. Regarding this as sci^ofulous matter, Virchow and Billroth would restrict tubercular deposit to the form of greyish, somewhat transpai'ent aud firm granulations, — the miliary tubercle, so called. Circumscribed tubercle is deposited most frequently on the outside of the skull, beneath the periosteum, constituting the strumous node ; and scarcely less frequently, in the cancelli of the articular end of a long bone, usually the tibia. Tubercle in bone sometimes becomes actually encysted ; as well as in the lungs, in which organs I have seen cretaceous tubercle enclosed in a distinct cyst. Tubei'cular deposit, in either form, is prone to undergo softening ; the diffused, it is said, passing into this state, less frequently and rapidly than the circumscribed. This change is always one of serious consequence. The softening of tubercular deposit induces, or is attended with, inflammation of the surrounding bone, and suppuration. An abscess thence results, and the bone around becomes condensed and indurated. Or Caries and Necrosis ensue, destroying the osseous textui'e. Thus, softened tubercle, a curdy, unhealthy pus, and carious or necrosed portions of bone are commonly found associated and intermixed. The matter extending, may sometimes find its way to the surface ; and a chronic abscess, communicating with the bone, remain, discharging, or with little disposition to heal. Such is the psoas abscess, as depending on caries of the dorsal or lumbar yertebrse. Or, the matter may find its way to a neighbouring joint, destroying the articulation. But the comparatiyely limited localization of tubercle diminishes the perilous results of these destructive changes. If the shaft of a long bone be affected, the articular ends are, generally, free ; and if either end of the bone be the seat of tuberculous deposit, the shaft escapes. Syphilitic ostitis does not seem to be distinguished from simple inflammation of bone by any structural differences of practical importance. (2.) Periostitis.- — Inflammation of the periosteum is usually con- nected with that of the bone itself — ostitis. The periosteal membrane becomes more vascular, thickened, softened, and loosened Fig. 348.* from its connection with the subjacent bone. These altera- tions may be seen, sometimes, in the bone of a stump, after amputation. Subsequently, an osseous deposit may take place between the periosteum and bone, with some enlarge- ment and induration of that portion of bone, constituting a node (Fig. 348). A syphilitic node, which may be regarded as the type, arises from an effusion of lymph between the periosteum and bone ; and proceeding from the former, at length involves the bone. Such nodes have eventually an ossific character. But not unfrequently, the swelling is, gummatous, — consisting of cell-proliferation and degenerative transformation of the connective tissue ; forming a soft, gelatinous or doughy lump ; which, however, becoming caseous or calcified, may resemble the ordinary node. A strumous node, on the other hand, consists of scrofulous matter between the periosteum and bone, in consequence of a carious .state of that portion of bone. * St. Bartholomew's Hosp. Mu.?., A. 23. ENDOSTITIS. SIGNS OF INFLAMMATION OF BONE. 841 Fig. 349.* ,*^i pi\ Suppuration will be noticed as a consequence of Periostitis. (3.) Endostitis. — Inflammation of the endosteum, or membrane lining the medullary canal and cancelli, is, probably, of less freqiient occurrence. This membrane, however, undergoes analogous changes to those of the periosteum, when inflamed — increased vascularity, and thickening. A deposit of lymph or pus ensues, in consequence of endostitis (Fig. 349). The section of a tibia, in this illustration of endostitis, shows not only that suppuration has taken place in the medullary canal and adjoining cancellous tissue, but also that the latter structure has become consolidated, in parts, by the production of new bone ; thus corresponding to the result of ostitis, which has also occurred, as shown by the great thick- ness of the walls of the bone. Signs. — Ostitis, affecting the deeper portion of the substance of a bone, is unattended with any appreciable signs, in the first instance. A deep- seated wearing" pain generally precedes any alteration of external appearance. This pain is more severe at night, and aggravated by changes of weather ; thus resembling rheumatic pain, for which it may be mistaken. Enlargement of the bone at length becomes perceptible ; with, perhaps, some redness, oedematous swelling, and tenderness of the integu- ment. This swollen state of the integument renders any enlargement of the bone more apparent than real. Softening of the bone, in some portion of its substance, may eventually be detected on pressure; but the diagnosis will be sufficiently obvious, without subjecting the patient to the pain of such examina- tion. Inflammatory fever, of varying intensity, ac- companies these local symptoms. Scrofulous ostitis is attended with more con- siderable enlargement of the bone, and of an indolent character. The surrounding integniments are oedematous, white, and painless ; becoming some- what red and tender, as suppuration supervenes. The concomitant symptoms of scrofula will also determine the diagnosis. Syphilitic ostitis must be diagnosed entirely by the concurrence of present and past symptoms of Syphilis. Periostitis. — The symptoms are similar to those of ostitis, but more simultaneous and superficial. A painful, puffy swelling is presented, the pain subject to exacerbations, and the swelling acquiring a bonv hardness. These diagnostic characters are well illustrated by an ordinary syphilitic node in a subcutaneous bone, as the shin ; or, not unfrequently, in other bones — the frontal, clavicle, or sternum. A gummy node differs especially in two characters ; the swelling is almost painless, or scarcely tender on pressure ; and it slowly undergoes ulceration — disclosing an ash-grey, sloughy lump, as of matted cellular texture, and at length exposing the bone in a carious state ; the integu- mental aperture having ii-regular, undermined edges or flaps, with * St. Bartholomew's Hosp. Mus., 1, 131. 842 SPECIAL PATHOLOGY AXD SURGERY. Fig. 350. surrounding bluish discolouration. The ulcer is very intractable. Sometimes a periosteal gumma atrophies and disappears. Although unaccompanied with the febrile disturbance of a common painful node, the gummy swelling is attended with the usual constitutional cachexia of tertiary Syphilis. This growth often attains to a larger size than the osseous syphilitic node ; nearly embracing the tibia perhaps, it may simulate the appearances of a sarcomatous or encephaloid tumour of the bone. Endostitis is not characterized by any peculiar symptoms, apart from those of Ostitis. Like the inflammation of other parts, ostitis and periostitis may be distinguished as acute or chronic, according to the more or less severe character of the symptoms, and their duration. In the latter or chronic state of osteal or pei'iosteal inflammation, the patient, worn down by long-continueil pain and sleeplessness, presents the consti- tutional symptoms of hectic. Variety of Chronic Ostitis — "OsteitisDeformans." — Under this title, Sir James Paget has described an hypertrophy- and softening of the bones, as the result apparently of chronic inflam- matory change ; and the chief characters of which disease are best expressed in his own abstract of the original communication to the Royal Medical and Chirurgical Society (1877) : — This form of chronic ostitis " begins in middle age or later, is very slow in progress, may continue for many years without influence on the general health, and give no other trouble than those which are due to the changes of shape, size, and direction of the diseased bones. Even when the skull is hugely thickened, and all its bones exceedingly altered in structure, the mind remains unaffected. " The disease alfects most frequently the long bones of the lower extremities and the skull, and is usually symmetrical. The bones enlarge and soften, and those bearing weight yield and become unnaturally curved and misshapen, suggesting the proposed name ' osteitis deformans ' (Fig. 350). " The spine, whether by yielding to the weight of the overgrown skull or by change in its own structures, may sink and seem to shorten, with greatly increased dorsal and lumbar curves; the pelvis may become wide ; the necks of the femora may become nearly horizontal. But the limbs, however misshapen, remain strong and fit to sup- port the trunk. " In its earlier periods, and sometimes through all its course, the disease is attended with pains in the affected bones, pains widely various in severity and variously described as rheumatic, gouty, or neuralgic, not especially nocturnal or periodical. It is not attended with fever. No characteristic conditions of urine or faeces have been found in it. It is .not associated with any constitutional disease unless it be cancer. * St. Bartholomew's Hosp. Mus., A. 183. Sections of Tibia and Patella. OSTEITIS DEFORMANS. 843 " The bones examined after death show the consequences of an inflammation affecting, in the skull, the whole thickness, in the long- bones chiefly the compact structure of their walls, and not only the walls of their shafts, but in a very characteristic manner those of their articular surfaces. " The changes of structure produced in the earliest periods of the disease have not yet been observed ; but it may be believed that they are inflammatory, for the softening is associated with enlargement, with excessive production of imperfectly developed structures, and with increased blood-supply. " Whether inflammation, in any degree, continues to the last, or whether, after many years of progress, any reparative changes ensue, after the manner of a so-called consecutive hardening, is uncertain." Causes. — Inflammation of bone usually results from external violence or from exposure to cold or damp ; but it arises under the influence of some predisposing constitutional condition of disease. These predisposing causes comprise secondary or constitutional syphi- lis, or the excessive influence of mercury — of rare occurrence nowa- days ; the scrofulous taint ; rheumatism ; fevers ; and probably other conditions affecting nutrition. Either class of causes — the traumatic or the constitutional — ^may be alone sufiicient to induce osseous in- flammation. The bones most liable to inflammation are, however, those most exposed to the action of external agents. Hence, the tibia, cranium, and especially the frontal bone, the clavicle, sternum, ribs, and bones of the foot and hand, are most commonly affected. Consequences. — The consequences of inflammation of bone have been incidentally noticed in describing its structural conditions, and particularly in connection with scrofulous ostitis. They may now be more definitely stated as follow : — (1.) Ab- sorption and rarefaction of the bone having taken place, the osseous texture may be found in this state, before the supervention of much deposit — representing the osteopo- rosis of Rokitansky, or a form of atrophy as affecting bone. (See Fig. 346.) (2.) Induration, or sclerosis, having taken place, an increasing deposition of plastic lymph and its ossification results in considerable thick- ening of the substance of the bone (see Fig. 347), and perhaps irregular osseous deposit on its free surfaces (Fig. 351). Thus, a long bone becomes thickened in the diameter or substance of its shaft, and deposition pro- ceeding within the medullary canal, its bore is narrowed ; while periosteal deposit, and perhaps osseous out-growth, at the same time enlarge the circumference of the bone — as in the analogous production of external callus, occa- sionally, during fracture-union. Elongation of a long bone is, sometimes, consequent on its inflammation. The tibia has thus become longer than its fellow by nearly two inches. The osseous substance, resulting from inflammatory induration, is more solid, heavier, and harder than that of healthy bone, increasing even to the consistence of ivory ; and the nutritious foramina are said to be increased in size. This state of hypertrophy corresponds to the inflammatory solidification of parenchy- * St. Bartholomew's Hosp. Mus., 1, 375. EiG. 351. 844 SPECIAL PATHOLOGY AND SURGEKY. matous organs. But, as regards bone, it is a termination by restoration to health, or something beyond the natural condition of healthy bone. (3.) Suppuration of bone — another consequence of inflammation, of an opposite character to induration — merits a separate notice; also Caries, or ulceration of bone ; and Necrosis, which is analogous to sloughing or mortification of the soft textures. Treatment. — In traumatic and acute inflammation of bone — whether in the form of Ostitis or Periostitis — the ordinary remedial measures for inflammation will nsnally suffice. "Warm fomentations, leeches, and rest, with the administration of calomel and opium, are appropi-iate. Billroth strongly recommends iodine paint applied to the whole limb, continued until large vesicles form, and renewed when this vesication disappears. In constitutional and chrmiic inflammation this treatment must be supplemented, or partly superseded, by the general tx"eatment for secondary syphilitic affections, scrofula, or rheumatism. Iodide of potassium is thus often singularly efiicacious in syphilitic or rheumatic ostitis or periostitis. Should the disease be, as frequently, of scrofulotis character, then the patient must be subjected to the renovating influences principally of pure air, and sea-bathing — if it agrees — coupled with plain nutritious food, rein- forced by tonics — especially the sulphate of iron and quinine, and the iodides of iron and of potassium, respecting the efficacy of which I know less. Cod-liver oil is an excellent adjunct both to our dietetic and medicinal resources. But whenever the osteal or periosteal in- flammation is a manifestation of any constitutional disease, the recovery- is very lingering, and the course of treatment will be protracted. The sufferer is often burthened with other fruit off the same tree, and wasted with misery ; we must encourage him, or her, to look for happier days. Tension and insupportable pain are more readily and permanently relieved by free incisions, than by any medicinal treatment. In peri- osteal tension, these incisions should be made down to the bone ; in tension resulting from ostitis, an incision may be prolonged, by means of a Hey's saw, through the bone, down to the medullary canal. Trephining the bone has been resorted to for the relief of osseous tension. Chronic thickening, unattended with much pain, may be re- moved or lessened by the application of blisters, iodine and mercurial ointments. When depending on constitutional causes, chronic ostitis is often associated with caries or necrosis, and will necessitate one or other of the operative procedures for removal of the dead bone. SuppuEATlo^f OF Bone. — Suppuration, in connection with bone, is liable to take place in either of the three situations described with reference to inflammation, and it may be either diffused or circum- scribed ; these conditions being also, less definitely, acute or chronic suppuration respectively. Thus we recognize — (1) Osteo-myelitis, diffuse suppuration of bone, within the medullary canal and cancelli ; (2) Diffuse Periostitis, and Periosteal Abscess ; and (3) Circumscribed abscess of Bone, within either the cancellated or compact structure. (1.) Osteo-myelitis. — This condition certainly occui-s, and not un- frequently ; but it is less often recognized at the bedside than in post-mortem examinations. The results are disintegration of the cancellated structure (Fig. 352), and diffuse suppuration, the can- celli being found loaded with pus, while the medullary merrjbrane is SUPPURATION OF BONE. 845 Fig. 352.* Fig. 354.1 Fig. 353.t injected and often sprinkled witli ecchymoses ; the periosteum having become involved usually, shows more or less inflammatory hyperEemia and thickening, and is often partly separated from the bone ; but the compact osseous texture has not generally undergone any appreciable change (Fig. 353). In the typical specimen here represented, the section of a tibia, from a boy eighteen years of age, exhibits the effects of acute inflammation both in its medullary canal and in the periosteum. Lymph and pus are abundantly de- posited in the cancellous tissue throughout its whole extent. The periosteum, separated from the shaft in nearly its whole length, is very vascular, thick, pulpy, and velvety on its inner surface. At this stage, in the larger bones, the disease usually terminates fatally. Otherwise, the pus may penetrate into adjoining parts, probably into the nearest joint, as the knee (Fig. 354) ; or central necrosis may ensue. In young persons, suppuration is apt to commence in the epi- physis, as in the knee- joint; affecting the end of the femur, or the head of the tibia, as one or other bone is the seat of epiphyseal mye- litis. The epiphysis becomes detachedfrom the shaft; or its sepa- ration may be conse- qu.ent on myelitis of the shaft. This will hap- pen in about ten days, or at a later period. Sometimes both epi- physes, upper and lower, are involved, Billroth having seen a double separation oc- cur once in the tibia. Synovitis is induced by myelitis — affecting the epiphysis, and the synovial inflammation being usually of an acutely suppurative character, the joint is soon destroyed. Sometimes, the joint- abscess is the result of pysemic infection from the myelitis. The Signs — during life— are neither absolute nor obvious. Separation of the periosteum, with diffused pain in the bone, and diffuse inflammation of the integuments, are equallj the * St. Bartholome-w's Hosp. Mns., 1, 4. Drawing. f Ibid. 1 195. X Eoyal Free Hospital. (Author.) ^ ri \\ 846 SPECIAL PATHOLOGY AND SURGERY. symptoms of osteo-myelitis and of diffuse periostitis. An absence of effusion between the periosteum and bone is distinctive of osteo- myelitis ; but this condition can scarcely be determined by external examination of the bone, and is often rendered more obscure by the superimposed oedematous swelling (Fig. 355). With detachment of the epiphysis, there is mobility, and perhaps crepitus, of the part, as in fracture ; and dislocation may be pi-oduced by muscular action. But these signs are found to coincide with the line of epiphyseal di.sjunc- tion, the joint itself remaining unchanged. Perhaps a sinus-openino- will admit a pi^obe into the detachment, and thus leaye no doubt as to Fro. 355.* what has occui'red. In the event of osteo-myelitis supervening on am- putation, the end of bone — sometimes projecting from a conical stump — presents a fungoid, reddish, purulent medullary membrane, projecting from the canal ; the adjoining areola of cancellous texttire having a pale appearance, infiltrated with purulent matter, and readily breaking down under the finger ; while the hyper-vascular and pulpy periosteum IS detached and everted to some extent from the ring of compact bone. On passing a pi-obe up the medullary canal, the membrane bleeds freely w^hen the healthy portion is reached ; thus indicating perhaps that a limited portion only of the bone is affected. The cause is usually some injury implicating the medullary mem- brane and cancellated structure of the bone affected. Thus, osteo- . myelitis not unfrequently follows compound and comminuted fractures, * Eoval Fi-ee Hospital. (Author.) SUPPURATION OF BONE. 847 gunshot wounds, amputations, and other operations exposing tlie medullary canal. It runs a rapid course, is commonly succeeded by pyemic infection, and thence terminates fatally. Treatment. — Preventive measures afford the only reasonable chance of anticipating this issue ; the cure of pysemia being beyond the reach of any known remedial agents. The ambiguous symptoms of diffused pain in a bone, with perhaps some oedematons swelling, Avill therefore warrant the Surgeon in ascertaining the state of the periosteum, to determine the diagnosis. Under these circumstances, an early, free incision should be made down to the bone. If the periosteum is discovered to be separating, without any notable effusion between it and the bone, it will be justifiable to trepJiine the bone, with the view of giving exit to any matter which may have formed in the deeper cancellated structure. This procedure should generally be taken with antiseptic precautions; although my own experience, in an hospital under healthy hygienic conditions, has not shown any difference in favour of the treatment for osteo-myelitis, so conducted. Dr. H. Demme, of Berne, affirms that the liability to septic infection is greater in the more acute stage of the disease ; accordingly, he post- pones incision until about the end of the second week, — meanwhile painting the limb with iodine-pigment to beyond the boundary of the swelling. The results compare most favourably with those of the early incision — originally advocated by Chassaignac. Of 17 cases, 4, at the earlier period of surgical interference, died in succession ; the remaining 13, at the later period of incision, all recovered. Excision of the affected portion of bone, — as a stump-end, or amputa- tion of the limb, must be had recourse to, as more extreme measures. I doubt, however, whether the limits of the disease can ever be so definitely determined, in the con- tinuity of a long bone, as to warrant the partial operation of excision ; and in the removal of a limb, amputation should not be performed through the continuity of the bone, but above the joint of the bone affected with the diffuse inflammation of osteo- myelitis. (2.) Diffuse Periostitis. — This diseased condition is of rather frequent occurrence ; but it has hitherto been less noticed in surgical works than its import- ance demands. Diffuse Periostitis — according to Mr. Holmes' observations- — appears to consist in the partial separation of the periosteum from the bone ; by effusion of lymph or other products on the surface of the latter. Copious suppuration soon spreads along the bone, detaching the periosteum, often from one end of the bone to the other (Fig. 356). At an early period, neither the periosteum nor the surface of the bone is visibly inflamed. The latter, indeed, may look white and bloodless, or sometimes slightly worm-eaten ; it yields, on pressure, large drops of blood from the periosteal vessels passing into it, and its superficial layers are more readily separable from * St. George's Hosp. Mus. Diffuse periostitis of the tibia, with necrosis and detachment of the lower epiphysis. Fro. 356.* 848 SPECIAL PATHOLOGY AND SURGERY. the deeper osseous texture, than in health. Necrosis is soon estab- lished, the whole diapbysis of the bone usually perishing ; leaving the articular ends unaffected, and therefore not involving the neigh- bouring joint. Sometimes it does not escape. The long bones are more often affected than the flat or irregular bones ; and, in the great majority of cases, the femur or the tibia. Signs. — Arising insidiously, an oedematous, painful swelling is presented — diffuse cellular inflammation — resembling acute fascial rheumatism. But suppuration soon following, the diagnosis is at once determined. The causes would seem to be some injuiy to the bone, occurring, however, in a scrofulous or weakly person. The disease is said to be met with more commonly about the age of puberty, and in boys more often than in girls. It rapidly runs its course ; pyaemia frequently supervenes and proves fatal ; or the matter burrowing among the muscles, forms numerous fistulous openings, exposing necrosed bone. The dead portion is detached much sooner, apparently, than in ordinary necrosis ; and reparation also seems to be equally active. Treatment. — Early and free incisions are here, also, primarily important. During the process of cicatrization, injections of very dilute hydrochloric acid may be used, as highly recommended by Chassaignac, to cleanse the suppurating cavity and hasten exfoliation of the dead bone. A generally stimulating and tonic plan of treat- ment will be required to support life through this trying ordeal. Periosteal abscess. — Preceded, for a few days, by acute pyrexia, with severe pain, or a dull heavy sensation in the limb, and powerlessness, — the swelling of periosteal abscess is characterized by its abruptly circumscribed margin, and doughy consistence, on deep pressure, obscured, however, by superficially diffused oedema. In the course of a few days more, the skin becomes reddened, or assumes a brownish clay colour, and the subcutaneous veins are well marked. The fluctu- ation of abscess is usually perceptible about the end of the second week. It may burst into a neighbouring joint, or externally, or in both directions. Extensive separation of the periosteum from the shaft of the tibia, was followed by the partial formation of new bone, lower down, in a case under my care. The patient, a boy, becoming rapidly emaciated, I amputated the limb, and he made an excellent recovery, soon regain- ing flesh and strength. Strict antiseptic precautions having been employed in the treatment of this case, as an open wound, before removal of the limb, and simply dry lint dressing having been applied to the stump, the whole clinical history, under these circumstances — and in similar cases — afforded a fair test as to the relative merits of both methods of wound-treatment. Treatment in general is the same as for the diffuse form of suppu- rative periostitis. Chronic periosteal abscess remaining, requires no special treat- ment. (3.) Circumscribed Abscess of Bone. — Always a chronic condition, this state of suppuration differs also from diffused suppuration, in its limited extent, and in being distinctly circumscribed. The abscess, thus defined, is seated within the substance of a bone, usually its SUPPURATION OF BONE. 849 Fig. 357. cancellated structure ; the cavity may be lined by a distinct pyogenic membrane — of wbich there is a rare specimen in the Museum of St. Bartholomew's Hospital — and the surrounding bone is more vascular than natural, thickened somewhat perhaps, and much indurated. The size of this cavity is never large, probably not exceeding that of a small chestnut, and containing two or three drachms of pus, _greenish yellow or dark coloured, sometimes mingled with' caseous matter and debris of bone. Always situated in one of the long bones, the abscess is commonly located in its upper or lower articular extremity, and very rarely within the medullary canal of the shaft. The tibia is most frequently affected, and its upper end near the knee-joint (Fig. 357) ; its lower end near the inner malleolus, next in order of frequency ; and among other bones, the lower end of the humerus near the elbow, ■and the femur, have severally been found the seat of circum- scribed abscess. Sir B. Brodie first discovered and described this abscess, and pointed out its appropriate treatment ; since the time of his observations, it has occasionally been met with by other Surgeons ; and more recently, Mr. T. Carr Jackson contributed an instructive paper with three cases bearing on the subject. In contrast with abscess of bone, a central cavity may result from atrophy ; the osseous tex- ture around being rarified, instead of having indurated by interstitial deposit, and with ex- pansion of the bone. Such was the case in the bone of a stump, after amputation (Fig. 358) ; a most instructive illustration of this distinction. Symptotns. — Pain is at once the earliest and most significant symptom. It is of a heavy, aching, and eventually throbbing character ; more severe occasionally, or perhaps periodically — generally during the night, and persistent for a considerable period — being probably of some years' duration. This pain is referred to a par- ticular part of the bone at one extremity — in, for example, the head of the tibia ; and a point of greatest intensity can be discovered by careful palpation with the finger, where the slightest pressure produces excruciating agony. A small and slio-ht puffy swelling, or induration, surrounds this spot ; and the skin may he adherent to the periosteum, without presenting any discolouration. Beyond this external appearance, little or no enlargement of the bone accompanies the remarkable pain of which the patient complains ; and there is an absence of any symptoms of joint-disease. Diagnosis. — The nature of this disease may, however, be mistaken for chronic rheumatism, or periostitis ; or still more probably, for a * St. George's Hosp. Miis. f St. Thomas's Hosp. Mus., C. 5. VOL. I. 3 I Fig. 358. 850 SPECIAL PATHOLOGY AND SURGERY. neuralgic or hysterical affection. The persistence of the pain is the most distinctive character of circumscribed abscess of bone. But other local conditions may give rise to the same continued and wearing pain ; as that which attends central necrosis, or chronic ostitis. Some enlargement of the surrounding bone, especially in the latter condition, with inflammatory thickening of the integument, will attract attention in these cases. Causes. — This abscess can, sometimes, apparently be referred to injury, or exposure to cold. The influence of tubercular disease is very uncertain. Early adult life seems to be the period most liable ; but the ages in recorded cases have varied from 13 to 50. Males and females have been affected indiscriminately. Course and Terminations. — The abscess slowly enlarging, by the excavation and condens.ation of the surrounding bone, never attains a large size. Ultimately, it opens into the neighbouring joint, which thus becomes disorganized ; and a disposition to this result is evinced by synovial distension and swelling from time to time, after exercise. Or the abscess may open externally, and discharge its contents with complete relief to the previous suffering. Cicatrization follows, the cavity filling* up as in the termination of other abscesses ; and the fibrous material which occupies the space, probably undergoing ossification, obliterates any remnant of the abscess. Treatment. — N"o topical applications or medicinal treatment have the slightest curative efiicacy. But the operative proceeding proposed by Sir B. Brodie is at once simple and safe, and affords immediate relief and a permanent cure. It consists in trephining the bone over the seat of abscess, and in thus giving vent to the pus. Chloroform having been administered, a crucial incision is made immediately over the painful spot externally, and extending down to the bone. A small trephine, having no projecting rim to oppose its entry, is then applied, and worked through the indurated bone ; penetrating to some depth, and entering the cavity of the abscess. The circle of bone is detached and removed by an elevator or gouge, and the pus evacuated. Or a drop may appear, and the bone must be penetrated further by the gouge until the cavity is entered. Sometimes no pus is discovered on raising the circle of bone ; the exposed surface should then be pierced in various directions to find a drop, and the oozing aperture freely enlarged with the gouge. Otherwise, an abscess may exist, but remain undiscovered. This misadventure happened to an experienced hospital Surgeon ; the limb was amputated and an abscess found at a small distance from the seat of perforation; showing that the removal of a small portion more of the bone would have preserved the limb. The preparation is in the Museum of St. George's Hospital. Only a small quantity of matter will issue in any case, the abscess itself being small. Sometimes, a small bit of blackish, necrosed bone may have to be scooped out from the interior. But the cavity having been fairly opened, the relief following the cessation of tension is instantaneous. A poultice or water-dressing will suffice during the course of reparation; which proceeding uninterruptedly, a permanent cure is established. An error of diagnosis even may be unimportant as regards the favourable result of this simple operation. For if the disease prove to be chronic ostitis — as happened in the case of one of Sir B. Brodie's CARIES, OE ULCERATION OF BONE. 851 patients — fclie removal of a piece of bone will relieve the pain, and may induce a healthier action. Caries, OR Ulceration of Bone. — The term Caries has been applied to different morbid conditions of Bone. Bj some Surgeons it has been used to denote scrofulous ulceration, exclusively ; and by others, to represent a morbid condition peculiar to bone, as distinguished from that of ulceration affecting the osseous texture. But the pathological identity of Caries and Ulceration is now generally acknowledged ; and as such I use the term to signify Ulceration, modified only by the textural peculiarities of Bone. Structural Conditions. — Caries is essentially a disintegration of the osseous texture ; and, like ulceration of the soft textures, it may be presented in two forms — as enlarging a pus-discharging* cavity or abscess in the substance of Bone, and as affecting the surface of a Bone. Carious bone is softened, and easily breaks down under pressure with a gritty resistance ; it is porous, and infiltrated with a reddish- brown oily fluid, and granular inorganic matter — the debris of the disintegrated texture. Small detached masses of dead bone may be found associated with the carious bone. It has a greyish, brown, or black colour, but the surrounding bone is highly vascular. Beyond and around the carious area, induration and hypertrophy may have taken place; the circumferential substance of the bone being dense, and presenting externally osseous nodules or spicula, with thickening of the periosteum. In the substance of bone, the appearance of Caries is more marked in the cancellated structure, which is also more especially the seat of caries (Fig. 359). The enlarged cancelli are filled with the detritus, and their walls are in a softened state ; the whole crumbles down under pressure with the finger, or may be readily penetrated by a probe, and yields with a grating sensa- tion. This state of disintegra- tion in the substance of bone is generally the consequence of scrofulous ostitis. Caries usually occurs in the articular extremity of a long bone ; as that of the tibia or femur, in scrofulous disease of the knee- joint affecting either bone ; but scarcely less frequently, it at- tacks the bodies of the vertebree ; or the bones of the tarsus or of the carpus, in the foot or the wrist- joint. On the surface of a bone, Caries presents a drilled, worm-eaten appearance (Fig. 360). The periosteum is loosened or detached, thickened, vascular, and villous. The projections, thus formed, pass from the under surface of the periosteum into corresponding depres- sions in the bone, its compact structure having acquired more the open character of the cancellous. The textural condition of the bone * St. Bartholomew's Hosp. Mus., 1, 163. t Ibid., 1, 221. Fig. 359.* Fig. 360.t 852 SPECIAL PATHOLOGY AND SURGERY. is similar to that already described as pertaining to deep caries. Superficial caries is, perhaps, more commonly met with in the com- pact portion of the bone, and as the consequence of syphilitic ostitis. Thus, more often seen in the cranial bones, and as resulting from secondary syphilis, this form of caries attacks also the surface of the tibia, or of the ulna, affecting the subcutaneous parts of these bones. A somewhat significant resemblance exists between the forms of syphi- litic ulceration in bone and syphilitic eruption on the skin. Thus, Sir James Paget has described anmtlar or circular, reticulated, and tuber- culated ulcers of bone. But these various forms are more interesting pathologically, than diagnostic. The Signs of Caries are the characters of carious bone, as just described. They are not declared until abscess having formed and discharged, the bone becomes exposed, or accessible. Superficial caries is more open to examination,; but the introduction of a probe Avill readily discover the state of the bone, both in it and deep caries. When, however, a long, narrow, and tortuous track leads down to the carious bone, a flexible and much longer instrument than the ordinary one must be used ; and Sayre's jointed or vertebrated probe is specially serviceable to reach the seat of disease. Both forms of Caries, deep and superficial, are attended with pain, more or less deep-seated, red- ness and swelling of the integument ; followed by suppiu^ation and the formation of abscesses. The soft parts around then present the usual characters of increased swelling, fluctuation, and discolouration. Any such abscess bursting, discloses Fig. 361.* ^^6 carious state of the subjacent bone, or leads to a carious cavity, as discovered by a probe. Fis- tulous openings remain, dis- charging unhealthy pus mixed with the granular detritus of bone (Fig. 361). Large, out- cropping, abortive granulations spring up ; and the surround- ing integument has a congested purplish appearance. Caries evinces little disposition to any reparative changes. The Causes of Caries are those which produce inflammation of bone, especially as occurring under the influence of some constitutional con- dition. Scrofula and Syphilis thus not uncommonly affect the bones, and in the form of Caries ; the disease arising often, apparently, "without any external occasion of injury as an exciting cause. Treatment. — The removal of any cause in operation is the primary rule of treatment in this, as in all other conditions of disease. Hence the remedial measures appropriate for Constitutional Syphilis or Scrofula will be requisite in most cases of Caries. Rest of the affected part is highly advantageous ; but any topical applications, as counter-irritation by iodine, blisters, or issues, are useless, com- pared Avith constitutional treatment. In an early stage, the disease may thus be arrested and the bone restored to a healthy state. Or, under the influence of this treatment, disintegration proceeds only so * After Liston. CAEIES, OR ULCERATION OF BONE. 853 Fig. 363. far as to gradually remove the affected portion bj a gTitty disctiarge ; recovery then taking place by granulation. Escharotics, such as the mineral acids, caustic potash, or the chloride of zinc, have been used, or the actual cautery has been resorted to ; with the view of completely destroying, and thus removing, carious bone, in order to gain a healthy surface for granulation. But little can be said to recommend, and much to reprobate, this principle of treatment. Unless in regard to quite superficial caries, any destructive application generally fails to arrest the disease, or actually provokes yet further caries, or destruction of bone. In a chronic state, the disease is beyond the power of restoration, and reparation is unable to discharge the carious portion of bone piecemeal. Operative interference, therefore, now becomes necessary. The diseased bone may be removed by excision, either of the affected portion only, or of the whole bone ; or amputation may be unavoidable, owing to the extent of the disease, or after excision, as the last resource. Excision of the carious portion. This should always be a patient proceeding, never a "brilliant" operation. The bone having been exposed by a crucial incision, the diseased por- FiG. 362. tion must be removed piecemeal by means of a gouge. Various forms of this instrument are used, according to circumstances. The ordinary scoop-gouge (Fig. 362) is generally most con- venient ; and Marshall's rose-head osteotrite (Fig. 363) will often prove very serviceable in finishing off a carious cavity. Care should be taken, in working with a cutting-gouge, lest the instrument suddenly slip, and be driven accidentally into the soft parts. A steady, slow movement of the hand, and grasp of the instru- ment almost to the point, are the best precau- tions against any such misadventure. The carious portion of the bone yields to the gouge with a gritty resistance ; whereas the sound bone remains firm, and vascular. The extent of bone to be removed may, therefore, be determined by these characters ; portions of softened, crumbling bone should be scooped out, imtil the firm, rose-coloured bleeding bone is reached. During this procedure, which may take some time, the constant welling up of blood in the cavity, obscures the appearance of the bone, and thus hinders the operation. The assistant, therefore, must con- tinue to firmly sponge the surface after almost every movement of the instrument. This inconvenience and delay may be prevented by the previous application of Esmarch's bandage to empty the limb of blood, followed by the elastic coil to preclude the reflux entry of blood when the bandage is removed. The gouging is thus rendered blood- less, the bone having a dry, yellowish appearance ; and this might mislead the operator to proceed deeper than the softened and disin- tegrated or carious bone; but on slightly loosening the coil from time to time, it will be seen whether the rose-coloured and firm bone is reached. The surface or cavity, having this healthy character, is then dressed 854 SPECIAL PATHOLOGY AND SURGERY. or plugged lightly with wet lint, and the wound allowed to fill up and heal by granulation. In this way I have removed, more or less suc- cessfully, carious bone from nearly every bone. The whole rim of the spine of the scapula having been excised in one case, the patient — a lady of very delicate health — recovered slowly but soundly. In another case, I removed the whole of the middle third of the shaft of the tibia, excepting a shell of bone posteriorly (Fig. 364). Gi-anu- lations, healthy and abundant, sprang up, and nearly filled up the large cavity; but the patient, by the rule of the hospital as to time, left incompletely cured, and I do not know the result. The articular end of a bone — affected by Caries — may require excision, as will be fully explained in treating of Diseases Fig. 364. of the Joints. Excision of the whole bone is rendered necessary by an extent of disease beyond the range of either of the previous partial operations, in the shaft or articular end. Amputation is justifiable only under exceptional, and perhaps extreme, circumstances; where the caries is too extensive in connected bones to admit of excision, or when constitutional exhaustion has supervened. The foot, for example, may be removed for carious disease involving the tarsal bones, with perhaps pro- longed discharge. When excision has failed, amputa- tion is necessarily the last resource. N^ECROSis. — The death of a portion of bone is analogous to Mortification of the soft parts ; and it has the same pathological relation to Caries that Morti- fication has to Ulceration. Caries is molecular death or disintegration of the osseous texture; Necrosis, the death of a visible portion or mass of bone. Not unfre- quently, both are associated in the same bone. Structural Condition. — Necrosis — like Caries — may affect the substance, or the surface, of a bone. In the one form of necrosis, the dead portion is named the sequestrum, a term more particularly applicable when the piece of bone is loose and enclosed by a new bone ; and when limited to the deepest poi-tion of bone around the medullary canal, the necrosis is sometimes named central ; while, in the other form, a super- ficial scale-like portion of dead bone is designated an exfoliation. Necrosed or dead bone is smooth or rough, hard and white, or of a yellowish colour ; becoming brown or black, and softened, when ex- posed to the action of decomposing pus and the air, from sloughing of the integument. It is avascular, not yielding any blood when wounded, and insensible. Reparation.- — The whole substance of a bone, or its central portion only, may be necrosed ; in point of extent also, the whole length of the shaft of a long bone may be dead, and occasionally even the epiphyses are involved. But the process of reparation will be typically described by reference to that form of necrosis in which the whole substance, or thickness, of the shaft of a long bone, e.g. the tibia, is necrosed ; and as consequent on acute ostitis. The periosteum, at first adherent, soon loosens its connection with the subjacent dead bone, and deposits 1 NECROSIS. 855 Fig. 365.* ossific lymph, between itself and the surface of the bone. This lymph- deposit undergoing ossification, forms a sheath of new bone over or around the dead portion, which thus becomes enclosed in an osseous case. The periosteum is the chief, but not the only, source of osseous reproduction in necrosis. The instructive specimen here represented, exhibits the periosteal production of new bone in the tibia of a boy, after necrosis of a large extent of the whole thickness of the wall. The outer surface of th.e sequestrum is quite smooth, the periosteum having separated without any portions of bone being attached to it. On the inner surface of the detached periosteum — the external dark line being the peri- osteum — a layer of new bone, half an inch thick, and forming almost a complete new wall to the tibia, has been produced (Fig. 365). The outer surface of this new bone is covered by the old periosteum, the continuity of which with that of the articular ends is shown ; and the inner surface of the new bone is lined by a soft vascular membrane, which was in close contact with the outer surface of the dead bone. But observation has shown that the original bone itself is an important source of new bone — by granulation — in the absence of the peri- osteal membrane, or in central necrosis ; and that the medullary membrane may contribute its share. The articular ends, in particular, evince a remark- able ossific power, when the shaft of a long bone is removed. I have seen an inch and a half of the shaft of the tibia thus reproduced. Apart from the periosteum, when this texture is destroyed, the soft tissues around the bone may acquire the power of forming ossific deposit. The dead portion, at first continuous with the healthy bone at either end, loses its connection at the line of continuity ; the living bone detaching itself from the dead. Not always, however, immediately, but at a variable period of weeks, or perhaps months, disunion begins, — when the general vitality of the org'anism can no longer tolerate union with dead matter. Preparatory to the commencement of disjunction, the border of the living bone becomes more vascular and has a succulent, ruddy appearance,- — thus corresponding to the inflammatory afflux of blood, prior to the line of demarcation in gan- grene of the soft textures. Generally, some reproduc- tion of new bone precedes any attempt at disjunction. Ulceration takes place at the line of continuity with the dead bone, the purulent discharge containing 2^ per cent, of bone-earth, phosphate of lime, as shown by Mr. B. Cooper ; or interstitial granulations are produced, by which a slight amount of bone is consumed, as Bill- roth states. A groove is thus formed around the junc- tion of the dead portion of bone (Fig. 366) ; and this groove deepening, at length completely detaches it. Pus collects * St. Bartholomew's Hosp. Mus., 1, 133. f Ibid., 1, 23. Fig. 366.t 856 SPECIAL PATHOLOGY AXD SUEGERY. around the sequestrum, and interrupting the complete formation of the periosteal sheath of new bone, leaves apertures therein — one or two to four or five in number — the cloacce, through which sinuous tracks between the sequestrum and fistulous openings in the in- tegument become established (Fig. 367). These orifices pout with large, abortive granulations. This twofold process goes on simul- taneously, though not perhaps equally ; constituting a separation oi the living from the dead bone, and reparation, chiefly by the periosteal reproduction of a cylinder of new bone enclosing the dead portions. Both changes are slowly progressive, extending over a period of weeks or months. But at length the sequestrum becomes complete, and ensheathed by the cylinder or involucnim of new bone (-Fig. 368). Fig. 368.t This latter is highly vascular, and of a bright red colour; although, when dried as a "pathological preparation," the new bony case is Avhitish brown, rough, and porous. It is perforated with apertures — the cloacce, unlike the enclosed sequestrum of dead bone ; which — in a specimen — may be further recognized, through the cloacae, by its white colour, smooth and firm surface, or sometimes having a brown or blackish appearance, and a softened or soddened consistence, from exposure to decomposing pus-maceration. The cloacae are formed apparently, as Troja observed, in consequence of deficient periosteal * Diagram from Billrotli. t Museum, Eoyal Free Hospital. Necrosis of Tibia. Appearance: I, Internal; E, External. NECKOSIS. 857 Fro. 369.* deposit, in small spaces, here and there, during the prodaction of the new bony case. The apertures thus left are Nature's provision for the exit of the enclosed sequestrum of dead bone, and for the free discharge of matter. The seqtiesiruvi is of smaller size, in length and breadth, than the involucrum of new bone, in which, therefore, it lies loose after its detachment. This diminution of the dead portion in length results from ulcerative disintegration, or from absorption by interstitial granu- lations in the living bone, during the process of disjunction ; and after- wards, reduction may be effected, in length and breadth, through the medium of granulations, which spring from the whole inner surface of the osteo-plastic cavity— the bone-ends and periosteal sheath ; absorp- tion being aided, perhaps, by the pressure also thus brought to bear upon the sequestrum. The doctrine of bone-absorption by granulations, and thence, moreover, the reduction of the sequestrum, after, as well as before, complete separation, was originally maintained by John Hunter ; and the results of observation by Velpeau, Lawrence, and Billroth have afforded corroborative evidence ; while Stanley, Gulliver, and Listen were led to the opposite conclusion. Rokitansky attributes any apparent absorption to ichorous corrosion and liquefactive dis- charge. The influence of close contact • — apart from the agency of granulations — is shown by the partial disappearance of ivory pegs, when imbedded in living bone. In consequence of progressive ab- sorption, the imprisoned or attached sur- face of the sequestrum at length acquires a rough, or worm-eaten, and irregular appearance, and the margins become serrated or spiculated ; resulting from the close adaptation of the encompassing granulations. Hence, any uncovered part of the sequestrum is not subject to absorption, and remains smooth ; so also, when the granulations suppurate, ab- sorption ceases, for then the surface is no longer in contact. Nature thus attempts to bring about extrusion of the sequestrum, as a foreign body. Having separated by ulcerative disintegration, or by absorption from the living bone through inter- stitial granulations, the dead and detached portion of bone is reduced in size, and loosened, by absorption, through the medium of encom- passing granulations, and subjected to the expulsive compression of granulation-growth. When removed, the sequestrum-cavity remains (Fig. 369). The involucrum, or sheath of new bone, is the scene of cei-tain formative changes. It increases in thickness, the longer the enclosed sequestrum remains as a source of osteo-plastic irritation ; so that, in the course of years, the bony case might become more than half an inch thick. Losing its rough and porous character, it gets smoother * Diagram from Billroth. 858 SPECIAL PATHOLOGY AND SURGEKY. Fig. 370.* W and more compact or stronger, yet somewhat tliinner ; thus altogether more nearly resembling the natural shaft of a long bone. The cloacae, having served the temporary purpose already noticed, become smaller; but ■whether they are ever entirely closed seems doubtful. When the sequestrum has been discharged, perhaps, in the natural course of necrosis, or has been extricated and removed by surgical interference — in either case, the cloacse providing apertures of exit — the osteo- plastic cavity may continue to gi-anulate and ossify, and thus still more completely restore the original substance of the shaft of bone. But "whether the medullary canal be reproduced, as after the reparation of fracture, is as yet undetermined ; although, from analogy, this final result is not improbable. If, in the production of the new bone-shaft, any muscles lose their attachments, they regain new points of insertion, and are thus admirably enabled to resume their respective actions. Modifications of Necrosis. — Certain deviations from the normal course of Necrosis — which Prof. Billroth has observed — are worthy of notice ; as relating to the detachment of the sequestrum, and the formation of the inyolucrum of new bone. In young persons, affected with acute periostitis, the epiphyseal cartilages of a long bone may undergo ossification, although rarely, at the upper and lower ends of the bone simultaneously; but then the sequestrum Avill be detached very early, before the new bony case can have completely formed. If, therefore, the seques- trum were removed at this period, the limb would be weakened, and remain weak, owing to removal of the foreign body, which, as a source of irritation, induces osteo-plastic deposit. Suppiiration of an epi- physis is also attended with early detachment of the sequestrum at that end ; and this event may lead to such displacement and projection, by muscular action, that perhaps the bone protrudes through the integu- ment ; instances of which have occurred, with regard to the femur, at the knee-joint, and the humerus, at the elbow. In such cases, destruction of the joint will probably be ine"\dtable. Partial Necrosis. — Various forms of partial necrosis sometimes occur. In the shaft of a long bone, necrosis may be limited to the walls, to a portion of bone within the wall, or to the cancellous structure, as a completely central necrosis. Such cases are rare. I shall, therefore, first draw attention to their existence by referring to certain valuable specimens in the Museum of St. Bartholomew's Hospital, and as de- scribed in the catalogue, respecting each such form of partial necrosis. (1.) Necrosis limited to the Walls of a long bone. — Section of a Tibia (Fig. 370), of which nearly the whole length and thickness of the walls of the shaft perished, and were in process of separation from the cancellous and medullary tex- ture, which has preserved its vitality and a nearly healthy condition. The groove formed between the dead and the living bone is filled with soft and very vascular granulations. On the internal surface of the • St. Bartholomew's Hosp. Mus., 1, 19. NECROSIS. 859 Fig. 371.* / periosteum, spongy and vascular new bone is formed in a nearly uniform layer, to supply the place of tliat which, has perished. The inner surface of this new bone is covered by vascular granulations. The walls of the bone perished after inflammation of the periosteum, produced by the application of nitric acid to a sloughing ulcer in the front of the leg. (2.) Necrosis within the TFaZZs of a long bone. — Section of a Tibia (Fig. 371), in which large portions of the wall are separated after necrosis. The separated portions in- clude only the middle laminae of the wall ; the outer laminae are entire, except in so far as they are pei'f orated anteriorly, and the inner laminae appear only somewhat thickened and less compact than is natural. The sequestraB thus lie in cavities between the separated internal and external laminae of the wall, which cavities open by four nearly round apertures through the anterior and inner wall. The patient was a feeble young woman, twenty-two 3^ears old, in whom the necrosis had existed more than a year before she died with pulmonary disease. About six months before her death, the existence of necrosis being suspected, in consequence of the large quantity of pus discharged through two nainute apertures in the front of the tibia, a portion of the bone was removed by the trephine, and some sequestrae were extracted. The patient benefited by the operation for a time ; but the openings into the cavities containing the other sequestra remained, and were only narrowed by the growth of new bone around them. The case is related by Mr. Stanley in his " Treatise on Diseases of the Bones," pp. 138, 139. In the specimen of necrosis figured from the Museum of the Royal Free Hospital (Fig. 368), it will be observed that a similar partial necrosis has occurred; a small sequestrum lying within the wall of the upper portion of the Tibia. There is also a Tery remarkable specimen in the Museum of the Royal College of Surgeons : a lower jaw with a very small sequestrum lying within the body of the bone, which at that part is greatly thickened and indurated ; externally, the circular mark of a trephine shows that an attempt had been made to reach a suspected sequestrura or abscess, which doubtless had been attended with pro- longed suffering during the surrounding ostitis. (3.) Necrosis of the cancellous structure within the shaft of a long bone. — Section of the upper part of a Tibia (Fig. 372), in which portions of the cancellous tissue have suffered necrosis and are partially separated. Lymph and pus are diffused upon and within the dead portions of bone ; the medullary canal contains them alone, the rest of its osseous and fatty tissue being removed. The walls of the tibia are thickened and * St. Bartholomew's Hosp. Mns., 1, 268. t Ibid., 1, 267. Fig. 372.t 860 SPECIAL PATHOLOGY AND SURGERY. penetrated by several apertures into the medullarj canal. The disease is limited to the shaft of the tibia ; its head is healthy. From an old man, in whom the disease had existed more than twenty years. Necrosis without Suppuration. — Necrosis is not invariably followed by suppuration. Mr. Stanley drew attention to this fact,* and it has been confirmed by Sir James Paget, Avho has recorded two examples of what he proposes to term " quiet necrosis."! Mr. Morrant-Baker has, however, shown that much more extensive necrosis than that to which the term quiet necrosis is applicable may occar without the formation of pus ; and he has recorded a case J in which nearly the whole femur perished, and at the time of the amputation of the limb, about three months after the commencement of the disease, not a drop of pus could be discovered. Mr. Baker supposes that this apparently strange deviation from the ordinary course of cases of necrosis is due to the fact that the death of the bone occurs in the course of chronic ostitis ; the shaft of the bone gradually dying as its sources of blood-supply are cut off, partly by inflammatory changes within it, and partly by the formation of new bone in and beneath the periosteum and endosteum. It might be expected, under such circumstances, that suppuration would be long delayed; and he suggests that if there were more frequent opportunities of examining, by section at an early stage, bones affected by chronic ostitis, deep- seated necrosis would be not infrequently found. As it is, however, no need commonly arises for operative interference until the presence of suppuration has removed the necrosis from the list of unexpected occurrences. Mr. Morrant-Baker suggests the term intra-osseous for that variety of necrosis in which the dead bone is enclosed by new bone on both its outer and inner aspects ; this new bone having been produced by both the periosteum and the medullary membrane, or endosteum. In ordinary cases of necrosis of the shaft of a long bone, the sequestrum is surrounded by a sheath of new bone, which has been formed b}^ the periosteum and, it may be, other structures external to it ; the medullary membrane perishing with the bone which encloses it. In cases of intra-osseous necrosis, on the other hand, new bone is produced by the endosteum as well as the periosteum ; and the sequestrum is thus often so completely "locked" as to render its removal almost an impossibility ; the difficulty being increased by the frequently long-delayed separation, under these conditions, of the dead from the living bone. Diagnosis. — Necrosis unattended with suppuration may simulate malignant disease, in the formation of a large tumour or swelling, which is hard and incompressible ; spontaneous fracture also some- times takes place, and yet this event may not, for at least many weeks, be followed hj suppuration. Mr. Baker relates a case of this kind, in which the femur was the seat of chronic osteal inflammation, and the swelling extended below nearly to the knee-joint and above to the trochanters. Spontaneous fracture took place, followed by deformed union. But the patient gradually lost flesh and was worn out by pain and sleeplessness. Under these circumstances, the limb was amputated at the hip-joint, and a rapid recovery ensued. Section of the femur * " A Treatise on Diseases of tlie Bones," 1849, p. 83. + Trans, of Clinical Society, vol. iii. X Trans. Medico-Chirurgical Society, 1877. NECROSIS. 861 Fig. 373.* then revealed the above condition of necrosis, not a drop of pus being found. Exfoliation, or superficial necrosis, presents the same appearances as to "the state of the dead portion of bone. But it results generally from the destruction of the periosteum ; consequently, no periosteal sheath of new bone is produced. The plate of dead bone is detached — as in deep necrosis — by linear ulceration forming- a groove circumferential ]y ; but the detached portion not being ensheathed by new bone, it is tkrown off from tbe surface or exfoliated, and exposed by open abscesses or sloughing ; or it can be easily removed surgically by forceps. The separation of an ex- foliated portion of bone, like the detach- ment of a sequestrum, is always a slow process ; in one case, after compound fracture of the tibia, in a bealthy boy, I removed a thin scale of bone, about an inch square, on the day four months from the time of the accident. The periosteum of the cranial bones — the pericranium — even when uninjured, does not seem to have the power of forming a sheath of new bone ; and thence the same result ensues — exfoliation (Fig. 373). The dura mater is nearly equally unproductive — within the skull. The Signs of Necrosis are tbe characters of necrosed bone, as already described. But — as with Caries — these characters are not. declared until, abscess having formed and discharged, the bone becomes exposed or accessible. The introduction of a stout probe will readily discover the rough, loose seques- trum ; or, when visible, it may be recog- nized by its dead-white appearance, or blackened by decomposing purulent dis- charge. Exfoliation is more open to examination. Necrosis is attended with violent and deep-seated pain, considerable redness, and swelling of the surrounding soft parts. Suppuration ensues sooner or later, in consequence of inflammation of the bone — ostitis — ^having led to necrosis, or as the result of prolonged irritation of the sequestrum, itself a foreign body. The matter discharged through the fistulous openings is usually sanious, dark coloured, and fetid, although sometimes it has the thick, yellow character of healthy pus ; especially in necrosis arising from an external cause, as compound fracture, and with a healthy constitution. The extent of the * St. Bj,-'th)lom3-.v's Hosp . Mus., A. 90. Fig. 374. 862 SPECIAL PATHOLOGY AND SURGERY. sequestrum will be fairly declared by the boundary of the integu- mental swelling, and by the spaces between the cloacae (Fig. 374), when a probe is introduced. The fever, which had been that of inflammation, during the previous ostitis, assumes an irritative cha- racter, when bone becomes necrosed ; and suppuration, with prolonged purulent discharge, is attended with hectic and great exhaustion. Unlike caries, necrosis occurs more frequently in the shafts, than in the articular ends, of long bones ; and more often in the compact, than in the cancellated structure, of any bone. This difference of liability is due apparently to the lower degree of vascularity, and of vitality therefore, in the compact osseous texture. Every bone is subject to necrosis, but certain bones are more commonly affected: the tibia, femur, humerus, ulna, i-adius, clavicle, lower jaw, upper jaw, scapula, and cranium. In the flat bones, last named, necrosis usually takes the form of exfoliation. Central necrosis is necessarily more obscure, owing to the depth of the morbid condition. The symptoms resemble those of chronic abscess in the substance of bone. Deep-seated and, perhaps, throbbing pain, with some swelling of the bone, or puffiness over a particular spot, are the more characteristic symptoms, and their persistence is even more significant. Causes. — External and trauviatic causes seem to have a more abso- lute effect in producing necrosis, unaided by any predisposing constitu- tional influence, than in relation to caries. Any injury detaching the periosteum will probably be followed by more or less necrosis ; except- ing in the cranial bones, or others which are highly vascular. Thus, compound and comminuted fractures of the long bones often lead to necrosis, either in the form of exfoliation or a sequestrum. Violent contusion may so damage the osseous texture and medullary membrane as to produce necrosis, or sometimes, by the extravasation of blood, detaching this membrane from the cancellated bone. The irregular application of a saw in amputation lacerates and contuses the bone- end, especially the periosteum, and is thus apt to be followed by necrosis, in the form of an osseous ring. Severe cold, as in frost-bite, and deep burns are also immediate causes. The impaction of a foreign body in bone, as from a gunshot wound, slowly induces necrosis. Any disease of bone, as cancer, is often associated with death of the portion of osseous texture affected ; and the pi'essure of an adjoining tumoui", or the extension of an abscess, may result in at least exfolia- tion. Powerful irritants have a marked effect, even apart from any inflammatory action. Thus, the application of a strong caustic — as the potassa fusa, or one of the mineral acids — to an ulcer over the tibia, may kill the subjacent bone ; and the plugging of a deep wound in the thigh, with perchloride of iron, to arrest hsemorrhage, has necrosed the femur. The fumes of phosphorus, in lucifer-match manufactories, often produce necrosis of the lower jaw ; this powerful irritant enter- ing the bone, apparently, through carious teeth. Any form of inflam- mation of bone — ostitis, periostitis, or osteo-myelitis — may also induce necrosis. Acute necrosis is met with chiefly in the form of diffuse inflammation — whether as diffuse periostitis or osteo-myelitis, rapidly terminating in death of the bone. The long bones are most liable to be thus affected, and specially the shaft of the femur or of the tibia. It occurs more frequently in children, after fever, exposure to cold, NECROSIS. 863 or from injury, as contusion. The pain might be mistaken for that of acute rheumatism, but for the concurrent swelling around the bone, and oedema of the limb. In many cases, the whole extent of the shaft perishes, as far as the epiphyses ; but acute necrosis may pass beyond this line, and even the joint m.ay be implicated, at either end of the bone. Constitutional causes are very influential ; sometimes predisposing to, or fi'equently producing, necrosis. Scrofula, syphilis, and formerly the excessive administration of mercury, represent this class of causes ; but necrosis occasionally results from typh oid fever, scarlet fever, small- pox, scurvy, and other exhausting diseases. The bone affected varies ; it may be the tibia, or the femur, as I have seen after typhoid fever. Although necrosis may occur at any period of life, as a manifestation of one or other of the constitutional conditions referred to, it is met with more frequently in youth, particularly as affecting the femur or humerus. In old age, the lower ends of these bones are subject to spontaneous necrosis, and also the lower end of the tibia especially; the bone dying as a form of senile gangrene, affecting the osseous texture, and involving the joint. Unlike gangrene, senile necrosis is more acute and takes a rapid course. At the other extreme of life — infancy and childhood — necrosis occurs usually in connection v^^ith caries, and in the bones of the tarsus or of the carpus. Consequences. — Continued suppitration accompanies necrosis, and in proportion to its extent. The matter burrows among surrounding muscles, and disorganizes the whole substance of the part ; while the numerous sinuses opening externally and communicating with the bone, continue to discharge an unhealthy pus. Large, protuberaut granulations, springing up around the orifices of these passages, evince an abortive tendency to close up the soft parts ; but reparation of the bone, by the formation of a periosteal sheath, is far more active. Albuminuria, and amyloid degeneration of the liver, are not unfrequent constitutional consequences of prolong'ed suppuration. Certain accidents are, however, liable to happen in the course of repair. As, in a long bone, like the femur, the ensheathing cylinder of new^ bone acquires strength at about an equal rate of progress to that of the disjunction from the sequestrum, the firmness of the limb will be maintained ; but if consolidation fail, then, subject to muscular action and the weight of the limb, fracture may take place ; or, the new bone under- going some alteration of shape and direction, the limb becomes deformed and shortened. But either of these events v^^ill depend very much on an insufficient length of sequestrum, within the new" bony sheath, to support the limb ; or on the want of sufficient support from a side bone, as the fibula in relation to the tibia, when the shaft of this bone is necrosed. The ulcerative detachment of the dead portion of bone sometimes extends to a large vessel, or the point of the sequestrum may be driven into an artery in some movement of the limb ; giving rise to serious hcemorrhage externally, or to the forma- tion of aneurism. But these perilous consequences are rare. The new bone which substitutes a necrosed portion of bone, may itself be attacked with necrosis ; in which event, any repair will be very defective. Am.yloid or Albuminoid degeneration of the liver, resiilting from prolonged suppurative discharge, generally in connection with caries 864 SPECIAL PATHOLOGY AND SURGERY. or necrosis, should be here noticed more particularly. But the same form of degeneration may occur in this, and other organs, as the result of long-continued suppuration in syphilis and scrofula, apart from bone-disease ; and in pyelitis, cystitis, empyema, pulmonary phthisis, and other cachectic diseases, which are attended with a constant drain of pus. The symptoms which betoken the supervention of amyloid or albuminoid degeneration of the liver, should be i-ecognized ; as by the timely removal of the cause of protracted purulent discharge — usually a sequestrum or carious portion of bone — the liver affection may be prevented, from which the patient would otherwise inevitably suc- cumb. In the coui'se of chronic disease of the bones or joints, the region of the liver should be examined fi-om time to time, that, in the event of any suspected degenerative change in this organ, operative interference may be resorted to for the removal of caries or necrosis, at an earlier period than might have been deemed necessary. The constitutional symptoms of approaching albuminoid disease, will be those of antemia, attended with marked debility and progres- sive emaciation, with a pallid or cachectic appearance. Then, pro- bably, palpation over the right hypochondriac region, will discover a distinct enlargement of the liver, — in the form of a hard, solid, and uniformly smooth-surfaced mass, having the shape of the liver, and presenting a corresponding area of dulness on percussion ; the lower margin of the enlarged organ, projecting downwards from below the ribs, may even be seen through the walls of the abdomen in an attenuated subject. The liver, thus affected, is singularly painless, and there is no tenderness on pressure. Nor is there, usually, any evidence of functional disturbance consequent on this hepatic enlarge- ment. The bile-ducts remaining free from albuminoid deposit, degene- ration of the liver progresses, without giving rise to jaundice, although the evacuations of clay-coloured f^ces may indicate a scanty secretion of yellowish bile ; and the portal vessels not being obstructed, the hepatic degeneration is unattended with ascites ; until perhaps, at a later period of the disease, the kidneys becoming similarly aifected, some abdominal dropsy may be associated with the anasarca from albuminuria. The diagnosis will be confirmed by discovering, not unfrequently, a similar solid, painless enlargement of the spleen — in the left hypo- chondrium ; with the accompanying symptoms of albuminuria, indi- cating the degenerative affection of the kidneys ; and the whole case being considered in conjunction with the clinical history of prolonged suppuration, fi'om bone-disease, as the most frequent cause. The pathology of albuminoid degeneration of the liver forms part of the general history of those changes which organs undergo in this kind of Degeneration (Chap. III.). The enlarged liver has a smooth surface, and is peculiarly tense and inelastic. The size to which the organ attains is sometimes enormous. I have known the enlargement to be such, tjiat the anterior margin of the liver reached down to the level of the anterior superior spine of the ilium, on the right side, — as shown hj post-mortetn examination. The weight of the liver, in that case, was 145 ozs. = 9 lbs. 1 oz. The kidneys had also under- gone the same albuminoid degeneration. The left pleural cavity contained 46 ozs. of purulent matter. The patient, a young woman, NECBOSIS. 865 Fig. 375. aged eighteen, liad long suffered ivora abscesses discharging in her back, from caries of the spine and ilium, followed hj pleurisy. Section of tlie liver shows a greyish or fawn- coloured surface, mottled with a reddish hue in parts less affected, and having a some- what translucent appearance from the albuminoid deposit ; the con- sistence is that of bacon — hence the name lardaceous degeneration, or like that of wax — waxy degeneration. When the surface is brushed with a solution of iodine, this reagent gives the characteristic colour of yellow, orange or mahogany brown — according to the more or less advanced state of the degeneration. Dilute sulphuric acid displays a blue or purplish colour. These distinctive colours are due to the presence in the tissue elements of a peculiar albuminoid substance, which, owing to the reaction produced by iodine, seemed to be allied to starch ; and to which, therefore, Yirchow gave the name of amyloid. Bodies, consisting of concentric layers, and thus resembling grains of starch — corpora amylacea — are also found in connection with this albuminoid matter (Fig. 375). But it is now known that these amyloid bodies are not essential to albuminoid degeneration, in the liver, or other organs ; and that they do not occur in connection with diffuse amyloid change, — although both the albuminoid matter, and the amyloid bodies, ag'ree in their reaction with iodine. Similar bodies occur also, quite independently of albuminoid degeneration, as the result of chronic inflammation affecting the central nervous system, and in brain-tumours ; also in the prostate gland ; not to mention other parts, and morbid conditions, with which these bodies may be more rarely associated. In the liver, the albuminoid deposit takes place within the hepatic cells of the lobules, and in the walls of the hepatic vessels and capillaries; thereby locating the colour, elicited by the iodine test, ^^^- 376.* in an early stage of degeneration /^''^^^^^Z^i ,^S^ "^ '"" '1^/ (Fig. 376). Similarly, in other organs, the blood-vessels, and secretory structure, seem to be the essential seat of albuminoid degeneration ; the glomeruli of the kidneys ; the Malpighian corpuscles of the spleen, as the most essential structural element of that organ. The elements affected with albuminoid deposit are enlarged, translucent, and structureless. As degeneration advances, other constituents of the organs may be- come involved, and thus a liver-lobule at last presents only a remnant appearance (Fig. 377). The appearance of an albuminoid liver, externally, and on section, may be modified by association with the structural changes which mark other diseases — fatty degeneration, syphilitic disease, or cirrhosis. _ Treatment. — The removal of any cause in operation must be the primary consideration. Traumatic causes, which have already ex- * Albuminoid (Amyloid) Liver. Early stage ; showing the walls of capillaries swollen and translucent. X 350. (J. Coats.) VOL. I. 3 K 866 SPECIAL PATHOLOGY AND SURGERY. Fig, 378. pended tbeir force, so to speak, in producing necrosis, are obviously not under control. But, as arising from detachment of the periosteum, exfoliation may sometimes be prevented by timely replacement of this vascular membrane ; or if adhesion takes place between the bone and adioining soft parts, or "Pip ^T*/ * 1 , ■ • •^'^■**''- granulations spring up from the surface of the bone, a new periosteum will be gradually formed. Constitutional causes cannot be altogether over- come, but their full effect may be prevented. Hence, the medicinal treatment appropriate for scrofula, or constitutional syphilis, proves very beneficial in most cases. Suppuration and ab- scess must be treated on ordinary principles ; Avhile the accompanying hectic, or the constitu- tional irritation arising from the presence of dead bone, should be supported by a tonic and stimulant plan of treatment with nourishing diet. Sequestrotomy . — Extraction of tJie seques- trum. — The dead portion of bone is a foreign body. Unless, therefore, it be thrown off by Nature, it must be removed by Art. Its removal is determined, both in point of time and the extent of dead bone to be removed, by the ulceratiA'c line of demarcation and the detachment of that portion ; a process of some weeks' or months' duration, and the progress of which should be ascertained, from time to time, by examination with the probe. The sequestrum may have become completely detached from the living bone, but yet remain fixed by adhesion to the gi'anulations w^hich closely penetrate its "worm-eaten surface ; so that it will perhaps be necessary to ascertain v\-hether the piece of dead bone can be made to move a little upwards or downwards, by gentle pressure alternately between two probes, introduced into cloaca, at some dis- tance apart. Sometimes I have noticed that the sequestrum, without being actually mov- able, yields with a resilient sensation fi^om the encasing cushion of granulations. A loosened sequestrum, impiisoned within a sheath of new bone, can only be extricated by surgical inter- ference. The operation consists in cutting down upon the bone, and * Albuminoid (Amyloid) Liver. Advanced stage ; the arrangement of the transparent amyloid material suggests its formation in the capillaries. Round fat=drops at periphery of lobule. X 70. (Thierfelder.) NECROSIS. 867 extracting the sequestrum, by means of serrated bone-forceps (Fig. 378). In making the incision, advantage is taken of the course of the fistulous tracks leading to the cloacge in the bony case ; and then the latter apertures are made available for removal of the sequestrum. The cloacae are usually found at the lower part of the bony case ; but they communicate with the cavity containing the sequestrum by osseous canals, of variable extent, and which have a more or less oblique direction upwards. JSTarrowed internally, and expanded somewhat outwards into a funnel shape, the apertures are round or fissured, and of small size — generally not larger than would admit a small quill or a probe. Sometimes, one of the cloacte is sufficiently lai-ge to allow of the extraction of the sequestrum through it. Or the cloaca may be enlarged, or two such apertures thrown into one by excising the intermediate portion of the bony case Fig. 379. with strong cutting-pliers, straight or Fig. 380. angular bladed (Figs. 379, 380). Some- times a chisel and mallet may have to be used, the new bone being so hard that it is more easily chipped away. The sequestrum may perhaps be pushed upwards or downwards, so that one end can be seized with the forceps, and thus the whole be withdrawn. Or again, it may be more convenient to divide the sequestrum by the same instruraent, and extract either frag- ment separately; or, by removing a central portion, either end-piece may be extracted. The removal of any por- tion of the bony case is undesirable, as the new bone is not reproduced, and the limb would remain proportionately weakened ; care also must be taken not to damage the interior of the sheath. The cavity of the new bone is usually single, but it is sometimes multilocular, and each interspace may contain a sequestrum. Hsemor- rhage occurs freely during this operative procedure ; the blood springing from the vascular soft parts around, or welling up from the new bone. It can generally be arrested by pressure; but in this, and other operations on bone, the Surgeon will find the advantage of Esmarch's elastic ligature around the limb, previously emptied of blood by means of the elastic roller. The bottom of the wound should be lightly dressed with lint, or plugged to sup- press hemorrhage ; any inflammation consequent on the operation must be subdued by ordinary treatment ; and eventually the limb should be supported by a starched bandage until granulation is com- plete, and the bony case has acquired sufficient strength to bear the weight of the body or the movements of the part. The resulting appearance is that of a linear depressed cicatrix. I have thus removed a loose sequestrum from the lower lialf of the shaft of the femur, in two cases ; guided by the sinuses, and preserving the osseous sheath which had formed around the bone. In a compound fractiire of the tibia with death of the periosteum, the end of the upper fragment, to Fig. 381. 868 SPECI.VL PATHOLOGY AND SURGERY. an inch and a half in extent, separated as a sequestrum, which I re- moved, together with several small scaly and spiculous portions from the lower fragment. Union ensued, bat imperfect consolidation ; a slight hinge-like mobility remaining for some months. An exfoliation may be thrown off naturally ; or, when partly detached, the extent of separation may be ascertained by passing a probe beneath the plate of bone, and perhaps by a little leverage with the handle of a scalpel, it may be raised from the subjacent granula- tions. For this pui'pose, one or more of the fistulous tracks will usually have to be laid open ; and then the exfoliated portion can be readily extracted with forceps. Excision of the lohole of the bone necrosed, or short of its articular ends. — This operation may, occasionally, be had recourse to in extensive necrosis. Thus, the lower jaw has not unfrequently been removed for necrosis caused by the fumes of phosphorus. The entire shaft of the radius, leaving its articular ends, was excised by Mr. Savory, on account of necrosis ; and afterwards, the bone was reproduced from either end to such an extent, that in eight months there remained an interval of only an inch and a half, and this appeared to be gradually diminishing. The fibula also has been excised. Removal of the ungual phalanx of a finger, for necrosis from whitlow, has proved perfectly successful in preserving the end of the finger. These re- sults are sufficient to encourage the practice of excision in other cases of extensive necrosis. In operations for bone-excision, in necrosis, as of the lower jaw, a short, narrow-bladed saw will often be found very convenient (Fig. 381). Amputation must be regarded as an extreme resource, but justifiable as a sacrifice of the limb for the preservation of life. In necrosis involving the neighbouring joints, or where the limb has become disorganized by prolonged and profuse suppuration, or the general health undermined by hectic, amputation is unavoidable. Thus, in a case of necrosis of the femur consequent on typhoid fever in India, the whole shaft of the bone was involved, the limb enormously thickened, and the muscles were matted together. I amputated the limb close to the trochanter, and the patient made an excellent re- covery, regaining his general health. As connected with compound fracture, necrosis may be treated by removal of the sequestrum ; but the death of the bone is so often associated with comminution, and severe damage to the soft parts, as from the direct violence of con- tusion, that necrosis consequent on compound fi*acture more often necessitates amputation. And in the more rare cases, where a main artery is opened by ulceration, or wounded by the sequestrum, removal of the limb will generally be preferable to ligature of the vessel, in situ, or of the main trunk. Rachitis or Rickets. — Structural Condition. — This disease affects more or less the whole osseous system. The earthy matter of the bones is diminished, and the organic basis, therefore, proportionately increased ; the cancelli are enlarged and filled with a brownish-red fluid. Both the periosteal and the medullary membranes appear t% EACHITIS OR RICKETS. 869 Fig. 382.* be more vascular than in health, and the former membrane becomes thickened. All these changes are more marked at the epiphyseal ends of the long bones. The flat and the short bones, particularly the carpal and tarsal bones, are thickened. Some relaxation of the ligaments accompanies the change of osseous texture. Bones in this state have acquired great softness and flexibility, thence under- going remarkable changes of shape, in consequence of the weight of the body, or other forces to which they are subject. The bones of the limbs, in particular, become curved inwards or outwards and distorted, the pelyis collapsed and twisted, the thorax contracted aboye and enlarged lower down by the dragging weight of the abdominal viscera, and the spine is often distorted by lateral or other curvature. , The cranium appears enlarged, o"wing perhaps to the imperfect development of the facial bones ; presenting a large head and diminutive face. There is also a general arrest of growth and development ; whereby, in the adult, the rickety skeleton may retain, in its different parts, the relative proportions of infancy. The Signs of rickets are some of these peculiar deformities of the osseous system. They are found often also in connection with manifestations of scrofula. Perhaps the earliest observ- able deformity is a swelling of the wrist, due to enlargement of the carpal epi- physeal ends of the radius and ulna. The knee and ankles often present en- largement in like manner. Deformities of the bones soon follow, and in the order, generally, as Guerin observes, from below iipwards. Under the weight of the trunk, the tibia and fibula of both legs are carved outwards and forwards, the arches of the feet yielding and turn- ing inwards ; with this excurvation of the legs, the knees also are bowed out- wards, accompanied perhaps with some excurvation and bending forwards of the femurs, and corresponding deformities of the thighs ; thus altogether presenting the rickety and bandy-legged appear- ance familiar to experience. Sometimes, the opposite curvatures take place : in- curvation of the legs and of the thighs, with a knock-kneed condition, and flat feet everted (Fig. 382). Occasionally, the curvatures have an opposite direction in the two limbs ; a general excurvation on one side, with incurvation on the other side. When the child crawls about habitually on his hands and knees, the bones of the upper extremities are no less liable to deformities, and at an early period. The constitutional symptoms are those of general debility, evinced more especially by night-sweats, affecting the head in particular, with a remarkable tenderness or sensitiveness of the whole cutaneous surface of the body. * St. Bartholomew's Hosp. Mus., A. 148. 870 SPECIAL PATHOLOGY AND SURGERY. The Causes of this disease are obscure. It would appear to be a condition of imperfect formation of the osseous texture ; rickets never arising after the bones have become fully ossified and consolidated ; nor, indeed, after the age of puberty. It is a disease of childhood or infancy, and possibly commencing in foetal life ; although its results remain in the adult. As ai^ising from malnutrition, rickets is eminently a constitutional disease, although manifested principally m the osseous system. Thus, observes Sir W. Jenner, it is no more a disease of the bones than is typhoid fever a disease of the intestines. In the bones, there is an increased disposition to ossification, but an abortive result in the imperfect formation of bone. Thus, the epiphyseal cartilages present a deeper transitional zone than in normal ossification, — the cartilage-corpuscles proliferating freely ; but this is not accompanied with a proportionate degree of calcification, the newly formed bone remaining soft, and to a greater extent adjoining the proliferating cartilage, than in healthy bone. The same deficient calcification occurs in the periosteal production of bone. And in either w^ay, the osseous texture produced has an imperfect structure. Scrofula and congenital syphilis have each been accredited with a tendency to rickets, and sometimes one or other of these constitutional diseases exists with rickets ; but the latter is essentially a distinct disease. Consequences. — In an early stage, before the disease is established, rickety deformities may disappear under favourable hygienic circum- stances and treatment. At a later period, the bones Fig. 383.* become strengthened by osseous deposit in the parts most requiring support; the long bones acquiring increased thickness in their small curvatures, and the deposition extending even into the interior, so as to partially ob- literate the medullary canal (Fig. 383). The epiphyses become thickened at the wrist, giving the appearance of a " double-joint," owing to a second depression in the skin, above the radial epiphysis. Modular enlarge- ments form on the anterior ends of the ribs, at the junc- tion of the costal cartilages ; and lying regularly one under another, they present the appearance named the " rachitic rose-g'arland." Unlike the tendency to periostitis and ostitis, in scrofula, rachitic periosteal and osteal thickenings never end in suppuration. Fracture, and more often incom- plete or green-stick fracture, is liable to occui- ; but bony union generally takes place, and in the usual period. Treatment. — The primary indication obviously is, to supply the deficient earthy matter ; and so, probably, arrest the disease. But no known medicinal prepara- tion seems to have this effect. The phosphates of lime, or lime-water, have been administered ; but in several instances I tried them without any perceptible result. Iron and quinine, combined with cod-liver oil, often prove more beneficial. These medicinal tonics, with due regulation of the bowels, nutritious diet, pure air, sea-bathing, frictions, and other means for improving the general health, constitute the most effectual plan of treatment. The nitro-muriatic acid bath is much recommended by Sir Ranald * St. Bartholomew's Hosp. Mus., 1, 35. MOLLITIES OSSIUM. 871 Martin, as a valuable adjunct. Daily exercise may be taken advan- tageously ; but tbe bones of the lower limbs sbould be relieved from the weight of the body, by the patient reclining at intervals during the day, and wearing steel-supports so applied as to resist any tendency to curvature. The support should be placed on the opposite side of the limb to the direction of curvature. When applied upon the curve, observes Mr. Brodhurst, pressure should be exerted only in the hori- zontal position, to avoid sloughing. Many a little, rachitic child, pot-bellied and bandy-legged, may thus be reared to man's estate ; •when E"ature will complete the cure. Permanent curvatures in the long bones may remain, after the osseous texture has become strength- ened by ossific deposit, and acquired perhaps sclerotic hardness. Any such deformity, if it interfere with the use of the limb, may resist m^echanical treatment by means of properly contrived apparatus. It has, therefore, been proposed to fracture the bone subcutaneously, and then set the limb straight ; or, if the bone be too firm, to perform subcutaneous osteotomy, as Langenbeck recommends. Successful results have been obtained by both these surgical procedures. But the probability of a natural cure taking place should ever be remem- bered ; that the bones will straighten in their growth, the child out-growing the deformity. MoLLiTiES OssiUM — OSTEOMALACIA — Malacosteon. — Structural Con- dition. — This diseased state of the bones is far more rare than rickets, only a few instances having been recorded ; but it is also far more serious. The earthy matter is greatly diminished, but replaced by a peculiar reddish gelatinous matter, chiefly fatty, and containing nucleolated nuclear cells, which have been desci-ibed by Mr. Dalrymple. This matter occupies the cancelli, which are considerably enlarged, and cavities in the compact texture ; infiltrating' the whole substance of the bone, until, as Dr. Ormerod remarks, it more resembles fatty matter enclosed in a periosteum than a bone. Bones thus affected are soft and flexible, and much lighter than natural ; on section, the osseous texture yields a gritty sensation, and has a reddish-brown or maroon colour, exhibiting the peculiar gelatinous matter in an extremely rare- fied osseous texture (Fig. 384). The characteristic appearances are well marked in the section of the lower half of the femur, as represented. Atrophy, by rarefaction of the cancellous texture, and thinning of the walls of the bone, is associated with the sub- stitution of the peculiar gelatinous and fatty matter. The periosteum and articular cartilage are healthy. The chemical composition of bone in this state, ac- cording to Dr. Lesson's analysis, is — in 100 parts, 18'75 animal matter, 29-17 phosphate and carbonate of lime, and 52-08 water. Commencing, apparently, in the cancellous tissue, the compact portion may retain its natural consist- ence, as an outer shell of bone ; and the whole length of a long bone may not be affected. But many bones are always simultaneously * St. Bartholomew's Hosp. Mus., 1, 233. See also Specimen 1, 129. Fig. 384.* 872 SPECIAL PATHOLOGY AND SURGERY. diseased. Fracture, or bending without fracture, ensues, according to the extent of the disease. When softening is limited to the internal part of the bones affected, leaving an outer shell of hard bone, fracture is liable to occur ; in one case, related by Tyrrell, twenty-two fractures happened; in another, by Arnott, thirty-one fractures. When the disease involves the loliole thick- ness of the bones, they become bent in various forms, and to an extreme degree ; presenting the most remarkable and frightful deformities (Fig. 385). Mollities ossium and Rickets have some structural characters in common ; the marked diminu- tion of earthy matter, and rarefac- tion of the osseous texture ; both diseases also affect more or less the osseous system generally. But in the former disease, decalcifica- tion occurs after previously perfect ossification ; and the gelatinous matter is peculiar to mollities ossium. In respect of its fatty character, the disease has some affinity to fatty degeneration ; while, in virtue of the nuclear and nucleated cells, a few of which may be caudate-shaped, there would appear to be some alliance to the structural elements of Cancer. As compared with senile ati^ophy of bone, mollities ossium is distinguished by the softness of the osseous texture, as well as by the medullary canal being filled with the peculiar gelatinous substance, and which also occupies the place of the compact walls of the bone, now reduced perhaps to a mere shell. Otherwise, the thin bony case resulting from senile atrophy so far resembles, and might, be mistaken for, the atrophy which accompanies mollities ossium. Signs and Symptoms. — Certain premonitory symptoms usually pre- cede fracture or deformity from mollities ossium. Wandering pains in the affected bones are experienced, and of a rheumatic character, but more severe and persistent. Marked failure of the general health accompanies these osseous pains ; while great exhaustion and some emaciation precede any perceptible change in the bones. Then a fracture here or there, and progressive deformity, leave scarcely any doubt as to the nature of the disease. Diagnosis. — From Rheumatism, it is at once diagnosed by these manifestations of morbid osseous condition ; from Cancer, by the very general distribution of the disease, affecting more or less the whole osseous system, and by the deformity. Thus, according to Litzmann, in 85 child-bearing women, the whole skeleton was affected in 6 cases, and all the bones except those of the head in 2 ; and in 46 other cases, all parts of the skeleton were diseased in 21, and all the bones except those of the head in 6. From Jiickets, as well as other diseases, Mollities Ossium maybe distinguished by the disease having occurred * Med.-Chir. Trans., vol. xxvii. Mr. Solly's case. MOLLITIES OSSIUM. 873 after the bones had become ossified and firm — at least, therefore, after puberty or towards middle age. The state of the urine is peculiar. It contains a great abundance of earthy matter, which was shown by Mr. Solly to be phosphate of lime, removed from the bones and eliminated through the kidneys. But the urine may also contain a peculiar substance, nearly allied to albumen, and in great abundance. According to the analysis of Dr. Bence Jones, in Mr. Dalrymple's case, this substance is the hydrated deutoxide of albumen, and 66'97 parts were passing out of the body in every 1000 parts of urine. Here, therefore, there was as mucla of this albuminous substance in the urine, as there is of ordinary albumen in healthy blood ; an ounce of urine passed was equivalent to an ounce of blood lost, as regards its albumen. " The peculiar characteristic of this hydrated deutoxide of albumen was its solubility in boiling water, and the precipitate with nitric acid being dissolved by heat and reformed when cold. By this reaction a similar substance in small quantity may be detected in pus, and in the secretion from the vesiculee seminales. The red- dening of the urine on the addition of nitric acid might perhaps lead to the rediscovery of this substance ; when found, the presence of chlorine in the urine, of which there was a suspicion in the above case, should be a special subject of investigation, as it may lead not only to the explanation of the formation of the albuminous substance, but to the comprehension of the nature of the disease which affects the bones." Causes. — The pathological cause of mollities ossium is unknown. But the disease in no way arises from an imperfect formation of the osseous texture, and does not generally occur before the middle period of life, or subsequently. It would appear to be hereditary in some cases. Females are more subject than males, and repeated pregnancy seems to engender a predisposing condition. Yet the tendency thus induced seems to be limited to some bones, more often than to involve the whole skeleton ; and Litzmann's statistics point to the specially interesting fact, that in child-bearing women, the pelvis is affected more frequently than in other women subject to mollities ossiura. The bones of the head are far less liable in the former than in the latter class of subjects ; but the other bones of the skeleton — in the spine, thorax, lower and upper limbs — appear to have a greater relative liability in women, apart from the influence of pregnancy. The supposed asso- ciation with rheumatism is more apparent than real ; owing to the similar character of the wandering pains. Syphilis also is an occasional concomitant, rather than a causative condition. Termination. — The fractured bones evince little or no tendency to the production of callus ; and as the deformity resulting from their bending inci'eases, the patient becomes a wretched cripple, yet living perhaps for years. Ultimately, death ensues from sheer exhaustion ; or functional disturbance, consequent on altered relations of the viscera or pressure from deformity, proves fatal. Treatment. — No known medicinal agents have any curative efficacy. A generally tonic and nourishing plan of treatment may somewhat relieve the concomitant exhaustion of mollities ossium, and opiates alleviate the wearing pains. Posture and mechanical contrivances are also of some use in counteracting the progressive deformity, and rendering life more tolerable to the patient, when bedridden. 874 SPECIAL PATHOLOGY AND SURGERY. Fragilitas O.SSIUM. — Brittleness of the bones is, pathologically, the opposite condition to Rickets ; implying a superabundance of earthy matter in their composition. The only specimen with which I am acquainted, is an upper end of the Femur in the Museum of St. George's Hospital. Occui'ring as a natural change in the bones as life advances, it may also, at other periods, be symptomatic of cancer, syphilis, scurvy ; and, probably, of other diseases of, or affecting, the osseous system. Hypertrophy and Atrophy of Bone represent an increase or dimi- nution of the osseous substance, accompanied often with correspond- ing alterations of size ; these conditions resulting from increased or deficient nutrition. Neither of them occur as independent alterations from the healthy standard of growth ; but are found in connection with various diseases of bone. As such, they have already been noticed. Here, therefore, it will suffice to take a general view of both these changes, and in conjunction with their associated diseases. Hypertrophy — signifying an increased production of bone-substance — may occur in either of two forms: as sclerosis or induration, in which the additional matter is deposited interstitially, whereby the bone affected becomes denser and harder ; or as manifested by increased size, coupled with interstitial increment. Thus, the long bones are increased in thickness, and sometimes in length. Usually, the normal structure of the bone-tissue remains unchanged. This twofold condition often results from chronic ostitis (see Fig. 347) — whether the inflammation of the osseous texture be of traumatic origin, or proceed from any constitutional cause, as scrofula or syphilis. The peculiar disease described by Sir James Paget, as osteitis deformans, is attended with most marked hypertrophy, as well as deformity of the bones. In consequence of common ostitis, some bones often become hypertrophied. The tibia and fibula, or the femur, may be found much enlarged and indurated, and possibly elongated. With the formation of abscess in bone, the surrounding wall of osseous texture is much indurated. And, in conjunction with caries, the adjoining, portion of bone is usually indurated and thickened. Contiguous inflammation may give rise to hypertrophy of bone ; and thus may be explained the thickening and lengthening of a bone from an ulcer in the integuments. Increased function is an occasional cause of hyper- trophy, as affecting bone. This is witnessed in the osseous thick- ening of long bones with rickety curvature; the shaft becoming strengthened by ossific de|X)sit within the curvature, as a com- pensatory support. Atrophy of bone — signifying a reduction in the quantity of osseous substance — may — like hypertrophy — be manifested by an alteration of size, or of density : or both changes may be combined. Thus, a bone may be reduced in thickness and in length — relative to the growth of a healthy bone of the same age ; or, by interstitial wasting of the bone- substance, the original thickness remains unaltered, — this condition consisting in absorption and rarefaction of the cancellated structure, which appears more open (see Fig. 358), and with reduction of the compact walls to a thin shell. This result is named " osteoporosis " by Rokitansky ; and it is the " eccentric atrophy " of bone, so named by Mr. Curling. The osseous texture, reduced in quantity, may retain its normal structure ; but, sometimes, the atrophy of bone is HYPERTROPHY AND ATROPHY OF BONE. 875 accompanied with a deterioration in ttie quality of its tissue, bj fatty degeneration. Among the diseases of bone with which atrophy is more commonly connected, inflammation seems to be the most frequent. In ostitis, the initial changes of fatty liquefaction of the fibrous matrix, with unloosening of the inorganic matter, is followed by absorption of the disintegrated bone-texture ; resulting in rarefaction or osteoporosis. In caries, disintegration is preceded by some atrophy of the bone- tissue. And, in conjunction with necrosis, from ostitis, the neighbour- ing portion of bone may be rarefied. (See Fig. 346.) Mollities ossium is attended with eccentric atrophy ; the cancellated structure having almost disappeared, and the compact walls being reduced to a thin shell. The interstitial substitution of a peculiar gelatinous and fatty matter, imparts to the rarefied osseous texture its remarkable soft- ness. In fragilitas ossium, the increased proportion of earthy matter seems to be due chiefly to absorption of the fibrous matrix, — another atrophic change. Hence, the brittleness of the bone-tissue. In rickets, an opposite condition exists ; a diminished proportion of the earthy matter, — with a rarefied state of the cancellous tissue, containing a brownish-red fluid — while the fibrous basis of the bone is relatively increased by the absence of earthy matter ; this condition resulting in the flexibility which distinguishes rickety bones. But here the state of the osseous texture is one of imperfect formation ; and thus rickets cannot be referred to any form of atrophy which bones are liable to undergo. Tumours of bone sap, as it were, the nutriment of the osseous tissue ; and living, therefore, at the expense of the bone on, or in, which they are seated, their growth is accompanied with atrophy of the adjoining portion of the compact or cancellous tissue. This occurs more especially in connection with tumours of rapid growth, such as Cancer. But tumours may also cause atrophy by pressure ; as occurs during the growth of an enchondroma within the substance of a bone, so that at last the tumour is enclosed in a thin, papery shell of the remnant wall, which yields with crisp crepitation under the fingers. Wound of a nutritious artery — cutting ofl: the supply of blood to a long bone, is likely to be followed by atrophy of the shaft, from deBcient nutrition. This result has been found after fracture, implicating the nutritious artery, of the femur, the tibia, or the humerus. Paralysis is sometimes attended with atrophy of the bones in the affected limb ; wasting of the osseous texture seeming to depend on some direct impairment of its nutrition, and not only on disuse of the limb, ^ut functional disuse is necessarily accompanied with atrophy ; as witnessed in wasting of the bones from anchylosis of a joint. Or, after amputation, the stump-end of the bone wasting, it becomes pointed. In old age, the bones are slowly atrophied, in common with the general wasting of the body from declining nutrition, as life advances. Hence, the increased liability to fracture. Thus, with senile atrophy of the neck of the femur, intra-capsular fracture is very apt to happen from the slightest injury. As distinguished from atrophy, the growth of bones may be arrested from disease or iujiiry of the epiphyses. The long bones are thus afi^ected, in regard to theu^ length ; by arrested growth becoming shorter, relative to healthy bones of the same age. Caries of an 876 SPECIAL PATHOLOGY AND SURGERY. epiphysis, leading to disunion from the shaft, or disunion from fracture, without repair, mar each have this result — arrest of growth and shortening. And, moi-e rarely, when, in the course of development, an epiphysis remains ununited, shortening results. So also, the removal of an epiphysis, in the excision of a joint, has the same liability. This may be obsei-ved more particularly, after excision of the knee-joint. If both epiphyses — the upper and lower — of a long bone be diseased, the shortening of the bone from arrest of growth will be more marked. Of the tvro epiphyses, the relative productiveness of the upper and lower, in regard to longitudinal growth, w^ill be noticed in connection with Excisions of Joints. Fig. 386.* Tdmours of Bone. Exostosis. — Structural Conditions. — Exostosis is an oat-growth of bone ; its texture therefore resembles either the compact or the cancel- lated structure of bone. The compact variety, consisting of solid bone, is of small size, and is very hard — hence named ivory exostosis. It is generally situated on the flat bones, especially the cranium, and in the orbit; on the upper and lower maxillEe ; occasionally on the scapula, ilium, or the great toe, from the ungual phalan:x of which I have removed such an out-growth. This variety of exostosis, observes Sir James Paget, occurs in two forms. Some grow on the exterior of the bones of the skull, in smooth, spheroidal, or lens-shaped lumps, attached, commonly, by i-ather narrow bases. Others, which are usually of deeply lobed and nodular shapes grow in the diploe, or the frontal or other sinuses, whence, as they enlarge, they project through the gradually thinned and perforated layers of bones that at first enclosed them. The former kind rarely increase to an inch in diameter; the latter may increase to many inches, and they commonly pro- ject into the cavity of the skull, as well as externally, or into the cavities of the orbits or any other adjacent parts. The cancellous or spongy variety, consisting of the open medullary texture of bone, containing marrow, and invested with a very thin layer of compact tissue, is of considerable size, and yields somewhat under pressure. It is generally situated on the shaft of a long bone ; particularly the femur, on its inner surface, just above the condyle (Fig. 386) ; the head of the tibia ; or the phalanges of the fingers or toes. Such exostoses are out-growths from the epiphyseal carti- lages, and are thence named by Yirchow " enchondrosis ossificans." Another very common situation, according to Mr. Holmes' observations, is beneath the deltoid miiscle ; but here I have never met with the cancellous variety of exostosis. In both conditions, the structure of exostosis usually resembles that the bones on which they severally grow. Thus, the compact variety has a concentric lamellar arrangement, with Haversian canals ; * St. Bartholomew's Hosp. Mus., 1 186. of TUMOURS OP BONE. 877 the cancellous variety, when continuous with the spongy substance of the epiphysis, is overlaid with a layer of hyaline cartilage, a line or a line and a half in thickness, and this growing in itself and from the periosteum or perichondrium, rapidly becomes ossified towards the centre. Both varieties grow from beneath the periosteum or adjoining perichondrium ; and however nearly the texture may resemble that of bone, a boundary line is generally apparent where the structure is dis- continuous. Mucous bursse sometimes form on epiphyseal exostoses; these sacs contain ossifying cartilaginous growths, loose or attached, and communicate with the neighbouring joint — -such bursee being, according to Rindfleish, prolongations from the articular synovial membrane. Inflammation and suppuration of any such acquired bursa may seriously complicate an exostosis, otherwise quiescent, and lead perhaps to destruction of the joint. Exostosis generally occurs singly ; but many may form, when they are usually symmetrical. This is particularly observed in the cancellous variety. A third variety of exostosis is recognized by some pathologists. It is attached to bone, although not as an out-growth, but proceeds from the ossification of tendons, fasciae, or muscles, and is consequent on chronic inflammation, induced perhaps by injury. Appearing in the form of long, spinous processes of bone, these exostoses may be found in con- siderable number, and connected with any one or more of the long bones, but affecting chiefly their articular ends at the attachments of tendons. Associated in their nature with this anomalous kind of exostosis are certain ossific formations in the substance of muscles, and which, as arising from some muscular strain or other injury, are known as " exercise-bones." Thus, in the deltoid muscle, osseous development sometimes results from repeated pressure or contusion by the habitual use of a rifle or fowling-piece. Hence, it is occasionally met with in the shoulder of soldiers and sportsmen. Signs. — The characters of exostosis are sufficiently obvious ; a very hard, or a somewhat yielding, rather pedunculated tumour, immovable or nearly so, and attached to the bone as an out-growth. Both forms of exostosis are slow-growing, and particularly the compact variety; but the cancellous attains a far larger size. Both may undergo certain destructive changes; necrosis, or sloughing away from the bone, and with ulceration of the superimposed integument. As a rare event in their history, fracture has occurred from direct violence, breaking off the exostosis through the neck or base of attach- ment ; and this has even been followed by absorption of the tumour. Sometimes, the growth of a long bone is arrested by the production of exostosis ; the lower third of the ulna — in a case under Erichsen's observation — having become much shortened, in consequence of a bony out-growth just above that part of the shaft. Exostoses may occasion various functional disturbancesbypressure. The situation of the tumour will very much determine these results. Thus, an ivory exostosis has projected into the orbit; or, growing from the inner table of the skull, has pressed upon the brain ; or, from the pubic bone, has perforated the bladder ; and cancellous exostosis, or tendinous formations, in the neighbourhood of a joint will more or less impair motion. True exostosis is never malignant ; and the osseous out-growth will thus be distinguished from an ossifying sarcoma or cancer out-growing from bone. 878 SPECIAL PATHOLOGY AND SURGERY. Causes. — The compact variety is attributed to syphilis, sci'ofula, or other diseases affecting bone, and which produce an out-growing hypertrophy of the compact osseous texture. The cancellous variety results from the ossification of an enchondromatous or cartilaginous tumour. It may, therefore, be said to be developed through cartilage ; while the ivory variety is rarely so produced. Age seems to have some causative relation to exostosis ; both varieties commencing, pi-obably, in earliest infancy. The epiphyseal exostosis can only occur in youth, or not later than the twenty-fourth year. (Billroth.) Men are said to be more subject than women to all these exostomatous formations. An hereditary tendency may sometimes be traced. Treatment. — Exostoses which remain stationary, or which form in certain situations, as the orbit, or involve a joint, such as the knee, are better left alone. The danger also of exposing cancellated bone should, always be considered ; diffuse suppuration and pyjemia being very liable to follow the operation of removal. The tendinous forma- tions will probably prohibit operative interference, by their number, and the predisposition to ossific deposits. Otherwise, an exostosis may be removed mechanically, by excision; or destroyed, by nitric acid or other strong caustic, applied to its exposed base. Compact or ivory exostosis is often very difficult of excision. Several instruments should be provided ; that one failing, another may prove efficient. A trephine saw, chisel and mallet, or cutting-pliers, are sometimes severally requisite to remove the little ivory hard lump of bone. They all, in turn, failed in the hands of an expert operator — the late Mr. Keate — although employed perseveringly for nearly two hours. The exostosis having been removed down to its base, caustic may then be applied to destroy the remaining portion by exfoliation. Potassa fusa and nitric acid were thus applied successfully in Mr. Keate's case. Subcutaneous section has been practised in a few cases, with a view to absorption taking place, — as after detachment of an exostosis by fracture ; and successful results have been thus obtained by Mr. Maunder. Exostoses do not recur after removal ; and, for- tunately, even when the base of attachment is left, the tumour is not likely to grow again. Enchondroma. — In connection with bone, enchondroma or cartilagi- nous tumour has already been considered, as being the most prominent part of the general pathology of this species of Morbid Growth (Chap. II.) ; for it occurs principally in connection with the osseous system The tumour has a more or less irregular, lobulated surface, and is of more or less firm, but somewhat elastic, consistence ; it varies also considerably in size, — being that of a pea, sometimes, when growing from one of the phalanges of the fingers, or attaining to the bulk of a cocoa-nut or larger mass, as when seated on the head of the tibia in the popliteal space. Enchondroma — or, occasionally, some other kind of growth — may be contained in the centre of a bone, and surrounded by an osseous shell ; it then feels so hard and inelastic as to resemble a large exostosis ; but, in a later stage of growth, the tumour seems to have become softer, at least in parts, from further expansion of the bone, which now yields with a crisp crepitation, like that of parchment, when handled. Treatment. — Excision or amputation will be appropriate, according to the size and relations of the tumour. When these conditions admit TUMOURS OF BONE. 879 Fig. 387.t of the removal of the tumoar, and, by an incision so as to examine the mass, it is found to be lodged within an expanded shell of bone, enuclea- tion — as proposed by Sir James Paget — may be practised ; the carti- laginous growth being turned out of its case, and the cavity plugged with lint. Encouraging results have thus been obtained.* Fibrous Tumour. — The formation of a fibrous tumour in connection with bone is far more rare than the cartilaginous tumour. It is illustrated by fibrous epulis and fibrous nasal polypus ; both of which, however, are fibrous out-growths. Periosteal fibroma — having its origin in the periosteum — invades the osseous texture, as well as growing out- wards. The fibrous tissue, in the form of fasciculi, may have a radiated arrangement from the periosteum outwards (Fig. 387). Externally, the tumour has a nodulated character, and its consistence may vary in different parts ; being hard and fibrous, or soft and succulent. In the speci- men, a portion of the morbid growth has formed also in the cancellous tissue of the femur, and occupies the medullary canal. The Signs of any such tumour much resemble those of enchondroma, and their diagnosis is unimportant. The Treatment is excision or amputation. Cysts. — Two kinds of cysts have been found in bone ; the serous and sanguineous. Their pathology for the most part merges in the general history of these cysts (p. 1.51). They are fnuUilocular, the cavities often com- municating ; and they are met with in the Ja.ws or in the long bones, their shafts or articular ends. They grow to a large size, that of a cocoa-nut or foetal head. Uni- locular cysts are also described by Nelaton as containing solid matter, of a fibrous or fibro-cartilaginous structure, occupying entirely the cavity of the cyst. These are found in the same situations as the last, but grow to a less size. Cysts in bone form mostly in adults. Signs. — They produce an expansion of the surrounding osseous texture, and at length being enclosed in a thin lamellar capsule of bone, yield a crackling sensation under pressure with the finger and a deeper or more obscure elasticity or semi-fluctuation. Perforation here and there taking place by progressive absorption of the lamellar capsule, the enclosed tumour becomes more clearly perceptible. The superimposed skin yields before the increasing tumour ; but without discolouration or any participation in the disease, and there is little or no accompanying pain. The tumour is thus plainly non-malignant in its development. Treatment. — Fluid cysts may be laid open by removing a portion of the bone, by trephining or otherwise, and the cavity dressed from the bottom with lint. Granulation will then obliterate the cyst. Solid cysts must be excised, or recourse had to amputation; according to the size and relations of the cyst. Cystic Tumours. — In bone, as in other "parts, tumours occur, * Med..Chir. Trans., vol. liv. f St. Thomas's Hosp, Mns., C. 250. 880 SPECIAL PATHOLOGY AND SURGERY. Fig. 388.* containing cysts. Fibro-cjstic tumour of bone commences, apparently, in the cancellous tissue, and growing outwards, occasions fracture. The annexed figure represents a section of an enchondroma of the scapula, showing cysts, formed by absorp- tion of the cartilaginous portion in parts, leaving the fibrous stroma (Fig. 388). The humerus was extensively involved. (See also Path. Soc. Trans., vol. i. p. 344.) The Signs are those of cysts in bone : an elastic sensation or obscure fluctuation. The absence of pain, integumental dis- colouration, and glandular swelling dis- tinguish this tumour and other innocent cystic tumours fi^om Cancer. The femur was the seat of the disease in four cases, one of which is related by M. J. Adams in the Fath. Soc. Trans., vol. v., and the remaining three, by Mr. Prescott Hewett, are appended to the report of that case. Amputation was followed by permanent recoveiy in the above cases. Hydatid cysts in bone are interesting chiefly in relation to the fluid cysts, above described. The entozoon has been, in all cases, the ecbinococcus or acephalocyst (Fig. 389); except in one case, mentioned by Mr. Stanley, where the Cysticercus cellulosee vpas found in the in- terior of one of the phalanges. But hydatid cysts are very rare; eight cases only being referred to in Rokitansky's work ; to which a limited number of instances might be added. These cysts may be seated in a flat bone, as the sknll or ilium, or in tlie expanded head of one or more of the long bones. The diagnosis with reference to ordinary fluid cysts can scarcely be drawn. The cysts increasing in size, fracture takes place, as pro- bably tbe first appreciable sign ; and the bone remains ununited. This, hoAverer, is incident to other diseases of bone. A discharge of fluid containing entozoa would determine any ques- tion of diagnosis. This may occur sponta- neously, or be obtained by puncture. The treatment, also, is the same as for ordinary fluid c^'sts ; but it will be advisable to destroy the interior of the hydatid cyst by freely applying nitrate of silver or other caustic. Sarcomata. — The bones are very liable to be the seat of sarcoma, Fig. 389. * St. Thomas's Hosp. Mns., C. 219. t Ibid., C. 230. Hydatids in bone, the medullary cavity of the hamerns being filled with echiuococci in various stages of development ; their growth has been attended with destrnction of the cancellous tissue, and thinning and expansion of the shell of bone, — eccentric atrophy. About the middle of the shaft, this state has resulted in fracture. The patient was a man, aged thirtv-fonr. (Presented by- Mr. Boot, of Lincoln.) TUMOURS OF BONE. 881 in eacli of its typica forms of histological character ; the tumour being either a round-celled, spindle-celled, giant-celled, or mixed-celled sarcoma. The growth may originate from beneath the periosteum, as a siob-periosteal tnmour : or from within the substance of the bone, as an endosteal or central tumour. Whether originating within, or on the surface of, bone, the long bones are most frequently affected, and especially their articular ends — although here the central tumour is usually met with. Thus, sarcoma more often occurs in the lower end of the femur, and upper end of the tibia or fibula, adjoining the knee-joint; or the upper end of the humerus may be affected, forming a tumour, as of the shoulder- joint ; or when the lower end of the radius or the ulna is the seat of origin, the wrist presents a tumour. But the flat bones may also give rise to sarcoma ; the scapula not unfrequently, the cranial bones more rarely. The round bones, as in the carpus and tarsus, are seldom affected. Generally, perhaps, it may be said, that the nearer the trunk, the more malignant is the growth ; as wit- nessed when either the humerus, or the femur, gives birth to sarcoma. The bones are apt to be the seat of production at either extreme period of life — youth or old age ; but more commonly mid-life seems to be predisposed. And both sexes appear to be about equally subject. The histological characters of sarcomata affecting boue, although not differing essentially from those of the typical forms as produced in other parts, are modified by the special structure of osseous texture, which may be associated with the particular form of cell-growth, con- stituting the tumour. Diffused within the substance of bone, or springing from its surface, beneath the periosteum, neither the central nor sub-perio steal sarcomas are encapsuled ; the one being encompassed only with a cortex of bone, expanding with the growth ; the other being enclosed only by an expansion of the periosteum, — which also bounds a central sarcoma, as the osseous cortex yields with the en- larging growth of the tumour to the surface of the bone. In the coarse of its growth, the structural elements of the tumour are prone to undergo degenerative changes, possibly by fatty transformation, usually by calcification ; the latter change affecting especially a sub- periosteal sarcoma, owing to the ossifying influence of the periosteum. With the alterations thus induced in the structural condition of the tumour, its physical characters are no less changed. The tumour, which was originally firm, or hard, more particularly in the central form of sarcoma, now becomes even harder, having the consistence of cartilage or of bone. These transformations may be designated chondrosarcoma and osteosarcoma, respectively, as varieties of Sarcoma affecting Bone. The diagnosis of sarcoma in, or on, bone may be obscured by the situation of the tumour; a central sarcoma being denoted only by a general enlargement of the bone, but which may be produced also by the formation of central cancer, intra-cystic growths, or even by thickening of an hypertrophic character, as resulting from chronic ostitis and periostitis; or by an abscess in bone, with some enlargement ; while a sub-periosteal sarcoma presents a more palpable tumour, but of scarcely less indefinite character. The more or less rapid growth, and infective course of the tumour, must, however, be taken into account; in a word, the vital histoiy of the growth overrules any doubt referable to the mere appearance of the tumour itself. This VOL. I. 3 L V2 SPECIAL PATHOLOGY AND SURGERY. behaviour of the tumour as a growth may, indeed, be similar to that which cancer exhibits, as it proceeds from Avithin the substance, or from the surface of a bone — a central or a sub-periosteal tumour, in the course of its development ; but this family resemblance in respect to their vital characters also, would not mislead the Surgeon with regard to the treatment of a tumour which exhibits the same malignant nature common to both Sarcoma and Cancer. The only treatment will be by operative interference for complete removal of the tumour, and at the earliest period of its growth. The operations of excision and amputation are subject to the same con- ditions as relating to Cancer. A central sarcoma admits of excision with less probability of recurrence than the periosteal form of growth ; provided only that the operation be performed at a sufficiently early pei'iod. But the diflBculty of diagnosing the tumour, when, thus located within a bone, it may be denoted only by some general en- lai'gement of the bone — say, of the lower articular end of the femur — will, perhaps, rarely warrant recourse only to excision. Amputation above the next articulation — at the hip-joint, in the case supposed — is usually the more secure operative procedure. Periosteal sarcoma would generally demand removal of the limb, and thus high above the source of disease, rather than amputation in the continuity of the shaft of the bone affected. In some localities, any operation may not be pi*acticable, owing to the uncertain anatomical relations of the tumour, — even at an early period of growth ; as sometimes in connection with the upper jaw ; or sarcoma affecting the ribs or the pelvic bones. Beyond these general considerations, no rules can be laid down which shall be applicable to all cases. The Surgeon must exercise his own judgment as to the tumour with which he has to deal — in relation to the choice of operation, or whether, perhaps, any operative interference may be justifiable. Thus, in the case of a myeloid sarcoma, about the size of a chestnut, springing apparently from the periosteum, at the outer condyle of the femur — I opened the joint, as for excision of the knee. Having removed the articular end of the femur, I was thus enabled to determine the periosteal origin of the growth ; and I then proceeded to complete the joint-excision, rather than amputate above in the thigh, as that operation would still have been done in the continuity of the bone, but with the sacrifice of the limb, — and secondary amputation could be resorted to in the event of the disease recurring after excision of the joint. The patient, a boy, made an excellent recovery, with a perfectly straight, and thoroughly useful limb, — without the recurrence of sarcoma, at least for some months after operation, while he remained under observation. The Myeloid form of Sarcoma — Giant-celled Sarcoma — in connec- tion with bone, is sufficiently described in the general pathology and treatment of this growth. The tumour is more or less lobulated. Tf enclosed within bone, its shape is uniform and spheroidal ; if seated on the surface of a bone, its outline is irregular, as seen in epulis. The fleshy, inelastic firmness of a myeloid growth is remarkable, although its consistence varies. The characteristic appearances on section are here delineated (Fig. 390). It presents a greyish- white basis colour, daubed with irregular blotches of a bright red, livid, or brownish tint. This blotched appearance is not dependent on vascu- CANCER OF BONE. 883 Fig. 390.* larity, the blood-vessels being scanty, even when the tumour is most ruddy. From the succulent cut surface, a yellowish fluid exudes. Recurrent osteoid tumour is illustrated by a series of thi^ee prepara- tions in the Museum of the Royal College of Surgeons, to the remarkable ■ history of which Mr. Holmes has called at- tention. A hard and heavy, dry osseous sub- stance formed around the ends of the femur and tibia, projecting into the knee-joint, ex- tending far up the thigh and implicating the popliteal artery, vein, and nerve, so as to cause oedema and severe pain. (Prep. JSTo. 3244.) Amputation was performed at the thigh. The patient remained well for five years ; then another osteoid tumour formed on the stump of the femur, accompanied with severe pain. Ampiitation was performed higher up. The tumour appeared to gTow, not from the bone itself so much as from the periosteum, and enclosed the femoral artery. (Prep. N"o. 3245.) An interval of health again continued for two years; when another tumour formed about the stump, progressed upwards, out of reach of operation, and finally proved fatal, by inflammation and sloughing of its soft coverings, twenty-five years after the first appearance of the disease. The general health of the patient, a male, remained unaflrected during the whole period. (Prep. No. 3245a.) Another, and very similar case, may be found in Paget's " Surgical Pathology." Treatment. — Both these recurrent tumours of bone admit only of free excision or amputation — as the size and relations of the mass may indicate. But the great liability to recurrence will generally render the former operation unadvisable ; and even amputation may prove in- effectual, the case above noticed having resisted three such ablations. Cancer. — Each species of Cancer — encephaloid, scirrhous, colloid, and epithelial cancer — is liable to form in connection with bone ; but encephaloid is the most frequent. Like other diseases of bone, Cancer may affect the substance or the surface of a bone : in the one situation, it is known as interstitial or possibly central cancer ; in the othei', as periosteal cancer. In the substance of bone, interstitial cancer occurs in the form of scattered nodules, having a whitish colour, and the consistence of scir- rhus, or hard encephaloid cancer. The cancer-cell — so little absolutely characteristic of cancer — may be indistinguishable or absent. These nodules coalescing, form a mass, which occupies the cancellous tissue, and extends into the medullary canal. The bone surrounding such a formation is expanded and thinned or thickened ; with osseous fibres traversing the substance of the tumour, radiating from its centre. It is situated most commonly in the articular ends of a long bone, or in a flat bone, as the pelvis or skull. As affecting the whole bone, this con- dition of the disease is sometimes designated infiltrated cancer of bone. On the surface of bone, periosteal cancer forms betw^een the bone * St. Bartholomew's Hosp. Mus., 1, 12. 884 SPECIAL PATHOLOGY AND SURGERY. Fig. 391.* Fig. 392.t and periosteum ; rarely involving the one, while the other may some- times be traced over the tumour. Osseous fibres radiate from the vsurface of the bone through the tumour; and a bony deposit, forming a coral-like mass, often spreads aronnd it. Periosteal cancer appears, usually, in the long bones, especially affecting their articular ends (Fig. 391). The incrusting cartilage of the contiguous joint generally escapes, in both this and the interstitial formation of cancer ; although the disease may extend to the capsule. Osteoid cancer is a term used to designate a further degree of os.siBcation than that commonly met "with in interstitial and periosteal cancer-growths. This is analogous to the ossification of enchondro- matous or cartilaginous, and fibrous, tumours. Osteoid cancer is de- scribed by Mr. C. H. Moore as being, in a well- marked case of the pri- mary tumour,a large mass of the hardest enamel or ivory-like bone ; the glan- dular disease is bony, though it may be less hard ; and the disease disseminated in the soft internal organs, and pro- truding . into the blood- vessels, is also in great part osseous. The osseous fabric or skeleton of any tumour which has under- gone ossification, may thus represent an osteoid tumour or growth ; as well as when such a tumour appears in the form of a purely osseous gi'owth or out-growth, e.g. exostosis. The cha- racteristic appearances of the new bony growth are seen when the soft growth, with which it is associated in the general mass of the tumour, is removed by maceration. I have here represented the skeleton of an ossified encephaloid cancer, as an osteoid tumour (Fig. 392. The section of a femur, showing the osseous part of such a tumour, which occupied the place of the shaft of the bone). The osseous substance is cancellous and spiculated ; but the form of the cancellous spaces differs from those of healthy bone. The whole tumour measured thirty-six inches in circumference. It was taken from a girl aged eleven years. Any .bone is liable to cancer- formation ; but some ai'e far more .so than others. The femur and tibia are most subject to the disease, and particularly the articular ends of these bones at the knee-joint. Thus, of 20 cases of cancer of the long bones of the lower limb, 11 were situated near this joint. The pelvis, spine, skull, especially the antrum, and the humerus, are also seats of cancer. It generally occurs in bone as a secondary formation. Signs and Diagnosis. — (1.) Cancer in the substance of bone produces expansion and an osseous tumoiir ; but the nature of this tumour can ♦ St, Bartholomew's Hosp. Mus., 1, 27. t Ibid., 1, 170. CANCER OF BONE. 885) Fig. 393.* scarcely be recognized at first. Tlie enclosed encephaloid cancer is much harder than when this disease affects the soft parts. At length, the enclosing shell of bone yields, and the mass declares itself at once, or very shortly, as the tnmour, nnrestrained, grows more rapidly. The ordinary characters of an encephaloid tumour become apparent : its soft consistence, lobulated coatour, and large size (Fig. 393) ; with purple dis- colouration of the skin, enlarged, ramifying veins, and pain throughout the course of the disease. Pulsation, of a thi-illing- or blowing character, may become perceptible, owing to enlargement of the vessels in the tumour, as it undergoes development. Fracture often occurs at the affected part. Grlan- dular swellings and constitutional symptoms will confirm the diagnosis. (2.) Periosteal cancer presents a tumour of more clearly cancerous character, and it grows more rapidly, at an earlier period. The muscles attached to the bone often become extensively infiltrated with cancer-cells. Thus may Cancer in, or on, bone be recognized and distinguished from any other species of tumour. But other evidence, gathered from the vital history of the growth, must be taken into consideration. The probability will be in favour of cancer- growth, when the tumour commenced before puberty or after mid-life, unless it be an enchondromatous or a bony tumour on a finger or toe, or near a joint ; or, when the tumour has grown rapidly, to perhaps double its size in six months, and is not inflamed. On the other hand, when a tumour has existed in, or on, a bone for a period of two years or longer, without showing symptoms of malignancy, it is probably not cancerous or recurrent. A tumour on the shaft of any bone but a phalanx, is rarely innocent; and so are any, except cartilaginous out-growths, on the pelvis ; and any, except the hard bony tumours, on the skull. (Paget. f) The diagnosis of malignant and non-malignant tumour of bone lies, however, principally between encephaloid cancer and enchondroma. Here the presence or absence, ultimately, of the signs which indicate an extension of the disease to the integument and neighbouring lymphatic glands, will mainly determine the question. Puncture with a grooved needle is also available as a critical method of examination, in this case, no less than in other doubtful forms of tumour. I was thus enabled to determine the nature of a tumour at the lower end of .tl/c femur, close to the knee-joint, which in point of consistence and lobulated appearance much resembled enchondroma. Amputation was performed, and the mass proved to be encephaloid. Pulsating encephaloid may be distinguished from aneurism by the expansive, heaving character of the latter, as compared with the thrilling vibration of the former. Treatment. — Excisio7i will be appropriate only in cases of limited cancer-growth in, or on, bone, and when situated where the whole * Trans. Path. 8oc., Lond., Yd\. x:i.[. Mr. H. Araott's case, t Med.-Chir. Trans., vol. \iv. 886 SPECIAL PATHOLOGY AND SURGERY. Fig, 39-4.* diseased portion can thus be removed. But under, apparently, the most favourable circumstances, the operation itself may prove most perilous. I once assisted my colleague, Mr. De Meric, in removing an apparently movable tumour, the size of a small orange, and situated over one of the mid-ribs. But this little mass sprang from the bone, the rib readily broke, and the welling up of blood from the tumour — an encephaloid cancer — was so profuse, that the patient nearly died on the spot. He sank in a few days from haemorrhage into the pleura. Amputation must generally be resorted to. This operation should be performed in the earliest recognized condition of the disease, and certainly before any enlargement of the lymphatic glands has evinced the supervention of systemic infection. Moreover, removal by am- putation can only be effectual for the prevention of the recui-rence of cancer, when the operation is performed high above the part affected, so as to be entirely free of the seat of the disease. Hence, in inter- stitial cancer of bone, the line of amputation should be, not in the continuity of the bone, but above the next joint; and in periosteal cancer the line will be most judiciously selected even higher up, above the origin of the muscles infiltrated probably by proximity to the disease. In considering the propriety of amputation, with a view to the prolongation of life, the probable evidence as to the existence of internal cancer should always be taken into ac- count — bone-cancer being gene- rally a secondary growth. * St. George's Hospital, II. 231. M.&Wgna.ni pulsating tumour of the ilium. The patient, a man aged fifty-one, was admitted into the hospital, October, 1855, with a small tumour in the neighbourhood near the saero-sciatio foramen, pulsating very distinctly. This disease was referred to an accident eight months previously. The case was distinguished from aneurism of the gluteal artery — a very rare condition — by the different character of the pulsation, by the fact also that pressure in the sacro-sciatic notch did not control the pulsation, and by the absence of bruit. In November, 1856, the tumour had increased very much on the nates, and pre- sented also in the iliac fossa, where fulness and pulsation were perceptible on deep pressure. The growth had now acquired a lobulated form, its consistence varied in different parts, and the softest parts of the mass were most pulsatile. There was paralysis of the sphincters of the bladder and anus, and occasional haematuria. The patient was emaciated. (Edema of the lower extremities, especially of the left, supervened ; and death ensued in about two years from the commencement of the disease. Post-mortem examination disclosed further particulars. lA very large mass of " malignant disease " was found connected with both surfaces of the iliac bone, and section on the dorsal aspect showed a cavernous siructnTe. The arteries communicating with these large spaces accounted for the pulsatile character of the tumour. Both the ilium and sacrum were extensively eroded, the sacro-iliac joint destroyed, and spicula of bone were found scattered about the substance of the growth. The two portions of this mass, on the opposite sides of the iliac bone, were continuous through the substance of the bone, and around the sacro-sciatic notch. In the course of the disease, the internal iliac and other veins had become infil- trated with malignant deposits, which had also taken place in the left kidney. PULSATING TUMOUK OF BONE, AND OSTEO-ANEURISM. 887 Pulsating Tumour of Bone, and Osteo-aneueism. — Structural Con- ditions. — A pulsating tumour in, or on, bone may be — (1) a tumour, not itself pulsating, but in connection with an artery which communi- cates its pulsations thereto ; as an enchondromatous, fibrous, or other tumour, thus connected ; (2) a vascular tumour ; usually cancerous and, particularly, encephaloid in the course of its development (Fig. 394) ; (3) a vascular growth or erectile tumour of bone, resembling aneurism by anastomosis in the soft parts, and constituting osteo- aneurism. This last condition is very rare, if it exist at all ; the best authorities, such as Cruveilhier and Rokitansky, are agreed respecting* the rarity of osteo-aneurism, and that most pulsating tumours of bone are highly vascular encephaloid tumours. The situation of such tumour is generally the cancellous interior of a bone, especially of the long bones, at their articular ends ; as the femur, tibia, humerus, radius ; also in the flat bones, as those of the pelvis and skull, and in the ribs. Signs and Diagnosis. — An enlargement of the bone, with a thrilling pulsation and bruit, are symptoms common alike to a highly vascular tumour, such as advanced encephaloid cancer, and aneurism by anasto- mosis. And this pulsation subsides on compressing the main artery of the limb. But the persistence of a tumour, and its incompressibility, would be distinctive of a mass having formed independent of the blood- vessels, a vascular tumour, and not a vascular groivth or enlarged con- geries of vessels. The bony case, however, which encloses any such tumour renders this test inapplicable, until the bone yields and the mass protrudes on the surface of the bone. Or compression of a main artery may be impracticable, owing to the situation of the tumour, as in the pelvic bones. Or again, the supply of blood may come from so many arterial branches, that it cannot be arrested by compression. A tumour, growing from bone, and pulsating in connection with an artery, is also distinguished from osteo-aneurism, in like manner, — the tumour being incompressible, and remaining when the supply of blood through the main trunk is cut off, although the pulsation ceases. Between osteo-aneurism and ordinary aneurism the diagnosis may be made, by the thrilling character of the pulsations, instead of a uniform expansion ; and if the absence of the latter be atti-ibuted to the probable consoli- dation of the supposed true aneurism, then the tumour — like any other solid unconnected tumour — could be lifted off the bone. In some situations also, where no artery runs of probably sufficient size to form an aneurism, the question as to its existence can hardly be suggested. When a pulsating tumour of bone — whether cancerous or erectile — has protruded from the interior of a bone, the distinctive characters of either form of growth become more apparent. Thus, an erectile growth or osteo-aneurism may be made to subside sufficiently, perhaps, for the Surgeon to feel the bony rim of the gap through which the protruded portion has come. Subsequently the nature of the tumour will be still further declared by its more developed characters ; encephaloid cancer, for example, enlarges rapidly, and involves the skin and lymphatic glands. Treatment. — Having due regard to the almost exclusive cancerous nature of pulsating tumour of bone, excision must have the same re- stricted applicability as with regard to cancer of bone in general. This operation has failed in cases of cranial and scapular pulsating tumours. 888 SPECIAL PATHOLOGY AND SURGERY. Amputation is the only justifiable operation of removal, in other than the few exceptional cases alluded to. The more decidedly en- cephaloid the disease, the more appropriate will be this more sweeping operation. It should be performed as soon as the nature of the disease is declared, and the line of amputation be chosen above the joint nearest to the bone affected. Ligature of the main artery leading to the part is said to have proved successful in some cases ; but probably not in pulsating tumour of bone having an encephaloid character. Compression might be tried previous to ligature. Diseases op Particular Bones. — Cranial Bones. — Caries and Ne- crosis of these bones are liable to occur, as one of the local manifesta- tions of Scrofula or of Syphilis. Commonly affecting the arch of the skull, and particularly the frontal bone, the ethmoid and sphenoid bones do not escape. The temporal bone seems specially prone to scrofulous caries. The stncctural condition and sig^is are both described under the general pathology of Caries as affecting the surface of Bone, and of Scrofulous and Syphilitic Ostitis, and exfoliation. The causes, most frequently constitutional, are sometimes traumatic ; an exfoliation resulting from a contused wound of the scalp, or other injuries of the head. The course of either state of disease is important with reference to the probability of cerebral complications ; meningitis with effusion, convulsions and coma, being apt to supervene and terminate fatally. Caries of the petrous portion of the temporal bone, as a form of Scro- fulous disease, is more particularly dangerous. Earache with chronic suppuration leads to perforation of the tympanum ; the ossicula crumble, loosen, and are washed out by a profuse fetid discharge, exposing the dura mater continuous with the cavities of the ear. If the disease be not fatal, permanent deafness results. Treatment. — The local measures for the removal of carious or ne- crosed portions of bone by operative interference, and the constitutional treatment of Scrofula or Syphilis, are in no way peculiar to the Cranial Bones. Other Bones are less frequently liable to caries and necrosis : the sternum, ribs, scapula, and jjeZrt'c bones. The pathology and treatment, in such cases, present no essential peculiarities. Diseases of the Jaws will be considered, under this title, in con- nection with Diseases pertaining to the Head. Diseases of the Spine. — See Spine. WOUNDS OF JOINTS. 889 JOINTS. CHAPTER XXXIV. INJURIES. — SPRAINS. — WOUNDS. — DISLOCATIONS. Sprains or Strains of the Ligaments of Joints. — These lesions repre- sent a stretching or partial rupture of the ligamentous tissue ; and thus essentially resemble similar injury of Tendons (Chap. XXIE.), which, with their sheaths, are usually involved in the spraining injury. The ankle or ivrist-joint is most commonly affected. Severe pain, possibly inducing syncope, is soon followed by swelling around the joint, or even by synovitis ; succeeded by stiffness, and continued inability to use the joint. A very severe sprain, or its repetition, may leave the joint in a state of permanent weakness, and liability to dislo- cation. Or disease of the joint may ensue, in persons predisposed by any constitutional condition, as a rheumatic or gouty diathesis. And it would seem that injury to a joint so alters its structural condition as possibly to induce disease under favourable circumstances ; and perhaps after the lapse of a considerable period. Thus, Sir B. Brodie, shortly before his death, I believe, suffered from a malignant tumour of the shoulder, which was, apparently, referable to some textural disorgani- zation consequent on dislocation of the joint some years previously. The cause of sprain is a violent and sudden twist or wrench of a joint, whereby the opposing" ligaments are stretched or somewhat ruptured. Even the epiphyses of bone may thus be detached, in a young subject. The treatment consists in an easy position and rest ; warm or cold applications, according to the inflammatory character of the swelling aud the feelings o£ the patient ; followed by stimulating* embrocations, and the support of a bandage, strapping wdth broad strips of plaster, or a starched bandage. Wounds of Joints. — A wound extending into a joint may, like other Wounds, be incised, punctured, contused, or lacerated ; and the joint, accordingly, is more or less opened, or extensively injured. But the admission of air into the joint chiefly determines the importance of any such lesion ; and thus the pathological condition of these different wounds must be estimated by this consideration. The extent of the synovial membrane or the size of the joint should also be taken into account. Signs and Symptoms. — The escape of synovia from the external aperture, or an exposure of the interior of the articulation, are the only pathognomonic or absolute signs of a wound into a joint. Synovial fluid is recognized by its translucent, viscid, albuminous character, resembling raw white of egg ; the interior of a joints presents the additional characters of glistening synovial membrane and cartilage, and the peculiar disposition of the articular surfaces. But these 890 SPECIAL PATHOLOGY AND SURGERY. appearances should be discovered by inspection, or gentle introduction of the linger; an exploring instrument might penetrate the synovial membrane, and cause a ^vound not otherwise existing. Wound of an adjoining bursa Avould be attended with the discharge of a similar fluid, but examination of the interior will determine the diagnosis. Inflammation of the synovial capsule rapidly siipervenes, presenting the usual appearance of synovitis, but distinguished by two pecu- liarities ; the intense pain, and more acute constitutional disturbance. Suppuration also is almost inevitable, with hectic, and irreparable destruction of the articular surfaces constituting the joint ; or pyaemia intervening at an early period, proves fatal. Treatment. — Preservation of the limb — without any operative inter- ference — should always be attempted, in the first instance. But the probability of success will depend chiefly on the nature of the wound, and the extent of the synovial membrane or the size of the joint. A small incised wound or puncture, in a small joint, as one of the tinger- joints, allows of preservation with great probability of success ; a large, open, and perhaps contused wound, in a large joint, as the knee, is almost surely fatal to limb and life. Among large joints, however, those of the upper extremity — the shoulder, elbow, and wrist — are, commonly, more favourably disposed than in the lower extremity — the hip, knee, and ankle. To save a joint, the synovial capsule must be thoroughly cleansed of blood-clot, grit, or other foreign matter, — as a source of septic poisoning, or simply of irritation ; and this having been effected bv antiseptic injection, the wound should be at once closed, accurately, with strapping of isinglass plaster, to solicit primary union ; and if a drainage-tube be inserted, the opening is to be placed dependent. Antiseptic dressing is then to be applied. Sutures may be inserted, to bring the lips of a joint- wound accurately together before applying the dressing, but they should be entered only skin deep, not through the synovial membrane ; and as matter is more apt to form, under the irritation of sutures, thus preventing primary union, and may perhaps find its way into the joint, I seldom have recourse to them for the closure of a small wound. Metallic wire is, however, less obnoxious than silk suture. An ice-bag, over the dressing, will aid in repressing inflammation. But the limb must be kept in a state of absolute i-est by means of a splint, and in such position, therefore, as shall be most conducive to relaxation and ease. By this plan of treatment, I succeeded in saving a knee-joint which had been opened by the kick of a horse, and with no anchylosis resulting. An elbow-joint, crushed between the buffers of a railway carriage — laying open the synovial membrane, with dislocation of the radius forwards, and severe contusion around the joint — presented a yet more severe injury; but with an equally good result under the same plan of treatment, minus antiseptic dressing, for which dry lint was substituted. In another case, under my care in the Hospital, a knee-joint having been opened by a semicircular lacerated wound, eight inches long, and forming a flap about three inches in extent, this flap was laid down and closed with silver-wire sutures ; the knee was encased Avith several folds of dry lint, and the whole encompassed with a roller-bandage. A drainage-tube was temporarily inti'oduced at one angle of the wound-flap. This dry, protective, and absorbent dressing was removed every second day, the flap cleansed by syringing DISLOCATION. 891 ■with water, and the dressing renewed. The wound healed by healthy granulation, with no pain, nor any notable febrile disturbance ; the patient — a carman, aged fifty-seven — always expressing himself as feel- ing well and comfortable ; and the joint remained fi'ee of any anchylosis. The other leg of this man was also the seat of a lacerated wound, two inches long, and exposing tbe tibia. This lesion healed equally well, under the same kind of dressing. Synovitis having proceeded to suppuration — the synovial capsule having become converted into an abscess, the joint should be laid freely open by incisions, as advocated by Mr. Gay ; and a position of the limb secured favourable for its utility, in the event of irreparable destruction of the articulation, followed by anchylosis. Destruction of the joint without this issue must be met either by excision of the diseased bone, or by amputation of the limb. The choice of these alternatives should be determined by a due consideration of the local and constitutional conditions. Fortunately, traumatic arthritis, as proceeding from the synovial membrane to the adjoining cartilages and bones, seldom engages these structui^es beyond the range of excision. But the constitutional exhaustion may be so severe, as to compel recourse to amputation, rather than peril life by the slow recovery consequent on excision. Or, amputation may become necessary — and then without an alternative — after excision- Primary amputation, it would thus appear, should not be resorted to in any case. But, in its preventive relation to pyeemia, more espe- cially, it is questionable whether this opei^ation might not be justifiable occasionally. An open, and perhaps contused, wound of a large joint, as the knee, represents conditions which may justify immediate ampu- tation. In two such knee-joint cases under my care, life might per- haps have been saved by at once removing the limb. Fracture involving the joint, or dislocation, as complications, in similar cases of wound, mostly demand immediate amputation. Wounds of Particular Joints are to be regarded in accordance with the general pathology and treatment of this kind of injury. Dislocation. Dislocation. — Structural Conditions. — Dislocation is a displacement of the articulatory portion of a bone from the surface on which it was naturally received ; accompanied by more or less laceration of the liga- ments, of the tendons and muscles, or other surrounding* structures, and with some effusion of blood around the seat of injury. As arising from external violence. Dislocations may be termed traam.atic ; and when consequent on destruction of this joint from disease, they are named spofitaneous or pathological — dislocations which take place chiefly in the hip and knee joints. Dislocations differ essentially in regard to the mode of their reparation, according as they are unaccompanied or attended by an open wound communicating with the dislocation ; the one being termed Simple, the other Compound. Complicated Disloca- tion is also a recognized distinction, signifying- the concurrent injury of some other part. But this is not an essential condition, as pertain- ing to Dislocation. Congenital Dislocation arises from malformation of the joint affected. In respect to the extent of displacement ; dislo- cation may be incomplete, as hinge- joint dislocations not unfrequently 892 SPECIAL PATHOLOGY AND SURGERY. Fig. 395. are ; or complete, as those of orbicular joints usually are (Fig. 395) ; this difference being due to the particular shape of the articular surfaces. The primary displacement is made more complete, especially in orbi- cular-jointclislocations, by tonic contraction of the muscles subsequently. Signs. — Dislocation is attended with a corresponding defacement or deformity of the outline of the joint ; as represented by dislocation of the shoulder-joint, downwards into the axilla. The natural pi'ominences of bone near the articulation either disappear, or are less conspicuous, as the great trochanter at the hip-joint ; or they may be more promi- nent, as the acromion, in dislocations of the shoulder. The length of the limb is altered, and especially if the dislocation be complete. Elongation, or shortening, is produced ; according as the head of the displacement bone happens to be lodged below, or above, the level of the articular surface on which it naturally moves. The possibility of either, or of only the latter, alteration of length taking place is deter- mined by the form of the articulation. An orbicular joint allows of dislocation in any direction from its circum- ference ; upwards, downwards, forwards, backwai'ds. Hinge joints cannot allow of displacement in more than three directions ; backwards, forwards, and laterally, to the right or left. The direction of the dislocated bone, and thence of the limb below, is cha- racteristic. Certain muscles being thi-own out of action, by displacement of the portion of bone to which they are attached ; others, thus acquirins: a mechanical advantage, pre- ponderate. The natui-al balance of opposing muscles, as flexors and extensors, is lost, and the limb acquires that particular attitude to which the predominant muscles direct it. To these positive signs may be added two negative ones : immobility of the limb, which gradually supervenes, in proportion to the tonic contraction of the muscles ; and also the absence of crepitation. A false crepitation can sometimes be felt, owing to friction of the articular head of the bone on the torn ligaments and tendons ; unlike the rough attrition of the bone-ends in fracture. The extravasation of blood gives rise to the appearance of ecchymosis or bruise, as the blood becomes subcutaneous ; but this may not take place for some days after the dislocation. Bruising will, of course, be more immediate and conspicuous where dislocation is produced by dii^ect violence to the part, as by a fall on the shoulder. In examining a dis- location, the limb should be compared with its fellow ; at least, in any doubtful case. Pain and inability to use the limb five functional sym- toms of Dislocation, but of equivocal value iu aid of determining the nature of the injury. Diagnosis. — The pain may be insignificant at first, before swelling supervenes ; and in oft-occurring dislocation, where the ligaments and muscles are weakened, especially in an old feeble subject. The power of motion may be retained under similar circumstances, for the tonic contraction of the muscles is insufiicient to fix the limb. But if both pain and powerlessness are present, they niay each rise from other causes than dislocation : from fractui-e. sprain, a bruise, or rheumatism. DISLOCATION. 893 The physical signs of Dislocation, are each, in various degrees, in- variably present, and are almost exclusively connected with Dislocation. It is only as compared with Fracture in the neighbourhood of a joint that Dislocation can be confounded. But, firstly, the outline of the joint is different, otherwise than in exceptional cases. Thus, dis- locations of the hip-joint may be distinguished from fracture of the neck of the thigh-bone, by this sign; so also, dislocations of the shoulder-joint, as compared with fracture of the anatomical neck of the humerus. When fracture exists, the reduction of displacement by extension of the limb, and the immediate return of displacement on leaving the limb to itself, will best distinguish this injury from dis- location, as a general rule. But dislocation may co-exist with fracture near the joint, as rare forms of double injury; pinncipally in the shoulder, wrist, and hip. Then, again, as to alteration of the length of the limb ; elongation is always peculiar to dislocation ; shortening may, however, be due to unimpacted fracture with displacement. Fracture may, thus far, simulate dislocation upwards, in orbicular dislocations ; or dislocation, .forwards or backwards, in hinge-joint dislocations. But it is only in such directions of displacement that shortening of the limb can be equivocal. The direction or attitude of the limb is almost always peculiar to dislocation. Lastly, the crepita- tion and mobility of fracture are both absent with dislocation. Tonic muscular contraction, whereby an articular displacement becomes fixed, proceeds slowly ; and immobility, therefore, can scarcely be regarded as an early sign of dislocation. In one case, a dislocation of the femur into the foramen ovale was examined by Sir A. Cooper, a few minutes after the accident ; the limb was still very movable, and continued so for the space of nearly three hours, when it became fixed. Paralysis may be attended with such muscular relaxation as to allow of free movement, in examining a limb with dislocation. But if the physical signs of Dislocation, taken severally, are thus insufE.cient ; collectively, they cannot fail to establish the diagnosis of this injury. Causes, and Effects of Dislocation. — Dislocation is produced, in general, by external force, suddenly applied. Predisposing causes are however, very influential. Some such causes are functional actions depending on anatomical conditions ; as the shape of the articular surfaces allowing a free range of motion, laxity of the ligaments retaining them, and the powerful action of many muscles on a long lever-like bone. All these pre- disposing conditions are combined in the shoulder- joint, and less so in the hip. Hinge joints, being more favour- ably circumstanced anatomically, are less liable to dislocation. Other pre- disposing conditions are acquired by disease ; and these also have * St. Bartholomew's Hosp. Mus., 3, 24. Elongation of capsule of hip-joint, to the extent of from four to five inches, with a tuft of filiform processes. Cavity of the acetabulum nearly obliterated. Head of the femur partially absorbed, and the round ligament has disappeared. See also Med.-Chir. Trans., vol. xxiv. Fig. 396.* 894 SPECIAL TATHOLOGY AND SURGERY. reference to the cartilage and head of the bone, which may be de- stroyed by ulceration and caries ; to the lioraments, as loosened by this process (Fig. 896) ; or to those muscles which naturally aid in retaining the articular surfaces in apposition, but which may have become wasted and enfeebled, or paralyzed. Dislocation is attended with more or less shock, followed by re- action ; or the latter is sometimes accompanied with exhaustion, this mixed state constituting traumatic delirium or prostration with ex- citement ; which may be succeeded by tetanus. But, in general, no such serious consequences need be apprehended ; after the dislocation has been reduced, the immediate shock of the previous injury soon passes off. Reparation. — The ruptured ligaments, and tendons, if any be torn, are disposed to reunite by primary adhesion, without inflammation. Lymph is effused which speedily passes into fibrous tissue, through the medium of nucleated blastema. Any superfluous reparative material, and the blood extravasated by the injury, are absorbed ; and thus the concomitant swelling subsides. The joint is ultimately re- stored to nearly its originally perfect construction. This presupposes the previous reduction of the dislocation. If the bone remain dislodged from its natural articulatory surface or cavity, then a new joint is constructed, the formation of which will be described in connection with Unreduced Dislocation. The Prognosis of reduced Dislocation is favourable, with regard to reunion of the ruptured ligaments and the tendons, if any be torn ; their reparation by adhesion being subciitaneous, and not affected by exposure to the air, as in the healing of an open wound. But the prognosis must be determined by a due consideration of all those internal causes which either aid the recurrence, or oppose the original reduction, of Dislocation ; and which naay render it irreducible. Causes of recurrence may be noticed first, they being among the conditions already mentioned as predisposing to Dislocation. Some of these conditions are, as we have seen, anatomical ; a patulous shape of the articular surfaces, laxity of the lig'aments, and a long lever-like bone, on which many muscles act. Hence dislocations of the shoulder- joint are specially apt to recur, and less so hip-joint dislocations. Hinge joints are, anatomically, less disposed to redislocation. Other such causes are morbid conditions ; ulceration of the articular carti- lages, with perhaps caries of the adjoining bone, relaxation of the ligaments, a weakened or pai-alytic condition of the muscles. Of causes opposing reduction, may be mentioned the anatomical shape of the articular surfaces ; as the prominent rim of the acetabulum, in hip-joint dislocations, and the cup-shaped head of the radius, which is locked in fi-ont of the humerus, in dislocation of that bone forwards. Any ligaments w^hich may not have yielded, with dislocation, seem to bind down the bone ; as the first phalangeal bone of the thumb when dislocated upon its metacarpal bone. Tonic contraction of the muscles can scarcely be regarded as an unconquerable source of opposition ; but the structural change of the muscles which accompanies their permanent shoi'tening and functional adaptation, in unreduced dis- location, is a condition of resistance, not to be overcome judiciously by forcible reduction ; and less so in proportion to the duration of this DISLOCATION. 895 condition. The prognosis is that of unreduced dislocation, with the formation of a new or substitute joint. Treatment. — After Dislocation, especially of the orbicular joints, the muscles which favour the particular displacement draw the head of bone into its new position, and there fix it ; but this displacement, and fixation, are accomplished gradually. The head of the humerus, for example, having* been displaced forwards by the violence which caused dislocation, it is then drawn inwards, and eventually there fixed. But, immediately after Dislocation, the muscles are always partially paralyzed by the shock to the nervous sjstem consequent on the injury, and for a short period they remain powerless. Subse- quently, their tonic contraction comes into operation. Therefore, at the time of dislocation, and soon after, the displacement caused by muscular action can be easily replaced ; and any resistance of this kind may be -partly neutralized by a position suitable to the further relaxation of the antagonistic muscles. The earliest condition of dislocation offers the most favourable opportunity for its reduction, when the muscles are as yet poiverless, ere they complete the displace- ment. Thus, immediately after a dislocation of the femur backwards, Liston, having this opportunity, reduced it, on the spot, without pulleys, or even the help of an assistant. If Dislocation be overlooked or neglected for a few hours, the muscles will then have become more immovably adapted to their new lines of action ; subsequently, they become shortened also ; a new joint is in process of formation; the track through which the head of bone has passed is occupied with plastic lymph ; if the rent in the ligaments be small, this aperture tightly embraces the neck of the displaced bone, which becomes adherent and more fixed ; and lastly, the natural articular surface or cavity gradually undergoes oblitera- tion. Replacement is, at length, scarcely practicable, if possible, and certainly not to be accomplished without endangering- many structures — muscles, nerves, vessels, and perchance the bone itself ; nor without reopening the track through which the head of bone had passed, and re-rupturing the ligaments ; and even then only to find the natural articular cavity effaced or obliterated. The rules of treatment are precisely analogous to those relating to Fracture. (1.) Reduction and Coaptation, or replacement of the displaced head of bone in relation to its natural articular surface or cavity. This implies a suitable position of the limb, as far as possible ; to relax the antago- nistic muscles which, by their tonic action, retain the head of bone in its new position. But coaptation also implies extension and counter- extension of the limb, sufficient only to bring the head of bone parallel to its natural articular surface or cavity; the "reduction" of dislocation. Coaptation is then readily effected. (2.) Maintenance of Coaptation, during the reparative process of reunion of the torn ligaments, tendons, etc. This still presupposes a suitable position ; not, however, with the view of relaxing such mus- cular contraction as maintains coaptation, but for the prevention of redisplacement by the spasmodic action of antagonistic muscles. It also implies the employment of suitable retentive appliances ; and both, to insure rest. The Beduction of Dislocation is a process ; in this respect differing 896 SPECIAL PATHOLOGY AND SURGERY. from the reduction of B'racture, which is readily effected. In Disloca- tion, reduction must be accomplished by retracing the displacement which has been caused by the muscles in operation ; the head of bone beino; conducted, through the course it has thus taken, back to the point -where muscular action began. Tonic contraction of the muscles Avill then effect coaptation. It is in retracing the course of displacement — the performance of redaction — no less than as regards the timeliness of Surgical intervention, that the guidance of pathology is chiefly experienced in the treatment of Dislocation. To facilitate reduction, muscular resistance is eluded, partly by undertaking reduction as soon as possible after dislocation, -svhen the muscles are as yet inoperative ; and partly by placing the limb in a suitable position, as far as possible, to relax the antagonistic muscles. The semi-flexed position, as nearly as it can be attained, is the happy medium generally desirable for this pui'pose. In hip-joint dislocations, flexion of the knee relaxes the three ham-string muscles ; while, for dislocations of the knee, the gas- trocnemius muscle also is thus relaxed. For shoulder-joint dislocations, flexion of the elbow relaxes the biceps muscle. And it should be re- membered that the flexor muscles are always stronger, and therefore more resisting, than the extensors. The resources for subduing muscular resistance will be noticed presently, in speaking of the act of reduction. Extension and counter-extension of the limb are necessary in all cases, and more especially for the reduction of ball-and-socket dislocations — otherwise than by manipulation. The extending force may be either manual, as exerted by the Surgeon with an assistant or more ; or mechanically applied, by pulleys. Manual extension is less steady and less enduring ; and as those who are so employed become fatigued, they relax their exertions, the muscles engaged in the dislocation regain their original supremacy and draw the bone back again to its former abnormal position, reproducing the displacement, and the work of extension has to be done all over again. Extension by means of pulleys is, however, apt to become too forcible, thereby endangering muscles, nerves, vessels, and even the bone itself ; but force applied by this means can be better directed than that of personal strength. In like manner, counter-extension may be maintained either by an assistant or more ; or by mechanical resistance, a cloth or strap being secured to some fixed point, as a staple firmly fixed in a wall. The relative merits of these two means of counter- '■ extension also should be estimated by the respective characters of the forces, which are thus applied. As a general rule, pulleys are required only to reduce hip-joint dislocations. When employed, precautions should be taken that the integuments of the part to which the force is applied are not injured. Exten- sion may, therefore, be applied to the limb through a belt, padded with soft leather. If a strong woollen cloth be used instead, the noose should be fixed around the limb by the clove-hitch tie, which retains its hold securely, without tightening (Fig. 397). Besides this provision against strangulation, a damp cloth, under the noose, will protect the skin from friction. DISLOCATION. 897 To what part of the limb should extension be applied ? Some of the m.osfc eminent French Surgeons have recommended extension to be made indirectly, from the distal extremity of the limb — from the wrist, in shoulder- joint dislocation; from the ankle, in that of the hip-joint. It is alleged that the advantage thereby gained is twofold. The muscles are not excited to spasmodic action, as they would be were force directly applied to the dislocated bone ; and besides this negative advantage, there is also the positive advantage of a longer lever, wherewith to act on the dislodged head of bone. The English School, represented by Pott and Sir A. Cooper in this branch of Surgical Practice, and supported by equally distinguished Continental Surgeons, as J. L. Petit, Duverney, Malgaigne, and Callisen, have advocated extension directly, fi'om the dislocated bone. Thus, from the arm, when the humerus is dislocated ; from the thigh, when the femur is dislocated. This direct application of extending force avoids endangering the intervening joints, and tells more effectually on the dis- placement. Certain it is, also, that a long lever is not requisite for any truly surgical purpose. If the muscles be relaxed, no such mechanical advantage can be necessary ; if not relaxed, muscular contraction can be so directed as to eventually complete the reduction without the aid of a long lever. Moreover, assuming the obvious advantage of a semi- flexed position of the proximal joint below the dislocation, this position will necessitate the application of any extending force directly to the dislocated bone. Counter-extension is most effectual when applied as directly as possible, namely, from the sui-face corresponding to the dislocation. Supposing counter-extension to be rightly adjusted, extension should be made first in that direction which the bone has assumed by disloca- tion. The head of the bone is thereby made to retrace its course, and is finally replaced without any additional laceration of the textures. Then, again, the extending force should be eqiiable, not jerking, and gradually increased ; accompanied, of course, by counter-extension, equal, and in the opposite direction. Any voluntary muscular resistance on the part of the patient, during reduction, is subdued by diverting his attention. A question now and then, as to how the accident happened, may answer this purpose, if no other ; and by inducing our patient to speak, we overcome any advantage which the muscles attached to the thorax would otherwise have, were the chest fixed, as when the breath is held. This point of practice will obviously be important in reducing dislocation of the shoulder-joint. Tonic muscular contraction is most surely overcome by the slow inhalation of chloroform ; but this should not be resorted to in the first instance. Supposing increasing- extension prove in- effectual, and that any further degree of such force would, or might, endanger the muscles, nerves, or vessels ; tlien only, in my opinion, is the administration of chloroform justifiable, for then only is the occa- sional peril of its action warrantable as our next resource. We thus steer clear of two risks : the former concerning the limb ; the latter, the life. The warm hath may prove sufficiently relaxing when the influence of anaesthesia, by the administration of neither chloroform, nor ether, may be deemed judicious. Unreduced dislocations, of some duration, and not reducible by ordinary extension, prolonged even for an hour or two, have sometimes been reduced by tiring the VOL. I. 3 m 898 SPECIAL PATHOLOGY AND SURGERY. antagonistic muscles ; simply by attaching a trifling weight to the limb for a few hours. This tiring-extension is quite safe, as regards both limb and life, and would therefore, whenevei' practicable, be far pre- ferable to increasing-extension under the influence of chloroform. The younger Cline, in this way, succeeded in reducing a dislocation of the shoulder which had been out for several weeks and could not be replaced in the ordinary way. Having fixed the shoulder, a bi-ick, attached to the hand, was suspended over the end of the bed. On visiting his patient next day, the bone had returned to the socket. In the course of extension, and especially towards its completion, it is the practice of some Surgeons to rotate the dislocated bone, so as to forcibly clear away any adhesions in the path along Avhich the dis- placed head of bone should return home. But this forcible detrusion of any and every obstacle is damaging and unnecessary. And if such obstacles have become established, in an old uni-educed dislocation, then indeed it is very questionable whether reduction should be attempted, and certainly not accompanied with the rupturing force of rotation. Coaptation, following adequate extension, is the next and final step, after reduction, which it maybe said to complete. The displaced head of bone has been reduced, or brought back to that point where the muscles first began to operate, and where it was situated immediately after the displacement as effected by the violence which dislodged the bone. It stands on the brink of its natural articular surface or cavity ; the one ready to regain, the other to re-establish, the articulation. This final step it is now the duty of the Surgeon to observe, or to unclertaJce, by coaptation — a manipulation analogous to the setting of fracture. Surgical assistance is needed according to the resistance offered by the shape and attitude of the two articular surfaces to be brought together. The head of bone may only need guiding to its proper place, into which the muscles, if not too much relaxed, will draw it ; or it may require to be lifted over the brink of the articular cavity, if this its margin be prominent; as that of the acetabulum, in relation to dislocation of the head of the femur. Direct manipulation is, however, more generally necessary in the coaptation of hinge-joint dislocations ; while, in ball- and-socket dislocations, the displaced bone is more usually guided into its hole, by properly directing the axis of the limb, towards the finish of extension. The ligaments scarcely ever resist. They are, in most cases, extensively torn ; the capsular ligaments especially so. But a small rent only, in a ligamentous capsule, may offer some impediment; or the aperture may be occupied by a portion of torn tendon or muscle. Any ligament peculiar to the joint is also generally torn through, as the round ligament in hip-joint dislocations ; but — according to the observations of Sir A. Cooper — if one such ligament remain entire, it may occasion difficulty in the reduction, as he experienced with I'espect to the knee and ankle joints. In dislocations of the latter joint, it is often necessary to twist the foot, in order to relax the untorn ligament, before reduction can be effected. In dislocation of the proximal pha- lanx of the thumb on the posterior aspect of the metacarpal bone, it may be necessary to divide, subcutaneously, one of the lateral ligaments ; the external being most easily reached. In all cases, coaptation should be guided by a due knowledge of the pathological conditions, and not effected by mechanical violence. Coaptation is announced by a snap, a jerk, or sensation of some- DISLOCATION. 899 thing having given way ; this being the signal that the muscles have clone their datj by drawing the head of the bone home. If, therefore, the muscular system be paralyzed, as under the influence of chloroform, or if the particular muscles engaged be weakened by prolonged ex- tension, or extension be overpowei'ing at the time of coaptation ; in either case, the usual signal cannot be given. But the limb immedi- ately assumes its natural length and attitude, as in repose ; and the natural contour of the joint is recovered. The latter sign is the one most available in practice ; for the natural length and shape of the limb cannot be compared otherwise than by suspending extension, a cessation of effort which would at once undo all that had been gained, if coaptation be not accomplished. The natural motility of the limb is immediately regained with coaptation ; and this sign, coupled with the anatomical characters just mentioned, plainly declares that the natural articulation is restored. Being thus assured of this event, the Surgeon need do but little more. Muscular contraction, having finally brought the bone into place, retains it there. Unlike fracture, the reduction of which is accomplished easily, but maintained only by watchful care, dislocation is reduced only by watchful care, after which the muscles take care of the joint. Manipulation of the limb, for the reduction of Dislocation, proceeds upon the principle of obviating the resistance offered by muscular contraction, the limb being conducted through such movements as shall relax the muscles which are opposed to reduction, — instead of ovei'coming the resistance by extension. At the same time, manipula- tion may evade the obstacles which sometimes arise fi'oni torn ligaments and the hitch of the articular ends of bone. This method of treatment will be described in the management of certain dislocations, especially of the shoulder and hip joints. To maintain coaptation, it is necessary only to fix the limb, and in a suitable position for the relaxation of any muscles which by their action might redislocate the bone. This indication is easily fulfilled by securing the limb with a bandage ; the arm to the chest, the leg to its fellow. Position and immobility are the more requisite on behalf of shallow joints, and if the ligaments be naturally loose ; both of which conditions characterize the shoulder-joint. The twofold pre- caution of position and immobility is yet more necessary on behalf of any dislocation, when the muscles which usually prevent its occurrence are themselves naturally flabby and weak, or have been weakened by the dislocation, and by the extension necessary for its reduction. If, in such case, the limb be not securely fixed and supported in a suitable position, it may redislocate itself, not so much by the action of antagonistic muscles, as by the mere weight of the limb. 'Best of the limb, thus retained in position, will also favour the subsidence of any inflammation which may have supervened. But, the inflammation being subcutaneous, it terminates in- resolution, very rarely in suppuration. Any so-called antiphlogistic treatment, there- fore, is as seldom necessary ; certainly not of a constitutional cha- racter, and locally only, by the application of a cold lotion in the first instance ; with subsequently friction daily to revive the dormant muscles. Ample time must be allowed for firm reunion of the liga- ments or other lacerated textures; failing which, the joint will be 900 SPECIAL PATHOLOGY AND SURGERY. permanently weakened and evei' liable to redislocation. On the other hand, jadicious exercise of the joint, by passive motion occa- sionally, will prevent the tendency, otherwise, to some degree of anchylosis and permanent stiffness ; with the irrecoverable loss of muscular power in the limb. Thus, in ten days or a fortnight, the Surgeon may begin to put the joint gradually through its movements ; especially the more firmly secured joints, as the hip and elbow; the shoulder-joint, being naturally looser, must be handled more lightly. Some months may elapse ere the patient regains free use of the joint and poAver in the limb. CoMPOrxD DiSLOCATiox. — Structural Condition, and Diagnostic Characters. — Compound Dislocation is, essentially, Dislocation with a -wound in the skin communicating ; thereby exposing the injured joint, however indirectly, to the action of the air. The structural disorganization, as regards the state of the joint, is the same as in simple dislocation ; but compound dislocation is usually accompanied with more severe contusion or laceration of the surrounding soft textures. This condition, coupled with that of the aperture externally, which is also contused or lacerated, together form a Contused or Lacerated TVound, connected with, and around, a Dislocation. The Signs of this injury are the same as those of simple dislocation, with the additional and distinctive character of an external irregular wound. In short, both the condition and characters are those of simple Dislocation, plus those of contused or lacerated Wound. Compound dislocation occurs most frequently in the ankle-joint, occasionally in the knee and elbow ; rarely in the shoulder and wrist; and very rarely in the hip-joint. Of the smaller joints, compound dislocations of the astragalus, and of the thumb, are most common. Causes, and Effects of Compound Dislocation. — Here also the patho- logical history is that of simple dislocation, with certain peculiarities superadded. Generally speaking, the dislocated bone having passed throug'h the adjoining soft parts, in the direction of the displacement, and come to the surface, it proti'udes through the skin ; and thus the wound is an extension of the injuiy fi'om icitliin. But, in some cases, external violence is the cause of the Tround in the skin and subjacent soft parts, as well as of the connected dislocation ; which may then be regarded as produced by an extension of the injury from without. In the one case, the force is applied indirectly, to the bone at some dis- tance off, and the injury is more a laceration, and less extensive; in the other case, the force is applied directly to the joint, and the injury is more a contusion. In both cases, the lacerated or contused textures are damaged beyond the apparent extent of injury; and the shock to the nervous system is more severe than with simple dislocation, owing to the greater damage to the soft parts, including nerves. Tetanus is, perhaps, more likely to ensue than after a contused or lacerated wound alone, and especially if the compound dislocation be that of a ginglymoid joint, as of the thumb. Injuries of unyielding fibrous or ligamentous textures are generally prone to induce Tetanus. The textures injured, being in a state of disintegration, die, at least to some extent around, if the wound be allowed to remain open. This purely traumatic gangrene is the same as that caused by a lacerated or contused wound. Limited, therefore, to the part injured, and defined, eventually, by a line of demarcation between the living COMPOUND DISLOCATION. 901 and dead textures, the gangrene is also immediate, if the injury itself be severe. Course and Terminations. — Inflammation supervenes, followed by suppuration, often profuse, and partial sloughing ; or gangrene, possiblj, on a larger scale. Yet this also is limited to the seat of injurj. Ultimatelj, compound dislocation, when reduced, not un- frequentlj undergoes reparation ; the torn lig-aments and tendons becoming' reconnected, and the wound closing up bj the healing pro- cess of suppurative gTanulation and cicatrization. Spreading gangrene — due to some morbid condition of the blood — is only contingent, occasionally, on compound dislocation ; just as it may be associated with compound fracture, and with contused and lacerated wounds. The phenomena of this species of gangrene were described under the last-named form of Injury. The Frognosis of Compound Dislocation, as gathered from the fore- going elements of its natural course and tendency, is far less favourable than that of simple Dislocation. An open wound, communicating with the joint, as compared with sabcutaneous laceration of the soft parts, is one unfavourable ground of prognostic distinction. Scarcely less so is the greater extent of their laceration, usually, in compound Disloca- tion, especially if produced by direct violence. Spreading gangrene is an adventitious condition, but as implying tbe co-operation of a con.stitutional cause, it has a most unfavourable significance. Treatment. — The same rules of treatment are applicable as for simp-le dislocation ; but certain particulars, having reference to the special pathology of compound dislocation, are peculiar to its treatment. Reduction of the displacement may present special difficulties. Thus, if the bone protrude, excision is preferable to violent efforts at reduction. In regard to the ankle, the knee, and elbow joints, removal of the ends of bone may be resorted to, with advantage and safety. The head of the astragalus has been removed, when, by dislocation forwards, it protruded and could not be returned. The practice of excision in compound dislocation, to aid reduction, is as old as the time of Celsus ; but in modern Surgery — revived by Mr. Hey, of Leeds, and advocated by Sir A. Cooper — relative to the ankle- joint, it has since been sanctioned, as an occasional expedient, by the united testimony of experienced Surgeons, English, American, and foreiofn. The Wound. — Reduction having been accomplished, and the limb retained in a suitable position — to prevent the recurrence of dislocation — by appropriate bandaging or apparatus, the treatment peculiar to compound dislocation is that relating to the wound, and state of the soft parts involved. The pri^nary indication is to close the wound, with the view of soliciting its union by adhesion, and thus convert the disloca- tion into a simple one. For this purpose, a pad of dry lint, overlaid with teenax, or lint soaked in carbolic-acid solution, should be applied over and around the wound, so as entirely to exclude the air. I much prefer a dry to any wet application, which becoming heated by the part, may act as a poultice in promoting suppuration. The carbolic- gauze dressing might, however, be employed, instead of t^nax, as a more potent antiseptic. But, watching the progress of the case, when primary adhesion becomes obviously impossible, the attempt to close the wound entirely should be forthwith discontinued, and a drainage- 902 SPECIAL PATHOLOGY AND SUKGERY. tube inserted, in order to give free vent to matter dui'ing the process of snppui'ation. With progressive suppuration, the diffuse accumulations of pus should be met, by eai-ly, free, and dependent incisions, as in compound, fracture, for the discharge of matter as it forms, and. to relieve tension, or to prevent burrowing around the joint. Under these circumstances, the previously dry dressing may be advantageous!}' exchanged for a poultice, or the more cleanly epithem of spongio-piline soaked in warm water, as a fomentation, will be a suitable application ; to be followed by light water-dressing, carbolic-acid solution, or boracic ointment, when the continuance of warmth with moisture would only sodden and relax, and when the wound is granulating. The same hygienic and onedical treatment also, as for compound fracture, will prove beneficial, in sustaining the system under the hectic fever and ex- haustion consequent on prolonged and perchance profuse supjDXirative discharge, and in overcoming the typhoidal fever induced by gangrene or sloughing. Amputation. — The " question of amputation " depending upon the supervention of gangrene, or of profuse suppuration, the propriety of this operation is determined by pathologico-anatomical conditions parallel to those of compound fracture. (1.) Primary amputation, only when the whole substance of a limb being involved by compound dis- location, the limb itself is already, in the first instaiTce, ^drtually lost, and life as inevitably endangered. Such was the condition of com- pound dislocation represented in Fig. 398, the integuments having been, removed fi-om the limb to display the various kinds and extent of lesion. Unique as a form of elbow- joint dislocation, by dislodgment of the radius and ulna outwards and upwards on to the externnl ridge of the humerus above the condyle, the forearm had thus undergone an " external latero-angular dislocation." The relative position of the bones, and thence the peculiar appearance of the joint externally and configuration of the limb, I have described in the Brit, and For. Med.- Chir. Bev., January, 1866. As justifying amputation, the lesions co- existing were these. A large lacerated wound about the middle of the forearm in front, exposing the muscles and a portion of both bones, with the interosseous membrane. All the flexor muscles, superficial and * Royal Free Hospital. (Author.) COMPOUND DISLOCATION. 903 deep, were torn across, partially or entirely, sparing their tendinous and aponeurotic portions, which appeared deep in the wound as so many shreddy strings from which the muscular substance had been raked off. All the vessels and nerves, however, excepting, of course, their muscular branches, had escaped rupture ; the ulnar nerve, the inferior profunda artery accompanying it above the joint, and the ulnar artery in the forearm, the median nerve with its interosseus branch and the corresponding branch of artery, and lastly, the radial artery and nerve. But the skin was almost completely detached from the sheath of the muscles on the front and back of the forearm, and some way above the joint. The large tract of subcutaneous cellular texture thus dis- organized was infiltrated with blood, not discernible through the skin, which appeared unbruised. A small contused apei'ture just above and behind the inner condyle communicated directly with the joint, con- stituting a compound dislocation. This extensive injury was caused by severe contusion and a lacerating wrench between the buffers of two railway carriages. (2.) Secondary amputation, when the extent of damage done by the injury being itself partial, the supervention of gangrene or of profuse suppuration is only proportionately probable, and the limb, therefore, not inevitably lost, nor the life perilled. Such postponement of amputation is justifiable to give the limb its chance of preservation by delay ; while the preservation of life is pro- vided for by timely amputation, when the adverse circumstances, alluded to, actually supervene. The rules laid down in surgical works, with reference to the extent of injury, are not the expressions of a sufficiently accumulated pathological experience, in different doubtful cases; and they over- look the necessarily unknown capabilities of reparation in different individuals. Cases occurring, from time to time, which have proved exceptional to any such rules, suggest the all-important consideration, ■ — in how many more cases might limbs be saved which are thus sacrificed sui"gically by amputation ? Thus, compound dislocation of the knee-joint was pronounced by Sir A. Cooper to be a condition of disorganization which imperatively demanded primary amputation. Exceptions, occasionally, have since disproved that dictum, in this form of injury. In the case of a boy, nine years of age, at the Westminster Hospital, Mr. White succeeded in saving the limb, by sawing off the condyles of the femur and reducing the bone. In the ankle-joint, the end of the tibia maybe removed and reduction accomplished ; a proceeding which I remember Mr. Listen advocated more than thirty years ago. A person jumps out of a carriage behind, while the horse is running away, and alighting on his feet, the tibia of either leg maybe driven through the integuments, and perhaps come in contact with the earth. Removal of the bruised portion of bone will facilitate the reduction, and has proved successful in preserving the limb. Dislocation of the astragalus maybe similarly treated. In two cases of compound dislocation of the foot inwards, one of which was complicated with compound fracture and dislocation of the astragalus, the parts could be reduced after excision of the external malleolus, and the patients recovered with useful limbs. Both cases occurred in the practice of Mr. Spencer Smith. Excision, indeed, bids fair to surpass amputation in other compound Dislocations. Complicated Dislocations. — Dislocation may be complicated by 904 SPECIAL PATHOLOGY AND SURGERY. association with the laceration of rmiscles which are put upon the stretch ; as the pectineus and adductor brevis, by dislocation of the thigh downwards into the thyroid foramen ; even their unyielding tendons are sometimes ruptured, as the sub-scapularis tendon, by dis- location into the axilla. Large blood-vessels occasionally share the same fate, accompanied with haemorrhage and livid swelling ; a inain nerve also may be torn asunder. Fracture of the shaft, or of the head of the bone dislocated, is another complication. This is more likely to occur in dislocation from direct violence ; as by a fall on the hip or shoulder, the neck of either bone is perilled ; the olecranon also may be knocked off ; the bulky head of the tibia shattered ; or the tarsal end of the tibia broken and bruised. Thus, then, all the parts around a dislocation are liable to be involved in the injury. But, obviously, none of those special injuries to internal organs can occur, which may complicate the Fracture of certain bones — the pelvic bones, the ribs, the bones forming the skull. Respecting morbid con- ditions ; local diseases, i.e. of the joints themselves, may predispose to dislocation and thence to its recurrence, by previous disorganization of the joint affected ; a parallel kind of complication to that of fi'acture from disease of the bone. So also, the diseased condition of the joint is frequently a local manifestation of some blood-disease — e.g. syphilis or scrofula, as a constitutional cause, rather than of traumatic or local origin. Whenever dislocation from disease of the joint has the former mode of origin, the reparative process is propor- tionately slow and uncertain; the more so when the constitutional disease is actually in operation. Treatment. — Both the general considerations of pathology, and the corresponding Rules of Treatment, pertaining to Complicated Fracture, are applicable also to Complicated Dislocation. Firstly. If any morbid condition be in operation, locally or consti- tutionally, predisposing to the occurrence of Dislocation, the treatment must be entirely subject to such causative condition. Secondly. If there be any injury additional to Dislocation, the treatment of the dislocation maybe of entirely subordinate importance, even although it be, as in many such cases, severely Compound. Complications of this kind may necessitate immediate amputation. Unreduced Dislocation and False- joint ; Congenital Dislocations, — These pathological conditions may be taken consecutively : the one as the result of neglected, or possibly irreducible Dislocation ; the other as being irreducible or incapable of continued reduction, owing to some congenital malformation. Both are supplementary to the pathology and treatment of ordinary Dislocation. Unreduced Dislocation and False-joint. — Structural Conditions. — The alterations of structure consequent on unreduced Dislocation are the formation of a new joint, the obliteration of the former or natural articulation, and of the track through which the head of the dislocated bone passed to its present locality. The new joint is more or less perfectly constructed. If the dis- placed bone be lodg-ed upon 'muscle, it gradually burrows for itself a convenient nest, the two surfaces become mutually adapted to each other, and a capsular ligament being formed of condensed cellular tissue, an imperfect joint is established. But should the bone have found a resting-place on bone, this, by absorption, loses its periosteum, UNEEDUCED DISLOCATION AND FALSE JOINT. 905 and that its articular cartilage ; a receptacle is excavated suitable to the impression of the displaced articular surface (Fig. 399) ; a bony- rim or lip is thrown up by the periosteum around the margin of this newlj formed cavity; the surrounding cellular texture, moreover, Fig. 399.* Fig. 400.t Fig. 401.t becomes condensed into a capsular ligament, which further provides against any displacement; and thus a far more perfect joint is constructed (Fig. 400). A porcelanous deposit takes the place of cartilage, on the head or surface of the dislocated bone ; or instead of this eburnation (Fig. 401), an imperfect fibro-serous surface or synovial capsule may be formed. The natural articular cavity — whence the bone was dislodged — loses its cartilaginous investment, and closes in. (See Fig. 399.) It is, at length, partially obliterated by a dense fibrous deposit. So also is the trach in the textures, through which the bone had passed. Associated with this articular transformation are certain accessory, but somewhat accidental changes, in relation to the ligaments, muscles, and tendons. The ligaments perhaps become firmly adherent to the neck of the bone, thus further opposing its re- duction, and if the rent be small through which the bone escaped, it may be tightly embraced. This is more apt to occur in a capsular ligament. Other ligamentous con- ditions are peculiar. The orbicular ligament around the neck of the * King's Coll. Mus., 1336, 2. _ _ t St. Bartholomew's Hosp. Mus., 3, 33. Old unreduced dislocation of elbow, joint, backwards ; with a new capsule embracing the articular end of the humerus ; there are also new capsules, for the articular surface of the ulna, and for the head of the radius. X Ibid., C. 34 906 SPECIAL PATHOLOGY AND SURGERY. radius may have been carried away entire I3- by dislocation of this bone, and be firmly attached at both ends to the humerus. A specimen of this kind is preserved in the jMuseum of St. George's Hospital. The viuscles which act on the displaced bone become permanently shortened, while their lines of action get accommodated to the displacement, and help to retain the bone in its new position. Or if any tendons were pai-tially or entirely torn across by the violence of dislocation, they may have acquii'ed new attachments, and such as are ruechanically unadapted to the action of the muscles. A ruptured tendon sometimes forms a band of adhesion between the bones. In one instance (St. George's Hosp. Mus.), the tendon of the brachialis anticus muscle having been torn off the coronoid process of the ulna, which was dislocated backwards into the olecranon fossa, this tendon became firmly united both to the trochlear surface of the humerus and to the ulna below its original attachment, forming a kind of soft anchylosis between them. A tendon having its attachment thus displaced, is unfavourable to the action of the muscle connected therewith, yet its new attachment may aid in rendering the dislocation irreducible. Bony nodules form, occasion- ally, in the tendons around the seat of dislocation. Lastly, in these general changes, should be noticed the important one of adhesion sometimes having taken place betw^een a large artery and the capsule or periosteum of the displaced bone.* All these structural alterations take place very slowly. The de- sti-uctive changes implying an irreparable sacrifice of the articular cavity, Nature reluctantly obliterates it, and with it depi-ives the Surgeon of the opportunity for reduction, only when long disappointed by delay and wearied by the lapse of time. Even after a period of thirteen years, in dislocation of the hip-joint, the acetabulum may still retain its form and depth and cartilage ; as shown by a specimen which Fournier has recorded. The reparative alterations — those pertaining to the formation of a new joint — are most complete in ball-and-socket dislocations, as the hip-joint ; the compensatory substitute for any hinge joint is far less complete. In some such instances even, bony anchylosis is the result. The Diagnostic Signs of unreduced Dislocation, and of the con- struction of a new joint, are — the physical signs of dislocation, coupled with restoration, more or less entirely, of the functional use of the limb or part. The characteristic alterations in the form of the joint, length of the limb, and direction of its axis, still remain ; while the power of using it is regained, and proportionately as the new articu- lation is perfectly finished off. Hence, this restoration of function is, at length, far more thoroughly established in unreduced Dislocation of a ball-and-socket joint, than in that of a hinge joint. Treatment. — The question of interference should be determined by the mohility of the new joint, (a.) When freely movable, the natural articular cavity or surface is probably obliterated, the processes of construction and destruction having proceeded equally. Hence, the indication is, not to interfere — to leave such an unreduced dislocation alone ; any attempt at reduction being useless or worse. Under these circumstances, reduction has, indeed, been effected, but with great injury to the limb, and even with a fatal result. In one such case, that of a dislocated shoulder, reduction was followed by great swelling * 'Fractures and Dislocations," by Hamilton, p. 492. Philadelphia, 1860. UNEEDUCED DISLOCATION AND FALSE-JOINT. 907 of the arm ; a tumour formed in the axilla, which, at the end of thirty- eight days, burst with alarming heemorrhage. Ligature of the sub- clavian artery fortunately saved the patient's life.* In other cases, suppuration in and around the joint, and gangrene of the limb, have been known to ensue. (Malgaigne.) (b.) When the action of a new joint is less easy, and less efficient, rediiction of the dislocation may be attempted, and with successful issue to limb and life. The kind aud amount of extension are, however, features in the treatment worthy of special attention. Extension, gradually increased, and continued for perhaps some hours, or renewed daily, is necessary, to overcome the resistance of the shortened muscles, any adhesions of the tendons or ligaments, and to extricate the bone from its new articular adaptations. But it should ever be remembered that, possibly, more than these mechanical obstacles to reduction exist. There is always some risk of producing one, or more, of several serious lesions which have occurred in the practice of various Surgeons. Laceration of the blood-vessels, a large artery, or vein, and which may have become adherent to the dislocated bone. Or the adjoining nerves may be involved. Even the muscles have been torn, or at least over- strained, leaving a permanently weakened, paralytic condition of the limb. Fracture of the dislocated bone has been known to occur ; or the articular surfaces may be injured. Nor should the possibility of tearing the limb off be overlooked, for even this horrid mtitilation has hajDpened suddenly. The occurrence of some such accident cannot be foreseen, otherwise than by observing the general rule laid down respecting any surgical interference. Other lesions may be somewhat anticipated, and precautions taken. Thus, the skin and the subcu- taneous vessels are liable to be ruptured, in any prolonged attempt at reduction, owing to the pressiu'e and straining force of extension. A lacerated and ecchymosed wound is produced. Lastly, without any apparent injury at the time, the soft parts may be so disintegrated by extension, as to fall into a low form of suppurative inflammation and disorganization. Of course, reduction should be conducted under the influence of chloroform. When pain and swelling have subsided, in the course of a week or two, passive motion should be commenced. The extreme periods of unreduced Dislocation, within which limits reduction is practicable, with safety to the limb and life of the patient, can scarcely be determined by experience. Nor is this question of much practical importance, considering the functional conditions, already mentioned, which should guide the Surgeon. Successful results have been obtained at extreme periods, varying from a few days to many months, and even beyond two years ! In a dislocation of the elhow, backwards, unreduced for six months, Mr. Darke con- tinued extension with pulleys during eight hours and a half, when the bones returned to their proper situation. Three other cases of this date were successful in the hands of Gorre and Gerdy. A dislocation of the shoulder, unreduced for six weeks, was overcome by Mr. Mash, in the Northampton Infirmary, by extension at intervals with pulleys, during eight hours. A dislocation of the head of the radius forwards, of twenty-five months, in a child of nine years old, was reduced by Dr. Stark ; extension being repeated daily for twenty-two days, consecu- tively. This is, I believe, the longest period at which extension has * Med.-Chir. Trans., vol. xxix. p. 25. 908 SPECIAL PATHOLOGY AJTD SURGERY. been successful, in unreduced dislocation of any joint in the upper extremity. Manual extension has proved sufficient in some cases. Thus, I reduced a dislocation of the radius hackivards, of ten weeks ; the adhesions about the head of the bone audibly giving way. In the lower extremity, the periods of limitation have been much less, with regard to the hip-joint. In two instances, dislocation of the femur on the dorsum ilii has been reduced after the lapse of six months. In both, reduction Avas effected by " manipulation ; " the one under the influence of chloroform, by Di\ Blackman, of Ohio, the other without chloroform ; * but in this case the patient, a boy, was feeble and the muscles flaccid. In both, the results were successful ; the limb recovering its functions and the muscles regaining their bulk and strength. Respecting the hip and shoulder joints ; Sii' A. Cooper's large experience led him to select two months in the one case, and three months in the other, as the extreme periods at which I'eduction can be safely accomplished. But the impossibility of determining the propriety of surgical interference by reference to the period of an unreduced dislocation must not be overlooked. In Fonrnier's specimen of hip-joint dislocation, the acetabulum retained its original character as an articular cavity after thirteen years had elapsed. Any opposing tendons, ligaments, or adhesions suggest the pro- priety of a previous accessory operation ; that of dividing them, sub- cutaneously. Simple as this may appear, it is not always practicable, with a fair degree of safety to the part, and even to the life of the patient. Yet there are successful results on record. Thus, in dis- location of the thumb backwards upon the metacarpal bone, reduction may be impossible, unless by subcutaneous division of the lateral ligaments. Sir Charles Bell first proposed the operation in this case, and it has since been successfully practised by Liston, Reinhardt, Gibson of Philadelphia, Parker of New Tork, and other Surgeons. Lizars and Syme advocate this practice in certain instances. An un- reduced dislocation of the shoulder-joint, of two years' duration, was overcome by Dieffenbach, in like manner. In one instance also, an old dislocation of the elbow, which still resisted after division of the tendons and ligaments, was reduced by dividing the adhesions. M. Blumhardt made a longitudinal incision on either side of the joint, laid open the capsule, freely divided the adhesions, and replaced the bones. The limb is said to have recovered its natural mobility, and the patient resumed his occupation as a carpenter. In cases such as these, the periods after dislocation at which opera- tions have proved successful are comparatively unimportant ; for the difficulties of reduction being thus overcome, the operation itself is the only important consideration, i.e. as to its propriety and practicability. CoxGExiTAL DiSLOCATioxs. — The whole pathology of "Dislocations existing at birth " requires further investigation, in respect to their structural conditions, causes, and vital history. Congenital Dislocations, ai-e, apparently, of three kinds : (a) Physio- logical dislocations : or those resulting from an original defect in the germ, or from an arrest of development, (b) Pathological dislocations ; or those resulting from some lesion of the nervous centres, from contraction or paralysis of the muscles, laxity of the ligaments, hydi'arthrosis, or some other diseased condition of the articulation. * Op. cit., Hamilton, p. 663. DISLOCATIONS OF THE LOWER JAW. 909 (c) Mechanical dislocations ; or those resulting from some peculiar position of the foetus in ntero, violent contractions or constant pres- sure of the walls of the uterus, falls and blows upon the abdomen, and unskilful manipulation of the child in delivery. These might be termed traumatic dislocations. Probably all the joints are liable to Congenital Dislocation, in some form or forms ; and with regard to most of the joints, this kind of lesion has already been established by dissection. Hamilton has collected many such instances ; but it appears to occur most frequently in the hip and shoulder joints. The Treatment of Congenital Dislocation is generally impracticable. What to do may be obvious ; the removal of any one, or more, of the known conditions which originally produced the dislocation ; but how to do this successfully may be impracticable, owing to those conditions being, generally, defective forms of structure, which, in producing, also perpetuate the recurrence of dislocation. It is therefore mostly incurable. CHAPTER XXXV. SPECIAL DISLOCATIONS. Fig. 402. Dislocations of the Lower Jaw. — Structural Conditions. — Complete dislocation on both sides — double or bilateral dislocation — consists in the dislodgment of both condyles from the glenoid fossae and their displacement forwards, in front of the anterior or transverse root of the zygoma, on either side ; the coronoid processes thus being brought forward, and corresjjonding to the under aspect of the malar bone, on either side (Fig. 402), Similar displacement on one side only — single or unilateral dislocation — represents the same altered articular relations of the condyle, on that side ; with a twist of the jaw to the opposite side. Partial disloca- tion, or subluxation of the jaw, is, apparently, a displacement in relation to the inter- articular cartilages ; the condyles slip- ping forwards in fi'ont of these cartilages, on both sides, or on either side alone. Bilateral dislocation occurs in about two of every three cases. Partial dislocation happens comparatively seldom. Signs.— CertaiiL obvious and characteristic signs attend dislocation of the jaw. The mouth is open, and cannot be closed, the jaw being drawn down by the action of the genio-hyoid muscles, aided by the genio-hyoglossi, the digastric, and mylo-hyoid muscles ; and the lower 910 SPECIAL PATHOLOGY AND SUKGERY. teeth project in front of the line of the upper teeth. Tliis open-mouthed appearance is more conspicuous at first, the distance between the teeth extending sometimes to an inch and a half ; subsequently the jaw becomes more closed, but the coronoid processes, hitching against the malar bones, mechanically oppose any nearer approximation. Degluti- tion and speech are interrupted, the lips moving when the person attempts to speak and the saliva di'ibbling over the chin. The cheeks are stretched and flattened, and the angles of the jaw directed some- what backward towards the mastoid process of the temporal bone, on either side, with a decided prominence of the coronoid process, below the malar arch; a depression can be felt in front of the external auditory meatus, corresponding to the natural situation of the condyle, and an oblong prominence in the temporal fossa, with fulness of the masseter muscle. Dislocation on one side only is denoted by the same signs ; but in a lesser degree, and one-sided, the jaw being twisted somewhat to the opposite side, though this alteration may be scarcely appreciable. Thus, the open mouth, and projecting lower jaw, has a singularly yn^j appearance. The pi^ominence of the coronoid process, with fulness, instead of flattening of the cheek, on the side of displacement, are also conspicuous ; and a depression can always be felt in the proper situation of the condyle, and not on the other side. Partial dislocation presents similar sigTis, but they are still less perceptible, and perhaps recurring, the condyle slipping to and fro. Causes. — Muscular action would seem to be the usual cause, in the act of opening the mouth widely; as in laughing, gaping, violent declamation, yawning, vomiting, convulsion, or an attempt to take too large a bite. The condyles mo^^ang forward on the transverse root of the zygoma on either side, are dislocated by the action of the external pterygoid muscles and anterior portion of the masseters, the genio- hyoid and other muscles then depressing the jaw. Consequently, the temporal, internal pterygoid and masseter muscles are placed on the stretch, or even strained. 'External violence is an occasional cause, as in tooth-extraction, or the foi'cible introduction of something into the mouth. Sir A. Cooper records such a case ; two boys were struggling for an apple, and the one in attempting to thrust it into his own mouth, dislocated his jaw. Age would certainly seem to have some predisposing influence ; complete dislocation occurring very rarely in infancy or ad- vanced life, owing probably to peculiarities in the form of the jaw at these periods. Nelaton attributes its gi^eater frequency in middle life to the length and anterior inclination of the coronoid process. Women .also seem more liable than men ; and to partial dislocation in particular, which arises probably from relaxation of the ligaments of the jaw. Unreduced dislocation of the jaw undergoes changes, whereby the jaw becomes approximated to the upjDcr, and its anterior projection is diminished ; some mobility and power of movement also are regained ; thus restoring mastication, deglutition, and speech so far, that the person at length experiences no great inconvenience from the displacement. Treatment. — Reduction is readily accomplished by retracing the dis- placement. The Surgeon, standing in fi-ont of his patient, introduces his thumbs — protected by a cloth — into the mouth, and applies them to the lower molar teeth on either side ; depressing the angles of the jaw, the chin is raised by the fingers externally at the same time, and the jaw is jerked in or returns with a snap. Chloroform may be DISLOCATIONS OF THE SPINE. 911 administered, when reduction cannot be accomplished without its aicl. Dislocation on one side is reduced in like manner ; and so also partial dislocation, which may, however, be returned by the natiiral efforts to open and shut the mouth, the patient being told at the same time to make a lateral motion, or, as suggested by Professor Pirrie, to bring the jaw forward. A four-tailed bandage must then be applied, as in fracture of the lower jaw ; and the patient fed on liquid food for some days, during reparation of the ligaments. After partial dislocation, the prevention of its recurrence may be aided by tonic treatment, and stimulant a23plications over the articulation. Reduction has been effected after periods varjang from days to several weeks ; after one month and five days, by Sir A. Cooper, in a case of. double dislocation; and after ninety-eight days, Donovan succeeded in another case. Congenital Dislocation of the Loioer Jaw — denied by Malgaigne, but aflBrmed by Guerin, R. W. Smith, and Hamilton — is, however, very rare, and apparently always unilateral. In Dr. Smith's complete account of one such case, dissection showed an arrest of development of the dislocated side of the face, the osseous and muscular structures being atrophied and imperfect. A singular deformity of the face was thus occasioned on the one side, as compared with the other; and the usual signs of dislocation were absent or reversed, — the front teeth of the upper jaw projected beyond those of the lower, there was no coronoid projection with fulness of the cheek, the mouth was closed or opened voluntarily, and these movements of the jaw were more extensive than in the normal condition. But this congenital dislocation must be distinguished from the appearances produced by chronic rheumatic arthritis as affecting the temporo-maxillary articulation. The history of the case, especially in regard to severe and long-continued pain, with perhaps a distinct ossific enlargement of the condyle of the jaw, will mainly determine the diagnosis ; and there is some projection of the lower jaw beyond the ujjper. The disease is usually symmetrical ; when occurring on one side only, the twdsted aspect of the mouth is also associated with enlargement of the condyle, and the wearing, chronic pain of the rheumatoid disease.* Congenital dislocation is incurable. Dislocations of the Spine — through the inter-vertebral substance — are almost necessarily accompanied with fracture of the articular pro- cesses, or of the bodies of the vertebrae ; excepting in the cervical region, the articular processes there being placed more obliquely than those of the other vertebrge. Any dislocation of the spine is rare, and more so without fracture. The displacement may be forwards, and more commonly in this direction ; lateral rotation, to either side ; or back- ward displacement. It is always incomplete, except perhaps in the cervical vertebrae, which may possibly undergo complete displace- ment, forwards. (Malgaigne.) The seat of dislocation varies ; this injury occurring in the cervical region most frequently, and particularly at the fifth or sixth vertebra; in the dorsal region occasionally, and particularly at the eleventh or twelfth vertebra ; in the lumbar region very rarely, but perhaps at the first or second vertebra in this portion of the column. _ It appears, therefore, that spinal dislocation is more often met with in the cervico-dorsal and dorso-lumbar regions ; at the * E. Adams, " On Eheumatic Gout," case xv., 2nd edit. 912 SPECIAL PATHOLOGY AND SURGERY. junctions of curvatures, and of flexible to comparatively inflexible por- tions, — the weakest parts of the column. In all dislocations of the spine, the cord is more or less involved. Detachment of the inter- vertehral substance, with displacement of the bodies of the vertebrae, is a very uncommon form of injury. I have seen one such case in the cervical region of the spine, as shown by post-mortem examination. The Signs and Symptoms of spinal dislocations are similar to those of fracture in this region; some irregularity or projection at the seat of dislocation (Fig. 403), and paralysis, more or less complete, of those ■r,,^ Ano * portions of the body which re- Jb IG. 4U0. '■ . ., 1 c ceive the nervous supply irom below the point at which the dislocation has occurred. The diagnosis, as compared with fracture, can hardly be deter- mined hj crepitus, which may be absent in fracture, and pre- sent in all the dislocations ac- companied with fracture ; but a peculiar rigidity of the spine in the position assumed by disloca- tion, the trunk inclining im- . movably forwards, backwards, or more commonly to one side, will generally be diagnostic. Causes. — The same as in fracture ; falls on the head, feet, or back, and violent flexions of the spine backwards,or to either side. Termination. — Dislocations of the spine are, obviously, of a serious or fatal character; and — like fracture — more so, the higher in the spinal column dislocation takes place. Treatment. — Reduction of the displacement is impossible, or would be perilous ; and but little can be done beyond the general treatment for fracture of the spine. Dislocations of the first two cervical vertebrae are conveniently referred to the first bone. The atlas may be dislocated from the occipital bone ; specimens of occipito-atloidean displacement having been reported by Lassus, Paletta, Bonisson, and Dariste. In each case, the displacement was incomplete; but death speedily ensued, except in the last case, where the patient survived for more than a year, and then died from tubercle in the brain. Dislocation of the atlas from the axis — atlo-axoid displacement — has been known to occur forwards or backv/ards, or as a lateral rotation of one articular process forwards. The ligaments which keep the odontoid process in place may or may not be ruptured. Thus, in forward dislocation of the atlas, the odontoid process of the axis passing backwards, may rupture * Royal Free Hospital. A case of partial dislocation, apparently, of the third and fourth cervical vertebrae, of some duration ; unaccompanied with any symptoms of paralysis. DISLOCATIONS OF THE EIBS AND CLAVICLE. 913 the transverse ligament, with its superior vertical appendage, attached to the basilar portion of the occiput, and carry down also the odontoid and suspensory ligaments connecting the process with the condyles of the occiput. Or, with similar dislocation of the atlas, the odontoid process may slip from under the transverse ligament to behind it, leaving that ligament intact, but rupturing its inferior vertical appendage, attached to the root of the process, and also caiTying down the odontoid and suspensory ligaments. In both these liga- mentous lesions, the occipito-axoidean ligament — -a continuation up- wards to the basilar grove, of the posterior common ligament — must also be torn. Lastly, fracture of the odontoid process at its base may have occurred. The obvious importance of these lesions, accompanying dislocation, is their relation to the falling backwards of the odontoid process on to the spinal cord ; complete compression causing instant death. This is said to be sometimes the mode of death in hanging ; and it probably happened also in the sad case of the late Bishop of Winchester, who fell on his head from horseback, and died instantly. Dislocations of the Ribs have been met with, occasionally, at either their vertebral or sternal articulations. In the fonner situation, the head of the rib is sometimes dislocated, and always forwards; generally one of the lower ribs, including the false or floating, has been thus displaced. This injury is usually associated with fractureof the transverse or spinous processes of the corresponding vertebra, or wdth fracture of another rib. The signs of this dislocation will be obscure ; the depression and mobility of the rib, adjoining the spine, might indicate fracture, and in such case the distinctive crepitus may be absent, owing to displace- ment, or imperceptible, through the depth of the fi^agments. Either injury also may arise from a fall or blow on the back. The treatment, however, is the same in both cases. It will be found impossible to replace the head of bone, but rest of the part should be secured by a roller rib-bandage, to fix the chest until any inflammatory swelling has subsided. At the sternal articulations, the rih-cartilages are liable to displace- ment forwards, in advance of the sternum, presenting one or more projections at the seat of the articulations. This displacement maybe accompanied with fracture of the sternum. But, generally, it is the slow result of some habitual muscular action throwing back the shoulders, as by the use of dumb-bells " to open the chest," or of an occupation whereby, in using the arms, the ribs are pressed forwards, as in the act of kneading dough. I have known the dislocation to be produced in pigeon-breasted children. Reduction vadij be accomplished by pressing the cartilaginous projection back into place, aided by the patient making a full inspiration at the time, or by bending the trunk backwards. A compress and rib-bandage are then applied. Dislocations of the Clavicle. — (I.) The sternal end of the Clavicle may be dislocated in three directions : forwards, in front of the sternum ; backwards, behind the sternum ; and upivards, or upwards and inwards, above the sternum (Fig. 404) . In these dislocations, the ligaments are more or less completely torn, according to the direction and extent of the displacement ; but the bone carries with it the clavicular portion of the sterno-mastoid muscle. Signs. — Dislocation forivards is denoted by a deformity, consisting of the sternal end of the clavicle in front of the sternum, which dis- vol. i. 3 X 914 SPECIAL PATHOLOGY AND SURGERY. appears by drawing the shoulders backwards and returns when such force is removed ; the distance between the acromion and middle line is diminished ; the head is drawn forwards and turned from the disloca- tion, in order to relax the sterno-mastoid Fig. 404.* muscle ; and there is inability to raise the upper extremity. Dislocation hackicards is denoted by the opposite appearance to the former one, a depression in the situation of the sternal end of the clavicle ; but there may be dyspnoea, dysphagia, obstructed cir- culation and pain, from pressure on the trachea, oesophagus, vessels and nerves, re- spectively. Several cases are recorded in the London and Edinhurgh Journal of Medical Science, October, 1841. Dislocation upwards is of rare occurrence ; four cases only have been collected by Malgaigne ; but Dr. R. W. Smith relates six cases in the Uuhlin Journal of Medical Science, December, 1872, with an additional case of his own — in which, as shown hj post-mortem examination, the sternal end of the clavicle was lodged beneath the sternal origin of the sterno-mastoid muscle. An extraordinary case is described by Dr. Rochester in the Buffalo Medical Journal, vol. xiv. This form of dislocation presents a projection above the sternum — or in the remarkable case alluded to, upon the front of the thyroid cartilage — the sternal end of the cla^acle having been thrown, upwards, with a marked sulcus below the inner third of the clavicle ; and there is also a corresponding depression of the shoulder. Causes. — A fall on the shoulder, anteriorly, or throwing the shoulder backwards, may cause the dislocation forwards ; compression of the shoulders, laterally, or a direct blow on the sternal end of the clavicle, may drive this portion of the bone backwards ; and a fall on the shoulder externally, or a blow upon the top of the shoulder, may start the bone upwards upon the supra-sternal notch. Treatment. — Reduction of these three dislocations is accomplished by directing the shoulder so as to retrace the particular displacement. Forward dislocation of the sternal end of the clavicle may be over- come by drawing the shoulder backwards and outwards ; in backward dislocation, similar traction of the shoulder, to even a greater extent, will be efficient ; while upward dislocation may be reduced by out- ward traction of the shoulder, at the same time raising the outer and depressing the inner end of the clavicle. Pressure directly on the displaced end of bone, when accessible, as in the first and last named dislocations, has comparatively little eSect in aiding reduction. Trac- tion of the shoulder is best effected by using the knee as a fulcrum iu the back, while an assistant places his fist as a fulcrum in the axilla ; the shoulders are then bent backwards, and the elbow brought down to the side, simultaneously. To retain the bone in position, a pad over the sternal end may have some effect in dislocation/orzcarcZ.s, but a figure-of-eight bandage applied to the shoulders will more effectually prevent the recurrence of dis- * St. Thomas's Hosp. Mns., B. 1. Dislocation of the sternal end of the clavicle, upwards and inwards, with fracture of the first rib close to the stemnm. The articular end of the clavicle rests upon the concave upper border of the sternum. DISLOCATIONS OF THE CLAVICLE. 915 placement in either of the tliree directions of dislocation, tlie arm being drawn back and fixed to the side. Some permanent displacement and deformity are almost inevitable ; tbe patient, however, recovering a good use of tbe arm. Indeed, it is a consolation to know tbat even when reduction has not been accomplished or maintained, almost the same good result has ensued. Compound dislocation occurred in one instance of dislocation back- wards, by direct violence — a blow with a pick-axe. (Hamilton.) (2.) The scapular end of the Clavicle may be dislocated — upivards, upon the upper surface of the acromion (Fig. 405) ; or downwards, under the acromion, or under the coracoid pro- cess. The first-named dislocation is the most Fig. 405.* frequent, and indeed the most common, of all dislocations of the clavicle ; the second very rare, only three cases having been recorded of dislocation under the acromion, and six under the coracoid process. The aero mio- clavicular lig'a- ments are torn in the dislocation upwards ; and also the coraco-clavicular and coraco-acromial ligaments in dislocation downwards. Signs. — Dislocation upwards is easily recog*- nized by the projection of the outer or scapular end of the clavicle, and which is more easily felt on tracing the spine of the scapula up to the acromio-clavicular articulation. Some depression and flatness of the shoulder will also be perceptible. Dislocation dotvnwards is recognized, and distinguished, by the oppo- site signs; a marked depression, in particular, corresponding to the usual situation of the outer end of the clavicle. Downward disloca- tion, under the coracoid process, is more particularly characterized by a corresponding projection of the acromion and coracoid process, and a rapid inclination downwards and outwards of the line of the clavicle, its outer end being felt in the axilla. Inability to raise the arm to a right angle with the body, will generally be found symptomatic of either form of dislocation ; but the arm can be moved, passively, in certain directions. Thus, the range of motion is most free in the upward dislocation ; whereas, in downward dislocation, under the acromion, the arm can be moved pretty freely backwards and forwards, but not outwards; and, with dislocation under the coracoid process, the arm cannot be moved inwards and upwards. Pain accompanies any opposed motion of the arm. Causes. — A fallen the shoulder would seem to be the usual occasion of these dislocations ; the force being applied upon the top or back of the shoulder, in upward dislocation ; and upon the clavicle, to produce dislocation downwards. Thus, in one instance of the latter displace- ment, a horse trod upon the shoulder ; and in another, the accident occured to a child, from an attempt to support a great weight upon the top of the collar-bone. But the upward displacement may be caused by force from below ; in one case having been produced by a bolt thrust up from under the clavicle. Treatment. — Reduction is easily accomplished by drawing the shoulders backwards and outwards, the Surgeon placing his knee * St. Thomas's Hosp. Mus., B. 2. Dislocation of the acromial end of the clavicle, on the acromion or spine of the scapula, with fracture of the acromion. 916 SPECIAL PATHOLOGY AND SURGERY. Fig. 406. between them, as recommended by Sir A. Cooper. Considerable diffi- culty will, however, be experienced in preventing the recurrence of dis- placement. A pad in the axilla, and the application of a bandage, as for fractured clavicle, constitute the most effectual retentive apparatus. Direct compression is available only in dislocation upwards. Many weeks should be allowed to elapse before this treatment is discontinued. Some deformity almost always remains, but with little loss of power in the movements of the arm. Dislocation of Both Ends of the Clavicle has been known to occur, simultaneously ; but it must be placed among the rarities of Dislo- cations. Dislocation of the Scapula. — The loiver angle of the scapula some- times projects, apparently having slipped from under the edge of the latissimus dorsi muscle, which there crosses the scapula. I have seen one such case, on the right side. Liston attributed this displacement to the arm being "suddenly raised above the head to an unusual extent." The vertebral border of the shoulder-blade projects to a great extent, and its inferior angle is so loosely connected to the chest, that the fingers may be pushed up between the ribs and the bone half-way to the glenoid cavity. Some time since, Mr. Edmund Owen exhibited to the members of the Harveian Medical Society a boy who was the subject of this condition on both sides. Indeed, the shoulder-blades looked like rudimentary wings. This appearance was well marked in a case which Sir W. MacCormac met with, as hei'e shown (Fig. 406). Mr. Owen refers this apparent dislocation of the scapula to paralysis of the serraius nnagnus muscle. The appearances come on slowdy ; if they were due to a sudden slipping of the bone over the latissimus dorsi, the patient or his friends would hardly say "the shoulder-blades have been growing out for weeks or months." The serratus magnus binds the scapula in its place against the ribs, and its inferior bundles play a most important part in raising the arm above the head. In the condition to which we are alluding, the power of elevating the ami is much impaired. The affection seems occasionally to follow a fatigue of the muscle. In another case cited by the same Surgeon, the patient, a nurse, attributed the weakness and pain in the shoulder to years of attendance on an old lady, whom she used to rub for chronic pleurisy. The clinical history of " paralysis of the serratus magnus " is recorded in a case which Dr. Vivian Poore brought before the Clinical Society of London, February 12, 1875. Treatment. — The treatment, observes Mr. Owen, should consist in rubbing and shampooing, and in the use of the interrupted current. One may give a more favourable opinion of the result if, on passiiig the current down the course of the nerve of Bell from the root of the neck to the costal attachments of the muscle, the scapula is braced DISLOCATIONS OF THE SHOULDER-JOINT. 917 Fig. 407.* Fig. 408.t np into its proper position. Bandaging- the chest is futile ; and if the surgical mechanician is intrusted with the treatment of the case, he will probably supply an ingeniously con- structed corset, whose expense is only equalled by its uselessness. DlSLOCATIOifS OF THE ShOULDER-JoINT. — These are the commonest of all Dis- locations. The head of the humerus may undergo displacement — downwards, into the axilla, suh glenoid ; forwards, suh- coracoid and stibclavicular ; backwards, on the dorsum of the scapula beneath its spine, subspinous. These dislocations occur, pro- bably, in the same order of relative fre- quency ; the first named being by far the most common ; the second, occasional ; and the third, very rare. Subcoracoid disloca- tion may, however, be the most frequent ; Professor Flower's investiga- tions showing that of 41 specimens in the Museums of the London Hospitals, 31 are subcoracoid ; and that in 50 cases known to him, 44 were of this form. Partial dislocation is said to occur ; either as the subcoracoid, or a disloca- tion npwards — supra-glenoid — under the acromion. But the former disloca- tion is complete, the head of the humerus being lodged entirely out of the glenoid cavity, in the illustrative case given by Sir A. Cooper ; the upward dislocation is incomplete, the head of the bone lying partly in the glenoid cavity. Struchiral Conditions. — (1) Disloca- tion dowmvards, or subglenoid ; — the head of the humerus is lodged in the axilla, just below the glenoid cavity, and resting on the inferior costa of the scapula (Fig. * St. Thomas's Hosp. Mus., B. 8. Dislocation of the head of the humerus down- wards into the axilla. The capsular ligament is laid open in front, and the head of the bone rests on the inferior costa of the scapula, beneath the glenoid cavity. t St. George's Hospital Museum, 1, 107. Dislocation of the head of the humerus upwards and forwards, with fracture of the coracoid process. The head of the humerus — as primarily displaced — rested on the anterior margin of the clavicle, just external to the junction of the pectoralis major and deltoid muscles, quite above the level of the glenoid cavity. In the figure, as from the preparation, it has fallen to the same level as that cavity. Owing to the fracture of the coracoid process, on which the head of the humerus also partly rested, erosion of the articu- lar cartilage has taken place, producing crepitus, when the head of the bone was rotated against it. The stump of this process appears behind the humerus in the figure. Its tip, not shown, was slightly separated by the tendons inserted into it, but the ligamentous fibres attached to the coracoid process opposed further dis- placement. The long tendon of the biceps was not ruptured. The injury was caused by a fall on the elbow, from a height of about thirty feet ; and the patient, a man aged forty -nine years, lived for a fortnight. For any further particulars, see Med.-Chir. Trans., vol. xli. 918 SPECIAL PATHOLOGY AND SURGERY. Fig. 409,* 407), between the subscapular muscle and the long head of the triceps. The capsular ligament is torn to a considerable extent, and generally the tendon of the subscapular muscle, near its insertion into the small tuberosity. The muscles attached to the great tuberosity are stretched or torn, particularly the snpra-spinatus ; and, possibly, the tuberosity itself may be detached. The axillary vessels and plexus of nerves suffer compression by the head of the bone. (2.) Dislocation forwards, or subclavicular ; — the bead of the humerus lies under the pectoral muscles, on the inner side of the coracoid process, just below the clavicle (Fig. 408), and resting on the second and third ribs. The capsule may be completely sepa- rated from the neck of the bone ; the lower scapular muscles much torn, namely, sub- scapularis detached from the smaller tube- rosity, infra- spinatus and teres minor from the great tuberosity ; and, possibly, this prominence of bone may itself be torn away from the bead of the humerus. The axillary vessels and nerves suffer compression. (3.) Dislocation hackicards, ov suh spinous ; the head of the humeriis lies jiist behind the glenoid cavity on the dorsum of the scapula, below its spine (Fig. 409), and between the infra-spinatus and teres minor muscles. The capsule is ruptured, and the muscles in front of the joint are stretched or torn ; namely, the subscapularis, supra- J? iG, 4ia spinatus, and long head of the biceps. Partial dislocation upioards produces structural alterations, but less extensive. In two cases (see supi'a- glenoid dislocation) the head of the hume- rus was partly dis- lodged upw-ards, under the acromion ; the cap- sule was slightly rup- tured, and the long tendon of the biceps thrown out of its groove inwards, on to the smaller tuberosity of the humerus. Signs. - — ■ Certain signs are common to all three dislocations of the shoulder. These signs are — flattening of the shoulder, externally ; a depression below the acromion, owing to the absence of the head of the bone, and a * St. Mary's Hospital Museum, A. a. 8. A very rare specimen. DISLOCATIONS OF THE SHOULDER- JOINT. 919 corresponding projection of the acromion above (Fig-. 410) ; the pre- sence of the head of the bone in an abnormal situation, downwards, forwards, or backwards ; some immobility, and inability to nse the arm, and pain, particularly when the arm is moved. But the direction of the axis of the humerus or arm, and the length of the arm, with the situation of the head of the bone, are distinctive in each form of dis- location ; thereby determining its diagnosis. Dislocation doivnioards into the axilla is accompanied with some inclination of the arm outwards, in a line with the trunk, and neither backwards nor forwards ; an elongation of the arm is observable, or can be ascertained by measurement, — taking the apex of the acromion as a fixed point above the joint, and the external condyle of the humerus below. The head of the humerus can be felt in the axilla. Dislocation /oJ'wartZs, or subclavicular, is distinguished by a direction of the arm baclcivards, and somewhat outwards ; with some shortening. The head of the bone can be felt under the clavicle. Dislocation bachwards, or subspinous, is characterized by a direction of the arm forivards, and somewhat outwards, or occasionally it hangs by the side ; with some shortening. The head of the bone can be felt under the spine of the scapula. Partial dislocation upwards (see supra-glenoid dislocation) is characterized, principally, by the position of the head of the bone, which appears to be drawn higher up in the glenoid cavity, and. un- naturally prominent in front ; abduction produces a sensation of crepi- tus, the humerus rubbing under the acromion, and becoming locked as the arm is raised ; and severe pain is experienced by any action of the biceps muscle. But the detection of any form of dislocation of the shoulder-joint, downwards into the axilla more particularly, may be rendered difficult, a few hours after the accident, by the supervention of swelling, both from inflammatory effusion and extravasation of blood ; the nature of the injury becoming more perceptible as the swelling subsides. This condition might mislead the Surgeon more readily, when the dislocation was caused by direct violence, in so far resembling simply a contusion of the shoulder. The Diagnosis of shoulder-joint dislocation, as compared with frac- tures of the neck of the humerus, may be determined by the presence of the signs common to all these dislocations, and the absence of true crepitus. Atrophy of the deltoid muscle, resulting from contusion or other injury, simulates dislocation only by the flattening of the shoulder, and the overhanging acromion. Causes. — Direct violence, as a fall on the shoulder, in the direction opposite to the particular form of dislocation. Thus, a fall from a height on the top of the shoulder may occasion dislocation dow^nwards ; upon the back of the shoulder, it may cause dislocation forwards ; and. a fall on the front of the shoulder has been known to produce dis- location backwards, or collision of the front of the shoulder against a tree, in the case of a person being thrown from a horse. Indirect violence applied to the arm, when itself in a position favourable to the particular form of dislocation. Thus, forcible abduction of the arm may occasion dislocation downwards ; and I have known it pro- duced, as a recurring dislocation in an elderly gentleman, by merely resting the fingers on a chest of di^awers, the arm being fully extended. 920 SPECIAL PATHOLOGY AND SURGERY. Violent contraction of tlie deltoid, in lifting a heavy weight, has also tilted the head of the bone downwards, out of the glenoid cavity. A fall on the elbow, the arm being directed backwards, may occasion dislocation forwards ; and dislocation backwards has been produced, by pushing a person violently, with the arm elevated. Spasmodic contraction of the muscles during an epileptic fit, was the cause of the former dislocation, in a case which Hamilton met with, and of the latter dislocation, in a case examined after death by Mr. Key. The causative relation of shoulder-joint dislocations to each other is worthy of notice. Dislocation forwards — subclavicular — may result as the completion of a subcoracoid displacement, which is then regarded as a partial dislocation forwards. Or, the subclavicular dislocation may, it is said, be consequent on dislocation downwards. Sir A. Cooper regarded the former as a primary dislocation ; other eminent Surgeons — for example, Desault, Petit, Dupuytren, Mr. Hey, and Professor Samuel Cooper — did not deny the possibility of its being piimary; but they believed it to be very seldom so, and almost always secondary to dislocation downwards. Unreduced dislocation of the shoulder- joint is followed by the slow formation of a new articulation, and destruction of the glenoid cavity ; with proportionate recovery of the use of the arm. Thus, in an old dislocation downw^ards — described by Sir A. Cooper — the head of the bone had become flattened, and a new shallow cavity had formed for the reception of the head on the inferior costa of the scapula anteriorily, a complete capsular ligament also surrounding- the head ; while the glenoid cavity was entirely filled ^vith ligamentous matter, in which were suspended small portions of bone, evidently of new formation, as no portion of the scapula or humerus was broken. Reduced dis- location is followed by good recovery of the use of the arm ; some stiffness, weakness, pain, and swelling of the shoulder-joint remaining, perhaps, for a considerable period, when reduction had been delayed, or attended with much extension, or when the joint had sustained previous contusion. Under these unfavourable circumstances, there is also an increased liability to redislocation. Aggravated by its recurrence, the looseness of articulation ultimately may be such that dislocation takes place on the slightest occasion of force in the right direction. In the case already alhided to of an elderly gentleman, dis- location downwards into the axilla had been overlooked by an Hospital Surgeon in attendance for tkree weeks ; and, after reduction by Sir William Fergusson, it recurred four times in a period of eighteen months. Upward motion of the arm was afterwards restrained by wearing a belt around the chest, attached to an arm-loop, which effectually controlled the tendency to dislocation. Treatment. — Reduction may be effected in various ways : — (1.) By direct extension and counter-extension. This method is perhaps most generally applicable. The patient being seated in a chair, a sheet or jack-towel is di-awn under the axilla on the dislocated side, around the chest over the opposite shouldei", and attached to some fixed, resisting object, or held by assistants. Extension is made from the arm, by means of a linen band fastened by a clove-hitch knot. The arm should be drawn out at a right angle to the chest, and extension slowly maintained, by an assistant, or by pulleys, when necessary. The Surgeon placing his knee in the axilla, and depress- DISLOCATIONS OF THE SHOULDER- JOINT. 921 lag the shoulder with one hand, while he slightlj inclines the arm downwards with the other, the head of the bone passes into the glenoid cavity with a jerk or snap, announcing the reduction. Extension is discontinued, and the arm brought to the side should be secured by a few turns of a roller around the chest, supporting the elbow by a few turns below. An axillary pad may be advisable in dislocation downwards. Any inflammatory swelling about the joint will sub- side, or can be readily subdued by cold evaporating lotions. For- merly, I thus reduced nearly all the dislocations of the shoulder which fell to my lot. But the inconveni- ence of this method in private practice is the assistance requisite, despite the relaxing iniluence of chloroform, and its administration would necessitate having another assistant. (2.) By the linee in the axilla, reduction can be effected without extension ; simply by drawing the arm well down over the knee, as a fulcrum, depressing the shoulder, at the same time, wdth the other hand. This was one of the methods recommended by Sir A. Cooper (Fig. 411). (3.) By the heel in the axilla. The patient lying recumbent, the Surgeon, sitting on the edge of the couch, plants his heel well up into the Fig, 412. axilla, and drawing the limb well downwards, inclines it inwards across the foot as a fulcrum. This also was another method employed by Sir A. Cooper (Fig. 412) . For many years I have adopted this method, 922 SPECIAL PATHOLOGY AND SURGERY. as the readiest, simplest, and most effectual. Instead of the heel, Skey employed a well-padded 'i7-on hnoh, in the axilla ; this fulcrum being furnished with two iron branches, to which are attached the cords for counter-extension, while extension is made by means of pulleys from the wrist or from the arm, the limb lying parallel to, and in contact with, the trunk. This method of reduction may be necessary in a very muscular subject, or in unreduced dislocations of some duration. (4.) By raising the arm. — The patient lying recumbent, tlie Surgeon, sitting behind the shoulder and fixing it with one hand, raises the arm up perpendicularly ; then bringing it down suddenly to the side, the head of the bone may snap into place. (5.) Dislocation hachwards may sometimes be readily reduced by bending the arm hachwards, and at the same time drawing fonvard the upper end oi the humerus with the other hand. (6.) Reduction by manipulation has been proposed, and practised, by Professor H. H. Smith, of Philadelphia. This method is said to be applicable to nearly all dislocations of the shoulder-joint, but it would appear to be specially eligible in dislocation doivnivards into the axilla. It consists, " first, in flexing the forearm upon the arm, and at the same moment the elbow is lifted from the body ; secondly, in rotating the humerus upwards and outwards, using the forearm as a lever; thirdly, in reversing this last movement by rotating the humerus downwards and inwards, while at the same moment the elbow is brought down again to the side." In dislocation forwards, this method of attempted reduction would inevitably increase the dis- placement, — rotation of the humerus upwards and outwards would have the eifect of driving the head further forwards. Unreduced dislocations of the humerus are to be overcome by one or other of these methods ; generally, by dii^ect extension and counter- extension, under the influence of chloroform ; aided, perhaps, by pulleys for making extension, which should be slowly maintained. Dr. Jarvis's " adjuster " has proved effectual when other means have failed. Its principal advantage is that during extension, the limb can be moved about freely in all directions, without relaxing the extension. The periods after dislocation when reduction has been accomplished, vary as to their extreme duration; a month, in one of my own cases ; after twenty-five weeks, by Mr. Brodhurst ; after seven months, and ten months and a half, by Mr. Smith, of the United States. Dieffenbach accomplished the reduction of a dislocation forwards after two years' duration ; but not until he had cut the tendons of the pectoralis major, latissimus dorsi, teres major and minor, and had divided the ligaments surrounding the new joint. The extreme period for the safe reduction of dislocation is probably best determined by observing the movements afforded by the new joint ; and which indicate also the probable utility, or otherwise, of reduction, although itself practicable. Accidents, of a most serious character, are liable to happen in the reduction of old-standing dis- locations ; laceration of the muscles and tendons, rupture of the axillary vessels and nerves, or fracture of the neck of the humerus. Or inflam- mation may speedily ensue, with suppuration in and around the joint. These lesions, or consequences, sometimes occur apart from any inconsiderate application of extending force. DISLOCATIONS OF THE SHOULDEE-JOINT. 923 Compound dislocation of the shoulder-joint is a rare form of injury. Erichsen mentions having seen two cases, and in two directions of dislocation: inwards — subcoracoid, and downwards— subglenoid ; to which may be added one more, into the axilla, as recorded by Hamilton, among his own cases ; and a compound dislocation of the shoulder by Sir A. Cooper. Treatment. — Redaction was effected in both Mr. Erichsen's cases, and they did well. The question of amputation must be determined by reference to the considerations which render the sacrifice of the limb inevitable in Compoukd Dislocation, generally ; and principally, regarding the injury to the axillary vessels and nerves. Complicated Dislocations of the Shoulder-joint. — (1.) Displacement of the long head of the Biceps muscle, and Supra-glenoid Dislocation. — In a few instances only, the long head of the biceps has been found displaced inwards irom. the bicipital groove, and the head of the humerus j^ar^mZZ^/ dislocated upwards above the glenoid cavity, — resting under the acro- mion or the coraco-acromial ligament. This anomalous form of double displacement was first verified by dissection in a case described by Mr. John Soden, jun., of Bath, and which is recorded in the Royal Med.-Chir. Trans., 1841. An injury to the right shoulder-joint was produced by a fall backwards, the whole weight of the body being received on the elbow. When the intense inflammatory swelling of the shoulder had subsided, the following symptoms were presented: — A globular swelling, as if the head of the humerus beneath the acromion process of the scapula, with slight flattening of the shoulder ; and some crepitation could be felt, when the shoulder was grasped above, and the arm was raised upwards and outwards, — this sensation arising from the attrition of the head of the bone beneath the acromion ; but the movement of abduction was limited, and the power of such motion was nearly lost. Thus, the man could move his arm backwards and for- wards, but was unable to lift the slightest weight ; and any motion of the biceps muscle was attended with great pain. This state having continued for two years, death occurred from a compound fracture of the skull ; and post-mortem Fig. 413.* examination discovered the real nature of the former injury. The capsular ligament had been slightly rent, and the long tendon of the biceps, thrown out of its groove inwards, was lying on the smaller tuberosity of the humerus (Eig. 41.3) ; with this displacement, the head of the bone, being no longer kept in position, was partly dis- located upwards from the glenoid cavity, lying beneath the acromion, and directed somewhat inwards toward the coracoid process. In a second case, Mr. Soden found the dis- location to be somewhat forwards, as well as upwards, in connection with inward displacement of the tendon, and to such an extent that it lay on the inner and posterior aspect of the joint. Prior to these observations, Mr. Stanley had called attention to this form of injury in the Med. Gazette, vol. iii. ; and in the 14th vol. of the same journal, Mr. Gregory Smith describes seven specimens met with in the dissecting-room, some of which showed the same altered * King's College Museum, 1341. 924 SPECIAL PATHOLOGY AND SURGERY. Fig. 414.* relation of the bones, and in all of which the tendon was more or less injured, — in five it had been ruptured, and in two it was displaced from, its groove. In one case, related by Mauget in the " Encyclopedic Methodique," the tendon appeared to be "dislodged to the outer side of the groove, for the elbow^ was immovably flexed." Professor Pirrie has since met with an additional instance of this double form of injury to the shoulder- joint ; that case also having been verified by dissection. A case may be mentioned in which a similar inw^ard displacement of the biceps tendon and upward dislocation of the humerus had taken place, but slowly, as the result of destructive disease of the shoulder- joint ; the nodulated character of the head of the bone, from ossific deposit, plainly distinguishing this condition fi'om the efEects of injury. The preparation will be found in the Museum of St. Mary's Hosjjital, and is referred to in a complete paper, by Mr. Edmund Owen, on this " so-called Partial Dislocation of the Humerus." (Med.-Ghir. Trans., vol. Iviii.) (2.) Dislocation, with Fracture of the Humerus in its Surgical Neck or in the Shaft.^-ln a well-marked case of dislocation of the head of the humerus forwards and iTpwards under the clavicle, there was also fracture of the surgical neck of the bone. This double injury having happened to a boy at tlie age of nine years, it is probable that the apparent fracture was a separation of the upper epiphysis of the humerus. On examination, I found a large globular swelling in the sub- clavicular hollow on the right side, and ex- ternally, beneath the deltoid muscle and under the acromion, another projection ; the one was plainly the head of the humerus, the other the broken end of that bone. These two projections together gave a remarkably enlarged appearance to the whole shoulder (Fig. 414). The arm was much shortened from the elbow, and the humerus was directed obliquely outwards from the side. On extension, the dislocated head could be readily reduced, by pressure with the fingers, into its natui^al position in the glenoid cavity, and the frac- ture being reduced at the same time, the shoulder regained its natural size and shape ; but on relaxation, the head of the humerus immediately became redislocated, and the fractured end of the bone passing upwards and outwards, the peculiar appeai'ance of the shoulder was easily reproduced. In the following complication of injury to the shoulder- joint, the fracture having detached the head and small tuberosity of the humerus, this portion of bone is di.s- located forwards and inwards on the ventral aspect of the scapula, half an inch below the base of the coracoid process; the articular surface of the head looking * Eoyal Free Hospital. (Author.) t Roy. Coll. Sui-g. Mus., 875. (Sir A. P. Cooper.) Fig. 415.t DISLOCATIONS OF THE SHOULDER-JOINT. 925 Fig. 416.* almost directly forwards (Fig. 415) . The subscapularis tendon remains attached to the small tuberosity, the broken surface of vrhich is firmly Tinited to tlie anterior part of the great tuberosity. The fractured end of the shaft of the humerus and of the great tuberosity, has passed into the glenoid cavity of the scapula, and has there become fixed ; and the tendons of the supra-spinatus and infra-spinatus muscles still remain attached to the great tuberosity. The treatment of these complicated injuries of the shoulder is the only peculiarity of practical importance ; as to whether the dislocation or the fi^acture should be reduced first ? The former manipulation can generally be accomplished without much difficulty. Extension will hardly avail much, or indeed be necessary, in effecting reduction of the dislocation. Pressure on the head of the bone, aided by the relaxing influence of chloroform, has proved quite sufiicient. Failing in this way, the fracture may be reduced and put up firmly, thus allowing of extension, or one of the other methods for reduction of the dislocation. Failing still to reduce the dislocation, the fracture must be alone regarded ; and then, at the earliest period after union of the fragments, reduction of the dislocation should again be attempted. This latter was the primary rule of treatment at one time, and it led to many successful results. But it implied that which experience has since disproved, the impossibility of reducing these complicated dislocations until the fracture had united. (3.) Dislocation forAvards and inwards, com- plicated with fracture of the scapula — the tip of t^e coracoid process and end of the acromion, and of the clavicle in its outer curve (Fig. 416). The head of the humerus rests against the anterior margin of the glenoid cavity, and the capsule is laid open behind ; the fragment of the coracoid process is attached to the coraco- brachialis muscle. The biceps tendon is un- injured. Congenital Dislocations of tJie Shoulder- joint. recognized by Guerin : dislocation of the head of the humerus dowm- wards ; dowTiwards and inwards, the head of the bone resting against the ribs ; and subluxation upwards and outwards, the head of the bone sliding in this direction, favoured by a corresponding displace- ment of the coracoid and acromion processes. Dr. Robert Smith has met with only two forms of congenital dislocation of the humerus, subcoracoid and subacromial: of the former he has seen several examples ; of the latter, only one. Either may be symmetrical. There is a variable malformation of the articular surfaces in the shoulder- joint, the capsular ligament is elongated, and the muscles are atrophied — the deltoid and scapular muscles more particularly. Characteristic appearances are presented. The articulation is so loose, that the glenoid cavity can be easily felt, the shoulder is flattened and droops, and the lengthened limb hangs uselessly by the side. "When the humei'us is pushed upwards, the shoulder somewhat recovers its natural roundness and fulness. These appearances are less obvious * St. Thomas's Hosp. Mus., B. 12, -Three varieties are 926 SPECIAL PATHOLOGY AND SURGERY. Fig. 417.* in early life, but as the bones undergo development, tbe original defect becomes more consiiicuous. Congenital dislocations, arising from a paralytic condition of the muscles, or from developmental imperfec- tions of the articulation, or from misplacement of the foetus in utero, are necessarily incurable. Dislocations of the Elbow. — This joint is liable to eight recognized dislocations ; four of which relate to both bones, one to the ulna alone, and three to the radius alone. Thus, (1) dislocation of both bones backwards ; (2) outwards ; (3) inwards ; (4) forAvards ; (5) disloca- tion of the ulna alone, backwards ; (6) dislocation of the radius alone, backwards ; (7) forwards ; (8) outwards. To these recognized dislo- cations may be added another ; dislocation of both bones outwards, and upwards laterally, and to nearly a right angle, on the humerus, con- stituting an " external latero-angular dislocation '* of the elbow-joint, as I so named this form of dislocation, in the only instance I have ever seen or can find recorded. (See Fig. 398.) Structural Conditions. — (1.) Dislocation of the radius and ulna baclcivards is the most frequent form. The head of the radius is lodged behind the external condyle, and the coronoid process of the ulna lies in the olecranon fossa ; the lower end of the humerus resting on the anterior surface of the radius and ulna (Fig. 417). All the four ligaments are ruptured, leaving only some of the fibres of the internal lateral one. The annular ligament remains entire. The brachialis anticus and biceps muscles are sti'etched or torn, the former sometimes carrying- away a portion of the coronoid process ; but the other muscles are relaxed, the triceps postei'iorly, and all the muscles originating' from either condyle of the humerus, excepting the supinator radii brevis. The median nerve is pressed forwards by the humerus ; and the ulnar nerve is, sometimes, painfully stretched over the projecting extremity of the ulna backwards. In the specimen represented there is an old unreduced dislocation of both bones of the forearm backwards. The head of the radius is lodged at the back of the external condyle, where a new articular cavity is formed for it, by the deposit of new bone, thus allowing of some amount of motion. The coronoid process, lodged in the olecranon fossa, was almost immovable. The brachialis anticus muscle is torn away from its insertion to the coronoid process, and was adherent to the lower end of the humerus ; also to the ulna, below the coronoid process. (2.) Dislocation of the radius and ulna outwards, or to the radial side (Fig. 418), is far less fi'equent than the foregoing, and usually incomplete ; com- plete dislocation having been known to occur in only eleven cases (Malgaigne), and all of which were met with in the practice of French Surgeons. Incomjolete dislocation; the ulna still articulates * St. George's Hosp. Mus., 1, 108. t Eoy. Coll. Surg. Mns., 878. (G. LangstafE.) Pig. 418.t DISLOCATIONS OF THE ELBOW. 927 with the huinenis, but the great sigmoid cavity is carried outwards from the trochlea, so that its central crest rests upon the depression which separates the capitellum from the trochlea. If the anniilar ligament remains unbroken, the radius is displaced in the same direc- tion and to the same extent, its head resting against and directly below the outer condyle. More complete dislocation may occur, and complete dislocation, rarely ; the head of the radius being, perhaps, thrown forwards or backwards. The specimen figured exhibits an unreduced dislocation of the radius and ulna outwards, and partially backwards, with osseous union in their displaced position. The ole- cranon and coronoid process, and the greater portion of the sigmoid cavity of the ulna, are thus united to the middle of the posterior surface and margin of the external condyle of the humerus. Fracture of the external condyle seems also to have occurred. The articulation be- tween the radius and ulna is natural ; and the radius, being fixed only by ligament to the humerus, may have had full freedom of motion. In a similar specimen — dislocation of the head of the radius outwards, and of the ulna backwards and outwards — a new joint is formed, in the form of a cup, partly bony, for the head of the radius. The inner condyle appears to have been fractured. (St. Thomas's Hosp. Mus., B. 14. Sir A. Cooper.) A variety of this dislocation is outwards and upwards or backwards ; the olecranon process of the ulna lying above and behind the outer condyle. In outward dislocations, the ligaments are more or less completely torn ; but, in the ordinary forms of such dislocation, the brachialis anticus and anconeus are the only muscles much disturbed, the biceps and triceps traversing the articulation a little more obliquely ; while the principal arteries and nerves do not suffer much, if at all. In the latero-angular variety which I have described, the state of the muscles is also fully noticed with the arteries and nerves ; of which the latter structures had singularly escaped injury.* (3.) Dislocation of the radius and ulna inwards, or to the ulnar side, is much more rare than dislocation outwards, „ . 4^-1 q j. and always incomplete, no example of complete dis- location inwards having been recorded. The ulna is driven over the elevated inner ridge of the trochlea, and falls down on the inner condyle, or epi-trochlea, embracing it instead of the trochlea ; while the head of the radius, passing inwards also, occupies the trochlea (Fig. 419). The head of the radius is generally in the same line with the ulna ; but it may be found a little forwards or backwards. A variety of this dislocation is inwards and up- wards or backwards ; the coronoid process of the ulna being thrust upwards above the inner condyle, and the head of the radius occupying the olecranon fossa. The ligaments and muscles suffer some injury, and the ulnar nerve is peculiarly liable to contusion between the olecranon and inner condyle. (4.) Dislocation of the radius and ulna forwards was considered impossible without a fracture of the olecranon, this opinion havino- * Brit, and For. Med.-CMr. Review, Jan., 1866. f Guy's Hosp. Mus., 1306. 928 SPECIAL PATHOLOGY AND SURGERY. Fig. 420." been taught by Sir A. Cooper and Vidal (De Cassis) ; but Monin, Prioi*, Velpeau, Canton, and Denuce have each reported one example — five in number. The structural condition of this dislocation requires further elucidation. In Velpeau's case, the head of the radius rested in the coronoid fossa, and tbe olecranon was carried upwaixls and a little outwards ; whereas in Mr. Canton's case, as depicted in Hamil- ton's work, the olecranon rested, apparently, on its summit against the forepart of the articular surface of the humerus, and the head of the radius Avas free lower down in the smaller sigmoid caA'ity of the nlna; thus constituting a complete dislocation of both bones forwards. (5.) Dislocation of the ulna alone, hackicards, seldom happens with- out some dislocation of the head of the radius ; yet it is possible that the coronoid process may pass backwards into the olecranon fossa. (A. Cooper.) In one recorded dissection of such dislocation, observes Professor Pirrie, the coronary, oblique, and part of the interosseous ligaments were torn ; the bi^achialis muscle was stretched under the ligaments, and the triceps much relaxed. (6.) Dislocation of the head of the radius alone, hackwards. — This dislocation is of rare occurrence, only twenty-eight supposed ex- amples having been collected. One only had been verified by dissec- tion, and this is reported by Sir A. Cooper. The head of the radius was behind the external condyle of the humerus, and rather to the outer side. The coronary ligament was torn through at its forepart, and the oblique had given way. The capsular liga- ment was partially torn, and the head would have receded much more, but it was supported by the aponeurotic fascia. But I may add the following specimen (Fig. 420). The bicipital tuberosity lies close to the unoccupied lesser sigmoid notch. The orbicular ligament still enclosed the neck of the radius, but its attach- ments to the ulna were ruptured, and it had become firmly united to the humerus on either side of the dislocated bone. Accordingly, the movements of pronation and supination could not be performed. The ulna allowed of flexion and extension through about a fourth of the natural extent of these motions. The Fig. 421.t /^^ outer condyle of the humerus is altered in shape, from the deposit of new bone. This dislocation had existed for about two years, and was caused by direct violence, the elbow having been struck by a stone. Incomplete dislocation, as occasionally happens in children, may not be attended with rupture of the annular ligament. (7.) Dislocation of the head of the radius alone, forwards,is relatively more common than backward dislocation ; although Boyer, Yelpeau, Chelius, Gibson (of Richmond, Va.), B. Cooper, and other Surgeons of large experience maintain the contrary. The head of the radius lies in front of the humerus, and generally somewhat outwards (Fig. * St. George's Hosp. Mas., 1, 109. t Ibid., 1, 110. DISLOCATIONS OF THE ELBOW. 929 Fig. 422.* 421). The anterior and external lateral ligaments, with, the annular, are nsnally more or less torn. Sometimes, the two former are alone broken, the annular ligament also being sufficiently stretched to allow of complete dislocation; or, the anterior and annular having given way, the external lateral remains intact. In the specimen I have figured, dislocation of the head of the radius forwards was complicated by fracture of the epiphysis of the olecranon, and fracture also of the ulna below its middle. The dislocation was compotmd, a large lace- rated wound having been caused by the passage of a carriage- wheel over the arm, in the person of a child two years old. Death occurred from pyaemia. (8.) Dislocation of the head of the radius alone, outwards, is a modification of, if not consequent on, forward dislocation, or, perhaps, backward dislocation. The head rests on the outer side of the external condyle. It is a very rare dis- placement, Denuce having collected only four ex- amples, unaccompanied with fracture. In the annexed illustration, the radial dislocation outwards is asso- ciated with displacement of the ulna backwards and outwards, and fracture apparently of the inner condyle (Fig. 422). Signs. — Certain characters are common to all dis- locations of the elbow, a resemblance which renders it convenient to take these injuries consecutively, in regard to their signs, as showing more clearly their diagnosis. Dislocation of the radius and ulna hacTiwards pre- sents a projection of the elbow .posteriorly — corre- sponding to the extremities of both bones, and of the olecranon in particular ; with another projection, the end of the humerus in front of the elbow (Fig. 423). There is also some shortening of the forearm, with semi-flexion at an obtuse angle, or approach- ing to aright angle Fig. 423.t .' occasionally, and / « semi - pronation ; with loss of the motions of flexion and extension, pro- nation and supina- tion, but an un- natural lateral mo- tion can generally be produced. Dislocation of the radius and u Ina ouftvards is characterized by an unnatural projection externally — the head of the radius, with a prominent projection internally, — the inner condyle ; while dislocation of the radius and ulna inwards is distin- guished by the opposite characters — a projection internally of the olecranon, and prominence externally of the outer condyle. The forearm is shortened laterally — on its inner aspect, by inclina- * St. Thomas's Hosp. Mas., B. 41. t Royal Free Hospital. (Author.) VOL. I. 3 930 SPECIAL PATHOLOGY AND SURGERY. Fig. 424.* tion to that side, in outward dislocation ; and on its outer aspect, by inclination to that side, in inward dislocation — or the whole forearm is shortened longitudinally, in either of these dislocations upwards. In both, there is also semi-flexion, and semi-pronation. The speedy supervention of swelling, in these and other dislocations of the elbow- joint, will often render the nature of the injury more or less obscure. Dislocation of the radius and ulna foricards would seem to be characterized by disappearance of the olecranon posteriorly, and the detection of this process and the head of the radius in front of the elbow ; with shortening of the foi'earm upon the arm, semi-flexion to a right angle, and marked supination. If accompanied with fracture of the olecranon, there will be some mobility and crepitus. Dislocation of the ulna alone, bachivards, would probably be i-ecog- nized by projection of the olecranon, the head of the radius being felt to rotate in its place ; by the inclination of the forearm to the ulnar side, with partial flexion, and complete pronation. If accom- panied with fracture of the coronoid process, there will be consider- able mobility, the dislocation readily disappearing and recurring, Avith crepitus. Dislocation of the radius alone, hackicards, is characterized by a projection of the head of the bone behind the outer condyle, where it can be felt to rotate ; while dislocation forivards is distinguished by a projection of the head of the bone in front of the humerus. In hoth dislocations, the forearm is shortened slightly on its outer side, and inclines to that side, with slight flexion, and pronation (Fig. 424). But the latter form of dislocation is distinguished by the position of the head of the radius, and the impossibility of flexing the forearm beyond a right angle, where the head of the bone im- pinging on the front of the humerus brings this motion suddenly to a dead lock. This peculiai'ity was first shown me, when a student, by ]SIr. Morton, in a case many years since at the University College Hospital ; and it was a well-marked sign in another case under my own observation and treatment at the Royal Free Hospital. Dislocation of the head of the radius, out- wards, may be recognized chiefly by the position of the head on the outer side 'of the external condyle, immediately under the skin, where it can be felt to rotate. Causes. — Indirect Ywlence is, probably, more commonly the cause of all these dislocations. Thus, a fall on the hand may drive both bones backwards ; possibly, outwards or inwards ; the ulna alone backwards ; or the radius alone backwards or forwards. But the position of the forearm, vrith regard to pronation or supination, will also affect the direction of the dislocation. The former position facilitates dislocation of the radius forwards ; and a violent effort to supinate the forearm, while it is grasped and held firmly in a state of pronation, will occasion dislocation of the radius backwards. Twisting or wrenching of the * After Liston. DISLOCATIONS OF THE ELBOW. 931 forearm, as by macliinerj, may also occasion dislocation of both bones outwards or inwards ; and less probably of either bone — the radius, in particular — backwards or forwards. The latter dislocation of this bone has been produced in children, by lifting the child suddenly from the floor by the hand, or an attempt to sustain the child when about to fall. Direct violence may also be the cause of most forms of elbow-joint dislocation. Thus, both bones may be thrown backwards, by a blow upon the back and lower part of the humerus ; or on the front and upper part of the forearm ; or the bones are usually thrown outwards or inwards, by a blow on the side of the arm or forearm opposite to the direction of dislocation ; and, in like manner, the radius alone has been started backwards, by a blow upon the front and upper part of that bone ; or forwards, by a blow upon the back of the head of the radius. Two dislocations of the elbow I have omitted to notice, in de- scribing the etiology of these injuries. Dislocation of the radius and ulna forwards is, however, too rare an accident to be included in any general statement. In Yelpeau's case, the man was knocked down by a carriage, the wheel passing over his right arm. Dislocation of the head of the radius, outwards — the other exceptional form of injury — is a modification of, or consecutive to, dislocation of that bone, forwards or backwards. Age would certainly seem to have some predisposing influence relative, at least, to dislocation of the radius and ulna backwards. In fifty-six cases under Hamilton's observation, the average age was about twenty years, and twenty-two of the whole number occun'ed in children under the age of fourteen. Unreduced elbow-joint dislocations are probably no exception to the pathological law of Dislocations in general : that the bones gradually adapt themselves to the particular displacement, forming a new articulation ; with more or less recovery of the use of the limb. An unreduced dislocation of both bones backwards, and of seven years' duration, is depicted in Liston's " Surgery." The movements of the hand were considerably regained. The structural conditions acquired in such cases, as shown by dissection, have been noticed in some of the cases I have figured from original specimens. Reduced dislocations of the elbow generally result in a complete recovery of the use of the joint, within a few weeks. But in one of several exceptional cases under Hamilton's observation, a dislocation of both bones backwards was easily and promptly reduced in a lad eight years old ; yet, six months afterwards, the arm had become bent to a right angle, and quite stiff at the joint. Four years later, the stiffness still continued, with only slight improvement. Treatment. — Reduction of all the dislocations to which the elbow- joint is liable, can be effected by the same method — bending the elbow over the knee — but those of the radius are, perhaps, better accomplished in another way. (1.) Bending the elbow over the Tcnee was the method recommended by Sir A. Cooper (Fig. 425). The patient being seated on a low chair or stool, the Surgeon, resting one foot on the seat, places his knee in the bend of the dislocated joint ; grasping the forearm, he presses the knee against the inner side of the forearm to unlock the ulna from behind the humerus, and drawing or bending the forearm round the 932 SPECIAL PATHOLOGY AND SURGERY. Fig. 425. knee, the bones readily come forward over tlie articular end of the humerus, into position. The action of the muscles will, in fact, effect reduction when the bones are dislodged. This result is announced by a sudden jerk of the bones slipping into place, with a restoration of the natural confirmation of the joint, Avhich may, however, be less perceptible owing to the suri'oiinding swelling ; but the immediate mobility of the joint, so that the forearm can be bent upon the arm, even to a right angle, without pain, will be a further guarantee of reduction. Another method, which, seems to be a modification of the preceding, was that recommended by Boyer. Extension is made from the wrist by one assistant, the forearm remaining at a right angle with, the arm, while counter-extension is made by another assistant holding the arm ; the Surgeon, grasping the elbow with both hands, presses the olecranon process downwards and forwards. This method does not so readily unlock the bones, and extension from the wrist tells more upon the radius than the ulna, II r X 1 1 which chiefly opposes reduction. It is, _ I , Ij^ 1 L therefore, preferable to grasp the middle — =4 la^MS.^ 1_^ of the foreai^m with both hands, and draw it forioards ; no assistant being required except, perhaps, to steady the arm. In either of these methods, it may be advisable to direct the arm backwards, so as to relax the triceps muscle. Listen, who recom- mended this position, at the same time made extension backwards, counter- extension being made fi'om the shoulder. (2.) Dislocations of the radius alone may be reduced by straight extension gradually from the wrist, the arra being fixed; aided by pressure on the head of the bone forwards or backwaixls, according to the dislocation. In backward dislocation also, forcible supination will aid in just throwing the head of the bone forwards over the articular surface of the humerus ; while, in forward dislocation, forcible prona- tion will similarly jerk the head into place. But these movements are useless until the head lies on the brink of reduction, and unless while extension is still being continued. Skey applied this method of straight extension in dislocation of both bones backwards ; but, according to my own experience, the ulna is thus less readily unlocked from behind the humerus. After reduction has been effected, it should be maintained by the application of a right-angled splint upon the back of the arm and fore- arm, with a compress over the head of the bone — in the case of radial dislocations ; and the forearm supported in a sling. The period for removal of this retentive apparatus should be regulated by the liability to redislocation, and to stiffness of the joint, which is, of course, a question of judgment. Dislocation with fracture, as of the coronoid or olecranon process DISLOCATIONS OF THE EADIO-ULNAE, AETICULATIONS. 933 of the ulna, maybe treated in tlie same way ; but retention of the bone in position must be continued for some weeks. Unreduced Dislocations of tlie Elhoiv are curable or incurable; partly according to their duration, principally however with reference to the form of dislocation. Recent dislocation of the ulna, or involving the ulna, is much more dijB&cult of reduction than that of the radius after a long period ; the difference being due to the irregular form of the head of the ulna, which opposes reduction. Dislocation of the radius alone has been reduced at periods varying from a few days to weeks or months. In one instance I reduced a dislocation backwards, of ten weeks' duration, and the patient, a laundress, recovered good use of her forearm. Dislocation of the radius forwards has remained unreduced in the hands of skilful Surgeons. Sir A. Cooper failed in two recent cases ; and of the six which came under his immediate observation, only two were ever reduced. Malgaigne states that in a collection of 25 cases, efforts at reduction were ineffectual in 11, and the accident was unrecognized or neglected in 6 ; leaving only 8, of the whole number, reduced. The golden rule should be observed in elbow-joint dislocations, as in all other such injuries, not to interfere when the motions of the joint are tolerably efficient. Compound Dislocations of the Elbow. — These injuries are always perilous ; both on account of their nature, the size of the joint, and as being caused by considerable violence. The " external latero-angular " dislocation, which I have described, was compound, and produced by a wrench of the forearm between the buffers of two railway carriages. Treatment. — These compound injuries present nothing peculiar in relation to their treatment. The pi'eservation of the limb, or operative interfei'ence, by excision or amputation, must be guided by similar considerations to those which relate to shoulder-joint dislocations, or to such injuries in general. Congenital dislocations of the elbow have been met with, in the form of both bones backwards, or as pertaining to the head of the radius. These imperfections are more curious pathologically, than interesting surgically. Dislocations of the Radio-ulnar Articula- tions. — The head of the' radius in its relation to the smaller sigmoid cavity of the ulna, consti- tuting the superior radio-ulnar articulation, may undergo dislocation in the direction already de- scribed, as dislocations of the head of the radius, — backwards, forwards (Fig. 426), or outwards. The loiuer end or liead of the ulna in its articu- lation with the lower end of the radius, is liable to dislocation, backwards or forwards. (1.) Dislocation backwards is characterized by an unnatural promi- nence of bone — the head of the ulna — at the posterior and inner part of the wrist, with loss of the motions of pronation and supination. In connection with fractiire of the lower end of the radius, this dislocation is not very uncommon ; alone, it seldom occurs, eleven or twelve cases only having been collected by Malgaigne ; to which 1 may add one * St. Bartholomew's Hosp. Mus., C. 37. 934 SPECIAL PATHOLOGY AND SURGERY. Fig. 427 * case from my o^vn experience, the dislocation backwards being of four years' duration, and irreducible (Fig. 427). The caMsewould seem to be, usually, violent pronation. Thus,Desault records the case of a laundress Avho, in wringing a wet sheet, produced dislocation of the head of the ulna backwards. But a fall on the hand, doubling the wrist forwards, was the occasion of this dis- placement in the case which came under my obser- vation. The act of lifting a child by the hand gave rise to it, in a case which Duges mentions, and the accident happened in both wrists, at different times. Treatment. — Reduction can be readily effected by forcible supination of the forearm, with pressure on the head of the ulna forwards. Generally the bone remains in place without fui-ther assistance ; or it may be necessary to apply a compress and splint. (2.) Dislocation foricards is denoted by a projec- tion of the head of the ulna at the anterior and inner part of the wrist ; the natural prominence of this portion of the bone at the back of the wrist having disappeared. The motions of pronation and supination are lost. This dislocation is even more rare than the former ; nine cases only having been collected by Malgaigne, to which Hamilton adds one more, as reported by Parker, of Liverpool. The cause is apparently, with hardly any exception, ^aolent supina- tion of the forearm. And this mode of production throws light on the comjDaratively less frequent occurrence of this dislocation; the motion of supination being less extensive than that of pronation, and less likely to be excessive in any of the offices which the hand has to perform. Treatment. — Rediiction is easily effected by forcible pronation of the forearm, with pressure on the head of the ulna backwards. Redislocation need not be apprehended. There was no such tendency in Mr. Parker's case. Dislocation of the Radio-carpal Articulation, or Wrist- joint. — This articulation may undergo dislocation backwards, or forwards. Believed by Boyer, Petit-, and the older Surgeons, to be a not un- common form of injury, it is probable that most of the apjDarent cases of wrist-joint dislocation Fig. 428.t were fractures of the carpal end of the radius, and that Dupuytren's final experi- ence is correct — this acci- dent is extremely rare. In my own practice I have never met with it, nor have I ever yet seen any such dislocation ; but instances have been re- corded by Malgaigne, Cruveilhier, Yoillemier, B. Cooper, Fergusson, and other Surgeons. It is probable, however — as R. W. Smith has shown — that, in some such cases, the dislocation was the result of cong'enital malformation of the wrist-joint. (1.) Dislocation of the hand and carpus, hackwards, presents a large projection — the carpus — at the back of the wrist (Fig. 428), and another * Koyal Free Hospital. f After Sir A. Cooper. INJURIES OF THE WRIST ALLIED TO DISLOCATION. 935 Fig. 429.* — the lower end of the radius and ulna — on the palmar aspect ; with flexure and immobilitj of the hand. (2.) Dislocation of the hand and carpus, forwards, presents just the opposite appearances : a projection of the carpus in front of the wrist (Fig. 429), and of the radiiis and ulna on the dorsal aspect, with extension and immobility of the hand. Causes. — A fall on the hand is the usual occasion of disloca- tion ; the back of the hand, pro- bably, receiving' the force of the shock in backward dislocation of the carpus, and the palm of the hand receiving' the force in forward dislocation. These dislocations are usually said to arise conversely ; but the cases described in Hamilton's work appear to clearly disprove the accepted representations in most surgical works. Treatment. — Reduction can generally be effected, in either form of dislocation, by extension and counter-extension ; at the same time drawing the hand in the contrary direction to which it is inclined, namely, backwards in the flexed position of backward dislocation, forwards in the more extended position of forward dislocation, and in either case aiding this leverage by pressing the carpus from behind, so as to bring it into place. Position should then be maintained by antero- posterior splints securing the hand, but allowing for the supervention of swelling. Injuries oi' the "Wkist allied to Dislocation. — (1.) Dislocation with fracture of the lower end of the radius, happens far more com- monly than dislocation alone. The diagnosis will turn on the presence of crepitus and mobility of the lower fragment, as determined by moving the hand, at the same time feeling whether the styloid pro- cesses of the radius and ulna move with it. Dislocation with fracture of the posterior margin of the articulating surface of the radius, is known as " Barton's fracture." Some difliculty may be experienced in keeping the bones in place. (2.) Fracture of the lower end of the radius may be mistaken for dislocation of the wrist ; but it can be distinguished in like manner. The comparative fre- quency of the former injury and rarity of the latter led Dupuytren to almost deny the possibility of radio-carpal dislocation ; though the occurrence of this dislocation is now established beyond a doubt. (3.) Fracture with impaction of the fragments (Fig. 430) is unattended with the usual fracture signs, mobility and crepitus ; but it may be distinguished from dislocation, chiefly, by the resistance offered to reduction. (4.) Sprain, also, simulates dislocation: here, however, the swelling is single, and not well defined, like the bony projections of dislocation ; it does not appear immediately, and gradually increases. * St. Thomas's Hosp. Mus., B. 18. Dislocation of the hand and carpus forwards, i.e. of the radius and ulna backwards. From a woman, aged thirty-three. No history. t St, Bartholomew's Hospital Mus., 3, 94. Fig. 430.t 936 SPECIAL PATHOLOGY AND SUEGERY. Compound Dislocation of the Wrist. — This accident is of rai'e occtir- rence. One case only has been seen by Hamilton, and one recorded by Sir A. Cooper. As associated with fracture, the injury may happen more frequently-. Always a serious injury, compound dislocation is even more so in consideration of the violence which causes it. Treatment. — The amount of damage done to the soft textures and to the bones will guide the Surgeon respecting the probability of preserving the hand, or the necessity for excision or amputation. Congenital dislocations of the wrist are described by Guerin as possibly occurring in three forms : forwards, backwards and upwards, backwards and outwards. These dislocations are connected with, and dependent on, imperfect conditions of the radio-carpal articulation, or incomplete paralysis of the muscles of the forearm and hand. As verified by dissection, Dr. R. Smith records a case in which hoth wrists were dislocated from congenital malformation ; on the right side the carpus being luxated forwards, and on the left, backwards. The patient — a female lunatic, aged thirty-six— had been able to use her wrists and hands freely. Dislocations of the Carpal Bones, among themselves. — Simple dislocations, or. rather subluxations, of the carpal bones take place occasionally ; but, perhaps, only in one direction — backwards. The bones thus liable to dislocation are the semilunar, cuneiform, and pisiform bones of the first row, and the os magnum of the second row, which is most fi'equently displaced, while, according to South, the unciform bone is also liable to displacement. All the bones of one row may be dislocated, the second row overlapping the first row, backwards; as in a case which jNFaisonneuve verified by dissection. Dislocation of any of the carpal bones may occur, in connection with gunshot injury, or other occasions of extensive fracture of the neighbouring bones. The Signs will be — a bony projection at the back of the wrist, with some loss of power. The Cause is usually a fall on the back of the hand, which being thus forcibly doubled under itself, occasions one of the carpal bones to start backwards ; the os magnunj, for example. The pisiform bone is said to have been detached by the action of the flexor carpi- ulnaris muscle, in cases seen by Fergusson and Erichsen. Treatment. — Pressure may easily replace the bone, but the applica- tion of a compress, and for some time, will be necessary, to guard against redislocation ; the os magnum, in particular, having a great tendency to slip out again. Dislocations of the Metacarpal Bones — at their Carpal Articulations. — Any such dislocation is rare, and usually limited to a single meta- carpal bone, haclcicards. The thumb is most commonly dislocated, and either hackiuards or forwards on the trapezium ; the former displace- ment occurring more frequently. Either may be partial or complete. The other metacarpal bones are very seldom dislocated, Malgaigne having collected only three instances, to which a few others have been added. All the metacarpal bones, except that of the thumb, had under- gone dislocation, in a probably unique case which Hamilton examined five years after the accident, by gunshot injury. The displacement backwards remained, but the motions of the fingers, except the fore and little fingers, were perfect. DISLOCATIONS OF THE FIKST PHALANGEAL BONES. 937 Fig. 431.* The Signs, in any case, are sufficiently obvious : projection of the end, or base, of the metacarpal bone, in the direction of displacement, and immobility. The direction of the thumb may be quite straight, or with flexion there is also some inclination of the metacarpal bone inwards towards the palm. Causes. — A fall on the thumb, bending it on itself, represents the ordinary mode of its dislocation. A blow upon the extremity and palmar aspect of the last phalanx may, however, cause dislocation ; the force then acting in the opposite direction, or from within outwards. Treatment. — Extension, with pressure on the end of the bone, will generally succeed in effecting reduction. A splint should then be applied, and perhaps a compress to prevent any risk of redislocation. The bulky base of the metacarpal bone of the tlmmh sometimes obsti- nately resists reduction; in which case. Sir A. Cooper recommends that the dislocation should be left to acquire the compensatory motion of a new joint, rather than the Surgeon run any risk of injuring the nerves and ialood-vessels, by dividing the muscles or ligaments. DisLOCATiOJsTS OF THE FiEST Phalaxgeal Bones — at tJwir Metacarjoo- Phalangeal Articulatio7is. — These dislocations, also, seldom happen; and usually the bone is driven 6acZ;if;a?-fZs, „ 4,s? + though sometimes forivarcls (Fig. 431). I have seen the phalangeal bones of the index and middle fin- gers partly driven back, in the left hand of a prize-fighter. The first phalangeal bone of the thumb is most frequently dislocated, and either hacJiivards or forivards (Fig- 432) ; the former displacement occurring more commonly. Hamilton has met with the backward dislocation nine times, the forward only twice. The Signs are characteristic : a projection of the posterior ex- tremity of the phalangeal bone, in the direction of displacement, and immobility. The thumb presents somewhat peculiar appearances. Its first phalangeal bone, having slid backwards upon the metacarpal bone, stands off from this bone at an angle ; thus allowing the head of the metacarpal bone to project prominently towards the palm of the hand ; while the second or ungiial phalangeal bone is flexed upon the first, and forms another angle in the thumb. The phalangeal bone is locked in its new position, and reduction may be proportionately difficult. This immediately arises either from the constriction of the neck of the bone between the lateral ligaments, as Hey believed ; or between the two heads of the short flexor muscles, as affirmed by Mal- gaigne, Vidal (De Cassis), and others. Sir A. Cooper attributed the difficulty of reduction to the resistance offered by all the six muscles which are inserted into the two phalangeal bones of the thumb, the flexors more especially maintaining- the displacement; or that the sesamoid bones oppose reduction : lastly, the difficulty may be due to * Gay's Hospital Mns., 1313. t King's College Mus., 1344-. In this case, witli dislocation of the first phalanx of the thumb forwards, there was also oblique fracture of the metacarpal bone. (John Wood.) 938 SPECIAL PATHOLOGY AND SURGERY. the interposition of the anterior ligament, toi'n from its attachmeuta and folded in between the joint, as alleged by Pailloux, Lawrie, and many others. Displacement of the long flexor tendon inwards or out- wards, so as to impede reduction, has been found by Lisfranc, Deville, and Wadsworth. Treatment. — Reduction can sometimes be accomplished easily ; by extension, inclining the finger towards the palm, with pressure on the displaced end of bone. Or, the thumb may require more powerful traction ; and by first bending the dislocated phalanx backwards, so as to increase the displacement, the articular end of the phalanx will be directed forwards towards the articular surface of the metacarpal bone, thus aiding the reduction. This Fig. 433.* preparatory movement was sug- gested by Roser, and it has since been generally adopted with advan- I ~^i_^^ — ^-j tage. Extension may then be ac- 'll/ ^J ^ complished by means of a strong Fig. 434. tape fastened on the phalanx with a clove-hitch knot (Fig. 433), care being taken to protect the skin by a piece of moist wash-leather wrapped round the part. Or pul- leys may be had recourse to, applied in like manner. A more effectual mode of extension, occasionally, is by means of a large door-key ; which, I believe, Mr. Listen originally suggested. Passing the ring of the key over the thumb, and hitching it against the projecting end of bone, extension and pressure can thus be brought to bear with advan- tage and taneously. extension - simul- Levis's instru- ment (Fig. 434) enables the Surgeon to apply flexion or leverage also, in any dii-ection. The Indian "puzzle," a cone formed of plaited ash-splittings, had long been used as an instrument of tortxire for the tx^action of a thumb or finger, but it was first employed by Hamilton to make extension in the reduction of dislocation. The thumb, for example, being intro- duced into the open end of this cone, on drawing the opposite end, the greater the traction the tighter the hold becomes ; yet the pressure is so equable and diffused over the whole surface, as to occasion little pain and no strangulation. When the traction is discontinued, the cone immediately loosens and relaxes its grasp. Before applying any extending force, reduction may be facilitated by soaking the thumb for some time in warm water, in order to relax the parts as much as possible ; a very useful recommendation given by Sir A. Cooper. SuhrAitaneous section of the opposing ligaments or tendons should be resorted to as the last resource. Originally proposed by Sir Charles Bell, it was employed successfully by Mr. Listen in a case of recent dislocation, — not an hour having elapsed, the patient an old man and very drunk ; no resistance, apparently, to reduction existed, and very * After Liston. DISLOCATIONS OF THE MIDDLE AND UNGUAL PHALANGEAL BONES. 939 Pig. 435.* powerful force had been applied and persevered in without avail. At last, the external lateral ligament was divided by the point of a very narrow and fine bistoury ; and then replacement became immediate and easy. Some inflammation followed, but was kept within bounds, and the man regained the use of the articulation. This method has since been practised successfully by Syme and Lizars, and by Reinhardt, also by Gribson, Parker, and other American Surgeons. Dislocations of the Middle and Ungual Phalangeal Bones occur even less frequently than dislocations of the first row. Their pathology, signs (Fig. 435), and treatment are similar. Compound Dislocations of the Bones of the Hand. — Those of the thumb are most common, as they are also the most serious and impor- tant with regard to the future use of the hand. But any such dislocation is usually connected with fracture, and extensive laceration of the palm. The causes of these injuries are always some occasion of extreme violence. The explosion of a flask of powder in the hand happens now and then, driving one or more of the bones backward, and otherwise shattering the hand. I have had to deal with two such accidents. Treatment. — Reduction can usually be effected without difficulty ; the obstacles of ligaments or tendons having already given way as part of the injury. The wound should then be closed, and the joint fixed, as in ordinary compound dislocations. Generally, however, the extent of injury requires some operative interference. JExcision of splintered portions of bone, or amputation of one or more fing'ers, may therefore become unavoidable alternatives. The preservation of the thumb, and perhaps of the little finger with it, is always a consideration of para- mount importance. This remnant hand will serve the useful purpose of a hook, or of prehension by the conjunction of the thumb and finger. Congenital Dislocations of the Fingers. — The last three fingers of the left hand in a foetus examined by Chaussier, were found to be dis- located at the metacarpo-phalangeal articulation. The thighs, knees, and feet were also dislocated. The last two phalanges of the fingers are, M. Berard states, incurved back- wards, occasionally, in newly boi'n children of the female sex ; and Malgaigne has himself seen a woman in whom, from birth, all the phalan- gettes were carried backwards to an angle of 135°, leaving the heads of the phalanges projecting forward under the skin. Dislocations op the Pelvis. — (1.) The Symphysis-pubis and the * St. Thomas's Hosp. Mus., B. 20. Dislocation forwards of the second phalanx of finger, consequent on disease of the joint. t St. Bartholomew's Hosp. Mus., C. 42. Pelvis, showing separation of sym- physis-pubis and sacro-iliac articulations, from violence, in a boy aged fourteen. The condyles of the femur were also detached at the line of epiphytic union. Pig. 436.t 9-iO SPECIAL PATHOLOGY AND SUKGERY. Sacro-iliac Articulations may, severally, undergo separation and dis- placement. In one case, I found all three articulations completely separated, in a young man whose pelvis had been subjected to severe compression. The same triple injury had occurred in the specimen here represented (Fig. 436). The Signs of any pelvic disarticulation are sufl&ciently obvious : some deformity and mobility at the seat of injury. The cause of disarticulation is always some extreme violence, and generally a compressing force. Treatment. — The same as in fracture of the pelvis. (2.) The Coccyx is more frequently bent or displaced than fractured. Such dislocation may be forwards, as the result of a fall ; or haclcwards, in consequence of pressure by the head of the child during parturition. Treatment. — The same as for fracture of the coccyx, or the coccygeal portion of the sacrum. Dislocations of the Hip-joint. — This joint is subject to four prin- cipal dislocations, and to five anomalous dislocations ; resulting from the freedom of the motion of the hip — as a ball-and-socket joint — in all dii'ections. The number of possible dislocations may therefore be added to by increasing experience ; any point in the circumference of a circle representing a direction in vphich dislocation of the hip might possibly occur, from the joint as a centre. Taking the four principal dislocations of the hip in their order of liability, they are as follow : — • (1) Dislocation upwards and backwards on the dorsum ilii ; (2) upwards and backwards on the great iscMatic notch ; (3) downwards and forwards into the obturator foramen ; and (4) upwards and for- wards upon the pubes. To these may be added, as anomalous and occasional dislocations — (5) Dislocation directly upicards, between the anterior superior and inferior spinous pi'ocesses of the ilium, or there- abouts ; dowmuards and bachivards, upon the posterior part of the body of the ischium, between its tuberosity and its spine; (7) downwards and backwards, into the lesser or loiver ischiatic notch ; (8) directly or vertically downwards, beneath the lower border of the acetabulum, between it and the tuberosity — subcotyloid; (9) and forwards, into the perineum, upon the ramus of the ischium and pubis, or upon the body of the pubes. The four first-named dislocations severally require special consideration; but even their relative frequency is very different. Sir A. Cooper states that in 20 cases of hip- joint dislocation, 12 will be on the dorsum ilii, 5 into the ischiatic notch, 2 into the tbyroid foramen, and 1 u]3on the ]Dubic bone. This was about the proportion in Hamilton's larger collection of the same dislocations; of the whole number, 104, the relative numbers were 55, 28, 13, 8. Chelius and Samuel Cooper reverse the order of liability in regard to thyroid and pubic dislocations, placing the latter before the former in frequency. Dislocations upwards and backwards (1) on the Dorsum Ilii, and (2) INTO THE GREAT Ischiatic K"OTCH. — Structural Conditions. — (1.) The head of the femur rests on the Dorsum Ilii, or within the fibres of the deeper gluteal muscles ; and it is directed backwards, the great tro- chanter forwards (Fig. 437). The capsular ligament, and especially its postei-ior half, is lacerated, and the round ligament ruptured; the small external rotator muscles are stretched or rent completely asunder, and the glut^eus maximus, medius, and minimus torn up more or less DISLOCATIONS OF THE HIP-JOIKT. 941 Fig. 437.* in extent from the dorsum ilii ; thus allowing the head of the femur to occupy its unnatural situation. The triceps adductor is put upon the stretch. The particular direction of the head backwards and trochanter forwards, has been attributed to the strong anterior portion of the cap- sule which proceeds to the anterior iuter-trochanteric line still remaining entire, and thus resisting the action of the rotator muscles. Resistance to reduction in this, and other dis- locations of the hip, has been ascribed either to the rent capsular ligament entangling the head and neck of the bone ; or to opposing muscles ; or to both this ligament and the muscles. (2.) Dislocation into the great Isdiiatic Notch corresponds so nearlj in its pathology with that on the dorsum ilii, as to require only a differential desci'iption. The head of the femur lies in the great sciatic notch, behind and a little above the acetabulum; being situated between the upper margin of the notch above, and the sacro-sciatic ligaments below (Fig. 438). It rests upon the pyri- formis inuscle ; or upon the gemelli and sacro-sciatic nerve, as in a case dissected by Mr. Syme. The attitude of the bone, and rupture of the liga- ments and muscles, are very similar to the condition of dorsal dislocation. With reference to the tendon of the obturator internus, the head of the femur passes downwards and back- wards, and then being carried up- wards, it is arrested by the tendon, or passes behind it. Hence Bigelow names this dislocation " dorsal below the tendon." Ischiatic dislocation is Fig. 438.t * St. George's Hospital Museum, 1, 209. Dislocation of the femur on tlie dor- sum ilii, with the remnant of the ilio-femoral ligament (inverted Y-shaped lio-ament Bigelow), the shaft of the femur being placed vertically to bring the ligament fully into view. The dissection showed that the head of the bone was lodged just above the great sacro-sciatic foramen, the capsule having been ruptured so as to form a hole of sufi&cient size to transmit the head of the bone. The pyriformis muscle was partially lacerated ; the other muscles were uninjured. This dislocation was caused by a fall from a height of fifty feet. t St. Thomas's Hosp. Mus., B. 23'. Dislocationof the femur on the sacro-sciatic notch, or, rather, just behind the acetabulum. The pyriformis and glutseus minimus muscles are stretched over the head of the bone ; the obturator internus, with the torn gemelli muscles (not seen), lie immediately below. (Presented by Mr. MacCormac. See also "Reports of the Hospital," vol. ii. p. 1.) 942 SPECIAL PATHOLOGY AND SURGERY. Fig. 439. sometimes secondary to tliat on tlie dorsum ; but more frequently the former, by secondary displacement, is converted into the latter. Mechanism of Hip-joint Bislocation. — The production of the different forms of Hip-joint dislocation seems to depend, essentially, upon the integrity or the disruption of the ilio-femoral ligament, in the act of dislocation. It should be remembered that this ligament is that strong band which extends over the front of the capsule of the hip-joint, passing obliquely downwards between the anterior inferior spinous pro- cess of the ilium, and the anterior inter-trochantericliue bounding the neck of the femur. (See Fig. 437.) Tbus attached at its extremities, the band is closely connected also to the forepart of the capsule, which it materially strengthens as an accessory ligament in front of the joint.' When not ruptured, the resistance of this ligamentous band allows of displacement of the femoral head only in four directions, thus produc- ing one or other of the four regr^tZar dislocations of the hip-joint; when ruptured, one or other of the irregular dislocations of this joint may be produced. With regard to the regular displacements ; dorsal dislocation owes its inversion to the external fasciculus of the ilio-femoral ligament ; in the ischiatic dis- location, the head of the femur is arrested in extension by the tendon of the obdurator internus muscle; in thyroid dislocation, the flexion and eversion of the limb are due to the ilio-femoral ligament ; and in pubic dislocation, the ascent of the femoral head is arrested by this ligament. Dissections instituted by Dr. Fenner of New Orleans, Gunn of Michigan, Moore of Rochester, Busch. of Bonn, and by Roser, Weber, Gelle, and Von Pitha, led the way to the more complete investigations by Dr. H. J. Bigelow^ of Harvard University. Signs. — H-) Dislocation on. the dorsum ilii presents very characteristic appearances. The limb is shortened to an extent varying from one inch and a half as the average, to three inches occasionally ; the knee is semi-flexed, and the thigh upon the abdomen, thus projecting the knee forwards ; there is marked inversion of the limb, the knee being directed inwards, as well as forwards, towards the other, and just above it ; thie foot also is inverted, so that the great toe rests on the opposite ankle (Fig. 439). The head of the femur in its new situation, Avith tbe gluteal muscles, give an unnatural prominence to the posterior aspect of the buttock, and the bone can be felt, especially on rotat- ing the limb ; the prominence of the great trochanter is diminished and drawn upwards and turned forwards near the anterior superior spinous process of the ilium. Immobility of the limb, at least in the direction of eversion, abdaction, and extension, will be more or less complete, and the patient has lost the power of such voluntary motion ; great pain also attends almost any movement of the limb. (2.) Dislo- cation into the great sciatic notch presents similar signs, but in a lesser degree ; thus rendering the characteristic appearances less marked. DISLOCATIONS OF THE HIP-JOINT. 943 Fig. 440. Shortening has taken place to an extent usually of half an inch, and not exceeding an inch. Flexion and inversion are such, that the axis of the dislocated thigh points the knee less across the opposite thigh, and the end of the great toe rests on the ball of the great toe opposite (Fig. 440) . The hip appearances are less conspicuous ; the head of the femur sinking into the hollow of the notch, where, howevei", it can be felt in a thin subject, or by introducing the finger into the rectum or vagina, and the great ti'ochanter approaches less nearly to the anterior superior spinous process of the ilium than in dislocation upon the dorsum ilii. The lumbar spine is arched, when the limb lies in a line with the trunk, but When flexed upon the pelvis, the back rests flat upon the bed. This arched appearance, and its subsidence, is due to the tension or relaxation of the psoas and iliacus muscles. It is a most valuable sign, ob- serves Mr. Syme, never being absent, nor is it ever met with in any other in- jury of the hip- joint, whether dislocation, fracture, or bruise. The diagnosis of these dislocations from other injuries is, generally, clear. Fracture of the neck of the femur, ac- companied with inversion of the limb, is comparatively rare ; and when it oc- curs, the absence of the head of the bone from the dorsum ilii, with mobility and crepitus of the fragments, will, usually, determine the diagnosis. Im- pacted fracture, however, with conse- quently an absence of these signs, is always an equivocal condition. In such a case, the limb cannot be brought down to its proper length, by any moderate and justifiable extension, to Fig. 441. unlock the impacted ends of bone ; and the diagnosis must turn upon the situation of the head of the femur in relation to the acetabulum. Two points of distinction be- tween dislocation of the hip upwards and back- wards, and impacted fractui'e, are laid down by Erichsen : that in dis- location, the head of the bone can be felt in its new situation by deep manipulation of the gluteal region ; and that the trochanter is diagonal in its relative position to the anterior 944 SPECIAL PATHOLOGY AND SURGERY. superior spinous process, wliei'eas in fracture it lies nearly in a per- pendicular line -with it. Nelaton's " test line " affords a ready and accurate indication of any elevation of the great trochanter having taken place. It is a line drawn from the anterior superior spinous process of the ilium to the most prominent aspect of the tuberosity of the ischium (Fig. 441). Tn the natural relation of the femur, and the limb in a straight line with the pelvis, this line coincides with the summit of the ti'ochanter; but in either form of backward dislocation — dorsal or ischiatic — the trochanter rises above the line to half an inch or an inch higher. Bryant's " ilio-femoral triangle " is bounded by a line drawn from the anterior superior spinous process of the ilium to the top of the great trochanter of the femur — corresponding with the first portion of Nelaton's test-line ; a vertical line, drawn from the spinous process downwards, over the iliac bone to the horizontal plane of the body ; and a third, or basic line, between the two, forming a right angle with the vertical line. (See Fig. 441.) The base is the " test-line." Any shortening of this (base) line, as compared Avith the length of the same line on the opposite side, will indicate dislocation of the femur backwards, and upwards. Shortening of the neck of the femur — from fracture or from disease, will have the same effect in diminishing the relative length of this line. But in the application of both these test-lines, the attitude of the limb — by abduction or adduction — will obviously alter the indication, as to shortening of the limb having taken place. To make the observa- tion correct, the limb must be placed straight in a line with the pelvis. Giraud-Teulon has devised a line of measurement which is unaffected by the attitude of the limb. Taking the middle of Nelaton's line as a point about opposite the centre of the acetabulum, a line drawn from that point to the inner condyle of the femur, may be compared with the length of the same line in the opposite thigh. Shortening of this femoral line will indicate dislocation upwards, or a diminished length of the femur. Disease of the hip-joint resembles dislocation upwards and back- wards, in its general characters; and particularly when advanced to the stage of shortening the limb. The antecedent histoiy of limping lameness and pain, before any such resemblance becomes established, will sufficiently decide the diagnosis. Failing to recognize the nature of the case, instances have occurred of attempted reduction in hip-joint disease ; a sad mistake, and which w^ould sorely aggravate the disease. Causes. — The attitude of the limb at the time of dislocation is always most influential in this, as in other such injuries. When the body is bent forward on the thigh or the thigh on the abdomen, and the thigh in a state of adduction close to the opposite thigh;* hip- dislocation upwards and backwards may then result from a fall on the foot or knee, and especially while the individual is carrying a load on the back ; or from the fall of a heavy weight, as a mass of earth, upon the back of the pelvis, the body being much bent for- wards. Dislocation may thus take place either on the dorsum ilii, or into the great sciatic notch ; but, to gain the latter situation, the limb must be in a position more nearly at a right angle vdth the trunk. * The state of abduction may be the only causative position in all dislocations of the thigh. See Med-Chir. Trans., vol. Ix. (H. Morris.) DISLOCATIONS OF THE HIP-JOINT. S'15 Age has a remUrkable relation to the frequency of hip-joint dislocation. Any such dislocation is comparatively rare in infancy and advanced life ; but it has been known to occur in an infant, six months old, as the earliest time, and at eighty-five years of age, as the latest time. The period of life during which dislocations of the hip occur more commonly, has been stated, by Sir A. Cooper, as being from twenty to fifty years ; by Malgaigne, as from twenty to forty-five years ; and by Hamilton, as from fifteen to thirty, but that the next, and nearly equal, order of frequency is from thirty to forty-five years. These sUght differences of statement are due to the dilferent ages at which each series of cases commenced, and they tend to confirm the general result. Males are more liable than females to dislocation of the hip ; owing to the more oblique direction of the neck in relation io the shaft of the femur, and also to the accidents, in the various occupa- tions of the former sex, which cause dislocation. Unreduced dislocation of the hip backwards proceeds to the forma- tion of a new joint ; the pathology of which may be regarded as the type of any such compensatory construction, and is, therefore, con- sidered in the general history of Dislocation. Cases are on record showing the efficiency of the limb eventually, in a state of unreduced dislocation ; one — related by Hamilton — after nine years' dislocation on the dorsum, where a young man could walk rapidly, although with a halt, yet without pain and discomfort ; in another case, after only eight weeks' dislocation into the sciatic notch, the limb was quite useful. Reduction of dislocation on the dorsum is, generally, followed by speedy recovery of the use of the limb ; in the course of a few weeks or months at most, the limb becoming as useful as before. The same may be said in favour of dislocation into the sciatic notch ; reduction soon restores the thorough efficiency of the limb. But, after an unusual force or prolongation of extension, I have seen a permanent muscular weakness and limping lameness result; without, however, any recurrence of dislocation. Treatment. — Chloroform should always be administered — unless specially contra-indicated — to relax the muscles. A warm bath may be substituted for the relaxing influence of chloroform, in exceptional cases. Reduction can then be effected in either of two ways : by ex- tension and counter-extension of the limb, pulleys being necessary to overcome the muscular resistance and its duration, in most cases ; or by flexing the limb on the thigh, and guiding it so into position, that the muscles themselves, probably, complete the reduction — constituting the method by " manipulation." (1.) Extension and Counter-Extension. — The patient must be placed on his back, inclining to the side opposite to that of dislocation ; and suflBciently raised from the ground on a bed or table, that the long axis of the thigh may be in a line with the force of extension, resisted by counter-extension, which should be applied in the following manner (Fig. 442). A padded belt is fastened round the lower part of the thigh, having a double strap attached to it, terminating in a ring ; to the latter a multiplying pair of pulleys, of three cords, is hooked, whereby extension is brought into operation ; the distal pulley being hooked to a ring or staple driven into the wall or some firmly fixed object, in a line with the thigh. A padded perineal band, for counter-extension, must be secured in like manner. An apparatus of VOL. I. 3 p 94G SPECIAL PATHOLOGY AND SURGERY. this kind, and ^yell adapted for the purpose, is manufactured by Messrs. Weiss. The cord of the pulleys may be intrusted to aa assistant, the Surgeon taking charge of the thigh and hip. Extension should be made sloivly, gradually increased, and steadily maintained. The great trochanter will be observed to descend, and to come more into position, as extension proceeds ; the upper part of the thigh should then be raised with one hand or by means of a towel passed under the thigh, in order to lift the head of the femur over the prominent brim of the acetabulum; while, at the same time, the thigh is rotated out- FiG. 442. wards with the other hand, thus to' incline the head of the bone downwards and forwards; it will, generally, be felt to slip in with a jerk, rather than a snap, the muscles being worn out beyond the power of any sudden contraction. On relaxing the extension, the perceptible disappearance of the signs of dislocation, in the length of the limb, etc., announces the certainty of reduction. The limb must then be retained in position, to guard against the liability of redislocation. A long splint and bandage, as for fracture of the thigh, has been recommended for this purpose; but simply connecting the reduced limb with the sound limb, by means of a few turns of a bandage around the thighs side by side, 1 have always found to afford a suffi- cient security. The patient must I'emain in bed for ten days or a fortnight, during the reparation of the ligamentous and other tissues. Dislocation into the sciatic notch is reduced in like manner, but with greater difficulty, owing to the imbedded position of the head of the femur (Fig. 443). Extension should be made across the middle Fitt. 443, of the opposite thigh, and the head of the bone more lifted out of its bed ; the patient inclining more to the opposite or sound side. To effectually raise the head of the bone, it is sometimes recommended that a towel, passed under the thigh, should be looped round the neck of an as.sistant, who, stooping over the pelvis and pressing downwards DISLOCATIONS OF THE HIP-JOINT. 947 with both hands, raises his shoulders ; thus bringing considerable power to bear in drawing the bone forwards towards its socket. Jarvis's adjuster is applicable, instead of pulleys, for the purpose of extension. This instrument offers the advantages of completeness, in requiring no assistant, and no additional means for fixing the pelvis, while the limb can be moved in any direction during the extension. But the great power which can be brought to bear must not be over- looked, lest serious damage be done by any undne force. Although a complicated apparatus — and, I may add, expensive — it may be specially serviceable in country practice, where the Surgeon is often unaided, or in the colonies. Reduction by rectangular flexion, with vertical extension — Bigelow's method — is guided solely by the state of the ilio-femoral ligament. The thigh must be flexed to a right angle with the trunk, thus to relax this ligament; then the dislocation can be readily reduced by making extension directly upwards. Manual extension may suffice, or the pulleys can be applied, by means of a tripod placed over the limb, to the apex of which they are hooked. Or Jarvis's adjuster may be employed instead of pulleys. In either way, counter-extension is main- tained by fixing the pelvis to the floor with a belt. Sometimes, there being only a slit in the capsule, which resists the return of the head of the femur into the acetabulum, it will be necessary to circumduct the limb, in order to tear the capsule open, before reduction can be effected. (2.) Manipulation. — This method of reduction was known to Hip- pocrates, and has since been variously practised by Surgeons in modern times, especially in 1815, by Dr. ISTathan Smith, of New Haven ; but, in 1851, Dr. W. W. Reid, of Rochester, N.Y., so attracted the attention of the profession to this procedure, as to have fairly introduced it as an established method of pi'actice. Dr. Reid's method consists : — "In flexing the leg upon the thigh, carrying the thigh over the sound one, upwards over the pelvis as high as the umbilicus, and then abducting and rotating it outwards." Hamilton's description of the proceeding is this : — " The patient being laid on his back upon a mattress, the Surgeon — assuming that it is a dislocation on the dorsum ilii — should seize the foot with one hand and the other he should place under the knee ; then, flexing the leg upon the thigh, the knee is to be carefully lifted toward the face of the patient until it meets with some resistance ; it must then be moved outwards and slightly rotated in the same direction until re- sistance is again encountered, when it must be gradually brought downwards again to the bed. We do not know that the whole process could be expressed in simpler or more intelligible terms, than to say that the limb should follow constantly its owti inclination." In attempting the reduction of dislocation into the ischiatic notch, by manipulation, the same author warns us of the special danger, " that the head of the bone will be thrown across into the foramen thyroideum." Bigelow's directions for manipulation are very similar : — To flex the thigh upon the abdomen, abduct and then rotate outwards (Tig- 444) ; or perhaps adduct and rotate slightly inwards to dislodge the feraoral head from behind the acetabulum, then to abduct and extend directly upwards. Circumduction may be necessary to lacerate the capsule more entirely, before reduction can be accomplished. In 948 SPECIAL PATHOLOGY AND SURGERY. making any manipulative movement, I would urge the advantage of supporting the femoral head with the hand, on the dorsum ilii, as a fulcrum for the leverage of the femur ; and this support will ^ also enable the Surgeon to feel the ^^' ' jerk Avhich occurs when reduction takes place. This sensation is not so palpable as the snap produced by muscular contraction in reduc- tion by extension ; and when the patient is under the influence of anesthesia, -it may scarcely be per- ceptible, even in the manipulation of a very muscular subject ; but the limb immediately resumes its length and proper attitude, when placed by the side of the other. " The following summary of a paper — prepared by Dr. Hamilton — with the view of determining, if possible, the relative value of the two methods — manipulation and extension — and exhibiting an analysis of 64 cases in which manipulation was employed, will enable the reader to form some estimate of the difficulty in which this subject is involved ; and if it does not actually decide a moot point, it will at least demonstrate that the method by manipulation is not without its hazards. Of 41 cases in which the fact is stated, 28 were reduced on the first attempt, 7 on the second, 4 on the third, and 2 on the seventh. In 7 examples, the head of the femur has been thrown from one position to another upon the pelvis, travelling from the dorsum ilii to the ischiatic notch, and from thence to the foramen ovale ; or directly from the dorsum to the foramen, and back again ; or in other directions, according to the character of the original dislocation ; in some instances these changes being made as often as seven times in succession. In the majority of cases, no evil consequences seem to have followed upon these changes of position." As complicated with fracture of the margin of the acetahulum, dislocation of the femur backwards not unfrequently occurs. It happens more often fi'om direct dislocation into the sciatic notch. Bigelow and Hamilton each record six cases, verified by dissection ; and Mr. F. S. Eve, of St. Bartholomew's Hospital, has collected nine cases more, with two additional specimens. f The diagnosis of this complication may be doubtful ; but the comparatively easy reduction, and the facility with which the displacement returns when the limb is left to itself, will generally indicate the nature of the injury. Some- times crepitus may be felt, on rotating the femur, with the other hand placed upon the trochanter. This sign might, however, suggest the existence of fracture in the neck of the femur; but the inverted attitude of the limb in backward dislocation, as coupled with shorten- ing, is distinctive — and the head of the bone is on the dorsum ilii. But fi'acture in the neck or head of the femur may also co-exist with backward dislocation ; a case, probably unique, of this kind having occurred in Mr. Birkett's practice. :|: Here again, the signs are similar to those of the acetabular fracture-complication of backward dislocation. There is some mobility and crepitus, even moi-e perceptible than in * After Bigelow. f Med.-CMr. Trans., vol. Isiii. J Ibid., vol. lii. DISLOCATIONS OF THE HIP-JOINT. 949 acetabular fracture, and the recurrence of displacement will be observed, wben, after extension, the limb is left to itself; but the limb may be inverted or everted, as well as shortened, and the Jiead of the femur lies on the dorsum ilii. Impacted fracture of the femoral neck may occur, possibly, in con- junction with dorsal dislocation. The head of the femur can be felt in its new situation on the back of the ilium ; and the limb may be inverted or everted, and is shortened to the extent of the displace- ment of the head plus the impaction of the neck of the bone ; but the neck being driven firmly into the great trochanter, no mobility or crepitus can be elicited by extension and inward rotation, and the dislodged head obeys the movements of the limb. This combined inju.ry is thus distinguished from dorsal dislocation, accompanied with ordinary, unimpacted fracture of the neck of the femur ; and the limb can be lengthened, even by pulley-extension, and reduction effected, without unlocking the impacted bone, — a result which could not be accomplished, unless this state oE fracture were accompanied with dislocation. After reduction, also, the limb remains somewhat shortened permanently, with great rigidity of the hip. The only case, so far as I know, which corresponds to the above description, came under my care at the Royal Free Hospital. A man, thirty years of age, sustained an injiuy to the left hip by a railway collision. There was plainly a dorsal dislocation of the femur ; the head could be felt on the back of the ilium, and the usual signs of this displacement were presented. But after manipulative movements of flexion, abduction and rotation outwards, the inverted attitude of the limb became exchanged for eversion, with the previous shortening to the extent of more than two inches — the head of the bone still remaining on the dorsum ilii. The injury then presented the usual appearances of an extra-capsular fracture of the femoral neck, with the dorsal dislocation. The head of the bone, however, moved with the manipulative movements of the thigh ; thus indicating that the fracture was impacted. This additional injury— impacted fracture of the femoral neck — being unattended with crepitus, or mobility apart from the head of the femor in its new situation, the co-existence of any fracture with the dislocation was not suspected at the time of the accident. But the subsequent course and result of the case corrobo- rates this diagnosis. Pulley-extension failed to bring down the limb to its proper length, and effect reduction. Manipulation having been again resorted to, reduction was thus accomplished ; the limb being restored to its proper direction, and nearly its natural length — when I felt the head of the bone jerk into the acetabulum. The manipu- lative movements were conducted by Mr. W. Hose, while I kept my hand upon the hip, covering the head and trochanter of the femur. A long external splint was applied, and weight-extension fi'om the foot continued for a month ; at the end of which period the limb remained still nearly at its natural length. The apparatus having then been removed, shortening gradually took place to the extent of about two inches and a half, in the course of two or three months, from depression of the femoral neck. There was no redis- location. But considerable rigidity of the hip-joint, with thickening around the great trochanter, rendered the movements of the thigh very limited ; slight flexion and rotation only being accompanied with 950 SPECIAL PATHOLOGY AND SUPvGERY. Pig. 445.* Fig. 446. a creaking sensation and great pain. The limb was neither inverted nor everted, and of the same size as the other, both in circumference of the thigh and calf of the leg. Dislocation Downwards and Eoewaeds into the Obturator Fora- men. — Slriicht-ral Condition. — The head of the femur lies in front of the obturator foramen, lodged upon the obturator externus muscle, the ball being directed inwards and the great trochanter outwards. The capsule has given way, especially on its inner side, and the round ligament is torn from its attachment ; but the constancy of the latter lesion is dis- puted. In the case here represented (Fig. 445), the cap- sular ligament is ex- tensively ruptured, and the round liga- ment torn, from its pit in the head of the femur. This injury occurred in a man aged twenty-eight, deformed by rickets, who had thrown him- self from a window sixty feet from the ground. The dislo- cation was reduced, but the case being complicated by a compound and comminuted fracture of the opposite thigh, death from shock ensued within fifteen hours after the accident. The dislocation was then easily reproduced, so as to replace the parts in their original position. (See also Trans. Path. Soc, vol. ix. A. Shaw.) Signs. — This dislocation, also, presents very characteristic appear- ances. The limb is lengthened from one to two inches in extent, the knee bent, and the body inclined forwards — apparently to relax the painful tension of the psoas and iliacus muscles; and the whole limb is in advance of the other, and much abducted ; the foot usually points forwards, but occasionally it is slightly everted (Fig. 446). The head of the femur can be felt in its new situation, particularly in a thin person ; and the prominence of the great trochanter has dis- appeared entirely, presenting a marked flattening of the hip, or a depression in the situation of the trochanter. Causes. — The limb must be in a state of abduction at the moment of injury. Any force from below, or acting on the back, may then produce dislocation downwards and forwards, into the obturator foramen. Thus, a fall from a horse, with the thigh under the body of the animal, has had this effect ; and Pirrie once found it caused by the person jumping in great haste out of bed, and while the left foot reached the floor, the * Middlesex Hosp. Mus., S. iii. 13, DISLOCATIONS OF THE HIP- JOINT. 951 Fig. 447. riglit was entangled bj the blankets in bed, thus separating the legs and thence jDrodncing dislocation into the obturator foramen. The fall of a heavy weight upon the back of the pelvis, when the body is bent for- wards and the thighs are apart, will also produce the dislocation. Treatment. — (1.) The patient is laid on his back. Extension mast be made upwards and outwards by a perineal gii'th connected with the pulleys; and counter-extension main- tained by another belt around the pelvis from the dislocated side. As the head of the bone is thus drawn towards its socket, the Surgeon, pass- ing his hand behind the sound limb, grasps the ankle of the dislocated limb, and drawing it inwards and backwards towards the middle line, thus throws the head of the bone outwards and upwards to the aceta- bulum ; observing not to flex the thigh, lest the head of the bone should start backwards into the ischi- atic notch. The limb is here used as a long lever, over the resisting perineal girth, as a fulcrum (Fig. 44 7) . This is Sir A. Cooper^'s method of reduction. Other methods have been devised, but they do not correspond more nearly to the direction of the displacement. In the absence of pulleys, however, it is well io have other resources, as follow : — (2.) Let the patient sit upon the front of the bed, astride one of the bed-posts, and grasp it; while ex- tension of the limb is made by two assis- tants. Then, the Surgeon crossing the limb over the sound one, and rotating it outwards, may thus succeed in reducing the dislocation. This method was pro- posed and practised with success by Mr. Hey, of Leeds, in one case. (3.) Manipulation seems to have suc- ceeded in another case. Mr. Hey flexed the thigh to siich an extent as to form an acute angle with the trunk, and then, by rotating it, accomplished reduction. Bigelow's more precise directions are these: — "Flex the limb towards a per- pendicular, and abduct it a little to dis- engage the head of the bone ; then rotate the thioh strongly inwards, adducting and carrying the knee to the flcor " (Fig. 448). * After Bisrelow. Fig. 448.* 952 SPECIAL . PATHOLOGY AND SURGERY. Fig. 449.* Fig. 450. Dislocation Upwards and Fornyards upon the Pubes.— 67?7small puncture or incision opposite the junction of the articular cartilages, and the introduction of a narrow sharp- cutting gouge, or a gouge-drill, which is driven between the ends of bone in difl^erent directions, so as to weaken their connection, and allow the limb to be straightened by gentle manual extension, aided perhaps by tenotomy of the hamstring muscles. Subcutaneous section of the bone in the vicinity oi an anchylosed joint, offers another resource, at least with regard to the hip- joint ; as in. ]\lr. W. Adams's operation— by division of the neck of the femur, subcutaneously ; Dr. Rhea-Barton's and Dr. Sayre's operations — by section through the trochanters ; or the operation which I proposed — section of the femur just below the trochanters. This procedure 1 have practised in two cases, and with successful results. A similar operation has since been applied to the knee-joint ; Volckmann having divided the femur just above the condyles, followed by Mr. Barwell, in this country. Section of the tibia and fibula, just below the joint, may be advantageously coupled with the supra-section, for extreme angular deformity ; thus to halve the gap left in the adjustment of the bones. The elbow has been submitted to operation in like manner — by supra-condyloid section of the humerus. Excision becomes justifiable after subcutaneous division has failed, or when that operation would be inappropriate to correct malposition of the limb. Thus, the removal of a wedge-shaped portion of bone, including an anchylosed joint, may be necessary to rectify an angular deformity of the limb, in the case of the knee-joint ; a mode of excision introduced by Birch, of Xew York, and which I have practised with considerable success. Dr. Rhea-Barton had previously proposed another mode of excision, under these circum- stances — the removal of a wedge of bone from just above the condyles of the femur, and not quite including their entire diameter ; the re- maining portion of bone is then fractured by bending the limb back- LOOSE CARTILA.GES IN JOINTS. 1007 Fig. 496.* wards, so that the limb could be straightened. Bat the former angular position was retained at first hj means of a corresponding splint, and the limb gradually extended before the period for bony union. Ampu- tation will be warrantable only in the extreme case of a useless limb, and which cannot be made tolerably serviceable by excision. Loose Caetilages ix Joints. — Small movable bodies occasionally form within a joint, and which may be quite free, or attached by narrow pedicles to the walls of the articular cavity. One such body sometimes exists, but not uncommonly two or three, and possibly many. In the left knee of a woman who died of apoplexy, Morgagni found twfinty-five smooth and polished globular bodies. A'^arying in size from a barley-corn to a chestnut, they are roundish or flattened, elongated or tuberous. In consistence, colour, and structure, these bodies may be soft and of a yellowish colour, like little melon-seed masses of fibrin ; or hard, whitish, and glistening, consisting of car- tilage or fibro-cartilage ; or converted into bone. N"either the term " cartilage " nor " loose " is, therefore, universally applicable. An y joint possibly may be the seat of these bodies ; but they occur asually in the knee, and less frequently in the elbow, shoulder, or lower jaw. They seem to arise from the vascular processes of the synovial membrane, as out-growths of that membrane, projecting into the joint (Fig. 496). They remain connected, or become detached, and are liable to undergo the changes of appearances and structiu-e above described. These cartilaginous bodies form most frequently as the result of chronic rheumatic synovitis ; and more often in adults than at an earlier period of life. Billroth's observations point to the liga- mentous capsule as the most frequent soui-ce of these ossifying cartilages, which may enter the joint, and become free. Rarely, they form in the synovial tufts. Other modes of origin seem pro- bable in some cases. Thus, the fibrinous con- cretions may be remnant blood-clots ; or, perhaps, represent exudations, or precipitations from the synovia. Possibly, aji out-growth from the arti- cular cartilage, a bit of cartilage, or a portion of bone becoming- detached from the articular sur- faces, or resulting from ossific deposit, may give rise to similar symptoms. Symptoms. — It will be readily supposed that any such foreign body getting nipped in between the articular surfaces, must occasion some remarkable symptoms. Hence, an attached cartilaginous body may remain quiescent ; a detached, or entirely loose cartilage, moving about in the synovial capsule, is more apt to slip in between the bones. Up to this time the patient may have experienced occasional twinges, as if of rheumatic character ; but now a sudden, intense, and sickening pain * St. George's Hospital Mus., Ill, 9. Synovial membrane of the knee-joint, exhibiting numerous excrescences, filiform or pedunculated, growing from the in- ternal surface of the membrane. These bodies are of a yellowish-Tv'hite colour, and would appear to contain ranch fatty tissue- History of the case unknown. (B. C. Brodie, from " Heaviside's Museum.") 1008 SPECIAL PATHOLOGY AND SURGERY. seizes him ; and the joint becoming instantly locked, the hitching or fixed inability to move the. limb may throAv him to the ground in the act of progression. Sudden dislodgment of the intervening cartilage is equally apt to occur, Avhereby the joint is immediately restored to its original state of painless mobility ; leaving only perhaps a little temporary effusion. These symptoms having recurred at intervals, on the slightest movement, and sometimes during sleep, the sufferer seeks relief. On careful examination, a foreign body can usually be found, and by palpation brought perhaps to a standstill at the edge of the patella — in the knee-joint, and there made to bulge under the skin ; or the patient can, perhaps, himself make the movable body perceptible, by a jerking movement of the joint; but the little smooth cartilage easily slips away from under the finger, and again disappears. Some such bodies having an attached pedicle, the movements vidll be restricted ; but if ahvays found in the same place, and incapable of concealment, the body is probably not within the joint. The consistence of the substance will perhaps indicate its nature — whether it be cartilaginous or osseous. But the diagnosis must be made between any such body and the overgrowth of synovial fringes, or of fat in the tufts. Either of these formations may occiir in the knee-joint. An hypertrophied fringe may be recognized by its yield- ing, on pressure against the bone, a soft rustling sensation — which Mr. Barwell aptly denominates the silken crepitus ; and a lipomatous growth has a doughy but somewhat elastic consistence, as if a slug were slipping between the thumb and finger. Sometimes, fibro-car- tilaginous plates form in the synovial capsule ; and any body so located, may be disting-uished from a false cartilage within the joint, by the thickness of the capsule, and its yielding with firmer elastic resistance than usual ; while the cartilaginous area can be depressed, but has no lateral mobility. Displacement of an inter-articular car- tilage is attended with similar symptoms ; sudden and intense pain, with locking of the joint. The diagnosis must be uncertain. Ultimately, the joint itself sometimes becomes diseased ; prolonged irritation inducing synovitis, with relaxation of the ligaments, which are loosened also by having been stretched by the repeated interposition of the cartilage between the articular surfaces. Treatvient. — Recurrence of the attacks of pain may be prevented by limiting the motions of the joint ; thiis fixing the loose cartilage tempo- rarily, or perchance permanently. Hence, an elastic bandage or knee- cap should be constantly worn. Often the relief afforded is such that no further interference becomes requisite. Removal of the foreign body is the only other resource ; but this should never be lightly entertained, considering the risk to the joint, and even to life, contingent on the operation of extraction — and although the strictest antiseptic precautions be adopted. It is justi- fiable only when the cartilaginous body is loose, and freely movable, of some size, and apparently single. Taking a favourable opportunity — after the pain and irritation of an attack have subsided — this opera- tion may be performed, in either of three ways. It is more difficult than would appear to one who has not done it. The cartilage must first be carefully fixed, in a steady spot, with the forefinger and thumb. In the knee, it may be made to project on one side of the patella. The skin is then to be drawn to one side, and an incision made directly TUMOURS CONNECTED WITH JOINTS. 1009 down upon the cartilage, whicli is thence allowed to escape. On relax- ino- the skin, the valvular aperture is at once closed with a strip of plaster, and the limb should be kept at rest until any symptoms of synovitis have subsided. In this way I removed a loose cartilage, the size of a shilling, but twice as thick, from the left knee-joint of a young man. Slight synovitis only followed the operation ; this was subdued by rest, and an ice-bag, with a perfectly successful result, — the joint remaining strong and freely movable. Another mode of operation consists in introducing a tenotomy knife slantingly underneath the skin, and dividing the synovial capsule upon the fixed cartilaginous body ; then, squeezing it through the synovial aperture into the external cellular texture, where it is allowed to remain, the integumental apertui'e is closed with a strip of plaster. If the cartilage should not become absorbed, it is extracted from its bed by a subcutaneous incision, when the synovial aperture has healed, after the lapse of some days. Both these methods of operation are hazardous ; but the subcu- taneous one is less so than the immediate mode of extraction, as would appear from a large number of cases the results of which were compared by M. Larrey. In ] 67 cases of removal of loose cartilages by operation, 121 were cases of the direct operation, and 98 were successful, 5 doubtful, and 28 died ; whilst of 39 subcutaneous operations, 19 were successful, 15 failed, and 5 died. A modification of the subcutaneous operation has been practised by Mr. Square, of Plymouth ; and by which Mr. Erichsen states that he has successfully removed in succession five loose cartilages from one knee. The capsule having been divided subcutaneously over the fixed cartilage, it is pressed into — not through — the synovial aperture, and retained there by a compress and strips of plaster. Adhesion speedily ensues, followed by absorption of the cartilage. Mr. Syme recommends yet another method, by which, he says, he generally succeeds without risk. It consists in " making a free sub- cutaneous incision through the synovial membrane and cartilage, and applying a blister over the part where it is retained." In attempting to remove a false cartilage by any of these pro- cedures, the Surgeon may be defeated ; when the body, having an attached pedicle, is not entirely loose ; or if free, it may slip away again and again, and at last getting concealed in a synovial fold or a cul-de-sac, thus elude extraction. Tumours connected with Joints. — Cancer of the Articular ends of Bone is sufficiently described in connection with Cancer of Bone gene- rally. " In cartilage,''' observes Virchow in his " Cellular Pathology," " malignant affections are so rare, that it is usually assumed to be altogether insusceptible of them." Th.e synovial membranes are equally indisposed to cancerous disease. Sir B. Brodie states that he had " no reason to believe that any truly malignant disease ever has its origin in the synovial membrane." For other Morbid Growths in the articular ends of Bone, see Tumours op Bone. Neuralgia of Joints is specially important in relation to the dia- gnosis from structural disease. See Hysteria, Neuralgia, and Syno- vitis. VOL. I. 3 T 1010 SPECIAL PATHOLOGY AND SURGERY. CHAPTER XXXVII. DISEASES OP PARTICULAR JOINTS. Diseases of the Hip-Joint. — The hip-joint is liable to the same in- fiammatoiy diseases as other joints, affecting- its component structures : synovitis, scrofulous caries, and ulceration of the articular cartilages. The second-named disease presents chai"acters worthy of a separate description. Scrofulous Disease of the Hip, or Morbus Coxarius. — Structural Conditions. — This disease commences in the cancellous tissue of the head of the/e?nttr, or of the acetabulum ; possibly, in both bones simultane- ously. It may also commence in the synovial membrane, as scrofulous synovitis ; or, it is said, in the round ligament. Respecting the latter seat of origin, although it is now generally ignored, the facts origi- nally adduced by Mr. Aston Key relative to the commencement of hip-joint disease in the round ligament, are worthy of notice. These facts have regard to the earliest symptoms, and pathological changes which are found in disease of this joint. Thus, inflammation of the round ligament would seem to be indicated by the pain experienced when the head of the femur is pressed against the acetabulum, the ligament, when swollen, not being accommodated in the space afforded by the pit in which it lies. Less significant evidence is given by the motions of abduction and eversion being especially painful, as the ligament is thus apparently put on the stretch. Then again, the earliest, and only, change of structure often found in hip- joint disease, is inflammation of the round ligament, and which may be even destroyed by ulceration, before any marked change in the articular cartilage of the femoral head ; lastly, ulceration of the carti- lage often takes place adjoining the ligament, rather than elsewhere, as if by an extension of the disease from this structure. My own opinion is, that the true interpretation of these observations would be to refer the incipient inflammation to the reflected sheath of synovial membrane, around the ligament ; an increased vascularity of this ensheathing membrane presenting the apparent origin of inflammation in the enclosed ligamentous structure. The name scrofulous disease of the Mp-joint is used as a general term including these different seats of origin. But there are cases in which the disease is not apparently a scrofulous affection ; the caries or the synovial inflammation being of a simple character, and arising in a healthy constitution, only from some external cause, as injury or exposure to cold. In scrofulous caries of the hip, the cancellous tissue undergoes the structural alterations described in connection with this disease of Bone; briefly, increased vascularity, softening, deposition of a reddish fluid in the enlarged cancelli, followed by a yellowish opaque tubercular matter. Suhsequent structural alterations are as follow : — The articular cartilages become involved and disappear, more or less completely; and abscess fornis within the cavity of the joint. The affected portions of bone become remarkably changed in shape and size. The head of SCEOFULOUS DISEASE OF THE HIP, OR MORBUS COXA.RIUS. 1011 the femur— bared, perhaps, of cartilage, and the open cancellous tissue exposed — is flattened and expanded, mushroom-like in form on the neck of the bone (Fig. 497) ; and the nech itself, sharing in the disease, may be so reduced as to leave nothing more than a slight nodular vestige (Fig. 498), if anj remnant, of the diseased bone p°ro- FiG. 497.* Fig. 498. jecting from the great trochanter (Fig. 499). This portion of the bone, and the adjoining portion of the shaft, are not unfrequently carious ; either by an extension of the joint-disease, or as the original seat of caries. The acetahtilar cavity, also denuded of cartilage, is enlarged in circumference, but shallow ; the cotyloid ligament and bony rim of this cavity having been destroyed (Figs. 497, 498). The round ligament may have disappeared, and the capsular- ligament at length giving way, the abscess bursts into the surrounding cellular texture. Thus, the joint is utterly destroyed. Term^inations. — (1.) Anchylosis rarely takes place, as a mode of reparation. (2.) The remnant of the articular end of the femur is Fig. 499.J Fig. 500. drawn up by the action of the muscles into the patulous acetabulum. Thence the femur has even been forced through the thin carious bottom of this cavity, and entered the pelvis (Fig. 500). (3.) But the ill-fitting, loose articulation, from advanced disease, is most liable to * St. Bartholomew's Hosp. Mus., B. 7. J Ibid., B. 10. § Ibid., B. 14. t Ibid., B. 8. 1012 SPECIAL PATHOLOGY AND SURGERY. Fig. 501.* dislocation. The femur, drawn upwards and outwards by the glutei muscles, passes over the reduced brim of the acetabular cavity, and slipping' on to tlie dorsum ilii, lodges there. More rarely, the femur is thrust out of the acetabulum forwards, and rests on the ramus of the pubes. Abscess finds its way to the surface by burrowing sinuous tracks, and opens in vainous situations. The openings relate some- what to the seat of the disease. When it originates in the head of the femur, the sinus extends some way down tlie thigh, and opens probably near the insertion of the tensor vaginas femoi'is muscle. Acetabular disease presents a sinus-opening in the gluteal region, near the anterior inferior spine of the ilium. Matter may also pass down by the rectum, bursting into it, or close to the anus. If the pelvic bones be involved, a sinus-opening is presented in the pubic region, above or .below Poupart's ligament ; above the ligament, it leads probably to intra-pelvic abscess ; below the ligament, to disease of the rami of the pubis or ischium. Signs. — (1.) Scrofulous disease of the hip-joint approaches and pro- gresses very insidiously. Commencing generally in early life, under the age of puberty, scarcely any pain — but what the mother will call " growing pain " — is com- plained of in the first instance, or for weeks, possibly months, as the disease slowly progresses. The first perceptible sign is a slight limp in walking ; the child shuffling, hobbling, or drag- ging his leg, step by step. This lameness is aggravated by exercise, but temporarily disap- pears after i-est. Some fixity of the hip-joint may also be detected ; in putting the limb through its various movements, as of flexion and extension, the pelvis moves with the thigh, — the patient lying recumbent. When standing, the whole weight of the body is thrown on the other limb, to relieve the halting member. This atti- tude is peculiar ; the hip of the sound limb being elevated, gives an obliquity to the pelvis down- wards and forwards on the diseased side ; the thigh is slightly bent on the pelvis, and the leg on the thigh, the toes touching the ground. The limb maybe somewbat abducted and everted, the toes being turned outwards, and in advance of the other side, haA'ing some resemblance to dis- location on the pubes, or fracture of the neck of the femur. But in the first stage of diseased hip-joint, the limb is apparently elongated (Fig. 501). This, however, is a deceptive appearance, arising from the ob- liquity of the pelvis downwards towards the diseased hip ; measurement with a tape from the anterior superior spine of the ilium to another fixed point below the joint, the inner malleolus, will at once show that there is no elongation in reality. The pelvic obliquity, and apparent lengthening' of the limb, will be shown \)j placing the body as straight as possible with the limbs ; then drawing a line, with tape, across the * Eoyal Free Hospital. From a boy, aged sixteen. Disease of about six months' duration. (Author.) SCEOFULOUS DISEASE OF THE HIP, OE MOEBUS COXAEIUS. 1013 pelvis, between tlie two anterior superior iliac spines, the angle of this line to the middle line of the trunk, on the diseased side, indicates the inclination of the pelvis downwards ; the greater the obliquity, the angle is less or more acute. If the transverse line be drawn across at right angles to the vertical line, the distance above the anterior superior spine on the diseased side, will measure the amount of pelvic obliquity. The limb becomes toasted from disuse, the glu- teal muscles especially, so that the buttock is flattened and flaccid, wider than natural, and the lower fold of the nates less marked, while the line between the nates curves towards the diseased side. Fain is now felt in the hip, or referred more to the inner side of the knee ; and the pain in the former situation is aggravated by any attempt to bear on the joint, by abduction or rotation of the limb, and especially by concussion of the bones, as by striking the tro- chanter or jerking the limb upwards from the sole of the foot. Pressure also on the trochanter increases the knee-pain ; but there is no tenderness at the knee, nor does pressure there increase the hip-pain. Pain on the inner aspect of the knee is a sympathetic sensation ; depending, probably, on the nervous relation between the hip and knee, through the obturator and perhaps the anterior crural nerves. Both these nerves supply articular branches to the hip, and to the inner side of the knee. A deeper-seated pain in the knee is probably sympathetic of disease of the femoral head, or may be directly transmitted through the shaft ; and this osseous pain in the knee may thus be diagnostic of disease commencing in the head of the femur, rather than in the capsule, to which the articular branch of the obturator nerve is distributed, — the articular branch to the knee being also distributed to the synovial membrane. Sometimes, less fixed pain is referred to the thigh, in front and its inner side; or to the buttock, near the anterior superior spine of the ilium. (2.) Heal shortening of the limb^ — succeeding its apparent lengthen- ing — marks the second stage, as it has been termed, of this disease. It coincides with advancement of the disease to destruction of the cartilages and of the head of the femur, acetabulum, or both bones ; whereupon the limb is drawn up by muscular action. Shortening varies, therefore, in different cases, but it increases as the disease progresses. The attitude of the limb is somewhat changed ; still re- maining flexed, it has now also become inverted and adducted, with projection of the buttock backwards and upwards, tilting the pelvis downwards and forwards on the opposite, or healthy side ; in these appearances resembling dislocation backwards on the dorsum ilii or into the ischiatic notch. Some apparent shortening of the limb is produced by this uprising of the buttock. The lateral inclination of the pelvis at length produces a compensatory lateral curvature of the spine, in the lumbar region — the convexity of the curve being to the healthy side ; with more or less incurvation or lordosis, owing to the uprising of the buttock backwards. In the recumbent position, this incurvation may be made to disappear, or be reproduced, by flexing or straightening the thigh ; the lumbar arch falling when the thigh is bent forwards, and rising again as the limb is straight- ened (Fig. 502). Wasting of the limb increases, as the disease pro- gresses. This shortened, flexed, inverted, adducted, and wasted limb, with obliquity of the pelvis and twisted lordosis of the spine, presents 1014 SPECIAL PATHOLOGY AND SUEGERY. a very characteristic appearance (Fig. 503). Pain also "has become more severe, and aggravated by the attrition of the exposed surfaces of bone, subject to spasmodic muscular action, has acquired the character of starting pains. Abscess within the joint bursts into the surrounding cellular texture, and forms a swelling in connection with the hip, which up to this time Fig. 502. Fig. 503.* Fig. 504.t has undergone no farther alteration than a. slight fulness in the groin, and enlargement of the inguinal glands. Abscess-swelling is rendered more conspicuous by the wasting of the thigh and buttock. When, at length, the abscess opens externally, the situation of the simis- apertures denotes, as already indicated, the probable seat of the disease ; whether in the head of the femur or acetabulum. Dislocation is very apt to supei-vene, commonly on the dorsum ilii ; yet, although attended with increased shortening, the atti- tiide of the limb, flexed and inverted, remains the same ; the obliquity of the pelvis, however, beginning to sub- side, and tbe pain being greatly relieved. The extent of shortening will not deter- mine the presence of disloca- tion.; it being impossible to apportion the amount due re- latively to pelvic obliquity or posture, and to bone-absorp- tion. Nelaton's line, between the anterior superior iliac spine and the tuber isehii, will show whether the trochanter has risen above, and to what extent ; but the altered rela- tions of the articular surfaces, from disease, renders this test inaccurate. But the head of the femur or its remnant, with the great trochanter, can be felt in its new situation, on the back of the ilium ; and often very distinctly, the gluteal muscles having wasted so much that the bone seems to lie immediately under the skin (Fig. 504). The additional symptoms — wasting of the limb, and sinuses discharging an unhealthy pus and leading down to diseased bone — complete the local diagnostic diif erences of appearance from traumatic dislocation. The genei^al health also * Another case. (Author.) f Eoyal Free Hospital. (Anthor.) SCEOFULOUS DISEASE OF THE HIP, OR MORBUS COXAEIUS. 1015 has now become worn down hj irritation and liectic ; and this consti- tutional condition, coupled with that of the diseased limb, form a picture Avhich leaves little or no doubt as to the nature of the case, not to men- tion the previous history of its insidious origin. In the young subject, and as a rare occuri-ence, separation of the epiphysial cap of the femoral head may simulate dislocation. But the shortening is even more marked, and accompanied with mobility, particularly downwards, so that the limb can be made of equal length with the other, without drawing down the pelvis. In the event of anchylosis taking place — without dislocation — the characteristic attitude of the limb is retained. Rarely, both hip-joints are diseased ; and then, with anchylosis on either side, the patient gradually acquires a remarkable cross-legged progression, to which Mr. Clement Lucas has called attention.* Meclianism of the Signs. — Different explanations have been offered as to the production of the sig-ns in disease of the hip-joint, with regard to the position and length of the limb — i.e. flexion, abduction with eversion, adduction with inversion, lengthening and shortening ; and the accompanying lumbar spine curvature with lordosis. It would seem that the position which the limb assumes, is due to involuntary muscular contraction, as the result probably of nerve irritation pro- ceeding from the joint-disease; but that the instinctive relief of pain also places the limb in the most easy position. Flexion is thus produced by contraction of the conjoined psoas and iliacus muscles, to relieve the tension of the joint-capsule. Ahduction with eversion, and adduc- tion with inversion, are equally neuro-muscular adjustments of position. Lengthening is always apparent, and occurring in the first stage of the disease, may be referred to the attitude of standing or walking, so as to throw the weight of the body more on the sound limb, with conse- quent tendency to obliquity of the pelvis downwards towards the diseased side. But it is alleged, that, owing to stiffness and pain in the hip-joint, with muscular contraction, a fixed state of the thigh, in altered positions of the limb, with the constant endeavour of the patient to bring the limb into parallelism, for weight-support, will produce pelvic obliquity, and thence apparent lengthening or shorten- ing — as the pelvis is inclined downwards or upwards, on the diseased side. Thus, with abduction — in the first stage of the disease, the (fixed) thigh must be brought inwards, and the pelvis descending, obliquely, the limb is apparently elongated ; and, with adduction — in the second stage, the thigh must be directed outwards, and the pelvis rising, obliquely, the limb is apparently shortened. Those who thus interpret these signs, proceed upon the assumption that the joint is always a fixed point, for tilting the pelvis downwards or upwards, by the leverage of the thigh, inwards or outwards ; and, with regard to apparent lengthening of the limb, it is further assumed that abduction is also of constant occurrence in the first stage of hip- joint disease. But neither of these conditions are invariably present — in connection with their apparent consequences; and respecting' the alleged influence of abduc- tion, I have noticed this attitude of the limb occasionally in conjunction with pelvic obliquity uptcards, on the diseased side. Spinal curvature, in the lumbar region, is readily explained. The lateral ciirve is produced by the pelvic obliquity having a lateral direction. Some curvature of * Trans. Clin. Soc, Lond., 1881. 1016 SPECIAL PATHOLOGY AXD SURGERY. the lumbar spine may thus follow the pelvis as it descends, towards the diseased side ; but this is exchanged for a curvature towards the healthy side, when the pelvis becomes tilted upwards. Lordosis is the result of continued flexion of the thigh upon the pelvis ; the patient habitually bringing the limb under the trunk for support, turns the buttock upAvards and backwards, and thus curves the lumbar spine forwards. This uprising of the buttock produces also that additional apparent shortening which accompanies the real diminution of the limb in length, as the disease progresses. But it is impossible to apportion the degree of shortening due to either cause — bone-absorp- tion or posture, in the combined result of both. Diagnosis. — Scrofulous disease of the hip- joint is liable to be mis- taken for other diseases, if any one particular symptom be alone con- sidered. It may resemble traumatic dislocation on the dorsum ilii, congenital dislocation of the hip-joint, infantile paralysis with wasting and defective growth of the limb, sprain of the hip- joint, interstitial absorption of the neck of the femur, rheumatism, disease of the knee, lateral curvature of the spine, psoas abscess, abscess near the joint, inflammation of the bursa under the psoas-iliac muscle, or of the bursa over the great trochanter, trochanteric periostitis or ostitis. More commonly, however, hysteria simulates disease of the hip-joint ; and thus the diagnosis of this hysteric aifection may primarily engage the Surgeon's attention — before considering the forms of structural disease or injury, to which hip-joint disease may bear some resemblance. As an hysterical affection, the symptoms and signs which might be referable to disease of the hip-joint, are much exaggerated or other- wise peculiar, and modified also as the patient's attention is fixed upon or withdrawn from that part ; but the signs of joint-inflammation, and its consequences, are always absent. Thus, the pain has all the pronounced characters of hysteric pain. It is unusually severe or even excruciating ; superficial, being elicited by the lightest touch rather than by deep pressure ; more diffused, extending over the thigh and buttock, and not located in the hip or traceable in the course of the obturator nerve; it is inconstant — sometimes present, sometimes absent ; or migratory to some other joint or part, or vanishing altogether. But the pain is not provoked by the movements of flexion, abduction, and rotation ; nor by pressure or percussion of the heel or tro- chanter. At a later period, starting pains may be experienced, but they do not occur during sleep, as in joint-disease, when the patient's will and attention are in abeyance. The objective signs of hip-joint disease are occasionally present : fixity of the thigh, the pelvis moving with it ; apparent lengthening, with a flexed and perhaps abducted position of the limb, or apparent shortening, with flexion and adducted inversion ; while the pelvic obliquity, with lumbar curvature and lordosis, may complete the pictui-e of real disease. But even these conditions vary from time to time ; so that, during examination, they may partly disap- pear when the patient's attention is withdrawn, and reappear in an exaggerated form, when he is reminded of his joint-affection. Muscular wasting of the buttock and of the thigh not unfrequently ensues from disuse; but this aspect of the limb is unaccompanied with signs of joint-inflammation — swelling in the groin and behind the trochanter ; or, as in a later stage, the supervention of abscess. Lastly, the general health remains throughout comparatively u:-affected. SCROFULOUS DISEASE OF THE HIP, OR MORBUS COXARIUS. 1017 Proceeding to the diagnosis of the various forms of structural disease or injury, for which hip- joint disease is perhaps liable to he mistaken, the concurrence of symptoms, and as compared with those of each of these diseases, will determine the diagnosis. Thus, the dis- tinction of hip-joint disease from dislocation of the femur on the dorsum ilii, has already been adverted to in this light. If the shorten- ino", and the flexed and inverted, attitude of the limb, as two signs of hip-joint disease, be taken alone, it might so far resemble dorsal dislocation, apart from the concurring signs of a wasted appearance of the limb, coupled with obliquity of the pelvis, and twisted lordosis of the lumbar spine, all of which signs are absent in dislocation on the dorsum ilii. When dislocation has taken place from disease, the additional signs of abscess, generally in the buttock, followed by sinus- openings in the situations already noticed, are diagnostic. The history of the case, as having the progressive character of disease, or as one of sudden violent injury, must always be further taken into account. In young subjects, howevei" — in whom disease of the hip-joint is m.ore commonly met with — congenital dislocation of this joint is more likely to be the question of diagnosis. The joint is imperfectly de- veloped ; and the loose gait of the child attracts attention, the move- ments are painless, and the dislocation is readily reduced, but it as easily returns, — the small, stunted femoral head slipping in and out of the shallow, misshapen acetabulum, being unsecured by a round liga- m.ent, and not restrained by the large and incomplete capsule. Infantile paralysis, with wasting and defective growth of the limb, will also be recog'nized as a peculiar affection, in relation to the differentiation of hip-joint disease. Sprain of the hip-joint simulates disease of the joint so far as to be attended with a painful, limping lameness; the hip is raised and the limb flexed, perhaps everted ; and in the course of time, there may be more or less wasting of the buttock and thigh ; all these symptoms arising from the pain provoked by any attempt to use the limb, in standing or walking-. But, while the pain is more acute than that which the patient complains of in the early stage of hip-joint disease, the hip is raised, as if the limb were shortened on the affected side ; and in a later stage of sprain, the limb still retains its natural length, — there is no real shortening. Here, also, the antecedent history of an injury will enter into the Surgeon's consideration of the case, but as a less important factor ; for a sprain might give rise to disease of the hip- joint. Interstitial absorption of the neck of the femur might readily be mis- taken for disease of the hip- joint. Arising from a fall on the trochanter, absorption of the neck of the bone proceeds slowly, and is attended with shortening of the limb. But the inverted position, seen in disease of the joint, is wanting to complete the resemblance. Pathologically considered, the state of the part is very different, interstitial absorp- tion of the neck being unattended with any destruction of the articular cartilage, which still caps the head of the bone. Otherwise, a section (Fig. 605) has the flattened, stunted appearance resulting from pro- gressive destruction of the head and neck. Mlieumatism of the hip-joint may be an acute or chronic affection. An acute attack of rheumatism will rarely settle in the hip-joint, as rheumatic synovitis, leaving other joints unaffected. The co-existence, 1018 SPECIAL PATHOLOGY AND SURGERY. Fig. 505." stiffness. therefore, of similar symptoms in other parts, will at once distinguish such an attack from scrofulous disease of the hip-joint. But the intense character of the pain, and tender, tense swelling in the groin, behind tlie great trochanter, or in both situations, are unlike the more passive state of the joint, in an early stage of caries. Chronic rheumatic arthritis, or synovitis, when limited to the hip- joint, certainly bears a general resemblance to scrofulous disease of the joint, in a more ad- vanced stage. But here, again, the character of the pain is even more distinctive; an aching, boring", gnawing pain, increased by motion, yet wearing off somewhat by exercise during the day, worse at night, and aggravated by exposure to variable climatic changes of cold and moisture. The irregular enlargement or deformity of the joint, from nodular ossific deposit, may not be so palpable as in rheumatic arthritis of other joints, as the knee ; but the peculiar rigidity or and crackling or grating sound on moving the joint, can scarcely be overlooked in the examination. The patient's age will also be considered ; although acute rheumatism may occur in child- hood, chronic rheumatic arthritis is usually a disease of mid-life. Diseases of th.e hip-joint might be mistaken for disease of, or originating in, other parts, if the Surgeon's attention were directed exclusively to any one symptom. Thus, the pain in the inner side of the itwee might be referred to disease of that joint ; unless the association of the other symptoms or signs of hip-joint disease be observed, and the absence of the characteristic swelling of synovitis, or of scrofulous caries, as affect- ing the knee-joint. But the possible co-existence of disease in both the hip and knee joints should not be forgotten as an occa- sional association. Lateral curvature of the spine is attended with obliquity of the pelvis, corresponding to the lumba]- curve ; the pelvis being raised on the side of concavity, and low^ered from the opposite convexity. Yet there are no other signs of hip-joint disease. Psoas abscess presents a swelling, often of considerable size, in the groin, — an exaggerated appearance of the fulness seen in disease of the hip-joint. But this swelling can be reduced or returned into the abdomen by compression, aided by the recumbent position ; and it has a marked impulse when the patient coughs or makes any straining effort; in both these respects differing from any inguinal fulness in connection with the hip-joint. Abscess near the hip-joint, but uncon- nected, may be extra-pelvic or intra-pelvic ; and in either case, the diagnosis may be determined by a thorough examination around the joint, and by rectal exploration, coupled with palpation through the abdominal wall. Enlargement of the hursa under the psoas-iliac muscle forms a swelling in that situation, distinct from the capsule, when the two do not communicate ; and the movements of the hip- joint are free and painless, except when the muscle is stretched by extension and rotation outwards of the thigh. More often, I think, there may be an enlargement of the bursa over the great trochanter ; the * From Liston. SCROFULOUS DISEASE OF THE HIP, OR MORBUS COSARIUS. 1019 painful swelling, in this case, being more plainly defined, and limited to the trochanter. Periostitis or ostitis of the great trochanter resem- bles disease of the hip-joint ; excepting in the more superficial seat of pain, and which is not aggravated by any movement of the joint itself, or by weight-bearing pressure, or by concussion upwards from the sole of the foot, nor is there any sympathetic pain on the inner side of the knee. No shortening of the limb results, as in a more advanced stage of hip-joint disease. Trochanteric disease co-existing with that of the joint no longer offers any ground for diagnosis ; and, practically, no distinction is necessary. Treatment. — The directions given with reference to scrofulous disease of the joints generally are here applicable, rendering any repeti- tion of detail unnecessary. Absolute rest of the joint must be secured, and a position favourable to the future use of the limb, in the event of anchylosis. A splint moulded to the hip and extending below the knee, with the limb straightened, may answer this twofold purpose. In the second stage of disease, the long, straight, extending splint may be applied with more advantage ; thus to counteract muscular spasm and pain coincident with ulceration of the cartilages in contact, and the liability to dislocation as the disease advances. But simple iveight- extension from the foot is the mode of treatment I now generally pi-efer; and the successful results thus obtained are undeniable. The weight should be proportionate to the muscular resistance, — weakened by wasting, but increased perhaps by spasmodic contraction. One pound to two or three will probeibly prove sufiicient. But the importance of keeping the trunk in a line with the limb, to correct malposition, will be obvious. A very useful splint has been devised by Mr. Thomas, of Liverpool. It consists of a metallic bar-support, extending underneath the limb, from about the middle of the calf to the middle of the back, the leg and thigh portion being straight, while the upper portion is bent to the form of the buttock and loins (Fig. 506). This is fastened by straps across the thorax, and further secured by a shoulder-strap. When the limb is first placed in this splint, it may be allowed to remain bent, as from disease of the bip-joint ; but gradually it yields to moderately tight bandaging from below upwards, and subsides into a straight position. This splint possesses at least two advantages : it prevents any movement of the thigh upon the pelvis, and thus fixes the joint ; and the whole trunk and limb form one piece, so that the patient can even be raised from the bed, without any disturbance of the joint. Both these conditions are very desirable, especially in young patients, and who are more frequently the subjects of hip-joint disease. In the case I have represented, a girl, who was thus treated by me in the 1020 SPECIAL PATHOLOGY AND SURGERY. ■Fig. 507. Royal Free Hospital, experienced great relief from pain, after the ordi- nary long, straight, external thigh-splint had been used for some time. Subsequently, however, the disease advanced to the formation of abscess, and I had recourse to excision of the joint. The same splint was reapplied in the after-treatment ; but discharge from the wound having a tendency to soak in between the buttock portion of the splint, I was compelled — for the sake of cleanliness — to return to the external, interrupted thigh-splint. In the ti'eatment by means of Thomas's splint, weight-extension from the foot can be as readily ap- plied ; but the special principle of its construction is that extension is unnecessary, or prejudicial, in the treatment of disease of the hip-joint ; it being only necessary to secure an immovable or fixed state of the articulation, for the purpose of absolute rest. With that one provision, the patient may be allowed to get about, on crutches, at a much earlier period than otherwise, greatly to the benefit of his general health. In walking, the sound limb alone is used ; the trunk, with the limb on the diseased side, move together as a whole. The construction of Thomas's splint, and the method of applying it, may be thus described : — The patient is placed in the standing position, with the foot of the diseased side raised, on some support, until the spine assumes a normal curve in the lumbar region — by reduction of the lordosis or incuiwation. Then the measurements, and form of the splint, are taken as follows : — A long piece of malleable iron — I inch by ^ inch for an adult, | inch by -^^ inch for a child, is placed, so as to extend from the lower angle of the scapula to the lower border of the calf of the leg, just internal to the centre. This rod is bent and moulded by a clamp-wrench to the form of the body. A thoracic belt, of hoop iron ■ — ^ inch by -^ inch — is fixed to the top of the rod. A thigh-belt, or half semicircle, of hoop iron — f inch by -g- inch — is attached at a point one or two inches below the fold of the nates. Below, at the end of the rod, another half semicircle of the same material, is fixed, half embracing the calf of the leg (Fig. 507). The apparatus is well covered with soft leather, to prevent any chafing of the skin at any point ; and the thoracic belt is fastened with a strap and buckle. To apply the splint — as thus fitted — the patient is placed recumbent, and the metallic belts ai'e expanded sufficiently to embrace the thorax and the limb. Then the splint having been put on behind, the Surgeon adjusts and fits it closely, by wrenching with the clamp ; thus adapting the thigh and calf belts, but leaving the thoracic belt sufE.ciently free for easy respiration. The buckle and strap are fastened, and the limb is bound up with a roller beyond the thigh-belt. SCROFULOUS DISEASE OF THE HIP, OR MORBUS COXARIUS. 1021 Fig. 508. Care must be taken tliat the posterior stern of the splint passes over the prominence of the bnttock, inclining inwards somewhat over the popliteal space ; whereby inversion of the limb is corrected, and a slightly everted position maintained. The foot is elevated by an iron patten, "at least four inches in depth" (see Fig. 507), so as to prevent the limb on the diseased side coming in contact with the ground, or receiving any jar from collision with a stone or other object. At a later period, the splint may be taken off at night ; and ulti- mately, during the day, the crutch and patten, on the sound side, are alone sufficient to prevent weight-bearing on the diseased side, the limb swinging in the act of walking, and gradually bringing the hip- joint into action. Contraction of the hip — as the result of joint-disease — may be counteracted by the annexed ap- paratus (Fig. 508), which success- fully combats each abnormal mal- position of the limb. The pelvic band, bears two lateral uprights, upon which the armpits rest, and from which strong laced bands pass around the thorax. This instrument is especially adapted for cases of severe hip-contraction. Anchylosis should be prevented, if possible, by timely, judicious passive movements of the limb. In the event of a stiff joint, coupled with much shortening, and an ad- ducted, inverted, and flexed state of the limb, the patient will be pro- portionately crippled ; but the lum- bar spine and sacral articulation acquire a considerable compensatory mobility, and thus, in walking, pro- gression is effected from that part, on the diseased side. Abscess should be opened to pre- vent burrowing of the matter among the muscles. The situation of pointing is selected, usually about an inch above and behind the great trochanter. For the convenience of dressing, a long "interrupted" splint may be used. The general treatment, medicinal and hygienic, consists in a course of iron, quinine, cod-liver oil, and nutritious diet, with as much pure air as possible. I have very beneficially placed my hospital patients in Ijed in the quadrangle of the hospital, for some hours daily, weather permitting. This plan of treatment must be pursued for a considerable period — some weeks or months — to solicit anchylosis ; or the subsidence of the disease, possibly, after dislocation, and a free discharge of matter with the detritus of the carious bone. Failing thus to bring the disease to a termination, and the general 1022 SPECIAL PATHOLOGY AND SUKGERY. health beginning to decline, operative interference becomes imperative. This Avill be considered under Excision of the Hip. Chronic Rheumatic Synovitis or Arthritis. — Morbus Cox^ Senilis. — Structural Condition. — This disease contrasts with scrofulous disease of the hip-joint, principally in the formation of osseous de- positions or out-growths around the joint, and in the absence of suppuration. Signs, and Diagnosis. — Commencing with stiffness and aching pains in the joint, both of which are somewhat relieved bj exercise, at length a grating attrition, which can be both felt and heard when the joint is moved, affords characteristic evidence of the disease ; coupled with its dry character, — the absence of suppuration in the joint, and its consequences, — the swelling of abscess and the dis- charging sinuses which would ensue in scrofulous disease. Shortening of the limb to some extent occurs, as destruction of the articular cartilages takes place, with expansion o£ the head of the bone, and lowering of its neck to even below the level of the great trochanter. The limb is dra^vn up and everted, the thigh and buttock are wasted ; the patient stands on the other limb, and walks with a limping lame- ness. In consequence of the stiffness and deformity of the joint, the body is habitually inclined forwards — in standing ov walking, with semi-flexion of the pelvis upon the hip, the buttock projects upwards and backwards, tilting the pelvis downwards on the sound side ; this pelvic inclination being attended with an opposite or compensatory lateral curvature of the spine in the lumbar region, and some incurva- tion or lordosis, fi*om backw^ard uprising of the buttock — thus pre- senting an apparent shortening of the limb, even more than has taken place, to the extent perhaps of about an inch. (R. W. Smith.) How much this picture, consequent upon chronic rheumatic arthritis of the hip-joint, resembles that resulting from scrofulous disease, in its second stage, bat for the position of the foot and limb — everted, not inverted. The disease progresses slowly, for years ; clearly distinguishing it from the sudden result of fracture. Other articulations being or becoming affected, would leave no doubt as to the nature of the hip- condition. Thus, the finger-joints are often attacked, being greatly deformed with nodulated chalk-stones ; while the ball of the great toe is frequently much enlarged, and the joint partially dislocated inwards. The general health is often little disturbed, the disease appearing as a local affection. Males are attacked far more often than females, and thin persons mostly. Chronic rheumatic arthritis, affecting the hip- joint, seldom occurs under the age of forty ; diffei'ing in this respect from scrofulous disease of the joint, as well as in its pathology and symptoms. Treatment. — See Chronic Rheumatic Synovitis. ISTeukalCtIA of the Hip. — The diagnostic Symptoms of Neuralgia are pointed out in connection with affections of the IS^erves. Neuralgia of some duration is attended with the alterations of atti- tude consequent on disease of the joint — whether scrofulous or i-heu- matic. The weight of the body being habitually thrown on the sound limb to relieve the affected joint of the other side, the lintb on this side becomes apparently lengthened and flexed, the toes touching the ground ; the pelvis is inclined obliquely to the same side, and some DISEASE OF THE SACRO-ILIAC JOINT. 1023 Fig. 509.* compensatory lateral curvature of the lumbar spine results. But, with neuralgia, no real shortening of the limb ever ensues. Disease op the Sac ro- iliac Joint. — Structural Condition. — The cartilaginous lamella of the sacro-iliac articulation seems to be the seat of a disease, occasionally affecting this joint. Ulceration of the cartilage, as the primary change, involves the synovial membrane — when present ; both of which structures are thus destroyed more or less completely. But the ligaments remain unaffected, or are only partially destroyed ; and the adjoining osseous surfaces seldom become carious or necrosed. This disease is of very rare occurrence. It may be associated with sacral caries, or with ex- tensive disease of the hip-joint (Fig. 509) . In the sacro-iliac joint here shown, are two large cavities containing pieces of necrosed bone, not quite detached ; and above there is a small cavity on the inner surface of the ilium, which contained scrofulous matter. This dis- ease occurred in a man aged twenty-three; and the symptoms of hip-joint disease were well marked. Numerous abscesses formed in various situations, and discharging very pro- fusely, the patient died from hectic exhaustion. Signs, and Diagnosis. — Fain is one of the earliest symptoms. It is confined to the region of the joint, and increased by any movement or position whereby the weight of the body is thrown upon the sacro-iliac joint. Thus, walking, stooping, or even standing, is attended with a sense of painful weakness in that situation, and as if the body were falling asunder. When the pelvis is at rest, or fixed in the recumbent position by the hand of the Surgeon, for examination, the hip-joint may be moved in any direction without pain, or stiffness of that arti- culation. The pain acquires a gnawing or rheumatic character as the disease advances. Sometimes the pain extends down the limb, or into that of the opposite side, as proceeding from the pressure of an intra- pelvic abscess lying on the sacral plexus. Inability to support the weight of the body occasions an insecure, ivriggling gait, from side to side. There may be the additional symptoms of some difficulty in micturition and defsecation. Sioelling makes its appearance over the joint ; it is pulpy and elastic, and of an elongated shape in the line of the articulation. The limb is apparently elongated, owing to a droop- ing of the pelvis on the diseased side, the limb being disused to support the trunk ; and this side of the pelvis is tilted forwards. Conse- quently, the anterior superior spine of the ilium is both on a lower level and more prominent forwards, than on the sound side. Measure- ment, however, from that prominence to the inner malleolus shows that the limb is not elongated ; that any apparent lengthening^ — say, half an inch — is not due to any change in the three large joints, or in the bones of the limb ; but that it must depend on some alteration above the anterior superior spine. Usually, the limb is straight, and becomes toasted as the disease progresses. Abscess occurs at a late period. It forms over the diseased articu- * St. George's Hosp. Mas., Ill, 93. 1024 SPECIAL PATHOLOGY AND SURGERY, lation, but spreads in various directions. The matter may point pos- teriorlj near the articulation, passing upwards perhaps to the loin, upon and just above the crest of the ilium, there forming a fluctuating swelling of considerable size ; or extending outwards over the buttock, it reaches forwards nearly to the trochanter, as a great gluteal abscess. In both these situations, lumbar and gluteal, the abscess is extra-pelvic. Litra-pelvic abscess, the matter accumulating within the pelvis, may pass out of the sciatic notch, and thence under the gluteal muscles ; or gravitate downwards into the ischio-rectal fossa, and present by the side of the rectum, or vagina ; or open into the rectum and discharge per anum. Shortening of the limb takes place, in consequence of, and proportionate to, the destruction of the sacro-iliac articulation. In one case, related by Sir B. Brodie, the ilium seemed displaced and drawn upwards, so as to shorten the alfected limb by two inches. The diagnosis will have to be made between this disease, and that of the hip, disease of the pelvic bones, saci-al caries, spinal disease, neuralgia of the hip, and sciatica. As compared with disease of the hip-joint, sacro-iliac disease differs m.ore or less notably in nearly all the symptoms : the loose, wriggling gait, — rather than dragging lameness of the limb; the early accession of pain, and its situation — in the sacro-iliac joint, — with the absence of pain in the hip-joint and the sympathetic sensation on the inner side of the knee. The absence also of hip-stiffness, and thence of pelvic mobility on the diseased side, is further characteristic ; although extreme and painful movements of the thigh may communicate a movement to the whole pelvis, from the lumbar spine. The swelling which supervenes corresponds to the articulation which is affected. Observing these signs, and the conspicuous absence of others, the Surgeon will not be misled by certain features of resemblance to disease of the hip-joint — in the apparent lengthening of the limb on the affected side, accompanied with downward obliquity of the pelvis on that side ; but it will be noticed that the anterior superior spinous process of the ilium is not only lower — it projects forwards and is viore prominent, in sacro-iliac disease, consequent on a tilting of the ilium forwards on the diseased side. I would not dwell on the attitude of the limb, which is usually straight, or very slightly bent at the groin and knee, perhaps also somewhat abducted and everted — altogether looking like a useless limb, the patient resting his whole weight on the other side. Ultimately, shortening takes place, and wasting, as destruction of the sacro-iliac articulation progresses. Pelvic caries, with abscess, is distinguished from sacro-iliac disease by the different situation of the presenting swelling — in the iliac fossa, or at the tuberosity of the ischium ; and there is no pelvic obliquity and prominence of the anterior superior spinous process. No shortening of the limb ensues. Sacral caries may exist independently, or be conjoined with sacro- iliac disease. The cancellated portion of the bodies of the sacral vertebrae being the seat of the disease, the signs are obscure ; but the swelling, and even the pain, are located more over the sacrum, and, low down, maybe detected per rectum. Abscess points near the great trochanter, in the course of the pyriform muscle, or in the groin, as a pelvic abscess, or it may be diverted into the ischio-rectal fossa. DISEASE OF THE SACRO-ILIAC JOINT. 1025 Spinal caries can hardly be mistaken ; for, being seated commonly in the dorsal region, the angular excurvation of the spine is removed from the sacro-iliac articulation. Neuralgia affecting the hip is unattended with all those objective signs which relate to structural disease; and the severity of the pain, its paroxysmal character, and migration perhaps to some other part of the body are very unlike the tender or fixed painful swelling of sacro-iliac disease. The age and sex of the patient will probably aid the diagnosis ; a young, hysterical female complaining of intense pain about the hip, diffused, superficial, or even cutaneous, and aggravated by the slightest handling, is not an affection likely to mislead the experienced Surgeon, who is intent upon discovering any evidence of structural disease. Sciatica also, as a painful affection, will be traced in the course of the great sciatic nerve, from the great sciatic notch downwards, external to, and lower down than, the pain of sacro-iliac disease ; and which is unaccompanied with any swelling or other objective evidence of structural disease. Occurring, generally, at a more advanced period of life, and associated with a rheumatic tendency, our sciatic patient is soon recognized as a far more familiar friend than the very rare case of sacro-iliac disease we may happen to meet with. Causes. — -Acute inflammation of this articulation may result directly from injury ; as in a case given by Louis, a sack of corn having fallen on the loins of a man who was stooping at the time. In Sir B. Brodie's case, the symptoms seemed referable to pregnancy, four years previously. From the histories of fifty-eight cases collected by Dr. C. T. Poore,* of St. Mary's Free Hospital, New York, it appears that iu eleven the disease was the result of relaxation of the articulation consequent on pregnancy or pysemic abscess. To rheumatism or gonorrhcBa, one case each may be assigned. The disease has a scrofulous origin — according to Mr. Erichsen's experience ; but he has never seen it in young children, only in young adults, from fourteen to thirty years old. jS"o difference of liability can be traced to sexual predisposition, beyond the tendency ai-ising from pregnancy ; and in the above series of cases, there were thirty males to twenty-seven females. The ages ranged from four years, as the earliest period of life, to sixty-one, as the oldest. In one case only, both articulations were affected. I have seen but one case of this disease, of which the history, by my notes, was briefly as follows : — F. H. H., aged eight, a weakly child from birth. The mother states that her four other children all died of water on the brain. Five years ago, this child fell down a long flight of stairs. Four months subsequently, she limped from side to side, in walking, like the motion of a milk-girl in carrying her pails. Shortly afterwards, she had intermittent fever, which lasted about two months. She met with a second fall down a flight of ten steps, and afterwards the limping gait became more marked. Then, the right gluteal region was observed, by her mother, to be larger than on the left side. For two years she continued to walk on crutches. During this period, some slight curvature of the spine had taken place, in the loins, and a spine-support was put on by a Surgeon at the Orthopaedic Hospital, in Oxford Street. A swelling presented near the vagina, on the right side, and that in the gluteal region remained. In April, 1866, ^ * American Journal of Medical Sciences, January, 1878. VOL. I. 3 u 1026 SPECIAL PATHOLOGY AND SURGERY. she was admitted to the Royal Free Hospital. The symptoms were those of the disease in an advanced stage ; abscess occupied the whole of the buttock, and pointed near the vagina, being therefore both extra-pelvic and intra-pelvic. Shortening of the limb, to a slight extent, had occurred, above the anterior superior spine of the ilium. The Course of this disease, as already indicated, is most unfavour- able ; and thence the prognosis is equally so. Continuing for months or years, the termination is nearly always fatal. In Sir B. Brodie's case, however, although shortening had taken place, recovery ensued. Treatment. — The same treatment, local and constitutional, as for disease of the hip-joint, represents the little that can be done in dis- ease of the sacro-iliac aiticulation. Counter-ii-ritation may have some beneficial influence on the carious disease ; but recumbent rest of the articulation is more important, and is to be secured by weight-extension from the foot, with a long external splint to steady the limb. Removal of the diseased articular surfaces, by excision, is, of course, out of the question ; but the removal of any carious portion, by gouging, or the extraction of a sequestrum, will be within the reach of art. Deep abscess may be drained, and washed out with weak antiseptic solution. In the event of recovery, the relaxed joint should be supported by a pelvic belt, controlling also the hip. Disease of the Shoulder-joint. — The shoulder-joint is i-arely the seat of disease, and few cases are recorded. Omitting rare in- stances of morbid gi'owths in connection with the humero-scapular articulation, and speaking from a large experience with regard to inflammatory affections of other joints, I have met with disease of the shoulder-joint in the form of caries very seldom, and as synovitis occasionally. Of chronic rheicmatlc arthritis or synovitis I now and then see a case ; and I have known acute synovitis, from exposure to cold, proceed rapidly, within forty-height hours, to suppuration and destruction of the joint; or again, abscess, of traumatic origin, has formed in the course of six months, giving a chronic chai'acter to the disease. But the following case is perhaps unique. The synovitis was of rheumatic origin, yet it proceeded slowdy to suppuration, and with the formation of a very lai'ge chronic a?>sce.ss in, and around, the joint; and the extra-articular portion being bilocular, lying partly under the deltoid muscle and in the axilla, and partly in the supra-scapular fossa. This suppurative synovitis resulted in complete destruction of the articular surfaces, leaving the capsule entire except an opening on the inner side, which communicated with the external abscess. The particulars relating to the clinical history and characters of this disease are worthy of notice. A man, setat. forty^tlu'ee, whose father had suffered much from rheumatism, had himself experienced rheumatic pains, chiefly in the hips, loins, and back, never in the knees or ankles. A year previous to my seeing him, he was laid up with such an attack, which lasted four months. He had never been quite free from pain since in the parts affected, and dates his present illness from that attack. At the end of nine months he first felt pains in the right shoulder, with a return of pain in the hips ; this attack having come on after straining efforts in using a chopper, which was his customary work. The shoulder pain gradually became more severe, and a month after its accession, a diffused swelling appeared all around the joint, giving some relief. DISEASE OF THE SHOULDEK-JOINT. 1027 Having suffered more or less in this state for two months longer, the man came under my care, in the Royal Free Hospital, November 30, 1881. The joint was then acutely painful, especially in the motion of abducting the arm, and this movement was attended with a dry creak- ing sound. The shoulder appeared double the size of that on the other side, owing to a considerable fulness of the deltoid muscle, and this swelling had a semi-fluid consistence, as felfc through the substance of the muscle, beneath which it evidently lay. The contour of the shoulder gradually enlarged, and then a second, softer swelling ap- peared in the supra-scapular fossa, which seemed distinct from the former around the joint, the indistinct fluctuation of the one swelling not apparently communicating with the other. I of|;en tried to deter- mine this question, not only by palpation, but also by patting the joint through its various move- ments, but whatever al- ^^' " tered relation the periarti- cular enlargement could thus be made to assume, the supra-scapular swell- ing remained unaffected, whether in point of size, tension, or the transmis^ sion of any fluctuation. At length the swelling beneath the deltoid ex- tended downwards into the axilla, and somewhat forward to about one inch under the clavicle. The whole appearance, so far as it could be included in one aspect, is represented in Fig. 510. Starting pains now occurred at night, and when the man attempted to raise the arm he felt a " click " in the joint. The general health remained undis- turbed by pyrexia ; but marked albuminuria made me unwilling to subject the joint-condition to any operative interference. Aspiration was resorted to, partly with the view of determining the diagnosis as to the presence of a large chronic abscess, or a soft fast-growing sarcoma. The supra-clavicular swelling was first appealed to ; it yielded a fluid too thick to pass through a large-sized aspirating needle. About a drachm having been withdrawn, it was found to consist of pus, with a large admixture of fatty cells. Aspiration of the axillary portion of the joint-swelling gave issue to a similar fluid. Another attack of severe pains in nearly all the joints was followed by a notable enlarge- ment of the shoulder. But the proportion of albumen in the urine diminished from a fourth to one-eighth, the specific gravity remain- ing at the same point, 1005, and the reaction acid. The general rheumatic attack seemed, however, to concentrate at length in the 1028 SPECIAL PATHOLOGY AND SURGERY. right hip, "which became exceedingly painful, with some swelling round the gi-eat trochanter. Choosing the best opportunity for operation, I opened the axillary tumour by incision ; only a small quantity of pus escaped, and then a drainage-tube was inserted. My usual di'essing, dry lint and taenax, was applied. The discharge from the axilla continued, and certainly brought relief. But the shoulder remained full and tense. It was, therefore, deemed desirable to repeat the operation over the joint. A longitudinal incision, from the acromion downwards, to the extent of four inches, gave free and dependent exit to a quantity of sanious pus, and allowed also of the introduction of the finger, so as to explore in all directions. The swelling around the joint evidently did not communicate wdth the supra-scapular swelling, the abscess was bilocular. The capsule of the joint was found to be entire, except a small opening on the inner side ; and as the articular movements were perfect, and without any grating sensation, the articular sur- faces were unaffected at this period of the case. A second incision was made in the supra-scapular swelling, and that cavity emptied. A drainage-tube inserted into either cavity, that round the joint, and that which lay above the scapula, provided a free exit for any dis- charge from both. A third drainage-tube in the previous axillary opening prevented any bagging in that direction. The wounds were otherwise closed, united with silver wire, and dressed with dry lint and tfenax pads. These procedures proved to be very salutary. The discharge con- tinued, but of a fairly healthy character, and daily diminishing in quantity. On the sixth day very little was found on the dressings. The temperature, which before opening the abscess had been 101'2°, fell to 99°. The general health rallied, the patient feeling stronger and taking more nourishment. But after a few days' further improve- ment, albuminuria prevailed to an overwhelming degree, and the man rapidly succumbed. Post-mortem examination revealed nothing beyond the usual ap- pearances of old-standing disease of the kidneys, and concomitant changes in other organs. The shoulder- joint had undergone complete destruction of the articular cartilages, exposing two or three patches of caries on the head of the humerus, and the glenoid cavity being also completely denuded. The capsular ligament remained entire, except on the inner side, a small opening there communicating with the large extra-articular bilocular abscess. The whole case is anomalous and instructive in its exceptional character among diseases of the joints. DEFORMITIES OF FACE AND NECK. 1029 CHAPTER XXXVIII. DEFORMITIES.* This large branch of Surgery forms the subject of several special Treatises. An abstract only — so far as the present discordant opinions respecting much of the pathology and treatment of Deformities will allow — can be given here ; sufficient for the requirements of the general Student, and for reference, in accordance with the design of this work. Deformities may be arranged in two general classes : — 1, Acquired Deformities ; 2, Congenital Deformities and Malformations. Class 1 embraces those deformities pertaining, in origin or result, to:— (1.) The Integuments — Burn-cicatrices. (2.) Bones — Fracture-union deformity. Rachitis, and MoUities Ossium. (3.) Joints — Dislocations unreduced. Diseases of joints with Anchylosis, and Malposition of the Limb. (4.) Musculo-JS^ervous System. Spinal Curvature — Lateral. Deformities of Face and J!^eck — Wry-neck — Squint. Deformities of Arm and Hand — Contractions. Deformities of Leg and Foot — Relaxatious and Contractions — Knock-knee — Bow-leg — Some forms of Club-foot. The first three of these sub-classes are considered in connection with other Injuries and Diseases. Class 2. Deformities and Malformations also are thus associated ; — e.g., with Congenital Dislocations, and with the pathology of Organs and Regions — Hare-lip, extroversion of the Bladder, etc. It remains only to notice here the affections included in the last sub-class (4) of Class 1 ; associating therewith any remaining De- formities of musculo-nervous origin or character, as that of congenital club-foot. Even in this sub-class. Spinal Curvature is more conve- niently considered elsewhere. Lateral Curvature of the Spine. — See Spine. Deformities of Face and Neck. — Wry-neck or Torticollis. — This deformity is a twist of the head and neck to one side, in the directions of action of the sterno-mastoid muscle ; the head being drawn down- wards, sideways, and rotated in the opposite direction to the contracted muscle. The ear of the affected side is drawn down towards the clavicle. In proportion to the duration of this deformity, the face is turned askew, the features losing their symmetry. The sterno-mastoid muscle is shortened, firm, and stands out prominently, as compared with that on the opposite side. Other muscles apparently become involved, the anterior margin of the trapezius acquiring an outline which defines the posterior boundary of that named triangular space of the side of the neck. The cervical vertebrae slowly undergo lateral curvature with rotation. * Revised and enlarged by William Adams, F.R.C.S. 1030 SPECIAL PATHOLOGY AND SURGERY. Causes. — Congenital wry-neck is the most common form of this affection. On the side of the deformity the head, neck, and shoulder appear to be considei-ably smaller than the parts on the opposite side, the shoulder and scapula unduly raised, and the features drawn down and unsymmetrical. The sterno-mastoid muscle is shortened, hard, and tense. Curvature of the cervical spine has taken place, latei-ally to the opposite side, and a compensating curve in the opposite direction lower down. Spasmodic contraction of the sterno-mastoid muscle of the affected side is a very rare cause of the deformity, — then known as spasmodic wry-neck. In this form the spinal accessory nerve would seem to be the source of this muscular action, and hence its extension, to the trapezius muscle. The spasm is remarkably jerking, painful, and constant, excepting during broken sleep, and it continues for naany years ; the sufferer ultimately sinking exhausted. This kind of wry-neck usually commences about the age of thirty, and in females not apparently hysterical, but whose families have an hereditary tendency to other cerebro-spinal affections. Sometimes, however, it is a symptom of hysteria. Paralysis of one sterno-mastoid is a cause of paralytic wry-neck. The head is drawn to the opposite side by the healthy muscle, not being counteracted by its antagonist. Disease of the cervical vertehrce, of scrofulous or rheumatic character, occasionally gives rise to this deformity. The exciting cause would appear to be, not unfrequentl}", exposure to cold, or some occasion of local irritation or inflammation of the cer^acal glands, resulting in stiffness of the neck. Burns of the neck, followed by contraction of the cicatrix, occasion remarkable distortions resembling wiy-neck ; but not depend- ing on any affection of the muscles, they are thus distinguished from wry-neck thence arising. Treatment. — Tenotomy, or the subcutaneous division of tendons and muscles, represents a principle of treatment, applicable to a large class of conditions, for the cure or correction of deformities depending on muscular contractions. Thilenius, of Frankfort, divided the tendo- Achillis about 1789, followed by Sartoi-ius in 1806, and Michaelis m 1809 ; but Delpech (1816) originated subcutaneous tenotomy as a method of treatment, and laid down the rules as to the exclusion of air, etc.,* essential to the performance of this operation. Stromeyer still further improved the operation, and brought it into practice in 1831 ; followed by Little and other Surgeons, who have established its remedial eflScacy in various branches of surgical practice — con- stituting Orthopgedic Surgery. Division of the sterno-mastoid muscle, subcittaneously. — This pro- cedure affords more or less complete relief of tension, when wry-neck deformity depends on contraction of the sterno-mastoid muscle. In congenital wry-neck, tenotomy is most successful ; in spasmodic wry- neck, less so ; while in the paralytic form, and that arising from disease of the cervical vertebrse, this operation will be unnecessary or useless. The muscle should be divided close above the clavicle, the situation of least risk to subjacent parts. By introducing a narrow- bladed tenotome just above the sternum, the steimal attachment of the muscle is divided ; and then the clavicular attachment, by re- puncturing the integument in that situation. This precaution is safer than division of the muscle by one incision ; as the two portions * " De rOrthomorphie," tome ii. p. 330. 1828. STRABISMUS OR SQUINT. 1031 Fig. 511. are not on the same plane, and passage of the knife to a sufficient depth for that purpose would be dangerous. Complete division is accompanied by a very sensible crack, and some alteration in the attitude of the head. Immediately after operation, Dr. Little found the difference in length between the affected and sound muscle reduced more than one-half. The advantage gained by this operation must be followed np by mechanical means, to maintain and gradually complete the readjust- ment of the head in position ; otherwise, the divided portions of muscle reunite, and the deformity returns. An apparatus represented by Mr. Bigg (Fig. 511), or that used by Mr. Adams, in which rotation is combined with the other movements, answers this purpose, by counteracting any tend- ency of the head downwards, sideways, and outwards, and thereby restoring it to its vertical position, and the chin to the middle line. Dr. Little highly commends cautious manipulation daily, as well as the use of a retentive ap- paratus. This after-treatment must be continued for a period varying from two to three or six months, when permanent cures have been accom- plished. If an hysterical affection, wry-neck should be submitted to the general treatment for hystei'ia, as noticed in connection with Deformities of the Arm and Hand. Paralytic wry-neck may perhaps be rectified by electricity, and other measures for the restoration of nervo- muscular action. A steel-spring cravat, or other contrivance for supporting the head, is the only mechanical resource available. Disease of the cervical vertebrae, as the cause of wry-neck, can be remedied only by the measures — medicinal, dietetic, and hygienic — appropriate for the particular constitutional condition ; and by wearing a well-adjusted, supporting, and slowly rectifying apparatus. Strabismus oe Squint. — A want of parallelism in the axes of the eyes, whenever both are directed to an object at the same time. This habitual malposition of the eyes results from irregnlar action of the internal or external rectus muscle ; the one producing convergent strabismus — the eye being directed towards the nose ; the other, diver- gent strabismus — the eye being dii-ected towards the temple. Either form of strabismus maybe single; doiible, ^vheTi both eyes converge or diverge. The latter direction is rare, and consequent on loss of sight in one eye, which has lasted for years. Causes. — Strabismus may arise fi'om a cause remote in some distant part of the body, of which the squint is symptomatic ; or from various 1032 SPECIAL PATHOLOGY AND SUKGERY. local conditions pertaining to the eye ; but more frequently from the fonner class of causes. Thus, this affection arises from intestinal irritation or teething ; or from disease of, or relating to, the brain, as hydrocephalus. It may be consequent on certain blood conditions, as measles or scarlatina, among the eruptive fevers. Inflammatory or other diseases of the eyeball, conjunctiva, or eyelids represent the class of local causes. Extreme shortness of sight, compelling the patient to converge both eyes in looking at near objects, may also induce strabismus ; and it sometimes results from the influence of insensible imitation. Treatment. — Removal of the cause, in any case, will probably restore the regular and equal action of the recti muscles. Hence, any source of irritation in the intestinal canal or elsewhere should be sought for, and removed, if practicable. Persistent causes render this principle of treatment impracticable, and strabismus must then be rectified as an effect, by division of the contracted muscle. This operation, first introduced in 1840, has since been modified. It now consists in sub- conjunctival division of the muscle affected ; commonly the internal rectus. The details of this procedure are' described in the chapter on Diseases of the Eye. Deformities of Arm and Hand. — Contraction of the muscles of the upper extremity differs from those of the lower extremity, in so far as the individual muscles of their analogous parts perform functional movements, more delicate, varied, and complex. Various muscles may be affected, producing deformities which correspond to their respective functions. Thus, contraction of the biceps is accompanied with per- manent flexion of the arm ; or the extensors of the forearm, the flexors of the fingers, or those of the wrist, or the pronators, may be severally engaged. As affecting the fingers, muscular contractions produce forms of club-hand. Hysterical contractions are met with, either of a spasmodic or tonic character ; but these muscxilar affections are distinguished by an absence of any evidence of local disease, as thick- ening or adhesion, or of any traumatic origin, as a blow or strain. They arise spontaneously, as it were, and, after a while, as capriciously cease ; and are associated with other manifestations of hysteric con- stitutional disease. Some such cases are graphically told by Mr. Skey in his Lectures on this subject. In an hysterical affection, the search for any locally causative condition will often be in vain. Its evil origin lies deeper, as a constitutional malady, the offspring perhaps of an hereditary predis- position, or of a vicious social education. The prominent elements of hysteria — general debility and muscular irritability — are, however, not unfrequently associated with some disordered function of the uterus, or of the digestive organs ; in males especially, hysteria being manifested as a rare expression of the bilious or hypochondriacal temperament. Treatment must have reference, primarily, to removal of the cause of contraction or paralysis, if possible. 'Hysterical contractions — rarely admitting of any such radically curative treatment — may per- haps be overcome by remedial measures of a medicinal and hygienic character. A course of tonics and anti-spasmodics — iron and qainine, in their various preparations ; the sulphate of copper or zinc ; nitrate of silver; the preparations of valerian, assafoetida, or ether, sulphuinc DEFOEMITIES OF ARM AND HAND. 1033 ether in particular — may prove effectual in different cases ; but any such treatment must be accompanied and reinforced by the judicious exercise of body and mind, aided by the salutary influence of pure air and sea-bathing, when the latter can be borne. The uterine and digestive functions must be regulated by appropriate treatment. Topical applications, of a sedative character, to allay pain and spasm, as by opiate ointment or the hypodermic injection of morphia, the ointments of belladonna or aconite, seldom afford more than temporary relief. The inhalation of chloroform has the same effect; but its relaxative influence is of value chiefly in the examination of the part affected, to determine the nature of the contraction. In hysterical contractions, as a general rule, all surgical interfer- ence by tenotomy and mechanical means is counter-indicated. In these cases the contractions are always aggravated by mechanical appliances, and they quickly relapse after tenotomy. Shampooing and manipula- tions maybe sometimes useful, but general rather than local treatment must be relied upon. In a few exceptional cases of long standing in which permanent contraction has occurred, more especially at the knee-joint, tenotomy and mechanical means may be employed to straighten the leg, and enable the patient to walk. Contraction of the Fingers, as depending on the 'palmar fascia, should be distinguished from contraction of nervo-muscular origin. The pathological condition was discovered, on dissection, by Dupuy- tren, and published by him in the year 1832, in his " Le9ons Orales de Clinique Chirurgicale." His account was afterwards verified by Goyrand, and other observers. It is said to result not unfrequently from habitual pressure on. the palm of the hand, as in bearing on a knob-headed walking-stick, or using an instrument which has this effect, in the exercise of various trades ; but this mode of origin is doubtful. But, without any ap- parent exciting cause, a rheumatic or gouty diathesis may give rise to chronic thickening or ^^^- ^^^' hypertrophy of the palmar fascia, in the form of projecting ridges extending towards the palm of the contracted fingers (Fig. 512). Mr. Adams believes that neither the tendons, nor the sheaths of the tendons in the palm of the hand, are ever involved, the fascia alone being affected, generally in the palm of the hand at first, and then the digital prolongations to the first and second phalanges. Sometimes, though rarely, the thick- ening and contraction of the fascia commences in the fingers, over the first and second phalanges, and in these instances either the second or third phalanx may be first drawn down. The little finger and the ring-finger are commonly affected first, and most severely ; the middle and forefingers less in frequency and degree, while the thumb is rarely involved. The articulations are usually free. It is a painless affection, and progresses very slowly ; thickening and contraction proceeding until the fingers may become tightly clenched, and even the nail pressed into the palm. Both hands sometimes undergo contraction, and symmetrically; or the 1034 SPECIAL PATHOLOGY AND SURGERY. disease may be associated with a similar hypertrophied condition of the plantar fascia in the soles of the feet. The treatment is, in principle, the same; manipulations, with mechanical extension, may be tried in the early stage, but severe con- traction can only be overcome by subcutaneous division of any tense fascial prolongations binding down the fingers. Mr. Adams recom- mends the subcutaneous division of all the contracted fascial bands, and immediate extension, or extension, as rapidly as it can be borne without pain. Sometimes, owing to firm adhesion of the skin to these bands, it has been the practice of some Surgeons to make a long incision and dissect back the skin on either side ; the bands must then be divided or dissected out. After either operation, the fingers are to be straightened and retained in position on a splint. In the case of a clergyman, aged seventy-nine, the tendons were involved, apparently as the result of chronic rhcnimatic inflammation, and presented an appearance nearly like that depicted in Fig. 512. Both hands were similarly affected. Being a man of uncommonly robust constitution, Mr. Gant performed tenotomy on the right hand, and then applied a palmar splint, padded so as to separate the divided ends of tendon by about half an inch, under a small lint compress ; in the course of a week, gradual extension was practised, and the fingers were brought down straight, whereby the free use of the hand became quite restored. Some tendency to the recurreaice of conti-action was checked by wear- ing for a time finger stalls, with elastic extending braces, attached to a wrist-band, — a little contrivance made by Mr. Bigg. As a rale, tendons in dense sheaths are unfitted for tenotomy; suppuration taking place up the sheath, or non-union of the ends of tendon. Congenital Deformities of the Fingers may be met with. Erichsen saw a case in which the fingers appeared as if they had undergone _ complete or partial amputation m utero. Some were marked by deep transverse sulci, others shortened and terminating in rounded nodules, with a nai'row pedicle attaching them to the proximal phalanx. Supplementary fingers, or a thumb, are found in some cases (Fig. 513). Deformities of Leg. — (1.) KnocJc-knee or In-l-nee — • Genu Valgum. — This deformity is an inward yielding of the knee-joint, the result of weakness of the ligaments and muscles which support the joint in that direction. It happens not unfrequently, and usually both knees are affected; giving the person a singularly ungraceful attitude when standing-, and in walking the knees knock and roll over each other with a shuffling gait. ^Sv^ -^ The causes of knock-knee are apparently mechanical ; Y' *^ some occasion of undue strain on the knee. It mostly arises from trying to make a child walk too early, or it may occur in tall, rapidly growing lads fi'om the age of twelve to eighteen ; in either case the knees yielding under the weight of the body. Habitual over- walking, exercise or fatigue in standing, has the same result. Hence certain occupations are causative ; and any habit of resting on one leg, or defect in the opposite limb, whereby an increased strain is thrown upon the sound limb, may induce this de- formity. But a rachitic tendency, or other constitutional condition of impaired nutrition, can often be traced as the predisposing cause. DBFOKMITIES OF LEG. 1035 Fig. 514. Treatment. — Eemoval of the cause in operation, will sometimes prove sufficient. Thus, if the attempt to make a child walk at too early a period be discontinued, an incipient knock-knee may disappear. Mechanical support is the only sure means of preventing* further deformity, and of restoring the limb to a proper shape, by allowing the ligamentous structures to gain sufficient strength. The patient must be placed in " irons." An iron stem, on the outside of the limb, extending from the trochanter to the outer ankle, is fixed by a pelvic band above, and into the boot below. A hinge in this rod at the knee allows of motion ; while, by means of a leathern pad furnished with straps, applied on the inner side, the joint is secured to the stem above and below the hinge, and drawn out- wards by tightening the straps (Fig'. 514). In more severe cases the knee must be fixed during a period varying from three to six months ; then freedom of mo- tion may be allowed for a part of each day during a similar period ; and, lastly, per- fect freedom a few months before the sup- port is discontinued. The total average duration of treatment, in advanced child- hood and bad cases, will probably extend to two years. Division of the external lateral liga^ ments, or of the biceps tendon, has been practised in obstinate cases ; but this, or any cutting operation, is not now con- sidered necessary. Constitutional treat- ment for the improvement of nutrition will aid the mechanical cure.. In very severe cases, when the arti- cular surfaces of the condyles of the femur, and the head of the tibia, have become altered in shape by the obliquity of the pressure during the period of active growth, osteo- tomy has been performed with great success, either by the subcutaneous method of Professor Ogston, of Aberdeen ; or by the less perfectly subcutaneous method of Dr. W. Macewen, of Glasgow, with antiseptic precautions. Professor Ogston, after making a puncture a little above the inner condyle, and opening the capsule of the joint, passes Adams' subcutaneous saw into the knee-joint between the condyles, and then completely detaches the inner condyle, which by a little movement is readily displaced upwards, and the articular surfaces of the condyles is at once overcome. Usually little or no inflammation follows the operation, and after two or three weeks' immobility, the motion of the joint is gradually restored. Dr. Macewen * avoids opening the knee-joint, and divides the shaft of the femur partly through, a Little above the condyles, with a chisel, completing the separation by fracture. The leg is then put up in a straight position and the deformity overcome. This operation is rarely followed by inflammation, and has been performed in a large number of cases. (2.) JBoived, or Bandied Legs — Gemi, Varum — present the opposite * "Antiseptic Osteotomy for Genu Valgum/' by W. Macewen. Glasgow, 1878. 1036 SPECIAL PATHOLOGY AND SURGERY. state of deformity of the Knees (Pig. 515). This deformity arises from relaxation of the external lateral ligament, and not, probably, from any contraction of the biceps femoris muscle. The treatment will consist in a form of apparatus to correct Fig. 515. eversion of the knee. ^^^- 516. Bow-Legs. — This deformity consists of a passive yielding and curv^ature of the tibia and fibula outwards, occurring either in delicate children with imperfect ossification — usually traceable to im- paired nutrition from inadequate supply of milk — or in children affected with general rickets. In slight cases, constitutional treat- ment, especially administering the hypo- phosphite of lime, with iron, and cod- liver oil, will be sufiicient ; but the child should not be allowed to stand long upon its legs at any one time. In more severe cases, an inside splint, attached to the boot and caiTied upwards on to the knee- joint (Fig. 516), should be applied. In either kind of deformity, Grenu Valgum or Varum, the condyles and articular surfaces of the femur and tibia at length undergo changes of form, which are inciu'able. Hence the importance of early treatment. (3.) Contraction of Knee-joint. — Unconnected with disease of the joint, resulting in anchylosis with malposition, simple contraction of the knee is liable to take place. The deformity may be eithev flexion of the leg on the thigh, at an angle of various degrees, or, combined with this state, some distortion laterally inwards, with rotation of the tibia Fig. 517. outwards. Displacement backwards of the head of the tibia, the end of the femur and patella projecting forwards apparently, is associated with rather an extended position of the leg, and laxity of the joint. The cause of these deformities — apart from joint-disease — seems to be some affection of the hamstring muscles, which induces their con- traction, and shortening ultimately. This may be a purely hysterical manifestation, and accompanied with other symptoms of the same constitutional disease. Treatment must have reference to the apparent cause of contraction. The more fugitive state of hysterical contraction can be overcome under the relaxing influence of chloroform ; the limb is then at once TALIPES OK CLUB-FOOT. 1037 brought down to a straight position, and retained by two lateral splints (Fig. 517). Or, reduction is gradually accomplisbed by a regulated extending apparatus (Figs. 518, 519). Division of the ham- string tendons may be necessary, fol- lowed by extension. Mr. Gant has done this, in some cases, with entirely satisfactory results. The biceps and semi-tendinosus always require division ; the semi-membranosus, seldom. This renders the operation more superficial and simple than it would otherwise be. Talipes or Club-foot. — Four forms of club-foot are recognized : talipes equinus, or elevation of the heel ; talipes varus, or inversion of the foot ; talipes valgus, or eversion of the ^^'^- ^^^' foot ; and talipes cal- caneus, or depression of the heel with ele- vation of the anterior part of the foot. Varieties of club-foot consist of combina- tions of two of these forms, the principal of which are — equi- no-varus, equino- val- gus, calcaneo-varus, and calcaneo- valgus. (1.) TalipesEqui- nus. — Structural Conditions, and Signs. — In the slighter forms of this affection, which essentially depends upon contraction of the muscles of the calf, and elevation of the os calcis, there are no structural changes affecting the bones ; but in cases of long standing, certain bones of the tarsus — the astragalus, scaphoid bone, and calcaneum — have undergone alterations from their normal con- dition. Diminished in size somewhat, the astragalus, in particular, is reduced, its natural articular surfaces for the tibia and fibula are partially deprived of cartilage, and new articular relations have formed posteriorly, more or less in that direction according to the degree of the talipes. The calcaneum may even contribute to this new articu- lation. The head of the astragalus, diminished in size, has an un- usually small articular facet in its connection with the scaphoid bone. The latter bone, also reduced in size but unaltered in shape, is drawn downwards ; thus presenting the head of the astragalus prominently on the dorsum of the foot, while a considerable portion of its upper surface has- slid from under the tibia (Fig. 520). The calcaneum, small, and perhaps articulating with the tibia, has a more limited connection with the cuboid bone ; and as the latter bone, with the scaphoid, is drawn downwards, the anterior and upper portion of the iFiinpWT^ 1038 SPECIAL PATHOLOGY AND SURGERY. calcaneum also projects forwards on the dorsum of the foot. The Fig. 520.* Fig. 521.+ Fig. 522.1 other bones of the foot, somewhat smaller than natural, retain their normal characters ; the remain- ing tarsal and the metatarsal bones conform to the general cur- vature — an increased convexity forwards, an increased concavity backwards ; but the toes are usually extended horizontally, and froiTL constantly bearing the Aveight of the body, the breadth of the fore portion of the foot becomes increased. Thus, then, the heel drawn up, in this form of talipes, brings the tarsus to nearly a vertical line under the tibia, whereby the weight is transmitted to the toes, on which the patient rests in standing or walking (Fig. * Talipes eqainns ; the deformity depending chiefly upon flexion of the foot upon itself from the transverse tarsal joint, in line a a. (After W. Adams.) t Talipes eqninvis, u-ithov.t paralysis of the extensor muscles. Extension of the toes upwards, from their metatarsal articulations, on which the foot rests. (From W. Adams.) X Talipes equinns, with paralysis of the extensor muscles. Backward flexion of the toes, from their metatarsal articulations, on which the foot rests. (Ibid.) TALIPES OE CLUB-FOOT. 1039 521) . But the fore part of tlie foot may be completely retroverted, so that the sole forms an acute angle with the projecting heel, and the weight is borne on the dorsum ; the cuticle there acquiring a thickened, horny character, as if it were on the sole of the foot. This callosity is liable to ulcerate or slough. In a slighter case the toes are retroverted (Fig. 522), and the weight thrown upon the ex- tremities of the metatarsal bones. The ligaments are relaxed and shortened, corresponding to the altered relations of the bones ; which facilitates the progress of the deformity, and impedes restoration of the foot to its natural position. The muscles, however, are the active agents in the production of talipes, one nauscle or set of muscles over- balancing another and antagonistic muscle or muscles. In talipes equinus, the gastrocnemius muscle is contracted. Fatty and fibrous deg'eneration of the muscular tissue ensue, as the result of old-standing talipes, especially when of paralytic origin. This form of talipes is usually single ; but both feet are sometimes clubbed. Causes. — The disturbed equilibrium of muscular action, in the pro- duction of club-foot, may be spasmodic, when referable to the contracted muscle ; or be due to paralysis of the opponent muscle. Thus, in talipes equinus, spasmodic contraction of the gas- _ ^ trocnemius may give rise to this deformity (Fig. '*^" " ' 623) ; or a paralytic state of the tibialis anticus, or of it and one or more of the other extensors of the foot, be the cause in question. Either muscular affection, spasmodic or paralytic, proceeds from some disease of the nervous centres, commonly of an inflammatory character, Avhich results in effusion or softening ; or, when congenital, some defect of development in the nervous centres may be the causative condition. But spasmodic con- traction is frequently a manifestation of reflex nervous action through the peripheral nervous system, from various sources of irritation ; as teething, or intestinal worms. On the other hand, local irritation is often the cause of contraction ; generally local inflammation, of a rheu- matic, scrofulous, or erysipelatous character, or as a consequence of injury. Thus, the muscles of the calf of the leg may become affected. Talipes equinus may be acquired, or congenital ; the latter very rarely, Tamplin, Lonsdale, and other authorities never having seen such a case. Treatment. — Tenotomy is the only mode of cure, otherwise than when the deformity is slight and pliable. Subcutaneous division of the tendo-Achillis allows the heel to be brought down ; but this must be accomplished through gradual extension, the foot being retained in position by a properly constructed extending apjaaratus. The operation is simple. The patient having been laid prone, the Surgeon grasps the foot and extends it forcibly, thus making the tendon tense and prominent ; a tenotomy knife (Fig. 524) is intro- duced, at either side of the tendon, about an inch above its insertion into the calcaneum ; passing beneath the tendon to the opposite side, the * Talipes equinus, with spasmodic contraction ; the toes extended from their metatarsal articulations, and flexed upon themselves, claw-like. (From W. Adams.) 1040 SPECIAL PATHOLOGY AND SURGEKY. knife is withdrawn througli the tendon slowly, or division may be effected by pressure with the edge of the blade, the tendinous fibres yielding with a creaking resistance, while, at the same time, the fore- FiG. 524. Fig. 525. finger of the left hand is applied over the tendon gently, just to give warning of the approach of the blade to the surface. The foot at once comes into position, or is readily brought down by extension with the hand, as the tendon is divided (Fig. 525). Scarcely more than a drop or two of blood escapes externally, and the puncture is closed by a small pad of lint. The apparatus for extension is known by the name of Scarpa's shoe, or its modification by Liston. Liston's shoe was provided with two curved levers (Fig. 526). The form of apparatus, or shoe, generally used for talipes equinus, is here represented (Fig. 527). It consists Fig. 526. Fig. 527. of a steel splint, a, on the outer side of the leg, with a foot support, d ; both of which are secured by padded belts, h e, around the leg and foot. At the connection of the splint and foot-board, a joint with a cog- wheel, /, worked by a key, regulates the extension. Stromeyer postponed extension until the puncture-wound had healed, and then applied it gradually. Both rules are still observed by TALIPES OR CLUB-FOOT. 1041 Little and other authorities. A pliant splint of pasteboard or metal is applied, after the operation, to retain the foot in its former position. On the fourth day, extension may be commenced, and should be continued gradually until completed in about a month. Union of the tendon thus becomes more perfect, and without entailing any risk of recurring deformity; the new portion of tendon being elongated to a proper length, without weakening it, while the alterations, articular and ligamentous, are slowly overcome. "Walking may be resumed as soon as the movements of the foot are regained, without any tendency to relapse — in, say, six weeks or two months. Ultimately, friction, passive motion, baths, and galvanism prove serviceable in completing the restoration of function. Slight talipes equinus will perhaps yield to mechanical extension, without tenotomy. Selapse sometimes takes place after an apparent cure. This may be remedied by the judicious reap plication of extending apparatus ; or a repetition of tenotomy may be necessary, followed by extension. Paralytic talipes equinus cannot be radically cured by tenotomy, nor by extension, which releases or overcomes the contracted muscles, but does not restore the action of the paralyzed antagonistic muscles. This condition depending sometimes on disease or congenital defect of the nervous centres, may be so far incurable. But, if the paralysis be incomplete, some restoration of power in the muscles affected may be gradually gained by the voluntary exercise of such muscles — the gymnastic or "movement" method of treatment — as of the extensor muscles of the foot, in talipes equinus. The influence of electricity, as a means of exciting contractile power, offers a most valuable resource in these local paralytic affections. This method of treatment must, however, be judiciously conducted ; and is considered more particularly in works on Medical Electricity. Mechanical contrivances may also be used with advantage. The " artificial muscle," used by Mr. Barwell, consists of an india-rubber band, adjusted so as to supply continued traction in the direction of the muscles affected. Similar principles and modes of treatment are applicable in other conditions of paralytic club-foot. (2.) Talipes Varus. — This is the ordinary form of congenital club- foot ; but it also occurs, in a less severe form, as a non-congenital affection, from infantile paralysis. The structural condition is similar, with regard to the alterations of the bones at the ankle-joint, the os calcis being elevated to an extreme degree in a severe case, and the astragalus partly extruded from the ankle-joint ; but the astragalus itself is materially altered in shape, the neck of the bone having an obliquity inwards, and the articular surface of the head of the bone presenting two articular facets — one for articulation with the navicular bone, which is displaced inwards and drawn under the inner malleolus by the action of the anterior and posterior tibial muscles ; and the other facet, left exposed on the outer side by the displacement of the navicular bone, forms a prominence on the dorsum of the foot. In talipes varus the distortion of the foot takes place equally from the two great centres of motion, viz. the ankle-joint and the transverse tarsal joint; whilst in talipes equinus the distortion takes place only from the ankle-joint. The muscles contracted are principally the gastrocnemius, ivith only the tibialis VOL. I. ' 3 X 1042 SPECIAL PATHOLOGY AND SURGERY. anticns and posticus (Figs. 528, 529). The foot is turned inwards, or inverted and adducted ; and these are the characteristic distinctions. Fig. 528.* Fig. 529.t The patient walks on the outer side of the foot (Fig. 530) ; or with extreme inversion, the weight is borne on the dorsum. The cause oi this deformity would appear to be spasmodic muscular contraction in utero, leading to permanent retraction and shortening of the most contracted muscles ; but it has been attributed by some authorities to pressure of the walls of the uterus. It is certainly most Fig. 530.1 frequently congenital; almost as exclusively so, as the equinus form is acquired talipes. Both feet, therefore, are usually affected. When only one foot is the subject of deformity, the right is twice as often affected as the left. A certain liability due to sex is shown by the greater * Congenital talipes varus, in a child aged six months. Anterior view. Ankle-joint, and transverse tarsal joint, a a, are laid open, showing altered relations of astragalus and scaphoid bone ; h, point for division of the anterior tibial tendon. (From W. Adams.) t Posterior view of the same foot, showing relative position of tendons. — a. Point for division of the posterior tibial tendon, just above the inner malleolus ; b, anterior tibial tendon, crossing the inner malleolus, and inclining backwards. The elevation of the OS calcis, and position of its tuberosity behind the fibula, and inclination of the tendo-Achillis, towards the fibula side of the leg, are also shown. (Ibid.) J Congenital talipes varus, in adult. — (1) Anterior view; (2) posterior view. (After W. Adams.) TALIPES OR CLUB-FOOT. 1043 frequency of congenital talipes in male than in female children, the proportion being three to one. Hereditarj influence is often evinced, and bj descent from either parent. Thus, on the father's side, Dr. Little has traced congenital club-foot through four generations ; the male infant, the father, the grandfather, and the great-grandfather. The tendency to hereditary propagation on the paternal side is, perhaps, the strongest argument against the influence of uterine pressure in the production of congenital talipes varus. Treatment. — In slight cases, remedialmeasnres may consist in gradual mechanical extension, aided by passive motion-manipulations. A tin splint should be applied, adapted to the calf of the leg, and provided with a foot-piece jointed at the ankle, the whole being properly padded ; and this should be so adjusted and bandaged as not to forcibly coerce the foot, in undoing the deformity. This method of treatment having failed, or when the varus is more extreme, operative interference must be resorted to, subject to Dr. Little's test — that when the foot is held in the noi-mal position, it springs vigorously back into the abnormal as soon as it is left to itself. The operation should not be delayed longer after birth than two months. Tenotomy for talipes varus consists in subcutaneous division of the tendons of all the contracted muscles ; both the tibial tendons, and the tendo- Achillis. This procedure may be accomplished in one operation in slight cases. But, in severe cases, the compound deformity must be overcome by a double operation ; first, section of the tibial tendons, and of any prominent band of plantar fascia, thus to rectify inversion, coupled with the application of mechanical eversion ; then, secondly, after a lapse of a month in the case of infants, or from two to four months for adults, the tendo- A chillis is divided. The advantage gained by this twofold procedure — first recommended by Dr. Little — is that, in the interval of the two tenotomies, the calcaneum affords a resting- point, fixed by the Achilles tendon, from which to stretch out and unfold the contracted and involuted sole of the foot. Otherwise, in- complete recovery often results ; in fact, a secondary talipes calcaneus may be produced, which deformity it will be difficult or perhaps impossible to overcome. The operation — according to Dr. Little's precise directions — is thus performed ; taking the tendons conveniently in order, as posterior tibial, anterior tibial, tendo-Achillis. The child being laid upon its back, with the limb rotated well outwards, an assistant holds the knee securely, and the Surgeon, seating himself in front, takes the heel of the foot in his left hand, and abducting the foot ynxh his right hand, puts the postei'ior tibial tendon on the stretch, with sufficient prominence to feel it under the left thumb ; or failing in this way to find the tendon, in a fat subject, the guide will be to the inner margin of the tibia, a line drawn exactly midway between the anterior and posterior borders of the leg, on its inner aspect. Then, entering a sharp-pointed tenotomy knife about a finger's breadth above the lower end of the inner malleo- lus, and close to the margin of the tibia, it is passed perpendicularly to a depth of a quarter to half an inch, and an opening made in the fascia ; a probe-pointed tenotome is then introduced between the tibia and the tendon, and this is divided by a slight lever- like cutting motion with the knife, while the assistant firmly abducts and depresses the inner border of the foot. A sudden jerk more or less plainly announces 1044 SPECIAL PATHOLOGY AND SURGERY. the division of the tendon. The puncture is closed with a dossil of lint. This operation may be completed with one knife instead of two ; but it will be safer to substitute the blunt-pointed knife in dividing the tendon, lest the posterior tibial artery be wounded, as in talipes varus the tendon lies unusually close to the vessel. This accident, however, has happened in the most experienced hands. The arterial hfemorrhage can be readily arrested by a compress and bandage, which should be continued for three weeks, before beginning extension. Velpeau divided the tendon at its insertion into the scaphoid bone, observing to insert the knife to meet the tendon about an inch below and in front of the inner malleolus, on the adult foot. In infants or children, this method would be impracticable ; and in severe cases of varus at a later period, it is also impracticable, as the posterior tibial tendon does not pass below, and in front of the inner malleolus, but passes directly downwards, or downwards and backwards to its inser- tion into the navicular bone. Next in order, the anterior tibial tendon is divided, the assistant abducting the foot, while a sharp-pointed tenotomy knife is entered flatwise, near the outer edge of the pro- minent tendon, opposite the inner malleolus ; passing the blade beneath the tendon, the edge is turned forward and elevated, as the skin is guarded by feeling with the finger of the left hand, until the tendon yields with a snap. A dossil of lint is placed over this puncture also. Lastly, after an interval of two or three weeks from the first operation, the tendo-Achillis is divided in the manner already described. But here again the posterior tibial artery is in danger ; the tendon, in some cases, being drawn inwards by the adducted state of the foot. The operations of tenotomy thus stated in detail, can be carried out in a few seconds each, and are bloodless. After the first operation for varus, the usual rule should be observed with regard to the after-treatment of club-foot ; i.e. that the foot be left in its former position until the punctures have healed — three or four days — during which time a moulded splint of paste-board or pliant metal may be applied, just to secure this posi- tion and rest the foot. Then mechanical extension should be continued gradually for a period of two or three weeks, in a child a metal splint being applied along the outer side of the leg, at first bent to the shape of the deformity and then gradually straightened. To this the leg and foot are bandaged, as shown in Fig. 531, so that the foot is gradually brought from the position of varus to that of equinus, which constitutes the end of the first stage of treatment. The second stage of treatment is then commenced by division of the Achilles tendon, and after the third day, gradual extension may be commenced by some appai^atus having a rack-and- pinion movement, by which the sole of the foot may be brought to a right angle with the leg, or a little beyond this angle. For infants the best apparatus is that known as " Adams' varus-splint " (Fig. 532). The steel support, h, is carried up to the Fig. 531. Fig. 532. TALIPES OR CLUB-FOOT. 1045 Pig. 533. Fig. 584. thigli, a, which prevents the foot being turned inwards from the knee- joint, and the metal sole-plate, c, is moved by a rack-and-pinion joint at the heel, d. By this instrument the foot can be brought into a right-angled position with the leg in a period of two or three weeks. After the third week, passive movement may be commenced, and after six weeks the varus- splint need only be used at night, and an ordinary boot may be made for the child, with a steel spring on the outer side, and free-joint at ankle (Fig. 533). At the walking period it is generally necessary to em- ploy steel supports attached to the boot, and carried either to the thigh or to the waist with a belt, to prevent the child turning in its feet and causing relapse of the deformity. Aveling's talivert is a useful contrivance, combining the three desiderata — abduction, flexion, and ever- sion. Dr. Langaard's well-known instrument for talipes varus is also deserving of notice (Fig. 534). Relapse of the deformity sometimes takes place, or the conversion of the deformity into the opposite state occurs, talipes valgus succeeding. In one such case, Mr. Gant found it necessary to resort to the operation for that deformity. (8.) Talipes Valgus, or in-anhle — as a congenital deformity — pre- sents the opposite arrangement of parts to that of talipes varus, and the peronei muscles are chiefly contracted, with, perhaps, the. extensor Fig. 535. Fig. 536. longus digitorum. The foot is turned outwards, or everted, and abducted, possibly also extended upwards, the patient standing or walking on the * Talipes valgus — congenital, a, Showing depression of the inner, and eleva- tion of the outer margin of the foot ; h, showing obliquity of the foot. (From W. Adams.) + Talipes valgus — congenital. Showing the elevation of the os calcis ; oblique position of the astragalus ; and displacement of the scaphoid bone by transverse rotation. (Ibid.) 1046 SPECIAL PATHOLOGY AND SURGERY. Fig. f^''': inner ankle (Fig. 535, and the dissected specimen, Fig. 536). Thence also the knee inclines inwards, combining knock-knee with this form of talipes. Flat or Splay-foot — as a non-congenital deformity — presents the same characters as the above deformity ; but, owing to relaxation of the ligaments in the sole of the foot, the arch sinks, and the foot is flattened (Fig. 537). The ca?S'ee Boil GALVANO-PUNCTURE in aneurism, 609 in varicose veins, 720 Gamgee, J. S., on pyaemia, 356 Ganglion, 564 clironic, 564 compound, 564 treatment, 564 in foot, 564 hand, 565 Gangrene, 257 acute, 257 Gangrene (continued) — amputation in, 268, 496, 513, 604, 756, 902 from aneurism, 262 aneurismal varix, 263 animal poisons, 260 arrest of, 266 from arrest of circulation, 261 arteritis, 262 causes of, 259 from chemical decomposing agents, 260 chronic, 258 cold, 258 from conditions of the part, 264 of blood, 260 contagious, 368 in contused and lacerated wounds, 490 dry, 258 from electricity, 260 embolism, 262 ergotism, 260 external agents, 259 extravasated blood, 259 fever of, 266 from fibrinous coagulum in artery, 262 obliteration of a venous trunk, 263 in fracture, 751 from frost-bite, 532 haemorrhage, 262 heat, 260 hosiiital, 368 hot, 257 humid, 257 idiopathic, 259 from inflammation, 111, 264 treatment of, 141, 268 injury, 259 internal causes, 260 after ligature, 604 of external iliac, 650 femoral artery, 652 subclavian artery, 640 causes of, 604 period after, 604 treatment of, 604 line of demarcation in, 266 from nerve-influence, deficient, 265 after operations, 45 for aneurism, 604 from phlebitis, 263 phleboliths, 263 pressure of aneurism, 262 on vein, 264 pulpy, 368 from rigidity of coats of arteries, 261, 713 rupture, partial, of artery, 262 senile, 261, 713 amputation in, 715 causes of, 714 INDEX. 1069 Gangrene {continued) — senile, duration of, 714 symptoms of, 713 treatment of, 714 separation of sloughs in, 112, 491, 507 signs of, 257 sphacelus from, 258 from strangulation, 111 tight bandaging, 264 traumatic, 259 amputation in, 269, 496, 757, 903 causes of, 259 spreading, 269, 490, 751, 901 symptoms of, 490 treatment of, 269. See Morti- fication from varicose aneurism, 263 varieties of, 257 from venous obstruction, 263 vround of a main artery, 262 Gangrenous inflammation, 111, 264, 490. See Gangrene phagedsena, 368 Garrod, A. B., observations on gout, 293 on rheumatism, 290 scurvy, 285 Gay, John, observations on diseases of joints, 981 on varicose veins, 718 Gelatinous cancer, 194 General pathology and surgery, 47 of degenerations, 224 diseases of the blood, 272 of contagious origin, 299 nervous system, 388 nutrition, 47 inflammation, 52 tumours or morbid growths, 145 ulceration and ulcers, gangrene and mortification, 241 Genu valgum, 1034 varum, 1035 Glanders, 385 treatment of, 386 Glioma, 167 Gonorrhoeal rheumatism, 976, 980 Gordon, treatment of fractured radius, 803 Gould, Pearce, cases of popliteal aneu- rism treated by compression, 656 Gout, 292 blood in, pathology of, 293 causes of, hygienic, 294 constitutional disorder in, 292 detection of uric acid in blood in, method of, 294 diagnosis of, 292 symptoms of, 292 treatment of, 295 curative, 296 preventive, 295 Granulations, 491 Granulations (continued) — adhesion of, 493 cicatrization over, 493 process of formation of, 491 pus-cells, relation to, 103, 493 sensibility of, 492 structure of, 491 vessels in, 492 Green-stick fracture, 735 Gross, observations on diseases of joints, 1006 Growth and development, 49 Guerin on congenital dislocations, 925, 936, 958 Guinea-worm, 552 Gull, Sir W., statistics of aneurism, 633, 635 Gummy tumours, syphilitic, 318 Gunpowder, injuries from, 524 in Clerkenwell explosion, 524 Gunshot wounds, 500 amputation in, 513 method of, 516 primary or secondary, 515 seat of, 515 antiseptic treatment of, 516 apertures of, 502 enlargement of entrance, 510 entrance and exit, appearances of, 503 number of, 502 arteries injured in, 500 of bones, 500 bullet-extractors, 510, 511 characters of, 500 concussion of body, 506 consequences of, 507 course of ball, 500 depth of, 500 dressing of, 512, 516 effects of, 505 excisions in, 514. See Excisional Surgery for Injury, vol. ii. extent of, 500 extracted ball, appearances of, 512 foreign bodies in, 501 detection of, 510 lodgment of, 501 removal of, 510 counter- opening for, 511 haemorrhage from, 504, 508, 509 arrest of, 508 secondary, 507, 513 inflammation in, 507, 512 of joints, 514 pain in, 504 prognosis of, 508 projectiles, kinds of, 505 momentum of, 505 motion of, 505 penetration of, 505 shock in, 506, 509 signs of, 502 slough in, 507 1070 INDEX. Gunshot -wounds (continued) — textures injured in, 500 treatment of, 508, 514 unextractcd ball. 507 df ankle-jnint, 514 elbow-joint, 514 femur, 514 foot, 514 hand, 514 knee-joint, 514 leg, 514 shoulder-joint, 514 wrist, 514 Guthrie, observations on gunshot wounds, 501, 503, 515 on hospital gangrene, 373 ligature of posterior tibial artery, 705 HEMATOMA, 487 HEemophilia, 464 Ha3morrhage, 463 into abscesses, 94, 134 arrest of, 468 arterial, 463 treatment of, 468 in complicated dislocation, 904 fracture, 759 constitutional effects of, 463, 484 treatment of, 480 from gunshot wounds, 504, 508 in hospital gangrene, 369 from incised wounds, 422, 429 after operations, 45 secondary, in gunshot wounds, 513 after ligature, 605 of abdominal aorta, 645 carotid, 631 common femoral, 652 superficial femoral, 657 common iliac, 646 external iliac, 649 innominate, 628 subclavian, 637, 640 periods of occurrence of, after gunshot wounds, 513 after ligature, 606 phenomena of, after ligature, 604 from suppurating aneurism, 604 treatment of, 605 treatment of, 468 by acupressure, 474 cauterization, 469 cold, 429, 469 compression, 469 ligature, 470. See Ligature double, 612, 615 torsion, 477 venous, 479 arrest of, 479 in pui'pura, 284 Haemorrhage in scurry, 283 Haemorrhagic inflammation, 145 diathesis, 464 ulcers, 253 Hair, syphilitic affections of, 317 cysts containing, 152 Hall, Marshall, on tolerance of blood- letting in inflammation, 121 Hamilton, observations on dislocations, 911, 915, 923, 928, 931, 936, 938, 940, 945, 947, 948, 957, 964, 967 on fractures, 765, 770, 774, 775, 782, 785, 789, 792, 797, 802, 803, 810, 812, 814, 816. 820, 832 Hammond on gunshot wounds for am- putation, 513 Hand, arteries of, wounded, 643 deformities of, 1032 dislocations of, 934 fractures of, 804 gunshot wounds of, 514 Haygarth, observations on diseases of joints, 982 Healing under a scab, 428 Healthy ulcer, 245 Hectic, 106 pathology, 108 treatment of, 140 Hennen, observations on gunshot wounds, 501, 515 Hereditary syphilis, 319, 337 Heterologous growths, 145 Heteroplasia, 146 Hilton, observations on rigidity of joints from tonic muscular contraction, 1002 nail-forceps, 541 opening of deep abscess, 134 pain, value of, in diagnosis, 580 Hip, disease of joint, 1010 dislocations of, 940 neuralgia of, 1022 rheumatic anthritis of, 1022 wounds of, 890 Hip-joint disease, 1010 abscess in, 1010, 1014 anchylosis in, 1011 arthritic, 1022 diagnosis of, 1022 signs of, 1022 treatment of, 1022 diagnosis of, 1016 from sacro-iliac disease, 1024 dislocation in, 1014 signs of, 1012 in first stage, 1012 in second stage, 1013 mechanism of, 1015 structural conditions in, 1010 terminations of, 1011 treatment of, 1019 of abscess, 1021 contraction, 1021 INDEX. 1071 -Podgkin's disease of lymphatic glands, 733 Hodgson, observations on aneoiism, 587, 591 Holmes, T., statistics of aneurism, 625, 627 I on diseases of bone, 847, 883 j galvano-punctureinaneurism,610 Horns, 543 Hospital gangrene, 368 causative relation of constitutional and local conditions in, 371 constitutional disorder of, 371 contagion of, 373 course of, 363 in blistered surface, 370 contused wound, 369 granulating wound or ulcer, 369 gunshot wound, 369 old sore, 370 puncture, 370 stump after amputation, 368 diagnostic characters of, 368 endemic character of, 372 epidemic, 372 external causes, 372 infection of, 372 infecting distance of, 373 local results of, 370 origin of, constitutional, 372 local, 371 period of latency of, 373 signs of, 368 treatment of, 374 constitutional, 374 preventive, 374 results of, 375 Housemaid's knee, 561 Humerus, dislocations of, 917 fractures of, 787 Humphrey, G. M., on wound-treatment by open method, 434 Hunter, John, in British school of sur- gery, 2 observations on aneurism, 599 on diseases of bone, 857 gunshot wounds, 502 inflammation, 54, 58, 60, 109 plastic operations. 21 pyaemia, 359 reparation of wounds, 423 subcutaneous reparation, 19 syphilis, 300, 308, 320, 326 ulceration, 242 Hutchinson, J., observations on statistics of aneurism, 597, 606, 658 on syphilis, 320, 322 syphilitic teeth, 321 Hydrophobia, 375 communicability of, 379 of rabies, 376, 379 by fomites, 376 Hydrophobia (continued) — condition of wound in, 37 constitutional disorder in, 377 diagnosis of, 378 pathology of, 376 period of latency in animals, 379 in man, 378 symptoms of, in animals, 379 treatment of, 378 virus of rabies, 375 Hydrops articuli, 977 treatment of, 980 Hygienic conditions in relation to opera- tions, 30 Hypersemia, local, 59 Hyperplasia, 146 Hypertrophy, 51 of bone, 839 Hysteria, 408 causes, 417 general symptoms of, 409 diagnosis, 409 local affections, 410 diagnosis of, in breast, 412 in joints, 411 muscular contractions, 414 painful afifections, 411 paralysis, 416 retention of urine, 414 spinal disease, 412. See Spine, vol. ii. tumours of abdomen, 413 treatment, 419 Hysterical disease of joints, 411, 1016 ICHOE, 244. See Pyaemia Idiosyncrasy, 30 Iliac abscess, 1024 Immediate union in wounds, 423 Impacted fracture, 736 In-ankle, 1045 In-knee, 1034 Incised wound, 42] cause and effects of, 422 prognosis of, 428 reparation, materials for, 424 modes of, 423 organization in, 425 symptoms of, 422 traumatic fever from, 422 treatment of, 428 after-dressing of, 432 antiseptic dressings of, 433 Induration, 62 of bubo, 305 chancre, 300 stemo-mastoid muscles, 1030 Infantile syphilis, 319, 337 Infiltrating growths, 147 Inflamed ulcer, 247 Inflammation, 47 1072 INDEX. Inflammation {continued) — abscess from, 100. See Abscess blood alterations in, 78 buffy coat, diagnostic value of, 81 production of, 79 chemical changes of, in, 81 blood-vessels in, 53, 55 causes of, S-l . exciting, 85 external, 85 internal, 85 predisposing, 85 constitutional symptoms of, 64 destruction of texture in, 53, 88 development of lymph effused in, 90 effusion-products, 89 coagulable lymph, 89 corpuscles, exudation, 94 plastic, 90 degeneration of, 95 pathology of, 95 pus, 93 cmigi-ation of blood-corpuscles in, 57 extension of, 87 contiguous, 87 continuous, 87 fever in, 64, 75 pathology of, 82 function derangement of part, 63 gangi'ene from. 111. See Mortifi- cation heat in, 59 diagnostic value of, 60 generation of, 60 hectic fever, 106 pathology of, 108 local signs of, 58 lymph, conditions of, 88, 89 membranes, false, 91 destructive consequences of, 92 reparative power of, 93 structure of, 91 metastasis of, 87 pain in, 62 diagnostic value of, 63 varieties of, 63 process of, 52, 95 productiveness in, 53, 88 pulse-tracings in, 75 pus, 93 varieties of, 94 pyogenesis, 97 redness in, 59 diagnostic value of, 59 varieties of, 59 resolution of, S8 septic infection from, 8" softening in acute, 62 state of circulation, local, in, 53 arterial and venous, 54 capillary, 54 Inflammation (continued) — suppuration from, 100 pathology of, 95 signs and diagnosis of, 100 swelling in, 60 diagnostic value of, 62 varieties of, 61 temperature in, 64 clinical thermometer, 65 terminations of, 88 textural changes in, 53 treatment of, 113 constitutional, 115, 120 antimony in, 126 blood-letting in, 120 conditions for, 120 tolerance of, 121 cardiac depressants in, 126 diaphoretics in, 125 diet in, 132 diuretics in, 125 iodide of potassium in, 131 mercury in, 128 nutritious diet in cod-liver oil, 132 opium, 127 purgatives in, 124 starvation in, 125 stimulants in, 131 tonics in, 131 venesection or phlebotomy, 122 arteriotomy a substi- tute for, 124 local, 115 blood-letting, 116 cupping, 116 leeches, 116 scarification, 116 cold, 115 irrigation, 116 heat, 116 dry, 116 with moisture, 116 incisions, 117 irritants, 118 issues, 118 seton, 118 varieties of, 119 position of part, 117 rest of, 115 removal of exciting causes, 114 conditions, pathological, 114 consequences, local, 114, 133 abscesses, 133 effusion, 133 suppuration, 133 sinus and fistula, 140 ulceration, 141 ulceration from, 110 urine in, 78 INDEX. 1073 Inflammation, varieties of, 142 Inflammation, acute, 143 asthenic, 142 adhesive, 93 chronic, 143 congestive, 144 diffuse. See Erysipelas in areolar tissue. See Cellulitis diphtheritic, 145 erysipelatous, 144 gangrenous, 112 hsemorrhagic, 145 phlegmonous, 143, 344 scrofulous, 272 septic, 87 specific, 145 sthenic, 142 subacute, 143 syphilitic. 8ee Syphilis of aneurismal sac, 591 after ligature, 604 arteries, 706 bone, 838 scrofulous, 839 syphilitic, 840 in burns, 525 of bursas, 560 cartilage, 997 in gunshot vfounds, 507, 512 of hip. See Hip-joiut Disease joints, 973 knee, 973 lymphatic glands, 731 vessels, 729 medullaiy membrane of bone, 844 nrascle, 557 nerves, 569 periosteum, 840 sheaths of tendons, 563 synovial membrane, 973 veins, 720 Ingrown toe-nail, 541 Inhalation of calomel vapour, 333 Inhalers, chloroform, 39 Injection of coagulating agents, in aneu- rism, 610 in varicose veins, 720 subcutaneous, in neuralgia, 572 prolonged sickness after chloro- form, 40 Injury, shock of, 388 Innominate artery. See Artery, In. nominate bones, fracture of, 804 Insects, stings of, 382 treatment, 382 Instruments for compression in aneu- rism, 595 for excision of carious bone, 853 extraction of bullets, 511 of necrosed bone, 866 Interstitial cancer, 883 Intra-cranial aneurism, 633 VOL. I. Irritable ulcer, 248 Irritation. See Inflammation JAWS, lower, dislocations of, 909 fractures of, 772 subluxation of, 909 upper, fracture of, 772 Joint-rigidity, without anchylosis, 1001 Joints, abscess of, 977, 988, 991 pyaemic, 358, 977 anchylosis of, 999 chronic rheumatic synovitis, 981 diseases of, 973 particular, 1010 dislocations of, 891 epiphysitis in, 996 false, 768 fracture involving, 759 gunshot wounds of, 514 inflammation of synovial mem- branes of, 973. See Synovitis inj Tories of, 889 loose cartilages in, 1007 neuralgia of, 1009 scrofulous disease of, 989 sprains of, 889 tabetic arthropathy, 986 traumatic inflammation of, 890, 974 joints most liable to, 974 tumours connected with, 1009 ulceration of articular cartilages of, 996 wounds of, 889 in compound dislocation, 900 Jones, Bence, observations on urine, 873 Jones, Wharton, observations on inflata- mation, 56 Josse on wound-treatment by irriga- tion, 433 KEITH, results of ovariotomy, 447 Key, Aston, observations on dis- ease of hip-joint, 1010 on dislocations, 920, 971 Kidneys, abscess of, 357 disease of, in operations, 30 Knee-joint, abscess of, 977, 991 anchylosis of, 1000 contraction of, 1036 chloroform in hysterical con- traction of, 1036 division of hamstring tendons for, 1037 extension in, 1037 treatment of, 1036 deformities of, 1034 disease of, 989 dislocations of, 960 compound, 963 congenital, 963 unreduced, 962 fractures near, 821 3 z 1074 INDEX. Knee-joint (continued) — gunshot wounds of, 514 internal derangement of, 962 wounds of, 890 Koch on organic dust in air, -443 LACERATED wounds, 488. See Con- tused Lachrymal bone, fracture of, 769 Lameness in hip-joint disease, 1012 in sacro-iliac disease, 1023 Lancereaux, observations on syphilis, 310, 318 Langenbeck, observations on diseases of joints, lOOfi Larrey on false cartilages in joints, 1009 on gunshot wounds, 501, 503^ 515 Larynx, necrosis of, 315 syphilitic disease of, 315 ulceration of, 315 Lawrence, Sir W., observations on ery- sipelas, 354 on inflammation, 54 Lebert's observations on inflammatory effusions, 90 Lee, H., observations on pyaemia, 360 on subcutaneous section of veins, 719 on syphilis, 300, 301, 304, 308, 311, 325, 327, 333, 336 Leg, arteries of, traumatic aneurism of, 659 deformities of, 1034 fractures of, 830 gunshot wounds of, 514 Lepra, syphilitic, 311. ■ See Diseases of Skin, vol. ii. Leprosy, 544 causes of, 546 forms of, 544 symptoms of, 545 treatment of, 546 Lichen, syphilitic, 311 Ligature of arteries, 470, 660 accidents after, 476, 602 application of, 472 compared with acupressure, 478 compression, 606 torsion, 478 in continuity of the vessel, 660 double, 662 effects of, 471 gangi'ene after, 604 general directions for, 660 incision for, 660 materials for, 472, 607 opening of sheath for, 661 at seat of wound, 662 secondarv hsemorrhage after, 476, 605 for aneurism, 599 Ligature for aneurism (cnntintied) — above and below sac, 601, 612, 615 accidents after, 602 Anel's operation of, 600 compared with Hunter's, 601 Antyllas's, 601 compared with Anel's and Hunter's, 601 Brasdor's, 608 collateral circulation after, 600. See Ligature of Ai'teries consequences of, 602 gangrene after, 604 haemorrhage after, 605 treatment of, 606 Hunter's, 599 mortality after, 606 needle for ligature, 661 recurrent pulsation after, 602 treatment of, 603 reapplication of liga- • ture, 604 results of, 606 secondary aneurism after, 603 signs after Hunterian opera- tion, 601 after-treatment, 602 suppuration of sac after, 604 Ligature of aorta, abdominal, 691 results of, 645 surgical anatomy of, 686 of axillary artery, 679 collateral circulation after, 680 surgical anatomy of, 676 varieties, 678 for traumatic aneurism, 642 wound, 642 of brachial artery, 682 collateral circulation after, 682 surgical anatomy of, 680 varieties, 681 for traumatic aneurism, 643 varicose aneurism, 644 wound, 643 of carotid artery, 666 collateral circulation after, 667 on cardiac side of aneurism, 631 distal side of aneurism, 628 for innominate anetu'ism, 625 with subclavian, for, 625 for intra-cranial aneurism, 636 intra-orbital aneurism, 636 external, 668 branches of, 669 surgical anatomy of, 667 varieties. See Common Carotid, and Lingual for traumatic aneurism, 636 wounds, 636 of branches of, 669 INDEX. 1075 Ligature of carotid artery (continued) — internal, 668 surgical anatomy of, 668 for traumatic aneiirism of, 636 wounds of, 636 pneumonia after, 632 recurrence of pulsation after ligature of carotid, 632 secondary haemorrhage after, 632 suppuration of sac after, 632 surgical anatomy of, 665 varieties, 666 for traumatic aneurism of, 532 varix, 632 of femoral artery, common, 696 collateral circulation after, 697 results of, 652 surgical anatomy of, 691 varieties, 695 for traumatic aneurism of, 654 wounds of, 654 superficial, 696 collateral circulation after, 697 gangrene after, 657 in Hunter's canal, 697 results of, 657 return of pulsation after, 657 secondary haemorrhage after, 657 surgical anatomy of, 691 in traumatic aneurism, 654 wound of, 654 of iliac artery, common, 690 collateral circulation after, 690 results of, 646 surgical anatomy of, 686 varieties, 688 external, 689 collateral circulation after, 690 for aneurismal varix, 651 gangrene after, 650 recurrent pulsation after, and treatment of, 650 secondary hemorrhage after, 650 suppuration of sac after, 650 surgical anatomy of, 686 tetanus after, 650 of innominate artery, 664 results of, 628, 639 surgical anatomy of, 663 varieties, 663 of internal mammary, 676 of lingual artery, 669 surgical anatomy of, 669 variety, 669 of peroneal artery, 705 Ligature of pojpliteal artery, 700 for aneurism, 658 surgical anatomy of, 697 for traumatic aneurism of, 658 -varieties, 699 for wounds of, 658 of radial artery, 683 surgical anatomy of, 683 varieties. See Ulnar Artery of subclavian artery, 674 for axillary aneurism, 640 collateral circulation after, 675 distal, after amputation, 628 in first part, 637 for innominate aneurism, 624 results of, 624 with carotid, 625 results of, 625 for subclavian aneiirism, 637 surgical anatomy of, 670 varieties, 673 in third part, for axillary aneu- rism, 640 gangrene after, 641 inflammation in chest after, 641 results of, 640 secondary haemorrhage after, 641 for subclavian aneurism, 628 suppuration of sac after, 641 of tibial artery, anterior, 702 surgical anatomy of, 700 varieties, 702 dorsal in foot, 702 posterior, 704 surgical anatomy of, 703 varieties, 704 of ulnar artery, 686 collateral circulation after, 686 surgical anatomy of, 684 varieties, 685 of vertebral artery, 675 Ligature of aneurism by anastomosis, 181 of main trunk in, 181 circumferential vessels in, 182 in osteo-aneurism, 888 Lightning, 530 appearances after death from, 531 burn from, 530 prognosis in, 530 stroke of, 530 treatment of, 531 Lip, syphilitic cracks of, 314 Lipoma, 161 Liquor sanguinis, eflfusion of, 89 in inflammation, 61 pathology of, 95 Lisfranc on aneurism, 587 1076 INDEX. Lister's antiseptic opening of abscess, 136 treatment of woands, 437 organic dust in air, 443 putrefying influence of air, 443 statistics of antiseptic amputations, 445 Listen, K., on dislocations, 895, 903, 908, 931, 938, 957, 971 on fractures, 765, 817, 832 shoe for club-foot, 1040 wound-treatment, method of, 433 Little, operation of tenotomy, 1030, 1031 club-foot, 1043 Little, Stromeyer L., observations on diseases of joints, 1006 on tenotomy, 1030 Local anesthesia, 44 syphilis, 300, 302 Locked-jaw, 394 Longmore, Thomas, observations on gunshot wounds, 501, 506, 514 Loose cartilages in joints, 1007 Lucas-Championniere, results of anti- septic treatment, 447 Lungs, disease of, in relation to chloro- form, 37 to operations, 29 in pygemia, 357 Lupoid ulcer, 255 Lupus, 255 Lymph, 89 absorption of, 91 characters of, 89 as affected by texture, 89. See Pathology of Effusion coagulable, 89 plastic cells in, 90 corpuscular, 89 development of, 90 effusion of, 89 destructive consequences of, 92 reparative power of, 93 false membranes from, 91 fibrinous, 89 typical conditions of, 89 Lymphatic glands, abscess of, 732 cancer of, 204, 209 chronic induration of, 732 cretaceous degeneration of, 732 inflammation of, 731 scrofulous enlargement of, 275. See Scrofula tumours of. See Morbid Growths lymphoma, 732 characters of, 733 origin of, 734 structure of, 734 treatment of, 734 Lymphatitis, 729 causes of, 730 diagnosis of, 730 diffuse suppuration from, 731 Lymphatitis (continued) — ■ pyaemia from, 731 symptoms of, 729 terminations of, 730 treatment of, 731 with erysipelas, 340 Lymphoma, Lymphadenoma, 732 "If ACCORMAC, Sir W., on antiseptic iii surgery, 446 Macewens osteotomy, 1035 Maclagan on infection of erysipelas from dead body, 349 Mahomed on sphygmograph, 67 Maisonueuve, observations on disloca- tions of carpal bones, 936 Malacosteon, 871. See Mollities ossium Malar bone, fracture of, 771 Malformations, 1029. See Deformities Malgaigne, observations on amputations, statistics, for gunshot wounds, 515 on dislocations, 897, 911, 914, 926, 933, 934, 936, 937, 964, 971, 972 on fractures, 772, 792, 820, 826, 837 Malignant pustule, 384 tumours. See Cancer, Encephaloid, Scirrhus, and Tumours Marey's sphygmograph, 67 Mayor on wound-treatment by immer- sion, 433 Medicine, surgery a primary division of, 1 Medullary cancer, 194 Melanoid cancer, 198 Mercury in inflammation, 128 in syphilis, 331 by fumigation, 332 inhalation, 333 injection, hypodermic, 332 inunction, 332 naouth, 332 preparations of, 332 Metacaqaal bones, dislocation of, 936 fracture of, 804 Metacarpo-phalangeal joints, dislocation of, 937 Metatarso-phalangeal joints, dislocation at, 972 Metatarsus, dislocation of, 971 fracture of, 836 Methylene, bichloride of, 43 Military surgery, amputations in, 514 Modelling process in wounds, 428 Mollities ossium, 871 causes of, 873 diagnosis of, 872 symptoms of, 872 termination of, 873 treatment of, 873 Morbid cicatrices, 519 growths, 145. See Tumours Morland, W., on ununited fractures, 765 INDEX- 1077 Mortification, 111, 257. See Gangrene Monatt and Wyatt, statistics of elbow- joint excisions for gnnslaot wonnd, 514 Month, syphilitic disease of, 314 in children, 320 Mucous membranes, erysipelas of, 345 inflammation of, 64, 99 scrofula in, 277 syphilis of, 313 in children, 320 Mnscles, contractions of. See Deformi- ties degenerations of. See Degenera- tions hernia of, 556 inflammation of, 557 injuries of, 558 rupture of, 553 spasm of, after fracture, 743, 748 sprains of, 553 tumours of, 558 Myalgia, 558 Mycetoma, 550 signs of, 550 structural conditions in, 551 treatment of, 551 Myelitis, traumatic, osteo, 844 Myeloid tumour, 174, 190 of bone, 882 Myoma, 169 Myositis, 557 Myxoma, 167 N^VUS, 179 cauterization in, 180 excision of, 180 galvano-puDctnre in, 180 indications for treatment of, 179 injection of, 180 ligature of, 180 subcutaneous, 181 operations for, 179 seton in, 180 structure of. See Vascular Tumour subcutaneous puncture in, 180 Nails, evulsion of, 541 ingrown toe-nail, 541 scrofulous disease of, 277 syphilitic disease of, 317 ulceration of matrix of, 540. See Onychia Nasal bones, fracture of, 769 necrosis of, 770 Neck, abscess of, 630 deformities of, 1029 induration of sterno-mastoid muscle in, 1029 nsevus of, 179 Necrosis, 854 amputation in, 868 causes of, 862 constitutional, 863 traumatic, 862 Necrosis {continued) — central, 854 signs of, 862 cloacffi in, 856 consequences of, 863 albuminoid degeneration of liver from, 863 excision for, 868 exfoliation in, 861 extraction of sequestrum in, 866 instruments for removing bone in, 867 involucrum around, 857 joint-disease in relation to, 991 modifications of, 858 partial necrosis, 858 of cancellous structure, 859 of walls of long bones, 858 within walls, "intra-osseous necrosis," 859 reparation in, 854 separation of dead bone in, 855 sequestrum in, 857 signs of, 861 structural condition of, 854 superficial, 861 syphilitic, 316 treatment of, 865 without suppuration, " quiet ne- crosis," 860 diagnosis of, 860 of cranial bones, 888 nasal bones, 770 patella, 825 Nelaton on fracture of radius, 800 on dislocations of fibula, 964 probe for gonshot wound, 510 test-line in hip-joint injuries, 944 Nerve-affections, symptomatic, 578 guidance of nerve distributionin,o80 pain as diagnostic of, 580 Nerve-lesions, subcutaneous, 568 Nerves, contusion of, 566 diseases of, 566 inflammation of, 569 injuries of, 566 complicating dislocation, 904 fracture, 759 consequences of, 569 reunion of, 569 tumours of, 581. See Neuroma wounds of, 566 Nerve-stretching, 574 fifth cranial, branches of, 576 sciatic, 578 Neuber on absorbable drainage-tubes, 435 Neuralgia, 570 causes of, 571 diagnosis of, 570 from structural disease, 570 parts affected, 571 symptoms of, 570 terminations of, 571 1078 INDEX. Neuralgia {continued) — treatment of, 572 nerve-stretching, 574 neorotomy, 572 operations for, 575 ' of hip, 1022 joints, 571 Neurit is, 569 causes of, 570 symptoms of, 569 treatment of, 570 Neuroma, 166 structure of, 166 differential, from painful tuber- cle, 166 treatment of, 166 Neurotomy. 572 fifth cranial, branches of, 576 Niti'ons oxide gas, -±2 Nodes, 8^0 strumous. 840 syphilitic, 316, 8-40 Norris, statistics of aneurism, 606, 628, 631, 641, 649, 655, 657 Nose, fractures of, 769 syphilitic disease of, 314, 317, 320 in infants, 320 Nussbaum on results of antiseptic treat- ment, 446 on treatment of carbolic poisoning, 442 Nutrition, diseases of, 47 in inflammation, 48 physiology of, 48 in atrophy and hypertrophy, 51 growth and deyelopment, 49 reparation, 52, 426 OBTUEATOR foramen, dislocation into. 950 CEdema, 263 CEdematous erysipelas. 344 ulcer, 249" Onychia, 540 Operations. 22 anaesthetics in, 35 local, 44 arrangements for. 33 instruments for, 34 room for. 33 table for! 34 assistants for, 34 causes of death after, 45 chloroform in, 35 with shock, 393 conditions fayourable for, 27 unfayourable for, 27 dangers attending, or consequent on, 45 delirium tremens after, 45 dressing of -vyound after, 45 erysipelas after, 45 exhaustion after, 45 Operations (co ntinued) — gangrene after, 45 hospital, after, 45 guidance of pathology in, 22 haemorrhage after, 45 inflammation after, 45 influence of general health on, 27 of hygienic conditions on, 30 patliology in performance of, 22 in plan of, 22 phlebitis after. i?ee Thrombus preparation of patient for, 33 pyaemia after, 45 results of, 45 shock after, 45 tetanus after, 45 traumatic delirium after, 45 treatment after, 45 Opisthotonos, 394 Opium in gangrene, 270, 715 in cancer. 211 indolent ulcer, 251 inflammation, 127 irritable ulcer, 249 phagedfenic ulcer, 253 j Orbit, aneurism in, 634 injuries of. See Fracture of Upper Jaw, 772 Ormerod, E. L., on fatty degeneration, 229 on mollities ossium, 871 Orth on yaccino-erysipelas inoculation, 349 Orthopaedic surgery, 1037 Os calcis, dislocation of, 970 fractures of, 837 compound, 838 Os magnum, dislocation of, 936 Osseous anchylosis, 1000 tumours, 876 Ossification of arteries, 261, 710, 713 Osteitis deformans, 842 Osteo-aneurism, 239, 586, 713, 887 amputation in, 888 diagnosis of, 887 signs of, 887 situation of, 887 structural conditions in, 887 treatment of, 887 Osteoid cancer, 884 diagnosis of, 884 signs of, 884 ' structure of, 884 in substance of bone, interstitial, 883 on surface of bone, periosteal, 885 treatment of. 885 amputation in, 886 excision in. 885 Osteomalacia, 871. ,S'ee Mollities ossium Osteo-myelitiS; 844 cause of, 846 signs of, 845 treatment of, 847 amputation in, 847 INDEX. 1079 Osteo-myelitis, treatment of, excision in, 847 Osteo-sarcoma, 881 diagnosis of, 881 treatment of, 882 Ostitis, 838 articular, 996 caases of, 843 chronic, 842 consequences of, 839, 843 scrofulous, 839 signs of, 841 syphilitic, 840 treatment of, 844 PAGET, Sir James, observations on carbuncle, 536 on degenerations, 224, 232 inflammation, 56 necrosis without suppuration, 860 osteitis deformans, 842 pus-production, 96 reparation of fracture, 739 of tendons, 554 wounds, 426 rodent ulcer, 256 tumours, 147, 151, 159, 170, 174, 177, 199, 201, 202, 203, 213, 215, 218 ulceration, 244 ulcers of bone, 852 Painful cicatrix, 521 subcutaneous tumour, 165 Pancoast's observations on diseases of joints, 1606 Paralysis from intra-cranial aneurism, 634 Pare, observations on gunshot wounds, 515 Paronychia, 539. See Whitlow Particular bones, diseases of, 888 joints, diseases of, 1010 Pasteur on organic dust in air, 443 Patella, caries of, 561 dislocations of, 958 fracture of, 823 compound, 829 treatment of, 825 by wiring, 827 inflammation of bursa of, 561 Pathological anatomy and pathology, relative guidance of, in diagnosis, etiology, and prognosis, 3 in plan and performance of surgical operations, 22 Pathology and surgery, general, 46 special, 421 Pelvis, dislocations of, 939 fractures of, 823 Penis, chancre on, 300 Perforating ulcer of foot, 542 Periosteum, inflammation of, 840 reproduction of bone by, 741, 855 Periostitis, 840 abscess from, 844 diffuse, 847 scrofulous, 840 syphilitic, 840 Phagedaena, gangrenous, 368 sloughing. See Hospital Gangrene Phagedaenic bubo, 307 chancre, 303. See Chancre ulcer, 252 Phalanges of fingers, dislocation, 937 of toes, dislocation, 972 Pharynx, syphilitic ulceration of, 314 Phimosis, 303 Phlebitis, 720 adhesive, 720 causes of, 721 connection of erysipelas with, 340 pyaemia with, 359, 721 diffuse, 720 structural conditions in, 720 suppurative, 720 symptoms of, 721 terminations of, 721 traumatic, 721 treatment of, 721 Phleboliths, 729 Phlebotomy, 122 Phlegmonous erysipelas, 342 inflammation, 143 Physiology in pathology, 8 Plastic surgery, 21 Poisoned wounds, 375 Poland, A., statistics of fractxires of pa- tella, 829 Polypus, 164 Porta, statistics of aneurism, 606, 641, 643 Porter, observations on aneuxism, 604, 632 Position in inflammation, 117 Posterior tibial artery, ligature of, 704 Pott, observations on dislocations, 897 on fractures, 744, 746, 820, 834 Preparation of patient for operation, 33 Prepuce, chancre under, 300, 304 chancroid ulcer under, 302 phagedenic chancre under, 303 Pressure-effects of aneurism, 588 of abdominal aorta, 644 femoral artery, 649 iUac arteries, 644 innominate artery, 618 popliteal artery, 655 intra-cranial aneurism, 634 intra-thoracic aneurism, 616 Primary adhesion, healing by, 423 bubo, 305 syphilis, 299, 326 Prognosis, 12 empirical and rational, 12 Projectiles, density of, 505 momentum of, 505 motion of, 505 1080 IXDEX. Projectiles (continued) — penetrating power of, 505 shape of, 505 size of, 505 velocity of, 505 Proliferous cysts, 152, 160 cutaneous, 152 cystigerous, 152 dentigerons, 152 glandular, 152 Prostration -with excitement, 395 Prussak's observations in inflammation, 57 Psammoma, 168 Psoriasis, syphilitic, 312 Pudendum, chancre of, 305 Pulse, elements of, 69 degrees of dicrotism, 70 formation of i:)ulse wave, 69 dicrotic wave, 70 percussion wave, 69 tidal wave, 69 tension, 73 variations of, 74 Punctured wounds, 497 causes and effects of, 498 characters of, 497 course of, 498 prognosis of, 498 structural conditions in, 497 treatment of, 499 of arteries, 466 Purpura, 284 Purulent deposits, 357 Pas, 89, 93 cancerous, 94 cells of, 94 characters of, 94 in secondary deposits, 358. See Pyaemia chemical composition of, 94 function of, 103 mucous, 94 pathology of suppuration, 95 pyogenesis, 97 relation of, to pale blood-corpuscles, 98 to connective-tissue corpuscles, 98 exudation corpuscles, 95 granulation cells, 493 sanguineous, 94 serous, 94 specific, 94 strumous, 94 syphilitic, 94 Pysemia, 355 abscesses, secondary, in, 357 diagnosis of, 358 formation of, 357, 366 situations of, 358 treatment of, 367 from animal or septic matter, 364 Pysemia (continued) — bacteria in, 364 causes of, 366 operation of, 366 changes of blood in, 358 death from, modes of, 357 ichorrhiemia, 364 leucocytosis, 363 miasma, 365 pathologj- of, 359 post-mortem appearances in, 358 prognosis of, 367 purulent infection, fi*om arteritis, 361 from lymphatitis, 361 phlebitis, 359 septicaemia, 358 symptoms of, 355 thrombosis, 363 treatment of, 367 preventive, 367 remedial, 367 QUAIN, E. (Dr.), observations on fatty degeneration, 229 Quain, P., varieties of arteries, 663 RACHITIS, or rickets, 868. See Pickets Radial artery, aneurism of, 643 ligature of, 683 Eadins, dislocations of, 928 fi-actures of, 799 Recklinghausen's observations in in- flammation, 57 Recurrent fibroid tumour, 170 origin of, 171 recurrence after removal of, 172 treatment of, 172 Redfem, observations on ulceration of articular cartilages, 996, 998 Redness in inflammation, 59 appearances of, in mucous mem- branes and in skin, 59 colour of, 59 a sign of, and its value, 59 from development of new vessels, 59 Rendu on inoculation of tubercle in scrofula, 273 Results of surgical operations, 45 Reverdin on skin-grafting, 246 in bums, 529 Rhea-Barton, observations on diseases of joints, 1006 Rheumatic arthritis, chronic, 981 of hip, 1022 synovitis, treatment of, 985 Rheumatism, blood pathology of, 288 causes, 289 diagnosis of, 240, 287 from aneurism, 586 INDEX. 1081 Rheumatism (continued) — diagnosis of, fromi circumscribed abscess of bone, 849 from hip-joint disease, 1017 mollities ossium, 872 fever of, 287 gonorrhoeal, 980 prognosis of, 289 symptoms of, 287 treatment of, 289 curative, 289 preventive, 289 Rickets, 868 causes of, 870 consequences, 870 diagnosis from mollities ossium, 872 signs of, 869 structural condition of bone in, 868 treatment of, 870 Ricord, observations on syphilis, 300, 301, 302, 305, 306, 308, 309, 316, 320, 324, 327, 329 Rodent ulcer, 256 Rollet, observations on syphilis, 303, 327, 329 Roussel's transfuse!', 481 Rupture of aneurism, 588 axillary, 640 carotid, 631 in neck, at root of, 624 popliteal, 656 subclavian, 637 of arteries, idiopathic, 588 traumatic, 588 bladder, 805 muscle and tendon, 553 urethra, 805 SACRO-ILIAC articulation, disease of, 1023 abscess in, 1023 attitude of limb in, 1023 causes of, 1025 diagnosis of, 1024 length of limb in, 1023 prognosis of, 1026 signs of, 1023 size of limb in, 1023 termination of, 1026 treatment of, 1026 dislocation of, 1024 Sacrum, fractures of, 806 Sanderson, Burden, observations on vaso-motor centre, 50, 57 Sanguineous cysts, 151 in bone, 879 in thigh, 158 pus, 94 Sarcocele, scrofulous, 279 syphilitic, 315 Sarcomatous tumours, 163, 182 general, origin of, 184 prognosis of, 187 Sarcomatous tumours (continued) — general, recurrence of, 186 signs of, 183 situations of, 184 structural changes in, and com- binations, 185 structure of, 183 special, differentiations of, 188 giant-celled, 190 mixed-celled, 190 round-celled, 188 spindle -celled, 189 treatment, 191 Saxtorph, results of antiseptic joint- excisions, 447 Sayre, observations on diseases of joints, 990, 993, 1006 on fractures, 782 Scab, healing under, 428 Scalds, 522. See Btu'ns Scaphoid bone, dislocation of, 970 Scapula, dislocation of, 916 fractures of, 784 Scarpa, shoe for club-foot, 1040 Schede, results of antiseptic operations, 448 Schroder, experiments on putrefying influence of air, 443 Sciatic artery, aneurism of, 647 Scirrhus, 194, 198 causes of, 201 characters of, 194 course of, 206 cyst-formation in, 199 diagnosis of, 192 effects of, 196, 204 number of formations in, 201 secondaiy, 209 situation of, 201 structure of, 192 terminations of, 207 tumour of, 195 ulcer of, 208 ulceration in, 207 varieties of, 198 Scorbutic ulcer, 253 Scrofula, 272 blood pathology of, 280 in bones and joints, 277 causes of, 280 in cellular texture, 276 inflammation in, 274 inoculation of, 273 in internal ear, 278 laryngitis in, 278 in lip, upper, 278 lymphatic glands, 275 mammary tumour in, 279 in mucous membrane, 277 nails, 277 nose, 278 operations in, 283 ophthalmia in, 277 relation to tuberculosis, 273 1082 INDEX. Scrofula (continued) — in salivary glands, 278 skin, 276 special forms of, 275 symptoms of, 27-4 in testicle, 279 tongue, 278 tonsils, 278 treatment of, 281 ulcer in, 275 Scrofulous caries, 852 of joints, 989 diathesis, 280 , necrosis, 863 ostitis, 839 ozsena, 278 periostitis, 840 synovitis, 987 temperament, 280 tumour of breast, 279 Scrofulous or strumous ulcer, 275 Scurvy, 283 blood pathology of, 284 symptoms of, 283 treatment of, 285 curative, 285 preventive, 285 Sebaceous cysts, 152, 157 Section, subcutaneous, in false-joint, 766 of nerve in neuralgia, 572 tendons, 1030, 1039 in reduction of dislocations, 908 of fractures, 748, 834 of varicose veins, 719 Secondary adhesion in wounds, 423 Semilunar bone, dislocation of, 936 Seminal cysts, 151 Senile gangrene, 713. See Gangrene Septum of nose, fracture of, 771 Sequestrum of bone, 857 Serous cysts, 151 Serpiginous or creeping inflammation, 340 Seton, 118 Sheaths of tendons, inflammation of, 563 Shock, 388 causes of, 388 predisposing, 389 chloroform in, 393 in burns, 524 gunshot wounds, 506, 509 of injury, 388 after operations, 45 operation during, 393 prognosis of, 391 reaction from, 390 traumatic delirium, 390 symptoms of, 388 terminations of, 390 of traumatic delirium, 393 treatment of, 392 Shoulder-joint, disease of, 1026 dislocations of, 917 fractures near, 785, 787, 924 Shoulder-joint, gunshot wounds of, 514 Sigmund on syphilis, 326 Simon's observations on heat in inflam- mation, 60 on treatment of inflammation, 120 Simple chancre, 300 cysts, 151 dislocation, 891. See Dislocation fracture, 735. See Fracture Sinus, 103 in hip-joint disease, 1012 scrofulous joint-disease, 991 treatment of, 140 Skin, and subjacent textures, surgical affections of, 533 Skin, cancer of, 200, 209. 217 recurrent, in, 209 cheloid cicatrix of, 519 chilblains, 588 corns, 541 epithelial cancer of, 215 horns, 543 mercurial eczema of, 334 morbid cicatrices of, 519 neevus of, 179 painful tubercle under, 165 scrofula of, 276 syphilitic diseases of, 311, 317 in infants, 321 tumours of, 552 ulcers of, 552 warts of, 543 Skin-grafting, 246 Slough, 110 in burns, 526 contused wounds, 489 formation of, 110 in gunshot wounds, 507 separation of, 110 treatment of, 141 in ulceration, 247 Sloughing of aneurism, 591 after ligature, 604 of bubo, 307 cancer, 207 chancre, 303 in erysipelas, 342 phagedena, 368. See Hospital Gan- grene Smith, Robert, observations on disloca- tions, 914, 925 on fractures, 787, 790, 800, 802, 809, 810, 812, 813 Smith, Stephen, statistics of aneurism, 646 Snake-bites, 381 constitutional disorder from, 381 local condition in, 381 period of latency in, 381 treatment of, 381 Soft bubo, 307 cancer, 194 chancre, 302 Softening, inflammatory, 62 INDEX. 1083 Special arteries, aneurisms of, 616 degenerations, 225 dislocations, 909 fractures, 769 tumours, 150 Special pathology and surgery, 421 Specific inflammations, 145 Sparine, observations on svphilis, 308, 338, 339 Sphacelus, 258 Sphygmograph, 67 pulse tracings, 69 Spinal cord, diagnosis of concussion of, from hysteria, 412 Spine, caries of, from disease of sacro- iliac articulation, 1025 dislocations of, 911 lateral curvature of, diagnosis from disease of hip-joint, 1018 Splints, Dupuytren's, 836 Gordon's, 803 Listen' s long, 817 Mclntyre's, 832 Nelaton's, 802 Thomas's, 994, 1019 Sprains or strains, 553 treatment of, 553 of joints, 889 Stanley, observations on diseases of bone, 857,''859 Starched bandage in fractures, 748 in joint-disease, 995 Statistics in surgery, 45 Sternum, fractures of, 778 compound, 778 Sthenic inflammation, 142 Stomach, persistent sickness of, after chloroform, 40 treatment of, 40 Stone (N.T.), statistics of amputations, primary and secondary, in civil and military practice, 515 Strangulation, gangrene from, 264 Strapping in disease of joints, 980, 995 Strieker's observations in inflammation, 57 Stromeyer, operation of tenotomy, 1030 Strumous node, 840 ulcer, 254 Stumps from contused and lacerated wounds, 489 from gunshot wound, 489 in hospital gangrene, 368 Styptics, 469 Subclavian artery, aneurism of, 636 ligature of, 674 Subcutaneous injection in neuralgia, 572 pneumatic aspiration, 138 section of tendons, 1030, 1039 in false-joint, 766 of nerve in neuralgia, 572 in reduction of dislocations, 908 of fractures, 748 varicose veins, 719 Subluxation of lower jaw, 909 of knee, 963 Superficial femoral artery, aneurism of, 651 ligature of, 696 Supernumerary fingers, 1034 Suppuration, 88 difEused, 100 hectic fever in, 106 pathology of, 95, 97 symptoms of, 100 in diSerent textures, 100 treatment of, 133 of aneurismal sac, 591 after ligature, 604 in axillary aneurism, after liga- ture of subclavian, 641 in carotid aneurism, after liga- ture of artery, 632 in femoral aneurism, after liga- ture of external iliac, 650 in popliteal aneurism, after ligature of superficial fe- moral, 657 of bone, 844 circumscribed abscess of, 848 diffuse periostitis, 847 osteo-myelitis, 844 periosteal abscess, 848 in burns, 525, 528 erysipelas, 342, 354 hip-joint disease, 1012, 1014, 1021 joints, 977, 988, 991 whitlow, 539 wounds, contused and lacerated, 494 gunshot, 507 punctured, 498 Suppurative arteritis, 706 granulation, healing by, 491 phlebitis, 720 Surgery as a science and scientific art, 2 Surgical fever, 422. See Traumatic Fever operations, pathology in the plan, and performance of, 22 Sutures, 430 button, 431 Glover's stitch, 431 interrupted, 431 quilled, 431 twisted, 431 uninterrupted, 431 of nerves, 567 Swelhng in inflammation, 60 causes of, 60 consistence of, 61 diagnostic value of, 62 shape of, in different textures, 61 size of, in diSerent textures, 61 Syme, James, observations on disloca- tions, 908, 939, 941, 943 on false cartilages in joints, 1009 Synovitis, 973 1084 INDEX. Synovitis (continued) — abscess in, 97-i treatment of, 979, 980 anchylosis from, 977 treatment of. See Anchylosis causes of, 976 chronic, 977, 980 diagnosis, 975 gonorrhceal, 976, 980 hydrops articuli, 977 treatment of, 980 pysemic, 977. See Pyemia rhenmatic, 981 scrofulous, 987 signs of, 974 structural conditions of, 973 terminations of, 977 treatment of, 979 Syphilis, 299 bubo, 305 diagnostic value of inoculation, 309 indurated and indolent, 305 inflammatorv, 306 treatment of, 329 varieties of, 307 causative relation of local to consti- tutional, 32-4 modus operandi of inf ection,326 chancre, 300 diagnostic value of inoculation, 307, 325 of induration, 300 duration of, 301 of specificity, 309 situations of, 304 termination of, 301 treatment of, 326 varieties of, 300 chancroid, 302 conversion into chancre, 303 diseased conditions of chancre and chancroid, 303 interchange of characters, 303 mixed chancre and chancroid, 303 treatment of, 327 constitutional symptoms of, 309 " Contagious Diseases Act " in, 328 diagnosis of, 323 incubation, period of, 310 indurated chancre in, 300 infantile, congenital, hereditary, 319 communication of, 319 mortality from, 322 prognosis of, 322 symptoms of, 320 teeth affected by, 321 treatment of, 337 infection of ovum in, 319 inoculation as the test of, 307, 325 local contagious ulcer, 302. See Chancroid pathology of, 323 Syphilis (continued) — primary, 300 H. Lee's four varieties of, 304 treatment of, 326 secondary, 309 syphilization, 338 tertiary, 317 treatment of, 326 of constitutional, 331 curative, 331 preventive, 331 of primaiy and local, 326 curative, 328 preventive, 326 imity or duality of syphilitic virus, 324 vaccino-syphilitic inoculation, 322 Syphilitic alopecia, 317 cachexia, 319 caries, 316 condylomata, 314 disease of lymphatic glands, 316 of bones, 316 hair and nails, 317 internal organs, 318 larvnx, 315 lips, 314 mouth, 314 in infants, 320 mucous membranes, 313 in infants, 320 nose, 314 in infants, 320 palate, 314 pharynx, 314 skin,' 311 in infants, 320 testis, 315 throat, 313 tongue, 314 tonsils, 313 ecthyma, 313 exanthemata, 311 gummy tumours, 318 impetigo, 312 iritis, 315 lepra, 311 hchen, 311 mucous tubercle, 314 necrosis, 316, 863 nodes, 316 onychia, 317 ostitis, 316, 840 periostitis, 840 psoriasis, 312 psydi-aceous pustules, 312 pustules, 312 roseola, 311 squamae, 311 synovitis, 976 teeth, 321 tubercles, 311 ulcer, 313. See Chancre and Bubo of tonsils, 314 INDEX. 1085 Syphilitic vermose, 543 vesicles, 312 warts, 543 Syphilo-dermata, or syphilides, 311 congenital, 320 tertiary, 317 TABETIC arthropathy, 986 Tait, Lawson, results of non-anti- septic abdominal operations, 448 Talipes, 1037 calcaneo-valgns, 1047 varus, 1047 calcaneus, 1047 treatment of, 1047 equino-valgus, 1047 varus, 1047 Adams's shoe for, 1049 equinus, 1037 causes of, 1039 relapse of, 1041 signs of, 1037 structural conditions of, 1037 treatment of, 1039 Scarpa's shoe, 1040 flat or splay-foot, 1046 valgus, 1045 causes of, 1046 treatment of, 1046 varieties of, 1047 ■ varus, 1041 causes of, 1042 relapse of, 1045 structural conditions of, 1041 treatment of, 1043 Adams's modification of Scarpa's shoe for, 1044 splint for, 1044 Langaard's instrument for, 1045 Tarsus, dislocations of, 970 fractures of, 836 Temperature of body in inflammation, 64 Tendons, diseases of sheaths of, 563 displacement of, 556, 923 division of, 1030 hamstring, contraction of, 1036 imperfect and non-union of, 556 treatment of, 556 inflammation of sheaths of, 563 injuries of, 553 reparation of, 554 rupture of, 553 causes of, 554 symptoms of, 553 terminations of, 554 treatment of, 555 sprains of, 553 Tenosynovitis, 563 Tenotomy, 1089 Tetanus, 393 acute, 400 causes of, 399 chronic, 400 condition of wound in, 399 diagnosis oP, 395 idiopathic, 400 after operations, 45 pathology of, 396 period of probation after injury, 400 prognosis of, 401 symptoms of, 393 terminations of, 400 traumatic, 400 treatment of, 401 trismus in, 394 varieties of, 395 Textures, injuries and diseases of, 421 Thermometer, clinical, 65 Thigh, gunshot wounds of, 514 Thomson on hospital gangrene, 372 on scrofula, 275 Thornton, statistics of shoulder- joint excision for gunshot wound, 514 Thornton, Knowsley, results of anti- septic ovariotomy, 447 Throat, syphilitic disease of, 313 Thrombosis, 722 Thrombus, 722 arterial, 722 causes of, 723 symptoms of, 724 transformations of, 725 embolism, 725 treatment of, 728 venous, 723 Thumb, dislocations of, 937 Thyroid gland, pulsating enlargement of, diagnosis from carotid aneurism, 630 Tibia, dislocation of, 960 disease of joint, 990 fractures of, 830 Toe-nail, horn of, 543 ingrowing of, 541 Toes, contraction of, 1050 dislocations of, 972 fractures of, 836 Tongue, fissures of, 314 milky stains on, 314 syphilitic mucous tubercle of, 314 Torsion of arteries, 477 comparison of with ligature and acupressure, 478 modes of, 477 occlusion by, 477 Torticollis, 1029 Transfusion of blood, 480 Eoussel's method of, 481 results of, 483 Traumatic aneurism, 588, 611 delirium, 390 fever, 422 gangrene, 259, 490 1086 INDEX. Tranmatic necrosis, 862 phlebitis, 721 synovitis, 976 tetanus, 400 Travers, B., observations on inflamma- tory fever, 83 on prostration with excitement, 395 Treatment, general indications of, 18 relative importance of diagnosis, etiology, and prognosis to, 3, 18 ■ reparative and restorative power in, 18 conservative surgery, defini- tions of, 18, 20 plastic surgery, 21 Trephining in circumscribed abscess of bone, 850 Trousseau, observations on erysipelas in new-born infants, 354 on vaccino-syphilis, 322 Tubercle in bone, 839 mucous, 314 painful subcutaneous, 165 pathology of, 273 syphilitic, of skin, 311, 317 Tubercular diseases of foot, 548 eruptions, syphilitic, 311 Tuberculosis, relation to scrofula, 272 Tufnell, T. JoUiffe, observations on aneurism, 594, 596 on dislocations, 971 Tumours, 145 adenoma, 191 adipose, 161 aneurism by anastomosis, 181 atheromatous, 152 cancer, 192 cyst-formation in, 199 situation of, 200 varieties of, 197 cartilaginous, 172 varieties of, 174 classification of, 148 colloid, 194 varieties of, 198 connective-tissue series, 161 embryonic connective tissue, 182 cylindroma, 168 cystic, 156 cysts, 151 diagnosis of, 152 parasitic, 153 proliferous, 152 simple, 151 varieties of, 153 encephaloid, 194 varieties of, 197 epithelial cancer, 215, 222 epithelial-celled, 191 erectile, 176 fatty, 161 varieties of, 161 fibro-cal car ecus, 170 Tumours (continued) — fibro-cellular, 164 fibro-cystie, 170 fibro-nucleated, 170 fibro-plastic. See Myeloid fibroid, recurrent, 170 fibrous, 168 varieties of, 170 general characters of, 145 etiology, 148 structure, 145 treatment, 150 vital endowments, 147 glandular, 191 glioma, 167 infiltrating growths, 147 localized, or non-infiltrating, 147 lymphoma, 168 malignant. See Cancer melanotic cancer, 198 myeloid, 174 myxoma, 167 na3vus, 179 neuroma, 166 osseous, 182 painful subcutaneous, 165 papillary, 192 psammoma, 168 sai'comatous, 163, 188 differentiation of, 188 general characters, 183 alveolar, 189 giant-celled, 190 mixed-celled, 190 net-celled, 167 plexiform, 191 round-celled, 188 spindle-celled, 189 scirrhus, 194 varieties of, 198 vascular. See Erectile, 176 wens, 152 of antrum. See Tumours of Jaws in axilla, 733 of bone, 876 groin, diagnosis from aneurism, 649 intra-thoracic, aneurismal, 616 of muscles, 558 neck, diagnosis from aneurism. 630 nerves, 481 skin, cancer, 215 corns, 541 horns of, 543 nsevus of, 179 warts of, 543 Tyndall on organic dust in air, 443 TJ LCEE, 242 cancerous, 208, 255 cicatrization of, 246, 491 diagnosis of, from wound, 421 INDEX. 1087 Ulcer (continued) — diagnostic characters of, 244 granulation of, 246, 491 healthy, 245 treatment of, 250 by skin-grafting, 246 hsemorrhagic, 253 treatment of, 253 indolent, 249 treatment of, 250 inflamed, 247 eczematous, 248 treatment of, 248 irritable, 248 treatment of, 249 local contagious, 302. See Chancre and Hospital Gangrene lupoid, 255 treatment of, 249 cedematous, 249 treatment of, 249 phagedsenic, 252 treatment of, 253 rodent, 256 treatment of, 256 scorbutic, 253 treatment of, 253 scrofulous or strumous, 254 treatment of, 254 sloughing, 247 syphilitic, 314 treatment of. See Species of, 245 varicose, 250 situation of, 250 treatment of, 251 venereal. See Chancre of burns, 526 cicatrix, 246, 493 duodenum, after bums, 525 lips, 278, 314, 317, 320 nose, 278, 314, 317, 320 skin, cancerous, 255 epithelial, 220 syphilitic, 313 tongue, 278 syj)hilitic, 314 tonsils, 278 syphilitic, 314 Ulceration, 241 causes of, 245 extension of, by ichorous discharge, 244 ichor, product o£, 244 pathology of, 242 in relation to degeneration, 442 to mortification, 111, 241, 257 from inflammation. 111 textural liability to, 265 treatment of. See Species of Ulcers of bone, 851. See Caries cancer, 207, 220 cartilage, articular, 996 sarcoma, 186 Ulna, dislocations of, 930, 933 fractures of, 798 Union by adhesive iaflammation, 427 by first intention, 423 granulation, 427, 491 secondary, 423 immediate, 423 of incised wounds, 423 mediate, 423 by modelling process, 428 of nerves, 426, 566 by primary adhesion, 423 scabbing, 428 Unity, or duality, of syphilitic virus, 324 Unreduced dislocation, 904 Ununited fracture, 762 causes of, 763 effects of, 764 structural conditions of, 762 terminations of, 764 treatment of, 765 Urethra, chancre of, 305 Urine, chemical composition of, 77 physical characters of, 77 physiological origin of consti- tuents, 77 febrile, 78 VACCINO-SYPHILITIC inoculation, 322 Valette on wound-treatmeiit by anti- septic immersion, 434 Valsalva, treatment of aneurism, 594 Varicose aneurism, 613 causes of, 614 consequences of, 614 signs of, 613 structural condition of, 613 treatment of, 615 ojjeration for, 615 preventive, 615 ulcer, 250 veins, 716 Varix, aneurismal, 613 of arm, 644 causes of, 614 consequences of, 614 in groin, 651 leg, 659 neck, 632, 640 signs of, 613 structural condition of, 613 in thigh, 654 treatment of, 615 of veins, appearances of, 716 causes of, 717 cauterization of, 720 compression of veins in, 718 diagnostic characters of, 716 excision of vein for, 719 inflammation from, 718 injection of, 720 locality of, 7l7 1088 INDEX. Varix of veins (^continued) — of saphena vein, 718 stmctiiral conditions of, 716 subcutaneous section in, 719 terminations of, 718 treatment of, 718 palliative, 718 radical, 719 twisted suture in, 719 venous bajmorrhage from, 718 Vein, aneurismal varix of femoral, 651, 654 of jugular, 632 subclavian, 640 Veins, air in, 483 gangi'cne from obstruction of, 263 haemorrhage from, 479 inflammation of, 720 injuries of, 716 pressure of aneurism on, 588 in abdominal, 644 aneurisms at root of neck, 621 axillaiy, 640 femoral, 649, 652 intra-tboracic, 618 popliteal, 655 subclavian, 637 stones in, 729 thrombus in, 722 varicose, 716 wounds of, 478 causes and effects of, 479 reparation of, 479 signs of, 479 treatment of, 479 Yein-stones, 729 Velpeau, observations on tumours, 211 on diseases of bone, 857 dislocations, 928 tenotomy for talipes varus, 1044 Venesection, 122 from external' jugular vein, 124 Venous vascular tumour, 176 Vent de boulet, 504 Ventilation, importance of, in relation to erysij)elas, 352 to hospital gangrene, 374 operations, 31 pyaemia, 367 scrofula, 282 Verrucae, 543 Vertebrae, dislocation of, 911 Vezin on wound-treatment, open method of, 433 Villous cancer, 198 Virchow's observations on degenera- tions, 229, 237 on fibrin-production in inflamma- tory effusions, 61, 96 pvogenesis, 97 thrombosis and pyaemia, 363, 725 tumours, 146, 149, 163, 167 of joints, 1009 Virchow's observations on ulceration, 244 Virus, hydrophobic, 375 syphilitic, 299, 324 Volkmann on results of antiseptic treatment, 446 on wound-ti'eatment by open method, 434 WALKER, observations on reunited fractures, 764 Waller, observations on inflammation, 57 Wardrop's operation for aneurism, 608 Warren, C. (Boston), rodent ulcer, 256 Warts, 543 of epithelial cancer, 218, 219 venei-eal, 543 Wasps, stings of, 382 Watson, Sir Thomas, on mercury in in- flammation, 129 Welbank's observations on hospital gan- grene, 372, 373 WeUs, Sir Spencer, on results of anti- septic ovariotomy, 447 Wens, 152 Whitlow, 539 involving sheath of tendons, 539 necrosis from, 540 treatment of, 540 William III., H.M. King, death of, from pyaemia, 444 Williams, C. J. B., observations on fatty degeneration, 227 in inflammation, 55 Wilson, Sir Erasmus, observations on cutaneous scrofula, 276 on copper colour in syphilitic erup- tions, 311 Wounds, 421 contused, 488 dissection, 383 dressing of, 429 after-dressing, 432 antiseptic, 437 gunshot, 500 incised, 421 lacerated, 488 poisoned, 375 punctured, 497 reparation of, 422 reparative power, nature of, 426 treatment of, antiseptically, 433, 437 methods of, 433 of ankle-joint, 890 gunsliot, 514 arteries, 462. See Arteries bladder, in fracture of pelvis, 805 elbow-joint, 890 gunshot, 514. See Escisional Surgery for Injury, vol. ii. heart, by fractured sternum, 778 INDEX. 1089 Vounds (continued) — of hip-joint, 890 gunshot, 514. See Excisional Surgery for Injury, voh ii. joints, 889 by fracture, 759 gunshot injury, 514 knee-joint, 890 gunshot, 514. See Excisional Surgery for Injury, vol. ii. lungs, by fractured ribs, 776 sternum, 778 mouth. See Cheeks nerves, 566 shoulder- joint, 890. See Exci- sional Suigery for Injury, vol. ii. gunshot, 514 tetanus from, 399 of veins. See Veins Wounds (continued) — of veins, arterio-venous. See Aneu- rismal varix wrist-joint, 890 gunshot, 584. See Excisional Surgery for Injury, vol. ii. Wrist, dislocations of, 934 injuries allied to, 935 fractures close to, 801, 935 gunshot wound of, 514 wounds of, 890 Wry-neck, 1029 causes of, 1030 treatment of, by apparatus, 1031 by operation, 1030 ZUELZEE, observations on erysipelas, 350 Zygoma, disarticulation of, 772 fractures of, 772 ElfD OF VOL. I. VOL. I PRINTED BY WILLIAM CLOWES AND SONS, LIMITED, LONDON AND BECCLES. 4 A .&^^:s>^:X!^Jywywv^ m'Ji ^H^¥^:^'^ Wj^^.m ^ ^ ^. vw; ^:m 'yj\<^ i\j\J^'p\i\0'^)^^'^ ^^y V^