College of ^fjpsficiang anb ^urgeong 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 Columbia University Libraries 
 
 http://www.archive.org/details/manualforpracticOObrya 
 
A MANUAL 
 
 PRACTICE OF SURGERY. 
 
 BY 
 
 THOMAS BRYANT, F.K.C.S, 
 
 MEMBER OF THE COUNCIL AND COURT OF EXAMINKKS OF THE ROYAL COLLEfiE OF SURGEONS; SENIOR 
 
 SURGEON TO, AND LECTURER ON SUROKRY AT. GUV'S HOSPITAL; MEMB. CORRESPOND. 
 
 DE LA SOClfiTE DK CIURURGIE 1)E PARIS. 
 
 WITH SEVEN HUNDRED AND TWENTY-SEVEN ILLUSTRATIONS, 
 
 FOUKTH EDITION, THOEOUGHLY REVISED. 
 
 PHILADELPHIA: 
 HENRY C. LEA'S SON & CO. 
 
 1885. 
 

 -^ 
 
 <rp . ^ 
 
 PBIN'TED BV 
 ELECTRuTYPEU BY 
 
 p rr,T^,.c^^r>xT William J. Doenan, 
 
 ^^ESTC■OTT & Thomson, 
 
 Philadelpbui. 
 
AMERICAN PUBLISHERS' NOTICE. 
 
 American surgeons have unmistakal)ly signified their appreeiation of Mr. 
 Bryant's Practice of Star/crt/ by demanding four editions sinee 1879. The tJiird 
 Ameriean edition, like the second, was reprinted from the third English edition, 
 and in order to cover the advances in Surgery made in the interval, it was 
 subjected to a very thorough revision by Dr. John B. Roberts, a former pupil 
 of ^Ir. Bryant. It has been thought well to reprint the fourth English edition 
 without alteration, since it comes fresh from the pen of the Author, and it 
 may be noted that he has seen fit to accept many of Dr. Roberts' additions. 
 The two volumes of the English edition have been arranged to occupy one iu 
 the American reprint — a change which conduces both to convenience in hand- 
 ling and comfort in reading. 
 
 November, 1884. 
 
PREFACE TO SECOND EDITION. 
 
 A SECOND EDITION of this manual having been called for, I have availed 
 myself of the opportunity to make some alterations in the substance a-s well as in 
 the arrangement of the work, and, with a view to its improvement, have recast 
 the materials and revised the whole. I have also, to make the work more com- 
 plete, added much new matter, including chapters on diseases and injuries of the 
 eye and ear, some remarks on dental surgery, on the diagnosis of ovarian tumors, 
 and on deformities, together with at least one hundred new wood-cuts. 
 
 I am well aware that I have foiled to realize in the execution of mv ta.-k the 
 ideal standard I at starting proposed to myself, and I knew, when I first under- 
 took to write the book, how difficult it was to compress the treatment of the vast 
 range of subjects included under the title of "Surgery" into one volume, but mv 
 object was to oifer such an epitome of the main princi])les and methods of practice 
 as should be serviceable to the student and practitioner ; and from the recej)tion 
 the first edition of this work, published in Xoveml^er, 1872, has met with in Creat 
 Britain and America, I feel justified in saying that I have not failed in the attempt, 
 and that the book supplied a want felt by the professional public. 
 
 To the many reviewers who have acknowledged my labors so fairly and so 
 fully my thanks are clearly due, but still more to the profession, which has wel- 
 comed my humble services so kindly. 
 
 Fully alive, therefore, to the generous appreciation of my past Mork, and assur- 
 ing my readers that no pains have been spared to bring the present up to as high 
 a standard as my time and opportunities have allowed, I submit it in all confidence 
 to the kind consideration of my professional brethren as no unworthy exposition 
 of modern British surgery. 
 
 In its execution I have endeavoretl to acknowledge on all occasions the claims 
 of othei*s and whatever merit or novelty may attach to their views or operations, 
 
 V 
 
vi PREFACE TO SECOND ELITIOX. 
 
 for mv w\:^h has been to represent not so iniu ii iny tjwn opinion, as the position 
 of surgery at the time I write. 
 
 It Kiilv remains for me to express once more my obligations to Mr. Thomas 
 Turner, the treasurer of Guy's Hospital, by Mhose kindness the materials in the 
 unrivalled collections of that institution were placed at my disposal ; to my col- 
 leagues, Drs. Moxon, Goodhart, and Purves, Messrs. Howse, C. Higgens, and 
 Moon ; and to Mr. Wesley, the artist who has so ably illustrated these pages. 
 
 Since I first undertook this work deatli has deprived me of two colleagues, 
 Mr. Poland and Dr. Phillips, lioth nf whnm rendered me many friendly services 
 and much valualjle assistance. I refer to their names with gratitude and regret. 
 
 53 Upper Beook .Street, GR0i5VEX0R SquARE, 
 March, 1876. 
 
CONTENTS 
 
 LIST OF ILLUSTRATIONS. 
 
 INTRODUCTORY CHAPTER. 
 
 Definition of Surjfery— How to Investigate a Case — Points for Inquiry 
 in Surirical Cases li 
 
 CHAPTER I. 
 
 Wounds — Repair — Inflaininatiou — Abscess — Sinus and Fistula— Ulcers 
 and Sores— Bed-sores — Mortification — Hospital Gang-rene— Erysipe- 
 las— Krytheina— Traumatic Fever — Septictemia and Pyieniia— Hectic 
 Fever 23 
 
 FIG. PAOE 
 
 1. riacoid cells 26 
 
 2. Diagram illustrating the process of re- 
 
 pair 27 
 
 3. Irrigating apparatus for washing 
 
 wounds 33 
 
 4. The interrupted suture 35 
 
 5. The continuetl suture 35 
 
 6. The twisted suture 36 
 
 7. The quilled suture 36 
 
 FIG. FAiiE 
 
 8. The button suture 36 
 
 9. Leiter's metallic coil for heat or cold . 49 
 
 10. Pus-corpuscles 68 
 
 11. Abscess knife 69 
 
 12. Sinus scissors 72 
 
 13. 14. Tliermographs of erysipelas ... 85 
 
 15. Thermograph of pytemia 92 
 
 16, 17, 18, 19. Thermographs of traumatic 
 
 fever 92 
 
 CHAPTER II. 
 
 Animal Poisons— Poisoned "Wounds — Insect-sting-s — Hydrophobia— Glan- 
 dcr.s — Malignant Pustule, or Charbon— Syphilis— Inoculation and 
 Syphilization— Vaccine-Syphilis 100 
 
 20. Anatomical tubercle 101 23. Hereditary syphilis 116 
 
 21. Bacilli from charbon 108 24. Syphilitic" teeth 117 
 
 22. Syphilitic deposit in testicle 112 25. Healthv teeth 118 
 
 CHAPTER III. 
 
 Tumors : Innocent, Semi-Malignant, 
 Tumors— Cysts— The 3Iicroscopical 
 
 26. Fattv tumor 126 
 
 27. Diffused lipoma 126 
 
 28. Molluscum fibrosum . 127 
 
 29. Fibrous tumor 128 
 
 30. Enchondromatous tumor 128 
 
 31. Adenoid tumor 129 
 
 32. Sarcoma of bone 131 
 
 33. Melanotic sarcoma 132 
 
 34. Epithelial cancer of stump 136 
 
 35. Rodent cancer 1.37 
 
 36. Colloid tumor of breast, with section • 138 
 
 Cancerous— Cancer— Granulation 
 Anatomy of Tumors 120 
 
 37. Fungating follicular tumor 141 
 
 38. Serous cyst of neck 142 
 
 39. Sebaceous tumors and horn in scalp . . 145 
 
 40. Microscopical anatomy of osteoma, en- 
 
 chondroma 148 
 
 41. Ditto, adenoma 149 
 
 42. Ditto, lymphoma 150 
 
 43. Ditto, sarcoma 151 
 
 44. Ditto, myxoma 152 
 
 45. Ditto, carcinoma 153 
 
 Vll 
 
viii COSTEXTS WITH LIST OF ILLUSTRATIONS. 
 
 SURGERY OF THE CUTANEOUS SYSTEM. 
 chaptp:r IV. 
 
 Contusions— Arrow AYoxiuds— Burns and Scalds— Skin-grafting— Chil- 
 blains— Frostbite— Boils— Carbuncle— AVarts— Moles— Corns— Bunions 
 
 — IngroAVu Toe-Xail—Onycbia—Elepliantiasis— Parasites 1 Jo 
 
 FlCi. PAGE FIG. PAGE 
 
 46. Eib pierced bv arrow 157 56, 57. Growth of black skin when grafted 
 
 47. Axillary cicatrix after burn 161 on sore of white man 166 
 
 48. Mode of applying extension after its 58. Bunion 174 
 
 division ." 161 59. Toe-cap for cure of bunion 1.4 
 
 49. Effects of burn on neck 162 60. Ingrown toe-nail 176 
 
 50. Cheloid of Alibert 163 61. Acute onychia 176 
 
 51. Cheloid of Addison 163 62. Chronic onychia • •. ^1^ 
 
 52. Congenital cicatrix of lip, nose. etc. . . 163 63. Horny growth beneath nail 177 
 
 53. 54. Cicatrization of sores by skin-graft- 64. Ungual exostosis . 177 
 
 ing '. 165 65. Elephantiasis Arabum before operation . 178 
 
 55. Scissors'^ for skin-grafting 165 66. Elephantiasis Arabum after operation . 178 
 
 I 67. Guinea-worm bleb 179 
 
 SURGERY OF THE LYMPHATIC SYSTEM. 
 
 CHAPTER V. 
 
 Inflammation of the LjTiiphatics and their (ilands— Diseases of the 
 Thyroid Gland 181 
 
 68. Exophthalmic goitre 185 70. Microscopical appearance 'of thyroid 
 
 69. Pedunculated thyroidal tumor .... 187 , glands 187 
 
 SURGERY OF THE >'ERYOUS SYSTEM. 
 
 CHAPTER VI. 
 
 Injuries of the Head— Contusions and Wounds of the Scalp— Blood 
 Tumors— Ostitis— Injuries of the Cranium— Concussion of the Brain 
 —Injuries of the Brain and its 3Iembranes complicating Fracture- 
 Compression of the Brain— Encephalitis— Trei)hining— Diseases of 
 the Scalp and Cranium— Trismus and Tetanus— Delirium Tremens— 
 Shock and CoUapse— Feigned Disease 189 
 
 71 Gutter-Shaped fracture of skull .... 192 77. Extravasation of blood between bone 
 
 72. Saucer-shaped ditto 192 and dura mater 202 
 
 73. Comminuted fracture of skull .... 193 78. Section of skull, with cranial contents. 203 
 
 74. Fracture of base of skull 194 79. Hernia cerebri 206 
 
 75. Fracture of anterior fossa of the base of 80, 81, 82. Operation of trephining ... 212 
 
 the skull 196 83. Meningocele at root of nose 2L 
 
 76. Punctured wound of skull 196 , 84. Encephalocele . 217 
 
 I 85. Necrosis of frontal bone 218 
 
 CHAPTER VII. 
 
 Injuries and Diseases of the Spine— Spina Bifida— Concussion— Intra- 
 spinal Inflammation— Spinal Paralysis after Concussion— Fractures 
 and Dislocations of the Spine— Wounds and Sprains— Curvature of 
 the Spine— Injuries and Diseases of the Nerves— Xeuralgia, Tic 
 Douloureux— Neuroma 229 
 
 86 Dissection of spina bifida 229 I 91. Dislocation of spine forward 238 
 
 87 Double spina bifida 230 92. Fracture of spine 238 
 
 88. Cured spina bifida 230 93. Fracture of spine and displacement 
 
 89, 90. Congenital coccygeal tumors . . • 232 i backward 238 
 
COSTKSTS WITH LIST OF 1 LLrsTIiATIOSS. 
 
 IX 
 
 CHAPTER \ \\.— 0>,it!nu,J. 
 
 FIO. I'Ai.K 
 
 94, 95. Lateral curvature of spine .... *244 
 
 96, 97. Anj;iil;ir curvature of .-.pine . . . 24") 
 
 98,99,100. Disrasi- ot rervical vertebne . 240 
 
 101. Synostosis ol" ribs to vertebra' .... 247 
 
 102. Kif^id spine of spinal disense .... 247 
 10.'}. Child suppiirtint^lMMly in spinal disease. 247 
 104, 105. Sa_vre'sapi)uratus for spinal curva- 
 ture 247 
 
 CILMTHll VIII. 
 
 Tlie Kyo I']xaiM!iiatioii of tlio Hall 
 At'CiuniiHulatioii -.\<'nt«'iH'ss aii<l 
 juries of tlu' Kye— OperatioiLS . . 
 
 aii<l its ApiM'ii«Iafi:os— KcfVactum— 
 Fi«»l<l ol" \'isioii l>is<'as<'S aii<l Iii- 
 
 10(i. Lielireich's ophtiialtnosrope 257 115. 
 
 107. hulirett ophtlialuioscopie e.xamina- 
 
 tiou 258 IIG. 
 
 108. Acconiinodation and refraction .... 2(51 
 
 109. Oldliaiu's <)i)litluilnioscope 2«3 117. 
 
 110. Position of patient for minor oplillial- 118. 
 
 niic operations 290 119. 
 
 111. Position for major ophthalmic f)pera- 120. 
 
 tions 290 121. 
 
 112. ('onij)ressoriuni forceps 293 122. 
 
 113. C'ompressorinm forceps applied . . . 293 
 
 114. Wile speculum 295 , 123. 
 
 (irooved director for slitting canalicu- 
 lus 296 
 
 Instruments for operations for strabis- 
 mus .300 
 
 Instruments for iridectomy 304 
 
 De Wecker's scissors 306 
 
 Artificial pupils 306 
 
 Instruments for extraction of cataract . 308 
 
 Incisions for extraction of cataract . . 309 
 Instnunents for removal of cataract 
 
 with scoop 311 
 
 Extirpation scissors 313 
 
 AftVftioiis of the Ear 
 
 CHAPTER TX. 
 -External — 3Iiddle— Internal— Deaf- 3Intism 
 
 322 
 
 124. Congenital occlusion of external audi- 127. Hfematoma auris 324 
 
 tory canal 322 128. Cheloid tumor of ear 324 
 
 125. Politzer's method of examining middle 129. Microscopical appearances of same . . 324 
 
 ear 322 130. Syringing ear 326 
 
 126. Effects of injury on ear 323 131. Appearance of niembrana tympani . . 332 
 
 SURGERY OF THE CIRCULATORY SYSTEM. 
 
 CHAPTER X. 
 
 Wounds of the Heart and Arteries— Hemorrhag-e and its Treatment— 
 Siirj»ieal Hreniostatios- Transfusion — Diseases of tlie Arteries— Em- 
 holisni— Aneurism— Nieviis—Lig:ation of Arteries — Special Aneurisms. 338 
 
 132. EflPects of natural haemostatics .... 3-10 
 
 133, 134. Effects of contusion on an artery . .341 
 
 135. Effects of ligation on an artery . . . 312 
 
 136. Effects of toreion on artery 312 
 
 137. Application of ligature to artery; tour- 
 
 nicpiet, torsion forceps, etc .... 345 
 
 1.38. Different modes of acupressure . • . 346 
 
 139. Tlie femoral artery twisted .347 
 
 140. Speir's artery constrictor 347 
 
 141. Koussel's injecting apparatus .... 351 
 
 142. Inflammatory chantje in artery pre- 
 
 ceding atheroma 353 
 
 143. Atheroma of artery 353 
 
 144. Section of artery plugged by an em- 
 
 bolus 356 
 
 145. .Sacculated traumatic aneurism . . . .357 
 
 146. Multiple aneurisms 358 
 
 147. Laminated clot from aneurism .... 359 
 
 148. Section through cured .'ineurism . . . 360 
 
 149. Mode of applying pressure to femoral 
 
 artery for cure of aneurism . . . .'■>64 
 
 150. Weiss's double pad for pressure . . . 364 
 
 151. Coles' pad for elastic pressure .... .364 
 
 152. Dix's mode of compressing artery . . 368 
 
 153. Different operations for aneurism . . 369 
 
 154, 155. Collateral circulation in the lower 
 extremity after application of a lig- 
 ature to external iliac artery . . . 374 
 
 156. Different forms of arterio-venous an- 
 
 eurism 374 
 
 157. Aneurismal varix of axillary vessels . 375 
 
 158. Cock's case of arterio-venous aneurism. 376 
 
 159. Cirsoid aneurism of temporal artery . 377 
 
 160. Cirsoid aneurism of foot 377 
 
 161. Degenerating nsevus 378 
 
 162. Mode of ligating nievus 379 
 
 163. Effects of nsevus of upper lip .... 379 
 
 164. 165. Modes of ligating large ni¥vi . 380 
 
 166. Needle for applying subcutaneous liga- 
 
 ture to na'vus 380 
 
 167. Application of ligature to artery . . . 382 
 
 168. Best form of aneurism needle .... 382 
 
 169. Incision for ligation of aorta or com- 
 
 mon iliac artery 383 
 
 170. Operation of ligating common carotid 
 
 and facial arteries 386 
 
 171. Operation of ligating the subclavian 
 
 and lingual arteries 389 
 
 172. Lisation of axillarv arterv 390 
 
 173. 174. Lisation of brachial'arterv . 390, 391 
 
CONTENTS WITH LIST OF ILLUSTRATIONS. 
 
 CHAPTER X.— Confinued. 
 
 175. Ligation of radial artery (upper third) . 392 
 
 176. Ligation of radial and ulnar arteries . 392 
 
 177. Ligation of external iliac and femoral 
 
 arteries 393 
 
 178. Ligation of posterior tibial artery . . 396 
 
 179. Ditto behind malleolus ....'... 397 
 
 180. Ligation of anterior tibial artery . . 397 
 
 181. Ligation of dorsalis pedis 398 
 
 CHAPTER XL 
 Injuries and Diseases of the Veins— Venesection 
 
 182. Obstruction of inferior vena cava . . 403 I 184, 185. Venesection 
 
 183. Varicose veins 404 | 
 
 398 
 
 407 
 
 SURGERY OF THE DIGESTIVE ORGANS. 
 
 CHAPTER Xn. 
 Affections of the Lips, Mouth, Tongue, Pahite, and Tonsil 
 
 409 
 
 186. Congenital fissure of lower lip and jaw. 
 
 187. Formation of upper jaw 
 
 188. Central fissure of lip 
 
 189. 190,191. Degrees of single harelip . . 
 192, 193. Double harelip 
 
 194. Position of [)atient for operation of 
 
 harelip 
 
 195. Operation for single harelip 
 
 196. Hainsby's truss for harelij) 
 
 197. 198. Collis' operation for harelip . • 
 
 199. Malgaigne's operation 
 
 200, 201. Operation for double harelip . . 
 202, 203, 204. Tiie same with projecting in- 
 termaxillary bones 
 
 205, 206, 207. Cheiloplastic operations ibr 
 deformed mouth 
 
 208. Cancer of lower lip 
 
 209, 210. Operation for formation of new 
 
 lip .• • 
 
 211. Hypertrophy of mucous glands of lip . 
 
 212. Hypertrophy of lip 
 
 409 
 
 213. 
 
 409 
 
 214. 
 
 409 
 
 215. 
 
 410 
 
 216. 
 
 410 
 
 217. 
 
 
 218. 
 
 411 
 
 219. 
 
 411 
 
 
 411 
 
 220. 
 
 412 
 
 221. 
 
 412 
 
 
 412 
 
 222. 
 
 412 
 
 223. 
 
 
 224, 
 
 412 
 
 226, 
 
 413 
 
 
 
 228. 
 
 413 
 
 229. 
 
 414 
 
 230. 
 
 414 
 
 231. 
 
 Cancrum oris 415 
 
 Ranula or sublingual cyst 416 
 
 Salivary calculus 417 
 
 Submaxillary tumor 418 
 
 Ichthyosis of tongue 422 
 
 0})eration for removal of tongue . . . 431 
 Different operations lor removal of 
 
 tongue 431 
 
 T. Smith's gag ._ 432 
 
 Fergusson's knives for operations on 
 
 palate 432 
 
 Paring edges of fissured palate after 
 
 introduction of sutures . . . . 433 
 
 Needles employed in fissured j)alate . 433 
 
 225. Operation for fissured palate . . 434 
 227. Fergusson's operation on hard 
 
 palate 435 
 
 Trendelenburg's tracheal tampon . . 436 
 
 Tonsil guillotine 437 
 
 Operation on tonsil with guillotine . . 438 
 
 Kemoval of tonsil with knife .... 438 
 
 CHAPTER XIIL 
 
 Diseases of the Gums, Jaws, Teeth, Pharynx, and CEsophagus- 
 Surgery— Affections of the Pliarynx and (Esophagus .... 
 
 232. Necrosis of lower jaw with condyloid 
 
 process 440 
 
 233. Fibrous epulis from gum 441 
 
 234. Epulis springing from bone 441 
 
 235. Tooth odontome 441 
 
 236. Odontome after removal 441 
 
 237. The same in section 441 
 
 238. Dentigerous cyst of u^jper jaw with 
 
 tooth 443 
 
 239. The same of lower jaw 443 
 
 240. Dentigerous tumor of upper jaw . . . 444 
 
 241. 242. Enchoudromatous tumor of upper 
 
 jaw • 
 
 243, 244. Lines of incision for removal of 
 upper jaw ■ • • _ 
 
 245. Saw for operation on jaw 
 
 246. Lion forceps for the same 
 
 247. Periosteal sarcoma of lower jaw . . . 
 
 248. Fibro-cellidar tumor of lower jaw . . 
 
 249. 250. Fibro-cystic disease of lower jaw. 
 
 251. Dislocation f)f lower jaw 
 
 252. Reduction of dislocation of lower jaw. 
 
 253. 254. Bandage and splint for fracture 
 
 of lower jaw 451 
 
 -Dental 
 
 444 
 
 445 
 
 445 
 445 
 446 
 446 
 446 
 449 
 449 
 
 255. Thomas' mode of adjusting fracture of 
 lower jaw 
 
 256. Moon's interdental splint 
 
 257. Metal caps for the same 
 
 258. Hammond's wire sj)lint for fracture of 
 jaw .... . ........ 
 
 259. Hammond's wire splint applied . . . 
 
 260. Vertical section of tooth 
 
 261. Development of lower molar tooth . . 
 
 262. Odontoplastic odontome 
 
 263. Radicular odontome 
 
 264. Dentigerous cyst not involving antrum 
 
 265. Denticle 
 
 266. Defective teeth 
 
 267. Pointed teeth 
 
 268. Child's jaws, showing the development 
 of tiie })ermanent teeth 
 
 269. Mouth mirror and searcher for exami- 
 nation of teeth 
 
 270. Progress of decay in teeth 
 
 271. Rhizodontropy 
 
 272. Pivoting with vent 
 
 273. Manner of holding tootii forceps . . . 
 
 439 
 
 451 
 452 
 452 
 
 452 
 
 452 
 454 
 454 
 456 
 457 
 457 
 458 
 459 
 460 
 
 461 
 
 468 
 470 
 470 
 470 
 476 
 
CONTENTS Wrril LIST OF ILLI'STIIATIOSS. 
 
 XI 
 
 CHAPTER \U{.— Co,itinur,l. 
 
 PIO. I'AUK , Vm. PAOE 
 
 274. Stump lorieps 477 | 278. Qisoplia^eal b<iiif,'ie witli metal oliv- 
 
 275. Sfdop i'k'v:it<prs 477 I arv end.s 4,S2 
 
 276. Kevdlviim pliaryiigual lonvps lor re- ' 271). Ilorseluiir pr<)l)ang for extracting for- 
 
 moviiig I'oreign l)<Hlie^^ 4S(( ^ eign Ixtdien from tesopliaguH . . . 4)S2 
 
 277. Impacted pudding in u-sopliagus . . . 481 ' 280. Money probang, with .sponge .... 482 
 
 CII.MTKK XIV. 
 
 Iigiiries oi' tlio Alulonu'n siimI its Contents— Wounds iiiv<»lviii^ Paricti'S 
 and >is(M'ra— Abnormal Anus, F<'<'al Fistula— FoiUMj^n liodios in tli«" 
 Sttnnacli and lnt<*stiiuvs — (ilastrotoniy anil Ciastrostoniy — Intestinal 
 Obstruction — AtMitc Internal Stranj;ulation of tlie liowel — Intus- 
 susf«'ptions — Laparotomy — Fiit<'rotoiny — Colectomy— Colotomy—Kx- 
 eision of the l*yb>rus— Tap|nn}.r tlu' Intestine— Tapping- the Alulo- 
 n»en— Hy<latid Tumors — Tumors of the Umbilicus 
 
 483 
 
 281. 
 282. 
 
 283. 
 284. 
 
 285. 
 
 Position of alxlominal viscera .... 
 
 Lembert's suture in wounds of intes- 
 tines 
 
 Czernv's suture 
 
 Piece of iron wire discliarged through 
 abdominal walls after having been 
 swalliiwed 
 
 Plate with teeth passed per anum . . 
 
 493 
 
 494 
 494 
 
 497 
 497 
 
 28r). Intestine strangulated by a band . . 502 
 
 287. Ileo-colic intussuscejition .506 
 
 288. Operation of enterotomy 508 
 
 289. Mode of fastening bowel to integument 
 
 in the .same 509 
 
 290. Thermograpii of ca.se of enterotomv . 509 
 
 291. Colotomv ". . 512 
 
 CHAPTER XV. 
 
 Hernia— Abdominal — Irreducible — Incarcerated — Ruptured — Straiijaru- 
 lated — Taxis — Herniotomy or Ivelotomy — Multiple and Displaced 
 Hernia— Injtuiual Hernia— Radical Cure of Hernia— Femoral Hernia 
 —Obturator Hernia — Umbilical Hernia— Trusses 
 
 292. Congenital scrotal hernia 524 
 
 293. Congenital hernia of the cord .... 524 
 
 294. Congenital scrotal hernia, with hour- 
 
 glass contraction ... .... 524 
 
 295. Acquired congenital form of hernia . 524 
 
 296. Acquired hernial sac 524 
 
 297. I)isj)laced hernia — .second variety . . 525 
 
 298. Third variety \ . . 525 
 
 299. Fourth variety 525 
 
 300. Reduction en iikix.h: 525 
 
 301. Oblique inguinal liernia 527 
 
 302. Direct inguinal hernia 527 
 
 303. Femoral hernia 528 
 
 304. Author's pad for tru.ss 529 
 
 305. 306. Met'hanisni of strangulation of the 
 
 bowel 532 
 
 307. Effects of strangulation of the bowel . 534 
 
 309. 
 
 310. 
 311. 
 312, 
 
 314. 
 
 315. 
 
 316. 
 317. 
 318. 
 319. 
 
 Stricture of bowel, result of strangu- 
 lated hernia 535 
 
 A. Key's operation for liernia ; b. Rel- 
 ative position of the abdominal 
 
 rings from within 539 
 
 Hernia knives 540 
 
 Spica bandage 542 
 
 313. Second variety of displaced her- 
 nia (Bell's) 544 
 
 Interstitial hernia with ruptured neck 
 
 of heinial sac — third variety . . . 545 
 Intra-parietal or fourth variety of dis- 
 placed liernia 546 
 
 Wood's operation for radical cure . . 550 
 Obturator hernia; external view . . . 555 
 
 The same ; internal view 555 
 
 Congenital umbilical liernia 556 
 
 CHAPTER XVI. 
 
 Surgrery of the Anus and Rectum— Malformations — Injuries of Rectum — 
 Foreign Bodies— Diseases of Rectum and Anus — Fissure and Pain- 
 ful Ulcer of Anus— Anal Abscess and Fistula in Recto — Hemorrhoids 
 or Piles— Treatment— Prolapsus Recti— Rectal Polypus— Ulceration 
 and Stricture of Rectum— Excision of Lower End of Rectum— Feed- 
 inj" and 3Iedication by Rectum 
 
 320. Rectum ending in cul-de-sac above 
 
 anus 561 
 
 321. Enormously distended rectum in man 
 
 after operation for imperforate rec- 
 tum in infancy 562 
 
 322. Speculum for examination of rectum . 566 
 
 323. Operation for anal fistula 570 
 
 561 
 
 324. Internal hemorrhoids 572 
 
 325, 326. Forceps for hemorrhoids .... 574 
 
 327. Clamp for hemorrhoids 574 
 
 328. Prolajjsus recti 576 
 
 329. Villous polyj)us of rectum 578 
 
 330. Microscopical drawing of the same . 578 
 
 331. Cancerous stricture of rectum .... 581 
 
xii CONTEXTS WITH LIST OF ILLUSTRATIONS. 
 
 SURGERY OF THE RESPIRATORY SYSTEM. 
 
 CHAPTER XVII. 
 
 Surgical Affections of the Xose— Wounds— Fracture— Epistaxis—Liimnia 
 —Lupus— Cancer— Rhinoscopy— Foreign Bodies— Xasal Calculi— Poly- 
 pus— Ozgena — Disease of Frontal Sinus— Rhinoplasty 586 
 
 FIG. PAGE FIG. PAGE 
 
 332. Kepair of incised wound of nose . . . 586 339. Removal of nasal polypi by noose . . 591 
 
 333. Forceps and nose truss for treatment of 340. Cancer of nose 592 
 
 deformed nose 586 341. Enostosis of frontal sinus 595 
 
 334. Nasal douche 587 342. Enostosis after removal 595 
 
 335. Bellocq's canula for plugging nostrils . 588 j 343. Diagram of flap for rhinoplastic opera- 
 •336. Lupus of nose 589 I tion 596 
 
 337. Form of flap for formation of new nose 589 344. Appearance of face after formation of 
 
 338. Tube for insufflation of tannin into I new nose 597 
 
 nose 591 1 
 
 CHAPTER XVIII. 
 
 Surg-ical Affections of the Larynx and Trachea— Wounds of Throat — 
 Foreign Bodies in W^indpipe— Scald of Larynx — Excision of Larynx 
 — Bronchotomy — Tracheotomy — Laryugotomy 597 
 
 345. Bone in larynx .... 601 350. Durham's canula and pilot 609 
 
 346. Date-stone impacted in right bronchus. 601 351. Bryant's canula 609 
 
 347. Gross' trachea forceps 602 352. Tracheal aspirator for removal of 
 
 348. Laryngoscopic examination C)0o lymph and foreign bodies .... 609 
 
 349. Operation of tracheotomy (308 
 
 CHAPTER XIX. 
 
 Surgery of the Chest — Contiisions — Rupture of the Pectoral Muscle — 
 Fractured Rihs — Wounds of the Chest — Tapping the Chest — Apnoea 
 or Asphyxia — Drowning— Treatment of Apnoea or Asphyxia 611 
 
 353. Mode of strapping che.st in fractured 354. Position of patient for ejection of fluids 
 
 ribs 613 , in case of drowning 619 
 
 355. Artificial respiration by direct method. 620 
 
 SURGERY OF THE URINO-GENITAL SYSTEM. 
 
 CHAPTER XX. 
 
 Diseases of the Kidney— Stone— Xephrotomy—Xephritis— Hsematuria— 
 Suppression of L^rine— Stone in the Kidney— Renal Surgery— Para- 
 centesis of the Kidney— Nephrotomy— Xephrectomy—Nephrorraphy 622 
 
 356. Urinary disease from obstructed ureter. 623 357. Clover's bladder evacuator 626 
 
 CHAPTER XXI. 
 
 Diseases of the Bladder and Prostate— Irritable Bladder— Inflammation 
 —Ulceration — Tubercular Disease — Tumors — Cancers — Atony— Yes- 
 ico-Intestinal Fistula— Incontinence of Urine— Diseases of tlie Pros- 
 tate — Inflammation — Abscesses — Hypertropliy 632 
 
 358. Sacculated bladder 634 364. Dermoid growth removed from blad- 
 
 359. Syphon mode of washing out bladder . 635 der, etc ■ • 640 
 
 360. Villous growth in bladder 637 365. Microscopical section of skin covering 
 
 361. Polypoid outgrowths from bladder . . 637 growth 641 
 
 362. Thompson's bladder forceps 639 \ 366. Enlargement of third lobe of prostate . 647 
 
 363. Rectal dilator for raising bladder out ! 367. Prostato-vesical calculus 650 
 
 of pelvis 640 [ 
 
coyTKSTs wrrif list or riJ.rsrn.iTioxs. 
 
 XIII 
 
 CIlAITKIl XXII. 
 
 Stone in tli4' Itlatltirr, and its Tri'atnM-nl I rinai'> I >«'|»osits — l{«*nal <'al- 
 i-uli Lit lioiil i-i|i( i«-s Lit li<>toMi.\ Lit hot rit > S«>iii-<-«'s 4»t' I>ifli<-ult> in 
 ljtliotoMi>, and li<»\v to A\oi4l tlwin <>lli«-i- <>|MTations ('ans<-> of 
 l>4-alli al't<T Lithotomy Stoii4> iii th<* l-'cinah* ItlatlUcr — Forci^^n 
 HtMlit'S in the IthMlth'i* r>.")l 
 
 FUi. 
 
 368. 
 3»)<.t. 
 37(1. 
 371. 
 37 J. 
 37:?. 
 374, 
 o<0. 
 377. 
 378. 
 379. 
 
 380. 
 381. 
 382. 
 383. 
 
 PACiE FKi. 
 
 Kpitluliiiiii rri'iii iiriiiiuv passages . . Col 384, 
 
 S|(«.Tiii:itiizn:i iiiul \a;ri":»l epillioliiiiii . (iol 386, 
 
 riiiiaiv I'a.sts <i.^2 388. 
 
 I'laii's' tir)2 :}89. 
 
 Iric arid 6.")3 .TJO. 
 
 O.xalaU- ..f liiiu' 6o3 391. 
 
 37 .J. I'iiospl.atos 6o3 392. 
 
 TvrosiiK' aiul leiu-ine 6o4 393. 
 
 Cystine 6o4 394. 
 
 Renal calculus 055 395. 
 
 Uric a<'i(i calcnlus witli oxalate of lime 
 
 nucleus 656 396. 
 
 Mull)errv calculus and section .... 657 
 
 Mi.xed calculus 658 397. 
 
 Cystic oxide calculus 658 
 
 Phospliatic calculus on piece of cathe- 398, 
 
 ter 658 , 
 
 666 
 
 385. Catheters 
 
 387. Operation of litliotrity 
 
 Litliotritc and cvacuator 
 
 Stalls for lithotomy 
 
 Knives for same 
 
 Scoops for same 
 
 Blunt gorfiet 
 
 Lithotomy IjraceleLs 
 
 Lateral lithotomy witii curved staff . . 
 Lateral lithotomy with straight .staH" 
 
 (Key's operation J 
 
 Calculus removed from female hiadder 
 
 per vaginam 
 
 Portion of catheter removed from male 
 
 hiadder 
 
 Stiletto removed from female bladder . 
 
 I'AOK 
 
 661 
 
 mi 
 
 6<;9 
 671 
 671 
 672 
 672 
 672 
 t;73 
 
 674 
 
 680 
 
 681 
 682 
 
 CHAPTER XXIII. 
 
 Surg'ery of tin' I'rrtlira— Obstruction— Organic Stri<'turo — Urotlirotoniy 
 — C"onii)li<*ations of Stricture — C'ifatricial or Traumatic Stricture- 
 Causes of Death from Stricture— Ruptured Urethra— Spasnuxlic 
 Stricture— Inflammatory Stricture. Retention of Urine— As a Symp- 
 tom of Enlarj;«'d Prostate and in the Ag-ed— As a Result <)f an 
 Elon.u'ate*! and Adherent Prepuce — From Org-anic or Ci<*atricial 
 Stricture— Puncture of the Bladder per Rectum — Extravasation <)f 
 Urine — Retention from Impacted Urethral Calculus — Urethral 
 "Shock" and "Fever" 6S2 
 
 399. Stricture of urethra 
 
 683 
 
 400 
 401 
 402 
 403 
 404 
 
 Olivarv elastic catheter 685 
 
 Mode of fastening catheter in bladder. 687 
 
 Richardsoti's urethral dilator .... 688 
 
 Urethrotome with guide bougie . . . 689 
 
 Syme's perineal catlieter 690 
 
 405. Grooved staff for Wheelhouse's opera- 
 tion 690 
 
 406. Teale's probe gorget 690 
 
 407. Wheelhouse's operation 691 
 
 403. Cock's operation of tapping urethra in 
 
 perin.i'um 692 
 
 409. Urinary fistula 695 
 
 410. Operation of puncturing bladder per 
 
 rectum 704 
 
 CHAPTER XXIV. 
 
 Affections of the Genital Orj«:ans — Phim<»sis— Circumcision— Paraphimo- 
 sis — Amputation of the Penis — Injuries to P<'nis— 3Ialforniation of 
 the Urino-(i<'nital ()r<ians. Lo<'al Venereal I)is<'ase — fionorrlnea — 
 Chorde*' — <»<»norrh<eaI Rheumatism— Herpes Preputial is — Chancre — 
 Phayethena — Hydrocele — Hs^^niatocele. I>iseases of the Testi<'le — 
 Inflammation of the Testicle — Epididymitis— Orchitis— Tubercular 
 Disease — Hernia— Cystic Disease — Cancer— Scrotal Tumors— Castra- 
 tion — Varico<*ele— Affections of tlie Scrotum— < Edema — Eleplianti- 
 a.sis—Canc«'r— Sterility— 3Iale Impotence and Spermatorrluea ... 
 
 411. Operation for phimosis 7('8 
 
 412. Circumcision i first stej)! 709 
 
 413. Operation for paraphimosis 709 
 
 414. Stump after amputation of the penis 
 
 by Hilton's method 710 
 
 415. Corpus spongiosum projecting from 
 
 urethra after injurv 711 
 
 416. Ectoj>ion vesica- in male 
 
 417. The same in female 
 
 418. Perineo-scrotal hypospadias 
 
 419. B, c, D. E. Operation for perineo-scro- 
 
 tal hypospadias 
 
 420. Encysted hydrocele of cord 
 
 421. Tapping hydrocele 
 
 708 
 
 ri2 
 
 -1 o 
 
 rii 
 
 ri3 
 r2.5 
 
 •26 
 
xiv CONTENTS WITH LIST OF ILLUSTRATIONS. 
 
 CHAPTER XXlX.— Contunmf. 
 
 no. PAGE FIG. PAGE 
 
 422. Mode of suspending testes with hand- 426. Strapping testicle 749 
 
 kerchief 735 427. Testicle in perinaeum ... ... 750 
 
 423. Hernia of testis following tubercular 428. Varicocele 750 
 
 disease 741 429. Morgan's suspender for varicocele . . 751 
 
 424. Cystic disease of testicle 743 430. Elephantiasis of scrotum 752 
 
 425. Cancer of testicle 744 
 
 CHAPTER XXV. 
 
 Surgical Affections of Female Genitals— AVoiinrts— Adherent Labia— 
 Viilviti.s — Xonia — Xnevi — Hernia— Labial Absce.sse.s — Labial Cysts — 
 Tumors — Cancer — Lupn.s — Syphilis- Imperforate Hymen— Enlargred 
 Clitoris — Clitorirtectomy — Kiipture of the Peiinteum — Prolapse of 
 Uterus— Vesico- and Ilecto-Vaj^inal Fistulae 756 
 
 431. Central rupture of the perinaeum . . . 758 ! 435, 436. Mode of paring edges of vaginal 
 
 432. Operation for ruptured perinaeum . . 759 fistula 761 
 
 433. Position of patient for operation for 437. Introduction of sutures in vaginal fis- 
 
 vesico- vaginal fistula 761 tula 762 
 
 434. Self-retaining speculum for the same . 761 438. Speculum dilator for female urethra . 763 
 
 CHAPTER XXVI. 
 
 Diseases and Tumors of the Breast— Inflammation— Mammitis— Mam- 
 mary Abscess — Induration —Tumors— Hypertrophy —Cancer — Cystic 
 Tumor— Galactocele 763 
 
 439. Submammary abscess 766 446. Cystic tumor in breast with intra-cystic 
 
 4r40. Adenoid tumor of breast dissected . . 769 growth 774 
 
 441. Cystic adenocele 770 447. Cystic carcinoma 775 
 
 442. Solid adenocele 770 448. Section of sarcomatous tumor of breast. 776 
 
 443. Hypertrophy of breast 770 449. Open cancer of breast 776 
 
 444. Section of infiltrating cancer 772 450. Excision of breast 779 
 
 445. Section of tuberous ditto 772 
 
 CHAPTER XXVII. 
 Ovarian Disease and Ovariotomy— Hysterectomy 780 
 
 451. Trocar and eanula for tapping ovarian ' 453. Omental clamp forceps 789 
 
 cyst with sliding forceps 788 454. Tait's clamp for hysterectomy .... 793 
 
 452. Nelaton's cyst forceps 788 , 
 
 THE SURGERY OF THE MUSCULAR AND OSSEOUS SYSTEMS. 
 
 CHAPTER XXVIII. 
 
 Affections of the Muscles and Tendons— Contusions— Compound Lacer- 
 ation—Dislocation of Muscles and Tendons— Rupture of Tendons- 
 Wounds of Tendons— Inflammation of Muscle— Atrophy of Muscle- 
 Writer's Cramp— Tumors in 3Iuscle— Ossification of 3Iuscle— Rider's 
 Bone— Tumors of Tendon— Inflammation of Tendons— Affections of 
 BursiB Mucosae, Synovial Cysts, Ganjflion 795 
 
 455. Rupture of rectus femoris 795 | 463. Semi-solid bursa 805 
 
 456. Thumb torn out 796 464. Bursa sloughing from over patella . . 805 
 
 457. Ruptured long tendon of biceps . . . 797 465. Compound ganglion of hand and fore- 
 
 458. 459. Chronic inflammation of muscle . 799 arm 810 
 
 460. Instrument for writer's cramp .... 801 466. Lipoma of the palm simulating gan- 
 
 461. Rider's bone 803 glion 811 
 
 462. Cancerous tumor of hand 803 
 
coyTKyrs with list or ii.i.rsTiiATioys. 
 
 XV 
 
 CIlAl'TKIt \\l\ 
 
 Ortlioi»;i'(li«- Siiryorv " <lMb-l\M»t I'lat-l-'oot Ivihm-U-I\ii«m' — T«*iiotoiiiy 
 tor ( out i'a«-t«'<l Liiiil> (Out rai-t ion of tii«> l''iii;;«'r.s lti;;i«| Atrophy — 
 N\r\-\«MU 811 
 
 H... fAi.K KKi. ,.A(iE 
 
 4()7. Types of tlie (lifleioiit kimis ol" (li-ri. nil- 47"). Little's slioe for talipes 819 
 
 ilies of the li:mii>. aiul leet .... SlU -17»). iMvies-CJollev's splint for talipes . . . 81U 
 
 4().S. Talipes e<|iiiniis SU 177. K.xtreiiie e.xuinple of talipes e<|iiino- 
 
 4(J'J. ('oii>;eiiital varus SI 1 varus H20 
 
 470. Etpiino-varus .si') 47S. The same jls remedied by operation 820 
 
 471. Talipes valgus, cou^^eiiital and ac- 47'.). Portions of bone removetl S20 
 
 i|uired S].") 4S0. Spurious talipes val;;us ...... S'Jl 
 
 47"J. Talipes oaleaneus, eon<;enital and ac- 4Sl. O^^ston's operation for j^enu valjjum S2'2 
 
 ipiired SKi 48"J. Limh before and after Macewen's ope- 
 
 47.). Mode of stretehing tendons by .strap- ration 822 
 
 piuic •*^17 483. ('ap and band for extension in wry- 
 
 •174. lUahanau's splint for talipes .... 817 neck 824 
 
 CHAPTER XXX. 
 
 Sprains— Contu.sioii.s and AVotiiid.s of Joints — Dislocations— Soparatioii 
 <>f Kpiphysi's— Conj-renital 3Ialforiiiatioiis of Joints 825 
 
 484. False joint alter dislocation of head of 5U4. 
 
 fenuir 827 
 
 485. Dislocation of sternal end of clavicle 
 
 forward 
 
 486. Dislocation of scapula 
 
 487. Dislocation of hea<l of humerus down- 
 
 ward and forward 
 
 488. Subcoracoid dislocation of head of the 
 
 humerus 
 
 489. Subglenoid dislocation of head of hu- 
 
 merus 
 
 490. Dislocation of head of humerus be- 
 
 neath clavicle and beneath spine 
 of scapula 
 
 491. Subspinous dislocation of head of hu- 
 
 merus 
 
 492. Mode of re<lucing dislocations of head 
 
 of humerus bv manipulation . . . 
 
 493. (love hitch . . ". 
 
 494. Reduction l)y extension of arm up- 
 
 ward 
 
 495. Dislocation of head of humerus with 
 
 fracture 
 
 496. Dislocation of radius and ulna back- 
 
 ward 
 
 497. Dislocation of radius and ulna out- 
 
 ward 
 
 498. Dislocation of radius and ulna for- 
 
 ward 
 
 499. Dislocation of head of radius forward . 
 
 500. Dislocation of head of radius backward. 
 
 501. Displacement of lower epiphysis of 
 
 humerus backward 
 
 502. Dislocation of hand forward 
 
 503. Dislocation of hand and radius for- 
 
 ward oti' ulna 840 
 
 
 505. 
 
 830 
 
 506. 
 
 832 
 
 507. 
 
 
 508, 
 
 833 j 
 
 
 
 510. 
 
 833 ' 
 
 
 
 511. 
 
 833 
 
 512, 
 
 
 514. 
 
 834 
 
 515, 
 
 834 
 
 517. 
 
 
 518, 
 
 835 i 
 
 
 836 
 
 520. 
 
 836 
 
 521. 
 
 837 
 
 522. 
 
 838 
 
 523. 
 
 838 
 
 524. 
 
 i 
 
 525. 
 
 838 
 
 
 839 
 
 526. 
 
 839 
 
 
 
 527. 
 
 840 
 
 528. 
 
 840 
 
 529, 
 
 Puzzle toy for reduction of dislocation 
 
 of phalanges 841 
 
 Levis' apparatus for the same .... 842 
 Recent dorsal dislocation of femur . . 842 
 Rent in capsule in dorsal dislocation . 842 
 509. llio-sciatic forms of dislocation of 
 
 head of femur 843 
 
 Dislocation of head of femur on dor- 
 sum 844 
 
 Dislocation into the sciatic notch . . . 844 
 513. Diagrams showing shortening of 
 
 limb in dislocation backward . . . 844 
 Dislocation into foramen ovale .... 844 
 516. Dislocation into foramen ovale 
 
 and upon os pubis 845 
 
 Dislocation upon os pubis 845 
 
 519. Method of reducing dislocations 
 
 of head of femur by manipulation . 846 
 Dislocation of the tibia and fibula for- 
 ward 849 
 
 Displacement of the leg bones with 
 
 lower epiphysis of femur inward . 849 
 Appearance of foot and ankle in I'ott's 
 
 fracture 850 
 
 Dislocation of foot inward with frac- 
 ture of inner malleolus 850 
 
 Dislocation of foot backward • • • . . 851 
 Astragalus driven upward between 
 
 malleoli .... 852 
 
 Dislocation of foot inward oH' the as- 
 tragalus 853 
 
 Compound dislocation of astragalus . . 854 
 Dislocation of the astragalus outward . 855 
 530, 531. Congenital displacement of 
 
 head of femur 856 . 
 
 CHAPTER XXXL 
 Fractures 857 
 
 532. Varietiesof complete fractures . . . . 857 
 
 53.3. Incomplete fracture of clavicle .... 858 
 
 534. Incomplete fracture of parietal bone . 858 
 
 535. Impacted fracture of neck of femur . . 858 
 
 536. Bavarian or immovable splint .... 865 
 
 537. False joint in humerus 868 
 
 53S. Hyperostosis of the tibia 869 
 
 539. Fracture of scapula S72 
 
 540. Fracture of neck of scapula 872 
 
 541. Fracture of head and tuberosities of 
 
 humerus 873 
 
 542. Impacted fracture of head of humerus. 873 
 
 543. Separation of shaft of humerus ott' up- 
 
 per epipiiysis 873 
 
XVI 
 
 CONTENTS WITH LIST OF ILLUSTRATIONS. 
 
 CHAPTER XXXl.— Coiithwcd. 
 
 FIG. 
 
 544. 
 545. 
 546. 
 
 547. 
 
 548. 
 549. 
 550. 
 
 551. 
 552. 
 
 553. 
 
 554. 
 
 555. 
 
 556. 
 557. 
 
 558. 
 
 559. 
 
 560. 
 
 561. 
 562. 
 563. 
 564. 
 
 565. 
 
 566. 
 567. 
 
 568. 
 
 Fracture of surgical neck of liumerus . 
 
 Splint for fracture of humerus . . . . 
 
 Comminuted fracture of condyles of 
 humerus . 
 
 Comminuted fracture of lower epiphy- 
 sis of humerus, with displacement 
 of bone and dislocation inward of 
 radius and ulna 
 
 Arrest of growth in humerus after in- 
 
 .)ury 
 
 Displacement of hand with the lower 
 epiphysis of the radius backward . 
 
 Fracture and backward rotation of 
 lower end of radius (Colles' frac- 
 ture) 
 
 Ajjjiearance of hand and wrist in Col- 
 les' fracture 
 
 Fracture of radius, with displacement 
 forward 
 
 Examples of Colles' fracture .... 
 
 Fractured end of radius and styloid 
 process 
 
 Splint for fracture of fore-arm .... 
 
 Carr's splint for fracture of fore-arm . 
 
 Gordon's splint for fracture of fore- 
 arm ... 
 
 Radius and ulna consolidated together 
 alter fracture 
 
 Fracture of coronoid process and head 
 of radius , 
 
 Compound dislocation of ulna and pro- 
 jection of shall of radius forward, 
 following displacement backward 
 of the hand with epiphysis of ra- 
 dius 
 
 Stromeyer's cushitm 
 
 Fracture of jielvis in a child 
 
 Fracture of pelvis 
 
 Head of femur driven through acetab- 
 ulum 
 
 Intracapsular fracture of neck of femur 
 showing ligamentous repair . . . 
 
 Impacted fracture of neck of femur . . 
 
 Comminuted fracture of upper end of 
 femur following imj)action of neck. 
 
 Figure showing elevation of trochanter 
 in impacted fracture 
 
 PAGE I FIG. ] 
 
 874 I 569. Bryant's test line for shortening or frac- 
 
 875 I ture of neck of thigh-bone .... 
 
 i 570. Intracapsular fracture of neck of 
 
 876 thigh-bone repaired 
 
 571. Doubly impacted fracture of neck of 
 thigh-bone .... 
 
 572. Gurdon Buck's sjtlint with weight for 
 
 877 fracture of neck of thigh-bone . . 
 
 573. Author's double splint for Iracture of 
 
 877 neck or shaft of femur or hip disease 
 
 574. 575. Absorption of neck of lemur 
 
 878 after fracture witii corresponding 
 healthy femur for com|iarison . 
 
 576. Separation of epi^)hysis of great tro- 
 chanter of femur 
 
 577. Drawing of the same during life . . . 
 
 878 578. Impacted fracture of shaft of femur . . 
 
 579. Liston's splint with foot-piece for frac- 
 ture of thigh 
 
 580. Hodgen's splint for the same .... 
 
 581. C. de Morgan's splint for the same, 
 
 879 with improvements 
 
 879 582. Treatment of fracture of femur by ver- 
 
 879 tical extension 
 
 583. Immovable bandage for fracture of 
 
 tliigli 
 
 584. Fracture of condyles of femur .... 
 881 585. Separation of lower epijjhysis of femur. 
 
 586. Multiple fracture of patella 
 
 881 587. Fracture of patella 
 
 588. Fracture of patella united by bone . . 
 
 589. Splint lor fracture of patella, with 
 elastic compression 
 
 590. Middlesex Hospital splint for fracture 
 
 882 of patella 
 
 882 591. Arrest of growth in shaft of tibia with 
 
 884 bowing of fibula, following injury 
 
 884 to upper epiphysis of tibia .... 
 
 592. Splint for fracture of tibia 
 
 593. Splint for fracture of fibula 
 
 594. V-shaped fracture of tibia 
 
 885 595. Process of setting fracture of leg . . . 
 
 886 596. Apparatus for fixing and swinging a 
 fracture of leg 
 
 597. Maclntyre's splint and Salter's swing . 
 
 598. Kathan Smith's anterior wire splint for 
 fracture of leg 
 
 889 
 889 
 
 890 
 
 890 
 S90 
 891 
 
 892 
 892 
 
 893 
 
 893 
 
 894 
 894 
 894 
 895 
 896 
 896 
 
 896 
 
 S97 
 
 898 
 899 
 899 
 899 
 900 
 
 900 
 901 
 
 901 
 
 CHAPTP]R XXXII. 
 
 Diseases of the Joints— Pathologieal Clianges— Diseases of Special 
 Joints — Treatment — Excision and Anipntatioii — Loose Cartilag-es in 
 Joints — Khenniatic or Chronic Osteo-Athritis— Joint Disease Asso- 
 ciated with Nervous Affections — Acute Bursitis and Suppuration 
 around Joints 905 
 
 599. Shedding of articular cartilage in artic- 
 
 ular ostitis 909 
 
 600. Section of bone showing rarefaction of 
 
 new bone 909 
 
 601. Necrosis of head of femur 913 
 
 602. Separation of upper ei>iphysis of femur 913 
 
 603. Apparent elongation of lower extrem- 
 
 ity from oAduction of fenuir . . . 914 
 
 604. ^6ducted lower extremity in hip dis- 
 
 ease 914 
 
 605. Apparent shortening of lower extrem- 
 
 ity from ac/duction of femur . . . 914 
 
 606. ylc/ducled lower extremity in hip dis- 
 
 ease 914 
 
 607. Displacement of femora on dorsum 
 
 from disease — front view .... 
 
 608. The same — side view 
 
 609. Lordosis in hip disease, with patient 
 
 erect 
 
 610. The same patient — lordosis eflfaced . . 
 
 611. Lordosis in hip disease, with patient 
 
 standing 
 
 612. The same — remedied 
 
 613. Position of lower extremity in ne- 
 
 glected hip-joint disease 
 
 614. Synostosis of hip-joint 
 
 615. Arrest of growth in neck of femur fol- 
 
 lowing articidar ostitis 
 
 914 
 914 
 
 915 
 915 
 
 915 
 915 
 
 915 
 916 
 
 916 
 
CONTENTS Willi LIST o/' I l.l.ls'li:ATI()NS. 
 
 xvn 
 
 ("IIAITKK XX 
 
 KKI, 1-A(.K 
 
 (ilti. Apiifuraiici' of kiiri'-joiiU in synovitis . '■)! 
 (>17. Aiipi'iiranco of kiu'c-inim in articular 
 
 ostitis it 17 
 
 t>lS. Appi-aranri' ol' foot at'irr ri'inovai of 
 
 scaplioiil, fiilioitl, ami tliiiT cnnei- 
 
 forni l)ont's 918 
 
 ()19. AiMonnt of Ik'xioii in t-lliow afti-r re- 
 
 coviTv from tiist-aso it'JO 
 
 t)'20. I)()nl)!c splint as appliod in hij) disoasf !)'J"J 
 621. Thomas' posti-rior splint lor hip ilis- 
 
 c-asf 9-J2 
 
 (i22. Ik'ad of foniiir altnvd liy disease . . !>2o 
 
 ()2;}. linniovahk- splint for hip discasi- . . 1)24 
 
 624. Modi' of applyint;- vxtonsion to lower 
 
 extremity in hip disease 1124 
 
 625. Anehylosis of hip-joint at ri^dit angles 1(24 
 
 626. Position of lind> after Adams' opera- 
 
 tion 924 
 
 627. Instruments employed for subeulane- 
 
 ons division of nei-k of thigh-l)one 925 
 
 628. Line of seetion of neek of thigh-hone 
 
 in Adams' operation 925 
 
 629. Splint for diseased knee-joint .... 926 
 
 (i.SO. Thomas' knee splint . ". 92(> 
 
 ().'>!. The same — applied 926 
 
 .X I I. — ( 'onlinittd. 
 
 7 6:52. 
 
 6:i3. 
 6.S4. 
 
 6:^5, 
 6.>C>. 
 637. 
 
 638. 
 
 639. 
 640. 
 
 641. 
 642. 
 
 643. 
 
 644. 
 645. 
 646. 
 
 647. 
 
 PAOK 
 
 Ilavarian splint, as rompleted for dis- 
 
 eii.se of knee 927 
 
 CJowan's exeision saw 931 
 
 Abscess in liead of tiFiia with necrosis, 
 
 hnrrowing into knee-joint .... 9.33 
 
 Splint for excision of knee 936 
 
 Foot after removal of aslraf^aUis . . . 9.37 
 Abscess cavity witii secpiestrnin in head 
 
 of humerus 938 
 
 Parts removed by resection of elbow- 
 joint . . . ". 939 
 
 Necrosis of head and neck of radius . 939 
 Vertical incision for excision of elbow- 
 joint 940 
 
 Splint for excision of elbow 940 
 
 Section of loose cartilage removed from 
 
 knee-joint 943 
 
 Microscojiical appearance of loose car- 
 tilages 944 
 
 Osteo-arthritis (jf knee-joint 946 
 
 Osteo-arthritis of head of tibia . . . 946 
 Changes in hip-joint tlie result of osteo- 
 arthritis 947 
 
 Ankle the seat of osteo-arthritis . . . 947 
 
 CHAPTER XXXIII. 
 
 l)isea.s«'s of tlu* B<nios— Iiirtaiimuitioii — Absce.s.s— Peri«>stitis and Endos- 
 titis — NocTosis— Caries — Tumors — Osteitis Deforniaiis 949 
 
 648. Superficial necrosis of frontal bone fol- 
 
 lowing wound caused by gnawing 
 
 of a ferret ". ". . . . 950 
 
 649. Periosteal necrosis of tibia following 
 
 periostitis 950 
 
 650. Necrosis of shaft of tibia resulting from 
 
 endostitis, with shell of new bone 
 surrounding it 950 
 
 651. Necrosed leg, with probes inserted into 
 
 cloaca^ leading to dead bone . . . 950 
 
 652. Necrosis of shaft of tibia 951 
 
 653. Necrosis of articular lamella of bone . 951 
 
 654. Sclerosis of bone 952 
 
 655. Abscess in head of tibia 954 
 
 656. New bone formed beneath periosteum 
 
 resulting from periostitis .... 955 
 
 657. Upjier iialf of humerus separated from 
 
 upper epii)hysis thrown oft" by nat- 
 ural processes 958 
 
 658. Instruments employed in operation of 
 
 se(iuestrotomy 959 
 
 659. Arrest of growth in til)ia after removal 
 
 of necrosed shaft 960 
 
 660. Hollow in face after escape of bony 
 
 tumor ".962 
 
 661. Tumor as discharged 962 
 
 ()62. Exostosis of femur, with section . . . 963 
 
 663. Periosteal exostosis 963 
 
 6t)4. Enchondromatous tumor 964 
 
 665. Enchondromatous tumors of hand . . 964 
 
 iSiS^. Periosteal sarcoma 965 
 
 667. Osteo-chondroma of fennir 965 
 
 668. The above during life 965 
 
 669. Myeloid disease of femur 966 
 
 670. Myeloid tinnors of bone 966 
 
 671. Cancer of shaft of femur with frac- 
 
 ture 966 
 
 672. Periosteal cancer of tibia 967 
 
 673. Osteoid cancer of bone 967 
 
 674. Epithelial cancer attacking bone . . . 967 
 
 675. Cancer of skin inva<ling bone .... 968 
 
 676. Hypertrophy and atrophy of bone . . 969 
 
 677. Section of normal bone 971 
 
 678. Section of bone affected with molli- 
 
 ties 971 
 
 679. Osteitis deformans 974 
 
 CHAPTER XXXIV. 
 On Gunshot Injuries— Osteotomy— Bone-Setting 975 
 
 680. English and foreign bullets 976 I 683. Gunshot wound of skull, wound of 
 
 681. Nelaton's probe, Coxeter's extractor, j exit 982 
 
 and Lecomte's stylet-pince . . 981 684, 685, Fracture of vitreous table of skull 
 
 682. Gunshot wound of skull, wound of j without fracture of external table . 983 
 
 entrance 982 ' 
 
 CHAPTER XXXV. 
 Ansesthetics 993 
 
 686. Junker's chloroform inhaler 
 
 687, 688. An.-iesthetic inhalers . 
 
 B 
 
 . 996 689. Richardson'^ spray apparatus 
 . 996 
 
XVlll 
 
 CONTENTS WITH LIST OF ILLUSTRATIONS. 
 
 CHAPTEK XXXVI. 
 Amputation — Preparation and Cleaning- of Spong^es 
 
 FIG. 
 
 690. 
 
 691. 
 692. 
 693. 
 
 694. 
 
 69o. 
 696. 
 
 697. 
 
 698. 
 699. 
 700. 
 
 701. 
 702. 
 703. 
 704. 
 
 705. 
 
 706. 
 
 707. 
 708. 
 
 Surgeon and his :i.ssistants arranged 
 for operation 
 
 Flap amputation oi' tliigii ...... 
 
 Tliigii stump, vvitli splint 
 
 Thigh stump, witli splint for exten- 
 sion 
 
 Mode of dressing stump by irrigation 
 witii trougli and water-ran .... 
 
 Teale's amputation 
 
 Carden's amj)utation througii the con- 
 dyles of femur 
 
 Amputation of leg by skin Haps and 
 circular division of muscles . . . 
 
 Stump after amputation of leg .... 
 
 Amputation at shoulder-joint .... 
 
 Amputation througii arm by flap ope- 
 ration 
 
 Amputation at elbow-joint 
 
 Stump after amputation at elbow-joint 
 
 Amputation of fore-arm 
 
 Diagram of hand showing joints, as 
 guide to amjiutation of fingei's . . 
 
 Hand after amputation of part of 
 thumb, index, and two outer fin- 
 gers 
 
 Lister's abdominal tourniquet . . . . 
 
 Amputation at hip-joint 
 
 Furneaux Jordan's method of amputa- 
 tion at liip-joint 
 
 i'.A.(ii'; 
 
 FIG. 
 
 
 709. 
 
 1005 
 
 710. 
 
 1006 
 
 
 1007 
 
 711. 
 
 1007 
 
 
 
 712. 
 
 1007 
 
 
 loos 
 
 
 
 713. 
 
 1009 
 
 
 
 714. 
 
 1009 
 
 715. 
 
 1010 
 
 716. 
 
 1010 
 
 717 
 
 
 718 
 
 1011 
 
 719 
 
 1011 
 
 
 1011 
 
 720 
 
 1012 
 
 
 
 721 
 
 1013 
 
 722 
 
 
 723 
 
 1013 
 
 724 
 
 1014 
 
 
 1014 
 
 725 
 
 
 726 
 
 1015 
 
 727 
 
 Stump alter amputation at knee-joint . 
 
 Stephen Smilli's method of ampu- 
 tating 
 
 Posterior aspect of stump after Smith's 
 method of amputating at knee- 
 joint 
 
 Foot after amputation of four outer 
 toes, with metatarsal, two external 
 cuneiform and cuboid bones . . . 
 
 Surgical guides to foot as expressed by 
 its anatomy 
 
 Stump alter Hey's amputation .... 
 
 Cliopart's amputation of foot .... 
 
 Stump alter Chopart's amputation . . 
 
 Tripier's am])utation of the foot . . . 
 
 Stump after Syme's amputation . . . 
 
 Pirogofl's amputation — heel Hap with 
 calcis 
 
 Pirogoff's amputation — division of 
 malleoli 
 
 Stnmjj alter Pirogoff's amputation . . 
 
 Stump alter circular operation of 
 
 tliigli .••••.■•• 
 
 Stump after Hap operation of thigh . . 
 Stump with ])atella after amputation at 
 
 knee-joint 
 
 Conical stump 
 
 Necrosis of stump 
 
 Bursa over end of stump 
 
 999 
 
 I'.\OE 
 
 1016 
 1017 
 
 1017 
 
 1018 
 
 1018 
 1019 
 1020 
 1020 
 1021 
 1023 
 
 1023 
 
 1023 
 1023 
 
 1024 
 1024 
 
 1024 
 1024 
 1025 
 1026 
 
"" Onlv the association of medicine with surc^ery forms the perfect physician. 
 The physician who is deficient in the knowledge of one of these brandies 
 resembles a bird with bnt one wing." 
 
 Art of Life (Ayur Veda): early Sanscrit, first century of Christian era. 
 
 " I dressed his wound, and God healed it." 
 
 Ambroise Pare. 
 
 "All that we have to do is not to obstruct Nature in the execution of 
 those offices, to which she is generally fully equal, in which we can lend her 
 no assistance beyond removing impediments out of her way." 
 
 P. Pott, 1773. 
 
 " Surgerv consists in curing a disease rather than in the removal of it by 
 
 mechanical means. But so differently do most think upon this subject that a 
 
 surgeon who performs most operations and gives most pain is commonly thought 
 
 the best." 
 
 John Hunter, MS. Lectures, 1787. 
 
THE 
 
 PRACTICE OF SURGERY. 
 
 INTRODUCTORY CHAPTER. 
 
 SrR<}ERY is of a twofold nature. It is a science and also an art — a department that 
 ■requires to bo known, and another to be practised. The science embraces a knowledtre 
 of the character, the causes, and the effects of disease and injur}', and also of the pro- 
 cesses by which they are best repaired ; the art consists of the treatment of diseases or 
 injuries as they present themselves, which, to be successful, must be based upon the sci- 
 ence. At the bedside the phenomena of disease must be studied, its symptoms recofrnized 
 and duly weighed; in the post-mortem room its effects are to be traced. The great object 
 (if the student, therefore, should be clinical and pathological investigation, the study of 
 the living and the dead, since it is by these alone he can hope to acquire a solid ba.sis on 
 which to ground his practice. 
 
 The e.xternal features of a local disease may appear the same to the student as to the 
 most accomplished surgeon ; whereas the phenomena of disease are often perceptible to 
 the latter alone, the acquired art of observation and the unconscious influence of experi- 
 ence giving to the mind of the one a power of recognition and interpretation which is 
 denied to others. 
 
 It is to the acquisition of this power, therefore, that the student should devote his 
 energies, and to this end cultivate the art of observation, for by it he will not only gain 
 the power of seeing correctly, but also of interpreting the meaning of what he sees, and 
 will thereby acquire a diagnostic acumen which cannot otherwise be obtained. 
 
 It is now necessary to consider by what method a correct opinion can be formed in 
 any given instance, how sources of fallacy are best eliminated and a good diagnosis estab- 
 lished, for it cannot be too forcibly impressed upon a student's mind that the treatment 
 of a ca.se will not be successful unless based on a clear understanding of its wants, and 
 that the.se can never be duly appreciated where a correct diagnosis of its nature has not 
 been made. 
 
 The mind of the surgeon should invariably be judicial ; it should possess nothing of 
 the advocate, but be so regulated as to be able to put aside all prejudices and precon- 
 ceived ideas, and avoid the advocacy of all unsupported theories and hypotheses ; it should 
 be open to accept clinical phenomena as they are observed, and arrive at a conclusion 
 cautiously and clearly after duly balancing the facts of the case, and carefully weighing 
 the possibilities and probabilities of its nature. 
 
 To form a diagnosis of a case mainly on probabilities as indicated by symptoms may 
 be a ready, but it will always prove a rash, proceeding. To form it on possibilities will 
 be a safe, although perhaps a less expeditious, course. The surgeon who acts upon the 
 first method must at times fall into grave errors, although his diagnosis will often appear 
 brilliant and may be successful ; while he who habitually forms an opinion after taking 
 into consideration every possibility of the case, and comes to a result by a process of 
 exclusion, must surely, on the whole, be more certain in his ends, as he will be safer and 
 sounder in his practice. I lay down, therefore, the following proposition as a guiding 
 principle of investigation applicable alike to all cases of injury as well as of disease : 
 
 That in the. dtaf/nom's of a case every possibility of its nature shonld be entertained, and 
 a conclusir>n arrived at by a jtre,ccss of elimination ; each possibility should be separately 
 considered and iceighed, and the most j)robable Jinally accepted, a diaffnosis wholly framed 
 on probabilities being most hazardous. 
 
 2 17 
 
1 8 INTR OD UCTION. 
 
 For example, a tumor at the femoral ring may ^>o.s>- //>(// l)e either an aV).scess, an aneur- 
 ism, a varix, cyst, hernia, enlarged gland, or a new growth. An abdominal tumor may 
 be ovarian, uterine, peritoneal, vesical, splenic, f'ajcal, renal, or hydatid. Its probable 
 nature will be best arrived at by eliminating each of these possibilities seriatim after a due 
 consideration of all its clinical symptoms, the most probable diagnosis being finally 
 accepted on evidence both negative and positive. 
 
 With the above great principle of practice as a guide in clinical investigation, I now 
 proceed to consider how any injury or disease is to be investigated, confining my observa- 
 tions to classes of injury and disease. I do not propose, however, to point out here the 
 exact mode in which it is well to examine a cage or to report it — for a report is only a 
 written examination — although at pages 21-23 an outline will be seen which may prob- 
 ably be found of service. I drew it out many years ago, when surgical registrar at Guy's, 
 where it has been generally followed ever since. 
 
 How TO Investigate a Case. 
 
 When a surgeon is callt'd to a patient, his questions naturally apply first of all to the 
 seat of disease or injury. Is it in the head, chest, abdomen, or extreniities ? He will 
 then ask as to its duration or when the injury was received ; or when was the disease 
 discovered? If a case of injury, his inquiries would tend to elicit the exact mode of its 
 production, the force employed, and the character of the instrument by which it was pro- 
 duced ; for these points are of essential importance under all circumstances, and in head 
 injuries they often give the key to the solution of many questions. By these means the 
 exact seat of injury will probably be indicated, and the surgeon will be led to make a close 
 examination of the injured part; but he should never fail to assure himself that all other 
 parts of the body are sound and in working order, and that no other is involved in disease 
 or is the subject of injury ; for it would be a forlorn hope to amputate for a crushed limb 
 when associated with a ruptured liver, or to reduce a dislocated joint when combined with 
 some fatal internal lesion. 
 
 In a case of injury to or disease of the head or nervous system, the most important 
 point the surgeon has to determine has reference to the exact seat of the affection. Is it 
 confined to the soft parts covering the bone, or are the contents of the skull in any way 
 involved? because, in the former, the affection is comparatively of small importance; 
 whereas, in the latter, its gravity cannot be too highly estimated. Scalp wounds, however 
 severe, have, as a rule, a successful ending; whilst brain injuries, however trivial, should 
 always be regarded with apprehension, for they may lead to the most serious complications. 
 
 When no signs of brain disturbance after an injury have been observed, the diagnosis 
 is not difficult ; for without symptoms, local or general, a surgeon may be excused from 
 entertaining the idea of brain complication, although he should know that cases of frac- 
 tured base have taken place without any symptoms to suggest the presence of such an 
 injury. AVhen indications of brain disturbance exist, the difficulty arises; for it cannot 
 be too firmly impressed on the student's mind that the same symptoms may be produced 
 by concussion as by compression of the brain, and that bone pressing on the brain, and 
 blood effused upon its surface or within its structure, give rise to precii^ely the same phe- 
 nomena ; he should know that the symptoms produced l)y apoplexy the result of a rup- 
 tured vessel, and by hremorrhage into the brain from an injury, are almost identical, and 
 that those produced by what is called functional disturbance of the brain closely resemble 
 those caused by organic mischief. Whilst, therefore, it is imperative on the student of 
 surgery to remember that a variety of different conditions may give rise to apparently 
 identical clinical symptoms, he must know that the clinical history of each of these cases 
 will on inquiry be found to differ widely, and that it is to the collateral evidence of the 
 case he must look to find the right clue to a successful diagnosis. 
 
 Where no clinical history can be obtained, the difficulties of diagnosis are indeed 
 great ; thus, when a surgeon is called to see a man who has been found in the street 
 insensible, who is, in fact, in an apoplectic condition, and has, at the same time, some 
 external evidence of injury to his skull, and may perhaps al.so smell of spirits. The 
 questions that arise in the surgeon's mind under these circumstances are very conflicting. 
 Did this man have a fit and then fall, or are the symptoms due to a brain injury the 
 result of an accident? Was he knocked down and injured, or was the injury the conse- 
 quence of a fall ? Are the symptoms caused by drunkenness, or how far are they com- 
 plicated with it ? Are they the result of blood-poisoning from kidney disease, or poison- 
 ing by opium ? 
 
ISriinDrcTlos. 19 
 
 To unravel all tlicso jmitits <;rfat caic and iliMiiminatiiiii art" n'<jtiir('(l. Ttxi much, 
 indeoil, cannot l>i' hcstowcil upon tlu- task, hecaust- to treat an apoplectic seizure or u case 
 of severe brain injury Ironi external violence tor drunkenness is a j;rave error; hut, 
 unfortunately, it is one whi(di is not unconinion. To mistake drunkenness for apoplexy 
 or severe head injury is, perhaps, a less jrrave, althoujrh it is, without doubt, a serious, 
 fault. As a matter of policy, however, it is L'enerally a wis*' rule to rej^ard all these .su.s- 
 ]>icious cases from the more serious point of view, and to watch and wait for }«vmptom.s 
 to indicate the ]»ractice that should be pursued. 
 
 What I wish, therefore, to imj)res8 upon the student is the necessity of bearing: in 
 mind that all these different conditions alluded to prc^^ent to the sur<rcon many features 
 in common, and that a correct diapiosis can only be arrived at by a |»roc(;ss <jf exclusion. 
 The possibilities of the case luivintr thus been reviewed, the i)rr)babilities can only be 
 weiL'hed by a riiriil in(|uiry, even into the minutest circumstances that can be ascertained. 
 
 In cases of local jiaralysis the ditheiilties of diairnosis are very great. Is the cause a rin- 
 /m/ one — that is, is it in the brain or cord? or is it p'riji/icnr/ — at the terminati<m of the 
 nerves? or is it foca/ without being (|uite ))eripheral ? If one or two of the former causes l>e 
 in operation, the history of the case will probably form a true guide to the surgeon, ami in 
 the latter some local injury to the nerves .supplying the part, .some tumor or atieurism 
 pressing upon the nerves, will probably be found ; or percliance it may be a case of lead 
 palsy or infantile paralysis. But, under any circumstances, a true diagnosis can only be 
 made by eliminating from consideration the many possible causes and adopting the most 
 probable. 
 
 Again, if ahoiild be an invariable riih- of practice in every case of injury or ili^ase to 
 compare tin- sound vith the affected sid<: of tlu- body. In the diagnosis of a dislocation or 
 fracture, the information gained by the comparison often furnishes at a glance to tlie 
 experienced eye a true suggestion as to tlie nature of the accident, and in joint disease 
 any effusion into a joint or enlargement of the bones is. as a rule, readily detected. 
 
 The nature of the disease or injury being thus suggested to the mind througli tlie 
 eye, the suggestion remains to be confirmed or corrected by a careful manual examina- 
 tion, by the other clinical symptoms, and by the history of the case, the facts elicited by 
 the sight, by the liand. and by the ear being made separately available, and the conclu- 
 sion drawn after a careful balancing of the probabilities and possibilities of the case. The 
 diagnosis will be well established when all these different modes of investigation lead to 
 one conclusion. 
 
 In surgery, as in medicine, tlie student must educate the eye to see and the hand to 
 feel, and the task is by no means .simple or easy ; indeed, it is one of the mo.st difficult to 
 learn, and cannot be begun too early in his professional career. Reading will not help, nor 
 thought aid: personal experience at the bedside alone will supply the want. 
 
 To recognize the existence of a wound or the deformity of a broken bone may not be 
 difficult, but to read aright the endless phenomena which a wound presents, and to make 
 out the character or tendency of a fracture, require much experience. To .see that a 
 swelling exists in a part is open to the uneducated eye. but to recognize the various 
 aspects that different tumors assume, to make out their form, position, and attachments, 
 to estimate their consistence, to recognize the fluctuation of fluid, whether superficial or 
 deep, and to detect pulsation, require considerable tactile pf)wer and long education. 
 What education alscj is demanded in order to read the phenomena presented in diseases of 
 the eye or the skin ! '' No study of the written observations of others could enable any to 
 appreciate those endless varieties of the pulse which entirelj" bafile description, or to distin- 
 guish between the warmth of the skin excited by various accidental causes and the pun- 
 gent heat accompanying the first stage of pneumonia, or acquaint him with the .shrunk and 
 shrivelled features derived from the long-continued disease of the abdominal viscera, the 
 white anil bloated countenance often attendant on changes in the functions or structure 
 of the kiilney. the squalid and mottled com])lexion of the cachexia dependent upon the 
 united effects of mercury and syphilis, the palli<l face of hjvmorrhage. the waxen hue of 
 amenorrhdca. the dingy whiteness of malignant disease, the vacant lassitude of fever, me 
 purple cheek of pneumonia, the bright flush of phthisis, the contracted features and cor- 
 rugated brow of tetanus ; all which shades of countenance, with many more that might 
 be enumerated, are distinctly rec<^gnized by the experienced eye." Yet all this, and 
 something more, is to be acquired by means of trained ob.servation, and no labor on the 
 students ]iart should be considered too great for its attainment. 
 
 Diathesis. — This subject claims the attention of the surgeon, on account of its 
 undoubted bearing on practical surgery. In the strumous, scrofulous^ and tuberculous 
 
20 INTRODUCTION. 
 
 diatheses — all of which appear to be closely allied — there is. no doubt, a tendency to 
 glandular enlarirenient, the formation of caseous deposits, and a low kind of inflamma- 
 tory action, whether in the bones, joints, skin, or lungs ; but beyond these clinical facts 
 we know nothing. Disease in subjects who have these diatheses is precisely identical in 
 its e.'^sential nature with the same disease in others who have them not. It may be 
 modified in its course by the diathesis, but it is the same. These names have, likewise, 
 no special signification when applied to local affections. 
 
 It is important to bear this fact in mind, for there can be little doubt that the expres- 
 sions •' .strumous disease " and " scrofulous disease" have had an injurious influence on the 
 practice of surgery. They have too often led the surgeon (and misled the public) to 
 regard a local aflection in a strumous or scrofulous subject as incurable, as depending on 
 some constitutional condition, and not on a local cause. In disease of the joints this 
 error has been much felt, and should be rejected. 
 
 The investigations of Drs. .Sanderson and Fox in England, and Dr. Waldenburg 
 abroad, tend, Viowever, to show that the scrn/itlous diathesis, in which there is a tendency 
 to inflammation of a low type, gives rise, under some circumstances, to /uberctilosis, and 
 that local inflammatory affections of a chronic nature are specially prone to be followed 
 by tuberculous disease.^ The gray granulations or tubercles are apparentlj- derived from 
 some pre-existing inflammation ; from the absorption into the blood of the caseous or 
 cheesi/ deposits which are supposed to be the residue of an antecedent inflammatory action 
 — whether in the bones, joints, glands, or lungs, and these are subsequently disseminated 
 in the form of miliary tubercle. Niemeyer, indeed, maintains that " the formation of 
 tubercle never takes place unless preceded by pneumonia terminating in ca.seous infiltra- 
 tion of the pulmonary tissue." To the surgeon this a.spect of the case is of immense 
 importance, for it is clearly his duty, under the.se circumstances, to hasten the recovery 
 of local suppurative disease as much as possible, and, where this cannot be carried out, 
 to remove it. For let it be once shown that local disease has a direct influence in pro- 
 ducing constitutional dyscrasia — call it by what name we will — and the necessity of deal- 
 ing actively with chronic local affections becomes a duty. I have occasionally acted 
 upon this principle with the best results, and in more than one case in which there was 
 progressive lung mischief associated with a disorganized knee have found the lung affec- 
 tion speedily sub.side after amputation. It must likewise be admitted that a local dis- 
 ease in a strumous subject may be as amenable to treatment as it is in a more healthy 
 one. The treatment may, indeed, require some modification from the fact of its occur- 
 ring in such a subject, but the principles of practice in both the strumous and the non- 
 strumous are the same, although we know that in the former all diseased action is of a 
 low type, and that there is always a greater tendency to degenerative changes than we 
 find in other subjects-. Some pathologists have been bold enough to say that the scrofu- 
 lous diathesis is the consequence of hereditary syphilis, but evidence is wanting to sub- 
 stantiate this view. 
 
 HsBinophilia, or the humorrhogic diathesis, as the result of heredity, is a subject 
 of peculiar interest to the surgeon, and is to be distinguished from a temporary disposi- 
 tion to bleed, Avhich is present in purpura or leucaemia, and is often acquired. It attacks 
 the boys of a family rather than the girls, and when bleeders beget children all, as a 
 rule, appear healthy, but when the girls have families their boys, as a rule, are bleeders. 
 It may appear at the very earliest period of life. It manifests its presence by a pecu- 
 liar tendency to bleeding on the .slightest provocation, and by the difficulty there is in 
 arresting haemorrhage when it does take place. The surgeon should always have before 
 him the possibility of his patient being a .subject of this diathesis ; for. although it 
 would not prevent the performance of any operation essential to save life, it would 
 materially affect the que.stion of operating for any reason of expediency, and would 
 influence the practice adopted. 
 
 The bleeding may take place from any part of the body or into any cavity. It may 
 be venous or arterial, and may occur without any definite cause or follow some .slight 
 injury. The swelling of the joints which takes place in this affection in some cases is 
 due to haemorrhage, but in others to serum. In a drawing in my possession the syno- 
 vial membrane was found after death covered with beautiful fine fringes stained a deep- 
 orange color from effused blood. Sir W. Jenner states that in those cases " the tissues 
 are soft, and Ijruise easily ; the blood is slow in coagulating, although it coagulates as 
 firmly as in health — that is. blood is formed rapidly, and there is a tendency to plethora 
 of the small vessels — and that when the patient is looking his best, injuries have the 
 ^Die Tuberculose und Scro/ulose, von Dr. L. Waldenburg 'Berlin, 18G9j. 
 
ISTIiODVi'TIOS. 21 
 
 worst effect uiiil si>oiitaiieous haMimrrliajres arc most likely to occur." In this disease, 
 thorctbre, ho advises a mercurial and saline jiurjie (.'Very three weeks, dry food, with a 
 considerable j)orti(»n nt" dry lihrinoiis meats, and plenty nf open-air exercise, ^jreat care 
 heinir fthserveil to avoid injurit.-s. The bleeding;, as a niU;, ceases .spontaneous! v. In the 
 ae<|uired disease iron is of threat value. 
 
 Cachexise. — D" they exist? I.s there any drtinite aspect associate*! with any 
 tleliiiite disease? Is there a eancerou.s cachexia? I have little hesitation in statin;^ that 
 in practice no such tiling can be established, and that a larL'e number of patients suHcr- 
 ini^ from cancer are as healthy-lookinir as any other (;lass. if not often healthier. There 
 can be no doubt that a patient suilerinir iVom cancer which, by its discharfres or ilevelop- 
 ment. interferes with the important functions of life and undermines his powers, has an 
 anxious, drawn, bloodless, and waxy appearance ; l»ut so has the suVjject of any orfraiiic 
 disease which interferes with the function.s of dijrestion and assimilation, and particularly 
 the subject of intestinal disease. The patient exhausted by suppuration, by .spinal, bone, 
 or joint mischief, the man or woman who from drink, syphilis, or mercury (.separately or 
 coml)ined) is gradually bein<r broutrht down to death's door, has a cachexia more or less 
 peculiar according to the oriran involved in the disea.se and the special constitution of the 
 patient ; but it is nierely the condition of looking ill. Clinically, I read the meaning of 
 a cachexia as •" looking ill," perhaps very ill. from some long-standing or shiwlv-acting 
 cause ; but it has no other definite signification than " looking ill " from cancer, " look- 
 ing ill ' from abdominal, rectal, suppurative, or syphilitic disease. 
 
 Points for Inquiry in Surgical, Cases. 
 
 Dise.ise or Injury. ^ Date when seen. Result. 
 
 NAMK, age, occupation, residence, general healtli. habits, and aspect. In some cases, hereditary 
 liistorv. 
 
 HIHITORY OF PRESENT DISEASE OR I X.J TRY.— Its assigned cause or nietliod of production. 
 
 ORDER OF SUCCESSION OF SYMPTOMS, with their former treatment, and date of any 
 marked chaiiije in eitlier svmptoins or treatment. 
 
 PR?:SENT CONDITION AND APPEARANCES, passing in review and noting when irregular 
 the condition of intellect, senses, and nervous system. Organs of respiration and circulation. 
 Pulse — frecjuencv, tbrce, volume, eoinpre.ssibility, distinctness, and rhythm. Temperature. Di- 
 gestive Organs — tonirue, apjjetite, bowels. Urino-<renital Organs — urine, catamenia. Integu- 
 ments — eruptions, moist or dry ; aljove or below natural heat. Locomotive organs — bones, joints, 
 and muscles; whether ])aralvzed or in imdue action. 
 
 PREVIOUS DISEASES OR INJURIES, with their dates. Treatment. 
 
 PROGRESS OF THE CASE. — Note carefully any cliange in the old or the appearance of new 
 symptoms, with the date of chan.tre and treatment, by medicine, diet. etc.. etc. Carefully fill in 
 the result, and date of departure; if unfavorable, the condition on post-mortem examination. 
 NoTK. — As the value of a report depends upon its conciseness, together with the accuracy and 
 munber of recorded observations, it is unnecessary to write one unless an appreciable change in 
 the symptoms exists. 
 
 SPECIAL POINTS FOR OBSERVATION. 
 HP2RNIA. — Variety and character — its position, period of existence, assigned cause, and form; 
 
 whetiier previously irreducible, and if a truss had been worn. 
 
 When Str.wgil.xted, give the symptoms, general and local, dating from the exact period of 
 
 strangulation, the first appearance of sickness, character of vomit. 
 
 Previovs and Pkesext Condition. — If by taxin, state wbether forcible, and how long 
 
 applied, with or withoiU chloroform ; when by operation, if sac was opened or not — if opened, 
 
 irhyf its contents and their apjjcarances. On reduction, note the time from the first symptoms 
 
 of strangidation ; succe,ss. immediate and final. 
 "WOUNDS. — Variety, position, extent, and depth ; how and with what produced ; when on sra/p, if 
 
 exposing bone. Complications — hemorrhage, etc. Treatment and result— whether imited by 
 
 adhesion or srranulation. 
 TETANUS. — Idiopathic or traumatic, partial or seneral ; time of appearance after injury; position 
 
 and condition of wound. Death — wiiether from spasm or exhaustion. 
 DISLOCATIONS. — Form and position; simple or compound; how and when producetl ; previous 
 
 treatment. 
 
 Symptoms, seneral appearance and position of the limb; moliility. pain, amount of injury to 
 
 soft parts. Treatment — time after injury: iiy manipulation or extension: mode of appli("ation 
 
 of extension, with its direction and duration ; chloroform, additional means employed. Result, 
 
 immediate and final. 
 FRACTUKES. — Simple or com|)ound,or comminuted: how and when produced; position and direc- 
 tion of the line of fracture; its tendency; amount of injury to vessels and soft parts; in compound, 
 
22 INTRODUCTION. 
 
 note position and extent of wound ; if jirodiued Vn- tlie primary force or broken bone, wliat 
 vessels, nerves, or joints are involved. Constitutional symptoms 
 
 Treatmknt. — Sand bajjs, standi bandajje, splints, form of splint applied; date of application. 
 Note the date of any clian<^e of local or jreneral treatment. 
 
 FRACTUKKD 8KULL. — Position; kind of injury and direction of the force; if attended by 
 hiemorrhage, its amount, and whether from nose, mouth, ear, or external wound. Give evi- 
 dence, if anv, of brain mischief 
 
 IN SUSPECTED FRACTUKED BASE.— Paralysis of facial nerve; flow of blood or serum from 
 ear, with the time of its first a})pearance after the injury and its duration; condition of hearing; 
 state of vision, and of pupils; presence of subconjunctival luemorrhage. If complicated with 
 internal injury, as concuffsiitn, co)iipressimt, etc., carefully report symptoms in their order of succes- 
 sion, and whether immediately following the injury or not ; the duration and amf)unt of uncon- 
 sciousness, insensibility; paralysis, its position, motion, sensation, or both; condition of sphinc- 
 ters; character and innnber of pulse, respiration; condition <>f skin. Treatment, etc. 
 
 DISEASED BONE. — Part atiected ; duration; cause, as external injury, syphilis, mercury; extent; 
 superficial or deep, partial or general ; previous treatment, especially as regards operations. 
 
 Present Symptoms and Appearances. — Condition of dead bone or s^equeMruin, fixed or 
 loose ; number and position of openings, or external cloactr, with the date of their first appearance. 
 Treatment. — If by operation, its immediate success. 
 
 DISEASES OF JOINTS. — Part afiected ; date of first discovery; a.ssigned cause, as injury. Note 
 the early symptoms in the order of their appearance, and date of any fresh symptom or marked 
 change; if pain or uneasiness preceded swelling, or was coeval with it ; if the former, how long? 
 Rapidity of progress; previous treatment, and its effects. 
 
 Present Appearances. — Position of joint ; if flexed, the angle of flexure; size and shape. 
 Character OP Swelling. — Uniform or bulging; nianipular indications, hard, soft, elastic, 
 or fluctuating; mobility, amount; if attended with grating, etc.; in the knee-joint, note if the 
 patella be free or not ; if free, the sensation felt on moving it ; condition of skin ; if fistulous 
 openings exist, their position, number, and character of their discharge ; deep or superficial ; 
 note the date of their first appearance, and if natural or artificial. Pain, acute or gnawing; its 
 position, general or local; if aggravated liy motion or interarticular pressure; if increased at 
 night. Sleep, if disturbed liy crying or starting of the limb ; sympathetic pain, and its position; 
 condition of muscles of limb; constitutional symptoms. Treatment. 
 
 STRICTURE. — Organic or traumatic ; duration and assigned ca«se, especially as regards gonorrhoea; 
 use of injections, or accident ; if previously treated by catheter; complications, as abscess, fistula, 
 with their position and date of appearance. 
 
 RETENTION. — Mention period of retention ; preceding symptoms, and cause, as stricture, calculus, 
 {)aralysis, abscess, prostatic disease, etc. Constitutional and local symptoms ; previous and pres- 
 ent treatment ; puncture per rectum, note the date of removal of the canula and arrest of tlie 
 flow of urine through the wound. 
 
 EXTR.VVASATION. — Cause, over-distension or accident; duration of retention before urethra gave 
 way, and period that elapsed before being seen. Describe the appearances and extent of parts 
 infiltrated ; constitutional symptoms and treatment. 
 
 VENEREAL DISE.\SE. — Chancre, duration ; position, glandular, urethral, coronal, or frsenal — 
 external, internal, or fringing preputial ; character, indurated, non-indurated, aphthous, raised, 
 excavated, irritable, phageda?nic, or sloughing; tubercle; condition of inguinal glands, indurated 
 or inflamed. Prevloiia treatmenl, particularly as regards mercury. 
 
 Complications. — Note the date or appearance and situation of each or any of the complica- 
 tions; the order and time of their occurrence after the primary sore. Present appearance and 
 treatment of each. 
 
 GoNORRHCE.\.^Date of contraction; former treatment, especially as regards injections, copaiba, 
 etc. Complication.s, and their duration; in epididymitis, if following suppressed discharge; use 
 of injections, copaiba, or violent exercise. 
 
 STONE IN BL.\DDER. — When discovered; date of earliest symptoms; if preceded by the pas- 
 sage of sand; amount of irritability of bladder; character of urine; constitutional and local 
 symptoms. Treatment — litlmtrity or lithotomy; in latter, note any peculiarity ; date of arrest 
 of the flow of urine through the wnund. 
 
 TUMOR. — Date of its discovery and size; rapidity of growth; general and local symptoms, in their 
 order of appearance. (Jeneral health prior to discovery, and since; hereditary tendency; 
 assigned cause; depressing influences. In mammary tumors, number of children; date of birth 
 of last; if ever suckled with aflected breast, when? condition of the catamenia; if ceased, how 
 long ? Previous treatment, and success. 
 
 Pre.sent Condition and Appearances.— Position of tumor; size, shape; external aspect 
 and condition of skin; pain, and its character; condition of lymphatic glands; manipular indi- 
 cations ; mobilitv, when in breast, whether moved by traction of the nipple ; feel hard, elastic, 
 etc., etc. Constitutional symptoms. 
 
 Treatment. — In recurrent growths, give the date of former operations; date when healed, 
 and of its first reappearance and position. 
 DPER.\TIONS. — Describe position, direction, and number of external incisions; the steps of the 
 operation as performed; its duration ; number of vessels tied or twisted, and amount of haemor- 
 rhage. In amputations, the part amputated, and position of amputation. In flap operations, 
 give the position of the flaps ; whether anterior, posterior, or lateral ; whether performed by 
 perforation or external incision. In the c<'nd)ined flap and circular, note the position of the 
 skin flaps; in all note the result and character of stump. 
 
LSCl^JJIt W'JlWDS. 23 
 
 ("llAl'TKli 1. 
 ON WOrXPS. Ki:i'All{. am> infi.a.mmatmin 
 
 KkiiM a clitiii-al jioiiit ot" vit-w. wounds may !•(.■ divided intd tlic Open and tluSubCU- 
 ta>neOUS, if «e i-xi'ludt- those liy wliitli uidiiial |ii»is(iiis are iiitrodiiccil into tlic >\-t<iii. 
 such as dissi'ftiiiu whuihIs, the stin<rs ot" insects, hites of snakes and rahifl animals, and 
 the wouiuls which afford an entrance to the {loison of jrlanders. mali<rnant jiustule. and 
 hist. hut not least, syphilis. The term "nj)<,i'\\s applied to all injuries caused ]>\ 
 external violence — the result either of accident or. as in an oj»erati(»n. of desifrn — in 
 which there is a solution of continuity in the soft ti.-sues. and in which the deeper parts 
 are exposed to the influence of the air through a more or less ga[»in<r orifice. The term 
 ^^ xtibcutaiu'ous" is applied to such injuries as follow external viftlenee, in which the deeper 
 tissues, bones, or viscera are broken, ruptured, lacerated, or crushed, without any breach 
 in the continuity of the std't parts covering them, and consequently without their exposure 
 to the influence of tlie external air. as well as to such operations as may be made by the 
 surgeon through a small external or open wound, as in tenotomy, myotomy, and oste- 
 otomy. 
 
 ■• Open " wounds are more serious, as a rule, than the '• subcutaneous." though the 
 latter, when large vessels and viscera are concerned, are among the gravest injuries the 
 surgeon has to deal with. Open wounds, moreover, heal by a more complicated process 
 than the subcutaneous, and are exposed to risks from which the latter are free. 
 
 Classification of Open Wounds. 
 
 When made by a sharp-edged instrument, either by accident or in an operation, 
 wounds are said to be iiuised ; when inflicted by a blunt instrument that tears, they are 
 called lacerated; and when caused by one that bruises, contused. Wounds caused bv the 
 thrust of a pointed instrument are called punctured, though when the weapon is sharp 
 the tissues are simply pierced and cut deeply ; but when blunt, irregular in shape, or 
 increasing in diameter from the point toward the handle, the soft parts are forced asunder 
 as by a wedge, and are consequently stretched and contused. A jiunctured wound under 
 some circumstances approaches the character of the incised, and under other circum- 
 stances that of the contused, form of injury. As a matter of fact, however, nearly all 
 wounds of Sijft parts are more or less contused, those inflicted with a very sharp instru- 
 ment being, of course, the least so. 
 
 Simple or Complicated. — A wound is called -simple" when it has been made 
 by a clean, sharp-edged instrument in a healthy subject, and when there is nothing in the 
 nature of the wound itself or in the state of the patient to prevent or retard repair, pro- 
 vided that the injured part be placed in a favorable position for the reparative process to 
 be carried out. The wound is called " compIicat€<V when there are foreign bodies lodged 
 in the part interfering with repair ; when it is attended with haemorrhage, with much 
 contusion or laceration of tissue ; or wten from the peculiarity of the patient there are 
 nervous symptoms, severe pain, constitutional disturbance, or local inflammation ; or when 
 repair is interfered with by the presence of such complications as bad health or old age. 
 
 Incised Wounds. 
 
 Open incised icounds are best seen as the result of operations, but they may also be 
 well studied as clean cuts accidentally made with sharp-edged instruments. They may 
 f/ape from the ela.«-ticity or contractility of the tissues divided, may /died from the division 
 or wound of small or large vessels, and may give rise to variable degrees of pain accord- 
 ing to the number or character of the nerves involved, and according to the susceptibility 
 of the patient. 
 
 The amount of " gaping " in a wound varies with the tissue divided. Skin, which is 
 the most elastic tissue in the body, retracts when divided far more than other tissues, and 
 transverse wounds of skin gape more than those which are longitudinal. Arfen'cs. when 
 wounded transversely or obliquely, gape much, and when completely divided acro.s3 
 retract far into the tissues. Divided veins retract less than arteries. ^Iuscies, when their 
 
24 LOCyiL AND CONSTITUTIONAL EFFECTS OF INCISED WOUNDS. 
 
 fibres are cut across, shorten rapidly by contraction, and thus aid tl)e gaping of a wound. 
 Fibrous fissaes and nerves when divided retract but little. All wounds, however, which 
 are made in parts in a state of tension gape much, and tissues which are on the stretch 
 when divided retract, far more than they would do if tliey were relaxed. Thus, an 
 incision made into the full breast of a suckling woman will probably by gaping ajjpear 
 as wide as it is long; while one made into the same organ in a flaccid state would gape 
 but little. Some tissues, on the other hand, never gape on division ; this is best seen in 
 wounds of the palm of the hand and of the sole of tlie foot. 
 
 The surgeon takes advantage of these known conditions of gaping and retraction of 
 tissues, and in his operations so places on the stretch the parts to be divided as to enable 
 him to make a clean and decisive section of the tissues with which he is dealing, a single 
 sweep of the knife, made under these circumstances, doing the work of many when made 
 under others less favorable. 
 
 Hsemorrhage from Incised Wounds.— The " bleeding" that attends an 
 
 incised wound depends princi])ally upon the size, Jiumber, and character of the ves- 
 sels that are divided, although it may be influenced by the personal peculiarities of the 
 patient, and more particularly by the fact of his being a " bleeder" or not ; or, in other 
 words, by his being or not being a subject of the " hsemorrhagic diathesis." The condi- 
 tion of the wounded part, moreover, whether inflamed or otherwise more than normally 
 supplied with blood, has some influence, and the effects of position mu.st always be taken 
 into account. 
 
 Putting aside, however, those peculiarities, constitutional and local, the myriads of 
 vessels that are divided in a wound made in a healthy subject with sound tissues rapidly, 
 if not instantaneously, close on the removal of the dividing medium ; for it is a fact that 
 capillary bleeding after an incised wound rapidly ceases by natural processes. That which 
 goes by the name of ''haemorrhage" is due to the issue of blood from wounded arteries of 
 some size or from wounded veins, and the bleeding, if it does not prove rapidly fatal, 
 persists till nature's haemostatic processes — unassisted or assisted by art — have time 
 to act. 
 
 Pain of Incised Wounds. — The " pain" attending an incised wound varies in 
 its nature and degree according to the position of the wound and the tissue wounded. 
 Some portions of the body, such as the skin of the face and fingers, the orifices of the 
 mucous tracts, the periosteum, and tense tendons, are far more sensitive than the skin of 
 the back and buttocks, the bones and the fasciae. The sensibility of the patient has like- 
 wise much to do with the degree of pain experienced ; so also has the condition of the 
 nervous sy.stem at the time at which the wound is received. Not only may one subject 
 of an operation be far more sensitive than another, but the same subject may feel pain 
 more acutely at one time than at another, the general condition of the physical powers, 
 and more particularly of the nervous system, greatly influencing sensibility. Unexpected 
 or unseen wounds, or wounds received during drunkenness or when the mind is intent on 
 other things, as in the excitement of battle, are often unfelt or I'elt but slightly; whereas 
 when the mind of a patient is fixed upon the performance of an operation the evil influ- 
 ence of anticipation aggravates his suff'ering. 
 
 Local and Constitutional Effects of Incised Wounds. 
 
 The "local eff'eots" of a simple incised wound on a healthy subject may extend little 
 beyond the breach of surface and the slight pain and bleeding which attend the injury. 
 The " constitutional effects" may be so slight as to be unobserved. In a general way, 
 however, local as well as constitutional effects show themselves, and these are greatly 
 influenced by the extent of the wound, the general condition of the patient, and the 
 treatment to which the injured part and the patient have been subjected. 
 
 Local Effects. — These are best studied in a deep incised cut which has passed 
 through skin, subcutaneous fat, and fascia. 
 
 The wound, directly after its infliction, will gape, and after the lapse of but a brief inter- 
 val of time this gaping will increase so that the subcutaneous fat will appear as if it 
 were being pressed out of its position, and as if the divided edge of the skin were retract- 
 ing from it and becoming everted. Within an hour, or an hour and a half, the edges of 
 the wound will be seen to be swo/Ien and slightly retf, from increased vascularity ; and if 
 the connective tissue of the wounded part is loose, as in the eyelid or male genital organs, 
 it will be puff'ed up and cedematous. To the patient the part will feel hot and stiff", and 
 it will be the seat of a dull, aching, or burning pain. The edges of the wound will also 
 
LOCAL A.\I> coSSTirrTloSAL L !' 1' I'J "I'S Ol' ISnsLI) W'Ol'SDS. 2'' 
 
 'inilialilv )•<-• nmri' .sensitive, th»' aiiKUint oi' pain <l<|Kiiiliiijr iniicli ii]iiiti the tuition of the 
 parts and upon the treatment to whieh tlit-y liavc \>vv\\ sulyi-cted. If the e(lf;e.s <»f the 
 wmuihI have lieeii stitehfd toiretlier and the parts are Miiich swnMen and (I'deniatous, tht-re 
 will he tension upon the wuiind and a dis|i(isitiiin to se|iarate and jrape. In a healthv 
 suhjeet, however, when repair jjoes on well, all these loeal phenomena will snhside and 
 disappear in the course of two. three, or lour days, aceordin;; to the; rapidity and perfci-- 
 tion of the healiuL' proei-ss. and a eure will then take j)laee. But should the loeal jdic- 
 nnmenu ahove deseriltetl he more persistent, increase in severity, spread lieyond the 
 niaririns of the wound and surnjundinji parts, or alter in character for the worst;, what 
 has heen a phvsioloirieal ri'parative j»rocess will jtass into a ])athido^ical or di.sea.sed one, 
 and the jiarts will then he sai<l to he '"inflamed." 
 
 Constitutional Effects. — The '-constitutional jilienomena" associated with the.se 
 local chauL'o vary ureatiy. In some suhjccts a trivial local injury, a mere cut. may jrive 
 rise either to a more or less severe " shock" or to a disturhance of the nervous system 
 whieh ex])resses itself in convulsions ; whereas in other persons a severe and exten- 
 sive wound may he folli»wed hy few, if any, constitutional .symptoms. 
 
 '• SiKK'K. " — The f^radations of shock and collapse are innumerahle, and the symjJtoms 
 1)V which they are characterizA-d vary from a passing faintness or disturbance of the 
 hearts action to final syncope. The state of collapse may he refranh-d as a chronic syn- 
 cope. Patients may umjuestionahly die from ".shock" followiufr slight injuries or minor 
 operations, though no satisfactory ca>ise for death may subsetiuently he discovered, the 
 lieart's action being suddenly stopped thntugh some central nervous influence. 
 
 The degree of '-shock" that attends an accident or operation depends, as a rule, upon 
 the imitortance in tlie animal economy of the organ injured, the extent and nature of the 
 violence which the tissues have sustained, the size of the blood-vessels which have been 
 involved, and the amount of blood which has been lost. A patient in good health will 
 bear a severe wound or operation with little shock ; while another with di.seased viscera, 
 and more particularly with diseased kidneys, will be subjected to severe .shock from even 
 a trivial injury. 
 
 The age and constitutional condition of the patient have an important influence under 
 all circumstances. 
 
 "Reaction." — When what has been described as the period of '-shock' after an 
 acci'lental or opeiative wound has passed away, the stage of " reaction " is readied; and 
 in a general sense it may be assumed that the intensity of this stage is fairly governed by 
 the intensity of that whicli preceded it — that is to say, where there has been little shock 
 there will be but feeble reaction ; and where the .shock has been severe or prolonged the 
 stage of reaction will be of a like type. Still, this rule^as innumerable exceptions, and 
 these exceptions seem to depend more on the individual peculiarities of the patient than 
 anything else: one person, after a slight injur}' or operation, experiences little .shock, but 
 sliarp reaction ; while another, suff'ering from a severe injury or operation, will have a 
 prolonged stage of .shock, followed by no more reaction than seems to be neces.sary to 
 restore the circulation to its normal condition, and to allow the functions of the body to 
 work efficiently. 
 
 Children and women and the subjects of neurotic tendencies always react rapidly and 
 in a marked way from all kinds of shock, whether mental or physical ; but, as a rule, 
 they do well. The rigors, nervous trenil)lings, and fears which are often met with in 
 nervous stibjects after operations, and which often cause alarm, are but rarely followed by 
 any bad results. 
 
 The si/iitj>foni:i of reaction, in their mildest expres.sion. are simply those of the restora- 
 tion of the circulatory and nervous functions to their normal condition, the heart, with 
 the circulation generally, so rallying from the dejiressed condition into which it has been 
 thrown by the - shock " of the accident or operation as to come up to the usual standanl 
 of health, and the nervous system so recovering from the temporary state of depression, 
 if not of uncon.sciousness, into which it has been cast as to resume its normal power of 
 governing and controlling the actions of the body over which it presides. The reparative 
 process, conse(|uently. under the.se circumstances may be expected to go on uninter- 
 ruptedly to a successful issue. The w(jund will undergo repair and heal, and the subject 
 of the wound will suflfer little or no constitutional evil beyond that occasioned directly by 
 the injury. The stage of reaction in a clinical sense will then be normal ; it will be such 
 as may be sai'l fairly to balance tliat of shock, and to tend toward recovery. 
 
 Traumatic Fever. — "When the symptoms of reaction, either with respect to inten- 
 sity or duration, exceed the normal standard : when the circulatory system acts power- 
 
26 
 
 PROCESS OF REPAIR IN WOUNDS. 
 
 fully and rapidly, the respirations increase in quickness, the brain and special senses 
 become abnormally active, and the temperature of the body rises and remains above that 
 of health ; and when with this elevation of temperature the functions of the body gener- 
 ally are disturbed and work badly, as indicated by thirst, a foul tongue, loss of appetite, 
 constipation, diminished secretion of urine, want of sleep, or disturbed rest, — " traumatic 
 fever" is said to exist. 
 
 This fever may show itself the day after the injury or operation or may not appear 
 till the second day, and it may last for twenty-four, forty-eight, or seventy-two hours. 
 When the case is going on satisfactorily toward recovery, the fever seldom lasts beyond 
 this period. Should the symptoms, however, continue, dangers are to be apprehended 
 and difficulties looked for. When the fever runs on into the fifth or sixth day, the sur- 
 geon may be sure that some complication is present ; and should the symptoms be still 
 more fixed, the probabilities are that the case is not only badly complicated, but that it 
 will pass on to a fatal issue. 
 
 Temperature Chart. — Under all circumstances, and in the treatment of every 
 wound, accidental or operative, the eye of the surgeon should be steadily fixed on the 
 temperature chart, such a chart aff"ording the surest indication of the advance or presence 
 of any such complication. 
 
 Process of Repair in Wounds. 
 
 Before entering into details, it is well to know, as a primary truth, that the processes of 
 repair are identical in all tissues ; that the reparative process in bone or muscle, integu- 
 ment or tendon, soft or hard parts, is the same, such modifications alone showing them- 
 selves as necessarily appertain to the anatomy of the tissue or to the special circumstance 
 of its position. Thus, tissues that are highly vascular may undergo more rapid and more 
 perfect repair than others less fortunately circumstanced, and bone tissue may require 
 more time to unite than skin ; yet in all the process is alike. Let us, therefore, inquire 
 what the process is, and see what changes take place in parts undergoing repair, and then 
 look at them where they are best seen — where an incision is made through the skin and 
 the edges are brought together. 
 
 The chief points that can be observed have reference to the capillaries. In them, at 
 the margin of the wound, the blood will be found coagulated up to the nearest anastomosis, 
 and the ci^pillary vessels in the neighborhood will be seen to be dilated. This dilatation 
 is caused by the increase of pressui-e to which the capillaries have been subjected by the 
 altered circulation of the blood in the immediate vicinity of the wound. When wounds 
 unite by mimrdiate union, no otfter changes than these take place, beyond the gradual 
 restoration of the capillary circulation through the parts that have been divided ; and 
 under such somewhat rare circumstances no scar or cicatrix is left. The soft parts at first 
 simply adhere together, and subsequently become continuous. 
 
 Adhesive Lesion. — Should the wound unite by what is called adhesive union or 
 primary adhesion (the " first intention " of John Hunter), in 
 Fig. 1. which a cicatrix is formed, other changes are to be seen ; 
 
 and these take place in the connective tissue, in which the 
 vessels of the part ramify. They consist of cell multiplica- 
 tion, and under the circumstances supposed we find between 
 the edges of the wound a vast accumulation of cells, filling 
 up in various degrees the spaces of this wounded tissue. It 
 is through these cells that cicatrization takes place. The cells 
 are in part simple nucleated cells, which may be called " em- 
 bryo cells " with connective-tissue corpuscles, and they con- 
 tain a nucleus and nucleoli, Klein's placoid cells (vide Fig. 1). 
 Whether this cell multijilication depends iipon changes in 
 the cell itself, as Virchow affirms, or whether the cells are the 
 white corpuscles of the blood which have escaped by exuda- 
 tion from the capillaries, as Cohnheim would lead us to believe, 
 
 A Group of Placoids In Different I do not noW Care tO inquire. All admit, however, the multi- 
 wandering. '^°(^//er Gow'V/^/n?*!} plication of cells in the affected tissues (vide Fig. 2). Pro- 
 fessor Redfern writes, " The facts must be recognized : the 
 floating blood cells are really the very cells which once formed the substance of the lym- 
 phatic glands, the spleen, and other organs, and they do in fact move through the walls 
 of the blood passages and wander about freely in what are called solid tissues." When 
 
PROCESS OF Hh'I'A/n /.V W'OIWDS. 
 
 27 
 
 we recolli'i-t Ikiw |i(iitir;ilplc iIm- tissues iif an animal arc, wt- .shall ccaw to be startled at 
 seeintr tlu-m lu-i-Mnu- tin- scat ul' iMitirdy ntw deposits, or timlin^ thoin traversed by 
 mi'.^ratin^ blctod eorjmscles as freely as a cnlluid is |ienetrated by a crystalloid. 
 
 ■19 — -1 
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 T = = 
 
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 >^' 
 
 Cicatrization. — Let us now inquire briefly how cicatrization proceeds, and note 
 that it is in the cells that the most important changes are to be recognized. Those 
 nearest the injured part gradually assume a spindle shape, and the intercellular tissue 
 into which tlu'se spindle-shaped cells are infiltrated becomes denser. The spindle-shaped 
 cells then gradually change into ordinary connective-tissue corpuscles, and in this way 
 new cicatrical tissue is formed. This new tissue, however, again undergoes change.* — 
 changes of consolidation. The intercellular tissue becomes gradually more condensed, 
 and the spindle-.shaped cells assume the flat shape of connective-tissue corpuscles and in 
 a measure disappear, the nucleus alone often remaining. The fluid that existed in the 
 newly-formed tissue is absorbed, and the new cicatrix by degrees becomes firmer and 
 denser, gradually contracting ; so that at last the delicate scar of a large wound becomes 
 solid and compact. The cicatrix in smaller wounds appears only as a thin red, and at a 
 later period as a white, line. 
 
 Changes in the capillaries of tlie ])art are, however, going on during all this period, 
 hut how far all the changes that have been briefly described are due directly to the capil- 
 
28 PROCESS OF REPAIR IN WOUNDS. 
 
 lary action is not yet determined. If Cohnheim's views be adopted, it is to the capil- 
 laries that the chief action in the tissues must be ascribed ; but if those of other patholo- 
 gists, such as Yirchow and Billroth, be accepted, the capillary action takes a secondary 
 place and the cell elements take the leading one. On either theory the importance of the 
 capillaries cannot be overlooked 
 
 With regard to the changes in the capillaries, it has been already pointed out that at 
 the beginning of the reparative process the capillaries of the part become sealed and the 
 collateral circulation in the neighborhood becomes irregular and pressed upon, and that 
 the coagula in these obliterated capillaries become reabsorbed, or possibly reorganized, as 
 repair progresses, since it is certain that the capillary network soon becomes continuous 
 through the newly-formed cicatricial tissue, and that the capillary meshes of the one side 
 join, by loops projected through the new tissue, similar meshes of the opposite one. 
 
 What injiuence the nerves of the ]m)t have upon the reparative process we do not 
 know. That they have an important influence there can be little doubt, since all physi- 
 ologists recognize their power upon secretion and nutrition ; the vaso-motor nerves doubt- 
 less have the greater power. But we must learn something more of nerve power gen- 
 erally and nerve distribution — something of the way in which the nerves terminate in 
 the tissues, and what relation they bear to the capillaries — before we can hope to find out 
 or understand the exact influence nerve supply has on repair. 
 
 Repair by Granulation. — All wounds do not, however, heal by immediate union 
 or by primary adhesion — /. ^., first intention ; and wounds that gape cannot so unite. The 
 process of repair in them differs, therefore, somewhat in its character from the process in 
 those which we have been considering: it takes phi ce hy (jramdation^ or the "second 
 intention of Hunter." If we closely examine the surface of a wound thus exposed, we 
 shall find that it becomes, within a few hours of its exposure, covered with a film of a 
 peculiar gelatinous, grayish-white appearance, which will be seen, with the aid of the 
 microscope, to be composed of granulation cells or white blood cells, " Hunter's plastic 
 lymph." After an interval of some hours the parts covered with this gelatinous grayish 
 film become more vascular, as indicated by redness, and the surface more even. The film 
 itself assumes a tougher character, and a yellow fluid, which is mixed with small yellow 
 sloughs of fibrinous tissue, is secreted. The wound begins " to clean," and to have a 
 smooth and consistent surface. After the lapse of another day, or some days, perhaps, 
 this .surface is covered with a number of elevations, known by the name of grmndations, 
 varying in size from a millet-seed to a hemp-seed, the smaller being highly vascular and 
 red, the larger being, as a rule, paler and more bloodless. The wound at this time is 
 "granulating." and the secretion from it is now of a creamy-yellow character, and is 
 called pus. The granulations are made up of cells called granulation cells, which resem- 
 ble inflammatory lymph cells, and each granulation contains a vessel the walls of which 
 consist of a thin membrane in which nuclei are embedded. " Some of these nuclei are 
 arranged longitudinally, others transversely, to the axis of the vessels. In the develop- 
 ment of these vessels changes occur answering to those seen in ordinary embryonic 
 development. Organization makes some progress before ever blood comes to the very 
 substance of the growing part, for the form of cells may be assumed before the granu- 
 lations become vascular. But for their continuous active growth and development fresh 
 material from blood, and that brought close to them, is essential. For this the blood 
 vessels are formed, and their size and number appear always proportionate to the volume 
 and rapidity of life of the granulations. No instance would show the relation of blood 
 to an actively growing or developing part better than it is shown in one of the vascular 
 loops of a granulation embedded among the crowd of living cells and maintaining their 
 continual mutations. Nor is it in any case plainer than in that of granulations that the 
 supply of food in a part is proportionate to the activity of its changes, and not to its 
 mere ".structural development. The va.scular loops lie embedded among the simplest pri- 
 mary cells, or, when granulations degenerate, among structures of yet lower organization ; 
 and as the .structures are developed and connective tissue formed, so the blood vessels 
 become less numerous, till the whole of the new material a.ssumes the paleness and low 
 vascularity of a common scar " (Paget). 
 
 Forrnation of New Skin. — If, at this time, when the granulations have attained 
 to the level of the skin, we look to the margins of the wound, we shall see a dry red 
 band of newly-formed tissue, with an outer border of a blui.sh-white color where it comes 
 into contact with sound integument. This band is the new skin forming, and is caused 
 by the gradual growth of the epidermis from the margin of the sound skin toward the 
 centre of the sore. Such a process is called ''cicatrization.'' The cicatrix is at first red, 
 
rnocKss OF iiki'MR is worsns. 29 
 
 as ill the linear t-icutrix, t(» wliicli \vc li!iv(! ain-aily aliudcMj, }»iit as it cdntracts it hnh.-^e- 
 (jui'iitly licrniiR'S j)ak'r, iimiH' r(tiiij)a(.-t, and aillicri'nt. Tlic iiatnn; of tin; s(;ar kt cicatrix 
 varies witli tlic tissue in wliicli it is turincfl, the \ww coniicctin*; UKMliiirn under all cir- 
 cunistanci's havinj; a powerful tendency to approach (he peculiar charact«-r of the tissue 
 in which it is placed. 'I'hus, a cicatrix in the skin in time closely reseinhles true skin; 
 a cicatrix in hone, trui' l)one ; and a cicatrix in tendon heconies tou^h and hard like 
 tendon. I'lider all circumstances the con.s(didatin;j; reparative material partakes of the 
 charailir nl' the parts wliich it connects. 
 
 Secondary Adhesion. — When two granulating; surl'aces are brought together 
 and union takes place lictwec!i them, /lealiin/ hi/ •' xtcoin/tin/ ml/icsio/i," or hy t/ic •■ lliinl 
 intent inn." is said to occur. The process of rej>air, under these circumstances, is similar 
 to that of imnu'diate uv adhesive union, the two layers of granulations adhering, either 
 directly or hy means of some new material, as two surfaces of divided tissue. 'I'he cafiil- 
 laries and cmliryo cells, under both circumstances, undergo changes such as have been 
 described. For this form of union to take ])lace, the granulations, however, must be 
 liealthy. 
 
 Scabbing. — ^\'lleM wounds Ileal •' 1)1/ seiil/ljiiit/," granulations do not form. In this 
 proces.s the reparative material which is poured out undergoe.s at once similar changes to 
 tho.se already described as taking place in adhesive union, and the wound cicatrizes rap- 
 idly beneath the scab ; for the .serum of the blood, when cffu.sed on the surface of a 
 wound, is of a highly plastic character, and quickly coagulates to form a film of a j»ro- 
 tective nature, under which repair may rapidly proceed, the embryo cells, with this — 
 Hunter's '' plastic lymph"' — being the medium of repair. The treatment of sujierficial 
 wounds is based upon the knowledge of this process, and the value of felt, cotton-wool, 
 or any similar material, when applied to an open wound, entirely depends upon this 
 plastic property of serum. Repair by scabbing is doubtless the best form of healing, 
 although it is, uiii'nrtuiiatcly. somewhat rarely obtained. 
 
 The Nature of the Heahng Process is physiological, and resembles closely that 
 of development and growth. The changes in the cell-elements which have been described 
 in repair, and the gradual development of the most elementary tissue into cicatricial 
 tissue or higher structures of the human body, are similar in nature, if not in form, to 
 those which are witnessed in the embryo when the blastoderm cells, or primary nucleated 
 mass of protoplasm, in the ovum, grow, develop, and differentiate into the various struc- 
 tures of the human animal. 
 
 For the healing processes there must be a sufficient blood supply for nourishment, and 
 there mu.st likewise be a regulating force to control and direct the formative process ; 
 and this lorce doubtless comes from the nerves. 
 
 When the vascular supply is deficient, growth or development must suffer and the 
 physiological process of repair cannot go on; when the vascular supply is in excess, 
 what would have been a physiological becomes a pathological process, and the part 
 undergoing repair after injury is said to be "inflamed." The process of construction, 
 under these circumstances, ceases, and that of (lesfmction may ensue ; or there may be 
 changes in the now inflamed but formerly repairing wound or granulating surface, which 
 will be considered under the heading of '• Diseases of Granulations.' What I would 
 now impress upon the reader is that whatever action is required for the healing proce.«s 
 is physiological, and is just equal to its purpose ; when it is excessive, it becomes patho- 
 logical, and is known as "inflammation." Inflammation, when it attacks a wound, at 
 first checks repair, and later on brings about disorganizing changes ; inflammation, under 
 all cireumstanees. has a destructive tendency. 
 
 Regeneration of Tissues. — It has already been pointed out that the proce.«.«e.s 
 of repair are identical in all tissues, that the re])arative process in bone or muscle, integu- 
 ment or tendon, capillary or nerve, is the same, such modifications alone showing them- 
 selves as necessarily appertain to the histology of the tissues ; and it is well that this 
 physiological truth should be fully recognized. At the .same time, it is to be e<jually 
 recognized that all tissues are not formed out of cicatricial or connective tissue, but that 
 the higher forms of structures, such as muscle, nerve, bone, etc.. are repaired by the 
 regenerating influence of the injured tissue itself, new cells springing or growing by a 
 kind of budding process from the divided ends of the injured part, the new cells in con- 
 tact with or poured out by the injured tissue, whether as embryo cells, connective-tissue 
 cells, nerve cells, mu.scle cells, or bone cells, being so influenced by the tissue with which 
 they are in contact, and from which they probably originated, that they anatomically 
 partake of its nature and bring about its repair. 
 
30 SOURCES OF INTERFERENCE WITH HEALING OF WOUNDS. 
 
 Repair of Muscle. — When muacnlar h'ssHc is wounded or more or less destroyed, 
 0. Weber tells us that it may be restored, and that the young muscular fibres are formed 
 out of the old by the division of the protoplasmic material of their extremities, the repair 
 of muscle being thus brought about by agencies closely simulating those of fcetal develop^ 
 ment. Gussenbauer gives a drawing of the process. Billroth, however, asserts strongly 
 that he has never seen anything which he could regard as a re-formation of muscular 
 fibres, and that the cicatrix in muscle is almost entirely connective tissue,' the extremi- 
 ties of the muscular fibres, after division and repair, uniting with the cicatricial tissue in 
 the same way as they do with the tendons. My own observations go to confirm those of 
 Billrotli. 
 
 Repair of Nerves. — There is good reason to believe that an injured, or even a 
 divided, nerve may be thoroughly repaired, since conclusive evidence has in recent times 
 been adduced to prove that such a large trunk as the median, the ulnar, or the great sci- 
 atic may be divided, and subsequently so joined by surgical skill as to secure, after the 
 lapse of a certain interval of time, perfect union of the divided ends, as proved by the 
 complete restoration of the functions of the nerve in their phvsiological perfection.'^ 
 
 It is likewise true that new cicatricial tissues become sensitive, and that parts 
 which by accident or operation have been deprived of the influence of one nerve regain 
 their sensibility, either by the growth of new nerves, or by the assumption on the part 
 of another branch of the same nerve or of another nerve of the physiological functions 
 of the one that has been destroyed. 
 
 From these facts the conclusion is clear that nerve tissue must be regenerated, and 
 that the divided ends of nerve must reunite by new nerve material. It seems, moreover, 
 highly probable that new nerves may develop. In a physiological point of view, these 
 facts are not only very remarkable, but they tend to demonstrate the perfection of the 
 reparative process, since, to allow of the conduction of nerve force to and from the 
 nerve centres, very powerful conductors are unquestionably required. 
 
 The process by which this repair is brought about has been carefully studied by 
 SchiflF, Hjelt, and others, and is much after the following fashion, as given by Billroth -.^ 
 " There is first of all a degeneration of the medullary sheath, possibly also of the axis- 
 cylinder, for a certain distance from the injury, which is quickly followed by the pro- 
 duction of cells in the neurilemma ; these develop into spindle cells, and spread into the 
 tissue which intervenes between the nerve fibrils, and which extends also between the 
 cut extremities of the nerves. From these cells, as in the embryo, nerve fibres are 
 developed, and these nerve fibres ultimately cannot be distinguished from ordinary nerve 
 fibres." 
 
 Sources op Interference with Healing of Wounds. 
 
 The diff'erent modes of healing, and the processes by which injured tissues are 
 repaired, having been fully described, I propose to consider the causes that interfere with, 
 retard, or prevent repair ; and these may be found either in the " ivovvd itself,'' in the 
 " sithjert of tlie wound," or in " its treatment." 
 
 Local Causes. — Among the causes which exist in the wound itself, the p?'ese?ice 
 of (nil/ foreign matter whatever must be placed first, since it is clear that where such is 
 found, even to a limited extent, repair by immediate, primary, or quick union is impossi- 
 ble. The foreign matter not only by its presence mechanically prevents the adhesion of 
 the surfaces between which it is placed, but also acts as an irritant or as a promoter of 
 septic changes, and thus excites an action in the wound which is not reparative, but 
 inflammatory. The truth of this general rule is not disproved by the fact that in excep- 
 tional cases foreign bodies become encysted in tissues and give rise to but little trouble. 
 
 The occurrence or j)ersistence of hleedlng in the wound is a second local cause of non- 
 repair, the reparative process not commencing until all bleeding, even capillary oozing, 
 has been arrested. When the hsemorrhage is great, this interference may be serious ; 
 and even when little, it is enough to retard and prevent the reparative process from being 
 carried out. Blood, if eff'used to any extent between the sides of a wound, interferes 
 with the reparative process much in the same way as does a foreign body, and forbids all 
 healing by quick or primary adhesion. If eff'used in very small quantities between the 
 divided surfaces, it may at times possibly change into cicatricial tissue and form a band 
 of union between the divided parts, and under these conditions it may become organized, 
 
 ' Syd. Soc, Billroth, Surfj. Path., vol. i. s. 151. 
 
 ^ Vifh. Dr. Weir Mitchell in the American Journal of Med. Science for April, 1876; Clinical 
 Soclely'x Trans., vol. xii. 'Billroth, vol. i. p. 152. 
 
sofriich's OF isri:iii'i:itES'('i': wrru iii.m.im; of wovsds. .31 
 
 as wlit'ii jiiMircil uiit nil tin- hrain ; l)iit. as a nili', llic cniisiini nf iiiiich hlooj into u 
 wniiiiilcii |>art is a rctanlcr of n-pair or a cause of" iioii-rf|iair. 
 
 Wlicii a wound lias to lical l>y granulation, a dot ol" hlood. as a (.'overin^. kept aseptic, 
 is ItcncHcial. .sincr it ai'ts as a protector to tiie surface of the wouiul and allows the 
 ^ranulatinu; process to f^o on uninterruptedly. It has heen saiti that such clots hecoiiie 
 oriranized, hut it is far more prohahle that llicy simply act, as ahove descriheil. as a pr<j- 
 tection to surl'aces that are ^'ranulatinu. 
 
 A ri)iifiisr(/ tir Inn liilrii surface in a wound is a third local cause of non-repair, and it 
 is well to recounize this imjtortant fact, since, with such a coiiditii>n of parts, the surp;eon 
 knows that immediate or primary union of the wotmd is not t(» he expected. I'nder 
 these circumstances a lim? of treatment will he indicated which will he far more likely to 
 he efficient than one l)ased on the hope of ohtaining <|uick repair. When the contusion 
 or hu'cration is sliiiht, tin; hope of securing; ju-imary unioti of the divided parts may, 
 indeed, he entertained ; hut when it is threat, such a hope would he alto^^ether <rroundle»8. 
 The gradations of contusi<in and laceration hetwecn these two extremes are numherle.ss ; 
 but it will he wiser for the surgeon to believe, and upon such a belief to act, that in ct)n- 
 tiised and lacerated wounds the prospect of obtaininjj^ quick union is slight, than for him 
 to act upon an opposite view, and attempt to obtain, in .severe cases, a mode of healing 
 the occurrence of which is improbable if not impossible. 
 
 Tn a contuse*! or lacerated wouml the surgeon should mentally .see dying or dead 
 matter which of necessity must be separated from the living ])arts and got rid of, either 
 by molecular disintegration or by a coarser slougliing process, before the act of healing 
 can rightly be .said to begin, and under these circumstances he will at once recognize 
 the futility of entertaining a hope of obtaining the repair of the wound by quick 
 union. 
 
 Constitutional Causes. — Of the causes of non-repair which are to be put down 
 to the account of the subject of the wound, '■'• ngc'' is all-imp(jrtant, the reparative pro- 
 cess in a man the wrong side of fifty being conducted with less vigor than in one who is 
 on the right. In the very old repair is at its lowest mark. The same remarks are applic- 
 able to patients who are the subject of '• orfjdnic discum^ or of dpgeniratue chdu'ips in 
 their tissues, and especially to fat and soft-tissued people, the old in years or in infirmi- 
 ties not possessing the recuperative powers of the young and vigorous. Under these 
 circumstances, in the case of a wound resulting from accident or operation in a patient 
 over fifty years of age or in one in ill-health, it would be wrong for a surgeon to expect 
 or to rely upon securing a mode of repair which in a younger or healthier subject he 
 might reasonably look for. People who are advanced in years or who are feeble from 
 frailty or disease, particularly visceral disease, have no, or an insufficient, capital at the 
 bank of health to draw upon. Of all subjects for wounds, whether accidental or opera- 
 tive, the ha})itu:il drunkard is the worst. 
 
 Defects in Treatment. — Of the causes of non-repair which are to be attributed 
 to treatment, a want of due care in maintaining the injured or wounded part in a state 
 of rest claims the first place ; for in such a delicate process as is that of repair it is plain 
 that in any movement of the injured part, whether in the way of separation of surfaces 
 or by manipulation, the process may be interfered with or retarded or the work already 
 accomplished may be undone. Tt is certain that the best and most rapid repair of an 
 injured part takes place when the wounded tissue is kept in an absolutely immovable 
 position, and when the wounded surface is protected from all external influences that can 
 possibly interfere with the physiological reparative process. It therefore clearly behooves 
 the surgeon to have this great truth always before him, in order that he may adapt his 
 treatment to the requirements of the case, and not have to blame hini.self for a want of 
 care in maintaining that ab.solute immobility of the wounded or cut part which is essen- 
 tial for rapid, or even good, repair. 
 
 Tn the treatment of fractures the evil effects of want of rest and immobility of the 
 broken bones are well exemplified, but it is to be remembered that the same want of rest 
 and immobility is as pernicious in wounds of the soft as in those of the hard parts — in 
 wounds of the surface as in those of the deeper structures. The term '• want of rest " 
 is here used in its fullest sense, as want of that thorough immobility of tissue and non- 
 interference which are all-important for the rapid ]terfection of the physiological repara- 
 tive process. 
 
 Gaping of W^Ound. — Again, if the edges of a wound are allowed either to gape 
 or to have too much tension upon them, repair will be interfered with, the parts in both 
 cases, from either want of care in their adaptation or want of caution in not making due 
 
32 TREATMEST OF WOUyDS. 
 
 provision for the escape of the redundant fluids (drainage), or from some over-action 
 (inflammation), not being allowed to remain at rest and undergo repair. 
 
 Oier-ucfioii in the vessels of a part which is undergoing repair — that is. inflammation 
 -^always has an evil influence. When it shows itself early in the case, it prevents 
 repair; and when manifested at a later period, it retards the healing process, or even 
 causes its retrogression. Indeed, under all circumstances when the vascular action of a 
 part which is undergoing repair exceeds what is essential for the steady perfection of the 
 process, the repair of that part is interfered with. Inflammation, when it attacks a 
 wound, at first checks repair, subsequently undoes it. and at a still later period brings 
 aibout di.sorganizing changes ; under all circumstances it has a destructive tendency. 
 
 The student, having learned how wounded parts heal by nature s processes, and more 
 particularly how .simple incised and open wounds are repaired — and having, moreover, 
 learned to recognize some of the most important influences which retard, if they do not 
 arrest, repair — will readily understand the more favorable conditions under which repair 
 can be carried out. and, what is more, will at once appreciate the surgical requirements 
 of the case he may have to treat, so that, as a surgeon, he may know when and where 
 to apply his art. how he can help nature in her beneficent action, and how he can best 
 guard against the intrusion of any outside influences that may tell asainst the steady 
 progress of the reparative process. For it cannot be too strongly asserted that the best 
 surgeon is the one who best understands natural processes in the repair of parts and who 
 knows how to use them to the greatest advantage, who recognizes the fact that these 
 natural processes are exact and when applied to the healing of wounds undeviating : who 
 knows that if he is to utilize these natural processes to the full he must bring up his art 
 of curing to nature's line, under the conviction that nature never .systematically bends her- 
 self or puts forth her hand to help the curer. tha,t she never deviates from her path — that 
 if, using Dr. Richardson's words, •• we do not molest her she goes on. as we say, naturally 
 toward a cure ; if we molest her a very little, she goes on. and the molestation is but little 
 shown ; if we molest her vehemently, she still goes on. showing molestation in proportion 
 to disturbance, nature under all circumstances going her own way. caring just as little for 
 ease as for pain, for life as for death.'" When a bone is broken, nature will heal it quite 
 irrespectively of the position in which it is placed : when a knuckle of bowel is strangu- 
 lated, nature will cast it ofi" quite regardless of the eff"ects of such a sloughing act. But 
 the surgeon who knows this knows, moreover, that the same natural process will work on 
 when the bone is " set " in a right position and maintained there by art. and that the 
 slouehing may be avoided when the strangulated bowel is relieved by art from its false 
 position and placed where it can be best repaired by natures means. 
 
 Treatzviext of Wouxds. 
 
 In the treatment of a simple cut or incised wound in which there is no dirt or foreign 
 matter to keep the edges of the wound asunder and to act as an irritant, in which there 
 is no hjemorrhage beyond capillary or venous bleedings, which can be aiTested by eleva- 
 tion of the part, moderate pressure, or the application of a cold or hot sponge, the sur- 
 geon has simply to cleanse the wound, bring its edges carefully together, and adopt means 
 to keep them so : while at the same time he makes such provision for the protection of 
 the wotind as may secure it from injury from without or within, and may allow the 
 reparative process which has been described as taking place in primary union to be 
 quietly perfected. 
 
 In more xev-re irounds a similar practice is to be advocated, though some care may be 
 called for in cleansing the wound, more caution required in the arrest of bleeding, and 
 more ingenuity demanded in bringing the edges of the wound together, as well as in so 
 fixing the injured part in position that the patient may be comfortable, while the wound 
 is kept immobile and protected from such injurious outside influences as would interfere 
 with the healing act. Provision, moreover, will have to be made for efiicient drainage — 
 that is, for the free exit of such sanguineous or serous fluids as are commonly exuded 
 after severe wounds or operations, and the retention of which always proves injurious. 
 
 Upon each and all of these points, therefore, a few lines may not be without value. 
 
 On Cleansing Wounds. — After full examination of a wounded part, and careful 
 consideration as to the mode of its production, the extent of injury, and the require- 
 ments of the case for cure, the wound should be cleansed. This should be efl"ected with 
 all completeness and gentleness, .since, on the one hand, everything like a foreign body 
 between the lips of a wound would of necessity prevent quick or primary union, and 
 
ti:i:atmi:st of worsDSi. 
 
 33 
 
 would ill all pi-nl.al.ilit y I'liivf injiuiniis t<i the .sul).se(|U(Mit prop^oss of the case; wliilo, 
 
 on the other iiaiid, aiiytliiii;.' like rou^diiiess wouM he (Iftrimeiilal to thr already injiircil 
 
 tissues. 'I'd etVect this eleausinir with i:en- 
 
 tleness, a stream of water medicated with 
 
 soiue atitise|tti(t is the hest means for tlie 
 
 surfreon to i-mploy. ami this stream may he 
 
 broutrht to hear ujion the part hy iisinjr tlie 
 
 irrij;atiuj;-hottle or the irriiratinfr-ean (Fifr. 
 
 W) I luive here tiirured. The stream of 
 
 fluid washes away hlood with all lijrht for- 
 
 eijzn matter, and what cannot he washed 
 
 away may he removed with finjit'rs or \\)Y- 
 
 cej>s. In j;unshot wounds special forceps 
 
 and otlier instruments may he rerpiired. 
 
 Those who helieve atmospheric trerms to 
 he the (diief cause of inflammation and sup- 
 puration, or of most, if n(»t all. tlm ills to 
 wliieh wounded flesh is heir, will employ the 
 means that are supjtosed to he capable of de- 
 strovinj; such maliuiiant foreign visitors, and 
 for this purpose will use the spray of carbolic 
 acid, one part in forty, or other antiseptic, to 
 kill the irernis in the air as they approach 
 tlie wound, and will dress the wound with the 
 carbolic lotion, carbolic irauze, protective, and 
 waterproofiuLT. according to directions lairl 
 down in a future page (vi(h^ Listerian method 
 of dressino; wounds) ; whereas those who 
 disregard atmospheric germs, and yet highly value means for purifying wound surfaces, 
 will use antiseptic irrigation of the wound with a lotion of carbolic acid 1 to 20, of 
 thymol 1 to 100(1. of chloride of zinc 20 grains to tlie ounce (originally used by Mr. C 
 de Morgan many years ago), or of iodine, made by adding 10 drops of the liquor iodi to 
 the ounce of water. I have employed the iodine lotion for years, and prefer it to any 
 other. It is always at hand, and is both simple and effectual as a wound cleanser. The 
 lotion may be used warm, and it has the advantage of not only cleansing the wound in 
 the fullest sense of the term — for iodine is an antiseptic — but it has a marked tendency 
 to arrest all capillary bleeding or oozing. I use it in about the proportions given above, 
 but the best practical guide is to pour the solution or tincture into a basinful of water, so 
 as to make tlu' lattt'r of a light sherry color. 
 
 Arrest of Bleeding. — It is well that haemorrhage should be effectually arrested 
 by some of the various means which the surgeon has at his command before the edges 
 of a wound are brought together, and it is wise to have even capillary bleeding stopped, 
 when it is possible : for blood effused in even limited (juantities between the surfaces of 
 an incised wmmd is to be regarded much in the light of a foreign body, and as forming 
 an obstacle to repair, more particularly when primary union of the wound is to be sought 
 for. Indeed, it was on this account that I was first led to employ. f(jr cleansing wounds, 
 the iodine water to which I have drawn attention, and which I cannot too strongly recom- 
 mend for general adoption. A sponge wrung out of this lotion (made with hot water), 
 and held to a wound for a minute, completely checks all oozing of blood, and tends more 
 than anything else, except prolonged exposure to the atmosphere, to the formation of 
 that glaze upon the surface of the wound which so much conduces to satisfactorv repair. 
 
 Irrigatiiig-Bottle and Apjjaratus. 
 
 On the Question of Repair by Primary or Secondary Adhesion. 
 
 When the surgeon has cleansed the wound, removed what foreign bodies may have 
 been present, and stopped all bleeding, he has to decide upon the means whereby the 
 reparative process may be best heljied, and as a primary point to determine either the 
 feasibility or expediency of attempting to obtain quick or primary ituion of the cut parts, 
 or the wisdom of looking to their repair by the slower npen^ (jruinihiting process. 
 
 When the wound is f)f the indued kind, the question is not difficult to answer : for it 
 may with confidence be asserted that, with few exceptions, in all wounds of this descrip- 
 tion, whether superficial or deep, accidental or the result of operation, repair by quick or 
 .3 
 
34 TREATMENT TO HELP QUICK OB PRIMARY UNION. 
 
 primary union is to be desired, and, what is more, may be expected if the subject of the 
 wound be healthy and not too old, and if nature's reparative process be so aided by sur- 
 gical art as to be allowed to take its course without interference. 
 
 The cleaner the cut is, the greater is the probability of its uniting by quick repair ; 
 the more ragged, contused, and lacerated the margins of the wound are, the less are the 
 prospects of obtaining primary union and the less the wisdom of making the attempt. 
 Between these two extremes are innumerable gradations. Where there is a doubt about 
 the wisdom of making the attempt to secure primary union in deep, contused, and lacer- 
 ated wounds, let the decision' be against it ; and when the doubt applies to the more 
 superficial or hopeful class of wounds, let it be decided in its favor. Care must, however, 
 be taken in these as in all cases to give up the attempt on the appearance of the slightest 
 local or constitutional symptoms. It is also necessary to bear in mind that by drawing 
 together the parts by sutures, etc., some retained blood, serum, or sloughing tissue may 
 keep them in a state of unrest^ either by tending to separate the lips of the wound and 
 exciting tension, or by undergoing chemical changes and decomposition and thus favoring 
 the production of some septictemic or pygemic conditions. For it must be recognized that 
 whilst in the cleanest incised wound there maij be no death of the divided tissues, and 
 consequently no animal matter to undergo chemical changes or putrefactive decomposi- 
 tion, in the contused and lacerated there mud (jf necessity be more or less. 
 
 When tissue dies, it must be shed or cast off fro)n the living parts before the physio- 
 logical reparative or uniting process can take its course. AYhen this dead tissue has been 
 separated from the living, it ceases at once to be influenced by the vital processes by 
 which it had been built up, kept clean, and eventually cast off; it consequently becomes 
 subject to the physical laws of all dead matter, and undergoes chemical changes — which 
 means too often decomposition. 
 
 The object of the surgeon, therefore, in the treatment of these cases of wound in which 
 the death of tissue is to be expected, and cannot be prevented, is to neutralize as far as 
 possible the evil influence of its death and probable decomposition. This is to be achieved 
 by so dealing with the injured part that the dead tissue may find a free outlet for its dis- 
 charge, and by rejecting all such applications or dressings as are likely to help putrefac- 
 tive decomposition, at the same time employing means and agents likely to neutralize its 
 pernicious influence and to control, in a measure, the process of decay. 
 
 Treatment to Help Quick or Primary Union. 
 
 To promote the primary union of a wound, the surgeon has six cardinal indications to 
 follow : 
 
 1 . To cleanse the wound. 
 
 2. To arrest all bleeding. 
 
 3. To effect coaptation'of the two divided surfaces of the wound, the deep parts as 
 well as the edges. 
 
 4. To maintain the wounded parts in a position of immobility beneficial to the natural 
 process of repair as well as comfortable to the patient. 
 
 5. To secure drainage of the wound by providing for the escape of such dead tissue 
 as may be thrown off, as well as of all fluids that are not required for repair. 
 
 6. To protect the external wound from all such outside influences as may be preju- 
 dicial. 
 
 The first two indications have been already considered — viz., the cleansing of the 
 wound and the arrest of bleeding (pp. 32, 33). In all forms of wound, and for every 
 form, of healing, attention to these points is most important ; but when quick or primary 
 union is to be expected, it is all-essential. 
 
 Third Indication : The Coaptation of the Edges and Surfaces of a 
 
 Wound. 
 
 The coaptation of the two divided surfaces of the wound may be efficiently carried 
 out in superficial or not deep wounds by means of sutures and adhesive plaster, sepa- 
 rately or combined. When, by the use of trustworthy adhesive plaster, the object sought 
 for can be obtained, sutures are not called for ; and when sutures are used, the form of 
 suture that carries out tlu> object in view in the simplest way is the best. 
 
 Interrupted Suture. — When the wound is supeyJrciaL the sutures need not be 
 introduced deeply ; but when the wound is deeji, the practice of bringing the edges of 
 
ruiiu) isDicATioy. 
 
 .35 
 
 V\r.. 1. 
 
 flo it. 
 
 How tiot to do a 
 
 The Interrupted Suture. 
 
 till' wiiiirnl, ami not the il('i"|icr |iaits, lu^tllicr is IVaiiulit with <laiii;iT, .siiicr the ic]iair ))y 
 priinarv uiiii»ii wliicli is loiikcil lur caiiiKit take place, ami lict wocii the sc)iaiat(;(l surt'aceH 
 (if till' (li'i'piT |>arts til' till' wiMiml hldnd, siTHiii, <ir iiillaiiiiiialury fluids will ciilli-ct ami 
 ^ive risi' ti» tntulilc. Ilciicc in (Iccp wiiiuids the sutures sliuiild citlier he all iiitniduccd 
 dee])ly or di'e[) as well as siiiicriieial sutures siiould he employed. 
 
 The infi'nii/tfrd (Fij;. 4) is the most useful I'onii of suture, and it is ap|)lieahle to 
 anpirflciii/ ■,\< well as to deej) wounds. It ean ]h' made 
 with a ciirvtMldr straight needle, aeetU'dini; to convenience, 
 armed with a siuj^le thread ol" well-wa.\ed silk, wire, or 
 lishing-<;ut. the tine silk line sold Ity tai-kle-iuakcrs hein^j; 
 the best tor ordinary purposes. The needle should he 
 introduced throu>;h one side of the wound ohliipu'ly from 
 without inward, and made to ])ass through the opjiosite 
 side in the rever.se direction i'miu within outward. The 
 knot of the suture slioiild he hnuiuht to one side of the 
 wound, as shown in lig. 4. In the xnpcijicidl it should be 
 inserted with sufficient depth and closeness to bring the 
 .surfaces and edges of tlie ])art accurately and closely 
 together, and it should be tied with enough Ibrce to carry 
 out these objects, but not with more, since to tie a suture 
 as a surgeon would a ligature is to do harm, as the suture 
 would cut rapidly through the strangulated tissues, and in 
 so doing irritate the ])art instead of helping repair. 
 
 In tlcrp wounds the suturse must be inserted deeply, as in hare-lip operations, and 
 introduced well away from the edges of the separated tissues, so that when they are 
 tightened the deeper parts as well as the superficial will be brought effectually into appo- 
 sition. In some cases deep and superficial sutures may l^e made to alternate. Superficial 
 sutures should include neither muscles nor deep fascia. 
 
 A double-reef knot is usually employed, but a "granny" (Fig. 137) is by no means a 
 bad one to make, since it is a slip-knot and can be tightened at pleasure by a third tie. 
 
 In the majority of cases in which sutures are employed it is an excellent plan to 
 alternate the sutures with strapping; a narrow band of the latter carefully adjusted 
 between the stitches not only materially aids the adaptation of the edges of the wound, 
 but, if well applied, tends to prevent ten,sion and to immobilize the wounded structure, 
 while at the same time it acts in the way of affording local pressure to the deeper parts 
 of the wound. In operations on the breast the advantages of this practice are well 
 exemplified. 
 
 Continued Suture, — The uninterrupted, continued, or Glover's suture (Fig. 5), 
 the stitch of the sem|»«;tress, is valuable in all cases in which a very close aiid accurate 
 adaptation of the margins of the wound is wanted, as 
 in wound of the intestine, as well as in those of the 
 eyelids and face generally ; indeed, a clean wound of 
 these parts, superficial or deep, may be so accurately 
 and well adjusted by means of a fine needle and 
 thread as to leave but a minimum of scar. In opera- 
 tions about the lip the same remark is applicable, 
 although in these care .should be observed to intro- 
 duce the sutures deeply and well away from the mar- 
 gins of the wound. In operations for phymosis in the 
 adult this form of suture is likewise of great value, as 
 it not only expedites recovery, but does much to make 
 the result of the operation more artistic. In these 
 
 cases the fine carbolized gut suture may be used. The stitches should be removed on the 
 third or fourth day. They may often be taken out of the face on the second. If left in 
 long, they are ajit to set up irritation and ulceration. 
 
 Twisted Suture. — The twisted suture (Fig. G) is of value in certain operations 
 on the lijis and cheeks, and in other parts where difficulty is experienced in bringing the 
 parts together, since by its use more force can be brought to bear upon the margins of 
 the wound, and their adaptation can thus be rendered more perfect. This form of suture 
 was in former times the one commonly employed in hare-lip operations, but it is not so 
 now. I have for years discarded it in favor of the interrupted suture of silkworm gut, 
 or wire, and employ it only in cases in which exceptional difficulty is experienced ia 
 
 Fig. 
 
 The Continued Suture as .Applied to the 
 Intestine. 
 
36 
 
 THIRD INDICATION. 
 
 bringing the parts togotlior. It is iisoful. liowever, in (•liciluplastic operations, as ■well as 
 in the Pirogoff anil Cliopart's an)putations. To apply it, some fine pins with flat heads, 
 
 silk, anil cutting pliers are wanted. The pins are em- 
 FiG. 6. ployed to bring the surfaces of the wound in contact, 
 
 and their points should be introduced half an inch or 
 ninre from the margin of the wound, and passed deeply 
 and obliquely, in lip operations, through the thickness of 
 the ti.ssues down to, but not through, the lining mucous 
 membrane (Fig. G). They should then be made to pass 
 through the opposite side and brought out through the 
 skin at a corresponding point. A piece of silk passed as 
 a figure-of-8 should be twisted around the two ends. 
 The wound may next be drawn together; and should the 
 apposition of the surfaces be imperfect, the pins should 
 The Twisted .Suture. be taken out and the parts be readjusted, and in this lies 
 
 ■ the great advantage of this form of suture. After the 
 silk has been tied in knots and the ends cut off', the points of the pins should be removed 
 and the soft parts protected from the ends, if necessary, b}' the introduction beneath them 
 of a small piece of lint or strapping. Instead of silk being twisted round the pins, a sec- 
 tion of an india-rubber tube in the form of a ring has been employed by 3Ir. Kigal, and 
 the late W. L. Atlee of Philadelphia. The ring is slipped over the ends of the pin, and 
 serves by its elasticity to keep the parts together. 
 
 Quilled Suture. — This form of suture (Fig. 7) is applicable where deep wounds 
 have to be Vtcil held together along their whole line, and more particularly for a brief 
 
 period, .say two or three days. In 
 Fig. 7. ruptured perineum it used to be in 
 
 general use combined with super- 
 ficial sutures, but the interrupted 
 sutures of silkworm gut, introduced 
 well away from the margins of the 
 wound and inserted deeph, are 
 ]>robably to lie preferred. 
 
 For the application of this su- 
 ture, a strong curved needle with 
 an eye at the end and threaded is 
 to be inserted at least three-quar- 
 ters of an inch from one margin of 
 the wound and made to pass well 
 down to its depths, then brought 
 out through the other margin in a 
 corresponding line. The loop of the 
 suture should now be caught and 
 held and the needle withdrawn ; a ])iece of bougie, cut the required length, being intro- 
 duced into the loop, is fixed by drawing the free ends of the ligature home (Fig. 7 a). 
 A second or third suture can be applied in the same way. A second piece of bougie 
 ought then to be tied on the opposite margin of the wound, the parts having been well 
 cleansed previously and carefully adjusted. The surfaces of the wound are only to be 
 held closely in apposition, and must not be pressed too firmly ; otherwise, the bougies 
 will set up ulceration. Superficial sutures may subsequently be intro- 
 duced into the edges of the wound (Fig. 7 B). 
 
 For the quill suture good fishing-gut is better than silk or wire, as 
 it is strong and unirritating. Before u.se it should be soaked in water, to 
 make it limp ; it can be readily tied or fastened with a .shot. The loops 
 of the (juill suture .should generally be divided on the fifth or sixth day, 
 but this depends on the amount of irritation caused by the bougie. 
 
 The Button Suture, as a variety of the quill, is useful in some 
 amputations, as the thigh, where the surgeon is desirous of keeping the 
 bases of the flaps together, and in breast cases and in hare-lip or other lip 
 operations (Fig. S"). 
 
 Material for Sutures. — With respect to the material used for 
 sutures, silk, wire, silkworm gut, prepared catgut, or horsehair are each 
 good in certain cases when rightly selected. "When there is little tension on the sutures, 
 
 The Quilled Suture. 
 
 Fig. 8. 
 
 Button 8uturt 
 
For inn isinrAnny. 37 
 
 silk or wire may be iniliffi-rently employe*!, the umi»unt of irritutiori exerted by one or the 
 otiier materiul ile|ieii«liii^ more upon tension than on any other condition. I have hiii^ 
 proved this to n>y own .satist'uction by testing both form.s of suture in the same subject 
 through a h»nj^ series of cases. 
 
 ill jilnstic operations silkworm ;rut well .softened in water before use is to be recom- 
 meiideil ; it holds well, and seems to irritate far U'ss than any other material. In ca.ses 
 of ruptured perineum and in operations for va<:iiial tistula and fissured |ialate it should 
 always be used. In the latter class of cases, where the .soft palate alone is involved, 
 horsehair is good, but it is not strong enough to resist much teiisi(»n. 
 
 In plastic operations, in which some skill may be called for in adjusting the parts, wire 
 sutures may be seb'cted, since they can be twisted and untwist«'d with facility, and the sur- 
 geon can coiisc(|ueiitly readjust the margiii> of the wound as re<juired to his .satisfaction. 
 
 Prepared catgut is not a reliable material f(jr sutures, since it is uncertain as to its 
 retaining power and is apt when sodden to yield ; it is, however, u.seful as a suture in 
 holding j»arts together for a brief period where there is no tension, and where there may 
 be a difficulty in removing the stitches subsequently. In operations on the penis it is 
 of special value. 
 
 Value of Pressure. — The effectual carrying out of the third indication in the 
 treatment of inciseil wound.s — viz., the coaptation of the two divided surfaces of the 
 wound, deep parts as well as edges — is not. however, always to be accomplished by means 
 of sutures and strapping, however well selected and applied these may be. Other means 
 are constantly demanded, and of the.se well-directed j>ris.siire is the most important, as 
 ably advocated by (iamgee. Indeed, the value of pressure in the treatment of all 
 wounds is worthy of more consideration than it has received. By it the surfaces of 
 divided parts are kept together, and particularly the deeper surfaces : mobility of the 
 injured tissues is checked, if not prevented; the vessels of the wounded parts are sup- 
 ported; and the evil influence of blood-stasis, with its effect, effusion, is neutralized. 
 Under the.se circumstances repair is helped, and nature's proces.ses are permitted to go on 
 under more favorable conditions. With this view of the value of pressure, well applied 
 pads of lint, absorbent cotton-wool, gauze, or sponge, saturated or not with .some anti- 
 septic drug, should be carefully adjusted over the flaps of all wounds when such exist, 
 and over tlie surfaces of others. The.se pads are kept in position by means of strapping 
 or bandages, aided by splints when the extremities are involved. After the removal of 
 a breast or tumor, the value of a well-adjusted pad, and more particularly of sponge 
 wrung out of iodine or carbolic water, cannot be too highly praised. After an amputa- 
 tion, the use of a splint adjusted to the stump, and pressure well applied to the bases of 
 the flaps, not to the edges, should never be omitted. 
 
 Fourth Indication. 
 
 The Maintenance of Wounded Parts in such a Position of Tmmn- 
 biUty as may be Favorable to the Natural Process of Repair and 
 
 Comfortable to the Patient is the fourth indication ill the treatment of incised 
 wounds : and. to say the least, this is as important as the preceding indication, since, if 
 neglected, the benefit that might be expected from efficiently coaptating the wound could 
 not be realized, and the process of repair in the wounded part would of necessity be 
 checked, if not altogether prevented. 
 
 To carry out this indication. immoliiUtt/ of the wounded part is of the first importance, 
 and its position next. The position is always selected with the object of giving ease to 
 the patient and of preventing pain : of relaxing the wounded tissues, and so guarding 
 against any tendency to bring about a separation of the edges of the wound, as in cut- 
 throat cases; and last, but not least, of encouraging the return of the venous blood from 
 , e wounded parts toward the heart. Thus, in wounds of the trunk the horizontal posi- 
 tic is the right one to be maintained, and in those of the extremities flexion and eleva- 
 tion of the limb ; in wounds of the lower extremity the foot should be kept higher than 
 the knee, and the knee than the hip ; and in those of the upper extremity the .same prin- 
 ciples of practice should be fidlowed. the elbow being generally flexed. Under all cir- 
 cumstances wounded limbs should be fixed upon splints, with the view of immobilizing 
 them, and, as a rule, they should be swung. This practice adds greatly to the comfort 
 of the patients by allowing them to move their trunks without their wounded extremities, 
 and without, therefore, interfering with repair. It should be added, however, that the 
 question of position ought always to be considered in reference to x\iQ fifth indication — - 
 
38 FIFTH IXDJCATTOX. 
 
 namely, the necessity of providing efficient means for the removal of the superfluous 
 fluids of the part, and for the escape of disintegrated dead tissue which may have to h-i 
 discharged, or, in other words, for draliiage. 
 
 Fifth Indication: Drainage. 
 
 Drainage, or the making of due provision for the escape from the wound of disin- 
 tegrated dead tissue, with such fluids as are not required for repair, and which, if left, 
 might prove injurious, is of primary importance in the treatment of all, and more par- 
 ticularly of deep, wounds. It should never escape the attention of the surgeon. In 
 scalp wounds and those about the eyelids, though they may appear trivial, it is of as 
 much importance as it is in the wounds that involve deeper parts and seem more severe ; 
 for in the one case, as in the other, pent-up fluids not only separate tissues which are 
 intended to unite, give rise to pain b}' producing tension, and consequently cause consti- 
 tutional irritation, but they are prone to excite inflammation in the part, and ultimately 
 to undergo septic changes, which in their turn may give rise to blood-poisoning in the 
 form of septicfemia or pyaemia. 
 
 No other than trivial wounds, consequently, should be completely covered in. and 
 deep ones very rarely. Some corner, and preferably that which is the most dependent — 
 some interval between the sutures or strips of the pla.ster — should always be left open 
 for the escape of disintegrated tissues and of superfluous fluids, such as blood or serum, 
 and where deeper structures are involved some conducting material, or '' drainage-tube," 
 should be introduced. The best is a tube of india-rubber perforated at intervals (as 
 originally suggested by Chassaignac. 1855). of a. size varying with the cavity or wound 
 to be drained ; but in some cases a strand of carbolized catgut or horsehair, a roll of gutta- 
 percha skin, or a piece of lint saturated with carbolic or terebene oil will do as well. In 
 abdominal cases, as after ovariotomy, a perforated glass tube is of great value, while 
 under other circum.stances an elastic catheter will answer the purpose. The particular 
 mode of accomplishing the object is of little importance, so long as the object itself is 
 secured. 
 
 Caution in Use of Drainage -Tube. — In using a drainage-tube, however, the 
 surgeon nfust remember that it is not to be made a seton. and that the sole justification 
 for its use is to drain the fluids from the deep tissues. For this purpose the tube is to 
 be made to dip deeply enough into the wound, but no more : it is not to be made a cause 
 of irritation. The size of the tube is to be regulated by the requirements of the case ; 
 several short tubes are often better than a long one. Care is also to be taken that the 
 outer ends of the tubes are left free ; when covered, they .should be covered but lightly, 
 and then with some absorbent cotton, oakum, sponge, or gauze. As a rule, however, 
 they should be left open. 
 
 Position of Tube. — In using the tube, when the end is cut off" level with the 
 wound, the outer extremity should be held by means of loops of carbolized silk, perfo- 
 rating its walls and secured externally by strapping or other means. The tubes should 
 always be introduced at what will be the most dependent part of the wound when the 
 patient is in the recumbent position, and they should be taken away as soon as they have 
 answered their purpose. When quick or primary union has taken place, they may safely 
 be removed at the end of twenty-four or forty-eight hours ; but when suppuration is 
 present, they must be left longer — sometimes even till the cavity has nearly closed. 
 A drainage-tube should, however, be shortened as rapidly as the progress of the ca.se will 
 allow, the shortening of the tube and the clo.sing of the cavity of the wound from below 
 going on together. 
 
 It is to be noted that at the present day the use of drainage, whether by tubes or 
 other material, is suggested with the view of jrrevcntwg suppuration in the treatment of 
 deep wounds ; whereas in former times, when Chassaignac introduced his tubes, it was 
 for the treatment of wounds and cavities in which suppuration already existed. 
 
 The value of the principle is. however, equally great in both classes of cases. When 
 carbolic acid is used as a wound-dres.sing. whether as a .sprav or as a lotion, or when 
 chloride-of-zinc lotion is employed, the use of the drainage-tube is more necessary than 
 it is when other forms of dres.sing are employed, since under the stimulating influences 
 of the.se drugs there is. as Lister tells us. more eff"usion of plasma than is to be looked 
 for in other circumstances. 
 
 Caution in the Closure of Wounds. — Whenever a wound is dosed, with the 
 view either of obtaining rapid or primary union or of converting an open as far as possi- 
 
o.\ Tin: sh-cn.M) ni:i:ssrya of a cr.oshn wnrxn. 39 
 
 ble intii a siilx-iitaiuMdis wuhihI, the iiutst careful iri.speetioii is called for, tr) fruard apainKt, 
 and even to anticipate, truiiMe. In these cases the wound siioiild he opened <»n the sli;rht- 
 est approach ol" local tension or overaction with elevation of temperature and traumatic 
 fever, since su(di local and constitutional disturhance will jiroltalily he i'oiind t«» he due to 
 tin- retention of some of the fluids of tlu; pari that are in excess of what i.s wanted ibr 
 rejiair, and can he relieved only hy the evacuation of su(di retained suhstanccs. 
 
 Sixth Indication: The Protection of the Wounds, etc. 
 
 The protection «d' the external wound from all such otitside influences as may be 
 prejudicial to the proL'ress of natural repair is the sixth and last indication for the sur- 
 f^eon to follow ; and it is in itself as important as the five which have preceded it, since 
 it includes the use of all means hy wliich the wound can he protected from outside 
 injury, as well as the dressing proper or covering: of the wound. 
 
 For purposes of protection, most wounds re(|uire a coverin<r; and when they are on 
 the extremities or other exposed parts, they also need some cradle or other mechanical 
 uiipliance to ki-e]) off the weight of the hedclothes. In wounds of the face, however, 
 coverings are rarely re(juired ; for all surgectus are familiar with the fact that there are 
 no wounds, operative or accidental, that do so well as these without any external appli- 
 cation, provided that they have been carefully brought together and adjusted. Indeed, it 
 IS probably from a knowledge of these f:icts that the "/len nu'f/iod .of treating wounds ha.s 
 been advocated. This method cannot, however, be recommended, except for wounds of 
 the face. For some years past I have been in the habit of dressing all wounds with dry 
 absorbent lint or with lint soaked in a mixture of tercbene one part and olive oil three 
 parts, and have every reason to be satisfied with the practice. I simply cover the oiled 
 lint with a second piece of dry lint and fix the whole with a retentive bandage, room 
 being left for drainage in all cases in which quick union is not to be expected, either by 
 loosely covering one corner of the wound which is left open or by perforating the lint 
 covering the wound, to allow of the protrusion of the end of the drainage-tube. Cotton- 
 wool of the absorbent kind is then arranged about the tube, to absorb all fluids that 
 escape, but not in any way to arrest their flow, since to insert a drainage-tube and then 
 smother up its orifice seems inconsistent practice. 
 
 When the sf)ray-and-gauze system (^Liskri'am) is adopted, all the precautions required 
 for security must be observed, the principle upon which this system is based being one 
 of exclusion, not only of air, but of all germs that nuiy be floating in it. and which are 
 supposed to be the cause of suppuration and of the decomposition of organic fluids. 
 
 Wet applications, and more particularly watery ones, are now seldom used, and cannot 
 be recommended, since it is well known that by moisture decomposition is encouraged. 
 When they are employed, they should be medicated — that is, they should contain some 
 drug which has an influence in preventing or arresting decomposition, or in neutralizing 
 the evil effects of the chemical changes which are sure to take place either in the con- 
 tused or devitalized tissues or in the poured-out fluids, whether blood, .serum, or pus. The 
 best of these drugs are chloride of zinc, carbolic acid, boracic acid, alcohol, terebene, 
 thymol, iodine, the permanganate of potash, and iodoform. 
 
 On the Second Dressing of a Closed Wound. 
 
 No fixed period can be named when the first dressing should be removed from and a 
 second applied to a wound which is being treated with the view of oVjtaining healing by 
 " quick " or primary adhesion. But this is certain — that no interference .should be 
 allowed under a week unless there is some indication, either in the form of local discom- 
 fort or pain, or some constitutional symptom, such as an elevation of temperature with 
 febrile disturbance, to justify the act. In truth, to use a legal phra.se, the surgeon 
 should in all cases show cause why he should interfere before he does so ; for it is not to 
 be denied that in changing dressing, even with the gentlest and most skilled manipula- 
 tion; there mu.st of necessity be some interference with the reparative process, some slight 
 tearing away of the new reparative material, some taking away of support where support 
 is essential or removal of Local pressure where such is needed ; in fact, there must always 
 be some injurious influence upon the healing part which should not be permitted without 
 a compensatory good effect. 
 
 A wound treated for repair by juimary adhesion, if left alone, will probably, under 
 favorable circumstances, heal within the week ; and a large wound, such as that made in 
 
40 ON THE SECOND DRESSING OE A CLOSED WOUND. 
 
 ovariotomy, in excision of the breast, or in anipntation, will lieal witliin two weeks under 
 the best conditions. If it does not, it is because tliere is something wrontr with the 
 patient's general condition, or something wrong in the wound, or more particularly in its 
 treatment ; for the primary dressing of the wound should liave been such as to render 
 early interference with it unnecessary. 
 
 To recapitulate: (1) the edges and surfaces of the wound should be carefully adjusted 
 and fixed together; (2) complete immobility of the injured part should be guaranteed by 
 the judicious application of splints, pads, and bandages; (3) the limb or wounded part 
 should be placed in the most comfortable position for the patient, as well as in that which 
 is iilost favorable for repair ; (4) due provision should be made for the effectual drainage 
 of the wound, and care should be taken that the effect of drainage is not neutralized by 
 any external application or dressing ; and, lastly (5), such dressings or external coverings 
 should be employed as will protect the wound from external injury and guard against or 
 neutralize the decomposition of such fluids as may be poured out. 
 
 A wound, however large, dressed pffechtollij on these principles, will probably not 
 require dressing for a week, or will not need more than the removal of the absorbent 
 material which has been placed to catch the secretion which has drained away from the 
 wound, and will be found, when dressed, to be well or nearly well. A wound, however 
 small, dressed ineffectually, will probably be unhealed and suppurating. 
 
 The nearer the surgeon can approach perfection in his first dressing, the more success- 
 ful will he be in his practice, and the larger will be his proportion of cures by primary 
 adhesion. 
 
 When a spcond dressing is called for, the surgeon should have at hand everything 
 which may be required for the purpose — lint, prepared in size and .shape, and steeped in 
 whatever dressing he may have arranged to use; scissors, forceps, bandages, strapping, 
 absorbent cotton, trays, and irrigators, whether in the shape of a can or in that of a dress- 
 ing-bottle (Fig. 3, p. 33). 
 
 Removal of Dressings. — When the wound is large and water is to be used in 
 quantities, he should have a piece of waterproofing to place beneath the part or patient, 
 and such assistants as may be required. He is then to remove the external dressings ; 
 and in doing this, as in every subsequent procedure, he is to employ the utmost gentle- 
 ness. He should, however, beforehand place his patient in the most comfortable position 
 he can, and then place himself comfortably ; for no surgeon can do his work well if he is 
 in a constrained posture. 
 
 In removing external dressings some time is often required, but it must be granted ; 
 for when dressings are glued to a wound by blood or secretion, they must be softened 
 with water — or, rather, medicated water — before they can be taken away without doing 
 harm. Having taken off the external dressings, rolled them up, sent them away, or 
 thrown them into a basin of antiseptic fluid, and having exposed the wound with its 
 sutures, and the strapping which possibly was applied for adjusting purposes, the surgeon 
 is then to cleanse the part ; and for this object he cannot do better than use the absorbent 
 cotton, either dry or wetted with the medicated lotion. The sutures should then be cut 
 and withdrawn, care being observed not to drag a long loop of suture covered with dry 
 secretion through the tissues, but to cut it off close to the skin through which it will 
 have to pass. When the union of the wound appears weak, or when, on an early day 
 after the first dressing, the second is being made, support should be given to the tissues 
 by the application of a piece of well-adjusted strapping as each suture is taken away, a 
 second and third, or more, pieces being successively applied as the dressing proceeds. 
 
 Removal of Sutures. — If the sutures are not irritating and the wound has not 
 healed well, they should be left alone. In deep wounds the surgeon .should never be in 
 a hurry to remove sutures, whether they are irritating or not, for if he remove them 
 before good repair has taken place the wound will gape, and under such circumstances 
 the prospect of securing repair by ])rimary adhesion will have disappeared ; and even 
 when the sutures are cutting through from overstretching of the part, it is, as a rule, 
 well to let them alone as long as they have any influence in holding large flaps together 
 or in preventing wide separation. At the same time, all sutures should be removed as 
 soon as they have answered the purpose for which they were introduced, or when all 
 hope of their fulfilling it has passed away. The removal of a stitch from a wound which 
 is suffering from the irritation cau.sed by tension, and possibly from some collection of 
 fluid, is always wise. 
 
 AVhen splints have been used to support and to ensure the immobility of wounded 
 parts, they should not be removed unless for some urgent cause. It is to be assumed 
 
(•<)STrsi:i> AM) L.\('i:n.iTi:i> wounds. 41 
 
 tliul tlit'V wtTi' s(i ;i|i|ilii'il at tirsi In allow I lie siir;^t'i)ii tn rciiiosc. wlicii riocessary, tiit; 
 oxtiTiial (Invssiiii^ witliuiit iiitcrrcriiiij: with tliciii. With tlic saim- vii-w, of pn-veritiii^ tlic 
 not'i'ssitv <»i its t-arly rt'iiioval, a splint sliuiild Itr covfrccl with s<mic protective, siicli as 
 gutta-porciia or oiled silk. 
 
 'I'o eoiiiplete the seeoinl dressiiiL', ;i IVesh piece ol' lint soakcil in the tcreheiic and oil. 
 or other selected application, is to he laid on tlu! wound, and tlie external parts covered 
 as after tlie first dressiiiL:, the surireon taking' care to sec tliat cHicient means are employed 
 tor the external protection, the inmioliilii y, and u'oo<l drainaLfc, of the wound. 
 
 Subsequent Dressings. 
 
 'i'lic third and later dressiims of a wonnd iimst he ::<ivcrned hy tlie same ])rinciple.s 
 whiidi have heen laid (h)wn for tlui second, ami they are to he conductetl in the same 
 <|iiiet, ficntlo, and yet decided, maniuir. They arc not likely to he very iiunicrons shonld 
 ])riinary adhesion he ohtained ; and when that lio])e has fled, they must \n'. carried out 
 (hiily, or ])ossihly more often. They will, howcviM', then have to be conducted on very 
 similar principles, although with different objects. 
 
 Contused and Lacerated Wounds. 
 
 These wounds, from a clinical ])oint of view, should be classed to«i;ether, since, in both, 
 the ed^es of the wound are, as a rule, so injured as to be irregular and the seat of ecchy- 
 mosis, and since, in both, before repair can practically begin, death of some of the injured 
 surface, or of some of the surrounding subcutaneous or other tissue, or margins or flaps 
 of the wound, is to be expected. 
 
 In the confused wound the breach of surface is brought about by a blunt in.strument, 
 moving with a greater or less velocity ; and the extent of bruising or contusion of the 
 soft ])arts in the neighborhood of the wound will be found to vary with the size of the 
 instrument which inflicted the injury, and with the force of its impact. When the mis- 
 sile is large, the extent of injury will be proportionate ; and w'hen the velocity is great, 
 the area of contusion around the edges of the wound will be lessened as the extent of 
 wound will be increased. 
 
 The most typical examples of contused wounds of all kinds are met with in military 
 practice, and are caused by the impact of spent balls or fragments of shell. 
 
 Lacrrdtiil wounds are generally brought about by a tearing or biting process, and 
 are characterized by great irregularity of the lacerated ti.ssues from the skin down- 
 ward ; this irregularity depends much upon the diflferent degrees of elasticity of the parts 
 torn, skin, arteries, muscles, and tendons all behaving difl'erently when submitted to a 
 lacerating force. 
 
 In ontasrd wounds the area of injury generally extends fiir beyond the area of the 
 breach of surface ; and when death of tissue follows, it may spread widely. In htrenitiij 
 wouiuls the area of injtiry is generally more localized, though this remark is not applic- 
 able to wouiuls in which muscles and tendons are involved. When, for instance, a finger 
 or thumb is torn off", the tendons connected with the injured part may separate at their 
 muscular origins in the fore-arm. 
 
 HsBmorrhage. — In both contused and lacerated wounds there is less primary 
 haemorrhage than there is in those of the incised variety ; the contudng force so affects 
 the vessels at the seat of injury as to favor the coagulation of the blood about their 
 open mouths, or so ru])tures the inner and middle coats of the bruised vessels as to 
 mechanically interfere with the flow of blood, and thus encourage the formation of a elot 
 by which the lumen of the injured artery may become occluded ; the kiverating force 
 likewise irregularly divides the different coats of the vessel and its sheath — even in the 
 case of a large artery — and thus favors the coagulation of the blood at the seat of Jacera- 
 tion. This temjiorary plug of the vessels is generally sufficient to close the orifice until 
 nature's ])ermanent h;emostatic processes have had time to act and to .seal the vessel {cid<; 
 Chapter X.). 
 
 Secondary H/EMORRH.vge. — In contused wouiuls there is a far greater proneness to 
 secoiulary h.vmorrhage than is met with in any other form of wound, the contusing force 
 often primarily injuring, but not opening, an artery, yet so destroying the vitality of its 
 coats as to excite an inflammatory, sloughing, or ulcerating process, which in its turn may 
 open the vessel and give rise to secondary hasmorrhage. Contused wounds are for this 
 reason of a more dangerous character than lacerated wounds. 
 
42 TREATMENT OF OPEN WOUNDS. 
 
 Subcutaneous Contused Wounds — that is, severe contusions of soft parts 
 
 without breach of surface or, exposure of the injured tissue from either the impact of 
 blunt instruments, the passage of a wheel over the part, or other force — are at times 
 more grave than those in which a breach of surface exists. The gravity of these cases 
 is best seen by studying the effects of such kinds of injury upon the abdominal and 
 pelvic viscera, an unbroken and apparently uninjured outside surface often covering a 
 fatal subcutaneous rupture of a solid viscus or a laceration of a hollow one. The same 
 fact may be also well seen in severe injuries to extremities, where from a contusing force 
 an artery may be stretched, bruised, or lacerated, large veins may be torn across, nerves 
 injured, and muscular and other tissues irreparably damaged. The amount of harm 
 which deep tissues may have sustained in any given injury can. therefore, onlv be esti- 
 mated by a correct appreciation of the force which has been applied, and of the position 
 and condition of the injured part at the time of the reception of the injury. It can 
 never be made out by simple in.spection of outside appearances. Such injuries always 
 demand great care in their treatment. 
 
 Treatment of Contused, Lacerated, and other Wounds which 
 Heal by Granulation. 
 
 The principles upon which the treatment of contused, lacerated, or (ipen wounds is 
 based are the same as have been laid down and explained in considering the treatment 
 of incised wounds, though they may require soiue modifications in their application, on 
 account of the altered circumstances in which they have to be carried out. For example, 
 in a deep lacerated wound the surgeon will have to cleanse it and arrest bleeding, as in an 
 incised wound ; but he will not have to adju.st the divided surfaces and applv sutures in 
 the same careful way that he would be called upon to do if a " quick union " was to be 
 looked and worked for. He will remember that this change of practice is demanded in 
 contused and lacerated wounds because there must of necessitv be more or less sloughing 
 or molecular disintegration of the lacerated tissue and contused parts around, and that, 
 as a con.sequence, it becomes a matter of primar\' importance to leave the wound open 
 for the free discharge of all such tissues as may have been destroyed or may die, as 
 well as for the evacuation of the fluids which must be poured out in the reparative pro- 
 cess. 
 
 He will, however, in this class of eases, as in the former, secure immobility of the 
 wounded part and fix it in the position which will be easiest to the patient and most con- 
 ducive to the healing, and he will not forget to make the fullest provision for the drain- 
 age of the wound from its lowest depths. He will, moreover, have to be additionally 
 careful in the dressing of the wound, since it is an open one. because, from such, septic 
 matter is more rapidly absorbed before the process of granulation has commenced ; and 
 when it has commenced, such a wound is readily influenced by external applications. 
 
 In one instance the wound may have to be regarded and treated as an open one from 
 the first, the excavated surface being filled in with a light dressing, as if it were a sur- 
 face wound. In another, where there is a tendency for the surface edges to fall together 
 and unite, and where this union would be injurious by interfering with the free evacua- 
 tion of such di.scharges as are to be looked for from the wound, or with the escape of 
 sloughs of destroyed tissue, the dressing may have to be inserted between the lips of the 
 wound, or even down to its bottom, for it is essential in these cases that the wound 
 should not be closed and that a free vent for all fluids should be maintained : whilst in a 
 third case the provision for free drainage may. from the position of the wound, be so 
 imperfect that a special opening ( counter-opening) may be called for at the most depend- 
 ent situation of the injured parts, or at some other position which the ingenuity of the sur- 
 geon may suggest. Under all circumstances, wounds such as these, which are not expected 
 to heal by quick union, should be so dressed as to allow of the free egress of all secre- 
 tions without disti;rbing the parts. 
 
 The primary dressing which I am in the habit of employing for fresh wounds is, as 
 alreadv mentioned, lint or absorbent cotton saturated Avith a mixture of terebene one 
 piart and olive oil three parts, the saturated dressing being covered with another layer of 
 drv lint or cotton. Where a wound has to be lightly filled with some dres.sing. I use the 
 absorbent cotton semi-saturated with the same terebene-and-oil mixture, and a light pad 
 of the absorbent cotton applied over the whole and held in position by a retentive band- 
 age ; and even when a drainage-tube or drain-orifice exists, the same light dressing is 
 useful to absorb sjich fluids as may escape externally In some cases a soft sponge which 
 
PUyCTURlI) WnUSDS. 43 
 
 has hccii wniiit,' (tut of iodine or carliolic lotion is a j,'oo(I Hultsfitutc lor the w;nl of 
 absoi'lx-nt cnttoii. 
 
 Ill rasi's of iiKtri' .sovcrc woiimls. wlicn- a l"r<i' liow of fluiil is to he ex|»c'fte<l. ami 
 wliere tlie ilaiiL'er oC its retention would l»e ^rreal.the o|ieniii;_' u{ the draina^e-tuhe of 
 discLiari:injr-oriliee sliould he lel't i'ree. In th»? dressiii;; u[' all stuiii|ts and most deep 
 iiieised or laceiatt'd wounds this practice shoiilrl he followed, since it eiiahles the suTjreoii 
 to lirinj; the parts more accurately to;,'^ellier than Wfiuld otluMwise he advisal*le. ami to 
 keep them ipiiet, and in apposition hy ineaiis (d" pressun; applied over the whole of tho 
 wound, except tho drain-oritice. This method has likewise tin; additional f^reat a<lvaiitafre 
 of allowinir the surj^eoii to leave the wound undistiirhed i'or some days, jirohahly for a 
 week, and to postpone his first dnsssinj^ till a pi!rir)d when nature's reparative jirocess will 
 have had time to shut ott' the wounded part frr)m the deeper tissues, and to do much in 
 the direction of its repair. There should always be a reason for dressin;; a wound. 
 Jh-essinu as a routine jtractice is not to be coniniended ; it should always be deferred 
 till it is re(|uired. 
 
 \\ (lunds must ho kept <l<fiii under all circunistaiiccs, an<l lice IVoni every septic risk ; 
 hut a wound must he kojit >iititt if repair is to f;o on steadily, and this (piiet is as necessary 
 for till' lacerated as it is for the cleaner kinds of wound. A form of dressinj^ such as ha.s 
 been doscril»od has advantages over many others, for it renders early and frerjuent dress- 
 ings of the wound unnecessary. 
 
 Punctured Wounds. 
 
 Punctured wounds, when made with .sharp-cutting instruments, are deep inclsrtl 
 wounds, and when with blunt or wedge-shaped tools deep ctiiitinit.il wounds. They differ 
 from other incised and contused wounds in their depth and in tlie uncertainty which, a.* 
 a consequence, follows with respect to the tissues that are wounded, but, above all, in the 
 difficulties whicli are always experienced in providing for the efficient evacuation of 
 blood, serum, or broken-down tissue, where drainage is needed. These difficulties are 
 clearly due to the external orifice of the wound Iteing but small in proportion to tlie 
 depth of the penetration. 
 
 When a punctured wound is made with a clian^ shitrp instrvment into the healthy 
 tissues of a healthy suVjject, harm may not be anticipated ; indeed, quick repair may 
 be looked for with almost as much confidence as if the wound had been of the more 
 simple incised kind. This observation is coiifirmod by the general experience of all who 
 practise subcutaneous surgery, although wlien large vessels or nerves are wounded 
 troubles may arise which are not lessened by being hidden. 
 
 When, however, a punctured wound is made by a hhinf anti tcedge-Hliapeil , or possibly 
 a ilirti/, instrument, the wound will be of the contused kind, and, being so, it will partake 
 of the disadvantages of such wounds in addition to those which appertain to it as a punc- 
 tured wound. It will conse(juently, being contused, be associated with death of some of 
 the injured tissues, for the escape of which due provi.sion will be required, and it can 
 only he expected to heal b}' the second or third intention. Being a punctured wound, 
 it will, moreover, exhibit the difficulties of providing for proper drainage under circum- 
 stances in which efficient drainage is particularly called for. As a con.secjuence of these 
 conditions, special dangers are developed W'hich can only be rightly met by a full recog- 
 nition of their nature and of the requirements essential to their prevention. 
 
 When tense fascijv; are punctured — such as are found in the palm of the hand, sole 
 of the foot, and scalp — or when deep muscles bound down by fa.sciae, as in the thigh, are 
 involved and secondary inflammation ensues, the case is often very serious. Punctured 
 wounds of cavities are wor.se than those of the soft parts covering bones, in the .same 
 way that all other wounds of cavities are graver, as well as from the fact that in punc- 
 tured wounds there is more uncertainty as to the nature of the parts wounded, and that 
 with this uncertainty there are. of course, loss clear indications for treatment. 
 
 Treatment of Punctured Wounds. — There is no form of wound which the 
 
 surgeon has to treat in which a greater uncertainty exists as to the results of treatment 
 than in the punctured, and all punctured wounds should be dealt with, therefore, with 
 the greatest caution. When the wound has been accidentally inflicted with a clean, 
 sharp instrument, and when it is treated, as it should be, like any other clean wound, 
 with moderate compression and the application of a dry or antiseptic dres.«ing. such as 
 terebene and oil, and is then left yirotected and at rest to heal, there will be every pros- 
 pect of repair going on as satisfactorily as in wounds which surgeons daily inflict in their 
 
44 TREATMENT OF OPEN WOUNDS. 
 
 operations of tenotomy and osteotomy. Even when the wound is of the contused kind 
 and repair by '• quick union " is not to be looked fur, tlie surgeon is probably justified in 
 employing the same means, although in doing so lie must be keenly alive to the risks of 
 the case and the dangers of the practice adopted. He must be ready, on the appearance 
 of any swelling, pain, heat, or redness, and more particularly of any elevation of temper- 
 ature, to remove all dressings, expose the wound, and adopt means to give vent to the 
 pent-up fluids of the part and relieve the local irritation caused by their retention ; by 
 so doing he will jtut an end to tension of the tissues, and probably check the further 
 absorption of substances which, if not already decomposing and undergoing chemical 
 changes, may soon do so and give rise to septicjvmia and blood-poisoning. 
 
 In one case this may be done by reopening the external orifice of the wound ; in 
 another, by enlarging it ; whilst in a third, a fre.sh r)pening may be called for in the most 
 dependent point of the injured region. Under all circumstances, however, the object is 
 the same — to give vent to pent-up fluids, whether inflammatory or otherwise. At the 
 same time, the injured part should be raised, to encourage the venous circulation through 
 the limb, and pain should be relieved by the local application of warmth and moi.sture, 
 whether in the form of a compress or in that of a fomentation mixed with sedatives, 
 such as opium or poppy decoctions. 
 
 Cold rarely gives comfort in these cases, and it certainly does no good toward checking 
 inflammatory action, which, if occasioned by retained .secretion, is only to be relieved by 
 its removal. For the same reason leeches are rarely applicable, although in a plethoric 
 and vigorous patient they may be permissible ; but even in such the judicious use of 
 small and repeated doses of sulphate of magnesia has a more powerful efl^ect for good, 
 with less risk of doing harm. 
 
 In the treatment of all punctured wounds it must be remembered that, as the chief 
 danger lies in the dilficulty of providing efiicient drainage, the result turns upon the 
 completeness with which this necessity is met. The surgeon who, on the first appearance 
 of local or general symptoms indicative of the presence of retained serum or other fluids, 
 makes an outlet by one of the means which have been suggested, will be more successful 
 than one who, from timidity or other cause, leaves the case to run its course till a large 
 inflammatory abscess has formed. In all punctured wounds which do not heal c|uickly 
 by primary union, and in which secondary inflammation occurs, with its necessary effusion, 
 an outlet should be made for the fluids of the part as soon as the fact of their retention 
 is clear. When thecae of tendons, fascia?, and fibrous coverings, as of bones, are in- 
 volved, the necessity of providing for this outlet is more important, if possible, than 
 when the softer tissues are implicated, and an incision into the deep parts for the evacu- 
 ation of simple serum, by relieving tension, will often prevent both the extension of 
 the inflammation and the destruction of tissue. 
 
 Tooth Wounds. 
 
 Tooth wounds are usually punctured, and rarely other than contused. They may, as 
 may all other kinds, prove to be poisoned wounds, but to them I do not refer. They 
 differ widely in their character, and, whilst one case may appear as a simple clean punc- 
 tured wound, another may exhibit all the worst features of the contused or lacerated 
 variety. 
 
 They are to be dealt with as punctured or contused wounds, each ca.se being treated 
 on its own merits. 
 
 Treatment of an Open or Granulating Wound. 
 
 When a wound is granulating, and consequently suppurating, it should be kept clean, 
 as should all wounds, and it .^^hould be dressed with such a material as may be.st protect 
 the granulations from outside injurious influences and allow the cicatrizing process to go 
 on without hindrance. The granulations themselves should never for purpo.ses of clean- 
 liness be touched by any coarse material harder than a camel-hair pencil, but should be 
 washed by means of a stream of some antiseptic fluid allowed to flow from either the 
 irrigating-bottle or dressing-can (Fig. 8). In my own practice iodine water is generally 
 used. When the granulating process is not of a healthy type, but shows either deficiency 
 or excess of power or some morbid action, medicated lotions and constitutional treatment 
 may be required, to which attention will be directed farther on. 
 
Srr.riM, rilEATMKNT Ol' Wol'SDS. 45 
 
 Treatment of Wounds to Promote Healing by Secondary 
 
 Adhesion. 
 
 As ill tlio tri'utiin'iit u[' a IVcsli wouikI tn nlitaiii a ''(jiiick or |»riiiiarv adlicsioii" the 
 sur;riM)ii lias siiiiitly to cleans^ tlic wound after arrest iii<r Ideediii;.', ami to liriii^^ tlu! two 
 surfaces into elose a|i|io.sition l»y the siinph'st means, and keep them so. thus in the treat- 
 ment of" a ease in whi(di healing hy seeomhiry adhesion is s<Mi<.'ht for he has siinplv to 
 hrinji to<;etiier the two jiraniihitiiij; surfaces, ch'ansed from all impurities hy such iiicuns 
 as are sujj:j;ested hy the special re(Hiireinents of tlu; case, and to leave tlieiii to unite. In 
 haredip or other lip operations, where (piick union has heeii iiii.ssed and secondary adhe- 
 sion is souiiht for, it may he ohtained hy the introduction of deep sutures, or even pins; 
 in dei'p flesh wounds or after operations, as on the breast, hy means of strapping well 
 applied; ami in stumps, after am])utation, by means of splints. ])a(ls. and handag(?s. In 
 all cases, the imiiKthility <d' tlu; jiart treated is suhse(|ueiitly to he rigidly atteudcMl to. and 
 time must hi' given for iinliiii to (•(im|il('te itself hefore llie dressing is disturbed. 
 
 The Special Treatment of Wounds. 
 
 To estimate correctly — with the light of our present kuowledtre — the value of any 
 special method of treating wcninds, it is neces.sary to keep constantly in mind the sijc 
 j)(iiii/s to which attention has been directed, since these points are essential juinciples of 
 practice which should be follow I'd under all circumstances. Indeed, so essential are they 
 that the value of any sj)ecial method of treating wounds may be tested by them, and the 
 method regarded as good, bad, or indifferent according to the measure or degree in which 
 it fulfils the re((uirements enumerated (r/V/e page 'M). A mode of dressing which satis- 
 fies all these re(juiremeiits or indications in a simple and efficient w^ay must be regarded 
 as perfect, and a mode which embodies in itself the greater number of these requirements 
 should be regarded with greater favor than another in which these requirements are less 
 efiieiently fulfilled. 
 
 With this standard of comparison ever prominent, I will now proceed to consider the 
 more important special modes of treating wounds. 
 
 The Treatment of Wounds by Occlusion (the Smothering 
 
 System). 
 
 This was, without doubt, the favorite method of dressing fresh wounds among the 
 older surgeons, and in proof of this it is only necessary to refer to the classical works of 
 John Bell to read how the processes of miii(di/)/iiiij, (U(j(x(iiig. {nainn'iii/. and riaifrlzlin/ 
 were carried out. 
 
 This method was doubtless the outcome of much observation, and was based on what 
 was seen daily in the healing of the wounds of animals by one of the natural methods of 
 repair — that of scabbing. '• This mode of healing under a scab" " is the most natural 
 and in some cases the best of all the healing processes. Very commonly, in animals, if a 
 wound l)c left wide open, the blood and other exudations from it dry on its surface, and. 
 entangling dust and other foreign bodies, form an air-tight and adherent covering, under 
 which scabbing takes place, and which is cast off when the healing is complete. The 
 exact nature of the process has not been watched, but it seems to consist in little more 
 than the formation of cuticle on the wounded surface, and it has the advantage that, as 
 no granulations are produced, there is little or no contraction of the scar. In man the 
 same process is less frequent ; it is more apt to be spoiled by inflammation, producing 
 exudations under the scab, which either detach it or prevent the healing of the surface 
 beneath it. Sometimes, however, the blood shed from a wound coagulates and dries on 
 it, and, remaining as a scab, permits healing nnder it; or if this does not happen, a simi- 
 larly effective scab may be formed by the serous fluid or lymph by which the surface of 
 an exposed wound usually becomes glazed ; or, more rarely, the pus of a granulating 
 wound may scab, and sound healing take place beneath it " 
 
 '' To obtain healing under a scab, if the wound be recent the blood and exuded 
 fluids, or if it be granulating the pus, should be left expo.sed to the air till it dries on the 
 wound, adhering to the edges and surface and comphfehj cjccludituj them from the air." 
 
 " There seems, however, to be a proneness to inflammation which makes the healing 
 under a scab precarious, and less generally obtainable than one could wish it. No morbid 
 
46 SPECIAL TREATMENT OF WOUNDS. 
 
 exudation sliould take place under a scab once formed ; everytliing of tlie kind painfully 
 compresses the wound and retards its healing " 
 
 kSuch is the mechanism of healing- under a scab, and such are souie of the methods 
 by which it can be brought about. In Sir A. Cooper's time (1820-40), with the same 
 olaject, wounds were often sealed with lint or other material saturated with blood, and in 
 more recent days they have been covered with collodion alone or applied on linen, with 
 colloid styptic, with tannin in powder, with dry earth or peat, with l*eruvian or Friar's 
 balsam, with cotton-wool medicated or otherwise. In some country districts coal-tar is 
 used for the same purpose, and with the same view, (yhassaignac's arrangement, by 
 which a wound was hermetically sealed from the air by consecutive layers of plaster 
 covered in with charpie or cotton-wool, has also been employed. The object of each 
 variety of this form of dressing is the same — viz., the complete occlusion of atmonpheric 
 air — and in each an attempt is made to place an open wound as much as possible in the 
 position of one which is closed or subcutaneous. 
 
 Cotton Dressing. — In recent times this method has attracted much attention 
 under the form of the " cotton dressing," which was introduced in 1853 by Burggraeve 
 of (rhent and advocated by Ilavoth. In their hands it was carried out by the immediate 
 application of splints thickly padded with cotton-wool to the wound and injured limb, 
 and by not interfering with the injured part for four or six days. If there was at th,e 
 end of that time neither inflammation nor suppuration, but a firm scab, the wound was 
 let alone, and only the surrounding wool was renu)ved. If suppuration was present, the 
 wound was dressed with cerate. This method has been described by Schultes as the 
 methodical application of so-called healing by scabbing extended to large wounds. 
 
 Dr. Graf uses cotton-wool and tannin, the latter being spread over the wound in a layer 
 as thick as the back of a knife ; he leaves the dressing untouched from four to fourteen 
 days. He and Fleck of Dresden regard tannin as a simple and cheap antiseptic and dis- 
 infectant, and as an unirritating haemostatic. Both surgeons advocate this method of 
 treating wounds in military surgery. Alphonse Guerin uses cotton-wool with the view 
 of filtering the air from germs before it reaches the wounded surface, and he applies the 
 wool by smothering the wounded part or limb with many layers, and leaving it undis- 
 turbed for twenty-four or thirty days unless some extraordinary complication should arise 
 — for the detection of which a close watch is always kept — to induce him to remove it. 
 Before he applies the dressing he washes the wound with cauiphorated alcohol or carbolic 
 acid, and in an amputation introduces the wool between the flaps. When the dressing is 
 removed, there is generally a healthy granulating surface with a little sweet pus covering 
 it, and the granulations, in the case of a stump, have probably driven out the cotton-wool. 
 This method has the advantage of giving rest to the wounded parts ; the gentle and 
 elastic pressure exerted by the wool is also beneficial, as are likewise the constant temper- 
 ature maintained and the freedom from pain which is the result of these conditions. 
 
 Oilier employs the same dressing as Guerin, but he, in addition, sprinkles the wadding 
 with carbolic acid. According to either plan, the dressing is a close one, and is based on 
 ■occlusion of the part from air, with antiseptic precautions. 
 
 Summary. — If we bring this method of treating wounds by " occlusion " to the test 
 laid down at the commencement of this section, it will be found that it fairly well fulfils 
 three out of the last four essential principles of practice, but fails entirely in the most 
 important, the fifth — that of drainage. That is to say, excepting in A. Guerin's practice, 
 it inchides the careful adaptation of the surfaces of the wound, ensures rest and immo- 
 bility of the part for some days, and provides for the protection of the wound from out- 
 side influences and for antisepsis, but it fails entirely in making the smallest provision 
 for " drainage ;" so that, as Syme cleverly expressed it, " there can be little difficulty in 
 perceiving why the sealing up of wounds should be the most certain means of keeping 
 them open." 
 
 Under these circumstances the conclusion is clear that, whilst this may be a safe and 
 •wise practice to adopt in small or superficial wounds, it is a risky and somewhat danger- 
 ous uiethod to follow in the treatment of those which are deep and complicated unless 
 very closely watched. It .should never be employed in any case in which the wound is 
 more than superficial uidess the probability of the part healing by immediate union can 
 with good confidence be nuiintained, and it should never be employed at all unless the 
 surgeon, carefully watching the temperature of the patient and the local and general 
 symptoms of the case, is prepared to at once expose the wound, if necessary, and to 
 evacuate any pent-up fluid that may be present. For my own part, whenever I seal a 
 wound with the hope of securing a good result by allowing the parts to heal quickly, as in a 
 
Tin-: oi'ES ji:/:atmj:\t or woiwns, 47 
 
 8iil)('ut:mouus or cldsiMl wound, I never do more than seal it witli lint soaked with hh)od 
 or Kriar s balsam, and I take f;ood eare to have the parts otherwise well exposed to obser- 
 vation, in order that I may, if" warned by the a])pearanee of any hical symptom, such as 
 swellinj;, heat, or jiain, or ol' any p'lieral symptom, such as increase of temperature or 
 fever, remove the scab, real or artificial, and j^ive free vent to the pent-up fluids. ], more- 
 over, never adopt the method for any other than a very clean an<l recent wound. 
 
 As a ireneral mode of practice this treatment by occlusion is not to be advr)(.-ateil ; irj 
 exceptional cases it may bo employed, but then otdy with extreme caution. In most 
 deep and complicated wounds it should be rejected. It is only applicable in the very 
 earliest treatment of wounds. 
 
 The Open Treatment of Wounds, or Treatment by Exposure. 
 
 This method was first systematically carried out by a ^'ienna surireon named Vencenz 
 von Kern in the betrinninj; of this century, and more recently by Bartscher and \'ezin in 
 lS5t), and by Burow in 180G. The.se German surgeons were led to adopt this mode of 
 treatment by careful observation of the healing process in wounds, and more particularly 
 by the bad results which followed the ordinary methods of dressing by occlusion, as then 
 em]>loyed in continental towns, by the use of bandages, charpie, lint, etc. The system 
 of dressing wounds by what has been described as the " smotherinir method,' in which 
 no air could get in or fluid get out, gave way to the ■' open method,"' in which the free 
 access of air was the main end sought for, and drainage the second. The success which 
 attended this practice was, moreover, considerable, since Bartscher and Vezin had only- 
 three deaths out of thirty amputations, and Burow three out of ninety-four. The 
 method, nevertheless, did not make headway, and it does not seem to have been followed 
 as a rule of practice by any surgeon except Messrs. Teale of Leeds, Professor Humj)hry 
 of Cambridge. Dr. R. W. KriJnlein of Zurich, and some members of the Surgical Society 
 of Mrtscow. 
 
 Teale and Humphry in 1850 and 18G0 (Brit. Med. Joh?-h. ), Krbnlein in 1872, and the 
 Mcscow Surgical Society in 1877, have given their respective experiences and recommen- 
 dations in regfard to this method of dressing. 
 
 Von Kern's practice consisted in freely exposing the wounded surfaces to the air and 
 simply keeping the edges of the wound in position by means of sponges. Vezin applied 
 no kind of means for uniting wounds. Burow used sutures, but in such a way that they 
 could be readily loosened in case of distension. Professor Huinphr}' wrote : ' '"It is 
 well known that wounds of the face commonly heal up in their whole length by first 
 intention. This is due, in great measure, to the vital qualities of the parts, and in some 
 degree also, I apprehend, to the fact that they are usually left exposed to the air. their 
 edges being held in contact merely by sutures. For some years we have adopted this 
 plan after amputations and all, or nearly all, other operations. The integuments are 
 united by sutures placed at intervals of about an inch, and the wound, as well as the 
 adjacent surface, is left quite exposed to the air, no plaster, bandage, or dressing of any- 
 kind being placed upon it. All the irritation, the galling pressure, the retention of heat, 
 and other inconveniences resulting from bandages and plaster are thus avoided. The edge 
 of the wound and the surrounding skin being uncovered, the eye can take cognizance of 
 what is going on, and we can cut a stitch here and there when required, can keep the 
 part clean, or take other measures, without difiiculty. Forasmuch as no dressings are 
 applied, there are none to be removed. The suffering which used to be caused by the 
 dressing of wounds after operations is got rid of. In many cases I do not touch the 
 wound, except for the purpose of removing the sutures, from the day of the operation." 
 We decidedly have more frequent union by first intention than when we were in the 
 habit of applying dressings to the wounds. If suppuration takes place, an early and 
 free vent should be aff'orded to the pus by cutting the stitches and opening the wound : 
 and care .should be taken to keep the wound clean. " Large open wounds — that is. where 
 portions of the skin have been removed, so that the edges cannot be approximated — are 
 in our hospital (Cambridge) not unfrequently left exposed to the air without any cover- 
 ing. A dry crust or scab forms upon them, beneath which cicatrization goes on, and we 
 find that the healing often proceeds more quickly in this way than when the part is kept 
 moist and the products of the wound are continually flowing away into the dressings. " 
 
 Krlinlein tells us, after analyzing six thousand cases, that the open method has 
 proved superior to all others, and demonstrates that the mortality of amputations, which 
 ^Humphry, British Med. Jownal, October 27, 1860. 
 
48 THE OPEy TREATMENT OF WOUNDS. 
 
 by former methods had been fifty-one per cent., fell by the open treatment of wounds to 
 twenty per cent. ; and Rose, who is the present director of the clinic at Zurich, follows 
 Kronlein. He exposes all his wounds to a fresh current of air. which is maintained by 
 means of open doors and windows. He regards stitches and bandages of all kinds as 
 interferences to be avoided, and trusts to absolute rt-sf of the part after afrefid arrest of 
 hh-ediiKj, to provision for thorough (h-ainuge^ and to ncnijudous chanliness. The wounded 
 limb after an amputation is kept in one position on a cushion so protected by mackintosh 
 that the discharges may easily escape into a vessel placed to receive them. 
 
 Some of the practitioners of this system are somewhat inconsistent, since they advo- 
 cate the frequent ablution of the exposed wound with carbolic water, or its protection by 
 pouring over it the balsam of Peru ; and C. Thiersch adds that whether the wound lies 
 quite free, or is covered with a piece of oiled silk, or with a water compress, cold or 
 warm, does not appear to be of importance if only free escape of the secretions is not 
 affected thereby; we may also, he says, add irrigation without changing the character of 
 the dressing, as practised by Bardeleben, and the permanent water-bath may also be of 
 use. Thiersch, moreover, adds that in cases of compound fracture and gunshot injurioi< 
 — since the free escape of secretions is one of the most important points in their treat- 
 ment — wounds may be enlarged by incisions, abscesses opened, counter-openings made, 
 and even free openings into wounded joints or resection practised. 
 
 The conclusions of the Moscow committee are also favorable to the practice, and mav 
 be condensed as follows: The essential feature of treatment by ((erafioii, as this commit- 
 tee calls it, consists in avoiding all local appliances for excluding air. and in placing 
 wounds in conditions favorable for free and direct contact with the atmosphere. Lint 
 and other such substances should never be used. Repair by primary union .should alwavs 
 be sought for when possible. Catgut ligatures and metallic sutures should be employed. 
 The advocates of this system believe that the '• Lister dressings" are injurious, but that 
 the antiseptics employed counteract the baneful effects of the coverings. 
 
 Summary. — The results of this open treatment are evidently satisfactory, and, judged 
 by the essential points to which attention has been directed, the open treatment of 
 wounds may be advocated, for it includes careful adaptation of parts after arrest of all 
 bleeding and due provision for thorough drainage; but, on the other hand, It takes little 
 care to guard against mobility of the wounded parts and disregards antiseptic applica- 
 tions and precautions. 
 
 The neglect is, however, probably due to the justifiable impression that if drainage 
 be provided for there will be, in the deeper parts, no retained dead tissues or fluids to 
 decompose or undergo chemical change, and that a free current of air upon the surface 
 of the wound is the best guarantee against septic changes of its fluids. Lideed, Profes- 
 sor Humphry clearly indicated this when he described how large open wounds by this 
 system heal more ((uickly than when the part was covered and kept moist. 
 
 Some of the advocates of this system believe the open treatment to be more adapted 
 to wounds in which union by stcoudar// adhesion is to be expected, since they as.sert that 
 if an open wound be maintained in a condition of perfect freedom from all irritating 
 causes, .such as foreign bodies, dirt, and decomposing elements, granulations will form, 
 and that suppuration is not an essential part of their formation. . 
 
 For my own part, after a careful review of the whole question, I must regard the 
 open treatment of wounds as being far superior to any other in which due provision is 
 not made for perfect drainage ; but at the same time I fail to see its advantages over 
 some others, and more particularly over that which I adopt, in which all the advantages 
 of the open system are secured, and in which, in addition, the wounded part is effectually 
 guarded again.st mobility and external injury, while at the same time due provision is 
 made by means of a light antiseptic dressing against the possibility of any septic changes 
 taking place at the surface as well as in the deeper portions of the wound. 
 
 The recent investigations of Pasteur^ tend greatly to support the advocacy of this 
 open dressing, since he claims to have proved '• that it is the oxgen of the air which 
 weakens or extinguishes germ virulence." Pasteur's experiments confirm those of Dr. 
 Downs and Mr. Blunt obtained in 1877, and those obtained by Tyndall in 1881, whereby 
 the influence of sunlight in arresting the development of bacteria was shown. 
 
 The treatment of wounds by ^^ irric/atifnr must be regarded as only a variety in form 
 of the open treatment, since its essential advantage consists in the cleansing and thorough 
 draining of the wounds of all secretions and impurities. The mode of carrying out this 
 method will be described under the heading " Water Dressing." 
 ' Acad, of Med., Lancet, November 6, 1880. 
 
sr/yiAL rni.A rMi.sr or worsDs. 
 
 49 
 
 III iruii^lint wiiiiiiil- <if' liiiilis ami in >Ioii;rliiiij.' or iiiihfalthy stiiiii|is or wounds this 
 njodi' of tivatiiii'iit liy irrij.'atioii is viTV satisfactory. It lias been fiiijilov<*<l at (Jiiv'h 
 Hospital for a ijuartfr of a iH-iilury, and can bo reconi mended. Esniarch speaks lii<rlily 
 of it ill military surgery. 
 
 Fig. 9. 
 
 On Water Dressing with and without Antiseptics in Solution. 
 
 Ill \^'l^\ the late Mr. Syme ])ul>lished a pap»'r in the Eillnhiirgh Mnliml imd Snrr/irul 
 Jnunml, .luly. in which he iKiinted out the evils of such old methods of dressing wounds 
 as those of mundifyinir. di<:esting, incarniiij.'. and cicatrizin};, and recommended that 
 wounds should he liirhtly dressed with wet lint or other simple dressing after their edges 
 ha<l lu'cn adjusteil and well brought together l»y stitches. To this surgeon, in connection 
 with Mr. liiston, may he pnthahly attrilmtcd the iiitrodiietitui into Hritish surgery of the 
 use of water dressing for wounds generally. 
 
 The practice was very rapidly taken hold of and adopted, every thoughtful surgeon 
 having recognized the evils that atteii<lcd the niethfids in which wounds were smothered 
 with masses of charjiie. lint, or otlu-r material, and left to heal as best they could under 
 cover of such dressing saturated with blood, serum, or pus. 
 
 The practice, moreover, was simple and cleanly, and when perfected wa.s comfortable 
 to the patient to whiun it was applied — that is. it became .so as .soon a.s the value of a 
 piece of oiled silk or thin gutta-percha tissue, applied over the wet lint, was recognized, 
 the wet lint without this addition having soon become dry, and what might have been 
 at first a wet dressing became thus converted into a dry one. 
 
 The water dressing likewise soon took the place of poultices, for by one. as by the 
 other, warmth and moisture were applied to the wound. 
 
 In 1835. ten years after the publication of Symes paper, M. Josse, a hospital surgeon 
 of Amiens, published a book on the use of cold water in surgical dressings, and advo- 
 cated its use — fjrsf. as a trustworthy and efficient means for the control of inflammation 
 in parts not wounded ;and Mcmdhj, as a dressing for wounds. 
 
 '• If we had the choice," he .says, referring to the treatment of the first class of cases 
 in which there is no wound, ''it might be established as a general principle that we ought 
 to employ water by aff"usion with a continual 
 stream, but the nature of the parts or of the 
 disea.se may prevent this and oblige us to recur 
 to another method ; thus, linen moistened with 
 water and renewed without ceasing may to a 
 certain degre prove a substitute for the affu- 
 sions, but this mode requires much attention."' 
 He subset juently describes his own method : '"A 
 vessel with a cock near its base is filled with 
 water and placed upon a narrow and high table, 
 near the patients bed, in such a position that it 
 shall be about a foot and a half above the dis- 
 eased limb, beneath which a cerecloth is spread, 
 intended to guard the bed and facilitate the flow 
 of the water, which is received in a bucket placed 
 near for that purpose, and into which the ex- 
 tremity of the cerecloth descends. The diseased 
 part should then be placed in the most conveni- 
 ent position ; it should be lightly covered with 
 compresses ; an additional piece of linen should 
 surround the cock by one of its extremities, while 
 the other is extended over the highest point of 
 the apparatus. This is designed to prevent the 
 water from falling with all its weight on the dis- 
 eased part, and rather to disperse it over a larger 
 surface." 
 
 I have described this method of using cold water fully, for it is one now recognized 
 as the treatment by " irrigation."' which, whether employed as cold affusion to check 
 inflammation in injured parts, as in joints, or to keep wounds clean, is of great value. 
 
 M. Josse likewise declared '"that when cold water is applied directly after the injury, 
 before reaction has taken place, and where it can be maintained with energy proportionate 
 4 
 
50 THE DRY DRESSING OF WOUNDS. 
 
 to the occasion, the phenomena of reaction will be prevented : heat. pain, and swelling 
 will be subdued, and, conseriuently, sympathetic fever will not take place ; but when the 
 cold has not been applied before the development of the inflammatory symptoms, they 
 will .still be conquered by its eflScient use." In these cf^iinions most surgeons will agree ; 
 but cold is not now often employed in the manner described, the introduction of ice and 
 ice-bags having led to the adoption of simpler and more effective methods of application. 
 The metallic coil of Leiter of A'ienna is probably the best method of applying cold. I 
 have used it freely, and like it much. It seems to embody in itself all the advantages, 
 without the disadvantages, of all other known methods of refrigerating a part. It is 
 also equally valuable for the application of heat (vide Fig. 9). 
 
 But. however valuable cold-water compresses or bandages, hot fomentations, or a warm- 
 water dressing ma}' be as applications to parts that have been injured, bruised, or inflamed, 
 they cannot be .strongly recommended as dressings to part.^ in which wounds exist ; for it is 
 now a fairly well recognized fact that water, ^)^>- .sr, helps better than anything else to en- 
 courage in an injured or half-dying tissue, as well as in the secretions of a wounded part, 
 chemical and fermentative changes by means of which septic poisons are generated or made 
 to flourish, and from the absorption of which blood poisoning is known to follow. 
 
 Water holding some antiseptic substance in solution may. however, be used, the 
 antiseptic preventing or neutralizing the septic changes which the water by itself might 
 encourage. 
 
 In wounds, therefore, that are much complicated with contu.sion and laceration of 
 parts, and to which hot or cold fomentations seem applicable, these medicated-water 
 dres.sings may be emploj'ed, it being left to the fancy of the surgeon whether he shall 
 use carbolic acid 1 in 20 of water, boracic acid 1 in 50, salicylic acid 1 in 50, thymol 1 in 
 1000, iodine tincture 1 in 80, or iodine liquor 1 in 160, or permanganate*of potash 
 1 part to 50. 
 
 Value of Oily Dressings. — For my own pai-t. I have for years given up u.sing 
 water as a dressing for wounds, whether with or without antiseptic substances, for I have 
 found that oily solutions of the same substances have advantages' over the watery prep- 
 arations which render them far safer and more satisfactory. Oily antiseptic applications 
 are without doubt the best dressings for wounds which we possess, and of these one com- 
 posed of terebene one part and olive oil three or four parts deserves, as already men- 
 tioned, the preference. 
 
 The Dry Dressing of Wounds. 
 
 A dry dressing to a wound is to be preferred to one of which simple water forms 
 a part, .since with it the sanguineous or serous exudations are more or less absorbed and 
 rendered inert, and the surface of the wound is kept quiet and protected as by a scab 
 from outside injurious influences ; whereas with a water dressing the injured surface of 
 the wound and the wound-exudations are encouraged to undergo chemical and fermenta- 
 tive changes by which the risks of absorption of septic matter or poison are much 
 increased and the dangers of the simplest wound greatly enhanced. 
 
 If the drv dressing be composed of some absorbent material, such as the absorbent 
 cotton or lint, and impregnated with an antiseptic sub.stance. such as boracic or salicylic 
 acid or iodoform, its efficacy will be increased, since the dressing, under these circum- 
 stances, may be left untouched for some days, even for a week, and the healing of the 
 part will not, therefore, be interfered with. Pvepair. as a consequence, will go on with 
 greater rapidity and certainty, the secondary wound dangers will be diminished, and the 
 ultimate issue of the case will be rendered more satisfactory. 
 
 When a wound is nnall and the surgeon has no doubt as to the propriety of seeking 
 to obtain its immediate union, the dry dressing can be recommended : for it. withoiit 
 doubt, helps better than any other to bring about the " quick union " which is wanted. 
 
 When the wound is Inrr/e or deep, the same recommendation cannot be made, and the 
 dry dressings, if used, should only be so after every care has been taken to provide for 
 the free drainage of the part. They should, moreover, only be employed when there is 
 a reasonable hope of the parts healing by primary union. 
 
 When a wound is much lacerated or cfinfmed. dry dressings are not applicable, since 
 in such no surgeon would entertain the thoughts of repair being brought about by rapid 
 union ; and where this hope cannot reasonably be entertained, the use of the dry dress- 
 inirs should be discarded. In brief, in all wounds, small or large, when repair by '■ quick 
 union " mav reasonablv be looked for. dry dressings are applicable, due provision having 
 
ALCnlKil.K- DUKSSLSC OF WOl'SDS. 51 
 
 been iiiailL' iur .'tViciciit draiiia;^*'. In all lacerated, contUHcd, or iJ«'t.'p wounds in wliich 
 repair by granulation is to be expected, tbese dressings art- imt to be reconmiendcil. 
 
 Earth Dressings. 
 
 Karth as a ilrcssini: fur \v(iuiMi> lias (b»ubtless been used by savaj^e nations from an 
 oarlv perioil of the wdrld's history, but it was first brouf^ht before tbe notii-e of surj^jeons 
 by i)r. Addiufll Ih'ws.in <»f IMiiladelpbia, I'nited States, in 1.S72, and from bis w<irk u|»oii 
 the subjeet it seems that he first resorted to this niodt; of treatment in ISCK. i)r. Ilew- 
 son was first led to employ the earth as a deodorizer in a bad example of eompound 
 fraiture of the let', and, as the result in this ea.se was f^ood in all respects, Ije bejran to 
 employ it as a primary dressing to wounds. The earth u.sed l)y Dr. Hewson was dried 
 yellow ferruginous «day which had been well sifted through a fine fiour-sieve. and he 
 claims for its use many a<lvantages. He maintains that it is '• cool and plea.saiit'' to the 
 patient as a local application, and that it has a markc<l influence in soothing jiain. In 
 burn and in carbuncle cases this relief is very striking. 
 
 Dr. llewson has satisfied himself that earth, besides being a deodorizer, lia.s a marked 
 influence in preventing putrefaction ; that in no ca.se does it provoke or aggravate inflam 
 niatory action in a wound, but that in many it retards or arrests it; and, above all. tliat 
 it ]»romotes the healing process in wounds of every description, as well as in ulcers. The 
 way in which the clay acts as a dressing may not be clear, but it seems reasonable, from 
 the evidence adduced by Dr. llewson and others, to conclude that it has by its powers of 
 ab.sorbing gases, and more jiarticularly ammonia, a chemical action upon the part to wliich 
 it is applied, and that by virtue of this action it is "an efticient means of <lelaying decay 
 and putrefaction, and of preventing fermentation in animal tissue." Besides this, it 
 excludes air from the wounded tissues, absorbs moisture and excess of discharges, and 
 helps in a measure to give support to wounded i)arts. 
 
 The dres.sing is applied directly to the wounded or ulcerated surface by dusting over 
 it the pulverized clay, or in the case of a stump by placing it upon a bed of dry clay in 
 a box extemporized of binder's board, and by completely covering in the whole surface 
 Vjy some more clay. In some cases, when the clay becomes saturated with discharge, the 
 dre.ssing has to be renewed daily ; in others, it may be left for two or more days. 
 
 Upon the whole, this mode of practice has not extended far beyond the sphere 
 occupied by its originator, and it does not seem to possess any advantages over the more 
 cleanly and simple processes which are now at the disposal of surgeons. Some years ago, 
 when Dr Hewson was in Londijn, I was tempted to give the method a trial, but I .soon 
 gave it up, as experience was not in its favor. The dirtiness of the dressing was not 
 compen.sated for by any advantage. This, however, may have been becau.se I was unable 
 to obtain the right kind of ferruginous clay. 
 
 Alcoholic Dressing of Wounds. 
 
 Hippocrates, Paracelsus, and others emjdoyed wine as a dressing to wounds, and 
 they did so under the idea that it dried the part, and with the belief that a dry condi- 
 tion was nearer a state of health, whilst humidity was nearer that of di.sease. Their 
 followers used wine in which astringents were dissolved, such as gall-nuts, oak-bark, etc. 
 All did so, moreover, with the view of arresting bleeding. In more recent times the 
 alcohol dressing has been made popular by Nelaton, who used it largely and found it of 
 value. It may be applied in the form of simple alcohol, or, which seems preferable, in 
 that of the camphorated spirit of wine, as originally used by Dionis. 
 
 The dressing is said to be a coagulant and astringent, and. with such properties, to favor 
 primary adhesion. In open wounds it is said to act as a healthy stimulant to the granu- 
 lations and as a disinfectant, thus helping repair and guarding against septica;mic changes 
 and other wound complications. Nelaton employed compresses saturated with alcohol, 
 and he believed the camphorated spirit to be u.seful only in proportion to the alcohol it 
 containetl. 
 
 M. Chedevergne asserts "that camphorated spirit of wine is, without contradiction, 
 the best disinfectant that can be found for the treatment of wounds and ulcers ; and lie 
 makes this statement after a careful investigation into the value of every known antisep- 
 tic, not excluding carbolic acid. The spirit is supposed to have the power of dissolving 
 the pus cell, of obviating its tendency to decompose, and of closing any open vessels. 
 
 Maisonneuve bathes the raw surface of the wound with the spirit, and, having 
 
52 ANTISEPTIC IRRIGATIOX OF WOUXDS. 
 
 brought the divided edges together and adjusted them with sutures or adhesive plaster 
 so placed as to allow of the free escape of discharges, envelops the whole in a Vjandage 
 steeped in tincture of arnica, and at times he applies over the whole the apjiaratus for 
 ''pneumatic aspiration." which will be again referred to. The disinfecting and cleansing 
 power of the spirit, applied in this manner, probably helps the draining influence of the 
 aspirator. 
 
 Upon the whole, the alcohol dressing may be favorably regarded, whether simple 
 alcohol or spirits of camphor be employed. It has. without doubt, a cleansing, and prob- 
 ably a disinfecting, influence on a wounded surface ; while, at the same time, it helps 
 materially to arrest capillary bleeding and that serous oozing which is so detrimental to 
 primary union. In its use, however, the surgeon should never be induced to forget 
 the value of the other essential points of practice to which attention has been drawn, 
 and particularly drainage. 
 
 Pneumatic Aspiration or Occlusion. 
 
 3Iaisonneuve"s method of •■ pneumatic aspiration." which he employed with some suc- 
 cess before 1867. and J. Guerin's plan of eff'ecting 'pneumatic occlusion." promulgated in 
 1865. were practised thus : Assuming an amputation of the thigh to have been just per- 
 formed and the vessels secured, the edges of the wound are brought together and held in 
 apposition with adhesive plaster, but without sutures. A hood of vulcanized india-rubber 
 is then passed over the stump several inches — a foot, if .space allows — from the estremitv. 
 It is essential that the aperture of the india-rubber cap should fit the limb accuratelv. but 
 the crown or lower part may hang some distance from the wound. To the centre of the crown 
 of the india-rubber cap is attached a tube of similar material about two or three feet long, 
 fitted by its opposite extremity, through a metallic canula. in a rubber plug, which fits into 
 a gallon glass jar. A second metallic tube pierces the india-rubber plug and is connected 
 with another vulcanized tube of convenient length attached to a brass exhausting-pump. 
 A few strokes of the piston morning and evening sufiice to draw the discharges from the 
 stump into the jar. where, in the absence of air, they accumulate without danger of 
 decompo.sition ; while the healing of the wound is facilitated by the accurate and 
 immovable adaptation of its surfaces and the exclusion of air. This practice of Maison- 
 neuve's has three main objects in view, all of which are good — first, to check the forma- 
 tion of matter ; second, to prevent its decomposition when formed ; and third, to prevent 
 its poisonous action on the system by entrance into the circulation. It is essentially 
 based upon the principle of "drainage." and in that point of view is vahiable. In excep- 
 tional cases, and particularly in certain cases of amputation, it ma}" be employed, but as 
 a general mode of treating stumps it does not appear to possess such advantages over 
 simpler methods as to make up for the difficulties and expense of its employment. 
 
 Antiseptic Irrigation of Wounds. 
 
 The value of the antiseptic irrigation of wounds is not at the present day likely to be 
 disputed by any surgeon, and a difference of opinion is only probable as to the antiseptic 
 which shall be used, the mode of its application, and the character of the wound to which it 
 is applicable. Every surgeon seeks to make and to keep his patients wounds as clean as 
 possible and by means of antiseptic solutions or applications to destroy, neutralize, or 
 guard against any and every outside or local influence that can pos.sibly bring about or 
 encourage chemical or fermentative changes in a wound. It is true that within the last 
 few vears a school of surtreons has Ijeen forn>ed the members of which talk of •■ antiseptic 
 surgery" and claim for themselves the title of " antiseptic surgeons," as if it were applic- 
 able to themselves alone, or rather to such of their body as have a belief in the germ 
 theory as a cause of mo.st. if not all, the surgical ills to which wounded flesh is heir, who 
 assert rather loudly and dogmatically that " antiseptic surgery" mu.st .stand or fall with 
 the theory upon which their practice is based, that no unbeliever in the theory is likely 
 to carry out the practice with any probability of success, since it is only \>\ a staunch 
 believer in the theory that care and attention to every detail of treatment sufficient to 
 bring about a good result is likely to be given. It is true, also, that the results claimed 
 for this practice are great — very great, beyond all previous belief; that, according to 
 these gentlemen, operations which in former times were looked upon as dangerous can 
 now be undertaken with a '■• certninti/"' of success, and that others which have hitherto 
 been regarded as unjustifiable are now legitimate and safe. In fact, the upholders of 
 
Asrixi'.i'i'ic ini'ji; Alios or wor.xns. 53 
 
 this tln'urv and :i(I(i|)tcr,s of this |tr:ictic«' maiiitaiii lliat i'X|ilnratiiry ami <i|M'rative 
 ineasun-s wliicli liavt; ht-i'ii n-f^ardfil as hciii^' hi'V'Miti tlie |ir(»viii<;(! <j1' tin; Hiir^'cMri 
 luav now 1)1' raliiily ami (juictiy iindiTtakcii with :i ••moni/ n'rtdinlt/" u\' heiti<^ fVtIlowcd 
 l)V ii ,u;t"»d rt'Siilt. Thus it is that our saiij;iiiiie rim/nriH talk of futtiiij; into ln-althy 
 joints with tlu' ••<■' r/ninti/" that no danger will follow, and dcudarc; that jTrcat opiTations 
 upon the lioncs of tin- knee may hf undertaken with the f'eelinir that in so doiri;: we ilo 
 not suhjeet the patient "to any risk whatirver;" that, a wecl^e-shapefl pit;ce <d' hone may 
 he taken from a deformed I'emur with the confidetK^e that so j)rodueed a compouii)l frac- 
 ture is "perfeellv safe" and '" without risk ; ' and last, hut not least, that the peritoneal 
 cavity, under antiseptic preeaution.s, may he opened '•v:ifh iui/nmifi/." 
 
 I need hardly say that much of this is hold assertion and nothiiifr more, and that it 
 is apparently due to the sanfriiine temjicrament whieli seems uttaehed to thos*; who pin 
 their faith to a takin<; theory ami adopt the practice whieh is has<;il upon it in hlind del'er- 
 enee to the authority of its distinguished oriiiinator ; for facts, calmly looked at. neither 
 hy their nuniher run- hy their weiirht justify these conclusions, hut irresistihly sufr^zest 
 that an enormous superstructure has been rai.sed by the intreiiuity of its builders upon u 
 narrow foundation, and that srood results have been too hastily attributed to causes whieli 
 have been but some of the factors of a work to whieh others efjually potent for good 
 have, without doubt, contril)uted. 
 
 Facts, indeed, have been employed by our self-styled "antiseptic" friends, as legal 
 advocates use small data which tell in their favor, to su])j»ort the cause they have in 
 hand, but not as the judge who has to weigh evidence and with an unbiased mind give 
 judgment. It is only by this explanation that we can understand how the '-antiseptic 
 ■surgeon," when he gets a good result, is so fond of asserting that such could not have 
 been brought about by any other form of practice than that which he adopted, and 
 when he is attemi)ting an operation which may in all truth be called experimental, if not 
 rash, maintains that he undertakes it ^^ nndf-r the sjira?/^' with all confidence and with a 
 " moral certainty " of meeting with success. We must admit, however, that surgery is 
 now much more successful than it was twenty years ago, and that of the many factors 
 which have brought about this result the employment of antiseptics stands forenio.st ; 
 and if we are not altogether indebted to Mr. Lister for their use, we are un<|uestionably 
 iiulel)ted to him ior the able and persistent manner in which he has both advocated their 
 employment and demonstrated their value. All honor, therefore, to the name of Lister 
 for having helped more than any one else to establish the value of anti.septic drugs and 
 antiseptic precautions in the practice of surgery all over the world. Let tho.se who smile 
 at his theory join with those who believe in it in giving him this just meed of prai.se. and 
 let those who do not believe in the efficacy of the " spray" do their best to prove to those 
 who do that all the advantages of the " anti.septic system" can be obtained by simpler 
 means than by its use. 
 
 Among these means what must be called '• antiseptic irrigation" of wounds, in my 
 judgment, stands foremost. Antiseptic irrigati(Ui means the washing of a wound with 
 an antiseptic solution with the view of destroying any and every germ or element that 
 might possibly set up chemical or fermentative changes in its secretions. It is as 
 applicable to fresh wounds, accidental or operative, as it is to the suppurative or foul, 
 and it is as valuable as a preventive as it is as a curative means. 
 
 In my own practice the solution employed is, as has already been mentioned, iodine 
 water — that is, a mixture of the tincture of iodine aiul water in the pro])ortioiis of 1 
 part to 80, or of the licjuor 1 in 160 — and after operations this should be applied hot. It 
 may be used by means of the irrigating-bottle as drawn at page 38, Fig. 3, or by means 
 of sponging. Where sponges are employed they should be well soaked in this fluid, and 
 subsequently, before the wound is dressed, should be used to ab.sorb all excess ; for this 
 lotion, when employed warm, has more power than any other of which I know to check 
 capillary bleeding, and to bring about that desirable '■ glazing" of a wounded surface 
 which is so valuable as a first step toward quick or rapid repair. In suppurating wounds 
 the same lotion cleanses better than anything else, and has the power of destroying germs 
 of evil as well as other more vaunted gormici<les. For the irrigation of a chronic abscess 
 or sinus it is equally to be advocated : indeed, as a purifying and antiseptic lotion for all 
 wounds of exfernal parts, as well as for all suppurating cavities, it can be highly recom- 
 mended. I have employed it for years past as a purifying agent, but without germicidal 
 intentions, with excellent results ; and, although I have .seen much of the spray and car- 
 bolic-acid practice, I cannot yet see that its results are better than my own. Those who 
 prefer carbolic acid as an antiseptic can use it in the same way in the strength of 1 in 
 
64 THE LISTERIAN METHOD OF DRESSING WOUNDS. 
 
 30 or 40, and thymol, boracic acid, chloride of zinc, oil of eucalyptus, or any other 
 known antiseptic, may be similarly employed. 
 
 The essential feature of the practice consists in the thorough ablution of the wounded 
 or diseased part with the anti.septic solution after the arrest of all bleeding, the drying of 
 the surface of the wound as far as possible with an antiseptic hot sponge applied with 
 njoderate pressure, and subsequently the careful dressing of the wound with some anti- 
 septic substance in the way that was described in an early page (" Protection of 
 Wounds"). 
 
 The Listerian Method of Dressing Wounds. 
 
 This methed is founded on the theory that the fermentation of the discharges of 
 wounds is due to the introduction into them from without of 
 
 " those viewless beings 
 Who.se mansion is the smallest jiarticle 
 Of tlie impa.ssive atmosphere," 
 
 now known as micro-organisms or bacteria. The practice, which is based upon the theory, 
 is framed solely and wholly with the view of destroying those aerial enemies by means 
 of the familiar cloud of carbolized spray (1 in 40) hp/ore they reach the wound, and by 
 the carbolic solution (1 in 20) when they have alighted on or entered it. the green pro- 
 tective gauze, carbolized catgut, and other paraphernalia being emploj'ed with the oV)ject 
 of guarding against the introduction of the same dangerous foes during the sub.sequent 
 progress of the case. 
 
 This method, which at its birth was named •' antiseptic," is how designated " the 
 aseptic," but the change is not acceptable, .since it contains an assumption of superiority 
 of '• the Listerian" over other forms of good antiseptic surgery when the object of all is 
 the prevention, exclusion, and destruction of the causes of fermentation in wounds. 
 
 The sponsors of the new term have evidently forgotten that Pasteur has proved that 
 '• it is the oxygen of the air weakens or extingui.shes germs ;" that Downes and Tyndall 
 have .shown that " sunlight arrests development of bacteria ;" that Lister has admitted 
 '' the probability that putrefaction in wounds is due rather to the septic matter in a con- 
 centrated form than to the diffused condition in which it exists either in water or in air ;" 
 that the spray is, beyond all question, the least important of our antiseptics ; that bac- 
 teria are unable to grow in normal serum and can only develop in that liquid when it 
 has been vitiated, whether by the addition of water or by the action of .<mall quantities 
 of the acrid products of putrefaction ;" and last, but not least, '' that the tissues of a 
 healthy living body have a power of counteracting the energies of bacteria in their 
 vicinity and preventing their development." 
 
 The surgeon who adopts the method must " act as if all the particles made visible by a 
 sunbeam were noxious, falling like snowflakes during every operation and every dressing, 
 seeking to insinuate themselves into the wound at every crevice. His aim should be to 
 destroy the intruders and effectually exclude their thronging companions." 
 
 To do this, the sl-in of ihe patient over and in the neighborhood of the intended wound 
 should be thoroughly washed with carbolic water (1 in 20), which must be allowed to act 
 for some little time, because the antiseptic has to mix with the fatty matters and to 
 penetrate into the folds of the skin, and the micro-organi.sms may be pecliliarly resistant. 
 The lianch of the operator are likewise to be cleansed with the same lotion, special care 
 being observed with the nails and the folds of skin about them. For the purification of 
 the instruments a porcelain or tin trottgh is provided and filled with the 1-20 solution, and 
 into this the instruments to be employed should be laid for at least half an hour before 
 the operation. 
 
 •• The sponges are washed in the 1-40 carbolic solution. After the operation they are 
 rinsed in water and then placed in a jar of 1-20 .solution till required again; then the 
 1-20 solution is squeezed out, and the sponge, when washed in the 1-40 lotion, is ready 
 for use. These sponges may be used for a long time — till, in fact, they wear out. In 
 some cases they get clogged with fibrine. To get rid of this, the sponge is placed in a 
 trough containing water and left for some days. The fibrine putrefies, and can then be 
 washed out readily. The sponge is then placed in a jar containing the 1-20 carbolic 
 lotion, and is ready for use when required."' 
 
 ^ From W. Watson Clievne's able article in Ashhnrst's International EncycIop<rdia of Surgery. 
 
THE Lisii:i:i AS Mi:iii(>i> or nnrssfM. \\(H\J)s. 55 
 
 '• The /iiiiificiitinii (if till (ilr is ('tt('(!ti'(l hy means (if a spray of carhfilic acid. The 
 s|>rav is product'd hy driving u rapid current oi' air tlirou^h the iiarnjw orifice of a hori- 
 zontal tnhe, which is phiced over the orifice of u more or lesH vertical one. The air, 
 rushing' over the opening; in the vertical tuhe, sucks the air out of that ; and if the lower 
 end tlips into a fluid, the fluid is sucked up and e.xpelled iVom the narrow orifice in the 
 fonii of fmclv-divided particles ctr spray. At present steam sprays are employed. The 
 fluid ill the retort is 1--0 watery solution of carholic acid, and tiiis mi.xin^' with the Hteain 
 iVom the Itoiler, forms a spray (d' ahout l-!>0. The spray is emj)loye<l during; the whole 
 ojicration — fill, in I'act, the dressing has been securely applied. 
 
 "The operation havinj; been performed with the precautions detailed, the lnrnntrrluKjr 
 niiisl /if (ii-nstril. This is done hy means ol" li<;atures (d" carliolized eatfrut. 'I'here are 
 two kiiuls (d' catiTut which are at present employed — the carholized eat<rut,' which was 
 that first intPnluce«l hy .Nlr. Lister, and the chromic-acid jrut." which lasts longer in the 
 tissues than the former and is more rapidly and easily jirepared. All Ideedin^' points are 
 tied, and the liiraturcs cut short. There is no excuse for leaving: any bleeding vessels, a.s 
 the ligatures eau.se no trouble afterward." 
 
 " With the view of excluding organisms nfter llic opcrdtlmt, the material usually 
 employed is the carbolic gauze. This is ordinary tarlatan impregnated with a mixture of 
 one part of carl)olie acid, four parts of resin, and four parts of paraffin. If the cotton 
 material were merely dipped in carbolic acid or carbolic lotion, the antiseptic would very 
 (|uicklv volatilize or be washed out by the discharge. It is neces.sary, therefore, to have 
 the antiseptic stored up, so that it may last for .some time. This is the purpose of the 
 resin. Resin and carbolic acid have a much greater affinity than water and carbolic acid. 
 Water, therefore, may pass over a mixture of resin and carbolic acid for a considerable 
 time without washing out all the anti.septic. If the gauze were impregnated with resin 
 and carbolic acid alone, it would be so .sticky as to be useless ; and therefore paraffin is 
 added to it in sufficient (juantities to do away with its .stickiness. As the gauze at ordiiuiry 
 temperatures does not give off" much carbolic acid, dust which falls on it is not deprived 
 of its fermenting property ; and if a piece of gauze covered with dust is applied over the 
 orifice of a drainage-tube, this dust may pass into the wound and entirely defeat the 
 object of the whole treatment. On the other hand, the watery solution of carbolic acid 
 acts very rapidly, and hence all that is neces.sary is to dip the layers of the gauze which 
 go next the wound in the 1.-40 lotion. Lest the carbolic acid should evaporate, the gauze, 
 if it is to be kept for some time, is preserved in closely-shutting tin boxes. 
 
 " Carbolic acid is a powerful irritant, and applied directly to a wound it will retard, or 
 even prevent, healing. With the view of overcoming this difficulty. Mr. Lister inter- 
 poses a material impervious to carbolic acid between the wound and the gauze dressing. 
 This material is termed the protective. It is ordinary oiled silk coated on both sides 
 with a thick layer of copal varnish ; outside this a .solution of dextrine is bru.shed, 
 because water runs off!" from the material without the dextrine just as from a duck's 
 back, whereas the dextrine dissolves in the lotion and the protective is equally and per- 
 fectly moistened. This protective is cut a little larger than the wound, dipped in the 
 lotion, and applied over it. Outside the protective we have the wet gauze, larger than 
 the protective and overlapping it in all directions, both together being called the ' deep 
 dressing.' 
 
 •• When used as a dressing, the carbolic gauze is packed into the hollows around the 
 wound, and then a regular dressing is applied. This consists of the gauze folded in eight 
 layers, beneath the outer layer of which is placed a piece of mackintosh cloth — what is 
 known as hat-lining. The object of this is to make the discharge traverse the whole of 
 the dressing and not pass directly through, as would be the case were the mackintosh 
 absent. If there were no mackintosh, the discharge, always passing through one part, 
 would wash out all the antiseptic in a very short time, and putrefaction would rapidly 
 occur. To avoid this risk a large quantity of gauze would be necessary, and this would 
 increase the expense of the treatment very much ; whereas by the use of the mackintosh 
 the discharge is made to pass from the centre to the edge of the dressing — that is, 
 through a mass of gauze equal in thickness to the distance from the centre to the edge 
 of the dressing. The same piece of mackintosh may be used several times — till, in fact, 
 it wears out. After the dressing has been removed it is taken out. sponged with carbolic 
 lotion, and introduced into the new dressing. Thus, though an expensive material, when 
 divided over a number of dressings, its expense becomes very little. Expense is also 
 saved by preserving the large pieces of gauze used in the dressings. They may be 
 
 1 Lancd, April 3, 1869. * Ibid., February 5, 1881. 
 
56 SUBCUTANEOUS WOUNDS. 
 
 washed and recharged with the carbolic-acid mixture. These dressings should be large, 
 and should overlap the wound for a considerable distance in every direction. 
 
 '' The dressing is ftistened on by a bandage. This may be made of carbolic gauze, 
 which is light, cheap, and u.seful in many ways. But a cheaper bandage, and one suiB- 
 ciently convenient — indeed, more convenient than the carbolic-gauze bandage in many 
 ways — may be made of thin muslin. As the dressing may not remain closely applied to 
 the skin during all the movements of the ])atient, more especially in the necii, chest, or 
 groins, there is a certain risk that air unacted on by the antiseptic may pass under the 
 dressing and reach the woimd, carrying active septic dust along with it. This danger is 
 obviated by applying an elastic bandage along the edge of the dressing. This may be 
 put sufficiently on the stretch to keep the edge of the dressing accurately in contact with 
 the skin without pressing injuriously or interfering with the circulation in the part. 
 Pins are put in along the edge of the dressing, fastening the dressing and the bandages 
 together at the important points. Safety-pins are the best for the purpose, as common 
 pins are apt to get buried and lost in the gauze." 
 
 In accidental wounds, to extirpate the germs, the wound should be washed in and out 
 with the 1-20 carbolic lotion, a syringe being employed in a case of compound fracture 
 or gunshot wound. " Care must be taken to have the external wound freely open, so 
 that the injected fluid may escape readily ; for otherwise there would be a danger of the 
 fluid penetrating among the layers of the cellular tissue and causing inflammation, or 
 even gangrene. It is well to squeeze out all the blood clots." 
 
 During an operation the surgeon should have .spread near him towels saturated with 
 the 1-20 carbolic lotion, upon which to place all instruments he may be using; a basin, 
 containing the 1-40 solution, should likewise be at hand to enable the surgeon to purify 
 his hands and instruments should they have been contaminated with septic dust. All 
 instruments and sponges should be handed through the carbolic spray. 
 
 The surijeon should know, however, for his comfort, "that there are comparatively few 
 particles capable of causing fermentation in ordinary air," that '• where no spray is at 
 hand the aseptic method may still be carried out, and that the spra}' is the least essential 
 part of the method as at present emploj'ed. The most essential part of the treatment is 
 the thorough purification of everything which comes in contact with the wound. The 
 introduction of an unpurified instrument into a wound is a much worse error, and one 
 far more likely to be followed by bad results, than the momentary deflection or cessation 
 of the spray." 
 
 " The dressing is always changed on the day following the operation, and afterward 
 the rule is that, if at the hour of the ordinary visit discharge is found at the edge of the 
 dressing, it is changed ; if not, it is left till the next day, when the same rule is followed. 
 The dres.sing is never left longer than a week unchanged. In changing the dressings the 
 spray is used." 
 
 If the surgeon does not have a spray at hand for the purpose of changing the 
 dressings, and it is necessary to expose the wound, it is pleasant to be told " that it 
 is well, by means of a syringe, to let a current of carbolic lotion flow over it when it is 
 exposed." 
 
 In fact, it may now be said that the Listerian mode of dressing has had its day, 
 though the principle upon which it is based survives, and is likely to do so. The anti- 
 septic irrigation of wounds, as considered in the previous section, is simpler and equally 
 effectual. 
 
 Subcutaneous Wounds. 
 
 When John Hunter, in 1704, in describing injuries, divided them into those in which 
 the injured parts do not communicate externally, as sprains, bruises, simple fractures of 
 bones, or divisions of tendons, and those which have an external communication, as com- 
 pound fractures and wounds of all kinds, and laid it down as a law that the injuries of 
 the first class seldom inflame, whilst those of the second commonly both inflame and sup- 
 purate, he established a principle of which, "indeed, it seems hardly possible to exaggerate 
 the importance " (Paget), and laid the foundation of a branch of surgical practice now 
 known as uMbcufaneons sniyfny. Why it is that extensive injuries to soft parts, when 
 covered with skin, should undergo quiet and thorough repair with little or no constitu- 
 tional disturbance may not be clear, but daily experience teaches us that dislocations of 
 large joints, fractures of bones, severe contusions and lacerations of soft parts associated 
 with copious local haamorrhages, and even cru.shes of all the subcutaneous tissues of a 
 foot or hand, as a rule, do well provided that they are not interfered with by meddle- 
 
SUBCUTANEOUS WOUNDS. 57 
 
 xiiiH' jtnict ice. hut arc [ilacnl in tlir iiiusi I'.ivor.ilili! |ni>itiori I'nr natural rc|)air tu carry 
 (lilt its silent work ; wlicrcas the same cxiicricncc tells lis witli no uncertain voice that 
 the presence nt" a wound, however small, may chanj^e matters all round and turn an 
 injury which, had it heeii siihciitaiicous, mij^ht have hecn n!<;arded as trivial into one of 
 a serious and coni]ilicated kind. This I'act is widl exemplilicd in the difi'ereiit course 
 asuallv taken hy a simple and a compound dislocation or fracture. 
 
 What there is in tin- air that makes this with' difVereiice is now, as it ev<?r has heen, 
 open to ari;umcnt ; and whether it is tht! stimiilatinir or (diemical influence of the oxyj^en, 
 the irritating- influence of atuKtspheric; jfernis, the len<;th ol" time the part is exposed 
 rather than the mere I'act of exposure, or some other cause, may be subject of dispute. 
 In modern times the <;erm theory has found much favor and has been the fashic>n, and 
 attempts have heen made to assign to the presence of germs every evil influence, and tw 
 regard tluMii as the cause of inflamniation and suppuration in every o|»cn wound. Hut 
 this view can hardly be sustained; Inr, on the one hand, even in subcutaneous injuries, 
 in which no air can get in, inflammation and suppuration may ensue, while, on the other 
 hand, in even severe examples of fractured ribs complicated with (Miiphysema over the 
 chest, l>ody, head, and extremities — in ca.ses in which the wholt; cellular tissue of the 
 body seems infiltrated with unfiltered air under mo.st unfavorable circumstances — it is 
 (|uite exceptional lor any inflammation of the infiltrated parts to take place, [ndeed, I 
 may say that I have never seen an instance in which it occurred. 
 
 Effects of Injection of Air into Tissues. — As corroborative evidence I may 
 refer to some observations made in 1S.")7 by .Malgaigne, who, to test this f|uestion, made 
 animals emphysematous with common unfiltered air and then fractured their bones, 
 divided their tendons, and opened their joints subcntancoutili/ : though the parts operated 
 upon were surrounded with air no inflammation followed. I may refer also to the experi- 
 ments of Wegner (^Lan;/eiiback^6 Archives, vol. xx.), who injected air derived from the 
 post-mortem room into the subcutaneous tissue of rabbits with impunity. 
 
 For my own part, I am disposed to think it is not the mere exposure of a wounded 
 part ttj the influence of air that does the harm, but its prolonged exposure, since it is 
 certain that where wounds are sealed rapidly after the receipt of an injury, and are thus 
 placed much in the position of subcutaneous injuries, repair goes on silently and well. 
 Even bad compound fractures, when sealed early i'rom the influence of air, heal, as a rule, 
 like subcutaneous injuries. 
 
 Repair of Subcutaneous Wounds. — Tt may be accepted as a truth that sub- 
 cutaneous Wounds art^ repaired much in the same way as open wounds that heal by 
 quick or primary union — that is, when the wounded hard or soft tissues are brought or 
 kept in contact, they simply reunite. The process of repair in both cases is a quiet 
 physiological one not unlike that of development and growth. The action that attends 
 the process is just enough to bring about the required result, but no more. AVhen it is 
 excessive, inflammation is said to exist; and this inflammation, in subcutaneous as in 
 open wounds, always ])revents, checks, arrests, or undoes the work of repair. In truth, 
 the less there is of inflammation in a wounded part, subcutaneous or open, the more per- 
 fect and steady is the reparative process. When inflamniation takes place in the site of 
 some subcutaneous operation, the process of repair is likely to be interfered with, if not 
 arrested ; for, as Paget observes, "the more manifest are the signs of inflammation, the 
 less is the (juantity of theproper reparative material, and the slower, in the end, is the 
 process of repair." 
 
 To Paget and W. Adams in England we are chiefly indebted for our knowledge of 
 this subject, and I shall use as much as possible Adamss description of this process, as 
 published in 1800 in his work on the Reparative Process of Human Tendons after Divis- 
 ion. His investigations have confirmed those of Paget, as well as added to our stock of 
 knowledge. 
 
 Where tendons are subcutaueously divided and drawn asunder, their repair takes 
 place as follows : 
 
 When such a tendon as the tendo Achillis is divided subcutaueously, the divided 
 ends separate, in an infant for half an inch and in an adult from one to two inches, the 
 degree depending much upon the healthy condition of the divided muscle and the amount 
 of movement subsequently permitted in the ankle-joint. 
 
 The reparative process begins by increased vascularity in the sheath of the tendon, 
 which is followed by the infiltration of a blastematous material into the spaces between 
 the fibrous elements of the sheath. This nuiterial exhi))its the development of innumer- 
 able small nuclei, a few cells of large size and irregular form, with granular contents, or, 
 
58 TREATMEyr OF SUBCUTAyEOl'S wouyDS. 
 
 perhaps, with one or more nuclei and studded with minute molecules of oil. A blastema- 
 tous material in which the cell form.s do not develop beyond the stage of nuclei appears 
 to be the proper reparative material from which new tendon is developed. This nucleated 
 blastema soon becomes vascular, capillary vessels havinir been seen in it on the eighteenth 
 day ; the nuclei assume an elongated, spindle-, or oat-shaped form, and are seen, after the 
 addition of acetic acid, to be arranged in parallel linear series. The tissue becomes grad- 
 ually more fibrillated. and at last fibrous, a solid bond of union subsef|uently forming 
 between the divided extremities of the tendon. The uniting medium is tough to the 
 touch, but to the eye presents, even for at least three years, a grayish, translucent appear- 
 ance, distinguishing it at once from the glistening old tendon. This new tissue remains 
 during life, and has little tendency to contract subsequently. Adams's observations 
 rather led him to the conclu.sion that the required portion of new tendon is to be obtained 
 during a lengthened period of formation — that is, about two to three weeks — under the 
 ordinary conditions of health ; but in paralytic cases, as in others of feeble health, this 
 period may be doubled. 
 
 Adams informs us, also, that the divided extremities of the old tendon take no active 
 part in the reparative process during its earlier stages, although at the later the cut ends 
 become rounded and their structure softened. They become enlarged and exhibit a tend- 
 ency to split, and thin streaks of new material similar to that already described are seen 
 between their fibres; the ends are joined by these means. At a later period the bulbous 
 enlargement gradually diminishes. 
 
 When a tendon is divided a second time, there is but little separation of its ends ; 
 and this is probably due to adhesion of the new tendon to the neighboring fibro-cellular 
 tissue, in which fact is found an explanation of the unsatisfactory results of second 
 operations. 
 
 There is no reason for believing that in the treatment of deformities by tenotomy 
 direct approximation and reunion of the divided extremities of the tendon must first be 
 obtained, and that the required elongation is afterward to be procured by gradual 
 mechanical extension of the new connecting medium, as we would stretch a piece of 
 india-rubber. 
 
 When much blood is effused between the divided ends of the tendon, it has to be 
 absorbed ; it acts merely as a foreign body in the part, and retards repair. 
 
 Treatment of Subcutaneous Wounds. 
 
 When rightly treated, these wounds are generally repaired readily, and. as Hunter 
 asserted, without inflammation ; but when not rightly treated. " the subcutaneous action 
 of a wound is not of itself a sufficient protection against inflammatory complications, and 
 a clumsily-performed subcutaneous operation may be as dangerous as an open wound — 
 sometimes even more so' (W. Adams). 
 
 In the treatment of these as of open wounds there are. consequently, essential points 
 of practice to be ob.served in order that good results may be obtained, and they are not 
 unlike those which have been laid down for the treatment of open wounds — that is to say, 
 the injured parts are to be placed as far as possible in a position of ea.se, and in which the 
 contact of the divided tissues is assured when contact is called for. The parts are, moreover, 
 to be fixed, by splints, bandages, or other dressings, in a condition of absolute immobility. 
 The seat of injury is to be protected from all outside injurious influences and to be sup- 
 ported by moderate pressure, and. what is more, is to be undisturbed, in order that neither 
 by manipulation nor movement shall repair be retarded; for a subcutaneous wound is as 
 susceptible to injury from mechanical interference as is an open wound. In treating the 
 wounds made by the operations of subcutaneous surgery the same principles of practice 
 are applicable, and they are well summed up by Adams as follows : 
 
 The conditions requisite to render the subcutaneous operations exempt from inflam- 
 mation are as follows: 1. That the knife used must be of small size; 2. That the oper- 
 ation must be performed quickly and readily, with decision rather than force, and with as 
 little disturbance to the soft parts as possible ; 3. That the wound must be immediately 
 clo.sed and a compress and bandage applied, so as to prevent eff'usion and to support the 
 part ; 4. That perfect (juiescence to the part be ensured for three or four days, and the 
 dressing remain undisturbed. When all these conditions are strictly observed, it matters 
 little whether large muscles or tendons or ligaments are divided, or even whether the 
 larger joints of the body are opened. From all this it is to be gathered that to the treat- 
 ment of subcutaneous wounds, whether of accidental or operative origin, •• position," 
 
VUMl'l.lCATloSS (,F worsDs. 59 
 
 • iiiiiiiohility. ' " pressure " to sii|i|Miit the |i:irt, and " time ' for repair to perfeet itself, 
 are tiie four essential re(|uisite> In In- provided for. 
 
 Complications of Wounds. 
 
 On the well-l'ounded assiiuiplioii that a wound, wlien made int<» healthy tissue.s in 
 a hi'althy suhjeet. will heal hy natural proees.ses if jdaeed in tlu; luost favorable position 
 for ri'pair aiul //o/ interjirnl uit/i, it cannot well he disputed, when a wound doe.s not lieul 
 thus kindly, that there must be some ob.staele or hindrance to its natural progress ; and 
 this will doubtless be i'ouiul either in the nature oi" the wound it.self, or the mode in 
 which it has been treated, or in the peculiarities of the subject of the wound, rir the sur- 
 rouudinirs of the case. 
 
 When the hindrance is due to the " uohik/ ifsc//"' or to it.s '' /rctUmcnf," it may be 
 that some foreiLMi body has been left to irritate; that the h;c'morrha];re which ensued 
 " primarily "' on its receipt has not been effectually arrested, and that a clot has formed 
 between the edjres of the wound; that a •'recurring" bleedin/z has taken place within 
 a day or so after the intliction of the wound and its first dressing from srune inifierfection 
 in the treatment of the bleedinj: vessel ftr from excessive reaction ; or that a collection 
 of serum has been allowed to form in the depths of the injured tissues. In most of 
 these ea.ses the causes of non-repair are clearly referable to a want of care or skill on the 
 part of the surgeon who has had the early treatment of the case, and must be set down 
 as jtreventable causes. By want of care the edges of the wound may not have been 
 properly adjusted or kept in apposition, the injured limb may not have been made 
 immobile, and as a result spasmodic muscular movements and jumpings of the limb may 
 have been excited ; or an insufficient provision may have been made for drainage, and. as 
 a consef{uence. tlie wound may have been irritated by retained secretions, and po.ssibly 
 made to inflame by the " teiision " which the retained secretions have produced. Harm 
 may also have been brought about by the want of due attention to the dressing of the 
 wound, and to its efficient protection from outside injurious influences. Other cause of 
 non-repair may be the unsuitable character of the dressing u.sed or the position in which 
 the wound has been placed. 
 
 When the obstacle to natural repair exists in the ^^ suhjrcf of the womur' or in the 
 surroundings of the case, it may perhaps be found in the age, temperament, or feebleness 
 of the patient, as expressed by deficiency in the healing act, excess of pain, or inflamma- 
 tion of the wounded parts, or, again, in the unhealthy atmospheric condition of the 
 patient's chamber or residence, or in the unsuitable character of the patient's food, or 
 in want of proper nursing. Under any circumstances, the ob.stacle to repair will be 
 found in one or more of these causes, and it is for the watchful eye of the surgeon to 
 discover the particular defect, in order that he may apply the proper remedy. 
 
 It is well, however, for the student to recognize the fact that most of the causes of 
 want of repair are preventable, and that they are, as a rule, due to some want of care in 
 the primary dressing of the wound ; let it be repeated, therefore, that in all cases and 
 under all circumstances too much care cannot be bestowed upon the management of fresh 
 or recent wounds to carry out the essential points of treatment to which attention has 
 been so often drawn. 
 
 Consecutive Haemorrhage. — This form of bleeding is that which takes place 
 within twenty-four or forty-eight hours after the reception of the wound. When it 
 occurs, it is of little consequence whether it is to be attributed to some imperfection of 
 the means employed to check the primary haemorrhage, or to the reopening, during the 
 period of reaction, of a vessel which had been temporarily sealed by a clot at an earlier 
 period of the case. It has to be dealt with, and with decision. When trifling in amount, 
 it need not be regarded with anxiety, and more particularly when there is room for the 
 blood to escape through the drainage-opening or tube, although even then it will be well 
 for the surgeon to see that the wounded part is elevated and watched. If the bleeding 
 vessel be a small or cutaneous one. these means will probably be enough ; if. however, 
 the bleeding is persistent, or if the parts about the wound swell and become tense and 
 painful, and more particularly if pallor of the .skin, feebleness of pulse, restlessness, and 
 other signs of collapse furnish definite signs and symptoms of loss of blood, the wound 
 must be opened, the clots turned out. the source of the bleeding looked for. and the vessel 
 secured. 
 
 At times the mere opening and exposure of the wound will arrest bleeding, and under 
 these circumstances, when the bleeding vessel cannot be found, it is well to have the 
 
60 COMPLICATIONS OF WOUNDS. 
 
 parts exposed for a few hours, and eitlier to bring them together again when they have 
 glazed and when most chances of bleeding have passed, or to leave them open to granu- 
 late. The wound should, however, be left open under only exceptional circumstances — 
 when the hope of quick union is very small or when such union is undesirable. 
 
 When tlie bleeding vessel has been found, it is to be secured, and the wound treated 
 as a fresh one and reclosed. At times, where oozing of blood is persistent, moderate 
 pressure upon a wound does much good, and this may be well applied by means of an 
 ordinary or a rubber bandage over a sponge or elastic antiseptic pad. Care must be 
 taken, however, that the pressure be not too great. 
 
 Secondary Hsemorrhage. — This is the form of bleeding which occurs after 
 the lapse of two or three days. It may occasionally be due to the existence of the 
 hjxjmorrhage diathesis, but is more commonly owing to some ulceration of the vessel in 
 the line of ligation before the vessel itself has been closed by natural processes, or to 
 some sloughing of the end of the divided artery or vein, with or without sloughing of the 
 wound itself; to some imperfection in the means employed for the arrest of the primary 
 bleeding, or to the accidental separation of a ligature. When it takes place in a wound 
 that appears to be healthy, and in which the reparative process seems to have progressed 
 in a satisfactory manner, the h;emorrhage will probably be found to have come from a 
 vessel that has been imperfectly secured or the end of which has been irreparably injured, 
 and under these circumstances, if the bleeding be profuse and evidently from a large 
 artery, the wound must be reopened and the bleeding orifice sought for and dealt with as 
 in the original wound. But if, on the other hand, the bleeding is not severe and the 
 probabilities of the case are that the vessel is not large, the injured limb should be raised 
 and moderate pressure applied ; for by such means there will be a good prospect of a 
 successful issue being obtained. Should a recurrence of the bleeding, however, occur, 
 and the effects of loss of blood show themselves, the wound must be reopened and the 
 bleeding vessel secured. When the bleeding comes from a vessel which, with the sur- 
 rounding tissues, has sloughed, it is a better practice to secure the vessel at a distance from 
 the wound. When, however, the bleeding takes place in a case in which an artery has 
 been tvcl In its contuiuiff/, the surgeon should delay reopening the wound, unless the evi- 
 dence be strong that the blood comes from the supplying or afferent trunk, since experi- 
 ence has fairly taught us that in a large number of these cases the blood comes from the 
 lower or distal orifice of the ligatured vessel, and that under such circumstances it may 
 be readily arrested by the elevation of the limb and well-applied pressure. In all cases, 
 however, when the bleeding is recurrent and persistent, the wounded vessel should be 
 looked for and secured either at the seat of bleeding or, when this is either diificult or 
 dangerous, at a higher point. 
 
 Pain. — There is no effect of wound or operation which varies more in degree than 
 pain. In one case the subject of a simple wound will suffer much pain, while another 
 individual with a severe wound will experience but little. Persons vary greatly in regard 
 to nervous susceptibility; nevertheless, pain is under all circumstances a serious symptom 
 and a grave evil, for it tends to depress the moral and physical forces of the strongest 
 patient, and to exhaust even to death the feeble powers of the fragile. I am convinced 
 that I have known pain to kill. 
 
 In all wounds, therefore, operative or otherwise, it is important that pain should be 
 guarded against ; and for this object surgeons can do much by care and forethought. 
 The wounded parts should be rendered immobile, well protected, and so placed as to give 
 rise to the least inconvenience or distress. The dressings, likewise, should be so regulated 
 as to give comfort. In most wounds, and after most operations, some pain will be neces- 
 sarily experienced, but as a general rule it will subside in the course of one or two hours. 
 To relieve this symptom, however, it is well to give opium in some of its forms; and for 
 this purpose, after an operation in which an auEesthetic has been used, it is an excellent 
 plan to introduce into the rectum, before the 'patient becomes conscious, a suppository 
 containing from one-third to one-half a grain of morphia. The anodyne begins to exer- 
 cise its calming influence before the effects of the anaesthetic have quite passed off, and 
 in some instances the action of the two drugs appears to be continuous. In other cases 
 the subcutaneous injection of a ><}naU dose of morphia may be resorted to, or a full dose 
 of the same drug may be given by the mouth. Under all circumstances, the early pain 
 after a wound or operation is to be subdued. 
 
 Causes of Persistent Pain. — When the pain is persistent and continuous after 
 the healing process has progressed or perfected itself, some nerve complication may be 
 suspected." It nnxy be that some nerve branch has been included in the ligature placed 
 
DEFECTS IS HE A Lisa PROCESS. 61 
 
 arouixl a vi-ssrl, <»r some iitrv»- trunk may Ix- >•) iiiv<»lv<(l in tlie cicatrix of" tlu- wound or 
 so liountl to l)one or fascia as to be kept continually irritated or even inflamed, or it may 
 be tliat no definite cause for the pain can lie made out. when the case, for want of better 
 knowK'dtre. is ret:arded as neuraifric. 
 
 When the cause of the pain can be dfttrmitn'd, tliis shouhl lie removed ; and whi-n no 
 cause can be ascertained, the sur^'con may be justified in cuttin<: down on the affected nerve 
 and stretchinir it or in subcutaneously dividinj; it, as su<r<;ested by Ilaticock. As constitu- 
 tional n-medii's narcotics may f»e given, with tonics such as <|uinine, iron, or arsenic. 
 
 Muscular Spasms. — The muscuhir spasm.s or twitchings which foUow wo\inds, 
 and iiion particularlv amputations, can <renerally be prevented by the careful apidication 
 \j\' splints aiul well-ilirected jiressure. They should be put down as preventable sources 
 of distress, and should be guarded against in tlie early dressing of the ca.se. Well- 
 adjusted pressure, with rest of the injured part, is the one thing to be relied upon to 
 jirevent and relieve this .symptom, and it rarely fails. The judicious use of narcotics 
 should, at the same time, not be neglected. 
 
 Defects in the Healing Process and Diseases of Granulation. 
 
 Defects in the healing process may show themselves in either " dijicifury'' or '^•excesa'' 
 of action, or in some morliid state of the granulating wound. 
 
 Deficiency of Action. — In the old and in the very feeble, whether from di.sease 
 or otherwise, deficiency in the reparative power is to be expected, since for repair a bal- 
 ance of reserve force at the Vjank of health is requisite, and where such a balance is 
 absent the extra force required for healing will be deficient. Wounds in subjects such 
 as these, consequently, simply fail to heal, or heal slowly or in the worst way, their fail- 
 ure resulting from a want of either the right quantity or the right kind of nutritive 
 supply and nerve force. In wounds in which quick union is aimed at the parts which 
 have been brought together will simply not unite, and they will remain together only as 
 long as they are held in position by the mechanical means emnloyed for the purpose. 
 
 In the young and in the middle-aged the same failure in repair is likewise at times 
 seen in cases of hare-lip or other plastic operations in which quick union is needed for 
 success; the parts do not unite by primary adhesion, but gape and granulate, and the 
 operations consequently fail. In such patients, also, fractures sometimes fail to unite as 
 they ought, or unite but slowly : and this ma}' be the case even when no definite cause for 
 the deficiency in the reparative process can be detected. In all such in.stances, however, 
 there is want of power from some general or local caii.se, which must be detected before 
 treatment can be rationally or successfully applied. 
 
 In wounds in which union by primary adhesion is looked for. the failure ma}- be 
 partial or complete. When it is complftf., the wound must be regarded and treated as an 
 open one ; and under these circumstances the sutures should be removed and the surface 
 clean.sed and kept clean, and then stimulated by some dressing, such as carbolized oil 1 
 to -io. terebene and oil 1 to -i. boracic acid lotion 1 to lU. or boracic acid ointment 1 to 5 ; 
 or chloral or chlorate of potassium lotion 10 grains to the ounce. At the same time, the 
 wounded part should be placed in the most comfortable position, and in that which will 
 be mo.st favorable for the process of repair. The constitutional treatment .should like- 
 wise be of a tonic and stimulating character, with good, abundant, though simple, food, 
 and with wine or spirits in sufficient quantity to aid digestion and to enable the feeble 
 heart to send its contents to the nerve centres, to give them force, and to the digestive 
 apparatus, to enable it to utilize the food and pass on waste matter. The patient at the 
 same time should be placed in the best hyLnoiiic surroundiiiLrs. 
 
 Treatment when Partial Union has taken Place. — When, however, the 
 
 failure in primary adhesion is not complete, but j»irfinl. and when there is the .smallest 
 foundation for the hope that by keeping the parts together the required repair may yet be 
 secured, the sutures should be left in position, the wound cleansed with some medicated 
 anti.septic lotion, and, if necessary, either another suture introduced or some other means 
 employed to bring and to keep the parts well together. Even should failure follow the 
 attempt to gain primary adhesion, success may crown an effort made to secure secondary 
 adhesion of the granulatings surfaces or union by the third intention. 
 
 AVhere the cause of non-union is local and only temporary, these measures will often 
 succeed, and will turn what seemed to be a failure into a satisfactory result. In hare-lip. 
 and in mo.st plastic operations, a rigid adherence to this surgery of hope and discretion 
 is to be highly commended. 
 
62 DEFECTS IN HEALING PROCESS. 
 
 Defects in the Healing Process from Excess of Action or Inflamma- 
 tion. — Wluiii excess of action takes place in a wound in which repair by primary adhe- 
 .sion is looked for, disappointment, in all probability, will be the result ; for whenever 
 there is in a wounded part more vascular action than is required for the reparative pro- 
 cess to perfect its work, repair is first interfered with, then stopped, and finally the 
 wound, when not held toircther mechanically by sutures, strappinji, or bandages, gapes or 
 opens. 
 
 When excess of action or inflammation attacks an open, wound that is granulating 
 and cicatrizing, repair likewise ceases; the granulations, instead of presenting a healthy, 
 florid appearance and secreting a bland, creamy ])us, become oedematous or glazed, what 
 has been a granulating becomes an ulcerating surface, and the secretion from the wound 
 changes from pus to a thin serous discharge, with more or less dehru of tissue. The 
 thin red marginal line, with its cicatrizing edge extending on to the granulating surface, 
 presents a more or less extended area of vascular congestion, this being, when the action 
 is Nthrnir, red to an extreme degree, but when asfhtu'f; tending toward blue, the redness 
 •shading off" in intensity toward the blue lividity of congestion. The surrounding parts, 
 moreover, will under these circumstances be tense from inflammatory eff'usion. hot and 
 painful when the inflammation is acute ; but when this is of a lower tyi)e, they will be 
 a'dematous, boggy, less painful because less tense and less hot. When the local inflam- 
 mation is sthenic, the constitutional disturbance will coincide with it in type, and the 
 symptoms will be those of inflammatory fever ; Avhcii the local action is of a low and 
 asthenic form, the constitutional symptoms will partake of the same nature, and will 
 approach those of low fever. 
 
 It is to be known, and also remembered, that the acute or i^theuic form of inflamma- 
 tion, as a rule, attacks a wound when newly made and is generally excited by some local 
 cause — possibly from the original injury, more probably from some imperfection in its 
 primary dressing, and most probably from the retention of some irritating fluid in the 
 depths of the wound from want of proper drainage. This is more likely to occur in 
 wounds of certain parts or tissues — as in wounds of joints, wounds of large cavities, and 
 deep punctured wounds — than in lesions ol' another character. 
 
 The asthenic form of inflammation, as a rule, attacks wounds at a more advanced 
 period — when the first eff'ort at natural repair has been made and has more or less suc- 
 ceeded, and when it might seem as if the effort to repair the part and the power to efl'ect 
 that repair were not commensurate. At any rate, in the treatment of these two forms 
 of inflammation when attacking wounds, it will be safe to assume that such is the fact ; 
 for while in the acute or sthenic variety a local cause for its production should be looked 
 for in order that it may be remedied, in the asthenic or later kind the recognition of the 
 fact that the inflammation is due to a (Icficifiicy of general jiower is all-important. 
 
 Treatment of Inflammation Affecting Wounds. — Tn the sfhenir form of 
 
 inflammation the local and general action is to be subdued by giving free vent to pent- 
 up fluids by the local application of ice or of some other means of applying cold, by the 
 local abstraction of blood, and by free purgation. In the latter purpose there is nothing 
 better, after a good purge, than repeated small doses of a saline cathartic, such as Epsom 
 salts. When suppuration takes place, it must be suitably dealt with. 
 
 In the asthenic form general tonics with stimulants and nutritious food are essential ; 
 locally, absolute cleanliness, the free exposure of the wound for purposes of drainage, 
 and the constant use of such stimulating antiseptic applications as the nature of the case 
 may suggest, with, possibly, warm medicated irrigation, should be employed. Cold, 
 locally applied, is rarely beneficial. 
 
 Diseases of Granulations. 
 
 When an open wound heals or a cavity fills up with reparative material, it does so by 
 a process of granulation ; and when this process takes place in a healthy subject and 
 under favorable conditions, the granulations present certain appearances known as healthy. 
 When, however, the same kind of repair is being effected in a feeble or diseased subject 
 or under circumstances which are not favorable for its progress, the granulations present 
 different appearances, these being, as it Avere, pathohx/ical, in contradistinction to those 
 which are seen when the ordinary jihi/sioJngical process of repair is being carried out — a 
 process which is very closely allied to, if not identical with, that of development and 
 growth. 
 
 In a healthy surface the granulations appear as small conical masses of granulation 
 
JUS/.AShS OF t;i:A.\lLAT/'K\S. i]:i 
 
 tis.siu' cfivficil witli a tliiti laytT of j>iis crlls. 'J'lii'V an- of a l»ri;rlit florid-ri'il colnr, and 
 are tViiiL'i'il at their skin Ixmler witli tlie well-known thin hhie line which is so indieutive 
 tit" healthy '• e'eatri/.ation.' Diirini: the whoh- ot" tin- healinj; process this appearance is 
 luaintaineil. the only visihle elian^e heinj; the trrailiial <liniiniition of tlie f:raiiulatin<4 sur- 
 face liy the steaily approach ot" the "thin hlue line" towanl the centre. llealthv wounds 
 underiro contraction at the rate ot troni one to one and a halt' inches a wer-k. In the 
 dit^erent ap|»earances of these •rrunulations under <li verse circumstances, the educated eve 
 of the surireon can ra])idly read not only every iniportunt chan<:e in the Imdilv condition 
 of the patient, hut almost every variation, from day to day. in the patient's health. I 
 have heeii huitr in the habit of de.serihin<r a granulating; surface as a kind of weatlier- 
 frlass or harometer of health in which the surgeon can read in the changed a|>pearance of 
 the granulations themselves, and of the ''• thin hlue line" of cicatrization, the slightest 
 deviations from the healthy tyjie; for while it is true that as long as a granulating surface 
 is healing kindly the inference is correct that the subject of the " sore" is liealtliv, it i.s 
 ei|ually certain, when the surface lias deviated from the healthy ]»ath. that there is .some- 
 thing wrong either in the patient, in the part itself, or in its treatment. Thus, in a patient 
 who is aniomic, the granulations will he pale and bloodless; an<] when this condition has 
 been id" long >tantling, they will lose their small conical form and ajipear as coarse watery 
 elevations. When there is any interference with the return of the venous blood from the 
 granulating i)art. from either heart disease, the dependent position of the limb, or the 
 improper u.so or bad application of bandages or other mechanical appliances, the granu- 
 lations will appear '• congested " to variable degrees, and may even bleed. They may be 
 so full of venous blood as to put on the purple appearance which suggested to the old 
 authors the name of the '"juniper ulcer,'' the granulations looking blue or black as a 
 juniper. When the ulcer bleeds, it is generally called Jtumorrhiijic. 
 
 WJien the reparative power is feeble and granulations form, they will be of a pale, 
 watery, (edematous character, and the discharge from them will not be normal pus. but a 
 seropurulent tluid ; the granulations that form are of a weak type, and the sore then con- 
 stitutes what is wrongly called a " weak" ulcer. 
 
 When from some constitutional or local cause the reparative process is more deticient 
 in force, the surface of the sore will either present a few ill-formed and feeble granulating 
 spots or appear smooth and apparently wanting in granulations altogether, and look to the 
 eye not unlike the tense mucous surface of the pharynx. In other cases, in which this 
 deficiency in force is greater, the sore may present a greenish, dirty-colored surface, dis- 
 charging an acrid or putrid substance which is clearly blood and serum mixed with the 
 decomposing elements of dead tissue, the ill-formed granulation or granulative tis.sue in 
 these cases dying superficially as soon as formed, for want of power to live and develop. 
 
 In still more extreme cases of deficiency of power, what may have been a reparative 
 process not only ceases to be so. but becomes retrograde ; what had been a co7istructive 
 changes into a fleatructue force, and the tissues that should have been repaired break 
 down and undergo molecular disintegration : the sore, instead of healing, becomes an 
 ulcer, the new tissue dying from want of vitality. 
 
 On the other hand, exi-fn^i of action may at times aifect a healing sore ; and when it 
 does so, it aft'ects the granulating process as much as it has been .shown to do a wound in 
 which quick union or primary adhesion is sought for. In the stage of irritation, or fhat 
 in which the granulation tissue is simply overstimulated, overaction shows it.self in an 
 excess of secretion from the granulating surface, in the shape of pus. and probably in 
 some increase in the size and redness of the granulations themselves ; and when this is 
 other than a passing condition from some temporary cause, it will soon become one of 
 inflammation. 
 
 When inflammation attacks a granulating sore, changes will occur similar to those 
 which have been described as taking place ^vhen it affects a healing wound. Physiolog- 
 ically there will be an arrest of the healing process, an arrest of seereti(»n from the granu- 
 lations, and, if the action be lasting, a change from what had been a healing process to 
 one of ulceration. The ulceration will be more or less rapid and associated with all the 
 local and general phenomena of inflammation, such as redness and heat of the margins 
 of the sore and the adjoining tissues, with pain and swelling. The degree and character 
 of the inflammation regulate these appearances ; an inflamed sore or granulating surface 
 presents as many different aspects as there are degrees or kinds of inflammation, for 
 inflammation must be regarded as an accidental complication of the sore, and it may 
 attack it in any stage of its progress or in any condition. 
 
 At times the granulating force may be in excess and so act as to prevent repair. The 
 
64 ON INFLAMMATION. 
 
 graiiulatioiis .sprout above and beyond tlie inargins in which tlie " outifying " action is 
 carried out. and appear either as elevated luxuriant growths in the centre of a sore or at 
 the orifice of a sinus, or as overhanging florid granulations at the cicatrizing border. In 
 these cases there is simply an excess of force, and this excess exliibits itself in fungous 
 granulations. 
 
 Again, a granulating wound, when of longstanding, may show on its surface or in its 
 surroundings evidence of the existence of many constitutional or specific conditions — that 
 is to say, a chronic sore in a patient who has a syphilitic taint may present features by 
 which the presence of the syphilitic poison can be recognized, and a chronic sore in a 
 scrofulous subject will manifest conditions which, if not special, as in the .syphilitic, will 
 be clear enough to indicate sufficient feebleness and torpidity of action to suggest the 
 existence of some general dyscrasia. 
 
 On Inflammation. 
 
 When a visible part is inflamed, there are four notable phenomena to be observed — 
 namely, redness, heat, pain, and swelling — and these four symptoms are all associated 
 with, if they are not directly due to, an active congestion of the capillaries, with more or 
 less blood stasis of the inflamed tissue. This hypersiemia, or congestion, is, moreover, 
 accompanied with cell changes in the seat of inflammation. There is likewise an arrest 
 or annihilation of the functions of the part, and in the case of a wound an arrest of its 
 repair, and later on destructive changes. Redness and heat are the most typical of these 
 four symptoms, and heat is the more characteristic, increase of heat being, without 
 doubt, the most important clinical local symptom of inflammation. 
 
 The ^'' reditesit" may be localized or diffused, of a bright-red color or of a livid hue, 
 the former tint indicating a healthy or sthenic, the latter (evidencing want of power) an 
 asthenic, inflammation. It is clearly due to the capillary injection of the part, for in the 
 sthenic form the circulation through the capillaries is more active than it is in the asthenic. 
 in which the dusky congested livid color suggests blood stasis. 
 
 The " increase of heat " is probably due to the accelerated flow of overheated blood 
 through the hyperajmic tissues, as well as to increased activity in the tissue changes of 
 the inflamed part ; but the local heat probably is never greater than that of the blood. 
 John Hunter's sagacious utterance on the sul)ject one hundred years ago—" that a local 
 inflammation cannot raise the temperature of an inflamed part above the source of the 
 circulation " — being declared by Sanderson now to be correct both in fact and theory. 
 
 The '■'■ swe-Iling'' or ''■hardness'" is to be explained by the nature of the tissue involved 
 and the degree of blood stasis which is attained in the tissues. The serum of the blood, 
 with its coagulable lymph, passively exudes from the gorged capillaries into the con- 
 nective tissue of the inflamed part in the early stage of inflammation when the stasis is 
 incomplete, and the emigration of the white blood corpuscles or leucocytes or proto- 
 plasmic atoms follows when it is more so. Absolute death of the involved tissue takes 
 place when the circulation through the capillaries is entirely stopped, the exudation from 
 the slowly-flowing blood stream of corpuscular liquid being, in the words of Sanderson, 
 *' the central phenomenon of inflammation." 
 
 '" Ffxin " is a symptom which vai'ies much as to its character as well as to its intensity, 
 and depends a great deal upon the amount of tension in the inflamed part. In inflamma- 
 tion of the bone, periosteum, or of any part bound down by an unresisting fibrous tissue, 
 such as the coat of the testis, the sclerotic of the eye, or the socket of a tooth, the pain 
 is intense ; in rheumatism in which the fibrous structures of the joints are inflamed it is 
 also marked. Probably it is caused by direct pressure on the extremities of the nerves 
 of the stretched or tense tissue. 
 
 We thus have redness, heat, streUinff. and pain as symptoms of overaction of a part, 
 or what is called in flam mat ion, and they one and all appear to be direct consequences of 
 extreme capillary vascularity of the tissue, whether that be the result of a wound or not. 
 The blood stream through an inflamed limb has been demonstrated by experiment to 
 exceed the normal flow in the proportion of something like four to one. These symptoms 
 may manifest themselves in every degree of severity, their extent depending upon the 
 intensity of the inflammatory action and the nature of the tissues that are involved. 
 When a loose tissue is involved, the redness will be much marked and the swelling will 
 probably be rapid, but the pain will certainly be slight, as the tension of the part is 
 rarely .severe. When the connective tissue situated beneath a dense fascia is the seat of 
 inflammation, or when bone is involved, the redness may be absent and the swelling com- 
 
Oy ISILAMMATIOS. 66 
 
 par;iti\ t'ly sli^^ht, since the peculiarities of the part affected prevent their being man- 
 itesteil ; but the pain will probably be severe, fur the ten.si(jn of the tissues and the 
 pressure ujton the nerves of the jiart will under such circumstances be necessarily {rreat. 
 
 When the intiainniation is acM/r or rapid, all these syinptonis manifest themselves with 
 great rapidity, and the results of the action are <|uiekly shown : when it is slow <jr cUronic, 
 they are less clearly marked. 
 
 As.sociated with these local symptoms of inflammation there will always be .some 
 constitutional disturbance, which is known as iiijidininntnri/ /» n r. This fever may man- 
 ifest itself in all de<rrees of severity, its intensity dependiu'r much upon the character 
 of the inflammation and its seat. When a local affection is iicnh' or of a xtfieitir nature, 
 the constitutional disturliance will be severe; when ilinmlr. it will probably be mild; and 
 when tist/it iiir. it will be markeil by >rri'at depression. It may show itself, therefore, only 
 as a slii^ht febrile state, or it may be marked by the severest .symjitoms. 
 
 •• Takin<.r, for instance, a case of severe compound fracture, without much hasmorrhage, 
 in a person otherwise sound and stronjr, as a type of the affection, we find that before 
 twenty-four hours have elapsed from the time of injury his <reneral system Vjegins to be 
 thus affected : He feels hot or alternately very hot and chilly. His skin and lips and 
 mouth are dry. lie passes urine in less (juantity. but of a higher color, than usual. 
 His pulse is (|uickened. A sense of general di.sorder gains upon him. He becomes rest- 
 less and intolerant of disturbance. Signs of drought increase with him. His urine 
 becomes scantier and more colored. His .skin feels hotter to the surgeon's hand, and his 
 pul.se. whether full or hard, is ({uicker and stronger than before. He craves more and 
 more for water. Ilis face has a flushed, anxious look. He is thoroughly uncomfortable, 
 for the most ])art feeling distressingly hot, but at irregular intervals feeling touches of 
 chilline.s.s — sometimes even of such cold that he shivers with it. His sleep is troubled 
 and unrefreshing, or as night comes on he gets delirious. His tongue, besides being dry, 
 is furred. If his bowels act (which commonly 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 lo.se their concentrated character ; the hard pulse soft- 
 ens 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.' ' 
 
 There can be little doubt that these symptoms are clearly due to an increase in the 
 temperature of the blood, and that their severity is measured by it. This is, indeed, as 
 Simon has so aptly expressed it, " the essential fact of inflammatory fever. It is to this 
 fact that the familiar language of feverishness bears witnes.s — the thirst, the scantv 
 urine, the heat and the shivering, the troubled brain, the excited circulation. As the 
 blood gets hotter and hotter, more and more do these symptoms become developed. As 
 the blcjod subseijuently gets cooler, ^o. more and more, do they decline. " 
 
 Average Temperature. — The average temperature of the healthy human body, 
 according to the Wunderlicli. is 'JS.G° F. or 37° C, but the range between, 97 and 99, is 
 quite consistent with health. A febrile condition arises from an increase of temperature 
 accompanied by more or less constitutional disturbance. 
 
 Excess of Temperature. — It seems from Dr. Montgomery's observations, made 
 for Mr. Simon, that ■• febrile excesses of bodily temperature range perhaps to ten degrees 
 above the normal heat of the blood ; the ' crisis ' of a febrile state consists in a rapid and 
 generally continuous reduction, the • lysis ' in a slow and generally di.scontinuous reduc- 
 tion, of this abnormal temperature." With respect to the causes of this greater heat of 
 blood, it is probable that the fever originates in the tissues themselves and is a disorder 
 of protoplasm, the results of inquiry showing " that either continuously during the 
 intensity of feverishness. or else more abruptly when feveri.shness begins to subside, 
 there can commonly be traced in the excretions an excess, more or less considerable, of 
 those nitrogenous, sulphurized, and phosphorized products which emanate from textural 
 and humoral waste ; that this increa.sed elimination is observed even when ingestion has 
 been reduced to a minimum ; and that febrile excretions do, therefore, as a rule, undoubt- 
 edly attest an increased devitalization of bodily material." The febrile process is then 
 clearly a disorder of nutrition in which, in man, the exchange of nitrogen exceeds the 
 normal expenditure by nearly three-(|uarters, and in which there is likewi.<e an exces.sive 
 discharge of carbonic acid. The discharge of nitrogen is evidently due to the disintegra- 
 tion of tissue, or possibly of blood. This fact explains the rapid waste of body which 
 takes place in fever. The blood coagulates with what is generallv described as a " buffy 
 ' Simon's art., Holmes's System of Surgery (second edition », vol. i. p. 26. 
 
66 THE EFFECTS OF INFLAMMATION ON THE TISSUES. 
 
 coat," and it seems highly probable that under these circumstances it contains more than 
 its normal complement of fibrin. There is good reason also to believe that this '■ bulTy 
 coat" is due to the fact that the blood corpuscles subside in the liijuor sanguinis during 
 coagulation, leaving the upper portion of the clot colorless. What this increase of fibrin 
 in the blood in inflammation means is a question that remains to be decided. Some pathol- 
 ogists believe that the blood is excellent in proportion as it is fibriniferous ; that solidi- 
 fying fibrin is almost incipient tissue ; that the fibrinous crust, as drawn in inflammation, 
 is the sign of its being specially adapted to the purpose of additional growth ; while 
 Simon, with others, holds " that the blood yields more fibrin, not in proportion as it is 
 ripe and perfect, but rather in proportion to quite opposite conditions ; that an increased 
 yield of fibrin portrays, not perfection, but post-perfection, in the blood ; that it corre- 
 sponds, not to the rise, but to the decline, of albuminous material ; that the relations are 
 not with repair, but with waste ; that its significance is that of something intermediate 
 between life and excretion ; that the fibriniferousness of the blood is undiminished — 
 probably even increased — by bleeding; that it is greatly developed during starvation, 
 during violent fatigue, during diseases essentially ana?mic ; that its increase under these 
 circumstances of exhaustion, weakness, and inanition is to the full as great as its increase 
 during inflammation." 
 
 " These latter views seem to be most in accord with truth and with the general chem- 
 istry of inflammatory fever. They seem to indicate that the fibriniferousness of the 
 blood in inflammation represents action of devitalization and decay in some albuminous 
 material. Whether this changing material be the inflamed texture gradually dissolving 
 itself into the blood, or be the albumen of the fevered blood itself undergoing accelerated 
 waste, cannot in the present state of knowledge be even approximately stated " (Simon), 
 
 The Effects of Inflammation on the Tissues. 
 
 More or less complete xtasis of hlood in the inflamed tissue is the first eff"ect of inflam- 
 mation, as hyperaemia with greater activity in the circulation of the part is the first symp- 
 tom. With this stasis there is a slowing of the blood stream through the dilated capil- 
 laries, with a crowding together of the white corpuscles or leucocytes along their wall.s, 
 and later on a migration of these same cells from the vessels into the tissues. 
 
 Blood Stasis. — When the sta.sis is more than transitor}'. the red blood cells them- 
 selves may extravasate into the tissues with the leucocytes : and when the stasis is com- 
 plete, death of the tissue in which the choked capillaries exist ensues, " sta.sis being the 
 mechanism by which inflammation kills" fSanderson). 
 
 Effusion. — The effusion which takes place into a tissue the seat of inflammation is 
 clearly due to stasis. • It begins from the moment that the damaged vessels are dis- 
 tended with blood and the internal surfaces of the walls pressed upon by their contents " 
 (Sanderson ), and it varies with the activity, character, or specific nature of the inflamma- 
 tion. When the inflammation is of a healthy or .sthenic kind, it tends toward the fibrinous 
 variety, producing plastic infiltration of the part ; when of a feeble or ayfhenic form, the 
 serous and corpuscular elements predominate. In the former case the soft tissues appear 
 firm and dense, and in the latter soft and fedematous. 
 
 ReCOVer57" by Resolution. — In healthy subjects this plastic material may be 
 reabsorbed and the ti.-.-ue into which it had been infiltrated left perfectly sound, recovery 
 then taking place b}' what is termed resolution; in exceptional instances the jilastic mate- 
 rial may become organized. 
 
 Other Effects of Inflammation. — In unhealthy subjects, or in cases of intense 
 infianmiatiori. in wliidi ri.->\i( is destroyed from blood stasis, the infiltrating material, with 
 the inflamed tissue, either undergoes destructive changes and breaks up — when what is 
 known as " sitppKrafion " takes place — or the tissue as a whole or in part dies or " mortifies.'' 
 The act of sirppifiiiflnn means the formation of pus and the.destruction of the inflamed tissue. 
 
 Mortification. — The death of a part from inflammation means its moyV{/7ca/io».; 
 when the action is a spreading one, it is called '■'■ govf/rene" ox ^'' sloughing phui/edsena" 
 and the dead part thrown ofl" is called a " slovgh."' The death of bone is called " necro- 
 .s/s," and the dead piece of bone a " sequestrum.'''' When a portion of tissue dies, the 
 dead is separated from the living piece by a process known as that of " ulceration^' ulcera- 
 tion of a part meaning its molecular death. When ulceration spreads, an ulcer is said to 
 exist ; when this undergoes repair, it does so by granulation. 
 
 "■Resolution," "suppuration." -ulceration," and "mortification" are the four events 
 of inflammation. 
 
A use ESS. 
 
 67 
 
 Fk;. 10. 
 
 Pus i'^ il'f |'r"«lii«i of iiiflainmation, and it consists of leucocytes, granules, and the 
 lilnis of the inflamed tissue floating in serum. Cohnheim considers the leucocytes to be 
 the sole source of j.urulent infiltration, and Strieker helieves that the f<jrnution of pus 
 is svnonvmous with disintegration of tissue, the cells of the inflamed jiart hy the act of 
 inflammation being made to return to their emhryonic state, and the amndtoid protofdas- 
 mic mati-rial «d' which tluy are eoinjtosed forming, hy suhdivision, amo.d)f»id cells. The 
 inflamed tissues hy these changes are transformed into jtus corpuscles. 
 
 l*us. when seen upon the surface of a granulating wound, varies with the condition 
 of the wound. Wlu-n the granulating tissue is healthy, the pus will he healthy — that is, 
 it will appear as a yellowish-white creanjdike fluid with a sickly snudl and an alkaline 
 reaction. I'nder the microscope the cells will appear like leucocytes. When the wound 
 is inflamed, leococytes will be present, hut under 
 changed condition."* — that is, they will appear as 
 nucleated cells, with two to five nuclei (Fig. lOj 
 mixed with granules and the debris of the inflamed 
 tissue; under other circumstances the jius nuiy Vtc 
 mi.xed with hlood. In indolent sores, where th'' 
 granulating jiower is at a minimum, the pus cells will 
 be few and the .>;erum in which they float abundant. 
 
 Living pus is composed -f leucocytes and serum 
 — li((Uor puris ; dead pus is made up of nucleated 
 cells containing from two to five nuclei, granules, and 
 serum. The leucocytes show their anueboid move- 
 ments in the living, but not in the dead. pus. All 
 pus is soluble in alkalies and has an alkaline reaction. 
 Acetic action dissolves the nucleus of a leucocyte, but renders clearer the nuclei of a 
 dead pus cell. The pus of a chronic abscess is not only dead, but undergoing degenera- 
 tion ; its cells are large and full of fat cells. The fluid in which the pus cells float like- 
 wise contains fat and granules in abundance. 
 
 Accidental elements may be found mixed with pus under exceptional conditions, such 
 as cholesterine plates and bone and other tissue elements : when vibrios and micrococci 
 exists, the pus is undergoing chemical and fermentative changes. 
 
 Varieties of Pus. — Pus, when thick and creamy, is known as '■ healthy." or laufl- 
 ohh.Yn>. when thin and water}' and containing ill-formed pu.s-cells. it is called •' puri- 
 form fluid," this condition being generally indicative of want of power; when it is 
 blood-stained, it is called •' sanious ; ' when thin and acrid, •• ichorous ;" and when it con- 
 tains flakes of curdy lymph. " curdy.'' Pus from the interior of a bone is oily, contain- 
 ing, as Brandsby Cooper showed, granular phosphate of linie. Pus from the brain is 
 often green, from the liver brown, the debris of broken-down tissue in different propor- 
 tions and of different kinds giving these appearances. 
 
 \. I'us corpuscles iiuatinitied •^■>0 diaineter- . 
 h. >-jLn\e iiui'ie trausparent with acetic acid. 
 ((. fell-wall. b. Nucleus. c. Nucleolus. 
 (A/ler Leliert.) 
 
 ABSCESS. 
 
 A circnmscribfd collection of pus in any tissue is called an " abscess." When pus is 
 not circumscribed, but diff"used in the connective tissue beneath the skin, between mus- 
 cles, or along tendons, and iiifiltratea a part, diffused suppuration is said to exist, this 
 latter condition always indicating want of power. 
 
 Varieties. — An abscess is always the result of an inflammatory process. When it 
 forms rapitUy and is associated with severe local as well as constitutional symptoms, it is 
 known as an " acute abscess ;" when it is of slow formation and the symptoms attending 
 its prog'ress are mild, it is called a '"chronic or cold abscess ;"' but there are many inter- 
 mediate forms. In an "acute"' abscess the pus and broken-down tissue are circumscribed 
 by the organization of the coagulable lymph and the parts around are infiltrated with 
 serum, as indicated by pitting on pressure. In a 'chronic" abscess the walls are thick, 
 from the organisation of the inflammatory products, whereby nature checks the extension 
 of the disease and forms what surgeons of old called the " pyogenic" membrane, whifh 
 is well exenijilitied in chronic abscess in bone. 
 
 An Acute Abscess is invariably preceded by the constitutional .symptoms of 
 inflammatory fever, and is accompanied by the usual local phenomena of inflammation, 
 such as pain, redness, heat, and swelling. As the abscess forms the local symptoms 
 become intensified, and perhaps concentrated : the pain alters in character, becom- 
 ing at first dull and heavy, and then throbbing ; the fever symptoms also sub- 
 
68 ABSCESS. 
 
 side, or rather intermit, and a shivering fit or rigor more or less well marked, 
 followed by heat, and possibly sweating, takes its place. The swelling, moreover, 
 which was previously diffused, becomes more localized ; a soft, and possibly tender, 
 spot, with a surrounding area of oedema, shows itself, and the parts covering it begin 
 to thin. With the fingers of one hand steadily kept flat upon the swelling, and 
 those of the other made to press upon it in another part, the walls of the abscess 
 will be made to rise against the fixed fingers and a sense of " fluctuation " be 
 given, this feeling of fluctuation indicating the presence of fluid, and, in this particular 
 case, of pus. Under these circumstances the " pointing " of the abscess will soon take 
 place ; meaning by this, the thinning of the part covering in the abscess in the direction 
 of least resistance, the subsequent bursting or sloughing of the skin, and the discharge 
 of the abscess cavity's contents. When the pus has been evacuated, the walls of the 
 abscess, by their natural elasticity, fall together or collapse, the external wound closes, 
 and the abscess either heals or contracts into a sinus or narrow canal, sometimes called a 
 fistula. When the pus is daeii-seatcd.^ or bound down by fascia or periosteum, what is 
 called " hurrourimj " takes place ; the matter makes its way between the soft parts, where 
 the least resistance is met with, and opens either into a mucous passage, serous cavity, or 
 joint. Abscesses beneath the periosteum constantly open into joints ; those beneath the 
 abdominal muscles or within the abdomen, into the intestinal canal; and others in the 
 extremities may burrow beneath the muscles and make their way to the surface a long 
 way from the original seat of the disease. In disease of the dorsal vertebrae an abscess 
 may burrow beneath the abdominal fascia, extend behind the sheath of the psoas muscle, 
 Poupart's ligament, and deep fascia of the thigh, and open on the inside or outside of the 
 thigh ; whilst in other cases it may pass into the pelvis and out again at the sciatic notch, 
 and appear in the buttock as a "gluteal abscess." In disease of the lumbar vertebme an 
 abscess may also form, burrow between the abdominal muscles, and appear in the front 
 of the abdomen above Poupart's ligament. An abscess beneath the scalp may undermine 
 the whole scalp tissue ; one behind the fascia and muscles of the pharynx may spread so 
 as to cause a large post-pharyngeal tumor and cause death by suff"oeation ; while deep- 
 seated abscesses of the neck may burrow into the thorax, and thus produce fatal mischief. 
 These instances serve to show how pus, when confined beneath a strong membrane, will 
 burrow along the cellular tissue of a part to find some outlet, and how necessary it is for 
 the surgeon to be aware of the fact in order that he may stop the process or trace the 
 cause of the disease to its source. 
 
 The " diagnosis " of an acute abscess ought not to be difficult ; but when the abscess 
 is chronic, the same cannot be said. Every hospital surgeon can record errors of 
 diagnosis in which chronic deep-seated abscesses have been mistaken for cancerous or 
 sarcomatous growths, and even for aneurism, and in which breasts have been removed for 
 cancer which were the subjects of chronic abscesses. The knowledge of these past errors, 
 it is hoped, will do much toward guarding against their future perpetration ; but the best 
 security is caution and a diagnosis of the case by the process of reasoning by exclusion 
 as laid down on pages 17, 18. 
 
 Chronic (djscesses are of remarkably slow formation and give rise to very little consti- 
 tutional disturbance or local symptoms other than swelling ; indeed, except mechanically, 
 they seem to be of little annoyance unless they are secondary to some organic disease. 
 Even then it is astonishing to what a size a chronic abscess will sometimes attain before 
 it is discovered or complained of. In spinal cases this is often verified. In children, 
 also, large abscesses form in the same quiet way. They are, however, never met with in 
 the robust and strong. Abscesses connected with enlarged glands are peculiarly passive 
 in their progress, and cause pain only when they begin to make their way through the 
 skin. Those, again, which occur in chronic joint disease when the disease seems to be 
 undergoing recovery show themselves in the same quiet way. Sir J. Paget' has described 
 these as " residual abscesses." They seem to be a simple breaking down of old inflamma- 
 tory products poured out in the cellular tissue during the more active period of the dis- 
 ease, and which had failed to be reabsorbed or to become organized, mtich in the same 
 way as a scar may break down after a fever. 
 
 Absorption of Pus. — Pus may be absorbed, the serous fluid in which the cells 
 float being taken up and the cells left to wither, these subsequently forming a pultaceous, 
 and at a later date a cretaceous, mass. Clinically, however, pus may disappear altogether 
 and leave no external evidence of its former existence. The fact is now clearly recog- 
 nized by surgeons, and the' absorption of pus is constantly seen in the eye in hypopyon, 
 
 * Clinical Led., second edition, 1879. 
 
ABSCESS. 69 
 
 as well as in the <lisa|i|>far:iii((' of |>t'iiustcal ciilarpements ami cliroriic siihciitaneous 
 abscrssfs. 'I'liis result, liiiwt'vcr, fan nrilv he expeetc*! in (•hmnir cases wliicli arc not con- 
 nected with <loe|i-seate(l oriranic miscliief". 
 
 Thkatm KN T. — In all cases of acute siijipiiration the ahscess shoiihl he (i|ieiie<l as sotm 
 as it has iurnietl. antl in many instances of acute local inflaniniation the iiiflaniinatory 
 fluids should he let out as soon as they have heen effused, with the view of (dieckiiif^ the 
 infiainniatory action and of •ruardiri'r ajrainst the evil effects of •' tension ' upon the 
 involved tissues. In acute iuHaiuination almut the thec;e of tendons of the hand and 
 foot or of the j)erio.steuiu this practice should he hinding, since an early incision in such 
 cases, by relievinjr tension, often saves tissue and cuts short disea.se. The ah.scess should 
 be opened, also, where it is pointing, and the inflained part cut into where it is most tense 
 and can be well drained ; and this pntceeding is best effected with a straight narrow hla- 
 toury. such as the pocket-ca.se finger-knife, unless the abscess be small, when a double- 
 edged knife, such as that illustrated in Fig. 11. should be employed. The incision in 
 both cases should be made by means of a 
 
 vertical puiu-ture into the ah.scess cavity. Fio. 11. 
 
 followed by a free cut outward, the open- 
 ing being large enough to allow a ready 
 escape of all pent-up fluid and the subse- 
 
 (luent irriiration of the abscess cavity with 
 ' • 1-' 1 • • 1 • 4 I>ouble-€dced Abscess Knife with droove in < 'mri- 
 
 some iodine or other antisc]>tic lotion. A (full-sized). 
 
 piece of lint .soaked in terebene or carbolic 
 
 oil, or a drainage-tube, should then be introduced into the abscess cavity to ensure the 
 
 escape of any effused fluids that may subse((uently be poured out, and the parts in which 
 
 the abscess exists should be made immobile by splints and bandages. By such treatment 
 
 the abscess cavity may be expected naturally to contract, its walls to unite, and recovery 
 
 to take place. 
 
 During the formation of an abseess. fomentation, poultices, and warm-water dressings 
 give comfort and may be used. They are only admissible, however, when suppuration 
 and external discharge may be expected. When absorption is probable, as in certain 
 residual or chronic abscesses, such means should not be employed, but rather ab.solute 
 rest of the affected part and an absence of all irritating applications, tonic treatment and 
 regimen being the chief general means upon which reliance can be placed. 
 
 Use of Aspirator. — To help this desirable result, it is a good practice to draw off 
 the pus frniu a chronic abscess with the aspirator of Dieulafoy. I have done this on 
 many occasions with a good result, and no re-collection has taken place, but as often as 
 not the fluid reaccumulated and a free incision was subsequently necessary. Whenever 
 an abscess is opened, the incision should be free enough to admit of a ready outlet of its 
 contents and to prevent any reaecunnilation. 
 
 Treatment of Deep Abscess. — Wherever burrowing suppuration in a part can 
 be detected, the sooner an external outlet is made the better, whether that burrowing be 
 beneath the scalp, behind the pharynx, among the deep cervical tissues, in the thecae of 
 tendons, between the layers of muscles of an extremity, or beneath the periosteum ; and 
 this is more especially requisite when the suppuration occurs about joints or beneath the 
 deep fascia, and particularly the fascia? of the perin^eum and anus. 
 
 Superficial abscesses ought always to be opened. On the neck and face the line of 
 incision should be made to correspond with the course of the superficial skin muscles or 
 the lines or folds of the part, the deformity re.'julting from the cicatrix being thereby 
 greatly diminished ; but in other cases the incision must be in the best direction for 
 emptying the cavity. In all abscesses the puncture should be made where the abscess 
 is '• pointing "' or the integument is thinnest, and where this indication is absent at the 
 most dependent part of the abscess. The operator should always avoid dividing super- 
 ficial veins and nerves, the position of the former being made out by intercepting the 
 flow of blood through them by the pressure of the finger. Deep vessels and nerves 
 should be carefully avoided, their anatomical position being always remembered. When 
 ab.scesses have to be opened in the neighborhood of these important structures, the 
 incision .should be made parallel to them. 
 
 Mode of Opening Abscesses. — In opening an abscess a plunge ought not to 
 be made. The operator >houl«l mark the point of intended puncture with his eye. then, 
 introducing his instrument with decision through the soft parts into the cavity, make the 
 incision of the required length by cutting outward as soon as pus oozes upward by the 
 sides of the instrument. To do this sleepily is to give unnecessary pain, whereas to do 
 
70 ABSCESS. 
 
 it with a stab or plunge only causes unnecessary alarm. It should be done, as ought 
 every other act of surgery, with confidence and decision, boldness and rapidity of action 
 being governed by caution and made subservient to safety. 
 
 To open an abscess that is pointing (or which has a cavity to be felt) by dissecting 
 down upon it is a had practice, although in deep-seated abscesses which are covered by 
 parts which it would be dangerous to wound, where .surgical interference is called for, 
 such a method may be the best, extreme caution being requisite under circumstances of 
 extreme danger. In such cases the surgeon should follow Mr. Hilton's method of open- 
 ing deep-seated abscesses, which has been practised at Guy's for man}- years. 
 
 In deep-.seated abscesses in the axilla, .•^ays Hilton (Li^ctures on Rent. 1803), " I cut 
 with a lancet through the skin and cellular tissue of the axilla, about half or three- 
 quarters of an inch behind the axillary edge of the great pectoral mu.scle. At this point 
 we can meet with no blood vessels. Then I push a grooved probe or grooved director 
 upward into the swelling in the axilla ; and if you watch the groove, a little opaque 
 serum or pus will show itself. Take a blunt (not a sharp) instrument, such as a pair of 
 dres.sing-forceps, and run the clo.sed blades along the groove in the probe or director into 
 the swelling. Now, opening the handles, you at the same time open the blades, situated 
 within the abscess, and so tear open the abscess. Lastly, by keeping open the blades of 
 the forceps during the withdrawal of the instrument, you leave a lacerated tract or canal 
 communicating with the collection of pus, which will not readily unite and will permit 
 the easy exit of matter." In this way deep cervical and post-pharyngeal abscesses, deep 
 abscesses of the thigh, leg, and fore-arm, may be fearlessly opened. 
 
 After-Treatment. — When an abscess has been opened, it should be left to dis- 
 charge by itself. Any squeezing or pressing upon the walls of the abscess is vxnneces- 
 sary and injurious. In some a piece of oiled lint should be introduced between the 
 edges of the wound to prevent their closure, more particularly when the deep fascia has 
 been opened ; whilst in others of large size the introduction of a drainage-tube made of 
 a piece of india-rubber tubing perforated at intervals may be re([uired ; in all. provision 
 for drainage should be made. 
 
 Tonics and good feeding are always essential elements in the treatment, .sedatives 
 being given only when required. 
 
 When a chronic abscpss requires opening — a question which in every case should be 
 well considered — a free incision should be made into its cavity, its contents evacuated, 
 and the cavity well washed with some antiseptic lotion. For this latter purpose a mixture 
 of one or two drachms of the tincture of iodine to each pint of tepid water is the best ; 
 a drainage-tube should then be introduced, care being taken that if air entei's its exit also 
 can be guaranteed. The abscess should be wa.shed out daily. 
 
 When the Listerian method of dressing wounds is employed, the abscess cavity must 
 be opened under the spray, drained with proper-sized drainage-tubes, and covered with 
 the gauze and protective. An excellent plan likewise consists in making a free opening 
 into the abscess, previously covered with a piece of lint soaked in carbolic oil (one part 
 of acid to twenty of olive oil), beneath which the pus flows away ; in this manner no 
 air is admitted. In the subsequent dressings care must be taken to keep the opening 
 surrounded with the vapor of the acid, and the lint should be removed only to be re- 
 placed by a freshly-steeped piece. No pressure should be made upon the walls of the 
 abscess for the purpose of empt3'ing its cavity without the opening being covered with 
 carbolic oil. I have, however, used, in several cases, olive oil alone with e(juall3' good 
 results. 
 
 Suppurating ovarian and hydatid cysts may be treated as large abscesses and with 
 considerable success. Empyemata or abscesses in the chest can also be dealt with on the 
 same principle, by a free opening into the thorax and a free outlet for the pus. In these 
 cases the drainage-tube is of great value, care being necessary to drop one end of it well 
 down to the bottom of the cavity. 
 
 The drainage-tube was suggested by M. Chassaignac, and is simply a small india- 
 rubber tube perforated every half inch or so with holes to allow of the free escape of 
 the pus. When large cavities are opened, they should be washed out at intervals with 
 an iodine lotion or other antiseptic fluid, so that nothing like decomposition, as indicated 
 by foetor. may be allowed. With this precaution, large suppurating cavities can be dealt 
 with successfully. 
 
 Hsemorrhage into Abscess Cavities. — When veins and large arteries are 
 opened by ulceration into abscesses — an accident of occasional occurrence — they should 
 be treated on the principle laid down in the chapter on hsemorrhage ; *'. e., if the bleeding 
 
ARREST OF ACUTK ISFLAMM ATKtS. 71 
 
 vessel he lar<re, it slmulil Ik- secureil, when |i(»ssil)le, at tin- |Miiiit at which it has <;ivcn 
 way. either by lijjature nr tor.-iuii ; mikI it' >iiiall, flic hreiiiniihaL'i- can easily )»(• arrested 
 by pressure. 
 
 Abscesses Associated with Enlarged Glands. — ciironie abscesses a.s.so- 
 
 eiatcil with irlainliilar ciilMrLrciiiciit luol imt he i>|miiii1 iimhr >oiiie eircuiiistanees, because 
 with cniistitutioiial trcatimnt they i)f'tcii <lisa|)|iear ; yet they shuuhJ be so treated as soon 
 as it is eh'ar that they will, if let alone, open by natural jirocesses. in onler to save the 
 uirlv cicatrix that tiikes place umler these circumstances from ulceration of the skin. The 
 surp'ou slmuhl make a small puncture in the best line t<j allow of the exit of the pus 
 antl to prevent disfimirement. (ientle pressure with cottctti-wool over the part afterward 
 often luistens the recovery. In subjects of the hiemorrhagie diathesis an abscess may l)e 
 opened by the cautery or caiiula. 
 
 Arrest of Acute Inflammation by the Obstruction of the Main 
 
 Artery of the Part. 
 
 To arrest acute inflammation in a limb, the delijjration of the main artery of the limb 
 or the arrest of the circulation through it by jtre.ssure upon the artery has been adopted. 
 ])r. Campbell of New (Jrleaiis speaks liighly of the practice, and even affirms that no 
 portion of an extremity should be amputated for destructive inflammation without tbi.s 
 experiment beintr attem])te<l. 0\\ the suggestion of the late Mr. Maunder of the London 
 Hosj)ital, Mr. Little in ISGT api)lied a ligature to the femoral artery for acute suppura- 
 tion of tlie knee with a success sufllicient to prove the value of the practice. 3Ir. >Iaun- 
 der hiuLself afterward had a similar successful result C" Lettsom. Lect.," Lunot. 1875). 
 The late Mr. Moore of the Middlesex Hospital also acupres.sed the brachial artery with a 
 good result. Previous to these cases, however, as early as 1813, Dr. Onderdonk of 
 America ligatured the femoral in a case of wound of the knee-joint to check acute inflam- 
 mation, and others since his time have followed his practice. It is a method of treatment 
 certainly worthy of attention, inasmuch as to cut off the supply of blood to an inflamed 
 part when too much is pa.ssing to it is sound in theory, and to do the .same to starve out 
 the disease is equally scientific. In ele|)hantiasis Arabum the practice does not .seem to 
 be without its good effect, and in acute di.sease it is certainly admissible. 
 
 I well remember as a student observing, under the care of the late Mr. Bransby 
 Cooper, a serious case of compound fracture of the leg complicated with a severe lacera- 
 tion of the thigh and division of the femoral artery of the .same side. He was in doubt 
 as to the practice he ought to follow, not knowing whether with the divided femoral the 
 supply of blood would be sufficient to repair the compound fracture. The success of the 
 case, however, proved that the fear was groundless, for repair went on uninterruptedly, 
 and a good limb was the result. The patient was a man of middle age. In 1873 I also 
 treateil with uninterrupted success a case of compound fracture of the humerus into the 
 elbow-joint in a man where the brachial artery was obstructed, in which recovery with a 
 movaltle joint was accomplished. 
 
 With respect to the treatment of inflammation by the Jiijitnl compression of the main 
 arterial trunks leading to the injured or diseased parts, it must be recorded that in 18G1 
 Dr. T. Vanzetti of Padua wrote a paper on the subject, which Mr. .*>. Gamgee has trans- 
 lated in his work On FrnctnnH (1871). He was led to ap])ly this treatment to cases of 
 inflammatory disease from its success in the treatment of aneurisms. He asserts that 
 compression will cure every incipient inflammation, and check it even when advanced ; 
 and he adduces cases of phlegmonous erysipelas and acute arthritis of the hand success- 
 fully treated by such a process. He adds, however, that - in the treatment of aneurisms, 
 as of inflammations, compression can never become a normal method until it be always 
 and exclusively effected with the finger.' 
 
 SINUS AND FISTULA. 
 
 A Fistula is an unnatural communication between a normal cavity or canal and the 
 outside of the body or with a second cavity or canal. 
 
 A Sinus is a narrow and often tortuous suppurating tract with oidy one orifice. 
 
 Amongst the Jisful^ there are the vesico-vaginal and the recto-vaginal fistula? in 
 women : the recto-vesical in men ; gastric and biliary fistuhu, fa?cal and anal fistulae, 
 salivary fistula, and urinary fistula ; there are also the congenital. 1»ronchial, or umbilical 
 fistula. The acquired fistula? are either due primarily to some suppurative or ulcerative 
 
72 STNUS AXD FISTULA. 
 
 process or to mechanical violence, operati%'e or otherwise, and subsequently to a want of 
 repair. When passages are close together, the fistula in some cases may be short and 
 direct, whilst in others it will be narrow or tortuous ; the orifice of the fistula may vary 
 much in size. When the cavity or canal is deeply placed or the inner opening deeply 
 situated, the fistula may be a long narrow tract. When the fistula is of recfut origin 
 and lined with granulations discharging pus. the walls will be soft, and will readilv bleed 
 on manipulation. When old. they will be smooth and hard, or " callous."' and non-sensi- 
 tive, and will secrete a thin, watery, non-purulent fluid. This fluid is. moreover, mixed 
 with the contents of the cavity or tract with which the fistula communicates, the dis- 
 charge tending to keep the fistula open. 
 
 The exfermil opening of a fistula or sinus presents very different appearances. It 
 mav appear as a direct or as a valvular opening, or may be depressed or raised. When 
 leading down to a foreign body or to bone, the external orifice will be surrounded by 
 weak granulations. Sometimes it may scab over for a time, and then reopen by the force 
 of the retained fluid. The mtemal opening of a fistula mostly appears as a defined orifice. 
 Causes of Sinus. — Abscess is the most common cause of ■•^imi.'ies or incomplete 
 fistula?, the external communication failing to clo.se from defect in the healing power of 
 the part, from some interference with the reparative process, from the want of a suffi- 
 ciently free vent for the discharge of pus. from mu.scular action which forbids that 
 amount of rest which is required for its repair, or. lastly, from the presence of some for- 
 eign body introduced from without, or from dead bone or cretaceous inflammatory prod- 
 uct from within. 
 
 The TREATMENT of the diff"erent forms of fistula? is given in the chapters devoted to 
 the special organs that are involved. In a general way, however, it may be asserted that 
 so long as the cause of the fistula exists repair cannot go on ; so that in •' nrivory Jxstula,'* 
 when stricture is the cause, the stricture must be treated before the fistula. In " aiu/V^ 
 fistula, when the action of the sphincter ani foi-bids repair, its action must be paralyzed. 
 In '• f^xal" fistula, when obstruction to the bowel is present, the obstruction must be 
 removed. In •• salivary " fistula the salivary duct must find a natural outlet before 
 its unnatural orifice can be expected to close. When any foreign body, tooth, or dead 
 bone 4s keeping the sinus open, it must be removed. When a suppurating cavity at 
 one end of the fistula continues to discharge, means must be taken to close it. When 
 the.se objects have been achieved, attention may be directed to the fistula or sinus itself; 
 and various are the means that can be employed for their cure. 
 
 Pressure in recent sinuses, to keep the parts in apposition, by means of pads, strap- 
 ping, or bandages, is sometimes of use. the muscles that move the part being kept thereby 
 absolutely at rest. In stumps and after mammary abscesses this practice is very beneficial. 
 Injection of some stimulating fluid, such as the preparations of iodine (either the 
 tincture alone or diluted with one or two parts of water) will sometimes set up a healthy 
 action : for the same purpose a .^eton has been used, and of all setons the small drainoge- 
 tube is the best, or a narrow coil of rolled gutta-percha. The conten/ is sometimes of 
 great use. and the galvanic is to be preferred. It can be accurately applied to the exact 
 spot, and its heat maintained for any required time. It is generally most useful in small 
 fistula-. 
 
 Laying open the sinus is. however, as a rule, the surest plan, dividing it from end 
 to end and keeping the sides asunder to allow of its healing from below. In superficial 
 sinuses, where the skin is undermined, the thin overhanging portions should be removed; 
 and this is best done with narrow scissors (Fig. 12). When done with a knife, the incis- 
 ion is to be made upon a grooved probe or director which has been previously introduced 
 
 through the sinus. This, however, may 
 Fig, 12. often be done to great advantage with 
 
 the wire of the galvanic cautery passed 
 tlirough the sinus on the grooved director 
 Mr threaded in an eyed probe, the surgeon 
 >ubsequently making traction on the two 
 ends of the wire, made hot by contact 
 with the battery, and dividing the tissues 
 with a sawing motion. The division with 
 the cautery has this advantage — that the 
 Probe-pointed .Sinus Scissors. surface of the sin US is SO destroyed that 
 
 it nuust granulate. There is. conse- 
 quently, less need of careful dressing ; and in old sinuses this is a point of importance, 
 
V WE lis ASH SOUKS. 73 
 
 fur their surt'accs arc so ciilloiis that tlicy rr(|iiiri' to lie scrajicil (ir othcrwiso renclered 
 raw t(» cxcitt' granulations to Wwxu. 
 
 The division of a Hstnia with a ligaliirt' is now rarely iierrornicd. ahhoiigli with one 
 of " in«lia-rul»l>t'r " it is i'casiltU-. In • hh-cdcrs " it inifrht he caHeil for. Itut in these the 
 win' id' the ;.;alvanie cautery is |)r(derahh> wlien it can l»e obtained. 
 
 Oilatation <d" the fistula hy niean.s of a sponge (tr ianiinaria tent is often of value. 
 
 Plastic operations for tlie cure of fistiil;i' are al.so means (d" great value, particularly 
 of vaginal and rectal tislMl,*-. These will he discussed in a future chapter. 
 
 Constitutional Treatment of Fistula. — Last, l)ut not least, in the treatment 
 of sinuses and li-tMl;e. constitutional treatment should be emplovcd. In the fistula fol- 
 lowing operations sucdi treatment is, as a rule, all that is wanted, and many are the cases 
 in metro|)olitan hospitals of sinuses about stumps, skin wounds, or mammary wounds 
 that will heal ra]»idly under the influence of fresli air. good food, and tonic medicine. In 
 all cases these means are most es.sential, and with them and local treatment success i.s 
 generally to be attained. 
 
 ULCERS AND SORES. 
 
 Ulceration is the result of an inflammatory process by which a .sore or chasm i.s 
 produced by the molecular disintegration of ti.ssue the .seat of cellular infiltration, the 
 nutrition of the tissue being so disturbed by what is called the inflammatory process as 
 to allow the chemical or disintegrating changes to have their way. 
 
 A sore is a chasm, a solution of continuity, caused by ulceration, the result of 
 injury or otherwise, upon an external or iiiternal surface of the body. 
 
 When a .•'ore is being formed or is spreading by the process of ulceration, an vher i.s 
 said to exist : when the ulceration has ceased, a xnrc remains. 
 
 Varieties According to Progress. — When an nicer spreads rapidly, it is 
 termed •'p/nii/tthtnic ;" when it spreads by gangrene. '•.^t/o^yA/W/;" and w^hen with this 
 gangrene the molecular death of the tissue, or ulceration, is combined, '• s/our/hi/ir/ phage- 
 dfena'^ is said to exist. All these processes are consequently different varieties of ulcers, 
 and are characterized by degrees of rapidity of the process, the simple ulcer being the 
 mildest and the sloughing phagedjisnic the most severe form. 
 
 Varieties According to Condition of Ulcer. — A healing or cicatrizing sore 
 
 heals by ^' grmut/dfio-n." and the process is the same as it is in any wound the result of 
 injury or operation. It may, consequently, assume many different appearances, and 
 these have been considered under the heading of diseases of granulations, p. 62. Sores 
 may. therefore, be henlffij/, in flamed, ri-e<(h\ indolent, s/oiif/hinff from excess rjf indolence, or 
 irritable — terms which are applied to granulating sores to express their conditions at the 
 time, but which have no .special signification ; for these appearances fluctuate according 
 to the general condition of the patient and the local treatment of the sore. A sore may 
 also at any time take on the ulcerative process and spread, or may assume any of the 
 other forms of spreading already described. 
 
 An Ulcer may have a Local or a Constitutional Cause. — Among the 
 
 loc(d causey: of ulcers are injuries ])roduced by blows, pressure, some chemical or irritat- 
 ing application, or some skin eruption set up or followed by inflammation and subsequent 
 ulceration. 
 
 Amongst the constitutional causes, exchiding cancers, may be classed anything that 
 superinduces a low condition of the vital powers, such as any illness, scrofula, certain 
 habits of life, syphilis, or scurvy. 
 
 A local ulcer or sore produced from local cau.ses may. however, fail to heal from some 
 constitutional defect, and a sore which has a constitutional origin may be kept up by 
 local causes. Thus, a syphilitic or cachectic ulcer originating from a constitutional cause 
 may take on any of the characters common to the local sore. 
 
 There are, likewise, special ulcers, such as lupus, rodent ulcer, epithelial or carcino- 
 matous ulcers, to which attention will be drawn later on. 
 
 Local sores, as already stated, have a local origin — something exciting an inflam- 
 mation and ulceration in the skin and a sore remaining — the disease being cutaneous 
 from the first. The ulcer fails to repair either because its position is iinfavorable for the 
 process to be carried on or owing to some local peculiarit}" of the circulation of the part, 
 such as varicose veins, or from some want of care in its local treatment or want of power 
 in the patient. 
 
 Constitutional sores have rarely a cutaneous oriirin. unless thev orisrinate in some 
 
74 ULCERS AND SORES. 
 
 ulcerating skin eruption, such as ecthyma or rupia. They almost always commence in 
 the subcutaneous connective tissue as a more or less circumscribed induration, which 
 lasts a very variable period and then softens down ; the skin over it inflames, sloughs, 
 and ulcerates, to give vent to a deeper slough, the sores or ulcers always being of a 
 '• celhi/ai-mf»tbraiious kind." These ulcers may have their cause in an ordinary cachexia 
 or in syphilis, but the cellulo-membranous ulcer is ahcii/s constitutional and requires 
 general more than Inad treatment. In syphilis the ixlcers are the result of broken-down 
 subcutaneous '• gummata." The appearance of these sores will depend much upon the 
 period at which they are seen, but from the time when the skin has broken and ulcerated 
 the margins of the opening in the skin will appear thin, irregular, and undermined, and 
 at the bottom of the opening the slough will appear. When simple, the slough will 
 appear more or less white, sometimes pearly ; but when syphilitic, it will have the aspect 
 of a piecr of icet icas/deathcr — at least, in the majority of cases. When any of the 
 slough has come away, the skin will at first be undermined and the margin of the sore 
 will fall inward, but as the granulations rise from below the skin will be pressed up. 
 When the wound has cicatrized, the sear will, however, almost always be a depressed, 
 and in syphilis a stained, one. 
 
 Around this sore several small openings often coexist, each one having foi-med to give 
 exit to a small slough, the margins of which appear as if they had been punched out. 
 These sores occur mostly about the lower part of the thigh and knee, elbow, shoulder, 
 and forehead : they are found, however, in any part of the body. The syphilitic are 
 always surrounded by a dusk// kind of inflammatoiy border, and are rarely painful ; the 
 non-svphilitic have a pinker blush. The washleather slough and dusky margin clearly 
 indicate the syphilitic sore. 
 
 It is by no means uncommon to discover in such a sore the specific character of a 
 disease that had been contracted some twenty or more years previously, and that had 
 lain dormant after having manifested its presence by marked .symptoms. Indeed, it is 
 from the occurrence of such sores as these that the surgeon inquires whether constitu- 
 tional syphilis is really ever cured — that is. eradicated — and whether a man once syphil- 
 ized, as once vaccinated, is not so permanently altered as to show under certain condi- 
 tions, with comparative certainty, that he is still under the influence of the poison, and 
 that other diseases must for ever after be modified by its existence. 
 
 A healthy, healing, cutaneous sore is known by the small florid conical 
 granulations that cover its surface and the healthy creamy pus thrown oflF from it. •' In 
 granulations new substances are formed, as if the earth was taken in heaps from one 
 place and laid in another ; the thicker and smaJIer /he heaps, the better the granulations" 
 (John Hunter. MS. lect.. 1787). The granulations are not so vascular as to bleed or so 
 sensitive as to cause pain on the slightest touch. The margin is natural, and where the 
 skin and granulations meet a band of cicatrizing tissue is to be seen, assuming, where in 
 union with the skin, a whitish line with a fine covering of epidermis (Fig. 50 b), but 
 where in contact with the granulations a more vascular appearance than at any other 
 part of the sore, the centre of the band being covered with a thin purplish-blue, semi- 
 transparent film. 
 
 By the gradual and centripetal cicatrizing process of the outer border of the band 
 and the gradual narrowing of its circle, the sore heals. 
 
 Treatment. — The surgeon's sole aim is to guard against anything that can interfere 
 with the progress of repair. The treatment, consequently, is simple, a piece of absorb- 
 ent lint, to protect the surface of the sore from injury, covered either with some anti- 
 septic oily dressing, such as the terebene or carbolic oil, eucalyptol ointment, or a lotion 
 of boracic acid, with the elevation and immobility of the part, being all that is required. 
 The surface of the .sore should be cleansed by means of a stream of tepid iodine water 
 or a wad of absorbent cotton-wool 
 
 When the granulations are disposed to rise too high, dry lint may be applied, and at 
 times a rub with lunar cau.stic hastens recovery. Small sores may be allowed to scab. 
 Rest, with elevation of the limb, is always beneficial in aiding repair; but should this be 
 impracticable, a good pure rubber bandage may be substituted, and a piece of thin sheet- 
 lead bound over the sore outside the dressing gives efiicient support and protection. In 
 removing the dressing care .«bould be taken not to injure the band of delicate cicatrizing 
 tissue. 
 
 Deviations from Typical Sore. — Accenting this description as that of a heal- 
 ing sore, deviations from this type constitute the diff"erent forms that have been described. 
 Thus, when the granulations assume a large, pale, elevated, watery appearance, the sore 
 
rij'h-jis AM) SO/IKS. 76 
 
 is said to ha " wcii/c," the granulations in jxipular language being " prouil flesli," the popu- 
 lar word "proud" hi'ing synonymous with wiolc. There is power in the sore to granu- 
 late, but the granulations hav(! little power of cicatrizing ; they are ilisposed, moreover, 
 to slough on the slightest cause. These re(juire local stinjulants, such as the nitrate of 
 silver in stick, sulphate of zine or copper lotion, carliolic acid lotion in the proportion of 
 two grains to the ounce, or terebeiic alone or diluted with one or two parts of olive oil. 
 Dusting the surface with powdered alum or tannin is also sometimes benelicial. 
 
 Tlie linili should l>e e.ifefiilly ele\ ntcd or bamlaged. ami t he general health attended to. 
 
 The Indolent and Callous Ulcer. — Wlu-n there is still less power in the sore, 
 no granulations I'orm ; the surface jtuts on the appearance of a piece of mucous mem- 
 brane, such as that of the pharynx, the sore being then called '' imlnUnl.'' At tinu!s a 
 few weak granulations are lound at one corner of its surface, but the greater part has a 
 smooth and glassy aspect, with a thin and watery, but not purulent, secretion. Where 
 the sore has existed long the edges will appear rai.sed and indolent, covered with a layer 
 of epithelium, and very senseless. It then ac((uires the term " 'v//Ay»«," a callous sore 
 being an indolent one of long standing. This inchdent sore is alway.s ready to take on a 
 sloughing action on any slight cause, such as some general derangement of the health or 
 the long assumption of the dependent position of the limb. It is common, indeed, to find 
 the surface of the indolent sore '^ s/tjiu/hiiii/ " — not, liowever, from inflammatory action, 
 h\\t h\m\ r.clremr inihth'ii(x ill tli.e (jidiinlatiiifj forcf. Under these circumstances the sur- 
 face of the sore becomes covered with a greenish, often fetid, secretion, the granulations 
 as they form dying. When the sore is large, this appearance is more general toward its 
 centre or lowest part ; and as repair goes on the sore may cicatrize at its edges, where the 
 granulations derive the full benefit of the vascular and nerve supply, while the centre of 
 the sore still sloughs. In old people the margin of the .sore may slough in one part and 
 heal in another. Authors have described this indolent sore in the old as atuHr. uher. 
 These sores are very common, and are usually found in the lower extremities — often, too, 
 associated with varicose veins; this condition of veins has, however, little to do with their 
 origin, although it tends much to retard their recovery. These have been described by 
 old authors as vnricosi' ulcers simply from the fact of the two conditions being often 
 found together. Such are almost always found in weak subjects with a feeble circula- 
 tion. 
 
 Till' TREAT.MKXT o/' flipse iiidoinif sonn consists in encouraging the venous circulation 
 of the i)art by its elevation, and by pressure where this cannot be secured by rest, and by 
 local stiujulants and general tonic treatment. For pressure, there is nothing equal in 
 value to the pure rubber bandage well applied, as recommended by II. Martin of Massa- 
 chusetts in 1877 ( 7'/v^n.s-. of Ameririin Med. Association^. When there is little or no 
 action in the sore, the application of one or more blisters to the surface is very beneficial, 
 or blistering liquid may be painted over its edges. When the surface is sloughing, half 
 an ounce of carbolic acid or six ounces of terebene to a pint of olive oil, with or without 
 the extract of opium, according to the amount of pain, forms an excellent application. 
 Where the edges of the sore are indurated and callous, so that the cicatrization and con- 
 traction are almost impossible, the free scarification of the margin every half inch is often 
 followed by a rapid change for the better, or two free incisions may be made on either side 
 of the margin of the sore for the same purpose. During this treatment, if the venous 
 circulati(ui is assisted by raising the leg higher than the hip, the utmost good may be 
 obtained. In private practice, when the leg can be dressed daily, the ulcer, with its dres.s- 
 ing, and the wliole limb may be covered with strapping. The strapping, therefore, ought 
 to be good — not such thin material as that spread on calico nor thick felt strapping, but 
 that spread on linen, such as is used at Guy's Hospital. The rubber bandage is^ how- 
 ever, to be preferred to the strapping. 
 
 When the sore is painful or the patient has an irritable pul.se. the beneficial effects of 
 opium twice a day in a pill are very marked, and quinine, iron, nux vomica, or the vege- 
 table bitters may be given, as the wants of the case indicate. The bowels also require 
 attention, drachm doses of the sulphate of magnesia, with quinine, being a good aperient. 
 When the sore is unusually large and there is little probability of the whole, from loss of 
 skin, healing, fresh centres of cntijii-atioii should be inserted by transplantation. In this 
 way I have brought about the cicatrization of a large sore of twenty-four vears' stand- 
 ing in three weeks, and many others of smaller size in an equally short period : indeed, 
 by this practice of skin-grafting, I believe the necessity of amputation in the more severe 
 forms of this affection will be greatly diminished, for. hitherto, indolent ulcers that sur- 
 round a limb have ever proved themselves incurable, amputation being their only remedy. 
 
76 ULCERS AND SORES. 
 
 All sores may inflame or become irritable, but there is an injlamed aore or nicer which 
 is found in subjects with thin and fair skins who are in some way reduced in power or 
 " out of sorts," either from irregular living, overwork, or bad feeding. It appears as a 
 small superficial, inflamed, irritable sore with a raw-looking appearance, an ash-colored 
 slough, or thick secretion over its surface, and discharges a thin ichorous fluid sometimes 
 tinged with blood. The patient will complain of its exces.sive painfulness, particularly at 
 night, and will dread its being touched. It will look red and angry, though superficial. 
 A blow or a graze may have caused it, or a local patch of eczematous inflammation pre- 
 ceded it, in which case it may be described as an ecznnatous nicer. 
 
 The TRE.\TMENT of these sores is very troublesome, the skin being usually highly 
 sensitive. They always want soothing, and the best lotion is one of diacetate of lead 
 mixed with the extract of opium ; but this sometimes irritates, while the lead or zinc 
 ointment gives comfort. At other times a cold bread poultice is the best application. In 
 all cases the limb wants rest and elevation. In the eczematous sore, where the discharge 
 from the eruption round the sore is profuse, the powdered oxide of zinc and starch, in 
 equal proportions, may be used, or the surface may be washed with a solution of nitrate 
 of silver in the proportion of ten grains to the ounce. Occasionally a solution of the 
 extract of opium is the best lotion. Simple nutritious food, with a moderate allow- 
 ance of stimulants, should be administered, but all high feeding is injurious. The general 
 health mostly requires tonics of a non-stimulating kind, such as the vegetable bitters with 
 alkalies, as the intestines are generally irritable. When the pain is severe, opiates and 
 sedatives are indicated. In very inflamed ulcers the application of a few leeches at some 
 distance from their edge occasionally gives relief. These sores are invariably obstinate. 
 
 Authors describe a varicose nicer, but does such an ulcer exist? Many indolent sores 
 are doubtless associated with varicose veins, and are probably indolent on account of this 
 association; but how far they are really caused by them is a diff'erent matter, for vari- 
 cose veins and ulcers of all kinds are constantly met with together. Of all ulcers 
 entitled to the term " varicose," the eczematous has probably the most claim ; for cer- 
 tainly eczema of the leg is a common consequence of varicose veins, and an ulcer the 
 result of the eczema. 
 
 Practically, however, it is well to remember that when varicose veins exist v;ifh an 
 ulcer repair cannot go on favorably unless the venous circulation of the limb be assisted 
 by position or pressure, and that where these varicose veins are present all ulcers or 
 sores, if neglected, are disposed to become indolent. When an ulcer takes its origin from 
 an inflamed vein, the term is applicable in a measure, but this ulcer has no special cha- 
 racteristics. 
 
 Sores that are prevented from healing by varicose veins must be treated by the ele- 
 vated position of the limb or by the use of the rubber bandage or strapping, and in bad 
 cases by the obliteration of the veins. Without this obliteration the treatment will of 
 necessity fail ; whereas with it the sore may be expected to heal with the use of such 
 general and local means as its nature may require. 
 
 How fir it is right to heal an old chronic sore has not yet been quite decided. Older 
 surgeons declared it to be inexpedient, as cases were met with in which apoplexy or some 
 other alarming condition supervened. Modern surgeons, however, are disposed to ques- 
 tion the explanation of these facts, and to look upon that practice as beneficial which 
 removes any abnormal condition, local or general. Still, it is wise, when a patient has 
 been in the habit of losing by discharge from the surface of a sore a certain amount of 
 material which would otherwise have been used to maintain' the general powers, to cut 
 ofl" the supplies in another way, to order more abstemious living, and to regulate the 
 bowels by some saline water, natural or artificial, as may suit the stomach. 
 
 Sloughing and phagedsenic sores are rarely seen except in connection with 
 syphilis or hospital gangrene. In syphilis sloughing is found in the intemperate and ill- 
 fed, and mostly in gin-drinking pi'ostitutes. It attacks any surface that has been made 
 sore either from venereal contact or other causes, and it is marked by the rapid way in 
 which the process destroys tissues, by the foetid character of the discharge, the great 
 depression of power which is an invariable accompaniment, and the constitutional di.s- 
 turbance. 
 
 Opium in full doses is required for their tre.\tment, with tonics and good nutritious 
 food. When these means do not control the ulcei-ation, the application of strong nitric 
 acid with a piece of wood to the surface of the sore is often useful ; sometimes, too, the 
 local application of iodoform, iodine, or bromine in solution is of great benefit. Fresh 
 air is always indicated, and abundance of disinfectants, such as Condy's fluid, terebene, 
 
ULCERS AND SORES. 77 
 
 or i'ail>nlic iicitl in sonic oi' its iorms. Those sores arc mostly due to some feeble coristitu- 
 tioMiil ('omlitiou, and not to a loi-al cause, altliou;;h at times the action seems local, when 
 the applieation of .somc^ j)owerf"ul escharotic, such as nitric acid, is called i"or. 
 
 Sir J. I'ajrc't descrilu'S rnlil, ulo rs: " They are like small inflammatory ulcers occurring 
 spontaneously in the extremities, especially at the ends <.>{' the fingers or toes or at the 
 roots of the nails. In some eases they are pnu-eded l>y severe pain and small garigrenou.s 
 spots. They are in many respects like ulcerated chilblains, but they occur without any 
 exposure to intense cold in patients whose feet and bands are commordy, «tr even habitu- 
 ally, but little warmer than the atmosphcn; they live in. Such patients arc among tln)se 
 who say they are never warm, and tiic skin of their extremities, uidess artificiallv heated, 
 is to the touch like the surface of a cold-blooded animal. With this defect, which is com- 
 mon in women, there is a small feeble pulse, a dull or half-livid tint in the parts which 
 in healtliy pcnplc are rmldy. a weak digestion, constipated bowels, and scanty men- 
 struatinii. 
 
 " The cure of the ulcers and prevention of their recurrence lie in the remedv of these 
 defects. Many tonic uiedieines may be useful, but the mo.st so is iron ; with it purga- 
 tives are generally neces.sary — ?..</., small doses of mercury and aloes or .sulphate of mag- 
 nesia. Full diet, exercise in the fresh air, dry warm clothing, especially of the lower 
 half of the body, and warm bathing are required ; dry applications or lotion of sulphate 
 of zinc or copper are the best local means, and the part must be kept warm ; healing is 
 always tardy at a low temperature." 
 
 Allied to cold ulcers are those formed on fingers or other parts which have been 
 deprived of their nerve supply by some injury. 
 
 Scorbutic Ulcer. — In Sir J. Paget's able article in Holmes's Sijstem occurs the 
 following description of the .scorbutic ulcer by Mr. Busk : "Although scurvy in itself 
 cannot be said to be attended with any peculiar form of ulceration, ulcers or sores of 
 any kind already existing from other causes assume, in consequence of this .scorbutic 
 taint, a more or le.ss peculiar character, and when thus modified have been usually termed 
 * scorbutic ulcers.' 
 
 " Scurvy essentially consists in an alteration in the constitution of the blood which 
 leads to the effusion into the various tissues of a fihrinona exiulafion, usually deeply 
 colored, and which has on that account been commonly regarded as a simple coagulum. 
 That this effusion, however, can scarcely be regarded in this light is proved by several 
 considerations, but more especially by the circumstance that it is from the first soIi</ and 
 capable of hecominc/ imperfecth/ organized — that is to say, it is after a time permeated by 
 newly-formed vascular channels. It is tlie presence of this effusion which causes the 
 spongy swelling of the gums, the tumefaction and induration of the intermuscular tissue, 
 the so-termed scorhutir nodes, and which, when poured out on the surface or in the sub- 
 stance of the corium, constitutes the vibices and petechijfi so characteristic of the di.sease. 
 It is the effusion, also, of flie same sent ip fas fie material on flie free siir/ace of sores or ulcers 
 which gives them the pernliar aspect termed scorhiifiey 
 
 " Ulcers of this kind are distinguished by their livid color and irregular tumid border, 
 around which no trace of cicatrization is evident, whilst the surface of the sore is covered 
 with 'a spongy, dark-colored, strongly adherent, foetid crust, whose removal is attended 
 with free bleeding and is followed by a rapid reproduction of the same material. This 
 cru.st. in bad cases, as remarked by Lind, attains to a ' mon.strous size,' and constitutes 
 what has been appropriately termed by sailors ' bullock's liver.' " 
 
 The Syphilitic Superficial Sore. — The deep cellulo-membranous syphilitic 
 sore has been already ilescribed (page 74). under the heading of constitutional sores, but 
 the superficial, cutaneous, rupial sypliilitic sore deserves notice because it is verv common. 
 It mostly succeeds an ecthyma or rupia, is mixed with the eruption in some other stages, 
 and is simply an ulceration of the base of a syphilitic eruption. This goes on increasing 
 irregularly in a serpiginous form, the sore healing in one place and spreading in another, 
 but it involves only the skin. The edges of the .sore — or sores, for they are often numer- 
 ous — are usually well defined, and frequently irregular; the surface, too. is generally of 
 a deep color, and when healing may either scab or granulate, as any other sore. "They 
 are met with at any period after the fir.st constitutional symptoms of syphilis have passed 
 away, and occasionally at a remote date ; they are always found in a cachectic or 
 enfeebled subject ; indeed, it appears as if want of power allowed the disease to- manifest 
 itself in the new form. 
 
 The treatment of these sores, when once they have been recognized, is not usually 
 difficult. Tonics, with the iodide of potassium or sodium, in doses of from three to ten 
 
78 BED-SORES. 
 
 grains, usually effect a cure — at least, for a tinu' ; liquor cinchontc and compound spirit 
 of ammonia in half-drachm doses are also good remedies. In other cases the mineral 
 acids, ((uinine, or iron is indicated. Mercurial remedies are sometimes, though rarely, 
 necessary ; and of these the perchloride of mercury, in doses of one-sixteenth of a grain 
 in bark, green iodide in one-grain doses in a pill, or the mercurial suppository, are the 
 best forms to employ. 
 
 Locally, the sores may be dressed with any simple dressing ; but when indolent, 
 a mercurial lotion, as the black wash, is the best. 
 
 Lupus, for convenience' sake, must be classed amongst the ulcers. It is met with 
 in two forms — the '■'■lupna ert/tliemafosiis'^ and the ^' lupus vulfjaris,'" the latter being more 
 common in young scrofulous subjects, and the former in the middle-aged. When asso- 
 ciated with a spreading ulceration, it has been called " fupus exedfus.'" 
 
 The " lupus erythematosus" occurs chiefly upon the face and is symmetrical ; each 
 patch has well-defined edges and a red. scaly surface, wnth small horny points upon it, 
 due to accumulation in the dilated mouths of sebaceous ducts. The " lupus vulgaris" 
 has its origin in a skin tubercle, or tubercles, of a flat form, fleshy consistence, and pink 
 shining appearance ; and these at times ulcerate. This lupus ulceration, when once 
 originated, progresses steadily, destroying every tissue it attacks, and when it reaches the 
 nose — its very favorite seat — it simulates cancer. The surface of the sore is sometimes 
 free from all- signs of granulations and often very irregular, while the edges are ragged, 
 raised, and often everted. It is painless. The tubercles themselves feel spongy, are 
 neither .so hard nor so well defined as cancer ; they are composed of granulation tissue. 
 
 These lupus ulcers are more commonly found on the face than elsewhere, and probably 
 next in frequency on the female genitals. They are most destructive when left alone, 
 but often very amenable to treatment. In young adult life they are uiore common than 
 in the old, and appear closely allied to tuberculosis. 
 
 Treatment.— -Although the disease has probably a constitutional origin and requires 
 tonic treatment, both by medicine and regimen, there is no disease that derives more 
 benefit from local treatment. When the ulceration is superficial and the skin is not deepljr 
 infiltrated, the local application of cod-liver oil on lint and the covering up of the part 
 with cotton-wool to keep it warm at times works wonders. But under other circum- 
 stances, when the skin is deeply involved and infiltrated with disease, the free removal of 
 the whole growth is the most efficient treatment; and this may be carried out by care- 
 fully scraping the surface of the growth or by destroying it with the cautery or caustics. 
 
 The most successful method is unquestionably the scraping, so long as it is done 
 boldly and effectually, for every particle of infiltrating tissue must be scraped away ; and 
 a blunt knife or a sharp spoon is the best instruTuent to use. After scraping, it is well 
 to dress the wound with lint soaked in liquid carbolic acid. If a healthy action follows 
 the operation, all is well and the parts will heal under a dressing of cod-liver oil. If any 
 signs of disease reappear, the sharp spoon should be at once reapplied. 
 
 When scraping is rejected, the free use of the electric or gas cautery may be substi- 
 tuted; and, so long as the local disease is effectually destroyed, the choice of means is not 
 very material. These means, however, have entirely set aside the use of escharotics. In 
 exceptional cases excision may be beneficial. 
 
 BED-SORES. 
 
 In theory bed-sores should never occur, yet in practice they appear in certain cases 
 in spite of the greatest care and attention. It is well, however, for the surgeon to act 
 upon the theory, as by so doing he is stimulated to do everything in his power to guard 
 against their occurrence ; and no better illustration of the old adage, '• Prevention is 
 better than cure," could be found than in such a case. 
 
 Bed-sores may briefly be described as the death of a part from mechanical pressure, 
 the parts involved in some cases literally dying from being deprived of their nourishment 
 by prolonged and continued pressure ; in others, from some'inflammatory action induced 
 by it. " ^ 
 
 Bed-sores may arise in healthy subjects who are kept unmoved for ten or fourteen days, 
 but in the old. the fat, or very thin they may occur at an earlier date, as they do in fever 
 cases of all kinds, and in spinal or partially paralytic cases ; completely paralyzed parts 
 are less prone to slough than the partially paralyzed. 
 
 Dirt and moisture, under all circumstances, accelerate their appearance. 
 
 A bed-sore may appear as a simple abrasion, a sloughing of the skin or subcutaneous 
 
MonriFlcATIOS. 79 
 
 tissue, and in severer cases the exposetl Imiie may ilie, ami in the worst the spinal canal 
 may he opened. 
 
 Thkat.mknt. — Since, as a rule, tlicy are caused hy cuntinual prcs.siire on a jiart, they 
 may very geneniUy he averted hy some ehanire of the patient's position. The necessary 
 amount of movement nuiy, as a rule, he allowed in all medical and in m<jst surpical cases, 
 but local pressure under all circumstances should he periodically relieved. 
 
 The skin of the part pressed upon should he hardeiu-rl hy washing: it at least twice in 
 the twentv-four houis with some camphor spirit ami water, vincfrar and water, or nitrous 
 ether and water, in the proportion of one jiart to three. An artificial coveriji;: of the 
 fle.Kihle collodion is occasionally of jrrcat use. 
 
 When the parts are about to slou<rh. these applications, liowever, are useless, and noth- 
 ing Imt the removal of pressure will suffice. With tliis ol>ject, well-filled water beds and 
 water (u- air cushions should lie employed. I have found a mattress divided transversely 
 into three parts and a water cushion substituted for the middle section of great use. At 
 other times the sections of the mattress may be simply separated for a few inches in the 
 line of pressure. 
 
 In spare patients, where the spinous processes of the vertebra? are prominent, thin 
 slips of felt plaster placed vertically down the back give great relief, and the .same plaster 
 applied to other painful parts is of value; cu.shions of amadou and well-adjusted pads of 
 cotton-wool or spongio-piline are also always of service. 
 
 When sloughing is present, a linseed-and-bread poultice with a solution of carbolic 
 acid, of iodine. Condy s fluid, or charcoal sprinkled upon the surface is the best applica- 
 tion, though a carrot or yeast poultice occasionally cleans the wound. 
 
 When the slough has separated, some .stimulating lotion or ointment may be required ; 
 and this is best applied on cotton-wool. The glycerine of boracic acid or a lotion of 
 chloral, gr. x to the ounce, is the best application. 
 
 In all cases where patients have to rest for a lengthened period, careful attention 
 should be paid to keep the bed smooth and the sheets free from rucks. Corded or 
 feather beds should not be used. The best is a horse-hair mattress placed upon a 
 second or spring bed. 
 
 MORTIFICATION, TRAUMATIC, ARTERIAL, AND VENOUS. 
 
 The mortification of any part of the body signifies its death. When a soft part is 
 " dying."' it is said to be in a state of '• gangrene ; " and when " dead," in that of 
 "sphacelus." The dead portion is called a *• slough," and the process of separation the 
 act of "sloughing." When bone is dead, the term " necrosis ' is employed, the dead 
 portion being called the "sequestrum" and the process of its separation " exfoliation." 
 
 The dead portion of any tissue is thrown off from the living by means of ulceration ; 
 and when the slough has separated, the parts heal by granulation, as an ordinary wound. 
 In the " sloughing phagedaena " the two processes of ulceration and sloughing are com- 
 bined, the molecular death of a part, or ulceration, going on with the more general 
 destruction of gangrene. 
 
 Ca.ses of mortification may Vte divided into three main groups according their causes — 
 viz. : 
 
 Traumatic ; anaemic, or arterial ; static, or venom. 
 
 Trmininfir gangrene includes cases brought about by external violence or chemical 
 action, the term " direct " being applied to those in which the vitality of the part is 
 destroyed at once, and " indirect " where the .same result is brought about by the inflam- 
 matory action which follows an injury. 
 
 Anaemic or arterial gangrene includes cases in which a part is .starved from the obstruc- 
 tion of its artery, either from operation, accident, or disea.se. 
 
 Static or venous gangrene includes those in which .stagnation of blood is cau.sed by 
 the mechanical arrest of the circulation through the veins, complicated or not with 
 secondary inflammatory action. 
 
 In ^h and all of these groups inflammation plays directly or indirectly an important 
 part. 
 
 Moist and Dry Gangrene. — When mortification takes place in tissues that are 
 filled with Idood. and more particularly with inflammatory fluids, "moist, hot, or humid 
 gangrene " is produced ; biit when it take place in parts in which no such stasis exists, 
 and where death of the tissues is the result of a want of arterial supply, " dry. cold, or 
 chronic ganirrene " is caused. These two forms, however, are in a measure convertible, 
 
80 MORTIFICA TION. 
 
 the rapidity of the proce.s.s and the amount of inflammatory infiltration influencing the 
 result. 
 
 Tissues suiFering from defective nutrition, either as the result of some want of nerve 
 supply or energy or of extreme debility the consequence of severe illness or other depress- 
 ing influence, are more prone than others to mortify on slight causes. 
 
 Direct traumatic gangrene is well exemplified in the destruction of skin from 
 the contact of a corrosive acid, such as sulphuric or nitric, in bad burns and " smashes." 
 It is also well illustrated in cases of extravasation of urine or faeces, and probably also by 
 the action of some animal poisons. 
 
 Indirect traumatic gangrene is also well seen in the integument after the 
 application of a blister to a child or feeble patient, the blister being followed by inflam- 
 mation of the blistered part and its subsequent death. It is more frequently met with, 
 however, in bad compound fractures in which the limb swells a few days after the acci- 
 dent and the skin assumes a mottled and livid hue ; loose blisters or phlyctenae of raised 
 cuticle appear on the surface, containing more or less bloodstained serum, and the tissues 
 become sooner or later cold and insensible, the temperature of the part often falling 
 rapidly. The fluids from the wound, likewise, soon become ofl"ensive. blood-stained, and 
 mixed with gas, and the tissues crepitate on pressure from its presence. 
 
 Line of Demarcation. — The gangrene may be limited or spreading. When the 
 action has attained its limit, a defined vascular line, " the line of demarcation," appears 
 where the living tissues come in contact with the dead. In this vascular line ulceration 
 takes place, and if left to take its course leads to the separation of the slough from the 
 living tissues. By it soft parts, and even bone, may be divided, the granulations, as they 
 spring up during the process of repair, materially assisting the ca.sting ofl" of the slough. 
 AVhen the deeper tissues of a limb are thus afi"ected. they rapidly decompose and give rise 
 to a horrible foetor, the extent of decomposition depending much upon the fluids in the 
 part. Should the limb be exposed, the integument will dry, become black, and gradually 
 wither, while the soft parts beneath will undergo decomposition. 
 
 This process is rarely attended with haemorrhage, the vessels becoming obstructed by 
 the coagulation of their blood during the sloughing action. In exceptional cases, how- 
 ever, the vessels give way, the more rapid the sloughing action in the part, the greater, 
 apparently, being the liability to bleed. 
 
 Anaemic Gangrene. — The best examples of this group are found after the appli- 
 cation of a ligature to a large artery, such as the femoral, for aneurism or injury ;. after 
 the contusion or stretching of an artery (rA/e Fig. 134) or its embolic plugging. In all 
 these instances the part dies by starvation from want of blood ; and the more sudden the 
 act by which the supply is cut off", the greater is the probability of gangrene being the 
 result. The more gradual occlusion of an artery, except in the aged, is more rarely fol- 
 lowed by such a result, the collateral circulation preventing it. In the form of gangrene 
 called " senile " it is very probable that arterial obstruction, the result of atheromatous 
 arterial disease or of embolic plugging of the vessel from the breaking loose of some 
 portion of the diseased arterial coats, is the immediate cause of the gangrene ; but the 
 feebleness of old age, the degeneration of the tissues that have been badly supplied with 
 arterial blood, coupled often with some slight local injury, are doubtless powerful agents 
 in giving efi'ect to the process. One or more of these agents may be the true cause of 
 the gangrene, but in the majority of cases they are probably combined. When the gan- 
 grene is purely a dry withering or mummifying process, the cause is probably the simple 
 want of blood supply ; but when inflammation coexists, the gangrene will be moist, the 
 feebly-nourished tissues, either from injury or otherwise, becoming inflamed from some 
 accidental cause, and ultimately dying. 
 
 In the gangrene met with from arteritis or embolism in the young or middle-aged, the 
 dry form is the usual, the parts becoming cold, bloodless, waxy, rapidly withering, turn- 
 ing black, and then mummifying. When caused by embolism, the onset of the gangrene, 
 or rather the early indication of the plugging of the vessel, is marked by a sudden shoot- 
 ing or crampy pain down the extremity, this symptom being speedily followed by those 
 of " arterial gangrene." 
 
 When the occlusion of the vessel is gradual, this pain is not present and the symp- 
 toms of gangrene are more chronic. 
 
 Gangrene from " cold " may be the direct result of want of blood supply, or may be 
 indirectly caused by the inflammation due to excessive reaction from cold ; this latter 
 form is called secondary mortification. Gangrene following the use of the " ergot of 
 rye " is dry, and follows precisely the same cour.se as when due to arterial obstruction. 
 
MnirniKArins. 81 
 
 Static Gangrene. — Tin- liot illu^tiatiuns lA' this varit-ty of ^aiifrrcno — which 
 results fruni i>hgtnirhiiii — are sct'ii in cases ot" st laiiLruhitcfl femoral hrniia ; where splints 
 are t(i(t tiirhtly applieil ; after the jirol()ii;;ed employment of the tonrnifjuet to cheek 
 hii'inorrhaire ; in a ti;iht paraphyinosis ; in slou<rhin.i; of protrmliriL' pih's ; in the {ranjrrene 
 of a liml) from the pressure of an aneurism or tumor up<ui the chief venous trunks; in 
 the sloii^hini; of the leirs, groins, or otlier parts of patients sufferiufr from some obstruc- 
 tive lu'art disease. In all these tlie parts may dit: from blood stasis mechanically j)ro- 
 duced. thouirh inflammation more or less marked, with its products, has generally an 
 important influence in j)rodueing the result. 
 
 Mortification is thus a com])ound process, and is brouL'lit about bv mixcil cau.ses, 
 direct injury, want of arterial sup])ly. and bhxjd stasis irom a mechanical obstruction to 
 the return of the vcikmis blood beiufr the three chief. At the same time, in each of tli«; 
 three ela.sses of cases inflammatory action has seccnidarily an important influence. Feeble- 
 ness of power from old aire, want of nutrition, or deficient nerve supply in a jtart at the 
 same time renders a patient or tissue more prone to the action of tliese cau.ses. and the 
 process more active. 
 
 The constitutional symjitonis associated with jrangrene vary witli its cau.se, but under 
 all circumstances a depressed condition of the onlinary powers is recofrnizable. In trau- 
 matic inflammation, durintr the stasre of excitement, the pulse may be rapid and the beat 
 .stronj;: there may be hi^di fever and other .symptoms indicative of sthenic action; but 
 when about to terminate in gangrene, all these .symptoms will be marked by a sudden 
 fall of the temperature of the body — .say from 104*' or 1(15° to !»9° F.' 
 
 When the mischief is extensive and the gangrene spreads, what are known as typhoid 
 symptoms may supervene. In the more acute ca.ses death takes place very rapidly, but 
 in the chronic the constitutional symptoms are negative. 
 
 Trkatmknt. — The mr^st important point the surgeon has to bear in mind in the gen- 
 eral treatment of every form of mortification is that the condition indicates a depressed 
 state of tlie sy.stem ; consef|uently, his eflFfjrts should be directed toward maintaining the 
 patients strength and cautiously building up liis feeble powers by means of nutritious 
 food, stimulants, and tonics, allaying pain, at the same time, by local and general sooth- 
 ing remedies, such as opium, morithia, or chloral, since nothing depresses more than pain. 
 
 In the local treatment of gangrene its cau.se has closely to be considered. To treat a 
 case of gangrene the result of a local injury as one due to an obstruction of an artery 
 would be clearly wrong, and to deal with an example of this latter form in the same 
 manner as with another due to blood stasis the result of mechanical obstruction to the 
 return of the venous blood of a part would be unscientific. I shall, therefore, consider 
 the question of treatment as applied separately to the three groups of cases already 
 formed. 
 
 Treatment of (Urect traumatic gangrene, when of a limifeil nature, need cau.se but little 
 anxiety. It should be treated on ordinary principles of local cleanliness, poultices, and 
 irrigation, or the local application of absorbent cotton, with some antiseptic lotion such 
 as iodine lotion, sulphurous acid. Condy's fluid, carbolic acid, or chloride of zinc, is all 
 that is needed. When the slough has come away, the surface is to be treated as an ordi- 
 nary sore. 
 
 When the gangrene is more extensive and involves possibly a portion of a limb, hut 
 yet define,!, the expediency of removing the dead part by amputation is not to be dis- 
 puted. No more of it, however, .should be sacrificed than is absolutely necessary, and to 
 ensure this object the flaps to cover the end of the stump may be cut of any shape. 
 Thus, in gangrene of the leg it is better to amputate below the knee with any form of 
 flap that can be made of sufficient size to cover in the end of the stump than at'the joint, 
 and it is far better to amputate at the joint than above it. 
 
 The treatment of indirect fraumotir or inflammatory gangrene is full of difliculties, 
 more particularly when .seen in a ca.se of compound fracture, since to remove a limb at 
 once, as soon as the action has declared itself, would be to take away what often might be 
 saved or to do that which will not arrest the disease ; and, on the other hand, to defer the 
 removal too often diminishes the prospect of recovery, the extension of the mischief 
 rendering the amputation a more formidable one or precluding the possibility of its per- 
 formance. It is xcise, however, in all cases, to amputate tchen the gangrene is extending, 
 oicing to the ivfiltrafion info the health// ti.<<.-iues of the decomposing fluids from the parts. 
 
 In a case of compound fracture which is so bad as to suggest the necessity of primary 
 
 amputation, but in which the surgeon has been desirous, if po.ssible. of saving the limb, 
 
 ' Peck, St. Georges Hospital ReporU for 1868. 
 t> 
 
82 MORTTFK 'A TION. 
 
 the first onset of an inflammatory action tliat assumes a gangrenous form should he met 
 by amputation ; while in a case less severe, where the injured limb has a good prospect 
 of being made a useful one, an attack of inflammatory gangrene need not necessarily lead 
 to its loss. 
 
 Where the gangrene is due to the injury, it will probably be limited, and may so 
 terminate that a good limb can subsequently be secured. Where it is due to constitutional, 
 and not to local, causes, amputation of the limb will not arrest it; for the gangrenous action 
 will in all probability attack the stump and continue till it finds a limit or destroys life. 
 
 When the gangrene originates from a local cause, amputation is clearly the best prac- 
 tice ; but when from a constitutional cause, it had better not be entertained till the action 
 has ceased and a limit to the disease been formed. In military surgery there may be many 
 reasons why this practice cannot be observed, for all conservative surgery or treatment 
 based on expectancy has to be sacrificed to the exigencies of the moment. 
 
 How, then, it may be asked, is spreading gangrene to be treated ? I reply. By main- 
 taining the part as free as possible from all foetid dischai'ges and employing incisions 
 when necessary to secure these ends, by local cleanliness and the use of antiseptic applioia- 
 tions, and internally tonics and good food. 
 
 Under this practice, when nature is strong enough to check the progress of the disease, 
 a limit to its extent will be formed and the local affection will be amenable to treatment ; 
 but when no limit takes place, death will ensue, which amputation would not have arrested. 
 
 When 'amputation is deemed necessary on the arrest of the action, the limb should be 
 removed as close as possible above the diseased part. There exists no necessity to saci'i- 
 fice any tissue, and much less a joint, to make an amputation neat. The only point for 
 consideration is that the diseased tissues should be avoided, but beyond these no healthy 
 structures should be sacrificed. 
 
 The Treatment of Anirmic or Arterial Gangrene. — The surgeon's object should be to 
 prevent its exten.sion, and to assist, when called upon, the separation of the parts. 
 
 To carry out the first of these, the mortified parts maybe wrapped in some lint dipped 
 in simple or carbolized oil ; and the whole extremity should be raised, to encourage the 
 venous circulation, and surrounded with cotton-wool, to maintain its warmth. 
 
 A liberal allowance of bland nutritious food should be given, aided with stimulants 
 and tonics to assist digestion ; the circulation, too, should be sustained, though anything 
 like overstimulating is reprehensible. Opium also may be given to allay pain, the patient 
 being kept gently under its influence. Where small parts only are implicated their sepa- 
 ration may be left to nature, but where hands or feet are involved in the gangrene the 
 surgeon should assist nature's processes by amputation above or about the line of demarca- 
 tion as soon as indicated. 
 
 AVhen a limb dies from embolic plugging, occlusion of an artery, or from the eff'ects 
 of ergot of rye, amputation may be performed as soon as the line of demarcation has 
 been indicated — that is, provided the general condition of the patient be such as not to 
 forbid it. In "senile grangrene" the interference should be of the mildest kind. 
 
 Where '' sphacelus" takes place after the application of a ligature to a large artery, 
 early amputation is sometimes called for, it being at times wise to remove the limb above 
 the line of ligature rather than to wait for nature to indicate the point, particularly when 
 the limb is fcdematous from blood .stasis and infiltrated with inflammatory products, this 
 practice saving much constitutional disturbance and economizing power. In cases, how- 
 ever, in which the gangrene assumes the an;<!mic form and spreads slowly, a line of 
 demarcation may be waited for, more particularly when the constitutional condition 
 of the patient is good. 
 
 In the treatmei)t of the fJiird group of cases. fJio.se of ^^ .<<fafic ffanc/rene^' caused by the 
 mechanical obstruction to the return of blood from a part, the first thing to be done is to 
 remove the cause. In hernia this is accomplished by dividing the stricture ; in paraphy- 
 mosis, by freeing the prepuce ; and when the result of the application of a tourniquet or 
 splints, by their removal. By this course, if the parts involved are not irreparably lost, 
 a recovery may take place by natural processes, their venous circulation being aided by 
 position and other means. When gangrene, however, has taken place in a limb, its early 
 amputation is necessary, it being wiser to remove the dead part at once before the setting 
 in of secondary inflammation, which may spread and cause more loss of tissue, the point 
 of application of the mechanical force fairly indicating the extent of mischief. 
 
 In gangrene of a limb from a ruptured artery or aneurism the same practice should 
 be resorted to, for similar reasons, delay, under all the circum.stances, being unnecessarj 
 as well as injurious. 
 
HosviTM. i;.{s<:ni':yE. 83 
 
 HOSPITAL GANGRENE, 
 
 or sltMiL'liiiiLr |ili;ii:iilaMi:i. is an iifrcciiun tli;it ;iit;nk> wuiiikUmI or iiijiircfl parts, and chiefly 
 ill ovorcntwtU'd, hadly-vciitilatcd, or ill-drained hospitals. At tiiiu-s it pn-sciits itself as 
 if jroiienitL'il ill a ward too closi-ly lillc([ with patii-iits who have sup[»uratiii^' wounds; at 
 others, as if eoiiveyeil into a ward Ity the introduetioii of a sloii<:hiii^ or f<etid sore. Want 
 of eh'aiiliness in the treatment of suppurating: wounds and want of attention to sanitary 
 laws have undouhtedly niiich to (ht with its propagation, for the di.sease seems to be eonta- 
 irioiis as well as infectious, througli its discharges. Its contagious character is admitted by 
 all, though some dispute its infectiousness, (luthrie, however, in his (JommnitaritH^riiX&iQii 
 the following striking fact bearing upon the point: '" Hurgmans says that hospital gangrene 
 prevailed in one of the low wards at Leyden in ITi'H, whilst the ward above it was free. 
 The surgeon made an opening in the ceiling between the two. in ctrder to ventilate the 
 lower or affected ward, and in thirty hours three patients who lay next the opening were 
 attacked by the disease, which soon spread through the whole ward." 
 
 Tiro forms of the disease exist. In one the gangrene takes place by small sloughs 
 and tlu' ulcerative action is the more violent ; wounds attacked with it rajiidly spread, 
 and skin, subcutaneous and connective tissues all disappear under its action. lilackadder 
 relates how a vesicle forms and ulcerates and the ulceration ra})idly spreads, leaving a 
 sharp well-defined edge to the ulcer. This form of the affection Delpech designated 
 "ulcerous," and Boggie "'phagedaena gangrenosa." 
 
 In the second form the tissues die in masses, forming pale, ash-colored, pultaceous, 
 horribly offensive sloughs, these sloughs giving the old term " putrid degeneration" to 
 the disease. In one epidemic the ulcerative form will predominate ; in another, the 
 sloughing; and at times it appears as if one form of the disease would give place to the 
 other. As a rule, though not always, an open wound .seems requisite for the disea.se to 
 fix upon. In 1849. when the wards of Guy's Hospital lust contained such ca.ses. a con- 
 tused part often took on the action, and the gangrene commenced as a vesicle the base 
 of which turned at once into a grayish slough, which rapidly extended. When it attacked 
 a wound, the edges or surf\ice would first cease to secrete, then assume a gray color and 
 slough ; and this action would spread, small wounds becoming large even in twenty-four 
 hours. When the slough had ceased to spread, ulceration would throw it off; and the 
 fietor of the slough, with the (Uhris of the ulcerating tissues, formed a mass of decom- 
 posing material unequalled in any other affection. Skin readily died under the influence 
 of the process on the connective tissue, and muscles became involved ; tendons and ves- 
 sels gave way only in prolonged cases, and haemorrhage was rare. 
 
 The constitutional symptoms of the disease in the epidemic I have witnessed were 
 absent at the out.set. and there was certainly neither fever nor other disturbance- to indi- 
 cate the approach of the action ; yet when the local disease had once manifested itself, 
 great depression became very general. It was always remarked, however, that the con- 
 stitutional .symptoms were never in proportion to the extent of the local affection. When 
 strong subjects were attacked, the local mischief told but little upon their powers; while 
 with feeble subjects the effects were more marked. 
 
 Military surgeons, however, have related that the con.«titutional often preceded the 
 local symptoms. Hennaii states this very clearly, and Thompson of America found a 
 like result : while Blackadder. Delpech, Guthrie, and Macleod found the local affection 
 took precedence in point of time. 
 
 It would rather appear, from the descriptions given of the epidemic at various times, 
 that the ulcerative form is more commonly preceded by constitutional .symptoms than the 
 sloughing, the sloughing being, apparently, a local affection at the first.' 
 
 During the late German campaign Professor Billroth met with a wound disease which 
 he had not seen before, and which he terms • diphtheritic phlegmon" or •• diphtheritic 
 infiltration ;" and he describes three ca.ses in which the diphtheritic appearance occurred 
 soon after operations and was speedily followed by fatal collapse. In these the surface 
 of the wound assumed a pale-gray or white color, and the entire muscular structure 
 of the part became hard and stiff from an indurated infiltration. The affection was dis- 
 tingui.shed from gangrene by an absence of any rapid increa.se of the ulcerative proce.ss 
 or of inflammatory redness in the vicinity, and by the surface of the wound exhibiting 
 a lardaceous gray or whiteness, and not the greasy pulpiness of hos]>ital gangrene. 
 The broad, hard infiltration so soon following the operation might seem to be due to 
 contagiftn by means of the dressings employed, but this was scarcely probable. In its 
 sporadic form it especially appears to affect the subjects of septic or pyjemic disease, 
 
84 ERYSIPELAS. 
 
 and perhaps certain conditions of tlie secretions inclined to coagulation may favor its 
 production. 
 
 Treatment. — Abnndwiec of fresh air, as maintained by a constant current allowed 
 to pass through the ward or room, is most essential, with isolation, the free use of anti- 
 septics and close attention to all sanitary measures. During the early stages of the dis- 
 ease irrigation seems to be the best local treatment, with the removal of oil slutit/Iis and 
 jnitrescent material by carefully cutting the existing slough with scissors or scalpel aided 
 by the dressing-forceps and mopping the surface of the wound with cotton-wool or tow, 
 thus tlioroiufhiij cl<;a)iniiig tlu' whole surface of the ico»n<L The next aim is to prevent tlie 
 extension or return of the sloughing, by means of local applications ; and of these nitric 
 acid was formerly the chief, the acid being freely applied to the diseased parts and care- 
 fully introduced into every hollow and excavation into which it could percolate. 
 
 To apply the acid, writes Welbank, "the sore must be thoroughly cleansed and all 
 its moisture absorbed by lint or tow. The surrounding parts must next be defended 
 with a thick layer of ointment ; then a thick pledget of lint, which may be conveniently 
 fastened to the end of a stick, is to be imbued with the acid, and to be pressed steadily 
 on every part of the diseased surface till the latter is converted into a dry, firm, and 
 insensible mass. The part may then be covered with simple dressings and cloths wet 
 with cold water." 
 
 Dr. Goldsmith of America, and others, have spoken very highly of the value of bro- 
 mine as an application which arrests ulceration and turns sJoug-hs into tough deodorized 
 tissues. It should be applied fref\y to the whole surface, and its application .should be 
 repeated when the sloughing or ulceration spreads. Iodine, carbolic acid, and the oil of 
 turpentine have also been advocated ; and the latter, it is said, has the power to dissolve 
 the sloughs and change the action of the disease. Delpech and some surgeons speak 
 highly of the actual cautery ; and when the benzoline cautery is to be had, it might be 
 used. The object of all these diiferent plans of treatment is to excite a new action on 
 the surface of the wound, and to destroy the sloughing tissues Avhich, doubtless, by mere 
 contact, have a power of keeping up or propagating the disease. 
 
 When the sore is extensive, an anaesthetic should be administered during this local 
 treatment. After the cauterization the surface of the sore should be dressed with car- 
 bolic or terebene oil ; whilst laudanum, iodine lotion, or bromine in solution, two drops 
 to the ounce of water, is also beneficial. 
 
 Dr. Packard of Philadelphia used powdered sugar or thick syrup, sugar being a 
 hydrate of carbon which does not give up its oxygen. He dusted the parts with the 
 sugar and covered the whole with wet lint. When odor exists, charcoal should be mixed 
 with the sugar. 
 
 The constitutional treatment consists in abundance of light, nutritious food, milk 
 being administered as freely as it can be taken, with sufficient stimulants to maintain the 
 circulatory system and assist digestion. 
 
 Tonics, such as quinine and iron, are often well borne in large doses, five grains of 
 the former dissolved in half a drachm of the tincture of the perchloride of iron being a 
 good recipe; or when quinine cannot be taken, the tincture of nux vomica in ten-drop 
 doses may be substituted. Opium is an admirable drug when the ulcerative action is 
 present, but in the sloughing stage it is not so satisfactory. Chloral is probably a good 
 remedy for a like purpose. 
 
 ERYSIPELAS. 
 
 Erysipelas is a contagious and infectious specific disease due to the presence of some 
 bJood poison that has probably been introduced into the body from without. It is inti- 
 nii'.'.-t^'y allied with other blood poisons, such as are found in scarlet or puerperal fevers or 
 septicaemia in any of its forms ; for these poisons seem to be convertible. It is connected 
 with d-.;fects of drainage or ventilation, but is not so much a hospital disease as is gen- 
 erally believed, only 186 cases having taken place in Guy's Hospital in the eight years 
 ending with 1879 out of 18,922 surgical patients which were admitted, or less than one 
 per cent. No less than 451 cases were, however, admitted icitli the affection, and some 
 of those recorded as Iniving been transferred from one of the wards simply passed 
 through it. 
 
 It manifests its presence in three forms — as a diffused cutaneous inflammation, 
 "simple cutaneous erysipelas;" as a diff"used inflammation of the cellular tissue, "dif- 
 fused cellular inflammation ;" and as a dift'used inflammation of both skin and cellular 
 tissue combined, " phlegmonous erysipelas ;" the latter two being included in the expres- 
 
ERYSIPELAS. 
 
 85 
 
 sion 'Tellulo-cutaiit'ous." The state of the system, the temperature and hahits of the indi- 
 vidiial. have iiiucli to do in (U'terininin<; the form of the affection. When tlie disease follows 
 an injury, it is called •• traumatic ;"' when it occurs sponlancftusly, it is styled " idiopathic." 
 
 The peculiarity oi" erysipelas lies in the diffu.sed character of the inflaniniatifm and in 
 its atonic nature. It is Itoth in/irfinns ami nmtitijloiis. 
 
 The attack is occasidually jireceded by some constitutional disturhancc. hut as often 
 as not su(di has not heen oliserved ; the severity of the <:eneral symptoms, moreover, in 
 no way hears any prttportion to that of the local disease. Febrile symjitoms ushered in 
 by chilliness and /vV/o/- are the most common, the tonj^ue bein<^ pntbably foul and the 
 bnwils either constipated or relaxed. As the disease advances the fever runs hi^di and 
 delirium of different forms appears ; the pulse becomes (juickened ; if full, it will always 
 be compressible, and often irrc<rular or intermittent. Toward the close of the disease, 
 ]>articularly when terminatintr unfavorably, the pul.se will be small and weak. The temper- 
 ature at the first onset of this di.sea.se, as a rule, ri.ses rajiidly, and in its decline falls as fast 
 (^vidi tigs. IM and 14 ). When the temperature remains hiirh, a bad prognosis should be given. 
 
 C. de Morgan, Nunneley, and II. Bird assert that if the pulse rise in fre«|uency after 
 the sixth or seventh day it is a very bad sign. I cannot, however, endorse this observa- 
 tion, although, as the end of the first week is about the time that complications appear 
 if they occur at all. it may pos.sibly Vje correct. 
 
 Frank has pointed out that when a patient has had febrile .symptoms for sonte hours 
 attended with pain, tenderness, and swelling of the lymphatic glands of the part, there is 
 
 Fir;, l:;. Fir;. 14. 
 
 BSISBBBSHI 
 
 Thermograph of erysipelas supervenin.: upou removal 
 of the tarsal bones after the traumatic temperature had 
 subsided, showing rajiid elevation of temperature — 
 nearly 5 degrees— at the onset of the disease and steady 
 fall during convalescence. Case of H B., set. 32. 
 
 ■■■■■■■g 
 
 ESSSlBaBDBDBBHDB 
 
 ThermoLTaph oi erysipelas in man. at. ■_".', after re- 
 moval (if parotid tumor. Operation iday li fol- 
 lowed by slight traumatic fever (day 2) anil steady 
 fall in temperature. Klevation of temperature 
 (day 4i when blush first became visible, and steady 
 rise for three days during increase of disease, 
 with rapid fall on its subsidence. Convalescence 
 on eleventh da v. 
 
 no doubt that erysipelas is coming on. Chomel held the same view, and Campbell de 
 Morgan relates " that Busk is so convinced of the invariable occurrence of affection of 
 the glands before ery.sipelas appears as to consider it a pathognomonic symptom," and he 
 believes that, although the blood became affected, the actual primary seat of the local 
 inflammation was in the absorbent system. Sometimes swelling and excessive tenderness 
 of the glands precede by many hours the appearance of a blush on the skin. These 
 views accord well with those which Dr. Bastian brought before the Pathological Society 
 in 1869, based on the po.st -mortem examination of a man who died from erysipelas in a 
 state of delirium and stupor. In this case, finding the small arteries and capillaries of 
 the brain plugged with embolic masses of white blood corpuscles, he suggested this con- 
 dition as the cause of delirium. He stated " that the blood change is a general one, and 
 through every part of the body this blood is carried with its rebellious white corpuscles ; 
 so that we may expect that in all organs alike the same obliterations of small arteries 
 and capillaries take place." Thus, when those of the liver are involved jaundice may be 
 produced, and when those of the kidney albuminuria, these conditions being occasionally 
 found in erysipelas. 
 
 If we accept Dr. Bastian's ob.servations pathologically, and look to the condition of 
 the white blood corpuscles for an explanation of many of the phenomena of ery.sipelas, 
 we may fairly admit the inference from clinical observations respecting the absorbent 
 system to which Frank and Busk have called our attention, for the glands of this system 
 and the white blood corpuscles are generally recognized as having a close relationship. 
 These views receive much confirmation from the pathological observations to be read on 
 page 87. 
 
 Local Symptoms. — In the simple form of cutaneous erysipelas mere excess of 
 vascularity, as indieatcd by the vivid redness of the part affected, is the chief local symp- 
 tom, and with this there is a sensation of heat or tingling in the part, and in rare instances 
 
86 ERYSIPELAS. 
 
 the formation of small vesications. Tho border of inflammation is invariably well defined. 
 The redness, wliieli spreads rapidly, disappears on pressure, to return directly the pressure 
 is removed ; but there will be no pitting of the parts to indicate oedema. In a day or two 
 these syniptouis will subside or disappear, and the cuticle will descjuamate. 
 
 In the 7iiorc sfvn-c form of cutaneous erysipelas the vascularity of the skin will be as 
 intense as in the simple, but it may be more livid. It will, however, be associated with 
 some perceptible thickening of the parts, tfhe inflamed tissues feeling raised on pal])ation. 
 Where much cellular tissue exists, as in the eyelids or scrotum, oedema will rapidly show 
 itself. Small or large vesicles may likewise form on the surface, containing either a clear 
 serum or a blood-stained or sero-purulent fluid, the latter form indicating great depression. 
 In the head or other parts where the skin is tight the feeling of tension is very great and 
 the surface looks shining, the features being altogether obliterated. There is rarely, 
 however, nmcli ])aiii. 
 
 Course and Duration.— The disease runs its course in al)()ut ten days. j)uring 
 the first three or four it spreads, and, having reached its height, declines, the redness and 
 swelling gradually subsiding and the .skin des(juainating. In some cases a local suppura- 
 tion takes place, and tliis is always to be sus])ected when any local redness remains after 
 the subsidence of the inflammation. In the eyelids and other parts containing loose 
 cellular tissue such a result is common. In the cachectic subject the disease is always 
 more (edematous than in the healthy. When it attacks a wound, the general symptoms 
 are the same, but the local consist in arrest of secretion in the part, then ulceration, and 
 later on, where union has existed, disunion, stumps and wounds sometimes reopening and 
 discharging a thin ichorous fluid. 
 
 After the disease has subsided repair is usually .slow, but at times it goes on healthily 
 to complete recovery. 
 
 Pr()(JNO.>>is. — Simple erysipelas, unless in the feeble or cachectic, is rarely a disease 
 of much danger. In free-living subjects, and in others who have l)ad viscera, it is, how- 
 ever, a dangerous affection, lighting up latent disease that often proves fatal. When it 
 attacks the scalp after head injuries, it is exceptional to find it followed by bad conse- 
 quences. 
 
 Where the erysipelas attacks the mucous lining of the throat, fauces, or larynx, it 
 may, from mechanical causes, threaten life. 
 
 In some cases the disease will affect different parts of the body consecutively or leave 
 one spot to attack suddenly another. Such cases usually indicate want of power, and 
 too often are found in those who have some organic disease of the kidney or other excre- 
 tory org.iii. 
 
 Diffuse cellular inflammation may clinically be looked upon as a form of ery- 
 sipelas, the disease attacking primarily the cellular tissue instead of the skin. It is cha- 
 racterized by the same diffused form of inflammation and by the same atonic character. 
 It is, however, more frequently the result of' some local injur}', such as a punctured or 
 dissection wound, than is the simple form, and it is even found in patients from whom no 
 such history can be obtained. It is generally as.sociated with absorbent inflammation 
 and glandular enlargement. 
 
 The disease appears as a diffused swelling and induration of the cellular tissue of the 
 part aflected, the tissues feeling infiltrated and brawny and the skin tense from over-dis- 
 tension. When suppuration or sloughing of the cellular tissue has taken ])lace. fluctua- 
 tion or crepitation will be detected or the parts may feel boggy. The skin, if not pre- 
 viou.sly inflamed, will now participate in the disease; it will inflame, ulcerate, or slough, 
 to permit the escape of the pent-up pus or sloughing cellular tissue. When resolution 
 takes place at an early period of this affection, the skin may escape uninjured; but such 
 a result is rare. 
 
 The constitutional symptoms attending these changes in the cellular tissue are always 
 those of great depression. The febrile symptoms will be of the typhoid type, the pulse 
 feeble, although rapid from the first, and the disposition to sink very marked. Profuse 
 sweating is an early and constant s3'mptom. Delirium also is sometimes present. Vis- 
 ceral complications are, as a rule, the cause of death, the connection between this affec- 
 tion and py;\!mia being very close. 
 
 Phlegmonous erysipelas is a combination of the two former. It is fiir more 
 serious than the sinqde, and as much so as the cellular inflammation. It is characterized 
 by a dift'used inflammation of the skin an<l cellular ti.ssue together, the parts having a 
 strong disposition to suppurate and slough. It is commonly the result of some punc- 
 tured wound or injury involving the skin and cellular tissue beneath, and begins locally 
 
KRYSII'EI.AS. 87 
 
 as a hrawny infiltriitiim <>f the part, tin- skin prescntiiifr cryMipolatous redness of a dusky 
 hue, and the houiidary lietweeii the intlaiiied and utiinflanied skin heirijr ill-niarki'd ; outside 
 the limit (»t' the rechiess the skin feels unnaturally Hrni. and the edlular tissue beneath as 
 if infiltrated. To the tinj^er the inflamed ])arts feel more solid and pit on pressure. Reso- 
 lution is almost unknown as a termination of the disea.se, one ca.se differin;r fr(»ni another 
 oidy in the extent of the destruetion of tissue with which it is accompanied. 
 
 As the di.sea.se protrres.ses. and the t-ellular tissue beneath the integument becomes 
 infiltrated with inflammatory pnnlucts, the skin will be made tense and cease in pit ; uni- 
 form hanlness of the tissues will irive jdace to a .sen.se of fluctuation, as of fluid, or to a 
 boiriry. (juajrsy. crepitatiuLr feel of slouirhiiii: cellular tissue. 
 
 If the case be left to nature, the skin will V)ecome thin and ulcerate in jiarts or slough 
 in masses, to give vent to the pent-up and sloughing tissues. Phlyct;cn;e will also 
 appear over the dead portions of skin, as in other forms of gangrene ; while the pus and 
 sloughs which escape are always fietid. In bad cases the whole cellular tissue of a limb, 
 with large portions of integument, in this way may die, bands of skin held down by fascia 
 being left, which during recovery will become the centres of cutification. 
 
 In the ordinary run of cases this dift'used infiltration of the cellular tissue is confined 
 by the fascia to the subcut^meous ti.ssue. but in .some instances the cellular tissue that 
 separates the muscles becomes involved, when the case assumes a far more .serious a.spect; 
 for the suppuration is then of a burrowing kind, and the sloughing is more exten.sive. 
 The prospect of recovery with a useful muscle becomes also very slender, for muscles 
 and tendons may not <jnly slough wholly or in part, but on recovery taking place they 
 may become .so closely bound together with the other ti.ssues that they are u.seless as 
 moving organs. From this cause, after phlegmonous inflammation of the hand and fore- 
 arm, a stiff and immovable extremity is often met with, and the hand becomes a kind of fin. 
 
 The constitutional symptoms associated with phlegmonous erysipelas vary con.sider- 
 ably, and their .severity depends much upon the rapidity with which the disease spreads. 
 They are. however, in character the same as are found in other forms of the affection, 
 though they are probably more severe. The rigors are more marked, the fever is higher, 
 the pulse more rapid, and the tendency to fall in power always greater. Thus, in the 
 suppurative or sloughing .stage of the disease the rigors frequently recur, and cold sweats 
 and fever intervene as in an ague. When the local affection is undergoing repair, or, at 
 any rate, has ceased to spread, and these " false ague-fits " persist, some internal or vis- 
 ceral complication may be looked for ; the blood becomes poisoned as in septicsemia. often 
 to the extent of destroying life. 
 
 The pathological appearances met with in cases of death from erysipelas 
 have l>een kindly drawn up fur nie liv Dr. J. F. Goodhart after a careful analysis of the 
 post-mortem records of the hospital. They admit of being classified as h/col and general^ 
 the former including all those morbid changes which occur in the primary focus and in 
 the surrounding parts directly extending from it ; the latter, the various alterations of 
 blood or tissue found in any secondary foci or in the system at large. 
 
 The local changes vary according to the severity of the disease and the rapidity with 
 which it causes death. 
 
 In the slighter forms, where it has not been the immediate cause, but has supervened 
 as an intercurrent affection in the course of some other disease, it may often happen that 
 no morbid appearance is visible po.st-mortem indicating erysipelas. Again, the skin alone 
 may be affected either with a mere faint purple discoloration or with slight oedema, or the 
 cuticle may be raised into bulht or separated more or less around. In more pronounced 
 cases, the areolar tissue beneath the skin and along the tendons and intermuscular septa 
 has numerous minute ecchymoses and extravasations of blood in it and is often soaked 
 with yellow serum or gelatinous matter, apparently produced by a delicate fibrinous 
 coagulum : in the more prolonged or in severe cases the serum is replaced by healthy 
 pus. Ecchymoses in the subcutaneous areolar tissue are very common, even in cases 
 where death has been very rapid and no other morbid appearances are seen. 
 
 It is charact*?ristic of the further changes that there is no tendency to the limitation 
 of the disease around the primary focus ; the pus or serum leads to the formation of no 
 abscess sac, but spreads along the subcutaneous tissues and intermuscular septa, sometimes 
 even making a complete dissection of some of the muscles. 
 
 There may or may not be phlebitis in the parts. Where it exists the interior of the 
 veins affected is discolored and filled with grunious chocolate-colored fluid, while the inner 
 surface of the vein-wall is rough from the inflammatory processes it has undergone and 
 the adhesion of small particles of clot. Where the disease has existed some time a tube 
 
88 ERYSIPELAS. 
 
 of semi-organized clot may line the vein, and within that -nill he found the broken-down 
 clot, which it is often impossible microscopically to distinguish from pus. 
 
 It is quite as common, however, to find the vessels unaffected as to find them plugged, 
 if not more so. Pus may even run along their course, sometimes apparently in their 
 adventitia. or more often immediately outside it. and still lead to no clotting. On micro- 
 scopical examination in these cases the pus is seen to lie in smooth-walled channels which 
 in all probability are lymphatic spaces (^suppurative lymphangitis). 
 
 Affection of Glands. — The neighboring lymphatic glands — >'. e.. those in the groin 
 if the di.-La.-e be >ituated in the leg, the axillary if in the arm — are usually swollen, red, 
 and ecchymosed on section, and are frequently surrounded by the same kind of serous 
 fluid as is found in the immediate neighborhood of the primarily diseased tissue. The 
 tissues of all the diseased parts are said to be crowded with small vegetable organisms 
 called " bacteria. " These constitute the local changes. It may be as well to add. j)er- 
 haps. when erysipelas affects the scalp, that a yellow color of the vault of the .skull is 
 often observed, and also that suppuration between the bone and dura mater and suppura- 
 tive arachnitis and meningitis are not very unusual sequences. About the neck it may 
 be followed bv cedema glottidis. and occasionally by pericarditis or suppurative inflam- 
 mation of the mediastinum. 
 
 The morbid appearances in the system at large are similar to those found in septicae- 
 mia from other cau.ses — viz.. ecchymoses about the pleura and pericardium, a fluid and 
 sometimes treacly state of the blood, congested kidneys, and a softened state of the liver 
 and spleen. So soft, indeed, is the latter organ that were it not for its capsule it would 
 at times lo.se all shape. The blood has been said to contain bacteria, but I have never 
 found such during life, though they are sometimes present when the blood is examined 
 some hours after death. In addition to these general changes, separate foci of diffuse 
 cellulitis are found — in both fore-arms and in the calf of the leg. for instance, after a 
 primary erysipelatous state of the scrotum : and in at least two recorded cases a similar 
 diffuse cellulitis or myocarditis has been noticed in the muscular wall of the heart. 
 Patients with erysipelas are also liable to suppurative peritonitis and pleurisy, which, 
 though commonly so. are not necessarily determined by the presence of a neighboring 
 wound. A subject of hernia or ovariotomy at a time when erysipelas is rife will be likely 
 enough to die of suppurative peritonitis ; while another who has undergone an excision 
 of the breast may die of a similar form of pleurisy without showing any external evi- 
 dence of erysipelas. 
 
 A wound, however, is not necessary. For example, in a post-mortem made not long 
 since a lady about sixty had been nursing a friend who died of some febrile affection 
 called •• low fever."' Within a few days she herself became exceedingly ill. and died 
 quickly. The inspection revealed what had only been evidenced by the faintest blush on 
 the skin during life — viz.. an early suppurative inflammation of the cellular tissue of the 
 right axilla and pectoral region, and pus on the surface of both pleurse ; all this without 
 any external wound whatever. 
 
 As occasional causes of death in erysipelas may also be mentioned acute lobar pneu- 
 monia and a diphtheritic sloughing of the mucous coat of parts of the bowel ; while, to 
 complete the history, it must also be said that at times when erysipelas is present in a 
 hospital or its neighborhood not only are cases of pyaemia, with its known manifestations, 
 such as abscesses in the viscera and pus in the joints, frequent, but patients suffering 
 from chronic suppuration become feverish and die without, it may be. any adequate cause 
 appearing in the viscera. 
 
 In this description of the pathological appearances found in erysipelas no attempt is 
 made to distinguish between it and cellulitis. The morbid changes in both are the same, 
 and it is as impossible in the deadhouse as at the bedside to. separate the two. 
 
 Treatment. — The disease in all its forms is essentially an fitonic one ; consequently, 
 nothing like ■• antiphlogistic " remedies are to be entertained, and in the simpler forms 
 which have a tendency to run a definite course the practitioner has merely to guide his 
 patient through the attack and to ward off whatever might prove injurious. "With these 
 objects, when the' patient's powers are eood and no indications of feebleness manifest 
 themselves, a mild aperient or purge, to clear out the bowels, with bland nutritious food. 
 such as milk and beef-tea. is probably a sufiicient remedial means, the disease on the 
 third or fourth day attaining its height, and then declining. 
 
 Should anv feebleness or want of power appear at the beginning or during the cour.se 
 of the disease, tonics are indicated ; and of these iron seems the best. The tincture of 
 the perchloride in half-drachm doses, or more to an adult, frequently repeated, with or 
 
f.Rysirh'LAs. 89 
 
 witlidiit ((uiiiiiu' or stryliriiii. acts at fiiiics liki- a ••liariii. and douhtlcsis often cuts short 
 the disease. Its iisi' was iiitroduci'(I to liritish siir^reoiis hy I'r. II. IJeli of Kdiiiljur^rh in 
 is.")!, ahhoiiiili V(d|ieau in ]X[l had previously declared its value. 
 
 In the earliest staj^e of the aflet-tion, when the first |iat<-h of intianiniatidn appears on 
 the skin or around a wouimI. an emetic may at times aliruptly (dn-ck the attack. 
 
 When I'ood cannot he taken, stimulants must he suhstituted ; and it is well to introduce 
 inid llieni, and particularly int(» stout, some essence of meat. The form of stimulant 
 must depend upon circumstances, but, as u rule, that which the patient has hc.cu in the 
 hahit of takinj; is the iie>t. When hraiidy is ^iven, it slnjuld be nii.xed with milk or efr<rs. 
 it being always better not to give stimulants alone. The amount nni^t be regulated with 
 care, for over-e.\citation of the system is always bad. 
 
 Hypnotics or sedatives should be used with caution, for they are not usuallv bene- 
 ficial. Of these chloral seems less liable to disagree than opium ; cam[dior and henbane 
 in five-grain do.ses are tlntught well of by some, while ammonia is as highly recommended 
 by others. 
 
 In jddegnionous and cellular erysipelas tlie same principles of practice are applicable. 
 In the suppurative or sloughing stages it is necessary to give abundance of good food of 
 all kinds, and stimulants in proportion; strong animal broths and milk are the best forms 
 of diet. 
 
 Lotwi.. Treatment. — The inflamed parts should always be kept warm and raised, air 
 being e.xcluded from the surface; consequently, when the head and face are implicated 
 with simple erysipelas, the old practice of dusting the parts with flour, fullers earth, 
 starch, or o.xide of zinc is effective. Mr. C. de Morgan used cotton-wool in addition. Warm 
 apjilieations. however, are in some cases the best, especially the lead lotion with opium. 
 Cold is always injurious. 
 
 In the face and head, when the parts are tense and j>ainfiil. relief is readily given by 
 following the practice of 8ir R. Dobson in puncturing the skin with a .series of small 
 punctures, oozing of blood or serum being encouraged l)y warm applications. 
 
 In erysipelas of other parts the application of the tincture of iodine is to be recom- 
 mended. Mr. Luke thouglit highly of the free use of collodion applied over the part; 
 Mr. Higginbottom, of a solution of nitrate of .silver twenty grains to the drachm of 
 water ; others, of the tincture of the perchloride of iron. I have employed at times all 
 these, and prefer the tincture of iodine to any ; but none of them have any certain power 
 of arresting the progress of the di.sease. Some American surgeons .speak strongly in 
 favor of the application of a solution of bromine on lint with oil-silk over the whole, and 
 quite recently the subcutaneous injection of a solution of carbolic acid has been highly 
 spoken of. Mr. Harwell has advocated white paint. 
 
 The local treatment of the cellulo-cutaneous forms of the disease must 
 
 be conducted on tlie same principles as the simple, but as soon as anything like tension of 
 the integument appears incisions should be made deep enough to allow of the escape of 
 the eff"used serum from the cellular tissue beneath the skin, and long enough to relieve 
 the tension of the whole. Some, and amongst them the late Sir W. Lawrence, recom- 
 mended the incision to be free, so as to extend the whole length of the affected part. 
 Others, among whom I claim a place, prefer a greater number of limited incisions. The.se 
 limited incisions answer the same purpose as the long, and are not attended with so copi- 
 ous a hicmorrhage or with so great a risk to life. Even after these the bleeding is at 
 times profuse, but it may generally be readily arrested by elevating the limb and by 
 temporary pressure. 
 
 When suppuration and sloughing exist, the surgeon must let out matter as soon as 
 formed ; for there is little doubt that the disease is kept up by its presence. The open- 
 ing into these abscesses should be free, and their cavities kept clean by careful wa.<hing 
 out at each dres.sing with Condy's fluid or iodine lotion — a detail which adds materially 
 to the comfort of the patient and the well-doing of the case. De Morgan prefers a solu- 
 tion of chloride of zinc fifteen grains to the ounce. Dressings with boracic acid lotion 
 ten grains to the ounce, and gutta-percha over the wet lint, .should be applied to the parts, 
 and frefjuently changed. Poultices are not so good, although at times patients say they 
 derive the most comfort from them. During the period of repair the surgeon will often 
 have to lay open sinuses. When the sloughing has been very severe, amputation may 
 be called for. 
 
 It has ever to be borne in mind that erysipelas is highly contagious and infectious. 
 In hospital practice, consecjuently, every case, as it arises, .should be separated from 
 others in which wounds exist and transferred to a separate ward. All dressings as they 
 
90 ERYTHEMA. 
 
 leave the ward or chamber should he burnt or disinfected, and a spouiie shoidd never be 
 used. Plenty of fre.sh air ouuht ro be admitted into the room, but no drautiht, and dis- 
 infectants should be freely distributed about. No medical ])ractitioner under any circum- 
 stances should go direct from a case of erysipelas to a midwifery case or to dre.ss a wound 
 of any sort, accidental or surgical. If he is obliged to attend a labor when in charge of 
 a case of erysipelas, he should allow as much time as possible to intervene before doing 
 so, and then should attend only after having changed his clothes and carefully disinfected 
 his hands ; for there is a direct connection between erysipelas and puerperal fever. 
 
 ERYTHEMA. 
 
 Erythema finds its place here, as in its clinical features it bears some resemblance to, 
 and has been mistaken for, the simple cutaneous erysipelas. It appears as a roseate or 
 more vivid injection of the .skin, of a local or general character, disappearing on pressure 
 and accompanied with some slight degree of oedematous swelling. 
 
 In its transitory form it may be regarded as a symptom of some bowel or intestinal 
 irritation induced by irregularity in diet or other cause. In so-called bilious subjects it 
 is by no means uncommon, and a local patch of redness on some part of the face or other 
 part of the body often indicates the approach of a " bilious attack." It is found, also, 
 where organic disease of the intestines is present. In other cases it precedes an attack 
 of smallpox, attends vaccinia, and is common in children. 
 
 Hebra gives the term ^'' Erijthema fugux^ to all these symptomatic forms of erythema. 
 
 Erythema, as a {/tsea!<e, more commonly attacks the extremities than the trunk, and 
 the dorsal surfaces in preference to other parts. When the eflSiorcscence appears in small 
 patches of papules or tubereules upon the fingers or hands, the terms E. j^nqyulatiim and 
 E. tHherculatiim are respectively given. 
 
 AVhen these patches assume the form of a red ring, the term E. annulare is applied to 
 it. When a second ring forms round the first before it has passed away, or when it is 
 represented by a small spot, the E. iris is formed ; and where many such circles or half 
 circles appear together and touch or coalesce and spread, the E. circinatnm and E. 
 gyratmn are respectively present. Wilson mentions a case in which the E. ijyratnm 
 covered the whole body ; but all these different forms of erythema must be regarded ag 
 different stages of the same disease. Hebra says, '' It will depend on the period at which 
 the patient comes under medical observation whether the case shall be diagnosed as E. 
 jwptilatum or E. gyrat}im.'" He gives one term to the whole, E. mnltiforme. As the 
 disease subsides a slight desquamation follows, and then some small deposit of pigment. 
 Mr. Morrant Baker' describes an Erythema serpens which follows a slight, probably 
 poisoned abrasion and spreads in a circular manner, leaving the injured part well. It 
 generally occurs in the hand. 
 
 Treatment. — All these forms run a definite course and have a tendency to get well, 
 lasting from one to three or four weeks. They require for treatment little else than a 
 well-selected diet and attention to the bowels. 
 
 Erythema occurs at times during the secondary stage of cholera. 
 
 The erythema that precedes or accompanies the progress of elephantiasis is worthy of 
 notice. 
 
 Erythema nodosum is a more definite aff'ection ; it is found in both sexes, but more 
 commonly in the female ; it is also usually seen upon the legs, but not rarely upon the 
 arms, as well as other parts of the body. It shows itself in rai.sed and tender oval patches 
 of a red color and of very variable size, some being as large as a .sixpence, others as of an 
 orange ; these patches at times join. At first they are of a bright-red color, but as they 
 die away they become of a livid hue and appear very like bruises; like them, also, they 
 lastly assume a yellow tint. The cuticle always desquamates. When the disease is 
 limited, there may be no constitutional disturbance, although occasionally some febrile 
 symptoms appear ; and there is usually some evidence of derangement of the digestive 
 organs, with a foul tongue. As often as not, however, the local disease is the first symp- 
 tom that attracts attention. The eruption is often symmetrical. When it appears over 
 the tibia and the skin is very red and painful, it is often mistaken for some more serious 
 affection, such as perio.stitis ; but the absence of the severe conf5titutional disturbance 
 which commonly attends this aff'ection ought to prevent such an error. The history of 
 the case is enough to distinguish it from a bruise ; and the diff"erent centres of redness or 
 congestion, from erysipelas. 
 
 1 St. Barthol. Hoi^p. Rep., vol. ix. 
 
o.v TRM'MATir i'/:\i:i:. Si:rTI<'.KMl.\. .\SI> rV.KMIA. 91 
 
 Its TiiKAiMKNT is siiuiilr Saline jiurj^ativcs, tonics, ami a can'rully rc^rulatcd diet are, 
 as a riili". .siiniricnt in a L:iii.ral way, and the ajijiliiatioii nf a Ifa<l lotion to tiie inflaini'd 
 part, with i-lcvatioii of the limlis. is trtnicraliy all tlir jcical tnainnMit tliat is rfi|uin'd ; 
 l)iit in cxfciilional cases warm rnuieiilatiMiis, with ur witlmut poppy decoction. <:ive 
 LM'oatcr coiiirorl. 
 
 ON .TRAUMATIC FEVER, SEPTICEMIA, AND PYEMIA. 
 
 Inliainniatory I'cvcr, suri^ical, suppurative, or traumatic fcvijr, scpticjcniia, icliora-niia, 
 puerperal fever, and pyitMuia. may all he considered as so many diljerent names for and 
 manifestations of one condition — viz., hlDixI-jKiiaoiiinij. 
 
 In inflammatory and surtiit-al fever '• the returniiiir fluids of the inflamed i)art. its 
 venous Idood, and its lymph are the agents of general infection" {.Simon;, the poisoninj^ 
 beinu; '• due to the introduction into the torrent of the circulation of toxic substances i)ro- 
 duced by the oruanism itself" (IMaisonneuve), the poison beiiiL: proljably derive<l from 
 </isiiifri/rii/t(/ /issiiia (Hid i/eii<r(iff<f /ruin iri'fhiii the hoili/. 
 
 Tn septicemia, ichor;omia, puerperal fever, and ])yiemia the absorption u\' jmtrlil inflam- 
 matorv products or of pus or jjus-formin*; material, or of some other ])oison, whether from 
 ft woMuded i)art or not, is the undoubted cause of the di.sea.se, //"' poinDii bi-imj tohni into 
 'he Ii'kIi/ either by the veins or by the ab.sorbents.//-o») irithont. Traumatic or surgical 
 f'ever mav, however, pass into septicjvmia and this intopyajmia. the first being the mildest 
 i^'orm of blood-poisoning, the last the most severe. Surgical fever generally ends in recov- 
 ery ; pyjvmia, after the formation of secondary absces.ses. either in the viscera, joints, or 
 connective tissue, in death. 
 
 Symptoms of Blood-Poisoning. — One and all are ushered in by very similar 
 general symptoms, and an outline of those met with in a typical example of inflammat<jry 
 fever wili be found on page G5, " but practically the affection shows numberle.ss grades 
 and differences and complications. First, there are wide differences of degree and cha- 
 racter ; for in proportion as the local process is less acute and less extensive there is less 
 attendant febrility, and in proportion as the local process has to invade fewer successive 
 strata of texture* the fever is of shorter course. ()n the one hand, it may be so slight as 
 readily to escape notice, and may end within a few hours of its commencement ; on the 
 other hand, it may last in full force during many successive days, and may be so severe 
 as to shake the patient's life to its foundation : and besides these differences there are 
 varieties of result, sometimes from complicative local conditions, sometimes from peculiar 
 susceptibilities of the patient. If the wound become the seat of some large textural dis- 
 organization, with consequent .soakage of putrefying material, more marked signs of hlood 
 pollution may be expected to mix with or supersede tho.se of common inflammatory fever. 
 The patient's general state will then incline to be one of depression and apathy ; his 
 tongue will be more than commonly foul, and foetid diarrhoea will probably exist; or if, 
 perchance, during the local process it happen (as is especially apt to be the case where 
 cancellous bone-structure is affected) that pus pa.s.ses up a vein into the general stream 
 of blood, the patient's improvement is abruptly cut short by the s^evere rccnrrnit rl(/ors 
 and sia'dfiiii/ of pi/tn'iitia, accompanied by local signs of secondary suppuration in parts to 
 which the pus is conveyed" (Simon). 
 
 Confirmed blood-poisoning, therefore, is characterized not only by all the .symptoms 
 of inflammatory fever, but by acvere rii/orx breaking in upon the febrile symptoms, by 
 siiddtn and mnrkrd variations of temperature (vide Fig. 15), hi/ pro/me anyats and great 
 depression of tlw patient's powers ; and when these symptoms occur in the course of an 
 attack of inflammatory fever, severe blood-poi.soning is certainly indicated, the gravity 
 of the attack being measured by the inten.sity of the symptoms. We generally meet, 
 moreover, in pyaiinia with local signs of inflammation of some internal organ or external 
 part of the body ; and this inflammation runs on to the formation of metastatic or second- 
 ary abscesses, as they are called. When an internal organ is involved in this disea.se. the 
 result, as a rule, is fatal. When suppuration attacks the integuments or extremities, 
 although it may be severe, there is alw^ays some hope of recovery. It is an interesting 
 clinical fact that these two different forms are rarely met with in the same subject. They 
 may for clearness be .separately called internal and external py:vmia. or acute or chronic, 
 pyaemia, when involving internal parts, being generally rapid in its course and fatal, and 
 when attacking external parts it is as a rule chrojiic ; at times, however, the latter may 
 supervene upon the former variety. 
 
 In many cases of pyaemia a peculiar sweet hay-like odor of the breath is undoubtedly 
 
92 
 
 ox TRAUMATIC FEVER, SEPTICEMIA, AND PYEMIA. 
 
 present. Some authors — and Braidwood is amongst them — look upon this symptom as 
 pathognomonic. 
 
 Traumatic fever, when it occurs, generally makes its ap|)earance from the second 
 to the ninth day after an accident or operation and seldom lasts over a week. Jn a simple 
 case it may subside after twenty-four hours, and in a severe one it may continue I'or a 
 week. When a relapse or a second sudden rise of temperature takes place, grave mischief 
 may be anticipated, as some local internal or external inflammation. Billroth has described 
 this second attack of fever as •'secondary fever." When it runs on for a more'lengthened 
 period than a week, severe complications are sure to exist to keep up the symptoms. 
 During its coitrse the temperature of the body, naturally \^'S'.'a° F., may rise suddenly 5° 
 or G° F., and in ordinary cases its fall is, as a rule, gradual ; while with its fall deferves- 
 cence takes place. Should the fall be sudden, a general breakdown of the powers of the 
 patient is indicated ; and under these circumstances sloughing of the wound may be 
 expected. The rise of temperature is generally accompanied by an arrest of secretion or 
 some change of action in the wound, but the fall of temperature indicates the oncoming 
 of suppuration. 
 
 These points are well seen in the following thermographs, figs. 15, 16, 17, 18, and 19. 
 It is, however, important to know that traumatic fever is by no means a necessary 
 
 consequence of an injury or 
 Fig. 15. operation, however severe, that 
 
 it may follow a trivial or fail to 
 follow a severe injury, and that 
 it is quite impossible to predict 
 its occurrence under any cir- 
 cumstances. After a large num- 
 ber of capital operations it is 
 entirely absent — I should sa}' 
 after one-third ; and since the 
 practice of the torsion of ar- 
 teries has been adopted, and 
 wounds have consequently been 
 freed from the presence of such foreign bodies as ligatures, the number of eases in which 
 it is absent has decidedly increased. 
 
 Fig. 16. Fig 17. Fig. IS. 
 
 DAY OF 1 2, 
 
 DISEASE M E M £ 
 
 lUSBjifazni 
 
 BHBBitBat^ngBBBi 
 
 rB!KH9tH3BroiBSBEII 
 
 14S;eo5o;5a 45158 56:72 - 
 
 Therniograiih of acute ostitis of ilie tiliia in .1 buy, a-t. ir,, followiriL.' a 
 Mow ;"aclniitted into GuyV ou ih'- luuiitenth day »ith iiya?niia, which 
 destroyed life nine dayslater. The table well shows the fluctuation of 
 temperature which is found in jiya-niia, with the night and morning 
 variations. 
 
 BMHH 
 
 Thermografih of traumatic fe- 
 rer, rise for three days, sud- 
 den fall, after amputation at 
 hip-joint, ill a boy, a;t. 9, ter- 
 minating in recovery. 
 
 Thermograph of traumatic fe- 
 ver, sudden rise and steady 
 fall after amputation of the 
 leg for disease of foot in 
 man, set. 52, terminating In 
 recovery. 
 
 Thermograph of traumatic lever after opera- 
 tion for ruptured perina-um. Kever at its 
 height on fifth .lay, when quill sutures 
 were removed, after which there was a 
 sudden fall and a .steady convalescence. 
 Patient set. 45. 
 
 Fk;. 10 
 
 Arrest of Secretion.— When blood-poisoning attacks a patient the subject of a 
 wound, whether caused by djieration or injury, it is generally to be observed that the 
 
 secretion of the wound becomes sanious. se- 
 rous, or foetid : probably it will be arrested, 
 and the surface will become glazed or glassy, 
 or perchance assume a .sloughing action. The 
 integument around the wound will often have 
 an erythematous blush, or acquire a peculiar 
 leaden, dusky appearance, which is somewhat 
 tvpieal. T'liion. if progressing, will cease, or 
 disunion may result. When any internal or- 
 gan is implicated, special symptoms indicative 
 of disturbance of its functions will be pres- 
 ent. When the brain is involved, there will 
 be sleeplessness or delirium of a low muttering kind or ''relapsing unconsc^v^!sness — 
 
 Thermograph of traumatic fever after ovariotomy in a 
 woman, aet. 4;i, ending in recovery. Temperature 
 never rose above lu(i. 
 
/^l77/o/,o^7r.|/, cDynfTi'tss fr')M i'Y.kmia rnrsi) .\rr/:n dkath. i>3 
 
 III ran; cases 
 
 iiiiciiiisciousness (Vnin wliidi tin- ]i;iti(iit i;iii lie r<>u>cc| only tu ri-l:i|i> 
 ariiti' doliriiiin and mania nccnr. 
 
 Wlu'ii tln' I's/iiitifnri/ niyniis aii' iiivulvcil — ami it may ln" statfil that tlicy arc so far 
 mnn- fVi'«nii'iitlv tliau any other — dittiiMilty of h|•(•athillu^ with a har.-h dry coii;;h. and 
 in'rhaiis viscid Idood-staiiiiMl s|mtum. art' the ]iromiiiiMit sym|ttoms ; occasionally pliMiritic 
 pains arc present, or symptoms of liromdiitis, with ^reat dysjiiKea. 
 
 When the nliilininiiiil riscrrn are affected, nausea or sickness and proru>e diarrhuu'a 
 are j)rominent symptoms ; the latter in some cases apparently <-arries rjff the poison. 
 When anvthiiiL; like sallowness of the skin or jaundice appears, liepatic; ahscess should he 
 fjusjiectcd . and under tlu'se circumstances there will <d"ten he pain in the rejrion of the 
 liver. At the same time, the reader must rememher that a sli<rht de-rree of jaundice is 
 often pre.sent without hepatic suppuration. The urine is rarely altered either in (diarac- 
 ter or in (juantity. although at times it is scanty and dark-colored. When .seven; or dull 
 pains are experienced in a joint, suppuration should he suspected ; and anythinfr like 
 so-called rheumatic ])ains occurring in a patient with py;emia hecomes a source of sus- 
 picion : •■ rheumatic ' pains in hlood-poisonintr too often mean joint or ))one miscliief of a 
 suppurative kind. It is also remarkahle how slij^ht the sym])toms often are in these 
 cases when severe local disease exists. This fact demands that the surjreon should ever 
 he on the watch to detect anything; like local chaii,u;es. inasmuch as it is a pathological 
 truth that there is no organ or ti.ssue of the hody in which sujipurative disease may not 
 take jilace in a case of hlood-poisoning or pyaMuia ; and it is certainly true that the exist- 
 ence of severe local disease is too often only first discovered on the posf-morf'iii tahle. 
 
 What, then, it may he asked, are the pdthiiliiijiail ruiuh'tioii^ found after death in a 
 case of hlood-poisoning or py:emia, using this word in a general sense ? 
 
 Analysis of 203 F.at.\l C.\ses of Py.emia. 
 
 Nature of .\ccideDt or Disease. 
 
 jCompoiind fracture 
 
 |Araputatioii after compound 
 ! fracture 
 
 Amputation for disease 
 
 (Injury to scalp and skull 
 
 I Inflammation and suppura- 
 
 j tion of soft parts 
 
 'Disease of urinary organs 
 
 Disease of hones and joints 
 
 Operations on soft parts -t 
 
 Carbuncle 6 
 
 Burns , 5 
 
 28 
 
 Total.. 
 
 Eg 
 
 a 
 
 is 
 
 i 
 <3 
 
 1 
 
 < 
 
 26 
 
 23 
 
 1142-3 
 
 3i< 
 29 
 11 
 
 34 
 24 
 11 
 
 1 «■ 
 
 33 
 
 30 
 
 9o-. 
 
 f3.1- 
 •'lOO- 
 
 203 
 
 186 
 
 78 
 
 
 or 
 91.fi 
 
 or 
 
 .38.4 
 
 
 per 
 cent. 
 
 per 
 cent. 
 
 I — I 
 
 34.61 
 
 .39.4 
 20.6! 
 63.6 
 
 Spleen. 
 
 Brain. \ Heart. Joint-<i. Cell-tissae- 
 
 S3 I 
 
 S I 
 
 11..5I 1 I 3.81 
 
 6 15.7 
 2 : 6.9 
 
 6.9 
 45.4 
 
 8 
 
 24.2 
 
 8 
 10 
 
 6 
 
 21.4 
 
 8 
 
 1 
 
 20. 
 
 1 
 
 3 
 
 50. 
 
 2 
 
 "522" 
 
 277 
 
 "3^ 
 
 24.2 
 4.5.4 
 
 28.5 
 
 20. 
 
 33.3 
 
 5 15.1 
 
 4 14.2 
 1 i20. 
 
 17.7; 19 9.3 
 
 6. 
 45 
 
 .1 4 I 15.3; 3 1 11.5 
 
 5 
 
 1 
 
 4 
 
 I 
 
 16.6 2 
 
 15.1 
 
 4.5 
 14.2 
 20. 
 .33.3 
 
 4 10.5 
 
 2 6.9 
 
 1 9. 
 
 8 24.2 
 
 6 21.4 
 
 3 7.8 
 
 4 1.3.8 
 2 18.1 j 
 
 5 ■ 15.1 
 
 1 4 5' 
 
 2 T.l 
 1 20. i 
 
 6.41 25» I 12.3, 21 10.3 
 
 • In which the lungs were alone involved. The small figures show the percentages. - The liver was involved, 
 
 alone in two cases only ; in all others the lungs were aflfected as well. ^ Sterno-clavicular in eight. I 
 
 The analysis (shown in the form of a tahle, ahove) of two liundred and three fatal 
 eases, wliich I have collected from the records of Guy s Ho.spital with the sanction of my 
 colleagues, Drs. Wiiks and Moxon. ])y whom all the examinations were made, will answer 
 this question. 
 
 Pathological Conditions from Pyemia found after Death. 
 
 The Lungs. — The most prominent fact indicated by this table has reference to the 
 lungs, for it proves that in the larger proportion of fatal cases of blood-poisoning the.se 
 organs are implicated, and, further, that in many they are the only parts involved. Lung 
 mischief was found one hundred and eighty-seven times in two hundred and three ca.ses ; 
 while in seventy-eight, cases, or thirty-eight in every hundred, the lungs were the only 
 organs affected. Lohnlnr pneumonia is the form in which the di.sease is generally found; 
 and when even a lobar pneumonia is present, it can usually be made out to have origi- 
 nated in lobules and to have spread from them as centres. This lobular pneumonia, like 
 the lobar form, is also generally seen in the Jmrer hUs. and not at the apices, and nearer 
 the surface than the central parts. The earliest indication of disease is a lobular pneu- 
 monia, and •• subsequently," says Wilks, '• these congested spots are found to contain 
 
94 PATHOLOGICAL CONDITIOyS FROM PWEMLi FOUND AFTER DEATH. 
 
 iiiflainniatdry products ; and tlni.s we have red hepatization, suppuration, or sloughing," 
 all these stages of inflammation being visible in individual masses. Associated with this 
 lobular pneumonia some icrlii/niosis of the surface of the lung will generally be found — a 
 purpuric condition, in fact — strongly suggestive of blood-poisoning. Pleurisy, moreover, 
 generally exists, the fact being accounted for by the superficial position of the lobular 
 pneumonia. 
 
 The Liver, like the lungs, is also attacked in its lobules, which may be either con- 
 gested, inflamed, suppurating, or sloughing. At times it is filled with small abscesses. 
 When these approach the surface of the liver, they ma}' burst and give rise to a general 
 peritonitis. The liver Avas involved in this aflection twenty-seven times in every hundred 
 cases, and almost always in association with disease in the lungs. Thus, out of fifty-five 
 case in which the liver was aff'ected. in only two were the lungs uninvolved. It would 
 appear, likewise, from the table that the liver is more frequently the seat of pytemic 
 suppuration after injuries to the head than after any other aff"ection, and that it is rarely 
 found involved after disease of the urinary organs and burns. 
 
 The Kidneys. — When these organs are aff'ected, they are so in a similar manner to 
 the lungs and liver, and present small isolated points of suppuration surrounded by a 
 zone of congestion either on their surface or in their cortical structure. They are not. 
 however, aff'ected so frequently as are the two former organs — not oftener, indeed, than 
 in seventeen cases out of every hundred, and then mostly after disease of the urinary 
 organs, or suppurative disease of the cellular tissue, particularly of that surrounding the 
 shafts of bones. 
 
 In the Spleen abscesses are often present, and in the Brain. Heart, Prostate. Tes- 
 tis. Tongue, Thyroid Gland, and. in fact, in any portion of the body, they may be met 
 with. In the cellular tissue of the trunk and extremities, as the joints, suppuration is 
 very common. 
 
 When inflammation attacks such serous membranes as the pleura and peritoneum, 
 there is good reason to believe that it is generally due to the extension of disease from 
 the lung, liver, or spleen. In the case of the synovial membrane of the joints no such 
 extension can be made out. The sterno-clavicular articulation is more frequently involved 
 than any other, for I find that out of twenty-five instances in which joint complication 
 existed this was involved in eight. Any joint may, however, be aff'ected. In some ca.'^es 
 the articulation is only filled with an increase of synovia; in others the contents are puri- 
 form, sometimes purulent. At times the pus in the joint appears to be so slightly irritat- 
 ing that the cartilage and the synovial membrane are uninjured by its presence, whilst at 
 others it is so destructive as to produce complete disorganization, the bones forming the 
 joint being under these circumstances exposed, and at times necrotic. When these 
 changes occur, they are probably sometimes due to acute articular ostitis. 
 
 The skin has occasionally a vesicular or pustular erupfiou upon it. and too frequently 
 purpuric spot.^ or patches are present, which at times lead on to mortification ; and in con- 
 nection with this subject •' we may mention another evidence of the blood disease in the 
 rapid decomposition of the bodies and the 'marking of the veins on the surface. Thus, 
 before the body is scarcely cold there may sometimes be seen the blue and red coursing 
 of the veins and the coloring which has exuded from them into the tissues" (Wilks). 
 
 Lastly, it is to be noted that it is exceptional to meet with any evidence of phlehith, 
 general or local ; and this leads me to consider, although briefly, the now already aban- 
 doned and untenable theory that phlebitis, or inflammation of a vein, is the invariable 
 cause of pyaemia. 
 
 The most telling evidence against the theory i.>; the one just mentioned — that it is only 
 in exceptional cases of pysemia that any evidence can be found of phlebitis; and the sec- 
 ond is almost equally strong, becatise, " so far from phlebitis being a cause of pya?mia. it 
 is remarkable how often the former occurs without any contamination- of the blood what- 
 ever — that is. if we can call that phlebitis where we find a vein and its branches quite 
 closed by coagulum or adherent fibrin" (Wilks). Moreover, "it is a (juestion whether, 
 in those cases in which the veins are plugged or inflamed, thrombosis and phlebitis are 
 not the local and pyaemia the general eff'ect of the same cause '" (8avory) — that is, blood 
 infection. With these views I cordially agree. 
 
 That blood-poisoning may take place through veins is certain, although, as I have 
 already shown, inflammation of their coats does not necessarily lead to it ; neither is it 
 probable that the absorption of pus, as pus, is the usual cause, for. Avhen pus mixes with 
 blood coagulation is produced, and thus its circulation is prevented. There seems, how- 
 ever, good reason to believe that the fluid portion of pus or of some decomposing inflam- 
 
IWTIlOlJxncM. COM'lTloSX Fi:<)M I'V.KMfA inI'M) AFTKlt DKATII. 05 
 
 matnrv product iiiav lie takfti ii|> l»y tlic veins iiml rarriftl into the system, and thus 
 fiiusi- |iv;i'iu:;t. The jmi.-nn niav l>o iuipnrted intn the <.'eneral cireuhition thri»uj:h either 
 a sn)all nr hirL'e vein when involved in a supituratinfr or sh»u<rhin<r tissue; this is a tVe- 
 <(Ui'iit occiir'-'-nic whin the vein is connecteil with an infianied or divich-d hone. 
 
 Theory of PyaBmia. — It may he fairly inferred that the iiiihh r /miiis of hluml- 
 poisii/n'iiif, sueh as trauniatie fever, are caused hy tin* circulation of morhid elejjients in 
 tlie hlood, which are L'enerated either within the Itofly or imported into it from without, 
 and that these morhid elements are at times carried off, .sometimes hy th(! lunps and at 
 other times l)v the intestines; that the niorr srrcre /'unim '>/' />f'tii(/-jtoisi>iiiii(/, as pyjcmia, 
 are caused 1)V emholism. thromhosis. or hlood extravasation, due tr» the aihnixturc witli 
 the Vdood of some morhid fluid ; and tliat this morhid material ori<rinates the chancres 
 wliich frive rise to the secondary or metastatic ab.sceH.se.s with which sur<reons and pathol- 
 oirists are sc f^imiliar. This view receives much support from the fact that disintegrating 
 fihrin may he carried from the heart through tlie arterial system into the smaller vessels 
 of the pari'nehvmatous organs, and give rise not only to constitutional symptoms much 
 akin to those which have heen described as being present in pya;mia, but to analogous 
 pathological contlitions. This condition is spoken (»f as arterial pyaemia. Thus, in the 
 more cctmmou form of pyjemia abscesses form in the viscera or in other parts, and iti 
 "arterial py;tmia" lobular fibrincms changes occur. Tn the former case secondary 
 abscesses are found after death ; in the latter, secondary fiV)rinous deposits. It .seems 
 probable, also, that at times these fibrinous deposits may break down and give rise to 
 abscesses. 
 
 This arterial pyjvmia is met with after ulcerative and rheumatic endocarditis ; it is. 
 doubtless, the cause of the .so-called rheumatic pains that follow .scarlet fever, and in rarer 
 instances it gives rise to the embolic plugging of some large vessel, which may be fol- 
 lowed by gangrene or by the formation of an aneurism. On two occasions I have had to 
 remove a leg for gangrene from embolism of the femoral artery after scarlet fever. I 
 have also seen cases of aneurism which have probably been due to the same cause.' 
 
 Arterial pva'mia is not necessarily fatal. Mild attacks come and gr). says Wilks. ''the 
 proof being found eventually in the cicatrices and remnants of deposits met with in the 
 organs of the bodies of those who have died with heart disease.' The mild forms manifest 
 themselves by pyrexia, prostration, and pains in the joints. 
 
 Hence, when a patient dies rapidly from blood-poisoning, the only ])ath(dogical change 
 found in the tissues mav be some lobular congestion of the lung, indicating the first stage 
 of pneumonia ; when life has lasted lonirer red or gray hepatization may be present, and 
 in a later stage suppuration, these different conditions depending upon the intensity of 
 the disease and its duration. '• The first stage of the morbid condition which is produced 
 in the viscera is a coagulation in the vessels, and the last stage is a suppuration" C Wilks). 
 
 In feeble patients who have no resistine: power against disease it is possible that even 
 these pathological conditions may not be found, life being, as it were, suddenly destroyed 
 in the first onset of the blood-poisoning. Under these circumstances no definite post- 
 mortem appearances would be seen, beyond, perhaps, a general softening of the viscera 
 or some pur|iuric conditioi!. 
 
 Duration of the Disease. — There seems reason to believe that a patient may 
 die in two or three days after the first appearance of the .symptoms, and. as a rule, bad 
 cases terminate during the second week. Others go on for six or seven weeks. The 
 longer a patient lives, the greater the hopes of a successful issue. 
 
 Prognosis. — In every ca.se of blood-poisoning great cause for anxiety exists, it being 
 impossible to foretell its course or its end. In one case a small dose of the poison will 
 prove fatal, while in another a full dose will be thrown oflT. The violence of the attack 
 does not depend upon the severity or size of the wound, for a trifling wound is at times 
 followed by urgent symptoms, while a severe local injury may be followed by but few. 
 if any. complications. Indeed, some of the severest cases of blood-poisoning are found 
 in tho.se in whom there is no wound. 
 
 A robust per.son. doubtless, has a better chance of recovery than a feeble, and an 
 abstemious one than a drunkard. Where disea.eed viscera exist, particularly diseased 
 kidneys, the prospects of recovery are small indeed, the capabilities of a patient to resi.«t 
 any di.seased action under these circumstances being slight in the extreme. A single 
 attack of traumatic fever may pass off" without trouble, but a relapse or a second attack 
 alwavs indicates serious mischief. Rigors rarely occur without suggesting the presence 
 of .some secondary deposit or local inflammation. One rigor may pass off" and leave no 
 
 ' Vide Pnih. Soc. Trans., 1877. 
 
96 PATHOLOGICAL COXDITIOXS FROM PY.KMIA FOl'SD AFTER DEATH. 
 
 trace of harm behind, but a succession of them is associated too frequently with the 
 gravest local complications, such as secondary metastatic abscesses. These abscesses, 
 also, when they occur outside any of the three great cavities of the body, are less danger- 
 ous than when they occur in the viscera. Acute pyasmia is always accompanied with 
 great danger ; when the disease is chronic, there is always more hope. 
 
 The occurrence of pya-mia in different surgical affections is well shown in the follow- 
 ing analysis of cases : 
 
 Of 217 consecutive cases of pyaemia. 68. or 31.3 per cent., were after compound frac- 
 tures, of which 24. or 11 per. cent., were not amputated, and 44, or 20.2 per cent., were 
 amputated : 2t). or 12 per cent., were after amputation for disease ; 28. or 12.9 per cent., 
 were after other operations : 21, or 9.6 per cent., were after injury of soft parts without 
 operation; 60. or 27.6 per cent., were after disease without operation: 12. or 5.5 per 
 cent., were idiopathic ; 2.9 per cent., puerperal. 
 
 Statistics of Co.mpound Fracture. 
 
 Out of 790 cases. 192 died, or 24 per cent. : 68, or 8.6 per cent., of pyemia. 
 
 Of 184 ca.ses treated by amputation, 89 died, or 47.7 per cent. ; 44, or 23.9 per cent., 
 of pyaemia. 
 
 Of 606 treated witliout amputation. lOo died : or 17 per cent. : 24. or 3.9 per cent., 
 of pyaemia. 
 
 Out of 324 cases of amputation of thigh, leg. arm. and fire-arm for disease. 126 died, 
 or 38.8 per cent. ; 26. or 8 per cent., of pya?mia. 
 
 Pyaemia is thus seen to be three times as fatal after amputatinn fa- comji'iund frac- 
 ture as for disease. 
 
 Out of 29,434 surgical ca.ses admitted into Guy's during ten years, there were 1749 
 deaths, or 5.9 per cent. ; 203 of these, or 11.6 per cent, of the fatal cases, were from 
 pyaemia, about 1 in 9 of the deaths arising from this cause. 
 
 But of the whole number of cases treated. pva?nna was fsital in 1 ease out of 145. 
 
 Statistics of last Five Years. EXDiMi with 1882. 
 
 During these years a better result than the above can be recorded : and out of 14,951 
 surgical ca.ses. of which 847 eases, or 5.6 per cent., died, only 42. or 5 per cent, of the 
 fatal eases, died from pyaemia, the general mortality of pyaemia in the last five years 
 having fallen from 1 in every 145 cases treated to 1 in every 356. 
 
 In the compound /racturfn. also, a like improvement is indicated by the fact that of 
 the 213 cases treated 32. or 15 per cent., died, and only 4 of these from pya?mia. 
 
 Of 120 cases treated conservatively. 9 cases, or 7.5 per cent., died. 1 from pya?mia. 
 
 Of 93 cases treated by amputation. 23 cases, or 24.7 per cent., died. 3 fmni ])ya?mia. 
 
 Out of 11 double amputations. 5 recovered. 
 
 But is pt/semia a ho><pif'fl disease? Does it arise from causes that are generated in a 
 hospital, or is it met with more frequently in a hospital because the class of cases in 
 which it is most prone to occur are there treated ? Is it found in private practice ? 
 
 As an answer to the last question it is only neces.sary for me to refer to Mr. Prescott 
 Hewett's presidential address at the Clinical Society in 1874, in which he gave the par- 
 ticulars of twenty-three examples of pvf^mia occurring in private practice and in six 
 only after operations, four of which were very trivial. 
 
 Sixteen of the.se were in town and seven in the country, and all were placed under 
 most favorable circum.stances. 
 
 We know, moreover, that some of the worst cases of pyaemia that are seen in the 
 London hospitals — and I can answer for Guy's — are admitted with the infection. 
 
 Under these circumstances it may confidently be asserted that what is known as pyae- 
 mia is hot peculiarly a hospital disease, and that it probably occurs after surgical injuries 
 and operations as frequently in private as in hospital practice. It is true that pyjemia 
 often takes its origin in hospitals, but equally true is it that it does so because the class 
 of cases in which the affection is the most prone to occur are there to be found. 
 
 Blood-poisoning may occur anywhere, in hospitals or in private houses : but it is 
 unfair and unscientific to attribute it without reason or evidence to what has been so 
 wronofully described as ••hospitalism. ' 
 
 Treatment. — An unlimited supply of fresh air. .simple nutritious food, and where a 
 wound or suppuration exists the most thorough cleanliness, are the main points of prac- 
 
PATiinij)ai('M. (osDirrnxs from pv.kmia roiwn .\rn:i: in:.\rii. 97 
 
 ticc tu 111' ai tciidol Id in the i real iiiciil of every fuse of traiiiiiiitie fever nr jivii'iiiiu. ('itrn- 
 pared with tlie.si', all ntlur imaiis are (if secomlary iinportaiiee. 
 
 As the disease is due tn a Iduod-poisoii oftcsii taken into tlie txxly froiii witlioiit. it is 
 tlie siirueoii's duty to sec that tlic patient's rooin is well ventilated, that it is neither too 
 hot nor too eold — as lioih extremes arc powcrlnl deprcjssants — that the air cireulatin<^ 
 throiitrh it is free. IVesli, and frairrant, that the room is iVefpiently purified hy eleansinj^ 
 antl disinfectants, larui' dishes of any disinfeetinj; fluid and cdoths .saturated with the 
 fame heinu distributed ahout ; s(did iodine exposed in a jtlate to the air i.s a good disiri- 
 teetant. and more persistent than some others. Care must be taken that no poison from 
 a drain or el<»set rea<diesthe room, and that all excretions are disinfected at once — ituh-ed, 
 passed directly into vessels containinjx disinfeetint:' fluid, such as Condy's, carbolic acid, 
 chloride of lime, or chloralum. The wound should be kept clciui^ and care should be 
 taken that all discharjics are allowed a free escape. I)ressin;.i:s, when employed to a sup- 
 purating; or shtuiihinii wound, should be saturated with disinfectinfr lotions and changed 
 every three or four hours. When possible, foul wounds should be irrigated, a stream of 
 warm water containing a disinfectant being allowed to run over the surface. I know of 
 no means so valuable for keeping a wound clean as thi.s. When sloughing of the part i.s 
 present, charcoal poultices are at times beneficial. Sponges should never be employed 
 where pus exists, but tow or cotton-wool, more particularly the ab.sorbing cotton-wool. 
 Poultices, when employed, may be put on tow or oakum, both of which materials, through 
 the tar they contain, being disinfectants. 
 
 In simple iinconipliaifcd tntnmaiic fever, when it stops within tlu; ordinary bounds and 
 neither runs on n(»r returns in any severity, no special treatment is called for. Should 
 restlessness or mu(-h pain exist, a sedative dose of chloral, opium, or morphia may be 
 given, either by the mouth, rectum, or skin ; and beyond this nothing is needed. In 
 more confirmed cases of suppurative fever, when systemic infection is declared, the vital 
 energies of the patient must be maintained or stimulated, and everything that tends to 
 lower must be warded off; thus, the administration of tonic medicine becomes a necessity, 
 the preparations t)f (juinine being the best, but strychnine and iron are likewise of great 
 use. From ten to twenty grains of quinine given at the first onset of pyncmia and 
 repeated every three or four hours help defervescence.' Stimulants must be administered 
 with caution and their amount regulated by the wants of the individual case. When the 
 patient's habits have been free, alcohol in one of its forms will be required, even in large 
 ((uantities ; whereas to an abstemious person a very moderate dose will be sufficient. 
 The form t)f stimulant to which the patient has been accustomed is apparently the best. 
 
 The diet should be as nutritious as possible, but its nature must depend upon the 
 assimilative powers of the stomach. Where milk agrees no better drink can be given, 
 either alone or mixed with eggs or some spirit; cream may be added at times, or the con- 
 centrated Swiss milk ; animal broths may likewise be freely used. When meat can be 
 digested, it may be given, although sparingly. When a patient refuses food, Liebig's 
 extract of meat or Darby's fluid meat may be mixed with the beer or wine without his 
 knowledge. When the stomach rejects nourishment, it must be given by the rectum, a 
 two- or three-ounce enema of beef-tea and egg being administered every four or six hours. 
 Ice may always be allowed in small quantities, as it gives comfort. When the nervous 
 system is disturbed from want of sleep or otherwise, opium may be given, small doses 
 frefjuently repeated being better than large. WHiere enemata are used, laudanum may be 
 mixed with them. 
 
 Should diarrhoea exist, it must not be checked too suddenly, for in some cases of 
 blood-poisoning it appears to have an eliminative tendency ; it should be stopped only 
 when telling on the patient's powers. To give remedies, however, with the view of elim- 
 inating the poison by the bowel is a rash practice and cannot be recommended. The sul- 
 phites and chlorides, which have been highly praised, do not a])pear. in any of their forms, 
 to have any power to neutralize the poison in the blood. The alkaline salts have like- 
 wise been .strongly recommended "to promote the changing and eliminating of the prod- 
 ucts of the retrograde metamorphosis of the tissues " (Savory), of which the carbonate 
 of ammonia is probably the best, either given alone or with the liquid extract of bark. 
 
 When secondary abscesses have formed in the cellular tissue and between the muscles, 
 they should be opened ; but great caution mu.st be ob.served in dealing with inflamed 
 joints. When the presence of pus can be clearly made out, it should be evacuated by a 
 free incision into the joint and care taken that it does not reaccumulate ; to prevent this, 
 a drainage-tube should be introduced into the cavity and the joint daily freely washed 
 
 ' Goodheart, Guy's Ho.<p.Rep., 1870. 
 
98 HECTIC FEVER. 
 
 out with a stream of warm water colored with Condy's or some other disinfecting fluid, 
 such as carbolic acid one part in forty, or iodine water composed of one drachm of the 
 tincture of iodine to a pint of water. Soothing applications should at the same time be 
 employed, poppy fomentations being probably the best. 
 
 When acute blood-poisoning has set in, it is almost needless to say that amputation 
 of a diseased limb has n6 influence in checking the disease, nor has the application of 
 caustics or cauteries to a wound ; indeed, no local treatment is known by which the for- 
 mation of secondary abscesses can be prevented. In chronic pyaemia, however, amputa- 
 tion is often of essential service. 
 
 How far blood-poisoning can be prevented i^* another question, and, as it 
 is an important one, it may be consi(h'red here. 
 
 As to the exciting cause of the disease nothing is known. It attacks the healthy as 
 well as the cachectic, those surrounded by perfect hygienic influences as well as those 
 subjected to the most unfavorable, and it is found in private as well as in public practice. 
 It is true that the cachectic and those who are subjected to close and unhealthy atmo- 
 spheres are the more prone to its attack, and that overcrowding in small wards, bad ven- 
 tilation, bad drainage, and bad feeding, with every other depressing influence, have an 
 injurious tendency. It becomes the surgeon's duty, therefore, to ward off", as far as he 
 can, all such influences. In cases for operation, when time is allowed for preparation, the 
 general condition of the patient should be investigated ; care should be taken that the 
 excretory glands are performing their functions, and if not they should, if possible, be at 
 once corrected. The feeble must be strengthened by tonics and good nutritious food, 
 and the supply of stimulants should be regulated in all. The intemperate man should 
 be brought to see the necessity for moderation, and to know that life cannot long be sus- 
 tained by drink alone ; he must learn, also, that stimulants are chiefly of value in assist- 
 ing digestion and the assimilation of nutritious food. The vn'ne under all circumstances 
 should he exdmmed for albumen ; for, although its presence would not deter the surgeon 
 from performing an operation of necessity to save life, it would aff'ect his prognosis, and 
 would most certainly influence his decision in an operation of expediency. All patients 
 after operation .should be kept in absolute repose, the wounds kept clean and lightly 
 dressed. Everything that tends to procure rapid union must be considered good, and 
 all that induces or keeps up suppuration bad. Blood-poisoning and suppuration, whether 
 with or without a wound, have a close connection. No one who has been in contact with 
 any infectious disorder, such as erysipelas or scarlet fever, should be allowed to come near 
 the patient ; for there can be no doubt that there is subtle connection between these 
 poisons and pyaemia. And, lastly, every cheering influence should be brought to bear 
 on the mind of the patient, as well as on his surroundings ; for among the agents predis- 
 posing to blood-poisoning mental anxieties and depressing emotions should doubtless be 
 reckoned. 
 
 HECTIC FEVER. 
 
 There can be little doubt that surgeons of former times included under the above 
 heading many cases of what we now call septicaMnia, pyajmia, or blood-poisoning ; and 
 even at the present time it is an open point as to how far the symptoms which denote 
 hectic fever are due to the absorption of some foreign element into the blood. 
 
 That hectic fever is never found except in those who are the victims of destructive 
 organic changes, chiefly of a suppurative nature, is an esta1)lished fact, and it is in such, 
 also, that confirmed blood-poisoning generally occurs. The physician meets with this 
 condition in pneumonia, phthisis, empyema, abscess in the liver, kidneys, or ovary ; the 
 surgeon, in suppurative diseases of joints and bones, in spinal disease, compound frac- 
 tures, diff"used suppurations, etc. The characteristic symptoms are of a remittent cha- 
 racter and usually appear at least once daily, generally toward evening, but they may 
 occur more frequently. They are not unlike those of ague. 
 
 A paroxysm of hectic may be said to commence with fever, of more or less intensity ; 
 the skin will be hot and dry, the pulse rapid and feeble. The face, too, will be flushed in 
 a single patch, and the palms of the hands and the soles of the feet hot and burning. 
 The tongue during the paroxysm may be dry and great thirst will be present. There will, 
 however, be no brain symptoms, no clouding of the intellect, no delirium. The febrile 
 condition may be preceded by shivering or chilliness, but such symptoms are unusual and 
 are always followed by a profuse and exhansfive sweat. This sweating is, indeed, pecu- 
 liar to tlie aff"ection ; for it bears no proportion to the febrile symptoms that preceded it. 
 At the commencement of the disease the febrility may be so slight as hardly to be noticed, 
 
iirji'ir F/:v /■:/:. 99 
 
 aiitl yet tlif |tatit'?it, mi laHiii;: •'> >li'f|i ami awakciiiriL'. will \n' ItatlK^d in jicrs|iiiaf ion. 
 Wlu'ii tin- iliscast' is at its lu'ijxlit, the fold, IidI, and sweating; stap-s iiiav I"' casilv seen; 
 but when it dfclincs, tlic fcUrilf syniptonis will ]n' cdnstant, altIioii<;li a}.';.'ruvat<'d toward 
 iii^ht, while till' MiurniiiLr " <"ollii|iiativc' ' swi-ats grudually beconic more iirol'iisc as lite; 
 ebbs away. 
 
 In till' I'aily stau^-s of this disease, hrliDiu the paroxysms, there may be no fever. 
 The tonjriu". dry durini^ the attaek, will }»e moist and elcan, l)Ut toward the close bt;eom(!S 
 morbidly red, smooth, and son;, with ajdithous uleeration. The appetite an<l digestive 
 or<;ans are rarely much afioeted ; indeed, they are little altered till the "general powers 
 are failiii<r rapidly. The skin, at first supple and moi.st between tlie attack.s, beeomes, as 
 the di.sease |)roi;rosscs, harsh, dry, and covered with branny .scales. The urine, alway.s 
 scanty and hitrh-colored, i.s more .so toward tlie close of the disea.se. Tlrc bowels are .some- 
 times consti|)ated, but more fre((ucntly loose. Throughout the disca.se, however, the 
 mental faculties remain unimpaired, even when the bodily powers are reduced to a 
 minimum. l)urin<;- the whole disease .sleep is usually obtained between the attacks. 
 Death always ensues from exhaustion, which bed-sores tf»o fre(juently ajrfjravate. 
 
 TKK.VTMKN'r. — The removal of the cause of the disease is the only means by which 
 a cure can be effected. As the affection is one purely of exhaustiini, the object must 
 be to maintain the streiiirth of the patient in every way })y the administration of abun- 
 ilance of simple nutritious food, with stimulants carefully adjusted to the special wants of 
 the case. The former should be given at certain short intervals in small (juantities. and 
 the latter in sufficient ([uantitics to aid digestion. 
 
 Tonic medicine .should always be given, quinine probably being the be.st, as this drug 
 has, doubtless, a power in checking febrile action, in keeping down tlie temperature of the 
 body, and in preventing sweats. It should be given in a full dose, five grains in the 
 .solid form, before the paroxysm. Iron and strychnine are also valuable drugs, and 
 the extract of belladonna in doses of half a grain or more combined with the 
 tonic is of great value. Diarrhoea, when pre.sent, should be checked by astringents, 
 but opium should be sparingly employed, except to relieve pain. 
 
 With respect to the removal of the cause of the disease by operation when such 
 is possible there can be no difference of opinion among surgeons, for hectic is a proof 
 that nature's reparative powers have been found wanting in their efforts to cure the local 
 affection ; and under these circumstances the surgeon's duty doubtless lies in operative 
 interference. If the disease can be removed, this should be done, and delay is almost 
 criminal. Let the source of irritation or weakness be removed, and it is wonderful how 
 rapidly the most feeble subject may rally after the operation. If the viscera are sound, 
 good hopes of a recovery may be entertained under apparently the most adverse condi- 
 tions ; but if the kidneys are diseased, the prospects of recovery are feeble. 
 
 MoxoN-, Guy's Hoxp. Repo)t'<, 1871.— Wilk.s, Gmi/'.s- Hosp. Reports for 1861 and 1870.— Lee, "On 
 Phlebitis," Practical Patholor/y. — Paget and Savory, St. Bart. Repitrt.% vols. i. and ii., 1865-6. — 
 VlKCHOw, Cellular Patholoqy. — Pick, St. Georcfe'n Hoxp. Reports, vol. iii.— BiLI.ROTH, Dr. Th., 
 Archiv. fiir Klh>. Chirurgie (Lansjenbeck's), b. ii., vi., viii., ix. — Bristowk, Trans. Path. Sloe. Loud., vol. 
 xiii., Reynold's System of Medicine. — Roser, Sydenhnni Soc. Year-Book, 1863, p. 192. — Prof. O. 
 Weber, Berl. Klin. \Vochen<rhr., 1864, Year-Bonk; 1864, p. 227.— Gibson, Brit, and For. Med. Chir. 
 Rev., January, 1866. — Cai.i.esdkr, Holmes's Syst. of Surr/., second edition, vol. i. — Sedillot, On 
 Pyiemia, 1849. — Arnott, Med-Chir. Trans., vol. xv.— Braidwood, On Pyemia, 1865. — Gresinger, 
 On Leukamia and Pywmia, discussion at Clin. Soc, 1874. 
 
100 POISONED WOUNDS. 
 
 CHAPTER II. 
 ON ANIMAL POISONS. 
 
 POISONED WOUNDS. 
 
 Dissection "Wounds. — These are of frequent occurrence, although it is excep- 
 tional to find them followed by any seriously ill eftects. In common with all wounds, 
 they may be attended with absorbent inflammation, inflammation of the cellular tissue, 
 suppuration, septicajmia, or pyaemia; and feeble or cachectic subjects are more liable to 
 these consequences than the strong and steady. In exceptional instances, however, 
 diff'erent results follow, and two forms of the affection may be recognized — the' mild 
 and the acute. 
 
 "The symptoms in the ^ niil<1' form partake," says Poland, "more or less of the ordi- 
 nary character of non-specific inflammation and scarcely present any noticeable character- 
 istic signs. Thus, the local appearances consist in the puncture assuming a defined red 
 aspect, which soon becomes pustular; this bursts, and ends in an unhealthy suppuration; 
 there is surrounding erythema of an erratic form and inflammation and pain extending 
 along the fore-arm and arm to the axilla, ending in the enlargement and suppuration of 
 the glands. The constitutional effects consist in febrile disturbance, loss of appetite, 
 diarrhoea, fetid eructations, etc. The prognosis and termination are favorable, and the 
 treatment required is to be based upon general principles." 
 
 The symptoms of the " acute ^ or severe forms are those of a truly specific disease; 
 the local signs commence by the appearance of a small circular or oval vesicle over the 
 seat of puncture, which soon becomes turbid, milky, and pustular and not unfrequently 
 has a defined margin resembling somewhat that of smallpox. This is generally unattended 
 with pain, but the patient often complains of intense pain in the shoulder and about the 
 axilla, which shoots down the chest. The glands in the axilla are early affected and seem 
 to act as barriers to the further progress of the poison ; they become enlarged and the 
 surrounding cellular tissue is implicated, with serous effusion ; there is erythema and 
 puffy swelling ; these extend to the subscapular and pectoral regions, spreading down 
 the side of the chest, yielding to pressure, and imparting a peculiar spongy feel. There 
 is, besides, an oedematous and doughy condition of the arm and fore-arm, owing to serous 
 exudation into the cellular tissue, which seldom, if ever, passes into suppuration." 
 
 " The coTistitutional symptoms are at fir.st those of strong excitement, but these are 
 soon followed by those of extreme depression of spirits and much suffering. Rigors, 
 headache, prostration of strength, vomiting, etc., supervene ; and, lastly, all the symp- 
 toms of low typhoid fever rapidly set in." 
 
 In some cases the absorbent glands are not involved, and death may occur from pros- 
 tration in the early stage of the disease; in others, suppuration and pyaemia may appear; 
 while in a third, extensive and diffused .sloughing of the skin may ensue; all these points 
 being materially inflaenced by the power of the patient to throw off morbific influences. 
 
 The PROGNOSIS in these acute cases must be unfavorable. Travers calculated that 
 one in seven recovers : probably this is rather in excess of experience ; but if the patient 
 does not sink during the violence of the attack, his powers will be tried to the utmost by 
 the protracted suppuration. 
 
 The inoculation from a recently-dead body is more serious than that from an old sub- 
 ject of the dissecting-room, and bodies that have been preserved by chloride of zinc are 
 less noxious than others. The fluids from a patient who has died from glanders, perito- 
 nitis, and scarlet or puerperal fever are far more dangerous than all others. Indeed, 
 there is reason to believe that the contact with such fluids is capable of giving rise to the 
 disease without any local wound or abrasion. 
 
 Treatment. — To keep the patient alive and to treat local symptoms as they arise on 
 general principles are the usual methods now pursued. 
 
 A student when he pricks his finger should at once clean and suck the wound, arrest- 
 ing at the same time the circulation of blood through it for at least a minute by pressure 
 applied with the opposite hand on its cardiac side. The part may then be closed over, a 
 piece of ijutta-percha skin made adherent with chloroform being an admirable application. 
 AVhen the wound is free and the poison is from a recent puerperal ca.se, some cau.stic, 
 
.I.V.17'0,1//r.l/. (II! I'.iriKU.nt.'fCAL 'I'l'llKlir'fJ-:. 
 
 I(»l 
 
 PUfli as iho nitrate of silver, eliliniile lA' /.inc. nr even nit lie iieid. may be applied. The 
 first two are pioi)alilv tin- hest. W'lieii aiiv inlianiniation appears, a p<nilti(:e .should he 
 applied and tlu' hand raised ahove the shoulder; and if therti should he any teii.sion of 
 the part, it is to he at onee relieved hy an incision. 
 
 Ahsorheiit or eelliihir inflainuiatioti should he treated hy fomentations or the applica- 
 tion of the e.vtraet of hellaihinna ruhhecl down with j:lycerin to the infiamed part. Some 
 surgeon.s have faith in the local application of nitrate of silver, iodine, or the solution of 
 the perehlorith; oi" iron as a means of arrestiiif^ its proL^ress. The f^lands, wht;ii etilarjred, 
 should he IVeely hathed with hot water and hot fomcntation.s constantly appli(Mi. 'I'he 
 earliest indications of suppuration ouj;ht to he looked for, in order that pus may he at 
 once evaeuateil. Slouj^hs ant to he removed hy moderate incisicjiis. Tonics should he 
 <;iven from tiie first — iron when it can he home with or without <(uinine in full doses, 
 ammonia and hark when ((uiiiiue and iron are inapplicable. Nutritious food (JUf^ht to be 
 given in abundance, milk being the best drink; stimulants, too, when needed, but alway.s 
 with caution. Country air, as soon as it can be enjoyed, is the great aid upon which reli- 
 ance may be placed for recovery. 
 
 r 
 
 Anatomical or Pathological Tubercle. 
 
 This is a chronic skin aflFection which is to be met with on the hands of those con- 
 stantly engaged in making ])Ost-mortem examinations. Dr. Wilks,' when describing some 
 models of the affection that are to be seen in Guy's museum 
 (Fig. 20), called it '' verruca necrogcnlcay In its earlier stages Fig. 20. 
 
 it is not unlike epithelial cancer. " It commences without any evi- 
 dent breach of surface, the parts affected being not those liable to 
 pustules, as the back of the hand or \vrist, but the knuckles and 
 joints of the fingers. If the disease should begin with a pu.?- 
 tule, the pustule bursts, but instead of healing a thickening of 
 the cuticle takes place around it ; and as from time to time a 
 little fresh suppuration occurs, so the thickening and induration 
 increase. Geiu-rally, however, these changes go on slowly with- _ 
 out any preliminary vesication. A warty thickening of the epi- '7^. 
 theliuni takes place, which in course of time becomes of a dark \J: 
 color, until a kind of iehthyotic condition is produced." 
 
 The disease is local and unattended by constitutional symp- 
 toms. The repeated application of the strong tincture of iodine, 
 acid nitrate of mercury, nitric acid, or, what is better, the benzo- 
 line-gas cautery, will effect a cure. 
 
 Insect-stings in England are not very severe, and unless 
 inflicted in large numbers are rarely brought under the 
 notice of the surgeon. Slight fever and constitutional disturb- 
 ance may follow them in children who are susceptible to exter- 
 nal influences, whilst local swelling, heat, and redness are very 
 marked in others. Should a wasp or bee accidentally be taken into the mouth with fruit, 
 and the base of the tongue, pharynx, or larynx stung, serious symptoms may ari.se from 
 oedema and swelling of the parts impeding respiration. When this accident happens, 
 scarifications should be employed with fomentation ; but if life be threatened, the wind- 
 pipe must be opened. 
 
 When the tongue or other accessi])le part is affected, the sting .should be removed, if 
 possible, with a pair of fine forceps, and thus much pain is saved. Where this cannot 
 be done a drop of either liquor ammonic'V, sal volatile, or oil of lavender applied to the 
 part generally gives relief. The parts should also be protected from the air by collodion, 
 flour, chalk, or strapping. 
 
 For mosquito-bites Dr. J. Stevenson of Ceylon advises (Edin. Mmifh. Jourii.. Feb- 
 ruary, 1882) the use of a moist cake of soap, the thin lather from the cake being allowed 
 to dry upon the bitten part. All pain and itching, he states, disappears within ten min- 
 utes of this application. 
 
 The bite of the scorpion, the tarantula, and other tropical insects is, however, more 
 troublesome, and is often followed by nervous depression, vomiting, and local pain. In 
 South America the mosquito-bite is at times attended with severe local inflammation, 
 and sometimes with ulceration. In Africa and Asia the scorpion, which is from six to 
 
 ' Guy's Bep., 1SG2. 
 
 \mtoniit il lubcrcle 
 (Model Guy's Mus. I9:J*o.) 
 
102 ANATO^^CAL OR PATHOLOGICAL TUBERCLE. 
 
 ten inches long, is so venomous as to cause by its bite, at times, loss of life. Olive oil is 
 the usual application for the wound, but liquor ammoni?e is probably better. Brandy and 
 ammf)nia should be given internally when great depression exists. 
 
 The bite of the spider is very .similar in its eifects to that of the scorpion, though the 
 wonderful stories as to its poisonous qualities are now regarded as fabulous. 
 
 Serpent-bites are often serious, and at times fatal, the poison being squeezed into 
 the ti.-MU' in the act of biting from a special apparatus situated at the base of the upper 
 fangs. In England the viper is the only poisonous reptile, and, although some local and 
 constitutional disturbance may follow its bite, a fatal result rarely ensues. 
 
 The cobra i/icapeUo, raltlemuike. ichipcord make, and jihoorsasv a ke are the most venomous. 
 
 In some cases the poison seems to spend its eifects upon the nervous system, killing 
 by convulsions or coma ; in others, its local effects are the more important. 
 
 Dr. S. Weir Mitchell of Philadelphia, who has carefully studied the effects of poison 
 by the rattlesnake, states that the bite is sometimes followed by pain of a pricking or 
 burning character, which gradually becomes more intense, also by bleeding, swelling, 
 and discoloration of the injured part and tissues around, these symptoms depending upon 
 the effusion of blood into the cellular tissue. The wounded e.xtremity becomes larger 
 and the pain greater, the skin assuming a mottled marbly a.spect. As secondary effects 
 inflammation and disorganization of the tissues occur; the inflammation assumes more 
 the character of the phlegmonous erysipelas and is associated with glandular enlargement 
 and suppuration, followed by gangrene as a common consequence. 
 
 Great depression of the nervous system and general prostration are the most promi- 
 nent constitutional symptoms, with profuse cold sweats, vomiting, dyspnoea, and diarrhoea, 
 and jaundice often precedes death. 
 
 When the dose of the poison is large or the susceptibilities of the patient acute, 
 death mav take place at once from general prostr^ition and local stagnation of blood in 
 the wounded extremity. In the case of a keeper of the London Zoological Gardens who 
 was bitten in the nose by a cobra death took place in little more than an hour after the 
 infliction of the wound, and half an hour only had elapsed when he was apparently dying, 
 being unable to speak, swallow, or support himself; the pupils became dilated, the face 
 livid, the heart's action feeble, and he was scarcely conscious. 
 
 Mitchell has recorded a case which proved fatal in five and a half hours. Of others, 
 one died comatose, another with dyspnoea and dysphagia, a third felt sleepy and died 
 without agony. 
 
 On the other hand, patients at times recover suddenly even when the symptoms have 
 been severe, as if the poison had suddenly lost its power. More commonly, however, 
 death ensues; and when recovery follows, it is only after severe local suppuration and 
 sloughing, leaving a maimed and useless limb. 
 
 After death Mitchell found ecehymoses in the thoracic and abdominal viscera, pur- 
 puric in their nature and clearly caused by a want of normal coagulating power in the 
 blood ; this altered condition of the blood, indeed, is the most common effect of snake- 
 poisons, and it is stated in some cases to last through life. Hence, in bites from the 
 Indian phoorsa snake there is said to be a hfemorrhagic tendency during life. After 
 death Mitchell could never detect the least alteration in the blood cells in acute ca.ses, 
 but in exceptional examples of chronic poisoning he found a few globules indented. In 
 chronic cases, also, where there has been time for the poison to act upon the blood, the want 
 of coagulating power in the blood is very constant, and putrefactive changes rapidly follow. 
 
 Dr. Halford of Melbourne .says he always found the blood after death dark and fluid. 
 It also contained germinal nucleated cells, which he regards as molecules of living for- 
 eign matter thrown into the blood from the venom ; and he accounts for the asphyxia 
 and death by the increase and multiplication of these molecules, which take place at the 
 expense of the oxygen normally wanted in inspiration. 
 
 Sir J. Fayrer tells us, however, that he has never been able to detect these changes 
 in the blood, although the poison affects the blood primarily and the nervous centres indi- 
 rectlv through it.' 
 
 Treatment should be most energetic ; otherwise, the depressing influence of the 
 poi.son will soon paralyze all action, a few .seconds often being enough for the absorption 
 of the poison. 
 
 Lorally. the aim should be to arrest the absorption of the poison by fastening a liga- 
 ture firmly on the cardiac side of the wound, by excising the wounded part, and by the 
 application of nitric acid, carbolic acid, or the nitrate of silver. 
 
 1 Inflifin Avtm/.i of Med. Science, 1870. 
 
BITES OF DISEASED AMMALS. 103 
 
 Fayrer records that the natives of Imlia ajiply a lifrature not only just aliovc the bite, 
 but at several plaees on the limit at intervals of some in<-hes ; they then j.laee a reil-hot 
 coal upon the wounded part. The daiiL'er and diflienlty lie in not applying' the litratnre 
 quieklv eiiou^di. The litratnre must also be tiirhteiied to the utmost, till the eireulation 
 is entirely arrested and the part is livid with retaine<l blood. The punctures slmuld then 
 be searitied, to allow the blood to tlnw freely, and the cautery or caustics afterward be 
 applied. 
 
 ('onstidttioiKiffi/, the best treatment lies in the administration of ammonia and stimu- 
 lants in sufficient (piantities to maintain the action of the nervous and circulatory sys- 
 tems, and thus to keep tlie patient alive while the poison is being worked oft' or becomes 
 exhausted ; for the man who is dying from snake-bites is perishing from rapid oxhau.stion 
 of nerve force. Any other measure that can rouse and stimulate the failing nervous 
 energy may also be emjdoyed. 
 
 Fowler's solutinii in full doses every half hour for four hours is said to have been 
 useful. Iodine has also been advocated, and olive oil internally in full doses has Vjeen 
 hiirhlv praised. In countries where poisonous snakes abound difierent roots have theii 
 reputation, such as the guaco. the sacra; vit;e ancora. radi.x corinese, decoction of Virginia 
 snake-root, etc., etc. ; but Fayrer, after repeated exiieriments, believes them to be utterly 
 useless. 
 
 Halford has inferred from his exi>erimeiits that the injection of twenty to thirty drops 
 of a solution of one part of strong liquor ammonite to three parts by measure of water 
 into one of the veins of the wounded limb, accompanied by the local application of li(|uor 
 ammoni;\> to the part, is a specific ; but Fayrer, who has tried the practice, has failed to 
 find the success looked for. Mitchell advises ligature of the cardiac side of the wound, 
 or excision, amputation, or destruction by cautery or escharotics of the poisoned part, 
 and even sucfion of the wound immediately after the bite, as the poison has no influence 
 in the stomach. lie thinks well, also, of the injection into the wound of iodine or ammo- 
 nia, and savs the natives believe the local application of olive oil to be the best. M. de 
 Lacerda communicated in 1SS2 to the Paris Academy a note in which he asserts that a 
 one-per-cent. filtered solution of the permanganate of potash injected beneath the skin or 
 into the veins counteracts very eff'ectively the poison of snakes. "With this local treat- 
 ment the patient is to be kept up by hope, the action of the heart sustained by stimulants 
 quite irrespective of quantity, and the general powers maintained by nutritious food. By 
 these means. '• if the person be not thoroughly poisoned, we may help him to recover. If 
 he be badly bitten by one of the more deadly snakes, we can do no more " (Fayrer). 
 
 Bites of Diseased Animals. 
 
 Hydrophobia, meaning the '• dread of water " — which is more correctly termed 
 "rahies' — is a disease contracted from the bite of a rabid animal through its saliva or 
 mucus. It appears at all seasons of the j'ear, and is, as a rule, fatal. 
 
 It is more common in temperate regions of the world than in the torrid and frigid 
 zones. It is unknown in Australia, New Zealand. Greenland, and Kamschatka. 
 
 Blaine and Youatt affirm that in animals rabies is entirely due to a trauTnatie action — 
 viz.. the bite of some rabid creature inflicted on another previously free from the disease. 
 Fleming, the most recent authority, tells us. however, that the virus of rabies may under 
 certain favorable conditions be generated directly without the intervention of any infect- 
 ing medium, although at present we are in complete ignorance of the conditions on which 
 its spontaneous production depends. All animals bitten do not contract the disease, as 
 is proved by Renault of Alfort. who cau.sed dogs, horses, etc., to be bitten several times, 
 and even inoculated them, when, out of 99 cases. 67 contracted the malady, and 32, or 
 one-third, escaped. Fleming calculates that 30 or 40 per cent, of people who are bitten 
 by mad animals go mad. 
 
 In the d"g there are three well-marked stages of the complaint. The prut is the mel- 
 ancholic, characterized by melancholy, depression, sullenness. and fidgetiness; the second, 
 the /itn'iiHS. by excitement or rabid fury ; and the A/s^ the paralytic, by general muscular 
 debility and actual parah/aix. 
 
 '• The dog.'' writes Trousseau. '■ looks ill and sullen after a period of incubation of a 
 very variable length : he is constantly agitated, turning round and round inside his ken- 
 nel, or roaming about if he is at large. His eyes, when turned on his master, have a 
 strange look in them expressive of sadness as well as of distrust. His attitude is sus- 
 picious and indicates that he is not well : by his wandering ' he seems to be seeking' for 
 
104 BITES OF DISEASED AXLMALS. 
 
 a remedy. He is not to be trusted : if he obeys at all. he does it slowly ; if you chastise 
 him, he may in spite of himself inflict a fatal bite."' ''His agitation increases: if in a 
 room, he runs about looking under the furniture, tearing the curtains and carpets, some- 
 times flying at the walls, at others jumping as if to catch flies; the next moment he 
 stops, stretches his neck, and seems to listen at a distant noise. He probably then has 
 hallucinations of sight and hearing."' 
 
 ■ This delirium.' says Youatt, •• may still be dispersed by the magical influence of his 
 master's voice ; all these dreadful objects may vanish, and the creature creeps to his 
 master with the expression of attachment peculiar to him. " 
 
 " There follows then an interval of calm : he slowly closes his eyes, hangs down his 
 head, his fore-legs seem to give way beneath him. and he looks on the point of dropping. 
 Suddenly, however, he gets up again ; fresh phantoms rise before him ; he looks around 
 him with a savage expression, and rushes against an enemy which only exists in his 
 imagination. By this time the animals bark is hoarse and mufiled ; loud at first, it 
 gradually fails in force and intensity and becomes weaker and weaker. In some cases 
 the power of barking is completely lost ; the dog is dumb, and his tongue hangs out 
 through his half-opened jaws, from which dribbles a fi'othy saliva. Sometimes his mouth 
 is perfectly dry and he cannot swallow, although in the majority of cases he can still eat 
 and drink. When he cannot drink, he will appear to lap fluids with great rapidity ; but 
 on looking closely it will be seen that he merely bites the water. He can still, in some 
 cases, swallow solids, and he may then swallow anything that is within hi.> reach — bits 
 of wood, pieces of earth, straw, etc." 
 
 '• Toward the close of the second .stage of rabid fury the dog often breaks his chain and 
 runs away ; he wanders about the fields, being seized from time to time with paroxysms of 
 fury, and then he stops, from fatigue, as it were, and remains hours in a somnolent state. He 
 generally dies in a ditch or retired corner, apparentlv from hunger, thirst, and fatigue." 
 
 Veterinary surgeons do not say that he dies from asphyxia brought on bj' spasm of 
 the pectoral muscles or by convulsions. The disease runs its course in from five to eight 
 days, and it is the same in the dog. cat. horse, and wolf, from any of which man may 
 become inoculated. 
 
 In man the disease may show itself at any period from six weeks to a year after 
 the inoculation, although Fleming and Bouley assert that the incubatory period in man 
 varies from one to two months, and that after the third month the chances of immunity 
 are great. Thamhayn (Schmidt's Jahrhuch.. 1859). in an analysis of 220 cases, showed 
 that in 49 the symptoms appeared within a month, in 98 during the second, in 29 during 
 the third, and in 2G during the fourth, month. 16 of the remaining cases showing them- 
 selves within twenty-six months, two cases only maturing at a period of four and five 
 and a half years respectivel}'. But these cases are always doubtful, and are probably 
 examples of hysterical or vervovs hi/dropliohia. Fleming,^ however, records some strik- 
 ing cases which seem to show that the latent disease may be induced or brought into 
 activity by mental agitation. 
 
 The disease may attack the infant at the breast or the aged, the male or the female, 
 and during the incubative stage no disturbance of the general health is usually observed. 
 Van Swieten has pointed out that during this period such a disease as variola may run 
 its course without any modification, two poisons thus coexisting in the same frame. 
 
 After the incubative stage has passed the Jirst si/mptom usually displayed is that of 
 sadness, the victim either not suspecting his complaint or carefully avoiding mentioning 
 the circumstance. His sleep is disturbed : he is fidgety, sighs deeply, and avoids society ; 
 he is troubled by noise or is very irritable and ill-tempered. The second stcK/e will be 
 marked by an aggravation of all these symptoms, but there will be in addition pain in 
 the region of the heart with some irregularity of the pulse ; rigors will soon appear, 
 which, says Trousseau, •' are true convulsions of all the muscles of the body ;" and, lastly, 
 the characteristic symptom of dread of water — not as fluid, however, but as connected 
 with the diflicultv of drinking. The sight of water is frequenth- sufiicient to bring on 
 shuddering, vet it is when the patient carries water to his lips that he is seized with the 
 typical terrors. A rabid man is always rational and tries to drink, but the attempt 
 excites terror and the expression of his inability. His eyes become fixed, his features 
 contracted, and his countenance expressive of the deepest anxiety ; his limbs shake and 
 the whole body shivers. The paroxysm lasts a few seconds, then subsides, but only to 
 be renewed on the slightest breath of air touching his body ; for hi/persesthesia is one of 
 the most marked symptoms of the aff"ection. 
 
 ' Rabies and Hydrophobia, 1872. 
 
nrn:s of 1)Iskasi:i> AsnrALS. 105 
 
 Diiriiig tho faliii. nausea, or even vuniitinir. may appear, ami priapism is often a most 
 distressiiifj symptom. Sudden terror of an unknown kind haunts the mind and iriiafrinary 
 .•allinj; of fiends often e.\i.sts. Dr. Ber«rerons records a case in which the patient heard 
 the iin<;in^' of bells and .saw mice run about over his bed. 
 
 In the tliiril nmf /nsf sliujr the hin;rinjr tor drink becomes intense, with an increasing 
 ina]>ilitv to take it ; the voice becomes hoarse and tlie mouth full of a frothy fluid. The 
 patient tries to get rid of this by sjiitting. and then becomes frightened at its results. In 
 some ca.ses he fears that by contact this fluid may pro|»agate the 'lise'ase. Convulsive 
 seizures increase in fre(|uency and intensity, the spasm of the respirat(jry muscles threat- 
 eniuL'^ life , at last a fatal spasm takes place, and death by asphyxia ensues. 
 
 Cause of Death. — In the dog death results from jiaralysis ; in man it is due 
 generallv to asplivxia, ami in exceptional cases to exhaustion. 
 
 Duration of Disease. — This painful affection rarely lasts longer than four days, 
 though it has been fatal in sixteen hours and has lasted as long as two or three weeks. 
 Thamhayn shows that 5tj out of 20:^ cases died within forty-two hours, 73 in forty-eight 
 hours, 88 between the second and third days, 19 between the third and fourth days, 7 in 
 five. 5 in six, and 4 in seven days. 
 
 The seat of wound or cicatrix rarely shows anything unusual. In three or four ca-ses 
 out of a hundred it may be slightly painful, irritable, and inflamed, or the seat of a 
 neuralgic pain, which in some instances is very severe and of the nature of '• aura," as in 
 epilepsy. 
 
 DiAGNOSi.s. — Taken as a whole, there is no disea.se like hydrophobia. In a certain 
 sense it resembles tetanus, yet the two. in their general features, are unlike. They may, 
 however, occur together, and so good an observer as Dr. J. W. Ogle has published a ca.se 
 of combined tetanus and hydrophobia in the Briti.<}i and Foreign Medico- Chir. Reviev:. 1868. 
 
 What Trousseau has called nervous hydrophobia — that is. true dy.sphagia brought on 
 by a dread of rabies — may, however, be mistaken for it ; '• but the sudden invasion of 
 this complaint, generally coming on through the person recalling to mind or hearing the 
 relation of a case of true hydrophobia, and the duration of the dysphagia over the period 
 of four days are amply sufficient to characterize the complaint and to enable the prac- 
 titioner to persuade the patient that he is suff'ering from mere nervous .symptoms which 
 will vani.-ih as soon as he ceases to fear. Besides, in nervous hydrophobia there is dys- 
 phagia only, but no general convulsions, the spasm aff"ecting the pharynx alone, while the 
 breathing goes on with regularity." 
 
 In the very early period of the disease, during its incubation. Drs. Marochetti, 
 Magistel. Xanthos. and others, have called attention to the presence of pustules or 
 vesicles near the fra^num of the tongue, known in Greece as ^y.<s?*; and they assert that 
 if these lyssi are cauterized all manifestations of disease can be prevented. Should these 
 observations be confirmed, a valuable means of diagnosis as well as of treatment in the 
 very earliest .stage of the disease will have been found. These lyssi are said to show 
 themselves at an earlier period in proportion to the amount of poi.son deposited in the 
 wound. Marochetti made early incisions through the vesicles, and then cauterized the 
 surface with a red-hot iron, with, he states, invariable success. 
 
 Pathology. — There are no patliological lesions peculiar to hydrophobia — at least, 
 none such have as yet been described. Mr. Durham, in a case that occurred at Ouy's in 
 1865, carefully examined the cord, prepared after Dr. L. Clarke's method, and found 
 extreme congestion of the gray matter of the cord and numerous minute patches of 
 extravasated blood in diff"erent sections. More recently Dr. Benedikt of A'ienna has made 
 out that in dogs '• the pathological process in this disease consists in acute exudative 
 inflammation, with hyaloid degeneration, which doubtless arises from the exudative infil- 
 tration of the connective ti.ssue of the brain" (^Wiener Medh. Pre^sp. June. 1874: London 
 Med. Rer.. September .30. 1874). 
 
 Treatment. — In all ca.ses of bites from dogs or animals in which the faintest sus- 
 picion of rabies exists free cauterization with lunar caustic should be performed. Youatt 
 states that he adopted this practice in upward of four hundred cases, and four times on 
 himself, with complete success, and that in all these there was no doubt as to the dog 
 being mad. With such a result no other caustic need be used : when this is not at hand, 
 any acid, caustic alkali, or cautery will suffice. When the escharotic cannot be obtained, 
 the part may be exci-sed. a ligature being fiistened beforehand on the cardiac side of the 
 wound. Some surgeons advise amputation. 
 
 Mental stimulants, in the way of in.spiring hope and removing fear, must be freely- 
 administered, and such general treatment as may be needed. No drug has yet been 
 
106 GLANDERS. 
 
 found that lias the least influence on the disease, either in preventing or eur'ng it. Dr. 
 Marochefti's treatment of the lyssi is the only one that can claim any degree of success. 
 How far the constant administration of chloroform would influence the disease is a ques- 
 tion that has yet to be put to the proof. To prevent asphyxia from taking place, trache- 
 otomy, as suggested by Dr. jNIarshall Hall, is a justiiiable measure, the operation being 
 based on a good theory, although it has never been performed on the human subject. 
 By it the immediate risk of death from asphyxia would be rendered impossible and time 
 given for remedies to act or for the disease to run its course. It seems that six or seven 
 days is the utmost period for the disease to be in existence. If life can be prolonged 
 thus far, the hope of a good result may be entertained. Anything that can tend to pre- 
 vent death and keep the patient alive is useful. Tracheotomy is one of these means and 
 deserves trial, wine and food being valuable adjuvants. 
 
 When a dog is known to be ipad, it ought to be destroyed ; but when any one has 
 been bitten by an animal in which there is a suspicion, but no evidence, of madness, it 
 should be kept, although apart from others and guarded, as time will prove the truth of 
 its condition and do away with the morbid fear of '• rabies " that may have been excited 
 by the injury. 
 
 Glanders. 
 
 This is a specific disease given to man by inoculation from the horse. Dr. Elliotson 
 first recognized its true nature, and described it under the term " Equina." It shows 
 itself in two forms. In one the disease attacks the mucous membrane of the nose and 
 the neighboring glands, and is then termed '■'■ glaiulcrs ;" in the other it affects the lym- 
 phatics of the body generally, giving rise to tumors or a knotty condition of the sub- 
 cutaneous glands called '■•farct/ hiich,'' and is therefore called "farci/." 
 
 In man these two forms are generally found together. 
 
 Symptoms. — There is .said to be a stage of incubation varying from two to fifteen 
 days from the inoculation, after which febrile symptoms with excitement appear, followed 
 by the specific eruption. The pains in the limbs accompanying the febrile condition are 
 generally associated with tenderness wherever glands exist, and on examination some 
 enlargement of these glands will be found. The eruption is very characteristic, being 
 made up of a crop of vesicles, which become pustular and are very hard, resembling 
 those of variola more than anything else. They are arranged in groups with inflamed 
 bases, the face, neck, and abdomen being, as a rule, more covered than the extremities ; 
 when close together, they become confluent. These pustules, with their indurated bases, 
 then soften down, leaving ulcerated excavated surfaces. They affect the mucous lining 
 of the nose, giving rise to the discharge. Virchow says that " these so-called pustules 
 are really due to the presence of a tenacious deposit in the corium of the skin, which has 
 much resemblance to tubercle and microscopically is made up of an amorphous granular 
 appearance mixed with cell elements, cell growths, and fat globules." This opinion is 
 supported by the clinical fact that tubercles in farcy are often found in subcutaneous 
 tissue, appearing as hard circumscribed blind boils or more or less diffused swellings. 
 These soften down and give rise to extensive sloughing of the skin and surrounding parts, 
 and are rarely absorbed. During the progress of the disease soft tumors not unlike 
 pyaemic cutaneous abscesses appear about the body, and sometimes attack deeper parts. 
 In the more advanced stages of the disease these tubercles or so-called pustules attack 
 the larynx and the whole respiratory tract, and more particularly' the lungs, and give rise 
 to Virchow's pneumonia of glanders — an affection which consists of a seiies of tubercles 
 beneath the pleura covering the lungs and surrounded by lobular pneumonic inflamma- 
 tion, as in pyremia. These tubercles are said to have been found in the testicles, kidneys, 
 pancreas, and joints. When they attack the nose — which they usually do at an early 
 period, and often before they appear in other parts — the secretion from the nose is at first 
 catarrhal, thin, and clear; subsequently it becomes thick, tenacious, and puriform, and is 
 often mixed with blood ; but in man}^ cases it is altogether absent or not noticed till a 
 later period of the disease. The face and head often swell from oedema and present a 
 puffy, erysipelatous, shining surface ; the conjunctiva also exudes a thick fluid, gluing the 
 eyelids. The tonsils are frequently involved and often suppurate. As the disease pro- 
 gresses the swellings and discharge increase, the inflammation around spreads and becomes 
 gangrenous, bullae appear on the skin, the constitutional symptoms become typhoid, a low 
 delirium sets in not unlike that from pyj^emia, and death ensues from coma and exhaus- 
 tion. When the glands and absorbents are involved, as in the farcy form, suppuration 
 and sloughing are superadded to those already laid down. 
 
(;r.\M>i:iis. 107 
 
 The I'HOiiNOSis of filaiiiliTs is most uiii;ivoral)lo, situ'O rocnvory only takos plafc in the 
 mikU'st cases of poisoninj;. The disease in its aeutest H{ii<nt has run its course in three 
 days, and may j)rove fatal in a week, hut in jicnerai it lasts for three or four weeks, and 
 in very chronic eases life luis been j)rolonged for months. In chronic " farcy " slough- 
 in<; glands may leave large sores, which remain o]m'm lur a long time; occasionally such 
 dironic cases end liy an attack of acute disease. 
 
 The ])ost-mortem appearances have been well descrihcil in rnhmd s article, Holmes's 
 S//st(iii, third edition, vol. i., in two recent cases, in both of wliicii there was an al)sence 
 of nasal discharge. One was l)i(;kinson's ca.se, and the other I'oland's. The first-men- 
 tioned subject died on the twenty-first day. The Idood was found fluid, the mu.scles soft 
 an<l rotten, the cervical and left parotid glands suppurating, the lower part of the right 
 Innti' solid witli urav lie|)atization, its tissues completely broken down and infiltrated with 
 jmruleiit fluid, and tlie left lung studded with numerous slate-colored patches of the size 
 of hazel-nuts. 
 
 The second patient died on the tliirtecntli day. There was no affection of the lym- 
 phatic glaiuls, but suppuration had taken place in the muscles of both calves of the legs, 
 accompanied by local abscesses in other parts of the body, chiefly in the muscles ; the 
 joints were free from suppuration ; there were recent patches of lymph on the pleura 
 and lobular pneumonia in the base of the upper lobe of the right lung, which was in a 
 state of gray hepatization ; throughout the lower lobes of both lungs were smaller hepa- 
 tized masses ; the liver was free from disease. 
 
 Billroth lays great stress on the presence of haemorrhagic ab.sces.ses in the muscles as 
 being characteristie of the pyjiemia of glanders. 
 
 Mode of Inoculation. — In man the poison is generally communicated through 
 the nasal discharge from the horse or by the discharge from farcy swellings. Where the 
 inoculation takes place from the latter the disease in man is more of the character of 
 farev. It can be communicated from man to man. The poison, to be absorbed, must be 
 applied, as a rule, to a wound or delicate membrane; yet cases are on record where the 
 disease has been set up by wiping the face with unclean hands or cloths. 
 
 Youatt states that the disease is not one-tenth part so common as it was, and, '• gen- 
 erally speaking, it is only found as a frequent and prevalent disease where neglect and 
 filth and want of ventilation exist." 
 
 Ghuulcrs, writes Dr. G. Milroy (Trnns. Epidem. Sue, vol. i.), is "a general -a^ well as 
 a propdijable disease; it is extremely apt in some seasons to develop itself in foul, unven- 
 tilated stables." Its development may, however, be controlled, even to absolute preven- 
 tion, by the observance of simple sanitary rules. 
 
 Treatment. — To keep the machinery of life going and to treat symptoms upon ordi- 
 nary surgical principles seems to be the best mode of practice, for there is no drug which 
 has any influence on the disease. Abundance of fresh air should be provided, with good 
 ^ut not too stimulating food, accompanied by tonics, such as quinine and iron. Pain 
 should be soothed by sedatives. When the nose is a source of trouble, it should be kept 
 clean by washing and by a stream of water passed through the nostril, and rendered anti- 
 septic by iodine, carbolic acid, Condy's fluid, or creosote, nitrate-of-silver solution, tannic 
 acid, and other more stimulating substances being at times valuable. Where the throat 
 is affected it should be sponged with some nitro-muriatic acid lotion, and a gargle of 
 chlorate of potash should be used. 
 
 Abscesses and softened tubercles should be opened early and freely, poultices, or 
 fomentations being applied to the parts. Perfect cleanliness should, of course, be ob- 
 served. 
 
 Glanders in the Horse, as Mr. Youatt tells us in his book on that animal, is 
 chiefly to be recognized by the persistent (Hschargr from the nostril and the singular 
 Itardnesii of the submaxillary glands, Avhich become adherent to the bone from the effusion 
 of inflammatory lymph around them. These glands are not very large except at the 
 commencement of the disease ; neither are they hot or tender. 
 
 When any doubt exists as to the nature of the disease, a condemned horse or ass 
 should be inoculated with the nasal secretion of tlie suspected animal ; and if the disease 
 be genuine, it will be reproduced in a few days. 
 
 Equina mitis is a local pustular disease affecting the hands and body of those who 
 dress the heels of horses affected with what Jenner has described as the "grease.'' It 
 consists of an inflammation and swelling of the heels of the horse, attended with the dis- 
 charge of a thin acrid matter therefrom. It is not unlike ecthyma or vaccinia, but more 
 angry ; the pustules are about the size of a sixpence ; they suppurate on the third day, 
 
108 
 
 MALIGNA^'T PUSTULE, OB CHARBON. 
 
 dry up about the tenth or twelfth, and form scabs which leave cicatrices, 
 runs its course, and is to be managed by rest and cleanliness. 
 
 The disease 
 
 Malignant Pustule, or Charbon. 
 
 This disease has been more common in recent years than it was formerly, and I have 
 seen at least a dozen of the seventeen cases that have been treated at Guy's Hospital 
 dui-ing the last ten years. My colleague Mr. Davies-Colley has given an excellent account 
 of it, and M. Bourgeois' has fully described it in a work entitled La Pmfiile Mallgne et 
 (Edeme Malin (Paris, 1860). 
 
 The disease is doubtless due to a distinct poison communicated to man by direct con- 
 tact with the body of, or with any material that has been in contact with, a diseased 
 animal. At Bradford, where there was an outbreak of it in 1880, it was termed " wool- 
 sorter's disease." At Guy's it is found to occur amongst those who work amongst hides 
 in the neighboring tanyards. It is found chiefly on the exposed parts of man, such as 
 the hands, fore-arm, neck, and face. It begins as a small red inflamed and itching spot, 
 which in twelve or fifteen lioura vesiculates, the skin beneath the vesicle appearing as a 
 dry brown or black slough. In the course of the second day another crop of vesicles 
 appear around the original seat of the disease, which run the same course. About this 
 time the seat of the original disease becomes more swollen, appearing as a defined lump 
 (" bouton"), the parts around being oedematous, and the whole subsequently sloughing. 
 " The raised indurated area with its central blackish depression surrounded by small ves- 
 icles can hardly be mistaken for any other affection." In this stage of the disease there 
 is little pain; the slough is always dry, and there is no pus; the .sloughing spreads fi'om 
 the skin down to the subcutaneous tissue instead of, as in carbuncle, from the latter to 
 the former. 
 
 This disease is usually rapid in its progress, four to nine days seeing its end. It is 
 ushered in with rigors, followed by vomiting and greaf depression ; often cold sweats and 
 
 delirium occur, and the patient dies from the de- 
 pressing influence of the animal poison before its 
 local effects have had time to Avork. In young 
 subjects the prospects of recovery are greater than 
 in the old ; and when the hands are involved, the 
 chance is better than when the head is affected. 
 
 By the microscope straight or slightly curved 
 bacilli are found in abundance along the sheaths 
 of the hair follicles and about the border of the 
 eschar (Fig. 21). They are likewise found in the 
 blood as w.ell as in the secretions of the body. In 
 the viscera they are the causes of local sloughs 
 from embolic capillary plugging. 
 
 Treatment. — The disease, being at its origin 
 local, should be locally treated ; and there can 
 be no doubt that the excision of the inflamed and 
 vesiculated area is the best practice to adopt even 
 in advanced cases. By this method thirteen out 
 of the fifteen cases in which it was carried out at 
 Guy's were cured, although in twelve the inflam- 
 mation had spread to the surrounding parts or had involved the lymphatic glands, and the 
 constitutional symptoms were more or less severe. In less severe cases the destruction 
 of the local disease by the thermo-cautery may be resorted to, or caustic, such as the 
 potassa fusa, as advocated by Bourgeois, or carbolic acid, may be substituted. 
 Tonics and diffusible stimulants are always of use. 
 
 Fig. 21. 
 
 Bacilli from Charbon. (Drawn hy Dr. F. C. Turner.) 
 Vide Mr. Davies-Colley's paper. 
 
 SYPHILIS. 
 
 Syphilis is a constitutional disease the result of a specific animal poison introduced 
 from without. Like other specific animal poisons, it is, as a rule, propagated by some 
 local inoculation ; but, unlike all others, it has, by its subtle influence through the 
 >3arents, the power of affecting the unborn foetus and the newly-born child. No other 
 blood poison appears to possess this power — at any rate, to the same degree ; and it is 
 1 Vide Med.-Chir. Trans., vol. Ixv., 1882. 
 
sy nil LIS. ]()0 
 
 Well In hear tilis iiii|Hiii:iiit |i()iiit of (litrri'ciicf in iiiiii<I. for in all other rosixM-ts tlicrc is a 
 stroiiLi- aiialoLiy lictwccii all. 
 
 Till' poison, oiii'f iiilroiluccil into llic system either liv inlieritance ( in/irn'/it/ .■<i/n/,i/is\ 
 or hy sonic hn-al iiiocnhitioii {iic<juir((/ si/ii/u'/is), iiiaiiit'ests its presenile in its own peculiar 
 way liy the a]>pcarancc oi" a s(»iucwliat irrc<:ular althou<rli cliaractcristic chain of svinp- 
 toins. Tlie^e arc uncertain in the jicriod fil" their nianircstation after tlie inoculation, in 
 the orilei' of their appearance, and in their form and clhicts ; yet tliey possess their own 
 sjtecial fcaturi's. They arc /orv// and yr/^r/v//. They run tlieir course, yet ilo not elimi- 
 nate tlie poison. They may disappear for a time, to reappear in some other lorm. 'J'lie 
 poison may lie dormant for years, atid in healtliy suhjeets show no si{;ns of its presence 
 till some weakening infltience has depressed the powers of its victim and given ri.sc to a 
 local affection in wliicli the practised eye will read witli more or less certainty the mod- 
 ifying influence of an antecedent sypliilitic affection. The poison has been .scotched for 
 a time only. ]>ut not killed, and in the weakness of its possessor has reas.serted its power. 
 No other animal poi.son a])])ears to have such tenacity of existence. Others produce 
 tlieir specific effects in a definite way and in a regular series of symptoms and are either 
 eliminated or destroy life ; they cease to act and become innocuous after having run their 
 course, their power for harm being exhausted. The ])oison of syphilis, however, is so 
 subtle that it is tolerably certain mo.st of the secretions of a sypliilitic subject are cap- 
 able of producing the same disease in another, clinical experience having dis}»roved Hun- 
 ter's opinion that syphilis could only be propagated })y the secretion of a primary .sore, 
 and Kicords pro])ositioii that "chancre at the period of progress is the on/// source of the 
 syphilitic virus.'" Indeed, it may fairly be asserted that a healthy woman, marrying a 
 man who has had syphilis, but in whom all symptoms have long disappeared, may give 
 birth prematurely to a dead f(ptus, to a stillborn child, or to an infant that will, cither at 
 its birth or within a few weeks subsequently, show symptoms of syphilis, all the.se results 
 being the effects of syphilis transferred from the father. On the other hand, no such 
 result may ensue. Maternal heredity has a stronger influence than paternal. When 
 both parents are syphilitic, the chances of a foetus being affected are grcatlv enhanced. 
 '■ The semen of a diseased man depo.sited in the vagina of a healthy woman will, by being 
 absorbed and without the intervention of pregnancy, contaminate that woman with the 
 secondary (constitutional) form of the disease, and that without the presence of a chan- 
 cre or any open sore cither on the man or the woman " (Dr. Porter, l)iib. Jourri. of Mefl. 
 Science, 1857). 
 
 A healthy woman nu^rrying a man Avho has had .syphilis, but who has lost all symp- 
 toms of it, may — not must — acquire syphilis either through the medium of a blighted 
 ovum or a series more or less prolonged of stillborn children, or through the medium of 
 the utero-plaeental circulation. 
 
 A healthy woman giving suck to -a child the subject of hereditary syphilis may 
 acquire the disease through some fissure of the nipple, the di.sease locally and con- 
 stitutionally manifesting its presence with all the intensity of a primary inocula- 
 tion. 
 
 Again, the secretion of any true syphilitic sore, chancre, or mucous tubercle, whether 
 of the mouth, nose, anus, vulva, or penis, is capable of transferring the disease ; and the 
 syphilitic poison may probably be simply absorbed by the vessels of a part { ph/jsviloqknl 
 nhs^orptioii) without giving rise to any local aft'ection. Hunter believed this, and Lane, 
 Marston. and Lee have published observations that tend to support the theory. 
 
 " It should never be forgotten that it is the virus which infects the system, and that 
 the sore is the mere local lesion, and not a neces.sary antecedent to infection " {Committee 
 on Si/philis, p. 8). '• It is impossible to predicate with ab.solute certainty of any given 
 sore that it will or will not be followed by con.stitutional infection " (J. Lane). 
 
 It should never be forgotten that the poison of syphilis, however introduced into the 
 system — whether inherited or acquired from primary sores or from the secretions of a 
 syphilitic subject — is the same, and manifests its presence in much the same way. 
 
 It may be difficult in individual cases to make out the direct source of the contagion ; 
 but if we recognize the fact that the virus, however diluted in one subject, may, when 
 introduced into another, behave as if it had been taken from a spreading primary chan- 
 cre, the explanation of most clinical facts becomes easy. 
 
 Syphilis is an animal and a human poison ; it is capable of propagation by any form 
 of inoculation from the secretion of any syphilitic to a virgin subject in all its intensity ; 
 it may likewise be inherited. Nothing is known of its nature, although its effects are 
 sufficiently familiar 
 
110 ACQUIRED SYPHILIS. 
 
 How, then, it may be asked, is syphilis to be recognized? Is it to be recognized in 
 its primary inoculation, or is it only to be known by its constitutional symptoms? 
 
 It has been already stated that most authorities ai"e agreed upon the fact that there 
 is no form of local sore or chancre that can be said with certainty to be the result of 
 the local inoculation of syphilis. In the cartilaginous indurated sore with enlarged 
 indurated glands there is every probability of syphilis manifesting its presence, and in 
 the multiple, suppurating, non-indurated chancre there is every probability of no such 
 symptoms appearing. But in the first form such svmptoms may not. and in the second 
 they may, appear ; consequently, as a law this distinction becomes of little value. 
 Indeed, syphilis as a disease can only be known by the manifestations of its consti- 
 tutional symptoms, and not by the inoculation, in the same way as smallpox, when 
 propagated by inoculation, is only to be recognized by the eruption, and not by the local 
 appearances resulting from inoculation. 
 
 Acquired Syphilis. 
 
 Cause. — Acquired syphilis is contracted through inoculation from a chancre, from a 
 syphilitic mucous tubercle, condyloma, or other syphilitic sore, or from the secretions of 
 a syphilitic subject, the secretion of one form of syphilitic sore from one subject being 
 capable of producing a chancre of another form in another subject. 
 
 Drs. Maury and Dulles' have traced it to a '' tattooer " Avith mucous patches using 
 his saliva to moisten the coloring-matter employed in his work. 
 
 Mr. John Morgan of Dublin, by experiments, has been led to belie>e that ■• the dis- 
 charge of a syphilitic female produces on !<ijpliiUtics the sore identical with that produced 
 from the soft sore or chancre." 
 
 After inoculation, a certain time, which varies from six to twelve weeks, usually 
 elapses before the poison manifests its presence. In exceptional cases the symptoms of 
 syphilis may appear within the month or fail to appear for four or more months, but 
 every week that passes after the third month without their manifestation lessens the 
 likelihood of their appearance ; and when six months have elapsed without syphilitic 
 symptoms showing themselves, the probabilities of their doing so are very slight. 
 
 The diiferent forms of syphilitic inoculation will be considered under the head of 
 '■'■ Chancre.' 
 
 Dismissing, therefore, the consideration of the character of the sore to which the 
 poison of syphilis usually gives rise with the simple reminder that there is positively no 
 specific sore, the constitutional symptoms of syphilis now claim attention : and the vari- 
 ety of forms they assume is very striking. They usually show themselves primarily 
 upon the skin in the form of an eruption, or upon the mucous membrane of the aliment- 
 ary canal, as indicated by sore tongue and throat, while some amount of fever and con- 
 stitutional disturbance at times precedes their appearance. This "syphilitic fever'' varies 
 according to the nervous susceptibilities of the patient. 
 
 The skin eruption may be only a ro.se rash, roseola, giving rise to a mottling of the 
 skin or to a more lasting staining. It may assume the papular form, lichen ; the pustular, 
 ecthyma ; the vesicular, nipia ; the tubercular, ulcerating or non-ulcerating, or the scaly, 
 lepra or j)!!orta.v'x. Bullae are rare except in hereditary disease ; when present, they indi- 
 cate a cachectic condition. 
 
 The mildest form of roseola may last but a few days and disappear, or leave a dusky 
 coppery stain behind of some durability. 
 
 The l^'ch/'ji will soon show the copper tint, and as it flattens may become a tubercle, 
 and this a scale, the skin, after the desquamation of the scale, showing much the same 
 as the macula of the rose eruption. 
 
 When the eruption is tubercular at the first, the same series of changes will be seen, 
 the raised, indurated, or spongy tubercle as it withers usually showing a scale upon its 
 surface and then flattening down to a macula. 
 
 The lepra and p.-toriasis appear as inflamed patches more or less extensive, as in the 
 non-specific forms, the epithelial scales varying in thickness and the fissures in depth. 
 The psoriasis commonly appears on the palms of the hands and the soles of the feet. 
 
 All these eruptions have a copper-colored tint, more particularly after their first 
 appearances have faded. But what is still more characteristic is the fact that upon the 
 same subject several forms of eruption are often found together, the macula, papule, pus- 
 tule, tubercle, and scale passing one into another. 
 
 ^American Journal of Med. Sci.. January, 1878. 
 
ACQUIRKI) SY I'll I LIS. Ill 
 
 What determines tlie form of tlie eruption at its first appearance is not known. Why 
 syphilis in one man should manifest its pre>ence hy an eruption of macuUc, in another by 
 a pa|)ular or sealy eru])tion, and in a third hy a j)ustular, tuhereular, or ulcerative form, 
 is not known The theory propounded by Carmichael — that each sort of eruption has 
 its own form of local sore or inoculation — was injrenious, but is not suj)ported by facts; 
 and the generally-received o|iinioii is that the peculiarity or power of the infected patient 
 has more to tlo with these phenomena than the nature of the jioison itself. The pustular 
 an<l vesicular eruptions are more prone to appear in cachectic than in the robust subjects, 
 and an ulcerative action is more likely to accoinpany — or, rather, to follow — their appear- 
 ance ; the l»ase of the |>ustule or of the vesicle, and at times the substance of the tuber- 
 cle, break down ami L'ive rise to a troublesonui and spreading ulcer. 
 
 Affections of the Mucous Membrane. — As the onttinh skin in syphilitic 
 
 subjects is attaiki'd bv eruptions, sinipk- and ulcerative, .so the iiisldt skin or 7ni(co)is mem- 
 hniiu's is etpially involved. " Every form of syphilitic affection of the skin," writes Lee, 
 "has its counterpart in the mucous membrane; but the appearances will bo modified by 
 the comparative thinness of the structure, by the absence of cuticle, and by the little 
 dispo.sition these parts have to take on tlie adhesive inflammation." The mucous tuber- 
 cle is the more common form, and is found in the organs of generation, tongue, mouth, 
 lips, nose, palate, throat, rectum, and anus, and occasionally in other parts of the aliment- 
 ary canal. It is known also in the laryn.x. At times these tubercles break down and 
 ulcerate, giving rise to irregular excavated sores. 
 
 Moist tubercles may appear in syphilitic subjects at any part of the body where two skin 
 surfaces are in contact, associated with moisture. When they are found between the toes, 
 they arc known as rfui'/nih's ; and when about the orifice of a mucous passage^ias a condyloma. 
 
 Syphilitic sore throat may a])pear as a mere mucous patch upoh the surface of 
 the mucous membrane, or at times as an ulceration of this patch, while at others it shows 
 itself as a distinct affection, the throat becoming swollen and of a livid color and rapidly 
 passing into ulceration. These ulcers may attack the soft palate, pillars of the fauces, 
 tonsils, or pharynx, and present every kind of appearance, shape, and character. They 
 may be serpiginous like the trail of a snake, horseshoe shaped or circular, superficial or 
 excavated with sharp edges, inflamed, sloughing, or indolent. By themselves they are 
 not typical of syphilis, however suspicious, and other concomitant symptoms are refjuired 
 to determine the diagnosis. The mucous patch is the most characteristic. Xo ulceration 
 is typical, although the sharply-cut excavated ulcer is the most unmistakable. In hered- 
 itary syphilis this form of excavated ulcer is rare, though I have seen the perforating 
 ulcer of the soft palate in an infected infant a month old. 
 
 Syphilitic disease of the tongue is a very troublesome affection and manifests 
 itself in a variety of ways ; it appears more commonly in the form of aphthous and 
 mucous patches, ulcerating or otherwise, but not unfref|ucntly the whole thickness of the 
 organ is infiltrated with the gummatous syphilitic material, either as an isolated nodule 
 or as a general infiltration. When this nodule has softened down and suppurated, a deep 
 excavated sore or fissure may be left, not unlike that of cancer; and when this sloughs 
 or is of a chronic nature, the diagnosis becomes still more obscure. In cancer, however, 
 there is probably a more marked local induration than in syphilis, and rarely a sharp, 
 well-defined edge. The history of the case is, too, very different (n't/r Chapter XII.). 
 
 The mucous lining of the mouth, lips, nose, etc., is also equally liable to syphilitic 
 disease, either in the shape of aphthous and mucous patches or of ulceration not unlike 
 that found on the throat or tongue ; indeed, the di.sease of one part of the mucous mem- 
 brane is the same as that of others, the local appearances and symptoms being modified 
 only by the peculiarities of the part. 
 
 In ulceration of the rectum syphilis bears an important part, and as a cause of stric- 
 ture it is not rare. When present, the disease usually spreads upward from the anus, 
 the bowel being in .some cases superficially, in others deeply, infiltrated and ulcerated. 
 This form of disease is more common in women than in men (vi<fe Chapter X\'I.). 
 
 Syphilitic disease of the periosteum shows it.self in the form of nodes, and 
 rarely as a single node. If the tibia be involved, several swellings exist ; and the same 
 occurs in other bones, particularly the cranium. The swelling is merely an efiusion of 
 the gummy material beneath the periosteuiu. When the bones are attacked, the disease 
 is mostly chronic and too often ends in the death of the part — /'. «?.. in necrosis. 
 
 Symptom.s. — In disease of the periosteum extreme tenderness and pain with local 
 swelling are the chief symptoms. When the bones are implicated, the pain is of a con- 
 stant aching character, and this is always aggravated toward night ; but there is neither 
 
112 
 
 A CQ riRED S YPHIL IS. 
 
 Fig. 22. 
 
 ^Syfihilitic [^ 
 de/iosit 
 
 such swelling nor so much tenderness as there is in the periosteal aflfi'Ction. Tn disease 
 of the bones of the skull the dura mater and brain may become secondarily afi'cctcd. 
 
 It must not be thought, however, that syphilis and its effects are confined to those 
 parts of the body that come under the immediate notice of the surgeon. It is hardly 
 probable that both ends of the alimentary canal should show evidence of the affection 
 without some part of its intermediate twenty-five feet being implicated, or without some 
 of the compound glands that are as.sociated with it being involved. The pathologist 
 knows this to be the case, and recent research has confirmed Wilkss observation {(luys 
 Rf'ports, I8O0) that " the extent of the influence of syphilis is only commensurate with 
 the tissues of the body," and that '• there appears to be scarcely a tissue which may not 
 be affected, and always in one particular and characteristic manner. The internal 
 organs may be affected equally with the external — not only the cranium, but the brain 
 within it, or the nerves; not only the muscles of the limbs and tongue, but the heart; 
 not only the pharynx, but the cesophagus ; not only the larynx, but the trachea, bronchi, 
 and lungs, also the liver, spleen, and other viscera." 
 
 "The peculiar effect of syphilis on the system," says the same writer, 
 
 "shows itself in a disposition to the effusion of a low form of lymph or fibro-plastic 
 material in nearly every tissue of the body, occasionally modified in 
 character to a slight extent by the organ in which it occurs. In 
 solid organs or in the interior of the tissues there is found a more 
 or less circumscribed deposition of an albumino-fibrous material, 
 whilst on the surface of the bod}' a similar material may constitute 
 merely the base and border of an ulcer."' In the testicle this is 
 well seen (Fig. 22). 
 
 Pathology of Syphilis. — In these observations the whole 
 patlinlogv of syphilis is included ; for, whether syphilis involve 
 skin, mucous membrane, connective tissue, muscle, bone, perios- 
 teum, or a viscus, the same exudation exists, either as an exudation 
 and induration or as an exudation breaking up with ulceration. 
 
 This exudation is the same in all stages of syphilis, in all tissues, 
 in hereditary as well as in acquired syphilis. When the exudation is 
 reabsorbed, a recovery is said to have taken place ; when it breaks 
 down, suppuration ensues. When it attacks the external tissues, 
 " secondary symptoms" are said to exist ; when the internal viscera 
 or the bones are affected, the .symptoms are called tertiary. 
 
 Affection of Bones and Larynx. — In cachectic and 
 
 feeble subjects, where visceral mischief has a tendency to appear, 
 syphilitic disease of the organ may occur. The bones, if affected, 
 are liable to become necrosed ; the larynx, to ulcerate ; and the 
 skin, when affected, to suppurate as well as ulcerate. In fact, 
 syphilitic disease in the feeble and cachectic is as liable to be associated with disorgan- 
 izing changes as any inflammatory or other affection. The longer the disease has existed, 
 the "greater, also, is the probability that the viscera and the tissues of the body generally 
 will be involved. But in all other respects the effects of syphilis are the same. The 
 virus, as it affects the body in all its different ways, is the same ; at all times it is the 
 same ; the so-called secnKhtn/ and fertian/ syphilis are the same, for these terms have no 
 definite signification. They have, I believe, tended to confuse rather than clear the sub- 
 ject, and were framed when the pathology of the disease was but little known. Syphilis 
 is clinically known by certain constitutional symptoms, and pathologically by certain 
 morbid conditions. It may manifest its presence in different subjects in different ways, 
 involving now one tissue, then another, with no apparent law regulating its action. In 
 one patient a tissue may be involved early ; in another, late ; but the node on a bone, the 
 nodule of lymph on the iris, the indurated gummy tumor in the connective tissue or in a 
 muscle, the puckered nodule of fibrous tissue beneath the peritoneal covering of the liver, 
 the mass of fibre tissue poured out in a syphilitic testicle, are all alike. These differ only 
 in their symptoms and effects according to their position, yet whether they occur soon or 
 late after the primary inoculation is a matter of no clinical importance. 
 
 '• While syphilis is thus unsparingly general in its attacks upon organs, yet it plays 
 over much the same series of organs as other diseases ; vulnerable or much-abused organs 
 which suffer disproportionately from common causes of disease suffer also in much the 
 same proportion from syphilis, while the thyroid, spleen, capsules, deep-seated bones, and, 
 indeed, generally those'parts which are not obnoxious to other 'common' diseases, escape 
 
 Hall a Testicle intiltrated 
 with Svphiliiic Deposit. 
 (2:«1S8." Prep. Guy's Hos. 
 Mus.) 
 
AC(,>rini:/) svrimjs. nr> 
 
 also ill syphilis" (Mox«»n. Mr,/, '/'inns, .Iiuif -\. 1S71 j. In fjict, hcyond tho Ii»cal inoc- 
 ulation, syphilis fixi-s upon, or rather attacks, an orjran much as any other disease, pos- 
 sossiiii; no lipeeial jiredileetion for one or^'aii or tissue; in preferenee to another, the so- 
 called secondary and tirliary afrcctions havinL' no real dinen-ricc save ordy in the surgeon's 
 mind. 
 
 'rKKATMKNT. — There is no remedy in the i'harmacopu'ia that can he relied upon as a 
 specific tor syphilis, althoUL'h there are many that have a very Itenefieial iiiHuence in aid- 
 ing the disappearance of the symptoms; they can, however, do no more. It is, indeed, a 
 (juestion whether the disease is really ever cured — whether a person once under the influ- 
 ence of syphilis is not really like one hroujrht under the influem;e of vaccinia; which 
 means that his hody has heeii so affected hy the poison as to he influenced by it for life. 
 After successful vaccination a .^second inoculation rarely takes as it does in a virgin sub- 
 ject, and after true syphilis a second attack rarely if ever ensues, Porter's law being 
 tolerably proved — " that the influence of syphilis never returns upon itself or recontam- 
 inates the source from which it had been derived" (JJuhfin Quart., 1857). Ilicord, Lee, 
 and others have proved that the .soft or non-infecting chancre is the oidy one that can be 
 inoculated with success on the same subject. It is true that in a large number of cases 
 syphilis appears to be cured, that the symptoms disapjiear, and that the health of the 
 patient is re-established ; yet it is ecjually true that in such ca.ses, after the lapse of years 
 — it may be, even after a (|uartcr of a century — the existence of former syphilis is 'again 
 recognized if the health of the patient is lowered. So long as the powers of the subject 
 who had syphilis remain good, no evidence existed of its presence ; but when these failed, 
 the ]toison reasserted its claim to recognition. It must, however, be stated with consid- 
 erable confidence that nature, unassisted by art, seems incapable of eliminating the dis- 
 ease or of arresting its progress. 
 
 On Ui<e of MercKiy. — In former times it was thought that in mercury the surgeon 
 possessed a specific against the disease ; and when all chancres were looked upon as syph- 
 ilitic and mercury was administered, a large proportion of supposed cures were recorded, 
 no constitutional .symptoms showing themselves. 
 
 In modern times, however, when it is known that at least three out of every four 
 cases of chancres of the penis are local venereal affections and not syphilitic, the real 
 success of the mercurial plan is acknowledged to be less extensive than was supposed, 
 although in .syphilis — that is, when the constitutional evidence of the disease is present 
 — the power of mercury in getting rid of the symptoms is indisputable. 
 
 In strong and healthy subjects, therefore, when syphilis is present either in the form 
 i>f skin eruption, sore throat, or other affection of the mucous membrane of the intestinal 
 or respiratory tract, mercury is beneficial. The best mode of using it is generally sup- 
 posed to be by inunction — /. e., the rubbing of mercurial ointment about the size of a 
 nut, or, what is better, of the oleate of mercury, ten-per-cent. strength, the size of a pea, 
 into the axilla twice a day till the gums are touched, and after then only once a day. Dr. 
 B. G. Babington recommended the inunction in adults to the soles of the feet, the rubbing 
 in being performed by the action of walking. The internal administration in bark of the 
 bichloride of mercury in doses of one-sixteenth of a grain three times a day is a good 
 form of administration, as is also the green iodide of mercury in grain doses twice a day, 
 with Dover's pill. Some surgeons still use the blue pill with opium. During the last 
 eight or ten years I have been using the mercurial suppository twice a day, and have 
 been greatly satisfied with its action ; the drug acts as well thus as by the mouth and in 
 no way interferes with digestion or the functions of the abdominal viscera. Indeed. I 
 am disposed to think it by far the best mode of administering mercury ; I know of no 
 objection to its use. Next to this plan, the calomel vapor bath is the best. 
 
 The most convenient calomel vapor bath, writes Lee,' is one which was made at my 
 request by Mr. Blai-se. In this apparatus the lamp which sublimes the calomel boils the 
 water at the .same time. In the centre of the top, immediately over the wick of the 
 lamp, is a small separate circular tin plate, on which the calomel is placed ; around this 
 is a circular depression, which may be filled one-third with boiling water, the apparatus 
 being placed on the ground and the lamp lighted. The patient then sits over it with an 
 American cloth cloak or mackinto.^h fastened round his neck. He thus becomes sur- 
 rounded with calomel vapor, which he is generally directed to inhale for two or three 
 separate minutes during each bath. In doing this the patient should not put his head 
 under the cloak, but simply allow some of the vapor to escape from the upper part and 
 breathe it mixed with a large proportion of common air. At the expiration of a quarter 
 ' Holmes's Surgery, third edition, vol. iii. 
 
114 ACQUIRED SYPHILIS. 
 
 of an hour or twenty minutes the calomel is volatilized and the water will have boiled 
 away, a portion of the calomel being deposited on the patient's body. The patient may 
 then gradually unfasten his dress and put on his nightgown, but must not wJ[)e his skin. 
 If he prefers it, he may go to bed in the cloak and wear it. The bath ought to be used 
 every night, and five or ten grains of calomel is the quantity that should be evaporated. 
 
 Bricheteau, Lewin, and Sigmond have employed the hypodermic injection of mercury 
 with some success, throwing in fifteen minims of a solution of corrosive sublimate, four 
 grains to the ounce of water. 
 
 Iodide of Fofaamnn. — For feeble cachectic subjects, however, mercury is ill adapted, 
 and for such the iodide of potassiiim in five-grain doses, gradually raised to ten, or more, 
 will do all that is needful. In London practice it is generally required to be combined 
 with some tonic, such as bark, quinine, or iodide of iron. The combined use of mercury 
 and i(jdide of potassium will occasionally be of great value. 
 
 When the mucous tracts are involved, the addition of some alkali, such as the bicar- 
 bonate of potash, in ten-grain doses, to the iodide is advisable. The addition of the 
 compound spirit of ammonia to the bark mixture is also useful. 
 
 When the symptoms begin to yield, the ti'eatment must be continued ; inc^eed, the 
 effects of the drugs, whatever they may be, should be kept up for at least six months 
 after the disappearance of all symptoms, otherwise a relapse will ensue. 
 
 Comparison of Mercury and Iodide. — Comparing the effects of the two drugs together, 
 it may be asserted that the mercurial plan of treatment is more applicable to the early 
 than the late symptoms of syphilis ; that in cases of relapses or of late syphilis the 
 iodide of potassium is preferable, although under both circumstances, in exceptional 
 cases, one plan of treatment will succeed whei'e another fails. When iodide of potassium 
 cannot be tolerated, iodide of sodium may be substituted. 
 
 Ij!('f, — During the course of syjihilis the patient should live on simple, nutritious, 
 but non-stimulating, diet. Wine and beer should be given in moderate proportions, spirits 
 never allowed, and smoking, as a rule, should be interdicted. 
 
 When mercury is being employed, the skin should be kept warm and the feet dry, all 
 sudden chills being bad. When suppuraticm or ulceration exists in any form of syphilis, 
 mercury is rarely applicable ; iodide of potas.sium combined with tonics is then the best 
 drug, with or without opium. Sarsaparilla has no specific influence in syphilis ; it is a 
 pleasant vehicle, but nothing more. Opium combined with other drugs is at times of 
 great value ; with mercury it is invaluable. It may be given in small doses whenever 
 the nervous .system has been overwrought and there is great irritability of pulse. 
 
 The syphilitic affections of the mouth, tonsils, throat, tongue, etc., 
 
 are expedited in their disappearance by the local apjilicatiou (if nitrate of silver, chromic 
 acid, gr. v to x to the ounce, chlorate of potash, boracic acid, or borax gargle ; constitu- 
 tional treatment should be simultaneously employed. 
 
 The mucous tubercles of the genitals and other parts are most successfully treated 
 by the local application of calomel, which should be dusted over the diseased surfaces 
 through a muslin bag. A good rub with nitrate of silver at times expedites the cure. 
 The parts should be kept well dry. 
 
 Condylomata are not so amenable to the calomel treatment as the moist tubercles; 
 they may, however, be successfully treated by the local application of the chromic-acid 
 solution, nitrate of .silver, or sulphate of copper, by a lotion of bichloride of mercury 
 gr. ij to the ounce of water, or of black wash. When the growths are very fle-shy, excision 
 is the best practice. 
 
 In ulceration of the throat iodide of potassium, in doses varying from six to 
 fifteen grains three times a day. is of great value, with the local application of the nitrate 
 of silver in stick or strong solution ; a gargle of alum, chlorate of potash, or borax, a 
 drachm to a pint of water, is also good. 
 
 In laryngeal disease the iodide must also be given quite as freely ; and when 
 ulceration has commenced and seems to be unaffected by general treatment, tracheotomy 
 claims serious consideration, because, unless the larynx can be kept quiet, repair will not 
 ■go on, and so long as ulcerative disease is present a sudden spasm of the glottis may 
 occur and render imminent the death of the patient. The operation should, however, 
 only be undertaken when the disease is steadily progressing in spite of treatment, and if 
 it is clear that the larynx will be destroyed as a vocal as well as a respiratory organ unless 
 some steps be taken to stop its progress. Of these steps there are none equal to trache- 
 otomy, for all surgeons are familiar with the fact that even under the most extreme con- 
 ditions of disease repair goes on in the larynx directly the tracheal tube has been intro- 
 
HEREDirMlY SYPHILIS. 115 
 
 duced, and physiological rest is given t<j the organ {viih' paper by author, Clin. S'jc. 
 Trans., 18G8). 
 
 In the (jummy tumors of the tongue, muscles, and cellular tissue large doses of the 
 iodide with tonics are as heneficial as they are in the pfriostraf affections of syphilis. 
 
 TnnfnHiif nf Inlirnnl Si/ji/iiii.-<. — There is rea>on. however, to ht-iieve that in the vis- 
 ceral as well as in other diseases which may he looked upon as the se«|ueUe of syphilis, 
 or as the result of the cachexia caused by the disease and the remedies emph^yed fur its 
 reniiival. ioilidf of jtotassium alone has little influence. J>r. Wilks has shown how the 
 lardaceous and wa.xy diseases of organs are found after .syphilis, and every one knows how 
 little amenable to treatment these affections are. Dr. Dickinson has. however, done some- 
 thing to prove that they are due to a want of alkalinity in the blood, and are to be pre- 
 vented, and in a manner cured, by the medical use of alkalies. With the same view a 
 non-nitrogeni>us diet should be allowed. 
 
 During the later period of the disease, when the gummous depositions take place, 
 whether it be visceral, osseous, glandular, or otherwise, iodide of pota-ssium in full doses 
 is of great value. In the sequelje, in waxy or lardaceous disea.se. it is of little u.se. alka- 
 lies with tonics being then apparently the best. Upon this knowledge it is probable that 
 the late Mr. Aston Key based his advocacy of lime water and the infusion of sarsaparilla 
 in the syphilitic cachexia. 
 
 Hereditary Syphilis. 
 
 That syphilis is capable of being propagated by hereditary transmission is a clinical 
 fact generally recognized, constituting the main distinction between syphilis and all other 
 animal poisons. To what an extent this influence spreads is still a debatable question. 
 According to some observers, instead of diminishing, the radius of its action appears to 
 be yearly increasing. 
 
 That the child of a parent who has had syphilis moT/ — not /»?/.«/ — inherit the disease 
 is generally acknowledged, and when both parents have been affeetefj the probabilities of 
 its transmi.ssion are. doubtless, increased ; but data are still wanting to determine under 
 what circumstances the offspring of such parent or parents is likely to be born healthy. 
 
 There is, however, some reason to believe that when the mother is at fault the early 
 conceptions are more likely to be blighted and the later come to maturity ; whilst when 
 the father is at fault the first conceptions .show few. if any. signs of the affection, the 
 symptoms becoming more marked in each succeeding one, till at last the ovum becomes 
 blighted and the wife constitutionally affected. 
 
 The probabilities of the child being affected, as well as the degree of the affection, 
 turn, likewise, much upon the period of time which has elapsed between the disappear- 
 ance of the con.stitutional symptoms in the parent and the date of marriage. 
 
 Daily experience proves, however, that a man who has had syphilis and lost all traces 
 of it under treatment, who enjoys good health and marries a healthy wife, maybe blessed 
 with healthy children in whom no traces of .syphilis can be found : but the .same experi- 
 ence also indicates that these subjects, marrying in a less vigorous condition or lapsing 
 into bad health, may give rise to diseased offspring. 
 
 A certain number of children succumb in their mother's womb to syphilis solely 
 because they are already affected with the disease. At other times the children come 
 into the world with lesions unmistakably .syphilitic : while in the great majority of cases 
 the child who inherits .syphilis has at first the appearance of health and some weeks after 
 birth presents signs which betray the evil transmitted to it from its parents, it being usu- 
 ally from the first to the third month of extra-uterine life that .syphilis manifests itself in 
 the new-born child. Cullerier cives a vear as the latest time for the disease to show 
 itself. 
 
 With respect to the symptoms of hereditary .syphilis, it may be well to a.ssert at the 
 beginning that, with the exception of the primary inoculation, they are much the same 
 as those of the acquired disease. Affections of the skin are found a-s-sociated with those 
 of the mucous memVjranes, bones, or viscera, and these manifest themselves in no definite 
 order. 
 
 At birth the child may be plump and fat. and for some days appear healthy in every 
 respect. After the lapse of a few days some difficulty in breathina will probably appear, 
 with symptoms of cold in the head, these so-called " snvjffes '" being always suspicious. 
 At this time, if the skm be carefully examined, more particularly about the buttocks and 
 feet, some eruption will be seen. This may be simply a staining of the skin or a more 
 definite papular, vesicular, or pustular rash : it may be associated with some affection of 
 
116 
 
 HEREDITARY SYPHILIS. 
 
 Fig. 23. 
 
 the internal skin or mucous nK'nil)raiie, mucous patches or condylomata showing them- 
 selves at the anus, about the mouth or within it, around the nose or other parts. The 
 seat of the eruption is greatly determined by the degree of cleanliness observed, the irri- 
 tation of dirt and moisture in any locality in syphilitic children being followed by condy- 
 lomata or mucous patches. 
 
 The orifices of the nose, mouth, and anus are at times fissured in a very marked man- 
 ner, and occasionally leave traces of the disease which can never be mistaken even years 
 afterward. In the annexed drawing these alterations about the face are most typically 
 shown (Fig. 23). 
 
 When the disease is allowed to run its course, the child's general condition suffers; 
 it becomes emaciated and puny, the digestive organs become deranged and refuse to 
 assimilate food, however good, while vomiting and diarrhcea are common consequences. 
 Evidence of starvation soon appears ; the skin becomes baggy and of a peculiar dusky 
 hue; when not covered or scarred with eruptions, it may have a jaundiced appearance; 
 and the child will pr(»})ably die from what is called marasmus, which means wasting from 
 starvation. 
 
 When the disease does not run so rapid a course, other symptoms show themselves. 
 It may be in the skin, bones, eye, ear, or viscera. 
 
 In the akin, subcutaneous or submucous tissues the disease may appear in the form 
 of ijummi/ swclfi)if^.s or tumors, which may break up and give rise to irregular excavated 
 cellulo-membranous abscesses. In the bonrs the disease may show itself as nodes, the 
 
 humerus appearing to be the bone most commonly affected, 
 though I have seen several instances in which the bones of ■ 
 the .skull were frightfully involved. 
 
 In the eye the symptoms are well known ; interstitial 
 keratitis, a form of disease, according to Hutchinson, which 
 is peculiar to hereditary syphilis, generally shows itself 
 between the ages of eight and fifteen years. It appears as 
 a iliflf'used haziness of the centre of the cornea, unattended 
 with ulceration ; this haziness begins in independent 
 patches, which subse((uently coalesce, the cornea at a later 
 date appearing like ground glass. The affection is attended 
 with photophobic pain about the orbit and the sclerotic 
 injection. It generally involves both eyes seriatim. Under 
 treatment the disease may be arrested ; but when it is 
 severe, patches of haziness renuiin which interfere with 
 vision and at times cause complete blindness (Fig. 23). 
 
 Iritis is another complication, though a rare one. as is 
 choroiditis, and also amaurosis. 
 Deafness is not unfrequent. the hearing failing without any external disease, such as 
 otorrhoea. In most cases both ears are affected. 
 
 Hydroceplialus and syphilis are also allied. Sj/philitic disease of the testicles is also 
 to be met with. I have seen several cases of this nature, and the most marked was in a 
 boy four months old, the third child of syphilitic parents, who had snuffles and mucous 
 patches on the lips. I]ach of the testicles was an inch and a half long and very hard. 
 The disease was cured by mercurial treatment. 
 
 There is reason to believe, moreover, that in hereditary as in acquired syphilis every 
 organ of the body, in different cases, may be found diseased, the viscera of the cranium, 
 thorax, and abdomen, with the glands generally, as well as the skin, mucous membrane, 
 mu.scles, nerves, and bones. 
 
 It is difficult to decide how far the syphilitic poison follows the subjects who inherit 
 it. It is no uncommon event to find a child entirely free from all evidence of constitu- 
 tional syphilis born of parents who had previously given, and may subsequently give, 
 birth to stillborn or diseased offspring. A healthy child may stand alone in a long series 
 of conceptions as a living proof of the power of life even over such a poison as syphilis. 
 I have also before me the notes of an instance of twins born of syphilitic parents ; 
 one passed through all the series of complaints common to hereditary syphilis, while the 
 other escaped altogether — that is, at the end of a year and a half no symptoms had 
 appeared. 
 
 I have the notes of another case of twins, born under like circumstances, in which the 
 symptoms appeared in one at the end of a month, and in the other in the fourth month. 
 Such cases as these would appear to show that the manifestation or non-manifestation 
 
 Hereditary Syphilis. {Frmu life.) 
 
iii:i:i:i)irMiY syriiius. 
 
 117 
 
 Fig. 25. 
 
 ^^^y 
 
 Syphilitic Teeth. 
 
 llealthv Teeth. 
 
 (it" till- .syiii|itniiis ul' licrnlilary .syi>liili.s (Ii'|m-ih1.^ inurh ii|>(iri tin' |)cr.s(iii;il power nl" the cliilil 
 who iiilicrit.s it, :i strong cliild throwiiiix oil' or fliiiiiniitiiitr tln' poLsoii. wliilc tin; WL-ak falls 
 uiaK-r its iiiHiifiicc. .sine*' in tlio case; of" the twiii.s altovt- iiii'iilioiird tiiere can he no niicstioti 
 as to the simiiaril y of" tin- foiidilions uinh-r which llicy wurc |ilacLMl. In hcn-ditary sv|iliilis 
 this conclusion is fomnlcd u)ion slroni; cvidcnct;, ami in the acijuin^d it is at least prohahlc. 
 
 Affections of the Teeth. — .Vmonirst tin; evidences of" li(;reditary syphilis estalt- 
 lislicil l>y .Mr. 1 1 iiicliinsori tlitic are often pr(;sent in the permanent teeth iinportatit indi- 
 cations — .so important, indeed, that when jiresent the existence of hereditary syphilis 
 nniy with .some confidence he pronounce*]. They, however, exist oidy in exceptional 
 instances of hereditary syphilis. '' The centnil iijtjtir incisorn of the, mrond xrt arc the tpM 
 teeth;" these are usually short and narrow, with a hroad vertical notch in the edges, and 
 their corners rounded of}' (Fifr. 24). Horizontal 
 notches have nothinii; to do with syjihilis. 
 
 " Next in value to the malformation of the teeth," 
 writes Hutchinson, ''are the state of the patients 
 skin, the formation of hi.s nose, and the contour of 
 his forehead ; the skin is ahmjst always tliick, pasty, 
 and opa(iue. It also shows little pits and .scars, the 
 relics of a t'ormer erujition, and at the angles of tlie 
 mouth are radiating linear scars running out into the 
 elieeks. The bridge of the nose is almost always 
 hroader than usual, and low ; often it i.s remarkahly 
 sunk and expanded. The forehead is u.sually large 
 and protuberant in the regions of the frontal emi- 
 nences ; often there is a well-marked broad depression a little above the eyebrows. The 
 hair is usually dry and thin, and now and then the nails are broken and splitting into 
 layers. Interstitial keratitis is pathognomonic of inherited taint; and when coincident 
 with the syphilitic type of the teeth, the diagnosis is beyond a doubt." 
 
 In Fig. 2o every point in this description is illustrated except with reference to the 
 teeth, which were unusually good. 
 
 There is, however, good reason to believe that the children of .syphilitic parents mm/ 
 be affected by the poison in a way wdiich cannot be classed amongst any of the ordinary 
 forms of hereditary .syphilis as described. 
 
 Treat:vient. — To help the disappearance of the symptoms of hereditary syphilis 
 remedies are of great value, and in an infant showing evidence of any constitutional 
 power the prospects of a recovery are very good. When the child is being suckled, 
 whether the mother shows or not, I have for many years administered my remedies 
 through the mother, giving her from six to ten or sixteen grains of iodide of potassium 
 with quinine, or other tonic mixture, three times a day, half an hour before the child is 
 put to the breast ; and I have been much impressed with the excellent results of the 
 practice. When this process acts slowly, I give the child in addition a grain of gray 
 powder, with three or four grains of dried soda every night. 
 
 Before this I administered the gray powder and soda twice a day. or rubbed in about 
 ten grains of blue ointment every night on the soles of the child's feet, the abdomen, or 
 the axilla, but I much prefer the practice previously laid down. In young infants the 
 mercurial ointment may be put on the belly-band and thus rubbed in. As the snuffles 
 disappear the eruption and mucous tubercles fade, and the child begins to fatten and show 
 signs of progress. The treatment should be kept up for at least a month after the disap- 
 pearance of all sympt(jms. 
 
 The chlorate-of-potash treatment in some instances is doubtless attended with no 
 unfavorable result, strong infants with care and nursing battling through the disease, and 
 possibly eliminating it. But the weaker die when through more active measures they 
 might probably have been saved. Many apparently hopeless victims of hereditary syphilis 
 become under treatment .strong and healthy infants. 
 
 A child with hereditary syphilis should under no circumstances be suckled by any 
 other than the mother, for many a healthy wet-nurse has been inoculated by such a crim- 
 inal practice. When the mother cannot attend to the child, it should be brought up by 
 hand. 
 
 Serpiginous Ulceration. 
 
 This is a rare and somewhat singular form of venereal disease. It would seem to be 
 more closely connected with the local suppurating non syphilitic sore than the syphilitic, 
 
118 SERPIGINOUS ULCERATION. 
 
 for it is rarely if ever associated with constitutional syphilis. It usually appears in the 
 groin or thigh after a suppurating bubo the result of a suppurating non-syphilitic chancre, 
 the opening in the groin spreading in crcscentic patches of ulceration, one part of the sore 
 increasing while a second is healing; when the cicatrix forms, it presents a smooth glazed 
 appearance. This ulceration is most obstinate ; indeed, medicine appears to have little 
 or no influence on its progress, and it may so spread as to extend over the thighs and 
 lower part of the abdomen and continue at intervals for years, but wearing itself out at 
 last. I have seen one case in which it spread as high as the umbilicus and as low as the 
 knee. The disease at one time promises to heal, and then spreads without any clear 
 cau.se. It is often found, too. in apparently healthy subjects, and appears to follow some 
 course of its own that is not yet understood. It should be added that this sore is capable 
 of being inoculated u{i()n the .same subject, the point of inoculation taking on the same 
 action. 
 
 Treatment. — Mercury and iodide of potassium appear to have little or no influence 
 on this malady ; and if the view indicated by its cour.se be correct — that the disease is 
 not syphilitic — such a result is only what should be expected. The local treatment of 
 the sore seems to be the most important, and the best practice con.sists in the local applica- 
 tion of some strong caustic, such as nitric acid, carbolic acid, or the cautery, either gal- 
 vanic or actual, the patient being under the influence of .some anaesthetic. The local 
 application of iodoform or of resorcine in solution fifteen grains to the ounce of distilled 
 water should also be tried. Opium in moderate doses is of use, and so also are tonics ; 
 but in a general way the subjects of this affection are in good health. In several 
 instances I have found a sea-voyage of more value than any other treatment. In three 
 cases the .sore rapidly healed after the operation of .skin-grafting had been performed. 
 
 When maij a man icho has had syphilid marry? is a question which is often asked; 
 and to answer it with any degree of confidence is no easy task, assuming, as I do, that 
 the opinions laid down in these pages are correct — that a man who has once had syphilis 
 can never be pronounced free from its influence, and that the poison, once in the body, 
 may reveal its presence a quarter of a century after all external evidence of its existence 
 in the form of local di.sease has disappeared. 
 
 A man who has had .syphilis may, therefore, when he marries so aff"ect the ovum of 
 his wife as to cause its death or produce some evidence of disease or feebleness ; or if the 
 wife be healthy and he himself in good condition and free from evidence of the disease 
 at the time of conception, the offspring may escape altogether and appear as healthy as 
 that of other uninfected parents. Indeed, it would appear that if a man marries when in 
 robust or good health a year after all evidence of the disease has vanished, he may be 
 the father of a healthy child ; but if his general condition fails and he becomes cachectic, 
 the poison may reassert its influence and manifest its presence by some feeble, or even 
 disea.sed. condition of the subsequent offspring. 
 
 When the mother is affected with the disease, the same risks are run. 
 
 Every parent who has had syphilis runs the risk of giving birth to feeble or diseased 
 off"spring ; these risks are diminished by the general vigor of the parents, and increased 
 by dimini.shed power. No man should marry so long as the .slightest taint of the disease 
 manifests its presence ; but if in good health and free from all evidence of its presence 
 for a year, marriage may be contracted. To ask for a longer delay when such a step is 
 contemplated is unfair and unnecessary ; a risk must be run, and the lapse of a longer 
 period will not lessen it. 
 
 Inoculation and Syphilization. 
 
 Ricord was the first surgeon who employed inoculation f(ir diagnostic purposes in 
 venereal affections, and through his experiments he was led to the conclusion that " a 
 chancre at the period of progress is the only source of the syphilitic virus." As a test 
 of the simple suppurating sore it may now be employed, for a second sore can readily be 
 obtained by inoculating a patient from the pus of his own primary one. Indeed, this 
 process of auto-inoculation may be continued for a long series, but only with any effect 
 from the suppurating sore. In the .syphilitic sore no inoculation will take, and in the 
 inoculation of common pus no reaction occurs, or next to none, a simple pustule probablv 
 alone appearing. 
 
 From these clinical facts it would appear that common pus, the pus from a suppurat- 
 ing non-syphilitic sore, and that from a syphilitic one are very distinct, including under 
 the term '• .syphilitic "' any sore that is followed by .syphilis. 
 
VAccfxo-svi'nfijs. 119 
 
 Hv iiinculaiiitii. tlicrcturi', :i siiru'i'iiii may fairly (Irtrriiiiiie tlic fact as to tlic nature 
 of u chancre, and under Minie cirennistances tlie evidence <)l)lained \i\ tlie practice mav 
 be valnalde. 
 
 Syphilization nri<:iiiated in 1st J throii^di sunie exjierinients of M. Auzias Turenne 
 U|>iin aninial> In iunciilate them with syphilis, and in these lu; i'ound that after a number 
 of inoeuhitions they Iteeame ])r<iof aj;ainst tin- syphilitic virus. It was followed up l)v 
 M. Sperino of Turin and i-xtoiisively (jmjiloycd by J'rofcssors Moeck. I''aye. and Kidenkap 
 at Christiania, several hundred eases havintr been treated upon the principle, the object 
 beinir '" to cure syphilis.' 
 
 The theory, as expressed by l^ieek, " that tlio syphilitic virus by continued inocula- 
 tion annihilates itself," was practically carried out by inoculating a patient the .subject 
 of syjdiilis with fresh matter from any active venereal sore of any kind till the inocula- 
 tions failed to take. The inoculations were repeated every three or four days, first on 
 the body, then on the extremities. When inoculation is no loiifrer possible, " the treat- 
 ment is finished and the ]>atient has recovered bis health." 
 
 Boeck never iMMctised syphilization until the constitutional symptoms appeared; for, 
 says he, " I cannot double a malady already j)resent, so I am f|uite certain not to do harm 
 to the patient." Syphilization is not used with e((inil success aL-^aitist all cases of syphilis. 
 " In those that have not been treateil with mercury the ]irn<iress of syphilization will be 
 retrular; the .syphilitic pheiionieiia will vanish away, immunity will take place eventuall}', 
 and recovery be attained with certainty. In those who have taken mercury syphiliza- 
 tion is not so certainly useful ; it ouj^ht to be tried. It does often cure syjihilis entirely, 
 and at least does good." These are Boeck's conclusions, but I need hardly add they are 
 not those of British surseons. The practice has been mentioned and briefly described, 
 but not to be recommended. It has no single advantage, and is certainly loathsome. 
 "\Ve are decidedly of opinion, write Lane and Ga.scoyen in an able article on the subject, 
 that "syphilization is not a treatment which can be recommended for adoption. We con- 
 sider that, even if it could be admitted' to possess all the advantages claimed for it by its 
 advocates, its superiority over other modes of treatment, or in many instances over no 
 treatment at all, would not sufficiently compensate for its tediousness, its painfulness, and 
 the life-long marking which it entails upon the jnitient " (Med. Chir. Trans., vol. i.). 
 
 Vaccino-Syphilis. 
 
 That sypliilis may be transferred by means of vaccination is a fact which must be 
 honestly recognized, although where it has occurred it seems more than probable that 
 something more than the unmixed lymph of the genuine vaccine vesicle had been 
 employed, such as the blood of the vaccinfer ; for no one can now well dispute the po.ssi- 
 bility of inoculating syphilis when the blood of a syphilitic vaccinifer is transferred with 
 the vaccine matter to a non-syphilitic subject. "Whether it be possible to transfer syphi- 
 lis through unmixed vaccine lymph is still an open (|uestion. In this country such a 
 misfortune as a sypliilitic inoculation through vaccination has been happily rare, and only 
 in recent days has the attention of the great body of the profession l)een directed to the 
 subject. In Mr. Hutchinson's paper and in the report of the- Royal Med. and Chir. 
 Society for 1871 there will be ftumd sufficient material to prove the truth of wlrat has 
 been written, and in Dr. Seaton's Ihtndhodk on Vaccination and in Dr. Ballard's work all 
 that is known on the sul>ject mav l>e ascertained. 
 
 Instructions for Vaccinators. — Vaccinate only subjects who are in good 
 health. Ascertain that there is not any febrile state, nor any irritation of the bowels, 
 nor any unhealthy state of the skin, especially no chafing or eczema behind the ears or in 
 the groin or ehsewhere in folds of skin. Do not vaccinate in cases where there has been 
 recent exposure to the infection of measles or scarlatina, nor where erysipelas is prevailing. 
 
 Lymph is to be used according to the following instructions : 
 
 1. In proceeding to use a charged capillary tube, snip off its two ends; then from one 
 end of the tube blow the lymph through the opposite end upon the arm of one of the 
 infiints, over the place where the operation is to be performed, having had previou.sly two 
 or three other infants' arms prepared for vaccination. The lancet is then to be loaded 
 from the drop and inserted into the arms of the children prepared to receive it. but 
 enough is to be left upon the original arm to vaccinate that child. L^nless the tube be 
 very copiously charged, not more than two children are to be vaccinated from it. The 
 insertion should ])e made in four spots, as hereinafter directed. 
 
 2. In operating with a charged ivory point use no wafer to so/ten the li/mph. In this 
 
120 TUMORS. 
 
 mode of vaccinating the operator shouUl make a few scratches just fhrovgh the cuticle, 
 only sufficiently deep to tlomp the surface with hJood. These scratches should he mode 
 ■in four qjots. each covering a surface, at nearly one inch apart. The scratches may be 
 abrasions of the cuticle by fine parallel lines or by further cross-.scratch. The operation 
 may be performed on both arms when the surface available or the po.sition usually selected 
 is of limited extent. The operator should proceed with caution and take time. On no 
 account should incisions be made and the point of the ivory inserted into them, and it 
 should be borne in mind that the vaccine virus ought not to reach the subcutaneous cel- 
 lular tissue. The child should be kept under observation till the spots are perfectly 
 dry, and orders Lnven that the arms mmt not he v:ashed. 
 
 'i. Selection of Lymph. — Never either use or furnish lymph which has in it any, 
 even the slightest, admixture of blood. In storing lymph be careful to keep separate the 
 charges obtained from different subjects, and to affix to each set of charges the name, or 
 the number in your register, of the subject from whom the lymph was derived. 
 
 4. Never take lymph from cases of revaccination. Take lymph only from subjects 
 who are in good health and. as far as you can ascertain, of healthy parentage, preferring 
 children whose families are known to you and who have elder brothers or sisters of 
 undoubted healthiness. Always carefully examine the subject as to any existing skin 
 disease, and especially as to any signs of hereditary syphilis. Take lymph only from 
 well-characterized, uninjured vesicles. Take it (as may be done in allregular ca.ses on 
 the day week after vaccination) at the stage when the vesicles are fully formed and 
 plump, but when there is no perceptible commencement of areola. Open the vesicles 
 with scrupulous care, to avoid drawing blood. Take no lymph which as it issues from 
 the ve-sicle is not perfectly clear and tran.sparent or is at all thin or watery. Do not, 
 under ordinary circumstances, take more lymph from a vesicle than will suffice for the 
 immediate vaccination of five subjects, or for the charging of seven ivory points, or for 
 the filling of three capillary tubes ; and from larger or smaller vesicles take only in like 
 proportion to their size. Never squeeze or drain any vesicle. Be careful never to tran.s- 
 fer blood from the subject you vaccinate to the subject from whom you take lymph. 
 
 5. Keep in good condition the lancets or other instruments which you use for vacci- 
 nating, and do not u.se them for other surgical operations. When you vaccinate, have 
 water and a napkin at your side, with which invariably cleanse your instrument after one 
 operation before proceeding to another. 
 
 With these precautions vaccination may be regarded as a perfectly safe operation ; 
 without them the risks of syphilitic inoculation, although slight, exist.' They tell, how- 
 ever, but little against the enormous advantages of vaccination. 
 
 Lee, Holmeii's System, third edition, vol. ili.— Marston, Med-Chir. Trans:., vols. xlv.. xlvi. — Laxc 
 AND Gascoyex, Med.-Chir. Tram., vol. 1.— Bf-MSTEAD, Edit, of ddlerier, Pliiladelphia. 1868.— Por- 
 ter, Dublin Quart., 1857. — Lanx-ereaux, Oji Syphilid, Xew Svd. Soc. — Wallace, On Venereal. — 
 Carmichael. On Venereal. — HuTcmxsox, Syphilitic Dliea.^es aj Eye and Teeth. — Report of Committee 
 an Venereal Diseases, 1868.— TuREXKE, Academie des Sciences, 1850.— Boeck, Edin. Med. Jour., 
 lSo8.— Dublin Journal, 1857. 
 
 CHAPTER III. 
 
 TUMORS. 
 
 I.\ the prepathological period, before the minute anatomy of healthy and diseased 
 tissues was understood and the microscope had rendered intelligible subjects that still 
 rested in darkness, tumor.^ had from neces.sity been .studied simply in their clinical aspects, 
 and surgeons, in their attempts to classify them, were guided .solely by the mo.st obvious 
 characteristics of the growths and by their real or fancied resemblance to the natural 
 tissues of the body. As time advanced more ambitious attempts at classification were 
 made, and the most important work was that of Ahernethy. who at the beginning of this 
 century puVjlished his Atttnipt to form a Classification of Tumors according to their Ana- 
 tomical Structures. In that able production he asserted " that the structure of a tumor 
 is sometimes like that of the part near which it grows, and sometimes unlike ; that in 
 many cases the nature of the tumor depends on its own action and organization and 
 merely receives nourishment from the surrounding parts.'" He thus gave expression to 
 
patlii)loj^ic!il tnitlis r)f tlio <i;reate.st iniportaiKM! ami that still remain iiironlrovcrtiliji'. 'I'lio 
 next roal advanco was duo to Hicliat, who rcco^^nizcd thti essential ditterence hetweeii 
 tumors and the parasitic nature of the eysticereus and eehinoeoeeus, althoujrh by his fol- 
 lowers this parasitic notion was carricMl out far too fully, for they looked upon caneer as 
 the prixluet of a parasitic t;;rowlh ol' ciitdZMu. It was left, however, to Ijohstein of Stras- 
 bourg; to emliody Hieliats idea ami to j^ive it full expression, which he «lid hy namiii;; 
 tho.se tumors /iniiiniip/ns/ii- which W(>re similar in structure to the natural eonstitucMits of 
 the body, and tho.so /ted roj)/iisfic which were composed id" products whi(di ilifler frr)m the 
 normal tissues. Since that time countless workers havt; becMi examining tumors and 
 attem|itinii- to classify them, one of the most prominent bein<^ Lebert, and to him must 
 fairly l>e attributetl the credit of assij;iiin^ specific elements to specific tumors, eacdi tumor 
 havinir, in his opinion, a definite structure ; cancer was to be known by the caudate fusi- 
 form cells that even now are looked upon by s(uno as typical of the di.sease. This notion 
 of specific elements was very feasible. f(jr it simplified knowled<re and induced men to 
 think they had a ready means of deciding upon the nature of any new growth ; and had 
 it not been for \'irchow, it is probable the theory would have long held its ground. In 
 this learned pathologist, however, it found an opjionent of consun»mate power; and, as 
 his reasons for disl)elioving it are the groundwork of his great book on (Jillidar Palholoijij 
 and TiiDiors, it is well to have them in his own words : 
 
 " In (Jermany the doctrine of specific elements has from the first made few j)roselytes, 
 and now it is entirely abandoned. From the commencement of my career I have been 
 compelled to combat this error, ami I believe that at the present moment we are in a 
 position to demonstrate in every direction that there do not exist in tumors true specific 
 elements which have no analogy with the normal tissues. It is enough for that to 
 remember that the tumor, however parasitic it may appear to be, is <i/wa>/s a part of the 
 hod !i from idilch it spriinj^, and that it is not develoj)ed in an isolated manner at the 
 expense of some juice, at some one place in the body, by the inherent force of this pro- 
 ductive juice. To admit such a mode of development dc voro was possible at a time 
 when it was also believed that entozoa were spontaneously developed in the body at the 
 expense of a liquid or an excretion, by equivocal generation, when no idea had been as 
 yet formed as to how a cy.sticercus arrived in the abdomen and there was able to develop 
 itself and grow. There was no other opinion which medical men could then form save 
 that entozoa sprung from aninuil substances, either from the tissues themselves or from 
 the intestinal mucus (^mbxrnt). In the present day, when it is known that entozoa 
 always penetrate into the body from without — by a way often, it is true, extraordinary, 
 yet always natural — this analogy can no longer be invoked. This is still more evident 
 since we have come to know that in a free exudation there is no new element produced 
 — that, furthermore, the elements of the body itself have a legitimate origin from father 
 and mother (or, to speak more correctly, from father or from n)other, for it is a case of 
 parthenogenesis) ; so that we must completely abandon the idea that a tumor can develop 
 itself in the body as an independent being. It is a part of the bodij ; it is not merely 
 contiguous to it, but proceeds from it and is subject to its laws. The laws of the body 
 govern also the tumor. This is the reason why it is not an object of natural history that 
 one can regard as foreign from the elements of the body ; it is, on the contrary, to be 
 
 looked upon as embraced within its limits Hair may make its appearance and 
 
 grow at a place where we do not expect to meet with hair, but no one will fancy or 
 believe that feathers will grow in the human body. As a matter of fact, there are 
 tumors in man which contain hair, and in cutting up geese tumors are sometimes found 
 containing feathers ; but if ever a man engendered a tumor with feathers or a g(jose one 
 with hair, this would be a production sui. generis^ because the thing produced would devi- 
 ate from the type inherent to the individual. 
 
 " The type which in (je)iir(d i/overns the devlopnirnt and formation of the organism gov- 
 erns equally the development and formation of its tumors. 
 
 " There does not exist a new, different, independent type. 
 
 " What is established by logic in this matter results also from the direct observations 
 of tumors themselves. This is why I deny that there is any heterology in the sen.se in 
 which it has been maintained since Bichat's time, or such as was suppo.sed even before 
 then — that is to say, that a tumor could develop it.self and exist in the body in accord- 
 ance with some quite new plan, some new law. I go farther: each .species of tumor, 
 whatever it may be, answers in its important parts to the elements of the body the type 
 of which is known, and the capital difference amongst divers tumors resides in this — that 
 tissues normal in themselves appear under tlie form of a tumor, sometimes in regions 
 
122 TUMORS. 
 
 where this tissue normally exists, sometimes in places where it does not exist in the 
 normal state of things. In the first case I speak of it as homology ; in the second, 
 as hetfroloiiij. 
 
 '' Wherever a normal tissue appears at a point which already contains some similar 
 tissue, then as a consecfuence the new tissue is identical with the old. so that the type of 
 the new production answers to the type of the pre-existing tissue ; in this case the new 
 tissue, the tumor, is homologous. When, on the contrary, the new type does not corre- 
 spond with the old one, when it deviates from the pre-existing type or that which is the 
 original and normal one of the region, then there is heterology. But this latter has like- 
 wise its analogue in the body, only in another part of the body from that in which the 
 tumor is situated. 
 
 "We cannot, in my opinion, distinguish tumors according to the tissues in such a 
 fashion that tumors containing certain tissues are to be regarded as homoeoplastic, whilst 
 those containing certain others are to be set down as heteroplastic ; cjuite the contrary, 
 the same kuid of tumor may he, under certain circumstances, Jiomologons, and under other 
 circumstances heterohgous^. The same sort of tumor may at one time appear at a point 
 where it is merely the expression of an excessive development of the tissue normally 
 exi.sting at this point, at another time at a place where this tissue is not in existence and 
 where its development is abnormal and strictly pathological Let us take an example. 
 A tumor may be formed of cartilage. The cartilaginous tumor is homologous, not 
 because it is formed of cartilage, but only if it springs from cartilage, if in this place 
 there is cartilage already. Thus, a costal cartilage may be the point of origin of an 
 enormous cartilaginous tumor ; this is homology. But it is also possible for a cartilagi- 
 nous tumor to be developed in the testis, which contains no cartilage, where this tissue 
 should not be met with : here the same product constitutes an heterology." 
 
 " Homology " and " heterology " have, therefore, very different meanings as used by 
 Yirchow and other writers. In Virchow's language a tumor is hornologous when it cor- 
 responds in structure with the tissue in v:hich it grows, and heterologous when it deviates 
 from that structure. A tumor that is homologous in one position may be heterologous 
 in another. On the other hand, in the French and other schools a tumor is homeAogous 
 when built up of elements naturally existing in some tissue of the body, heterrjlogous 
 when composed of elements that deviate from the natural structures, these definitions 
 having nothing whatever to do with the position of the tumor. In Virchow's language 
 the terms are relative ; in that of other pathologists they have a definite clinical meaning 
 of no slight importance, for homology means innocence and heterology malignancy in a 
 tumor. Yirchow, however, admits that his heterologous tumors are suspicious, although 
 every heterologous tumor is not of a malignant nature. " There are a great many such 
 tumors borne without any ill consecjuences, and whose properties are quite similar to 
 those of which the nature is benign. Malignancy follows a certain scale among heterol- 
 ogous tumors, from species to species ; and we are able to show how it is manifested 
 more and more strongly, for the most part following two directions. In the first place, 
 heterology is distinguished according to the degree which it attains. The tissues of con- 
 nective substance have a much nearer relationship existing among themselves than they 
 have with epithelial tissues or with the specific animal tis.sues. When, therefore, a car- 
 tilaginous or bony tumor is developed in connective tissue, or even a mucous tumor in 
 adipose tissue, that is not nearly so heterologous as when an epidermoid tumor is formed 
 in connective tissue or a tumor of cylindrical epithelium in a lymphatic gland. A carti- 
 laginous tumor which is developed in connective tissue or in the tissue of bone is indeed 
 heterologous, but it is not so to the same degree as an epithelial tumor or a muscular 
 tumor would be in the same place. But a still more important circumstance is this — 
 that tumors engender certain liquid substances which we speak of under the name of 
 'juice.' This is the humor or juice of the tumor, of which much has been said." 
 
 '• This parenchymatous juice is sometimes related to the cells, sometimes to the inter- 
 cellular substance ; and, accordingly, it appears under the form of fluid, either intracellu- 
 lar or intercellular, contained in the cells or interposed among them in a liquid state like 
 serosity. Whenever a tumor contains much juice, it gives evidence of more troublesome 
 qualities and it possesses to a high degree the property of infection. A dry tumor of 
 the epidermoid kind is by far less dangerous than a moist one ; a soft cancer is much 
 more to be dreaded than a hard one. 
 
 " The more a tumor is poor in vessels, the less it will extend its infecting action 
 beyond the neighboring parts ; but the more it is rich in blood vessels and lymphatics, 
 the more it is traversed by the blood and lymph, the more the parenchymatous juices 
 
rcMons. J 23 
 
 arc in t'diitact witli tln' lilinnl. sd iinidi the iiiun,' is the iiifcctinii likely t<i liccoinc 
 gciiorai. 
 
 "I give llins an iiilcr|ir('taliiiii nf Tacts, Imt it is in accnrd with (iliscrvatinn. 'I'lie 
 dciireo of cnutaLiiousnfss nf timiurs increases in |)r(i|nirti(in as tliey hecnine more rich in 
 vessels, and that ahtngsich^ the vessels tiiey contain an alMindance of li(|i)id materials. 
 Every soft succulent tumor is sus|)icious, and that just in |iro|)ortion as it contains many 
 vessels and eidis. The more the juice is intercellular and in contact with the vascular 
 stronni td' connective tissue, the nnuv the mali;_'nant properties which are manifested l»y 
 an ever-new t'xcitation t(t the progressive jyroduelion oi' the tumor. 
 
 " I ought, iiuleed, to speak more at length as to the nature of these juices, hut, in 
 trutli. I do not know wliat to say upon the subject. The results which chemists have 
 arrived at on this suliject have no kind of value. Here the field is o|)en to in(|uirir)g and 
 progressive sjiirits, and I hope that hereafter researches will he undertaken in this direc- 
 t'utu, and that they may be crowned with success." 
 
 But, as this is not a work on pathology, I cannot allow myself to enter further into 
 tliese speculations, and must refer the reader to Virchow's masterly work on Celfuldr 
 P(if/i(tfof/i/ (iiid fill Tumors for a fuller elucidation of the .subject. 
 
 In the .se(|uel I shall regard tumors in their clinical aspect alone, giving their anatomi- 
 cal characters only so far as they illustrate the practical aspects of the subject. All 
 speculative ])athologieal doctrines will be set aside as tending to confuse rather than to 
 elucidate clinical phenomena until the day wlieii pathological science shall have so far 
 advanced as to allow of an anatomical classification of tumors being made that will fully 
 dovetail in with that founded on clinical observation. The microscopical anatomv of 
 tumiu's has been furnished by the pen of my friend and colleague Dr. Mo.xon. 
 
 I ]iropose to lay down here some few pathological points which have an important 
 clinical bearing, and which tend to illustrate the subject of the diagnosis of tumors. 
 
 A tumor mai/ be defined to he a nciv growth, eijstic or solid, uiJUtrntliicf. separate from 
 or coiduiuonx with normal tisKites. It is an addition to natnral jtarfs, and it manifests its 
 independent existence hy its disposition to grow irrespective of the part in ichich it is j^laced. 
 
 All tumors, with the exception of the hj/datid, are vinde up of one or viore of the natural 
 elementary tissues (f the body in a rudimental or inorhid state, and in no single example has 
 any extraneous or neio element ever been detected. 
 
 A mere increase or overgrowth of natural parts is a hypertrophy. Just as the natu- 
 ral body is built up of cells and fibres in one or other of their different forms, so tumors 
 are made up of like elements, although, it may be, of unecjual proportions. Tumors, 
 like the natural tissues, differ, therefore, anatomically according to the nature of the ele- 
 mentary structure of which they are composed ; and this again appears to be materially 
 determined by the part of the body in which they are developed. 
 
 From this, therefore, a second leading principle may be fairly deduced — viz., tliat all 
 tumors partake of the nature of the part in ivhich they are developed <uid are more or less 
 made up of the elements which natur(tlly enter info its formation. 
 
 Hence a tumor developed in the stroma of a fibrous structure will probably be fibrous; 
 if connected with bone, more or less osseous ; and if situated in a gland, it will in all 
 probability partake of the gland structure. But new growths never assume the compli- 
 cated structure of a fully-developed gland: they only in a degree simulate it. Wilks well 
 expresses it when he says that " the great difference between physiological and pathologi- 
 cal formations appears to be that nearly all new growths are of the simplest composition, 
 not putting on the form of the complex organs near which they may be placed, but con- 
 sisting principally of cells and fibres." The cells and nuclei of a part, instead of develop- 
 ing into normal tissues, err in their course, multiplying and possibly growing, and, 
 '• whilst conforming generally with the part in which they are placed in minute structure 
 and composition, yet they more and more widely deviate I'rom it in shape and size " (Paget). 
 
 The practical bearing of these pathological principles is by no means unimportant, 
 because to the surgeon who has once recognized the true position of a tumor there is a 
 certain amount of probability as to its nature which will at once suggest itself to his 
 mind. If the tumor is situated in the skin or subcutaneous tissue, a strong probability 
 exists that it will be composed of some one or other of the structures of the tissue ; thus 
 it may be the sebaceous tumor, which is rarely found in any other position, or the fatty, 
 for these two materials enter largely into cutaneous structures: or it may be one of the 
 fibrous or fibro-cellular nature, fibre-tissue existing abundantly also in these parts. Should 
 the tumor be located between the muscles of a part, the tumor will proV»ably be composed 
 of connective-tissue elements in the form of a sarcoma or myxoma. Should bone, again, 
 
124 TUMORS. 
 
 be the seat of the disease, some one of the elements of bone will to a certainty enter 
 into its formation, the probability of its being an enchondroma, an osseous, or a myeloid 
 tumor naturally presenting itself to the mind. And, lastly, should a tumor be present in 
 a gland, such as the breast or prostate, the probability of its being an adenoid or glandu- 
 lar tumor cannot be overlooked ; for pathologi.sts now all recognize the fact of the close 
 resemblance of tumors so situated to the natural gland structure. Even in malignant 
 tumors, if modern recorders are to be relied upon, the same principle holds good; for car- 
 cinoma is now generally recognized to be an epithelial growth, and only occurs primarily 
 where true epithelium already exists. Secondary growths can only be produced by the 
 direct propagation of the epithelial cells, which may be transported from their primary 
 seat either through the lymph vessels or as embola are carried through the blood ves.sels 
 to a suitable place, where they develop like the germs of entozoa. 
 
 Tumors are eiflLcr simple or cancerous, innoceut or mjjtigniint. the simple or innocent 
 approaching in their nature to the more completehj devehiped natural structures of the hoily, 
 even to the perfect gland alar, and the malignant or cancerous simulating the more elementary 
 or embryonic. As the normal tissues were formed from, a simple cell, and in tJteir higher 
 grades are but a development of that cell or those cells, so the sarcomatous and cancerous ele- 
 ment c(msists in a persistence of the simple cell type or that of the undeveloped embryonic 
 nucleus. The group of cases called " 7'ecurreut" must be placed in an intei-med iate jiosition ; 
 for, while in their earlier stages they tend to build up embryonic tissue, this subsequently 
 becomes lost in cell proliferation. 
 
 In proportion, therefore, to the amount of the embryonic cell element in a tumor its 
 cancerous tendency may be determined ; and the greater the proportion of the fibrous or 
 well-developed structure, the greater the probability of its nature being innocent or 
 simple. The more a tumor simulates the natural structure of a tissue or gland, the 
 greater the probability of its being innocent ; the more a tumor simulates the undevel- 
 oped cell structure, the greater the certainty of its being cancerous ; malignancy appear- 
 ing to diminish in proportion as the cells become more fully developed. As. moreover, 
 it is in the nucleus of a cell that the active principle of its growth is to be sought, so it 
 is clear that the more the tumor is composed of nuclei, the more malignant is its nature ; 
 and the better the formation of the cell wall, the less malignant is the growth. 
 
 The nearer a new growth approaches, both in its elements and in the ai'rangements 
 of its elements or structure, to the complex organs of the body, the greater are the prob- 
 abilities of its being innocent, new growths under no circumstances erjualling the perfec- 
 tion of a true gland tissue. 
 
 Simple tumors separate tissues in their groicth, but never infiltrate ; cancerous, as a rule, 
 infiltrate and rarely separate. No more important practical point than the above can be 
 adduced to aid the surgeon in his diagnosis of a tumor. A simple or innocent tumor, 
 however long it may be in growing or large a size it may attain, will never do more than 
 separate the parts between and beneath which it may be developed. The bones may be 
 absorbed by its pressure, but they will never be infiltrated, and the skin may be so 
 stretched and attenuated by its distension as to ulcerate or burst, but it can never be 
 infiltrated with the elements of the tumor. This fact is well exemplified by a close 
 examination of the margin of a cutaneous opening the result of overdistension, for it 
 will appear as if cleanly cut, or rather punched, at its edges, and never thickened or dis- 
 eased. An intra-cystic growth may project from it as a fungus and put on many of 
 the appearances of a cancerous tumor, yet the margin of the opening will be free, and 
 not infiltrated. In the cystic tumors of the breast this clinical fact is easily perceiv- 
 able. 
 
 Simple tumors, by expanding parts, cause the cellular tissue around to become con- 
 densed and to form a capsule'; consequently, most of the innocent tumors are encap.suled 
 more or less completely. With the majority of cancerous tumors, however, a very differ- 
 ent condition has to be described ; for a cancer has the peculiar property of freely infil- 
 trating all the tissues upon which it presses, at its base, round its borders, and upon its 
 cutaneous aspect. As the tumor approaches the surface the integument first appears to 
 be drawn down to it, and afterward seems as though glued to its surface. At a later 
 stage the skin becomes infiltrated with cancerous elements, feeling to the finger firm, 
 fibrous, or tuberculated ; and when ulceration has commenced, the edges of the .skin 
 are palpably indurated, thickened, and infiltrated with cancerous products. The con- 
 trast between the.se different conditions of integument in the two classes of tumors is 
 most marked and very important, forming a very valuable means of diagnosis in the 
 extreme stage of simple or malignant tumors. 
 
TUMORS. llio 
 
 Diagnosis of Simple and Cancerous Tumors.— Simpfr <>,■ !,n,ur,„t hinnns 
 
 affovl lln jxilitnt sol'li/ //iminj/i tin ir load iiijlin mi . Tlni^ i/k/io hi/ lh< ir oicii iiihcn nt jn'Of'- 
 trtiis, imsjircfire i>f lliv (jnnvlh of l}ie parts in which tht// art- jtlitcctl, h<ive little (lispositiuit 
 tn sft/t'ii <lfiuii nr iilct r<it<\, mid no teiiilcnri/ tu iiiidtijtliiiitiini in ot/ur tissnis or to iiivolv tin; 
 (disorhcnts with irhirh thri/ iirr coiuiictnl. Molii/nuiit tumors not oiili/ offcct tin- jxtticnt 
 throiit/h thfir lonil tiijlnnnr^ hut hiirc a initrvclloiis trndiiiri/ to innltijiliiittion in nni/ port of 
 tht hod I/. Tliroiiijli thi li/infdi<itir si/stcin thiy involve tlir f/ltinds of tin: port itith vhich tlnif 
 are coiincctrd^ irhilc throinjh the vasnilur si/stt m tiny sprrnd to otlur jnirtx. Tin ly an prone, 
 alxo, to dei/ein rate and iilerrate. 
 
 Wlifii simple tuinors ari' iimltiiilc. they invariably arc found in the sanio tissue ; when 
 maliuiiaiit tumors arc multipK', they are mostly found in different tissues. 'J'lius, 
 amonjist the innoeent i^rowths multiple fatty tumors of tin; skin are not uncommon ; mul- 
 tiple fibromata of the uterus are often seen ; multiple glandular tumors of the breast are 
 met with, inv(dving one or both organs; and there are records of multiple fibroplastic or 
 myxomatous tumors. It is not seldom that multiple enchondromatous tumors and exos- 
 toses are seen, but in all these instances the tumors occupy one tissue. 
 
 In the malignant and cancerous multiple tumors no such description can be given, 
 for they spread in ever-widening circles from the parent tumor, the cell elements spread- 
 ing locally in connective tissue as freely as the floating blood cells move through the 
 walls of the blood passages, as a colloid is penetrated by a crystalloid, wandering about 
 in what are called solid tissues. They follow the course of the lymphatics and affect the 
 glands, and at times seem to follow the course of the venous circulation. Tliey recur by 
 continuity of tissue as from constitutional reproduction, and Mr. Moore, in his work on 
 Rodent Cancer, has referred to a case of Mr. de Morgan's in which from a cancerous 
 tumor within the skull some detached fragments which had sunk in the fluid of the 
 arachnoid adhered to the spinal cord and grew. They spare no ti.ssue or organ, but 
 invade one and all, without order or law, in their destructive objectless growth. 
 
 Recurrent or Intermediate Tumors. — All tumors cannot, however, be 
 
 divided into the innocent and the nudignant, for there are some of an intermediate kind 
 which in structure approach the innocent, but in habit the cancerous, as they recur after 
 removal. They have consequently been called recurrent tumors; but, as the habit of 
 recurrence is not the only point in which they approach the cancerous tumors, it is bet- 
 ter, perhaps, to term them xenii-malir/nduf. 
 
 I proposi'. tlicrefon'. to describe tumors under the following headings: 
 
 A. Innocent Tumors, or those composed of the normal adult tissues. This .sec- 
 tion includes Lipoma, Fibroma, Chondroma, Osteoma, Adenoma, Papilloma, Neuroma, 
 Angioma, and Lymphoma. 
 
 B. Semi-Malignant, or those composed of embryonic connective tissues, includ- 
 ing the Sarcoma and Myxoma. They form a class of tumors which in a measure belong 
 to the one that precedes it as well as to the one that follows it, since it includes cases, 
 such as some of the myxoniata and sarcomata, that are very little malignant, and like- 
 wise some sarcomata that are very much so. Nor is that all, for it occasionally happens 
 that some innoeent tumors become malignant, and lymphomas which are classed as inno- 
 cent are sometimes quite the reverse. 
 
 C. Malignant, or those compo.sed for the most part of epithelial structures, includ- 
 ing Epitlielial and Hard and Soft Colloid Cancers and Rodent Ulcers. 
 
 I>- Granulation Tumors, or those composed of granulation tissue, including 
 Follicular. Keloid, (.iuuiuiala, etc. 
 
 E. Cysts. 
 
 A. Innocent Tumors, 
 
 Or those compo.sed of the normal adult tissue, vary with the tissues. They are innocent 
 or benignant in that they do not, like cancers, infiltrate the parts in which they grow, but 
 rather separate them, and are a source of trouble more from mechanical than other 
 causes. When they interfere with life, they do so generally from pressure on important 
 parts. They may stretch skin even to its rupture, but the margin of the skin-opening 
 will be uninvolved in disease. In cystic breast tumors this is well seen. 
 
 1. Lipomata, Fatty Tumors, otherwise called " steatomata," are very common. 
 They are fmiiiil wherever fat exists naturally in the body; and as this nuiterial is more 
 especially deposited in the integument, it is in and beneath this that fatty tumors are 
 most frequently met with. They occur at all periods of life from infancy to old age. and 
 are even eontrenital. Thev attack the male .sex as well as the female, but tliev are three 
 
J 26 
 
 TUMORS. 
 
 Fattv Tumor of Thiriy-Seven Years' Growth on Arm of AVoman 
 set. C9. 
 
 times as common in the latter. They are generally .single, but occasionally multiple. 
 I have seen a ca.se in which the whole integument was studded with them, and under 
 these circumstances they are usually small. It is impossible to a.ssign any valid cause 
 for their development, hereditary and accidental influences having doubtful effects. 
 They are troublesome only from their position and the deformity they occasion (Fig. 26), 
 
 and are at times the seat of pain, 
 Fig. 26. though such a .symptom must be 
 
 looked upon as an accident due to 
 their position. 
 
 The.se tumors are. as a rule. " en- 
 capsuled." although in rare cases 
 they ai'e " continuous " or " diffused." 
 This latter variety differs only from 
 the former in that they are made up 
 of smaller globules of fat and are 
 more dense, while they are more com- 
 mon about the nape of the neck and 
 face than the encapsuled variety 
 (Fig. 27) ; the large double chin is an 
 example of the continuous lipoma, 
 and congenital lipomata are generally 
 of this nature. The encysted lipo- 
 mata are most common on the 
 .shoulder, thigh, and trunk ; some are 
 deep-seated, as between the muscles 
 of the limbs or within the abdomen or scrotum. Fatty tuniors at times shift their posi- 
 tion — that is. they drop downward ; .'^everal such ca.ses have passed under my notice in 
 which the tumor has travelled some distance. Such an occurrence is peculiar to this 
 form of tumor and suffices to fix its nature. 
 
 The DiAGNO.sis is not usually difficult. If subcutaneous, these tumors are '' lobu- 
 that is. are defined by a distinct boundary, their cy.st-wall being 
 formed by the condensed fibro-cellular tissue in which they 
 are developed. To the hand of the examiner the tumor will 
 feel more or le.ss firm and made up of lobes ; when frozen by 
 the application of ice, it becomes harder. To the eye the 
 tumor will, on raising it from its ba.se and distending the 
 skin, appear dimpled, and in parts the skin will be quite 
 drawn inward toward the new growth. If the tumor be 
 deep, a doubt may be felt ; but practically the question is 
 not of great moment, for it only refers to the nature of a 
 .simple growth, and not to its treatment. 
 
 Treat.ment. — When no neces.sity exists for their 
 removal, tumors .should be left alone. When large and 
 unsightly, cumbersome or growing, they should be removed 
 by excision or enucleation. A single incision through the 
 centre of the growth is the Vjcst and most expeditious 
 method for turning the cyst out of its bed, which can be done readily by the finger. 
 Where the growth is pendulous the whole .should be cut off. leaving enough skin to cover 
 the wound. After the operation the edges of the wound .should be brought together by* 
 sutures and strapping and supported by steady pressure : rapid union usualh- follows. 
 Fatty tumors, when removed, very rarely return. Curling has recorded a ca-^e, how- 
 ever, in which a recurrence. took place, but .so much connective tissue was present in 
 that example as almost to remove it from the class of lipoma (Path. Tram., vol. xviii., 
 1867). I have also removed from the buttock of a lady a lipoma of two years' growth 
 the size of a fist, having removed from the same part a like tumor twelve years previ- 
 ously. 
 
 The " continuous " fatty tumor should never be removed unless under very urgent 
 circumstances. The operation is comparativelv formidable, so much dissection being 
 required. In oliiMren. however, the.se tumors mav be dealt with. 
 
 2. Fibromata are tumors composed of " hard " or •• soft " fibrous tissue, the .soft 
 being composed of masses of " connective " and the hard of " fiVjrous " or closely-packed 
 connective-tissue elements. The " soft "' kind are found as outirrowths from the subcu- 
 
 lated " and '■ encvsted 
 
 Fig. 
 
 Ditfused Lipoma of Neck. 
 
taneous tissuo, ami frer|uently in tl»c f'fiiialc external f^iMiihil orfjans ; they are known as 
 " fibro-celliilar <;rn\vths." Tliey are nu-t witli also in tin- lower extremities under tlie 
 form ot" " molusciim tihrosum " (rn/e Kij;. liS). 
 
 Some eontain much fat, and thus a|)|)roa('h tlie li|Miniata. These tumors are mostly 
 outgrowths, and appear as the softer polypi and eulaneous pendulous tumors. The 
 polypi of the nose are the hest specimens of the looser kind of 
 irrowths, as in eonsisteiiee they vary from a watery pellnci<l pen- ^■'"- -'^• 
 
 dulous out<rrowth to a firm, more compact, and fihrous tissue. 
 They are, however, always ectvered with mucous mem))rane with 
 its ciliated epithelium. Tin; softer tumors ol" the antrum are also 
 of the saint' nature, as are the mucous polypi of the uterus, blad- 
 der, and ri'ctum. in the rectum the tumor is intimately mixed 
 with the irlandular elements (jf the pail. .Vmonj^st the outtrrowths 
 of the intcL^ument those of the mah' and female tjenital orpins are 
 the commonest. The tropical elephantiasis scroti is ol'this elass. 
 The pedunculated outgrowths of the skin are also of the sam<' 
 kind. 
 
 Deep-seated tumors of this nature are very rare. They do 
 oceur, however, in the connective tissue of the body, the inter- 
 mu.seular spaces of the thiuh and arm being the commonest .seat. 
 They nri' (t/irai/s surroiaideil by a atpsidr^ and when not confined 
 by unyielding parts are more or less ovoid ; at times they are 
 lobed. They possess a smooth outline as well as an elastic feel ; <'»\«, of Moluscum Fibrosum. 
 
 f. ,, * ' f.. , . 1 1 1 • ., • , 1' a ■ 1 rpu '-^''■- I>avies-Colley's ease.) 
 
 some ot the softer kinds, mdeetl, give tlie idea of tfiud. Ihcy 
 
 are tumors of adult life, being rarely met with in children. They increase in size with 
 variable rapidity, the amount of fluid they contain materially affecting this feature. The 
 pendulous outgrowths, mucous or cutaneous, at times swell out and at others contract, 
 while those of the skin appear shrivelled and loosely encapsuled. Those of the genital 
 organs may attain a very large size, some which are on record having weighed as much 
 as forty pounds. At times these tumors inflame, slough, or ulcerate in an indolent, but 
 in no way a typical, manner. 
 
 The "firmer" kind are met with in many shapes. They are always solid, and mostly 
 encapsuled. When, as in the uterus, mixed with the non-striped mu.scular fibre, the 
 growth is known as ^- frbro-mnsrultir" or as a ^'■myomtt'" (Virchow's term). When as.so- 
 ciated with cysts, it is called ^' Jibro-cijatic-/' and when with calcareous matter, '• Jibro- 
 cnlcanousy These varieties are found chiefly in the uterus. Fibrous outgrowths, or 
 pnb/pi are commonly met with in the uterus, nose, pharynx, and rectum. They have 
 been found in the intestine and other parts. Fibrous tumors are found likewise in the 
 uterus and prostate, and oramonnlhj in connection with the bones and periosteum, in the 
 latter as an epulis. In tho.se about the bones the elements of bone or cartilage are usu- 
 ally found. 
 
 The fibrous outgrowths have no capsule, but are continuous with the 
 
 tissue from which they spring, and are made up of fibre tissue more or less closely packed 
 and arranged in bundles or in concentric circles ; they are but feebly va.scular. Those 
 of the uterus are the most typical (Fig. 20). 
 
 Fibrous tumors are always encapsuled and have a tendency to assume 
 an ovoid or globular form when not confined ; but when eompres.sed or bound down by 
 surrounding ]»arts, they take an irregular lobular .shape. In structure they are very simi- 
 'lar to the outgrowths. 
 
 Fibrous tumors are firm, and occasionally most unyielding. They are slow in their 
 increase and give pain only from their po.sition. When bound down by a dense fa.scia or 
 situated near a nerve, they cau.se much distress. They only interfere w-ith life or comfort 
 mechanically. They are usually single, except in the uterus and when in connection 
 with the nerves. As they come under the notice of the surgeon, those connected with 
 the periosteum or bones, called jvrlostcal sorconui. are the most common, and of all the 
 bones the jaws are the most frequently affected by them. They are chiefly periosteal 
 and appear as outgrowths {vuk chapter on '• Tumors of Bone "). They are found in the 
 pharynx, on the lobule of the ear. and on the nerves as " neuromata." 
 
 The subcutaneous fibrous tumor is a hard movable tumor beneath the skin. 
 It is usually small ; but when of a less dense kind and more nearly approaching the fibro- 
 cellular tumor, it may attain a large size. Under these circumstances the skin will 
 become part of the tumor: it will then often ulcerate and allow the growth to protrude 
 
128 
 
 TUMORS. 
 
 Fig. 29. 
 
 through the opening and ulcerate, or even slough, and thus these tumors sometimes bleed 
 freely. At times fibrous tumors seem to grow from the deep fascia. 
 
 Treatment op Fibrous Tumors. — Excision is the only treatment which offers any 
 prospect of success ; and when these fibrous tumors are removed, a recurrence is rarely 
 
 met with. The fibro-niuseular, fibro-cystic, and fibro- 
 calcareous tumors are mostly uterine. 
 
 3. Chondromata, or cartilaginous tu- 
 mors, iire most commonly met with in connection 
 with bone, but they are found in the parotid or sub- 
 maxillary regions, the soft parts, as the testicles, inter- 
 muscular septa, and other parts. 
 
 They appear, as a rule, in young subjects, in people 
 under middle age, and are far more common, accord- 
 ing to my own notes, in the female than in the male. 
 They are usually slow in growth, the majority having 
 existed years before the patient seeks advice. The 
 instances of tumors of rapid growth on record arc rare. 
 These tumors, when not outgrowths, are always encysted 
 and have a smooth, tense, and elastic feel. In some 
 examples they are uniform and even, in others bossy 
 and nodulated ; they rarely cause pain, and produce 
 anxiety simply from their po.sition and size. Tho.se in 
 the parotid or submaxillar}' region appear to grow su- 
 perficially and to be movable, but they often dip down 
 deeply into the tis.sues, and considerable care is required 
 in their removal. In a case treated by my colleague, 
 Mr. Durham, the tumor appeared more as a pharyngeal 
 than as a parotid growth. As often as not they are 
 very adherent to the surrounding parts. These simple 
 parotid tumors rarely involve the facial nerve or cause 
 When the cartilaginous tumors grow tcifhiu bones, they 
 
 Fibrous Tumor. 
 (Prawing 307"-, CJuy's Hosp. Mus.) 
 
 C^^***'*^^''**,,^^ 
 
 paralysis, as do the cancerous, 
 expand them into a thin shell. 
 
 Cartilaginous tumors are usually innocent, and consequently only separate the parts 
 
 between which they are developed. They never 
 Fig. 30 involve the integument by infiltration, but only 
 
 (fi 71-^ — ^__ Stretch it ; in exceptional instances they excite 
 
 ■^^,J^~"'~>--,.,_^ inflammation and ulceration in the skin, with sub- 
 
 ^^Nisiijj^s^^^^ sequent perforation ; they do not affect the sys- 
 tem through the glands, although it must be 
 added that rare examples are on record in which 
 cartilaginous tumors have returned and affected 
 the lymphatic system like a cancer. Sir J. Paget 
 has recorded such an instance in the Mcd.-Clu'r. 
 TnaiK., 1855, and De Morgan in the Path. Trans., 
 
 vol. XX. 
 
 The section of a cartilaginous tumor is fairly 
 characteristic (Fig. 30). It cuts cri.sply and pre- 
 sents a smooth surface ; it may appear of one mass or made up of many lobules. In 
 some ca.ses the consistence of the tumor is close and is composed of translucent or bluish 
 masses of fcetal cartilage, as is best seen in the periosteal forms. In others it is loose and 
 granular, as in those expanding the bones. In many of them fibrous or glandulnr tissue 
 is intimately mixed with the structure of the tumor, the parotid tumor affording the best 
 type of this kind. In the cartilaginous tumors of bone, bone elements are always pres- 
 ent ; in those of periosteum, fibrous elements; and where glands are involved, glandular 
 .structure. When cartilaginous tumors .soften down, cysts are found, usually containing 
 a dirty brown serous fluid, or simply filled witli broken-down tissue and pus or with a 
 more tenacious synovial kind of fluid. 
 
 Microscopically, cartilaginous tumors present diverse forms, simple fcetal cartilage cells, 
 embedded in some cases in a hyaline or in a granular matrix, in others in a fibrous or 
 glandular stroma, or even both in different parts of the same growth. The most typical 
 form is that in which the cartilage cells are grouped together in masses surrounded by 
 fibre tissue. From this type great deviations occur, the cells being more or less scattered 
 
 Section of an Enchondromatous Tumor 
 e.xpanding Metacarpal Bone. 
 
TCMOIIS. 
 
 120 
 
 hctwcen the Bhros. In some instances the nuclei of the cells are free and hunierr)iis, in 
 others they are tilled with granules or oil-globules, ajiparently degeneralinfj. Occasionally 
 the eartilaj»'e cells are developing and take on the mature form of hone cells (Fig. 40). 
 
 TuK.\TMKNT. — The removal of the cartijaginous growth is the oidy efficient treatment, 
 but the practice must be determined by the position of the growth and all the other 
 points with which the tumor is clinically surrounded. When removed, a return rarely 
 takes place. Ca.><es, however, are on record (the (iuy's museum containing a few; in 
 which a return t-nsued after a second or third excision; but such instances are exceptional. 
 
 The cartila<_'ini>us tumors of bone will be considered under the head of '• Diseases of 
 Bone.' 
 
 4. Osteomata, or osseous tumors, naturally come to be dealt with after the 
 cartilairinous. for the two elements arc usually conibincd ; and as in the enchondromata 
 traces of bone may be found, so in the os.seous tumors traces of cartilage may exist 
 (Fig. 40). 
 
 These are found in several forms, as exostoses or bony outgrowths, as ivory or perios- 
 teal exostosis, and as tumors of bone. The ivory growth is peculiar to the bones of the 
 skull. 
 
 The cancellous exostosis is almo.st always developed through cartilage and made up 
 of tissue precisely similar to the cancellous tissue of bone. In some cases it is covered 
 with a thin casing of compact bone, like the cartilaginous tumor growing within a bone, 
 but in most it is covered with a layer of cartilage, by the ossification of which it grows. 
 A diagram illustrating these points will be found in the chapter dealing with exostosis, 
 and the clinical aspect of the subject will be again considered in the chapter on " Tumors 
 of Bone."' 
 
 5. Adenomata, glandular or adenoid tumors, are new growths simu- 
 lating more or It-.-s perfectly the gland structure in the neighborhood of which they grow, 
 and are not hypertrophies of the gland, but distinct tumors. In the breast the usual 
 innocent tumor of the organ is of this nature, and is called adenocele ; but it is also 
 found in the prostate, uterus, lips, tonsil, thyroid, and integument. Fig. 41 represents 
 admirably the microscopical features of the adenomata as a cla.ss, and Fig. 31 the appear- 
 ance of such a tumor in section, some parts being solid and others composed of pendulous 
 intra-cystic growths. 
 
 Thev are generally growths of young life, and are found during the active period of 
 a gland's existence. They are always encapsuled. and can usually be turned out of their 
 bed with ease on dividing the capsule. They generally assume a rounded or ovoid 
 shape, and are distinctly movable beneath the integument which is not involved. '• On 
 section," says Paget, " they commonly appear lobed or intersected with partitions of con- 
 nective tissue and are pale, grayish or yellowish-white, in some specimens looking trans- 
 lucent and glistening; in others, opaque : in nearly all. acinous or glandular. To the 
 touch, some, especially the white and more opaque, are firm, tenacious, and elastic ; others, 
 especially the yellow and more glistening, are softish, brittle, slippery, and succulent, with 
 fluid-like serum or synovia. Not rarely cysts are embedded in the solid growth, and these 
 are filled with serous or other fluids like tho.se which are found in the barren cy.sts of the 
 mammary gland itself. In the labial and parotid glandular tumors portions of cartilage 
 or bone may be mixed with the glandular structure, and sometimes, chiefly in the mamma, 
 the glandular tumors appear as if 
 
 formed wholly or in part of clusters Fig. 31. 
 
 of small sessile or pendulous 
 growths, which fill cysts or parti- 
 tioned spaces ; thus they indicate 
 their relation to the proliferous cy.sts 
 and suggest that they originated in 
 such cysts. The textures around 
 the tumor are usually quite healthy, 
 altered only by displacement." These 
 glandular tumors are often single, 
 but at times multiple. Thus, in the 
 breast they may be many and so 
 loosely encapsuled as to move about 
 as in a bag : in the lips they are 
 commonly numerous : while lymph- 
 atic glandular tumors are almost always multiple. They grow with very variable rapidity 
 
 Adeno- 
 
 :u>trarinc the Pathological Appearances 
 .-■1" AdeDoid Tumors. 
 
130 TUMORS. 
 
 — at times more slowly, at others with great rapidity. They require removal simply from 
 the inconvenience caused by their mechanical jiressure. 
 
 Treatment. — To remove them it is only necessary to divide their capsule and the 
 soft parts covering them in and to enucleate them. This need not, however, be done 
 under all circumstances, for these glandular tumors not only cease to grow, but at times 
 disappear ; thus operative interference should only be entertained when the growths are 
 large or increasing or very painful. jMedicine does not appear to have any influence in 
 checking their growth. 
 
 The glandular tumors of special regions will receive iintice in the different chapters 
 devoted to their coiisidcratioii. 
 
 PapilloiTiata are found in the outside or inside skin and in the mucous membrane, 
 while instances are on record where they were found on serous meniln-anes. On the skin 
 they occur as warts, cauliflower or sessile, and as condylomata. .Some of the horny skin- 
 growths arc of this nature. On the mucous membrane they occur on the lips, larynx, 
 hard and soft palate, tongue, and rectum, and as villous growths in the bladder and rec- 
 tum. They seem to be a mere delicate outgTowth of subcutaneous or submucous tissue, 
 with their natural epithelial covering, at times involving the gland structure of the part. 
 They are usually innocent. 
 
 Neuromata, or fibrous tumors developed in and about a nerve, will be considered in 
 a later cliai)tcr, as will the angiomata in chapter on the " Diseases of the Vascular System." 
 
 Lymphoma is a disease of the lymphatic glands which is at times local, at others 
 general. When local it has, as a rule, local causes ; when general, constitutional and is 
 associated with leuca3mia or leucocythiiemia. 
 
 The glands are, as a rule, movable in the surrounding parts, and can be shelled out. 
 In exceptional cases they are matted together, as in cancer, and, like it, are also dis- 
 seminated as secondary, growths. (For " Histology " viiJc Fig. 42.) 
 
 B. Semi-Malignant Tumors. 
 
 1, Sarcoma. — The semi-maligmmt tumors, or those composed of embryonic con- 
 nective-tissue elements, include what are known as the '-sarcomata" and " myxomata," 
 and these clinically present a vast variety of shapes and types. They approach the sim- 
 ple growths in that they do not infiltrate tissues, but separate them ; and they approach 
 the malignant in that they are prone to recur after removal, and that on each recurrence 
 they come nearer the characters of the cancer. 
 
 To the naked eye they are succulent, with every degree of solidity, but a section does 
 not give milky juice on scraping, and it never presents the concavity like a cancer. 
 
 in some cases, where recurrence has taken place, the second tunnn-, doubtless, has been 
 simply the external manifestation of a small growth which existed when the original 
 tumor was removed, or the increased growth of a portion of diseased tissue that was 
 unconsciously left. On two occasions when removing a mammary adenoma I have exposed 
 a minute growth of a similar structure by the incision made through a portion of the 
 healthy mammary gland to reach the principal growth. In both these cases, had the 
 small tumor been left, a recurrence would have been recorded. In cases of recurrent 
 fatty tumor or of the soft fibroma it is highly probable that a small portion of the tissue 
 was left. On one occasion, when I was enucleating one of these, of several years' growth, 
 from beneath the fascia covering the scapula, I discovered two smaller growths which 
 might have been overlooked and would certainly have grown. f]ach tumor as it recurs 
 generally becomes less solid, more succulent, and more rapid in its growth. With each 
 recurrence the cell elements increase in proportion and in all ways ; " later formed tumors 
 assume more of the character of malignancy than the earlier." All these sarcomatous 
 tumors are composed of round, elongated, oat-shaped, caudate, nucleated cells like those 
 found in granulation and embryonic connective tissue (vide Fig. 43). 
 
 It must be observed that these tumors, as a rule, attack the young and healthy. 
 They grow from a fascia or aponeurosis, are of slow growth, particularly at first, and 
 destroy life only after many years and from local causes. They return either in the spot 
 from which they originally sprang or from its immediate neighborhood. They simply 
 aff"ect the part mechanically by separating and surrounding tissues, but never by infiltrat- 
 ing them.' The skin is stretched over the tumor, but never involved in it; and if 
 destroyed, it is by ulceration from overdistension, while the absorbent glands are never 
 secondarily involved, even in extreme conditions. Such tumors are to the hand more or 
 less fibrous and lobulated, their fibrous feel being much influenced by their rapidity of 
 
77 -MORS. 
 
 131 
 
 Fui. ■:± 
 
 
 Sarcoma of Bone. 
 
 (I'rep. <iuy's Mus.) 
 
 •growth. WhiM cut into, they present a more or less compact surface, a clear serous fluid 
 iiitiitratiii;: its incslics ; while even tlie finest microscopical section will be found toufrh and 
 tenacious and incapaldc id" hcin^ pressed into a ditHueiit mass. I'nder the micn^scope 
 thi'V present an excess of nucleated cells and nueleateil fihres, these, again, ."-liowinL' their 
 tendeiicv toward the characters ol" the malii;nant irrowth. 
 
 When a sarcomatous tumor spriuL's from jx-riostcum. it is often separateil into x-otions 
 ]>V hands of lihres; and when it oriixinatcs in hone, it 
 mav he similarly divided hy thin plates or outgrowths 
 of ossific matter, these plates or laminn; heini: some- 
 times distinctly seiiarate. at others so closely packeil 
 toircther as to form .somethinjr like a skeleton tunnjr 
 (Fig. ^^2), the sarcomatous elements clothing the bony 
 outgrowths or surrounding and covering them in. For 
 diagnostic purposes the detection of the.se bony plates 
 is of great value. 
 
 The treatment of recurrent tumors need Tiot differ 
 from that of the inimceirt. for as long as the disease is 
 local there is a reas((nahle hope that it will at last cea.se 
 to recur after reinnval. 
 
 Myeloid or giant-celled sarcomatous 
 
 tumors are as primary growths generally I'ound 
 associated with bone, either growing from the bone, as 
 in " epulis." or more comnioidy in the bone, and when 
 in this position usually in its articular end. The term 
 was given to the class by Paget on account of the like- 
 ness between its cells and tho.se of fuctal marrow. 
 Lebert called them " fibro-plastic,'' and Virchow •• giant- 
 celled sarcoma."' 
 
 When these tumors are periosteal, they have the clinical features of a fibrous growth ; 
 Avhen within the bone, they appear as chronic expansions of the articular extremity or 
 shaft. When large and so expanded as to have burst through their osseous case, they 
 appear cystic and semi-fluctuating, even to the extent of being pulsatile. They are usu- 
 ally slow in their progress, and often painless ; and it is fair to supjiose that many of the 
 cases of cystic expansion of the articular extremity of a bone are due to myeloid disease. 
 The disease is one of youth and young adult life, and the growth is usually single. It is 
 not connected with any cachexia or glandular enlargement, as happens with cancer ; and 
 when removed, it rarely returns. Instances of recurrence, however, have occurred, and 
 I have seen one. Sir J. Paget has recorded others. 
 
 A myeloid tumor presents in section a peculiar appearance. It may be solid or cys- 
 tic in variable degrees; osseous matter, fibrous matter, or fluid may exi.st in different pro- 
 portions ; yet in every specimen the cut surface will present blotches of a pomegranate 
 crimson or of a darker blood color, these tints mingling more or less regularly with tho.se 
 of the other tissues. 
 
 Under the microscope the characteristic polynucleated cells are seen ; the.se are large, 
 round, or irregular cells containing manv — even ten or more — oval, well-defined nucleated 
 nuclei floating in a clear or granular substance. They are found in masses or distributed 
 throughout the tumor between the bundles of fibre tissue. They are diagnostic of mye- 
 loid disease. With these cells Lebert's caudate or spindle-shaped cells are also found 
 {cH/r Fig. 4:-I). 
 
 Melanotic sarcoma is essentially a tumor containing pigment, having its origin in 
 a natural tissue, as in the choroid of the eye or in a mole in which pigment exists; but 
 what it is that determines the development of the.se growths in tissues that have had a 
 lifelong exi-stence remains to be explained. The black sarcomata have, however, one 
 peculiarity, and that is in their tendency to multiplicit}-. In this thev' are often mo.st 
 remarkable : the skin and subcutaneous tissues at times become studded with melanoid 
 growths of all sizes and shades and colors. Fig. o3 is taken from a woman over who.se 
 whole body melanotic cancerous tumors were distributed, the disease having originated 
 in a mole which I had previously excLsed. 
 
 Pathology. — If it were necessary to adduce a forcible illustration of the fact that a 
 tumor when first developed in a part partakes, iji a measure, of the nature aiul peculiarities 
 of that part, and even when repeating itself in the lymjihatic glands and internal organs 
 still preserves the characters which it originally ac(|uired from the seat of its primary 
 
332 
 
 TUMORS. 
 
 Melanotic Sarcoma. ( From Model, Guy's >rus.) 
 
 development, no better could be adduced than that derived from the natural history of 
 primary and secondary melanotic growths; for a melanotic sarcoma always grows from a 
 part which naturally contains pigment, and a mole is unquestioriaVjly its commonest seat, 
 
 while pigment in some of its 
 forms is almost always to be 
 met with in all its secondary 
 growths. It may be. perhaps, 
 that the secondary glandular 
 enlargements in their rapidity 
 of growth out.strip the tumor 
 from which they originally ini- 
 liibed their peculiar nature ; 
 nevertheless, their true cha- 
 racter is maintained and pre- 
 served to the end. This sar- 
 coma, as a rule, is of the soft 
 form and runs a very rapid 
 course, an extreme example of melanotic sarcoma, indeed, presenting all the worst features 
 of a cancer. In rare examples of this disease the melanotic pigment may be found in 
 the urine (Fagge, Path. Soc. Trans., 1876). It has, however, peculiarities of its own, to 
 which attention will be subsequently directed. 
 
 The oxfeo sarcoma and chondro sarcoma will receive attention in the chapter devoted 
 to the tumors of bone (Chapter XXXII.). They are all probably only modifications of. 
 the medullary cancer affecting bone, although it may be mentioned that exceptional eases 
 are on record wliere an osteoid cancer originated in some intermuscular interspaces. 
 
 2. Myxoma. — These tumors are very like the soft fibromata and certain fatty 
 tumors. They are encapsuled, very soft and succulent, and exude a peculiar mucous 
 juice. They are most common in the subcutaneous or mucous tissue, but are found 
 everywhere. They are seen as parotid growths, and often mixed with fibrous or cartilag- 
 inous elements. They are doubtless often mistaken for colloid cancer. In the typical 
 mijxoma the tumor is less firm but more elastic than the sarcoma ; its nature is far less 
 homogeneous and presents less well-marked interlacing fasciculi of connective tissue, and 
 from the meshes of this tissue will flow a variable stream of clear, translucent, viscid 
 mucus. The fibres of the connective tissue are visible under the microscope, but in 
 smaller bundles and more drawn out. Abundance of cells, also rounded, elongated, 
 branching, and even anastomosing, together with nuclei, will be found to fill the cavities 
 formed by the confused network of delicate fibres of which the tumor is composed. In 
 the structure of the myxomata fat often forms an important element; glandular elements 
 may also be found, their presence being determined by the position of the growth and 
 the propinquity of a gland. Bone or cartilaginous elements are at times mixed with the 
 others (Fig. 44). 
 
 Mi/.romnta are not rare about the angle of the jaw, nose^ breast, and abdomen. They 
 are met with also in the extremities and in the eye, as well as in the delicate connective 
 tissue of the nervous system, particularly of the brain, and also of the nerves. When 
 attacking the brain and nerves, such growths are commonly found in the young. Vir- 
 chow has named them fjliamaUi. (Fig. 43), the cells being of a small round or pointed 
 form, embedded in granules, and held together by delicate fibres. In some cases the 
 fibre element approaches the firmer kind of fibro-cellular tumors (Fig. 43). 
 
 Treatment. — Excision is the only practice that can be followed, although this opera- 
 tion need not be performed when the tumor is small and not progressing, especially when 
 it occurs in aged people. Good success usually attends the practice. In the firmer 
 varieties of myxomata a return of the tumor is not to be expected, but in the softer, 
 where cell elements predominate, the risks of a return are great. 
 
 C. Cancerous Tumors. 
 
 What is a cancerous tumor ? Of what is it composed ? and. How can it be recognized? 
 are questions which the student is constantly asking ; and few are more difficult to answer 
 with accuracy or precision. 
 
 Pathologically, a cancerous tumor is compo.sed of cells which more or less conform to 
 an epitlictiiil type, but the student must be prepared in all — at any rate, rapidly growing 
 — tumors to find a great variety of cell forms ; and it may with truth be said that the 
 
CANCEROirs TV MORS. 1;};J 
 
 iiuire tlie ci'll elements prodnniiiiutc in u i:r(»\vlli. ami the inmc tliey apiintadi an epithelial 
 type, the <jjreater is the prohahility nl" its licin<i malignant, and iheiefore eaneerous, fur 
 the soft caneers, which an- lUKlunhtcdly tlit; ninst viruh'iit, are niadi,' up almost entirely 
 of cells and nuclei, oidv en<iui:ii liKrc tissue existiiii: t<i himl ami hold these cells ti»'_'ether 
 
 It has heeii already shown how the sarcomatous tumor approaches the malijinant in 
 some of its features; ami it must have heen id)served that these, which form the inter- 
 nieiliate links hetween the innocent and nialiL,Miant, structurally apju-oaeh the latter in 
 liaviuL^ more of the cell elements in their eo.uposition. The recurrent tumors exist as 
 proofs of this. 
 
 Hut these jmints touch only the anatoniv, and not the symptoms, of those ^Towths ; 
 tlii'V do not assist the surgeon to ascertain before its removal whether the tumor he a caii- 
 eer m- unt. 
 
 Symptoms. — What, then, are the external and jreneral symptoms by which this 
 point can be determined? And hero it niu.st be premised that in makin<r a diagnosis the 
 history and the proj^ress of the disease are at least as important as the physical characters 
 of the tumor. 
 
 If a tumor be found iiifillriifiiiij llir fisKurs in which it is placed, there can be little if 
 any doubt as to its bcinj^ a cancer ; for no innocent LM"owth iiitiltrates tissues: it oidy sep- 
 arates them. 
 
 .\ cancerous tumor, however, does not always infiltrate a part, althoiicrh an infiltratins 
 tumor is almost always a cancerous one; for it may appear as a distinct and isolated 
 LM'owth. being then, in surgical language, described as tuberous. What, therefore, are the 
 symptoms by which a tuberous cancer may be known ? What peculiarities has the tumor 
 itself by which its nature may be recognized? Unfortunately, a negative answer must 
 be given to this (juestion ; for although it may not be unfair to suspect the presence of a 
 cancer when the tumor does not present any of the special appearances or symptoms 
 which commonly characterize the innocent growths, it can only be a su.spicion, as many 
 innocent tumors are often deficient in the special symptoms which when present readily 
 attest their true nature. 
 
 A subcutaneous tumor unconnected with the integument, with an irregular bossy out- 
 line, and of a firm, fil)rous feel Avill, in all probability, be of a simple nature, for these are 
 not the characters of a malignant tumor; but another with a smooth uniform external 
 .surface may be cither a sim])le or malignant growth. If, however, any adhesion or draw- 
 ing in of the integument to the surface of the growth can be detected, or any immobilitv 
 of the tumor upon the parts beneath, the suspicion of its being a cancer may be enter- 
 tained ; for the surgeon should ever remember the tendency which the maliirnant tumor 
 possesses to involve by infiltration the tissues in its neighborhooil, and that this tendency 
 does not belong to the innocent growths. 
 
 I proceed further to direct attention to another .symptom which, if present, is most 
 characteristic of cancer ; and it is a .secondary glandular, lymphatic enlargement. If this 
 .symptom appears, the probabilities of a tumor being cancerous become very strong, as inno- 
 cent and mm-malignant tumors are rarely, if ever, attended with enlarged lymphatic glands. 
 
 A distinct and i.solated tumor, therefore, which does not possess any of the special 
 characters of a simple growth, which is attended with some evidence of secondary affec- 
 tion or infiltration of the parts, and with which an enlargement of the lymphatic glands 
 in its neighborhood exi.sts, may safely be regarded as cancennis. It is, however, only in 
 the early stages of the development of a tumor that a difficulty in diagnosis is usually 
 felt, because, as a rule, in the long-standing and well-developed growth the diagnosis is 
 not difficult. 
 
 The soft and so-called medullary cancer is the form which is usually met with during 
 young life. It generally makes its appearance suddenly, and often after the receipt of 
 soJiie blow or injury. It grows, too, very rapidly, presenting a surface which, as a rule, 
 is .smooth and uniform or of a semi-solid and fluctuating feel, and with large full veins 
 wandering across. It is recognized by its sudden appearance, rapid growth, and uniform 
 surface — points very different from those which simjtle tumors present, innocent growths 
 being generally slow in their development and more marked in their outline. The cases 
 of medullary or soft cancer run their course very rapidly, and destroy life within a very 
 short period of their development. 
 
 Hard caneers are the affections of middle age and adult life. They grow more rapidly 
 than the innocent growths, often not requiring more than a few months to establish their 
 true nature ; they seldom put on the external ap])earances of a simple tumor, and never 
 
134 aiycEROus tumors. 
 
 • 
 
 exist long without assuming features which are more specially characteristic of cancer, 
 the implication of neighboring tissues and secondary glanduhir enlargements being the 
 chief features. 
 
 Summary. — A amceroits tumor has, therefore, four characteristics: 
 
 1. It infiltrates the tissue it attacks and spreads by infiltrating neighboring structures. 
 
 2. It spreads to the lymphatic glands of the neighborhood through the absorbents. 
 
 3. It affects the body generally through the vascular system, thus giving rise to sec- 
 ondary deposits — that is to say, to the development of similar growths in the viscera or 
 remote parts, the lungs and liver being particularly prone to its attack. 
 
 4. It is lial)le to recui- after removal. 
 
 Cancerous Tumors have been variously described by authors. In these pages 
 they will be treated of as the hard, or scirrhus ; the aoft. or encephaloid ; the epithelial ; 
 the colloid and hone cancers, or osteoid. 
 
 All have, however, the four special peculiarities that have been already described as 
 characterizing the disease. 
 
 Hard or scirrhous cancer is the most common ; it is the hard or fibrous species 
 denominated •' carcinoma fibrosum." It is the usual form found in the fenude breast, 
 and is seen in the testicle, tonsil, skin, bone, eye, rectum, or any tissue. When attacking 
 a tissue either by infiltration (the most usual method) or deposition, it gradually 
 encroaches upon the tissue ; and when this is soft, it causes its contraction, as in the 
 breast. The disease spreads outward, and soon takes possession of neighboring struc- 
 tures by infiltrating them. In this way it becomes gradually less movable, and at last 
 fixed. No structures resist its influence, fat, skin, mu.scles, and bones becoming filled 
 with cancerous elements as the disease progresses. It is said "to increase most on the 
 side of the chief arterial supply, and in that toward which by lymphatics and veins its 
 constituent fluids most easily filter" (Moore). 
 
 Thus the lymphatic glands become enlarged, and these in their turn may press upon 
 nerves, causing pain, or upon veins, producing oedema. But cancers have not the power 
 of living like innocent tumors : they are apt to degenerate and die ; and thus, after a 
 time, a cancerous tumor may soften down in its centre and burst or die as a whole and 
 slough out, or its surface may ulcerate. But, whatever happens, the disease spreads in 
 the neighboring parts; indeed, after the sloughing of a cancerous tumor, this spreading 
 action in the bed from which it has been enucleated seems to be more rapid. Thus, the 
 death of one part of a tumor is seen with the rapid increase of another part, and in tliis 
 manner the disease goes on encroaching upon and infiltrating and destroying all tissues in 
 their turn, causing death either by exhaustion, hemorrhage, or some internal complication. 
 
 In some instances of cancer the integument over or about the tumor, before ulcera- 
 tion occurs, becomes infiltrated with small shot-like tubercles ; such a tubercle in its early 
 stage feels to the finger like a foreign body introduced into the cutis, and as this grows it 
 appears as a distinct skin tubercle. No clinical .symptom is more characteristic of cancer 
 than the presence of these skin tubercles. 
 
 In other instances the whole integument becomes o^dematous and brawny — in fact, 
 infiltrated with cancerous elements — this state betokening the most rapid form of cancer. 
 This brawny condition of integument commonly follows venous obstruction from glandu- 
 lar enlargement, but at times it takes place before any such complication. In rarer cases 
 the cancer withers, " atrophic cancer," the disease slowly progressing t(» a point and then 
 disappearing by a gradual process. Thus, cancerous tuloercles will appear and disappear; 
 cancerous nodules will form and fall off" by the contraction of their own fibres. In this 
 way cancer may become cured or so stationary as not to interfere with life. I have had 
 a case under observation in which the disease existed for twenty-three years and seemed 
 still local. I have recorded another, in which the disease lasted twelve years, appearing 
 and crumbling away at times during that period almost to a perfect cure. Cancers dis- 
 play a very variable degree of growing or existing power, and there does not seem to be any 
 condition of the patient or of the tumor which either favors or disfavors these properties. 
 Some have an apparent vigor of increase that is remarkable, whilst others show no 
 such tendency. In many ca.ses a tumor that has been (juiescent for a long period will 
 suddenly increase actively. 
 
 The same thing may be said as regards the cancerous vlccr. In the atrophic form 
 this may be merely a superficial loss of substance on the surface of the tumor, which 
 may be covered with a scab or present a glazed or a very slightly discharging surface. 
 In other cases the ulcer will show an irregular surface with an elevated everted edge 
 infiltrated with new tissue (Fig. ?A). 
 
CA AV •I:r O I 'V TIJMOIIS. 1 35 
 
 When a (.-avity exists, fdniu'd liy tlit- sdl'tciiiri;; <l<»\vii of tlie centre of the tumor or 
 the I'liiulcatidii ui' lU-ad tissiu', the irrt'j:iihir outline of the eavity,the i'etid seuii-puruh-rit 
 siiiiious (liseharire, as well as the rajrjred ami inliltialed ed;.M' of tiie wound, are eliaraeter- 
 istic signs of its cancerous nature. 
 
 In such cases a cachexia heconies visible, a pale, hloodless, ha<.'<rar<l look of sorrow 
 and surterinir. hnuiirht on hy jiaiu, sleeplessness, and exiiaiisting discharges. 
 
 Pain ill the development of a cancer is a very variable .symptom. In primary 
 growths it is rarely severe unless .some tierve trunk he jtressed u|ton (»r the tumor is 
 bound down by a tense fascia or is developed within a bone. I'ndcr all th(;s(! circum- 
 stances the pain is constant, of an "aching or of a so-called rheumatic kind. ' In others 
 it is usuallv eomjiared to an occasional dart (if pain through the part. 
 
 As a sign of si'condary deposits pain, however, is a valuable .symptom, neuralgic pain 
 following the course of a nerve being enough to excite fear of some deep-seated .secondary 
 growth. Than this no nmre valuable or reliable clinical symptom exists. 
 
 The srrfinii of a scirrhous cancer is genejally attended with a grating sensation, the 
 parts cutting crisjily; it presents a concave mirjace, and yields, on scraping, a milky juice. 
 The tumor has no defined margin, the diseased and healthy tissues, as it were, dipping 
 into each other. The surface of the cut portion iiuiy be vascular or bloodless, and has a 
 bluish-gray or streaked yellow aspect, according to the amount of cell or fibre elements 
 entering into its formation or to its progress toward degeneration, the yellow spots being 
 indicative of degeneration. Occasionally cysts, or rather cavities, contaiijing .serum, 
 blood, or broken-down tissues, are found in the tumor, and at others creaujy, saponified 
 masses of degenerated tissues. 
 
 The microscopical appearances of carcinomata are well .shown in Fig. 45. 
 Medullary cancer, like the .scirrhous, is either in/iltnitliKj or fiiheroiis, and pos- 
 sesses in a marked degree all the cancerous peculiarities. It is doubtless only a form of 
 cancer, and not distinct from the scirrhous varieties, becau.se both often coexist, and the 
 irrowths which are secondary to the hardest primary cancer are generally the soft variety. 
 >Iedullary cancer is, however, the special form that appears as a congenital tumor and 
 which attacks children and young adults, and may be called '' the cancer of young life." 
 These growths form very rapidly and run their course far more quickly than the harder 
 kind. They increase so tast that they push away the tissues with which they are sur- 
 rounded more like the innocent tumors which separate them ; their capsules prevent that 
 general infiltration of the parts which is observed in the infiltrating form. It is found, 
 although rarely, in the breast, yet more frequently in the intercellular tissue and about 
 the periosteum and bones. It is the usual form attacking the eye. uterus, tonsil, testis, 
 and ovary, the bones and cavities of the head and face appearing peculiarly liable to its 
 inroads. 
 
 These sid't cancers usually appear as deep-seated swellings, and when not bound down 
 by fascia or connected with bone are rarely painful ; but when so situated, a gnawing pain 
 or ache is a frequent concomitant. As they progress and become more visible they may 
 present either a nodular lobulated or a .smooth and uniform aspect, but in either case the 
 integument covering in the growth will be traversed by many very large and dilated 
 veins ; while in .some instances the growth has a blui.sh congested aspect, as if filled with 
 venous blood. These tumors are often so vascular as to pulsate, and thus simulate an 
 aneurism. Such a symptom, however, is mo.stly observed in those connected with bone. 
 To the touch the swelling feels soft and fluctuating, often giving the idea of fluid ; 
 and should the surgeon, to satisfy himself upon this point, puncture the tumor with an 
 cxploring-needle. blood will freely escape, and with it .some creamy tissue, which under 
 the microscope will be seen to be made up of cells and nuclei. 
 
 When these soft cancers have burst through their fascial envelopes, they grow more 
 rapidly ; and when they have made their way through the skin. they, as it were, pulp out, 
 and project much as a liernia cerebri does after ctjmpouiid fracture of the skull. The .«oft 
 succulent granulations and blood-infiltrated tissues that project suggested to Mr. Hay of 
 Leeds the term ■• fungus haematodes." AVhen a soft cancer is filled with blood, it is kncjwn 
 as a " h;«matoid variety."' 
 
 When they appear in the parotid region, they usually, if not always, pi'oduce paraly- 
 sis of the facial nerve — a clinical symptom, I think I may say, never found in the ordinary 
 innocent parotid tumor; so that when present this symptom is of value. As a rule, how- 
 ever, this soft cancer surrounds nerves and vessels without materially pressing upon them, 
 large vessels and nerves being often found passing completely through their substance. 
 The section of a soft differs from that of a hard cancer as the '• infiltrating " differs 
 
136 
 
 EPITHELIAL CAyCER. 
 
 from the '• tuberous " (compare Y\<z<. 440 and 447;. and differs also very materially in 
 itself at different times. It ma}- be firm or nearly fluid, white and creamy, or red 
 and blood .stained. It may be soft' from inflammatory action or degenerating from natu- 
 ral decay. 
 
 Under all circum.stanees. however, it will be divided into lobules. fiVjrous septa or 
 fibrous envelopes separating these lobules from one another as the fibrous capsule of the 
 parent growth separated it from the other tissues. 
 
 The material composing the.se cancers, says Paget. " is a peculiar, .soft, close-textured 
 sub.stance having very little toughness. ea.sily crushed and .spread out by compression with 
 the fingers. It is very often truly brainlike, most like foetal brain, or like adult brain, 
 partially decomposed or cru.shed. Many .specimens are. however, much .softer than brain, 
 and many, though of nearly the con.tistence of brain, are unlike it. being grumous. pulpy, 
 shreddy, or spongy, like a placenta with fine soft filaments. Ver}- few have a distinct 
 appearance of fibrous or other regular structure." 
 
 These tumors, when pressed or scraped, yield abundant '• cancer juice ;"' and such 
 juice is generally diffusible in water. No better rough test, says Paget, exi.sts for the 
 diagnosis of medullary cancer than this. The .stroma of this cancer element is filament- 
 ous and more or less condensed ; it is also generally very vascular. The cell element 
 always predominates, but the cells in no way differ in character from those found in the 
 fibrous or .scirrhous form. They are. however, le.ss closely packed together, and seem to 
 be su.spended in the juices of the trrowth or enclosed within its delicate connective tissue 
 (Fig. 45 . 
 
 Epithelioma and epithelial cancer are terms given to a form of cutaneous 
 cancer frijin its similarity in structure to the epithelial elements of the natural skin, these 
 elements assuming in some cases, as in the cancers of the face, the smaller type of the 
 epithelial elements, and in others, as in the lip. the larger. 
 
 In one case the disease may appear as a superficial thickening of the part affected, 
 and in another as a nodular or warty growth. All these growths, however, have a tend- 
 ency to break down ; and this tendency varies in each case. In some it is very .slight, 
 whilst in others it is so rapid that the degenerative changes keep such even pace with the 
 formative that the disease assumes from its very origin the appearance of an ulcer, when 
 it is known as the -rodent ulcer" (Fig. 35). In the chain of malignancy epithelial can- 
 cers are linked to the recurrent tumors, for thev have both a tendency to return in a part 
 after their removal and to affect the sy.stem through the lymphatics ; while in exceptional 
 instances they may be found in the internal organs. 
 
 These tumors affect the .skin or mucous membrane, and never originate in any other 
 tissue. They possess this feature also in common with the more malignant cancers, in 
 
 that they have a constant tendency to infiltrate the parts 
 with which they come in contact, and do not, as innocent 
 tumors, simply separate them. They are the common forms 
 of cancer found in the lip. tongue, oesophagus, rectum, scro- 
 tum, penis, clitoris, os uteri, vulva, etc.. and may be described 
 as the cancer of the skin, while in sweeps it is known as the 
 '• chimney-sweep's cancer." Epithelial cancer is essentially 
 an infiltrating disease : it is not. as the sebaceous, fatty, fibro- 
 cellular. or fibrous tumor, a distinct growth developed in the 
 tissues and separating them, but it is from its very begin- 
 ning an iiijiHration. It begins, as a rule, in a wart or tuber- 
 cle, which grows ; it may fungate, crack, fissure, or ulcerate; 
 and when this latter stage has been arrived at. its true cha- 
 racter will at once be observed by the careful examiner, as 
 the integument forming its base and margin will be evidently 
 infiltrated with the cancerous material, presenting the well- 
 known raised, indurated, and everted edges (Fig. 34). 
 These appearances form a marked contrast to the con- 
 dition of integument which is met with where an innocent growth has ulcerated through 
 or ruptured by overdistension its cutaneous covering. 
 
 As a local disea.se epithelioma may progress slowly for years and cause little pain, 
 inconvenience, or injurious effects, and five. six. eight, or even fifteen, years have elap.sed 
 in some of the cases that have been under my notice before advice was sought : it may. 
 moreover, continue for many years before it affects a patient in other ways than as a 
 local disease. On the other hand, when it once begins to spread, it may do .so rapidly ; 
 
 Fig. 34. 
 
 Cancer of Stump of Two Years' 
 Standing. (From a man at. .58.^ 
 
CA ycERors ti 'mors. 
 
 VM 
 
 ami after rcninval it iiiav return at miee. nut oiily in tlie part, Init in tlie lynipliutios of 
 tlie district, and even in the internal i>rt;ans. W Inn it spreails lueally, it may us a eaiioer 
 inliltrate and invade every tissue \vlii(di it reaidies. I liav*; .seen it more than once origi- 
 nate in skin and end in a total destruction (d'a hone (ridr (/iii/s I/osj). Jie/)., 1.S75). 
 
 Ispithelial cancer is made up (d' c( lis whicdi difler luit littlt; Irorii those of ordinary 
 epitludium, tliouuh they are grouped very ditVerently ; they iidiltrate tlic tissues in which 
 thev an; |)laeed or are cdustered toirt'thi-r in masses, tlu'se masses heiiij; deseril)ed as 
 " ue.sts" (Fii;. d;')). 
 
 The surface (d' an cpitludial cancer lu.ay he dry ami warty or ulceratin;^ ; when uieer- 
 atiuLi, it will he, like all cancerous sores, irrejxular. and will <lischar<;e a thin or a creamy 
 Huiil. The ed^e will always he thick and elevated, like a wall <jf new ti.s.stic huilt up 
 between tho healthy and disea.sed structures ( Fig. 84). When the di.sea.se spreads, it 
 will invade and infiltrate every ti.ssue, forming deep excavated sores. It may involve 
 the lymphatic glands, like any other cancer; and these glaiuls may soften down and 
 give ri.se to a cancerous abscess or an open sore. It usually destroys life from local 
 causes, and not from secondary infiltration of the viscera, such a consequence being 
 <|iiitf exce|itional. 
 
 Ti{i:at.mk.\t oi' Im'I riiKi.i.vL Cancer. — These cancers should always be removed; 
 and the sooner this is accomplished, the better the prospects of a cure or of a long 
 reprieve, for if any cancer has a local origin the epithelial has, and if it be removed 
 before any glandular eidargement has taken place the prospects of a good result are 
 great. Sibley (Mn/.-('hir. Tran^.^ vol. xliii.) made out from the Middlesex Hospital 
 records that e])ithelial cancers, on the average, destroyed life in fifty-thret; months, while 
 scirrhous lasted but thirty-two. When removed by the knife, care should be taken to 
 cut well free of the disease; for it is not unusual in this, as in all cancers, to find the 
 tissues around the tumor sparsely infiltrated with cancerous elements which if left would 
 cause a return of the tumor. The same advice is a])plicable when caustics are employed. 
 
 In many examples of this form of the disease the removal by the galvanic cautery is 
 ])y far the i)est method of treatment we pos.sess, either as a cautery applied to the surface 
 or as a wire ecraseur applied around the base. 
 
 Rodent ulcers arc forms of epithelial cancers. Dr. J. C. Warren of Boston, 
 T^iited States, in an able essay upon this disease, asserts that the cells of the rodent 
 ulcer differ from tliose found in the epithelial by be- 
 ing smaller. They are local cancerous affections and 
 expend their force in destroying every tissue attacked, 
 but tbey do not s^pread by means of the lymphatics or 
 by secondary growths. They usually begin on some 
 part of the face, head, or other locality as a dry wart, 
 which after it has shed many skins begins to ulcerate. 
 The ulcer then spreads slowly and regularly, with a 
 border of new tissue as a wall, to separate it from the 
 healthy parts; outside the border 'the parts are soft 
 and natural, inside they are generally smooth, as an 
 indolent sore, devoid of granulations, and glazed 
 (Fig. 35). There is little discharge from these sores 
 "when superficial ; but when they are extensive and 
 have dipped down deeply into other tissues, this is 
 not the case ; and when they inflame, they discharge 
 a fetid ichorous pus. Thev .seem to attack healthy 
 as well as feeble subjects, and have little efliect upon 
 the general health until they touch vital parts. 
 They appear after middle age and are of extreniely 
 slow growth ; they are to be treated locally by their 
 destruction, cautery, escharotics, or scalpel being 
 u.sed, as seems most applicable. In local sores the 
 knife, when it can be u.sed, is probably the best 
 instrument, but in others the galvanic cautery is 
 unrivalled. In lieu of this the benzoline cautery 
 may be u.sed, and next to this escharotics; "the 
 caustic burns through the entire depth of the solid 
 disease, and upon the casting of the subsc(|uent 
 slough cicatrization is rapidly completed" (Moore) 
 
 Fig. 35. 
 
 V 
 
 /\. 
 
 />^v 
 
 3^^ 
 
 / 
 
 \ 
 
 / 
 
 Rodent Caiicer of the Face. (From an origi- 
 nal diawinj; of'.sir Charles Hell's, contained 
 in the niiiseiini nf the Middlesex Hospital, 
 and recojinized hy Messrs. Shaw and f'anip- 
 hell <ie .Moiu'an. ' It was intnidiiced to my 
 notice liy my friend Mr. Henry Morris of 
 the .Middlesex Hospital, and kindly placed 
 at my disposal hy the museuui committee 
 of that institution.) 
 
 Chloride of zinc, potassa fusa, 
 
138 
 
 THE CAUSES OF CANCER. 
 
 Fig. 3(1. 
 
 Vienna paste, or acid nitrate mercury may be applied ; the zinc, rubbed down in a warm 
 
 mortar with equal parts of fresh plaster of Paris, is probably the best, because it destroys 
 
 and dries the tissues. 
 
 Colloid, cancer is hardly recognized as a special disease, for the term " colloid " 
 
 is applied to tumors made up of intercellular spaces of variable sizes filled with a clear 
 
 glairy fluid like glue, which contains abun- 
 dance of granules and large nucleated cells 
 (Fig. 45). The clinical history of some of 
 these growths is that of an innocent tumor, 
 whilst in others it is that of a cancerous 
 nature. Colloid tumors are found in the 
 breast, parotid region, ovary, rectum, and 
 intestinal canal, it being known in this last 
 region as the alveolar or gelatiniform can- 
 cer. Their true nature is not yet fully under- 
 stood. 
 
 In the case Fig. 36 the patient was sixty- 
 five years of age and the disease had been 
 growing for two years. The tumor occupied 
 the outer portion of the gland and had burst 
 the skin covering it in. The colloid growth 
 projected through the opening, the margins 
 of which, however, were not infiltrated with 
 disease. There were no enlarged axillary 
 glands. This patient was eight years subse- 
 quently readmitted into Guy's under my 
 care, in jMay, 1881, when she was seventy- 
 three, with a true carcinomatous affection of 
 the nipple of the opposite breast which had 
 been recognized for six munths. The nipple 
 was retracted and involved in an indurated 
 mass of disease about the size of a walnut. 
 The lymphatic glands were healthy, as was 
 the scar of the old operation. 
 
 Villous growths niay be cancerous as 
 well as benign. When made up of cell 
 elements, their cancerous nature is to be 
 suspected ; but the fact is only to be dis- 
 cerned by the clinical career. The nature 
 of villous and colloid disease has been very 
 ably discussed by Mr. Sibley in the 31(d.- 
 and Path. Trans., vols, vii., viii., and ix. 
 
 Case of ("oUoid Tumor of the Kreast discharsiins Exter- 
 nally, in a Woman let. 65, with Section of the same. 
 
 Chi'r. Trans., vol. xxxix. 
 
 The Cau.ses of Cancer. 
 
 These are most obscure, but the most constant cause is, without doubt, persistent local 
 irritation. Local injur?/ also appears to have a very marked influence in determining the 
 seat of a cancer; many cases supporting this view have fallen under my observation, and 
 one of such occurred to me recently in the case of a boy aet. 18, who, after an injury to 
 his right spermatic cord, in a few weeks became the subject of a pelvic tumor, which 
 rapidly grew, and eventually destroyed life by obstructing the rectum as well as the 
 ureters. After death the tumor was found to have been cancerous, having originated 
 apparently in the right or injured cord, spreading downward along the vas deferens to the 
 base of the bladder, and subsequentl}^ ascending from the pelvis, above the level of the 
 umbilicus. 
 
 Heredlfari/ inflnrncc has always been considered as a very decided cause ; still, in how 
 small a proportion of cases can any such be found ! Sir J. Paget traced it in one out of 
 every three ; Mr. Sibley, in one out of every nine ; and in 222 consecutive cases of my 
 own it was ti-aceable only in one out of every ten instances. In many other affections, 
 even the most innocent, as large a proportion might be found. In fatty tumors and in 
 deformities all surgeons recognize the frequency of an hereditary history. Indeed, look- 
 ing at cancer as one of many diseases, there is no reason for regarding it as more heredi- 
 
TRKATMEST OF ('ASi'ER. 1 :i9 
 
 tiirv tliiiii uiiv nilicr; :iim1 1 iiiii iii<liiMil to ai;ro(> with Mr. do Mnrpran when he said " that 
 Jill that cniihl he said with rf<iartl to tlu; coiistitutioual nature of cancur aftplied cr|ually 
 to the constitutional nature of any, the smallest, ;,n-o\vth that can ho found in the hody." 
 
 The death-rate of eaneer. aeeiU'din^' to the re<:istrar-;reneiars report, is one in "JilSiJ 
 ca.ses, hut — and iVoni the same authority — eaneer is heeomt! more eominoti. Mr. W . II. 
 (Vipps shows in a paper in the Si. Har/h Ifnsp. Rip., 1H7H, that the death-rate from ean- 
 eer in the community in suhjects over L!(> is ahout one in every liK.l cases. 
 
 Strikinir examples of the hereditary nature of canc(;r are met with in practice, hut 
 they are not more strikinjj; than, if so much so as, the hereditarines.s of ;rrowthsof a sim- 
 ple kind. Sir J. l*airet has pointed out, however, that when a local disea.se or deformity 
 is inherited, it passes from pro^'cnitor toort"s]»rin^ in the same tissue, if not in exactly the 
 same place; whereas, when a cancer is hereditary, it may hreak out anywhere. "The 
 cancer of the hreast in the parent is marked as cancer of the lip in tin; oflsprin<; ; the 
 cancer of the cheek in the parent becomes cancer of the bone in the chihl. Tliere is in 
 these cases absolutely no relation at all of place or texture." 
 
 Cancer is a di.sease of adult life, although it may attack a f<jctus in utero or an infant 
 .soon after birth ((lui/a IIosp. Rep., 1875). In a general way, it is most prone to attack 
 an organ that has passed through the active period of its existence and is degenerating, 
 as in the breast or uterus. Sir J. Paget describes it as being "essentially a disea.se of 
 degeneracy," and asserts •• tliat it increases in frequency in proportion to the number of 
 persons living as age goes on." When it does affect an organ in the full vigor of 
 its functional activity, it partakes of that activity and runs its course with marvellous 
 rapidity. 
 
 Cancer appears to be in its origin a local disease, and to become general either by the 
 influence of the juices of the primary tumor exercising an impregnative spermatic influ- 
 ence (Simon) upon other parts or by dissemination of its elements. This dissemination 
 at first may radiate from its local source, and at a later period may become general through 
 the fluids of the body. The secondary growths will partake largely of the characters of 
 the primarv ; thus tlie osteoid cancer will propagate osteoid, and the nielanotic melanosis, 
 each cancerous growth, like a parasite, growing at the expen.se of the tissue in which it 
 lies. Moore, in his work on the Antecedents of Omm; and De Morgan more recently, 
 have, I believe, established this fact. From a clinical point of view this i.s, without 
 doubt, of very practical significance; for surgeons now admit that the earlier a cancerous 
 tumor is removed the better are the prospects of a cure, or, at least, of a long immunity 
 from the di.sease. 
 
 Trkatment of Caxcer. 
 
 The grnn-al treatment of cancer resolves itself into the improvement of the general 
 nutrition of the body by hygienic means, good nutritious diet, and tonic medicines. No 
 medicine has any special influence on the disease. 
 
 The load treatment may be summed up in the word " removal ;" for all cancers should, 
 if practicable, be taken away as soon as their true nature has been established. In the 
 early stage of a cancerous tumor, before the diagnosis has been made out, it should be 
 protected froiu external injury ami from all irritating causes. No rough manipulation 
 should be allowed, nor any nu)vement of the muscles that surround or influence it. 
 Warm or hot applications should be avoided, since they appear to encourage its growth. 
 The most acute cancer of the breast I ever saw was one that originated as a chronic infil- 
 tration, and was nuule active by the application of hot fig poultices for a week. The 
 gland itself, and the skin over it to the limit of the application, became infiltrated to an 
 extreme degree with cancer, which rapidly broke down and destroyed life. 
 
 Moore u.sed to think highly of the local application of the iodide of lead and opium 
 ointment applied on lint to the tumor, and he believed it had some influence in diminish- 
 ing and retarding its growth. Some have faith in iodine as a local application, but I 
 must admit that I have never been able to discover that any of these or other applica- 
 tions had the slightest influence in checking the progress of a cancer, and have conse- 
 quently discarded them. When pain is present, the belladonna extract rubbed down with 
 glycerine into a fluid the consistence of treacle, or of the extract of opium similarly 
 diluted, seems to be a valuable application. An opium or belladonna plaster spread on 
 leather gives comfort and protects the part. The best protective application, however, is 
 cotton-wool. 
 
 Excision. — When the diagnosis is established, the tumor should be removed ; and 
 the best method, doubtless, is that of excision, delay being only ju.stifiable when the gen- 
 
140 TREATMENT OF CANCER. 
 
 eral condition of the patient forbids the attempt. To delay is only to increase the risk 
 of a local dissemination of the cancerous elements, and thus diminish the prospects of a 
 successful result; to give time for the lymphatic glands to become enlarged, when 
 removal of the primary growth becomes of less value ; and to increase the chance of 
 some internal or remote organs becoming involved, when operative interference is futile. 
 
 Free Removal. — In removing a cancerous tumor the surgeon should not be too 
 sparing of surrounding tissue; but when it is encapsuled, there is no necessity for doing 
 more than enucleating the mass. When it infiltrates an organ, the only correct treatment 
 is its removal ; and in removing it care should be taken to cut away all skin that is in any 
 way adherent to its surface, with as much of the surrounding fat as circumstances will allow. 
 When the tumor has been removed, all surrounding parts should be carefully exam- 
 ined, because it is not uncommon to find small cancerous tubercles in the connective 
 tissue, fascia, or muscular sheaths, which if passed by unheeded would soon increase and 
 give rise to a recurrent growth. It is from these points, indeed, that such recurrent 
 growths probably often arise, and these, by care and observation, the surgeon may often 
 prevent. De Morgan, after excision of a cancerous tumor, washed the wound with a 
 solution of chloride of zinc twenty grains to an ounce, in order to destroy the cancer 
 germs. The surgeon, too, had better remove all skin and allow the wound to granulate 
 up than save integument which is of doubtful integrity for the sake of making an appar- 
 ently more complete operation. When lymphatic glands are enlarged, they should be 
 removed at the time of operation : and they should be enucleated by the fingers or handle 
 of the scalpel rather than be excised. Their capsules ought to be divided and the glands 
 turned out. 
 
 Cancerous tumors of the tongue, penis, clitoris, labium, neck of the uterus, etc., may 
 be removed by the wire or chain ccraseur, either with or without the cautery ; but this 
 part of the subject will receive attention in other pages. 
 
 Removal by Caustics. — When a cancerous tumor cannot be excised or the cut- 
 ting operation is rejected, it may be removed by caustics; but such a method is more 
 painful and slower than excision, and not so successful. When employed as a substitute 
 for it, it is, like all substitutes, only second-best; yet it is. however, often applicable 
 where excision is not. The French surgeons do this by inserting around and into -the 
 tumor thin, conical, flat wedges of chloride of zinc made into a hard mass with flour or 
 plaster of Paris, holes being made into the tissue by the scalpel for the introduction of 
 these fleches. Maisonneuve is the chief practitioner of this school. These " caustic 
 arrows " of M. jNIaisonneuve are composed of wedge-shaped pieces cut from a thin cake 
 of paste made by mixing one part of the chloride of zinc and three parts of flour with 
 as much water as may be found necessary. These pieces or arrows are dried, and may 
 be kept in a bottle for a long time without injury. 
 
 Strong Acids and Caustic Paste.— In England this jdan finds little favor. 
 The following method is more general : In a tumor that is not ulcerated let the skin be 
 destroyed by the application of some strong sulphuric or nitric acid, and in this slough 
 let one or more incisions be made, and into these incisions let a paste of chloride of zinc 
 and flour mixed with the extracts of the Sangvlnnria CdncKlcm^i!^ and stramonium be 
 introduced, fresh incisions being made through the thickness of the slough thus I'ornied 
 every other day and fresh paste inserted. By this means the whole tumor may be 
 destroyed or enucleated. The paste is a modification of that introduced into London by 
 Dr. Fell of the United States, and is, without doubt, the best working caustic pa.ste we 
 possess. The following is the mode of its preparation : Boil down to a liquid extract 
 some decoction of the Saiiguinaria Canadensis, and with an ounce of the extract dissolve 
 a similar quantity of the chloride of zinc. ]Mix this with two ounces of the extract of 
 stramonium, and the soft paste is ready for use. 
 
 Caufjuoin's paste is composed of chloride of zinc and flour in equal parts, a few drops 
 of water being necessary to make it into a paste. A second form is probably better: 
 Chloride of zinc, one part; muriate of antimony, one part; flour, one part and a half; 
 water, a few drops. This paste is of the consistence of .soft wax. At the 3Iiddlesex 
 Hospital they use a paste made by mixing chloride of zinc and boiled starch with lauda- 
 num till it reaches the consistence of honey. 
 
 When the tumor is ulcerating or open, the paste may be applied directly to the part 
 and fastened on by cotton-wool and strapping ; the thickness of half an inch applied for 
 twelve hours usually produces a slough an inch deep. 
 
 Some prefer a solution of chloride of zinc alone inserted on cotton-wool. M. Rivallie 
 uses nitric acid applied on lint or asbestos; Velpeau, sulphuric acid on saftVon. By some 
 
a I! A .V I'LA Tins Tl 'MORS. 
 
 the Vienna paste is prt'tVrrtd. Ai-t'iiic as a caustic has hail its day, ami is dangerous and 
 less t'ft'c'ctivL' than zinc 
 
 For cutancnus epithelial cancer the caustic ticatnicut is the best. The chloride of 
 zine made into a paste with tluur or with san^'uinaria may he usimI, if j»rcl'erred. The 
 potassa I'usa is likewise a useful f<uin. When the galvanic or therino-cantery can he 
 obtained, epithelial skin cancer may he readily dcstroy<'<l. I have liurnt down many such 
 affecting the nose, cheek, eyelid, scalp, hand. arm. lip, and other parts. iiy it lar^'c sur- 
 face of di.scased tissue may he completely carhonized and a JH-althy surface produced after 
 the removal id' the eschar. The operation should he performed with the aid of chloro- 
 form and the whole thickness ami edtres (d' the diseased tissue tlestn»yed. The after-pain 
 is very sliirht. the cautery destroyinj; all nerve sensihility. It is hy far the best mode we 
 possess of dealinir with skin cancer, is more rapid in its action and certain in its result. 
 besides bein^ far less jtainful. When the di.sease e.vtends, it may be removed with the 
 scalpel and the base of the sore cauterized. No more efficient n»ode of removin;^ a .skin 
 cancer is within our reach. 
 
 The treatment of tumors by injection of fluids into their sub.stance, as originally .sug- 
 gested by Sir .1. Simpson, and more recently practised })y J)r. Broadl>ent, has in it tlie 
 elements of a successful plan, but has not yet been brought to any available state of per- 
 fection. Fattv tumiU's may be destroyed by the introduction into their substance of a 
 few drops of deliipiescetit chloride of zinc, but cancerous tumors do not ajipear amenable 
 to a like remedy. l)r. Hroadbent believes that he has succeedetl b}' injecting a li<juid 
 composed of one part of acetic acid and three of water, while Messrs. Moore and De 
 Morgan assert that they have each succeeded by these means in obtaining gradual diminu- 
 tion of cancerous growths. I tried the plan in twenty cases when it was first intro<luced. 
 bHt never found any good result ensue. It was often very painful, and many patients 
 refused to have it repeated, although they asked for the excision of the growth. More 
 recently the injection of twenty drops of a solution of bromine dissolved in spirit, rr^v 
 to a ."jj. has had its advocates. 
 
 The treatment by pressure is of no practical utility. 
 
 By way of summary it may be stated : 
 
 I. That cancerous tumors .should be excised when practicable ; and the sooner the 
 operation is pertormed after the diagnosis is clear, the better: that with the primary 
 growth all lymphatic glands that are involved should be removed likewise. 
 
 II. Open cancerous tumors, as a rule, should be treated by caustics, the best being 
 those which contain chloride of zinc. 
 
 III. For skiu cancers caustics are. as a rule, the most available, although excision in 
 some instances, as in the lip, is to be preferred. The galvanic or thermo-cautery. how- 
 ever, .should be employed when possible, it being the most rapid and efficient destructive 
 agent we possess. 
 
 D. Granulation Tumors 
 
 Include all composed of granulation tissue and have their origin in inflammation, whether 
 of a specific or simple kind ; the fungating and follicular tumor and the pedunculated 
 umbilical growths are its best examples, but it occurs in many other shapes. 
 
 Fungating and Follicular Tumors. — In neglected examples of sebaceous 
 
 cyst tile euiiteiits oi' the tuiimr may .soften down and. suppurating, escape externally by 
 ulceration. From the inner surface of the evacuated cyst a new growth may spring up, 
 which, when forming an irregular, fungating. bleeding 
 surface, may at times put on an appearance which has 
 been mistaken for cancer. On examining the edges of 
 the wound, however, this mistake can scarcely be long 
 entertained, as it will be at once observed that the edges 
 of the wound are healthy, and not infiltrated with new 
 matter, as would be the case in a cancer (Fig. 37). 
 This fungating growth is really composed of exuberant 
 granulations from the cyst itself. Abernethy recog- 
 nized this when he said, •' I have also seen, after the 
 bursting of an encysted tumor, the surrounding parts 
 indurate and throw out a fungus, forming a disease 
 appearing like cancer, and which could not be cured." 
 And ■' it is no uncommon circumstance to meet with 
 
 Fig. 37 
 
 Kuuguting Follicular Tiiiuor. 
 
 wens that have burst spontaneously and have thrown out a fungus which, like a fungous 
 
142 
 
 CYSTS. 
 
 body, prevents the surrounding integument from healing." The best account of tlic afFec» 
 tion is by Mr. Cock (6r»_y's Rej)., 1852). 
 
 Treatment. — There is but one form of treatment which is applicable to these tumors, 
 and that is their excision, care being ob.served to cut away the whole of the diseased tissue. 
 
 (jranulatiou tumors probably include the keloid. 
 
 Fig. 38. 
 
 E. Cysts. 
 
 These are developed in many ways : 
 
 1. Some are possibly new growths or largely developed cells having an independent 
 life and being capable of secreting tlieir own contents or producing solid growths — •• auto- 
 genous cysts," as Sir J. Paget calls them. 
 
 2. Some are formed in an accidental way by the simple effusion of fluid into the 
 spaces of connective or other tissues, the walls of the f^e false cijats gradually consolidating, 
 as is commonly seen in bursas and in ordinary tumors. 
 
 3. Others, again, are produced mechanically by the dilatation of occluded ducts or 
 natural gland orifices, the cyst enlarging by the secretion of the ducts or gland contents. 
 Of these the mucous cysts of the mouth and vagina, the sebaceous cysts of the skin, and 
 the milk cysts of the breast are the best examples. Alrchow calls these " cysts by 
 retention." 
 
 In many cases, however, it is impossible to ascertain how the cysts are formed. Some 
 are para.sitic. 
 
 Serous cysts are most commonly found connected with one of the vascular glands 
 of the budv. as the kidney, ovary, thyroid, or breast ; but they are not rare in the con- 
 nective tissue, and are found even in bones. When seen in the neck, they are described 
 as "hydroceles of the neck." Some of these are congenital, but the majority occur later 
 in life. They appear as single or multilocular cysts made up of thin membranous walls 
 lined with pavement epithelium. Like a serous membrane, they contain a limpid, watery, 
 or tenacious, highly albuminous fluid more or less stained with blood, occasionally hold- 
 ing cholesterine in suspension. These cysts are found in the neck anywhere between the 
 
 lower jaw and clavicle, beneath which they at 
 times pass (Fig. 38) ; they are usually deeply 
 seated; and occasionally superficial ; they give 
 annoyance only from their size, and are painless ; 
 when inflamed, they ma}' suppurate. They are 
 recognizable by their globular cystic form, soft 
 fluctuating feel, and painless increase. 
 
 These cy.sts are not to be confounded with 
 those of the tJij/rouJ gJamf which are far more 
 common, and at times attain a large size, grow- 
 ing as quietly and painlessly as do the cervical. 
 Usually, however, they have thicker walls, are 
 more tense, and are commonly multiple ; more- 
 over, the}' move up and down with the gland 
 on deglutition. Their contents are more viscid 
 and frequently mixed with blood in variable pro- 
 portions ; indeed, some of these thyroid cysts are 
 Uood cjjuts. which when tapped would go on bleeding, if allowed, even to the death of the 
 patient. I have recorded such a case {Giii/\ Reports, 18G4). It is probable, as Sir J. 
 Paget has suggested, that many of the cervical cysts are thyroid in their origin, spring, 
 ing from some outlying portion of the gland. 
 
 Cysts are also found over the thyroid cartilage, but these mostly contain grumous 
 blood and rarely grow larger than half a walnut. In a case under my own observation 
 a cyst completely covered the thyroid cartilage, and was lost on either side in the deep 
 tissues of the neck. It existed in an adult man as a soft fluctuating swelling, and had 
 been growing for some years as a painless formation. 
 
 Cvsts which are possibly bursal are likewise found in connection with the hyoid bone. 
 Treatment. — Cervical cysts had better be left alone, unless from their size they 
 require surgical treatment, because there is always danger in dealing with any deep-seated 
 cvst in this region from the liability of subsec|uent diffused inflammation of the cellular 
 tissues of the neck. I lost a patient some years ago from this cause, after simply tap- 
 ping the cyst. 
 
 Serous Cyst of the Neck (Birkett's case). 
 
6'>'.S7'.V. 143 
 
 W'licii siirL'if:il trcatinciit is calli'il l'(ir./H////V////r means had better he primarily adopted. 
 This trcatiiii'iit consists in iiit'iily ihawiiiu nH the ooiitciits oi' tlie cyst hy means of" a 
 trocar and cannhi or the '• aspiratiir.' Sliuiilil tin- fluid n,'-coih'ct rapidly, the operation 
 luav he repeated. In pi-rlorinin^ tins operation tin; surgeon, to j;uard a^rainst jmnetiir- 
 iiij; any oi' the snpcrticial veins or deep vessels, sliould recall their jiosition heion- pune- 
 turin,L'. 
 
 Slioulil tlii'sc measures i'ail even after several repelitiuiis. the hest jtrai-tiee is to intro- 
 dtice into the cavity of the cyst a draina;:;e-tnl»e. When the tappirijr has induced some 
 sup])uvative action, the oj)enini: may he eidarjred and the tuhe inserted ; hut when the 
 cvst is lar<;e, it is well to pass the tuht; completely through it. 'J'liis may readily he done 
 hv means of a lonij trocar and eanula, such as that (Muployed for puncturinji the hladder 
 per rectum, the pilot tr<iear heiiig introduced into tlie cyst after it has been ojjetied and 
 made to traverse the cyst to its most dependent jioint, jio.ssihly heneath the sterti(j-mastoi<l 
 muscle. The pilot trocar should then be removed, th(! drainage-tube pa.ssed through tlie 
 eanula, and the canitla taken away, the two ends of the tubing being fastened tog<!th(!r 
 to ])revent its slipping out. I have treated niany eases of deep cervical cysts in this 
 manner with success. 'J'lie great point to attend to is the free escape of pus and the cyst 
 contents; if air gets in, let the opening be free enough for it to jiass out. Slujuld fetor 
 appear, the cyst should be washed out daily with iodine or chl(tride-i»f-zinc lotion, Condy's 
 fluid, or some other disinfectant. As the cyst contracts the tube may be removed, but so 
 long as any cavity remains it should be lei't. The passage of a set(jii through the cyst is 
 another method which may ])e adopted, and this is probably more suitable ibr small than 
 for large cysts. Injecting the cyst with iodine is a third plan which has proved succes.s- 
 I'ul, though it is as dangerous as any other and not more successful. Extirpation of any 
 large cervical cyst is a mode of treatment which should not be entertained, since it i.s 
 fraught with danger and difficulties. 
 
 Thyroid cysts and their treatment will receive attention in another chapter. 
 
 The student should remember that nxvi, when they degenerate, commonly .show cyst.s 
 in their structure (Fig. 101) ; these are, however, usually clustered together in a cuta- 
 neous or subcutaneous group. When they appear in the neck, they might be mistaken 
 for one or other of the cysts already alluded to. This mistake will be prevented by 
 remembering the fact that they do occur and ]>y the history of the ca.se. 
 
 Congenital cystic hygroma or tumor is a peculiar affection, the nature of 
 which is not clear. It may appear in the neck, its most conimon seat, or elsewhere, as a 
 cystic swelling or as a more or less compact .solid growth, the cystic element varying in 
 each case. It is always deeply j)laced beneath the fascia and dips down beneath muscles, 
 tendons, and vessels. The skin over the tumor is, as a rule, healthy and movable ; but 
 in some cases, from the lobulated nature of the tumor, the skin is dimpled as in a lipoma. 
 From its appearance and position it may simulate many other affections, such as naevus or 
 spina bifida ; but pressure upon it has no influence in lessening its size. 
 
 The di.sease has a tendency to disappear naturally, though at times it may grow 
 rapidly. In some cases it inflames and then shrinks. 
 
 When treatment is absolutely called for, that by setons, as suggested by ]Mr. Thomas 
 Smith (^V. Baith. JIosp. Rtp.^ ISlK!), is the best. The knife should be employed in 
 excejjtional cases alone. The value of injection of iodine or INIorton's iodo-glycerine 
 solution has yet to be tested. 
 
 Mucous cysts are found wherever mucous glands exist, and are caused by some 
 obstruction to the escape of the gland contents. They contain highly tenacious mucus- 
 like liquid albumen. They appear on the mucous membrane of the lips as hihinl ci/atA, 
 and are small, tetise, glol)ular, painless swellings. They are found within the cheeks, 
 upon the tongue and gum, particularly of the upper jaw and antrum, and very commonly 
 beneath the tongue, as snhlhignal mucoux ci/sfs^ when they have been described as cases 
 of '^raniila." Such cysts, however, are now known to be due to okstruction of the ducts 
 of Kivini's mucous glands, and are not necessarily connected with the salivary organs 
 (Fig. 214). These cysts may develop about the larynx and cause obstruction, and they 
 have been found in the oesophagus. As hihinj and vnginal murjnis ci/stx they appear as 
 tense, globular tumors beneath the mucous membrane of the parts. I have seen them 
 as large as an orange. These cy.sts generally contain thick, ropy, mucoid fluid of a color- 
 less or slightly yellow tint. Occasionally the fluid is mixed with blood in diflferent pro- 
 portions. I have seen them contain black, milky, or coffee-ground fluid. Sometimes they 
 inflame and suppurate and run on into abscesses. 
 
 Treat.ment. — Small labial cysts may often, on dividing the mucous membrane over 
 
144 CYSTS. 
 
 I'hetn, be turned out as a whole ; but the sublingual and larger vaginal cysts, as a rule, 
 cannot be thus treated. A free opening into them or the removal of their external wall, 
 and the introduction into the cavity of a plug of lint soaked in iodine to excite suppura- 
 tion, may at times suffice to bring about a cure, but not always. In the so-called ranula 
 it may be tried before other practice is attempted. In the sublingual, labial, and vaginal 
 cysts I have for some years been in the habit of seizing the upper surface of the cyst 
 with a pair of forceps or tenaculum and cutting it off with scissors, thus freely exposing 
 the deeper wall. In the sublingual this practice is, as a rule, successful without further 
 treatment; but in the labial and vaginal cysts I have, in addition, generally destroyed 
 them by the application of some caustic, such as nitrate of silver or carbolic acid, to the 
 exposed surface, after which the wound will granulate healthily. When these cysts can 
 be excised, the operation can be performed. 
 
 The mucous cysts of the antrum and u]>per jaw will be described amongst the tumors 
 of the jaw. 
 
 Cutaneous sebaceous cysts, as they come under the notice of the surgeon, 
 appear as ^^ coni/eiut(ir' and ^'' dcijuircd" tumors. They are analogous to the mucous cysts, 
 the glands of the tissue being in both instances at fault. Some are doubtless caused, as 
 first described by Sir A. Cooper, by the obstruction to the orifice of the sebaceous glands 
 of the skin, for this occluded orifice may often be seen as a small, depressed, black 
 umbilicated spot upon the tumor ; the contents of the cyst may often be squeezed through 
 this orifice, or into it a probe may be passed. In a larger proportion of cases, on making 
 an attempt to raise the skin from the tumor, a dimple or evidence of connection between 
 the two will be visible, thereby revealing its nature. But in other cases no such obstructed- 
 duct, or even cutaneous depression, can be observed ; and, although the tumor may be 
 developed within the integument, it is probably a new fornuition, an adenoid or glandular 
 skin tumor. 
 
 The congenital sebaceous tumors differ from those usually met with in the adult, 
 or the acquired form, in that they are more deeply placed and mostly lying beneath the 
 fascia of the part, occasionally beneath the muscles ; they are rarely cutaneous. They 
 are more common about the orbit and brow than any other part, the external angle of 
 the eye being their favorite seat. They appear as small, hard, semiglobular masses deeply 
 placed, and are often, indeed, upon the bone. Cases, too, are on record in which by their 
 presence they have produced perforation by absorption of the bone. In the ear this 
 result is not rare. These cysts are thin-walled and often contain liquid secretion, some- 
 times of a pearly whiteness and not rarely mixed with hair. I turned a complete ball of 
 hair out of such a cyst on one occasion, though usually the hairs are fine like eyelashes 
 and are mixed with the sebaceous matter. The contents of these congenital cysts are 
 rarely offensive. 
 
 The acquired sebaceous cysts may be found on any part of the body that is cov- 
 ered with skin. They are more common on the head and lace than elsewhere, two-thirds 
 of all cases occurring in these regions. When on the scalp, they are known as "7<v?(.s" 
 (Fig. 39). They are always surrounded by a cyst-wall composed of fibrous tissue more 
 or less dense, and which can always be seen after these tumors have been enucleated from 
 their beds. In " Avens," however, there is a marked peculiarity which demands some 
 notice. " The chief peculiarity consists in a thick, dense, horny capsule which is closely 
 in contact with the fibrous envelope of the original gland. This horny capsule was for- 
 merly regarded as the cyst-wall altered by pressure, until Sir Prescott Hewett demon- 
 strated its true relations and anatomical structure in his lecture at the College of Sur- 
 geons. It is now clearly proved that when one of these sebaceous tumors is squeezed out 
 after the division of the .skin, the fibrous cyst remains behind. This cyst can be after- 
 ward excised, and its structure is identical with that of all the others. But the con- 
 struction of the horny capsule requires explanation. If carefully examined, it is found 
 to consLst of epithelium, layer upon layer, mixed up with sebaceous matter. Sometimes 
 a solid mass of epithelium is formed ; in other instances a cavity exists in the centre, 
 filled with soft sebaceous secretion. This capsule, then, seems to be a production of the 
 epithelium of the sebaceous gland, which, being subjected to the pressure of the unyield- 
 ing textures in which the tumor is developed, becomes converted by .slow degrees into a 
 tissue closely resembling horn or fibro-cartilage " (Birkett, Gin/i^ Rf'p., 1859). 
 
 These sebaceous tumors are more frequent in women than in men, and are, beyond 
 doubt, hereditary ; Sir J. Paget says " they are certainly more commonly hereditary than 
 are any forms of cancer." 
 
 The dermoid cysts of the ovary are only of pathological interest, as are the dentigerous 
 
TUK MIcnoSCOriCAI, A. \ ATOMY OF TUMORS. 
 
 45 
 
 cysts of these parts. Tlic di'iitiircrous cyst of tin- jaw will he trcutcii of in tho oliuptcr 
 on dist'ast's of the jaw.s. 
 
 Oil cysts iiro iiu't with, tliouj^h rarely, ami tiny an- prolialily always dermoiil. I 
 rcnittviMl Olio IVoiii the ])arotiil re- 
 gion of a fiirl iot. is which was Fio. .'W. 
 coiiir(>nital. It eoiitained liijiiid oil 
 {r„tl,. Soc. Trans., vol. .'UJ, 1.SS2). 
 
 Tkkatmknt. — The oidy cor- 
 rect treat incut of tliese sebaceous 
 or skin cysts, wlicthcr wlioh*, bro- 
 ken, or l"un<;atini;-, consists in their 
 removal. In rcniovinji' " wens" or 
 iivqin'n(/ cysts, liowever, it is not 
 necessary to be too careful in di,s- 
 sccting them out entire, and the 
 most eft'ective method is to slit open 
 the tumor with a bistoury and then 
 turn it out with the forceps or 
 handle of the knife. In the re- 
 moval of sebaceous cysts from 
 other parts of the body the capsule 
 of the c^'st should be taken away, 
 while in the funjrating tumor the 
 whole mass ought to be excised. 
 In the treatment of the roiujenUal 
 tumor it is always better to try and dis.sect out the cyst entirely ; but nothing is more 
 unsatisfactory than operating in such cases, for the cyst is always deep, its capsule thin 
 and adherent, and any attempt to dissect it out as a whole is too often foiled by the burst- 
 ing or puncturing of the capsule and the escape of its contents. When this occurs, the 
 surgeon must take away as much of the capsule as he can and then close the wound, a 
 good result following, as a rule, though at times a recurrence of the growth will ensue. 
 
 The fear of erysipelas after these operations is really almost groundless. It niav arise, 
 but out of more than one hundred cases consecutively observed I have not seen one 
 example. Pvicmia may follow this, as it may any other minor operation, but not more 
 frequently. When patients are cachectic, such an operation of expediency as that for 
 the removal of a " wen " had better be postponed ; for under low conditions of health 
 blood-poisoning is likely to follow. Should, however, its removal be urged, this may be 
 ♦lone by the injection into the cy.st of some caustic, such as a few drops of deliquescent 
 chloride of zinc, of carbolic acid, or the external application of nitric acid or potassa fusa, 
 to produce a slough througli the skin, when the contents of the cyst may be turned or 
 drawn out. 
 
 Sebaceous Tumors in .Scalp, and Horn. 
 
 THE MICROSCOPIOAL ANATOMY OF TUMORS. 
 
 By Dr. Moxox. 
 
 Every texture of the body in its earliest embryonic stage of development is alto- 
 gether composed of cells which have in their primitive condition no noticeable sub- 
 stance between them. As the texture progresses in its development the uniformlv 
 cellular composition of its primitive substance undergoes modification. Some of the 
 cells become separated by intercellular substances of various kinds ; others change to 
 capillaries, lymphatics, and nerves ; yet others retain their cellular form and remain in 
 close contact with each other. The general result is that when the .«everal textures of 
 the fully-developed frame are studied in the course of minute anatomy, each texture is 
 found to shew in its ultimate construction some remains of its cellular oriirin. more or 
 less evidently recognizable. In some tissues, such as the epithelial coverings and linings 
 and the cellular parts of the lymphatic glands, of the thyroid, etc., the cells remain always 
 distinct from each other, although in close mutual contact. In the several kinds of tissues 
 of the connective class, including cartilage, tendon, bone, etc., a large proportion of inter- 
 cellular matter separates the cells, this intercellular matter taking the form of hyaline or 
 elastic substance, as in cartilage ; of fibres, as in connective tissue and tendon ; or of cal- 
 cified substance, as in bone. The cells remain separate in cartilage, but in the other 
 tissues of this class they send out processes which unite to form a network throuirhout 
 10 
 
146 THE MICROSCOPICAL ANATOMY OF TUMORS. 
 
 the calcified or fibrous intercellular substance which constitutes the greater part of the 
 tissue. 
 
 Tumors of Nonstriated Muscle. — In the proper substance of mu.^^cle and 
 nerve, tissues endowed with special dynamic powers, the original cells generally blend 
 more completely, composing tubes or fibres. These tissues show very little disposition to 
 form tumors, or even to share in their formation. There is one exception to this indiffer- 
 ence in the case of non.striated muscle : the fibres of this kind of muscle retain to a large 
 extent their embryonic characters and never quite lose their primitive cellular composi- 
 tion ; the original cells are comparatively little altered and remain still distinct. And 
 with these embryonic characters the fibres of nonstriated muscle show a capability of 
 extensive new growth ; rapid production of this tissue occurs during adult life in the 
 pregnant uterus. Ana tumors of nonstriated muscle fibre are not uncommon in the 
 uterus and elsewhere. This texture is, indeed, of great interest pathologically, as show- 
 ing the association of a power of new growth in a highly endowed tissue, with a persist- 
 ence of embryonic form in its elementary fibres. It is perhaps the most striking example 
 of what is generally true in both normal and pathological histology — namely, that with 
 embryonic form in texture elements goes always power of increase and multiplication. 
 
 Blood Vessels in Ne"W Growths. — The behavior of the blood vessels in the 
 formation of new growths is an interesting field of study, in which useful observations 
 may yet be made. It will be found that the blood vessels which arise in tumors com- 
 posed of normal adult texture, such as bone, fibre, etc., are themselves composed of the 
 textures proper to normal adult blood vessels ; but, on the other hand, the blood vessels 
 of tumors which are composed of embryonic substance are themselves also composed of 
 more or less embryonic cell-forms. 
 
 The constitution of the blood vessels in any growth must be considered when we are 
 endeavoring to throw light upon those conditions which enable a tumor to infect the 
 blood passing through it, so giving rise to secondary tumors in the course of the circula- 
 tion. There are tumors in which blood vessels attain to undue proportion, and sometimes 
 tufts of blood vessel make up almost the whole of a new growth. Such tufts, projecting 
 on a free surface, bring danger of serious hemorrhage. 
 
 Activity of Embryonic Cells. — The discovery within a tumor of any large 
 proportion ot embryonic cells may generally be taken as a sign of active growing power. 
 Such cells are known by their indefinite transitional shapes, their large nuclei and many 
 nucleoli. These cells were formerly looked upon as special to the more dangerous kinds 
 of new growth, and were spoken of as " cancer cells." It was thought that one might 
 know a cancer by the presence of such cells. 
 
 But you cannot find out the character of a new growth by scrutinizing its cells indi- 
 vidually. It is true that .some kinds of tumor contain a large proportion of cells that are 
 so far peculiar as to be almost characteristic, such as the giant cells in a form of sarcoma 
 and the lymphoid cells of lymphoma ; yet cells of either of these kinds are met with in other 
 forms of tumor. Indeed, it is now generally admitted that the hope of being able to 
 determine the nature of a growth by the study of detached cells must be given up, and 
 the character of a tumor must be estimated by a general consideration of its whole struc- 
 ture, for experience has established the fact that the structure of a tumor indicates its 
 character ; so that dangerous tendencies are constant in tumors of certain construction, 
 such as carcinoma, and are as con.stantly absent in the case of tumors of a wholly differ- 
 ent construction, such as adenoma, whilst in yet other tumors there are lesser degrees of 
 danger. 
 
 Xow, in every tumor the new material is developed, like the natural tissues of the 
 body, from embryonic cells. And in any growing tumor some proportion of such cells is 
 always to be found in the part of the tumor then in the act of development. 
 
 But the several kinds of tumor differ exceedingly in the proportion of embryonic and 
 adult material contained in their composition, some appearing to the naked eye to be alto- 
 gether made up of an adult texture, whilst others are throughout constituted of embry- 
 onic substance; and it may be said that the more embryonic substance present in a tumor, 
 the greater will be its rate of increase, and generally the greater the danger attaching to it. 
 
 A tumor whose substance differs much from any of the natural tissues is generally a 
 tumor endowed with the embryonic ((uality of rapid increase, and hence is a dangerous 
 tumor ; whilst a tumor whose composition resembles that of any fully-developed tissue, 
 such as bone, fat. ligament, etc., is generally a tumor of .slow growth and comparatively 
 little danger. The most important exception to this general rule is in the case of carti- 
 lage. Tumors composed of cartilage may grow rapidh' and prove dangerous, but it must 
 
Till-: MICROSCOI'ICM. AS ATOMY OF TI'MollS. 117 
 
 be remembered that, altlidugli cartilaj^e is a tissue of the adult liuiiiuri frame, yet there 
 is such a thing as eml)ryoiiie cartihige ; and thus, indeed, cartilage may claim to he 
 regarded rut her as emhryouic than as adult. 
 
 When the substance (d" a tumor develops into adult tissue, the tumor so lormed is 
 always ciunposed of one <d" the proper tissues of the human body, ligament, fat, hone, 
 etc. The tissue thus developed is nearly always the same tissue as that from which the 
 tumor ari.ses — bone from bone, tihre from iiltre, fat from fat, papilUe from the papillary 
 layer (d" the skin, etc. Uut it must he iully understood that we are here speaking only 
 of [»rimary tumors, for it is most curious, interesting, and suggestive to observe how, 
 when a tumor in any tissue ari.ses as secondary to another tumor in another tissue, the 
 secondary tumor contains the tissue of the primary tumor, and therefore usually the 
 tissue of the seat (d" origin of the primary tumor. Thus, if a tumor arising from the 
 humerus and containing bone gives ri.'^e to a secondary tumor m the lung, the lung tumor 
 will then probably contain bone; but if primary tumors commonly reseirible in microscopic 
 structure the i)arts they arise in, this resemblance is only reached when the tissue of the 
 tumor attains to complete development ; for if the elementary cells of the new growth 
 remain permanently in an incomplete stage, and do not go beyond the form of embryonic 
 cells, the suhstanee of the growth will of course have characters differing from those of 
 the adult tissue wherever it ari.ses, and it may differ exceedingly from the adult form (d" 
 that tissue. 
 
 Indeed, if any primary tumor does not resemble the texture it arises in, this is nearly 
 always because its substance is in an embryonic state or stage. But with this embryoidc 
 stage is naturally associated a power of increase ; and hence it is that when a tumor does 
 not resemble the tissue in which it grows, that tumor will probably prove to be a rapidly 
 increasing, and therefore a dangerous, tumor. 
 
 It is not, however, only tlirough great growing power that a tumor becomes dangerous. 
 The chief danger, and the most dreaded danger, lies in the tendency of the tumor to 
 prove infectious either to the adjacent tissues or the corresponding lymphatic glands or 
 to more remote organs and parts of the system. 
 
 By infecting the neighboring textures the tumor will grow again from them after the 
 surgeon has done his best to remove it. By infecting the glands secondary tumors arise 
 in the seats of tho.se glands, whilst by infecting the walls of blood vessels, or otherwise 
 setting free its germinal particles in the blood stream, the tumor gives rise to secondary 
 growths in the great vascular viscera, the lungs and liver, or in the cancellous tissue of 
 bones, or generally elsewhere. 
 
 The possession of this infective power is what is meant by the term " malignant," 
 and the word " cancer " is popularly applied to any malignant tumor. 
 
 The microscopic structure of a tumor may throw some light upon its malignant or 
 infective powers. Thus careful inspection of sections of the edges of the tumor may 
 discover that its cells are already spreading into surrounding parts when no sign of their 
 presence is given to the unaided eye. Or it may be found that minute blood vessels 
 have their walls invaded and transformed by the new formation. A large proportion of 
 juice in the texture of the growth, especially if there be also a large share of easily 
 movable particles, will usually be associated with infective powers. The microscope 
 reveals that these particles are actively-growing nuclei and cells. It thus explains the 
 usual rough test by \vhich a tumor is tried for malignancy when the cut surface of its 
 section is scraped, and a milky juice being obtained is held to characterize a cancer. 
 
 But the proper manner of judging a tumor is by a thorough examination of its hi.sto- 
 logical structure and a reference of the tumor to its proper structural kind. 
 
 General experience has shown the degree of danger belonging to each sort of tumor, 
 and by a knowledge of the structure of tumor its tendency may be fairly inferred. From 
 the hi.stulogieal point of view tumors may be divided into the following groups. 
 
 OSTEOMA, OSTEOID CHONDROMA, EXCHONDROMA. 
 
 • When bone forms a large part, or apparently the whole, of a tumor, the tumor is 
 called an osteoma ; but no tumor is ever formed altogether of bone : there is always 
 present an ossifying matrix, by the ossification of which the bony part of the growth 
 enlarges. The kind of matrix varies much. Thus sarcomata, or even carcinomata. may 
 directly ossify, and so we get osffo-.saromn and osteo-carcinoma ; but the kinds of matrix 
 which produce growths of practically a bony nature are generally two — viz., periosteum 
 and cartilage. Periosteum — or, to speak more exactly, a tissue resembling closely the 
 
148 ADEXOMA. 
 
 deeper layer of the periosteum — forms large tumors whose transformation into bone takes 
 
 place in the manner shown in the left side of Fig. 40 ; the cells take the shape of bone 
 
 cells, and the matrix calcifies. These tumors are called osteoid cltondroma or periosteoma. 
 
 Cartilage often appears to be ossified when it is only petrified by deposit of calcareous 
 
 Fig. 40. 
 
 
 Fikromn 
 
 C^ 
 
 V 
 
 
 ^ ^J/irJiondro7n» 
 
 r'eihification 
 
 I 'f<ru rial ion. 
 
 
 s -f' 
 
 
 
 Microscopical Anatomy of Osteoma, Osteoid Chondroma, and Enchondroma. 
 
 salts in its matrix (see right side of Fig. 40) ; this change is, as is well known, the first 
 step in ossification of cartilage. In many cartilage tumors the process goes no farther, 
 or it may proceed to complete ossification through the several stages shown in the right 
 size of a figure — viz., vacuolation, formation of medulla-cells in the vacuoles, and direct 
 transformation of these to bone cells, as seen in the lower and right part of the drawing. 
 More rarelj' the cartilage cells, without calcifying, proliferate and change directly into 
 bone, as seen in the middle of the figure. 
 
 The amount of cartilage, periosteum, or bone present varies indefinitely in different 
 cases. When cartilage preponderates, the tumor is called an eticJioiidrovia ; when bone 
 preponderates, an exo^tosis^ osteoma, etc.. VLCCor^m^ to its shape and connections; when 
 periosteum preponderates, an osteoid chond romri , as before said. 
 
 Occasionally the amount of bone and cartilage is so equal that it is a matter of diflS- 
 culty to decide which name shall be used, and then the term cartilaginous exostosis or e}.'isi- 
 fyinej enchondroma is employed. OsterAd clwndromata are to be suspected of malignancy ; 
 such tumors compose a part of wliat were called osteoid cancers, and now called sarcomata. 
 
 ADENOMA. 
 
 The essential character of adenoma lies in the possession of a glandular structure, 
 but the comparative amount of the glandular element varies much. There is also vai'iety 
 in the kind of tissue which is found between the gland follicles. Some tumors show 
 structure almost identical with that of compound racemose glands, having natural-look- 
 ing follicles separated by delicate connective tissue ; more commonly the follicles are 
 dilated more or less, so as to form cysts ; one or more of these may prevail, so as to give 
 a cystic character to the whole (cystic adenoma). Besides the cysts arising in this way, 
 others may be formed by a breaking down of the intermediate tissue, especially if it 
 happen to be mucous tissue. But, as a rule, the glandular elements are surrounded and 
 separated by a more plentiful formation, which may be so much developed as to more or 
 less entirely take away the glandular character of the growth ; this interstitial tissue 
 may either be fibrous, sarcous, or mucous, or more rarely cartilaginous or areolar, or it 
 may present characters combining these or mediate between them (^adeno-Jibroma — sar- 
 
LYMI'IIdMA. 
 
 1-49 
 
 coma — myxomn). Wlicii the proportion of <rlan(l is small, there is doubt whether it is 
 not part ol" the original ;,'lanti-tissue persistin- in the new substance. Thus, the relative 
 aujrinentation of the cavities of duets or follicles may make the tumor take the charac- 
 ter of cvst, or the relative auj.Mnentation of the intermediate tissue may make it take the 
 character of sarcoma, myxoma, or fibroma; but if the glandular substance is maintained 
 in due proportidU. the natural resemblance of aden<ima is to carcinoma. 
 
 And, indeed, if the glandular substance is maintained in due proportion, then a very 
 little change is needed to give to adenoma the characters of carcinoma. When the cha- 
 racters of carcinoma are studied, it will be found that these characters are of the .same 
 general description as those of adenoma. In either case there is a mesh work of fibrous 
 or sarcous substance, iVirming sjtaces in which cells of a more or less epithelioid type are 
 packed together. The difference is one sometinies requiring close observation, and not 
 always to be determined quite .satisfactorily, wliilst in other ca.ses it is obvious enough. 
 The structural difl'en-nee between adenoma and carcinoma lies in thi.s — that in an adeno- 
 matous tumor the glandular epithelium is regular and composed of even-sized and rela- 
 tively small cells whose nuclei are generally .single and do not contain many nucleoli ; the 
 
 /from dreasij 
 
 Adenoma 
 Y-frorn ireast, 
 
 yroiLC/ry cystic^ 
 
 Adenoma ^ 
 i^rum shin 
 r^fcrc arm) 
 
 AdeTio-fibro- 
 sarcoTna 
 . fyrum ftp J 
 
 Microscopical Anatomy of Adenoma. 
 
 cells do not vary in form, and line the follicles of the adenoid texture in an even and 
 orderly manner : whilst in carcinoma the nuclei in the cells are larger and brighter and 
 have many nuclei, and the cells vary much in form and size and compose usually compact 
 masses projecting into irregular bulbs in the sarcous stroma, instead of lining follicular 
 cavities. 
 
 LYMPHOMA. 
 
 The name " lymphoma " is given to such growths as have a microscopic structure 
 like that of lymphatic glands — in particular, which have a finely reticular meshwork, 
 connected with which are some fixed cells at tolerably regular intervals, not unlike the 
 fixed cells of connective tissue, but generally larger. AVithin the meshes of this net- 
 work are numerous cells which resemble lymph cells, and hence are also like pus cells 
 and white blood cells. The proportion of network to the contained lymphoid cells is 
 variable ; sometimes the quantity of fibre is great, and the structure is then like lymph- 
 gland tissue hardened by chronic inflammation. In other cases the proportion of cells 
 becomes very large, while the network grows very delicate and open-textured. The 
 fixed stellate cells here appear to multiply and produce a progeny of the loose movable 
 cells in the meshwork. as if infected by the latter. The whole mass then appears as fine 
 filaments making bold meshes, which are filled with round granular cells like lymph cells, 
 but generally larger than these, and having large nucleus and many bright nucleoli. Such 
 
150 
 
 SARCOMA. 
 
 cells at first appear to make up the whole substance, but they easily brush or wash out 
 of the meshes, leaving the network very conspicuous. It will be noticed that the degree 
 of structure here described is very rudimentary. Indeed, sections of ante-viorlem blood 
 clot from within a vein (see figui'c) closely correspond to the description. So also does 
 tubercle in the more recently formed outer edge of it, where its texture is very like blood 
 clot ; hence it is by some classed with lymphoma. Scarlatinous tonsils and typhoid Pey- 
 er's patches likewise have lymphoma structure. However, the plan of structure is so 
 meagre that it is not enough to form a bond of union between diseases clinically so 
 remote. 
 
 When found in the form of tumors, more properly so called, lymphoma generally 
 takes its rise in the lymphatic glands ; those of the neck are especially liable to it, then 
 
 Fig. 42. 
 
 Ante-morfem 
 fi/uocl- clot 
 
 fffroma 
 
 jltnfi//i 
 ouL 
 
 Cervical 
 Glani/t 
 
 
 Tonsil in 
 Scarlatina 
 
 fi/irem/inq 
 inlt '^ 
 
 Tubercle 
 
 _^^, 
 
 I'm/I aubmiLcoiiE coat ojjh vm/iri7'//i//n//cil/(il 
 Microscopical Anatomy of Lymphoma. 
 
 those of the abdomen and of the mediastinum. It is also found in the alimentary canal, 
 especially the small intestine and stomach, and in the spleen, liver, kidney, etc. For- 
 mations of a similar structure have been met with in various organs in leukfemia, chiefly 
 in the liver, in the form of small grains of a pale substance. 
 
 Lymphoma may prove malignant — that is. infectious to parts around — especially when 
 the cellular elements are very numerous (in which case the tumor is called ^- lympho-sar- 
 coma" by Virchow) ; it then' corresponds to a part of what used to be included under the 
 whole name " medullary cancer," which, as formerly used, would include also soft .sar- 
 coma and soft carcinoma. Indeed, these tumors, when the cell elements greatly prepon- 
 derate, become very much like each other, if not undistinguishable as far as their mere 
 structure is concerned. 
 
 SARCOMA. 
 
 The schematic figure (43) is composed of accurate drawings of portions of the several 
 kinds of sarcoma named, but they are gathered together in a diagrammatic way. the forms 
 being graduated into each other as they are when found side by side in the same tumor. 
 You meet, indeed, with all gradations of intermediate forms ; for although, as a general 
 rule, one kind of sarcomatous tissue prevails in a tumor, it is far from unfrequent to have 
 more than one of the kinds present together, the characters of each changing into those 
 of the other. 
 
 The distinctive histological character of surcoma is the possession of a stroma between 
 the cells, an atmosphere of intermediate matter which surrounds each and is between 
 them all ; the qualities of this intermediate or " intercellular " matter determine the kind 
 of sarcoma, as in the class of connective tissues whose developmental stages the several 
 kinds of sarcoma closely resemble. The class of connective tissues includes the several 
 
MYXOMA. 
 
 lol 
 
 kinds of texture whoso office in ilir ImmIv is ]>as.sively mechanical, either in serving as 
 adjuncts to the luuscuhir syslrui or l»y tillinii up interstices between (»rj;ans of the body 
 or by entering! into textures to support tlu'ir component j)arts, bhjod vessels, etc. Those 
 connective tissues wliicli penetrate info iiiiy ol' tlie organs of the body are modiii<-d in 
 consistence and in arrangemt'Ut of ilnir cIcnKiits according t(j the re<|uirements of the 
 organ. Thus, in the brain the coniu'ctive tissue, caMed "neuroglia," is very dulicate and 
 soft and has scarcely any distinctness. Also the connective tissue which enters into the 
 lymphatic glands bcconu-s reduced to very soft fibrillar matter between the lyniph cells. 
 In these instances, and in others, the connective tissue thus comes to have j»eculiarities 
 and to constitute strongly-marked varieties. Vet all connective ti.ssues possess this com- 
 mon feature in their elenuMitary structural composition — that they are made up lA' cell- 
 ular bodies between wliich their proper substance forms an intercellular matter. 
 
 The relation of sarconui to the connective class of tissues appears to be thi.s — that 
 when one of these tissues i.s produced very rajtidly it has no time for its intercellular 
 matter to ac(|uire the i)roper characters, and so remains indeterminate, while it also is 
 small in quantity, the cells greatly preponderating. Thus, any of the normal connective 
 tissues may produce by rapid development a tumor of .sarcous tissues or sarcoma (the 
 name is well chosen : thii^, wliich e((uals caro or our word Jfish, means commonlv any 
 soft animal substance, not blood nor bone). Thus it follows that there are several kinds 
 of sarcoma, according to the tissues from which they are developed. The principal of 
 
 Fig. 43. 
 
 Lai-ge 
 Trabecular Spindle -cell Spin file rell 
 jicutly cross cut ^ 
 
 Giant -cell 
 orMyeloid 
 
 Fibro 
 
 Traiecular /(y\^/r^ >/ 
 
 croKS-cut 
 at -J- 
 
 Sarcoma VJ / L/^ ^ff^ 
 
 Glw Sarcoma -• 9 
 orifwi[li mucous Intercellular 
 Mys-U Sarcoma 
 
 Small Round Cell 
 or Ly7nj)ho Sarcoma 
 
 these are seen in the above schematic figure. The round-celled kinds generally arise 
 from lymph gland or neuroglia or mucous tissue ; hence they are common in myxo- or 
 glio- or lympho-sarcoma. The spindle-celled kinds arise from connective, fibrous, or bony 
 tissue, and hence are most common in fibro-sarcoma or osteo-sarcoma. 
 
 One other form of sarcoma is usually described, the alveolar sarcoma, which is not 
 mentioned here. It is a rare form of tumor, and resembles superficially a cancer or car- 
 cinoma. It is formed of a stroma, which maps out large spaces, and these are filled with 
 large round cells. By careful pencilling the characteristic intercellular substance may 
 be distinguished. 
 
 MYXOMA. 
 
 The name " myxoma" is given to all tumors of connective-tissue type (not epithelial) 
 which contain mucus or mucin in their intercellular matter. It corresponds nearly to 
 gelatinous sarcoma, collonema. and fibro-cellular tumor of old authors ; tlie forms of the 
 cells are very variable, but in the most typical examples, and especially in the older and 
 fully developed parts, the cells are large and usually multipolar or '' stellate." with a dis- 
 tinct nucleus and nucleolus : the stellate branching rays of the cells are mutually con- 
 
152 
 
 MYXOMA. 
 
 nected. so as to form a more or less open network, in the interstices of which the mucous 
 semi-fluid lodges. Beams and bands, which generally have a stiff, rigid appearance and 
 an angular rather than a wavy disposition, pass about, dividing up the substance of the 
 tumor into very imperfectly defined sections more or less visible to the naked eye ; from 
 
 Fig. 44. 
 
 Myxomatous EncJumdroma 
 
 Stellate-cell 
 Myj.vma 
 
 '^^ LeijiTma 
 
 SruhondwmcK 
 
 Eound cell 
 Myxoma 
 
 Spindle cell 
 Myxoma 
 
 these arise fine fibrils continuous with the cellulo-fibrillar network. Much of the tumor. 
 and especially the younger part, may be found formed of spindle-cells : these are really 
 connected, by threads from their sides, with the intermediate fibrillar network, and it can 
 often be seen that the stellate forms are produced by the drawing out of these threads to 
 greater lengths, through the .separation of the texture elements by the increasing quan- 
 tity of mucus. In yet other examples or parts the prevailing form of the cells is round 
 or with one pole : the round cells resemble ordinary mucous corpuscles and are scattered 
 among the fibrils in the mucoid matter : they also contain many fat-grains and are found 
 in the oldest part? of the tumor, representing the senescence of its cells. There is also a 
 great variability of the intercellular sub.stance — first, in proportion of the fibrous to the 
 cellular part ; and second, in the proportion which these solid elements bear to the mucoid 
 interstitial matter : thus, there is a fibrous myxoma and a clear pellucid variety, with 
 much mucous fluid, pierhaps even forming cysts (hyaline and cystic myxoma). In some 
 examples there are large polynucleated cells identical with the so-called giant cells of 
 " giant-cell " sarcoma. 
 
 In the theory of types, myxoma is affiliated to certain natural tissues, in particular 
 the jelly of the umbilical cord, the vitreous of the eye at a stage of its development, and 
 the early stages of adipose tissue, or to a stage of bone formation out of cartilage. It 
 will be seen that these typical tissues are onlv transitory in their nature as compared 
 with .such stable tissues as bone, cartilage, tendon. In accordance with this instability 
 of their type, myxomas themselves .show many transitions to various kinds of connective 
 tissue : these transitions are chiefly toward cartilage or fat (myxomatous enchondroma. 
 myxomatous lipoma). Tumors are not infrequent, especially in the parotid region, which 
 are intermediate between cartilage and mucous tissue, .so that one cannot say to which 
 they most properly belong ; also many fatty tumors .show clear gelatinous patches of 
 mucous tissue in all transitions to fat, while many myxomata .show opaque spots composed 
 of true adipose tissue. 
 
 rARflXOMA. 
 
 The term •• carcinoma" is now distinctively applied to such tumors as have a structure 
 of the following description — viz., a mcshwork of fibrous or sarcous substance compo.sing 
 an alveolar structure, whose interstices are filled with cells. These may have no orderly 
 or methodical-looking arrangement, being packed in the crevices in the mcshwork (or 
 alveoli, as they are called^ and extending casually from alveolus to alveolus, so as to 
 
C'J/.v7.Vo.i/.|. 
 
 153 
 
 luake a oumpleuu'iitary iiu'sliwork. TIk- carciiH.niatous cliaracter in determined Vjy the 
 presence dl" sueli alveolar structure with cell ciilleeti(»iis lodjred in it; the decisive point 
 consists in these cells lyinj; dose toj^ether without any intercellular suhstance ; the cells 
 generally vary in shape and have larj^e nuclei, with lar^rc and bri<rlif nu<le(»li. But often 
 the cells have an arran^renient very like the e|iith(lial liniii<r of the follicles of the secret- 
 injr Inlands — a stnictiirr wliich may Itc mi well iirondunced as to hriii^^ tlnni almost into 
 
 Jlitrd 
 
 Cari'inomo 
 (Livrrsecoiiitl' 
 t,(,r»,xl l/,r 
 right side shcu 
 halftrmis/'ornwt 
 fiver hysurl/u 
 Ifft scirrhous 
 stihstnncc, I hr cells 
 alinosf thvimllctl 
 
 Utl'tll/-) 
 
 r^ 
 
 Hard 
 Cnrrinoina 
 (yifeurn, scoml^^ \ 
 to brenst, l/u 
 eerr/i/ sluc/r 
 at Uiis (nil J 
 
 Cen^iJ , nr All rolrjr 
 Curci/idiiia {'nc/ii/Ji 
 frir/ht side s/iotis 
 lAe rfids n/two 
 Lider/Kii/infullidcs, 
 
 ^ Ctirrinoiiiit 
 Cerebrl/iuii, srcotidtirtf 
 lu l/rcast^ 
 
 &rft Carruiomn 
 (Kidney steont/z/r'/ iO 
 fis. (K.'iop/ia(^a\'. louvr 
 hfl /land coriur showi 
 . II mull (uliuti u'lHi a 
 C(jsl ; l/it lun caneir 
 .a rent UP luxl III is air 
 ■vidrntli/ transfonna- 
 'niris of'sm:h lu/ics 
 Hiqlil fdi/c, new yra- 
 iiiitf (i^suc i;/ the 
 >tromaf Lefl edye, 
 drve/op -' of l/iis ialo 
 a spi/idie cell Slrai/ia 
 
 Hard Carcinoma 
 (pleura S(cy 
 lu breast. 
 
 I he oldest 
 part at 
 
 I his end) 
 
 
 
 FipilAe/ioma or 
 
 uilhelial CarcC- 
 
 Cy/t rider - 
 £/iillielieil 
 
 Ce/r, iiioiiut 
 
 I'coluii, tt ^ 
 
 sinit/tirstrito [^ 
 t:urrjFiiiiJid 
 in li'ver fif 
 same casrj 
 
 I ma ^shtfi of 
 ':, e/r sk/>u i/iy 
 /land-like 
 si rielure resemS- 
 liny a/so t/ie lym - 
 ' phaltc ducts, several 
 dirds Pfsl todies are 
 seen I lie slrvma it 
 of coi/ntcltve lis- 
 siie ^ tiiphlu clierr- 
 aid with T/ciiiQ 
 • cells.) -^ ^ 
 
 £/iithelioniei , 
 
 or K/iilheliiil 
 
 Curcitio/iKt 
 
 SfitMioma 
 
 or 
 Epithrlial 
 CarnTuma 
 
 
 Separate 
 Cells 
 
 Microscopical Anatomy of Carcinoma. 
 
 continuity with adenomas ; they differ from these chiefly in their history, as being infec- 
 tious, so as to extend into the neighboring tissues, to the glands, or to the viscera, the 
 structure showing only those minor peculiarities which I have just described. 
 
 Five leading types of carcinoma may at present be conveniently distingui.shed : 
 1st. Those in which the fibrous meshwork is in preponderance and the epithelioid con- 
 tents of the alveoli arc scanty, and perhaps also prone to perish early, so that they are 
 found more or less degenerate within the fibrous meshes : Hard Carcinoma, or Scirrhus. 
 2d. Those in which the fibrous meshwork is in smaller proportion and the epithelioid 
 
154 CARCINOMA. 
 
 contents are plentiful, making large collections of cells, but with no evident approach in 
 the form of these collections to the shapes of gland acini, and no evident resemblance of 
 the component cells either to the columnar epithelium of mucous glands or the squamous 
 epithelium of cuticle : Soft Carcinoma. This kind occurs especially in glands, and the 
 transformation of the glandular tubes or follicles to cancer alveoli can be seen in all 
 stages in the growing margin of the tumor. (See the two upper drawings in Fig. 45, 
 from the liver and kidney.) 
 
 '3d. A structure essentially such as that last described, but with this difference — that 
 the epithelioid cells have a quantity of mucus between them, which is regarded as arising 
 from a transformation of them. This change to mucus may be carried to such an 
 extreme that scarcely any cellular elements are left, while the alveolar meshes in which 
 the mucus is contained become very strikingly visible from their nakedness and the pellu- 
 cidity of the mucus : Colloid, or Alveolar Cancer. A common seat of this is the wall of 
 the alimentary canal, where it may be traced arising from Lieberkiihn's follicles. 
 
 4th. A structure in which the epithelial cells resemble squamous epithelium and form 
 masses which are very like the follicles of cutaneous glands, or occasionally like rudiment- 
 ary hairs ; the tubular and bulbous forms may, however, be seen ramifying like the 
 lymphatic vessels of the skin, as if their form were moulded to the lymphatic plexus : 
 Epithelioma. In these cancers peculiar bodies are. found, composed of flattened cells 
 disposed concentrically so as to form a scaly-walled globe (a, Fig. 45) who.se appearance 
 is like the section of an onion or like a bird's nest ; these are so large as often to be vis- 
 ible to the naked eye ; when they are numerous and well characterized, they are diag- 
 nostic. Some authors (Billroth) distinguished a variety of this cancer in which the 
 stroma preponderates over the epithelial part, calling it scirrhus of the skin : Squamous 
 p]pithelial Carcinoma. 
 
 5th. A structure in which the epithelial cells resemble ordinary columnar epithelium, 
 and the structure itself is quite like normal mucous membrane, in which it always pri- 
 marily arises (alimentary canal, especially colon, uterus) ; the secondary formations 
 which occasionally occur in these cases, in the liver especially, have the same .structure, 
 and thus a tissue like the glandular mucous membrane of the colon may be found in the 
 liver : Cylindrical Epithelial Carcinoma. 
 
 The fourth and fifth varieties are distinguished from the three first as epithelial can- 
 cers or epitheliomata. Some authors have used the term " cancroid '" for the fourth 
 variety, as though it were not completely cancerous. These are less likely to infect the 
 viscera than the first two varieties, which are the most infectious of all tumors, though 
 they are very far from being the only kinds of infectious tumors. 
 
 YiRCHOW, 7)/e Krankhaften Gesehwuhte, 1862— 5. — Paget, Surylcal Padiolotjii, 1870. — Abkrnethy, 
 On Tumors. — Pathological Societi/ Trans. — WiLKS and Moxon, Pathology.— Bu.i.B.OTii, Eteviens de 
 Pathologie Chirurgicale, 1868. — Holmes, System of Surgery, 1882. — Debate on Cancer of Pathological 
 Society, 1874. 
 
SURGERY OF THE CUTANEOL.S ^V.STEM. 
 
 CHAPTER IV. 
 CONTUSIONS. 
 
 A "contusion" is an injury, caused either by a fall, a blow from a blunt instru- 
 ment, or sevtMv pressure, in which there is no .solution of continuity of the skin. The 
 degree of injury depends upon the amount of force a])])licd and the re.sisting power of the 
 tissues injured. Ilealthy tis.sues .suffer little where the soft or unhealthy suffer much. 
 The subjects of hioniophilia fare worse than all others. When the force has been suf- 
 ficient to produce rupture of the small vessels in the skin and subcutaneous tissue, an 
 " ecrlii/niosiV or " hniixe" is said to exist; when it so injures the deeper tissues a.s to 
 cause effusions of blood from rupture of some of the larger vessels, '• fxtravasation of 
 hloo(V' is said to be present ; when the blood effused fijrms a local swelling, it is known 
 as a " hir.mntunKi.' 
 
 After a slight contusion there may be no luuising. but only local pain and 
 swelling, the swelling becoming red and then disappearing. The wheal that rises after a 
 lash with a whip is the best illustration of this condition. 
 
 An ** ecchymosis" is an effusion of blood iato the skin and subcutaneous tissue, 
 and it shows itself, according to the force employed and depth of tissue injured, within a 
 few minutes or hours of the injury, as a livid red, deep-blue, or black patch, which in the 
 course of twelve or eighteen hours becomes larger and lighter at its margins. About the 
 third day it assumes a violet tint ; on the fifth, an olive brown ; on the sixth, a green ; 
 on the seventh or eighth it has a yellow aspect, and this, fading into a lemon tint, then 
 disappears altogether. An ordinary bruise generally runs through all the.se stages in 
 about two weeks, the rapidity of the process depending much upon the amount of blood 
 effused and the reparative power of the patient. When no blood has been effu.sed into 
 the skin, but '■ extravasation" has taken place in the deeper parts beneath a dense fascia, 
 the discoloration of the integuments may not appear for three, four, or even fourteen, 
 days, while in some cases, where the blood has made its way between the tissues and 
 reached the skin away from the seat of injury, the "ecchymosis" will be at some distance 
 from the spot at which the injury was received and may not show till late. When much 
 effused blood exists, the swelling will be great. 
 
 The (tbstiicf of ecchymosis is no proof that a contusion ha.s not been experienced, since 
 a fatal rupture of deep parts or of some viscus may be present without any external signs 
 of injury. 
 
 On making a section of a bruised part the skin will be found throughout its thickness 
 infiltrated with' blood and firmer and thicker than natural : whereas, when the effusion 
 has been the result o? violence applied to the body after death, the blood will be beneath 
 or upon, but not in, the cutis, and it will be in small quantities and venous. 
 
 Neither />(/;y)»/v'(' putclii't^ nor those o^ ''' erj/thema ^lodosuni' ought to be ni'staken for 
 bruises. The general diffusion of the spots over the body in the one case, and the history 
 and the general aspect of the other affection, should prevent the error. It should be 
 remembered, however, that in purpuric patients and in '• bleeders" a slight blow or pinch 
 may be followed by a severe bruise. 
 
 A severe contusion may cau.se a rupture of a large artery or vein, under which 
 circumstances a fatal extravasation may ensue ; or it may so crush or pulp the tissues as 
 to destroy their vitality : this a spent cannon-ball may accompli.sh ; or it may so rup- 
 ture a viscus as to cause death. More frequently, however, a severe contusion causes a 
 separation of the skin from the deep "tascia and deeper parts, with more or less extravasa- 
 
 155 
 
156 ARROW WOUNDS. 
 
 tion of blood into the split tissues. The effects of a contusion also vary according to 
 locality ; thus, in an adult, a blow over the scalp may be followed by a local effusion of 
 blood, and in a child this effusion may go on so as to form a swelling involving more or 
 less of the whole vertex. In the buttocks and loins blood may be so effused as to give 
 rise to a large fluctuating tumor. In the loose cellular tissue of the scrotum or female 
 genitals an effusion of blood may give rise to enormous enlargement, and in the eye every 
 one is familiar with the change. 
 
 Where the extravasation of blood has been extensive, the removal of the clot is a 
 work of time. In some cases the blood remains fluid for a long period, and at length 
 becomes absorbed ; in others it breaks down and gives rise to suppuration. In some, 
 again, it persists for weeks as a large blood tumor, and then suddenly softens down and 
 is absorbed. In exceptional instances it becomes apparently encysted ; and " there is 
 sufficient reason to believe," says Paget, " that blood extravasated in a contusion may be 
 organized, acquiring the character of connective tissue, becoming vascular, and taking 
 part in the repair of the injured tissues," as is seen in the repair of fractures and in liga- 
 tured or twisted vessels. 
 
 Treatment. — A slight bruise, if left alone and not manipulated, will get well ; for 
 blood is often rapidly absorbed, as is seen in the eye. To check extravasation, cold is the 
 best application, in the form of pounded ice in a bag, or a mixture of salt and saltpetre, 
 or the iced poultice,' or, what is far better, Leiter's metallic coil (Fig. 9, p. 49), and in an 
 extremity elevation of the limb with rest. To check any inflammatory action during the 
 progress of the case cold is equally effective. To hasten the absorption of the effused 
 blood tonics are often of service, and the application of gentle pressure by means of 
 bandages or strappings is valuable. 
 
 A lotion of the tincture of arnica one ounce to a pint of water, or one of the stimu- 
 lating liniments, such as the soap or opium, seems to have some influence in hastening 
 the absorption of blood. 
 
 In cases in which there is extensive effusion of blood, and where the circulation in 
 the part is interfered with, lint soaked in oil and covered with cotton-wool is the best 
 dressing to maintain warmth in the part ; moist applications are not good. 
 
 When the blood remains fluid and is not absorbed, the surgeon need be in no hurry 
 to interfere, for occasionally interference brings trouble, although, when time pres,ses, the 
 use of the "aspirator" to draw off' the blood — or, rather, bloody serum — often expedites 
 recovery. AVhen aspiration has proved ineffectual and a blood-clot remains, this should 
 be evacuated by a free incision, and the exposed cavity irrigated with iodine, boracic acid, 
 or carbolic lotion and then drained, well-applied pressure and immobility of the part being 
 employed. When the blood has broken up and suppuration appeared, a free incision is 
 essential, the case subsequently being treated as an abscess. 
 
 Arrow Wounds. 
 
 These, which are punctured and incised wounds, have been made the subject of a 
 special essay by Dr. Bill in the American Journ. of Med. Science, vol. xliv., 1862. He 
 tells us that it is exceptional to meet with single wounds, the American Indians discharg- 
 ing their arrows so rapidly — an expert delivering six in a minute — that if one takes effect 
 it is immediately followed by others. The Washington Army Medical Museum contains 
 specimens of penetrating arrow wounds of the skull. Where both tables are punctured 
 there is little or no Assuring externally or internally, as the vitreous table is penetrated 
 as cleanly as the outer. " This is in such marked contrast to the results of bayonet or 
 sword thrusts, or of the impact of gunshot projectiles, as to merit notice." 
 
 Arrow wounds of the chest are not always fatal ; those of the abdomen are generally 
 so. Dr. Bill tells us that the Indians, on this account, always aim at the umbilicus, and 
 that the Mexicans when fighting the Indians, on this account, always protect the 
 abdomen. 
 
 The velocity of the arrow when first projected is so great that it has been estimated 
 
 '/ce poultices, as suggested by Maisonneiive, are excellent for tlie local application of cold, and are 
 made as follows; Take of linseed meal a sufficient quantity to form a layer from three-quarters to 
 an inch thick ; spread a clotii of proper size ; upon this, at intervals of an inch or more, place lumps 
 of ice the size of a big marble; then sprinkle them over lightly with the meal, cover with another 
 cloth, folding in the edges to prevent the escape of the mass, and apply the thick side to the surface 
 of wound. The exclusion of air retards tlie melting of the ice, and the I hick layer intervening 
 between it and the surface prevents painful or injiu-ious contact. In injuries to the abdomen this 
 remedy is very applicable. Dr. W. H. Doughty of the U. 8. A. speaks highly of it. Circular No. 3. 
 
Ji[riL\S AM> SCALDS. 157 
 
 to etjiuil nearly that of a imiski't-liull, hut arrow-tirin;; is incfl't'ctive over a hundrcil yards. 
 
 At a short distaiici' an arrow will pcrloratc tli»; 
 
 larjji'r hones without conMniniitiiiL' them, or will Fio. ■!*). 
 
 cause a slijjhl tis.sure only, reseinhlini:; in these JB 
 
 respects the efieet of a pistol-hall Kred throu";!! ;i , ^^^ 
 
 pane of i;lass a few yards off. This is well seen /' . . ^ 
 
 in the drawing; (l'"'^- ■^^*)- \ ^^-"^^ ~ j 
 
 The wound of entrance in the soft parts is a [ _ ^--^^^ ^^^''^^ - ■' 
 
 contusetl depressed slit; tliat of exit, a mere slit. ., , „ , ,, . ~ 
 
 \\ hen an arrow strikes tlu? skin ol>li(|uely, tlie (.surgeouGenfrara (jtlke, L. .s. <:iiL. ;.) 
 
 wound will l)e that of a loiii; incised wound. 
 
 The treatment of these wounds is thus summarized hy Dr. IJill ( Inti ruationnl Hniydo- 
 j)tri/iit of' Siiiyrr//. vol. ii.): 
 
 1. \u arrow-head must he removed as s(jon as found. 
 
 2. in the seanli for the arrow e.vtensive incisions are justifiahle. 
 'A. All arrow may he j)ushed out as well as plucked out. 
 
 4. The tiiiLTcr should he used for e.\i)loratioii in preference to a probe. 
 
 5. (Ircat care must be taken to avoid detachment of the shaft. 
 
 6. Healing by tirst intention should be encouraged. 
 
 BURNS AND SCALDS. 
 
 A burn is caused by the ai>plicatioii of concentrated '//// heat to the body ; a SCald, 
 by the application of hot or boiling li(|uid. As a rule, scalds are les.s .severe accidents 
 than burns, because water, being the ordinary fluid through which the scald is produced, 
 is never hotter than 212° Fahrenheit; yet when any other chemical compound is the 
 scalding medium, the effects are, at least, often as bad as the worst burns. The worst 
 local burn I ever saw was when a man put his booted foot and ankle into a pot of molten 
 lead. Tiie limb came out covered with a boot of metal, and was destroyed even to the bones. 
 Mr. Aston Key amputated the limb at once below the knee without removing the metal. 
 
 A moderate degree of dry heat applied in the pursuit of a calling indurates the skin 
 and blunts its sensibility, and an iron-worker or a blacksmith can maniijulate pieces of 
 hot iron that would " burn " ordinary people. Thus, some .skins or parts of the body are 
 more sensitive than others, and under the same influence may be differently affected. 
 
 The effect of heat when applied to the body varies according to its intensity and the 
 (hirnfion of its application ; it may cause a simple redness of the surface or the death of 
 the part. 
 
 Thus, its jirst effect is mere redness and tenderness of the surf^ice, and after a few 
 hours the.se .symptoms may subside, the cuticle possibly desquamating. 
 
 In the second (h'tjree of heat inflammation is the result, this action manifesting its pres- 
 ence by the formation of a hiistcr, from the effusion of serum beneath the cuticle. 
 
 In the third degree the superficial layer of the true skin is destroyed, the siir/nee 
 appearinr/ of a graij-yeUoicish or hrorcn color, not painful unless roughly handled. The 
 vesicles that exist contain a blood-stained or brown fluid. The papilla? of the skin, with 
 its nerves, are first destroyed ; but when, in the course of a day or so, the dead surface 
 has been -'shed" and the nerves exposed, the pain is very severe and the exposed surface 
 has a reticulated surface. 
 
 In the /our f/i degree the whole thickness of skin is destroyed, with more or less of the 
 subcutaneous cellular tissue, the parts being converted into a hard, tough, dry. and insensi- 
 ble eschar mottled with blood : vesication does not exist in this degree, all the superficial 
 tissues having been destroyed. The skin surrounding the eschar may be blistered, but 
 where it comes in contact with the injured part it will ])e drawn into folds from the con- 
 traction, owing to the drying of the burnt integument ; this puckering fairly indicates 
 the important fact that the whole skin has been destroyed. The eschar does not begin 
 to separate fur four or five davs, an inflammatorv zone of redness with pain of some sever- 
 ity indicating the commencement of a process that will not be completed for two or three 
 weeks. When the slough has come away, a long and tedious process of suppuration and 
 granulation must be gone through prior to the repair of the exposed parts. 
 
 In the Jj/th degree the skin with the deeper parts is involved, a black, brittle, charred 
 mass taking the place of healthy tissues. 
 
 In the sixth degree the whole thickness of a limb is carbonized. 
 
 These divisions, originally made by the great French surgeon Dupuytren, .so well 
 
158 BURNS AND SCALDS. 
 
 accord with all observation that they have been invariably adopted by modern surgeons ; 
 and, although in burns and scalds one degree passes imperceptibly into another and in 
 bad cases coexist, in the main they can be made out. 
 
 Prognosis. — Next to the intensity of the heat and duration of its application, the 
 extent of surf ace involved is the most important point; indeed, as regards life, it is of far 
 greater importance than the other two, because a superficial burn spread over a large sur- 
 face, although not locally so injurious as a more severe one, is more fatal. In the major- 
 ity of cases of deaths from burns and scalds, more particularly in children, the ri.sk to 
 life is fairly to be measured by the extent of surface involved ; when more than half the 
 body is injured, a fatal result generally ensues. A severe burn of a limited character 
 may be, however, only a local affection. 
 
 Thus, the danger to life turns upon many points. In both young and old all burns 
 or scalds of any extent are serious. At any age extensive burns, however superficial, 
 are to be feared, and they become serious from their immediate depressing effect upon the 
 system ; patients sometimes die from shock, and the very bad cases are marked by the 
 sensation of coldness and persistent shivering. When the period of shock — which varies 
 from twelve to forty-eight hours — has passed, and that of reaction has set in, other dan- 
 gers appear. Should the injury be over the thoracic cavity, chest complications may be 
 looked for ; and if over the abdomen, intestinal and peritoneal troubles. Burns and scalds 
 of the head are not so likely to be followed by intracranial as those of the chest are by 
 thoracic mischief. All intestinal complications should be carefully observed, as there 
 seems to be a liability to irritation of the inte.stinal mucous tract, which may terminate 
 at times in ulceration. Dupuytren first observed this in a general way, but Long (Lond. 
 Med. Gaz., 1840) and Curling (Med.-Chitr. Trans., \o\. xxv., 1842) showed that ulceratioi. 
 of the duodenum, as proved by inspection after death, and indicated during life by vomit- 
 ing and purging of blood, is by no means an unfrequent result. 
 
 Out of 125 fatal cases collected by Holmes and Erichsen, 16 presented ulceration iii 
 the duodenum, of which 5 died during the first week and 5 in the second, the situation 
 of the burn in all but two being on the chest or abdomen. " The ulcer always has an 
 indolent aspect and is situated below the pylorus ; often there are two or three close 
 together ; the edges of the ulcers are neither raised nor everted ; there is little or xuo evi- 
 dence of inflammatory effusion in their neighborhood ; w^hen they ai-e recently formed, 
 they look simply as if a pjortion of the mucous membrane had been cut out ; but when 
 the ulcer has penetrated more deeply, so as to threaten perforation of the gut, lymph may 
 often be found effused on its peritoneal surface. Sometimes the glands of the duodenum 
 may be found enlarged "' (Holmes). 
 
 The symptoms of duodenal ulceration are most obscure, as neither pain nor tender- 
 ness exists ; diarrha?a is neither constant nor excessive ; vomiting is perhaps a more com- 
 mon symptom ; and the presence of blood in the motions is highly su.spicious. When 
 the ulcer has perforated the intestine, intense pain, vomiting of blood, melrena, collapse, 
 and abdominal distension mark the fact. 
 
 It should be noted that cicatrized duodenal ulcers have been found in patients who 
 have died of other complications. 
 
 Casting Off of Sloughs. — In the second or injiamm atari/ stage the injured parts 
 are being thrown off, and most writers allow for this process about fourteen days, though 
 in some cases it is less and in others more. When, however, the slough has separated 
 and the parts begin to suppurate, the third stage, or that of suppuration, has commenced. 
 In this stage, although there may be less probability of visceral complications appearing, 
 there is the equally great danger of exhaustion, hectic, or pyaemia, Should these risks 
 have been surmounted, there is yet the long and tedious process of the healing of the 
 granulating surface, and at a still later period evils arise connected with the gradual con- 
 traction of the cicatricial tissue. This contraction only takes place when the tcholc skin 
 has been destroyed. When the surface of the skin merely has been involved, and not 
 its depth, the sore, on the removal of the slough, has a peculiar net-like appearance, with 
 a whitish or yellowish ground, through the meshes of which granulations project. 
 
 Cause of Death. — When a person dies from a burn within forty-eight hours, it 
 arises from shock or collapse, pain doubtless having its full influence ; when a similar 
 result takes place during either the stage of reaction or of inflammation, it is from vi.s- 
 ceral complication ; and when during the third or suppurative stage, from exhaustion, 
 visceral changes, or pya>mia. 
 
 When a person is said to have been "burnt to death," he dies from suffocation, the 
 fumes of the fire destroying by asphyxia, and the fire subsequently burning the body. 
 
BURNS AM) .SCALDS. 159 
 
 II:iH' tho oases of burn aihniltiil intu a hospital <lir. and half of those that die do so 
 within tile first thfee (hiys. 
 
 The total deaths in Kn^land and Wales in a y^'ar (Voin hnrns and sealds are about 
 21M)(t, the feniah'S not hrinj; uiiich in excess of the males. 
 
 Out td" ddS eases eonseeutively admitted into (iuy s, 275 were femahis, 14.'{ males, 
 the majority beiiiji,' ehihlren under five years old. Dr. Steele has ahso shown, in liis Sep- 
 t'liniiii licjiint of Giii/'s for ISCtS, tl\at out of 111') cases of burns from fire 60 per cent, 
 died; of !(!!• sealds, ItJ.o per cent, died; of 18 burns from jras e.xplosions, 11 percent, 
 proved fatal ; and of 28 ca.ses of burns from gunpowder, 14 per cent, succumbed, the 
 differonee between the.se clas.ses of eases being very great, burns lieing four times as fatal 
 as sealds, and tliese half as fatal again as gas explosions, ete. 
 
 P.\Tli<»LO(}Y. — Holmes has gone into this (juestiou more thoroughly tlian anv other 
 autlior (Si/sfrtii, ed. :{d, vol. i. p. '-VJl), and has given us an analysis of <;8 fatal cases 
 examined after death. Nine died from shock ir. the first two days, all being children ; 
 17 from exhaustion. ') within the week and 12 at later periods; .S, all burns of the scalp, 
 from erysipelas; .'5 from pya-mia ; and 2 from tetanus. In 11 cases of children cerebral 
 complications caused deatn. and in most of these the symptoms appeared soon after the 
 accident. In ll eases infiammation of the larynx proved fatal, evidently from the direct 
 inhalation of the flames; in 12 ca.ses, in which the burn was thoracic, chest cf»mplication.s 
 killed ; in 4, abdominal couiplications proved fatal, and one of the.se had peritonitis, the 
 result of a deep burn, two had hemorrhage from ulceration of the duodenum, and one 
 had vomiting from the same cause. 
 
 Holmes and Erichsen also dwell upon the fiict that cerebral and general visceral con- 
 gestions are always present in fatal cases ; indeed, in all the congestion is a passive con- 
 dition due to the " sudden revulsion (jf blood from the surface," caused by the skin 
 injury. 
 
 Tre.\t.ment. — In all burns great care should be observed, in removing the clothes, 
 to save the cuticle. Blisters should be carefully punctured and their contents evacuated, 
 the raised cuticle being gently pressed down to the true skin and covered by dressings. 
 When the patient is cold or shivering exists, he should be covered with a warm blanket 
 and placed near the fire, some wine or brandy and hot water being administered. Pro- 
 fessor Hebra speaks well of the warm bath under these circumstances. When the injury 
 is extensive, one part should be uncovered and dressed before the other, as a free exposure 
 of the surface tends to increase the shock and adds to the pain. 
 
 Exclusion of Air. — As pain is the constant accompaniment of all burns and scalds, 
 and the exclusion of the air from the injured surface the best means of neutralizing it, 
 the surgeon's object has ever been to find some method of treatment by which this result 
 can be secured ; and at Guy's Hospital the application of carron oil, consisting of equal 
 parts of lime water and linseed oil, applied on lint and covered with cotton-wool, has long 
 been the favorite remedy, the whole being carefully kept in place by a bandage. At 
 University College the burnt surface, of whatever degree, is well covered with the finest 
 wheaten flour l)y means of an ordinary dredger. At the London Hospital the application 
 of zinc ointment on lint is employed. Dr. S. Gross of America used white lead paint, and 
 more recently powdered clay has been employed. Some surgeons advocate the use of a 
 lotion of colnmon soda. I have recently been treating burns of all degrees with va.seline 
 and finely-powdered boracie acid spread on lint with marked success. The dressings must 
 not be changed for some days — not, indeed, until they have been loosened by the dis- 
 charges or become offensive, inasmuch as the process of dressing any large burn is neces- 
 sarily painful, and consequently injurious. To obviate the necessity of frequent changes 
 of dressing, carbolic acid has been used dissolved in the oil in the proportion of one part 
 to ten or more. 
 
 Small burns or scalds may be treated by water dressing, lead lotion, collodion, Friar's 
 balsam, goldbeater's .skin, flour, chalk and water, etc. Two parts of collodion to one of 
 castor oil is also an excellent application. In superficial burns this treatment is probably 
 all that is required, the cuticle being re-formed in three or four days, and beyond some 
 increase of redness in the parts the cure is nearly complete. Opium should be given 
 early to relieve pain, and where it is severe the hypodermic injection of morphia should 
 be emploved. 
 
 When the fraf dressing has been removed and the surgeon is able to make out the 
 extent of tissue injured as well as the depth of the sloughs that are expected to separate, 
 some stimulating dressing may be called for, to hasten the sloughing process. Carbolic 
 oil, made of one ounce of carbolic acid to a pint of olive or linseed oil, is very eff"ective, 
 
160 ' BUBNS AND SCALDS. 
 
 or an ointment made of carbolic acid 5iv, lard 5iv, and castor oil 5j ; l^ut these drugs 
 will not avail when a very large surface is involved, and under such circumstances they 
 had better be applied to the sloughing parts, and the vaseline and boracic acid, carron oil, 
 or zinc, resin, or creosote ointment, n|^x of the last to an ounce of lard, to the other parts. 
 A lotion composed of one drachm of the compound tincture of iodine to a pint of water 
 or powdered iodoform is also beneficial. Sloughs, as they loosen, should be cut away, 
 but never dragged. Deep sloughs are well treated by poultices, the turpentine oint- 
 ment hastening their separation. When the surface is granulating it must be treated as 
 any other open sore ; and when the entire thickness of skin has been lost, as in burns of 
 the fourth degree, the surgeons closest attention is needed to counteract the contraction 
 of the wound that will take place, thereby preventing the advent of those frightful 
 deformities with which all are too familiar. 
 
 This can be done by extension, applied in some instances through mechanical appli- 
 ances, in others by means of bandaging and strapping. "When the latter is used, the 
 pressure should be exerted over the granulating surface as well as over the cicatricial 
 border. The strapping must be good and made of linen, thin calico and leather yielding 
 too much ; and in the majority of cases nearly all requirements can be met by these 
 means. The process of extension must be kept up during the whole period of granula- 
 tion and cicatrization. Thus, in burns of the anterior surface of the neck, the chin must 
 be extended to the utmost from the sternum ; in those of the thorax, the arm must be 
 kept from the side ; and where the groin and parts around are involved, the thigh mu.st 
 be kept extended. 
 
 Skin- Grafting. — In addition to these means, we possess M. Reverdin's method of 
 skin-grafting — a practice consisting of the transplantation of small portions of true skin, 
 these centres of cutification not only rapidly growing in healthy granulations, but having 
 the power of imparting to the margins of the granulating tissue a skin-forming power 
 which is as remarkable as it is beautiful to witness. 
 
 By these means large granulating surfaces may not only be rapidly healed, but healed 
 without such a surface of cicatricial tissue as necessarily exists after ordinary burns or 
 scalds, and therefore without that tendency to subsequent contraction that appertains to 
 cicatrices. 
 
 When Amputation Necessary, ^ — AVhen a hand or finger, foot or toe, is charred, 
 amputation must be performed ; and where the soft parts are so injured as to slough, the 
 same practice may be called for. The time, and also the necessity, for operation in any 
 patient's case must be left to the judgment of the surgeon. 
 
 The constitutional treatment of burns in the first stage is to prevent coIlaj)se by the 
 judicious use of stimulants and external warmth; allay pain by local treatment and 
 soothing drugs, such as chloral or morphia ; maintain the poice.rs of the patient by simple 
 nutritious food, such as milk, beef-tea, eggs, etc.; and after the stage of reaction, when 
 that of suppuration has set in, to prescribe good food of all kinds and tonic medicine. 
 
 Complications are to be treated on ordinary principles, understanding that the 
 injury is depressing and requires no additional lowering influence in the way of treat- 
 ment. 
 
 Thoracic complications may be dealt with by moderate doses of tartar emetic and 
 salines, as well as nutritious and possibly stimulating diet. 
 
 Abdominal complications, with opium, alkaline remedies such as lime water in bark, 
 and simple diet. 
 
 For children an opiate is best given in the form of the opium ointment ; while for 
 adults, where the drug upsets digestion, the same plan is equally effective. 
 Scalds of the glottis will be considered in Chapter XVIII. 
 
 Burns and accidents from lightning rarely occur in this country [England], 
 and average about twelve a year. In 1861 there were twenty-six, in 1862 twelve, in 1863 
 three, andin 1864 six. Holmes, who has written a careful compilation on the subject, 
 tells us that a person struck by lightning is usually more or less completely deprived of 
 consciousness at the time. In many cases this is not so, as in a remarkable example 
 which occurred in the practice of G. Wilks (Clinical Society s Trans., vol. xiii., 1880). 
 This is sometimes a consequence of the shock given to the brain, and is accompanied by 
 more or less paralysis of motion and of common or special sensation. Occasionally, and 
 perhaps more usually, it is merely the effect of fright, and is then only transient. This 
 insensibility sometimes lasts for a considerable time. The paralysis by which it is usually 
 accompanied may last for an indefinite period : in one case it lasted four months ; in an- 
 other, three. It is more common in the lower than in the upper limbs. Other affections 
 
THE DISEASES AS It THE ATM EST OF CICATRICES. 
 
 • il 
 
 caused l>y lif^htniiij^ arc burns, criipiiims of crvtlieiim or urticariu, loss of hair over parts 
 or the whole of the body, woiimls, heiiiorrhafre from the mouth, nose, or ears, loss of 
 sight, smell, spciech, hearing, and taste, or, in rare eases, exaltation of tliese special senses, 
 eataract, imliccility. or abortion. It somotina-s k-aves arbonisccnt marks on the body, even 
 on parts eoveri'd liy elotlics, which have (iftcn bccdi (htseribed as a kind of jdiotograph of 
 neighboring trees or (»ther subjects. Persons not killed on the; spot usually recover, thougli 
 some die from exhaustion ; recovery can be hastc^ned by tonic treatment, and galvanism is 
 l»enelieial in paralysis. liurns caused by lightning are deep and obstinate; sometimes, 
 however, they arc mere vesications and should be treated as other burns. 
 
 In Wilks's ease the man was thrown down and strij)pe<l naked of a well-nuide suit 
 secured with straps and buckles, and stout lu'w hob-iuiiled l)0(»ts. The clothes were 
 stripped into shreds aiul boots burst asunder. The man was burnt su[)erficially where 
 the flannel touched the skin, but deejdy where the cotton trou.sers were in contact. He 
 had also a compouiul fracture of one leg. Wherever there was a piece of metal (waist- 
 belt, watch, boots) there was an explosion, or at least a greater development of heat. The 
 man recovered completely. 
 
 In sudden deaths from lightning the shock to the brain is the cause; the heart is 
 found flaccid and empty, the blood sometimes coagulated ; and Taylor tells us, from Sir 
 C. Scudamores experiments, that in animals killed h)y electricity the same conditions 
 existed. 
 
 The Diseases and Treatment of Cicatrices. 
 
 Cicatrices or scars, however produced, grow with the growth of the individual, 
 and at the same time have a tendency to disappear ; so that indurated scars may indeed 
 in time become non-indurated. In small scars this is often observed, and even in larger 
 it is so occasionally, the large cicatrices of burns becoming soft and pliable. As often as 
 not, however, the opposite occurs, and the disposition to contract is very formidable, pro- 
 ducing deformities of a frightful kind, those of the neck being perhaps the most hideous. 
 The arm may be fastened to the side (Fig. 47), and I have seen in one case the head of 
 
 Fig. 4" 
 
 Fig. 48. 
 
 Axillary Cicatricial Web after Burn. 
 
 Mode of .Supplying Extension after 
 its Division. 
 
 the humerus displaced forward beneath the clavicle, and in a second beneath the coracoid 
 process and the development of the upper extremity arrested by the contraction. There 
 is no limit, indeed, to the effects of such a powerful and constant force as that of cicatri- 
 cial contraction. 
 
 Operative Measures. — The surgeon is called upon not unfre(juently to remedy 
 these delects, and where his eff'orts are successful the surgery is satisfactory, but too 
 often the result is far from what is required. 
 
 The operation consists in the free division of the cicatrix and its subjacent tissues, the 
 subsequent extension of the divided parts during the healing process, and the transplan- 
 tation of diff"erent centres of '• cutification '' during the granulating stage, after the 
 method of Keverdin. 
 
 In dividing the cicatrix the incision may be directly across the scar, running into 
 healthy tissue on either side, or in the form of a natural or inverted V. according to the 
 line of induration, the V-flap being dissected from the tissues beneath; or a number of 
 n 
 
162 
 
 THE DISEASES AND TREATMENT OF CICATRICES. 
 
 Fig. 49. 
 
 small incisions may be made, subcutaneous or otherwise. But in all these divisions the 
 surgeon must remember that the seat of the contracting cicatricial material is in die sub- 
 cutaneous tissue as well as in the skin, and that unless it also is divided no permanent 
 good can be expected. It is on this point — and, indeed, upon it alone — that a prognosis 
 can be based. The most favorable cases for operation are those in which a web of tissue 
 connects an extremity with the body, or the chin with the chest ; for such a web contains 
 within itself most of the cicatricial material upon which the deformity depends, and on 
 its division the whole will be freed. Great care is needed, however, in the division of 
 these webs ; for they often contain important parts, such as nerves and vessels that have 
 been displaced by the contracting process. Thus, in treating a case in which the right 
 arm was fixed by a web from the axilla and elbow to the chest, the web seemed to be so 
 cutaneous that I was half tempted to perforate with my knife and slit it up. Had I done 
 
 so in the position I had noted, I should have passed my 
 bistoury across the brachial plexus, artery, and biceps 
 muscle — these parts having been completely drawn across 
 to the thorax by the affection — and then been forced to 
 amputate the extremity. I did, however, what I should 
 always advise others to do — divided the parts carefully 
 and deliberately, and thus steered clear of any harm, I 
 brought also a piece of healthy skin from the posterior 
 part of the wound and fixed it to the anterior about the 
 lower border of the axilla, thus dividing the large ex- 
 posed surface by a bar of healthy integument, and kept 
 the arm at a right line to the shoulder with a splint 
 extending from the elbow to the hip. When the wound 
 had assumed a healthy aspect, I inserted ten pieces of 
 skin the size of hemp-seed, and after this cicatrization went 
 on with wonderful rapidity, the child recovering with a 
 useful arm and movable cicatrix. In this case I have 
 fairly indicated the points requiring attention to secure a 
 successful operation : free but deliberate division of the 
 cicatrix and subcutaneous tissue, extension from the first 
 during the healing process by some fixed mechanical 
 appliance, and skin-transplantation when the surface of 
 the sore has assumed a healthy granulating surface, the surgeon, where he can, partially 
 detaching a piece of integument from one side and connecting it with the opposite, in 
 order to divide the wound and thus increase its skin margin for granulation. Where a 
 bend in a joint exists this practice is still more valuable. After the operation the wound 
 should be dressed with vaseline on lint and covered with cotton-wool, as in a burn. Fig. 
 48 illustrates a simple method of applying extension of the arm after the division of an 
 axillary cicatrix of great size, and Fig. 49 illustrates the effects of a burn upon the neck. 
 In dcfonnitieii affecting the jaw in which immobility of the bone has been produced, 
 Esmarch and Rizzoli have proposed the division of the bone and the excision of a small 
 wedge of bone at the fixed side with a view of making a false joint. The operation is a 
 sound one, and has been accomplished successfully by Mr. C. Heath and others. In 
 suitable cases it should be repeated. 
 
 Ulcerating cicatrices are not uncommon, for " new cutis and new-formed granu- 
 lations are neither so strong, nor have they the living principle so active in them, as the 
 old cutis" (John Hunter, 1787), and an old scar may break up and become the seat of 
 an indolent sore when its possessor has been weakened by any fever or exhausting pro- 
 cess, in the san)e way as old subcutaneous cicatricial tissue may give rise to a residual 
 abscess. I have seen this repeatedly occur in adults in cicatrices formed in infancy. In 
 one case the cause of the scar was a burn, in another an injury, in a third an operation ; 
 but in all the scars were alike, and they underwent the same degenerating process. These 
 sores require to be treated by rest and local stimulants, the patient receiving tonics and 
 good food to improve the weakened powers. In one case I transplanted with complete 
 success. These " cicatricial sores " are, however, always obstinate, those over the ends of 
 bones being unusually stubborn. 
 
 Warty and Cheloid scars are classed together, because it is difficult to distin- 
 guish the indurated, lumpy, warty scar from the true cheloid. The former, however, 
 appears directly after the wound has healed, and is clearly connected with the healing 
 process ; while the latter attacks any scar at any period of its existence. 
 
 Effects of Burn on Neck : Contraction of 
 Cicatrix. 
 
rili: DISEASES AS I) TREATMENT OF CICATRICES. 
 
 163 
 
 Tlu' tliifki'iifil warty scar appt-ars as an iiiilmatiitn nf tlu- wliolc cicatrix and is often 
 associated with heat and irritation. It is l>cst treated l>y hjcal stimuhmts, such as iodine 
 or l)listerin,u Hiiid. the ohject heinu: to l>reaii up hy some h)cal inHaniuialory process the 
 hiwlv-nriraiii/.ed tihrmis productinn. 
 
 Cheloid tumors uniw as indurated smooth tiihendes, at first havinj; a red or 
 pinkish cohir, but as they increase Itecouiing pale. Tliey arc at times painful — or. at 
 least, irritable — and rarely attain a larue size. They had better be left alone, for they 
 are apt to return in the cieatri.\ formed after their removal. Cheloid tunujrs <renerally 
 grow from cicatrices. These cheloid tumors are known as those of Alibert, to distinguish 
 them from those named after Dr. Thomas Addison, who in 1854 (Mfd. ('hir. Traun.) 
 described another form of cheloid, which he calls the " true cheloid," the induration 
 beginning in the skin and stibcutancous areolar tissue, and often going on to produce 
 such a contraction of the part afi'ected as to resemble the indurated cicatrix of a burn. 
 Figs. ;")() and T)! rejtresent the two affections. 
 
 The cheloid tumor which follows the perforation of the ear for an ear-ring is a curious 
 
 Fio. 50. 
 
 Fig. 51. 
 
 0¥ 
 
 
 Cheloid of Alibeit. 
 
 Cheloid of Addison. 
 
 Thus, 
 
 (From models in Guy's Museum.) 
 
 form, and seems less liable to return than others of a like nature. From the deformity 
 it causes, it should be excised with a portion of the healthy lobule. 
 
 Cancer may attack a scar ; and when it does so, the scars are generally old. 
 I have treated a man who had a cancerous lip, the 
 disease having developed in a scar he had had for 
 fifty years. It began as a thickening of the scar, 
 and then showed itself as a tubercle, which grew, 
 broke down, and ulcerated, the ulceration rapidly- 
 spreading. 
 
 In December, 1871, I was called upon to ampu- 
 tate above the knee in a man aet. 58 a leg stump 
 that was the seat of a frightful cancerous disease 
 which had existed for two years, and had appeared 
 in the cicatrix of an old amputation performed fifty- 
 four years before for gangrene after fever (Fig. 84). 
 
 Cancers in cicatrices mostly appear after this 
 fashion, are usually epithelial, and are to be treated 
 bv the removal of the growth. 
 
 Painful cicatrices ;ii-e often due to the divided 
 ends of the nerves being bound in by the cicatricial 
 tissue, and as often as not they are caused by a 
 
 bound-down bulbous growth at the extremitV of a Congenital Cicatrix of Lip, Fissure of Nostril, 
 _ , > , •• , and Contracted Evelid. 
 
 nerve, in a case 1 had .some years ago the external 
 
 popliteal nerve, as it wound round the head of the fibula, was so bound down by the cicatrix 
 of a burn as to cause severe agony in the whole course of its distribution. The sj'mptoma 
 were relieved by two free vertical incisions through the cicatrix, and the patient recovered. 
 
164 OX SKIX-GEAFTIXG. 
 
 Should I ever see a similar case. I shall pursue the same course, except that I shall sub- 
 sequently transplant pieces of skin in the wounds as soon as they assume a healthy appear- 
 ance. When the pain is due to an adherent or bulbous nerve, the nerve must be freed and 
 removed. When doubt as to its condition exists, Mr. Hancock's suggestion may be adopted, 
 to divide subcutaneously the suspected nerve. Where no such causes as have been men- 
 tioned are to be made out, the case may be treated as one of neuralgia by full doses of 
 qixinine. arsenic, or iron, and local sedatives (the extract of stramonium or belladonna 
 rubbed down with glycerine being a good application). Cases, however, of painful stump? 
 or cicatrices are sometimes met with that defy treatment. 
 
 Congenital cicatrices are met with in practice. Thus, I have seen four patients, 
 all females, with cicatrices in their upper lips, as if they had been operated upon for 
 harelip (Fig. 52 was taken from one of them, and Fig. 188, Chapter XII., from another). 
 In the former there was likewise a fissure of the nostril and a narrowing of the fissure 
 of the eye. Bridles connecting the lip with the gum in an unusual manner are not 
 uncommon. 
 
 ON SKIN-GRAFTINa. 
 
 When John Hunter, a century ago, succeeded in transplanting the spur of a young 
 chicken from its leg to its comb, as well as into the comb of a second bird, and found 
 that it not only lived, but grew, he probably never dreamt in any flight of his genius 
 that the fact which he then established would be so applied in the practice of surgery as 
 to mark an era in its progress, and to bring a class of cases which surgeons were apt to 
 look upon with little interest amongst the most curable and tractable of local aifections. 
 And yet this has come to pass, M. Reverdin of Geneva, on October IG, 1869. having suc- 
 ceeded in transplanting small portions of skin taken from one part of a mans bod}' to the 
 granulating surface of a large sore, under which treatment the ulcer healed. He read 
 the case before the Surgical Society of Paris on December 15, 1869, and asked. " Is the 
 growth of skin due to the effect of contact or neighborhood, or is it due to proliferation 
 of the transplanted elements?"' 
 
 Mr. G. D. Pollock of St. George's Hospital, encouraged by M. Reverdin's success, 
 followed up tlie practice, and the good results he and his colleagues obtained soon induced 
 all other surgeons to follow in their wake. The facts can be read in the Transact ions of 
 the O'tnical Society for 1871, and at the present moment it may now be considered as a 
 well-established practice. 
 
 Since its introduction I have very extensively carried it out. and in most instances 
 with success. I look upon the suggesrion as very valuable, its adoption rendering many 
 cases curable that were not so previously, facilitating the cure of as many more, and giv- 
 ing interest to a class of patients in whom formerly there was but little. In the manage- 
 ment of healing ulcers it is a great boon, while in the treatment of the large granulating sur- 
 faces so common after extensive burns its value cannot be overestimated. As an adjuvant 
 to many plastic operations, more particularly on the face and in the case of deformities, 
 it is invaluable. 
 
 Under the action originated by the transplanted fragments of skin, a process of repair 
 goes on which at first appears almost magical : the grafts soon become islets of skin, 
 round which cicatrization proceeds; the margin of the sore receives an impulse in cica- 
 trization, which rapidly extends ; and between the grafts themselves and the margin of 
 the sore connecting links of new skin rapidly form, which divide the sore into sections 
 (Figs. 53 and 54). ' By these means large surfaces speedily cicatrize which under former 
 circumstances would have required many months. 
 
 Moreover, the contractions and subsequent deformities that under other conditions 
 were too well known to follow in such cases do not occur. 
 
 The practice seems applicable wherever a large granulating surface exists, and in its 
 adoption the only desirable point to observe is that the mrface of the sore should he healthy. 
 This clinical fact includes another — that the patient's health is good, for there is no 
 better barometer of health than a sore, its surface assuming a healthy or unhealthy 
 appearance with every alteration in the general condition of the body. I have attempted, 
 however, by way of experiment, to graft skin upon sores that were not quite healthy, 
 and have sometimes succeeded. In some indolent sores in which a small patch of healthy 
 granulations sprang up I have succeeded in securing by tran.splanting a new centre of 
 " cutification,'' which proved of great value in aiding the healing process ; in some others 
 the graft has been enough to excite a more healthy action in the sore ; still, in many, 
 poor success followed the practice. It may, therefore, be accepted as a truth that a 
 
O.V SKIS-CllAlTISa. 
 
 1 0.5 
 
 hcitUhji rfritintlnttii'i siirfarr is iiii unjinrldiit, iiIiIkiiiijIi not an essnitinl, rrtjiu'siff f'i,r siiccesn 
 in shin-</i(iJ'lliiij. 
 
 I'lKdi this l)a.si.s I imw [yrocciod t<» roiisidi-r liuw the opi-ration is to l>c' ])L'rf<jrin('<l. 
 
 I'tillofk tells us that Hcvcrdiii's method is to remove a very minute portion of tlie 
 skin, plaee it on the surtaee of the f^ranuiations, and there retain it with a strip of plaster. 
 He writes: "1 have usually removed the skin hy nipping up a very small jinrtinn with a 
 
 Fio. r)3. 
 
 Fig. 54. 
 
 Drawings illustrating the Cicatrization of Sores by Skin-G rafting. 
 
 fine pair of forcejts and cutting it off close with sharp scissors. At first I made a slight 
 cut in the surface of the granulations and then embedded the piece of skin, but of late 
 I have only laid it on the surface of the ulcer. I cannot say that I have found any dif- 
 ference in tlie result. I do not think there is great, if any, advantage to be gained by 
 the transplantation of a large piece, but where the ulcer is large I think much is gained 
 by the transplantation of numerous small pieces. The disadvantage of transplanting a 
 hirge piece is the sore it creates ; while the small sores formed by the removal of the 
 minute pieces heal in a short time and without trouble" (Clin. Soc. Trans., vol. iv.). 
 My DWii experience in every point confirms that of Pollock. 
 
 Mode of performing Trans- 
 plantation. — For the removal of the ^^^- '^^• 
 sound skin I either employ a pair of 
 scissors (here figured) which Messrs. 
 Krohne made for me after Macleod's 
 suggestion in a medical journal, or a fine 
 lancet, after the elevation of the skin 
 upon the point of a needle. I generally 
 take the skin from the fore part of the 
 arm or the side of the thorax. 
 
 Having taken away the skin, the 
 fragment should be cut into three, four, 
 or more pieces, and these placed about 
 
 Scissors for Skin-G rafting. 
 
 half an inch or three-quarters of an inch from the margin of the sore, and ahoiit one inch 
 apart ; for there is no doubt that the engrafted centre has a stronger influence in excit- 
 ing a healing action in the margin of the sore when placed near it than when i.solated in 
 the centre of a granulating surface. 
 
 The pieces should be placed upon the granulations and gently pressed in. There is 
 no necessity to wound the granulating surface. They should be covered with a piece of 
 oiled gutta-percha skin and the whole supported with cotton-wool, a bandage being sub- 
 sequently applied .so as to press moderately upon the part and keep the dressing in posi- 
 tion. On the third day, but not before, the dressings may be removed with the greatest 
 care, and a fresh piece of oiled gutta-percha skin should be subse(|uently applied. 
 
 The appearance of the engrafted pieces on the removal of the first dressing vary con- 
 siderably. At times they will seem palpably to have taken root and be alive ; at others 
 to have disappeared altogether ; whilst in a third class the surface of the cuticle will be 
 
166 
 
 O.V SKIS-GRAFTING. 
 
 Fig. 56. 
 
 Fig. 
 
 seen floating as a thin film upon the secretion of the sore, the basement membrane of the 
 cuticle — the essential part — being left (Fig. 53). 
 
 Under all these circumstances, however, the surface of the sore is to be cleaned with 
 the greatest care, a stream of tepid water from a dressing-can or .squeezed from a sponge 
 over the part being the best means to employ. The surface is on no account to be wiped, 
 for the grafted portions of skin are easily uprooted, whilst those that seem to have died 
 or that have disappeared often show themselves again later as " cutifying centres." As 
 soon as the new centres are established in large sores other pieces should be engrafted, at 
 about the same distance from the new pieces as those were originally inserted from the 
 margin of the sore ; and in this way the whole granulating surface may be speedily 
 covered with new skin, and a rapid recovery follow. 
 
 How the engrafted pieces act in the healing process is now satisfactorily settled, for 
 experience has proved that the grafts not only grow themselves by cell proliferation, but 
 they stimulate the skin-forming powers of the margin of the sore, for as .soon as the 
 '' grafts" have taken, the margin of the sore nearest to them is seen to cicatrize and to 
 send out prolongations of new cicatrizing tissue to meet similar prolongations from the 
 new cutifying centres, the sore in this way becoming .subdivided by bands into smaller 
 sores and then rapidly healing (Fig. 54). 
 
 That the engrafted portions grow b\' the pro- 
 liferation of their own cells is likewise proved 
 by the fact that in the case of a white man upon 
 whose granulating ulcer I engrafted four small 
 pieces of black skin, the whole being no larger 
 than a barley-corn, the Vjlack skin grew twenty- 
 fold in ten weeks, to the extent illustrated in 
 Fig. 5(J, the grafts subsequently enlarging and 
 sending out prolongations which joined to form 
 one patch of black skin (vide Fig. 57). The 
 sore healed as rapidly where the black skin 
 was grafted as where the white was placed. 
 
 The same result may likewise ensue when large 
 pieces of skin are transplanted from the patient 
 or from some recently amputated limb. But 
 there .seems to be no advantage in this practice, 
 and in the cases in which it has been adopted 
 a large proportion have failed. In a case of 
 mine the grafts took root and excited a healthy 
 action in the margin of the sore ; they, however, 
 grew but little, and remained on the cicatrix 
 of the sore as bosses of skin with well-marked borders. They were grafted, it is true, 
 but the grafts seemed to have no power of assimilating themselves to the tis.sues on 
 which they were placed (ride model Guys Mus.j. When this practice is adopted, the 
 pieces of skin, on removal, should be dropped into warm water in their passage to the 
 wards where they are applied. 
 
 To take large pieces of skin from the patient's own body is an objectionable practice 
 on account of the large wound it creates, and. moreover, is unnecessary in the majority 
 of cases, as small pieces appear to do better. To take them from another suVjject is also 
 objectionable for like reasons, but .still more so from the risk that is necessarily run of 
 introducing into the blood of the living subject some new or poisonous element — a risk 
 to which I think a patient should not be subjected, and that I would not allow on myself. 
 . For these reasons I have forbidden my dres.sers adopting the practice. 
 
 In the case where black skin was tran.splanted I did it with the full concurrence of 
 both patients ; indeed, both were rather disappointed that the operation could not be 
 repeated. They were firm friends, and the link I formed bound them closer ! 
 
 There seems to be no objection to dividing the portion of integument which is to be 
 employed into minute fragments — that is. into pieces the size of millet-seeds — the thumb- 
 nail of the surgeon being the best table for the purpo.se. In children, where it is unad- 
 visable to remove much health}- skin and the granulating surface to be covered is large, 
 the plan is excellent, though I prefer pieces the size of half a hemp-seed, when they can 
 be obtained. The practice of applying '■ skin-dust.' or the products obtained by scraping 
 the skin, cannot be recommended, as it is rarely successful. 
 
 Whether this newly-engrafted skin pos.sesses the same power of resisting disintegrating 
 
 Drawings illustrating the Growth of Black Skin 
 when (irafted on to the Sore of a White Man. 
 
CUILELAiyS. 167 
 
 chanjrt" s as the old skin is not yf t proved. Some observations I have made lead nie to sus- 
 pect that it is in some cases rather liable to break down and ulcerate as soon as the patient 
 begins to walk after the sore has completely healed, whilst in others I have found a sore 
 in this way healed is more capable of resisting disintegrating changes than another healed 
 by unassisted natural ])rocesses. At any rate, it is necessary to observe as much care in 
 the after-treatment of the case as ought always to be observed after the cure of any other 
 sore, and nmre ]iarticularly to afford moderate supj>ort and pnttection to the part. For 
 this purpose there is nothing better than to bind on a piece of sheet-lead over the cicatri.x 
 when the seat of mischief is on the leg, as by it equal pressure as well as protection is 
 afionU'd. 
 
 The new skin soon becomes as sensitive as the old ; the sensibility of the cicatrix 
 under these circunjstances, indeed, seems to be greater than when unaided cicatrization is 
 allowed to take place. 
 
 Sponge Grafting. 
 
 Dr. Hamilton of Edinburgh introduced this practice into surgery with a view of 
 expediting the repair of deep wounds in which much loss of tissue has taken place, and 
 he did so " thinking that sponge would imitate the interstices of the fibrinous network in 
 a blood clot or in fibrinous lymph, '' and that the blood vessels of the new surrounding 
 tissues would push into these interstices and grow, and so fill up the cavity, the sponge 
 eventually becoming absorbed. He gave cases which were apparently successful, and 
 many have been recorded since. 
 
 To carry out the practice, a fine section of sponge should be applied to a healthy 
 granulating surface and the sponge covered with oil silk. A layer of lint saturated with 
 carbolic or terebene oil should then be applied, and the whole wrapped in some antiseptic 
 gauze or boraeic or salicylic wool. The dressing should be removed every second or 
 third day, according to the quantity of discharge. The sponge is prepared by being 
 steeped in diluted nitro-muriatic acid, to dissolve the silicious and calcareous salts, and 
 later on washed in a solution of ammonia or potash, to remove all excess of acid. Before 
 being applied it is purified by prolonged treatment with a five-per-cent. solution of carbolic 
 acid. In the original paper Hamilton recommended thick sections of sponge; he now u.ses 
 fine ones, fresh layers being con.secutively applied as granulation tissue grows. I have 
 employed sponge grafts on many occasions, and have seen more cases in which the prac- 
 tice has been carried out ; and I can testify to the fact that the sponge becomes as it were 
 incorporated with the granulation tissues, but whether it really expedites repair or not, or 
 becomes of any practical value in the repair of deep wounds. I am not prepared to say. 
 
 Chilblains. 
 
 Chilblains are local inflammations of the skin, and are to be met with in subjects 
 of a feeble circulation. They are more common in the young, and in women than in men, 
 are generally seen on the toes, fingers, nose, or ears, and are caused by any sudden change 
 of temperature or any sudden application of cold or warmth. 
 
 They show themselves as simple congestions of the skin attended with tenderness or 
 itching; vesication of the skin, when the inflammation is more severe', or .sloughing arid 
 ulceration of the skin, when a broken chilblain occurs. The disease may begin and stop 
 at the first or congestive stage or run through all the stages. 
 
 Toward evening the symptoms of irritation are always increased, and any external 
 warmth, as of a fire or bed. any full diet or stimulating drink, aggravates them : in fact, 
 anything that excites the circulation in the part, at any hour of the day or night, is apt 
 to increase the symptoms. 
 
 Tre.\tment. — The local treatment of chilblains is no less important than the general, 
 and more successful ; for, whilst tonics, good diet, external warmth, and exercise are neces- 
 sary to improve the general powers of the patient and the circulation, local stimulants 
 are of great value. When the chilblain is not broken, the local application of the tinc- 
 ture of iodine, of a solution of sulphate of copper (three grains to the ounce), of camphor 
 liniment, of soap liniment with opium or one-fourth part of the tincture of cantharides, 
 of compound tincture of benzoin, or of simple spirit, not only gives comfort, but hastens 
 the cure of the disease. The parts should also be covered with strapping spread on 
 leather. 
 
 When the parts are broken, vaseline, boracic-acid ointment, with the use of thick lint 
 ' Edinburgh Med. Joiirn., Nov., 1881. 
 
168 FROSTBITE. 
 
 and oil silk or elastic tissue, are tlie safest remedies, stimulating lotions being used later 
 when the parts are indolent in healing, such as terebene and oil or carbolic oil with opium. 
 Warm socks and loose shoes or boots are always indicated, but anything like pressure 
 is most detrimental. Exercise also should be taken when possible, and an equable tem- 
 perature ought to be maintained. 
 
 Frostbite. 
 
 It has already been shown that the sudden application of cold to any exposed part of 
 the body of a feeble or depressed subject is liable to be followed by '■'■ chilhlahi ;^' and 
 when concentrated cold is applied, under these circumstances, for a period sufficient to 
 arrest the circulation in a part, a ^^ frostbite^' is the result. Sudden and severe alterna- 
 tions of heat and cold under exposure, even in healthy subjects, may produce this result ; 
 in military life this fact is well known. 
 
 The first eifect of cold upon a part is a sense of numbness and weight with a feeling 
 of tingling. To the eye the skin will probably appear redder than usual ; and if the part 
 be removed from the influence of the cold at this time, recovery, or in feeble subjects a 
 superficial '• chilblain," may follow. If the cold, however, be allowed to act longer, the 
 parts will become stiif, and at last insensible, feeling '' dead." To the eye they will 
 assume a white and waxy aspect and be senseless to all impressions, the blood having 
 been completely driven from the surface. When the cold has been suddenly applied and 
 is sufficient to kill the structure outright, the frozen part will have a mottled aspect, 
 from the retention of blood within the tissues. Many of these effects may be produced 
 by the aether spray. 
 
 The constitutional effrcti^ of cold are at first stimulating, and subsequently depres.sing, 
 excitement passing into sleepiness, and this into torpor. If the latter be yielded to, the 
 sleep will end in death, the blood being sent from the surface of the body to the brain 
 and other viscera, and death being produced by blood engorgement, as in apoplexy. 
 
 In the " sleepy and depressed stage " of cold, if the patient be brought suddenly under 
 the influence of warmth and placed too near a fire, the risks of lung engorgement, as well 
 as of rapid gangrene of the frozen parts, are very great ; for by sudden reaction the arte- 
 rial circulation becomes quickened when the parts gorged with blood have lost their 
 power of propelling onward. In gangrene from frostbites there seems reason to believe 
 that ulceration of the duodenum may follow, as after burns. Mr. Adams has recorded 
 such a case in the American Med. Times, for 18G3. 
 
 Treat.ment. — Any sudden alternation of temperature being most injurious, the aim 
 of the surgeon should be to recall the affected parts fjrinJnally to their normal condition 
 — firstly, by assisting the venous circulation by gentle friction in the course of the veins 
 with furs or flannel ; and secondly, the arterial by comparative warmth applied externally 
 and gentle stimulants administered internally. Neither warm water nor air nor fire 
 should be allowed to approach the parts until the natural temperature has been partially 
 restored, and then only with great care. Friction with snow or iced water is most useful. 
 On reaction, the parts may be raised and lightly covered with flannel or cotton-wool or 
 exposed to the warm air of a chamber ; whilst food and stimulating drinks are carefully 
 administered, warm milk with a little brandy being the best. Should reaction be too 
 severe, it must be checked by lead or spirit lotions. 
 
 When gangrene follows — and it mostly does when the third degree of freezing, or the 
 mottling stage, has been reached — and only small portions of the body suffer, such as the 
 integument, the parts may be dressed by some stimulating application to hasten the sepa- 
 ration of the slough, and should be kept warm. Carbolic acid and oil are probably the best 
 applications; tonics should also be given. 
 
 When large portions of the body suffer, such as the whole foot (and in this country I 
 have seen a coachman who had on new tight boots on a bitter winter day lose both feet), 
 amputation may be called for, the surgeon always waiting till the line of demarcation or 
 limit to the sloughing process is fairly marked. 
 
 Boils. 
 
 Boils are, in a measure, allied to carbuncles, and both are due to inflammation of the 
 skin and subcutaneous tissue, though the disease probably commences in the latter. In 
 both there is effusion of lymph into the areolar tissue of "the part, and in both this gene- 
 rally sloughs, although in the boil the slough is local and confined to one central point, 
 
BOILS. 169 
 
 whilo ill rarhiinclo tlio process may cover an extent of integument varying from the size 
 of half a eniwn to that of a phite. 
 
 Boils are met with in two forms — '<»'■ as a subcutaneous affection atten<Je<l with litth) 
 pain until the skin over it intiames and supj)urates. It then appears as a conical-pointed 
 swellinjj;, with inflamed indurated areola; this causes .severe distress until the parts give 
 way, when the feeling of tension and throbbing is followed by relief due to the termina- 
 tion of the sloughing process and discharge of the '* core." \Vhen the slough has been 
 di.sdiarged, an irregular orifice in the skin is seen covering in a cavity in the cellular tis- 
 sue, which subse<juently granulates, leaving a depressed and indurated cicatrix. The 
 core or slough is eomposed of skin infiltrated with lymph. 
 
 The secoiii/ form of boil begins as an inflamed follicle or pimple, which occasionally 
 becomes vesicular and has a scarlet, exi|uisitely sensitive areola. It suppurates slowly, 
 and. as a rule, terminates with a less well-n)arked slough than the former kind. Such 
 boils are more usually multiple than the other, and are often caused by the application 
 of moist dressiiiiTs or of some cadaveric irritant. 
 
 Causes of Boils. — With respect to the cdusrs of ialU nothing definite can be laid 
 down. That they are always associated with some debilitating or allied cause is belied 
 by daily experience, for they are certainly often seen in men and women in whom no 
 such condition exists, and in subjects who often declare that they '" never felt better in 
 their lives."' As a rule, however, this is not the case, because they more commonly 
 occur in subjects who have either been fed to excess or been subjected to some sudden 
 change in the nature of their diet — such, for instance, as in men who undergo training 
 for athletic pleasures, or who are subjected to the influence of fetid animal exhalations 
 as met with in a skin-yard, pathological-room, or dis.secting-room. They are seen also in 
 the diabetic and cachectic subject, as well as in patients enfeebled by any fever or other 
 debilitating cause. Ganigee tells us that they are often the result of eating di.sea.sed 
 meat. They are also produced by the local contact of certain cadaveric emanations, the 
 newly-appointed post-mortem clerks of our hospitals often falling victims, the poison act- 
 ing at first as a direct irritant upon the follicles to which it is applied. They are far 
 more common in some years than in others. In persons who are predisposed to their for- 
 mation any local irritation is apt to produce them, such as the friction caused by rowing, 
 the application of a poultice, water dres.sing, strapping, or a blister. They attack the 
 integument of any part of the body, the palms of the hands and soles of the feet being 
 apparent exceptions. 
 
 In the dense integument of the nape of the neck, buttock, and outside of the thighs 
 they are more chronic and painful than in the .skin of looser texture. They are trouble- 
 some local affections, but seldom endanger life. In rare instances they are followed by 
 septicaemia and death, but only in one instance have I known this to occur. 
 
 Treatment. — The general treatment must depend upon the condition of the body 
 and the apparent cause of the complaint, any unwhole.some habit being corrected and any 
 evident want supplied. Under other circumstances, the practice must be directed on 
 general principles. The diet should be nutritious, but not too stimulating ; exercise 
 short of fatigue should always be allowed, and fresh air obtained when possible. The 
 secretions .should be looked to, and when out of order corrected, mild laxatives being 
 often of service. AVhen the skin is secreting unhealthily, the Turkish or warm bath is 
 of great benefit. Moreover, alkalies or acids ought also to be given when the condition 
 of the stomach needs them ; alkalies and bitters are often of great benefit. 
 
 When debility exists, quinine is invaluable : and in London or large towns its com- 
 bination with iron is required. When diabetes is present, the " full-feeding' treatment is 
 probably the best. Dr. Jackson of the United States gives twelve to sixteen grains of 
 quinine a da}-, increa.sing the dose daily until its special effects are produced, and then 
 decreasing it. He continues the treatment for a month. Veast in doses of a tablespoon- 
 ful. taken fasting three times a day, occasionally appears to have a rapidly marked bene- 
 ficial effect, although in what way it acts it is diflScult to .say. 
 
 The local treatment must be directed much by the local symptoms, it being, as a rule, 
 a better course to let the boil discharge it.self or dry up than to lance it. In the early 
 stage of the papular or follicular form of boil the free application of alcohol, spirit of 
 camphor, the nitrate of silver, liquor potassfe. or iodine tincture is often followed by its 
 disappearance ; but in the other kind all such applications are worse than u.seless. Cov- 
 ering up the areola of the boil with a perforated piece of plaster is a good practice. At 
 times painting the areola with collodion or colloid styptic answers well. 
 
 When the pain is great from the tension of the part, and the areola of inflammation is 
 
170 CARBUNCLE. 
 
 spreading, relief may generally be given by lancing ; and when the slough is slow in 
 separating, the introduction into the opening of a point of potassa fusa is followed by the 
 rapid cleansing of the wound and its granulation. Poultices may be applied for a limited 
 period during the sloughing stage, but not for any length of time, as they often encour- 
 age the appearance of others. When boils succeed one another seriatim without any 
 definite cause, change of air is a most successful remedy. 
 
 Carbuncle. 
 
 This is a far more serious affection than a boil, for it is almost always met with in the 
 feeble and cachectic subject, and generally in men, rich or poor, over forty-five. It is 
 very frequently associated with diabetes, and gouty patients are particularly prone to its 
 attack. 
 
 It generally occurs singly and is slow in its progress, the inflammation in the skin 
 and cellular tissue beneath spreading as a brawny inflammatory effusion with no defined 
 border. The redness of skin is rarely vivid, more frequently livid ; at times the local 
 pain is severe and constitutional depression very great. The sloughs separate slowly, 
 many openings, as of many boils, allowing them to escape, and the whole skin at times 
 separates as an ash-colored layer, leaving an irregular cavity undermining the neighboring 
 tissues. The favorite seats of carbuncle are the skin and subcutaneous tissue of the nape of 
 the neck, back, and buttock. The}- occur, however, on the front of the body and the extrem- 
 ities and on the lip or face. The disease is so slow in its progress as at times to occupy 
 many weeks, one part going through its course while it spreads in another. It may- 
 destroy life by exhaustion or by pyremia. The worst form of pyaemia arises from it ; 
 indeed, M. Labat {Med.-Chir. Soc. Bordeaux, 1868) believes pyagmia to be the most com- 
 mon cause of death in carbuncle. Rare cases have been recorded in which peritonitis 
 was caused by the extension of the disease from the abdominal walls into the peritoneal 
 cavity. 
 
 When the treatment by incision is adopted, life is too often shortened by loss of blood. 
 As a general rule, however, carbuncle is not a fatal disease. Its danger depends much 
 upon its extent, and more upon the complication with which it is associated. 
 
 Treatment. — In former days the one form of local treatment that every surgeon fol- 
 lowed was that of the crucial inci.sion, +, the knife being passed freely through the 
 tissues to the base of the inflammatory effusion ; the object of this was to give room for 
 the slough to separate and come away. In modern times the value of this practice has 
 been much questioned, for it was too often found to be followed by loss of blood where 
 blood was much needed ; nor has it been thought that the incision did much to hasten 
 the progress of the ease or the separation of the slough. It is still, however, a popular 
 form of practice. I was taught it, but after observing its effects have long given it up, 
 believing that it did little or no good and was often followed by a harmful hemorrhage. 
 
 The treatment I prefer, and have adopted for many years, has been that by caustic ; 
 and the more I see of it, the better I like it. It has been strongly advocated in this 
 country by Pritchard, and in America by Dr. Physick. It is applicable in the stage of 
 the disease when the cellular tissue is brawny and the early inflammation of the skin has 
 subsided ; it may be used before any openings in the skin are found, either, as Pritchard 
 advises, by rubbing the caustic potash freely in the centre of the carbuncle until an 
 eschar is fully formed, or, which is preferable, by puncturing with a scalpel and inserting 
 the stick or a small piece the size of a pea well into the diseased tissues. When the car- 
 buncle is large, many punctures may be made, one to every area of surface of the dimen- 
 sions of half a crown. Where openings exist, the surgeon has only to insert the caustic 
 and allow it to melt, either in the stick, or, what is better, in pea-like masses, by means 
 of dressing forceps, passing them well down into the subcutaneous tissue. By this prac- 
 tice the slough is certainly cast off more readily than when incisions are made or the case 
 left to nature. No bleeding takes place, and very little pain is given excepting at the 
 time. W^ith this treatment large carbuncles become soon healthy granulating wounds. 
 The only care required is to pi'event the caustic running over the sound skin. During 
 this treatment a wad of absorbent cotton-wool should be applied, with some lotion, such 
 as that of boracic acid, carbolic acid, or alcohol ; a solution of opium applied to the part 
 often gives relief to pain. Tonics, good living, and fresh air are also essential. The 
 French surgeons prefer the iise of the A^ienna paste. Paget prefers the common resin 
 cerate. By these means, unless the carbuncle is associated with some serious malady, 
 euch as diabetes or pygemia, a good result may be looked for. 
 
rKIlFonATISll ULCER OF TnE FOOT. 171 
 
 Tilt' |)lim (if iiiakiii}; ii sulx-utaiioous iiici.sioii lias hcon alily advficatcd liy Mr. French 
 and -M. (iiuTiii, ami that nl" ('((niprcssiiui liy .Messrs. O'Ferrall and .M. II. ('(dies of hiildin 
 {/)i(h. (Jiiiirf. Jiiiir.. 1S(»4). The fnniu'r plan 1 have trie<l, hut have failed t(i find its 
 advantage. The latter I have not eni|doyed, having been already well satisfied with the 
 eaustie treatment. 
 
 Facial Carbuncle. 
 
 This has hei'ii often miscalled "malignant imstule," to whi(di attention has been 
 drawn (p. 108). It was pndiably first described by a clever young surgeon, Harvey 
 Ludlow (Med. Tiinis anil (!az., Septemlxir, 1852). It is generally found on the lip. the 
 upper one being the more commonly involved, as an ccdematous inflammatory swelling of 
 the part, involving the nose and cheek, often preceded by some pustule or vesicle, and 
 generally accompanied by tliem. It is almost always a.ssociated with severe pain. It 
 ends, as do most ca.ses of carbuncle, with sloughing, and at times the whole substance of 
 the li|> or cheek gives way. It is associated, like carbuncle, with great constitutional 
 de|)ression, and its special danger is thrombosis ami phleltitis of the c<!rebral sinuses; the 
 inflammation of the veins extends from tlie affected parts through the ojihthalmic veins to 
 the cavernous sinus. I have seen six cases at least of this affection — four of the ujiper 
 and two of the lower lip — ami all recovered. In only one did the disease extend beyond 
 the lip, while in all the disease, as far as local treatment was concerned, was left to natu- 
 ral processes, cleanliness and fomentations being alone employed. Tonics and good diet 
 were given, and quinine with iron, in full doses, appeared the best. Paget advises quinine 
 in sufficient doses to produce symptoms of cinchonism. 
 
 jM. Keverdin of Oeneva gives a very elaborate essay on this subject in the Archives 
 Generab'n de Medecim-, 1870. At p. 1(52 of the August number he thus sums up his 
 conclusions : 
 
 1. Anthrax and furuncle of the face present a special gravity.* 
 
 2. This gravity is due to the ready complication with [ihlebitis. 
 
 3. The facial phlebitis is attended with death, eitlier by extension to the sinuses of the 
 dura mater or by becoming the source of purulent infection. 
 
 4. Of anthrax of the face, that of the lips is more frequently complicated with phle- 
 bitis than the others. This may be explained by the peculiar texture of tlie lips. 
 
 5. Anthrax of the lips has nothing in common with malignant pustule. 
 
 6. The involving of the orbit in the phlebitis, as demonstrated by exophthalmia, shows 
 almost for certain the implication of the sinus. 
 
 7. Incision, speedily and extensively performed, seems to be the best means of pre- 
 venting, and sometimes of arresting, the phlebitic complications. 
 
 Perforating Ulcer of the Foot. 
 
 This affection was so called by Vesigne of Abbeville in 1850. It is an aff"ection which 
 Mr. Hancock brought prominently before us in an able paper published in the Bn'f. Mfd. 
 Joimud^ June 2(), 18G9, although Cloquet, Boycr, and Nelaton, of Paris, have also 
 described it. Nelaton says it " commences with phlyct.-cna in the pad of the foot. The 
 epidermis is raised by a small quantity of purulent serum. Others describe it as com- 
 mencing like a flat corn, which ulcerates. When this is opened the subjacent dermis 
 appears of a rose color, and when touched is highly sensitive. This state may continue 
 for some time, when the dermis in its turn gradually ulcerates, and a small fi.stulous open- 
 ing is established in the subcutaneous cellular tissue, which will not heal, but continues 
 to discharge serum slightly tinged with pus. If after five or six weeks the sinus is exam- 
 ined by a probe, the subjacent bone is felt rough and necrosed, and a sequestrum subse- 
 quently forms." An attempt has been made' to connect this local affection with nerve 
 lesion, central or peripheral ; but evidence is still wanting to prove that there is more 
 than an accidental connection between the two conditions. 
 
 Treat.ment. — The disease is most obstinate in its character, generally spreading over 
 years. It is, however, chiefly local and confined to the anterior portion of the foot, 
 ^ledicine has little power over it ; Fowler's solution has been much vaunted for its cure, 
 but with insufficient evidence ; and, as far as facts can guide us, it appears Hancocks 
 conclusion — that when dead bone exists it should be removed — is the only right one. 
 " But if, notwithstanding, the disease returns, there can no longer be a question that, 
 when once perforating ulcer of the sole of the foot is established and recognized, it is 
 1 Savory, Med. Chir. Trans., vol. Ixii., 1879. 
 
172 MYCETOMA, OR THE FUXGUS DISEASE OF INDIA. 
 
 better at once to remove the whole of the metatarsal bones either by Chopart's, Syme's, 
 or PirogofF's amputation.'" 
 
 These cases are not to be confused with the suppurating bursje or bunions found in 
 feet deformed from short or tight boots. 
 
 Delhi or Oriental Sore. 
 
 This disea.se, which is identical with the Moultan sore, Aleppo boil, or Bi.skra bouton, 
 '' yaws of the West Indies," and Parange of Ceylon, is a cutaneous disease due to the 
 entrance of a parasite into the body, during bathing or washing, through an opening in 
 the cuticle caused by an abrasion of the skin, such as a mosrjuito-bite. The parasite 
 is supposed by Messrs. Alcock and Fleming of the Indian army (J/^r/. R'p.. 1868) to 
 dwell in the foul, brackish, hard well-water (the Delhi well-water containing 45 to 50 
 grains of carbonate of lime per gallon). Such good observers as Messrs. Lewis and Cun- 
 ningham ( Appenih'x to 12th Report of Sonituri/ Commissioners icifh Government of Tndia^ 
 assert, however, that the disease is of the nature of a lupus and should be treated as such. 
 Indeed, they describe it as "lupus endemicus "' (^Lancet, April 7. 1S77). It may attack 
 dogs and horses. " It appears on the exposed parts of the body, at fir.st as a small pimple, 
 like an irritated mosquito-bite, and remains in this .state for several days or weeks, some- 
 times for months. It then slowly increases, and a thin fluid escapes from the top. which 
 dries and forms a circular scab, gradually increasing in size and thickness. When this 
 scab is removed, an indolent ulcer is exposed, with undermined edges and lobulated 
 granulations in the centre, in healthy subjects like raspberries, but paler and more blue 
 in cachectic cases. These ulcers, when very broad, show signs of cicatrizing from the 
 centre; in all there remains a depressed cicatrix after healing. The disease may last 
 from six months to two years" (Surgeon-Gen. Murray. Epidem. Society, March, 
 1862). 
 
 Treatment. — It is to be treated by personal cleanliness, the avoidance of the use of 
 foul hard water, the early destruction of the sore by the cautery or caustic, and the appli- 
 cation of metallic astringents. Tonic treatment, a good diet, and if possible change of 
 locality and climate, should be secured. 
 
 Mycetoma, or the Fungus Disease of India. 
 
 This disease has been described by Dr. Carter of Bombay in the Trans, of the Med. 
 and Phys. Sejc. Bombay, 1861, and in a memoir publi.slied by Churchill. 1874, and it is 
 supposed by him to be due to the presence of a fungus. Other authors have thrown 
 doubt upon this point, and amongst them F. B. Lewis and D. Cunningham of Calcutta, 
 who conclude that it is reasonable to infer that localized spots in the tissues undergo 
 degenerative changes into a sub.stance peculiarly adapted to the development of filament- 
 ous growths. The origin of the fungus in situations where no spore could penetrate 
 must remain a matter of perplexity (3L J. Berkeley, Xature. November 9, 1876). The 
 disease, however, is well recognized. Berkeley observes that the bodies found in the 
 disease " so nearly simulate fungous growths that it is diflScult to get rid of the notion 
 that they are really vegetable growths" (InteUerf. Observ.. 1863). The disease is more 
 frequent in men than in women, and affects all classes, rich as well as poor ; but it has 
 never attacked an European. 
 
 The disea.se is chronic and affects most commonly the foot, sometimes the hand, and 
 but rarely other parts of the body. It is very slow in its progress and has no tendency 
 to get well if left alone. L^sually it begins on the plantar surface of the foot or the 
 palmar of the hand, as an induration in or under the skin ; this subsequently softens 
 down ; a bleb then forms over the spot and bursts, leaving a sinuous opening, from which 
 exudes a thin, sanious, sero-purulent discharge. As the disease progres.«es other indura- 
 tions, followed by sinuses, form, till the foot or hand becomes one indurated diseased 
 mass riddled with holes, the orifices of sinuses, which may or may not lead to bone ; and 
 in extreme cases the bones are tunnelled. These sinuses discharge freely a putrid sero- 
 purulent fluid containing '■' fungus particles." The fungi are of two kinds, each, accord- 
 ing to Dr. Carter, marking a variety of the disease. One. the dark or dark-brown, is 
 globular or ovoid in form, hard and friable in consistence, and of the size varying from a 
 pin's head to that of a bullet. The other is pale or yellowish in color, soft and cheesy in 
 consistence, and of the size of a minute .<peck or pea. Dr. Carter and others believe that 
 excision or amputation of the affected part is the only sound practice to be adopted. 
 
ir.iA'7\ MOLLS, AM) coiiys. 173 
 
 Warts. 
 
 Tlicso AW ontf^mwtlis (if the jcipill.-o of tlu- skin, the ]iapill;e Ix-iii^' usually elongated 
 ami their cpitlit'liul covering tliiekeneil. They an; eonmioii on the liands and other partH 
 of the hotly of the young, and nmre rare in the adult. When on expo.sed part.s of the body, 
 they assume a horny hardness; hut when surrounded with moisttire or the secretion of 
 the skin, they are .soft and more sensitive. 
 
 The flat wart is called nrrncii siiti/ilex ; the pedunculated, tw/'Ho/ iU(jil(it<i ; and these 
 are said to be more common in the scalp. I have seen them on the neck, orifice of the 
 nose, mouth, eyes, ears, and anus, also on the prepuce and labia. I have .seen them also 
 on the tongue. Thi'y occur at times beneath the nails un<l are very painful — nub-unyual. 
 The worst crop of warts I ever saw was around the anus of a boy. 
 
 The flat warts occasi(Uially come and go in a way which cannot be accounted for; as 
 a rule, they are, however, jiersistent. They rarely last into adult life ; but wlien they do, 
 they .seldom grow or give trouble. Tn excei)tional cases, under stnne local irritation, they 
 mav increa.se and assunu' more the character of an epithelial cancer. When on the face, 
 this change is peculiarly liable to occur. Not long ago I destroyed an eiiithelial cancer by 
 the ala of the nose, the size of a florin, that had suddenly a])peared in a wart which had 
 existed for sixty years — nearly all the patient's life ; and I have removed from the lip of 
 a man a cancer that had grown from a wart which had existed as long as he could 
 remember. 
 
 Venereal warts are very abundant, whether they grow from the glans penis or 
 prejiuce (»f the nuile or labia of the female. They are pedunculated, moist, and highly 
 vascular, and are clearly contagious. Warts, however, may occur at times in these part.s 
 without any venereal contact. 
 
 Treatment. — Some powerful alkali, such as ammonia, to dissolve the cuticle, and 
 the subsetjuent application of the glacial acetic acid, nitric acid, or acid nitrate of mer- 
 cury, to destroy the jiupilh^, is the best plan to get rid of the harder or flat warts. Lunar 
 caustic is an unsatisfactory and tedious remedy. Pedunculated dry warts should be cut 
 oft" with the knife or scissors, and the mo{>^t may be treated in the same way when not too 
 extensive. When, however, they are extensive, they may be made to dry up by the 
 application of some powder, such as the oxide of zinc, or even starch. Powdered fresh 
 savine is a good application ; Mr. T. Smith recommends it to be mixed with the powdered 
 diacetate of copper. The perchloride of iron in tincture is also serviceable. Venereal 
 warts and others, when extensive, may be readily destroyed by means of the galvanic 
 cautery, the patient being under chloroform. At times excision is the best practice. In 
 the large masses that are found on the genital organs of women, of venereal origin, 
 nothing but the removal of the whole with the labium can be entertained ; when the 
 ecraseur of the galvanic cautery cannot be obtained, the ordinary wire instrument may 
 be used. The hemorrhage from these venereal warts is generally severe, and the surgeon 
 should never attempt to remove them by excision, when they are exten.sive, without 
 having at hand some good styptic, such as the solution of the perchloride of iron, matico, 
 alum dry and in solution, or the cautery in one of its forms. 
 
 Moles. 
 
 Using the word in the broad sense to include .«mall spots of discolored skin, and 
 cutaneous connective-tissue tumors with pigment, with or without unnatural growth of 
 hair or skin glands, they are very common, few people being without one or more upon 
 the surface of the body, while many have them in numbers. I have seen a woman 
 studded all over with hairy moles, the hairs having been in some half an inch long and 
 bi-istly. Moles are generally congenital, but at times put in an appearance later in life ; 
 they are rarely of any great importance beyond the disfigurement they produce. Occa- 
 sionally, however, they degenerate or become the seat of a cancerous disease; the mela- 
 notic sarcoma has frequently its origin in such congenital spots. This clinical fact, which 
 is now fairly recognized, is important, and renders it expedient for the surgeon to excise 
 any mole that has a tendency to grow or to become indurated in middle life. Many of 
 the most virulent forms of multiple cancer the surgeon sees have their origin in moles. 
 
 Corns. 
 
 These are thickened cuticle, the result of occasional pressure, whether on the toes or 
 feet, from tight or hard boots, or on the hands, from the mechanical irritation of tools, etc., 
 
174 BUNIONS. 
 
 or elsewhere. It should be remembered that they are the result of occasional, and not 
 constant, pressure, the latter causing atrophy and absorption. " Not only," wrote Hunter, 
 " the cuticle thickens, but the parts underneath ; and a sacculus (bursa) is often formed 
 at the root of the great toe, between the cutis and ligaments of the joint, to guard the 
 ligaments below.'' This bursa is found under all corns when the pressure is not removed. 
 A corn, when newly formed, can by maceration be elevated from its position as thickened 
 cuticle only, the cutis being unaffected ; but in old corns the cutis appears to atrophy and 
 the papillce to disappear. Such corns, writes Mr. T. Smith (^Holmes's St/st., vol. v.), " may 
 be found based upon the fibrous tissue of the sheaths of the extensor tendons of the 
 toes, all intermediate structures having been absorbed." When a bursa has formed, it 
 may inflame or suppurate and give rise to troublesome conditions such as will be described 
 under " Bunion." 
 
 A corn is called " soft" when it forms between the toes. It is far more painful and sen- 
 sitive than the '' hard ;" it grows also more rapidly, probably owing to its greater moisture. 
 
 Treatment. — Remove the cause and the disease will disappear. This is a doctrine 
 which applies to corns of all forms when acted upon early. Boots which are too loose 
 are as injurious as those which are too tight : where one presses the other rubs, the result 
 being the same. A well-fitting boot with a broad sole, straight inner border^ and square 
 top is the best. To remove the cuticle nothing equals warm water ; and after soaking 
 the part in it for some time, or keeping the corn covered for a night or more with water 
 dressing and oiled silk, the whole may be carefully peeled off by means of a knife. 
 After the removal of the corn the skin should be protected by a piece of soap plaster 
 spread on leather. The application of nitrate of silver has been recommended, but I 
 have known it produce great pain, and when applied to an inflamed corn much harm — 
 indeed, in one case, sloughing of part of the integuments covering the little toe. In old 
 people it is dangerous. The application of the glacial acetic acid is to be preferred. 
 When suppuration takes place beneath a corn, it should be relieved by a puncture as soon 
 as possible, and water dressing applied. Bursal swellings are to be treated as bunions. 
 Soft corns are best treated by taking away pressure by means of the introduction between 
 the toes of absorbent cotton-wool and the use of some dry powder, such as the oxide of 
 zinc ; the corn thus soon becomes a dry one and is easily eradicated. Acetic or carbolic 
 acid is a good application in obstinate cases. 
 
 Bunions. 
 
 When from excessive or long-continued pressure a bursa forms over one of the tar- 
 sal or metatarsal articulations, a " bunion " is said to be present ; and the most common 
 seat for this affection is the metatarsal joint of the great or little toe. This fact is to be 
 
 explained by the evil tendency which boots, as 
 Fig. 58. Fig. 59. generally made, have to draw the toes together 
 
 toward the central line of the foot, the central axis 
 of the undeformed great toe, which runs parallel 
 with the metatarsal bone through the centre of the 
 heel, being thus made to deviate from the normal 
 to an abnormal line, in which the great toe itself, 
 looking outward, forms with the metatarsal bone 
 at the joint an angle pointing inward, and the axis 
 of the toe falls far within the normal one of the 
 _ . foot (Fig. 58). 
 
 BuniouT''"*'^ Toe-Ca^lb^ the Cure of Aston Key,' however, attributes this deformity 
 Bunion. more to exces.sive weight received on a weak tarsus 
 
 and metatarsus from over-standing, the great toe being gradually forced outward by the 
 oblique bearing of the foot on its inner plantar surface when the arch of the foot has 
 given and the foot becomes flat. Too short boots greatly favor this change, the foot by 
 such being compressed longitudinally and the arch of the tarsus increased, the toes even 
 being drawn up to form angles with the metatarsal bones, the great toe suffering the most. 
 When bursae form over the projecting bones, it is to save the joints from injury ; and at 
 times these form over the dorsum itself. Under extreme conditions the bursa may inflame 
 and suppurate, giving rise to obstinate and troublesome sores. In still more extreme or 
 neglected cases the joint of the great toe may be involved, ending in its destruction with 
 or without exfoliation of bone. 
 
 1 Gtiy's Hosp. Rep., 1836. 
 
i.y-ajiowy tok-sml. ■ 176 
 
 TiiKATMKNT. — Wlipn tlip nuturt! of a luuiion is un<lerstoofl, the principles of its treat- 
 ment lu'conu' clear. Preventive treatment is the best, and consists in maintainin<r the 
 natural eimdition of the foot; in y«)ung children, and in jrirls especially, hy jruarding 
 aj^ainst the flattening of the foot from over-standing or walking during the jteriod of 
 growth, and against altering the axis of the great toe by keeping the inner line of the 
 boot straight; and in no way by too short boots cramping the foot longitudinally. 
 
 When a bunion has formed, the oidy consistent treatment is that which tends to 
 restore the mis])laced toes to their natural position — when the great toe i.s inv»jlved, either 
 by Key's jilan of having a .separate compartment made; in the boot, so Cfjiistructed as to 
 keep it in a straight line with the foot, or by the simple apparatus given in Sayre's work 
 on orthopii'die surgery ( Fig. •")!•), which consists of buckskin or linen caps to the toe («), 
 a few inches of elastic webbing (h)^ a piece of adhesive plaster to go round the foot (c), 
 and two circular j)ieces of the same ('/) to retain all in position. Even in .severe cases 
 this practice may be successful, and in the old and confirmed cases the same is to be 
 adopted ; palliative treatment, however, is at times alone practicable. 
 
 The common ])lan, wrote Key in l.S!:5U ((tiu/s Ifosp. Ji«p.), "resorted to for the relief 
 of bunion palliates the evil in some degree by removing the pain and taking off the press- 
 ure, but it does not go to the root of the evil. The plasters on thick soft leather are 
 agreeable to a painful bunion by keeping the skin in a pliant .state and by protecting the 
 part from pressure," but they do not cure the di.sease. 
 
 Under all circumstances, pressure is to be removed ; nothing like a tight boot ought 
 to be thought of. a wide and easy one being worn. To the inflamed bunion water dress- 
 ing is the best application. Should suppuration take place, an early incision into the 
 bursa should be made. In old people, however, .some caution is called for in carrying out 
 this practice, because in such, where from diseased arteries or other causes the circulation 
 is feeble, gangrene of the part or a troublesome suppuration may ari.se. AVhen suppurat- 
 ing sores exist, they may in the aged ret|uire stimulating applications; in the middle-aged, 
 the bursa may be laid open and allowed to granulate or be excised. In the early stage 
 of a bunion the mechanical means suggested may be aided by the local application of a 
 small blister, and Mr. Thomas Smith speaks highly of the local use of the biniodide of 
 mercury ten grains to an ounce of lard {Holmes's S>/sf., vol. ii. p. 938, 3d edition). 
 
 In the last stage, when the joint is destroyed, the case may have to be treated by 
 incision of the parts, excision, or even amputation. 
 
 In-Grown Toe-Nail. 
 
 This is a troublesome and painful affection, and is more commonly met with on the 
 outer side of the great toe-nail than on the inner, though it may occur in both places. It 
 is usually caused by external pressure upon the soft parts, the movable soft parts being 
 pressed upon the immovable nail. As often as not it is due to the collection of cuticle 
 beneath the edge of the nail, this cuticle acting as a foreign body and by its pressure 
 causing ulceration. Ulceration having once been set up. the healing process is prevented 
 by the presence of this cuticle, together with the pressure of the edge of the nail and 
 the soft parts covering it in ; fungous granulations, as a consequence, frequently form, 
 and copious discharge takes place, the affection being attended with severe pain. 
 
 Treatment. — The disease being the result of pressure applied from without in the 
 shape of tight boots, or from within in the form of indurated cuticle beneath the nail, the 
 surgeon's main object in the treatment is to take away the exciting cause, and when the 
 collection of cuticle exists, by the careful introduction of a probe beneath the nail, to 
 procure the evulsion of the foreign body. In the early stages of the disease this treat- 
 ment is often sufficient. When external pressure has been the cause and ulceration 
 exists, the soft parts may be carefully pressed away from the sharp edge of the nail by 
 the careful introduction beneath the overhanging integument of a .small roll of lint, which 
 should be well pressed down to the bottom of the sore and fixed in position by means of 
 strapping, applied so as to draw the soft parts away from the nail. This treatment, by- 
 removing all pressure from the sore, as a rule, is successful. When the fungous granula- 
 tions are excessive and the discharge is profuse, the free use of the powdered nitrate of 
 lead before the application of the lint is of great value. After one or two applications 
 of the lint in the manner described, the soft parts will have been so pressed to one .side 
 as to expose the edge of the nail with the surface of the .sore, when the lint or a piece 
 of thin sheet lead or tinfoil may be introduced beneath the edge of the nail and the 
 dressings renewed. By this treatment a rapid cure readily ensues; and if no external 
 
176 
 
 ONYCHIA MALIGNA. 
 
 Fig. 60. 
 
 pressure be reapplied and the nail is allowed to grow up in its normal square form, there 
 will be no recurrence. In severe cases, where the soft parts so overhang the nail as to be 
 unaffected by the means here suggested, or where the nail perforates the soft parts (Fig. 
 GO), the best course is to excise the overhanging integument by means of a scalpel ; the 
 ulcer by this method is exposed, and the sore during the process of cicatrization so con- 
 tracts as to draw the soft parts away from the nail, which will then grow up in its normal 
 form and act as a covering to the toe. 
 
 When the ulcer has spread far under the nail, it may be expedient to remove a portion 
 of the latter to allow of cicatrization, though, in a general way, to 
 remove half the nail, to take away a V-piece from the central part of 
 its edge, to scrape or notch it, are only temporary remedies. They may 
 succeed for a time and allow the sore to heal, but it is certain to recur 
 in all severity as soon as nature has restored the parts which the sur- 
 geon has removed. 
 
 To cut the corner of the nail under the idea that it is the offending 
 body is a futile proceeding ; it may for the moment appear to be of ser- 
 vice, but in the end it is injui'ious. Indeed, the nail should be left 
 square, as nature made it, and care should be taken to see that the soft 
 parts are in no way pressed over its edge. 
 
 Onychia Maligna. 
 
 luvLludllKJIlOll ™, . . ,. „ , ., . in 11. 
 
 Inis IS a disease oi the nail matrix, and a lar more severe and obsti- 
 nate affection than the last. It is found most commonly in unhealthy children, and, as a 
 
 rule, is started by some local injury, such as 
 
 Fig. 61. 
 
 Fig. 62. 
 
 a squeeze. It commences as a swelling of 
 the end of the toe or finger, with the other 
 external signs of inflammation — redness, 
 heat, and pain. These symptoms are soon 
 followed by the exudation from beneath the 
 nail of a serous and often fetid fluid ; the nail 
 itself loosens, sometimes falls off, or either 
 flattens out or curls up at its edges (Fig. 61). 
 When this occurs, a foul ulcer is visible be- 
 neath. In extreme cases the affected parts 
 assume a flattened bulbous form and look as 
 incurable as any local affection can well ap- 
 pear, and in rare instances the disease in- 
 volves the last phalangeal joint or bone. It 
 is never found in other than feeble and ca- 
 chectic children. The worst case of this 
 nature I have seen occurred in a child ast. 10, 
 in whom the fingers and thumbs of both 
 hands were involved ; and the disease had 
 existed for years. 
 
 Treatment. — In favorable and not extreme examples of this affection tonics inter- 
 nally and water dressing externally suffice to bring about a cure ; while in others more 
 active local treatment is called for, such as the application of some mercurial lotion, as 
 black-wash or Abernethy's lotion (formed of the liquor potassae arsenitis 3ij to Sj of 
 water) or the red-oxide-of-mercury ointment. In the case to which I have already 
 alluded all this treatment failed, even after the evulsion of the nails — a plan of treat- 
 ment that should always be adopted in obstinate cases. The cure was at last effected 
 by making a clean shave of the dorsal aspect of the extreme phalanx, taking away nail 
 and soft parts. This course was resorted to only after the disease had existed for five 
 or six years and had resisted every form of treatment, even to the repeated evulsion of 
 the nails, the pain being agonizing and demanding surgical interference. Fig. 61 was 
 taken from one of the fingers of this patient. Professor Vanzetti of Padua strongly 
 advocates the application of the powdered nitrate of lead to the ulcer, and my own expe- 
 rience of its value justifies me in strongly recommending it. Constitutional treatment, 
 with tonic regimen, is always necessary. 
 
 The disease may at times have a syphilitic origin, when it will be wise to adopt 
 specific treatment. 
 
 Acute Onychia. 
 
 Chronic Onychia. 
 
ELEPHANTIASIS. 1 77 
 
 Other Diseases of the Nails. 
 
 TIiultT the iiifliiciicr of sitiiic aciitc diseiisiis, the nails cease to <jrow, and tlio arrest 
 becniiics inanit'cst. as (•(divalescH-nce advances, by a transverse groove in tlic nail, while 
 the width of the irroove denotes the duration of the arn^sted <rrowtli. 
 
 Ridged Nails. — As a result of hereditary .syphilis .Mr. IIut(diin.son has shown that 
 the nails niav herduie completely riilired, while even in ac((uired syphilis llut(diinsi>n, 
 Wilks, and Fair,u;e have fairly provtid that the nails may hecome narrow, thick, ill-fnrmed 
 bodies, or concave, rough, and hiaek. 
 
 Psoriasis att'ects the nails somewhat in the same; way. the nail thicktMiing and split- 
 ting \ ertically ; and in fariis Fagge has shown that the nails may become thickened and 
 of a yollow color from the interstitial deposit of 
 
 the parasitic disease. Wilks in the Lancef for ' Fio. 63. Fig. 64. 
 
 ISCS, and Fagge in Giu/s IIosj,. Rep., 18611-70, 
 have written fully on these j)oints. At time.s \)^ 
 the nails become .soft and in feeble subjects 
 very oonve.x. This condition is .said to be com- 
 mon in phthisical su])jects, but in .surgical dis- 
 ease I have often observed the same condition 
 appear during illness and disappear as strength 
 returned. I regard it only as an evidence of 
 feeble power. 
 
 Horny growths occasionally spring up 
 
 beneath the nail, as seen in Fig. 03, and ungual 
 
 ^„^.-,4-^^;^ 1 • 1 ; „ u .,„ „,,* ,..4^k 4^',. ... Horuy Growth from beneath fngual Kxostosia. 
 
 exostosis — which IS a bony outgrowth trom •' jj^jj ^ 
 
 the extreme phalanx of the great or otlier toe — 
 
 very frequently appears as seen in Fig. G4. Both require excision. 
 
 ELEPHANTIASIS. 
 
 This term has been applied to two very different diseases- — the Elephantiasis Grx- 
 corinn, or true kjrrosy, and the E/epJtanfiasis Arahiim, or Cochin or Borhadoes hfj. The 
 former is probably constitutional and appears as a tubercular affection of the skin, more 
 especially of the face, attended with some loss of sen.sation ; it is usually ushered in with 
 slight febrile disturbance and local oedema. As it advances the skin thickens and the 
 tubercles multiply ; the disease spreads and involves the tongue, mouth, no.se, eyes, and 
 even larynx and lungs. In extreme cases ulceration and disease of the bones exist, the 
 subjects of the affection dying from exhaustion if not from suffocation. It is, happily, 
 rare in this country, although it does occur occasionally ; it is, however, common in Nor- 
 way, in the Mediterranean, and in the Indies. Dr. Webster in the Meil.-Chir. Trtnn^. for 
 1854, and Mr. Day in the Madron Quart. Journal for 1800, give valuable information 
 upon the subject; and Dr. Carter in the Trans. Med. and Phijs. Society of Bombay, vol. 
 viii.. new series, enters fully into its pathology. 
 
 The disease has been regarded as incurable, although, since the introduction in 1873 
 of the Ourjun or wood oil by Dr. Dougall of the Indian medical service, better results of 
 its treatment have been realized. The oil is used as an external application, made into 
 an emulsion with lime water, in the proportion of one part to three, and should be well 
 rubbed in twice a day for two hours at a time. It has ahso to be taken internally in two- 
 drachm doses mixed with the same quantity of lime water twice a day. With this treat- 
 ment the tubercles are said to soften down, and in their place watery blebs form, which 
 burst and discharge a clear .serous fluid, and then the induration gradually subsides. The 
 oil taken internally is a diuretic and purgative. 
 
 Elephas. 
 
 To the surgeon the second form of elephantiasis, or the Elephantiasis Arahnm, is of 
 the greatest interest. It is quite distinct from the true leprosy. It appears generally in 
 one or other of the lower extremities or in the male or female genital organs. It shows 
 itself as a general infiltration into the skin and subcutaneous tissue of an organizable 
 material, whereby the integument becomes hypertrophied and greatly thickened. It is 
 commonly associated with some enlargement of the lymphatic glands, and frequently with 
 dilatation of the Ivmphatics. It is occasionally associated with chyluria. In advanced 
 12 
 
178 
 
 ELEPHAS. 
 
 Fig. 65. 
 
 disease the skin falls into great folds, and between these fissures form, which subse- 
 quently pass into oozing ulcers. At times the foot and leg become the seat of extensive 
 ulceration, which rarely cicatrizes. 
 
 It generally begins with some febrile attack, and the aifected part becomes the seat of 
 erythematous redness and swelling, which sub.side, again to recur ; each attack leaves 
 some extra thickening behind it. I have ohserved this very clearly in many cases, and 
 have no doubt that the erythema had some di.stinct relation to the disease. 
 
 Treatment. — Dr. Wise of Calcutta in 1835 looked upon elephas as a disease of the 
 venous system and inflammatory. 31r. Day. in the paper already alluded to. regards it 
 as consecutive to malarious fever, while 31r. Dalton {Loncet, 18-lG) looks upon it as a 
 constitutional disease, like the leprosy; and upon this theory the sciatic nerve of the 
 afiected limb has been resected by Dr. J. S. Morton of Pennsylvania with some success. 
 Dr. Carnochan of New York believes it to be associated with an enlargement of the 
 arterial trunks of the part, and upon this theory based his practice of tying the main 
 artery of the limb, thereby starving the disease. He performed this operation for the 
 first time (in January-, 1851), and the success he met with, as published in a memoir on 
 the subject in 1858, induced me to follow his example in 1865. My case in all its details 
 was published in the Med.-Chir. Trans., 1866, and the benefit of the operation was most 
 striking. It occurred in the case of a Welsh girl aet. 25 ; the disease had been of two 
 years' standing and was spreading. The thigh of the affected limb (Fig. 65) measured 
 twenty-seven inches round and the leg nearly twenty-three, the affected leg being nine 
 
 inches in circumference larger than the sound one. 
 and the thigh seven. Five weeks after the ligature 
 of the external iliac artery the calf of the aff'eeted 
 limb measured .seven inches less than it did at the 
 time of operation ; and when she left the hospital^ 
 the limb apjieared as in Fig. 66. The rapid disap- 
 pearance of the thickened tissue was very remark- 
 able. Since the operation the girl has gone on 
 well, is companion to a lady, and can now walk ten 
 or twelve miles. The limb becomes slightly (Ede- 
 matous only on over-exertion. 
 
 I have performed the same operation three 
 times since, but not with similar success. I liga- 
 tured the femoral artery of a man who had the 
 whole limb involved, the thigh being only slightly 
 so, and for a time everything promised to be as suc- 
 cessful as in the case previously recorded ; but an 
 attack of erythema came on. followed by renewed 
 swelling of the extremity, which never disappeared. 
 In this case the size of the superficial femoral 
 artery was extraordinary, the loop of the .silk liga- 
 ture when it came away being capable of admitting 
 a No. 12 catheter. The vessel seemed to be nearly the diameter of my finger and was 
 very thick. In a more recent case, however, gangrene of the foot, followed b}" death, 
 took place. 
 
 When this operation is performed, the vessel should be ligatured well above the dis- 
 ease. I may add that Butcher in 1863 and Alcock in 1866 had succes.sful cases, though 
 Sir Joseph Fayrer and Buchanan of Glasgow have not met with successful results. 
 
 AVhen surgical interference of this kind is not applicable, elevation of the affected 
 limb or pressure should be employed. In severe cases amputation may be called for. 
 
 On three occasions I have had to circumcise patients with elephas of the penis and 
 scrotum, and in each after the operation the whole of the thickening of the scrotum dis- 
 appeared. This fact is worthy of record. 
 
 Pathology. — Within recent times an opinion has gained ground that the true pathol- 
 ogy of this elephantoid disease is to be found in the lymphatics and that it is due to 
 lymphatic obstruction. It has. moreover, been thought by Dr. T. Lewis that the pres- 
 ence of the Filaria .fant/iiiin's hominis might have something to do with it. since the para- 
 site has been found in the blood of patients who have had elephas. 
 
 In support of this view a very striking paper has recentlv been published by Dr. 
 I'atrick ]NIanson in the China Customs Ca-effe. Medical Report, for the six months ending^ 
 March. 1882. an abstract of which mav be read in Med. Times and Gazette, Feb. 12, 1883. 
 
 Case of Elephantiasis Arabum before and after 
 the Application of a Ligature to the Femoral 
 Arterv. 
 
n\ I'M:. [SITES. 
 
 179 
 
 " In the instances, " writes Munson, • in wliicli tlic jcucnt worm lias hccn diM-fivcreil, 
 she was f'(iun<l in lyinjihatic vessels (»n tlu- disial sidt-ot' the ;.'lan<ls. This has been shown 
 to he in many, if not in all, eases her normal hahitat. Her pro^reny. therefore, must 
 travel aloni: the atVereiit vessels, throntdi the L'laml.-. and so on to the thoraeic dnet, and 
 theiiee into the hlood. The lonii-. sinuous, and powertul Intdy of the embryo is well 
 a<la|ited to ju-rfuMn this journey. Hut su|i|Mise. instead of this mature emliryo, an ovum 
 is launched into the lymph-stream prematurely atid helore the contained iinhryo has suf- 
 tieientlv extended its chorion : then this jtassive (»vum must certainly he arrested at the 
 first Ivmjdiatie L'land to which it is carried l»y the advancin^'^ lymjih-current. It measure.s 
 tV((" ' zhji" • ^^''"^''"i"'''' '''*^' outstretched emhryo is only ahout ■^X)^(j" in diameter. It is 
 much too lar'j:e to pa.ss the glands, and the emhry<», rolled uj* in its chorional envelope, 
 cannot aid itself. It becomes, in fact, an embolus. Now, tilari;e are jtnjdi<^iou.sly prolific. 
 Myriads of younj; are exjielled in a very short time. I have watched the process of par- 
 turition in the minute Flhnla rarri loii{ii((ti. Every few seconds a peristaltic contraction, 
 bejjinnitiL' low down in the uterine horns and extending to the vagina, expels some twenty 
 or thirty emltryo>^. If this process of parturition occurs prematurely, or peristalsis is too 
 vigorous and extends to a point high up in the uterine horns where the embryo has not 
 yet comjiletely stretched its chorional envelope, then ova are expelled. These, as they 
 reach the glands, where the afferent lymphatic breaks up into fine capillary vessels, act as 
 emboli and jdug u|) the lymph-channels one after another until the fluid that carries them 
 can no longer jiass. In this way the gland or gland.s directly connected with the lym- 
 phatic in which the aborting female is lodged are thoroughly obstructed. Anastomoses 
 for a time will aid the passage of lymph, but the anastomosing ves.sels will carry the 
 embolic ova as well as the lymph. The corresponding glands will then in their turn be 
 invaded, and so on until the entire lymphatic system connected directly or indirectly with 
 the vessel in which the parent worm is lodged becomes obstructed." The degree of 
 embolism and location f>f the worm determine the site and character of the resultant 
 disease. 
 
 ON PARASITES. 
 
 Guinea- W^orm. — The Drdcmicnlus or Filaria inedinensis is one of the most trouble- 
 some parasites known in Africa, Asia. India, and tropical America. In Europe it is only 
 occasionally met with in those who have visited the above districts. 
 
 The mature worm varies in length from two to six feet. It is cylindrical in form, 
 white in color, has a smooth surface, is tough and elastic ; its mouth appears as a circular 
 orifice and it has no anus. How it 
 
 enters the body is unknown, although ^'^'- "'• 
 
 it is evident that it does so from .> 
 without, and probably through the ^i 
 skin of some part that has been in ij^ 
 contact with water, inasmuch as it '^ 
 is more eomnmn in the feet than in 
 other parts of the body, although 
 the Madras water-carriei's are said 
 to have them in the V»ack. At any 
 rate, the worm gets into the subcu- 
 taneous areolar tissue, where it re- 
 mains. Busk tells us that it does 
 so usually for aVjout twelve months, 
 although it may l^e eighteen. When 
 mature and tlie time has come for the discharge of the embryos with which it is filled, it 
 makes its presence known by boring the skin, protruding its head under the cuticle, rais- 
 ing a bleb, and coming out bodily, discharging its young filariae externally. 
 
 Treat.ment. — The first manifestation of the disease is usually a circular bleb, as rep- 
 resented in Fig. (57. although it often happens that pain and stiffness of the affected part 
 have been complained of for some time previously. The bleb contains sero-purulent 
 fluid, and the surgeon, in order to find the worm, should cut the raised cuticle off. 
 " There will then be seen protruding from a little hole in the centre of the denuded cutis 
 one or more inches of the worm, of the size and color of vermicelli or of a wax match. 
 The surgeon now makes a small quill-like roll of adhesive pla.ster, rolls the worm around 
 it, and gently draws as much as will come without the risk of breaking; and this is 
 repeated day after day. till at last the tail, which end- in a small hook, comes wriggling 
 
 Guinea-Worm Bleb just ( ut oH". (Dr. Druitt, Med. Times and Gaz., 
 Jauuary 3, 1874.) 
 
180 ON PARASITES. 
 
 out, and the case is at an end." ' Under these circumstances a rapid cure takes place. 
 Should the worm break, a subcutaneous abscess is almost sure to form higher up ; and 
 when this is opened, a loop of the worm can most likely be got out on a probe, and so be 
 extracted as before. 
 
 At times no bleb forms, but merely a subcutaneous abscess. In exceptional ca.ses 
 more than one worm may exist. Druitt quotes a case in which nineteen had been 
 extracted. 
 
 Cnn,-<i(lL-rable constitutional di.stuj'bance often attends these local changes. 
 
 Chigoe, Chigger, or Gigger, or Sand-Flea. — This is found in the "West Indies 
 and in South America, but the impregnated female only infects man. It makes its way 
 beneath the nails or between the toes by means of its long proboscis, and, having gained 
 an entrance, rapidly increases to a white globular vesicle the size of a pea. Some local 
 irritation attends its presence. To prevent trouble, the insect should be carefully turned 
 out of its bed by dilating the orifice through which it entered with a needle, care being 
 observed not to rupture the globular vesicle which contains the ova ; for if these escape 
 into the cellular tissue, the accident is often followed by tedious suppuration and 
 ulceration. 
 
 The echinoCOCCUS, or hydatid, the larva of the Tsenia echhwcoccus, is a common 
 entozoon in the human subject, and it may exist as a microscopical object or as a cyst of 
 many inches in diameter. It has highly-elastic laminated walls lined with a granular 
 layer, and it is usually enclosed in the parts of the body infected by it in a distinct cap- 
 sule formed by exudation into and the consolidation of the surrounding tissue. It con- 
 tains a clear, watery, non-albuminous fluid, in which at times float some taenia heads or 
 scolices, the so-called echinococci. or in which are found the booklets which surround the 
 head. 
 
 These hydatids are met with in any part of the cellular tissue of the body — in the 
 lungs, liver, abdominal cavity, pelvis, and even in the bones; a specimen exists at Guy's 
 in which the spinal column was so aftected. I have seen them turned out of the breast, 
 tongue, thyroid gland, pelvis, vagina, uterus, thorax, and bladder, and have removed cysts 
 containing them from the muscles of the neck, axilla, and thigh, and have also treated 
 many in the liver. 
 
 At times an acephalocyst contains many secondary cysts. I removed a basinful from 
 one occupying the pelvis, and they were of all sizes (Path. Soc. Traits.^ vol. xvii.). Hy- 
 datid tumors are to be recognized by negative symptoms ; they appear as tense, globular, 
 elastic swellings in a part, and give rise only to such symptoms as are to be explained 
 mechanically by their presence; when dead, they give rise to suppuration. 
 
 Treatment. — This must var}- with the position, size, and growth of the hydatid 
 tumors. When the parasite occupies some position other than one of the great cavities 
 and can be turned out of its bed by means of a free cut into its capsule, no better treat- 
 ment is required. When it occupies one of the abdominal viscera or one of the serous 
 cavities, it should be left alone, unless from its size it interferes with important functions 
 or threatens life, when it should be tapped ; but this point will be discussed in another 
 page. 
 
 The CysticerCUS Cellulosse, the cystic scolex of the common tapeworm, is found 
 in man, and is said to be the common parasite of the "measly pig. ' It has a quadran- 
 gular head, short neck, and cylindrical vesicular body, the head being .surrounded with 
 characteristic booklets. It is found more particularly in the muscles and intermuscular 
 tissue, and may afl'ect the viscera as the former hydatid. It is known to occur in the 
 eye, brain, heart, etc., and can be treated, when interference is called for, by an incision 
 into the part and removal. 
 
 Trichiniasis will be con.sidered in the chapter devoted to the aflections of the mus- 
 cles. 
 
 ' Druitt, Med. Times and Gaz.. Jan. 3, 1874. 
 
SURGEllV OF THK LYMPHATIC SYSTEM. 
 
 CHAPTER V. 
 
 INFLAMMATFOX OF TIIK LYMPHATICS AND TFIEIR GLANDS. 
 
 Lv.Mi'iiATlcs iiiav !>(■ wouikUhI by accitlcnt <ir by dosiLMi and im bad result ensue. At 
 times, however, a fistulous opening that diseharires lymph may remain. The same con- 
 sequenee may be the result of disease. Dr. IL V. Carter of Bombay has recorded three 
 such cases in the Me<l.-(li!r. Tntiis., vol. xlv., and ])r. Day another in the Clim'ad Soc. 
 Trans., vols. ii. and xi., which through his kindness 1 had an opportunity of seeing. It 
 was reported on by a committee of the society, and they confirmed the view taken of it. 
 It was one of hypertrophy of one lower extremity of a boy. with the occasional discharge 
 of chyle from vesicles, which were formed on varicose lymphatics. The hypertrophy 
 had clearly an intimate connection with the distended .state of the lymphatics of the 
 limb. 
 
 An obstructed condition of the lymphatic vessels, giving rise to lymphatic oedema is 
 now accepted as a cause of " Elephas "' or f^lephantiasis Arabura (rUi^ page 178). 
 
 Occasionally the lym])hatics after inflammation appear as a hard cord beneath the 
 skin. In a case I had under my care some years ago this cord remained hard and con- 
 tracted for many weeks after all .signs of inflammatory action had ceased. It occurred 
 in a gentleman who was in the habit at night of going through .<ome simple muscular 
 exercises, and in doing this the cord in the arm snapped on the inner side of the biceps. 
 I saw him a few minutes after the accident, and felt the two ends of the cord, which were 
 apart for about an inch. Next morning the thin skin covering the anterior surface of the 
 fore-arm was elevated, loose, and baggy from the effusion of fluid beneath. There were 
 no signs of inflammation or pain beyond local tenderness at the point of rupture of the 
 lymphatic cord. In four or five days the fluid was reabsorbed and convalescence restored; 
 the hard cord gradually disappeared a:nd all traces of its separation became lost. I looked 
 upon the eff"used fluid as lymph that had been poured out by the divided lymph tube, and 
 which had been taken up again. I have not seen a similar accident since. 
 
 The absorbent glands, with their ducts, are liable to inflammation (-^ adenitis" or "a?;- 
 geioleucitis'). and this action is probably the result of the absorption of some septic mate- 
 rial. It is almost always associated with a wound, punctured or open, inflamed, suppu- 
 rating, healing, or scabbing ; with some point of irritation or suppuration, such as a 
 papule or pustule; with some centre from which morbific elements may be taken up. In 
 what is called a simple wound the inflammation of the absorbents may be acute, but in 
 the poisoned it is violent and difi'used. The inflammation always follows the course of 
 the absorbents, leading from the centre of absorption toward the glands — that is, toward 
 the body — and it never spreads backward. When it has reached the glands, the diseased 
 action ceases to spread — that is, it expends its force upon the group of glands in which 
 the absorbents naturally end and does not extend through another series of absorbents to 
 a second group. The morbific material is arrested in the glands ; at least, such is the 
 usual course of the aff"ection. AVhen pyjemia follows or complicates the case, it may be 
 open to question whether the poisonous fluid circulating in the lymphatics has not been 
 allowed to pass into the blood through its usual channels — that is. through the inflamed 
 glands onward ; but it is at least as probable that the same septic material that poisoned 
 the lymphatics and set up inflammation in the tubes and glands was taken directly into 
 the blood through x\\v vrimus clianiu'ls. thus giving rise to blood poisoning. 
 
 Absorbent inflamination usually manifests its presence in a definite way. Pain 
 and tenderness in some of the glands are irenerally early symptoms ; with them, or soon 
 
 ISl 
 
182 IXFLAMMATIOy OF LYMPHATICS AXD THEIR GLAXDS. 
 
 following them, will be seen a painful band of redness leading from the wound or infect- 
 ing centre toward the gland. This red liifb may be continuous or interrupted, it may be 
 a thin streak or a broad stripe of redness, and in some instances it may so radiate into 
 the surrounding tissues as to simulate erysipelas. It should be noted that the red lines 
 follow the course of the absorbents, and not of the veins. With these local symptoms 
 there will be some febrile disturbance, and very probably the attack will have been ush- 
 ered in with a rigor. 
 
 Under favorable circumstances and treatment these symptoms mav subside, and the 
 red line, with the swelling of the glands and cellular tissue around the inflamed parts, 
 together with the constitutional symptoms, will disappear. 
 
 In less favorable examples suppuration may take place, either as a local or diflfused 
 suppuration of the affected glands and surrounding cellular tissue, as a local abscess in 
 the course of the lymphatics, or as a series of local absces.ses. In extreme cases the 
 suppuration may partake more of a diff"used character, such as that already described 
 as taking place in phlegmonous ervsipelas. 
 
 With these local changes the constitutional symptoms will assume diflferent features : 
 the febrile disturbance will be probably great and marked by depression ; rigors may 
 repeat themselves at regular intervals, and will generally indicate some suppurative pro- 
 cess. When typhoid symptoms appear with rigors and sweating, the case has clearly 
 become one of blood poisoning or septicjemia. 
 
 There are thus three diff'erent classes of cases : 
 
 The '• simj^Ie," terminating in resolution ; the - ynore severe^" ending in local glandular 
 or lymphatic suppuration ; and the " complicated,'' marked by diff"used inflammation and 
 suppuration, with general blood poisoning. 
 
 In the simple form the poisonous element is probably of a diluted or but slightly 
 irritating nature, and is generally .some altered secretion of a simple wound due to exter- 
 nal irritation. In the more complicated or severe forms the poisonous element is of a 
 more active kind, and has been either introduced from without in the form of a distinct 
 animal poison, such as is derived from a dissection wound or the bite of an animal, or is 
 generated from within, as seen in puerperal cases. 
 
 Inflammation of the absorbents, erysipelas, phlegmonous or otherwise, and septicaemia 
 are all closely connected. 
 
 The eff"eets of inflammation of the absorbents, however, are not constant or alike in all 
 cases. In some the glandular enlargement alone is to be recognized, with more or less 
 extensive suppuration of the glands and their surrounding connective tissue, without any 
 external evidence of inflammation of the lymphatics leading to the glands. In others 
 the red line of inflamed absorbents will be visible without glandular complication or little 
 more than a .slight induration of the gland. At times there will be suppuration only 
 along the track of the lymphatics, but none in the glands, this suppuration taking the form 
 of local abscesses. I have seen in a case of absorbent inflammation of the fore-arm and arm 
 four distinct abscesses in the line of inflammation, with only axillary glandular tenderness. 
 
 This absorbent inflammation is most common in the extremities, though it may occur 
 anywhere. There seems no doubt that a large number of the cases of glandular abscesses 
 are of this nature. Pelvic abscesses in women are known to be of this kind, because pus 
 has been found in the absorbents of the part. 
 
 Glandular .suppuration in the neck is. from its position, a dangerous aff"ection. the con- 
 nective tissue of the parts being so loose and the fascia covering them so firm that bur- 
 rowing suppuration often takes place. These deep-seated suppurations .should be opened 
 early and as soon as any local evidence of pus exists, and in this way — viz.. by cutting 
 through the fascia with a lancet and thrusting a director or forceps into the deep con- 
 nective tissue. I have opened an abscess at the base of the tongue in this manner from 
 beneath the jaw with an excellent result. The swelling aflfected deglutition and re.>jpira- 
 tion and threatened life. 
 
 Treatment. — When indications of absorbent inflammation appear, the wound or sore 
 should be well cleansed, the scab removed, and any collection of pus let out. The affiected 
 limb should be raised, the foot, when involved, brought higher than the hip. the hand or 
 elbow than the shoulder, and warm poppy fomentations should be applied along the whole 
 course of the lymphatics up to the group of glands in which they terminate. Some sur- 
 geons, particularly the French, advise that the inflamed line should be pencilled with 
 caustic and dry warmth applied, such as cotton-wool ; but I prefer the practice already 
 indicated, as 4t gives more comfort. The application of the extract of belladonna and 
 glycerine to the part is also most beneficial. 
 
ISFLAMMATIDS <>l' LYM I'lIATU'S AM) THEIR (iLANDS. 1«3 
 
 As soon as su|>|)iiratii)ii a])|)oars tlio abscess must be opened, whether tliis follows 
 directly upon the iiitlaniniation or subse(|U(!ntly. At the vc^ry earliest period of the 
 intlanunation, when the tonj.nie is foul, an emetic has some influ<'nc«i in checking its prog- 
 ress. A good saline ))urge is also beneticial. 
 
 Sedatives slionld bo given to allay pain, su(di as small doses of morphia three times a 
 (lav, with a donl)le dose at night to induce sleep. When siip)Hiration has taken place, 
 tonics may be administered, of which iron is the best. 
 
 In chronic cases, where induration in the track of the ducts remains, mercurial (unt- 
 ments and IViction are sotnetimes valuable. 
 
 Glands, and particularly those in the neck, are very apt to inflame after fevers or the 
 exanthemata, and to give rise to much local distress. In j)atients who are not extremely 
 feeble these eidargements. as a rule, subside by themselves under careful management, 
 though in exceptional cases they suppurate. 
 
 Local warmth a])plied by means of cotton-wool, tonics, and nutritious food are the 
 best remedies ; but when supjiuration threatens, warm fomentations are more grateful to 
 the patient. Ab.sce.s.ses should be opened early. Before opening, however, it is well to 
 try what drawing ofi" the pus by means of the "aspirator" may acc'omplish, repeating 
 the operation as the pus re-collects. In some instances a cure may Vje effected by these 
 means, and thus a scar is prevented. Should aspiration fail, an incision ought to l>e made. 
 
 The local application of iodine under these circumstances, although ii common remedy, 
 does n(tt ajipear to be of much value. 
 
 Chronic glandular enlargement is a very common affection. It is found in 
 the strumous and feeble child as a chronic and slightly painful enlargement of a gland 
 or glands, more particularly those beneath the jaw and about the neck, and comes on 
 either after exposure to cold, some slight illness or local irritation, such as bad teeth, or 
 without any definite cause. It often subsides spontaneously on the removal of the cause 
 or on the improvement of the general health. At times these glands suppurate and leave 
 ugly sores, the cellular tissue around the gland becoming destroyed and the skin conse- 
 quently undermined. The pus from these glandular enlargements is sometimes ill formed 
 and curdy ; and when it attends the breaking down of some old disease, it may contain a 
 chalkv deiHisit, the produce of some degenerated or dricd-up tuberculous or other matter. 
 
 Hodgkin's Disease of the Glands, or General Lymphadenoma.— 
 
 There is, however, another chronic enlargement of the glands that appears to diflFer in 
 all ways from the local enlargements to which attention has just been drawn. It was 
 first described by Dr. Hodgkin in the Med.-Chlr. Trans., vol. xvii., and may be called 
 Hodgkin's disease of the glands, or, for the sake of distinction, glandular tumors. He 
 observed it first in the mesenteric glands, though any or all may be affected. In it the 
 glands become very much enlarged, even to the size of an egg, and apparently more 
 numerous; they present a smooth external appearance and have a soft semi-fluctuating 
 elastic feel. On section the surface of the gland presents a .smooth, bloodless, semi-trans- 
 parent, loose, succulent structure ; microscopically, it is made up of glandular tissue and 
 abundance of fibro-nucleated tissue ; it is of a tough, leathery consistence and exudes a 
 clear serous fluid. The tumors are always free, each being separable from the others. 
 
 To the surgeon the disease at times appears as a local movable glandular tumor of a 
 slow painless growth which medicine has little or no power of influencing ; it has the 
 local clinical appearance of a benign fibro-cellular tumor, and has often been excised 
 as such. 
 
 In other instances the tumors are multiple, three, four, or many more existing in one 
 locality, chiefly in the neck. In exceptional instances the tumors are more numerous. 
 I have seen cases in which, on one side of the neck, the subcutaneous tissue seemed filled 
 with loose glandular tumors readily movable one upon the other, as if simply confined by 
 skin, in the same way as the adenoid tumors of the brea.st are occasionally met with. In 
 still rarer examples the whole glandular .system seems to be affected, every group of 
 glands not only being apparently enlarged in size, but also increased in number. 
 
 This disease is often associated with an enlarged spleen, and appears pathologically 
 to be allied to that blood disea.se now known as leucocythfemia, notwithstanding that in 
 many in.stances the white corpuscles are not in excess. 
 
 On one occasion I had an opportunity of watching the gradual development of this 
 aflfection. It began in the cervical glands and gradually involved the whole glandular 
 system, the patient, a boy at the age of fifteen, dying with an enormous spleen and gland- 
 ular tumors in every region. His blood was made up almost entirely of white blood cor- 
 puscles, death resulting from exhaustion. 
 
184 DISEASES OF THE THYROID GLAND. 
 
 Another ease I treated five years ago, a woman aet. 56, has lately returned conva- 
 lescent from lymphadenoma, but affected with an acute cancer of her breast. 
 
 Treatment. — For the ordinary or strumous enlargement of the glands in children 
 there is no drug equal to cod-liver oil, the syrup of the phosphate or of the iodide of iron 
 or the tincture of quinine being capital additional remedies. 
 
 I have not much faith in the local application of iodine in the form of the tincture, 
 as after the second application the skin ceases to be an absorbing surface, and the iodine 
 becomes, therefore, a mere irritant. For some years I have been accustomed to order 
 the solid iodine to be placed in a perforated wooden box and on a shelf in the sitting- 
 and bed-rooms, the iodine in this way evaporating gradually and iodizing the air. In all 
 glandular, as in thyroid, enlargements, this mode of employing the drug seems to be of 
 considerable value. 
 
 The iodide of ammonium as an ointment is a useful application when rubbed in, the 
 iodide by this process becoming absorbed. 
 
 Good food and fresh air are also essential points in the treatment of these cases. 
 
 In Hodgkin's glandular tumors full doses of iron, as well as of cod-liver oil, seem to be 
 the best remedies — that is, patients who can take them appear to improve in their general 
 health, while the disease does not progress so rapidly under their use as without it; but 
 upon the ultimate issue no remedy seems to have any decided influence. The late Mr. 
 Bradley advocated strongly the administration of pihosphorus in doses of one-fiftieth to 
 one-fifteenth of a grain twice a day. Indeed, I am disposed to think that where the 
 enlarged glands can be removed they should be, for I am sure that I have seen life pro- 
 longed by such an operation, if not a cure of the disease brought about. When, however, 
 the spleen or liver is involved, no operation is justifiable. When isolated glandular tumors 
 exist, they may be dealt with as local tumors and removed. 
 
 In all glandular enlargements, however, the local cause of irritation should be looked 
 for, with a view to its removal ; for practically it is well to regard all glandular enlarge- 
 ments as due to a chronic source of irritation, in the same way as acute adenitis is known 
 to be a result of inflammation of the lymphatics. 
 
 Disease of the glands, as connected with cancer and syphilis, is referred to in the 
 chapters devoted to these subjects. 
 
 DISEASES OF THE THYROID GLAND. 
 
 The thyroid is a lobulated, encapsuled, ductless gland with a cellular structure, the 
 cells of which contain a glairy fluid. It is highly vascular, and has as large a vascular 
 supply as any gland in the body ; it is supposed to have some connection with blood 
 formation. It is also freely supplied with lymphatics. The entire gland may be congeni- 
 tally absent. When it is simply enlarged, it is said to be hypertrophied, or the seat of 
 goitre or hronchoceJe — simjyle adenoid enlargement — and it is well known that these goitres 
 attain a large size. Sometimes they are apparently composed of simple increase of tissue, 
 the enlarged gland having much the same appearance on section as the small and healthy 
 one ; at other times the structure of the tumor is coarser, more cellular, or cystic — n/atic 
 hronchoceJe— i\ie cysts occasionally assuming large dimensions ; while in a third the gland 
 is more solid and fibrous or more or less mixed with cysts — -fihron>^ Irronchocele. The thy- 
 roid gland may inflame as well as suppurate, and may be the seat of distinct adenoid 
 tumors or of cancer. Hydatid cysts have also been enucleated from its body (^vide Prep., 
 Guy's Hosp. Mus., 171 1"'")- 
 
 Goitre — or Derbyshire neck, as it is generally known in England — is very common. 
 In its most usual form it appears as a simple bronchocele or hypertrophy of the thyroid 
 gland, and gives rise to symptoms which are mainly attributable to the size of the tumor. 
 At times, however, small tumors cause symptoms such as dyspnoea or the cough as of a 
 broken-winded horse on exertion, and even difiiculty in breathing on the slightest cause. 
 At other times they mechanically press upon the large vessels and respiratory tract, pro- 
 ducing headache and a feeling on stooping or coughing of fulness in the head, with 
 evident respiratory obstruction, and even difficulty in deglutition. These symptoms may 
 also appear for a time and then disappear, leaving the patient comfortable in all respects 
 during the intervals. In other cases goitres which appear to be of the simple kind begin 
 to pulsate under excitement or other unknown cause, and are attended with some pro- 
 trusion of the eyeballs. These symptoms disappear with rest and time, and the case 
 subsequently reassumes the clinical features of a simple goitre. All tliese tmnors rise and 
 fall icith the larynx in deglutition. 
 
disI':asI':s of riih: tiiyi:<)Ii> i.la.M). 
 
 185 
 
 Fig. 68. 
 
 Such cases as these stan«l as a kind of link lictwccn tin- sini|ilf and tliat known as the 
 e.roj>h//iii/mir ^'oitre, (iraves s or IJasedow s dist-asi-; and yet Ix-twi-cn these lw(» affections 
 there innst be some wide differenee. lor the siniide jroitre appears to he a hical affV-etiun, 
 whereas the exophthahnie lorni is prohaltly part of" u more <:eneral disease marked hy the 
 enlargement of the thyroid hody, often hy prominenee of the eyohalls. always hy palpita- 
 tion <d" the lieart. a peculiar thrill in the hlood vessels, and a jreneral want (»f mnscnlar 
 and hrain power (KijT- <)!^). "'There is no known post-mortem condition of the thyroid 
 gland proper to this disease " (Wilks and Moxonj. .Modern notions tend to indicate that 
 this form <d' goitre is a neurosis of the cervical sympathetic. ' 'i'iie numerous functional 
 disorders which occur in (Jraves's disease are either due to temporary congestion of the 
 sympathetic nerve or a permanent structural alteration of the ganglionic nervous system " 
 (Trousseau's Ciin. Mid.). This view, however, of the affection is not yet pri>ved. and 
 the whole suhject requires investigation. 
 
 TuK.VTMKNr. — Siin])le goitres are to he treated on ordinary jirinciples — viz., hy atten- 
 tion to the genera' health, the inhalation of fresh air. and hy tonic medicines. Filtered 
 or distilled water such as the salutaris should always he taken, more particularly in dis- 
 tricts where chalk, lime, and magnesia ahound. In Derhysliire and the Tyrol districts it 
 is generally believed that it is from the water that the disease is produced. Iodine has 
 always been held in high repute in this aff"ection, originally as burnt .sponge and recently 
 in the form of the iodide of potas.sium ; and in four- or five-grain doses, given with bark 
 or (juinine, this drug is of use. For .';ome years, how- 
 ever. I have given tonics alone by the mouth, and have 
 ordered the air of the room to be kept iodized by 
 means of solid iodine put into a box with a per- 
 forated lid. as already described ; the metal thus 
 evaporates steadily into the room where the patient 
 sits and sleeps, and in this way it becomes absorbed. 
 Under its influence I have often been surprised to find 
 how rajtidly goitres disappear. With this treatment I 
 at times rub in an ointment of the iodide of ammonium, 
 a drachm to an ounce. To paint a goitre with the 
 tincture of iodine is useless, as one application renders 
 the skin hard and incapable of absorption. Dr. R. 
 Stoerk of Vienna (1874) injects alcohol into the soft 
 parenchymatous and cystic varieties, one or two 
 drachms being introduced by means of a Pravaz .syr- 
 inge, turning the goitre hard by causing coagulation of its colloid contents. The injec- 
 tions should be repeated at intervals of several days in diff"erent parts of the tumor. He, 
 however, advises that a few drops of iodine should be added to the alcohol, to prevent 
 fermentation taking place. Dr. Llicke of Berne is in the habit of treating hard goitres 
 by injecting strong tincture of iodine into the tumor, one or more punctures being made 
 at a time according to the size of the tumor, and, he reports, with good success (Lancet, 
 1859). Dr. Mouat of Bengal spoke (Indian Annafs of Med. Science, 1857) very highly 
 in favor of the use of biniodide of mercury in combination with the rays of the sun for 
 the cure of goitre. He used the mercury as an ointment of the strength of three 
 drachms to a pound of lard. It was rubbed in for t*en minutes an hour after sunrise, and 
 the patient had afterward to sit with his goitre held well up to the sun as long as he 
 could endure it. After this a fresh layer of ointment was to be applied with a careful 
 and tender hand, the patient sent home, and the ointment left to be absorbed. In ordi- 
 nary cases this treatment was said to have been sufficient to eff'ect a cure, and that only in 
 exceptional cases was a fresh application necessary. He gives his cases of recover}' by 
 thousands. It is possible that in England the treatment has failed for want of the rays 
 of the sun. I have tried it without the .slightest beneficial result. The practice I have 
 followed with encouraging success during the last few years has been the injection into 
 the tumor of 20 or 30 drops of a mixture in equal parts of the tincture of iodine and 
 alcohol. In some cases one injection brings about a cure ; in others many are required. 
 
 In Graves's di.sease iodine appears to be not only useless, but injurious. Tonics, more 
 particularly iron, are apparently the most applicable. 
 
 In exceptional cases a goitre may so increase and press upon the larynx and sur- 
 rounding parts as to threaten life, and may even cause death by a gradual process of 
 suff"ocation, but more commonly by exciting some sudden laryngeal spasm. In 1869 I 
 treated such a case, sent to me by Mr. Holman of East Hoathly. in which a large thyroid 
 
 Exophthalmic Goitre (Wilks's case). 
 
186 DISEASES OF THE THYROID GLAND. 
 
 gland was causing chronic suffocation by its mechanical pressure, and it ultimately pro- 
 duced immediate death by exciting some laryngeal spasm. Dr. Herbert Da vies has 
 recorded a similar ease {FoJh. Soc. Trans. , 1849). and in the museums of St. Georges 
 and Bartholomews hospitals preparations exist with similar histories. 
 
 In .some cases the treatment by setons has been of value, suppuration of the thvroid 
 having been followed by a rapid subsidence of the hypertrophied or fibrous structure of 
 the gland. Mr. Hey of Leeds adopted this practice with much success. In other exam- 
 ples of goitre the question of operative interference may have to be entertained, and will 
 be considered in another page. 
 
 Cystic Bronchocele. — Cysts are often met with in this gland, and occasionally 
 they assume large dimensinns. They appear as more or le.ss globular, tense, fluctuating 
 tumors moving up and down with the larynx, as all thyroid tumors do. Thev mav con- 
 tain only the glairy fluid of the gland, or a more serous or sanguineous fluid or old gru- 
 mous blood. Occasionally, on being punctured, they will go on bleeding, even to the 
 death of the patient. Such cysts appear either in one or other lobe or in the isthmus. 
 In 1872 I treated, with Dr. Hess, a case of blood cyst of the isthmus- in a girl, and drew 
 off about half an ounce of a thick, grumous. coff"ee-looking fluid. In 1803 I tapjied a 
 cyst the size of a cocoanut in the right lobe of the thyroid of a woman aet. 2(J which 
 bled pjrofusely. and the hemorrhage was onl}- arrested by closing the wound. The cyst 
 filled up at once nearly to its former size, but subsequently gradually contracted ; and 
 after five or six years scarcely any remains of it could be found. Simply tapping a 
 serous cyst may cure it. "When it fails, the cyst should be injected with half a drachm 
 of the mixture of iodine and alcohol, mentioned above, or. on this failing, of one of the 
 .same mixture and the liq. ferri perchloridi in equal parts. When these fail, a .seton ha.«» 
 been recommended : but the practice is dangerous and .should only be adopted when sim- 
 pler means are unavailing and further intei-ference is requisite. In cysts of the isthmus, 
 more particularly blood cysts, an incision into the cavity is a good and successful opera- 
 tion. Should a cyst, after tapping, suppurate, it must be dealt with as an ab.scess and 
 freely opened as soon as the existence of pus can be made out ; for the thyroid is in a 
 dangerous -position for suppuration to occur. I have .successfully treated one case of 
 suppurating thyroid cyst after tapping by incision, but the cases in which this treatment 
 is called for are rare. 
 
 Dr. M. Mackenzie has (Lancet. May. 1872) advocated the practice of converting the 
 cy.stic disease of the thyroid into a chronic abscess by the following means : •• First 
 empty the cyst. When p»racticable. it is well to make the puncture as near as possible 
 to the median line and to select the most dependent portion of the tumor for the intro- 
 duction of the instrument. As soon as the trocar is felt to pierce the cyst-wall it should 
 be withdrawn, and the canula passed farther in by means of a blunt-pointed key. The 
 fluid having been withdrawn through the canula. a solution of the perchloride of iron 
 (two drachms of the salt to an ounce of water) is injected through the canula by means 
 of a syringe. The plug is reinserted and the canula secured in position by a strip of 
 plaster. The injection of iron is repeated at intervals of two or three days until suppura- 
 tion is e.stabli.shed. A\'hen this, point is reached, the tube is withdrawn, poultices are 
 applied, and the case treated as a chronic abscess. Where the tumor consists of more 
 than one cyst, it may be necessary to make a second or a third puncture ; but it fre- 
 quently happens that other cysts carf be opened through the cyst originally punctured." 
 Some cysts become calcareous and should be treated by excision. The practice is only, 
 however, to be entertained when the cyst cau.ses symptoms which threaten life. In 
 Guys Hosp. Museum there is a preparation of a calcareous cyst with an intra-cystic 
 growth. 
 
 Acute inflammation of the thyroid gland is doubtless a rare affection. I 
 
 have never seen such a case. Holmes Coote records one in Holmes's System. Suppura- 
 tion of a cyst in the daiid after surgical interference is more common. 
 
 Acute hypertrophy may appear and produce dangerous, if not fatal, symptoms. 
 Sir Risdon Bennett, in his interesting Lnmleian Lectuns for 1871. has recorded such an 
 instance, which I had the advantage of seeing in consultation with him and Mr. Jack.son 
 of Highbury. It was in a young man aet. Ifi. who three months before became the .sub- 
 ject of paroxysmal attacks of asthmatic dyspnoea, associated at times with a wheezing or 
 whistling respiration and some general enlargement of the base of the neck. Three days 
 before his death this difficulty became extreme, the paroxysms became more frequent and 
 severe, and on the day of his death a severe paroxysm took place, which passed on to a 
 forced and heaving respiration bevond anvthinsr T had ever before witnessed, and speedy 
 
DfSIJASKS OF Till-: TUYHoin f.'f.AXl). 
 
 87 
 
 death resulted. I performed tracheotomy upon the ]):itit'iit with the slender liope that 
 some lijrht inijjht he thrown H])(m the nature (jf tlic; (rase to ^'uidc us in its treatment, if 
 not to <i'\vc relief; hut in doinjj; so what was prohal)le hefore heeame evident then — viz., 
 that the ohstruetion was l)eh)W. I had no ]>erforated instrument with me lon<r eiiou^rh to 
 foree l)eyon(l the point of oh.structiou e.veept a fomalc cathctiT. which struck a;:ainst 
 some solid Ixidy that prevented its projrres.s. After death tlie tliyroid hodv was found to 
 he much enhirued, and niaiidy helow the sternum and ah>nir the sides of the trachea. 
 The trachea Ixdow my o|»eninf; was flattened laterally to within half an inch (d" the hifur- 
 eation and was also twisted to the left, hein;^ surrounded hy the t:reatlv enlarged and 
 firm lateral lohe of the thyroid. The structure of this eidarged gland was clearly that of 
 hypertrophy, not of cystic or other aj)j)arent disease. As an examj)le of acute rapid 
 hypertrophy of the thyroid, the case, says liennett, "points to the propriety of regarding 
 any acute enlargement of this gland in young ))e()ple with more anxiety than we are per- 
 haps accustomed to do." particularly, it should he added, when the lohes of the gland 
 pass down heliiml the sternum. 
 
 Thyroidal tumors ilouhtless exist, although they are ncjt common ; these may he 
 adciifiiil and iiuioeent or cunceroiix growths. 
 
 An adenoid growth may appear as a tumor within the gland itself or connected with 
 it, or more commonly as an intra-cystic growth similar to that seen so frequently in 
 the hreast. In their clinical history 
 
 such cases cannot well he diagnosed iui. C>9. Fig. 70. 
 
 from the ordinary goitre, although, 
 when the disease is unilateral and 
 assumes a rounded or irregular form 
 and appears to be an isolated out- 
 growth of the gland itself, the nature 
 of the tumor may he suspected ; when 
 placed, however, within the gland it- 
 self or within a cyst in the gland, 
 the diagnosis is impossible. In Fig. 
 69. taken from a drawing by Dr. 
 Moxon of an old preparation in the 
 Guy's Hospital Museum (1711^'), a 
 tumor the size of a grape is depicted 
 hanging down loosely by a pedicle 
 attached to a lobe of the gland. In 
 the gland there is a well-marked, 
 cuplike depression, from which the tumor had fallen out, the pedicle mainly consisting of 
 a large artery emerging from the gland. The growth had an ossified capsule and was 
 composed of a structure like that of thyroid tissue (Fig. 70). My late colleague, 3Ir. 
 Poland, has recorded a like case in which excision was. successfully performed (Gui/'s 
 Hasp. Rep.^ 1871). Frerichs, Rokitansky, and Virchow record somewhat similar instances. 
 Paget thus refers to the subject of accessory thyroid tumors : " These growths of new 
 gland tissue may appear not only in the substance of the enlarging thyroid, but external 
 to and detached from the gland. Such outlying masses of thyroid gland are not rare 
 near bronchoceles, lying by them like the little spleens one sees near the larger mass. 
 Their history is merged in that of bronchoceles (see Virchoic, lect. 22), with which they 
 are usually associated, whether imbedded as di.stinct masses in the enlarged gland or lying 
 close to it. but discontinuous." 
 
 Cancerous growths appear as infiltrating affections of the gland or as distinct 
 tumors : they have no special clinical characters until they attack the surrounding tissues 
 by continuity or break down. In a case of my own the disease perforated the trachea. 
 The Guy's Hosp. Mus. contains four preparations of this disease. 
 
 Pedunculated 
 Tlivroidal Tumor. 
 
 Microscopical .\p])earance of Thyroid 
 Glands. (From Dr. .Moxon's drawing.) 
 
 Operative Interference in Thyroidal Tumors. 
 
 Many operative proceedings have been suggested and adopted for goitre and thyroidal 
 tumors. Sir AV. Blizard. Earle, and Coates (Med.-Chir. Trans., vol. x.) tied the superior 
 thyroid arteries, with the view of .starving the disease, and Coates's attempt was attended 
 with success ; but the operation is necessarily a severe one, and the free arterial supply 
 from the inferior thyroid arteries tends to neutralize its good. At the present day it is 
 properly discarded. Setons have likewise been used with good success an<l deserve a 
 
188 OPERATIVE INTERFERENCE IN THYROIDAL TUMORS. 
 
 more extended trial. Injections of the tincture of iodine or of iron have been of proved 
 value. 
 
 Removal of the isthmus is an operation which commends itself to our attention, since 
 it is said to have been of use in the hands of continental surgeons, and Mr. Sydney 
 Jones related at the Clinical Society on May 25, 1883, a case in which. a complete cure 
 followed the measure in a boy with a large goitre attended with dangerous symptoms. 
 The isthmus was excised after having been ligatured on both sides, and after the opera- 
 tion the lateral lobes withered. 
 
 Excision is an operation worthy of consideration when life is jeopardized from the 
 growth and less severe measures have failed or are inapplicable. That it can be done 
 successfully has been proved by Reverdin of Geneva, P. H. Watson of Edinburgh, and 
 Dr. W. Warren Greene of Maine. 
 
 Hemorrhage is the chief danger to be dreaded in the operation ; but if the fingers be 
 well used to enucleate the growth, without dividing or cutting into its capsule, and if the 
 pedicle containing the vessels which supply it be rapidly reached and ligatured, bleeding 
 may be disregarded. As an extra point of caution it appears to be a sound practice to 
 ligature before cutting all parts that req-uire division, in the same way as the surgeon does 
 in ovarian cases, and for the same reason. Should the tumor turn out to be an adenoid 
 growth in or connected with the gland, as in Poland's case, it may be removed with com- 
 parative facility ; and should it be an enlarged gland simply, even a pound and a half in 
 weight, success may follow, as was proved by Greene's and Watson's cases. Indeed, I 
 cannot do better than give the several steps of the operation in Dr. Greene's own words : 
 
 " 1st. Exposure of the tumor by linear incision of ample length, avoiding most sed- 
 ulously any wounding of the tumor or its fascia propria. 
 
 " 2d. Division of the fascia propria upon the director. 
 
 '• 3d. The reflection and the enucleation of the tumor with the fingers and handle of 
 the scalpel, paying no attention to hemorrhage, however profuse, but going on as rapidly 
 as possible to the base of the gland and compressing the thyroid arteries. 
 
 " 4th. Transfixion of the pedicle from below upward with a blunt curved needle 
 armed with a double ligature, and tying each half, or, when practicable, dividing the 
 pedicle into as many portions as there are main arterial trunks and tying each portion 
 separately. 
 
 " 5th. Excision of the gland and subsequent dressing of the wound, as in ordinary 
 cases." 
 
 Dr. P. Heron Watson, in an interesting paper on the operation (Edin. Med. Jotiri)., 
 September, 1873), strongly advises that •' the investing fascial sheath of the thyroid 
 should be left undivided until the mediate ligature of the vessels included in their fine 
 cellular sheath has been effected ;" and he proved by cases that this can readily be effected 
 through the wound made for the removal of the gland. He condemns anything like 
 roughness in the removal of the gland, and believes that the operation he advocates, and 
 had successfully performed in five cases, is easy, rapid in execution, and devoid of risk. 
 
 I cannot forbear, however, from fjuoting Dr. Greene's concludiiig remarks, which are 
 so full of sound sense and wisdom : " I cannot refrain from one Avord of warning to my 
 younger brethren, whose ambition may make their fingers tingle, lest they should in the 
 light of these successful cases be too ea.sily tempted to interfere with these growths. It 
 is, and always will be, exceedingly rare that any such interference is warrantable — never 
 for relief of deformity or discomfort merely, only to save life ; and if it is beyond all 
 question determined in any given case that such an operation gives the only chance for 
 snatching a fellow-being from an untimely grave, be it remembered that accurate anatom- 
 ical knowledge and a perfect self-control under the most trying ordeals through which a 
 surgeon can pass are indispensable to its best performance." 
 
suuijiEin' or T\\\<] XKKVors systExM. 
 
 INJURIES OF THE HEAD. 
 
 CHAPTER VI. 
 
 CONTUSIONS AND WOL NDS OF THE SCALP.— BLUUD TUM(JliS.— 
 
 OSTITIS. 
 
 Inmiries of tlie head .should alway.s be estimated primarily with reference to the 
 amount of injury tlio cranial contents have sustained; and sfcinulnrili/. with reference to 
 the risk of their V>econiing involved. 
 
 However trivial an injury of the head may appear to be. it is never to be lightly 
 regarded, since what may seem a simple cutaneous bruise the result of a blow upon the 
 head unaccompanied by any symptoms of brain disturbance may be followed by an acute 
 inflammation of the diploe of the skull — a condition fraught with great danger — or a 
 chronic inflammation of the bone, which is scarcely less serious ; and when, as a primary 
 effect of injury, there is evidence of brain concussion, which, as a rule, means brain 
 bruising, the risks of secondary hemorrhage or intracranial inflammation are not slight. 
 The latter complication follows the slighter as well as the graver injuries. It is well for 
 the student to have these truths impressed on his mind at the beginning of a chapter on 
 injuries of the skull, for they have a practical bearing of wide importance. 
 
 Contusions of the Scalp and Blood Tumors. 
 
 The integuments of the scalp have this peculiarity — that they are intimately con- 
 nected with the aponeurosis of the occi])ito-frontalis muscle ; indeed, practically, the.se 
 parts may be regarded as one, for they are not to be separated and move together 
 over the cranium. They are well supplied with vessels, and, conse(|uently, have consid- 
 erable power of repair ; they rarely slough. When any great effusion of blood compli- 
 cates a contusion, a blood tumor is said to exist ; and when this occurs on the scalp, the 
 affection is known by the term cephal-hsematoma. In newly-born children this affection is 
 frequently met with, and it is commonly, although not always, a result of a diflScult or 
 instrumental labor. It is usually situated over the parietal bone, showing itself as a 
 more or less circumscribed, soft, fluctuating tumor; but the largest I have ever seen was 
 over the occipital bone. When the tumor is small and confined to one bone, the blood is 
 probably effused beneath the pericranium (.sj/6/;^'/v'cr<7?( /a/ yb/-?>i). When the swelling is 
 larger and spread over more than one bone, the effusion, doubtless, is poured out beneath 
 the apoueurosis of the .scalp (^linlxiponeurotic form'). 
 
 In the subpericranial form the indurated base may organize, or inflammatory matter 
 may be poured out around it and assume the character of bone : whil.st in neglected cases 
 suppuration may follow, which occasionally passes on to involve the bone itself. 
 
 In the subaponeurotic form the blood is generally rapidly absorbed, and during the 
 process a peculiar characteristic crackling sensation will be often given to the hand in 
 manipulation. In feeble infants this process of absorption may be delayed or may fail 
 altogether ; under which circumstances, surgical aid is called for. 
 
 In the adult, in addition to the forms of blood tumor just described as a consequence 
 of injury, blood may be effused into the skin it.self. and appear as a hard unyielding 
 lump. 
 
 When a blood tumor has an imlurated base, rising from, and apparently continuous 
 
 1S9 
 
190 SCALP WOVXDS. 
 
 with, the bone, with a defined edge toward the centre, the idea may present itself that a 
 fracture with depression exists. Under such circumstances the surgeon will be assisted 
 in his diagnosis by firmly pressing his thumb or finger for a few seconds upon the ridge : 
 this act in a recent case, by displacing the fibrin, reveals the uninterrupted continuity of 
 the bony surface, and thus proves the nature of the case — more particularly when there 
 is an absence of symptoms of fracture. "When the case is complicated with brain symp- 
 toms or a ruptured artery, giving rise to pulsation in the tumor, some difficulty in diag- 
 nosis may be experienced. 
 
 Treatment. — A simpk contusion of the scalp, uncomplicated with any great eff"usion 
 of blood or other local injury, requires little surgical attention ; it has a tendency to 
 recover like contusions of other parts. Its best application is a cold or spirit lotion, 
 muriate of ammonia in solution being as good as any. "When a blood tumor exists which 
 feels tense or pulsates, broken ice in a bag or one of Leiter's coils (Fig. 9, p. -id) should 
 be applied, the cold checking the further flow of blood and encouraging absorption. 
 When the rupture of a large artery, such as the temporal or occipital, is suspected, as 
 indicated by the pulsation of the tumor or other significant symptom, it may be advisable 
 to apply pressure over the trunk of the vessel. When absorption of the effused blood 
 does not take place, the cystic swelling should be aspirated and pressure applied, 
 sponge pressure being the best ; and this operation may be repeated several times. 
 Should tapping fail, an incision ought to be made sufficient to allow of the free escape 
 of the pent-up fluid and to prevent its re-collection ; gentle pressure should subsequently 
 be applied on the part. In very obstinate cases the tumor may be treated as a serous 
 cyst and injected with iodine. When the effused blood breaks up and causes suppura- 
 tion — a somewhat rare result — a free incision with drainage is required and the case must 
 be treated as one of abscess. During this period tonic treatment is often requir<;d to 
 improve the patient's powers. When the tumor is large, the patient should be kept quite 
 free from excitement and the diet carefully regulated according to the special wants of the 
 case. As a rule, all such cases do well. 
 
 Scalp Wounds. 
 
 Wounds of the scalp are very common, and large portions of the scalp may be torn 
 away from its connections with the pericranium or bone and on readjustment live, though 
 much bruised and injured, the extreme vascularity of the scalp favoring its repair. Such 
 injuries, when not complicated with injury to the skull or its contents, generally do well. 
 Blunt instruments, forcibly applied, produce scalp wounds very like those caused by sharp- 
 cutting ones.' Wounds which exhibit entire hair bulbs projecting from the surface of 
 their sections have been probably produced by a blunt instrument, while on the other 
 hand, when the hair bulbs are found cut, the wound has to a certainty been caused by 
 a sharp one. 
 
 It is generally thought that scalp wounds are especially " liable to prove the exciting 
 cause of erysipelas." I doubt the accuracy of such an assertion, because from my notes 
 of 175 cases of .scalp wounds admitted consecutively into Guy's in eight years — and it 
 must be added that only the severe are admitted — I find that erysipelas followed only in 
 three, or in 1.71 per cent., this proportion being about the same as that obtaining in sur- 
 gical cases generally. 
 
 Lacerated or contu?;ed wounds of the scalp rarely slough and should be treated as the 
 incised. Punctured wounds are. however, liable to be followed by diffused inflammation 
 beneath the scalp. 
 
 Treatment. — Under all circumstances and conditions, scalp wounds should be gently 
 and carefully cleaned with tepid water and their edges adjusted and maintained'in posi- 
 tion ; and to aid this the hair should be removed in the neighborhood of the wound. 
 When the wound is not exten.sive and its edges can be adjusted by plaster, sutures are 
 not needed; but when any difficulty is experienced, they may be as fearles.sly applied to 
 the scalp as to other parts. In extensive lacerations, indeed, the application of sutures 
 is decidedly preferable to any other form of practice, ina.smuch as with their use the 
 wound can be kept clean and moist by dressings, which is not possible where a quantity 
 of strapping has been employed. In the application of the suture, however, care must 
 be taken not to include the aponeurosis of the occipito-frontalis muscle, for there is more 
 danger of setting uyj mischief in the cellular tissue beneath this tendon when this prac- 
 tice is adopted than when the sutures simply pass through the .skin itself. The kind of 
 ^Vide paper Glasgow Med. Jonru., January, 1876, bv Dr. Wm. MacEwen. 
 
CONTUSION OF Tin: HOSES OF THE SKULL. 191 
 
 HUturo is iiiiiiii|Mirt;iiit. altliuutrli iimiiy sur<.M'(iiis prcl'tT the iiii'tallic. All sutures sliouid 
 be rciiidVi'd (111 till' sccdiid day, as wnuiuls of the sral|i Ileal raiiidly. Tlic head in all 
 tlu'Sf i-asi'S sliduld Ik' kept cunl. 
 
 W'lu'ii tlu' iiericraiiiuiii is t(trii ott' and tin- Ikuk- cxjioscd, no diflcrcnff in ])racticc i« 
 iK'fdfd. I lie jinisiR'cts oi" a satisfactory rc'covi-ry under these eircuiiistaiiees heiiij: as <;ood 
 as ill a less eoiiiidieated ease. When the Immic. however, has heeii iniieli iiijure(l, super- 
 tic'ial neerosis may lollow. Should e.xudative or inHaiiiiiiatory fluid eolleet heiieath the 
 flaps, the sooner a free escape is jiiveii to it the better, since by its retention suppuration, 
 wliieli is always as.soeiated with great danger to the perio.steiini, to the bone, and even to 
 the life (d" the patient, is encouraged. To attain this end the edges rd" the wound should 
 be .separated in parts l>y iiieans of a jirobe. (»r iiniifn/ incisions should be made through 
 
 the tissues down to the 1 e. By adopting this practice early the inflammation will often 
 
 be prevented or cheeked and the extent of mischief limited. 
 
 When diffused supjuiratioii has taken place beneath the scalji. the juis sliouhl be evac- 
 uated by incisions well placed for drainage, the acticjii lA' the occipito-frontalis muscle con- 
 trolled by tlu" jtressure of a circular elastic liandage or strapjiing. and the surfaces of the 
 suppurating cavity ke)>t in apposition by spfuige pressure. 
 
 To the wounds absorbent aiitisejitic dressings should be applied. 
 
 When extensive sloughing takes place, there is no reason why a good recovery should 
 not follow if the powers of a patient be good and his kidneys sound. 
 
 The powers of a patient must be kept up by tonic medicines, such as iron or quinine, 
 generous diet allowed, and stimulants employed when needed. Sedatives to procure sleep 
 are also essential. 
 
 When bleeding is troublesome, the arteries should be twisted, acupressed. or ligatured ; 
 when it occurs merely as a general oozing of blood, pressure may be applied either to the 
 wound or to the trunks of the supplying vessels. In rare cases, where the deep vessels 
 of the temporal fossa are wounded and bleeding cannot be arrested, the question of apply- 
 ing a ligature to the external or common carotid may have to be entertained. It has never 
 fallen to my lot, however, to witnes's such a case. 
 
 Contusion of the Bones of the Skull. 
 
 This is. doubtless, a common consetjuence of scalp injuries both with and without a 
 wound, as is a scratching or abrasion of the bones; and yet in the majority of such cases 
 a good recovery takes place. In exceptional cases, however, a ditterent result is met with, 
 in the shape of either an acute inflammation of the bone with all its dangers, or a chronic 
 inflammation with all its difficulties. 
 
 Acute nifiamiiuition of the bone is a severe affection, more particularly when the diploe 
 is involved; for the diseased action may extend inward and give rise to a local suppura- 
 tion between the bone and the dura mater or between the layers of the arachnoid, running 
 on to a diffused inflammation of this membrane and of the brain itself. 
 
 A chronic injiammntion of the Itorte may be followed by very similar results or by a 
 thickening of the injured bone. 
 
 W^hen neerosis of the skull is present, these results are always liable to occur, and 
 with it a low kind of jthlebitis of the cerebral sinuses and pyjemia are prone to follow. 
 
 Symptci.ms. — The symptoms which indicate either of these two conditions appear at 
 variable periods after the accident and vary in intensity according to the action. In 
 OAiite cases the symptoms may show themselves within a few days with severe constitu- 
 tional irritation and headache, passing on to general brain disturbance, convulsions, 
 paralysis, coma, and death. In chronic disease the symptoms may not appear for weeks 
 or months, and they will be less severe ; but persistent headache is always present. 
 When the inflammation spreads inward toward the arachnoid and brain, other symp- 
 toms show themselves, such as severe local pains, delirium, twitching of the muscles, 
 convulsions, paralysis, coma, and death, the rapidity of the progress of the disease gov- 
 erning the symptoms. When marked rigors appear, suppuration is indicated, often of 
 the py.-emic'kind ; and convulsions of an epileptic nature are frequently found in the 
 chronic form of the disea.se. Fersi.slent hemhiche after an injury to the head is always a 
 symptom demanding anxious attention, as it too often means progressive mischief within 
 the skull. This subject will, however, receive further elucidation in the chapter on 
 " Intracranial Inflammation." 
 
192 
 
 FRACTURES OF THE SKULL. 
 
 INJURIES OF THE CRANIUM. 
 
 There are some leading practical facts or principles which should be impressed upon 
 the memory of every surgeon who has to deal with injuries to the head. These I have 
 formulated as follows, believing it to be well to place them at the beginning of a chapter 
 on such injuries. 
 
 1. A concussed should be regarded clinically as a bruised brain. 
 
 2. Fractures or injuries of the skull are of importance so far as they are associated 
 with damage to the skull contents, a compound fracture uncomplicated with .shaking of 
 or injury to the cranial contents being less liable to be followed by bad results than a 
 simple fracture associated with brain mischief. 
 
 3. The amount of injury to the brain cannot be estimated by the severity of the pri- 
 mary symptoms, a severe injury to the brain being frequently associated at first with 
 mild, and a slight injury with severe, symptoms. 
 
 4. A general shaking (concussion) of the brain, whether associated or not with simple 
 or compound fracture, may give rise either to temporary suspension of brain functions, 
 ending in recovery, to laceration of the membranes, to a more or less severe bruising of 
 the cortical structure of the brain, or to laceration of its deeper substance. The amount 
 of hemorrhage which complicates the case depends upon the size, number, and healthi- 
 ness of the ruptured vessels. Thus a general shaking or concussion in a healthy brain 
 may only produce a temporary suspension of cerebral functions, when the same injury in 
 an unhealthy or aged one in which diseased vessels ramify may be followed by a fatal 
 hemorrhage or apoplexy. 
 
 5. Under certain conditions of the system, and particularly where the kidneys are 
 diseased, a slight concussion will be followed by a fatal secondary inflammation of the. 
 brain-coverings; while under other conditions a severe injury to the brain will be fol- 
 lowed by no such result. 
 
 6. Intracranial inflammation is as prone to follow the milder as the graver cerebral 
 injuries. 
 
 7. The character of the accident and the mode of its production furnish the best 
 means for estimating the nature and severity of the injury and its probable results, since 
 a fall upon the head from a height or a blow from a heavy weight causes a generul injury 
 of the brain, and a fall upon or a blow from a sharp instrument a local one. 
 
 With these general propositions, which the student should learn and think over as a 
 guide, I now proceed to consider the subject of fractures of the skull. 
 
 FRACTURES OF THE SKULL. 
 
 These may be divided into fractures of the '• vmdt " and fractures of the " hnse^'' a third 
 and large division including those of the '• vault and base." They may likewise be " sim- 
 ple'^ or ^' compouiid." ''^ comminuted^" "■ depres-^ed" or "undepressed." 
 
 Fractures of the vault are generally caused by direct blows upon the part or 
 falls upon sharp bodies. They include most of the punctured fractures and incised 
 
 wounds of the bone, as in sword wounds, 
 etc. They are of necessity compound, and 
 often comminuted ; and the brain injury 
 which is associated with them is for the 
 most part local. 
 
 When not punctured, the fracture may 
 appear as a simple fissure, the extent of 
 which is determined by the amount and 
 character of the force employed, the line of 
 fracture being influenced by the sutures and 
 ridges of bone. When the force is local and 
 moderate, the fracture may be limited ; when 
 concentrated and severe, the fracture will 
 be "starred," and generally "comminuted." the fissures radiating in all directions, involv- 
 ing many bones, and passing downward toward the base. When inflicted with a blunt- 
 edged instrument, the fracture will be depressed in a gutter shape (Fig. 71) ; when 
 with a round one, as a hammer, the bone will be depressed more like a '• saucer " 
 (Fig. 72). 
 
 Gutter- and Saucer-Shaped Fractures of the Sku 
 
FiiAcniiKs or Tin: shTi.L. 
 
 193 
 
 Coniiiiiiiuted Fracture of Skull 
 with JJepre^^sion of luner 
 Talile from Direct Local Vio- 
 lence (Prep. Guy's Mus.;. 
 
 Cunnniuiiftif /rncfitrrs ure trcni-rally the ri'.siilt of a coiict'titratiMl local violence, and are 
 coiiseijucntly fomid chu-tly in tin- vault and are mostly conijioiind (Vijs. 7-i). 
 
 In sonjo cases of fracture of the vault the hone will he (h'presscd ttr driven in upon 
 the cranial contents ; in sabre wounds it may he elevated, ploughed up, or displaced 
 outward. 
 
 The fracture will he confined in some cases to the outer tahle of the skull, in rarer 
 instances to the inner, a fracture with depression <d" the inner tahle occasionally existing 
 without any fracture of the outer. 
 
 When the force acts from iritliuni mul is <ji<<it. the whole thickness of hone may he 
 hrokcn, the inner tahle prohahly irivinir way first and being fractured to a <rreater extent 
 than the outer; hat when the force is sllijht. the inner tahle 
 niav be alone fissured, loo.seiied. or driven in. 
 
 When the force acts from irithln. upon the inner tabic 
 first, the reverse of the above holds jrood. the outer table 
 giving way before the inner and being fractured to a greater 
 extent. In Preji. 1082'". in Guy".s Museum, this not suffi- 
 ciently recognized fact is well demonstrated. In it, the force 
 having been applied by a pistol bullet which was sent by a 
 suicide through his brain, the point of impact on the inner 
 table is represented by a black mark, whilst the outer table is 
 starred; and in Prep. 1083", taken from a boy aet. 12, fracture 
 of the outer and inner tables exists, but not in correspondini; 
 parts. 
 
 An interesting paper on this subject will be found in the 
 Anu'ruaii Jnnru. nf' .]//:>/. Srfeuc<\ April, 1882. b}' Mr. J. 
 Lidell. 
 
 As points of practice, however, it is well to remember 
 that in all ordinary ca.ses of fracture, with depression of the 
 bones of the skull, the injury to the inner table is far greater than to the outer, and 
 the point of exit of any foreign body through the skull is always larger than that of 
 entrance. 
 
 Whether depression of the bones of the skull of an adult ever occurs without a frac- 
 ture is an open question. There is certainly no good evidence in support of the fact. In 
 children it has happened without giving rise to any symptoms of brain compression ; yet 
 even here, says P. Hewett. •• .some of tlie bony fibres must have given way." In these 
 cases tlie dcprc-st'il bone may subsequently rise up again to its natural level. 
 
 Brain Complications. — The practical interest, however, attached to all these 
 varieties of fracture is concentrated in the question as to how far the cranial contents 
 are involved in the injury. Has the brain been slightly concussed, or so .shaken as to 
 have been bruised or lacerated? Have the membranes of the brain been torn, lacerated, 
 or injured? Is the fractured bone a .source of irritation to the dura mater? Is there a 
 loose fragment of the inner taVde of bone acting as an irritant ? A compound fracture 
 with or without depression, not complicated with brain di.sturbance or brain injury, is a 
 cause of far less anxiety than a simple fracture in which severe brain concussion has 
 taken place and is indicated by symptoms ; a severe shaking of the brain, whether com- 
 plicated or not with a fracture, is a far more serious accident than any local injury to the 
 skull alone. 
 
 Fractures of the base of the skull or vault and base combined — 
 
 for the.se conditions ought to be considered together — are invariably severe injuries. 
 They are generally, except when produced by a crushing of the head, caused by a dif- 
 fused force, such as that occasioned by a fall from a height upon the vertex or by a 
 heavy blow. '-When the former, the plunge of the body is suddenly arrested by the 
 vertex coming in contact with the ground, and the entire superincumbent weight, with 
 the superadded momejitum ac(|uired by the velocity of the fall, is concentrated around 
 the condyles of the occipital bone, and the central compartment of the base of the sknill 
 is thus broken across" (Fig. 74). The fracture is the result of direct violence, and not 
 of so-called contre-coup. 
 
 " Thus, if the injury be inflicted by the fiill of a hm-d and heavy body on the vertex, 
 this part would be fractured ; and if the weight were not very great, the mischief might 
 end there, as the resistance offered by the head ma)" so far exhaust the momentum of 
 the falling body that the force would not be transmitted in sufficient amount to cause 
 fracture of the base. But if the weiirht and momentum of the falling body were in 
 
 12 
 
194 
 
 FRACTURES OF THE SKULL. 
 
 Fig 
 
 Fracture of Base of Skull from Fall on Vertex. 
 
 excess of the expenditure of force in causing fracture of the vertex, the impulse would 
 drive the head down upon the summit of the spinal column, and fracture of the base 
 would result ; in that case, viewed mechanically, the lower fracture would be succes- 
 sive to the upper. But if the falling weight 
 which struck the vertex were of a yielding 
 material, fracture, if any, would be in the 
 base, and not of the vertex, because the vis 
 iiierfia of the skull would be overcome, and 
 it would be driven down upon the spine 
 without the application of circumscribed 
 force to the vault. The same reasoning 
 applies when fracture of either the vault 
 or base, or of both together, is the effect 
 of a fall on the vertex ; or this result may 
 be varied by the blow being received on the 
 forehead or occiput, the anterior or posterior 
 divisions being thin and severally more ob- 
 noxious to fracture." 
 
 Injuries to the occiput are commonly 
 
 followed by longitudinal fracture of the 
 
 base, involving both the posterior and 
 
 middle fossae. 
 
 Injuries to the temporal region or about the ear are followed by fracture of the 
 
 petrous bone and the middle fossa ; they are always serious. 
 
 But it is rare in diffused injuries to the head to find one fossa alone involved : fissures 
 generally pass through two fossae and extend from the vault or part struck. 
 
 The evidence afforded by my notes of two hundred cases of fatal head injuries clearly 
 establish these points, which have also been experimentally proved by Dr. Aran. 
 
 " In precipitating a large number of bodies. from various heights on to the head. Dr. 
 Aran found that the part of the vault which first struck the ground gave, as it were, the 
 key to the fracture which would take place at the base. Similar results were also 
 obtained when diffused blows were dealt upon different parts of the skull by means of a 
 large and heavy hammer. In the front part of the vault injuries thus produced led to a 
 fracture of the anterior fossa, in the middle part of the vault they led to a fracture of 
 the middle fossa, and at the back of the head to a fracture of the posterior fossa. In no 
 single instance was a fracture detected at the base without a line of fracture in the cor- 
 responding part of the vault. The truth of this has been proved by an analysis which 
 I made of all the cases of fractured base of the skull admitted into St. George's Hos- 
 pital during a period of ten years " (Prescott Hewett). 
 
 My own observations go entirely to prove the correctness of tlaese views. The mid- 
 dle fossa is the one, however, most frequently involved. 
 
 Compound fractures of the skull are, as a rule, local fractures. They are gen- 
 erally the result of a concentrated blow upon, or a puncture of, the part, the force 
 employed having been expended in producing the local injury. They are, consequently, 
 often starred or comminuted and depres.sed fractures. When the brain is involved in the 
 injury, it is chiefly beneath the seat of fracture ; it is rarely shaken or concussed as much, 
 as it is in simple fractures the result of a diffused blow. 
 
 The dangers attending a compound fracture do not, therefore, arise so much from the 
 direct injury to the brain as from secondary intracranial inflammation the direct result 
 of irritation of the dura mater by the depressed or comminuted bone, the dura mater 
 being frequently punctured or torn and in all cases irritated by the depressed bone. 
 These facts have an important bearing on practice, since they encourage the surgeon to 
 remove the depressed and irritating portions of bone, which have such an injurious influ- 
 ence on the progress of the case. When the brain is injured by the accident, the danger 
 is far greater. 
 
 THE DIAGNOSIS OF FRACTURE OF THE SKULL. 
 
 There are no special symptoms by which a fissure of the vault uncomplicated with a 
 wound can be recognized. The best guide to the diagnosis of a fracture of the skull is the 
 nature of the injury. Extensive fractures of this kind are constantly found upon the 
 post-mortem table where no suspicion of their presence was entertained during life. 
 
Tin: /)/ K/.vo.sY.v OF rn.Krrni-: of the skull. 195 
 
 Wtiin :i wuiiiiil complicates the ca.sc, a iVacliiii" can usually be made out, as the fissure 
 can l>c seen as a red line. ('ar(>, however, slioiijil lie taken in these cases not to mistake 
 a auturi' for a fracture. 
 
 When depressed lione exists with I'ractiire, the dia;;nosis is rarely difficult, unless it 
 should so happen that the fracture has taken jilace hcneath the body rd" the temporal 
 imisele, when it is almost impossilile to diaLTUose its existence by direct signs. 
 
 An efiusion of blood beneath the pericranium may be mistaken for a fracture with 
 depressed boiu', unless care bi' observed, as may a natural depression in the skull, [lar- 
 ticularly in the occipital rt>i;ion. 
 
 Fracture of" the skull the result of a jnnicfiiml wound can, as a rule, be reailily recog- 
 nized, thouuch when the point of the perforatiiiL: instrument has been broken short off at 
 the surface of the bone much care is needed. 
 
 T/ir (h'lii/iiiisis of n frticlnrv of tftc haur, or of the base and vault combined, is always 
 a source of difficulty, since there are no signs, but only symptoms, to assist ((pinion. The 
 nature of the accident is without doubt the surgeon's best guide ; a fall from a height or 
 a heavy blow ujmiii the head is the usual cause of such an accident, though a crushing 
 force ap]died in any direction may produce the same result. 
 
 Should the fall have been upon or the force applied to the vertex, the middle fo.s.sa of 
 the skull will probably be the seat of injury ; and the diagnosis of a fracture through 
 the petrous bone may with some confidence be made when such an injury is followed by 
 profuse or ])ersistent hemorrhage from the ear, succeeded by the copious discharge of a 
 watery, and perhaps saccharine or slightly albuminous, fluid, and jiaralysis of the parts 
 supplied by the facial nerve. Slight hemorrhage from the ear is no po.sitive sign ; the 
 moderate discharge also of a water}- fluid alone is not characteristic, nor is facial paraly- 
 sis. But profuse and prolonged bleeding from the ear, or .slight hemorrhage, followed 
 by a watery discharge, is, however, strongly indicative of a fracture, as is also a copious 
 watery discharge directly following the injury. Facial paralysis, however, combined with 
 either of these symptoms, renders the diagnosis complete. This watery discharge is now 
 generally admitted to be an escape of cerebro-spinal fluid through a fracture of the 
 petrous bone, passing across the internal auditory canal, and attended with rupture of the 
 membrana tympani. I have known this to continue for eight days. 
 
 In injuries to the mastoid process, if a local emphysema exists, the presence of a 
 fi'acture may be diagnosed. 
 
 Fracture of the Anterior Fossa. — Should the blow or fall have been upon 
 the anterior part (d" the skull, the probaliilities of the case point to fracture of the 
 anterior fossa ; and where any injury to any of the nerves of the orbit can be made out, 
 as indicated by local paralysis of some of the muscles of the eye, or when hemorrhage 
 has taken place beneath the conjunctiva, the diagnosis is certain. Hemorrhage into the 
 eyelids by itself is of no value as a diagnostic sign, although when it follows the acci- 
 dent at a later period and is consecutive to subconjunctival hemorrhage it is a symptom 
 of some importance. 
 
 Falls upon the occiput coniinonly produce longitudinal fissures of the base. 
 
 Copious and obstinate bleeding from the nose or pharynx is by no means unfrequent 
 in a case of fractured base, and when accompanied with other suspicious symptoms is of 
 diagnostic value. I have the notes of a case of injury to the head in which the patient 
 apparently died from bleeding from the nose and mouth, no blood coming from the ear; 
 and after death a fracture of the base was foiind completely separating the petrous por- 
 tion of the temporal bone from its connections and laying open the lateral sinus. The 
 right tympanum was full of blood, but the membrana tympani was entire. The stomach 
 was full of blood, the blood from the lateral sinus having apparently found its way 
 through the Eustachian tube into the pharynx and stomach. 
 
 I have also the particulars of a second case, in which the carotid artery was divided in 
 its passage through the petrous bone and the lateral sinus laid open, the lungs and 
 bronchial tubes being found filled with blood, even down to the air cells. Each of these 
 patients lived only two hours after the accident. 
 
 Fracture of the base unassociated with any injury to the brain itself is of no more 
 conse((uencc than fracture of another part ; but as the base is the most delicate part of 
 the brain, and any injury to it is sure to be followed by severe, if not fatal, symptoms, 
 the subject of fracture of the bones upon which it rests becomes of proportionally greater 
 interest. 
 
 This fracture of the base may be associated with all the intracephalic injuries to 
 which fractures of the vault are liable. It may be complicated with simple concussion 
 
196 
 
 THE DIAGNOSIS OF FRACTURE OF THE SKULL. 
 
 of the brain, or with the more severe form associated with laceration of the brain struc- 
 ture, or extravasation of blood upon or within the brain itself. If blood is eflFused, there 
 may be compression of the brain followed by death, or the same result may be produced 
 by a secondary inflammation of the membranes and injured parts. 
 
 It is difficult, upon the whole, to separate the two cla.sses of cases, inasmuch as the 
 dangers arising from injuries to the skull do not depend upon the seat of fracture, but 
 upon the injuries to the cranial contents ; and, as the same injuiies may be produced by, 
 or rather ma}- be associated with, fractures of the base, the complications and dangers 
 are the same in each. 
 
 Having, then, so far shown that the dangers of all forms of fracture of the skull are 
 really alike, and that the same intracephalic complications attend fractures, whether of the 
 vault or of the base, I now proceed to illustrate the special symptoms generally regarded 
 as being diagnostic of such injuries by a brief analysis of cases from my note-book. 
 
 Among thirty examples which are there recorded, twelve were associated with .simple 
 concussion, in all of which recovery took place. In three cases the fractures extended 
 through the orbit, as indicated by subconjunctival ecchymo.sis. In eight there was 
 hemorrhage from the ears ; in all, this was followed by a discharge of serum, and in 
 seven of the cases it was associated with paralysis of the facial nerve upon the same side. 
 In these it is quite fair to conclude that the line of fracture extended through the petrous 
 portion of the temporal bone. In two there was bleeding from the nose ; in one there 
 was a serous discharge from the ear. accompanied by paralysis of the facial ; in another 
 this discharge followed hemorrhage from the ear and was unaccompanied b}' paralysis. 
 
 To test the value of these different symptoms as indicating fracture of the base in 
 various positions, the following analysis of the fatal cases will prove of value ; and, taking 
 the symptoms separateh', subconjunctival hemorrhage will first claim our attention, as 
 being one which more or less accurately marks a fracture through the orbital plate. In 
 the eighteen fatal examples, this symptom was manife.sted in four instances, the line of 
 fracture extending in each of these through the orbit. 
 
 In two cases there was copious hemorrhage from the ear, while in both the fracture 
 passed through the petrous bone. 
 
 In three examples there was some epistaxis. In one of these the fracture extended 
 across the ethmoid bone, in another the frontal sinuses were full of blood and fractured, 
 and in the third the tympanum was found full of blood, the membrana tympani perfect, 
 and upon careful examination the lateral sinus of the brain was found to have been 
 lacerated. 
 
 Seven of the eighteen fatal cases died from direct injury to the brain, the post-mortem 
 examination in all revealing severe contusion or laceration of the brain structure, with 
 effusion of blood upon the surface of the brain or upon the membranes. 
 
 Seven other cases died from arachnitis as a result of the injury. In four of these 
 there was contusion of the brain, and in one ecchymosis of the ventricles ; in two there 
 
 Fig. 75. 
 
 Fig. 76. 
 
 "^?<=>> 
 
 Fracture of Anterior Fossa of the Base of Skull. 
 (Prep. No. 10858^, (Juy's Hosp. Mus.) 
 
 a, Punctured Wound through Frontal Bone. 
 6, Portion of Wood which perforated Bone. 
 (Prep. No. 1086M Guy's Hosp. Mus.) 
 
 was no evidence of contused brain, nor was there any effusion of blood ; in one interest- 
 ing case the inflammation spread from the internal ear. In three the cerebral mischief 
 was complicated with some thoracic or abdominal injury which caused death, and in one 
 hemorrhagre was the immediate cause of death. 
 
CONCUSSIOS OF THE IIHAIX, AM) ITS I! I' F i:CTS. 197 
 
 A sevcro hlow ii|miij tlic iioso, hy driving in the otiniutid horn-, may cause fracture of 
 the uiitcriur fossa of the base* of the skull (riilr ]•'!•;. 7')), and 1 liavc had under my care 
 several cases in wliicli a severe Itlow m|miii tlic jaw produced a fracture of the niiddh; 
 fossa. At St. (JcurLM's Hospital there is a s|ii'ciinen in which a fracture of the base was 
 caused hy ilif tondylf nf the hiwcr jaw hein;; driven aj^ainst the ;j;lenoid fossa with such 
 force that the condyif proji-cted into the cavity of the skull, and in (luv's Ur)spital 
 Museum there is a simihir specimen, whicdi was sent in with Mr. Hutchinson's prize 
 essay. I'unctured wounds of the orhit arc; Ity no means infre(|uent causes of i'racture of 
 the base ; many are recorded. I was once called to a case in which a lead-pencil had 
 perforated tlii' l)one and the brain throuL'h the orbital plate, and Fijr. 7<> was taken from 
 a preparation in which the fnnital Itoiie was perforated. The diu^'intsis of these ca.ses is 
 not dillicult. When bruin matter escajies externally throu<:h the wound, there is no room 
 for duulit. 
 
 The treatment of fractures of the skull will be described after the subjects of injuries 
 to the brain and extrava.sation of blood within the cranial cavity have been considered. 
 
 CONCUSSION OF THE BRAIN, AND ITS EFFECTS. 
 
 '• A man receives a blow on the head by wliich he is only stunned for a longer or a 
 shorter period. Wiiat is said to have happened? Concus.sion of the brain. 
 
 " A man dies instantaneously or lingers some time perfectly uncon.scious after an 
 injury of the head; there arc no marks of external violence. Again, what is said to have 
 happeiu'd ? Concu.ssion of the brain. 
 
 " The head is opened, and what is found ? In one case no deviation from the healthy 
 structure ; in another, simply great congestion of the cerebral vessels ; in another, numer- 
 ous points of extravasated blood scattered through the brain substance ; in another, a 
 bruised appearance in some parts of this organ. In all, the ca.se, in common parlance, is 
 said to have been one of concussion of the brain. Such are the after-death appearances 
 ascribed by different surgeons to concussion of the brain." 
 
 These words of an eminent surgeon (P. Hewett) so accurately describe the ordinary 
 teaching of the schools that I have transcribed them as a fitting introduction to the sub- 
 ject of which I am about to treat. They arc likewise practically true, although expe- 
 rience of the post-mortem room shows that in ca.ses of death from concussion of the brain, 
 with the rarest exception, some changes in structure are to be found if carefully looked 
 for, some bruising or laceration of the brain, some bleeding into its substance. In fact, 
 death from concussion of the brain without change of .structure hardly ever takes place, 
 concussion untl vontiixion of the brain being. <ts <i rnle, associafed in fafol casis. At Guy's 
 Hospital, for twenty consecutive years, no case is recorded of death from concussion with- 
 out change of brain structure, and it is only quite recently that an example has occurred. 
 
 " In every case," remarks P. Hewett, " in which I have seen death occur shortly 
 after, and in consequence of, an injury to the head, I have invariably found ample evi- 
 dence of the damage done to the cranial contents." 
 
 Concussion and Contusion of Brain Identical.— Mr. Le Gros Clark states : 
 
 '• I have never made nor witnessed a post-mortem after speedy death from a blow on the 
 head where there was not palpable physical lesion of the brain ;" and Dr. Xeudorfer of 
 the Austrian army declares that he has never seen concussion, properly so called, except 
 in a])parently trivial injuries. 
 
 M. Fano, a recent French writer, has al.so come to the conclusion " that the symptoms 
 generally attributed to concussion are due, not to the concussion itself, but to contusion 
 of the brain or to extravasation of blood." In fact, all authorities now agree that when 
 death follows a severe shaking or concussion of the brain, contusion or bruising of the 
 brain is almost invariably found. 
 
 How far these views arc correct in cases of concussion that are not fatal is an open 
 question, but in the few cases of concussion recorded in which death has followed from 
 other causes some injury to the brain sub.stance has always been found, and in all 
 instances in which a fatal result has taken place from secondary inflammation evidence 
 of some bruising of the brain has been detected. A bruising of the brain, however, with 
 a slight extravasation of blood, may be recovered from ; but when there is extensive effu- 
 sion, compression of the brain and death are the usual result. 
 
 Whf-n if /.s (jincrnllij accepted as true that concussion and contusion of the brain are 
 practical/^ s^non^mous, the principles of the treatment of such injuries ivill be better 
 appreciated. 
 
198 CONCUSSIOX OF THE BRAIN, AND ITS EFFECTS. 
 
 In the simjilcsf form of concussion of a healthy brain a slijiht and transient loss of 
 power and consciousness is the only symptom. 
 
 In the more severe form, when a blow or injury produces some severe shaking of the 
 cranial contents, this shaking is followed by a loss of consciousness more or less complete 
 and a loss of all power of motion ; the skin of the patient will be cold, the features more 
 or less contracted, the pulse slow and intermittent, and the pupils very variable: in some 
 cases they will be dilated, in others contracted, while in a third one pupil will be dilated 
 and the other contracted. If the case be neither one of great severity nor complicated 
 with any grave injury to the cranial contents, after a variable period the patient will 
 show signs of movement, and may, perhaps, move a limb in an impatient and purposeless 
 manner. If he is spoken to in a loud A'oice, he Avill perhaps show some signs of return- 
 ing consciousness, either by making some inarticulate noise or by merely opening his 
 eyes, and afterward returning to his stolid condition. If the case be still carefully 
 observed, the mode of respiration may be seen to be altered, and from being slow and 
 labored it will be irregular, and perhaps sighing. After a time, if recovery is to take 
 place, other signs of what are termed reaction will make their appearance. The skin will 
 become warmer and more natural, the shrunken and contracted features will return to 
 their normal condition, the pulse be more regular and rapid, and vomiting may occur. 
 The appearance of this symptom is generally of moment and the first result of a more 
 active circulation through the cerebral centres. As the case proceeds, if all goes well 
 the patient rapidly recovers and returns to his natural condition, feeling, perhaps, some- 
 what heavy and dull for a few days, and indisposed for any bodily, and much less for 
 mental, labor. But if, on the other hand, the case goes wrong, the symptoms may either 
 persist or pass into those of compression, as indicated by complete insensibility, coma, 
 and death, or the symptoms of reaction may become excessive and run into those of 
 inflammation of the brain or its membranes. 
 
 In this brief sketch of an ordinary example of concussion of the brain the symptoms 
 described are of a typical kind, and have been purposely dissociated from those of such 
 complications as are liable to occur cither primarily or after the period of reaction has 
 taken place. 
 
 Effects of Concussion on the Brain. — What change of structure is present 
 in such an injury is. of cuur.se. an open question. In the simplest case the local injury 
 must be slight ; in the more severe there is every probability that some bruising of the 
 brain has been produced ; while in the worst laceration of the brain and extravasation of 
 blood will probably have taken place. 
 
 In what is called concussion of the brain epistaxis is very frequent and hemorrhage 
 into the lids of both eyes is not uncommon, though beneath the conjunctiva it is very 
 rarely met with. Hemorrhage from the ear directly after the accident is occasionally 
 seen, and I have known it continue for several hours; the extravasation of blood takes 
 place in all these cases as a direct result of the accident. 
 
 Again, in certain cases, a patient, having regained his consciousness, relapses into 
 insensibility — relapsing tincrjuscioui^jios — from which he may recover as perfectly as if no 
 relapse had taken place. It would appear as if this condition were produced by the ear- 
 liest effects of reaction, the vessels yielding too freely to the heart's pulsations and thus 
 producing a plethora of the pai't, which induces a comatose or semi-comatose condition. 
 The following case illustrates these points. 
 
 A boy tet. 11, having received a blow upon the head from a falling piece of timber, 
 became perfectly unconscious and quiescent. He remained in this state for fifteen min- 
 utes, but, recovering, he walked home, some short distance. He soon began to feel sick 
 and vomited, the vomiting being attended with ejnstaciis. He was then brought to Guy's 
 with a cold skin and laboring pulse. He was very slightly conscious and unable to 
 answer any questions, while his limbs remained in the position in which they were placed. 
 The pupils were dilated, but active. He was left in bed with the head raised and a cold 
 lotion applied to it. Warmth was applied to the feet. He gradually recovered, and left 
 the hospital in ten days convalescent. 
 
 The epistaxis and relapsing unconsciousness in this case, coming together at the time 
 of reaction, point clearly to the cause. 
 
 Again, in children, reaction is not unfrequently attended with convulsions, which 
 generally, however, ]>ass away and leave no mark behind. Convulsions, when they 
 appear in an adult, are symptoms of grave anxiety, since they almost always indicate 
 brain injury and forbode mischief. 
 
 When reaction is excessive, it is attended with symptoms of fever and brain disturb- 
 
7:;a'77M r. I.S.I v'/o.v nr hlood as iii:sri/r of ('(jycfssioy. 199 
 
 aiit'O, siuli :is tlflirium, fxcilriiicnt, and coma. Tlw suhjijct <tf" intracranial iiiHainmation 
 will claim alti-ntinn in amttlicr pairc. 
 
 Extravasation of Blood as Result of Concussion. 
 
 If the liraiu be violently shaken, hnii.sinLC of" it.s .snh.staiice ami more or Ics.s extravasa- 
 tiiin of hlood must ensue 
 
 When the iiijurv is the result of a direct l>lo\v, the hruisinir may he hut local ; yet it 
 is more usual to find jhe opposite side of the hrain also hruisetl, hy what is riirhtly termed 
 " contre-coup, " and. indeed, it very often hapitens that tin; mis(diief t<j thir hrain liy coiifre- 
 aiiif) is jjreater than that at the seat of hlow. When the fall or hlow has heeii upon the 
 vortex, the base is bruised; when on the occiput, the anterior lobe; when on the rij^ht 
 parietal rejiion, tlu; base of the left middle lobe ; in fact, the base of the brain is almost 
 always the seat of injury. 
 
 The amount of extravasateil blood will depend upon the de^rree (jf force a])pIiod ; 
 but when the ves.sels are diseased, the hemorrhat^e may be excessive. When the extra- 
 vasation of blood is upon the surface of the brain, it will be either within the cavity of 
 the arachnoid or the meshes of the pia mater; and under both circumstances the blood 
 will gravitate to the ba.se. When the extrava.satioii of blood takes place into the struc- 
 ture of the brain, it may be found in anj* part of the cerebrum, cerebellum, or pon.s 
 N'arolii, or oven in the ventricles, the extravasation rarely showing itself in the form of 
 one large clot, but commonly in small and numerous spots of extrava.sation. 
 
 Results of Post-Mortem. — On referring to my notes on this subject. I find, in 
 n case of concussion wliicli proved fatal sixty hours after the injury, that the brain was 
 Itruised all over and blood eti'used at the injured spots; the fluid in the ventricles was 
 blood-stained, and the ventricles themselves ecchymosed. In another ca.se of death from 
 <'oncussion, the result of a f\\ll, in a man tet. 31, in whom convulsions and coma super- 
 vened on the tifteenth day after the injury, a layer of blood was found universally dif- 
 fu.sed over both hemispheres, dipjiiiig between the convolutions and passing downward 
 toward the base. The clot, which was .shreddy, of a dull, reddish-black color, had evi- 
 dently been efi'used for some days. The surface of the brain beneath the seat of injury 
 was softened, and at the base, where it had been injured by con f re-coup, similar changes 
 had taken place. The vessels were healthy. In a third case, where deatli followed from 
 concussion and the vessels were diseased, multiple extravasations were detected after 
 <leath throughout the substance of the brain. 
 
 In all these typical cases, illustrating the different effects of '• concussion," fatal 
 results took place from changes brought about by severe .shaking of the brain iinassoci- 
 ated with fracture ; but it is to be remembered that where a fracture is present, unless it 
 be atteiuled with depressed bone, the .shaking of the brain, and not the fracture, is the 
 main .source of danger. 
 
 From what has been thus stated the conclusion nuiy be drawn that the tiature of the 
 accident is the best guide to the diagnosis of contusion of the brain, and the severity of 
 the symptoms or their persistency is doubtless a valuable indication as to its extent. 
 ^' Tonic spasms of the limbs ; intense restlessness, with con.stant rolling and tossing about 
 in bed ; unconsciousness, more or less complete ; drowsiness, without any stertorous 
 breathing, and in the slighter cases simply contraction of one pupil or of one eyelid ; 
 spasmodic movements about some one muscle or another of the face or lips, giving rise 
 to a difficulty of pronunciation," — are by the French surgeons looked upon as diagnostic 
 of a contused brain ; and Mr. Le Gros Clark lays stress upon the following: '-More or 
 less constant restlessness, accompanied by spasm, in which some particular member is 
 affected or amounting to general convulsion. If capable of giving expression to his feel- 
 ings, the patient will point to some particular part of the head as the seat of pain. In 
 some instances noisy incoherency and (d)tuseness of intellect accompany this condition 
 from the first ;" and these symptoms are doubtless enough to point to brain injury. 
 When they a))pear rapidly after the accident, tliey may be accepted as suggestive of a 
 bruising of the organ ; but when they come on a few days later, they are as likely to be 
 due to .secondary inflammation of the brain as to contusion. 
 
 The diagnosis of primary concussion and contusion of the brain is unnecessary. The 
 symptoms are so intermixed that the real nature of the lesion is not apparent. The signs 
 attributed to concussion, such as loss of consciousness, collapse, small, scarcely perceptible 
 pulse, and lowered temperature, merely indicate that the functions of the brain and their 
 influence on the system at large are in a state of abeyance : and it can only be declared 
 
200 REMOTE EFFECTS OF HEAD INJURIES. 
 
 that the brain was contused in the first instance (/'///e sj/mjjtoms continue or become aggra- 
 vated. 
 
 Seat of Injury indicated by Paralysis. — The seat of injur}- to the brain 
 
 may likewise often be indicated b}' some paraly>is, partial or complete, of one or more of 
 the cerebral nerves. This paralysis may be either a passing or a permanent symptom. 
 Paralysis of the seventh pair, including the facial nerve, has been already alluded to as a 
 somewhat typical symptom of fracture through the petrous portion of the temporal bone. 
 This may appear as an immediate result of the injury, indicating laceration of the brain 
 by the fracture, or, what is more usual, at a later date, when it .may be the effect of 
 pressure by effused blood upon the nerve trunk in some part of its course, or. at still later 
 period, by inflammatory effusion. 
 
 On referring to my own notes of cases admitted into Guys Hospital at different 
 periods during the last twenty years. I find examples of injur}" to the optic nerves, as 
 indicated by blindness, paralysis of the muscles of the globe of the eye as a whole, and 
 paralysis of the external rectus muscle alone. Paralysis of the facial and auditory nerves 
 is very frequent, and at times there is paralysis of the fifth nerve, as indicated by com- 
 plete loss of sensation of the face, etc. Paralysis of the hypoglossal has also been 
 observed. In "the majority of these cases the symptoms appeared as a direct result of the 
 injury; in some they came on two or three days later, associated with febrile symptoms, 
 biit in most they disappeared in the course of a few weeks. In some instances, however, 
 of facial paralj'sis the symptoms were permanent. In all these there must have been 
 injury to the base of the brain. " The coexistence of hemiplegia on one side with paral- 
 ysis of the third nerve of the opposite side is indicative of lesion of the crus cerebri 
 on the side on which the third nerve is paralyzed " (Le Gros Clark). 
 
 I had once under my care a man who received a severe blow on the left side of the 
 head, above the ear. The injury was followed by symptoms of concussion, which soon 
 passed away ; but he had complete aphasia. In the course of a few days he partially 
 recovered the ability to speak, but then spoke so thickly that he was unintelligible ; in 
 about three weeks he could be understood, but he did not recover his natural powers of 
 speech for at least three months. During the greater part of this time he was subject to 
 headache, which the least exercise or excess in diet made wor.se. There can be little 
 d(»uV>t that in this case the base of the middle lobe of the right side had been contused. 
 Mr. Callender' tells us " that symptoms of aphasia are more apt to follow injury of a part 
 of the left hemisphere outside the corpus striatum than any other part, that injuries to 
 the right hemisphere are more rapidly fatal than are equal injuries to the left, and that 
 the right-side brain lesions are more often as.sociated with convulsions than are similar 
 hurts at the opposite side." The evidence of these opinions is not strong. 
 
 Remote Effects of Head Injuries. 
 
 There are. however, many injuries to the head which, without producing such definite 
 symptoms as have been described as the result of concussion, etc.. yet cause .serious and 
 often permanent damage to the patient. 
 
 The effects of a blow on the head are by no means to be determined by the immediate 
 symptoms that result, for a person may receive a trifling or severe injury, from which he 
 is supposed to have completely recovered, and yet the case may end in a permanent enfee- 
 blement of the mental powers or be followed by paroxysms of uncontrollable excitement. 
 It behoves the surgeon, therefore, to be mo.st cautious in giving an opinion as to the 
 issue of a case of injury to the head. 
 
 Insanity. — The records of lunatic asylums and convict prisons prove unhappily, 
 that many cases of apparently trivial injury to the head, unaccompanied by .symptoms 
 which would indicate any positive affection, such as concussion, paralysis, etc.. have ended 
 in an affection of the brain which has rendered the patient hopelessly demented or a 
 criminal, and. moreover, has left no visible traces of the malady in the brain after death. 
 The following may suffice as illu.strations : 
 
 A boy aet. 16 fell from a tree and was found partly insensible. After a few days' 
 treatment he was dismissed from the hospital as •' cured." In a few months he was 
 obliged to be placed in a lunatic asylum, where he remained several years. 
 
 A gentleman put his head out of the window of a carriage while travelling by rail- 
 way, and received a scalp wound from striking against a post. He was rendered insensi- 
 
 ^Brit. Med. Jour., June 6, 1874. 
 
i\.iri!i/:s or rur: /.•//. i/.v <(imi-li<- \risi; FiiAcrriu-:. -joi 
 
 l)I(' at tlic liiiif, liiit smiii iiii|ini\ ('(1. Tin re were no si<:iis of iiii|i(iihiiic(', vt in a l"<'\v 
 WCi'ks ho was in a state ot' inc-ntal ulirrratiori, aiitl ilit-cl in a year. 
 
 A man was kicki'tl l»y a liorse in tlie stomach ami fell, strikin<r his head on the stahh; 
 floor, l)iit had no ccrchral symptoms. Iti :i I'rw weeks he jrot ileliiioiis and conlnsed in 
 mind, and heeame in lime liopehissly insane. 
 
 Such instances mij;ht he mnltiplied endlessly, all |»ointin<r to the .supreme importance? 
 of injuries to the head, however slij^ht the immediate symptoms. The reader may fitid 
 tliis suhject well discussed and illustrated hy Dr. J. ('. Browne in the first volume of the 
 Wist lildliKf Asi//iii)t I^rpnrfs, in Abercroinliie's works, Dr. Azane, Arcltlrfs (Inifi-dlm tie 
 Mhhciiir, Kehruary, IMHl, and ehsewhere. 
 
 It may be laid down as a jtrinciple that jiersons with any hereditary predisposition to 
 insanity or nervous di.sease are more liable to sufi'er from cranial injuries than others. The 
 temperate have a better chance of esca|)e than those addicted to excesses of any .sort. 
 
 INJURIES OF THE BRAIN AND ITS MEMBRANES COMPLI- 
 CATING FRACTURE. 
 
 When the student has recognized the fact that a blow upon the head //"/ comjilicated 
 with fracture is capable of producing, by "concussion of the brain,' injuries such as 
 have been sketched in the previous pages, he will be quite ready to understand that a 
 blow upon the head complicated with fracture is likely to be followed by results that are 
 at least equally severe, since the force required to produce a fracture of the skull is, as a 
 rule, either more violent or more concentrated than that required to produce what has 
 been described as a concussion of the brain. There are, moreover, complications which 
 are frequently associated with or peculiar to fracture, such as depression of bone with or 
 without compression of the brain ; extravasation of blood external to the dura mater 
 from rupture of a blood vessel, .such as the middle meningeal artery or venous sinus; 
 injury to the dura mater or membranes; and direct injury to the brain. He must also 
 be aware of the fact that a fracture of the skull may take place without producing any 
 cerebral disturbance ; for example : 
 
 A man aet. '11 received a blow over tlie vertex from a broken sword. An exten.sive 
 scalp wound was the result, and a very evident incised wound in the upper portion of the 
 frontal bone, apparently involving only the external table. It was not complicated with 
 the slightest cerebral disturbance, and good recovery followed. 
 
 A boy received a compound fracture over the frontal region from the kick of a horse; 
 he had no head symptoms whatever, and he recovered. 
 
 In the former case there was an incised wound of the skull, and in the latter an unde- 
 pressed compound fracture. In neither was the brain materially shaken, bruised, or other- 
 wise injured, and in both a good recovery ensued. Cases such as these, however, are 
 comparatively rare, the more frequent being examples of fractured skull associated with 
 brain symptoms similar to those which have been described under the head of .simple con- 
 cussion — cases in which the functions of the brain are for a time more or less interfered 
 with or suspended, but which have a tendency gradually to return to their normal condi- 
 tion ; in which the injury to the skull has been severe enough to break the bone and gen- 
 eral enough to shake the brain and cause a suspension of its functions. The importance 
 of these, however, lies in the injury the brain has sustained, and not upon the fracture, 
 the fracture being only a complication ; and, so long as there is no depressed bone irritat- 
 ing and compressing the brain, the danger is in no way increased. If, however, in any 
 given instance, the injury is complicated with laceration of one of the large arteries of the 
 bone, such as the middle meningeal artery or large venous sinus, other conditions may 
 arise which produce special symptoms. 
 
 Fractures of the Skull associated "with Extravasation of Blood 
 
 BETWEEN the DuRA MaTER AND THE BoNE. 
 
 As a result of an injury to the .skull, whether with or without a fracture, small extra- 
 vasations of blood between the dura mater and the bone are not unfrecjuent, and are due to 
 the rupture of some of the small vessels which pass from the dura mater to the bone. 
 They give rise to no symptoms by which they can be recognized, and usually are only 
 discovered after death. 
 
 When any large extravasation occurs, tlie blood comes, as a rule, from either the trunk 
 or one of the branches of the middle meningeal artery, which runs upward in a groove 
 
202 
 
 IS JURIES OF THE BRAIN COMPLICATING FRACTURE. 
 
 Fig. 
 
 of the anterior inferior angle of tlie parietal l)one and divides to sui)ply the lateral parts 
 of the base and vault of the cranium, or it may come from a venous sinu.s. A fissure, 
 therefore, of a bone involving any of these parts may lacerate one of these vessels and 
 give rise to a hemorrhage sufficiently copious to produce symptoms of compression of the 
 brain. 
 
 It is well to know, however, that the brain will sustain a great deal of pressure with- 
 out giving rise to any sj'mptoms, and that several ounces of effused blood rapidly poured 
 out are required to produce sucfi symptoms as ai'e recognizable. 
 
 The following is an excellent case to illustrate the accident : 
 
 Case.^A man aet. 49, when riding in a gig, was thrown out upon his head. The 
 accident produced a scalp wound over the h-ft side of the vertex and some slight insensi- 
 bility. He got up and walked for half an hour, when he became confused, staggered, and 
 went into a shop, being supposed by the shopkeeper to be intoxicated; but, as he gradu- 
 ally became quite insensible, he was brought to Guy's. When admitted, he was perfectly 
 unconscious and comatose, with dilated pupils, laboring 
 pulse, and slow respiration. Soon afterward he became 
 convulsed, the r?///;/ arm being more affected than any 
 other part; in a few hours it was completely paralyzed. 
 He remained in this condition for two days, and died 
 comatose. After death, upon removing the calvaria, 
 which was fissured in a vertical direction from the mid- 
 dle of the left parietal bone to the jugular foramen, a 
 large clot of blood was seen lying upon the dura mater, 
 clearly proceeding from the middle meningeal artery. 
 This was about two and a half inches in diameter and 
 moi'e than an inch in thickness. It formed a glohuhir 
 tumor and caused an extensive depression upon the left 
 cerebral hemisphere, which pressed the longitudinal 
 fissure to the right side. The brain itself was healthy. 
 
 Prep. 1606'"' in Guy's Hosp. Mus. shows the condition. Drawing showing clot (ft) external to the 
 
 In Fio-s 77 and 78 these iioints avp wpII s.^ph ^'""'^ Mater (c, from Laceration of the 
 
 in rigs, i i duu lo luese p(juus die \\eu seen. ^ Middle Meningeal Artery (») following a 
 
 Such a case may fairly be accepted as a typical Fracture. (Drawing su^", uuy's Hosp. 
 example of this form of injury, and special attention 
 
 should be paid to the fiict that the man recovered from the immediate effects or shock 
 of the accident, remained sensible for a definite period, and then gradually became uncon- 
 scious. In compression from hemorrhage this "interval of time" — provided it be a short 
 time — between the accident and the occurrence of the symptoms is most important from 
 a diagnostic point of view. It is very commonly, although not constantly, present ; but 
 when present, it is characteristic of hemorrhage in some form. The symptoms, to be 
 those of compres.sion, must also be lasting ; nor must they be mistaken for the " relaps- 
 ing unconsciousness" of a shaken brain, to which attention has been already directed. The 
 persistency of the symptoms is consequently a valuable diagnostic symptom. 
 
 But, it may be asked, how is extravasation of blood outside the dura mater the result 
 of a lacerated meningeal artery to be diagnosed from extravasation of blood either within 
 the cavity of the arachnoid or upon the surface of the brain, or within the brain itself? 
 For under all these varied circumstances the symptoms may appear some time after the 
 accident, and the inference drawn from the " interval of time" is the same in each; 
 under all the symptoms of compression will be identical, for they will be those of apoplexy, 
 and, as in apoplexy, varying in each case ; for '• when extravasation takes place on the 
 surface or within the substance of the brain, it is accompanied — and, indeed, produced — 
 by lesion of the cerebral texture, which lesion is mostly indicated by paralysis, by irritation 
 and spasmodic action affecting some particular part, by derangement of the pupils, or by 
 other symptoms" (Cock). The surgeon's best guide, however, in forming his diagno.sis 
 will always be the history of the case and the nature of the accident. 
 
 In uncomplicated cases of hemorrhage exteryial to the dura mater the injury is gene- 
 rally a local one, produced by a sharp blow or fall ; the brain, as a whole, is not .shaken 
 or injui'ed; the symptoms of compression are, moreover, generally very marked and 
 rapidly produced, and the paralysis of half the body is also commonly complete. 
 
 In cases of hemorrhage itito the arachnoid' cavihf or ripon the surface of the hrain the 
 injury is mostly of a general character, such as a fall from a height or a blow from a 
 iieavy weight, the whole brain having been violently shaken or " concussed," and, as a 
 result, its delicate structure — more particularly that of the base — has been bruised or 
 
n.KMOlirJIAdl'. ISTO IIIIMX. 
 
 203 
 
 Dura, mater. 
 
 hiceratod, weak nr iliscasi'd vessels Ix'in;^ very apt tu f^ive way, producinjr lieiaorrhage. 
 lieiiinrrhage external tu the dura mater may. it is true. In; present in tliese cases of 
 jreiieral injury, Imt it will l»e enmjdieated with extravasation into deep<.'r parts; and thi.s 
 point of diajrnosis is all-important, since in the former class of cax-s, when the hlood \a 
 between the hone ami dura mater, surjrical treat- 
 ment may he of itiestimahle value, wliilst in the 
 latter it can he of no service. 
 
 llemi>rrhaire Upnn tlir siir/drr >>/' tin- Innln is 
 a very important siihject, occurriuL' in variable 
 detrrees in every case of severe or jreneral in- 
 jury to the skull, whether complicated or not 
 with fracture ; the hrain'itself may be not only 
 brui.sed at the .seat of injury, but it will be 
 etjually. if not more, injured at the opposite 
 pitint bv coiifff'-roii/i. and this Ijruisintr and ex- 
 travasation is irenerally found at the base of the 
 brain. The hen»orrha<re associated with this 
 bruising may l)e so slight as to give rise to no 
 symptitms and recovery may take place, or it 
 may be .so great as to induce symptoms of com- 
 pression. But when a larL:e vessel of the pia 
 mater is ruptureil. the bleeding will Vje severe; 
 and under these circumstances the Vjlood may 
 spread into all the parts down to the base, cov- 
 ering in the cerebellum and spinal cord. 
 
 It is this fact that renders all cases of geu- 
 ei'ff I iiijiin/ to the brain so serious and tells so *.».vv„i««^. Blood dot. 
 
 powerfully again.st any operative interference Transverse section of skull with frauiai "rontents. 
 
 in such a class of cases, the surgeon beintr quite s^liowing Fractured Skull, Kupture »( Mfnlngeal 
 
 , , , , n '• 1 Arterv. a f'lot of Blood outside I»ura Mater, and 
 
 unable to reacll the source or COmpre.SSlon by Compiessed Brain, d-rom Prep, (iuy's Hosp. Mus., 
 tr.<>i.1i!i<iiirr lo9;'/''.) "A life lost that perchance might have been 
 
 trephining. . ^ , , ., saved' (Good ham. ^ 
 
 Iletnorrhage nifo th' cnvity of the ara'linoiti 
 is ])y no means a common consequence of head injury, but it may occur as a result 
 either of a local or direct or of a diffused injury to the skull, and the effused blood 
 may be poured out upon one or both sides of the cerebrum. When the effusion is gradual 
 and not extensive, no definite symptoms of compression will be produced : but when exten- 
 sive, although symptoms of compression may appear, there will be nothing to indicate the 
 precise position of the hemorrhage. 
 
 In patients who have albuminaria or diseased arteries there is reason to think that a 
 slight injury to the head may cause extravasation of blood into the arachnoid, and this 
 fact has an important practical bearing, furnishing a key to the .solution of many a 
 doubtful ease of head injury. 
 
 Pathology has taught us that blood clot may organize and form what are now known 
 as arachnoid cysts, having smooth external surfaces like a .serous membrane, which when 
 recent will be .soft and pulpy, when old fibrous. They may contain only serous fluid 
 more or less blood-stained, or clots of blood altered by time. Sometimes the.se cysts are 
 found to be loo.se in the arachnoid cavity ; at others, fixed to the parietal arachnoid. 
 They are usually found ncddenfdllt/ after death in those who have suffered from mental 
 disorder or general paralysis, and, although more commonly they exist on one side of 
 the head only, they are .sometimes found on both. 
 
 Dr. Crichton Browne (Journal of I\i/c]iolo(i>cal Mprliciiv, December, 1875) telLs us 
 thit out of 1240 post-mortem examinations made at the West Riding A.sylum there were 
 51) examples of arachnoid cysts — 48 occurred in males. 16 in females — and the majority 
 were in the left side. In half the cases general paraly.sis was the cause of death. Dr. 
 Browne does not think that these cysts have a traumatic origin, but are due to the rup- 
 ture of a vessel from cerebral hyperajmia. 
 
 To Sir Prescott Hewett ( Med.-C/ii'r. Tmns.. vol. xxviii.) must be assigned the credit 
 of explaining how these cysts are formed from a chronic change in previously effused 
 blood. For a full elucidation of the subject, however, we are indebted to Drs. Wilks, 
 Ogle. Bacon, and Sutherland (^Journal of Mental Science, vols. x. and xi. ; Bep. ^yest 
 Riding Aai/htm. vol. i.). 
 
204 COMPRESSION OF THE BRAIN. 
 
 COMPRESSION OF THE BRAIN. 
 
 The brain may be compressed in many ways, though there are four special causes of 
 compression : Compression from " depressed bone." the resuh of fracture, simple or com- 
 pound ; compression from the '-extravasation of blood" into any part of the cranium; 
 compression from the ^^ formation of matter'' between the dura mater and the bone; and 
 compression from the "effusion of injiammatori/ protfucfs' into the brain or its membranes. 
 
 The .symptoms of compression' under all these different circumstances are much alike, 
 although the clinical history of the cases and the date of the appearance of the symptoms 
 after the injury vary in each class. When the symptoms are due to depressed bone, they 
 follow immediately the accident. When caused b}" extravasation of blood, there is almost 
 always some interval of time between the accident and the accession of the symptoms, 
 although that interval may be but short. When caused by the effusion of inflammatory 
 products into or on the brain, the symptoms generally appear some days after the acci- 
 dent and are gradttal : and when the result of the formation of matter between the dura 
 mater and the bone, the symptoms rarely show them.?elves for two or three weeks after 
 the accident. In both of the latter classes of cases, morepver, headache and other inflam- 
 matory symptoms coexist. 
 
 The si/mpfoma of comjrrension of the brain are those of apoplexy, and their severity 
 depends entirely upon the suddenness and amount of the compression. The skull may 
 be fractured and the bone depressed, and still no symptoms arise. Extravasation of blood 
 may also take place to a limited degree within the skull and not be recognized. There is 
 good reason to believe, indeed, that a considerable amount of blood may be poured out 
 sloxdy upon the surface of the brain without giving rise to compression, the brain gradu- 
 ally accommodating itself to the pressure. The most marked cases of compression are 
 usually due to rapid extrava.sation. When the bones are much depressed, or when the 
 brain is saddeidj/ compressed by the local effusion of blood, symptoms show themselves, 
 such as complete insensibility, slow. diflBcult. and perhaps stertorous, respiration, and a 
 full, slow, laboring pulse. In very severe cases the respiration will be of a peculiar 
 p^iffing character. There may also be complete loss of the power of swallowing, inability 
 to retain feces, and retention of urine, incontinence or overflow of urine being the last 
 symptom. The pupils may be either dilated or contracted, but they will be always fixed, 
 and will not respond to light : whereas in alcoholic coma. Dr. ^lacf^wen tells us. •* the 
 pupil is contracted when the person is left undisturbed, and it is dilated when an attempt 
 is made to rouse him " ( GJnu'ion: Jonrvol. January. 1879). 
 
 When the brain is widely and uniformly compressed, the symptoms are '' general " — 
 i. e., one side is not more paralyzed than the other. When the compres.sion is localized.^ 
 the paralysis is partial and corresponds with the region affected, though when extravasa- 
 tion is extensive the general effect may mask the local symptoms. The best examples of 
 this form of limited compression are found in cases of fracture of the skull from a local 
 injury and extravasation of blood between the bone and the dura mater. The case 
 quoted on page 202 is a good one in point, though the following is probabl\- a better, 
 as it is complete : 
 
 J. P , aet. 46, a painter, having fallen from a height upon his head on a piece of 
 
 iron, received a severe scalp wound on the right side of the median line of the head, with 
 slight concussion. He was admitted into Guy's under Mr. Cock's care in 1841, con- 
 scious, and remained so for eleven hours ; four hours later, however, he was found in a 
 state of utter unconsciousness, with stertorous breathing and insensible pupils. He con- 
 tinned gradually to get worse. The left arm and leg when pinched were readily retracted. 
 The right side was completely paralyzed. No fracture could be discovered. Trephining 
 was performed above and behind the anterior inferior angle of the left parietal bone over 
 the trunk of the middle meningeal artery ; a large piece of bone was removed. A gush 
 of blood then took place, and a large coagulum was removed from outside the dura mater. 
 The deep stertor at once ceased, and the next day the man moved his right arm and leg 
 freely and recognized his wife. He progressed favorably after the operation, though 
 recovery was retarded by bone exfoliation. He resumed his work and occupation, and 
 continued in good health for thirteen years. During this period, however, he had at inter- 
 vals exfoliation of some portion of the skull at the seat of injury ; in the ninth year he 
 had fits, which during the last six years of his life recurred at intervals, the attacks, as 
 Mr. Cock reported, becoming gradually more frequent and severe in their character. Six 
 months before his death he had paralysis of the opposite side of the body to that of the 
 injury ; the face was included in the paralysis, and his speech was somewhat affected. 
 
COMI'liKSSloX OF Tllh: HUMS. 205 
 
 lie (lioil af'tor II severe miopleetir lit. Alter dcatli tin- ))raiii )»ftii;atli the iiijiireil l)i»ne 
 was foiiml snf'teiuMl and aillien-iil tu tlw nkull, ami it cuiitaiiM'd a recent clot of thniti or 
 four ounces ttf hlooil, which liMcil tlic ventricles. • it appeared prohahle," ways Dr. Wilks, 
 who math' the c.\aniination. "that a softeiiin^^ had hecn ;;oinjr on for .some months in the 
 middle lii-niispherc of the hrain, involvinj; tiic contij;uous surfaces of the corpus striatum 
 and thalamus, and that at last a rupture ^^' the V(!S.sel had taken place, intiltratinj: all 
 these disi-ased structures, as well as the ventricles." The trephine opening: was tilled in 
 liV a touirh niemhrane, and around its inarL'ins then,' was evidenci! that cousiderahle ostitis 
 liad taken place (Cock, (lui/'s J/osji. liijunts, \s7u ). 
 
 When a patient receives a direct hlow u|>nn oni- siile of the head, causing; a fracture 
 with depression of the hone, and attende(l with |)aralysis of the opposite side of the hody 
 and a tixt-d and dilated pupil on the side of the injury, the conclusion is int.-vitahle that 
 the depres.sed hone is the cau.se of the paralysis hy producin;.' ])ressnre upon the hrain : 
 the dejircssion must, however, he very •j;reat to f::ive.rise to sucdi symptoms. 
 
 When a patient sustains a similar injury, with or without depression of the hone, hut 
 followed after a distinct interval of time hy paralysis of one side of the hody, whether of 
 the injured side or not, it is (juite fair to assunu- that hemorrluifre has taken place inside 
 the skull and is the cause of the compression. 
 
 In both these ca.ses a local injury is followed hy local mischief, causinir a local paral- 
 ysis ; consequently, surjiical treatment is of i.rreat promi.se. 
 
 When a patient receives a <^encral injury to the head — such as commonly results from 
 a fall ui)on tlic head from a height or a diffu.sed hlow from a heavy falling body — and this 
 is followed directly or after an interval of time by symjitoms of compression, whetlier 
 a.ssociated or not with a fracture, the paralysis is, as a rule, ireiieral ; and even if more 
 complete on one side than another, the injury to the brain is, for the most part, too dif- 
 fused or extensive to admit of surgical relief. The case is clearly of a mixed nature, 
 contusion or laceration of brain structure being a.ssociated with hemorrhage. 
 
 Symptoms of Brain Injury. — When a patient suffering from brain shock, with 
 or without a fracture, is unconscious, motionless, and perhaps pulseless, has lost control 
 over the action of the bowels and the bladder, and has a feeble respiration and paralyzed 
 pupils, it is impossible for the surgeon to form any opinion as to the nature of the cere- 
 bral injury. These symptoms may be the result of so-called concussion, from which 
 recovery may take place, and not of severe brain contusion ; they may be associated 
 with bruising of the brain and extravasation of blood — not sufficient, perhaps, to cause 
 fatal compression of the brain structure, but enough to set up cerebral symptoms, which 
 cannot pass away for many months under the most favorable conditions ; or they may be 
 accompanied by severe brain laceration or extravasation of blood upon or into its struc- 
 ture, which wiil prove fatal by coma. The position of the extravasation has no influence 
 on the symptoms, although it would appear that death is very rapid when it takes place 
 into the ventricles. The primary symptoms of severe concussion and of general com- 
 pression are identical, and are often not to be distinguished ; both may be the result of 
 the same kind of accident. '■ But," says P, Hewett, " there is this marked difference : 
 in concussion the effects are instantaneous, and in compression from extravasated blood 
 some little — it may be very short — time elapses before the symptoms manifest them- 
 selves. In the former, also, the symptoms gradually pass off, but in the latter they 
 become more and more marked." 
 
 '• The symptoms of concussion may be continued or renewed either by extravasation 
 of blood, pus, or both" (John Hunter, MS., 1787). 
 
 '' The diagnostic .signs of concussion and compression are, no doubt, distinct in a certain 
 sense, yet compression rarely exists as a consequence of violence without concussion, and 
 both are complicated with shock. Further, symptoms of simple concussion may become 
 developed at a later period into those which indicate some more serious le.sion ; and it is 
 in exceptional cases only that we can identify with any degree of certainty the efficient 
 and sole cause of compression. Thus, in the stunning effects which succeed a blow on 
 the head, if we can rouse a patient from his state of unconsciousness, even for a few 
 moments, if the breathing is calm and noiseless, if the pulse is feeble, the pupils are 
 contracted, and reflex action can be excited, we conclude that the condition is one of 
 concussion. The intensity of the effects of so-called concussions are marked by the 
 character of the symptoms and by their duration. The probable explanation of pro- 
 tracted somnolence and other evidences of brain disturbance is the presence of diffused 
 extravasation of blood over the surfiice of the hemispheres " (F. Le Gros Clark). 
 
 Hemorrhage into Brain with Fracture. — Again, in a general shaking of 
 
206 
 
 WOUNDS OF THE BRAIN. 
 
 the brain, blood may be extrava.sated into the brain itself; and when the injury has been 
 sufficient to produce fracture, there is no limit to the amount of hemorrhage or its seat. 
 " But in dealing with such cases great caution is necessary in order to avoid, if possible, 
 mixing up cases of apoplexy with those of traumatic effusions. An accident coexisting 
 with an extravasation of blood into the cerebral substance does not necessarily imply 
 cause and effect. The previous condition of the brain or the outpouring of blood from 
 diseased vessels may, in fact, have been the cause of the accident" (Hewett). 
 
 On referring to my notes, I see that in a case of brain injury which lived only one 
 hour blood was found filling the ventricles. In another the ventricles were bruised and 
 the septum lucidum lacerated. In other cases blood was poured out into the thalamus 
 opticus or into the corpus striatum. 
 
 In all these the brain had been severely shaken, the hemorrhage being doubtless the 
 result of the shake and the cause of death, while the fracture of the skull was merely a 
 complication. 
 
 General Summary. — It has been already shown that concussion of the brain too 
 often implies contusion or laceration of its structure, with extravasation of blood, and -in 
 the same way compression indicates as severe, if not more severe, injury. Concussion 
 does not by itself produce definite symptoms ; and when paralysis, vertigo, sickness, or 
 other such phenomena, arise, the inference is that there is some structural damage to the 
 brain. Compression implies a more severe degree of the same sort of injury, with effu- 
 sion of blood or depression of bone. Compression of the brain, when not excessive, is 
 seldom the durct cause of death. It proves fatal in the majority of cases by being the 
 starting-point of an intracranial inflammation, since it has been proved that blood can be 
 absorbed or encysted and depressed bone may be gradually raised by the brain itself, or 
 the brain may accommodate itself to the pressure. 
 
 Compression of the brain as a' result of traumatic encephalitis will receive attention 
 in a subsequent page. 
 
 Wounds of the Brain. 
 
 In some injuries to the skull the brain may be wounded or lacerated, and brain matter 
 may even escape from the wound directly after the accident. Such accidents are always 
 of a very grave nature, and, as a rule, fatal. Wounds of the anterior and upper portions 
 of the hemispheres are the least dangerous ; wounds of the posterior hemisphere or base 
 of the brain, the most so. Recovery may, however, at times follow very severe injuries 
 when no secondary inflammation takes place. 
 
 When brain matter is pressed out of the skull in cases of fractured base, a grave 
 injury is always indicated, since the crushing force must have been severe to have given 
 
 rise to such a complication. Some remarkable 
 instances of recovery after the escape of brain 
 matter are, however, i-ecorded; and several have 
 passed under my own observation, but they are 
 too rare to be dwelt upon as holding out any 
 hope in bad cases. Foreign bodies may like- 
 wise lodge in the skull for a long period without 
 causino; death. Wounds of the brain are not 
 cluiracterized by any special symptoms apart 
 from those of concussion or compression. 
 
 Wounds of Dura Mater.— Wounds 
 
 of the dura nuUer are pr()l)ably as dangerous 
 as wounds of the brain, for inflammation of the 
 membranes is readily set up by such injuries. 
 It is from this fact that compound fractures 
 of the skull are so serious, that simple frac- 
 tures associated with comminution of the inner 
 table of the skull are so often fatal, and that 
 punctured fractures have so dangerous a tend- 
 ency ; for in all these cases the dura mater is not oidy torn, but irritated, by the pro- 
 jecting spiculae of bono, and secondary inflammation is the result. This inflammation, 
 as a rule, rapidly spreads over the brain and causes death. 
 
 Prognosis. — Wounds of the dura mater, as well as wounds of the brain, are some- 
 times recovered from, but the prognosis in either case must be unfavorable. 
 
 Hernia cerebri, or protrusion of brain matter alone, or brain matter mixed with 
 
 Fig. 79. 
 
 Hernia Cerebri. 
 
ENCEVUM.ITIS. 207 
 
 inflaiiim.itDry priMliicts, is always tlic result ni' ;i wiiiiinl nr s](iii<:h of the iliira mater 
 sectmdarv citluT ti> a n)ni|Mimnl t'ractiin' (»r to tin- rciimval nl" }'ractur('<l nr <liscasi'(l Ixjik-. 
 It is probalily always assdciiitcd with some sii|i])iiratii)ii (lucal) (»i' tlie hraii). due to exten- 
 sion of iiiflaiiiinatoiy inischift" to that part in contact with the diseased dura mater and 
 bone. It is t<t he treated with jrreat caution. Some surj^eon.s are in tht; iiahit of" eut- 
 tinj; ott" the projecting! mass, others of applying pressure; hut proliahly the hest practice 
 lies in doinj; very little, in keeping the parts clean and dry, and leavinj; their repair to 
 natural processes. If the local aflection lie sfi limited in its nature as to \h'. cajialile of 
 repair, the pntjectinjj; mass will sloufrh naturally after a time, and cicatrization will follow ; 
 whereas interference on the part of the surj^eon does harm. The hest treatnient is at 
 first to apply a piece of lint to the jtart, and at a later stage to keep the hernia dry by 
 dustinj:; it with oxide of zinc or powdered alum. Exci.sion and the application of cau.stics 
 or pressure do not appear to be .satisfactory forms of treatment. 
 
 The ex]»erience of army sur<reonsdiirin<j: the American war confirms these ob.servations. 
 
 INFLAMMATION OF THE CRANIAL BONES, BRAIN, AND MEM- 
 BRANES THE RESULT OF AN INJURY TO THE HEAD. 
 
 In all cases of injn'"} to the head, simple or severe, attended or unattended by frac- 
 ture, in all cases of concussion, contusion, compression, or laceration of the brain, or of 
 injurv to the dura mater, inflammation of the bones, of the brain, or of its nn'inbranes i.s 
 liable to arise ; and when it does, it is a very grave complication. It is this fact which 
 makes all injuries of the head, even simple contusions of the bone, sources of danger, 
 becau.se inflammation, commencing in the bone, too frequently spreads inward to the 
 membranes of the brain and to the brain itself, and thus destroys life. The free com- 
 munication between the pericranium and the dura mater by means of the blood vessels 
 of the diploe is a probable explanation of this occurrence in simple scalp and bone con- 
 tusions. In injuries to the bones of the skull and to the brain or its membranes, the lia- 
 bility to encephalic inflammation appears to be greatly determined by the severity of the 
 accident. 
 
 In the present chapter, traumatic encephalitis, acntr and chronic, as the result of brain 
 shocks, whether with or without a fracture, will claim attention. 
 
 The itcKfc or diff'used form of arachnitis is the cause of death in most of the cases of 
 head injury that survive the immediate results of the accident. 
 
 These cases, for the most part, are the result of a severe general .shaking of the brain, 
 with or without fracture, complicated with contusion or laceration of the brain .structure or 
 its membranes. They are consequently cases of arachnitis and inflammation of the brain 
 substance itself, the inflammation of the membranes being general. " I have never 
 known," says Wilks, ''such an aff"ection as arachnitis spring up as a spontaneous disease; 
 and therefore, when met with, you should always look for some mischief w'ithout. When 
 arising in this way. the interarachnoid eftusion is often purulent and so copious that it 
 may pour cut when the dura mater is removed. I have never seen extensive eff"usion 
 into the interaraelinoid space without an injury on the head." 
 
 Chronic Result of Injury. — The chronic ca.ses are. for the most part, the result 
 of a locul injury and begin in the bone, spreadine; inward to the dura mater, and at last 
 involving the two layers of the arachnoid membrane, the pia mater, and even the brain 
 itself. Localized sujipuration is frequently found in these cases, either between the bone 
 and dura mater or in the brain itself, from extension of inflammatory action from without 
 inward. The same localized changes may take place in all cases of chronic ostitis of the 
 calvarium, whether from accident or disease. 
 
 The symptoms of the acute aflection appear in the stage of reaction ; indeed, they 
 may be looked upon as indicating reaction in excess, febrile symptoms, headache, convul- 
 sions or convulsive twitchings, delirium or mania more or less acute, terminating rapidly 
 in paralysis, coma, and death, being the general order of symptoms. Suffusion of serum 
 takes ]»lace into the ventricles and upon the brain, causing at times compression, or effu- 
 sion of pus or ptiriform lymph occurs either upon the brain itself or in the meshes of the 
 pia mater, or into the cavity of the arachnoid. 
 
 Whenever the brain has been severely shaken, and consequently bruised or lacerated, 
 inflammation may appear at the injured spots; hence it at times shows itself beneath the 
 seat 0/ the hloir. but more frequently begins on the opposite side of the brain to the seat 
 of injury where the brain has been hruised or lacerated by contre-coup. From these cen- 
 tres inflammation may spread either to the membranes from the cortical structure of the 
 
208 ENCEPHALITIS. 
 
 )jrain or to the substance of the brain itself; thus, in all cases of a general shaking of the 
 brain, the seat of inflammation is in most cases at the base of the brain. The pia 
 mater and cortical substance of the brain are commonly the seats of inflammation, but 
 the cavity of the arachnoid is likewise involved in many cases secondarily by exten- 
 sion of the morbid action. There are no symptoms by which the precise seat of 
 inflammation in the brain or its membranes can be made out ; they are alike in all 
 cases. 
 
 In chronic encepludilis the symptoms may show themselves soon after the injury, but, 
 as a rule, they do not appear for weeks, or even for months. They are most insidious in 
 their nature ; they may begin by want of sleep, with an irritability of brain and inapti- 
 tude for any bodily exertion, but headache of a constant exhausting kind, aggravated by 
 mental or physical exertion, is a most prominent symptom. As the disease progresses 
 the patient gi-adually becomes emaciated and exhausted, and toward the close of the case 
 epileptiform convulsions, local paralysis, and coma supervene. 
 
 It will thus be seen that the two classes of cases of acute and chronic encephalitis are 
 distinct in a measure. The acute is the result of a bruising of the brain by a severe 
 shaking or concussion, the bruising being, as a rule, at the base of the brain by contre- 
 coup. The inflammation begins in the pia mater, spreads outward, and is for the most 
 part diff"u.sed, and not local. Consequently, it is beyond the reach of surgical opera- 
 tion. The chronic is generally the result of contusion or fracture of the bone and 
 local in its action. It involves, by extension from without, the dura mater, the 
 arachnoid, pia mater, and brain consecutively in the same way. It is consequently 
 loithin the reach of surgical art, particularly in its early stage. 
 
 Treatment. — Acute encephalitis, when following a general injury to the brain, for 
 the most part runs such a rapid course that there is little time for treatment to take 
 effect. It attacks patients, moreover, who have been already knocked down by the 
 injury, in more ways than one, in- whom there is rarely much resisting force; and there 
 is, consequently, not much chance of success by treatment. Still, there is much to be 
 done. 
 
 The head must, of course, be shaved and raised on a pillow, and cold should be 
 applied to it by means of one of Leiter"s coils (Fig. 9, p. 49), or an ice-bag where the 
 former instrument cannot be obtained. The ice, when applied in a bag. must be broken 
 up into small fragments ; while the bag containing it should be large, in order to cover 
 the whole vault of the skull. The cold douche is also a powerful remedy. Free purging 
 should be resorted to, the old dose of calomel mixed with butter introduced into the 
 mouth being probably the best mode of administration, or an enema of turpentine or 
 castor oil may be administered. 
 
 In a strong man, when symptoms of acute encephalitis appear after a slight injury, 
 bleeding is a mo.st valuable practice. It should be performed boldly and freely at the 
 first onset of the symptoms, so as to take effect upon the patient, during the state of 
 excitement, before effusion has taken place and brain oppression appeared, and it may be 
 repeated. In severe general injuries it is useless. Some employ leeching and cupping 
 on the nape of the neck, and speak highly of the practice. 
 
 French surgeons still employ blisters to the scalp, but these cannot be compared in 
 value with bleeding and the local application of ice in the early stage of the affection. 
 In the chronic stage they may be beneficial. When they are employed, they should be 
 applied to the nape of the neck, and, where mercury is relied upon, the latter may be used 
 in the form of an ointment to dress the blister. Antimony is still given by some surgeons 
 of eminence. I have no experience of its use, and therefore cannot recommend it. 
 \yhen recovery takes place — a rare result — the patient must be cautioned as to the 
 future ; for any excess of diet or of mental or physical exercise may produce a relapse. 
 The greatest quiet ought to be observed for many weeks, and the patient should live on 
 the simplest food. Milk diet and animal broths are sufficient for some time, solid animal 
 food being taken with great caution. Stimulants should only be administered if the 
 patient's powers are feeble. 
 
 In chronic cases calomel, given in small and repeated doses to touch the gums, com- 
 bined or not with opium, has its advocates, and patients, doubtless, have recovered under 
 its use. The gray powder in three- or four-grain doses, with five grains of Dover's 
 powder, is a useful combination when delirium is present, and at times larger doses of 
 opium or morphia may be given. Great care, however, must be observed in the use of 
 these drugs, for, unless they are carefully given and their effects watched, they are 
 injurious. 
 
ENCEPHALiriS. 209 
 
 Wlu'ii syniptoius ol' coinpri'ssiKii ol' tin- hiMiii inllow tlinso of nmtr encephalitis the 
 result of a tjinmil Injiinj nr shakiii^^ of the hraiii, tliirre is little (hmbt that its cnnipri'ssioa 
 is (luc to the effusion ol" inflaniniatory fluid into, upon, or hcrn'ath the hrain ; ami undtT 
 sueh ciri'Uinstanci's the (juestion ol" sur;_'ieal interl'crt'net; sliouM not he; entertained. Such 
 is to lie thouirht of only in eases of local i-hnniif suppuration tli<! result of a local c<jntu- 
 sion of the hone or otlu-r injury. (»r of disease, and when tlie seat of suppurati(Mi is usually 
 between the hone and the tlura mater. At times, however, a local abscess is formed in 
 tlie cavity of the arachnoid ; and under the circumstances when stronj^ evidence of this 
 condition exists the j)arietal layer may be punctured, since jrood results have followed 
 this ))ractice. . 
 
 Puncturing the Brain for Suppuration. — In niore advanced cases suppura- 
 tion may involve the iirain itself, and it is a serious (|Uestion whether a surjreon is ever 
 justified in ])unctnrini;- this orjian with a view of layinjr oj»en the supjiuratin^'- cavitv. 
 Should, however, good evidence exist of suppuration in the cerebral hemisphere beneath 
 the seat of injury, I have no doubt as to the surgeon being justified in making an 
 ex])loratory puncture; for Mr. Ilolden has recorded in <SV. liartholoinrir's llm^it. ll<^t. for 
 iSTi^ a case, and Mr. Ilulke others, and in the American Jonrn. of M>d. Scitticr for July, 
 IST.'K five otlier instances may be referred to in which success f(dlowed this practice. 
 Dupuytren had a successful case of the kind, and pathological anatomy furnishes exam- 
 ples in which such a practice might have been of use. On the other hand, many bold 
 attempts are on record in which surgeons have punctured the brain to relieve symptoms of 
 suspected suppuration in its substance. Weed's case is without doubt the best, as it was 
 successful (Nashi-i//'' Journ. Med., April, 1872), but Detmold's and Maisonneuve's are 
 encouraging. 
 
 I am disposed to think that surgeons are too apt to leave these cases alone too long 
 and allow them to get beyond relief. 
 
 A man receives a blow upon the head, followed by passing symptoms of .so-called con- 
 cussion ; he has a slow convalescence, attended, and perhaps followed, by headache. He 
 may display some irrital)ility of brain, inability to do much work or to undergo any phys- 
 ical fatigue ; some febrile disturbance may perhaps manifest it.self, but a.s often as not 
 none appears. The pulse probably will be feeble and irritable, at other times slow and 
 hi))oring. On examining the seat of injury tenderness on pressure may be experienced, 
 and occasionally increase of heat will be felt. Pressure upon the injured part may even 
 excite a convulsion where such had previously occurred. Under these circumstances, 
 which are fairly indicative of local inflammation of the bone, spreading inward — though 
 how far is uncertain — a free inci-sion to the bone is of great value. I have known this 
 operation relieve immediately all the symptoms, general and local, and have never known 
 it followed by harm. It should always be performed when evidence of local inflammation 
 exists, with umlefined and persistent brain svni]itonis. 
 
 Symptoms of Abscess beneath Bone. — When, however, evidence exists that 
 the inflammation has spread from the bone to the ])arts beneath, as indicated by symptoms 
 of feverishness, severe headache, and probably rigors, with sleeplessness, delirium, con- 
 vulsions, and paralysis, particularly when hemiplegic. other surgical treatment may be 
 thought of; for if these sym])toms are associated with such a history as has just been 
 sketched, there is every probability that suppuration exists within the skull and that sur- 
 gical art may reach it. General treatment, moreover, in these cases is both unsatisfac- 
 tory and unsuccessful ; and if the case be left alone, bad results always follow. Surgical 
 interference, it is true, as a rule, is not very .satisfactory, though some striking examples 
 of success exist. In the hands of Pott trephining the skull for matter beneath the bone 
 outside the dura mater yielded a good result in five out of eight cases. No modern sur- 
 geon, however, can show a like success; '"indeed," says Sir P. Hewett. "the successful 
 issue of a ca.se of trephining for matter between the bone and dura mater is, I believe, all 
 but unknown to surgeons of our own time.'' Xevertheless. the operation is clearly justi- 
 fiable under such severe circumstances as have been described : for our want of success is 
 probably due to the fact that surgeons are too readily disposed in these cases of local 
 encephalitis to wait too long, to trust too far to natures own processes, and by so doing 
 to allow the local suppurative action to spread inward beyond the dura mater to the brain 
 itself, when the prospects of a successful result are certainly poor. They wait for what 
 are called well-marked brain symptom.s — coma and hemiplegia — before they interfere ; 
 which well-marked symptoms too often mean fatal brain complications. Trephining the 
 seat of injury, therefore, under such circumstances is clearly a justifiable, if not a hopeful, 
 measure, should the operation be performed as soon as it is manifest from the history of 
 U 
 
210 TREATMENT OF CONCUSSION. 
 
 the case that the local action is spreading. When pus is found between the bone and the 
 dura mater, great hopes may be entertained of a successful issue, although, when the same 
 suppurative "action has involved the cavity of the arachnoid and the brain, the prospect is 
 not good. 
 
 Should no pus be found, however, between the bone and dura mater, is the surgeon 
 justified in opening the membrane? Without doubt he is when there is strong reason to 
 believe that pus exists, when the dura mater on exposure hubjcs firmly into the opening in 
 the bone which has been made with the trephine, and is tense as well as absolutely puhr- 
 lesa; for cases of success after this operation have been recorded by Guthrie, Ptoux, Dum- 
 ville, and Hulke. The evidence required to sanction any incision into the brain in search 
 of suppuration, as has been already stated, must be very strong. 
 
 Acute encephalitis as a result of blood poisoning needs only to be mentioned. It is a 
 hopeless condition from the first, and is always associated with the worst and most general 
 form of pyaemia. 
 
 TREATMENT OF CONCUSSION AND COMPRESSION OF THE 
 BRAIN, AND OF FRACTURES OF THE SKULL. 
 
 "A mere crack in one of the bones of the cranium, ahstractedli/ consuhrcd. is not more 
 likely to produce any serious complaints than a simple fissure in any other hone ; and if 
 symptoms of consequence do frequently attend the accident, they proceed either from the 
 bone being beaten inward, so as to press upon the brain, or from the mischief done to the 
 parts within the skull by the same force that broke the bone itself. The same violence 
 which breaks the cranium may occasion a concussion of the brain, an extravasation of 
 blood in or upon it, or subsequent inflammation of that organ, and its usual consequences" 
 (Sam. Cooper). 
 ■ The truth embodied in this extract renders it necessary to consider the treatment of 
 head injuries as a whole, since it is impossible to say. in any case of severe injury to the 
 skull, whether two or more of the conditions mentioned are not associated. 
 
 When brain concussion has taken place, it may or may not be associated with fracture, 
 and it may or may not be followed by symptoms of compression, either from extravasation 
 of blood or secondary inflammation ; and when a fracture is known to exist, either with or 
 without depression of bone, the difficulty is not lessened. The symptoms may be a mere 
 temporary suspension of the brain's functions — or. as they are commonly called, those of 
 a passing' concussion — or they may be of a much more serious nature and such as indi- 
 cate brain contu.sion, laceration, or blood extrava.sation. The severest complications are 
 often ushered in by the mildest symptoms, and therefore the surgeon should always treat 
 every case of injury of the cranium and its contents as serious. He should also be as 
 guarded in his prognosis as he necessarily is uncertain in his diagnosis. 
 
 In any case, therefore, of concussion, however slight, the patient ought to be kept 
 quiet, and should observe moderation in diet, take little or no meat, and avoid all stimu- 
 lants. If he moves about, it is at a risk — a risk of fatal secondary inflammation of the 
 shaken or bruised brain. These precauitions should be continued for at least three weeks. 
 
 In severer concussion, in which, after an injury to the head, there is a more or less 
 complete suspension of the functions of the brain, whether with or without a fracture, 
 equal care is needful. Should the collapse indicative of the first stage be severe, reaction 
 may be hastened by means of warmth to the body generally, more particularly to the 
 feet, and by the application of some stimulant to the nostrils. It is seldom right to do 
 more than this, because, if reaction does not set in naturally and is not hastened by the 
 means mentioned, it is tolerably certain that the brain mischief is of a severe, if not fatal, 
 character. Under these circumstances, any more powerful means, such as the adminis- 
 tration of alcoholic stimulants or powerful enemata, are likely to excite reaction to excess 
 and either encourage secondarv hemorrhage or inflammation within the skull. 
 
 Reaction and its Treatment.— When reaction has set in after the collapse— 
 the second stage of authors — every source of excitement, mental or phy.sical, should be 
 removed. The patient should be kept in bed with his head raised and shaved, and the 
 bowels emptied with a mild saline or mercurial purge. Leiter's coil (Fig. 9), cold lotions, 
 or an ice-bag .should be applied to the head, and particularly if it be hot. the pulse rapid, 
 and other symptoms of general febrility and brain excitement show themselves. When the 
 symptoms of excessive reaction are persistent, the commencement of traumatic encephalitis 
 should be suspected ; and under such circumstances venesection, boldly performed, is a 
 valuable remedy. It may even be repeated should the symptoms return and the pulse 
 
TIlKATMF.yr OF COMrRKSSfOX. 211 
 
 * 
 
 ami tfiiipfratun' rist-. In fcrMo jcitii'iits. IidWcvcr, lilci'diiif: is inadmissible, ami umlcr 
 all i-ircuiiistaiu-rs it oiitrlit only t(» In- resorted to after careful eoiisidoratioii. 
 
 The diet should ln' li(|ui<l ami of a simple kind. Milk, when it can he taken, is tlie 
 best ; hut w hi'u it eaniiot. weak heef tea or l)roth should he given, and then otdy in 
 moderation. 
 
 Treatment of Fracture and Concussion. — Coneussion of the hrain eompli- 
 
 eated witii lither siui]ile or eoiu|MMind UM<le](re>sed fracture of the vault or fracture of 
 the base is to be treated upon like principles and with e(|ual persistency and care, for 
 simple fractures of the vault, compound fractures of the vault, and simple fractures of 
 the base, or of the vault and base combined, ituttssociated with t/ixji/tiretjient, require no 
 special treatment beyond that indicateil by the l)rain symptoms. 
 
 It should be here .stated that the treatment of all the.se conditions is to be continued 
 f(»r at least a month or six weeks after the injury, since there are many cases on record 
 in which sec(mdary inflammatory .symptttms appeared at least a montli after the accident 
 or after the suli<iilrin-e i>\' tlie primary symptoms. 
 
 Treatment of Compression. — When the brain symptoms fidlowint: an injury 
 to tlie liead partake more of the nature of compression — that is, when they are persistent 
 in their character, and, instead of iroiiiK on toward recovery or to the restoration of the 
 natural functions of the brain, tend rather toward their more complete abeyance — other 
 <|uestions of treatment come before the surgeon ; and the most important has reference to 
 the fact whether surgical art can do anything toward relieving the condition. 
 
 The student who has carefully read the remarks that have already been made can 
 now understand, when the injury to the brain or skull has been the result of some (j'-ueral 
 iiijnn/. such as a fall upon the head from a height or a blow from a heavy body, that the 
 brain mischief which follows is certain to be of a general character; and when sj'mptoms 
 of local mischief complicate the case, little good is to be gained by treating these local 
 symptoms when others of a more general or fatal character exist. In examples of brain 
 or skull injury, therefore, as a result of diffused or general .shaking of the head and its 
 contents, local interference of any special character is generally useless. 
 
 In hcdf injuries, however, the question may be seriou.sly discussed. 
 
 In cases of dt-prrssed fracturr^ ought the bone to be elevated? and should the fact of 
 the fracture being compound influence the decision? I have no hesitation in answering 
 both questions and asserting that in neither instance ought surgical interference to be 
 adopted as a rule of practice, since experience has taught us that depressed bone jier se 
 may exist to a great degree without giving rise to any serious brain complications, and 
 that when even brain symptoms follow as an immediate result of the injury they may all 
 pass away. 
 
 Extravasation of Blood between Bone and Dura Mater. — Should, 
 
 however, the symptoms indicate the ]>resence of effused blood beneath the fracture suf- 
 ficient to cause compression of the brain, as shown by the lapse of an " interval of time " 
 between the accident and the symptoms, and should local paralysis point out its seat, 
 surgical interference is called for ; and in both simple and compound fractures the 
 trephine may be required in order to elevate the bone. The operation is necessary on 
 account of the brain .symptoms present in the case and has no reference to the character 
 of the local injury — to the presence or absence of a scalp wound. 
 
 In cases of simple fracture in which brain symptoms exist a free incision down to the 
 injured part for purposes of exploration is often called for. 
 
 In compoiiiid fracture of the skull, however, associated with depression and commi- 
 nuti'iu of the bone, both with or without brain symptoms, the surgeon ought to remove 
 loose pieces of bone and may elevate the depressed portions when this can be done with 
 the elevator without difficulty, as splintered bone is always a dangerous body when in 
 contact with the dura mater. 
 
 When the brain is injured, the same course should be followed, the greatest care 
 being observed not to add to the irritation by any rough manipulation. Should difficulty 
 be felt, however, in removing bone, it had better be left in sifii rather than by inter- 
 ference incur any extra ri.sk of injuring the brain or its membranes. 
 
 Should there be. on the removal of Vione. severe hemorrhage from a meningeal artery, 
 the piece should be left ; and should this practice fail to arrest the bleeding, a small piece 
 of sponge or plug of carbolized catgut in,serted beneath the bone may succeed, or the 
 ajiplication of a pair of spring forceps may be called for. It is not often, however, that 
 such a complication is met with. 
 
 In every case of punctured fracture of the skull trephining should be resorted to. 
 
212 
 
 TREPHINING FOR HEAD INJURIES. 
 
 General Summary to Surgical Interference. — It thus appears that in sim- 
 ple or compound unamiminuttal depressed fracture from a local injury operative interfer- 
 ence is not called for unless associated with marked symptoms either of compression of 
 the brain or extravasation of blood between the bone and the dura mater ; whereas in 
 compound commiuided fracture and m punctured fracture, with or without symptoms of 
 brain compression, the bone should be elevated and all fragments removed. In other 
 cases, as in fracture of the base, no surgical interference can be justified. 
 
 Did space permit, many instances might be quoted to illustrate these points, for cases 
 of fracture of the skull with depressed bone without brain symptoms in which recovery 
 has taken place are numerous ; indeed, experience has proved that there may be much 
 depression of bone without brain symptoms, and I am tempted to believe that depressed 
 bone by itself never gives rise to marked symptoms of compression, and that when these 
 are present hemorrhage exists with it. 
 
 Many cases might also be quoted illustrating the value of surgical interference in 
 compound fractures with depression ; I give the following : 
 
 Compound fracture of skull with depression from local injury. A feeling of perma- 
 nent weight on the head was the only symptom, which was at once relieved by removal 
 of the bone, and recovery followed. 
 
 Compound fracture of skull with depressed bone from local injury. Constant vomit- 
 ing and pain in the head, which was relieved at once by removal of the bone, the patient 
 recovering on the fourth day. 
 
 Compound fracture of skull with depressed bone from local injury. Persistence of 
 symptoms of oppressed brain. Elevation of depressed bone, and rapid recovery. 
 
 THE OPERATION OF TREPHINING OR FOR THE ELEVATION 
 
 OF DEPRESSED BONE. 
 
 "Much has been written and said on the treatment of injuries to the head, and the 
 result of modern experience and judgment has so far altered the practice of our prede- 
 cessors as to render us cautious of inflicting an additional injury on our patient for the 
 sake of gratifying an impertinent and useless curiosity as to the exact nature and extent 
 of the original lesion." Thus wrote my colleague, Mr. Cock, forty years ago; and what 
 he then said is true now, although, perhaps, surgeons at the present day are less disposed 
 to trephine in head injuries than they were even at that time. 
 
 At Guy's Hospital trephining and elevation of bone for bead injuries have been 
 performed in fifty-one cases during seven years, and of these only twelve recovered. At 
 
 Fig. 80. 
 
 Fig. 81. 
 
 Fig. 82. 
 
 Showing the Operation of Trephining. 
 
 A, Trephine prepared for use, with centre pin clown. 
 
 B, With centre pin withdrawn, the outer table having been divided. 
 
 Elevator. Hey's Saw. 
 
 St. Bartholomew's Hospital it was recorded by Callender in 1SG7 that the operation had 
 not been performed for six years. At University College, Erichsen gives six cases of 
 recovery out of seventeen. 
 
 The operation is, however, valuable in two classes of cases: 
 
Tin: <)ri:i:.\ri()S of i/nriiiMNa. 213 
 
 First. To relieve e(im|ire>si()ii dl' tlie Inairi iliie to either depres.sed hone or exlravasa- 
 tiuii of blood. 
 
 SiToiuUi/. To j)rcvi'iit, ehock, or relieve initalidii nl' tlie Inaiti or its uienibratics when 
 caused by (1 ) depressed and coiiiiiiiiiuted boiie, by ( '1) iiifiaiiied and .swollen bone (whether 
 the result of aeeident or disease), or by (!>) an aectiinnlation of pus Itetween the bone 
 and dura mater eonipressini; the brain ; and it may be stated at on<e that the operation 
 <»f trephininjr uMius mure support from the seeond than from the first ^n(jup <»f cases. 
 
 With respect to the first, it will have been j;athered from preceding chapters that 
 depression of the bones of the skull is rarely sufficient of itself to give ri.se to persistent 
 symjitoms of compression; that when it is, the injury has ju-()bal»ly been of such a 
 severe nature as to produce grave intracranial complications fntm which any operation 
 would be iiica])able of affording relief; and that hemorrhage l)etween the bone and the 
 dura mater is rarely so mieomplicated with brain miscliief as to render it jirobable that 
 the operation of trephining will ]»e successful. 
 
 When, however, it can be fairly determined that brain .symptoms of a defined and 
 aggravated character are the re.sult of either of the.se two causes, .separately or combined, 
 the operation of trephining may be performed. In diffused injuries to the skull the 
 probabilities are all against the operation, while in local injuries they are in its favor. 
 
 In both simple and compt)und fractures of the skull, with or without depression of 
 bone, the symptoms of compression of the brain as a ])rimary result of the accident must 
 be very marked indeed to justify the ojjcration of trephining, altliough in coihixjiukI frac- 
 turex it is expedient to elevate depressed bone wlieri any .symptoms of brain irritation 
 manifest themselves, such as local pain and weight, spasms, or convulsions ; and under 
 all circumstances it is best to remove fragments when the bone is comminuted. In a 
 eomjiound comminuted fracture of the skull the dura mater is jirobably exposed, and is 
 likewise irritated by the broken bone. A careful elevation of tlie depressed portion of 
 the bone and the removal of the connninuted fragments can in no way add to the mis- 
 chief, but must tend toward its diminution. 
 
 In local injuries^ whether simple or compound, when incipient symptoms of brain irri- 
 tation or inflammation appear two or three days after the injury, the use of the trephine is 
 indicated, inasmuch as there is a probability that the symptoms originate in the presence 
 of a fragment of bone irritating the brain or its membranes, which, if left, must set up 
 encephalitis. 
 
 In all cases of pan(tin\il fidcturc the treidiine should be employed. 
 
 Pus between Dura Mater and Bone. — When an abscess can be made out 
 as existing between the bone and the dura mater after a head injury, the operation of 
 trephining is demanded, though the diagnosis of such cases is difficult. The chief indica- 
 tions are found in the prolonged period which fre(juently elapses between the injury and 
 the supervention of the symptoms, their gradual and, it may be said, irregular approach, 
 the general and cerebral irritation that is present as a rule, the exacerbation of all these 
 symptoms, and, above all, the constant headache. 
 
 The direct symptoms of compression produced by the formation of pus are, moreover, 
 in no ways so definite as those afforded by blood extravasation ; they are of a less decided 
 nature and are never associated with the deep-toned stertor and rapid progress of the 
 symptoms, '' which with overwhelming influence (juickly annihilate both motion and con- 
 sciousness when blood has been poured out in any considerable quantity after injury to 
 the cranium " (Cock). They are, however, fairly marked by the clinical history of the 
 case, and can be generally recognized. 
 
 The Operation of Trephining. 
 
 The instruments required for the operation are the trephine^ or circular hand-saw, of 
 which there are two sizes; a small aaiv with a straight and circular edge, generally known 
 as Hey's saw ; a sharp scalpd with a handle rounded at the end, to press back the perios- 
 teum and soft parts from the bone ; a //rt/ probe thin enough to introduce into the groove 
 made by the trephine, to guide the surgeon in his attempt to perforate the bone and to 
 prevent him going too far ; a pair of cntting forceps, to remove sharp points and edges of 
 bone ; an elevator, to raise depressed bone ; and dissecting, dressiniz-, and torsion forceps. 
 ( FiV/e Figs. 81 and 82.) 
 
 The patients head having been placed upon a pillow, shaved so far as requisite, and 
 held firmly, the first thing the surgeon has to do is to expose the bone he wishes to per- 
 forate or elevate. This must be done freely, eithi'r by enlarging the wound that pre- 
 
214 THE OPERATIOX OF TREPHINING. 
 
 viously existed or by an incision crucial or otherwise. The soft parts should be divided 
 by one cut down to the bone, and these, including the periosteum, should be gently 
 pressed back with the handle of the knife. Bleeding at this stage should be arrested by 
 ligatures, torsion, or the application of a cold sponge and pressure. 
 
 Supposing the case to be one of fracture with depression, and that fragments of bone 
 exist, they should be- removed, great care being taken in their removal not to twist the 
 broken bone and thus run the risk of tearing the dura mater ; and when an opening is 
 thus formed, the depressed bone may be raised by means of the elevator carefully intro- 
 duced beneath its free border. To facilitate this proceeding, perhaps the removal of a 
 piece of projecting bone by forceps or Heys saw will be found beneficial ; and if so, the 
 trephine is not required, for the surgeon's object, under the circumstances — to raise the 
 depressed bone and remove the comminuted portions — may be completed without the 
 trephine. 
 
 Should the bone be so depressed, however, as not to present an edge for the surgeon's 
 forceps, as is seen in the '-gutter' fracture illustrated in Fig. 71, the trephine must be 
 emplo3'ed. The instrument should be previou.sly prepared, the central pin being made to 
 project sufficiently far to perforate the external table, and so fixed as to allow the saw to 
 bite the bone (Fig. 80. a). In a depressed fracture this pin should never he placed vpon the 
 fractured, but upon the border of the sound, bone. The instrument is then to be applied 
 and the external table cautiously divided with a few semi-rotatory movements of the sur- 
 geon's wrist. A groove having been made deep enough to allow the saw to work steadily, 
 the instrument is to be removed and the central pin withdrawn and fixed (Fig. 80, b), as it 
 would be a fatal error to go on working with the pin projecting through the inner plate 
 of bone into the dura mater. The surgeon ought now to proceed with the utmost caution, 
 and feel his way ever}- few turns with the flat probe, for as soon as he has divided, or 
 even reached, the inner plate, the elevator may be employed and the loose ring of bone 
 removed. When the inner plate is fractured to a greater extent than the outer, it may 
 not be necessary to divide it, the removal of the external table with the diploe being 
 sufficient to allow of the introduction of the elevator and the removal of fragments. 
 Should this not be the case, however, the inner table must be perforated ; for the whole 
 thickness of the bone must be removed. The operator cannot be too careful at this .stage 
 of the operation, and should always proceed with the conviction that the bone is thinner 
 at one spot than another, and, further, that '• there is only the thinness of paper between 
 eternity and his instrument '' (Sir A. Cooper's MS. lectures). The depressed bone may 
 then be raised by the elevator. 
 
 If the operation has been performed for extravasation of blood beneath the bone and 
 a clothe discovered, it should be removed, the utmost gentleness being used. Should pus 
 exist, it will e.scape naturally. 
 
 Should troublesome hemorrhage from a meningeal artery ensue, it may be arrested by 
 tucking a small portion of sponge or carbolized catgut beneath the vessel and compres.sing 
 it against the bone, or it may be held by a short pair of spring forceps against the bone. 
 Free bleeding of this kind, however, is not frequent. 
 
 On Puncturing the Dura Mater. — If. however, no blood or pus be found 
 external to the dura mater, and strong evidence exist that it is placed beneath this 
 membrane, the dura mater may be punctured. This step, however, is not to be under- 
 taken without grave consideration. Yet, it may be asked, if the operation fail in its 
 object, is the operator ever justified in making a second opening into the skull in search 
 of blood or of pus? Certainly, it mu.st be answered, not at a hazard; although, when 
 there is evidence to point to a second position in which it is reasonably probable that the 
 offending fluid may be found, a second perforation may be performed. Cases are on record 
 in which three or more pieces have been removed with a good result. 
 
 The wound, after the operation, must be treated on general principles, the edges of 
 the soft parts being gently brought together, but not stitched; boracic acid lotion on 
 absorbent cotton is the best dressing, and the head should be kept cool by the ice-bag. 
 If the parts heal and the case does well, a metallic .shield may be required as a protec- 
 tion, although it is interesting to see how firm the membrane that fills in the cavity 
 becomes after a time. 
 
 Hernia Cerebri. — Should a hernia of the brain follow at a later stage, the same 
 local treatment should be employed. Excision of the projecting fungous mass is a prac- 
 tice that is not advisable. The whole will probably wither by natural processes if a cure 
 takes place ; and the less the surgeon interferes, the better. 
 
a Eyh'Ii . I A t'OSCL us I OSS. 2 1 
 
 General Conclusions on Injuries of the Head and their Treatment. 
 
 1. Iiijurit's of the head arc id' iiiiiiortaiifo only "^<» far as tli(;y primarily or Sfoondarilv 
 iiivolvo the cranial contents, a east; of simple tuie<implicated fractiin; of the skull heing 
 of less danger than one of ireneral concussion of the hrain. 
 
 2. A slijrht shakin;,' of the hrain. which manifests itself by a pa.ssin;,' .suspen.sion of 
 tlie cerehral functions. a.s.sociated or not with a fracture of the vault or of the base of the 
 skull, generally does well. 
 
 !{. A severe eoneus.sion or shaking of the brain a.ssociated or not with a fracture of 
 the vault or of the base of the skull is probably associated with contusion or laceration 
 of the brain substance, either uj)on its surface or within its ventricles, and consequently 
 with more or less extravasation of blood ; when the vessels are disea.sed, a copious hemor- 
 rhage often follows a slight injury. 
 
 4. In ca.ses of .severe concussion the l)rain is at least as much injured by cmtt-p-coup as 
 it is at the .seat of injury, its base suffering the most. Fracture by coiiln-roiip does not 
 take place. 
 
 5. A fall upDU the vertex from a height or a blow upon the head from a blunt instru- 
 ment may or may lujt be followed by fracture of the skull, but such an accident produces, 
 as a rule, a general concussion of the V^rain, with contusion or laceration of its structure 
 and efTusion of blood either upon its surface or within its substance or ventricles. 
 
 G. Falls upon a pointed object or blows with a sharp instrument are, as a rule, fol- 
 lowed by local fracture; and if the brain be injured, it is at the seat of injury. As a 
 conse(|uence. the symptoms may be accounted for by local causes only, and the surgical 
 treatment should be directed b\" local considerations. 
 
 7. When symptoms of compression of the brain imraediatelj' follow an injury to the 
 skull which has been ))roduced by a fall from a height or by a blow from a heavv and 
 blunt instrument, the cerebral injury will be general, the brain will be contused and lace- 
 rated, particularly at the base, by contrr-conp; and if extravasated blood be found external 
 to the dura mater, blood will also be found upon the surface of the brain or within 
 its membranes. The ojieration of trephining under these circumstances can be of no 
 avail. 
 
 8. If symptoms of compression of the brain follow a local injury produced by a fal\ 
 upon a sharp object or a quick blow from a pointed one, such .symptoms, as a rule, are 
 produced by local causes, such as depressed bone or extravasation of blood from a rup- 
 tured vessel, and such local injuries should be treated by the elevation of the depressed 
 bone or by trephining. 
 
 9. W^hen compres.sion of the brain follows a local injury over the cour.se of the 
 meningeal artery, and the symptoms come on after reaction has been establi.shed and the 
 lapse of an interval of time from the receipt of the injury, the operation of trephining 
 may be performed, although no depressed bone be present. 
 
 10. Encephalic tnjiiimmation may follow the slightest concussion or injurv to the 
 brain, whether complicated or not with fracture ; and the danger of such a result is in 
 proportion to the encephalic injury. In cases of contusion or laceration of the brain with 
 extravasation of blood, inflammation is almost sure to occur, and. as a rule, will cause a 
 fatal termination. This inflammation may appear within a few hours of the accident or 
 it may be po.stponed for days ; it may be very rapid in its course or very in.sidious in its 
 nature. If the brain alone be affected, either a diffused or local abscess may result ; 
 while if the membranes are involved. eflFusions, convulsions, general or partial paralysis, 
 coma, and death will rapidl}- take place. 
 
 11. Fractures of the base of the skull may take place alone and be marked by only 
 special symptoms. They may be associated with, and are generally found in. all cases 
 of severe fracture of the vault when produced by a heavy fall or blow, the fissures radiat- 
 ing downward in a direction parallel to the forces employed. 
 
 12. Fractures of the base may be complicated with encephalic injuries similar to tho.se 
 which complicate fractures of the vault ; consequently, they may be manifested by gene- 
 ral as well as special symptoms, and in severe cases the former completely mask the 
 latter. 
 
 13. All injuries to the head should be treated with extreme care and always regarded 
 as serious, rest in the horizontal posture, freedom from excitement, bland, nutritious, 
 unstimulating food, being essentials under all circumstances, the great principles of 
 practice consisting in warding off" excess of reaction and inflammation of the cranial 
 contents. 
 
216 DISEASES OF THE SCALP AND CRANIUM. 
 
 DISEASES OF THE SCALP AND CRANroM. 
 
 Besides the blood tumors of the scalp to which attention has been already directed, 
 the head is very frequently the seat of the common skin or sebaceous tumor which is 
 called a '' wen," these morbid growths being more frequently found on the head than on 
 any other part of the body. They are more common also in women than in men, seventy 
 out of one hundred and seven consecutive cases of sebaceous cysts which I have analyzed 
 having occurred in women and eighty-four on the head. In many instances these wens 
 are doubtless due to an obstruction of the duct of a sebaceous follicle, as the orifice of 
 the duct is often visible and through it the contents of the cyst can be squeezed ; while 
 in others no such obstruction can be made out, it being probable that .some of these 
 tumors are new formations — true adenoid tumors of the skin, such tumors usually lying 
 beneath the skin, but without any connection with it. These cases have, however, been 
 fully considered at page 144. 
 
 The scalp may likewise be the seat of other tumors, simjjle or malignant, of epithelial 
 cancer of the skin, or of any other affection of the integument. These require no special 
 attention here. 
 
 NaBvi are very common in all their forms — cutaneous, subcutaneous, or mixed ; but 
 this subject will be considered in another chapter. Let me caution the student, however, 
 not to adopt hastily any surgical proceedings with a ntevus situated over a fontanelle ; 
 for, although such may be dealt with with impunity, I have known a fatal inflammation 
 attack the membranes of the brain after the application of a ligature to an undoubtedly 
 cutaneous na^vus placed over this region. If possible, he should wait till the bones have 
 closed before he interferes. 
 
 Perforating tumors of the skull occasionally come under the surgeon's notice, 
 and demand attention. The majority of them have their origin from the membranes cov- 
 ering the brain, and mainly from the dura mater. They are generally cancerous and are 
 often secondary deposits, though occasionally they seem to be of the " sarcomatous " 
 nature. They were first described by Louis in 1744 under the term '' fungus of the 
 dura mater" (Mem. cle TAcad. Boj/. tie Chlr., tome v.). Since his day all perforating 
 tumors of the skull have been included under this heading. It must be remembered that 
 a tumor growing within the skull and pressing outward will cause absorption of the cran- 
 ial bones ; which fact is rendered familiar to pathologists by the enlargement of the 
 Pacchionian bodies. 
 
 Symptoms.- — The symptoms indicating the presence of this aff'ection are very uncer- 
 tain, although headache more or le.ss constant* and severe may exist with epileptiform 
 convulsions and other brain symptoms ; yet as often as not the first marked condition to 
 which the patient's attention is directed is a swelling in one of the bones, the disease hav- 
 ing progressed thus far without having given rise to any symptoms whatever. When the 
 diseased mass has perforated the bone, the swelling, receiving its impulse from the brain, 
 will be pulsatile ; and this symptom is of importance as a distinctive one between tumors 
 of the bone itself and the perforating tumors of the membranes. In cancerous disease 
 the bone itself will be infiltrated with cancerous elements and destroyed, while in benign 
 tumors the bone will be absorbed simply by pressure, as is seen in aneurism. In the 
 former case the opening in the bone will be ill-defined and irregular, and in the latter it 
 will be smooth as well as regular. 
 
 Treatment. — With respect to treatment, it is almost needless to say that nothing can 
 be done by way of removal of the growth. The symptoms to which it gives rise can only 
 be relieved by sedatives, and life can only be prolonged, if at all, by general treatment. 
 
 The bones of the skull are liable to tumors, cancerous or benign, to exostoses, particu- 
 larly of the ivory kind, and to myeloid growths, though in this place it is only necessary 
 to mention the fact. 
 
 Meningocele and Encephalocele. 
 
 These terms are applied to conditions of the head found in children at the time of 
 birth, and infants thus aiFected are generally hydrocephalic. The words indicate a pro- 
 trusion, a hernia, through the skull, either of the membranes of the brain or of the brain 
 itself, the protrusion appearing as an elastic tumor in the line of one of the sutures. Such 
 cases are always associated with some deficiency of the bones of the skull — it may be of 
 some portion of the frontal bone, near the root of the nose (Fig. 83) or near its external 
 angular process, and by far the most frequently of the occipital bone. In rare examples 
 
MENiy< ; 0( 'EL E A SJ) E.\( El'JI. IL0( 'EL E. 
 
 217 
 
 the tloticii'iit V may Ik' at the liase of the skull. I>r. Mclitcriltcr^' has roconlud a case in 
 the Tnniftfirh'iiiiH nf tin PuthnUxjlritl Sorlrtif^ vol. xviii., in which the tumor was haii^'iuc 
 out of tlie ehihl's imiiitli and (•nimiimiicalinic with the .-l^ull thrmiL'h an o[M'nin;i- in front 
 of the seMa turcica. 
 
 Varieties. — In ii inniinijiii; h the incmhranes may protnich' as a whoh-, hut sometimes 
 the dura niatcr ah)ue projects (c/iA I'rcp. inti.")"", (luy's Museum). In the true inirji/ut- 
 
 /iiri/f the hrain itself is pres.sed out of tlie skull into the 
 J"'"- ^•»- external tuiiuu'. This was well .seen in a patient from 
 
 wlutin the accompany inj; drawinj^ i^^^iC- H4) was taken ; 
 
 the skull contained the anterior and part of the middle 
 
 lobes of tlie brain, and the sac the remainiiif.^ portions. 
 
 Via. 84. 
 
 Meninpocele at Root of Nose. 
 (Mr. Poland's case.) 
 
 Meningocele. 
 (Drawing 501'«', (iuy's Hosp. Mus.) 
 
 The ventricles were likewise divided between the two. The posterior lobe.s were adherent 
 to the membranes that formed the sac. In a hydnncephalocch', in additimi to tlie brain 
 substance, there will be a portion of one or both of tlie ventricles filled with fluid. 
 
 "An enceplmloci li\'' writes Sir P. Hewett (*SV. Georcfe'ii Ho!<p. Rcji.. vol. vi.j, "is of a 
 round or oval .shape ; in .size it seldom exceeds that of a small orange ; its attachment is 
 broad ; the integuments covering it present little or no alteration. In the earlier periods 
 it has the characteristics of a watery bag. but later on, as the fluid gradually di.sappears, 
 the brain matter fills the sac, and then the tumor becomes soft and doughy." 
 
 A hyil rencephalorele "• in shape is more or less pyriform, with a marked contraction at 
 its attachment, and sometimes a long and narrow stem ; in size it is apt to become much 
 larger than an encephalocele. The integuments over it are thinner ; fluctuation exi.sts 
 about the hernia, and large veins may be traced under the skin." 
 
 When the.se tumors are small and have a very minute communication with the cranial 
 contents, they have been, and may be again, mistaken for some simple cyst or tumor. 
 The surgeon should therefore always suspect that a cy.stic tumor situated over a fonta- 
 nelle or suture, and particularly when over the nose, may have some communication with 
 the membranes, and he should coii.secjuently po.stpone all operative interference till the 
 diagnosis is clear. As the bones ossify the opening between the tumor and the cranial 
 contents may close. The cyst, if small, may then be excised ; if large, it may be injected 
 with iodine or ^lorton's iodo-glycerine solution. The utmost caution, however, must be 
 employed in the treatment of these cases, and where uncertainty exists as to their true 
 nature or attachments the prudent surgeon had lietter leave the case to nature than risk 
 life by any hazardous enterprise. 
 
 Serous cysts simulating encephaloceles are met with. Billnjth {CUn. 
 
 Siir;/., -p. 4ii) and Atlee [ Auicriatii Janni. of Mrd. »SV/r'«ci". January, 188.3) have each 
 recorded an example. Both were congenital and on the back of the head, with serous 
 contents. In Billroth's case, when the child died, the cyst was found to consist of a thin 
 wall with a very smooth lining. It lay in the cellular tissue beneath the scalp and 
 was entirely removable from the bone. Atlee's case was tapped, and two ounces of 
 serous, not cerebro-spinal. fluid were drawn ofl" with success, and the sac subsequently 
 withered. 
 
 Ostitis and periostitis of the bones of the cranium are common afl^ee- 
 
 tions, and may occur either as a conse(|uence of a local injurv. of svidiilis. of ostitis, or 
 of other causes. They are also often associated with brain complications. Under the 
 heading of •' Traumatic Encephalitis " this subject was discussed, together with its treat- 
 ment, and ostitis coming on from any cause other than injury presents very similar symp- 
 toms. I have seen in an infant periostitis the result of hereditary syphilis, and ostitis 
 
218 
 
 MENINGOCELE AND ENCEPHALOCELE. 
 
 ending in necrosis. I have seen also half the frontal bone of a babe exfoliate after a 
 punctured wound from a nail without any brain symptoms. In the adult the complica- 
 tions attending inflammation of the bones, syphilitic or otherwise, are very variable. 
 
 Symptoms. — The symptoms are generally local so long as the inflammation is con- 
 fined to the periosteum covering in the bone, the chief being pain and tenderness with 
 local swelling, though when the inflammation has spread to the inner periosteum or dura 
 mater other symptoms appear, such as constant headache and great irritability of brain ; 
 any worry or work increases pain, causes fever, restlessness, and want of sleep. As 
 the disease progresses delirium, convulsions, paralysis, coma, and death may be the 
 result. 
 
 The inflammation in the bone may go on to suppuration or necro.sis, and the dead 
 bone may exfoliate in masses (Fig. 85) or in small portions. Should no external outlet 
 for the pus form or be made, either by natural processes or by the surgeon, the retained 
 pus within the skull may give rise to symptoms of compression of the brain, when it is 
 probable that the brain itself and its serous membrane will become involved and the case 
 assume a most serious aspect. It is, con.sequently, a point of gi-eat importance for the 
 surgeon to anticipate such a complication, and, if possible, to prevent it. 
 
 Treatment. — When a patient has had a blow upon the head and been either the 
 subject of syphilis or of chronic suppuration of the ear, and as an after symptom has a 
 local swelling associated with pain of a constant and wearying character, the presence of 
 a local ostitis should be suspected. When the swelling is tender to the touch and pain is 
 aggravated by local pressure, this suspicion should be strengthened ; and when these con- 
 ditions are attended by pyrexia more or less severe, by sleeplessness, a quick irritable 
 pulse, and a contracted pupil, inflammation of the bone, probably implicating the dura 
 mater within and the periosteum without, may safely be diagnosed. Under these circum- 
 stances a free incision down to the bone 
 ^^'^^ "^ ' should be made, since experience has 
 
 proved that by the adoption of this prac- 
 tice pain and other symptoms are, as a 
 rule, relieved, and serious brain compli- 
 cations are often pi-evented. When ex- 
 ternal suppuration is present and dead or 
 dying bone is exposed, it is less common 
 to meet with cerebral symptoms, since 
 the pus finds its way externally through 
 the wovxnd, and there is consequently 
 less irritation of and pressure on the 
 dura mater, as well as less brain irrita- 
 tion. Should, however, brain complica- 
 tions appear, it is important to prevent 
 their spreading for the surgeon to interfere, as, when confirmed brain symptoms have 
 manifested themselves, the case is almost hopeless. The surgeon, under these circum- 
 stances, should attempt to remove the necrosed bone or perforate it by the trephine, both 
 these operations having one common object — viz., to give free vent to the pus beneath 
 the bone. Indeed, trephining, under such circumstances, is not only a ju.stifiable but a 
 valuable operation, and if performed with care can do little harm. When operation is 
 postponed till confirmed brain symptoms have appeared, there is too much reason to 
 believe that irremediable changes have taken place, such as suppuration within the hemi- 
 sphere or arachnitis, which no operation is likely to relieve; and yet "trephining" has 
 been of use even in such cases when complicated with epileptiform convulsions. The 
 surgeon, however, should anticipate this stage of the disease when he can and interfere 
 before such symptoms appear, headache of a local and persistent character associated with 
 evident signs of local ostitis or necrosis being always an indication of the propriety of 
 trephining. 
 
 I need hardly add that constitutional treatment such as has been mentioned under the 
 heading of " Encephalitis," and will be alluded to when the subject of syphilis is consid- 
 ered, ought to be carefully followed out. 
 
 M. Akan, Archives Genevales cle Medecine, 1844. — CoCK, Gm.?/'.s Hosp. Reports, 1842. — Hewett, 
 iSystevi of Surrjery, by Holmes, 3d ed., 1883. — Le Gros Clark, Lectures at Royal College of Surf/eons, 
 1869. — Pott, Injuries of the Head, 1768. — Guthrie, Coximentaries on Surgery, 1853. — Erichsen's 
 Surgery, 5th ed., 1869.— Hutchinson's Prize Essay (Astley Cooper), 18(55. — Brodie, Med.-Chir. 
 Trans., vol. xiv. — Wilks and Moxon's Lectures on Pathology. — Callender, St. Bartholomew's Hosp. 
 
 Necro.sis of Frontal Bone. 
 
 (From Emily ,s- 
 1S70.J 
 
 *t I'l, June, 
 
Oy TJilSMrs AM) TI'lTANVS. 219 
 
 Reports, \nh. i. and iii. — IIii/roN, " ( linicul Lectures," Lnnret, 1853. — NAlaton, Alice's edition, 
 185."). — (i.vMA, 'J'railfM ilfx I'laie* lU Ti'te, l.S.'}5.— Ada.Ms, Ihnpir'n Surg. Dictioiutnj, 1801. — J. Nkidoii- 
 Ki;u, M.D., I'rafiiie, Udmlbitck dir Kreii/nchirun/ie, 18f)7.— I'liuxioKK, N. Leipzig, 18t)4. — Stroiiiever'rt 
 oilitioii nt' W. MacCdH.MAi's XoleH of an Atnhuldnre Surgr.on, 1871. — Wk-st, Mul.-Chir. Traiw., 1880, 
 vol. Ixiii. 
 
 ON TRISMUS AND TETANUS. 
 
 WluMi a patient i.s the sul)jt;i;t <il" an uneuntiullahle .spa.iinmlif contraction of the mu.s- 
 clo.s of the lower jaw, he is .said to have " (risiiins," or h)ek-jaw ; and wlien the same con- 
 dition attacks other or all the voluntary nui.seles of the hody. he is said tr» have '■• (efmius." 
 Tetanus includes trismus, and jrcnerally hejj^ins with it, though trismus may be a local 
 attection. It is found in children as a result of dentition, and in adults as a (;oiise(|uenec 
 of diseases involving the teeth, gums, or jaws. It is a spasmodic affection produced l>y 
 reticct(Ml irritation set uj) by a local disease, is rarely ass(»ciated with any constitutional 
 disturl)ance. and is. for the most ])art, cured on the removal of its cause. 
 
 Varieties. — Tetanus is likewise generally as.sociated with some local source of irri- 
 tati(Ui, sonic wound or injury, and is then called '•• frinniKitir.' When no external or visi- 
 ble cause can be made out, it is denominated '' Uliopntliir." Wiieii rapid in it.s cour.se, it 
 is called " tiriitt' ;" when slow, ••■ clironir."' The acute form is usually the re.sult of an 
 accident, and generally fatal. The chronic is for the mcst part idiopathic and more 
 curable. 
 
 Infantile Tetanus. — Tetanus is met with in new-born infants, and is then known 
 as tris)iiiis iKiaccutiniii or frdtmts infantum. It usually comes on the second week after 
 birth, and may be so acute in its course as to destroy life in from ten to thirty hours, or 
 life may be prolonged to eight or nine days. It is a common affection in the West Indies, 
 aiul has been known to occur frequently in ill-ventilated lying-in hos])itals. Bad ventila- 
 tion, conse(|uently. has been put down as one of its causes, the others being cold, exposure, 
 internal irritation, an<l the division f)f the umbilical cord. 
 
 Predisposing Causes of Tetanus. — Dismissing the last form of the disease 
 from our consideration, it seems that tetanus may be found at any period of life, though 
 more than half the cases occur between ten and thirty years of age. The youngest case 
 on record was in a child of twenty-two months, and the oldest in an adult of seventy-five 
 years. 
 
 It is more than seven times as common in males as in females, and it is found in the 
 healthy as frequently as in the cachectic ; nor do the intemperate seem more prone to its 
 attack than the temperate. It is, too, as frequent in the winter as in the summer months, 
 though in warm climates the natives are more susceptible to its attacks than Europeans. 
 Exposure to damp, cold, or sudden changes of temperature have doubtless a powerful 
 influence in exciting this disease, in both the idiopathic and traumatic forms. Larrey 
 records that after a great battle a hundred soldiers were found affected by it in one 
 morning. 
 
 Exciting Causes. — Tetanus is rare in the course of ordinary surgical disease, 
 altliougli it may follow any form of injury, from the slightest contu.sion to the severest 
 compound fracture. It may occur after the extraction of a tooth or the gravest operation 
 in surgery, and it is known in obstetric practice as ^}«''/;/>e;7/Metanus. It is most common 
 after the more severe varieties of accidents, such as burns, compound fractures, and 
 injuries to the fingers and toes, though there is no evidence to prove that it is more fre- 
 quent after slight injuries to the fingers and toes than to other parts. Lacerated seem to 
 be more frequently followed by tetanus than incised wounds, particularly in children ; 
 but the state of the wound does not appear to have any influence on the disea.se. Seven 
 years' experience at Guy's Ho.spital gives the following facts (Poland) : 
 
 Tetanus occurred in 1 ca.se out of 1304 cases of major and minor operations. 
 " " 9 cases " 594 " of wounds of all varieties. 
 
 " " 1 case " 856 " of injuries and contusions. 
 
 " " 3 cases " 456 " of burns and scalds. 
 
 " " 9 " " 398 " of compound fractures. 
 
 23 3698 " or 1 in every 160 cases. 
 
 Date of Appearance. — There is no definite period at which tetanic symptoms 
 are prone to appear. When they set in soon after the injury, they are for the most part 
 acute and very fatal ; after the lapse of three weeks, the chances of their appearance are 
 very small. Acute cases, however, occasionally occur during the second week ; upon this 
 point Poland gives us the following facts : 
 
220 ON TRISMUS AND TETANUS. 
 
 Of 277 cases, 130 began before the tenth day, and of these 101 died. 
 
 " " 126 " between the tenth and twenty-second days, and of these 65 died. 
 
 " " 21 " after the twenty-second day, and of these 8 died. 
 
 In tetanus following exposure to cold the symptoms generally appear rapidly after 
 the exciting cause, and with the same exciting cause similar results occur in the trau- 
 matic form. 
 
 Symptoms. — There are no general or local premonitory symptoms by which the onset 
 of this aifection can be recognized, and the earliest indications of it>s approach are gen- 
 erally a difficulty in opening the mouth and stiffness in the muscles of the lower jaw ; yet 
 these symptoms may be so slight as to pass unheeded or be misinterpreted. When, how- 
 ever, some rigidity of the muscles of the neck, throat, or abdomen can be made out and 
 the first indications of the "tetanic grin," or risus sardoiiicii>' — which is caused by the 
 drawing down of the corners of the mouth by the muscles of the face — are recognized, 
 the diagnosis becomes certain. Difficulty in swallowing will then soon appear (any 
 attempt to drink fluids exciting spasm of the muscles of deglutition, and often of respira- 
 tion), with pain, due to spasm of the diaphragm, shooting through the body from the 
 scrobiculus cordis. 
 
 As the disease progresses the muscular system of the body generally will be more or 
 less affected, and in different cases different groups of muscles will be involved. Those 
 of the back are the most frequently attacked, and their contraction may be so powerful 
 as to cause an arching backward of the frame, producing what is known as '■'■ opisthotonos.'" 
 In rare cases the body is bent laterally or forward, the terms '■'■ jileurosthotonos''' and 
 " emjirosthotonos " being respectively applied to such conditions. 
 
 The muscles of respiration are. as a rule, affected in acute cases, and the chief danger 
 to life consists in the severity of the spasms which attack them. When severe, the first 
 spasm may be fatal and may occur at an early or at a remote period of the affection. In 
 a case under my care of severe traumatic tetanus all the symptoms were disappearing 
 and recovery was confidently expected, when, on the tenth day of the disease, the first 
 spasm of the laryngeal muscles took place, which destroyed life. 
 
 When the jaw is unlocked by a fepasm of the depressor muscles, the tongue is some- 
 times suddenly shot out from between the teeth, and often wounded. 
 
 Progress of Disease. — As the disease advances the jaws become completely 
 fixed, and deglutition is then impossible. The spasms of the muscles of the frame 
 become more intense and frequent and the powers of the patient rapidly decline. The 
 pulse, which was rapid, becomes more feeble, while the expression of the countenance 
 betokens agony of the body and despair of mind. The slightest manipulation or move- 
 ment of the patient sets up a fresh spasm, and any emotion may do the same. The skin 
 becomes bathed with a cold sweat; and if death is not caused by suffocation, exhaustion 
 soon puts an end to suffering. 
 
 There is rarely any fever during the whole course of the disease ; the bowels are 
 always costive, the stools offensive, and the urine, as a rule, natural. 
 
 The intellectual faculties of the patient almost always remain unimpaired throughout, 
 while the senses are morbidly acute. Anything like delirium is rarely seen. 
 
 Should the case tend toward recovery, the spasms will become milder in character and 
 recur at longer intervals till they disappear. It should he rcmemhered ., however, that as 
 long as the slightest evidence of disease exists a sudden sjJasni of the glottis may at any time 
 destroy life. 
 
 Diagnosis. — This should not be a difficult task, and in every instance of lock-jaw the 
 possibility of its being the commencement of tetanus ought to be entertained. Local 
 irritations, however, may produce a locking of the jaw more or less complete ; but such 
 are never accompanied by uncontrollable spasm, as is the case in tetanus. 
 
 To diagnose between tetanus and poisoning by strychnine may be difficult, the symp- 
 toms of both being very similar ; yet in tetanus the symptoms are progressive, while in 
 poisoning they appear suddenly in all their severity. In tetanus muscular rigidity is 
 always present, and aggravated at intervals ; in poisoning there are complete intervals of 
 relaxation of muscle. In tetanus, too, there is constant rigidity of the muscles of the 
 jaw ; in poisoning, the jaw is never locked except during the spasm. These points of 
 difference are sufficient to assist the surgeon in the investigation of a doubtful case. 
 
 Again, hydrophobia and tetanus have been mistaken the one for the other; but any 
 one who has seen the former disease could hardly fall into such an error. The peculiar 
 restlessness of mind and body, the complete intervals of rest and absence of spasm, the 
 peculiar aversion that is shown to fluid, accompanied by thirst — all symptoms character- 
 
ON TRTSMUS AM) TETASUS. 221 
 
 istic *>[' liydrophobia — are ciiouf.'!! to ilistiiit;uisli between the two. Nevertheless, it 
 shniild hi' rt'iiu'iiihtTcd that Dr. J. W. Otrh-, hitc nf St. (Jeorge's, lia.s recorded a case of 
 tetanus and h3<lr(i|)liohia coinhiiieil.' 
 
 l'K(i(i.\(»sis. — III acute traumatic cases tiierc are small Impes of recovery, while in 
 chronic the chances are jxreater. The lonj;er the j)atient lives, the better .seem the pros- 
 pects (if a fjood result; and it" ten days pass after the tirst appearance of tlie .symptoms 
 and the disea.se is on the decline, the projrnosis is i'avorable. 
 
 Takiiit; all cases toi;ether, Poland <;ives one recovery to seven and a half deaths. More 
 than half die within five days. The most rajtid death" has been in from i'our to live 
 hours, and the loni^icst duratinii of life on record in a fatal case is thirty-nine days. 
 
 How Death is Caused. — There can be little doubt that acute tetanus connuonly 
 destroys life liy apinea, spasm of the muscles of res])iration, and more particularly those 
 of the larynx, beinji; the immediate cau.se. Poland tells us that this was the ca.se in 
 thirty-two out of forty-six cases at Guy's Hospital in which the mode of death was 
 noticed. 
 
 In chronic tetanus death is commonly caused by exhaustion. These facts have an 
 inijiortant bearinu' on the treatment of the disease. 
 
 Patii(»i,(»(JV. — The late Mr. William King of Guy's is stated by Poland to have been 
 in tlie habit of remarking at the post-mortem table whenever there was an examination of 
 a case of death from tetanus, '•Gentlemen, we will now proceed to give you a demonstra- 
 tion of a case of healthy anatomy, for there will be no visible morbid appearances other- 
 wise than congestion of the organs in various degrees, owing to accidental circumstances." 
 And at the present day these remarks hold good. It is true that Kokitansky. Demme, 
 Lockhart Clarke, and JJickinsoii have given us some descriptions of structural changes in 
 the spinal cord which they have observed, and their ob.servations, moreover, seem to coin- 
 cide. These changes consist of disintegration and softening of a portion of the gray sub- 
 stance of the cord, which appears in certain parts to be almost diffluent. The semi-fluid 
 substance thus formed, however, "is at first more or less granular, bedding in suspension 
 the fragments and particles of the disintegrated tissue, but in many ])laces it is perfectly 
 pellucid.'' Yet it is to be remembered that Billroth and other pathologists have failed to 
 find these changes in the instances which they have examined, and it cannot, therefore, 
 be accepted as certain that these pathological conditions are constant in tetanus. There 
 can be little doubt, however, that the nerves of the injured part are at times found 
 inflamed and irritated, and from this fact the theory has been advanced that through the 
 injured nerves of the ])art the spinal centres become involved, and manifest these states 
 of excitement through the motor nerves by producing muscular spasm, the disease being 
 one essentially of the excito-motory system. Clarke believes " that the spasms of tetanus 
 dej)end on the conjoined operation of two separate causes : First, that they depend on an 
 abnormalh' excitable state of the gray nerve tissue of the cord induced by the hypera'mic 
 and morbid state of its blood vessels, with the exudations and disintegrations resulting 
 therefrom ; second, that the spasms depend on the persi-stent irritation of the ]>eripheral 
 nerves, by which the exalted excitability of the cord is aroused."' 
 
 Treatment. — Every imaginable form of treatment has been employed in this disease 
 with success, to be discarded in its turn for something new. No settled form of practice 
 can consequently be laid down. Still, much can be done in guiding the patient through 
 this disease, in keeping him alive, and in warding off death. 
 
 To keep the patient alive the most careful attention to feeding is required, milk and 
 concentrated liquid animal food being the best diet. If these can be taken in sufiicient 
 quantities, no other mode of administration is required; but if not, they must be given 
 as enemata every four or six hours, as the case demands. Stimulants must be used cau- 
 tiously, though when the powers are failing they may be freely given. 
 
 Upon this principle of practice quinine has been strongly recommended ; it may be 
 given in full doses to an adult, such as five grains every three or four hours, and then 
 increased, or in one large dose, such as twenty grains, to be followed by the smaller one. 
 
 Among specific remedies that have been greatly vaunted, the Calabar bean stands 
 foremost, and may be trusted; it should be given in full doses, such as half a grain of the 
 extract every two or three hours, or one-twenty-eighth of a grain of its essential prin- 
 ciple, eserine, increased to double, even the tenth of a grain. Camphor also recommends 
 itself to our notice in doses of from five to ten grains. The woorara poison has failed in 
 its purpose. The bromide of ammonium or potassium has, however, been administered 
 with advantage. 
 
 ' Bril. and For. Med. Reiieii: 1868. 
 
222 DELIRIUM TREMENS. 
 
 It was hoped that a valuable drug for this disease had been found in chloroform, but 
 experience has not justified the expectation. The hydrate of chloral has now taken its 
 place and been of some service. Demme has advocated with much success the use of the 
 curara, eight cases out of twenty-two having recovered under such treatment. In India 
 the Indian hemp has been highly recommended. Nicotine and tobacco have also been 
 successful. Aconite is another drug that offers some advantages, while opium has an 
 unquestionable influence in allaying pain and mitigating the severity of the spasm. Ice, 
 also, applied in bags along the spine, has apparently been of great value in the hands of 
 American surgeons. The administration of remedies by subcutaneous injection in these 
 cases promises to be a valuable adjunct to practice, enabling us rapidly to introduce into 
 the system drugs that act antagonistically to tetanic spasm. 
 
 The patient should always be kept quiet, warm, and free from draught. He should, 
 moreover, be so watched that in his spasms no injury can be sustained ; attention should 
 be paid to his bladder and bowels, for catheterism is sometimes called for; and purgatives 
 and enemata to clear out the intestines are beneficial, although violent purgation cannot 
 be advised. 
 
 Question of Amputation. — With respect to hcaJ treatment, much may some- 
 times be done. In severe local injury when the nerves of the part are probably involved 
 amputation ought certainly to be performed, for a sufficient number of cases have been 
 recorded in which success has followed the practice. In 1845, Mr. Key amputated a leg 
 on account of tetanus which had appeared six days after an unreduced dislocation of the 
 astragalus; the symptoms disappeared at once after the operation. On dissecting the foot 
 the posterior tibial nerve was found to have been put violently on the stretch by the pro- 
 jecting astragalus. 
 
 In some cases soothing applications, such as opium, may be applied to the wound, and 
 in all perfect cleanliness should be enforced. 
 
 One other means of cure remains to be noticed which has reference to the mode of 
 death in this disease. It has been shown that in the larger proportion of cases — in all 
 the acute — death is caused by suffocation from spasm of the laryngeal muscles. It is 
 also fairly recognized that this disease runs its course, and that the most our science can 
 accomplish is to maintain life and ward off death. To this end the operation of trache- 
 otomy seems to be of value, for with a tube in the trachea death by laryngeal spasm can- 
 not take place, and a better prospect of recovery is consequently given. 
 
 I have employed this practice in one acute case, in which the Calabar bean was like- 
 wise given, and the patient sank from exhaustion, free from spasm ; and there seems good 
 reason to believe that if I had performed the operation in the case I recorded in the early 
 part of this chapter life would have been saved. This matter, however, requires grave 
 consideration, and the practice is not to be rashly followed. 
 
 Morgan, On Tetanus, 1833. — Curling, On Tetanus. — Poland, Guy's Hospital Reports, 1857. — 
 Dr. Ogle, Brit, and For. Med. Review, 1868.— Dr. Dickson, Med. C'hir. Trans., vo\. vii. — Dr. L. 
 Clarke, ibid., vol. xlviii. — Dr. Dickin.son, ibid., vol. 11. — Demme, Schmidt's jahrb., vol. 112. — 
 TiiAMHAYN, O., (■6i(/.— Fea/'-£ooi-, Sydenham Society, 1862-64, etc.— " Puerperal Tetanns," Dublin 
 Quart. Jour., 1865; Med. Times and Gaz., 1865. — Billroth, Pathol. Chirurg., 1868. 
 
 DELIRIUM TREMENS. 
 
 It often falls to the surgeon to treat cases of pure delirium tremens uncomplicated 
 with any surgical malady, and it is well, therefore, to refer to this subject by itself. 
 There are other cases, perhaps, more aptly described by the term " traumatic delirium" 
 in which the nervous symptoms are developed as a consequence of an injury received. 
 In both classes the symptoms are essentially the same and the treatment required is sim- 
 ilar; still, it is right to bear in mind the difference in causation, as in the one we have to 
 deal with a nervous disease in an intemperate person, and in the other with the same 
 symptoms as an incident in a surgical case. In simple delirium tremens, to use the 
 familiar term, we have to deal with the case of a person who has indulged for an uncer- 
 tain time in injurious doses of alcoholic liquors. It may be that a young man after a 
 prolonged debauch has an attack of the " horrors," but the symptoms more frequently 
 occur in those who have for a long period accustomed themselves to the excessive use 
 of beer or spirits, even without amounting to drunkenness, and who at length are sub- 
 jected to some shock or depressing influence. Inasmuch as the habits which have been 
 mentioned as superinducing this disease are opposed to the simplest laws of health, it 
 follows that they cannot be indulged in with impunity for long, and consequently we find 
 
DELIRH'M rilKMESS. 223 
 
 the subjocts of if, as a rule, ol" t'rclilc |M)\vcrs of rcsistiiiicc ami ol'tcti with disoascti vIh- 
 cera. Sucli persons arc hatl siihjcfts I'nr any aihnfrit, and it often lia|t|M'iis that when a 
 person ol'this sort breaks his h'U' or meets with some injury rc(|niriii^' sur;_'ical treatnn-nt 
 he becomes the subject of (U'lirium tremens. Other causes are oceasionally at work, such 
 as starvation, mental an.viety. ami the overuse of tobacco or opium. 
 
 'Pile disease is at times ushered in by certain premonitory symptoms, as patients who 
 have onci' been the subject of an attack are sometimes conscious of tin; approach of 
 another. .\ brewer who liad been treated for this affection at («uy's some years af,'o, when 
 lie felt warninj:;s of its advance on several occasions applied for admission, and as a result 
 the attack was warded off. 
 
 Depression of mind and de))re.ssioii of body are the chief premonitory .symptoms, 
 with restlessness and agitation, <floom, and foreboding of evil. Home slight febrile dis- 
 turbance may also exist, but the out' invarialile and most important symptom is sleepless- 
 ness. The tongue is generally pale and flabby, as well as coated with a whitish i"ur, and 
 is never dry. The appetite is bad. the breath often fetid, and the bowels confined. The 
 pulse may be quick, though soft and powerless. Tiie skin is always moist, and at times 
 bathed in perspiration. With the.se .sym]»toms the characteristic delirium with trembling 
 is not far off. It may, however, in surgical practice set in suddeidy without warning. 
 The nature of the delirium is very characteristic and is always accompanied by allusions 
 which are generally spectral. The patients see objects that do not exist and hear sounds 
 that are imaginary, these being always of a strange or frightful nature. At times some 
 delusion as to business or home matters agitates the mind. These same unsound ideas 
 are sometimes fixed during the whole attack, but more commonly succeed one another in 
 rapid rotation. Sleeplessness, under these circumstances, is a constant accompaniment. 
 The patient will be quiet for a time, muttering words without meaning, or he will be rest- 
 less and get out of bed in obedience to some imaginary call. He will pull about his bed- 
 clothes, will rise up in bed at one moment under one impression and lie down again under 
 another. If asked to put out his tongue, he will do so, but probably with a jerk ; if to 
 give his hand, he will project it with a thrust. A nervous trembling of the extremities, 
 with an utter want of control or steadiness of purpose, is characteristic. If the.se symp- 
 toms continue and rest cannot be obtained, prostration of all the powers will rapidly 
 appear and death will supervene from exhaustion or coma. If sleep — sound sleep — can 
 be .secured, the symptoms usually mitigate rapidly. 
 
 The PROGNOSIS must depend on several considerations. If the patient be young 
 and the attack ensue after a short period of drinking, the chances of recovery are hope- 
 ful ; but if the attack occur in a man of middle age habituated to overdrinking, and if 
 his liver or kidneys be unsound, it is fraught with much greater danger. If the attack 
 be associated, moreover, with an injury such as a wound or fracture, another element of 
 danger is introduced. The best guide to the patient's real condition is the study of the 
 pulse — not merely as to the number of its beats, but with regard to its character. The 
 sphygmograph is of great service in such cases, as by its help a '• dicrotic " state of pul.se 
 is often shown where the finger would not indicate it ; and such a condition is a bad omen. 
 The most frecjuent ciunplication is pneumonia, which often comes on rapidly and insidi- 
 ously and is a frequent cause of speedy death even when the excitement has subsided. 
 
 Treatment. — This disease essentially being one of depression of the nervous system 
 associated with sleeplessness, the main object of the surgeon is to induce .sleep, to calm 
 the excited brain, and to give it time to recover its normal functions ; and with this end 
 absolute quiet and the use of bland and nutritious food are most essential. 
 
 Easily-digested nutritious food mu.st be administered when it can be taken by the 
 mouth ; but when refused or rejected, resort must be had to enemata. Milk is undoubtedly 
 the most suitable form of nourishment, either alone or mixed with eggs ; but it does not 
 suit all stomachs. The question of giving stimulants, and to what extent, is one of great 
 importance. As a rule, the less given the better, but in some cases it is advisable to give 
 them ; and that form of alcohol to which the patient has been accustomed is the best. 
 Young men with an acute attack may do well without any, but in other cases the feeble 
 powers of the patient re<(uire some such aid to stand against the exhaustion caused by 
 the restlessness and excitement. The chief reliance, however, should be placed on other 
 forms of food, such as strong animal broths. Darby's fluid meat, or .similar preparations. 
 
 Opium in one of its forms is a drug still in favor, although some reject its u.se alto- 
 gether and trust to feeding and time, relying upon the knowledge that the disease has a 
 natural tendency to terminate in sleep after the second or third day. In an ordinary case 
 of the disease one grain may be given as a dose, or ni^xx of the tincture, repeated every 
 
224 SHOCK AND COLLAPSE. 
 
 tliree or four hours or oftener. till sleep is procured. In other cases two or three grains 
 may be given at once and followed by grain or half-grain doses. 
 
 The best naethod of administering drugs in this disease, however, is by subcutaneous 
 injection : and I recommend the injection of morphia in solution in doses of a quarter or 
 half a grain in preference to any other plan, because the condition of the stomach of 
 patients suffering from the disease is far from satisfactory either for absorption or assimila- 
 tion, and by the hypodermic method of introducing the narcotic into the system its 
 absorption is more certain and rapid. In some cases the beneficial influence of morphia 
 thus employed is very remarkable, and only in exceptional instances the treatment fails. 
 
 The use of chloroform has also been urged, though such a plan is not devoid of dan- 
 ger and can hardly be advised except for some temporary purpose, such as to dress a 
 wo«nd or to enable an enema to be given. The hydrate of chloral is a drug of great 
 value as possessing hypnotic qualities without the evils attendant on other drugs of this 
 class. It may be given in doses of twenty or forty grains, and repeated at moderate 
 intervals till sleep is procured ; when combined with ten-grain doses of the bromide of 
 potassium, it seems to be of more use. Drs. Kinnear and Lawson in the Melville Hos- 
 pital have treated from seventy to eighty cases successfully with large doses of cayenne 
 pepper, from twenty to eighty grains having been given as a dose. Dr. Maclean of Net- 
 ley trusts to quiet and the use at short intervals of strong beef tea highly charged with 
 cayenne pepper. 
 
 Of late years the value of digitalis has been greatly extolled, but vl\\ experience of it 
 has not been favorable. It is given in large, if not poisonous, doses, such as two drachms 
 of the tincture every hour for three or four doses till sleep is produced. It is a dangerous 
 mode of treatment, and -cannot be recommended. 
 
 When great excitement and some fever exist, antimony in small doses has been much 
 advocated. The condition of the bowels almost always demands attention, as the tongue 
 is usually foul and the secretions morbid. A purge sufficient to empty the colon is con- 
 sequently of service, but violent purgation is injurious. 
 
 Tonics, such as quinine and iron, with or without opium, will be required as the 
 disea.se .subsides. The combination of the tincture of iron with the tincture of opium in 
 carefully regulated doses is preferable. In other cases ammonia with bark may be 
 administered. 
 
 Question of Restraint. — With respect to coercive measures in the treatment of 
 these cases, there is no doubt that they ought to be condemned. In exceptional instances, 
 where sufficient help cannot be obtained to prevent the patient from injuring himself or 
 others, the jacket doubtless must be employed, but under no other circumstances is it 
 justifiable. An attendant who combines decision of character and firmness with a gentle 
 and soothing manner will almost always succeed in '■ influencing" the most troublesome 
 patient. He is to inflvpnce him, however, and not to direct him : for contradiction and 
 the exercise of authority over the subjects of this disease invariably excite opposition. 
 
 Chronic Intemperance. — There are some people who are never drunk, yet are 
 always drinking — in whom the tissues are so weak that under injury they rapidly break 
 up and under disease show no power of repair. In such it is difficult to induce wounds 
 to heal or show any vigorous action. 
 
 The best remedy is to supply such patients with all sorts of nutritious food, to give 
 tonics and a moderate amount of stimulants, and thus endeavor to improve their habits 
 as well as restore them to a more healthy tone. 
 
 SHOCK AND COLLAPSE. 
 
 Sh.OCk. — A man receiving unexpectedly some startling news which excites severe 
 emotion, and dying suddenly, is said to die from shock ; a .second receives a fatal blow 
 upon the epigastrium ; a third is struck dead by lightning : death in each case is said to 
 be due to .shock. In all the heart's action is suddenly arrested through the nerve centre 
 — in one case through the mind, and in the others through the body. Under these cir- 
 cumstances the heart is found full of blood, distension having paralyzed its action. 
 
 Collapse. — A man receives a severe compound fracture, gunshot or other injury, 
 and is not killed, but collapsed. Another, or possibly a child, is much burned or has a 
 large portion of the integuments of a limb torn away or crushed, in which the peripheral 
 nerves are seriously involved, and as a result reflex paralysis of the heart occurs. Both 
 have sustained a shock more or less intense, and as a consequence become cold and 
 almost, if not quite, pulseless. In either case the skin appears to be bloodless and cov- 
 
sirof'K A\i> foLLM'si-:. 225 
 
 ert'd with ;i cold claniiiiy swi'at. lie may lircallic aliintst iiiipcrccptildy, fctrlily, or with 
 sijj;hs and ;;as|>s. His imstrils will innliahly he dilaliMl, his eyes ilull, his vision imperfect, 
 and eonseioiisncss may In- lost in vny variaMe de<;rees ; the patient may j)ossil»ly he 
 roused, yet, as a riUe. he n-ijuires roiisin<; to prove the existence of consciousness. At 
 otiu'r times the intellect remains quite clear. 
 
 'riu'se are, briefly, the sii^ns of c(dlapse or shock the result of injury. They are to be 
 found in variable decrees after most accidents, and are by no means usually fatal urdes.s 
 the injury it.self is fatal. Of course, if the shock from the injury is very jrreat, the heart 
 may cease to l»eat and the luiijis to breathe, collapse passing more or li!ss slowly into 
 death ; but m()rt^ usually, after a variable period, the heart's action frradually improves, 
 the respiratory act becomes more rcLiular, and jicrfect color returns to the bloodless lip.s 
 and skin, w.irmth rcap]icars on the surface of the body, and consciousness becomes more 
 manifest. Tlu'se syni|)toms indicate what is known as reaetimi ; and when they are 
 excessive, febrili' .symptoms nuiy appear. It sliould be noted that voniitin<r is often the 
 first indication of reaction in jrcneral collapse, as it is often in that of head injuries. Should 
 the nature of the accident be such that heni<jrrha<r(; complicates the ca.se, the collapse 
 will be more lasting, the shock of the accident passing into collap.se from hemorrhage ; 
 under such circumstances a fatal result is very likely to ensue (the amount of bleeding 
 and its rapidity determining the result), for it should be known that hemorrhage by 
 it.self is enougli to produce collapse, or syncope, and this, addcil to the shock of the 
 injury, is often more than enough to destroy life. Li abdominal injuries this combina- 
 tion is well .seen, the hemorrhage from a lacerated liver or other organ, as a rule, appear- 
 ing with the first manifestations of reaction from the .shock of the accident, and thereby 
 proving fatal. 
 
 The longer the reaction is delayed, the more grave is the a.spect of the case ; not 
 nnfrecjuently relapses appear, signs of reaction and of collapse alternating in variable 
 degree, till one or the other asserts itself in recovery or in death. 
 
 In rare cases, even from the .shock of a slight accident, reaction is followed by excep- 
 tional symptoms ; thus I had a man under care who was admitted with a slight concus- 
 sion of the brain, in whom reaction was attended with an acute attack of maniacal 
 excitement which left him after two days to pass on to a steady convalescence, A woman 
 with a similar injury attended with a scalp wound had a like attack, which lasted a fort- 
 night and then subsided without any bad results. I have recorded also in another page 
 a ease of general tetanic spasm which showed itself in the reaction after a ca.se of spinal 
 injury. More commonly, however, reaction is attended with what Travers has described 
 as '-prostration with excitement" — a state bordering on and often passing into that known 
 as delirium tremens. 
 
 Under some conditions of the S3'stem shock and collapse are more readily produced 
 than at others ; thus very young and very old subjects, those enfeebled from age or 
 other cause, mental or physical, are ])articularly apt to die of shock after injury or 
 operation. When bones are involved in the injury and .symptoms of '• shock" appear 
 after a day or two's satisfactory progress. Professor Nussbaum believes them to be due to 
 fat embolism as evidenced by severe dyspnoea, oedema of lungs, and sudden death. 
 Patients with bad kidneys, also, are very liable to suffer from shock and to succumb to 
 any operation, however trivial. Surgeons see this at times in the sinking after small 
 operations. Thus I lost some years ago, after the removal of a fatty tumor, a woman of 
 middle age, simply from asthenia, the operation having been unattended by any loss of 
 blood : also a child vet. 8 after some operation on a cicatrix of the neck in the .same way. 
 In both, bad kidneys were found after death. The idio.syncrasy of the individual has 
 ahso a powerful influence on " shock." 
 
 Treat.ment. — Shock or eollap.se uncomplicated with hemorrhage may be treated in 
 one way. shock or collapse the consequence of or combined with hemorrhage in another. 
 
 In both cases the hearts action must be either excited or maintained; ''the heart 
 must beat and the patient must breathe." or life will fiiil. Even in the worst cases, as 
 long as any signs of life exist, the respirator}' process may be aided by artificial respira- 
 tion and the warmth of the body kept up by external applications. Savory in an able 
 article (llohurs's Si/ste7n, ed. 2, vol. i.) advises as the result of experiment and reasoning 
 that, should no evidence of the heart's action be detected and no hemorrhage con)plicate 
 the case, a vein should be opened— ^as the external jugular — in order that the overdis- 
 tended heart may resume its action as soon as it is relieved from its paralysis by distension. 
 
 In the extreme collapse following hemorrhage transfusion is also " a fair and rational 
 expedient." 
 
226 SHOCK AND COLLAPSE. 
 
 In less severe examples the surgeon's object should be to keep the patient alive, but 
 he ought not to try to do more, as to force nature is always injurious, and sometimes fatal. 
 The failing powers of a feeble subject may be excited to act only to give way again ; they 
 may not a second time respond to the former stimulant. 
 
 A too rapid reaction may so stimulate the heart as to set up a fatal hemorrhage, when 
 by the collapse the wounded artery might have become sealed by nature's own blood-clot. 
 
 In all cases of shock and collapse, therefore, complicated with lucal injury, great judg- 
 ment is called for. To do enough to maintain life is essential, but to do more is injurious. 
 
 The horizontal position under all circumstances should be observed, and external 
 warmth secured by means of blankets and hot flannels applied to the pit of the stomach. 
 Sir J. Simpson's i)lan of applying heat to the body is very beneficial — by filling six or 
 eight soda-water bottles with boiling water and tightly corking them, and then drawing- 
 over each a woollen stocking wrung out of hot water. The bottles so covered are then 
 to be packed around the patient in bed. Stimulants in carefully adjusted (juantities may 
 be given, and brandy is the best. This should be given in small quantities; and if the 
 heart's action fail to respond to its administration after two ounces or so have been swal- 
 lowed, more is of little service, the stomach usually rejecting it. When the stomach 
 rejects brandy or the patient cannot swallow, an enema of brandy in warm starch, milk, 
 or gruel sometimes acts very rapidly. As soon as the heart's action is estal)lished liquid 
 food, such as warm milk, may be given, though only in small quantities, and the case 
 should be carefully watched ; food and stimulants should be given with discretion and as 
 the symptoms indicate, the greater the loss of blood, the greater being the necessity for 
 food. 
 
 Excess of reaction is to be checked by soothing remedies — ojiium in any of its forms, 
 henbane, and chloral are also very valuable — a few hours' calm sleep generally acting like 
 a charm ; yet when brain comjilication appears, this treatment is to be adopted with care. 
 Anything like coma contraindicates it. 
 
 Amputation in Collapse. — In compound fractures and other local injuries 
 demanding operation the question of operating on a patient in a state of shock is- 
 important. Can the operation act as a stimulant and tend to rouse him? or may it 
 act as a second shock and tend the other way ? 
 
 When the shock is severe and the patient almost pulseless, it is doubtless the wiser 
 plan to postpone all operative interference till the heart's action is re-established. To 
 amputate a limb under extreme collapse is to destroy what chance of life exists or to do 
 an unnecessary operation. To amputate when reaction has set in after the lapse of a few 
 hours, when external warmth, stimulants, and tonics have had their influence, is likel}' to 
 prove successful. 
 
 In less severe examples of collapse, however, the same practice does not seem to be 
 necessary, especially when hemorrhage has been the partial cause and is still continuing,, 
 because the loss of very little extra blood by oozing forbids, when collapse is present, any 
 hope of a good reaction being established ; and under such circumstances no benefit can 
 be acquired by delay, but only harm. The administration of an anfesthetic has, more- 
 over, a stimulating influence upon the heart and nervous system which is often very val- 
 uable. I have fre((uently performed primary amputation upon subjects in a state of 
 partial collapse after injury under these cii'cumstances, and have never regretted it. 
 
 With a patient in a state of collapse no amputation should be performed when by 
 delay no harm can accrue. When hemorrhage, however trivial, is going on or is likely 
 to recur at any moment, the surgeon should interfere and remove the part when it& 
 removal is essential. When the collapse is associated with semi-consciousness, chloro- 
 form is not needed, the operation itself acting as a sufficient stimulant ; but when the 
 mind is clear as to what is going on, its use .should not be withheld, because, although it 
 is true its secondary effects are sometimes depressing and may be injurious, in a general 
 way it has a beneficial influence and tends to prevent a second shock, both mentally and 
 physically. 
 
 When Extreme Collapse Exists. — " How far," writes Savory, '• the patient 
 should be allowed to rally, and when he has reached that state which will enable him to 
 bear the operation, are, of course, questions which cannot be answered in a general man- 
 ner, but which must be decided by the surgeon in each case." 
 
 When the surgeon is in doubt about acting, he had better decide in favor of delay. 
 When no doubt exists as to the wisdom of removing an injured part and by delay harm 
 must or may probably ensue, he should act at once, even when the patient has not quite 
 rallied from the shock of the injury. When, so far a% the local injury is concerned, the 
 
rh'ii;M:i> wn iivsrhn/cAL o/: Mnii('Ki:i> disease. Til 
 
 (Iclav nt' a I'rw (la\> (ir Imiirs is iiiiiiii|iiiitaiit . all ii|icrat ivt; iiitfriVrciicc; should be post- 
 |i(iii(-il. 
 
 ill severe e(iiii|MMiii(l IVael iirc-:s. ^iiiislmt (ir utlieiuise, liemurrliaj;<* is almost suro to 
 occur as soon as reaction apitears. ami the ^hoclv of the removal ot" a limit is not so much 
 to he (Ircudcil as tin* loss ol" hlood. 
 
 • Wounds <d' the lari^e arteries ol' the Iclcs and arms I'rom halls ami shells always hlced 
 more or less at the tinu- of reception, and more freely as the shock to the nervous system 
 passes oil and reaction comes on. Kvi-n when this nervcms shock is not sufficient to pro- 
 duce immetliatc death, \\w chances of ultimate recovery must frequently turn <jn the 
 mere (|uestion of loss of hlood. " 
 
 In military practice primary amputation upon the field is now ^em.Tally preferred to 
 soccuulary, and in civil practice a like rule should generally he enforced. 
 
 Sr.M.MAUY. — To perform any capital operation on a patient in a condition of extreme 
 collapse or shock is bad practice. To do so, however, when a minor degree exists and 
 the ])ulse can he felt, when by delay other dangers, such as continued or renewed hemor- 
 rhage are to l)e expected, is soutul ami good surgery. To an uticonscious or only slightly 
 conscious patient an an;usth(!tic is not necessary. To the conscious it has often a bene- 
 ticial action, and ten<ls toward the encouragenu'nt of reaction. 
 
 FEIGNED AND HYSTERICAL OR MIMICKED DISEASE. 
 
 I have placed these two classes of cases together for purposes of convenience, and in 
 this section, as they are cs.scntially diseases of the nervous system. Both in a measure, 
 and with ditl'erent degrees of accuracy, simulate real or organic disease. In feigned dis- 
 ease the will of the patient is strong to deceive ; it is bent to simulate the symptoms of 
 an affection of which the individual knows something, though not all, and from this the 
 full knowledge of the surgeon or physician is to override the imperfect knowledge of the 
 impostor and expose him. In the hysterical the will of the patient is weak ; functional 
 derangement is allowed to assume the garb of organic disease ; subjective symptoms are 
 intensitied — not. however, from motives of deception, but from a want of the controlling 
 influence of health, more particularly of the nervous centres, a condition of hypertesthesia 
 commoidy existing I'rom some imperfect nutrition of the nervous centres. In exceptional 
 cases anaesthesia is present, more particularly in the larynx. 
 
 Feigned disease is a voluntary deception from beginning to end and is unreal. Hys- 
 terical disease is an involuntary exaggeration of some functional derangement, '■ an 
 unwilling imitation of organic disea.se, ' and real. 
 
 Fdijncd iiffecfli'iis are met with chiefly in the intellectuall}' weak or those of crafty 
 character, and in a general point of view are attended with an exaggeration of symptoms 
 far beyond those met with in real or organic disease; pain is said to be far more intense 
 than is usually met with, and paralysis more complete ; every symptom simulated is 
 extreme; inconsistencies are present which are not reconcilable with the .symptoms 
 usually met with in the disea.se .simulated. These inconsistencies and exaggerations 
 should always excite suspicion in the mind of the practitioner, causing him to test 
 quietly every symptom or grou]> of symptoms and to doubt his diagnosis until he has 
 proved its truth. To the sn/t/rrfive symptoms, or those complained of by the jtatient, 
 these remarks are very applicable ; but to the o/>Jec/ire, or those palpable to the observer, 
 they are so to a degree. The subjective symptoms are always exaggerated, the objective 
 inconsistent, the former being too bad for truth, the latter inconsistent with experience. 
 For example, the rigor of an ague may be simulated, while the hot and the sweating 
 stage is impossible. Epileptic convulsions, catalepsy, or madness may undoubtedly be 
 imitated, but in all these there will be, when present, some exaggeration or incon.sistency 
 not found in the real disease. Nerve pains may be felt, but they will nor follow any 
 anatomical nerve distribution. Paralysis can also be readily simulated, but it will prob- 
 ably be too complete ; it will on testing, more particularly when done unexpectedly, be 
 associated with a greater degree of sensibility in the skin than is usuallj- present. When 
 of long standing, it will not be attended with the usual wasting. Vomiting, coughing, 
 or spitting of blood can be artificially produced, though under these circumstances the 
 severity of the symptom will probably contrast strangely with the mildness of any others 
 with which it nuiy be attended. 
 
 In fact, in feigned diseases, on a careful investigation into the history of the case, 
 the succession of symptoms, their progress, intensity, and duration, some element will 
 be brought out which is irreconcilable with truth, some suspicion that deception is at 
 
228 FEIGNED AND HYSTERICAL OR MIMICKED DISEASE. 
 
 work will be excited, which, if worked out, must unmask the imposture and prevent 
 error. 
 
 The subjects of hysterical disease or of nervous mimicry are mostly what are called 
 nervous and emotional. They have commonly " a very unusual mental character : in 
 the majority there is something notably good or bad, higher or lower, than the average 
 — something outstanding or sunken." In this affection " every part of the body may 
 become under provocation the seat of an apparent disease that in reality does not exist ; 
 it may, and often does, assume all the attributes of reality with an exactness of imitation 
 which nothing short of careful and accurate diagnosis can distinguish from the real dis- 
 ease." In joint and spinal disease the truth of this is most frequently seen, Brodie 
 having stated " that among the higher classes of society at least four-fifths of the female 
 patients who are commonly supposed to labor under diseases of the joints labor under 
 hysteria." 
 
 Di.\GNOsis. — How, then, it may well be asked, is the hysterical affection to be made 
 out from the real ? How is the surgeon to avoid falling into the error of treating some 
 functional derangement as organic disease ? 
 
 In a general sense, it may with truth be laid down that in hysterical affection of a 
 part local pain and sensitiveness on manipulation are always great and bear no relation 
 to the amount of changes visible or to be detected in the part. The slightest touch 
 excites pain, which probably a bold one fails to do ; the pain, too, rarely, if ever, follows 
 the anatomical course of any nerve or nerves, and the onset of the symptoms is generally 
 more sudden and severe than that usually ushering in organic affections. Febrile dis- 
 turbance or increase of temperature, moreover, rarely complicates the case, however 
 severe the local symptoms may be, and the nervous "disturbance very rarely takes the 
 form in which morbid nervous influence produces, not mimic, but real, organic changes." 
 In fact, all the subjective symptoms are much more severe than the objective, the latter 
 being either very slightly marked or non-existing. For example, a girl is suddenly seized 
 with severe and lasting pain in the hip, knee, or other joint, aggravated by movement or 
 the slightest touch, and yet no visible alteration in its outline or structure can be detected, 
 even after the lapse of many months. Another is as suddenly affected with spinal affec- 
 tion, as indicated by local pain in the back, inability to stand, etc., without any local 
 evidence of organic disease. A third suddenly finds herself unable to flex or extend a 
 limb, and the slightest force excites severe muscular spasm and pain. A fourth is 
 attacked without a cause with some muscular spasm, possibly involving a finger or 
 fingers — a spasm that resists all attempts at extension. A fifth suddenly loses sensation 
 or the power of motion in some part of a limb, quite irrespective of nerve supply. In 
 these cases, again, however severe the pain may be during the day, it is rarely felt at 
 night. Such patients, as a rule, sleep well and quietly. During sleep, also, it often 
 happens that joints which are immovable by day are found to be more flexed or more 
 extended. Patients with supposed diseased spine are found on their sides coiled up in a 
 natural attitude. As an aid to diagnosis, the value of some anaesthetic cannot be too 
 highly praised, as with a patient under its influence rigid parts rapidly yield and rigidity 
 of muscle returns only with consciousness ; parts supposed to be paralyzed often move, 
 and suspected joint disease disappears by a close examination where previously doubt 
 existed. 
 
 Hysterical disease is more commonly met with in female than in male subjects, in the 
 single than in the married, in those whose nei'vous systems have been unstrung from 
 some mental or physical trial, or where the emotional centres are inadequately balanced 
 by the higher controlling ganglia. It is characterized by the suddenness of its attack 
 and the severity of all its subjective symptoms, neither the clinical history of the case 
 nor the objective symptoms present being consistent with those usually met with in 
 organic disease ; the exaggeration of certain symptoms and the absence of others, coupled 
 with the anomalies of its nature, mark the hysterical affection over the organic, and are 
 sufiicient to excite a doubt as to the true nature of the affection. 
 
 For valuable information on this subject, the reader may be referred to the lectures 
 of Brodie, Skey, and Paget, Russell Beynolds's essay on hysteria, and Anstie's lectures in 
 Lancet. 
 
.V/7.V.I ItlllHA. 
 
 229 
 
 CHAPTER VIT. 
 
 INJURIES AND DISKASKS Ol' TIIK Sl'TNi:, KTC. 
 
 Spina Bifida. 
 
 A SPINA i{iK(i>A is essentially a con<:ciiital licniia ofthe membranes of the cord through 
 an oponin;^: in the spine, due to deficiency, IVoiu arrest of development, of the neural 
 arches of some td" the hones formin<r th(i 
 
 spinal column. It is analogous to the 
 meningoceles of the craniiim, which have 
 It always con- 
 
 been already described 
 tains subarachnoid fluid, and often the 
 spinal cord itself or large nerve trunks. 
 Sir P. Hewctt believes that when the 
 fluid has collected in the subarachnoid 
 space or between the cord and the mem- 
 branes the cord is pressed, and that 
 when fluid alone is present the collection 
 is situated in the cavity of the arachnoid. 
 In the specimen figured (Fig. 8G), taken 
 from a dissection kindly made for me by 
 Dr. Pye-Smith, there was a funnel- 
 shaped opening leading from the tumor 
 into the persistent central canal of the Aradmoiu 
 cord, the nerves being spread out under 
 the internal lining of the sac, and thus 
 forming one of the layers of its wall. 
 
 Characters of the Tumor. — 
 
 The spinal hernia is sometimes covered 
 by the whole thickness of integument ; 
 at others the integument, though pres- 
 ent, is very thin ; while occasionally the 
 walls are represented only by a transpa- 
 rent membrane. This last condition was 
 present in ten out of twenty-seven qow- 
 
 Opening 
 
 into central 
 
 Canal r,f 
 
 Cord 
 
 Dissection of Spina Bifida. 
 
 secutive cases that have fallen under my care. The tumor may have a broad base and 
 free communication with the spinal canal, or a narrow and more or less pedunculated 
 one. Under the former circumstances, the probabilities of the cord being directly 
 involved are greater than under the latter. The tumor is always more or less globular, 
 ten.se. and elastic. When the child is asleep or quiet, the swelling may be soft ; but 
 when the child cries, the tumor will rapidly fill out. The edges of the bony orifice are 
 occasionally to be felt. The integument is in some instances ulcerated even at birth, 
 while in others there will be a small opening in the walls, through which the serous 
 spinal fluid exudes. 
 
 Associated with Hydrocephalus. — The tumor is often associated with hydro- 
 cephalus, and in exceptional instances is double (Fig. 87). A nsevus is not seldom found 
 situated over the tumor. Such complications as club-foot or paralysis of the lower limbs 
 frequently coexist with it, and under such circumstances it is tolerably certain that the 
 cord is included in the hernia : and possibly the nature of the deformitv may have been 
 determined by the special nerves which are involved. Paralytic symptoms are more com- 
 mon in the broad-based hernia than in the narrow. Incontinence of urine or of feces may 
 coexist with the paralysis or be independent of it. 
 
230 
 
 SPIXA BIFIDA. 
 
 Fig. 87. 
 
 r 
 
 The lumbo-sacral portion of the euluinn is more frequently affected than any other, 
 but the cervical and dorsal portions are also liable to the defect. Thus, in twenty-seven 
 examples which came consecutively under my care, thirteen occurred 
 in the lumbar region, four in the lumbro-sacral, and nine in the sacral. 
 One was double, a small tumor being in the lumbar and a large one 
 in the sacral region (Fig. 87). Twelve of these cases were uncom- 
 plicated with any paraly.sis or deformity. In eleven there was incon- 
 tinence of urine and feces, associated in four with paralysis of the 
 lower extremities. Four were complicated with hydrocephalus, two 
 with na^vus, and one with talipes. I have seen but two examples 
 in which the tumor was in the cervical region. AVhen the tumor 
 is complicated with hydrocephalus, fluctuation may often be felt 
 between the two parts, pres.sure on the head causing a fulness of 
 the spinal hernia, and vie versa. In exceptional cases the spinal 
 i i -|. hernia may protrude on the anterior part of the spine, 
 t - f'' i Diagnosis. — In a general way. there is no difficulty in diagnosing 
 
 ' a spina bifida. In anv infant a congenital tumor over the spine is 
 
 Double Spina Bifida, probably a spina bifida : if globular and tense or capable of becom- 
 3^momh*'f*^ '^^ ^"? tense when the child cries, the probabilities are almost converted 
 into a certainty, inasmuch as the only cases for which this affection 
 is liable to be mistaken are congenital tumors unconnected with the spine — cystic, fibrous, 
 fatty, or foetal tumors. These may be hard and tense, but they are rarely, if ever, made 
 so much more tense from the child crying, as is the spinal hernia. 
 
 Prognosis. — The majority of these cases prove fatal. Many of the subjects are 
 ill-developed and die within a few days of birth ; death from convulsions is verj- usual 
 when the sac bursts and its fluid contents escape, more particularly when the escape is 
 rapid. The rupture of the sac is not, however, necessarily followed by this result. I 
 have watched a child with this affection for four years, in which at birth the tumor was 
 transparent and soon burst, and subsequently discharged at intervals for three years ; it 
 has now gradually contracted up into a solid mass. This case is an example of a natural 
 cure, which takes place by the gradual approximation of the bony walls and closure of 
 the orifice of the hernial sac. The more pedunculated the tumor, the better the progno- 
 sis, so long as no complication exists that threatens life. 
 
 Treatment. — Palliative treatment is all that can be adopted in the majority, although 
 in exceptional instances operative interference promises to be of service. The tumor must 
 alwavs be guarded from injury by some soft protective material, such as cotton-wool or 
 spongio-piline. Slight pressure sufficient to prevent rapid increase of the tumor is also 
 beneficial, and the best method of applying it is by a casing of gutta-percha or felt 
 moulded to the part. The application of collodion is sometimes useful. 
 
 Successful cases are recorded in which tapping of the hernia has been performed. 
 
 The practice, however, is dangerous, as the drawing ofl^ 
 
 of the fluid has been followed by convulsions, and even 
 
 death. Xevertheless, it is the least formidable form of 
 
 ■^ practice that can be undertaken, and should always be 
 
 "^1 employed before more active treatment is resorted to, if 
 
 / only as a preliminary measure. The puncture should 
 
 / always be made at the side of the tumor, for the cord 
 
 / when present is probably placed in the median line. The 
 
 whole of the fluid should never be drawn ofi" at once. 
 
 ' Fig. 88 represents a case cured by puncture. It oc- 
 
 \ eurred in the person of a man aet. 20. who came under my 
 
 \ care at Guy"s Hospital in 1874 for some ulceration of his 
 
 I left foot, which, with the left lower extremity, was wasted 
 
 i from infantile paralysis. He had also a lateral curva- 
 
 t ture of the spine toward the right side and a cured 
 
 spina bifida in the lumbar region. I discovered from the 
 
 patient that he had been treated for the spina bifida by 
 
 Mr. AV. E. Image of Bury St. Edmund's, who. in answer 
 
 to a note, kindly sent me the following account of the 
 
 case : 
 
 " The child was brought to me when about two years 
 old because the tumor was increasing in size, and convulsions were produced whenever 
 
 Fig. 88. 
 
 >'^t3fe 
 
 ^ 
 
 Cured Spina Bifida. (Taken from a man 
 set. 26.) 
 
SACRAL AM) cnrCYGKAL TUMORS. 231 
 
 any jirt'ssurt' was ii|)])lii>il lu tin- tiiinnr. ev«Mi from tlie woi^'ht of the Ixxly when i*iaced 
 ill the supiiH' |)(tsitiiiii. The tiiiiinr was lar;.'e ainl si'iui-traiisparetit. 1 punctured it 
 i)lili([uelv with a tiarninir-iK'iMlh' at intervals of two or three days, four or six tinn-s. and 
 applied a compress of lint liy means of strajipini: over the tumor. After this the fluid 
 was not airain seereted. the eonvulsions eeased. and the ease pit well." At the i»resent 
 time a hard pucken-d tumor alone «'xi>ts to indicate tiie atfeetion. \ model of the ea.se 
 may now he found in (Juy's .^Iu.se^lm. 
 
 Dr. James .^Il(rton of (llasirow has advocateil the injection at intervals of .seven or ten 
 days of half a drachm of a solution made hy di.^solving ten irrains of iodine and thirty 
 i jrrains of iodide of potassium in an ounce of trlyeerine. The injection should he thrown 
 into the sac after tl»e withdrawal of some small ])ortion of the spinal fluid. Dr. Morton 
 reports ( (iliKi/inr Mol. Jouni.. May. ISSl) that out of twenty-nine cases operated upon 
 there were hut si.x failures. Tiiis success is enei.urai^injr. The operation, however, has 
 its daiiLTers. In a ease of my own. after the .second tapjiinir. there was .so much draining 
 of the fluid from the cord that the child died from exhaustion. After death there were 
 no signs of inflammation of the memhranes. 
 
 Tn no ease where the ha.se or neck of the tumor is lar<;e. injr in others in which it is 
 evident the cord is implicated or larire nerve trunks are involved, .should this or any other 
 operation he |)erformed. In pedunculated tumors it may be attemjited. 
 
 With respect to the pxrisiuu of the tumor, a succes.sful case has been recorded in the 
 Filth. Soc. TniD.s., vol. xiv., in which Dr. Wilson of Clay Cross removed the tumor five 
 days after the closure of its neck by means of a clamp: and when excision is entertained, 
 this plan is probably the soundest. It should, however, only be thought of when the 
 nock of the tumor is narrow and there is no paralysis of the lower limbs or incontinence 
 of feces or urine. In all broad-based tumors associated with paralysis operative measures 
 are out of the question. 
 
 Exceptional cases of recovery are on record after every form of practice, but. on the 
 whole, the results of treatment are not very encouraging. 
 
 Sacral and Coccygeal Tumors. 
 
 Congenital tumors are by no means unfrequent in the neighborhood of the coccyx or 
 sacrum. They are sometimes composed of cysts, occasionally of fat or fibre tissue, and 
 also of fuetal remains. They are generally central. Many of these have doubtless been 
 described as false spina bifida, and in rare examples there is reason to believe they are 
 cured cases of spina bifida, the sac of the hernia having been occluded at its neck by the 
 natural contraction of the surrounding parts. I have seen one such ca.se in an adult 
 where the tumor was successfully excised. Mr. Pollock has recorded in the eighth vol- 
 ume of the J\i'/t. J/-a//.s. an example of a congenital fatty tumor which he successfully 
 removed from the central lumbar i-egion of a child jet. 7, and Mr. Athol Johnson, in the 
 same volume, a rare ca.se of fatty tumor clearh' developed in the spinal canal itself. I 
 have had occasion to remove a large congenital sebaceous cy.st placed between the anus 
 and coccyx from a child xt. 10, and from another child a tumor containing ftetal 
 remains, situated between the sacrum and the bowel. I may further refer to a third 
 interesting case of cystic tumor of the sacrum, possibly spina bifida, in which the cyst 
 burst and complete recovery followed. The following are the brief notes of the two 
 latter cases. 
 
 Marie B , ret. seven weeks, was brought to me in 1SG8 with a congenital tumor 
 
 the size of a large orange projecting from between the bowel and coccyx and apparently 
 passing up in front of the bone fFig. JsO). It had been growing rapidly .since birth and 
 was pressing upon the bowel, though the child in all other resjiects was healthy. I 
 excised the growth and found that microscopically it was made up of fat. fibro-cellular 
 tissue, mucous membrane, cartilage, and bone elements. Recovery ensued, and the child 
 has kept well. 
 
 A male child two days old was brought to me on July 30, 18G8, with a large cystic 
 tumor covering in the lower half of the sacrum and occupying the perina?uni. It was 
 the size of a cocoanut and transparent as a spina bifida, yet in all other respects the child 
 was wellformed. The next day it burst and many ounces of a blood-stained fluid escaped. 
 The .sac collapsed, but no evil result followed this bursting of the cyst. I watched the 
 child for many months, and on November 80. 1871. the tumor had contracted up to an 
 irreizular indurated mass of integument. The child was very healthy. 
 
 Treat.ment. — The only effective treatment is the excision of the growth, which 
 
232 INJURIES OF THE SPINE, CONCUSSION, ETC. 
 
 should be done unless symptoms exist, such as extensive or dangerous connections of 
 the tumor, to contraindicate the practice. Special care should be taken to ascertain that 
 
 no communication exists between the tu- 
 FiG. 89. Fig. 90. mor and the spinal canal. 
 
 1^ ^ ^j Fig, 00 represents a most interesting 
 
 case, the particulars of which were kindly 
 forwarded to me by Dr. Mercer Adams 
 of Boston, Lincolnshire, who operated. 
 The tumor was successfully removed 
 from a female cliild get. 10, and meas- 
 ured 22 inches in circumference ; it wa.s 
 composed of cysts, and the largest, which 
 was central, was lined with true skin cov- 
 ered with long silky hair.s. This cyst con- 
 tained thick putty-like material. From 
 one of its walls grew an improperly de- 
 veloped foetal leg and foot having three 
 Congenital Coccygeal Tumors. toes with perfect nails. There were also 
 
 several curiously shaped foetal bones scat- 
 tered through the tumor — one like two coalesced ribs, and another a parietal bone. The 
 tumor had deep pelvic attachments, and had to be dissected from the rectum. The lower 
 part of the sacrum merged on the tumor. 
 
 Hewett, Med. Gnz., vol. xxxiv. — Behrend, Jourii. f. Kinderkrankheilen, vol. xxxi. — Xelaton, 
 Path. Chir., vol. ii. — Holmes, Snrrjical Treatment of Children's Disease.", 1869. 
 
 INJURIES OF THE SPINE, CONCUSSION, ETC. 
 
 The spine is a flexible tubular column composed of ring bones alternating with a 
 dense elastic intervertebral substance. These bones articulate by means of joints, and 
 are bound together by strong yet elastic ligaments. From the upper orifice of the tube 
 the spinal cord with its membranes is suspended in a chamber filled with cerebro-spinal 
 fluid and surrounded by large venous plexuses. The coi'd terminates opposite the second 
 lumbar vertebra, but the membranes are continued down to the second piece of the sacrum. 
 It is suspended in position by the nerve trunks that pass with the processes of dura 
 mater that accompany them outward between the bones. 
 
 A local injury to the spine, such as a forcible bend forward, may sprain or lace- 
 rate the ligaments that hold the bones in position. A still more forcible bend may 
 crush the bodies of the vertebrae that form the anterior portion of each ring. If the 
 force be still continued upon the broken bones, displacement may take place, when the 
 delicate cord itself will either be slightly pinched between the displaced bones and con- 
 tused or completely crushed or divided. In the cervical and lumbar regions — not in the 
 dorsal — the bones may be dislocated, the amount of injury to the cord depending 
 entirely upon the amount of displacement that has taken place. When such displace- 
 ment is very slight, the cord may be uninjured. Sprains of the back may also at a later 
 period be followed by disease both of the joints and bones of the spine. 
 
 A diffused injury to the spine, such as that caused by a fall from a height 
 upon the back or by a heavy falling body, may produce some fracture or dislocation of 
 the bones of the spine, but it must to a certainty likewise cause a severe shaking, as 
 from a railway accident, or a concussion of the spinal cord itself, as manifested by a 
 more or less complete suspension of all the functions of the cord, either for a short 
 period or for life. This concussion or shaking of the spine may be accompanied by 
 hemorrhage into or upon the cord, giving rise to compression, or may be followed by 
 acute or chronic intraspinal inflanmiation. terminating in paralysis and death. 
 
 In both local and d'lffnaed injuiiea of tlie .yjuie the (jrarity of the cat^e dependn chlcfli/ 
 upon the amount of injury the cord hai< sKsfa^'ned ; a severe local injury to the osseous 
 part of the spine can be completely repaired without danger to life, whilst any injury to 
 the cord and its membranes is fraught with danger, either directly by suddenly arresting 
 the functions of the parts to which the injured nerves are distributed, or indirectly by 
 setting up chronic inflammatory changes in the cord. 
 
 Concussion of Spine. — When the functions of the cord have been directly sus- 
 pended by any local or diffused injury to the spine, the patient is said to have suff"ered 
 from concussion of the spine. Should the symptoms be complete and persistent, there is 
 
i\.iii:ii:s or Tin-: sr/XK coscussios, etc 233 
 
 fjdod rcasdii tu liclicvc tliat tlic ciinl l)a> Ittcii (•ni>Iic(l Ky .'»<>iin' (lis|»lacciii('iit of a f'rac- 
 turril or dislocated Imiic. Should soiiu' interval of tiiiu- have taken plaee hctweeri the 
 roeeipt of the aeeideiit and the )»aralysis. there is a lair suspicion that the paralysis is 
 th<' result of some heinorrhatrc into or around the cord. Should the paralytic symptoms 
 have i'ollowi'd the accident after a few days and he attende(l with constitutional disturh- 
 aiice (U" spasm of the muscles of the limhs, the cause of the paralysis was prohahly some 
 inflammation of the cord and its memhranes ; and should the paralysis liuve been of a 
 slow and |»roirressive nature, the jirohahilities are that it is the consequence of some 
 chronic softening of the cord, because all those different results have followed local and 
 difiused injuries to the spine. Moreover, it is the knowledge that they may take place 
 which renders any spinal injury a matter of importance, both as regards the immediate 
 effects of the injury and its secondary eonsef|uences. I am bound, however, to add that 
 Mr. I'age in his recent interesting book on spinal injuries "doubts whether any jiassing 
 paralysis following a severe l»low on the vertebral column is not m<tst likely to be due to 
 the pressure of extravasatcd blood, which in course of time bec(tmes ab.sorbed, " for he 
 states that '• we know of no case, nor can we discover the history of any, where a tran- 
 sient parajdegia or a suspension of the functions of the cord has followed a lilow or fall 
 upon the spine. 
 
 In rare instances symptoms similar to tetanus follow spinal injury. T have seen such 
 in two cases. One was that of a man ?et. 85. who fell from a height on liis head, bend- 
 ing the neck forward. He was paralyzed for a few hours from the neck downward, and 
 on the appearance of reaction had marked tetanic symptoms with the contracted brow 
 and risus sardonicus. Spasms could be excited on the slightest touch being applied to 
 his neck. In twelve hours, however, all these symptoms disappeared, and recovery 
 ensued. 
 
 In the second case a man received a crush in the loins between two carts. Lock-jaw 
 followed, with general spasms of all the muscles of the body. In five hours the spasms 
 subsided, but they were followed for five days by hyperiv?sthesia of the integument, and 
 on the sixth day by weakness of one leg. In a month he was convalescent. 
 
 Analogy between Spinal and Cerebral Injuries. — In former chapters it 
 
 was shown that the functinns of the brain may for a time be interfered with or sus- 
 pended by a simple shake or concussion of its substance : that a severe concussion may 
 give rise to contusion of the brain, either at the seat of injury or on the opposite side by 
 contre-coup ; that extravasation of blood either upon the surface of the brain or within 
 its structure may follow such an injury : that fractures of the skull are of importance 
 in proportion to the severity of the intracranial complications; and that intracephalic 
 inflammation is too frequently the result of any head injury. In injuries to the spinal 
 column and its contents similar results have to be recorded. A simple coiicusst'oii or shak- 
 ing of the spine may produce a partial or complete suspension of the functions of the 
 cord, yet by rest and quiet these symptoms may disappear and a perfect recovery follow. 
 A wo/r xpi-ere shaking may give rise to some injury of the nervous structure, to some 
 extravasation of blood upon or into the cord itself. Such a complication will necessarily 
 be associated with more marked symptoms, more complete and per.si.stent paralysis and 
 anaesthesia of that portion of the body supplied with nerves from the injured centre, the 
 completeness and persistency of the paralysis and anaesthesia depending upon the .severity 
 of the mischief and on the seat of injury. When the paralysis is severe, but incomplete, 
 there will be retention of urine, this symptom arising from loss of voluntary power over 
 the mu.scles that regulate luicturition. But when the paralysis and ansesthesia are com- 
 plete, there will be absolute paralysis of the bladder and all its muscles, with incontinence 
 of urine. This incontinence, however, must not be confused with the dribbling of an 
 overdistended viscus from retention, the incontinence of retention of Gross, such as 
 occasionally occurs in the less severe cases. 
 
 When the injury is in the cervical region, one or both arms may be more or less 
 paralyzed; when in the lower dorsal, one or both legs; but. as a rule, the paraly.sis is 
 symmetrical and the symptoms depend on the nerves that are involved. The loss of sensa- 
 tion is also generally complete. In one case, however, there may be paralysis of one 
 limb and loss of sensation of the other; in a second, exalted sensibility with paralysis. 
 In one the power of motion may be regained, while that of .sensation remains lost, and 
 in another the reverse ; indeed, on these points there is every possible variety, the seat 
 of injiirv clearly determining the nature of the paralysis. 
 
 Brown-Sequard's observations and experiments on the decussation of the motor and 
 sensory fibres of the cord have done much toward the elucidation of these points, and it 
 
234 INTRASPINAL INFLAMMATION, ETC. 
 
 may now with some confidence be asserted that when one antero-lateral column of the 
 cord is divided or irreparably injured there must be motor paralysis of the same side of 
 the body below the seat of injury and loss of sensation upon the opposite side of the 
 body, the motor paralysis being due to the destruction of the white substance and the 
 loss of sensation to that of the gray. 
 
 When any portion of the white substance is left intact, some motion will remain ; and 
 when any part of the gray is uninjured, some sensation. Complete division of the cord 
 is necessarily followed by complete paralysis and loss of sensation in the parts below, 
 although, by what is called reflex action, the muscles of the parts may be made to con- 
 tract on the application of any stimulant, such as tickling, to the sensory nerves. 
 
 Pain in the course of a sensory nerve or in an extremity is to be taken as represent- 
 ing the irritation of the cord or nerve at its central origin, and in cases of fracture as the 
 spot where the bone has been broken. Symmetrical pains mean central mischief; uni- 
 lateral pains, local. 
 
 ■ A severe blow upon the upper cervical region may produce, according to Erichsen, 
 instantaneous death from concussion When the va(jHs nerve is affected, a .sense of suffo- 
 cation, with irregular action of the heart or constant vomiting, may be produced. When 
 the spiji((l accessor// is injured, spasm of the trapezius or sterno-mastoid muscles occurs ; 
 and irritation of the phrenic nerve causes hiccup, as well as the sensation of an iron-band- 
 like constriction round the bod}'. When the injury is in the lumbar region, the paralysis 
 is always partial, as the cord terminates at the second lumbar vertebra. 
 
 The temperature of the paralyzed limb is always lower than the rest of the body, even 
 when to the patient it may feel hot or burning. 
 
 The PROGNOSIS in any case of concussion of the spine depends entirely upon the 
 changes that are produced in the cord by the injury, and the.se are fairly to be measured 
 by the severity of the symptoms and i\\e\Y persistency. This latter guide is very reliable, 
 the persistency of symptoms being generally indicative of organic change. Again, when 
 organic change has taken place, there is the greater probability of some secondary inflam- 
 matory action in the injured part, and on this the prospects of the case hinge ; for in 
 injuries to the spinal cord or membranes, as in injuries to the brain, this intracephalic or 
 intraspinal, inflammation is the cause of danger or of death in every case that survives 
 the immediate effects of the accident, while it leaves, even when life is spared, more or 
 less complete paralysis of the parts below the seat of injury. 
 
 INTRASPINAL INFLAMMATION.— SPINAL PARALYSIS AFTER 
 CONCUSSION.— RAILWAY CONCUSSION. 
 
 Intraspinal Inflammation. — " Every injury of the spine should be considered 
 as deserving of minute attention. Inflammation of the cord and its membranes may 
 supervene upon very slight injuries of the spine ; it may advance in a very insidious 
 manner even after injuries that were of so slight a kind that the}- attracted at the time 
 little or no attention." Thus wrote Abererombie in 1829, and his observations are as true 
 now as they were then ; indeed, it is upon such views that the whole treatment of injuries 
 to the spine, simple or severe, ought always to be based. 
 
 The preventive treatment of spinal as of head injuries means the adoption of such 
 measures as experience has proved are most valuable in warding off the acces.sion of 
 intraspinal and inti'acephalic inflammation and thus preventing paralysis. The simplest 
 shock or concussion of the spinal cord, the slightest blow upon the spine or sprain of its 
 ligaments, any bruising of the former or laceration of the latter, and, a fortiori, any 
 severer lesion, is apt to be followed by an acute or chronic intraspinal inflammation, and 
 by changes in the structure of the cord that may give rise to a paralysis, partial or com- 
 plete. The surgeon has, moreover, no guide by which to measure the danger or calculate 
 the probabilities of the occurrence of this secondary inflammation, since it may follow a 
 slight accident and fail to follow a severe one ; at the same time, the prospects of its 
 appearence and its danger depend much upon the gravity of the injury. 
 
 When the cord has been much contused or crushed by a fractured or dislocated ver- 
 tebra, the paralysis that necessarily follows such a lesion is not likely to be aggravated by 
 any secondary inflammatory changes in the injured cord, although the termination of the 
 case may be hastened by these changes. Under such circumstances, the complication is 
 not of such a nature as to add to the surgeon's anxiety. In less severe examples of 
 injury, however, in which the primary symptoms do not indicate any organic lesion beyond 
 that which manifests its presence by some temporary suspension of the functions of the 
 
/.V77M.S7'/.V.I/, ISri.AMMATIOS, KT(\ 2.35 
 
 curd, it Iti'CKint's a iiiattcr ul' primary iiiipurtaiice ti> rcco^nizi,' \\ut very oarliost iiidicution 
 of iiitlaiimiatiiiy artimi, in unli-r that it may \n' arn'strd ; f'ljr. as it lias been shown tliat 
 tin.' cliifi' aim in tin* trcalnu-nt ot" all tlu'si- injuries is to prevcMit the occurrL-not' of inflam- 
 mation, sti the si'cund is t(i try and arrest its inoj^ress as soon as it has a|i|ieaied. When 
 it has liecome thoronirhly estahlished, neither medical nor siir<;ieal art has much power in 
 eheekini; its projrress or in correetini:' its etteets, as the delicate structure of the spinal 
 cord ap])ears to ho incapahle of underjroin;; material repair when softcMied hy disease or 
 crushed Itv accident. The cord structure, whi-n once destrtjyed, is replaced hy means of 
 a fihrous suhslance. I'aralysis or loss of function, under these circumstances, is jM-rma- 
 neiit. [n any case, therefore, of spinal injury, when the symptoms are persistent or tend 
 to hevome worst', when after their partial or complete disajjpearance for three or four or 
 more days they recur or appear in s(>me altered form, when local pain is increased and 
 inovemont of the hack is more difficult or distressing, when pain follows tlie course of 
 the nerve trunks that emanate from the injured spinal centre and muscular spasm or 
 paralysis is ])resent, and, moreover, when constitutional disturbance or general fehrility is 
 present. — whtu any or all of these symj)toms, few or many, are found to follow a spinal 
 injury after the first effects of the accident have passed away, the diagnosis of secondary 
 inflammation of the cord may fairly be made and action taken upon it. 
 
 In ii' ni'iiil r(iiicKssit)iis of the ^piuid cord, more particularl}' from railway accidents, 
 when, owing to some general shaking of the body, the spinal, cerebral, sympathetic, and 
 circulatory systems are all more or less involved, there is an undoubted disposition for a 
 chronic inflammatory change of a most insidious and creeping kind to supervene. In 
 some eases, however, the change is rapid, as in the case of a matj get. 46 who was admit- 
 ted into Cruys with complete paralysis and loss of sensation of his body below the first 
 rib, the result of a fall down twelve stairs the day previously. The day following his 
 admission some slight feeling returned in his body, and a few days later he could move 
 his legs. The paralysis, however, never left him, and he died on the thirty-eighth day, 
 of lung di.sease. After death the spine was found uninjured, but the spinal cord opposite 
 the sixth dorsal vertebra was soft and diffluent and contained granules. There was no 
 trace of eftused blood. 
 
 It is now well known that the primary sjiinal symptoms are often so mixed up with 
 the general as to be masked, and, beyond a general but temporary loss of power and con- 
 sciousness, there is often nothing special by which spinal mischief is manifested. On 
 recovering from the shock of the accident and the mental disturbance the sufferer often 
 feels no definite injury, no special local symptoms, and it may be that it is not till after 
 some time has elapsed — the duration of which is also uncertain — that any special symp- 
 toms make their appearance. 
 
 It will then probably be found that the patient has never been himself since the acci- 
 dent ; he has been unable to work, mentally or physically, with the same force or energy 
 that he did previously, is irritable in his manner, and perhaps feeble in his powers. Sleep- 
 lessness, too, has been more complete or common than it was before, and headache with 
 general malaise now often exists. 
 
 Premonitory Symptoms. — Some slight unsteadiness of gait is often the first 
 observed symjitoni. a feeling of heaviness in the limbs, some abnormal sensation, such as 
 that of pins or needles, numbness along the course of a nerve, cramps, perhaps retention 
 of urine, or some evidence, in fact, of want of control or power over the muscular appa- 
 ratus, and more marked generally in the lower extremities than in the upper. The cen- 
 tres of sensation may. at the same time, show indications of disturbance, either by a .state 
 of lessened sensibility or perhaps by a hypenvsthetic condition. From sj'mptoms such 
 as the.se the attention of the surgeon is probably arrested. On testing the muscular 
 apparatus thoroughly it will probably be found that the patient will be unable to stand 
 steadily on one leg, or, what is a better test, if he place his heels together, he will totter 
 on making the attempt to raise his body on his toes. When asked to stoop to pick up 
 anything from the ground, he will probably bend his knees rather than his back and walk 
 with a rigid spine. On giving him a small object, such as a pin. he will take it clumsily 
 and with tremor — will fumble at most things with his hands and stumble at anything 
 that is in his way. 
 
 On examining the spine some tenderness may be manifested on firm pressure, but 
 probably only in certain places. Percussion on the bones is hardly a fair test ; when 
 employed, it should be indirect, through the fingers. Pressure applied to the spine 
 causes at times severe pain, as does any movement; it is the latter condition which 
 induces the rigidity of the spine in walking, before alluded to. 
 
236 INTRASPINAL INFLAMMATION, ETC. 
 
 The brain and organs of special sense may likewise be aifected, either by over- or 
 under-sensibility. Vixion may be imperfect either in one or both eyes ; luuriiui may he 
 over-sensitive or defective ; taste and touch may be perverted or lost and Rmdl at times 
 destroyed or morbid. In fact, the whole nervous system, cerebral and spinal, may be 
 disturbed and its functions more or less damaged. 
 
 The course which such cases run is very uncertain, and the prognosis is therefore 
 difficult. When the motor-power has been lost from spinal mischief, the best test is gal- 
 vanism. A healthy muscle supplied from a healthy nerve centre will always contract on 
 the application of the galvanic current. When the nerve centre is so diseased as to cause 
 paralysis, the galvanic current produces no movement — no contraction. This test is 
 beyond the patient's control and cannot be resisted; it is consequently valuable. 
 
 Caution in Interpreting Symptoms. — In interpreting these symptoms, more 
 particularly in a railway case, or in any where the question of damages is involved, it is 
 most important for the surgeon to separate the symptoms of which the patient complains, 
 the suhjWfive. from those he can himself perceive, the objective. Let him doubt and cross- 
 examine in every way upon each of the former to test their accuracy. He may rely, 
 however, upon the latter, and any positive opinion ought to be based upon these alone. 
 There always hangs a suspicion over the former because self-interest points to making 
 the worst of them. 
 
 All the symptoms, taken as a whole, undoubtedly indicate a chronic or subacute 
 inflammatory change of nerve tissue, an inflammation of the membranes or of the cord. 
 When they appear as a consequence of a general concussion of the spine, the cord is 
 probably the seat of mischief, its delicate structure being more liable to injury than the 
 tougher membranes, and, consequently, to secondary changes. When they follow some 
 local injury, such as a twist, blow, or forcible bending of the back with laceration of liga- 
 nients, the disease in the cord probably is secondary to disease in the membranes, the 
 inflammation of the latter being due to the extension of inflammatory action from the 
 injured part inward. '• Inflammation of the membranes of the cord, as of the brain, is a 
 disease not idiopathic, but proceeding from some cause without." But whenever this 
 commences it is progressive, and in the end involves all the tissues in its destructive 
 changes. 
 
 Pathological Changes. — The pathological changes themselves are tolerably defi- 
 nite. In the cord they put on the appearance of red softening in recent disease, and of 
 white in chronic. The parts are .soft and pulpy, the microscope showing them to contain 
 granule corpuscles and elements of the inflammatory process. The wlnte matter of the 
 cord will appear at times sound, while the gray substance is soft. The disease may be 
 local or more general. In concussion the latter is the more common condition. When it 
 is in the cervical region, death is rapid ; when in the lower dorsal, life may be prolonged 
 for some time. This fact is well illustrated in fracture and dislocation of the spine. 
 
 Treatment. — In all cases of concussion of the spinal cord, simple or severe, absolute 
 rest m the horizontal posture is most essential, and in mild cases this is probably the only 
 treatment called for ; the symptoms, by the observance of this rule, gradually disappear, 
 and the health is restored. The prone position in more severe cases is generally to be 
 preferred to the supine, but the best guide in this matter is the ease which the patient 
 experiences. The surgeon, however, must enforce quiet for many days after the disap- 
 pearance of all symptoms, even in the mildest cases, on account of the primary danger 
 of intraspinal inflammation, and the period of rest to be enforced must be in proportion 
 to the severity of the .symptoms. In cases of railway concussion this practice is of 
 primary importance, and I am disposed to attribute the frequent occurrence of obscure 
 railway spinal cases to the non-observance of this rule. It is true that in the majority 
 of cases there are no definite indications of spinal injury after the accident, though the 
 nature of the accident itself is a sufficient guide to the case. A general shaking of the 
 body means a general concussion of the spinal cord with every other part, and the 
 nerve centres, by reason of their structure, are most liable to injury. It would be well, 
 therefore, to keep all patients who have been the subjects of such injuries quiet and in 
 repose for several weeks after the accident. By doing this much mischief would often be 
 avoided. 
 
 After concussion, when severe local pain is experienced, relief is often given by the 
 application of a dry cupping-glass on either side of the painful part, and the operation 
 may be repeated. In exceptional cases the local extraction of blood may be found of 
 benefit. The application of cold is a powerful remedy for good when there is much eflFu- 
 sion of blood or pain in the part, and when the symptoms of reaction are too marked. 
 
FiiAcrrinis am> hisi.ocArioys or riir. sriM-:. 2:i7 
 
 The ilift >liuiilil III- iiiitrilii)iis, Imt iiiist iiiuilat iri<;, and iiijtliiii<r likdy to ki;c|i up or 
 caiisi' iiu'iital ur |>liysi<al cxcittfiiieiit alli)\vt'il. WIk-ii recovery of* power in the linihs is 
 slow anil no syniptoius ol" secondary inflammation of tin; coni exist, convalescence is pro- 
 moted Ity the application of electricity in one or other oi" its forms to the enfeebled 
 muscles. 
 
 When svniptonis of intraspinal inflammation have appeared, some advocate moxas or 
 setons in addition to the ahove treatment ; and <d' the two the moxa is, perhaps, prcfer- 
 al)le. Mercury in one of its forms appears to he a valuable remedy, and the perchhjride 
 is perhajts the best ])reparation, jriven in doses of one-sixteenth ol' a j.'rain two (jr three 
 times a day combined with bark, (|uininc, or s(»me other vejretable bitter accordinj^ to the 
 wants of the patient. When mercury is inapplicable, the iodide of potassium should be 
 substituted. Sedatives should be allowc(l. to procure sleep, and the hytlrate of eldoral 
 .seems to be the best, in twenty- or tliirty-!j.rain doses, at bedtime. ShoiiM pain be con- 
 stant, fifteen ,<;rains of the same dni;^ may be given twice a day. a double dose being 
 allowed at night. The extract of belladonna in one-third of a grain or half-grain doses 
 is likewise a valuable sedative. Strychnine is a dangerous drug in sj)inal disease — at 
 least, in progressive spinal disease. It is a distinct stimulant to the spinal centres, and i.s 
 conset|uently most injurious as long as any progressive inflammatory action exists. When 
 only the eflects of the disea.se remain and all inflammation has cea.sed, strychnine may be 
 given. Should general feebleness exist, iron may be given with it ; amJ 1 know of no 
 nervine tonic so beneficial as the combination of the tincture of the perchloride of iron 
 in doses of fifteen minims with five minims of the tincture of nux vomica or one or two 
 grains of (juinine. Cod-liver oil is a valuable adjunct to all treatment in this as in many 
 other cases. 
 
 Great care should be observed throughout the treatment of these affections to prevent 
 the occurrence of bedsores. They form very rapidly when spinal paralysis is present. I 
 have seen .several instances in which all the soft parts over the bones sloughed and the 
 spinal canal was opened, while in others the .sacral bone may partially exfoliate. The 
 back should be kept very clean and dry and occasionally sponged with spirit lotion or 
 spirits of camphor. It should also be protected further by leather strapping, felt plaster, 
 and by cushions of air or water. 
 
 When retention of urine complicates the case, the utmost caution is required in pass- 
 ing the catheter. An elastic instrument should be preferred and of a large size, the 
 French vulcanite catheter being the best. The catheter .should be kept scrupulously clean. 
 
 FRACTURES AND DISLOCATIONS OF THE SPINE.— WOUNDS 
 
 AND SPRAINS. 
 
 In a practical point of view, it is expedient to consider fractures and di.slocations of 
 the spine together. They are not, however, invariably combined, for, although in four- 
 fifths of the injuries to the spinal column involving the bones some fracture is present, in 
 the remaining fifth .simple dislocation exists. The majority of these cases of pure dislo- 
 cation occur in the cervical region ; in the dorsal such an accident is almost impossible, 
 while in the lumbar it is very rare. The difference in the anatomical arrangement of 
 these divisions of the column affords an explanation of these facts. To the practical sur- 
 geon these points are, however, of small importance ; that which concerns him the most 
 in any injury to the spine has reference to the cord : How much injury has it sustained? 
 Is it reparable or not? 
 
 When complete paralysis follows the injury, there is little douljt that the cord has 
 been injured. It may be that it has been more or le.ss completely crushed, or even divided 
 by displaced bone. In less severe injuries, le.ss severe symptoms show themselves. The 
 nearer the injury is to the respiratory centre, the greater the danger: thus injuries of 
 the cervical are more dangerous than those of the dorsal region, and the.se again than 
 those of the lumbi r. Any crushing of the cord above the third cervical vertebra is, as 
 a rule, followed by instant death, this point being above the origin of the chief respiratory 
 nerve, the phrenic. In cases of injury to the cervical vertebra giving ri.se to any .symp- 
 toms of paralysis death generally takes place within three days, and commonly within 
 two. Thus, out of thirty-six fatal cases extracted for me by Mr. Rendle from the Guy's 
 records, twenty-five died in less than seventy-two hours and twenty in less than forty- 
 eight ; eight only survived the former period, and in those there were no symptoms of 
 paralysis as an immediate result of the accident. Eleven of the thirty-six were cases of 
 pure dislocation, twenty-five were examples of fracture and dislocation combined, and all 
 
238 
 
 FRACTURES AND DISLOCATIONS OF THE SPINE. 
 
 were below the third cervical vertebra. In every case, also, of dislocation the upper ver- 
 tebra was thrown forward upon the lower, as seen in Fig. 91. The reverse holds good 
 
 Fig. 91. 
 
 Fig. 93. 
 
 Dislocation of the Spine 
 Forward. ((iuy's 
 
 Hosp. Mus., No. 103:5.) 
 
 Fracture of Spine and I'isplace- 
 ruent of Upper Vertebra Far- 
 iviird. (Ciuy s Hosp. Mus., No. 
 10a.5-'5.) 
 
 Fracture of Spine and Displace- 
 ment of Upper Vertebra Back- 
 wiirn. A fifth, B sixth, vertebra. 
 
 only in exceptional cases, as in the one illustrated by Fig. 93, in Avhich a man set. 20 
 struck his head against the bottom of a bath when jumping for a dive a height of twelve 
 feet. The drawing shows a displacement of the fifth cervical vertebra hack ward, with a 
 fracture of the fourth and fifth and crushed cord. The man lived seventeen months. 
 
 Fractures of the dorsal and lumbar vertebrae associated with displacement and giving 
 rise to paralysis below the seat of injury are less speedily fatal than those of the cervical 
 region. 
 
 Fracture of the spine may, however, take place and not be associated with any 
 paralysis. The spinous processes of any of the vertebrae may be fractured and no spinal 
 symptoms follow. This accident is generally the result of a direct blow. When I was a 
 dresser, I saw a case of fracture of the spinous processes of three cervical vertebrae asso- 
 ciated with a temporary paralysis, and in this instance complete recovery en.s«ed. I have 
 since treated successfully a case of fracture and displacement of the spinous process of 
 the fourth cervical vertebra without paralysis. 
 
 In other cases fracture of the spine may take place and not be detected until after 
 death. Thus, in 1879, a man aet. 23 was admitted into Guy's Hospital under Dr. Wilks 
 for some throat aifection, as suggested by difficulty in swallowing and inflammation of 
 the soft paltite, with a sloughy patch of tissue in the pharynx. The symptoms had come 
 on after a fall of ten feet down a ship's hold three days previously. There were no symp- 
 toms of paralysis. The man died on the fifth day of his admission and eighth day after 
 the accident with dysphagia as his most prominent symptom, associated with febrile dis- 
 turbance and delirium with tremor. After death the body of the fifth cervical vertebra 
 was found fractured and its lower fragment projecting forward. The cord was not 
 aiFected. There was a sloughing prevertebral abscess communicating with the pharyn- 
 geal wound which had been clearly caused by the fractured fifth vertebra. A portion of 
 the laminje of the fifth vertebra was necrosed and bathed with putrid pus, which had 
 spread upward to the base of the brain and caused death. In 1857 a woman in an attack 
 of mania was admitted into Guy's under the care of Mr. Cock for some contusion of the 
 back caused by a fall out of a window. Beyond the contusion, no injury could be made 
 out. There was no paralysis, but, on the contrary, violent muscular movement. On one 
 occasion the patient got out of bed and struggled to open a window to throw herself out. 
 She lived sixteen days, and during the last week of her life rested (|uietly in bed with 
 her eyes closed. She would only at times rouse herself and speak. After death atrophy 
 of the brain was found, with general fatty degeneration of the viscera. The last dorsal 
 and three upper lumbar vertebrae were fractured through their bodies, but not displaced \ 
 one or two spinous processes were also fractured. The, spinal marrow was uninjured. 
 
FiLirTii:i:s AM> insLor.vnnsss or Tin: sn.\i:. 239 
 
 Till' fact of tluTf btMn<; im (lis|ilac«'iiu'iit of tlic luokcn Itoncs and no injury to tho cord 
 pn-vciitoil a correct diagnosis hcint: made. 
 
 I have seen also u case of fracture of the spinous processes rtf the last dorsal an<l the 
 first luiiiliar vertebnv, with lateral displacement, the injury havinjr been treated for some 
 months previously as a simple contusion of the hack. In this ca.se no paralysis existed 
 or other spinal sympt<ims. 
 
 Fractures and dislocations of the sjtine are irt'iitrally the result iA' litilliftf /nrriK, such 
 as severe falls. A forcible bendinf.' forward of the cervical spine may cause dislocation 
 of tlie cervical vertcbne. and a similar accident to the dorsal spine mav cause fracture. 
 In tlicse cases, too. there is always some laceration of the liframents and crushinjr of the 
 anterior edges of the bodies (»f the vertebnv. ( Vide ¥i<^. !t2. ) A forcible beiidiriL' back- 
 ward <if the spine may jiroduce a like result, the lamina* of the dorsal or lumbar vertebrae, 
 under these circumstances, beinir much broken. Direct viiilencc to the cervical rejrion of 
 the spine may produce dislocation ; whilst to the lower vertebne it jrenerally cau-ses frac- 
 ture of the spinous processes or laminae. Mr. Holmes has recorded in the P<(th. Soc. 
 Trans., vol. X.. an interesting case of displacement of the last dorsal from the first lumbar 
 vertebra, associated with some slight fracture of the processes the result of a direct blow. 
 
 Fracture of the sternum is not uncommonly associated with injuries to the spine from 
 the forcible bending forward of the head. It was found in four out of fifty-six fatal ca.ses 
 that occurred at Guys. 
 
 Of the.se fifty-six. fatal cases of fracture and dislocation of the spine, thirty-six were 
 of the cervical region, eleven being examples of pure dislocation, eighteen of the dorsal, 
 and two of the lumbar, injuries of the cervical being apparently twice as frequent as those 
 of the dorsal region, the greater mobility of the cervical vertebrae and the obliquely hori- 
 zontal aspect of their articular processes favoring di.slocation. 
 
 In the thirty-six the injury was below the third cervical vertebra in all but three 
 examples. In one of these it involved the second, third, and fourth vertebrae: in another, 
 the arch of the atlas and spinous processes of the second and third vertebrae; and in the 
 third case the bodies and arches of the third, fourth, and fifth vertebrae. 
 
 In the eighteen dorsal .seven were in the upper and eleven in the lower half, the lower 
 part of the cervical and of the dorsal regions being clearly more, liable to injury than the 
 upper. 
 
 When the cord was sufficiently injured in the cases of injury to the cervical region to 
 give rise to paralysis, death generally took place within three days, and in the majority 
 of instances within two. 
 
 When it occurred as a result of injury to the dorsal region, suppuration of the kid- 
 neys, cystitis, or bedsores were the most common causes of death. 
 
 Of the eleven cases of pure dislocation of the cervical vertebrae, four were between 
 the fourth and fifth, two between the fifth and sixth, three between the sixth and seventh, 
 and two between the seventh cervical and the first dorsal. In none of these was there 
 the smallest trace of fracture. In .six the displacement was so great as to crush the cord. 
 In five there was no displacement and no marked paralysis as a direct result of the injury, 
 although secondar}- paralysis appeared subsetjuently. from stretching or other injury to 
 the cord. 
 
 In injuries to the cervical region pure di.slocation occurs in thirty per cent, of the 
 cases. 
 
 Cases of sudden death after a fall from a height upon the vertex are doubtless often 
 due to a fracture or dislocation of the cervical spine. It may be a fracture of the pro- 
 cessus dentatus of the axis, a laceration of the transverse ligament binding it in po-sition. 
 or a fracture of the atlas allowing the head to slip forward. Dislocation of the occipital 
 bone from the atlas has been described : it is. however, verv rare. 
 
 When fracture of the odontoid process takes place, as it may from external violence 
 or during the progress of some disease in the vertebrfe. death, as a rule, occurs suddenly, 
 the victim being literally pithed. In other cases — and these, generally, of disease — the 
 displacement may be gradual, death being then often preceded by paraly.sis of an arm or 
 leg, or both, with difficulty in swallowing, pain in the neck, and inability to raise the head 
 into the erect position or to rotate it. 
 
 Vide paper on fractures of the odontoid process, by Dr. Stephen Smith of New York 
 (American Jounnd of Med. Sci.. October. 1871). 
 
 Diagnosis. — When a patient has received a severe injury to the spinal column fol- 
 lowed by complete paralvsis. the cord has been injured, and it is probable that a fracture 
 or dislocation, with displacement of the vertebrae, has taken place. When the paralysis 
 
240 FRACTURES AXD DTSLOCATTOXS OF THE SPINE. 
 
 is ptirtiaL it is probable that the cord has been only partially involveJ, but more or less 
 bruised or stretched, according to the nature of the accident and the extent of the dis- 
 placement of the injured bones. When no paralysis is present, the dianrnosis of fracture 
 or dislocation is difficult. 
 
 When any inequality or irregularity in the spinous processes is present, any pain in 
 one spot aggravated by pressure, any crepitus on manipulation, any local eflPusion of blood 
 about the spine, any inability to move the spine or support the body ; when priapism 
 appears early in the case ; when one or more or all of these .symptoms come on after such 
 an accident as is liable to produce them, — the diagno.sis of a fracture or dislocation is 
 tolerably clear. 
 
 When paralysis of an arm or leg follows a spinal injury, it is possible that the paral- 
 ysis may be caused by pressure upon one or more of the nerves that pass outward from 
 the spine, or by laceration of a nerve trunk from some partial displacement of the injured 
 bone. When paralysis is incomplete, the motor-power is generally more completely lost 
 than that of sensation : indeed, it often happens that there is hyperajsthesia in that por- 
 tion of the body contiguous to the paralyzed part, owing to the portion of cord above the 
 injury being overactive or irritated by the .sharp parts of the fractured bone. Intense 
 pain in the line of junction of the paralyzed and non-paralyzed parts signifies fracture, 
 in Mr. Erichsen's opinion. In estimating the seat of injury from the po.sition of the 
 paralysis, it is right to remember that the nerves come off obliquely from the .spinal cord 
 and pass downward, the cervical and dorsal nerve trunks leaving the spine one or two 
 vertebrae lower than the spot whence they are given off, while the cord terminates, at the 
 second lumbar vertebra. Thus, when fracture takes place below the second lumbar ver- 
 tebra, the patient may be unable to stand or walk wholly or in part, yet there may be no 
 paralysis, for place him on his back and there will be free movement of his legs. In 
 other cases the nerve trunks around the cauda equina may be involved. 
 
 When a patient has received a severe spinal injury, there may or ma\- not occur what 
 is called '• shock ;" but when these symptoms have passed off and those of reaction appear, 
 there will commonly, in cervical injuries, exist some throbbing of the arteries and increase 
 of the temperature of the paralyzed parts. These conditions are due to paralysis of the 
 arteries as a result of injury to their vaso-motor nerves. At a later period, however, this 
 increase of temperature subsides and a diminution can be detected. In exceptional cases 
 the vaso-motor paralysis is associated with coldness of the parts, and it is probable that 
 when this coldness exists it is due to great depression of the heart's action. 
 
 Priapism is a common consequence of spinal injuries, and more particularly of cervical 
 and upper dorsal. It may occur, however, in lower dorsal, not so in the lumbar. I have 
 recorded an example occurring in the lower dorsal (Path. Soc. i^a??s., vol. vii., p. 332). 
 
 Prognosis. — The nearer the injury is to the respiratory centre, the greater the danger 
 to life. Thus, in injuries to the cervical spine above the origin of the phrenic nerve or 
 third cervical vertebra causing paralysis, death may be instantaneous ; when below this 
 position, and the respiratory process is maintained only through the diaphragm, life is 
 rarely prolonged beyond the third day. and. as a rule, not be\ond the second. Exceptions 
 to this rule, however, are met with. Mr. Hilton has recorded in his lectures On Rtst a 
 case in which a man lived for fourteen years completely paralyzed from the neck down- 
 ward after a fi-acture of the cervical vertebrae, and in my own practice I had a case in 
 the person of a gentleman aged 29, whom I saw with Mr. Roberts of Southgate, Novem- 
 ber 25. 1870. with complete paralysis of the whole bodv- below the fifth cervical vertebra, 
 caused by a fall upon the neck ; he lived nearly ten j-ears and died from lung disease, 
 breathing solely by the diaphragm. 
 
 When the cord has been injured in the lower dorsal or lumbar region, life may be 
 prolonged for many months, the immediate cause of death being generally some renal or 
 vesical mischief, some bedsore or other complication the direct result of loss of nerve 
 power in the paralyzed parts. The longer these complications are delayed by careful 
 nursing and attention, the longer can life be maintained. 
 
 In other ca.ses. again, in which only partial or no paralysis at all is present as a direct 
 consequence of the injury, inflammatory changes may ensue in the injured part, and, 
 spreading upward, cause death. The prognosis in such instances will be mainly deter- 
 mined by the seat of the injury and the extent of the mischief in the cord. 
 
 The lovctr the seat of injuri/. the hetter the prospects of a cure ; and the less the cord is 
 involved in the mischief, the greater the chances of a recovery. 
 
 Thus fractures of the lumbar region are quite capable of a complete cure, and frac 
 tures of the lower dorsal vertebrae are not unfrequently recovered from. Injuries to the 
 
FiiAcrniEs AM) Disi.oiwrioss of rill: si'iM-:. iMl 
 
 cervical part uf tin- >|iiri(' arc f^oncrally fatal witliiii tlin-i- days. Iiijiirirs to the dorsal, 
 when not proviii;^ fatal witliiii tin- tliinl wtnk. may l)o surviviMl fur iiKtiiths, and even 
 years, the duration ol" lil"e JMinir greatly determined !)y the warilin^' off of the secondary 
 eoni|>lications wiiieh so frcijiiently arise. 
 
 Tkk.vT.MKNT. — The iliairnosis of a fracture or dislocation of the s](ine having' lieen 
 made, the most essential point to attend to is to keep the part aljsoliitely unmoved. The 
 patient should he examined with the j^reatest care and moved with every pos.sihie 
 ])recaution, as any motion may add to the injury the cord has sustained and increase the 
 danger to the patient. Ivxtension of the spine may be employed when much deformity 
 exists, and j)articnlarly when severe pain ari.ses fnnn nerve j)ressure, but extreme caution 
 is reijuired in followiiiL; this practice ; it is not to be employed in every instance, but 
 onlv when local svmptoius seem to suggest the probabilities of a reduction of the dislo- 
 cated or disphiced bone or the relief of pain. I have known cases in which a successful 
 reduction of displaced bone has been effected by extensitjii, and seen others in which 
 marked relief was afforded ])y this course. Practised with discretion, extension of tht 
 spine is doul)tless a valuable means of treatment. A good example of this occurred in 
 the ])ractice of my colleague, Mr. Davies-Colley, on March 14, ISS!^, when a n)an ;et. 50 
 was brought into (Juys after having been double<l u]» forward, with projection of the 
 first lumbar vertebra three-((uarters of an inch behind the level of the last d<irsal. and 
 some paralysis of motion and sensation of the right lower extremity. Under chlorol'orm 
 powerful traction was made upon the legs by assistants, and 3Ir. Davies-Colley, who.se 
 hand was placed upon the projecting bone, felt it gradually sink to the level of the upper 
 vertebra ; at the same time crepitation and mobility were felt, as if the bone immediately 
 above had been broken. A plaster-of- Paris jacket was then applied. For ten days the 
 urine had to be drawn off. At the end of a month sensation had returned in the right 
 leg. but the foot was in the position of talipes valgus from paralysis of the peronei 
 muscles. The jacket was removed, and no deformity existed. The man could move in 
 bed without pain. He left the hospital cured, but with the talipes. 
 
 When the injury is in the mid or lower dorsal region, the application of a plaster or 
 other jacket, with the patient in a horizotital position, gives comfort by ensuring immo- 
 bility and helps recovery. 
 
 "When the patient is placed on his back, the parts have a natural disposition to fall 
 into place ; this j)osition, therefore, must be maintained. The bed should be firm, yet 
 elastic, and a water bed is the best when it can be obtained; otherwi.se, a spring mattress 
 or ono of horsehair should be employed. It .should be well protected by waterproof 
 cloth, etc. from all contact with urine or feces. 
 
 The condition of the bladder should be attended to from the very first. Retention is 
 certain to be present for a time, and overdistension is most injurious. The utmost care 
 ought to be employed in drawing off the water. A moderate-sized elastic or the French 
 vulcanite catheter .should be used, and the operation repeated twice a day, night and 
 morning. If the urine becomes offensive, the l)ladder must be washed out with a lotion 
 of boracic acid ten grains to the ounce ; but no syringe should be used. A stream of 
 medicated water ought to be allowed to run in and out of the bladder through an elastic 
 tube attached to the irrigator and fitted to the top of the catheter, no force being applied. 
 ( Viife Fig. 350.) The api)lication of leeches to the spine or cupping is seldom called for. 
 The condition of the bowels must be attended to. and enemata are to be preferred rather 
 than ])urgatives. The greatest care is needed to keeji the patient clean, particularly 
 when incontinence exists. 
 
 There are no special medicines applicable to these ca.ses. The general health of the 
 patient should be maintained by tonics and simple nutritious food, and .sedatives should 
 be given to procure rest and relieve pain. 
 
 The condition of the back mu.st be daily watched to prevent bedsores. This is best 
 secured by removing pressure as far as possible or in relieving it by means of soft 
 cushions and pads, the water cushion being the best, and also by keeping the parts dry. 
 The application of a soft felt plaster over the sacrum and hips is sometimes beneficial ; 
 so also is the freijuent application to the parts of some spirit lotion. Should it be neces- 
 sary to turn the patient on one or other side, the attendants ought to be taught to rotate 
 the hips and shoulders at the same time. By great care and attention life may be pro- 
 longed, and even recovery may occur. 
 
 The subject of trephining the spine requires brief consideration. Cline was 
 the first to put it into jiraotice, and on his great authority the operation has been 
 repeated, but with no success. The great argument, however, against the operation is 
 16 
 
242 SPRAiy OF THE BACK. 
 
 derived from the fact that in few post-mortem examinations has the condition of parts 
 indicated that the slightest good could have been derived from its performance. The 
 danger of a fractured or dislocated spine lies in the injury to the cord, the result of a 
 stretching or crushing of its substance. When the cord is much injured by the acci- 
 dent, the mischief has been done, and no removal of the displaced bone can undo it or 
 neutralize its evil. If the cord is uninjured, no operation is called for. 
 
 One successful instance of trephining is recorded by Dr. Gordon of Dublin, and in 
 rare and exceptional cases it is possible the operation may be justifiable. To perform it 
 because it may by chance do good is not advi.-^able. The onus of proving that an ope- 
 ration is likely to be of use always devolves upon the surgeon who performs it. There 
 is, however, reason to believe that a cord may at times be only squeezed or pressed upon 
 by effused blood, and under such circumstances relief might be afforded by removing 
 enough bone to take away the pressure and thus give the cord a chance of recovering 
 itself. 
 
 In the ease of Mr. Roberts"s patient, referred to at p. 240, such a probability 
 seemed reasonable, and three months after the accident I cut down upon the injured 
 vertebra and removed the spinous process and lamina of the fourth cervical, thereby 
 exposing the cord. No harm followed the operation, although no immediate good was 
 produced. The wound healed rapidly, and in the course of a few weeks some slight 
 power returned in the muscles of the shoulders, the patient being able to raise the arms 
 from the bed. He, however, made no further progress ; and yet I look upon the case 
 as an encouraging one. 
 
 " The end proposed in an operation of this kind.'" says Le Gros Clark, '• is to remove 
 displaced bone which is supposed to press upon or irritate the cord ; but it is most likely 
 to prove abortive, from the inaccessibility of the displaced bone. If the cord have been 
 crushed and the operation have been consequently useless, probably life may thereby be 
 only curtailed; but if the cord be not cru.shed, it' appears to me that the bek chance of 
 the patient's recovery is thereby extinguished. Indeed, my conviction is that the ope- 
 ration has been advocated on the erroneous hypothesis tliat tlie spinal cord can be com- 
 pressed without serious disintegration of its texture." 
 
 Wounds of the Spinal Cord. 
 
 These are very rare in civil life. They may take place, however, as the result of a 
 stab or gunshot wound. If the cord is injured, some .symptoms of paralysis will appear 
 corresponding with the part that is involved, the extent of the paraly.sis and its seat 
 fixing the position of the wound. Mr. Holmes has recorded (Mfd. Chir. Trans., vol. 
 Ixv., 18S2) an interesting case, in which the theca vertebralis was opened in the lumbar 
 region with a knife, and in which cerebro-spinal fluid escaped in considerable quantities 
 for seven days without any bad result. 
 
 Sprain of the Back. 
 
 The word '•' sprain " is very broad, and when applied to the back is indeed vague. It 
 may mean simply a stretching of the muscles or ligam.ents of the back, or a more com- 
 plete laceration of the latter and separation of the spinous processes of the vertebrae, with 
 exposure or injury of the cord. The number of articulations in the spine — nearly eighty 
 — renders such an accident as a sprain a common occurrence ; any twist of the spine or 
 forcible flexion may consequently injure .some of these joints. Sprains may. moreover, 
 be followed by acute or chronic joint disease of a serious and in.«idious nature : and this 
 truth .should ever be before the surgeon to influence his practice. When the head is 
 bent violently forward, the muscles and ligaments may be so torn as to give rise to 
 effusion of blood, .swelling, and severe local pain. Wlien the body is flexed with vio- 
 lence not .suflacient to give rise to fracture, there may be the same results ; and so also 
 when a man falls upon his buttocks. In each case there may be external evidence alone 
 of injury, or there may be evidence of some affection of the cord such as is afforded by 
 the presence of paraly.sis, proving that the cord has been stretched, if not permanently- 
 injured. If the symptoms rapidly, or even gradually, subside, no grave mischief, prob- 
 ably, may have taken place. When they are persistent or obstinate, a less favorable 
 opinion should be formed. If the lumbar region is the part involved, it is not uncommon 
 for haematuria to appear; and this may be slight and pass away or be more persistent. It 
 is not generally a very serious .symptom, unless the kidney is ruptured ; as a rule, it dis- 
 
l.ATEHM. <rnVATl'llE OF THE SI'LSE. 24;$ 
 
 appears f^radually, and no ovidi'iicc remains that i»r;^ani<- n-nal disease is ever the conse- 
 (juenee. " Of the many casi-s I have witnessed, " says \m (Iros Chirk, " T liave never had 
 reason to suspeet that nephritis nr orj^anic disease foHowed " (Hi it. Miii. ./onrn., Octol)er 
 ;>, ISllS). Mr. Sliaw, in /Iii/ims's Siiiyrri/, <.Mves a case where the hh'edin<: lasted lor 
 lour days, eeased lor two, and then rea|>peared in all its severity. Alh-r tin; lapse of 
 two more days it aj^ain eeased for twenty-four hours, reappearin*; lor a third time severely, 
 then eeasinir. and a j/ood recovery folhtwed. When tin- kidneys are dis(!used. and when 
 ealeuli :i1mp f\i^t in tlnni. tlii- «-ynipl>im i- luorc lik<'ly to appear after injury. 
 
 Hemorrhage into Spinal Canal. — ileniorrha^t' may take plaee into the spinal 
 canal as the result of a sprain or laceration of the li;^aments, the hlood prohahly ll(»wiiif^ 
 from a laceration of some of the larjre veins that surround the cord or from a spinal 
 artery. Sir !'. Ihwett has related a ease of sudden death from a fall on the head, 
 recorded hv Mr. heville in 1S4;) ( Mnu. ilr ht .Sue. tic C/iinny. <lc Purls, t. iii.J, in which 
 no other injury was found to the nervtuis centres than hemr)rrhage into the canal in its 
 wlude leuirth. Mr. Ijc (Jros Clark has recorded a second, in which a man was struck 
 viidently on the hack, though there were no immediate spinal symptfuns. Paraplegia 
 soon followed, however, which extended upward, destroying life hy asphyxia; and after 
 death the theca was found distended with fluid blood derived from a ruptured spinal 
 artery. lie gives al.>io another ca.se somewhat similar in symptoms, though not in result, 
 where the patient recovered after two year.s 
 
 Tre.vt.mf.nt. — In all the.se cases of sprain, slight or severe, re.st is es.sential, the suf- 
 ferer being allowed to assume the position in which the greatest ease can be rtbtained. 
 The application of cold by an ice-bag or a metallic coil is al.so of great .service where 
 much swelling or jiain exists. In other ca.ses a warm poppy fomentation gives relief, or 
 a mixture of belladonna and opium rubbed down with glycerine and applied on lint. 
 When spinal symptoms are present, the greatest caution is needed, and the case ought to 
 be treated as one of concussion of the cord. 
 
 In bad cases it is wise to fix the spinal column in a surgical ca.sing, with the object 
 of guarding against secondary inflammatory changes both of the spine and cord ; and 
 this absolute immobility of the spine should be maintained for months. 
 
 Rest in the horizontal position for seven or eight weeks is essential in less .severe 
 cases, and even in the mildest forms exercise must be sanctioned with caution. 
 
 When hicmaturia occurs, it requires no special treatment unless severe, when gallic 
 acid in gr. v or gr. x doses two or three times a day may be given, or, what is better, the 
 subcutaneous injection of ergotin in doses of two to five grains dissolved in five or ten 
 minims of distilled water employed. 
 
 CURVATURE OF THE SPINE. 
 
 There are two forms of curvature of the spine — iateral and angnhir. The lateral is 
 due to a relaxation of the ligaments and muscles of the spine, which in a healthy subject 
 maintain the bony column in its normal position. The angular is secondary to organic 
 disease of one or more of the bodies of the vertebrae or of the intervertebral substances, 
 and is generally known as " Pott's curvature." 
 
 Lateral Curvature of the Spine. 
 
 This is by far the more common form of spinal curvature. It is generally found in 
 girls between ten and twenty years of age, sometimes in young children, and is fre- 
 quently, though not always, associated with want of power. It is more common in the 
 middle and higher classes of society, where sedentary occujiations and luxurious ener- 
 vating habits too often exist, than in young women who make full use of all their mu.s- 
 cles and lead an active life. 
 
 It is encouraged by any one-sided posture of the body, whether this be the result 
 of some fault}- habit or of occupation, of overuse of one limb, or of any disease or 
 deformity of a lower extremity which occasions shortening of the limb. 
 
 In its early stage it is seldom discovered, and attention is, as a rule, drawn to the 
 disease by some " growing out ' of one shoulder, generally the right, .some distortion of 
 the chest, or some tilting upward of a hip. The.se deformities are frequently fir.st noticed 
 by dancing- or drill-masters. When a curve has taken place in the upper dorsal region 
 of the spine to the right side, a compensatory curve is certain to be found in the lumbar 
 to the left. In investigating a case it is important to bear this fact in mind, as the con- 
 
244 
 
 LATERAL CURVATURE OF THE SPINE. 
 
 Fig. 94. 
 
 Fig. 95. 
 
 Anterior view. Posterior view. 
 Lateral Curvature of the Spine. 
 (Guy's Hosp. Mus., No. \m&». Taken from Emma J , ret. 14.) 
 
 secutive or compensatory curve, unless of long standing, will soon be remedied when the 
 original one has been cured. 
 
 Associated with the lateral curvatures there nece.ssarily must be some rotation of the 
 spine. The amount of this is very variable and depends upon the extent of the curva- 
 ture ; it is doubtless due to 
 the forcible bending of the 
 bones downward with the 
 ribs, these latter helping to 
 rotate the vertebrae upon 
 their axes. The bones may 
 be so twisted that their 
 transverse processes project 
 backward, carrying the ribs 
 with them, the anterior sur- 
 ftices of the bodies of the 
 vertebrae looking toward the 
 convexity of the curve and 
 the spinous processes later- 
 ally toward the concavity. 
 The thorax is thus much 
 distorted, the side corre- 
 sponding to the curve being 
 expanded and the oppo- 
 site one greatly contracted. 
 This is well seen in the 
 annexed drawings, Fig. 95 
 taken from a living patient and Fig. 94 from a preparation. 
 
 In some otherwise healthy and in rachitic subjects there exists an exaggeration of the 
 natural curves of the back. When it is in the upper dorsal region and backward, it is 
 called '■^ q/pliosis;'' when in the lumbar and forward, "lordosis." This latter curve is very 
 frequently found as an accompaniment and result of hip disease when the thigh is flexed 
 or adducted, and it is always present in congenital displacement backward of the head of 
 the femur. 
 
 The DIAGNOSIS is not very difl&cult when the deformity is well developed, the double 
 curve giving the spine a sigmoid form, which is typical. In less severe cases this curve 
 can readily be removed by extension of the body, either by lifting the patient from the 
 ground by a hand in each axilla or by — what is better — the vertical suspension of the 
 patient by his hands from a bar or a pulley. In the more severe forms, such as that 
 shown in the above figures, the deformity is permanent ; the ribs are thrown out in an 
 extreme degTce, pushing the scapula outward and upward, and the lumbar curve is in 
 the opposite direction to the dorsal. The whole thorax, abdomen, and pelvis are alterec^ 
 in shape and position by the deformity. 
 
 Treatment. — In treating these cases it is necessary in the first place to determine 
 the cause of the deformity. Should there be any structural disease, such as a growth or 
 carious. bone, this will require attention, and the alteration in the spine becomes thereb}' 
 a secondary matter. But in the great majority of cases of lateral curvature the spinal 
 affection is the result of impaired health, and constitutional remedies are demanded. The 
 treatment must be directed to an improvement of the general health, and tonics should 
 be administered, such as iron, quinine, and cod-liver oil. Good air and good food are also 
 essential. In certain cases local treatment is of great value. 
 
 The feeble muscles and weakened ligaments should have rest, though they are to be 
 kept in health by moderate exercise ; they are never, however, to be fatigued. If fatigue 
 be experienced from walking one hour, such exercise must be curtailed to a shorter 
 period. If backache be produced by exertion, less must be taken. Exercise is to be 
 allowed, but not to the extent of producing fatigue. Sitting and standing ought not to be 
 sanctioned. The patient should recline at stated intervals in any position that gives the 
 greatest ease. When the deformity is definite and the dorsal curve is to the right side, as 
 is nearly always the case, the patient should rest upon that side with a pillow beneath the 
 right arm, the weight of the body in that position acting as an extending force upon the 
 curved spine, and thereby tending to reduce the curve. By resorting to this practice two 
 or three times a day for a definite period, depending upon the nature and severity of the 
 alFection, much good may be obtained and very severe curvatures remedied. Cold sponge 
 
sr/XAL i>fsj:As/:. 
 
 245 
 
 or slmwtr ImiIis. if tlicy fan lie Iportic, arc always iMinficial ; sd also is a iiKnIi-ratcl v firm 
 hi'd, a sjiriiiLC luattri'ss lii-iii^ Ixtti-r than a Icatlicr linl. (itMitlc falistlicni<- exorcises are 
 valiialilc ailjuncts to treatment when practised with (liscreti(»n, and jtariicularlv the volun- 
 tary vertical extension of the jiatient's iKtdy }»y manual suspension IVom a liar or pulley; 
 yet it should he n-meniliered that a weak sjiini! is heinj.' dealt with, and ativthin^' like 
 vioh-nee may he very detrimental. 
 
 Should the curvature have heen cncouraLreil hy any faulty hahit. such as slaridiii;: on 
 one \v<x <»r in one position, or the use of one arm, it is almost needless to say that the 
 habit should he disecuitinued. 
 
 The objeet.s of treatment arc, therefore, 1. To imprf>ve the jreneral condition of the 
 body ; 2. To give rest to the strained atul weakened muscles and liframents ; ;>. To 
 streuirthen the muscles that .support the spine by exerci.se carefully regulated, .so as to 
 prevent fatigue ; 4. To restore the spine to its normal direction by posture, muscuhir 
 extension, aiul l)y pressure applied in the horizontal position. 
 
 Mechanical contrivances have l»een much vaunted and are often employed. I 
 confess, however, to having little faith in their value as cnrtitirc iKjciita. They tend to 
 cause atrophy of the muscles tliat support the back instead of strengthening them, and 
 thus to make the deformity permanent. In bad and exceptional cases they may. how- 
 ever, be employed when the treatment sketched out cannot be borne or is inapplicable. 
 The best supjtort is that of Sayres or one of the felt jackets. When the deformity is 
 irremediable and sujiport essential to allow the patient to move about, an instrument is 
 of great value. 
 
 It is probable that the deformity in its early stage chiefly arises from a compres.sed 
 condition of the intervertebral substance, it being well known that this material is capa- 
 ble of being compressed one-fourth of its thickness. Hence a person by maintaining 
 the erect posture during the day will be an inch shorter at night than in the morning. 
 Any lateral curvature of the spine, however ju-oduced, unless remedied, will increase and 
 be complicated with rotation. When unequal vertical compression is, therefore, kept up, 
 the deformity produced by it becomes permanent, and the growing bones necessarily 
 assume shapes and positions corresponding to the deformiiy and tending to increase it. 
 
 Organic Disease of the Spine and Angular Curvature. 
 
 This disease of the spine is due to a destructive inflammatory change of the bodies 
 of the vertebra and intervertebral sukstances. It begins usually in the latter structure, 
 although the bone itself may be its primary seat. It is at times associated with tuber- 
 cular deposit in the tissue, though 
 
 Fio. 9( 
 
 Fig. 97. there is no evidence to prove that 
 
 it is always due to the presence of 
 tubercle. The curvature, gener- 
 ally known as " Pott's curvature," 
 is directly due to the destruction 
 of the bodies of the vertebne and 
 the intervening intervertebral sub- 
 .stance, the upper vertebra falling 
 down toward the lower and join- 
 ing with it. When the bodies of 
 many of the vertebra* are involved, 
 the deformity will be .severe ; a 
 prepai-ation in Guy's Museum 
 (lOOr)^. Fig. OG) shows the bodies 
 of twelve vertebriv implicated, 
 but a cure resulted. Paralysis 
 
 Angular Curvature of the .Spine, the "'''*}' attend this aff"ection. though 
 same as ih.it iiiustraieU in Fig. 9r.. it is rare to find the cord involved 
 
 ('taken from a iiatient iet. :>5.) 
 
 ^i/^'\ 
 
 Angular Curvature of the 
 Spine. 
 
 in the disease, even when the 
 most destructive changes have taken place in the bones. Great deformity, even to an 
 acute bending of the cord, may exi.st without giving rise to nervous complication (Fig. 
 97). The paralysis, too, may be lasting, but more commonly is only temporary. Angu- 
 lar curvature may occur at any period of life, but is more liable to appear during the 
 growth and development of the spine, and consequently is more frequently found in child- 
 hood. From a remarkable preparation in the Guy's Hosp. Mus. (1004*') it would seem 
 
246 
 
 SPINAL DISEASE. 
 
 that it may attack the foetus in iitero and be repaired, the bodies of three or four of the 
 dorsal vertebra? in this case being clearly fused together from disease, thus giving rise to 
 angular curvature. 
 
 When a cure takes place, it is generally by anchylosis ; occasionally, however, the 
 parts are held together simply by fibrous tissue. 
 
 Tlie disease more commonly attacks the lower dorsal region of the spine than any 
 other, although the cervical and lumbar regions are not seldom implicated. In rare cases 
 it attacks two different regions of the spine. It may run through its whole course, even 
 to a cure, without giving rise to any extei'nal suppuration ; more comnionlv, however, 
 an abscess makes its appearance. 
 
 Spinal Abscess. — Pus will sometimes find its way from the dorsal region beneath 
 the fascia that covers in the psoas muscle under Poupart's ligament, and then appear as 
 a swelling in the groin at its inner half (psoas abscess). The swelling may burrow down- 
 ward and involve the whole thigh in one large abscess. When the disease is in the lum- 
 bar region, pus may burrow between the dense layers of fasciae that bind in the quadratus 
 lumborum muscle and appear in the front of the abdomen above Poupart's ligament, and 
 in rare cases pass down the inguinal canal and appear in the groin, simulating an inguinal 
 hernia, or in the loin (lumbar abscess). In other cases it will make its way under the 
 fascia that covers in the iliacus muscle and appear beneath Poupart's ligament, but at its 
 outer half. In other instances, again, the matter will find a passage downward into the 
 pelvis, and either make its way through the sciatic notch into the gluteal region (t/fufeal 
 abscess) or pass downward behind the trochanter major to the thigh. In still rarer cases 
 the pus appears by the side of the rectum. 
 
 When the cervical region is the seat of the disease, suppuration may appear in the 
 pharynx as a pharijuge.al abscess^ or externally in the neck behind the sterno-cleido- 
 mastoid muscle. The following case is a good example of this : 
 
 A boy Jet. 3 was brought to me at Guy's in 1862 for some affection of his upper cer- 
 vical vertebrae consequent on a fall down stairs vipon his head. x\n abscess formed two 
 months after the accident behind the left sterno-cleido-mastoid muscle, from which place 
 a piece of the lamina of a vertebra escaped six months afterward. He kept his bed for 
 upward of a year, when he got up with a stiff neck. He was unable to nod or rotate the 
 the head, clearly showing that the joints between the occipital bone and the first two 
 vertebrjB had been diseased and become anchylosed. In 18(37 this boy again came under 
 my notice. His head was quite fixed ; the cervical vertebrae seemed shorter than usual, 
 but no irregularity existed. 
 
 The annexed drawings (Figs. 98. 99, lOU), taken from Ellen T . set. 1-4, a patient 
 
 of Mr. Poland's, illustrate a severe case of cervical disease with lateral deformity. In this 
 
 Fig. 98. 
 
 Fig. 99. 
 
 Fig. 100. 
 
 patient a good result was obtained by means of the apparatus depicted in Fig. 100, the 
 cure resulting in anchylosis. 
 
 Exfoliation of Bone. — From any of these abscesses bone may exfoliate, and it 
 may be coughed up from the phar3-nx or discharged through the neck. I have seen a 
 mass of bone the size of a nut come away from a lumbar abscess, and a piece of bone 
 clearly spinal discharged from an abscess of the thigh, opening above the knee-joint. In 
 a case brought under my notice by a valued dresser, Mr. Burgess, the anterior half of 
 the atlas, with its articular facets, was expectorated, recovery ensuing, the man being 
 well eight years subsequently ; and in Gruy's Hosp. Museum (prep. 1018'^) there is a prepa- 
 ration of the odontoid process which a woman who had had a stiff neck for months coughed 
 up, and from which complete recovery ensued. Mr. Keate so long ago as 1835 recorded 
 
si'f.wii. hrsi-:.\si':. 
 
 247 
 
 (^Mfil.. Gaz.) a case in wliicli the aiiti'iiur liull" of the atlas (•xf'uliate*!, ami Mr. CoHis in 
 his honk on .SV/y/A/V/.s, uiid Mr. ('(ippiii^er of l>ul)liii, in the iJiihlin .lonni.. Dccfiiiher. 1S7U, 
 have both jmlilished iiistaiiees in whieh the eorn'SpoiKling 
 
 portion of hone exloliati-tl. In fact, from all these sni'mt/ . 
 
 4ih.'ifrsgis hone may i)e (liseliarired, ami, wliat is more, recov- p^^5^Js^. 7V«/i»n 
 
 cry fdllow. 
 
 Anchylosis without Suppuration.— Suppura- 
 tion, liowevtM", does not always take plaee. A woman let. 
 .'{0 came iinder my eare in lS,")lt f(»r a stiHtiess of her head 
 nn<l neck that had heeii inereasini:; for two years, and which 
 she regarded as rhenmatic. When I saw her. the head was 
 imniovahly fixed and slii^htly rotated to the ri<;ht side. 
 Rotation and nodding were impossible. There was much 
 thickening about the cervical vertebno, with pains darting 
 upward to the vertex and downward to the shoulder. JJy 
 rest in bed, fomentations, and tonics all these disappeared 4>^,"iv'^^ 
 and recovery ensued, but with a stiff' neck. My colleague, ^i!^X''^^<jt,<^J 
 Dr. Fagge, has also recorded in the J'ath. Soc. TroHS. for '^'J^^S^'^j 
 1877 a remarkable case of synostosis of the arches of the li^^^-'^- ^?^ \?'/ 
 vertebrjv, of the ribs to the vertebra), and of the hi])-joint, t^^^^VEt^V 
 
 rrJte process 
 
 in whiidi a bending of the dorsal vertebrjv; forward with ^^^;;*{^^ 
 
 immoliilitv were the oidy symptoms of spinal disease that i\f^7^- 
 
 existed durint!; life fFiu'. KM). It occurred in a man ivt. 
 
 r, I 1 1- 1 "^^ -xi • ii ' ,■ 1 T1 ^ i- !• ii 1 Synostosis of Kills to VertebrtE, etc. 
 
 .54. who died with intlammation and duatatioii ot the bron- ' 
 
 chial tubes from asphyxia, his breathing having been entirely diaphragmatic from a want 
 of movement in the costal joints. 
 
 DiAONOsis. — When an angular curvature of the spine exists, there can be no diffi- 
 culty in recognizing the nature of the disease or the process by which the curvature has 
 been brought about. When a large abscess coexists with the deformity, there is good 
 reason to suspect that the one is the direct result of the other, more particularly when 
 the suppuration can be traced up to the spinal deformity. But in the early stage of the 
 disease the diagnosis is not .so easy, and yet it is here that a correct one is most needed ; 
 for if any decided good is to be gained by treatment, it is at this early period. AVhat, 
 then, are the indications which denote the presence of incipient spinal disease? Local 
 avd pirxliiteiif pain is probably the earliest; and when this is accompanieil by local tender- 
 ness on firm pre.ssure and pain is experienced in the distribution of any of the nerves com- 
 ing from the seat of the affection, as over the shoulders and dow^n the arms in lower 
 cervical disease, around the abdomen and above the umbilicus in upper dorsal, and below 
 the umbilicus and down the thighs in lumbar disease, the surgeon's suspicions should be 
 excited. When the patient complains of any sudden jar of the back by a slip down 
 stairs or by any jump, when added to these symptoms he exhibits extreme caution and 
 a rigidlt/j of the spine in walking or mov- 
 ing, and when, on being told to pick up 
 anything from the ground, he bfnds his 
 knees in prefcreiice to hending his hack 
 (Fig. 102), and when, moreover, he rolls 
 off a couch instead of rising up boldly 
 from the recumbent posture, and sup- 
 ports his body, when standing, with his 
 hands either upon his thighs or neighbor- 
 ing piece of furniture (Fig. lOi^), the 
 diagnosis becomes certain. When, more- 
 over, coughing or sneezing excites pain, 
 and last, but not least, when any consti- 
 tutional disturbance is present, such as a 
 quick pulse, occasional febrility, and a 
 furred tongue, — when all these symptoms, 
 or man}' in combination, exist during 
 that period of life when bones are grow- 
 ing and bone disease is apt to appear, 
 the surgeon .should always suspect disease of some portion of the spine, and until he can 
 satisfy himself that none such exists it is a wi.se plan to treat the case as if it were pres- 
 
 FiG. 102. 
 
 Fig. 103. 
 
248 CURVATURE OF THE SPINE. 
 
 ent. It is true that by adopting this rule of practice he will he occasionally misled and 
 at times treat a case of hysteria as one of spinal disease, but then what harm ? He will 
 probably do good to the hysterical patient by the treatment he would adopt for the 
 spinal complaint, while he would certainly do much harm to the latter by neglecting such 
 measures as are essential for its successful treatment. 
 
 TreaTjMENT. — It is an interesting clinical fact that the best cases of recovery from 
 the worst examples of spinal curvature and disease are to be found amongst that misera- 
 ble class of patients who have never had any chance of receiving proper treatment, who 
 have never had rest or any care, in whom the disease has run its course untended and 
 uncared for, and yet in whom a cure has taken place with firm anchylosis, although with 
 deformity. The majority of these cases are examples of disease of the dorsal vertebrae. 
 How far this deformity might have been lessened or prevented by proper treatment is an 
 open question. Nevertheless, it is beyond all doubt that in the early stage of this dis- 
 ease immobility of the spine, rigidly and persistently maintained, and the removal of 
 downward pressure upon the vertebrae, are absolutely essential points of practice to be 
 observed. Not, however, rest upon the back, for in many instances this supine position 
 tends rather to separate parts that ought to be kept in contact, but rest in any position, 
 prone or supine, the patient feels to be most comfortable. 
 
 The general health of the patient must be maintained as much as possible by simple 
 nutritious food, stimulants enough to assist digestion and no more, with tonics, such as 
 iron, quinine, and cod-liver oil. 
 
 When pain exists, local fomentations are often a comfort ; occasionally, too, the appli- 
 cation of a few leeches relieves. Small flying blisters placed alternately on either side 
 of the painful spot are sometimes of use, and a plaster of belladonna or opium rubbed 
 down with glycerine over the part is a valuable adjunct. When severe nerve pain is pres- 
 ent, the hypodermic injection of morphia may be used. Sedatives must be given to 
 induce .sleep when it cannot otherwise be obtained. Setons, moxas, and mercury are not 
 to be recommended. 
 
 By the adoption of this line of treatment a cure may be obtained. It must, however, 
 be followed out for months, and even years, the greatest care being taken that the patient 
 is not released too soon, for a relapse is always a very serious affair. 
 
 Dr. Lewis A. Sayre's plaster-of-Paris jacket appears to me to be the best kind of 
 apparatus, for it is simple, economical, easily applied, and efficient, securing absolute 
 immobility of the spine and at the same time giving comfort to the wearer. It can be 
 readily applied by any medical practitioner with little expense, and does not debar the 
 patient from the benefit of fresh air and change of scene. 
 
 The body of the patient to whom it is to be applied is first to be covered with a thick 
 closely-woven merino .shirt, which is to be fastened above over the shoulders and below 
 between the thighs ; in a female over a handkerchief. A pad, which Sayre calls a dinner 
 pad, made of cotton-wool, folded in a handkerchief so as to form a wedge-shaped mass 
 with the thin edge downward, is then to be introduced beneath this shirt over the region 
 of the stomach, of sufficient size to supply, when it is removed, a space which will permit 
 of distension of the abdominal parietes. All projecting spinous processes of vertebrae are 
 to be protected from pressure by the application on either side of them of a strip of thick 
 felt plaster. The patient is then to be supported by straps carefully adjusted to the 
 axilla?, symphysis mentis, and occiput (Fig. 104), attached to the extremities of a cross 
 bar which may be suspended from a hook fastened to a beam or high door by a compound 
 pulley, the body being sufficiently suspended to allow of its w^eight serving as an extend- 
 ing force, but af.ic(n/s icithln tlie limit of pain. Elevation of the heels is enough for the 
 purpose. The trunk is then to be carefully encased from below the crests of the ilia 
 upward to the axillag by the rapid application of coarse muslin or crinoline bandages, 2j 
 inches wide, into which dnj frrshltz-grinind plaster-of-Paris has been rubbed, the bandages 
 just before they are used being placed vertically in tepid water deep enough to cover 
 them and left a sufficient time to allow all bubbles to escape. The bandages should be 
 well squeezed before they are rolled round the body, and in their application care should 
 be taken to see that they are applied flat, without making any traction, and well smoothed 
 down. It is well also during this process to wet the jacket with water and rub in more 
 plaster. 
 
 The patient should be laid down in the recitmbent position upon a mattress before the 
 plaster is quite set, the dinner pad removed, and the casing slightly flattened in front of 
 the anterior supei'ior spinous processes of the ilium, to guard against pressure. The 
 merino jacket may then be unfastened beneath the thighs and above the shoulders and 
 
crnvATvni: nr riii: si'im-: 
 
 249 
 
 turm-d at both vuds u\vr tlii' casing, tlie emls In-iii': fastciiecl down by a few extra t\iriirt 
 of till- jilasttT baiulap'. 
 
 Ill the course of a f(»rtiii^'ht, if all things •:<> on well and no evidence of undue pressure 
 in anv j>art exists, the casin;; may be split up alon<: the frdot. its edj/es bound, eyelets 
 
 Ki(i. 1(14. 
 
 Fig. 104.— Description of S.ayre's Apparatus as improved by Golding Bird, by which tl>e drag on the amis and head 
 can be varied by altering the relative length of cords I and o. The smaller the angle at g, the more the drag on 
 the head, and i-ur rersa." 
 
 A fross-bar suspended by running tackle to Sayre's tripod or to hook secured to cross-beam of a folding-door. b. 
 Pulley acting upon central bar, to the end of which are suspended the iron rings c, attached to the head-piece, e. 
 D. Pulleys connected with arm suspender, F. by hook g, and h, ring, worked by running cord :16 inches long, 
 ■which can be lengthened at will and fastened by cleats, o. K. Head-piece made of 2-inch worsted webbing sewn 
 into a circle '2'k inches for adult, 2:J inches for children, with ^0 chin-piece made of wash leather, and (fti two 
 circular sliders of same wel>, fi inches round, attached to iron rings, c. The sliders, by being slid forward or 
 backward, can be made to pull more or less against the chin or occiput. F. .Arm-pieces made of 2-inch cotton- 
 web 1 yard round, capable of being shortened by buckle. They are softly padded with horsehair in the middle 
 and covered with wash leather : each carries an iron ring, h. On first suspending a patient the running cord, g, 
 should be at its shortest, the centre cord, /', at its longest. 
 
 Fig. 105. Sayre's .Tury-Mast Apparatus —a. Two pieces of malleable iron bent to fit the curve of the back. 6. Three 
 or more roughened strips of tin attached to iron, long enough to encircle the body. c. Central shaft carried in a 
 curve over the top of the head and capaMe of being elongated at will, springing from cross-pieces of n. </. Swivel 
 cross-bar with hooks attached to end of c, from which straps depend to support head and chin collar, e. This 
 apparatus is applied over the jacket with a plaster bandage. 
 
 introduced, and a lace inserted, in order that it may at times be removed for personal 
 cleanliness and comfort and reapplied. The jacket should be worn .so long as it is easy ; 
 and when worn out, another should be substituted. 
 
 When the cervical or upper dor.sal region is diseased, a vertical splint. Sayre's jury- 
 mast apparatus (Fig. 105), to take off pressure of the head and prevent rotation, will 
 be re<|uired. 
 
 When this splint is used for lateral curvatures, the patient should suspend himself 
 by his arms. 
 
 In female patients a pad should be placed over each breast and removed with the 
 dinner pad ju.st before the plaster sets. Smaller pads may likewise be placed over the 
 anterior iliac spines. " When the disease is situated in the dorsal region, the jacket 
 should not be opened, for the reason that if the respiratory movements of the chest 
 are permitted to go on without restraint the heads of the ribs will necessarily move 
 freely and the disease will be increased rather than diminished. But if the ribs be held 
 still and the diaphragm thus made to act more fully, the breathing, instead of being 
 thoracic, is rendered diaphragmatic and abdominal, and all the short, grunting, catching 
 respiration ceases." 
 
 Caution. — In acute or progressive disease suspension is dangerous, and vertical 
 
250 SPINAL ABSCESSES. 
 
 extension is to be applied with the greatest caution. Immobility of the spine is the 
 essential object to secure. 
 
 Treatment. — Spinal abscesses should not be opened hastily, inasmuch as they may 
 become absorbed and wither away. When steadily progres.sing, however, they must be 
 dealt with, and a good method without doubt is to makea free opening under a piece of 
 lint saturated with oil, carbolized or not. I have, however, in recent years made a free 
 opening into the abscess without any such precautions, washed out the abscess cavity 
 with iodine water, boracic acid, or chloride of zinc lotion two grains to the ounce, with 
 equally good resailts, making the opening so free that no pus could be retained ; and if 
 air got in, it as freely got out again. In all cases a drainage tube should be introduced 
 and the cavity kept empty and clean by repeated irrigation. Retained pus and air are 
 sure to decompose ; but if a free vent be made for both, harm rarely ensues. To allow 
 abscesses to enlarge to any extent without interfering is not good surgery, as the amount 
 of constitutional disturbance that follows the opening of an abscess is closely propijrtioned 
 to its size, and a large abscess cavity secretes more pus than a small one. It is true that 
 after the opening of a chronic abscess a patient who may have been fairly well becomes 
 feverish, and possibly exhausted by hectic ; but it should be remembered that by delay 
 the abscess will become larger, and the constitutional disturbance as a consequence more 
 severe, when the opening has taken place. 
 
 Disease of the Upper Cervical Vertebrae.— Disease of the upper two cer- 
 vical vertebrie and of the occipital articulation is often found, and may be accounted for 
 by the greater mobility of the joints, and consequent liability of the ligaments to sprain 
 and laceration. Disease may be situated in the bones entering into the formation of the 
 joints or in the soft parts binding them together, and with the disease some displacement 
 of one of the vertebrae is occasionally met with. When the disease is in the second ver- 
 tebra, the odontoid process may separate, and even exfoliate. 
 
 When the transverse ligament is diseased, the odontoid process may become displaced 
 and the cord injured (Guy's Musuem, Prep. 1289*'). When the displacement is great, 
 sudden death may take place under these circumstances; and when partial, more or less 
 paralysis may ensue, according to the amount of pressure the cord has sustained. Fixed 
 pain about the cervical vertebrae, with pain in the occipital region, in the distribution of 
 the occipital nerves, and stiff neck, is always suspicious of cervical disease; and when to 
 this is added a disinclination to rotate the head and a preference to rotate the body instead, 
 when the chin is tilted up and a modified form of opisthotonos exists or there is slight 
 torticollis, when the patient supports the chin with his hand to prevent it falling forward 
 on the sternum, and when pain is aggravated by rotation or downward pressure of the 
 head, the case is serious and the diagnosis clear. 
 
 Treatment must be conducted on recognized principles. The danger of sudden death 
 by the displacement of the bones must be diminished by the application of a support to 
 keep the head straight and prevent its falling forward, and this may be accomplished by 
 the application of a collar round the neck, passing under the chin with a support embra- 
 cing the head, an inflating rubber collar being by far the best, or by Sayre's jury-mast 
 apparatus (Fig. 105). Rest in the horizontal position, is, however, of greater value, care 
 being observed to keep a small firm pillow underneath the neck to preserve the liollow, 
 and in this way, as pointed out by Hilton in his classical work On Rest, "to lift up the 
 body of the second vertebra and remove the odontoid process fiom the lower part of the 
 medulla oblongata, and thus prevent the fatal results of pressure upon it." At the same 
 time, the head should be kept at rest by means of sand-bags applied laterally. Remedies 
 that have been mentioned in th^ treatment of angular curvature of the spine are here of 
 use. In cases of severe spinal curvature there is good reason to believe that the span of 
 life is often shortened on account of the interference with the respiratory and circulatory 
 functions caused by the deformity. My colleague. Dr. Fagge, has written an interesting 
 paper on this subject {Gni/s Hosp. Rep., 1874)^^ 
 
 INJURIES AND DISEASES OF THE NERVES. 
 
 When a nerve is struck or contused, pain is produced ; and it may be of a passing 
 tingling character or of a far more severe kind. Most people are rendered familiar with 
 these facts by an occasional blow upon the ulnar nerve, or what is called the " funny 
 bone." When the blow has been severe, the pain may be lasting and the functions of the 
 nerve so disturbed or interfered with as to give rise to loss of power or sensation in the 
 parts supplied by the injured nerve. A man aet. 29 went to sleep with his elbow resting 
 
W'orxDs OF .\i-:r\i:s. 251 
 
 on a tal)l(' ; and wln'ii lie awcikf. iIhtc was <-inii|ilctc paralysis Imtli nf iiidtidri ami sensa- 
 tion of tlio jtarts .sii|>|ilit'(l Ky tlir ulnar nt'ivc. When 1 saw liiin. two days afterward, 
 tliesi' syni|>t<inis wrre very marked, there was also tendc^riiess over the nerve hehind the 
 inner eomlylc, to which spot a hlister was applied. in a fortnij^ht returnin<r sensation 
 appeared, with some slitiht power of nmtion, and in live weeks he was well. This wu.«i 
 cK'arlv a ease of ])aralysis id' a nerve from eontiision. A man ;et. K! received a hlow npoti 
 his ulnar nerve against a chair. No ]>ain appeareil at tin; time, hnt three hours later pain 
 and nnmliness showed themselves, and at this time some thickenin;r over the spot could 
 he made out. In the course of three weeks these .symjitoms di.sappcared and recovery 
 was eoinph'te. In this case it would appear as if some hemorrliajre liad taken place 
 into the nerve sheath, {livinir rise to the jiaralysis. wliiidi disajipeared as the hlood was 
 absorhed. 
 
 Wounds of Nerves. 
 
 When a nerve is vouinhil, pain is produced ; and this may be of a passinj^ (jr more 
 permanent (diaracter. In nervous, hysterical suV^jects the nerve pain is .sometimes severe 
 and persistent, and is then called "* neuralgia. It may be confined to a branch of the 
 injured nerve or it may involve the whole trunk. 
 
 Wlu'u a nerve is dividtd. coin})lete paralysis of the i>arts sujjjjlied V>y it follows. It 
 may. however, reunite and recover its functions. Paget has related a case of complete 
 division of the meilian nerve in which the trunk had nearly recovered its conducting 
 power a month after the wound. I have seen a similar case in which recovery ensued in 
 four months. The following is another example in point : A woman ;ct. 'M) came to me 
 with an incised wound behind the inner condyle of the humerus. The ulnar nerve had 
 been divided, and there was complete paralysis of motion and sensation of the parts sup- 
 plied by it. The edges of the wound were adju.sted and the arm placed in a sling. A 
 month later .she returned with a burning pain in the little finger, which was really cold, 
 but red, swollen, .shining, and blistered ; and when touched, some slight sen.sation was 
 produced. Cotton-wool and oiled lint were applied, and the arm was fi.xed upon a 
 straight splint. The original wound had nearly healed. In two weeks the finger looked 
 natural ; sen.sation in it and all other pai'ts supplied by the nerve had improved. In 
 another month she returned with the old symptoms as l)ad as ever. They had reappeared 
 upon the removal of the splint two weeks previously, but on its rcapplication with the 
 cotton-wool they again disappeared. The splint was then kept on for two months, when 
 sensation became natural, complete repair having taken place in four months. When 
 seen six months later, she was still well. 
 
 The red, swollen, shining, and blistered condition of a finger deprived of nerve force 
 is characteristic, and is generally a.ssociated with the sensation of a burning pain and loss 
 of temperature, amounting sometimes to a depression of 9° or 10° Fahr. There may 
 likewise be a curving of the nails, as seen in phthisis, or ulceration of their roots. 
 These symptoms are clearly due to malnutrition. When the nerve repair does not take 
 place, these .^symptoms are very apt to return from time to time on any change of tem- 
 perature or depression of the general power of the patient. 
 
 Joint Affections. — The joints of /imhs in which the nerve supply has been inter- 
 fered with, after injury undergo a change which consists essentially in a painful swelling 
 of these joints, which may attack any or all of the articulations of a member. It is. 
 says Mitchell, distinct from the early swelling due to the inflammation about the wound 
 itself, although it may be ma.sked by it for a time ; nor is it merely part of the general 
 oedema which is a common consequence of wounds. It is more than these — more 
 important, more persistent. Once fully established, it keeps the joints stiff and sore for 
 weeks or months. When the acute stage has departed, the tissues about the articulations 
 become hard and partial anchylosis results ; so that in many cases the only final cause 
 of loss of motion is due to this state of the joints (W<ir of RelwUiou. part iii.. vol. 2, 
 p. 745). When the uliuir nerve is completely paralyzed — in which case atrophy of the 
 muscles supplied by it ensues — the aspect of the hand is very characteristic, the wasting 
 of the interosseous muscles, with the abductor indieis (also an interosseous), and all 
 those of the little fingers, giving rise to a peculiar hollowing of the parts between the 
 metacarpal bones which is typiical. Nerves when divided do not. however, always 
 reunite. When a piece has been removed either by accident or by design, as in the 
 operation for tic douloureux, the restoration of function is very rare, though it may 
 occur. 
 
 Treatment. — Bruised nerves are to be left alone, natural processes being, as a rule, 
 
252 NEURALGIA, TIC DOULOUREUX. 
 
 amply sufficient to effect a cure. When recovery is slow and associated with pain in the 
 injured part, the application of a small Vjlister is beneficial. Divided nerve should always 
 be brought together by .sutures and the limb placed in the best po.sition to prevent any 
 separation of the divided ends ; the paralyzed parts should be kept warm with cotton- 
 wool and of an equable temperature, and the whole limb at rest, until complete repair 
 has taken place. Even after a nerve has been divided for some weeks there is a good 
 prospect of the divided ends uniting on their readjustment by sutures after fresh trans- 
 verse sections have been made of the separated ends (vir/e Hulke, Ciin. Sor. Trans., 
 vol. xii.). Mr. Favell of Sheffield has recently puVjlished some good cases in favor of 
 the practice.' and Dr. Weir Mitchell' has shown that in one hundred and twenty ca.ses of 
 nerve section regeneration of nerve took place in most in about six months. When much 
 pain exists, belladonna or opium ruVjbed down with glycerine is a nice application, and 
 the hypodermic injection of morphia is often of much value. The application of a 
 suture to a divided nerve is not. however, uniformly successful. 
 
 NEURALGm, Tic Douloureux. 
 
 The subject of neuralgia belongs more properly to the physician than to the surgeon, 
 yet the latter is often called upon to consider cases of this nature. The first point to 
 determine is whether the pain is due to any local cause, and if .so. to remove it. Thus a 
 decayed tooth too often is the cause of pain in the cour.se of branches of the fifth nerve, 
 although the tooth may have neither ached nor exhibited any external evidence of decay. 
 The pressure of a small tumor on a nerve, some irregularity in the bone, or a cicatrix 
 involving a nerve are causes which sometimes require the .surgeons interference to effect 
 a cure. The following example illustrates these remarks: A man set. 41 came under my 
 care in ISOG for severe pain down the anterior and outer portion of his left leg and foot, 
 with almost complete paralysis of the extensor muscles. The symptoms had been com- 
 ing on gradually for years, and had followed a severe wound sustained twelve years pre- 
 viously over the head of the fibula. There was a hard cicatrix over the head of the 
 fibula which clearly involved the external popliteal nerve. I made two deep vertical 
 incisions on either .side of the cicatrix, by this means taking tension off the nerve and 
 affording complete relief ; six weeks later he was still well. Whenever neuralgic pain is 
 associated with a cancerous tumor or comes on after its removal, the surgeon should sus- 
 pect the existence of some secondary- cancerous deposit in the course of the sensory 
 nerve. 
 
 The great majority of cases of neuralgia, however, have a con.stitutional origin, and 
 their cause is to he found in .some hereditary tendency, in depression, anxiety, or some 
 obvious derangement of health such as is expressed by the term - anaemia." Many, too, 
 have a malarious origin and depend on climatic influences, such as residence in a damp 
 or wet place. The disease known as •• tic douloureux is an affection of the fifth nerve 
 and its branches, but any nerve in the body is liable to suffer. The pain is often very 
 intense, and recurs in paroxysms at certain hours or on exposure to draught or cold. 
 
 Treatment. — The treatment of these cases of neuralgia must be regulated entirely 
 by their cause. When a local cause can be made out. its removal is the only remedy — 
 for example, the removal of a tooth, of a tumor, or of a bulbous extremity of a nerve. 
 When hy.steria complicates the case, or any uterine disturbance, tonics are suggested, 
 such as iron, zinc, or quinine, and of these full doses may be given. When malaria 
 appears to be the cause, bark or quinine is invaluable. In all forms of local neuralgia, 
 more particularly in sciatica, the hypodermic injection of morphia in one-third or half- 
 grain doses, injected in the cour.se of the nerve, often acts as a charm. Chloroform, 
 belladonna, and opium, locally applied, are also valuable. The general condition of the 
 patient should always be attended to and the treatment directed to its improvement. 
 Good food, fresh air. and tonics are always essentials. Purgatives are seldom necessary, 
 and must be regulated so as not to depress. Stimulants, but not in excess, are of great 
 use. In females the condition of the uterine organs should always be carefully attended 
 to. 
 
 Division of Nerve. — In obstinate cases of neuralgia the division of the nerve 
 has been performed with occasional success. It is not. however, an operation in favor of 
 which much can be said. When the cause of the neuralgia is peripheral, it may succeed 
 for a time, but in these cases spontaneous recovery is not unusual ; and when some cen- 
 
 ' "Address on Surgery," Brit. Med. Jovrn., Aug. 5, 1876. 
 ' Amer. Journ. of Med. Sci., April, 1876. 
 
SEC ROMA. 253 
 
 tral mispliit'f is the source of tho pain, tlio opfratiun is nut likely to be of service. 
 Novortlu'lfss, ill (lespcrato cases the exeisinn ut' a portimi mI' the <(fferi(iiiifr nerve is a 
 justitiable operation ; it has been of use, ami may be so aj^ain. Sir .1. Kayrer has related 
 in the Mtil. y'iitiis lor iStlO a ease of sciatica in a syphilitic man, ;t't. .']0, in whom swell- 
 ing was detected in the nerve sheath, ami pain was at once relieved by puncturing the 
 j)art with a knife. 
 
 As much may likowi.so be said for iuTve-stret(;hinL'. which is to I*c preferrc<l. 
 
 Neuroma. 
 
 Any tumor connected with a nerve is called a •• neuroma." These neuromata may be 
 of a til)rous or of a fibro-ctdlular kind, and there is reasoji to believe that they have an 
 inflanunatory origin. They may be very small or of large dimen.sions ; and when large, 
 they may contain cysts. Sometimes they are developed vithiu the nerve sheath ; at 
 others they are situated iipnu it. In a third class the fibrillai of the nerve trunk appear 
 to be separated by the new tissue or to become incorporated with the growth. They are 
 at times single, but more fref|uently multiple, and occasionally involve nearly every cer- 
 cbro-spinal nerve in the body. Wilks has recorded sucli a case in the Path. Soc. Trnna., 
 vol. X., in which after death neuromata were found all over the body, appearing as nod- 
 ules on some nerves and as distinct tumors on others ; the nerves aj)peared of irregular 
 size and were indurated, the til)rous tissue being infiltrated among the nerve fibres. The 
 pneuniogastric nerve had a tumor the size of an egg upon it. Dr. Smith of Duldin, in 
 his unrivalled monograph on the subject, has recorded an instance in which many hun- 
 dreds of such tumors existed ; other similar cases might be quoted. 
 
 Symptoms. — These tumors are not painful, as a rule; indeed, in the most marked 
 examples of this disease, in which the tumors are multiple, they are often not recogniz- 
 able till after death. Pain, however, is sometimes present, aggravated on pressure and 
 apparently depending much upon the mode in which the nerve is involved. The affection 
 is not to be confounded with the jyainful suhcutaiteouA tumor. 
 
 When the ends of a divided nerve become bulbous from fibrinous effusion, what is 
 called a traumatic neuroma is formed. When this becomes involved in the cicatrix of a 
 stump, it is an exceedingly jiainful affection, and is thought by some surgeons to be more 
 common after flap amputations than others. It must be remembered, however, that all 
 nerve trunks become more or less bulbous after amputation. 
 
 Treatment. — There is no reason why neuromata should be removed or touched unle.ss 
 they are large or painful. When from these causes they require treatment, the operation 
 should be performed, care being observed to di.ssect the tumor from the nerve when it is 
 possible, which, however, can rarely be done. In 1882 I removed a cy.stic tumor the size 
 of a large nut with permanent success from the upper cord of the left brachial plexus 
 of a lady-patient of mine who had suffered continual agonies of pain down the arm ; the 
 cyst was in the nerve cord itself. I have removed others from the median and sciatic. 
 In the former case the tumor had been treated by another surgeon as a ganglion and 
 punctured. 3Iany cases ai"e on record in which large neuromata have been excised with 
 the nerve trunk and a good recovery has followed, even with a restoration of the func- 
 tions of the divided nerve. Traumatic neuromata should always be excised when caus- 
 ing much pain ; but when associated with symptoms of spinal irritation, which may 
 possibly be due to a neuritis travelling up the affected nerve trunk, the forcible 
 stretching of the nerve, as recommended by Billroth and Nussbaum and practised by 
 others, should be employed. 
 
 On Nerve- Stretching. 
 
 In 1869, Billroth cut down upon the sciatic nerve with the view of removing a 
 neuroma, and, though no tumor was found, the manipulation and stretching of the nerve 
 brought, unexpectedly, permanent relief to the pain the patient had experienced. Three 
 years later (February, 1872) Nussbaum of Miinich cut down upon the brachial plexus to 
 stretch some of its trunks for painful spasmodic contraction of the ilexors of the arm and 
 hand, and the operation was successful. 
 
 Since these early operations of nerve-stretching many have been undertaken with 
 yery variable success. 
 
 It would seem from the excellent papers noted' that when a nerve is stretched 
 ' Revue de Chirurc/ie, 18S2, Paris; J/erf. Rec. Xew York, September, 1S82, 
 
254 PAINFUL SUBCUTANEOUS TUMORS. 
 
 extravasation of blood takes place within its sheath above and below the point of 
 traction where the vessels from the nerves penetrate the sheath, and that these extra- 
 vasations entirely disappear in about five or six weeks ; that embryonic cells under the 
 sheath and wasting of the superficial nerve-fascicles with some segmentation of the 
 nerve cells are found ; that if the nerve be drawn away from the spinal cord anaes- 
 thesia with slight paresis follows, but iT toward the cord the paresis is increased and 
 there may be a loss of reflexes. 
 
 There is also evidence to show that the stretching may produce some change in the 
 nerve centres themselves, as indicated by more or less persistent modifications of function 
 of different parts of the body. 
 
 In seventy operations for sciatica statistics indicate that in sixty the patient was 
 either cured or greatly relieved, and that in the majority of cases the relief was per- 
 manent. 
 
 In thirty-seven operations on the fifth pair of nerves success was reported in twenty- 
 nine, and that in traumatic neuralgia the success was equally good. 
 
 Xerve-stretching for locomotor ataxia has been attempted in fifty-seven cases, and in 
 sixteen with decided success. It has likewise been employed for traumatic tetanus in 
 fifty cases, with ten recoveries. 
 
 Langenbeck states very decidedly that it is better to stretch the sciatic nerve in its 
 middle or lower third below its muscular branches, there being thus less risk of the ope- 
 ration being followed by atrophy of the limbs. 
 
 The dangers of the measure are such as attend all operations. It is, consequently, an 
 operative proceeding of a justifiable kind, but one that requires caution in its application. 
 
 The operation consists in the free exposure of the nerve trunk by incision and the 
 application of forcible traction to it, both proximally and distally. The traction has 
 been great, as one author, in describing the operation as applied to the sciatic nerve, says 
 that " the limb of the patient should be lifted from the table by the sciatic nerve." This 
 is probably unnecessary, but under all circumstances the stretching should be enough to 
 destroy the sensibility of the nerve for some days. 
 
 Painful Subcutaneous Tumors. 
 
 These tumors are clinically to be sepai'ated from the neui*omata, which have just been 
 considered, although they have often doubtless been confused with them. They are not, 
 however, nerve tumors. They were first described by Wood in the Edinburgh Mediad 
 Journal for 1812. They are usually single and situated in the subcutaneous tissue, and 
 are rarely larger than a small bean. They are encysted and give to the finger a hard 
 elastic touch. To the eye they appear bright yellowish or a pearl}- white, and are made 
 up of fibro-cellular or fibrous tissue.' Intense pain/ulness is their clinical peculiarity, 
 although they have no such nerve connection as will explain their excessive sensibility. 
 The pain, says Sir J. Paget, is of the nature of that morbid state of nerve force which 
 we call neuralgia. 
 
 The painful character of these tumors is very peculiar. It is not constant, nor does 
 it appear to depend upon any injury, and sometimes comes on without any assignable 
 cause or after only the slightest touch, the pain beginning in the tumor, gradually increas- 
 ing in intensity and extent till it becomes almost unendurable, darting from the tumor up 
 and down the limb or over the body. The muscles of the limb may likewise be spas- 
 modically affected. The paroxysm may last only a few minutes or may continue for 
 hours, and subsides, as it appears, gradually, leaving the parts tender that were the seat 
 of pain. These painful tumors are most frequent in the female, the neuromata more fre- 
 quent in the male. 
 
 TreaTiMENT. — The only treatment is the excision of the growth, which is generally 
 effectual. These tumors rarely recur, although Sir J. Paget has recorded one or two 
 examples of recurrence. 
 
 ' Rtvue de Chirur<jie, 1872, Paris. 
 
L'XA.^fiSA'rioy or nir: faehali. a.\j> rj's aj'I'ENDAges. 255 
 
 en APTKK VITT. 
 DISEAS l-:s A N I » I N.I I I ; I lis ( » I" T 1 1 K HYE, ETC. 
 
 Hv CIlAin.KS IIHi(ilN.S. 
 
 EXAMINATION OF THE EYEBALL AND ITS APPENDAGES. 
 
 The exaniiiiatioii of the eyeball will be coiisideretl under lour heads: 
 1st. By the unaided eye. 
 2d. By lateral illuniinati(tn. 
 3d. By the iiphthahnoseupe. 
 
 (a) Direct examination. 
 
 (/<) Indirect exaniiiuitiou. 
 4th. By manipulation. 
 The rtfrxctitiii of the eyeball, the field of vision, etc.. will also receive a .short notice. 
 
 I. Examination by the Unaided Eye. 
 
 In order to examine the outer surface of the eyelid.s, ocular conjunctiva, cornea, 
 anterior portion of sclerotic, aqueous chamber, and lachrymal apparatus, it is necessary 
 to place the patient in a jrood light (as before a window) and direct him at first to close 
 the eyes, then open them widely and look by turns in different directions. 
 
 To examine the palpebral conjunctiva it is necessary to evert the upper lid and to 
 draw the lower one downward. Ever.sion of the upper lid can be accomplished thus: 
 The surgeon, standing in front of the patient, should direct him to look downward and 
 close the eyes ; he should then place the forefinger of one hand upon the lid at the 
 attached or upper border of the tarsal cartilage and make gentle pressure downward and 
 backward, so as to cause the free edge of the lid to stand away from the eyeball, then 
 place his thumb beneath the margin of the lid and make a slight upward movement, at 
 the same time continuing the pressure with the finger ; by this means the lid will be made 
 to turn u])on itself and become everted. The lid may also be everted by pre.ssing a probe 
 horizontally upon its outer surface and drawing it upward by means of the lashes, at the 
 same time making pressure downward with the probe. 
 
 To examine the conjunctiva covering the lower lid. all that is necessary is to place the 
 finger upon the margin of the lid and draw it strongly downward, when its conjunctival 
 surface will become exposed. 
 
 Normal Appearances. 
 
 The outer surfiice of the eyelids is covered by soft, delicate skin, which is thrown 
 into folds on every contraction of the orbicularis ; their free margins are of some thick- 
 ness. From the outer edge of this free margin project the lashes in two or three rows, 
 those of the upper lid being thicker and longer than those of the lower. The la.shes 
 extend along the whole outer edge of each lid, but are much fewer and more delicate in 
 that portion extending from the tear punctum to the inner canthus. 
 
 The inner edge of each margin is occupied by the orifices of the Meibomian glands, 
 which are seen as a close set of yellowish points. 
 
 T/ie ocular coiijuucfini is smootn. moist, .shining, and transparent, allowing the white 
 sclerotic to show plainly through it ; a few vessels are generally seen running from the 
 outer and inner canthi toward the cornea, but these are perfectly consistent with a 
 healthy condition of the membrane. The caruncle and semilunar fold occupy the space 
 immediately external to the inner canthus. the former appearing as a small reddish-gray 
 projection, the latter as a well-defined pinkish fold. The palpebral covjimctiva is also 
 smooth, moist, shining, and transparent, and appears to have somewhat of a yellowi.sh 
 color, from the tar.sal cartilage, to which it is closely and evenly united, showing through 
 it. That portion of conjunctiva reflected from the lids to the globe {fornix) appears 
 somewhat thickened and wrinkled and is slightly more vascular than the ocular and 
 palpebral portions. 
 
 Parts requiring Special Notice. — Certain parts of the conjunctiva require to 
 
256 EXAMINATION OF THE EYEBALL AND ITS APPENDAGES. 
 
 be specially examined. The portions next the thickened margin of the lid, the fornix, 
 and about the caruncle are the most likely situations for the lodgment of a foreign body. 
 That portion covering the attached border of the tarsal cartilage also should be noticed, 
 as it is here that granular ophthalmia manifests itself most plainly. 
 
 The cornea is smooth, shining, and perfectly transparent throughout, except in the 
 case of old people, in whom a bluish-white rim (arcus senilis) is often seen occupying 
 more or less of the structure, somewhat within its margin ; no blood vessels are seen on 
 its surface or in its substance. 
 
 The anterior jyort ion of the sclerotic is pearly white or of a pale bluish tint and shining. 
 It is plainly visible through the transparent conjunctiva covering it; some fine vascular 
 twigs may occasionally be seen traversing it in front of its equatorial region. The aque- 
 ous chamber is filled by the aqueous humor, which is transparent, colorless, and of such 
 quantity as to preserve the proper curvature of the cornea without causing tension or 
 allowing of laxity, and to keep it separated from the iris by a considerable interval. 
 
 The iris varies in color in diiferent individuals ; it is bright, shining, and marked by 
 slight radiating ridges around the pupil ; it presents in health no appearance of blood 
 vessels. Its plane is exactly vertical ; the pupil, situated somewhat to the inner side of 
 the centre of the iris, is perfectly circular and dilates and contracts quickly with vari- 
 ations of light. 
 
 The examination of the lachrymal apparatus gives chiefly negative results ; the posi- 
 tion of the tear puncta closely in contact with the ocular conjunctiva must be noticed ; 
 pressure with the finger over the lachrymal sac causes no escape of fluid through the 
 puncta, neither can the lachrymal gland be felt or seen in a normal condition of the 
 parts. 
 
 n. Examination by Lateral Illumination. 
 
 By this method all the parts mentioned above are seen more clearly ; minute foreign 
 bodies, slight opacities of the cornea, etc., which might be overlooked in examining with 
 the unaided eye, are discovered, and in addition the whole of the lens and the anterior 
 portion of the vitreous can most satisfactorily be looked into. 
 
 The method of examination should be as follows : The patient should be seated in a 
 dark room (the pupil having been previously dilated with atropine) and a lamp placed 
 at abovit two feet distance on the left and rather in front of his face. The surgeon should 
 stand nearly in front, or rather to the patient's right side, and facing him ; he should then 
 take in his right hand a bi-convex lens of about 2i inches' focal length.* and with it con- 
 centrate the light on the surface of the cornea ; with a little manoeuvring he will find that 
 he can thi'ow the light through the pupil to a considerable depth into the eye. The 
 patient should be told to look in various directions, so that all parts of the anterior por- 
 tion of the eye may be examined. 
 
 Results Obtained. — The results obtained by lateral illumination are chiefly nega- 
 tive. The lens in health is perfectly transparent and in youth is nearly colorless, but 
 some bluish lines showing its division into diff"erent segments can be recognized by care- 
 ful examination. As age advances these lines become more marked and the whole lens 
 appears of a bluish-gray color, though its transparency is still unaff"ected. 
 
 Behind the lens all appears dark, but any tumor, hemorrhage, etc., occupying the 
 anterior part of the vitreous would be discovered. 
 
 It should be noticed in the examination by lateral illumination that opacities of the 
 cornea, etc., always appear with greatest distinctness on the side which is farthest from 
 the light. A second lens may also be used to magnify the parts illuminated by means 
 of the first. 
 
 in. Examination by the Ophthalmoscope. 
 
 Description of the Instrument. — The ophthalmoscope, as used at the present 
 day, consists essentially of a mirror of silvered glass or polished metal having a central 
 opening, with certain accessory portions in the shape of convex lenses of different foci, 
 used as objective lenses, clips and other contrivances for holding ocular lenses behind the 
 sight-hole of the ophthalmoscope, together with the ocular lenses themselves. The oph- 
 thalmoscope since its introduction has undergone innumerable modifications, both in prin- 
 ciple and detail, the number of diff'erent instruments now in use being nearly or quite 
 as great as that of ophthalmic surgeons. 
 
 ^ A lens of 2| inches' focal length is about equal to one of sixteen dioptrics in the metrical 
 svstem. 
 
(H'liril ALMnscoriC /•;.V.1.1//.V.I770.V. 
 
 257 
 
 Fig. lOG. 
 
 Till' IlKist USfl'iil t'linii nf (i|ilitli:illiin>rii|)c IS tli.it n\' I ii el ircidi ; tlic latest liioililiciition 
 (Fi<,'. Hit!) (if this iiistniiMciit cdiisists <it" a silvcffd ;^l:iss (•(Hicavc iiiirfor oi' almut H inclics' 
 fui'al k'ligtii, liaviii'; a rcntral opi-iiiiij; in the silvi'riiij; ui" a line and a half (liaiiictcr. The 
 luirrttr is fixi'd in a metal hack, havin<:: a central perforation ahout douhle the diameter 
 of the opeidnir in the silvering. l')>on the metal hack is fixed a clip for the j)nrpo>e of 
 holilini:; an ocular lens; the hack is screwed to a liandle ahout U 1 inches lonj;. The acces- 
 sorv jxirtions consist of t\V(t ohjeet lenses of 21 and '.'» inches" local leiijrth respijctively,' 
 autl live ocular lenses — two convex, of (I and 12 inches positive foci /^ three concave, of 
 S, 12, and 24 inches nepitive i'oci ;'' all are made to lit into the ahove-mentioiied clip A 
 Verv convenient case contains the whole. 
 
 Method of Using the Ophthalmoscope. — There are two methods of usinp 
 
 tliis instrument. The lirst, which re(|uires much |iracticc, i.s called the direct method of 
 examination, or examination of the im/ iiiiiuj>\ with the ophthalmoscope alone, witliout" 
 the aid of a hi-coiivex ohjeet lens. 
 
 The secoiul, which is much the easier of the two. is called the indirect method, or 
 examination of tlic Inverted imaeje ; in it hotli tlie ophtlialmoscope and a bi-convcx lens 
 are used. 
 
 Direct (//i/il/id/Di'isiiijiir Kxaniiiudion. — In this method a virtual erect image situated 
 behind the eye is seen. The examination is conducted in the followiii'.'' manner: 
 
 The patient being seated in a dark room, a gas or other lamp (gas being preferable) 
 should be placed at the side corresponding to the examined eye, on a level with it, but so 
 situated as to leave the cornea in shade ; he should then be directed 
 to look forward and a little upward, at some distant object, and to 
 keep the eyes as steady as possible. 
 
 Supposing the right eye to be examined, the lamp should be 
 placed at the patient's right side ; the observer, standing in front at 
 a distance of LS inches or 2 feet, should take the ophthalmoscope in 
 his riglit hand, look through the sight-hole with the right eye, and 
 reflect the light from the lamp through the pupil of the patient's 
 right eye. If the examination be conducted properly, the pupil 
 will appear of a bright-red color. The observer should then look 
 for the optic disc, which is situated rather to the inner side of the 
 axis of the eyeball ; he will know that the disc is in view from the 
 alteration in c(jlor of the pupil, which will turn from red to white 
 or pinkish white. Having obtained the peculiar reflection of the 
 optic disc, the observer (taking care to relax his own accommoda- 
 tion) should approach the eye until an interval of only 2 inches 
 separates his cornea from that of the examined eve. Some difficulty Liebreich's Ophthalmo- 
 
 . . , . , "^ "^ scope 
 
 will be experienced in keeping the eye illuminated, increasing as the 
 
 distance between the observed and the observer becomes less ; this, however, will be over- 
 come by practice. When the observed eye has been approached to within a distance of 
 2 to 8 inches (supposing both the examining and examined eye to be emmetropic), a dis- 
 tinct erect and greatly magnified image of the parts occupying the fundus of the latter 
 should be obtained ; most observers will, however, find the image sharpened in outline 
 and detail by using a weak concave lens behind the sight-hole of the ophthalmo.scope. 
 Should either the observer or the patient be myopic, it will be found necessary, in order 
 to examine the erect image, to place behind the sight-hole of the ophthalmoscope a con- 
 cave lens which rather more than neutralizes the existing ametropia. 
 
 The examination of the erect image, although requiring considerably more practice 
 than that of the inverted, should never be neglected, as it gives much more satisfactory 
 evidence of minute changes in the fundus oculi, all the parts being seen liighly magnified 
 (about fourteen and a half times). It gives, however, a less extensive field of vision, on 
 account of the size of the objects, wdiich only allows small portions of them to be seen 
 through the pupil at one time. 
 
 The optic disc, retinal ves.sels, and other parts occupying the fundus should be exam- 
 ined by looking in different directions through the pupil, the observed eye being kept 
 steadily fixed during the examination upon some distant and suitably situated object. 
 
 The right eye having been examined, the lamp should be placed on the patients left 
 side aud the manaMivre repeated, the observer using the left hand and left eye instead of 
 
 ' Sixteen and thirteen dioptrics, metrical system. 
 
 ^ Ahout .'ieven and three dio])trics, convex. 
 
 ^ About five, tliree, and one decimal five, dioptrics concave. 
 
 17 
 
258 
 
 OPHTHALMOSCOPIC EXAMINA TION. 
 
 the right hand and right eye. The condition of refraction of the eye can be diagnosed 
 by the direct method of examination. 
 
 Indirect Ophtludmoscopic -Examination. — In this metliod of examination an inverted 
 aerial image of the fundus oculi is formed by the interposition of a bi-convex lens 
 between the observer and observed eye. (See Fig. 107.) 
 
 Fig. 107. 
 
 A observer's. B observed, eye. F, the light. S, the mirror. L, the biconvex lens, a fi, some portion of the retina 
 or the disc, a' /3', its inverted aerial image formed between the mirror and bi-convex lens. (From Carter's trans- 
 lation of Zaiider on the Ophtlialmoscope.) 
 
 The position of the patient and observer should be the same as for the direct exami- 
 nation ; the same lamp also can be used, but should be placed rather farther back and 
 kept on the patient's left side during the examination of either eye. The ophthalmoscope 
 should be held in the same manner and the light reflected through the pupil as detailed 
 above ; but, the red I'eflection having been obtained, the observer must not approach the 
 eye, but remain at a distance of about 18 inches. 
 
 The patient should be directed to look at some distant object so situated that the axis 
 of the observed eye is turned slightly inward; this brings the optic disc (which lies some- 
 what to the inner side of the optic axis) opposite the ophthalmoscope, and its peculiar 
 bright reflection will be at once ob.served. 
 
 The bi-convex lens should then be held in front of the observed eye at a distance 
 about equal to its own focal length from the cornea, and steadied by the observer resting 
 his ring-finger and little finger on the patient's brow. By this means an inverted image 
 of the optic disc and vessels of the retina is immediately seen, which, although apparently 
 within the eye, is in reality formed in the air between the observer and the bi-convex 
 lens, and (in emmetropia) at a distance from the latter corresponding to its focal length. 
 
 If the image of the disc appear indistinct, the observer may be sure that his own eye 
 is not accommodated for the distance at which the image is situated, which is, in reality, 
 shorter by some inches than it appears to be. Should this be the case, the observer must 
 increase the ten.sion of his accommodation or withdraw somewhat farther from the observed 
 eye. 
 
 A better method, however, than either of the foregoing is to employ habitually behind 
 the sight-hole of the ophthalmoscope a convex ocular lens of about 10 or 12 inches' focal 
 length. If this be done, a clear and well-defined image will always be obtained without 
 tension of accommodation, provided precautions be taken that the distance between the 
 observer's eye and the image be not greater than the focal. length of the convex ocvlar lens. 
 
 The disc and parts immediately surrounding having been examined, the patient should 
 be directed to look straight forward, so as to bring the region of the yellow spot opposite 
 the ophthalmoscope ; this having been carefully examined, the eye should be turned 
 upward, downward, to the right and left, so that all parts of the fundus ma}' be exam- 
 ined in turn. 
 
 In the indirect method of examination the observer should use his right eye and hold 
 the ophthalmoscope in his right hand and the bi-convex lens in his left in examination of 
 the right eye, and vice veraCi in examination of the left. 
 
 Difficulties of Opthalmoscopic Examination. 
 
 Considerable practice is required in order to become proficient in the use of the ophthal- 
 moscope ; the beginner will be frequently much disheartened at his want of success. 
 Some of the difiiculties are only to be overcome by practice ; others are easily remedied. 
 Reflections of the mirror from the two surfaces of the object lens often prove very 
 troublesome ; the inconvenience ari.sing from this source is obviated by holding the lens 
 
 ^ Four or three dioptrics. 
 
OrilTllALMOSCOPia EXAMISATlnX. 259 
 
 KoiiR'wliat ()l)li(|uely, wlu-ii tlio two iiiia^(!.s will recede from each other and leave a clear 
 .space Ix'twffii tlu'iii. llefleetioii IVnm the surface of the cornea may he trouhlesoine, hut 
 can n>u;ill\ lie overcome hy a little nian<euvriiijr- Cniitraction of the pupil is also an 
 iiisuriiiouiitahle ohstade to the he<;inner, hut can he removed hy dilatation with atropine; 
 fi>r this purpose a solution of one grain to one ounce of water should he dntpped into the 
 eye ahout half an hour hefore the examination is made, or the patient may he ordered to 
 use a solution of (tne-eighth grain t<t one ounce two or tliree times on the day preceding 
 it. When e.xperientu' has heen gained, however, atropine can he dispensed with, except 
 in some few eases or in those where it is nece.s.sary to make a very careful examination 
 hv l:it(M-al illuniiiiatiiiii. 
 
 II" the patient ln' diroeted to look at a distant ohjecf , the accommodation is relaxed, and 
 sutheieiit increase in the j)upillary area will generally take jdace. 
 
 KiVery ophthalmoscopic examination should be conducted on a certain delinite system. 
 
 The Jirst xh-p should he to examine the condition of the refractive media by lateral 
 illumination. 
 
 Xf'xf, the cnwUtion of refrttrli'nu of the eye and tlie state of the vitreinis cliamher 
 should he ascertained by the direct metliod of examination. 
 
 Thinllj/, II i/eiienil sitrvet/ of tlie fundus oculi should he made ])y the indirect method. 
 
 Ami, f'onrthli/, any ahnttrmalities having l»een discovered hy the indirect examination 
 should he fully and carefully studied in detail by the direct method. 
 
 If tliis systematic plan of examination be carried out, few mistakes will be made, and 
 no abnormality of importance is likely to be overlooked. 
 
 Normal Appearance of Parts seen by the Ophthalmoscope. 
 
 The refractive media (cornea, aqueous humor, lens, and vitreous), as stated under 
 " Lateral Illumination," are perfectly transparent. 
 
 The retina is either quite tran.sparent and colorless, or in dark eyes may appear as a 
 faintly gray cloud covering the choroid ; its position is marked by that of its blood ves- 
 sels. The bright-red reflection previously mentioned is due to the blood in the choroid ; 
 the depth in color of the reflection varies with the amount of pigmentation of this vas-' 
 eular tunic : in blue or gray eyes it is light red, in dark ones of a much deeper tint, and 
 in the negro a])pears to be dark blue. The parts of the fundus oculi retjuiring special 
 attention are the oj)tie disc and parts immediately surrounding it and the region of the 
 yellow spot. 
 
 The disc appears at first sight to be of a uniform pale pink color, hut on closer 
 examination different portions are found to present different shades. 
 
 Its centre is pale, or even white ; next to this succeeds a zone of pink, this being 
 again bounded by an apparently double border of lighter color. The pale appearance of 
 the central portion of the disc is caused by connective tissue surrounding the blood ves- 
 sels in this situation. The succeeding pink zone consists entirely of nerve fibres and 
 delicate capillaries. The outer pale double border is formed by the margins of the sclero- 
 tic and choroidal rings, which do not accurately cover each other, the choroidal ring being 
 somewhat greater in diameter than the sclerotic opening, the margin of which, being left 
 uncovered by pigment, shines through the transparent nerve fibres. 
 
 Both the white central portion and the outer ring are in some cases so distinctly 
 marked that the appearance produced might be taken by an inexperienced observer as 
 evidence of disea.sc, but both conditions are perfectly consistent with health. From the 
 pale central portion of the disc proceed the retinal blood vessels ; the.se appear upon its 
 surface usually at the same point, but may emerge separately or in groups of two or 
 three. 
 
 As a rule, ahout eight ves.sels are seen upon or close to the disc, four of these being 
 arteries, with a corresponding number of veins ; two of each pass upward and a like num- 
 ber downward, to be distributed over the retina. The lateral branches are comparatively 
 insignificant, and are given off from the principal trunks either upon the nerve surface 
 or in the retina near its margin. 
 
 Distinction between Arteries and Veins. — The veins are distinguished from 
 
 the arteries by being of greater calibre, the proportion being ahout 3 to 2. There is also 
 a difference in color between the two, the veins being the darker ; the arteries are marked 
 by a double contour and their central ]iortion is much lighter than their borders. 
 
 Occasionally a dark spot is noticed in one of the vessels at its origin or termination in 
 the disc. This might be taken for a clot, but the appearance is caused by a peculiar 
 
260 OPHTHALMOSCOPIC EXAMINATION. 
 
 arrangement of the vessel, which at this point is seen, as it were, on end and foreshort- 
 ened. 
 
 Spontaneous pulsation of some of the retinal veins may also be observed ; the occur- 
 rence of venous pulsation is. however, perfectly consistent with health and has no patho- 
 logical import. 
 
 In any eye. pulsation, both arterial and venous, can be produced by pressure upon the 
 globe, but should it occur spontaneously in the arteries has the gravest significance. (See 
 " Glaucoma.") 
 
 Anomalies of Optic Disc, etc., consistent with Health. 
 
 Certain phenomena are not unfrequently obsei'ved with the ophthalmoscope which, 
 although contrary to the condition usually met with, are perfectly consistent with a 
 normal state of the parts. 
 
 The appearances caused by the connective tissue surrounding the central vessels, the 
 occurrence of pulsation, unusual distribution, and existence of dark spots in the latter, 
 together with the unusual distinctness of the sclerotic ring, have been already mentioned. 
 
 Other anomalies are : 
 
 1- A dark crescentic figure bordering some portion of the margin of the disc. 
 This appearance is caused by a peculiar arrangement of the choroidal pigment ; it is 
 congenital. 
 
 2. Variations in the depth of color of the disc are frequently met with, 
 Due regard must be had to the color of the surrounding fundus in forming an opinion as 
 to whether the tint in any particular case is so much deepened or lessened as to consti- 
 tute a diseased condition. 
 
 In light eyes the disc appears much redder than in dark, the apparent difference 
 being due more to contra.^t with the surrounding parts than to actual change in color. 
 
 Slight deviations are only to be determined by careful examination and long experi- 
 ence. 
 
 3. Excavation of the Optic Disc. — Not unfrequently a sloping, or even an 
 abrupt, depression is met with occupying the centre of the disc, but usually extending 
 somewhat farther toward the yellow spot than in other directions. The whole nerve 
 surface, however, is never included in the cup ; the vessels do not bend under its edge, 
 their calibre is not altered, neither is spontaneous arterial pulsation observed, as may be 
 the case in the excavation of glaucoma. (See " Glaucoma."') 
 
 4. Persistence of the Hyaloid Artery. — Occasionally a small whiti.sh cord 
 may be seen extending from the centre of the disc to the back of the lens ; it is the 
 remains of a vessel which during foetal life nourished the latter structure. 
 
 5. Senile Changes. — As age advances the refractive media become less trans- 
 parent, the retina grows somewhat hazy, and the disc appears whiter than natural. 
 
 6. An appearance of white wisp-like patches, extending from some 
 
 part of the margin of the disc over the surrounding fundus. These patches have in-egular 
 jagged borders and are often of considerable size ; the retinal vessels pass through and 
 are obscured by them. Occasionally white threads may be continued for a considerable 
 distance along the sides of the vessels. 
 
 The patches are caused by the opac(ue nerve sheaths, which should end at the lamina 
 cribrosa. being accidentally continued beyond this point into the transparent retina ; they 
 are congenital and do not interfere with vision. 
 
 7. the choroidal vessels are at times Tespecially in light eyes) very plainly 
 visible, appearing as an irregular network of pale pink bands. 
 
 The region of the yellow spot presents in health no very marked ophthalmo- 
 scopic signs, but requires special notice, as it is frequently the seat of pathological lesions. 
 In the normal condition it is recognized by the absence of blood vessels, which appear to 
 avoid this part of the retina and pass above and below it. by some deepening in color, 
 and occasionally an indistinct, dark, transversely oval figure can be detected. 
 
 IV. Examination by Manipltlation. 
 
 The fourth method of examination, hy manipulation, consists simply in ascertaining 
 the tension of the globe by digital pressure. The examination should be conducted as 
 follows : 
 
 Tension of Globe. — The patient being directed to look downward and close the 
 
REFRACTION. 
 
 2t;i 
 
 eye prcntly. Imt not to sorow up the lids, tlie surtreoii .sIimiM make pentle alternate 
 pressure with the f'nretiiitrer of each hand placed upon the closed upper lid; the pressure 
 should be made in a direction liackward ami somewhat downward, s<j as to compress the 
 glohe a<;ainst the flcinr ol' the orhit. 
 
 In health the eyeball is firm, tense, and semi-fluctuating; in disease the tension may 
 deviate in the direction of increase or decrease. The degree of tension may be expres.sed 
 as follows : 
 
 If normal, as Tn ; if above par, as T 4- 1, T -r 2, T + 3, according to the amount of 
 increase ; if below par, as T — 1, T — 2, T — 3. If a doubt exist, as T -}- ? or T — ?, 
 according as the doubt is on the side of increase or decrease. 
 
 REFRACTION, ACCOMMODATION, ACUTENESS, AND FIELD 
 
 OF VISION. 
 
 DEFlNlTtoN. — By refraction of the eye we understand the power which the refractive 
 media (cornea, humors, and lens) possess by virtue of their curvatures and densities of 
 bringing together y>")v</A7 rays of light and forming them into an image at a certain spot 
 (known as the principal focus of the refractive or dioptric system) irithoiit the employiwnt 
 of iini/ adjust iiiij poirer. 
 
 The refraction is said to be normal or abnormal according to the position of the retina 
 with regard to the focus of the dioptric system. The former condition is known as 
 emmetropla. the latter as ametropia, the terms " normal " and " abnormal "' being seldom 
 applied. 
 
 Emmetropia. — The emmetropic eye (Fig. lOS) is of such a shape that the retina 
 is situated at the focus of the dioptric system, and in such a po.sition that a distinct and 
 inverted image of any object (Me rays of light ju-occedimj from uhich are parallel ) is 
 formed upon the layer of rods and cones. 
 
 Ametropia. — The ametropic eye differs from the emmetropic in two opposite direc- 
 tions ; the deviations are known as atiomalies of refraction. In the first and (m this 
 country') most commonly met with anomaly the retina lies irithin the focus of the diop- 
 tjic system — that is to say, the axis of the eyeball is too short from before backward ; 
 
 Fig. 108.2 
 
 a. Erametropia. 6. Myopia. c. Hype r metT Op ia. 
 
 (From Donders, Accommodation and Refraction of the Eye. i 
 
 and images of objects the rays of light proceeding from which are parallel are formed 
 behind the retina instead of in its substance. This anomaly is known as hi/permetropia, 
 or far sight. (See Fig. lOS, c.) 
 
 To the second anomaly an opposite state of things pertains : the axis of the eyeball 
 
 ' It is generally believed amongst English, and is also supported by continental, oplithalmologists 
 that in this country hyperraetropia is of more frequent occurrence than myopia. It appears to me 
 that the reverse may obtain. . We are rarely in hospital practice consulted about slight myopia, as it 
 gives no inconvenience. On the other hand, a very slight degree of hypermetropia may incapacitate 
 the seamstress. skille<l mechanic, or clerk ; so that, whereas we get all degrees of hypermetropia. we 
 are only applied to in the higher degrees of myopia. 
 
 * In these diagrams o" shows posterior focal points of the dioptric system ; j, in b and c. the 
 abnormal position of the retina. 
 
262 REFRACTION. 
 
 from before backward is too long; consequently, the retina lies outside the focus of the 
 dioptric system, and the image of an object the rays of light coming from which are par- 
 allel is formed in front of it. This anomaly is known as myopia^ or short sight. (See 
 Fig. lOS. b.) 
 
 Diagnosis of Anomalies of Refraction. — The diaijuoi^l^ of anomalies of 
 
 refraction can be made by trial with lenses, by direct ophthalmoscopic examination, and 
 by '' kcratoscopy." If we wish to diagnose and measure the degree of anomalies of 
 refraction by trial with lenses, we must be provided with a set of trial glasses and a 
 book of Snellen's test types. (See p. 2G5.) 
 
 The trial glasses which have now come very generally into use are arranged accord- 
 ing to what is known as the " metrical system." The unit in this system is a lens of one 
 metre focal length ; it is called a " dioptric " (= D). A lens of two dioptrics is double 
 the strength of that of one dioptric and has a focal length of half a metre (50 centimetres), 
 and so on. The box of trial glasses contains convex and concave spherical and cylindri- 
 cal lenses. It can be obtained from any good optician. 
 
 Test of Refraction by Lenses. — We test refraction with lenses as follows: 
 Having placed our patient at (J metres from the sheet on which are printed letters from 
 D = 6' to D = 60, we direct him to look toward it. Should he be hypermetropic, he will 
 be able to make out all or most of the letters ; he will already have told us that he can- 
 not see to do near work or read for any length of time without the eyes becoming fatigued 
 and vision growing misty. We ascertain how many of the letters can be read by each • 
 *eye separately. Should both eyes read the same letters, we hold before them convex 
 glas.ses, beginning with + 1 D, and continue the trial until we have ascertained the 
 stron(/cst convex lens with which the greatest attainable acuteness of vision is still main- 
 tained. Thus, supposing our patient reads D = 6 at 6 metres, we find the strongest con- 
 vex lens with which he can still read D ;= G ; should he read D = 12 without a convex 
 lens and D = 6 by the aid of one, we find the strongest with which he can still read 
 D ^= 6 ; if we cannot improve vision so that he reads more than D ^= 12, we find the 
 strongest convex glass with which he can still read D = 12, and so on. Should there 
 be a difference between the two eyes, we must test the refraction of each separately, 
 keeping one covered during the trial of the other. The strongest convex lens which still 
 allows the patient to see as well at a distance as is possible, either with or without the 
 aid of glasses, shows a part of the accoiumodative power which he was obliged to exer- 
 cise in order to bring parallel rays of light to a focus upon the retina of his too-short eye. 
 The employment of such a lens prevents this waste of accommodation and reserves it to 
 be used when required for near work. 
 
 Should our patient be myopic, he will probably tell us that he is near-sighted ; he 
 will make out but few or none of the letters at G metres ; if the small types be given him 
 to read, he will hold them near the eyes, but will make out the smallest provided the 
 book be held close enough. 
 
 We notice at what distance the small types can l)e read by each eye separately, and, as 
 in hypermetropia, if there be no difference between the two, test their refraction together. 
 
 We tell our patient to look toward the sheet on which are the letters from D = 6 to 
 D — GO, and hold before his eyes concave lenses beginning with that the negative focal 
 length of which corresponds to the distance at which small types are read. 
 
 Thus, if the small types can be read at 20 centimetres, we begin the trial with a lens 
 of 5 D, the negative focal length of which is 20 centimetres. 
 
 We continue the trial until we have found the vcakesf concave lens with which dis- 
 tant letters can be most plainly seen. Should our patient by the aid of any concave lens 
 be able to read D =^ G at G metres, we find the rreakcst with which D ;= G can still be read. 
 Should he be able only to make out D = 24, D = 12, etc., we must still find the weakest 
 concave lens with which the best vision is attainable. 
 
 As in hypermetropia, should there be a difference between the two eyes, we test each 
 eye separately. 
 
 We must be careful to ascertain tJie icedkent lens with which the best vision for distant 
 letters is attainable, because we wi.sh only to so open out the pencil of parallel rays of 
 light as to allow of their being brought to a focus in the retina of the too-long eyeball. 
 
 If we give too strong a lens, our patient will see ecpially well ; but then we have 
 opened out the pencil of parallel rays too much, and he must use his accommodative 
 power in order to overcome the excessive divergence. 
 
 ' The smaller letters D = 5, D = 4, D = 3, etc., placed at their proper distances, will do equally 
 well if we have not a distance of 6 metres at disposal. 
 
Rh'J-n.K Tff)X. 
 
 263 
 
 Diagnosis by the Ophthalmoscope. — In tin- dia^tiosis and mfasuromont of 
 aii(tMialii> 111' nlVailidH hy diirrt uplil iKilinuMopic i-xaiiiiiiution we act upnii the .same 
 priiu'ijde as in the diairuosis by trial with lenses — with this exception, however, that we 
 use uur own eye as a t»'st, instead ol' tlu- patient's vision. 
 
 .\s stated at p. li")", nntliinjr lA' the details (d" the I'limliis i»t' tin- «iiiin<'tropic eye can 
 he i/nii/i/ made out until we have approached it vi-ry near. Now, on the (••mtrary, should 
 any object occupying; tin- fundus lie ilnirli/ srm whilst we are still separated fnim the 
 observed eve by a considerable interval, we may be certain that we have to deal with an 
 anomaly of relVaction. 
 
 The ((uestion now arises, Is the ea.s(! one of hypernuttropia or myojiia ? W<r answer 
 the (|uestion by ascertaininj; whether the object we sec; is viewtid in an erect or inverted 
 j>osition. If till" former, the eye is hypermetropic; if th(! latter, it is myopic. We can 
 ascertain the position (d' the imajre l)y moviiii: our head from side to side. If the imajre 
 be erect it will move in the same, if invcrtcil in an opposite, direction to the niovement.s 
 of the head. 
 
 If wt- wish to ascertain the amount of hypermetropia or myopia present, we take one 
 of the ophthalmoscopes mentioned below, go a.s close as possible to the patient's eye, 
 revolve the lens containinj; discs placed at the back of the in.strument until we have 
 ascertained, in hypermetropia the strongest convex, in myopia the weakest concave, len.s 
 with which we can still see clearly the optic disc and retinal vessels. 
 
 The number of diojUrics of the strongest convex or weakest concave lens with which 
 the greatest attainable acuteness of vi.sion /or distant letters is .still maintained expre.sstf.s 
 what is known as the degree of '• ametropia'." Thus, we say that an eye which sees a.s 
 clearly or more clearly through a convex lens of two dioptrics has a hypermetropia of 
 2 I), an eye of which the acuteness of vision is most improved by a concave len.s of three 
 dioptrics has a myopia of H I), and so on. 
 
 The same holds good in the measurement of anomalies of refraction by the ophthal- 
 moscope. The strongest convex lens in a case of hypermetropia, the weakest concave in 
 one of myopia, through which a clear view of the fundus can .still be obtained, expresses 
 the degree of '" ametropia " present. 
 
 Two very u.seful ophthalmoscopes by means of wliich anomalies of refraction can not 
 only be diagno.sed, but also accurately measured, have been devised — one (Fig. 109) by 
 3Ir. Charles J. Oldham of Brighton (see 
 
 Report of Fourth OpIttJialmic Cotir/ress, Via. 109. 
 
 1872), and another by Mr. W. L. Purves ; 
 the latter is, I think, the more convenient 
 of the two.' 
 
 The third method of ascertaining the 
 form, and also the degree, of ametropia by 
 '• keratoscopy,"' is conducted as follows : 
 The patient, being seated, and the lamp 
 placed rather behind the level of the face, 
 is directed to look straight forward. The 
 observer should stand or sit at a distance 
 of about a metre and a quarter, and with 
 the ophthalmoscope reflect the light from 
 the lamp upon the patient's eye. As soon 
 as the bright red reflection of the fundus 
 is seen the mirror should be rotated. If 
 ametropia be present, a shadow will be 
 seen to pass across the illuminated area. 
 The diagnosis of the anomaly present is 
 decided by the direction of this shadow. 
 If it passes in the same direction as the 
 rotation of the mirror, the eye is myopic ; 
 if in the opposite direction, the eye is 
 hypermetropic. 
 
 In slight degrees of ametropia and emmetropia the shadow is so faint as to be made 
 out with difficulty ; if seen at all, it moves in the same direction as the mirror in slight 
 M, slight H, and E. 
 
 ^ Many other refraction ophthalmoscopes are in use, but the two mentioned, and another smaller 
 and cheaper instrument known as Loring's oplulialnioscope, will be found as useful as any. 
 
 Oldham's Ophthalmoscope. 
 
264 DISEASES OF ACCOMMODATTOX. 
 
 We can ascertain the degree of anomaly present by finding, in myopia, the weakest 
 concave lens which, held before the eye, makes the shadow begin to move against the 
 mirror ; in hypermetropia, the strongest convex lens which causes the shadow to begin to 
 move with the mirror. 
 
 In the examination of refraction by keratoscopy it is well to have the pupil and 
 accommodation fully under the influence of atropine or other mydriatic. 
 
 The observer must be naturally emmetropic or made so artificially. 
 
 The TREATMENT of anomalies of refraction consists mainly in neutralizing the defect 
 by suitable spherical lenses. We must, however, in myopia take care not to give too 
 strong glasses. 
 
 For further information on the subject of refraction the reader is referred to works 
 treating specially of ophthalmic subjects, more especially to that on The Accommodation 
 and Refraction of the Eye (DondersJ. 
 
 Accommodation. 
 
 By accommodation is meant the power which the eye possesses of altering the condi- 
 tion of its refractive media so as to form upon the retina images of near objects the rays 
 of light from which are divergent equally as distinct as images of more distant ones the 
 rays of light from which are parallel or nearly so. 
 
 The power of accommodation depends upon the elasticity of the crystalline lens, the 
 curvature of which can be increased to a considerable extent ; the alteration of curvature 
 is brought about by the action of a ring of inorganic muscular fibres situated between 
 the sclerotic and choroid, just external to the greater circumference of the iris. This 
 ring is known as the ciliary muscle. The manner in which the ciliary muscle acts upon 
 the lens is as yet a disputed point, one theory being that the lens is m'aintained in a flat- 
 tened condition by tension of its suspensory ligament so long as the eye is adjusted for a 
 distant object — that upon accommodation for a near one the ligament is relaxed by con- 
 traction of the muscle and the curvature of the lens (more especially that of its anterior 
 surface) increased by virtue of its own elasticity. The other theory is that the ciliary 
 muscle compresses the lens in some manner and so alters its curvature. 
 
 Range of Accommodation. . 
 
 We speak of the range of accommodation, and by it we mean the power of a lens, 
 which we suppose the crystalline adds to itself when we change our look from the far- 
 thest to the nearest point of distinct vision. Thus, an eye which sees clearly at infinite 
 distance when its accommodation is relaxed, and at 16 centimetres with greatest ten- 
 sion of accomiuodation. has a ranae or " amplitude " of accommodation equal to a lens of 
 iJ)_o = 6 D, about. 
 
 Accommodation is accompanied by convergence of the optic axes from the action of 
 the internal recti muscles and by contraction of the pupil. 
 
 Diseases of Accommodation. 
 
 Paralysis of accommodation is met with in cases of paralysis of the third 
 nerve accompanied by ptosis, divergent strabismus, and more or less dilatation of the 
 pupil; it may be caused by injuries, as blows on the eyeball itself or in its vicinity; 
 sometimes it is met with without apparent cause, not unfrequently in persons recovering 
 from diphtheria or from any exhausting disease, and accompanied by no paralysis of the 
 external ocular muscles ; it can always be produced artificially by the use of atropine or 
 other mydriatics. 
 
 Symptoms. — Dilatation of the pupil, general mistiness of vision, and inability to see 
 near objects plainly, the last condition being capable of correction by the use of a con- 
 vex lens. 
 
 Treatment. — This depends on the cause ; if the paralysis of accommodation be 
 associated with paralysis of other branches of the third nerve, the treatment must be 
 directed against any existing constitutional condition — syphilis, rheumatism, etc. — most 
 improvement being brought about by the use of iodide of potassium in increasing doses, 
 alone or in conjunction with bichloride of mercury. If dependent on injury, the eye 
 should be kept bound up and inflammatory .symptoms treated as they arise. If arising 
 idiopathically, without apparent cause, a solution of sulphate of eserine should be used 
 
/•7/;/./> OF VISION. 265 
 
 twii i>r tliroe times a day in order to stiiimlate the oiliary mu.scle to contract, and attfii- 
 tiiiii |i;iid to the pMieral health. In any case, a convex h-ns may he used if rcfiuired. 
 
 Spasm of acCOinmodation is met with in sinm- cases of liypermctropia, and 
 occasionally in myopia; it ut'ten masks a cdn.sidcrahlc amonnt of hypermetro|iia, and may 
 at times (^ven make the eye appear to he my<>]»ic. If it exists with myopia, tin; de<rn;e 
 of short siiiht is increased. 
 
 Sv.Ml'To.MS. — Severe and constant pain in the eyehalls and forehead, incrijased on any 
 attempt to use the eyes, and associated with some anomaly of refraction T^enerally hvper- 
 metropia), inaliility to see near or distant ohjects distinctly, these symptoms heiiii^ modi- 
 tieil or entirely removed hy the use of atropine. 
 
 Tkkat.MKNT. — Paralyze the accommodation hy the constant use of a stronj^ .solution 
 of atropiiu' (<ir. iv of sulphate of atrojiia to ^j of water) and accurately neutralize any 
 oxistinji; anomaly of refraction hy suitahle lenses. 
 
 ACUTENESS OF ViSION. 
 
 By acuteness of vision we understand the perceptive and conductive power of the 
 structures concerned in sight : this may he ascertained hy the use of test types — i. p., 
 letters of certain definite proportions which can he recognized hy a fairly sharp-sighted 
 eye at certain distances, which distances are marked over each set of letters. 
 
 The hook of test types we use is that of Dr. Snellen ; in it we find types variously 
 numhered from .o to (50, the former heing .5 of a metre, or 50 centitnetres, the latter <J0 
 metres, at whi(di distances the types can he read hy an emmetropic eye of normally acute 
 vision. The hook of types can be obtained of Williams k Norgate, Henrietta street, 
 Covent Garden [or of any optician in the large cities of the United States]. 
 
 Field of Vision. 
 
 By the field of vision we understand the area over which objects situated in the same 
 vertical plane can be distinguished, the eye being kejit fixed on some point. The limits 
 of the field of vision are marked by the most excentrically placed points of objects which 
 can still be distinguished, the direction of the visual axis of the eye; lieing unaltered. 
 
 Mode of Ascertaining the Extent of the Visual Field. — The extent of 
 
 the visual field is easily measured by either of the two following methods : 
 
 1. The patient, being placed at a distance of 12 inches from a blackboard about 3 
 feet square having a white cross in the centre, .should be directed to look steadily at the 
 cross, which must be situated on a level with the eyes ; one eye being closed, the sensi- 
 bility of the retina of the other should be tested by moving a piece of chalk fixed on a 
 dark handle from all directions toward the cross, a mark being made at the point where 
 the chalk first becomes visible. 
 
 The whole area limited excentrically by a line joining the points at which the chalk 
 is first seen when approaching from every direction is known as the quantitative field of 
 vision, in contradistinction to an area bounded excentrically by much narrower limits, 
 over which objects are distinctly defined and letters can be read, etc., known as the quali- 
 tative field of viaion. 
 
 2. Another very simple and effectual method of investigating the condition of the 
 visual field is conducted as follows : 
 
 Having placed the patient in a convenient position, we stand opposite to him. at a 
 distance of about 2 feet, and, supposing his left eye to be examined, we direct him to 
 look steadily at our right eye, which is opposite to his left ; the patient's right eye and 
 our left being kept closed, we then move our hand in various directions in the peripheral 
 parts of the field and notice if its movements are perceived by the patient at the same 
 distance from the centre as by our own healthy retina. 
 
 Care must be taken that the hand is moved in a vertical plane situated midway 
 between our own and the patient's eye, and not nearer one than the other ; we must also 
 take care that he keeps his eye fixed. 
 
 Supposing that the eye under examination distinguislies all movements of the hand 
 at the same distance from the centre as our own. we decide that his field of vision is 
 normal ; but if a falling off is noticed in any particular direction, we infer that the sen.si- 
 bility of the corresponding portion of retina is impaired. 
 
 it must be remembered that each part of the visual field corresponds to a part of the 
 retina opposite to. and not on the same side as, the object seen ; e. y., suppose that the 
 
2Q6 AFFECTIONS OF EYELIDS. 
 
 movements of the hand arc not perceived in the outer half of the fiehl, the inner half of 
 the retina is defective, and vice versa. 
 
 It must also be borne in mind that the heifrht of the bridge of the nose has a consid- 
 erable influence in limiting the inner half of the visual field. Limitation or contraction 
 of the visual field is a very constant accompaniment of retinal changes ; it is also one of 
 the earliest symptoms of glaucoma, and occurs as a physiological condition with advancing 
 age. 
 
 Stereoscopic Test for the Retina. — A very simple and eifectual method of 
 testing the sensibility of the retina has been devised by Mr. Joseph Towne of Guy's 
 Hospital : it consists in presenting simultaneously to non-corresponding halves of the two 
 retinaj similar objects. 
 
 The examination is carried out by means of a stereoscope provided with two slides ; 
 on each slide are two white semicircles described upon a red ground, those on the one 
 slide being so contrived that when looked at through the stereoscope they correspond to 
 the nasal halves of the two retinae, whilst those on the other slide correspond to the two 
 malar halves. In cases of want of sensibility of the whole or any part of the retina, from 
 whatever cause arising, a part or the whole of one or both semicircles corresponding to 
 the affected portion of retina appears misty or entirely obscured. The degree and 
 extent of the mistiness or obscurity is governed by the degree of insensibility and extent 
 of the impaired portion of retina. Mr. Towne has made the stereoscopic test for the 
 retina the subject of some very interesting papers in Gii^^s Hospital Reports, series iii., 
 vols, xi., xii., xiv., xv. 
 
 DISEASES AND INJURIES OF THE EYEBALL AND ITS 
 
 APPENDAGES. 
 
 Several of the more important affections of the organ of vision will be briefly alluded 
 to in future pages ; the present section is devoted to a short description of those diseases 
 and injuries which (with a few exceptions ; e.(/., glaucoma) do not call for operative inter- 
 ference. 
 
 THE EYELIDS. 
 
 Congenital Anomalies. — Absence of the eyelids, a failure of closure of the foetal 
 fissure leaving a cleft in one or both lids (coloboma), ptosis, complete or partial, develop- 
 ment of a third lid, pigment spots, moles, nsevi, and warty growths have all been occa- 
 sionally met with. 
 
 Ulcers. — Simple ulcers, primary venereal sores (chancres), syphilitic and cancerous 
 ulceration, are sometimes met with. The first three require to be treated on general 
 medical pi'inciples ; the last by operation, if the disease has not proceeded too far. 
 
 Phthiriasis. — The pediculus pubis (crab louse) is sometimes found amongst the 
 eyelashes close to the margin of the lids. The edges of the lids appear to be covered 
 with scabs and crusts somewhat resembling tinea; on close examination the insects them- 
 selves will be discovered adhering closely to the margin of the lids, their eggs being 
 attached to the lashes near their bases. 
 
 Treatment. — The daily use of some kind of mercurial preparation, none being better 
 than the Ung. Hydrarg. Ammnniatum. 
 
 Paralysis of the orbicularis muscle occurs in some cases of facial paralysis : 
 there is inability to close the eye, the lower lid falls away from the globe, there is con- 
 siderable collection of lachrymal secretion at the inner canthus, and constant watering of 
 the eye consequent on the displacement of the lower tear punctum. 
 
 Treatment. — General medical treatment should be adopted. 
 
 Spasm of the orbicularis muscle may occur from long-continued intolerance 
 of light consequent on affections of the cornea. 
 
 Treatment must be directed against the corneal affection. (See " Diseases of the 
 Cornea.") 
 
 Spontaneous t'witching, more especially of the lower lid, popularly known as 
 "live blood," is met with in some cases of hypermetropia or in persons whose digestions 
 are out of order ; it is very probably a symptom of undue contraction of the ciliary 
 muscle. 
 
 Treatment. — Correction of existing hypermetropia, instillation of atropine, and 
 attention tf> the general health. 
 
 Inflammation of the eyelids niay occur during or after acute diseases (measles, 
 
TITF fnyjiwcTiVA. 267 
 
 scarlatina, etc.), in the course of erysipelas, as the result of injuries, or in cr)iineetion with 
 severe in flam mat ion of uei^'hhoriiij,' parts; «.//., purulent ophthahuia. The swelliiif; and 
 redness are usually considerable and the eye cannot he opened ; the inflaniiuation gener- 
 ally ends in resolution, hut may (especially it' it result I'rom measles, scarlatina, etc.) j^o 
 on to the formation uf abscess, or even to sloujrhinjr of the skin. 
 
 'rKKAT.MK.NT. — iiOcally. fomentations with hot water nr decoction of jxippy-heads ; if 
 an aliscess form, it should be opi-ned — preferably thmuLdi the conjunctiva. 
 
 'file patient s ucueral health shouhl also be attended to. 
 
 Stye (."hordeolum") is a small red and painful swellin<^ situated on the o\iter 
 surface of the lid or near its inar<.,'iii, and consists in a circumscribed inflammation of the 
 lid dependent on morbid chanuc in the .Meibomian jrlands. Styes frenerally occur in 
 weaklv, delicate persons ; several may appear siujultaneously, or there may be a .succes- 
 sion of them ; they <rive rise to considerable irritation and are often extremely ftainful. 
 Tlie inflammation usually p^oes on to suppuration. 
 
 Tkk.vt.mknt. — Fomentations, poultices, the administration oi' tonics, and good living. 
 When pus has formed, the little tumors should be opened. 
 
 Tinea (ophthalmia tarsi). — Patients sufl"ering from tinea present themselves with 
 yellowish-brown dry crusts hanging to the eyelashes, which have often dropped out to a 
 considerable e.vtent. 
 
 In old cases the nuirgins of the lids are much thickened, giving rise to displacement 
 of the lower tear punctum and consc((uent watering of the eye. On removing the crusts 
 the margin of lid will be found ulcerated, fi.ssured, and easily bleeding. The disease con- 
 sists in inflammation and ulceration about the roots of the lashes; it runs a very chronic 
 course, often lasting for years in spite of remedies. 
 
 Tre.\tmk.\t. — Slight cases can generally be cured by the use of a lotion containing 
 four to si.\ grains of alum to the ounce of a water, applied three or four times a day, and 
 of mild nitrate of mercury ointment (one part of the ordinary nitrate of mercury ointment 
 to eleven of lard') smeared along the margins of the lids night and morning. 
 
 The patient should be directed to remove all the crusts before applying the ointment. 
 
 More severe ca.ses should be treated by pulling out the lashes and removing the scabs 
 with forceps, and then applying solid nitrate of silver to the raw surface left. 
 
 In cases where the lower tear punctum has become everted the punctum and canal- 
 iculus must be slit up. (See p. 2lMj.) 
 
 Injuries. — Wounds of the eyelids, however extensive or ragged, should, after having 
 been thoroughly cleansed, be brought accurately together; they will usually heal readily 
 enough. Should there be any loss of substance, an endeavor must be made to prevent 
 distortion of the lids by contraction of the resulting cicatrix. 
 
 Ecchynaosis of the lids (black eye) freciuently occurs as the result of blows, and 
 may be caused by leech-bites or operations. 
 
 Treatment. — Most cases may be left alone ; but if it is desirable to get quickly rid 
 of the eff"used blood, a poultice made of equal parts of the scraped root of black bryony 
 and bread crumbs should be applied. The poultice should be kept on as long as the patient 
 can bear it. The application is often accompanied by a good deal of stinging pain. 
 
 Emphysema of the lids sometimes occurs from rupture of the mucous membrane 
 of the tiose, air being forced into the cellular tissue of the eyelids on sneezing or blowing 
 the nose. Gentle pressure with cotton-wool and a bandage and avoidance of violent expi- 
 ratory movements, sneezing, etc.. is the only treatment required. 
 
 The Lachrymal Apparatus. — The principal aflfections of the tear passages, 
 etc., will be described in the next section. 
 
 THE CONJUNCTIVA. 
 
 Ophthalmia. — Under this head are collected all the diff"erent forms of inflammation 
 of the conjunctiva. The following characters are common to all: more or less vascularity 
 of the membrane, uneasiness and stiffness of the lids, pain of a smarting character, some 
 kind of discharge, and gumming together of the lids during sleep. 
 
 Inflammation of the conjunctiva has to be distinguished from inflammation of the 
 sclerotic or subconjunctival fascia or the injection of these structures which is present in 
 many of the inflammations of deeper parts of the globe. The distinction can be made by 
 paying attention to the following points: 
 
 ' The ointments employed in tlie oplulialmic department at Guy's Hospital are now almost 
 invariably prepared witli vaseline instead of lard. 
 
268 THE CONJUNCTIVA. 
 
 Diagnosis. — 1. The inflamed conjunctiva is bright red, the ve'ssels are large and tor- 
 tuous and anastomose freely, forming a dense network ; they are of greater calibre about 
 the fornix and taper off toward the cornea. 
 
 The inflamed sclerotic or episcleral tissue is pinkish or bluish in color ; the vessels are 
 small and straight, and the vascularity is usually most marked in a ring around the eye- 
 ball just external to the corneal margin. 
 
 2. The vessels of the conjunctiva can be somewhat displaced and made to glide over 
 the surface of the eyeball by gentle pressure ; those situated in deeper parts cannot be 
 made to alter their positions. 
 
 3. The pain in inflammation of the conjunctiva is of a smarting character, while in 
 inflammations of deeper parts it is dull and aching and often very severe. 
 
 Treatment. — Inflammations of the conjunctiva are best treated by astringent appli- 
 cations. 
 
 Any of the following formulaj may be employed : 
 
 Strong Alum Lotion. 
 
 Alum, gr. X ; Water, 5J. 
 
 Useful in cases of purulent ophthalmia. 
 Alum Lotion. 
 
 Alum, grs. iv to vj ; Water, 5J. 
 
 Sulphate of Copper Drops. 
 
 Sulphate of copper, gr. ij ; Water, 5J. 
 
 Sulphate of Zinc Drops. 
 
 Sulphate of zinc, gr. ij ; Water, 5j- 
 
 Nitrate of Silver Drops. 
 
 Nitrate of silver, gr. j ; Water. 5J. 
 
 Chloride of Zinc Drops. 
 
 Chloride of zinc, gr. ij ; Water, Sj- 
 
 Most useful in cases of chronic ophthalmia. 
 
 Atropine and Astringent Solution. 
 
 Sulphate of atropia, gr. h to gr. ij ; Sulphate or chloride of zinc, gr. ij ; Water, 5j- 
 Useful in cases where iritis or corneitis occurs in the course of ophthalmia. 
 
 Antiseptic Lotion. 
 
 Boracic acid, gr. xv ; Water, 5J. 
 U.seful in purulent ophthalmia and sloughy ulceration of the cornea. 
 
 Any of these remedies may be given to the patient to use himself; they should be 
 applied from three to six times a day or oftener, and the patient should be directed to 
 wash away all discharge before using any of them, and to take care that the lotion goes 
 well between the lids. 
 
 Some kind of ointment (spermaceti, mild nitrate of mercury, etc.) should also be 
 ordered to be smeared on the margins of the lids at night, to prevent their becoming 
 gummed together during sleep. 
 
 The condition of the patient's general health should also be attended to. 
 
 Other applications, which should be used by the surgeon himself, are — 
 
 The mitigated nitrate of silver stick (consisting of nitrate of potash and nitrate of sil- 
 ver in the proportion of three parts of the former to one of the latter. — Green stone — 
 lapis divinus (consisting of equal parts of alum, nitrate of potash, and sulphate of copper, 
 with a small quantity of camphor) — and solid -nitrate of silver. In order to apply any of 
 these the patient should be seated in a chair and the surgeon, standing behind, as in Fig. 
 110, should evert the lids and lightly rub their conjunctival surface with either. If a 
 preparation of nitrate of silver be employed, the conjunctiva should be washed with salt 
 and water immediately after the application. 
 
 Varieties of Ophthalmia. 
 
 Catarrhal ophthalmia is commonly caused by draughts of cold air, is highly 
 contagious, and acute in its course. 
 
 The conjunctiva, both ocular and palpebral, is highly injected and sometimes swollen; 
 there may be small extravasations of blood in the structure of the former ; there is a 
 thick yellow, tenacious discharge. 
 
VARIETIES or onrniALMiA. 269 
 
 Oiii' (»r })utli I'Vi's iiiiiv Ix" allcctcd, the disease usually cfiniUKiiieiii^ in (Uie, and sproa<l- 
 iuj; to the other in the course of two or three days. 
 
 TuKAT.MKNT in the early sta<jes, l)ef'ore there is any ;ininiiut uT discharfrc Some 
 sootliinj:; ajiplicatioM (as deeoetion ol" |io)i|(y-heads) sh(»uld he (Muployed ; later on an 
 astrintrent should lie used, and sonic mild nitrate- of nu-rcury <"' spermaceti ointment 
 sim-ared on the ed<;es of the lids at bedtime, to prevctnt their hecomiiijj; gummed to<rether 
 during sleep. 
 
 Thf /xifiiiif (or, in the ca.se of a child, its parents) should he warned of the contajri'JU.s 
 nature of tlu' disease, and no spoiijres, towels, etc., which he is in the hahit of usinj.^ 
 should he used by other jteople. Amoni; the; |»o<irer classes it is very common to .see a 
 wliole family sufVerinu' from catarrhal ophthalmia. 
 
 Chronic ophthalmia is usually a sequel of some more acute form ; the palpebral 
 conjunctiva is redilened, the ocular conjunctiva presenting patches of sli^rhtly increased 
 vascularity, but no general redness, as in cases of catarrhal ophthalmia ; the lids are often 
 somewhat thickened ami the caruncle and semilunar fold swollen. There is slight 
 mucous discharge, which forms dry crusts on the margins of the lids, and at the inner 
 canthus overflow of tears may occur from obstruction or displacement of the tear 
 puncta. 
 
 Thk.vtmknt, the same as that of catarrhal ophthalmia. The disease may c(mtinue 
 for almost rtny time ; and when one remedy aj)})ears to have lost its effect, another should 
 be trie(l. 
 
 Phlyctenular ophthalmia, usually met with in children and young adults, 
 especially females, is characterized by the existence of small whitish elevations on the 
 conjunctiva, most commonly near the margin of the cornea; each little elevation has a 
 wi.sp of blood vessels leading to it if near the corneal margin, and is surrounded by a zone 
 of vascularity if situated in any other part of the conjunctiva. There is some watering 
 of the eye and slight mucous discharge. 
 
 Patients are freijuently met with who suff'er from repeated attacks of phlyctenular 
 ophthalmia. 
 
 Trkat.mknt. — In treating phlyctenular ophthalmia our object is to set up a certain 
 amount of irritation of the conjunctiva, by which the phlyctenulfe will be de.stroyed. 
 This can be attained by dusting calomel into the eye daily, or by ordering a small qiian- 
 tity of an ointment containing two grains of yellow oxide of mercury to 3j of lard or 
 vaseline, to be applied to the inner surface of the lower lid at bedtime. Either of these 
 remedies will soon cause the phlyctenulst; to disa])))ear. The disease, as aff'ecting the con- 
 junctiva covering the cornea, will be spoken of under diseases of that structure. Tonics 
 should be given if required. 
 
 Granular Ophthalmia. — This disease occurs at all ages and is very common 
 amongst the lower classes, especially the Irish ; it is highly contagious. Granular oph- 
 thalmia is often very prevalent where large numbers of persons are crowded together in 
 workhouses, parish seliools, barracks, etc. It would appear that in those who have lived 
 for a considerable time under unfavorable hygienic conditions a peculiar granular state of 
 the palpebral conjunctiva becomes developed. Persons thus aff"ected are said to be predis- 
 posed to granular ophthalmia. The predisposed eyelid is characterized by the existence 
 of small pale spherical bodies situated in the structure of the conjunctiva ; the little 
 bodies much resemble and are known as sago grains ; they are most constantly found 
 upon the lower lid, near the outer canthus. 
 
 This predisposed or granular condition of the eyelids may remain stationary for an 
 unlimited time without giving rise to inconvenience ; but, on the otlier hand, attacks of 
 inflammation are ever liable to be set up, giving rise to the development of granular oph- 
 thalmia as we see it in practice. 
 
 We meet with three principal forms of granular ophthalmia, which may be distin- 
 guished from each other by the nature of the granulations present: 
 
 One, characterized by the predominance of the sago grains, already alluded to. 
 around which inflammation has been set up, is known as "follicular granulation." 
 
 Another form, characterized by the predominance of hypertrophied pa]iill;\?. by which 
 the sago grains, if they exist, are obscured, is known as '" papillary granulation." 
 
 A third form, characterized by a mixture of follicular granulations and hypertrophied 
 papilla?, is known as " mixed granulation ;"' this is the most .severe form of the three. 
 
 In old cases, and especially those that have been treated by strong caustics, the con- 
 junctiva may be found converted into a mass of rough harsh cicatrices and its secreting 
 power destroyed, the condition known as '" xerophthalmia" being developed. 
 
270 VARIETIES OF OPHTHALMIA. 
 
 Granulations in active granular ophthalmia, unlike the sago grains which characterize 
 the predisposed lid, are always found most developed on the conjunctiva covering the 
 attached border of the tarsal cartilage of the upper lid. Their appearance is more or 
 less altered by treatment ; they are accompanied by. thick yellow discharge, and there 
 may be more or less severe intolerance o^ light. 
 
 Sequelse of Granular Ophthalmia. — The cornea may become more or less 
 opacjue and vascular, especially at its u|)per part; the condition is known as " pannus," 
 and is caused by constant irritation of the cornea by the rough surface of the lid. 
 
 The conjunctiva may be destroyed to a greater or less degree, extensive cicatrices 
 being formed, which by their contraction cause shrinking of the membrane and distor- 
 tion of the lids, giving rise to entropion and narrowing of the palpebral aperture. The 
 hair bulbs may become displaced, causing the eyelashes to be misdirected — " trichiasis." 
 (See p. 292.) The results of granular ophthalmia are frequently aggravated by unskil- 
 ful treatment. 
 
 Treatment. — In treating granular ophthalmia our object is to destroy the granula- 
 tions with as little damage as possible to the conjunctiva itself. 
 
 The use of atrong caustics must he carefidhj avoided, as they cause too much destruc- 
 tion of tissue, followed by the formation and subsequent contraction of cicatrices. 
 
 Slight cases can be cured in a short time by the application of mitigated nitrate of 
 silver stick twice a week or oftener, and the use of sulphate of copper drops from three 
 to six times a day. 
 
 More severe cases will remain under treatment for months or years, but if persevered 
 with will improve greatly, and may ultimately recover. If the ophthalmia be of recent 
 date, the granulations should be touched twice a week with the mitigated nitrate of silver 
 stick, or if possible every day, sulphate-of-copper drops being used from three to .'^Ix times 
 daily. 
 
 In chronic cases the green stone .should be used instead of the nitrate of silver stick. 
 The application of calomel powder or quinine to the granulations has also been found 
 useful in some cases. 
 
 When the cornea is completely opaque and fleshy-looking, inoculation with pus from 
 a case of purulent ophthalmia may be tried, but only in extreme cases ; otherwi.se, we 
 may do more harm than good by causing sloughing of the cornea. Should but one eye 
 be affected, care must be taken to prevent the other becoming inoculated. 
 
 Iritis not unfrequently supervenes in the course of granular ophthalmia ; when it 
 occurs, a solution of atropine should be dropped into the eye from three to six times 
 daily, in addition to other remedies. 
 
 Pannus requires no special treatment, and if not very dense disappears as the granu- 
 lations are cured. In all cases some simple ointment should be applied to the edges of 
 the lids at night, to prevent their becoming gummed together. 
 
 Purulent Ophthalmia. — Purulent ophthalmia may be met with as ''ophthalmia 
 neonatorum" in children soon after birth, or in older persons. In the former case it may 
 be caused by contact of acrid vaginal secretions, by want of cleanliness and fresh air, or 
 a combination of the two ; in the latter by contact with some form of specific pus or by 
 constant irritation of the already inflamed conjunctiva. It is highly contagious. 
 
 The worst form of the disease, whether occurring in infants or older persons, is that 
 caused by inoculation with gonorrhoeal matter — " gonorrhoeal ophthalmia." 
 
 " Ophthalmia neonatorum" makes its appearance a few days after birth ; the eyelids 
 are found red or bluish-red and swollen ; the eyes can only be opened with difficulty, and 
 on attempting to separate the lids thick yellow purulent discharge escapes from between 
 their edges ; both eyes are almost always affected. 
 
 Purulent ophthalmia in older persons may affect one or both eyes; it commences with 
 intolerance of light, lachrymation, and injection of the conjunctiva, at first much resem- 
 bling an ordinary attack of catarrhal ophthalmia, but in about twelve to twenty-four hours 
 its real nature becomes apparent by thick yellow discharge from between the swollen, red, 
 and sometimes everted lids. The conjunctiva is bright scarlet, traversed by large dis- 
 tended blood vessels, and much swollen, especially the ocular portion (chemosis), which 
 may overlap the cornea and protrude in folds between the lids ; there is pain and intol- 
 erance of light, and there may be much depression, especially if the attack have lasted 
 long. The patient may be suffering from gonorrhoea. The great danger to be feared in 
 purulent ophthalmia is implication of the cornea, which may be partially or entirely 
 destroyed by suppuration or sloughing. 
 
 Treatment. — In all cases the patients themselves or their parents should be warned 
 
VMIIETIES OF orilTIIM.MIA. 271 
 
 of tilt' coiitiiuinus nature ot'tlif (liscasc ; ami il'ttiie eye only be affected, the greatest care 
 slioiild lit' takt'n < jtnitt'c-t tlu' ntlitT. If ])i>s.sil)Ie, a fjotKl view of the cornea should be 
 olitaiiH'd. as its contlition niaterially iiifliienccs the ])ro<.MH»sis with rejranl to si^'ht. The 
 exuniinatiiin slioiilil l»e made with eare, as the cornea may be rnptiired whilst making it. 
 
 In ophthalmia nt'oiiatornm the only treatment retjuired is to wash out the eyes every 
 liour t»r half hour with stronjr alum lotion (see j). 2(i8j until the diseharj^e is lessened; 
 the lotion need oidy be useil thus lVe([uently for twelve hours <Mit of twenty-four (from 
 S A. M. to S i>. .M.i, the chilli beintr allowed to sleep ut nijrht ; as the discharge gets less 
 the lotion mav be used less frei|uently. Some simple ointment slmuld bt; applied to the 
 margin of the lids once or twice a day to keep them from sticking together. 
 
 Slight cases of jiurulent ophthalmia in older persons may be treated in the same 
 manner, but the more severe forms (especially the gonorrhtcal) reijuire that much more 
 energetic measures be taken. 
 
 The treatment should lie both local and constitutional. 
 
 Local Trrafnif'iif. — When the jiatieiit is first seen, the lids should be everted and the 
 whole conjunctiva brusheil over with a stick of solid nitrate of silver or ))ainted witli a 
 solution of forty to si.xty grains of the salt to .5J f»^' water; tlic application should be 
 repeated in the course of two or three days if no improvement have taken place. The 
 patient should be kept lying down in a dark room and a bag of ice or lint kept wetted 
 with iced water a])plied over the closed lids ; the ice or lint should be removed and the 
 eves washed out every liour or halfhuur with some astringent or antiseptic lotitjn. the 
 greatest cleanliness Vicing observed. 
 
 Should there be much pain and the patient be strong, blood may be taken from the 
 temples by leedies or the application of the artificial leech ; but, as before stated, most 
 ])atients suffering from severe purulent ophthalmia are mucli depressed and will not bear 
 depletion. 
 
 Omstifiifi'Hiti/ Tre'itmnit. — The free administration of tonics, especially iron and 
 quinine, with gootl living and a fair amount of stimulants. 
 
 If perforation of the cornea threaten or have taken place, the eye should be kept firmly 
 l)andaged. so as to prevent as much as possible any escape of the contents of the globe. 
 
 Diphtheritic Ophthalmia. — This form of ophthalmia is but rarely met with \i\ 
 London [or America] : it affects persons of all ages. At first sight the case appears to 
 be one of severe purulent ophthalmia ; its chief characteristic, however, is a solid infil- 
 tration of the substance of the conjunctiva, with or without the formation of diphtheritic 
 membranes on its surfjice. The affected eye is frei(uently lo.st from implication of the 
 cornea. The disease is best treated by sedative applications, as fomentations of poppy- 
 heads, or belladonna, attention being paid to the patient's general liealth. 
 
 Injuries. — Wounds of the conjunctiva usually heal readily enough, requiring only 
 simjde treatment. 
 
 Biinis are usually caused by contact of lime or hot metals ; the damage done may be only 
 slight, or the whole conjunctiva and cornea may be converted into a dead white slough. 
 
 Treatment. — The conjunctiva should be carefully examined and all foreign bodies 
 and portions of sloughy tissue removed; should the injury have been caused by lime, 
 the surface of the conjunctiva must be carefully cleansed with a weak solution of acetic 
 acid or simple warm water. Some oil should be placed between the lids and the eye 
 bound up with wet lint and a bandage. If any symptoms of iritis appear, a solution of 
 atrojiine shotdd be dropped into the eye from three to six times a day. Should there be 
 much discharge, alum lotion may be used. 
 
 When the sloughs have separated, care must be taken to prevent adhesions between 
 the raw surfaces left by passing a probe between the lids and eyeball once or twice a day 
 and directing the patient to draw the lid away from the globe frequently. 
 
 Fureign bodies — small pieces of coal, iron, etc. — are sometimes found embedded in 
 the conjunctiva, and must be removed. 
 
 Ilemorrhiuje into the substance of the conjunctiva or beneath it may occur spon- 
 taneously or from injury ; no treatment is necessary. The patient may be assured that 
 no harm will come of it. and that the blood will disappear in the course of a week or 
 longer. 
 
 EXTERNAL MUSCLES OF THE EYEBALL. 
 
 StraV)i>inns will lie considered in the next section. 
 
 Nystagmus signifies a peculiar involuntary quivering motion of both eyes, 
 dependent on rapid contraction of antagonistic pairs of muscles. The disease is usually 
 
272 THE CORNEA. 
 
 developed in infancy, and is always associated with considerable impairment of vision, 
 arising from congenital cataract, opacity of the cornea after purulent ophthalmia, atrophy 
 of choroid, etc. Nystagmus occurs in some nervous disorders, as locomotor ataxy ; also 
 in persons who work in bad light, as those employed in mines, when it is described as 
 '' miners' nystagmus." 
 
 Treatment. — Nothing can be done to remedy nystagmus in the two first classes of 
 cases, but miners' nystagmus may be entirely cured by removing the patient from his 
 work and the administration of tonics. 
 
 Paralysis and Paresis. — Paralysis signifies total loss of power of the affected 
 muscle ; paresis, only partial loss. 
 
 The symptoms of paralysis and paresis are double vision and total loss or impairment 
 of mobility of the eye in some particular direction. 
 
 The causes are affections of the brain or spinal cord ; disea.ses within the orbit, as 
 tumors, nodes, or inflammatory exudations, pressing on the nerves supplying the mus- 
 cles ; and affections of the nerves themselves or of the muscles. As a rule, the cause of 
 the paralysis or paresis can only be conjectured, but very many cases will be found con- 
 nected with syphilis. 
 
 Treatment. — A careful inquiry should be made into the patient's previous history, 
 and remedies given in accordance with this, those of an anti-syphilitic nature being gen- 
 erally required. If the affection has not lasted more than tliree months, a favorable 
 prognosis may be given ; but if, on the contrary, it has existed six months or more, 
 recovery is very improbable. 
 
 Paralysis of all the external muscles of the eye. " ophthalmoplegia externa " (Hutch- 
 inson), is occasionally met with. The eye looks nearly straight forward and is almost 
 immovable ; there is partial ptosis. 
 
 The disease is probably of syphilitic origin, but is little influenced by treatment : it is 
 often associated with symptoms of serious central disease. 
 
 Insufficiency of the internal recti muscles gives rise to somewhat obscure 
 
 symptoms, which have been mistaken for manifestations of cerebral disease. 
 
 Patients thus affected complain that they cannot do near work for any length of time, 
 as objects looked at become indistinct or appear double. They suffer from giddiness and 
 pain in the brows and head generally. In.sufficiency of the internal recti should always 
 be suspected if in a case of hypermetropia relief cannot be given by the use of glas.ses. 
 
 Treatment. — Any anomaly of refraction should be accurately neutralized and the 
 weakened muscles assisted by the use of prisms, or of spherical lenses so arranged as to 
 have a prismatic action. 
 
 THE CORNEA. 
 
 Inflammation (corneitis, or keratitis). — Five different forms of inflammation of the 
 cornea are met with: (1) Simple corneitis; (2) interstitial or ])arenchymatous corneitis; 
 (3) pustular corneitis; (4) keratitis punctata; (5) corneitis with sloughing or suppuration. 
 
 Symptoms. — Corneitis is characterized by watering of the ej'e, impairment of vision, 
 intolerance of light, and pain, at times severe, at others insignificant ; on examination 
 more or less of the cornea will be found cloudy or quite opaque, and blood vessels may 
 be seen in its substance or on its surface. 
 
 Diagnosis. — It is of importance to notice the course and position of the blood ves- 
 sels in any case where the cornea has become vascular. Should the vessels lie altogether 
 in the cornea, commencing near its margin and passing for a variable distance in its 
 substance, the case is probably one of interstitial keratitis ; but should the vessels be 
 continuous with those of the conjunctiva, pass over the margin of the cornea, and lie 
 superficially on its surface, the vascularity is probably due to mechanical irritation from 
 granular lids or inverted lashes, and the condition known as pannns is present. 
 
 It is very necessary that the difference between these two forms of vascularity should 
 be recognized, as their treatment varies widely. 
 
 In the former case the treatment of keratitis, to be presently described, should be 
 adopted; in the latter, treatment must be directed against the cause of the vascularity 
 (granular lids. etc.). 
 
 Simple corneitis may be caused by injuries or the lodgment of foreign bodies on 
 the surface or in the substance of the cornea. There is some pain, intolerance of light, 
 and lachrymation. and .some part of the cornea is found occupied b}' a halo of dulness. 
 
 Interstitial or parenchymatous keratitis (corneo-iritis. syphilitic keratitis, 
 
 keratitis, diffuse keratitis, A'ascular corneitis). — Interstitial keratitis occurs as a rule in 
 
consEiris. 273 
 
 persons will) are affootod by hereditary sypliilis : it is frequently, but by no means 
 invariably, associated with ehau^es in the teeth, peg^red canines, notched incisors, or 
 dome shape'of first molars ; flattened nose, fissures aroiiml tin- angles of" the nioutli. or 
 other manifestations of (Congenital syphilitic disease. 
 
 It usually first makes it.s apjiearance between the fifth and ei^diteenth years, but ha.s 
 been seen as late as thirty ; it always afi'eets both eyes, either simultaneously or at short 
 intervals ; it runs a very chronic course and is most intractable, a .severe attack often 
 lasting from twelve to eighteen months. 
 
 Sv.Mi'ToM.-^. — Interstitial keratitis ])re.sents all the symptoms of inflammation of the 
 e(»rnea in a marked degree. The opacity is peculiar, and is caused by iiitiltrati(»n of the 
 substance of the conu'a with opaipie material. 
 
 At first the cornea becomes spotted in its centre, but the spots .s(jon run together, 
 forming a grayish haze ; opacity then ccjmmences at the up|ter and lower corneal mar- 
 gins and gradually sprea<ls, until the wliole structure resembles somewhat a piece of 
 ground glass, apparently blo(»d-staiiied in parts, from the development of innumerable 
 minute blood vessels. There is always a well-marked band of ciliary injection. Inter- 
 stitial keratitis is not unfrequently complicated by iritis ; hence the name " corneo-iritis.' 
 
 The opacity, having reached a certain point, may remain .stationary for month.s. but 
 at length clearing commences and the cornea regains more or less of it.s normal trans- 
 parency, recovery always taking place to a much greater extent than would be at first 
 e.\pecfe(l. In some few cases a choroido-iriti.s is set up, and the eye eventually shrinks. 
 
 Pustular COrneitis (phlyctenular, strumous, vascular, corneitis ; strumous <jph- 
 thalmia, fascicular keratitis^. — Pustular corneitis is met with in children and young 
 adults ; it often follows measles, scarlatina, or other acute diseases ; it is fre<juently 
 accompanied by eczematous eruptions on the eyelids, about the nostrils and angles of the 
 mouth, and on the head ; the patients often present well-marked strumous diathesis and 
 are generally said to be delicate. 
 
 Sv.MPTOMS. — In most cases there is profuse lachrymation, accompanied by great 
 intolerance of light ; the lids may be swollen, covered with eczematous eruption, and 
 tightly screwed up, .so as to cause the greatest difficulty in examination. 
 
 There is more or less injection of the ciliary region (ciliary redness). Upon the sur- 
 face of the cornea may be found (1) small grayi.sh elevations (phlyetenulae) ; (2) 
 phlyctenulae in a state of suppuration (pustules); (3) small ulcers left on discharge of 
 the contents of the latter. Any of the.se are usually found in greatest quantity round 
 the margin of the cornea, but its whole surface may be found dotted over with phlyc- 
 tenula;. pustules, or ulcers, or examples of all three may be met with in the same eye. 
 There is more or less haziness and vascularity surrounding the affected portions of cor- 
 nea. In some cases there is thick mucous or muco-purulent discharge in addition to the 
 lachrymation. 
 
 Cases of pustular corneitis accompanied by great intolerance of light, much swelling 
 of the eyelids, profuse lachrymation, and thick muco-purulent discharge, occurring in 
 strumous children, are sometimes described as a separate di.sease under the name of 
 " .strumous ophthalmia." 
 
 Fascicular keratitis is a somewhat rare form of the disease, characterized by the 
 existence of a fasciculus of vessels running on to the cornea from its margin, the 
 fasciculus terminating in a .small ulcer, phlyctenula, pustule, or small inflamed patch of 
 cornea. 
 
 Pustular corneitis is very likely to recur. 
 
 Keratitis punctata occurs, as a rule, in young adults, rarely in children, but 
 may be met with at all ai:es as a part of sympathetic ophthalmia ; it much resembles the 
 early stages of interstitial keratitis and probably arises from the same cause. As a rule, 
 one eye only is affected ; there are the usual symptoms of corneitis, but the intolerance 
 of light is not very .severe ; the cornea is dotted over with small gravish opacities, which 
 are collected most thickly in its central portion and on careful examination will be found 
 to occupy the posterior layers of the structure. The disease is most intractable and may 
 be accompanied by iritis. 
 
 Corneitis with sloughing or suppuration is usually the result of .sharp 
 
 blows, a.s flicks from twigs, etc.. or is caused by the irritation of foreign bodies, as the 
 husks of corn ; it may also occur after operations for cataract. 
 
 Symptoms. — Those of corneitis. severe pain being, as a rule, one of the most marked ; 
 some part of the cornea will be found occupied by a collection of pus. part of which may 
 have escaped into the anterior chamber and collected at its lower part, giving rise to the 
 IS 
 
274 ULCERS OF THE CORSE A. 
 
 condition known as "hypopyon," or the pus may have gravitated down between the 
 layers of the cornea to its lower margin, forming a collection much resembling hypopyon 
 and known as •• onyx." Suppurative corneitis is met with in cases of neuro-parnhjtic 
 ophf/i((/ini(i, a peculiar form of inflammation associated with paralysis of the ophthalmic 
 division of the fifth nerve and consequent anaesthesia of the parts supplied by it. 
 
 Instead of a collection of pus, some part of the cornea ma}' be found occupied by a 
 dead white slough or a large ulcerated and sloughing surface. 
 
 The iris may also be inflamed and suppurating. 
 
 Treatment. — The treatment of corneitis should be both local and constitutional. 
 
 Local Treatment. — All foreign bodies or other sources of irritation should be removed ; 
 the eyes must be protected from light by a large shade, protectors, or, better still, by a 
 bandage. Sedative applications should be employed, none being better than belladonna 
 lotion containing from six to ten grains of extract of belladonna to one ounce of water^ 
 or, if preferred, a weak solution of atropine, gr. A to a pint of water, may be used instead ; 
 the eyes should be bathed three or four times a day with either of these and kept bound 
 up with lint wetted with one or the other. 
 
 If iritis exist, a stronger solution of atropine, gr. i to gr. ij or iv to the ounce of 
 water, should be dropped into the eyes as often as may appear necessary. 
 
 In corneitis with suppuration warm applications will be found most beneficial ; the 
 eye should be well bathed with warm belladonna lotion or decoction of poppies several 
 times a day and bound up firmly with lint soaked in one or the other. If pain be a 
 prominent symptom, it may be greatly relieved by taking blood from the temples. 
 Should a large area of the cornea become infiltrated with pus. a free incision should be 
 made by transfixing with a cataract knife and cutting out obliquely through the centre 
 of the infiltrated portion. 
 
 In cases of corneitis, especially of the pustular form, where there is obstinate intoler- 
 ance of light and the disease constantly relapses or recurs in spite of other treatment, a 
 seton should be placed in the skin of the temple on one or both sides. (See p. 291.) In 
 some cases the spasmodic contraction of the orbicularis may be kept up by the irritation 
 of small fissures at the outer canthus ; in such, a free division of the junction of the lids 
 and orbicularis by cutting through the canthus will often effect a speedy cure. 
 
 The inhalation of chloroform is also said to act beneficially in some cases. 
 
 If in a case of suppuration or sloughing pei-foration of the cornea appear imminent, 
 iridectomy should be performed. (See p. 304.) 
 
 Constitutional Treatment. — Simple corneitis requires no constitutional treatment. In 
 the interstitial form anti-syphilitic remedies should be employed. To older patients the 
 bichloride of mercury in doses of one-sixteenth to one-twelfth of a grain, combined with 
 bark or other tonic, should be given twice or three times a day ; to yoving children, hyd. 
 cum cret. gr. j to v three times a day. 
 
 The other forms of corneitis. especially the pustular, are best treated by the adminis- 
 tration of tonics, as steel wine, dialyzed iron, tincture of perchloride of iron, quinine, etc. ; 
 and in strumous children cod-liver oil .should also be prescribed, with good living and 
 plenty of fresh air. 
 
 Ulcers of the cornea present a great variety of forms. They may be trans- 
 parent or opiKjue : they may be healing, indolent, vascular, or sloughing. The depth to 
 which the corneal tissue is destroyed varies from slight abrasion of its surface to destruc- 
 tion of its whole thickness, causing perforation. The area of the cornea which is 
 destroyed also varies from a small point to its whole surface. 
 
 Ulcers are sometimes described as marginal or central, according to their position. 
 Ulceration of the cornea is constantly met with in cases of debility, from whatever cause 
 arising. It is very common in patients recovering from acute diseases, as mea,sles. scar- 
 latina, and more especially smallpox, from impaired nutrition, not from formation of 
 pustules or eruption on the cornea. Children are much more frequently affected than 
 adults. 
 
 The SYMPTOMS of ulceration are very similar to those of corneitis. On examination, 
 any kind of ulceration may be found (one variety has been mentioned under " Pustular 
 Corneitis"). There rnay be one or more small transparent vlcers. which can only be seen 
 in certain lights and are very likely to be overlooked. They appear like small abrasions 
 of the epithelium ; sometimes the greater part of the surface of the cornea is found to be 
 aflFected either by several small transparent ulcers or one large one. This form of ulcera- 
 tion is most commonly met with in adults of irritable, nervous temperament, and should 
 always be carefully looked for when a patient of this description presents himself suffer- 
 
ri.('i:i:s or riii: < ni:si:.\. 075 
 
 iu^ from st'Vrrc iiitiilfiaiict' ni" liirlit. watcrinj: (it'tlif eye ami smartiii;.' pain witlicuit any 
 wry a|»|iareiit caiisi-. 
 
 (flKi</ii> iilccin ari' visiltlf t'iniu<:h ; they may l)e ol" any size or riuinhfr. At tinii-s tliey 
 a|)|>i'ar to l»e healing ; in wliifli ease, the ed^res a|){iear Mnooth and tht; surface of the 
 uh-er roufrh and oiKKjue or chmdy. At others they are indoh-nt, and a;.'ain they iiiav he 
 spreadinir. when their ed;;es are found to he elean cut. as if u piece iif tlie c«»rnea had 
 lifcn piincheil out hy some sharj) instrument ; the surface of the uh-er appears ^hissy and 
 is often deeply excavated. 
 
 S/i>ii>f/iiii</ ii/rir is nioic or h-ss opa((iie. spreads rapidly, hotli in area and depth, and 
 if the process he not soon arreste<l the cornea will he pi'rforatcd and a prolapse of the 
 iris of trreater or less extent (accordinj^ to the size of the perforation) will take place. 
 If the opeiiinLT he larj:e, the lens or some of the vitreous may escape. 
 
 In the irreater mnnher (d" cases oi" perforation of the cornea the iris puslies forward, 
 tills tin- opiMiinir. and hecomes adherent to its marjrins, formin<r an "anterior synechia;"' 
 hut a considerahle prolapse may take place, forming a projection or hulge from the sur- 
 face of the cornea — " staphyloma." 
 
 Mun/fnit/ fir cicsccnfic //Av-r (ulcus cornias .serpens) is a somewhat peculiar form of cor- 
 neal ulceration ; it is njet with in persons of middle age, is very intractable and very liahle 
 to recur or relapse. This form of ulceration is accompanied hy very severe pain, great 
 intolerance of light, and very profuse lachrymation. On examination, a crescentic patch 
 of ulceration is found, skirting, generally, the ujtper margin of the cornea: the ulcer is 
 deep, its margin clean cut. and its surface glassv-looking. 
 
 The ulceration spreads rapidly up to a certain point, remains stationary fjr a time, 
 and then commences to heal slowly, the healing process being frefjuently interrupted by 
 relapses. 
 
 The ulcerative process may involve both the upper and lower segments of the cornea, 
 but never pass up to its centre. 
 
 Treatment. — The treatment of ulcers of the cornea is very similar to that of cor- 
 neitis. In many cases, however, more especially those of marginal ulcer, the instillation 
 of solutions of sulphate of eserine (gr. j to iv to 3J of water) three times a day or oftener will 
 be found mo.st beneficial. In all severe cases the eye .should be kept carefully bandaged. 
 Iridectomy should be performed in anv case should perforation be imminent. (See 
 p. 3(U.) \ 
 
 Opacities of the cornea are the result of inflammation, ulceration, or injury. 
 
 Thry arc met with of all densities and sizes ; thin cloudy opacities are known as 
 " nebuhe."' dense white ones as "leucomata." A dense white opacity involving the 
 whole cornea is called a '"total leucoma ;" an opacity of the same description occupying 
 a part only, a ''partial leucoma." Should a corneal opacity have been caused by a'per- 
 forating iilcer or wound of the cornea, an '• anterior synechia " will probably be found 
 associated with it. 
 
 False Pterigium. — Fleshy opadtirx are sometimes met with near the margin of 
 the cornea and continuous with the conjunctiva. They are composed of granulation 
 tissue, and are frequently the result of burns. 
 
 Treatment — Corneal opacities have always a tendency to disappear, especially in 
 children. Their removal may be aided by the use of slightly irritating applications 
 which set up a certain amount of increased vascularity and thus aid ab.sorption. The 
 remedies generally employed are drops of sulphate of copper, iodide of potassium, or 
 opium : turpentine, pure, or mixed in various proportions with olive oil ; calomel powder, 
 or the yellow oxide of mercury ointment. Any of these may be used for some considera- 
 ble time. Should no improvement have taken place at the end of two or three months 
 and the opacity be so situated as to interfere with vision, an artificial pupil must be 
 made: and if the opacity be disfiguring, it should be tinted. (See p. 3(t2. ) The fleshy 
 opacities may l>e renioveil by operation. ImU are very liable to reappear in their former site. 
 
 Injuries. — Abrasions of the cornea niay be cau.sed by scratches from thorns, 
 ends of straw, finger-nails, etc. They give rise to severe pain, much intolerance of light, 
 and watering of the eye. 
 
 Tre.\tment. — The eye should be kept carefully bandaged with lint soaked in bella- 
 donna lotion till the abrasion has healed. 
 
 Penetrating wounds of the cornea generally involve the iris or lens: in the 
 former case an adhesion of the iris to the cornea (anterior synechia) is likely to be formed, 
 or iritis set up : in the latter the lens will probably become opaijue. a traumatic cataract 
 being developed. 
 
276 STAPHYLOMA OF SCLEROTIC. 
 
 Very extensive wounds of the cornea may allow the escape of the lens or vitreous. 
 
 Treatment. — The eye should be kept carefully bound up with lint soaked in bella- 
 donna lotion ; and in cases where the lens has been wounded or iritis set up a solution of 
 atropine one grain to one ounce of water should be dropped into the eye from four to six 
 or eight times daily. 
 
 Should the lens swell and cause pain and increase of tension, it must be removed 
 without delay or iridectomy must be performed. 
 
 Iridectomy may have to be performed at some future lime for optical reasons or to 
 obviate the irritation caused by dragging on an anterior synechia. Traumatic cataract 
 may also rc(|uire to be treated. 
 
 Burns of the cornea by lime, hot metals, etc., usually occur in conjunction with like 
 injuries of the conjunctiva; they usually leave behind them opacities of greater or less 
 extent and density, according to the severity of the injury, or may cause sloughing and 
 destruction of the whole or greater part of the cornea. 
 
 Treatment, the same as that of burns of the conjunctiva. 
 
 THE SCLEROTIC AND EPISCLERAL TISSUE. 
 
 Episcleritis. — Inflammation of the sclerotic or episcleral tissue, or more commonly 
 of both together, is a somewhat rare disease ; it is characterized by the presence of purple 
 swollen patches covered by enlarged conjunctival vessels and situated usually about the 
 insertion of the recti muscles. 
 
 The purple patches often disappear from one portion of the globe and appear again at 
 another ; the inflammation is chronic in its course, but subsides after a time, leaving some 
 discoloration of the afl'ected part ; it is very liable to recur. 
 
 It occasionally follows operations for strabismus. 
 
 Treatment. — Sedative applications, as decoction of poppy-heads or belladonna fomen- 
 tation, should be used three or four times a day; and if there be much conjunctival vas- 
 cularity or any mucous discharge, some astringent lotion, as chloride-of-zinc drops (see 
 Formulae, p, 2G8), should also be employed. 
 
 Any constitutional treatment that may appear called for should be adopted. In some 
 cases tonics do most good ; others, again, may be greatly benefited by a course of mer- 
 cury or iodide of potassium. 
 
 This disease is usually described as " episcleritis." 
 
 Stapliyloma. — A bulge of the sclerotic may occur from softening of its structure 
 by inflammatory changes, which usually commence in the choroid. 
 
 Staphyloma may be met with in the ciliary region (ciliary staphyloma), about the 
 equator (equatorial staphyloma), or near the optic nerve (posterior staphyloma). Little 
 can be done in the way of treatment. 
 
 Gummata are occasionally seen upon the sclerotic ; they occur as vascular, well- 
 defined bosses, either singly or in groups of two or three. Their diagnosis is not easy ; 
 they are likely to be confounded with sai'coma or patches of episcleritis. From the 
 former they can be distinguished by their course, which is, though slowly, toward 
 recovery; from the latter, by being more aljruptly defined and raised above the surface 
 of the globe. 
 
 They are generally associated with syphilitic history, and often with other manifesta- 
 tions of syphilis. They require vigorous anti-syphilitic treatment. 
 
 Injuries. — The sclerotic may be wounded by sharp instruments or ruptured by blows ; 
 in the latter case the lesion usually takes place in the ciliary region, near the upper mar- 
 gin of the cornea. 
 
 The sclerotic (as also the cornea) may be pierced by a .shot or chip of metal, which 
 may be lodged within the globe or have pa.ssed clean through it. 
 
 Treatment. — The treatment of injuries of the sclerotic depends much upon the 
 extent and nature of the damage done. 
 
 Small incised wounds will usually heal readily enough if the eye be kept carefully 
 bandaged. Larger wounds may require to be closed by a suture. 
 
 Blows often cause complete disorganization of the globe, the aqueous and vitreous 
 chambers being filled with blood and hemorrhage having taken place between the sclero- 
 tic and choroid, although no rupture of the external tunic has oceiirred. 
 
 Such cases must be carefully watched and the eye kept bandaged with lint soaked in 
 belladonna lotion. 
 
 In cases of extensive incised wounds, large ruptures, or wounds as.sociated with lodg- 
 
rill-: ciiYsTM.i.isi: less. 211 
 
 iiii'iil iif ;i tun-iLni l)(i(ly witliiii llie ;:lul)c', rxlirpaliiui of tlie ('yeliall will jtiulialily hive to 
 lie in'if'tiiim'tl. (Si'c i>. iiliJ). 
 
 THE CRYSTALLINE LENS. 
 
 Congenital Anomalies. — N'ariations in shape, ubsence of the wlnde (aphakia) 
 or j.;irl III' I hi- liiis. and «li>|ihu(.iin'iit.s are met with as coiifreiiital defects. 
 
 Presbyopia (old sij^ht). — I'resbyoitia depends on senile cliange of the crystalline 
 lens. I»y which il is rendered harder than in youth and its elasticity is iniitaired. As a 
 conse(|uence, its curvature can only be altered to a limited extent by the action of the 
 ciliary muscle, and the power or raniie of uceonimodation is eorrcsj»ondin<rly diminished. 
 
 Persons iri-nerally bci:in to experience the ett'ects of presbyopia about the ajrc of forty- 
 five. The nearest jtoint of distinct vision, which year by year has been receding'- from 
 the eyes, now becomes inconveniiMitly far off", so that small print can only be read with 
 difficulty or not at all ; distant vision, however, still remains acute. 
 
 It has been arbitrarily decided that a person shall be consideretl presbyopic as .soon 
 as his nearest point of distinct vision comes to stand at 'I'l centimetres or fan her from the 
 eyes, and the dej^ree of presbyopia is expressed by the number of dioptrics {D) which it is 
 necessary to give the eye in order to bring its near point up to tliis di.stance, or, in other 
 words, to give it an accommodative power equal to 4.5 D, which is tlie power of the lens 
 which the crystalline must add to itself in order to see di.stinctly at 22 centimetres. 
 Thus, a person aged forty-five can only see distinctly at 28 centimetres — that is, he can 
 only add to his crystalline a lens equal to 3.5 D. In order to enable him to see distinctly 
 at 22 centimetres, we mu,st give a lens which makes up the difference between 3.5 D and 
 4.5 I) — /. ^., 1 D. A person of forty-five, therefore. re((uires a convex lens of 1 D to 
 remedy his presbyopia ; the number of this lens also expresses the degree of presbyopia. 
 
 It has been determined by observation that presbyopia increases by one dioptric for 
 every period of five years from forty to sixty, sometimes by one dioptric and sometimes 
 by a half only for each similar period from sixty to eighty. 
 
 The following table sliows the lens required at each period of five years by the erame- 
 tropic eye. Sh(uild hypermetropia exist, its degree must be ascertained and added to the 
 number given in the table. The degree of myopia, on the contrary, must be subtracted : 
 
 Age. 
 
 Dioptrics. 
 
 Age. 
 
 Dioptrics. 
 
 Age. 
 
 Dioptrics. 
 
 40 . 
 
 . . . (» 
 
 oo . 
 
 . . ;■! '< 
 
 70 . . 
 
 , . . 5.5 
 
 45 . 
 
 . . . 1 
 
 (ill . . 
 
 . . 4 
 
 75 . . 
 
 , . . 
 
 50" . 
 
 '1 
 
 (Jo . . 
 
 . . 4.5 
 
 80 . . 
 
 . . 7 
 
 Should our patient require to see at some particular di.stance. the numbers in tne 
 taVjle need not be adhered to : he may be allowed to select those lenses which he thinks 
 suit best. As a matter of fact, we often find that the glasses given in the table are too 
 strong, especially in hypermetropic persons who have become presbyopic before taking to 
 glasses. Such persons have long been accustomed to strain their accommodation to the 
 utmost, and will not thank us for giving them glasses which neutralize the whole of their 
 hypermetropia as well as their presbyopia. AVe shall give much greater .sati.sfaction by 
 orderitig glasses which a little more than neutralize the hypermetropia, and so give a lit- 
 tle helj) without being an absolute correction. 
 
 Injuries. — Opacity of the lens (traumatic cataract) may be cau.sed either by pene- 
 trating wounds of the cornea or simply by concus.sion. 
 
 Uislocatifjii of the Lens. — As the result of blows upon the eyeball, the lens may 
 become partially or entirely displaced ; it may still retain its transparency, but often 
 becomes more or less opaque. 
 
 Displacement of the lens may take place upward or downward, laterally, forward into 
 the anterior chamber, backward into the vitreous, or it may be entirely extruded from the 
 globe through a wound in the sclerotic and lie beneath the conjunctiva. In the first three 
 positions the displacement is only partial, and the margin of the lens can be .seen by 
 obrujue illumination occupying some part of the pupil. 
 
 In displacement forward the pupil will be found dilated, irregular in shape, and fixed ; 
 oblique illumination will show the lens lying partially or entirely in the anterior chamber. 
 
 In displacement backward the iris will be tremulous, the pupil sluggish, and the 
 anterior chamber deepened. Direct ophthalmoscopic examination will probably detect the 
 lens lying in the ciliary region at the lower part of the eye. 
 
278 AFFECTIONS OF THE IRIS AND CHOROID. 
 
 In displacement beneath the conjunctiva the lens is found forming a small rounded 
 tumor somewhere near the corneal margin, most frequently at its upper part. 
 
 Treatment.— If the lens be displaced partially or into the anterior chamber and still 
 retain its transparency, it may be left alone. But should it become opaque or appear to 
 be setting up irritation, it should be removed by extraction, preferably associated .with 
 iridectomy. A transparent lens may remain for years in the anterior chamber and, with 
 the exception of impairment of vision, give rise to no inconvenience. If its capsule has 
 been lacerated, however, it will become opaque, and if not extracted will gradually be 
 removed by absorption. 
 
 A lens displaced into the vitreous chamber will very probably act as a foreign body 
 and set up glaucomatous changes, in which case it should be removed at all risks ; but if 
 it produces no irritation, it is best left alone. 
 
 A lens displaced beneath the conjunctiva may also be left to itself. 
 
 Cataract will be considered in the section on operations. 
 
 THE IRIS AND CHOROID. 
 
 Congenital Anomalies. — Coloboma signifies a cleft condition of the iris or 
 choroid dependent on failure of closure of the foetal fissure. In the iris it occurs as a 
 deficiency of the lower segment, appearing as if iridectomy had been performed down- 
 ward. In the choroid it is seen (on examination with the ophthalmoscope) as a brilliant 
 white figure, commencing at the optic disc and continuing downward and forward for a 
 variable distance toward the ciliary processes, through which, in extreme cases, the cleft 
 may extend, and be even continuous with a similar deficiency of the iris. 
 
 In the Albino the pigment of the iris and choroid is absent to a greater or less 
 extent, and with the ophthalmoscope the fundus of the eye appears of a yellowish-white 
 color. 
 
 Iridereniia, or congenital absence of the iris, is occasionally observed. 
 Persistency of the Pupillary Membrane. — »^mall portions of the membrane 
 
 which at a period of foetal life covered the pupil occasionally remain, and may be seen as 
 one or more fine threads, somewhat resembling cobwebs, passing across the pupillary area 
 and attached at either end to the anterior surface of the iris, near the margin of the pupil. 
 
 Anomalies of Color. — The iris of one eye may be brown, that of its fellow being 
 blue, or difterenee in color may occur in different parts of the same iris. 
 
 Tremulous iris (iridodonesis) signifies a tremulous condition of the iris, which 
 shakes about as the eye is moved. This condition is met with when the iris has lost the 
 support of the crystalline lens, when the vitreous humor is abnormally fluid or the iris 
 totally paralyzed. 
 
 The term jmral/ysis should, strictly speaking, be applied only to cases where the iris is 
 tremulous, all its proper movements being destroyed and the pupil of moderate size ; but 
 it is often used in the. condition of dilatation of the pupil met with in some eases of paral- 
 ysis of the third nerve, in which, however, only the circular fibres are affected. 
 
 Mydriasis signifies abnormal dilatation of the pupil ; Myosis, abnormal con- 
 traction. 
 
 Cases are occasionally met with in which the ciliary muscle, circular and radial fibres 
 of the iris are all paralyzed, the pupil is of medium size and does not act. The disease 
 has been called " ophthalmoplegia interna " by Mr. Hutchinson. 
 
 Tumors seldom originate in the iris itself, but its structure often becomes implicated 
 by growths commencing in deeper parts of the globe (see " Tumors of Eyeball ") ; 
 instances, however, of malignant growths, dermoid and simple cysts, and of the cysti- 
 cercus have been met with in the iris. 
 
 Inflammation of the Iris (Iritis). 
 
 Causes. Locnl. — Irritation from foreign bodies in the conjunctival sac or cornea; 
 friction of the cornea by granular lids or inverted lashes ; injuries to the iris itself by 
 operations or accidents, with or without the lodgment of foreign bodies in its substance 
 or on its surface ; pressure by a swollen crystalline lens and exposure from perforation 
 of the cornea. 
 
 Constltutioudl. — Debility after acute disease, overlactation, etc. ; certain specific dis- 
 eases, as syphilis, rheumatism, and gout. 
 
 Symptoms. — The following symptoms are met with in most cases of iritis : changes 
 
Ri'jsri/rs or inirrs. 279 
 
 oi" ciiliir. cliimiiiit'ss aii<l li)>,> (if jMilisli of the iris, slu<^f^ishne88 or complete iiiiiiiol)ility 
 uiul (as a rule) eoiitractioii of the )Mi|iil. iiijeetioii of tlic ciliary rej^ioii (ciliary reiliiess), 
 wiiterinj:: of the eye, and iiiiitainiieiit of vision. ()ilicr symptoms met with oceasionally 
 ure j)ain, intolerance of lijrht. irre<;ularity in outline of the pupil, intlammatorv i)ro(Jucts 
 — pus or lymph nodules — visilile to the nakt'il eye. 
 
 Three varieties of iritis are commonly nut with: I. Simple iritis; 2. Kecnrn-nt 
 or rheumatic iritis; '.',. Svphilitic iritis. 
 
 Simple Iritis. — All the more constant .symptoni.s of iritis are present, often accom- 
 panied l»y more or less severe pain. An uncom])licated attack lasts from one to two weeks 
 or longer, and usually ends in resolution, the iris (juite recovering its normal condition, 
 but a few adhesions may form between the iris and lens capsule (posterior synecbijc). 
 In this as well as in the other forms of iritis, however, the intiammation may run on to 
 the f<innati(iM of a cnnsidcrahlc i|uaiitity of new material or into suppuration. 
 
 Recurrent or rheumatic iritis <)eeurs in persons who are subject to attacks of 
 rheumatism or gout, and also in the children of rheumatic or gouty jtareiits. An attack 
 of this form of intiammation presents all the more constant symjitoms of iritis, and has 
 one character peculiar to itself — viz., its tendency to recur, some patients having had as 
 many as twenty or more separate attacks ; in some cases the attacks observe a remarkable 
 periodicity, recurring regularly at the same time of year. The inflammatitjii sometimes 
 appears in one eye. sometimes in the other, or perhaps in both — rarely, however, simultane- 
 ously, but at short intervals, the second eye becoming aftected long before the first has begun 
 to recover. Recurrent iritis is frequently accompanied by more or less haziness of the 
 cornea and aijueous humor. In .some cases very severe pain of a dull aching character is 
 esperienceil in the eyeball, forehead, side of nose, and temple ; in others, the attack is mo.st 
 insidious, the patient's attention not being attracted until a considerable amount of new 
 material has been thrown out. extensive adhesions formed, the sight of one eye much 
 impaired, and the inflammatory action extended to the other. The great feature of this 
 form of iritis is its tendency to recur. The cause of the recurrences is not very evident ; 
 they are probably due primarily to '■ posterior synechife," and are prevented by the per- 
 formance of iridectomy. 
 
 All persons, however, who have " posterior synechitie " are not subject to recurrent 
 iritis ; so that in all probability in those who are liable to repeated attacks there is a 
 tendency to the lighting up of inflammation upon very slight provocation, such as 
 dragging of posterior synechij\?. 
 
 Syphilitic iritis is, perhaps, the most common of all the forms. 
 
 A typical case presents all the constant symptoms of iritis in a very marked degree, 
 the zone of ciliary redness being extremely well defined. There may be. besides, cer- 
 tain peculiar nodular excrescences, of a dirty yellow color (known as Ij'mph nodules), 
 situated on the surface of the iris or at its pupillary margin and at times extending into 
 the pujiil, which may be completely blocked by them. These excrescences are syphilitic 
 gummata, and their existence renders the diagnosis of syphilitic iritis certain ; they are. 
 however, only occasionally present, and in the greater number of cases met with the 
 surgeon will have to take into consideration the ]>atient's previous history, ascertain the 
 existence of other signs of syi)hilis. and make his diagnosis accordingly. 
 
 Syithilitic iritis occurs most frequently between the ages of fifteen and forty, but is 
 occasionally met with as a manifestation of congenital syphilis in infants, and often in 
 cases of interstitial keratitis. 
 
 Results of Iritis. — In many cases, especially if early and properly treated, per- 
 fect recovery takes place ; in others, permanent signs of inflammation are left. The 
 morbid changes more commonly met with are — 
 
 1. The iris it.self may be found utropJiicd. rhjitl, or rotten . and very prone to bleed 
 freely on the slightest wound. These conditions become mo.st apparent when operating 
 upon its structure. On attempting to perform iridectomy considerable diflftculty will be 
 experienced in removing a portion of the iris, which may be so tough that none of it 
 can be torn away or so rotten that only the portion included between the branches of the 
 forceps is removed, or hemorrhage may take place to such an extent as to prevent the 
 completion of the operation. 
 
 2. Adhesions to neiijlthor!nij parts (•• st/nechifr ") may have formed, those most com- 
 monly met with being between the iris and lens capsule (" posterior synechias "). 
 
 Posterior synechia) are generally situated at the jnipillary margin, and vary in extent from 
 a few adherent tags of this part only to complete adhesion of the whole posterior surface of 
 the iris to the lens cap.sule, this latter condition being known as "total posterior synechia.'' 
 
280 RESULTS OF IRITIS. 
 
 Adhesion of the iris to the cornea — •• anterior synechia '' (shouhl this occur at all as 
 the result of iritis) — will be found about its greater circumference. 
 
 3. Closure of the p\ipll by inflammatory material ; opacities upon the hm-capsule caused 
 by adhesion of the •' uvea "" detached from the posterior surface of the iris. 
 
 4. Dense inflammatory deposits in or beneath the capsule, or involving the superficial 
 fibres of the lens itself {capsular cataract^, may also be met with. 
 
 Treatment. — In treating iritis we must take care, Jirst, to remove any local cause, 
 such as a foreign body, opaque swollen lens, etc., and to cure granular lids or remove 
 inverted lashes ; secondly/, we must endeavor to dilate the pupil ; thirdly, to relieve pain ; 
 /b»/-?/i/y, any constitutional treatment , that may appear called for should be employed. 
 (The means of carrying out the first indication are detailed elsewhere.) 
 
 Local. — In order to dilate the pupil a few drops of a strong solution (gr. iv to 5j) of 
 sulphate of atropine should be placed between the eyelids by the surgeon himself at each 
 visit, and a weaker solution (gr. \ to gr. 1 to Sj ) should be used by the patient from four 
 to eight or twelve times a day. If the case is treated at the commencement, more or less 
 dilatation of the pupil will usually take place; but should the iris have become infiltrated 
 with inflammatory matter and adhesions formed, little or no efl^ect will be produced. The 
 atropine should, however, be persevered with. 
 
 Some patients are extremely intolerant of atropine ; in such it produces swelling and 
 inflammation of the eyelids and face of an erysipelatous nature, known as '' atropism." 
 
 If atropism occur, a'substitute must be found for the atropine. Daturine, hyoscyamine, 
 duboisine, hematropin, or other mydriatics, may be tried, or the atropine may be used in 
 the foi'm of an ointment, gr. \ of sulphate of atropine to 5j of vaseline. In one case I 
 found, after all else had failed, that mixing gr. 1 of carbolic acid in 5j of atropine solu- 
 tion prevented atropism. 
 
 In cases of iritis with suppuration the eye should be fomented frequently with hot 
 belladonna lotion and kept bound up with lint soaked in the lotion. 
 
 In cases accompanied by much pain blood should be taken from the temples by 
 leeches or the artificial leech. Atropine may give rise to pain by causing dragging upon 
 adhesions, and should be used with cavition in cases where its application is attended by 
 much suff"ering, especially if it have no efi'ect upon the pupil. The eyes should be pro- 
 tected from light by a green shade or protectors until the inflammation has subsided. 
 
 Constitutional. — Of constitutional remedies, there is none so useful in the treatment of 
 iritis as mercury. The drug should be given, in some form or other, so as speedily to 
 aft'ect the system in all cases where inflammatory products are plentifully produced, 
 whether the inflammation be of syphilitic origin or not. A pill containing gr. ij of pil. 
 h3'drarg. and gr. \ of pulv. opii may be taken three times a day and is a very conve- 
 nient and eff'ectnal mode of administration. Mercurial inunction or vapor baths may 
 be employed if preferred. 
 
 If the iritis occur in debilitated states of the system or the inflammation go on to 
 suppuration, tonics, as iron or quinine, should be prescribed, and a plentiful supply of 
 good food given. Should there be much pain, opium must be given ; and it is well to 
 prescribe the drug in conjunction with extract of belladonna or hyoscyamus. In rheu- 
 matic iritis salicylate of soda in doses of gr. xv to gr. xxx three times a day often does 
 much good. 
 
 The reavlts of iritis, should they seriously interfere with vision, require the perform- 
 ance of iridectomy or some one of the operations for artificial pupil. Iridectomy should 
 also be performed in cases of recurrent iritis. The removal of a portion of iris in, some 
 manner — probably by preventing dragging on adhe.sion.s — has a marvellous efi'ect in pre- 
 venting recurrences. 
 
 Injuries. — The iris may be cut. toi-n, or bruised, prolapsed through or adherent to 
 the cornea in cases of penetrating wounds of that structure (see " Wounds of the Cor- 
 nea"), or it may be separated from its insertion to a greater or less extent by concussion 
 without external wound. Any of these injuries are liable to set up iritis, which may pos- 
 sibly be followed by suppuration. 
 
 Treatment. — The injured eye should be kept carefully bandaged with lint soaked in 
 belladonna lotion ; and if much pain is complained of or infiammator^' symptoms arise, 
 blood should be freel}' taken from the corresponding temple, either b\- leeches or the arti- 
 ficial leech. 
 
 As in ii'itis from other causes, the pupil may become blocked or extensive .synechite 
 form, requiring operative interference at some later period. (See " Operations on Iris.") 
 
ciionoiniTis. 281 
 
 Hyperemia of Choroid. 
 
 TiHToasoil vasciiliirit y nt' lln' clKPrnid is not iiiirrr(|iiciit 1 y nift with, iiinrc ('S|icciallv in 
 iuyi>|iir |i('rsi)iis; it slimilil Ik- .«ii.'<|i('t'tf(l if a ifcliiij: of t'lilncss ami t(ii>i(iii of the eyes, 
 aefdiiiiiaiiiftl hy wateriiit;' an>l iiitnU'raiiee of li^ht, i.s ciiiiiithiiiMMl of. 
 
 ( )ii exaiiiiiiatioii with the uphthahiio.scupe iiicrea.seil retliie.ss of* tin- choroid (esjM'ciallv 
 ot" that portion nearest tlie outer side of the optie dise) and some enhir^eiueiit of the 
 (dioroidal vessels ean he made out; these ehaiiiics will, however, very prohahlv he over- 
 looked hy an inexperienced ohserver. 
 
 Trk.vtmknt. — The eyes should be ke])t carefully at rest, protected fium li^dit, cold 
 diuu'hes employed, and all positions (as stoopini^ or hangiuii- the head) which cause con- 
 gestion of the eyeballs carefully avoided; blood may be taken from the temples; and if 
 •rlasses have been worn, their u.se must be discontinued. When tlie more acute symp- 
 toms have ])assed otl", any anomaly of refraction must be carefully neutralized by suitable 
 lenses. 
 
 Inflammation of the choroid, "Choroiditis," occurs uiidcr much the .^ame 
 
 conditions as iritis; it also phiys a ])rominent part in .sympathetic o])htlialmia and is not 
 unfrt'(iuently associated with inflammation of the iri.s — '• choroido-iritis.' Two forms will 
 be commoidy met with, simple and sy))hilitic. 
 
 Sy.mI'TO.ms. — In all cases of choroiditis more or less lo.ss of transparency will be found. 
 Pain, intolerance of light, impairment of vision, fulness of tlie veins emerging from the 
 sclerotic in the ciliary region, ciliary redness, dilatation and sluggishness of the pupil, and 
 increased tension of the globe are symptoms often met with in choroiditis, but are by no 
 means characteristic of it. A diagnosis can only be made with certainty by examination 
 with the ophthalmoscope. 
 
 The changes seen in the choroid with the ophthalmoscope are. grayish or yellowish 
 patches or spots of exudation surrounded by more or less redness (hyper;cmiaj, and at a 
 later period patches of atrophy. The exudation may occur in one or more large patches 
 or be distributed over the whole or greater part of the choroid in the form of spots, this 
 latter condition being known as '• choroiditis disseminata."' We know that the morbid 
 changes noticed are in the choroid, from their relation to the retinal vessels which pass in 
 front of and are not oltscured by the opacity. 
 
 SyphiUtic choroiditis (in typical cases) is characterized by the presence in the 
 choroid of yellowish lymph nodules similar to those seen in syyjhilitic iritis ; but, as in the 
 latter disease, typical cases are only occasionally met with, and we n)ust be guided by the 
 same rules in forming a diagnosis. Choroiditis disseminata is syphilitic ; the atrophic 
 changes left by it are seen in spots of white and dark dotted about the fundus, often 
 combined with an irregular band of dirty white extending round the optic disc. These 
 changes are frequently seen in the subjects of congenital syphilis; the choroidal disease 
 is in many instances associated with floating opacities in the vitreous and may be looked 
 upon as a certain indication of syphilis. 
 
 Choroiditis is frequently associated with inflammation and opacity of the vitreous 
 humor; the retina covering the affected portion of choroid is usually involved in the 
 inflammatory change, and the optic disc may be implicated if choroiditis exist in its 
 vicinity. 
 
 Atrophy of the choroid, as above stated, frequently follows inflammation. The 
 ophthalmoscope shows white or dirty white patches, or spots corresponding to the areas 
 previously occupied by inflammatory exudation, caused by destruction of the choroid, 
 allowing the white sclerotic to show more or less plainly through it. The atrophic 
 patches are frequently surrounded by dark bo-rders, from accumulation of pigment which 
 has been disjilaced by the inflammatory material. 
 
 Inflammation of the ciliary portion of the choroid (ciliary body) is known 
 as '• cyclitis." 
 
 Cyclitis is characterized by redness and swelling of some part or the whole of the 
 ciliary region, with considerable eidargement of the veins of the retina, choroid, and iris, 
 and pain in the eyeball, aggravated by pressure in the ciliary region. Cyclitis may be 
 caused by injury or may depend upon syphilis, inherited or ac(|uired. Softening and 
 shrinking of the globe is very likely to follow, from impairment of nutrition, dependent 
 on interference with the circulation of blood. Suppuration may also take place. Wounds 
 implicating the ciliary region of the sclerotic should always be looked upon as much more 
 serious than those of other portions of the tunic, as cyclitis is frequently set up by such 
 injuries. Cyclitis is not uncommonly associated with iritis — • irido-cyclitis." 
 
282 SYMPATHETIC OPHTHALMIA. 
 
 Treat.mext. — The treatment of choroiditis should be very .similar to that of iritis. 
 Iridectomy does good in some chronic cases or in those in which there is increase of ten- 
 sion of the globe. For the atrophic changes no treatment is of much avail. 
 
 Bone upon the Choroid. — Deposits of bone are not unfrequently met with upon 
 the inner surface of the choroid in eyes that have been blind and shrunken for years. 
 
 Tubercles in the Choroid. — In cases of general tuberculosis deposits of tubercle 
 have occasionally been met with in the choroid. 
 
 Injuries. — The choroid may be injured by foreign bodies entering the eyeball or 
 ruptured by violence without perforation of the tunics. 
 
 In the former case (more especially if a foreign body be lodged in the structure of the 
 choroid) inflammation is very liable to follow, the eyeball being eventually lost by sup- 
 puration or shrinking. A rupture of the choroid from external violence is attended with 
 more or less hemorrhage, which fills the rent made in its structure with blood and may 
 cause considerable displacement of the retina. 
 
 Seen with the ophthalmoscope soon after the receipt of the injury, a ruptui'e of the 
 choroid appears as a more or less elongated blood clot : later the blood becomes absorbed 
 and a white linear figure is left, from the white sclerotic showing through the rent in the 
 choroid. This form of injury is not often followed by destructive inflammation. 
 
 Treatment. — Injuries of the choroid .should be treated in the same manner as 
 injuries of the sclerotic, cornea, or iris, with belladonna lotion, lint, and a bandage. 
 
 Sympathetic Ophthalmia. 
 
 '• Sympathetic ophthalmia " is the name applied to a peculiar form of inflammation 
 of the choroid, ciliary body, and iris coming on in one eye in consequence of morbid 
 changes which have previously existed or are .still in operation in the other. 
 
 The mo.st common cau.ses of sympathetic ophthalmia are injuries of one eye, especially 
 vxninda implicating the ciliary region, or associated with lodgment of a foreign body in the 
 interior of the globe. 
 
 Shortly after the receipt of an injury the wounded eye may become affected by kera- 
 titis punctata and choroido-iritis of a marhedly adhesive character ; pain moi'e or less 
 severe will be complained of. sight rapidly lost, extensive synechias form, the tension 
 of the globe — at first .somewhat above par — diminish, and shrinking of the eyeball 
 follow. 
 
 At an_v time during the foregoing changes in the injured eye the sound one may 
 become irritable and painful, and a similar inflammation may be set up in it, leading 
 rapidly to a like result. 
 
 Treatment. — Where sympathetic ophthalmia has been once established, in all proba- 
 bility irreparable damage will be done ; the great point to bear in mind is to prevent its 
 occurrence by timely extirpation of the damaged glohe. (See " Extirpation of the Eye- 
 ball.") Should the disease have become fairly establi.shed, little benefit can be expected 
 to result from such extirpation, as the morbid changes will probably continue in the sym- 
 pathetically inflamed globe in spite of the removal of that primarily aflfected. The sym- 
 pathetically aff"ected eyeball (or. if excision have not been performed, both eyes) should 
 be kept carefully bandaged with lint soaked in belladonna lotion ; all light should be 
 carefully excluded by using a black bandage and keeping the patient in a darkened room. 
 Pain must be relieved by the same methods as in cases of iritis. Any constitutional 
 treatment that may appear necessary .should be employed, and as soon as the acute 
 inflammatory symptoms have entirely subsided iridectomy should be performed. This 
 operation often exerts a very beneficial influence upon the nutrition of the globe (see 
 " Iridectomy "). and should be repeated a second, or even a third, time should the new 
 pupil become (as is very likely to be the case) occluded by inflammatory exudations. 
 
 Should suppurative inflammation be .set up in one eye, sympathetic changes need not 
 be feared in the other : it is only in the adhesive form of choroido-iritis that sympathetic 
 ophthalmia is likely to occur. 
 
 Sympathetic Irritation. 
 
 It not unfrequently happens that soon after the receipt of an injury to one eye its 
 fellow becomes .slightly painful, intolerant of light, and irritable. These conditions may 
 remain unchanged week after week and eventually sub.side. They make up what is 
 known as " sympathetic irritation." 
 
(^LAlroMA. 283 
 
 Wlicii sympatlit'tic initaliim Dcciirs, we iiiiisi alwavs watdi tlic iMJiircd (>v<' ••aref'ullv ; 
 and if sii^iis of clniroido-iiitis or ktTatitis puiiclata appt-ar in it, it should be ininicdiatidy 
 excised. If no such symptoms occur, liowcvcr, its removal is not necessary. 
 
 THE VITREOUS HUMOR. 
 
 Opacities i" the vitreous are fretjuently met with in eases of niyoj»ia. and often as 
 the rcsiihs of choroiditis. 
 
 Inflammation <»f the vitreous occurs occasionally ; it is generally of syphilitic ori- 
 gin or causcil liy injuries, especially the lodfjnient of foreijrn bodies within the globe. 
 ^'ision becomes misty, and on examination the humor is found to l»c more or less 
 turbid. 
 
 Tkkat.m KNT. — Should the inflammation be of syphilitic origin, anti-syphilitic n-medies 
 slnuild be emploved ; should it dejiend tin injury, the eye must be kept banrlaged with 
 lint soaked in bclladoiiii;i lotion and nirasures taken to subdue the inflammation. 
 
 Hemorrhage into the Vitreous. — Occasionally l)leeding takes place into the 
 vitreous humor to a considerable extent. Impairment of vision is complained of, usually 
 coming on suddeidy, and (jften during some exertion. Examination with the ophthalmo- 
 scope (direct method) shows the vitreous chamber to be occupied by a turbid irregular 
 cloud which floats about as the eyeball is moved, gradually subsides to its lower part 
 when the movements are discontinued, and is stirred up again on the movement.s of the 
 globe being repeated. The blood becomes absorbed to a greater or less extent in the 
 course of time, but very commonly some permanent opacity is left. 
 
 GLAUCOMA. 
 
 By glaucoma we understand '• a series of morl)id changes of the eyeball ; the most 
 prominent, and apparently the one which causes all the others, being an increa.se of ten- 
 sion of the globe"' ( Bader). 
 
 The cause of the increase of tension is unknown, but is supposed to result from undtie 
 accumulation of the intraocular fluids, dependent on hyper-secretion or deficient removal. 
 Glaucoma is said to be simph' when the increase of tension progresses slowly and continu- 
 ously wMthout inflammatory outbreaks; acute or chronic when attended by attacks of 
 inflammation. 
 
 Simple glaucoma presents no very marked symptoms, its on.set being most insidi- 
 ous. It is characterized by gradual decrease of acuteness of vision, with narrowing of 
 the visual field, impairment of the power of accommodation, causing rather rapid increase 
 of presbyopia, sluggishness in the movements of the iris, some dilatation of the pupil, and 
 some apparent haziness of the lens. Increase of tension is probably one of the earliest 
 symptoms, but is very liable to be overlooked until the disease is far advanced and con- 
 siderable hardness of the globe has taken place. With the ophthalmoscope spontaneous 
 pulsation of the retinal arteries may be seen, or pulsation may l)e produced by very slight 
 pressure upon the globe. The ves.sels, especially the veins, are thinner on the surface 
 of the optic disc than in the surrounding retina, and the disc itself may be more or less 
 cupped. The cup of glauconui is characterized by a bluish appearance of the greater por- 
 tion of the disc ; upon this blue portion the vessels appear very small and indistinct, or 
 they may be quite invisible ; the margin of the disc is white, and the large tortuous reti- 
 nal vessels are seen curling up over its edge and appearing on the surface of the retina 
 at a point not continuous with their course upon the nerve surftice. Small hemorrhages 
 may also be met with upon the retina. 
 
 Absolute Glaucoma. — Sooner or later, in any form of glaucoma, if relief be not 
 given, the condition known as ahsohifi- f/fduronid is established. The eyeball becomes 
 stony hard, the pupil widely dilated and fixed, the cornea hazy and anaesthetic, the iris 
 and acjueous humor discolored, the anterior chaml»er shallow, and the lens more or less 
 opaque. A few dilated veins are seen issuing from the globe in the ciliary region ; the 
 sclerotic may be somewhat bulged in places and bluish in color, and the conjunctiva is 
 extremely rotten, tearing on any attemjit to seize it with forceps. On examination with 
 the ophthalmoscope, all appears dark behind the pupil or a dull-red reflection may be 
 returned from the interior, but no details of the fundus can be made out. All perception 
 of light is lost. 
 
 In some cases of acute glaucoma, and almo.st invariably in chronic glaucoma, the 
 onset of the disease is preceded by premonitory symptoms. 
 
284 GLA UCOMA. 
 
 These are, as in simple glaucoma, rapidly-increasing presbyopia and slight increase 
 of tension of the globe, sluggishness and dilatation of the pupil, some apparent haziness 
 of the lens, and narrowing of the visual field. 
 
 Besides these, we may find some congestion of the veins emerging from the sclerotic 
 in the ciliary region. There may be periodic attacks of dimness of vision, objects appear- 
 ing as if veiled by a grayish or yellow mist (London fog) ; in the later stages we may 
 have a halo around a flame or the appearance of a rainbow, and at times attacks of pain 
 in and about the eyeball. 
 
 Acute glaucoma usually commences suddenly with well-marked inflammatory 
 symptoms. The ]»atient will state that he was seized (frequently during the night) with 
 sudden severe pain in the eye ; the pain will be described as affecting not only the eye- 
 ball, but the whole of the corresponding side of the head, and he will have found that 
 the sight of the painful eye is much impaired or entirely lost. On examination, the eye- 
 lids will be found slightly reddened and swollen, the conjunctiva somewhat chemosed, 
 and its vessels, as well as those situated more deeply in the subconjunctival tissue, 
 enlarged. There will be profuse lachrymation, and often much intolerance of light; 
 the aqueous humor will very probably be somewhat turbid. The pupil will be 
 moderately dilated, somewhat irregular and fixed, and the tension of the globe greatly 
 increased. 
 
 On examination with the ophthalmoscope, some of the appearances mentioned under 
 " Simple Glaucoma " may be found, but the media will probably be so hazy as to ob.*cure 
 the parts behind, a dull-red reflection being all that can be made out. 
 
 The acute symptoms may pass off in the course of a few days or weeks, leaving the 
 eye more or less permanently damaged. Similar attacks may recur, but more frequently 
 the disease relapses into a chronic state. 
 
 Chronic glaucoma, the form most commonly met with, is characterized by the 
 occurrence of slight inflammatory attacks associated with temporary increase of dimness 
 of vision and more or less pain in and around the eyeball. On examination, the field of 
 vision will be found to be limited, the tension of the globe increased ; and if the patient 
 present himself during an inflammatory attack, the conjunctiva and subconjunctival tissue 
 will be found unduly vascular, the pupil somewhat dilated, and the movements of the 
 iris sluggish. 
 
 The loss of vision in cases of chronic glaucoma is attended by symptoms like those 
 of the premonitory stage. Patients complain that their sight is always somewhat misty, 
 that there is an appearance of a bright halo around a candle or other flame, that they .see 
 colors resembling a rainbow and often of great beauty, and occasionally flashes of light 
 and fiery circles ; the last-mentioned symptoms are, however, common to all forms of 
 retinal irritation. Vision is always worst during the inflammatory attacks and recovers 
 to a certain extent during the remission, never, however, returning to the same condition 
 as before the attack. 
 
 The ophthalmoscope shows changes similar to those mentioned under '• Simple 
 Glaucoma." 
 
 Glaucoma Fulminans. — There is yet another form of glaucoma requiring men- 
 tion — fortunately, rarely met with. Its principal characteristic is the extreme suddenness 
 and violence of its onset ; its symptoms resemble those of acute glaucoma in an aggra- 
 vated form. This variety of glaucoma is known as glavcoma fidminans^ and the eye 
 attacked by it may be entirely lost in the course of a few hours. The attack is occasion- 
 ally accompanied by severe headache and vomiting. 
 
 Glaucoma is essentially a disease of the latter half of life, occurring mo.st frequently 
 between the ages of forty and sixty, but occasionally in young adults, or even in chil- 
 dren. Glaucoma almost always affects both eyes — not, however, simultaneously, but at 
 more or less considerable intervals. 
 
 Diagnosis. — In order to diagno,se glaucoma we must be well acquainted with the 
 method of ascertaining the tension of the globe, and also with the use of the ophthal- 
 moscope. (See " I^xamination of Eyeball," etc.) 
 
 We must also remember that the injurious effects of pressure are evidenced earliest 
 in the peripheral portions of the retina, and should therefore very carefully examine the 
 condition of the visual Jiehl in all suspected cases. (See " Examination of Field of 
 Vision.") 
 
 Cases are frequently met with in which great contraction of the visual field has taken 
 place, although central vision is still acute. Another symptom which should lead us to 
 suspect glaucoma is the rajnd increase of presbyopia. Patients affected by the simple or 
 
Tin: iniTlSA AM) (JJ'TJC MlllVI-:. 2Ho 
 
 pliroiiic tonus <if'tli»' disrasi' an- fdu.staiitly cliiin^jiiiLr their glasses, as tliL'y find that tliose 
 wliii'h at lirst uj)])»'ar to suit hi'coiiif uscK'ss in the foiirx- of a few months. 
 
 A|i|ian'iit ha/.iiicss n\' the crystalliiif U-ns is u symiitoui rfi|iiiriii<.' special attention ; 
 otiieiwise, the surui'on may tall into the fatal error of mistaking clirotiic <ir simple ^'lau- 
 eoiiia for eatarart ami allow the disease to eonliiiiie until si^dit is irrevocahlv lost. In 
 such cases opht halnioseopie e.\amination will most prcthahly show that there is little or 
 no nal opacity of the lens, and this, aided hy a careful examination of the tension of the 
 ^lolie and the state of the visual litdd, will prevent so disastrous a mistake. 
 
 Secondary Glaucoma. — Uesid(!s the forejioinf;, we not unfre(|ueiitly meet with 
 wh.it is known as " st'conilary trhiucoma" — /. '.. <rlaucoma comiiifr on in tin; course of 
 sonic other disi'ase, as ecu'neitis. ulceratifin of cornea, iritis, etc. tilaiieoma (jccurrinir in 
 younu: per.sons is usually seconilary. (Ilauconia following: injury is spoken of as "trau- 
 matic <rlauc(uua. ' 
 
 TKK.\T.Mi;N"r. — (ilaueoma can he remedied l>;/ 'ijitra/ioii iilnui'. Anil it is our iliity to 
 explain to the patient the nature of his case ami to ur<re ujxui him most stron<.dy the 
 iinr-isi'i/ for operativ*' interference. 
 
 Patients sufVeriuir from <rlaueoma often evince the trreatest uiiwillinj^uess to undt.-r^ro 
 an operation : this unwilliimness is explained hy the fact that durinj; the reinissionx of the 
 disease little or no inconveiiienee is experiiuiced, and, moreover, even at the time that an 
 attaek of inflammation is pre.sent the sutferer will he encouraged by the hope that the 
 symptoms will pass olf' (as they in all probability have done in previous attacks), leaving 
 the eye but little damaged. Nevertheless, we must always bear in mind that an opera- 
 lion^ to he si(ccc!<!<f'tt/, miisf be performed e(xr/i/, and must not be .satLsfied until we have con- 
 vinced our patient of this. Most patients will readily submit to an operation when one 
 eye has been lost and the disease has commenced in the other. 
 
 Several operations have been practised for the relief of glaucoma, but iridectomy and 
 sclerotomy are those which give the best results. Iridectomy and sclerotomy, to be 
 etfectual, should be performed as early as possible ; as a rule, no good is likely to result 
 from an operation in cases where vision has been reduced t(j bare ])erception of light, but 
 in acute glaucoma much improvement may take place even though all perception of light 
 have been lost f(jr some days. 
 
 In performing iridectomy for glaucoma we must take care to remove the iris well 
 down to its insertion and to excise a good broad piece (see p. 306) ; merely cutting away 
 a portion of the iris near the margin of the pupil does no good. The operation is easy 
 enough of performance in cases of acute glaucoma, but in those of old standing, where 
 the structures are rotten or the pupils so widely dilated that the iris has become a thin 
 rim at the periphery of the anterior chamber, it is anything but simple. In such ca.ses 
 sclerotomy is to be preferred to iridectomy. 
 
 In cases of glaucoma where for any reason an operation does not seem advisable we 
 must do our best to give relief by medical treatment. The means which will be found 
 most useful are the instillation of solutions of sul))hate of escrine (gr. ij to iv to water .'^j), 
 application of sedative fomentations, administration of opium, and the local abstraction 
 of blood by leeches or the artificial leech. 
 
 Atropine s/ioid(/ not be n^ed in glaucoma, as it causes increased vascularity of the 
 globe, and with it augmentation of tension. Its application is recommended in most 
 works on ophthalmic subjects, but it do.es more harm tlian good. Eserine, however, has 
 a contrary eftect and is often of great benefit. 
 
 THE RETINA AND OPTIC NERVE. 
 
 Vision. — Space will not allow of a detailed account of all the anomalies of vision 
 which may be met with. Before the introduction of the ophthalmoscope all cases of 
 leant o/ si'//if occurring without cause apparent to the unaided eye were collected together 
 into two classes ])eariug the names " amblyopia" and " amaurosis." 
 
 Amblyopia and Amaurosis. — T<^ the former were referred all cases where the 
 vision was much impaired, but not entirely lost ; to the latter, ca.ses in which not even 
 perception of light remaineil. But, now that the ophthalmoscope has come so generally 
 into use, making the interior of the globe as accessible to our sight as the exterior, we 
 have come to refer " amblyopia" and •• amaurosis' to their proper causes, and the terms 
 have fallen into comparative disuse. For instance, if in a ca.se of want of sight we find 
 on ophthalmoscopic examination that there is haziness of the vitreous, inflammation of 
 the retina, etc., we do not .say (as formerly) that the patient is " amblyopic." but that he 
 
286 RETINITIS. 
 
 is suffering from opacity of the vitreous, retinitis, etc. Again, in cases of total blindness, 
 the ophthalmoscope will in all probability detect atrophy of the optic nerve or other 
 lesion, and, instead of saying that the patient is '• amaurotic," we say that he is suffering 
 from atrophy of the optic nerve, etc. The terms " amblyopia" and '' amaurosis" may,, 
 however, still be used in some rare cases where there is a partial or complete loss of sight 
 associated with an apparently healthy condition of all the ocular structures. 
 
 Hypersemia of the retina occurs from overstrain of the eyes in doing near work 
 (especially in hypermetropic or astigmatic persons) or from constantly looking at bright 
 light ; the disease is not uncommon amongst engine-drivers and others who work over a 
 blazing fire. 
 
 The patient complains of some dimness of vision and a feeling of fulness and discom- 
 fort in the eyes. On examination with the ophthalmoscope, the retinal vessels, both 
 arteries and veins, will be found increased in size, and a greater number of each will be 
 visible than in the healthy retina. 
 
 This form of hyperaemia may be described as " active ;" another form of hypertemia, 
 affecting only the retinal veins, which become enlarged, tortuous, and sometimes varicose, 
 may be described as " passive;" this condition is indicative of obstruction to the return of 
 blood from the eyeball. (See " Ischaemia.") 
 
 Hypercemia of the retina, especially the active form, is not easily recognized, as the 
 limits between health and disease fade almost imperceptibly into each other, and consid- 
 erable experience is required in order to judge with certainty where one ends and the 
 other begins. 
 
 Treatment. — Active hyperasmia should be treated by rest, carefully shielding the 
 eyes from bright light by means of neutral-tint protectors or a shade. After the sub- 
 sidence of the hyperemia any anomaly of refraction should be carefully neutralized. 
 
 Passive hypertemia is usually an indication of some more serious disease, and requires 
 no special treatment. 
 
 Inflaniniation of the Retina (retinitis). — Retinitis most frequently depends 
 on some constitutional condition, as albuminuria or syphilis ; it may also arise from 
 embolism of the vessels of the retina, hemorrhage into its substance, or from cerebral 
 disease ; from tumors or entozoa within the globe, exposure to sudden flashes of bright 
 light, or wounds of the eyeball. It may also be secondary to choroiditis, iritis, or cyclitis. 
 
 Retinitis is characterized by hyperaemia of the retina associated with more or less 
 dense and extensive opacity of its structure, and frequently with extravasations of blood 
 in its substance. 
 
 Disturbance of vision may be a prominent symptom, or the patient may hardly be 
 aware that anything is amiss with his eyes. The degree of impairment of vision depends 
 upon the situation and extent of the inflamed portion of the retina ; for instance, a small 
 patch of inflammatory exudation in the region of the yellow spot will cause much loss of 
 sight, whereas a considerable amount of opacity situated peripherally will give rise to 
 scarcely any symptoms. 
 
 Pain, photophobia, colored vision, and flashes of light are symptoms occasionally met 
 with in inflammation of the retina. 
 
 Acute retinitis is rarely met with, and if it should occur would hardly be recognized, 
 as the inflammatory exudation would be transparent, and therefore invisible ; conse- 
 quently, the only appearance revealed by the ophthalmoscope would be enlargement 
 and tortuosity of the retinal vessels. 
 
 The forms of retinitis which give rise to striking ophthalmoscopic appearances are 
 essentially of a chronic nature and are frequently associated with inflammatory changes 
 in the choroid and optic nerve. 
 
 Retinitis may affect one or both eyes, those forms which are of constitutional origin 
 usually affecting both, though not always in the same degree. Several varieties of reti^ 
 nitis are described. 
 
 Simple Retinitis. — The ophthalmoscope shows a more or less general turbidity of 
 the retina, varying from a scarcely perceptible cloudiness (giving the idea that the struc- 
 ture is colored and visible instead of entirely transparent) to a uniform grayish-white or 
 mottled opacity, which appears to cover the choroid like a veil. 
 
 The outline of the optic disc is indistinct. The retinal veins appear enlarged, dark- 
 colored, evidently gorged with blood, often twisted in their course, and they may be in 
 parts hidden by the inflammatory exudation. The condition of the arteries is nearly 
 normal, or they may appear too thin. 
 
 Small hemorrhages are frequently detected in the course of the distended veins. 
 
RET IS IT IS. '2H7 
 
 Hemorrhagic Retinitis. — Tl"- <'|'ti<- nerve will he IVmhkI rcdilened, soinewliat 
 HWdlliii, its oiilliiif (>l>lit( r;it(il. its tr;ins|i;ir»MH'y so iiiiirli aflccti-<l tliiit the course of the 
 retiliitl vessels ii|toii its siirfiiee aiitl in its sulistaiiee caiiiiut Ite traced ; the retinal veins 
 are tur;;i(l and tfirtuous in their course, jiresenting alternately light and dark portions, 
 according as they lie deeply in the eiigctrged retina or more superficially near its inner sur- 
 tuee. The retinal arterio. as in the simple form of retinitis, are nearly normal or too thin. 
 
 The principal characteristic (»f the disease is the occurrence of extensive hemorrhage, 
 most marked around the optic disc, and fading away gradually into the surrounding parts. 
 The bhtod extravasations have a peculiar striated appearance, and radiate spoke-like from 
 the oj»tic disc as a centre. In snnie cases the retina iinmedi:itely surrounding the disc is 
 uniformlv soaked with hlood. the bright-red c<dor thus produced gradually shading off 
 externally into the sjioke-like appearance above meiKioned. 
 
 As time giies on the extravasated blood undergoes changes, becoming brown in color, 
 and fvciitiiallv piirtiiillv '>v intirely absorbccl. 
 
 Retinitis pigmentosa i> a peculiar lorm of degeneration of the retina met with 
 moat fre<|uently in the orts|tring of blood relations; the sufferers are often deaf and 
 dumb, and may be partially idiotic. 
 
 The most marked symptoms of the di.sea.se are nii/hf hlinilneim and (jrinlnnl inirroii-ing 
 of thf ri»iiul field ttiffi'iiit<f/aiicoi)i(ifoii.tsi/m/j(oins. The ophthalmoscope reveals the most 
 striking changes : the retina, more especially about its peripheral part.s. is dotted more or 
 less thickly with black-pigment spots ; these spots appear somewhat like a multitude of 
 small black spiders with many legs ; they have also been likened to bone corpuscles. The 
 spots of pignjent appear to follow the course of the blood vessels of the retina, and, as 
 before stated, are collected most thickly in its peripheral parts. 
 
 The blood vessels themselves are much diminished in size and visible number and the 
 optic disc is markedly anivmic. 
 
 Albuminuric retinitis is a peculiar form of retinitis met with in Bright's di.sea.se. 
 The cliaiigo whirli take place in the retina are inflammation with effusion and hemor- 
 rhages, followed by fatty and fibrinous degeneration of its structure, and subsequent 
 atrophy. 
 
 The ophthalmoscope shows, in the early stages of the disease, retinal hyperaemia 
 (more e.specially venous) with increased vascularity and redness of the optic disc. Next 
 the retina becomes cloud}' (more especially around the optic disc, the outline of which 
 becomes obscured), and numerous hemorrhages in the form of streaks and spots occur in 
 various parts of its structure. 
 
 The cloudiness goes on increasing and obscures the smaller vessels ; later, in different 
 parts of the fundus, but mostly in a ring situated at a little distance from the margin of 
 the disc, appear glistening white spots and patches ; later the disc itself becomes gray and 
 opaf|ue. 
 
 Whilst the above changes are going on in other parts of the retina characteristic 
 appearances may be developed in the region of the yellow spot. A number of small 
 white glistening spots — which, however, do not coalesce so as to form a patch, but remain 
 di.stinct — make their appearance. These glistening spots are arranged in a somewhat 
 radiated position around the macula as a centre and somewhat resemble a constellation ;. 
 the appearance is quite characteri.stic, and. once seen, is not likely to be forgotten. 
 
 As the opacity of the retina increases the vessels become more and more obscured, so 
 that when the disease has reached its height only a few large venous trunks are .still visi- 
 ble. Fresh hemorrhages may occur at any time and cover over and obscure the opaque 
 portions of retina. After a time a retrograde process sets in : the hemorrhages and 
 peculiar opacities slowly disappear, the retina being at length left in a state of atrophy. 
 Displacement of the retina may occur. 
 
 Albuminuric retinitis is usually associated with granular kidney ; it is dependent on 
 the blood-va.scular disease ''arterio-capillary-fibrosis. Gull and Sutton) of which the kidney 
 affection is only a part. The retinitis often appears before any sign of the kidne\' mis- 
 chief is manifested, and it is the ophthalmic surgeon who first discovers the nature of the 
 case. 
 
 Leucsemic Retinitis. — A peculiar form of retinitis somewhat resembling the 
 albuminuric has been described as occurring in connection with leucocythsemia. 
 
 Leucajmic retinitis is marked by pallor of the optic disc, a peculiar rose-color of the 
 retinal vessels, hemorrhages, some opacity of the retina around the optic discs, and white 
 glistening spots similar to those met with in albuminuric retinitis, which, however, are 
 situated in the peripheral parts of the retina. 
 
288 ATROPHY OF THE RETINA. 
 
 Embolism of the Retina. — A form of retinitis associated with plugging of the 
 central artery conies on suddenly without apparent cause, with complete loss of sight. 
 Ophthalmoscopic examination shows some pallor of the optic disc and diminution in cali- 
 bre of the vessels emerging from it, but the most marked change is seen in the region of 
 the yellow spot. 
 
 The retina around the spot is gray and oparjue, and numerous blood vessels not visi- 
 ble under ordinary conditions come plairdy into view ; the macula itself is seen as a 
 bright-red spot (which might be taken for a hemorrhage by a careless observer) situated 
 in the centre of the opaque portion of retina. 
 
 The bright-red appearance of the macula arises from the anatomical arrangement of 
 the parts ; the retina in this situation, being thin and firmly bound down to the parts 
 beneath, does not become infiltrated with inflammatory exudation, and conseijuently the 
 normal red color of the fundus appears in striking contrast to the surrounding opaque 
 retina. Hemorrhages may occur. 
 
 Syphilitic Retinitis. — A form of inflammation attectin'g the retina immediately 
 surrounding the optic disc has been looked upon by some as of syphilitic origin, but, like 
 syphilitic iritis, rarely presents any very characteristic signs. Should retinitis occur with 
 other manifestations of syphilis, congenital or acquired, it may be looked upon as 
 syphilitic. 
 
 Treatment. — Both eyes should be kept thoroughly at rest by prohibiting all near 
 work, paralyzing the accommodation by atropine, and shielding the eyes from the stimu- 
 lus of too bright light by neutral-tint protectors. Everything that is likely to cause 
 disturbance of the ocular circulation, as stooping positions, excitement, stimulants, too 
 rapid variations of temperature, etc., should be carefully avoided. 
 
 In simple retinitis blood should be taken from the temples by leeches, or, preferably, 
 by the artificial leech, and in this form, as well as in retinitis connected with syphilis, mer- 
 cury does good ; it should be given so as quickly to afiect the system either by the 
 mouth, by inunction, or in the form of vapor baths. In cases of long standing, however, 
 small doses of the bichloride of mercury, taken regularly for some months, may be bene- 
 ficial. The other forms of retinitis are of only secondary importance to the disease with 
 which they are associated, and against which treatment must be directed. (See " Causes 
 of Retinitis.") No treatment is of much avail in retinitis pigmentosa. 
 
 Atrophy of the retina may be the sequel of inflammatory changes. Its princi- 
 pal characteristic seen with the ophthalmoscope is a condition of bloodlessness, in some 
 cases associated with opacity of the retina and frequently with atrophic changes in the 
 choroid. Bloodlessness shows itself in a diminution of the visible number, and also of 
 the calibre, 'of the retinal blood vessels, more especially of the arteries, some of which 
 may appear pervious to red blood corpuscles in part of their course only, their continua- 
 tions being marked by a yellowish-white cord. Opacities, if they occur, are of a grayish- 
 white color and situated for the most part around the optic disc. 
 
 The disc itself is frequently extremely anaemic or atrophied. (For treatment of atro- 
 phj' of the retina, see "Atrophy of the Optic Disc") 
 
 Hemorrhage into the Retina. — Besides the form of hemorrhage described as 
 .occuring in retinitis, bleeding may take place into the structure of the retina from rup- 
 ture of a retinal blood vessel without previous inflammatory change. The hemorrhage is 
 usually considerable, and will be seen as an irregular patch of blood situated somewhere 
 in the course of the ruptured vessel, and often surrounded by inflammatory exudation. 
 
 The extravasated blood becomes gradually absorbed, but usually leaves behind it 
 some indications of its previous existence. 
 
 Treatment. — Rest of the eyes, protection from bright light, and blisters to the 
 temples. 
 
 Displacement of the retina is associated with effusion of serous fluid between 
 it and the choroid ; it may be caused by blows on the eyeball or the head in its vicinity ; 
 it may occur without apparent cause and is often met with in myopic eyes. Displace- 
 ment of the retina occurs by preference at its lower part, but may vary in extent from 
 detachment of a small fold to total separation of the whole retina from the choroid, the 
 only points of attachment left being at the optic disc and ciliary processes. 
 
 The ophthalmoscope shows a gray, opaque, movable cloud, over the surface of which 
 the retinal blood vessels can be traced. 
 
 Treatment. — Little can be done to remedy displacement of the retina, but an 
 attempt should be made to procure absorption of the fluid by the administration of such 
 drugs as iodide of potassium and mercury, and by the application of blisters to the tern- 
 
ATimriiY or orric m:iivh. 289 
 
 pli'. ir till' (li>|il;iffiii('iil iicciir ill (•innicrtioii with iiivipia, tin- aiioiiialv of rcfracliori 
 shouKl lit' cMivfully Ill-lit lalizi'd l)y siiitalilc glasses ; aii<i in all (lascs rest .should he ('(isurcil 
 to till' i-yi's, so as to jiri'vciit, as iiiuch us iiossihle, further (letaehiiieiit. 
 
 Inflammation of the Optic Disc optic neuritis, neuro-retinitis). — The 
 
 ojihl lialiuoscii|)f shows a icililisii-L^rav tiirliidily ol' tln' disc and the suniiiindiii^' /one id' 
 retina, aeconipaiiied hy swelliiiLi <d' the parts. The retinal veins are eiijror^red, but their 
 visihle iiumher is not increased ; the arteries are thinner tlian usual, and all tin; vessels 
 are more or less shnunled and concealed IVoin view in the o[ta(|ue jtortioii of retina and upon 
 the nerve surface. Numerous small hemorrha'.M's may occur upon the disc and around it. 
 
 Ischsemia of the Disc (choked diso. — Chokinf^ of the optic disc has been 
 (and still is by some) looked upon as distinct from optic neuritis. It would, however, 
 appear that the difference is one of degree only. The ophthalmoscope .shows great swell- 
 ing and an intense red cobu' of the disc, its outline being entirely lo.st ; there is, however, 
 but slight swelling or opacity of the surrounding retina; small hemorrhages are fre- 
 quently seen on the nerve surface. The retinal veins arc enormously distemled, their 
 course extremely tortuous, ami they may be varicose ; their visible number i.s also con- 
 siderably increased. The arteries an; thinner than natural or of normal calibre; none of 
 the vessels are shrouded and concealed from view as in neuritis. Ischa'mia may go on to 
 neuritis. 
 
 In many cases of neuritis and choked disc sight is unaffected ; in others, vision is 
 much impaired or reduced to perception of light oidy. 
 
 Optic neuritis and iscluvmia may be looked upon as indicative of irritation of the 
 nerves in some part of their cour.se, as would occur in meningitis, or of obstruction to the 
 venous circulation resulting from pressure directly on the main trunks, as in cerebral 
 tumor, or from any form of disease whatever which causes overcrowding of the content.s 
 of the cranium. Both neuritis and isch;i2mia are usually bilateral. 
 
 Tkk.vt.mknt. — Optic neuritis and isch;omia of the disc are of only secondary import- 
 ance to the disease which gives rise to them ; they are of much greater interest to the 
 physician than to the oculist, as their existence enables him to diagnose cerebral lesion 
 with great certainty. The cerebral lesion is, however, often syphilitic ; and it may be 
 laid down as a rule seldom to he departed from that optic neuritis and ischajmia call for 
 the adiniiiistratidii oi' iodide of potassium or mercury in full doses. 
 
 Atrophy of the optic nerve may be the result of preceding neuritis, when it is 
 called ••consecutive atrophy," or the atrophy may have commenced as such and slowly 
 progressed without intiammatory change — " simple atrophy." 
 
 With the ophthalmoscope the optic disc will be seen to be white or bluish-white in 
 color ; frequently its nuirgin appears irregular and it may be cupped. The atrophic cup 
 varies from the glaucomatous in not having steep sides, so that the ves.sels do not appear 
 broken in their course, as in the latter affection ; it does not take in the whole nerve, but 
 only its central part, which slopes gradually backward ; the vessels appear curved on the 
 surfoce of the disc, but are not altered in calibre, as in glaucoma. Atrophy of the retina 
 freijuently goes along with atrophy of the optic disc. 
 
 In cases of atrophy of the optic nerve vision is always much impaired; some patients 
 with extremely white dLscs can count fingers, distinguish large letters, or even read ordi- 
 nary print, but in the majority of cases vision is reduced to a bare perception of light. 
 
 Treatment. — The treatment of atrophy of the optic nerves, especially if associated 
 with a similar condition of the retina, is most un.satisfactory, and, indeed, almost hope- 
 less. Should a certain amount of vision still remain and no change have taken place for 
 many months, Ave may safely assure our patient that he will retain what sight he has. 
 The drugs which have been principally used are iron, either alone or in combination with 
 nux vomica, strychnia, taken by the mouth or injected hypodermically, phosphorus, 
 quinine, or other tonics, and opium in gradually increasing doses. Galvanism has also 
 been employed. 
 19 
 
290 
 
 OPERATIONS ON THE EYEBALL AND ITS APPENDAGES. 
 
 OPERATIONS ON THE EYEBALE AND ITS APPENDAGES. 
 
 Position for Minor Operations, 
 (sitting.) 
 
 Position for Major (Jperalious. 
 (Lying.) 
 
 POSITION OF THE PATIENT AND OPERATOR, ETC. 
 
 All the minor operation.s, such a.s slitting the canalieuli. ]ias.-in<: jirohes down the 
 nasal duct, opening tarsal cysts, etc., can best be performed when the patient is seated in 
 a chair and the operator stands behind him, the patient's head, over which a towel has 
 first been thrown, resting against the operator's chest. (See Fig. 110.) 
 
 The more important operations, as extraction of cataract, iridectomy, squint, etc., 
 should be performed whilst the patient is lying on a hard couch, his head resting on a 
 
 bolster covered by a towel, which 
 Fig. 110. Fig. 111. should be thrown forward over 
 
 the forehead : the operator should 
 sit or stand behind. (See Fig. 
 111.) In whichever position an 
 operation is to be performed, the 
 chair or table .should be placed 
 in front of a large window, so as 
 to ensure a good light, and care 
 be taken to prevent assistants 
 and others from interposing their 
 heads or bodies between the pa- 
 tient's face and the source of 
 light. It will be found whilst 
 operating that, with the excep- 
 tion of occasional pronation and 
 supination, there is little occa- 
 sion to use the arms, which 
 should be kept with the elbows 
 near the sides, the wrists resting 
 on the patient's head or face in 
 a position which allows of free movements of the hands and fingers. 
 
 Every ophthalmic surgeon .should learn to use his fingers, cultivate his sense of 
 touch, and, if pos.sible, become ambidextrous. 
 
 It will be found that incisions can best be made by holding the knife lightly between 
 the thumb and first two fingers of whichever hand is most conveniently situated. 
 
 In all operations incisions commencing at or situated entirely on the outer aspect of 
 the globe should be made with the hand corresponding to that side, the opposite hand 
 being employed upon the inner side. That is to say, if the right eye is operated on, the right 
 hand .-ihould be used to make an incision at its outer side, the left at its inner, and vice versa. 
 Incisions above or below may be made with either hand ; scissors should also be used 
 with whichever hand is most favorably situated. 
 
 In one operation — that for internal strabismu.s — the positions of patient and operator 
 are somewhat different from those already described, the operator standing in front, at the 
 side of the couch on the patient's right, in.stead of behind his head. 
 
 The scissors may be used with the right hand for both eyes, but in operating on the 
 left the hands will have to be crossed. 
 
 Before performing any operation the operator should look carefully to the condition 
 of the instruments he is about to use. Knives .'ihould be passed through a piece of thin 
 leather tightly stretched on a small metal cylinder, and care taken to ascertain that they 
 have good points and that there are no notches in the blades. 
 
 Scissors should be carefully examined and tried ; it should be seen that forceps close 
 perfectly and are free from rust or dirt ; silk for sutures should be black, as fine and 
 strong as possible, w^ell waxed, and free from flaws or kinks. Inattention to these details 
 may very possibly mar the success of an operation. 
 
 Administration of Anaesthetics. — The operator will find that he has much 
 more command over the eye when the patient is under the influence of an anaesthetic 
 than when consciousness remains, and in by far the greater number of cases he will do 
 well to administer one. 
 
 Occasionally patients are met with who will bear operations most quietly: such should 
 
lysEiiTiox OF A sKTo.y i\ Tin: tkmi'i.i:. 291 
 
 be operatetl nii witlmut aiuvsthesia ; l»iit if (liirinj; the operation the patient hcoome 
 uiistoady <>>" l»et;iii tn strain, it is })e.st not to risk failure, hut to discontinue the opera- 
 tion and administer an an;esthetie. If" the L'hihe luis been opened, it must he carefully 
 <;uarded hy a jtad and handatre duriiii: the administration. If no aiuL'stlietic l)e employed, 
 tlu' operation should lie ptrlornie(l as sim)dy and i|uiekly as jmssihle; no speculum should 
 he used, nor should the eye he fixed with forceps, hut the operator should kcr-p the lids 
 open and steady the <;Iohe with the tintrers. 
 
 Aktkk-Tukat.MKNT. — Operations on the tear passaires. removal of tarsal cyst, and 
 strahismus re(|uire little or no after-treatment ; the parts lu'ed oidy to he washeil twice 
 or three times a day with tepid water. 
 
 After more severe operations on the eyelids, and in all cases where an iiu-ision has 
 heen made into the <fhd)e, the eye should he carefully covered with two small folds of lint 
 wetted with odd water and secured hy a sinjrle turn of handaire. the lint heing kept wet 
 aiul the eye hound up until the incision has healed and all irritation subsided. Wounds 
 of the globe made in operations, as a rule, heal rapidly, union having fre(|uently taken 
 place at the end of twelve hours. 
 
 The great danger after operations on the globe is the occurrence of inflammation. 
 
 Occurrence of Inflamraation. — Inflammation, once .set up. may subside shortly, 
 leaving no trace behind it ; it may continue until more or less irreparable damage has been 
 done, or may run on to suppuration of portions or the wliole of the globe. The cornea is 
 more liable to this change than any other structure. 
 
 The symptoms of inflammation usually appear within the two days immediatelv suc- 
 ceeding an operation, and little fear need be entertained for the safety of the eyeball if 
 all has gone well for a week. 
 
 Occasionally, after cataract extraction, eyes have been lost through inflammation, or 
 suppuration commencing at a later period ; but these cases are rare, and probably it 
 will be found that some damage has been done to the eye shortly before the symptoms 
 appeared. 
 
 The treatment of inflammatory changes consists in the local abstraction of blood from 
 the temple by leeches or the application of the artificial leech ; the use of fomentations 
 of water, poppy-heads, or belladonna constantly applied ; the administration of opium in 
 full doses, either alone or combined with mercury. The treatment must, of course, be 
 varied according to the condition of the patient : should he be weakly and ana?mic, we 
 should be careful about blood-letting, and. instead, quinine and iron, with good living and 
 a fair amount of stimulants, should be prescribed. 
 
 The local abstraction of blood, however, acts most beneficially in relieving pain, and 
 should, therefore, be employed in cases where pain is a prominent symptom, even though 
 the patient does not appear to have much blood to lose. Strong, healthy patients should 
 be leeched freely and kept on light diet. 
 
 During the treatment the eye must be kept carefully closed and bandaged, excepting 
 during the time that fomentations are being applied. Moderate pressure by carefully- 
 applied pads of lint and cotton-wool secured by a few turns of flannel bandage is said to 
 exert considerable influence in cases where the cornea is threatened by suppuration ; it 
 should have a fair trial if pressure can be borne. 
 
 If the inflammation go on to su])puration of the whole globe, the case must be treated 
 in the same manner as abscess in any other part. (See •' Ophthalmitis.") 
 
 Insertion of a Seton in the Temple. — In order to place a seton in the tem- 
 ple, the i)0sition of patient and operator should be as in Fig. llO. p. 290. The operator 
 should pinch up the skin with the finger and thumb of one hand just in front of the 
 patient's ear and pass a seton needle armed with a double thread of stout silk through 
 the fold thus produced ; the silk should be drawn through and tied in a short loop. The 
 seton should pass for about li inches beneath the skin, and should be placed amongst the 
 hair, so as to avoid, as much as possible, disfigurement from the subsequent cicatrix ; the 
 silk should be drawn backward and forward through the wound every morning: it may be 
 left in as long as appears necessary. 
 
 Care must be taken in passing the needle not to wound the temporal artery ; should 
 this accident happen, the seton must be removed and firm pressure applied with a pad and 
 bandage. 
 
 Application of the Artificial Leech. — This instrument consists of a small 
 sharp steel cylinder (worked by a spring arrangement), with which a circular incision 
 can be made through the skin of the temple, and a hollow glass cvlinder. which can be 
 placed over the wound and the air in its interior exhausted by means of a piston worked 
 
292 OPERATIOXS ON THE EYELIDS. 
 
 by a screw; as the air is removed the blood flows up to fill the vacuum. Care must be 
 taken not to work the screw too quickly, but only to move the piston at the same rate as 
 the blood flows ; neither must the edge of the cylinder be allowed to compress the skin 
 against the parts beneath, otherwise the flow of blood will be impeded. 
 
 THE EYELIDS. 
 
 Tumors. — Various small growths are met with about the eyelids. 
 
 Molluscum occurs as a small yellowish-white projection, having a depressed and 
 often blackened centre, situated on some part of the skin of the lids ; there may be only 
 one or many of these little growths. They can be easily removed by thrusting a knife 
 through them and then squeezing out the contents with the thumb-nail. 
 
 Dermoid cysts are not unfrequently met with situated deeply beneath the skin 
 and the muscle, often near the outer angle of the orbit. They are congenital, filled with 
 sebaceous matter, and often contain haii*. They must be carefully dissected out, much 
 more trouble being experienced in so doing than would be at first suspected ; and they 
 will in all probability be opened during removal. These little tumors will be found 
 attached deeply to the periosteum, and may have caused a depression in the bone. 
 
 Warts are not unfrequently met with about the eyelids ; they should be cut off 
 with scissors. 
 
 Tarsal cyst is met with as a dusky-red or colorless projection from the outer sur- 
 face of the lid ; its position is marked on the conjunctival surface by a bluish spot, from 
 which a granulation is occasionally seen growing. The cyst is formed by obstruction of a 
 Meibomian gland and retention of its secretion; it is sometimes in a suppurating condition. 
 
 The lid should be everted, the cyst freely opened from the conjunctival surface with 
 a small knife, and its contents squeezed or scooped out ; it must be thoroughly emptied, 
 or it will in all probability re-form. 
 
 The cavity left on removal of the contents of the cyst will always fill with blood, and 
 shortly after the operation the tumor will be as large as, or larger than, before ; the 
 patient must be warned of this. 
 
 The swelling will most probably disappear in the course of from four to six weeks ; 
 if it remain longer, the operation should be repeated. 
 
 A tar.sal cyst sometimes degenerates into a hard fibrous little mass, feeling somewhat 
 like a large shot beneath the skin, which is known as a cltalazion ; this should be dissected 
 out throvigh an incision in the skin of the lid, which should afterward be closed by a fine 
 suture. 
 
 Xanthelasma is often met with as a small yellow patch on some part of the skin 
 of the eyelids ; its most frequent site is the surface of the upper lid, near the inner 
 canthus. The little patch may be excised if it is a source of anxiety to the patient. 
 
 Simple serous cysts occur about the margins of the lids ; they are about the 
 size of small peas and nearly transparent. A portion of the cyst wall should be cut out 
 with scissors. 
 
 Trichiasis signifies a faulty direction of the eyelashes, which turn inward andi 
 irritate the cornea ; it is usually caused by contraction of the conjunctiva (following 
 granular ophthalmia or its unskilful treatment), producing displacement of the hair 
 JoUicles. 
 
 Treatment. — Only a few lashes may be misdirected, or the whole row may be 
 inverted. If only a few of the lashes turn inward, it is sufficient to pull them out with 
 forceps whenever they become troublesome. If a considerable number or the whole row 
 are inverted, their roots should be removed by operation. The operation should be per- 
 formed as follows: The patient being placed in the usual position (see Fig. Ill, p. 290), 
 the lid should be secured by a compressoi'ium forceps (Figs. 112, 113), by which means 
 it is steadied and hemorrhage prevented ; care must be taken not to screw the instrument 
 up too tightly, or sloughing of the lid may follow. The lid being well secured, the operator 
 should make an incision through the skin, about three lines from the free margin of the 
 lid and parallel with it, of such a length as to corre.spond to the lashes which are mis- 
 placed ; the incision should be carried down to the outer surface of the tarsal cartilage ; 
 a second incision should then be made of the same length as the first, in the margin of 
 the lid, and so conducted as to split the lid and separate the skin and hair-bulbs from 
 the subjacent sti-uctures ; the ends of the two incisions should then be joined by two 
 short cuts, and the portion of skin included with the hair-bulbs dissected off the tarsal 
 cartilage. The raw surface should then be wiped with a sponge and any black dots 
 
OI'EIIATIDSS OS THE I.Y F.I.I DS. 
 
 293 
 
 Fig. 11:i. 
 
 'r>: 
 
 effl«?^;4p 
 
 Coinpressoriuiu Forceps Applied. 
 
 denoting the prcstMirc nl" liair-})ull>.s carefully rcniovfil. Tin' luinprcssoriuni fnrceps 
 slutuld then be unsi-n-w t-tl. wlioii sharpish hcii'tirrhajrt! will take phn-e. The (•}».• must 
 lur" ciivt-reil Ity two jiicccs of wet lint securcil l»y a turn <jf haiulafre. 
 
 Entropion siLMiifiis a ntllin^ inwanl nf the whole li<I. the winkle row oC lashes 
 lii'iuL: cninplctclv tiniud toward the eyeball; it is n»<jst lre<|Uently met with in the lr>wer 
 liil, more espt'fially in old people 
 with a superabundanee of" loose Fkj. 112. 
 
 skin about the laee. It is often 
 the eause of niueh trouble and an- 
 noyanee, as well as oi' dan«rer to the 
 eye. after eataraet extraetiun. 
 
 The inversion may be caused 
 cither by spasmodic contraction of 
 the orbicularis muscle or by distor- 
 tion and thickeiiinir of the tarsal 
 cartilaue after irranular ophthalmia. 
 
 Entr<>])ion caused by contraction 
 of the (trbicularis is easily remedied 
 as follows : The jtatient lyin<r on a 
 couch (see Fi.ir. Ill, p. "2!tO), the 
 operator should seize with forceps 
 the skin of the lid at a point near 
 one or other canthus, about two lines 
 from its marjiin, and then with scis- 
 sors remove a portion in breadth cor- 
 respondinj; to about half the surface compressorium Forceps, 
 of the lid and extending along its 
 whole length ; he should then seize and remove the orbicularis muscle to a corresponding 
 extent : no suture need be used ; the eye should be bound up with wet lint and a band- 
 age. The subsequent healing of the wound and contraction of the cicatrix will remedy 
 the inversion. 
 
 Entropion depending on distortion and thickening of tlie tar.sal cartilage is usually 
 met with in the upper lid. It can be remedied by removal of a wedge-shaped piece of 
 cartilage, including the more thickened portion, by the following operation : The patient 
 being in the usual position (see Fig. Ill, p. 290) and the lid fixed by a compressorium 
 forceps, with a sharp knife an incision should be carried throui:h its whole thickness, 
 parallel with and about two lines distant from its margin, along the whole extent of the 
 thickened portion. A somewhat lunated incision should then be made from one end of 
 the first around the base of the thickened portion of tarsus, joining the first incision at its 
 other extremity ; the second incision should not be carried vertically through the carti- 
 lage, but obliquely, so as to meet the first at the conjunctival surface ; the portion of 
 cartilage included between these incisions shovdd then be removed, the wound closed by 
 sutures, and the eye bound up with lint and a bandage. The skin and muscle covering 
 the cartilage may be removed or not. according to the fancy of the surgeon. If their 
 removal is not desired, they should be dissected back before making the second incision. 
 After the operation the margin of the lid should appear rightly directed. 
 
 Ectropion signifies an everted condition of the lid ; the extent of eversion varies in 
 different cases, from slight falling away of the margin of the lid from the globe to ever- 
 sion of the wliole extent of the lid and adjoining fornix of the conjunctiva. 
 
 The .slighter forms are caused by distetision of the lid from inflammatory swelling, 
 and are easily remedied by slightly narrowing the palpebral aperture by paring the 
 edges of the lids near the outer canthus, and bringing the raw surfaces together by a 
 suture, when firm union will take place between the two. 
 
 The more extreme forms are caused by the contraction of cicatrices of burns, wounds, 
 or inflammatory changes, about the orbit. 
 
 No definite rules can be laid down with regard to' the treatment of the.se cases. The 
 surgeon must be guided by the conditions as they present themselves, and do the best 
 he can. 
 
 In any case, if the tarsal cartilage be left entire, it .should be carefully dissected away 
 from its attachments and replaced as nearly as possible in its normal position, in which it 
 must be kept by paring its margin and that of the opposite lid and securing extensive 
 and firm union between them by careful coaptation of their raw surfaces. The lids must 
 
294 OPERATIONS ON THE EYELIDS. 
 
 not be opened until all further contraction of the original cicatrix is at an end, and it is 
 better to leave the eye closed for considerably too long a period than to open it a day too 
 soon. Ectropion is also frequently seen in the more severe forms of ophthalmia or in 
 cases of severe intolerance of light, and is specially liable to occur when an attempt is 
 made to open a firmly-closed eye. In these cases the eversion requires no special treat- 
 ment, but disappear.-^ as the affection causing it is recovered from. 
 
 Formation of a New Eyelid. — In some cases of burn or from ulceration of a 
 lupoid character more or less complete destruction of the eyelids may take place. To 
 remedy this defect, a flap of skin from a neighboring part may be brought, placed in the 
 gap. and there secured b}' means of sutures, care being ahvays taken that the piece of 
 skin is considerably larger than the surface it is intended to cover. Before removing any 
 skin search must be made in any portion of the eyelid that may be left for the tarsal car- 
 tilage, and if this be found it must be carefully dissected out and preserved, its natural 
 form being as much as possible restored ; it should be fixed in its proper position by unit- 
 ing its margin to that of the opposite lid. Even if no flap of .skin be applied over it, it 
 will in time become covered with cuticle and form a very efliectual covering to the eye- 
 ball. 
 
 Symblepharon signifies adhesion of the conjunctiva of the eyelid to that of the 
 globe. It is usually caused by burns with lime or hot metal, and may occur to any 
 extent, varying from a thin band of union to fusion of the greater part or whole of both 
 lids with the globe. 
 
 This condition requires to be remedied by operation. "Where only a thin band of 
 adhesion exists, it .should be first carefully secured b}^ a suture passed through the 
 extremity nearest the eyeball, and then be divided and drawn into the fornix by passing 
 the suture through the lid and securing it to a small roll of strapping placed upon the 
 cutaneous surface. By this means the raw surface left by removal of the band from the 
 globe is brought into contact with healthy conjunctiva and granulates over, healing with- 
 out forming adhesions. 
 
 If more than one band exi,st, each .should be dealt with separately. 
 
 Cases of more exten.sive adhesion give rise to the utmost difiiculty in treatment, and 
 until lately the operations performed for their relief were attended with only indifferent 
 succes.s. One plan of treatment recommended was to dissect away the adhesion and 
 interpose a .shell of glass between the raw surfaces, but, as healing invariably commenced 
 at a point remote from the free margin of the lid. the shell was gradually pushed out and 
 the adhesion re-established. 
 
 The insertion of pieces of wire deeply beneath the adhesion, which were left in until 
 the walls of the canal made by them had healed, the remainder of the adhesion being 
 then divided with scissors, was followed by no more satisfactory results. 
 
 Lately an operation has been introduced by Mr. P. Teale of Leeds which has Ijeen 
 attended with the best .success. The operation has fur its object the separation of the 
 raw surfaces by a piece of conjunctiva taken from some other part of the eyeball. The 
 following is an extract from the account of the operation given by Mr. Teale in the 
 Tro.nmctions of the Fourth Ophthalmic Congress, 1872: 
 
 " The patient being under the influence of an anas.sthetic. the eyelid is freed from its 
 attachment to the lid; next, a band of somewhat circular form is marked out with a sharp 
 knife upon the sound conjunctiva ; the band commences at one end of the gap left by 
 liberation of the lid and passes round the sound side of the cornea, terminating at the 
 opposite extremity of the gap. 
 
 '• Four stitches are then inserted, two on each edge of the flap thus formed. The flap 
 is next separated on its under surface, whilst its extremities are left continuous with the 
 conjunctiva: it is then drawn across the surface of the cornea and fixed, raw surface down- 
 ward, into the gap formed by the liberation of the eyeball from the lid ; it is secured in 
 its new position by the sutures already alluded to. aided by as many others as may appear 
 necessary.'' 
 
 Mr. Teale states that " the operation is most tedious," and that he rarely completes it 
 within the hour. 
 
 Anchyloblepharon signifies an adhesion of the lids to each other. The adhesions 
 must be divided with scissors, and if possible some skin or conjunctiva interposed between 
 the raw surfaces : but if this cannot be done, reunion mav be prevented by passing a 
 probe between the lids daily. 
 
 Narrowing of the palpebral aperture ("Blepharophymosis) is usually 
 
 a result of granular ophthalmia, and is accompanied by entropion, displaced tear puncta, 
 
LACIIIIVMM. M'l'MlATUS. 295 
 
 and consequent watering; of the eye. It rcfuiires U) be remedied by operation, which can 
 
 be thus iierfornied : Tlie lids bcin-r kept widely open and ctii the stretch l)y a wire specu- 
 
 hun ( Fijr. 114), an incision should b(; made with stron;^ 
 
 scissors throuirh tlie outer canthus. A flap of" conjunc- 
 
 tiva of soiuewhat couical shape slutuld tlien be niarke<i ^ \f^ \; 
 
 out on the surface of the ey('l)all, the flap freely (lis- ga^^^ 
 
 sected from the subjacfnt structures, but left attached ^»J) 
 
 at its base, which is toward the cornea, and then fixed f jT 
 
 by sutures in the incision made by the scissors, in such "°^^^ 
 
 a maniu'r as to kcfj) the raw edges separated by a mu- ^^^^^ ^^ jfc ^s 
 
 cons surface. ^^-*"-— «s^ ''W.'^^V 
 
 U. 1 i* I Wire Speculum. 
 
 IS sometimes necessary to narrow or dose entirely ' 
 
 the palpebral aj\erturc. This operation, known a.s ttuxordphij^ can be performed as fol- 
 lows : The lid beint^ held with forceps, a portion of the Inner edjr of its margin should 
 be removed with a small iridectomy knife, care being taken not to cut away any of the 
 outer edge containing the lashes, nor to wound the tear puncta or canaliculi. The oppo- 
 site lid should then be treated in the same manner and the raw edges brought together 
 by sutures ; firm union will soon take place between them. 
 
 Ptosis signifies a drooping of the upper eyelid to a greater or less extent, with 
 inability to raise it. Ptosis occurs with divergent strabismus and more or le.ss impair- 
 ment of the mobility of the eyeball in cases of paralysis of the third nerve, and is gen- 
 erally, but not invariably, accompanied by dilatation and fixity of the jtupil. 
 
 It is also met with as a congenital defect, and occurs .sometimes after severe inflam- 
 mation of the lid or protracted intolerance of light and constant spasmodic action of the 
 orbicularis muscle. Women past the middle period of life with a superabundance of 
 loose skin about the face are also subject to a form of partial ptosis. 
 
 Tre.\tment. — In ptosis from paralysis of the third nerve treatment mu.st be directed 
 against the cause of the paralysis, no operation being advisable ; other forms can be 
 remedied by the removal of some skin and orbicularis mu.scle from the surface of the lid. 
 
 The operation may be performed as follows : The .<kin at the upper part of the lid 
 should be pinched up with forceps, the amount included between their blades being such 
 as to rai.se the margin of the lid well above the ujiper border of the pupil. Then with 
 scissors a strip of skin of the required width .should be removed, along the whole extent 
 of the lid, parallel to its mai'gin ; the orbicularis muscle should then be cleanly dissected 
 off the tarsal cartilage to about the same extent, the wound closed by one or two fine 
 sutures, and the e3'e bound up with wet lint and a bandage. 
 
 The wound will heal in the course of a few days, and the shortening caused by the 
 removal of the skin and muscle and subsef(uent cicatrization (possibly aided by the 
 entanglement erf some fibres of the occipito-frontalis in the scar) should keep the lid in 
 the desired position. 
 
 In cases of congenital ptosis we often find movement of the eyes upward greatly 
 impaired ; it seems probable that the superior rectus is badly developed or altogether 
 absent. 
 
 THE LACHRYMAL APPARATUS. 
 
 The lachrjnual gland is occasionally the seat of malignant or other growths and 
 may require extirpation. 
 
 A cyst is sometimes met with caused by obstruction of one of the ducts of the 
 gland and accumulation of secretion. The disease is known as (facri/opis. 
 
 Trkatment. — Its treatment consists in establishing an opening into it from the sur- 
 face of the conjunctiva; this is easily done by passing a curved needle armed with .silk 
 from beneath the upper lid through the wall of the cyst into its cavity, and out again at a 
 convenient distance ; the silk should then be drawn through and the portion of cy.st wall 
 included between the entrance and exit of the needle firmly ligatured ; the ligature will 
 slough out and leave a permanent opening, causing no inconvenience. If the cyst be 
 opened throutrh the skin, it may leave a troublosonie fistula. 
 
 The Tear Puncta and CanalicuH. — The tear puncta in the normal condition 
 lie in contact with the ocular conjunctiva ; they may be either everted, as seen in old and 
 neglected cases of tinea, or rolled .somewhat inward : they are sometimes found entirely 
 obliterated either by disease or injury, burns of the evelids being the most common cau.se. 
 
 The canaliculi may also be found more or less obstructed in any part of their cour.se, 
 at times by a little mass of fungus. Any of these conditions are accompanied by trou- 
 
296 OPERATIONS ON THE TEAR PASSAGES. 
 
 blesome watering of the eye — " epiphora." They can be remedied by slitting tlie tear 
 puncta and canaliculi. 
 
 The lachrymal sac is often the seat of acute inflammation, whicli may arise in 
 the sac itself, spread to it from the conjunctiva, or be caused by disease of the surround- 
 ing bones. It is characterized by a dusky-red tense swelling situated at the side of the 
 nose, close to the inner canthus, the swelling and redness often extending outward alono- 
 both the upper and lower lids ; one or both sacs may be affected. The inflammation may 
 end in resolution or go on to the formation of an abscess ; in the latter case the swelling 
 becomes soft and fluctuating. 
 
 ^ Treatment. — At first hot fomentations and poultices must be applied and attention 
 paid to the general health ; if abscess form, the pus must be let out by a free incision. 
 If an abscess of the lachrymal sac be allowed to burst, a fistulous opening will very prob- 
 ably be left; but if a free opening be made so soon as the formation of pus is suspected, 
 the wound heals readily. 
 
 Distension of the Lachrymal Sac (Mucocele).— The lachrymal sac not 
 
 unfrequently becomes distended, forming a tumor of varying size beneath the internal 
 palpebral ligament (tendo oculi) ; pressure on the tumor 'causes the escape of a transpa- 
 rent, somewhat tenacious fluid consisting of mucus and tears, in some cases thickened 
 from the admixture of pus cells. Distension of the sac is caused by stricture of the nasal 
 duct and consequent accumulation of secretion ; it is accompanied by more or less water- 
 ing of the eye and may be remedied by relieving the stricture of the duct. 
 
 Discharge from the Lachrymal Sac (Blennorrhoea).— A muco-purulent 
 
 or purulent discharge from the sac is often met with following inflammation, especially 
 if disease of the adjacent bone exist. It may be treated — 1st. By ensuring a free exit 
 for the discharge by slitting the canaliculus and passing a large probe down the lachry- 
 mal duct ; 2d. By washing out the sac ; od. By obliteration of the sac. 
 
 Stricture of the nasal duct may be met with in any part of its course ; the 
 obstrucrion, however, is most frequently found at its junction with the lachrymal sac. 
 Occasionally the duct is found almost obliterated by dense bony deposit. 
 
 Fistula of the lachrymal sac occurs as a small, sometimes scarcely perceptible 
 opening situated at some point over the sac ; it is found in connection with obstruction 
 of the nasal duct. If the passage be re-established, the fistula will probably close. 
 
 Operations on the Tear Passages. — The operation of slitting the tear puncta 
 and canaliculi may be performed thus : The patient should be seated ina chair, the ope- 
 rator standing behind him (see Fig. 110, p. 290). Supposing the lower punctum and 
 canaliculus on the right side to be operated on, the small and ring fingers of the left hand 
 should be placed upon the patient's face near the outer canthus, the lids drawn tight with 
 these two fingers, and kept so ; then a small grooved director (Fig. 115) should be taken 
 in the right hand and passed at first verrically to the margin of ithe lid through the tear 
 punctum, its handle then depressed, and its point passed horizontally along the canaliculus 
 into the sac. To ascertain that the point of the director is in the sac, the tension of the 
 
 lids mu-st be relaxed and the director pushed 
 
 Fig. 115. gently onward. If there be any puckering at 
 
 — . ■M^— le— — r- , the inner canthus when the director is thus 
 
 Grooved Director for Slitting Canaliculus. pushed, its point has not entered the sac, and 
 
 a further attempt must be made ; if no pucker- 
 ing occur, the lids should be brought again into a state of tension and the handle of the 
 director transferred to the thumb and forefinger of the left hand. A cataract or any 
 small knife that will cut should then be taken in the right hand and run along the groove 
 of the director well into the sac, the knife and director being then withdrawn together ; 
 the upper lid must be kept out of the way by one of the fingers of the right hand. The 
 operation can be performed on the left side in the same manner, with the exception that 
 the hands are reversed. 
 
 The upper punctum and canaliculus sometimes require to be slit : this operation is 
 not quite so simple as that on the lower lid, but is performed in much the same way. In 
 lieu of the grooved director and knife, a small probe-pointed canaliculus knife may be 
 employed ; it should be passed through the tear punctum and canaliculus in the same 
 manner as the director, and will cut its way out as it goes. 
 
 The patient must be seen at intervals of two or three days for a week or longer after 
 the operation, and a probe passed along the incision to prevent its closing. 
 
 Probing the Nasal Duct. — For the treatment of stricture ofthe nasal duct a 
 set of silver probes (Bowman's) are used ; there are three probes in a set, the two extrem- 
 
OI'i: HAT IONS ON Till': COSJl'SCTIVA. 297 
 
 ities (if eudi Iumiil: nl' iliflrri-nl lliickmssfs, so tlmt thcic aw six sizes, No. 1 heirifr the 
 sinallt'st, No. (I tlu' laru;isl. 
 
 To j)ass a prol)o down the nasal liinl, tlic canaliculus slioulil he lirst slit, or, what is 
 liettcr. sh(»uhl havo hccn slit at some previous time. The surgeon shftuld stand behind 
 the patient in the same position as for perforniinj; the last (jperation. and. the lids Iteinj; 
 made tense in the same manner, the prohe should he; pas.sed alon<r the slit canaliculus 
 until the point is well within the sac, as shown hy the absence of puekerinj: at the inner 
 eaiithiis on relaxation of the tension of the lids; th(! opposit(( extremity should then be 
 raised alon<r the maruiii of the orbit until the jirobe has attained a viu'tical direction, care 
 beinii' taken, while .so doint;-, to keej) the end whicdi is in the sac ]»r(!ssed firndy against its 
 inner side ; the ])robe, havinj; been brought into a nearly vertical ])osition, should be 
 pushed <rently but firmly downward and slightly backward and outward in the direction 
 of the duet ; when it has been passed as far as it will go, it should be slightly withdrawn, 
 .so as to raise its end off the fiocjr of the iio.se. If the probe lias been properly pa.s.sed 
 down the duct, its upper part will remain firmly in contact with the margin of the orbit; 
 but if it moves freely about, the i)robe is not in the duct, but has been forced through 
 its wall. This little accident is of no particular moment, and needs oidy that the probe 
 be withdrawn and passed afresh in the right dirih;tion. 
 
 If the end of the probe is not well within the ,sac before an attempt is made to pa.s.s 
 it down the duct, it may slip backward into the orbit or forward and downward in the 
 cellular tissue of the cheek. A probe, having lieen satisfactorily pas.sed, sliould be left 
 in for about twenty minutes, and the ojieration be repeated about twice a week. The 
 treatment of stricture of the lachrymal duct is, on the whole, unsatisfactory, but the 
 ]trot)ing should be carefully and perseveringly carried out. It is well always to com- 
 mence with the largest pr(d)e (No. (i), and try a smaller one if thi.s cannot be passed. 
 
 Washing out the Lachrymal Sac— For washing out the lachrymal sac a 
 good .syringe lifted with nozzles of different sizes is re((uired. One of the nozzles should 
 be fitted to the syringe, which has been previously filled with fluid (water, a weak solu- 
 tion of nitrate of silver, chloride of zinc, etc.) ; the nozzle should then be pa.ssed along 
 the previously slit canaliculus into the sac and the fluid injected; the patients head must 
 be bent forward during the injection, or the fluid will run back along the floor of the nose 
 into the jiliarynx. 
 
 Obliteration of the Lachrymal Sac. — In some ca.ses of obstinate discharge 
 from the .sac. especially if dependent on diseased bone, the discharge may be stopped and 
 the ]iatient made more comfortable by closing up the sac entirely ; of course, more or less 
 watering of the eye will remain after the operation, but is far to be preferred to the annoy- 
 ance of a constant purulent discharge. 
 
 Obliteration of the sac may be attempted in any of the three following ways : A free 
 incision having been made into it and the blood carefully sponged out. its lining mem- 
 brane may be destroyed — (1) by filling its cavity with a thick paste of chloride of zinc 
 and starch, in equal parts, •enclosed in a small piece of lint, (2) by the application of 
 nitrate of silver, or (3) by the galvanic or other cautery. By any of these procedures 
 adhesive inflammation is set up, more or less obliteration of the sac following. 
 
 Operations for obliteration of the lachrymal .sac are by no means always successful 
 and may have to be repeated, perhaps more than once, before a satisfactory result is 
 obtained. 
 
 THE CONJUNCTIVA. 
 
 But few operations are performed on the conjunctiva alone; it is. of course, cut in 
 some of the operations on the eyelids and in that for strabismus, and some others. 
 
 Warts are occa.sionally found on some part of the membrane ; they require to be 
 removed with scissors. 
 
 Pterygium is a peculiar, somewhat triangular growth, the base of which is situated 
 in the ocular conjunctiva, generally near the inner canthus, the apex encroaching more 
 or less upon the margin of the cornea or passing for a considerable distance upon its sur- 
 face. The growth is of a reddish color and variable density ; it consists of hypertrophied 
 connective tissue. 
 
 Pterygium is not common in this country, and when met with is usually found to 
 occur in sailors and others who have been in the East. Should it give rise to any incon- 
 venience or threaten to impair vision, it must be removed by operation. 
 
 The patient should lie on the couch, the lids be opened by a wire speculum, the 
 growth seized with toothed forceps, and with a cataract knife dissected up from the sur- 
 
298 STRABISMUS. 
 
 face of the cornea. A small portion of conjunctiva should then be removed parallel with 
 the margin of the cornea and the apex of the growth fixed by a suture in the wound. 
 The eye should be kept bound up for a few days with wet lint and a bandage. 
 
 If a pterygium is simply cut off, it will in all probability grow again ; but if trans- 
 planted, it will shrivel up and disappear without giving further trouble. A cicatrix 
 always remains upon the cornea after removal of pterygium, so that it uiust never be 
 allowed to grow over the pupil. 
 
 Ping"uicul8B are small yellowish growths situated beneath the conjunctiva, gene- 
 rally near the outer and inner margins of the cornea; they are surrounded by a few large 
 blood vessels and are occasionally the source of constant irritation, causing the eyes to 
 be bloodshot and uncomfortable. Pinguicula can be removed, if desired, by making an 
 incision over it, turning back the conjunctiva, then seizing the little growth with forceps 
 and dissecting it away from the parts beneath. The growth having been removed, ti.e 
 conjunctiva should be closed over the wound by a suture and the eye kept bandaged for 
 two or three days after the operation. 
 
 Lipoma is met with as a tumor projecting beneath the upper lid, near the fornix, 
 and often between the superior and external recti muscles; it somewhat resembles a third- 
 lid. If the tumor gives any trouble, it must be removed by operation, thus: The patient 
 lying on the couch, the lids should be kept as widely open as possible by a wire spec- 
 ulum, an incision made with a cataract knife through the conjunctiva over the tumor, 
 and its most projecting portion seized with toothed forceps and removed with scissors; 
 care must be taken not to drag upon the growth, as it is continuous with the fat in the 
 cavity of the orbit, a great portion of which might be pulled out. As much of the tumor 
 as is thought necessary having been removed, the conjunctiva should be closed over it 
 with sutures and the eye bound up. 
 
 NSBVUS occasionally occurs in the conjunctiva ; it may be removed by the knife or 
 destroyed by the galvanic or other cautery. In the latter case due precautions must be 
 taken to guard the eyeball from injury during the operation, and to prevent as much as 
 possible the evils arising from subsequent cicatrization. 
 
 Cancerous ulcers may also be met with ; they must be thoroughly extirpated, 
 the eyeball being excised if neces.sary. 
 
 Cysts containing a clear serous fluid are occasionally met with in the conjunctiva; 
 they must be punctured, when they at once subside, but sometimes re-form, in which 
 case a portion of the cyst wall must be excised or a fine seton passed through it. 
 
 CysticerCUS also occurs, and should be treated by incision of the cy.st. 
 
 EXTERNAL MUSCLES OF THE EYEBALL. 
 
 Strabismus (squint). — " Strabismus is a deviation in direction of the axes of the 
 two eyeballs, in consequence of which the two yellow spots receive images from different 
 objects. In convei'gent strabismus the two visual lines do *not cross each other at the 
 point it is desired to observe ; only one of the two — that of the undeviating eye — reaches 
 it. Under this deviation not only does the expression of the face suffer from want of 
 symmetry in its most eloquent parts, but the power of vision — at least, in one of the 
 eyes — is u.sually disturbed, and the squinter always loses the advantage of binocular 
 vision " (Donders). 
 
 Strabismus must not be looked upon as a special form of disease ; it is in by far the 
 greater number of cases a.ssociated with some anomaly of refraction, which, being the 
 primary cau.se of the deviation, gives rise to the strabismus. Other conditions which 
 may induce strabismus will be subsequently considered. 
 
 Two forms of squint are commonly met with : 1. Convergent; 2. Divergent. Other 
 rare forms are superior and inferior' strabismus ; these will receive no further notice. 
 
 Convergent strabismus is the most common of all, and is almost always the result of 
 hypermetropia. 
 
 Divergent strabismus is usually the result of myopia. 
 
 Convergent strabismus, as just stated, is nearly always the result of hyperme- 
 tropia. The question naturally ai'ises. How does hypermetropia produce it? 
 
 The hypermetropic individual must always accommodate strongly when looking at 
 even a distant object, and as the object is brought nearer the tension of accommodation 
 must be correspondingly increased. As stated at page 204, accommodation is associated 
 with convergence of the visual lines. Now, the greater the degree of convergence, the 
 more strongly is the accommodation brought into play ; consequently, there is an ever- 
 
CONVERGEST STRABISMUS. 2i>9 
 
 increasing tendency on the |i:irt of tlie hypernietropic individual to converge too much, 
 in order to bring his accnninindutiiui into the highest possihle state of tension. If the 
 convergence of the visual lines be excessive or they do not meet in the same point, con- 
 vergent strabismus results. 
 
 Till- (|uc?«tii>n next arises, Whv <1<> ""t all livpcrnit'troj)ic individuals s(|uint ? The 
 reason is that if both eyes are of the same refraction and have e(|ual acutencss of si^dit 
 there is always such a desire to maintain binocular vision that the visual lines will remain 
 directed to the same p(»int. even though the eyes arc not accurately accommo<lated for 
 that i>oint. the individual being content with ill-defined retinal ima;:cs rather than sacri- 
 tice binocular vision by increasing his convergence. 
 
 l?ut if vision of one eye be less acute than that of the other or if there be a differ- 
 ence of refraction b»'tween the two. the desire for binocular vision is lost or its value very 
 much le.s.sened, and the necessity for a well-defined image on one retina is immediately 
 felt. The aecommodation is put fully on the stretch, and with it the degree of converg- 
 ence becomes excessive, both visual lines being directed to points nearer to the eyes than 
 that for which they are accommodated, the deviation of the more defective eye being 
 greater than that of its fellow. 
 
 Ordinary convergent or '-concomitant " squint has to be distingui.shed from squint the 
 result of paralysis — "paralytic" squint. This can be done by noticing the relation of 
 the convergence of the eye which is observed to be s((uinting — '• primary " squint — to 
 the deviation — '"secotidary 8((uiiit ' — which occurs in the properly directed eye when it 
 is covered and an attempt ina<le to fix an object with the .sf|uinting eye. In concomitant 
 squint the " primary "' and " secondary " deviations are equal ; in paralytic .squint the " .sec- 
 ondarv ' deviation is greater than the " primary. ' 
 
 Thkat.mknt. — Slight cases of convergent strabismus, especially if the deviation is 
 not constantly present, but only occasional (periodic squint), may be cured by the use of 
 glasses which accurately neutralize the exi.sting hypermetropia. 
 
 In more severe cases division of the internal rectus tendon in one or both eyes is 
 necessary. 
 
 It is often difficult to decide whether only one or both eyes .shall be operated on. 
 
 If it is found that one eye S(|uints habitually and to no great extent, the other being 
 always used for fixing an object, division of the internal rectus of that eye which habitu- 
 ally deviates alone is necessary. 
 
 If each eye deviates alternately (alternating strabismus) and to no great extent, 
 division of one internal rectus may be sufficient ; but if, three weeks or a month after 
 the operation, the squint still continues, tenotomy of the internal rectus of the other eye 
 should be performed. 
 
 If one eye squints considerably and habitually or if the deviation is excessive and 
 alternating, the internal rectus in both eyes must be divided. In any case, if there be 
 a doubt as to whether one or both eyes should be operated on, it is well to be on the safe 
 side and do only one at a time. 
 
 Operations for Convergent Strabismus. — There are two principal methods 
 
 of operating for convergent strabismus. 
 
 1. The operator .should stand on the right side of the patient, placed in the usual 
 position (Fig. Ill, p. 290), and. the eyelids being kept well open with a wire speculum, 
 should seize the conjunctiva and subconjunctival fascia with the toothed forceps (Fig. 
 116, <j) at a point about midway between the margin of the cornea and semilunar fold 
 and just below the inferior margin of the tendon of the internal rectus muscle. An 
 incision should then be made with strabismus scissors (Fig. IIG. c) through the conjunc- 
 tiva and subconjunctival tascia. well down to the sclerotic, and the strabismus hook (Fig. 
 IIG, //) passed through the opening and inserted between the tendon and the eyeball. If 
 properly introduced, the hook will be brought up short at the insertion of the tendon 
 into the sclerotic when it is pulled forward ; it should be held firmly in position, the scis- 
 sors passed through the opening, one blade following the hook between the tendon and 
 the eyeball, the other being kept outside the tendon, which is thus included between the 
 two blades, and the tendon should then be divided by one or two sharp strokes with the 
 scissors. 
 
 The scissors may now be withdrawn and the hook pulled forward ; if the latter meets 
 with no resistance, but passes freely up to the corneal margin, the operation has been 
 successfully performed. To make sure of this, however, the hook should be withdrawn, 
 the action for hooking the tendon repeated, and any fibres that may have escaped division 
 cut throug'h. 
 
500 
 
 CONVERGEXT STRABISMUS. 
 
 -trabismus Hook 
 
 On the division of the tendon the muscle retracts, the retraction being limited by the 
 subconjunctival fascia with which it is intimately connected. If the eye is not properly 
 directed after simple division of the tendon, a greater effect may be produced by further 
 freely severing the subconjunctival fascia. 
 
 2. In the second operation the position of the patient and surgeon should be the 
 same and the lids be kept open with the wire speculum, as in the one already 
 described. 
 
 An incision should be made with scissors through conjunctiva and subconjunctival 
 
 fascia over the insertion of the 
 tendon, instead of below its infe- 
 rior margin, the tendon then picked 
 up with the strabismus hook, and 
 divided close to the sclerotic. The 
 wound in the conjunctiva should 
 be afterward closed with a fine 
 suture. 
 
 No after-treatment is required 
 for strabismus operations ; the pa- 
 tient may go about as usual and 
 simply keep the eyes clean. But 
 if, when the eyes have quite re- 
 covered from the effects of the 
 operation, there should be any re- 
 turn of the squint, the degree of 
 hj-permetropia must be carefully 
 ascertained and glasses which thor- 
 oughly neutralize it ordered to be 
 used for all purposes. In mo.st 
 cases this will be found sufficient ; 
 but if, after the glasses have been 
 perseveringly worn for some weeks, 
 no effect is produced, the operation 
 should be repeated in one or both 
 eyes. 
 
 Use of Anaesthetics in 
 Operations for Convergent 
 
 Strabismus. — AVhetlier ana?s- 
 tlietics should be employed or not 
 in squint operations appears to be 
 a matter of opinion, some eminent oculists never employing them, others again rarely 
 operating without. For my own part, I prefer not to emplo}" an anaesthetic if the patient is 
 pretty steady, but with children and nervous adults I always use one. taking care, how- 
 ever, that a full effect is not produced ; and if there is any doubt as to whether one or 
 both eyes are to be operated on, I allow the patient to come nearly to after finishing one 
 eye, so as to ascertain the effect produced by what has been done. If an anaesthetic is 
 given to such an extent as to exert its fullest influence and produce thorough muscular 
 relaxation, an erroneous idea of the effect of the operation is likely to be formed, and on 
 the return of consciousness the squint may remain as bad as ever. 
 
 Other conditions than hypermetropia which may produce convergent strabismus are — 
 
 1. Disease of the brain. 
 
 2. Paralysis of the external rectus muscle. 
 
 3. Inflammatory or other changes in the internal rectus muscle itself, producing 
 shortening. 
 
 In the first two of these no operation is advisable ; the third may sometimes be rem- 
 edied by operative interference. 
 
 Divergent strabismus, as already stated, is often the result of myopia ; it is 
 usually consequent on high degrees of the anomaly and is brought about as follows : 
 The highly myopic individual requires to bring objects very near the eyes to see them 
 distinctly ; con.sequently, a very high degree of convergence is necessary to keep both 
 visual lines directed to the same point. Now, not only has a high decree of convergence 
 to be maintained, but in myopia the length of the eyeball and the consequent impairment 
 of its mobility place the internal recti at a disadvantage. Moreover, in order to direct 
 
 Toothed and Fixing Forceps. 
 a, their points shown in 
 side view ; b, front view. 
 
 i^trabismus Scissors. 
 
()i'/:/:.iTin\s nx riii: coiisr.A. .'}01 
 
 the visual liiii's of the iiiVDpic i-yt's t(» th»! saiiu! jmiiit, a ^rrcatrr pidpiirtidMato aiiioiiiit of 
 convcrgciuH' is mjuiivd than in t-nmu'tropia. 
 
 As u c()nsiM(UL'iicL'. thi' iiitcrnal rt'ctus of one eye sooner or hiter becomes wearied and 
 gives in and the eye deviates outward, hinoeuhir vision Iteinj; saeriticed. 
 
 Tkkatmknt. — Many eases (»f diverj^ent strahisiniis may be remedied by the use of 
 coneave <;hisses. whieh enal)h( the individual to see distinctly at a distance up to which 
 conver^jenee of the visual lines can be maintained withitut undue strain of the internal 
 recti muscles. 
 
 11". in spite of the use of jilasses, the diver<;ence continues, it must be remedied by 
 ojteration. In cases where the eye oidy deviates outwanl alter an object has been lookeil 
 at for some considerable time, subconjunctival division of the external r(?ctJis of the devi- 
 atiiijr or of both eyes may sutVice for a cure ; but in cases where one or both eyes diverj^e 
 constantly, and the visual lines can only be made to meet in one point by a ^'reat effort, 
 or not at all, the ojieratioii of •' readjustment" must be perfornKjd. 
 
 This ojteration can be jterfornuul as follows: The patient being plaee<l in tlw; usual 
 position (Kijr. Ill, l». 2IK>) and thorouirhly an;estheti/,ed, the operator should stand 
 behiiul, fix the lids open with a wire speeuiiini. with scissors make an incision throufjh 
 the conjunctiva and subconjunctival fascia below the insertion of the external rectus, 
 hook up the tendon, and divide it subconjunctivally close to the sclerotic. 
 
 An incision should then be made through conjunctiva and subconjunctival fascia, 
 about midway between the insertion of the internal rectus and inner margin of the cor- 
 nea, of such a length as to reach about two lines above and a like distance below the nuir- 
 gins of its tendon, which should then be hooked up and divided. The muscle and 
 subconjunctival fascia should be freely separated from the parts beneath and together 
 with the conjunctiva turned back toward the caruncle. Two curved needles holding fine 
 silk should then be passed through the tissues next the margin of the cornea and the silks 
 firmly tied, two free ends being left ; the needles should then be carried from within out- 
 ward through the muscle, subconjunctival fascia, and conjunctiva, as near the inner 
 canthus as possible, and the silk drawn through ; a considerable portion of the mu.scle 
 and other tissues should then be removed with scissors, the free ends of the two fine 
 pieces of silk and the portions to which the needles are still attached then tied firnily 
 together (the eye being rolled well inward by an assistant as the knots are pulled tight j, 
 and the ends of the two sutures cut off close. 
 
 The eye should be bound up \vith wet lint and a bandage. The sutures will probably 
 ref|uire removal in about four or five days, but may be left longer if they cause no 
 irritation. 
 
 Divergent strabismus is met with in cases of paralysis of the third nerve ; it may also 
 occur in non-hy])ermetropic eyes if the sight of one has become much impaired and 
 binocular vision is no longer possible, and may be caused by too free a division of the 
 tendon in the operation for convergent squint. In the first of these cases no operation 
 is advisable ; in the second, no improvement of sight is to be expected from readjustment, 
 but the operation may be performed simply to remedy disfigurement; in the third, read- 
 justment should be performed. 
 
 THE CORNEA. 
 
 The affections of the cornea which recjuire an operation upon the structure it.self are 
 six: 1. Sloughing ulcer; 2. Conical cornea; 3. Corneal opacity; 4. Staphyloma; 5. 
 Lodgment of foreign bodies : (I. New growths. 
 
 Paracentesis, or Tapping the Cornea. — Tliis operation is sometimes per- 
 formed in cases of sloughing ulcer, or suppuration, threatening perforation ; by the timely 
 evacuation of the contents of the aqueous chamber a large rupture of the corneal tissue, 
 with its acconqianying evils, may in many cases be avoided. 
 
 Tapjting the cornea may be done thus: The patient being in the usual position (Fig. 
 Ill, p. 21X)), the operator should stand behind and fix the lids open by a wire speculum 
 or by the fingers. A broad needle shmild then be passed through the cornea at some 
 convenient part of its margin : when the point of the needle has fairly entered the 
 anterior chamber, its handle should be rotated, so as to bring the breadth of the blade 
 across the incision and thus open it ; as soon as the contents of the anterior chamber 
 have flowed out the needle should be withdrawn, a drop of eserine solution placed 
 between the lids, and the eye bound up in the usual manner. 
 
 Iridectomy, however, is to be preferred to paracentesis. 
 
302 OPERATIONS ON THE CORNEA. 
 
 Conical cornea (" Staphyloma corniae pellucidum "), as the name implies, signifies 
 an alteration in the curvature of the cornea of such a nature that it assumes the form of 
 a cone. The origin of the affection cannot clearly be traced. 
 
 The most prominent symptom is gradually increasing myopia, which cannot be reme- 
 died by concave lenses. On looking at the cornea in profile its conical form is very 
 evident. 
 
 On examination with tlie ophthalmoscope by the direct method, the apex of the cone, 
 which may, however, be the seat of some opacity, appears brightly illuminated ; around 
 this bright portion is a dark ring corresponding to the sides of the cone, this being again 
 succeeded by an area giving a bright reflection and corresponding to a portion of the 
 cornea which retains more or less its natural curvature. 
 
 Objects occupying the fundus of the eye are seen through the apex and sides of the 
 cone near its base in an inverted position, as in myopia, whilst we obtain a more or less 
 ■distinct erect image of the same parts through the portion of cornea which still retains 
 its normal curvature. The retinal vessels appear to have a whirl-like motion as we 
 change our point of view from side to side. The appearance is quite characteristic, and, 
 once seen, is not likely to be forgotten. 
 
 Treatment. — Conical cornea can only be remedied by operative interference ; two 
 methods of operating are practised, the object of each being to flatten the cone and restore 
 to the cornea moi'e or less of its natural curvature. 
 
 In one operation an elliptical portion including the whole thickness of the cornea is 
 removed from the apex of the cone. The operation can be performed thus (for the posi- 
 tion of patient and operator see Fig. Ill, p. 290): An ana\sthetic should be given, the 
 lids held open by a wire speculum, and the eyeball fixed by seizing with the toothea 
 forceps the conjunctiva and subconjunctival fascia at some point near the corneal margin. 
 A straight cataract extraction knife (Fig. 120, <:•) should then be thrust through the cone 
 from side to side, a small flap formed by cutting out either ui)ward or downward, and the 
 flap so made seized with iris forceps and removed with scissors. 
 
 In this operation the anterior chamber is opened and the cornea collapses as soon as 
 the first incision is made. Care must be taken that the portion removed includes the 
 most prominent part of the cone, and that the opening left is exactly opposite the pupil. 
 
 After the operation the speculum must be very carefully removed, and the lids gently 
 closed and bandaged in the usual way ; the eye must on no account be examined for a 
 week, so as to give time for the opening in the cornea to fill up. The wound will in all 
 probability heal in the course of ten days, the anterior chamber being restored. 
 
 The margin of the pupil is not unfrequently caught up in the incision, an anterior 
 synechia resulting. 
 
 The operation described gives the most satisfactory results, the curvature of the 
 cornea being greatly improved and a corresponding amount of vision regained. 
 
 In the second operation a superficial portion only is removed from the apex of the 
 cone with a small trephine, a raw surface being left, which by its subsequent cicatriza- 
 tion and contraction causes considerable flattening of the cone. 
 
 Tinting the cornea is called for in cases of dense white opacity (leucoma), caus- 
 ing disfigurement. The operation can be performed as follows (for position of patient 
 and operator see Fig. Ill, p. 290): An anaesthetic having been given, the operator 
 should place the wire .speculum between the lids, fix the globe with the toothed forceps, 
 paint some Indian ink upon the opacity, and prick it thoroughly in with a bunch of 
 needles fixed in an ivory handle ; the ink should be sponged away from time to time in 
 order to allow the operator to see what progress he has made. 
 
 The opacity having been thoroughly tinted, the speculum should be removed ; no 
 bandage need be applied, and no after-treatment is necessary ; very little irritation fol- 
 lows. If, after the lapse of a week or ten days, the opacity do not appear sufficiently 
 blackened, the operation may be repeated. 
 
 If the ink be allowed to get into the wound made in the conjunctiva by the toothed 
 forceps, a black mark will be left ; care should therefore be taken to fix the globe at a 
 point to which the ink cannot run. Should the anterior chamber be opened, the opera- 
 tion must be discontinued, as the lens may be wounded. 
 
 Staphyloma, first so called from its supposed resemblance to a grape, has now 
 come to mean a bulge on any part of the eyeball. On the cornea it is caused either by 
 yielding of its structure or more commonly by prolapse of iris through a perforation in 
 it, the prolapsed portion being firmly coated over with inflammatory material. Staphy- 
 lonui is said to be " total " where the whole of the cornea is affected, '' partial " when 
 
OPKRATJnSS O.V 77//; IRIS. 303 
 
 hoiiu' jmrtidii of it rt'tiiiiis its iiortiial ciirvatun'. Total staphylonia slioiild Itc removed 
 bv abscission (see p. 27')), or the eyeball may be exeisetl. Partial staphyloma may sub- 
 side on the performance of iridectomy or can be reniovtMl as follows : The position of 
 jiaticiit and operator should be as at l''i;;. Ill, p. li'.K), and an amusthetic should be 
 administered. The lids bciiiL' ke|»t open by the wire sj)eculum, a curviMJ needle armed 
 with tine silk shonlil be passed tbrouirh the })ase of the staj)hyloma, an elliptical portion 
 of which should (hen be removed with a straight cataract knii'e ; tin; silk should then be 
 drawn through and tied, thus brin^in;^ the cdt^cs of the ^aj» nnide by the removal of the 
 elliptical portion tot::elher, and the eye bandaiied in the usual way. The suture may be 
 rciMiivcd ill tlic ciMirsc of three or four days. 
 
 Foreign Bodies. — Small fraj,nnents of metal, chips of stoiut, thorns, etc., are not 
 unfreijuentlv found lodir,.d in the coriu-a. To remove them the jtosition (»f patient and 
 operator shouhl be as at Kii;'. 1 1<(, p. 2IK(. As a rule.no an;t\sthetic wavA })e administere<l. 
 The lids .slu)uld be kej)t open by the fore and rinii fiii<i;ers of one liand, and the <:lobe 
 steadied by irently ])ressinj; upon it with thesecond tinjrer ; the forei<rn body should then 
 be carefully lifted ironi its bed with the ))oint of a knife or small spud held li<i;litly in 
 the other Iiand. Foreign bodies, especially thorns, are .sometimes so firtnly atid deeply 
 embcildcd that they re(|uire to be cut out. 
 
 New growths miiy be met with sjirinfrinir from the cornea. 
 
 Congenital tumor is a small white flattened elevation usually situated near the 
 corneal maruin, encroachini;- on ])oth cornea and sclerotic ; it lies beneath the corneal epi- 
 thelium and conjunctiva and appears to extend pretty deeply into both cornea and scle- 
 rotic ; the urowth is present at birth, but usually increases somewhat as the child grows 
 up. It may give rise to astigmatism by causing distortion of the cornea. 
 
 The growth may be single or there may be two or three little tumors. Their struc- 
 ture is that of connective tissue, and occasionally small hairs grow u])on them. 
 
 Should the little growths give rise to inconvenience, they can be shaved off level with 
 the cornea, but, as a rule, they cannot be entirely removed. 
 
 Round and spindle-celled sarcomata have also been met with growing from the cor- 
 nea. Such cases usually call for extirpation of the eyeball. 
 
 THE SCLEROTIC. 
 
 Sclerotomy, as already stated, is one of the operations for the treatment of 
 glaucoma. In ].erlorming the operation, the position of operator and patient should be 
 as in Fig. 111. p. 2U0. The instruments required are a straight cataract knife (Fig. 
 120, c), .speculum, and fixing forceps. The lids should be held open with the speculum, 
 the eyeball fixed with the forceps. The knife should be entered on the outer side of the 
 globe as far back in the sclerotic as is consistent with the entering the anterior chamber 
 quite at its periphery, pushed across the chamber, and brought out at a corresponding 
 point on the inner side. The transfixion having been finished, the incisions should be 
 eidarged to about double the width of the knife blade, which .should then be withdrawn, 
 its point being carried round the margin of the anterior chaiuber so as to notch the parts 
 bounding it, but not cut through the sclerotic. The division of the sclerotic may be 
 made either upward or downward, the points of puncture and counter-puncture be situ- 
 ated midway between the ho'rizontal meridian of the cornea and its upper margin in the 
 former case, midway between its horizontal meridian and lower margin in the latter. 
 
 THE IRIS. 
 
 Iridectomy is called for in all cases in which it is desirable to influence the tension 
 or nutrition of the eyeball ; it is associated with some operations for cataract, in a some- 
 what modified form is one of the methods of making an artificial pupil, and is useful in 
 some other conditions. 
 
 The operation is performed — 
 
 1. To influence tension. 
 
 (rt) In shiuqhhi;]/ nlccrs, or suppuration of the cornea, accompanied by pain and threat- 
 ening perforation. In such cases iridectomy gives almost instant relief to the most 
 severe pain, and in all probability will save the cornea from rupture. 
 
 (//) In injiiriex of the ci/rhnU in which the crystalline Ions, being wounded, has become 
 opaque and swollen and is pressing on surrounding parts, causing severe pain and threat- 
 eniuir: the inteirritv of some of the delicate structures within the iriobe. In these cases 
 
304 
 
 OPERATIONS ON THE IRIS. 
 
 not only does iridectomy diminish tension, and so relieve pain, but gives room for any 
 subsequent swelling of the lens. 
 
 (c) In staphyloma of the cornea iridectomy often causes complete subsidence of the 
 projection. 
 
 (d) In glaucoma a timely and well-performed iridectomy causes instant and lasting 
 diminution of tension and places the eye in comparative safety ; the operation should be 
 
 performed on any eye that can dis- 
 FiG. 117. tinguish bright light, and to relieve 
 
 pain in any case, whether there be 
 perception of light or not ; in acute 
 glaucoma it must be tried even if 
 all perception have been lost for 
 some days. 
 
 2. To influence nutrition, iridec- 
 tomy should be performed in chron- 
 ic choroido-iritis, recurrent iritis, 
 and in cases of total exclusion of 
 the pupil where there is no com- 
 munication between the anterior 
 and posterior divisions of the aque- 
 ous chamber. 
 
 3. Associated with operations 
 for cataract, iridectoni}' should be 
 performed previous to a needle ope- 
 ration if much swelling of the lens 
 be anticipated, or it ma}- require to 
 be done after the needle has been 
 used if pain or increase of tension 
 occur. 
 
 The operation .should also be 
 performed at some time previous to 
 or simultaneously with small flap or 
 linear extraction of cataract. 
 
 4. Iridectomy for artificial pupil is mentioned at another page. 
 
 5. Other conditions in which iridectomy may be required are — 
 (a) Hemorrhage into the vitreous humor. 
 
 (6) Displacement of the retina. 
 
 (c) As an aid to the removal of foreign bodies from the globe. 
 
 {d) Some peculiar conditions of intraocular circulation. 
 Operation of Iridectomy. Instrummtf. — A wire speculum (Fig. 114), a 
 straight or bent iridectomy knife (Fig. 117, a), a pair of toothed forceps (Fig. 116, a), a 
 pair of iris forceps (Fig. 117, /^), iris scissors (Fig. 117, c), and a curette (Fig. 120. «). 
 For the position of patient and surgeon see Fig. Ill, p. 290, The patient should be 
 brought fully under the influence of an anesthetic, the lids kept widely open by the wire 
 speculum, and the eyeball fixed by seizing the conjunctiva and subconjunctival fascia 
 near the corneal margin with the toothed forceps ; then, with a straight or bent iridectomy 
 knife of medium size, an incision should be made in the sclerotic in such a position that 
 the knife enters the anterior chamber quite at its peripheral part and close to the anterior 
 surface of the iris. 
 
 The knife, having entered the anterior chamber, should be pu.shed steadily on (care 
 being taken to keep its point well forward toward the cornea, so as not to wound the 
 lens) until the point is opposite the centre of the pupil. The point should then be turned 
 to one side, so as to be out of the pupillary area, and the knife slowly and gently with- 
 drawn, the hold of the forceps being let go at the same time. The incision thus made 
 should be of such a length as to correspond to a little more than one-fourth of the cir- 
 cumference of the iris. 
 
 The next step in the operation is the removal of a portion of the iris. If, as is not 
 unfrequently the case, the iris has become prolapsed, it needs only to be seized with the 
 forceps and a piece of the desired size removed with the scissors. If the iris does not 
 protrude, the iris forceps should be introduced, .shut, through the wound in the sclerotic, 
 and pushed on until the extremities of their branches are opposite the nearest portion of 
 the pupillary margin ; they should then be allowed to open of themselves, when the iris 
 
 a. Bent Iridectomy 
 Knife. 
 
 h. Iris Forceps. 
 
 Iris Scissors. 
 
Ol'EllATlnSS O.V 77//; IIUS. 305 
 
 will bf puslicil between tlie braiielie> l>y tlie |ire>>ure of the parts behind ; no backward 
 pressure must l)e made with the fnreejis. but they shuiiM be ^'ently eh>se<l ajraiii and 
 withdrawn, oarryini; the iri> with them, which sln»uhl tlien l)e cut across witli the scis- 
 sors. eh)se to one an;_de of the wound, drawn over to the other an^rle. and a piece cut off; 
 the curette shtiuhl be passed between the lijis of the wound, .so as to pusli back any por- 
 tions of iris tlnit may liave become entan<rled in it. The eye sliouhl then be bound up 
 with lint and a banthige. The form of the pupil after a well-performed iridectomy should 
 resemble Fii:. HI*. D.' 
 
 With rejrard to the position of the portion of tlie iris to be removed opinions are at 
 variance. If the surgeon In- a skilful and experienced operator and has tin* aid (»f a com- 
 petent assistant, the irideetomy should be done upward. s<t as to place the <:ap beneath 
 the upper lid. and thus conceal it as much as possible. 
 
 To perform iridectomy upward, a bent iridectomy knife should he used and the incis- 
 ion made in the sclerotic above the upper mar<rin of the cornea; an assistant should then 
 draw the eyeball downward with forceps, the iris forceps should be inserted, and the por- 
 tion of iris removed as previously directed. 
 
 An inexperienced operator will find it much easier to remove the portion of iris from 
 its outer and lower segment. In this ca.se a straight iridectomy knife can be u.sed and 
 no assistant is required. The result is rather an ugly gap, the disadvantage of which, 
 however, is quite counterbalanced by the ease and safety with which the operation can be 
 perfnrnied. 
 
 Accidents which may happen during the Operation of Iridectomy 
 and Difficulties which may be encountered. — The accidents which may occur 
 
 are — 
 
 (1) Wound of the lens from insufficient care in keejiing the point of the knife well 
 forward and out of the area of the pupil. This accident will in all probability be followed 
 by the formation of traumatic cataract. 
 
 (2) Escape of vitreous humor is very likely to occur in hard eyes if the knife be too 
 quickly withdrawn or if undue pressure be exerted on the globe with the fixing forceps. 
 
 (8) The iris may be torn away from its insertion at a point opposite to the incision If 
 undue triictimi be exerci.<ed upon it with the iris forceps. 
 
 Difficulties. — The iris may be found so rigid that it cannot be seized with the 
 forceps, or so rotten that only very small portions can be brought away ; sometimes it 
 bleeds profusely when touched, filling the anterior chamber with blood and considerably 
 hindering the ojteration. 
 
 Artificial Pupil. — The operation for artificial pupil is performed to open a new 
 path for ray> y<\' liirht to the retina, the natural passage being obstructed. 
 
 It is indicated in the following cases: (\) In opacity of the cornea, with or without 
 anterior synechi;e : ('!) In closure of the pupil : (3) In extensive posterior synechias ; 
 ;4) In central opacity of the lens or its capsule. 
 
 The artificial pupil must be small, as nearly central and as well defined as possible. 
 Care must be taken to make it behind that portion of the cornea which is mo.st trans- 
 parent and least altered in curvature, the best situation being ascertained by oblique 
 illumination. The new pupil must not be made upward, or it will be covered by the 
 upper lid. 
 
 An artijirial pupH can be made in any of the following ways: (1) By incision of the 
 iris ; (2) By tearing it away from its insertion ; (3) By excision of a portion (iridectomy 
 for artificial pupil) ; (4) By ligature. 
 
 In operations for artificial pupil the position of patient and surgeon should be the 
 same as in •• iridectomy." and an anaesthetic should be administered. 
 
 1. (a) Incision TFig. 119 A). — This operation is called for in cases of complete closure 
 of the pupil t'i>ll..\ving removal of the lens either by operation or injury, but is not advis- 
 able unless the lens be absent. In these cases the iris may be found changed intw a tense, 
 unyielding membrane which cannot be seized with forceps. 
 
 The operation of " incision " may be performed either by thrusting a broad needle 
 through the cornea near its margin and then incising the iris, so as to cut across its radial 
 fibres, or. an incision having been made with an iridectomy knife in the sclero-corneal 
 margin, a pair of scissors (having one sharp and one blunt-pointed blade) may be intro- 
 duced through the wound, one blade being thrust through the iris at its nearest point and 
 passed behind it. the other carried along its anterior surface, and the iris then cut fairly 
 across from one side to the other. 
 
 Whichever plan of incision is adopted, the vitreous humor pushes forward into 
 20 
 
306 
 
 OPERATIONS ON THE IRIS. 
 
 the wound and keeps its edges widely separated, a pupil resembling Fig. 119 A, being 
 formed. 
 
 Two other methods of making an artificial pupil by •' incision " have been lately intro- 
 duced ; they are known as single and double "iridotomy." 
 
 For the positions of patient and surgeon in performing either of these operations sec 
 Fig. Ill, p- 290. 
 
 (h) Single iridotomy should be thus performed : The eyelids being kept open with the 
 wire speculum and the eyeball fixed by seizing the conjunctiva and subconjunctival fascia 
 
 close to the margin of the cornea 
 Fig. 118. at its inner side, an incision should 
 
 be made with an iridectomy knife 
 in the cornea about midway be- 
 tween its margin and the pupil and 
 opposite to the point of fixation 
 with the forceps. The forceps 
 scissors (Wecker's, Fig. 118) must be then introduced, closed, through the wound into 
 the anterior chamber, the blades opened, one passed through the pupil behind the iris, the 
 other on its anterior surface, and the sphincter of the pupil be divided with one sharp 
 cut. The scissors should then be withdrawn, any prolapse of iris that follows replaced 
 with the curette, a drop of atropine placed between the lids, and the eye lightly bandaged. 
 This operation is applicable to cases where the lens is present, its centre being opaque 
 and its peripheral portion clear. 
 
 (c) Douhle iridotomy is applicable to cases of closed pupil after cataract extractitm. 
 An incision should be made through the upper part of the cornea, the knife carried 
 through the iris and along its po.sterior surface, so as to make a fair-sized wound in it ; 
 the incision being finished, the knife should be carefully withdrawn, and very possibly 
 some vitreous humor will follow it. 
 
 Wecker's Scissors. 
 
 Fig. 119. 
 
 A. Pupil after Iiici^nm 
 
 /<ij?7lFir?x. 
 
 'iipil after Excision. C. Pupil aftei Ligature. 
 
 D. Iridectomy for Glaucoma, etc. 
 
 The next step in the operation is to pass the forceps scissors, closed, through the 
 wound in the cornea into the interior chamber, open them, pass one blade behind the iris, 
 the other in front of it. make an incision in a direction downward and inward; then 
 change the direction of the scissor blades and make a cut downward and outward. Thus 
 a small piece of iris is enclosed by a V-shaped incision, the apex of the V being upward. 
 The small portion of iris contracts up and a somewhat triangular pupil is left. The eye 
 should be bound up as usual. 
 
 2. Tearing away the Iris from its Insertion flridodialysisX — An 
 
 incision having been made through the cornea on the side opposite to that on which 
 the iris is to be removed, a pair of iris forceps should be pas.sed through the wound and 
 across the anterior chamber, the iris seized close to its greater circumference and torn 
 forcibly away from its insertion ; the instrument should then be carefully withdrawn and 
 the eye bound up. If necessary, the whole iris may be removed in this way. This opera- 
 tion is applicable to cases of dense corneal opacity (leucoma) occupying the whole of its 
 central part, some transparent cornea being left at the margin. 
 
 3. Excision ; Iridectomy for Artificial Pupil. — An incision .should be made 
 
 of the requisite size through some part of the sclero-corneal margin, the iris forceps intro- 
 duced through the wound, the ends of their branches passed fairly up to the margin of 
 the pupil, the iris seized and drawn out through the wound, and a small portion removed 
 with scissors. The curette should then be passed between the lips of the wound, so as 
 to push back any portion of iris that may have become entangled in it ; a pupil resem- 
 bling Fig. 119, B, should be formed. 
 
 4. By Ligature (Iridodesis, or Iridesis). — An incision should be made with 
 a broad needle near the margin of the cornea, a small noose of silk laid upon the surface 
 of the eyeball so as to encircle the incision, an iris hook or canular forceps then passed 
 through the noose and wound, and the iris drawn gently out ; an assistant with two pairs 
 
(•ATM: ACT. .307 
 
 of ln();ul-('ii(l((l rurccps ^lioiild sci/c lacli ciiil nf tlus noo.se and firmly ligature the includf-d 
 portion of iris; tlu- iijiiitiirt' will drop oil in tin' course of a few days, a pupil resenibling 
 in shape Fig. ll:>, (\ being left. 
 
 THE CRYSTALLINE L^NS. 
 Cataract. 
 
 Hv eataraet we understand an opacity of tlie crystalline lens. 
 
 The causes of this opacity arc .snnunvhat obscure, but it probably depends on impair- 
 ment of nutrition of the lens consc((uent on senile decay or constitutional condition." 
 (r. y., diabetes). 
 
 It also (tecurs in cdunection with inHanimatory changes in adjacent parts — the choroid, 
 ciliary body, vitreous, and iris — is met with as a congenital defect, and very frequently 
 results frnni injury. 
 
 Forms of Cataract. 
 
 There are two principal forms of cataract: 
 
 1. 77//' cortiad or soft aifaracf. 
 
 2. The nucJi'((r or Jiard cataracf. 
 
 In the first form the cortical substance of the lens is primarily affected, the nucleus 
 afterward becoming opaque, the whole being soft, or even fluid. 
 
 In the second the nucleus of the lens first becomes hard, yellowish, and opaque, the 
 cortical substance being subsequently affected. 
 
 The cortical cataract is met with as an idiopathic disease in childhood and early adult 
 life, and as the result of iujury at all ages. 
 
 There are several varieties of cataract. 
 
 (a) ZonuJar or JnmrU<(r catorxct is either congenital or commences soon after birth; 
 it is characterized by an opacity of circular form and well-defined outline, situated in the 
 cortical substance of the lens, but at some distance fr,?m its surface; the margin, nucleus, 
 and superficial layers of the lens are transparent. 
 
 (6) Ordinar)/ congenital cataract is a bluish-white opacity of the whole lens. 
 
 (c) Traumatic cataract is an opacity of the lens often accompanied by swelling and 
 caused by rupture of its capsule from injury and the subsequent action of the aqueous 
 humor upon its substance. 
 
 (ff) Posterior polar cataract, an opacity situated at the posterior pole of the lens ; and — 
 
 (e) Entircl// fluid or diffluent cataract., caused by changes in the lens secondary to 
 inflammation of adjacent parts. 
 
 The variety of cataract met with in diabetes is composed principally of soft material ; 
 but if the patient be advanced in years, there is usually a hard nucleus. 
 
 Xnclear cataracf occurs in persons who have passed the middle period of life and is 
 characterized by the presence of a hard yellowish central portion or nucleus of varying 
 size and density ; the nucleus is surrounded by moi;e or less soft cortical substance and is 
 occasionally of a greenish or almost black color, giving rise to what is known a.?, green or 
 hhtrk cataracf. 
 
 Diagnosis. — The existence of cataract is easijy ascertained by oblique illumination, 
 the pupil having been dilated with atropine previous to making the examination. 
 
 Treatment. — The treatment of cataract is entirely operative, no kind of medication 
 being of the least use. 
 
 Our object in performing an operation is to open a path for rays of light to pass t<> 
 the retina. This can be attained in one of two ways, the method adopted depending on 
 the kind of opacity present. 
 
 1. In cases (as lamellar cataract) where the bulk of the lens is clear, the opacity 
 being situated in the axis of the normal pupil, very useful vision is procured by making 
 an artificial pu]iil opposite a transparent portion of the lens. (See ''Artificial Pupil.') 
 
 2. When tile whole lens is opa(ine. its entire removal must be accomplished. 
 Varieties of Operation. — Three varieties of operation are performed to secure 
 
 the removal of the whole lens : 
 
 1. The operation for solution or absorption. 
 
 2. Extraction. 
 
 3. Suction. 
 
 Forms of Cataract to which each Operation is Applicable. — As a 
 
308 
 
 CATARACT. 
 
 broad rule, cataract occurring in persons below 20 is of the soft or cortical form and 
 should be removed by sofiition or suction; cataract occurring in persons above 30 (except 
 traumatic cataract) is of the hard or nuclear form and must be removed by extraction. 
 
 In the intermediate decade a doubt may arise as to what is the best plan of procedure ; 
 in these cases the surgeon must be guided by the general appearance of the cataract. If 
 it appears bluish in color and somewhat swollen, it is probably soft and can be removed 
 by solution or suction; if there is a distinct yellow reflection from its centre, denoting the 
 presence of a hard nucleus, it should be removed by extniction. It must also be borne 
 in mind that loss of time is a very serious consideration with most patients; consequently, 
 a preference must always be given to that operation which will allow them to resume their 
 occupations as early as possible. 
 
 Solution, though perhaps somewhat safer than extraction, is always a tedious process, 
 and the more so the older the patient ; consequently, preference must be given to extrac- 
 tion in all cases where the condition of the patient's sight is such as to prevent him fol- 
 lowing his occupation, even though there be no appearance of a hard nucleus. In cases 
 where the cataract is evidently soft and one eye retains useful vision solution is to be 
 preferred to extraction, as the patient can continue at his work during the time that 
 absorption is going on. 
 
 Before performing any operation for cataract we must take care to ascertain that the 
 eye has good perception to light, indicating that the retina is in a normal condition ; 
 otherwise, no improvement in vision will result from removal of the lens. 
 
 Oper.ations for Removal of Cataract. 
 
 Solution. — In the operation for solution the capsule of the lens is opened, and its 
 substance thus allowed to be acted upon by the aqueous humor, by which it is broken up 
 and softened, absorption finally taking place. 
 
 The operation can be performed as follows (for the positions of patient and operator 
 see Fig. Ill, p. 290): No anaesthetic is needed; the pupil should be well dilated with 
 atropine; the operator, keeping the eyelids separated by the fore- and ring-fingers of 
 one hand and steadying the globe by pressing the second finger gently upon it, should 
 take a cataract needle in the other hand and pass it obliquely through the cornea at such 
 a distance from its centre that any resulting cicatrix will not interfere with vision ; the 
 needle should then be pushed on across the anterior chamber into the area of the pupil, 
 its point then depressed and three or four incisions made with it in the lens capsule, so as 
 to divide it freely. Care must be taken to use the needle very gently and not to pass it 
 
 too deeply into the lens ; otherwise, 
 Fig. 120. the suspensory ligament nuiy be torn 
 
 and the lens displaced. 
 
 The capsule having been freely di- 
 vided, the needle should be carefully 
 withdrawn and a drop of solution of 
 atropine placed between the lids ; the 
 only after-treatment required is the 
 constant use of atropine, so as to keep 
 the pupil widely dilated. 
 
 If the eye be examined in the 
 course of a few days, white flocculent 
 lens matter will be seen protruding 
 through the opening in the capsule 
 into the anterior chamber, showing 
 that the lens is swelling and under- 
 going solution. 
 
 The operation will probably re- 
 quire to be repeated in about a month 
 or six weeks, and possibly on one or 
 two subsequent occasions, before the 
 whole lens is absorbed. Care must 
 be taken not to do too much at one sitting, or the lens may swell too rapidly and press 
 upon the surrounding parts, giving rise to severe pain, increased tension of the globe, 
 iritis, cyclitis, etc. 
 
 Extraction of Cataract. — The object of operations for extraction of cataract is 
 
 Instruments for Extraction of Cataract. 
 
 a. Curette and pricker. 6, Triangular cataract knife, c, Straight 
 
 cataract knife (Graefe's). d, Sharp hook. >-, .Scooj). 
 
CATAnAf'T. 
 
 .'}09 
 
 the rciimval of tin- lens tlimutrli ;iii iiirisiun altup-tlicr in tin- (•«»riK'a, the sclcrD-coriieal 
 maiiriii. partlv in tlic .scliiotic and partly in the sclfro-cfuiical iiiarfrin, or wlidlly iti the 
 sfltTiitic, tlu' incision lifini: I'itlicr siiM|)I«' or asso('iat«Ml with excision of a portion of iris. 
 
 Kxtraction can hi- hcst pirfornicd hy oiii' of the five fuMowinj; methods: (\) I'Map 
 extraction; (li) Small flap with iridectomy: ('A) Kxtraction }»y ohli(|U(! corneal section ; 
 (4) Ijnear extraction ; (.")) Kxtraction hy means of a fraction instrnmerit. In the first 
 and third methods no iris is removed; in the second, fonrth. and last, iridectomy should 
 be performed either at the time of removal of the lens or sonu' weeks or months previ- 
 ously. All entirely opacpie lenses (mature cataracts) may he removed hy the first or third 
 methods ; all partiallv npa(|ue lenses (immature cataracts) must ho extract erj hy the .second 
 or fnurtli. a fraction instrument hein^ used in any case; where ^^reaf difticulty i« encoun- 
 tered or where escape nf vitreous has taken place hefore the lens has been extracted. 
 
 We shall, however, lind that in all cases we obtain mo.st uniform success by extrac- 
 tion a.ssoeiated with iridect<»my ; we should never attempt to extract an immature cata- 
 ract without first excisinir a portion of iris, and it is well to do so as a preliminary soma 
 Weeks ln'fure the lens is removed. 
 
 Flap Extraction. — The instruments re(|uired for flap extraction are a triangular 
 cataract kiiit'c. sharp hunk, and curette (Fig. 120, /y, if, a). 
 
 For the p(»siti<iiis of patient and operator see Fig. Ill, p. 2JM(. Xo anjcsthetic is 
 re(|uired; the jtatient should Ite requested to look downward, the lid.s kept open and the 
 eyeball steadied Ity the operator's fingers as in tlie operation for sf)lution. 
 
 The incision should be made by passing a triangular cataract knife through the outer 
 margin of the cornea at a point just above its horizontal meridian, into and across *he 
 anterior chamber, bringing it out through the cornea at a corresponding point on the inner 
 side, ami completing the section by pushing the knife onward until its heel cuts out along 
 the upper margin of the cornea (Fig. 121, A). 
 
 Fig. 121. 
 
 A 
 
 A, Flap. B, Oblique corneal section. C, Lineal incision. 
 
 Incisions for Extraction of Cataract. 
 
 This simple onward movement of the knife is sufficient if the inci.sion has been 
 properly planned ; but should the cornea have been entered too low down, the knife will 
 not be wide enough to cut out, and then the section mu.st be completed by slightly with- 
 drawing the blade or by a sawing movement. Care must be taken not to withdraw the 
 knife until it has passed some distance through the opposite side of the cornea, or the 
 aqueous humor will escape too soon and the iris fold over the edge of the knife and be 
 wounded. 
 
 If the incision has been properly made, it will lie within the corneal margin, and a 
 semicircular flap, including a little less than half the cornea, will be formed. 
 
 The section having been finished, the patient should close the eyes gently and be 
 allowed to rest for a moment. 
 
 The next step in the operation is the removal of the opaque lens. The upper lid 
 being drawn gently upward and the patient directed to look downward, the sharp hook 
 must be introduced through the wound and the lens capsule lacerated by gently scratch- 
 ing it : the hook should then be withdrawn and the patient allowed to close the eyes for 
 a short time. 
 
 The eyes should then be gently opened and the lens removed by lightly pressing, the 
 lower lid against the globe, just below the inferior margin of the cornea, with the thumb 
 of one hand, counter-pressure being similarly applied with the forefinger of the other 
 hand at a corresponding point above. If the manoeuvre be properly executed, the pupil 
 gradually dilates, the lens slips gently through it into the anterior chamber, and then 
 escapes by the corneal wound. Any prolapse of iris that may occur must be carefully 
 returned with the curette : each eye should then be covered with two pieces of wet lint 
 and a light bandage applied. 
 
 Small Flap with Iridectomy. — A flap section should be made by transfixing 
 
310 CATARACT. 
 
 the eyeball through the sclero-eorneal margin with the straight extraction (Graefe's) 
 knife (Fig. 120, c), and then cutting out in the line of the sclero-eorneal junction. 
 
 The section may be made either upward or downward, and the point of transfixion 
 should be about one-third of the distance from the horizontal corneal meridian to the 
 upper or lower margin of the cornea. The steps of the operation, with the exception of 
 the incision, are exactly similar to those of linear extraction (see below) ; but should it 
 be thought fit to perform the operation without anaesthesia, no speculum or fixing forceps 
 should be used. 
 
 Oblique Corneal Section.— This operation often goes by the name of Bader's 
 or Liebreich's operation, when the section is made downward ; Lebrun's '• extraction by 
 small median flap," when the section is made upward. It seems to me that the term 
 " oblique corneal section " expresses all and dispenses with much unnecessary prolixity. 
 
 The instruments required are a thin straight cataract knife, a sharp hook, and curette 
 (Fig. 120, i\ d, a). (For the position of patient and surgeon see Fig. Ill, p. 290). Xo 
 anaesthetic is required, and, with the exception of the incision, the steps of the operation 
 are much the same as in flap extraction. 
 
 The incision may be made either upward or downward (Fig. 120, B), by passing the 
 straight knife through the sclero-eorneal margin on the outer side at a point (puncture) 
 corresponding to the horizontal corneal meridian into and across the anterior chamber, 
 out at a corresponding point on the inner side (counter-puncture), and then cutting for- 
 ward by a sawing movement, ohUqmlij, through the cornea, midway between the pupil 
 and upper or lower corneal margin — the former if the incision is made upward, the latter 
 if it is made downward. In entering the knife and pas.sing it across the anterior chamber 
 care must be taken to keep its edge directed forward toward that part of the cornea which 
 it is desired to incise ; if the knife be rotated in any wa}' after the anterior chamber has 
 been opened, the aqueous humor will escape and the blade become entangled in the iris. 
 
 The capsule should be lacerated and the lens removed in the .same way as in flap 
 extraction ; the position of the incision near the centre of the cornea, however, will not 
 allow the lens to be pressed out immediately, as is done in the flap opei"ation. 
 
 Before attempting to squeeze out the cataract its margin must be brought opposite 
 the incision by gently pressing upon the globe above or below, according as the section 
 has been made upward or downward. 
 
 The bulk of the cataract having been removed, care must be taken to get away any 
 soft cortical substance or fragments of lens that may be left. The soft matter can be 
 removed by gently rubbing the cornea ; small hard fragments must be drawn out by the 
 curette or a small scoop. The whole of the cataract having been removed, the iris — 
 which will in all probability have somewhat prolapsed — must be replaced with the curette, 
 some solution of eserine dropped into the eye to keep the pupil contracted and so reduce 
 the risk of recurrence of the prolapse, and both eyes carefully bandaged. 
 
 Linear Extraction. — In this operation the cataract is removed through a linear 
 incision, partly in the sclerotic and partly in the cornea, or altogether in the former; 
 usually associated with iridectomy, performed at the time of extraction of the cataract 
 or some months pi'eviously. 
 
 By linear incision is generally understood an incision made in the same direction as a 
 straight line drawn from the centre of curvature of the cornea to its circumference (one 
 of its radii). Many modifications of linear incision are practised, but only one will be 
 described here. The instruments required for linear extraction are a wire speculum (Fig. 
 114), toothed forceps (Fig. IIG, «), a straight cataract knife, a curette, sharp hook (Fig. 
 
 120, c, «, fZ), iris scissors, and iris forceps (Fig. 117, 6, c). 
 
 The operation should be performed thus, and, as in the other forms of extraction, the 
 incision may bemade either upward or downward (for position of patient and operator 
 see Fig. Ill, page 290): The patient should be thoroughly ana?sthetized, the lids kept 
 open by a wire speculum, and, supposing the incision to be made upward, the globe must 
 be drawn gently downward with the toothed forceps, holding the conjunctiva and sub- 
 conjunctival fascia close to the lower margin of the cornea ; then with the straight cata- 
 ract knife puncture and counter-puncture should be made in the schrotic. just beyond the 
 sclero-eorneal margin, the knife entering at a point on the outer side of the globe, situ- 
 ated about two-thirds of the way between the horizontal meridian of the cornea and its 
 upper margin, and emerging at a correspuiiding point on the inner side; the edge of the 
 knife should then be directed nearly straight forward, and by a sawing movement made 
 to cut its way out through the cornea at a short distance from its upper margin (Fig. 
 
 121, C). 
 
CATAJLWT. 
 
 'Ml 
 
 If iriili'ctiiiiiy lias not Ih'imi previously perforiiMMl, a piece of tlic iris sIkhiM next be 
 oxciseil t'nini the upper seiinient. (See '' Iriileetoniy.'"^ 
 
 The next step is t(» laeerate the capsule. 'I'he operator should fix the eve anu draw it 
 jjently downwaril with the toothed loreeps, tiien introduce the sharp hook throufrh the 
 incision and freely lacerate the capsule with it. The cataract can then he removed by 
 niakinu: trentle ]>ressure with the curette upon the eyeball, n(!ar the lower margin (»f" the 
 cornea, tlu; globe being steadied and held in position by fixing the conjunctiva with the 
 toothed forceps. 
 
 The nucleus and bulk of the catarart having escaped, the curette slntuld be passed 
 gently over the surl'ace of the cfUiiea IVoni all directions toward the incision, so as to 
 press out any cortical substance that may be left, and if any bh^od or portions of lens 
 remain in the incision they must be carefully removed, .so as to ensure perfect coaptation 
 of its margins ; the s])eculum should then be removed and both eyes bandaged in the 
 usual way. 
 
 The incision for linear extraction, as already stated, may be made downward as well 
 as upward, the Ibrmer method of operating being much the easier and not requiring the 
 aid of an assistant. 
 
 The same objections apply to extraction downward as to iridectomy in the same direc- 
 tion, but the results obtained are eijually good as from upward sections, and the ease with 
 which the operation can be performed quite counterbalances any objections which may 
 be made lui tlie score of disfiuMrcnicnt. 
 
 Extraction of Cataract by a Traction Instrument. — Cataract can be 
 
 Fig. 122. 
 
 "removed by^a traction instrument, either through a 
 flap section or a linear incision peri])herally situated, 
 iridectmny being performed in either ca.se. 
 
 The patient should be thoroughly anae.sthetized, 
 and. whichever incision is made, the eyelids should 
 be kejit open with the speculum and the globe fixed 
 Avith the toothed forceps while the section is made 
 and during the subseciuent removal of the lens. 
 
 The traction instrument employed is either a scoop 
 or a sharp hook (Fig. 12l). r. (/). 
 
 Removal of Cataract by the Scoop 
 
 (scoop extraction). — Scoop extraction can be 
 accomplishL'<l thus : The section having been made 
 and iridectomy performed, the convex surface of the 
 scoop .should be pressed gently upon the more periph- 
 eral margin of the incision, so as to cause it to gape 
 somewhat ; the instrument should then be pasiied with 
 the utmost gentleness through the incision, beneath 
 the margin of the lens, along its posterior surface and 
 beyond its posterior pole, until the lens lies well in its 
 concavity, and it should then be carefully withdrawn, 
 carrying the cataract with it. the removal being as- 
 sisted by gentle pressure on the exterior of the globe. 
 
 Removal of Cataract with the Sharp 
 Hook sharp-hook extraction). — The hook 
 
 sliMiiM be passed well behind the lens in the same 
 
 manner as the scoop, fixed into its posterior surface, 
 
 and then carefully withdrawn, carrying the lens with 
 
 it. Two sharp hooks may 1>e used instead of one. and should be fixed into the lens at 
 
 different points, so as to prevent it rolling round (as sometimes happens when only one 
 
 hook is used), instead of passing in the desired direction. 
 
 After removal of the lens by either method both eyes should be bound up in the 
 usual way. 
 
 Suction. — The removal of cataract by suction is indicated in cases where the lens 
 has beoome nearly or entirely fluid, as occurs in many instances of traumatic cataract, 
 and frequently after a needle operation has been performed. 
 
 The instruments required are a wire speculum, toothed forceps, broad needle, and 
 suction tube (Figs. 114, 11(5 ./. 122 u, b). Before operating, the pupil should be well 
 dilated with atropine. (For position of patient and surgeon see Fig. Ill, p. 290.) 
 
 It is best, but not absolutely neces.sary, to place the patient under the influence of an 
 
 a, Needle for making 
 iticisioD in suction 
 operation. 
 
 b, Suction tul)e. 
 
312 CATARACT. 
 
 anaosthetic. The lids should be kept open by a wire speculum, the eyeball fixed by the 
 toothed forceps, and a small linear incision made in the cornea with the broad needle, 
 about midway between its summit and margin, in any convenient position. 
 
 The operator should then place the mouthpiece of the suction tube in his mouth, pass 
 its nozzle through the incision and behind the softened lens, and by sucking gently remove 
 as much lens matter as will come away easily. No force must be used ; and if any por- 
 tion of the lens be too hard to pass easily into the tube, it may be left to become absorbed 
 or be dealt with on a future occasion. When as much lens as will easily come away has 
 been extracted, the suction tube should be removed, the speculum taken out, a drop of 
 solution of atropine placed between the lids, and the eyes bandaged in the usual way. Th.e 
 bandage should be continued and the pupil kept dilated with atropine until all irritation 
 has subsided. 
 
 Accidents during Extraction of Cataract. 
 Premature Escape of Aqueous Humor, — If care be not taken in making 
 
 the section, the a((ueous humor may escape too soon and the movements of the knife be 
 hampered by the iris falling forward. Should this happen, the knife must be carefully 
 withdrawn and the section completed with scissors. 
 
 Bleeding into the Anterior Chamber. — In some cases hemorrhage from the 
 cut iris or conjunctiva takes place to such an extent as to fill the anterior chamber with 
 blood and hide the cataract entirely from view. 
 
 If the blood does not flow out easily on placing the curette between tjie lips of the 
 incision and making gentle pressure on the cornea, the operation should be discontinued, 
 the eye bound up and left till the blood has become absorbed, unless the lens capsule has 
 been lacerated, in which case the lens must he removed at all risks, or it may swell, press 
 upon surrounding parts, set up inflammatory action, cause increase of tension of the globe, 
 and very probably lead to destruction of the eye. 
 
 Prolapse of Vitreous Humor. — If any undue pressure be exerted on the globe 
 during extraction, the suspensory ligament of the lens gives way and a prolapse of vit- 
 reous follows. Should the prolapse of vitreous occur before the escape of the lens, the 
 cataract .should be removed as quickly and gently as pos.sible by the aid of a scoop or 
 sharp hook. 
 
 Prolapse of vitreous is more likely to occur if the humor is abnormally fluid. The 
 accident may give rise to no bad results, but is .sometimes followed by a form of chronic 
 choroiditis which ultimately destroys the eye. 
 
 If vitreous has been lost, great care must be taken to bandage the eye so as to keep the 
 lids immovable and prevent them pressing upon the globe and cau.sing further prolapse. 
 
 Displacement of the Cataract. — In some cases, on an attempt being made to 
 press out the lens, the suspensory ligament gives way, and the cataract, instead of coming 
 forward into the anterior chamber, passes behind the iris or sinks backward into the vit- 
 reous chamber ; it should, if possible, be removed by the scoop or sharp hook. If left 
 within the globe, it will probably act as a foreign body, set up inflammation, and destroy 
 the eye. 
 
 After-Treatment of Extraction of Cataract. 
 
 Immediately after the operation each eye should be covered with two folds of wet 
 lint secured by a bandage which has been contrived for the purpose by the late Mr. 
 Dunnage ' of the Central London Ophthalmic Hospital. The patient should then be put 
 to bed, where he should remain for three or four days. 
 
 The lint must be kept constantly wet for the first week, and fresh pieces should be 
 applied every two or three days. 
 
 On no account should the eye be examined until the end of the first week ; if the lids 
 remain in a normal condition, we may rest assured that all is going on well, and opening 
 the eye too early can do no good and may do a great deal of harm. 
 
 At the end of a week the eye may be opened and its condition ascertained. Should 
 the section be healed, the anterior chamber re-established, and no .signs of inflammatory 
 action present, the sound eye can be safely left uncovered, the one that has been operated 
 on being kept bandaged with dry lint and a large green shade worn over both. At the end 
 
 ' Duunasje's bandage consists of a [liece of material of an open texture, througli which water will 
 easily run. of such a length as to cover botli eyes and leave some to spare. To each end of this piece 
 are attached tapes, by which the bandage is secured. 
 
i:xrii:r Ai'ios of rili: i:yi:i'. \li.. 
 
 :n3 
 
 of three week^ I lie lnill(l;iL;e lii;iV lie removed iVniil (lie eye on wlliell ext racf inn lias lieell |i(!r- 
 foniiud, liut tlic sliade nr iiidtectnrs slKiiild lie worn iiiil il aU imdiie vascularity li:is siiltsideil. 
 
 At the end <>!' aliout two months (if then' he no intolerance ol" li;.dit or irritahility of 
 the I'Vt' ) Jilassi'S should he ordered, two jiairs heiiij; jrivcn. one for ;:nin{r ahoiit and one 
 for reiulin«r ; convex 1.'5 1) will usually he found most suitahle for the former |>urpose, 
 convex 1<> l> for the latter. Hut should the jiatient have been inynpie or hypermetropic 
 before the ojieration, i:lasses weaker or stroiiiicr than these may lie re<(iiired. 
 
 Tllis is the usual cniirse of cases of ext ract ion of cataract ; all do not. however. ;:<» on 
 SO favorably. 
 
 A dav ">r two (lavs after the oiieratioii the jiatient may coin|ihtin of severe |iaiii in the; 
 eyeball, temph\ and brow, and on removinti the bandaLit' the lids may be found Jiiiffy and 
 red, or perhaps niueh swollen. 
 
 These .symptoms always indicate inflammatory chan^'^es in some of the ocular struc- 
 tures ; the inflammation may be simply an attack of iritis, which will probably proceed to 
 a favorable termimition, but may subse(|uently aflect the choroid, a chronic form of 
 ehoroido-iritis beint;- set up, which leatls to softening, and eventually to shrinking, of the 
 globe; the cornea may be inflamed or sujipurating, or inflammation and suppuration of 
 all the ocular structures (panophthalmitis) may have set in. (For the treatment of these 
 cases see " Iritis," '' Corneitis," etc.) 
 
 A not uncommon cause of pain and irritation is the occurrence of entropion of the 
 lower lids ; this must be remedied by operation. (See " Operations on the Eyelids.") 
 
 Causes of Unsatisfactory Results of Cataract Extraction. 
 
 The result of an ojieration for extraction of cataract may be marred by closure of the 
 pupil consequent on iritis, by obstruction of its area with opa(|ue lens capsule, or by 
 opacity' of the vitreous luimor. 
 
 Occlusion of the pupil should be remedied by making an artificial one (.see " Artificial 
 Pupil ") ; capsular obstructions should be torn through with cataract needles, cut across 
 •with scissors, or removed bodily with forceps. 
 
 The greatest caution must always be exercised in meddling with opaque capsule, as 
 an operation upon it, especially an attempt to tear it forcibly away, is very likely to be 
 followed by increase of tension, inflammation, or even suppuration of the eyeball. 
 
 For opacity of the vitreous humor nothing can be done. 
 
 EXTIRPATION OF THE EYEBALL. 
 
 Removal of the eyeball is called for under.the following conditions : 
 
 1. In all cases of injury causing complete disorganization, with collapse of the globe 
 and escape of its contents. 
 
 2. In cases where one eye, having been damaged by injury or disease to such an 
 extent as to render it jiractkalh/ usefriss, becomes irritable or painful and the sound eye 
 appears threatened by sympathetic ophthalmia. 
 
 3. In cases where an eye lost from injury or disease, and qinte hUiuI, is a source of 
 annoyance, even though the other eye be not threatened. 
 
 4. In cases where the globe has become the seat of malignant disease. 
 p]xtirpation of the eyeball should be thus performed (for position of patient and 
 
 operator see Fig. Ill, p. 290): The instruments recjuired are a wire speculum, toothed 
 forceps, a pair of blunt-pointed 
 
 scissors curved on the flat ( Fig. Fig. 123. 
 
 123), and a strabi.smus hook. 
 The patient being thoroughly 
 , under the influence of an an- 
 aesthetic, the operator should 
 place the wire speculum be- 
 tween the lids, then by the aid 
 of the forceps and scissors cut 
 through the conjunctiva all 
 round the cornea as close to 
 
 its margin as possible; he Extirpation Scissors. 
 
 should tlfen with the strabis- 
 mus hook take up the four recti muscles, one after the other, and divide them with the 
 
314 AFFECTIONS OF THE ORBIT. 
 
 scissors, either the external or internal rectus being cut at a little distance from the globe, 
 so as to afford a hold for the furcejis in the subsequent steps of the operation, and the 
 other three muscles as close to it as possible. 
 
 The muscles having been divided, the hook should be made to sweep round the globe, 
 so as to be sure that nothing is left uncut. By pressing the speculum backward the 
 eyeball will become dislocated in front of the lids, and then, being steadied by holding the 
 piece of muscle purposely left with the forceps, the scissors should be passed behind it 
 until their points are found to be in contact with the optic nerve, then slightly with- 
 drawn, opened widely, pressed forward again, and the nerve divided by a single cut. 
 
 As soon as the nerve has been cut through, the eyeball will be almost free, being held 
 only by the oblique muscles, which should be divided close to the sclerotic. Should 
 there be free hemorrhage, the speculum may be left between the lids, a piece of sponge 
 pressed firmly into the orbit and secured by a turn of bandage ; when all bleeding has 
 ceased, the sponge should be removed with the speculum and two small pads of wet lint 
 and a bandage applied. Should the hemorrhage be but slight, two or three small pads 
 of wet lint must be laid over the closed lids and secured by a bandage in the same man- 
 ner as in other operations on the eye. In about a month or six weeks an artificial eye 
 may be ordered. 
 
 ABSCISSION. 
 
 Abscission is the removal of that portion of the eyeball (including the ciliary region) 
 situated in front of the attachments of the recti m-uscles. these being left intact. The 
 object of this operation is to leave a movable stump on which an artificial eye can rest 
 and be moved in harmony with the movements of the sound one. 
 
 Abscission is indicated in staphyloma occupying the whole or greater part of the 
 former situation of the cornea, the remainder of the globe retaining its normal curvature. 
 
 The opei'ation should be thus performed (for position of patient and operator see Fig. 
 Ill, p. 290) : The instruments required are a wire speculum, toothed forceps, strabismus 
 scissors, a triangular cataract knife, a curved needle, and silk. The patient being thor- 
 oughly under the influence of an anftsthetic, the wire speculum should be placed between 
 the lids, the conjunctiva divided all round close to the corneal margin (as for extirpation) 
 and dissected back to the desired extent. Then with the curved needle a single suture 
 should be passed through the edge of the divided conjunctiva at five or six different 
 points, so as to surround the wound in it in much the same manner as the string sur- 
 rounds the mouth of an ordinary bag, and the ends of the silk left hanging on the 
 patient's face. 
 
 The staphyloma, the whole of the ciliary body, and sclerotic corresponding to it, 
 should then be removed by transfixing the globe with the triangular knife just in front 
 of the insertions of the internal and external recti muscles, cutting out upward in front 
 of the insertion of the superior rectus and finishing the removal by a sweep of the knife 
 in the opposite direction. 
 
 The silk should be then drawn up and tied, by which means the conjunctiva will be 
 made to cover the wound in the globe, and wet lint and a bandage applied. As soon as 
 the parts have firmly healed an artificial eye may be worn. 
 
 Abscission should be performed in preference to excision of the globe in children ; the 
 presence of the stump left prevents to a great extent the shrinking or non-development 
 of the orbit which will occur if the eyeball be removed entirely. 
 
 In older persons excision is generally to be preferred, as' the stump left after abscis- 
 sion is very liable to become troublesome, and in the very old is prone to suppurate. 
 
 AFFECTIONS OF THE ORBIT. 
 
 Protrusion of the Eyeball. — As many of the diseases of the orbit, and to a 
 considerable extent tumors of the eyeball itself, cause more or less protrusion of the 
 globe, it will be w^ell to say a few words on the subject before describing the morbid 
 changes which may give rise to it. 
 
 The symptoms are obvious enough and do not require description. The causes are 
 the following : 
 
 1. Inflammation within the orbit, either with or without the formation of abscess. 
 
 2. Hemorrhage into the orbit. 
 
 3. Vascular protrusion of the eyeball. » 
 
 4. Exophthalmic goitre. 
 
AFFEOTTOy^ OF TIIF OJllllT. .'315 
 
 ;'). Tumors within tlic oiliit, iindcs, exnstoscs, iiiali^'iiant <;rowtli.s, cysts, rucvi, etc. 
 
 (1. Kiilar^M'int'iit ^A' tin- ey»'liall itsclt' tVtuii ('/) jrnnvtli.s, iiiali^'iiant or .simple; (J)) 
 iiiflaiiimatinii ami sii|i]iuratioii nf tlie whole eyehail (oiihlhalmitisj. 
 
 7. I'aralysis of its muscles, allowiuir the jrlohe to (lru|i jurwanl and thus assume an 
 iiiuisual ju'omineiicc. 
 
 l)(MiltIe visiiui is i/i n> niUi/ eniii|ilaine(l of in jirotrusion of the eyehail. 'I'lie ill-effeCtH 
 of tlie aluHU-mal position are seen hoth in the jrlohe itself and in the lids. Shuuhl the 
 protrusion he so ureat that the lids cannot he closed over the eyehail, the eornc^u will he 
 left unprotected, and may hi'come opa(|ue and afterward ulcerate or slou^rh. If the pro- 
 trusion continue for lonjr. the lids hecome distended and tlaccid. their inovemttnts heinp 
 much iujpaired ; the tear puncta may also hecome displaced, Lrivinjr rise to continual 
 wateriiiL'^ of the eye. 
 
 Tkkat.MKNT. — In all eases where the eyehail is healthy care shouhl he taken to pro- 
 tect the cornea from injurious expo.sure hy drawinji the li<ls over it an<l keepin<,' them fixed 
 by a compress and handa<;e, hut in extreme cases the edj;es of the outer third of the lids 
 must l)e jtared. unite<l hy sutures, and allowed to heal firmly together. 
 
 Inflammation within the Orbit. — Inflammation may affect the .soft ti.ssues 
 within tile orhit. the periosteum, or the hone itself; it may end in resolution, the part.s 
 returning to tiieir natural condition ; chronic thickening may result, causing more or less 
 permanent protrusion and impairment of the movements of the eyeball, or abscess may 
 form, and in the case of periostitis or ostitis caries and necrosis of the bony walls may 
 supervene. 
 
 8v.MPT0.MS. — Inflammation within the orljit is accompanied by more or less febrile 
 disturbance, pain of a throl)bing ch.aracter, much increased by pressure, swelling of the 
 conjunctiva and lids, more or less prominence and inijtaired movement of the eyeball, 
 intolerance of light, and watering of the eye; it may be the result of cold, injuries, or 
 general diseases, as erysipelas and (in the case of periostitis) of syphilis, or may come on 
 in debilitated states of the system, during recovery from acute disea.ses (scarlet fever, 
 measles, etc.). or from over-lactation. It is not easy to distinguish inflammation affecting 
 the soft parts only from inflanunation of the periosteum or bone. 
 
 Treat.mext should consist in allaying pain and inflammation by means of opium 
 internally, fomentations of poppy-heads to the affected part, leeches to the corresponding 
 temple (two to six in number), and rest in bed in a darkened room ; any general medical 
 treatment which may appear most applicable should also be employed. 
 
 For instance, if the patient be strong and healthy, low diet, purgatives, etc. should 
 be had recourse to ; if weakly, as during recovery from some acute disease, tonics and 
 good diet should be prescribed. Should the patient be the subject of syphilis, this 
 should be treated. 
 
 Abscess. — Should the inflammation go on to the formation of abscess, the symp- 
 toms are aggravated, the conjunctiva becomes more swollen and in some cases almost 
 covers the cornea, the lids are greatly swollen and red, the prominence and impairment 
 of movement of the eyeball increase, and rigors may occur. Vision becomes misty, and 
 in some cases all perception of light is entirely lost. After a time fluctuation may be 
 detected ; if left to itself, the abscess will burst, the pus being discharged either through 
 the. skin or conjunctiva. The abscess having been emptied, in favorable cases the swell- 
 ing will disappear, the eyeball resume its natural position, and the opening heal. But in 
 some cases, especially if the suppuration be associated with caries and necrosis of the 
 bone, the abscess will remain open or the orifice alone heal, the sac again becoming filled 
 with pus. 
 
 TuEATME.VT. — As Soon as the surgeon feels satisfied of the existence of pus in the 
 orbit it should be evacuated. If fluctuation can be detected, the diagnosis is easy 
 enough, but even if this cannot be done and suppuration is suspected, an exploratory punc- 
 ture should be made, when the escape of pus will clear up any doubt. 
 
 The best method of opening an abscess in the orbit is that recommended by Mr. Hil- 
 ton for evacuating pus situated at a depth from the surface amongst important structures. 
 1 he operation should be performed as follows : An incision having been made, either 
 through the skin or conjunctiva, at that part w^here the eyeball appears most thrust away 
 from the wall of the orbit, a grooved director should be thrust in (the surgeon bearing 
 in mind the direction of the wall along which he is passing the instrument and the depth 
 of the orbit). As soon as pus is seen escaping along the groove of the director a pair of 
 small dressing forceps .should be passed along it until their points are within the abscess : 
 the blades should then be .separated slightly, and drawn out whilst so separated ; a ragged 
 
316 AFFECTIONS OF THE ORBIT. 
 
 opening will thus be left, which is nnt likely to close too soon, and the danfror of cutting 
 important structures will be obviated. 
 
 The greatest care must always be taken not to injure the eyeball. As the operation 
 is very painful, an anaesthetic should be given. 
 
 Immediately after the operation search should be made by means of a probe for dis- 
 eased bone or foreign bodies. If a foreign body or loose sequestrum be detected, it should 
 be at once removed ; diseased bone, if still tirm, may be left to itself, and will either 
 come away spontaneously or may require removal at a later period. If the opening 
 appear inclined to close too soon, it should be kept open by means of a piece of lint 
 passed intd it ; (inly light water dressings need be applied. 
 
 Periostitis or Ostitis followed by Caries and Necrosis of the Walls 
 
 of the Orbit. — The symptoms of periostitis or ostitis going on to caries or necrosis are 
 similar to those above described, excepting, perhaps, that the pain is more severe and 
 often aggravated at night. This form of inflammation should always be .suspected in 
 persons suffering from syphilis, and occasionally nodes may be met with at the margin of 
 the orbit or on the forehead ; their existence should always lead the surgeon to suspect 
 that the inflammation within the orbit is periosteal. When the abscess has formed and 
 burst or has been opened, the seat of inflammation becomes evident from the character 
 of the pus, which is of that peculiar unhealthy and bad-smelling variety met with in 
 abscesses connected with diseased bone, as well as from the condition of the opening, 
 which remains patent and is surrounded by large unhealthy granulations, and from the 
 fact that the bare bone can be felt with a probe passed through the opening. 
 
 Caries and necrosis usually end in recovery after a time, the diseased bone being- 
 thrown off" and the sinus becoming closed. The disease generally attacks the margin of 
 the orbit and often leaves cicatrices, which cause great disfigurement and deformity of 
 the eyelid. Should caries or necrosis occur deeply in the orbit, the results may be most 
 serious, the optic nerve becoming aff"ected and vision lost, or the disease may spread to 
 the interior of the skull, set up meningitis, and cause death. 
 
 Treatment. — In the earlier stages the treatment should be the same as that described 
 under inflammation and abscess of the orbit ; but when the abscess has burst or been 
 opened, its cavity should be syringed out daily with some mild disinfecting solution ; care 
 must be taken to prevent its too early closure, by means of a piece of lint pushed into 
 the sinus; exuberant granulations should be kept down by the application of nitrate of 
 silver, and distortion of the lids, if likely to occur, must be prevented by uniting their 
 edges. (See " Operations on the Eyelids.") 
 
 If any pieces of bone are found loose, they should be removed by operation. 
 
 Hemorrhage into the Orbit. — Orbital hemorrhage may depend upon the spon- 
 taneous rupture of a vessel within the orbit, and, should it be considerable, may produce 
 displacement of the eyeball. The blood may become diffused and appear beneath the 
 conjunctiva, being subse(juently gradually removed by absorption ; occasionally, how- 
 ever, the clot becomes encysted, and permanent displacement of the eyeball results. 
 Hemorrhage into the orbit also occurs in fracture of its walls, frequently to a consider- 
 able extent, subconjunctival ecchymosis being a prominent symptom in some cases of 
 fracture of the base of the skull extending through the roof of the orbit. 
 
 Hemorrhage sufficient to cause displacement of the eyeball has occurred after the 
 operation for strabismus. 
 
 Treatment. — In cases of spontaneous hemorrhage light pressure should be applied 
 to the eye by a pad of lint or cotton-wool and a bandage. Where excessive hemorrhage 
 occurs after operations for strabismus, a large pad of lint should be placed on the closed 
 lids and firm pressure by means of a bandage kept up for a few hours after the opera- 
 tion. Hemorrhage from fracture of the orbital walls is only of secondary importance to 
 the injury which caused it. and may be left to itself; it is of more interest to the general 
 surgeon than to the specialist. 
 
 Vascular Protrusion of the Eyeball. — This is the name applied, and very 
 justly, by Mr. Thomas Nunneley (3Ierlico-Chir. Trans., vol. xlviii.) to a set of cases 
 formerly considered to belong to the class of " aneurism by anastomosis," but which, Mr. 
 Nunneley .shows, differ in many essentials from the latter affection, both in their clinical 
 aspect and history. He has also had opportunities of verifying his diagnosis by post- 
 mortem examination, and in no case has he met with an instance of the above-mentioned 
 affection due to this cause. Mr. Nunneley has reported in all seven cases, and mentions 
 some ten or twelve others described by various writers. The cases reported are chiefly 
 either instances of traumatic aneurism or aneurism arising spontaneously from rupture 
 
r.i.sv77..i/; i'i:nriirsi()S nr rur: j:yi:n.iLL. 317 
 
 III' a ilix'a.M'il aiinv in an cMrrly imTmiii, Imt in one cax- a immcltdus f^ruwtli was tuiiiKl 
 iiivulviiiu; tlu- (nliit ami ollirr |iarls. 
 
 Till' sviiiptuiiis fdinplaiiii'il ol" \i\ tin- |iati<'Mt art- nuiM- in the licail ami fcclinjr uf It-n- 
 Hion, siiiirin^ in tlio cars, pain in the mhit an<l rycball, all of which arc utr;iravate<i by 
 stoopin;;, or cxcrtiim, but arc. nevertheless, most aniioyinj; at ni^ht. These .syinptoiiis 
 arc aecoinpanii'tl by more or less jtrotnisioii and iinpaireil ino))ility of the eyeball, 
 dimness of vision, much conj;estioii, principally venous, of the eyeliils and conjunc- 
 tiva, and chemosis, pulsati(»n ( which may be controlled l»y pressure on the carotid of 
 the .same si(K') in any |)art of the orbit and communicated to the eyeball, and often 
 a bruit heard on auscultation over the lirovv or otln'r parts immediately adjuining the 
 orbit. 
 
 In most ca.ses these symptoms have come on at a varying; time after some injury to 
 the head, or liave occurred spontaneously :ind suddenly. 
 
 The nu)rbid chanires met with in tlie three cases examined after death by Mr. Nuii- 
 neley were, in one (in which the disease commenceil spontaneously, and tlie patient died 
 sixteen days after liijature of the carotid), a dilatation of the carotid at tlie point of giv- 
 ing oft' tlie oplitlialmic branch, the dilatation lieing tilled with and surrounded by coagu- 
 lum ; the oplitlialmic artery itself was somewhat dilated, its coats thickened, and athero- 
 nuitous in parts ; two of its branches were much dilated and filled with clot. In another 
 case, also of s])ontaneous origin, a circumscribed aneurism of the ophthalmic artery clo.se 
 to its origin was discovered. The third case was found to be one of cancerous disease 
 within the orbit associated with cancerous tumors in other parts of the body. 
 
 In the majority of cases of " vascular protrusion " of the eyeball the disea.se is not 
 "within the orbit, but intracranial, the protrusion being dependent on obstruction to the 
 return of venous blood and analogous to the swelling and congestion seen in the limbs 
 when the main artery is aifected by aneurism. 
 
 It is easy to understand how in a small and firmly-bound space like the cavernous 
 sinus a very insignificant dilatation of the commencement of the ophthalmic artery, or of 
 the carotid itself at any point within the sinus, or a small hemorrhage from either, may 
 prove a most serious impediment to the return of venous blood — much more so than the 
 same amount of disease situated in the cavity of the orbit it.self. 
 
 Nicvus, as is well known, is not unfrequently met with in the orbit, but is usually 
 easily enough diagnosed. (See p. 310.) 
 
 A case of traumatic aneurism of the orbit — which is, I believe, unique — came under 
 7ny observation in September, 1873. 
 
 The patient, a young gentleman, was some two months previou.sly opening a hamper 
 in which were some bottles of soda-water; one of these burst, and a large piece of glass 
 was driven with considerable force into the left orbit, inflicting a wound in the upper eye- 
 lid just external to the internal angular process of the frontal bone ; the glass dropped 
 out; sharp arterial hemorrhage occurred, which was stopped by pressure; much swelling 
 and ecchyniosis of the lids followed. The wound healed, the swelling and ecchymosis 
 disa])peared, and all seemed to be going on well ; but shortly before being seen by me the 
 eyeball .seemed to be somewhat protruded and considerable congestion of the eyelids and 
 conjunctiva was noticed. When first seen by me, there was much venous congestion of 
 the eyelids and conjunctiva (no chemosis), marked protrusion of the eyeball in a direction 
 somewhat outward : a small pulsating tumor could be distinctly felt near the inner angle 
 of the orbit ; a marked thrill was communicated to the eyeball, which could be felt on 
 placing the hand upon the closed lids ; a buzzing in the head was complained of, especially 
 on stooping ; there was a small linear cicatrix over the pulsating tumor, marking the seat 
 of the original injury. 
 
 Ophthalmoscopic examination showed an extremely dilated and tortuous condition of 
 the retinal veins, but detected no pulsation ; there was no impairment of vision. 
 
 Pressure on the left carotid at once stopped the pulsation and caused considerable 
 decrease of the venous congestion. 
 
 Aneurismal varix was diagnosed. Perfect rest and pressure applied directly to the 
 part were tried for some months without benefit. It was at length determined by the 
 patient's medical attendant to perform an operation ; accordingly, an incision was made 
 over the tumor, and several fair-sized vessels which appeared to communicate with it were 
 tied. The wound healed kindly. 
 
 I saw the patient again at the beginning of the summer of 1S74. The congestion 
 had disappeared, the pulsation ceased, and the eyeball had returned to its natural po.sition. 
 the only sign of the disease remaining being a small linear cicatrix in the upper eyelid 
 
318 TUMORS OF THE ORBIT. 
 
 and a slight thickening near the inner angle of the orbit in the position previously occu 
 pied by the pulsating tumor. 
 
 Treatment. — Rest, low diet, with depressing remedies, as cold applied locally and 
 the administration of digitalis or antimony, should always have a fair trial. Pressure 
 applied locally by means of a pad and bandage should also be employed if it can be 
 borne. 
 
 These means failing, recourse must be had to digital pressure of the carotid, kept up 
 for .some hours, the patient being under the influence of an anaesthetic, as pressure in the 
 neck gives rise to such intolerable pain that even the most resolute can only bear it for 
 a few minutes at a time. 
 
 As a last resource a ligature must be applied to the common carotid on the same .side 
 as the disease. 
 
 This operation was performed in all but one of ^Ir. Xunneley's cases with the best 
 results. 
 
 Should a case similar to that reported in this article occur, the operation which proved 
 so successful in it sliould be performed. 
 
 ExoPHTKALivnc Goitre (Basedow's Disease). 
 
 This disease is characterized by protrusion of the eyeball, impairment of the move- 
 ments of the lids, and diminished sensibility of the cornea and conjunctiva, accompanied 
 by disturbance of the hearts action and sy.stolic murmurs in the heart and great blood 
 vessels of the neck, together with dyspncea and enlargement of the thyroid body. 
 
 Treatment. — Should the protrusion of the eyeballs be very extreme, ulceration and 
 perforation of the cornea may occur ; this may be guarded against by protecting the cor- 
 nea with a small pad and light bandage applied over the closed lids, or the outer third 
 of the palpebral aperture may be closed by operation. These patients are, however, 
 extremely intolerant of anaesthetics. General medical treatment should also be employed; 
 for this the reader is referred to works on general medicine. 
 
 Tumors of the Orbit, Orbit and Eyeball, and Eyeball alon^e. 
 
 Tumors of the orbit alone are : exostoses, naevi. cysts, nodes, and malignant growths.. 
 Those of both orbit and eyeball are usually malitrnant and commence primarily either in 
 the eveball or some of the other structures within the orbit ; those of the eyeball alone 
 are also for the most part malignant, but simple sarcomatous and cystic growths are occa- 
 sionally met with. 
 
 Tumors of the Orbit alone. 
 
 Exostoses. — These are of two kinds, either hard, ivory-like masses consisting of 
 compact bonv tissue, or soft spongy growths of an open cancellated .structure. 
 
 Bonv tumors are generally met with as hard more or less circumscribed outgrowths 
 of varving size, growing either from the bone itself or from the periosteum. They aifect 
 the orbit alone or mav project into neighboring cavities — a fact which should be borne in 
 mind when attempting their removal. 
 
 Treatment. — Should exostosis of the orbit give rise tr> inconvenience, it may be 
 removed by operation. An inci.sion .should be made, parallel with the margin of the 
 orbit, over the most prominent part of the growth, which, having been thoroughly exposed, 
 should be removed in any way which may appear the most effectual, the greatest care 
 being taken to guard the eyeball from injury, and. if possible, to preserve the continuity 
 of the lachrymal canaliculi and position of the tear puncta. In the removal of the hard 
 ivory exosto.sis the greatest difficulty will be experienced, some hours' patient work with 
 chisel and mallet being occasionally required. The operation can. however, be greatly 
 facilitated by boring through the base of the tumor with a drill worked by a " dental 
 engine." The surgeon who undertakes the removal of such a growth should be aware 
 of the extreme difficulty to be surmounted, and arm himself with a corresponding amount 
 of patience and perseverance before commencing the operation. The soft, spongy growths 
 are much more easilv removed : the tumor, having been thoroughly exposed, can usually 
 be broken off with .^tronir forceps. Should the ^rrowth be on the inner side of the orbit 
 and much force be used in its removal, the cavity of the nose may be opened, and the 
 operator may be rather alarmed at seeing large Vjuantities of air blown out with the blood 
 This accident.however, need occasion no uneasiness, as it makes no difference to the prog- 
 
rvMoiis OF (iiir.ir A.\n i:yi:ii.\ll. 319 
 
 ress <»1' the case; in'VcrllifU'ss, care slioiild always l)c taki-ii not Id rractiiri' the urhital 
 'walls. Sliuuld the IVactuif taki' |ilac-t' in tla* nnif iiistt-atl of in tliu inner wall, the t-on.sc- 
 (|iU'nc('s would Ik' most disastrous, as the cavity <d' the cTaniuiii would lie t»|K'nod. 
 
 N£evi ;H'e not imcoiMinonly nu-t with in or ahout the orltit. situate<l ^reiierally near its 
 niaiLiiii. or in tlie eyelids, hut sonn'times jrrowin^' deeply in the orliital eavity. They pre- 
 sent niueh the same characters as in other situations, heinjr soft to the tou<di. of a lilnish 
 color, and hecominir hanlcr an<l more tense durinjr cryinfr or straining;. 
 
 Tkk.vtmknt. — The n:eviis should, if possilile, he excised. Suhcutaneous ligature is 
 most applicahle in some cases, hut care should be taken t(» prevent, as much as possible, 
 subsei|uent cicatrization, in conse<(uence of the deformity it may jiroduce in or about the 
 eyelids. Other cases may be treated by setting ujt adhesive inflammation within the 
 growth, by the use of the galvanic or other cautery, or by passing a number of small 
 setons soaked in perchloride of iron through its sulistance. The setons should be left in 
 until they have set up a slight amount of sujipuration. Injection of the growth with 
 perchloride of iron, solution of tannin, or chloride of zinc may also be tried ; but the 
 greatest caution is necessary, as the operation has occasionally been followed by the 
 sudden death of tlie patient. 
 
 Cysts. — Various kinds of cysts are met with in and about the orbit, the most com- 
 mon being the congenital dermoid cyst. (See '• Operations on the Eyelids. ') Simple 
 cysts, probably the reniains of hemorrhages, and cysts connected with the lachrymal 
 gland, are also met with. Hydatids have occasionally been seen. 
 
 Nodes. — Periosteal nodes are not unfrequently met with ; they occur as hard, and 
 sometimes painful, tumors, usually situated somewhere about the margin of the orbit, but 
 sometimes deep in its cavity. The existence of a node deep in the orbit should always 
 be suspected in cases of paralysis of any of the ocular muscles, displacement of the eye- 
 ball, etc.. if these symptoms be associated with nodes on the forehead or margin of the 
 orbit and other symptoms of syphilis. Nodes gradually disappear under anti-syphilitic 
 treatment. 
 
 Sarcomatous or cancerous growths may be met with ; and when pos,sible, 
 they should be removed by operation. 
 
 Tumors of Orbit and Eyeball. 
 
 The tumors affecting the orbit and eyeball are malignant growths which have usually 
 commenced within the eyeball and afterward perforated the tunics and implicated the 
 tissues of the orbit. They are generally of the variety known as melanotic sarcoma. 
 
 The appearance of the tumor varies according to the .stage of growth at which it has 
 arrived. In an advanced case a large fungoid mass, of a dirty grayish or browni.sh color, 
 having a foul surface covered in parts with dark scabs, in others discharging thin 
 unhealthy matter occasionally mixed with blood, will be seen protruding between the 
 swollen and distended lids. On clo.ser examination the eyeball (as such) will be found 
 nearly destroyed, portions of the sclerotic abme remaining in their proper position. The 
 movements of the globe are much impaired or altogether wanting, the growth having 
 implicated the whole of the tissues of the orbit in one malignant mass. It is curious how 
 the growth, as it advances beyond the limits of the eyeball, loses its melanotic character 
 and becomes lighter-colored. 
 
 The constitutional disturbance in these cases is often severe, especially when the 
 disease is fitr advanced. 
 
 Treatment. — The treatment of these growths depends much on the extent to which 
 the tissues of the orbit are implicated and the state of the patient's health. 
 
 If the tumor is fairly circum.scribed. so that there appears to be a reasonable hope of 
 removing the whole, and the patient is in such a state of health as to preclude the like- 
 lihood of similar deposits in other parts, extirpatien of the eyeball and other diseased 
 tissues should be performed, any portions of growth that may be left being afterward 
 destroyed by some escharotic. But should the orbit be so filled by cancerous depo.sit 
 that there appears to be little hope of removing the whole growth, more especially if the 
 patient is in a cachectic condition, no operation should be thought of. and the surgeon 
 must content himself with palliative treatment, as opiates to relieve pain and attention to 
 the general health. 
 
320 TUMORS OF THE EYEBALL. 
 
 Tumors of the Eyeball. 
 
 1. Glioma. 
 
 2. Sarcomata, melanotic, round, and spindle-celled. 
 
 3. Carcinoma. 
 
 4. Tubercular deposit. 
 
 5. Pseudo-glioma. 
 
 Glionia is most commonly met with in children, but occasionally in older persons. 
 
 Sarcomata, melanotic, round, or spindle-celled, are usually met with in persons of 
 from fifty to sixty years old, and occasionally in early adult life. The melanotic is the 
 most common form. 
 
 Carcinom.a has been met with in persons past the middle period of life, but its 
 occurrence is rare. 
 
 Glioma occurs mo,st commonly in children ; it commences in the retina and presents 
 the following appearance ; The patient will generally be healthy-looking and present no 
 signs of cachexia ; attention has been drawn to the eye from a peculiar glistening appear- 
 ance of the pupil (cat's eye). On examination, the surgeon will notice the peculiar reflec- 
 tion through the pupil, which is generally somewhat dilated, but movable, in the earlier 
 stages. Examination both by means of the ophthalmoscope and by lateral illumination 
 will show a whitish growth projecting into the vitreous chamber, either as a single prom- 
 inence or in nodules ; the growth will gradually increase, its surface become covered with 
 blood vessels, the retina be displaced, and sight soon entirely lost. 
 
 As the disease progresses the tension of the globe increases ; the pupil becomes 
 widely dilated and fixed, the iris pushed forward and nearly in contact with the cornea, 
 and the lens opaque, preventing a view of the interior of the eye. The whole globe now 
 gradually enlarges, frequent inflammatory attacks occur, the sclerotic becomes thinned, 
 and at last, if the growth is allowed to remain, a slough forms near the centre of the 
 cornea, which ruptures, and a fungoid bleeding mass protrudes. 
 
 The increase of the growth now becomes much more rapid, and it may grow to a 
 considerable size in a short time. 
 
 As soon as the growth becomes exposed to the air it commences to discharge thin 
 sanious pus and blood and becomes more or less coated with a dirty yellow scab. The 
 eyelids become inflamed and swollen, sharp attacks of hemorrhage may take place, the 
 general health suff'ers, and the patient dies from exhaustion or from extension of the 
 disease to the brain. 
 
 Glioma in its early stages is likely to be confounded with tubercular deposit within 
 the eyeball or pseudo-glioma, but it is not likely to be thus mistaken after perforation 
 has occurred. 
 
 Treatment. — The only treatment of glioma is extirpation of the globe, and this 
 should be done as soon as the nature of the disease has been made out ; but, however 
 early the operation may be performed, the disease is almost certain to return either in 
 the optic nerve or in the brain. 
 
 Melanotic sarcoma, or black cancer, affects persons of advanced age ; it is a 
 variety of soft cancer, characterized by the development of black pigment-cells ; it may 
 grow either from the interior or exterior of the eyeball, but generally commences in the 
 choroid. It is said not to be so liable to recur as glioma. Round- and spindle-celled 
 sarcomata also commence most commonly in the choroid. 
 
 Treatment. — Early extirpation. In all cases of excision for malignant growths the 
 optic nerve must be cut back as far as possible. 
 
 Carcinoma, as above stated, is rarely met with. 
 
 Tubercular Deposit. — The appearance of this deposit within the eyeball closely 
 resembles that met with in the early stages of glioma. The patients are usually children. 
 The deposit is in the choroid; there, is the peculiar glistening appearance of the pupil 
 noticed in glioma, and blood vessels may be seen upon the surface of the growth ; the 
 retina is more or less displaced by fluid between it and the choroid and floats in the 
 vitreous chamber. The growth goes on increasing ; the pupil becomes dilated, its mobil- 
 ity is destroyed ; the lens becomes opaque, the sclerotic thinned, the whole eyeball some- 
 what enlarged, and suppuration may occur; supposing the disease to have gone on up to 
 this point, there is nothing by which it can be distinguished from glioma. 
 
 Diagnosis. — Now, however, the difl"erence becomes manifest : the growth, instead of 
 increasing, destroying the cornea, and projecting from the eyeball, commences to shrink, 
 and with it the eyeball, which becomes soft and is at length reduced to a small irregular 
 
IM-I.AMMATlnS AM) sri'l'lllArinS OF Till-: EY KHALI.. :V1\ 
 
 mass. The jirowth of tubercular deposit may lje<'ome arrested at any time, and tlie shrink- 
 in;: of the eyeball commence; in this, a^ain, it ditt'ers from f^lii^ma. 
 
 Ajtpearances somewhat similar to glioma are also produced by inflammatory deposit 
 in the vitreous; the disease has received the name of '' Pseudo-glioma." It is possible 
 to distiniruish the two by the fact that in glioma the anterior chamber is in the early 
 statues of irood depth ; in pseudo-i^lioina it exists only at the periphery. More<n'er, in 
 pseiido-irlioma there are often evident siirns of past iritis and the tension of the globe is 
 below par. 
 
 Tkk.vt.mknt. — Tonics and udod ofiieroiis diet. In all doubtful ca.seH and in tho.se in 
 whiiii there is inuch pain the eye should be incised. 
 
 Inflammation and Suppuration of the Eyeball (" Ophthalmitis,'. 
 
 Ophthalmitis is usually the result of injuries, especially of those complicated by the 
 lodgment of a foreign body within the globe ; it unfortunately not infrequently follows 
 operations for cataract, and is occasionally met with during erysipelas, pyajmia, .scarlet 
 fever, etc., and sometimes in women after confinement, especially if the strength is low- 
 ered by over-lactation. The disease may begin in any of the structures of the eyeball. 
 Should it commence in the cornea and iris, the former will become cloudy, and soon 
 ab.scesses will form in its substance, the iris likewise becoming discolored and covered 
 with pus. The suppuration may stop short here, the cornea and iris being alone 
 destroyed, and the eyeball left with some perception of light. (See '• Suppuration of 
 Cornea " and •• Iris." ) Should the di.sease, however, commence in the deeper structures 
 of the eyeball, rapid impairment of vision will take place, all perception of light being 
 lost in perhaps a few hours. 
 
 If the pupil be clear, pus may be seen behind it, but in most cases all appears dark ; 
 the movements of the eyeball are much impaired and the lids and conjunctiva consider- 
 ably swollen. As the disease advances the eyeball becomes enlarged and its tension 
 increa.sed, and if left to itself will rupture and discharge its contents, much to the 
 patient's relief. The globe afterward shrinks to a small button-like stump. Pain is 
 very severe in many cases, but occasionally is altogether wanting. Suppuration of the 
 eyeball rarely sets up sympathetic changes in the fellow-eye. 
 
 Treatment. — This depends upon the cause of the disease and whether one or both 
 eyes are affected. Should the inflammation depend upon the lodgment of a foreign body, 
 this should be removed without any reference to its position or the state of vision ; if the 
 eye have still good perception of light, it will certainly be destroyed, and, whatever diffi- 
 culties the surgeon may encounter, he cannot possibly make matters wor.se, and he should 
 not hesitate an instant or he will lo.se his chance of preserving any sight that may be 
 left. Any foreign body having been removed, the surgeon's next care should be to 
 relieve pain, and, if possible, check the progress of the inflammation. 
 
 The.se indications are best carried out by the application of leeches (if the patient be 
 strong and can bear blood-letting), by opium internally, and by the constant use of sed- 
 ative fomentations, the best being the Fotus Belladonnae (made by dissolving a drachm of 
 extract of belladonna in a pint of warm water) mixed with an equal quantity of Fotus 
 Papaveris (made by boiling an ounce of poppy-heads in a pint of water) ; a piece of rag 
 or lint soaked in this mixture as hot as it can be borne should be kept con.stantly applied 
 to the affected eye. Poultices may also be employed. Most patients will require the admin- 
 istration of a fair amount of stimulant, good fjod, with iron and quinine. 
 
 AVhen suppuration has V)een fairly e.stablished and all perception of light lost, the eye 
 ball must be treated as an ordinary abscess and the pus let out by incision. 
 
 21 
 
322 
 
 AFFECTIONS OF THE EXTERNAL EAR. 
 
 CHAPTEK IX. 
 
 AFFECTIONS OF THE EAR. 
 
 By Mr. LAIDLAW PURVES. 
 
 :^ 
 
 
 V- 
 
 AFFECTIONS OF THE EXTERNAL EAR. 
 
 Malformations. — The malformations of the external ear which are met with are 
 very varied, extending from cases in which there occurs an entire want of the auricle to 
 those in which the possession of a double set is seen. In cases where the hearing is not 
 affected by the malformation the surgeon may be consulted as to the propi'iety of an ope- 
 ration with a cosmetic view. He must in these regulate his opinion by the usual surgical 
 rules, having regard to any possible interference with the acuteness of hearing which an 
 operation might entail. The most common malformation is a congenital, either partial or 
 entire, want of the auricle, with a failure of the meatus auditorius externus or an occluded 
 meatus, the lobules of the ear occasionally being displaced either on to the neck or cheeks 
 P , J24 ' (i^V/cFig. 124). But the auri- 
 
 cle may be absent from injuries 
 and the meatus closed fiom 
 otitis, lupus, etc. Such defects 
 do not necessarily occasion an 
 absence of the hearing-power, 
 and cases are on record in 
 which patients with this de- 
 fect could hear sufficiently 
 well to hold conversations 
 with those to whose voices 
 they were accustomed. Be- 
 fore deciding to operate in 
 such congenital cases it is 
 advisable to keep the child 
 under observation for some 
 time for the purpose of not- 
 ing if anj' signs of hearing 
 are developed. 
 
 Treatment. — Should it be determined to operate, the .point of operation may now 
 and again be fixed by passing a current of air through the Eustachian tube and noting 
 the point at which the impingement of air at the end of the rvJ-dr-Ritc is heard best. Tliis 
 is accomplished by using what is generally called " Politzer's method" (Fig. 125), which 
 
 consists in passing the soft nozzle of a caout- 
 chouc bag filled with air into one or other nos- 
 tril of the patient, and while he swallows a 
 mouthful of water compressing the nostrils 
 with the fingers of the left hand, so as to 
 prevent the exit of air through them. At 
 the same moment the right hand forcibly 
 ?^>-' expels the air from the bag • in such a way 
 '^^' that, finding no passage open except the Eus- 
 tachian tubes, it rushes up them, passes into 
 the tympanic cavit3^ and pushes out the mem- 
 brana tympani. It is this sudden rush of air 
 against the external wall of the cavity which 
 the surgeon listens for by means of a tube of 
 india-rubber passing from the meatus of the 
 patient to that of the surgeon. In cases of 
 ab.sence of the meatus a stethoscope may be 
 used, by which the surgeon determines at which point the air impinges most forcibly, 
 and at this point he makes his opening. If hard and bony at this spot, the trephine will 
 
 dulous outgrowth on left nostril. 
 
 (Taken^ from a female patient of Mr. Bryant's, 
 
 ' '' " than left, and more defoimed. 
 
 The child had likewise a jien- 
 
 Drawing of Occluded Ears, 
 aged three months.) Right auricle smaller than left, and more deformed. 
 The pendulous bodies contained cartilage. 
 
 Fig. 125. 
 
 Politzer's Method of Inflating the Middle Ear. 
 
AFFIXATIONS OF THF EXTERNAL EAR. 32:3 
 
 be necessary ; it' soft, tin- knife will siifVicc, niakini: ;i cnuial (ijicniri;.' and keeping tlie 
 openinj; patent by means ui' tents or dllicr luivi<.'n lnnlii-s. In (•un;ienital eases tlie open- 
 inj; (intxlit tn bi- made very earet'ully, watcliin^- for the niembrana tympani; l)Ut sbonld 
 there be nii membrane (uiind un enttinj.' down tn the nsual ]ii)sition of sneli, it is advisa- 
 ble to allow the arlilicial opening;- to close a;j:ain. If the deafness before operatinfr is very 
 ^reat, it is pr(d)ably better to diseoimtenanee any operation, as the results of interference 
 with congenital malformations of the ear have <renerally bet-n by no means satisfactory. 
 
 Cutaneous Affections of the External Ear.— Hypertrophy from chronic 
 
 intlaiiini.ilinii. ee/enia (miite and elinmic i, lierpo. iiiipetiL;n, pemphigus, <;rysipelas, affect 
 tlie auricle and have nundi the same appearances, follow the same course, and are amen- 
 able to the same treatment, as in other parts of the body. 
 
 TKKAT>tK.\T. — Particular attention ought to be paid to any skin affection which may 
 be present in the neighborhood id' the auricle, es]»ecially in the hair, careful note being 
 paid to the sort of pomade or other application the patient uses for cosmetic purposes. 
 The meatus auditorius e.xternus ought to be cleared once daily by a lukewarm water 
 injection of any collection of epidermis or cerumen, which is apt to be of a greater quan- 
 tity than niinnal iluring the progri'ss of the skin affection. 
 
 Injuries to the External Ear. 
 
 Injuries to the external ear are by no means rare, but, hajipily, if confined to the auricle, 
 they affect the hearing of the sufferer but slightly, l^ider the usual treatment they 
 generally do well, care being had to make as perfect an adjustment of the 
 parts as possible. In lS(i(i, Mr. Bryant treated a girl of twelve years of *^' ^^' 
 
 age for the effects of an ulceration of the external ear some years previously. 
 The condition of the ear i.s indicated in the accompanying engraving (Fig. 
 120). By paring the edges of the pendulous portions of the auricle and the 
 skin covering over the parts behind, a good-looking entire ear was made, with 
 great addition to her comfort. 
 
 The tumors of which the auricle may be the seat are the 
 oth;omatoiiiatoiis, gouty, fibru-plastic, fibro-cartilaginous. sebaceous, erectile, 
 epitholiomatous, and sarcomatous. The tibro-plastic or cheloid has been 
 already alluded to as occurring in the lobulus of the ear after the operation 
 of puncture. I have seen many such, the largest having been the size of a 
 walnut (Fig. 12S). They generally do well after excision, but if not 
 thoroughly removed will grow again. The otba?matomatous requires special '"^'^'"e 224 \ 
 mention, but the others are to be recognized and treated as in other parts of the body. 
 
 Hsematoma. — Idiopathic hjematoma auris, or vascular tumor of the ear, consists, 
 according to the latest trustworthy authorities, of a degenerative morbid process induced 
 by general disturbances of nutrition. The cartilage of the auricle is its seat, but the 
 pathological appearances differ, as some bave found the perichondrium separated from 
 the cartilage, while others have found " pieces of the cartilage attached to the perichon- 
 drium." In other cases the cartilage has been found thicker but no harder than natural, 
 the thickened part presenting no appearance of a cyst, but under the microscope showing 
 hypertrnphied cartilage cells and intercellular matter. This idiopathic hfomatoma com- 
 mences by a flushing of the auricle, which becomes hot and painful. In a few hours an 
 effusion of blood takes place, which, generally commencing in the concha, gradually 
 spreads over the auricle, feeling firm to the touch, but allowing of fluctuation being 
 detected if looked for with care (Fig. 127). It is believed to be peculiar to patients 
 suffering from dift'erent forms of insanity, general paralysis having the largest share, 
 melancholia, acute and chronic mania, and dementia following in the order named. Dr. 
 Hun thinks that the affection obtains such an exclusive position amongst the in.sane that 
 any one suffering from ha?matoma auris, although sane at the time of observation, ought 
 to be suspected of insanity. 
 
 That the aft'ection occurs in persons Avho bave no hereditary history' and show no 
 symptoms of insanity is undoubted, but whether the pathological changes at the seat of 
 the tumor are the same in those*ca.«;es or differ in the other cases in which there is a his- 
 tory of traumatic injury is yet undetermined, though I am inclined to believe, from the 
 ca.^es which have come under my own notice, that those resulting from injur}- do not 
 arise from the same pathological changes. 
 
 Treat.aient. — The modes of treatment recommended by different authorities vary. 
 Grul)er recommends evacuation of the fluid and coagula and the after-use of a compress 
 
324 
 
 AFFECTIONS OF THE EXTERNAL EAR. 
 
 bandage, while Wendt relates a case where vascular tumor recurred twice after incision 
 but passed off under lead-water applications and compression. I have tried the different 
 methods proposed, once passing a seton through the tumor and keeping up a slight dis- 
 charge from it, and find them get well under all the different methods. 'Since the appli- 
 cation of a.stringent lotions and a compress is less alarming to the patient and .seems as 
 effectual, I am inclined to follow it in future cases, keeping up the compression by a 
 modified letter clip applied to the ear, padding the arms of the clip, so as to prevent 
 injury to the skin of the auricle. 
 
 Report by Dr. Goodhart on Ciieloid Tlmor.s of the Ear. 
 
 The small tumors or thickenings of the skin which usually go by the name of che- 
 loid (Alibert), are of inflammatory nature, with more or less tendency to become fibrous. 
 
 Fig. 127. 
 
 Fig. 1-29. 
 
 Hfenialoma Aiiris. 
 
 Fig. 126. 
 
 Cheloid 1 i,.,,.j, .j, ]:ar. 
 
 Fig. 128 gives the microscopical appear- 
 ances of one of those cheloid tumors, 
 from the pencil of Dr. Goodhart. 
 
 Q- Horny layer of epidermis. 
 Q^ ' Its limit. 
 
 - h Cutis vera. 
 
 Limiting layer of epithelial cells. 
 
 Corium of fibrous tissue with 
 nuclear elements scattered 
 ■through it. They are appar- 
 ently inflammatory, for they 
 do not alter the ti.ssue in any 
 way; they merely lie in the 
 sjjaces. 
 
 Hyaline bands of fibrous tissue, 
 taking the carmine stain well, 
 iiut having no definite struc- 
 ture. 
 
 These drawings (Figs. 128, 129), made from a section of one of these growths in the 
 lobule of an ear which had been pierced for an earring, show the microscopical character- 
 istics. Its macroscopical appearance was that of a fibrous tumor. It will be .seen that, 
 in addition to newly-formed tissue, there is also a great deal of nuclear germination 
 going on. 
 
 Affections of the External Meatus. 
 
 To examine the external meatus, it is usually necessary to employ a .speculum for the 
 purpose of straightening and widening the canal, and so allowing of the pas.sage of rays 
 from a natural or artificial light. The specula are formed of silver or caoutchouc and are 
 of various forms. The silver speculum of Wilde with a round aperture at the narrow 
 end will be found as convenient as any, it being necessary to have three or four different 
 sizes. If available, sunlight, either direct or reflected from a white cloud, is. I think, 
 the best mode of illumination, as it gives different tints of the meatus and tympanic mem- 
 brane more truly than any artificial light. Seating the patient near a window, with the 
 ear to be examined away from the window, you receive the rays on a mirror either held 
 in the hand or placed on the forehead, and reflect them into the meatus by inclining the 
 mirror to the required angle. If you use the rays direct from the sun itself, it is neces- 
 
AFFKCTlnSS nF TIH: FXTFUXAf. AM A'. ;j'Jo 
 
 sarv that a i>laiic iiiirror slioiiM lie tisfd, tin- ii-<iial concave mirror soon causinp; such an 
 aniiMiiil of Ileal to Ik- l«'lt at tlic spot on which tiic reflected rays are tlirown that tlie patient 
 cannot endnre a hdij; examination. Shoiihl sntVn-ienf daylijrht n(»t be olitainalde. an ar;^'and 
 burner, with or witliont a bnll's-eye hintern placed over it, will act as a jrood sulistitute. 
 llavinir arraiiL'ed your flood of li^ht so tliat it falls on the auri<de and external meatus, 
 yon take the superior ami posterior part ol' the auricle between tlie middle and index fin- 
 ders of the left hainl. and, puUinu the auricle backward and upward, you widen more fully 
 the lumen ol" the meatus, into which you introduce, by the rij.'ht hand, the small rouml 
 end of the spe<-ulum. Passinir it irently in by a slii;htly rotating motion, you reach a 
 spot where, there being no foreign body to occlude the view, if the meatus is fif a mjrmal 
 width, the tympanic menibrain> will be expo.sed t<» view. On aceomjtlishing this, the 
 external edge of the speculum is passed to the care of the thuml) and index fingers of the 
 left hand, which move it in diflerent directions, so as to throw rays on the different por- 
 tions of the canal and the tympanic membrane, while the right hand is left free to u.se the 
 mirror, or. placing the mirror on the forehead, to use any instruments which may be 
 necessary. 
 
 The most freipient change in the external meatus which comes befiu'e the surgeon on 
 thus looking into the canal is an accumulation of cerumen, known by its position, form, 
 color, and light reflecti<ui. It occurs on account of some hypenemia of the ear, of which 
 a very common cause is the irritation arising from .scratching the meatus with pencils, 
 pins, etc.; but anvthing which causes an increased flow of blood to the lining membrane 
 of the meatus will cause a greater accumulation of cerumen than normal. It also occurs 
 in those much exposed to the sun and dust, in those who perspire freely, and in the old, 
 in whom the cerumen is denser and stiff'er than in the young. 
 
 Symptoms. — The subjective symptoms caused by such accumulations are pain, vertigo, 
 confusion of ideas, tinnitus aurium, and deafness, the latter .symptom being often character- 
 ized by its sudden entrance and departure. 
 
 PRO(iNOSls. — The prognosis is not so favorable as is generally supposed. If, in the 
 affected ear, a vibrating tuning-fork placed on one of the incisors or on the middle line of 
 the vertex is not heard better than, or so well as, in the non-affected, you may expect 
 some complication, and the mere removal of the cerumen will not probably be followed 
 by much beneficial result to the deafness. Toynbee gives, as the results of his removal 
 of accumulations of cerumen from the meatus causing deafness, a table of 165 cases, of 
 which (iO were cured, 43 were improved, and the remaining 62 were '• either but slightly 
 or not at all improved.'' Mr. Ilinton gives one in six as his proportions of recovery in the 
 same. It will thus be seen that in a large pro])ortion of eases of accumulation of cerumen 
 in the external auditory meatus there is a complication present which does not give way 
 on the removal of the cerumen and which clouds the prognosis considerably. 
 
 Treatment. — If you can easily lay hold of the accumulation by means of the forceps 
 without risk of pushing it against the membrane and without causing pain, it is well to 
 remove it in that way, e.specially if you are removing it for the purpose of obtaining a 
 view of the parts behind which you wish to examine on account of some affection pres- 
 ent, as, should there be some abnormality of the parts behind, the passage of a strong 
 current of water might prejudice them. But should it not be practicable to remove the 
 accumulation by the forceps without causing irritation, the syringe must be used in the 
 manner described in treating of f(U-eign bodies in the meatus. 
 
 A lessening of the secretion is sometimes seen in acute aflfections of the middle ear 
 and in nervous deafness, but before making 3"our diagnosis in such. in(|uiry of the patient 
 as to what he has done to the ear before coming to you is useful in eliciting a good rea- 
 son for the condition found. The use of some slight emollient and attention to the pri- 
 mary cause, if any such is detected, comprise the treatment. 
 
 Foreign Bodies. 
 
 In no department of surgery is the aphorism that " blind zeal only hurts " more neces- 
 sary to be remembered than in that relating to foreign bodies in the ear. The form of 
 the canal is so peculiar, being that of a s})iral turning anteriorly inward and downward 
 and having expansions at either extremity, and the forms of the foreign bodies which 
 enter or are placed in the meatus are so varied, that the cflForts to remove them by any 
 other means than a current of water must be used only where the practitioner is guided 
 by an accurate knowledge of the anatomy of the external meatus if damage to the deli- 
 cate structures which limit the inner end of the meatus is to be avoided. So common 
 
326 AFFECTTOyS OF THE EXTERXAL EAR. 
 
 are forcible attempts to extract by those unaccustomed to meet such cases thai it is 
 exceptional that a case is seen by the surgeon before such efforts have been made as 
 have caused a certain amount of inflammation of the canal and its consequent lessening 
 in calibre. In such, where the calibre has been rendered too narrow to admit of the pas- 
 sage of the foreign body without consideral>le force, the first indication is to allav the 
 inflammation by rest, leeches, and fomentations. The exudation having been absorbed 
 and the canal having nearly or wholly resumed its normal size, the surgeon ought to 
 determine whether there is a foreign body present, and, if possible, its .size. form, and 
 position ; for cases continually occur in which a patient sufiering from chronic disease of 
 the middle ear has the feeling of a foreign body being present, while others are either the 
 subjects of delusion from other causes or are attempting to delude you. This information 
 is obtained by means of the usual mirror, speculum, and probe. Vjy the last of which 30U 
 can determine if the body is hard or soft or moves easily. 
 
 Treatment. — If the last is the case, you may by inclining the head to the side of the 
 ear affected shake it out. or by laying the one hand on the ear a sharp percussion on the 
 
 hand so placed may remove it. But the persevering use 
 Fig. 130. of an injection of lukewarm water from a four- or five- 
 
 ounce syringe, the point of the nozzle of which has a 
 calibre of from one to two millimetres, is the method 
 which ought to be used above all others, which carries 
 with it the least danger, and is by far the most successful. 
 A bowl being held by the patient .so that the rim is 
 pressed against the skin close under the lobule of the ear. 
 the surgeon draws the auricle upward and backward so as 
 to straighten the external meatus, and. the nozzle being 
 pas.sed slightly within the external opening and pressed 
 against the upper wall, a moderately forcible current is 
 made to pass along the upper wall, sweep across the 
 menibrana tynipani. and \)\ it is directed outward, in 
 which latter course it meets with the foreign body, and, 
 carrying it with it. forces it along the lower wall of the 
 Svringing Ear *' Canal and out at the external opening. It may be neces- 
 
 sary so to change the position of the patients head as to 
 give the stream a different direction, according to the po.sition of the foreijrn body in the 
 canal, the endeavor being always to pass the inward current beyond the body, which 
 ought to be influenced only by the outward rush. Should the body be impacted, it may 
 be necessary to loosen it by the probe before you can remove it by the syringe ; but the 
 first injections generally suffice to do this. This failing, which is extremely rare, and 
 the body being soft, you ma}" pa.ss a hook into it from the side and so extract it ; or 
 should it be too large for this, vou may. having fixed it with the hook so as to prevent it 
 passing farther in by your manipulations, pull pieces out of it by means of small kneed 
 forceps and so reduce its bulk sufficiently to extract by the hook. When the body is 
 hard and .so formed that the current cannot have much influence upon it and a hold by 
 forceps or hook cannot be obtained. Lowenberg's method of bringing the point of a camel's- 
 hair pencil armed with joiner's glue or other glutinous material into contact with the 
 body, allowing the viscous substance to harden, and thus binding the pencil and the 
 foreign body together and .so extracting them, is sometimes useful. Many other instru- 
 ments have been proposed to remove foreign bodies, most of which are not worthy of a 
 place in the surgeon's armamentarium : but mention must be made of Wilde's wire snare, 
 which may be found very useful and has the advantage of being very safe, and Mr. 
 Durham's ear forceps, which allows of the passage of the instrument through a narrow 
 speculum — a very great desideratum. 
 
 It may happen that none of the above-mentioned means will enable you to extract 
 the body, and yet the symptoms of pressure on the nervous structures — giddiness, confu- 
 sion, delirium, etc. — are so urgent that removal is imperative. In such you may be 
 compelled to place the patient under chloroform, enter the meatus by loosening the 
 auricle from its superior attachments or throuirh the mastoid process, and so reach the 
 offending body and extract. But resort to such serious measures will only be called for 
 b}- the most pressing symptoms, and then probably in cases where violent unsuccessful 
 efforts to extract have been made, os tlip mffc jjreseuce of a foreign body in tlu external 
 
 Modes of Softening Foreign Bodies. — Before attempting to remove certain 
 
AJThCTFOXS OF TIIF. EXTERSAL EAR. ;J27 
 
 Imdu's it is iicci'ssary t(i |il;ic»' tliciii in a coiiditioii favorahli- tn tlicir rt'iimval or to allay 
 till- uiilicaralde irritation causfil l»y .some of tlieiii. For examplf, a liall of ccruineii may 
 lit' so liaril that no iiistriimciit will pierce it sufticieiitly to j:ivc; the surgeon suflicieiit 
 l»urchase upon it to extract it, or it may he too large to ])ass the isthmus of the external 
 meatus without the use of undue lorce. in sueh you are eompelied to soften it hy 
 repeated soakings in hot water or a solution of glycerine or some alkaline solution before 
 endeavoring to break it up. Again, wlien some small animal has passed into the ear and 
 its movements are causing great annoyance by irritating the excessively sensitive tym- 
 panic meml)rane, it is necessary to introduce toba<-co-smoke or water, (»r a little spirit and 
 water, or <iil. to kill it. and at oni-c allay tlic inilatimi licturc attempts at removal are 
 undertaken. 
 
 Maggots are sometimes found in the external meatus and tympanic cavitv. especially 
 in cases of otorrluea. and are generally dittieult to remove. Should the membrane iifjt be 
 perforated, the syringe will suffice; but, as in the eases in which they are mostly found 
 the meml»rane is ))erforated, the force{)s is found more effectual. To allay the pain gen- 
 erally occasioned by their presence, the itijection of ten drops three or four times daily 
 of a lukewarm solution of a grain of acetate of lead and a grain of acetate of morphia in 
 an ounce of water will be found of service. \'arious kinds of as])ergilli are met with, 
 especially in climates warmer than that of England; but even in Kngland they are more 
 Cfimmon than is generally believed, judging from the cases reported in the medical jour- 
 nals as rarities and worthy of notice. The ap])earance on examining the meatus with the 
 speculum is as if fine meal had been blown into the ear, or as if "coal-dust had been 
 blown on to white sand." The true diagnosis can be made certain by the microscope 
 only. The parasiticides pro])osed are many, but warm water often used or a mixture of 
 spirit and water will suffice in all cases. 
 
 Should it be found, after the removal of any foreign body, that the tymj)anic mem- 
 brane has changed its jiosition and does not of itself recover its normal situation, the air- 
 bag or catheter or the vacuum speculum may be of benefit in assisting you to replace it. 
 
 A piece of wadding should l>o lightly inserted in the meatus after the removal of the 
 foreign body and kept there for some hours, so as to protect the irritated parts from cold, 
 strong noises, etc. 
 
 It ought to be remembered that foreign bodies in the ear may cause many reflex 
 actions, such as tickling in the throat, giddiness, pain and heaviness in the head, vomit- 
 ing, cough and expectoration, sneezing, an;vsthesia of side, epilep.sy. etc. 
 
 Furuncles of the external meatus originate generally in one of the hair folli- 
 cles or in one of the ceruminous glands. They occur mostly as the symptom of some 
 constitutional affection, in which case they are as.sociated with boils on other parts, or of 
 some deeper local chronic inflammatory lesion, and are considered in such as a favorable 
 sign. The long-continued use of astringent lotions, especially of alum solutions, seems 
 to place the meatus in a condition favorable to their formation, if it be not the actual 
 cause in some cases. The symptoms they occasion are great throbbing and pain, conse- 
 quent on the unyielding condition of the skin and connective ti.ssue of the external meatus 
 to the pressure from the accumulating pus, fever (especially during the evening), some- 
 times tinnitus, a feeling of tension in the ear, and more or less deafness, according to the 
 position and extent of the inflammation. They occur at all ages and in all constitutions, 
 but middle age obtains by far the majority of cases. The prognosis is favorable, though 
 you may be unable to check the fornuxtion of new crops, which go on for months, even 
 in the most robust people. 
 
 Treatment. — The treatment is conducted either with a view to arrest the develop- 
 ment of the abscess, or, the formation being complete, to give the pus free exit. The 
 former may be brought about by painting the swelling with a strong solution of nitrate 
 of silver (3ss— 5j to 5J of water) or a solution of sulphate of zinc of the same strength. 
 The latter is best accomplished by a small narrow knife — so narrow in the blade and 
 handle that it does not exclude your view of the part while nuiking a free incision 
 through the boil. After making tlie incision I found it useful to apply a vacuum specu- 
 lum (Siegle's ; see article on '"Affections of the Membrana Tympani ") to the meatus and 
 by suction empty the abscess as much as possible of pus and at the same time obtain a 
 free flow of blood from the wound. The application of moist heat afterward by fre- 
 quently filling the ear with warm water, and laying for half an hour or so a cataplasm 
 over the whole ear so filled, of leeches in front of the tragus if there is much pain, or of 
 a plug of cotton which has been saturated with glycerine (Fisher), changed twice daily, 
 for the same purpose, and the judicious use of purgatives, result in a favorable termina- 
 
328 AFFECTIONS OF THE EXTERNAL EAR. 
 
 tion to the particular boil in question ; but the constitutional treatment must follov/, to 
 prevent, if possible, the development of others. As a local preventive Mr. Hinton con- 
 sidered that the application to the meatus of red or white precipitate ointn)ent was of 
 service. 
 
 Narrowing of the meatus in the cartilaginous portion occurs not unfrequently 
 in the aged, on account of the tense tissue bundles of the posterior and upper walls hav- 
 ing become loosened and sunk forward against the anterior wall. This narrowing seldom 
 leads to complete closure, and therefore does not influence the hearing-power to any 
 extent ; but its presence prevents the normal exit of the cerumen, and so tends to the 
 formation of cerumen balls beyond the narrowed part of the meatus, and their results. 
 Other narrowings besides those which are congenital arise from thickening of the skin 
 after frequent attacks of inflammation of the meatus, after furuncle and other tumors, 
 eczema, and the long use of astringent lotions or ointments. Except in the case of 
 tumors, you may widen the canal by the use of the laminarla (liyitdfa^ or sponge dila- 
 tors, sufficiently to form your diagnosis and apply remedies. 
 
 Treatment. — Treat any aff"ection of the tympanic cavity which may be present. 
 Keep the canal clear of cerumen and epidermis by injections of lukewarm water or the 
 passage of a dry camel's-hair pencil, and by the use of small ivory bougies gradually 
 increased in size, so that the amount of pressure may be kept up, promote absorption. 
 
 Exostoses of the meatus are found in individuals of the gouty, rheumatic, and 
 syphilitic diatheses, though their connection with this last diathesis is not well estab- 
 lished. They are certainly frequent in the meatus of good livers, who are likely to have 
 their mucous membranes frequently congested. On looking into the meatus an elevation 
 is seen, generally about the middle third, the skin over which is reddened and moist and 
 pressure on which by the sound causes pain. 
 
 Treatment. — The treatment is not sati.sfactory unless the exostosis has a pedicle, in 
 which case it may be broken off". In other cases, having paid attention to any aff'ection 
 causing congestion of the mucous membrane of the tympanic cavity, the application of 
 iodine to the growth itself, and behind the ear, so as to keep up a slight counter-irritation 
 for a lengthened time, and the exhibition of it internally, offer the best hopes of resolu- 
 tion. Should, however, the exostosis prevent the exit of pus from the parts internal to 
 it, the formation of a channel by a hammer and chisel, trephine, dentist's drill, or elec- 
 trolysis, and the maintaining of it by tents, may be imperative for the purpose of keeping 
 the parts clean and the application of medicaments to the parts beyond. 
 
 Hyperostosis of the bony meatus is seen after a chronic otorrhoea, and gen- 
 erally extends through the whole of the bony canal. It is caused by inflammation of the 
 periosteum, which results in a well-developed bony formation. The skin along the 
 narrowed portion of the canal is more or less congested. The treatment is that of exos- 
 tosis. 
 
 Molluscous tumors of the meatus consist of accumulated laminae of epidermis 
 and sebaceous matter enveloped in a thick membrane. Though thus composed of com- 
 paratively innocuous material, they have the power of causing absorption of the bone 
 lying in contact with it, passing through it by a clean-cut aperture without affecting the 
 bony sides of the canal thus caused, and so pursuing their course pass to and press on 
 the parts beyond, causing symptoms varying according to the parts implicated. The 
 diagnosis of this molluscous tumor from exostosis is made by pressing a probe on the 
 skin over the tumor and noting the hardness of the enlargement. Laying open the 
 tumor, washing out the accumulated epidermis by the syringe, and withdrawing by the 
 forceps the lining membrane is the treatment recommended. 
 
 Syphilitic affections of the meatus occur as fissures and ulcerations near the 
 orifice, condylomata, and exostoses. The ulcerations exhibit the usual punched-out- 
 irregular contour and discharging surface. The treatment is the usual — general and 
 local. 
 
 Inflammation of the external auditory meatus, or otitis externa, is 
 
 an inflammatory affection of the cutaneous tissues of that canal, involving more or less, 
 according to the violence of the attack, the periosteum of the osseous part of the canal 
 and the membrana tympani. 
 
 Symptoms. — The patient complains of a continual itching sensation, with a feeling of 
 heat and dryness, in the canal, which compels him to pass any suitable instrument which 
 may be at hand into the meatus for the purpose of scratching the part implicated. This 
 irritation may pass off without forcing the patient to seek advice, or it may pass on to 
 one of pain shooting over all the affected side of the head, increased by every motion of 
 
AFFECTIOSS <>!■' Till: nXTlHiXA L I'.M:. • 329 
 
 the li(';i(l or liv iii:i>tii-;iliiiii. ami ;ici-niii|i;mic(| liy a I'l'diiiLr '»!" lulni',-:- in llic car. Iiy fever 
 1111(1 ilt'iifncss. Alter this cdii^ested state lias lasted tor t\V(t or tlir l:i}s. that (if exu- 
 dation ('liters — at. first as a hrijrht watery disehurire. \vlii<di ^rradiially asHiiiiies ii iiiueoiis 
 character; and this in its turn <;ives way t(i a yellow jturiilent a|i|ieararice. Tlu; pain, 
 which till now has heeii usually severe, suhsides when the |iiirulent diseharjre shown 
 itself, or soon afterward, and the jiatieiit feels litihtcr and fre(!r (d' the sensation of '• nunih- 
 ness " or '' fulness " of wliicdi he hefore coni|iIainc(l. A favorahli! terniinatioii without any 
 treatment mav now take jilacc, thoiiirh more fn'(|uently the attccti(»n Itecoines (dironic and 
 the patient sutlers from recurrent attacks on Keiiii:' affected hy any excitin;r cause. 
 
 Al'PKAU.VNCKS. — In e.xamiiiiiiir the ear it is not always easy to arrive at a satisfactory 
 diagnosis, on account of tln^ painful swcllin;^ ol" the canal, wliicdi is particularly sensitive 
 about the middle third and resents the introduction of a .speculum. When you are able 
 to introduce the specuhun sufficiently well to sei; the inner part of the nieatu.s, you may 
 find a mass of moist or macerated white epidermal lanielhc obstructing your view of the 
 membrane, necessitating the careful use (d' the forceps or injection of warm water for 
 their removal. Having removed the.se and obtained a view of the mcmbrana tympani, 
 you find, in those ca.se.s in which that iiHimliraiie is aff"(!cte(l (and it is rare that you are 
 consulted before it is so), the vessels of the membrane increased in number and size and 
 fullv injected ; or if the case has reached a i'urther stage, the single vessels are no longer 
 visible and the whole has a resemblance to a red blennorrlneic conjunctiva. The natural 
 angle formed by the skin of the external meatus and its continuation with the deniKjid 
 layer of the meinbrana tympani is obliterated, or nearly so, by the pressure of the exu- 
 dation inside the cutaneous tissues. But the exudation may be so great and may have 
 so narrowed the canal of the meatus that only a small part of the membrane can be seen, 
 its appearance depending upon the part seen and the stage of the afiection. The acute 
 stage being neglected, it passes gradually into the chronic form, in which there is gener- 
 ally little swelling of the meatus, possibly here and there slightly macerated or pus- 
 covered spots, which bleed easily on being acted on by the speculum, or brown, badly- 
 smelling crusts standing upon half-dried secretions. The amount of secretions vary from 
 a moisture discerniltle at the external opening of the meatus to three or four ounces 
 daily of a high-smelling yellow discharge, and changes by the seasons and other influences. 
 The alarming results of the affection are dependent upon the continuance of this otor- 
 rh(x?a. which, if of long standing, may cause opacity or thickening of the membrane, 
 polypi, maceration of the surrounding tissues, with ulceration of the niemlirane and its 
 conse(|uences. inflammatory and purulent processes in the dura mater and its sinuses. 
 These latter are especially frecjuent in children, in whom the conditions for the transmi.s- 
 sion of such processes are easy. 
 
 The diagnosis of this diffuse inflammation of the meatus from that of furuncle of 
 the meatus is made by means of a speculum in which a small mirror placed at the end 
 of the instrument may be revolved, so as to give the observer a reflected image of the 
 different parts of the meatus in succession, or by means of Blake's small mirrors ; or 
 should neither of these be admissible, by the contraction of the meatus, by the moist 
 appearance of the dermoid covering of the membrana tympani in furuncle, the same layer 
 in otitis externa having the appearance of the re.st of the meatus. 
 
 Causes. — The causes of inflammation are the passing of any acute or chronic exan- 
 themata to the meatus, irritation or injuries to the ear, as by the application of heat or 
 spirits to the meatus, the prolonged use of injections, the pressure of foreign bodies, the 
 passage of cold currents of air or water, the non-drving of the ear and hair round it 
 thoroughly after washing, the presence of fungi, and, in short, anychiiig causing a con- 
 gestion and irritation of the lining membranes of the meatus. 
 
 The affection may run its course in ten or fourteen days if the purulent stage has 
 not been reached, but, that stage having supervened, it lasts from five to eight weeks 
 generally. 
 
 Pro<}N()sis. — The prognosis in a usual primary case under treatment is favorable, but 
 relapses are common. The form following an acute exanthem is very different, as, should 
 the middle ear inflammatory process be well developed and the membrane much affected, 
 the chances of saving an entire membrane are les.sened. 
 
 Treatment. — The treatment is etiological. If there are foreign bodies present, their 
 removal demands your first attention : and after this the prevention of any purulent 
 accumulation and the use of frequent injections of warm water are the chief treatment. 
 Should the swelling be great, scarification of the meatus or an incision and ab.straction of 
 blood by the vacuum speculum seems to be of more use than any other means in causing 
 
330 AFFECTIOXS OF THE MIDDLE EAR. 
 
 a speedy subsidence of the thickened membranes, which you may also assist by keeping 
 up a pressure on the circuniference of the canal b}- charpie gently pressed into the 
 meatus, being careful that the charpie is frequently renewed and the meatus cleared of 
 discharge. Wliat is called " Wilde's incision."' from its having been first brought into 
 notice by Sir William Wilde, is a favorite means of remedy with some, and in the relief 
 of pain or as a means of giving exit to any exudation which may have passed toward the 
 mastoid process is very useful. It con.sists in making an incision down to the bone over 
 the mastoid process at a distance of from half to three-quarters of an inch from the 
 auricle, carefully avoiding, if possible, severing the posterior auricular artery. The appli- 
 cation of leeches in front of the tragus (should the patient be too timid to allow of the 
 abstraction of blood b}' incision or scarification) is advisable where the pain is severe. 
 During the painful stage no strong astringent lotions must be used, those of a .sedative 
 nature being preferred, as morphia in the strength of gr. j to aq. dest. oSS, or sulphate of 
 of atropine gr. ij. to ^j. This stage being passed, the use of the customary astringent 
 lotions — alum, sulphate of copper, sulphate of zinc, in solutions of from one to four 
 grains to the ounce, or nitrate of silver of from ten to twenty grains to the ounce — are, 
 with attention to any complication of the middle-ear apparatus and to the diathesis pres' 
 ent, sufficient to ensure a favorable course. Should the affection have assumed the 
 chronic form, .stronger solutions of the astringents mentioned ought to be employed ; and 
 the keeping up of a counter-irritation behind the mastoid by tincture of iodine, cantha- 
 rides ointment, or other irritant, will be found serviceable. 
 
 Polypus. 
 
 Aural polypi generally show themselves during a chronic purulent discharge from the 
 tvnipanic cavity or external meatus, and are not only caused by such a discharge, but are 
 themselves a means of increasing it by furnishing an additional secreting surface, and. by 
 preventing the exit of the discharge, keeping the parts pressed upon by the pus in an 
 unhealthy irritable condition. They are of different forms and appearances, being of a 
 lively red, rich in blood, soft, and easily bled by touching, or firm and solid with a glan- 
 cing surface, grape-like or ragged, so small that their presence can be determined only by 
 a careful inspection of the deeper parts or so large that they protrude from the meatus. 
 Their po.sitions are as varied as their forms, as they arise from any part of the meatus or 
 tvmpanic cavitv or membrane, the different authorities not being agi'eed as to which are 
 the most frequent sites. Happily, their diagnosis and treatment are the same, the former 
 being their capability of displacement by the sound, and the latter their removal either 
 by caustics, a.stringents. the forceps, scissors, knife, hooks, the galvanic cautery, or Wilde's 
 snare. 
 
 Treatment. — If the polypus is sensitive, which is not usually the case, and the 
 patient will not suffer the removal by instruments, the application of undiluted liquor 
 plumbi or alum or tannin powder regularly for a time, care being taken that each new 
 application meets with a clean surface, will suffice : but the treatment above all others is 
 the immediate removal by in.struments as far as possible and the application thereafter to 
 the root of some caustic, such as acetic, nitric, or chromic acid, by means of a glass rod 
 or piece of wood. The in.struments employed for the purpose are numerous, those which 
 I find most useful being Wildes snare. Durham's forceps, and Hinton"s forceps. Wilde's 
 snare is especially valuable, as by its means you are capable of reducing a polypus to a 
 considerable extent without endangering any of the structures near it. while the others 
 have the advantage of easier adaptation to an excrescence which is difficult of reaching. 
 Should the polvpus be very snlall or .so situated that you cannot use a cutting or tearing 
 instrument, the application of a thin layer of nitrate of silver, obtained by heating a 
 cry.stal of the caustic over the flame of a spirit-lamp and placing a probe or piece of 
 stout silver wire against the heated crystal, will be found useful in cauterizing it. and at 
 the same time limiting the application to the desired spot, which is not so easy when solu- 
 tions are employed. After the removal of the polypus, the disease of which the growth 
 was only a .symptom must be attended to. 
 
 Affections of the Middle Ear. 
 Injuries to the Membrana Tympani. — Eupture of a healthy tympanic 
 
 membrane is usually caused by the introduction of some sharp instrument through the 
 external meatus, the efforts to extract some foreign bodv from that canal, or by a sudden 
 
Mi'iX'TioNs or Tin: middle i:ml 
 
 331 
 
 concussion over tlic auricle, us l>y a blow from tin- liaiid. tlie unexpected explosion of 
 artillery, or such like. Tlie (liu<rnosis of rupture in .mu«-1i is easily ascertaine<l. hut nic<l- 
 ico-lei;al (juestinns sonu-tiines arise in which it is nec»'ssary to ileterniiiie whether a rup- 
 ture was caused l)y a hlow on the ear or was present hefore the hlow was <:iv<'n, or whether 
 the nieinhrane was in such an unhealthy condition that it would he easily injured. The 
 rupture of a healthy ineinhrane caused liy a hlow is usually a lon;r j-'apin;^ tear — the 
 jrapiui: dependinu: on the action (d" the railiatini: fihres of the middle layer — the edj:es of 
 which have a eoatini; of hlood upon them. The rest ot" the mendjrane is healtliy, free 
 (d" thickeniuir, opacities, cretaceous or other deposits, tlnuiirli jiossihlv hvper;«Miiic. On 
 ]>a>sinu: a current td" air throuirh the Kiistaidiian you hear a continuous hroatl .soft sound, 
 unlike the broken hiss from the perl'oratir)n of a <liseased mcmhianc, unless some time 
 has elapsed since the rupture was made, in which case infiltration and exudation nuiy 
 have occurred, <riviii<r the appearances and .sounds (d' a di.seased membrane. 
 
 Prouniksi.'s. — The profrnosis, unless pus has formed to some extent and deafness to a 
 considerable extent is present, is very favorable, and the perforation will be (juickly 
 healed without further treatment than keepin<r the membrane jtrotected from cold. 
 Should, however, considerable deafness and tinnitus have i>ccurred fnnn a blow, either 
 with or without rupture of the membrane, the j)roj:iiosis is unfavorable, as probably the 
 stapes has been driven into the labyrinth, tearinir the nerve fibres and jmssibly remaining 
 fixed there ; and you must keej) the j»atient a leniitliened time under observation before 
 
 giviMLT any oj. 
 
 if what the results will be. 
 
 Fig. 131. 
 
 Appearance of Meiiibrana 
 Tyiiipani. showine the 
 relation of Parts lo each 
 other. ^Kighi ear.) 
 
 Inflammation of the membrana tympani, or myringitis, is probably 
 
 always associated with some affection of the internal or external parts eonti^'nous to it. 
 The diasrnosis and treatment will be found in the description of inflammation of the 
 external meatus. 
 
 In examinin<i the membrana tympani the point.^ to be noted are its color, transparency, 
 lustre, light cone, inclination, curvature, entirety, tension, whether adhesions are present 
 or not, and the position of the malleus, especially of its short pro- 
 cess. For a full description of these we must refer the reader 
 to Politzer's Beleuclitungs/jihfrf (/rs Trommeljilh !m Gexundeit kid/ 
 Kilt liken Znatiriule (Wien, 18G5), but the following short note of 
 changes seen in the nu)st common affections in which it is impli- 
 cated may be found useful in diagiujsis. In acute inflammation the 
 membrane is smooth and glistening, and more or less red according 
 to the amount of hyjtenvnjia present. When the mucous layer is 
 hypertrophied. and accordingly a greater amount of secretion pres- 
 ent than in the normal state, the memljrane is less .shining than 
 natural and has a whitish-gray parchment look. If there is a con- 
 siderable accumulation of mucus which has lain in contact with the 
 membrane for some time, it assumes a sodden appearance, as if the 
 parchment had been .steeped in fluid. The changes of inclination and curvature of the 
 membrane depend upon closure of the Eustachian tube, adhesions to the other walls of 
 the cavity, accumulations of pus. mucus, or tumors, internal or external to the cavity, 
 and perforations or thinnings of the membrane, and can only be diagnosed by seeing 
 numerous cases at an aural clini(|ue. The fact that usually only one eye is brought to 
 bear at a time on the meml)rane makes it difficult for the observer to judge of displace- 
 ment, protrusions, or any changes in which the judging of distance is reijuired till he 
 has accustomed himself to the use of one eve only. 
 
 Chronic perforation of the membrana tympani is one of the most com- 
 mon affections of tlie ear on whicli yijii will l)e consulted. The diagnosis of the affection 
 is easy, either by the speculum, by asking the patient to drive a current of air by a for- 
 cible expiration through the Eustachian tubes, the nostrils and lips being held firndy 
 together — this method being called Valsalva's method — by passing a current of air from 
 Politzers bag. as described under malformations of the external ear. or by passing the 
 Eustachian catheter and forcing a current of air from the mouth or from an india-rubber 
 bag through the catheter. By the.se three last methods you will obtain, the Eustachian 
 tubes being open, a sound more or less of a hissing character, depending upon the rush 
 of a column of air through a small orifice. The usual causes of the perforation of the 
 membrane, apart from those of a traumatic origin, are scarlet fever, measles, tuberculosis, 
 and any greatly debilitating affection in which the mucous membranes are affected. 
 
 Prooxosis. — The prognosis is regulated greatly by the dy.scrasia present, but it ought 
 always to be remembered that a perforation may heal without leaving anv' discernible 
 
332 AFFECTIONS OF THE MIDDLE EAR. 
 
 pathological changes and without in the slightest recognizable degree lessening the power 
 of hearing. The hopes for such a happy result are the greater the shorter the acute 
 attack which has caused the perforation, while it is rare after a chronic affection accom- 
 panied by otorrhcjea ; but no opinion ought to be hazarded till you have carefully washed 
 out the ear and seen the extent of the perforation and losses which have already resulted 
 therefrom. The process of healing is known by a gradual diminution of the secretion 
 and of the perforation, the cicatrix being formed by the dermoid and mucous layers, but 
 of a much more delicate structure than the natural layers and not separable into laminae. 
 The hopes of cicatrization are at an end for the time when the edges of the perforation 
 become cicatrized and a gap still remains, but a new impetus may be given to the regen- 
 eration by any future affection which causes a hyperaemia in the part and a softening of 
 the cicatricial edges of the perforation. 
 
 Treatment. — In the treatment of a perforation the rule is to close it if possible, on 
 account of the exposure caused by the perforation of the tender mucous membrane of 
 the tympanic cavity to cold air or water, dust, and other foreign bodies. These by their 
 irritation may cause a purulent discharge, and that, being once present, may lead to results 
 of the most disastrous nature. But if the perforation have existed some time and be of a 
 considerable extent, the question arises whether the closing of the perforation will not 
 impair the patient's hearing-power ; and before doing anything to close such it is advis- 
 able to temporarily close the gap by a drop (jf glycerine or other thick fluid and note the 
 effects. Should the result be to lessen the hearing-power to any considerable extent, you 
 must carefully consider the probabilities before determining upon your action. While 
 the affection is still in the acute stage, the keeping of the parts clean by gentle injections, 
 and the use of some slight astringents, for the purpose of reducing the secretion of the 
 membrane and bringing it into a more normal condition, are all that are required, with 
 the use of a little wadding in the ear when the patient goes out, unless the weather is 
 very mild, when the latter may be dispensed with. Should discharge be present which 
 by some means has become thickened, and by its presence closes or tends to close the 
 p]ustachian tube, Politzer's operation ought to be done now and again ; and if this is not 
 sufficient of itself, the softening of such an accumulation by an alkaline solution, as bicar- 
 bonate of soda 3ss-.5j to an ounce of water, and then the Politzeration, will suffice to 
 remove it. Should you determine to try to close a large perforation, you carefully and 
 gently stimulate the edges of the perforation by the application to them of nitrate of 
 silver or other irritant, either in solution or by touching the moistened edges with a thin 
 layer of the crystals placed on a probe, as mentioned in the treatment of granulations, or 
 by abrading the edges with a knife, conical file, or plug of wadding turned in the perfor- 
 ation. But if you fail to close it by the growth of new cicatricial tissue, and yet believe 
 that its closure would improve, or at least not impair, the hearing capability, you may 
 resort to the artificial drum, the success of which in some cases is very great. Numerous 
 modifications of artificial drums have been proposed, but the most simple, the most easily 
 applied, and one that is as successful as any other is a piece of cotton-wadding moistened 
 in water or some antiseptic solution and applied over the perforation and lapping consider- 
 ably over the edges. The difficulty of its use is its first adaptation ; but if once applied 
 successfully, the patient can adapt it in future for himself more truly and quickly than 
 his medical attendant. The conclusion as to whether it will be of benefit or not must 
 only be arrived at after several attempts have been made, changing the point of pressure 
 and adapting it more closely to the remnant of natural membrane at different points at 
 each attempt. When it has been used for some time with success, the patient feels it very 
 inconvenient to be without it. If found of service, it ought not to be worn above an hour 
 or two at a time for some days, gradually increasing the duration of its application, but 
 always removing it at night, and the patient should be directed to attend to the most per- 
 fect cleanliness at each renewal of the wadding. How the artificial membrane acts is still 
 a matter of doubt. It is considered that it is a support to the ossicles and membranes, 
 and this is probably its action in the majority of cases. From observations at the differ- 
 ent positions in which it increases the hearing-power, I think it may have also a reso- 
 nating action. 
 
 Artificial Perforation of the Tympanic Membrane. — Having spoken of 
 
 the means of closing a perforation, it is convenient here to speak of artificial perfora- 
 tion of the membrane. The operation is recommended in cases of accumulations of pus 
 or mucus within the tympanic cavity, of impassable .stricture of the p]ustachian, of thick- 
 ening of the membrane, of adhesions of the membrane to the tympanic walls, in case of 
 tinnitus, and in cases where no benefit is derived after prolonged use of other curative 
 
AFFEcTKiSS or Till-: MI />/>/. !■: EAR. 333 
 
 nu':iii> ami the (liauiiusis is iml drar. Iiiit I lie acoustic i.s intl iiiiirl, aflcctcd. That licricfit 
 may he tli-iivt'd in all such cases cannot he denied, hut unha|i|(ily we are not yet in a posi- 
 tii>n to say that |)erroration will henetit this or that case. <'xcc|)t in ca.ses of accumulation. 
 The |niint of operation is th'termineil in ea.se.s of accumulation hy the point of the meni- 
 lM"ane at which huliriii.ir i"< present, while in other cases a spot hehind the maiiuhrium is 
 usually chosen. Hrinuing the nu-mhrano well into view hy the usual niethoil. the opera- 
 tion is made hy means oi' one of the numerous instruments which have heen proposed 
 for t lie pur]tose. If it is merely as an experimental proi-eedinjr to determine whether an 
 openiiii; will he of hiiutit to the hearini:. or for the [(urpose of allowin<r the exit of pu.s 
 or mucus, a small jilain duuhle-edjicd scalpel is all that is required. Having made the 
 openin<: sufficiently large, you renntve all impediments to the passage <if soutid by caus- 
 ing an air douclie to be pas.sed through the cavity by one of the usual methods, having, 
 if necessary, previously softened any accumulations. It being thus empirically determined 
 that a permanent opening in the mend)rane would be desirable, you attempt to keep the 
 opening irom closing by a bougie or l^ditzers eyelet, l»y making the perforation by the 
 galvano-cautery. by removing a j)art of the nuilleus with a ])ortion of the membrane, by 
 the constant use of the air douche, by repeated renicnals of the cicatricial membram.', by 
 digestion with popsine. acids, etc. But as yet no method has been proposed which act.s 
 with certainty <>f success. 
 
 Catarrh of the Middle Ear. — The ordinary nffcctlons <>/ the niidjllt car which 
 tlie general practitioner will be called upon to treat are included under tlie title of 
 "catarrhal affections," and may be of an acute or clironic character. The principal 
 objective .symptoms of acute catarrh are a liypertiemic swelling of the mucous membrane, 
 with an increased secretion therefrom, the pharytigeal mucous membrane near the orifice 
 of the Eustachian tube leading to the affected ear being nearly always implicated. This 
 state of the mucous membrane gives to the observer who passes a current of air through 
 the Eustachian tube and listens by means of an otoscope, one end of which is placed in 
 the meatus of the patient and the other in his own, sounds ranging from a harsh dry 
 sound, like that caused by distending a dry bladder, to a mucous rale. The tympanic 
 membrane varies in appearance, according to the stage of the affection, from that of a 
 glancing polished copper plate to that of a dull wet bladder from which all bright reflex 
 has gone, corresponding to the dry and infiltrated states of the tissues. A more or less 
 obliteration of the malleus may be present, depending upon the passage of the exudation 
 between the layers of the membrane. A bulging of the membrane will be observed 
 should an accumulation of fluid have taken place to a considerable extent. The chief 
 subjective symptoms are a pain in the depth of the ear, which is increased by every 
 motion of the parts, such as by coughing or swallowing, an impairment of hearing, a 
 feeling of heaviness, fulness, or pressure in the ear — often described as " a drop of water 
 in the ear" — tinnitus of various characters, as singing, knocking, or surging, the position 
 of which, whether outside or inside the head, the patient cannot always tell, giddiness, 
 confusion of thought, and other symptoms of pressure. The subacute form is merely a 
 combination of the same symptoms in a milder degree. If the case is properly attended 
 to while in the acute stage, no grayer disturbances of the organism ought to arise ; but 
 it must always be remembered that, the tendency of the affection being to thickening and 
 swelling of the membranes implicated, adhesions and solderings are apt to take place 
 between the closely-situated delicate structures of the tympanic cavity. The general 
 position of such adhesions is between the manubrium and promontory, the tympanic 
 membrane and incus or stapes, the tendon of the tensor tympani and stapes, and especially 
 often in the niches of the two fencstrcB, binding the walls together or to the stapes. 
 
 But should the acute stage be neglected, the acute passes into the chronic form, gen- 
 erally, like the acute, implicating both tube and cavity. It may, however, be localized, 
 and consist in repeated swellings with gradual condensations and thickenings of the 
 mucous membrane, which becomes gradually less elastic, and by proliferation form bands 
 in the cavity. These by their physical (|ualities as well as by their interference with the 
 swinging faculty of the sound-conducting apparatus materially interfere with the hearing 
 capabilities. This chronic form, once established, is most obstinate to treatment and leads 
 to increase of the deafness, which depends more on the locality of the changes than on 
 their extent. It also causes an increase of the .symptoms of pressure, the tinnitus possi- 
 bly becoming so harassing that persons have been known to have committed suicide to 
 escape from it, and often causing such dej)ression by the effects of the vertigo and vomit- 
 ing which it occasions that an inclination to resort to intoxicating fluids is thereby 
 aroused. 
 
334 AFFECTIONS OF THE MIDDLE EAR. 
 
 Prognosis. — The prognosis is generally favorable, but the treatment is prolonged 
 over such' an extent of time that the patient frequently ceases to attend before 
 restoration is accomplished, or aid is not sought in time to prevent changes which, 
 having once occurred, cannot be undone. In these cases we must endeavor to stay the 
 course of the disease-, which, if left to itself, will certainly lead to total deafness. The 
 older the patient the more chronic the affection ; and the greater the changes formed in 
 the tympanic cavity, the less hope is there of a good result. If the tinnitus is continuous 
 and has been present for some time, the prognosis is unfavorable, even although under 
 treatment the hearing-power is improved ; while if nearly total obliteration of the cavity 
 has occurred, especially if chalky deposits are present on the tympanic membrane, a 
 favorable prognosis is almost negatived. 
 
 TREATiMENT. — The treatment, besides the constitutional and hygienic, consists in local 
 blood-letting while the pain and hyper^emia are present, the application of the air douche, 
 the injection of medicaments to the Eustachian tube and tympanic cavity, the treatment 
 of any naso-pharyngeal aff'ection which may be present, and the performance of diff"erent 
 operations on the sound-conducting apparatus. Two methods of passing a current of air 
 into the tympanic cavity through the Eustachian tube have been already described 
 (p. 322). The passage of the Eustachian catheter, used either for the conveyance of air, 
 fluids, or vapors or for the better guidance into and tlu'ough the tube of bougies, elastic 
 catheters, or instruments for electrical purposes, is by no means so difficult as is generally 
 believed. The silver catheter with an obtuse angle of from 110° to 120° is, I find, the 
 most generally useful in the hands of those accustomed to pass it. The caoutchouc ones 
 are apt to break after being used some time, and do not convey to the operator such 
 accurate knowledge of the position of the beak in relation to the structures over which it 
 passes as those composed of metal, although the caoutchouc are less likely to make a false 
 passage in the hands of an inexperienced operator. The patient ought to be placed with 
 the external openings of the nares horizontal and oppo.site to the right shoulder of the 
 operator, Avho, tilting the point of the nose upw^ard by the fingers of the left hand, dis- 
 closes the cavity of the nares more fully, upon the floor of one of which he places the 
 beak of the catheter. Keeping the beak on the floor, he passes it through the cavity and 
 onward across the pharyngeal space till it comes against the posterior pharyngeal wall, 
 which in its normal condition gives him much the same feeling of resistance as he receives 
 on pressing the catheter against the tense open palm of the hand. Drawing the catheter 
 toward him, and at the same time elevating the end which he holds in his hand, he brings 
 the concave curvature of the opposite end against the po.sterior edge of the nasal floor, 
 and then, turning the beak outward and upward, keeping it at the same time against the 
 external lateral wall of the pharj-nx, he will feel it make a slight dip into the pharyngeal 
 opening of the p]ustachian tube. 
 
 The above method is the one usually adopted, but there is that proposed by Bonne- 
 font, which consists in turning the beak of the catheter from the posterior pharyngeal 
 wall outward into Midler's depression and drawing it then toward you till you feel that 
 it has passed over a swelling and then fallen into a depression ; or Lowenberg's, consist- 
 ing of turning the catheter beak inward after reaching the post-pharyngeal wall, drawing 
 it toward you till the curve catches on the posterior edge of the nasal septum, and then 
 revolving it upward or downward toward the lateral pharyngeal wall, when it will proba- 
 bly pass into the tube. If there is a difficulty in passing the catheter through the nasal 
 cavity, it is generally most easily overcome by keeping the beak toward the external wall 
 and passing along it. But should you fail in passing it through the nostril correspond- 
 ing to the Eustachian tube into which you desire to introduce it, by using a catheter with 
 a longer curve you can reach the mouth of the Eustachian tube from the other nostril, or 
 you ma}'^ pass it into the tube from the mouth. You know that the nozzle has passed 
 well into the mouth of the tube by the position of the catheter not being disturbed when 
 the patient speaks or swallows, by the fact that the nozzle will not pass further upward, 
 and especially by the fact that on blowing air into the catheter, either by mouth or india- 
 rubber bag, you recognize its passage into the tympanic cavity of the jiatient by having 
 placed a tube of communication from his meatus to your own. In children the outward 
 turn of the catheter is usually more limited in extent than in the adult, in whom it is 
 generally from a fourth to three-eighths ; but a latitude must be allowed, as the forma- 
 tion of the part varies. In a new patient, if you wish to pass the catheter into the 
 Eustachian tube, it is advisable to try the right side first, as it will be found usually 
 easier to pass on that side, on account of the septum gently inclining toward the left. 
 The mistake generally made is that the catheter is not brought sufficiently forward after 
 
Ari'i:<ri()ss of tiii: Minnu-: ear. 335 
 
 liaviiii: ri'McliciI ilic |iii-liTinr |ili;irvMi:c;il \V:ill. xi tli;it tlic liciik falls info the depression 
 posterior to the opeiiiiij: rif tiie tiilie. Hut tliis may l)e easily averted liy attending to 
 the directions ahove ;:iven as to feeling pressure of the curve on the hack of the septum 
 or soft palate hefore turninir the heak outward. 
 
 Dr. Wchcr-Liel ol" lierlin has lately introduced a small elastic catheter for the jnir- 
 pose of socurinu: the jiassa^e of injections directly into, or the removal of accumulations 
 irom. the tympanic cavity. This is passed throuL'h tin- usual silver catheter as a director 
 to the tuhe, and having- thus, on its exit from the silvti- catheter, obtained a positioti in 
 the tuhe, it is passed on with a little care throutrh the tuhe and into the tympanic cavity. 
 
 The injecticuis ]>assed throuirh the catheter consist (d' preparations of potass, amnioida, 
 iodine, mercury, silver, zinc, atropine, chloral, etc., in solution, care heinir taken that the 
 tiuiil is lukewarm at the time of entrance. 
 
 The fidlowlnt; solutions may he found useful : Sul|)liate of zinc in varyin<r strcntrtlis from 
 one to ten jrrains, of muriate »d' ammonia five to twenty <:rains. of iodide of potassium ten 
 t<» si.\ty grains, iodine one to five grains, chlorate of soda live grains, to the ounce of dis- 
 tilled water. Before using them always see that the tube is pervious and cleared of mucu.s 
 or other removable obstruction to their entrance. They are proVjably mo.st useful when 
 employed every second or third day for from three to eight weeks, after which an interval 
 of a month or more of rest is advisable before continuing their application. The injec- 
 tions through the elastic catheter, passing directly to the tympanic cavity, ought to be 
 much weaker. 
 
 Siiould objections be made to the passing of the catheter, so that you cannot use it in 
 passing fluids or vapors to the ear, the instruction of the patient in doing Valsalva'.s 
 method of inflating the tympanum, by which he may drive steam impregnated with a 
 little iodine and acetic ether, will serve the purpose. The method of doing .so is as fol- 
 lows : Having placed from ten to twenty drops of a solution consisting of e(|ual parts of 
 tincture of iodine and acetic ether in a pint of hot water, the patient inhales a mouthful 
 of the steam, and, having closed the nostrils with the fingers, makes a violent expiration, 
 keeping the mouth and nostrils firmly closed. The .steam by this forcible expiration is 
 driven against the walls of the naso-pharyngeal space and month, and, the Eustachian 
 tubes being the only spots for exit, rushes up these and fills the tympanic cavity, a sensa- 
 tion of fulness, and po-ssibly warmth, being felt in the ear by the patient if the operation 
 has succeeded. This ought to be done several times at a sitting, the patient swallowing 
 between each inhalation. But should the Eustachian tubes be not rendered pervious by 
 the force used, as is not unfrequently the case when the mucous membrane is consider- 
 ably swollen, the catheter must be resorted to, as by the passage of a current from an 
 india-rubber bag directly through the catheter to the tube an obstruction which will not 
 give way to Valsalva's method will be overcome. 
 
 The treatment of the naso-pharyngeal space consists in topical application to the 
 mucous membrane of the space of astringents such as alum, tannin, or nitrate of silver. 
 A very useful form is the drawing of a solution of alum up the nostrils, allowing it to 
 pass back into the pharyngeal space, expectorating it, and then blow^ing the nose violently. 
 When the alum is thought not sufiicient for the condition present in the pharynx, a nitrate- 
 of-silver solution of from 5ss-3j to the o of water applied to the pharynx, and especially 
 to the membrane round the Eustachian regions, will be found a valuable agent. The 
 patient being seated so that good light is thrown into the mouth, and the tongue being 
 depressed by a tongue spatula or the index finger covered by a stall, he is desired to take 
 a deep in.spiration, at which moment the surgeon takes the opportunity to pass the brush, 
 which has been dipped in the solution, to one of the Eustachian regions, and. making a 
 half revolution upward, passes over the whole roof of the space to the Eustachian region 
 of the opposite side. The use of gargles at home between the applications of the caustic 
 is to be recommended. 
 
 Professor Gruber and others use what is called the nasal douche by driving from a 
 syringe the nozzle of which fills one nostril, the other being closed by the fingers of the 
 operator, a current of some astringent solution up one nostril and so into the other, the 
 obstruction to its exit from the other nostril by the fingers regulating the force with 
 which it acts on the pharyngeal walls. But it is so diflicult to regulate that force with 
 the resistance of the p]ustachian tubes that the fluid may pass into the tympanic cavity 
 with such a rush as sometimes to do serious damage, and accordingly I would not advise 
 its being applied by those unaccustomed to its use 
 
 The operations on the tympanic membrane and structures of the cavity are perfora- 
 tion, division of adhesions, and tenotomy of the tensor tympani. The perforation of the 
 
336 AFFECTIONS OF THE INTERNAL EAR. 
 
 membrane has been spoken of at p. 332. The division of adhesions and of the tensor 
 tympani is made by small curved bistouries or by revolving cutting hooks made for the 
 purpose. Those of Weber-Liel and (jruber will be found most useful. The determina- 
 tion of adhesions, with their exact positions, is best made by using Siegles pneumatic 
 speculum, by which, on creating a vacuum in the meatus, you are able to note what part 
 of the membrane is bound down and does not fall into the vacuum with the rest of the 
 membrane. It requires a considerably lengthened experience in aural diagnosis to be 
 certain of the necessity for or advantage to be derived from such operations. 
 
 Otitis media or purulent catarrh is merely a higher grade of inflammatory 
 mucous discharge, but it has always a much more unfavorable prognosis than simple 
 catarrh. The symptoms are much the same as in simple catarrh, but more violent, being 
 accompanied with severe, pain, fever, and nearly always leading to perforation. This, 
 should there be an accumulation of considerable extent in the cavity, is to be desired 
 rather than feared; because, should the membrane not give way, as is apt to be the case 
 in a thickened membrane from chronic catarrh, the pus is apt to find its way through 
 some of the many passages which often exist between the tympanic and cerebral cavities, 
 and so cau.se meningitis. 
 
 Treatment. — The treatment is conducted on the usual principles. Give the pus 
 every opportunity of free exit, either by natural or artificial channels, and thus allay 
 fever and pain and save time and tissue. Leeches, opiates, purgatives, and warm-water 
 injections into the meatus, keeping the Eustachian open so as to have a natural drain, if 
 necessary perforation of the membrane at the point of bulging, and when otorrhoea has 
 occurred regular syringing of the ear with lukewarm water to which an aiitiseptic or 
 astringent has been added, are what are generally found successful. To make the astringent 
 employed pass into the cavity and through the Eustachian tube, it is useful to fill both 
 canals with the astringent, causing the patient to keep it there till you pass a current of 
 air through the Eustachian, on which the fluid in the external canals will rush into the 
 cavity and Eustachian, or by driving a current of fluid with or without medicaments 
 through the Eustachian tube and tympanic cavity from one side or other. In addition 
 to the local treatment, that of the constitution must be attended to. the residence of the 
 patient in such chronic discharges being of especial importance. 
 
 The pus catarrh of children is often most insidious in its progress and may 
 cause great injury before its presence is suspected. Till a discharge appears, probably 
 the ear has not been looked upon as the seat of any disease, on account of the child's 
 inability to localize its pain or tell of its deafness. The screaming of the child when pus 
 has formed is loud and persevering, especially at night, is increased by every movement 
 or concussion of the body, especially by movement of the head, and, above all, by suck- 
 ing at the breast, which at last becomes so painful that the child refuses to take the 
 breast entirely, preferring to be fed by the spoon. 
 
 Treatment before Perforation. — In nearly all the cases of suppuration in the 
 tympanic cavity which come before the surgeon the pus has already made its way 
 through the membrane, and the child is brought to you on account of the discharge 
 from the ear. Should you, however, see the child before the pain is relieved, you may, 
 by the timely use of the remedies mentioned as useful in otitis media and the free open- 
 ing of any enlargement over the mastoid process, with, if necessary, opening into the 
 mastoid itself if there be indications of pus-accumulation there, prevent the destruction 
 of valuable structures. The great cause of the aff"ection is scarlet fever, though measles 
 and typhoid fever contribute largely to the number of cases. 
 
 Treatment after Perforation. — When the acute purulent has become chronic, 
 there is a widespread prejudice amongst both the laity and professional men against the 
 stopping of such a discharge by treatment. This prejudice cannot be too strongly com- 
 bated, as, though in such chronic cases there are generally present slight deafness and 
 only occasionally pain, we can never be certain that complications arising from the con- 
 stant otorrhoea, such as polypi, paralysis of the facial, ulceration, caries and its results, 
 will not occur. 
 
 Affections of the Labyrinth. — The chief symptoms of this class of cases are 
 great deafness, gradually or suddenly acquired, diagnosed by the patient's inability to 
 hear the vibrating-fork when placed on the bones of the skull, vertigo, tinnitus, with pos- 
 sibly nausea, vomiting, and pain. The conditions causing such aff"ections are believed to 
 be hyperaemia of the labyrinth or hemorrhage into it, inflammation of the labyrinth — 
 wliich is generally in children considered under the term of " meningitis" — and malignant 
 affections. But aff"ections of the internal ear are much more numerous as secondary 
 
AFFh'CTFOyS OF TIIF ISTFIISM. FAR. 337 
 
 aff<'ctiiiii> rt'sultinjr I'loiii an cxti'iisioii nt' ilisrasi- (if tin- mnlilli' car, iiicniii^ritis, fevers, 
 tuiiKirs, aneurism, aiiii'inia, livstt-ria, cliililltirtli. or syphilis. Witli tlu; latter, arisirijr from 
 luMvtlitary syphilis, are ;;eiierally seen tlu; syphilitic physioj^tioiny ; and in all the cases 
 wliii'li have yet eoiiM' liefore me in whieh the acoustic was considerably impaired, cliaiiges 
 ill the <lioroid wen' iiivariahly ioiind il' tlie media were .sufficiently dear to allow of a 
 view ol" the retina heinj; ohtained. 
 
 Tkkatmknt. — The treatment, sliniild syphilis lie the cause, is not eiitiiclv liopeless, 
 liut if from other causes is almost nil. Strytdmia, (juinine, morphia, and local remedies 
 have their ditferent advocates. Khu-tricity may he tried, but a suilicicMit nu:nb(;r of 
 earrfiillv recorded cases is still re(|uire<l liefore an opinion of its value can be given. 
 
 Deaf-Mutism. — Hy I'ar the majority (above three-fourths) of the eases of deaf- 
 mutism arise from congenital affections, tlu; n-maiiider resulting from fevers, teething, 
 hvdidct'phalus, convulsions, etc. The hereditary influt-nces are undoubt(!d ; and when 
 such are jire.sent it is often .seen combined with retinitis [tigjiientosa. The pathological 
 conditions found in such are changes in the tympanic cavity with defects in the sound- 
 conveying apparatus, abnormalities in the labyrinth or cerebrum, especially near the 
 fourth ventricle. But the inner ear or cerebrum may have no perceptible changes suf- 
 ficient to account for such a high degree of deafness as is present. The treatment is the 
 careful cultivation of any remnant of hearing which may be present and the placing of 
 the child in an institution for the education of deaf mutes, where by the careful watch- 
 ing of the lips of tlie speaker tliey are able to follow him in conversation, and by a labor- 
 ious teaching of tlie positions in which the organs of speech are to be placed in forming 
 the different syllables they are rendered capable of answering. 
 
SURGERY OF THE CIRCULATORY SYSTEM. 
 
 CHAPTER X. 
 
 WOUNDS OF THE HEART AND ARTERIES— HEMORRHAGE AND ITS 
 
 TREATMENT. 
 
 Wounds of the Heart. 
 
 Although it is quite possible for the anterior mediastinum to be traversed from side 
 to side by a foreign body without any important structure being wounded, it is far more 
 common for some severe lesion to be the result, such as a wound of the pericardium, 
 heart, lung, or of the great vessels. A wound of the pericardium aloue may occur and 
 not prove fatal. Dr. G. Fischer has collected fifty-two reputed cases of this nature, 
 including punctured, incised, gun.shot, and lacerated wounds, of which twenty-two recov- 
 ered. The chief danger of this local injury lies in secondary inflammation of che mem- 
 brane. From a unique preparation shown by Mr. Morrant Baker in May. 1877. at the 
 Pathological Societ}', it would seem that an omental or other hernia may take place from 
 the abdominal cavity through the diaphragm into the pericardium by an aperture the 
 result of some antecedent stab. 
 
 The operation of " paracentesis pericardii '" has been performed with advantage, and 
 generally with the aspirator. The best point for puncture is probably the left fifth inter- 
 costal space nearer the rib below than the one above, and about two or two and a quarter 
 inches from the median line of the sternum. Dr. J. Roberts' of Philadelphia, has tabu- 
 lated sixty cases of the operation, of which twenty-four recovered. When pus exists and 
 can be diagnosed, it may be evacuated by an incision in the left intercostal space below 
 the nipple, and the pericardium drained, as proved by the case of Dr. .S. West, read at the 
 Roy. Med. and Chir. Society, April. isSo. 
 
 W^OIinds of the heart itself are generally mortal, rare instances only recover- 
 ing. Death takes place immediately in about one-fourth of the cases, and in the bulk 
 of the remainder after a few days. The symptoms of a wound of the heart are very 
 uncertain, but the most important, sa3\s Poland, '"is the presence of a lesion in the neigh- 
 borhood of the heart, with extenuil hleeding. followed by all the signs of sudden internal 
 hemorrhage." Sudden collapse is a very general consequence of the injury ; when it 
 comes on some time afterwai'd, it is probably due to secondary hemorrhage from the 
 giving way of the clot in the wounded heart. Dyspnoea^ according to Fischer's analysis, 
 is not con.stant ; in some cases it is immediate and intense. It seems to be due to com- 
 pression of the heart by the eifusion of blood into the pericardium and pleura. The puhe 
 is often unequal, small, and intermitting. Pain is uncertain. The position of the exter- 
 nal wound is a valuable aid to diagnosis, and it is well to remember that the sternal end 
 of the second left intercostal space corresponds to the left side of the base of the heart, 
 and the lower margin of the fifth rib to the apex. In a medico-legal sense it should also 
 be known that " when a person is found dead with a wound in the heart, attended with 
 abundant hemorrhage, it must not be supposed that the flow of blood took place in an 
 instant or that the person died immediatel}' and was utterly incapable of exercising any 
 power" (Taylor). The symptoms as well as the duration of life are much influenced by 
 the direction and size of the wound. Thus, if made in the cour.se of the muscular fibres, 
 there will be little or no hemorrhage, and consequently less collapse and dyspnoea ; but 
 if the heart be cut across, the edges will separate to a great extent and sudden death 
 ensue from the immediate gush of blood. In oblique wounds there will be le.ss gaping 
 
 23S 1 7»v'7(x. Amer. Mffl. Akkoc, 18S0. 
 
H'or.\7>.v or rni: .\irn:i:ii:s. ;;;}9 
 
 c»t" the I'dj^fs. With ri'sjtfct to tlic cuso of rt-covci y, S:m.»oii has recorded an iristaiicc in 
 whifli :i cicatrix in the heart was found some h-n;rthencd |)eriod after the receipt of a 
 wound from which the patient liad recovered in twenty-ei;_'ht days. Velpeau has cited a 
 second, of a man aj:ed ."»(>. who died nine years after having' received a wound in the left 
 side of the chest from a tahh' knife, and in whom the jierieardium was found hirjrely 
 opened and adherent to the parietal cicatrix, while fihrous lines traversed the wlnde thick- 
 ness of the riirht auricli- at a point corresponding to the hreach of surface in tluj [)eri- 
 cardiiini. In the Maiicni Tini>s nml (in:., of April 4. 1S74, a case is also reported of a 
 
 Captain H . set. 4(1. who died from dysentery, and after death a leailen bullet, which 
 
 had (-ntered tlie chest above the nipple eleven years previously, was found encysted out- 
 side the pericardium, between the orijrin of the juilmonary artery in front and the a.scend- 
 ing part of the arch of the aorta behind. The heart may also be lacerated by a severe 
 contusion or pressure upon the chest without external wound or fracture of the ribs. 
 (Thus at (luys there is ii prep., 140(P, in which both auricles of the heart are lacerated 
 with the pulmonary veins, which was taken from a child aged four, over who.se back tlie 
 wheel of a cart had passed. There is also another in the Koyal College of .Surgeons of 
 Edinburgh which demonstrates this {loint.j. The diagnosis and treatment of thi.s form 
 of injury are the same as in ca.ses of wounds. 
 
 Tkkatment. — As hemorrliagc after a wound of the heart is the main fear, .so to pre- 
 vent and arrest it should be the chief aim. With this object absolute repose is essential, 
 and the local and general employment of cold should be maintained throughout the case. 
 To calm the excited action of the heart, belladonna and digitalis have been recommended, 
 and so, even, has venesection. The diet should be nutritious, but unstimulating. W^hen 
 the pericardium is full of blood, it has been suggested to lay open the cavity to let it 
 out ; but the uncertainty of diagnosis is sufficient to forbid the attempt. For further 
 information on the subject I may refer to Poland's article in HolmeiCs Snrgnnj., which con- 
 tains an admirable analysis of Fischer's paper; also to a paper by West in the »SV. 
 
 T/lonnls's Ifnsj,. Rr/... ISTO. 
 
 Wounds of the large vessels of the chest are generally fatal, death being 
 immediate in most cases from internal hemorrhage. Dr. Heil, however, records a ca.se in 
 which a man. after receiving a stab which penetrated the aorta, recovered and lived a 
 year. Pelletan also cites another, in which a man was run through with a foil, which 
 entered the chest above the right nipple and came out at the left loin ; yet no violent or 
 marked .symptoms followed the accident beyond constant pain in the loins. Two months 
 later he suddenly died in great agony from hemorrhage into tlie right side of his chest, 
 and after death an opening the size of a quill was found in the aorta above the diaphragm. 
 The Hunterian Mu.seum (No. 1565a) contains a specimen of the a.scending aorta of a 
 sailor, in which was lodged a bullet in a piece of integument surrounded by lymph. The 
 wound was produced by a rau.sket-ball pas.sing through the diaphragm and pericardium 
 into the aorta ; it entered the chest between the eighth and ninth ribs and was followed 
 by a rush of blood. All hemorrhage, however, very soon ceased. The man lived three 
 days after the injury. 
 
 Wounds of the Arteries. 
 
 When an artery is romphtclj/ cut acrosx, bleeding takes place and the blood jets forth 
 per .saltuni, as it is called, with each pulsation of the heart. Pulsation in the ves.sel 
 below the seat of injury is likewise lost. The blood is usually of a bright-red color 
 unless the patient be asphyxiated or fully under the influence of some anaesthetic, when 
 it is often as black as venous blood. Pressure upon the artery above the wounds arrests 
 or diminishes the hemorrhage. When an artery is ouli/ p(u-tiuUi/ wounded, either trans- 
 versely, obliquely, or longitudinally, the bleeding will probably be less profuse ; and the 
 blood rarely jets out as from a divided vessel, but wells up in a deep wound or flows in a 
 continuous stream, after the manner of venous blood. When the blood is red, its arterial 
 nature can easily be recognized ; but when black, its recognition is more difficult. Should 
 pressure, however, above the wound arrest the flow and pulsation in the vessel below the 
 wound be lost, the probabilities of the blood being arterial are strengthened. It is an 
 important fact to bear in mind that when a large artery is partially divided just befow a 
 large anastomotic branch, bleeding will take place from the lower end of the wounded 
 artery, as well as from the upper, and pulsati«m in the vessel below will only be dimin- 
 ished. 
 
 When hemorrhage takes place from a large vessel, it is generally, unless instantly 
 checked. ?.o profuse as to destroy life rajiidly. When from a small, it is less copious and 
 
340 
 
 NA TURA L -H.EMOSTA TICS. 
 
 has a natural tendency to stop — at any rate, for a time — and to give an opportunity for 
 natural haemostatics to take effect. 
 
 Whatever favors retraction of a divided artery and its contraction tends to arre.st bleed- 
 ing ; whatever hinders these processes prolongs and increases it. Thus, vessels that 
 traverse loose textures cease bleeding more readily than others circulating through those 
 that are close and compact, such as the integument of the head and sole of the foot ; and 
 bleeding from an inflamed or rapidly-growing part is checked with greater difficulty than 
 that from other tissues. 
 
 The size and form of the wound in the vessel have also inucli to iId with the result. 
 A puncture in the axis of a large artery may heal by natural processes and be unattended 
 by much bleeding ; a small vertical wound may likewise close, whereas an ohlique wound 
 will gape, and is consequently attended with copious bleeding ; while a transverse wound 
 is of all others the most dangerous, on account of the difficulty of controlling hemorrhage 
 and the improbability of natural hfemostatics unassisted by art acting with any perma- 
 nent advantage. The retracting power of the vessel tends to cause gaping of th'e wound 
 rather than closure, and encourages rather than checks bleeding. 
 
 It is well, therefore, to consider now how wounded arteries heal and by what means 
 bleeding can naturally be arrested. 
 
 Repair of Wounded Arteries.— Small wounds of arteries may heal by 
 immediate union or primary adhesion, and larger may likewise for a time be' closed by 
 the clot of blood that covers the wound, or even by .some .stronger reparative material ; 
 but " the closure of a wound in an artery is often ineffectual or only for a time, and fresh 
 bleedings ensue, either increasing the accumulation of extravasated blood or pushing out 
 the clots already formed. In this manner, with repeated hemorrhages at uncertain inter- 
 vals, the wound in an artery is often kept open, and at the end of two or three weeks 
 may show no trace of healing, but rather appear widened and with softened everted edges. 
 In such a case it is possible that the wound in an artery may still heal by granulations, 
 either rising from its edges or coalescing over it from adjacent parts, but the event is too 
 unlikely to justify the icaitinrj for its occurrence if there be opportunity for surgical inter- 
 ference ; and even if healing should go so far as to close the opening in the artery, yet 
 is it likely to be insecure, for both the elastic tissue and the smooth-fibred muscle on 
 which its strength largely depends are very .slowly formed in scars. Hence, a form of 
 traumatic aneurism seems not very rare in which the sac is chiefly formed of scar tissue 
 which closed the wound in the artery and then yielded to the pressure of the blood." 
 
 Thus a partial is a more serious injury than a complete division of an artery, and 
 requires as prompt surgical treatment, because the means adopted by nature for the 
 permanent arrest of bleeding in a divided vessel are acting at a disadvantage, and are 
 rarely effectual in one only partially wounded. In practice, therefore, the surgeon, by 
 the complete division of a partly divided vessel, often gives natural haemostatics a fair 
 chance of effecting a cure. Hemorrhage from vessels of small size, as a rule, ceases 
 after the first rush, or, at any rate, as soon as nature's proces.ses for controlling bleeding 
 have had time to act. Indeed, " gradually, with or without surgical help, all the vessels, 
 divided by a wound are clo-sed and cease to bleed, the larger being often aided to this end 
 by their retraction among the looser textures, by the coagulation of the blood within or 
 over their orifices, and by the diminution of the heart's force with 
 the increasing loss of blood. Coincidently the flowing blood becomes 
 gradually brighter and paler. And if the wound be left open after 
 ■ pure blood has ceased to flow, there is an oozing of blood-tinged 
 serous-looking fluid, and this is gradually succeeded by a paler fluid, 
 some of which collects like a whitish film on the surface of the wound " 
 (Paget). 
 
 Natural Hemostatics. 
 
 Fig. 13-2. 
 
 In a Divided Artery. — When an artery is divided across, five 
 things happen : (1) The divided ends (Fig. 132 (?) retract within the 
 .sheath (a), and (2) by contracting diminish the calibre of the canal ; 
 (3) Blood coagulates in the sheath (a) around the orifice of the divided 
 vessel, and (4) in the artery itself (b) up to the first large branch (e) ; 
 and, lastly (5). plaxtic lymph is poured out from the divided coats of 
 Natural Hieuiusiatics. ^'^^ vessel, and by its organization the permanent closure of the vessel 
 takes place. The clot subsequently becomes organized and contracts. 
 In a large proportion of the cases of divided arteries these natural haemostatic pro- 
 
.S7 IK! K : I /. ll.KM'isr. I TK 'S. 
 
 ;ui 
 
 cesses arc aiiij 'c >>{' tliciiisflvfs lar the arrest of hlecdiiiL'. wliile it is only in the lar^rcr 
 arteries tliat aiiv siirL'ieal or artilieial aids are re(|iiired. 
 
 In Torn Artery. — W'Jhh oh arfin/ is torn across, t\ni saiiie eliaiijres take place ; 
 hut titii/ itrt vtirrinl out to (in mliuintatjf, as the streteliiii;: or t<trsioii <»!' the vessel hel'ore 
 it <rives way eiifourages itn ^^ ntriirtion '^ and '■'■ rout ror.l Ion ^' atid the hieerated ed^cs <if* 
 the vessel help the eoa^Mjlatioii (if the hlond. It thus happens often that siieli large 
 arteries as the femoral and hrachial may lie torn asunder and ii<t l(lee(liri<r follow, 
 and whole limits avulsed from the trunk without hemorrhage. The lacerated ves.sel 
 apjH'ars under these circumstances as if drawn out, with its external elastic tunic 
 stretched into a conical form ovt'r the imicr 
 
 coats that have been divided and ri'tractcd. An Vu;. V.V.',. Vm I."4. 
 
 artery, however large, divided l»y laceration 
 or torsi(»n conser|uently rarely bleeds ; and it 
 was the oliservatiun of this fact that suggested 
 to Anuissat the idea of practising torsion of an 
 artery. 
 
 In a Stretched and Contused Ar- 
 tery. — 117/' /( (III iirti 11/ /.s- cnii/HS'i/ or so 
 .stretched as to .suffer s(unething less than 
 complete rupture of all its coats, it may be- 
 come obstructed ; and this obstruction is proba- 
 bly caused by a more or less complete circular 
 laceration or breaking up of its inner tunics, 
 for the different museums contain prejiara- 
 tions which prove that an artery so treated, 
 when apparently maintaining its continuity, 
 may have a complete circular laceration of its 
 inner coats, a separation of these coats from 
 the external cellular one, or an incurvation of 
 these tunics into the lumen of the artery, as 
 
 in torsion f B. Figs. Vo.j. 13-i), the deposition Laceration und Recurvation of Intprnal Cats of an 
 
 of clot subscouentlv taking place within the -V'^^^'fr^'V Kx'ernal injury (Takeiifron. prepara- 
 
 i . . ' 1 tions now in the Museum ot th'> .Middlesex lios- 
 
 meshes of the divided coats, and, as a COnse- pital by the kind permission of the surgeons.) 
 
 quence, the complete occlu.sion of the vessel. 
 
 I have known this obstruction to follow many injuries, and have seen the external 
 iliac artery obstructed in a case of a broken pelvis, in one instance followed by gangrene 
 of the lower extremity, and in a second by cure. I have also known the common and 
 the superficial femoral artery, the axillary and the brachial arteries, to become perma- 
 nently closed in a similar manner. It is a question, indeed, whether, as a result of con- 
 tu.sion, adhesive inflammation ever takes place in an artery to cause its occlusion without 
 some such laceration of its inner tunics as has been described. 
 
 Sometimes a vessel will rupture, some days after the injury, at a part that has been 
 severely contused, causing a secondary subcutaneous hemorrhage and the sensation of 
 something giving way. Such a result, however, is rare in civil practice, although in 
 military, from gunshot wounds, it is more frequent. The bleeding, under such circum- 
 stances, occurs after the fifth day. Cold lotions will generallv suffice to induce aV).sorption 
 of the Vjlood when the hemorrhage is slight, although in some cases the fluid blood may 
 be drawn off with a good result. In exceptional ca.ses an aneurism may form and require 
 treatment. 
 
 Surgical Hemostatics. 
 
 It has been asserted that by natural processes alone divided vessels are permanently 
 sealed and arteries in continuity occluded ; it will be well, therefore, to in(|uire into the 
 modes of action of the different means which the surgeon has at his disposal to bring 
 about these results, since it may be stated in limine that the means are to be regarded as 
 good in so far as they aid and turn to account the natural proces.ses that have been 
 described. 
 
 Thus, the exposure of, and the appJirntion of cold to, a divided artery favor its 
 '•contraction.'' this physiological explaining the practical fact that on the free opening 
 of a wound hemorrhage often ceases, never to return. 
 
 Pressure upon the end of a wounded artery favors '• coagulation"' in the vessel, and 
 the value of acupressure rests mainly upon this j>rinciple, the pins and pressure mechan- 
 
342 
 
 5 UR GICA L HjEMOSTA TICS. 
 
 ically arresting the flow of blood, wliilst coagulation is taking place in the vessel up to 
 the first branch. 
 
 When (I lujatnrc is applied firmly to an artery, the inner coats are usually more or less 
 regularly divided and the outer is so constricted as to arrest the current of blood 
 
 through the vessel. The blood thus arrested consetjuently 
 coagulates and forms a clot or thrombus, which is, as a rule, 
 conical, with its base toward the ligature and apex pointing 
 to and reaching the first branch (Fig. 135, h). This clot sub- 
 AK'J^Jiy/iiH.-s sequently contracts and becomes organized. The inner and 
 
 7 ''l^P 1^^, \ middle coats, from their divided edges, pour out (f) plastic 
 
 lf!3i.-. -V \ lymph, which heals the wound and eventually cements to- 
 
 gether the outer and inner coats and the clot into one homo- 
 geneous mass ; and if in the sequence of events nothing (oc- 
 curred to interfere with the steady evolution of this reparative 
 process, all would indeed be well, but unfortunately such is not 
 always the case, ftr the ligature has often to come awav. To 
 this end the outer coat of the artery, where constricted, must 
 slough or ulcerate, and the vessel itself, in either case, at the 
 line of ligature thus becomes divided. By such action, there- 
 fore, what nature by the processes already described might 
 have well done too frequently becomes undone ; and unless a 
 firm clot has filled both ends of the artery or plastic lymph 
 become organized around the divided coats, the risks of secon- 
 dary hemorrhage are very great. It is this fact which makes 
 the practice of arresting hemorrhage by means of the silk, 
 hemp, or wire ligature so unsatisfactory. To Stilling and Dr. 
 J. F. D. Jones, 1805, we are indebted for most of our know- 
 ledge on these points. 
 
 When the carbolized prepared catgut ligatures are em- 
 ployed, the primary eifects of the ligature are the same as 
 with the permanent (wu/e Fig. 135 ; Trans, of Clin. Soc. 1878), 
 but the secondary changes which have been described do not 
 of necessity follow. The prepared catgut ligatures, conse- 
 quently, may be regarded as temporary ligatures which may 
 either dissolve within a few days of their application or be- 
 come loose. If, therefore, an aj-tery to which such a ligature 
 has been applied does not become permanently closed by natural haemostatic processes 
 before the ligature has dissolved or become loose, the circulation through the vessel may 
 be restored or secondary hemorrhage may ensue ; and this accident has occurred. The 
 
 prepared catgut ligature is not, therefore, so safe as 
 torsion for divided arteries. It is, however, a safer 
 ligature than the silk or hempen, as it does not, like 
 the latter, of necessity require an ulcerative process 
 for its discharge. 
 
 Barwell's flat ox-aorta ligature occludes an artery 
 by mechanically holding its coats together, and its 
 safety depends upon the coagulation of the blood in 
 the artery and its power of holding long enough to 
 give time for the organization of the clot. With it 
 there is no division of the inner coats of the artery. 
 I do not, therefore, believe it to be as safe as the pre- 
 pared gut or silk ligature. 
 
 The Effects of Torsion on an Artery.— 
 
 Wlien an artery is closed hy what i< termed torsion, the 
 Effects of Torsion upon an Artery, showing i^^er coats are ruptured (Fig. 13(), B and c), and the 
 
 the Incurvation and Laceration of the outer (a), when not twisted off", closed by the tWlStS tO 
 Inner Coats. (From paper bv the author, i • i -^ i i i.- ^ j t> ^ j.\ • „,.,*„ 4„ 
 
 Med-ciiir. Ti-ans., is6s!) " which it has been subjected. But the inner coats, in- 
 
 stead of being simply divided in a linear manner, as 
 occurs when the ligature is used, become ruptured, separated from the outer coat, and 
 incurved, their divided ends turning into the vessel and in the most perfect examples 
 forming complete vessels not unlike the semilunar valves of the heart. The blood, which 
 is consequently arrested by this valvular incurvation of the inner tunic, undergoes changes 
 
 Effects of Carbolized Catgut Liga- 
 ture on Common Femoral Ar- 
 tery. (Taken from a girl tet. 19, 
 who died on the twentieth day, 
 from gangrenous leg, after the 
 application of the ligature to the 
 arterj' for elephas. The ligature 
 in this case was firmly attached 
 to the vessel and had acted upon 
 its coats as a permanent liga- 
 ture.) 
 
 Fig. 136. 
 
oy Ji F.MnnnuMii: .\\/> //s treatmkst. 343 
 
 pn'cist'ly MJinilar to tliosi' alrcaily ih'scrihcd. I'la.stic lynipli Ih poured out by tho divided 
 tuuic's ill the sunie way as has been shown in the application of the lijjature, and it acts 
 the same part in cementing all the arterial tunies and clot together. Between the two 
 forms of practice. hi>wever, there is this difference — that where the pi;rmanent ligature 
 has hi'cn use<l ulceration of tlie vessel is prone to occur to allow of its escape, and thus 
 may undo all that nature has floiie to seal the artery and prevent hemorrhage; when'aH, 
 when torsion has been effieiently perfnrnieil and the heinrjrrhage arrested, no sub- 
 se(|Ui'nt action is lialjle to undo the good work that has been done or to hinder the 
 permanent closure of the vessel. With both ligature and torsion natural luemostatics 
 are aiiled in their work, but with the former the ulceration set up by the ligature may 
 materially interfere with the perfection of the jtrocess, while with the latter there is 
 n(»thing to jirevent the proces.s going on to its completion. 
 
 On Hemorrhage and its Treatment. 
 
 When bleeding takes place rapidly from a wound after an injury or operation, it is 
 called primary; when it occurs on reaction from shock within twenty-four hours, or in 
 rare cases within two days, it is called recurring or intermediary; and when after 
 a lajtse of a longer period, secondary. 
 
 The /in'iiiiiri/ is due to tlie ilin-et injury of the vessel ; the recurrin;/, to the increa.sed 
 force of the circulation during reaction and the displacement of clots that were sufficient 
 to seal vessels when the circulation was feeble, to the overlooking of a ves.sel during the 
 dressing of a wound, or to some imperfection in the mode of securing it at the time of 
 operation. The seromfdn/ is caused by the giving way of an artery or vein, by ulceration 
 of the ligature, by slouirhing of the vessel alone or with the tissues around by the acci- 
 dental separation of a ligature, injury, or owing to the hemorrhagic diathesis. 
 
 When blood escapes from a wound externally or into a cavity, the term hemorrhage 
 is applied; when it is effused beneath the integuments or amongst tissues, extravasation 
 or e(f'iis{on is said to occur. 
 
 The SYMPTOMS of external hemorrhage require no de.scription, the slow flow or the 
 stidden gush of the lifes blood being recognizable by all. Tho.se of concealed inter- 
 nal hemorrhage or extrava.sation require, however, .some attention. They are those of 
 local injury pfus those general symptoms which denote hemorrhage generally. 
 
 '• In slow and in sudden hemorrhages." wrote John Bell .seventy years ago, " the 
 symptoms are very different. In the former the patient is very slowly exhausted ; at 
 each return of bleeding the patient faints and is laid in bed and the cold applications and 
 the fainting save his life. He rises, after some days. pale, languid, and giddy. The 
 pulse flutters and is hardly to be felt ; the breathing is quick and anxious, accompanied 
 with sighing and great oppression : the heart palpitates on the .slightest motion, and the 
 slightest inclination of the head or rising suddenly from the couch endangers fainting. 
 The voice is low ; the eye is languid, colorless, and of a pearly white ; the flesh feels soft 
 and woolly, and the skin is pale, yellow, gelatinous, and, as it were, tran.sparent, like 
 modelled wax. After this stage of weakness the blood loses its color ; from this time 
 forward it is a bloody serum only that distils from the vessels ; dropsv appears and the 
 slightest loss of blood proves fatal. But when the patient expires suddenly bv an impet- 
 uous bleeding from some great artery, when he dies of the bleeding from a femoral 
 aneurism, when he is wounded among the vLscera and some great vessel is pouring out 
 blood, the blood in the general circulation, in place of being forced onward by the con- 
 tractions of the arteries, runs backward toward the wound from all parts of the 
 body. The arteries no longer push on the contents of the veins ; the blood cea.ses to 
 "flow toward the heart : the heart ceases to act, and the countenance assumes, as in 
 asphyxia, a livid hue. from want of circulation. The face becomes all at once deadly 
 pale; the circle round the eyes is livid, the lips are black, and the extremities are cold. 
 The patient faints, revives, and faints again, with a low and quivering pulse ; he is sick 
 and his voice is lost. There is an anxious and incessant tossing of the arms, with rest- 
 lessness, which is the most fatal sign of all. He tosses continually from side to side : his 
 head fiills down in the bed ; he raises his head at times suddenly, gasping, as it were, for 
 breath, with inexpressible anxiety ; the tossing of the limbs continues ; he draws long 
 convulsive sighs : the pulse flutters and intermits from time to time, and he expires. The 
 countenance is not of a transparent paleness, but that of that clayey and leaden color 
 which the painter represents in assassinati<tns and battles ; and this tossing of the limbs, 
 "which is commonly represented as the sign of a fatal wound, is, indeed, so infallible a 
 
344 ON HEMORRHAGE AND ITS TREATMENT. 
 
 sign of death that I have never known any one to recover who had faHen into this con- 
 dition " (^Principles of Siirgeri/, voh i. p. 143). 
 
 This sketch is so graphic that I have extracted it as a whole. Since my student 
 days, when I first read it, it has been fixed in my memory. It is, however, only a page 
 out of the work of a master-surgeon which still deserves close study. 
 
 A patient may lose a large quantity of blood and yet rally. Children bear the loss 
 of blood badly, yet rally quickly. In old age a small hemorrhage is of grave importance, 
 the rallying-po-wer being very small. 
 
 Treatment. — To treat a case of arterial hemorrhage successfully, the surgeon, wrote 
 Robert Liston, " must learn to look boldly on the open mouths of arteries." He must 
 know, moreover, that hemorrhage from any vessel, however large, is readily controlled 
 by the application of well-applied direct pressure upon the tvoundrd pxtrt ; conse(|uently, 
 any surgeon on being called to a case of wounded artery, having cleansed the wound and 
 exposed the vessel, should put his thumb or finger on the bleeding orifice and check the 
 flow until more permanent hajmostatic methods can be adopted. When moderate bleed- 
 ing comes from a wound and its source is unknown, whether arterial or venous, the mere 
 act of cleansing the ivound and removing clots is often sufficient of itself to arrest bleeding, 
 not only for the time, but permanently. When the bleeding is venous, the elevation of the 
 limb has always a most beneficial and rapid action. When direct pressttre is employed to 
 check bleeding, it should be well applied ; a small and compact pad corresponding in size 
 to the last joint of the thumb should first be applied to the bleeding part, and over this 
 a larger one .should be carefully adjusted, a third covering in the whole. These are to be 
 firmly bound down over the bleeding ves.sel with a 1)andage or some unyielding strapping, 
 care being taken that the pressure employed is sufficient to control the bleeding, but not 
 enough to arrest wholly the circulation through a limb, thereby producing gangrene of 
 the parts below. 
 
 When direct pressure is inapplicable, indirect pressun-^ as it is called, may be applied 
 to the main artery of a limb above the wound, and for temporary purposes this may be 
 efficiently performed by the thumb or finger of the .surgeon or of a skilled assistant ; but 
 for a lengthened period this method is untrustworthy, it being impossible for any ordinary 
 man to maintain firm pressure upon a vessel for more than a few minutes consecutively. 
 As a temporary means of arresting bleeding, however, manual pressure is of immense 
 value and should be applied to the femoral artery below Poupart's ligament for the lower 
 extremity, and on the inner side of the biceps muscle for the upper, the fingers or thumb 
 of the surgeon being employed, according to convenience. In some cases the use of the 
 weight, as shown in Fig. 149, may be recommended. 
 
 What is known as Esmarch's method of arresting hemorrhage has in recent times met 
 with considerable support. It consists, first, in the application of an elastic bandage from 
 the extremity of the limb to be operated on to a point above the site of the operation ; 
 and secondly, in the adjustment of an india-rubber band or tube tightly above the upper 
 border of the elastic bandage, which can then be removed. By this method the parts 
 below the band have been rendered bloodless, and the surgeon may explore a limb, excise 
 a tumor, joint, or bone, and even amputate, with the loss at the time of a spoonful of 
 blood. The method has, however, one objection ; which is, that when the band is removed 
 blood oozes from the soft parts to a far greater extent than it does under other circum- 
 stances, the smaller vessels apparently becoming paralyzed by the compressing bandage 
 or from having been completely emptied. The operation, which is bloodless during the 
 cutting process, is, on the whole, therefore, followed by the loss of as much blood as gen- 
 erally follows other methods. All the good of this method, without the evil, may, how- 
 ever, be obtained in an amputation by raising the limb for a few minutes before the appli- 
 cation of the elastic tourniquet and smoothing heartward with the hand the soft parts, to 
 empty the veins. I feel bound to add that this method of emptying a limb of venous 
 blood before amputation was practised at Guy's by the late Mr. Aston Key in 1849, when 
 I was his dresser, in a case of compound fracture which re((uired amputation, and in 
 which it was necessary that the loss of blood should be reduced to a minimum. The ca.se 
 did well. The late Mr. Hilton subsequently often adopted the practice. For exploratory 
 operations and the removal of small foreign bodies, excision of joints, and removal of 
 necrosed bone, the compressing bandage has. however, great advantages. 
 
 Tlie tourniquet is doubtless an excellent instrument for the compression of an artery, 
 and J. L. Petit's is probably the best for the extremities. It should be applied to the 
 limb directly over the vessel to be compressed, the pad being adjusted in the axis of the 
 vessel. The ends of the band are then made to pass round the limb and are secured 
 
ox iLKM()iii'Ji.\<:i-: .i.\7> /7'.v Tiii:.\rMi:sr. 
 
 345 
 
 either h\ a Imcklf or :i knot, the innncr liciii;^ preferaJde. TIk' fwn plates can then he 
 Heparated hv the rotafidii nt' the ^cnw and a sufiieient amount of jiressurc cmpluyed to 
 stop the current of hhxid. and iki more {vidr Kifr. 137). Jiister ha.s invented an adniirahlo 
 
 Vic. VM. 
 
 tourniquet for compressinir the ahdominal aorta, and many others liave heen constructed; 
 hut these are ample for all ordinary purposes of arresting or preventing hemorrhage. 
 
 When a tourniquet is not at hand, as in the field, a stone or any hard substance may 
 be rolled up in a handkerchief, applied over a ve.ssel, and bound round the limb; the ends 
 of the handkerchief, too, should be attached to a stick or sword, any amount of com- 
 pression being obtained by simply twisting them. 
 
 As temporary means of arresting hemorrhage, therefore, the surgeon may employ 
 digital or instrumental pressure either upon the bleeding spot — *', e., direct ; or upon the 
 main artery of the part — i.e., indirect. The wound in both ca.ses should be well exposed 
 and cleansed and all coagula removed preparatory to the application of such permanent 
 means as may be at command. Of these, the lirfoture, torsion, and acnpreasKre are the 
 chief. Styptics and the cautery are only employed when the three means mentioned are 
 either inapplicable or have proved unsuccessful. 
 
 On the Use of the Ligature. 
 
 Since Ambrose Pare reintroduced the use of the ligature (1550) it has been the favor- 
 ite means for the arrest of hemorrhage, the speedy way in which bleeding from an artery, 
 however large, is checked by its application, and the feeling of relief experienced on know- 
 ing that for a time at least all fear of bleeding has been removed, having so influenced 
 the majority of practitioners in its favor as to induce them to put aside untried all other 
 suggested means as being unnecessary. It took, however, nuire than two centuries for 
 the ligature to become established in practice ; in fact, its adoption was not general till 
 Dr. J. F. I). Jones had demonstrated by his experiments, already alluded to (p. 342), the 
 physiological processes by which hemorrhage is naturally arrested in a bleeding vessel, 
 and that by the ligature these were utilized. 
 
 To tie an artery efficiently, the vessel should be taken up cleanly, drawn out. and tied 
 with a smooth cord of prepared silk or catgut with sufficient force to rupture the inner 
 coats of the vessel (such a result, although desirable, does not appear, however, to be con- 
 stant) and occlude the outer coat ; the ligature should be made secure by what is called 
 the sailors reef-knot ; the surgeons doultle-knot should not be used. Tn forming the 
 loop the ligature should be pressed down to the artery by the finger or thumb, as indi- 
 cated in the drawing (Fig. 137); otherwise, the extremity of the artery will, if diseased, 
 be liable to be broken ofi". 
 
346 ACUPRESSURE. 
 
 When the vessel is deeply phiced and cannot be isolated, it must be ligatured with 
 some of the adjacent tissues. When it is so embedded that its free end cannot be taken 
 up with forceps, a tenaculum may be passed beneath the bleeding vessel, and all the 
 tissues taken up by the instrument should be strangled by the ligature. The ends of the 
 ligature used to be left hanging out of the wound, but at the present time the practice of 
 the late Mr. de Morgan, which is a revival of that of the last century, of cutting off both 
 ends of the ligature, leaving the knot //( sifO., and closing the wound, has become general. 
 
 When the vessels are diseased and brittle, extra care is needed in the application of 
 the ligature. The vessel should not be tied too tightly lest too much of the artery be 
 torn and the ligature be made to .separate before natural haemostatics have closed it. 
 Some have suggested the use of a flat ligature under these circumstances, but it seems 
 scarcely needed. In 1865 I was called upon to apply a ligature to the femoral artery of 
 a man over seventy years of age for femoral aneurism. The vessel was so brittle that I 
 felt the coats give way on the application of the ligature ; the included tissue, too, 
 seemed so thin that I expected to find the ligature come away in my hatid, which did 
 not occur. The case ultimately did well, and no bleeding ensued. 
 
 When a vessel is wounded, the artery is to be secured at the seat of injury by a liga- 
 ture applied above and below the wound. Some surgeons then advise the division of the 
 vessel between the ligatures. Dr. J. A. Lidel of New York, in his able article on 
 " Injuries of Blood Vessels," in the International Cycloj)sedia of Surgery (vol. iii. p. 
 81), speaks decidedly upon this point, giving as his reason, '-so that both ends of the 
 divided vessel may be able to retract." 
 
 Acupressure. 
 
 The late Sir James Simpson brought this method of arresting hemorrhage before the 
 profession in 1860, and on his authority many resorted to the practice. The late Mr. 
 
 Pirrie of Aberdeen gave it his 
 Fig. 138. warmest support, but since his 
 
 death the practice has been 
 given up except in rare cases. 
 The principle of the practice is 
 very simple — viz., the occlusion 
 of the artery by the temporary 
 pressure of a pin without lacer- 
 ating the vessel or setting up 
 inflammatory and suppurative 
 action, as in the ligature. The 
 
 Difterent Modes of Applying Acupressure. pin is removed on the seCOnd Or 
 
 third day. according to the size 
 of the artery. The advantages thus claimed for it are very great, but experience has not 
 decided in its favor. There are three leading forms of acupressure. 
 
 In i\ie first the artery is directly compressed between the pin, which crosses its free 
 end, and the muscle beneath (Fig. 138, 1). 
 
 In the Hecond the same result takes place, the pin being made to give a half twist 
 through the tissues between its first and second insertions (Fig. 138, 2). 
 
 In the third the pin is simply passed beneath the vessel and pressure applied to the 
 artery by means of a loop of wire or silk looped over its point and made to cross the 
 vessel, the ends of the loop being secured upon the shaft of the pin (Fig. 138, 3). 
 
 The good point in acupressure is the absence of any foreign body for more than a few 
 hours or days. Its disadvantage lies in the fact that its success depewds upon the coagu- 
 lation of the blood in the vessel down to the first branch— one of nature's temporary 
 hfemostatic processes — and not upon the permanent closure of the coats of the vessel. 
 As a consequence, it is not so secure as the ligature, or physiologically so sound as the 
 practice of torsion. As a mode of temporarily arresting hemorrhage in certain cases 
 where the ligature and torsion are inapplicable, as in wounds of the palm or the sole of 
 the foot, it is indeed valuable, and particularly, also, as a means of arresting the flow of 
 blood from a leech bite or other bleeding point, the passage of a needle through the skin 
 and a figure-of-8 ligature over being of great service. 
 
 An ingenious modification of this process has been devised and successfully used by 
 Mr. Dix of Hull. A wire passed through the flaps by means of two needles and twisted 
 over a cork outside compresses the bleeding vessel in the same way as the needles. It is 
 
o.v mnsio.y. 
 
 347 
 
 called l»v its author ' tlu' wire coiiiiirt'ss." and is liilly dt-scribcd in ili,' h'i/iiiliiir(//t Afrt/inil 
 Jniiniii/, Si'pti'inhcr, ISllJ. It scfiiis, ImweviT, to he more ada|itc<| for scruriiijr an artery 
 in its continuitv, us in the treatment of aneurism, under wlii( h head it will he described 
 
 •tail. 
 
 On Torsion. 
 
 Fi«. i.w. 
 
 livnh: 
 
 In a |>hvsi(doirical ]K)int of view, there is no method mori' pi-rfeet at eommaixl for the 
 eoutrol of liemorrha.L'e than that of torsion, heeause, uidike acupressure, wliieh u.ses one 
 only ol" nature's ha'niostatie processes, or the li<;ature, which is a forei<rii body in a wound 
 and becomes ii source of dan;;er by undoing at a later what has been done at an earlier 
 
 period of the ease, it utilizes to the utmost all the physio- 
 logical processes emj)loyed by nature to prevent and arrest 
 bleeding and places the vessel in the most favorable position 
 for them to take effect (vide page ?>M)). 
 
 For the application of torsion a good pair of forceps is 
 
 re([uired {ri<li' Fig. i:J7) that will hold the end of the artery 
 
 Vrlr/fri/ ti"""'!}'^ th'it 'I'l^ "'^ lateral motion, and with serrations blunt 
 
 enough to obviate any laceration or cutting of the parts 
 
 seized by the blades. The vessel should then be drawn 
 
 out. as in the application of the ligature, and three or four 
 
 , ■ m - sharp rotations of the forceps made. In large arteries, such 
 
 j;t.crfca..ir/o/'mnrrG,ats j^^ the femoral, the rotation should be repeated till the >^emp 
 
 effects of Torsion on Fen.oral ^^j. ,.,,,.j-,^^„^,, J^,^^ p^,,,,,,/ The ends should not be twisted off. 
 
 In small arteries the number of rotations is of no importance, 
 and their ends may be twisted off or not as may be preferred. In Fig. 139 the appear- 
 ance of a femoral artery sufficiently twisted is well shown. 
 
 When the vessels are diseased, fewer rotations of the forceps are required, the inner 
 tunics of the vessels being .so brittle as to break up at once and incurve. If the surgeon, 
 therefore, twi.st more, he will break away the external or cellular coat, which is of essen- 
 tial importance not only in maintaining the lacerated inner coats in position, but in allow- 
 ing blood to coagulate and lymph to organize between them. AVith this caution, diseased 
 arteries appear to be as amenable to the treatment as the healthy ; and torsion requires 
 no more care under these or any circumstances than the application of a ligature. 
 
 The physiological arguments in tavor of torsion are numerous, while the practical 
 advantages seem to be not less. After fifteen years' experience of the practice among 
 
 Fig. 140, 
 
 1. An artery taken up I)_v the constrictor. 2. Artery constricted. 3. Effects of cnstriction upon vessel. 4. As seen 
 
 wlien laid open. 
 
 vessels of all sizes (the femoral being the largest^ I have had no mi.shap. I have further 
 observed that wounds have united more rapidly and kindly, primary union being the rule; 
 there has been less constitutional disturbance after operation, and consequently less lia- 
 bility to traumatic fever, pyj^mia, and other complications such as we are all too familiar 
 
348 ON HAEMORRHAGE AND ITS TREATMENT. 
 
 with in the practice of surgery. Stumps have healed in a week and patients been up in 
 two without one single drawVjack, rapid and uninterrupted convalescence following the 
 operation. In other ca.ses equally good success can be recorded. At Guy s Hospital we 
 have had two hundred consecutive cases of amputation of the thigh, leg, arm. and fore- 
 arm, in all which the arteries had been twisted (one hundred and ten of them having been 
 of the femoral artery), and no case of secondary hemorrhage. 
 
 The Artery Constrictor. 
 
 Dr. Fleet Speir of Brooklyn, New York, has had an artery constrictor made (Fig. 140) 
 which, as he has demonstrated upon both the living and the dead, has the power of divid- 
 ing the inner coats of an artery and allowing them to recurve as in tor.sion. He has used 
 it on all the larger vessels except the iliac and subclavian, and has never had any trouble, 
 union chiefly by first intention having followed (^Med. Mirror, ^e'w York, April. 1871, and 
 Archives of Clinical Snrgcri/^ SeptemVjer, 1876). 
 
 The instrument he recommends (Fig. 140) should be " tight-fitting enough to con- 
 strict thoroughly, and yet grooved and smooth enough not to lacerate the external coats, 
 while it makes a complete invagination of the inner coats. For operating upon vessels in 
 continuity, as for aneurism, I prefer to place the limb, after constriction, in a relaxed 
 position, so as not to stretch the vessel after being constricted." 
 
 In Fig. 140 the instrument is shown applied to an artery, and in Fig. 140 ("4) a sec- 
 tion of the artery subsequent to its constriction. I have tested this instrument on the 
 living and have made a large number of experiments on the dead, and find it does all that 
 Dr. 8peir asserts. I believe it to be of value for obstructing arteries in continuity, as it 
 does for such precisely what torsion does for divided vessels. In May. 1882. I employed 
 the instrument with encouraging success in the case of a man set. 48 with popliteal aneu- 
 rism.' The wound healed by '"quick union,"' and the aneurism was cured. 
 
 Other Methods. 
 
 Astringents or styptics are valuable agents in the arrest of bleeding when the 
 means pi-eviously mentioned are inapplicable, their value being much increased when 
 combined with pressure. The perchloride or persulphate of iron, pounded matico, alum 
 in powder or solution, applied to a bleeding surface on a pad of lint or dossil of cotton- 
 wool and bound on, are the best applications, though tannic acid. Ruspini's styptic, or oil 
 of turpentine is also serviceable. Before applying any of these the bleeding part should 
 be wiped as dry as possible and all coagula removed. In uterine surgery injections of 
 some of these astringents are much used. In rectal surgery the bowel may be plugged 
 with lint or sponge saturated with a styptic, and in epistaxis the nose ma}' be plugged in 
 a like way. 
 
 " Cold " is a powerful .styptic, cold air often permanently arresting even copious hem- 
 orrhage on laying open a wound. A .stream of cold water directed to a bleeding part, or 
 ice pounded and placed in bladders or bags and laid on bleeding wounds, is at times of 
 great assistance. '• Heat," also, is equally good, and when applied in the form of a hot 
 sponge wrung out of an iodine or antiseptic lotion is enough to stop all capillary oozing. 
 I have adopted this practice after operations for some years with excellent success. 
 
 Cauterization, which was the common mode of arresting bleeding by the ancients, 
 is now seldom employed ; yet it is a valuable agent in ca.ses where neither torsion, liga- 
 ture, nor acupressure is available. In spongy tissues from which blood is oozing, and 
 also in other cases, the hot iron will often act most beneficially. It may be applied 
 through iron buttons or cones brought to a black heat by means of fire, or through plati- 
 num or porcelain instruments heated by means of benzoline vapor or the galvanic battery. 
 In any case the heat should be enough to cause a dry eschar upon the bleeding part, 
 while care should be exercised subsequently not to remove this too soon ; indeed, the 
 eschar scab should be left for natural proces.ses to throw oif. In no case should the cau- 
 tery be too hot^ — that is. red hot — as it destroys the vessels too much. It should be 
 merely of a htack lieat. 
 
 Capillary Hemorrhage. — Hemorrhage from the capillaries or small vessels 
 rarely takes place to any dangerous extent unless it occurs in " bleeders " or such as 
 labor under the hemorrhagic diathesis. It has always a tendency to stop by it.self 
 through such natural haemostatic processes as have been described, [f, however, it be 
 
 ^Brii. Med. Journal, vol. li., 1882. 
 
O.V ll.i:MnniillM;i: am, its trkatmest. 310 
 
 too porsistt'iit, tilt! siirl'iK'f ol' tlic woimd >li()ulil lie »'xp(»s('(l :iiiii cleansed, tlit; stimulus of 
 the air being ol'teu siitlieieiit to excite cliisure of the ve.H.sels. Moderate pressure upon 
 the surf'aee of the wcnind or u stream of cold water over it is also a valuable auxiliary. 
 
 Summary of Treatment of Hemorrhage. 
 
 All divided or wuiiiidcd artcrio fmni \vlii(di MihmI thiws arc. 11" piosibjc. to l)c t\vi>lcd 
 or tied at the seat of injin y ; and to aeeomplish this, when room is nM|uired, the wound 
 may be eidar<;ed. When an artery is lUvlilnl. hull, nuh are to be dealt with separat»dy. 
 When an artery is wutiiiilnl. John Hunter's advice is still sitund : " Tirst apply the tour- 
 nicjuet. then lay the artery siitlieicntly bare, and tie the ves.sel above and below the 
 wounded ]iart ' (.MS. Lect.. 1T><7). In some eases the vessel had better be (■<)mpletelv 
 divitled ; with the brachial I have tollowe<l this praetiee on three (tccasirjns, and twisted 
 its two emls. with i^ood nvsult. and advise its adoption as a rule of practice in arteries of 
 less calibre. In lar<;er arteries it is also j)robably good. 
 
 When there is no bleeding pre.sent. an operation is not required, although, in excep- 
 tional ea.-<es, when a renewal of the liemorrhage may endanger life, this rule may be devi- 
 ated from. 
 
 When moderate arterial hemorrhage exists and the artery cannot be taken up in 
 the wound without an operation, the graduated comj)rcss may be employed with a fair 
 chance of success ; but should it fail, the vessel must be secured. 
 
 When arterial hemorrhage endangers life and the artery cannot be treated at the 
 wound, the trunk of the vessel is to be secured above the wound. 
 
 When recurring hemorrhage is severe, the wound is to be reopened or erdarged, all 
 clots turned out, and the vessel tied or twisted. When moderate, it can be treated hy 
 elevating the part, by pressure over either the main trunk of the ves.sel or the wound, 
 and l)y tlu' aiiplication of cold, such as the ice-bag. 
 
 At times all bleeding ceases on the mere exposure of the open wound ; at others there 
 is merely a general oozing. Uuder these circumstances, if exposure of the wound to the 
 air or to a stream of cold water fails to check it, well-applied pressure will often suffice. 
 In exceptional ca.ses styptics may be required. 
 
 Secondary hemorrhages are to be dealt with in the wound as primary — that 
 is. when bleeding is profuse, the artery is to be religatured'or twisted at the bleeding 
 point ; when not severe, it will probably be restrained by pressure and the elevation of 
 the part, .since in a general way, when secondary hemorrhage takes ])lace after the appli- 
 cation of a ligature to a wounded artery, the bleeding comes from the lower end of the 
 vessel. Guthrie has clearly shown that in the lower end of a divided vessel repair is less 
 perfect than in the upper, that there is less contraction and retraction of the ves.><el, less 
 perfect coagulation of blood, and less effusion of plastic lymph. 
 
 Venous Hemorrhage, unless from the trunks of large veins, quickly ceases, 
 usually from the collapse of the veins. Where any impediment exist.s.to the return of 
 the blood from the wounded part, it may, however, prove troublesome, yet its arrest will 
 probably be secured on the removal of the obstruction. The elevation of the wounded 
 part will tend much toward this end, as will also the application of cold or firm pressure 
 upon the spot. 
 
 When large veins are divided and the bleeding is copious, they must be tied or twisted. 
 When veins are wounded, they .should be divided and tied ; to close a small opening into 
 a large trunk with a fine ligature is not safe practice. Wounds of veins heal rapidly, as 
 is .seen after venesection. 
 
 Injuries of the large venous trunks, however, are of grave importance, and any wound 
 or injury that induces, directly or indirectly, the complete arrest of the venous circulation 
 through one of these is probably of greater consequence than the wound of an artery. 
 The internal jugular vein has, however, often been tied with success. 
 
 A vein is known to be opened when black blood flows from the wound in a steady 
 stream and from its distal part, when pressure above the wound increases the flow and 
 pressure below retards or stops it. 
 
 Phlebitis is the chief evil to be feared from an injury to a vein ; and when it 
 occurs, it is very fatal. Veins, however, will doubtless bear much more manipulation 
 without any such danger ensuing than our forefathers believed. 
 
 The entrance of air into a wounded vein is a source of great danger; 
 
 but the subject will receive attention in a succeeiling chapter. 
 
 Ulceration of arteries in contact with pus occasionally occurs in feeble subjects; 
 
350 TRANSFUSION. 
 
 and when the artery is large, death may follow. I have lost a case of iliac abscess from 
 this cause, the deep circumflex iliac artery having been opened ; many similar examples 
 are on record. When the hemorrhage is recognized and the source of bleeding known, 
 an exploratory incision is called for ; the opened artery should be treated as a wounded 
 one. 
 
 The General Treatment of Hemorrhage, 
 
 though of importance, is subsidiary to the locaf. When syncope has taken place from loss 
 of blood, the surgeon should not be too hasty to overcome it, since it is, without doubt, 
 one of the most valuable means nature employs to check bleeding and to assist natural 
 haemostatics ; but, at the same time, great care is needed that the syncope be not fatal. 
 If such an event appears imminent, the patient should be kept in the horizontal posture 
 with the head low ; cool air should be allowed to blow upon the face or cold water sprin- 
 kled over it; some diifusible stimulant, such as ammonia, ether, chloroform, or the nitrate 
 of amyl, may be inhaled, or brandy given in small quantities. In extreme cases some 
 surgeons advise pressure being made upon the abdominal aorta or large arteries, to con- 
 fine the blood to the nerve-centres, or even transfusion may be employed. This operation, 
 however, has never been in high favor with surgeons, though from accoucheurs it has 
 received considerable support, the late Dr. James Blundell having given it his energetic 
 advocacy. When attempted, it should not be delayed until too late — ('. f., till the hope 
 of rousing the nervous and circulating system has become almost forlorn. Under all cir- 
 cumstances plenty of bland liquid nourishment should be given, such as milk, eggs, 
 broths, etc., and stimulants in moderation. When there is a prospect of a recurring 
 hemorrhage, all food should be given cold. In the convalescing stage iron and quinine, 
 ammonia, and bark are of the greatest value. Opium is a drug that must not be forgot- 
 ten, as in the restless stage of bloodlessness its action is most beneficial. It must, how- 
 ever, be administered with caution ; for with a feeble heart large doses are apt to depress. 
 Half-grain doses repeated at intervals are probably the safest ; larger, however, may at 
 times be given. When capillary bleeding takes place to any extent after an operation, a 
 full dose of opium, say a grain, is often very valuable. 
 
 When the hemorrhagic diathesis exists, iron in full doses is of great service, the tinc- 
 ture of the acetate or perchloride in half-drachm doses being the best. Oil of turpentine 
 is likewise a valuable remedy, twenty-minim doses being sufficient for an adult. Gallic 
 acid in ten-grain doses and acetate of lead in one-gi'ain doses are also beneficial. All 
 these act upon the blood and dispose it to coagulate. 
 
 Transfusion. 
 
 When Dr. Lower of Oxford, with .Sir E. King, in 16G5. first practised transfusion, 
 blood was drawn from an artery and conducted directly by means of a tube into the vein 
 of the patient, the blood being propelled simply by the force of the circulation of the 
 emitter. As time progressed the inexpediency of opening an artery was felt, and the 
 plan of transmitting blood from vein to vein came into use. In 1785 this plan was also 
 warmly advocated by Dr. Harwood of Cambridge. With this change of practice the 
 mode of operating had to be altered, because the force of the venous circulation was 
 found to be insufficient to propel the blood. The indirect or mediate mode of operating 
 consequently came into use, the blood of the emitter being received into a vessel and 
 transmitted by a tube or syringe into the vein of the patient. To James Blundell is due, 
 undoubtedly, the credit of having devised an apparatus by which the operation can be 
 efficiently performed. He called it first an " impeller," and when improved a " gravita- 
 ter."' Since his time Drs. Aveling, Hewitt.- Braxton Hicks,^ and particularly Roussel, 
 have done much toward rendering the practice more safe and certain. The object of the 
 surgeon in the operation is to transfuse blood from a healthy into a bloodless patient, and 
 his aim should be to prevent the coagulation of the healthy blood during the operation, as 
 well as to guard against the introduction of air into the veins. This operation should only 
 be undertaken when a trustworthy apparatus is at hand, and of these Dr. Roussel's is. with- 
 out doubt, the most complete. Aveling's, however, is excellent. 
 
 Dr. Roussel's instrument is made of hardened pure caoutchouc ; it is composed of a 
 
 tube with a Higginson's syringe large enough to contain two and a half drachms of fluid 
 
 (Fig. 141, 14) in its course. One end of the tube is attached to a rigid cjdinder (10) 
 
 open at each end and applied over the seat of the vein required to be punctured (3), 
 
 1 Lancet, 1829. ^ obMet. Tram., 1865. ^ Guy's Rep., 1868. 
 
DISEASES OF III I-: AinKIiHiS. 
 
 351 
 
 which has het'ii dhhtructed by the huiul (1). Tlic t-ylinder is fixcil in ponition by beinp 
 surroniuled by a ri;;i(l fu|>, which can be exhauster! by an elastic puinp CJ) in connection 
 with it. The exliaustion oJ" this cup nut (»rily fixes the ajiparatiis to the arm. l»ut also 
 increases tlie tur^'idity of the vein over which it is appliol. The cyliruh-r witliin it (11 ) 
 is then closed by the introduction at its upper extremity of a lancet (12;. the exact depth 
 of which can be re;.Milated (l.'>). Before opcratin*: the air should be driven out of the 
 cylinder and tube by filling: them with tepid water (»>), in which a little bicarbonate of 
 soda may be dissolved, by means of the syrin;.'e (!(; an<l the tube (H and 7j. which i.s 
 attached to the cylinder opposite to the conducting tube ( ITj. When about to operate, 
 the lancet (lli) is depressed into the vein. 
 
 To the extremity <d" the cotiductiuL' tube a stopcock (17) with two canuhe (lt» and 
 18) is attached, the stopcock being inserted to direct the flow of flui<l into one or other 
 of the caiiuht*. One «d" thc.-e canuhe is introduced into the vein of the recipient (:}). 
 The apparatus (10) being filled with water, the vein is opened by the lancet and the con- 
 tents of the cylinder and tube are pumped out through the free canula (18; until blood 
 only flows through it. The stopcock (17) is then turned, and the blood is injected into 
 the patients arm through an opening in the vein (4). The syringe by this apparatus 
 forces "the blood into the vein of the recipient by degrees as it draws it from the vein 
 
 Fk;. 141. 
 
 Dr Ron 
 
 Injecting Apparatus. 
 
 of the donor, every particle of it having remained less than a second out of the human 
 vessel, enclosed in a full tube, and the blood conducted by an artificial vein and heart 
 hermetically closed, damp, warm, and soft as are the human vessels. The blood is not 
 modified as regards its fibrine. globules, gas. temperature, or density : it passes from one 
 system to another with all its primitive vitality, and continues to live on." 
 
 Not more than six to nine ounces of blood should be transfused at one time ; the 
 injection, too, should be gradual — that is. about six .syringefuls a minute. 
 
 DISEASES OF THE ARTERIES. 
 
 Arteritis. — Under this heading. Vx'sides the rarer forms of disease, we shall include 
 atheroma, as there is no longer any question of its inflammatory nature. Of this Vir- 
 chow. Billroth. Wilks. and Moxon have given sufficient evidence, though in modern text- 
 books the old view is still taught and the weight of Gulliver's investigations ( Mefl.-Chir. 
 Truns. vol. xxvi.) has not yet lost its influence. We by no means think that Gulliver 
 was altogether in error in holding that atheroma was a fatty and calcareous degeneration 
 of the inner and middle arterial coats, with subsequent thickening of the adventitia : on 
 the contrary, it is not improbable that atheroma may sometimes be a simple retrograde 
 metamorphosis of the arterial tissues : but there can be no doubt that it more often 
 begins as a subinflammatorv process. This conclusion has been reached partly upon 
 histological grounds and from the fact that the disease is most prone to occur where the 
 wear and tear is greatest, and inflammation, consequently, most likely. Syphilis has 
 doubtless much to do with arterial disease, and, as a consequence, with aneurism : and 
 the frequent association of syphilis and aneurism in the army has been adduced as strong 
 
352 DISEASES (jF the A I ITER I ES. 
 
 evidence in favor of the conclusion. Mr. Myer.s ha.s. however, shown (Path. Tram., vol. 
 XX. p. 13-t) by comparing the array with the navy, where .syphilis and overexertion are 
 about the same, that in the former aneurism is fifteen times as common as it i.s in the lat- 
 ter; and he believes that the constriction of the collar and coat of the soldier, bv obstruct- 
 ing the blood stream, favors arterial disease more than syphilis. 
 
 Arteritis is usually described as - acute " and '• chronic." and it will be well for us to 
 adopt the terms in general u.sage. But the student must remember that the pathologist 
 applies the one to a process the product of which i.s cellular or nuclear, the other to 
 that which shows organized or tissue product or some degenerative change such as the 
 calcareous, which must necessarily have taken some time in its production. From a clini- 
 cal point of view, both terms are more arbitrary than exact ; and there is other evidence 
 than pathological to .show that changes judged by such a standard to be chronic are 
 rapid in their course, and, in the .same way. others which must be called acute, in that 
 micro.scopically they are cellular, are not necessarily of short duration. If we. then, con- 
 tinue to describe arteritis as acute and chronic, it is evident that no strictly histological 
 basis is broad enough for accuracy ; and we have therefore adopted that classification of 
 acute arteritis which accords best with our own experience. 
 
 Acute arteritis is found under four conditions : 
 
 l.-t. As -li-litly raised grayi.sh or piellucid patches on the lining membrane of the 
 artery, which when examined microscopically .show a multiplication of the cells of the 
 superficial layers of the inner coat. It is a disea.se which is not. perhaps, of much impor- 
 tance when attacking the aorta or larger vessels : but when it affects the visceral arteries, - 
 it may lead to a considerable diminution of their calibre, to thrombosis, and thus to all 
 those changes which ensue when the circulation becomes arrested. It is a change of this 
 kind which Heubner lately described in the vessels of the brain as particularly liable to 
 occur in the subjects of syphilis, and it is probable that a similar result may be induced 
 in the larger arteries from the .same cause. 
 
 2d. As a general affection of the arch of the aorta in wliir-li that vessel is grayi.sh, 
 softened, thinned, and dilated, but without any strictly atheromatous or calcareous change 
 in it. It would be better, perhaps, to call this state " acute softening." though the nature 
 of the process is essentially inflammatory. 
 
 3d. As a local disease in the arch of the aorta in cases of acute rheumatism. This is 
 rare, sometimes originating in the friction produced by large valvular vegetations which 
 are washed backward and forward in the blood .stream, and sometimes without any such 
 cause, and apparently as a spontaneous arteritis. In either ca.se it is liable to lead to 
 aneurism or imperfection of the aortic valves. 
 
 •ith. As a local disea.se in the arteries secondary to the lodgment of emboli, which by 
 their presence set up an arteritis. 
 
 Chronic arteritis niay occur as a wide.spread and continuous disea.se in mo.st of 
 the arteries of the body or as one which is localized to various parts, .specially the larger 
 vessels. Of the former — a very rare di.sease — examples have been published by Wilks 
 (Guys Rej>.. 1869) and Savory ( MefJ.-Chir. Troas.. 1856). In Wilks s case the principal 
 arteries of the body were thickened and obstructed, the vessels being filled with old clot 
 that was " so closely adherent that the wall of the vessel would split rather than part 
 from the clot. At both the ending and commencing parts the clot was white and like 
 fibrous tissue and could not be distinguished from the coats, which here were swollen and 
 atheromatous. The atheroma, indeed, appeared to be here in the clot also as well as in 
 the arterial clot." 
 
 There seems little doubt also as to the fact that a vessel may become completely 
 obstructed by a strictly local arteritis. 
 
 It may be noted in passing that the descriptions of the naked-eye appearances in 
 these cases exactly correspond with that of the .so-called syphilitic disease of the cerebral 
 arteries just alluded to as having been described by Heubner. and which has been classed 
 by us as acute arteritis, inasmuch as it is a disease purely cellular. 
 
 Such cases as the last, however, are rare compared with those of local chronic aneritis 
 such as is met with in the arch of the aorta at its bifurcation and other parts. It is 
 indicated by thickening of the vessel and lo.ss of its elasticity, by the external coat 
 changing into a tough fibrous tissue, and the affected parts. in.stead of feeling thin and 
 pliaVile. becoming hard and leathery. " Xow. such changes as these are commonly present 
 along with the atheromatous pulp in the deep inner coat, and these are the part of the 
 changes that go by the term -atheroma" as commonly accepted. Changes of a kind that 
 cannot be regarded as other than inflammatory are present in nearly all bad examples of 
 
ijisj:asj-:s or riii: a!:ti:i:ii:s. 
 
 353 
 
 atluToiiia ; the oxtciit of the iiiHaiiiiiiatdry cliaiijris L'liicrally surpasses that of the atheru- 
 iniituiis, and these iiiHaiiMiiatory ehaii-res oeeur often witlioiit any atlieroina, ami e.>j»eciallv 
 ill vouiif.'er suhjeets, ahoiit or uiitler middle a;re. The more inflammatory chan^reK tend 
 more to prodiiee aneurisms than <lo the atheromatous jiatehes. When atheroma is thor- 
 ouL'hlv i>talili>hed, so that a pulpy mass is formed in the coats at any spot, this is j.'en- 
 erally thiek and hard and unyielding, and does not ^ive way to pressure so as to form an 
 aneurism. The disease that leads to aneurism is the same disease as leads to atheroma, 
 and I think it is a eorreet way of describin*: these relations to say that they are alterna- 
 tive results of tlie disease of the coats. I mean so that if the suhinflammation is geverer, 
 then the eoats are softened and yield early, before tlie thiekeniiifr and stiffening ehronic 
 process that leads to the atheroma patch has had time to occur. On the other hand, if 
 the subiniiammation is lower and slower, then there is not such s(»ftenin<r at any time in 
 its course as to lead to aiieurismal yielding; but the result is a slow thickening, which 
 reaches a considerable and a sufficient degree before any fatty degeneration occurs within 
 it. and then always the thickening goes farther than the granular change, so that the; wall 
 of the artery is rather .stronger there than weaker; and if the suhinflammation be yet 
 slower and slower, the fatty or granular change in the coat goes on to an accumulation 
 of lime salts or petrifaction of the spot, the stone in the wall showing sometimes some 
 rude bone cells, so that ossification may be thought really to occur, though the bone is 
 truly a very rough production, if it be bone at all. Now, if, instead of being thus slow, 
 so as to give time for the calcareous change of its products, the suhinflammation be very 
 acute, then the arterial wall may rupture and either sudden death or a false aneuri.sm be 
 the result." •' I might." adds Moxon, '' give practically any number of ca.ses and draw- 
 ings showing the active cell formation in cases of atheroma, this cell formation found in 
 the deep layer of the inner coat especially and causing the production of little nests of 
 cells in which fat and lime soon accumulate. In severer cases the middle and outer 
 coats and the deep layer of the inner coat are seen to be charged with lymph cells in 
 enormous numbers, crowded together and separating the proper elastic and the muscular 
 fibres into little patches and shreds, while both elastic and muscular fibres fall into a state 
 of fatty degeneration " (Moxon, Guy's Ifoxp. R< p., 18711-71). 
 
 In Figs. 14li and 1-13, taken from drawings kindly made for me by Dr. Moxon. these 
 changes can be seen. His description is appended. 
 
 Dr. Moxon and others believe — and I think rightly — that mechanical strain is the 
 main cause of atheroma of the arteries. It is chiefly found at points where the strain 
 
 Fifi. 142. 
 
 Fig. 142 shows the incipient inflammatory stage of the change in an arterv which leads to atheroma, and in which 
 aneurism usually o<-cur~. 
 
 Fig. 14;i shows the final degenerative stage of the same change in the artery which constitutes atheroma. 
 
 Fig. 142 is a small portion of a fine section of an artery from the neighborho<Kl of an aneurism; the arterv was here 
 soft and swollen and had a more pellucid and bliiish api>earaiice th.in natural. \ small and earlv patch of the 
 disease is represented. The cells of the artery wall are found enlanied, their nuclei multiplied, and at the centre 
 of the patch they burst toward each other to make a cluster of cells derived from the nuiltii>lied nuclei. 
 
 Fig. 143 is taken from the same artery at another spot, where the coat had the well-known vellow appearance of 
 atheroma. Here the patch of multiplied cells has degenerated to a heap of oilv and earthv matter with some 
 plates of cholesterine. The individual cells around are seen to be degenerated in the same wav. Some of those 
 at the upi»er part of the figure are. on the other hand, developing into elastic fibrils. This is a' frequent accom- 
 paniment of the atheromatous process, and its etiect is to ultimately strengthen the arterial wall at the diseased 
 spot. 
 
 upon the coats is greatest and in men who follow laborious occupations. Gulliver 
 originally described it as a disease of the larger arteries, but it is now known to involve 
 the whole arterial system. 
 
 23 
 
354 EMBOLISM. 
 
 In advanced disease calcareous plates are found in the larger arteries, while the 
 smaller are converted into completely solid tubes. The vessels, moreover, alter in shape 
 and become tuberous as well as tortuous, dilatation taking place at the points of bifurca- 
 tion. When the disease is very extensive or advanced, the inner coats become destroyed 
 and undermined with blood. When this undermining takes place to any extent, what is 
 known as a dissectinc/ (nieurism may be produced ; but in other cases the inner coat is so 
 raised by the clot of blood behind it that the arterial canal becomes closed and gangrene 
 of the parts supplied by the occluded vessel may ensue. In a preparation in Guy's 
 Museum (1465) the aorta was thus aifected, causing gangrene of the extremities. In 
 others the vessel may rupture and cause death from hemorrhage. In rarer cases the 
 vessel may be completely closed by the calcareous disease ; in some the roughened raised 
 patches become the centres of fibrinous adhesions which may either cause occlusion of the 
 vessel directly by their size or indirectly by being carried into more distant arteries as 
 emboli. In both cases gangrene of the parts thus deprived of blood will be produced. 
 Senile (jangrene doubtless is occasionally caused in this manner. Thus it is seen that this 
 atheromatous disease of the arteries is often the cause of gangrene of a part by direct 
 occlusion of the vessel as well as by embolism. As a general rule, however, in those 
 instances in which portions of the artery are found to be withered and converted into 
 fibrous cords, evidence is wanting of arteritis being the cause, recent investigations 
 having tended to show that such changes are the natural result of an obstruction of the 
 vessel, and that this obstruction is probably due to the plugging of a canal by a clot or 
 to what is now known as an embolus. 
 
 Fatty degeneration of the inner and a primary calcareous change in the muscular or 
 middle coat of medium-sized vessels must also be mentioned. These may be, and no 
 doubt are. mostly associated Avith chronic inflammatory changes in the arterial system ; 
 but there is also reason to believe that sometimes they are essentially primary degenera- 
 tions which lead to contraction of the vessels and senile gangrene, as do atheromatous 
 changes. 
 
 Embolism 
 
 is a somewhat common affection, and consists in the occlusion of a vessel, large or small, 
 by a plug of fibrin or calcareous matter carried by the blood from some diseased artery 
 or distant part, and generally from the heart. The physician meets with it in cases of 
 paralysis more or less complete associated with valvular disease of the heart, acute rheu- 
 matism, or aortic disease caused by a thrombus formed in an atheromatous vessel and 
 carried forward into a cerebral vessel, or by the plugging of a capillary by the oily or 
 fatty debris derived from the disintegration of an atheromatous patch. The surgeon 
 meets with it in certain forms of amaurosis and local gangrene and as a precursor of 
 aneurism. The pathologist sees it in the fibrinous clots (infarcta) found frequently in 
 the lungs, spleen, kidneys, or other organs. 
 
 The SYMPTOMS of embolic occlusion of an artery are sudden and severe pain in the 
 part from which the circulation is cut off, the pain in some cases extending down the 
 whole course of the artery; in others it is a local numbness; tenderness is usually present 
 in the course of the vessel. Symptoms of a deficient circulation in the part soon appear, 
 such as coldness and pallor of the skin, which may go on to complete gangrene. All cases 
 of embolic occlusion of an artery, however, do not end in death of the part, since in 
 patients of good power the collateral circulation may become subsequently established 
 and a recovery follow. In patients of feeble power gangrene is to be feared. In not a 
 few cases embolism leads to the formation of an aneurism (vide page 357). 
 
 A woman set. 47 who never had any illness was seized in June, 1868, with a mild 
 attack of hemiplegia on the left side, from which she perfectly recovered in three weeks. 
 She remained well and returned to her ordinary duties — those of a laundress — for three 
 months, when, whilst kneeling, she suddenly felt a severe pain in the right leg, extending 
 down the calf. This was rapidly followed by numbness and coldness of the leg and dis- 
 coloration. She was admitted into Guy's under my care, three days subsequently, with 
 gangrene of the foot and lower two-thirds of the leg. The pulsation in the femoral artery 
 was normal, but no vessel could be felt below the thigh. I amputated the limb at the 
 knee-joint on October 13, twisting the popliteal and other arteries. Some sloughing of 
 the stump followed, but recovery appeared probable, when acute bronchitis set in, fol- 
 lowed by delirium and death. Dr. Fagge kindly examined this patient's heart before the 
 operation and reported : " There is scarcely any evidence of cardiac disease, but I think 
 that I discover a short presystolic bruit. If this is so, the mitral orifice is probably con- 
 
i>is/:.\si:s or riii: Airrrnih'S. 3/35 
 
 truc'ttMl ; :iinl a clni I'liniH'il on tlir valvi- ur in mir of tlic licurt's oavitics iiia}' have Ihtmi 
 carritMl iiitd tin- artcrv of the Idwcr liiiili." After di-atli tin- mitral was iournl tin- size of 
 a biittnii-holi'. Anmiwl its (mIitc witc rfcciit vcixt'latimis, ami uiic of tlifiii, doubtlfss. lia«l 
 hoi'ii carrit'il into tin- circulatidii, caiisiiii^ tin; L'aiiirrfiif. as aimtlitr liail rausi-d the paral- 
 vsis three iiiniitiis |irevii»iisl y. 
 
 Maiiv cases nt' senile L;aii;^rene are doiihtless eniliolic. tVoin tlic washing' away oC snine 
 eali-areniis t'rairnieiit fVniii an atlieniniatmis vessel. 
 
 In some eases of oeelnsion of an artery Ity an emholus, after the application of a liir- 
 atiire hvper.Tsthesia and increased tcmpcratnre of the part Itelow the seat of ohstniction 
 mav he met with. These .symptoms arc clearly due to the infiiieiice oi' the nervous sys- 
 tem and tlie eoiiiicstion of the smaller collateral vessels. 
 
 Arterial Pyaemia. — l>r. W'ilks has also shown (Oui/n Unsp. Rrp.^ 1870) that as 
 in phlehitis niorhid matters may he taken up by a vein and carried into tlie circulation 
 throiiiih the riuht side of the heart, thcrel)y f;iviii<i rise to vennKs jn/ftmitt, no disintegrated 
 tihrin of the hlood may l»e carrii-d into the arterial systi;m from the left side of the heart 
 and give rise to (irtirinl jti/friin'tt. Kehrile symptoms with joint-]iains and rigors associated 
 with aiu-tic and mitral limit ought to excite suspicion of this latter affection ; hut when 
 the liver or s])leen is I'ound enlarged, the diagnosii^ is confirmed. He also points out how 
 this occurs in a secondary fever of the nature of ])yivmia after scarlatina, which is often 
 followed by ioint-])ains, and not uiifre(|uently hy endocarditis. In confirmation of the.se 
 views I may mention that it lias twice fallen to my lot, in the case of lemale patients 
 aged respectively fifti'en and twenty years, to amputate a leg for gangrene the result of 
 occluded femoral artery after scarlet fever. In neither of these cases had any ves.sel to 
 he secured, while in hotli a good result rapidly ensued. 
 
 Pulmonary embolism, remains to be considered — a form which is important to 
 tlie surgeon not so mucli as a disease of the lung as because it is generally a sequence 
 of some clotting — or tlirombosis, as it is called — in the veins. This clotting is very com- 
 mon in all kinds of cases under treatment in surgical wards. We can hardly represent 
 the case too strongly, and we know of no more important subject than this relation of 
 thrombosis to pulmonary emlxilism. Whenever a patient undergoes prolonged rest in 
 bed, especially if he be naturally weak, bloodless, or debilitated from any cause what- 
 ever, if the blood be overfibrinous, as in lying-in women, whenever there is any surgical 
 fever, and in other states too numerous to mention, there is a risk of clotting occurring 
 in the qniit parts of the circulation, especially in the veins of the lower limbs and in tho.se 
 of the pelvis. The symptoms are often slight. If the clot be due to phlebitis, then there 
 may be pain ; if not, there may be no more than the slightest oedema about one ankle. 
 This, however, is sufficient to put the surgeon on his guard, and by the subsequent 
 enforcement of prolonged rest time is given for the adhesion of the plug to the vein wall, 
 and pulmonary embolism is arrested. It should be remembered, too, that clot forming 
 in contact with a comparatively healthy vein wall, as is the ca.se in many instances, takes 
 time, and sometimes a very long time, before adliering to the wall ; and until it does there 
 is the risk of its detachment when the patient moves. There can be no doubt that many 
 have died of pulmonary embolism wlien with a little more vigilance on the part of the 
 attendants they might liave been saved. 
 
 These remarks ap])ly to embolism of the larger branches of the pulmonary arteries, 
 which never give rise to furtlier changes in the lungs, and the patient dies from asphy.xia. 
 If the smaller branches, liowever, become plugged, then arise those secondary inlarcta 
 already mentioned, and in the case of septic embolism the lobular pneumonia of pyivmia 
 and gangrene of the lung. 
 
 Pathology. — The changes which take place when an artery becomes plugged differ 
 according to the size of the afl'ected vessel. If it be a tenniital vessel, the immediate 
 result is congestion of the vascular area concerned, with sub.sequent hemorrhage and 
 atrophy of the tissue. The various stages may be studied with great precision by the 
 ophthalmoscope in occasional cases of embolism of the arteria centralis retinjv. It i.s 
 unnecessary to discuss whether the process is due to vasomotor paralysis or alteration of 
 blood pressure, since it is of pathological rather than of surgical interest, and the ques- 
 tions involved are fully stated in all pathological works. We shall, therefore, only remark 
 further that em])olism of the small vessels is important or otherwise according as the 
 source from wlience tlie plug is derived is healthy or not. If the clot be septic, then the 
 resulting infection will probably lead to an abscess ; and hence the probable connection 
 of abscesses in the pelvis with those in other parts after labor or after operations in the 
 viscera or connective tissue of the body. But embolism of the medium size and larger 
 
356 DISEASES OF THE ARTERIES. 
 
 arteries is followed by chano;es of the very greatest iiioinent in the walls of the affected 
 vessels. Unfortunately, they have up to the present time not been fully worked out as 
 regards embolism, though we can obtain considerable aid toward understanding what 
 takes place by availing ourselves of the exp«^riments which have been made for us by the 
 ligature of vessels. When an artery of any size becomes closed by an embolism, the 
 canal may, of course, be gradually restored by the disintegration and washing away of 
 the plug ; if not, the presence of the clot acts as an irritant, inflammation is set up. and 
 the clot becomes adherent to the wall of the vessel. It is a disputed point whether the 
 next stage is one of organization and vascularization of the clot, or of absorption of the 
 clot by vascular granulations which spring up from the wall of the vessel. Weber holds 
 the former, but Cornil and Ranvier the latter, view. This difference, however, does not 
 matter, as all that is important would be granted by either — viz., that embolism leads 
 sooner or later to a local inflammation of the arterial walls. But if arteritis is thus pro- 
 duced by a simple and healthy clot, the intensity of the local disease will be gi-eater when 
 the clot is septic, the plugs so exciting the component elements of the surrounding arte- 
 rial coat that its tissues will become disorganized, its cellular elements multiply rapidly, 
 and the coats, as a consequence, give way. Indeed, we know that these changes do 
 actually occur in small vessels and abscesses follow ; so, without doubt, also — though the 
 fact is less generally recognized — the same changes occur in the larger arteries and lead 
 occasionally to aneurism. I shall revert to this subject in the chapter on " Aneurism," 
 and will add no more here, since what has been already said, together with the subjoined 
 woodcut of the state of the arterial coats after embolism, may sufficiently explain the 
 morbid processes set up in the larger vessels. 
 
 Treatment. — The objects which surgeons should have in view in the treatment of a 
 vessel occluded by an embolus are to favor the venous circulation through the limb by 
 its elevation and to establish the arterial collateral circulation by maintaining the warmth 
 of the limb by means of cotton-wool carefully wrapped round it over oiled lint. Pain can 
 be relieved by sedatives, such as chloral or opium, given by the mouth, or morphia injected 
 subcutaneously, while the powers of the patient are to be maintained by nutritious diet, 
 by stimulants carefully administered, and by tonics. 
 
 When gangrene has taken place, the parts may be covered with some antiseptic mate- 
 rial, as carbolic acid in a watery or oily solution, one part to thirty, or with powdered 
 
 Fig. 144. 
 
 
 
 
 .,t^\> 
 
 
 Transverse Section of the Upper Part of the Radul Arter\ plugged b\ an Embolus of "^cptic Oiigin some Days before 
 I)eath. (From a ease of ulcerative endocarditis, boy set. 19. Drawn by Dr. J. !■'. Uoodtiart, to show the condition 
 of the aclventitia.) 
 
 a, Clot. /, Adventitia crowded with abnormal nuclei and propor- 
 
 (*, Internal coat. tionately thickened. 
 
 c, Internal elastic or fenestrated membrane. /', Region of vasa vasorum. 
 
 (I, ^liddle muscular coat. g, Fat. 
 
 e, Outer elastic membrane. 
 
 charcoal, chloralum, terebene, or MacDougal's disinfecting powder ; but if the odor is not 
 very offensive, simple oakum surrounding the part may be sufficient. 
 
 When the line of demarcation has formed and the gangrenous part can be removed 
 by amputation, such an operation may bo performed ; but the surgeon should always be 
 cautious in interfering with these cases. He should at the same time take every precau- 
 tion that any necessary or desirable operation is not unduly postponed. 
 
I'.\rilnlj)(;Y OF AXEl'lilsM. 
 
 357 
 
 Fig. 14o. 
 
 ANEURISM. 
 
 All aiK'iirisiii is cither :i suniilntiil hinnn- (•(iiitaiiiiii;,^ IiImmiI cijiiiiiiiiiiif'atiiiL'^ witli the 
 caiiul dt" ail arti'i V and loniu;<l iiKire or h;s.s tVoiii its walls, or a /'nsi/'t/nii illlntntinn »{' an 
 artory. \\ lu'ii all tin- coats arc involved in the saccnlatcd dilatation, it has h(.'cn the cu.s- 
 tttni to describe it as hi-inji; true ; and wluui tlic two inner coats liave <;iven way and the 
 external or cellular alone remains, as /(thr. I a<rree witli Holmes, however, that it is 
 impossihlc clinically to perceive any difi'erence hetween true and false aneurisms at tlie 
 time they jfcnerally come under ohservation, inasmuch as tlie true become false a.s they 
 «j:row ami the false an; liy far the more common. I hohl, moreover, with Moxon, that 
 pathoIo<j;ically, '' when an aneurism has readied any size, and often before it ha.s well 
 started, the several coats of the vessel have lost by inflammation their di.stinctive cha- 
 racter, and that the sooner the division of aneurisms into varieties by the supposed behav- 
 ior of the several coats becomes purely a matter of history the better." 
 
 When the distension of a vessel involves its whole CiiWhra^-ji fusiform or tnljidiir ontnr- 
 is»i or aneurisnial dilatation is said to exist, whether the enlarfrement 
 be or be not due to an inflammatory disease of the arterial coats. 
 
 What is described as a (fijfnsrd^ spurious, or consrcntirr aneurism is 
 where the sac of the aneurism is I'ovmed by the muscles and conden.sed 
 cellular tissue of the part into which the blood has been extra vasated 
 from a ruptured aneurism or a ruptured artery rather than by the 
 arterial coats. These terms should not be applied to cases in which 
 there is diffused extravasatioii of jjlood. 
 
 .1 (fissecn'iiff nneiiri'sm is one in which the inner is separated from 
 the middle coat, or where blood is extravasated into the thickness of 
 the middle coat itself or between the middle and external coats, the 
 blood re-entering the cavity of the artery at some distant spot. The 
 aorta is the part usually affected, and even its whole length may be 
 involved. An excellent example of this affection has been recorded 
 by Dr. Fagge {MtnL-Chir. Trans., vol. Hi.). These cases, however, 
 rarely come under the hands of the surgeon. There are also cirsoid 
 and arterio-venous aneurisms, to which attention will be drawn. To 
 show what an aneurism may do. the following figure (Fig. 146) is 
 given. It was taken from a drawing in Guy's Hospital Museum. 
 The aneurism of the innominata has involved the left carotid and root of the subclavian, 
 a second aneurism of the left carotid existing; above. 
 
 SaciMihitnl Ti.inMiatic 
 Aneurism. .T'lawing 
 44'8,(;uy's IIosp. Mus., 
 Mr. Poland's case.) 
 
 Pathology of Aneurism. 
 
 A low form of inflammation of the arterial walls is, without doubt, the most common 
 predisposing cause, while overaction of the heart and circulation is the exciting cause of 
 aneurism. Direct injury to an artery is an occasional cau.se (traumatic), although more 
 frequently the injury sets up the disease that produces the aneurism. Whenever the coats 
 of an artery are weakened by accident, disease (suppurative or otherwise), or the loss of 
 their natural support, they become liable to dilate under any .sudden or prolonged increase 
 in the force of the circulation. Dr. Rendle of the Queen's Prison, Brixton, has recorded 
 two cases in which abdominal aneurism could be traced to the .shock caused by a .sentence 
 of transportation. Aneurisms are more common in the aorta, where chronic inflammatory 
 changes are so likely to appear and the heart's action is more directly felt ; at the bifur- 
 cation of an artery, where the force of the circulation is always more powerful ; or at the 
 flexure of joints, where muscular action is the most liable to tell by overstretching or 
 bending. 
 
 That aneurism is a disease of the arterial system and not always of traumatic origin is 
 proved from the fact that a man may have an aneurism form when in bed and that the 
 whole arterial system may be involved in the disease. Broca has mentioned a case of 
 Pelletan's in which sixty-three aneurisms were found in one body. It is also a disease 
 of middle age, half the cases occurring between the ages of thirty and forty-five. It is 
 not uncommon, however, to find it in young persons. Dr. X. Moore exhibited one of the 
 external iliac artery in a child aet. 7 (Path. Soc, October 17, 18S2). Syme has recorded 
 an instance in a child of nine. My colleague. Dr. Habershon. reported an example of 
 femoral aneurism in a boy of ten with heart disease. Cerebral aneurism in early life is 
 still more common. But such ca.ses, almost without exception, are associated with vege- 
 
558 AXEUEISM. 
 
 tations on the valves of the heart, and often with ulceration of the valves, and are prob- 
 ably due to embolism. The symptoms are those which Dr. Wilks has described under the 
 term '• arterial pyaemia ;' they are, mainly, considerable pyrexia and 
 Fid. 14H. enlargement of the spleen. Many such are now on record, and, 
 
 besides the parts above mentioned, they have been found situated on 
 the brachial, ulnar, popliteal, axillary, mesenteric, and many other 
 smaller vessels. Indeed, the frequency of their occurrence can only 
 be estimated by looking into the literature of visceral aneurisms. 
 It will then be "found that, though the relation between heart disease 
 and aneurism has not till of late years been studied, very many cases 
 of aneurism associated with endocarditis and emboli in the solid vis- 
 cera have been recorded at diiferent times. Among the earliest 
 writers on the subject are Joliffe Tufnell in the Duhlin Journal^ vol. 
 XV. p. 371 ; Dr. Ogle, Futli. Trans., vol. viii.; Dr. AVilks. do., vol. xi.; 
 Mr. Holmes, do., vol. xii. Other cases have been recorded in the 
 same Transact ion.f more recently by Drs. Church, Goodhart, Gowers. 
 Murchison, Semple. and myself. Similar cases may also be found 
 in various medical publications (viWe Brigld's Medical Reports, vol. 
 Drawing 4^«.J-'U.Vs Ho.p. ji ^ 266 ; Gull, Guys Hasp. Rep., 3d series, vol. v. p. 299 ; Ponfick, 
 Virch. Arcldv, Bd. 58, 1873. See also Wilks and Moxon, Path. 
 Anaf., pp. 158, 159; Holmes, Si/st. Surg., etc.). 
 
 Various explanations have been given of the occurrence of aneurism under such con- 
 ditions. It has been maintained by some that the plug leads to sudden obstruction and 
 afterward to dilatation of the vessel behind it. But a look at preparations of such aneur- 
 isms shows that the dilatation is not behind the embolus, but actually at the plugged spot. 
 Moreover, if the local obstruction leads to dilatation behind it, we ought to find aneurism 
 a more common result of ligature than is the fact ; we ought to find it more frequently 
 after embolism than we do, because embolism is a very common aflPection in one part or 
 another of the body. Other ingenious though somewhat labored explanations have been 
 offered, which need not be mentioned here ; and the only one of any importance is that 
 recently ably argued by Dr. Goodhart, attributing the aneurism to a "local arteritis which 
 in its turn has been caused by the embolism. It has been already asserted that when an 
 artery becomes blocked, the clot, unless it softens and breaks down, becomes adherent to 
 the wall and subsequently becomes vascular. If this be true — and that it is so is allowed 
 by nearly all observers — then there must have been some preceding inflammation of the 
 wall of the vessel to allow of this new formation of capillaries. That embolism causes a 
 local arteritis is admitted, but how it is that under these circumstances an aneurism is so 
 rare a result has yet to be explained, and the explanation is probably to be found in an 
 examination of the cases in which emboli exist. They are, almost without exception, 
 examples of ulcerative endocarditis in which there is a very severe local inflammation 
 attended with symptoms of blood poisoning which is supposed — and we think rightly so 
 — to be due to the septic nature of the emboli which are detached from the ulcer and 
 carried to all parts of the body. When this septic clot becomes lodged in some part of 
 an artery, in proportion to its septicity the artery will inflame, and as a consequence, in 
 the more severe cases, there will be the rapid formation of an abscess and perhaps a false 
 aneurism, whilst in those somewhat less severe cases there will be acute softening and 
 cellular infiltration of the arterial coats, with probably the formation of a true aneurism. 
 In the majority of cases, however, as the embolism is not caused by septic clots, there 
 will be neither aneurism nor abscess. 
 
 In June, 1883, through the kindness of my colleague. Dr. Pye-Smith. I saw a man 
 set. 25 who had been admitted under his care at Guy's with heart disease and symptoms 
 of embolism of the spleen, kidney, and right brachial artery at its bifurcation. The 
 arterial obstruction had taken place the day before his admission, when he was at work, 
 with sudden severe throbbing pain in the bend of the elbow, soon followed by swelling. 
 On admission there was a local swelling at the point corresponding to the bifurcation of 
 the vessel, pulsation in the brachial artery down to this spot, but not at it, no pulsation 
 in the right ulnar artery, and very feeble pulsation in the radial. On the second day a 
 hard lump was felt at the bifurcation of the brachial. On the fourth day the pulsation 
 in the lower ves.sels had improved. On the sixth the collateral vessels about the elbow 
 were enlarged. On the thirtieth day where the lump had been at the bifurcation of the 
 brachial artery strong pulsation was felt. On the thirty-fourth day an aneurismal sac 
 ■was clearly to be felt, with a marked bruit over it. On the forty-sixth it was as large as 
 
A.\/:ii;isM. 
 
 359 
 
 a nut. Tlic |(uls;itiniis in the ratlicK' ulnar artrrics were Cull. In lliis case tlir whole 
 ooiirst' di" fViMits may In- >,i\(\ to havi- lu-cn lUKlcr uhM-rvation. and tlie fact fit tin- iornia- 
 tiuii of an anrurisni tiilhiwinu an (•inlMili.><in was ck-aily ilcinonstrated. 
 
 Progress and Natural Cure of Aneurism. 
 
 An aniMirism. wlu'n nm-e tunnL-d, has a natural teink'ncy tci increase — the " saccu- 
 latrd ' more so than tlie " I'lisif'orm ; " and the " sacculated '" eommiinicatiiig by a small 
 oin'iiinLr witli tin' cavity of an artery has a tendency to increase more rapidly than 
 another in which the openin<r is free, the force of the circulation l>cin<r more concentrated 
 upon one point of the aneurismal sac in the former case than in the latter. Hence sac- 
 culated aneurisms attain a much larger size than the fusiform, and are much more liable 
 to rujiture. 
 
 When an aneurism is cured, it is so by its cavity becomint: tilled with blood clot, 
 which subse([nently contracts, and in the best cases l)y the occlusion of the arterial trunk 
 upon which the aneurism is placed ; the .sacculated aneurism is 
 more capable of a natural cure than the fusii'orm. When the 
 arterial coats are rou':;hened by disease and weakened, the fusiform 
 is as likc'ly to iiu'rease as the .sacculated and is as capable of a 
 spontaneous cure. In any case of sacculated aneurism, as well as 
 in some of fusiform, a sjxnitaneous cure may take place by the 
 coajjulation of the lilood in the sac and the subsecjuent consolida- 
 tion of the clot. When this process is slow, the fibrin of the 
 blood is deposited in layers or lamina) (Fig. 147) ; the external 
 layer in contact with the walls of the sac becomes at times more or 
 less united with them, and so strengthens them as to prevent their 
 dilatation: the clot also becomes dense by contraction and decolor- 
 ized. Subsequent layers form in the same maimer as the process Ja'i>>"atH Coafnihini re- 
 
 n ' 1 • t-i 4.1 11 • au ^ 1 £ 11 "loved Irom Axillary An- 
 
 01 recovery proceeds, until the wlioie sac is nlled and nnally eurism twelve years after 
 obliterated. A section of an aneurismal sac thus cured much ,^|,bcl^fvL'n''Uierv''^%^''- 
 resembles that of an onion, the outer lamin* of fibrin being thin,* ration performed i><2:i. 
 fibrous, firm, and bloodless, each successive layer toward the centre 7achmeru"'""o 'The ""sac' 
 approaching more to the color and consistency of newly-coagulated Prep. <;uy's Hosp. Mus., 
 blood. The laminated coagulum lining the sac is frequently called, 
 
 after Broca, '' active clot," and the soft coagulum in the centre " passive clot," from the 
 idea that this latter is a mere post-mortem and not a vital deposit. This view, however, 
 can scarcely be correct, as there can be little doubt tliat in all cases of aneurism that are 
 rapidly cured by pressure, digital or otherwise, the consolidation of the aneurism must 
 be due to the simple coagulation of the blood in the sac and its subse(|uent induration 
 and contraction, inasmuch as a few hours are evidently too .short a period for the coagu- 
 lum to form in any other way. In the following beautiful drawing (Fig. 148) by Dr. 
 Moxon, taken from a specimen of popliteal aneurism, which was cured, in a man under 
 my care two years before death, by digital compression applied for four and a half hours 
 (see Gii}/'s Ihisj). Rip., 18t!il), the whole pathology of aneurism is .shown, with the con- 
 solidation of the aneurism and occlusion of its supplying artery. 
 
 Colles of Dublin, and some older pathologists, believed that tlie fibrin which lines the 
 sac was the product of an exudation from the lining membrane of the sac. and that suc- 
 cessive exudation of this material formed the lamina?. This view, however, is now almost 
 exploded. Le Fort also accounts for the cure of the fusiform aneurism by inflammation 
 of the inner lining of the sac, and he regards the fusiform as a simple dilatation, which 
 it is not in all eases. Most pathologists, however, now admit that where the inner tunic 
 of an artery exists in a healthy state in an aneurism, coagulation of the blood does )iot 
 take place within the sac, and conse((uently that a spontaneous cure is impossible, and 
 that in the sacculated or fusiform aneurism successive deposits of fibrinous lamime only 
 take place when the internal membrane is absent, from the contact of tlie blood with the 
 rough walls of the sac. 
 
 Mr. Poland has recorded a case, probably uniiiue, occurring in the practice of Dr. 
 Adams of Dublin, of fusiform aneurism of the subclavian, which tends to support this 
 theory {Mcd.-Chir. Trans., vol. Hi. 18t)!>). 
 
 An aneurism may also be cured by the " distal occlusion " or plugging of the artery 
 beyond the sac with a clot that has been dislodged by the force of the circulation, acci- 
 dent, or design. The vessel at first may be only partially clo.sed by the clot, yet fresh 
 
360 
 
 AXEURrSM. 
 
 fibrin will soon be deposited upon the " embolic plug " and com])lete obstruction be pro- 
 duced. This natural mode of cure is utilized in the distal operation for the cure of 
 aneurism, and in the cure by manipulation. Recover}- may also be caused by the 
 "sloughing of the tumor" (suggesting the treatment by caustics). It is likewise on 
 
 Fig. 148. 
 
 o, The section edge of 
 the arterial coats where 
 healthy. 
 
 (ta, The coats in the 
 diseased and occluded 
 part of the artery. Their 
 sulxstauce is dispersed 
 and lilended with the 
 new tibrous tissue, b, 
 whicli fills the vessel. 
 yet not so much difJ'used 
 but that they can still 
 be traced to the mouth 
 of the aneurysm (opposite 
 the upper c). 
 
 e, The aneurism . sac, 
 composed of laminated 
 clot and compressed tis- 
 sue welded together in- 
 definitely. 
 
 <1, Scarcely laminated 
 clot, filling "the hollow 
 of the sac. 
 
 The vein, with two 
 valves in its lower part, 
 is seen close behind the 
 artery. 
 
 Section through an Aneurism of the Popliteal Artery, cured nearly two years before by Digital Pressure. (The 
 aneurism is not dissected out, but left embedded' in the popliteal fat,'f, e. The artery is occluded with the 
 aneurism.) 
 
 record that the artery with which the aneurism is connected may be obstructed either 
 above or below the sat by the pressure of the aneurism itself, from its being bound down 
 by a strong fascia or from the pressure caused by effused blood following its rupture, and 
 in the treatment by flexion this natural mode of cure is made use of. As an aneur- 
 ism increases and encroaches on the neighboring parts, tissues are separated, and even 
 absorbed ; bone may even be gradually worn away by the steady pressure of the pulsa- 
 ting tumor, so that in thoracic aneurism the sternum may be perforated or the bodies of 
 the vertebrae eaten away and the spinal canal opened (Prep. 1489'*", Guy's Hosp. Mus.). 
 During this increase the tissues surrounding the sac may inflame, though they rarely 
 suppurate, and by becoming condensed give the aneurism some support and tend to 
 retard its growth. In rare cases this inflammatory action may involve the sac itself 
 and cause sloughing ; but when the aneurism increases unchecked, it will eventually 
 give way. A thoracic or abdominal aneurism may burst into a mucous tract such as the 
 trachea, phar3'nx, oesophagus, or intestine; and, when it does, Dr. Gairdner (Med.-Chir. 
 Trans., vol. xlii.) has shown that it proves fatal by a recurrent hemorrhage through a 
 s7n(iU orifice. When it bursts into a serous cavity, such as the pleura, pericardium, or 
 peritoneum, it de.stroys by a sudden hemorrhage through a /aiyf aperture. Cases are 
 also on record where it discharged itself into a vein or the pulmonary artery. External 
 or surgical aneurisms burst by the formation and giving way of a slough. Aneurism 
 of the extremities, or surgical aneurism, may give way into a joint or cellular tissue. It 
 may bur.st externally, but only in rare instances. An aneurism may be fairly filled with 
 clot and yet increase, the blood making its way round the clot and thus dilating its walls. 
 This is prevented only when the artery connected with the sac as well as the aneurism is 
 filled with clot. 
 
 The surgeon, however, has more to do with external than internal aneurisms, and, 
 although the pathology of both forms is alike, the treatment diff'ers. It is to surgical 
 aneurisms, therefore, that the following remarks may specially apply, and first of all as 
 to their symptoms and diagnosis. 
 
 Symptoms and Diagnosis. 
 
 An aneurism has no pathognomonic symptoms, and its early symptoms are very 
 uncertain. It often happens that the patient's attention is first directed to some sv:elling, 
 
/>/.u;.vo,s7\ oi' Asr.rinsM. 361 
 
 alt liiMiLili it may In- nnly tliat t\\' Imul lliiDhliiiiij — soiiii' wcakm-ss ur -tiHricss ufaii cxtrcin- 
 ity, nr some m rvc iinin |(it'C(Mliii<; the discnvcry (tf tlic iliscasc ; yet siicli sytii|»t()iii.s arf, 
 not cdiistaiit. Whi'ii, liowi'Vcr, tlin surj^cuii is consiiltcil \'nv pain that sIhidIs down the 
 roiirsc of a luTVi? runiiiiii; in contact with a hir^'c artery, he shouhl alhiw the tliou^'ht of 
 ani'urisnial jiressurc to pass tliroii^rli his mind ; and when tlii.s is asso(riafed with the j)res- 
 ence of a tumor connected with the vessel, the suspicion ot" its heiiifr aneurismal shouhl 
 he excited. It" tliis tumor he si)/(, rxjxnisi/r^ and pu/sufini/. if it Ijccome tense on the 
 application of pressure to the trunk of tht; arttsry on the distal side ami flaccid, non-pulsa- 
 tile, and vanishiut; on pressure on the cardiac side, and shouhl pressun; on the tumor 
 modify the ]»ulse in the vess(d helow, the chances of its heinj:; aneurismal amount almost 
 to certainty. Shouhl it expand aj^ain readily on the removal of the ])ressure, and this 
 expansion he accompanied with a ])(M!uliar thrill on the readmission of hlood into the sac, 
 with a bellows murmur or aneurismal bruit synchronous with the pulse — audible, too, on 
 the application of the ear to the tumor — the diagnosis is com])lete. 
 
 The pulse of the extremity l)elow the swellinj; is frenerally afl'ected ; it is weaker and 
 slower than its fellow, and as the disea.se progresses it may cease altogether. The blood 
 will then flow in a "' venous stream" or cease to flow, either from the obstruction of the 
 arterial trunk by the pressuri; of tlie aneurism or the eml)olie occlusion of the ve.s.sel 
 below from a dislodged coagulum. Under tlu>se circumstances, fulness of the veins with 
 tedema of the ])arts supjdicd by the artery will soon appear, and at times excruciating 
 pain from stretching of the nerves will arise. If the aneurism be cervical and the circu- 
 lation through the brain be interfered with, giddiness and loss of consciousness may be 
 present : and where any pressure is made upon the recurrent laryngeal nerve, a peculiar 
 and characteristic hoarseness will be produced. This hoarseness i.s sometimes as.sociated 
 with loss of voice and laryngeal .spasms simulating laryngeal disease. In the case of a 
 women ;et. 22 under my care, in whom an aneurism existed involving the aorta below 
 the opening of the left subclavian and pressing upon the left bronchus and trachea, this 
 symptom was so severe as to call for tracheotomy. When the cervical sympathetic gan- 
 glia are pres.sed upon, the pupil of tlie affected side may be permanently contracted, and 
 nerve pains will be present according to the amount of pressure applied. 
 
 When an aneurism luis partially consolidated and has either so. enlarged or become so 
 diffused as to press upon the soft parts, so as no longer to exhibit any pulsation — for 
 there are aneurisms that do not pulsate — when it feels firm, with po.ssibly a soft point 
 here and there, some difticulty may be felt in forming a diagnosis, and the surgeon, under 
 these circumstances, will have to depend as much upon the history of the case as upon 
 the pliysical symptoms. When external signs of inflammation or suppuration are present, 
 the difficulty will be enhanced ; for it must be recorded that aneurisms, under these cir- 
 cumstances, have been opened for abscesses. I remember a popliteal aneurism having been 
 so maltreated with a fatal result. Such mistakes of diagnosis, however, ought not to 
 occur, as they are due to carelessness. The diagnosis of an aneurism may generally be 
 made by attending to the history of the case and to the existing symptoms. An abscess 
 in contact with an artery may receive pulsation from it, as may any cyst, or even solid 
 tumor ; but in all these the pulsation will cea.se on the application of pressure to the 
 artery above the tumor without any change whatever taking place in the tumor itself. 
 I have seen a case of lumbar abscess which pulsated freely from aortic contact. It is 
 also rare for such tumors to cause a bruit. Cases are on record in which an artery in 
 contact with an abscess or suppurating hydatid cyst has been opened by ulceration and 
 given rise to the idea of an aneurism. Pulsatile tumors of bone may also be mistaken 
 for aneurism, but from the former being in bone and more or less ossific, from the bone 
 being expanded — although, perhaps, irregularly — and from a bruit rarely existing in it, 
 the diagnosis ought not to be difficult. Tumors lying near large arteries and receiving 
 pulsation from them may likewise be mistaken for aneurism, but. from the pulsation not 
 being expansile and the tumor being capable of being drawn away from the vessel, a cor- 
 rect diagnosis should be made. It must be admitted, notwithstanding, that men of the 
 greatest skill and experience have mistaken such cases for aneurism. 
 
 Treatment. 
 
 There is probably no disease a surgeon has to treat which requires to be dealt with 
 more on scientific principles than aneurism, since all treatment, to be effective, must be 
 based upon the physiological processes of a natural cure ; and this natural cure is brought 
 al)out by the coagulation and subsequent consolidation of the blood in the aneurismal 
 sac, and in the best examples in the artery upon which the sac is placed (vide Fig. 148). 
 
362 TEEATMEXT OF ANEUBJSM. 
 
 To induce coagulation of the blood in the sac and artery by natural processes becomes, 
 consequently, the chief object of treatment, and this is to be brought about by general 
 as well as local means. For this purpose it is necessary to have a feeble circulation 
 through the sac-; and to this end r^st in the recumheut position is an essential point to be 
 ohyerved. and it ought to be maintained in every case ; indeed, there is every reason to 
 believe that by it alone aneurisms have been cured. Luke (^Lond. Med. Gaz., May, 1845), 
 Bellingham, Tufnell. Stanley (Path. Soc. Trans., vol. v. p. 107). and others have recorded 
 in.stances of this nature. Tufnell allowing for diet about ten ounces of solid and eight 
 ounces of fluid food in the twenty-four hours. As a preliminary to all otJier treatment, 
 '■'• abaohite rest^' is. therefore, most essential. 
 
 With the .same object " bleeding " has been employed, and was at one time largely 
 practised on the authority of Valsalva, who powerfull}- advocated it, and probably to 
 excess. There seems no reason why it should not be adopted when the force of the circu- 
 lation is strong and the powers of the patient ai*e good, as bleeding not only lowers the 
 force of the circulation, but at the same time tends to render the blood more fibrinous. 
 In internal aneurism it is calculated to be of more service than in external, but, practised 
 with caution, it is doubtless of value in both. Medicines do not seem to have much influ- 
 ence in encouraging the coagulating process, though the acetate of lead gave some prom- 
 ise of value in the hands of m^' former colleague. Dr. G. 0. Rees, but more extended 
 experience has not confirmed the hope held out ; the iodide of potassium or sodium has 
 been also much vaunted, more particularh' when syphilis is su.?pected. 2Cnfritions, but 
 unstimnlating. food .should be given in all instances to maintain the powers of the patient, 
 though not to increase the force of the circulation. All mental excitement should be 
 positively forbidden. 
 
 The object of the local treatment of aneurism is to arrest or diminish the circulation 
 through the sac, and the success which is to be expected from whatever practice may be 
 adopted will depend as much upon the shape of the aneurism as upon the size and po.si- 
 tion of the opening into the sac. The surgeon has for this purpose a variety of means 
 at his disposal, which may be divided as follows : 
 
 1. Compression of the artery above the aneurism — " indirect pressure." 
 
 2. Compression of the aneurism itself — '"direct pressure." 
 
 3. Compression of the artery as it leaves the aneurism — " distal pressure." 
 
 4. The Hunterian operation of applying a ligature to the artery on the cardiac side 
 of the aneurism or the occlusion of the afferent vessels by other means. 
 
 5. The application of a ligature to the artery within the aneurism itself — operation 
 operation of Ant^^llus. 
 
 6. The application of a ligature to the artery on the distal side of the aneurism — 
 " di.stal operation." < 
 
 There are likewise other means which may be justifiably employed in exceptional 
 cases — such as the treatment by manipulation, galvanic puncture, and the introduction 
 of some foreign body into the sac — to which attention will be drawn. At Guy's Ho.s- 
 pital in the fifteen years ending 1880, 42 aneurisms were treated by compression alone, 
 and 19 by the Hunterian operation when compres.sion had failed. In 13 cases the 
 Hunterian operation was primarily employed. In 3 the operation of Antyllus was per- 
 formed. In 3 the distal ligature was used. In 1 primary amputation was called for, and 
 in 1 the aneurismal sac was plugged with horsehair. In all, 82 cases were treated. For 
 full details ride valuable paper by Charles Symonds (Gut/'s Rep., vol. xxv., 1881, p. 447). 
 
 Treatment by Compression. 
 
 1. Indirect Pressure. — This plan of treatment, to which the term " Dublin 
 method " may fairly be given, has now found a lasting place in surgery : Todd. Hutton, 
 Bellingham. Tufnell, and Carte, though not originating the practice, having adduced ample 
 evidence of its scientific and practical value. It consists essentially in the more or less 
 complete cutting off" the supply of blood from the aneurismal sac by the application of 
 pressure to the artery on its cardiac side ; and the more completely the current of the 
 blood is arrested, the more rapid appears to be the cure, modern experience having fairly 
 proved the soundness of Dr. W. Murray's observation in 1871, that the principle on 
 which the rapid method rests is clearly •• the complete stagnation of a mass of blood in 
 the aneurism until it coagulates." Whether this is to be done under the influence of an 
 anaesthetic or without, whether by pressure both above and below or only above the sac, 
 and whether the pressure is to be made by the hand, by flexion, by a weight, or by a 
 
Tni:.\TMi:sT nv (•(fMi'ni-:ssi().\. 363 
 
 touriii(|Uot, arc (iiu'stimis wliicli in no wav (micli ilic {iriiici|il(; nii wliidi tlic treatment 
 is based. The |>ractiee is tlutirelieallv Mtiiinl aii<l jiraetieally safe, ami is ea|ialile by 
 itself hI" ciiriiit^ tlic iiiaj(trity of surfrical aiieiirisnis, and even some that are internal. At 
 least I'oiir eases i>l' aneurism of the neelc have l»een cimMl l»y dijrital eompression ol' the 
 eoinmon eamtid, and .Nl. Kuiii^e of Lau.sanne re|Mirts a fifth, in which a man iet. (!H had 
 a earnti<l ain-iirism cured in seventeen days by lateral jiressure between the thumb, in 
 IVont (if the sternu-masloid mu.M'le, and the fin<rers behiiul (Hull, dr In Sue. ih Chlr.. IHdK, 
 ]i. Kil). .Mr. (iay has al^i a|i|parctitly cured ;i sixth case by tin- same process {Lnuirt^ 
 Hcdmes's lect., ISTo). 
 
 ('(impression should not be altem|ite(l where evid(Mice exists of jiressure ujion the 
 main vein of the limb, as indicate<l by (edema, or where the aneurism is rapidly increa.s- 
 intr or a rupture ol' the aneurism appears immim-nt, because in sucIj cases a lifrature 
 should be a|)plied to the arterial trunk. It should not be persevered with when slouph- 
 inj: of the skin has been induced, nor ouffht it when, from some constitutional irritability, 
 indocility, or stupidity, the patient fails to second the surgeon's aim; for to make the 
 patient understand the objects which the surgeon has in view is doubtless a valuable 
 means of guaranteeing their successful accomplishment. Tt mu.st be known, however, 
 that when compression has failed to cure, "the patient is in a worse, and not a better, 
 state for subscMpient operation."' Mr. Holmes has demonstrated this fact (Lanrit. Octo- 
 ber 12, 1S74). 
 
 This treatment can be carried out by " digital " or " instrumental " compression or by 
 means of '' Esmarchs bandage," a form of pressure which differs from the other in some 
 es.sential points, to which attention will be drawn. 
 
 l)ii/if(il prrs.tiirt\t(> be successful, must be well applied; when indifferently carried out, 
 it is probaldy less to be relied upon than instrumental pressure. To keep up a steady pres- 
 sure u])on the trunk of an artery for any tiuie consecutively is a difficult task, and few men 
 could do it for more than ten uiinutes. AVhat is wanted is the steady equal pressure of a 
 finger or thumb applied directly over the vessel which is to be compressed, such pressure 
 being .so adjusted as to be suflScient to arrest the flow of blood through the artery, but no 
 more. Greater pressure than this is a waste of power on the part of the surgeon and a 
 cause of needless distress to the patient. Neither vein nor nerve need be much pres.sed 
 upon, as a rule, nor much pain produced. To carry out this treatment three good men 
 should be employed for four or five hours consecutively, each in rotation carefully apply- 
 ing pressure for ten minutes at a time. By ado|iting this practice 1 have cured an aneur- 
 ism of the thigh in twenty-four hours, and in other ca.ses even less time has sufficed. 
 In a case I recorded in Guys I/o.y>. R<p. for iStiO a patient act. 32 cured himself of a 
 popliteal aneurism by pressure in four and a half hours. In one more recent a man net. 
 4(1 cured himself in eighteen hours, after flexion and prolonged surgical treatment by 
 instrumental pressure had utterly failed. M. Vanzetti in 1855 records a case in which 
 digital compression cured a popliteal aneurism in four hours. 
 
 When digital pressure can be employed and is successful, it is more rapid than any 
 other, and, as a rule, less painful. It can also be used where instrumental pressure is 
 inapplicable, as in the case of the carotid. In fact, when admis.sible, it should always be 
 primarily employed in preference to any other form of treatment. 
 
 I)i>itri(menfal Compnssiou. — W/ien (ligltcd eompresaion cannot he applied, flif nc.rf best 
 is instrumental pressure, and for this purpose there is nothing equal to a conical weight of 
 lead (Fig. 149, a) covered with leather and perforated with an iron axle (b), upon which 
 extra pieces of lead (c) can be dropped (Bellingham's method), the weights being so 
 adjusted as to arrest the circulation through the artery, and no more. This weight can 
 be slung to a cradle placed over the limb, held by an assistant or left to the intelligent 
 patient. It can be shifted gently from one spot to another when pressure causes pain, 
 and is far less painful than any other instrument. In popliteal aneurism the weight may 
 be adjusted to the upper part of the groin, and it is an excellent plan to apply a semicir- 
 cular tourniquet lower down, by which means pressure can be applied alternately. The 
 instruments of Signorini, Bellingham (Fig. 149, d), Skey. Crampton, Carte, or any other 
 that allows the pad to press upon the vessel and not otherwise interfere with the circula- 
 tion through the limb, may be used for this purpose. All of these consist of a circle or 
 semicircle of steel, a fixed pad being attached on one side for counter-pressure, and a 
 movable pad, adjusted by a screw, for direct pressure. Indeed, with these instruments 
 carefully adjusted by the aid of a trustworthy a.ssistant w'ho will see that pressure is well 
 applied, maintained, and shifted only when required, most cases of aneurism of an extrem- 
 ity may be treated. In Fig. 150 is depicted an ingenious contrivance made by Weiss, on 
 
364 
 
 INSTRUMENTAL COMPRESSION. 
 
 the principle suggested by Mr. F. Bulley, for the application of pressure to an artery by 
 means of pads which may be used alternately and adapted to Bellingham's instrument (d, 
 Fig. 149), either by the rigid screw or elastic pressure of Coles's pa"d ; and in Fig. 151 is 
 shown a very valuable arrangement suggested by Mr. George C. Coles— the pressure being 
 
 JBar of cradle 
 
 Fig. 150. 
 
 Weiss's Double Pad. 
 
 Mode of applying Pressure to the P^emoral Artery for the Cure of Aneurism. 
 
 elastic — which may be used as hand pressure or adapted to any of the tourniquets. The 
 treatment by compression requires intelligent supervision, and then is very successful, but 
 without such it is uncertain in its effects. 
 
 My friend and colleague, Mr. Davies-Colley, who happened to have been my dresser 
 when a case of popliteal aneurism was under treatment by digital compression, informed 
 me that he proved by experiment that he could readily arrest the circulation through 
 the femoral artery for six or eight hours at a time with his finger applied directly over the 
 vessel and the weight adjusted upon his finger, the weight acting in lieu of the muscular 
 power that would otherwise have been required as the compressing force. 
 
 To neutralize the effects of the local irritation of the skin by the pressure, free use 
 may be made of French chalk, starch, or violet powder. To allay pain opiates or chloral 
 
 in full doses may be given, 
 Fig. 151. and in some cases even chlo- 
 
 rofonii may be used and its 
 influence kept up for several 
 hours, to allow of complete 
 compression being main- 
 tained. Dr. Mapother did 
 this for twelve hours. There 
 seems little doubt that in a 
 general way complete obstruc- 
 tion to the circulation is more 
 likely to be followed by a 
 rapid cure than is incomplete, 
 and that next to completely 
 stopping the flow of blood 
 till the aneurism has consol- 
 idated the application of the intermittent complete compressing force is to be advocated, 
 or, in other words, complete compression may be maintained for a certain time and then 
 given up, to be returned to as soon as the condition of the patient will permit. The total 
 suppression of the circulation is doubtless the most rapid plan of curing an aneurism, but 
 
 JMMMfil 
 
 llus instrument consists of a trephine handle, to which is attached a 
 straight rod telescopically arranged. The two upper segments of this 
 rod are hollow tubes, each containing a spiral spring; the lower segment 
 IS a solid brass rod fitting into the upper, having at its extremity a screw 
 at an ol)tuse angle. To the end of this is adjusted a pad composed of 
 cotton-wool and horsehair. 
 
ti'j:.\tmi:st nv i:a.\1)A<;i:. ;iG5 
 
 tlu' partial .supprossion is likewise successful, altliou}.'li slowiT. On all these points, liow- 
 ever, I shouUl like the l)uliliii surjjeoiis to speak. Dr. Kawiloii Maciiaiiiara has clone so 
 ill an able paper (lirlt. Mnl. ./mtr., August VJ, 1871), IVoin which the following extract 
 has heen taken. It epitomizes the whole: 
 
 "A ca.sc of ]iopliteal ane.iirisni presents itself for treatment. We determine to use 
 (•(impression. We first carefully ascertain the ccjiitlition of the patient's general health. 
 If an;iMiiic or hypenemic, we take appropriate measures; and when we are satisfied upon 
 this point, we ap])ly snine one or other of the most improved compressors — tho.se in 
 which the comjtressing power is modified elasticity. With this we compress the artery 
 ill the upper ])ortioii nf its course, having previously arranged, some three or four inches 
 lower down, the aiixiliarv instrument by means of which we propo.se to alternate the 
 pri'ssure. The upper instrument is now made to control the artery, so as hut just to 
 arrest the pulsation in the sac. This is the most delicate step in all the procedure, and 
 is regulated by the hand of an intelligent assistant, who at once informs us when the 
 pulsation is arrested ; and then and there the further application of pressure is arrested. 
 A roster of intelligent students is now organized, and to them is entrusted the manage- 
 ment of the case. Two are appointed to take charge of the patient for one hour, when 
 tliev arc relieved by two others, and so on during the day, whereby we secure unwearied 
 attention during the period that pressure is kept up ; and. as in Dublin we visit our ho.s- 
 pital at 1) o'clock A. M., the treatment generally commences about that hour and is 
 continued up to nine o'clock P. >[., when all pressure is rem<jved and the patient is 
 encouraged to take his night's rest undisturbed. Next morning the treatment is resumed, 
 and so on until the cure is perfected. At the commencement of the ca.se we take the 
 patient into our confidence, explain to him the nature of his case and the method we are 
 about to adopt for his cure, placing clearly before him the alternative, with all its possi- 
 ble dangers, which we should have to adopt in case compression should fail. The value 
 of this procedure is very frequently demonstrated by the intelligent interest exhibited by 
 our patients in the management of their own cases — so intelligent as in protracted cases 
 to supplement, if not altogether to supersede, the supervision of them by our students. 
 In the selection of our compressing force we adopt in its widest sense the maxim 'Nullius 
 addictus jurare in verba magistri.' Should one compressor prove irksome, we try another; 
 if all should fail, we have recourse to digital compression or to compression by means of 
 weights ; but in every instance, convinced of the soundness of this plan of treatment, we 
 leave no stone unturned to .secure its success." 
 
 Compression by (he Elasdc Bdinhige of Esmardi. — The treatment of an aneurism by 
 this method differs from all other forms of treatment by compression in that in it the 
 blood is totally arrested in all the vessels of the extremity to which it is applied and iKit 
 in the main artery alone, as in other forms of compression. Under such circumstances, 
 the method has its own dangers, in addition to those it shares with others ; and the chief 
 I believe to be gangrene, due, apparently, to the clotting of the blood in the collateral 
 vessels of the limb upon which its vitality depends. The following case illustrates the 
 point. 
 
 The case was that of a man fet. 45, who was admitted into Guy's, under my care, in 
 March, 1877, with a po])liteal aneurism, which was increasing so rapidly that active 
 treatment was called for. The man could bear neither digital nor instrumental pressure 
 upon the afferent artery. I consequently applied the elastic bandage to the limb below 
 the aneurism, using moderate pressure, allowed the aneurism to fill with blood, and then 
 so compressed the thigh above the sac as to entirely check all pulsation in it. these three 
 being apparently the essential points to observe. A subcutaneous injection of morphia 
 was also given. The pressure was maintained for three hours consecutively and a second 
 dose of morphia injected; but when the bandage was removed, the aneurism was decidedly 
 harder, although pulsation still existed in it. Four days later all clot .seemed to have dis- 
 appeared, and. as the aneurism was as big as ever, the elastic bandage was again applied, 
 only on this occasion, to soothe the man, an antvsthetic was used. This treatment was 
 continued on this occasion for three hours, and at the end little had been gained from it. 
 A fortnight was then allowed to elapse to allow the parts thoroughly to recover them- 
 selves, when a carbolized catgut ligature was applied to the artery, and within one week 
 the wound had completely healed by immediate union, not a drop of pus having been 
 exuded ; indeed, the patient had no idea that any operation had been performed upon 
 his thigh. 
 
 The foot, however, soon became the seat of anaemic gangrene, and a fortnight after 
 the application of the ligature amputation in the middle of the leg \\as required and a 
 
366 TREATMENT BY DIRECT PRESSURE. 
 
 good recovery followed. At the amputation every arterial trunk was found obstructed. 
 No vessel required torsion or ligature. 
 
 In this case I am disposed to attribute the gangrene to the employment of the elastic 
 bandage, and fear that from its two applications the collateral vessels that would have 
 carried on the circulation through the foot after the ligature of the femoral had become 
 blocked, and, as a consequence, gangrene followed. 
 
 This plan of treatment was first suggested and carried out by Staif Surgeon "\V. Reid, 
 R. N. {Lancet, 1875), and it has since been practised in more than 7<l cases. I have 
 employed it in 3. Mr. Pearce Gould, an able assistant surgeon of the Middlesex Hospital, 
 has in an interesting paper ' tabulated 72 examples, 35 of which or half the cases were 
 cured. In 2 the treatment was doubtful; in 20 a cure followed the ligature of the artery; 
 3 were cured by compression and 1 spontaneously, and 1 (of bracheal artery) by the 
 introduction of catgut into the .sac. In 3 the artery was ligatured without success ; in 3 
 death took place whilst under treatment, and in 1 the limb was amputated with a fatal 
 result. Of the whole number of 72 cases — omitting the 3 of which no subsequent his- 
 tory was known after the failure of the method and the 2 doubtful — G died. 35 were 
 cured, and 25 were successfully treated by other means after the failure of Esmarch's 
 bandage, in my own case after amputation — a result which is certainly encouraging. 
 The method is most applicable to small sacculated aneurisms in fairly healthy subjects, 
 and ought not to be practised when the aneurysm seems thin and likely to rupture, and 
 when by pressure it materially interferes with the venous circulation of the limb. 
 
 When employed, the bandage .should be so applied as to secure complete blood stasis 
 in the aneurismal sac and its atljacent artery, and this stasis should not in the majority of 
 cases be maintained for inore than one hour, or for more than two in any. The bandage 
 should primarily be applied below the aneurism with sufficient firmness to arrest the cir- 
 culation through the limb. It should be passed lightly over the aneurism, so as to sup- 
 port but not compress it ; and when carried fairly above the tumor, which should be allowed 
 to become well filled with blood, it should so constrict the limb above as to prevent any- 
 thing like a circulation being carried out. In irritable subjects a subcutaneous injection 
 of morphia should be given before the treatment is commenced, and in others an anaes- 
 thetic may be used. When the sac appears to have been filled with clot and pulsation in 
 it has ceased, it is wise to have digital or instrumental pressure kept up upon the aflferent 
 artery for ten or twelve hours, and even when a doubtful cure has taken place a like 
 treatment may bring about a good result. Indeed, in all cases of rapid cure of aneurism 
 by this or other modes of compression this treatment should be pursued, because the clot 
 that has filled the sac must of necessity be soft, and a very little may cause its displace- 
 ment, and thus interfere with that natural contraction of the fibrin of the blood that is to 
 fill the sac permanently, prevent its dilatation, and cure the disease. At Guy's Hospital, 
 out of 17 cases of popliteal aneurism consecutively treated b}' pressure, 11 were cured; 
 and Mr. Holmes informed us in his college lectures that out of 124 cases so treated in 
 different hospitals, 66 were treated with and 58 without success. Of the latter, in 44, 
 the femoral artery was afterward tied, and in 8 amputation was practised, 5 dying. Death 
 occurred in 1 case and in 4 there was no evidence of subsequent treatment (^Lancet, 
 December 19, 1874). In the majority of these cases instrumental pressure was employed, 
 and in some the treatment was imperfectly carried out. 
 
 2. Treatment by Direct Pressure. — The treatment of aneurism by direct 
 compresiiirm next claims attention, and in modern times it is known as that hx flexion ; for 
 there can be little doubt that the modus operandi of flexion in the cure of aneurism is 
 mainly due to three conditions : first, to direct compression of the aneurismal tumor itself: 
 secondly^ to indirect compression through the medium of the tumor, intercepting either 
 wholly or partially the supply of blood to the sac: and. thirdlij. to displacement of the 
 clot, as suggested by Holmes, and the consequent obliteration of the mouth of the aneur- 
 ismal tumor. This mouth may likewise be so situated as to be closed by the bending of 
 the artery, an aneurism in the posterior wall of the popliteal artery being in a far more 
 favorable position for cure than one on the anterior. At the same time we know that 
 forced flexion of a limb is capable of arresting the flow of blood through the healthy 
 artery. In England. Mr. E. Hart demonstrated the success of this method of treatment 
 in the year 1858.^ although in 1857, Dr. Maunoir of Geneva recorded the first successful 
 case in U Echo Medicate (Neufchatel), and since that time many surgeons have success- 
 fully applied the practice. To carry it out. the limb must be carefully bandaged from 
 
 ' Trans, of Internat. Congress, 1881, vol. ii. p. 209. 
 ^ Med.-Chir. Trann., vol. xlii.; Pvoceediny.*, vol. iv. 
 
ri'J'.ATMKST nV DISTAL PRF-^.^mE. 367 
 
 helow upwanl to the am-urisiii. and in the case of the pnjjliteal artery the knee shouhl 
 l»e hent, sutticient force l)einji; ein|ih»yL'd to iliininish or arrest the pulsation of the tumor, 
 hut no more, some turns of the roller maintaininj; the limh in this p(jsition. The tliij^h 
 shouUl then he flexed upon the pelvis and the patient turned on his side with tlie linih 
 restintr o.i a pillow. My this plan tlie arrest of the cireulation throujrh the aneurism may 
 freiierally he efl'ected and a cure expected. When the flexion is forced, the jiatient is too 
 often unahle to endun' the sufVerin;; cause<l hy the jiosition. To lar<re and rapidly }rrow- 
 inir aneurisms this method is inapplicahle, and jtrohahly dangerous, as it may induce rup- 
 ture ; and when any iuHammation or other complication exists, it ought not to he em[»loyed, 
 nor ought it he persisted in when it is not lihviously doing go(jd. The plan, however, in 
 small ant'urisms is .so simple, and when liearahle is so successful, that it should always be 
 attem]>tcd where it can he applicil ; and when unsuccessful, it is almost harmless. 
 
 Pressure may likewise he used with riexion where the latter is insufficient, many ca.se.s 
 having been reported in which success followed the conjoint means. In one under my 
 care in 1S71 I cured aneurisui helow the popliteal space in eighteen hours by alternating 
 the flexion of the leg with digital pressure in the groin. 
 
 M. Liegoi.s in an interesting paper (^IJ Utiian Med., August, 18G9) gives 11 ca.ses in 
 which flexion alone proved successful in popliteal aneurism, and also 11 in which it wa.s 
 successful in combination with other measures. In 4 it succeeded after other means 
 had failed. On the other hand, it failed in 23 eases, or nearly half the whole number, 
 and of the.se 7 are stated to have suffered rupture and 1 had inflammation of the .sac. 
 Holmes's statistics show nearly the same results. 
 
 3. Distal Pressure. — The compression of an artery on the distal side of an aneur- 
 ism for purjKiscs of cure claims a notice as a resource open to the surgeon when all others 
 are ina]>](lical)le, since there is enough evidence to show that by such means an aneurism 
 may be cured. In my own practice, in 1S72. I treated a case of abdominal aneurism on 
 this principle, and kept up pressure for sixteen hours; and, although the patient died 
 from peritonitis, bi'ought on by the pressure, the condition of the sac filled with clot was 
 enough to prove the pos.sibility of a cure being brought about. In the Tmnsorfions of 
 the Royal Med. and Chir. Society, vol. Iv., the ca.se is published in detail, with some 
 remarks on distal treatment which need not be repeated in the.se pages, although it may 
 be stated, from my own cases, from Edwards's case of the innominate (Lancet, January 
 9, 1858), from Porter's (DuhUn Quart. Jonrtiaf, November, 1867). and others, that the 
 distal treatment of aneurism by compression or ligature, whereby the efferent artery of 
 an aneurism can be obstructed, claims the surgeon's close attention when other means are 
 ina]i))licable. 
 
 Tiwporary Occlusion nf Artery. — The wire compress of Mr. Die of Hull, already 
 alluded to (see p. 34(3). requires naming as a means of dealing with aneurism. It is a 
 method that has been advocated by Porter of Dublin (Di(h. Quart. Jfntm., November, 
 1867). Hilliard, and others (vide Mr. Dix's paper in the British Medical Journ.., October 
 30. 1875, p. 551). It is in reality treatment by compression, and not by strangulation. 
 It does not cut the artery nor obliterate it at the seat of operation ; therefore in principle 
 and methodus medendi it ranks not with the ligature, but with the tourniquet and other 
 modes of pressure. But, forasmuch as the application of the wire requires exposure of 
 the artery by a cutting operation, this process cannot enter into surgical competition with 
 the simpler methods of compres.sion and flexion ; yet where these have failed or are inap- 
 plicable, and operative procedure is inevitable, "then," says the author, '• I back my ope- 
 ration, for certainty, rapidity, and .safety, against any form of ligature — silk, hemp, or 
 catgut — or against any kind of forceps, ' artery constrictor." or compressor applied in or 
 through a wound. " 
 
 The operation is as follows, and it seems to be specially necessary to follow out the 
 exact details with care and attention : 
 
 The artery is exposed by incision and the aneurism needle passed in the usual way. 
 A piece of surgical wire about 9 inches long is threaded through the eye of the aneurism 
 needle and carried beneath the artery by the withdrawal of the needle, which is then 
 separated from the wire. A straight surgical needle is then attached to either end of the 
 wire and the two needles (first one and then the other) are passed through the ti.ssues to 
 the surface, so that they emerge on the skin, one about a quarter of an inch and the other 
 three-quarters of an inch from the edge of the wound, on whichever side of it may seem 
 most convenient, hut loth on the same side (Fig. 152). By drawing them through 
 together the wire forms a loop over the artery and the intervening tissues, and the needles 
 are then detached from the wire. The half of a vial cork, flat side downward, is now 
 
368 
 
 TREATMENT BY WIRE COMPRESS. 
 
 Fig. 152. 
 
 U/XT*- 
 
 t tL ourtc Tit ~ ~; 
 Dix's Mode of Compressing Artery. 
 
 placed on the skin between the ends of the protruding wire and firmly pressed down by 
 the fingers of an assistant in the exact line of the urteri/, the wire being at the same time 
 drawn tightly upward and sharply twisted over the cork till the current through the artery 
 
 is effectually stopped and the pulsation of 
 the aneurism ceases. It Is of great import- 
 ance that the po.sition of the cork should 
 be longitudinally over the course of the 
 artery, so that the blood current is checked 
 as much by the downward pressure of the 
 cork as by the upward tension of the wire, 
 the intervening tissues forming a firm com- 
 pressed pad. The superfluous ends of wire 
 are then cut off" and the wound closed and 
 dressed according to the predilections of the 
 surgeon. 
 
 "When the depression of anaesthesia goes 
 off" and the circulation revives, it will be 
 found that a feeble pulsation returns in the 
 aneurism. This, according to the author (who strongly advocates the gradnal rather than 
 the rrqnd method of producing coagulation in the sac), should be allowed to go on for two, 
 or even three, days, when the wire is to be tightened in the following manner : 
 
 The cork being firmly pressed down over the artery, the wire is drawn uj)ward by 
 gentle traction on its twisted ends, and two or three small wooden wedges are pushed in 
 hy an assistant between the cork and the wire, so that sufficient tension is caused to 
 entirely stop all pulsation in the aneurism. If the wire has been sufficiently drawn 
 tightly, at fir.st very small wedges are required, such as two or three bits of a lucifer 
 match, for instance. The wire is on no account to be twisted afresh, lest it break-. 
 Meanwhile, by the action of the two or three days' feeble current the .sac has been pre- 
 pared, as it were, for the coagulation of sudden sfft clot which is now formed, whilst the 
 collateral circulation has also by the same means been encouraged, the result being that 
 in from twenty-four to forty-eight hours consolidation is perfect ; thus about the fifth or 
 sixth day the cure is complete and the compress may be removed, which is thus done : 
 Untwist the wire and remove the cork ; separate widely the two ends of the wire, to 
 lessen the curve as much as possible ; clip off" one end close to the skin ; make gentle 
 pressure with one finger where the cork has been, and by steady traction on the other 
 end of the wire it is readily withdrawn. If it should seem to adhere, leave it till next 
 day. when it must have becom'^ loosened in the tissues and will be easily removable. 
 The advantages of this ruethod are thus summarized by Mr. Dix : 
 
 I. The wire does not cause ulceration or any damage to the coats of the artery, either 
 external or internal ; therefore, the blood channel being unopened, bleeding — one of the 
 chief dangers of the old operation — is impossible. 
 
 II. By causing at first a retarded circulation and a diminished current it most accu- 
 rately imitates the natural cure of aneurism, and by allowing time for the establishment 
 of the collateral circulation the risk of gangrene — the second great danger of the ligature 
 — is very much diminished. 
 
 If, nevertheless, there be coldness of the limb and a threatening of gangrene, the 
 wire can be at once untwisted and relaxed, or even removed. 
 
 III. Ultimately the current through the artery and the sac is entirely obstructed, so 
 as to produce the needful clot. Of course this complete obstruction can be effected at 
 first if desired, and therefore this operation does what an operation by ligature or forceps 
 cannot do — viz., it gives the surgeon a choice between the rapid and the gradual method 
 of treatment. 
 
 It will be seen that in the opinion of the author the gradual method is much to be 
 preferred, and he. considers it one of the chief merits of his operation that this effect can 
 be produced. 
 
 lA^. The -jvire does not act as a foreign body in the wound, setting up suppuration 
 and impeding the healing process, as a ligature does. 
 
 V. It is not a fixture upon the artery remaining for an indefinite period, but, its work 
 being done, it can be at on<:-e got rid of. 
 
 VI. The clot produced by this concurrence of the gradual and rapid method is less 
 likely to break down and suppurate than the soft sudden clot, which is the eff'ect of the 
 ligature. 
 
TRKATMhWr I'.Y I.IC ATrilE. 
 
 ;ifj9 
 
 Fio. 153. 
 
 Anol's. Hunter's. 
 
 Wardrop's. 
 
 \'II. .\n(l lastly. .\.'h tlicrt' i> no |Mis.sil)ilit y nl' lilciMlini:; rrmii tlic artery, the Hiirj.'(!(»n 
 ha.s a wider elioiee dI" loeality fnr u|ierati(iii. I"'(ir in.staiice, tlie <<iiiiiiiiiii leiriorul rir the 
 external eamtid, whieh dm iiecimiit of heiiiorrliai^ic ri.sk.s i.s usually avditJeil hy the (ipe- 
 rutDr. may he .safely treated on this plan, which is, indeed, applieahle to all arteries alike. 
 
 N. U. InasMMudi as it i\y)vs not idditerate tlit! artery at the site oC the application of 
 tlie wire, this procedure, in ifs /msi nf ('unn. is not suitahhr for tin; distal operation ; hut 
 it is prohahhf that complete ot-clusion and ohlitiMution may he clh-eted hy tin; simple nnjdi- 
 ticalion of applyinir '"'" wires upon the vessel ahoiil Imli' an inch a]iart, lielween whieh a 
 clot would iorm and hecome or<;anizeil. 
 
 This nu'thod is (|uite trustworthy in trainnalic aiMuri^in and in a wounded artery, 
 where a wire should he applied on either side of the orilice in llie artery and the ves.sel 
 divided hetwei-n them. It has also proved succe.ssful in amputution, etc. 
 
 4. The Treatment by Ligature. — When the treatment of an aneurism hy com- 
 pression in one of its forms is inappli(;ilile either from the position of the antMirism or from 
 the unsatisfactory comlition of the ])atient, or 
 when su(di treatment has proved unsuccessful, 
 then the treatment hy li<j;ature should he enter- 
 tained ; and this should he carried out hy the 
 Hunterian method (Fijr. !'>;}) — that is, hy the 
 application of a ligature at some distance from 
 the sac, ratlier than hy the " methode d'Anel," 
 in which the li<rature is ap])lied close to the 
 aneurism. The advantages of the Hunterian 
 operation are the slight flow of blood through 
 the aneurism when the main flow is arrested, the 
 maintenance of the collateral circulation, and the 
 probability of the artery being more healthy at 
 some distance from than clo.se to the seat of dis- 
 ease. The operation is also, as a rule, less diffi- 
 cult. 
 
 The ligature employed should be of either 
 carbolized silk, ox aorta, kangaroo tendon, or 
 prepared catgut. The ends of the ligature should 
 be cut ort" short after the band has been tied, and 
 an attemj)! should be made to get quick union of 
 the wound. To leave the ends of the ligature 
 long encourages suppuration and ulceration of the artery at the point of ligature ; the 
 vessel may ulcerate through or a portion of the artery may slough away with it — a pro- 
 cess which takes from nine to twenty days, or more in large vessels. With the prepared 
 catgut ligature now en)ployed, some ulceration of the vessel at the seat of ligature may 
 likewise follow, but a complete division of the artery by ulceration need not take place. 
 On that account the catgut ligature is preferable. 
 
 Causes of Death after Llijatiir' . — When the ligature fails and death ensues, it is from 
 gangrene of the parts below the seat of disease or from secondary hemorrhage. The 
 former is the more fre(|uent cause of death, and, according to Dr. Norris, out of fifty 
 fatal eases of ligature of the femoral artery, twenty-three died of gangrene and only eight 
 of hemorrhage. To lessen the risk of hemorrhage some excellent surgeons have within 
 the last lew years returned to the old practice of ligating the artery in two places and 
 dividing it between the ligatures. They have done this under the idea that by such a 
 practice the tension of the vessel is lessened, and, as a con.sequence, the risks of bleeding 
 are diminished. Signor Corradi of Florence follows this method, as a rule,' and Dr. J. 
 Lidell advises it. 
 
 When a ligature is ap))lied to the main artery of a limb, the circulation is for a time 
 
 more or less cut off"; conse(niently. coldness of the part, and even gangrene, may ensue. 
 
 Congestion, however, generally takes place gradually in the extremity, from the blood 
 
 being forced into the collateral vessels, and with this some increase of temperature may 
 
 be felt, with hypenxjsthesia. This point has been already noticed in my remarks on 
 
 embolic arterial obstruction. Brown-8e<|uard explains the elevation of temperature that 
 
 is often observed in a part after the application of a ligature to its main artery l)y the 
 
 paralysis of the vaso-motor nerves that ramify on or in the coats of the vessel, this 
 
 paralysis producing a corresponding paralysis of the ramifications of the vessels, and, as 
 
 * Ashhurst's Internat. Eiiciiclon. of Sun/., vol. iii. 
 24 J I J J' 
 
 Diagram showing the DifTerent Operatiou.s for 
 Aneurism. 
 
370 TREATMENT BY LIGATURE. 
 
 a consequence, the blood finds its way freely through the collateral branches into the part 
 below the seat of the ligature ; this increased activity of the collateral circulation produces 
 the congestion of the part as well as the concomitant elevation of temperature (Arc/iives 
 de Physiolotjie, 1851). The surgeon should, however, after the application of a ligature 
 do what he can to maintain the temperature of the limb, which is best effected by cover- 
 ing it thickly with cotton-wool, at the same time keeping the part raised, to encourage 
 the venous circulation. Simple nutritiou.s food should be allowed, but stimulants only 
 with great caution, and in quantity merely enough to help digestion and maintain the 
 force of the heart's action, the habits of the patient forming the best guide as to quantity. 
 Should pain be present, opium, morphia, or chloral must be prescribed, either by the 
 mouth or subcutaneously. 
 
 When the ligature has separated, the wound healed, and the aneurism consolidated, 
 no forcible or prolonged exercise of the limb must be allowed for some weeks, although 
 gentle exercise is beneficial. The limb should also be kept warm, for it has happened 
 that the circulation through it has failed to become full or even sufficient after the opera- 
 tion, and some permanent weakness and loss of sensation has been left. A patient may, 
 however, live a long life even after a double operation. In 1864 I saw a man aet. 51 
 upon whom Mr. B. Cooper had operated twenty-three years before (1841) for popliteal 
 aneurism of the left leg, and of the right in 1843. He had been an orange-porter, and 
 subsequently followed his work. When gangrene takes place, it is generally as a direct 
 result of the cutting off of arterial supply from a limb and of the ensuing blood stasis. 
 As a consequence, it occurs within a few days of the ojieration. It may, however, be 
 produced by the presence of an inflamed or rapidly increasing aneurism, and has then 
 little or nothing to do with the operation. It should be dealt with energetically. If it 
 spread rapidly and threaten life, amputation of the limb about the line of ligature should 
 be performed without delay. Should it, however, be limited in its nature and slowly pro- 
 gressive, the expectant treatment must be employed. The warmth of the limb at the 
 same time should be carefully looked to, the sloughing or dying parts covered with well- 
 oiled lint, the venpus circulation assisted by the elevated position and by gentle friction, 
 and the powers of the patient stimulated by food and wine, opiates being administered for 
 the alleviation of pain. 
 
 When the sac of the aneurism inflames and suppurates after the application of a liga- 
 ture, the case may be regarded as one of local gangrene the result of the operation ; it is 
 a dangerous complication and no definite rules can be laid down for its treatment. 
 Hemorrhage is occasionally a result of this action, the blood coming from the lower end 
 of the vessel ; pyaemia or blood poisoning is another. In general, when an aneurismal 
 sac suppurates, amputation is the best practice when it can be performed, and where it 
 cannot the operation of Antyllus may be successful, as in a case of carotid aneurism 
 reported by Mr. H. Morris, Med. Chir. Tram., vol. Ixiv. In August, 1871, I applied a 
 ligature to the left carotid artery of a man set. 29 for a large aneurism, and death ensued 
 on the thirty-fourth day from suppuration of the sac and sloughing of nearly the whole 
 aneurism. This process had been preceded by some hemorrhage on the thirteenth day 
 after the operation. The same result may take place after the cure by compression^ 
 rapid or slow. It is an open question, however, whether aneurismal sacs that have been 
 suddenly filled with coagula are not more liable to break up and suppurate than others in 
 which the process has been more gradual. 
 
 In rare instances after the Hunterian operation the pulsation of an aneurism reap- 
 pears, and a passing feeble pulsation in the sac a day or two after the application of the 
 ligature is by no means a rare occurrence, nor need it excite any alarm, as it is doubtless 
 due to the passage of a feeble current of blood through the sac by means of a collateral 
 branch. This is more likely to occur when a cure by pressure has been, previously 
 attempted and failed, the collateral circulation having been enlarged by the pressure. 
 Should, however, the pnhnflon continue peraisfenf, even after the application of a ligature 
 to the main trunk, it will be fair to infer that a " vas aberrans " exists, by which the 
 blood is brought direct to the aneurism, and which must be ligatured before a cure can 
 be expected. At times the existence of this vas aberrans may be made out at the time 
 of operation, when the vessel must be looked for when the main trunk is tied ; indeed, it 
 may be possible that no necessity will be found to tie the main trunk, as the operation for 
 aneurism is to tie the vessel that supplies the sac, and this may be connected only with 
 the vas aberrans. 
 
 Operation of Antyllus. — Should it not be possible to apply a ligature to the efferent 
 vessel, and the case is one in which other means are inapplicable or the aneurism is 
 
TREATMF.ST HY M [SIl'H.ATIOS. 371 
 
 clearly the result ni' a wounded artery, the formidable original operation for aneurism — 
 that of Antyllus. practised more recently l)y Synie — may he re(|uircd. which is the layiti;; 
 open of the sac of the aneurism, llu' reujoval of its contents, and the apftlication of a lifra- 
 ture ahove and lielow its connection with the artery. To do this, however, much bold- 
 ness and operative skill are neci-ssary to prevent a fatal hemorrhage. With this object, 
 in a case of axillary aneurism. .^Ir. Syme made an incision above the clavicle aion^' the 
 border of the stcrno-mastoid muscle, to enable an assistant to compress the subclavian 
 artery airainst the first rib.' acting.: upon the sann- principle as he adopted thirty years 
 bef«>re, when he nnnle an incision behind the anj:le of the jaw to enal)le an assistant to 
 compress the internal ma.xillary artery before the removal of the upper jaw. In IHdl he 
 laid open a <;luteal aneurism, havinj; previously thrust a bistoury into the tumor over the 
 situaticui of the gluteal artery and introduced a fin<!:er, .so as to prevent the blood from 
 flowinji; except l)y occasional <rushes. He eventually thrust his hand into the .sac, rapidly 
 turned out the clot, and had the bleeding orifice at onee under subjection by the pressure 
 of the hand. Both cases did well. Still, this practice i.s only applicable to desperate 
 cases where all other modes of treatment have failed or are out of the question. In 
 aneurisms of small arteries, however, it is very applicable. I have successfully employed 
 it in many cases of aneurism of the radial and ulnar arteries for traumatic aneurism with 
 good results, and in several cases I divided the ve.s.sel completely and twisted both end.s, 
 a rapid recovery followinL^ 
 
 Diafnf Litjii'iii'. — WIkmi a ligature cannitt be applied to the cardiac .side of an 
 aneurism and the treatment by compression has failed or is inapplicalde. the distal opera- 
 tion of Brasdor or the a|iplicati(in (»f a ligature to the vessel as it leaves the aneurism 
 (Fig. \h'.^) may be entertained, with the view of assisting coagulation of blood in the 
 aneurism by "slowing" the blood current; for it may fairly be accepted, as proved by 
 the cases of C. Heath. Annandale. Holmes, and Barwelk that the application of a ligature 
 to the left carotid artery in aneurism of the aorta is of benefit. The credit of the sug- 
 gestion, however, mu.st be given to Dr. Cockle, who wrote on the subject (^Lmnef, 1869), 
 although three or four ca.ses had previou.sly been recorded in which the operation had 
 been performed with success for supposed carotid aneurism. Evidence likewi.se exists to 
 show that the application of a ligature to the right carotid artery in ca.ses of innominate 
 or mixed innominate and aortic aneurism may do good. This practice is to be followed 
 up. if needs be, by the application of a ligature to the subclavian vessel, Mr. Fearn's 
 ca.se ajid others having made the repetition of the operation justifiable. In Augu.st, 1871, 
 I performed Wardrop s operation on a man xi. 33 for innominate aneurism. The sub- 
 clavian was ligatured with a carbolized catgut ligature ; the wound was closed and sealed 
 with lint saturated with the compound tincture of benzoin. A good recovery ensued, 
 and considerable consolidation of the aneurism. The man left the hospital thirty-six 
 days after the operation so well satisfied with the success of the treatment that he did 
 not return to have the carotid ligatured ; indeed, he went on so well up to about six 
 weeks Vjcfore his death that he thought nothing of his trouble. He died from dyspnoea, 
 the result of pressure, in August, 1874, three years after the operation. After death the 
 aneurism was found to be full of solid clot, and there was a passage through it to the 
 carotid, with a smooth lining. T'nfortunately, the gentleman who took out the prepara- 
 tion threw away the bulk of the clot that filled the sac, which was as big as a fist. The 
 success of the operation, however, was encouraging. 
 
 The Treatment by Manipulation. 
 
 This method was introduced into surgery in 1852 by Sir W. Fergusson,* and it is based 
 on natural although exceptional processes — viz., the embolic occlusion of the distal end 
 of an artery by a dislodged clot. It is practically to be carried out by the manipulation 
 of the sac of an aneurism with the view o^i dislodging the blood clot it may contain, with 
 the chance of such being carried- by the circulation into the afferent artery. It may 
 likewi.se be employed " to alter the relations of the laminated fibrine in the cavity of the 
 aneurism, so as to bring about a further deposition of fibrine on the projecting surfaces 
 of the di.splaced lamina? " (Oliver Pembertons Aildress on Snrgfri/, Brit. Med. Assoc). 
 Sir W. Fergusson practised it in two cases, and in both the success was sufficient to sanc- 
 tion the repetition of the means in appropriate cases and when all other treatment is out 
 of the question. Holmes told us {Lanat, vol. i.. 1873. p. 159) that it had been used in 
 five cases of subclavian and two of femoral aneurism. In two cases a cure was obtained, 
 ' Med.-Chir. Trans., vol. xliii. * Ibid., vol. xl. 
 
372 OTHER METHODS. 
 
 and in a third it was probable. In cervical aneurism the practice is not applicable, on 
 account of the dangers of embolism of the cerebral arteries. 
 
 Galvano-Puncture, or Electrolysis. 
 
 To induce or assist coagulation of the blood in the sac other means have been sug- 
 gested, and of these tlce treatinenf hy galvcuio-puncture^ as advocated by Abeille in 1849 
 (J /■'■//. Qin. de Medecine) and by Ciniselli in IHolJ, is one of the mo.st promising in theory, 
 though the practical results have not been equally satisfactory. In consists in the intro- 
 duction of the two needles of a constant-current battery into the sac, witli the view of 
 coagulating the blood into a firm clot. The practice is one that can be entertained only 
 in exceptional cases — i. e., in those which cannot from their position be submitted to other 
 forms of operation. It is, however, well adapted for the treatment of aneurisms at the root 
 of the neck and the thoracic aorta, and possibly for some forms of abdominal aneurisms. 
 
 The constant-current battery should be used, and a moderate current, say of five cells, 
 be first employed, its strength being increased gradually, but never to cause pain. The 
 battery may be used for half an hour at a time, about twice a week, yet this will depend 
 upon its eifects. The needles should be of steel gilt, sharp, very fine, and about three 
 inches long, and should be insulated to within half an inch of the point. They are to 
 be introduced and removed with a rotatory motion, and may be attached to either pole 
 of the battery. The dangers of the operation are, as stated by Holmes, principally from 
 two causes, " the inflammatory action produced in the sac and the cellular tissue which 
 surrounds it, and the gangrene or ulceration of the skin at the points of entrance of the 
 needles." 
 
 Other Methods. 
 
 The treatment by injection is a mode that demands notice, although hitherto 
 it has not been satisfactory. Alcohol, tannin, acetic acid, and the perchloride of iron 
 have all been used as coagulating agents, but the last is the drug for which the most can 
 be said. That it has a powerful influence in causing the coagulation of the blood is well 
 known, but to produce this in the sac of an aneurism is a dangerous proceeding. The 
 most dangerous result is embolism, and the next inflammation and suppuration of the 
 sac. A solution of the perchloride diluted to one-twentieth the strength of the British 
 Pharmacopoeia preparation is strong enough, and not more than about twenty drops of 
 the solution ought to be dropped into a large sac. The graduated glass syringe with 
 screw piston should be employed, such as is generally used for subcutaneous injections. 
 Care should be taken that the perforated trocar be well introduced into the cavity of the 
 tumor, and that the afferent as well as eflerent artery be well compressed. The escape 
 of arterial blood is the only test of the trocar having entered the sac. The fluid should 
 then be injected, and by manipulation mixed with the blood. When the sac seems solid, 
 the canula should be withdrawn ; but the pressure upon the cardiac side of the sac 
 should be maintained subseqiiently for a full hour, to prevent the consolidating mixture 
 of blood and iron being sent onward into the circulation. 
 
 With objects similar to the above, the late Mr. Moore inserted twenty-six yards of iron 
 wire into an aortic aneurism through a canula, his object being merely to detain the fibrine 
 of the fluid blood {Med.-Chir. Trans., vol. xlvii.). Dr. J. Levis of Philadelphia in Octo- 
 ber, 1873, inserted twenty -four feet of horsehair into a thoracic aneurism in a man xt. 41 
 with some advantage, and on November 25, 1873, I adopted a like practice, introducing 
 into the sac of a rapidly-increasing popliteal aneurism due to embolism twenty feet of 
 horsehair through a fine canula, with the eft'ect of causing almost complete consolidation 
 of the tumor. The patient was a man aet. 33, admitted with ulcerative endocarditis, who 
 survived the operation five days. Mr. Gould records a case in which a Dutch surgeon. 
 Van der Meulen, cured a brachial aneurism in a woman xt. 22 by the introduction of cat- 
 gut into the sac. The results thus obtained are quite sufiicient, therefore, to justify a 
 repetition of the operation under circumstances in which all other plans of treatment are 
 unjustifiable or have failed. 
 
 In recent times Langenbeck, with the view of causing contraction of the walls of an 
 aneurism, has been led to inject the parts surrounding the sac with a solution of ergotin. 
 Dr. Dutoit of Berne relates in Lcnu/cnbcck's Arcln'v (Band xii.. No. 3) a case in which he 
 successfully adopted the practice ; the man was forty years old and the aneurism was sup- 
 posed to be subclavian. Fifteen injections were made at intervals of two or three days 
 over the tumor, which gradually diminished. To render the cure certain, however, digital 
 compression was subsequently employed. 
 
'n:.\rM.\ric .\\/:ri:isM. ;}7;] 
 
 Traumatic Aneurism. 
 
 All ailtrv rt'ccivfs a |Miii(t iirctl or an iiicisi'd wound; Mccflinj; fakes place; pressure 
 is applied to eontnd it, and tlie wound lieals. In course of time a pulsatint: sw(dlin^' is 
 discovered at the seat td" injury, and a traumatic aiu-urism is said to exist. 
 
 A man in wrestling' or after niakiii'; some sudden unprepared-lor muscular exertion 
 finds something irive way in his lej; or fancies he has sprainetl his knee. In a shorter or 
 loiif^er period a swellintr ajijtears in the popliteal space, which steadily increases and is 
 pulsatile: he has heconie the subject of an aneurism. In the former case, doulitless, the 
 injury was the direct cause of the aneurism: in \\\v hittir \t produced it indirectly hy 
 actinjr upon a diseased vessel. And yet. if tlii' former aneurism is sacculate<l cither hy 
 the expansion of the reparative material with which tlu! wound of tlie artery had hecri 
 closed or l»v the hernial protrusion of one or more of the coats of the artery throu<rh a 
 rupture or wouiul ol" the outer (tr l»y the condensation of the cellular tissue intr) which the 
 blood has escaped, it diflers in no sin<,de practical j)oiiit from the latter or any other aneu- 
 rism that has been alreaily considered; and, what is more, it must be treated on the .same 
 principles, although, as the artery of a traumatic is healthier than that of a si)oritaiieously 
 formed aneurism, the traumatic may be more readily cured. 
 
 When, however, an aneurism caused by an injury is vaguely or not encysted, when 
 either from the first it is " diffused" or it becomes so from the rupture of its sac, or when 
 atiij onlimirj/ (tiicKrixni nij>fiiris, a different condition presents itself to the surgeon, and 
 the case ajiproaches that of a ruptured artery and is to be treated accordingly — that is, 
 the artery is to bo cut down upon, if possible, at the scat of rupture, and its two ends 
 ligatured or twisted, or the aneurismal sac is to be opened and the operation of Antyllus 
 performed. Amputation may be called for. 
 
 Wlu'ii with a sprain, fracture, or dislocation there is evidence by want of pulsation 
 and other symptoms that the main artery (d" the part is obstructed, it is not to be assumed 
 that the vessel is lacerated and should be cut down upon and tied, because a large propor- 
 tion of such cases as these recover without any such proceeding being called for. Indeed, 
 in one where the extravasation is severe and no pulsation exists, it is impossible to make 
 out with any clearness the true condition of affairs. A limb either with or without a 
 fracture may be greatly distended, and this from effused blood; but whether the blood 
 has been poured out from the rupture of a large artery or vein or some smaller vessel 
 there can be no means of knowing, .since even the pulsation in the vessels below may be 
 indistinguishable on account of the effusion. Under these circumstances no active pro- 
 ceeding can be carried out. The limb should be elevated, cold applied, and the ca.se left 
 to nature, and in a large number of instances a beneficial result will ensue. I can recall 
 several such cases where I anticipated bad results, but witnessed good. If the effusion is 
 so severe as to be followed by evidence of arrest of circulation in the limb, the surgeon 
 will be justified in cutting down upon the vessel at the point where the history of the case 
 indicates that it is wounded, and in tying both ends after having turned out all clot, etc. 
 In other cases the main artery may be tied, but too often there will be nothing to be done 
 but amputation, as gangrene may set in. This operation, however, must be postponed till 
 the line of demarcation is ftiirly indicated. No general rule can, however, be laid down 
 for the treatment of all these cases, as each one must be treated on its own merits. 
 
 But the student .should remember — 
 
 1. That every encysted aneurism, however caused, is to be treated upon the previously 
 described general principles. 
 
 2. That ruptured traumatic aneurisms arc to be regarded as ruptured arteries. 
 
 H. That the rupture of an artery when bound down by a dense fascia, such as the 
 popliteal, is generally followed by the complete arrest of both the arterial and venous 
 circulation in the liinb, and, as a result, by gangrene, which requires to be treated by 
 amputation. 
 
 4. That in cases of partial rupture there may be less extravasation, and consequently 
 less severe effects ; under such circumstances pressure upon the main trunk above may 
 suffice to bring about a cure, or, if this fail, the application of a ligature to the wounded 
 vessel may be required. 
 
 5. That a ruptured artery in parts less fascia-bound than the leg (as, for instance, the 
 arm) may be treated more as in the case of injuries to arteries, by the application of a 
 ligature to the wounded vessel. 
 
 Collateral Circulation.— When an artery is obstructed, the circulation is carried 
 on bv what is called the collateral circulation, in which the vessels coming off above the 
 
374 
 
 ARTERIO - VENO US ANE URISM. 
 
 obstructed part communicate with those which arise below it. At first the vessels are 
 very numerous, but as time goes on their number diminishes, and only those most con- 
 
 FiG. 154. Fig. 155. 
 
 Anterior View. Posterior View. 
 
 Sf^~ tt 
 
 Fig. 154. — a, Common iliac artery, ft, External iliac, r, Internal iliac. </, Femoral, e, I'rofunJa. f, External circum- 
 flex, g, Internal circumflex, h. Iliac artery, which had been tied and had shrivelled into a cord. i, Kemains of 
 aneurismal sac. A, Anastomosing branches of the circumflex ilii. /..Anastomosing branches of the circumflex 
 externa, m, Obturator artery, anastomosing with, n, circuniflexa interna. 
 
 Fig. 155. — o. Gluteal artery. 6, Ischiatic artery, c, Anastomosing branches of gluteal with the circumflex, rf, .Anas- 
 tomosing branches of the ischiatic with the perforating branches of the profunda. (Prep. 15191'-, Guy's Museum.) 
 
 veniently situated for carrying on the circulation become rajjidly or gradually and per- 
 manently enlarged. 
 
 To illustrate this beautiful compensatory natural act I submit two drawings (Figs. 
 154, 155) taken from a preparation in Guy's Museum, made by Mr. Cock in the year 
 1826, from a patient £et. 58, in whom Sir A. Cooper had applied a ligature to the external 
 iliac artery for femoral aneurism eighteen years and a half previously. 
 
 A full description and preparation of the case is to be found in the first volume (first 
 series) of the Guys Reports, by Mr. Cock. The drawings need no lengthy description, 
 as they explain themselves. 
 
 Arterio- Venous Aneurism. 
 
 When an artery and a vein communicate with each other, the arterial blood passing 
 directly into the vein without the intervention of a sac, an aneiiri»mal vari.i: is said to 
 
 exist (a, Fig. 156) ; and when 
 a sac exists into which the 
 arterial blood flows in its pas- 
 sage to the vein, this condi- 
 tion is called a varicose aneu- 
 rism (b, c, and D, Fig. 156). 
 Both these varieties of ai"te- 
 rio-venous aneurisms are now 
 rare ; but when venesection 
 was a common operation, they 
 were far more frequent, as 
 they are usually produced by 
 the perforation or division of 
 an artery through a vein, the 
 opening between the vessels 
 remaining permanent. Both 
 forms may originate sponta- 
 Goupil (Paris, 1855) recorded the fact that out of fifty-seven 
 
 Illustrating the Difterent Forms of Varicose Aneurism. A, 'I'ho artery and 
 vein directly communicating. B and C, The dilatation being more in 
 the vein. I), Aneurism laid open. 
 
 neously from disease. 
 
.\irri:nii) - \ i:\oi 's . i .\i:i l'/s.u. 
 
 375 
 
 Aneurisnial Varix. 
 
 cases iif tills jitVcclinii. tliiity-niif wcif tlic icmiIi dl' lilrcdiii;.^ Cases are on reeonl wliere 
 the anita ami siijierior or iiilerior vena cava eoiiimunieateil. Wade ( Duhlin Mnl. J'rixg, 
 IStil ) has leeordeil a ease in wliieli an openiii}; existe<l hetween the aorta and jmlinoiiary 
 artery; in 1SS2 1 suw a ease with my coliea^rue, Mr. |)avies-('()ney. in which this condi- 
 tion existed hetwoen the snperlieiai femoral artery and t'einorul vein, the result of" a f^un- 
 shot wound, and my friend Mr. Morris informs nie that hu lias seen a like ease in the 
 femoral reiiion. the result ot" a jtistol-shot received hy a s|)ortsm.iii in America. Indeed, 
 all the lar<ie arteries and v«'iiis may he similarly affected. 
 
 In an aneurismal varix the vein assumi-s in some de;:ree the i»ro|Mrties of an 
 artery and liecoim- riil:ir.:til I'mm the arterial impulse, liesides hein;; irrejrularly <lilated 
 and tiu-tuous, the dilatation assumes a fusiform or sacculated ajipearance, while it also 
 hecomes thickened and pulsates, the mixe(l hlood currents iriviiiLT rise to a peculiar thou<jjh 
 characteristic " huzziu;^" murmur which when once heard is not likely to he mistaken. 
 
 In some instances the condition is conj^eiiital ; it was so in the one illustrated (Fig. 
 157). in which the st>at of commiinicatioM of the ves.sels was ahmit the axilla. The boy, 
 ait. 14, was admitted under my 
 
 care at Guy's in 1 S7!» f<ir hleed- I''u;. l'>7. 
 
 in^ from an opi-u ulcer on his 
 loft intlex fiiii:er, the ulcer hav- 
 iiiLT followed an injury eifi'hteen 
 mouths previously. The in- 
 jured fiuirer was spoiiiiv from 
 vascular tissue, and the palm 
 of the haiul had the apjicar- 
 ance of a cutaneous ua'vus. 
 TIk^ veins of the whole limb 
 were immen.scly distended and 
 thrilled very markedly ; the 
 buzzing- murmur so generally present in these case.s was very characteristic. The case 
 was treated by elevation of the limb after it had been firmly fixed to a splint ; under such 
 care there was no recurrence of blee«jiiig, and a rapid healing of the ulcer on the finger 
 followed. It was not thought expedient to interfere with the disease. 
 
 In the varicose aneurism the sac may or may not freely communicate with the 
 artery or vein. In some case.s it will involve the whole calibre of both vessels, or the 
 vein may be hypertrophied and enlarged, as in the aneurismal varix. In a unifjue case 
 (Fig. 158). recorded by Mr. Cock ( Mn/.-Chir. Tnnis., 1851), of atraumatic varicose 
 aneurism of the popliteal artery, the sac was small, but involved the whole calibre of the 
 artery and vein, and the whole of the arterial l)lood passed through it. The secondary 
 effects of the disease were also shown with singular clearness. It occurred in a man set. 
 28 who eleven years previously had received a punctured wound in the popliteal artery 
 for which two weeks subsequently, on account of secondary hemorrhage, the femoral was 
 ligatured. He convalesced and returned to his work, but two years afterward became the 
 subject of •' varicose veins." He remained well until three or four months before hia 
 admission into Guy's, when he had fever, and on convalescing and trying to walk discov- 
 ered his leg was stiff, painfid. and swollen. He was admitted with what was supposed 
 to be a large collection of pus beneath the superficial mu.scles of the calf. The femoral 
 artery below Poupart's ligament and the anterior and posterior tibial arteries were pul- 
 sating freely. The cavity was opened; .some ounces of dark grumous, pitchy, non-eoag- 
 ulaltle blood escaped. The next day a ((uantity of offensive pus flowed away mixed with 
 coairula. For a fortnight everything went well, when arterial hemorrhage took place, and 
 he lost nearly three ])ints of blood. After due consultation, amputation was performed, 
 from which an excellent recovery ensued. 
 
 On dis.secting the limb ]Mr. Poland found connected with the popliteal artery an 
 aneurismal sac (Fig. 158, .s) the size of a pigeons e'J!:p:. which w'as of cartilaginous hard- 
 ness and lined with fibrine. The artery ( ^4) freely entered the sac from above. The 
 vein ( F) was obstructed above with coagulated blood, and below was lost in the walls 
 of the sac as a fibrous cord. From the lower part of the sac two vessels issued ; the 
 smaller one (o) was the continuation of the popliteal artery, c/i-fafli/ iJimiimhifl in size, 
 which divided as usual to the leg. The larger ( Va) was the popliteal vein greatly hyper- 
 tro])hied, pouched, and puckered. It was quite pervious and pas.sed down for about two 
 inclies, when it divided into two trunks : one, which accompanied the anterior tibial artery, 
 was quite ohl iterated, the other led directly into a second aneurismal sac (s^) the size of a 
 
376 
 
 ARTERIO -VENOUS ANEURISM. 
 
 Fig. 158. 
 
 Mr. Cock"s Case of Arte- 
 rio-Venous Aneurism. 
 
 duck'.s effg. witli th*^ walls of which its coats became identifiod. It was this that had been 
 opened. From the lower part of this venous .wc emerged three or four large impervious 
 branches that were clearly veins accompanying the posterior tibial 
 and peroneal arteries. The contents of these veins could be washed 
 out and the valve-s seen. 
 
 It should be added that the cutaneous veins above described as 
 varicose were greatly hypertrophied. and it was evident that the 
 whole of the blood from the leg was returned through them. 
 
 It would appear also that in this case, as a dtrect result of an 
 injury, a varicose aneurism formed, into which the whole of the arte- 
 rial blood flowed. Moreover — 
 
 That the arterial blood subsequently found a more direct course 
 through the popliteal vein than through the artery, and as a result 
 the vein became hypertrophied and the artery atrophied. Also — 
 
 That the force of the arterial blood current upon the thin coats 
 of the vein caused the gradual dilatation of the vein and the subse- 
 quent formation of an aneurism in its course, and that by the giving 
 way of this aneurism bleeding had taken place. 
 
 The wasting of the femoral vein ahore and the hypertrophy of the 
 same vein hehnc the upper sac, from its taking on the functions of an 
 artery, are points of interest ; and not the least important change was 
 the great hypertrophy of the cutaneous veins through which the whole 
 of the venous circulation of the leg must have been carried on. 
 
 I have given this case at some length because it illustrates better 
 than any general description the whole effects, primary as w^ell as secondary, of a varicose 
 aneurism. 
 
 With reference to diagnosis, it may be stated that at the point of junction of the arte- 
 rial and venous streams a peculiar burring bruit is often felt and heard, and this bruit fre- 
 quently extends along the course of the dilated veins. Where a sac exists in which the 
 two blood currents meet between the artery and the vein, there is likewise a soft bruit. 
 The sac is rarely very large, and is made up of .condensed cellular tissue and plastic 
 matter. 
 
 Treatment. — In these cases surgical intei'ference is not generally required. Should, 
 however, the disease be extensive and either from pain, mechanical causes, or chances of 
 rupture of the vessels require treatment, a cure may be attempted by the occlu.sinn of 
 the artery above and below the point of communication between the artery and the vein. 
 The case should be treated as one of wounded artery. The vein need not be interfered 
 with, as it will gradually wither so soon as its arterial communication has been cut off. 
 
 Pulsating exophthalniOS, or vascular protrusion of the eyeball, associated with 
 a marked swelling and enlargement of the vessels, a peculiar rushing bruit, and arterial 
 pulsation, is an affection of much interest and of some ob-scurit}-, since it may be due to 
 intraorbital aneurism, to rupture of the internal carotid artery into the cavernous sinus, 
 or to some condition of vessels apparently independent of arterial disease. Mr. Bowman's 
 dissections have fairly demonstrated that this affection may exist during life and after 
 death show no patholog}'. 3Ir. W. Rivington has written an excellent article upon this 
 subject (Med.-Chir. Trans.. Iviii.), and has proved that in many cases this affection has 
 been preceded by some fracture of the base of the skull, complicated, probably, with 
 laceration of the venous sinus and obstruction or laceration of the internal carotid artery, 
 and in idiopathic cases the like changes probably exist ; in fact, some of these cases of 
 pulsating exophthalmos had better be looked upon as examples of arterio-venous aneuri.sm. 
 Treat.aiext. — Some of the.se cases do well without treatment; but when they show 
 evidence of steady progress. Rivington's facts clearly prove the propriety of apph'ing a 
 ligature to the common carotid artery, success having followed this practice in fifteen out 
 of eighteen idiopathic and twenty-three out of twenty-.six traumatic cases. 
 
 Cirsoid Aneurism, Erectile Tumors, and Aneurism by Anastomosis. 
 
 These have nothing in common with the spontaneous and traumatic aneurisms that 
 have been already described beyond the fact that they are diseases of the arterial system. 
 They are vascular tumors made up of arterial tissue and formed by a dilatation and elon- 
 gation of arteries, the term cirsoid anruri>im being employed when the trunks of the larger 
 vessels are involved (vide Fig. 159), and aneurism hy anastomosis, or cirsoid arterial tumors, 
 
CIRSOID .\si:ritisMS. 
 
 377 
 
 l-K.. 1. ■)'.». 
 
 wlifii tlic siiijillcr vessels (ir ciiiiillaries are afleeted. In tlie eirsoid aiii-urisiii (irie vessel 
 
 or iiiaiiy vessels may Ik- diseased, tlie disease sli(t\vin<: itself liv tiie arterv lii'coniiiiL: tur- 
 
 tiKiiis, dilated into jioiudies, and ciinvuluted. When (trie vessel 
 
 aldiie is atl'eeted, (Insseliu ealled it itrtiriitl nirix. Wlien lln' 
 
 disease is on the sealp (its most (Mimiiion seat), three; or I'luir 
 
 larL'e idrtimiis arteries may lie seen eonver<rin<_' to the eentre. 
 
 where a eonireries ol" dilated arteries will he found, prohahlv 
 
 of" new growth. It may, however, affect the arteries of the 
 
 extremity. I have seen it in the foot fFiir. Iiid). and Crii- 
 
 veilhier has reported a case in which the external iliac arterv 
 
 was so af!'eeti'd. Cirsoid aneurism is i;<'nerally found in youn<: 
 
 jieojde dnrinir the period (d' <:rowth, and in the majority of eases 
 
 can he traced to local injury. It can he ri-adily made out liy 
 
 its pulsatiufi; nature ami the jieculiar tortuous and convoluted 
 
 appearance of the diseased ves.sels, not only of the vessels form- 
 
 inii" the tumor, hut of the arteries hy which it is supplied. 
 
 Tkk.vtmknt. — All forms id' treatment have been tried in 
 these cases, such as direct pressure, injection, the application Artery. (Taken from a man 
 of lijratures to the vessels that converge toward the arowth, *t.«"who was under my care 
 
 , ^ ^ m 1881.) 
 
 and to the main artery that goes to the part; the tumor has, 
 
 moreover, been laid open and treated by pressure, with the view of causing its ohditeration 
 by inflammatory exudation ; Grlif, Bell, Arnott, and Lawrence have each recorded suc- 
 cessful instances of this form of practice, but no good success in the majority of cases 
 has been achieved. 
 
 The best success has. however, follow'ed the removal of the growth, either by the 
 application of the ligature or by excision. In 1S70 I excised a cirsoid aneurism, situated 
 below the jaw in connection with the facial artery, from a lady, set. 25, with success. In 
 
 Fig. IfiO. 
 
 pluniur u.rUTif 
 
 This drawing was taken from a patient of Mr. Poland's, a girl xX. 19. The di.sea.se followed an injurv, and was treated 
 by amputation, other nieasuies having failed {Gin/s Hosp. Rep., 18r>9). 
 
 1867 I treated a boy aet. 14 for a large cirsoid aneurism of four years' growth, situated 
 on the right temple. It was supplied with blood by tortuous vessels converging from all 
 quarters, and pulsated freely. I applied acupressure pins to all these vessels, even to 
 their division, without success ; the growth for the time became flaccid, but quickly reap- 
 peared and increased. Under the.se circumstances I exci.sed the tumor, making my incis- 
 ions at some distance from its margin, and ligatured about twenty large vessels a.s I pro- 
 ceeded ; a rapid recovery followed, and the boy was well three years later. In this case 
 it was remarkable to see how rapidly the tortuous convoluted arteries that supplied the 
 tumor withered and became of their normal size so soon as the central disease was 
 removed. This process illustrates John Hunter's opinion that " vessels have a power 
 of increase within themselves, both in diameter and in length, according to the ncces.sity 
 of the tissues, whether natural or diseased," and indicates that the attracting power had 
 its centre in the growth, and not in the afferent arteries. In a third case, that of a girl 
 aet. 12, I removed the aneurism by a subcutaneous ligature with like success, and more 
 recently in a man who had such a vascular pulsatile growth in his left cheek, which 
 appeared to have had all the afferent arteries tied without succe.ss before he came into 
 my hands. I ligatured the whole mass subcutaneously, and a recovery followed. Four 
 
378 
 
 NuEVUS. 
 
 years later, however, tlie disease returned, and in June, 1S77, I excised it, tlie wound heal- 
 ing rapidly. Indeed, the only successful cases of treatment of cirsoid aneurism that 1 
 have dealt with or seen have been those in which the growth itself was treated by 
 removal. 
 
 Cases of aneurism by anastomosis are very amenable to treatment by styptic injection, 
 the galvano-cautery, or the ligature. 
 
 N^VUS. 
 
 Telangeiectasis, erectile tumor, or angeioma, is essentially a disease of the capillaries, 
 appearing in a general way to be made up of a mass of vascular tissue, the tubes freely 
 intercommunicating with each other. It is true the walls of the vessels are indistinguish- 
 able in an advanced case of the disease, the nsevus appearing as a collection of cells or 
 spaces opening widely into one another, through which blood flows. When the arterial 
 supply is very free, the growth appears florid, warm, and pulsatile, and is then called an 
 arterial rixoits ; when the venous element predominates, the growth is less florid, has a 
 congested bluLsh appearance, and does not pulsate, and is termed a venous ttaevus. 
 
 These growths for the .most part appear in the skin or subcutaneous tissue, are fre- 
 quent on the head and often multiple. Rare examples are on record where they affected 
 deeper parts, even the viscera and the brain (ride Wilks and 3Ioxon, Path. Aiuif., and 
 Morris, rofh. Tram., vol xxii.). In a clinical point of view they may be divided into the 
 ciifaneoiis or pure skin naevus, the suhcutaneous or cellular tissue najvus. and the mixed 
 form, where both tissues are involved ; which distinction has an important practical 
 bearing. Nrevi are, as a rule, diffused — that is, they have no distinct capsule ; but in 
 many cases they are encysted and may be treated accordingly. A^enous subcutaneous 
 n^vi appear to be more frequently encapsuled than the cutaneous and arterial. 
 
 Najvi. moreover, are generally congenital or make their appearance soon after birth. 
 They occur, however, at a later period of life, and then seem to be due to some injury or 
 wound. These n^vi at times grow quickly, the cutaneous form rapidly .spreading; the 
 more florid and arterial the growth, the greater is its tendency to spread ; the venous 
 najvus is less progressive. They may grow also for a time and then stop ; indeed, they 
 all have a tendency to become stationary after a period, and even to degenerate. It is 
 not uncommon to meet with na?vi that have begun to undergo this process before the 
 birth of the child, and I could adduce many cases in which the njevus was ulcerated, or 
 
 even sloughing, at birth. In feeble or cachectic children it 
 is not uncommon for these '' marks" to ulcerate or slough, 
 and after measles, fever, or other depressing illness the de- 
 struction of the growth is sometimes very rapid. These 
 facts show that njevi. although blood tumors, are not long- 
 lived growths and have a tendency toward early death. 
 When they do not ulcerate or slough, they undergo degen- 
 erative changes, and the most characteristic is the cystic 
 form (Fig. 161). When the skin undergoes this cy.stic 
 change, the surface becomes warty and vesicular, the ves- 
 icle.-* containing more or less blood-stained serum. When 
 the cellular tissue is the part involved, cysts will still ap- 
 pear of a like nature, but occasional!}' the whole growth 
 passes into a mass of cysts of diff'erent sizes bound together 
 by fibrous tissue. This degenerative change is very typical. To accoutit for the forma- 
 tion of these cysts is no easy matter; no satisfactory explanation, indeed, of their pro- 
 duction has }'et been given. 
 
 Some na3vi are pigmentary, and are then termed '• moles." They are fiar less vascular 
 than the forms already alluded to and have no tendency to spread. They grow, it is 
 true, with the growth of the subject, but as a rule in no greater proportion ; in excep- 
 tional instances their increase is rapid. They do not appear to have a tendency to ulcer- 
 ate, slough, or undergo the cystic degeneration like the vascular nfevi, but have a .special 
 tendency to become the seat of disease, and particularly of the melanotic form of sarcoma 
 or cancer — that is, subjects who become the victims of cancer and have moles are often 
 attacked primarily in .such structures, and, as the cancer originates in a pigmentary 
 growth, it takes on its character and becomes melanotic. I have seen many such cases, 
 and so many others have been now recorded as to place the question beyond doubt. 
 
 Treatment. — Unless a noevus is so situated as to be an eyesore or an inconvenience, 
 
 Fig. 161. 
 
 Drawing of J)egei]eratintr X;evus. 
 (Guy's Mils., Iti054. Hilton's case 
 
TREATMKSr OF S.KVUS. 
 
 .'i79 
 
 or unless it show a (IccicK-d toiidoncy td rupiil incn-iisf, tlicre is no necessity fur operative 
 iiitorfcrcnco. Fur a certainty, after a tinn-, it will cease to jrrow, and also as certainly 
 (IcLjeneratc or waste; and nnder sneli eirennistanees it is not necessary to interfere. 
 Should, however, the n;evus he so situ.ited as to he an inconvenience or a deforniitv. <jr 
 should it Ljrow so rapidly as to threaten t<i heconie either, soniethin^^ must he atteinpte<l; 
 and this suniethiiiu is to he dett'rinined hy the nature of the n:evus and of the tissue in 
 which it is ])laced. If jiiinli/ tii/inirtnis and not involvin<; deeper tissues, it may he 
 destroyed hy some external application, such as caustic, nitric acid, or ]»otassa fusa, 
 chhu'lde of zinc, ethylate of sodium, or tartarized antimony, the former two heinir applied 
 directly to the part, the latter two in the form of \'icnMa paste or otherwi.se. The hot 
 iron and the pis or <::alvanic cautery are also very valuahle destructive aj.M'iits, one touch 
 of either of these latter, steadily ap]tlied to the surface or as multiple punctures, de.stroy- 
 inir the <;rowth. and with hut little pain. 
 
 In the piiir/i/ siiliritftiiitiiiis lufriia the treatment hy caustics or cautery ap[)licd as a 
 caustic is clearly inapplicahle. When encysted, as very often 
 it is, rxciKioii is the hest remedy ; !)nt care should he taken to Via. ]iV2. 
 
 save the skin. When such treatment cannot he adopted, the 
 n:evus may he straniiled hy a liuature applied suhcutaneously. 
 as illustrated in the drawini;-, Fig. 1()2, or it may he injected 
 with the perchloride of iron of the pharmacopeia strentrth, 
 with a .solution of tannin in water in the pro]tortion of ."j to C'\^/ ^ 
 5j, or of the chloride of zinc grs. xij to .^j of water, about ^i:::^:""^ 
 twenty drops heinii thrown into the centre of fhe growth, -^ 
 care being taken beforehand to tear up the texture of the 
 tumor with a needle. The object of this treatment is to 
 coagulate the blood in the tissue, and thus promote its Mixed Xavus, with the Ligatures 
 consolidation and cure. In many cases injection causes in- netfiL*ry Sre I'eln^^Ued"*^*^"'*' 
 flammation, suppuration, or even sloughing of the growth ; 
 and though in this manner a cure may be obtained, it is often by deformity. 
 
 The treatment by injection when the nanus is on the head or trunk is, however, 
 attended with great danger, more particularly from embolism. I lost a patient where 
 the n:vvus was on the cheek from this cause in a few minutes after the operation. For 
 the above reason it is well to apply a ligature to the base of the growth and then inject, 
 or to isolate the growth by means of the pressure of a metallic ring hi/ore injecting. 
 
 In the mixe(/ rnn'rfi/, when the skin appears to have been involved secondarily by the 
 extension of the disease from the cellular tissue, the nj\?vus may be treated by excision, 
 igni]iuncture. subcutaneous ligature, or injection. 
 
 When the skin, with the cellular tissue, is extensively involved and the naevus 
 defined, the whole may be removed by excision ; but when otherwise, by ignipuncture or 
 ligature. AVhen the nsevus is pendulous or when it can be isolated from the parts 
 beneath, exci-sion is most suitable ; and when hemorrhage is dreaded, the base of the 
 growth may be previously held in a flat clamp. In several instances I have excised the 
 naevus by cutting on pins that have been inserted beneath its base, keeping the pins as 
 points round which a ligature might be applied,- and by which the edges of the wound 
 might be brought together. When the thickness of the lip is involved in the disease and 
 the disease is limited, a V-piece may be taken out with the growth advantageously ; but 
 when the whole lip is involved, the growth may be dis.sected out, leaving the skin. The 
 drawing below is of a case in which this operation was successfully practised (Fig. 163), 
 
 Within the last few years I have 
 successfully treated maiuy of the Fk*. H>3. 
 
 mixed varieties of na?vi with the 
 ar-tual or galvanic cautery by simply 
 perforating them with the heated 
 needle in many points (ignipuncture). 
 introducing the needle at a l)lack heat 
 into the healthy margin of the growth 
 down to its base. The cautery de- 
 stroys the subcutaneous growth, and 
 
 with it the skin. l- Xitvus involvinc the whole of the upper lip. 2. After removal 
 
 rni ^ . . . f> T<r i ;i. Flatteiiinsof the teeth from the pressureof the niBvus. (From 
 
 ine treatment oi a diffused nanus Om/s R'-pm-ts.) 
 by means of setons is a practice that 
 can also be strongly recommended. Several setons steeped in the solution of the per- 
 
380 
 
 THE LIGATURE OF ARTERIES. 
 
 chloride of iron are often sufficient to coagulate the blood or to set up enough inflamma- 
 tory action to cure the growth. When a njevus is extensive and is to be treated by the 
 ligature, it may be dealt with piecemeal (Fig. 16-1). It occasionally happens that the 
 
 Fig. 164. 
 
 Fu; 
 
 Illustrating the method of ligaturing a large 
 mixed ntev us in sections around pins. At 
 one end the pin has been removed and the 
 knot completed (/i. 
 
 ligaturing of half a nasvus cures the whole by the extension of the inflammatory action. 
 In naevi involving the eyelids this suggestion is of value, and in my own practice several 
 instances of cure have followed the application of a ligature to half the growth. 
 
 In a mixed n^evus of moderate size, when the cure by ligature is to be carried out, a 
 pin may be pa.ssed beneath the growth, and also a needle at right angles to the pin, 
 armed with a double ligature (Fig. 165). The naevus is then strangled in halves by the 
 ligatures tightly drawn beneath the pin, but before the ligatures are finally tightened it 
 is well to puncture it to let out the serum and blood, to relieve tension, and to allow of 
 the more perfect strangulation of the growth. When this act is completed, the pin may 
 generally be removed. 
 
 Small naevi may be vaccinated, although the chances of a cure by such means are 
 very small. The same also must be said for compression. 
 
 Fig. 166. 
 
 The best needle for the application of a subcutaneous ligature to a nrevus is shown 
 above. 
 
 RiCHET, "Aneurism" in Did. de Med. el de Chir. Prat., vol. ii. — Leox de Fort, Diction. Ency- 
 clopediqne des Sciences Medicakfi, 1866. — Broca, Traiie des Aueurysmes, 1856. — Lisfranc, Des differens 
 Methndc!', etc. pour I' Obliteration rfe.s Arteres, 1834. — Scarpa, On Aneurism, Wishart's Translation. — 
 Bellingham, On Aneurism, 1857. — Tufnell, On Treatment of Aneurism by Compression, 1851. — 
 Holmes, System of Surgery, 3d ed., 1883. — Hodgson, On Arteries and Veins, 1815.— Dr. Norris, 
 American Journal. — Dr. Stephen Smith, ditto. — Erichsen's Cooper's Sun/ical Diet., 1861. — War- 
 prop, Cyclop, of Surgery. — Syme, Obaerv. in Clinical Surgery, 1861. — Fergupson, Sir W., Med.-Chir. 
 Trans., vol. xl. — Dr. Jones, On Hemorrhage. — Bryant, Lancet, April 4, 1874. — Gould, Trans. Inter- 
 national Congress, 1881. — Holmes, St. George's Hasp. Rep., vol. vii. — Ashhur.st's International Ency- 
 dop., vol. iii., 1883. 
 
 THE LIGATURE OF ARTERIES.— SPECIAL ANEURISMS, Etc. 
 
 John Bell wrote seventy years ago ''that the right way of securing a great artery is 
 perhaps one of the most important points in practical surgery;" and I may add that to do 
 this with nicety and precision requires a sounder and more accurate knowledge of anatomy 
 than any other operation. 
 
 " Before undertaking to tie an artery the surgeon ought to know its general course 
 
Tin: iJi:.\Triii: of arteriks. 381 
 
 and its rflaliuns. ami cspcciall v tin- pnniiiiiiiit |iait or )iarl> wliii-li arc to ^iiiilf liiin lu the 
 ])ositi(iii 111" the vi's.sel ; he oiij^ht to liavi' raiiiiliari/.ctl liiiiisidt' by t'rt'ijiuMit tlis.sectioii with 
 tlu' thickness of the parts eoverint; it. and their appcaranee as far as that can he judjred 
 of in the (h-ad l)ody; and tinally. he onirht to know tlie usual position of its principal 
 hranehcs and the anastoinosi> l»y whicli the circulation may he exp(;ctcd to he restored. 
 It is advisalih' also to he aware of the lea<linLr peculiarities in course, relations, hifurca- 
 tion, etc.. which the operator may jK-rhaps nn-et with, and for whicdi lu; ou^ht to he pre- 
 pared" ( /Ill/ill is' K ,Si/sfiiii. \iA. iii. p. !•'.*). In I'act, without anatomical knowledge, any 
 attempt to tie the trunk of a lar^t; artery must he surrounded with difficulties and fraught 
 with danger, whilst with it the operation l>ecoine.s in the hand of an experienced surgeon 
 an act of precision ami apparent simjtlicity. 
 
 1m a former chapter the mode <if applying a ligature to a divided artery after operation 
 was discussed and illustrated, and in the ])resent attention will be directed to the applica- 
 tion of a ligature to an nrfcri/ in con fin in'///, as in the operation for aneurism or the arrest 
 of hemorrhage from a puiicture<l wound. To acccjmplish this, the surg(!on has to go 
 through several stages of thought as well as of action. He haajirsf of all to make out 
 with ])reeision the rxacf coiirsi- o/' /he nssrf /o h<' li(f(i/nrt'.il, which may be d(jne by the arti- 
 ficial linear guides with which he ought to be familiar, the muscular guides to its position, 
 and the recollection of the anatomical relations of the vessel. 
 
 He has, seroniJ///, to decide on f/w point at zvhic/i the fii/atiire shon/i/ Ix- (ipplied. When 
 for a xoounil in the vessel, this point is already settled, it having been laid down as a rule 
 that whenever jiossible a wounded artery is to be exposed at the seat of iujury and two 
 ligatures applit'il. one al)0ve and one below the seat of lesion. 
 
 Point of Selection. — When for aneurism, the question is more open, the '• point 
 for ligature" having to be determined by the surgeon. In deciding this important (jues- 
 tion it should be remembered that if the ligature be applied too near the aneurism, there 
 is a risk of the ligatured vessel partaking of the disea.se for which the operation is 
 required ; and if too far ojf, the circulation through the aneurismal sac may be too free 
 on account of the collateral circulation of the part. 
 
 But, above all, the surgeon should avoid selecting a spot n:here an artery Itifnrcatea or 
 gives off larije //ranches, as under these circumstances the clot that is required to plug the 
 vessel behind the ligature must be absent and one of Nature's most important haemostatic 
 agents become lost. 
 
 With the decision of these primar}^ and important points the operation itself has to be 
 considered, which resolves itself into the exposure of the artery, its isolation, the application 
 of the ligature around it, and the after-treatment, the position of the patient for the opera- 
 tion being previously determined. 
 
 The position of the patient should be such as to render prominent the anatom- 
 ical guides to the course of the artery, to make the skin tense, and to facilitate its division. 
 It should, moreover, he one of extension ; yet, after the artery has been exposed, it is well 
 to remember that the muscles of the part luust be relaxed, as the artery is thus better 
 brought into view and the subsequent steps of the operation are rendered more easy. 
 
 The exposure of the artery is to be made by incision, its course having been 
 clearly made nut. and the point di'termined on beforehand for the application of the liga- 
 ture. The incision should be in the course of the vessel, its centre corresponding to the 
 point where the ligature is to be applied, an occasional obliquity being .sometimes prac- 
 tised when the exact position of an intermuscular interspace in which the vessel lies is 
 uncertain and when the artery lies deep. It should, moreover, be free. It need not be 
 so long in a thin as in a fat subject, nor in the case of a superficial artery as in that of a 
 deep vessel ; but under all circum.stances the skin wound should be enough to allow room 
 for manipulation. 
 
 The first incision .should include the skin and superficial fascia down to the deep fascia, 
 and in making it the operator has only to avoid the division of any large vein, such as the 
 external jugular in operations on the neck, or saphena in operations on the thigh. He 
 should, consequently, mark out their position by arresting the circulation through them 
 on their c^xrdiac side and make his incision parallel with them when they lie in his 
 course. 
 
 When the deep fascia is exposed, it should be laid open, and in this step the use of a 
 director is .sometimes valuable; the fascia, moreover, should always be divided to the full 
 extent of the external incision. The student .should renieml)er that the trunks of all arte- 
 ries except the cutaneous are covered in by fascia. With the division of the fascia the 
 use of the knife can for a time be dispensed with, as the intermuscular septa and cellular 
 
382 
 
 THE LIGATURE OF ARTERIES. 
 
 tissue are readily separated by the handle of the instruinent or finger, so that the sheath 
 of the vessel can be thus well exposed. 
 
 " If," writes Malgaigne, " immediately after the first incision, the surgeon attempts to 
 find the artery, he tries an impossibility, since he cannot reach it till after the last incis- 
 ion." He will then proceed uncertainly and at random ; hence the following rule of the 
 guiding points : " The surgeon should not at the commencement occupy himself with 
 looking for the artery, but should seek the first marked point of guidance, then the sec- 
 ond, then the third, and so on to the end. ' 
 
 In looking for the sheath every anatomical guide is to be made use of, to prevent 
 undue manipulation or separation of parts. 
 
 When the sheath is found and the pulsating artery is felt within, the end of the 
 operation is not distant. Yet many errors may be committed. Every possible mistake 
 
 should consequently be thought over 
 Fig. 167. Fig. 168. beforehand in order to be avoided. The 
 
 operator must ask himself as to the posi- 
 tion of the nerves and veins about the 
 part, so as to avoid them. He need not 
 look for them as in a dissection, for this 
 would necessitate superfluous manipula- 
 tion, but their existence ought to be 
 present in his mind. He should only 
 remember their relative position to the 
 vessel where the ligature is to be ap- 
 plied, and then guard against their being 
 injured. The sheath having been found, 
 it must be raised by the forceps and care- 
 fully opened (Fig. 167, A), such opening 
 being only sufficient to admit a probe or 
 aneurism needle ; and the less the sheath 
 is separated from its vessel the better. 
 The needle (Fig. 168) with the ligature 
 is then to be passed (Fig. 167, B), and it 
 should be introduced between the artery 
 and the vein, because when it is passed the 
 other way the vein may be perforated or 
 mistaken for fascia ; yet in the hands of 
 a careful surgeon this point need not weigh against convenience. With the exposure of 
 the artery all anxiety ceases, for to put an ordinary silk, wire, or catgut ligature around 
 it is a comparatively easy task with the majority of arteries ; so when this is accom- 
 plished, the operation, as such, is all but completed. To do this, however, the surgeon 
 must be careful not to elevate the artery from its bed by the ligature, but to tie the knot 
 with his fingers well passed down to the vessel {vid<' Fig. 167, C). He should also sat- 
 isfy himself, when the vessel is on the needle, that pulsation exists and that pressure 
 arrests pulsation in the aneurism. When the ligature has been applied, the displaced 
 parts must be readjusted, the wound cleansed, its edges brought together, and 
 some light application employed, such as dry lint or water dressing. Where the artery 
 of an extremity has been tied, the limb should be raised, to facilitate the venous circula- 
 tion, and cotton-wool wrapped round the part, to maintain its heat ; but beyond this no 
 local treatment is required. It need hardly be stated that an anaesthetic should invaria- 
 bly be given in these operations, and that the subsequent treatment of the case should be 
 based on general principles. When veins bleed or large venous trunks require to be 
 divided, they may be tied or twisted, though gentle pressure often arrests bleeding from 
 small vessels. The wound should be carefully cleaned during the operation by the firm 
 pressure of a well-squeezed sponge ; the edges should be held apart after the sheath has 
 been exposed by hooked directors, but the surgeon on no account should allow his assist- 
 ants to draw the parts so far asunder as to make them lose their relative positions. With 
 these general remarks, the application of a ligature to special arteries will now claim 
 attention. 
 
 Ligature of the Abdominal Aorta. 
 
 In 1817, Sir A. Cooper tied the abdominal aorta, having failed to find the communi- 
 cation between the common iliac artery and an aneurismal tumor, after the introduction 
 
 This diagram represents three distinct operations: 
 A, Opening of the Sheath. B, Drawing ligature 
 round the artery. C, Tying artery. 
 
77//; i.idArriu'. of Airn:i:n:s. 
 
 383 
 
 of his tiiiL'^cr tlin>ui:li a small (i|pciiiii^' in tin- ni|itiirc(l sue. lie iuikIc his iiicisinii ilirou;_'li 
 the liiica all»a In the Icl't of tin- iiiiiliilicus, ilircrtly (iVi-r thf a(»ita. 'I'hc paiifiit liv('(l forty 
 hours. James of Kxeti-r ( IS:?!*), ami Murray of tlie ('a|»(' (if (JcxmI I|(»|.<-. fullowcd his 
 cxaiuplo with no lu'ttcr success, tlie patients surviviiifr three and a half and twenty-three 
 hours resjK'ctively. In isili (Lidinf, y. '.V.Vl) Dr. ('. li. Moiiteiro <if Kio Janeiro ree(»rdcd 
 H ease in whieli the patient died from hemorrhage on the tenth (hiy. In 1H5«). Mr. South 
 {/jiiiiccf, vol. ii.) operated on a patient who lived forty-three hours. In lH(iK ( Ayiim'raii 
 Jiinniitl (if Mcdlrnl Svifiivi) \)i\ .Alcduirc ol' llichmond, X'irjrinia, recorded a si.\th ca.se, 
 in which the patient lived twelve hours. In iStiM, J)r. I'. H. Watson of Edinhurgh 
 (^lin'f. Mrti. Joiini., 18(j*J) i.s .said to have performed the operation on a man who survived 
 it sixty-five hours; and in the Diihlin Qiiurf. lor IS'ID Mr. Stokes, Jr., has recorded an 
 eifrhth ca.se, in which a temporary ligature was applied, but without success. 
 
 In all these the operation was perfornu'd for aneurism <»f the common iliac arterv, hut 
 the results u)» to the present offer little eiieourajrement for its repetitioti, more particularly 
 when we have (»ther means at our command holding out a hetter pntmise of success, such 
 as pressure by the abdominal tournii(uet while the patient is uiuler the influence of chhiro- 
 form. Cures of abdominal aneurism by this uieans have been recorded by Dr. .^Iurray of 
 Newcastle-on-Tyne (Rapiif Citrc a/ Aiienn's»i hi/ JWssin-f\ 1S71), Dr. Heath of Sun<li'rland 
 (Jh-if. Mr, I ./,.,ini., IStlT. p. L\S7),*Mr. Ilolden (Sf. Burthol. llo^p. Rrp., IHOtl), Dr. Mox(»n 
 and Mr. Durham {M(<f.-('/iir. 7V(uis., 187-^, and Dr. Greenhow (ihid.^ 187^:$). 
 
 I believe, nevertheless, the operation of placing a ligature upon the abdominal aorta 
 to be justifiable under exceptional circumstances, such as in cases of aneurism of the 
 coninion iliac artery when all other means are inapplicable. 
 
 The best incision by which to reach the abdominal aorta is the hidirecf, a modification 
 of that adopted by Sir P. Crampton ^ in the case of the common iliac artery (Fig. IG'J) — 
 
 Fig. 169. 
 
 Incision for the .\pplication of a Ligature to the .Aorta or Common Iliac .Artery. 
 
 viz., one extending from the anterior superior spinous process of the ilium of the left side 
 to the cartilage of the tenth rib, the peritoneum being reflected. The great difficulty in 
 this operation is in the application of the ligature to the vessel. 
 
 Ligature of the Arteria Innominata. 
 
 The first operation was by V. Mott of New York in 1818, and since then this artery 
 has been tied eighteen times, but only once with success (by Dr. Smyth of New Orleans 
 in 1864, the patient living ten years), and in that case the carotid and vertebral arteries 
 were likewise ligatured, the former at the same time as the innominata, the latter on the 
 fifty-fourth day, for secondary hemorrhage. Dr. Smyth accomplished this on the sug- 
 gestion made by Mott in 1818, when he wrote . " By thus intercepting the retrograde 
 current through the primitive carotid there would be less chance of any reflux hemor- 
 rhage in the event of a phagedjvnic ulceration taking place in the wound." In all the 
 other cases a fatal result rapidly ensued. Graafe's case lived sixty-seven and Thomson's 
 
 ^ Med.-Chir. Irfin."., vol. xvi. 
 
384- THE LIGATURE OF ARTERIES. 
 
 forty-two days {Brit. Med. ,/oinu., October 14, 1882). It can only be entertained, there- 
 fore, in cases of injury to the carotid or subclavian near their origin or in exceptional 
 cases of disease. When decided on, the ojieration should be proceeded with as follows : 
 
 Operation. — The head being thrown back to the left and the shoulder depressed, 
 the vessel may be secured by making an incision along the anterior border and .sternal 
 origin of the sterno-mastoid muscle, or by a transverse one over the upper border of the 
 clavicle, making its centre correspond to the upper border of the sterno-clavicular joint, 
 or by both combined. Under all circum.stances the sternal, and sometimes a part of the 
 clavicular, origin of the muscle will recjuire division. The sheath of the cervical vessels 
 will then come into view, with the internal jugular vein on the outer side of the carotid 
 artery and the vagus nerve between them. On tracing these downward the innominate 
 vessel will be reached. In a healthy subject the artery is always to be found behind the 
 right sterno-clavicular joint, but in disease its relative position may be altered by mechan- 
 ical displacement. Dr. Cooper of San Francisco has reached the artery on two occasions 
 by removing the sterno-clavicular articulation. A stout animal ligature should be used. 
 
 In aneurism of the innominate there is no possibility of applying a ligature 
 to its cardiac side, even if the disease involves only the upper part of the artery ; yet, as 
 a rule, this form of aneurism is almost sure to be associated with dilatation of the aorta. 
 The distal operation, however, may be thought of, the carotid and subclavian arteries 
 being ligatured simultaneously or consecutively. Of five instances in which the former 
 practice was followed, one (Ensor's case. Lancet, July 31, 1875) lived sixty-five days 
 and one recovered ; while out of three of the latter an equal success may be recorded. 
 
 The credit of the successful case in the former clas.s — for a success I take it to have 
 been — belongs to Mr. C. Heath, who tied the subclavian artery in the third part of its 
 course as well as the common carotid simultaneously in 18G5. The operation was fol- 
 lowed by marked relief and the diminution of the tumor; the woman, get. 30. survived 
 the operation four years, and died from rupture of the aneurism. After death the aneu- 
 rism was found to be of the aorta, the innominate being only slightly involved. ( Vit/e 
 Prep, in Mus. of Royal Coll. of Surgeons, and Path. Tran>(., vol. xxi.) 
 
 The successful issue to the case in the latter class belongs to Mr. Fearn of Derby, who 
 tied the carotid in 1836, and the subclavian in the third part of its course two years later, 
 for innominate aneurism. The patient died four months after the second operation, from 
 pleurisy. I had an opportunity in 186(3 (Patli. Soc. Trans.. \o\. xviii.) of carefully exam- 
 ining and reporting on this preparation, which is now in the College of Surgeons' Museum, 
 and a better specimen of a cured small sacculated aneurism could not possibly be seen. 
 
 Aneurism of the innominate has likewise been treated by ligature of the subclavian 
 or of the common carotid alone, Wardrop's operation ; and in Wyeth's prize essay (New 
 York, 1879) and Hulmens ISnrgery & most interesting list of references to such cases can 
 be found. Out of eighteen, Evans's case, as recorded by Wardrop, was cured ; his own 
 lived tAvo years. Morrison's case lived twenty months, two others lived six months, and 
 the remainder lived only a few days or weeks. 
 
 In August, 1871, I ligatured the subclavian in a man aet. 33 for this affection, and a 
 rapid convalescence followed, with great diminution and consolidation of the aneurism. 
 The man lived three years after the operation {r,ide page 371). This result, therefore, is 
 not so discouraging as to preclude the question of operation in favorable cases. It should 
 only be entertained, hoAvever, under exceptional circumstances, and more as a palliative 
 than as a curative remedy. 
 
 Ligature of the Common Carotid Artery. 
 
 This operation was first performed for aneurism by Sir A. Cooper in 1805, but unsuc- 
 cessfully. The same surgeon, however, had a successful case in 1808, the man surviving 
 thirteen years (C^^^'.s Hosp. Rep., vol. i.). The operation may be demanded for aneurism 
 of the trunk itself or one of its branches, for erectile tumors of the orbit or of the scalp, 
 etc., and for wounds or hemorrhage. It mav also be called for as a distal operation in 
 aortic aneurism. It is a dangerous, and sometimes a difiicult, operation ; but in a mod- 
 erately thin subject it may be performed with facility. It .should only be resorted to 
 when all other means of treatment are inapplicable or have been found inefiectual ; for 
 aneurism it ought not to be performed unless the treatment by digital compression has 
 been rejected. Holmes well sums up the matter in his College Licfures (1873) as follows: 
 " That the experience of surgeons hitherto leads to the conclusion that aneurism of the 
 trunk of the carotid artery may be very often treated succes.sfully by compression, and 
 
77//; lk; AT! •/:!■: or mitkiuf.s. p>85 
 
 tliat tlu- fiirc liv fnin|iri's.-itiii tV<'(|iiciitly liavcs tlic iirtrry uriohlitcratcd, and tlicrcfore 
 exposes till' [»ati«.'iit to a far less risk of (•LTcl)ral iiiiscliicr tliaii tlic lifratiirc ; that the lifr- 
 ature of the rarotid for siu-li tumors is oxtrciiicly (hiiijrcroiis and oiifrht not to he; under- 
 taken until attempts well devised and perseverinjrly carried (tut have failed (o efleet the 
 cure 1)V eompression ; and that when the surjreori has heen eompelled l»y the position of 
 tlie tum(»r to place his liirature close to the proximal side of the sac, it is worth very 
 ^'reat consideration whether it would not he hetter to evacuate the tumor and tie the 
 distal part of the artery also; limilly, that cases d(» occur in whi<di lirasdor's method 
 l>ulds out a ratiftiial h(»pc of cure, hut that this operation oujrht not to he jiractised 
 except in cases cd" <:rowin>r Jtncurism when ditrital pressure checks the pulsation u\' the 
 tumor, yet has failed to effect a cure" (/>a//fy/, June, 187.i). The vessel may he lijr- 
 atured in the upper part of its course at the apex of the carotid trianjrle, in a line witli 
 the cricoid cartila<:e, or lower down than this; the former yiosition is the preferahle and 
 the operation there is more easy, and for disease of any of the hranches of the vessel it 
 should he selected. The latter should he rcs(»rted to only for disease of the U|)pfcr part 
 of the trunk itself. The course of the artery can always he made out, correspondiiifr,. as 
 it does, with a Hne drawn from the sterno-davicular joint to the anjrle of the jaw ; the 
 vessel divides on a level with the u[)pcr part of the thyroid cartilage and .should he tied 
 opposite the cricoid. The centre of the incision made to expose it should he opposite to 
 the cricoid, and should extend ahout three inches alonir the anterior marjLMn of the sterno- 
 mastoid muscle. The position of the patient should therefore he such as to render this 
 muscle prominent, which is ensured by the extension of the head Itackward, the face 
 beintr turned to the opposite side. 
 
 Operation. — Before makinp: the first incision throujrh the skin, platysma. and super- 
 ficial fascia the surgeon should assure himself that no large vein, such as the anterior 
 jugular, is likely to be divided; gentle pressure below, enough to interfere with the 
 venous cir(;ulation of the part, readily supplies this information. The deep fa.scia cover- 
 ing in the sheath of the vessel may then be divided, care being taken to do this to the 
 whole extent of the external wound. The sheath of the artery will then come into view, 
 lying between the trachea and sterno-ma.stoid muscle ; the piilsation of the vessel likewi.se 
 can be detected. The head of the patient at this stage of the operation .should be slightly 
 raised, so as to relax the sterno-mastoid muscle and allow its being gently drawn outward 
 by means of the retractor, as well as to permit of the separation of the cellular connective 
 tissue of the part. The anterior belly of the omo-hyoid muscle will then probably be at 
 once visible with its fibres passing downward and outward; and when this muscle is 
 broad, it will cover in a great part of the vessel. The desccndens noni nerve may like- 
 wise be seen lying upon, or sometimes within, the sheath ; due care should be taken that 
 it is not wounded or included in the ligature ; and if it be in the way, it must be gently 
 held aside by a retractor, as should be, also, any large vein that crosses the sheath. The 
 inner border of the .sheath is then to be taken up and firmly held with forceps, and a suf- 
 ficient opening made in it by the knife, held with its flat surface toward the artery, to 
 allow of the introduction of the aneurism needle. The needle is then, as generally rec- 
 ommended, passed (inntd, though this is not a point of importance, for nnnrmid it is 
 passed with greater facility. By a little manijtulation the needle may be passed round 
 the artery from without inward, introducing it between the vein and vessel and keeping 
 its point close to the artery. The sheath may be dropped from the forceps and the loop 
 of the ligature seized, or the needle may be threaded and withdrawn. The surgeon must, 
 however, satisfy himself beforehand that the right vessel has been exposed and that the 
 vagus nerve is not included. The ves.sel can now be tied, great caVe being observed that 
 it is not raised from its bed or manipulated more than is necessary ; the knot should be 
 tightened by the index fingers pa.s.sed well into the wound. The wound should then be 
 adjusted and the patient put to bed, the mo.st perfect quiet being enjoined. The surgeon 
 ought to remember all through this operation that the jugular vein is on the outer .side 
 of the artery and often overlaps it, while the vagus nerve is behind and the descendens 
 noni in front (Fig. 170). None of these parts need be looked for. however, so long as 
 care is observed that they are neither wounded nor included in the ligature. 
 
 The operation for ligaturing the hnnr part of the cnrofi'/ is .somewhat similar to the 
 above ; the operation is, however, more diSicult from the vessel being deeper, particularly 
 on the left side. The incision should in this instance extend lower down over the sterno- 
 clavicular articulation. The muscles will also require more retraction, and probably some 
 division. 
 
 Mr. Cock related to me a case which he authorizes me to quote, in which Mr. Aston 
 25 
 
386 
 
 THE LIGATURE OF ARTERIES. 
 
 Key applied a ligature to the left carotid for aneurism and the man died on the table — 
 indeed, died on the application of the ligature. After death it was found that the right 
 carotid had been previously obliterated, and the operator had by ligaturing the left so 
 interfered with the supply of blood to the brain as to cause death. 
 
 Fig, 170. 
 
 jint.'' herder cf jSternO 
 
 (This figure, with many others in this chapter, is based upon tliose given in Sedillot's work.) 
 
 With respect to the prognosis after this operation, much depends on the object for 
 which it is performed. Dr. Pilz of Breslau (^LangenhecJcs Arclilvts, 1868) makes out 
 that 48 out of every 100 die; Dr. J. Wyeth of New York, in a careful analysis of 789 
 cases, gives 41 per cent. Pilz says that of 228 cases in which the operation was per- 
 formed for hemorrhage, 128, or 56 per cent, were fatal; of 87 for aneurism, 31, or 35 
 per cent., died; of 142 for tumors, 49, or 34 per cent., died; of 71 for extirpations, 25 
 died, or nearly 34 per cent. ; of 34 for affections of the nervous sy.stem, only 1 died, or 
 3 per cent. ; and of 38 for aneurism on the distal or Brasdor's method, 25 died, or 65 
 per cent. 
 
 Secondary hemorrhage is a common cause of death, but brain complications are the 
 more frequent, abscess in the brain and atrophic softening from want of arterial supply 
 being the usual form — local gangrene, as it were, of the brain. Brain symptoms in some 
 of their forms also occur frequently after the operation, when death does not take place 
 simply from altered cerebral circulation. Suppuration of the aneurismal sac is not 
 unfrequent, and in a case of my own it was the cause of death. 
 
 Ligature of the external or internal carotid artery has been rarely per- 
 formed, the ligature of the common trunk being preferred ; but the wisdom of this prac- 
 tice is not very clear. INIr. Cripps has shown, in a valuable paper upon the treatment 
 of hemorrhage from punctured wounds of the throat and neck, that the application of a 
 ligature to the exteiiidl carotid above the superior thyroid artery or one inch above the 
 bifurcation of the common carotid is the " point of selection " for the application of a 
 ligature. The incision for the operation should be made in front of the sterno-mastoid 
 muscle from behind the angle of the jaw downward to a point below the level of the 
 thyroid cartilage. The deep fascia and parts over it having been divided, the i'acial and 
 lingual veins will be seen. These may be turned aside or ligatured and divided if in the 
 way. The artery will be found behind the stylo-hyoid and the posterior belly of the 
 digastric muscle, crossed by the hypo-glossal nerve, with the internal jugular vein and 
 internal carotid artery along its outer side. 
 
 The same incision is required for the application of a ligature to the internal carotid 
 artery. 
 
LIHATVRK OF THK Sl'JiCLA VIAX. 387 
 
 Dr. .lolm A. NVvctli of New Vmk in an alilf ]iiize essay (\H'H) advocated tliis view. 
 Ill' slniws that nut of IH cases (if ligature of tiie external carotid only 4i per cent, died, 
 anil asserts that the eoininon carotid artery should lu'vcr he tied lor a wound of the exter- 
 nal or one id" its hranchi's when then- is room enoutrh hctween tlie wound and the hifur- 
 eation of the common carotid to allow of the application tA' a lii^ature to tlie external. 
 
 in the Xnr Yinh- Mai. ./oiinin/, (January. 1S74) a case is recorded hy J>r. H. 1*. 
 Sands of New York of successful ligature of the infmial carotid artery ahove and l)elow 
 the bleeding point for secondary hemorrhage occurring ten days after the removal of a 
 cancerous tumor. This oi)eration has been ))erformed four times. 
 
 Cervical aneurisms situated on one of the secondary carotids should he diligently 
 treated hy com])ression. and the Ilunterian o])eration performed oidy when treatment liy 
 eoni])ression has lailed. 
 
 The lingual artery has been ligatured lor wounds of the tongue and of the 
 arterv itself, to cluck the growth of cancerous tumors, or to arrest heinorrliage from 
 their substance. The operation is difficult. The trunk of the vessel is always to be 
 found at a point abare tlic (jrcat rtirnn of tlie. hjjoid hoar., and this point must be rendered 
 prominent by the head being well drawn over to the S(»und side and there held. The best 
 incision is horizontal, on a level with the hyoid bone, its centre c(jrresponding to the end 
 of the greater cornu. The skin and fascia having been divided, the submaxillary gland 
 will become exposed. On hooking this upward and dividing the border of the mylo- 
 hyoid muscle the hypoglossal nerve will be seen resting on the hyoglossus muscle. 
 Beneath this muscle, and at a lower level than the nerve, the artery will be found. It is 
 in close contact with the tendon of the digastric muscle. The fibres of the hyoglossus 
 will always require division to admit of the ligature l^eing applied. Fig. 171 illustrates 
 these points. 
 
 An excellent paper on this subject by M. I)emar(|uay may be referred to (6V/.:. Mid. 
 de Pans, 18(57). 
 
 The facial artery is always to be found in the greater part of its course close to 
 the anterior border of the masseter muscle, where it is only covered in by skin, platy.sma, 
 and fascia ; and at this part a transverse or oblique incision at the lower insertion of the 
 muscle will expose the artery, where it can be ligatured (n'lfc Fig. 170). It is difficult to 
 understand under what circumstances this operation can be called for. as the artery can 
 be so readily controlled by pressure, an acupressure needle and twisted suture over it 
 being the best form to employ. But where the artery comes off from the external caro- 
 tid and lies in the submaxillary gland beneath the jaw, it is somewhat deep and an ope- 
 ration for its ligature by no means easy. I have, however, had only one opportunity of 
 practising this operation, and it was on a lady a?t. 25 who was suffering from a cirsoid 
 aneurism of the vessel as it passed through the submaxillary gland. The operation was 
 successful. T saw the case with Dr. Hehsham of Brixton. 
 
 The teraporal artery can always be found and pressed upon in front of the pinna 
 of the ear, over the zygoma. It lies buried in the dense cellular tissue which exists in 
 this spot beneath the skin and fascia, and can readily be exposed by a vertical or oblique 
 incision an inch long, one-third of an inch in front of the tragus. 
 
 The occipital artery can be traced by a line drawn from the mastoid process to 
 the occipital ])rotuberance, and lies beneath the skin and cranial aponeurotic origins of 
 the sterno-mastoid, splenius trachelo-mastoid, and digastric muscles, which must be divided 
 to reach the vessel in the deep part of its course. The artery can be felt about the centre 
 of the line mentioned. 
 
 Ligature of the Subclavian Artery. 
 
 This operation in the Jjrst part of the vessel's cour.se has been performed twelve times, 
 but never with success. It is an unscientific as well as an unsuccessful operation, and, 
 for disease it is scarcely a justifiable proceeding, though for a wound it may perhaps be 
 entertained. The incision for the ojteration would be similar to that for the innominate. 
 
 The point usually selected for the application of a ligature to the subclavian is in the 
 third part of its course, where the artery emerges from behind the scalenus muscle. This 
 operation may be demanded for aneurism of the axillary artery or for a wounded vessel. 
 
 Aneurism may affect the subclavian artery in any part of its course ; it may involve 
 the whole of the artery or be confined to its first or third portion. When situated on the 
 artery to the inner side of the scaleni muscles, it may be mistaken for an innominate or 
 aortic aneurism, or a common aneurism may involve all these vessels on the right side of 
 
388 LIGATURE OF THE SUBCLAVIAN. 
 
 the body. AVhen affecting the artery external to the scaleni, it is most frequently asso- 
 ciated with disease of the axillary artery. 
 
 The DIAGNOSIS of subclavian aneurism is by no means easy, and is thus referred to 
 by Nekton : 
 
 " In subclavian aneurism the tumor extends, generally externally, to the clavicular 
 origin of the sterno-mastoid muscle, reaching the posterior and inferior triangle of the 
 neck ; becomes more elongated transversely than vertically ; the bruit is propagated more 
 toward the axilla than the neck, and remains the same on compressing the carotid ; the 
 the radial pulse enfeebled ; the limb painful and oedematous and incommoded in its move- 
 ments. In carotid aneurism the tumor is seated between the sternal and clavicular origins 
 of the sterno-mastoid muscle, becomes more elongated in a vertical direction than in a 
 transverse one, and on auscultation gives to the ear a hruit de souffle, which is propagated 
 more toward the side of the neck than the arm, with diminution of the arterial pulsation 
 in the corresponding side of the face and cranium, and without weakening the radial pulse 
 on the same side. In innominate aneurism the tumor is placed under the sternum or at 
 the inner border of the sternal portion of the sterno-mastoid muscle, with weakening of 
 the pulse in the subclavian and carotid arteries, and with absence of the other signs pecu- 
 liar to the two other forms." When a cervical rib is present and the subclavian artery 
 passes over it, the existence of aneurism may be simulated; but the knowledge of the fal- 
 lacy should prevent such an error of diagnosis being made. 
 
 The PROGNOSIS must always be regarded as unfavorable, for these aneurisms are pecu- 
 liarly liable to become diffused even in the early stage of their development as a visible 
 tumor ; yet there are several instances on record of their slow progress, and some for- 
 tunate examples of their ultimate cure by natural efforts. 
 
 The TREATMENT of these aneurisms is most unsatisfactory, the space at the disposal 
 of the surgeon being so limited that he is at a loss to know where he can attack the dis- 
 ease by the few means that are at command. Ligature of the first portion of the subcla- 
 vian, ligature of the innominate, the distal ligature of the subclavian and axillary arte- 
 ries, and ligature of the carotid have all been performed, and, with one exception, been 
 attended with fatal results. The exceptional case is that of Pr. Smyth of New Orleans, 
 who tied the innominate and carotid, and subsequently the vertebral artery on the fifty- 
 fourth day. It is only in small aneurisms occupying the third portion of the artery and 
 the commencement of the axillary that the operation of tying the subclavian external to 
 the scaleni has been successfully performed, and in some of these instances the outer fibres 
 of the scalenus anticus muscle have been obliged to be divided. 
 
 The amjndation at the shouMer-Jfrijif on the distal side of the aneurism has been sug- 
 gested by surgeons for the cure of the disease. It has, too, been successfully performed 
 by Professor Spence of Edinburgh. 
 
 Galvano-pimctiire has been successful in one case by Abeille, and escharofics in another 
 by Bonnet. Manipulation has been employed by Fergusson in two cases and by Lidell in 
 one case, with satisfactory results in the latter one only. A case of Porter's may also be 
 accepted as successful. Direct compression of the aneurism has been tried by Warren 
 with a favorable issue, although much danger was risked in the proceeding. Corner's case 
 (^Med.-Chir. Trans. ^ vol. Hi.), though one not actually of the same kind, was a very good 
 instance of the value of preventing an aneurism from enlarging and exerting such mod- 
 erate compression as to incite fibrinous deposition in the interior of the sac. Poland's 
 case of successful 7J?-e.ss!(?'e on the artery on the cardiac side of the aneurism is quite excep- 
 tional. Gay also has recently met with success. The use of acupressnre by Porter, 
 though successful on the distal side of the aneurism, proved fatal when applied on the 
 cardiac side to the innominate artery, and injection into the sac was performed in one case 
 with a fatal result. Langenbeck has recently injected the parts over the aneurism with a 
 .solution ofergotin, the object being to cause contraction of the aneurismal sac. Such is a 
 list of the means which have been resorted to, but the success has never been great. The 
 question naturally arises, therefore, whether we should not discard such measures and 
 treat these aneurisms on the ordinary principles of internal aneurisms, by rest, attention 
 to diet, and medicinal remedies. 
 
 Mr. Poland, in an admirable essay in the Gny's Rejwrts for 1870, gives a very favor- 
 able return of cases which he has been able to collect in reference to this question of 
 treatment. It stands thus : Out of 13 that underwent general and local treatment^ 7 recov- 
 ered, 1 was relieved, and 5 died ; out of 22 cases in which an expectant treatment only 
 was pursued, 4 recovered and 18 died ; thereby giving a total of 11 recoveries and 23 
 deaths, 1 being relieved. Of the 23 fatal cases, the duration of life was noticed in 17. 
 
LinAi'rni: of riir. sri:ci..\vi.\s. 
 
 389 
 
 111 21 i-ast's in wliidi tin- siilichiviun artt^ry was liiiat un-il in iIm; thinl fHtrt uf I'fs course 
 for aiuMirisiii, !) recovcri'tl (in of tlu'so it wa.s tlio left aitfiy tliat wa.s li^aturtMlj.anfl 12 
 dioil ; S (if till' (U'atlis wi-ro due to lu'niorrliaj^c and 4 to hraiii complications or rjtlicr .symp- 
 toms, rnland's facts thus accord well with Koch's, who gives 'M') recoveries out of (;.'> 
 eases, somcthinii' less than half dyin;:; — a success which is in a dej^ree encouratrintr to sur- 
 geons to uiulertakc the operation. 
 
 Ol'KUATION. — It has heen already stated that the ajiplication of a ligature to the suh- 
 elavian in the first part of its eour.se is scarcely a justifiable operation, hut when under- 
 taken the ineisioii on the right side would be similar to that for the innominate ; on the 
 left side it is scarcely practicable, on account of the depth and relations of the artery. 
 
 In the tfiinf jxirt of i.ts course the operation should be performed as follows Tthe 
 method being similar for both sides): The patient should be raised on a ])illow with his 
 head thrown back and face turned to the opposite side, an assistant drawing the arm 
 down as much as jxissible, to depress tlie shoulder. An iilcision three or fi>ur inches 
 long should then l)e made on the upper surface of the miildl(> of the clavicle (Fig. 171) — 
 
 Fig. 171. 
 
 Ligature of Suliclavian .iiid Lingual Arteries. 
 
 not above the bone, as the external jugular vein might then be wounded. Some surgeons 
 advise the skin to be drawn down from the neck upon the clavicle, so as to diminish this 
 risk. In this incision the skin with the superficial fascia and platysma will be divided. 
 The deep fascia is then seen with the extei'nal jugular vein coursing over it; this must 
 be held aside with a retractor. When its division is a necessity, it should be done after 
 the application of two ligatures, one above and another below the line of section. The 
 cervical fascia can then be divided in the whole extent of the wound, and this must be 
 done with care on a director. Should more room be wanted, a portion of the sterno-mas- 
 toid or trapezius muscle may be divided. The knife is now to be laid aside and the 
 artery looked for in the space exposed, the parts being separated by a director or the 
 handle of the scalpel. The vessel will be found just on the outer side of tlie scalenus 
 anticus muscle (the edge of which can generally be felt) and behind the tubercle on the 
 first rib, a point which can almost always be made out. Several arteries of large size will 
 probably be found cro.ssing this space, as well as many veins. The supra-scapular artery 
 and vein will always be seen behind the clavicle. The brachial plexus lies above and 
 behind and the subclavian vein in front and below the subclavian artery. When the 
 vessel is seen or felt, the sheath is to be opened and the aneurism needle passed around it 
 from above downward, care being taken not to injure the vein or include a nerve. 
 
390 
 
 LIGATURE OF THE AXILLARY ARTERY. 
 
 Ligature of the Axillary Artery. 
 
 This is a rare operation, although it may be demanded for some wound of the vessel 
 or for aneurism of the Vjrachial. It may be performed in one of two positions — either 
 immediately below the clavicle or in the axilla. 
 
 The subclavicular operation is carried out by an incision made immediately 
 below the bone from the coracoid process to the sternal end of the clavicle, dividing 
 integument and fascia and carefully avoiding the cephalic vein that runs along the 
 anterior border of the deltoid to join the axillary. The clavicular origin of the ftectoral 
 muscle will be divided, and the deep fascia or costo-coracoid membrane covering in the 
 sheaths of the vessels will be then exposed and divided. In this step of the operation 
 some of the branches of the thoracic acromial artery will come into view, and if wounded 
 must be secured. The coracoid insertion of the pectoralis minor can also be seen. The 
 fascia covering in the vessels will be exposed, and on laying it open the greatest care is 
 necessary, as the axillary vein lies immediately beneath it. while above will be found the 
 vessel resting on the first intercostal muscle. The brachial plexus is above and behind. 
 The axillary vein should be drawn downward and the aneurism needle passed from below 
 upward, care being taken not to include the external respiratory nerve of Bell that pas.ses 
 behind the artery. When the vessel has been expo.sed. the passage of the ligature will 
 be facilitated by bringing the arm down to the side of the body. On the dead subject 
 this operation is not difficult, but the number of veins and arteries that exist in the space 
 must ever render the operation on the living far from easy. 
 
 To tie the axillary artery in the axilla, the aim should be well raised 
 
 upward and the course of the 
 vessel marked out slightly pos- 
 terior to the middle line of 
 the axilla. An incision should 
 then be made along the inner 
 margin of the coraco-brachialis 
 muscle through the skin and 
 fascia for about two or three 
 inches and the deep fascia ex- 
 posed. This .should be carefully 
 divided to the whole extent of 
 the wound, when the artery with 
 its attendant nerves and veins 
 will come into view. In this 
 .stage of the operation the fore- 
 arm should be flexed on the arm, 
 to relax the parts. The vessel, 
 as a rule, has the median nerve 
 on its outer side and nearer to 
 The internal 
 
 Fifi. 172. 
 
 f areata - In-a eiial 
 
 ■ccle 
 
 Ligature of A.xillary Artery. 
 
 pectoralis major muscle, and the vein and ulnar nerve to its inner side, 
 ineous nerve is in front. {VkU Fig. 172.) 
 
 the 
 cutaneous 
 
 Fig. 173. 
 
 jiledian nerve 
 
 Ligature of Brachial Artery. 
 
 Mr. Guthrie condemned the subclavicular operation altogether, and advised the sur- 
 geon to expose the artery by an incision three inches long, carried upward along its 
 
LKiATi'iu: or Tin-: iihaciiim. Airri:iiY 
 
 391 
 
 course, coiiiiiicnciiit;- at the Inurr lidnlcr nl" the iiccioriil iiiiisclc ; yet few liavc; f'nllowod 
 this advice, most siirueinis |in'l'eniii;i tlie ii|ieratiiiii named siilx-lavieiilar, one of" its riiodi- 
 tieatiiiiis, or the lit^atiire uftlie siiheiaviaii. l-'nr the superior o|ieratioti Mr. Kriidiseti j»re- 
 li'rs all incision iiiaih' IVoiii the cent re of t lie da vich- downward in the course of" the vessel 
 
 Vu.. 171. 
 Tendinous . Ilioneurofis 
 (III itietl 
 
 I.inaluii: ni l;i,u hi.il Ailcry. 
 
 to the michllc of tlio anterior fohl of the axiHa, sucdi incision necessitating: tlie divi.sion of 
 the great pectoral muscle, and often of the small. He says " that this division need not 
 leave any permanent weakness of the limb, as by proper position ready unicm may be 
 effected between the parts." 
 
 In all these operations on the axillary artery the surgeon must ever be on the out- 
 look for almormal division and relations of the vessel. 
 
 Ligature of the brachial artery is a very successful operation, and may be 
 demanded for direct injury to the vessel, lieinorrhage from a wound of one of its divisions 
 in the hand or fore-arm which cannot be treated locally, aneurism, etc. It can be per- 
 formed readily in any part of its course. The middle of the arm is the best point to 
 choose. The course of the vessel is indicated })y a line drawn from the middle of the 
 axilla to the inner side of the biceps tendon at the bend of the elbow, while the inner 
 border of the biceps muscle is the guide to the incision. 
 
 Operation. — The vessel may be exposed by a cut, two or three inches long, made in 
 this position, with the arm extended and supinated. The skin, which is always thin, and 
 the fiiscia should be carefully divided, and the deep fascia which is thus exposed ought 
 then to be laid open, but with care, for the basilic vein lies immediately below it on the 
 inner side of the brachial artery. The ulnar nerve will be found on the inner side of the 
 vein and the median in front of the artery, but there is no regularity in these relations ; 
 consequently, much care is required in finding the vessel and discretion in trying it, for a 
 high division of the vessel or the existence of some vas aberrans may mi.slead and con- 
 fu.se. When the right vessel has been found, the application of a ligature is readily 
 concluded. In performing this operation care must be taken not to open the sheath of 
 the biceps muscle, and it should be remembered to flex the fore-arm on the arm after the 
 division of the deep fascia has taken place. In several cases in which the occlusion of 
 this artery was required I have divided it and tor.sed both ends with excellent results. 
 
 Ligature of the brachial in its lower third is now rarely performed. In 
 the days of bleeding it was by no means unfrequently required for traumatic aneurysm, 
 though it has never fallen to my lot to witness its perfornnince for such a cause. The 
 operation may be performed with the fore-arm extended by making an incision tw^o and a 
 half inches long on the inner side of the tendon of the biceps, care being taken to avoid 
 the large veins that ramify in the superficial fascia. The tendinous apOneurosis of the 
 biceps will then come into view, and on its division the artery will be exposed with its 
 venae comites. the tendon of the biceps being on its outer and the median nerve on its 
 inner side. The fore-arm should then be flexed after the artery has been expo.sed. when 
 a ligature can be passed without trouble. 
 
 Ligature of the Radial Artery. — A line drawn frojn the outer side of the 
 biceps tendon at the bend of the elbow to half an inch internal to the styloid process of 
 the radius at the wrist marks out with sufiicient clearness the course of the radial artery, 
 and the vessel may be tied in any part of it. In the upper third of the fore-arm 
 (Fig. 175), between the supinator longus on the outer and pronator teres on the inner 
 side, it can be found by an incision two inches long made in the line above mentioned, 
 dividing the integument and deep fascia, care being taken not to divide the large cuta- 
 
392 
 
 LIGATURE OF THE ULNAR ARTERY. 
 
 neous veins unnecessarily. On separating the muscles with the hanJle of the knife, the 
 fore-arm being partially flexed, the artery will be brought into view with its venfe 
 comites, the nerve being to its outer side. A ligature can' then be easily passed round 
 the vessel. 1 have had to cut down upon the radial artery in this part of its course for 
 
 Fig. 175 
 Su/iinato?- hnrfUS 
 
 i.iganirf of liatUal Artery. 
 
 a traumatic aneurism the result of a punctured wound ; I divided the vessel and twisted 
 both ends, convalescence speedily following. 
 
 At the lower third the vessel may be found external to the flexor carpi radialis 
 muscle, but internal to the supinator longus. It lies beneath the deep fascia, and on the 
 division of this the artery can readily be found (Fig. 17U). On the dead subject the 
 principal cause of difiiculty in applying the ligature'lies in the fact that students look 
 for the artery too superficially, mistaking the .superficial radial vein for the deep. I have 
 had to ligature or twist the radial on seven occasions for aneurism — in six for traumatic 
 
 Fig. 176. 
 
 Bcefijftscta 
 
 aneurism .situated above the wrist, and in one for aneurism at the back of the wrist. In 
 all a good result ensued. 
 
 Ligature of the Ulnar Artery.— This vessel lies beneath the superficial layer 
 of muscles in tlic upper half of its course, and in the lower between the tendons of the 
 flexor carpi ulnaris on the inner side and flexor sublimis digitorum on the outer, being 
 covered with integument and deep fascia. Its position is roughly indicated by a line 
 drawn from the inner side of the biceps tendon to the radial side of the pisiform bone, 
 the upper part of the vessel describing a curve with the concavity outward. 
 
 To ligature the artery in the upper half of its course, an oblique incision must be 
 made crossing the line above indicated, and the radial border of the flexor carpi ulnaris 
 should be found. Through this the incision must be made, when the artery will be .seen 
 between the two layers of muscles. This operation is very difiicult and uncertain, and it 
 is an open question whether it ought to be performed. I am disposed to think that the 
 brachial, under all circumstances, except for wound, ought to be tied rather than have 
 recourse to it. 
 
 To tie the ulnar above the wrist is not more difficult than to tie the radial 
 (Fig. 176). An incision along the outer side of the flexor carpi ulnaris. dividing skin, 
 superficial and deep fascia, exposes the vessel, with its venae comites. and the nerve on 
 its inner side. A ligature can easily be passed round it. The drawings well illustrate 
 these points. 
 
 Hemorrhage from the palm of the hand is always alarming and trouble- 
 some, more particularly when caused by a punctured wound. In a superficial incised 
 wound the vessel may generally be found and ligatured or twisted, but in the case of a 
 deep wound it is rarely expedient to cut into and explore for such a purpose. 
 
 When the vessel cannot be tied, a graduated compress may be applied over the wound 
 
i.icM'riu'. or Miri:i:!i:s of iiii: i.nwi.n r.srnF.Miry 
 
 ;{l>3 
 
 ami llii' fiiiLTi'i's l);iiiil:iLrt'il, IK-xctl. ami lnniml ilnwii uvcr a hall ur l.ldck u\' wood, ilir arm 
 lu'iii!^ wi'll raisi'd in u vortical juisitinii. 'I'liis ilrcssiiiir should not In- undnni' for at Ica.st 
 live or six days. If tlitvsi- iiifaiis fail — which they rarely do when crticiently c*iii|iloved — 
 the radial and ulnar arteries may tie <'om]»ressed with aciipressnre needles; and Hhonld 
 this ])rove unsuecessliil. the a|)|ilication <if a ligature to the hraehial artery inav he 
 re<|nired. In ne<;lected cases, where the parts are all inliltraled and ho^riry. this practice 
 mav he called for at once. It is well, licnvever, hefore resorting: to this practice, to try 
 «'.\tronie He.xion <d' the fore-arm upon the arm, with forctid supination <d" the hand, with 
 or without a pad at the hi'iid of the arm, as it is now well known that hy this positi(jti the 
 eircuhition throui^h the l)ra(diial artery can be com])letely arrested ; indeed, under all cir- 
 eiimstanees, whether for injury or di.sease of the arteries of the liand and fore-arm in 
 which surji:ieal iutt^rfereme is rtMniisite. it wouhl Ije well to remember this treatment, it 
 beiui; uu)st effective. It should be known, how(!ver. that repeated liemorrha<re may take 
 place from the palm of the hand from the presiuice (»f a slouLHiini.' tendon. In illustra- 
 tion of this I may mention a very interesting; case I had with j)r. Hunny of Newbury, 
 where a <i;entlemau ;et. '.V.\ had his middle Hnicer bent back .so forcibly by a cricket-ball as 
 to cau.se ru])ture of the intei^ument in iVout of the extreme joint and laceration of the 
 flexor tendons of the Hnirer about the wrist. Suppuration and sIouLchin;; (jf the tendons 
 followi'd, attended by repeated attacks of jialmar lieuKjrrhaLre, which ceased at once on 
 the riMuoval of the di'ad tendons. 
 
 I'friteneam. 
 S/terma^i'c Cord 
 
 LIGATURE OF ARTERIES OF THE LOWER EXTREMITY. 
 
 The External Iliac Artery. 
 
 This operation may be reipiired for aneurism of the common femoral artery, or for 
 any other affection in which it is necessary to arrest the flow of blood tlirouuh the lower 
 extremity. It should not, how- 
 ever, be performed for any disease 
 unless pressure of the artery, digi- 
 tal or instrumental, has proved 
 ineft'ectual or is inapplicable, for 
 Mapother {D\ih, Med. Fress^ 18G5). 
 Eck (.SV. Barthol. Hosp. Rep., 
 18(J0), and Hilton (Med.-Chir. 
 Traii.^., 18G9) have all recorded 
 instances of cure of inguinal an- 
 eurism by these means. The 
 operation of ligature is, however, 
 a successful one, and Norris and 
 Cutter give 47 fatal cases out 
 of 153 (Am. Journ. Mid. Sci.. 
 1847 and 18G4). I have performed 
 it on six occasions, and in all with 
 success. The course of the vessel 
 is clearly indicated by a line drawn 
 from the left side of the navel 
 where the aorta bifurcates to the 
 middle of Poupart's ligament, the 
 upper third of this line correspond- 
 ing to the common iliac and the 
 lower two-thirds to the external. 
 
 Abernethy. in 1796, was the 
 first to ligature the vessel. The 
 incision he practised was vertical 
 in the course of the artery, begin- 
 ning an inch above Poupart's liga- 
 ment. The peritoneum, however, 
 is too much disturbed by this pro- 
 ceeding, as well as the abdominal 
 walls weakened. The best incision Ligature of External iliac and Superficial Femoral Arteries. (In this 
 is that employed by Sir A. Cooper. "S»re the incision for the femoral artery is placed too low., 
 
 a slightly curved one, about half an inch above Poupart's ligament, commencing on the 
 
 Def/t fasfia 
 
 SarUrtus inusrlc 
 
 Xieny Sa/i/iena 
 
394 LIGATURE OF THE COMMON ILIAC ARTERY. 
 
 inner side of its centre, curvint; upward and outward for about three inclies toward the 
 anterior superior spine of the ilium (Fig. 177). This incision should divide all the soft 
 parts superficial to the external oblique muscle. All vessels that are divided should be 
 secured. 
 
 The tendon of the external oblique muscle should then be divided the whole length of 
 the skin wound, together with the internal oblique and transversalis muscle when they 
 cannot be drawn outward, and care should be taken not to injure the peritoneum ; the 
 cord which then comes into view should be drawn inward and the parts held well aside 
 by hooked retractors. With the fingers the transversalis fascia should be separated from 
 Poupart's ligament and raised upward with the peritoneum and the sheath of the vessel 
 exposed, the vein being to the inner side of the artery. The sheath can then readily be 
 opened and a ligature passed, the needle being introduced between the vein and artery. 
 To divide the transversalis fascia the whole length of the wound is an unnecessary pro- 
 ceeding, but to deal with it as suggested above is an extra protection to the peritoneum 
 and in no way renders the operation more difficult ; indeed, I have been led to believe 
 that it facilitates the operation. It certainly does this on the dead subject, and in the 
 eight cases in which I have been called upon to perform it on the living, this opinion was 
 confirmed. The genito-crural nerv.e, which lies upon the vessel, should not be included 
 in the ligature. The operation is only applicable for tumors situated below Poupart's 
 ligament ; for others, Abernethy's operation or that suggested for the common iliac should 
 be selected. 
 
 Ligature of the COmniOn iliac artery has been performed about thirty-nine 
 times, but only ten times with success. It was first successfully performed by Mott of 
 New York in 1827. I have seen it done but once, and then by my colleague, Mr. Cock, 
 in 1863, on a man aet. 27, with success. 
 
 To expose the vessel, the incision must be long, its length being determined bv the 
 size of the aneurism and the depth of the artery. A curved incision commencing outside 
 the internal ring and passing upward and outward, as if for the external iliac artery, 
 appears to be the best, the muscles being divided to an equal extent. The transversalis 
 fascia must be laid open or torn through and the peritoneum turned upward. It is at 
 this part of the operation that the greatest difficulties arise, for as soon as the transver- 
 salis fascia is divided the peritoneum covering the intestine bulges into the wound. This 
 membrane also is frequently found adhering to the aneurismal sac, and much difficulty is 
 felt in separating it. This was markedly so in Mr. Cock's case. The oozing of blood 
 into the wound also masks the vessel. The depth of the wound likewise renders the 
 application of the ligature a matter of great difficulty. Xevertheless. these difficulties 
 can be ovei'come by care and good aids. The operation is similar to that last described, 
 though more difficult. In 1846, Mr. Stanley ligatured the common iliac artery by an 
 operation suggested by Sir P. Crampton and described by Skey. The patient was placed 
 upon his side and an incision made from the end of the last rib downward and forward in 
 front of the iliac crest; the transversalis fascia was divided and the peritoneum rolled up. 
 The common iliac artery was then found and tied with apparent facility. On the dead 
 body this operation is far from difficult, and promises to be of service to the living when 
 the aneurismal tumor is large and high up. Indeed, it is probably the better operation 
 of the two given. The abdominal aorta, too, could, be ligatured by the same means 
 (Fig. 169, page 383). 
 
 Ligature of the Internal Iliac. — Stevens of Vera Cruz, in 1812. was the first 
 to perform this operation in a case of gluteal aneurism, occurring in a negress. and the 
 operation proved successful. Since his time the operation has been repeated eleven 
 times, and in six with success. The incision and steps of the operation are the same as 
 for the common iliac. Stevens, however, cut down through the anterior abdominal walls, 
 similar to Abernethy's operation for the external iliac. It should not, however, be per- 
 formed for gluteal aneurisms unless rapidly increasing till other means of cure have 
 been tried and failed, such as pressure upon the aorta or common iliac, or even galvano- 
 puncture. Besides, Holmes has clearly shown in his College Lecture!^ that in cases of 
 imperfect or ruptured sacs either the operation of Anel or that in which the sac itself is 
 opened should be practised. 
 
 In operating upon any of the iliac vessels it should be remembered that great variety 
 exists as to their length. When the common iliac is long, its branches are short, and 
 vice versa. 
 
Lit;Arri:i: of riii-: ri.MouAL Anii.nv. liijo 
 
 Ligature of the Femoral Artery. 
 
 This vi'sscl i-aii be tied in iiiiy part nC its course ; and whrn llir tliiirli is straij:lit, a 
 lino drawn from the ct'iitrc ol' Poiipart's liframcnt to the iiiner side ot" the jiatcila will 
 mark out its position with tok-raltic accuracy. When the thi<:h is ahdnctcd and rotated 
 outward, a line drawn from the same point ahove to the inner side of tlu; inner eondyhj 
 indicates the upper half of its c(»urse. In tlu? upper third it is tolerahly superficial ; in 
 the middle and lower, it is covered by the sartorius muscle, which varies much in its 
 width, and hy the mendtrane formiiif; the roof of Hunter's canal. At the present day it 
 is an exceptional act to li<:;ature the vessel in llunt(!r"s canal. F(M' popliteal aneurism the 
 artery is <reiu'rally ligatured in the middles third of its course, at tlie ape.x of Scarpa's 
 trianj;le. ^^)r aneurism of the femoral itself the common femoral niay In; tie»l helow 
 Poupart's liiiameiil. 
 
 'flu- COmmOIl femoral is usually ahout an inch and a half in Icn^'th ; it doi-s not 
 exceed one inch in one case in four, while in oiu; in four it is between an inch and a half 
 and two inches ( Xunn.). It is from these facts that surtreons have <^enerally preferred to 
 ligature the external iliac rather tluin the common femoral. The two Porters, however, 
 as well as Macnamara of l)ul)lin, have adduced sufficient evidence to prove that succe.ss 
 may attend the ])ractice, giving thirteen eases between them, and eleven proving success- 
 ful. ( Vide Dnhlin Qiutrf. Jouni., 1800, and Brit. Med. Joiirii., October, 1<S()7.) 
 
 The operation, moreover, is not difficult, the ves.sel being readily exposed by a ver- 
 tical, oblique, or transverse (Porter's) incision. The sheath of the artery is then to be 
 opened without touching the vein — indeed, the vein should never be exposed — care being 
 taken not to enclose the crural branch of the genito-crural nerve running down in front 
 of the vessel in the ligature. 
 
 The main arguments against the operation are founded on the uncertain length of the 
 artery, the proximity of the ligature to large branches, and the lial)ility to gangrene 
 from the occlusion of the main nutrient arteries of the limb. On the other hand, there 
 are the success of the operation and the facility with which it can be performed. More 
 experience, however, is recjuired before the operation can be recommended, though it 
 should not be dismissed without due consideration. 
 
 Ligature of the femoral artery in the middle third of its course is a 
 
 capital ojtcratioii, an(l,^moreover, a successful one. Norris gives 40 fatal out of 188 
 operations for aneurism, or one-fourth of the cases collected from all sources, from John 
 Hunter's first operation in 1785 down to 1848, and undertaken, too, under many different 
 conditions. Syme informs us that he has had 23 successful cases consecutively, and at 
 Guy's Hospital, during fourteen years, the femoral artery was tied for aneurism 24 times, 
 with only 1 death from py;emia and 1 failure, these cases including G in which pressure 
 had been tried and failed. Pressure had been employed in 17, and in 11 with success. 
 During the fourteen years ending 1880 the results have not been so good. Mr. Charles 
 Symonds having shown in his interesting paper (Gin/s Rep. ^ vol. xxv., 1881) that 6 cases 
 died out of 20, or, eliminating 2 which died from causes quite unconnected with the 
 operation, 4 out of 20 ; but in considering these figures it must be remembered that the 
 ligature of the femoral artery is resorted to in the bad cases alone, in which the treat- 
 ment by compression is inapplicable or has failed. Mr. Holmes, in his lectures at the 
 Royal College of Surgeons in 1874, moreover, gives some statistics of recent hospital 
 practice which possibly place the operation in even a better light, inasmuch as out of 77 
 cases of popliteal aneurism treated by ligature at once the deaths were 11, or 14 per 
 cent., and the failures 15, or 19 per cent. ; while, in 44 other cases in which the ligature 
 was applied after the treatment by pressure had failed. 31 succeeded and 13 ftiiled, or 29 
 per cent., the mortality in the latter class of cases, as might have been expected, being 
 larger than in the former. 
 
 I may add that, of 124 cases of popliteal aneurism collected by Mr. Holmes, pressure 
 succeeded in 60 and failed in 58. In 44 of the 58 ca.ses the artery was tied, as seen 
 above, 13 of these dying, and. of the remaining 14, amputation was practised in 8, death 
 occurred in 1, while in 4 there was no evidence of subse((uent treatment. 
 
 Oper.vtion. — To tie the vessel the limb of the patient should be slightly abducted 
 and rotated outward, the leg being partially flexed and the knee supported on a pillow. 
 The line of the vessel should then be marked by the eye and the point at which the liga- 
 ture is to be applied determined, the lower part of Scarpa's triangle being the " point of 
 selection" (Fig. 177). An incision about three inches in length must then be made 
 parallel to the vessel dividing the integument and superficial fascia down to the deep 
 
596 
 
 LIGATURE OF THE POSTERIOR TIBIAL ARTERY. 
 
 parts, the course of the superficial veins having previously been ascertained by making 
 pressure upon the saphena vein where it joins the deep femoral, in order to avoid it. If 
 the vein be in the way, the incision can be made by its side ; but generally it is on the 
 inner side of the wound. The deep fascia may then be divided and the inner border of 
 the main guide to the artery, the sartorius muscle, looked for. This is readily recogniza- 
 ble by the course of its fibres dou-mcard and imcard, and underneath this the sheath of 
 the vessel is certain to be found. The muscle having then been gently separated from its 
 attachments by means of the finger and held outn-urd with a retractor, the sheath will be 
 exposed with the artery in front and vein behind, the long saphenous nerve generally, 
 and sometimes a nerve to the vastus internus, lying upon the vessel. The sheath should 
 then be opened with caution and its inner side held tense, an opening being made suffi- 
 cient to expose the vessel and admit the aneurism needle ; moreover, care should be taken 
 to keep the end of the needle close to the artery, in order that the vein may not be 
 injured or included in the ligature. The needle ought to be passed from within outward. 
 The ligature having been passed, the surgeon must satisfy himself that nothing but the 
 artery is surrounded and that the vessel sought for has been exposed ; he may then tie it, 
 readjust the parts, and close the wound, covering the limb with cotton-wool and raising it on 
 a pillow. Should the vein be wounded by the needle, it must be ligatured below the wound. 
 A silk ligature may separate from the femoral artery in nine or ten, or not even for 
 thirty, days, a wide diiference existing on this point, an analysis of cases decisively 
 proving that no general rule can be laid down as to when its separation may be expected. 
 
 Ligature of the Popliteal Artery. 
 
 I hardly know under what circumstances the popliteal artery may require the applica- 
 tion of a ligature, except for a wound, as for rupture of an ai'tery or for aneurism the 
 operation is as inapplicable as it would be unsuccessful. Mr. Poland has pointed out 
 how the posterior ligament of the knee-joint is frequently involved in the laceration of 
 the vessel. Some years ago I was called upon to cut down upon a large needle that had 
 perforated the popliteal space and become lost in its tissues, all movements of the joint 
 being impossible by the pricking pain occasioned. I discovered the foreign body lying 
 obliquely across the popliteal artery with its point fixed in the posterior ligament of the 
 knee-joint. The artery was exposed without difficulty by an incision made along the 
 outer edge of the semimembranous muscle, the leg being extended. The vein is more 
 superficial than the artery and can always be found to its outer side above ; the nerve is 
 still more superficial, and above still farther out, but it lies over the artery at the back 
 of the knee and to its inner side where covered by gastrocnemius. 
 
 Ligature op the Posterior Tibial Artery. 
 Guthrie brought the weight of his great authority to support the recognized practice 
 
 Fig. 178. 
 
 Ligature of Posterior Tibial Artery. 
 
 of tying a wounded vessel at the wounded part even in the case of the deeply placed 
 posterior tibial and peroneal arteries, and practically carried it out in a supposed wound 
 of the latter vessel by making a free incision through the muscles of the calf of the leg 
 down to the wounded artery. Arnott, also, acting on Guthrie's suggestion, tied the pos- 
 
LicATi'iiE OF Tin: A.\Th'i:/>)/: TIl:/.\L AnTl.'l:)'. 
 
 :V.i7 
 
 Vui. 179. 
 
 toriur tiliial \>\ tliis method, thoufrli lu-itlicr tli<' n'|i(>rt of tlif case (M'd.-C/iir. Tnmn.^ 
 vol. xxix.) nor Mr. Arni»tt s remarks are encoura;:iii;r in any way in favor of its repeti- 
 liiin ; intleetl, modern surjrediis have universally rejeeted the method in lavor of that 
 which has now }>een deserilied. 
 
 It must he ])remised that tlie vessel lies beneath the sujterfieial layer of muscles form- 
 inj; the ealf and heneath the deep fascia, the nerve being toward the inner side above, 
 but to its outer side, in the greater part of its course. Its course, too. is indicated by a 
 line drawn lV(»m the centre of the popliteal Hpacc to a point midway ))etweeii the inner 
 malleolus and the tendo Aehillis. 
 
 In order to tie the artery, the leg must be partially flexed upon the thigh and made 
 to rest ujion a ]»illow on its outer side, the heel being raised, to relax the mu.seles. An 
 incision about four inches in length should then be made about half an inch from the 
 edge nf the tibia and parallel with it, through the integument, down to the deep fascia, 
 avoiding, if possible, any largo suj)crficial veins. ^ The deep fascia can then be divided 
 and the muscles ex]»osed. The lower border of the 
 tibial origin of the .soleus muscle should then be 
 lonked fur, and l)eneath it a director introduced; the 
 til>ial iirigin of this muscle should then be divided 
 the wlnde extent of the wound. The glistening ten- 
 dinous covering of the deep surface of the muscle is 
 an excellent guide to the vessel and should not be 
 mistaken for the deep fascia, which lies deeper and 
 beneath which is found the vessel. To search for 
 the artery, the leg must be well flexed, the heel 
 drawn up, and the muscles retracted. The ligature 
 can then be pa.«^sed in the most convenient way. 
 
 On the dead subject this operation is not diffi- 
 cult, and on the living, more particularly when per- 
 formed with the aid of Esmarch s bandage, it can 
 hardly be -so '• difiicult, tedious, bloody, and danger- 
 ous " as Mr. Guthrie has described, and as is his Ligature of Posterior Tibial Artery behind 
 
 luuer -Malleolus. 
 
 own operation. 
 
 The operator .should be careful, however, not to divide the tibial origin of the soleus 
 too near the tibia, as in doing so he may penetrate the deep fascia and thus Icse his best 
 guide — viz., the glistening tendinous tibial origin of the soleus. 
 
 To tie the artery at the loicer third of the leg behind tin- inner malleohta is a simple 
 operation. It lies with its venae comites at the junction of the anterior with the middle 
 third of the space between the malleolus and the heel, the nerve being behind. It can 
 readily be exposed by a curved incision two inches long over the course of the vessel, 
 dividing integument and deep fa.scia, which is thick from receiving many fibres from the 
 internal lateral ligament. The relative position of the vessel can easily be seen in the 
 drawing (Fig. 17D). 
 
 Ligature of the Anterior Tibial Artery. 
 
 This operation is far from simple, inasmuch as the vessel lies buried in the upper two- 
 thirds of its course between the muscles on the interosseous membrane ; its course 
 
 Fig. 180. 
 IibiaJis anticus 
 
 Ejctensor /onj/us 
 tiiaitorum 
 
 Ligature of the Anterior Tibial Artery. 
 
 is indicated by a line drawn from the inner side of the head of the fibula to the ba.se of 
 
398 
 
 INJURIES AND DISEASES OF THE VEINS. 
 
 the great toe. The surgical guide to the vessel is the tibialis anticus muscle, which lies 
 to its inner side throughout its course. 
 
 To reach the vessel in the upper two-thirds of its extent, it is important to expose the 
 intermuscular space separating the tibial muscle from the extensors communis digitorum 
 and proprius poUicis; and the best way to accomplish this is to make an oblique incision 
 ibur inches long, commencing at the outer edge of the tibia and directed downward and 
 outward toward the external malleolus, dividing the integument and superficial fascia. 
 The deep fascia will then be exposed, and the first white line external to the tibia will be 
 
 found to mark the intermuscular space outside 
 Fig. 181. the tibialis anticus muscle in which the anterior 
 
 .. n tibial artery is to be found. The fascia over this 
 
 I :| line may then be opened and the muscles sepa- 
 
 rated, the foot being well flexed to facilitate this 
 measure. The anterior tibial nerve will then 
 come into view, and beneath it the artery will 
 be found. The ligature may be passed as best 
 can be done. 
 
 J^jctensor 
 or f vis dig I torum\ 
 muscle 
 
 Trnr7on n/^ 
 T.y/cn-sor 
 /iro/iriiis 
 /lollicis 
 
 Ligature of Dorsal Arteries of the 
 Foot. 
 
 The dorsalis pedis artery should be 
 
 ligatured to the outer side of the extensor pro- 
 prius pollicis muscle, by the side of which it lies. 
 The vessel can readily be exposed by an incision 
 made along its course, the integument and deep 
 fascia being divided (Fig. 181). It is crossed 
 at its lower part by the tendon of the extensor 
 brevis digitorum muscle, and the nerve lies out- 
 side the vessel, while venae comites attend the 
 artery. The tendon of the last-named muscle 
 is an infallible guide to the artery, as it crosses 
 
 it, whilst the tendon of the extensor proprius pollicis muscle is the guide to the incision. 
 
 The surface line of this vessel extends from the middle of the joint of the ankle to the 
 
 base of the first metatarsal space. 
 
 Ligature of Dorsalis Pedis Artery. 
 
 CHAPTER XI 
 
 INJURIES AND DISEASES OF THE VEINS. 
 
 The blood from a wounded vein is black, flows in a steady stream, and never jets out 
 as from an artery. When mixed with arterial blood, as occurs when both artery and vein 
 are punctured, it appears as a dark band streaming through a red, or vice versa, the rela- 
 tive thickness of black or red band indicating the extent of the wound in the artery and 
 the vein. Pressure on the distal side of a wounded vein controls bleeding, whilst pressure 
 on the cardiac side increases it. 
 
 Wounds of veins unite as do wounds of arteries, the reparative process being alike in 
 both. After a clean incision into a vein repair may be so perfect in a few days as to 
 leave no trace of injury behind. The lips of a wound in a vein readily unite — as after 
 venesection — when kept together by gentle pressure or the application of a ligature. 
 
 A completely divided vein contmcts, though somewhat less than an artery ; it 
 also re/nic/s into its sheath, and the natural arrest of hemorrhage is helped by these 
 actions, together with the coagulation of the blood in the vein and around its orifice. 
 But these processes are slow in their action, very feeble, and practically insufficient. 
 Fortunately, however, hemorrhage from a divided vein is easily arrested by well-adjusted 
 pressure and by elevation of the limb. After amputations, if venous bleeding persist on 
 the removal of the tourniquet, and should the means just indicated have failed, the bleed- 
 ing vein may be acupressed, ligatured, or, what is better, twisted. 
 
L\.n'i:ii:s .wd Dishwsi.s or rur: viciys. 309 
 
 A partially divided vein of'tcn ^rivt-s inmli in.ulplr, altlnm^'li not wIh-h s^yMv- 
 
 /('<•/<*/, ln'caiisc tlu' I'lovalioii ol" tlic liiiili and a f(»iii|»n'ss carclully .strapped (ir l)uiida<;tMj 
 over the wnmided jiart are i^eiierully .siillieieiit tn clieck the hh-edin^r, and in tliree (tr four 
 davs repair may he enniideted. 
 
 W^OUlldS of deep veins, however, an- ol" urave importance; and when tin' veins 
 are hirL'e, lln-v are as si'rious as wounds id' hirire arteries, ami iiniiealthy inflammation of 
 tin- vein witli all its dangers may loUow. 
 
 'I'kkat.mkn T. — In wounds (dany of the veins of the extremities \vell-applie»l pros.suru 
 is, a> a rule, sulVieient to arrest hleedinjr and jiive time for repair; when the trunk of the 
 femoral vein is wounded in o]ieration, as in lij;ature of the femoral art(!ry. the; vein should 
 be divided and tied with a tine prepared eat<;ut lij^ature. The .same should he done to a 
 punetured wound of the internal juf:;ular or any larj^e vein. To tie the operiiiij; in the 
 vein is now known to be an error. Wounded vein.s, indeed, should be treated on the 
 same prineijdes as wounded arteries. When pressure i.s enoufrh to arrest hemorrhage 
 from a vein, however lar^e, the liirature is not retpiired ; but when it fails or is inappli- 
 oal)le. the ligature may ))e fearlessly em))loyed. The dread of setting uj) ])hlehitis by 
 liuaturing veins is ba.sed on prejudice, and not on experience; it is doubtless due to the 
 intlm^nce of authorities who have pronounced against it. It cannot, however, be disputed 
 that )>hlebitis occasionally i'oUows the surgical treatment of veins. When it occurs, the 
 afteetion is serious, and takes jdace oidy in the enfeebled and cachectic. 
 
 Wounds of the internal jugular and subclavian veins are as fatal as, and 
 
 probably more so than, wounds of the carotid or subclavian arti-ries. When the internal 
 jugular is wounded near the base of the skull, life is speedily destroyed ; and when near 
 its cardiac end, to the danger of hemorrhage is added that of the introduction of air into 
 the heart. When the internal jugular is divided above the clavicle, the orifice remains 
 open, the walls not collapsing, as they would at a greater distance, owing to their connec- 
 tions with the deep cervical fascia; reflux bleeding consequently takes place from the 
 cardiac end, and during some violent inspiratory act air may be drawn into the circula- 
 tion and into the heart, causing death. Hence great care is always required in operating 
 about the root of the neck to avoid large veins, and to compress or ligature them when 
 wounded. 
 
 When death takes place from primary hemorrhage from the internal jugular, it is 
 generally within an hour. I recorded in the Trans, of Path. Soc. in 1857 such a case, 
 which occurred in the practice of Mr. Birkett ; a second was recorded by !Mr Henry 
 Gray in Holmes s S^irijcri/, and a third by Mr. Sanuiel Cooper in his First Lines of Snr- 
 
 When death does not supervene from either of these two causes, it may occur from 
 secondary hemorrhage or from }>ya!mia. 
 
 A vertical incision into the internal jugular vein is not necessarily attended with a 
 fatal hemorrhage. When bleeding occurs, it will be recurrent. This was well illustrated 
 in a case recorded by Mr. Woodman of ICxeter {^Bn't. Med. Journ., 1873), in which the 
 internal jugular vein was ligatured with a successful result. 
 
 Coagulation in Veins. 
 
 Adhesive Phlebitis. — When a vein was found by the older surgeons obstructed 
 by a fibrinous clot, the suspicion of phlebitis was excited ; and when this clot contained 
 in its centre a " puriform " fluid, the evidence of inflammatory action was considered to 
 be strong. When the clot was nu)re or less adherent to the inner membrane of the vein 
 and this membrane presented a pink appearance, the evidence was thought to be com- 
 plete. At the present day, however, none of these phenomena are accepted as true 
 indications of an inflamed vein, as it is known that blood coagulates spontaneously in a 
 wounded, lacerated, or bruised vein, that it does so when the venous blood is stopped 
 circulating from pressure upon its walls or from inflammatory or ulcerative changes in 
 the parts around, and that in ill-nourished and cachectic subjects there is a renuirkable 
 tendency for the fibrin of the blood to become de])0sited upon the serous lining of the 
 veins, either idiopathically from some altered condition of the blood or on the .slightest 
 injury, without the existence of inflammatory action. 
 
 The supposed pus found in the centre of the fi})rinous mass is known to be made up 
 of the white blood corpuscles present in all coagula, while the pinkish tint upon the 
 serous lining of the vein is due to the mere imbibition of coloring matter from the blood, 
 and not to inflammatory injection. 
 
400 IS JURIES AND DISEASES OF THE VEINS. 
 
 A clot once formed in the vein rapidly increases, the stream of blood as it flows over 
 it depositing fresh layers, until the whole calibre of the vein is obstructed. When the 
 process is slow, regular layers of fibrin may be seen in section ; but when rapid, the 
 clotting is irregular. At the extremities of the clot, also, like accretions are deposited ; 
 the coagula increase more or less rapidly in all directions and into all branches, till com- 
 plete obstruction or thrombosis, takes place. This clotting of blood in the vein becomes 
 arrested only by the blood stream of a junction trunk. These coagula can readily be 
 removed by washing ; and when removed, the lining membrane of the vein will generally 
 be found natural and the valves visible. The coat of the veins at times may appear 
 thickened from contraction, but Mr. Callender has shown that this is not a real, but only 
 an apparent, condition, the coats of the veins readily yielding to pressure under water. 
 [n the process of cure sometimes the clot will contract toward one side of the vein, thus 
 allowing the blood to pass and the circulation to become re-established. In rarer cases 
 the blood "'may drill for itself a passage through the centre of the clot." In many, 
 again, the clot will eventually disappear and the vein become patent. Ordinarily, how- 
 ever, a different result takes place ; the vein becomes permanently obliterated, the clot and 
 vein ultimately contracting so as to form a firm and shrunken cord. In rare cases the 
 clot may subsequently organize. Authors have described these as instances of ci(l/iesive 
 phlebitis. In feeble and cachectic subjects, however, these curative changes cannot take 
 place. The clot, instead of organizing, will soften and disintegrate, giving place to blood- 
 stained puriform fluid that may be carried into the pulmonary circulation, cau.sing a 
 lobular pneumonia such as is found in pyaemia from embolism of the pulmonary artery. 
 This was well illustrated in the following case, extracted from the catalogue of the Guy's 
 Museum, No. 1521"": Jugular vein exhibiting a wound occupying about half its circum- 
 ference and situated about half an inch above the subclavian, the neighboring branches 
 
 showing the effects of phlebitis. James F , aet. 30, under 3Ir. Birkett. He 
 
 received- a stab with a knife in the left side of the neck which wounded the jugular 
 vein ; much hemorrhage followed, and continued for some days, when symptoms of 
 phlebitis, .set in, and he died of pneumonia twenty days after the accident. The vein 
 was found to be wounded, as seen in the preparation, its coats infiltrated with lymph, and 
 its interior filled with fibrin. The lungs were filled with abscesses. 
 
 Results such as these, however, do not occur under all circumstances, but only in the 
 feeble and cachectic ; for ''the clot, when softened, is usuall}- shut off" in an upward-and- 
 downward direction by newly-added coagula. The softening begins in the coagula last 
 formed, and not. as Virchow states, in those first depo.sited ; for in the advance of the 
 malady the patients health fails and the fibrin becomes more and more prone to disinte- 
 grate and soften into a puriform fluid" (Callender). The clot softens also in the centre, 
 and not at its periphery; and such cases have been described as examples of suppurative 
 pJdehifis. 
 
 Symptoms. — The most prominent symptoms of an obstructed vein are cedema of the 
 parts below the obstruction, some fulness of the superficial veins, with local pain and 
 tenderness, constitutional disturbance of variable degrees of severity generally preceding. 
 When superficial veins are involved, the symptoms ma}' be chiefly local, but in the case 
 of deep veins constitutional disturbance is sure to accompany local action. Among the 
 superficial veins the saphena of the leg and thigh is most commonly aff"ected, and is often 
 a sequela of a varicose condition. Under these circumstances, the tortuous, dilated, 
 indurated vein becomes a marked object, set. as it were, in a frame of hardened, inflamed 
 skin and cellular tissue. The parts themselves will to a certainty be painful, and the pain 
 and tenderness probably extend up the thigh as far as the groin. Among the deep veins 
 the common femoral or iliac is more frequently involved than any other, and what is 
 known as a " white leg " is due to this aff"ection. it being an oedema of the leg from an 
 obstruction to the femoral or iliac vein, with local pain and tenderness and more or less 
 constitutional disturbance. In some cases the phlebitis is of a very mild character, and 
 then a good result may be anticipated ; but in others it is very severe, and in such sup- 
 purative changes will probably take place. 
 
 It sometimes happens that a limb becomes much enlarged and solid in the deeper but 
 not in the superficial parts — that is, no cedema of the cellular tissue beneath the skin 
 will be present, although the superficial veins may be turgid. The absence of this 
 symptom, however, must not mislead, as it simply indicates that the superficial circula- 
 tion is efficiently carried on and that no stagnation exists sufficient to allow of passive 
 serous exudation. 
 
 When these cases proceed favorably, the swelling will gradually subside, as will also 
 
i.\ji/:ii:s AM) nisj:.\si:s of tiih veins. loi 
 
 every ntlirr syiii|itiiiii, tlic vein cillicr nvovcrinir its normal cuiKlitioii or tli(! l)loorl tiniliti;^ 
 its way tliroiiirli otlu-r cliaiiin'ls Wlicii they j^o on iiiifiivoriihly, suppiirutiori will take 
 placi' ; and it' tlic tlfcp parts are involve<|. the case ussuiues u very serious aspect, as a 
 local or a dittused abscess may result (the hitter condition bein<^ the more cutiiinon), and 
 then Ii1(mk1 poisoniu": too fre<|uently ensues with its usual consecjuences. 
 
 TliKATMKNT. — The two f^reat indications for treatuieut in these cases are (1) to 
 faviir thr rniaiis rlrciiltilii)n of fli<' jxn't, and ('!) I" iiiii>rorr f/ir i/inirn/ loin/ifion uf lite 
 piifirii/. 
 
 The first can Itc attaine<l l>y elevation of the limit, the foot hcin;; rais»;d higher than 
 the hip, and hy the a|)plication of warmth to the part in the shape of fonunitations or 
 
 COttoM-Wool. 
 
 The second can lie carried out liv the administration of a simple nutritious diet, tonics, 
 such as (|uiniiM', hark, or iron, and stimulants caref'ullv adjustecl to the wants of the 
 individual case. 
 
 I'ain must he allayed hy both local and general means, as poppy fomentations and the 
 internal use of ojtiuin, mctrphia, or chloral. 
 
 Leecliini; should never be resorted to, nor mercury in any of its forms, as the prac- 
 tice was based on a mistaken pathology, and therefore should be discarded. 
 
 When suppuration appears, it must be dealt with on ordinary principles, as it is wise, 
 as a rule, to evacuate it as soon as it has declared itself. 
 
 Gouty Phlebitis. — Subjects who are gouty from hereditary or acquired causes are 
 likewise liable to (t<fh'siiv' jtldchllla. Sir J. Paget has well described tlie affection in his 
 Cliniad Lectures (1875), and IMr. (jay has also written ably upon it {Luiicrl^ May 19, 
 1877): '"In such cases the phlebitis may have no intrinsic characters by which to dis- 
 tinguish it, yet not rarely it has peculiar marks, especially in its symmetry, apparent 
 metastases, and fre(|uent recurrences." 
 
 Like other forms of phlebitis, it is more common in the lower than in the upper 
 extremities, yet it may be found anywhere. It affects, however, the superficial rather 
 than the deep veins and often occurs in patches, affecting on one day (for example) a 
 short piece of the saphenous vein, and the next another piece of the same, some other 
 distinct vein, or a corresponding piece of the opposite vein. 
 
 The inflamed portions of vein usually feel hard and are painful to the touch. The 
 soft parts coveriixg the vein become slightly thickened and often have a dusky reddish 
 tint. When the deep veins are involved, oedema appears, with the well-recognized results 
 of venous obstnu^tion : "the limb becomes big. clumsy, featureless, heavy, and stiff: its 
 skin is cool and may be pale, but more often it has a partial slight livid tint, which might 
 be discerned by comparison with the other limb, and has mottlings from small cutaneous 
 veins visibly distended." The limb thus enlarged feels uidematous throughout, but firm 
 and tight-skinned, not yielding easily to pressure, and not pitting very deeplv. 
 
 By almost this .state alone the disease can sometimes be recognized. 
 
 The coNsTiTiTio.NAL svMi'TOMs associated with this local affection vary from some 
 slight febrile condition to those met with in acute gout. Complete recovery may 
 take place in this as in other forms of phlebitis, the veins becoming pervious in some 
 ea.ses and obstructed in others, the limb rea.ssuming its healthy condition or becoming 
 permanently enlarged, cumbrous, and heavy. The risks of embolism are also the 
 same. 
 
 Tre.\tmknt. — Nothing special can be recommended, as the so-called gout remedies do 
 not appear to have much influence on the local di.sease. Rest, elevation of the limb, lead 
 lotion to the inflameil vein when superficial and fomentations when deep, are tlie chief 
 points to be attended to in the local treatment, and a lower diet, abstention from stimu- 
 lants, and saline drinks in general. When feebleness exists, the li(|Uor ammonia in doses 
 of five to ten drops with Itark is an excellent remedy, but at others quinine is called for. 
 
 Suppurative Phlebitis.. — There is. however, another form of phlebitis that must 
 be mentioned, and which is by far the most .serious — viz., the uuhadtlii/ <li(f'use or siippu- 
 rativt phlihitis. It is an affection of the cellular tissue around the veins, these veins 
 themselves being secondarily involved. It is a species of erysipelatous inflammation of a 
 low type, and it is only found in the feeble and cachectic. It comes after a severe injury 
 to or operation on bone ; after a slight contusion or a severe wound ; it may supervene 
 on the puncture, division, or ligature of a vein, or chronic suppurative disease, more par- 
 ticularly of the bones of the cranium. It occurs also in the puerperal state. Dejiending 
 upon a vitiated condition of the blood. " we are able to appreciate how it is that the many 
 different forms of jthlebitis may follow various dissimilar injuries, arid reconcile the fre- 
 26 
 
402 INJURIES AND DISEASES OF THE VEINS. 
 
 quency of their occurrence after operations involving the venous system. The dangers are 
 not to be looked for when the general condition of the system of the individual is good 
 and when the walls of the vessels are in a healthy state, but they may be anticipated in 
 enfeebled and broken-down constitutions, more particularly when the coats of the vessels 
 are abnormally changed. Upon such a class of persons operative procedure should, there- 
 fore, if possible, be avoided" (Dr. 8. W. Gross, 1867). 
 
 Local Symptoms. — The disease shows itself as a purulent infiltration of the cellular 
 tissue surrounding the vein with a thickening and softening of the coats of the vein itself. 
 As the disease progresses abscesses form around the vein, whilst the circulation through 
 it is arrested by the formation of coagula in one spot and a sloughing abscess in another. 
 In superficial veins, such as in the leg, all these changes can be well observed, but in the 
 deep they are difficult to diagnose. In the superficial the external signs of inflammation 
 are well marked, local redness and brawniness of skin around a dilated, thickened, and 
 tortuous vein being the chief symptoms. As the disease progresses local abscesses appear 
 in the vein itself, which yield blood and pus on being opened, these contents being, doulit- 
 less, broken-down coagula. 
 
 Constitutional Symptoms. — The constitutional symptoms vary with the extent 
 and severity of the disease, marked depression of the general powers always being pres- 
 ent, while rigors not only usher in the attack, but attend its progress, each one probably 
 indicating some suppurative change. Local pain and sleeplessness are common accom- 
 paniments, and in cases that cease to be local and have an infective tendency those known 
 as typhoid symptoms occur. When blood poisoning or pyaemia appears, the symptoms 
 are such as have been described in an early chapter. 
 
 On the Presence of Air in Veins. 
 
 That air may find its way to the heart through an open vein and cause sudden death 
 is a clinical fact with which all surgeons should be familiar, also that this entrance gen- 
 erally occurs during the removal of tumors about the neck and axilla, amputations at the 
 shoulder-joint, and operations or wounds involving the cervical or other veins. It has 
 likewise occurred in uterine surgery from the injection of air or gas, etc. Two-thirds 
 of the patients affected die from the accident, half within a few minutes, others living 
 hours or a few days. The accident is favored by a thickened state of the vein, and is 
 generally indicated during the progress of an operation by a sudden gurgling, hissing, or 
 bubbling sound in the wound, associated with venous bleeding, sudden faintness, and 
 insensibility of the patient, or convulsions, probably terminating in death. When this 
 result does not at once transpire, there will be labored and irregular respiration, tumul- 
 tuous action of the heart, and feeble pulse, the lividity of the patient gradually disap- 
 pearing, the heart then regaining its natural action, and the patient recovering. Bubbles 
 of air may at times be seen in the wound. In some cases the patient will give a sudden 
 cry with the first onset of the symptoms. 
 
 After death evidence of the admixture of air with the blood has been found in the 
 form of bubbles in the vessels of the brain or in the large venous trunks and arteries. 
 In some cases air has been found in the right cavities of the heart. Where a suspicion 
 of this cause of death exists, the heart and large vessels should be opened under water, 
 to make manifest the escape of air-bubbles, one single bubble indicating air in the heart, 
 and many bubbles air in the vessels. Experiments on animals by Erichsen and by a 
 French commission tend to confirm this observation. 
 
 Treatment. — How to deal with these cases has now to be considered, and, witliout 
 doubt, preventive are more important than curative measures. In dealing with large 
 veins, or, indeed, any veins near their cardiac ends, the surgeon should be careful to apply 
 pressure and to maintain it during the operation, while in some instances it is more expe- 
 dient to ligature before dividing or twisting them. When the bubbling sound has been 
 heard, pressure must at once be applied to the spot where the bubbles appear. When a 
 large vein has been wounded by accident, it should be tied ; and when this cannot be done, 
 the opening must be taken up by forceps and carefully closed with a fine silk ligature. 
 
 When air has been admitted into the heart and its action interfered with, the surgeon's 
 aim should be to keep up its action and help the respiratory act by artificial means, such as 
 by cold water on the face and thorax, stimulants, as ammonia to the nostril, etc. Amus- 
 sat ascribed recovery in one of his cases to pressure upon the chest, leaving the opening in 
 the vein free, so as to allow of the escape of the admitted air ; but in adopting this prac- 
 tice care must be observed to close the orifice of the vein in the inspiratory act. Brandy 
 
INJUKIKS .\.\n I USE ASKS O/' 77//; I'AVAW. 
 
 40;i 
 
 rcuin.stanoes as 
 tinn iii' ;i part 
 
 Kir:. IS". 
 
 and (liHu.^ililo stiiniilatits .><h(iul»l also \>v iVccly ^'ivcii, to sustain and .stiinulato tlio vital 
 t.r<:ans.' 
 
 Hypertrophy and atrophy <•*' vt-ins occm- in incciscly similar fire 
 hypiTtropliv and atrophy (tf other structurt's. Thu.s where increase ol' fuiie 
 exists, or increased p;rowth, (he veins will elonfjate, dilate, 
 and thicken. When decrease of I'linctioii or di.soase of a 
 part takes place, the veins waste or hec(tnie atrophied with 
 other structures. Hence, after auiputattun of the thi<;h, 
 the femoral artery and vein lieeonie as small as the ante- 
 rior tihial ; and in Mr. Cock's ease of arterial varix, re- 
 lated in pa<;e liT'), the vein ahove the varix withered to a 
 mere cord. On the other hand, in the same case of arte- 
 rial varix, the popliteal vein helow the varix, when takin*r 
 on the action of an artery, heconie miieh eidarjred and 
 thickened — in fact, hyportrophied — simply on account of 
 the increase of work it had to jierform under its new con- 
 dition, and the superficial cutaneous veins through which 
 the whole of the returning blood must have jjassed be- 
 came enormously enlarged. An equally good instance of 
 hypertrophy of veins can be seen when any obstruction 
 occtirs to one of the cava3 or any large venous trunk, the 
 venous circulation making its way through other channels, 
 which consequently enlarge. Thus, in Fig. 182 the skin 
 veins of the abdonu'u and chest are seen to be enormously 
 distended and hypertrophied to carry on the circulation 
 from the lower part of the body to the heart, the lower 
 vena cava having been completely obstructed from cancer- 
 disease. The woman, fet. 47, a patient of Sir W. W. (lull, 
 had no oedema of the lower extremities all through the 
 case, thus proving the perfection of the compensatory 
 venous collateral circulation, and probably indicating the 
 gradual progress of the obstruction. 
 
 Calcareous and atheromatous diseases of the coats of veins may 
 
 occur, but are rare afeetions when compared with their frequency in the arteries. In 
 Guys Museum (1588'^) there is a good specimen of ossified saphena vein, and at St. 
 Thomas's Hospital and the College of Surgeons' Museums may be found examples of 
 calcareous degeneration of other veins. Gay has also described a dissection of a varix 
 which " appears to have been occasioned by disease, originally atheromatous, followed by 
 softening and ulceration of the inner and middle tunics of the vessel," and 3Ir. Pick of 
 St. Georges Hospital (^Faf/t. Tnain., 18(37) has given a somewhat similar example. How 
 far, however, this atheromatous and calcareous degeneration is a distinct disease, or an 
 "after-change in some local deposit of fibrin,'' is an open question. 
 
 Collateral Veuous Circulation. (^Taken 
 from a woman iet. 47. under the care 
 of .Sir W. W. (iull, in whom the in- 
 ferior vena cava was completely ob- 
 structed from cancer. Guy's Hosp. 
 Mus., Iirawing 44''0.) 
 
 Varex. — Varicose Disease of the Veins and Phlebolithes. 
 
 The term " varicose vein " is unfortunate, as it is applied to any enlarged tortuous 
 vessel, to such as have been already described as hypertrophied veins, and to others that 
 are clearly due to some diseased action resulting in hypertrophy with dilatation. In the 
 sequel the term will be confined to the latter condition. A'^arix is commonly an affection 
 of the veins in the lower extremities, and mainly of the branches of the saphena vein. 
 When it involves the submucous veins of the rectum it is called a hemorrhoid, and when 
 the veins of the spermatic cord a varicocele. But '■ all the veins of the body may become 
 varicose,' said M. Bri(|uet in 1824. In 18(!9 a child aet. 4 was brought to me with a sac- 
 culated varix the size of a nut connected with a vein on the outer side of the right fore- 
 arm ; it had been coming on for a year and a half. Taking varix of the lower extreiuity 
 as a type of the affection, it appears as a disease involving one or more, and in extreme 
 cases all, of the branches of the saphena vein. In most instances it is confined to the 
 larger trunks ; in some it spreads to the smaller tributaries. 
 
 In some, however, the affection appears to begin in the capillaries of the skin and to 
 spread toward the larger trunks, and such cases are most common in women. They appear 
 
 ^ The reader may refer to an admirable paper on this subject by Dr. J. S. Green of Massacliusetta, 
 Amfr. Med. Journ., 1864. 
 
404 
 
 INJURIES AND DISEASES OF THE VEINS. 
 
 as '■ clusters of diseased venous radicles " (Gay) and rarely involve other than the smaller 
 branches. 
 
 It must not be thought, however, that this affection is one of the superficial veins 
 alone, for such is not the case. Boyer asserted this many years ago, and on his authority 
 the opinion has been accepted. Verneuil corrected the error, and in the Gazette Hehdo- 
 madaire e,t Medicale, 1855, showed that varix is as often a disease of the deep veins as 
 of the subcutaneous, the latter often indicating the existence of the former. He believed, 
 moreover, that the intramuscular veins are sometimes aftected without the subcutaneous. 
 Hilton, and more recently Callender, have told us that the varix of a subcutaneous vein 
 is found wherever the intramuscular veins pass into the subcutaneous, mentioning that 
 " the valves obstruct below and the column of obstructed, slow-moving blood resist 
 above." Callender has failed, however, to confirm Verneuil's remarks, that varix of the 
 intramuscular branches is constant. 
 
 Mr. Gay, an able author on varicose veins (1868), concludes from his experience of 
 many dissections that " with superficial varicosity there are other serious lesions affecting 
 both arteries and veins, deep and superficial, such as would lead to the conclusion that the 
 genei'al circulation has been subject to a very considerable and long-standing embarrass- 
 ment, some incompetency of the arterial system or impediment to the venous, or both 
 combined;" and these conclusions are probably correct. 
 
 The CAUSES of varicose disease of the vein are obscure. Surgeons of the past 
 regarded such affections as the invariable result of some obstruction to the venous cir- 
 culation, such as prolonged standing, the presence of abdominal or pelvic tumors, patho- 
 logical, fecal, or foetal, patients of a relaxed and feeble habit naturally suffering more than 
 the robust ; and in a measure, doubtless, their opinions were correct. Mr. Herapath of 
 Bristol maintained that the cause of varix was the narrowing of the saphenous opening 
 of the thigh, and cases are on record where its enlargement seemed of value ; facts, how- 
 ever, are wanting to support this view. General testimony also admits that this disease 
 is as common in the higher as in the lower ranks of life and in women as in men ; that it 
 is as frequent on the right as the left side, and more frequently on both ; that it is a dis- 
 ease of the young as much as of the middle-aged ; that it is met with in the strong and 
 healthy as well as in the feeble and cachectic ; in fact, it is found under every condition 
 of life and in every variety of subject. Some evidence exists that gout and hereditary 
 predisposition are efficient causes, with local injuries and prolonged muscular exertion. 
 
 The SYMPTOMS vary according to the place of its origin. When it commences in the 
 venous capillaries — its common seat in women — it appears as a fine capillary injection 
 giving an arborescent appearance to the skin, with more or less congestion, and as it 
 extends the larger venous trunks become involved, the main trunks being rarely affected. 
 When it originates in a large trunk, the varix may appear as a fusiform enlargement 
 or a .simple dilatation of the whole length of the vein. In some there will be thinning 
 of the venous coats, in others a thickening, whilst in a third class one part will appear 
 thin and another thick. 
 
 Again, the affected vein becomes tortuous and knotted to an extreme degree, and it is 
 far Irom unusual to find it the diameter of a finger (Fig. 183). The valves of the veins 
 under these circumstances are clearly lost — not, however, from a yielding 
 due to backward pressure of the column, but from their action being ren- 
 dered imperfect by the dilatation of the vein behind ; the '• valve cusps, 
 being unable to meet and close the canal, shrink and atrophy." 
 
 As the disease progresses the tissues around the affected vein become 
 gradually absorbed ; the skin is thinned, and even the bone grooved, the 
 skin, indeed, becoming so thin as even to rupture ; and a fatal hemor- 
 rhage is far from being a rare result. At Guy's during the last few years 
 several cases of this sort have taken place. Subcutaneous rupture of the 
 vein may at times occur, of which I saw a severe instance in a man, set 
 G2, in 1858. More frequently, however, the soft parts around the dis- 
 eased vein thicken or inflame. They thicken from a kind of passive exu- 
 dation into the cellular tissue, the result of impeded venous circulation, 
 and give rise to a slightly anasarcous condition of the part, which in 
 chronic cases becomes somewhat permanent, producing what Liston so 
 well described as a " solid oedema." In extreme instances this solid 
 (edema is so marked as to give rise to appearances similar to the dis- 
 Varicose Veins, easc called " elephas," or Arabian elephantiasis. 
 oOh'^jtcobson/ On the other hand, it is a very common result for the cellular tissue 
 
 Fig. 183. 
 
IXjrnihS AM) DISEASES OF THE VEIXS 405 
 
 ari)iiti(l till' vein, ami |ir<il>atily tin- vein itscH", to inflatiu'. The parts armiml the varix 
 or tortuous vi'iii Itocoim" iiMluratrd, ml. ami |iiiiiil"iil. In licaltliy sultjcct.s tliis iiiHaiii- 
 inatioii may end as an adlirsivf (tno (local ailhcsivc phli'liitis ) and in the f'celiU- as a 
 sujtpurative, local or difluscd alisccsscs sul»sc<|ni'ntly sliowini; tlicnisclvcs. When the 
 powers of the patient are very low or blood poisoning: takes place, that terrible disease 
 iinhealthv suppurative phlebitis, previously described, may ensue. 
 
 In the early period of the di.sease an aehinj; of the limb.s on standitig or after exer- 
 cise may be the only .symptom, a local pain occasionally indicatinjr the seat. In a more 
 advanced period ledema around the ankle may be ob.served. 
 
 When the femoral vein becomes dilated where the f^rand venous junetion takes p'.aoe 
 at the saphenous openin<r. the swellinj^; may <tn a careless examination be mistaken for a 
 femnrnl h> ruhi ; for both will disappear on the patient assuminir the recumbent posture, 
 and reappear on his couL'hinir. There is. however, this point of distinction — that, while 
 by loeal pressure on the crural rinjr a femoral hernia can be kept in its position, a femoral 
 varix can be made to enlar<re. 
 
 As a secondary result of varicose disease the blood iti the vein may coagulate, gi\ ing 
 rise to t/iromfiosis ; and this coatrulum may break up. causing a local ab.scess, or it may 
 wither and organize, causing occlusion of the vein, and consequently a partial cure. 
 There is reason, also, to believe that this may dry up and become so altered as to form 
 what are known as phleboiif/i' x, as these have a laminated character, and in Dr. Franklin's 
 analysis are ."aid to be composed of protein matter and phosphate of lime, with a little 
 sulphate of potash and lime. 
 
 With varicose disease of the veins there is very frequently associated an eczematous 
 condition of the leg. the eczema being apparently due to the feeble venous circulation of 
 the part. If this eczema be neglected, a superficial ulceration of the skin may ensue; 
 and if no attention be paid to this condition, the ulcer becomes chronic. But beyond 
 this no special form of ulcer can be said to exist as a result of varico.se veins ; in fact, 
 there are no "• varicose ulcers." In practice every variety of ulcer is found associated 
 with varicose disease, and the existence of the latter doubtless renders the repair of the 
 former somewhat more difficult. Thus it appears that chronic indolent sores associated 
 with varicose diseases have been termed " varicose ulcers."' 
 
 Treatment. — Varicose disease of the veins in its early stage is very amenable to 
 treatment, but later on none are more obstinate, the patient being only relieved, and 
 rarely cured. Happily, however, under common care it never threatens life. 
 
 When the affection is first discovered, the local treatment mu.st be directed to assist 
 the venous circulation by the raised position of the limb, the patient being recumbent ; 
 friction, too. shoald bo steadily applied upward; all sitting, standing, or walking should 
 be strictly prohibited ; and when possible, this treatment should be persevered in for 
 three or four weeks. When exercise is allowed, .steady pressure by a well-applied band- 
 age from below upward should be maintained or an elastic stocking worn, and in the 
 course of time, the extent of which greatly varies, a cure may be effected and main- 
 tained. 
 
 During this time the general treatment must not be neglected. Where the powers 
 are feeble tonics mu.st be given, and of these iron is the best, twenty drops of the tinc- 
 ture of the perchloride. with ten of the tincture of nux vomica and a drachm of glycerine 
 in water, being an excellent compound. 
 
 A generous diet must be given when indicated, and the rever.se where the portal sys- 
 tem has been overgorged by excess. Mild aperients are always of value under these cir- 
 cumstances, salines being preferable to the purgative extracts. The natural waters are 
 of great value. 
 
 When rest cannot be given, well-applied pressure must be relied upon, the best forms 
 being a pad of cotton-wool over the part, with a bandage of Domett elastic tissue or pure 
 rubber applied from the toes upward. The patient must be impressed, however, with the 
 necessity of assuming the horizontal position as much as he can. aiding the circulation by 
 friction, as already indicated, and by general treatment. The bandage should alwavs be 
 put on before the legs are moved off" the bed and removed only after the recumbent po.si- 
 tion is again resumed. 
 
 In bad cases of local varix the pressure may be more local and permanent, a pad of 
 cotton-wool well fixed on by strapping being very valuable. When the veins are inflamed, 
 they must be treated on principles already laid down in the chapter on phlebitis. 
 
 If a vein burst, bleeding can be controlled by the application of a finger to the .spot, 
 and any further flow is prevented by the elevation of the limb. A pad carefully adjusted 
 
406 INJURIES AND DISEASES OF THE VEIXS. 
 
 to the bleeding point and fixed by strapping applied like a bandage or by a roller makes 
 the patient safe. 
 
 Operations for Varicose Disease of the Veins. 
 
 It has been observed that nature not unfrequently obliterates a varicose vein by means 
 of a coagulum which subsequently contracts, and even organizes, the clot and vein together 
 forming an impervious cord. Acting on this knowledge, surgeons now endeavor to make 
 use of nature's processes, and by artificial means to induce coagulation of the blood in 
 some portion of the varicose vessel, with the hope that it may contract or so to destroy 
 some part of the vein itself as to compel the circulation to find another course. This is 
 the so-called " radical cure," but it is to be thought of only, as Mr. Gay so truly says, 
 when the vein is hopelessly deteriorated or so inflamed and painful as to threaten to 
 burst, or in cases in which all palliative and other treatment is inapplicable or has failed. 
 
 Caustics were employed by ^layo for this purpose, and also by Brodie. Key. and 
 others. They should be thus applied : A small piece of A'ienna paste (compo.sed of four 
 parts of potassa fusa and four of quicklime, made into a paste with spirits of wine prior 
 to its application), or chloride of zinc paste of the size of a small pea, should be applied 
 upon the vein, the surrounding skin being previously protected by a ring of plaster care- 
 fully adjusted ; the paste should be fixed on and left, the object being to cause a .slough 
 through the tissues into the vein. This slough should not be large, but three, four, or 
 more applications may be simultaneously made about an inch apart, in order to guarantee 
 success. The caustic may be left for twelve or twenty-four hours and then removed, 
 water dressings being afterward applied to the part. During all this treatment the patient 
 must be kept in bed with the limb raised. I cannot, however, recommend this treatment. 
 
 Subcutaneous division of the vein was practised by Brodie, but after some 
 experience he came to the conclusion that •• it really appears it is not worth patients' 
 while to submit to it."' 
 
 Excision of a portion of the diseased vein has likewise been employed with success, 
 and where an operation is called for it is doubtless the best. My colleague. Mr. Davies- 
 Colley, in 1874 reintroduced the practice (Guj/s Boxp. Rep., vol. xx. series iii.), which 
 has been followed by myself in bad cases and others. The operation, which is a good 
 one, consists in the exposure of the varix by a free incision and its removal after the 
 application of a carbolized catgut ligature to the trunk of the diseased vein above and 
 below. Mr. Marshall in 1875 adopted a like practice { Lancf. June 23. 1875). taking 
 away some inches of diseased vein with forceps and sei.'ssors after having isolated the por- 
 tion to be removed by means of pins passed under the vein above and below. 
 
 Another operation much favored and practised is that of aoupressiire. It is performed 
 by passing a pin beneath the vein, but not through it, as in Davat's plan, and obstructing 
 the circulation through the vein by means of a twisted suture either of .silk, india-rubber, 
 or wire applied round the pin. or by a piece of thin india-rubber stretched across it on the 
 pin, as suggested by Mr. Lee. Two, or even six, of these acupressure needles may be 
 inserted about an inch or an inch and a half apart, according to the extent of the disease. 
 Mr. Lee employs, also, the subcutaneous division of the vein between the pins at the 
 same time, and my own experience confirms the wisdom of this practice. Mr. A\ ood 
 employs an elastic steel spring to keep up tension on tire ligature till it cuts its way 
 through the vein. 
 
 On several occasions, having obstructed the circulation through the vein as already 
 described, I have injected the vein between the pins with perchloride of iron, one drop 
 being generally sufficient to cause coagulation of the blood : in others I have used a con- 
 centrated solution of tannin ; and in all a good result ensued. The syringe should be 
 that used for hypodermic injections. 
 
 The time for withdrawal of the pins varies according to the effect intended to be pro- 
 duced. When inserted to induce coagulation of the blood only, and not inflammation, 
 they may be withdrawn on the third or fourth day, and in the practice suggested of acu- 
 pres.sure and injection this plan .should be followed. Sir W. Fergusson states: '-They 
 should be left until' they have excited considerable swelling and slight ulceration, and in 
 some instances, where the former is not very conspicuous, the}' may be permitted to 
 separate, by ulceration through both vein and skin. I recommend that the process of 
 inflammation should be more implicitly relied upon than that of coagulation. ' He adds, 
 moreover, that he has not met with any seriously unpleasant eff"ects out of the numerous 
 instances in which it has been employed. 
 
VENKSECTIoy. 
 
 407 
 
 / 
 
 It iinist 1)0 ropi'iitcd, Iiowcvi-r, that tlics*? Dpcrations Hhoiild hf prar-tised only in 
 extreme cases, and not wliere palliativi' treatment is apjilieahle. Wlien a vein threatens 
 to hirst or lias hurst ami endaiiLrers lite. siir;_'i<-al treatment is justitiahle. 
 
 Mr. (Jay called attention ( jjoml. MimI. Soc, Oetoher, IHTI^ to a class of cases in which 
 the superficial or complementary veins, as he calls tlium, arc ohiiteratcil, and as a result 
 the ri'tiirn ot" the venous hlood is carried on entirely hy the deep veins. These con.se- 
 (pii'iitly hecome disca.sed, tlu" circulation tliroui;h them <rrr)ws f'eehle, and dc^rcneration 
 t)t" the tissues ensues, as.sociateil with deep-seated solid a'dema of the limh, not suhcuta- 
 neous Lcdema, which boloiiL's to ohstruction only in the suhcutaneous veins. For this 
 <lisorder exercise, warm applications, tonics, etc., are re(|uired, but bandages and rest do 
 harm. 
 
 Venesection. 
 
 At the present time this operation is very rari' indeed, and at 'Juy'.s Hospital it i.s as 
 rare as. if not more so than, amputation. Forty years ago it was one of the mo.st com- 
 mon, and there seems some reason 
 to believe that it will soon be prac- 
 tised again with greater fre(|uency, 
 especially when we find Sir dame.s 
 Paget asserting '• that we undoubt- 
 edly overvalue the blood and esti- 
 mate too cautiously the hjss of it ;" 
 that '■ the loss of blood up to faint- 
 ing, and in some cases I remember 
 with those e])ileptiform convulsions 
 that come with the loss of blood, is 
 absolutely harmless" — that is, when 
 performed upon a large series of 
 healthy persons, as was the custom 
 in his student days (Lancet, August 
 15, 1874). 
 
 It is not a difficult operation, but 
 requires nicety and care. It is usually performed at the bend of the elbow. The first 
 thing the surgeon has to do is to render the veins prominent by arresting the circulation 
 through them by means of a piece of broad tape or narrow bandage carried twice round 
 the arm a few inches above the elbow and tied in a bow, 
 but not tight enough to stop pulsation in the arteries 
 (Fig. 1S4). He then selects the vein, the largest being 
 the best. Where the outer vein or median cephalic is of 
 good size, it .should be cho.sen, as the inner or median 
 basilic lies immediately over the brachial arterj- ; either, 
 however, may be selected, care being observed not to go 
 t/niiii;/fi the vein. He should also assure himself that no 
 malposition of the artery exists, as many cases are on 
 record where a superficial artery has been opened for the 
 vein. 
 
 The vessel, then, having been selected, the surgeon 
 should stand in front of the extended arm and hold it 
 with his left hand, the thumb being fixed on the vein below 
 the s;)ot which is to be opened. With his right hand an 
 obli(|ue incision, not a puncture, should be made through 
 the skin into the vein, describing with the lancet a semi- 
 circular movement. The bleeding-basin having been 
 brought close to the arm. the surgeons left thumb may 
 be removed and the stream of blood allowed to flow. If 
 this be feeble, the patient may be asked to grasp a stick 
 and jiut the muscles of the fore-arm well into action. 
 
 The required amount of blood having been withdrawn, 
 the tape can be removed, the left thumb of the operator 
 being applied to the wound, and the parts clean.sed. A 
 pad of lint is then to be placed over the incision, the edges of which are to be kept well 
 in contact, whilst the thumb is slipped downward to allow of the adjustment of the pad, 
 
 Venesection. (From Heath. 
 
 Fig. 185. 
 
 After Venesection. 
 
 / 
 (From He.ith.) 
 
408 VENESECTION. 
 
 which is to bo fixed by a figure-of-8 bandage (Fig. 185). The arm should then be 
 slightly bent, care being taken that the pad does not slip during this process. 
 
 On the second or third day the pad may be removed, the wound having probably by 
 that time healed. 
 
 Opening of the external jugular vein is sometimes called for, particr.l.rly 
 when venesection is required in a child, and that part of the vein where it passes over the 
 sterno-mastoid muscle should be selected. The vein can be steadied and rendered prominent 
 by the left thumb of the surgeon applied at the root of the neck above the clavicle, or this 
 may be done by means of a pad. It then is to be opened with the lancet by an incision made 
 in the course of the sterno-mastoid muscle, and consequently across the platysma. Blood 
 will then flow freely, and when enough has been taken, the wound should be closed by 
 means of a pad carefully adjusted. The thumb, which hitherto has been acting as a 
 compress, may then be removed. The pad should be fixed by good strapping. 
 
 In both these operations of venesection, if the wound in the skin be made smaller 
 than that in the vein or the position of the arm be changed, a blood tumor or thrombus 
 may form, from the escape of blood beneath the integument; and if this interferes with 
 the flow of blood, instead of reintroducing the lancet, the best practice is to untie the arm 
 and apply a pad to the wound, opening a vein in the other arm. 
 
 In fat subjects there is occasionally some difficulty in finding a vein. Friction of the 
 surface of the fore-arm will at times help the surgeon, or the application of a hot flannel 
 round the arm, which should be made to hang down by the side of the body. When these 
 means fail and venesection is imperative, a vein of the foot may be opened. 
 
 In opening the jugular vein great care must be taken not to admit air into it by the 
 removal of the thumVj during the operation and until the pad has been adjusted ; other- 
 wise, life may be endangered. 
 
 Gross, Dr. S. W., Amer. Journ. of Med. Science, 1867 and 1871. — Callender, Holmes's Syylem of 
 Surgery, 3d ed., 1883. — Travers, Surcfical Ensays, 1818. — Laxgexbeck of Berlin, Archiv fiir 
 Klinmhe Chir., 1860. — Arnott, Med.-Cidr. Trans., vol. xv., 1829. — Lee, Henry, Disease of Veins, 
 1866. — Greene, James S., Dorchester, Mass., American Journ. of Med. Science, 1864. — Gay, Vcricose 
 Diseases of Ley, 1868. 
 
T\iK siiiu;krv 
 
 K DKiESTlVE OIUUNS. 
 
 CHAPTKK XII. 
 
 AFFECTIONS OF THE LIPS, MOUTH, TONGUE, PALATE, AND TONSIL. 
 
 Wounds of the Lip. 
 
 Under all circuinstances these womuls slioiikl be well cleansed from dirt, foreifjn 
 bodies, and blood, and then carefully brought tof^fether by sutures, which should be 
 deeply inserted and removed on the second or third day. 
 
 Plaster, as a rule, is not required. Superficial wounds in Fig. 186. 
 
 the inside from the teeth may be left to granulate. When 
 much bleeding exists the surgeon should examine the 
 part with care, as Erichsen adduces a case in which from 
 the coronary artery so much blood was lost, swallowed, 
 and brought up again by vomiting as to lead to the sus- 
 picion of .some internal injury. 
 
 Congenital Fissures of the Lips. 
 
 These occur more frequently as harelip than in any 
 other form. Sir W. Fergu.sson has, however, quoted 
 three cases in his Practical Surgert/ in which the fissure 
 
 extended from the an^le of the mouth in one case to Congenital Fissure of Lower Lip and .Taw, 
 
 the malar bone, in the second toward the angle of the dike-s'^casl.r *" ^'''"'"'' ^^'' '^''"'"°' 
 jaw, and in the third to the base of the lower jaw; and 
 
 from a case reported in the Med. and Surg. Reports of the City Hospital of the citv of 
 Boston, LTnited States, 1882, it seems that the lower jaw and soft parts over it may be 
 fissured in the median line (Fig. 18G). In the case recorded, when the patient, fet! 20, 
 opened her mouth, the two halves of the lower jaw protruded laterally like horns and pre- 
 sented a large cavity, and the tip of the tongue was bound down to the tissues in front 
 of the hyoid bone. Dr. Thorndike, who reports the case, closed the fissure by first dis- 
 secting up the tongue from its adhesions' and uniting the bones and soft part by a plastic 
 operation. 
 
 Harelip. 
 
 congenital deformity is due to a want of union between the natural centres of 
 development of the upper lip. Thus, the upper 
 lip is made up of a central and two lateral portions, 
 the central being connected with the intermaxillary 
 bones and the lateral with the superior maxil- 
 lary (Fig. 187). A want of union between the 
 central and lateral piece on one side gives rise to 
 simple harelip ; a want of union between the cen- 
 tral and lateral pieces to double harelip. 
 
 When the fissure is central — a very rare condi- 
 tion — the intermaxillary bones are either absent or 
 divided. A specimen of the former exists in the 
 Museum of the Royal College of Surgeons, London, 
 and a drawing of a like case taken from a patient 
 of my colleague. Mr. Howse, is seen in Fig. 188. These fissures may be partial or 
 
 409 
 
 Fig 
 
 Showing the Develop- 
 ment" of the Inter- 
 maxillary and -Max- 
 illary Bones. (From 
 Fergusson.) 
 
 Central I issure ot 
 Lip with Deficien- 
 cy of Intermaxil- 
 lary Rones. (Mr 
 Howse's case.) 
 
410 HARELIP. 
 
 complete, and may involve the skin alone, as also the bone, and the latter in variable 
 degrees. 
 
 Congenital cicatrices are occasionally met with in the upper lip (vii/e Fig. 52) along 
 the line of union of the central with one or other lateral portion. Fig. 189 was taken 
 from a patient with this imperfection, and in her case there was a slight elevation of the 
 
 Fig. 189. Fig. 190. Fig. 191. 
 
 Fig. 190. 
 
 A'f , 
 
 ,iuMy 
 
 ^#-^^. 
 
 Tarelip as Slight Notch. 
 
 Congenital Cicatrix. Harelip as Slight Notch. As Deep Fissure on Right Side. 
 
 mucous margin of the prolabium. which may be said to be the very earliest indication of 
 a harelip; the child of this woman had a complete fissure. In more complicated cases 
 the cleft will extend through the alveolar process in a line corresponding with the labial 
 fissure, Fig. 191 ; in others it will involve the hard palate; while in a still worse class 
 both hard and soft palate will be fissured. 
 
 In a small percentage of the cases — about a tenth — the harelip is double. In these 
 it is not uncommon to find a double fissure extending through the palate, the two superior 
 
 maxilU>3 with the skin having failed to unite with 
 
 Fig. 192. Fm. 193. the intermaxillary bones. Under these circum- 
 
 ^^„ stances the intermaxillary bones will often pro- 
 
 '~^ _, ject, covered with a small flap of skin, and at 
 
 times even stand out from the tip of the nose. In 
 
 a rare case (illustrated in Fig. 193) the fissure 
 
 involved the lip and intermaxillary bones alone, 
 
 the maxillae being complete. 
 
 This affection' is more frequent on the left, 
 than on the right side of the mouth, and is more 
 
 Uncomplicated Complicated with Fissure , • i .lT, • r i i -i • ^i 
 
 Double Harelip. of Alveolus and Projec- Common in males than in feniales, while in the 
 
 tion of Intermaxillary more Complicated examples this disproportion 
 
 Bone, the Palate being , '- ., . Vm ■ i • n 
 
 Perfect. becomes more striking. Ihus, in an analysis oi 
 
 cases to be found in my Leffsomiaii Lecftirfs on 
 
 the Surgical Disrasfn of Children, 18(33, four-fifths of the bad cases were in boys, those 
 
 of double harelip almost always being found in the male sex. 
 
 Treatment. — When ought a child with harelip to be operated upon? Sir W. 
 Fergusson says, " I am of opinion that the earlier the operation is performed, the 
 better — assuredly before teething;" and the majority of surgeons would support this 
 opinion. Judging from my own experience, I am not disposed to coincide altogether 
 with this view ; for in my analysis of cases at Guy's Hospital a larger number of failures 
 followed the operation when performed during the first few weeks of life than after the 
 third month. In healthy inftmts it is probable that success may attend the operation 
 whenever undertaken, but in the more feeble it is equally probable that success will be 
 more certain at a later than at a very early period. Under these circumstances, I always 
 advise the operation to be postponed until after the third month — that is, when no neces- 
 sity exists to hurry on the operation, such as inability to take food, etc. On account of 
 this last-named condition, I have operated with complete success on the fifth day. 
 
 The position of the patient is important. If an infant, the whole body and 
 arms should be bound round with a good towel and the head fixed by the hands of an 
 assistant, placed on either side. The child should be firmly held in a nurse' lap, in the 
 sitting posture (Fig. 194). In other cases the child's head may be laid on the surgeon's 
 knees, the body on the nurse's. 
 
 If an older child, the semi-recumbent position should be chosen, with the head raised 
 on a pillow and fixed as directed above. 
 
 The operator may sit or stand behind the patient when the recumbent position is 
 selected, or at one side if the patient be sitting. 
 
 Operation. — Anaesthetics may be given without fear in such cases, although in 
 uncomplicated examples the operation is so expeditiously performed as not to render it 
 essential. ' 
 
 The surgeon has in the operation two main objects in view — viz., to pare the edges of 
 
II Ml i: I.I r 
 
 ni 
 
 Operation fi)r 
 Single Harelip. 
 
 tlif fissurf, and ti> adapt tliciii so a.s to midi-r ilir drl'oriiiit y :is slij^lit as possible. But 
 litd'orc this an important pndiininary sti^p demands attontion, and on it the success of the 
 cast- materially rests: it is to freely separate hoth sides of the lip from the alveoli, and 
 when the nostril is widely e.xpainled to freely separate al.so the alu nasi from the hone. 
 'I'lie olijeet of this step is to allow the soft parts to movt; freely over the bones and to be 
 ji iiuirht the more readily into apposition. Some save the true frjenum and divide all 
 (>;her adlu-sions. but I see no necessity for this practice. To pare the edj^es of the 
 cleft the knife should be employed, such an instrument making a cleaner .section than 
 scissors; and this cleanness of the incision is a point of importance. With respect to the 
 I'.irm of incision, numbers have been devi.sed, but most surgeons fall back upon the old- 
 fashioned straiirht one above the prolabium, commenciu}.; at the apex of the cleft and 
 y ^,)^ ending at its free l)order, care beinjr taken to cut off* a good piece. The 
 
 plan I always follow when the knife reaches the red border of the lip 
 is to turn its edge oblifjuely toward the cleft, thereby .saving a portion 
 of the mucous covering of the lip and lessening materially 
 the notch in it (Fig. 1 !>.')). The incision having been made Fig. lOo. 
 and all bleeding vessels twisted, the surgeon should pro- y 
 ceed to adjust the parts ; and he had better commence at v^^*- 
 the free margin. When pins are used, they should be 
 fine, with flat heads, and one should be introduced about 
 .1 third of an inch from the margin of the wound and 
 brought out just under the mucous lining of the lip, rein- 
 
 /\\vi^^,-_^.j/j, < roduced on the opposite side, and passed through the lip. 
 l//"/ ' ' if \ \ ' '"^ edges can then be brouglit together by means of a twisted well- 
 \/' / \V ■ \ "iled suture, care being taken to adapt accurately the parts at the red 
 laargin of the lip. If this end be attained, the second and third pins 
 should be inserted above, one close to the nostril, the second between the 
 two. and both fastened separately. If the interrupted silk, gut, or horsehair suture be 
 e.uployed instead of pins — a practice I greatly prefer, having given up i)ins in simple 
 cases — it is wi.se to introduce a needle as the first pin to adjust the parts, and then insert 
 the second and third stitches, initting in afterward the marginal suture by simply draw- 
 ing the needle that had been introduced as a pin tlirough the flaps. In most cases it i.s 
 serviceable to insert a fourth suture into the red border of the lip itself. The button 
 suture (Fig. 8) may be used instead of the above, if preferred. 
 
 After the operation Hainsby's tru.ss should be employed wdien 
 possible (Fig. 196). It keeps the parts well together and prevents Fig. 196. 
 
 any traction upon the wound. It is a valuable instrument. When 
 it cannot be obtained, the cheeks .should be well drawn forward 
 and held by some good plaster, applied either from ear to ear or 
 from the temple on one side beneath the chin to the temple on the 
 other. The sutures or pins may generally be removed about the 
 second or third day at the latest, and after their removal the 
 clieeks must be held forward by strapping. 
 
 Mr. Maurice Collis in 18()() ( Diih. Quarf.). in an able paper on 
 h:\relip, among other points laid great stress upon the propriety 
 of utilizing the ])arings. He never threw away a particle of them, 
 but used them all. I have followed his suggestions — in many 
 cases with admirable succes.s — and am disposed to think that iiainsby's Truss. 
 
 where the lips are thin his method is of service. His operation is 
 
 as follows: He first made an incision from A to B (Fig. 197) through the thickness of 
 the lip down to the mucous membrane, but not through it. and turned the flap back. On 
 the other side he transfixed the lip at c and Separated the flap as far as D, dividing 
 the flap in the centre at E. He then brought the two sides together by fixing the upper 
 flap, c E, by a suture to A. and the lower flap. E D, to B. " Two intermediate sutures 
 ])eing applied (Fig. 198), I thus obtain," says ('ollis. " a lip nearly double in depth what 
 I could possibly have got by the ordinary incisions." 
 
 Malgaignes operation is, in a measure, somewhat similar to the above, utilizing as it 
 does the flaps of skin by turning them down and stitching them together TFig. 199). In 
 some cases one of the pared edges may be left attached and united with the opposite side 
 that has been sloped to receive it. This suggestion T had from 3Ir. Dix of Hull in 1859 
 (MrJ. Tim,!, ,n„I Gaz.. Julv 2)- 
 
 Double Harelip. — When this is uiicom])licated with bone displacement, it can be 
 
412 
 
 CHEIL OPLA STIC OPERA TTOXS. 
 
 dealt with as simple harelip. In a general way. it i- well to operate on both side? at once, 
 more particularly if the lower flaps of the lateral portions are utilized by being turned 
 down and united beneath the central piece (Fig. 201). If there be. however, much 
 
 Fig. 197, 
 
 Fig. 198. 
 
 Fig. 199. 
 
 Fig. 200. 
 
 Fig. 201- 
 
 Collis b Operation for Harelip. 
 
 Malgaigne's Opera- 
 tion. I From Holmes.) 
 
 Operation for DouMe Harelip. 
 
 Fig. 204. 
 
 separation, and. consequently, traction upon the lateral portions, the operations upon the 
 two .sides should be performed separately. 
 
 When the intermaxillary bones project to any extent and are separated from the 
 maxillary, there will be some difficulty in the treatment. I believe the better plan is to 
 remove them with the knife or scissors ; for when broken and bent back, the central 
 incisor teeth too often grow in some abnormal position and are in the way. When 
 removed, the maxillary bones subsequently approximate, and the lateral incisor teeth 
 frequently assume the position of the central. Sir W. Fergusson latterly removed these 
 
 bones, or the milk tooth with its bonv bed, sub- 
 cutaneously. and. I think, with advantage. When 
 they are so pu.shed forward as to form a kind of 
 appendage to the tip of the nose, as seen in Fig. 
 2(12. they ought to be removed. The portion of 
 skin over the bones, however, must always be util- 
 ized, either to form a columna nasi where none 
 existed, as in Figs. 203 and 204. or to be brought 
 down and inserted between the two lateral portions 
 
 Lefore Opera- of the lip. 
 
 tion. When primary union fails, the surgeon can 
 
 often succeed in securing union by the third inten- 
 tion by scraping the .surface of the wound and reapplying the sutures ; and he mav do 
 this, although the parts have sloughed at first, as soon as healthy granulations appear. 
 
 Fig. 203. 
 
 
 Front View. 
 
 Fig. 205. 
 
 Cheiloplastic Operations. 
 
 These are demanded for deformit\- of the mouth from destructive ulceration or slo^.icrh- 
 ing. as from canerum oris, and are somewhat similar to tho.se for harelip. When under- 
 taken for contraction of the mouth, the surgeon .should always try and turn up some 
 
 portion of the mucous membrane from within the 
 mouth, to cover over the new angle and thus pre- 
 vent its subsequent contraction. I have done this 
 in several cases with gratifying success, one of 
 which is figured Fig. 205. The deformity was the 
 result of .sloughing after fever. At times new tis- 
 sue must be brought up from the chin or down 
 from the cheek. Indeed, these cases tax the in- 
 genuity of the surgeon to the utmost, since no 
 general rules can be laid down regarding them, each requiring to be dealt with on its own 
 merits. But this much may be said — that no part of the body heals .«o rapidly or so well 
 as the face, and in none are plastic operations more satisfactory. 
 
 Deformity Hesiili 
 of Sloughing. 
 
 After Second. 
 
 Cancer of the Lips. 
 
 This term is generally applied to epithelioma or cancroid disease, true cancer or car- 
 cinoma being very rare. It is a disea.se of middle life, four out of five cases attacking 
 patients between forty and .sixty years of age. The 3'oungest .subject I have seen affected 
 by it was a sweep aet. 27. and the oldest also a sweep aet. 86. It affects the lower lip more 
 frequently than the upper in the proportion of 25 to 1. In my own table of 54 consecu- 
 tive cases. 3 instances were found in women to 51 in men. 
 
CANCKii or Tifh' urs. 
 
 413 
 
 Kxtrtiue K.xaniple of Cancer of 
 l.ip. 
 
 Siiinkiii^, or ratlicr tin- irrit;iti»ii ni' ;i |ii|M'. has generally been ascribed as a euiiimon 
 cause ; and it is probable that such an irritation is sufficicMit to set up the disease when a 
 pre<lisp(»sition to its development already exists. It is interest- 
 inir to note, however, that It out of 54 eonseeutive eases in which 
 I made the in<|uiry had never smoked ; and this proportion is 
 probalilv about that (d'tlie non-smokers amtmiist the male jiopu- 
 lation in this eountry. 
 
 The disease irenr'rally commences as a dry seal) on the red 
 niarLcin of the lij), and it may be that this scab forms over a 
 crack or excoriation, but as often as not it apjiears alone; occa 
 sionally, too, it commences as a wart. In its early stage the 
 progress of the disease is generally very slow, and only when 
 some ulcerative action ap])ears does it develop more rapidly. It 
 is under these circumstances that the patient first applies for 
 advice ; the disease in the dry state is passed by uidieeded. 
 
 The appearance of an epithelial cancer is tolerably characteristic ( Fig. 208) ; it has 
 generally an irregular warty aspect, but when ulcerating has thickened everted edges. 
 It has always a well-detined indurated base. When ulcerating, it discharges a sanious 
 pus containing epithelial scales in abundance ; and when dry, it is covered with a .scab 
 of the same material. Microscopically, it contains epithelial elements arranged in cap- 
 sules. ( ]7(/*' Fig. 45.) 
 
 In its early stage it should be regarded as a local disease. It rarely affects more than 
 one part at the same time, but I have seen several cases in wliich two separate centres 
 existed, and one in which there were three. In the latter, two growths on the lower lips 
 were excised, and nine years subsequently a similar disease attacked the tongue, which I 
 removed in June, 1870. 
 
 AVhen the ulceration stage has set in and the disease has been left to run its course, 
 the glands beneath the jaw" will probably become affected, and the affection will steadily, 
 if not rapidly, progress until all the tissues with which it comes in contact — integument, 
 gums, bone, teeth, and glands — are destroyed. It destroys life by exhaustion and hemor- 
 rhage, and may do so by secondary deposits in the lungs or viscera, but far less fre- 
 quently than does carcinoma. In a case under the care of Mr. Howse, in 1875, the dis- 
 ease spread from the lip to the lower jaw and along the course of the fifth nerve to the 
 base of the skull and brain, destroying life by meningitis. 
 
 Tre.vtment. — There is but one treatment that can be recommended, and that is the 
 speedy removal of the disea.se. When once the nature of the case is clear, the sooner the 
 growth is taken away the better; and in doing this the surgeon must deal freely with the 
 surrounding parts. He had better err by removing too much than too little of the sur- 
 rounding tissues. To tease the parts with mild caustics is bad practice, as it merely irri- 
 tate >, and rarely destroys, the whole growth. Caustics cannot as a rule, be recommended. 
 Exci.-«ion is probably the best method. When the disease is superficial, it may be sliced 
 off, leaving the parts to granulate ; when it involves more of the lip. a V-shaped piece 
 may be taken out, the two edges being brought together as in harelip. When much of 
 the lip is affected, the whole must be removed and a new lip formed by bringing up the 
 soft parts from the chin as indicated in Figs. 209, 210. 
 
 •200. 
 
 Fig. 210. 
 
 Diagram showing the Lines of Incision for New 
 Lip after Removal of a Cancer. 
 
 Diagram showing Position of Flaps when 
 brought Up. 
 
 Recurrence of Disease. — After the removal of the disease a cure may follow, 
 but in the majority of eases a return takes place, and generally in the same spot. Similar 
 treatment must again be resorted to, even to a second and third operation, as there seems 
 
414 
 
 HYPERTROPHY OF THE MUCOUS GLANDS OF THE LIP. 
 
 reason to believe that after each operation a longer interval, of immunity may be promised. 
 Thus, a man who had a cancer of the lip removed a year after its appearance was well for 
 two years, when a second operation was required. He remained well for three years, 
 when a third was performed and this time four years elapsed before a return took place. 
 It was then excised for a fourth time. 
 
 In another case a man set. G5 had a cancer of his lip removed fifteen years before he 
 came under my care. He remained well for eight, when, the disease returning, a second , 
 operation was demanded ; and seven 3'ears after this he was well. Epithelioma of the lip 
 is of slow growth. I have removed one from a man Kt. 7-i of twenty years', and another 
 from a man fet. 5h of eight years', growth. 
 
 Horny growths may spring from the lip. as from other parts of the cutaneous 
 surface (Prep. 1678^. Guy's Hosp. Mus.). 
 
 Ch.ancres, syphilitic or otherwise, are at times met with on the lips, and the sur- 
 geon should be on his guard not to mistake them for cancer. They mostly appear as 
 raised smooth sores with bases of cartilaginous hardness, and are usually attended with 
 considerable inflammatory swelling as well as with secondary glandular enlargement. 
 They have neither the clinical history nor aspect of such an affection as cancer, but make 
 much more rapid progress, and are, moreover, usually met with in younger subjects. 
 When syphilitic, the constitutional symptoms — commonly called •' secondaries " — will 
 mark their true nature. 
 
 Hypertrophy of the Mucous Glands of the Lip. 
 
 The mucous covering of the lip is often found to be thickened, two elevated or pen- 
 dulous portions of tissue appearing, one on either side of the middle line. This con- 
 dition authors have described as /i>/pertrophi/, though the name does not appear to be 
 
 Fig. 211. 
 
 Fig. 212. 
 
 CA...^ 
 
 Hypertrophy of Mucous Glands of Lip. 
 
 Hypertrophy of Lip. Olr. Davies-Colley's case.) 
 
 always correct, for on removing the so-called hypertrophied mucous membrane in many 
 cases a number of small granular bodies the size of hemp-seeds, and made up of gland 
 cells, are to be found underlying a healthy mucous membrane. The disea.se appears, 
 therefore, to be often due to an increase in the size of the natural glands, and not of the 
 mucous membrane of the part (Fig. 211). It should be treated only by the careful 
 excision of the diseased submucous tissue, the incision being made in the line of the lip 
 and the edges brought together by fine sutures. I have seen as many of such cases in 
 the upper as in the lower lip. and rarely does it involve both lips. I have never known 
 it to recur. 
 
 A genuine hypertrophy of the hp it>elf is a common affection. It often 
 begins as a chronic inflammation, or rather oedema, of the part, the inflammatory deposit 
 becoming organized. There can be little doubt that many of the so-called thick strumous 
 lips have this origin. Attention to the general health and its improvement is the means 
 by which cure may be expected. In some instances the hypertrophy is very marked. 
 Thus, in a case recorded by Mr. Davies-Colley,^ and illustrated in Fig. 212, nothing less 
 than an excision of a V-piece from its centre was of any use. 
 
 Cystic Tumors of the Lip. 
 
 Mucous cysts are often seen, and generally in the lower lip. They appear as 
 tense, globular, and at times semi-translucent, tumors beneath the mucous membrane, 
 
 ^ C^in. Soc. Trans., vol. xvi. 
 
.1 rirriioi s stoma riris. 415 
 
 and lire ri-adily <'urc(l hy cxcisiiiii ur liy ciitliiiL' ofl llicir iipjicr Wall hy means of scissors 
 and sliar|i-|i<iiiiti'(l i'orccip^. An iiici>inii into tliiin laniy docs ;z"od. Tlicy coiitaiii a 
 plairy iiiin-nid fluid. 
 
 Glandular Tumors. — <)" st-vt-ral «icc-asioiis I h-AW. turm-d out of the lip, fruiu 
 liciicalli till- uiiiciius imiuhratu'. s(did ciicysti'd tuin<irs witli a j:laiidular structun-. 
 
 Naevi "»f tho lip ari- often seen ; and wlitii tliey involve the whole thielcness of the 
 part, their reniovul hy a V-ineision is the hest treatment. I have done this on many 
 occasions with a henctieial result. When they are <inly su[)erficial or beneath the mucous 
 lininir. they may he treateci locally, as already nn-ntioned in the chapter on naevuH. 
 
 Phlegmonous or carbuncular intlainmation of the lijt is an alarming affection ; 
 it is never foun<l except in the feeble and eaehectic. It attacks the upper as well as the 
 lower lip, and shows itscH" as a <reneral infiltration of the part, which becomes enormously 
 swollen, tense, and painful. When seen in an early stage, a free incision into it or its 
 mucous surface gives relief and expedites the sloughing of the cellular tissue that is 
 sure to follow. Fomentations and warm-water dressings are the most beneficial, with 
 good living and tonics, such as (juinine and iron in full doses. At times this affection 
 ends in sloughing, and then puts on the appearace of what is called " cancrum oris." It 
 is very prone to be followed by septicemia. 
 
 Cancrum oris, or gangrenous stomatitis, is generally met with in the ill- 
 fed and feelile child after one of the exantlicuiata. It is seen also where mercury has 
 been given to salivation. It commences often as a phleg- 
 monous inflammation of the cellular tissue of the cheek or ^^^- 2^^- 
 lip, going on rapidly to sloughing and phagedaenic ulcera- 
 tion, or to sudden death of a part of the cheek, the tissue 
 becoming white and bloodless and then sloughing. At times 
 this sloughing process will involve a large portion of the 
 cheek, and even of the gum or the bone. It is a most fatal \ 
 and dangerous disease. Before the sloughing has taken 
 place the part involved will be much thickened and indura- 
 ted. It will feel of a brawny hardness and appear of a dusky 
 color in the centre, with a red border. When the skin cover- 
 ing in the dead cellular tissue has sloughed away, a deejt. 
 excavated, irregular surface will be seen discharcciiiir an ,,, i i o^w?"^™'^*^"^\t 
 
 a- ■ • a ■^ i -p i t i • ^i .(McKiel 26^, Guv's Hosp. Museuiu.) 
 
 offensive sanious fluid : and it the disease spreads, it does 
 
 so by sloughing and ulceration (Fig. 213). It generally kills by exhaustion, sometimes 
 
 by bleeding from the sloughing of an artery. 
 
 Treat.ment. — The general treatment consists of tonics and good feeding, milk, eggs, 
 and wine, beef tea, and any other nutritious food being of primary importance. When 
 food cannot be taken by the mouth, it must be given by the bowel as enemata. Tonics 
 also must be administered, as the li<|uor cinchonte, quinine, or iron, in such doses as the 
 child can bear. 
 
 LoaiUi/. till the slough has separated, little more than fomentations and cleanliness 
 can be employed ; but when the sloughing and ulceration spread, the application of 
 strong nitric acid or tincture of iodine is of great value. It must, however. l>e liberally 
 brushed over and into the parts, so as to destroy all their surface and induce a fresh 
 action. 
 
 Absolute cleanliness should,be observed, the wound being washed and irrigated by 
 means of a steady stream of water to which carbolic acid one part to twenty, Condy's 
 fluid, chloride of zinc, or iodine tincture in the proportion of n^xx to the ounce of water 
 may be added. When recovery takes place, it is frequently with the loss of large portions 
 of the affected parts, for which some plastic operation will subsequently be required. 
 
 Aphthous stomatitis i?' another affection often mistaken for cancrum oris, but is 
 not, hiiwcver. half so dangerous. It occurs, likewise, in the unhealthy and ill-fed child, 
 but as often as not is independent of the exantliemata. It begins as an aphthous ulcera- 
 tion of the tongue, gums. lips, or cheeks, by which these parts become covered with a 
 white or ash-colored secretion. With these local symptoms there will be a foul tongue 
 and fetid breath, as well as some evident symptoms of derangement of the bowels and 
 digestive organs. In very feeble children this superficial ulceration may pass on to 
 sloughing of the parts, or ulcemtire sfomafitif!, thus simulating caucrnm oris, but with 
 this difference : in cancrvm oris the disease begins in the cellular tissue, the skin slough- 
 ing subsequently ; in ulcerative stomatitis or noma it begins as a skin or mucous mem- 
 brane ulceration, sloughing following upon it. 
 
416 
 
 RANULA OR SUBLINGUAL CYSTS. 
 
 Treatment. — Of all drugs, the chlorate of potash has the best action, and should be 
 administered in five-, or even ten-, grain doses mixed with bark or with milk, a lotion of 
 the same drug, 3J to a pint of water, being used as an application. Milk diet is the 
 best where it can be taken, beef tea and eggs being given otherwise or in addition. 
 Wine must be administered with great caution, and only when the powers of the child 
 are very feeble, as in the phagedj\inic form. A rhubarb purge is usually required at the 
 beginning of the aifection. to clear the way, as foul excreta are too often present, and in 
 the later stage the more powerful tonics, such as iron or quinine, are often demanded. 
 At times small doses of laudanum, say one or two drops every few hours, relieve pain 
 and allow the child to feed with comfort, and consequently with benefit. This affection 
 is a disease generally due to intestinal irritation from bad feeding, and requires, there- 
 fore, for its treatment careful attention to this matter. 
 
 Eanula or Sublingual Cyst, with" Salivary 
 Duct lying upon it. (Guy's Hosp. Mus., No. 
 22931J. Hilton's case.) 
 
 Ranula or Sublingual Cysts. 
 
 These are now known not to he due to any obstruction of the salivary ducts, submax- 
 illary or sublingual, but to ob.struction of one of the mucous glands situated beneath the 
 tongue, such as the glands and ducts of Rivini. They are probably analogous to the 
 mucous cysts of the lip already alluded to, and of the mucous passages generally. They 
 
 contain a clear, glairy, mucoid fluid, but never saliva. 
 I have the notes of several that were congenital. 
 They sometimes attain a large size ; and when placed 
 beneath the tongue (their usual position), the sali- 
 vary duct can readily be traced lying over them (Fig. 
 214). Sometimes they are multiple, and on several 
 occasions, on opening one cyst, 1 have seen a second 
 within. When neglected and allowed to increase, 
 Ton^iut they may so press the tongue upward as to prevent 
 the patient speaking, or they may form a large swell- 
 ing beneath the jaw. Within the mouth they appear 
 as semi-transparent cysts beneath the tongue, and 
 they are, as a rule, painless and merely give trouble 
 mechanically. When opened, a glairy mucoid fluid 
 escapes. This operation, however, rarely is service- 
 able, as the fluid re-collects. 
 
 Treatment. — The best treatment is to raise the 
 upper wall of the cyst by means of a pair of pointed forceps or a tenaculum, and with 
 scissors to cut it off". M. Panas of Paris has lately injected these cysts with three to ten 
 drops of a solution of chloride of zinc (forty-five grains to an ounce of distilled water) 
 with success. In large tumors the cavity may be plugged with lint soaked in iodine 
 after it has been freely incised. The application of a seton is at times beneficial, though 
 an uncertain remedy ; simple plugging of the cyst was a mode of treatment that I for- 
 merly employed till I discovered that the plans above suggested were preferable. It is 
 rarely possible to excise the cysts, as they have no definite walls. I have, however, seen 
 this practice carried out with success. 
 
 Encysted, tumors are, however, met with beneath the tongue. I have had two 
 under care, and both I mistook for ranula. The error w'as discovered only on opening 
 them, and in both, on making my incision, I had to cut through the mucous lining of the 
 mouth over the cyst, and then the cyst wall itself. From both a cheesy sebaceous secre- 
 tion escaped. 
 
 These tumors — which have nothing to do with ranula — have distinct capsules beneath 
 the mucous membrane and appear to be sebaceous ; they are probably congenital. In the 
 cases I have mentioned the patients were under twenty years of age. In both I pulled 
 out as much of the cyst wall as I could, dissecting it from its bed, and in one with com- 
 plete success. In the second a return followed, which called for another operation, 
 which was crowned by a good result. I have never known any of these cysts require 
 removal from below the jaw. In one of my cases I contemplated this plan, and Sir W. 
 Fergusson and Mr. A. Barker give cases where it was adojited. It is probable, however, 
 that incising and plugging the cyst, to set up suppuration, after evacuating its contents, 
 ■would be a simpler and equally eflScacious practice. 
 
SAi.iwu:)- iis'ni.A. 117 
 
 Salivary Calculus. 
 
 Tlu' salivary tliicts liciicatli the t(»ii<xiu! may be obstructed iti exeepliorial eases from 
 the introtluetioii ol' fVtreiLTii liodies. but more e((iiimoMlv Iritin ctifni/ns. Steiio's or the 
 duet <»t" the parotid may be thus aH'eeted, but the W'hartoniau or the sublin<.'ual salivary 
 duct is that more eouimoiily involved, ^\'hell the obstruction is eomjilele. 
 |mtieiit.s eomplaiii duriuu" de;:lutiti(tii ofitain and swelling; in the eorresjtondin;^ I'l''. -lo. 
 salivary j;land ; such syni|)toius, which arc clearly due to retained salivary 
 secretion, soon subside on the completion of maHtication. In exceptional 
 examples suppuration may attack the ^dand. 
 
 The calculus depicted in Fi<;. 21') was taken f'r(»m the sublirif^ual duet of 
 a man by my IVii-nd Mr. C. Sells of" (.Juildf'ord, and weijrhed forty-eight 
 grains. 
 
 This affection can usually be easily recr»gnized on the a|)|pIicatioii of the 
 finger beneath the tongue, the calculus, as a rule, holding a superficial posi- 
 tion. On feeling the stone the surgeon may often with his nail tear it out of 
 its bed. I have removed .several by this plan when not larger than }iem[>- 
 seeds. When larger, the best plan is incision, the surgeon being careful to 
 cut through the duet where it seems to be thinnest and scoop the calculus 
 out of its bed by means of a director or bent probe. These calculi may attain 
 considerable dimensions, even one inch long. On one occasion I Vjroke a calculus to 
 pieces in attempting to remove it from the centre of a suppurating sublingual gland of a 
 man aet. 42 who had had evidence of its presence for years. He came to me with the 
 parts hard as well as ulcerating, having been told he had a cancer, but a rapid recovery 
 followed its removal. Occasionally after the removal of a calculus from a salivary duct 
 a stricture results, and then the gland, under stimulus, may inflame and be the source of 
 trouble. I have seen several ca.ses demonstrating this fact. A free division of the duct 
 is then the right treatment to adopt. 
 
 Salivary Fistula. 
 
 When Steno's duct, the duct of the parotid gland, has been obstructed near its orifice 
 in the mouth or has been opened by a wound or ulceration, a salivary fistula may take 
 place — that is. the saliva, instead of being poured into the mouth, will escape upon the 
 cheek. When this affection originates in some obstruction to the duct itself, it will com- 
 mence as a soft fluctuating swelling in the cheek, caused by retained salivary secretion ; 
 and after a time, usually when the duct has acquired about the size of half a walnut, the 
 swelling will ulcerate through the skin and clear saliva or saliva mixed with pus will 
 escape. If this swelling be opened, the same result will ensue; and after this the cavity 
 may contract, but the fistula will remain. 
 
 Treat.ment. — Tlie only successful treatment of this affection is to establish a free 
 opening into the mouth from the oral end of the duct, which may be effected bv passing 
 a fine probe into the fistula through the duct into the mouth. When this can Ite accom- 
 plished through the natural opening, all the better; but it is not a matter of much import- 
 ance, as an artificial opening near the oral orifice of the duct will answer everv purpose. 
 The probe should be armed with a piece of thick .silk or three or four threads of fine silk 
 and drawn through the mouth, the ends hanging from the cheek and those from the mouth 
 being tied together, the whole acting as a seton to establish an artificial fistulous commu- 
 nication with the mouth. This object will probably be secured in about a week or ten 
 days, when the seton may be removed. The fistula in the cheek will then probably con- 
 tract and close of itself; but if this does not take place, the edges of the fistula mav be 
 cauterized by the galvanic or benzoline cautery, and thus cicatrization be encouraged. 
 The operation may be repeated if required. A plastic operation may be attempted when 
 these means fail. 
 
 Cervical Salivary Fistula. — I have known parotid salivary fistula follow upon 
 the suppuration of the gland after fever in three cases, the orifice in all being small and 
 placed behind the angle of the jaw. In none of these was there any obstruction to 
 Steno's duct. It was troublesome only from the trickling of saliva during mastication, 
 though to one of the patients, who was a lady, this caused much annoyance. I tried the 
 cautery in one of these cases, but without success. 
 37 
 
418 AFFECTIONS OF THE TONGUE. 
 
 Parotiditis, or " Mumps." 
 
 This is a simple although an infectious disease, having a tendency to get well with 
 simple fomentations of the parts, a saline purgative, and a mild tonic. It generally 
 attacks the young, but I have met with it in a lady -xi. 82. Its incubation period may 
 extend over three weeks. It is frequently meta.stutic to the testicle. When it follows 
 upon a fever, it is a severe aft'ection, and not unfrequently passes on to suppuration. 
 Such abscesses spread easily, the deep fascia covering them in forbidding a natural 
 outlet except by burrowing. As a complication of pya?mia it is very serious. Salivary 
 fistula in the neck may follow in such cases. Professor Crocq of Brussels believes this 
 disease is the result of a stomatitis propagated along the duct of the parotid gland to the 
 gland itself. 
 
 Parotid Submaxillary Tumors. 
 
 These have one peculiarity — viz., that they are almost always more or less cartilag- 
 inous, the ordinary form of tumor in this region being the fibro-cartilaginous ; they are, 
 
 moreover, mostly encysted, having a peculiar hard, elastic 
 Fig. 216. feel and botryoidal outline. The}' are generally imbedded 
 
 in the structure of the gland and vary much in their depth, 
 tumors that appear movable and superficial too often dip- 
 ping deeply down into the tissues, and thus increasing the 
 difficult}' of their removal. These simple tumoi's may grow 
 to a large size and stretch the skin greatly over them : they 
 should always be removed — the earlier, the better. In re- 
 moving them the surgeon should be careful to make his 
 incision well, down to the capsule, when he will probably 
 be able to enucleate the growth. It is far better practice 
 to do this, even with the application of a little force, than 
 to be too free with the knife ; for the facial nerve is gen- 
 erally in close contact with the tumor and the deep vessels 
 are beneath. He should also always cut upon the tumor, 
 ' dividing only such tissues as hold it down, taking great 
 
 Submaxillary Tuiuor. ^^^'e too that the large vessels are. if possible, left unin- 
 
 jured. In deeply-placed tumors this removal by enuclea- 
 tion is still more necessary. "When the tumor is large, there is always a strong probability 
 that the facial nerve will be divided or injured; hence it is as well to prepare the patient 
 for the fact. Fig. 21 6 illustrates the situation and external appearance of one of these 
 tumors. 
 
 Cancerous tumors of the parotid are likewise met with, but assume a very 
 diff"erent appearance from the last. They are mostly infiltrations of the gland, fixed, dif- 
 fused, and deep-seated ; they are, moreover, generally associated with paralysis of the 
 facial nerve, diff"ering in this way from innocent growths. In such cases surgical inter- 
 ference is rarely beneficial. 
 
 The difficulty of deciding as to the removal of large growths in this position is very 
 great, and the best guide is their mobility. Sir W. Fergusson, who had more experience 
 in these cases than any man of modern times, says, " If it were evident that the part slid 
 freely over the subjacent textures, I should not hesitate about using the knife, whatever 
 might be the bulk of the disease," etc. ; " but if the tumor seemed fixed, its limits were 
 not clearly defined, or an attempt to move it caused pain, I should not readily be induced 
 to use the knife, however small the mass might be ;" and I endorse these views. 
 
 AFFECTIONS OF THE TONGUE. 
 
 Tong'Qe-tie is occasionally met with, but not a tithe of the cases so ascribed are of 
 this nature. It is due to a tying down of the tip of the tongue by the frajnum lingua?, 
 which prevents the infant from projecting the organ beyond the gums, thereby interfering 
 with suckling. 
 
 Treatment. — It is easily remedied by dividing the fra?num perpendicularly downward 
 behind the gum with a pair of blunt-pointed scissors, the point of the tongue being eleva- 
 ted with the finger or a pair of dressing forceps applied beneath. 
 
 Ankyloglossis. — Under this heading cases of fixed tongue are grouped. In some 
 the organ is whollv adherent to the floor of the mouth ; in others, by bands. Under the 
 
CONG KMT. IL A Fl'i:< TlOSS. -1 1 !> 
 
 latter ciiciimstances fret'ditiii iiiav l»c' ^ivfii hy tin- (livi>ii»ti of tin? han«ls. hut urnl<T the 
 roniicr litth' hupf can he expectrd hy trfatiin-iit, althuiiirli an attempt to rai-i' the (»r;raii 
 would hi; justitiahle. 
 
 Wounds of the Tongue. 
 
 Tliese arc soinetiinos troiihlesoiiu' from hcmorrliage, l)ut when the parts arc hrou<rht 
 toj^fther the hleedin;:, as a rule, ceases; all hlce(lin<: vessels, however, ou^'ht to he tied 
 or twisted. I have known death to follow a small wound in a child IVom the lrickliii<^ 
 of hlood <lown the jdiarynx as well as the larynx, the child dyiii<r in the latter case 
 asphyxiated ; and all surireons recoj^nize the danger of slow hleedin;^ after a t<»n<;ue ope- 
 ration. Sutures should always he employed when gaping exists, and these must he put 
 in deeply, to draw the whole thickness of the divided jiarts together. (Jn (»ne occasion, 
 owing to a neglect of this practice, I had to pare the surface of an old wound that had 
 pas.sed through the half of the tongue transversely, and then hring the j)arts together. 
 The child was unahle to talk clearly, on account of the injury; yet after the oj»eration 
 all was well. 
 
 Dentists' W^ounds. — Since the introduction of nitrous-oxide gas for dental ope- 
 rations, the element of hurry has had the effect of causing many wounds of the tongue 
 of the contused kind. They are the result of the forceps of the dentist seizing the tongue, 
 with or without a tooth, in a hastj' extraction. On .several occasions I luive found it 
 neces.sary to cut off the contu.sed and lacerated flap of tongue. When hleeding is ohsti- 
 nate and the parts cannot be brought together, the cautery or pcrchloride of iron may be 
 usefully employed. In exceptional cases the ranine artery may refjuire a ligature. Ice 
 in the mouth arrests slight hemorrhage. 
 
 Congenital Affections. 
 
 Hypertrophy, or macnj-glossia, is, without d(uiht. a congenital affection, although 
 in certain rep'yi-t( d cases it may not have been observed till the first or second year of 
 life. It is usually an affection of slow growth and trouldesome on account of the mechan- 
 ical obstruction it causes to deglutition and speech ; when tlie disease has existed for years, 
 it produces deformity of the teeth and jaws, from the local pressure of the tongue upon 
 the former and the non-closure of the mouth. Syme published a case in which the tongue 
 projected for three inches out of the mouth of a girl aged 14; and Humphry another, in 
 a child aged 11, in which, when the tongue was withdrawn into the mouth as far as pos- 
 sible, the expo.sed part measured, from the upper lip to its tip, two inches. Many other 
 cases are also on record. As a rule this affection involves both sides of the tongue, but 
 in exceptional cases it may affect but one. The growth is generally painl'?ss, and the dis- 
 ease not rarely affects idiots and children wnth. ill-formed crania. A ca.se in which the 
 disease was congenital and confined to the right half of the organ occurred in a boy who, 
 when six years of age, was admitteil intct (Juys Hospital, under the care of the late Dr. 
 Thomas Addison, with his tongue protruding far out of his mouth and obstructing res- 
 piration. His mother stated that the tongue had been affected ever since his birth, and 
 that he had never been able to articulate distinctly. Whenever he took cold, the tongue 
 became swollen and blisters formed upon it, which burst and bled. The increase of the 
 disease had been gradual. He was treated with mercurials, and he derived so much 
 benefit from them that he left the hospital with the tongue fairly retracted. He reap- 
 peared, however, three years later (185(j) with the same disea.se, the growth having 
 rapidly increased for one month before his admission; he then came into the hands of the 
 late Mr. John Hilton. At that time the right half of the tongue, with the submaxillary 
 glands, was much enlarged ; the whole organ was protruding from the mouth and the 
 papilla on the affected side of the tongue were much hypertrophied. He was again 
 treated with half-drachm doses of the solution of the perchlnride of mercury, and left 
 relieved. In anr)ther three years the tongue had grown as large as ever, and he was 
 readmitted for the third time, when the tongue presented much the same appearance as 
 it had on his previous admission, although the papill;\? seemed coarser. He was treated 
 in the same way as on the two previous occasions, and he left relieved. No further his- 
 tory of his case is known. 
 
 It should be mentioned that in this case there were no .symptoms of the presence of 
 njevoid tissue. The tongue appeared coarse, thickened, and enlarged, as if from simple 
 muscular hypertrophy, and yet, from the fact that the enlargement diminished under the 
 influence of mercury, there must be a question as to this being its true nature. Indeed, 
 
420 ON GROWING AND DEGENERATING NJ^VI OF THE TONGUE. 
 
 the case appears pathologically to be like one shown at the Pathological Society in 1872 
 by Mr. H. Arnott, in which, after its removal, there was visible niicroscopically very little 
 true muscular hypertrophy of the organ, but the epithelial covering of the tongue was 
 very thick and the papillae were enlarged ; the blood vessels were larger than usual, and 
 there were large irregular spaces with thin walls, which were filled with blood or clear 
 •fluid ; a few vesicular bodies, which may have been enlarged lymphatics, were also present. 
 Macro-glossia, as a disease, is, according to Mr. Arnott, probably due to a variety of causes 
 — that is, to (1) a true muscular hypertrophy of the organ; (2) a nsevoid affection of its 
 blood vessels ; (3) a thickening and induration caused by a long-continued subinflam- 
 matory state ; or (4) a general enlargement of the lymphatics of the tongue. 
 
 Treatment. — The treatment of this affection has hitherto been excision either of a 
 wedge of tongue, as successfully performed by Humphry, or the removal of the project- 
 ing portion of the organ by the knife or ecraseur. Good, also, has said to have been 
 derived from ignipuncture. But mercurial treatment should certainly be employed in 
 some cases before recourse is had to surgical interference, since in the case I have 
 recorded the benefit of the drug was most striking. 
 
 In some cases of enlargement, and more particularly when the disease is not con- 
 genital, but acquired, and consequently probably inflammatory, the eff"ect of the iodides 
 should also be tried. In the following case of a gentleman Eet. 20 who consulted me 
 some years ago for enlargement of the tongue of twelve years' standing, and which I 
 from its history regarded as inflammatory, the drug proved valuable. The enlargement 
 was associated with a protrusion of the organ and all the consequent evils. lodism, 
 induced by ten-grain doses of the iodide of potassium three times a day, was followed by 
 the speedy disappearance of the aff'ection, though at the time death appeared imminent 
 from the excessive swelling of the organ caused by the drug. 
 
 I should like to mention that so early as 1807, Sir A. Cooper removed a portion of a 
 tongue weighing on removal 2 ounces 2^ drachms (Troy) and measuring 3>] inches in 
 length, 3 inches in breadth, and Ih inches in thickness, from a man aet. 53 who had been 
 troubled with the enlargement for six months. The disease was supposed to have been 
 brought about by the use of mercury given for syphilis. The case did well. 
 
 On Growing and Degenerating N^vi of the Tongue. 
 
 These cases are not very common, and out of about half a dozen that I have seen the 
 following is the best. I first saw the case when the girl was an infant, and the tongue 
 presented the appearance and feel of a vascular sponge. The whole organ at that time 
 was swollen, and large distended veins coursed over and under its surface, more particu- 
 larly on its right side ; it had likewise a very full arterial supply. On the application of 
 pressure by means of the thumb and fingers the tongue was readily emptied of its blood, 
 and on its removal it at once refilled. The case was brought to me for treatment. I 
 advised that nothing should be done, and I did so on the recognition of the fact that na3vi 
 have a tendency to undergo degenerative changes, and in the hope that these changes 
 would take place in the tongue. In this hope I was not disappointed, for during the 
 twelve years that passed since I first saw the case many changes took place in the part, 
 and the most typical was the cystic degeneration of the naevus. These changes began 
 when the child was about six years of age and have steadily continued. At present the 
 tongue has quite lost its spongy feel. In consistence it is tolerably firm, but it feels 
 harder in some spots than in others. To the eye its surface looks to be made up of vesic- 
 ular warts, these vesicles being filled either with clear or more or less blood-stained serum. 
 In fact, the tongue appears precisely as any nasvus appears which has undergone the 
 peculiar cystic warty degeneration to which such growths are prone. It has, however, 
 probably less of the papillary hypertrophic growths on its dorsum than many na3vi on 
 mucous surfaces show. These appearances are confined to the upper surface of the 
 tongue, for its lower aspect still presents, in a degree, the venous engorgement which, 
 originally characterized the whole growth. 
 
 The appearances I have described are absolutely typical of a degenerating najvus, 
 since no other growths ever undergo like changes or present any like features. 
 
 I must mention here a curious co7vph'ciifion which presented itself in this case, and 
 which is difficult to explain, though I am disposed to think it had something to do with 
 obstruction of the lymphatics. It appeared when the child was ten years of age and 
 when the cystic degeneration of the naevus had far advanced ; it showed itself as a pain- 
 less swelling of the neck, which began in the right submaxillary region and descended 
 
iciiriiYosis OF Tin: rosavE. 421 
 
 hackwanl tnwanl tin- aiiirlt' i»f tlic jaw ami ilnwiiwanl aluiiL' tlic in rk. NNln-ii I saw it, 
 tluTc was a sul't, tiaccitl, l)ai:i:y fiilarL^i-iiiciit nf the part, witlmiit any extiTiial or ;;eiieriil 
 si^iis of iiiflaiiiiiiatiiiii. I looki'd iipuii it as cystic and adviscfl its removal. On uttcmpt- 
 int; to carry tint tiiis )iracticf I louinl no sii^ns of a cyst wall. Itut sini|»Iy a collection ot" a 
 thin, watery, l»iit liii,'lily alliiiminous fluid in tlic deep comu-ctive tissue of the neck. 
 Indeed, when an incision had i)ecn made into the swelliiiL: and the fliiiil was evacuated, 
 I never saw nor made a more perfect dissection of the sulimaxillary and dijiastric .sjtacc-, 
 than then showed itsidf. The Hiiid had clearly heeii poiin-d out into the connective tissue 
 of these deep spaces ami there was no cyst wall. I waslie<l the cavity out with iodine 
 water ami introduced a drainaj;e-tul)C. and under the kind care of Dr. () '.Mcara of Sutton 
 Bridire. Lincolnshire, the case subse(jueutly did perfectly well, and no return of trouble 
 ha.s taken place. 
 
 It is (|uite possible that at the present time the tonjrue of this child, beiiifr lar<:e and 
 coarse in a])jn'arance. mitrlit be mistaken for a case of macro-<rlossia or one of the forms 
 of hvpertro])liy. Xo one, however, who recojrnizes the peculiar cystic appearance of its 
 surface shouhl mistake it or fail to recognize its lutvoid oriLfin. 
 
 Such ca.ses as this have doubtless been described by authors as examples of vesicular 
 disease of the tonirue. 
 
 Nicvi of the toiiiruc do not, however, more than \yx\'\ of other parts, always underfro 
 desrenerative chanires. although, when they do, they for the most i)art assume such modi- 
 tioations as of necessity result from the surface being cutaneous or mucous. Such naevi 
 will prol)ably reijuire treatment. 
 
 Congenital Tumors of the Tongue other than N^vi. 
 
 These do occur, though rarely, and they may appear as outgrowths, warty orotherwi.se. 
 
 I have seen a warty growth covering the dorsum to the extent of a sixpence, and a 
 growth as large as a rice-seed projecting as an outgrowth. 
 
 I remember al.so cutting oft' from the dorsum of an infants tongue a pedunculated 
 fibro-cellular congenital growth the size of a pea. and a good recovery followed. 
 
 In removing these pedunculated growths it is well to cut well into their bases, since 
 cases have been recorded in which a return after removal has taken pdace. 
 
 Congenital tumors of a deeper kind may likewise occur, though none have come under 
 my notice. A remarkable instance of such was recorded by Mr. Hickman in the twen- 
 tieth volume of the Pathologivdl Societj/s D-ansarfions, in which, sixteen hours after birth, 
 an infant was suft'ocated by a growth on the base of the tongue, made up of hypertrophied 
 racemose glandular structures normally existing in the part. 
 
 Amongst the congenital tumors of the tongue must likewise be mentioned the exist- 
 ence of gummata in the subjects of hereditary syphilis. 
 
 Ichthyosis of the Tongue. 
 
 This peculiar disease of the tongue, to which the attention of surgeons was first 
 drawn by Mr. Ilulke in 18(34 (Clin. Soc, 18(58), is now generally recognized, although 
 it is often known as "psoriasis." It is met with in several forms. In the /tfisf common 
 variety the papilhv themselves seem to be hypertrophied and the disease appears as a 
 coarse tongue, in which the papillje are very large and in some cases covered with a den- 
 dritic, horny epithelial covering. In the more common kinds the surface of the tongue 
 wholly or in part assumes, on the one hand, a smooth and bluish-white appearance, tessel- 
 lated in a small or large pattern and delicately furrowed, with an absence of papilhi?. or. 
 on the other hand, it presents a more or less extensive whitish or yellow raised plaque 
 made up of finer or coarser epitlielial elements with a uniform surface, the parts when 
 wet having a wet white-kid or yellow wash-leather aspect and a harsh feel, and when dry 
 a brown appearance and a horny touch. 
 
 These three forius of disea.sc may well be called, as suggested by Mr. Henry Morris, 
 the p'ipi/lomatoits (Fig. 217), smooth trsseJlatecL and raised jylaque varieties. 
 
 The disease is generally met with in subjects of middle age. although I have .seen it 
 in a woman as young as twenty-two ; and it is more common in men than in women. It 
 is in the majority of instances confined to the tongue, but in about one-third of the cases 
 the buccal membrane is implicated as well. 
 
 It is very frequently associated with cancer, as in four out of the last ten cases I have 
 noted, and in thirteen out of twentv-seven tabulated bv Mr. Morris: it is said by some 
 
422 ICHTHYOSIS OF THE TONGUE. 
 
 authors always to lead up to it. It may or may not be found complicated with syphilis, 
 but that it has a syphilitic origin can with some confidence be denied. 
 
 In one instance I found it associated with elephantiasis arabum of the legs and geni- 
 tals. It was in a gentleman ;T3t. 42 who had had the elephan- 
 ^'if' -^" tiasis for ten years and the ichthyosis of the horny type much 
 
 longer. It is met with in the temperate, but more frecjuently 
 1^ in the reverse ; and it is as often as not found in those who do 
 not smoke. It is a slow, insidious disease, and is rarely recog- 
 nized, except by accident, until it has assumed a very marked 
 type or become the seat of changes which suggest or charac- 
 terize epithelioma. 
 
 The microscopical features of this disease are somewhat cha- 
 racteri.stic ; they have been well described in the following reportj 
 made by my friend Mr. Symonds, of a specimen which was taken 
 
 from Mr. B. , aet. 64, 1882, in whom the ichthyotic disease 
 
 had existed for twenty years and the cancer for seven months : 
 
 Papiiio.natou.s Ichthyosis of '"^^^^ microscopical examination shows the papilla3 to be 
 
 Tongue. much wasted, their arrangement resembling more that in the 
 
 skin than in the tongue. 
 " The superficial layer of epithelium is very much thickened. The deeper layer varies 
 in different parts. The cells are seen with a higher power to become altered and to be 
 mingled with those of the mucosa. As the epithelioma is approached the limit is more 
 marked for some distance, and the processes are shorter until the epithelial ingrowths are 
 reached. 
 
 " The mucosa is infiltrated with crowds of nuclei. They diminish rapidly toward the 
 epithelioma, but remain fairly abundant in the opposite direction. This diminution of 
 nuclei, with increased definition of the basement membrane toward the epithelioma, is a 
 striking feature in the sections." 
 
 Treatment. — It has been already stated that the majority of the cases of this dis- 
 ease do not come under the notice of the surgeon until the affection is a confirmed one, 
 and under these circumstances it can readily be understood why the affection has been 
 pronounced incurable. If seen earlier and treated, there is some reason to hope that 
 benefit might be derived from treatment, if not a cure brought about. 
 
 This hope is supported by the assertion of those who tell us that they have seen cases 
 of so-called psoriasis (not syphilitic) of the tongue cured ; and I am sure that in several 
 examples of ichthyosis I have found arsenic as an internal remedy, boracic acid or chlor- 
 ate of potash as a local one, and as near an approach to milk diet as possible, with a total 
 abstinence from wines, spirits, and smoking, highly beneficial. 
 
 In cases of advanced disease it is difficult to find patients who will submit for a suffi- 
 cient period to this treatment, but in others, where it is met with in its early stage, the 
 treatment would not be of necessity so prolonged. I am, however, convinced of its value 
 and would urge its adoption. 
 
 In confirmed disease I know of nothing but the excision of the organ, wholly or in 
 part, that can offer any prospect of effecting a cure ; and if the pathological doctrine be 
 correct that this disease always ends in cancer, there can be no difficulty about the course 
 which should be taken. I think, however, at present it may with some confidence be 
 asserted that this positive opinion is " not proven ;" and under these circumstances, Avhilst 
 the surgeon is justified in not rushing into operative interference in all cases, he should so 
 watch the case as to be prepared to take steps for the complete removal of the aflected 
 organ as soon as he can see that active changes are occurring in it or anything like an 
 ulcerative or degenerative change makes it appearance. 
 
 If the surgeon should err, let him do so on the side of early interference rather than 
 that of delay, for it must be added that when a cancer attacks a tongue the subject of 
 ichthyosis, it usually develops rapidly ; and when the disease returns after removal, it 
 does so more commonly in the submaxillary or cervical glands than in the part. The 
 return growtli, moreover, always display great malignancy. 
 
 In connection with this subject of ichthyosis of the tongue and its close association 
 with cancer I should like to record the following fact : 
 
 In 1879 I saw a gentleman aet. 57 who was the subject of congenital ichthyosis of 
 his skin, with an ulcer on his foot of six years' standing, which became cancerous and 
 had to be removed. 
 
 This gentleman was one of nine, the eight being women, and four of these eight had 
 
inn. inn osr i.\ riii: rosdui':. \'i:\ 
 
 llio saiiH' iciitliyntic (liscasc. Tlif iimlliiT nl" tliot- iiiiic lia<l the sarin' <liscasr, and Iht 
 latlicr Id-lnrc Iht. Tin- ;.M'iitl»'inaii liiinsrlf was inarruil and liad .six (.liiMnri, three huyn 
 and three L'irls. Two td' the hiiy.s were siniihirly aHeeted. 
 
 Inflammation and Suppuration of the Tongue. 
 
 Inllannnation <d' the tunLMU', when deep-seated and irein-ral, is a <:rave affection, since 
 the swellinL' wliitdi aeeonipanies it i.s often so Huthh-n and severe as to tlireaten life l)y 
 sufloeation. Siudi oases are, however, rare ; I have seen hut one. 
 
 I say this e.\eludin<; from consideration tho.se cases of .sudden enlar^'cment of thi- 
 totijrue tlie result of salivation from mercury or iodism,as in a case already reported. In 
 the.se the sym])toms, though severe, as a rult! subside rapidly under local treatment and on 
 tlie removal of their cause. 
 
 In rare cases, however, the tont:ue may slouirU <>tV al'ter jityaiism. 
 
 Inflammation of the tonjiue. when local, may he acute or chronic. It may follow an 
 injury or come on without any other asifj;na])le cause than cold or exposure. It may begin 
 as a sudden swelliiiLr "f one-half of the orj;an, associated with con.stitutional symptom.s 
 of fever, etc., or it may show itself simply as a chronic enlargement of the part, with 
 few. if any, general symptoms, and no more local, than are to Vjc explained by the 
 mechanical enlargement id' the organ. 
 
 The disease, however, under both circumstances, is not dangerous, since it is well 
 amenable to treatment and has a tendency toward recovery. I have seen many examples 
 of this affection, and in all a good result took place. 
 
 Tkeat.mknt. — When acute inflammation attacks the tongue as a whole and threatens 
 life by suffocation, free puncturing or free incisions made in a vertical direction into the 
 organ may be recjuired, these openings being made with the view of relieving mechani- 
 cally the turgid condition of the vessels and of giving exit to the inflamnuitory fluids 
 which infiltrate the part. Serious hemorrhage may, however, at times follow these incis- 
 ions, and in a case I witnessed of the late Mr. Poland's the result was nearly fatal. 
 
 In more local inflammations the benefit of puncturing the swollen part is very great 
 — in the early stage to let out the serous fluids, and in the later to let out pus. 
 
 By way of medicines, salines and tonics are beneficial ; but the di.sease has a tend- 
 ency to get well by natural proces.ses. 
 
 Hydatid Cyst in the Tongue giving Rise to Suppuration. 
 
 The possibility of a chronic cystic enlargement of a tongue, as of other parts, being 
 due to the presence of an hydatid should always be in the mind of the surgeon, and more 
 particularly when the enlargement is paiidess and gives rise to trouble mainly from 
 mechanical causes. Also when a chronic, painless globular tumor has existed in a part 
 for some time, say months, and then suddeidy increases, the possibility of the swelling 
 being due to the presence of an hydatid which has died and given rise to suppuration 
 should be entertained, for hydatid tumors in their early stages, in the tongue as else- 
 where, give rise to symptoms of a mechanical kind, and at a later period, when they die, 
 to suppuration. 
 
 I have seen two cases of this affection ; one occurred in the person of a middle-aged 
 patient who had a chronic cystic enlargement of one .side of tht; tongue. When the cyst 
 was punctured, a globular hydatid escaped, and a good recovery ensued. 
 
 The second case occurred in 18S1, in the person of a girl rot. 17 who came to me with 
 a central cystic swelling of the tongue of seven or eight months' existence. The enlarge- 
 ment had been ouite painless and felt like a tight globular tumor embedded in the tongue. 
 
 I punctured the swelling with a lancet and evacuated a collapsed hydatid cyst floating 
 in pus, and a good recovery took place. 
 
 In the first case related the hydatid was turned out entire ; in the second, the hydatid 
 had died and had given ri.se, as any foreign body might, to suppuration. A cure in both 
 cases took place as soon as the foreign body was removed. 
 
 Chronic Superficial Glossitis or Smooth, Glossy Tongue. 
 
 A smooth glazed tongue is often mot with in practice, and tliere can be little doubt as 
 to its being the result of a chronic inflammation of the mucous membrane of the organ. 
 At times it is associated with ulceration. This inflammation is in many cases due to the 
 heat or irritating influence of a hot pipe, cigar, or spirits. 
 
424 THE SIMPLE OR DYSPEPTIC ULCER OF THE TONGUE. 
 
 It is well described by Mr. F. Clarke (Diseases of Tongue^ pp. 159-lGl). It shows 
 itself in patches more or less oval or oblong, of a deep red color and raw a.spect, the 
 other portions of the tongue presenting their natural appearance. The surface of these 
 patches is smooth and glossy, though at times ulcerated. The tongue itself is occasion- 
 ally swollen, and where the disease has existed for some time the patches feel thickened 
 and as if elevated. Should the disease be checked in its progress, a complete recovery 
 may ensue ; but more commonly the patches remain smooth and shining or become the 
 seat of a white patch. 
 
 In Preparation 1672''', Guy's Museum, there is an interesting example of the affection, 
 which occurred in a man aet. 49 who was admitted with pemphigus and erysipelas in 
 March, 1878, and who gave a clear history of syphilis five years previously. 
 
 The preparation, as described by Dr. (xoodhart, shows that the tongue was changed in 
 appearance completely. Its surface, in place of being rough-looking, had lost all its 
 papillae, even the circumvallate, the whole being scarred over with smooth cicatricial 
 tissue. The mucous covering of the tongue was thicker than normal, smooth, and white. 
 At two spots were ulcers, one the size of a threepenny piece, with an indolent, unhealthy 
 surface, the other larger and more superficial, healing. The tongue was not fissured. 
 
 Microscopically, these patches " are either entirely denuded of epithelium or it is 
 reduced to an extremely thin layer, and the papillse are obliterated by distension." 
 Pathologically, the disease " appears to be a chronic inflammation of the mucous mem- 
 brane which has gradually produced complete alteration in the characters of the epider- 
 mis and thickening of the corium and submucous tissue " (Butlin, MeJ.-Ckir. Trans. ^ 
 vol. 61). 
 
 The disease is constantly tlie precursor of a cancer. 
 
 Ulceration of the Tongue. 
 
 In a clinical point of view it is expedient to divide the ulcers of the tongue into the 
 stiperjicial and deep, since, in a general sense, the superficial are local, simple, and readily 
 curable, whereas the deep — which are due to the breaking down of inflammatory, tuber- 
 cular, syphilitic, or cancerous elements — are complicated, difficult to diagnose and treat, 
 and, moreover, are dangerous. 
 
 The superficial sores include the aphthous and dyspeptic ulcers, those associated 
 with chronic glossitis, ulcers excited and kept up by decayed or ragged teeth, as well as 
 some due to syphilis, congenital or acquired. 
 
 The deep ulcers are always either syphilitic, cancerous, or tuberculous. 
 
 Superficial Ulcers. 
 
 The ordinary aphthous inflammation of the tongue is a common affection, and is 
 met with in children and adults as a result of irritation of the stomach or intestines from 
 dietetic or other causes. In feeble subjects the white aphthous spots may ulcerate and 
 thus become the source of much trouble, and the ulceration may be extensive, though 
 rarely deep. In cachectic patients the parts may slough. 
 
 The TREATiMENT of these cases must be mainly determined by the cause, but in the 
 majority a lotion of chlorate of potash, or boracic acid of five grains to the ounce of water, 
 and the internal administration of the same drugs, with or without bark or the mineral 
 acids, is generally sufficient to bring about a cure, though in feeble subjects this may be 
 slow. 
 
 In the more limited affection the local application of the nitrate of silver often acts 
 very beneficially, and in the more chronic quinine is of great value. 
 
 The Simple or Dyspeptic Ulcer of the Tongue. 
 
 This form of superficial ulcer of the tongue may be the sequel of the aphthous, but 
 more commonly it begins as an ulcer, a result of chronic glossitis, which steadily spreads. 
 It rarely, if ever, dips into the muscular tissue of the organ, but is confined to the mucous 
 membrane covering it. The ulcer may be inflamed, indolent, sloughing, or irritable ; indeed, 
 it may vary as may any ulcer in another part of the body ; and if chronic, it will be indu- 
 rated. Its surface, however, will almost always be smooth, and it will never display the 
 irregular or deeply-excavated appearance of the deep sores ; it will, moreover, almost 
 always be seen upon the dorsum of the tongue, although in exceptional instances it may 
 spread downward. 
 
SYl'llll.iric DISEASE or THE ToSal'E. 425 
 
 'I'kKATMKNT. — 'Pile nlilv mhiikI |)riliri|i|c nl' t rent liic'lll is :i mmiI liili;.' mi«\ ail<l tllc cllii'f 
 pootl is to 1)0 ;;aimMl hv iiu'iiiis of ilii't. 'I'liis is to he rt';^uiatcil in flic most can-i'iil maii- 
 MiT, and all food sliotiM Im- tor))i(l(li>ii that can possibly irritate Milk food, when it can 
 he taken, is tlit" hest, and with it it is \v<'ll to 'X\\^- alkalies, siwdi as lime water, hicarhonute 
 of potash, or chlorate of potash. an<l at times opium in small dosc's. Animal hroths are 
 liencliiial ; hut little meat should he allowed. All heer and sjiirits should he interdicted; 
 and when stimulants are ahsolutely m-cessary. they should he ^Mven as wine well diluted. 
 
 liocallv, the lotion of horacic aeid or chlorate of |)otasli is henclicial. and caustics are 
 rarelv re(|uired. Uf tonics the harks are the hest I'orm, hut at times the mineral aeid.s 
 are of value. 
 
 Ulcers Originating from Local Irritation. 
 
 These are very coninmii in the toiitiue, and the fact is due to the restless imdjility of 
 the ori,^an and the necessary friction which it must receive from any sharp process, of a 
 hroken or decayed tooth, or any ed<rc of rouirh tartar, or even from the jiresence of an 
 exostosis of the lower jaw. T have known an ulcer due to the last cause to he looked 
 upon as cancerous. 
 
 These ca.ses are at times very troublesome and obstinate unless their cause i.s recog- 
 nized, and they may, and do, without doubt, often become cancers. 
 
 They in:»y show themselves as mere bli.sters or superficial ulcers, the other part of the 
 toiiLiue being healthy, but in chronic cases the local sore may be indurated and thus simu- 
 late a cancer. In the case of a woman aged 40 the ulcer had existed two years. 
 
 Some subjects are more susceptible to irritation than others, and I have known a 
 patient have repeated blistering and ulceration of the tongue from the irritation of a 
 rough decayed tooth after sleeping on the aifected side. The mere weight of the tongue 
 against the tooth and the unconscious friction between the two parts when in contact 
 proved enough to ]>roduce a blister in the soft parts. 
 
 Treatmknt. — The nun-e knowledge of the cause of this affection suggests the reujcdy 
 — namely, the removal of the cause, the removal of the point of irritation when possible, 
 and the extraction of the tooth when nothing less is sufficient. Indeed, as a general rule 
 of practice, the surgeon should always advise the removal of any local source of irritation 
 I'rom the tongue, as frcun any other part of the body, for such is, without doubt, the cause 
 of the majority of local cancers. 
 
 Infiltrations and Deep- Seated Ulcers of the Tongue. 
 
 I have of necessity grouped these cases together, for the majority of the deep-seated 
 ulcers of the tongue begin as local infiltrations and are due to the subsequent breaking 
 down of the infiltrated and infiltrating material. 
 
 The group con.se(|uently includes cases of syphilitic di.sease, of epithelial cancer, and 
 of tubercular disease of the tongue, each of which claims a distinct notice. 
 
 Syphilitic Disease of the Tongue. 
 
 This shows itself in many ways and under many circumstances. Thus, it may occur 
 as a comjenital (tffectio)i and appear either as a mucous patch on the tongue associated 
 with other constitutional symiitoms. or as a deep fissure, as recorded by Dr. Barlow {Path. 
 Sue. Trans., \o\. 31) or as a superficial ulceration. Of the former kind I have .seen several 
 examples ; of the latter but one, and that through the kindness of my colleague. Dr. Good- 
 hart, in whose practice it occurred. 
 
 A full report of tlie case may be read in the Guys Hospital R< ports for 1883. 
 
 As an acquired disease, .syphilitic disease of the tongue shows itself either as a mucous 
 patch or as a more or less extensive local infiltration of the tongue with gummous deposit, 
 the breaking down of which leads either to superficial .sores, to fissures, or to deeply exca- 
 vated irregular ulcers, and later on to the iiulurated and irregular cicatricial tongue. 
 
 In some instances the gummous material is either poured out soft or as a solid which 
 soon breaks down, under both circumstances appearing as a cystic enlargement in the 
 body of the tongue. I have seen, in some cases, four or five of these cystic swellings in 
 a tongue thus affected, and on opening the sanu^ have given exit to a thin fluid. 
 The enlargements appear as single or multiple globular tumors in the body of the 
 tongue. 
 
426 SYPHILITIC DISEASE OF THE TOyCiUE. 
 
 When the disease occurs in the shape of mucous patcJirs, it is usually associated with 
 other symptoms : the patches are commonly multiple and are for the most part situated 
 on the upper surface and edges of the organ. They appear either as moist papules with 
 whitish tops, as i-ed, circular, or irregular excoriations, or as granulating surfaces project- 
 ing as white, moist, raised growths. The mucous patches in the tongue are precisely like 
 those seen in other mucous membranes, and, indeed, are identical with them. 
 
 The}' may occur with the first onset of constitutional symptoms or not show them- 
 selves till a remoter period of syphilitic inoculation. They are very prone to reappear 
 after their supposed cure. 
 
 When syphilis attacks the tongue as a local infiltration of gummous deposit, it does 
 so usually long after the primary inoculation, even after twenty or more years. 
 
 It may do so as a single or more commonly as a multiple, more or less rounded infil- 
 tration of the submucous or muscular tissue of the tongue, and the swellings may be 
 pea-like or nut-like ; at first these swellings will be hard, but as time progresses changes 
 will occur in them. If allowed to run their course, they will enlarge and break down, 
 open and discharge ; if treated, they may soften and be reabsorbed or wither and dry up, 
 the latter change being very rare. 
 
 When this affection is allowed to run its natural course, the swelling will enlarge and 
 subsequently break up ; the hard lump will increase and become softer ; the soft parts 
 covering it in will redden, inflame, and open either by an ulcerating or sloughing process ; 
 and when the contents of the lump have been discharged, either a ragged cavity will be 
 left to granulate or a fissure to heal. The edges of the cavity or fissure are under all 
 circumstances perpendicular and sharply cut. 
 
 The cavity, when the parts have opened by a sloughing process, will be more or less 
 ragged, according to the amount of destruction of the tissue of the tongue, and it will 
 present a surface which will vary according to the stage of the disease. When looked at 
 during the period of sloughing, the dead tissue infiltrated with the yelloio infiltrating 
 material, of a wet, wash-leather appearance, will readily be recognized ; and when seen at 
 a later period, the irregularly excavated cavity with sharply-cut perpendicular uninfil- 
 trated edges will generally enable the surgeon to diagnose the disease from the one for 
 which it is often mistaken — a sloughing cancer. The common want of enlargement of 
 the lymphatic glands in this specific affection of the tongue is another help to diagnosis. 
 At a later period, when repair has taken or is taking place, an irregular, yellow-white 
 cicatrix (leucoma) will be seen, and the tongixe eventually will show marked evidence of 
 the destructive processes of which it has been the seat, wasting of some parts of the 
 tongue, scarring of others, mixed up with irregular cicatricial tissue, being the chief 
 characteristics of a repaired syphilitic tongue. 
 
 In tongues that are brought rapidly under the influence of appropriate treatment, the 
 changes that have now been described may be considerably modified. Thus, the nodular 
 infiltrated mass may soften and the deposited material may be reabsorbed. The tongue 
 itself will become supple and more natural, and a cure may take place — a cure, however, 
 which in some cases is attended with a wasting of the portion of tongue that was infil- 
 trated, or a loss of the natural papillary tissue upon the surface of the tongue which cor- 
 responds to the seat of infiltration. 
 
 AVhat, however, is of far greater importance to remember is that a tongue which has 
 been the seat of syphilitic disease frequently becomes the subject of a cancer. The 
 altered nutrition brought about by the irritation of the one affection encourages the 
 development of epithelial disease. A relapse of this aff'ection after an apparent cure is 
 also very common. 
 
 Treatment. — When the diagnosis of this many-faced disease has been made, the line 
 of treatment to be adopted is not difficult to lay down, for there can be but little doubt 
 that some mercurial medicine is the most certain drug to employ where there are no indi- 
 cations against its use ; and, on this being rejected or found wanting, the iodides of 
 potassium, sodium, or ammonium, in gradually increasing doses, are to be used. 
 
 The disease must be dealt with as a general, and not as a local, one ; and the local 
 aff'ection is to be regarded as one of the manifestations of a constitutional disorder which 
 may appear in other seats, though as yet it may not have done .so. 
 
 when mercury is prescribed, the perchloride in doses of one-sixteenth of a grain in 
 bark may be given, or, what I like as well, a pill of half a grain of the green iodide of 
 mercury twice a day. In both cases the dose should be gradually raised to double the 
 strength indicated. 
 
 When mercury is contraindicated on account of the patient's cachectic or feeble con- 
 
CANCER OF Till:- To.\(;rj:. -127 
 
 ditioii, tlu' icMlidc'S may '"i' (••iiiimfiiffil at fivc-triaiii dnscs and steadily iinTcascd wi-i-k l»y 
 wt'i'k hy a grain up to twtdvi--, tirtccn-. or twenty-grain doses tlirco times a dav. The 
 iodide ol' sodium may he at times suhstituted tor the iodide of jxttassium. Tonies are 
 often re<|uired at tlie same time, with good simple food, fresh air, and regular hahits. 
 Stimulants should he givi-u very sparingly, and all smoking should he strietly jindiiliitcd. 
 A.s ii loeal ajiplieatiou tin- lotion of horair acid or (ddorate of potash gr. x to the ^ of 
 water is of value, and the n-eomniendation of Mr. II. Morris to ruh a piece of hlue-pill 
 nia.ss onee or twiee daily over the surface of the .s(»re is worthy of adoption. When the 
 di.seu.se has apparently di.sappeared, the treatment must he continued for some — possihly 
 for six — months, this practice heing necessary to guard against a relapse. The routine 
 practice of apjdying the nitrate of silver to these .sores cannot be too strongly con- 
 demned. 
 
 In the " lumpy tongue," in the stage in which the lumps are softening, I have found 
 the .simple operation of puncturing the tumors to he of great use hy procuritig the esca]»e 
 of the contents of the lumps, which are often serous, thereby relieving tension and cer- 
 tainly expediting the cure. 
 
 In cases of long-standing disease the fear of the tongue becoming the seat of cancer 
 shmild ever be b(»i'ore the surgeon, and the fact of a tongue having been the seat of an 
 old syphilitic affection should tend rather to support tlian to weaken the view of a doubt- 
 ful excavated ulcer of the tongue being of a cancerous nature. At any rate, where the 
 doubt exi.st.s, let it rather encourage surgical interference than prolonged n)edicinal treat- 
 ment ; for in a clinical point of view a chronically affected syphilitic tongue had better 
 be occasionally removed than a cancerous one left to run its course. 
 
 Cancer of the Tongue. 
 
 This distressing disease is met with in about five out of every hundred cases of 
 cancer, and is an affection of adult life. An analysis of 102 consecutive patients 
 admitted into Guy's Hospital, and seen by me, shows that 80 out of every 100 aff"ected 
 by it were over the age of forty-five; 12 were under forty years of age; 27 between 
 forty-one and fifty ; 31 between fifty-one and sixty ; 25 between .sixty-one and seventy ; 
 and 7 over seventy years of age. This disease may. however, occur as early as twenty- 
 seven. It is more common in male than female subjects, in proportion of 80 to 22. 
 
 The disease is ahiays of the epithelial form, and is essentially an isolated infiltration 
 of the papillary or mucous surface. It usually shows itself as a blister, crack, ulcer, 
 wart, or superficial tumor upon the tip or side of the tongue, and is in the majority of 
 eases single. It then breaks down and discharges, leaving a more or less ragged, irregu- 
 lar, excavated sore with raised, indurated, infiltrated, and mostly everted edges. 
 
 The disease is at first always local, but later on, when allowed to take its course, it 
 will spread and involve the floor of the mouth, fauces, gums, or jaw-bone. It will, more- 
 over, always, sooner or later implicate the lymphatic glands. 
 
 At times the diseased parts slough more or less extensively, and in a case which was 
 under my care in 18G6 the whole organ sloughed off" before the man died. It aff"ects one 
 side of the tongue as much as the other, and is at times central. But, wherever it may 
 commence, it will soon involve neighboring parts. 
 
 It originates at times without anj- definite cause, but in the majority of cases it is 
 excited by some local irritation, such as that caused by a broken or rough tooth, a hot 
 pipe, an antecedent .syphilitic affection, or the disease which is now known as ichthyosis. 
 
 It may originate also in a scar on the tongue, as it is well known to do in scars of 
 other parts. In 1880 I saw a case in which the disease had attacked the tongue of a man 
 aet. 57 who had bitten off" its tip five months before in an epileptic fit, and a second in 
 1875, in a man aet. 70 who had injured his tongue by a fall two years before. 
 
 Diagnosis. — Any localized iujiltration of the' papillary or mucous covering of the 
 tongue, however limited it may be, in a patient over forty, .should be su.spected to have 
 an epithelial origin ; and should this be found in a part of the tongue in which no local 
 source of irritation can be discovered, the suspicion becomes a certainty. 
 
 Should the infiltration coexist with ulceration and a local source of irritation be made 
 out — such as a broken or rough tooth — the probabilities of its being due to this local 
 irritation may be regarded as great ; but should the di-sease fail to undergo a rapid cure 
 upon the removal of its supposed cause, the conclusion should be drawn that the disease 
 is cancerous. 
 
 When a tongue has been the seat of a chronic syphilitic aff"ection, and more par- 
 
428 CANCER OF THE TONGUE. 
 
 ticularly is one in which a series of relapses has taken place, with uncertain intervals of 
 apparent convalescence ; and when, it presents an indurated, infiltrated tissue, with a more 
 or less excavated, ulcerating, or sloughing cavity, with irregular, everted, and raised, 
 rather than sharply cut and defined, edges, — the diagnosis of the disease being cancerous 
 is highly probable ; and when with these symptoms the lymphatic glands beneath the 
 jaw are found enlarged, the diagnosis becomes a certainty. 
 
 When, again, this local infiltration, with or without ulceration, is found in a tongue 
 which has been the seat of an old syphilitic leucoma or the subject of that peculiar 
 disease of the papillary mucous membrane known as ichthyosis, there should be no fjues- 
 tion as to its true nature ; for it should be accepted as a fact that chronic syphilitic as 
 well as chronic ichthyotic disease renders the tongue peculiarly liable to undergo changes 
 in its epithelial elements which most commonly reveal themselves as epithelial cancer. 
 
 Mr. Morris has recorded, in an able paper on this subject,' the fact that out of 55 
 cases of cancer of the tongue, in 13, or about one-fourth, the organ had been the seat of 
 ichthyosis. I am quite prepared to support him in this average. 
 
 Treatment. — There is but one form of treatment of cancer of the tongue that can be 
 recommended with any confidence, and that is the removal of the disease by some sur- 
 gical operation. And there is but one period at which this operation is likely to prove 
 successful as a cure, and that is in the early stage of the disease when the cancer is local 
 and when it involves no other tissues than those in which it was primarily placed. 
 
 When the disease has extended beyond these limits and through the lymphatic chan- 
 nels has implicated the lymphatic glands, the prospects of a cure are not favorable, even 
 if they can be said to exist, since, whilst the glands that lie along the ramus of the jaw 
 may be readily removed, those that lie buried behind the angle are beyond the surgeon's 
 reach, and to remove some, and not all, of the infected glands, is a futile proceeding. 
 
 When a local cancerous disease is removed, it should be a rule of practice that all 
 enlarged lymphatic glands should be removed likewise ; and this rule is as applicable to 
 the tongue as it is to other parts. 
 
 As to the best means for the removal of a tongue, wholly or in part, surgeons are 
 found widely to diiFer — one advocating strongly the removal by the knife or scissors, 
 whilst others as stroTigly urge the use of the ecraseur, employed either as a crushing or 
 as a burning force. The chain or wire instrument is used in the crushing, and the 
 platinum wire heated by means of a galvanic battery as the cautery ecraseur. For many 
 years I employed the galvanic ecraseur and found no fault with it ; of late I have again 
 resorted to the chain or wire instrument, but have had no reason to be better satisfied 
 with- my results. I altei-ed my practice in deference to a strong opinion that has been 
 given by some surgeons as to the dangers of the galvanic and greater safety of the simple 
 ecraseur, but this opinion does not find support from my facts. 
 
 With the view of testing this point I have extracted from our Guy's Hospital records 
 46 consecutive cases of operation, and find that of 36 operated on by the galvanic ecraseur 
 
 4 died from the operation, or 11.1 per cent., and 4 from other causes. Of 7 cases operated 
 on by the chain or wire ecraseur, 1 died from the operation and 1 from the disease. Of 
 1 removed by excision and 2 by ligature, none died. Of the whole number of 46 cases, 
 
 5 died from the operation, or 10.8 per cent., and 5 from other causes. 
 
 Of the 5 fatal cases from the operation, 2 sank on the eighth day — 1 from pleurisy 
 and the other from broncho-pneumonia ; 1 on the twentieth day from broncho-pneumonia, 
 and 1 on the twentieth from exhaustion and repeated small bleedings. The single fatal 
 case after the use of the chain ecraseur was on the twelfth day from broncho-pneumonia. 
 
 One of the 5 cases that died after the operation, though not from it. sank on the 
 thirty-sixth day, from recurrent disease and gangrene of the lung ; 3 on the fifty-third, 
 forty-eighth, and thirty-second days, respectively, from recurrent disease and exhaustion ; 
 and 1 on the thirty-eighth day, from recurrent disease and pya?mia. 
 
 It will be thus seen that f/irce out of the 8 cases that died after the use of the gal- 
 vanic ecraseur, and o)ic out of 2 cases that had been operated on with the chain or wire 
 instrument, or four out of the whole number of 46 cases of operation, or 8.7 per cent., 
 died from lung complication ; and the records of the pathologist tell us that such a com- 
 plication is by no means infrequent when no operation has been performed. At any rate, 
 evidence is wanting to show that this lung complication is more common after operation 
 than it is without, or when it follows operation that the operation has anything to do with 
 the lung disease. 
 
 It is true that the inhalation of fetid or septic elements, when the tongue is slough- 
 
 1 Trans, of Med. Soc, 1882. 
 
c.ixch'n OF THE ToMiri:. 429 
 
 iiii; citlicr liy ii;itiir;il proi-i-sst's (ir ;is a (■(iiis('(|iu'ii('c nl" n|ifr;itii)ii, iiiiisl nl' iicccssit v be 
 proiio to liiiiiij; tmt this liiii^'^ inmldo; l)iit tliis iact, iiistt^ad dl' l)eiii<r adducctl as an ar;ru- 
 luc'iit against opiTat ivc iiilcircri'iKH', may fairly hi' used as oiic in its f'avdr. siiK-e t<» ^'ct 
 rid of till' sldiij^liinii' and I'ctid or;^an is one i\\' tin- suri^con's aims in an (i]i('ration, an<l to 
 do so in the (|nicki'st, salrst, and simplest way is liis olijccl. 
 
 Wlicii tilt' liiilvaiiic I'crasi'iir is used and tlii' cauterized tissue is renden-il asepti(.' )>v 
 means ol a pliij:; of iodoform <iaiize well iiressed upon the surface after operation, or when 
 the clianid (ir bruised surface, aficr the use of the fi;alvanic or wire ecraseur, is kept 
 tweet liy the repeated aj»plieation of the colloid styptic — wliich, Mr. Morris tells us, 
 •' tans the surface of the wound, causes little or no slou<;h, and corrects the fetor of dis- 
 char<;e '" — there is less fear of any evil result from septic; causes than there was before 
 the disease was removed. 
 
 There is, coiise((ueiitly. no ari^unient auaiii.'-t the use of the ecraseur that has any 
 weight. 
 
 Whilst, therefore, for the removal of a tongue, wholly or in part. I have a jiicference 
 for the ecraseur, and f(U' the •ralvanic over the wire or chain instrument. I am ready to 
 admit the value of excision by means of scissors or the knife, or of any of the ditt'erent 
 inoditieatioiis of these of)erations which the ingenuity of different surgeons has suggested, 
 for T believe that in individual cases one form of operation may be more applicable than 
 another, and that in the hands of any surgeon the mode of operating he excels in is the 
 best for his patient. 
 
 I may say, however, tliat I have not yet seen a case in wliich the division of the 
 lower jaw as taught by Syme has been required. 
 
 Most tongues can be removed tlirough the mouth, liowever extensive the disease inay 
 be, if the organ be well drawn forward by means of a thick ligature introduced througli 
 the body of the tongue, and if it is freed from its attachment to the lower jaw and fauces 
 by the division of its mucous membrane attachments. There is no objection to the 
 removal of a whole tongue in halves, though there is no advantage in so doing. If more 
 room should be recjuired. this is best obtained by means of an incision across the cheek 
 from the angle of the mouth, the ecraseur being then worked sideways. 
 
 Bleeding during an operation need cause no alarm if the operation be performed 
 leisurely, since it can be speedily controlled by the torsion of the divided artery if the 
 tongue be well drawn forward ; in many cases the simple drawing forward of the tongue 
 suffices to bring about this result, the artery receding into the muscular tissue. 
 
 I can see no advantage in adopting the practice of Demarquay of ligating before the 
 operation the lingual arteries, although when severe bleeding takes place after the opera- 
 tion the practice may be good. The operation, however, may be performed, in ca.ses in 
 which the removal of the disease is inexpedient or impracticable, with the view of bring- 
 ing about wasting of the diseased organ. The division of the lingual gustatory nerve on 
 the inner side of the lower wisdom teeth, as practi.sed by Hilton (1850) and Moore 
 (18G1). for the purpose of relieving pain, is also a practice to be strongly recommended. 
 
 It mu.st likewise be recorded as one of the advantages of excision of the tongue that 
 should a return of the disease take place it is more likely^ to do so in the lymphatic 
 glands of the neck than anywhere else. Under these circumstances, the patient is relieved 
 of his distressing local affection and sinks slowly and comparatively painlessly. I have 
 often heard with pleasure, even under these miserable conditions, expressions of grati- 
 tude from patients who have gone through the operation — gratitude for the sufferings 
 they have been released from and spared. 
 
 I may also add that it seems probable that life is materially increased by the opera 
 tion. In some cases I have to record, the increase was great, and even when a return 
 takes place there is a degree of increase. Mr. Morris states that out of 15 cases opera- 
 ted upon the average duration of life was sixteen months, whereas in those which no 
 operation was performed it was but ten and a half, only two ca.ses having been known to 
 ha'.'e lived eighteen months. 
 
 In the cases I now record a decided increase to life must be admitted, and particularly 
 if we take the average of life with this disease when left alone as ten and a half months. 
 
 In 18GG I removed the anterior half of the tongue from W. P. , a3t. GO. The 
 
 patient remained well, so far as the tongue was concerned, for fi/feen years, when disease 
 reappeared in the scar. The patient at this time was suffering from hemiplegia and 
 senile decay, of which he died. 
 
 In 1872 I removed from Mr. S . a?t. 45, half his tongue for a local cancer. He 
 
 reported himself to me as well (ei) i/earg later, 1882. 
 
430 TUBERCULAR ULCERATION OF THE TONGUE. 
 
 In 1871 I removed a. local cancer from the tongue of Mr. K. W . No return ever 
 
 took place, though the patient lived y?i'e years and died from anaemic gangrene of the foot. 
 
 In 1870 I operated on H. S , a3t. 70, and removed a cancer, with the anterior 
 
 two-thirds of the tongue. Three and a half years later he reported himself as well. 
 
 In 18G9 I removed a portion of the tongue from H. J , fet. 42. He lived two 
 
 years and had no return, and died from lung disease. 
 
 I can trace two cases now alive and well who have been operated on for two years, and 
 two who are well one year after operation, and have records of three who survived the 
 operation for eighteen, eighteen, and eleven months respectively. 
 
 Altogether, out of a somewhat limited personal experience, the above record of facts 
 must be regarded as encouraging, clearly showing the possible benefit of the operation, 
 and the probability of a cure being obtained in a larger number of cases if the operation 
 were undertaken as soon as the diagnosis of the local disease has been made. 
 
 Tubercular Ulceration of the Tongue. 
 
 It is right that this disease should have a special notice, since it is neither common 
 nor generally recognized. It has. however, features of its own which claim attention. I 
 have seen several examples of it, but have records of only two. 
 
 Symptoms. — It occurs in feeble subjects, and begins as a papule which soon ulcerates 
 and in spite of treatment passes into a sore or fissure. A second and a third sore soon 
 follow the first and run the same course, the same in its obstinacy and the same in its 
 tendency to form a fissure or excavation. When it presents the latter appearance, the 
 surface of the sore will be that of an old indolent ulcer on other parts ; its base will be 
 more or less infiltrated, but never hard, like that of cancer ; and its edges, though infil- 
 trated, will not present the sharply cut aspect of the syphilitic fissure or the elevated 
 everted irregular border of the cancerous ; the secretion from the sore is often cheesy. In 
 fact, the sore is neither like the syphilitic nor like the cancerous, and yet, for want of its 
 recognition, it is usually taken for one or the other. 
 
 In one case the ulcer appeared as a fissure with an indurated base and infiltrated edge. 
 In another the ulcers were irregular, their edges but little thickened or hardened, and 
 their floors were formed by a soft-looking cheesy material. Add to this that the cuticular 
 covering of the tongue was unnaturally glazed and red or livid, with numerous small super- 
 ficial erosions, of similar type to the larger ones, aff'ecting a large part of the surface, and the 
 disease makes a picture which, once seen, is neither likely to be forgotten nor mistaken. 
 
 " Sections of the tongue showed that the cheesy material had invaded the muscular 
 structures to some depth, and of the microscopical examination it is only necessary to say 
 that it revealed a thick infiltration of the tissue by lymphoid cells, which were in many 
 parts granular from degenerative changes." ^ 
 
 Altogether, the clinical and pathological features of this disease make up a picture 
 which possesses characters of its own sufficiently marked to render its diagnosis tolerably 
 clear. 
 
 Could the ulcerating surface have been well scraped and thus destroyed, it is probable 
 that a cure might have been brought about, but this method of treatment could hardly 
 have been carried out in such an organ as the tongue ; at any rate, its removal answered 
 well, as a speedy cure followed. 
 
 The case is allied to chronic inflammatory sores of other parts in which the inflamma- 
 tory elements organize as granulation tissues and dip down deeply into the parts around. 
 In such nothing less than the complete excision or scraping of the infiltrated tissue will 
 Turing about a cure. 
 
 Other tumors of the tongue are met with, and I have recorded some in the Guys 
 Hospital Reports for 1882, vol. xxvi. — more particularly an example of blood cyst at the 
 base of the tongue, and another of adenoma. Such cases are, however, rare. 
 
 The Operation for the Removal of a Tongue. 
 
 This operation is comparatively a successful one, about one case in ten dying. It 
 moreover interferes but little with articulation. There are two good methods of perform- 
 ing it — one by means of the ecraseur, galvanic or otherwise ; the other by excision, 
 efl"ected by either a knife or scissors. As a rule, when the tongue is diseased, it is wise 
 to remove the whole width of the organ ; and under all circumstances care should be taken 
 
 1 Guy's Hosp. Reports, 1883, p. 134. 
 
TiiK ()i'i:n.\'ri()S for tiii'. removal or a roxauE. 
 
 431 
 
 to keep well clear of the disease. A |Mii-tioii <>\' tin- t()Mi::iu,' slioiiM l>e taken away only 
 wIu'U the disease is very local. 
 
 'i'o reuiov(! a tongue wholly or in part, tiic patient shniijil In- anaesthetized, and when 
 the galvanic eeraseur is used clilorot'onn eni])loyed. The mouth shouhl he kept open 
 
 I'Ki. -Jl.S. 
 
 >A.-y-U. 
 
 Ficj. 219. 
 
 l)rawiMg showing' tin; <)]ii'iati()ii for the Iteiiioval of the Anterior two-thirds of the Tongue. 
 
 with a gag-, and the t()nfi;ue well drawn out of the mouth by means of a thick ligature 
 passed through its substance ; and this necessary proceeding will be much aided by the free 
 divi.sion with scissors of the attachments of the organ to the fauces and to the lower jaw. 
 
 When the eeraseur is used, one or more curved needles on handles .should then be 
 passed well behind the growth, to isolate it from the healthy parts and to prevent the wire 
 or chain of the eeraseur slipping forward. The eeraseur is then to be adjusted behind 
 the needles, and, being made secure, slowly screwed home. Should the operator prefer 
 to divide the tongue down the centre as a preliminary measure, each half of the organ 
 niav be removed separately. AVhen the scissors are used, the part to be removed should 
 be snipped away slowly and all divided vessels twisted. Mr. W. Whitehead of ^lanches- 
 ter warmly advocates this method. 
 
 The amount that can be removed through the mouth by these means is measured 
 only by the a])pliances the surgeon has at his command to fix its posterior boundary. 
 In the case figured above more than the anterior two-thirds of the 
 tongue were removed, and by means of the curved needle shown in 
 the drawing no difficulty was experienced in passing the ligature or 
 in removing the organ. When the diseased tongue cannot be iso- 
 lated and surrounded with certainty through the mouth, various 
 expedients have been suggested. Professor Syme divided the lower 
 lip and jaw in the median line to give room for the operation 
 (a to B, Fig. 219). Regnoli of Pavia made an incision from the 
 hyoid bone to the chin, and two lateral cuts from the anterior 
 extremity of this along the lower border of the jaw (b to E and 
 c to D, Fig. 219). dividing through to the motith all the tissues that 
 connected the tongue with the lower jaw at the symphysis, thereby 
 giving abundant room to draw the tongue downward. Nunneley of 
 Leeds introduced beneath the jaw, between its ba.se and the hyoid bone, 
 a sharp-pointed curved knife four inches long, and brought it out 
 
 in the mouth at the fr:>jnum linguji? (n, Fig. 219). With a probe illustrating the Different 
 guided upon this knife he then drew through the wound the wire 
 rope of the eeraseur, drawing a good loop throtigh the mouth and 
 withdrawing the probe, the two ends of the rope hanging beneath the chin. He then 
 seized the tongue with forceps, forcibly pulling it out of the mouth, and pushed through 
 the base of the tongue three long and strong pins, making their ends appear in its upper 
 surface near the base and behind the disease. He then passed the loop of the ecra.seur 
 behind the pins and drew it tight, thus completely encircling the whole organ. The pro- 
 cess of removal then went on. Sir J. Paget has done away with the submental puncture, 
 and gives freedom to the tongue by dividing the soft parts that hold it down at the flSoor 
 of the mouth close to the bone, thus allowing the organ to be pulled well forward. At 
 the same time, he rightly insisted that care should be taken to divide the tongue perpen- 
 dicularly through its thickness, and not obliquely ; this practice, however, is fairly 
 guaranteed by the introduction of pins, as already mentioned. Collis of Dublin advised 
 
 Operations for the Re- 
 moval of a Tongue. 
 
432 
 
 FISSURES OF THE PALATE. 
 
 that the cheek be laid open from below its angle to give room for manipulation when the 
 disease is far back (r, Fig. 219). By one or other of these means room can be obtained 
 to free the tongue from its attachments, to isolate the growth by pins and remove it by 
 the ecraseur, wire rope being used when the galvanic cautery ecraseur cannot be 
 obtained. To isolate the disease, I have found the curved needle, as seen in Fig. 218, 
 introduced through the base of the tongue, behind the disease, to be very valuable. 
 
 Fig. 220. 
 
 Fissures of the Palate. 
 
 The hard and the soft palates are liable to fissure, partial or complete, or both palates 
 may be involved. It may be that the fissure appears as a mere notch in the alveolar 
 process, in the line of junction of the superior maxilla^ with the intermaxillary bone, as 
 is seen so commonly in harelip, or it may pass backward toward the velum. On the 
 other hand, the soft palate may show only a bifid uvula or a complete fissure. The 
 fissures in the hard and soft palates are almost always in the middle line, although where 
 they involve the alveoli they diverge as they involve one or both sides of the inter- 
 maxillary bone ; in fact, they usually follow the line of suture, as seen in Fig. 187. 
 Fissure of the soft palate alone is more common than that of the hard. Yet it is very 
 rare for the intermaxillary bone to be so displaced, as seen in Fig. 198, without fissure of 
 the palate. Mr. Mayland has recorded an exceptional example of this deformity (^Lan- 
 cet, November 24, 1883), and in a case I recently treated the girl had a transverse band 
 half an inch wide joining the two sides of an otherwise complete fissure at the level of 
 the palate bone. These malformations, when severe, interfere much with speech and give 
 rise to much difficulty in sucking and deglutition, the food passing through the nose. 
 To relieve this, Mr. Oakley Coles has ingeniously adapted a flap of india-rubber to the 
 upper surface of the nipple of an ordinary feeding-bottle, which, when the infant sucks, 
 rises up and fills in the gap. Where this cannot be obtained, the child should be fed 
 from a bottle with a piece of elastic tubing on its nozzle to fall over the roof of the 
 tongue. Partial fissures are of little importance. 
 
 Treatment. — When fissure of the palate coexists with harelip, the lip may be 
 operated upon as usual, irrespective of the fissure. Operations for the repair of the 
 
 fissure have till recently been put off' till the 
 child was of an age to give assistance to the 
 operator. Billroth was the first to operate 
 in infancy, and did so with success on a child 
 twenty-eight weeks old in three operations. 
 In 18G8, Mr. Thomas Smith introduced to 
 the profession a gag (Fig. 220) that holds 
 the jaws open and depresses the tongue, 
 enabling the surgeon (with the patient under 
 the influence of chloroform) to undertake the 
 operation at a very early period ; indeed, 
 Mr. Smith has quoted cases where he ope- 
 rated at three years of age (Met/.-Chir. 
 Trans., 1868; *SV. Barth. Hosp. Rrp., 1871). 
 It may generally be undertaken at the age of five in a healthy child, and I have per- 
 formed it successfully at four years of age. 
 
 Roux was the first who practised the operation with advantage, having in 1819 suc- 
 cessfully treated a medical student for cleft palate. Dr. Mason Warren of Boston did 
 also much toward encouraging the practice, but in this country there is no doubt that 
 to Sir W. Fergusson is due the credit of having demonstrated the value of the operation aud 
 
 of suggesting improvements therein. In his chief paper, 
 published in"l8-t5 {Mcd.-Cldr. Trans.), he showed "how 
 the levator jnilati on each side had such free and uncon- 
 trolled action that whenever excited it drew the margin 
 of the cleft outward and upward, and so tugged upon 
 the stitches put in by the surgeon that ulceration in 
 their sites was a most" probable result." He therefore 
 suggested the division of this muscle in all cases, and 
 that of the palato-pharyngeus in some. He did this by 
 means of a curved knife (Fig. 221) passed through the 
 fissure, so that its point can be laid on the tissues immediately above the soft velum, 
 
 T. Smith's Gag. 
 
 Fig. 221. 
 
 Fergusson's Knives. 
 
FISSURES OF THE I'ALATi:. 
 
 433 
 
 inidwav Ix'twooii its attacliiiiciit to the Ixtrics atnl tlic iiostcrinr margin and aV)out half- 
 way Ix'twi'i'ii tlio vt'lmii and tlie lower end <d' tlic Kiistacliiaii tube. The point is then 
 tlirust deep and curried half an incli or more backward and forward, so as to cut the 
 levator jiahiti. By these means tlie jtahite is paralyzed for a tinu;, and so repair goes on 
 with greater certainty. 
 
 For fissures of the hard ])alate much lias been done in more recent times. Dr. Mason 
 Warren in lS4;i described the jirocess oi" separating the hard from the soft palate with 
 the view of its closure, though it lias been left to iiangenbcck, iiillroth, I'ollock, Avery, 
 Lawson Tait, Aiinaiidale, T. 8mitli, and others to perfect the process. 
 
 Opekation. — (Miloroform is not necessary in a patient old enough to understand the 
 necessity of being still and assisting the surgeon. In young children, with Smith's gag, 
 it is an advantage. 
 
 The recumbent position, with the head sufficiently thrown back, is probably the best, 
 although some surgeons make the patient sit. The operator should stand on the patient's 
 
 Fig, 
 
 Figure showing the Paring of the Edges 
 of Fissure after the Introduction of 
 the .Sutures. 
 
 Needles employed in Fissured Palate. 
 
 right .side or in front. The steps of the operation have been hitherto as follows : Pare 
 the edges of the fissure, pass the sutures, paralyze the muscles, and fix the stitches. To 
 pare the edges a blunt-pointed bistoury is generally used and a thin border of mucous 
 membrane cut off from below upward, the bifid uvula being held by a tenaculum-pointed 
 forceps (Fig. 222). The incision also should be made as clean as possible. When it is 
 made from above downward, a sharp-pointed bistoury is needed. To pass the sutures, a 
 corkscrew needle may be employed, or a curved needle flattened laterally (Fig. 223). with 
 a slit in it for an eye, or an eye in the end. The lowest suture should be inserted first 
 and both ends held, this practice facilitating the introduction of the others. The best 
 material for sutures is fine gut ; Mr. Smith uses horsehair for the lower stitches. I have 
 rarely used anything but gut for all plastic operations since the year 1860, taking the 
 precaution to select and to soak it in water for some minutes before using it. 
 
 If Sir W. Fergusson's plan of paralyzing the muscles be employed, it should be, as 
 he advises, as a preliminary step to the operation. If Sedillot's or Pollock's plan be fol- 
 lowed (Fig. 225, b), it may now be done by inserting a knife through the velum about a 
 third of an inch from the highest suture and cutting along the posterior edge of the hard 
 palate toward the free margin, but not through it. This is the course I have until recently 
 adopted. The two pillars of the fauces may then be snipped with .scissors. The sutures 
 have then to be fastened, and the best plan is to run a perforated shot over the gut and 
 clamp them, tying the ends of the gut in a knot, to prevent the possibility of their slip- 
 ping. I usually begin at the highest. Care should be taken not to draw the stitches too 
 tightly. •• Sutures," says Pollock, •' should hold, not draw, parts together, if union is to 
 follow." The parts should be sponged as little as possible ; and the less manipulation 
 there is, the better, any irritation causing .so free a secretion of mucus as to interfere 
 greatly with the surgeon's proceedings. Rapidity in operating is, consequently, an advan- 
 tage. When the parts require to be cleansed in the adult, iced water may be used as a 
 
 28 
 
434 
 
 FISSURES OF THE PALATE. 
 
 gargle ; and with a child under chloroform the stitches may at times be inserted and the 
 edges pared before any cleansing is required. In deep mouths, where difficulty is expe- 
 rienced in passing the sutures, a clever manoeuvre suggested by Avery may be called for, 
 and is illustrated in Fig. 225, b; one end of the gut C is pulled through the soft palate 
 and the end passed through a loop of silk a inserted on the right side ; on pulling the 
 
 Fig. 224. Fig. 225. 
 
 Figure illustrating Line of Incision. <^Employed 
 to relieve tension of the palate after the edges 
 have been adjusted.) 
 
 A, Avery's plan of passing sutures. 
 
 B, Fergusson's plan of fastening sutures. 
 
 loop the end c will be drawn through the right side. When silk is used, the double reef 
 knot, as shown at the lower part of Fig. 225, and generally adopted by Fergusson, is very 
 serviceable. 
 
 In some cases I have been able to simplify the operation by altering its steps ; that 
 is to say, I have first introduced sutures through the soft palate, taking care to do .so a 
 quarter of an inch from the free border of the fissure, and secondly pared the edges, 
 employing for this purpose a pair of scissors with short blades placed at right angles to 
 their shanks, or a knife. By this practice the introduction of the sutures is an easy pro- 
 ceeding, and consequently very rajiidly effected, and the bringing together of the pared 
 edges can be readily accomplished. 
 
 To relieve tension of the parts. I now divide the soft palate laterally, as shown in 
 Fig. 224. the side cuts (a ) subsequently gaping, so as to appear as arches (b); in this 
 way the muscles of the palate are completely paralyzed, and the soft palate itself appears 
 as one large uvula. 
 
 I have performed the operation already described on many occasions, and with suc- 
 cess. In none was there even a pinhole left. Its simplicity is very striking. It cannot, 
 however, be applied in all cases. 
 
 The stitches may be left in for five, ten, or even fourteen, days, the amount of irri- 
 tation being the guide to their removal. When union has taken place, the sutures only 
 act as irritants ; and in this as in all pla.stic operations they should be removed as early 
 as possible with safety. During the process of repair the patient may freely take soft 
 food, swallowing by no means tending to sepjarate, but, on the contrary, to close, the 
 wound. Stimulants may be given when desiral>le. The operation should be undertaken 
 only in healthy patients ; in the feeble it is almost sure to fail. After the operation the 
 patient's friends .should not be led to expect that an immediate change for the better will 
 be traced in the voice, as such is never the case ; indeed, a long interval of time, as well 
 as a process of education, is necessary to acquire this result, although in many instances 
 the improvement is very great. How far an operation in infancy tends in this direction 
 has not yet been proved, sufiicient experience in these early operations not having as yet 
 been acquired. If a small orifice near the hard palate be left after the operation, no 
 necessity exi.sts to interfere again, because it is a clinical fact that they have a .strong 
 tendency to contract ; and the younger the patient, the greater the probability of com- 
 plete closure. 
 
 Mr. Tait believes — and I think rightly — that if the muco-periosteum of the hard 
 palate be elevated with a raspatory from the semilune of the palate bone, the tendinous 
 attachment of the ten.sor palati will be raised with it and thus paralyzed, thereby doing 
 away with the necessity of any such division of muscles as practi-sed by Pollock or -Fer- 
 gusson and diminishing the ri.sk of the pinhole orifice at the junction of the hard and 
 soft palates. He advocates, moreover, two or more operation.s — viz., the hard palate to 
 be first closed, and the soft after some months' interval. 
 
VLVFJlATloys OF Tin: IIM'J) WD SOFT I'M.ATFS. 
 
 1:55 
 
 Fu 
 
 >26. 
 
 Fir;. 227. 
 
 B— 
 
 Fissures of the Hard Palate. TImsc urc to In- ircatfd on .similar itriiiciple.s to 
 tliu-c ot" tlir .siit't, till,' ;rr<';it jKiiiit <il' (liHiTfiicf fon.sistiii^' in tlu; .xf)iarati<iii nl' the .^nft 
 parts with the pi-riiLsti-iuii I'miu the hmic. For thi.s |»ur|>o.s(' Ijaii^a-iihcck s iii.stniint'iit is 
 the he.st — a kiiul of .small Imi' ; with this, after making' an iiieisiitii ihtwti to the hone ahjiij^ 
 the eil<:e of" the jrum. he serapes all the .soil parts tiom the hone down to the free honler 
 of the tissnre, the.eoverinj^ of the ])alate then han^injr as a free eurtain. Care is reijuired 
 in this pmeeedin^' not to tear or injure! the soft parts, and more particularly the anterioi 
 and posterior ]Mirtions where the ves.stds enter. The other steps of the operation are sueh 
 as have heen aln-ady deserihed. Sinee Novemher 22, l.S7!>, howevtjr. Sir \V. Ferfrusson 
 has adopted with <;reat sueeess a metlu)d of dealinj; with fissures of the hard palate whi(di 
 was ori<rinally proposed by Diefteidjach in Ins O/irrftfivf Sitrt/rn/ (1845). There is a want 
 ot'evidenee that the operation was ever previously performed, and Sir W. Fergusson wa.s 
 not aware even of the suggestion when he published his paper (Brit. Med. Juiirn., April, 
 1S74). The operation as seen in Figs. 2li)! and 227 is as follows: 
 
 Holes are first drilled with a curved l)rad-awl through the margins of the hard palate 
 (Fig. 22(!, (•) lor the jiassage of the threads, while the palate itself is then cut through 
 with a chisel in a line j>arallel to 
 and about half an inch from the 
 edge of the cleft ( Fig. 22(1, h), such 
 a step being much facilitated by act- 
 ing upon .Mr. .Mason's suggestion of 
 previously drilling the bone with the 
 curved brad-awl (Fig. 22G, a). This 
 loosening of the nnirgins of the hard 
 palate allows the borders of the cleft c 
 to be brought together along its 
 whole length after the margins have 
 been pared and the stitches twisted 
 (Fig. 227). When any difficulty is 
 experienced in appro.ximating the 
 loosened portions of the hard palate, 
 the bones may be separated and 
 prised down by means of the chisel 
 and the lateral openings plugged 
 with lint. Indeed, if the bones are 
 well loosened and the lateral oi)enings well plugged, no sutures are required through the 
 hard palate, the parts falling well together. The operation is very valuable, and in my 
 hands has been successful. 
 
 When operative relief cannot be given in these cases or has failed, the patient must 
 be handed over to an experienced dentist ; for with a good obturator of gold or other 
 material great comfort can be given, and even a velum may be supplied of india-rubber. 
 On these points an article in JI>/lmes\s Surgery^ by my friend Mr. James Salter, may be 
 consulted with advantage. Operative relief, however, is always superior to instrumental, 
 as in the latter the patient is entirely dependent upon the mechanist. 
 
 W^OUnds of the palate are met with in practice from patients falling with pointed 
 instrunuiits in their nmuths. such as pipes, sticks, spoons, etc. Small wounds need no 
 attention and generally do well ; lacerated wounds dividing the velum should be brought 
 together by sutures : Init where they have been left and a separation ensues, the edges 
 may be sulise(|iiriitly juired and lirought together as a fissured palate. 
 
 Perforations of the hard palate are generally due to the exfoliation of bone, 
 and no plastic operation is of use. The proper treatment of such cases is to close the 
 aperture by an accurately-fitting plate of metal or vulcanite attached to the teeth and 
 arching immediately below the palate, but making no pressure upon the edges of the hole 
 itself, as the effect of a plug is to enlarge the aperture by absorption. 
 
 A, Preliminary punctures with awl to give line for chisel. 
 
 B, Incision through bone completed by chisel. 
 
 C, Holes bored through hard and soft palate for sutures. 
 I), .Junction of hard and soft palate. 
 
 E, Lateral openings subsequently filled up by granulation. 
 (These drawings were kindly made for me by Mr. W. Rose.) 
 
 Ulcerations of the Hard and Soft Palates. 
 
 These are very common as a result of syphilis, and appear as superficial idceratious 
 about the pillars of the fauces and margins of the velum. They are often preceded hy 
 an erythematous redness and take on a sloughing action in cachectic subjects. They 
 appear, too, also as tnurous patches at anj' stage of syphilis, congenital or acquired, involv- 
 ing at the same time the topsils, tongue, etc. They appear as slightly elevated spots 
 
436 
 
 ULCERATIONS OF THE HARD AND SOFT PALATES. 
 
 covered with ashy or yellowisli membranes, beneatli which .some sliglit ulceration may be 
 found. Fre(juently they are associated with other symptoms. They are to be treated as 
 part of a constitutional disease, such local treatment being applied as the aspect of the 
 surface may demand. Local astringents, as alum and borax, are, as a rule, of value, and 
 also nitrate of silver or iodoform when local stimulants are needed. 
 
 Strumous Ulceration of the Palate. — 'I'his is a distressing affection, the 
 ulcerative actidii being oi'ton s(j rapid as to destnjy within a few days the whole fauces. 
 It is chiefly met with in the young and feeble. In other instances it is slower in its 
 action, though equally destructive, gradually eating away all the soft tissues, even to the 
 hard palate and pharynx, and is often mistaken for syphilitic disease, or vice versa. The 
 history of the ease alone can determine the point. Tonics and local stimulants are, as a 
 rule, the only re(juisite treatment, good food of a liquid nutritious kind being supplied in 
 abundance. When gargles are difficult to use, carbolic acid lotion, sulphurous acid, 
 Condy's fluid, or iodine lotion (a drachm of the tincture to a pint of water) may be 
 scattered over the parts with the spray-producer. In certain cases a powerful local 
 caustic, such as nitric acid, applied with a glass brush, tends to arrest the action. As 
 a result of ulceration of the soft palate, it sometimes happens that the palate becomes 
 completely adherent to the posterior part of the pharynx. In one case under my obser- 
 vation there was only an opening the size of a crow-quill between th.e pharynx and the 
 nose, which I subsequently enlarged and kept dilated by means of tents with great 
 advantage. In another a central fissure existed, leading down to the oesophagus and 
 upward to the nose. In this case the patient experienced great difficulty in deglutition. 
 He had to eat with the greatest caution ; otherwise, the food would pass into the larynx. 
 Cases are on record in which it has been found necessary to enlarge this pharyngeal open- 
 ing, and even to open the trachea to maintain life. Under such circumstances it is prob- 
 ably a wise maxim always to open the windpipe before any operative interference is under- 
 taken, in order to enlarge the pharyngeal opening. 
 
 Tumors of the palate, cystic or solid, are occasionally met with. I have treated 
 several cases of warty growths, simple and malignant, and in Gin/s Reporti^ (18(59) I 
 have recorded an interesting case of myxoma which covered the whole of the hard palate 
 and was cured by removal. 
 
 In August, 1872, I also removed from the soft palate of a man ret. 38 a globular 
 fibrous tumor of six years' growth, the size of an unshelled walnut, which 'had been for 
 six weeks seriously interfering with deglutition and respiration. 
 I enucleated the growth after making a free incision into its 
 capsule, having previously been obliged to perform tracheotomy 
 to prevent suftocation. In this case I employed Dr. Trendelen- 
 burg's tracheal tampon (Fig. 228), and found it of great value. 
 It effectually prevented the entry of blood into the air-passages, 
 allowed the jtatient to be kept under the influence of chloro- 
 form, and enabled me to complete the operation with facility and 
 safety. (See Med. Timr.s mid Guz., May, 1872.) Where tliis 
 instrument is not at hand, the fauces may be well plugged with 
 sponge after simple tracheotomy. 
 
 The majority of cases of tumors that involve the palate 
 spread from the gums or upper jaw. 
 
 Elongation of the uvula from inflammatory oedema 
 is sometimes a very acute affection. It comes on rapidly at times 
 and gives rise to suffocative symptoms. I have seen a case in 
 which the uvula became as thick as a finger and rested on the 
 Section of Trachea,"^ Dr. tongue with its tip forward, and of this there is a drawing at 
 Trendeieaburg's Tracheal Quy's. An incision into it, or several punctures, may give relief ; 
 '^^'"^'"'' but, as a rule, it is better to cut off the lower half of the 
 
 organ. Elongation from congenital or other causes is far more common and is generally 
 to be recognized by the peculiar hacking cough and husky voice to which it gives rise, 
 the end of the uvula acting as a constant irritant to the epiglottis, or even to the glottis. 
 There is reason, indeed, to believe that not a few of the cases of suppos-ed laryngeal irri- 
 tation are due to this cause. The removal of the lower half of the organ by means of a 
 long pair of forceps or scissors rapidly gets rid of all the symptoms. 
 
 A polypus composed of simple mucous membrane may grow from the uvula. I 
 have removed one from the tip, and another from the base. They give rise to symptoms 
 identical witli those of elongation. I had also a case under observation in which the 
 
 Fig. 228. 
 
ciUKiMc i:si.M'j.i:mi:s r or /•///■; rnssn.s. 
 
 437 
 
 nolypiis hail so ImiLr a iicdiinclc as to fall al liiiHv- into tlic milirc nl' tlic laiviix and excite 
 a violent spa-iinMlie eiiiit:;|i, l»ut tin- Iiiaii ri'liiseil In liaV4' it reliniVeil. 
 
 Tonsillitis. — As an aeiiti- art'eclidii this is known as i/ninxj/. and is ehaiaelerized hy 
 tlu- rapid swelling ol' tin- part, aeute pain. I'onl ton!j;ne, and I'ever. Within three <hiy.s, or 
 loiiirer, snppnration may occur; and when snthii-ativ*- symptoms make their appearance, 
 thf siirjrooii s interrerence may Ix' (h'lnandetl. At tinn-s life may he sacrificed hy tin- want 
 of" suri^ical attention. Some years a;:o a case came hef'ore my notice where a diild two 
 years of" aire was sutlocated from the InirstiuLr of a tonsillitie ahsccss. 
 
 <ireat redness and rapitl swellin;; of tlie ort;aiis are tlie chief hical symptoms. 
 
 'I'kk.vtmknt. — Fomentations externally, the inhalatii f iiot steam. an<l the admin- 
 istration of saline purL'atives are essential points (d' jiractice. As t(» dru^s. none seem to 
 have so ]iowerfiil an intlueiici' over the disease as i^uaiaeuni an ounce of the tni.\tiire with 
 some comp(Uind spirits of ammonia heini;- the best form; and when this is employed early, 
 suppuration rarely appears. When an aliscess has formed, the sooner it is o]iened the 
 better. The bi-st mode of doinu' this i,s to cover a straight bistoury to within half an inch 
 of its ]ioint with lint, and, havini;' depressed the tonj^iie with the fitifrer. to introduce it 
 into the swollen tissue, makin;j; a free incision, care beiii<: taken not to direct the point 
 of the knife outward, Imt directly backward. Should ]ius a))pear behind the pharynx, it 
 must be let out. Tonics, such as ((uinine or iron. >1i(mi!(1 tlitii be i^iven, with good footl ; 
 a speedv convalescence, as a rule, ensues. 
 
 Tonsillitis Maligna. — This is a fonn of inflammation of the tonsihs met with in 
 feeble subjects which results in ulceration and is often most intractable. It begins a.s 
 other forms of inflammation and runs its course rapidly, the ulcerating process being gene- 
 rally associated with sloughing. The parts about the tonsils, even the root of the 
 tongue, often become involved. The disease is at times associated with .scarlet fever or 
 
 Treatment. — This affection, l)eing always found in feeble or cachectic subjects, 
 requires tonic treatment with both food and medicine. Good broths and milk, with 
 stimulants, are always reijuired ; nutrient enemata should be used when enough nonri.sh- 
 ment cannot be swallowed. Quinine and iron as medicine are also called for. with small 
 doses of laudanum to soothe ]>ain. Locally, suljdnirous acid. em])loyed every hour or 
 less as a spray, is very beneficial, or tlie local application of the mixture of iron and gly- 
 cerine. 
 
 Chronic Enlargement of the Tonsils. — This is frequently met with in feeble 
 children as well as in adults living in marshy and damp localities. It is often a sequel 
 of the acute inflammation, but more often it appears without any such cause. There is 
 reason, too, to believe that some of the cases of so-called chronic enlargement of the ton- 
 sils are due to new adenoid tonsillitie growths. On two occasions when removing these 
 enlarged organs I have turned out distinct tumors the size of nuts embedded in and sur- 
 rounded by tonsillitie tissue. The tumors were distinctly glandular, and under the micro- 
 scope could not be distinguislied from tonsil tissue. In both cases the enlargement was 
 unilateral. Bilateral increase is probably always due to hypertrophy or chronic inflam- 
 matory enlargement. 
 
 Enlarged tonsils give rise to a peculiar nasal twang in speaking and to a most distress- 
 ing snoring, the patient, as a rule, having a half-opened mouth night and day. They are 
 
 Fig. 229. 
 
 Cniillotiuo prepared for Use. 
 
 commonly associated with irritable mucous membranes generally. I have seen them so 
 troublesome in a child three and a half years old as to prevent the deglutition of solid 
 food, the patient having lived for six months on liquid nourishment. Tonic treatment is 
 essentia] in all these cases; so is a simple nutritious diet. A mixture of bark and soda 
 at first is the best to soothe and give tone to the digestive api)aratus. cud-liver oil. quinine, 
 
438 
 
 CANCER OF THE TONSIL. 
 
 and iron being subsequently prescribed. "When the organs are congested from inflamma- 
 tion, a mixture of glycerine and tincture of the perchloride of iron in equal parts should 
 be used. It is wise, also, to give the patient some solid iodine in a perforated box, to 
 stand on a shelf in the day as well as in the sleeping-room ; the gradual evaporation of 
 the iodine purifies and iodizes the air in a beneficial manner. 
 
 When the glands are white and hard, all hopes of curing them by medical treatment 
 are at an end ; excision is the only thing to do. For this purpose the guillotine (Fig. 
 
 Fig. 2.30. 
 
 Fig. 231. 
 
 Operation on Tonsil with (niillotine. 
 
 Removal of Tonsil with Knife. 
 
 229) is the best instrument to employ when it is at hand ; otherwise, a pair of vulsellum 
 forceps and a bistoury must be used, guarding the base of the latter with lint or strap- 
 ping to protect the lips (Fig. 231). 
 
 Calculus in the Tonsil. 
 
 In 1860 such a case came under my care. A man aet. 38, after having suffered from 
 enlargement of the right tonsil for a year and a half, expectorated a calculus the size of a 
 nut, the expulsion of it having been preceded for three days by severe local pain and 
 immediately beforehand the sensation of something having given way in the parts. 
 "When I saw him, there was a distinct cavity in the tonsil. The stone was hard and 
 ragged, and appeared to be made up of phosphatic salts ; but the patient claimed the 
 stone, and therefore it was not examined. Small calculi the size of mustard-seeds are 
 more common, and are supposed to be calcified tuberculous deposits. In Guy's Hosp. 
 Mus. (Prep. 1677^") there is a specimen, analyzed by Dr. Babington, which consisted of 
 phosphate of lime. 
 
 Cancer of the Tonsil. 
 
 This rapidly fatal affection happily is rare and has not received much attention. It 
 may appear as a primary or secondary affection and in the encephaloid or fibrous form. 
 The /bn?ifr, being the more frequent and rapid in its course, destroys life mechanically 
 by secondary glandular enlargement, as well as by pharyngeal and laryngeal obstruction. 
 The latter is seen mostly as an ulceration and proves fatal by exhaustion. I have in one 
 case seen this disease cause death by sudden and violent hemorrhage owing to extension 
 to and perforation of the internal carotid artery. 
 
 This affection begins as an ordinary enlargement of the gland, but is more rapid in 
 its growth, and is mostly attended by early enlargement of the lymphatic glands at the 
 angle of the jaw, and subsequently of those of the neck. When it ulcerates, the ulcer 
 assumes the indurated jagged appearance of a cancerous sore, not unlike the deep syphi- 
 litic sore after the breaking down of a gummy tumor. It has, however, a more indurated 
 base and border than the syphilitic. It attacks men mostly of middle age. bat I have 
 had under m}- care a sweep only seventeen years of age with the hard form. 
 
 Treatment. — Palliative treatment is probably the best to adopt, although Dr. 
 Cheever of Boston has proved that the tonsil may be successfully extirpated by external 
 incision (Boftton Med. Surg. Jnurn., 1871). Its removal from within seems almost hope- 
 less, whether by caustics — Maisonneuve's plan — the ecraseur, or enucleation. I attempted 
 the latter in one case only with partial success, and the operation prolonged life. 
 
 Dr. Cheever performed his operation through an incision made below the angle of the 
 jaw of three and a half inches, along the anterior border of the sterno-mastoid muscle, 
 with a second incision extending along the lower border of the jaw. The flaps were 
 
DTSEASFS ()F Till': CfMS, ./.Ill's'. ETC 439 
 
 n'flcctcd aiiJ a lar<re <;laiKl wa.s fiiuclfated. The (lijrastric, .stylu-hyoiJ. and .styl'>-;rlo.x.su8 
 luu.sclos wore cut, the tihre.s of the .superior con.strictor heiii;; divided u])on a director. 
 The pharynx wa.s opened. The finjjjer of the ()])erator wa.s then swept round the di.sea.sed 
 tonsillitic mass, which was enucleated. The heniorrlia<;e was free, tlioujrh not excessive, 
 and twelve liiratures were apj)lied. A steady convalescence followed. "'The lacility." adds 
 Dr. Cheever, " with which the tonsil can he enucleated with the finger is surprisiufr." 
 This operation has been frci|Ui'ntly repeated, and with enou;ih success to justify its per- 
 formance ill cases in which the ulamls are not too far involved. For further information 
 on this sultjcct refereiict' may he made to the article ''Aniyj^dales, No. 2," I)i' liimiiuirn de 
 JUti/ecine, 180"). and to Poland's artiflc. /hit. (iml Fonlijn Rrririr. April. 1S7-. 
 
 CHAPTER XIII. 
 
 DISEASES OF THE GUMS, JAWS, TEETH, PHARYNX, AND (ESOPHAGUS. 
 
 Hypertrophy of the Gums. 
 
 Cases of this nature have been recorded by Salter, Gros.s, Heath, and others, and 
 they are said to be congenital. The disease may be jreneral or local, and for its cure 
 nothintr less than its exci-sion, with the aft'ected alveolus, is of any use, the gum dipping 
 down into the sockets of the teeth in the same way as other periosteal growths are seen 
 to do. 
 
 Polypus of the gum, or outgrowths of gum structure, are due to the irritation 
 of carious teeth or to uncleanly habits. They can be cured by the removal of the growth 
 and its cause. 
 
 Vascular tumors are met with on the gums, and generally between the front 
 teeth. They are sometimes, but not always, associated with carious teeth. The out- 
 growth is usually small and more or less pedunculated, bleeding on the slightest manip- 
 ulation. The vascular tumor occasionally presents more the features of a naevus. I 
 have destroyed many of these growths by means of the galvanic cautery with .succe.ss, 
 but they can be removed by the knife or any caustic. When a carious tooth appears to 
 be the cause of the disease, it should be at once removed. 
 
 A cancerous disease <>f the gums puts on precisely similar appearances to tho.se 
 seen in similar diseases of the fauces, face, or tongue — an irregular, excavated, ulcerating 
 surface discharging fetid pus, associated with pain and glandular enlargement. Most of 
 the cases of cancerous epulis are epithelial. The benign form of epulis is generally an 
 affection of young life, and the cancerous of the old and middle-aged. 
 
 Inflammation and ulceration of the gums is met with in children, the 
 
 result of stomatitis, and in adults from other cau.ses. It always occurs in cachectic sub- 
 jects and must be treated generally. 
 
 Abscesses about the gums are very common and are frequently the result of 
 disease of the teeth. Dentists tell us, however, that these " gum-boils "' rarely induce 
 any disease of the bone, though they sometimes arise from it. When connected with a 
 carious tooth and of long standing, nothing but the removal of the tooth will effect a 
 cure. A free incision, however, into the inflamed gum generally gives relief, cuts short 
 the disease, and may save a tooth : it may, moreover, prevent burrowing and much 
 further trouble. When associated with disease, such as *■ necrosis," or death of the bone, 
 the removal of the dead portion is an absolute neces.sity. 
 
 Necrosis of the Jaws. 
 
 Necrosis may take place as a result of ostitis or periostitis or it may follow a fracture. 
 It is well known to follow an exanthem and to be brought about by the fumes of phos- 
 phorus or of mercury. It is found in both upper and lower jaws. An analysis of 50 
 consecutive cases shows that 10 were in the upper. 29 in the lower, and 2 in both, thus 
 controverting the assertion of Stanley, which has been repeated by others, that necrosis 
 of the upper jaw is rare. It may show itself at any period of life. I have seen it in an 
 infant a furtnioht old. althouiih it is more common in the vouiiir and middle-aired than in 
 
440 NECROSIS OF THE JAWS. 
 
 the aged. It may attack any portion of the bones, and even the condyloid processes of 
 the lower jaw may die and be removed, leaving a movable jaw by the spontaneous for- 
 mation of a new joint. The child, ast. 8, from whom I removed the bone illustrated 
 below (Fig. 232), could move the jaw as well as if the condyle had never been destroyed, 
 
 and in Guy's Iloi^p. Rep. for 1869 I recorded another 
 F'iG. 232. similar case. After necrosis of the upper jaw there 
 
 is little or no osseous repair to be expected ; in the 
 lower jaw it may be very complete. 
 
 Necrosis of a bone is always preceded by symp- 
 toms of inflammation, such as swelling and pain, fol- 
 lowed ra])idly by suppuration and the formation of 
 sinuses leading down to the bono, which may be felt 
 l)y a probe. A single sinus beluw the jaw or in the 
 neighborhood may be due to the presence of a dis- 
 
 Portion of Lower Jaw reiiKivtii IVir Necrosis *^'^^t;d tOOth. 
 
 irom a Child at. 8, the .Movements of the Necrosis is likewise a common aifcction as the con- 
 
 ,Jaw subsequently being perfectly Ke- o n ^i i xi • £■ i. • 
 
 gained. ^ ■' " ' •' sequence oi some lever or exanthem, and this lact is 
 
 now fairly recognized. It is more common in chil- 
 dren than in adults. As a rule, it appears on the decline of the fever, with pain and 
 swelling about some portion of the gums, and rapidly passes on to suppuration and death 
 of the bone. The necrosis, however, is generally confined to the alveolus ; in exceptional 
 instances only it involves the body of the bone. Both jaws are equally liable to the 
 affection. In the Guy's IIosp. Reports for 18<J0 I recorded a series of cases to illustrate 
 these points. In one case, narrated in detail — that of a woman a?t. 25 who in infancy 
 had lost a large portion of her upper jaw after measles — the lower jaw had grown up to 
 fill in the deficiency in the upper. It was nearly one inch higher in its vertical measure- 
 ment on the right side than theleft; it seemed, indeed, as if the lower jaw had grown 
 upward for want of the regulating influence of the natural pressure which the teeth of 
 the upper jaw must exert upon those of the lower when in contact with them. I have 
 recently seen a similar case where the increase of growth had taken place in the upper 
 jaw, in consequence of a deficiency in the lower. 
 
 Necrosis of the jaws as a result of the phosphorus poison is now rarely seen, in conse- 
 quence of the common phosphorus being less frequently employed than formerly in the 
 making of lucifer matches. Dr. Bristowe in his report to the Privy Council in 18G3 
 clearly showed that it is to its influence the disease is to be attributed, flie amorplious 
 2>hosp/ioriis being harmless. The first notice of the affection in this country was by my 
 colleague. Dr. Wilks, in the Guy's Hasp. Rep.. 1847, page 1(J3. The disease is acute in 
 every sense. It may involve a part only or the whole of the upper or lower jaw. both 
 seeming to be equally liable to the affection ; but in the majority of cases the teeth of the 
 aff"ected bone are more or less diseased or deficient. It is a rare thing to find the disease 
 in subjects who have sound teeth or in those who have a complete set. Some openings 
 down to the bone, either through carious or deficient teeth, appear to be necessary to 
 enable the phosphorus fumes to act upon the bone. Dr. J. Wood of New York records 
 a case in which the whole bone died and was restored. The disease begins for the most 
 part by a general aching of the teeth, followed by rapid suppuration and necrosis of the 
 aff"ected bone. The constitutional are usually as severe as the local symptoms. 
 
 Treatment. — When dead bone can be detected in either the upper or the lower jaw, 
 its removal is the only one form of practice which ought to be entertained ; and this 
 should be eff"ected by the mouth with as little disturbance as possible to the soft parts or 
 to the new bone-forming tissues, such as the periosteum. When external incisions are 
 neces.sary, they should be made where afterward they will be little seen. 
 
 In necrosis of the upper jaw the bone can nearly always be reiuoved by means of 
 incisions made heneeith the cheek. An incision through the check never seems necessary. 
 In necrosis of the fow;^?- jaw, when incisions through the integument are demanded, they 
 should be made below the lower border of the bone. When the dead bone is fixed, or 
 rather before it has been thrown off" from its attachments and before a new easing of bone 
 has been formed, all operative interference must be condemned, particularly in the lower 
 jaw, as there seems little room to doubt that the muscles, acting upon the new bone before 
 it has become consolidated, may alter its shape and produce deformity. Under these cir- 
 cumstances, the surgeon should content himself with seeing that all pent-up pus has free 
 exit by means of incisions through the gum, also that the patient's mouth is kept as clean 
 as possible by frequent washing, and that his general condition is maintained by means 
 
KPrrjs. 
 
 441 
 
 of toiiif nu'tlicine and nutritious diet. Wlu-n thr necrosis is confincil to the alveolus in 
 which the teiujiorary teeth are situated, j:reat care should he taken that the parts heneath 
 are not disturhed and that the ]iernianent teeth are not interfered with. Even when 
 exposed, these penuanent teeth need not of necessity he removed. In youiiL' |iatients 
 where nuich loss of hone has taken place it seems desirahle to have some artificial suhsti- 
 tute, in order to prevent the occurrence of such an overirrowth of the opposin;.' jaw as 
 took place in the cases already referred to. Where the antrum is exposed l»y exl'oliation, 
 much mav he done hy the dentist to till in the jrap. At times, also, the fistulous f»peninj; 
 takes jdace externally; thus, in 1S(I4, I was called on to treat a woman :et. v>4 who nine 
 years previously had had extensive necrosis of the upper jaw. and. as a conse<|uence, a 
 fistulous openini: the size of a sixpence was left l»el<tw the riL'ht eye. communicating 
 directly with the antrum. The soft jiarts were firndy connecte<l with its marL'^ins and the 
 lower lid was drawn down. I raised the intei;iimcnt from the hone hy making free suh- 
 cutaneous incisions, pared the edges of the flajis, and hntught them together over the 
 ojiening in the hone. Good union followed, and the deformity was removed. 
 
 Epulis. 
 
 Under this term ■epulis'" arc included, rightly or wrongly, most of the tumors of the 
 gums, polypoid or difiused, simple outgrowths from the gums due to the irritation of a 
 carious tooth or stumji, papillar}', fihrous, fibroplastic, myeloid, ejuthelial. and cancerou.s 
 tumors. 
 
 The true or fibrous, fibroplastic, and myeloid epulis (for the-^e elements enter in differ- 
 ent proportions into all the benign forms of epulis) are diseases chiefly of the periosteum 
 
 Fig. 234. 
 
 Filirous Epulis Irmii < luin. 
 (Drawing, (iuy's Hosp. Mus., 171'". Mr. Birkett's case.) 
 
 Epulis springing from P?one. 
 (Mr. Key's case, i 
 
 (Fig. 233) and are rarely cured without removal, together with the portion of bone upon 
 which they are placed, since the growth dips down into the sockets of the teeth about 
 which it springs. At times, however, they invade the bone itself (Fig. 234), the endo.steal 
 membrane which lines the bone being continuous with the periosteal covering it. They 
 appear as simple fleshy outgrowths of the gum about a tooth and develop into a large 
 mass of a firm or semi-elastic tissue. At a later stage this mass may ulcerate and break 
 down. 
 
 In exceptional cases a tumor that appears to be an epulis results from the abnormal 
 development of a tooth; this was the case in a boy xt. 11, from which Fig. 235 was 
 
 Fig. 235. 
 
 Fig. 236. 
 
 Front view of Tumor of Alveolus. fDue 
 to hypertrophy and dilatation of 
 tooth fang.) 
 
 Odontone after Removal. 
 
 Section of Odontone, showing 
 expanded thickened Foot of 
 Incisor Tooth. 
 
 taken, the expansion of the alveolus having been brought about by the development of 
 an odontone of the root fang of an upper incisor tooth which had been growing for three 
 or four years. 
 
442 TUMORS OF THE JAWS. 
 
 Fig. 235 illustrates the swelling of the gum before the removal of the disease, Fig. 
 236 the tumor on its removal, and Fig. 237 the same in .section. My friends Messrs. Sal- 
 ter and Moon informed me that this is a unique case. In the diagnosis of such a case 
 the protrusion of the crown of the tooth becomes a valuable guide. 
 
 Treatment. — The removal of the disease of the teeth or stumps that are involved 
 in it, as well as of the bones with which it is connected, is the only sound practice to 
 adopt. A good pair of cutting pliers which will nip off' as much of the alveolar process 
 as seems involved is the best instrument to use, a small hand-saw having marked out ver- 
 tically the limit of the incision. AVhen the bone is not removed, a return of the disease 
 is almost certain. 
 
 Tumors of the Jaws. 
 
 Some of the most remarkable tumors of these bones are due to hypertrophy or hyper- 
 ostosis, the lower jaw, with other bones of the face and head, being generally involved. 
 Mr. Howship's well-known case of disease of the upper jaw. which is noticed everywhere, 
 is a case in point: so is that of 3Ir. Bickersteth, which was exhibited at the Pathological 
 Society in 1866, and which he described with all minuteness in the Transactions of the 
 year. The disease is usually symmetrical, showing it.self as a uniform enlargement of 
 the bones involved, the upper jaws projecting as two large globular masses. When the 
 ascending ramus of the lower jaw becomes hypertrophied and elongated, a curious one- 
 sided deformity of the face exists. 
 
 Cystic Disease of the Antrum. — This is a special affection and often connected 
 with irregular dentition, though how often has not yet been determined. 
 
 Suppuration of the cavity is often due. doubtless, to an extension of inflammation 
 from the teeth, and may arise from a blow or other cause. It is known by severe local 
 pain extending over the face and forehead, local swelling, and extreme tenderness, the 
 constitutional symptoms being often very severe. AYhen pus has formed, there may be 
 rigors ; and the abscess may burst either into the nose or into the mouth beneath the 
 cheek, the antrum, under these circumstances, becoming much distended. In rare cases 
 it may make its wa}' through the cheek, and in one where this occurred an opening into 
 the antrum the size of a fourpenny piece was found on making an incision down in the 
 bone beneath the cheek. In neglected instances the floor of the orbit may be displaced 
 and vision interfered with, or even destroyed. ( T7c7e Salter. Meil.-Chir. Trans., 1863.) 
 
 Treatment. — When suppuration has been made out, the antrum should be opened ; 
 and if its anterior wall be expanded, an opening may also be made into it without fear at 
 the most projecting point with a trocar or other sharp instrument. The relief given by 
 these means is very .signal. In one case of a lady that came under my care some years 
 ago it was instantaneous and permanent. When diseased teeth are present in the bone, 
 they should all be tested by a sharp blow and the most tender removed. A jet of ether 
 spray on each tooth will prove an admirable test, the cold searching out the slightest dis- 
 ease. It is never advisable to remove sound teeth unless some evidence exists of their 
 alveoli being diseased. In all these cases the cavity must be kept clean by syringing. 
 A chronic abscess in the antrum may be so insidious in its formation as to induce the 
 surgeon to believe that a tumor exists. Liston gives an instance in his Practical Sure/cry 
 of such an error, in which removal of the jaw was attempted. In all tumors of the upper 
 jaw the probability of the pi*e.sence of a large cyst should never be forgotten. 
 
 Hydrops Antri. — Under this term is grouped a number of "cases which include 
 examples of cysts of the antrum, cysts of its wall, and cysts placed outside the bone, 
 and all are characterized by a gradual, painless expansion of the part which rarely pro- 
 duces other symptoms than tho.se due to mechanical pressure. The swelling may encroach 
 on the nose, and cause obstruction ; on the orbit, and press on the globe : on the mouth, 
 and produce bulging of the palate ; and on the cheek, so as to cause deformity ; indeed, 
 it is often because of this that the patient is induced to seek advice. When the expan- 
 sion is great, the shell of bone may become so thin as to crackle like parchment under 
 pressure or to appear as if only membranes. M. Giraldes in 1853 ( Montyon prize) was 
 the first to describe these cy.sts with clearness, although Mr. W. Adams had previously 
 recognized them. (See St. Thomas's Hospital Museum Catalogue.') The old surgeons 
 looked upon this affection as the result of obstruction to the aperture between the nostril 
 and antrum, the dilatation of the bone being due to retained mucus : but this is now 
 known to be an error. Giraldes regards these cysts as dilatations of the glandular follicles 
 of the mucous membrane. The fluid contents of these cysts are always viscid, occasion- 
 ally clear, but mostly blood-stained, sometimes purulent, containing cholesterine, but 
 
Ti'M>>i:s OF Tin: ./.I ii'.s'. 
 
 443 
 
 iii'vcr pure imii-ii- 
 
 II l^TS I Ii:i(l a casf in :i 1m. y .ft. !'•. witli tlie lato Mr. K. I*lullii».s 
 of Lfiii>t('r S<|iian', \vli('r<' tlu" fluid was .scnuis ami lil<i(Hl->laiiir.l in a lii;ili ilc;.M-L'e. 
 
 Tlu" Ininrjiiw may likewise he the seat ul' a simple cystic tuiimr (ir expansion. In 
 IST") 1 hail a ease in a wnnian ;i'l. I- in wlmm tin; eyst hail expamleil the aseemlin}^ as 
 well as part of the hori/oiital ramus, ami it loiitaiiieil no irrowth. The preparation is in 
 the tJiiy's .Mii>riiiii ( lOlM'). 
 
 DentigerOUS cysts ;'i<' iliuiially elo.-ely allinl to thoM- jii>t ile>rril>eil ; patholoj.M- 
 eally they may ilifler ; hut there ean he no iloul)t that the cysts are coniiecte<l with the 
 teeth, wliieh are in some cases fully ilevelopeil ami in others imperfectly so. 'i'hey are 
 fouml in hoth upper ami lower jaws. Heath, in his e.vcellent Knsnij on llii Jnux (oil eilit., 
 ISSl), informs us that cysts of small size in connection with the fari^rs of jiermaiieiit teeth 
 are frei|ueiitly found on extracting the latter, Itut -ive rise to no symptoms ilemamliii<,' 
 surpcal interference. Occasionally j^rowing to a large size, they i.rodiicc ah.sorittion of 
 the containinu; alveolus and give rise to a prominent swelling. The disea.se is generally 
 slow in its i)rogress and tolerahly painless; hy its pressure the cyst may cause ahsorption 
 of the hone with which it is in contact and lead to a deep excavation. Paget relates in 
 his Suiyic'if I',ithi>ln,ji/ such a case as a cyst near the gums, and 1 have had under oh.ser- 
 vation a woman whi) had a tumor in her left cheek for years, which when opened dis- 
 charged some watery fluid. She applied to me for a hony jjrojcction of the cheek that 
 was clearly the edge of the alveolar jiroce.ss of the ui)per jaw, the bone above having 
 become absorbed by the pri'ssure of the cyst, thus causing a cup-like dejiression. She 
 had had all her teeth removed at ditterent times by dentists, under the impression that the 
 disease was due to them. 
 
 The (Iriifii/t'i-ods ci/sf^ arc found in both jaws, and are almost always connected with the 
 permanent teeth, rare cases being recorded in which the temporary were implicated. In 
 
 Fig. 238. ' l'"- -•;'•'• 
 
 Tooth as seen tlinnigh opening in 
 L"pper Jaw. 
 
 Natural Size of Tooth when 
 Removed. 
 
 Canine Tooth as seen in Case of Mis3 
 
 R . in eximiuled Lower .law, 
 
 with Tooth (6) of its Natural Size. 
 a, bone removed by the trephine. 
 
 this affection the teeth fail in development and remain within 
 
 the jaw; the tooth acts as a foreign body, sets up irritation, 
 
 and causes the cy.stic affection I am now considering, or some 
 
 solid growth. Thus, in a boy 'Xt. G who came under my care 
 
 some years ago a cystic enlargement of the jaw of three 
 
 years' development existed. It encroached on the orbit, 
 
 mouth, and cheek. 1 made a free opening into the anterior 
 
 wall of the cyst, in the bone, and through this an incisor 
 
 tooth was seen with its crown upward (Fig. 23S). The 
 
 tooth was removed, and a good recovery ensued. In January, 1872. T treated a similar 
 
 case in a girl xt. 17. .sent to me by ]Mr. Salter, who had her under observation for two 
 
 years. The disease was in the right upper jaw, and the right canine tooth was deficient. 
 
 I exposed the cavity and removed the tooth (which was growing in an abnormal direction 
 
 upward and inward), a good recovery taking place. On July 24, 1875. I trephined a 
 
 tumor of the lower jaw, of three or four years' growth, of Miss R , xt. 30, a patient 
 
 of Mr. K. Moon of Norwood and also of Mr. Salter, and removed from it a canine tooth 
 which was resting obliquely in the cavity (Fig. 239). Mr. Salter has collected many 
 similar cases. It is well to remember that these dentigerous cysts, like other cysts of the 
 jaws, may simulate solid tumors. When they occur in the lower jaw and expand the 
 bone, this error is very likely to take place. Thus, in 1881 a gentleman a^t. 58 came to 
 me with an enlargement of the left horizontal ramus of his lower jaw which had been 
 coming on for years, and with this there has a little discharge from his gums. I explored 
 this and struck a tooth, which Mr. Moore skilfully removed. It was a molar tooth, which 
 was lying horizontally in the bone with its crown forward and its fiings grasping those of 
 the last molar. In all tumors of the jaws that have a smooth or cystic outline it is well 
 
444 
 
 TUMORS OF THE UPPER JAW. 
 
 Fig 
 
 to make an exploratory puncture for the purpose of diagnosis. Wlien the walls crackle 
 \om the thinness of the expanded cavity, the diagnosis is simple. 
 
 Treatment. — The free opening of the cyst, with the extraction of any tooth that 
 may be present in it, is the one essential point of practice to observe in all these cystic 
 diseases of the jaws, upper or lower. This can be done with a knife or a sharp pair of 
 forceps after a perforating wound has been made by a trephine, drill, gouge, or pointed 
 instrument. To induce suppuration of the cyst, it is a good practice to plug the cavity 
 with lint. When the cavity is large, it is wise to take away a considerable portion of its 
 wall. Removal of a segment of bone for cystic disease is rarely needed. Before, how- 
 ever, the pathology was understood, this nuilpractice was often perpetrated, as our differ- 
 ent museums too truly testify. 
 
 DentigerOUS tumors may likewise occur. In Fig. 240 is illustrated a case in 
 •which I removed the iiitper jaw of a child set. 8 for a nearly solid myeloid tumor of the 
 jaw clearly originating in a malplaced tooth which was growing from 
 the posterior part of the orbital plate of the bone ; one or two cysts 
 existed in the growth enough to allow of its being called cystic. There 
 was no possibility of making a diagnosis in this instance ; such exam- 
 ples are very rare. 
 
 Tumors of the Jaws. — These are of different kinds, simple 
 and malignant, connected and unconnected with teeth. When in the 
 antrum, their dental origin should be suspected ; but in both upper 
 and lower jaws solid tunuirs of all kinds have been found with teeth 
 as their centres. 
 
 Polypi of the antrum — as are those of the nose — are occa- 
 sionally met with, and they show themselves mostly as ])rojections 
 into and through the nostril, the tumor making its way through the 
 nasal wall of the antrum, and at the same time generally expanding 
 its facial wall. I have seen four well-marked cases of this sort, and in two the whole 
 mass was removed through the nostril, which was laid open and turned back. In the 
 third the cheek was reflected outward at the same time and a large opening made into 
 the antrum, allowing the surgeon to scoop out the growth. Two of tliese eases occurred 
 in the practice of Mr. Cock, and two in my own. The constant flow from the nostril of 
 the aff"ected side of a quantity of clear fluid is a valuable symptom of these growths, as 
 shown by Paget's case (*"////. <SV>r. Tnins., 1879). 
 
 Tumors of the Upper Jaw. — Weber, quoted by Heath, informs us that in an 
 analysis of 307 cases of tumors of the upper jaw, more than one-third of the whole 
 number may be set down as sarcomatous simple tumors, one-third as osseous, and less 
 than one-third cancerous, the myeloid being included in the first of these groups. They 
 may grow also from any part of the bone or periosteum. When they originate in the 
 
 Dentigerous i iiinor 
 J:nv 
 
 Fig. 241. 
 
 Fig. 242. 
 
 Knchondroma of Upper ,Taw. 
 Before operalion. (Model, Guy's IIosp. Mus., SS'".) .\fter death. (Model, Guy's IIosp. Mus., .^S'S.) 
 
 antrum, they expand its cavity, as is the case in the cystic disease, and cause a bulging 
 of one or more of its walls. When they spring from a surface or plate, the tumor will 
 project from it, leaving the other surfaces unaffected. The fibrous, in all its forms, and 
 the osseous are usually of slow growth. They are often painless, and trouble only from 
 
r)rsi:.\sKs or rin-: jaws. 
 
 445 
 
 their size. The sarcomatous, myeloid, ami cancerous are of more rapifl ^Towth. The 
 fibrous «)r sarcoMjatous are usually periosteal jrrovvtlis; tlu? osseous aii«l myeloid, eiulos- 
 teal. The cancerous may li«'lon^ to liotli. The cartila;:iiious are very variable in their 
 ])r(»j;ress — now very slow, ami then rapid. Tliey are cliieHy of the mixed kind, fibre tis- 
 sue larjrelv ])redominatinji in tumors of slow formation. They frecjuently invtdve many 
 bones. Sir J. i'aj^et (Snniicdl l'<itli.) states that in tht; (»nly case on rt!Cord (jf enchon- 
 droma of the upper jaw aloiie tlic disea.si; was removiMl by .Mr. .Morjran. late of (Juy's, 
 from a man ;et. '1\\ the tumor was of the ri<;ht ma.xilla and was of nine years' growth. 
 The patient survive<l the operation .seven years. Figs. 241 and 'lA'l illustrate the case, 
 the first being taken before .Mr. .Morgan s operation and the second after the patient's 
 death. Dr. llevfelder of .Munich says, however, that he found S su(d> cases out of 4r)() 
 of disease of the upper jaw. 
 
 Tkk.vT.MK.N'T. — .Ml solid tumors of the upper jaw must be e.xtirpated. but imt inon,- 
 (if I lie biiiie should l)e reuiovi'tl than is necessary. Sir W. Fergusson established this 
 rule in practice, and it is one that all surgeons should strive to follow. Thus, when the 
 disease .springs and projects I'rom the facial surface of tlie bone, the tumor, with tlie facial 
 plate alone, requires excision. When the alveolar process is alone implicated, the other 
 portions of the bone must not be touched. Where ]»ossible, the palate plate should be 
 preserved ; and it is bad surgery to interfcMc with the orbital plate without an aVj.solute 
 necessity. When the whole bone is involved in the disease, it must be removed ; but 
 such cases are exceptional. In many cases when; the disease originates in the antrum a 
 partial renu)val of the bone will suthce, if the surgeon can at first only lay open the cavity 
 and find out the base of the growth. For ])erforating the antrum with a view to explora- 
 tion Sir W. Fergusson recommends an ordinary carpenter's gimlet. 
 
 Operation for the Removal of Part or the Whole of the Upper Jaw. 
 
 — The incision now almost universally adopted for the removal of tumor,-, from the u]iper 
 jaw is the one of Sir W. Fergusson (Fig. -4:5), as by it all the necessary room is given to 
 remove even the largest growth. The facial nerve and artery are divided where by their 
 size they are of small conseciuence and the scars are so placed as to become almost imper- 
 ceptible. In tumors of modc.rufe size the incision should be carried through the median 
 line of the lip into the nostril, when, by raising the nostril and retracting the cheek out- 
 ward, abundant roirm is o])taincd. When more room is required, the operator may extend 
 
 his incision round the ala and up the side of the nose 
 toward the inner canthus ; and if this is still insuffi- 
 cient, a third incision may be made, from the termina- 
 tion of the second along the lower border of the orbit. 
 These incisions are indicated in Fig. 243. which 
 was taken from a man xi. 35 from whom I removed 
 an osteo-chondroma. of twelve years' duration, involv- 
 ing the facial and palate plates of the superior max- 
 illa. The dark line indicates the incision made ; the 
 dotted extra line, that which may be required in excep- 
 tional instances. Fig. 244 illustrates Gensouls and 
 Liston's method. 
 
 In some cases the ala of the no.se alone may be 
 turned up. T removed a fibrous tumor growing from the nasal process of the superior 
 maxilla by this incision, and found ample nxnn. The incision having been made and the 
 integument reflected sufficiently to ex])ose the tumor, all bleeding should be stopped by 
 ligature or torsion. Assuming that the whole bone has to be removed, the incisor tooth 
 of the affected side must be extracted and the palate plate of the U})per jaw witli the 
 alveolus divided with a fine .saw (Fig. 245) introduced into the nostril. The malar process 
 
 Fig. 244. 
 
 Ker^u.sson's Incis- 'I'he dotted line, n, (ien- 
 ion for Iteinov- .soul's Incision ; }>, Li- 
 al of Upper .law. zar's and Liston's. 
 
 Kk;. ^lAr^. 
 
 Fig. 24(i. 
 
 Lion Forceps. 
 
 of the maxillary bone is then to be partially sawn through, as well as the nasal process 
 of the superior maxilla, their complete section being made with bone forceps. The tumor 
 should then be seized with the Lion forceps (Fig. 246) and the whole wrenched off, bone 
 
446 
 
 DISEASES OF THE JAWS. 
 
 forceps and scissors being employed to complete any section that may be required. The 
 infraorbital nerve should be divided with scissors and the soft palate left as little injured 
 as possible. If any portions of the disease remain, they can now be removed. All bleed- 
 ing vessels are to be treated by ligature, torsion, actual cautery, or styptics, and the parts 
 carefully brought together with interrupted sutures. 
 
 When the disease, says Heath, is of less amount and the orbital plate not involved^ 
 this should be preserved by carrying a saw horizontally below it ; and if the palate be 
 not involved, this may be advantageously kept intact by making a similar cut immediately 
 above it. Sir. W. Fergusson advises that the disease should be cleared out from the centre 
 toward the circumference, so as not to remove healthy structures unnecessarily ; and this 
 may be readily accomplished by means of the many forms of curved bone forceps with 
 which surgeons are now familiar, aided by the gouge. 
 
 In a case of myeloid disease of the upper jaw involving the whole of the hard palate 
 I peeled off all the soft parts from the bone, beginning at the alveolus, and, having 
 removed the diseased bone, brought them up again in position and fixed them to the mu- 
 cous membrane of the cheek where it had been separated from the bone. By this means 
 I preserved the roof of the mouth from the first, and, what is more, eventually obtained 
 an excellent new palate. The practice, particularly in young subjects, is probably worth 
 following. 
 
 Fig. 247. 
 
 Periosteal Sarcoma of Lower .hiw. 
 View of sectiuii. Kxternal aspect of Tumor. 
 
 Tumors of the lower jaw grow to enormous dimensions, and pathologically are 
 very similar to those of the upper. The fibrous in one of its forms is probably the most 
 common, the periosteal tumor being more frequent than the endosteal. The latter may 
 occupy the dental canal, as illustrated by a case of Mr. Cock's (Guy's Hosp. Mus., 
 1091") in which the dental nerve passed through the tumor. The periosteal growth is 
 often an epulis, and a good example of this form is represented in Fig. 232. But a more 
 typical example of a true periosteal sarcoma, which I removed in 1872 from a girl aet. 20, 
 
 Fig. 250. 
 
 Fig. 248. 
 
 Fig. 249. 
 
 Fibro-Cystic Disease of Lower ,Taw. 
 Guv's Hosp. Mus., Drawing 45'. Guy's Hosp. Mus., 10905o.( Key's 
 
 "(Key's case. During life.) case. Tumor after removal.) 
 
 is illustrated in Fig. 247. The tumor was of three months' 
 growth. It returned three months after removal and destroyed 
 life by suffocation, having grown to the size of the patient's 
 head. Microscopically, the tumor was a spindle-celled periosteal 
 
 Eow«Sf^"'^^r^H^ath'.s caS sarcoma. One of the largest fibro-cellular tumors of the bone 
 on record occurred in Mr. Heath's practice, and is illustrated, 
 
 with his permission, in Fig. 248. It was removed from a man aet. 32, and the disease was 
 
 of eleven years' growth ; it weighed 4 pounds 6 ounces. The man died from exhaustion 
 
 on the sixth day. 
 
I) rsi:. I .s7;.v of rir/-: ./ . 1 1 1 's. 1 1 7 
 
 FibrO-Cystic tumors "f tin- lowt-r jaw an- vi ry coiiiiiKiii ami liav*; the saiiu; 
 clinical history and aspfrt as the cystic tiiiiiois to whidi attention lias liccii already 
 directed. The most lieaiitiful e.\aiii|ile on record is that \vhi(di was removed liy the late 
 I>r. Iluttoii of the l{ichmond llosjiital, iMihlin, and is illustrated in Heath's huolc ; it was 
 made up of cysts <>{' nine years' };n»\vth and in a younir woman oidy LJO. A yet mom 
 remarkalile case was operated upon hy Mr. Key in ISH in a hoy let. \'.i f Fijrs. 24It, 'i'lO). 
 The tumor was of two years' j^rowth and painless, .^lr. Key removed the whole hy saw- 
 ing; throuiih the lowi-r jaw just helow the anule on eaidi side, and a ^'ood recovery ensued. 
 Mr. Kve in his exci-llenf leeturi'sat the Colleire r»f' Surj;eons in iSSlJ strove to show that 
 thex- t'v>tie luniniv 111" the lower jaw are in their orijrin e.vamples ot" epithelioma. 
 
 Cartilaginous growths :iie uncommon and occur in early life, and. as alreaily 
 
 stated, are periosteal and endosteal. A iii xaniple of the latter can he seen in Prep. 
 
 lO'Jl''. and lOltl"', (luys llosp. Mus., wiiich Mr. Key removed in 1S4(! from a woman iet. 
 29 in whom the di.sease had heen comint; on for nine years. In the preparation the fibro- 
 cartilajiinous substance is seen to be placed between the plate.s of bone of the jaw, the 
 teeth beinu: in the middle of the new growth. The perio.steal tumor grow.s to a large size. 
 
 Osseous tumors arc simictimes the result of ossified enchondroma. There is in 
 St. Thomas s Museum a specimen of this kind which was removed by .Mr. ('line. Bone 
 luav. however, (tccur as an independent growth in the form of cancellated or ivory exos- 
 tosis, which may sometimes grow to a large size. Other troubles may .spring from such 
 a growth ; for example, iu .March, 1877, I had to remove a portion of the lower jaw from 
 a lady ;vt. 50 who had had an exostosis growing for twenty years from its inner surface 
 at a point corresp»mdiug to the right bicuspid and canine teeth. The growth had not 
 given rise to any trouble till the soft parts ccn'ering its apex had begun to ulcerate, when, 
 from its roughened surface, the bone .so irritated the floor of the mouth as to set up 
 ulceration which was thought to be cancerous. I removed the excstosis with the bone, 
 and then reached the suppo.sed cancer, which I isolated by needles passed through the 
 base of the growth and removed by means of the galvanic ecraseur. A good result fol- 
 lowed, and the lady is now well. 
 
 Sarcomatous tum.OrS are met with in great variety, the softer kinds being recur- 
 rent and clinically malignant. Some of the very vascular pulsate. 
 
 Cancerous tumors are mostly periosteal and invade the bone by extension. They 
 are of the epithelial I'onu when attacking the gums and mucous membrane, and of the 
 tuliular variety in the nose and antrum when originating where the epithelium is columnar. 
 
 Thkat.mknt. — Tumors of the lower jaw, as of the upjier, are to be treated by excision, 
 and the operation, though large, is most successful. I have on more than thirty occasions 
 removed large portions of the jaws with but one death, and that was from inflammati(Mi 
 of the lungs. Heath .says that Mr. Cusack removed large portions in seven cases with 
 only one fatal result, and Dupuytren operated in twenty with only one death. The suc- 
 ce.ss of Sir W. Fergus.son, Syme, and Li.ston is well known. 
 
 Small tumors of the jaw, and particularly of the alveolus, may with good cutting for- 
 ceps be removed from the mouth. If more room be required, an incision may be made 
 outward or downward at the angle of the mouth. On many occasions I have obtained 
 all the room I required by making a horizontal inci.sion below the level of the jaw and a 
 dissection of the soft parts oft' the bone. 
 
 3Ir. Maunder has shown that large portions of the lower jaw the seat of tumor may 
 be taken away without external incision after detaching periosteum by means of the 
 raspatory. 
 
 When a large tumor has to be removed, it may readily be exposed by a curved incisirm 
 carried along the posterior surface of the tumor froni above the angle of the jaw to the 
 median line, turning the soft parts up. In doing this the facial artery will be divided, 
 when the two ends should be at once secured by torsion. The knife, says Fergu.sson, 
 should be so lightly carried over the artery that the vessels need not be divided till the 
 flap is being raised. In this way blood is saved. The labial margin of the lip rarely 
 need be divided. The tumor having been exposed, its surface must be well examined, 
 with the view to the removal of the growth by cutting away the external plate of bone 
 which covers it in, by means of the gouge and bone forceps. This step is wise in doubt- 
 ful cases, as a large number of tumors of the jaw. particularly the cystic, may be scooped 
 out, and recovery will ensue. If the tumor and jaw reipiire excision, a tooth must be 
 extracted in front where the bone is to be divided and a small saw applied, after which 
 the bone should be grasped with the Lion forceps and drawn outward, the surgeon subse- 
 quently carefully dividing all the soft parts that hold it in position on its inner surface 
 
448 DISEASES OF THE JAWS. 
 
 and keeping the knife dose to the hone. When the disease stops at the angle, the saw 
 and forceps are again to be applied and the tumor removed. Where disarticulation is 
 required on account of the extension of the disease, the jaw must be forcibly depressed, 
 so as to bring the coronoid process within reach and allow of the division of the insertion 
 of the temporal muscle. The condyle may then be twisted out, the knife dividing cau- 
 tiously the insertion of the external pterygoid and such ligamentous fibres as are put on 
 the stretch. Fergusson says that in doing this he found that the condyle actually sepa- 
 rated from the periosteum on its inner side, thus facilitating its removal ; and in two cases 
 of my own I found this to occur — in one after the division of the periosteum Avith the 
 knife. When the tumor is so large as to be wedged in and to prevent this mode of dis- 
 location, the best plan is to reapply the saw and cut off the tumor as high as may be, 
 and subsequently to remove the remaining portion of jaw. 
 
 When the central portion of the lower jaw is removed, there is danger of the tongue 
 falling back and causing suifocation ; to prevent this a ligature may be passed through 
 the tip of the tongue and held during the operation, and on the completion of the ope- 
 ration fastened to the wound. The ligature should be removed on the second or third day. 
 
 After the operation all arterial bleeding should be stopped and any oozing arrested 
 by the application of a sponge wrung out of hot iodine water ; the edges of the wound 
 .should be brought together by interrupted sutures. Convalescence is generally rapid 
 and recovei'y complete. The deformity that follows the operation is in most ca-ses so 
 slight as not to be observed ; the interval left by removal of bone is filled with dense 
 fibre tissue. Bone is never reproduced, but the tissues soon become firm enough to bear 
 the support of artificial teeth. 
 
 The half-sitting position is probably the best in all these operations on the jaws, and 
 chloroform may be given without fear. 
 
 For more details connected with this subject the student may refer to Heath's admir- 
 able Monograph on the Jaivs ; Fergusson's Surgery; Liston's paper, J/«7.-CV///-. Trans., 
 vol. XX.. and his Pract. Surgery. 
 
 Disease of the tempore -maxillary articulation is rarely met with — more 
 
 rarely, indeed, than disease of any joint in the body. Uf the few examples of it I have 
 seen, one was in a woman aet. 34 who had had it for nine years, suppuration having 
 existed for six ; several sinuses led down to the joint and the jaw was nearly fixed : dead 
 bone appeared to be present, but the patient refused to have any surgical interference. 
 Another case was a girl aet. 18 in whom both sides of the lower jaw were completely 
 anchylosed. In Guy's Hosp. Museum there is also a splendid specimen (No. 1070) of 
 complete synostosis of the articulation. 
 
 The cases already quoted of necrosis of the condyloid process of the lower jaw and 
 recovery with a sound joint may here be referred to. 
 
 Closure of the jaws niay be caused by some spasmodic condition of the muscles 
 of the jaw secondary to disease of the teeth or to the cutting of the wisdom teeth. In 
 the latter case the mouth must be forced open, under chloroform, by means of the screw 
 gag or wedges, and the tooth removed, or. what is better, room made for it to come for- 
 ward by the extraction of a neighboring molar. It may Hkewi.^e be caused by anchylosis 
 or by the contraction of cicatrices, either within or without the mouth. In February, 
 1878, I operated upon a woman tet. 43 who for thirty-seven years had had her jaws 
 locked from adhesions between the cheeks and gums which had compelled her to live on 
 liquid food for the whole of this period. I divided the cicatrices and opened the jaws 
 with a promise of a good recovery. Two years later she could take and masticate food. 
 The condition had followed scarlet fever. Dr. S. Gross, in his System of Surgery, informs 
 us that ulcerative causes are the most common, and he attributes the majority to the evil 
 practice of giving calomel to salivation. In rarer cases the immobility is occasioned by 
 an osseous bridge extending from the lower jaw to the temporal bone, this condition 
 being generally associated with chronic articular arthritis. " HoAvever induced." writes 
 Gross, " the effect is not only inconvenient, seriously intei'fering with mastication and 
 articulation, but it is often followed, especially if it occur early in life, by a stunted 
 development of the jaw, exhibiting itself in marked shortening of the chin and in an 
 oblique direction of the front teeth.'' 
 
 Treatment. — Where the cause is in the joint, and cannot, as can dead bone, be 
 removed, the surgeon may attempt to break uj) the adhesions by forcibly opening the 
 mouth under chloroform, or he may divide the bone below the joint. When due to cica- 
 trices and nodular plastic matter, little good has ever been derive<l from their division, 
 although in the case previously alluded to the result was satisfactory. Esmareh of Kiel, 
 
DfsijicATio.x or riiF. ./.III'. 
 
 119 
 
 in ;i papt'i" (hi f/ir Tmitniftif nj' ('/usiirr "/' tin .Imrs j'roiii dioi/ririK^ 1S()0, has, however, 
 dt'.Sfrilie<l an operation which the- .Messrs. Henry. ('. Heath, .MacCoriiiac, Mason, liawson, 
 and Annanihile in this eountry have practised with success enoutrh to indicate its value. 
 
 ()l'Kll.\Tl<»N. — This eon.sist.s of the removal of a piece (»!" tlu' h)wer jaw for the forma- 
 tion of a new joint, and is to he curried <Mit hy makin;r an incision ahtn<r the h»wer l»ordcr 
 of the jaw in front ot"tlie masseter. raisinj; the intejrunn-nt, and reinoviii^r with a liand- or 
 cli;iin-saw a weduc oi' hmio measurinii; ahout an inch ahove and a half incli l)elow. Where 
 oidv "»ne side of the jaw is affected, it is. without doubt, the l)est operation that can be 
 performed, the |)atients recovering; their masticatory power in two or three W(!ek.s. It mii.st 
 be mentioned that about the year IS()(), Kizzoli of Holofrna performed a .somewluit similar 
 operation to Ksinarch's, dividintr the jaw, but not removing any portion of it. 
 
 Deformities of the jaws :ire sometimes .seen a.s a con.se({uencc of .some disease 
 of the toniiue, such as hypertropliy, the mechanical pressure of tumors during growth, 
 the evil influence of cicatrices, more ]iarticularly about the neck and mouth, and of 
 various other causes. For these surgery may often do much ; but when this fails, the 
 dentist can often give relief. I have seen the upper jaw in at least si.x cases of torticollis 
 nearly one inch less in its vertical diameter than the opposite l)one, and I have already 
 alludetl to a ca.se where the lower jaw was nearly an inch higher than natural, to make 
 up for a deticiency in the teeth of the upjier jiw which had e.xi.sted from childhood. 
 
 Fi( 
 
 DLslocatioii of the Lower 
 Jaw. (Couper's case, 
 J.iinilim Hosp. Rep., 
 1S64.) 
 
 Dislocation of the Jaw. 
 
 This may involve one or both condyles, two out of every three cases being bilateral. 
 It may be caused by direct violence on the jaw, but more frequently by yawning. Sir 
 A. Cooper tells of a case in a child where it was produced by the 
 forcible introduction of an apple into the mouth, and dentists know 
 of its being produced even by the extraction of a tooth. 
 
 Tn the double dislocation the mouth is widely open, the jaw is 
 fixed and projecting, the lips are separated, and, as a consequence, 
 speech is very difficult. Deglutition is much interfered with, and 
 the saliva flows from the open mouth. Tn front of the ear a marked 
 hollow will be perceptible, and aborr. the zygoma, in the temporal 
 fossa, an undue prominence (Fig. 251). Adams of Dublin (^Dub. 
 Quart. Journ. Med. Science., vol. i.) first noticed these symptoms, and 
 Dr. R. W. Smith (^Frachires, 1854) believes them to be caused by 
 the " displacement and stretching of the fibres of the temporal 
 mu.scle on the upper surface of the condyle." 
 
 In the single dislocation the chin is oblique, but usually directed 
 toward the sDimd in.stead of toward the injared si(Je, as in fracture of 
 the neck of the bone. In exceptional cases, however, this is not to 
 be observed. The other symptoms are similar to those of double dislocation, the hollow 
 in front of the ear being the most characteristic. 
 
 Congenital dislocations have been described by Smith, Guerin, Langenbeck, 
 and Caiitnii. Sir A. Cooper has also drawn attention to si(b/i(xa(t'ou, in which he 
 assumed that the condyle of the jaw slip))ed in front of the 
 interarticular fibro-cartilage. It is caused and characterized 
 by the same conditions as those of dislocation, and it is prob- 
 ably a partial di.slocation forward. 
 
 Tre.\t.ment. — Partial dislocations or those described as 
 subluxations are usually reduced by the patients themselves 
 by some lateral movement of the jaw^ or by gentle pressure 
 upon the chin. Cases of complete dislocation have likewise 
 been similarly reduced, but more frequently the surgeon's aid 
 is demanded. To reduce the dislocation, the surgeon should 
 stand in front of his patient, who should be seated in a chair 
 with his head su]q)orted. The surgeon should then introduce 
 his thumbs, well protected with a towel or lint, into the 
 patient's mouth upon the last lower molar teeth and grasp 
 the jaw with his outer fingers ; he should next make pressure 
 upon the teeth downward and backward, so as to depress the 
 condyles from their false position, and at the next moment 
 elevate the chin with the outer fingers (Fig. 252). Some 
 29 
 
 Via. 2o: 
 
 IJeduction of Dislocatiou of Lower 
 Jaw. 
 
450 FRACTURES OF THE JAWS. 
 
 surgeons prefer using a piece of wood or the handle of a fork introduced between the 
 molar teeth to depress the jaws. When strong leverage is required, as in old cases, 
 Stromeyer's forceps may be employed. Nelaton's advice to press directh^ upon the 
 coronoid processes, and Pollocks practice of applying pressure upon the chin by means 
 of Petit's tourniquet fixed upon the head, are worthy of attention. It is well to reduce 
 both sides together, and old standing dislocations may be thus reduced. Mr. Morley 
 reduced one after thirty-five days, Spilt after fifty-eight, Demarquay after eighty-three, 
 Donovan one after ninety-eight, Pollock after four months, and Golding-Bird after eigh- 
 teen weeks. 
 
 Fractures of the Jaws. 
 
 Fractures of the upper jaw are not nearly so frequent as those of the lower ; 
 and when they occur, it is generally from direct violence : when the " key " was employed 
 for the extraction of teeth, a fracture of the alveolus was frequently the result. In 
 severe injuries much displacement and copious hemorrhage may take place. Cases are 
 on record where the internal maxillary artery was ruptured and fatal results ensued. 
 The infraorbital nerve or its branches are occa.sionally injured, when some loss of sensa- 
 tion in the cheek will be produced. I have known emphysema of the cheek or orbit to 
 follow such an injury, and have seen subconjunctival hemorrhage from it. One of the 
 worst examples of fracture of the upper jaw I have seen occurred in a man aet. .30 from 
 a fall from a height. Both upper jaws were completely detached from the skull and 
 could be moved about in any direction, yet a good recovery ensued. I saw a second in 
 an asylum, and it was caused by the blow of a lunatic's fist. In this case the whole of the 
 alveolar process of the right upper jaw was broken off" and the lower jaw fractured in 
 two places. 
 
 Tre.\tment. — Where no displacement has taken place, little treatment is required ; 
 the parts should be left alone for natural processes to effect a cure. When tJiqjla cement 
 exists and can be remedied by manipulation, such means .should be applied, some slight 
 retentive bandage, with or without a pad. being employed to keep the parts in position. 
 When the palate plate is much interfered with and displaced, the dentist's aid may be 
 called into requisition, a gold plate well adapted to the parts tending to keep the frag- 
 ments together. (See Salter. Lemcet. 1860.) Hemorrhage, as a rule, can be arrested by 
 the application of ice or styptics. When the soft parts are injured and bleeding takes 
 place from them, the vessel should be secured. When the bone is comminuted, there is 
 no need for the removal of fragments ; !Malgaigne laid this down as a law. and Hamilton 
 asserts that, owing to the extreme vascularity of the bones composing the upper jaw, the 
 fragments have been found to unite after the most severe gun.<hot injuries. In rare cases 
 of separation of the maxillte a spring passing behind the head and causing pressure upon 
 the maxillae, after the manner of Hainsby's harelip apparatus. Heath says, might be 
 advantageously employed. 
 
 Fractures of the lower jaw, like those of the upper, are. as a rule, the result of 
 direct violence, and when produced by gunshot injuries are at times most severe. They 
 are almost always compound toward the mouth, as the gum tissues readily give way. 
 The body of the bone is more frequently broken than any other part, although the ramus 
 and the neck of the jaw may be fractured. The line of fracture is generally oblique 
 and very commonly near the canine tooth. Double fractures are very common, eleven 
 out of twenty-four cases recorded by Hamilton being of this nature. Comminuted frac- 
 tures are more rare. A case came under the care of Mr. Poland at Guy's in which the 
 jaw, by the kick of a horse, was broken in five places. 
 
 Symptoms. — The symptoms of fracture are generally very clear, crepitus being often 
 felt by the patient in attempting to move the jaw, and it is readily made out by the sur- 
 geon. The irregularit}- of the teeth is also a very characteristic symptom, and the care 
 of the patient to hold the parts in position, conjoined with his inability to speak, is a 
 typical sign. When any doubt exists as to the presence of a fracture, the mobility of 
 the broken bones will disperse it. Considerable displacement sometimes complicates the 
 case ; the position and the line of fracture determine the degree : an oblique fracture 
 near the insertion of a large muscle, as the masseter. necessarily shows a tendency to 
 override. In double fracture of the body of the bone this displacement is usually very 
 marked, the muscles that connect the lower jaw with the hyoid bone draAving the lower 
 portion down. In some cases this displacement cannot be completely remedied. 
 
 In rare cases the teeth may be depressed into the alveoli, and the bone at the same 
 
I'll M Trill's or Tiir jaws. 
 
 151 
 
 tiiiu' iiiav I'f lniiktii. Such a casi- i-aiiu- uinltr my fare in May, l!SSt2, in tlir person of a 
 porter ;i't. 17 who in a fall ofV a slcanicr stru<'k his chin ajrainst the ed'rt; of the (juav. 
 As a result he was renderetl inseiisilile I'or a hrief perioil, and was hrou;_dit to (Juy s with 
 a wound lienealh the (diin ; there was also loosenin;.' of the left eaiiimr tooth, with a frac- 
 ture of its alveolus ; there was, hesides, most eomjdcte depression of the two rifrht lower 
 bicuspid and two mcdar teeth, their cusps hein*.' (Ui a level with tlie necks of the other 
 tooth, and vertical spliltin;,' of one (d" the hicuspids and two of tiie molars of tlie left 
 iipjier jaw also existetl. There was likewise lileedin;r fntin the left ear, which lasted 
 twenty-four hours, and later on jtaralysis oi" the facial nerve, suf;<rc.stive of a fracture of 
 tlio base id' the skull. The teeth were rai.scd hy -Mr. .Ninon, but they never became firm. 
 Othi-rwi.so, the man (piite recovered. 
 
 Fractures of the neck Of the jaw ;tre always the result of direct violence, and 
 are not very readily made out. Pain ai^'L^avated by any attempt to move the jaw is a 
 constant symptiun, and so ahso is crepitus, perceivable by the patient. '"The condyle," 
 says Heath. " is drawn inward and forward by the ptery<.'oideus e.xternus, as can be 
 ascertaine(l by passiuL' the tinjrer into the mouth, and the jawbone is ajtt to become 
 slightly displaced, so that the chin is turned toward the afll'ected side, and not from it, as 
 in dislocation." I liave had under my care a man mi. .'>') with a fracture of both sides 
 of the jaw just below the condyles, and with fracture of the symjdiysis. jtrrjduced by a 
 severe blow upon the jaw behtw the chin; from the displacement that followed the house 
 surgeon thought il was a case of double dislocation, but on attempting; to reduce it it 
 '• wont in " without the characteristic snap of dislocation. O.stitis and necro.sis of the 
 whole bone below the condyles followed the accident, and a new jaw formed, the man 
 recoveriiiir with good movement of tlie bone. 
 
 Fracture of the COronoicl procesS i'' very rare, and Sansom says that such a frac- 
 ture never unites. 
 
 Tkk.vt.me.nt. — When the bones can be brought into apposition, the treatment may be 
 described as simple ; and where difficulties are met with in reducing the fracture, the 
 treatment is most difficult and uncertain. In an ordinary ca.se of fracture of the jaw, 
 where no or very little displacement exists, the common four-tailed bandage, a yard long, 
 with a slit in the chin-piece of about four inches, made and applied as illustrated in 
 Fig. 2."))], is useful for temporary purposes, but for pcrmancut treatment, in the few cases 
 in which no displacement exists, it is well to mould on a splint of gutta-percha made 
 
 Fig. 253. 
 
 Fig. 254. 
 
 Fi(4. 255. 
 
 -K^y 
 
 Bandage and Splint for Fracture of Lower Jaw. 
 
 Thomas's mode of adjusting Fractiires of the 
 Lower Jaw with Wire and Key. 
 
 according to the shape given above (b) and applied as seen in Fig. 254, A, or, what is far 
 better, adjust a four-tailed bandage made of five or six layers of muslin dipped in fresh 
 plaster of Paris and moulded to the chin, the bandage being held in position whilst the 
 plaster sets. When healthy teeth are present at the line of fracture, they may be fa.st- 
 ened together with wire, after the method of Hammond's splint (Fig. 258)' 
 
 When difficulties are felt in the adjustment, as in double fracture, where the chin is 
 much drawn down, a good pad may be firmly tied under the chin or a block of wood 
 adjusted. But in these cases the surgeon's ingenuity is often taxed to the utmost to 
 meet the wants of the individual case. 
 
 Some surgeons have suggested that the bones should be fastened together by sutures 
 when all other means fail, and Mr. Hugh Owen Thomas of Liverpool has published cases 
 to illustrate the practice. He applies the wire litrature after the fashion illustrated in 
 
452 
 
 FRACTURES OF THE JAWS. 
 
 Fig. 255, using a one-twenty-fourth-incli silver wire and fixing it with a key (Fig. 255) 
 {JLanctt., 1867, and pamphlet, 1875). In the case of comminuted fracture already alluded 
 to, two or three wire sutures were applied with the best results. Others advise the use 
 of wedges of cork so adjusted between the teeth as to maintain the jaw in its right line. 
 Hamilton speaks highl}" of gutta-percha moulded to the teeth and gums within the 
 mouth, and Tomes has invented a silver cap to fit the teeth for some distance on each 
 side of the fracture. Barrett carries out the same idea in vulcanite. Berkeley Hill's 
 modification of Lonsdale's apparatus is serviceable, and Moons splint, as made for him 
 by Millikin, is excellent. It has the advantage of all the other interdental splints already 
 enumerated, is readily adapted to a jaw of any size, and, being introduced separately, is 
 easily applied, and can be as readily I'emoved, when desired, without shifting the cap, 
 which fits the teeth on either side of the fracture. Moon's splint, therefore, seems to be 
 the best interdental one we possess, and it should be used when simpler forms are inap- 
 plicable (Fig. 256). Mr. Moon tells me that Gunning's interdental splint is one of the 
 most valuable for some fractures of the upper jaw, and also for fracture of the lower jaw 
 where the teeth will not admit the use of Hammond's. 
 
 Fig. 256. 
 
 Fig. 257. 
 
 Moon's Interdental splint. (Made in two halves, 
 BB, with horizontal rods to keep cap, Fig. 257, in 
 position.) 
 
 Metal Cap fitted over Fractured Jaw. fRepresentsd 
 as wired on for a time, after the witlidrawal of 
 external splint.) 
 
 Among these simpler forms I must class Hammond's, which I had brought under my 
 notice in 1874 by Mr. Moon. It is a very simple and valuable splint for the general 
 treatment of fractures of the jaw, and has answered admirably in the many cases to 
 which I have had it applied. 
 
 Fig. 258. 
 
 Fig. 259. 
 
 Hammond's Wire Splint for Fracture of the Jaw. 
 
 Hammond's Wire Splint applied to Fractured Jaw. 
 
 The following description of the apparatus and its application is given in Mr. Ham- 
 mond's own words : 
 
 " I first place the patient in as convenient a position as circumstances will permit, then 
 direct him to rinse the mouth with alcohol and water largely diluted, which not only 
 cleanses the mouth, but removes the fetor of the breath. I next bring (temporarily) the 
 broken ends into approximation by passing a silk thread between and round the two teeth 
 on each side of the fracture, and then secure by tying in front. Then with a suitable 
 tray and very soft wax I take an impression of the teeth, to which, after its having been 
 cast in plaster of Paris, I adjust a frame of iron wire (Fig. 258), which can be done with 
 a pair of small curved pliers. When all is ready, I slip the frame over the teeth in the 
 mouth (Fig. 259), and while it is held in position by an assistant proceed to tie by pass- 
 ing small lengths of thin iron binding wire after the manner shown in Fig. 259, twisting 
 them in front until each ligature is nearly tight, turning the ends on one side until they 
 are secured. Next, with the aid of an assistant, I twist the wires quite tight, working 
 alternately each side of the mouth, so as to exert an equal pressure, and thus bring the 
 
Itl'.STM. Sl'IiCKRY. 453 
 
 bone iiitii a natural position, also takiiitr rare imt t(j ovcrtwist or break thcin. T th.-ri cut 
 oft' the iiids aixl turn tlicni in lietwi-cn tin- ti'i-lli. Now tlu; jaw will be t'ound cunijiara- 
 tivt'ly Hnii — so solid, indi'cd, tliat tlu' |»atit'nt can bite steadily <tri it without pain. All 
 that now remains to be done is to secure the jaw perfect rest by the four-tailed bandaj^e" 
 (^Mnittlili/ lirrlnr iif Deiitnl Siirffrn/, May, iHTiJ). 
 
 It is not absolutely necessary in all cases to take a cast of the broken jaw, although it 
 is so in some, for the surgeon may mould a frame of iron wire of the thickness that will 
 pass between the necks of the teeth as far as possible on each side of the fracture, and 
 fix the ends by passing them through a small tube a <(uarter of an inch long an<l l)eiiding 
 them baekward on the tube. This method is far preferable to any twisting of the ends. 
 It has been taught at (iuy's for some time Ity Mr. Moon. 
 
 This frame should In- worn for six weeks. 
 
 DENTAL SURGERY. 
 
 Hy Mr. henry .MOOX. 
 
 General Remarks on Dental Surgery. 
 
 Dental surgery, in its manipulative details, must necessarily, for the most part, be left 
 to those wlio make its practice a specialty ; but some acquaintance with affections of the 
 teeth and with the principles on which they are treated is required by every one who i.s 
 engaged in the practice of medicine or surgery, for without such knowledge he will be 
 unable to advise his patients on the preservation of their teeth (a subject of importance 
 as regards their general health) or save them from the sometimes serious local complica- 
 tions which may attend tooth disease. Nor will he be able to diagno.se the true nature 
 of certain tumors and cysts of the jaws, or to attach the proper importance to the teeth 
 as the possible cause of neuralgia of the head and face and of more remote nervous affiec- 
 tions. 
 
 In the following pages only a sketch of this branch of surgery is aimed at, and the 
 reader is referred for details to the excellent Dental Surgery by the Messrs. Tomes, and 
 to the interesting pages of Mr. Salter's work. Dental Pdfhology and Surgeri/. 
 
 The various parts of our subject ma}' with advantage be discussed in two main divis- 
 ions. In the first section will be considered the defects in structure and abnormalities 
 in form which maj- arise during a tooth's development, together with irregularities in its 
 placement. In the second section will be considered the diseased conditions to which a 
 fully formed tooth is liable after it has assumed its destined position in the mouth. 
 
 The eff"ect which disease or malposition of a tooth may have on the structures imme- 
 diately around it and on the general health will also be noted. 
 
 That a clear idea of the.se subjects may be obtained, some points in a tooth's develop- 
 ment, structure, and connection with surrounding parts must be borne in mind. 
 
 Description of a Tooth : its Development and Connections. 
 
 A perfected human tooth (see accompanying illustration. Fig. 260) may be described 
 as consisting of an unyielding case of dentine or ivory enclosing a highly sensitive vas- 
 cular pulp; the portion of this case that forms the crown of the tooth is protected by a 
 covering of an extremely hard substance. " enamel." which, becoming lessened in thick- 
 ness as it extends down the sides of the crown, finally terminates at the neck of the tooth; 
 the portion of the case that forms the root or roots is covered by " crusta petrosa," or 
 tooth bone, and is implanted in the alveolar portion of the jaw; the crusta petrosa is 
 covered externally by a sensitive and vascular membrane, " the alveolo-dental membrane," 
 or '• periodontum ;"' this membrane invests the root of the tooth and lines the bony 
 socket, and is, besides, intimately connected with the dentinal pulp at the apex of the 
 root, and with the gum also where the latter structure encircles the neck of the tooth. 
 
 Through the foramen at the end of the root blood ves.sels and nerves pass for the 
 supply of the dentinal pulp, while other nerves, derived from the same source (viz., the 
 second division of the fifth in the case of the upper and the third division in the case of 
 the lower teeth), are distributed to the alveolo-dental membrane. The teeth are implanted 
 
454 
 
 DEVELOPMENT OF TEETH. 
 
 Fig. 260. 
 
 in the alveolar process of the jaw, which is. developed with them and is reahsorhed when 
 
 they are lost. 
 
 Development. — The twenty developing temporary teeth, enclosed in their respect- 
 ive sacs, are contained in the jaw at the time of birth, as 
 are also germs of the permanent molars and those of the 
 anterior permanent teeth ; these latter, receding from their 
 position near the surface of the gums and becoming encap- 
 suled, gradually pass down in the rear of the temporar}- teeth 
 and remain embedded in the jaw, developing at leisure within 
 their bonj' crypts until wanted to replace their more fragile 
 predecessors. (See Fig. 2G6.) 
 
 The following is the normal process attending the eruption 
 of one of the anterior permanent teeth : The roots of the ante- 
 cedent temporar}' tooth having been absorbed, its crown is 
 shed, and the tooth, released by the absorption of superja- 
 cent bone, gradually uprises from the gum, the jjrotrusion 
 of its crown taking place simultaneously with the continued 
 elongation and development of its root. 
 
 The development of a permanent tooth thus occupies 
 many years. Take, for examples, the fii'st permanent molar 
 and central inci.sor, the teeth which are the first developed 
 of the permanent set. Their pulps commence to take form 
 during foetal life ; their calcification commences by birth or 
 in the first months of infancy. Their eruption takes place 
 
 from the sixth to the eighth year, and their root canals, with their terminal foramina, are 
 
 not reduced to their ultimate dimensions for two or more j'eai's later. 
 
 The three hard structures which enter into the composition of a tooth have distinct 
 
 sources of origin. ( Vide diagram. Fig. 261.) 
 
 Fig. 261. 
 
 /> 
 
 A Vertical Section through a Lower 
 Wolar Tooth, showing its differ- 
 ent Component Structures and its 
 Connection with Parts around. 
 
 Diagram of developing Lower Molar Tooth. 
 
 A, Dentinal pulp becoming centripetally encased by dentine. 
 
 B, Space occupied Ity enamel organ between centrit'ugally forming enamel and tooth sac 
 
 in the formation of a dentigerous cyst. 
 
 C, C, The base of dentinal pulp, which remains attached and developing until the tooth is comjileted 
 
 outgrowth at this point a radicular odontome would be formed. 
 
 In this space fluid collects 
 By abnormal 
 
 The enamel, developed from the "enamel organ" of epithelial origin (which occu- 
 pies the space B in the accompanying diagram), is formed centrifugaUi/ on the coronal 
 dentine, and through the obliteration of its formative organ becomes, on the eruption of 
 the tooth, incapable of further growth or nutritional change. 
 
 The dentine is developed from the " dentinal pulp " of vascular connective tissue 
 (vide diagram. Fig. 261, a) by the immediate agency of a .superficial layer of cells called 
 odontoblasts. 
 
 The dentinal pulp or bulb, arising from the bottom of the tooth sac and projecting 
 into its interior, grows up beneath the enamel organ and progressively takes the destined 
 form and dimensions of the dentine ju.st prior to the formation of that structure ; thus, 
 the free end of the bulb having taken the form of the cutting edge or masticatory sui-- 
 face of the future tooth, becomes capped by dentine, which forms on it from without 
 iuAvard, and, this crown cap being formed, the remainder of the tooth is developed by the 
 gradual growth of the pulp at its attached surface or base (see diagram. Fig. 261, c, c) 
 and its subsequent encasement by dentine. In the fully-developed tooth the pulp comes 
 to occupy a comparatively constricted central chamber corresponding in form pretty accu- 
 rately to the external contour of the tooth, and this chamber may be yet further dimin- 
 ished in size by a renewal of the centripetal growth of dentine. 
 
 Dentine, remaining as it does in connection with its formative organ through the 
 medium of the tubuli of which it is mainly built up, is capable of a certain amount of 
 
U DOS TOMES. -155 
 
 ineroascd sdlidiiicatioii. I'ven at its ]M'rijilicrv, ami iinilcr certain conditions is eiidnwed 
 witii must aciitt- sciisitivi'iii'ss. 
 
 The Crusta petrosa i>< forinfil on tlic mailuallv cionjratin^' root tliri>u'.'li the 
 ai:iiicv i>r till' dental >ae iir ra]>siile wliieli sunoiinds the rmmini.' tooth cruwn. and 
 ultimately eonies to invest the mut in the Iniin ol' the lihin-vaseniar ■• alveuln-fh-ntal 
 niemlirane." ' 
 
 The alvotdar jiortion of the jaw grows up with and is moulded around the developing 
 tet'th.and upon the eruption of their crowns affords the teeth firm implantation by closely 
 surrounding: their roots. 
 
 llavinir thus far traced a tooth's development, we now pass to the consideration of the 
 etVects which fidlow departures from this nt)rnial process. 
 
 Odontomes. 
 
 Tumors wliieli result IVom tin- ahnornial and e.\C(!ssive development of tlie dental 
 structures at any time ilurini;' the tooth's formation have heen grouped together hv M. 
 Broca under the name "odontomes."'- and elassitied by him as follows: 
 
 I. Odontomes EmbryoplastiqueS. — Those which arise l)efore the dental i)ulp 
 has develn|HMl odontolihists. and liefore the enamel organ has acfjuired special enamel- 
 forming cells. 
 
 II. Odontomes OdontoplastiqueS. — Those which arises after the si)ecial den- 
 tine- and enamel-forming cells have been developed, but prior to the formati(jn of the cor- 
 onal cap of dentine. 
 
 Ill- Odontomes Coronaires. — Those which arise while the crown is forming. 
 
 IV. Odontomes RadiCUlaireS. — Those which arise during the formation of the 
 root. 
 
 These four designations, pointing respectively to the periods in the tooth'.s develop- 
 ment at which the hypergenesis of the pulp has arisen, also indicate to a certain degree 
 the structural formation of a tumor formed at either jieriod ; but in adopting these terms 
 it must be understood that in one sense the embryoplastic and odontoplastic conditions 
 are present con.secutively during the whole period of dentitication, and also that if the 
 odontoblast layer of cells is destroyed at any point true dentine will not there be formed, 
 although tlie imlp may uiidiTgn ealeitieation, resulting in a kind of osseous structure. 
 
 Embryoplastic Odontomes. — Under this name M. Broca ranges encysted 
 fibrous and tibro-plastic tumors of the jaw. As the dental germ at the time of their 
 origin contains no special dentine- and enamel-forming cells, di.stinctive dental .structures 
 would of necessity be absent from these growths ; and such absence must of course leave 
 their dental origin in doubt. 
 
 In one instance (mentioned by Tomes) M. Robin met with a tumor in the lower jaw 
 of a child ait. 2 years and t! months; this tumor, apparently fibrous, was studded with 
 papilla?, on which distinct dentine and enamel were found. Now. whatever doubt may 
 arise as to the origin of the before-mentioned tumors, tliere can be no doubt as to the 
 dental origin of this one, and it is probable that in it a longer existence would have been 
 accompanied by further dentification. In another odontone, which occupied half of the 
 lower jaw of a girl a;t. 2 years and 9 months, M. Broca found the formation of dentine 
 proceeding at numerous points ; and the fusion of these secondary bulbs, coated as the}' 
 were with enamel organ, would result in bringing about the structural conditions found 
 in an odontoplastic odontome. 
 
 Odontoplastic odontomes, in outward form, may bear not the slightest resem- 
 blance to a tooth. 
 
 Structurally, they consist of a more or less confused ma.ss of dentine, enamel, and 
 osseous structure, the dentine occurring in tracts, between which the enamel has dipped 
 down, f^namel is also found capping nodular projections which occur on the surface. 
 
 The bulbs of one or more teeth, normal and supernumerary, may enter into their for- 
 mation. 
 
 The case met with by Dr. Forget, and reported by him, may be cited as an example. 
 
 ' From the dental sac is also probably derived the membrane known as the " cuticula dentis." or 
 "Xasmyth's menibrane," which in an unworn tooth is found continued over the crown, and is 
 regarded by C. Tomes as an undeveloped cemental layer. 
 
 - Exostosis of the root and "deinine excrescence" in the pulp chamber are called by Mr. Salter 
 "secondary odontomes" and naturally come Tuider tliat desi.<niation, as niisrbt also the outgrowth of 
 the pulp which sometimes follows the exposure of that structure; but, as these are affections of the 
 fully-developed tooth, they will be considered in the second division of our subject. 
 
456 
 
 ODONTOMES. 
 
 Fig 26i>. 
 
 A man ast. 20, presented himself with disease of the lower jaw from which he had suffered 
 since Jie was five years old. On looking into the mouth a hard, smooth tumor was seen 
 occupying nearly the whole of the left side of the lower jaw. None of the teeth beyond 
 
 the first bicuspid were present. On removal (by 
 .section of the containing bone), this tumor proved 
 to be a hard, oval, tuberculated mass the size of an 
 egg, chiefly composed of dentine, with enamel invest- 
 ing the nodules and dipping into crevices. Be- 
 tween the tumor and the osseous crypt which it 
 occupied there was a thick fibro-cellular membrane. 
 The forming second bicuspid tooth and the crown 
 of a molar were found impacted in the jaw through 
 the superposition of this mass. 
 
 In one case reported and figured by Tomes a 
 large tumor presenting the appearance of a malig- 
 nant growth occupied the incisive region of the 
 upper jaw of a man xt. 25, his four upper incisors 
 Represents, on a much reduced scale, the half of not having appeared. A probe introduced into the 
 the jaw removed in this case (The dots across t^mor impinged on something hard, which proved 
 
 the ascending ramus mark the line of its sec- i ^ T i i 
 
 tion.) to be sundry masses of tooth structure, best de- 
 
 scribed as odontoplastic odontomes, together with 
 some ill-formed teeth. These specimens, numbering, in all, fifteen, are in the mu.seum of 
 the Odontological Society of London. 
 
 In a case reported by the late Mr. Harrison an odontoplastic odontome occupying the 
 space between the incisors and molar teeth came away spontaneously. This case and the 
 nature of other reported cases show that the extirpation of an odontome should never 
 involve the removal of the containing portion of the jaw. 
 
 In one or two reported cases the tooth bulb, having produced an eccentric formation 
 such as described instead of an ordinary crown, has afterward assumed normal limits and 
 formed fairly-shaped roots. 
 
 Coronary Odontomes. — In these the main outline of the tooth is preserved, but 
 an irregular outgrowth nmre or less circumscribed projects from the crown. This out- 
 growth, having arisen while the crown was in process of formation, consists of the coro- 
 nal tooth structures — viz., enamel, dentine, and possibly enclosed pulp. If small and 
 involving the neck of the tooth, an outgrowth of this nature may be at first mistaken for 
 tartar. 
 
 Somewhat allied to these cases are those in which a tooth presents one or two super- 
 numerary cusps or supernumerary teeth merged with it. 
 
 A small globular projection of enamel is also occasionally met with on the root of a 
 tooth, and has been ranged among odontomes by Salter, who, finding that it caps a cone 
 of dentine, calls it " a submerged tooth cusp." The crown of a simple supernumerary 
 tooth has been found attached in the same po.sition. and probably these cases have 
 a like origin. 
 
 Radicular Odontomes. — This form of tumor, which in several recorded cases 
 has attained the size of a chestnut, is found attached to the neck and root of a fully- 
 formed tooth by a moi'e or less constricted base, and results from an irregular outgrowth 
 from the dentinal pulp. 
 
 Structurally, radicular odontomes generally consist of osteo-dentine more or less cov- 
 ered in by a layer of dentine, with a coating of cementum externally. 
 
 An odontome of this kind, embedded in front of the anterior margin of the ascending 
 ramus of the lower jaw and passing vtp behind the tuberosity of the superior maxilla, was 
 removed by me at Guy's. This tumor (see Fig. 2Go) was attached to the lower wisdom 
 tooth of a woman aet. 38. The patient had experienced no inconvenience from her mouth 
 rip fo the age of fhirfi/, when great swelling over the ascending ramus occurred, accompa- 
 nied by closure of the jaws and excruciatir^g pain. These symptoms — icf/h intervals of 
 complete cei^sation for two or three months at a time — recurred until the odontome, which was 
 gradually being extruded, was removed (very easily) by extracting the tooth to which it 
 was attached. 
 
 In the case which is figured and reported at page 441 of this volume. Fig. 236, a sym- 
 metrical enlargement of the whole root occurred, producing a dilated hypcrtrophied tooth 
 fang. 
 
 Odontoplastic and radicular odontomes are very rare, only a few cases of each in the 
 
ohos roMi'.s. 
 
 ■')4 
 
 iitlicrs wliifli have 
 
 ; lull I lie rcco; 
 denial (iri'Mti ii 
 
 riiitiiiii i>r til 
 
 true nature o 
 of the 
 
 I' tlicsf titiii(jr.s 
 V\(i. ii*i:i 
 
 I^Klic'iiliir • iili III tome. 
 
 hiiniaii 
 antl III" 
 
 liiulicsi iiii|Hirtaiici'. as it will avert an unnecessarily severe (ijiera- 
 titui tor their reinnval. In the ease ul" tumors anil cysts nf the jaws 
 the undue alisenee uj' any tooth will jioint to the ](r(d)aliility of 
 their dental (U'iLrin. hut the possihility of such ori^'in would not lie 
 exeluiled if the mwinal uuniher id' teeth were |)reseut. as a sujier- 
 liunu'rarv looili may oriuinale either an odontonie nr a dentii:erou> 
 
 A irlanee at the close packiiit:' ol teeth ill a cliild > .ii'\\'- ii"^ 
 sliown ill i-'ii:'. 2()S, will show the stroni: ]iroltal)ility of a dental 
 origin for tiiiniu-s and cysts of the jaws in youii<: suhjects. especially 
 when it is reuienihered that eaidi of the forty-eight teeth to he seen 
 in such jaws at one time is, or has heen. the centre of develo|i- 
 luental activity ; the likelihood, also, that tumors may cause in- 
 volvement or displacenieiit (d' iieiuhhiUMULr teeth will he readily realized. 
 
 Gemination, or the union of eontiu'iious ti'eth. due to the fusion id" their pulp.s, i.s 
 met with nceasiuiially in hoth the temporary and the permanent set. Normal teeth may 
 he thus joined, lU" normal and supernumerary. 
 
 Dilaceration, or the ahrupt chan<:;e in the direction of the tirst- and last-formed por- 
 tions (d" a tooth, sometimes occurs, and i.s due to a shifting of the forming tooth on its base. 
 
 DentigerOUS Cysts are cysts formed by the accumulation id" fluid within the 
 dental capsule at some period of the tooth's development, or around a fully-developerl 
 tooth which has not erupted. They may, therefore, advantageously be classified, like 
 odontomes, according to the point to which the tooth's development has proceeded wlien 
 the change occurs which eventuates in tlieir formation. 
 
 When fully developed, a dentigerous cyst usually con.sists of a thick membranous sac 
 covered in by a thin osseous shell, formed by the expansion of tlie bone oi' the jaw. In 
 a case met with by Mr. Fearn one-half of the lower jaw was expanded by a cyst which 
 separated its external and internal plates and contained a canine tooth. In a unii|ue 
 specimen of Mr. Cartwright's a cyst with calcified walls containing a supernumerary 
 tooth expanded so as to fill the antrum, while having attachment only to the floor of 
 that cavity. The cyst at first usually contains a serous fluid, which may become puru 
 lent through the occurrence of inflammation. 
 
 The uncut tooth (temporary, permanent, or supernumerary) about which the cyst hag 
 expanded may be represented by a small shapeless calcified mass if its formation was 
 disturbed in the earliest odontoplastic period. This fact was 
 well exemplified by the case of a girl aged 13 who was at 
 Guy's under the care of Mr. Cooper Forster. (8ee Fig. 2(i4.) 
 Here two small irregular masses of dentine and enamel, the 
 representatives of an absent canine and lateral incisor, were 
 contained in two distinct cysts, which caused great protrusion 
 of the anterior wall of the superior maxilla. The enclosed 
 tooth may be attaclied firmly to the cyst wall or may be 
 found free within the cyst. 
 
 A dentigerous cyst, forming in the uj)])er jaw. may ex- 
 pand into atul cause di.stension of the antrum. Professor 
 Baum met with a case of immense dilatation of both antra, 
 one containing a molar, the other a canine. 
 
 In .some cai^es the tooth crown only or the crown and part 
 of the root have been formed prior to the expansion of the 
 capsule by serum, and these may be said to behtng to the 
 coronary and radicular periods. In other cases, again, the 
 cyst develops around fully-formed impacted teeth, which may 
 
 be found inverted. In one in.stance. mentioned by Tiunes, no less than twentv-eight 
 separate and adherent denticles (or small sujiernumerary teeth) were found in a cyst of 
 the upper jaw. and are probably to be looked upon as the ununited constituent parts of 
 teeth that were missing. 
 
 Although both odontomes and dentigerous cysts have their origin in early life, years 
 may elapse before the irritation caused by the presence of the odontome or the increasing 
 disfigurement and pain resulting from the enlargement of the dentigerous cyst may lead 
 a patient to seek surgical aid. 
 
 Fig. 2(54. 
 
 Case of Dentigerous Cyst not 
 involving .Antrum. 
 
458 SYPHILITIC TEETH. 
 
 Cysts developed on the root of erupted and fully-formed teeth are not classed here as 
 (hntigerous, as they form only an appendage to the tooth. They will be referred to 
 among the diseases of the teeth, but it may be here remarked that they sometimes attain 
 to a large size, and may, like dentigerous cysts, expand i?'to the antrum, and also that 
 their contents under inflammation may become purulent. 
 
 Supplemental teeth — /. e., extra teeth exactly corresponding to a neighboring 
 normal tooth — are occasioiuilly developed in both temporary and permanent sets, usually 
 in the front of the mouth. If they cause crowding or are placed before 
 Fig. 265. qj. behind their doubles, they should be extracted. 
 
 Supernumerary teeth — i. '.. teeth differing in form from any 
 of the normal .series — -are not infrequently found in the upper incisive 
 region, and occasionally in other parts of the mouth. A pair of teeth 
 somewhat resembling incisors, but of greater anterio-posterior depth, are 
 occasionally developed behind the permanent upper front teeth, and 
 others more resembling small molars or bictispids are also occasionally met 
 Denticle or most witli ; but by far the commonest form that the crowns of supernumerary 
 elementary Tooth teeth present is that of a siniide cone or of a cone truncated and fitted on 
 
 Formation. . ^., ,,, ^ ,,' , .. -i,, -ii- 
 
 its summit, and tliese teeth have a characteristic straiglit terminal line to 
 the enamel at their necks. They are, in fact, the most elementary form of tooth forma- 
 tion. (See Fig. 265.) 
 
 Treatment. — As a general rule, supernumerary teeth are to be extracted, and 
 will alwav's be found to have a single root, which may. however, be contorted and 
 expanded. 
 
 Malformed Teeth. — Abnormalitie.s^in the form of teeth may result from the dwarfing 
 or excessive development of the different parts or lobes of which they are architecturally 
 built up, and also from a defective formation of their enamel. These abnormalities may 
 be of great value in the diagnosis of constitutional peculiarities and in throwing light on 
 the condition of health present during a patient's early years. 
 
 Syphilitic Teeth. — Mr. Jonathan Hutchinson in 1860 first pointed out the asso- 
 ciation between congenital syphilis and a given niisshapement of the permanent incisor 
 teeth, and this fact may be considered fully proven. In 1875. Mr. Hutchinson drew 
 attention at the Pathological Society to his belief that defects in enamel were in many 
 cases due to the administration of mercury in infancy. The investigation of a large num- 
 ber of cases has convinced the present writer of the truth of this belief, and, in fact, 
 when he first gave his attention to the subject, in 1868, it was apparent to him that tlie 
 illustrations of syphilitic teeth given in several works were misleading, and that the mal- 
 formation they portrayed was not that one distinctive of syphilis, but, if at all due to 
 that cause, was one that had been obscured by some complication. 
 
 Certain popular teething powders, containing calomel together with an opiate, appear 
 to be the commonest form in which mercury acting injuriously on the enamel has been 
 administered. 
 
 The distinctive change of shape in the syphilitic tooth is essentially due to a deformed 
 development of the dental pulp prior to its calcification ; while rocky or honeycombed 
 enamel is a result and permanent record of depressed or interrupted nutrition of the 
 forming enamel at a particular period, brought about by the action of mercury, and 
 probably also by illnesses which lower the system generally or disturb the circulation 
 locally. 
 
 The key to the right understanding of these and other maldevelopments is to be 
 found in an accurate knowledge of the normal forms of the teeth, and in the recognition 
 of the fact that they are archlfecfnralli/, though not structurally, built up of simpler forms 
 which are liable to an individual alteration under certain pathological conditions. The 
 distinctive features given to teeth by syphilis and by mercury are apt to be obscured by 
 the action of both in the same case. As through this and other causes vague notions on 
 this subject are still prevalent, typical forms of normal, syphilitic, mercurial, and what 
 may be regarded as syphilitic-mercurial teeth are on page 459 presented at one view, 
 together with a verbal description of their differences. 
 
 Fig. 266, A, B, C, D, represents four typical sets of teeth. The bicuspids, which in 
 neither case suffer alteration, are withdrawn on the right side to bring the finst molars 
 better into view. 
 
 A. Normal teeth. — The labial surfaces of the incisors are seen built up of three equal 
 columns and present a greater width at their cutting edges than at their necks. The upper 
 central incisors are longer than the laterals. The first lower molars are large and angular 
 
SYl'lIIJJTTC TEETH. 
 
 459 
 
 teeth and have live well-inarkeil eiisps. shar|i-|M(iiiteil throuj^'h the greater pnimineiice cjf 
 a eeiitral tuljereh-. The ii|i|ti'r first iiinlars are also larg*' teeth with \vell-»iiarkc(l cusp.s. 
 The euttinijedires i>t' the iiieisurs t|iiickly 
 hiso tlu'ir tlir«>e pnniiiiiciices hy wt-ar. 
 
 H. Si/j>li!litir hith. — -In the ii|>|i(r 
 central ineisors the eentral enlunin is 
 <finii/ii/ anil the side enliinms incline 
 toward eaeh other, eaiisini; the enttinLC 
 cd<re of the tooth to he less in hreadth 
 than its neck. 'I'liey are often niiieh 
 less prouiinent than the teeth on eaeh 
 side of them. thronLrh their diminished 
 size, and also from a want of vertical 
 depth in the portion of alveolar process 
 in which they are imi)lanted. C'ora- 
 monly tliese teeth have a (piarter turn 
 which hrintrs their distal side.s to face 
 sliiihtly to the fn)nt. The h)wer inci- 
 sors have their cutting edges rounded 
 oft', and therefore not touching their 
 neighhors. The first molars are re- 
 duced in size and r/owj^-shaped. through 
 the dwarfing of the central tubercle of 
 eaeh cusp. Syphilitic teeth may have 
 a perfect covering of enamel, and will 
 not then he di.scolored. 
 
 C. Tcrfli icitli dcfcctlvi' enamcL — 
 Alia.ses. " stomatitic," " honeycombed," 
 ^' rocky," " mercurial." Are malformed, 
 not through a changed shape of dental 
 pulp, but from failure of enamel to 
 form an even centrifugal encasement 
 over tliem. If the deficiency of enamel 
 is superficial, the color of the tooth may 
 be uiu\ltered ; but if the pittings are 
 deeper, they usually appear as black 
 points, or the more or less discolored 
 dentine is revealed and imparts to the 
 tooth a dirty "'size-colored" appearance. 
 The bicuspids, second molars, and wis- 
 dom teeth usually escape through their 
 later development. The age at which 
 the depressed nutrition occurred and its 
 duration are accurately recorded on the 
 teeth. 
 
 D. Si/philf'(ic-mercurial fnt]). — As re- 
 gards syphilis, the contour of these teeth 
 would be the point of chief diagnostic 
 
 value. In the left central upper inci.sor a small central tubercle of dentine is seen 
 denuded of enamel, which looks as if it had l)een gouged out from above downward ; in 
 the right central the exposed dentine has broken away, leaving a crescentic notch. In the 
 first molar a dcjiressed area is seen on the masticating surface, circumscribed by a ridge 
 of enamel, the denuded and ill-formed points of dentine representing the cusps having 
 been lost. 
 
 Syphilitic malformation of teeth ranges from an excessive dwarfing, in the worst cases 
 leaving only a shapeless peg to represent the incisor, to the merest indication of the typ- 
 ical form. It is not present at all in some cases of congenital .syphilis, and one child in 
 a family even may escape it. while the older and younger children have it. 
 
 In honeycombed teeth an irregular aiul insufficient develojunent of enamel produces 
 horizontal groovings or pittings of its surface and most often afi'ects the first-formed 
 points of the cusps, sometimes leaving them entirely denuded, as shown in the figure 
 given ; but when the agency which arrests the enamel formation is brought to bear later, 
 
460 CUTTING OF THE TEETH. 
 
 the cutting edges of the incisors and the tips of the cusps of the molars will have a per- 
 fect covering of enamel and the defective lines will be below them. Sometimes, presum- 
 ably when the cause has been gently exerted for a long time, slight horizontally-arranged 
 pittings cover the whole crown. 
 
 The irregularly-formed enamel may be structurally defective, as shown by its dis- 
 coloration ; and this may conduce to decay, as does also the pitting of the enamel if it 
 extends through to the dentine. In other cases the diminished size of these teeth — which 
 prevents their being crowded and exposes their sides to healthful friction — renders them 
 less obnoxious to decay than might have been expected. 
 
 Some children of different families seen by me 
 Fig. 267. present, together with great peculiarities of their 
 
 eyes and a general weakness in the development 
 of their dermal structures, the following peculiar- 
 ities in their teeth : The middle lobes are sharp, 
 recurved, and excessively long, while the lateral 
 lobes are dwarfed. In these cases, however, the 
 resulting pointed form can be readily distinguished 
 
 Pointed Teeth well covered with Enamel (not ,> ^i , , i -, • i-i p ^■^• 
 
 syphilitic). irom the truncated screw-driver-hke lorm indica- 
 
 tive of congenital syphilis. (See Fig. 267.) 
 
 Imperfections in Structural Development. 
 
 At the present day the early decay and loss of teeth are very common, and are prob- 
 ably in part due to an insufficient supply of food containing the elements which go to 
 build up the osseous structures, malnutrition in early life, from whatever cause, leaving 
 inevitably its mark on the exteriors of the teeth, which, once ill formed, have no power 
 of recuperation. 
 
 In infancy and childhood plenty of good milk and the use of " rclwlc flour meal " are 
 to be recommended ; it is to be borne in mind that until a child begins to take animal 
 food the above are the sources of supply of lime salts. The diet of the pregnant mother 
 may also with advantage receive attention. 
 
 Structural Defects in Enamel Development. — Perfect enamel contains 
 
 upward of 95 per cent, of earthy matter, and consists of rods united together without 
 intervening matrix and placed at right angles to the surface of the dentine. Enamel, 
 when well formed, is semi-transparent, but when defective from a want of homogeneous- 
 ness in its structure presents an opaque, white, chalky appearance, and is then easily 
 disintegrated. At the bottom of the natural sulci of otherwise well-formed teeth 
 enamel is sometimes deficient in thickness and in soundness, and this favors the ingress 
 of decay. 
 
 Structural Defects in Dentine Formation. — AVell-formed dentine is uni- 
 formly dense and ivory-like. It is built up of tubuli and intertubular substance, the 
 tubuli serving to convey nutrition from the pulp to the periphery. Dentine is endowed 
 with sensitiveness through the soft tissue, which passes from the pulp to the surface and 
 renders the dentine immediately beneath the enamel especially sensitive. 
 
 Through imperfect development a (so-called) granular layer which is found on the 
 surface of dentine in the root may be present on the surface of coronal dentine. The 
 (so-called) globular condition of dentine is another developmental defect. When the 
 enamel covering is lost, imperfect dentine softens rapidly under decay without becoming 
 darkened, and is also apt to be exceedingly sensitive. 
 
 Cutting of the Teeth. 
 
 During the eruption of the temporary teeth, if there is disturbance of the general 
 health traceable to dental irritation, and especially if there be the least sign of cerebral 
 (disturbance, there should be no hesitation in freely lancing the gum — tumid or tense — 
 which covers the tooth that is presenting. In the case of a front tooth a straight incision 
 should be made on to i\\e front of its cutting edge ; in the case of the molars a crucial 
 incision should be made from corner to corner. 
 
 As a rule, the permanent teeth erupt very easily, but an incision with a lancet may 
 sometimes with advantage be had recourse to in cases where cerebral disturbance is easily 
 excited ; and it is often well to remove bodily the gum from above an erupting wisdona 
 tooth when an antagonist tooth bites upon and irritates it. 
 
iiiiiim I 'LA iiiTY OF Ti'.irni. 
 
 M'A 
 
 Irregularity of Position. 
 
 liriiiiiliiilti/ iA' ;irr;iiii:<'iin"iit li;iriliv fViT orciirs amorij.^ tlic ti'iii|)()r:iry Ici'tli, luit ;iii 
 uiuluc primiiiu'iifi! nf (lie ii|i|)fr incisfirs, wliit-li soiin'tiiiics is aci|iiirc<l tlinMi^h tlmrulj' 
 suc'kiiii: ami a tt'iidi'iicv to iiiiilfrliaii^iiiijr, iVuiii tlic ftvcr-iltnrlopiiieiit nl" tliu lower jaw as 
 coiuitait'd witli tin- u|i|M'r, slimild ivccivc attcntinii, in order that thi-st' comlifioiis may not 
 he perpetuated in the sreond set. The ahsenee of tlie spaeiii;; of the temporary tettth, 
 whicli shoiihl |MH'ee<h' their sht-ddiiiL'. will point to a likelihood <d' crowding anioni.' the 
 fomintr permanent teeth and deniaml watchfulness. 
 
 limiuJiirUy of the permanent teeth <iften resiilt.s from the want of timely e.xtractioii, 
 and even oftener from the untimely extraction of temporary teeth. It therefore behooves 
 the surgeon who may he ealled ujton t<j e.xtract teeth from young subjects to aeijuaint 
 himself with the time of eruption (d' the different permanent teeth and with the points 
 ol" diflerenee between temporary and |iermanent teeth. 
 
 \Vell-develo|ieil adult jaws should eonseijuently In; thoroughly studied as a type and 
 compared with the jaws in ehildhood. It will be then seen that develoi)ment has <jccurred 
 longitudinallv backward for the ai-comiuodatiou of tin; permanent molars, while the part 
 of the jaws that was occupied by the ten temporary teeth, having undergf^ne additional 
 development on its anterior face, is in the adult occupied by the incisors, canines, and 
 bicuspids. In order tluit these latter may have room for even arrangement, it is import- 
 ant that the anterior ]>ermanent molars (the si.x-year-old teethj shouhl not be allowed to 
 take 11)1 a too forward position, which they will do if the temporary molars are prema- 
 turely lost from neglected decay. Un this account, therefore, the timely stopping of the 
 back temporary molars is a practice to be recommended. 
 
 The accompanying figure will show how easily 
 irregularities may be brought about, as the retention Fig. 268. 
 
 of the root of a temporary tooth is enough to pre- 
 vent the permanent tooth from taking up its proper 
 position. 
 
 In judging of the amount of space that there 
 will be for the accommodation of the coming teeth, 
 it is to be renieml)ered that the alveolar portion of 
 the jaws grows up with and is moulded around the 
 teeth it supports, and that there is a strong tendency 
 for teeth to assume their proper position (the action 
 of the tongue and lips conducing thereto), while the 
 replacement of the temporary molars by bicuspids 
 increases the space for the front teeth. 
 
 A ver}' common form of irregularity results in 
 otherwi.se well-developed jaws from the permanent 
 upper incisors being erupted to the rear of their 
 unshed predecessors. In such a case the prompt 
 removal of the temporary teeth is demanded ; for if, 
 on the further elongation of the upper permanent 
 incisor, the edge once passes behind the incisor of the lower jaw, at each closure of the 
 mouth the evil is increased, and can then be corrected ordy by the use of a regulating 
 plate. On the same score, lower incisors may sometimes be kept in the rear of the tem- 
 porary teeth in order that they may be ready to wedge forward the upper incLsors and 
 thus secure the ovf-rJapping of the. iijjpi r front teeth, which allows of their true incisive 
 action, while it spares them undue wearing away. 
 
 In spite of the above precautionary measures at the time of the second dentition, 
 cases of irregularity will occur from malformation and insufficient development of the 
 jaws. Some of the .slighter of these irregularities are amenable to surgical treatment — 
 that is, a timely extraction will allow nature to .set all straight ; but if a tooth is taken 
 out on one .side of the mouth to relieve overcrowding, the preservation of symmetry will 
 often demand the extraction of another on the opposite side. The patient's profile and 
 the relative prominence of the upper and lower dental arches have to be considered in 
 deciding whether permanent teeth should be extracted for regulating purposes, while the 
 soundness of teeth, the direction taken by their roots, the firmness of their implantation, 
 and their comparative durabilitv are all points to be considered in deciding which tooth 
 should be sacrificed for the benefit of the remainder. 
 
 Sometimes the first permanent molar may with advantage be taken out when the tend- 
 
 M A'' 
 
 A, Permanent incisor teeth. 
 
 B, Peruiaiieiit canine. 
 
 Drawing of .laws of <"hild set. 6. (.\ and B point 
 to permanent incisors and canines. The Id- 
 cuspids are seen embraced by the roots of the 
 temporary molars. The permanent molars, 
 with the e.Kception of the wisdom, are pres- 
 ent. i 
 
462 IRREGULAEITY OF TEETH. 
 
 ency to overcrowding is decided. If this tooth, which is particularly liahle ta decay, is 
 pa*t hope of permanent preservation by stopping, its extraction in time allows the second 
 molar to come forward and partly occupy its .site and the wisdom tooth to come well into 
 place, while it also enables the front teeth to .spread and thus escape undue lateral pres- 
 sure and consequent decay. 
 
 On the other hand, there is the strongest reason for preserving this tooth when the 
 upper incisors are so prominent as to require drawing back, as it often affords the only 
 satisfactory point from which traction can be exercised; and a bicuspid in such cage 
 should by preference be sacrificed. Another valid objection to the extraction of the first 
 permanent molar occurs when the withdrawal of the prop which this tooth affords at the 
 back of the mouth would cause the lower incisors to bite up unduly on to the necks of 
 the uppers and drive them forward. 
 
 .Here it may be remarked that in all attempts to improve the regularity of the teeth 
 the relative positions of the antagonist teeth in the other jaw must be taken into account. 
 
 So far. only those cases have been considered that are capable of being benefhed by 
 timely extraction, but many cases require for their treatment the use of mechanical appli- 
 ances. Among these appliances a lever for expanding the arch of the upper teeth (while 
 it presses back the lower) and elastic bands are of great use. while in more advanced 
 cases a regulating plate must be worn, the principle of its action being that it affords a 
 fixed j)oint from which continuous pressure or traction is kept up on the teeth to be moved. 
 
 The movement of teeth by mechanical means should be gradual, or absorption of 
 bone will result without a compensatory development and the teeth will be loosened. 
 Twisted teeth can be turned on their axes. In-standing upper front teeth can be trained 
 out, and will be retained in their new position as soon as they are brought to overlap^ the 
 lower teeth ; prominent and projecting upper teeth can be gradually trained in, but will 
 be required to be kept in place for some time by mechanical means, to prevent their 
 reverting to their original position. The lower lip pa.«sing behind prominent upper inci- 
 sors inci'eases the deformity which is usually associated with a contracted arch. 
 
 In regulating teeth much greater difficulty has to be overcome where contraction or 
 malformation of the jaw causes the irregularity than in those cases where there is simple 
 misdirection of the teeth them.selves. 
 
 In some cases complete underhanging of the jaw is present — i. e., the xipper teeth, 
 back as well as front, are set within the arch of the lower teeth ; this condition does not 
 admit of much remedy when once firmly established, but may be prevented to a certain 
 extent by timely extraction of lower teeth together with a training out of the upper. 
 The earlier that irregularities receive attention the better, in order that the misplacement 
 may not be increased, and also because the moving of teeth can be safely effected only in 
 the young. 
 
 Canine and wisdom teeth, owing to the lateness of their eruption and the position they 
 occupy during development, are peculiarly liable to be shut out from the dental arch. 
 The canine, being a durable tooth, should in many cases have room made for it by the 
 extraction of one of the teeth that have closed in upon its .site. The cutting of wisdom 
 teeth is frequently attended with much trouble, and it may be remembered, in the case 
 of young subjects with small maxillfe whose first or second molars are much decayed, 
 that the timely extraction of either of these teeth may allow the wisdom tooth (if devel- 
 oped) to erupt easily and occupy a useful position. In the upper jaw, if the wisdom is 
 forced to take an outward direction, and so cause irritation of the cheek, it .should be 
 extracted. In the lower jaw. where there is insufficient room for it between the second 
 molar and the ascending ramus, its efforts to erupt often produce nerve irritation, chronic 
 spasm of the masseter. the formation of pus between the crown of the tooth and the super- 
 jacent gum ; it may also cause absorption of the root of the second molar and lay bare 
 its pulp. 
 
 In all cases where the impaction of a lower wisdom tooth is a source of irritation the 
 impaction .should be at once got rid of by the extraction of either the wisdom tooth or 
 the tooth in front. The operation required, as well as the serious results which may 
 attend purulent inflammation about an impacted wi.sdom tooth, will receive notice later. 
 
 Teeth are sometimes erupted in strange positions ; thus, Salter records a case of inver- 
 sion and eruption of lateral incisors in the nares. and Tomes figures the case of a molar 
 erupted in the median line of the palate, and another case in which the crown of a molar 
 pierced the cheek at the angle of the jaw. In another case, figured by Tomes, the crown 
 of a molar presented at the sigmoid notch, but remained impacted. 
 
 Impaction, or retention of a tooth within the maxillary bone, often occurs witliout any 
 
ininMrLMirrv or tf.eth. 103 
 
 ill iTsuIrs, hut occjisidiiallv it is iirdtliictivc ul' st-vcrc iiiisfliift". Tliiis, in ;i ciiM- wliidi 
 occiinfj ill ilif |ii:ictici' ut' Mr. {'artwrii.'^lit. Sr. (ami which is repdrtcd at h-ii^th hy Mr. 
 Salter ), it wj^ iiiddiictive of si'Vcrc iicural^Ma. In this casti the in-t'sciice of an inipaott-d 
 upper (-aninc, which caused a pri>niinenc(! itu tho palate, ^ave ris/^ for ci^'ht years to con- 
 stautlv-recurrin^^ most .seven; neuralj.'ie pain, conHued to a cir(;uinscrihcil spot u\\ the left 
 side of tlie vertt'.v oi' the heail. In other cases it may jrivc rise to cystic eidar<:eincnt or 
 altsccss, the latter perhaps late in life, fntui the Imried tooth hecomin;; more superficial 
 t-hrouirh ahsorptinn ut' the containing hone. The palate may he involved if a tooth is 
 impacted within the pahitine process of the superior maxilla, or an ah.sce.ss may be 
 formed helow the tongue from impacted lower teeth. 
 
 The foUowiut; case was reported hy Mr. McCoy in the Lnnat, 1871 : A boy ;et. 14 
 had a tumor of the antrum the size of an apricot, due to an impacted canine, the crown 
 of wlrieli projected into the antrum, while the root was impacted in a socket in the na.sal 
 proccjis:; the antral cavity contained a litth; j^lairy fluid, hut was chiefly filled by a gelatin- 
 ous sflirstauce — apparently thickened mucous membrane. 
 
 Absence of Teeth. — A few cases are recorded of edentulous jaws. Wisilom ami 
 upper lateral incisors — the teeth most liable to variations in size and shape — are also the 
 most liable to su])pression. Occasionally other permanent teeth — notably, lower second 
 bicuspids — fail to make their a]ij)earance, in which case it may be right to leave their pre- 
 decessors undisturbed if they show no signs of loosening; temporary molars may in such 
 cases serve for many year.s. 
 
 The tendency of particular teeth to take irregular positions and the liability of others 
 not to be developed are facts that have to be borne in mind in connection with the prob- 
 able dental origin of tumors and cysts of the jaws. 
 
 Before passing to the second division of our subject it may be useful to enumerate 
 the miu-bid conditions which may be simulated by the tumors, cy.sts, etc. which origin- 
 ate from an unerupted tooth in the ways described in previous pages. 
 
 Odontomes niay give ri.se to appearances such as may be presented by benign or 
 malignant tumors, whether arising spontaneously or due to the impaction of a foreign 
 bodv. such as root of tof)th, splinter of bone, or a bullet. 
 
 iDentigerOUS cysts, when slowly forming and before they have thinned the enclos- 
 ing bone to an extent which would allow of the characteristic sign of crfojnrmrtit on pres- 
 sure, may be diffieult to diagnose from solid tumors. 
 
 A dentigerous cyst may also produce the .same symptoms as a cyst formed on the root 
 of an erupted and diseased tooth; and when, through inflammation, its fluid contents 
 become purulent, it may in like manner resemble an alveolar abscess — /. e., an abscess 
 formed around the root of a diseased tooth — and, like it, will be apt to give rise to a fistu- 
 lous opening. 
 
 Empyema. — Suppuration in the antrum, or empyema, arises probably in two dis- 
 tinct ways. Ill the one case it is due to inflammation of the lining membrane of the 
 cavity, which, being continuous with the mucous membrane of the nose, allows of the 
 escape of the contained purulent fluid into the middle meatus by the natural orifice. In 
 the other case the pus is contained in a sac which has expanded into the antral cavity, 
 carrying the lining memlirane before it, and then the pus does not find exit by the na.sal 
 opening; this latter condition (as pointed out by Otto Weber) is generally present when 
 the root of a tooth originates the mischief by penetrating the cavity, and when an alve- 
 olar abscess extends into it, while cysts formed on a root and dentigerous cysts expand 
 into tliQ cavity in this manner and may afterward suppurate. 
 
 Dl.\GN'OSl.s. — The history of these cases may throw light upon their nature, while a 
 careful examination of the mouth should be made to decide whether the due number of 
 permanent teeth have been erupted as to the existence of disease in any tooth in the 
 neighborhood of the tumor. An exploratory puncture or opening should be made in any 
 case that may have a dental origin before any serious operation is undertaken for the 
 extirpation of the disease. 
 
 Tiu:.\TME.\T. — For treatment, it will here sufiice to say that the complete removal of 
 any tooth or dental formation involved is demanded, and that for the renniining treatment 
 the ordinary rules of surgery apply. 
 
 Diseases of the Teeth. 
 
 The largeness of the nerve supply to the dental pulp and periodontal membrane, and 
 the liability to irritation and inflammation to which these confined vascular structures are 
 
464 DISEASES OF THE TEETH. 
 
 subject, give an importance to diseases of the teeth which they would not otherwise pos- 
 sess ; the pain, direct or reflex, which nearly always attends the involvement by disease 
 of these dental vascular structures and the serious local lesions which may follow their 
 suppurative inflammation often cause the mere destruction of the tooth as an organ of 
 mastication to be a matter of secondary importance, although in itself sufiiciently regret- 
 able. Bearing in mind the description of a tooth given at page 453. it will be understood 
 how the maintenance of a tooth in its usefulness depends on the integrity of its compo- 
 nent structures, and how it happens that the pulp and alveolo-dental membrane, which in 
 a condition of health are tissues simply subsidiary to the nutrition of the hard structures 
 around them, become, when the tooth is attacked by disease, the parts which have espe- 
 cially to be protected from invasion. 
 
 The morbid conditions which may produce irritation of the dental nerves may with 
 advantage be grouped in two divisions. 
 
 T/ie first division, including those which cause irritation of the nerves supplied to the 
 pulp with their continuation into the dentine, consists of — 
 
 (o) Exposure to irritation of sensitive dentine through loss of enamel resulting from 
 caries, erosion, or fracture. 
 
 (b) Irritation and chronic or localized inflammation of the pulp when deprived of its 
 protective covering of dentine through the more extended action of the destructive 
 agencies named under (a). 
 
 (c) General inflammation of the pulp, following sooner or later on the previous con- 
 ditions and resulting in its sphacelus. 
 
 (d) Irritation of the pulp through the presence of irregular formations of secondary 
 dentine in the pulp chamber. 
 
 Tht^ second division, including the morbid conditions that cause irritation of the nerves 
 supplied to the alveolo-dental membrane and to the dental nerves external to the tooth, 
 consists of — 
 
 (a) Dental periostitis — i. e., inflammation (plastic or suppurative) of the periodontal 
 membrane. This results by far the most commonly from inflammation and sphacelus of 
 the dental pulp ; it may be caused by rheumatism and by syphilis or may be a symptom 
 of salivation. It may be produced by irritation of the periodontum at the neck of the 
 tooth where it meets the gum, and occasionally results from the undue pressure of an 
 opposing or contiguous tooth. 
 
 (/j) Exostosis—/. (?., hypertrophy of the crusta petrosa — sometimes resulting from, 
 sometimes the cause of, irritation and inflammation of the periodontum. 
 
 (c) A needle-like pointing of the end of the root and a roughening of its end by 
 absorption. 
 
 ((/) Impaction of permanent teeth in the maxillary bones and futile attempts to erupt 
 made by such teeth, especially in the case of lower wisdoms. 
 
 (e) Overcrowding of the teeth. 
 
 Irritation of the dental nerves may excite pain at the point of irritation, pro- 
 ducing toothache, the pain being either confined to the faulty tooth or centred in it and 
 radiating to the adjoining teeth and to the nerves of the same side of the face and head ; 
 but not "infrequently it gives rise to reflex pain, in which case the tooth at fault often 
 escapes suspicion on account of its freedom from pain. More remote sympathetic nerve 
 afi"ections are also sometimes caused by dental irritation. 
 
 A most unequal amount of pain or nerve disturbance occurs in difl"erent subjects from 
 dental lesions of an apparently similar nature. Such diS"erences must be referred to struc- 
 tural peculiarities of the teeth, to the conditions of health, and to the diathesis of the 
 patient. 
 
 A faulty tooth is the real origin of many cases of neuralgia about the head and face, 
 although cold or depressed vital power will determine the time of onset. 
 
 That remote sympathetic pain may be due to dental irritation will be easily realized 
 by any one who has felt the distribution of his spinal nerves demonstrated on the scraping 
 of sensitive dentine in his tooth. 
 
 Toothache (or localized dental pain) varies in character according to the part of 
 the tooth involved; these diff'erences will be apparent as the effects of disease in the sev- 
 eral dental structures are considered, but it may be here remarked that a darting pain 
 (which may fade away with an ache) betokens irritation and probable exposure of the 
 pulp ; that intense pain of a violent, throbbing character points to general inflammation 
 of the pulp and may be expected to cease entirely with the destruction of that structure's 
 vitality ; and that the pain which attends irritation and inflammation of the periodontal 
 
IIKMOTI: Sl.llVnrs AFFKCTIOSS. lOo 
 
 imiiiKraiu' is id' ;i dull or L'liawiiiLT diaiaftrr, Iml may assuiiu; ;i tlircthhiii^r character if ati 
 lilvciilar alisci'ss is t"c'iiiu'(l. 
 
 HyperaBSthesia of the pulp may Im expected to coexist with the coiiditi<.tirt 
 whicli act oil its iierves, ami is eviiU-iiced hy sensitiveness of the to(»tli to heat and cold. 
 A hot instrument ajijdit'd in succession to tlu' crowns of" susj»ected teeth may afford valu- 
 able eviih'uce on this point, and tapping; the teeth may also reveal the oversensitiveness 
 of any one tooth. Slight periosteal irritation may accompany this condition. 
 
 Dental periostitis at its onset is often attended Ity a sensaticju of fulness in the 
 tooth w liirli iMclincs tlic patii'iit to )>ress it firmly into its socket ; this .sensation is suc- 
 ceede«l hy painful tendi'rness on pressure of the tooth, whicdi is often slightly raised and 
 looseiu'd, while the |^uni. which at first presents a narrow red line arouiul the neck of the 
 tooth, tends to become diffusely red and tender over the root. 
 
 In ob.scure cases of pain the presence or absence of cireunj.scribed periodontitis and 
 of irritation due to exostosis may be diagno.sed by pressing the crown of the tooth in 
 different directions, so as to tilt the end of the root against the socket ; the biting of 
 something hard witli one tooth after another may also be adopted as a means of finding 
 out if irriiiitiiui of this obscure nature is present in a root. 
 
 Reflex Nerve Affections due to Dental Irritation. 
 
 The nerves of the second and third divisions of the fifth are more liable than any 
 others t(j reflex affections due to dental irritation. Next to the several branches of the 
 trigeminus, the nerves of the cervical and brachial plexuses are most often involved. 
 
 Neuralgia. — The following are the most common sites for the manifestation of 
 reflex pain ; 
 
 (a) Another tooth than the one in fault, frequently the one that antagonizes it in the 
 opposite jaw, and occasionally a tooth in front of the one irritated (thus, an innocent 
 bicuspid may ache when the wisdom tooth is at fault). 
 
 (/O The side of the head, with the focus of pain near the parietal eminence, due to 
 irritation of a tooth (generally an upper back one) of the same side ; this is the source 
 of many cases of unilateral headache. ♦ 
 
 ((') The eyebrow, with the focus of pain at the supraorbital notch, and the cheek, with 
 the focus of pain at the infraorbital notch, the irritation in these cases being located in 
 the upper teeth. 
 
 (^/) From irritation of the back lower teeth there may result earache and pain extend- 
 ing over the temple, and also pain passing down the neck. 
 
 Pain over the upper cervical vertebi'a appears generally to come on secondarily to the 
 above-mentioned neuralgias. 
 
 More Remote Nervous Affections. 
 
 Pain, to quote the words of ^Ir. Salter, is only one of the phenomena of reflex dental 
 nerve irritation. There may be produced muscular spasm and muscular paralysis, paraly- 
 sis of some of the nerves of special sense, perverted nutrition. In these pages only an 
 enumeration of some of these affections can be made, and the reader is referred for details 
 of cases to the work on Dental Fatliologu (tud Surycri/, by the above-named author, and 
 to the second edition of Tomes's Dental Sunjery. 
 
 The following secondary and remote nervous affections may arise from irritation iu 
 the teeth and be curable by the removal of the exciting cause: 
 
 Convulsions, etc., resulting fi'om irritation in teething. 
 
 Epileptiform seizures. In these cases, when an uneasy sensation is felt in the mouth 
 previous to the attack, the best results may be hoped for from stopping or extraction, as 
 the case may demand. 
 
 Delirium from retarded eruption of wisdom teeth. 
 
 Firm closure of the mouth through chronic spasm of the masseter muscle is a fre- 
 quent complication of irritation in or about the lower back teeth. 
 
 Wry neck. Pain in the course of the cutaneous branches of the cervical plexus. 
 
 Partial paralysis of the arm and hand, with an inability to grasp with the fingers, 
 accompanied by aching pain. (Several such cases have recently been under my obser- 
 vation — a f\\ct which shows their comparative frequency.) 
 
 Amaurosis. Strabismu.*. (Ptosis and deafness are also recorded complications.) 
 
 Ulceration in the course of a branch of the fifth nerve. 
 ;io 
 
466 REMOTE NERVOUS AFFECTIONS. 
 
 A case of obstinate leucorrhoea and acute uterine pain cured by the extraction of a 
 tooth was recorded by the kite Mr. Sercome. 
 
 One case of fatal tetanus is quoted by Mr. Tomes as having followed the operation of 
 pivoting. 
 
 Such are some of the reflex pains and remote complications which may arise from 
 dental irritation in a patient of neuralgic diathesis, but apparently similar exciting causes 
 are constantly present without producing any such results. 
 
 Dental Diseases. — In an apparently sound tooth an irregular formation of dentine 
 in the pulp chamber is sometimes the cause of neuralgic pain, and may be suspected if 
 hypersesthesia of the pulp exists in a tooth exhibiting no other cause for oversensitive- 
 ness. 
 
 Exostosis, and occasionally needle-pointing of the fang, may also be the cause of neur- 
 algic pain at the root of a sound tooth, and may have their probable presence revealed 
 by the tooth exhibiting tenderness on pressure into the socket, and perhaps later on by 
 other evidences of periosteal irritation. Being otherwise irremediable, extraction is 
 demanded in these not-to-be-foreseen conditions. 
 
 With the exception of the above comparatively rare cases it will be noticed, by 
 referring to the list of morbid dental conditions given at page 4G4, that all the aff'ections 
 there enumerated may result from the spread of disease from one dental structure to 
 another, and therefore demand treatment for their prevention and limitation. Thus, when 
 the exterior of a tooth is the first part attacked — as it always is in caries and erosion — 
 the aim should be to preserve the pulp from irritation and exposure ; and when the pulp 
 is already exposed through the above diseases or by fracture, the aim should be to prevent 
 its inflammation, while, if the vitality of the pulp is past saving, means should be taken 
 to prevent the involvement of the periodontum ; and finally, if that tissue is involved, 
 extraction of the tooth may be demanded to relieve pain and to prevent the formation of 
 alveolar abscess with its possible complication of fistulous openings on the face, or the 
 still graver consequences which inflammation external to the tooth may bring about. 
 
 Three facts in the nature of a tooth aid dental surgery in its conservative efl'orts. 
 
 The first is that the dense and evascular character of the enamel and dentine allows a 
 diseased portion of them to be removed and the remainder to be preserved by friction or 
 by a filling inserted in the place of the removed portion. 
 
 The second favoring fact is the continued presence on the surface of the pulp of the 
 odontoblast layer of cells, ready to form secondary dentine over the pulp, and thus shield 
 it, if they are stimulated to renewed action by irritation of the primary dentine. 
 
 And thirdly, the small calibre of the root canal in a perfected tooth, and the minute- 
 ness of the aperture that remains at the end of the root for the passage of the vessels 
 and nerves, cause the pulp to be so comparatively isolated that when diseased it can 
 with safety be destroyed by escharotics and be extirpated before its sphacelus has 
 involved the structures external to the root. 
 
 The practical remark may here be made that up to middle age probably 90 per 
 cent, of the teeth that are. lost owe their destruction to caries, while later in life recedence 
 of the gums and absorption of the alveolus — often prematurely induced by the presence 
 of tartar — lead to the loss of many teeth by depriving them of implantation. 
 
 Before reviewing the agencies destructive to the teeth it will be well to consider the 
 nature of secondary dentine and cemental exostosis, which occupy a debatable position 
 between healthy and pathological tooth formations. 
 
 Secondary Dentine. — Three diff"erent developments come under this name. The 
 firat^ called by Salter " dentine of repair," has been already alluded to. The loss of 
 dentine externally through abrasion, caries, erosion, or fracture will oftentimes produce 
 compensatory development internally at the point where the affected dentinal tubuli abut 
 on the surface of the pulp ; this reparative growth prevents pulp exposure when from 
 attrition the enamel and a considerable portion of dentine have been worn away from the 
 surface of a tooth, and sometimes it will obliterate the pulp chamber. In cases of decay 
 "dentine of repair" does not often, unaided, prevent exposure of the pulp, but it hinders 
 it and becomes a valuable auxiliary in its protective treatment. (See bicuspid, in D, 
 Fig. 270, p. 470.) 
 
 Second Form. — Cases have been described by Salter and others in which a nodular 
 outgrowth of dentine or osteo-dentine has projected into the pulp chamber of a sound 
 tooth and given rise to severe neuralgia. This development must be regarded as morbid, 
 and has been named by the above author " dentine excrescence." 
 
 The third form ^ or secondary dentine, is essentially an affection of the pulp. " Intrin> 
 
DENTAL CARIES, OR DECAY. }(;? 
 
 sic {•iilcilication" is tlic iiaiiii' proposctl i'ur it l>y Mr. Salti-r. wlut has described its foriiiu- 
 tiiiii as tluis (ifcurriiit; : Isolated masses ul" osteo-deiitiiie f'onii, at first usually in the axis 
 of the )»ul|) ; these masses eiilar<re and mor^e into one another, spread t(»\vard the periph- 
 ery, and may at length occupy tlie whoh; of the l»ulp ehamher. _ This formation may 
 he reuarded as .sometimes resultinLT from and as sometimes the cause of pulp irrita- 
 tion. 
 
 Exostosis if* !i term applied U) enlur<.'ement or out<rro\vth of the crusta jtetrosa (see 
 molar, in J], I'iu. 270), ranj^iiif^ in amount from a .sli<rht ^'eneral thickeninj^ (when it can 
 hardly he reiiarded as ))atholoj;ical) to an outjrrowth which may double the size of the 
 root and sometimes has i'used toi:;ether the roots of contiguous teetli. The dejiosition cd' 
 cementmn may alternate with its absorption, and not inlVefjuently it will be found thiek- 
 eiu'd on the upper part (d" a root where chronically inllained j»eriosteum exists, while the 
 end of the root will be bare of it and bathed in the juis of an alveolar abscess. It often 
 causes a ulobular enlariremi-nt of the end of the root. Sometimes snuill excrescences of 
 it will form on tooth alter tootii, and by i^ivini:- rise to most severe neuralgia will nece.s- 
 sitate their extraction. 
 
 Exostosis may arise secondarily to inflammation of the periodontum, and will then be 
 accompanied by extra va.scularity and tenderness of adjacent ^^um. etc. The means for 
 detecting its presence in its early stages, when arising primarily and causing neuralgia, 
 have been already mentioned ; symptoms that will be likely to attend its prolonged pres- 
 ence as a source of irritation are those of periodontal inflammation. 
 
 The nature of the agencies tliat destroy the dense structures of the tooth will now be 
 considered, and, ina.smuch as the sequence of disease, when once the pulp is exposed, is 
 much the same whether the exposure has occurred through caries, erosion, or fracture, 
 the treatment of progressive dental disease and the various affections of the pulp will be 
 considered and illustrateil once for all ; and, finally, dental disease external to the root, 
 with its complications, will receive notice. 
 
 The great ))revalence of caries at the present day makes it desirable that its nature 
 and the means for its prevention should be understood. These subjects will therefore be 
 discussed somewhat at length. 
 
 Dental Caries, or Decay, 
 
 may be described as the disintegration of the hard structures of the tooth by decalcifica- 
 tion. It always commences on the exterior of a tooth and saps inward ; when the crown 
 is attacked by it, a fault in the enamel is the first step in its course and may be due to 
 original faulty development or to mechanical or chemical injury. 
 
 Fracture may produce the enamel lesion. 
 
 A fre(|uent cause of disintegration of the enamel is the attrition exercised by the sides 
 of crowded teeth on each other, and, as this sets up interstitial decay, a nidus is thereby 
 formed, which serves as a laboratory for the production of chemical destructive asrents 
 which act on the adjoining tooth. 
 
 Chemical solvents are formed by acids derived from the buccal mucus and food mixed 
 with saliva, which, lodging between the teeth and in natural depressions, undergo decom- 
 position. 
 
 It is now also pretty clearly established that micro-organisms, which are constantly- 
 found present in carious cavities, play an important part in the disintegrating process. 
 
 Overcrowding of the teeth, viscid buccal mucus giving an acid reaction, a vitiated 
 condition of the fluids of the mouth due to derangement of the digestive organs, the eat- 
 ing of sweetmeats (as carried by some young people to a most injurious extent), conduce 
 to decay, and should therefore be avoided or prevented. The condition of the mouth 
 attendant on fevers accelerates decay. 
 
 The great preventive of decay is friction — that is. the keeping of the surfaces of 
 the teeth swept clean of the food, mucus, etc., that tend to lodge between or about them. 
 With this object their lingual as well as labial and buccal surfaces should be brushed 
 night and morning; the direction of the brushing .should be always from the gum — i.e., 
 downward for the upper and upward for the lower teeth — as this removes "food from 
 between them by the natural lines of clearance ; the masticating surface of the back 
 teeth should also be brushed. Where the mucus is ropy and clings to the teeth, a sapo- 
 naceous tooth powder should be used. 
 
 Rinsing out the mouth after meals is a practice to be generally encouraged, and the 
 use of a weak alkaline mouth-wash may with advantage be had recourse to in order to 
 
468 
 
 TEEATMEXT OF DECAY. 
 
 correct undue acidity of the oral fluids, and also to neutralize the local effects of strong 
 acid medicine. 
 
 Among preventive measures must be classed what may be termed •• preventive stop- 
 ping. For example, a small spot of decay is often found near the distal edjre (of the 
 masticating surface) of the second temporary molar ; if this be not 
 stopped, the decayed posterior surface of the tooth will come in 
 contact with the mesial surface of the first permanent molar on its 
 eruption and deca}' be started in it ; then, on the shedding of the 
 temporary molar, its successor, the second bicuspid, will have its 
 distal surface exposed to decay from contact with that already 
 existing in the first molar, and thus, from lack of a small stopping 
 in a temporary tooth, two permanent teeth are frequently lost or 
 saved only by elaborate fillings. 
 
 The progress of decay is usually very insidious, a minute and 
 unnoticed fault or fissure of the enamel often leading to extensive 
 decay of the dentine. (See decay depicted on masticating surface 
 of molar in D. Fig. 270. ) A warning by pain is by no means 
 always given, but sometimes a twinge or slight ache is experienced 
 when the periphery of the dentine is reached and becomes irritated 
 by saccharine or sapid substances or by thermal changes ; if this 
 warning is neglected, often nothing more is felt till an acute twinge 
 shows that the pulp is exposed or the caving in of the enamel 
 reveals a large cavity. It thus happens that the detection of 
 decay in its earlier stages can be ensured only by frequent inspec- 
 tion of the teeth. Such inspections should begin with the first 
 teeth and be carried out systematically several times a year if the 
 teeth are to be preserved and much stopping avoided. 
 
 For the purpose of examination, a mouth mirror and a pointed 
 
 instrument are required ; the double-pointed searcher here figured 
 
 (Fig. 269) is particularly useful, its curved ends being adapted to pass between 
 
 the necks of the teeth : it .should be employed very lightly in finding out 
 
 whether a pulp is exposed. 
 
 The natural fissures and all depressions of the tooth's surface, together 
 with the sides of such teeth as are in contact, should be carefully examined. 
 A darkening of fissures often points to decay in their depths, and its presence 
 „ in them may be considered certain if the fine point of the searcher passes 
 
 J ' through to the dentine. Enamel on the plane surface of a tooth, when affected 
 
 y^ by decay, is usually first opaque and of a chalky whiteness, but may become 
 
 bi'own or blackened. 
 In interstitial decav the defect in the enamel, being out of sight, usually escapes 
 detection, and the first evidence of its presence is given by a darkening of the underlying 
 dentine, which darkening shows through the enamel, and in the case of a front tooth is 
 first observable on the lingual or labial surface, and in the case of the back teeth usually 
 on the masticatory surface. (See Fig. 270, A.) The amount of discoloration varies, 
 sometimes a distinct black spot being visible and showing through the enamel, in other 
 cases a smoked appearance or a slate color being imparted to the affected quarter of the 
 tooth, the variable depth of shade being dependent on the distance from the enamel sur- 
 face at which the decayed dentine lies, and also upon the character of the decay. 
 
 In young teeth, with their deficient den.sity. decay runs a rapid course, and the pulp, 
 being larger, is quickly exposed. The teeth of women during the term of pregnancy are 
 apt to decay rapidly and to be peculiarly sensitive — a reason for having them put in good 
 order in anticipation of that event. 
 
 Treatment op Decay. 
 
 To stay the progress of decay in the hard structures of the crown two methods are 
 practised — viz.. '• cutting out" and " stopping." In either case the affected dental struc- 
 tures must be thoroughly removed and the cavity obliterated. 
 
 '• Cutting out ■' decay is accomplished by removing adjacent sound enamel and den- 
 tine, together with the disea.sed portion, in such a manner that there is left an even sur- 
 face of hard and healthy tooth, which should be well polished. The full depth to which 
 disease has affected the dentine should be ascertained before the adoption of this method, 
 
riu:.\TMi:sr of my ay. 469 
 
 wliitli sliimld 1)0 liad nwourso li» only in Inaliliy iiioutlix .iiiil only in casos wlicn- tin; (-ut 
 snrtai'i' will lie ('X|Hist'il to IViction. 
 
 Sto|i|»inu: consists in tlio mnoval of (liscascil structure, in tlic ^'iviufr to the resulting 
 cavity a retaininjr sliain', and in the insertion into it of a sto])|»in^' wliicli is luude flush 
 with and accurately adapted to the edfjcs oi" sound surrouuilin;; tooth structure. 
 
 The accurate preparation of the; cavity and its edges is of the higliest inijiortance in 
 stopping. 
 
 In practice, cutting away and stopping are often conihimrd. Dentine lel't e.vposed 
 should always he well polished; an<l il' s(!nsitive, spirits ol' wine may with advantage be 
 applied to it daily, or it may l)e touidied with chloride; of /inc. or in the hack of the mouth 
 nitrate ol' silver or a spirit solution of tannin may he a])]»lied to it. 
 
 Narious materials are usimI for stoppings. 
 
 (lold, skilfully inserted, gives the best results wlien the tooth is in a condition to 
 bear its introduction. 
 
 Amalgauis (among wliiidi the so-called gohl amalgam is ver)' good) can Ite introduced 
 into a cavity in a plastic state, and therefore can be packed round corners and adapted to 
 thin walls that might not bear the pressure necessary to con.solidate gold. 
 
 I*rei)ared gutta-percha, from its non-conduction of heat and cold, is valuable a.s a tem- 
 porary tilling, and is particularly well adapted for cavities which pas.s below the gum ; in 
 positions where it is not exposed to the wear of mastication it sometimes la.sts for 
 years. 
 
 •• ().steo " stoppings, consisting of oxychloride or oxyjdiosphate of zinc, have the 
 advantage of clinging to the walls of the cavity, which consequently i-equires less shap- 
 ing ; they are also non-compressible, which, with their property of non-conduction, ren- 
 ders them valuable as tcTnporary fillings where the pulp is almost or quite exposed. 
 They will not last long if in contact with the gum, and are not to be trusted in interstitial 
 fillings, but for .stopping large cavities on the masticating surfaces of teeth in which the 
 pulp is almost exposed '• o.steo " is a most valuable substance ; and if it wears away on 
 the surface, some of it may witli advantage be left in the lower part of the cavity, while 
 the upper part is packed with gold. A saturated solution of mastic in spirits of wine (or 
 some such preparation), mixed with cotton-wool, is serviceable as a temporary filling 
 when a carbolic-acid dressing has to be retained in the tooth for any time not exceeding 
 a fortnight. 
 
 Whatever stopping is used, the cavity should be kept absolutely dry Avhile it is being 
 filled. 
 
 The front upper teeth, whicli are very liable to interstitial decay, can (especially in 
 the young) be temporarily separated by wedging them apart, thus allowing of their being 
 filled from the side or lingual surface without interfering witli their contour or leaving 
 the stopping visible ; B and C in Fig. 270 show how hidden cavities in other situations 
 can be reached and stopped if they cann(jt be got at by a gradual process of wedging. 
 
 In shaping cavities for filling the proximity of the pulp with its outstanding cornua 
 has to be borne in mind and its exposure avoided. (8ee molar, in D, Fig. 270.) 
 
 If a liealthy ])ulp is exposed in preparing a tooth for stopping, a cap of .some non- 
 conducting material which has been moistened with carbolic acid should be at once placed 
 over it, and then a stopj)ing introduced. (See bicuspid, in D. Fig. 270.) 
 
 If an exposed pulp has become inflamed at the point of its exposure and has taken 
 on a secreting action, repeated dressings with carbolic acid or eucalyptus oil and iodoform 
 to get rid of this ulcerating condition maybe liad recourse to, and if successful a stopping 
 may be introduced over the capped pulp ; but, as a rule, if the pulp has shrunk away 
 from the aperture of exposure or been the seat of continued pain, it cannot be preserved 
 with comfort, and the best treatment in such a ca.se consi.sts in rapidly bringing al)out its 
 death by the application of arscnious acid, and then, when it is devitalized, by withdraw- 
 ing it and thoroughly filling the pulp cliamber and its root extensions. (See bicuspid, in 
 E, Fig. 270.) 
 
 The accompanying series of drawings (A, B, C, D, E, Fig. 270) illustrate progressive 
 disease in a tooth, and its treatment. 
 
470 
 
 TREATMENT OF DECAY. 
 
 Q 
 
 -'^- A represents the masticatory surfaces of second upper bicuspid and 
 
 first molar. The darkening of the decay beneath shows through the 
 enamel on the bicuspid. A searcher is introduced to explore the mesial 
 surface of the molar for decay. 
 
 B. the same teeth. The front surface of the molar, having presented 
 superficial decay, has been chiselled down, which gives space for stop- 
 ping-instruments to be brought to bear upon the deeper cavity in the 
 bicuspid. 
 
 C, the same teeth with decay more advanced. The cavity in the front 
 of molar, proving too deep for "cutting out.'' is reached by stopping- 
 instruments introduced via the cavity in the bicuspid. The latter tooth, 
 having had the enamel on its masticatory surface too much undermined 
 for preservation, will have its contour restored by a stopping introduced 
 into the dovetail-shaped cavity, here seen from above. 
 
 D represents continuation of disease as seen in vertical section of lower 
 bicuspid and first molar. In the bicuspid the pulp has been just 
 exposed, but. being healthy, has had a carbolized cap and a non- 
 conducting stopping placed over it. and has developed a protective 
 shield of secondary dentine. A gold stopping is seen in the molar, of 
 a shape that would ensure its retention if solid. Commencing decay 
 is also shown at the masticating surface of this tooth. 
 
 E. same teeth. The pulp of the bicuspid is supposed to have been 
 destroyed with arsenious acid and withdrawn from the pulp chamber,, 
 which, with its extension to the end of the root, is represented as filled, 
 the lost portion of the crown being also restored. The eflfects of 
 unchecked disease are seen in the molar, the anterior root being occu- 
 pied by purulent fluid and its apex bathed with pus of an alveolar 
 abscess. The posterior root, in which some living pulp still remains, 
 is represented as exostosed. but might with equal truth have been 
 depicted as covered with thickened and inflamed periodontum. 
 
 When a pulp has been extirpated immediately after its loss of vital- 
 ity, the root canals should be stopped to their apices forthwith ; but 
 when a dead pulp has remained in a tooth for any time, a thorough 
 purification by the use of antiseptics must precede the stopping. 
 
 In some cases after the pulp has been extirpated, instead of filling 
 the roots, an alternative plan must be adopted if the tooth is to be 
 saved. 
 
 This consists in drilling a fine canal beneath the free edge of the 
 gum into the emptied and cleansed pulp chamber, which is then covered 
 over with a cap and superjacent stopping. 
 Fig. 271 represents a tooth so treated. The gum in this case acts as a valve opposed 
 to the ingress of food. etc. The vent fwhich may be made through a stopping), by pre- 
 venting the accumulation of fluid or gas in the pulp chamber, stays 
 J^~ Fi^^--'-- the development or allows the subsidence of inflammatory mischief 
 about the root. 
 
 Pivoting'. — When no other teeth want replacing and the crown 
 of one of either of the six upper front teeth is lost through fracture 
 or decay, the operation of pivoting a new one on to the root is much 
 to be preferred to other modes of attachment. 
 
 In the case of a healthy root the crown can with advantage be 
 pivoted on it once for all after the end of the canal has been filled 
 with gold or other durable stopping, but in other cases the following 
 mode of operating is to be preferred : The canal at the end of the root is left open and 
 the new crown is affixed to the root by a split gold pin. which is sheathed in a platinum 
 tube fixed with stopping into the rifled barrel of the root. Here the tooth crown can be 
 removed and replaced at pleasure, while the root is preserved from further decay by 
 being lined with metal : and by this method a root not fully formed or one that is the 
 subject of alveolar abscess mav safelv be used for supportins: a pivoted crown. (See 
 Fig. 272.) ' ' IF - F 
 
 Decay at its commencement is. as a rule, capable of sati.sfactory and quite or com- 
 paratively painless treatment. The difficulties of its successful treatment increase with 
 its onward progress, while the nerve complications that have been noticed and the severe 
 
AFFKCTIOSS OF TIIK FT LP. }71 
 
 inflainuiatory lesions wliidi will lie cmiiiHrattMl iartlitr on are most f'rtMjiieiitly the 
 8e((uel;e ot" neglected decay. 
 
 Fracture of Teeth. 
 
 Teeth, espeeiallv |irnjfctini; npjK-r incisors, are liable to he fractured. It' only :» 
 small portion of" the crosvn is chijiiicd ofl', the fractured edge may he .•imoothed with a 
 tile or stone and touched with >|)irit to keep it hard and insensitive (tiling to amend shape 
 shouhl not lie had recourse to while the jiaticnt is very young). If the portion broken 
 otf is so large that the tooth will lu' jiermanently disfigured, and yet the [lulp has escaped 
 destructive irritation, the remainder of the crown may he removerl and a new crown 
 pivoted on to the root ; in a young suhject the destruction of the pulp preparatory to 
 pivoting should lie postponeil until it is reduceil to its ultimate tenuity liy the perfecting 
 of the root. 
 
 If it is evident that the pul|i has become inflamed through the fracture, it will be 
 desirable to at once destroy and extirpate it, in order that the periodontum may be pre- 
 served in a healthy condition, and therefore the rout be in a positi<tn to carry a pivoted 
 crown with comfort. In young subjects, when the teeth are much crowded and rela- 
 tively prominent as compared with those in tlie lower jaw, it may be desirable to extract 
 the fractured tooth and to train in the neighboring teeth to occupy its site. 
 
 Arrested or Carbonized Decay. — Sometimes, in young .subjects, when the 
 enamel is lost almost simultaneously over the whole masticating surface of a molar tooth, 
 decay becomes arrested, the exposed dentine assuming a dark mahogany or black color 
 and presenting a tlensity which (jualifics it for mastication. 8uch a result may be aided 
 by the muniling off of projecting enamel edges. 
 
 Erosion. — Occasionally the enamel and the subjacent dentine are gradually lost by 
 a process which was called by Hunter '• decay by denudation," and by recent writers 
 " erosion." The surface of the cavity so formed remains hard and polished and often free 
 from discoloration. It is probable that this gradual wa.sting awa}' of the tooth substance 
 without any of the ordinary appearances of caries is due to the combined action of chem- 
 ical solution and friction ; the enamel, in the first in.stance, being affected over a compar- 
 atively large area, the dentine, when reached, is exposed to friction, which prevent.s it.s 
 softening. 
 
 This erosion may affect other parts of a tooth, but usually attacks the labial surface 
 at the neck ; frequently many teeth in the same mouth are affected by it. a groove being 
 gradually .scooped in the teeth just above the gum until the pulp is exposed. 
 
 Tre.vtmknt. — An alkaline mouth-wash should be prescribed and horizohtal bru.shing 
 interdicted : and if the exposed dentine is sensitive, either of the solutions mentioned at 
 page 4tJ9 may be applied to it. In cases admitting of it stopping should be had recourse 
 to, that the pulp may be preserved from expo.sure. 
 
 Affections of the Pulp. 
 
 An exposed dentinal pulp is subject to mechanical, thermal, and other irritation. The 
 pain produced by such irritation is of a sharp lancinating character, sometimes passing 
 away with an ache. 
 
 Chronic Inflammation. — Circumscribed superficial inflammation with increase 
 of sensitiveness may be developed in the pulp at the point of exposure and may continue 
 for a long time in an unsuspected cavity, giving rise to reflex pain or (so-called) neur- 
 algia. 
 
 Ulcerative Condition. — The exposed surface of the pulp may take on a secre- 
 tive action and the tooth be free from pain as long as the exuded sero-purulent fluid finds 
 an exit and the pulp escapes fresh irritation. 
 
 Acute or general inflammation of the pulp is attended by terrible pain 
 of a violent throbbing character, which after lasting several hours or days may cease as 
 suddenly as it began, its ees.sation betokening the death of the pulp. In this case every 
 factor for the production of agonizing pain is present ; the distensible pulp, largely sup- 
 plied with nerves, undergoes vascular engorgement within an unyielding case closed in at 
 all parts except at the aperture of exposure, through which it may bulge and -uffer fur- 
 ther constriction. The pain is not usually confined to the faulty tooth, but spread^ from 
 it to the neighboring teeth and to the side of the face : during the paroxysms the tooth 
 often becomes tender to pressure, owing to a sympathetic irritation of the periodontal 
 membrane. Prompt measures should be taken to prevent the products of decomposition 
 
472 ALVEOLAR PERIOSTITIS. 
 
 ■which resuh from the sphacelus of the pulp from passing beyond the interior of the tooth, 
 and so causing the inflannnatory involvement of the periosteum and the formation of 
 alveolar abscess. 
 
 The l>ulp occasionally loses its vitality without producing noticeable j)ain. 
 
 Tardy Destruction of the Pulp. — Instead of losing its vitality at once, the 
 pulp niay die piecemeal, the chronic irritation that attends tliis process often being pro- 
 ductive of morbid changes on the exterior of the root. A pulp chamber that contains 
 the remains of a decomposed pulp emits a strong and peculiar phosphatic smell. 
 
 Calcification of pulp has been described already under the head of '' Secondary 
 Dentine." 
 
 An insensitive polypoid growth of the pulp, consisting of granulations which throw 
 off a secretion and readily bleed, sometimes projects from the pulp chamber into a cavity 
 in the crown of a tooth ; it usually necessitates the extraction of a tooth on account of 
 the successful resistance it offers to extirpation. 
 
 A sensitive sprouting of the pulp may follow fracture of a tooth. Extraction would 
 be the treatment for this condition, which, by extirpation of the pulp, should be prevented 
 from developing if the retention of the root is desirable. 
 
 Necrosis of the pnlp may occur within the unopened pulp chamber of a sound 
 tooth. It is most often consequent on a blow (sometimes a very slight one) rupturing 
 its vessels as they enter the apex of the root. It may supervene on fever. A darkening 
 of the whole tooth results, and is due to the permeation of the dentine by the decomposed 
 coloring matter of the blood. 
 
 Salter has pointed out that the pulp thus devitalized may be disposed of by fatty 
 degeneration. In the absence of treatment — /. e., extirpation of the pulp, etc. — it often 
 leads to alveolar abscess. 
 
 A tooth knocked out and immediately replaced may become quite firm and obtain 
 vital connection with the alveolo-dental membrane, and will then be in the same condition 
 as the above. In this case or in cases of transplantation the replacement of the dead pulp 
 by an indestructible filling is required to prevent after-inflammation. Death of the pulp 
 will be evidenced by the absence of sensation in a tooth when touched with an instru- 
 ment hot enough to evoke sensation in its neighbors. 
 
 Affections of the Alveolo-Dental Membrane. 
 
 Dental periostitis i»'iy be local or general, chronic or acute. 
 
 General inflammation of the periosteal investment of the teeth and their sockets 
 results from rheumatism or attends on a debilitated or unhealthy condition of the system, 
 and demands constitutional treatment. 
 
 Treatment. — When slight in amount and causing only a loosening of the teeth and 
 a sense of fulness and uneasiness about them, no local treatment may be required beyond 
 the use of an astringent mouth-wash. When the gums also are congested, they should 
 be scarified and a stronger astringent (tannin dissolved in spirits of wine is eificient) 
 applied to them. Tincture of iodine is a favorite application with some. Any root or 
 tooth that may be an excitant of inflammation is best removed, and tartar should be 
 thoroughly got rid of from beneath the free edges of the gum. 
 
 The continuance or oft-repeated recurrence of a congested condition of gum leads to 
 the absorption of the alveolar edge and consequent loss of implantation for the teeth ; 
 the gradual deposition of tartar upon the root, besides being one of the commonest causes 
 of this condition, is apt to attend upon and increase it when arising from other causes. 
 When the periosteal inflammation is more acute and pus is formed about the necks of the 
 teeth, a solution of chloride of zinc eight grains to the ounce will be found a beneficial 
 mouth-wash and will correct foetor. 
 
 The general symptoms of dental periostitis have been given at page 406 ; it may be 
 added that when due to rheumatism toothache is apt to be present and swelling and sup- 
 puration absent; that it will often subside of itself, while in a scrofulous subject or when 
 due to syphilis the pain is often slight and the tendency to suppurative inflammation 
 marked ; that in these cases the loss of the teeth is imminent ; and that their extraction 
 at once may be desirable. Periostitis of the alveolar process of the jaw, leading to necro- 
 sis, may be caused by a primary syphilitic chancre (apt to be mistaken for a gum-boil), 
 also syphilis in its tertiary stage, by sloughing of the gums, by acute alveolar abscess, or 
 may have a traumatic origin. 
 
 Rigg's Disease. — In dyspeptic patients the above conditions occur in their greatest 
 
A I A' EO LAI I .1 HSCKSS. 173 
 
 si'Vi rit\ . Tlif tuiniil liuins, coiifji'sttMl witli venous 1)1(i(kJ, are detacluMJ from tlie necks of 
 tlif teeth, IVnni altout the roots of which a thiek letiJ disohar<ie can be pressed uj». The 
 runts (if the teeth are ^^radiially denmled of their periosteum and c(»vered ]>y hard dark- 
 uri'en iKiduIi's of tartar. whiK' the reeedintr edires of the alveoli disappear hy caries. 
 
 TitKAT.MKNT. — The local treatiueiit of this condition consists in free scarification of 
 the irunis, a thornuirli renmval with tine special instnimcnts of tin.' encrustinjr tartar, ami 
 the application of stroni;' carbolic acid introduced on thin slips of wood hctween the root 
 and the socket which is desertini: if. 
 
 IJitr.ir, who called marked attentinn to this eonditidn. n'C(iinnieiiile<l the reninval Uvilh 
 strong scrapinir instruments) of the afi'ected marjrins of the alveoli; hut the thorou^rh 
 antiseptic treatment above described seems as satisfactory as can be expected. 
 
 The fumes of phosphorus, productive of '• phosphorus necrosis," jtrobably find a readier 
 inirress when tlu' pulp of a tooth is exposed, and other irritants productive of periosteal 
 inflammation may act through the .same channel. 
 
 Necrosis of the alveolar portion of the jaw in cliildren may follow either of the exan- 
 themata, and will not always lead to the loss of tlie permanent teeth if due time i.s given 
 for the separation of the necrosed portion. 
 
 Inflammation of a sultacute type n)ay attack the pcriodontum of one tooth after 
 another and lead to their successive loss in cases where the roots of the teeth are e.xposed 
 throuLrh the rcccdence of the uums and alveolar margin from senile absorption or other 
 causes. 
 
 Local Dental Periostitis. — Witli the exception of the condition just named, 
 inflammation attacking the alveolo-dental meml)rane of a single tooth results from pre- 
 existing disease in the tooth or is due to some local cause of irritation, such as a ligature 
 applied carelessly for regulating iiurpo.ses or for fracture of the jaw, the accumulation of 
 tartar, or the undue and obli(|ue jiressure of an antagonist tooth. Chronic inflammation 
 and thickening of the periodontum are often complicated either as cause or effect with 
 exostosis or with a very small chronic alveolar abscess about tbe apex of a stump, and 
 are in these cases associated sometimes with severe neuralgia. 
 
 Dental Cysts. — The dental cysts which sometimes form on the roots of teeth are 
 probably generally the outcome of conditions which in their more sthenic form lead to 
 the formation of alveolar abscess. An alveolar abscess may pass into a cystic condition, 
 and it is certain that the.se cysts (which may contain cholesterine) may suppurate, and 
 then, to all intents and jiurposes. they become converted into alveolar abscesses. 
 
 Periodontal inflammation of an acute form, producing alveolar 
 
 abscess, is the natural se([uel of death of the pulp, the products of the decompositicjn 
 of this structure passing through the foramen at the end of the root giving rise to it. 
 Pus formed between the root and its investing membrane may separate the latter from 
 the former and escape around the neck of the tooth ; in which case, if the dentinal pulp 
 also is dead, the tooth becomes absolutely necrosed and is to be regarded as a foreign 
 body. Pus may become diffused beneath the gum, and this is especially likely to occur 
 in the case of lower iiupacted wi.sdom teeth. Far more commonly, pus derived from the 
 pulp chamber or due to the breaking down of inflammatory lymph which has been thrown 
 out about the apex of the fang is contained in a circumscribed abscess which embraces 
 the end of the root (.see Fig. 27U, E) and occu))ies an excavation in the maxilla. Pre- 
 ventive treatment consists in the complete clearing out of the root canals and their thor- 
 ough purification by antiseptics ; this, with the administration of a saline purgative and 
 the local abstraction of blood from the gum over the root, affords the best chance of cut- 
 ting short periodontal inflammation that tends to the formation of abscess. The forma- 
 tion of an alveolar abscess is usually jireceded by great local tenderness to pressure on or 
 over the root of the tooth and attended by pain of a throbbing character, sometimes by 
 rigors and considerable constitutional disturbance. The possible occurrence of pyaMnia 
 fr(un this cause is not to be overlooked. Great serous effusion into the cancellated bone 
 and the soft surrounding tissues not infrequently takes place, mistaken sometimes for 
 erysipelas and oecasiorially resulting in suppuration ; the closure of the eye of the 
 affected side or a swelling from the lower jaw reaching half down the neck may thus be 
 produced. An abscess connected with an upper molar sometimes causes a fulness over 
 the lower jaw. "When an abscess is formed, the contained pus tends to find an exit either 
 through a gum-boil (so called) or by a fistulous opening on the face. etc.. an opening on 
 the gum being naturally formed when the mucous membrane is reflected from gum to 
 cheek at a distance from the alveolar border, and a canal through the body of the bone 
 if the root of the tooth extends below such reflection of the mucous membrane. 
 
474 IXFLAMMATORY ACTION. 
 
 An alveolar abscess attached to the upper teeth may perforate the antrum, when 
 attached to an incisor may open into the nare.s, or when connected with a lateral incisor 
 may pass backward between the compact layers of the palatine pi'ocess of the superior 
 maxilla or between the periosteum and the hard palate and open through or behind the 
 soft palate. It may also form fistulous openings on the face .near the inner canthus or 
 under the edge of the malar bone. An alveolar abscess connected with lower incisors 
 may open under or in front of the chin and above or under the margin of the jaw when 
 connected with the other lower teeth; from a wisdom tooth the pus may pass forward to 
 the canine, backward to the fauces, or escape at the angle of the jaw. Pus from an 
 alveolar abscess may pass down the neck, and in one case it found final exit below the 
 clavicle, and in another and fatal case it reached the armpit. 
 
 The pus of an alveolar abscess that distends the mucous membrane of the gum or 
 cheek should, of course, be evacuated by an incision if the extraction of the tooth does 
 not suffice for the purpose. A chronic gum-boil ma}- be regarded as a safety-vent, but 
 abscesses with such a fistulous opening on the gum may sometimes be cured by pumping 
 carbolic acid through the root of the tooth until it escapes on the gum, followed up by 
 stopping of the root. 
 
 When alveolar abscess has formed and does not tend to open on the gum. but causes 
 a distension of the bone over it, together with local inflammation, the tooth, as a rule, 
 should be extracted without delay to prevent further mischief, although in some cases a 
 clearing out of the pulp chamber and the performance of rhizodontropy, coupled or not 
 with a direct opening into the abscess to evacuate the pus, may be the right practice. 
 
 In alveolar abscess of the lower jaw a prominence passing out from any diseased tooth 
 and obliterating the natural sulcus between gum and cheek will point to the tooth which 
 should be extracted, and a vertical incision across the abscess track within the mouth may 
 be advisable to prevent the next step in the formation of an external fistulous opening — 
 namely, the distension and thinning of the skin preparatory to its perforation. In these 
 cases warm water should be held in the mouth, and poultices should not be applied to the 
 outside of the face. 
 
 A fistulous opening on the face which has given exit to a continual discharge for 
 years will at once close up on the extraction of the tooth or buried root which has caused 
 it, but a permanent depressed cicatrix will be left ; in these cases a probe introduced from 
 the outside wall very likely impinge on something which feels rough and hai'd like dead 
 bone, but is really an exostosed and roughened tooth fang. Absence of fetor in the dis- 
 charge and singleness of the opening point to the presence of a diseased tooth and not 
 bone disease. 
 
 Serious Local Complications of Inflammatory Action set up by 
 
 Tooth Disease. 
 
 The disfigurement of a fistulous opening on the face due to neglected alveolar abscess 
 is comparatively common, but far more severe complications are sometimes, but very 
 rarely, produced by the inflammatory involvement of surrounding structures. The 
 seventh nerve has thus been involved, producing facial pstralysis. Necrosis of the involved 
 bone has led to a fatal result. Sevei'al cases are detailed by Salter in which permanent 
 loss of sight in one eye followed antral abscess or inflammation about the upper teeth. 
 In one case amaurosis of thirteen months' duration was got rid of by the extraction of a 
 carious tooth from the end of which a splinter of wood projected. In the case of a patient 
 who recently came with symptoms of tumor in the orbit into Guy's and there died. Dr. 
 Goodhart traced the origin of mischief to caries of the first left lower molar, which gave 
 rise to abscess, suppuration in the inferior dental canal, acute ostitis of left side of lower 
 jaw, extension of disease by pterygo-maxillary fossa to orbit, suppuration in both orbits, 
 ostitis of vault of skull, and pyaemia. 
 
 The spasm of the mas.seter which frequently attends disease about the lower back teeth is 
 sometimes probably due to inflammatory involvement of the nerve, -and not simply to reflex 
 irritation. Extraction of the tooth is its cure, and the mouth may be opened sufficiently 
 to allow of this being accomplished by the persevering use of a wedge between the teeth. 
 
 Tartar, or salivary- calculus, consists of lime salts precipitated from the oral fluids, 
 together with " leptothrix buccalis," epithelial scales, etc. ; it especially tends to form on 
 the lingual surface of the lower front teeth and on the buccal surface of upper molars ; 
 a small rim may be often found on all the teeth under the free edges of the gum, which 
 
Ill 
 
 EXTii ACTIOS or TKirrii. 475 
 
 „.uv tlu'M prt'Si'iit a narrow hliic liiu- or \tc y^vnvr.iWy eonjfested. I{ru>Iiiii;; in the inaiiiier 
 rcfoiiiinemlrd I'or the prevention of ih-eay eheeks its (h-positioii. Its presence in lar^'e 
 muss may eaiise uK-eration <»t" the tonfrue, etc., ami in much smaUer (piantity causes hiose- 
 niiijr. !iii<l if allowed to accumulate the loss, of the teeth, it should he carefully and 
 thorouuhly remove«l with small scalinu' instruments, used so as not to make the ;.'um Meed. 
 
 All t«'etli that are retained in the mouth should he rendered as sound and firm as 
 possilile hv stoppinj^ and scaling:. A patient with tartar-loaded and decayinj; teeth may 
 travel I'or fresh air. hut will hardly find it. 
 
 All sharp and ja;:Lred I'dires of teeth should he rcinovcil l.y a tih" ; this is of special 
 importance in after-lil'e. as localization of epitheliuma of the t<jnjrue is fre(|uently trace- 
 ahle to irritation so produced. 
 
 Tumors and other Affections of the Gums. 
 
 8undrv L'uni ath-ctions are intimately connected with the teeth. 
 
 Simple hypertrophy of the trums. chiefly on their labial .surface, is sometimes met 
 with when the teeth are overcrowded, the fruni beinjj .shut out, a.s it were, from between 
 the necks of the teeth. The preventive treatment for this condititm is self-evident, but 
 when it is established and extraction is inadmissible, it may be reduced by free scarifica- 
 tion and the application of tannin, etc. 
 
 Occasionally, in unhealthy sulijects. hypertrophy- assumes lar<:er yiropcjrtions, the 
 crowns of the teeth beinji buried in lobulated masses of gum. The treatment consists 
 of scalintr. free scarification (and sometimes excision), together with the local use of 
 astringents and fetor-correcting applications. Absorption of the underlying alveolus, 
 and consequent loss of implantation for the teeth, is apt to attend upon this hypertrophy, 
 as it does u])on continued extra-vascularity of the gums. 
 
 A polypus of the gum is fre(|uently found to project into dental carious cavities 
 which extend beluw the gum ; it is vascular and insensitive, ami should be cut away and 
 packed out of the tooth cavity preparatory to the filling of this latter. This gum poly- 
 pus is .sometimes liable to be mistaken for polypus of the dentinal pulp. 
 
 Epulis. — The tumors classed under this name present in varying proportions a 
 fibrous or myeloid character, and not infrecjuently have small o.s.seous development at 
 their basis. As regards the maxillse. these growths es.sentially belong to the alveolar or 
 tooth-bearing portion, and conse<|uently can, as a rule, be completely removed without 
 interference with the basal portion of the bone. The fibrous tissue of the gum. the 
 endosteum, and the alveolo-dental membrane, having continuity, may each share in the 
 development of an epulis ; it therefore follows that for the complete eradication of the 
 disease the extraction of an adjoining tooth or root may be demanded, together with the 
 excision of the growth and involved bone. 
 
 Vascular Tumors. — Mr. Salter has recorded a case of a vascular tumor the 
 size and color of a Morello cherry which he found attached by a narrow neck to the peri- 
 osteum of a tooth. In my own practice a lobulated tumor of polypous character and 
 having much the appearance of an epulis overlapped the hard palate, and was found to 
 be attached by an exceedingly narrow^ pedicle to the edge of the periosteum of a decayed 
 molar tooth. In both these cases hemorrhage of a really alarming extent had occurred, 
 and in both the tumor was removed by extracting the tooth. 
 
 The painful ulcerative stomatitis so fre(|uently met with in hospital practice 
 among young children olttu demands the extraction of loosened and irritating teeth, 
 coupled with the internal administration of its specific remedy, chlorate of potash. 
 
 The Extraction of Teeth. 
 
 Speaking generally, extraction may be required for regulation of teeth, which includes 
 the prevention of overcrowding ; to prevent or get rid of impaction of a wisdom or other 
 tooth ; for neuralgia and nerve irritation when its origin in a tooth is not confined to 
 .some condition of the pulp which can otherwise be got rid of; as a rule, in eases where 
 periodontitis (not rheumatic) is established and resists curative treatment; when an alve- 
 olar abscess tends toward opening externally ; in cases of vertical fracture of the tooth ; 
 in the case of loose and di.seased teeth or roots which keep up an unhealthy condition of 
 the mouth : w^hen an epulis has probable connection with alveolo-dental membrane ; and. 
 finally, in some cases, to allow of more satisfactory artificial restoration. 
 
 Forceps and elevators are the instruments now used for the extraction of teeth. The 
 
476 EXTRACTION OF TEETH. 
 
 forceps adapted for the removal of the different teeth will be found described in Tomes's 
 Dental Sure/cry, and only a few special points will be here noticed with regard to them 
 and their use. Forceps should be finely made and well tempered, with blades which 
 should grasp the tooth's neck without pressing on the crown, as extraction is seldom 
 required for sound teeth, but for those that are broken down or hollowed out by decay. 
 
 In extracting a tooth the forceps should be applied lightly and closely to its neck and 
 then sent firmly up (or down, as the case may be) until they grasp a part of the tooth 
 that will resist some pressure ; the edges of the blades will thus, as a rule, be made to 
 pass just within the edges of the socket, while in the case of the molars the points of the 
 blades will take grip at the bifurcation of the roots ; the right hold being obtained by this 
 first movement, the instrument is thenceforth kept at one with the tooth, which is first 
 separated by a particular movement from its socket attachments and then withdrawn. 
 
 The accompanying drawing (Fig. 273) shows the manner of holding forceps. The 
 little finger may be used as a kind of opening spring, and the thumb should act as a stop 
 between the handles and prevent any crushing pressure. 
 
 The particular movement required for the dislodgment of a tooth depends on the 
 shape of its root. Thus, the upper incisors and canines, together with the lower bicus- 
 pids, are more or less conical, and are therefore to be 
 Fin. 273. rotated ; while the lower incisors and canines, together 
 
 with the upper bicuspids, are more or less flattened 
 from side to side, and therefore are to be moved out- 
 ward and inward. The molar teeth are also to be 
 moved outward and inward befoi'e being extracted. 
 The direction in which teeth are withdrawn from 
 ]\ranner of holding Forceps. their sockets depends on the position held by their 
 
 roots. Upper molars are extracted downward and 
 outward; lower molars upward and often somewhat backward; while, in order to follow the 
 curves of their respective roots, upper wisdoms should be extracted downward, backward and 
 outwai'd, while the crowns of lower wisdom teeth should be carried backward and upward. 
 
 An elevator should not be used in extracting the upper wisdom tooth, on account of 
 the fragile nature of the tuberosity of the maxilla in which it is lodged, but may some- 
 times be used with advantage for a lower wisdom when the second molar is sound and 
 firmly implanted. 
 
 Before attempting to extract a buried and impacted lower wisdom tooth a careful 
 examination should be made with a probe to see how it is situated ; sometimes it will be 
 found to hold a horizontal position, its crown impinging upon and causing absorption of 
 the root of the second molar. In cases where it is possible to extract the impacted tooth, 
 lower hawksbill stump forceps with a double curve and an elevator, such as is shown in 
 Fig. 275, B, will be found very useful. In cases where the ascending ramus would be 
 necessarily injured in attempts to remove the wisdom, the second molar should be 
 extracted, and then the buried tooth may erupt without further trouble or can be easily 
 removed if still a source of irritation. Stump forceps, as here figured (Fig. 274), are far 
 better adapted for the extraction of bicuspids than the so-called bicuspid forceps. 
 
 In the case of a much-broken-down or hollowed-out lower molar, instead of using molar 
 forceps, it is better to grasp with stump forceps the one of the two roots which offers the 
 best hold ; and if the union between the roots is not strong enough to allow of their with- 
 drawal together, the remaining separate root will be easily removed. 
 
 The three undivided roots of a crownless upper molar may be extracted with " Cole- 
 man's forceps," or with long flat-bladed, loose-jointed stump forceps as made by Collins. 
 
 Occasionally dividing forceps may be used with advantage in extracting united roots 
 of either upper or lower molars. 
 
 When a root is partially covered over with gum, the position of its edges should be 
 defined with a probe before any attempt is made to grasp it. 
 
 With well-made forceps lancing the gums before extraction is usually unnecessary, 
 but sometimes, in isolated teeth, especially wisdom teeth, the gum is strongly adherent 
 to the tooth, and is apt to be torn away with it if not first separated. 
 
 Fistulous openings on the fiice are seldom seen in connection with children's tempo- 
 rary teeth, but the external alveolar plate is often perforated and the end of a root pro- 
 jects through and causes ulceration, which may lead to adhesion between gum and cheek; 
 the teeth causing this irritation are easily pushed out with an elevator. 
 
 Persistent hemorrhage following the extraction of a tooth and resisting cold may be 
 stayed by tightly packing the socket with rolls of softened matico leaf (Tomes) or with 
 
AFFECTioys or 'nil-: /'irAinwx .ixn (i:sni'/r.iGUs. 
 
 a strip of lint cut to a |H.iiit ami dipped in a spirit solution ol" tannin, a (<ini|)ress being 
 placed over and kept in place liy the (tpposite teeth. At the sann; tinit; astringents or 
 iron should he given internally if the henjorrhagic diathesis exists, or appropriate measures 
 he taken if the hleeding in the case of a woman appears to he vicarious. 
 
 \\ hen natural teeth are lost, artificial ones un(|uestionahly conduce to comfort and 
 health, 
 
 (iiild is generally lln- hest hase for artificial ileiitures when a few teeth only want 
 restoring; hut when the gums have heeri ahsorhed and many teeth lost, vulcanite or 
 
 Fk;. -j: J. 
 
 in. — A, I'pper stump forceps. Fig. 27.i. — Wcdnc-Shaped Scoop Klevators, wliidi are very useful 
 
 H, Lower stump forceps, in extractiiit; Ijuried or much liollowed-out roots, such a-s ('. 
 
 A, Elevator for upper roois. B, One of a pair of elevators de- 
 vised by Mr, (', Rogers for lower stumps. Such a root as »' may 
 sometiiiies be best removed from the upper jaw with an instru- 
 ment having a spiral cut on it, used like a corkscrew, 
 
 some such substance is preferable. Various modes of fixing teeth are adopted. Atmo- 
 spheric pressure alone, bands applied to the natural teeth in the least liarmful way, and 
 occasionally springs (those devi-sed by Mr. Henry Rogers being by far the best) are each 
 to be used in fitting cases. 
 
 In elderly people teeth that project in an unsightly manner can often be shortened 
 with much advantage and without pain. The roots of upper front teeth and of lower 
 teeth, if healthy, may often be retained in the mouth with gain. The wholesale and 
 indiscriminate extraction of teeth is to be strongly reprobated, leading, as it does, to 
 premature ab.sorption of the alveolar processes, and thus often reducing in middle age 
 the lower jaw to a level with the root of the tongue, and therefore ill fitted to support 
 artiOcial teeth. Several painful cases resulting from extreme absorption due to this prac- 
 tice have lately been seen by me. 
 
 In the cases of cleft or perforate palate which are not amenable to surgical treatment 
 artificial restoration should be had recourse to. 
 
 An obturator should span the orifice only in recent cases of perforation, in order that 
 occlusion by the approximation of the edges of the opening may not be interfered with ; 
 and in no case should a method of fixing in the plate be used that will tend to enlarge 
 the aperture. 
 
 AFFECTIONS OF THE PHARYNX AND (ESOPHAGUS. 
 
 Inflammation and Suppuration of the Pharynx 
 
 are met with in the feeble and cachectic subject, and come on with general and local 
 symptoms not unlike those of quinsy ; indeed, the two affections are often associated. 
 The chief local symptoms are pain and swelling, with difliculty in swallowing, and the 
 chief general symptom fever with constitutional disturbance. 
 
 Abscess which ma}- be the result of an acute or chronic inflammation of the part 
 shows itself by some bulging or projection of the mucous covering of the pharynx, and 
 it may be so large as to interfere with, if not to prevent, deglutition, or even to impede 
 respiration. I have seen this occur at least twice in cases of spinal disease. When these 
 
478 DYSPHAGIA. 
 
 conditions exist, the abscess must be opened ; and the best instrument to use for the 
 purpose is a straight bistoury protected up to the point by a piece of lint or strapping. 
 Tonics, such as quinine, iron, or the mineral acids, are almost always required in these 
 cases. Steaming the throat gives great comfort, as well as external warm applications. 
 Nutritious food should always be allowed. The surgeon should remember that a post- 
 pharyngeal abscess may be due to disease of the vertebrje or base of the skull, but such 
 (rases are generally chronic. He should also be alive to the fact that such an abscess 
 may be associated with a fracture of the spine. ( Vide " Fracture of Spine." p. 238.) 
 
 Tumors of the pharynx may also give rise to the external appearances of a 
 chronic abscess by pressing the mucous membrane forward ; cancerous tumors are very 
 liable to do this. One of the most marked cases of the kind I ever saw, which turned 
 out to be a syphilitic gumma, was so large as to make me suspect its cancerous nature ; 
 it was cured by ten-grain doses of the iodide of potassium in bark three times a day. 
 
 The cancerous tumors generally commence in the upper part of the pharynx and cause 
 obstruction of the posterior nares ; as they grow downward they simulate a pharyngeal 
 polypus. Two such cases in young people have been under my care, and terminated 
 fatally. It was a question in looth whether the disease was not originally in the tonsil, 
 but it appeared to have originated above the gland. 
 
 Granular pharyngitis, or hypertrophy of the adenoid tissue of the pharyngeal 
 mucous meuibrane, shows itself as a chronic catarrhal affection, associated with the secre- 
 tion and hawking up of a thick viscid mucus, which is often tinged vrith blood. 
 
 There is also at times a constant burning sensation in the throat, and frequently a 
 nasal twang in the voice. There is likewise commonly deafness. To the eye the pharynx 
 presents a granular appearance, the granules at times being as large as peas. I have at 
 times seen them larger — once as large as half a nut. 
 
 Treatment. — There is but one form of treatment of use, and that is the removal of 
 the glandular bodies by scraping or the galvanic cautery. When the disease is limited, 
 the latter practice is preferable ; but when extensive, scraping should be employed, the 
 operation not only removing the new tissue, but starting up a new action in the membrane 
 which is beneficial. Tonics and the local application, later on, of glycerine and iron expe- 
 dite cure. 
 
 Soft polypi grow occasionally from the pharynx. In 1883 such a case came under 
 my care in the person of a man a?t. 80. It had been growing two years and was about 
 the size and color of a large mulberry. It sloughed off after much manipulation. 
 
 Dysphagia 
 
 is a symptom due to a variety of conditions, and it may arise either from some want of 
 power in the pharyngeal muscles or from oesophageal nlcemtioii or obstruction. In the. 
 former case the condition may be due to a paralysis of the muscles of the part from cere- 
 bral disease, hysteria, or a previous diphtheria, a more or less complete loss of power in 
 the act of swallowing existing under all these circumstances, food or fluid passing into the 
 nose or larynx, producing suffocation. This condition is. moreover, often present after 
 the operation of tracheotomy for croup, the want of adaptive power in the muscles of 
 deglutition allowing liquid food to travel down the larynx and appear at the external 
 tracheal wound. 
 
 Dysphagia from oesophageal obstruction may be brought about by either spasmodic 
 or organic stricture of the tube itself secondary to cancerous, syphilitic, or simple ulcera- 
 tion. It may be produced likewise by pressure from a thoracic, cervical, or aneurismal 
 tumor, or by the presence of a foreign body in the tube. Laryngeal and pharyngeal 
 tumors and tumors about the base of the tongue can also produce the same symptom. 
 
 Stricture of the oesophagus, as a rule, takes place at its junction with the 
 pharynx behind the cricoid cartilage, though it may occur at other parts. It may be 
 ^ptmnodic or hysterical, but more frequently it is associated with .some simple, syphilitic, 
 or cancerous iilcerative action ; occasionally it is cicatricial., the result of a former injury, 
 such as the swallowing of a corrosive fluid. In the majority of cases, however, the 
 disease is due to cancer. It is a great question whether a simple fibrous stricture of the 
 oesophagus, such as is found in the urethra, ever takes place. Thoracic aneurism is 
 capable of prodvicing every symptom of this affection. 
 
 Spasmodic or hysterical stricture is usually met with in the young, but it 
 may be found at all ages. Paget has described it as a kind of stammering of the mus- 
 ■cles. It is probably always associated with some local irritation, follicular inflammation. 
 
(EsoriiAdF.M. oiis'iiircrms. 179 
 
 or iiIciTatinii, wliidi \\:\< cillirr urii^inali'd liv itscH'itr Inllnwcil an injury siidi as a scratch 
 from tin' j»;iss!il:;i' oI' ;i lijinl or sharp hoily. It is, Mmrrovcr, usually associatcil with 
 dysphaiiia. 'I'lu- tlys|ihai.'i:i is likewise interMiitteiit and iiM<-ertaiii, and a patient, when 
 •riven food or Huid to test her power, will often say that it is inipo.ssihle for her to do 
 what is re(|uired ; and should she attempt to swallow, she will to a certainty lialf choke. 
 Yet at other times, when otherwise en^aired, food ean he taken. If a prolianir he used to 
 examine tlie part, its introduction will he violently opposed hy the pharyngeal muscles, 
 thouuli with a little steady prosiire all olistniction will l>c overcome. 
 
 (Esophageal Obstruction. 
 
 When a patient complains of difficulty in swallowinji'. or rather of difficnity in passiiif; 
 food (inward down the a\sopha<;us alter tho act of swallowin<; ha.s bccti performed, and 
 of Its suhse(|ueMt return into tho moutli, the surgeon, in hjoking for it.s cause, should first 
 think of thoracic aneurism, then of cancer of some portion of the tuhe. and lastly of sim- 
 ple or .syjihilitic ulci-ration. lie should also always in(iuirc into the history of the ca.se 
 and satisfy himself that in no previous ]teriod has the patient sustained any local injury 
 from tlie swallowinir of a foreiiiii body, of hoilinu- water, or of corrosive fluid. If the last 
 cause he eliminated and a careful examination of the chest with other modes of investi- 
 iration dispose of the (|uestion of aneurism, then that of cancer becomes the most import- 
 ant, since there is little doubt that such, in the majority of ca.ses of organic stricture of 
 the oesophagus, is the true cause. The minority include examples of simple and of syjdi- 
 ilitic ulceration or contraction. Tn the early stages of the affection the diagnosis is diffi- 
 cult ; indeed, at this period the surgeon is seldom consulted, for so long as solid food 
 passes the patient is hardly aware of any obstruction existing, the habit of swallowing 
 smaller boluses of food gvowmy: pari passu with tlie obstruction. An attack of spasm is 
 perhaps the first symi)tom that attracts notice — a spasm which completely closes the canal 
 and causes rcgnrgitatiou of the food. 
 
 At this early period of the disease the surgeon will probably be able to pass a pro- 
 bang, thougli it may be oidy a small one. As the disease ])rogresses some signs of ulcer- 
 ative action may appear, such as the discharge ofpus or blood, which usually comes up with 
 the regurgitated food ; and when this occurs, there is no better indication of the presence 
 of ulcerative action. If the patient be middle-aged, the probabilities of the disease being 
 of a cancerous nature are very strong ; and should there be any local thickening behind the 
 larynx or glandular enlargement, these probabilities are enhanced. When, however, the 
 patient is a young adult and a history of syphilis exists, its syphilitic nature is rendered 
 probable. .Sim])le or syphilitic ulceration of the u?so])hagus is sufficient of itself to cau.se 
 complete oesophageal obstruction and to simulate stricture, the spasmodic contraction of 
 the muscles of the tube having much to do in bringing about this result. The following 
 case, which occurred in a patient of Dr. Habershon's, illustrates these points very forci- 
 bly : The patient, ast. 48, was dying from starvation caused by inability to swallow on 
 account of oesophageal disease, and for it I performed the operation of gastrostomy. The 
 man lived six days afterward, and died of pneumonia. After death nearly a complete 
 ring of ulceration was found at the upper part of the a^sophagus, which had caused all 
 his symptoms. Its syphilitic nature could not be decided, although the man gave a his- 
 tory of having had the di.sease twent}- years previou.sly. The repair at the seat of opera- 
 tion was most complete, the stomach and integuments having tirndy united. No peri- 
 tonitis existed. 
 
 I once saw. in consultation with Mr. Pink of (xreenwich and Dr. Wilks. a case of 
 complete a^sophageal obstruction which we all believed to be cancerous, but which so far 
 improved under the expectant treatment as to allow of the passage of well-minced food 
 with comparative comfort. Several months later, however, complete dysphagia returned 
 and the man died, a direct communication having taken place between the oesophagus and 
 the respiratory tract from extension of the cancerous ulceration. Had a bougie been 
 passed in this case, a fatal result would probabh' as a consequence have taken place. 
 
 As the disease progresses other symptoms will appear, for the ulcer may eat its way 
 into the larynx or trachea, when it .soon proves fatal. It is from this fi^ct that the sur- 
 geon should always be very chary of pas.sing a bougie down the a'sophagus, and more 
 particularly when there is any evidence of the presence of ulceration, since he will be 
 very liable to do harm, and may cause perforation of the ulcer into the air-passages or 
 pleura. 
 
 Treatment. — Assuming the pathology of stricture of the oesophagus which has been 
 
480 FOREIGN BODIES. 
 
 given to be correct, the treatment by dilatation must be looked upon as a dangerous meas- 
 ure except when the stricture is of the cicatricial form.^ the passage of an instrument in 
 cancerous or any ulcerative disease being likely to hasten the fatal termination of the 
 disease. In the cicatricial form, however, or that which follows some local injury, such 
 as can be produced by an irritant or caustic fluid, dilatation is of gi-eat value ; and such 
 treatment, if it does not cure the disease, will at least prolong life. A bougie as large as 
 can be passed should be introduced daily and retained. The patient should, when pos- 
 sible, take solid food finely minced ; and when otherwise, fluid nourishment. Milk can 
 often be drunk when other food is refused. Beef tea is always useful, and Hassall's 
 flour of meat mixed with it is an excellent addition. Brand's li([uid essence of meat is 
 also invaluable. 
 
 When swallowing becomes impossible, the cautious passage of a fine flexible tube 
 through the stricture for the introduction of liquid food may be undertaken ; and my 
 colleague, Mr. Durham, has advocated its retention, the tube in some cases irritating less 
 by its retention than by its frequent passage. The practice seems a good one when it can 
 be tolerated. Nutritious enemata are always of great use, beef tea thickened with flour 
 or arrowroot, with milk and egg or part of a mixture of a pound of minced beef and one- 
 third of a pound of fresh pancreas, as a suppository, administered every four hours alter- 
 nately, tending more than anything else to keep up the powers of the patient. When, all 
 these means fail — or. rather, before, for it is known that life cannot be very long main- 
 tained under such circumstances — the question of opening the stomach by an operation 
 mu.st be entertained. 
 
 Billroth recently has cut down upon the oesophagus and excised the cancerous growth, 
 but without success ; the operation is commended to our considei-ation only by the emi- 
 nence of the surgeon who performed it. 
 
 W^OUnds of the pharynx as a result of accident are occasionally met with, 
 falling with a sharp body in the mouth being the most frequent ; and Avhen they do not 
 involve any large vessel, they generally do well. Durham relates a case of a boy aet. 7 
 in Holmes s System of Surr/ery (third edition, vol. i. p. 745), in which Mr. Johnson of St. 
 George's had to ligature the carotid artery for repeated bleedings following a punctured 
 wound of this part, produced by the end of a parasol, in which an excellent recovery 
 ensued. 
 
 Foreign Bodies 
 
 are occasionally arrested in the pharynx, and when pointed may become fixed in the soft 
 parts about the base of the tongue or between the pillars of the fauces ; but when bulky 
 and solid, they are generally arrested at the narrowest portion of the tube, its lowest por- 
 tion, behind the cricoid cartilage, or at the cardia. The discomfort caused by this acci- 
 dent is at times very great, and difficulty in swallowing, pain, and the disposition to vomit 
 are common symptoms. A pricking sensation in the part is generally present when the 
 
 substance is pointed, although it must be remem- 
 FiG. 276. ^ bered that this symptom often remains after the 
 
 substance has been dislodged. Where the epi- 
 glottis or upper orifice of the larynx is irritated, 
 cough and other laryngeal symptoms will be pro- 
 duced, and the same may be said when a solid 
 body becomes impacted behind the larynx, the 
 larynx under the.se circumstances being either 
 so compressed as to cause suff'ocation or so irri- 
 tated as to give rise to spasm, either of these 
 causes being sufficient to produce death. 
 
 When small bodies lodge in the part, they 
 
 may give rise to inflammation and abscesses in 
 
 the pharynx and neck; indeed, instances are on 
 
 record in which disease of the cervical vertebrae 
 
 Revolving Pharyngeal Forceps for the Removal of has been the result. Coins may be impacted in 
 
 Foreign Bodies, etc. ^j^^ pharynx for many months, and Dr. 0. Ward 
 
 relates a case {Path. Trans., 1848-49) in which a halfpenny was so placed for eight months, 
 
 the child at last in a fit of coughing bringing it up. 
 
 Treatment. — Whenever a foreign body, large or small, is suspected to have become 
 lodged in the pharynx, a surgical exploration of the mouth, base of the tongue, and 
 fauces should be made; and by carefully sweeping these parts with the index finger any 
 
FORKKis nnnihs i.\ Tif/-: (lyorn.iaus. 
 
 181 
 
 fon'iirii Ixiily will 111' (IciiMtcd. liy tliis |ni)c litiir tin- f'urcitrii IhmIv iiiuv )»' ilisiu(l;.'t'd. 
 
 Wlit'U any Ixuly is tixtMl in a part, it may In* rfinovcd hy rnrrcps. the onlinarv <lrfssiiifi^ 
 lorcep.s. as a rule, snrtifinir; wlicii tlic Ixiily is lower down, the revolvinj,' a'sii))lia;;i,'al 
 loreejis as made tnr me liy Mr. Kroline ( Kiir. -7<») may \ni used. When a coin has lieen 
 swallowed l»y a eliild and Ix'come impacted in the pharynx, tlie (diild should l»e laid acroHH 
 a i)illow upon his Kelly on a tahle, with the head han<;in;; over tht; end, and supported. 
 The surgeon should then Introduce his iiuLier into the mouth and depress the child's 
 tonirue, the coin l»y tliis inameuvre sliilinir out ol' its place. 
 
 When a solid mass has beconu! impacted in the lower part of the pharvn.v Ixdiind the 
 cricoid cartilage and the fini^er cannot dislodL,^' it, no f'orcihle attempt should be made to 
 ])ush it down into the stomach, althouuh laryn;i(jtomy may he called for to preserve life. 
 If rt second attempt to move the impacted body fail, it is well to desi.st, as by the lapse 
 of time the spasm which existed when tlie first attempt failed may disappear, and a 
 renewed effort may lie crowned with success. Soft })odies likewise become softer, and 
 oonse(|ucntly can be the better removed or puslied downward. A iroml deal mav. how- 
 ever, l)e done by digital manipulation, both inside and outside the imtuth, either to dis- 
 Iod<j;c the foreiiin body or to so alter its sliape by s(jueezin<; as to enable it to pass down- 
 ward. The larynLiosoo])ie mirror is (d'ten of <ireat service in detecting tl)e presence of a 
 small impacted l)ody and in liuidiiiu the surireon to its positi<Mi. False teeth not infre- 
 (|uently ))ecome dislodtreil ami impacted in the ))haryiix. Pat^et has related such a ca.se,' 
 where a man in a tit had one of his sets in the pharynx, where they remained four 
 months. They were afterward dislodi;ed from Itetween the base of tonirue and the epi- 
 glottis. 
 
 Before giving dilorot'orm to old people the teeth always should be examined and 
 false sets removed. When such bodies become impacted, much care is needed in their 
 extraction, ami tho utmost gentleness used. 
 
 Foreign bodies in the oesophagus are mostly arrested at the two narrowest 
 portions of the tube — its origin behind the cricoid cartilage, or at its lower end just above 
 the diaphragm — and anything that can be swallowed may be so impacted. The symp- 
 toms to which this accident gives ri.se are extremely uncertain. When the upper part 
 of the tube is obstructed, the laryngeal symptoms are generally alarming (Fig. 277) ; 
 and when the obstruction is not complete, they may be very .slight. 
 Vomiting, however, under both circumstances, will probably take 
 place to expel the obstructing body ; and when this is severe, rup- 
 ture of the aaophiKpoi ma}' ensue. This accident is to l)e suspected 
 when, after severe and repeated straining, the foreign body is 
 ejected with violence, its ejection being attended with hemorrhage 
 and followed by emphysema of the neck. An interesting paper on 
 this subject may be referred to, by Dr. Fitz {American Journal of 
 Med. Science., January, 1877). As a rule, however, besides the 
 mechanical symptoms which the luere presence of a foreign body in 
 the tube produces, secondary inflammatory symptoms may be set 
 up which Tuay give rise to a ftital result. Thus, a case is on rec- 
 ord in which a fish bone perforated the heart and caused a fatal 
 hemorrhage (Andrews, Lancrt, 1860) ; in another, where a sharp 
 spiculum of bone cau.sed ulceration on the third day into the aorta 
 (Hume-Spry, Patli. Thiva.. vol. xix. ]). 219) : and in a third, where 
 disease of the spinal cord ensued as a consequence of ulceration of 
 the intervertebral substance following the arrest of a piece of bone 
 in the (esophagus (Ogle, J. W., Fofh. Tranx.. vol. iv. 1858). 
 Krichsen also records a case in which a piece of sjutta-percha 
 
 f.irmed for itself a bed in the wall of the esophagus for upward of ^^Mec^'of Pud.nnKimpact 
 six months, and destroyed life by causing ulceration into a ve.ssel 
 and hemorrhage : and a .second, in which a man died suddenly from 
 hi\?matemesis, the cause being discovered after death to be a half 
 crown impacted in the oe.sophagus, ulcerating into the aorta. 
 Gairdner likewise gives a case where a fish bone passed through the posterior wall of the 
 oesophagus ami was found embedded in pus in front of the vertebral column < Mnl.-Chir. 
 Soc, Edinburgh. 1850). and my friend Dr. Sutton also has told me of an instance where 
 a lunatic so plugged his jdiarynx with tow as to cause death by suffocation. 
 
 DiAONosi.s. — It is impossible for a surgeon under all circumstances to say with cer- 
 
 ' Med. Times, 1862. 
 31 
 
 Fig. 27 ■ 
 
 ed in <Eso|>bagus of a 
 Child a;t. 2 years, which 
 caused Death by Laryn- 
 geal .Spasm, ((iuy's Hosp. 
 Mus., 1793<".r 
 
482 
 
 FOREIGN BODIES IN THE (ESOPHAGUS. 
 
 tainty as to the presence or absence of any foreign body in the oesophagus. When it 
 can be felt by the finger or bougie, no doubt can be entertained ; yet, on the other hand, 
 when no such evidence is obtainable, a foreign body may often be present, and, being of 
 
 Fig. 278. 
 
 (Esophageal Bougie with Metal olivary End. 
 
 small size, may become so fixed in one side of the tube as to escape detection in the pas- 
 sage of an instrument. The best bougie for diagnostic purposes in one made of whale- 
 bone with a smooth polished iron knob at its end (Fig. 278), the one with a sponge at 
 the end being useless. 
 
 Treatment. — When a foreign body is detected, the sooner it can be taken away the 
 better. If the material be so/f and (ligestihle, it may be pushed downward by means of 
 an ordinary sponge or ivory probang or the tube of a stomach pump, care being taken 
 not to use force, for such material will .soften by the' natural secretion of the part after 
 the lapse of a few hours, and thus will be more readily pressed on. Should, however, 
 the oifending body be pointed, hard, or large, all idea of pushing it on must be dismissed, 
 such a practice being most dangerous, although it has been done with impunity, a jagged 
 plate with teeth having been pushed into the stomach and passed per anum. Sm<dl 
 pointed bodies may be caught by the "horsehair" probang (Fig. 279), pas.sed carefully 
 
 Fig. 279. 
 
 Fig. 280. 
 
 -r^^^rt — 
 
 Horsehair Probang, Expanded and Unexpanded. 
 
 Money Probang, with .'Sponge at one End. 
 
 beyond the position in which the foreign body is supposed to be placed, and then gently 
 expanded, rotated, and withdrawn, the compression and rotation of the instrument caus- 
 ing the hair to spread out and to expand the oesophagus. The addition of a skein of silk 
 to the extremity of the probang adds at times to its value. Sharp-pointud bodies or 
 impacted hard irregular boi/ie!< should, when possible, be removed by forceps. Those fig- 
 ured in No. 276 are the best, as they can be made to open when in the pharynx in all 
 directions. 
 
 Vomiting will often cause the dislodgment of a foreign body, though at times it may 
 render it more fixed. When vomiting cannot be produced by the administration of medi- 
 cine, a solution of tartarized antimony, or of apomorphia gr. Jq, injected beneath the skin 
 is said to act as well. 
 
 Coins and other flat but not pointed bodies can often be removed by means of the 
 money probang (Fig. 280) or Graafe's coin catcher, the circular hook catching the coin 
 and drawing it upward. 
 
 Swallowing a large bolus of bread may carry downward any fine hone or bristle, a 
 draught of any liquid assisting the process. 
 
 CEsophagotomy for the removal of foreign bodies has an established position in 
 practical surgery, and the principles laid down many years ago by Arnott' are now gene- 
 rally accepted — viz., " Where a solid substance, though only of moderate size and irreg- 
 ular shape, has become fixed at the commencement of the oesophagus or low down in the 
 
 ' Mecl.-Chir. Trans., vol. xvlii. 
 
ly.fi'Kih's or Tin-: .\r. domes. 48:3 
 
 y)h:ir}n.\, mid lias resisted a lair trial iur its extraetioii or (lis|ilaeemerit, its renioval slimild 
 (// oncf he etteeted l)V iiieisiuii. alth(iiij:li iid ur;;eiit syiii|it(iiiis may be present." Mr. ('nek 
 endorsed this opinitiii wlieii he wrote in l.S(!7:' "The hmp-r a foreijrn l»«>dy is aUowed to 
 remain, unh'ss we wait — a t'nrhtrn hope — for su)»piiration to hiosen it. the m<ire finnly it 
 will heeome impacted. It would appear that suecess attends a speedv operation ; whereas, 
 where the useid'tlie knite has lieeii delayed until local iuflainmati(jn, suppuration, or (.'Veii 
 sloiiirliini:. has heen estaltlished, the result oi" the operation has heen fatal. Dr. I). Cheever 
 of Boston, r. S.. likewise iiri.H's it. I'p to the end of ISSIJ, 45 cases of this operation for 
 the removal of fnrei<rn hodies were recorded, and of these i-J') were successful, and in the 
 fatal cases the result was m(»re from the (hday than the operation. 
 
 This operation has heen recently advocated in case.s of .stricture, cancerou.s or otlier- 
 wise, with the view of introduciiif; food permanently into the stomach; but the re.sult8 
 of the operation are not sufficiently satisfactory to enable me to advise its adoption. It 
 is only possible when the seat of stricture is lii<rh up. and advisable when the stricture is 
 of the cicatricial form ; under other circumstances, gastrostomy should be preferred. 
 
 Ol'KHATloN. — The patient should be jdaced in the recumbent position, with his 
 slioulders sliirhtly elevated, the head being turned to the right or left side, according 
 to the {loint of projection of the foreign body. Where this guide is lost, the left side 
 should be selected, the (csojthagus inclining rather to that .side. An incision should then 
 be made along the anterior border of the sterno-mastoid muscle, about four or five inches 
 long, its centre corresponding to the position of the foreign body, and all the .soft part.s 
 carefully divided. The omo-hyoid will then ct)me into view, and underneath this the 
 carotid sheath, with its vessels, will be .seen. The deep cervical fascia is then to be laid 
 open ; and if more room be required, the sterno-hyoid and sterno-thyroid muscles may 
 also be partially divided. The vessels, with the .sterno-mastoid muscle, should then be 
 drawn well (uitw^ard by means of hooked retractors. The larynx, with the u?sophagus 
 behind, can then be examined and the position of the foreign body accurately made out, 
 pressure with the finger on the opposite side tending materially to make this point clear. 
 Should the foreign body project, the larynx may be drawn well forward or toward the 
 opposite side and a cut made down upon the projecting part, the wound being carefully 
 enlarged to allow of an extraction without force. When the foreign body does not pro- 
 ject, a guide should be used, such as a silver catheter, flexible lead or tin sound, or a long 
 pair of forceps introduced througli the mouth downward into the pharynx, the point of 
 the instrument pressing forward the oesophageal wall. All vessels that bleed during the 
 operation should at once be twisted or ligatured. On opening the oesophagus the recur- 
 rent laryngeal nerve should be carefully avoided. The wound should be left open. The 
 patient must be fed for a few days by means of a small oesophageal tube, introduced 
 through the mouth into the cesophagus below the wound, care being taken during its 
 introduction to keep the point again.st the opposite wall. Convalescence, as a rule, goes 
 on steadily. I have been fortunate enough to see the operation successfully performed 
 twice by my colleague, Mr. Cock, and the facility with which it was done has given me a 
 very favorable opinion of its value. 
 
 CHAPTER XIV. 
 
 INJURIES OF THE ABDOMEN. 
 
 Contusions and Rupture of the Viscera. 
 
 Injuries of the abdomen, like tho.se of the cranium, derive their principal importance 
 from the nature of the cavity's contents. The integuments and muscles that form the 
 abdominal parietes may be severely injured and results follow which are simply of local 
 importance : but when the peritoneal lining of the cavity is involved or any of the vi.scera 
 are injured, the case assumes a grave aspect. The gravest internal abdominal injuries 
 may, however, coexi.st with the slightest or with no external evidence of mischief, and 
 even without shock. When a wound is present, an extra element of danger is added 
 which is to be measured by the extent and character of the visceral complication. 
 
 ^ Guy's Reports, 1858, lS'o7. 
 
484 INJURIES OF THE ABDOMEN. 
 
 Under certain conditions a trifling blow on the abdomen may give rise to symptoms 
 of an alarming nature, when a severe one may be recovered from without exciting more 
 than a fear. " The absence of shock immediately succeeding a severe lesion may lull 
 suspicion, as its presence may by simple contusion excite alarm." Every abdominal 
 injury, however trivial it may appear, must consequently be regarded with apprehension 
 and the utmost care observed in its treatment. This can be easily accounted for. says 
 Poland,' " when we consider the numerous and vital structures contained in the abdomen 
 — a serous membrane highly prone to inflammation ; the ' peritoneum," occupying an 
 extensive amount of surface ; a lengthy coil of organized tubing, ' the stomach and intes- 
 tines ;' solid substances, made up chiefly of blood vessels, etc., the liver, spleen, and 
 kidneys, readily lacerable and liable to rupture, causing nearly always fatal hemorrhage ; 
 receptacles for fluid, 'the gall and urine bladders,' which under distension and undue force 
 may burst ; large vessels coursing along the posterior wall. ' the aorta, vena cava,' etc. ; 
 and lastly, above all, the sympathetic nerves, consisting of the solar plexus and its 
 numerous satellite plexues and branches of such high organic importance that injury or 
 shock thereto may be attended with irreparable results. All these structures are. moreover, 
 enclosed with soft elastic parietes capable of great distension, which, although readily 
 able to resist shock and external violence without injury to themselves, yet may allow 
 the force to be transmitted and expended on the contents with dire effect, and yet with- 
 out leaving a trace or mark on the exterior." 
 
 In forming a diagnosis in this class of cases exclusion is the only sound method ; 
 every possible complication should be entertained and dismissed only when the weight of 
 evidence is against it, the ultimate conclusion being founded as much on negative as on 
 positive evidence. 
 
 " I am unacquainted," writes Le Gros Clark (^Surgical Diar/nosiii, 1869), " with any 
 diagnostic sign by which we may predicate whether shock following an abdominal injury 
 exists primarily, apart from, or as expressive of, actual breach of texture. Time alone 
 can develop the true nature of the case, either by renewal of vigor or by the develop- 
 ment of fresh symptoms." 
 
 An injury to the abdomen from a blow, fall, or the passage of a wheel over the part 
 may cause either a more or less severe contusion of the abdominal wall with no visceral 
 complication whatsoever, or a laceration or rupture of a viscus or vessel which will end 
 in death, without any (or very slight) external sign of mischief. 
 
 Shock or collapse as a direct consequence of a blow, when of a passing nature, is 
 of small value as a diagnostic sign, although when j^ersisfoit or relapsing it indicates great 
 mischief, as more or less complete collapse is a common effect of all abdominal injuries. 
 A collapse, however, coming on at a distinct interval of time after an injur}-, as a rule, 
 indicates internal hemorrhage. 
 
 Pain as an immediate effect of injury is no indication of internal mischief, for in 
 simple abdominal contusions it is at times very severe. When, however, it lasts or 
 becomes Jixeil, it is a symptom of importance : and when it radiafes from a point, it is 
 most characteristic. 
 
 Persistent vomiting is always a suspicious symptom of visceral injury. 
 
 How far sudden death is attributable to a shock or collapse from a blow on the epi- 
 gastrium or stomach without organic lesion is not yet a settled question. Dr. A, Taylor 
 in his Mediral Jurisprvdpncp adduces a case, that of Mr. Wood, in which a man, when 
 fighting and intoxicated, suddenly died after the receipt of a left-handed blow on the pit 
 of the stomach ; but the evidence in the case, as well as the facts revealed at the po.st- 
 mortem, was by no means conclusive as to the cause of death. The opinion has probably 
 been accepted on the authority of Sir. A. Cooper, who was in the habit of relating that 
 as two men were working, one of whom was wheeling along a heavy load, his comrade 
 thus addressed him : " That is too much for you ; stand a.side, and let me. a better man, 
 take it." He accompanied these remarks with a slight blow on the scrobiculus cordis, 
 and the man immediately let the barrow fall and died on the spot. After death no lesion 
 was discovered. The case, however, had only been related to Sir A. Cooper. Surgeon 
 A. Harding, of the Army Medical Department, in his Report, 1881, vol. xxi., Appendix No. 
 VII., gives a case " the history and post-mortem appearances of which apparently point 
 to sudden death the result of shock to the sympathetic system of nerves, paralyzing the 
 cardiac plexus, and thus causing cessation of the heart's action. The man, as far as can 
 be ascertained by inquiring of his intimate comrades and examination of his medical 
 history sheet, had been previously perfectly healthy, thus excluding heart disease, and 
 
 1 Guys Rep., 1858. 
 
I.X.I rinhs OF Tin: .\v,i><>mi:s. 48o 
 
 no tract's (if injiny liciiii: tniiml \v\h\> lairlv tn ilio almvc (•(difliisioii." Tlie case wa* that 
 Iff J. Coyli', an (itficcr'.s servant, who in drivin;: away a jiony from his master's tent received 
 a kick from the animal over i\\v reirioiiof the liver, lie at once said to a comrade stand- 
 ing near liim. " I'm done for," and fell down dead. I>r. Hanlin;.:: saw him so live minutes 
 after the accident. At the aiito])sy, made twenty-two hours after death, all the viscera 
 wiMc found heahliy ; luiit^s collapseil ; heart full of Huid hhiod ; liver normal in size, hut 
 full of l.lnod . s)ileen and kidneys also full (d" lilood. I concur, however, with Mr. 
 I'ollock. that ••sudden death att rihutalile to a lilow on the stomach or epijxastriuni must 
 he a rare occurrence, and that nu'dical men should he extremely guarded in offering an 
 opiniim as to the cause of death in such supposed injuries without satisfyinj; themselves 
 by mo.st careful and minute post-mortem investigation that no violence lias been done to 
 the viscera, either ahdominal or thoracic" ( IlolinesH S//sfrm, :^d edit., vol. i. ji. S(»7j. 
 
 What, tlii'n. it may he asked, are the usual conseiiuences of an alidominal injury or 
 contusion, and what are its risks and complications? The following facts will answer 
 these i|ueries. 
 
 At (Juys IIos])ital, during eight consecutive years, seventy-one cases of ahdominal 
 injuries were admitted. In xcvcnteeu cases, or about one-fourth of the whole number, 
 rupture of the viscera took place. \n foiti/-fonr, beyond a passing collapse and tender- 
 ness over the injured part from the contusion, no evidence of any internal mischief 
 showed it.self. In these ca.ses rest in bed for a few days, with the local ajiplicatiftn of a 
 •warm fomentation, was the chief treatment, and in all convalescence was rapidly estab- 
 lished. In ti-n r((ses syniptoms of peritunitis followed, as evidenced by excessive tender- 
 ness over the injured part, increased by movement, thoracic respiration — resulting from 
 the indisposition of the abdominal mu.scles to act, and the pain caused during that action 
 by pressure on the inflamed peritoneum — nansea, and in some cases vomiting. Fever and 
 constitutional disturbance varied according to the severity of the inflammation. In seven 
 of these ten cases tihsolufe rest in the horizontal posture, warm local applicatiims, either 
 by means of fomentation or cataplasms, in some instances leeching, and in (ill opium given 
 in moderately full and repeated doses, was the treatment adopted; and in every case the 
 inflammation was subdued before it had attained a dangerous degree of severity. In the 
 remaining tlirie rases, however, acute peritonitis set in, which in one terminated fatally. 
 As a type of an ordinary case of peritonitis after injury, I adduce the following case : 
 
 A man set. 22 received from a woman, while figliting, a blow on his right side, which 
 was follow'ed by syncope, but from which he soon recovered ; no pain or inconvenience 
 followed the injury for a week, and the man resumed his usual occupation. At this date 
 severe abdominal pain appeared at the seat of injury, which rapidly increased and spread 
 over the whole abdomen ; vomiting also began, accompanied with considerable constitu- 
 tional disturbance ; and in this condition he was admitted into Guy's. He was put to 
 bed, twenty leeches were at once applied to the seat of injury, and a grain of opium 
 given, which was ordered to be repeated three or four times daily ; perfect rest was also 
 enjoined. In a few days these .symptoms subsided and he was enabled to take food with- 
 out vomiting, pain ceased, and convalescence became gradually esta})lished. 
 
 Re.marks. — Such a case is interesting from the fact that some days elapsed between 
 the receipt of the injury and the appearance of the peritoneal symptoms, as well as from 
 the important practical point to be learnt from the rapid success that followed upon the 
 treatment which was pursued. Rest to its fullest extent was, doubtless, the chief ele- 
 ment of success — rest by position in the horizontal' posture, and rest of the injured parts 
 maintained by the administration of opium. It is not unfair to maintain that if this 
 treatment had been adopted earlier, the symptoms exhibited would never have made their 
 appearance; but, the man following his occupation, the repair which was ref|uired after 
 the injury could not be efficiently carried out, and, as a consequence, inflammation ensued. 
 Of all cases, abdominal injuries require absolute rest, and in no example, however, appar- 
 ently trivial, should it be neglected. If the mischief is but little, that little will more 
 rapidly be repaired ; if great, its evils and its consequences w^ill be materially modified. 
 The case already quoted indicates both points — viz., its primary necessity and its .second- 
 ary good results. 
 
 It is thus seen that a blow upon the abdomen may be followed by a simple contusion 
 of the abdominal wall, and in exceptional eases by peritonitis, which may terminate 
 fatally, although in the majority where such a result ensues it is from rupture or lesion 
 of some internal part. A local peritonitis after an injury is not, however, to be looked 
 upon with di.spleasure, for. as pointed out by Mr. Hilton, the coagulable lymph whitdi is 
 poured out under these circumstances forms a temporary splint until the injured struc- 
 
18() RUPTURE OF VISCERA. 
 
 tures repair themselves. The inflaimnatory effusion produces a certain degree of rest to 
 the injured structures, and thus contributes to the work of reparation. 
 
 ^Yhat, then, are the symptoms of an internal abdominal lesion ? How can the pres- 
 ence of such be made out? And what guides are there to the viscus that is wounded? 
 
 To answer these questions satisfactorily much space is needed — more, indeed, than can 
 Well be spared in this work ; yet helps to diagnosis may be given, and among these the 
 nature and position of the injury are the best. Where the loins are the part involved, 
 the kidneys are most likely to suffer : where the right hypochondriac region, and the ribs 
 on that side are fractured, the liver is probably the organ that may be injured. When 
 the injury is on the left side the stomach or more probabh' the spleen, when in the 
 umbilical region the intestines, when in the pelvic region the bladder, are the organs 
 involved. 
 
 Rupture of the liver usually destroys life by hemorrhage, and in the majority 
 of cases within a few hours of the injury — in some within a few days. Thus, out of 
 nine consecutive cases of ruptured liver, five died rapidly : three survived three, seven, 
 and nine days respectively. 
 
 There is little doubt, however, that recovery may take place when the fissure is limited 
 and the case uncomplicated. Preps. 19-48-1 95P in Guy"s Hosp. Museum, with drawings, 
 illustrate this truth. Such cases, when they occur, are classed with those of traumatic 
 peritonitis ; and when they prove successful their true nature is not revealed. 
 
 When the laceration is extenshr, death is always speedily produced by the shock and 
 hemorrhage ; coldness and general pallor of the whole body, with a feeble pulse, sighing 
 respiration, and restlessness, preceding the fatal issue. When the laceration is kss severe 
 life may be prolonged ; and I have recorded in another work the case of a man aet. 45 
 who when drunk fell from a cart and the wheel was said to have passed over his head. 
 Intoxicated to an extreme degree, he was admitted, under Mr. Birkett's care, into Guy's 
 Hospital, presenting no collapse or s3'mptom of abdominal, or even cranial, mischief, 
 beyojid slight hemorrhage beneath the right conjunctiva. He was put to bed, soon fell 
 asleep, and on the following morning, with the exception of the hemorrhage into the 
 orbit, )io sigim of mischief could be detected. Rest, however, in the horizontal position 
 was strictly enjoined, but to this he would not submit ; and thirty-six hours after the 
 accident he got up, walked about, and with a sudden pain in his side fell back and died. 
 After death a fissured fracture of the skull was found passing across the right orbit, 
 without brain complication, and about a pint of blood in the peritoneal cavitv, which had 
 evidently escaped from a severe laceration of the liver, a mass, situated in the right lobe, 
 the size of a man's fist having been nearly separated. The right kidney was al.so fissured 
 on its surface and covered with coagulated blood. In this case the man clearly died from 
 secondary hemorrhage the result of the ruptured liver. In October. 1883, a boy aet. 16 
 icalked into Guy's Hospital, although in pain, after the wheel of a cart had passed over 
 his abdomen. There were no external signs of injury, and the only prominent symptom 
 was vomiting. He appeared to be doing well, when on the fifth day. after an action of 
 the bowels, he suddenly died. After death a fissure three inches in depth was found in 
 the right lobe of his liver, filled with clots and covered with lymj)h. 
 
 In rare instances the liver may be crushed partially and. strange to say, its peritoneal 
 covering be uninjured ; yet in such cases life can be prolonged, and when the mischief is 
 not extensive may be saved. 
 
 Fissures of the liver are usually met with on its upper surface, and a diseased organ 
 is more liable to rupture than a healthy one. 
 
 The spleen is frequently injured, and such cases are by no means always fatal. 
 Prep. 2018. Guys Museum, illustrates its repair after injury. This organ, too. is some- 
 times lacerated by a fractured rib or torn by a dragging of its surface. When fatal, the 
 result occurs from hemorrhage or peritonitis. A child xt. 5 was run over and admitted 
 with fracture of the left ribs and lower jaw. He had no abdominal symptoms. On the 
 tenth day he sat up, when symptoms of acute peritonitis set in, followed by death on the 
 twelfth day. After death pleurisy and fractured ribs were found, with blood in the left 
 loin and four ounces of blood and pus between the surfaces of a ruptured spleen. 
 
 Subdiaphragmatic abscess way occur as a consequence of abdominal injury, 
 and the surgeon should suspect its presence in all cases where recovery is slow and 
 attended with abdominal pain. 
 
 Rupture of the stomach generally proves fatal from shock or irrecoverable col- 
 lapse, the amount of distension of the organ, its contents, and the extent of laceration 
 influencing the result. When the rupture is large and effusion of its contents into the 
 
iiri'Tiiu-: OF VISCERA. 487 
 
 altdniiiiiiiil ciivity fiikes place, acute peritonitis, witli or without hemorrliafre, will prove 
 fatal, ii' the siiock does not. When the rupture is small and tin; stomach empty, there is 
 some ehanee of recovery, local pc^ritonitis sul>s(M|ueMtly Lcluin^j the itijurtMl part to the 
 surroundint; tissues. 
 
 When death is imt iiiiiiicdiate, the jiatii'iit will (•(unpjaiii ut" an acute and constant pain 
 radiatiiiL' tVmn the seat oi' inj\irv — so peculiar, ini]ei;d, that " tlu; intensity of it ahsorhs 
 the whole mind of the patient, who within an hour from the enjoyment of perfe(;t health 
 expres.ses his serious and decideil conviction that if the pai:i he not s|ieedily alhiviated he 
 must die ' (Poland). \'omitinir is a ctuistant .symptom. Hrst ot" the contents of the stom- 
 ach, and often afterward of hlood ; collapse, ri<^or, ami syncope are often met with. 
 
 Incomjilete rupture of the coats of the stomach is found .sometimes after death, and 
 in (Juv's Mu.seum (Prep. lS17"'j there is the stomacli of a child ;et. 7 in which, from a 
 sudden Mow upon the distended viscus, the mucous memhrane was detached and lacerated 
 in a reniarkalile manner. 
 
 Rupture of the" intestines, l»oth lar<re and small, is a .somewhat common form 
 of alxloininal iiijurv. and may tie produced by a fall, a blow, the passage of a whetd over 
 the abdomen, or even violent muscular exertion. Hennen (Millfdri/ Siir<j' ri/) <;ives a 
 case where a soldier received a contusion of the abdomen, and sloujrhinfj: of the integu- 
 ment followed with artificial anus, yet in six months the feces resumed their natural 
 course and a recovery took place. In (jruy's Museum there is a specimen (Prep. ISol'^^j 
 of jierforation of the small intestines of a man who had received a kick from a horse and 
 died thirteen days after the accident with extensive peritonitis from fecal effusion. Prep. 
 IS;")!'*'' consists of a portion of jejunum taken from a man who had been kicked in the 
 abdomen, the injury being quickly followed by .symptoms of extravasation and death in 
 forty-eight hours; Prep. 1850'*- was taken from a case of perforation of small intestine 
 from the kick of a horse, terminating in death in twenty-four hours ; No. 185P* is a por- 
 tion of jejunum in which are two openings through which the mucous membrane is 
 inverted and resulting from a kick in the abdomen ; No. 1851"' is an example of lacera- 
 tion of the jejunum in which the bowel is completely divided. It was taken from a man 
 jet. ;57 who had been run over by a cart and lived twenty-four hours. Lastly, the speci- 
 men marked 1S51-' is from a case that occurred in the practice of my father, the late Mr. 
 T. E. Bryant of Kennington, and is a portion of ileum in the coats of which there is a 
 small perforation, the injury being produced by running against a post, and followed by 
 collapse, from which the patient did not rally, but died on the third day. 
 
 Cases are also on record in which, after injury, a portion of intestine has sloughed 
 and subsequently pas.sed per rectum, a recovery taking place. In the anatomical museum 
 of the University of Edinburgh several such preparations exist. 
 
 The duodenum, is rarely ruptured, its position protecting it ; nevertheless, such 
 an accident does occur. Taylor, in his Medical Jurisprudence, gives a case where a boy 
 jet. 13, after a blow on the abdomen, walked a mile with but little assistance; and when 
 he died (thirteen hours after the accident), the duodenum was found to be completely 
 torn across. In a case of my own a man jet. 25 walked into Gruy's after an abdominal 
 injury. He lived thirty-six hours, and after death his duodenum was found ruptured. 
 
 The jejunum is doubtless more frequently ruptured than any other part of the 
 intestines, its fixed position rendering it liable to be torn away from the duodenum by 
 such an injury as the passage of a wheel over the abdomen. Poland gives fourteen 
 examples of this kind, and in half of these the laceration was at its upper part. In one 
 case, after death, three or four pints of thin pink-colored fluid were found in the abdomen 
 — probably the iced water of which he had freely partaken after the accident — and in all 
 death took place from collapse and peritonitis. A man aet. 40 received a kick on the 
 abdomen from a horse. He walked to the hospital, but did not appear to be very ill. He 
 was admitted for precautionary reasons. He died suddenly in thirty-.six hours, and after 
 death fecal extravasation was found, and a perforation in the jejunum three feet from the 
 duodenum. 
 
 The ileum is also frequently ruptured, and most commonly from a direct blow or 
 fall on a hard body. In the majority of such cases there is no external mark of injury, 
 and fecal effusion with peritonitis is the usual cause of death. AVhen the rupture is large, 
 little hope exists of a recovery ; when small, such a hope, however, may be entertained. 
 In these ca.ses death is usually rapid : in the following case, however, of a man an. 21 
 who was run over and vomited, death did not take place for eighteen days. It followed 
 an action of the bowels, and after death a coil of intestine three feet from the caecum 
 was found lacerated and adherent. 
 
488 RUPTURE OF VISCERA. 
 
 When a patient is the subject of hernia and receives a blow upon the tumor, a 
 ruptured intestine may doubtless take place. Aston Key made this the subject of a 
 memoir in the Guys Reps, for 18-42. and Poland has collected many such cases in the 
 same periodical for 1858. Rupture of the gut is the usual result of .such an accident; 
 and when it occurs, a fatal termination is to be expected. When the bowel is only 
 bruised, however, it may recover or slough and be followed by an artificial anus. 
 
 In none of these cases, when symptoms of inflammation or of injury are severe, 
 should any attempt at reduction be made. The surgeon should, however, explore the 
 sac. In all recorded eases where the bowel has been returned a fatal result took place. 
 
 The large intestine is rarely ruptured from violence. When over-distended from 
 fecal accumulation tlic result of stricture or otherwise, such a result may ensue, but 
 under ordinary circumstances it is too well protected. I have, however, known florid 
 blood to flow from the bowel after an abdominal contusion, and have from that fact sus- 
 pected laceration of the colon. 
 
 Treatment. — The chief point to insist on is the absolute necessity of treating everi/ 
 case of injury to the abdomen with excessive caution, as very severe mischief may be 
 caused by violence and yet the immediate symptoms not be marked. Collapse after the 
 injury, as has been shown, is by no means a necessary consequence ; for rupture of the 
 intestine itself may take place without exciting such a condition, and a patient may walk 
 after having ruptured liver or intestine. The surgeon, therefore, should be guarded in 
 his prognosis as well as careful, watchful, and expectant in treatment. 
 
 Collapse, when present, unless it threatens to be fatal, should be disregarded, since 
 it ma}' have a most beneficial influence in checking or preventing bleeding. 
 
 Ill every case absolute rest in the horizontal position should be secured and maiutained. 
 If the injury be slight, convalescence will soon be established by such treatment ; if 
 severe, secondary bad results may be prevented, and. at any rate, be relieved. The 
 application of cold to the injured part gives comfort, and by checking the circulation 
 does good. A Leiters metallic coil {Fig. 9) is the nicest mode of applying it. or an ice 
 poultice or bag when the coil cannot be obtained. In some cases fomentations or 
 cataplasms give greater comfort. In exceptional ca.ses. when local pain from peritonitis 
 is great, the application of twenty or thirty leeches gives relief. Opium should always 
 be given in small and repeated doses, such as one grain every four or six hours- for an 
 adult. It allays pain, assists, by checking peristalsis, in maintaining rest to the injured 
 peritoneum and viscera, and tends materially to arrest inflammatory action. 
 
 The patient should be kept free from all excitement and as little nourishment admin- 
 istered by the mouth as will suffice to su.stain life ; if the intestines are believed to have 
 been ruptured, starvation treatment must be carried out. Whatever is given should be 
 liquid and cold. Milk and ice in limited quantities make the best and simplest combina- 
 tion, and upon this life can be sustained without difficulty. If great thirst exists, ice 
 may be given ; but this must be given with caution, as the case already quoted well 
 illustrates. When the intestine is believed to be injured, the allowance of food must be 
 very scanty, the patient s powers being kept alive by enemata of beef tea administered in 
 small quantities, say three or four ounces repeated every four or .six hours. 
 
 Ort no account ought a purgative to be adriiinlster< d. This rule is golden in these 
 cases and should never be deviated from, as by infringing it in a careless moment the 
 whole of nature's processes in repairing the injury may be undone and irreparable mis- 
 chief follow. Constipation is the .sign of a passive condition of bowel to the preservation 
 of which all our treatment is directed ; a purgative is merely an irritant and in its eff'ects 
 in these cases absolutely destructive. 
 
 In all cases the prognosis and treatment should be most guarded, cautious, and 
 expectant, and in all the state of the bladder should be well attended to. for retention of 
 urine from disturbed nerve influence is a common accompaniment and mu.st not be over- 
 looked. No case of abdominal injury, however trivial, can be pronounced well within a 
 fortnight. 
 
 Rupture of the kidney is an accident from which recovery is more common 
 than from any otlier viscus, and its po.sition in the loins outside the peritoneal cavity is 
 doubtless a sufficient explanation of this fact. When the injury is not very severe and 
 uncomplicated with other injuries, such cases usually do well. It is generally known by 
 an attack of htematuria and local pain following the blow on the lumbar region. The 
 haematuria may be but slight and passing or not .show itself till the second day. It may 
 cease al.so after the lapse of two or three days, when it is probable that only a contusion 
 of the kidneys had taken place, for in more severe injuries the bleeding may last fifteen 
 
nri'Ti'iu-: of visceha. 489 
 
 or even more days. At times elnts will lif pussed, }issumiii<: the shape of the ureter, and 
 I have before nie the notes of sonic liall' dozen eases in whieh these symptoms were 
 present and from which recovery took phiee. These elots, liowever, at times frivo rise to 
 retention of urine liy hlockini; up the nretlira. lictraction of the testiele is an occasional 
 symptom, and so is pain in tlic coiirst; of tin; ureter and ah)!ijr tlie course of one of the; 
 lumliar nerves. 
 
 TllK.VTMKNT. — Tlie ireatMient to lie piirsueil in these eases is rest in lierl und milk iliet. 
 In cases where tlie hleedin^r is profuse the tincture of erpit in full doses is a valuable 
 dru^, or a trrain of the acetate of lead may be triven with half a L'rain of opium three 
 times a day. or jrallie acid in teii-jrrain doses. Opium should always be ;.'iveii with 
 caution. 
 
 When the orfran is crushed, the injury is likely to be complicated with other mi.sehief, 
 and under such circumstances peritonitis and hemorrha<re. siii<rly or combined, frenerally 
 prove fatal. When the organ is single and becomes injured, a fatal result is also likely to 
 occur. In page 125 of my Ctinicdl Hnrijrrij I have recorded such a ca.se. When peri- 
 tonitis exi.sts, opium is of great value ; where urinary ab.scess in the loin follows, as it 
 occasionally does, particularly in gunshot wounds, the surgeon must make a free incision 
 into it on the outer border of the quadratus lumborum muscle. 
 
 Rupture of the ureter was first ntiticed by Stanley in the Mcd.-iliir. 7/v///.s-., 
 vol. .x.wii.. and in the two cases he related a fluctuating tumor formed by the effusion of 
 urine e.visted in both. Poland, in the (iliti/a Rfj). for 1808, has recorded a third case; 
 but beyond these no others are on record. Four cases of wounded ureter are. however, 
 published bv lleuiieii (Mil. Siny.). In all these cases, it seems, the ureter was ruptured 
 iiv stretcdung. its ri'ual end having suffered ; and I have seen two of these which occurred 
 in the practice of my colleague, ^Ir. Ilowse. 
 
 The symptoms are very obscure, particularly where no exteriuil wound exists ; indeed, 
 there are none to indicate the nature of the accident in its early stage. At a later period 
 a lumbar tumor may appear, of a cystic nature, caused by the retention of the secreted 
 urine, and there may be more or less peritonitis. When a lumbar .swelling exists, tap- 
 ping the cavity should be performed, the operation being repeated from time to time as 
 the fluid re-collects, the kidney in time probably ceasing to secrete. When this treatment 
 fails, there is little doubt that a free opening into it in the loin is the correct treatment. 
 Nephrectomy may be required. Under other circumstances the case must be treated as 
 all others of abdominal injury, by rest and opium. 
 
 Mr. Holmes records in the Mcd.-C/iir. Trans, for 1877, vol. xlii., an interesting case 
 of wound of the ureter which occurred in a boy aet. 13 where a clasp-knife had entered 
 his body from l)ehind, upward and outward, just on the right of the middle line and about 
 on the level of the posterior superior spine of the ilium. The wound discharged urine for 
 two weeks and then closed, the boy recovering. 
 
 Rupture of the gall-bladder has been recorded as the result of accident ; and 
 when it occurs death is usually rapid. The accident is marked by extreme collapse and 
 pain in the seat of injury. Poland in his Fothergillian prize essay, has given us .such a 
 case, and Dr. Fergus, in the Med.-C/n'r. Tnais.. vol. xxxi., has recorded another. In one 
 the death occurred from eolla])se, and in the other from peritonitis. 
 
 Rupture of the hepatic duct may also occur. In Poland's Fothergillian essay 
 such an instance is recorded, and occurred in a boy as the result of a blow on the abdo- 
 men, the accident being (juickly fatal. My friend Dr. Sutton has kindly given me the 
 details of a second ca.se, which took place in the Loudon Hospital in 18(i7. It was in 
 that of a man iiet. 21( who was knocked down, and the wheel of a spring-dray passed over 
 his .stomach. He felt pain in the right hypochondriac region directly and ' liad hard 
 work to get his breath." Abdominal pain increased and jaundice ajtjieared. and for a 
 month he kejit his bed. On the thirtieth day after the accident, as he did not improve, 
 he was admitted into the London Hospital under Drs. Herbert Davies and Sutton. Then 
 he had abdominal pain, tenderness, and di.sten.sion. There were distinct a.scitic fluctuation 
 over the abdomen and deep jaundice. He sank eight days after his admission and thirty- 
 eight days after the accident. The autopsy revealed the fact that the hepatic duct was 
 torn across a ((uarter of an inch above the spot where the cystic joins the common duct ; 
 no other part of the liver was injured. The abdominal cavit}' contained (juarts of olive- 
 green bile-.stained fluid, and the peritoneum was covered with yellow matter of the color 
 and consisteuce of jiaiiit. wliicli was found to V»e inspissated bile. 
 
 Rupture of the urinary bladder may occur with or without fracture or dislo- 
 cation of the pelvis. It is usually, but not always, due to external violence applied to a 
 
490 RUPTURE OF VISCERA. 
 
 distended organ. As a rule, the rupture takes place at its posterior wall, the urine escap- 
 ing into the peritoneal cavity and rapidly causing death. In exceptional cases it affects 
 the anterior wall, when the urine infiltrates the cellular tissue of the pelvis. In the 
 former cases the term " ?'«^ra-peritoneal " is applicable : in the latter, " f-rAro-peritoneal." 
 
 In estimating any suspected case the surgeon .should remember that a distended blad- 
 der can scarcely e.scape from an abdominal contusion, when an empty one mav elude the 
 greatest violence, and that a bladder partially distended is more likely to be bruised than 
 ruptured by direct external violence or torn when dragged backward. 
 
 This accident is more commen in men than women in the proportion of five to one, 
 and it occurs chiefly in young adults. The »?.x-Y/v/-peritoneal is far less dangerous than 
 the /»^r«-peritoneal rupture, but " the accompaniments of fracture and dislocation of the 
 pelvis cannot be said," according to Rivington. " of themselves to exercise much influence 
 in the length of the survival.'" 
 
 The bladder generally gives way in its weakest point. The main predisposing condi- 
 tion of rupture is distension of the organ, but this need not be very great. In exceptional 
 cases, as in one recorded by Rivington. the bladder was empty, the undistended viscus 
 being dragged backward with the peritoneum when a cart-wheel pas.^ied over the patient's 
 abdomen. The rupture in this case was in front, above the prostate gland. 
 
 A second predispo.sing condition is some obstacle to the exit of urine, urethral or 
 prostatic : and where with this obstacle there is .sacculation of the bladder, a very little 
 external violence, or vesical contraction only, brings about a rupture. 
 
 In 283 fatal cases collected by Rivington. 224 were brought about by traumatic and 
 59 by idiopathic causes — that is, in the latter the bladder was ruptured by muscular 
 action combined with overdistension from some obstructive cause such as' .stricture. I 
 have seen one ease of this kind the result of stricture in which the bladder gave way on 
 its anterior or upper wall outside the peritoneum, which got well after free abdominal 
 incision. A rupture from overdistension may be either intra- or extra-peritoneal, accord- 
 ing to the conditirfn of the individual bladder. Gross reports that in his cases the peri- 
 toneum remained intact in all. The aperture in the bladder when ruptured is not a clean- 
 cut one, but partakes of the characters of a lacerated wound. The edges are more or less 
 jagged and contused, one coat being often torn more than another. 
 
 The bladder, as a rule, contracts after rupture, and it is only in exceptional oases that 
 it holds more than a few ounces. There may be much bleeding from the wound, post- 
 mortem records revealing the fact that a large quantity of blood may be found in the 
 peritoneal cavity after death. Mr. Bransby Cooper stated that in his case three or four 
 pints of blood had been poured out. 
 
 Symptoms and Diagnosis. — '• The typical primary symptoms of rupture, whether 
 traumatic or idiopathic, are a feeling of .something giving way. pain, shock, inability to 
 stand or walk, desire, but want of power, to micturate, and removal from the bladder 
 with the catheter of blood only or a small quantity of bloody urine. The deficiency of 
 urine and the loss of power to micturate often continue throughout." The.se words are 
 those of W. Rivington. taken from a recent monograph on the subject (1884) which 
 merits praise, as it claims close study. In any given case there may be no external signs 
 of injurv. though the abdomen may be swollen, prominent, and tender. 
 
 Should an attempt be made to pass a catheter, a variable quantity of blood or of blood 
 and urine may be drawn off: and should the catheter by chance pass through the rent in 
 the bladder, the quantity of fluid evacuated may be great. Mr. Durham in one case 
 removed three quarts. The catheter, when in the abdominal cavity, will probably be 
 passed its whole length and be very movable. Indeed, in some cases it has been felt 
 through the abdominal wall. The stream of fluid, when it comes from the peritoneal 
 cavity, is slow and languid ; it may be intermittent. As the case progresses .symptoms 
 of more or less acute peritonitis develop. 
 
 Should the patient survive the accident five or six days, there may be hope of recovery; 
 for repair locallv will have gone on. and with it both local and general symptoms will have 
 ameliorated. The bladder will then probably begin to act naturally, pain will have dimin- 
 ished, and the patient will be able to take food. Dr. S. Smith reports (1851) three cases 
 in which the inability to urinate continued, and twelve in which it returned on the second 
 or a later day. In extra-peritoneal cases all the primary sA'mptoms will be more subdued 
 than in the intra-peritoneal, and the secondary symptoms will approach those of extrava- 
 sation of urine elsewhere, such as diffused cellulitis locally and those of blood poisoning 
 constitutionally. 
 
 Treatment. — Up to the present time no definite line of treatment has been laid down. 
 
nrrrrin: or vis<'i:n.\. l!H 
 
 suid as a cuiisiMiiu'iirc the results ul" trfatinciit liavt- hceri most ilisustroiis. Out of more 
 than two liuiidrcii cases tahulated \\y liiviuirton, but eij^ht have Ikm-ii n-corilud as exaui- 
 |)l('s of rccoviTV. and it must he a(hh'd that in them the tividiMiee of their hehjnjiin;; to 
 the //(//'/-peritoneal <;rou|i is not unim|ieaehal)le. Still, a careful examination of tiic evi- 
 dence artorde(| l»v these and other exam)iles is encouraging, and iMiou^h t<i support a line 
 of treatment wliicli is liased upon a principle and upon lines which may hrinir aljout a 
 <;;ootl result. 
 
 The treatment, tn Itc siicces>ful. must he local ; <^('neral treiitment hy itself has been 
 proved to be absolutely useless. 
 
 The indications for local treatment are — -Jii-Atlij, to withdraw the extravasated urine 
 from the peritoneal cavity ; and srcoiu/lj/, to secure a free exit for fresh urine as secreted. 
 
 To carry out the first when the diaj^nosis is clear, laparotomy should be performed 
 by an incision two or three inches in len<;th made above the pubes. throu<rh which the 
 peritoneal cavity should be well (deared of all })lood and urine and sponj^ed dry with anti- 
 septic sponges. The rent in the bladder should be closely stitched by a silk suture like 
 that of Lembert's for the intestine ( FIlt. -H2, pa<;e 4i>4), and to facilitate this step I would 
 sugjrest the nse of the rectal inflator as described and illustrated (Fig. 'Mf'-i), since by its 
 use the base of the bladder and prostate will be raised out of the pelvis and well into 
 view, thus facilitatini; manipulation. 
 
 After this operation and the abdominal wound has been carefully stitched up, cyst- 
 otomy should be performed for drainage |>iirposes. 
 
 Should, however, much difficulty be experienced in suturing the vesical wound, the 
 surgeon may find comfort in the result of Dr. Walter's case (Jirnikinf/s Abstract, 1862), 
 in which laparotomy was performed, the abdominal cavity was cleaned, and a rent two 
 inches long seen in the fundus of the bladder left alone, the bladder being, sub.sequent to 
 the operation, relieved by catheterism, and recovery took place. 
 
 When the diagnosis is not sure, the treatment above advised rejected, or the ca.se is 
 late for treatment, a drain for the urine should be made by lateral cystotomy, after which 
 the urine will flow away as secreted. Median cystotomy with the introduction of a tube 
 within the neck of the bladder is likewise good practice, but it does not .satisfy the require- 
 ments of the case .so well as the lateral. 
 
 When a catheter has been passed per Hrcthrmn into the bladder, and probably through 
 the rent into the peritoneal cavity, a free irrigation of the cavit}' should be employed. 
 Mr. Thorp's case ( Dublin Quart. Journal, vol. xvi.), so far as it goes, tends to support 
 this practice, and Mr. C. Heath strongly advises it. 
 
 In extra-peritoneal rupture and urinary extravasation, supra-pubic, and possibly peri- 
 neal, incisions may be called for and a free vent for secreted urine provided by lateral or 
 median cystotomy. 
 
 The probabilities of obtaining a successful result in any of these cases turns, how- 
 ever, more upon the time that has elapsed when they are put into execution than any- 
 thing else, fresh urine not being nearly so irritating to a healthy surface as urine under- 
 going septic changes ; and these, when once begun, go on rapidly. In Walter's successful 
 cases the operation of laparotomy was performed ten hours after the extrava.sation ; in 
 Willet's and Heath's, unsuccessful, thirty and forty-two hours respectively. 
 
 •' The records," writes Rivington, " appear strongly to indicate the necessity of bold 
 action. The chances of recovery entirely hinge upon the promptitude of the surgeon 
 adopting efficient measiires. In doubtful cases an exploration with the finger through a 
 perineal incision would be perfectly justifiable and could .scarcely introduce any fresh 
 element of danger. If the diagnosis of intra-peritoneal rent be clear at the outset, the 
 urine cannot too soon be evacuated by a supra-pubic incision and the peritoneal cavity 
 carefully clean.sed. At the same time, a perineal opening may be made with advantage. 
 I am disposed to think sewing up the rent in the bladder unnecessary, provided a free 
 perineal exit V;e secured for all urine secreted after laparotomy." 
 
 The only general treatment should be the admini.stration of opium, a grain of the 
 solid or its equivalent of liquid being given every four or six hours, to allay pain and 
 relieve peristalsis. 
 
 Food of a simple character should be given all through. 
 
 Injury to the uterus, when large from pregnancy, deserves a passing notice, for 
 such cases are serious. A contused organ may inflame and be followed by abortion or 
 miscarriage, or, should pregnancy continue, its .structure may be so altered as to be liable 
 to rupture. In obstetric works cases ase recorded in which this accident happened. I have 
 known also an intra-uterine fracture of a child's thigh to take place as a.consequence of a fall. 
 
492 WOUNDS OF ABDOMEN. 
 
 Rupture of an ovarian cyst from a blow is also recorded, and under certain 
 circumstances a good result may take place ; all obstetricians have met with such cases. 
 The removal of the ruptured cyst is probably the best practice to be followed, since, if 
 left, a fatal peritonitis irenerally follows. 
 
 Rupture of the diaphragm occurs in practice, but it is an accident difficult to 
 diagnose. It is generally the consequence of some violent injury, such as a crush or the 
 passage of a heavy wheel over the waist. In such cases the injury is complicated, and 
 usually with hernia of the abdominal contents into the thorax. This injury can occur 
 only on the left side. Dr. Wilks, in the Lancf^t for 1858, reported three instances of this 
 diaphragmatic hernia, and pointed out that fxcesdve thirst was the most prominent symp- 
 tom in each. I had the opportunity of seeing these three cases, and others since have 
 come under my notice in which this symptom of insatiable thirst was most characteristic. 
 
 Wounds of the Abdomen involving Parietes and Viscera. 
 
 The parietes of the abdomen are often wounded by sharp substances, whether by 
 accident or design ; and so long as the wounds are confined to the parietes, the danger is 
 small. When the peritoneum is punctured or perforated, the viscera are also probably 
 involved : and under such circumstances th(5 case becomes serious. In rarer instances the 
 intestines protrude, when an additional element of danger is added. 
 
 Wounds of the parietes alone rerj^nre the same treatment as wounds of any 
 other part. The surface should be well cleansed and ;J1 foreign bodies removed. Hem- 
 orrhage should be arrested by torsion or ligature and the edges of the wound brought 
 together with sutures. In deep or lacerated wounds, where the muscles are involved and 
 the risk of suppuration great, absolute rest in the horizontal position should be enjoined. 
 When suppuration appears, the surgeon must be careful to let out all fluid, either by 
 reopening the wound or by a fresh opening. All punctured icounds should be left open; 
 when bleeding persists, the wound should be enlarged and the vessel secured. 
 
 Penetrating Wounds of the Parietes. — There is always a difficulty in diag- 
 nosing these cases — that is. in making out the true nature of the accident, more particu- 
 larly in punctured wounds. When the depth of the wound is known by the extent of 
 insertion of the offending body and the relative position of the viscera at the wounded 
 spot also, some notion as to its nature may be formed ; but when no such guides can be 
 found, the surgeon has to rest upon surmise and probabilities. As a rule, where want of 
 evidence is felt, it is well to treat the case as serious. All penetrating wounds are serious, 
 whether incised, lacerated, punctured, or gunshot : but punctured wounds are bv far the 
 most common. 
 
 When there is a total absence of all symptoms be3'ond those of the parietal wound, 
 the viscera are probably uninjured, these neyntire si/mptoms wffording the Lest positire evi- 
 dence of the simple nature of the accident. When the viscera are injured, there will gen- 
 erally be more or less lasting s^'ncope or collapse ; there will probably be severe local 
 pain, soon becoming radiating; there will also frequently be vomiting, possibly of blood, 
 or the passing of blood from the bowel or bladder. If life is prolonged, there will be 
 peritonitis. When the bowel or omentum protrudes, when the feces, bile, urine, or blood 
 appear at the wound, the evidence is clear. The surgeon, however, will find much help 
 from collateral evidence in forming an opinion — as, for instance, in the size of the wound 
 compared with the instrument that inflicted it, the position of the blood-stain on the instru- 
 ment, the force with whieli the blow was struck, the direction of the force in relation to 
 the position of the patient, and the thickness of the abdominal parietes. By these several 
 means an approximate opinion may be formed, but in no case can a positive diagnosis be 
 made with certainty. 
 
 Under all circumstances, however, the tre.a.t.me.\t must be the same. Absolute rest 
 in the horizontal posture, with the legs flexed to relax the abdominal muscles, is essen- 
 tial ; no movement should be allowed, not even for passing the evacuations. With respect 
 to LOC.^L TRE.\TMEXT. the greatest simplicity should be employed. The wound should be 
 cleansed and all bleeding vessels secured, but anything like an exploration of the wound 
 is to be condemned. All probing, fingering, or manipuJating the wound should be avoided 
 as dangerous and only pertaining to surgical curiosity. The edges of the wound, when 
 it is large, .should be brought together by sutures and some simple antiseptic dressings 
 applied, with cold by the metallic coil. Punctured wounds, when perforating, like others, 
 should be left open. Even after the lapse of .some days, when no symptoms of wounded 
 viscera appear, the same caution should be observed, two or three weeks being ahvnys 
 
i\.n'i:ii:s m riii: Aiu>nMh\\. 
 
 493 
 
 allowed before frcfiloin i> u'ivfii. I'lKltT ;ill circunistaiiccs the cori<liti<jfi of the />/<i</<l^r 
 slioiilil lie iiHUiireil into. 
 
 Onliiiii ill iiioderate or full doses, accordiiijr to cireuinstances, is demanded, to keep the 
 bowels i|uiet and check peristalsis, it beiiiir well to keep a patient under its influence for 
 several days by irivin<.' oik; f^rain every four or six hours. Lov diet — that is. milk iliet — 
 •should be allowed, all food bein-,' <j:iven cold and in small nuantities ; iee to suck is refre.sh- 
 inir. J'lin/iifirrs shoiihl on no account be ixiveii till the nature of the ca.se i.s declared. 
 
 Penetrating Wounds with Protruding Viscera. 
 
 It is hardly neces.sary to remark that the special risk of any of these cases is deter- 
 mined jrreatly by the viscus that is involved and the amount of injury it has .sustained. 
 Thus, a penetratinir abdominal wound with protrudin-r omentum is far less dangerous than 
 when hernia of the intestines ex- 
 
 ists, and a protrmliii": wounded 
 bowel is of irraver importance 
 than an uninjured one. It is 
 consef[uently necessary for the 
 surgeon in all these cases men- 
 tally to run over the position of 
 the viscera, in order that he may 
 form an opinion as to the prob- 
 abilities of the case. Fig. 281 
 will refresh his memory on the.se 
 points. 
 
 '•Of the hollow viscera any 
 portion of the intestinal canal 
 may be protruded, from the 
 stomach to the sigmoid flexure, 
 according to the situation and 
 degree of distension of the vis- 
 cera, the small intestines most 
 frequently, next tJie large, then n.^itineu 
 the stomach, and, lastly, the ^, ,.,. 
 
 _. „ ' , 1-1 - • Lmbuicus 
 
 caecum. Of the solid viscera 
 the omentum is by far the rao.st 
 common, and is often associated 
 with that of the viscera" (Po- 
 land's prize essay). 
 
 In Amall wounds a limited 
 hernia of the abdominal con- 
 tents can alone take place ; but 
 when it occurs, the protruded 
 viscus is very liable to be stran- 
 gulated. In hirrjp wounds the 
 hernia will probably be of great- 
 er extent, but their constriction 
 is rare. 
 
 Fig. 281. 
 
 Diagram showing the Positions of the Abdominal Viscera. 
 
 When the omentum protrudes through a recent wound, and uninjured, it .should 
 be washed by means of a stream of antiseptic water and returned with all gentleness, the 
 patient being placed in such a position as to relax the injured muscles. The wound should 
 never be enlarged to allow of the return of the omentum. When the omentum has been 
 extruding for some time and is congested from incarceration or strangulation, when it has 
 become inflamed, or perhaps sloughing, it is well not to make any attempt at its reduction. 
 As time goes on and the projecting mass swells and granulates it may be ligatured in 
 halves. This should not be "done, however, for at least two weeks after its protru.sion. 
 During this time the greatest (juiet -should be enforced and moderate doses of opium given 
 with li(|uid food. After a few days all fear of peritonitis will have passed. Some prefer 
 not to interfere with the ])rotrusio'n. in the belief that it will wither up sooner or later, but 
 such a process is tedious; the application of a ligature to it in halves is, moreover, rarely 
 attended with any risk. If the omentum is much bruLsed or torn at the time of injury, 
 such injured portions may be cut off and all divided vessels secured. 
 
494 
 
 INJURIES TO THE ABDOMEN. 
 
 When the bowel protrudes throujih the Wdnml and is itiiiiijurid. it sliDuld be 
 cleansed and returned under all circnmstdncfs. the wound being carefully enlarged for the 
 purpose in the course of the muscular fibres should its reduction be otherwise impossible. 
 To facilitate this the muscle should be relaxed and the parts last descended returned first. 
 In returning the intestine the pressure should be directly backward : if made obliquely, 
 the bowel might be pushed up beneath the fascia or muscles, and thus outside the peri- 
 toneum. The wound should be closed by sutures and treated as already described. 
 
 When the protruded bowel is gangrenovs. it must be left in situ to slough and that an 
 artificial anus may form, the wound in the abdominal parietes being enlarged, but where 
 there is any prospect of its recovery the abdominal cavity is its best place. 
 
 When the intestine is "wounded and the opening a mere prick tlirough which 
 no intestinal contents exude, the bowel may be returned, a few hours being enough for 
 the wounded part to become sealed by plastic exudation and repair to be completed. 
 
 Fig. 282. 
 
 Fig. 283. 
 
 Sut'uns l,'ir(iut/]i srrou! ront 
 
 ires Cliroutih 
 Jnueous coat 
 
 Fig. 282. — Lembert's Suture, including Peritoneal Coat alone. 
 
 Fig. 283. — Double Suture. 1. Of mucous and muscular coats. 2. Of serous, as in Lerabert's. (In distal side of bowel 
 the serous suture should precede the niiicuus; in proximal, the mucous suture should be applied first.) 
 
 When the mucous lining protrudes, the opening should be tied by a single fine ligature. 
 W^hen the wound is suflBciently large to permit of the escape of the visceral conitnts^ it 
 must be stitched up with the form of suture seen in Fig. 282 or 283, cleaned, and 
 returned, the ends of the sutures being cut ofl' close. 
 
 When the wound involves nearft/ the whole calibre (f the Imu-d and the bowel is much 
 bruised or injured, it is wiser to stitch the edges of the bowel to those of the wound, 
 thereby making an artificial anus, than to stitch the two divided ends of the intestine 
 together, and to return the whole into the abdominal cavity, although, says Pollock, if 
 the division be caused by a clean sharp instrument, the extremities may be brought 
 together by sutures and returned ; but if the separation be the result of an irregular lace- 
 rated wound, as from gunshot, etc., we should not hesitate to fix the edges to the exter- 
 nal wound and risk the chance of an artificial anus. When the bowel is stitched to the 
 edges of the external wound, care should be taken to maintain the line of the canal as 
 much as possible, and not to draw the intestine more out of its position than is absolutely 
 necessary. 
 
 The general and local treatment of all these cases is similar to that already laid down 
 for the treatment of other abdominal and visceral injuries. 
 
 Penetrating abdominal wounds complicated with wounds of the 
 
 viscera, but without protrusion, are, doubtless, far more serious than any that 
 have been hitherto considered ; and tlieir eflfects depend greatly on the condition of the 
 viscus when wounded. Thus, the puncture of a distended stomach, intestine, or bladder 
 will to a certainty be followed by extravasation into the abdominal cavity, and, as a 
 result, by great shock and diff'use peritonitis : whereas these organs, when empty, and 
 therefore contracted, may receive a limited injury without any such consequences taking 
 place, local inflammation rapidly arising under these circumstances and sealing the 
 wound. 
 
 The chief risks of wounds of the viscera when the solid organs become implicated 
 are hemorrhage ; and when the hollow, extravasation. When the contents of the wounded 
 organ escape externally through the wound, the danger of the case is undoubtedly less- 
 ened. When the stomach is supposed to be wounded by a puncture, the utmost care is called 
 for to prevent the administration of any food; indeed, nothing should enter the stomach 
 for several days, and life should be maintained by nutrient enemata, because to excite 
 any action of the organ would undo what nature may have done for the repair of the 
 injury, and thus jeopardize life by increasing the risk of extravasation. When the intes- 
 tine is wounded or suspected to have been wounded, the .same care is necessary. When 
 the bladder is wounded, it should be drained by lateral cystotomy. 
 
ABSOiiMAi. .wrs, I'ly.iL Fisrri.A. 4H5 
 
 (J/n'iini slidiihl l»(' jiivcii, aii<l is lu-st :Mliiiiiii.>-t«T»<l l»v Mi|«|n)>it(irics. tlu- iiiorphia sup- 
 positories of tin* IMi:iriiia(n|iu'ia ht-iiiL"^ tin- licst |irfparati<iii to ciiiiiloy in all casi-s of altdom- 
 inal surirtTy. Tin- priiiciplfs of tri-aliunit. liowi'Vcr, art- tlu- saiiii; as liavi- Id-t-ii laid 
 down ill former pa<.'t's. In marked peiietratin<r woumls of tlie alxlonieii in wliieli evidence 
 of a wounded liollow viseus exists, the /not/ irouml, as ^ein-raily advisi-d. slmnlil !,<■ It ft 
 njHiis or covered only with a loose eovi-riiiL' ; for to elose the wound so as to prevent tlie 
 eseape of the eoiiteiits of the wounded viseus externally wouhl he to elose the only ;rate 
 throuLrh which return to health i> possilile. 1 am. however, disposed to think that the 
 wisest course would he to enlar;:e the wound or reopen the ahdoininal cavity, search for 
 the wounded vi.scus. and sew uji the opeiiiiifr in it. suhse«juently cleansinj: tlie alxhtniina! 
 cavity and dealin<r with the case as described in a former jtajre, the chances of a jrood 
 result heiiiL' I'ar u'reater by this practice under the circumstances than they can by any other. 
 
 Heniarkable eas«-s of recovery after iDi]ialemeiit are on record, and not the least is that 
 of a boy ;et. 11 who fell upon a rick stake, the stake penetrating' his body for seventeen 
 and a hall" inches. Tt entered the abdominal cavity in the n't//i/ ^^roin. beneath I'ou]>art's 
 ligament, passed thr<iui:h it to the left side into the thorax, through the diaphragm — dis- 
 placing tlie heart and pushing it to tlie right side of the sternum — into the left lung. an<l 
 passed out of the chest, between the seventh and eighth ribs, into tli.e axillary space. 
 Tlie stake was removed four hours after its introduction, and not a teaspoonful r)f blood 
 was lost. Some intestine which jirotruded from the wound in the groin was replaced and 
 the inguinal wound stitched up. Opium, with calomel, was freely given subse(|uently. 
 and in six weeks the boy was able to sit up. {day, and eat his ordinary food. F'ive months 
 after the accident he was free from pain and able to walk freely. The case occurred in 
 the practice of Mr. Reynolds of Thame. Oxon, and is recorded in the M'd. Times and 
 Gaz., September 23, 1871. 
 
 Abnormal Anus, Fecal Fistula. 
 
 Confining the term urtijicioJ mm^ to the surgical operation of forming an anus other- 
 wise than natural for the relief of intestinal obstruction, whether by colotomy or enter- 
 otomy. and nbii'>nnal anus, or intestinal fistula — -fical fistnhi — or an unnatural communi- 
 cation between the intestinal canal and the outside of the body, is generally the result of 
 sloughing or iilcerating bowel in strangulated hernia, although it may occur either from a 
 wound to the intestine from some external cause, or from a perforation of the intestine 
 from an ulcerating process originating from within. 
 
 When it follows a hernia, the opening is usually at the neck of the hernial sac ; when 
 it follows a wound, at the seat of injury ; when it is the result of some ulcerative process 
 originating from within, the fecal abscess may burrow into the pelvis (opening into the 
 vagina, bladder, or even bowel again), or between the abdominal muscles, and make its 
 appearance in the groin, iliac fossa, or loin. When the opening is large and direct into 
 the bowel, it has been called "artificial anus;' when small, indirect, or fistulous, "fecal 
 or intestinal fistula." 
 
 The most important point, however, connected with this subject has reference to the 
 amount of intestine involved. When only a small ]iortion of its calibre has been lost, 
 the fistula generally will be small : when a large portion of its calibre or a whole knuckle 
 has been involved, the fecal orifice will be large. Tender the.se circumstances, the two 
 orifices communicating with the upper and lower ends of the bowel respectively can gen- 
 eralh' be made out, a fold of membrane ffirmed by the junction of the h>ent tube stand- 
 ing as a partition between the two portions of the gut. At times this partition will pro- 
 ject so far forward as to close completely the orifice of the lower part of the bowel, and 
 this is the usual state of affairs when a complete knuckle of bowel has been involved in 
 the disease and under these circum.stances a cure by natural processes is almost impossiVjle. 
 At other times the partition will be but limited and a portion only of the contents of the 
 bowel will pass externally, the other jiortion taking its normal course downward toward 
 the anus, when it is more than probable that nature alone or but slightly assisted by art 
 will effect a cure. When the orifice is large, there is almost always some prolap.se of the 
 bowel. Under all these conditions the intestines within the abdomen are closely connected 
 by means of adhesions to the external orifice, the serous surface of the intestine becom- 
 ing firmly fixed to that of the opening in the abdominal parietes. Beyond these adhesions 
 it is rare to find other coils of intestine adherent about the part : on the contrary, the 
 parts are otherwise usually so free that coils of bowel will be found separating the two 
 portions of intestine that are adherent at the wound, and may so dip down between them 
 
496 ABNORMAL ANUS, FECAL FISTULA. 
 
 as to push forward a serous sac into the artificial opening, and even to form a hernia. The 
 nature of the discharging fluid will fairly indicate the portion of the bowel involved : 
 when well-formed feces pass, the large or lower part of the small intestine is probably the 
 seat ; when the fluid is thin and inoflPensive, the jejunum is indicated. 
 
 Prognosis. — The yellow semi-feculent contents of the ileum can generally be recog- 
 nized. The nearer the opening is to the stomach, the worse is the prognosis, as nutrition 
 under such circumstances must be seriously interfered with. The nearer it is to the lower 
 end of the canal, the better are the prospects of life. 
 
 Treatment. — When the orifice is fistulous and the canal below the fistula is fairly 
 open for the passage of feces a cure may with some certainty be looked for by natural 
 processes ; and such a result is by no means unusual in the artificial anus, which is met 
 with after the return of a small hernia into the abdomen, and particularly of a femoral 
 hernia. In these cases the surgeon has little more to do than to keep up the strength, 
 give simple nutritious diet, maintain perfect cleanliness of the wound, and ap])ly gentle 
 pressure to the part. When the fistulous communication is larger, the san)e treatment 
 must be employed, though with less hope of success. Lawrence recommended the con- 
 stant use of a truss in these cases to prevent jirolapsus, and Pollock strongly advocates 
 the importance of the recommendation, adding that "a compress of linen placed on the 
 opening, with a larger pad over it, and a truss applied over the whole, will in a great 
 measure restrain the contents as well as prevent the protrusion of the bowel." To assist 
 the contraction of small fistulas the edges may be cauterized, or even ])ared, a plastic ope- 
 ration being justifiable under certain circumstances. 
 
 With respect to surgical interference in these cases, the recommendations I have to 
 offer are not very satisfactory. Dupuytren ' suggested an operation to get rid of the pro- 
 jecting fold or septum that has been described. He did this by an instrument called an 
 enterotome. a pair of forceps with one blade grooved, into which the other closed, the 
 approximation of the blades being regulated by a screw. The septum was crushed 
 between the blades, and so held till its destruction was effected. The instrument, as a 
 rule, came away about the seventh day, and, Dupuytren says, " by the division and loss 
 of substance the ridge and the double septum which separate the two ends of the bowel 
 are destroyed, so as to re-establish the interrupted communication between them and 
 restore the natural course of the aliment and feces." Jobert advises the pressure of the 
 instrument to be gradual, fatal cases having occurred when Dupuytren's rapid process 
 has been employed. The theory of this operation is good, and is based on nature's own 
 processes ; for I have seen the septum of an artificial anus ulcerated through by natural 
 processes, leaving an opening through which feces passed from the upper to the lower 
 bowel, a narrow band above alone existing to prevent a freer feculent flow. The success 
 of the operation has also been good, inasmuch as out of forty-one operations recorded by 
 Dupuytren twenty-nine recovered, nine were relieved, and three died. In this country 
 the operation has been little practised. Dr. Buchanan of Glasgow, however, has recorded 
 a successful case (Edin. Med. Jonm., 18G9). 
 
 When a fee(d ahsce.^tti has formed in the abdominal walls, the .sooner it is opened, the 
 better; and when opened, the incision should be free. In abscesses connected with the 
 csecum or its appendage this rule is important ; and if acted upon, good results may be 
 anticipated. For intestinal fistula opening directly into the vagina little can be done 
 surgically beyond attending to the general condition of the patient, giving nutritious 
 food, though not such as is likely to distend the bowel, and observing perfect cleanliness 
 of the passage. The external opening should be enlarged, however, if anything like 
 retained pus exist. Under these circumstances a natural recovery may take place. In 
 recto-vaginal fistula plastic operations are most successful. 
 
 When the horvel has ulcerated into the bladder, natural processes appear to be rarely 
 capable of effecting a cure ; and under such circumstances, to save the patient from the 
 miseries caused by the passage of solid feces into the bladder, the operation of colotomy 
 may be entertained. I have performed this operation on many occasions under these 
 circumstances with success, the operation in all giving great relief. One of my patients 
 is now (1884) alive, free from all pain, the operation having been performed on July 5, 
 1870 (Clin. Soc., 1872). In another case, operated upon on August 16, 1869, the gentle- 
 man lived to March, 1875, and died from heart disease at the age of seventy. The third 
 died from some kidney affection some months after the operation (Med.-CJiir. Rev., 1869). 
 The others died some weeks after, from the cancerous affection for which the operation 
 was demanded, but free from all pain. 
 
 • 1 Mem. de I' Acad, de Med., 1828. 
 
FORKicy nonncs /.v thk stomach ash istestises. 
 
 497 
 
 Foreign Bodies in the Stomach and Intestines. 
 
 Forei{j;n bodies are ofti'ii tukcii intutlic stoiiiach fnjin accid(;iit and design, and the 
 roeords of casi's ])rove that tVoin the ahst'iite or niihiness of syn)|)toins no surgeon should 
 pronounce against the |)ossil)ility of their introduction. They are ]»assed as often as not 
 P'l- miitiii witliout giving rise to very distressing symptoms, although when retained they 
 cause nothing hut evil. Snntut/i /innf f/oi/iis, such as e<»ins and stones, as a rule, pa.s.s 
 readily without giving rise to any, or other than slight colicky, symptoms ; hut shurj) and 
 piiiiiftt/ IdhHos, such as hones, jiins. knives, metallic plates with teeth. (;tc., give rise to 
 such as vary according to the position of the intestines at which they hecome impacted. 
 
 A foreign hody taken into the stomach may be ejected by vomiting, discharged exter- 
 nally through the abdominal parietes. retained in the stomach, or passed onward. In 
 Fig. 284 is illustrated a piece of inm wire that was swallowed by a female lunatic a3t. 50 
 
 Fig. 284. 
 
 Fig. 285. 
 
 Piece of Iron Wire l)iscliai>,'ed I'i-diii .\l)scess in Alidoniinul Wiills after having been Swallowed. (Natural size.) 
 
 on March 10, IST^^. The .symptoms that followed were .so slight that some dou})ts as to 
 the occurrence existed, and it was not till May lo. two months later, when a swelling wa.s 
 detected in the right of the umbilicus, that the history was credited. The swelling rap- 
 idly increased, and opened on ^Nlay 20, and the point of the iron wire projected. This 
 was withdrawn by Dr. T. B. Dyer, the surgeon of ("olney Hatch, and a rajiid recovery 
 followed, no single bad .symptom making its appearance. My friend Mr. Lund of Man- 
 chester has likewise recorded a similar case in the Liiy>ipool and MoncliPister Mpd.-Snrg. 
 Reports for 1873. When retained, a foreign body may re.st without giving rise to very 
 serious symptoms — a rare result — or set up ulceration, which may in its turn give rise to 
 a fatal peritonitis. In the more fortunate it will be passed on through the canal and 
 discharged. 
 
 To prove these points I may record the case of a man aet. 22 who came under 1113- care 
 in 1882, two days after having swallowed, in the night, an artificial metal plate, two 
 
 inches long by one wide, with three incisor teeth, 
 and metal hooks to catch the right two and left 
 first bicuspid teeth (Fig. 285). He passed the 
 plate per (tnnrn without pain, on the eighth day, 
 and restored it to its original position, and was no 
 way injured by its passage. The reader may also 
 refer to Mr. Pollock's article in Holmes's Si/sfem, 
 vol. i.. where he gives a ca.se in which a lady vom- 
 ited a gold plate three-quarters of an inch long, 
 with two false teeth, after it had been lodged in 
 the oesophagus for nineteen and in the stomach for 
 ninety-.seven days. A case is likewise on record 
 in which a lady passed/)^;- amim a plate two and 
 fi quarter inches in diameter, with four teeth, six months after she had swallowed it. 
 
 A remarkable case of this kind has been recently recorded in the Tln'rtieth Reiv.rt of 
 (lie Commissioners in Liinoq/, 1876. A woman <\?t. 43 (having made previou.slv many 
 suicidal attempts) on July 31, 1875, swallowed thirteen screws, each .screw consisting of 
 a body two and a half inches long and half an inch thick, a raised collar nearly two- 
 thirds of an inch in diameter, and a s(|uare head, the whole thirteen screws weighing 
 twenty-four ounces. She was fed on pudding and gruel, morphia was injected subcuta- 
 neously to relieve pain, and after a few days ounce doses of castor oil were given daily. 
 On the forty-first day the first of the screws passed by the bowel, and by the end of the 
 sixth month the last came away. The screws in their pas.sage had lost four ounces and 
 three-quarters in weight. This case occurred in the Bristol Asylum under the- care of 
 .Or. Thompson. Poland has also recorded in his prize essay the case of a lunatic who 
 died from ulceration of the duodenum owing to the pressure of a spoon-handle that had 
 been swallowed about three months before, with fhirti/ others, besides nails, pebbles, and 
 pieces of iron. These foreign bodies were extracted from the stomach after death, and 
 weighed in all forty ounces. The most complete list of cases of foreign boilies in the 
 
 Plate with Ted 
 
 on Eiuhth 
 
498 GASTROTOMY AXD GASTROSTOMY. 
 
 digestive canal will be fouml in tlie L'nion Mi'dlcah for November. 1874, b}- Dr. 
 Mignon. 
 
 In Guy"?- Museum (Prep. 1800) there is an enlarged and thickened stomach of a sailor 
 who had swallowed clasp-knives. He was net. 23, and in June, 1799, he swallowed four 
 clasp-knives, which were discharged from the bowels. In March, 1805. he swallowed 
 from fifteen to twenty more, after which his health became impaired. He vomited the 
 handle of one and passed portions of the blades of others, and in ^larch, 1809, died in a, 
 state of exhaustion. After death one blade was found perforating the colon opposite the 
 kidneys, but without extravasation of feces, and another was fixed across the rectum. In 
 the stomach, too. were numerous blades partially dissolved, or between thirty and fnrty 
 fragments in all. 
 
 At times intestinal calculi form from the agglomeration of hair, husk — particularly 
 oat-husks — or other foreign substances, and prove fatal. Dr. Down has recorded such a 
 case' in a boy aet. 13 who died of exhaustion after fifteen days' illness. Not many years 
 ago I saw an artist a?t. 36 who died from intestinal obstruction, through whose abdominal 
 walls a globular indurated mass was readily felt on the right of the umbilicus. I sus- 
 pected it to be made up of hair, for he was in the habit of sucking to an excess the paint- 
 brushes of his pupils ; but the diagnosis could not be verified after death. 
 
 Treatment. — Rest in the horizontal position and expectant treatment are in these 
 cases the two essential points to be observed. Purgatives should on no account be given. 
 The " smasher," according to Pollock, who con.stantly swallows false coin when caught in 
 the act of passing it. avoids pvrgatiLes, but takes a constipating diet, such as hard-boiled 
 eggs and cheese, together with his usual food, thinking that the money is more likely to 
 be caught, and consequently passed, in a bulky stool than in a liquid one. The surgeon 
 should act on this principle. When the foreign body becomes impacted in the stomach 
 or intestine or sets up inflammator}' action and peritonitis, the abdomen should be opened 
 and the foreign body removed by gdRtrdtomy. ten cases out of eleven in which this opera- 
 tion has been performed having recovered. ( Vide paper by Dr. Pooley of Xew York, R'n li- 
 mond Med. Jouni., April, 1875. J 
 
 Gastrotomy and Gastrostomy. 
 
 When the stomach has to be opened for the removal of a foreign body, the operation 
 is rightly described as that of '• gastrotomy." When the same operation is performed 
 •with a view to establish a permanent fistula for the introduction of food, as first per- 
 formed by Sedillot in 1849, and described by him as gastro-stomie. the term " gas- 
 trostomy." as suggested by Dr. Poole}-, seems to be the more applicable term. 
 
 That the operation of gastrotomy is not necessarily fatal is proved by the fact that it 
 has been performed at least eleven times, and in ten with success ; and though in the fifty 
 or sixty cases in which gastrostomij has been undertaken for cancer life has never been 
 prolonged for more than six months (my own case. Lancet. May 6. 1882). the relief it 
 has afforded to those who have been subjected to it is sufiicient to prove that it is based 
 upon a sound principle and a humane practice, the operation having been undertaken 
 more with a view of mitigating the horrors of a death from hunger and thirst and of 
 prolonging what remained of life than from any curative object. I have had an oppor- 
 tunity of watching the progress of some of the early cases under the care of my colleagues, 
 Messrs. Cooper Forster and Durham, of many under my own care, and of some under the 
 care of other colleagues, and I am free to acknowledire that the advantages given by the 
 operation are worth the risk, and that if life was not prolonged it was certainly rendered 
 more endurable. 
 
 When the operation is performed for a cicatricial stricture, better results may be 
 recorded; for out of eleven cases reported eight recovered. The interesting cases operated 
 upon at Rostock by Dr. Trendelenburg, March 8, 1876 (Med. Record.^ March, 1878), in 
 Paris by M. Verneuil {Gaz. de.< Hop.. October 28, 1876; Lancet, January 13, 1877), and 
 my own case i Lancet. April 8. 1881) support this view. 
 
 Trendelenburg's case was in a lad who had swallowed some sulphuric acid six months 
 previously, and the stricture was in the lower end of the gullet. At the end of the fifth 
 month after the operation the weight of the boy's body had increased by one-fourth. The 
 boy took food, as usual, by the mouth, masticated it. and then blew the contents of his 
 mouth through a long elastic tube directly from the mouth into the cavity of the 
 stomach. 
 
 1 Path. Trans., 1867. 
 
tiASTRnroMY AM) CASTROSTOMV. 400 
 
 \'i'riu'uil .s jiatitiit was a iiiasdii a-t. 17. and tlie stricture a cicatricial one due to the 
 accidental swallowiii'; of some caustic putasii i»n l''e))ruary 4, iSTtl. (Kso]dia^<itoinv was 
 out of the (|U»'stiou, as the stricture was situati'd h»w (hiwri in the tiihc, and relief was 
 called for Itecause Hwallowini:: was inipossiMc. < )n .lune litJ <;astrostoiny, conse((uently, 
 was performed, and a rapid recovery foilnwed. The man was up and about on Aujrust 
 20. A caoutchtnie .sound was kej)t in the w<iund for feeding purpo.ses. In the report of 
 the ca.se it is stated that when food is poured into the stomach the oidy sensati«»n experi- 
 enced is that of heat or cold. iSaliva, however, is at the time freely .secreted, and the 
 man executt's masticatory movements. l)i<;estion goes <jn well without the aid of saliva. 
 
 .^ly own ease was a girl ivt. 'I'l who seven months before her admissirjn into (Juy's, in 
 July, ISSO. had swallowed a wineglassful of sulphuric acid. The ce.sophagus was almost 
 co\npletely closed, and no Ixtugie could he passed. A rapid recovery fulluwed the opera- 
 tion, and the itpeniug int(» stomach was very small. The jiatieiit is now well, but unable 
 to swallow anythiuir. The opening into the stomach is hardly visible and the ]»arts 
 around it are (juite dry. She can feed herself when standing and no regurgitation of 
 food or fluid takes place. 
 
 These cases are most satisfactory, and are sufficient to encourage the belief that better 
 success wouhl follow this operation, even when undertaken for cancer, if it were per- 
 forme<l at an earlier period of the di.sease than has hitherto been the practice. 
 
 We perform colotomy on a patient with cancerous stricture of the intestine or other 
 mechanical obstruction without hesitation, and surgeons are now willing to admit the 
 great advantages afforded by this means. Surely, the advantages offered by '• gastros- 
 tomy ' for stricture of the oesophagus, cancerous or otherwise, are not less potent; and 
 slioitll it /»' iiiuhrfaken he/ore tlie puti'mt^ poircrs Ittivr, breu hronglit to too low un ebh^ there 
 is no reason why it should not be e((ually effective. In one of my own ca.ses performed 
 for cancer the man lived five days, and the operation had nothing to do with the death, 
 there being no peritonitis, and the local repair was most complete. In the second case 
 the patient lived two days; in the third, tifty-one days; in the fourth, six months. So 
 also was colotomy unsuccessful till it was undertaken at an earlier stage of the disease. 
 Gastrostomy, as a rule, has been put off until too late; it has, however, now become an 
 established operation in surgery. 
 
 Operation. — An anaesthetic should be given, although the risks of vomiting as a 
 consequence are not slight. The patient .should be placed upon his back and an incision 
 made parallel with and half an inch below the margin of the left ribs. The cut should 
 be from three to four inches in length, and its centre should correspond with the line of 
 the linea semilunaris ; the tissues should be divided seriatim down to the peritoneum. 
 Every vessel should be twisted or tied as it bleeds, and all capillary oozing arre.sted by 
 a large sponge. The peritoneum may then be divided and the stomach sought. In the 
 ca.ses I have operated upon it was seized readily. If the liver presents, it should be 
 raised ; and if the omentum comes into view, it should be drawn downward. The colon 
 should not be mistaken for the stomach. When the stomach is found, it .should be held 
 well forward against the abdominal parietes with a pair of tenaculum pointed forceps and 
 two loops of fine silk introduced, one-third of an inch apai't, by means of a delicate curved 
 needle, through the peritoneal and muscular coats of the viscus. The ends of these 
 loops should be left long, for a purpose to be described later on. The stomach may then 
 be carefully secured to the margin of the wound by means of a sufficient number of silk 
 sutures ; the sutures should be made to include the peritoneal and muscular coats of the 
 stomach and the parietal layer of peritoneum and muscles. Some surgeons introduce a 
 double row of sutures, but I do not believe this step is neces.sary. 
 
 The first half of the operation is now completed. 
 
 The second half is really the completion of the operation, for it includes the opening of 
 the stomach : and this should be carried out on the fifth or sixth day after the first step, 
 and is effected with ease and without pain by simply holding the stomach forward by 
 means of the two loops of ligatures which were introduced into its walls when first caught, 
 and puncturing the exposed area with a tenotomy knife. The opening into the stomach 
 need not be larger than one-eighth of an inch. The silk loops niav now be removed. By 
 this small puncture the surgeon gains all he can desire, for the walls of the stomach 
 being elastic, the small opening readily yields to the slightest pressure, so that a tube the 
 .size of a No. 10 catheter can readily be introduced into the stomach for feeding purposes, 
 and by virtue of this same elasticity, when the tube is withdrawn, the artificial orifice 
 closes, and as a result there is little or no escape of the contents of the stomach to satur- 
 ate the patient's linen or to irritate the soft parts around the artificial orifice and thus add 
 
500 INTESTINAL OBSTRUCTION. 
 
 to the patients discomfort. In the case recorded above the wound is now, as it has been 
 since ISSU. quite dry. 
 
 For feeding purposes after the first few days have passed, and during which warm 
 milk with eggs is the best diet, the food should be thick, and for its easy introduction 
 Messrs. Krohne of 8 Duke street, Manchester Square, have made for me an apparatus 
 which con.sists of a small Higginson's springe with a small tube at one end to be intro- 
 duced into the stomach, and a larger one in the other connected with a glass funnel as a 
 receptacle for food. With this thick food, such as peptonized meat, can easily be thrown 
 into the stomach. 
 
 It must be added that Sedillot was the first person to perform the operation in 1849, 
 and Mr. Cooper Forster, on the suggestion of Dr. Habershon. was the first to do it in 
 this country in 1857. Since then it has been repeated about fifty or sixty times. 
 
 By way of conclusion, gastrostomy .should be undertaken for cancerous or cicatricial 
 stricture of the oesophagus as soon as there is a practical difficulty in the introduction of 
 solid food into the stomach, life being prolonged and much misery saved by such a prac- 
 tice when the di.sease is cancerous, and life being saved indefinitelv when the cause is 
 traumatic. 
 
 When the ulceration is not cancerous, but simple or syphilitic, a cure may be looked 
 for. my colleague, Mr. Davies-Colley. having now a patient alive for whom he performed 
 gastrostomy some years ago to save her life from starvation, and nine months later closed 
 the fistula, the ulceration having healed and the power of swallowing having been restored. 
 
 The operation should, when practicable, be divided into two steps, as suggested hy 
 Mr. Howse, and, his improvement being so great, it should be described as " Howse's 
 operation." 
 
 The opening into the stomach should not be larger than that made by an ordinary 
 tenotomy knife, or about one-eighth of an inch. 
 
 Intestinal Obstruction. 
 
 In cases of acute or chronic intestinal obstruction, when the physicians art has failed 
 to give relief, the surgeon's aid is required ; and it would be well for the medical mind to 
 recognize the fact that in a large proportion of iu.stances this aid is sought at too late a 
 period — that is. when the patient's powers have become so exhausted as to exclude all 
 hope of a successful issue being obtained by any treatment, or when the involved tissues 
 have undergone such changes from peritoneal complications as to forbid any reasonable 
 expectation of the competency of nature's reparative powers to efl'ect a cure even where 
 the cause of the obstruction has been removed. 
 
 It should ever be remembered that cases of acute intestinal obstruction, like those of 
 strangulated hernia, require prompt and active treatment if they are to be successful, 
 and that those of chronk obstruction require a no less decided line of action. It must 
 be admitted, also, that there is no class of cases which claim for diagnostic purposes more 
 thought and judgment, that the difficulties of diagnosis as to the cause of the obstruction 
 are sometimes great, and that the question of operative relief has to be decided, conse- 
 quently, upon uncertain grounds. But such arguments, to my mind, are in favor of 
 operative measures for diagnostic as much as for curative purposes, and in no way tell 
 again.st them when the diagnosis is clear. 
 
 When the diagnosis is clear and the nature of the case decided, delay is dangerous 
 and a want of courage in the surgeon to act upon the diagnosis is criminal. The ques- 
 tion of diagnosis is, consequently, all-important and will first claim attention. 
 
 Diagnosis. — In a clinical point of view, cases of intestinal obstruction may be divided 
 into acute and chronic. The acute include strangulation of a portion of bowel from exter- 
 nal or internal hernia, omental, mesenteric, peritoneal, or foetal bands, or twists of the 
 intestine ^volvulus). The chronic embrace inflammatory, syphilitic, or cancerous stric- 
 tures of the large or small intestine, the occlusion of the bowel from the mechanical pres- 
 sure of tumors, adhesions of the intestines from inflammatory peritoneal changes, and last, 
 but not least, the impaction of feces. 
 
 Perityphlitis, the passage of a gall-stone, and acute peritonitis due to perforation may 
 simulate acute ob.struction. Intussusception belongs to both divisions, since, when the 
 invaginated portion of bowel is acutely strangulated, acute symptoms will show them- 
 selves ; and when the same portion is incarcerated, the symptoms will be chronic, although 
 in their onset they may be sudden. The relative frequency of these conditions will be 
 seen in the followin<r table; 
 
Acrri-: istkhsm. strangulatios or riii: r.oWEL. 
 
 '^)\ 
 
 Causes of Intestinal Obstruction, excluding Hernia, 
 
 bfiiik' ill! aiiiily.siK of VH consecutive ciwch extracted from the |io>*t-ni(>rteiii rceordn of (iiiy's Mo><(>ital tiy I)r. Hilton 
 iiiKKu from 1H.VI to \m^ (<t<tij> AV/.., IMlM, und Mr. Kusseil I'roiu !»«» to l«7« i uiipuljliblied^. 
 
 (iiiy's 
 
 Cases. 
 
 33 
 
 .Vtl'TK 
 OUSTKUCTION. 
 
 CUKONIC 
 OBSTRUCTION 
 
 15 
 
 Intussusckp- 
 
 TIONS 
 
 124 
 
 1 littiTiml huriiiii. 
 
 7 twistw (volvulus 
 
 1 i 1 
 
 pit. 
 ') (liviMticiila. 
 
 2") liaiids 
 
 AnalyNix of K', ca.se» of stricture of 
 •) ..iiiii'tiiliv <"i.<-i intestines as civen in a paper by 
 
 - .l|>|HIl 11\ (..(1. Coupland ainf Morris ' /ir<7. .»/«/. 
 
 I 2 til iK'ck (it IliTUial .xac. ./oui«., .lanuary 2f., 1W7H). 
 
 I t'roiri |)C'(lulcM)f ovarian tiiiiKpr. Middlesex I'atlioloKical 
 
 < a.ses. 
 
 1 iinpa.lion. :.^^.'!'^ 
 
 .'5 iiu'ciiaiiical pfcssiirc of tumors. 
 
 f 
 
 r 2 small 
 
 intfstine. 
 ( 4") large. 
 
 23 mattinjr together of in- 
 testinal coils from 
 peritoneal and can- 
 cerous disease. 
 (Contractions.) 
 2 rectal. 
 7 ileo-ctecal. 
 6 small intestine. 
 
 >'•> rectimi and sig- 
 ntoid flexure . 
 
 7 tran.sveise colon 
 with hejtatic 
 and splenit- 
 flexures .... 
 
 5 ciccum or ileo- 
 cjecal 
 
 Miiall. 
 
 24 
 
 3 
 1 
 
 .Society. 
 
 .'.\ iarije 
 
 intestines, 
 
 1 small. 
 
 (ienenJ 
 Total. 
 
 21 
 
 9 
 1 
 
 = 78 
 
 In all 
 
 s (if intestinal obstruction the diagnosis should be made upon the principle 
 of exclusion, the [iractitioner coming to a conclusion by first running over every possible 
 cause and eliminating each sen'dtiin, and subsequently weighing the points in favor of the 
 proliable cause. 
 
 The possibility of the symptoms being due to a strangulated or incarcerated external 
 hernia should always be carefully investigated. 
 
 Acute Internal Strangulation of the Bowel, 
 
 whether from an internal hernia, twist (volvulus), or a foetal or peritoneal lymph band, 
 may take place at any period of life, and the symptoms to which it gives ri.se are those 
 of an acute strangulated external hernia — viz., sudden and definite onset of the illness in 
 a healthy subject, .severe paroxysmal central abdominal pain, attended by sickness and 
 more or less collapse ; constipation, inability to pass wind downward, and hiccough ; occa- 
 sionally, also, scanty urine, or even its suppression ; coils of distended bowel are some- 
 times visible through the parietes. 
 
 There will, however, be no distinct abdominal tumor, no tenesmus, and no hemorrhage 
 from the bowel, such as is often present in an acute intussusception. There mav, how- 
 ever, be some evidence of one coil of intestine being more tense or distended than 
 another. 
 
 When, therefore, a case presents itself with these symptoms, there can be no difficulty 
 in coming to a conclusion as to its nature, although it may be difficult, if not impossible, 
 to diagnose the precise cause of the .strangulation. If, however, we refer to the table 
 above, some guide will be found ; for it will there be seen that out of 33 cases 25 were 
 due to bands, 7 to volvulus, and 1 to internal hernia. 
 
 When there has been a history of old hernia, the probabilities of the existence of a 
 band are much enhanced, since it is true that with hernia such bands are not uncommon. 
 Duchaussoy in his paper *• On Internal Strangulation"' (Mi'm. <fr FArad. <Ip Mi'tf.^ 1860) 
 gives such cases. Fagge quotes one, and in my own practice four have occurred. One 
 died unrelieved; in the second I opened the empty hernial sac, and so enlarged my inci.s- 
 ion upward for about two inches as to detect a band high up in the abdomen, which I 
 divided with a pair of scissors, and a perfect recovery took place. This case occurred in 
 the practice tif |)r. Wilkinson of Sydenham, and is fully recorded in the Med.-Chir. Trans. 
 for 18(>7. The patient is still alive. Tho third and fourth died after the operation, but 
 the band was divided and a large coil of intestine released. The operations had been 
 delayed too long. 
 
602 
 
 ACUTE INTERNAL STRANGULATION OF THE BOWEL. 
 
 Mr. Gay's analysis of 148 cases tells us that 102 were in the male and 4G in the 
 female, and that the largest number of cases took place in patients between 15 and 35. 
 
 The surgeon under the circumstances related, however, has a clear case and an 
 important decision before him ; for if the diagnosis be correct and a portion of bowel is 
 stfaiiyalatid within the abdomen, obstructed by some solitary band, or twisted, he knows 
 
 that very little can be htoked for by mcd- 
 
 Ifim 
 
 \ 
 
 Fig. 286. 
 
 ' iillaeluJ li 
 
 imi, II ri 
 
 ^^ 
 
 I junuTV, 
 
 ical treatment — that by leaving things 
 alone and the case is unrelieved death is 
 inevitable ; and he is aware, moreover, 
 that the hope of a cure by natural pro- 
 cesses is very meagre ; and if I estimate 
 that hope as being nearly on a par with 
 that entertained in a case of ordinary 
 strangulated hernia when left to itself, I 
 shall probably be about the mark, since 
 cases of strangulated hernia do occasion- 
 alhj go up of tjiemselves when all surgical 
 efforts short of herniotomy to reduce them 
 have failed, and cases of internal strangu- 
 lation, from whatever cause, do occasionally 
 free themselves. Nevertheless, no pru- 
 dent mind, on the strength of these ex- 
 Case of StraiiKulation of the Howel by Lvmph Rand constrict- .• 1 II •ii- 1 
 ing Ileum alx.ut three inches from Csecuin and a Coil of CCptlOnai Occurrences, WOuld Willingly 
 
 Jejunum. (Taken trom a man set, 2G, who died after bowel leave a case of external strangulated 
 
 ob.struction 01 hiteen days duration. This case occurred in , . . ,„ iti-ii 
 
 my father's practice in 18:i8, and is recorded in Trans. Med. hernia tO itsell ; and i think that no pru- 
 
 ' rativtfXSnce:) '^^e suggestion was then made of ope- ^ent surgeon ought to leave unrelieved 
 
 any case of internal hernia or strangula- 
 tion to the same almost forlorn hope, because, granting that the diagnosis of the case can 
 be made, by no medicine, 'no manipulation, no expectant treatment can the mechanical 
 obstruction be overcome, and under these circumstances a fatal termination must be 
 anticipated. 
 
 Opium may relieve pain, mask symptoms, and give rise to a pleasing delusion that all 
 is doing well in cases of internal strangulation, as it is well known it does in others of 
 external hernia, but in the one as in the other it does no more. It does not accomplish 
 the only true remedy — viz., relieve the mechanical strangulation to which the bowel is 
 subjected. 
 
 In external acute strangulated hernia the only recognized correct treatment when the 
 hernia cannot be reduced is herniotomy ; and when the hernial tumor does not seem to be 
 the seat of strangulation and symptoms of strangulation exist, the surgeon regards an 
 exploratory operation at the seat of hernia for purposes of diagnosis not only a justifiable, 
 but a called-for, measure. 
 
 In /?(^'rjta/ hernia, or in any case of acute strangulation from whatever cause, I main- 
 tain that a like principle of practice should be acted upon; for when the diagnosis is 
 sure, it is by '• laparotomy " alone that a cure can be brought about ; and when it is 
 uncertain, it is by " laparotomy " alone that the diagnosis can be made out and a correct 
 line of treatment adopted. 
 
 The operation of ovariotomy has proved to us that the exposure and the manipulation 
 of healthy intestine are not of themselves fatal measures, and there is every reason to 
 believe that in the cases now under consideration a good result might often be secured if 
 the operations were performed before a fatal peritonitis had set in or the strangulated 
 bowel been injured past recovery. At any rate, as matters now stand, a recovery by 
 medical treatment from an internal strangulation is a matter of wonder, and it would be 
 well, as all collateral experience indicates, that a bolder practice should be employed. 
 
 If we appeal to pathology — and it is only there, unfortunately, that we can ajjpeal — 
 we receive ample facts, since the late Dr. Fagge. in his able article already referred to, 
 tells us that '■ there might in many cases have been no little difficulty in finding a band 
 among the distended coils ; but I regard the facts derivable from our post-mortem records 
 as indicating no insurmountable obstacles to the success of an exploratory operation in 
 the great majority of the cases of true internal strangulation which are to be found in 
 these records." Dr. Brinton, in his analysis of six hundred cases, points also to the same 
 conclusions. Under these circumstances I feel bound to express my conviction that on 
 the diagnosis being made of an internal strangulation, from whatever cause, the operation 
 
( 'iirjiSK ' i.\TJ:sTf\. I /. oiisTii I ■( Tiny. 
 
 5(^3 
 
 of •• l;i|iar((t(iiii_v slimild he |pcrli>nin il. ;ui<l lliat i>\\ llir iliatriiosis of" tlit- cause heiiig 
 uiH-fitaiii laparotiiiii y is likcwix- ralKil iur to clt-ar iij) iliml)t.s aiiil to deal witli conditioas 
 wliitdi ail' otIuTwiso inciiudialdf. l{ut this ojifiati<iii is not to bu jtciloniii'd as a ih mli-r 
 ri'ssurt uioro than that ior f.vtcrnal hernia, hut sliould he carried out as early in tlie prog- 
 ress of the case as the diairnosls will justily — when, in sjtite of the f^ravity of the meas- 
 ure, irood results may he Icmkcd I'm'. 
 
 A Help to Diagnosis in Cases of Abdominal Obstruction. 
 
 
 " l.,et uo one set too 
 
 nucli value on any one sign or symi)tom." — l''A<i<< 
 
 K. 
 
 
 Aei'TK— 
 
 ClOtONlC OlLSTISeCTION. 
 
 AccTK OK Chronic— 
 
 
 Obstruction orSlran- 
 
 Iniiii l>i.seasi' of Large I'roin Ki.'tease of .Small . . .. 1 
 
 Previous cDiulition 
 
 gulaliou. 
 
 Intestine. 
 
 Intestine. luui.Hsuscepuou. 
 
 In good health. 
 
 Ailing for some time 
 
 Ailing with previous In good health. 
 
 of subject. 
 
 
 with abdominal sy m)>- 
 
 attacks of incomplete 
 
 
 
 toms. . 
 
 obstruction. 
 
 ' Modeuf uttui'k 
 
 Very sudden and 
 
 Symptoms gradually 
 
 I'aroxysms of colicky Sudden on.set, and in- 
 
 1 
 
 acute. 
 
 increasing in severity, 
 
 pain, upon old symp- creasing when acute, ' 
 
 
 
 or acute grafted upon 
 
 toms. suli.siding whea ' 
 
 
 
 chronic. 
 
 chronic. ' 
 
 1 arly symptoms: 
 
 
 
 
 
 k aiu 
 
 Abduntinn! jiitin, 
 
 Pnin, dilTused and in- 
 
 Pahi, iiaroxysmal.with 
 
 Pnin, fixed and often 
 
 
 fixed, central, and 
 
 creasing with disten- 
 
 intervals of ease in 
 
 relieved by pressure. 
 
 
 paroxysmal. 
 
 sion. Iiypiigastric sit nation. 
 
 1 
 
 Noiuiting 
 
 1 iimitiiiii, rapidly be- 
 
 Intermittent and fecal (iccasicnal during at- 
 
 Rapidly becoming fecal ' 
 
 ! 
 
 coming I'ecal. 
 
 towaid the last. tack of pain. 
 
 in acute cases, ab- | 
 sent or intermitteot 
 in chronic. 
 
 1 (.'oUapse 
 
 Cotlnpse, very mark- 
 ed. 
 
 Absent till tlie end. 
 
 Absent till late. 
 
 Very marked in acute 
 cases, not so iu 
 chronic. 
 
 CoDstipation 
 
 Absolute constipa- 
 
 Gradually increasing 
 
 Attacks of constipa- 
 
 Occasionally present, 
 
 
 tion and inability 
 
 in severity. 
 
 tion, alternating with 
 
 but, as a rule, "dys- 
 
 
 to pass flatus. 
 
 
 natural relief. 
 
 enteric" symptoms, 
 straining, tenesmus, ' 
 muco-sanguineoua 
 stools, or hemorrhage. 
 
 Abdominal disten- 
 
 Rapid and severe. 
 
 (iradually increasing. 
 
 Never great, increased 
 
 Rarely .severe. 
 
 sion. 
 
 central and hypo- 
 gastric. 
 
 lumbar and epigas- 
 t ric. 
 
 during attack. 
 
 
 Manipular indica- 
 
 Tympanitic, distend- 
 
 A tixed swelling at 
 
 A doughy condition 
 
 Distinct tumor often to 
 
 tions. 
 
 ed coils at times to 
 
 times to be felt in of bowel, becoming 
 
 be felt, its shape vary- 
 
 
 be felt. 
 
 either iliac fossa. knotty during attack. 
 
 ing during attack. 
 
 Visible indications... 
 
 Abdomen tense in 
 
 Abdomen broadly dis- Coils of intestine very 
 
 Nothing marked to be 
 
 
 umbilical and hy- 
 
 tended, coils of iutes- visible. 
 
 seen. 
 
 
 pogastric regioTis, 
 
 tine visible. 
 
 
 
 
 with visibly dis- 
 
 
 
 
 
 tended coils. 
 
 
 
 
 Peristalsis 
 
 Rarely visible. 
 
 Marked. 
 
 Very marked. 
 
 Not visible. 
 
 trine 
 
 Scanty or suppressed. 
 
 Natural in ((uanlily. Natural. 
 
 Natural 
 
 Rectal examination.. 
 
 Lower bowel prob- 
 
 Stricture of bowel may Nothing abnormal. 
 
 Rectum may contain 
 
 
 ably quite empty. 
 
 be felt in rectum or 
 
 mucus, blood clot, or 
 
 
 
 in sigmoid Hexure by 
 
 invaginated bowel. 
 
 1 
 
 
 manual examination. | 
 
 
 Chronic Intestinal Obstruction 
 
 now claims attention, and it is to be observed /// 1 1 mine that the clinical history of these 
 cases is very distinct from that of the acute ; for whereas in the *■ acute" the .symptoms 
 appear, as a rule, suddenly in patients who have been apparently in good liealth. in the 
 "chronic" it will almost always be found that there has been for a more or less leniftliened 
 period some abdominal ]>ain or .symptom, some difficulty in ol)taiiiin<r a movement^ of the 
 bowels or in the act of defecation, some discharue. })robably, of ylairy mucus, of pus, or of 
 blood, separately or combined, at uncertain intervals, and last, but not least, .some cliaiiire in 
 the form and character of the stools, the motions at one time being liquid and loose, at 
 another hard and marble-lik;:. while at intervals they are pipe- or tape-like. Under all 
 circumstances there will be .symptoms of long standing; and if acute symptoms exist 
 when the case comes under notice, they will be found to have been grafted upon the old. 
 If, therefore, we are called to see a patient suffering from marked symptoms of obstruc- 
 tion of some days" duration and obtain such a history of the case as has just been 
 sketched, and find him with abdominal tympanitic di.stension. and probably pain, possibly 
 visible ])eristalsis. nausea, vomiting, hiccough, and borborygmi. we may safely come to 
 the conclusion that the case is one of chronic obstruction, and that it has for its cause 
 one of those named in the table (page 501). It will prove to be .stricture of either th« 
 colon or the rectum, the mechatiical pressure of a pelvic or abdominal tumor, the mat- 
 ting together of the intestinal coils from old or chronic inflammation of the peritoneum 
 or mesentery or from cancerous abscess, and last, but not least, to fecal accumulations; 
 
504 CHRONIC INTESTINAL OBSTRUCTION. 
 
 and ill every case of obstruction the last possibility being the cause should be borne in 
 mind. Rare instances are also on record in which other causes have existed, and I have 
 given, in the chapter on hernia, some in which the obstruction had been clearly traced to 
 the influence of an adhesion between the bowel and a hernial sac or some part of the 
 abdominal parietes, or to an obstructed obturator or other hernia. 
 
 The effects of obstruction, from whatever cause, ai-e very uniform, and every case will 
 terminate fatally from either exhaustion or peritonitis if the obstruction is not overcome. 
 When chronic peritonitis occurs, it is due to the obstruction ; and when the peritonitis is 
 acute, it is due either to a perforating ulcer of the sigmoid flexure secondary to the stric- 
 ture, to some ulceration of the caecum or colon the result of overdistension, or to the 
 mechanical rupture of the ctecum the direct result of the pressure of the fecal accumula- 
 tion acting backward upon the ca3cal cul-de-sac. My notes describe two cases in which 
 the caecum burst — one in which it was purple in color and measured fifteen inches round, 
 and another in which it had sloughed. I have also notes of a case of a male child born 
 with an imperforate rectum who died on the sixth day from ruptured ca2cum. And out 
 of eleven consecutive fatal cases of untreated stricture of the rectum at Guy's Hospital, 
 collected by my dresser, Mr. Russell, death was caused by ruptured caecum in three, by 
 perforation of the sigmoid flexure in two, by peritonitis after puncture to relieve flatus in 
 one, and by exhaustion in three. Hence the importance of early relief before tliese 
 changes have been started. These points have been ably brought out in Coupland and 
 Morris's paper. 
 
 Diagnosis. — To diagnose the true cause of the obstruction is therefore the surgeon's 
 next aim, and it would be well if I were able to add that the task is an easy one, but 
 such is not the case. It is true that when the obstruction is in the rectum a digital 
 examination of the part may find it out, that when in the sigmoid flexure the cautious 
 introduction of the whole hand into the rectum (after the method of Simon of Heidelberg) 
 may detect it, and that when a tumor is to be felt by palpation to the left of the umbili- 
 cus, through the abdominal walls, the probability is suggested of the disease being in the 
 colon ; but without these guides little definite knowledge is to be obtained by either pal- 
 pation or percussion, by the passage of the long tube, or by the amount of fluid that may 
 be injected into the colon. 
 
 Under these circumstances, therefore, the surgeon is thrown back upon the probabili- 
 ties of the case as read by the light of pathological knowledge ; and it is gratifying to be 
 able to show that these facts speak with no uncertain sound. Indeed, they speak so 
 strongly and decidedly that the surgeon may rely upon them with confidence and base 
 his practice upon their indications. 
 
 The facts are revealed in the table to which I have already drawn attention. There 
 it will be seen that out of the 7(1 fatal cases of chronic obstruction, 3 were due to fecal 
 impaction, 3 to the mechanical pressure of tumors, 23 to what Dr. Fagge described as 
 " contraction," caused by the matting together of the intestinal coils from peritoneal or 
 cancerous disease, and 47 to strictures of the bowel. 
 
 Now, cases of fecal accumulation do not require any lengthened treatment in these 
 pages. When they come under the surgeon's care as examples of obstruction, they are 
 to be treated by the mechanical removal of the feces from the rectum by such means as 
 the finger, the lithotomy scoop, or the handle of an iron spoon, these measures being aided 
 materially by the free use of grease, oily enemata, and medicines. 
 
 The fact that fecal accumulation may give rise to the worst symptoms of mechanical 
 obstruction, and even to death, should always be before the surgeon and induce him to 
 examine the rectum with care in all cases of obstruction. 
 
 Obstructions due to the presence of some abdominal tumor, hydatid, cancerous, ovarian, 
 or otherwise, are to be diagnosed and dealt with on their own merits, although, when it 
 is the lower part of the bowel that is obstructed, right or left lumbar colotomy should 
 not be neglected when other means of relief are not available. I have performed this 
 operation on most occasions for such a cause with gratifying success. 
 
 We come now to the two larger divisions of cases — viz., those of sfricfui'e and contrac- 
 lion ; and a very little consideration will show that these cases have as distinct a clinical 
 history as they have a pathology, and that they moreover require a distinct line of treat- 
 ment. 
 
 With respect to their pathology, it may at once be stated that " contraction " is the 
 cause of chronic obstruction of the .small intestines, and " stricture " of obstruction of the 
 large bowel ; that the cases of " contraction " are due to the matting together of the 
 intestinal coils from more or less diffused inflammatory or cancerous peritoneal disease, 
 
VllltoSIC IXTh'STIXAL oiismn TIOS. 505 
 
 while cases (if strict lire ;irc dm- to a local iiarrowiiiL'' ol' tlir liowcl from disease of its 
 coats. 
 
 In the cases of ••contraction " tlif iiction ol' ilir intestines (small or larL'cj is interfered 
 with from adhesions or from a bendinir or douliliiiL' of the liowcl iipoii itseli", and conse- 
 quently there is an interl"crcnce with the iicristaltic movements; in those of '' stricture," 
 the action of the Imwels is jircvcnted from the direct mechanical ohst ructifin occasioned 
 by the strict uri-. 
 
 The clinical history and symptoms of tliese tw(» classes of cases consef(uently differ. 
 
 In the case of " contraction "" the symptoms are (dearly referable to a difficulty in the 
 passajre downward of the intestinal contents; in that of "stricture," t(i a difficulty iti 
 defecation. 
 
 In the f'nrnicr case the symptoms are attacks of ;j:ripin<r. colicky abdominal pain, 
 irrcirular and incomplete intestinal evacuations, and the painless dischar<re of healtliy 
 motions ; in the /u/tcr there is mostly an absence of abdominal pain lieyond that due to 
 distension, more or less complete constipation, alternatinjr with looseness of bowels, the 
 occasional or frequent mixture of mucus or blood with the motions, and painful defecation. 
 
 In "contraction,"' when sickness exists, it will be passinti and lasting only during tlie 
 attack of colicky pain; in "stricture" it will occur toward the close of the disease when 
 the obstruction is more complete. 
 
 In " contractions " the abdomen probably will not be much distended, and, if it be so, 
 only during the attack ; the distension, moreover, will be central and hypogastric. " The 
 intestines will then," writes Fagge, " be seen writhing and coiling, and a gurgling of fluid 
 is heard; there will also lie visible distinct peristaltic movements of the intestines." In 
 " stricture " the abdomen will to a certainty be distended, and the distension will be lum- 
 bar and epigastric ; large coils of distended bowel w'ill also be visible with peristaltic 
 movements, the visible peristalsis in both cases being due to the chronicity of the affec- 
 tion, and consequently to the hypertrophy of the bowel from overwork. 
 
 Such. then, are the broad points of distinction between the two large elas.ses of cases of 
 chronic intestinal obstruction, and they are enough to guide the surgeon in his practice. 
 At times, however, the distinctions f^iil. Indeed, when a history of a ca.se of either con- 
 traction or stricture is deficient, the diagno.sis is most difficult; and if seen when the 
 symptoms are at their height, one or other may be mistaken for a case of acute obstruc- 
 tion, the chronic symptoms of which nothing can be known having lighted up into the 
 visibly acute, in the same way as a case of incarcerated or obstructed hernia may sud- 
 denly develop into one of acute strangulation. 
 
 Having, then, thus mapped out the chief points of distinction between the two classes 
 of cases of chronic intestinal obstruction, and bearing in mind that in the " contractions" 
 the small intestines are the parts that are involved and in the " strictures" the large, it 
 remains for the surgeon in the latter class of cases to determine the seat of the disease, for 
 a correct knowledge upon this point is clearly requisite before any precise operative treat- 
 ment can be entertained. On reference to the table this point comes out very strongly ; 
 for, out of 104 cases which have been tabulated, in 78 the disea.se was in the sigmoid 
 flexure or rectum, in 19 it was in the colon or one of its flexures, and in 7 it was about 
 the caecum. In three-fourths of the cases the disease was consequently below that part 
 of the bowel that would be opened by left lumbar colotomy, and in about four-fifths 
 below the seat of right lumbar colotomy ; in but a very insignificant number was it 
 higher up. 
 
 With these hard facts before us, the conclusion seems tolerably clear that in all cases 
 of obstinate constipation due to mechanical ob.struction in the large intestine, when 
 medicinal treatment has failed and the removal of the disease by operative measures is 
 out of the question, in.stead of w^asting valuable time by the persistent administration of 
 aperients which must do harm, of eneniata which can do no good, of opium and allied 
 remedies which only mask symptoms arid mislead the practitioner, colotomy should be 
 performed. The operation should be in the f't'f loin when the diagnosis has been made 
 of disease of the rectum or sigmoid flexure, and in the n'///if when the exact position of the 
 stricture cannot be determined, for from our table it would ajipear that in not one case in 
 fifteen is it likely to be above this point; right lumbar colotomy also, so far as the relief 
 it gives is concerned, is as sati.sfactory an operation as left. It must be .stated, moreover, 
 that this relief should not be postponed too long, becau.se. from the f\icts alleged, the 
 operation will be of little avail when from the mechanical effects of the fecal distension 
 a peritoneal inflammation has set in. or changes have tf^ken place in the caecum or large 
 intestine of an ulcerative or inflammatorv character. 
 
50(3 
 
 INTUSS USCEPTIONS. 
 
 With respect to the treatment of "contractions," much may be done by judicious 
 medical measures, more particularly by helping the passage onward of the contents of the 
 intestinal canal^ by means of laxatives, those of an oily kind being the best, such as the 
 oily mixture of the Guy's Fharmacopojia. 
 
 A time will, however, come when these means will fail and others must be looked for, 
 unless the patient be left to his ftite ; and of these " enterotomy" is most applicable. The 
 operation consists in opening the small intestine in the right or left iliac fossa, and so 
 ■establishing an artificial anus. 
 
 The operation will be considered farther on. 
 
 Intussusceptions, 
 or the invagination of some portion of the bowel into a lower segment (Fig. 287), may 
 occur at any period, though most common in infancy and child-life. Tliey may take 
 place also in any part of the intestine, my table recording that out" of the 15 cases tabu- 
 
 Fig. 2S7. 
 
 Tttv,Tnm() 
 
 tccl Ilcivnt'^ 
 
 Intussusception, with Diagram showing the Entering, Returning, and Receiving Layers of Ileum into Colon. 
 
 lated 2 were rectal, 7 ileo-caecal, and 6 small intestine. The statistics are supported by 
 Gay's analysis of 74 cases, in which 8 involved the large intestine alone and were colic, 
 33 ileo-caecal, and 33 small intestine. The rectal variety is, however, more frequently 
 found in the adult, the iliac in young adults, and the ileo-cjecal in infancy and childhood. 
 When the invaginated portion of intestine becomes sfnnif/iilafed, the symptoms are acute ; 
 when simply incarcerated^ they may be chronic. Sudden invasion of symptoms, however, 
 is the rule in both forms, with tenesmus and muco-sanguineous discharges, more particu- 
 larly when the ileum is involved ; discharge of blood jier rectum occurs in the acutest 
 cases. 
 
 Symptoms. — The symptoms may be very acute and destroy life in three days, or so 
 mild as to be only those of intestinal irritation. The development of symptoms, as well 
 pointed out by Mr. Howard Marsh (*SV. B(trfh. Rep., vol. xii., 1876, p. 98), depends upon 
 the occurrence of constriction — an intussusception in this respect being like a hernia, 
 which maybe "down" without being strangulated or even obstructed — the various symp- 
 toms in each case depending, not on the mere displacement of the intestine, but on the 
 constriction produced by the displacement. 
 
 When acate^i a case of intussusception at' its onset may be mistaken for one of strangu- 
 lation by a " band ;" and yet marked points of difference exist between the two. In both 
 the attack is sudden and fcdlowed by collapse, butjn the case of a hainJ pain is localized 
 from the first, is paroxysmal and remains severe to the last, and is also unassociated with 
 tenesmus. In the infitssuscej/fi't/ii pain varies much in both seat and intensity, is often 
 relieved by pressure, and toward the last ceases. The pain is likewise commonly associ- 
 ated with tenesmus. In strangulation by a " band " vomiting soon becomes fecal and is 
 constant; in "intussusception" it may also be the same, but it as often ceases. In 
 " band " constipation is the rule, with inability to pass flatus ; in " intussusception" diar- 
 rhoea, tenesmus, and bloody mucoid stools are characteristic ; constipation is, however, at 
 times present in chronic cases. In " band " central and hypogastric abdominal distension 
 is an early symptom; in " intussusception" it may never exist. In " band " the most 
 that may be felt is a single coil of distended bowel ; in "intussusception" a distinct tumor 
 may be felt. 
 
 Dr. Leichtenstein of Tubingen, in a valuable analysis of 593 cases of this affection 
 (Fraqer Vierteljahrschriff, Bd. 11*9, 121, 1874), informs us that when a tumor is recog- 
 nized in the epigastric region the ileum is probably the part invaginated ; when in the 
 
INTUSSUSCEPTIOXS. 507 
 
 riu'lit iliac f'ctssa, the ilouin into the ea'c-iim ; and wlien it can be felt in the rectum, it is 
 pro})alilv ik'iun. Mr. Morris ( I'nih. Tnnis., p. i:{:j, 1S77) has, however, jjointeij out the 
 piissiliilit V ol" niistakinir Itlood fjut in tlir rectum tor the lower end of intussuscepted 
 itowel ; so that the use of the speculum should he hrouj^ht to the aid of the tin;j:er in any 
 case of doubt. Lcichtenstcin says also that when the intussuscepted j)ortion of bowtd 
 .sloughs ort" it occurs between the eleventh and twenty-tirst days from the be<rinning of 
 the disease, and that it is trenerally part of the ileum. This result, however, is very 
 rarely nu't with in infancy. 
 
 Tki:.\tmi:nt. — In the trcatnimt i>\' iut u>>u>ifption opt'rati\f interference is not to be 
 undertaken in a hurry, as it is not to be ijuestiom-d that cases of this affection cfjiistantly 
 occur which riulit themselves either by. or even without, the aid of medical or surgical 
 treatment, the bowel either freeing itself by an unexplained jducess or in some acute 
 cases sloughing away, and a so-called cure resulting. Fagge, however, well ob.serves 
 upon this point that " when this cure by expulsion occurs it frequently only po.stpones 
 the fatal termination instead of entirely preventing it. The patient dies .some months 
 afterward from contraction of the cicatrix which had formed at the seat of the di.sease, 
 this fact affording a weighty additional argument in favor of an attempt to explore and 
 pull out an ilco-c:vcal intussusception when the case is correctly diagnosed at an early 
 stage." Mr. Morris says, " It would ap])ear that when small intestine is intussu.scepted 
 into xDt'if/ intestine the iiira^iimfiu;/ portion, owing to its small relative size, is too much 
 damaged by com])ression from within to allow of recovery by expulsion of the reflected 
 and entering portions." 
 
 No operation should, however, l»e tliouglit of in intussusception until well-considered 
 minor measures have been eniployed and failed, care being taken that too much time is 
 not expended upon them. In aciife intussusception, however, where the bowel is clearly 
 strangulated, but a few hours should be given, because, unless relief is speedily found, 
 death ensues ; and the younger the patient, the more rapid the result. 
 
 In chronic intussusception, where the bowel is probably only incarcerated, the surgeon 
 should not withold his hand for more than a week, because, if relief is to be obtained by 
 treatment, it should be obtained within the seven days it is justifiable to expend in the 
 attempt ; and if failure follows, the operation of laparotomy should be undertaken. In 
 acute strangulation, if relief is not speedily found, sloughing of the invaginated bowel 
 may take place ; and in the chronic, adhesion of the invaginated bowel. Under either 
 circum,stance operative interference mu.st fail. 
 
 Operative interference in intussu-sception. however, has not hitherto been very suc- 
 cessful, and its failure. I believe, is owing to its having alway.s been postponed to too late 
 a period. Yet recent experience has been more encouraging, even under not very favor- 
 able circumstances, for Hutchinson has recorded a case (Af/d.-C/n'r. Trans., vol. Ivii., 
 187-1) in which he opened the abdomen of a child aet. 2 on the thirteenth day of the 
 symptoms and drew out the invaginated bowel with a successful issue. Mr. Howard 
 Marsh had a second ca.se. in which a like good result was obtained in a male infant seven 
 months old after symptoms of fourteen days' duration ; while my colleague. Mr. Howse, 
 had a third, in a woman xt. 28. a patient of Dr. Fagge {ibhf.. vol. lix.. 1876), in which 
 recovery took place. I have likewise performed the same operation in a dog, pulling out 
 on the fifteenth day six feet of invaginated bowel with a good result. 
 
 Dr. H. B. Sands of New York has also published another successful case, in a child 
 six months old (Xctc York Mul. Jmirn.. June. 1877). the operation having been per- 
 formed eighteen hours after the appearance of the .symptoms. In intussusception, how- 
 ever, some success has followed, at times, the practice of inflation — a plan of treatment 
 that was originally recommended by Gorham years ago. When inflation cannot be used, 
 injections may be substituted. This operation has. however, its dangers, as bowels have 
 been ruptured by its u.se. I cannot, therefore, recommend it. 
 
 Invpvsion of the body has likewise been advised, with th« chance that the weight of 
 the contents of the bowel above the involuted or ob.structed .segment may suflSce to dis- 
 engage it. Mechanical kneading of the abdomen and the administration of an anjx'sthetic 
 have also been employed with a similar object. 
 
 Opium should always be given in all ca.ses of mechanical obstruction, the drug not 
 only relieving i)ain. but checking the jKM-istaltic action of the bowel which is so injurious. 
 
 These remedies, however, are doubtful at the best ; they should, however, be tried in 
 early cases, as well as when the diagnosis is uncertain : they must not be used when the 
 diagnosis is certain or more active treatment is called for unless such treatment is abso- 
 lutely rejected. 
 
508 
 
 EyTEROlOMY. 
 
 Laparotomy 
 
 rfrom kar.aoa. "the soft parts of the bod}- below the ribs." and rtir^oj, "I cut") is a 
 name which has been given by Dr. John Ashhurst. Jr. (^American Jonrn. of Mrrl. Sciena\, 
 1874 j. to an exploratory operation upon the abdomen for the relief of an internal strangu- 
 lation or intussusception, and is so good that I adopt it. The term '• gastrotomy " is 
 applied to operations upon the stomach for the removal of foreign bodies ; •• gastrostomy," 
 to an operation upon the .stomach with a view of establishing a permanent fistula ; " colot- 
 omy." to tho.se upon the large intestine ; and ■• enterotomy. " to those upon the small. 
 
 In laparotomy the abdomen should be ojtened in the median line below the umbilicus^ 
 though, if an old hernia exist, the sac should be explored and the abdominal incision 
 made upward from its neck. The abdomen should at first be explored by the finger, 
 and more particularly toward the umbilicus, since it seems that bands are more often 
 found opposite the promontory of the sacrum than anywhere else. The finger should 
 then be passed toward the right iliac fossa, to examine the caecum and to feel for the 
 contracted empty small intestine which so frequently dips into the pelvis at this spot, 
 and if found forms the best guide to and proof of intestinal obstruction. If the finger 
 fail to find out the seat of oVjstruction. the opening must be enlarged and the part.s 
 inspected. When the operation is performed for intussusception and the bowel is exposed, 
 difficulty has been experienced in freeing the involved bowel, and under such circum- 
 .stances the expedient used by Mr. Hutchinson should be employed and the invaginated 
 portion pushed out backward from its sheath. After the operation the peritoneal cavity 
 should be well cleansed with antiseptic sponges and the wound carefully adjusted by 
 stitches. The p»atient should be kept under the influence of opium or morphia, the 
 morphia suppository every five hours being the best form to use. Milk diet should be 
 given in small quantities ; and if recovery is to follow, it will probably be speedy, a.s 
 repair takes place rapidly in all abdominal sections when a ease goes on well, and death 
 ensues early when the rever.se occurs. Ashhurst has collected 123 eases of laparotomy, 
 of which 37 recovered and 86 died. 
 
 Enterotomy, 
 
 or the opening of some portion of the small bowel, generally in the right groin, is an 
 operation of great value, and it is to be regretted that it has not received sufficient notice. 
 It was fir.st p»erformed Vjy Xelaton. at least twenty-five years ago, upon a patient of Trous- 
 seau for chronic intestinal obstruction, and is applicable to ca.«es of abdominal obstruction 
 in which the clinical evidence points to the conclusion that the obstruction is high up in 
 the large intestine or low down in the small : to cases in which • laparotomy "' is inap- 
 plicable and •• lumbar colotomy " is out of court : to cases of obstruction in which relief 
 is required and a more exact method of giving it is not clear, either from some difficulty 
 in diagnosis or other cause. It is described by Trousseau as follows {Clin. Med., Lec- 
 
 FiG. 2^ 
 
 Inguinal Wound made in X-'laton's Operation of Enterotomy. 
 
 ture 77) : '• I begin the operation, as Nelaton advises, by making in the right side an 
 incision an inch in length, a little above the crest of the ilium, parallel with Poupart's 
 ligament (Fig. 288) ; the length of this incision is subsequently increased to three or 
 
ESTEROTOMY. 
 
 509 
 
 Fig. 289. 
 
 Miide of securing Howel before 
 opening it. 
 
 four inclu'S. In diviilinjr, layer l)y layer, tlu; skin, tlie cellular tissue, the iiiu.scles, and 
 a|ii)neur(»ses, tying as may ln' re<|nin'il the larjre vessels involved in the incision, we at 
 hist come to the most det'i»ly-seated ajioneuntsis. I'njceedinj^ always very slowly and 
 l>ein<r very particular in spuniiinu' the wound carefully, this deej> aponeurosis is cut 
 throuirh. when forthwith the peritoneum is reache<l. It is taken hold of hy a small for- 
 ceps and incised ; afterward, usini; the <:reatest j>ossihle precautions, a silver thntad is 
 carried hv means (d' a curved needle, tirst throu;j.h the intestine and then throu<j:h tlie 
 ahdominal walls; four sutures are then made, two on each side of the incision; two others 
 are made, om- at the superitu' and the otiier at the inferior an<rle oi' the wound; hut this 
 tinu' tlic ahdominal parietes are first jierforateil, then the intestine, and afterward the 
 ahdominal parietes on the opposite side oi" the wound. ( Vide V\\i. 2lS!>.j In this way 
 the intestine is ti.xed everywhere, laterally and from al)ove 
 downward to the walls of the ahdonien ; by this proceeding; n<j 
 exudation can take place into the peritoneum. It is then onli/ 
 necessdfj/ to muke aii excrcdlugly sjiiaU Incision in the intestine 
 by means of a sharp-pointed bistoury. The openitig which 
 N61aton makes is less than a third of an inch." 
 
 If the case is not so ursrent as to demand immediate relief. 
 it would be well to postpone opening the small intestine for 
 one or two days, in order to give time for firm adhesion to take 
 place between the bowel and the abdominal parietes. Indeed, 
 it may be a (|uestion whether it is necessary to fix the intestine 
 to the abdominal parietes by sutures, and whether it will not adhere to the part as a result 
 of its simple exposure in the wound. 
 
 This operation is very warmly advocated by Trousseau in all cases of intestinal occlu- 
 sion, from whatever cause, '• when the symptoms of occlusion have existed for six or eight 
 days, when there is great tympanitis, when the matters vomited are of a stercoraceous 
 character, and, finally, when the persistence and severity of the symptoms presage immi- 
 nent death." He had recommended its adoption in five ca.ses, and in two with complete 
 success, the patients recovering, who without it would have been hopelessly lost. 
 
 In recent, times this operation has been successfully performed by Mr. McCarthy on 
 the suggestion of Mr. Maunder in 1872 (M'd.-Chir. Trans. ^ vol. Iv.), by Mr. Wagstaffe 
 (St. Thomas's Ho.^p. Rf'p., 1873), by Mr. Maunder himself in ^fovember. 1875 (Trans. 
 Clin. Soc.. vol. ix., 187(J), and by others. 
 
 I have performed it three times — once in 187G on an infant twelve davs old. who was 
 born with an imperforate rectum, and survived the operation eight days, having been 
 gre.itly relieved by it, but operation had been postponed until too hite. The second was 
 in May, 1877, on a man jet. 57 who had been a patient of Dr. Wilks for chronic obstruc- 
 tion of small intestine of many months' standing, the chronic condition being aggravated 
 every week or ten days by .symptoms of a severe character which threatened life. The 
 seat of the obstruction was too uncertain to allow of the operation of colotomy being per- 
 formed ; indeed, the symptoms pointed to the small bowel as being the seat of the disease, 
 and on that account enterotomy was undertaken. The operation gave rapid and perma- 
 nent relief, and the man was convalescent in a mouth. His temperature, as shown by 
 the chart, was never higher than 1U(I°. He is alive and well at the present day. but the 
 
 Fk;. 290. 
 
 DAY or 
 
 DISEASE. ^ ^ 
 
 1011 12 13 14 j: 
 
 immmmf^immmSSkmmmmmmmA 
 
 •Ise \64\66\73\7^\76\7o\76id6W8^M\9O^^90\78\72\3'^\84'84\9c 76 
 
 Therinograpli of i ase i)f Knterotomr in a Man jet. " for fhronio *>hstructi'>n. 
 (Temperature never readied luo^, and patient \va- cmivalescent in a niontli. Fluctuation of temperature very slight.) 
 
 inconvenience connected with the artificial anus is so troublesome as to neutralize greatly 
 the advantages of the operation. The third was on the person of a man xi. 50 whom I 
 saw in consultation with Dr. Cortis of Kennington in July, 1877, for complete intestinal 
 obstruction. He had been ill two months with abdominal pain and constipation, but 
 sought advice only when the pain had become very severe and vomiting appeared. When 
 I saw him, the constipation was insuperable, vomiting incessant, and the abdomen much 
 
510 COLECTOMY. 
 
 distended. No obstruction could be felt in the rectum ; both loins were ver}' resonant, 
 and it was believed that the obstruction was about the cjujcuui. I consequently per- 
 formed Nelaton's operation of enterotomy, as described, on July 7. The operation gave 
 immediate relief and everything went on well subsequently, the temperature never rising 
 beyond 99°. He left the hospital six weeks afterward, the whole of his motions passing 
 through the artificial anus and not a trace of wind or motion passing jjer a num. 
 
 On his return home, for want of good nursing, a bed-sore appeared, and he died in 
 November, 1877. After death it was found that the lower part of the ileum had been 
 opened three inches from the cascum, and that the seat of stricture was in the ascending 
 colon, just above the caecum. It was cicatricial and evidently due to the contraction of 
 some old ulcer ; the viscera were healthy. I subsequently learnt from Dr. Cortis that 
 this patient had hurt himself in the right side of his abdomen three years before his ill- 
 ness in a fall over a case of goods, and that the accident was followed by sickness and 
 pain, with nausea and occasional vomiting. It is quite possible that the stricture was 
 the result of this injury. 
 
 This patient, as well as the other, complained sadly of the annoyance caused by the 
 constant flow of feces from the inguinal anus, no mechanical appliance having the power 
 of controlling it. . , 
 
 Colectomy. 
 
 This term is applicable to cases in which a portion of the colon has been removed 
 either by abdominal section or through a lumbar wound. Under the former circumstances 
 the operation might be called " abdominal." and under the latter " lumbar," colectomy. 
 
 I was the first to suggest and to perform the latter operation in this country, and I 
 did so on September 10, 1881, for a lady tet. 50 who had sufl'ered from eight weeks' 
 obstruction, with such success that she lived between thirteen and fourteen months, and 
 died October 29, 1882, of cancer of her liver and spleen. (See Met/.-Chir. Trans. ^ vol. 
 Ixv., 1882). 
 
 OPERAxroN. — I commenced the operation with my usual oblique lumbar incision, as 
 for " colotomy," and, having reached the bowel and found that the strictured portion 
 could be drawn out of the wound, I determined to excise it. This I did by first stretching 
 the presenting wall of the intestine above the strictured portion to the margins of the 
 wound, evacuating the contents of the bowel through a limited orifice, and subsequently 
 securing the under lip of the upper portion of bowel to the lower margin of the wound, 
 having with scissors .carefully detached the strictured segment of the colon from its upper 
 attachments and stretched the bowel to the orifice of the wound step by step. 
 
 The strictured segment of gut was then separated from its attachments below, and 
 the upper orifice of the lower portion of the bowel carefully secured to the wound in 
 close contact with the upper portion. Great care was observed all this time to keep the 
 parts clean and prevent anything gravitating into the abdominal cavity. 
 
 The operation was not a difficult one. 
 
 The idea of removing an organic structure of the large bowel through the wound 
 made for a left lumbar colotomy suggested itself to me several years ago, after having 
 seen, in operations of colotomy as well as in the post-mortem room, many examples of 
 annular or localized stricture of the bowel which were freely movable in the peritoneal 
 cavity, free from all attachments, and within easy reach of the surgeon's fingers through 
 the lumbar wound. For it is in these cases, and in these alone, that the operation is 
 possible. 
 
 The thought was likewise encouraged by the analyses of cases tabulated on page 501, 
 from which it was shown that in three out of four cases of chronic intestinal obstruction 
 the stricture is located in the descending colon, and that in about one-third of these cases 
 the disease is of an annular or local character, such strictures being the least malignant 
 of epithelial growths. 
 
 Should this operation meet with the support it deserves, some change in practice may 
 be required ; for it would be wise to entertain the operation of colectomy at an earlier 
 period of the stricture's progress than it has hitherto been the custom for physicians or 
 the majority of surgeons to entertain that of colotomy, since the operation of colectomy 
 would be more readily performed when the bowel above the stricture is undistended and 
 comparatively healthy than when it is full of retained feces and probably ulcerated from 
 overdistension. The operation, moreover, when performed under those more favorable cir- 
 cumstances, would be safer, since in the healthy bowel above and below the strictured seg- 
 ment the surgeon may with more confidence draw the inward portion upward from the- 
 
COLOTOMY. 511 
 
 pt'lvis or ili>wii\var<l and liackwanl riipiii ilii' splriiic rcirinn, and (•(nisci|M«iitlv n-inov*^ it 
 with irri-atcr safi-ty and facility. 
 
 The consideration of cnlcctoiny in any ;.'ivon case will consofjucntly ;rive a lu;lp to 
 colotoiny where it is most netMled. for it will enci>ura^(! medical men to entertain the (jue»- 
 tion of operative relief for ohstruetion as soon as the dia<;noMis of organic stricture has 
 been made, and not to ]iostpone it till, as I have heard it advised, oltstrnetion has existed 
 for six weeks, when the chances of success hy any operation are indeed small. 
 
 I helieve tin; operation of colectomy for the treatment of localize(l strictures of the 
 sigmoid Hexure will he foun<l to he a valual)le adilitional means of <rivinfr relief, and po.s- 
 f<il>ly of curintr a certain proportion (d" cases. It should he considered in all ca.se of stric- 
 ture <d' the deseendintr liowtd not rectal, and entertained as snon as the iliajrnosis (jf the 
 case has heen made ami lielure symptoms ot' oKstniction are a source of anxiety or of a 
 threatenini,' character. 
 
 Since the one recorded 1 have seen two cases in which the ojieration seenaed desirable. 
 Iti one the a<lvice was rejected, in the other it was acted upon; and the sur<;con who pcr- 
 formeil it found the diairnosis correct and removed the stricture, but without success. My 
 friend .Mr. .Icdiii Marshall has recorded a later case in the Laiiat for May <», 188-, and 
 has given an interesting lecture ujion the subject which may be read with benefit. 
 
 COLOTOMY. 
 
 For irremediable stricture or mechanical obstruction of the rectum from any cause, 
 wluMi colectomy is iiiaj))dioable, Cd/fisfn'.s operation of opening the colon in the fe/f loin 
 should be lollmved ; but when the seat of obstruction is higher than the rectum, and if 
 there be a doubt wliether it is in the signioid flexure or transver.se colon, Ai)iiisstif's ope- 
 ration in the right loin should be performed. Callisen first suggested colotoiny in l~iU] 
 and applied it to the descending colon, but Amussat revived the operation and extended 
 it to the ascending coIoh in 18iJI>. 
 
 The colon in this ])osition lies behind the peritoneum, immediately beneath the tran.s- 
 versalis fiiscia. The kidney is in close contact with it above, and in one case on which I 
 operated the organ was placed so low down as to fill in the space between the rib and 
 pelvis, and had to be pu.shed upward to allow the colon to be seen and opened. The ope- 
 ration on the left loin can be performed as follows: 
 
 The patient is to be placed on his right side, with a pillow beneath the loin, in order 
 to arch somewhat the left flank, and he should be turned two-thirds over on his face ; the 
 outer border of the erector spinne and of the quadratus lumborum muscle can then be 
 made out. this latter muscle, which is on a deeper plane, being the surgeon's main guide. 
 Its outer border, with the descending colon, is to be found half an inch to an inch po.ste- 
 rior to the centre of the crest of the ilium, the centre being the point midway between 
 the anterior and posterior superior sjiinous processes. Allingham says that in more than 
 fifty dissections he has always found the descending colon to be situated at the former 
 point. When difiiculties are felt in the operation, he believes they arise from the colon 
 being looked for too fixr from the spine (.SV. Thomas's Uo^pi/nl Rrporfs, 1870), and in that 
 opinion I cordially agree. An incision is then to be made, four or five inches long, begin- 
 ning an inch and a half to the left of the spine, below the last rib, and passing downward 
 and forward parallel with the crest of the ilium ; the line of the incision should pas? 
 obliquely across the external border of the quadratus lumborum muscle about its centre, 
 •so as to take the same direction as the nerves which traverse this part. By this incision 
 the integuments ami muscles and fascia are divided and the outer border of the quadratus 
 muscle exposed. The abdojninal muscles can be divided, to give room. All vessels are 
 now to be secured. The transversalis fascia will next come into view, and beneath this 
 will be the colon, a layer of fat intervening. The fascia is to be opened with caution, for 
 in the loo.se fat and cellular tissue the colon is to be found. When distended, the bowel, 
 on dividing the fascia, comes at once under the eye; but when empty, some little trouble 
 may be experienced in hooking it up with the finger. The inflation of the colon with air 
 by means of an enema syringe or Lund's apparatus is at this stage of the operation often 
 of great a.ssistance, the inflated bowel rolling up into the wound in a very satisfactory 
 manner. The bowel can always be found in front of the lower border of the kidney. 
 This organ should, consequently, be sought, as it is the only certain guide to the bowel. 
 I have found, however, on several occasions, at this stage of the proceeding, great help by 
 rolling the patient over on his back-, the bowel fiiUing by this manoeuvre on the finger and 
 beiii'.'' then readily caught. 
 
512 
 
 COLO TOM Y. 
 
 When the bowel has been caught, it should be partially rolled forward, in order to 
 expose its posterior surface ; for if this be not done, there is a risk of the surgeon wound- 
 in ti- the peritoneum where it is reflected from its anterior surface on to the abdominal wall. 
 The bowel, having been drawn up to the wound, is then to be secured to the integument, 
 and not to the muscles, by the passage of a ligature introduced through one margin of 
 the wound, then through the bowel, and lastly through the other margin. The bowel can 
 then be opened by an incision about half an inch long between the ligatures that have, 
 traversed its canal; the centres of the ligatures are then to be drawn out through the 
 wound and divided, the two halves of the ligatures fixing the two sides of the divided intes- 
 tine firmly to the margins of the wound ; two or more stitches may then be introduced, to 
 make the artificial anus secure. AVhen the necessity of giving relief to obstruction is not 
 great, the bowel may be carefully stitched to the margins of the wound and opened, as in 
 enterotomy and gastrostomy, on the third or fourth day, the risks of peritonitis being 
 diminished by this means. The surgeon may. however, do what my colleague Mr. Howse 
 has done — simply draw the bowel out of the wound and hold it out for two or three days 
 by means of forceps, when the protruded bowel will have become firmly united to the mar- 
 gins of the wound and may be opened with safety or removed as in a colectomy. The 
 margins of the wound may be oiled, to guard against the irritation of feces, and the 
 patient placed in bed. At times the feces escape in large quantities directly the bowel is 
 opened ; at others some slight feculent discharge will take place at the time, the larger 
 flow taking place later. This is not, however, a matter of any importance, and the sur- 
 geon should take no measures to cause the bowels to act ; indeed, it is better, so far as 
 the operation is concerned, that the flow be postponed, for within an hour or so the parts 
 about the wound become sealed with lymph, and thus the risks of extravasation are 
 diminished. 
 
 Callisen originally suggested the vertical incision in the left loin, and Amussat the 
 trdiisce/f;'' in the right, the latter crossing at right angles the outer border of the quadratus 
 luniborum muscle, the former run- 
 ning parallel with it. The oUujue Fig. 291. 
 appears to me to be preferable to 
 either, as it gives more room for 
 manipulation when the colon is 
 empty ; it takes the line of the 
 nerves and vessels that traverse 
 this part and lessens the ri.<^k of 
 their division ; it follows the or- 
 dinary integumental fold of a 
 patient when assuming the re- 
 cumbent posture, and thus favors 
 repair, and seems to tend much 
 toward the prevention of the pro- 
 lapse of the bowel that is always 
 liable to follow such an opera- 
 tion. Fig. 291 illustrates the line 
 of incision and the appearance 
 
 of the artificial anus. It was taken from a patient set. 64 whom I operated upon in 
 1860 for vesico-intestinal fistula, and who died five and a half years subsequently 
 (1875) from a ruptured heart. The gentleman followed his avocation without any 
 discomfoi't. 
 
 After-Treatmext. — After the operation a sedative should be given, such as opium, 
 morphia, or chloral, and the recumbent position maintained, a piece of oil lint covered with 
 oakum and kept in place with a soft towel being the best application. 
 
 The sutures may be removed on the fourth or fifth day. according to circumstances, 
 while perfect cleanliness must be observed. 
 
 Nutritive food and stimulants maybe given within a day or so of the operation, repair, 
 as a rule, going on favorably. 
 
 When the wound has cicatrized, the patient may get up and a pad be applied, covered 
 by a folded napkin and fastened on with a lumbar binder or a pure rubber plug and shield 
 as made for me by Messrs. Krohne of 8 Duke street. Manchester !<quare. 
 
 With the oblique incision the prolapse of the bowel does not appear to be the cause 
 of much annoyance, since it seems to take place to a very slight extent. 
 
 When contraction of the orifice takes place to too great an extent, a .sponge tent or 
 
 Artificial Auus after Colotomy with the Oblique Incision. 
 
courroMY. 51. '3 
 
 short hdii^'if may <lai!y Ik' intnMliiccd. I have, hnwi-v* r. met with Ijiit one case requiring 
 this treatiui-nt. 
 
 AfU'r I'ouvak'scont'o it is well occasionally to wash out the lower j»ortion of the howcl 
 with warm wat«'r, as some feces are apt to pass the artificial ojtening and rest in the rectum, 
 causin<r irritation. When the anal end is open, it is best to do this through the natural 
 openinu; and when closed, throu^^h the artificial. 
 
 i'uuci.vosis. — I have now perfurnicd this oporation about eighty times, and in no 
 single case have I ever regretted doing so, although in a large number I have wished 
 earnestly that I had had an ojiportunity of performing it earlier, since in no instance did 
 it fail to give relief One of the cases of vesieo-intestinal fistula lived nearly six years 
 after the operation, and died let. TO from rupture of tin- heart. Another is now alive, 
 thirteen years after the operation, ami enjoying life, suffering, indecil. very little incon- 
 venience from the artificial anus {Clin. Sor.,\H~'l). The patient with fibrous growths 
 in tile rectum was operated upon November 14. ISTT. and is now living in comfort. 
 
 Of the patients with stricture, cancerous and otherwise, one lived five years, two four, 
 three lived three years after the operation, several two. and very many one. Many were 
 alive when last heard of, two having been operated ujion three years previou.sly, two two 
 years, and two within the year. In every ca.se marked relief wa.s afforded to .symptoms, 
 and in many the patients' expressions of gratitude for such were very strong, .several 
 having deeply regretted that the operation had not been performed at an earlier period. 
 In many of these cases the operation was undertaken as a last resource. 
 
 In one of the patients colotomized for vesico-intestinal fistula, who is now alive, thir- 
 teen years after the nporation. urine finds its way. when he is recumbent, out of the lum- 
 bar artificial anus: and in another, who survived the operation nearly six years, the same 
 complication presented itself. In neither instance, however, was the flow a source of 
 trouble. This flow, however, might have been enough to keep patent that portion of the 
 intestine that existed between the artificial anus and the bladder and to preserve it from 
 atrophy, such a result of colotomy being clearly possible. The late Dr. Michael Harris 
 of Liverpool recorded in the Llorpool Hospital Rrports for 1S74 the particulars of a post- 
 mortem examination where 3Ir. Hakes had performed colotomy five years previously for 
 vesieo-intestinal fistula, in which the descending colon from the artificial anus, together 
 with the sigmoid flexure and rectum as far as the bladder, had become rompletelij ohUf- 
 erated and was found to be replaced by a cylindrical mass of fat. The length of this 
 fatty column was about six or seven inches, and in the centre of it was found a fibrous 
 cord of about a line in thickness, but no trace of a canal of any kind could be therein 
 detected. 
 
 The operation of colotomy is beneficial in all cases of vesieo-intestinal fistula when 
 solid feces flow with the urine ; in all cases of stricture of the rectum that cannot be 
 removed by colectomy so soon as the obstruction becomes serious and local distress great; 
 in all other cases of mechanical obstruction to the rectum from pelvic causes when no less 
 severe measures for relief can be suggested; and, last, but not least, in extensive ulcera- 
 tion of the rectum, cancerous, .syphilitic, or simple, when local treatment fails to give relief 
 and local distress is great, when the general powers are evidently giving way from the 
 local disea.se quite irrespective of mechanical obstruction. 
 
 In no case, however, should the operation be postponed till the patient's powers are 
 failing, when the pro.spects of recovery would be greatly lessened and convale-scence is 
 often rendered improbable. 
 
 Si'MMARY. — By way of summary, therefore, it may be stated that — 
 
 Laparotomy is an operation which should be performed in all cases of acute 
 intestinal uli-tructinn due to bands, internal hernia, and intussusception that do not 
 speeilily yield to otiier treatment. 
 
 Lumbar Colectomy should be performed when the stricture in the large intes- 
 tine is aiimilar. localized, and movable. 
 
 Colotomy is applicable to cases of obstruction to the large intestine from stricture 
 or the mechanical pres-ure of tumors that cannot be relieved by other means. 
 
 Enterotom.y aflbrds a means of relief for all other cases of intestinal obstruction 
 to which the two former operations are inapplicable, and more particularly when the small 
 intestines are involved. 
 
 33 
 
514 
 
 LUMBAR COLOTOMY. 
 
 REMARKS. 
 
 I have been induced to tabulate and analyze my own cases of lumbar colotomy, and 
 to embody the results of the analysis in a paper which I read at the Copenhagen Medical 
 Congress, 1884. (See Transact ioits.') 
 
 The Tables and the conclusions drawn from the analysis and consideration of them 
 tell much in favor of lumbar colotomy, and on that account I have deemed it expedient 
 to introduce them in this volume. 
 
 The conclusions to which I was led in my paper were embodied in the following prop- 
 ositions, which I believe my material proved ; 
 
 Table I. — Cases of Lumbar Colotoray for Cancer 
 
 No. 
 
 Hospital or Private 
 Patient. 
 
 Name of Patient. 
 
 Age. 
 
 Date of 
 Operation. 
 
 Colotomy 
 Right or Left. 
 
 1 
 
 Hospital.— 
 
 Dr. T. Addison. 
 
 Mary P . 
 
 48 
 
 Oct. 6, 1859. 
 
 Left. 
 
 2 
 
 Private. 
 
 Mr. T . 
 
 61 
 
 Nov. 2, 1868. 
 
 Left. 
 
 3 
 
 Hospital. 
 
 William B 
 
 52 
 
 xMay 12, 1871. 
 
 Left. 
 
 4 
 
 Hospital. 
 
 Thomas M 
 
 68 
 
 Aug. 20, 1872. 
 
 Left. 
 
 5 
 
 Hospital. 
 
 Edmund B . 
 
 67 
 
 May 7, 1872. 
 
 Left. 
 
 6 
 
 Hospital. 
 
 William H 
 
 64 
 
 July 17, 1873. 
 
 Left. 
 
 7 
 
 Private. 
 
 Mr. H 
 
 69 
 
 July 10, 1873. 
 
 Left. 
 
 8 
 
 Hospital. 
 
 Frederick D . 
 
 38 
 
 Aug. 26, 1873. 
 
 Left. 
 
 9 
 
 Hospital. 
 
 Emma W . 
 
 44 
 
 Jan. 12, IS74. 
 
 Left. 
 
 10 
 
 Private. — 
 
 Mr. R. Phillips. 
 
 Mr. G 
 
 37 
 
 June, 1874. 
 
 Left. 
 
 11 
 
 Private. — 
 Dr. Baber. 
 
 Mrs. B . 
 
 56 
 
 March, 1875. 
 
 Left. 
 
 12 
 
 Private. 
 
 Mr. P . 
 
 45 
 
 July 30, 1875. 
 
 Left. 
 
 13 
 
 Hospital. 
 
 William M 
 
 44 
 
 Sept. 3, 1875. 
 
 Left. 
 
 14 
 
 Private. — 
 
 Drs. Huddard and Habershon. 
 
 Mr. B 
 
 52 
 
 March, 1876. 
 
 Right. 
 
 15 
 
 Private. — 
 Dr. Owens. 
 
 Mr. S 
 
 37 
 
 Aug. 14, 1877. 
 
 Left. 
 
 16 
 
 Hospital. 
 
 Eliza C . 
 
 56 
 
 Jan. 9, 1877. 
 
 Left. 
 
 17 
 
 Hospital. 
 
 William T 
 
 54 
 
 Aug. 15, 1877. 
 
 1 
 Left. 
 
 18 
 
 Hospital. 
 
 Michael S . 
 
 55 
 
 Anril 4, 1879. 
 
 Left. 
 
 19 
 
 Private. — 
 
 Dr. Gorham, Tunbridge. 
 
 Miss H 
 
 52 
 
 Nov. 30, 1880. 
 
 Left. 
 
 20 
 
 Hospital. 
 
 Arthur le G . 
 
 62 
 
 Nov. 22, 1881. 
 
 Left. 
 
 21 
 
 Private. — 
 
 Dr. Deeping, Southend. 
 
 Mr. S 
 
 64 
 
 Feb. 10, 1882. 
 
 Left. 
 
 22 
 
 Private. — 
 
 Mr. E. Wright. 
 
 Mr. H 
 
 64 
 
 April 26, 1882. 
 
 Left. 
 
 23 
 
 Private. — 
 
 Mr. W. Burton. 
 
 Mr. H 
 
 47 
 
 June 25, 1882. 
 
 Left. 
 
 24 
 
 Private. — 
 
 Dr. May of Maldon. 
 
 Mrs. . 
 
 51 
 
 Oct. 18, 1882. 
 
 Left. 
 
 25 
 
 Hospital. 
 
 Eliza H . 
 
 55 
 
 Dec. 5, 1882. 
 
 Left. j 
 
 26 
 
 Private. — 
 
 Dr. Neumann. 
 
 Mr. A . 
 
 52 
 
 Aug. 22, 1883. 
 
 Right. ! 
 
 Analysis of the Twenty-six Cases. — 19 in males, 7 in females. Average age, 53§ j-ears. Average 
 age of men, 54J ; of women, 51^. Twenty-four of the cases were on the left side and 2 on the 
 
i.rM/iAi: coi.nToMY. 
 
 515 
 
 Propositions. 
 
 1. Tliat ill all i-asi's of caiiccrmis stricture (if'tiic rcctiiiii nr colon, iiicliidiii^ tlic annu- 
 lar — wliicli arc not aincnal)Ic to liiniKar rt,l,rti,nij/ or anal excision — ri;:lit or lel"t lunihar 
 colotoniy is stronjriy to l»e atlvocatcd. wiili the \vell-^'roiiinIc»l hope of relievinj; Kuft'erinf;, 
 rctanliim the |iroj::ress ol" tho di.seasc, and of prolontrinir |ilc even lor five or six yi'ars. 
 
 '1. 'i'hat liiiiiliar colotoniy is valiiahle 'as a rnrtitirc operation in syphilitic and simple 
 ulcerations (d" the howel which resist other treatnieiit, includin^r cases ol" recto-ve.sical 
 listiila, and that it is n'iiie(lial in examples of volvulus of the sigmoid flexure, as well as 
 of olistniclions caused l»y tuiimrs. 
 
 :!. That to secure these advantages, it is necessary i'or the operation to he performed 
 Ik rmc the |ieriiicious elli-cts of ohstruction occur. 
 
 1 trust this material will help to place the operation ai' luml»ar colotoniy in the posi- 
 tion to wliirli it is cut itlcil. 
 
 that Di^d within the Month ("Too Late Cases' 
 
 Disease for which Operation was performed. 
 
 Result. 
 
 Annular stricture of rectum. Obstruction complete 
 
 for f) weeks. 
 Cancerous stricture of rectum. Symptoms 2 years. 
 Epithelioma of anus and rectum of fi years' growth. 
 
 Cancerous stricture of rectum. Syiiipti>nis 2 years. 
 
 Cancerous stricture of rectum. Severe symptoms S 
 months. 
 
 Cancerous stricture of rectum. Symptoms 2 years, 
 blood for months. 
 
 Cancerous stricture of rectum. Obstruction complete 
 for weeks. 
 
 Increasing obstruction for 6 years. Reeto-vesical 
 fistula for months. 
 
 Cancerous stricture, with symptoms for 5 years. Ob- 
 struction for 5 months. 
 
 Cancerous stricture of rectum of many months' 
 staniling. 
 
 Chronic obstruction complete. 
 
 Cancerous stricture of rectum. 
 
 Cancerous disease of rectum, with fecal fistula 9 
 
 months. 
 Annular stricture of transverse colon. Symptoms 1 
 
 j'ear, obstruction 4 weeks. 
 Cancerous stricture of rectum of slow contraction. 
 
 Cancerous stricture of rectum. Symptoms 3 or -4 
 
 years. Blood. 
 Cancerous stricture of rectum. Pain, blood, and 
 
 mucus, with feces, for S years. 
 Cancerous stricture of rectum. Nine months. 
 
 Cancerous stricture of rectum many months. Ob- 
 struction ?> weeks. 
 
 Cancerous stricture of rectum. Bleeding for 18 
 months. 
 
 Cancerous stricture of rectum. 
 
 Cancerous stricture of rectum. 
 
 Cancerous stricture of rectum. 
 
 Cancerous stricture of rectum. 
 
 (^ancerous stricture of rectum and vagina 15 months. 
 Stricture of rectum. 
 
 Sank. Died on 12th day, greatly relieved. 
 
 Sank on 2d day. 
 
 Died on 24th day. Sank ; operation wound 
 
 healed. 1'. M. — Cancer of viscera. 
 Sank on ."'d day. P. M. — Large cancerous mass 
 
 in jtelvis. 
 Sank on 6th day. P. M.— Disease quite local. 
 
 Sank on .^.d day. Peritonitis; bowel had rup- 
 tured above the stricture. 
 Sank on 20th day. 
 
 Sank on 10th day. Cancerous ulcer into blad- 
 der, with secondary growths. 
 
 Sank on ;jd day. Peritonitis; cancerous ulcer 
 between the rectum and jejunum. 
 
 Sauk on 4th day. 
 
 Sank on 7th day. 
 
 Sank on 3d day. 
 
 Sank on 3d dav. Peritonitis. P. M. — Bowel 
 
 above stricture ruptured. 
 Sank on 1 0th day. P. M. — Confirmed diagnosis. 
 
 Sank on 5th day. 
 
 Sank on lid day. P. M. — Cancer in viscera and 
 
 peritoneum. 
 Died on ISth day suddenly, from sudden pain, 
 
 collapse, and ruptured spleen. No peritonitis. 
 Sank on 23d day. P. AI. — Peritoneal cancer 
 
 and volvulus of sigmoid flexure. 
 Sank on 3d day. 
 
 Sank on 4th day. P. M. — Peritonitis and much 
 
 cancer. 
 Sank on 5th day. 
 
 Sank on 5th day. 
 
 Sank on 5th day. 
 
 Sank on 5th day. 
 
 Sank OP 27th day. 
 Sank on 4th dav. 
 
 No. 
 
 9 
 
 10 
 
 11 
 
 12 
 13 
 
 14 
 
 15 
 
 16 
 
 17 
 
 18 
 
 19 
 
 20 
 
 21 
 
 22 
 
 23 
 
 24 
 
 25 
 26 
 
 right side. Eighteen of them died in the first week, 3 in the second week, 2 in the third 
 and 3 in the fourth week. 
 
 week, 
 
516 
 
 LUMBAB COLOTOMY. 
 
 Table II. — Cases of Lumbar Colotomy 
 
 No. 
 
 Hospital or Private 
 Patient. 
 
 Name of Patient. 
 
 Age. 
 
 Date of 
 Operation. 
 
 1 
 Colotomy 
 Right or Left. 
 
 1 
 
 Hospital. 
 
 James W . 
 
 39 
 
 July 31, 1868. 
 
 Left. 
 
 2 
 
 Hospital. 
 
 Martha P . 
 
 57 
 
 May 31, 1870. 
 
 Left. 
 
 3 
 
 Private. 
 
 Miss B 
 
 18 
 
 Sept. 6, 1871. 
 
 Right. 
 
 4 
 
 Hospital. 
 
 Eliza B . 
 
 38 
 
 Oct. 10, 1S71. 
 
 Left. 
 
 5 
 
 Hospital. 
 
 Richard C . 
 
 46 
 
 Jan. 9, 1872. 
 
 Left. 
 
 6 
 
 Private. 
 
 Mrs. B . 
 
 24 
 
 Feb. 10, 1872. 
 
 Left. 
 
 7 
 
 Hospital. 
 
 George S — — . 
 
 56 
 
 April 14, 1873. 
 
 Left. 
 
 8 
 
 Private. — 
 
 Dr. Stillwell and Sir W. Gull. 
 
 Mrs. B . 
 
 72 
 
 Dec. 6, 1874. 
 
 Right. 
 
 9 
 
 Private. — 
 
 Dr. Brown, Ealing. 
 
 Mr. R 
 
 64 
 
 June 2, 1876. 
 
 Left. 
 
 10 
 
 Private. — 
 
 Mr. T. Harries, Aberystwzth. 
 
 Mr. T. D -. 
 
 57 
 
 Feb. 12, 1877. 
 
 Left. 
 
 11 
 
 Private. — 
 
 Drs. Chambers and Menzies. 
 
 Mr. A 
 
 57 
 
 Dec. 30, 1876. 
 
 Left. 
 
 12 
 
 Private. — 
 
 Mr. Hodgson, Brighton. 
 
 Mr. B 
 
 54 
 
 April 16,1878. 
 
 Left. 
 
 13 
 
 Private. — 
 Dr. Drewry. 
 
 Mrs. B . 
 
 56 
 
 Mar. 4, 1878. 
 
 Left. 
 
 14 
 
 Private. — 
 Dr. Wallace. 
 
 Mr. S 
 
 42 
 
 June 13, 1878. 
 
 Left. 
 
 15 
 
 Hospital. 
 
 John B . 
 
 39 
 
 June 27, 1S7S. 
 
 Left. 
 
 16 
 
 Hospital. 
 
 George W . 
 
 51 
 
 Nov. 12, 1878. 
 
 Left. 
 
 17 
 
 Private. — 
 Dr. Bowes, Heme Bay. 
 
 Mr. S 
 
 64 
 
 April 5, 1879. 
 
 Left. 
 
 18 
 
 Private. — 
 
 Dr. Kiddle, Leamington. 
 
 Mr. H 
 
 66 
 
 Xov. 8, 1879. 
 
 Left. 
 
 19 
 
 Hospital. 
 
 Marv T . 
 
 59 
 
 Dec. 9, 1879. 
 
 Left. 
 
 20 
 
 Hospital. 
 
 Alice P . 
 
 25 
 
 Aug. 6, ISSO. 
 
 Left. 
 
 21 
 
 Hospital. 
 
 Eliza C . 
 
 29 
 
 Feb. 3, 1880. 
 
 Left. 
 
 22 
 
 Private. — 
 Dr. Andrews. 
 
 Mr. W 
 
 42 
 
 Nov. 15, 1880. 
 
 Left. 
 
 23 
 
 Hospital. 
 
 Emma R . 
 
 38 
 
 Nov. 61, 1880. 
 
 Left. 
 
 24 
 
 Private. — 
 
 Mr. J. Burton and Dr. Higgens. 
 
 Mrs. S . 
 
 42 
 
 April, 1881. 
 
 Left. 
 
 25 
 
 Hospital. 
 
 Charles H 
 
 64 
 
 June 18, 1S81. 
 
 Left. 
 
 26 
 
 Hospital. 
 
 Samuel Robinson. 
 
 15 
 
 Dec. 30, 1881. 
 
 Left. 
 
 27 
 
 Hospital. 
 
 John James. 
 
 60 
 
 Feb. 15, 1881. 
 
 Left. 
 
 28 
 
 Hospital. 
 
 Eliza W 
 
 46 
 
 Feb. 4, 1881. 
 
 Right. 
 
 29 
 
 Hospital. 
 
 Sarah A . 
 
 33 
 
 Nov. 2, 1881. 
 
 Left, 
 
 30 
 
 Hospital. 
 
 Richard H . 
 
 62 
 
 Feb. 10, 1882. 
 
 Left. 
 
 31 
 
 Hospital. 
 
 Daniel S . 
 
 39 
 
 May 12, 1882. 
 
 Left. 
 
 32 
 
 Private. — 
 Dr. Bailey. 
 
 Mr. S 
 
 35 
 
 July 28, 1882. 
 
 Left. 
 
 33 
 
 Private. — 
 Dr. Calthrop. 
 
 Mr. T 
 
 62 
 
 Mar. 16, 18S2. 
 
 Left. 
 
 34 
 
 Hospital. 
 
 John C 
 
 52 
 
 April 8, 1884. 
 
 Left. 
 
 -J 
 
 Analysis of the Thirty-four Cases, or 56 per cent. — 9 died within 6 months, 7 lived from P 
 to 12 months, 9 lived from 1 to 5 years, 1 was alive 5 years after, 8 left the ho.spital convalescent: 
 
LCMIlAl: ciiLoroMY. 
 for Cancer that Recovered from the Operation. 
 
 517 
 
 lUsi'ii.si' for «liiili Oiniiiliiui wiis pi-rfiiriiifd. 
 
 Result. 
 
 Survived 
 (>|H.'ratiun. 
 
 No. 
 
 Cuiiccrous .st lift mo nl' rci'tiiin. Sviiiptuiiit* 
 
 Convalesced. 
 
 I)ied of iibilominal can- 
 
 IS nihs. 
 
 I 
 
 ."! voars. 
 
 cer. 
 
 
 
 
 ("ain'crcdi.-' stricture of rectimi. 
 
 Convalesced 
 
 in 7 weeks. 
 
 Left hospital. 
 
 2 
 
 Anmilur stiiotiiii' of ri-ctiim. 
 
 Convalesced. 
 
 cer. 
 Convalesced. 
 
 Died of internal can- 
 
 \) iiiontliH. 
 
 3 
 
 Supposcil fiiiii'iT III' ifcliim. Sviii]iti)iiis IS 
 
 
 Alive 5 years «ub- 
 
 4 
 
 iiKinths. Itloiiil ami iiiiu'us. 
 
 
 
 quently. 
 
 
 ram-or i>l' recto-vcsiral si'|>luin. 
 
 Convalesced. 
 
 
 Lett hospital. 
 
 5 
 
 lv\loii.''ivi> rei'lal iilforatiim, .sii|iiiipscil to he 
 
 ('onval(!sced. 
 
 Sank. 
 
 .■{3 months. 
 
 6 
 
 canctT anil slrirtiirt-. 
 
 
 
 
 
 Cancfion.s stricturo of rci'tum ami iiniis. 
 
 CiiniilcsiM-d. 
 
 Sank. ."Much liK-al can- 
 
 Hi months. 
 
 7 
 
 witli ti'cal tistula. 
 
 cer, no visceral. 
 
 
 
 Colloiil oant'i-r of reftmii ami sigmoid 
 
 Convalesced. 
 
 Sank later from disease. 
 
 21 months. 
 
 8 i 
 
 Hoxiirc. 
 
 
 
 
 1 
 
 Cani-eroiis stiit-turo of rcelmii, with recto- 
 
 Convalesced. 
 
 Sank. 
 
 3i months. 
 
 9 1 
 
 vesical tistula, ."> months. 
 
 
 
 
 1 
 
 rancorous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Sank. 
 
 in months. 
 
 10 
 
 1 year, nieciling U months. 
 
 
 
 
 
 Cancerous stricture of rectum 2J years. No 
 
 Convalesced. 
 
 Sank. 
 
 4 months. 
 
 11 
 
 solid feces for \\ years. 
 
 
 
 
 
 Cancerous stricture of rectum 1 year. 
 
 Convalesced. 
 
 Sank. 
 
 7 months. 
 
 12 
 
 Cancerous .stricture of rectum, with profuse 
 
 Convalesced. 
 
 Sank. 
 
 12J months. 
 
 13 1 
 
 hemorrhage, 1 year. 
 
 
 
 
 
 Cancerous stricturo of rectum, with fecal 
 
 Convalesced. 
 
 Sank. 
 
 12 months. 
 
 14 
 
 listula many months. 
 
 
 
 
 
 Cancerous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Died of stricture of 
 
 10 months. 
 
 15 
 
 Ifi months. 
 
 urethra (?) 
 
 
 
 
 cancerous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Sank. 
 
 y^ months. 
 
 16 
 
 2 years. tJreat obstruction. 
 
 
 
 
 
 Cancerous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Died of apoplexy. 
 
 41 months. 
 
 17 
 
 1 year. 
 
 
 
 
 
 Cancerous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Sank. Internal cancer. 
 
 2t) months. 
 
 18 1 
 
 about 1 year. 
 
 
 
 
 1 
 
 Cancerous stricture of rectum 9 months. 
 
 Convalesced. 
 
 
 Left hospital. 
 
 19 
 
 Colloid cancer of rectum. 
 
 Convalesced, 
 of growth 
 
 Died from perforation 
 into ]ieritoneal cavity. 
 
 weeks. 
 
 20 
 
 Cancer of rectum. Symptoms 6 months. 
 
 Convalesced 
 
 n 5 weeks. 
 
 Left hospital. 
 
 21 : 
 
 Canceri>us stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Sank. 
 
 3 months. 
 
 22 , 
 
 fi months. Obstruction 2 weeks. 
 
 
 
 
 
 Epithelioma of rectum and anus 2 years. 
 
 Convalesced. 
 
 Sank. 
 
 13i months. 
 
 23 
 
 Cancerous stricture of rectum. Obstruction 
 
 Convalesced. 
 
 Sank. Visceral cancer. 
 
 15 months. 
 
 24 
 
 3 months, complete 2 weeks. 
 
 
 
 - 
 
 
 Cancerous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 
 Left hospital. 
 
 25 
 
 6 months. 
 
 
 
 
 
 Cancerous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Sank. 
 
 3i months. 
 
 26 
 
 h months. 
 
 
 
 
 ' 
 
 Cancerous stricture of rectum. S\'mptoms 
 
 Convalesced. 
 
 
 Left hospital. 
 
 27 
 
 2.i years. Blood, mucus, and increasing 
 
 
 
 
 1 
 
 difficulty of defecation. 
 
 
 
 
 
 Cancerous disease of rectum. Sj'mptoms 9 
 
 Convalesced. 
 
 Died from extension of 
 
 6 weeks. 
 
 28 1 
 
 months. 
 
 local disea 
 
 se. 
 
 
 
 Cancerous disease of rectum. Symj)toms 2 
 
 Convalesced. 
 
 Died suddenly. Much 
 
 30 days. 
 
 29 
 
 years. Blood and ]iain. 
 
 local disease. 
 
 
 
 Cancerous stricture of rectum. 
 
 Convalesced 
 
 m six weeks. 
 
 Left hospital. 
 
 30 
 
 Cancerous stricture of rectum. Symptoms 
 
 Convalesced. 
 
 Sank. 
 
 lOJ months. 
 
 31 
 
 6 months. 
 
 
 
 
 
 Cancerous stricture of rectum. 
 
 Convalesced. 
 
 Sank. 
 
 6 months. 
 
 32 
 
 Cancerous stricture of rectum. 
 
 Convalesced. 
 
 Sank. 
 
 6 months. 
 
 33 
 
 Cancerous stricture of rectum. 
 
 Convalesced 
 
 in 1 month. 
 
 Left hospital. 
 
 34 
 
 21 occurred in males: 13 in females; 'i\ were on the left and 3 on the right side. .Average age, 44; 
 of men, 46 ; of women, 41. 
 
518 
 
 No. 
 
 Hospital or Private 
 Patient. 
 
 Hospital. 
 
 Hospital. 
 Hospital. 
 Hospital. 
 
 ■ Hospital. 
 Hospital. 
 Hospital. 
 
 LUMBAR COLOTOMY. 
 
 Table III.— Cases of Colotomy for Simple or 
 
 Name of Patient. 
 
 Eliza , married, 2 
 
 children, 4 stillborn, 1 
 miscarriage. 
 
 Louisa C . 
 
 Mary S , married, no 
 
 children. 
 
 Hans K , been abroad, 
 
 but not had dysentery. 
 
 Age. 
 
 29 
 
 .33 
 
 46 
 
 65 
 
 Date of 
 Operation. 
 
 Colotomy 
 Eight or Left. 
 
 Mar. 19, 1872. , Left. 
 
 Dec. 5, ISO". 
 Mar. .3, 1876. 
 
 Left. 
 Left. 
 
 Dec. .30, 1881. ' Left. 
 
 Eliza B , married, 1 | 42 | Feb. 6, 18S;i. j Left. 
 
 I Bowel torn 
 ' across. 
 .37 I Nov. 28, 1877. i Left. 
 
 child, 1 miscarriage. 
 Harriet K- 
 
 James R- 
 
 49 
 
 Nov. 14, 1882. I Left. 
 
 Cases of Lumbar Colotomy for Non-cancerous 
 
 8 
 
 Hospital. 
 
 William D . 
 
 40 
 
 April 5, 1867. 
 
 Left. 
 
 9 
 10 
 
 Private. — 
 
 Dr. Habershon. 
 Hospital. 
 
 Robert R . 
 
 Mary L . 
 
 46 
 
 38 
 
 July 5, 1870. 
 Aug. 12, 1873. 
 
 Left. 
 Left. 
 
 11 
 
 Hospital. 
 
 Mary P , married, no 
 
 children, no miscar- 
 riage. 
 
 37 
 
 Nov. 9, 1881. 
 
 Left. 
 
 12 
 13 
 
 Hospital. 
 Hospital. 
 
 William H , no syph- 
 ilis. 
 Philip K . 
 
 27 
 35 
 
 Nov. 7, 1881. 
 Dec. 2, 1882. 
 
 Left. 
 Left. 
 
 14 
 
 Hospital.* 
 
 Caroline H, married, had 
 
 28 
 
 May 10, 1878. 
 
 Left. 
 
 15 
 
 Hospital. 
 
 miscarriages. 
 William B , syphilis 
 
 25 
 
 July 12, 1878. 
 
 Left. 
 
 16 
 
 Hospital. 
 
 3 years. 
 
 Susan S , married, had 
 
 miscarrlagesi 
 
 40 
 
 May 3, 1881. 
 
 Left. 
 
 17 
 
 Hospital. 
 
 Louisa P , married, 1 
 
 child, 1 miscarriage, 
 had syphilis. 
 
 24 
 
 Sept. 2, 1874. 
 
 Left. 
 
 18 
 
 Private. — 
 Sir W. Gull. 
 
 Mr. T . 
 
 64 
 
 Mar. 16, 1869. 
 
 Left. 
 
 19 
 
 Private. — 
 
 Mr. R. Phillips, 
 
 Mr. S 
 
 46 
 
 Nov. 14, 1877. 
 
 Left. 
 
 20 
 
 Hospital. 
 
 John S . 
 
 38 
 
 July 16, 1880. 
 
 Left. 
 
 21 
 22 
 
 Hospital. 
 Private. — 
 
 Mr. R. Phillips. 
 
 Fred. R . 
 
 Mrs. M . 
 
 18 
 46 
 
 Mar. 2, 1874. 
 April 5, 1870. 
 
 Left. 
 Left. 
 
 Analysis of T"wenty-t"wo Cases not Cancerous. — 19 for stricture and ulceration of the rectum not 
 cancerous, 1 for obf^truetion from volvulus of the sigmoid flexum, 2 ditto from pelvic tumors; 10 of 
 the 19 cases of stricture occurred in females, 9 in males. Average age of 19 cases, 40 years; of 
 
Syphilitic Stricture of Rectum that Died wiihin the Month. 
 
 519 
 
 Diseuse fur which (iperutluii was |iurfuriiicU. 
 
 Svphilitii' Hiricturt' of ri-i'liiiii. ATlor lust 
 rliilil, two vi'iiTM 11^11, hail liowvl lriiul>lc', 
 whifh stMin j;iivc ^i^o to fct-iil, \ ii^iiiiil, uml 
 (lUlilllMll tistiilif. 
 
 C'hroiiii- iilci-nitioii of roftiim, with iiicicii.*- 
 iiij; oli.slrnctioii for iiioiitlis. 
 
 Very narrow stricture from I inch above 
 anus: bloud, mucus, ami jiain for months, 
 witli incrcasinj; olistruction. 
 
 Ailiiiittcil witli rccto-vcsical fecal fistula of 6 
 weeks' standin;.; : 12 years before this |ia- 
 ticnt iiad for weeks ))asse(l wind witii his 
 water, from which he hail recovered. 
 
 Cicatricial stricture, witli ulceration of 5 
 years' standing, commencing A inch from 
 anus. 
 
 Very narrow stricture and ulceration after 
 t> months' symptoms. 
 
 Ueiiult. 
 
 .Survived 
 Ufie ration. 
 
 No, 
 
 Stricture and ulccr;iliipn. 
 blood for () months. 
 
 -Mucli jiain and 
 
 ."»ank. 1'. .M. — (iood repair in loin : On Kith day. 
 rectum almost obliterated from cica- 
 tricial bands. 
 
 .'^ank. I'. M.^.'-^ijfinoid flexure, rec- On llh day. 
 
 tiim and uterus all matted together; 
 
 bowel very narrow and thickened. 
 Sank. P. M. — E.xtremc ulceration of On ;!d day. 
 
 rectum from 2 inches above anus, 
 
 with sinus. 
 Sank. 1'. M.— .Marked signs of old On 17th day. 
 
 ulceration and contraction of rec- | 
 
 tum ; sign of old cicatrix into blad- 
 der, with recent fistula. 
 Sank. P. iM. — Howcl very ulcerated On -Ith day. 
 
 and friable up to colon : it had been i 
 
 torn through at operation. 
 Convalesced. Died of ))hthisis. Bowel I 28 days. 
 
 repaired ; one stricture ;! inches, and 
 
 a second fi inches, from anus. 
 Sank. P. M. — Colon much ulcerated ; { oO days. 
 
 bowel contracted. i 
 
 Stricture or Disease that Convalesced after Operation. 
 
 Recto-vesical fecal fistula, with rectal ob-- 
 
 struction and ulceration. 
 Recto-vesical fecal fistula, with obstruction. 
 
 Stricture of rectum after ulceration for 
 
 years. Much bleeding. 
 Rectal symptoms for 1,') years. Pain, blood, 
 
 mucus with feces. Admitted with narrow 
 
 stricture, probably syphilitic. 
 
 Stricture and ulceration of rectum 17 months. 
 Blood and mucus with feces. 
 
 Stricture and ulceration of rectum. Symp- 
 toms two years. 
 
 Syphilitic stricture and ulceration 30 months. 
 No solid feces passed for 6 months. 
 
 Very narrow stricture, lA inches above anus. 
 Symptoms for 2 years. 
 
 Admitted with narrow stricture and vaginal 
 and perineal fecal fistula. No history of 
 syphilis. 
 
 Admitted with recto-vaginal fecal fistula 
 and fistula in buttock. Operation per- 
 formed for relief. 
 
 For vesico-rectal fecal fistula. 
 
 Multiple-rectal fibrous )iolypoid growths of 
 3 years' standing. Had had polyjd re- 
 moved twice before. Great tenesmus and 
 discharge of blood and serum. At once 
 relieved by the operation. 
 
 Complete obstruction for C weeks. Opera- 
 tion to save life. Case, one of voh-nhis in 
 all probability. 
 
 Cancerous j)elvic tumor occluding rectum. 
 
 Pelvic tumor obstructing rectum (cancer- 
 ous). 
 
 Convalesced. Died of kidney disease. 
 
 Rectum repaired and contracted. 
 Con\alesced. 
 
 Convalesced. Died of kidney disease. 
 Rectum healed and contracted. 
 
 Convalesced. Sank from kidney dis- 
 ease and large spleen : lower 3 
 inches of rectum, lost its mucous 
 membrane with cicatricial tissue 
 outside. 
 
 Sank. 
 
 Convalesced. Bowel healed and al- 
 most closed. 
 Convalesced. Died from bronchitis. 
 
 5 months. 
 
 14 years, alive 
 
 and well. 
 34i months. 
 
 40 days. 
 
 18 weeks. 
 
 18 months, well l.S 
 
 and comfortable. 
 
 1 year. 14 
 
 Convalesced. Bowel had healed and 2i years later ' 15 
 
 almost closed 2 years later. alive and well. ! 
 
 Sank. P. M. — Rectum greatly indu- , 9 weeks. 16 
 
 rated, contracted, and ulcerated; j 
 
 ulcers vertical. • 
 
 Died of hi]) disease. All the. fistulic 4J months 
 
 had closed soon after operation. 
 
 P. M. — Lower 4 inches of rectum 
 
 covered with bands of cicatricial i 
 
 tissue much contracted. 
 Rapidly convalesced. No feces pass- 5J years. 
 
 ed after operation through rectum. 
 
 Died of ruptured heart. P. M. — 
 
 Rectum healed ; old fistula into blad- 
 der small. 
 Convalesced, and died from pneu- 41 months. 
 
 monia. 
 
 Convalesced. 
 
 Sank from the disease relieved. 
 Relieveil by operation. Died from rup- 
 tured cancerous mesenteric tumor. 
 
 4 years, alive and 
 "well. 
 
 7 weeks. 
 4 days. 
 
 females, 35: of males, 45. All operations on left loin. Nine died within the month; 5 within G 
 months; 4 lived respectively 1 year, 3, 3i, and oj years, Four are now alive and well, IJ, 2J, 4 years, 
 and 14 years after the operation. 
 
520 " TAPriSG THE JSTL'STIXE. 
 
 Analysis of the Whole Number of Eighty-Two Cases of Colotomy. 
 
 60 were iierformed for cancerous stricture. 
 
 19 " " " stricture and ulceration of the rectum not cancerous. 
 
 1 was performed for volvulus of the sigmoid flexure of the colon. 
 
 2 for obstruction due to pelvic tumors. 
 
 Side operated upon : 
 
 Left lumbar colotomy was performed in 77 and right lumbar colotomy in 5 of these cases, all 
 of the 5 being cancerous. Right lumbar colotomy was called for in 1 outof 12 cases of cancerous 
 stricture. 
 
 Duration of life nj'ler the operation : 
 
 26, or 43 per cent., of the cancerous, and 6, or 31.5 per cent., of the non-cancerous, cases, with 
 1 of the ca.ses operated upon for obstruction, or 40 per cent, of the whole number of 82 cases 
 operated upon, died within the month. 
 
 .34. or 56 per cent., of the cancerous, and 13, or 68.5 per cent., of the non-cancerous, cases, 
 with the case of volvulus and 1 of the cases of obstruction, or 60 per cent, of the whole number 
 of cases operated upon, received more or less fully the benefit of the operation. 
 
 Of the forty-nine sucees-'ful cases — 
 
 16 cases, 9 cancerous and 7 non-cancerous, died within 6 months. 
 8 ■' 7 " 1 '• lived from 6 to 12 months. 
 
 12 'I 9 " 3 " lived from 1 to ol years. 
 
 o " \ " 4 " were alive from li to 14 years after operation. 
 
 _8 " _8 " _ had left the hospital convalescent. 
 
 49 34 15 
 
 Sex: 
 
 Of the 60 cancerous ca.ses, 40 were in males, 20 in females. 
 
 " 19 non-cancerous, 10 " 9 " 
 
 " 1 case of volvulus, 1 was in male. 
 
 " 2 cases of obstruction, J^ " _ 1 in female. 
 
 Of the 82 cases, 52 were in males, 30 in females. 
 
 Cancerous stricture is more frequent in males. Xon-cancerous stricture is found equally in 
 both sexes. 
 
 Age: 
 
 The average age of the cancerous cases, 
 AVhen fatal, was 53; in male subjects 54, in female 51. 
 
 " successful, was 44 ; " 46, " 41. 
 
 The average age of the successful was about ten years less than that of the fatal cases. 
 1^0 abnormality as to the position of the colon was met with in any of the 82 cases. 
 
 Excision of the Pylorus. 
 
 This operation was first performed for cancer by Pean of Paris in 1879, and Billroth, 
 Wblfler. Nicolay.sen. Czerny, Southam, and others have repeated it with enough success 
 to justify its repetition in ca.ses in which the diagno.sis is tolerably certain and the di.s- 
 ease movable. Full details of this difficult and dangerous proceeding are to be found in 
 Billroths Cluneal iiurgerij. publi.^hed by the New Sydenham Society (1882). 
 
 On Tapping the Intestine. 
 
 The practice of tapping the intestine with a fine trocar and canula in cases of intes- 
 tinal obstruction is one which deserves serious consideration, since there is good reason 
 to believe that a small puncture mav often be made into a distended intestine and wind 
 drawn oif without any extravasation of the contents of the bowel taking place, and that 
 if the di.stension of the strangulated, twisted, or otherwise obstructed bowel can be 
 relieved by the operation there is some ground for hope that natural efforts may then 
 release the bowel from beneath its band or from some internal peritoneal ring, and that 
 even a twisted bowel may untwist. The operation, however, is not without its risk, as I 
 have on several occasions known fecal extravasation to follow the practice, and Coupland 
 and Morris quote other cases. I have been also led to believe that even in a large hernia 
 its strangulation might be relieved by a like operation and a natural reduction take place, 
 for a strangulated bowel, outside as well as inside the abdominal cavity, is damaged by 
 the distension of the intestine itself more than from any extra-intestinal influence : and 
 
TM'I'ISC rUi: Alllxi.MKS. 621 
 
 if tilis <list(Misi«iii can lie rdicvcil )iy siuiply ilrawiiiL: "fV tin- contents of I lie liowcl Uv 
 means of a very fmt' troear ami <-anula, the walls of tlie intestine would c<)||a]»se, stran- 
 jiiilation cease, ami. unless ailliesions eunliiu'il the howel in its jtosition. its return ini;^ht 
 be looked for hy natural efforts. Tliest; remarks are Inised upon the fact that intestine 
 may he so treated without any extravasation I'ollowin^; and sueh a result aetually came 
 before me in a ease (»f ileo-colie scrotal hernia in a L'entleman a't. 7<i, when, to enable luc 
 to reduce the bowel. I was driven to puncture the protruilinj; intestine in four or live 
 places, and, althouLrh mueli mani])ulation f(dlowt'(l this |»ractice, no extrava.sation occurred 
 at the time or after, and a rapid recovery ensued without a dro)» of sMp|turation. The 
 case occurred in the ]>ractice <d" Mr. Kidson Wriidit of Keiinin^'ton. 'I'hese remarks are 
 only to be read as su,i.'tr<'sti'»ii'<. and more particularly as applied to larfre umbilical and 
 scrotal herni.-e. Since the introductifin of the pneumatic aspirator l)V Dr. Dieulal'ov this 
 practice has rcceivetl much I'McouraL'cmeiit. For more detailed evidenc(! on the subject 
 of intestinal obstruction and its treatment, the followinj^ [tapers may be referred to: 
 
 HiUNTON, Crnoniiin Lfcliiren, 1X59. — Fagge, (?«_»/'•'♦ R''j>ori>i, 1808. — G.VY, 7Vani>. Lond. Med. Soc, 
 1861, 1S()"J. — (ioKii.vM, Guy's Reports, vol. iii., series 1. — HlXTO.v, Amiciation Med. JoidtujI, 1853. — 
 Smith, Amiricnii Joiiniul of Med. Srienre, 18()2. — Bhyaxt, Meil. Timea, 1872. — A TreiUUe on the Pneu- 
 vvttic .Anpiratinn of Morbid FInidx, by Du. Gkorgk DikuI-AFoV, 1873. — TroU-S-SKAU's Clinical Metl- 
 irine. — IIlTcuiXsox, Med. Chir. Tranif., vol. Ivii., 1874.— Coipland and MoRRI.S, Bril. Med. Journ., 
 Jamiary 2ti, 1878.— Bryant, Lunret, May, IS7H.— CI inirfd Sorietij, IHIS.—Mcd.-Cltir. Tram., 1882. 
 
 On Tapping the Abdomen. 
 
 Whenever fluiil collects in the abdominal cavity so a.s to interfere with life's func- 
 tions, the ojieration of tapjting may be called for. It may be for osrifeSj a C(dlection of 
 fluid in the peritoneal cavity ; for orariait ffrups//. a collection of fluid in a .single or in a 
 polycystic tumor; or for fu/i/utid, whether hejtatic, pelvic, or peritoneal. It iDay also be 
 called for in reudi or i^plmiic cyst.s. 
 
 It would be out of my province to enter minutely into the diagnosis of all these con- 
 ditittns. as the majority of such ca.se.s come under the care of the physician, the surgeon 
 being called in simply to operate. Nevertheless, it may be as well to give some of the 
 leading points of diagnosis, for I need scarcely say that the operating surgeon is not 
 relieved of all responsibility of diagno.sis by the fact that a medical man has charge of 
 the case. The operator, as such, assumes part, at least, of the responsibility of the case 
 as well as of the operation. 
 
 Diagnosis. — In a general way it may be asserted, therefore, that ascites is the result 
 of a chronic action that has been going on for some time, arising from liver, peritoneal, 
 heart, or renal disease, the abdominal dropsy being one of the results only. The history 
 of the case, consequently, will be a great help in arriving at a conclusion. The fluid, 
 moreover, will be found to fill the abdominal cavity equally, fluctuation being perceptible 
 across the abdomen and from befoi-e backward well into the loins, even when the abdomen 
 is resonant. As a rule, the intestines will be found floating upward, thus giving reso- 
 nance on percussion, the position of the bowels being influenced by that of the patient. 
 With the body horizontal, they will give resonance at the umbilicus ; with the pelvis 
 depressed, above this point ; with the pelvis well rai.sed, resonance may even be detected 
 near the pubes. In almost all these ca.ses the sound over the loins will be dull. On 
 looking at the abdomen the surfiice will be found smooth and the enlargement equal. 
 The subject of diagnosis of ovarian and uterine disease will receive attention in Chapter 
 XXVII. 
 
 Operation. — The instruments required for the operation are a moderate-sized trocar 
 and canula. an india-rubber tube about six feet long adapted to a silver tubular plug that 
 fits the canula when the trocar is removed, a lancet or small scalpel, a pad of lint, and a 
 roll of good .stra])ping. 
 
 Some surgeons prefer one of the modern instruments by which the india-rubber tube 
 is attached to the canula at right angles, and they are very good ; but those I have named 
 are efticient. 
 
 The patient should be brought to the edge of the bed and placed in the recumbent 
 position, with the shoulders raised, a folded sheet or piece of mackintosh cloth having 
 been previously so arranged as to protect the sheets. A catheter .should first be pas.sed ; 
 then, with the trocar and canula warmed and oiled and a pail at hand, into which the end 
 of the india-rubber tube is allowed to hang, the surgeon may with a lancet make a small 
 incision through the skin and soft parts, about three inches below the umbilicus or at any 
 other spot at wiiich the operation is to be performed. He should next introduce the 
 
522 II YD A TIB TUMORS. 
 
 trocar and canula with a direct force and semi-rotatory movement of the wrist, and. with 
 his forefinger fixed about one inch from the end of the canula. guard against inserting 
 the trocar too far. The abdomen having been punctured, the trocar may be removed 
 with the right hand, the canula being pushed farther in at the same moment with the 
 thumb, and its orifice plugged at once with the left thumb, to prevent the escape of fluid. 
 The silver plug of the india-rubber tube may then be introduced and the fluid allowed to 
 escape, the distal end of the tube being kept submerged in the fluid in the receptacle, the 
 tube acting as a syphon. 
 
 To facilitate the flow and to evacuate the whole contents of the cavity, .some surgeons 
 roll the patient over on the side or place him so at the first, but such a proceeding is 
 unnecessary. 
 
 When the fluid has ceased to flow, the canula is to be gently removed, the tliumli and 
 finger of the left hand nipping up the soft parts as its end appears, so as to prevent the 
 admission of air into the abdominal cavity and the trickling of any fluid down the 
 patient. The edges of the wound may then be adapted by a piece of good strapping, 
 and a pad of lint applied when oozing appears, but not otherwise ; two or three bands of 
 strapping three inches wide should then be adjusted to the front of the abdomen from 
 side to side. Where great hollowness is left, a pad of cotton-wool often gives comfort. 
 The old-fashioned flannel bandage may be abolished, as it is only an inconvenience. 
 
 All pressure on the abdomen during the flow of the fluid should be avoided as unneces- 
 sary, and also all pressure after the operation, support only being required. 
 
 The usual place to perform the operation is in the linea alba, about two or three 
 inches below the umbilicus ; but in ovarian disease any point in the linea semilunaris may 
 be opened, and in rare cases any other. 
 
 When a hydatid, renal, or splenic cyst requires to be tapped, a small trocar and 
 canula. such as is employed for tapping a hydrocele, should be used, though in these 
 cases the pneumatic aspirator is of great service, for by its use the fluid can be removed 
 without the possibility of air being introduced. 
 
 Hydatid Tumors 
 
 of the liver, spleen, or other parts of the abdomen are occasionally met with. and. how- 
 ever large a size they attain, they rarely produce other .symptoms than those mechanically 
 caused by their size ; and on that account they may require treatment. Their origin is 
 indicated by their position, although, when situated in the pelvis, there may be an impos- 
 sibility in diagnosing them from ovarian cysts. They are almost always very globular 
 and tense, and rarely give rise to distinct fluctuation. The external feel of a hydatid is 
 somewhat peculiar and characteristic. In 1868, I removed, with permanent success, an 
 enormous hydatid tumor from the abdomen, although apparently not from its cavity, of a 
 lady-patient of Dr. Oldham, aet. 35, who was believed to have had ovarian disease (Gui/'s 
 Hasp. Rip.. 1868), while Sir Spencer Wells records a case in which the hydatids were 
 turned out of the abdominal cavity. Sometimes the hydatid dies without surgical inter- 
 ference, and, as a consequence, severe suppuration is set up, with violent constitutional 
 disturbance, which requires surgical aid. 
 
 Not long since I opened with marked success a large abscess OA'er the liver of a boy 
 aet. 17, and evacuated a quantity of pus bearing the peculiar odor of hydatid pus. The 
 abscess clearly came from the liver and was a suppurating hydatid. The boy previously 
 had suflfered from tapeworms. In 1869, I had to open freely a suppurating hydatid 
 tumor which half filled the abdomen of a gentleman a?t. 40 who had had it tapped some 
 months before in Australia, and a complete recovery ensued. A quantity of dead hj'da- 
 tid cy.sts escaped through a large canula that was introduced. The cy.st was washed out 
 daily with great benefit. This gentleman is now quite well. I have had at least ten 
 other cases in which a like treatment was employed with success, nor have I lost one, 
 although several have had a very narrow escape. The secret of the treatment of suppu- 
 rating hydatid cysts consists in a free outlet for all purulent and dead hydatid deposits 
 and the frequent washing out of the suppurating cavit}' with water containing iodine, 
 Condy's fluid, carbolic acid, or creosote, with or without the introduction of a drainage- 
 tube or elastic catheter. For the operation a large trocar and canula should be employed, 
 the canula being left in for some days until a- good opening is established ; it may then be 
 exchanged for an elastic catheter or large drainage-tube. 
 
 Before suppuration takes place, however, other treatment is applicable, such as drain- 
 ing off" partially or wholly the fluid contents of the hydatid by means of a very fine trocar 
 
Tr.MoIlS OF Tin: I'MJI/IJCCS. o23 
 
 iiiul raiiiila. I liuvf iifrfuriiu'd this tijH'iatiuii mi iiiaiiy o<'casi()iis witli succos, liul jrcn- 
 erally prefer to draw oft" only a few ounces of tin; fluid, clinical exiierience indicating.' that 
 by this measure ahme the hydatid may lie kiMed, sul»se(juently witlieriiifr up and ccasin;^ 
 to liurt. |)r. J. MiUer of Tasmania, where this disease; is fre(j_uent, speaks liif:lilv of tlie 
 use of twenty-irrain doses of the liromide of potassium three times a (hiy after the tap- 
 pin;.', and I)r. IJird of .MeMxturne eoinhine.s with it drachm (hises of the tincture of 
 kanii'Iii. At times, also, cases which have hcen looked upon as cured are n<tt so, and 
 after till' lapse of years the disease reappears. Wlien suppuration follows tappinj;, how- 
 ever, a cure ensues. 
 
 The (»])eration of simply tapping' a liytlatid with even the finest instruments is not. 
 however, free from danircr, for in .January, 1877, I tapjted a man ;et. 4lJ who. with the 
 exception of the hydatid tuuKtr of the liver, was in perfect health, and drew off" half a 
 pint of hydatid fluid, havin<,' to perforate the structure of the liver to the depth of an 
 inch to reach the eyst. The operation was not attended by the slijjhte.st distress, but on 
 the removal of the needle an agonizing pain attacked the man's face and jaws, accom- 
 panied with flushing of the head and neck. This was followed by vomiting, extreme 
 pallor, and stertorous breatliing for a minute, followed by death in two njinutes. At the 
 necropsy nothing was found to account for this sudden end — that is, there was no embol- 
 ism or heart troul)le, no brain disea.se, nothing but a large hydatid cyst behind the liver. 
 The needle had, however, passed through a misplaced portal vein on its way to the livda- 
 tid. and the (|uestion arose as to the possibility of death being due to the mixing of the 
 hydatid fluid with the venous blood. No blood was extravasated (Cllii. tSock'iij. 1878). 
 3Iy colleagues, Dr. Fagge and Mr. Durham, have given us some evidence that a cure can 
 be obtained by electrolytic treatment on Dr. Althaus's plan of introducing into the tumor 
 two electrolytic needles, one or two inches apart, connected by means of wire to the nega- 
 tive pole of a galvanic battery of ten cells, and completing the current through the tumor 
 by means of a moistened sponge attached to the positive pole of the battery, applied for 
 ten or more minutes at a time to diff'erent points over the swelling (^Med.-Chir. Trans., 
 vol. liv.). This operation may be repeated according to circumstances. 
 
 Such treatment may be employed when simple tapping fails to cure. Some of the 
 patients reported as cured by these means have returned, however, with the disease; and 
 it is still a question whether more is gained by this method than by simple puncture and 
 the withdrawal of some of the hyadit fluid. 
 
 Further information may be gained from Murchison's work on the liver (1SG8) ; 
 Harley's paper, Med.-Chlr. Trans., vol. xlix. ; and the book by Dr. Bird of Melbourne. 
 
 Tumors of the Umbilicus. 
 
 Pedunculated outgrowths from the umbilicus are not uncommon, and are alway."? found 
 in children, being composed of simple granulation tissue; indeed, it seems probable that 
 they are really due to excess of granulation growth from the point at which the umbilical 
 cord separated. They .sometimes attain a large size and have occasionally a .slight central 
 canal or orifice, though the former never travels far. I have .seen one the size of the last 
 joint of my little finger. They are easily cured by the application of a ligature to their 
 bases. 
 
 These tumors, however, mu.st not be confounded with a condition that is occasionally 
 met with — viz., the presence of a fleshy outgrowth not unlike a glans penis, through 
 which a real canal extends into the bladder, the canal being clearly an open urachns. I 
 have seen two such cases; one I recorded in my Lettsomian lectures on the surgical dis- 
 eases of children (18G3). I wished to cauterize the surface of the canal and thus cause 
 its contraction and closure, but was not allowed. 
 
 I have also seen a large hernial protrusion appear at the umbilicus, with the whole 
 surface ulcerated, in which there were some solid contents, which I took to be the liver. 
 It sub.sequently completely cicatrized, and a good recovery ensued. The drawing of this 
 case is in Guy's Hospital Museum. {Vide Fig. 319.) 
 
 Sebaceous tumors, as well as accumulations of sebaceous matter, are also met with at 
 the umbilicus in dirty people. I have turned out large masses of such indurated secre- 
 tion from the cuplike depression. 
 
 Cancerous tumors, etc., as well as simple warty growths and syphilitic condylomata, 
 may also exist in the same position. 
 
524 
 
 HERNIA. 
 
 CHAPTER XV. 
 
 hp:rnia. 
 
 Diagrams illustrating the Different Forms of Hernia, with some 
 
 OF its Complications. 
 
 In all these diagrams the thick black line represents the parietes covering in the 
 hernial sac ; the thin line, the peritoneum and hernial sac ; the small body at the bottom 
 of the sac, the testicle. 
 
 Fig. 292. 
 
 Fig. 293. 
 
 Fig. 292. This diagram illustrates the tubular vaginal process of peri- 
 toneum open down to the testicle, into which a hernia may descend. When 
 the descent occurs at birth, the hernia is called " congenital ;" when at a 
 later period of life, the "congenital form," Birkett's "hernia into the vagi- 
 nal process of peritoneum," or Malgaigne's "hernia of infancy." 
 
 Fig. 293. The same process of peritoneum open halfway down the 
 cord, into which a hernia may descend at birth or at a later period. 
 Birkett's " hernia into the funicular portion of the vaginal process of 
 the peritoneum." 
 
 Fig. 294. 
 
 Fig. 294. The same process undergoing natural contraction above the 
 testicle, explaining the hour-glass contraction met with in the congenital 
 form of scrotal hernia, as well as in hydrocele. 
 
 Fig. 295. 
 
 Fig. 295. Diagram .showing the formation of the " acquired congenital 
 form of hernia" — the " encysted of Sir A. Cooper," " the infantile of Hey" 
 — the acquired hernial sac being pushed into the open tunica vaginalis, 
 which encloses it. 
 
 Fig. 296. 
 
 Fig. 296. Diagram illustrating the formation of the " acquired " hernial 
 sac, distinct from the testicle or vaginal process of peritoneum which has 
 closed. 
 
AIIDOMISAL UlinSlA. 
 
 525 
 
 Via. 297 
 
 Fl<i. lillT illustrates tlif neck nf the licniial sac |iiis1i(m1 
 back boncatli the atiiliniiiiial parit-ti's with tlic straii^ailalcd 
 buwd. ( IV./r Fig. :{1L'.) Mcll's form. 
 
 Second 
 variety of 
 displaced 
 hernia. 
 
 Fifi. '298. 
 
 Fi(i. lilts shows tlie space in the subperitoneal connective 
 tissue into which intestine may be jtushed throu<;h a rup- 
 ture in the neck of the hernial sac, tlie intestine being still 
 strangulated by the neck. (^Vidr. Fig. 314.) 
 
 Third 
 variety of 
 displaced 
 hernia. 
 
 Fig. 2!M). Diagram showing how the neck of the vaginal 
 process may be stretched into a sac placed between the tis- 
 sues of the abdominal walls either upward or downward 
 between the skin and muscles, muscles themselves, or be- 
 tween the mu.scles and the internal abdominal fascia, form- 
 ing the intra-parietal, inter-muscular, or interstitial sac. 
 Hernia en hinMic of the French ; '• additional sac " of Birkett. 
 ( Vide Fig. 315.) 
 
 Fig. 300. Diagram illustrating the reduction of the sac 
 of a hernia en masse with the strangulated intestine. 
 
 Fig. 
 
 Fourth 
 variety of 
 displaced 
 hernia. 
 
 Fig. 30U. 
 
 First 
 ^ variety of 
 displace i 
 hernia. 
 
 ABDOMINAL HERNIA. 
 
 Abdominal hernia or rupture signities the ])rotrusion of any viscus through 
 an opening in the parietes of the abdominal cavity. This protrusion for the most part 
 occurs at the iii(/i(iiifd and femoral canals or umbilicus, though occasionally at other parts 
 when the abdominal walls have been weakened by some inflammatory, lesion, rupture, or 
 division of muscle from injury or operation, and more rarely at such weak points of the 
 abdominal walls as the obturator foramen, the perineum, the ischiatic notch, the dia- 
 phragm, or the vagina. 
 
 It is met with in subjects of every social condition, but most frequently among.st the 
 so-called working classes, because " hernia occurs oftenest in the most numerous classes, 
 and not in the most laborious." 
 
 Agnew tells us that in the American w^ar 50 out of 1000 recruits were rejected on 
 account of rupture ; that in Germany the proportion was 82 ; in FVaiice, G5 ; in England, 
 39; in Ireland. 30 ; in Italy, 70. 
 
 Hereditary Tendency. — Hereditary predisposition to hernia is also doubtless a 
 reality, since a third of all cases acknowledge a history of having a parent with rupture; 
 and such predisposition probably exi.sts as a general laxity of the mesenteric _folds and 
 parietal layer of peritoneum. I have been called upon to operate on an old gentleman 
 the male branches of whose family for four generations — twelve in all — have been rup- 
 tured. Inguinal hernia is often due to a failure in the natural closure of the .sheath of 
 peritoneum that travels down with the descending testicle ; w^hich failure is more common 
 on the right -side. 
 
 Subjects w;ho are congenitally feeble and others who become weak from illness or old 
 age are more liable to hernia than the robust, the weakness of the abdominal parietes 
 
526 ABDOMINAL HERNIA. 
 
 yielding to tlie natural pressure of the abdominal contents under the influence of some 
 sudden or prolonged muscular exertion. A large number of the cases of hernia are slow 
 in their development, many are sudden, and in all muscular exertion plays an import- 
 ant part. 
 
 Proportion as to its Seat. — Out of every 100 cases of hernia. 84 are inguinal, 
 10 /emor(d, and 5 innhilicnl. It is more common in males than in females in the propor- 
 tion of 4 to 1, 18,402 females only having been applicants for trusses at the Truss 
 Society, out of the total of 90.886 (i?e/;>o;V,l871). 
 
 Hernia in Females,- — Femahs are as liable to inguinal as they are to femoral 
 hernia — to the inguinal in earl}^ life, from the canal of Nuck being open ; to the femoral 
 in middle and old age. In females under twenty years of age there are 87 cases of 
 inguinal to 13 of femoral hernia, and after forty years there are 32 cases of inguinal to 
 68 of femoral. The largest number of cases of femoral hernia are developed during the 
 child-bearing period of a woman's life — that is, between twenty and forty years of age. 
 Prior to menstruation it is so rare as to be almost unknown. Kingdon gives only four 
 such cases. 
 
 Hernia in Males. — In males inguinal hernia is the usual form, Kingdon's table 
 showing that the largest number of cases occur during the first ten years of life, from a 
 want of closure of the vaginal process of peritoneum that covers the spermatic cord. It 
 is about half as frequent between the ages of ten and twenty years, while between twenty 
 and forty it is as common as it is at the early period of life, but its frequency rapidly 
 diminishes after that pei-iod. 
 
 Femoral hernia occurs in the male in about 4 in every 100, though it becomes, as in the 
 female, relatively more common than inguinal as age advances. During the first ten years 
 of life it is not met with more frequently than 1 in 300, whilst between the ages of ten 
 and twenty, 2 per cent, are femoral ; between twenty-one and forty, 4J per cent. ; between 
 forty-one and 60, 6 per cent. ; and above sixty, nearly 8 per cent. 
 
 Average Age when Strangulated. — The average age of persons suffering 
 from ittranguhtteil Inguinal hernia is forty-three, but from femoral fift^'-five. A hernia 
 that becomes strangulated in its first descent is far more acute and fatal than that which 
 has been of long standing, and a femoral hernia is more liable to become so strangulated 
 than an inginual in the proportion of 3 to 1. These ''recent cases" of femoral hernia 
 mostly occur in old women about sixty years of age, and of inguinal in young men, the 
 hernia being in the latter of the " congenital kind." 
 
 Anatomy of a Hernia. 
 
 A hernial tumor, with few exceptions, is composed of a sac with its contents and 
 the soft parts covering it. 
 
 The sac, which is made up of peritoneum, is formed in two ways — -firstly, by the grad- 
 ual stretching and pouching of this membrane through an opening in the abdominal 
 parietes by the protruding viscera, and, being artificial, has been well named by Birkett 
 the acquired hernial sac, this variety being common to all forms of hernia ; and secondly, 
 of the open vaginal tubular process of peritoneum formed by the descent of the testicle, 
 the opening that normally exists in f«tal life not having closed owing to some deficiency 
 in the obliterating process that naturally commences at the internal ring and proceeds 
 downward toward the testis in the scrotum, this variety — etjually well named the congeni- 
 tal hernial sac — being found only in inguinal hernia. 
 
 The formation of the hernia in the former case is a gradual, but in the latter a rapid, 
 process, the '• acquired " hernia being an aff"ection of middle and old age, the '" congenital 
 form " usually one of infiincy or young adult life. 
 
 The sac is also composed of a bod}' and a neck, which communicates by a mouth with 
 the abdominal cavity. When the hernia is small, the neck and body appear as a small 
 pouch, into and out of which the hernial contents pass with facility, the sac having no 
 narrow neck by which the return of the intestine can be retarded ; but when the hernial 
 sac is large and has escaped into looser tissues, its body or fundus so expands as to render, 
 by comparison, the neck of the sac a narro"w canal or orifice, when the return of the 
 hernial contents often becomes one of difficulty ; indeed, it is under these circumstances 
 that it frequently becomes strangulated. 
 
 The neck of the sac also undergoes changes which it is essential to understand, par- 
 ticularly in cases of scrotal hernia, where the peritoneum is so forced outward through the 
 inguinal ring as to fall into puckered folds. 
 
MUxiMISM. IIIIIMA. 
 
 b-ll 
 
 Tlit'se fnlils will tliMipiM'iir, liowcvfr, il'llif litTiiiii ami >a(' lie i-imIuccmI into tin- iilxlidiii- 
 iial cavitv or tlu' cniistrictiii^^ riiiL' «»t' tissue cxtcrtial t<i it In- iliviilcil, tlu' <lc<rr<'c nf uiii'uld- 
 iiiLr of till' iii'fk nf the sack hriiij; ri'jriilatcd l>y tin- aiin»uiit of i-xpaiisioii of wliicli it is 
 capaliM'. IJiit sliduld the sac he iieitlicr rctiinicil nur its constricting riiijr of outside tissue 
 diviilcil, the |iuckcrcd folds of jteritoiieuin will adhere, and jirohahly the suhperitoiiciil con- 
 nective tissue will unite with it. The neck of the sac. under these circunistunces. liecomes 
 indurated ami thickened, and as time proj^resses contracts; as a conse<|Uence. a narrow- 
 in*; and ritridity of the lu'ck <d' the sac ensue, which necessitates in old iiifruinal hernia, 
 when an operation lor strauLrulation is reipiired. (he openini: nf the sac and :i Wi'v division 
 of its neck. 
 
 When a hernia forms at the seat of a wouml in the at)d((niii)al wall, there is no .sac; 
 and the .same occurs when the c;ecum uy colon ]tn»trudes throui:h the iniruinal canal. 
 
 The contents of a hernia are usually small intestine and funentum. a portion of the 
 last two feet ot' ileum heiuLT, as a rule, involved ; the c;ecum ami colon also arc riecasion- 
 ally so, and cases are on record in which the lihidder. stoma(di, tivary. or gall-hladtler has 
 hoen found in the sac. 
 
 At times the omentum is .so pushed before the intestine as to cover it completely, thus 
 forming an inner sac ; tlie bowel, as a rule, however, lies behind the omentum. 
 
 When intestine protrudes, the hernia is called an e/(/e/oce/« ; when omentum, ''y>»y>A^- 
 ci'h' ; when both intestine and omentum occupy the sac, cntero-fpiplocele ; when bladder, 
 ct/stoci'lf ; when stomach, i/nsfrocelf, etc. 
 
 The tissues that cover in a hernial sac will necessarily depend upon the 
 seat of the hernia. Thus, in the iiinhlliriil it may be only the menil)rane of the conl. skin, 
 and al)dominal fascia; in the .>>c/v;/cr/ it will be the scrotal tissues; in the /'f»io/vir/. the ^kin 
 with the superficial and deej) fasciae; but in all, and more particularly in the femoral, the 
 sur<;eon should boar in mind the anatomical fact that a layer of fiiscia, which lines the 
 abdomiiuil muscles and separates them from the peritoneum, covers in the true peritoneal 
 sac, and is known as the " fascia propria " of Sir A. Cooper, and between this fascia and 
 sac some subperitoneal fat often exists. 
 
 When a hernia comes down into a sac and i^oes up again, either by itself or aided by 
 position or by the surgeon, it is called rtdncible ; when it cannot be returned, it is called 
 irnduciUe ; when it is constricted sufficiently to interfere with the return of the contents 
 of the protruding viscera, it is known as incarcrafed, but would be better called ohatrncted ; 
 and when, in addition, the circulation of the part is interfered with, it is said to be strangu- 
 lated. 
 
 When the i)rotrusion takes place ahore Poupart's ligament, through the internal ring, 
 but does not traverse the canal sufficiently far to appear through the external ring, the 
 
 Fig. 301. 
 
 Fig. 302. 
 
 Oblique In$;iiinal Hernia. 
 
 Bubonocele on ri^'lit .-ide. hut passing through 
 
 external ring on left. 
 
 Direct Inguinal Hernia. 
 
 hernia is called a Imhonocelr (vide right side of Fig. 301) ; when it protrudes through the 
 external ring into the scrotum, a scrotal hernia (vide left side of Fig. 301). both forms 
 being included in the<erm oblique imjninaJ hernia. 
 
 When a hernia makes its way directly through the external ring without having 
 passed down the inguinal canal, it is called a direct iiKpiinal (Fig. 302). 
 
 A crural or femoral hernia is lehnc Pouparts ligament, the protrusion having 
 
528 ABDOMINAL HERNIA. 
 
 come down through the crural ring on the inner ^^ide of the sheath of tlie femoral vessels 
 (Fig. 'i(\y,). 
 
 An umbilical hernia or exomphalos is a protrusion at the navel. A ventral is 
 a protrusion at any other part of the abdomen. The names of every other form are 
 according to the locality. 
 
 Symptoms. — A hernia in its early stage may show itself as a mere fulness about the 
 internal inguinal ring, the crural ring, or other opening, this fulness becoming very mani- 
 fest on the patient standing and coughing. The patient's 
 attention has probably been drawn to the part by a feeling 
 of iceakiiess o\\ n^aking exertion or in performing any natu- 
 ral act demanding the strong action of the abdominal mus- 
 cles. AVith this weakness there is often associated some 
 grijiing abdominal pain or feeling of uneasiness — wrongly 
 attributed to constipation — and in old people these symp- 
 toms should always attract the notice of the surgeon. 
 
 As the hernial pouch increases the tumor in the in- 
 guinal canal, at the femoral ring or umbilicus, will show 
 itself as a distinct swelling, this being manifest when the 
 patient stands or coughs, but disappearing on his lying 
 down. It will, moreover, be prevented from returning on 
 Femoral Hernia. the patient assuming the erect posture if the finger of the 
 
 surgeon is placed over the ring. The swelling always comes 
 from above and travels downward. As the tumor still further increases a distinct impulse 
 will be felt by the hand when placed over it if the patient coughs, and a peculiar gursling 
 sound will be heard on the application of pressure to the part to cause its reduction. The 
 return of the bowel also into the abdominal cavity will be marked by the disappearance 
 with a jerk of the contents of the sac and a distinct appreciation by the finger of the aper- 
 ture through which it has passed. 
 
 " If the surface of the tumor be uniform ; if it be ela.stic to the touch ; if it become 
 tense and enlarged when the patient is troubled with wind, holds his Itreath. or coughs ; 
 if in the latter case it feels as if it were inflated ; if the part return with a peculiar noise 
 and pass through the opening at once. — the contents of the swelling are intestine. If the 
 tumor be compressible ; if it feel flabby and uneven on the surface ; if it be free from 
 tension under the circumstances just enumerated; if it return without a noise and pass 
 up gradualh', — the case may be considered as epiphxeJe. If a portion of the contents slip 
 up quickly and with noise, leaving behind something which is less easily reduced, the case 
 is probably an enteio-epyi jdocele^ (Lawrence). 
 
 In infants, where ilalgaigne's " hernia of infants" exists (Fig. 292), or Haller's 
 " hernia congenita.'" both being caused by the descent of intestine into the open vaginal 
 process of the peritoneum, the tumor is very often large when first discovered, and often 
 scrotal. In young adults, where the same kind of hernia exists, the swelling comes sud- 
 denly and at once by one ru.sh downward into the scrotum, this ru.sh being accompanied 
 with pain. 
 
 Tre.-vtmen'T. — In all these forms of hernia, when reducible, either xXxe pallia I ivi plan 
 of treatment may be employed, or what is known by the radical cure. 
 
 The palliative treatment consists in the application of a truss — an instrument 
 composed of a pad or cushion connected with a metallic spring or with straps, and so 
 arranged that the pressure of the pad keeps the hernia from descending ; the spring 
 maintains the pad in position and at the same time allows perfect freedom of movement 
 of the body. Any truss that accomplishes this is beneficial, but any that fails in this is 
 worse than useless, as it is injurious and gives false confidence. 
 
 The operation for the radical CUre of hernia will be considered under the heading 
 " Inguinal Hernia." 
 
 Hydrocele of the Hernial Sac 
 
 is a very rare affection, and not more than six cases are on record. I have seen but one 
 true example of it — that is. if the term be confined to such cases of accumulation of fluid 
 in the hernial sac in which the neck of the sac is occluded by some«adherent omentum or 
 intestine or by the radical cure. The case occurred in a man aet. 40 who had been treated 
 for hydrocele of the right testicle £or twenty years, and had frequently been tapped. He 
 came under my care with a right scrotal swelling which extended up to the internal ring. 
 
iitRF.i) I V •iiii.r. iii:i:.\/A. 
 
 529 
 
 anil uhscuri' sviiiptoiiis ni' intfstinal obstruction. lit- was tappcil ami serous fluid was 
 drawn ofl", hut the syniptoins continued. After tlie lapse (A' two or three days, as the 
 ahdoininal symptoms increased in severity in my absence, an exploratory operation was 
 performed, and a mass of what was suj)posed to he omentum or an omental sac contain- 
 in<i intestine was found hlocking up the internal ring. This was opened and the inucouK 
 inenihraru' of the bowel ex]>osed. The <»peiiiiij; into the bowel was stitched up. but the 
 symptoms persisted ; and tlu! man died two days later, of ])eritonitis. An examination 
 after death showed that what had been rej^'arded as an hydrocele was a dropsy of a con- 
 •^euital hernial sac, ami what had btM'n opened as a mass of ometitum or omental sac was 
 a kniiekli' of ileum matteil totfether and to the niick of the sac by lymph, this adhesion 
 j^ivin^- rise to the fatal obstruction. \o hydrocele existed. Such cases as these should 
 not be mistaken for dropsy or suppuration of tlu; liernial sac after herniotomy, which are 
 bv no means unfre(|uent eoiiditioiis, and siiould be treated by tajiping or a free incision. 
 
 Irreducible Hernia. 
 
 When the contents of a hernial tumor cannot be returned into the abdominal cavity, 
 an irreducible hernia is said to exist ; and this condition may be temporary, brought about 
 by anything that alters the relations between the bulk of the tumor and the neck of the 
 sac or the opening through which they would have to return, such as .some excess of 
 feces or flatus in the part or some fresh descent of omentum or bowel. A hernia may 
 be made j)ermanently irreducible by adhesions between the .sac itself and its contents, by 
 bands traversing the sac, or by adhesions between the intestine and .some fold of omen- 
 tum. In long-standing herni;e the .same result will ensue, from the development of fat 
 in the omentum. 
 
 The tonic or spasmodic contraction of the structures outside the neck of the sac 
 under the influence of irritation, as well as the induration of the neck of the sac itself 
 or of the surrounding parts, has also an important influence in preventing the reduction 
 of the tumor. 
 
 AVhen the caecum or large intestine forms the contents of the hernia, the rupture may 
 be irreducible, from the fact that the peritoneum, which is naturall}' adherent to these 
 parts and is dragged down with them, becomes fixed to the tissues into which it is protruded. 
 A cjecal hernia is, however, always difficult of reduction. In one case I had to puncture 
 the bowel with a trocar and canula and draw off the air it contained before I succeeded. 
 Xo harm followed this step, and the patient did well ; but the measure is not without its 
 dangers. 
 
 Prognosis. — An irreducible hernia is always a source of anxiety and danger, because 
 when composed of omentum a piece of intestine may at any time slip down behind it and 
 become caught in one of its folds ; and when composed 
 of omentum and intestine, any accumulation of the con- 
 tents of the bowel within the hernial sac may give rise 
 to obstruction, and then strangulation of the hernia is 
 not distant. An irreducible hernia, moreover, is always 
 liable to injury. 
 
 An irreducible scrotal, or even femoral, hernia will 
 sometimes attain a large size. I have seen examples 
 of both reaching halfway down the thigh, but umbilical 
 hernia will sometin)es attain a still greater size. 
 
 These forms of hernia often give rise to dyspeptic 
 .symptoms, to irregularity of bowels and colicky pains ; 
 but the chief danger lies in their tendency to become 
 strangulated. 
 
 Trkat.ment. — A large irreducible entn-o-epiplnceJf 
 mu.st be treated by a bag truss — that is, with an instru- 
 ment so adapted as to support the hernia and prevent, 
 as far as possible, its increase. A .small irreducible um- 
 bilical, inguinal, or femoral hernia ought to be treated by 
 a hollow truss, the only reliable pad being one moulded 
 upon a plaster cast of the hernia, taken when the tumor 
 is at its smallest, after a day's rest. The pad should 
 be made of metal moulded to the cast and lined with wa.sh-leather (Fig. 304 : vide paper 
 by author, British Medical Journal^ February IG, 1884). A omental, hernia should be 
 
 Fig. 304. 
 
 Drawing showina on the Eiohi Siile aTrus,s 
 fitted loan Irreducible Hernia, in which 
 the Pad has been mouldetl upon a Cast of 
 the Patient's Groin ; and on the L'fl .Side 
 an Irreducible Hernia with the Hollow 
 of the Pad exposed to View, prepared for 
 Application. 
 
530 ABDOMINAL HERNIA. 
 
 treated by a truss made, in the way described, upon a cast. Every patient with an irre- 
 ducible hernia should be warned against takinir violent exercise or overdistending the 
 abdominal viscera. The bowels should never be allowed to become constipated, and, 
 above all, the slightest symptom of pain or increase of size in the tumor should be brought 
 at once under medical advice, since these irreducible herniae are treacherous things and 
 become obstructed and strangulated very in.sidiously. 
 
 In many cases of irreducible hernia, and particularly in recent cases, reduction may 
 be effected by rest in the horizontal posture, a brisk purge or enema, and the administra- 
 tion of small doses of saline purgatives, such as the sulphate of magnesia, so as to keep 
 up a gentle action of the bowels, with the local application of ice. the diet being at the 
 same time nutritious, though not of a bulky nature. In this way I have procured the 
 reduction of cases of hernia that had been down for three months ; in .several cases I have 
 succeeded after three week's treatment. Old irreducible hernia? are. however, rarely made 
 reducible by treatment, but the not very old examples and the recent can generally be 
 made reducible by the means already indicated. 
 
 Obstructed or Incarcerated Hernia. 
 
 The .SYMPTOMS of an obstructed hernia, as of ob.structed intestine, are not very defi- 
 nite, but the chief are ob.scure abdominal pains with a di-agging sensation about the 
 umbilicus after food, nau.sea, and at times vomiting. Con.stipation, when present, aggra- 
 vates the symptoms and renders the local nitjns of obstructed hernia more marked, the 
 tumor becoming distended, tympanitic, and painful. On manipulation, the intestine in 
 the hernia may be partially or wholly emptied of its gaseous if not of its solid contents, 
 and the compression of the tumor be accompanied b}- the peculiar gurgling sound of gas 
 and fluid as these traver.se the canal toward the abdominal cavity. When such symp- 
 toms are chronic, they are generalh- known as indicating an incarceratefl hernia; but 
 such a term is not sati.sfactory, it being applied to the obstructed as well as to the redu- 
 cible hernia, and should be discontinued. 
 
 Treatment. — These cases require great care in their treatment, because, if neglected, 
 they pass on rapidly to inflammation or strangulation. Rft^t in the horizontal position is 
 of primary importance, and the tumor, if scrotal, should be slightly elevated. \Wirmili 
 to the hernia also often gives comfort, relaxing the parts, and thus favoring reduction. 
 
 When constipation, vnaccompanied by voraitinff, exists, a brisk purge may be given ; 
 but with this .symptom a purgative enema is to be preferred, the natural action of the 
 bowels being stimulated by these means and the contents of the hernial sac moved on. 
 The tumor itself .should not be manipulated at this stage of the case, such a step doing 
 harm by bruising or setting up inflammatory action. When success does not attend these 
 efforts and the symptoms persist, the source of obstruction will have to be sought by the 
 surgeon, as it will probably be mechanical, and the case have to be dealt with as one of 
 strangulated hernia. 
 
 Inflammation of a Hernia. 
 
 An inflamed is not a strangulated hernia. Inflammation of a hernia is generally the 
 result of .some injury to an irreducible hernia, from either accident, a badly-fitting truss, 
 or ill-advised manipulation. An irreducible hernia after an attack of obstruction may 
 inflame. A reducible hernia, becoming temporarily irreducible and inflaming, may become 
 permanently irreducible by adhesions forming between the sac and its contents. 
 
 The local siyns of an inflamed hernia are pain, swelling, and induration. When the 
 tumor contains omentum, it becomes nodulated and irregularly hard ; and when intestine, 
 much fluid will be poured into the sac. When the action is enough to interfere with the 
 natural function of the tube, symptoms of general peritonitis or obstruction will appear, 
 which must be dealt with on ordinary principles. 
 
 Treatment. — Re>it and the local application of ice in a bag are the mo.st important 
 remedies, also purgatives when obstruction in the hernia does not exist, and opium when 
 it does. By such means the sv-mptoms are generally arrested ; and when this result does 
 not take place, the case passes on to one of obstruction, if not of general peritonitis. 
 
 Rupture of a Hernia, 
 
 or rather of the sac and integuments over it. has been recorded by B. Pitts of St. 
 Thomas's Hospital (^Lancet. April 7, 1883). and the accident, as proved by the case, is 
 
lyrKSTiXAL ni!STi:r<rnK\, inv. 5;51 
 
 nut iK'oi'ssarily tatul. It ncciiiiiMl in a wnniaii a-t. 1*1 who lia<l ln-cii i)|iciat(Ml u|inii t'ur u 
 straiijjTulatril /I ///"/<«/ lu-riiia two Vfars and tlin-c inoiiths previously. She had not worn 
 a trusts for a yi-ar bctorr tlir accident, and tlie hernia hml hecunie as hir^re as a ehihJ'a 
 liead. It liurst durinjr a tit of couj^hinjr, and the line of rupture was in the sound skin 
 near the cicatrix ; intestine at once jirotruded tlirough the wound. After the hipse of 
 three hours Mr. I'itts .saw her, and found a stout woman much eolhip.sed. with a f(M»t an<l 
 a half of small intestine. Iiruised. congested, dirty, and very cold, protrudinir through an 
 external wound altout one inch long. lie cleansed the part with warm carlxdic lotion, 
 and after enlarging the skin opening returned the protruding liowel, and with it the cjccum 
 and ahmit live feet of small intestine that had Keen in the sac. lie cut f>ft" redundant 
 skin ami sac and stitched uji the part, making good provision for drainage. A good 
 recovery ensued. A .second case like the above is also recorded by Mr. Jones (Luncff^ 
 Aj.ril, 1SS(»). 
 
 Intestinal Obstruction and Peritonitis as a Result of the Adhesion 
 6f a Piece of Intestine to the Hernial Sac. 
 
 I published such a case in 1801 in Part III. of my Clinical Snryi ri/, and Mr. Birkett, 
 in his excellent article in Holmes s Snrgert/ f third edition, vol. ii., 1883j, has given a sec- 
 ond case with a drawing, which I also had the advantage of seeing; and he alludes to the 
 fact that M. Littre called the attention of the profession to the cases illustrated by the 
 above in a paper, " Sur une nouvelle espece de Hernie,' Mem. de CAcud. Roijolf; dcg 
 SciiiiceK. 1700, p. 300. The notes of my case are as follows: 
 
 Lmbilicid Ilentla ; Ohgtruciion to tlu: BoiveU from a Socmhited Adherent Colon; 
 Death. — A woman a?t. 56. having had a hernia for many years, was suddenly seized some 
 twenty-four hours before her admission into Guys, under the care of Mr. Cock, with 
 symptoms of strangulation. The taxis, under the influence of chloroform, proved success- 
 ful, but collapse and death followed in twelve hours. After death general peritonitis was 
 found to have been present, the intestinal coils being all adherent. An umbilical omental 
 hernia the size of a fist existed, the omentum forming a distinct sac. To the centre of 
 this the anterior wall of the transverse colon was firmly adherent, forming a kind of 
 pouch. The colon was, however, tolerably free. The intestines above this point were 
 distended, and below it contracted and empty. The ca?cum was of an enormous size, 
 almost filling the lower part of the abdomen. It was here that the tension had been 
 experienced ; it was black and in places the peritoneal coat was fissured, leading to the 
 belief that but little extra distension could have been borne without a rupture taking 
 place. The mucous membrane was also lacerated transversely, while the walls were so 
 thin that they were nearly ruptured in handling, these conditions being such as we com- 
 monly meet with in cases of chronic intestinal obstruction. 
 
 In this interesting case death had doubtless been caused by peritonitis, although not 
 from the strangulation of the umbilical hernia, but from a partially-ruptured and over- 
 distended cjvcum — a condition of bowel which had clearly been produced by the traction 
 exerted upon the transverse colon, the result of the adhesion of its walls to the omental sac. 
 
 As elucidating a secondary result of hernia this case must be regarded as most valu- 
 able, illustrating, as it does, a point not perhaps sufficiently recognized — namely, the influ- 
 ence of the adhesion of the bowel to a hernial sac or to the abdominal walls upon the 
 functions of the intestines, since, doubtless, such adhesions are sufficient to account for 
 many of the griping and painful symptoms which exist in an old and irreducible hernia, 
 as in other cases of abdominal trouble. The case referred to must also be regarded as a 
 good illustration of the result of a long-continued interference with the bowels action, 
 for the overdi,stension of the caecum, with its attendant consequences, was apparently due 
 entirely to the interference with its functions resulting from the union of the walls of the 
 transverse colon with the omental sac. The calibre of the colon itself was not materially 
 diminished, but its power of acting had become paralyzed ; the greater the distension of 
 the intestine above, the greater must have been the traction caused by the adhesion, and 
 as a sequel the greater was the effect of this interference. At last complete paralysis of 
 the part had taken place, and complete obstruction, giving rise to all the symptoms and 
 conditions which had terminated in death. 
 
 These cases tend to prove that the smallest traction of a portion of the calibre of the 
 intestine in hernia or elsewhere, although accompanied with an open passage of the 
 bowel, is quite sufficient to interfere with the bowel's action, and even to cau.se complete 
 obstruction. In a former page I have pointed out how strangulation of the bowel within 
 
532 
 
 ABDOMINAL HERNIA. 
 
 the abdomen may result from the formation of bands associated with an external 
 hernia. 
 
 Strangulated Hernia. 
 
 A rupture is said to be strangulated when, in addition to its solid contents being 
 irreducible, the venous circulation of the parts involved is more or less completely 
 arrested. 
 
 This result may be brought about whenever a knuckle of intestine slips through an 
 opening in the abdominal walls (external hernia) or is constricted from any cause within 
 the abdominal cavity (internal hernia) by air or motion entering the upper extremity of 
 the knuckle, and distending it so as to compress its lower end against the neck of the 
 constricting orifice through which it may have passed (Fig. 306). The greater the pres- 
 
 FiG. 305. 
 
 Fig. 306. 
 
 Distemlccl & 
 con rie sled te»^^ ^ / 
 
 necTt ojf sa c 
 
 An I'nstransrulatefl Hernia. 
 
 A Straiisulate.l Hernia. 
 
 sure from above, under these circumstances, the more the lower end of the bowel will be 
 compressed ; consequently, the more complete will be the obstruction, and the sooner 
 the compressed or strangulated bowel will lose its life, the part dying from static gan- 
 grene. 
 
 Strangulation may happen in the first descent of the rupture — recent hernia ; but 
 more commonly it takes place after a hernia has existed for man}- years — old hernia. An 
 analysis of cases that I made in 1856 {Guj/'s Rejiort.^) indicated that the average dura- 
 tion of an inguinal hernia previous to its becoming strangulated was twenty, and of a 
 femoral eleven, years. The same analysis likewise showed the most important practical 
 fact that when an inguinal hernia becomes strangulated in its first descent it is generally 
 of the " congenital," and not the " acquired," kind; also that femoral hernia was far more 
 liable than inguinal to strangulation, and to strangulation on its first descent, and that 
 umbilical hernia is less liable to strangulation than either of the two other forms, that it 
 is little liable to stxangulation in its first descent, and that when strangulated it is almost 
 always of very long standing. 
 
 A hernia strangulated on its first descent, whether of the inguinal or femoral form, 
 requires operation more frequently than the " old " hernia and is far more fatal, a stran- 
 gulated inguinal hernia of the " congenital '' kind being by far the most. 
 
 The SYMPTOMS of strangulated hernia are those of strangulated intestine from what- 
 ever causes, and they are due rather to the obstruction of the venous circulation of the 
 strangulated part than to the obstruction of the intestinal contents. In old inguinal 
 hernia of many years' standing they may be chronic; in recent hernia, and more particu- 
 larly of the femoral or congenital inguinal form, they are acute. 
 
 It thus often happens that in an acute or " recent " inguinal or femoral hernia its 
 descent is accompanied by severe abdominal pain in the region of the umbilicus, vomiting 
 first of the contents of the stomach, then of those of the duodenum (biliary vomiting), 
 and at a later stage of the yellow contents of the small intestine, and even of feces, and 
 later on by more or less collapse. Constipation is also usually present, although on the 
 first onset of the symptoms it is not uncommon for the large intestines to empty them- 
 selves. AVith these general symptoms of obstruction the local signs of hernia will be 
 present at one or other of the sites at which a hernia may occur; the hernial tumor will 
 be tense and painful and without impulse on the patient coughing. 
 
 The general symptoms thvis described are common to every form of acute intestinal 
 obstruction, whether outside the abdominal cavity from a hernia, or inside from internal 
 strangulation, ileus, or other cause. In every case in which they occur the practitioner 
 
I'ATIlOLiH.KAL r//.i.\v;AX 533 
 
 sliould (Mnf'ully cxainiiif the site of every jiossiMe lieniia and rint trust to the patient in 
 any way, as tlie K)eal are often inaskeil \>\ tlie severity of tlie f^eiieral symptoms, and the. 
 local eaiiso is thereby overlooki-d. 
 
 The svmittoins in an '• old hernia " are less acute and are more those of chronic 
 ohstruetion ; they arc not, however, less characteristic whrii vomltiiKj has sot In. In all 
 jirolialiilitv. h'dore this symptom appears, the patient will have complained of some gen- 
 eral altdoniinal uneasiness, such as flatulence, a feelinj; of faintness, nausea, and fulness, 
 with loeal pain in the hernia; the nausea, however, will soon be followed by persistent 
 eructations, hice(tu<j:h, and vomiting; in most of the cases constipation too will be present, 
 though in some the desire to go to stool will be great and the straining severe. The 
 local signs of strangulation or obstruction are often so slight as to be disregariled by the 
 ])atieut, and uidess the hernia is discovered by the surgeon his attention will probably 
 not be drawn to it by the sufferer. Thus, at Christmas, llSTO, I reduced a femoral hernia 
 by the taxis strangulated for a hundred hours in a man who was unconscious of its pres- 
 ence till a few hours before. 
 
 If the obstruction remain unrelieved, the powers of the patient will pmbaliiy become 
 prostrate and more or less complete collapse will show itself, with a feeble pulse and cold 
 clammy skin. The vomiting abso may diminish in intensity, or even cease, at times 
 remaining only as a passive pouring out through the mouth of the intestinal contents. 
 Pain previously severe may also suddenly disappear. The collapse, indeed, may be so 
 great that the parts about the neck of the sac will become rela.xed, and the hernia may 
 go up either by itself or by the gentlest ])ressure ; and such symptoms indicate a serious 
 collaj^se of the general power of the patient as well as a destruction of the parts strang- 
 ulated. Under these circumstances death juay be looked for, either from the shock to 
 the nervous system, gangrene or death of the strangulated bowel, rupture of the bowel 
 at the line of stricture, fecal extravasation, or peritonitis. 
 
 "When gangrene of the bowel is the cause of death, the collapse may be as 
 great as it is i'mm shock, althougli of greater duration. Death, however, is slower. 
 
 W^hen rupture of the bowel with fecal extravasation is followed by collapse, 
 it will have been preceded by .symptoms of local or general peritonitis or by a sudden 
 severe abdominal pain ; for in all cases of strangulated hernia in which any delay in 
 reduction has taken place symptoms of inflammation of the protruded parts, of local peri- 
 tonitis around the neck of the sac. and subsequently of general peritonitis, will be sure 
 to .show themselves. 
 
 Strangulated omental hernia is characterized by the same symptoms as the 
 intestinal, though less marked and acute. The pain is not so severe nor the vomiting so 
 constant, constiftation is less complete and insuperable, while the constitutional symptoms 
 are also milder. The local distress is likewise inconsiderable, the tumor feeling harder, 
 more nodular, and like to an obstructed hernia, permitting manipulation more freely than 
 when it contains intestine. As time progresses, however, symptoms of inflammation in 
 the hernial tumor will .show themselves with tho.se of local peritonitis ; and when these 
 appear, they are as severe and destructive as they are in other forms of strangulated 
 hernia. In exceptional cases, however, the omentum may slough. 
 
 A strangulated omental hernia requires, consequently, as active surgical treatment as 
 any other, as it leads to the same end — a fatal peritonitis. 
 
 Pathological Changes the Result of Strangulation. 
 
 These are the same when they take place within the abdominal cavity as in an exter- 
 nal hernia, and under both circumstances the first eff'ect of the partial arrest of the venous 
 circulation through the parts is congestion, this congestion being associated with its usual 
 accompaniment, serous effusion. When complete arrest has taken place, the congestion 
 will be more thorough, the surface of the bowel appearing of a red jiurple or blacki.sh 
 hue, and the tissues themselves thickened from efi"usion into their meshes or blackened, 
 wholly or in .spots, by extravasated blood (Fig. 307). When they have been much 
 manipulated by the taxis, the extravasation of blood into the tissues is often very 
 marked, the degree of congestion depending upon the completeness of the strangulation. 
 
 When the .strangulation has been acute or of long standing and an inflammatory 
 action been added to that of congestion, the bowel will be not only swollen, but soft, and 
 the natural glLstening aspect and elasticity of its coats will have become changed for a 
 dull appearance and leathery condition. Its serous surface may. indeed, be covered with 
 a layer or with flocculi of lymph, or the knuckle of intestine may be wholly or in part 
 
534 
 
 ABDOMIXAL IIKRMA. 
 
 soft and gangrenous, with asli-colured spots on its surface, and even perforations. When 
 the bowel dies from strangulation, the gangrene will be of the static kind. 
 
 At the neck of the sac other changes will also be found, and these depend materially 
 upon the character and seat of the constricting: force. Thus, when the line of a stran- 
 gulation is rigid and linear, as it is in direct inguinal and femoral hernia, the knuckle of 
 
 Fig. 3U7. 
 
 Extreme Venous Congestion and Interstitial Hemorrhage the Effects of Severe Strangulation of the Bowel. 
 
 (Drawing 4816. Birkett.) 
 
 Strangulated bowel, either as a whole or in part, may be rapidly destroyed by gangrene ; 
 and when the pressure is more diffused and less rapid, as in large inguinal hernia, ulcer- 
 ation of the mucous membrane at the line of stricture, even to perforation, is more com- 
 mon, the grooved or sulcated condition of the serous surface in the line of stricture being 
 found in both. 
 
 Within the abdomen every indication of peritonitis, from the mere greasy condition 
 of peritoneum to fibrinous, or even suppurative, effusion, may be met with. In most 
 cases local peritonitis will be found about the seat of hernia, and in some the peritonitis 
 will be general. The strangulated portion of bowel will almost always be found at the 
 neck of the sac, if not adherent to it. with more or less matting together of the neighbor- 
 ing coils. 
 
 That this peritonitis is to be directly attributed to the strangulation of the intestine 
 is generalh' acknowledged, few cases of strangulated hernia remaining long unrelieved 
 without local or general peritonitis making its appearance, the peritonitis commencing in 
 tlie bowel above the seat of strangulation. It is also indisputable that this peritonitis is 
 often aggravated and at times caused by the reduction of the inflamed and injured con- 
 tents of the hernial sac into the abdominal cavity, but to assert with som.e surgeons that 
 in the bulk of cases it is the return of the intestine into the abdomen that gives rise to 
 the peritonitis is an assumption which facts hitherto known do not bear out. 
 
 When the intestine has sloughed wholly or in part and discharged itself through the 
 wound, an artificial anus is said to exist : and this result is far more common after femoral 
 than inguinal hernia. 
 
 When the bowel subsequently ulcerates after its reduction, either at the line of stric- 
 ture, as it may in inguinal hernia, or at the centre of the knuckle, as is the more common 
 in femoral hernia, extravasation of feces may take place, half of the.se cases of extravasa- 
 tion being either general into the peritoneal cavity and fatal, or local and at the neck of 
 the sac. 
 
 The following facts, published by me in Gio/s Hasp. Rep.. 185G. on tlie causes of death 
 in hernia, will tend to prove these points. Out of 17 cases of artificial anus after hernia 
 13 followed femoral. 3 inguinal, and 1 umbilical. Out of 15 cases of gangrenous bowel 
 11 were femoral. 4 inguinal. Hence, out of ?j'l cases of gangrenous bowel. 24 were fem- 
 oral, 7 inguinal, and 1 umbilical, clearly proving that gangrene of the intestine and arti- 
 jicial anus are more common a ft rr femoral than iiigninaJ hernia. 
 
 Of 15 cases of hernia in which the strangulated bowel was found perforated 10 were 
 femoral and 5 inguinal ; in 4. all inguinal, the perforation was at the line of stricture ; in 
 
Ti:/:.iTMi:.\T or sTi:.\M;ri. \ri:h iii:i:si.\. 
 
 535 
 
 11 the |M'rri>r;itinn was in tin- (('iilic i.l" tin- knuckle. In licinii li'mnral. In S (jf these 15 
 cases extravasatiiin of feees was preventetl l»y inHainniatory exu<lati<iri sealing' the aper- 
 ture. Ill 7 it existed, hilt ill .') only of these was it jreiieral ; in tlie otlier '1 it was |(jeal. 
 or these 7 oases, in '1 the taxis was the direet cause, in 1 ;iaii;rreiie, hotli hein^ cases (jf 
 i'eiiuu'al hernia; in 4 iilei-ratioii at the line of stricture was the cause, all heiii^ inguinal. 
 
 Fmni f/i<'sr /'dcfs il in rrlilrnt " llint iilrrrntiini in the lliif of' si rirlnrf irit/i frrnl nrlrm-ii- 
 siifinii i\ iii'irr /hi/miif ill iiit/ninni than in fi'mond /ifinin, nm/ fhut irlun it in funnil in tlif 
 hitter it i.< t/meniff// from rn/tture of the hoirel from forcilile taris.^' 
 
 As a result of u strangulated horniu I iiiust mention a stricture of tlie intestine due 
 to contraction of the howel that had heeii straiifjulated. a uni<|iie example of which took 
 place in my ])ractice in 1S70 in a woman ict. ')'2 upon whom I had operated for stranjru- 
 lated fi'inoral hernia of thirty hojirs" duration witln»ut opening the sac. Convalescence 
 followed the operation, hut ahoiit the .seventh week vomiting appeared, and death tor^k 
 place ill the eleventh week, from intestinal obstruction. After death a complete .stricture 
 of a knuckle of howel was found ( V'tis. ;»I>S). 
 
 I'lfi. .308. 
 
 Disttnrltd Bmirl 
 ahoie St ri rill re 
 
 Colli rarteilBowd 
 below Stricture ^\;if 
 
 Strictuit.' of tlie Small Intestine after .^strangulated Hernia. 
 
 The fluid found in the hernial sac varie.s according to the condition of its 
 content.s. In the early period of strangulation, when the venou.s circulation through the 
 contents of the liernia is only partially arrested, simple serum will be found. When blood 
 stasis is more marked, the serum will be blood-stained. "When it is complete and blood 
 has been extravasated into the tissues, lilood elements or blood it.self will be found in the 
 sac. When the hernial contents are inflamed, flakes or flocculi of lymph will be found 
 floating in the dark fluid. When the bowel is gangrenous, the fluid in the sac will be 
 fetid. When perforation has taken place, feces, and often gas, will be mixed with the 
 fluid. When the hernial tumor is red. infiltrated, and emphysematous, the surgeon may 
 safely infer that sphacelus of the gut exists. 
 
 Thus, the condition of the fluid in and the external aspect of the sac are valuable aids 
 to diagnosis and prognosis in strangulated hernia. 
 
 Treatment of Strangulated Hernia. 
 
 When a hernia is strangulated, nothing but its immediate reduction should be enter- 
 tained, since by delay the venous circulation through the strangulated bowel honrfi/ 
 increases and the risks of static gangrene are rapidly increased. In the surgeon, indeed, 
 delay is criminal. This may be done by manipulation, or by what is technically called 
 '• the taxis," and. when this fails, by '• the operation" of herniotomy. 
 
 To aid the surgeon in the adoption ofthe.se means the u.se of an anaesthetic cannot be 
 too highly praised, containing as it does within it.self all the advantages of every other 
 form of treatment without a single disadvantage. It renders the reduction of a hernia by 
 the taxis a gentle and comparatively simple measure, and certainly a tar more successful 
 one than of old. It facilitates, also, the ojieration of herniotmny on the failure of the 
 taxis. In strangulated hernia the value of an am>?sthetic is so great that I would urge, 
 where it can be rendered available, that the taxis should never be employed without it, 
 and that on the reduction of the hernia failing to be accomplished " the operation" ought 
 to be performed. The warm bath, the administration of opium, the local application of 
 ice. are poor and unreliable remedies for strangulated hernia, since they encourage delay, 
 although in oliKtructed or inflamid hernia they are of use. 
 
 The taxis is not equally successful in every form of external strangulated hernia. In 
 
536 ABDOMINAL HERNIA. 
 
 inguinal cases two-thirds, at least, are reduced by the taxis, a large proportion of these 
 being successfully treated with the patient under the influence of an an;i2sthetic when the 
 taxis without an anaesthetic had previously failed. Strangulated old are also more suc- 
 cessfully treated by the taxis than recent hernite, and more particularly when the recent 
 cases are of the congenital form. 
 
 \n femoral hernia, on the contrary, the taxis is not half so successful as in inguinal, 
 and it is much more fatal. It is most successful in " recent," whilst in old cases it seldom 
 succeeds. 
 
 In umbilical hernia two-thirds of the cases are reducible by the taxis. 
 
 The Taxis. 
 
 With the patient under the influence of an anaesthetic and placed on the back, the 
 shoulders raised, and the legs partially flexed and rotated inward, in oi'der to relax all the 
 parts that can possibly aff"ect the neck of the sac, the surgeon should steadily grasp with 
 the fingers and thumb of one hand the neck of the sac, so as to fix it, and at the same 
 time prevent the contents of the sac, on being pressed, from bulging round the orifice. 
 With the other hand he should then raise the tumor, if large, and gently compress it, so 
 as to empty it of its serous, gaseous, fecal, or venous contents, and thus lessen its size. 
 Having done this, he should draw the tumor first to one side and then to the other, with 
 the view of opening the constricted lower end of the strangulated gut, to allow the con- 
 tents of the bowel to pass onward. ( Vide Fig. 30G.) He should remember that this ca)tnot 
 be efi"ected by any direct pressure upon the hernial tumor itself, but it maj/ be by lateral ; 
 for if the slightest movement of the lower or constricted end of the knuckle can be made 
 in the direction of the upper or distended one, the lower opening will probably be freed 
 and the reduction of the hernia efi'ected by its sndilen rush backward into the abdominal 
 cavity, when the surgeon may be assured that all is well. 
 
 When the tumor has diminished in size and its diminution has not been accompanied 
 by the well-known rushing sensation, a feeling of doubt should ever remain in the mind as 
 to the result, since the want of this symptom of proper reduction should suggest the 
 possibilit}' of a rupture of the bowel, or of a reduction into one or other of the unnatural 
 pouches which are now known to exist under certain circumstances at the neck of an 
 inguinal hernia. 
 
 To facilitate reduction Vi gentle kneading movement of the fingers at the neck of the 
 sac may be made in inguinal hernia, as well as a steady traction downward of the tumorj 
 this traction rendering the neck of the sac a straighter channel for the hernial contents 
 to pass through. With a similar object the sac itself may at times be pinched up with 
 the fingers of one hand and drawn downward. Violence in manipulation is unjustifiable 
 under all circumstances, and in proportion to the period of strangulation as indicated by 
 the vomiting, is the danger increased. In femoral hernia also it is comparatively much 
 more injurious than in inguinal, for not only may the bowel be ruptured by forcible 
 taxis — an accident more common in femoral than in inguinal hernia {GuyaKej}., 1856) — 
 but it may be so bruised as to be irreparably injured A preparation and drawing (Fig. 
 307) in Guy's Museum show such extravasation of blood into the strangulated bowel of 
 a femoral hernia as to cause its complete death, this being clearly due to a forcible taxis. 
 
 Where evidence exists that gangrene of the contents of the sac has taken place, or 
 where, indeed, there is a suspicion of such a result, the taxis must not be used. When 
 the hernia is inflamed or has been much manipulated, the same advice should be followed. 
 In recent or old femoral hernia, where fecal vomiting has existed for some hours, the 
 taxis is a dangerous practice, and in all old cases it is so unsuccessful that reduction by 
 herniotomy is a more certain and safe method. If there be hiccough, the taxis is inad- 
 missible. The taxis may succeed without an antesthetic, but with it a hernia that is 
 capable of being reduced by the taxis, as a rule, returns on the gentlest manipulation : 
 and when such a result does not follow, force will be not only unsuccessful, but injurious. 
 When the taxis succeeds, vomiting usually disappears, although it may be kept up to a 
 slight extent as an effect of the anesthetic. The abdominal dragging pain will, however, 
 be at once relieved. 
 
 Treatment after Reduction. — After the reduction of the hernia a sponge pad 
 should be carefully adjusted over the neck of the sac, to guard against its re-descent ; and 
 when the patient has a cough, the necessity of doing so is increased, as I have known 
 the hernia re-descend and a renewal of all the symptoms take place from a want of atten- 
 tion to this point ; indeed, it is wise to adapt a pad till a truss has been obtained. The 
 
THE TAX IS. 537 
 
 patient, iimliT nil (•ircunistiiiiccs, sIkuiIiI In- kept at n-st for a t'i'W days al'tiT the n-fliiction 
 of a .straii<:ulati'(l lu-riiia. Tlic diet, too, should l>c nutritious, Imt not sidid. //// llir hniriln 
 harr artnl si>i>iiftiiii(>iis/i/, and no aperiont iiniK-r any l)Ut cxoeptional circunistaiices sliould 
 bi' adniiiiistt'rcd. for the Ixiwtds will to a certainty act a.s soon as the effects of their 
 straiiLMilatioii iiavc jiassed away ainl they have recovered their natural tone. If, how- 
 ever, al>ilo:ninal symptoms a|ipear whicdi can he attriliuted to a want of the natural action 
 of the liowcl, an enema may he trivcn. and rejieated with advanta^re when rcfpiired. 
 Stimulants should l>e \ised with cijution. When the howi-ls have acted naturally, the 
 patient may be ])ronounced convalescent, and the onlinary diet, etc., allowed. 
 
 Where an aiiitsthetic is not at hand or cannot readily be obtained, a ;rood do.se of 
 opium, such as a <rrain and a half (»f the .solid or thirty drops of the tincture, may be 
 given to an adult and rejieated ; for when a patient with an old obstructe<l hernia is 
 brouirht fully under the influence of this dru<:. reduction may often be obtained by manipu- 
 lation. In the very earliest luuirs of strantrulation, before vomitin<r has become severe or 
 passed beyond stomach vomitin<r. this practice is also at times successful. It may be 
 tried, moreover, when the surgeon cannot obtain the patient's consent to perform herni- 
 otomy and reduction has not been effected by the taxis under an anjesthetic. or when 
 time has necessarily to be lost in making arrangements for o[ierative relief. Fntler the 
 same circumstances, a hot huth (!(!t° F. ) may be used. The local application of ice should 
 be employed in cases of ohi hernia where the symptoms are more those of obstruction 
 and delay is a necessity or expedient. In omental hernia also it is particularly valuable, 
 and should be applied over the whole tumor in a loose bag or as a metallic coil. A purga- 
 tive is never admissible with a strangulated hernia. 
 
 The taxis with inversion of the body, the legs flexed, pelvis raised, and 
 shoulders depressed, has been succes.sful in causing the reduction of a hernia, the 
 intestines, by their weight, drawing upon the incarcerated or .strangulated bowel and 
 helping reduction. On a bed it may be done by pillows placed below the pelvis ; but if 
 one of Alderman's chairs or a lithotomy couch is at hand, it may be used. Some sur- 
 geons, with the patient in the recumbent position and a folded sheet placed rouiTd the 
 abdomen over the umbilicus, have forcibly drawn the contents of the abdomen upward. 
 Both these methods are founded on the principle of withdrawing by position and force 
 the contents of the sac into the abdominal cavity. They are ^>ci.\-.s//^/// justifiable when 
 herniotomy is not sanctioned nor an auiosthetic employed and delay is dangerous. I 
 cannot recommend them. 
 
 The taxis should never be employed for any lengthened period. With the patient 
 under an anaesthetic, femoral hernia of average size (that of a walnut) should never be 
 manipulated for more than two minutes ; half that time or less is usually sufficient to 
 effect reduction where it is to be secured, while any more prolonged effort will be injuri- 
 ous. The taxis .should never be forcible. In large femoral, inguinal, or umbilical herniae 
 five minutes may possibly be allowed, but the (juarter and half lutur s manipulation so 
 frequently talked about is dangerous in the extreme. It is from this fact, coupled with 
 another — viz.. that without an anjcsthetic twice the force is needed — that the use of such 
 is to be recommended. 
 
 The reduction of a hernia bv 'jentJc taxis with a patient under an anjesthetic is a 
 simple, rapid, and successful operation. The reduction of hernia hy fore i/i/>' or prolonged 
 taxis without an anaesthetic is a dangerous and far less successful proceeding. In femoral 
 hernia, indeed, herniotomy had far better be employed. Under an anaesthetic the taxis 
 is almost always successful in inguinal hernia not of the congenital form. 
 
 When the taxis has failed, nothing but an immediate operation is ju.stifiable. The 
 operation is not of itself dangerous, although the condition that demands it is exceed- 
 ingly so. It is not, and should not be. regarded as a last resource, for in many cases it 
 should be the first. W'hen a patient is hanging, the first thing any one does is to cut 
 the rope that is causing strangulation ; and no other means are admissible. When a 
 piece of bowel is strangulated, the strangulating medium refjuires division to give it 
 freedom, the doing of it adding nothing to the danger of the case. The danger lies in 
 the strangulation, which increases every minute. 
 
 Herniotomy or Kelotomy 
 
 remains now to be described ; and let it be repeated f/uit it is to he performed (JlrcctJi/ the 
 redurtion of a strangulated hernia hy the taxis has failed, and, if an ansesthetic is used, 
 while the patient remains under its influence. To submit a patient to the depressing effects 
 
538 ABDOMINAL HERXTA. 
 
 of an anaesthetic to apply the taxis, and on its failing to allow any j)(_'ri(j(l (if time to pass 
 before re.sortins; to lierniotoniy. is a practice to be condemned. It would be better for the 
 patient, and far better practice, to delay the application of the taxi.s till an anaesthetic can 
 be obtained, and the arrangements for operation nnide in case the taxis fails. 
 
 The objects of the operation are to liberate the strangulated hernial contents, 
 and in a general way to return them into the abdominal cavity, exceptional cases occur- 
 ring in which it is better practice to leave them in the sac wholly or in part, and others 
 in which it is impossible to reduce them ; but to these points attention will be directed 
 farther on. 
 
 To Kberate the strangulated hernial contents, the cause of the strangu- 
 lation must be divided; and, as jireviously shown, this may be found either in the tissues 
 outside the sac, in the neck of the sac itself, or in the contents of the sac. 
 
 When the cau.se of constriction is found out.side the sac, as is usual in femoral hernia, 
 the opening of the sac is rarely needed, division outside being all that is required. 
 
 When the neck of the sac is the seat of obstruction and prevents reduction, an open- 
 ing into it sufficient to allow of its division is all that is necessary, as in large old inguinal 
 and umbilical hernia?. 
 
 When the difficulty lies in the contents of the sac, the surgeon will be recjuired to lay 
 the whole open and to expose it in order to its removal. But it should be remembered 
 that the less the contents of a hernia are exposed, and consequently manipulated, the 
 better are the results ; also, when all that is desired can be secured by the division of the 
 tissues outside the sac, there is no need of doing more ; and that when the division of 
 the neck of the sac allows of the reduction of the hernia, a greater exposure of the con- 
 tents of the sac is unnecessary and wrong, for in hernia, as in all surgical interference, 
 the surgeon should carry out his objects in the simplest way his art can allow, and fehould 
 never allow himself to do more than the absolute neces.sities of the case demand. ^leddle- 
 some surgery is always bad, but in hernia it is too often fatal. 
 
 These remarks, however, are only entirely applicable to cases of strangulated hernia 
 in which the whole contents of the sac are reducible, since, when some portion remains 
 behind, a feeling of doubt may at times remain as to the thoroughness of the reduction 
 of the strangulated portion or the condition of what is left, and under these circumstances it 
 is usually advisable that the sac be opened and explored ; yet it is better to do so after the 
 partial reduction of the hernia, when, in all probability, the strangulated bowel has been 
 reduced, and is consequently out of harm's way, than with the whole contents of the sac 
 in siffi and when they may be exposed. When the hernia cannot he reduced icithout opening 
 the sac, the whole must necessarily be explored. It will thus be seen that the question 
 of opening or not opening the sac resolves itself into the neces.sities of the individual 
 case. When reduction can be effected without it, the '• minor" operation is sufficient ; 
 where reduction cannot be effected b}- the ■• minor"' the major" operation must be per- 
 formed. 
 
 The surgeon who opens the sac in everf/ case clearly often does what is unnecessary. 
 He who opens it only when reduction cannot be effected without so doing, or when any 
 uncertainty exi.sts as to the condition of the parts contained in the sac, is free from such 
 an error ; " and although we dare not venture to say that some of the fatal eases which 
 have occurred after opening the sac might have terminated diffei'ently had it not been 
 incised, we do not hesitate to affirm that the untoward circumstances stated as likely to 
 happen when the sac is not opened have not occurred " (Birkett). This view is sup- 
 ported by my analysis of 126 fatal cases of hernia (Giif/'s Rep., 1856) — in which I 
 proved fairly that in no single fatal ease could the opening of the sac have had the 
 slightest influence in retarding or pi-eventing the fotal result — as well as by my own per- 
 sonal experience. The surgeon who advocates the major operation in most cases will try 
 the taxis, and, I take it. is always well pleased to effect the reduction of a hernia by such 
 means. The operation of herniotomy '• external to the hernial sac" differs only from the 
 taxis in the skin wound ; yet in what way the necessity for that wound renders the taxis 
 an unsafe measure it is difficult to conceive. It would be as reasonable to reject the- 
 administration of an anjosthetic for the renewed application of the taxis in eases where 
 the taxis had failed to reduce the hernia withoiit its aid as to say that because the taxis 
 had failed and a cutting operation is demanded, the ocular inspection and manipulation 
 of the strangulated, and therefore already injured, bowel is required. To argue that the 
 liberation of a strangulated bowel is not complete until it has been carefully examined, 
 and that, moreover, without opening the sac, a hernia that is strangulated by omental or 
 other adhesions or by the neck of the sac may be reduced, is to raise objections which, if 
 
lli:i:SI()TnMY oil KEI.ornMY 
 
 539 
 
 upplicuMc III all. all' as rnriiltlc airaiiist tlio taxis as any njn'ratiDii. ami an-. imlciMl. ol" 
 littli" \VL'i;(lit. 
 
 'riie i»itenitii)ii of lifriiiutniiiy witliiml ii|ii'iiinii tin' sac has hceii ahly a<lvo(;ateil by Petit, 
 who first ailiipti'il it in I 7 IS. I»y Miiiiii). in ITTH. Astuii Kry. in Is.'}.'), Jjiiki-. ami otliors. 
 
 Si) i'ar as statistics arc nt' value towanl the M)liitii)n of this matter, they are in I'avor 
 of not njteninji the sac. Thus, out of" .")!• caso of stran^rulateil femoral liernia o|»erate<l 
 upon at (luy's Hospital in eii^lit years in wiiicli the sac was <>i»n<'il. the mortality was 00 
 l)er cent., ami out of 4.") cases in which the sac was not opi inil, it was only 20 ]»er cent., 
 the ilifierence between the two classes of cases ljein<^ 20 per cent, in favor of the minor 
 oj)eration. 
 
 Out of!).") cases of inj^uinai liernia in which the sac nnx itjHucil. 00 per cent, dieil. ami 
 out of II in which the sac was not opened. 2. or only 22 per cent, died, the difi'erence 
 between the two classes in inguinal hernia bein<r 40 per cent, in favor of not opeitin'/. But 
 it must be remembered that as a rule the cases in which the sac was not opened were of 
 a more favorable kind than those in which it icna. 
 
 In umbilical hernia it is a rare thinti', however, to save a patient after openin;r the .sac 
 and exposinir its contciits, thnu</h when this is not dojie a good result may be looked for. 
 
 Whenever the taxis is applicable to a .strangulated hernia and fails, herniotomy 
 without opening the sac is applicaltle, and where reduction is effected nothing more is 
 needed. Where reduction cannot be efiected or a doubtful something remains in the sac, 
 where the contents of the .sac have not gone back with their normal rush or the symptoms 
 persist and any doubt al)out the condition of the parts at the neck of the sac is raised, an 
 exi)loration of the sac aii<l its neck is at>snlutely neces.sary. 
 
 Whenever the taxis iS inapplicable — that is, when the strangulation has been 
 of long duration, the symptoms severe, fecal vomiting persistent, and the local as well as 
 general symptoms indicate the probability that the sti'angulated gut has died or is dying; 
 whenever, moreover, during the application of the taxis, by the sudden collapse or yield 
 of the tumor without its reduction, the fear is excited of .some rupture of the bowel hav- 
 ing taken place, — herniotomy by the minor operation is inapplicable, and the sac must be 
 laid open. 
 
 Opekatikn. — The patient, having been brought under the influence of an anaesthetic, 
 should be placed with the shoulders slightly raised, the knees Hexed upon a pillow, the 
 integument over the .seat of hernia .sliaved of all hair and well washed ; an incisson should 
 then be made over the neck of the sac — that is, in inguinal hernia, along the line of the 
 inguinal canal, from the internal to below the external ring: in femoral, over or on the 
 inner side of the crural ring, either in a vertical direction or in the course of Poupart's 
 
 Fig. 309. 
 
 A B 
 
 VnAilkalf 
 Ring ^ 
 
 Eztenud 
 Riivq 
 
 Key's Director passed beueatlx the Seat of Stricture 
 of a' Strangulated Femoral Hernia outside the Sac 
 beneath the Fascia Propria. (Taken from his 
 work on Hi'inia.) 
 
 Obturator 
 
 Drawing to illustrate the Relative Position of all 
 the Abdominal Rings from within. 
 
 ligament, the former being preferable. In this incision all the soft parts should be cut 
 through consecutively down to the sac, each layer of tissue being divided the full extent 
 of the wound, while all vessels, as they bleed, should be twisted. 
 
540 
 
 ABDOMINAL HERN FA. 
 
 When the sac lias been exposed, the seat of stricture outside its neck must be felt for 
 with the index finger ; and when felt, a director may be carefully passed beneath it. 
 Aston Key's flat director, shown in Fig. 30[), a, being by far the best. 
 
 With a straight or curved hernia knife, such as that figured (Fig. 310), or with a 
 niotome (Fig. 310, B), the .stricture should then be divided, the incision upward being 
 
 Fig. 310. 
 
 Hernia Knife. 
 
 Ilerniotoiue Director. \, lihide withdiuwn. H, Blade expo.sod. 
 
 heriuoiome iny;. oiu, i>j, me .siricture snouiu men oe uiviuea, tne incision npic<ir<i being 
 
 the safest. This division must not 
 be too free, a quarter of an inch 
 being generally ample in a small 
 hernia. It should, under all cir- 
 cumstances, be only enough to al- 
 low of the return of the hernia 
 without force. It is better to have 
 to extend it than to make it too 
 large at first. The stricture hav- 
 ing been divided outside the sac, 
 reduction by the gentlest nianijiu- 
 lation can then be attempted ; and 
 when the contents of the sac go 
 back with a rush, all the surgeon needs has been effected. When no indications of 
 reduction show themselves or a portion of the contents of the sac has disappeared, but 
 not with the characteristic jerk, or some piece has been left behind, the sac must be 
 opened. To open the sac care is needed, the danger of carelessness consisting in wound- 
 ing the bowel. To avoid injury to the contents the sac may be nipjted between the 
 thumb and finger or seized with forceps, and, being slightly raised, opened with a scalpel 
 applied laterally. Through this opening a director should be passed, its point being kept 
 close to the inner surface of the sac toward its neck, and upon it the sac should be 
 divided with a bistoury. The escape of fluid usually indicates the opening of the sac, 
 and the character of the fluid the condition of its contents. But fluid does not always 
 run away when the sac is opened, and at other times the escape of fluid from a cyst on 
 the hernial tumor may mislead. The sac having been opened, its contents should be 
 examined; and in doing this the utmost gentleness must be employed. When a hnucMe 
 of intesfiiie is present and is neither gangrenous nor perforated, the abdominal cavity is 
 the best place. It may be black from congestion and spotted from eccliymosis ; it may 
 be granular from lymph, or even covered with fsdse membrane ; but as long as it pos- 
 sesses its living resiliency, is not fetid, flaccid like wet wa.sh-leather, ruptured, or perfor- 
 ated, it should be returned. 
 
 When a Icn'ge qiutntity of tnjiircd Intentinr is found in the sac, it had better be left, the 
 surgeon simply relieving the constriction by the division of the stricture. To do this a 
 director should be employed, and its point kept close to the inner surface of the sac and 
 away from the bowel ; it should not be introduced farther into the abdominal cavity than 
 is required to ensure the safe division of the stricture ; when the knife is passed along the 
 groove of the director, the finger of the operator should carefully press the strangulated 
 bowel away to protect it from injury. The finger, however, is the best director, and 
 should be introduced to the neck of the sac, with the knife upon it, having its side 
 pressed into the pulp of the soft parts. Both having thus reached the neck, the knife 
 may be carefully turned upward and the tissues divided, the point of the finger measur- 
 ing the extent of the incision. 
 
 When a herniotome such as that figured (Fig. 310, B) is used, no director need be 
 employed. 
 
 When the intestines are adherent to the sac or to one another by filamentous or soft 
 adhesions, these may be divided ; such are, however, only met with in recent hernia. The 
 fibrous adhesions of old hernijc had better be left alone and the hernia considered as irre- 
 ducible, the surgeon being satisfied, under these circumstances, with dividing the stricture 
 and thereby relieving the .strangulation, but not attempting the reduction of tlu; hernia. 
 If a fresh piece of bowel comes down, it should be reduced ; but the old hernia ought to 
 be left. 
 
 The strangulated intestine, under all circumstances, should be handled with extreme 
 delicacy. An?/ drawing down of the horoel to examine its condition should be avoided, 
 since such an act can do no good, but often does much harm in tearing away adhesions 
 that would have sealed an ulcerated orifice, prevented extravasation, and as.sisted rejiair. 
 Anj/ introduction if tiip fimjcr into the abdominal cavity save under exceptional conditions 
 is also to be condemned. With the careful return of the bowel within the neck of the 
 
UKHSInluMY nU Kl.l.nlnMY. 541 
 
 sac surgical interfcri'iice ought to c-«»a.sc. Tlie surgfoii may .satisfv liiinself that such an 
 eiul has hceu attained witliout probing the ahiloniinal cavity with his finger, and thus 
 risking life hy tearing away adhesions and undoing in a moment what nature by her own 
 processes had probably been attempting from the first pirriod of strangulation — namely, 
 to shut out from the general abdominal cavity what might prove injurious and dangerous 
 to life. 
 
 When the Iminl is t/,,ii/, as indicate(l liy its flaccitlity and a>hy color, all thought of 
 its reduction must be abandoned. The soft parts covering in the sac. with the sac it.self, 
 .should be freelv laitl open, so as to ex]>ose the whole sloughing mass, mul the intmllnf Ifj't 
 f'l iiiifiin . to ]»ass into what is called an " artificial anus. ' The neck of the sac may be 
 carefully divided — not, however, with the view of relieving the strangulation, for the gut, 
 having lu'conu- gangrenous, is no longer strangulated, but with a view of allowing the 
 intestinal oiuitents to escape when an external opening takes place, and should life be 
 spared, and likewise for the subsei|ueMt retraction of tlif bowel toward the abdominal 
 cavity, to efl'ect a natural cure. 
 
 No free incision into the gangrenous bowel, no stitching of the intestine to the mar- 
 gin of the wound, is required, as feces will soon find their way through the opening that 
 has been made by the artificial anus, and the surgeon may be certain that within the 
 abdomen sufficient repair has gone on to fix the intestine that had been strangulated to 
 the neck of the sac and thus prevent its immediate retraction ; for it must be remembered 
 that as time goes on this retracting process is precisely that which nature adopts to pro- 
 cure a spotitaneous cure of an artificial anus. 
 
 Within recent times a gangrenous knuckle of bowel lias been resected (vide Revue de 
 Chiniiyii. May 10, 1888). and with success. When this operation is performed, the 
 bowel above and below the constricte<l portion will have to he drawn down, resected, and 
 stitched together as illustrated in Fig. jJSrJ, or the two ends of the resected bowel may be 
 retained at the neck of the sac by sutures or forceps. 
 
 When the hoicel is jwrforatnl hy ulceration or ruptured^ and the <jpeniiig is not large, 
 the neck of the sac must be incised, as in an ordinary case, and the intestine that appears 
 reparable replaced, the perforated or ruptured portion being left at the mouth of the .sac. 
 When the rupture or perforation is small, there is no objection to the surgeon suturing 
 the wound and replacing the gut within the orifice of the sac, for plastic lymph will prob- 
 ably be poured out within a few hours and the parts become sealed from the abdominal cavity. 
 
 When the hoivd is in a dimhtfnl condition, and the surgeon is ntjt certain whether he 
 can .say it is irreparably dead or going to die, the abdominal cavity is still its best jilace, 
 when it can be returned. Aston Key advocated this plan many years ago. and modern 
 experience has not disproved its value. '' The danger of abdominal extravasation will 
 not be increased by replacing the injured bowel within the neck of the sac ; for should 
 sloughing of its coats ensue, the slough may be walled in by addition of the surrounding 
 peritoneum, and fecal extravasation be prevented"' (Key, fini/s Rep., 1842). 
 
 In an inquiry in 185() into the causes of death in hernia, founded on an analysis of 
 156 fatal cases, the same conclusion was arrived at. The weight of evidence led me then 
 to express the opinion that there is only one condition of intestine in which its reduction 
 within the neck of the sac is not advantageous, and that is when it is decidedly ruptured 
 by gangrene or ulceration, my own materials tending to support the opinion of Mr. A.ston 
 Key. as stated to the writer in 1840, ■•that in all conditions of the intestines the abdomen 
 was their right place." 
 
 Mr. Hutchinson, who believes peritonitis to be the direct result of the reduction of 
 an injured bowel into the abdominal cavity, advises in all cases that the damaged gut. if 
 fouiul in a bad condition, should be left in the sac ; while Mons. Girard goes further, 
 advising the contents of the hernia, under all circum-stances, to be left, the surgeon con- 
 tenting himself by freely dividing the stricture. I cannot concur in this practice, nor 
 with the principle on which it is based. 
 
 When the contents cannot be returned, on account of adhesions, the neck of the sac 
 should be incised and the case left to nature. In large umbilical herniae, also, this prac- 
 tice is valuable. 
 
 When omentum is found in the sac with intestine and has only recently descended, it may 
 be returned. When it has been down for some time, is irreducible, and is only a small 
 piece, it .should be left alone, the omentum, doubtless, often acting as a plug to the orifice 
 of the sac. When it is diseased or in large quantities, it should be ligatured in two or 
 more portions and cut off. the ligatures being applied as near to the neck of the sac as 
 possible, care being observed not to disturb the parts at the neck. 
 
542 ABDOMINAL HERNIA. 
 
 Simply to cut off the omentum and to tie o^- twist the vessels is risky, the omentum 
 always being highly vascular and small vessels being apt to bleed much ; indeed, cases 
 are on record in which a fatal hemorrhage supervened after this practice. When diseased 
 omentum is left in the sac, prolonged suppuration often follows. Whenever intestine and 
 omentum are found together in a hernia, much care is required. The intestine is gener- 
 ally to be sought for behind the omentum, but is often wrapped up in it, and in not a few 
 cases covered by an omental sac. Under all these circumstances, the intestine should be 
 exposed and carefully reduced, care being taken that no adhesions at the neck of the sac 
 or no bands bind the bowel down to the omentum, thereby keeping up the strangulation. 
 An omental sac is on no account to be returned into the abdomen unopened. Omental 
 sacs are generally found in femoral hernia. An interesting paper by Prescott Hewett 
 (^Med.-Glilr. Traiix., 1844) may be referred to on this subject. 
 
 It has been my practice, and that of most of the surgeons at Guy's Hospital during 
 the last three or four years, to dissect out the sac after the operation, stitch up its neck,, 
 and excise its fundus, this measure apparently but little, if at all, magnifying the opera- 
 tion, and being successful as a radical cure. 
 
 After-Treatment. — When a hernia has been returned into the abdominal cavity^ 
 the more the case is left to nature, the better. As a matter of precaution after the ope- 
 ration, as after its rediiction by the taxis, when the wound has 
 Fig. oil. been brovight together with strapping or suture, a pad may be 
 
 ^\ adjusted over the part with a spica bandage (Fig. 311). A 
 \ sponge is the best form of a pad. 
 
 A suppository of half a grain of morphia or more should 
 be at once introduced into the rectum, and repeated in an hour 
 should pain render it necessary ; a little ice, too, may be al- 
 lowed for the patient to suck when thirst is great ; but the less. 
 that is taken by the mouth, the better. When the powers are 
 very feeble, brandy, soda-water, and ice may be given in small 
 quantities. 
 
 If no anaesthetic sickness complicate the case after the first 
 twelve hours, beef tea, arrowroot, or milk may be given, a pint 
 or a pint and a half in the twenty-four hours being ample. Stim- 
 ulants should be allowed as the powers of the patient indicate, 
 but always with caution. 
 „ . ,, , On the second day the wound should be dressed, some sim- 
 
 pie dressing being all that is usually required, the lower end 
 of the wound being left open for the escape of fluid. Should pain continue and symp- 
 toms of peritonitis appear, opium should be given, or morphia suppositories twice a day 
 or more frequently ; indeed, the patient should be kept under the gentle influence of 
 opium till the symptoms are relieved ; hot fomentations should also be applied to the 
 abdomen. Purgatives ought never to be given if the bowel has been bruised or other- 
 wise injured by strangulation, for as soon as it has recovered its tone its natural action 
 will return, and any goading of it to action by medicine must do harm. "A bruised 
 bowel," says Aston Key (Grij/'s Rep., 1842), "is placed by nature in a state of rest; the 
 exhaustion of the nervous energy of the part diminishes in the muscular tissue the dis- 
 position to contract. Such inactivity of the Loicd sJtouId be encoiirae/ed^ and nejf thwarted 
 by irritating purgatives. The surgeon's anxiety to procure stools should yield to the 
 evident necessity for time being allowed for the restoration of the natural powers of the 
 injured bowel. 
 
 Three, five, ten, or even twenty, days may be allowed to pass without any action of 
 the bowels without anxiety or without purgatives, so long as no other indications of mis- 
 chief show themselves ; but during this time only liquid food is to be given, with stimu- 
 lants as may be required. When some local distress is present which the surgeon can 
 fairly attribute to the constipation, an enema of gruel and olive oil may be administered, 
 which may be repeated if necessary, such a simple intestinal stimulant being usually suf- 
 ficient to induce the bowel to act should it have recovered its tone. \\"hen the bowels 
 have acted naturally, convalescence may be declared and the usual diet allowed. 
 
 Any violent action of the bowels soon after the operation must be regarded with 
 anxiety, and in the aged it is too often followed by a fatal collapse. When too frequent, 
 it must be checked by opium. The patient should on no account be allowed to get up 
 and walk until he has been fitted with a good truss. 
 
 It occasionally happens that after the reduction of a hernia by operation the symp^ 
 
Disi >i.A( HI) iiijisL /•;. 543 
 
 tonis ol" straiiL'iilatinii persist ami the suiL^cnii is in flmilit as tu their eaiise. Moreover, 
 thi' liiiwel may ii<»t have jroiie ii|> at the time i»t' the o|ierati<m with the usual rush, (ir the 
 suriretin uiay have a thmht in liis miiul as t(i its ri^rlit re»lueti(iii. Ttnler these oircuiii- 
 stances. the woiiiul may at times re(|uire reitpeiiiuj; ami the parts at the neck of the sac 
 re-exi)hired. since the ease may he one of those " displaced heriii;u " to which attention is 
 now to he drawn. 
 
 As a rule, however, the persistency of the .symptom.s is due to tile ohstruction caused 
 by the injured Kowi-l or to the anaesthetic. 
 
 Multiple Hernia. 
 
 Wlu'U tiro or Diorr Itcniht exist with syin]itiinis of straii^rulation, the one that on care- 
 ful examination ajipears to be the most temler ouirlit first to be explored, and should this 
 operation not irive relief the second should be treated in a like manner: indeed, if no relief 
 be given by the second operation and a third hernia exi.st, it should also be explored, for 
 it canmit be too often repeated that the operati(»n is not one of danger when compared 
 with the necessity of the case that demands it. Dupuytren in his Liroiis Oralis has 
 recorded such a case. In the third part of my CUniail Snrycrij. p. 204, I liave likewise 
 recorded another in which Mr. Cock was the o[)erator. The patient was a man ajt. 7U ; 
 the left side was first explored, but, as the symptoms continued, the right was operated 
 upon twelve hours later. Both herniae were old inguinal ; in both the sac was opened, 
 and recovery took place. In the ca.se of a Jewess set. 30 I was called upon to .see. with 
 an umbilical and double femoral hernias, I operated on the right femoral for strangu- 
 lation, and a year later upon the umbilical, with success. 
 
 Displaced Hernia. 
 
 No eases demand closer attention than these. When understood and appreciated, 
 they may be successfully treated ; when misunderstood, they are sure to be overlooked. 
 Hence it may be accepte<l as a fact that a strangulated hernia with its sac may be bodily 
 reduced within the abdominal ring and behind the abdominal parietes, the intestine being 
 .still held by the neck of the sac (Fig. 300). This form was first described by the French 
 writers as reduction en bloc or en masse, and by ]Mr. Luke in this country (^Med.-CJu'r. 
 Trans., 1843). The majority of ca-ses reputed to be of this nature are, however, probably 
 caused by other lesions of the sac, and the credit of having made this out is due to 3Ir. 
 Birkett, in an able paper read before the Royal Med. and Chir. Society in 1859. He 
 describes three forms, though his observations apply only to inguinal hernia. 
 
 There are four varieties of displaced hernia, and in the inguinal they are mostly found 
 as Complications of the congenital form. 
 
 First Form. — In this the strangulated hernia with its sac ma}- be bodil}- reduced 
 within the abdominal ring and behind the abdominal parietes ; it is to a femoral hernia 
 that this accident is most prone to occur, but it may do so to an inguinal. It is the true 
 reduction en bloc or en masse of the French writers and of Luke. Such ca.ses are, how- 
 ever, rare. In November. 1871, I had this fact demonstrated to me in a case I was called 
 to see by Mr. Berry of Pentonville. It was in a lady aet. 04 who was said to have been 
 ruptured for years, and had worn a truss. AVhen I saw her, she had been vomiting for 
 a week and a tense femoral hernia existed. Under chloroform I cut down upon the sac 
 and divided the neck of the crural ring, and, on attemptnig reduction of the sacs contents 
 by gentle manipulation, to my surprise the sac with its contents suddenly disappeared 
 into the abdomen. By a little abdominal pressure it was made to reappear, and it did .so 
 in the same sudden way. A second attempt at the taxis was followed by the same result, 
 and renewed [U'essure upon the abdomen with a like reappearance. For the sake of fully 
 satisfying myself and my medical friends of the nature of the case. I reduced the hernia 
 en HHf.v.vf a third time, and then found some little difiiculty in securing its reappearance. 
 When I did so, I took hold of the sac with my forceps, carefully opened it. and exposed 
 the bowel without letting the .sac go; I then divided its neck by a herniotome and reduced 
 the bowel, keeping the sac well down. On the second day the bowels acted, but the 
 patient subsecjuently died of a low form of peritonitis. In this case the whole process 
 of reduction f-n mf(sse was demonstrated most clearly, and it compelled me to ask the 
 question whether the same result might not have taken place had I attempted its reduc- 
 tion by forcible taxis without operation, since the facility with which the sac passed up 
 within the crural ring was something startling. 
 
544 
 
 ABDOMINAL HERNIA. 
 
 In Prep. 2508^", (iuy's Hosp. Museum, this accident may be seen. It was taken 
 from a woman aet. 58, and my friend Mr. Henry Morris showed a specimen illustrating 
 this fact at the Pathological Society. (See Trans, for 1871.) 
 
 Second, or Charles Bell's, Form. — In the second form the neck of the sac 
 becomes detached by force from the internal abdominal ring and pushed upward beneath 
 the abdominal walls, the intestine within the sac being strangulated by the orifice of the 
 sac. This variety is illustrated by Fig. 297, and still better in Figs. 312 and 313, which 
 I have copied from page 48(J of the first volume of the Medical Gazette, published in 1828. 
 The case formed the subject of a lecture by Sir Charles (then Mr.) Bell. It occurred in 
 a man fet. 47 who had been the subject of a right scrotal hernia for twenty years. The 
 hernia had come down and become strangulated three days before he was seen, but had 
 been reduced, or rather made to disappear. The .symptoms, however, continued, and death 
 followed. During the last twenty-four hours of the patients life the hernia came down 
 repeatedly during the day, and was each time reduced with great facility. 
 
 After death the hernia was found to be in the scrotum, strangulated and mortified 
 (Fig. 312). On applying pressure to it " the intestine could very easily and effectually 
 be pushed through the external abdominal ring, so as to be hid from sight. On looking 
 to the inside, however, it was seen that the portion of gut had cai-ried the neck of the 
 sac before it into the abdominal cavity (B, Fig. 312), and the duplicature of peritoneum 
 which hung upon the inside of the neck of the sac, being unfolded, had formed a new 
 .sac for the intestine in the inside of the abdominal muscles. Thus, the fold of intestine 
 was pushed through the external ring, through the spermatic canal, and through that 
 part which is described to be an internal ring (but of which no trace could be seen), and 
 was reduced within the abdominal muscles, but not within the abdominal cavity," the 
 neck of the sac still grasping the included portion of gut (B, Fig. 313). The hernia was 
 also clearly of the congenital form, although it had not descended as far as the testicle. 
 
 The two drawings (Figs. 312 and 313) and descriptions are as originally given 
 by Sir C. Bell. 
 
 Fig. 312. 
 
 Drawings illustrating the .Second Varieties of Displaced Hernia. 
 
 Fl<i. :5I2. 
 A portion of the abdominal muscles, with the peritoneal lining. 
 Tlie strangulated fold of intestine. 
 
 The testicle. The dark lines at the neck of the .sac represent the duplicature of the peritoneum, which, being 
 unfolded, formed a sac for containing the intestine when reduced. 
 
 Fio. 31:^. 
 
 Peritoiit imi lining the abdominal parietes. 
 
 The tumor formed when the strangulated intestine was pushed through the spermatic canal into the sac formed 
 
 by peritoneum in tlie inside. 
 The superior portion of intestine. , 
 
 The inferior. 
 The scrotal hernial sac. 
 The testicle, with the vaginal coat opened. 
 
 This case I have described .somewhat fully, as I believe it to be the earliest on record 
 in which this accident has been clearly made out. 
 
 Third Form. — In this (Figs. 21)8 and 314), " as the effect of forcible and long- 
 sustained compression of the hernial tumor, the delicate serous membrane of the sac is 
 rent, burst, or torn, and the hernia makes its escape through the aperture into the sub- 
 serous connective tissue ; its course outside the peritoneal sac is advanced by continued 
 pressure, and, detaching the connections of the neighboring peritoneum, it forms for 
 itself a pouch between that serous membrane and the internal abdominal fascia " 
 (Birkett). The posterior part of the neck of an inguinal hernial sac is the usual seat 
 of the rupture, and the position of the artificial sac is downward and outward. The 
 '• congenital " form of hernial sac is also the more liable to the accident. ( Vide Fig. 314.) 
 
 The indications of the accident having taken place are as follows (I give them in 
 
niSl'I.ACKI) IIIJISI.K. 
 
 545 
 
 Hirkctt's \V(jrd.s) : "Tin' liiiiiur 1m'i(»iiic,> flaic'ul. iimi t lifn-loic smalltT ; tin- Ijulk of iIk; 
 tuniKi- slowly diuiiiii.slu's :is the |»rt'.ssiire is rDiilimicd, until at last vt-ry little, if anything, 
 can ))<.' t'l'lt. hut the .s;//v/<<(// Imx /'nllitl In I'l-^tfiinicr (hut sin/i/i n J>r/i so c/mrnrJt ristir u/ tlu 
 esca/n I,/' till- Itirnla IVnni the irripe iif the ninuth of the .sac as it enters the ahdoniinul 
 cavity. After the eflects of the chloroform have passed away "// tlf si/nij>h,nis u/ .sfnni'/ii. 
 Infill hnnil nciii\ and perhaps with increased force. Even the tumor itself may reappear 
 and recede on tlu' application of sliuht pressure.' 
 
 When this condition is found, there is hut one form of practice to follow, and that i.s 
 the exploration of the .sac. At its netHv two orifices will l)e found, oiu; dippin«; down into 
 the artificial .sac and the second into the ahdominal cavity ; from the latter the howel will he 
 seen to pa.ss through the former into the artificial sac. The surgeon must then draw out 
 the bowel from the .sac throuj::li its false orifice, and, havin<r freely divided the true neck 
 or ahdominal orifice of the sac, replace the intestine ; and '• the c.xerci.se of great care 
 and caution is needed to prevent the entrance of the hernia once more into the abnormal 
 space oi'tside the peritoneal cavity ' ( liirkett). 
 
 Tliird Variety, 
 luterstitial Hernia, witli ruptured neck of hernial sac. 
 
 Fourth Form. — In this an intermuscular, interstitial, or intra-jxirietaJ sac ha.s also 
 been described, bciu^- a kind of diverticulum from the inguinal sac, and is almost always 
 found, according to Eirkett, associated witb the congenital form of hernia. The sac may 
 be found in the anterior abdominal walls in an upward, outward, or inward direction, 
 mostly behind the abdominal muscles in front of the abdominal fascia, though in some 
 instances in front of the external oblique muscle beneath the skin. Birkett refers to a 
 case recorded by Scarpa, and to a second by Dr. Fano. 
 
 I saw an example of this in 1883 in a patient of Dr. Kershaw of Surbiton. The 
 patient was over sbcty and had been ruptured for years. A day or so before I saw him, 
 in attempting reduction, the hernia partially left the scrotum, and a swelling appeared 
 above the groin and steadily increased till it reached nearly to the umbilicus. The swell- 
 ing, when I saw it, was nearly the size of a cocoanut, soft, and resonant. It was clearl}- 
 bowel, and not strangulated. Ice was applied, and in the course of time it returned into 
 the scrotal sac and gave rise to no inconvenience. 
 
 In some cases the sac extends to the iliac fossa and rests upon the iliacus muscle, 
 between the internal abdominal fascia and peritoneum, or, directing itself inward, it passes 
 behind the horizontal ramus of the pubes and reaches the side and front of the urinary 
 bladder (Birkett). Fig. 299 illustrates this form of hernia, but Fig. 315 does so much 
 more clearly. It was taken from a preparation now in Guy's Museum, which was removed 
 from a man aet. 36 upon whom I operated on September 23, 18G9, for strangulated hernia. 
 The man had been ruptured for fifteen years and had worn a truss. The hernia had 
 descended two days before his admission into Ouy's, but the man had pushed it up by 
 manipulation after a little trouble, though it did not go up, as usual, with a rush. After 
 its reduction vomiting appeared and local pain, and in this condition he was admitted into 
 the hospital. 
 
 When I saw him, all the symptoms of strangulation were present. No hernia was 
 
 down, but there was some fulness at the internal ring, and above this, toward the crest 
 
 of the ilium, a tense globular swelling could be felt. This swelling I explored, and, 
 
 having laid open the inguinal canal, I exposed the empty hernial sac (D. Fig. 315), with 
 
 35 
 
646 
 
 ABDOMINAL HERNIA. 
 
 Fig 
 
 the testicle, showing that the hernia was of the congenital form. I then passed my finger 
 into the internal ring, and came against a knuckle of tense distended intestine. I enlarged 
 
 the opening, and this intestine, which was 
 of a dark color, but still glistening, at once 
 protruded. In following this up my finger 
 passed downward and outward into a dis- 
 tinct cavity, which was not the abdominal 
 cavity (C, Fig. 315), filled with bowel. It 
 was a distinct sac with a smooth surface 
 and about the size of an egg. At its upper 
 surface it communicated with the hernial 
 sac, and above this with the abdominal 
 cavity. I then increased the orifice lead- 
 ing into the abdominal cavity, drew out the 
 
 Drawing illustrating the Fourth Variety or Intra-Parietal Strangulated bowel from the iutra-Darictal 
 A, PeritoneunfHnLg^hSo^i^al^ltcles (B). '^f , (^'^ ^^-i^^^^ ""'^ ^'"^"^'"f '\ "^'? '}'^ 
 
 c, intraparietai sac with strangulated bowel. abdomen. The sac was clearly placed be- 
 
 D, Scrotal hernial sac leading down to testicle (T). i„j.i-i. i- ii.i. ±\ -l. 
 
 E, Director passed from the congenital scrotal sac through low the internal ring and between the ab- 
 
 the internal ring. , ^ ,, • . ^ ^ dominal musclcs and peritoneum. The man 
 
 In the drawing the strangulated bowel has been introduced -,• ■• n • ..'^ to ^ ^ i- 
 
 to make the description clearer. died iroiu peritonitis On the lourth day, his 
 
 death allowing me to take the very excellent 
 
 preparation from which Fig. 315 has been taken. The case was clearly one belonging to 
 
 Mr. Birkett's third or my fourth form, an intra-parietal sac (Fig. 315, C) existing below 
 
 the internal ring. 
 
 The disappearance of the tumor without the characteristic jerk and the persistence of 
 the symptoms indicate all these forms. The treatment in all is the same as that described 
 in the third variety. 
 
 Prognosis. — As the danger of a strangulated hernia depends upon the amount of 
 damage the intestine has sustained by the strangulation, so the amount of damage 
 the bowel has received is to be measured by the intensity of the strangulation and 
 its duration. A tight, unyielding strangulation such as usually exists in a recent femoral 
 or in a congenital or direct inguinal hernia does more harm in a short period than a less 
 tight and more yielding constricting force, such as is met with in an old oblique inguinal 
 hernia, in a longer period, violent taxis adding materially to the danger of the case. 
 
 The existence of peritonitis before the reduction of the hernia is always an unfavor- 
 able sign, as it is not likely to be lessened by the introduction into the peritoneal cavity 
 of a portion of bowel already inflamed and altered in character. A hernia in an other- 
 wise healthy subject, that has not been strangulated for many hours, that has not been 
 injured by violent manipulation, and has been reduced by the " minor" operation, will 
 probably do well, whereas one that has been strangulated for days or been subjected to 
 violent taxis will probabl}'' do badly. 
 
 Where disease of the kidneys or of other viscera exists and in old people, the prog- 
 nosis is always unfavorable. 
 
 A case in which the intestine has been freely exposed is more unfavorable than one 
 in which no exposure has taken place, and any excessive manipulation of the hernial 
 contents always adds to the danger. 
 
 The reduction of a severely damaged intestine is more liable to be followed by a bad 
 result than where little injury exists, but a bowel only slightly injured in an aged or 
 unhealthy subject is always likely to do badly. 
 
 A hernia strangulated in its first descent requiring operation is always far more fatal 
 than an " old case." 
 
 In private practice, where herniae, as a rule, are discovered and treated early, good 
 success follows herniotomy ; but in hospital practice, where neglect and delay combined 
 have had their influence, treatment is very unsuccessful, nearly one-half the cases dying. 
 At Guy's Hospital the average period of strangulation for femoral hernia is seventy-six 
 hours ; of inguinal, fifty ; and half the cases that die after the operation do so within 
 forty-eight hours, the injury to the bowel being so great and the power of the patient so 
 reduced that any reaction after the reduction of the hernia is rendered impossible. 
 Under these circumstances, the worst that can be said for the operation is that it fails 
 to cure. 
 
L\(;ri.\AL ni:i:si.\. 547 
 
 Inguinal Hernia. 
 
 Inguinal hernia, oi' tlmi Inrm which imitriKh-.s tlinjii<:h the intornal or oxtcrnal 
 abihniiiiKil riiiLTS, iiiclu(h'S two-thirtls of all cusl-s of ht-niia and ahout half of all cases of 
 straiij^iilatril hrniia. Two out of three eases oi" straiijiiilated in;^uitial hertiiu are reduci- 
 ble by the taxis, the third re((uiriii<; operation. In hospital practice half of those operated 
 iijtoii die, operations in recent cases beitij; most fatal. 
 
 An inguinal hernia is called ohliijnc when it passes throuf:;h the internal ring and along 
 the iiiLniinal canal downward toward the scrotum ; dii-fct^ when it do(!S not pass through 
 the internal ring, but througli the external in a direct way. 
 
 The obli«|ne, from bi'ing anatomically jilaced external to tin; deep epigastric artery, i.s 
 called i.i-itiiKil (thllifur^ while tluMlircct, iVom being internal to the same vessel, is known 
 as tlu' lute null (/iri'ft. 
 
 When the obiicjue has not passed tlic external ring, it is known as a Itiilxmurclr ; when 
 the obli((ue or direct has passed into the scrotum, it is called a turolnl hrrnin or oscheocple. 
 
 In the iililitiiit' iii</in'iii(l the sac of the hernia may be the natural " vaginal process of 
 peritoneum " that was formed on the descent of the testicle in fuetal life and has not clo.sed 
 — /.<'., (/ cdiu/niifal !<<ic (Figs. 21(2, 2!>3, 29-4) — or an tiajidrcd ><<ic formed by the gradual 
 pouching of the parietal peritoneum through the ring (Fig. 29(5). 
 
 In the ifiirrf linjulndl the sac is alway.s of the acquired form. 
 
 This " vaginal tubular process of peritoneum " which communicates above at the inter- 
 nal abdominal ring with the peritoneal cavity, and V^elovv is in clo.se contact with and 
 adherent to the testicle, lies in front of the spermatic cord, and before birth, or soon a^'ter, 
 " it contracts near the head of the epididymis, its surftices adhere firmly at that spot, and 
 thus two cavities arc formed." The inferior one forms the permanent covering to the 
 testis, and is known as tlie tunica vaginalis propria testis. The superior canal, whci no 
 arrest of development takes place, subse(|uently contracts till the canal cea.ses to exist. 
 
 When an arrest of development occurs and the abdominal orifice of the tubular pro- 
 cess remains patent, a piece of ititestine may at any time descend. Wlien the v-liole leuijth 
 of the canal is open, the hernia will pass down at once into the scrotum to the testicle, 
 masking its presence ; and in this way the congenital hcrnid of Haller, the hrnia of 
 in/aiici/ of 3Ialgaigne, or the hernia into the vayinal process of peritoneum of Birkett, is 
 formed (Fig. 292). 
 
 When the closure of the canal takes place higher up — and such an event is possible 
 at any point from the testicle upward — the descent of the hernia will be limited, though 
 its nature is the same, the only difference being that in this condition the testicle will be 
 found below the hernial sac at a variable distance and separated from it. To this form 
 of rupture Birkett has given the name o^ hernia into the fnnindar ptortion of the vaginal 
 process (f the peritoneum (Fig. 293 or Fig. .313). 
 
 It should also be mentioned that it is not uncommon for this tubular vaginal process 
 to close at its abdominal orifice at the internal ring and yet remain more or less open as a 
 cavity below, and under these circumstances any sudden rupture or giving wai/ of the clos- 
 ing medium will be followed by the rapid formation of a hernia, the hernia being scrotal 
 wholly or in part, lying upon or separated from the testicle, according to the absence or 
 position of any point of closure. This form of hernia differs only in the sudden giving 
 way of the abdomimil orifice of the vaginal process from those last described, and is very 
 common in young adults. 
 
 For all those forms of hernia in which the sac is composed of the natural tubular 
 Vaginal process of peritoneum the term congenital form of hernia would probably be the 
 best, as indicating their nature, distinguishing them from the other form, rightfy called 
 the acijitired. 
 
 This congenital f(»rm of hernia is also frcijuently associated with some malposition of 
 the testicle, such as its non-descent or partial descent. 
 
 The uifaiitHe hernia of Hey or the enct/sted hernia of the tunica vaginalis of Sir A. 
 Cooper is an acquired hernia, the hernia gradualli/ pushing the tissues closing the orifice 
 of the vaginal ])rocess of peritoneum downward into the open canal, the protruded 
 parts, together with the sac, being contained in the tunica vaginalis testis, and the true 
 sac being within that which might have been the congenital (Fig. 295). 
 
 The liour-glass contraction ff a scrotal liernia is always found in the '' congenital form," 
 and is due, as described by Birkett, to the imperfect closure of the vaginal sheath above 
 the testicles, where union of its walls normally takes place. Prep. 23G8 in Guy's 
 Museum will explain these cases, also Fig. 294. 
 
548 jyGUIXAL HERNIA. 
 
 The acquired form of inguinal herniti, oblique and direct, i?- nhrnys dov: in its forma- 
 tion, the pushing downward of the parietal layer of peritoneum by the protruding viscera 
 being a gradual process, thus forming a marked contrast with the congenital form. In 
 the oblique it begins as a slight yielding at the internal ring, and in the direct at the 
 external, this yielding passing into a " pouching." till at last the pouch may reach, and 
 even fill, the scrotum. In the early stage this yielding may be scarcely perceptible, but 
 the patient it will give rise to a feeling of weakness, and often of pain, on any abdominal 
 muscular exertion being made. "When a" pouching'' — or. according to ^lalgaigne.a '-point- 
 ing " — of the hernia has. commenced, any act of cougliing or straining will make it visible. 
 
 "When the oblique hernia has filled the inguinal canal, it will appear as an ovoid swell- 
 ing above Poupart's ligament {vile Fig. 3U1) beneath the tendon of the external oblique 
 muscle. AVhen it has passed through the external ring, the long axis of the tumor, and 
 more particularly its neck, will still be in the inguinal canal above and parallel with Pou- 
 part's ligament : but, having escaped from beneath the external oblique muscle, it will 
 appear as a pyriform scrotal tumor of variable size. The testicle will always be found 
 below and distinct from the sac. the cord being behind the tumor. 
 
 In the direct inguinal form in which the pouching of the hernial sac is directly behind 
 the external ring (Fig. 302), there will be no inguinal neck such as exists in the oblique, 
 the hernia passing directly through the external ring down into the scrotum. This form 
 of hernia has thus a more globular shape than the oblique. 
 
 When the ohlique inguinal is reduced, the surgeon can pass his finger through the 
 external ring along the inguinal canal upward and outward into the internal ring, and 
 thus into the abdominal cavity, although in old herniie the two rings are brought closer 
 in apposition than in the more recent. In direct inguinal, the finger, having passed the 
 external ring, seems to enter at once into the abdominal cavity, the opening being 
 directly behind the external ring, and, with the finger passed through the neck, the 
 external border of the rectus muscle may be felt on the pubic bones. By these points the 
 diagnosis between the acquired oblique and the direct inguinal can be made out. 
 
 With respect to the points of difference between the •• congenital and ■• acquired 
 form of oblique inguinal hei*nia a few words are needed, and may be thus epitomized : 
 The •• congenital "' form is tht hernia of infancy and young adult life ; the " acquired. " 
 that of middle life and old age. A hernia that has formed >vddeidy and passed at ouce 
 into the scrotum is probably of the " congenital," whereas one that has been produced 
 slowly is more likely to be of the '-acquired." form. "When the hernial tumor envelops 
 the testicle and renders its detection impossible or difficult, the •• congenital form" is indi- 
 cated ; when the testicle is in its right place and distinct from the hernial sac, the 
 " acquired." 
 
 A hernia with a long tubular neck occupying the inguinal canal is probably of the 
 " congenital " kind, a short thick neck being more common in the " acquired." 
 
 The youth of the patient, the rapidity of its formation, and its close connection with 
 the testicle are the three chief points characteristic of the '• congenital "' form of hernia ; 
 the age of the patient, the slowness of its production, and its distinct separation from 
 the testicle, the three points indicative of the " acquired." 
 
 The dlngnosis of an inguinal hernia from other tumors is only difficult in exceptional 
 cases. No scrotal tumor beginning in the scrotum and developing upward can be a 
 hernia, for all hernise descend toward the scrotum. So. when a distinct separation exists 
 between the .scrotal tumor and the external ring, no difficulty in diagnosis ought to be 
 experienced. In this way ordinary hydroceles, haematoceles. and all diseases of the 
 testicle are excluded. 
 
 ^Yhen a hydrocele, however, passes through the external up to the internal ring — a 
 condition by no means uncommon in infancy and young adult life — when the vaginal 
 process of peritoneum is only closed at its abdominal orifice, some difficulty may be 
 experienced: but in the absence of all symptoms of hernia the translucency of the tumor 
 and the history of the case — viz.. that the swelling began below and travelled upward — 
 are sufficient to point out the nature of the affection. 
 
 Cone/enital hydroceles into the vaginal process are to be distinguished from congenital 
 hernia by their transparency, by the gradual filling of the sac. and by their vibration on 
 percussion : whereas a hernia is opaque, enters the sac rapidly, leaves it quickly, and 
 does not vibrate. 
 
 An encysted hydrocele of the cord appears as a tense, fluctuating, tran.sparent. irreduci- 
 ble tumor, and ought not to be confused with a bubonocele when no other symptoms of 
 hernia exist bevond the swellinjir. 
 
Tin: i:.\f>i':iL crin: of iii:i:si.\. 549 
 
 'I'lic wniiiiv f'ci'l of ii ritn'cni-ilc (ir varicdso sjic^niiatir veins, ami the fact tliat prc-suro 
 siiHicicnt to keep any licriiia in position with tlu; patient erect over the external ring 
 renders the varicose veins more marked, should prevent it being mistaken for a lierniu. 
 And if the surgeon wouhl only h">k for the tw(t testicles in every case of scrotal, or even 
 inguinal, swelling, he could not fall into the error of mistaking an undescended testicle 
 or one resting at the internal ring or iti the inguinal canal for a hernia or any other 
 disease. 
 
 When a hernia and iiydrneelo coi!xist, sonic dilhculty may he experienced in the diag- 
 nosis : l)ut. as ea(di atfection has its own symptoms, the diagnosis ought not to he very 
 dittieult. 
 
 Whenever a douht in diagnosis is felt ahout an inguinal tumor and symptoms of a 
 strangulated hernia are present, the golden rule in suri:ery should be observed, and the 
 doubtful tumor exphu'ed. 
 
 I had an interesting case (February, 1872) witli the Messrs. Toulmin of Clapton 
 illustrating this in a boy fct. 4 who had an acute hydrocele associated with a sudden 
 descent of a hernia into the vagina! process of the peritoneum of the cord. I tapped the 
 hydrocele and left the inguinal tumor, thinking it might be possibly a hydrocele of the 
 cord, as no .symptoms of strangulated bowel were present. These, however, soon 
 appeared ; and chloroform was given with a view of exploring the tumor, when, by 
 the taxis, the hernia was happily reduced, and the boy recovered. 
 
 InquinaJ hrrnia in very common in flic female child; indeed, under puberty, it is the 
 usual kind, and is always of the " congenital form,"' the bowel coming down into the open 
 canal of Xuck. It is found, however, at all periods of life, though as a direct hernia it 
 is only seen in the adult. The rupture may consist of the ovary and descend into the 
 labium. It can be recognized by the same symptoms as in the male, and should be 
 treated on the .same principles. A hydrocele of the cord may be mistaken for a hernia. 
 
 Tre.vt.ment. — A reducible inguinal hernia is to be kept up with a truss, whether in 
 the infant, child, or adult ; the truss, too, must be well fitting, exerting sufficient pressure 
 to keep the hernia in position, hit no more. In the adult the truss should always be 
 moulded upon a cast of the groin taken with the hernia reduced. Should the hernia 
 come down when the truss is on, it ought to be reduced and the truss reapplied. The 
 pressure of the pad in the oblique form should be over the internal., but in the direct over 
 the external., ring. In infants a complete cure is often obtainable by these means in a 
 year or so ; and if no descent or any other symptom of hernia shows itself for another 
 year, the truss may be left off. In cases of hernia occurring after infanc}" it is, however, 
 never safe to leave off a truss. When some malposition of the testis complicates a case 
 of the congenital form of hernia, care must be taken that the pad of the truss does not 
 press the testicle ; and when the testicle and hernia are both in the inguinal canal, the 
 only truss that can be tolerated is one made upon a cast of the parts after rest, as already 
 advised in page 530. 
 
 Irreducible, inflamed, obstructed, and strangulated inguinal herni;i3 are to be treated 
 on the principles already stated. 
 
 A strangulated direct inguinal hernia is, however, a far more serious affection than 
 the ohlique, the sharp unyielding edge of the ruptured tendon surrounding the neck of 
 the sac acting as rapidly upon the strangulated bowel as does the edge of Gimbernats 
 ligament in femoral hernia. 
 
 When a hernia cannot be kept up with a truss, the question of the operation for the 
 radical cure of the hernia may be' entertained. The operation has its dangers, and AVut- 
 zer, its early, and Wood, its present, advocate, admit that a truss is necessary subse- 
 quently throughout life. 
 
 The Radical Cure of a Hernia. 
 
 This has been the aim of surgeons from time immemorial, and were hernia only a 
 mechanical lesion due to a weakness of the walls through which it protrudes or of the 
 neck of the sac, some success would probably have attended the practice ; but, as a rup- 
 ture is more probably due to something more than this, it can hardly be expected that 
 any very good result should have been obtained. Gerdy, Wutzer, Rothmund, Wells, and 
 Davies have all tried to accomplish this by plugging the mouth of the sac with its invag- 
 inated fundus, Gerdy fixing the invaginated fundus by means of two sutures ; Wutzer, 
 by means of a cylindrical wooden plug passed into the inguinal canal in the hollow of 
 the invaginated structures up to its neck, and a grooved wooden pad being applied 
 
550 
 
 INGUINAL HERNIA. 
 
 externally over the first to hold the parts in position, the two wooden instruments 
 being held together by a needle (which is enclosed in the cylindrical part and made to 
 pass through the internal ring and external tissues) and a screw ; the plug should be 
 retained for six or seven days, llothmund, Wells, Davies, and others have only improved 
 upon Wutzer's method. Mr. Birkett, however, tells us, on the authority of Dr. Otto Weber 
 of Bonn, the late clinical assistant to Wutzer, that Wutzer is stiil of opinion that his opera- 
 tion is not dangerous when properly performed, and that by his method the fundus of the 
 invaginated sac may be made to adhere to its neck ; and, as a consequence of this, //' the 
 patient continue to wear a trims /or fi/e, a return of the hernia may he avoided. Dr. 0. 
 Weber, moreover, writes that he has never seen any of the so-called '' cured cases " rad- 
 ically cured ; that the plug of skin is by degrees entirely drawn out again ; that the 
 external and internal rings are not closed by the operation ; that an imperfect cure may 
 be effected by means of a partial closure by adhesion of the internal walls of the neck 
 of the sac and thickening of the surrounding tissues. In London practice it is also well 
 known that a fatal peritonitis has followed the attempt. With these facts before us 
 respecting Wutzer's operation, I cannot recommend it. 
 
 Mr. Wood of King's College, believing that Wutzer's principle of practice was as 
 wrong as his practice was unsuccessful, devised in 1863 an operation by which the 
 hernial sac, without the skin, is invaginated into the canal, and the hinder and inner 
 walls of the inguinal canal are drawn forward by means of sutures and fixed to the 
 anterior and outer walls. 
 
 The steps of the operation are co^^ducted as follows (they are taken from Druitt's 
 Vade Mecum as revised by Wood): 
 
 The patient being laid on his back with the shoulders well raised and the knees bent, 
 the pubes cleanly shaved, the rupture completely reduced, and chloroform administered, 
 an oblique incision about an inch long is made in the skin of the scrotum over the fundus 
 of the hernial sac. A small tenotomy knife is then carried flatwise under the uiargins of 
 the incision, so as to separate the skin from the deeper coverings of the sac to the extent 
 of about an inch, or rather more, all round. The forefinger is then passed into the wound 
 and the detached fascia and fundus of the sac invaginated into the canal. The finger then 
 feels for the lower border of the internal oblique muscle, lifting it forward to the surface. 
 By this means the outer edge of the conjoined tendon is felt to the inner side of the fin- 
 ger. A stout semi-circular needle mounted in a strong handle, with a point flattened 
 antero-posteriorly and with an eye in its point, is then carried carefully up to the point 
 of the finger along its inner side and made to transfix the con- 
 FiG. 316. joined tendon, and also the inner pillar of the external ring. 
 
 When the point is seen to raise the skin, the latter is drawn 
 over toward the median line and the needle made to pierce it 
 as far outward as possible. A piece of stout copper wire, sil- 
 vered, about two feet long, is then hooked into the eye of the 
 needle, drawn back with it into the scrotum, and then detached. 
 The finger is next placed behind the outer pillar of the ring 
 and made to raise that and Poupart's ligament as much as pos- 
 sible from the deeper structures. The needle is then passed 
 along the outer side of the finger and pushed through Pou- 
 part's ligament, a little below the deep hernial opening (inter- 
 nal ring). The point is then directed through the same skin 
 puncture before made, the olfher end of the wire hooked on to 
 it, drawn back into the scrotal puncture, as before, and then 
 detached. Next, the sac at the scrotal incision is pinched up 
 between the finger arid thumb and the cord slipped back from 
 it, as in taking up varicose veins. The needle is then passed 
 From Wood. across behind the sac. entering and emerging at the oppo.site 
 
 ends of the scrotal incision (Fig. 310). The end of the inner 
 wire is again hooked on and drawn back across the sac. Both ends of the wire are then 
 drawn down until the loop is near the surface of the groin above, and are twisted together 
 down into the incision and cut off' to a convenient length. Traction is then made upon 
 the loop. This invaginates the sac and scrotal fascia well up into the hernial canal. The 
 loop of wire is finally twisted down close into the upper ])uncture and bent down, to be 
 joined to the two ends in a bow or arch, under which is placed a stout pad of lint. The 
 whole is held steady by a spica bandage (Fig. 311). The wire is kept in from ten to 
 fourteen days, or even longer if the amount of consolidation is not satisfactory. Very 
 
77//; L'ADKWL ('I'lll-: OF IIIJIMA. 551 
 
 lillK' sii|i|piir;itiiiii usiiallv I'nllnw.s, lnit jil'tcr a lew days the jiarls can- 1)0 felt tliickciK-il by 
 udlu'sivc (Icposit. 'IMic wire bt'coiin's lnost'iicd hy iilcciatiuii in its track until it cuii be 
 uiitwisti'd ami withdrawn iipirnri/. In this (tjn'ratiitu tlio hernial canal is clusi-d al<Mi<; its 
 whole length, and an extended adherent snrlaee is obtained to resist future jiriitrusion. 
 
 After the operation, Wood says, a horseshoe pad should be worn i'or a lew months; 
 (I lid titt' truss is nut In hi tliroini nsiile ir/ii:ii //ir jm/it nf is iihoiif to hr siihlirtnl to rioleiU 
 sfniiiis or ti/tiuij. This is important to remember, thouLdi it tends mutdi to do away with 
 the value of tlie operation. 
 
 Modifications of the operation art; employed for infants, etc. 
 
 The o|)eration I have dt;scribed is a subcutaiieous one and i.s infrenious. It has, more- 
 over, its danLTors. Wood writes he has operated '.»?>' times with 4 deaths, and out of 107 
 cases in which the results were known in 4.S a failure followed and in .')!( a satisfactory 
 result was secured. Thus, in the most favorable lij-dit, there is one failure to one success 
 and risk to life. It is to be feared, liowever, that a lar<re number of the.se set-called .satis- 
 factory cures are only so when they leave the ojtcrator's hands, since Kinjr<hjii's Rrports 
 of the City of London Truss Society tell us that within ten years fifty persons who had 
 under<rone siune operation for the radical cure had, in conse<)uence of its failure. a])plied 
 for trusses : and this number is large, considering the surgeons who ])erform this ojteration 
 are not numerous nor the ca.ses abundant. 
 
 For my own part, I believe tlaat where a hernia can be kept up by a truss, and the 
 patient is likely to remain in a civilized country where trusses can be obtained, an opera- 
 tion for the I'adical cure is not called for. To risk the life of a patient on the theory of a 
 cure, when a truss, as a matter of safety, lias to be worn subsequent to the operation, is 
 both unfair and unsati.sfactory. 
 
 When a hernia is reducible and (;annot be ke])t in ])lace l)y a truss, when a patient is 
 going abroad where trusses are not to be obtained or only o])tained at too great a cost, the 
 operation for the radical cure may be undertaken. Indeed, under these circumstances, I 
 have performed Wood's as well as Wutzer's operation with good succes.s — that is, the 
 patients who previously could not keep up their hernia, on account of the great size of 
 the inguinal ring, were enabled to do so. 
 
 In the '-congenital form" of inguinal hernia there seems a better prospect of success 
 following the operation than in any other, and a better basis for the practice ; for, '• thus 
 allowing nature to guide our procedure, we must make it a rule to .select those cases in 
 which her efforts have failed, and by acting as her handmaid we may reasonably hope to 
 arrive at a successful result' (Birkett). 
 
 The corkscrew operation, known as that of Mr. Spanton of Hanley, is another subcu- 
 taneous operation of which I have had no experience. It .seems to have been successful 
 more particularly in children, and is worthy of an extended trial. 
 
 Mr. Spanton's object in his operation is to fill the canal itself with organized tissues 
 and at the same time to approximate its tendinous boundaries. The operation I describe 
 nearly in Mr. Spanton's own words: 
 
 The instruments required for the operation are a narrow-bladed knife for making the 
 scrotal incision, dressing forceps ar>d the screw instrument (or strephotome). shaped like 
 a corkscrew, with a wide spiral which tapers somewhat toward its base. The point is 
 flattened, but sharp, .so as to tran.sfix the tough tissues wnthout tearing, and the handle 
 consists of a movable bar, which it is sometimes convenient to leave in position, .so as 
 effectually to steady the instrument. In cases where it is intended to use a ligature by 
 means of a screw a glass rod perforated with two holes at each extremity will be required 
 for fa.stening the ends of the ligature. The patient should have an aperient and an ordi- 
 nary enema previous to the operation, and, if necessary, the pubes should be shaved. The 
 patient being anaisthetized, the operator, standing on the patient's left, makes an incision 
 large enough to admit the" forefinger through the skin of the scrotum over the fundus of 
 the hernial .sac. usually an inch and a half or two inches below the pubic sj)ine. The sac 
 •with the fascial tissues covering it is then separated from the skin by jiassing the knife 
 or handle freely around the internal surface of the wound, until a sufficient extent of it 
 has been separated to permit the finger easily to invaginate the sac into the hernial canal, 
 which is readily accomplished by pushing the .sac with the left forefinger up to the internal 
 ring. After carefully examining the condition of the parts within reach of his finger — 
 especially with regard to the ])osition of the blood vessels and the boundaries of the aper- 
 ture — the operator retains his forefinger in the inguinal canal, thereby protecting the 
 spenuatic cord, which lies below his finger, and at the same time closing the internal ring, 
 so as to prevent any protrusion of the bowel. Sometimes with a very patent ring it ia 
 
552 FEMORAL HERNIA. 
 
 nect'Hsary (or ;in nsHstant to place his finger externally on the groin to make perfectly 
 sure of this, especially if there is any cough or struggling. It is, however, wiser to wait 
 a few moments and to let the patient become (juiescent before proceeding further. Then, 
 holding the " strephotome" firmly in the right hand, the surgeon thrusts the point through 
 the skin of the groin at that part of the surface which corresponds to the outer pillar of 
 the internal ring, which is also pierced by the point, which now comes in contact with the 
 left forefinger. Having given the screw a turn, the point is made to pierce the invagin- 
 ated sac and pushed on through the internal pillar (conjoined tendon) as high up as can 
 be safely reached, the left forefinger carefully guarding the point of the instrument 
 throughout. Another turn is now made, causing the screw to pass through the invagin- 
 ated tissues and across the pillars of the external ring as many times as the length of the 
 canal and the nature of the case will permit. The left finger is gradually witlidrawn as 
 the point passes downward and outward through the opening in the scrotum, the spermatic 
 cord lying behind and slightly compressed by the gradual tightening of the hernial canal. 
 The point of the screw is then protected by a .small india-rubber ball, and the handle lies 
 flat on the outer surface of the abdomen. The scrotal wound is closed by a single wire 
 or hair suture. A pad and soft bandage are then applied over the whole. After a few 
 days — usually seven to ten — the parts become sufficiently consolidated, and the screw i.s 
 then removed without any difficulty and an oiled pad and bandage kept applied until the 
 parts are firm. 
 
 If a continuous ligature is preferred, the screw with a large eye at the point is passed 
 in the manner already described, then thi^eaded v.nth the ligature when the point appears 
 through the scrotal opening, and the screw is gradually withdrawn upAvard. the ligature 
 following its track and occupying its place. In order to keep the ligature tight, each end 
 is fastened to a glass rod, which lies on the groin until the parts are consolidated — ten to 
 fourteen days usually ; the ends are then cut off and the ligature remains. After the 
 operation a pad should be worn as a support and to give time for the parts to become 
 consolidated. 
 
 The most satisfactory cases are those of congenital herni;e in the young, and this ope- 
 ration is especially adapted for those in which the hernial aperture is large and the sac 
 bulky or where a congenital rupture is of old standing. The more tissue we can securely 
 invaginate, the better the result, as a rule ; and when the pillars are soft and lax, it is 
 easier to bring all the parts firmly together and to secure a firm, unyielding barrier. 
 Experience alone can teach which are the most suitable cases for each operation. Mr. 
 Spanton tells me that he has operated in over 60 cases and has had no death. 
 
 Within recent times an oj^eio operation, a method by dissection, has grown in favor, 
 and I for some years have employed it in preference to Wood's operation. It consists of 
 cutting down upon the sac, dissecting it out, tying its neck with carbolized gut or silk 
 sutures, excising the fundus of the sac, and stitching up the abdominal rings w'ith good 
 silk or wire .sutures. Where omentum is present I cut it off, after ap]»lyiiig a ligature to 
 its neck. In fact, as an operation for the radical cure of a hernia, I do what I and most 
 of my colleagues at Guy's have for years done after an operation of herniotomy with 
 good success. Wood tells me he has recently performed a like operation in about 53 
 cases with a good result. This open operation has been ably advocated by Banks, 
 Guenod of Basle, Annandale, Franks, and others. Banks employs silver sutures. 
 
 References. — Banks, Brit. Med. Journ., November 13, 1882; Annandale, Edln. Med. Jonrn.,\ol. 
 xxvi. ; GuENOD, Thcae de Bade, 1881 ; Franks, Med. Press, January, 1884. 
 
 Femoral Hernia. 
 
 This forms about one-tenth of the whole number of cases of hernia, and about forty 
 per cent, of all cases of strangulated hernia. It is also far more liable to become stran- 
 gulated than inguinal, and less likely to be reduced by the taxis. The taxis, moreover, 
 is more prone to produce injury. Thus, one out of three cases of strangulated femoral 
 hernia is reducible by the taxis, two being operated upon ; and of these, forty out of every 
 one hundred die, the operation after " recent hernia " being twice as fatal as it is after the 
 " old," a strangulated femoral hernia going on more rapidly to destruction than any other, 
 and a strangulated " recent " than an '• old " hernia. 
 
 Femoral hernia descends from the abdominal cavity through the crural ring iii.sidr the 
 femoral vessels. The free margin of Gimbernat's ligament bounds its inner side, and the 
 sac, which is always " acquired," pouches downward beru-ath ]\)upart's ligament and 
 emerges through the saphenous opening to the inner side of the falcilbrm process of the 
 
ii:m(h:m. iiinxfA. oo.'j 
 
 fascia lata. 'I'lii' lnTiiia fxpaiids laliiallv, n-stiiiL' ii|miii tliis la«cia. and as it •■iilar;.'-('S 
 turns upward dvci* INiu|tan s lii^anK'nl, tlicii in tlic ilir«'<-ti(iu dl" tlic cn-st ol" tlic ilium, very 
 rarolv sprcadinir downward. Its Iiiult diameter will lie transverse, and imt vertical. Tlie 
 neck of the hernia will always \'n\ onlsih the s|»ine of tin- piihes or the tendttii oftlu! lonj; 
 abductor, while an inj^uino-scrotul or laliial hernia will always he loutul insiJr those 
 points, 'riie deeji ejiij^astric artery and vein usually lie <uitside tlur neck of tlic sac and 
 are free IVoin harm in the operation, tlnui^di, when the obturator comes ofl" from the epi- 
 gastric and arches over the neck ol" tiic hernia to dip down on its inner si(h' toward the 
 obturator loramen, it niav be ilivided when a //w incision is made. 
 
 |{are cases of femoral hernia occur cxtcrinil to the femoral vessels, as related by 
 Partridirc (/'if/i. Sue., vol. i.j, as well as throuL'h (limbernat's litrament. or with a divi-r- 
 tieulum tlirouirh the cribriform or superlieial fascia. ( I'/V/r Hirkett.) 
 
 l)i.\(JN'(isis. — The points alreaily slated will enalde the stmleiit t<i distiuLMiish a femo- 
 ral from an intruinal hernia. 
 
 A /tstiiis (ihxccss dilates on couLrhinij; and disappears or diminishes on the patient lying 
 down, just as docs a hernia ; but it is usually placed beneath and outsich' instead of inside 
 the vessels. Tt is often accompanied also by spinal symptoms, and nu niMuipulation gives 
 the sign of fluctuation from above to below I'oupart's ligament. 
 
 ^4 ntrix of t]ie fcmnnd rein may also in a nicasuve simulate a hernia ; but wherea.s, in 
 a hernia, with the patient erect, pressure over the crural ring and vessels will prevent its 
 descent, in varix it will cause its enlargement. 
 
 ^4/1 iiiliirqcd iflinul ought not to be mistaken for a rupture, as the liistory of the ca.«e 
 and concomitant .symptoms generally mark its nature. 
 
 Cysts in the crural ring are doubtless difficult to diagno.se, although from their always 
 being in the same spot uiulcr all circumstaiu-i's. and from their not being influenced by 
 position, coughing, etc.. they are unlike hernia. When associated with a strangulated 
 hernia, they may complicate the case, but seldom lead to error. 
 
 Trkat.mknt. — Reducible hernia can be treated by a truss, the [lad pressing in the 
 hollow below and external to the spinous process of the pubcs. The radical cure has 
 been ])erf(>rnu'(l by Wood. Wells, and Davies, but it cannot be recommended. 
 
 Strangulated femoral hernia reciuircs the most prompt attention, for the parts 
 constricting the neck of the sac are so unyielding as to produce in a .short period an 
 amount of damage which is too often irreparable. Tn the application of the taxis the 
 utmost gentleness .should be employed, and the administration of an anaesthetic .should 
 always precede the attempt. Tn the reduction of an old femoral hernia the taxis rarelv 
 succeeds. 
 
 In reducing a femoral hernia by the taxis the surgeon should always remember tlie 
 position of the orifice of the sac. for when it has turned over Poupart's ligament, any 
 pressure on the tumor can only do harm. The tumor should be gently raised bv the fin- 
 gers and drawn slightly downward and to one side before pressure is applied, which must 
 be of the mildest kind. If the slightest disp<isition to yield be shown, the pressure may 
 be continued, because, when any of the contents of the sac are cTuptied. the probabilities 
 of the reduction of the whole are greatly enhanced. If no yielding be felt in the parts, 
 the taxis had better be given up and the operation performed. 
 
 In all operations for femoral hernia the reduction of the hernia without opening the 
 sac should be preferred, and in " recent " hernia this " minor " operati(m is generally suc- 
 cessful. The incision to expose the sac, consef|uently. should be a limited one. Ltike 
 suggested that '• a fold of integuments is to be pinched up and divided by transfixing it 
 with a narrow blade, so that the incision, when the skin it;! replaced, shall fall perjiendicu- 
 larly to the body, with its centre opposite to the depres.sion which indicates the seat of 
 strangulation." But this plan is, in a measure, dangerous, as I have seen Mr. Aston Key 
 with the point of his knife, in perforating the skin-fold, divide all the tis>ues outside the 
 sac, and even the sac itself, and I have known a less skilful surgeon open the bowel. 
 
 Mr. Gay advises '• an incision rather more than an inch long to be made near the inner 
 side of the neck of the tumor. The sujierficial fascia to be divided, and a director or 
 histouri cache introduced down to the neck of the tumor and through the crural ring by 
 the least amount of force, arul with the aid of a little gentle compression of the inner 
 side of the tumor by the finger, the point of the bistoury may be insinuated between the 
 sac and the pubic margin of the ring; the edge of the knife is then to be turned toward 
 the pubes, and by projecting the blade the seat of stricture in that direction may be eff"ec- 
 tively divided." When a director is used, or the finger, the ordinary hernia knife may 
 be applied in the same way. 
 
554 OBTURATOR HERNIA. 
 
 Nothing can be more satisfactory than tliis operation when reduction is effected by it, 
 and it should always be attempted. If" it fail and the sac has to be opened, no harm can 
 possibly have been caused by the proceeding, as the incision can readily be enlarged if 
 necessary, the sac opened, and its neck divided. Any modification of the incision, how- 
 ever, may be made. The essential point is that the incision should be of such a nature 
 as to allow the surgeon to reach with facility the neck of the tumor. In operating, the 
 surgeon must also remember the fascia propria or fascia that is external and superficial 
 to the sac, which will always appear as a well-defined sac on the division of the soft parts 
 that cover it, and that may be mistaken for the true sac. On its division a layer of fat 
 will often be found more or less lobulated, which is the subperitoneal fat, and beneath it 
 will be found the true peritoneal sac. In Gay's operation, as already described, when the 
 parts outside the fascia propria have been divided and the hernia cannot be reduced, there 
 is no objection to the surgeon dividing the neck of the sac upon a director ; and when 
 this fails, the sac mvist be fully opened. The flow of a stream of serum will probably 
 attend this step, and, as previously stated, the nature of the fluid will indicate the con- 
 dition of the parts within. When intestine is alone seen, the director may be carefully 
 introduced into the neck of the sac and the constricting orifice divided, the intestine being 
 then reduced with the gentlest pressure. When omentum covers the bowel, it should be 
 carefully raised and unravelled, and when an omental sac exists, it must be torn through 
 or carefully divided and dealt with as previously explained. The neck of the sac should 
 be divided outside the omentum. The less the parts at the neck of the sac are disturbed, 
 the better, no introduction of the finger beyond the neck of the sac -being necessary, and. 
 no passing of the director or hernia knife called for beyond the neck. When the neck 
 of the sac has been divided and the sac has subsequently to be opened to ensure the 
 reduction of its contents, it is seldom necessary to reintroduce the Vjistoury, the parts 
 yielding enough to the finger to allow of the replacement of the hernial contents ; for the 
 less the neck of the sac is divided, the better. The surgeon should always be careful 
 that the hernia is not reduced within the crural ring, together with the sac ; if so, the 
 sac must be brought down again, opened, and held in situ whilst its contents are returned. 
 The after-treatment of the case is to be based upon the principles which have been 
 already laid down. 
 
 Obturator Hernia, 
 
 or hernia through the foramen of that name, deserves a notice, as its successful treatment 
 can only follow its diagnosis. It is more common in females than in males, and is often 
 unattended by any external evidences of its existence. Birkett has collected twenty-five 
 examples of this affection, though in fourteen the hernia was not discovered till after 
 death. In three only was a successful operation performed — by Gbre in 1851, by 
 Bransby Cooper in 1853, and by Lorinson in 1857. Mr. Copper's case I had the good 
 fortune to see. 
 
 The sac of the hernia is always " acquired." It emerges in the thigh, beneath the 
 pectineus and between the abductor longus and femoral vessels. The hernia is conse- 
 quently on a lower level than the femoi'al and comes forward instead of downward. An 
 obturator hernia is not. however, always to be felt, and a diagnosis has consequently to be 
 made out of the general symptoms ; and of these pain in the course and distribution of the 
 ohturator verve is the most marked. It is not, however, always present. In several of the 
 recorded cases, during the development of the hernia the pain described as " spasmodic 
 contraction of the abdominal muscles " existed ; and this fact is explained by Birkett in 
 recalling the association there is between this nerve and the muscular filaments distributed 
 on the abdominal muscles, all being branches of the lumbar plexus. Birkett also observed 
 that movement of the hip-joint in the affected side excites or aggravates the pain, so does 
 deep local pressure and pelvic examination, either ^jer varjinam or rectum. In the follow- 
 ing case, however, which came under my care in 1875, none of these symptoms were 
 present, though a fixed pain in the left iliac fossa existed. Susan G , ost. 05, a mar- 
 ried woman, was admitted under my care into Guy's Hospital on the 2()th May, 1875. 
 She had enjoyed excellent health till 1871, when one morning, after considerable exertion, 
 she experienced great pain in the left side and was able to sit down only with difficulty. 
 The medical man who saw her said she had a hernia, but that it had gone up. Her health 
 after this remained indifferent, though she was able to go about till six months before her 
 admission, when she passed no motion for nine days and was very sick. Purgative 
 draughts, however, acted upon the bowels very freely, and she convalesced. She then 
 continued well until ten days before her admission. At that time no motion had passed 
 
oiiTiHAini; iu:i:\i.\. 
 
 555 
 
 fur ten (lavs; she had coiit iiiiiall V viiiiiitcil, luciknl very imlicaltliy. much i-muciuti>d and 
 vdhiwisli. was oAd and cdlhipscd, tlif altihiiiH'ii liciiii: Minifwhat distt-mh-d, with vi.^ihle 
 cciils (d' small iiiti'stinc and jn'ristalsis. Slu- alstj complaiiiiMl ul" dilbiM-d ahiluminal pain. 
 Nil L'rowth coiild 1)1' deti'ctt'il in the ivctiim. Opium wa.s atlmiMisitTcd and warm Joummi- 
 tatitins applieil t(» the ahddincn with ndiid", and al'tcr lour days tin; howids acted twice 
 .spimtancnusly ; antl sul)sci|ucntly she had repeated l()r)se evacuations. She left the liu.s- 
 jiital convalescent, thouirli much emaciated, on June 1.'), 1S7.'). nineteen days after her 
 admission. She was. however, readmitt«'d on Deceniher litl of the same year, huviri;^ 
 remained (juite well till December ','>, thouirh for the last three months she had heen in 
 much reduced circumstances. On December '.i .she was ajrain violently sick and had much 
 ])ain in the Ay' sii/r of the abdomen, which was increased on passin;z a motion. The 
 bowels were confined and the feces small. She had now a double femoral reducible rup- 
 ture. IL^r abdomen was natural, and a rectal examination showed nothing; abnormal. 
 She was placed under the influence of opium, when the sickness cea.sed and the bowels 
 acted, (^)n January (!. however, the symptoms returned. She was ajrain sick and liad 
 much pain in the left side of the abdomen, while the tenijjerature n»se to 101° F. From 
 that time she irradually sank. The bowels were ncjt ai^ain relieved ; the abdomen became 
 tvmpanitic and the vomitinii' cea.sed only a few days before death, which toi>k j)lace on 
 February 4. with incrt-asinij exhaustion. She had at no time anythin<r like obturator 
 pain, and, tliouuh all the regions of hernia were carefully exanuned, nothing was noticed 
 to suggest the disease 
 
 Antiipm/ III/ Dr. <i(>o(Ih<irt. — The )>ody was very emaciated ; there was no marked di.s- 
 tension of the abdomen : the peritoneum was injected all over. A little pu.s was smeared 
 over the coils in the neighborhood of the cjvcum, and in the pelvis two ounce.s of pus or 
 more had gravitated to the bottom of Douglas's pouch. No evident source of the pus 
 could be discovered, though it is probable that it arose from periontitis due to overdisten- 
 sion of the bowel. The small intestine was only moderately distended, but crammed with 
 pultaceous, yellow, fecal contents, and the coats were somewhat thickened. Following it 
 ilownwaRl, the distension continued till two feet from the c;vcum, where a piece of the 
 bowel passed through the left obturator foramen (Fig. 318). Below this the intestine 
 was very contracted. The aperture in the obturator foramen was not large, and the inte.s- 
 tine did not api)ear to be nipped in any way. A knuckle of bowel was in the sac, but 
 the pas.sage onward would not allow of the introduction of the little finger. The bowel 
 Avas intimately adherent to the sac throughout, so that on opening the latter the bowel was 
 wounded. The included bowel was grayish, but neither gangrenous nor inflamed. The 
 mesentery was somewhat thickened at its neck and within the bowel were some old ulcera- 
 tions, as judged from the amount of thickening of the edges of an ulcer found at the 
 neck of the hernia. The ulceration, however, w-as not within the neck, but rather on the 
 opposite unincluded surface of the intestine. The sac pushed the obturator nerve and 
 vessels well to the outer side and to its upper part, with the exception of one branch of 
 artery which ])assed to the thigh on the inner side. 
 
 The obturator muscle, which was in front of the sac. had to be scraped away to get 
 at it. The sac was of nodular shape and about two-thirds of an inch in diameter (Fig. 
 317). It caused no fulness externally on the thigh. This was looked for particularly, 
 because the protrusion was fir.st 
 discovered from the inside. In 
 addition to the hernia, another 
 coil of bowel (small intestine 
 considerably higher up) was ad- 
 herent by a strong band at the 
 hernial neck, and about this the 
 distended coils had twisted in a 
 peculiar and indescribable man- 
 ner ; yet no obstl-uction had re- 
 sulted therefrom, the distension 
 continuing both above and below 
 it. A slight femoral protrusion 
 also existed on both sides. On '^"'"''^ ""'"^ ^"f 
 the right side a little omentum obturator Hernia. 
 
 was adherent at the neck of the E.xternal Mew. internal vtew. 
 
 sac, and by its adhesion dragged down the pyloric orifice of the stomach and the textures 
 in the porial fissure. 
 
 Fig. 317. 
 
 Fig. 318. 
 
556 
 
 UMBILICAL HERNIA. 
 
 Death in this case was clearly due to chronic inte.-^tinal obstruction caused by the 
 adhesions of the bowel to the hernial sac. The only special symptom worthy of ntHice 
 was the fixed pain in the left side of the abdomen, above Poupart s ii<rament. 
 
 Treatment. — The taxis can hardly be expected to be a successful proceeding in 
 obturator hernia, the sac beins so low down in the thigh and so little under control. 
 Nevertheless, it .should be tried, with the adductors relaxed Vjy means of steady pressure 
 applied downward in the hollow of the thigh and inward between the adductors. 
 
 To explore the parts an incision should be made below Pouparts ligament and to the 
 inner side of the femoral vein, down to the pectineus muscle, which may then be divided. 
 If no sac appear and the obturator foramen covered by its muscle be reached, the fibres 
 of this muscle must then be separated and the obturator canal found ; for a .small hernia, 
 as proved by the case I have recorded, may be hidden completely by the muscle. When 
 a sac is felt, the parts constricting it must be divided by a knife and its content.** 
 reduced. The obturator nerve should, if possible, be avoided. 
 
 Umbilical Hernia. 
 
 This may be a congenital or an acquired affection, and is common in children from 
 want of closure of the umbilicus. It is far from rare in fat women and in others who have 
 had many children. It is also met with in men. forming five per cent, of all cases of 
 liernia and six per cent, of cases of strangulated hernia. 
 
 The Congenital Form. — Children are occasionally born with a hernial protrusion 
 of some of the abdominal viscera into the umbilical cord, the covering of the vi.scera 
 
 consisting of the thin translucent sheatli 
 Fig. 319. of the cord ; this deformity is probably 
 
 due to an arrest of development. Among 
 the few examples of this affection that I 
 have seen was one in which the liver pro- 
 jected, and in it the serous covering sub- 
 sequently granulated, contracted, and so 
 pressed the parts back into their normal 
 position that a recovery followed. Fig. 
 ol9 represents the case in the fifth month. 
 In the case of a male child one day fild 
 in which a hernia into the cord the size 
 of a small egg existed, and through the 
 thin walls of which the caecum with its 
 appendix was clearly visible, I pressed the 
 bowel back with my finger and thumb, 
 stitched up the cord at its umbilical ori- 
 fice with some deep sutures, and ligatured 
 the cord itself at the apex of the congenital translucent hernial sac ; and complete recov- 
 ery followed without any bad symptoms. The child was alive and well two years after 
 the operation. The case was brought to me on June 16, 1876, by an old dresser. Dr. 
 W. Cock of Peckham. The practice adopted in the case is that which I advise to be 
 followed. 
 
 The Acquired Form. — In the acquired form of hernia the sac is always formed, 
 in both the infant and tlie adult. Vjy the pushing forward of the p)arietal abdominal layer 
 of peritoneum. The jtarts covering it. Vjeing occasionally very thin, are only integument 
 and fascia, the internal abdominal fascia being over the true sac ; at times the tumor 
 attains a large size, and, as it generally increases (hAcnuard, the surgeon must look for 
 the neck of the sac at its upper part. These hernias at times assume odd .shapes. 
 
 Treatment. — When in an infant and reducible, a cure may with .some confidence be 
 promi.sed ; indeed, with the majority of cases in young life, an opening "in the navel will 
 contract if care be observed to fix with good strapping & flat elastic ring or pad covered 
 with leather over the part. A convex pad tends to keep the ring open. A belt or truss 
 in early life is a delusion, since it never keeps its place. In lieu of a pad. it is an excel- 
 lent plan to pinch up the integument over the hernia with the thumb and finger and then 
 to turn the folds sideways upon the umbilical opening, fixing it in its position by water- 
 proof strapping, the folded integument Vjy this method acting as a pad and assisting 
 recovery. 
 
 Messrs. Lee, Barwell. and Wood have suggested an operation for the closure of the 
 
 I'oiiit of 
 Attar lime /it of cord- 
 
 Congenital Umbilical Hernia. 
 
VMitii.K'M. in:n\f.i. r,r,7 
 
 uinl)ili»'al orifu-c : Init siifli a iiicasiiic caiiiiut Ik- r.MniniiMiKli'd. sinco to ri>k lifi- imm'ce.s- 
 sarily lor an aHi-ctioii tlial i> im>>tly i-iiralilc \>\ liiiic ami natural |iri)ee.s.st'H assisted liy art 
 is hardly justitiaMf. 
 
 Adult patii'iits with n-tliicililc vi-iiiral heniia should also wt-ar somk; incchaiiical appli- 
 ance, such as a riiij; truss; aiitl an irreducilili- rupture should he protected l»v a truss 
 luude upon a cast of the rujilure when at its smallest, after a day or so rest in hed. 
 
 When tlu'se tumors arc hir^e and irrcducihle, they trive rise to trouhlcsume ahdoiniiial 
 .symptoms. They supply, indeed, the hest examples seen of so-called olotructed hernia; 
 feces and Hat us enter the incarcerated intestine and remain immovable, eausinir naus(!a, 
 colicky pains, and constipation. Kest in the horizontal position, the local application of 
 euld, a udod inema to empty the lower liowel. and a ])urjr<' to clear out the upper, will 
 often, under these circumstances, pmve of ^ircat l)cnefit, and should he tried in all ea.se.s. 
 
 When symptoms of stran<:;ulatioii e.\i.>t, such measures, however, must not he thought 
 of. The taxis should then he emjdoyed, and with a patient under an aiuusthetic, as 
 a rule, it proves successful. In ajiplyini;- it to a larire tumor, where it is ]irohal»le a fresh 
 descent of intestine has taken place and the symptoms are due to its stran<rulation, the 
 surgeon should examiiu; the tumor carefully, to discover if oim part is more tense than 
 another, as then the taxis should ])e applied to the tense in preference to the other jjart. 
 On several oecasiiuis, by adopting this practice, I liave been able to reduce the strangu- 
 lated porti(Ui of the contents of a hernia with complete success. When vomiting, consti- 
 pation, local pain, and an absence of impulse in the tumor are persistent, the reduction or 
 freedom of the mass from strangulation by operation must be ent(;rtained. 
 
 When herniotomy is called for, it is a matter of immen.se imjtortance that no manipu- 
 hition of the contents of the .sac should take place, because, when the sac is opened and 
 the parts exposed, it is an exceptional occurrence for a cure to follow, no cases of hernia 
 under these circumstances being more fatal than the umbilical. When the .sac is not 
 opened, however, so as to expose its contents, or only opened at its neck to allow of the 
 division of the strangulating orifice, a good result may be expected. 
 
 In many cases in which I have adopted this practice a good result followed, the 
 oldest patient being seventy -four years of age, with strangulation of five days" standing. 
 
 In irreducible hernia of large size and of long standing, when reduction of the con- 
 tents of the sac, as a whole, cannot be expected, and there is no evidence of strangulation 
 within the sac by some of its contents, the surgeon should be satisfied with relievinsr the 
 strangulation by dividing the neck of the sac and leaving the case to nature. To explore the 
 whole sac and to expose the irreducible bowel to the air and manipulation are unnecessary as 
 Avell as fatal. 1 had a case in 1874 with Dr. Brockwell of Sydenham in which, in a lady, 
 an irreducible hernia of .seven years' standing became strangulated ; I simply divided the 
 neck of the sac and left the parts alone. After two days the whole contents of the sac 
 returned, and a rapid and complete recovery took place. I have followed this practice on 
 several occasions with a similar result. A double sac is found at times in umbilical 
 hernia. Some time ago I was called on to operate in such a case. The woman was aged 
 forty-four and had been ruptured for years, the hernia being irreducible. She came 
 under my care at Guy's with symptoms of two days' strangulation. The rupture was 
 clearly inflamed, the slightest manipulation causing intolerable jjain. Under chloroform 
 I cut down upon the tumor and found two distinct sacs, their orifices, which were placed 
 laterally, being .separated by a piece of dense fibre tissue. One contained a mass of 
 omentum ; the second, intestine, which was black from congestion and covered with 
 lymph. The orifices of the sacs were freely divided and their contents left, but the 
 patient died, and no examination after death was allowed. In another case I found 
 i^trangulated bowel in a small omental sac introduced into an irreducible hernia. 
 
 Ventral hernia is a term applied to any protrusion through the abdominal walls 
 not belonging to the usual forms. Most of these herniae are found in the linea alba 
 above the navel. One of the largest I ever saw was over the right iliac fossa and fol- 
 lowed a rupture of the abdominal muscles caused by a fall of twenty feet upon the 
 handle of a pump ; it was the size of a man's hand and strangulated. By the taxis I 
 reduced the mass, and by the use of ice locally and opium internally the man recovered. 
 He had, however, subsequently, to wear a pad to supjxut the part. 
 
 After the operation of ovariotomy a very large protrusion may take place if a good 
 belt be not worn. The same may arise after the weakening of the abdominal walls from 
 abscess. 
 
 When the hernia takes place below the xiphoid cartilage, is is called epigastrir, and 
 in the loins lumbar. Birkett quotes two such cases. In 1875 I saw an example of the 
 
558 HERNIA. 
 
 epigastric form with Mr. Treves of Margate in a lady aet. (IS who had at the same time 
 an irreducible umbilical hernia. .Symptom.* had existed for one hundred and eight hours 
 when I operated, and the bowel slipped back unseen on dividing the parts at the neck of 
 the sac. The patient, however, sank. 
 
 Perineal hernia descends in fr(3nt of the rectum and appears in the perinajum, 
 and is most common in women. When the hernia descends outside the vagina, along the 
 ramus of the ischium, it shows itself in the labium — lnhial ov piuhndal hernia ; and when 
 it appears in the vagina, vaginal hmila. 
 
 Vaginal and labial herniae may be mi.stakeu for the raucous cysts of those parts, but 
 the herni?e are reducible ; and when irreducible or strangulated, they give rise to symp- 
 toms indicative of these conditions. The cysts are only local affections and cause no 
 general symptoms. They are tense, elastic, globular tumors fixed in the tissues, and 
 have no neck pa.<sing upward into the pelvis. 
 
 Ischiatic hernia is a hernia through the sciatic notch, above or below the pyri- 
 formis muscle. The gluteus maximus muscle covers it in, but as the hernia enlarges it 
 may appear below the lower border of that muscle. Dr. F. C. Crosse in September, 1873 
 (^Dnblin Journal of Medical Science^, has recorded an interesting example of this kind in 
 a woman aet. 40. The tumor occupied the lower border of the right gluteal fold ; it was 
 the size of a foetal head, soft and pulpy to the touch, dull in parts, tympanitic in others, 
 and coughing gave an impulse to it. It was treated by a truss. When a rupture of this 
 sort becomes strangulated, an operation must be performed, the surgeon making such an 
 incision as will best expose the tumor and its neck. 
 
 Diaphragmatic hernia is met with as the result of an accident (traumatic)^ 
 and is generally fatal ; it has been alluded to under the heading of " Abdominal Injuries." 
 page 491. It may ahso be the result of some " congenital " defect or the pushing of the 
 abdominal viscera through a natural or other opening in the muscle (acquired form). It 
 rarely calls for surgical aid. 
 
 On Trusses. 
 
 A truss is an instrument employed for the purpose of preventing the descent or 
 enlargement of a hernia. It is composed of a pad, to be placed over the seat of the 
 hernial protrusion, and a spring or belt, to keep it in position. Any truss that will keep 
 up the hernia under all circumstances and does not cause pain or lasting discomfort is 
 probably beneficial. Every truss that fails to carry out this object should be condemned. 
 An instrument with a too feeble spring is a delusion and a snare, but one that is too 
 powerful may tend to do more eventual harm than present good by causing absorption 
 of the abdominal parietes, upon which it presses, and, as a consequence, enlargement of 
 the opening through which the hernia descends. For the same reason a pad that is 
 unduly convex is also to be condemned. 
 
 A pad. to be efficient and comfortable, should be moulded upon a cast of the part to 
 which it is to be applied, since no two groins are alike. When this is done, the most per- 
 fect and most comfortable truss is provided (Fig. 304). 
 
 Every subject of a hernia, young or old, male or female, .should wear a truss, and in 
 a good proportion of cases, particularly of the young, a cure may take place — that is, 
 the neck of the sac may close. But even after a cure or an apparent cure has taken 
 place it is well, for the sake of safety, to wear the instrument, as cases are far from 
 infrequent when a supposed cure has taken place, and after the lapse of years a sudden 
 descent has occurred, jeopardizing life. This is the more common in the congenital form 
 of hernia. 
 
 The truss should be Avorn all day, from the act of rising out of bed to that of retir- 
 ing, as its object is to prevent the descent of the hernia under any sudden act of 
 exertion, and with the truss off it is impossible to guarantee that any such may not be 
 made. Some patients habitually remove their trusses when they are sitting in their 
 drawing-room, but this practice is to be condemned, since I have more than once been 
 called upon to treat a strangulated hernia which came down during some unguarded act 
 under these circumstances ; and it is in these unguarded moments that the truss is cal- 
 culated to be of so much benefit. 
 
 When the truss is first applied, it will doubtless cause some inconvenience ; with the 
 moulded truss this is very slight. The use of plenty of starch or violet powder, the 
 bathing of the point of pressure with some spirit and water, and attention to keep it very 
 dry are excellent remedies for any little local source of discomfort. 
 
 The Pad. — This should be regulated according to the size of the hernial aperture, 
 
o.v TiiUssEs: 559 
 
 a small nponintr r('(|iiirin<; a small pad ami a larL'c; rtpeninp: :i larjro one. The pad shouM 
 always nvcrlap t'nr alioiit halt' an iiwli all round the hernial aperture, and in larfre lieriiiiu 
 for ludre. It should he adapted to the individual <rroin and he made flat or concave, 
 aocordini; to its anatomy. It should also he so adapted to its spriuL' as to keep its place 
 under all circumstanet-s. 
 
 In in<ruinal hernia it should, mon-over, he so fixed to the sprinjr as to t^xert a pressure 
 at rij^rht anjrles to the plane of the hernial aperture. Thus, in larj^'e jtendulous hellie.s the 
 pressure may he upward or inward and upward, hut in thin suhjects directly hackward. 
 In femoral rujiture the pressure should always he hackward, in order to close the crural 
 riiifr. Any truss that applies its pressure only in one direction must fail in it.s purpo.se in 
 a lar«;o nuniher of cases. It is, indeeil. in this curve of the spring or direction in which 
 the pressure of the pad is emjdoyed that the chief diflference in the great varietie.s of 
 trusses is found. 
 
 Some pads are rigidly attached to the spring that holds them in position, while others 
 are connected by means of movahle joints of different construction. Salmon and Ody's 
 well-known truss has a hall-and-socket joint, as has the excellent Champion truss of 
 America. 
 
 The spring of a truss is a matter of importance, although not so much as the pad 
 and the direction of the line of pres.sure. Its strength should be carefully regulated 
 according to the requirement.s of the individual case. It ought to be strong enough to 
 keep the pad in position and prevent the descent of the hernia under all circuni.stances, 
 but not so strong as to cause pain. The French spring consists of a coil like that of a 
 watch-spring, is always in action, and pres.ses inward. The German form is more rigid 
 and inelastic and holds the pad firmly in its place, thereby resisting the protrusion of the 
 hernia under any expulsive effort. The English makers employ a variety of springs. A 
 too rigid one. as the German, is not to be recommended, whilst the French is also objec- 
 tionable, its action being too severe and con.stant. 
 
 The best is that which holds the pad in position, keeps it there under all movements, 
 counteracts any expulsive action of the hernia, and causes little if any discf)n)fort. The 
 lighter it is. under these circumstances, the better and the closer it is adapted to the body, 
 the more comfort it affords. 
 
 The only truss that has no circular-body spring and is kept in position bv a band i.s 
 the Moc-main lever. The pressure is kept up by means of a thigh-strap attached to a 
 small spring-lever connected with the pad. Such a truss is doubtless comfortable, as its 
 action is not enough to produce inconvenience ; but it is not safe under mo.st circum- 
 stances. In old people, where the inguinal rings requii-e only a little support it may be 
 u.sed ; but in the middle-aged, when the hernia has a tendency to come down, it is a dan- 
 gerous and unreliable instrument. 
 
 In oblique inguinal hernia the pad of the truss should be placed orer the infernal 
 ring fin</ cuiuil. and not over the external ring, the object being to give support to the 
 weak internal ring : in direct inguinal, it is placed over the external ring. In 
 femoral hernia, when the crural arch is natural and not relaxed, a small pad may 
 be employed over the neck of the sac ; but when the arch is relaxed and movable, a 
 large pad so adjusted as to press upon the ligament itself is required. After the opera- 
 tion of herniotomy for crural hernia this f^ict is worthy of attention ; for when a free 
 division of Gimbernats ligament has been made, the neck of the sac is alwavs large and 
 the ligaments relaxed. 
 
 Varieties of Truss. — To give a description of every variety of truss is needless. 
 Egrf>( tnn^x is in all respects rigid, and keeps its place when once fitted. Cohss truss is very 
 good, is light, and has a thin metallic pad covered with leather and acted on by spiral rings. 
 When properly adapted, with a not too convex pad, it gives elastic pressure, but is not 
 so well calculated to retain a hernia under violent exertion as another truss with a more 
 solid pad. the elastic pad being apt to yield and allow the hernia to descend. This objec- 
 tion applies to all elastic pads, although air or water pads, in some cases, are very com- 
 fortable and valuable, particularly in the healthy aged subject. 
 
 Among the trusses with solid pads Wood's must be mentioned. Thev are made bv 
 Matthews, with flat pads, composed of wood, ivory, or vulcanite, an india-rubber water- 
 bag being occasionally applied to the surface of the pad. They are held in position by a 
 spring that encircles the body. The size of the pad varies with the nature of the hernia 
 and the size of the hernial aperture. For oblique inguinal hernia the pad is of an 
 obliquely curved horseshoe shape, the outer limb over Poupart's ligament being shorter 
 than the inner, and the spermatic cord and pubic spine lying in the cleft. The curve of 
 
560 HERNIA. 
 
 the horseshoe is placed over the inner hernial aperture. For direct inguinal or umbilical 
 hernia the pad is made the shape of an ovate ring, with a hole corresponding to the her- 
 nial opening in the centre. For femoral hernia the pad is egg shape. Newsom's truss 
 has a thin round wire spring and a hard pad, which is very comfortable when well adapted. 
 The truss of Dr. C. Edwards of Cheltenham is good, the pad being so arranged that it 
 may revolve as well as slide on the spring when required. Those of Salt of Birmingham 
 and of L'Estrange are also good instruments. Down, late Milikin, of St. Thomas's 
 street, S.E., makes also an excellent truss, with a pad which, being movable upon a ball- 
 and-socket joint is readily adapted to any case. 
 
 The Vjest truss, without doubt, is the one already alluded to. with a pad made upon a 
 cast of the groin of the individual requiring it. and fa.stened to a spring with adjustments 
 like those of the American Champion truss, as made for me by Messers. Krohne (page 530). 
 
 The Main Objects of a Truss. — Whatever truss is selected to be of use. it must 
 answer to a nicety tlie i>urpu.-e fi>r which it is required. The pad should be adapted to 
 the abdominal hernial orifice or to the hernial tumor itself, and not below it. The amount 
 of pressure applied to the pad ought to be carefully regulated, as well as its direction, 
 and enough employed to keep the pad in position under all circumstances without causing 
 pain, a slight force applied in the right direction being of more value than a greater mis- 
 directed. 
 
 The pad may be flat, concave, or .slightly convex, and made of a solid or elastic mate- 
 rial. A metal one with wash leather taking the shape of the parts is the best. Sand pads 
 covered are of value, as they can be moulded to fit more comfortably and accurately than 
 many others. For an irreducible hernia (not scrotal) the pad should always be framed 
 upon a cast of the hernial tumor, taken when at its smallest, after rest. No other pad 
 will keep its place. 
 
 To Test the Value of a Truss. — The patient should be made to cough and 
 strain, and. wlieu possible, to jump. He should be placed on the edge of a chair with 
 his legs apart, or made to stoop forward with his knees apart and his hands resting on 
 his knees, and then to cough, these positions tending more than any other to relax the 
 lower parts of the abdomen and to loosen the truss. When the hernia by the.se means 
 fails to descend or to excite in the patient a sensation of weakness in the region of one 
 of the abdominal rings, the truss is probably efficient. The patient should be taught, 
 under all circumstances, what the truss is expected to do. and be made to understand the 
 danger he will incur if it fail in its purpo.se; as well as the necessity of again seeking advice. 
 
 The surgeon, moreover, should always take upon himself the responsibility of seeing 
 that the truss fits, and not rest satisfied by sending his patient to buy a truss where he 
 likes and of what kind he likes ; he should also tell the maker what is wanted, and not 
 leave him to find it out. 
 
 To Measure for a Truss. — The following points should be noticed — viz., the 
 nature of the licniia. the size of tlie hernial aperture, the side, or if double. The circum- 
 ference of the pelvis should also be given one inch below the crest of the ilium, and the 
 girth of the body, commencing and ending at the hernial orifice, as well as the distance 
 from the hernial aperture to the iliac spine. The surgeon, moreover, should always indi- 
 cate to the maker the directions of the pressure required by the pad. and this should 
 always be made out, when the patient stands, by a digital examination. In pendulous 
 and fat subjects with inguinal hernia it may be upward, backward, and inward; in thin 
 subjects, simply backward. In femoral rupture the plane of the crural ring is horizontal 
 and may be closed by a backward pressure. No general rules can be laid down, though 
 this is a point upon which the whole value of the truss depends. 
 
 To estimate the force required to keep the hernia in- position is a difficult matter. 
 Up to the present time the only true test is that of trial. Mr. Wood has had an inge- 
 nious pressure-gauge made for the purpose, which may pos.sibly turn out of value (Brit. 
 Med. Joiirn.. October 12. 1871). Mr. Holthouse has "^likewise invented a skeleton truss 
 which promises to be of use for indicating the length and shape of the spring required 
 and the correct angle at which the pad should be fixed. 
 
 Extra Spare Truss. — Patients who are liable to employ at times great muscular 
 exertion .should have two trusses — one. for ordinary wear, with a sufficient press power to 
 keep the hernia in position ; and the second with an increase of power, which is to be put 
 on when occasion demands. They should also have extra bathing trus.^es. 
 
 When a Double Truss* is to be Used.— When any tendency exi.sts for a 
 double hernia, as indicated by a bulging of the opposite ring or a sense of weakness on 
 making exertion, a double truss should be worn ; indeed, in inguinal hernia. I believe 
 
MM.rnllMATlOSS. 
 
 5<;i 
 
 that a double truss should always W fuiployctl. It is at least as coinfortahle as a single 
 one, besides being an extra iinitectioii il' well adjusted; certainly it can do no hann. 
 
 BlKKKTT, HohiifK'n Sygf., vol. 11., M cm!., 1HS.'{; Mol.-Chir. TranM., 18'>9. — BkvanT, Gny'i* JieiimlR, 
 185(»; (.'tin. Sun/., part '.i, IKOl.— (."ooI'Kk's Suri/lnil Did., Htli ed.— (iAV, On Hnni'i, 184H.— I*. IIi:\v- 
 ETT, Mftl.-i'liir. 'J'idiis., 1S44. — IlrTclllXsoN, Loml. IIoxp. Hep., IWo. — J.x.MKS, 0;t Urrnln, 1K.V.». — 
 Aston Ki:y, On Ifirnia, IS.S.'i; (iiii/'s li'i,., 1S4'2. — KlN(il)oN, Mt<l.-('ltir. Tnuis., ISdJ. — LcKK, Mnl.- 
 Chir. VVdjis., vols. x.wl. and xxxi.— L.\ wiiK.NCi:, On liuplnrtK, IS:{.'), .')lli (•<!. -Sti;imii;ns, On Oli.-<liitrle/l 
 Hnnia, IX'l'J. — ScAKTA, Wisliart's cd., 1.S14. — Wakd, (Jn Slranyiduted Hernia, 18o4. — Wool), On Jiup- 
 ttire, 18(53. 
 
 Fig. 320. 
 
 CITAPTF/R XVT. 
 SURGERY OF TIIK ANTS AM) IlKCTrM. 
 
 Malformations. 
 
 The anus and rectum are not rarely the seat of congenital malformations, which show 
 themselves in a variety of forms. In one the anus is imperforate, the rectum being either 
 partially or wholly deticient ; in a second the anus exists in its normal condition, but opens 
 into a cu/-(h-s(u\ the rectum being partially or wholly deficient (Fig. 3llU) ; and in a f/iird 
 the anal orifice is absent, the rectum opening into the bladder, urethra, 
 vagina, or other abnormal position. And it will be observed, says Mr. 
 Curling, to whom wc are indebted for the bulk of our information on 
 this subject (Mrd.-Chir. Trans., vol. xliii.), that .the classification of 
 these im])erfections is founded on states that can generally be recog- 
 nized during life, although, unfortunately, the conditions of the ter- 
 minal portion of the intestinal canal and its relation to the parts 
 around cannot be predicated with any certainty, since in the first two 
 classes of cases of imperforate anus or of anus opening into a cnl-de- 
 snc the intestinal canal may terminate in a blind pouch at the brim 
 of the pelvis, the rectum being wholly wanting ; or, as in the third 
 class, an imperfect rectum ma}"^ form and show itself as a short sac 
 descending to the floor of the pelvis, or to the neck of the bladder ■^'t i iiiia r ') 
 in the male or the commencement of the vagina in the female. An ^^--!5S^ 
 explanation of these difterent conditions is to be found in the fact ^^"n'^/J,^, ^^^^a c«/wS 
 that these malformations are clearly due to some failure in the foetal above the .\nus. (Prep, 
 development and to the want of junction of the two ends of the rectal "" ' '"' * 
 tube. The anal portion of the bowel, which develops from below, grows uj)ward. while 
 the intestinal descends from above ; and these two parts subsequently advance and in a 
 natural condition unite, the membranous diaphragm at the point of their junction disaji- 
 pearing at a later period by interstitial aVjsorption. When a failure in this uniting pro- 
 cess takes place, the second class of congenital imperfection is formed ; when the failure 
 occurs at an early period of development the two ends of the approaching tubes will be 
 far distant, and when at a later period they may be in closer contact. The closure of the 
 anal orifice is due to a firm adhesion of the integument. 
 
 Sometimes the blind pouch in which the intestinal canal terminates is connected with 
 the anal integument or with the anal cul-de-sac by a cord prolonged from the bowel above, 
 and it seems po.ssible, from Curling's and MM. Goyrand and Friedberg's observations, that 
 such cases are caused by an obliteration of the bowel, which was originally w^ell formed, 
 from some intra-uterine inflammatory action, instances being on record where the mus- 
 cular tissue of the intestine was clearly traced into the cord. Where the upper bowel 
 communicates with the urinary or vaginal pas.sages, it is owing to the incomplete sepa- 
 ration of the natural cloaca that exists during the development of those parts. 
 
 A clear understanding of the way in which these deformities are caused will explain 
 the difiiculties that are met with in their treatment. 
 
 Treat.mext. — On the birth of every child the condition of the different outlets of the 
 body should invariablv be examined; and even when the anus appears normal, a digital 
 examination should be made on the second day if the bowels have failed to act, as many 
 an infant's life has been lost for the want of this attention and the consequent postpone^ 
 ment of surgical relief till too late a period. 
 36 
 
562 
 
 SURGERY OF THE ANUS AND RECTUM. 
 
 In the shnpleat cases, when the anus is closed by a tliin membrane and the bulging of 
 the distended rectum indicates its nature, a cautious central incision through the soft parts 
 should at once be made ; and a good result is generally obtained, the power of the anus 
 usually l)eing complete. Mr. 11. Harrison of Liverpool records the case of a child who 
 was born with an imperforate anus, and was successfully operated upon in the anal region 
 thirty-three days after birth {Lancet, February 26, 1876). 
 
 In the more complicated cases, where the anus is closed or absent and no Judging of the 
 hoicel exists, where the surgeon has no means of making out the true position of the ter- 
 minal end of the bowel, a cautious incision may be made over the .spot in which the anus 
 ought to be found, the finger of the left hand acting as a pilot. The incision may be free 
 as long as it is carried upward and backward toward the sacrum, and not forward toward 
 the urethra or vagina. It must not, however, be made too high. Where there is not suf- 
 ficient room to carry out this practice, the coccyx may be cut away. 
 
 When these means fail, all further attempts must be relinquished. Blindly to intro- 
 duce a knife or a trocar and canula upward with the vain hope of puncturing the distended 
 bowel is a practice to be unhesitatingly condemned. Mr. Curling's figures, too, prove that 
 the perineal exploratory operation, unless undertaken with great care, does more harm than 
 good, though when skilfully performed it is followed by considerable success. 
 
 In the treatment of the second class of cases, when the rectum terminates above in a cul- 
 de-sac, an exploratory operation may be made as just described ; but the uncertainty as to 
 the true position of the bowel rendei's any operative proceeding hazardous. When the 
 two tubes are in contact and separated only by their membranous ends, as in the case 
 illustrated (Fig. 320), a good result may be expected ; but when they are far apart, no 
 such success can be anticipated. j\Ir. Curling in his table gives 31 examples of this class 
 of cases. In 27 an attempt was made to reach the bowel, in 16 with success, while 10 
 of these subsequently recovered. 
 
 When the bowel is opened in any of these cases and is not far from the anus, the sur- 
 geon should use all fair endeavors to draw down the intestine to the margin of the external 
 opening and fasten it with sutures to the skin. He cannot often, however, succeed in 
 accomplishing this, the bowel being rarely found at a less distance than an inch from the 
 perinaium ; but when possible, the advantages of the practice are great. Where this can- 
 not be attained, repeated ^dilatation of the perforated bowel is absolutely essential to main- 
 tain its patency, as otherwise, like all artificial openings, its subsequent contraction will 
 take place. The introduction of a finger once or twice a week is sometimes sufficient for 
 this purpose, and in several cases I have had under care, where the tendency to contract 
 rapidly was marked, the introduction of a large sea-tangle tent answered admirably, the 
 tent being placed in water for a few minutes beforehand, to make it swell. 
 
 When the anus opens in an abnormal position, as in the vagina, and the anus made by 
 the surgeon is established, there is a natural tendency for the abnormal opening to close, 
 
 several cases being on record in which this result 
 ensued. Three have occurred in my own prac- 
 tice. When success has followed any operative 
 procedure in these cases, it is important that close 
 attention should be paid to the condition of the 
 bowel for many years, and, indeed, for the whole 
 of life, because there seems reason to believe that 
 the bowel which forms the upper cid-de-sac has 
 but little muscular power and is liable to dilate 
 under fecal collection, as well as to become para- 
 lyzed, death, under these circumstances, taking 
 place from obstruction. In Fig. 321 this fact is 
 
 illustrated. It was taken from William L , aet. 
 
 26, who had been operated upon as an inftmt for an 
 imperforate rectum. He died in June, 1874, from 
 exhaustion and peritonitis following intestinal ob- 
 struction, this obstruction being clearly due to the 
 narrowing of the rectum at the seat of the early 
 operation^ At the post-mortem the rectum was 
 
 Enormous Dilatation of the Rectum following f„,,„fl i„ oppnnv half the abdominal cavitv, and 
 Obstruction due to the Contraction of an Arti- lOUncl tO 0CCUp> na I uie aouomiudi tdwi,) , a. « 
 
 ficiai Opening made into an Imperforate Rec- y^as thirteen inches louii' and eleven in circumier- 
 
 tum Twenty-Six Years previously. ^^^^ j^^ ^.^jj^ ^^^.^ ^^^.^^ ^-^^^^ ^^ ^j^j^j. ^^ ^^^, 
 
 ural, more particularly the peritoneal coat. 
 
 Fig. 321. 
 
 Dilate^ 
 Rectuni 
 
Wlii-n tlu' I'xploraton :iiio-]M'riii;i';il oiM-ratiun has failed to <;ive rclii-f or wlicn it is 
 iiH'xiit'<liL'iit to iiiakf the atti'iiipt from the very hackwanl position of the fjenital or;:aii. 
 other measures must l)e a(hiptetl ; ami of" these tlu- fipeiiiri;.' ol'the large intestine throu^ih 
 the aliilomiiial wall is eertainly the best. M. Kochard, in the Mi'miiin-a ilc l Arinliniii- 
 lmpniitlf <!)■ .)/r/////rtr ( I.S.')i)), <rives ten authentic sueeessfiil cases of Littre's operation 
 in the ^roin for this afi"eeti(»n. Holmes informs us, in his admirable work On tlir Sun/iiul 
 DisntacK i>j Chllihiii, that he ha<l n<tt met with the aeeount of any permamMitly successful 
 operation since the publication of llochanl's paper. (Juersant opened the colon in the 
 <;roin eleven times in succession, and once in the loin, without savinj; a patient, (iiraldes, 
 however, had one ca.se in which a child lived two niontlhs and a lialf. and then died from 
 another cause. 
 
 The operation, to be successful, must be undertaken early, before the infant is 
 exhausted and peritonitis has set in. Delay is justifiable only when the bowel is not 
 distended and the symptoms not in any way ur<rent. 
 
 With respect to the form of o])eration, that known as liittre's is proliablv the best — 
 viz., openiiiLC the bowel in the <;roin. The left groin is usually selected, (iiraldes having 
 shown from dissection that in thirty infants operated on for imperforation the intestine 
 was found on the left in all (^XmirraH Diet, dr Mill, et de ('hirnnj. pratiqnei^. 1804). 
 Huguier has. however, recommended the right, on account of the frequent bend in the 
 colon toward the right groin and the absence of the rectum in these cases. I have on 
 three occasions performed Huguier's operation with temporary success. In the last case, 
 operated upon in December, 1870, the child (a male) was twelve days old before relief 
 was souglit, and he lived eight days, dying from chronic peritonitis, which had evidently 
 existed before the operation. The artificial anus had been made in the lower part of the 
 large intestine ; and had the operation been performed at an earlier period good succes.s 
 would probably have been attained. The question of side is, therefore, still sub jndicp. 
 Amussat's operation in the loin is rightly put aside in these ca.ses, on account of the nat- 
 ural looseness of the colon at this part in children and the very usual oblique turn of the 
 colon after its splenic flexure. Figures likewise favor this conclusion, since, out of four- 
 teen instances in which Littres operation was performed, nine recovered, whereas two only 
 out of seven recovered al'ter the lumbar operation. 
 
 The operation itself has been described in page 508 ('• Enterotomy "). 
 
 In the trmtmeut of the third r/ff.s-.s of casics^ where the rectum opens into the vagina, the 
 surgeon may lay open the rectum from the position of the natural anus, having previously 
 passed a director into the vaginal orifice of the gut as a guide, drawing down, when pos- 
 sible, the bowel and fastening it to the integument by sutures, as originally performed 
 with success by Amussat. As a guide to the perinatal incision a bent probe may be 
 passed into the vaginal orifice of the bowel and the end turned toward the perinfeum, 
 cutting down carefully upon it. I have done this with success on four occasions, and in 
 all stitched the bowel to the margin of the integument, forming a good anus. In two 
 cases the vaginal orifice subsequent^ closed. In two that were operated on several years 
 ago the patients have good control over their motions, while the vaginal fecal fistula seems 
 to be contracting, liquid motions alone passing. 
 
 In exceptional instances the deformity, though persisting, seems to cause no inconve- 
 nience. Ricord has recorded one {Gaz. de.f Hop.. 18(53). in which the woman was married 
 and her husband was (juite unconscious that anything abnormal about the parts existed. 
 Le Fort has recorded a second, in which the woman was married and had had three chil- 
 dren, the malformation having been accidentally di.scovered in an examination for some 
 suspected disease of the bowel. 
 
 " In such cases as these," adds Holmes, " the termination of the rectum in the vagina 
 mu.st be tolerably free, and there must either be an external sphincter or the internal 
 sphincter must be hypertrophied." 
 
 When the bowel empties itself into the bladdn- or urethra, the case is very hopeless, 
 though the prospects of a successful issue are better under the latter than under the 
 former conditions. An exploratory operation in the region of the anus mav. however, 
 be made with the usual caution, in the hope of reaching the intestine, which when found 
 may be dissected away from its attachments and brought down to its normal position. 
 On the failure of this operation Littre's should be ])erformed. Mr. Curling has related 
 a successful case of Littres operation in a boy eight years of age who had a good anua 
 in the groin, yet suffered from the occasional passage of feces into the urinary passages. 
 
 By way of summar\- the following conclusions may be given : 
 
 1. In all but exceptional cases of imperforate anus, obstructed rectum, or misplaced 
 
564 SURGERY OF THE ANUS AND RECTUM. 
 
 anus an exploratory operation in the normal anal position and an attempt to bring the 
 bowel into its right place should be made, success following the attempt in nearly half 
 such cases. 
 
 2. Such exploratory operations, however, to be successful, should be undertaken early 
 and conducted with great caution, the line of puncture or incision being upward and back- 
 ward toward the sacrum. 
 
 3. When these means fail or are inapplicable, the intestine must be opened in the 
 groin (enterotomy), it being still an open question whether the right or the left side 
 ought to be selected, though the latter is the usual one. 
 
 4. When an artificial anus has been made, its constant dilatation is a necessity. 
 
 For further information on this subject refer to Curling's paper, Med.-Otir. Trans., vol. xliii., 
 and French edition of Holmes's Surf/ical Disea.'ies of Children, by Dr. Larcher. — Bodexhamer, 
 Wm., On Malformations, Wood, New York, 1860. — Ashton, On Rectum, 3d ed., 1860. — Cripps, St. 
 Bartholomtvf s Ho><p. Reports, 1882. 
 
 Injuries of the Rectum. 
 
 The anal orifice and lower part of the rectum may be wounded by accident from falls 
 or by design ; and when this occurs, hemorrhage is a common result. Repair, however, 
 rapidly goes on in these regions, and with the arrest of bleeding by either securing the 
 divided artery or pressure and some simple dressing a good result may be anticipated. 
 
 In 1876 a severe example of this kind came under my cai'e at Guy's Hospital in a 
 boy set. 12 who was impaled upon a rail, the iron spike entering the pelvis on the inner 
 side of the right tuberosity of the ischium, perforating the rectum about two inches up, 
 and lacerating the anterior wall of the rectum and base of the bladder. The injury was 
 followed by collapse and attended with hemorrhage. I saw" him directly after the acci- 
 dent, and made a free incision into his bladder as for lithotomy, in order to secure a free 
 passage for the urine, it being clear that the recto-vesical peritoneal pouch was lacerated. 
 Some, though not severe, peritonitis followed, and feces passed per anwn as well as 
 through the external wound. On the sixteenth day I consequently gave opium, to lock 
 up the bowels, with the view of making a splint, as it were, of the feces, and to keep the 
 rectum and intestinal wound quiet. Success followed the practice, and the wound in the 
 bowel closed. After four days the bowels were opened by a do.se of castor oil, and con- 
 valescence became established. 
 
 In parturition the rectum is sometimes laid open by a rupture, either alone or 
 with the perinajum ; and when this occurs, the rent ought to be brought together at 
 once, for if this practice be not adopted a plastic operation subsequently will have to be 
 performed. Cases are also on record in which, during parturition, the child's head passed 
 into the rectum and was delivered per annm. M. Queme (^Revue de Cliirurgic^ 1882) 
 cites seven cases of this kind. 
 
 Laceration from Act of Defecation. — In the act of defecation small lacera- 
 tions of the anus are not uncommon when the motions are very large or hard. 
 
 Treatment. — In the milder forms of laceration of this kind, cleanliness and laxa- 
 tives, as a rule, are sufficient to allow the parts to heal. In some instances the rent does 
 not heal and the case becomes one of fissured anus or painful ulcer of the rectum.- and 
 should be dealt with accordingly. 
 
 Wounds of the rectum inflicted by the surgeon, as a rule, heal readily, as is fairly 
 proved by the cases of fistula in ano treated by operation and the recto-vesical operation 
 for stone. The puncture made in the operation of tapping the bladder jjer rectum for 
 retention also heals quickly. 
 
 It is well to remember that the rectum may be wounded by the passage of a bougie, 
 enema syringe, or the introduction of an O'Beirne's tube. Guy's Museum contains speci- 
 mens illustrating all these forms of injury, and at St. Bartholomew's there is a specimen 
 of perforation of the rectum by a metallic clyster pipe through which gruel was injected 
 into the pei'itoneal cavity. 
 
 Rupture of the rectum may occur during a violent eff"ort at defecation, but there 
 is no evidence to show that such an accident can occur when the bowel is healthy. In 
 the majority of cases in which it has- taken place some prolapse of the rectum was present. 
 The rupture is usually in a vertical direction. It is known by the sudden appearance of 
 a mass of small intestine protruding through the anus, following a sharp abdominal pain 
 the result of an eff'ort at defecation. 
 
 H. Mayo {Dis. of Rect., 1833) relates the case of a lady who during a violent eff'ort 
 
7>/.s7;.i>/> oy- Till-: .\srs asd iiinrrM. 5G5 
 
 at iK'Tccation frit soinotliiii'r ^ivo wny, and (jii the fnllowin;; inoniiii;/ discovcrcfl W'Ca's in 
 her vasiiia. An exaniinatinii n-vcalctl a rent two inches up the bowel large enough to 
 aUow the e:;-' nf the linirfr to pass fioni the rfctiiin into tht; vagina. 
 
 Foreign Bodies in the Rectum. 
 
 Those may he intnxlueeil tVoni irif/mnf, citlier fVnin mischief or from accident, and 
 trouhh' may he experienced in their removal, their shajte and jiositioii influencing the 
 result. More commonly, however, they have been swallowed and have passed down the 
 canal, becoming caught or impacted in the rectum. They are not unfref|Uently the eau.se 
 of anal abscess, bones, pins, bristles, etc., being constantly found in the rectum under 
 these circumstances. Stones, hairs, or husks may likewise form concretions that are 
 foreign bodies. When large foreign bodies have been introduced into the rectum or con- 
 cretions or solid mas.ses of feces become there impactedj an anaesthetic should be given 
 to allow of their removal, care being taken not to injure the walls of the bowel more than 
 can be helped, since cases are on record where the i'oreign body has passed into the peri- 
 toneal cavity. With the patient under the influence of an an.'esthetic the sphincters 
 become so rela.xed as to allow of the introduction of large instruments, or even the intro- 
 duction of the hand to guard the bowel and remove the foreign body. JJottles, pots, cups, 
 corks, rings, jHMicil-cases, bougies, sticks, stones, etc., have been impacted in these regions, 
 and considerable care is needed in their removal, to prevent injury. 
 
 TuKATMKNT. — The injection of plenty of warm oil before the attempt greatly facili- 
 tates the operation. Lithotomy scoops or forceps are likewise valuable, but the ingenuity 
 of the surgeon is necessary in every case to apply the best means to carry out the end in 
 view. Linear rectotomy may be performed whenever it is called for. and occasionally the 
 foreign body may have to be removed by laparotomy. M. Verneuil related such a case 
 at the Societe de Chirurgie, June, 1880. It was that of a man aet. 40 who introduced a 
 piece of wood into his rectum to arrest a dysenteric discharge. A few days later, after 
 the introduction of the hand into the rectum had failed to reach the foreign body, a 
 median abdominal incision was made and the foreign body pressed downward, when it was 
 seized and removed after the rectum had been incised from the anus. The man made a 
 rapid recovery. Dr. Thorndike of Boston, United States, also records a successful case 
 in which a large stone was removed from the peritoneal cavity after having passed into it 
 through a ruptured rectum (AV^>. of City Uoi^p., 1882). 
 
 A large collection of such cases, with their treatment, is given by ^L Morand in 
 Memoirs of the Frnich Academy of Snrrjerjj^ vol. iii., by Ashton in his work Ou thf Rec- 
 /H»j,and by Poulet in a general treati.se on foreign bodies in surgical practice (New York, 
 1880). 
 
 Diseases of the Anus and Rectum. 
 
 These have only recently received sufficient attention from the great body of surgeons, 
 and, as a consequence, have been too often allowed to fall into the hands of "quacks;" 
 and, although able and respectable specialists have since rescued tliis important cla.ss of 
 case^s from their hands, much remains to be done by the profession as a whole to bring 
 the diseases of these parts into their right position — that is, into the hands of the general 
 practising body of the profession. Again, in no class of cases are so many mistakes met 
 with, and these almost always arise from a want of proper local examination of the parts. 
 The anus or rectum is either unlocked at or unexamined from some mistaken notions of 
 delicacy, or badly examined from want of knowledge or want of inclination. But such 
 should not be, and every patient who complains of anything like persistent symptoms in 
 those regions should be as carefully examined as he or she would be were any other locality 
 equally affected. To do this some nicety is required, and to help the student the follow- 
 ing hints n)ay be acceptable. 
 
 Examination of a Patient. — The best position is on the side, with the legs well 
 drawn up and the thighs flexed upon the abdomen, the hips being brought to the edge of 
 the bed or couch in a good light ; the surgeon, with one hand having uncovered the parts 
 sufficiently to expose them, may then raise the upper buttock, and in doing this the anus 
 conies well into view ; in operations this may be done by an as.sistant. When an abscess 
 exists, it will then be seen ; if a fistula be present, its external orifice will be apparent. 
 Fissures, warts, condylomata, or fleshy, flattened, cutaneous vegetations or cancerous 
 tubercles will also be at once recognized. 
 
 Pendulous loose folds of skin about the anus will suggest the former existence of 
 
566 
 
 SURGERY OF THE ANUS AND RECTUM. 
 
 external hemorrhoids ; blue, turgid, venous projections, their present existence. A tightly 
 contracted and rigidly drawn-up anus, as a rule, means some painful ulcer of the part, 
 and a patulous anus through which flatus or discharge passes without the patient's wish 
 too often indicates extensive rectal ulceration or stricture. 
 
 Intcrmd piles, when prolapsed, will appear as turgid, vascular, mucous projections 
 covered with mucus or blood, surrounded by everted integument more or less oedematous; 
 prolapsus recti, as a greater or less annular projection of smooth or rugous mucous mem- 
 brane, with a central intestinal orifice. A. polypus projecting will appear as a cherry, sur- 
 rounded by healthy structures. All these points are taken in at a glance and understood. 
 A digital examination should then be employed, to confirm or refute the suggestions thus 
 taken in by the eye. To do this well the index finger must be thoroughly anointed with 
 lard or ointment, it being a good plan previously to fill the nail with a piece of soap. It 
 should then be applied to the anus and the patient told to bear down, as in doing this the 
 sphincter is relaxed. The surgeon can then with ease and without pain introduce his 
 finger. When an ulcer exists at the anus, pain will be caused by and spasmodic resistance 
 off"ered to the introduction of the finger, and, with the pulp of the finger slowly moved 
 round the anus, the ulcer will probably be felt. It should be stated, however, that in 
 many cases this ulcer will be seen by a careful drawing down of the skin of the anus till 
 the margin of the mucous membrane becomes visible. A spongy nodular feel of the 
 mucous membrane just within the sphincter will suggest internal hemorrhoids ; a local,- 
 tender, and raw surface, the probability of a simple ulcer ; a circular, indurated raw sur- 
 face, that of a syphilitic sore ; while a cancerous ulcer is known by an infiltrated nodular 
 and thickened surface. A stricture within two inches of the anus can always be detected 
 by its annular form or the obstruction which it causes. AVhen a healthy piece of bowel 
 separates the anus from the stricture or ulceration, the probability of the disease being 
 cancerotis is rendered great. When no such healthy tissue exists, syphilitic disease is 
 rendered probable. A digital examination will always detect the presence of scybala or 
 impacted feces, and also the encroachment of uterine or pelvic tumors in women and 
 prostatic tumors in men. To confirm these opinions thus formed, a speculum may be 
 used, which should be introduced well warmed and greased in the same way as the finger. 
 Mr. Curling says, "When the mischief is high up in the rectum, let the patient stand on 
 the left leg, with the right thigh and leg bent, the foot resting on a chair. Tell the 
 patient to .strain. This action will then force the parts down." I have found this method 
 of examination serviceable. 
 
 Mr. Allingham " advises the prone position, with the hips well elevated upon hard pil- 
 lows, to such an inclination that the intestines will gravitate toward the diaphragm, so 
 that when expiration takes place the rectum becomes patulous and you can see as far as 
 the sigmoid flexure perfectly distinctly." This mode of examination, he infoi'ms us, was 
 suggested by Dr. Marion Sims (^Oii Diseases of the Rectum, 1882.) • 
 
 The speculum represented in Fig. 322, as made for me by Krohne, is the one T prefer. 
 
 Fig. 322. 
 
 A nest of three, 
 
 Rectal .Speculum. 
 
 Two adapted for use. 
 
 The practice of iutroducinrj the whole hand into the rectum has been frequently adopted 
 by several good surgeons, and from my own personal experience I believe it to be of 
 value, more particularly for diagnostic purposes, in cases of suspected disease of the rec- 
 tum above the brim of the pelvis, in pelvic or abdominal aff"ections. In the female patient 
 it is more readily performed than in the male. The operation, however, is neither easy 
 nor free from risk, .since laceration of the rectum has been recorded. It should be per- 
 formed with the patient under the influence of an anaesthetic and with extreme slowness 
 (five minutes may well be spent in pas.sing the sphincter ani) ; the hand should be well 
 
FISSURK AM> I'M S FIJI. UlJ'hi: OF TUE ANUS. ',07 
 
 greased and iiitindnccd with a s<Ti'\viii^'^ iimtidii. Wlicti tlic hand has passed witliin tlic 
 rectum, imudi eare is rf(|iiin'd ; and wlu-u tlie narr<»\VMess of" tlie gut i'nrbids easy advance, 
 no lorce shouhl he eni|doyed, lor hy force tlie peritoneal covering of" the howel has been 
 rujitured. With the hand in the rectum the jtarts above the brim <d" the pelvis may be 
 readily examined; indeed, the kidneys have been felt, and pulsation in the larger branches 
 of the abdominal a(trta can be traced, and conse<juently controlle(i. 
 
 With these brief general remarks. I now proceed to treat id" the special affections. 
 
 Fissure and Painful Ulcer of the Anus. 
 
 This most distressing affection produces more misery than any other loeal disease with 
 which I am ac(|iiainted. and nsnders the natural act (d" defecation an agoidzing one. of"teii 
 '■ causing great dro])s of jicrspiration to course down the temples." It is usually caused 
 by the meidianical sjditting of the orifice of the anus, from the passage of a large or 
 indurated motion at the junction of the mucous membrane of the bowel with the skin, 
 although it is not always traceable to such a cause. In .some instances it seems to owe 
 its origin to scratching the parts when highly irritable. It is usually a disease of adult 
 life and common to both .se.\cs, though it has been found in children even so young as a 
 year and a half {^Hrit. Med. Juitrn., June G, 1874). It is met with as often in the healthy 
 as in the feeble sul))ect ; but where it has been allowed to go uncontrolled, it soon tells 
 upon the strongest patient. Constipation, high feeding, sedentary habits, and want of 
 local cleaidiness are the common causes, but anything that sets uji irritation in the intes- 
 tines is likely to produce it ; and when once started, unless treated with discrimination, 
 it may go on for years ; indeed, it is by no means unusual to hear that the .symptoms 
 have been endured for two. four, or even six, years. It generally manifests its presence 
 by some local uneasiness in the act of defecation, this uneasiness passing on to more or 
 less severe pain. This pain, as a rule, is experienced during the passage of the motion, 
 but in some instances it comes on after the lapse of a few minutes, or even an hour or 
 more, after the act, and may last a few minutes or hours. When it passes away, the 
 patient is easy till the same cause excites the same symptoms. The motions will often 
 be streaked with a line of pus or blood and diminished in size, sometimes being flattened, 
 at others, pipe-like ; and this diminution is produced by the spasm of the sphincter, the 
 size of a motion Ijeing. in disease as in liealth, greatly determined by the condition of the 
 sphincter. 
 
 On examing the anus the first fact that strikes the observant eye is the unnatural 
 resistance the patient makes on separating the buttocks, and, on doing this, the powerful 
 contraction of the sjdiincter that will be visible. On attempting to introduce the finger 
 considerable resistance will be encountered, and the greatest pain caused if the surgeon 
 persevere in his attempt. 
 
 The .symptoms and local signs of the afi'ection are, indeed, so characteristic that the 
 true nature of the ca.se can, as a rule, be diagnosed without the aid of a digital internal 
 examination, and a careful external examination will often reveal the presence of an ulcer 
 on the verge of or within the sphincter; when within, the outer border only will be visi- 
 ble. The ulcer is usually, though not invariably, placed at the posterior margin of the 
 anus, and is rarely larger than a sixpence, if so large. When recent it will be soft with 
 slightly elevated edges, and when of long standing indurated with an irregular surface, 
 small jiolypoid growths fringing its border. The ulcers are at times multiple, in excep- 
 tional cases involving the bowel higher up. It is an affection of the mucous and submu- 
 cous tissue and painful only from its position, besides being obstinate in healing from its 
 connection with the sphincter ani. Simple fissures of the anus rarely involve other than 
 the mucous meml)rane and skin around the parts and are often associated with piles, 
 though occa.sionally with small polypi. Ulcers are often hidden from view when piles or 
 folds of skin exist about tlie anus, but pain indicates their presence. 
 
 In women this affliction is so often associated with reflective uterine symptoms as to 
 be frequently overlooked, and in men urinary irritation may mask the disease. 
 
 Reflected nerve pains in the perinaMim and down the leg, as in sciatica, or in the loins, 
 as in lumbago, etc., are often induced by the affection. 
 
 Tre.\t.mext. — Happily for patients, the treatment of this disease is as successful as it 
 is simple. Simple fissures are readily treated by the administration of a laxative, the 
 local application of the nitrate of silver or of lead lotion mixed with the extract of opium, 
 and local cleanliness, with simple, nutritious, and unstimulating diet. When the parts 
 are indolent or syphilis is suspected, black wash may be used, or calomel dusted over the 
 
568 SURGERY OF THE ASUS AND RECTUM. 
 
 part or applied as an ointment of five grains to a drachm of lard. In other cases the 
 application of mercurial ointment with the extract of belladonna gives relief. Injections 
 of the decoction of rhatany twice a day, or of an enema composed of a drachm each of 
 the extract and tincture of rhatany in five ounces of water, are sometimes of great use, 
 as also is an ointment ten grains of iodoform to the ounce. 
 
 When a larger nicer exiafs and is quite recent, the same treatment may be employed ; 
 but when the ulcer has existed for any time and has a hard base, it is quite exceptional 
 for a cure to take place by these means, the surgeon being hardly justified in making the 
 attempt when he has at hand such an efficient means as the division of ilie base of the uher 
 vith the snperfcial fihrea of the external sphincter. This can be done in many cases by the 
 introduction of the finger with a probe-pointed bistoury pressed flat upon it and introdu- 
 cing them to the upper margin of the ulcer, and then turning the edge of the knife toward 
 the surface of the ulcer and incising it. Boyer, who first suggested this principle of treat- 
 ment, advised the free division of the sphincter, but Copland and Brodie introduced the 
 minor operation, which in the bulk of cases is sufficient to effect a cure. In very chronic 
 instances Beyer's operation may be demanded. When an anaesthetic is given, a speculum 
 may be used ; and the ulcer, being exposed, should be divided by a sharp bistoury, tran.s- 
 fixing the tissues at the base of the ulcer on cutting inward. The essential point of prac- 
 tice to observe is the free division of the base of the ulcer down to healthy tissue, the 
 mode of doing it being unimportant. When any fold of skin or pile exists near the ulcer, 
 it should be removed. The forcible dilatation of the sphincter and its laceration with the 
 thumbs in the rectum, as practised abroad, is a barbarous treatment compared with the 
 above, though when a patient is under an anaesthetic it may be followed. 
 
 After-Treatment. — In the after-treatment the bowels must be kept slightly loose, 
 and for this purpose nothing equals in value a mixture of one ounce of olive oil rubbed 
 down with forty-five grains of cai'bonate of potash and mixed with seven ounces of pep- 
 permint or chloroform water, one ounce being given two or three times a day, to produce 
 a soft evacuation. Indeed, before as well as after the operation this mixture should be 
 employed ; when it fails, enemata ought to be used. The diet should be simple and rest 
 maintained till the cure is complete, for where this rule has not been observed I have 
 known the ulcer become so indolent as to require a second division, which under other 
 circumstances is rarely required. Tonics are often of value during the convalescing 
 period. 
 
 Spasm of the sphincter is not a disease, but a symptom, caused by reflected 
 irritation from some rectal, uterine, or other local affection. It may be a small or super- 
 ficial ulcer beyond the verge of the anus ; the presence of worms, the existence of a 
 small polypus, or some other local cause of iri'itation of the mucous membrane lining the 
 bowel will be found after careful investigation. 
 
 The same remarks are also applicable to neuralgia of the rectum, though it is 
 quite reasonable to believe that a pure neuralgia may occur of this part, as of any other. 
 Yet, as a rule, it is caused by reflected irritation from some nerve with which the part is 
 connected, and the surgeon should clinically so regard it. It is said to be common in 
 gouty subjects, and can certainly be relieved by free purgation. At times it is caused by 
 malaria and cured by large doses of quinine. 
 
 Anal Abscess and Fistula in Recto. 
 
 The two subjects of anal abscess and fistula in recto are classed together, as the latter 
 disease is almost always preceded by the former, though a large number of cases of anal 
 abscess recover without passing into a fistula. Of my notes of 230 consecutive cases of 
 the two diseases, 43 commenced and ended as anal abscess, while the remaining 193 were 
 treated as fistula in recto ; 74 of these cases were females and 162 males, men being evi- 
 dently more liable than women to this affection. It rarely occurs in children, though I 
 have successfully treated a case in a male child four months old, and a second in one of 
 fifteen months ; in the latter the fetor of the discharge was very great. 
 
 Of the causes of this disease little positive information can be given, because, as a 
 rule, the abscess is obscure in its origin and slow in its progress and repair, some patients 
 even professing to have been uncon.scious of its existence till it was about to burst. In 
 other cases, however, it is very acute in its action, and very painful. 
 
 That an anal abscess must always result from some ulceration of the bowel within 
 the sphincter is an opinion which can scarcely be regarded as true, there being no evi- 
 dence to support such a view ; and the fact that so many as 43 out of 236 cases of anal 
 
.I.V.I/. Al!sri:ss AM) FIsrri.A IS llF.rro, 509 
 
 aliscoss rfcovcii'il witliout t'Mriniiii; a listiilu ^dcs far to prove its error. It is not unfair, 
 tlu'rcforc, to iiil'iT that in nianv cases it de]>etKls uiM)n a (liH'ereiit cause. 
 
 in iistnia in recto tiiis ar;j,iunent tniist lu; e(|ually stronj^, since it is frenerally heliev(!<l 
 that this ath'ction is merely the .se(|uel of tlie anal ahseess ; we niu.st, cuiise<|uently, h>oii 
 for some other and more irt'iieral cause than tiiat ordinarily received — namely. |ierforation 
 of tlie l)o\vel from uiceratifui. 
 
 Thi' mechanical irritation oi' a foreij:;n hody is douhtless an occasional cause, it being 
 bv no means uncommon f(tr a suriietm to remove i'rom the anus, when o])(!nin<r an abscess, 
 a jtiece of Hsh-h(UU', bristle, or other foreiiiii body. Quit(! n^-ently I removed a pin. 
 
 These atl'ections may occur at any period of life, though I have .seen a fistula in a 
 child fnui' months old. and in the majority (d' instances it is found in adults betw(!en 
 twentv and forty years of age. i>r. Jiipsconib of St. Albans related a case to me which 
 took iilace in his jiractice that was congenital, the mother having conceived when worry- 
 ing al)out hi'r husband, who was suffering from fistula. It is very common to be informed 
 that the Kstula had existed for .several years before surgical aid is sought. 
 
 With respect to the connection between phthisis and fistula it is difficult to give any 
 positive information. During the eight years that I was registrar at (luy's I iufjuired 
 carefully iuto this point in every ease, but had only ?t out of 193 in which either hjcniop- 
 tysis or other symptom of marked phthisis was present. In the majority of cases the 
 patients presented no more severe cachectic symptoms than is usually met with in other 
 liospital patients, and I confess to being somewhat doubtful as to the fact that fistula in 
 recto is a common conse((uenee of phthisical disease. When, however, fistula and 
 phthisis are associated, the former is usually of a bad form. 
 
 When a fistula has two openings, one externally and the other into the bowel, it is 
 called conipletc. When there is an external but no internal opening to be found, it is 
 known as the blind external ; when an internal but no external, blind internal. 
 
 That, as a rule, an internal opening exists is now scarcely doubted, although at times 
 there may be great difficulty in finding it. M. Ribes in 1819 examined the bodies of 
 seventy-five people who died with fistula, and in all he found an internal opening; in 
 nearly all this was placed just within the sphincter, but in no instance was it higher than 
 half an inch. Modern surgeons now accept these facts. The pus that forms in these 
 parts is very offensive at times, as often from the absorption of fetid gases through the 
 mucous membrane as from the mixture of feculent matter. In a large number of ca.ses 
 the discharge has no fecal odor. 
 
 It should always be remembered that an anal fistula may accompany severe rectal 
 di.sease, such as stricture or ulceration, or that it may be connected with disease of the 
 pelvic bones, etc. In the case of an old man with an enormous abscess Vjetween the base 
 of the bladder and the rectum constitutional symptoms were very severe till two deep 
 incisions were made on either side of the perinteum, giving exit to a quantity of pus, 
 when an excellent recovery ensued. In this instance it was a question whether the pros- 
 tate gland was in fault, but no other symptoms of such a complication could be ascer- 
 tained. 
 
 Treatment. — In cases of anal abscess free incision is the best practice, which should 
 be made as soon as fluctuation can be felt e^^ternally or through the bowel. Deep-.seated 
 abscesses in these regions .eliould not be left to natural processes to open. When the 
 abscess is in front of the anus and rectum, an early opening may be called for. on account 
 of the retention of urine to which it may give rise. The incision should be made from 
 without inward in a line radiating toward the anus. In deep-seated abscesses one or two 
 fingers may be inserted well into the rectum and the abscess pressed forward before the 
 incision is made, a sharp straight bistoury being the best instrument to use. A piece of 
 oiled lint should be in.serted into the wound and kept there for a day. 
 
 In a case I saw in 1872, owing to the neglect of making an early opening, emphysema 
 and phlegmonous inflammation of the perinacum, scrotum, and penis, and of the abdomen 
 even up to the axilla, took place, a free communication evidently existing between the 
 bowel and the abscess. The patient died from the constitutional irritation of the disease. 
 The sloughing of the cellular tissue was very extensive, and the fetor of the sloughs was 
 something to remember. 
 
 After the abscess has been opened the j^atient should be kept at rest in the horizontal 
 posture, some antiseptic dressing applied to the wound, and the most perfect cleanliness 
 ob.served, laxatives being given when the motions are hard, and also tonics to improve the 
 health. 
 
 When ajistida exists, the best operation is its division into the bowel, the action of the 
 
570 
 
 SURGERY OF THE ANUS AND RECTUM. 
 
 Fig. 323. 
 
 sphincter ani having, doubtless, a powerful influence in retarding repair. The bowels 
 should previously be cleared by a mild purge two days before the operation, and an enema 
 given on the morning of its performance. The patient should be placed on the side upon 
 which the fistula exists, with the legs well drawn up, and brought to the edge of the bed 
 or couch. An assistant should separate the buttocks. The surgeon ought then to intro- 
 duce a fine probe-pointed grooved director into one of the fistulous openings and with the 
 greatest gentleness guide it through the fistula. Anything like force will excite re>sist- 
 ance on the part of the sphincter to its introduction and cause pain. When the end of the 
 probe p'asses into the bowel through the internal opening, all that is required has been 
 effected ; and if difficulty be experienced in doing this, the well-greased index finger of the 
 opposite hand can be carefully inserted into the rectum and the internal opening felt for, 
 through which, when found, the end of the pi'obe can readily be guided into the bowel. 
 
 When no internal opening exists (a rare condition), 
 the director must be forced through the bowel at the 
 upper part of the sinus. 
 
 As soon as the director is felt in the rectum the 
 patient should be told to strain, the surgeon at the 
 same time with his index finger hooking its end down- 
 ward. By these means the director will be made to 
 protrude from the anus, when the whole of the tissues 
 bi"idged over can be readily divided (Fig. 323). 
 
 When the fistula runs high up and much force is 
 called for to turn the probe out of the anus, it is 
 better to pass a speculum and to divide the fistula. 
 When a long sinus runs up by the side of the 
 bowel, it should be laid open through a speculum, to 
 leave it alone not being a safe practice ; for, although 
 in some cases a cure may take place, in many the dis- 
 charge into the rectum will continue and but little 
 good will have been effected by the external opera- 
 tion. The pi-esence of this internal discharging fistula 
 is generally indicated by the appearance of pus upon 
 the motion. 
 
 When many sinuses exist, they should be laid 
 open, although it is not necessary to divide the sphincter in more than one place, as a 
 double division of the sphincter is apt to be followed by incontinence. 
 
 After-Treatment. — After operation the wound should be well plugged with dry 
 cotton-wool down to the bottom, and no careless introduction of the plug will suffice. By 
 this measure all bleeding can be controlled, and any amount of f ressure applied by means 
 of a T-bandage. When no bleeding exists, only a moderate-sized plug is necessary. 
 
 On the second day the dressing may be removed, there being no occa.sion to reintro- 
 duce the plug, a piece of oiled wool or lint gently introduced to absorb discharge being 
 all that is required. The wound should be kept clean. When indolent, it can be stimu- 
 lated by some lotion of nitric or carbolic acid, terebene, or tincture of iodine, tonics and 
 good diet being also valuable. The horizontal position — not in bed, but on a sofa — must 
 be maintained, however, till the parts are healed. 
 
 In the hlhid internal fistula a guide to the external wound may often be found by means 
 of a bent probe hooked through the internal opening, and the case treated as any other. 
 
 When severe bleeding complicates the case, a speculum may be passed and the vessel 
 seized and twisted. Where this cannot be done the rectum may be well plugged wnth a 
 sponge saturated in alum; but, as a rule, a well-applied pad and pressure, adjusted with 
 a T-bandage, are sufficient to control it. 
 
 A piece of ice put into the centre of a cup-sponge and applied to the anus not only 
 arrests bleeding, but gives great comfort in this, as in almost all anal operations. 
 
 When a cutting operation is inexpedient, as in " bleeders," or when the patient will 
 not submit to it, the division of the fistula with a metallic wire heated by the galvanic 
 cautery is a faultless method. Indeed, in all cases of fistula, where this apparatus can 
 be obtained, it is the best means. It readily divides the tissues, the two ends of the wire 
 being made to project through the two orifices of the fistula, thus burning their way out 
 with a sawing movement. There is little pain at the time, and scarcely any after, with 
 no loss of blood, and, what is more, no need of subsequent dressing, as a cauterized sur- 
 face must heal by granulation. 
 
 Grooved Probe passed through Anal Fistula 
 before its Divisiou. 
 
III.MonininlDS, (III I'lLKS. 571 
 
 When this plan cannot he Inlhiwctl, the treatment hy li^'atnre has hoen adopted. Mr. 
 Luke revived the |)raetice in 1S45, hut it has now fallen into desuetude. Were I ealled 
 on to adopt the praetice. 1 should use an iiidia-ruhher lijrature. 
 
 In rare eases fistula may he treated hy injiu'tion, a daily iiijection of the sinus with 
 some tincture of iodine, sulphate of zinc, or nitrate; of silver haviufr heen followed hv a 
 cure; yet suidi cases are too exceptional to justily the recommendation of such treat- 
 nieiil. 
 
 W'luii llie patients condition is sneli ;..< lo i'orhid any hope of repair in the wound 
 takiiiu place, the operation for fistula should he set aside; hut the existence of pulmonarv 
 mischii'f, if not far advanced, is no ar<rumcnt ajrainst its adoption : nay, it may he mad<,' 
 use of as an arirument in favor (d" surj^ical interference, recent investigations, as already 
 alluded to in an early chai)ter, having indicated that the long existence of .suppuration is 
 liahlc to set up tuherculous disease. Practically, however, it is undoubtedly true that 
 tistula nuiy he divided and heal in far from healthy subjects, and the general health 
 improve after tlie operation. 
 
 There is no need to keep the bowels locked up after an operation for fistula. 
 
 Hemorrhoids, or Piles. 
 
 In a clinical point of view, ihese.may be divided into tlie hlrcding and the non-hlpfd- 
 iii</. The former are generaly the itifmial, and composed of a highly vascular tissue 
 involving the mucous membrane of the rectum and the submucous tissue, with enlarged 
 arteries and veins. Where the arterial element predominates, the tumor has a bright-red 
 strawberry aspect ; where the venous, a dusky hue. They are cloisely allied to naevoid 
 structure and discharge arterial blood. 
 
 The non-bleeding, or external, piles are composed of the loo.se folds of skin 
 that surround the anus, or a varico.se, inflamed, or ruptured vein. When inflamed, these 
 folds become oedematous and infiltrated with organized inflammatory products, and appear 
 as fleshy growths of various degrees of density. The venous hemorrhoids also become 
 swollen and appear as bluish, tense, and painful tumors. When in an active state, they 
 may encroach upon the mucous membrane of the rectum and a])pear as large as a walnut, 
 but, as a rule, they are about the size of a nut. They rarely give rise to much annoy- 
 ance when cleanliness is observed, but under other circumstances they cause much local 
 irritation. When swollen or inflamed, however, they give great distress, from the sensi- 
 tive condition of the skin at these parts. Plxternal piles also are occasionally the cause of 
 hemorrhage, the blood at times coming direct from an ulcerated vein and then being venous. 
 At other times it will be profuse, but its exact seat is not so evident. The flow comes 
 from between the pendulous flaps of .skin, and ceases when they have been removed. 
 
 The TREATMENT of external piles is simple, and excision is the only radical cure. 
 The pendulous flaps of skin that surround the anus may be removed with a pair of sharp 
 scissors, the tumor having been drawn forward with a pair of forceps. These incisions 
 should be made in lines radiating toward the anus. When coagulated blood has been 
 poured out into the pile and a tense, painful tumor exi.sts, it may be punctured or laid 
 open with a lancet, bleeding, when it occurs, being easily arrested by cold and moderate 
 pressure. AVhen the pile is inflamed, leeching often gives comfort, and the application 
 of a poultice covered with the extract of opium gives relief When the part suppurates, 
 the abscess may be opened. 
 
 In the early stage of the affection local cleanliness and abstinence from highly-seasoned 
 food and strong wines are mostly sufticient, the bowels being kept clear by enen)ata or 
 the occasional dose of a mild aperient, such as the compound rhubarb pill, before dinner, 
 some saline, purgative water, or an electuary. When local irritation exists, an ointment 
 composed of e({ual parts of zinc, nitrate of mercury, and subacetate of lead is very valu- 
 able ; some recommend the compound gall ointment. An ointment of zinc and the 
 extract of belladonna is very useful. 
 
 Internal piles are very insidious in their growth — so insidious, indeed, that bleed- 
 ing is often the first symptom that attracts notice. On inquiry, however, it may gener- 
 ally be made out that constipation has been the normal condition, and that irritation 
 about the anus, with a feeling of heat and fulness in the parts, had previou.sly existed. 
 These piles often appear after parturition. When the parts inflame, there will be throb- 
 bing, and pain in defecation ; when they protrude, there will be one, two, three, or more 
 masses of thickened mucous membrane with n{X3Void structure, presenting either a smooth 
 and tense or a reticulated surface. Sometimes there will be oozing of blood from the 
 
572 
 
 SURGERY OF THE ANUS AND RECTUM. 
 
 Internal Hemorrhoids. 
 
 whole surface, or the bh^od may spurt from a distinct orifice. The blood is almost always 
 red and arterial, and the mucous projection is surrounded by skin more or less pendulous, 
 oedematous, or infiltrated with inflammatory products (Fig. 324). 
 
 When the parts are not inflamed, this hemorrhoidal 
 mass may protrude only during defecation and return 
 naturally or after a little pressure. When the disease 
 has been of long duration, the pile may protrude on 
 the slightest exertion, even on the patient assuming 
 the ei-ect posture or on coughing, the whole mucous 
 membrane of the rectum often participating in the 
 prolapse and adding to the discomfort. 
 
 The jmin attending the development of these piles 
 varies vastly, small hemorrlioids often giving rise to 
 severe local distress, while the larger cause but little. 
 An inflamed pile is, however, always painful, and a 
 prolapsed inflamed one the most of all. Where pain 
 is excessive and more particularly felt after defecation, 
 there is a strong probability that a Jissure or an ulcer 
 complicates the case. 
 
 The amount of Jiemorrliage bears no proportion to 
 the extent of the disease. In one of the worst cases 
 of hemorrhage T ever saw, in which a lady was blanched and almost pulseless, the pile 
 was not larger than half a nut ; it was of the reticulated kind, and the blood spurted out 
 from a vessel as large as the radial artery. On the removal of the pile a complete recov- 
 ery ensued On the other hand, it is remarkable to what an extent the local disease may 
 develop in some cases without producing excessive bleeding. 
 
 The bleeding, as a rule, takes place after the action of the bowels and covers the 
 motion ; occasionally it precedes it ; but in many instances it is quite independent of all 
 action of the bowels, blood flowing on the patient assuming the erect posture or at odd 
 times without any such cause. 
 
 The amount of blood said to have been lost vinder these circumstances is somewhat 
 remarkable, writers upon these subjects relating the loss of three " chamberpotfuls," 
 " eight or nine pounds," etc. Doubtless in many of these accounts there is exaggeration ; 
 still, all surgeons must at times be astonished at the loss of blood that takes place in these 
 cases daily, sometimes for years, but with little apparent interference with the general health. 
 The discharge of a thick mucus from the anus is a frequent accompaniment 
 of this aff"ection ; and when ulceration complicates the case, the secretion is of a muco- 
 purulent character. 
 
 Urinary irritation, and at times retention, in both male and female subjects, 
 and in women WOmb COmphcationS, often add to the distress. 
 
 Nerve pains passing upward to the loins, hips, and round the sacrum, or even 
 downward to the heel and sole of the foot, are likewise met with. Brodie gives a case in 
 which the heel pain was the most prominent feature. 
 
 What are called dyspeptic symptomS are almost always present, the assimilat- 
 ing organs suffering as well as the circulatory and nervous systems. 
 
 This aff"ection is usually met with after puberty. In early life men are probably 
 more liable to it than women, but after forty-five both appear equally liable. 
 
 Constipation has probably an important influence in causing the disease, and cer- 
 tainly in increasing it ; but sedentary occupations and high living appear to have a 
 stronger eff"ect. In the prosperous classes of society this malady is comparatively com- 
 mon, although in the poor daily hospital experience does not help to confirm the notion 
 that it is rare. Whatever tends to retard the flow of blood from the hemorrhoidal veins, 
 such as pregnancy and abdominal tumors, aggravates the disease ; and whatever tends to 
 keep up irritation in the rectum, such as drastic purgatives, worms, and pungent food, 
 acts in a similar manner. 
 
 A pile may be mistaken for a polypus, but the smooth, firm surface and pedunculated 
 form of the latter will reveal its true nature. Again, a ring of piles might be confounded 
 with prolapse of the rectum, but the uniform smooth and generally non-bleeding surface of 
 the latter, with its broad attachments, ought to be enough to prevent falling into the error. 
 External piles, when ulcerated, may also assume very much the aspect of venereal 
 anal outgrowths, which can be made out only by the history of the case and other clini- 
 cal symptoms. 
 
SUItdlCAL rUEATMEST OE llEM<>J:J:ilnfI)S. .073 
 
 Finally, it must iint Kr I'lUL'^uttcii llial IiciiinrrlKtiils may he iiii'itiy a r"(»iisfiqueiict' of 
 another disease. mu-Ii as .stricture ol' tin- rectum. 
 
 TllKATMKNT. — All piles (lit not re(|uire removal. In llie early periml of their growth 
 thi'V may 'jl' so sueeessfully treated hy what is <'allc<l imllinlirr treatment as to reiirler 
 more active measures unnecessary, ami in the very eacht;clie ami diseased it may not h«; 
 CXjietlieiit to do more than relieve, althoujrh it must he added that uidess orj^anic disease 
 exists to threaten life there are lew ;reneral conditions of a patient that forhid the removal 
 of a severe bleediiiLi pile. A<rain. when jtile.s occur in plethoric subjects who are pcirhap.s 
 what has been described as ajioplectic or gouty, and an attack of them is preceded by 
 constitutional disturbance and tollowed by relief; the surgeon should be careful in clieck- 
 ing suddeidy the flow of blood, as such a measure is undoubtedly sttnietimes followed by 
 alarming constitutional symptoms, though such cases are rare. 
 
 The /xil/inlirr {)r f/eiitinf treatment of piles means attenti<tn to diet, the giving up of 
 high living and strong drinks, beer and spirits in particular being avoided, and the taking 
 of simjtle nutritious food in moileration. 
 
 The bowels should be regulated by the mistura olei, already described (p. 508). or by 
 castor oil, rhubarli and magnesia, or s(jme saline medicine or mineral water, such as Vichy, 
 Frietlrichshall. or Pullna. an<l when these fail by enemata. Indeed, the daily enema of 
 cold water or the use of the rectum plug, through which cold water is allowed to flow, is 
 of great value. Violent purgation, more particulary by aloes and colocj'nth, should be 
 avoided. Some prescribe copaiba, but its nauseous <jualities forbid its general use. The 
 confections of senna or sulphur are useful, and that of black pepper (Ward's paste) has 
 been always popular. A mixture of confection of senna 5J, confection of sulphur ^, 
 powdered guaiacum ^ij, and treacle is very beneficial. The compound liquorice powder 
 is of great use. Dr. Cleland recommends (Fract it loner, January, 1870) the use of the 
 li«(Uor bismuthi ."^ij. mixed with .^i of starch, as an enema, to be used at night in prolapsus 
 recti. In ])iles, in both the child and the adult, drachm doses of glycerine combined with 
 fifteen grains- of citric acid and some vegetable bitter three times a day may be administered. 
 
 When the secretions of the liver and intestines are unhealthy, a little blue pill or gray 
 powder and chalk at bedtime is sometimes of use, some bicarbonate of potash in gentian 
 or calumba assisting recovery. 
 
 Absolute local cleanliness should always be observed, and the recumbent position 
 assumed after defecation, the prolap.sed pile being always reduced at once by gentle 
 pressure. By these diff"erent means an attack of piles may pass away never to return, or 
 to return only after a long interval ; but even in the worst cases relief may be given. 
 
 When the piles are inflamed, the application of leeches occasionally gives great relief, 
 bleeding being encouraged by hot fomentations ; such means, however, are rarely called 
 for. the complete washing out of the lower bowel, rest, and fomentations being generally 
 sufficient. In some cases the application of ice in a cup-sponge gives more relief under 
 these circumstances than any other remedy. 
 
 When the prolap.sed internal piles are strangulated by the sphincter spasmodically 
 contracting around the mass, sloughing of the whole may take place. Under these cir- 
 cumstances great pain is caused by the tension of the parts, and on one occasion I was 
 tempted to cut off with scissors some of the projecting portions, when the relief was so 
 marked that T would repeat it under the .same circumstances ; to adopt this practice with 
 safety, the pile must be in the condition that precedes its death. When this sloughing takes 
 place, a cure may follow. During the sloughing process a poultice is the best application. 
 
 The mucous discharge from the bowel in long-existing piles can be met only by ene- 
 mata and the application of astringents, such as an ointment of tannic acid ten grains to 
 the ounce, of gall and opium, or of extract of rhatany half a drachm to the ounce of 
 lard or spermaceti. The occasional introduction of a suppository of tannic acid into the 
 rectum is likewi.se a valuable expedient, and an enema of alum or tannin five grains to 
 the ounce is also .serviceable. Allingham speaks highly of an ointment of the persul- 
 phate of iron half a drachm to one drachm of the unguentum cetacei, or, as a lotion, 
 twenty grains to an ounce. 
 
 Surgical Treatment. 
 
 Unless the general condition of the patient forbids, all piles, external or internal, 
 should be removed, not only when they give local annoyance, but when by the hemor- 
 rhage produced they disturb the general health of the patient and induce weakness. To 
 accomplish this many means are at our disposal. 
 
 External hemorrhoids ought to be removed by abscission. 
 
574 
 
 SURGERY OF THE ANUS AND RECTUM. 
 
 Internal piles ought never to be excised, but destroyed by the galvanic or actual 
 cautery, crushing, or the ligature. In the hands of many surgeons the ligature still 
 holds Its ground, but with as many it has been nearly, if not altogether, superseded by 
 crushing or the cautery. I have used the ligature only in exceptional cases for at least 
 twenty years. In a few cases nitric acid is of service. In Paris a plan of treatment 
 has been successful which claims attention, as it receives the support of M. Verneuil. 
 It consists of forced anal dilatations, either by the thumbs of the surgeon or by means 
 of a dilator, the piles withering after one full dilatation of the anus ( Union Medicale, 
 March 6, 1877). 
 
 The Ligature. — The patient, having made the hemorrhoidal tumors protrude by 
 straining over a stool containing hot water or by an enema of warm water, should be placed 
 
 on his side, with his legs drawn 
 Fig. 325. up and the parts well brought into 
 
 view by an assistant separating 
 the buttocks. The surgeon should 
 then grasp the base of the tumor 
 that is to be ligatured by a pair of 
 forceps (Figs. 325, 326) and sepa- 
 rate the pile from the skin and 
 submucous tissue by scissors, sub- 
 sequently transfixing it with a 
 needle armed with a double silk or 
 hempen ligature. He should then 
 divide the coi'd and tie the pile 
 tightly in halves, cutting off with 
 scissors at least half of the strangu- 
 lated portion before finally tighten- 
 ing the second ligature ; a second 
 or third mass should be similarly 
 treated ; the ends of the ligature 
 should then be cut off and the whole returned within the sphincter. The surgeon should 
 be careful to include in his ligature all the diseased tissue ; and when this has not been 
 done with the forceps, it is better to pass a needle or tenaculum through the base of the 
 pile higher up, and loop a ligature round it, than to remove the forceps and reapply it. 
 He should also take care not to include any of the external skin. 
 
 The ligatures may be expected to separate about the seventh or tenth day, and they 
 should always be allowed to slough off. 
 
 Apter-Treatment. — After the operation an opiate may be given, 
 or a full dose of chloral (half a drachm). The bowels should be left 
 undisturbed for at least two days, when a dose of castor oil or other 
 purge may be administered, or, better still, an enema. The horizontal 
 position must be maintained throughout the case. If oedema of the 
 parts follow, ice may be applied, or a lotion of lead and opium ; bella- 
 donna rubbed down with glycerine at times gives relief. Until the 
 bowels act the diet should be simple, nutritious, but not stimulating. 
 This operation is successful and has no special danger, though it is per- 
 haps more tedious than the treatment by cautery. 
 
 The Cautery. — When internal piles require removal, the clamp 
 and the cautery are means I generally employ ; and the thermo or gal- 
 vanic cautery is preferable to "the actual. Cusack of Dublin suggested 
 this practice in 1835, but Henry Lee and Henry Smith have done more 
 to establish it than any other surgeons. It is adopted as follows : The 
 patient having been prepared for the ligature and the piles protruded, 
 the anus is to be dilated forcibly, with the view of allowing free manip- 
 ulation of the piles, as well as of preventing subsequent spasm of the 
 sphincter. Each mass is then to be seized seri<ifini witk the vulcellum 
 forceps, drawn down and secured at its base by clamps (that represented 
 in Fig. 327, a modification of Curling's, being as good as any), the 
 upper end of the clamps presenting toward the anus. The projecting 
 half of each mass must then be exit off with scissors, the surface wiped 
 dry, and the cautery, heated to a white heat, applied to the surface ; 
 the whole projecting portion being burned down to the level of the clamp ; a dense eschar 
 
 Fig. 327. 
 
si'Rt;i<:i/. Tin: AT mi: ST or ni:M<)i;i;nn/i)s. 575 
 
 is tliu> tnriiicil. W'licii tlif ilicrinu i>v ii;il\ .iiiic caiihTy caiinot Iti- lijid, tin- actual cautery 
 must lie cuipluvcil, a second hciiiL: at liainl t(t us(! as tlie first cools. 
 
 'I'lic eschar is luori' soliil aixl liiiii alter the theniio or ;;alvaiiic than after the actual 
 cautery ; it is likewise follo\ve(l liy less pain, the heat hein^' so intiMise as to destroy all 
 scnsihility. Aiuple ex|>erieuce with hoth has convinced nie ol" this fact. 
 
 As eacli mass is destroyi'd the clani|i should he removed, care ljein<^ taken not to dis- 
 turl) the eschar. When all have lieen treated, the wIkjIc projecting mass may he returned 
 into the rectum with the Hn<;er well j^reased, it being a good plan at this moment to intro- 
 duce a sup])ository of opium or morphia to soothe pain. 
 
 AFTKU-'ruK.VT.MENT. — Patients should he kept at rest for at least two week.s after this 
 operation, hut thi-y will often he an.\ious to go al)out much sor)ner, saying that they feel 
 ipiite well. A fortnight is the aviTage titne for convalescence, hut a week in good cases 
 .seems suHicient. In one of the worst ca.ses of internal ])iles I ever treated I applieil the 
 clamp to four masses and l)urned them down as described with the galvanic cautery. 
 After the first day all pain had gone ; on the fourth the bowels acted naturally without 
 the slightest inconvenience, and in a week the man was up, no single drawback having 
 taken place. Such a ca.se, however, is e.Kceptionally good even for the cautery. 
 
 The al'ter-treatment is the same as in ligature, the local a])plication of ice perhaps giv- 
 ing greater comfort. 
 
 Ignipuncture. — In not a few examples of internal hemorrhoids where one or two 
 sessile masses alone existed I have by means of a speculum, without the aid of a clamp, 
 applii'd the galvanic or thermo cautery to their surfaces direct, and in others I have 
 merely punctured them in two, three, or more places, according to their size, taking care 
 to rotate rather than pull on the cautery in its removal. Nothing but good results have 
 followed the ])ractice, and I am disposed to think that in such cases it is the best to 
 adopt. Mr. Reeves has recently strongly^ advocated this method. A good sound eschar 
 forms at once, and on its removal a recovery takes place. 
 
 Demarquay (Gar:, dr Pan's, 18(J0) merely passed a hot iron over the surface of the 
 pile to produce a superficial eschar. He advised also linear ecrasement where the piles 
 only protrude on deiecation and can be replaced, and where the sphincter is not relaxed 
 nor the mucous membrane of the rectum prolapsed. In all other cases he prefers the 
 cautery. 
 
 Treatment by Crushing. — This method was introduced into practice by Mr. G. 
 Pollock {Ld licet, July o, 1880) and a clamp suggested by Mr. Benham employed. 
 
 The instrument is to be adjusted as in the operation for cautery, and the protruding 
 pile cut off with scissors. The clamp, which is very strong, is left on the pile for one 
 minute. Messrs. Pollock and Allingham have employed this method of crushing very 
 largely, and speak favorably of it. It is said to be safe and to be followed by less pain 
 than other methods. I have followed this practice in only a few cases, but have no rea- 
 son to prefer it to the cautery. 
 
 Treatment by the Subcutaneous Injection of Carbohc Acid. — This 
 
 method has been employed freely in America, and apparently with success. It is appli- 
 cable to internal piles alone, and one pile should be treated at a time, about a week being 
 allowed between the operations. About one to six drops of a solution of one part of car- 
 bolic acid in thirty of olive oil or glycerine should be injected with a hypodermic .syringe 
 into the pile, which turns white, and in successful cases withers without pain or sloughing. 
 An ointment of vaseline should be smeared well over the parts around the pile, to guard 
 against any injury from the dropping of the fluid. The majority of cases treated in this 
 way. according to Dr. Andrews of Chicago, are cured rapidly. 
 
 When nitric acid, is used, the patient should be prepared and treated in the same 
 way as for the cautery ; the acid should be applied with a piece of wood to the diseased 
 surface. The spoon-shaped clam)) forceps are probably the best to use under these cir- 
 cumstances. After the application of the acid the parts should be well oiled and returned. 
 This practice was suggested by Dr. Houston of Dublin in 1857. To small, flat, straw- 
 berry-looking internal hemorrhoids this plan of treatment is applicable, but is not so satis- 
 factory as the cautery. I never now employ it. Ulcerating piles may be treated in the 
 same way as others. 
 
 When a fissure or painful ulcer coexists with hemorrhoids, its base should be divided 
 before the operation for hemorrhoids is undertaken, or, what is better, lacerated by forci- 
 ble dilatation of the anus. 
 
 In operating on internal piles the surgeon must be careful not to take the everted, 
 and possibly oedematous, skin that encircles the mucous hemorrhoidal mass for external 
 
576 SURGERY OF THE ANUS AND RECTUM. 
 
 piles and remove it. This should on no account l>c touched. Pendulous external hem- 
 orrhoids can also be taken away at the same time. 
 
 In rectal operations, when an anaesthetic is employed, the patient requires to be 
 brought completely under its influence. It is probably advisable to use anaesthetics in 
 all cases. 
 
 Local anaesthesia in these operations is worse than a delusion except for the removal 
 of external piles, but it is of use to assist their reduction when inflamed and edematous, 
 and to give relief after operation. 
 
 The danger of operating is but small, though fatal cases have followed both the liga- 
 ture and the cautery ; the advocates of the latter say it is safer than the former. Mr. 
 Henry Smith had only four deaths in four hundred cases operated on by the actual 
 cautery. 
 
 Prolapsus Recti. 
 
 This is met with in every degree of severity, from the mere protrusion of a ring of 
 mucous membrane through the anus (Fig. 328) to the prolapse of even a foot of etdire 
 
 bowel. In children a mild form is very common ; it is 
 ifiG. 6^». usually a symptom either of some urinary irritation, such 
 
 as a stone, or of a long or adherent prepuce ; worms, con- 
 stipation, dysentery, a poli/pus, or any rectal irritation 
 may likewise induce it, as may a cough in very feeble 
 subjects where the sphincter has lost its tone. One of 
 the worst cases I have seen in an adult was due to the 
 existence of a villous polypus high up the rectum ; the 
 straining accompanying the affection and the hemorrhage 
 were very severe, but a rapid recovery ensued on the 
 removal of the growth. In another case, that of a lady, 
 where the bowel had come down for sixteen years, 
 accompanied with daily hemorrhage, and in which walk- 
 ing was rendered impossible from the extent of prolapse 
 '"'.■'"' (about six inches of bowel), the removal of the mucous 
 
 „ , I. f^ membrane in three portions by clamp and cautery 
 
 rapidly effected a cure. To ascertain the true cause of 
 the affection, consequently, is the first aim of the surgeon, the treatment being then com- 
 paratively simple. On its removal the prolapse rapidly disappears. 
 
 Treatment. — Whenever the bowel comes down, it should be returned; and this can 
 usually be effected by placing the patient in the recumbent posture and pressing with 
 oiled fingers flat upon the part. In children the utmost gentleness should be employed, 
 for with pain resistance is produced, and with it increased difficulty in reduction. Under 
 all circumstances the patient should be kept in the recumbent posture. The bowels 
 should in children be relieved lying down, and in adults the horizontal posture ought 
 always to be assumed after natural relief. Brodie advised nocturnal relief of the bowels 
 to be encouraged with this object. When the parts have been down for some time, the 
 greatest trouble is often experienced in their reduction ; indeed, sometimes it is impos- 
 sible, although, with the patient antBsthetized, success may attend the gentlest efforts 
 when forcible attempts had previously failed. When the bowel has been reduced, a good 
 pad or sponge fastened on with a T-bandage will keep it in place, or the nates may be 
 fastened together with some good bands of strapping. When the bowel is inflamed or 
 ulcerated — a condition that soon occurs in chronic cases when the patient goes about — 
 some slight scarification may be called for ; but the application of cold in the form of 
 ice is probably the best treatment. In obstinate cases in children the free application of 
 the nitrate of silver in stick to the whole mucous surface, previously wiped with lint and 
 subsequently mopped, is often followed by its reduction and retention. I have never seen 
 this practice do harm, and one application has often cured the disease. The injection of 
 three or four ounces of Vater made astringent with tannic acid in the proportion of three 
 grains to the ounce, or with tincture of iron ten drops to the ounce, or of the infusion 
 of krameria or decoction of oak bark, with or without alum, after the bowels have been 
 relieved, is a valuable adjunct; in adults the tannic acid suppository twice a day is use- 
 ful, as also the application of the tannic acid glycerine before its reduction. A mixture 
 of the solution of the perchloride of iron with two of glycerine is likewise a good appli- 
 cation. Costiveness should never be allowed, either enemata being used to keep the 
 bowels empty or the mildest laxatives, as rhubarb, castor oil, or some natural saline 
 
I'ni.vrrs OF ruF. iiFrrr.M. 577 
 
 water, as tlic I'ulliia or I'licilriclisliall, 'I'o ^ivi' the lj<»\vcl toin;, tonics, as a rule, are 
 n'(|uiro(l, mix voinica l)i'iiiir prohalily tlic Ix'st, cither almic or in comhinatiMU with iron. 
 1 have never eiii|thiyi'(l this (IriiL,^ in chihlren, as the siinph'r tonics usually sutiicc, thijujifh 
 some suri;eoMs speak hit^hly "i" it. In cliililrtMi, as an alt(!rativc. rhubarb, soda, ami 
 caluiuba mixed arc to \w rceomniended. In mor»3 severe eases (»f' prolapse the upplicatioii 
 of nitric aeid in vertical strips is very valuable, or, what is l)etter, the thernio eauterv, 
 similarly aj)plied. In l>ad cases it may be necessary t<i remove three or four vertical folds 
 of mucous membrane with the clamp and cautery, as for piles. Kew operatiojis in sur- 
 i;ery are more successful than this; and althoutrh in children it is jirobably never rcfjuired, 
 yet in adults it should never be rejected exce])t for the same causes as operations for lien»- 
 orrhoids. In very extreme ca.scs of j)rolapse tlic linear cauterization of the prolap.sed 
 bowel may be advantageously employed. 
 
 The treatment of such a case wouli' be jirecisely similar to tliat laid down in the last 
 section for piles. 
 
 Polypus of the Rectum. 
 
 This is not so rare a disease as authors would lead us to believe. In the adult it is 
 so, comparatively, but in tlie child it is thi; priiuip'il rmise of hcmorrluiffe from the bov)el, 
 and from this fact cases of polypus have been doubtless put down as those of piles. 
 These iirowths arc ji;enerally found in children under ten years of age, and in male more 
 commonly than in female subjects, since out of 18 consecutive cases 14 were in males, 13 
 in children under ten, and 5 in adults. These growths vary in size from that of a pea to 
 that of a large cherry ; they grow from the submucous tissue and are covered bv mucous 
 membrane. When far beyond the reach of the sphincter and small, they })robal)ly do not 
 cause any inconvenience, tliough when large they may give rise to straining of the bowel, 
 to prolajisus recti, and even to intussusception. One of the worst examples of prolapsus 
 recti I have ever been called upon to treat was due to the presence of a til)rous polypus 
 situated some inches up the bowel of a man fifty years of age who had suffered from it 
 for twenty years. He was cured by the removal of the growth. Mr. l\)llock ( Holmes's 
 Si/sf., vol. iv. ed. 2) has given a case in which intussusception took place, and in a case 
 of my own the same result ensued. As it nears the sphincter local irritation and hem- 
 orrhage are produced, the growth appearing often at the anus as a pink or red cherry. 
 Blood sometimes flows from the anus only during defecation, at other times quite inde- 
 pendently of it. When the polypus is low down, there is usually with the blood a free 
 discharge of mucus. 
 
 Whenever a child is brought with these symptoms, a local examination should be 
 made ; and to do this efficiently the surgeon should sweep his finger well into the rectum 
 completely round the walls of the bowel. By doing this the polypus will be dragged 
 from its attachment and its pedicle made tense. Sometimes several polypi exist together. 
 I have on one occasion removed three. They are made up of fibro-cellular tissue, being 
 more or less fibrous according to the age of the patient ; in the adult the fibrous element 
 predominates. 
 
 When polypi have been discovered, their removal is the only correct practice. In 
 children, when I detect them with the finger, I generally manage to hook them down, 
 and in so doing break them off. I have never seen any bleeding follow this measure. 
 On several occasions, when I have brought the growth external to the sphincter, the 
 action of the muscle has broken it away ; and in this manner, doubtless, many cases of 
 polypi are naturally cured. When they do not break off', a ligature may be applied to 
 the pedicle and the growth cut off beyond the knot. In adults the ligature should 
 always be employed. 
 
 On the removal of the disease the symptoms disappear ; but when they continue, a 
 second ]iolypus will generally be found. 
 
 Papillary or villous growths are occasioiu\lly met with in the rectum, as in 
 other ))arts of the large intestine ; and when low down, they give rise to violent .straining 
 and hemorrhage. This straining may, indeed, give rise to an intussusception of the bowel 
 or to prolapsus recti. This was well exemplified in the case of a woman xt. 43 whom I 
 had under my care in June, 1867. She had suffered from prolapsus recti, with more or 
 less bleeding after every motion, for twenty years, the straining at times being most dis- 
 tressing. When I saw her. the bowel was down for about nine inches ; blood was then 
 passing, and the pain was great. I made a careful exaiuination, but failed to find any- 
 thing. I reduced the prolapsus and prescribed rest. On my second visit, with the bowel 
 only down a very little. I examined her again, and with mv finger could just touch a new 
 37 ' 
 
578 
 
 SURGERY OF THE AXUS AND RECTUM. 
 
 growth. With a pair of long fenestrated forceps I took hold of it and l)roiight it down 
 finding a splendid specimen of the villous polypus. I put a ligature round its base at 
 
 Fig. :r29. 
 
 Fig. 330. 
 
 Fig. .330. — Vertical section of Polypus through the line a. Fig. 
 .329, showing vascular simple and compound villi covered witl» 
 a columnar epithelium, large vessels in the base on which the 
 villi rest, and sections of tlie follicles of Lieberkiihn. This 
 section represents half the thickness of a lobule of the poly- 
 pus seen by 1 4-inch power. (Dr. ^loxon's Report on Villotts 
 Growth, with drawings.) 
 
 In 
 
 Villous Polypus of Rectum. 
 
 once and cut off the growth. No single 
 unfavorable symptom subsequently ap- 
 peared ; all her former troubles at once 
 vanished, and a complete recovery en- 
 sued. In June, 1870, this woman was 
 still well. The growth is illustrated in 
 Fig. 329, and its microscopical appear- 
 ances in Fig. 330. 
 
 Condylomata are also very com- 
 mon about the anus, and are mostly, but 
 
 not always, syphilitic, the irritation of dirt being probably sufficient to produce them 
 children they seem to come from the irritation of worms. 
 
 Treatment. — Cleanliness, the application of nitrate of silver, and the dusting of 
 their surfaces with calomel or oxide of zinc generally produce a rapid cure. Vegetations 
 due to the irritation of acrid discharges, such as gonorrhoea or syphilis, require to be 
 excised. 
 
 W^arty grovrths are also met with about the anus, as on other cutaneous surfaces. 
 Sometimes they grow to a great extent, and then require excision. I have removed a 
 mass the size of a fist. 
 
 Pruritus ani should generally be looked upon as a symptom of some rectal or intes- 
 tinal irritation, constipation, or rectal disease. It is always a source of great distress, the 
 most distressing cases being those in which the symptoms occur at night in bed, preventing 
 sleep. The best application I know for its relief is a cold sponge, and, having dried the 
 parts, the ointment made of equal parts of zinc, nitrate of mercury, and subacetate of 
 lead ointments. Zinc and opium ointment is also beneficial. The application of cold 
 through the rectum plug may also be recommended. These remedies, however, only 
 relieve the symptom ; in order to cure it the cause must be found out and removed. If 
 ascarides be the cause, Agnew advises an injection of carbolic acid and olive oil (one part 
 to six), and in obstinate cases an enema of bromide of potash .^ss dissolved in cosmoline 
 giv ; in nocturnal pruritus, iodoform gr. iij or iv as a .suppository. When due to the 
 presence of minute cracks and fissures, a solution of nitrate of silver gr. x to xx in an 
 ounce of spirits of nitre is good. 
 
 Ulceration of the Rectum and Stricture. 
 
 The painful ulcer of the anus or anal orifice of the rectum has been already noticed, 
 and it remains for us to con.sider briefly such other forms of ulceration of the rectum as 
 are met with in practice. They may be described as simple, si/phil'dic, and cancerous. 
 Simple ulceration is by no means unfrequent ; and when not involving the anus, it gives 
 rise to symptoms which are usually looked upon as dysenteric. The passage of lumpy 
 feces with blood and muco-purulent discharge is the chief symptom. The rapid passage 
 of the intestinal contents through the sigmoid flexure and rectum gives rise to a slight 
 griping pain, but beyond this there are few general symptoms. On examining a rectum 
 under these circum.stances a single ulcer will probably be found, but occasionally others. 
 It may be somewhat indurated at its edges, though its base is not so as a whole. It is 
 often circular, and at times surrounding half the rectum, [n the case of a bov act. 16 
 
iij'EiiATios OF riii: nhciTM A.\n sruicrriii:. ,-,79 
 
 under my t rfatinciit the siirlacc ol'tlic ulcer was su rnxliilar that I <lioul<l li.ive suhpeeted 
 its euiieiM'ous nature had I uiet with it in an adult, hut in this instaiiee it had existed i'ur 
 many mduths, and the granulations had assumed a ixtlypoid nature. It ended in a 
 recovery. These simple ulecrs are also likely to y»erforate the hhulder and to induce 
 recto-vesical fistula. 1 liave had five such cases, and in four ccdotomy was performed 
 with success, the operation takin>r away tlie chief source of distre.s.s — viz., the passaf^e of 
 feces with the urine — |)ndonj;in;; lil'e. and ajtparently allowin^-^ the ulcers to heal. ( Vidr 
 paper by author, ('liiiivnl Sue, ISTli. ) 
 
 Trk.vT.MK.NT. — These cases can he treate(l hy jreneral means, such as a careful rejru- 
 lation of the diet, alkaline medicines with tonics, the administration of laxatives, such as 
 the mistura olei, to cause and maintain a .soft cfnidition of the feces, and the daily adminis- 
 tration of a small two-ounce enema of starch and ojiium or simple oil. The recumbent 
 position should lie maintained as much as possible. 
 
 Tnder these circumstances a jrood recovery frenerally takes [ilace. 
 
 When these ulcers involve the anus, they give ri.se to the same painful symptoms as 
 the painful ulcer of the anus and must be treated in a similar way — viz., by divisifin of 
 the superfiii:il Hlncs nf the >phincter. 
 
 Syphilitic disease of the rectum is a more common affection and is met with 
 in both sexes, though more fretjueiitly in women than in men, the disea.se apparently 
 creeping IVom the vagina to the rectum. Occasionally it is due, doubtless, to direct intro- 
 duction of the poison. It appears as a more or less extensive ulceration of the lower two 
 inches of the rectum, and, as a rule, involves the anus, as well as passing higher up the 
 rectum. It is a disease of the mucous and submucous tissues, and is indicated in its 
 early stage by a syiongy induration of these tissues, and later by ulceration and the dis- 
 charge of a highly irritating, sero-purulent. or sanguineous discharge and by a patulous 
 anus. The anus itself may also be the seat of the lateral, flattened, fleshy, cutaneous 
 outgrowtli so common in syphilis, or it may be ulcerated. It is generally a di.sease of 
 young adult life and associated with some syphilitic history. 
 
 8v.MPTOM.s. — There is almost always some pain in the act of defecation, some looseness 
 of the bowels and discharge of blood, .pus, or mucus. Anal or vaginal fistulas sometimes 
 complicate the case. In neglected cases, where cicatrization has gone on with spreading 
 ulceration, there may be constipation and some stricture ; indeed, as a cause of stricture 
 of the rectum, this syphilitic disease is by no means unusual. 
 
 Treat.mext. — Recognizing its .syphilitic origin, large doses of the iodide of potassium 
 ought to be given — five grains, gradually increased to ten or twenty, three times a day — 
 in some bitter infusion or bark ; but when tonics are indicated, they may be given in 
 combination. The bowels should be kept slightly loose by the daily dose of olive oil or 
 castor oil, so regulated as not to purge, and the daily employment of an enema of starch 
 or gruel, with or without oil, to keep the parts clean and free from the irritation of feces. 
 
 The recumbent posture should likewise be observed, and simple, nutritious, but not 
 bulky, food taken. 
 
 Locally, absolute cleanliness is essential. Where contraction exists or is taking place, 
 the daily introductiotj of a bougie anointed with some mild mercurial ointment such as 
 the unguentum metallorum may be used, but for the patient the daily introduction of a 
 candle similarly anointed is preferable, candles being made of all sizes. Nothing like 
 mechanical dilatation should be thought of, as it is dangerous in the extreme. By these 
 means a cure may be effected, though such can only be complete after the treatment of 
 months. In very neglected or severe cases a cure is almost hopeless without colotomy. 
 I have had some striking examples under my care illustrating well the advantages 
 of this operation. The recognition of the disease as syphilitic is the main point of 
 importance. 
 
 Foreign authors describe chancroid disease of the rectum as venereal, and not syphili- 
 tic ; but in this country it is hardly recognized. Such may, however, be found amongst 
 the cases described as simple ulceration. 
 
 Cancerous ulceration of the rectum, usually epithehal, sometimes vil- 
 lous, rarely carcinomatous, is generally met with two or three inches up the bowel. It 
 occasionally occurs higher up and beyond the reach of the finger in the rectum, and occa- 
 sionally lower down, nearer the anus or involving it. It is remarkably insidious in its 
 origin and uncertain in its progress, giving rise at first only to such symptoms as are usu- 
 ally put down to con.stipation, for this symptom is the most prominent feature, while the 
 occasional pain and bearing down or straining are looked upon as the result of the consJti- 
 pation. In a general way, it is only when some blood or sero-purulent fluid has pas.sed, 
 
580 SURGERY OF THE AXUS AXD RECTUM. 
 
 with or without a motion, that surgical aid is sought ; and it is under such circumstances 
 that the surgeon discovers, on making a local examination, that such a serious disease 
 exists. 
 
 The cancerous ulcer can rarely be overlooked and occurs as an indurated, nodular, 
 irregular mass. In its early stage the surface may be smooth ; in a later, irregular, from 
 ulceration ; the discharge, which is generally very often.sive. is made up of broken-up tis- 
 sue, blood, and thin pus. The disease involves, as a rule, the whole circumference of the 
 bowel ; at others, only a part. It is always associated with a narrowing of the canal, 
 which will go on to cause its complete occlusion. It generally attacks patients pa.st mid- 
 dle life, but it may be found in the young. I have seen it in a boy aet. 15, and in Sep- 
 tember, 1871, I attended, with Mr. Turner of Bermondsey. a girl aet. IS who had had 
 insuperable constipation for seven weeks. I opened her colon in the n'>jJit loin with great 
 relief, and she was up and about in six weeks. She died ten months after the operation 
 (June, 1872) with a rectum complete!}/ occluded from cancerous disease, and with second- 
 ary tubercles in the pelvic peritoneum. The disease was examined at the Pathological 
 Society by the committee on morbid growths, and was found by Dr. Hilton Fagge and 
 Dr. Goodhart to be of a cancerous nature, confined to the peritoneum and ovarv. and 
 only leading to sti'icture of the bowel by a secondary process of contraction. The stric- 
 ture has an ulcerated surface, but the mucous membrane did not show any cancerou.s 
 elements (Trans. Path. Soc. 1875). 
 
 Treatment. — Palliative treatment can alone be thought of. such as the maintenance 
 and improvement of the general health by diet and tonics ; the removal of all local causes 
 of irritation by the use of laxatives, to render the motions more liquid, and consequently 
 more easy for evacuation ; and the relief of pain by the use of enemata of starch and 
 opium or by morphia suppositories. 
 
 In the very early stage of the affection, before ulceration has taken place, the use of 
 bougies may be justifiable and useful, but when ulceration exists they are injurious and 
 dangerous. When the ob.struction becomes a symptom of importance, surgical treatment 
 will have to be thought of; but this will be considered under the heading "Stricture of 
 the Bowel." 
 
 Complications of Ulceration. — All cases of ulceration of the rectum may go on 
 to cause stricture : the cancerous cases to a certainty must, the syphilitic often do. and 
 the simple may when extensive. The two latter cause a cicatricird stricture resulting 
 from the contraction of the cicatricial tissue in the mucous and submucous tissue, the 
 first producing a stricture by simple increment. Thej- may also be complicated with 
 deep-seated abscesses and fistulje and with hemorrhoids. The surgeon should, therefore, 
 always be careful, when treating these affections, to examine the rectum minutely, as it is 
 only too common to meet with cases that have been subjected to useless operation for 
 piles and fistula when these affections were the results of a far more serious disease, such 
 as stricture or ulceration of the rectum. 
 
 Again, any of these forms of ulceration may extend into the bladder or urethra. I 
 have had five examples of such cases of vesico-intestinal fistula under my care in males 
 and one in a female, in all of which the agonies of a foreign body in the bladder were 
 added to those produced by the ulceration, and in the four male cases complete relief was 
 afforded by colotomy. In three of these the ulceration seemed to be of the simple kind. 
 In another the existence of rectal ulceration was first revealed by a sudden rush of urine 
 through the rectum after an attack of retention. 
 
 I have seen many cases of recto-vaginal fistula as a consequence of syphilitic and 
 cancerous di.sease. 
 
 Stricture of the Rectum. 
 
 In the majority of cases this is caused by cancerous disease ; in many it is the result 
 of an inflammatory process, simple or svphilitic, from the cicatrization of deep-seated and 
 extensive ulceration ; in others it is due to the contraction of inflammatory material poured 
 out in the submucous tissue : in exceptional instances it may arise from contraction of the 
 parts external to the bowel after pelvic cellulitis : and Curling quotes a case where it was 
 the direct result of an injury. 
 
 In all these conditions the calibre of the intestine is gradually or rapidly encroached 
 upon, till at last complete obstruction takes place. The stricture may appear after death 
 as an anmdar contraction of the bowel with adventitious material in the submucous 
 tissue and hypertrophy of the muscular coat, looking very like a so-called scirrhous 
 pylorus, or as a thickened, ulcerated, irregular mass of cancerous material infiltrating all 
 
STiucrriir: or riii: /:i:<rrM. 
 
 681 
 
 Stricture of Rectum. 
 (32.5iJ<-', (juy's Hosp. Mifs.) 
 
 tin- li.ssufs ol' llic liKWcl altliiui^li rarely cxti-iKiiiij: IicY'MkI two or tlin-c inclics in li'ri;:lli. 
 Tlu- Ixiwi'l iibdVf the stricture will ul\v;iys lit- tlilatcd, at times even to riipl iiriii;:. ulceration 
 of tile colon lieiii^' a very common conse(juence ot" tlie <lilatation. 
 IJelow the stricture there will olteii he found pcfluiiculated, flerthy, 
 or cancerous <:rowths. These points are well seen in Ki^. \\\\\. 
 
 It has heen already |)ointe(l out that fistula, isehio-reetal, vesi- 
 cal, or va>:iiial, ahscesses, and hemorrlinids are conminM accom- 
 yianinicnts of stricture. 
 
 The disease, taken as a whole, is twice as common in women as 
 in men, and I found from my own notes that W'l out of 4S consec- 
 utivi' casi's were of the former sex. Hut syphilitic stricture i- 
 more common in the female, and cancerous in the male. Curlin;;. 
 in »|Uotinjr t!7 cases of cancer, jxives 44 in males. In my 4S cases 
 2(» were found in suhjects under thirty, 1.') of these hein<; women, 
 and mostly, if not all, .syphilitic; 22 were in subjects over forty, 
 half heiuir men, the majority of these being probably cancerou.s. 
 
 The approach of the disease is very insidious, whatever may 
 he its origin or nature, and the symptoms are generally such as 
 have been given under the heading of '• Cancerous Ulceration of 
 the Bowel." 
 
 OniatiiKtiliiH is the one early symptom, and it is not till some 
 ulcerati(jn has commenced, either at the stricture or above it, that 
 others a{)pear. Of these the most common are diarrhced with 
 lumpy stools containing blood, pus. or mucus; sfrnitu'iif/ at stool and a sf/isafion <>J hnni- 
 ing'in the part afterward ; at last a complete stoppage, abdominal distension, and dyspeptic 
 symptoms. 
 
 An examination with the finger carefully introduced into the rectum will, as a rule, 
 at once reveal the true nature of the ca.se ; for about two inches up the bowel the nar- 
 rowing will usually be felt, with or without ulceration, or the infiltration of the part with 
 new ti.ssue. Sometimes the .stricture is beyond the reach of the finger, and then, prob- 
 ably, Vty pressure upon the abdomen above the pelvis with the free hand or by the intro- 
 duction of the hand into the rectum, the disease may be felt. 
 
 When the stricture is annular, it is probably cicatricial or fibrous, possibly cancerous. 
 
 When ('plthell(d or positively cancerous, it will be infiltrated with a nodular, irregular 
 mass of new ti.ssue, which may be breaking down and ulcerating ; and occasionally the 
 mass can be felt externally at the brim of the pelvis, over the left iliac fossa. 
 
 When si/jt/n'/(fi(\ the ulceration will pntbably extend upward from the anus, and such 
 anal integuniental outgrowths as have been already mentioned will exist. 
 
 In ordinary cases of cancerous stricture there is an inch of healthy rectum between 
 the stricture and the anus, though in exceptional instances and where disease is extensive 
 the anus is involved. 
 
 In advanced ea.ses the anus will appear patulous, and on separating the buttocks a 
 red. a brickdust-colored, feculent discharge may run out ; wind will also pass without 
 effort. 
 
 To the flat, tape-like, or figured feces which some authors regard as being character- 
 istic of this disea.se I concur with Curling in not ascribing much importance, .«;ince such 
 a condition of motion is not uncommon even in a state of health when the bowels are 
 irritable ; besides, many other conditions of the pelvic parts may give rise to the same 
 thing. When a patient never pa.s.«es a well-formed motion, large or small, the case looks 
 suspicious; and when, on the other hand, a large well-formed stool is occasionally seen, 
 the probabilities of a stricture existing are very slight. 
 
 The examination of a diseased rectum with a tube, flexible or otherwise, with or with- 
 out injection, requires the greatest care and gentleness, as the gut is easily perforated or 
 ru]itured: moreover, the surgeon may be misled to suspect obstruction where none exists 
 by the end of the instrument striking against the sacrum or being caught in a fold of 
 mucous membrane. 
 
 It must also be remembered, in examining a rectum for a supposed stricture, that its 
 calibre may be more or less completely encroached upon by pelvic tumors, uterine, ova- 
 rian, prostatic, hydatid, or bony. Some few years ago I had a case with Dr. DeAth of 
 Buckingham in which a hydatid tunmr caused complete obstruction to the rectum as 
 well as to the bladder, and. although the latter organ was emptied on the evacuation 
 of the hydatid contents, the patient died unrelieved from an enormously over-distended 
 
582 SURGERY OF THE ANUS AND RECTUM. 
 
 and ruptured colon (Trans. P,ith Socicfy, 1886). In April, 1870, I saw, with Mr. Phillips 
 of Leinster Stjuare, a mo.st intere.sting case of complete ob.struction of the bowel.s in a lady 
 set. 46, caused by the presence of a large, loose, cancerous growth hanging from the peri- 
 toneum into the pelvis, covering in the promontory of the sacrum. The tumor had been 
 regarded by an eminent {thysician-aceoucheur as uterine. Colotomy was performed with 
 great relief, but death took place on the third day, from collapse caused by a sudden rup- 
 ture of the tumor and escape of its softened contents into the peritoneal cavity. In 
 March, 1875, I also opened the descending colon of a boy a3t. 18 for complete obstruction 
 of the rectum from a cancerous tumor that filled the pelvis and the abdomen as high as 
 the umbilicus. The boy survived the operation two months, dying from other causes 
 than obstruction. 
 
 Treatment. — It is so rare for a surgeon to be consulted about a stricture of the 
 rectum till either the ulcerative stage has set in or almo.st complete obstruction has taken 
 place that he has few opportunities of testing the value of dilatation of the stricture, 
 since this practice is clearly useless, if not injurious, under these circumstances. In cica- 
 tricial or inflammatory strictures, however, it is the only form of practice upon which 
 reliance can be placed. 
 
 Dilatation should be effected by mechanical means, but applied with caution ; forcible 
 dilatation is inadmissible. Many instruments have been invented for the purpose, but 
 the elastic-gum bougie is the favorite. I have, however, known so much harm to follow 
 its use that I have abandoned it and prefer the sponge-tent, by which a stricture can be 
 dilated in a painless and less dangerous way. When it does not produce any irritation, a 
 second and larger may be passed in two days ; but when irritation is .set up, the repetition 
 of the operation should be postponed till it has subsided. By these means a simple stric- 
 ture may be checked in its progress, and even dilated, though rarely cured. This prac- 
 tice may, however, prolong life for years. Mr. Curling gives a case in which he believes 
 he cured an annular stricture in a lady set. 24 by incisions and dilatation. I can record a 
 case which occurred in a lady agt. 30 who some years before had had what she called 
 dysentery. When I saw her, the rectum, about one inch from the anus, was narrowed by 
 a diaphragmatic stricture which would only admit a probe. I incised this in three direc- 
 tions and kept it dilated with bougies. Three years later, when she died, no evidence of 
 stricture could be made out. Another case in whicii for two years a lady has been in 
 complete comfort after the operation has come under my care. 
 
 M. Verneuil, in the Gazette Mediade de Paris for January, 1873, has advocated the 
 operation of rectotomy for the cure of stricture. This operation consists in an incision by 
 means of a blunt-pointed bistoury introduced flatwise through the stricture, guided by the 
 index finger of the left hand, and the divi.sion of the entire thickness of the strictured 
 bowel downward and in the median dorsal line, through the anus and the sphincter, the 
 free division of this muscle evidently playing as important a part in giving relief as 
 the division of the stricture. Drs. C. Lente (American Journ. of Med. Sciences, July, 
 1873) and C. B. Kelsey of Xew York (Neir York Med. Jovrn., March, 1880) have also 
 advocated a like practice, at the same time adopting an anterior as well as posterior incis- 
 ion in non-malignant strictures. Dr. Kelsey's paper shows that where the disease is 
 quite low down and within easy reach of the finger this operation gives almost as much 
 relief as colotomy. 
 
 This dilatation, however, is only a means to an end ; and that end is to secure an open- 
 ing for the passage of the intestinal contents. Enemata are valuable aids to efl"ect this 
 purpose, the daily washing out of the bowel with gruel and oil or the daily use of mist, 
 olei with manna, confection of senna with sulphur, or any other gentle laxative that the 
 patient by experience has found to suit, giving great relief. Cod-liver oil in full doses 
 often acts as a laxative as well as a tonic. Care, too, should be observed in the introduc- 
 tion of the tube ; for in a cancerous bowel perforation is very liable to occur, and even 
 in a healthy one this accident has taken place. The Guy's Museum contains a prep. 
 (1877'*") in which the colon was perforated by a bougie thirteen inches from the anus for 
 an imaginary stricture, and a second (1877-°) in which an O'Beirne's tube perforated the 
 rectum five inches from the anus in an attempt to pass it up the healthy bowel to give 
 relief in a case of obstruction after the reduction of a hernia. 
 
 How far it is safe to allow a patient to pass a bougie for himself or herself is another 
 question. I am disposed to think it is unwise to allow it when the bougie is solid, hav- 
 ing seen great irritation, and consequently harm, follow the practice, and in several cases 
 deep-seated suppuration. Curling has given a case where the patient caused his own 
 death by perforating the bowel half an inch in extent above the stricture. I have con- 
 
j:.\cjsi().\ or rui: i.nwi:/: i:\n or riir. rectum. 583 
 
 .s('(|iifiitly liffii ill tlic li;il)it (if iiistnictiiij:: my patients tu use lullnw imikUcs as I)i»u(^ie8, 
 ami liavi' l)ffii satisliftl with the pracliic. 
 
 'I'litTc cimics a time, liowi'vcr. when tliis tn-atiiifiit l»v iliialatiun ccuhiis to Ix; ht-iiftioiul 
 »ir wlicii it is associated with mih-li distress, as wliuii thi- stricture has dostid or ulceratcid. 
 I'lidcr thc.-c circumstances the i|uestiou of r.irislnii of this disease or of the operation of 
 e()h>totiiy may l»e coiisiih-red. 'I'he former operation may he disi-ir-sed hiter on. 'I'he hitter 
 ;;ives comfort to a ih'i;ree tliat sometimes astonishes and always j^ratities; it prohjn^s life 
 and adds materially to its comfort, and little more than this can hi; said of most operations ; 
 nitU'cover. it is not fmml to be practically associated with such inconvenience as sur^^eons 
 of old have theoretically attributed to it. Hut it should not b(! postponed till the powers 
 of life have become so exhausted as to render poor tlic chances of recovery from the ope- 
 ration, or till th(> ciocum or lar<;e intestitie has l)econ»e so distended as to be much damaged 
 or iuHamed. It shouhl be undertaken as scjon as it is clear that the disease has i»aHsed 
 beyoiul the ri'acdi of local treatment and the n'cneral powers of the patient ava hftginnlnf/ to 
 fail, CM' as soon as the local distress finds no relief from jialliative measures and a downward 
 course is evidently a)»proachinu'. Tin; ditiiculties of colot<imy are not great, nor are its 
 dangers numerous; when Kiisiirccs!<fii/j it has often been nuide so by delay in its perform- 
 ance, from the want of power in the patient, or from the secondary effects of the disease 
 on the alxlomiiial viscera. When iiinxf siicrtss/iilj it gives immediate relief to most of the 
 •symptoms and makes life worth retaining ; when Ini.sf so, it lessens pain and renders endur- 
 able what remains of life. The operation is now established, and creditably so to surgical 
 art, although it must be admitted that in the general way it is apt to be postponed until 
 too late a period to demonstrate its full value. 
 
 Excision of the Lower End of the Rectum. 
 
 This operation lias but recently received attention in this country as a means of cure 
 for cancerous and other strictures of the rectum, although practised abroad by Lisfranc 
 and others fifty years ago. It has, however, been performed by Billroth, l)y Dr. Levis of 
 Pennsylvania, and by other surgeons. Billroth reports that he lost 19 out of 45 cases of 
 this operation, and that tlie majority of liis cases were unsatisfactory. Cripps's statistics 
 are more satisfactory ; he records also (Jacksonian prize essay 1877) that in 23 cases 
 defecation was subsecjuently normal, in that feces could be retained when not too fluid, 
 and in 7 that there was incontinence. With these facts, it is clear that the operation for 
 the removal of cancerous or other disease of the rectum by excision is a justifiable, and 
 possibly a beneficial, measure, and that it should be undertaken when the disease is local 
 and can be so defined and isolated as to come within the reach of the surgeon's skill. 
 
 It is clearly inapplicable when the disease has extended high up and the parts around 
 the rectum are infiltrated with cancerous disease. I quite accord with this view, and have 
 acted upon it in four cases, all females, with good success. All survived the operation — 
 one for t\vo years, when a return took place, and the patient died from visceral cancer ; 
 one lived fourteen months, and two are now alive, twelve and thirteen months after the 
 operation, and in comparative comfort. 
 
 It would seem that about two and a half to three inches of rectum may be removed 
 with .safety, and that when the bladder is fairly distended and traction is made upon the 
 rectum the peritoneal pouch is less likely to be drawn down with it than when the bladder 
 is empty. I have satisfied myself upon these points by experiments upon the cadaver. 
 
 Operation. — After a metallic bougie has been introduced into the bladder to serve as 
 a guide to the position of the urethra and to steady it, an incision is to be made from the 
 base of the scrotum to the coccyx, encircling both sides of the anal aperture. The hand 
 of the operator may then be introduced behind the bowel into the hollow of the sacrum, 
 in order to tear the rectum loose from its posterior attachments. By means of the finger 
 and a pair of scissors the adhesions all around the rectum where, on account of the disease, 
 it may be firmly attached to the prostate gland and neck of the bladder, should be broken 
 up. The cancerous gut should next be carefully dissected from these parts, exposing to 
 view the prostate and the lower part of the bladder ; all bleeding vessels should be care- 
 fully ligatured or torsed as soon as divided, and sutures pas.sed through the rectum, above 
 the proposed line of incision. These should not, however, be fastened, but left in posi- 
 tion, to give perfect control over the parts. When the rectum, including the cancerous 
 portion, has been thus carefully and thoroughly isolated, it should be drawn down and 
 separated by means of scissors: there is no advantage to be gained by stitching the gut 
 to the surrounding integuments. After the operation a good drainage-tube should be 
 
584 SURGERY OF THE ANUS AND RECTUM. 
 
 introduced well into the posterior part of the sacral cavity, and sutures employed to bring 
 the integuments together. The wound should be kept clean by daily irrigation. 
 
 Atony of the Colon and Dilatation of the Rectum. 
 
 These conditions are not unfrequently met with in practice. In old people the colon, 
 for want of power, often becomes enormously distended with feculent matter from gradual 
 accumulation, and this condition frequently causes death. In some cases it gives rise to 
 the idea of stricture of the rectum, and every surgeon must have been called to cases in 
 which impacted feces in the rectum and colon, associated with the discharge of small, 
 loose, offensive motions, mixed with mucus, and sometimes wuth blood, have misled the 
 attendant. Some years ago I was asked to see a lady over seventy who had been bed- 
 ridden for six months and was supposed to be dying from constipation and stricture of 
 the rectum, nothing but small, lumpy, and loose motions having passed. Xo disease 
 whatever existed beyond the impacted rectum and distended colon from atony of the 
 bowel from old age. The masses were mechanically removed by means of the lithotomy 
 scoop and enemata of oil, etc., and she lived four years afterward and died .simply of old age. 
 
 Treatment. — In this form of constipation the value of nux vomica is well seen, a 
 pill composed of half a grain of the extract with half a grain of belladonna, twice a week 
 or oftener, giving tone to the intestine and acting as a purge. 
 
 In women especially who have been in the habit of neglecting their bowels and allow- 
 ing the rectum to be a closed receptacle for feculent matter the cavity not only becomes 
 much distended, but seems to lose the power of contracting and expelling its contents. I 
 had some years ago, at Gruy's, a case illustrating these points. The rectum, on examina- 
 tion, feeling like a loose bag, large enough to admit a fist, was always full, having evi- 
 dently lost all power of expulsion. The woman in young life had neglected her.«elf. and 
 in middle age could not overcome the effects of such neglect. By daily enemata of cold 
 water to wash out the bowel, and the subsequent injection of an astringent liquid such as 
 the decoction of bark and alum, with the daily use of a pill containing half a grain of 
 extract of nux vomica mixed with gentian, a complete recovery took place. 
 
 The Administ.ration of Food and Medicine by the Rectum. 
 
 Physiologists have Jong known that water and certain forms of food and medicines are 
 absorbed by the rectum, and physicians have acted upon this knowledge, though possibly 
 the physiological fact .has not been utilized so fully as it deserves. 
 
 It has. however, such an important bearing for good u])on surgical practice that it 
 would be well to regard the rectum as a second stomach, and in certain cases to use the 
 one for nutritive or medicinal purposes as a substitute or accessory for the other. I have 
 for years acted upon this principle, and have every reason to be satisfied with the result. 
 Indeed, in any case of disease or injury in which nutriment is essential and the stomach 
 refuses to receive or retain food, I have never hesitated to resort to the nutrient enema. 
 
 I do so also in cases of abdominal injury or disease in which it is inexpedient to give 
 the stomach or small intestines work to do. In aged patients, after injury or operation, 
 when, from shock, the stomach seems incapable of doing its duty, as well as in all cases 
 of persistent vomiting, whether after the use of ansesthetics or otherwise, it gives time 
 for the stomach to regain its tone. The use of the nutrient enema for a few hours often 
 tides over a slight, and for days over a great, difficulty, as without doubt it supplies food 
 to the body almost as well as the usual meal, and does so under circumstances in which 
 the latter cannot or ought not to be administered. In a case I had with Dr. Parsons 
 Smith of Addiscombe life was entirely maintained for fifteen weeks by its use. and I 
 could adduce others in which its beneficial influence was most marked. Dr. Flint of 
 New York has published one case in which life was sustained for fifteen months by this 
 method, and he adds that during five years the patient had depended almost entirely 
 upon it. In cases of unconsciousness from anaesthetics or otherwi.se this practice should 
 be followed in preference to any other, as it seems more than probable that under these 
 circumstances any fluid which it is attempted to pour into the mouth passes into the 
 Jungs rather than into the oesophagus, and consec{uently hastens death. 
 
 Directions for Use. 
 
 The bowels should be emptied by a simple enema before the nutrient one is intro- 
 duced. 
 
DIRKCriOSS FOR USE. 585 
 
 The nutrient ciicnia sIkhiM Ik- used cvt-ry four nr six li(*iirs, and should not consist of 
 mor»' than four nr six ouiut-s. 
 
 Thf matt-rial shuuKl he Ifpid and intmducrd slmrlif, as the rectum repudiates any 
 Hudden distension. 
 
 After its administration a najikin shouhl he jircsscd against the anu^ until tin- disjio- 
 sition to expel it has passed away. 
 
 When tile expulsive tendency is great, five or ten drops of the tincture of opiutn may 
 be atlded tn the enema ; indeed, under all circumstances, it is of advantage. 
 
 At times the enema is retained better when introduced some six inches into the rectum 
 than when only just within the sphincters. 
 
 When injections are badly tolerated at first, they may at times be well retained if they 
 are j>ersisted in. 
 
 The best materials for these enemata are milk, eggs, meat juices, with pancreas or 
 pancreatic emulsion. These may be employed at different times, since it is a mistake to 
 kee}» t(»o long to one kind. 
 
 Milk and eggs, alternating with one of meat juice and pancreas, seems to be pref- 
 erable. 
 
 I>arby's peptonized fluid meat is very good. 
 
 As a meat emulsion Kaufmann's mixture is excellent, composed of a pound of minced 
 or scraped beef, a third of a pound of fresh pancreas, and half a pint of cold water, the 
 whole allowed to macerate for three-quarters of an hour, gradually raised to the boiling 
 point, and boiled for two minutes. The mixture will then have been reduced to the con- 
 sistence of a thick soup. 
 
 Wlien this mixture is not at hand, good beef tea or mutton broth may be employed, to 
 which Liebigs extract of meat may be added. 
 
 In making beef tea or broth long boiling does no good. A pound of finely-minced 
 meat macerated in half a pint of cold water for three or four hours will give an excellent 
 mixture ; and if the whole is well shaken for half an hour, nearly the .same result is 
 obtained. 
 
 Chi several occasions I have found Slingers (of Yorkj nutrient suppo.sitories of great 
 use. 
 
 Rectal medication in its way is as valuable as alimentation, more particularly 
 when morphia, opium, or mercury is prescribed, the former drug, administered after an 
 operation Vjefore the influence of the anae.sthetic has passed ofi". doing more to calm the 
 patient and give rest than any other method, more particularly in cases of abdominal 
 surgery. 
 
 The mercurial suppository employed twice a day acts on .syphilitic patients in such a 
 quiet and beneficial way as to lead me to look upon it as the best method of bringing any 
 one under the influence of the drug. 
 
SURGERY OF THE RESPIRATORY SYSTEM. 
 
 CHAPTEK XVII 
 
 SURGICAL AFFECTIONS OF THE NOSE. 
 
 Congenital and other Defects of the Nose. 
 
 The nose may be congenitally absent or fissured, as illustrated in Fig. 52 ; the nostrils 
 may likewise be congenitally or otherwise occluded from cicatricial contraction after ulcer- 
 ation or small-pox ; and for these defects surgery may be successfully called into requi- 
 sition either to establish an orifice or to prevent its contraction. 
 
 Wounds. 
 
 Incised and lacerated wounds of the nose generally progress well, on account of the 
 freedom of its vascular supply. The edges of any wound should consequently be brought 
 carefully together and fixed with sutures, even if the part be nearly or wholly separated 
 from the body. For this purpose very fine silk ought to be used and great care exer- 
 cised in the accurate adjustment of the parts, a suture being passed through the cartilages 
 when they have been divided. In the case illustrated in Fig. 332, where the nose was 
 nearly cut off, the edges of the wound were adjusted, and a good recovery followed. 
 
 Fracture of the Nose. 
 
 This accident is not uncommon and may be simple or compound. It may likewise be 
 followed by little or great deformity, the amount depending much upon the care and skill 
 
 Fig. 332. 
 
 Fig. 333. 
 
 Drawing illustrating the Repair after an Incised 
 Wound ol the Nose. 
 
 Forceps and Nos 
 
 • Truss for Treatment of Deformed 
 Nose. 
 
 with which the broken bones have been readjusted. When displacement has taken place, 
 the surgeon must restore the misplaced bones by external manipulation, aided by pressure 
 applied from within the nasal cavity by means of the blades of the ordinary dressing for- 
 ceps or a steel probe. When the parts have been restored to their natural position, 
 or as nearly so as is possible, care must be observed that no external pressure is 
 employed by which they can be displaced. Plugging of the nostrils is useless. 
 . 68t; . 
 
A7'/7MA7V. 
 
 587 
 
 WluMi little or IK) (lis|)Ia<H'iiiont exists, nothing; Itetter is re(juire<l tliiiii the applifation of 
 culd-watiT (Ircssiiiir, <»r |ti'rlia|»s ice, for the first ft!\v hours, as these hones rapidly reunite. 
 
 Dr. li. 1>. .^Iaslt^ of Mrooklyu, I'nitcd States, has sujrjrested the use of a wire suture 
 ])assed transversely through the nose to keep depressed IVaetures in jtosition (Annals of 
 All, If. (iiiil Siny. Sotirfi/, ISSO). 
 
 When the foree has heen .severe anil direct tipnn the nose, fraeture of the skull may 
 (•oni]>li(ate the ea.se — fraeture either of the ethmoid bone forniinir the floor of the base of 
 the skull, as has been illustrated in the ehapter (ju injuries (jf the skull (Fijr. "')), or frac- 
 ture of the frontal l)one. This latter form may be generally recognized by swelling and 
 crepitation of emphysema about the forehead or the crepitus of the fracture with displace- 
 ment, etc. ('a.ses of fracture of the frontal .sinus require no special treatment, and gen- 
 erally do well. 
 
 In children the cartilage of the nose may be displaced from the nasal bones in conse- 
 <iuence of an injury, and. unless replaced, permanent deformity and obstruction \vill 
 ensue. The surgeon, conse(|uently, wlieii this accident takes ])lace, shouM do his best to 
 restore the misjdaced parts and to keep them in ajtposition, although some difficulty is 
 often experienced in its accomplishjuent. 
 
 With the view of ])reventing or correcting deformity, Mr. W. Adams has suggested 
 that tlie broken or bent septum should be straiglitened by strong plate-bladed forceps 
 (Fig. XV^, B) and the broken na.sal bones raised, these parts sub.sequently being main- 
 tained in position by an ivory clamp, and the side of the nose pressed into place by a 
 nose truss (Fig. 333, A) connected with a forehead plate (a) and band (h). The plates 
 (c) are shaped according to the outline of the nose and are made to diverge by rotating a 
 central controlling screw, the pressure of the plates being regulated by two circular 
 springs. The ivory clamp must be worn day and night for three or four days after the 
 deformity has been corrected, and the nose truss for some months during the day. 
 
 Epistaxis. 
 
 Bleeding from the no.se is an occurrence of eon.siderable frequency, and when not too 
 free or lasting rai'ely requires surgical interference. It may be the result of an injury — 
 trauimitlc — or associated with some cancerous affection or fibrous growth from the base 
 of the skull or other local cause, or it may be the direct consequence of .some fulness of 
 the vessels of the head or heart disease. It is found also as a kind of passive exudation 
 in an;\?mic and cachectic subjects after purpura or from hepatic disea.se, and also as supple- 
 mentary to the catamenia. 
 
 Trkat.mknt. — With a view to successful treatment, the cause of the bleeding mu.st 
 be ascertained. ^Vhen traumatic, it usually stops without aid. AVben due to plethora 
 of the vessels from any cause, it is often 
 
 salutary, and should be checked only when Fig. 33-1. 
 
 too copious or lasting. AVhen of a passive 
 nature, it is serious, since anaemic feeble 
 subjects cannot bear loss of blood, and the 
 loss tends to aggravate its cause. In one 
 case, therefore, saline purgatives may be 
 of value ; in another, iron in full doses, 
 or gallic acid in gr. v or gr. x doses. As 
 to its treatment no definite rules can be 
 laid down, it being a common accompani- 
 ment of so many different conditions, local 
 and general. • 
 
 W' hen, however, life is threatened by 
 its severity, real or comparative, the sur- 
 geon is bound to interfere. The head 
 should be kept raised and cold applied by. 
 means of ice to the nose and frontal si- 
 nuses. A steady stream of some cool saline 
 li(|uid (a teaspoonful of carbonate of soda 
 and common salt to a pint of water being 
 as good as any) passed through the nostril 
 is a very effectual mode of treatment. For 
 this purpose the double-action india-rubber 
 enema apparatus with a nose-piece to introduce into the nostril may be employed, or Dr. 
 
 iSt/filwn (uZm: 
 with Wd{/ht 
 
 Nasal Douche. 
 
688 SURGICAL AFFECTIONS OF THE SOSE. 
 
 Ra.<ch"s vaginal syphon douche, applied as in Fig. 334. the patient V»reathing at the time 
 through the mouth, which .should he kept wide open. Prof. AVeber of Halle having dis- 
 covered years ago that while the patient is breathing through the mouth the soft palate 
 completely closes the posterior nares and does not permit any fluid to pass into the 
 pharynx. The popular methods of placing the patient in the erect piosture and raising 
 both arms above the head may likewise be tried, as they are unquestionably good. If 
 these measures fail, the nostril or nostrils mu.st be plugged. 
 
 Plugging Nose. — To do this effectually some skill is necessary ; to do it otherwise 
 is usek>>. if lint injurious. To plug from the anterior nares alone is to trifle with the 
 hemorrhage and merely to mask the escape of blood as well as to direct it down the 
 pharynx, under which circum.stances severe loss of blood may take place without know- 
 ledge. To perform the operation of plugging effectually, a plug of lint, cotton-wool, a 
 sponge tent, or compressed sponge, an inch and a quarter long and an inch wide, should 
 be.prepared and fastened in the middle by a double piece of strong .silk or whipcord, an 
 end about six inches long being left on one side, and two ends or a loop a foot long on 
 the other. With Bellocq s canula (Fig. 335), a long-eyed probe, or an elastic catheter a 
 
 loop of the same material should be 
 Fig. 335. p)assed into the nose along its floor 
 
 through the posterior nares into the 
 pharynx, and caught either by the fin- 
 gers or forceps. This end should then 
 be fastened to the long ends on the plug 
 and the instrument withdrawn through 
 the nostril. The plug, having been well 
 oiled, is then to be drawn into the month 
 by applying traction upon the ligatures 
 protruding from the nostril, tilted with 
 Bellw^'s Canula for Plugging Nostrils. the finger behind and above the soft pal- 
 
 ate, and carefully adjusted or wedged into 
 the posterior nares, by which means the escape of blood into the pharynx will be pre- 
 vented. The two cords hanging from the anterior nares are then to be separated and the 
 nasal cavity filled with compressed sponge, lint, or cotton-wool, which should be intro- 
 duced between them, the whole mass being made secure by tying the two cords across 
 the plug that has been introduced in front and fastening them in a bow. to allow of unfas- 
 tening. When any styptic is deemed necessary, the .sponge, cotton-wool, or lint intro- 
 duced into the anterior nares may be saturated with the solution of the perchloride of 
 iron, tannin, matico, or a concentrated sohition of alum. By this means the p»ossibility 
 of any escape of blood from either opening of the nose can be effectually prevented and 
 the most dangerous epistaxis absolutely controlled. To remove the apparatus, the knot at 
 the anterior nares should be undone and the anterior plug taken out. the posterior being 
 readih" drawn from its position by means of the short end attached to it in the pharynx, 
 which may be left hanging down the patients throat. The plug should not be left in 
 more than three or four days, but may be reintroduced if necessary, the surgeon, in doing 
 so, taking care to preserve in situ the two pieces of cord that have been passed along the 
 floor of the nose. The inflating nasal india-rubber plug of Mr. H. C. Howard is like- 
 wise good for plugging purposes. It can readily be inflated when in position, and as 
 readily removed (Brit. Med. Joum., 1881, p. 8I;'G). 
 
 Lipoma — or, more correctly, Hypertrophy , 
 
 of the nose — is a readily recognizaV>le aff"ection and is a disease of the .skin and subcuta- 
 neous tissue (not of the cartilages), in which the follicles may or may not participate. It 
 is confined to the apex and the ala^ of the organ. The enlargement is sometimes general ; 
 at others the swellings are pendulous, lobulated. and loose. The capillaries of the part 
 are sometimes congested, giving the growth a purplish hue. As a rule, it is painless and 
 causes only mechanical annoyance It interferes at times with vision and the functions 
 of the nose. and. moreover, wounds vanity. 
 
 Treatment. — Nothing but the removal of the growth can be suggested, which can 
 be done without dantrer and with no great difficulty. The redundant mass is to be dis- 
 f;ected off", care being observed not to encroach upon the nostril. This is best done by 
 introducing the little finger or a spatula into the nostril and shaving the redundant mass 
 off the cartilage with a scalpel. Any bleeding that ma}- take place can usually be checked 
 
Rirf.ynsrory, 
 
 589 
 
 by c'lild, styptics, or torsion; tho woiiml thai is li-f't should he ullowtMi to granulate. Th»5 
 surgt'on should ho (raref'ul not to take away too much <ir to gu too deep, hut to leave Houie 
 oovcriuir to tlic cartilai^es. Tl>e disease rarely returns. The late Mr. Hey ot" Leed.s was 
 the first to pcrf'iirni the operation described. 
 
 Lupus. 
 
 This afVcction is more common on the iiose than in any otlu^r part of the body and is 
 often very destructive — so much so, indeed, as to destroy the whole or<^an. it is, how- 
 ever, more amenable to treatment than is usually supposed. Too often it is described as 
 a strumous, ami therefore constitutional. atfe(;tion, and rcfrarded as incurable. It would 
 be well, however, if surijeons would i»ractically rej^ard it iiKjre as a local disca.se, 
 
 Tkkat.mknt. — The best local treatment is its entire destruction, which may be effected 
 by serapini; away the diseased tissue with ;i blunt ktiil'c or the handle of a scalpel, followed 
 by the aiiidication of carbolic acid (Ui ,• ... ,. _ 
 
 lint to tile expo.sed surface, hy excision 
 or tile free application of the galvano- 
 or thermo-eautery. One of the wor.st 
 cases of lupus of the iio.se that I have 
 seen was that illustrated in V\g. ',i',H). 
 It had existed for years, and was cured 
 in a month after one tree application 
 of the galvanic cautery, every ulcerat- 
 ing tubercle of unhealthy tissue being 
 freely destroyed. 
 
 Tonic treatment also must not be 
 neglected, while as a palliative appli- 
 cation cod-liver oil is very beneficial. 
 Arsenic is also highly commended by 
 Messrs. Hunt and others, and Don- 
 ovan's solution when there is an}- 
 syphilitic taint. 
 
 The lupus iion-exedens may be regarded as an early stage of the lupus exedens ; both 
 have a i)apular origin and become tubercular, the tubercles ulcerating at a later stage. 
 
 Lupus of Nose, with the Outline of a Tlaj) for a New Nose. 
 (From life.) 
 
 Epithelial Cancer and Rodent Cancer 
 
 may attack the nose, the former usually appearing at first as a wartv growth, which sub- 
 seijuently ulcerates; the latter as a firm, uncolored. solitary nodule, which excoriates, 
 then scales and bleeds, and finally ulcerates, deepening and extending the scabbed excor- 
 iation. In the epithelial cancer the margin (»f the sole is more irregular and thicker than 
 in the rodent ulcer, although, until the lymph glands are affected, it is somewhat difficult 
 to distiiigui.sh between the two. Indeed, the epithelial cancer may be for long undistin- 
 guishable from the rodent cancer. The treatment of both, however, consists in the total 
 destruction of the ulcerating surface and its edges by cautery, escharotics. or the knife. 
 I have treated many of the epithelial forms by means of the galvanic cautery with grat- 
 ifying success. The disease, like other cancers, is, however, liable to return. 
 
 Rhinoscopy. 
 
 1'he examination of tlie nasal cavity may be made through the nostrils by means of 
 a .speculum, and for the purpose reflected sunlight is the best, or, this failing, reflected 
 artificial light must be employed. The posterior iiares can Ite examined by means of a 
 mirror introduced behind the soft palate, after the same fashion as in laryngoscopy, the 
 parts being reflected from the mirror, which is illuminated by sun- or artificial light. The 
 best aid may also be obtained by means of the finger introduced through the mouth behind 
 the soft palate. Czermak speaks highly of the value of a small mirror introduced throutih 
 the nostril, which should be well illuminated. I have, however, found all the help I wanted 
 in digital examination and posterior rhino.scopy, taking care to draw forward with great 
 gentleness the soft palate by means of forceps. This method of examination is. how- 
 ever, at times difficult. 
 
590 SURGICAL AFFECTIONS OF THE NOSE. 
 
 Diseases of the Nostrils causing Obstruction. 
 
 These are very cunnuon, and for such the surgeon is often consuhed. In the infant 
 such a condition may be the result of congenital syphilis, which will be indicated by the 
 history of the case and the concomitant symptoms. The muffles in infancy are very cha- 
 racteristic, and should always direct the practitioner to look out for some syphilitic aflec- 
 tion. In isolated cases such a symptom may be the only one of hereditary syphilis, and 
 by proper treatment it may be cured without any other complication making its appear- 
 ance, although as a rule, if looked for, some cutaneous aifection will be observed, a grain 
 of gray powder with three or four grains of dried soda twice a day generally proving 
 quite sufficient to cure the disease. When the mother is suckling, the child may be 
 physicked through the mother, taking five or more grains of the iodide of potassium with 
 quinine half an hour before suckling three times a day. 
 
 Warty growths are sometimes met with at the orifice of the nostril, causing 
 obstruction. They are to be cured by the removal of the growths. 
 
 Foreign Bodies in the Nasal Cavity. 
 
 When a child suflers from any obstruction to the nasal cavity, and particularly when 
 such is one-sided, the presence of a foreign body should be suspected ; and the prac- 
 titioner in such instances should never allow himself to be misled by the absence of a his- 
 tory of its introduction, since instances are not uncommon where some foreign hody has 
 been left in the nasal canal for months. A child four years of age came under my care who 
 had suffered from all the miseries of an obstructed nasal passage for eight months from 
 the presence of a plum-stone. Many remedies had been tried, but without effect, the 
 foreign body being unsuspected. Its removal was rapidly followed by convalescence. 
 Ulcerations of the mucous membrane from the inflammation excited by the foreign body 
 may tempt the surgeon to overlook the nature of the case. He should therefore remem- 
 ber that such a disease as ulceration of the nose in children, except at the immediate 
 orifice, is by no means common, and that the probabilities of its being excited by a for- 
 eign body are very great. When only one nostril is affected, the diagnosis is more sure. 
 The removal of these bodies when firmly impacted requires some care, and the adminis- 
 tration of an anaesthetic cannot be too highly recommended, particularly when the child 
 is young. A firm, hook-bent probe introduced down the floor of the nose may be passed 
 with facility behind the foreign body, or a noose of wire, twisted or not, inserted along 
 the septum and half turned, will generally, after one or two attempts, hook out the offend- 
 ing body. In some cases a pair of forceps will suffice. Gingerbread and other soft mate- 
 rials may have to be scooped out and the nose well syringed. I have never known any 
 good result from syringing this cavity when any solid body has become impacted, except 
 for the sake of cleanliness. Mechanical means always succeed and are the simplest, par- 
 ticularly when the child is under the influence of an anfesthetic. In older children and 
 in adult life obstruction to the nasal passage may be produced by many diseases. When 
 the presence of a foreign body is the cause, a true history of the case will generally be 
 given, and thus the surgeon is more likely to arrive at a just conclusion as to the charac- 
 ter of the disease. 
 
 Nasal Calculi, or Rhinolithes. 
 
 Such cases have been recorded ; I have seen but one instance, and that proved to be 
 due to the introduction of a foreign body. It occurred in the practice of Mr. B. Duke 
 of Clapham. On examination by Dr. Stevenson the calculus was found to consist of 75 
 per cent, of earthy carbonates and phosphates, and 25 per icent. of organic matter with 
 cotton-wool. They may be small or so large as to obstruct the nostril. Obstruction and 
 more or less pain are said to be the chief symptoms, and occasionally a copious discharge 
 of mucus or pus. The calculus can be detected on examination; and when found, it 
 should be removed by douche, snare, or forceps. Cases are on record in which the con- 
 cretion was crushed before removal. 
 
 Polypus Nasi. 
 
 This is a common affection, and may be found in one or both nostrils of the old or 
 young. It may be of a simple mucous or fibrous structure or it may be of a malignant 
 nature. The mucous are by far the more common forms, and are not difficult to recog- 
 
roLvrrs yAsr. 
 
 rm 
 
 Fig. 338. 
 
 nize ; they, as a rule. s|>riii<r f'nuii tho middle ttirltiiiatcd Imrn' and from its poiSterior por- 
 tion, thoii';li tlu'V may jrr<t\v fVum other j>arts. I have removed oidy <»ne from tin- septum. 
 They are sehhtm reco^ni/.ed in an early eimdition, since they cause no pain and hut little 
 inconvenience. A slijiht e.\cess of discharjie is the earliest symptom, and this is frener- 
 ally rejrarded as heinjr the result of " cold ; ' hut when this secretion is examined, it will 
 he ohserved to he more serous than is found to exist in an ordinary coryza. In excep- 
 tional eases the .serous flow may he very free. .Sir J. i'ajjret has recorded ( Cfiu. Soc. 
 TVans., Vol. xii.) a case in which this symptom existed and where after death fine polypoid 
 growths were found in the antrum. The disehar<:e. eontiiiuin;:. may at last cause some 
 anxietv to the ]>atient ; and if the surireon he consulteil. a careful examination with a 
 speculum should he instituted, when a jiolypus. or rather a frinfre of polypi, will often he 
 ohserved on the maririn u\' the middle turhinated bone. 
 
 Trkat.mk.nt. — When the di.<ease has heen made out, removal of the growth is the 
 only efl'ectual treatment. Tonics and local astringents may for a time retard its growth, 
 hut rarely effect a cure. The use of tannin as a snuff has heen very successful in my hands 
 in causing the sloughing off of even the largest polypi (Lancef, 
 February, 18G7). but the remedy is uncertain ; it is, however, 
 always of value in destroying the smaller, and thus in check- 
 ing the progress of tlie disease. Of late years I have em- 
 ployed a spray composed of ecjual parts of alcohol and a ten- 
 grain solution of Vjoracic acid to the ounce of water, the alco- 
 hol withering the small growths. 
 
 I have had several instruments made to apply the tan- 
 nin, but the bent glass tube is as good as any. It is modified 
 from one made by a patient for his own use. and answers well. 
 
 The tannin is put into the small receptacle in the upper half, that end of the tube being 
 inserted into the nostril, and the other into the mouth, and the patient then blows tannin 
 into his nostril. 
 
 Tiie removal of the softer kinds of polypi should always be by abruption. Some sur- 
 geons employ a long pair of narrow well-made forceps, which fix the pedicle, and then by 
 a slight twist and some force the removal of the growth is effected. When the polypus 
 hangs far back, the introduction of the finger into the mouth and behind the fauces facil- 
 itates its removal. The best instrument known is the '' noose. ' and that illu.strated in 
 Fig. 339 is the form I prefer. It is so constructed that a loop of wire introduced along 
 
 Fig. 339. 
 
 Removal of Nasal Polypus by Koose. 
 
 the septum and half turned can be made to pass over the polypus and encircle its pedun- 
 cle. The loop is then drawn home, the growth strangled at its neck and abrupted. By 
 these means the polypus is removed as a whole and V)leeding is prevented ; consequently, 
 by the use of this instrument, the nose can generally be cleared at one operation. In 
 some cases I have cured the disease by cutting off with a long pair of scis.sors the turbi- 
 nated bone from which these polypi grow. A few days after the removal of the polypi 
 by the snare, tannin as a snuff or the alcohol and boracic acid lotion used as a spray may 
 be employed. 
 
 In severe cases in which this treatment has been employed with but poor success, 
 Rouge's operation, as suggested by him for the treatment of certain cases of oza?na in 
 1873. may be performed, the operation consisting in the elevation of the upper lip and 
 soft parts of the nose from their os.seous attachments by means of an incision made 
 beneath the lip through the mucous membrane where it is reflected from the lip into the 
 
592 
 
 SURGICAL AFFECTIONS OF THE NOSE. 
 
 gums, the lip and nasal cartilages by these means being so freed from their attachments 
 as to allow the surgeon to lift them up as a whole toward the forehead, and thus reach- 
 ing the nasal cavity for purposes of exploration or operation. To give more room, the 
 septum nasi may retjuire to be separated from its base. After the operation the parts 
 readily fall into position, and should be kept there by strapping. No deformity or vis- 
 ible scar follows the operation. 
 
 The mucous form of polypus seems to be more common in men than in women and 
 is a disease of young adult life. I have known it, however, to appear in a man aged 
 seventy-five. 
 
 The firmer and fibrous forms of polypi are by no means so common as the 
 mucous, and seldom spring from the turbinated bones. They grow more frequently from 
 the upper and posterior portion of the nasal cavity, from the top of the pharynx and the 
 posterior nares, and have a periosteal origin. They do not make their appearance so 
 early in life as the mucous, are far more serious in their nature, and more difficult to 
 treat, on account of their position; and when removed, they rarely return. 
 
 Treatment. — The best mode of treatment is to ligature them through the nose by 
 means of a loop of whipcord or wire passed through the nostril into the pharynx and 
 slipped over the growth. When this operation cannot be performed, the nostril* may be 
 laid open, to give room for manipulation, or it may be necessary to remove the nasal pro- 
 cess of the superior maxillary bone or displace the body of, but not remove, the upper 
 jaw itself to reach the tumor. In 1865 I removed a large tumor of this kind which 
 completely obstructed the posterior nares of a boy ajt. l-t by the ligature introduced 
 through the nostril (Path. Trans., vol. xviii.), and in 1868, I'removed a second from a 
 lad aet. 18 in the same way. In 1872, in another case, I took away a portion of the 
 upper jaw to get at a tumor of the spheno-maxillary fossa which filled up the nostril 
 from behind. In 1883 I removed by evulsion from a man who was dying from bleeding 
 a large growth from behind the palate and posterior nares, but with a fatal result, the 
 growth having sprung from the base of the skull and invaded the cranium. Some of 
 these polypi grow from the antrum and press inward. The surgeon should bear this fact 
 in mind in examining a case, as it may materially afteet his treatment. 
 
 Cancerous tumors of the nose are found in practice, although not frequently. 
 They may attack the body of the organ, as seen in Fig. 340, or grow from within and 
 press forward or backward, filling in the anterior or posterior 
 nares, when they are difficult to diagnose. They are perhaps 
 more common in the old than in the young, although two cases 
 have pas,sed under my care in patients under thirty. They are 
 generally associated with bleeding, from either the nose or the 
 pharynx. When they grow from within, their removal, when 
 possible, is an expedient practice, if only to give relief; and 
 this can be done much in the same way as in the other varieties 
 of polypi. 
 
 Conditions simulating Polypus. — The conditions of 
 
 the nasal cavity which are not infrequently mistaken for poly- 
 pus are numerous. Many such have passed under my notice, 
 the patients applying for the removal of such a growth, when 
 in reality no growth existed. 
 
 Malformation of the septum nasi is one of the most 
 
 common deformities of the nose. In it the septum projects into 
 either the right or the left nostril, causing more or less obstruc- 
 tion to respiration and leading a superficial observer to believe 
 in the presence of some new growth. This deformity may some- 
 times be the result of an injury; and when so, there is generally some lateral twist of 
 the nose itself. The knowledge of the existence of such a condition is quite sufficient to 
 prevent any careful surgeon falling into this error. For the relief of this deformity an 
 attempt may be made by Adams's forceps to loosen the septum and to fix it in a better 
 position, or comfort may be given by admitting air through a perforation of the septum 
 made by cutting forceps. 
 
 A chronic inflammation and thickening of the mucous lining of 
 
 the nose is another condition which may be, and frequently is, mistaken for jiolypus. 
 In it the patient complains of difficulty in respiration and feels that there is something in 
 the nose which mechanically impedes that function. On examining the cavity a smooth, 
 projecting, and firm outgrowth will be observed on its outer wall, which may be regarded 
 
 Fig. 340. 
 
 Cancer of Nose. 
 
OZ.KSA. o!>3 
 
 tts a jxilvpus, Imt wliicli is really <'iily I lie lower tiirhiiiatetl l)i)tU! covered by a thiekened 
 u'deniatoiis nr iiiHaiiieil iiiiieniis iiieiiihraiie. In a ease such as this, if a little ean; he 
 taken ill sit'tiiij,' its liisturv. it will pniltalily he t'lMiiid that an i(hstrii(;tioti to the respira- 
 tiun will ho the uiily syiiiiitniii of iiii|Mirtaiice ; there will he no senms discliarge, such as 
 is so copious ill cases of polypi, altli()iii;h there may he a discharj^e of tenacious mucus; 
 yet tills is not common, since the seeretiiiL' I'linelinii nl" the mucous mcmhrane in these 
 cases will ireiierally he found diminished and a iinat dryness present, accompanied by a 
 lo.'.s of the sense of smell. 
 
 TuKATMKNT. — The hcst treatment in such examples is the constitutional in the form 
 of ionics, usin«r that which appears to he most suited to the jiciieral wants <d" the patient's 
 system. Some sli«rlit stimulating:; lotion, such as the sulphate or chloride of zinc, or 
 nitrate (d' silver <d" the streiiirth of two j.n-ains to the ounce, may at times he re<|iiire(l. but 
 constitutional means alone are generally sufficient. Itemoval (jf the turbinated bom; for 
 this afi'ection has been advocated and perlormed by some surgeons. 1 have ailopted the 
 practice in some obstinate cases with marked success. 
 
 It is worthy <d' observati(ni that this disease is at times confined to the mucous mem- 
 brane over the lower turbinated bone, and for reasons which 1 am unable to explain. 
 
 The septum may likewise be the seat of inflammation, either acute or chronic ; and, 
 as a result, great swelling of the soft parts covering it in will be pre.sent, giving rise to 
 obstruction. When pus e.xists, an early opening is advantageous. In .some cases a per- 
 forating ulcer may appear ; in others, exfoliation of the cartilage. I have removed from 
 a boy a rmliliiijlnnii^i i>>ifi/roicf/i from the septum which obstructed the nostril, which had 
 a base the size of a si.xpence. 
 
 Oz^NA. 
 
 This term is applied to a large and important class of cases where an oflFensive dis- 
 charge, or rather smell, is the common symptom, which is due to many different morbid 
 conditions. 
 
 It has been said that this offensive smell is the result of some morbid secretion of the 
 part, but my own experience has not furnished me with any information tending to con- 
 firm such an idea, and I believe that the fetor is generally, if not always, the result of the 
 decomposition of retained mucus. At one time it may be associated with inflammation or 
 ulceration of the mucous membrane, and at another with some diseased bone the result of 
 syphilis or otherwise. Under all circumstances the disease is an insidious one, and many 
 months have usually elapsed before it comes under the notice of the surgeon or medical 
 adviser. 
 
 SvMl'TOMS. — Tiie patient at first believes the symptoms to depend upon an ordinary 
 catarrh, the discharge from the nose being thick, but not offensive, and the sense of smell 
 more or less impaired. If these symptoms continue, the health of the sufferer often 
 declines ; and the physician is consulted on account of want of power, the local symptoms 
 assuming a secondary importance. If the nose be examined at this time, as it should be, 
 with a speculum, to obtain a good view of the whole, the only visible morbid condition 
 may be either intense congestion of the mucous membrane, which will not be much, if at 
 all, thickened, or some ulcer, this congestion of the mucous membrane being associated 
 with excess of secretion and the ulcer with a variable discharge. When dead bone exists, 
 a probe will detect it. 
 
 Treatment. — In the majority of cases the only correct and satisfactory treatment is 
 the constitutional. When the general condition of the body is improved, the local disease 
 will disappear. To this end the hygienic conditions by which the patient is surrounded 
 should be considered. If tonics, as quinine or iron, are indicated, they should be admin- 
 istered ; the secretions also should be attended to. and all external and internal causes 
 which may prove detrimental to health removed. The hctt/ treatment consists in absolute 
 cleanliness and the removal of all retained secretions ; for this purpose there is nothing 
 equal to the use of the douche (Fig. 334) with saline medicated lotions. The inhalation 
 of steam will at times assist the removal of the secretion and relieve the state of fulness 
 of the part of which some patients so much complain, especially if the discharges have a 
 tendency to desiccate, adhere to the mucous lining, and. as a consequence, to putrefy, 
 since it is this putrefaction of the retained muco-purulent secretion on which essentially 
 depends the condition denominated ozxna. Medicated lotions are sometimes required, 
 such as iodine or boracic acid lotion ten drops or grains to the ounce. Condy s fluid, 
 carbolic acid, the sulphate or chloride of zinc, or nitrate of silver, in the strength of 
 :iS 
 
594 SURGICAL AFFECTIONS OF THE NOSE. 
 
 about one grain to the ounce of water. The inhalation of the fumes of iodine is always 
 useful. 
 
 When ozaena is associated with some ulceration of the passage — an ulceration that 
 may be seen through the speculum, and, if not seen, suspected to exist when an occa- 
 sional escape of a blood-stained niuco-purulent secretion takes place — tonics are still 
 called for, with cleanliness locally, topical stimulants being employed when simpler means 
 have failed or when great indolence of the part is present. 
 
 These cases are, however, very obstinate, and much time is frequently required to 
 bring about a cure, several months being often not long enough ; but the fetor, which is 
 the chief symptom of annoyance to the suiferer, may speedily be removed by the 
 mechanical and local means already suggested, and so the worst feature of the disease 
 becomes destroyed and the mental as well as the physical comfort of the patient .secured. 
 
 When, however, this inflammatory action, and perhaps ulceration, is allowed to con- 
 tinue, a diff'erent result will ensue ; the bone itself may become involved, and as a result 
 necrosis follow. In so-called .strumous subjects this condition is not infrequent. I have, 
 however, no evidence to give that such a necrosis is always the result of the extension 
 of the inflammation from the soft parts around the bone to the bone itself. In many 
 cases, I believe, if not in the majority, the disease originates in the bones. 
 
 Necrosis of bone in the nose is not an unfrequent condition, and, as such, is 
 another cause of the disease described as ozseno. It is found in children as well as in 
 adult life, and may be the result of injury, extension of disease from the soft parts cover- 
 ing the bones, or associated with the so-called strumous diathesis or with the .syphilitic 
 poison. Occasionally it takes place without any such distinct cause, when it is described 
 as idiopathic, it being well known that inflammation of bone may arise jjer se. 
 
 When oz^ena is the result of necrosed bone, the fetor is generally of a peculiar cha- 
 racter, such as is well known to accompany diseased bone ; and under these circumstances, 
 by careful examination with the speculum' or probe, bare bone will often be detected, by 
 which the nature of the disease becomes tolerably evident. In early life I believe that 
 inherited syphilis is a more frequent cause of this affection than is generally suspected, 
 and this opinion has been confirmed by the presence of other marked symptoms in some 
 cases, such as old skin diseases, syphilitic teeth, or keratitis. 
 
 Diagnosis. — To form a correct opinion in all cases of ozrena, a careful history of the 
 case must be obtained and well-known symptoms not overlooked ; for unless an accurate 
 knowledge of the ease can be acquired, the treatment adopted must be doubtful, and con- 
 sequently unsuccessful. 
 
 Treatment. — When the presence of necrosed bone has been made out as the cause 
 of the disease called ozaena. it is tolerably evident that the patient will not recover until 
 the fetid bone has been removed, or rather has exfoliated. To this end the preservation 
 of perfect cleanliness by means of a douche or syringe, with or without .stimulating or 
 antiseptic lotions, may be employed, and tonics should be administered. If syphilis, 
 either hereditary or acquired, is the apparent cause, our remedies must be modified to the 
 general requirements of the patient. Mercurials are seldom necessary, although in chil- 
 dren suffering from this disease, where the hi-stor}' and other symptoms of congenital 
 syphilis are present, I have given them, associated with tonics, with marked benefit, and 
 in obstinate cases in adult life such a combination may also be employed. The perchlo- 
 ride and green iodide have proved the best forms in my experience, and when combined 
 with tonics, such as quinine, bark, or iron, are invaluable. I generally prescribe the 
 perchloride with bark and the iodide in pills at bedtime, the patient taking at the same 
 time the syrup of the iodide of iron and the iodide of potassium in some bitter infusion, 
 such as quassia. If mercurials are not indicated or required, the combination flf the 
 iodides of iron and potassium cannot be too highly valued. 
 
 In strumous subjects, perfect local cleanliness, and perhaps stimulants, accompanied 
 with tonics, as cod-liver oil, quinine, or iron alone or in combination, generally suffice. 
 In exceptional cases an operation may be required for the removal of the dead bone, and 
 where by forceps the bone cannot be taken away Rouge's operation (vide p. 591) may be 
 performed. 
 
 Disease of the Frontal Sinus. 
 
 The frontal sinuses, as part of the nose, are liable to many of its diseases. Acute or 
 chronic catarrhal inflammation is by no means uncommon, both giving rise to a dull heavy 
 pain over the forehead, which the inhalation of the fumes of half a grain or more of 
 opium thrown on a hot piece of metal often speedily relieves. 
 
DrsTi:.\'srf)y of tiii: fiiostm. sisus. 
 
 595 
 
 Acute suppuration ol" (Im'sc siiius»'s is (icc.'i.si'niaily met with, and is atton<lr(l with 
 BeviTO local and j^ciicral syiuptimis. I'lidcr these circuiustuiiccs the.' application u\' tlie 
 trephine to the outer sh«'ll of hone may he re<|uireil. Nc^crosis of tlie hones covcrin;^ in 
 the sinuses may exist, and the latter are also lialdc to fracture. New growths may like- 
 wise be fouml in this locality, cancerous, myeloid, or hony, the Ivory nxsrutix yroutlm being 
 more fre(|uently found in the air-cells of the frontal bone and nasal fossjc than in any 
 other loc-ality. From modern investigations they appear to have a periosteal origin and 
 soon become loose. Ill Hilton's well-known case the growth sloughed away. In the 
 
 I'K,. .{41. 
 
 Fig. 342. 
 
 Enostosis of Frontal .'^inus. 
 
 il.t'izt 
 
 Enostosis after Removal. 
 
 case of niv own. from which Figs. :>41 and 842 were taken, the osseous mass was evidently 
 dying when it was removed. It had been growing in the frontal sinus of a man aet. 24 
 for four years, and had gradually encroached upon the orbit. I enucleated it from its 
 bed by means of an elevator, after having taken away the layer of frontal bone that 
 covered it in. A good recovery ensued {Guys Hoi^pitdl Reports^ 1873-74). M. Olivier's 
 treatise upon the subject, published in Paris in 1869, gives all the facts known about such 
 growths. 
 
 In all tumors occupying the centre of the frontal region in children the possibility 
 that anv one mav be a hernia of the brain atul its membranes should be borne in mind. 
 
 Distension of the frontal sinus is an affection not sufficiently known ; indeed, 
 it has been described only by Lawson and Higgens. It shows it.self as a chronic swelling 
 or expansion of the bone near the inner angle of the orbit above the lachrymal sac. and 
 is attended at times with pain of a dull aching character. Occasionally the affection is 
 painless or the pain is intermittent. Sometimes with the swelling there is some watering 
 of the eye, and in rare cases the eyeball is pu.shed outward. Injury is said by Lawson 
 to be its common cause, but in the three cases I have seen it come on of it.self. When 
 injury has been the cause, it was probably a fracture, the fracture bringing about a 
 closure of the communication between the middle meatus of the nose and frontal .sinus. 
 The .swelling contains a more or less purulent tenacious fluid. 
 
 Distension of the frontal sinus, writes Higgens.^ " has probably no early symptoms. 
 There is at no time .severe pain, nor. indeed, any until the disease has far advanced." 
 Indeed, it is probable that the disease is not to be recognized until the orbital wall of the 
 .sinus begins to bulge or the bone has so thinned as to allow the distended .sinus to appear 
 as a soft fluctuating swelling with a raised Vjony and dearly-defined margin. In one of 
 my cases this condition was very niarked. 
 
 Diagnosis. — When the swelling is hard and bony, it may be mistaken for an osseous 
 growth, such as is figured in Fig. 341. When it is soft and fluctuating, it may be 
 regarded as an ab.scess connected with the lachrymal sac. When the bone has thinned 
 and gives a crackling sensation on pressure, or when, as noted above, a .soft fluctuating 
 swelling surmounts an elevated bimy ridge, its true nature is rendered probable ; and 
 when the tumor varies in .size at different times of the day. the diagnosis is certain, this 
 variation in size being, according to Higgens, " due to the fluid becoming — when the 
 patient lies down — evenly diffu.sed throughout the sinus, whilst it gravitates to the part 
 after the erect position has been maintained for a few hours." 
 
 ' Guy's Hogp. JRep., vol. xxv., 1881. 
 
596 SURGICAL AFFECTIONS OF THE NOSE. 
 
 Treatment. — There is but one kind which can brinp; about a cure, and that is the 
 free opening of the swelling and its efficient drainage into tlie nose, wliich should be guar- 
 anteed by the introduction of rubber tube. The cavity should be washed out daily with 
 some antiseptic. In two of my three cases a cure was effected by these means after the 
 lapse of months. In one case the sinus through the forehead is still open. 
 
 Rhinoplastic or Taliacotian Operations. 
 
 Gaspar Tagliacozzi. or Taliacotius, professor of anatomy and surgery in the University 
 of Bologna, was the first to bring these operations into notoriety, and they have conse- 
 quently been named after him. He was not. however, the originator of the operation, as 
 he himself refers to earlier men, such as A. Pare and others, who have recommended it ; 
 but he was the first to practise it with much success, and quite deserves the fame that 
 attended his efforts. His principal work, published in 15!»7 at Venice, only two years 
 before his death, gives the histories of the cases in which he operated. 
 
 His method consisted essentially in taking a flap of skin from the arm and transplant- 
 ing it to the nose, and so restoring that organ to its normal appearance where there had 
 been any loss of substance. 
 
 Modern surgeons, instead of following the great Italian example, generallv prefer to 
 adopt the Indian method and take the integument from the forehead. The operation is 
 
 by no means common. It may be undertaken to restore 
 Fig. .34.3. the nose wholly or in part, and the amount of healthy 
 
 integument required for this purpose will be regulated by 
 the want. The ingenuity of the surgeon, too, will be 
 taxed in every case to adapt his operation to its special 
 requirements. He must, however, always be careful to 
 give himself abundance of new material ; and, having sat- 
 isfied himself of the wants of the individual case, and 
 that the parts upon which he is about to operate have 
 long lost all traces of disease, he can then map out upon 
 the centre or lateral portion of the forehead of the patient 
 that portion of integument he proposes to transplant, hav- 
 ing planned it beforehand on a piece of paper, plaster, 
 or wash-leather. The shape required for a nose and 
 columna will be such as is indicated in Figs. 337 and 343, 
 the flap measuring three inches in each diameter. The 
 surgeon shall then make raw the whole surface of the old 
 nose to which the flap is to be united, cutting a deep 
 groove close down to the bones bounding the nasal cavity for the reception of the new 
 flap. A sponge may then be firmly pressed upon this raw surface to arrest the bleeding, 
 while the surgeon proceeds to dissect up the integument he had previously marked out 
 upon the forehead. In doing this care should be observed not to bruise or otherwise 
 injure this borrowed skin. The inci.sion should be clean and extend down to the bone. 
 The flap should be dissected up boldly and freely, care being observed to leave a good 
 neck, through which the circulation can be maintained, and to make it long enough to 
 allow of its being turned round. For this purpose it is a good practice to make the inci- 
 sion on the side to which the twi.st is to be made a little longer than the other. 
 
 When all bleeding has ceased, the frontal flap, with the external surface still upper- 
 most, should be turned half round and applied to the nasal raw surface, to wdiich it is to 
 be carefully stitched, the columnar portion being well pressed down into the groove made 
 for it and fixed. The new nostrils ought to be supported by oiled cotton-wool or lint, and 
 the surface covered with the same sort of material, to maintain its warmth. The gaping 
 wound on the forehead can then be brought together as far as possible by means of strap- 
 ping and left to heal by granulation, the operation of skin-grafting expediting repair. The 
 sutures may be removed on the second or third day. For the next month the greatest 
 care is requisite in the dressing of the wound and in keeping the nostrils up with a plug, 
 the one suggested by Langenbeck being the best, and as soon as the new flap has consol- 
 idated the neck of integument at the root of the nose may be divided. In the case illus- 
 trated (Fig. 344) such a practice was not called for. I operated upon it in 1872 with an 
 excellent result. When the formation of the columna is required, Li.ston's plan is the 
 one generally employed, and is thus described in his own words : 
 
 " Restoration of the columna is an operation which, in this and other civilized coun- 
 
iniisoi'i.AsTic ()i'i:ii.\ri()ss. 
 
 597 
 
 I'lO. 344. 
 
 ^ 
 
 tri«'s, must Im' more rri>(|iiciitly r(M|uin'(l than llio rcstoratinn of the wlinh; nose. This 
 latter oju'ratioii came tn he praetiscMl in cniisciiiictife of tin; frcfjiicricy of tnutilutioiis 
 as a ]>iiiiisliiii*'iit, Imt llic |iiMiisliiiiciit for suiiic ol' mir sins is Iclt to nature, and she 
 generally n-lciits liet'ori' the wholi' of the orjiaii disuf)- 
 poars. This coliinina is fre(|iMMitly destroyed hy ulct-ra- 
 tion. Tiu' deformity produced hy its loss is not far short 
 of that caused l»y destruction of the whole n«)se. Map- 
 pily. after the ulceration has heeii cheeked the jiart .mm 
 be renewed neatly, safely, and without much sufferiiiL' i ■ 
 the patient. The operation whicdi I have practised suc- 
 cessfully f'lr some years and in many instances is thus 
 perfonni'd : The inner surface of the apex is first pared. 
 A sharp-|tointed histoury is then passed thr(»uu:h the upp(!r 
 li|> — previously stretched and raised hy an assistant — close 
 to the ruins of the former columna and ahout an ei<.dith 
 of an inch on one side of the nn'sial line. The inci.xion is 
 continued down in a strai;rht directittn to the free mar<rin 
 of the lip, and a similar one, parallel to the former, is made 
 on the opposite side of the mesial line, .so as to insulate a 
 flap about a quarter of an inch in breadth and conipo.sed 
 of skin, mucous membrane, and interposed substance. The 
 fnenulum is then divided and the prolabium of the flap re- Appearance of Face after Formation of 
 moved. In ordtn* to tix a new cnlumna firmly and with accu- 
 racy in its ]»roper place, a sewintr-needlc is pa.s.sed from without through the apex of the nose 
 and obliquely tliroui^h the extremity of the elevated flap ; a few turns of thread over this 
 suflice to approximate and retain the surfaces. It is to be observed that the flap is not 
 twisted round, as in the operation already detailed, but simply elevated, so as to do away 
 with the risk of failure. Twisting is here unnecessary, for the mucous lining of the lip, 
 forming the outer surface of the columna, readily assumes the color and appearance of 
 integument after exposure for some time. The fixing of the columna having been accom- 
 plished, the edges of the lip must be neatly brought together." 
 
 The sutures can be removed on the third or fourth day, when, as a rule, the parts have 
 cicatrized. The ultimate result of the case depends materially upon the care be.stowed 
 upon its after-treatment. In the case illustrated in Fig. 344, which I operated upon sev- 
 eral years ago, a gratifying result ensued, the bridge of the no.se requiring no second ope- 
 ration. Dr. Lichtenberg has had within the last few years some very successful cases, 
 and the late Mr. Skey had some excellent results in his practice. I saw one that he had 
 operated upon years before, which was very excellent. It is well, however, to remember 
 Mr. Skey's advice when he says, •• Let it be the patient who urges the operation."' 
 
 Of late years Langenbeck has suggested the propriety of dis.secting up the periosteum 
 from the frontal bone with the skin flap, so as to give a bony nose, but it is a question 
 how fiir this osteorhinoplasty is an advantage. The operation has not found much favor. 
 
 When only one ala has to be re.stoi'ed, the flap may be taken either from the nose 
 itself or from the cheek, the particulars of the plan being left to the ingenuity of the 
 surgeon to determine. 
 
 CHAPTER XVIII. 
 
 SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. 
 
 The larynx and windpipe may be contu.sed from external injury, or the cartilages and 
 trachea rings fractured, the nature and .severity of the symptoms following these accidents 
 varying with the character and the amount of injury ; some years ago a case came under 
 my care in which the tlnjrnUl cartilage was fractured obliquely across the body. The acci- 
 dent was attended with much bleeding and cough, but these soon disappeared, and an 
 excellent recovery ensued. In 1877. Dr. A. Corley of Dublin recorded a case in which, 
 after death, the second, third, and possibly the fourth, cartilages of the trachea were frac- 
 tured and projected unevenly into the tube, associated with suppuration around a necro.<ied 
 
698 SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. 
 
 cricoid cartilage. The preparation was taken from a woman ajt. ?A\ who had been squeezed 
 in the throat some weeks before, and was admitted into the Richmond Hospital with dysp- 
 noea, stridulous breathing, congestion of the face, and external signs of inflammation about 
 her throat, and for which tracheotomy had been unsuccessfully performed. There is more 
 danger when the cricoid cartilage is involved than when the thyroid. 
 
 The trachea may also be completely divided snhcMtaneously. I saw this in June, 1876, 
 at Guy's Hospital, in the case of a man ajt. 47 who was crushed between a barge and 
 the side of a vessel, the prow of the barge striking his neck. The accident was followed 
 by dyspncjea and some emphysema of the neck, but the symptoms were not urgent so long 
 as the erect position was maintained, but the recumbent was impossible. The man lived 
 fifty hours and died quietly. After death the trachea was found to be completely severed 
 below the thyroid body, the two ends being separated for an inch and a half, while the 
 lower end was below the innominate vein. 
 
 There was no external bruise to denote the severity of the injury. 
 
 Wounds of the Throat. 
 
 These are generally made by the hand of the suicide, and consequently have a double 
 interest, the dangers of the local injury being complicated with the peculiar mental con- 
 dition of the sufferer. It is essential, therefore, for the surgeon to dwell seriously before- 
 hand upon the necessities of these cases, in order that he may be prejiared to act with 
 decision in the hour of danger. 
 
 In the majority of cases of '• cut throat " the wound is only of a superficial nature 
 and simply involves skin or skin and muscle, and does not implicate either the pharynx 
 or the respiratory tract. These cases require no other local treatment than that usually 
 employed for skin wounds, such as sutures and some simple dressing. 
 
 When the wound is of a deeper character, it may penetrate into the pharynx and air- 
 passages or involve the deep vessels, the dangers of the case being much determined by 
 the position of the wound. 
 
 My colleague, Mr. Durham, in an able article in Holmes s Surgenj (8d ed.), shows that 
 of 232 uns,elected cases the wound was 
 
 Above the hyoid bone in 
 
 Througli the thyro-hyoid membrane in .... . 
 
 Througli the thyroid cartilage in 
 
 Througli the crico-thyroid membrane in .... . 
 Into tlie trachea in ........ . 
 
 J/ 
 
 cases. 
 
 80 
 
 " 
 
 42 
 
 " 
 
 36 
 
 u 
 
 57 
 
 li 
 
 The respiratory tract was opened in about two-thirds of the cases. 
 
 In all cases of cut throat hemorrhage as the direct result of a divided or wounded 
 artery or vein is to be apprehended ; and although from the deep position of the carotid 
 artery and jugular vein these vessels in the majority of cases escape injury, yet when 
 they are divided death is usually rapid. Partial or complete division of some of the 
 branches of these vessels is, however, not unfrequent. 
 
 A man in Guy's, aet. 21, in a fit of despondency cut his throat, and died from profuse 
 hemorrhage into the lung before help could be obtained. The blood was found after 
 death to have come from a divided superior thyroid artery. An inmate of St. George's 
 divided the left common carotid artery and wounded the internal jugular vein with a pen- 
 knife, and died before the house surgeon could arrive. "A gentleman who committed sui- 
 cide by cutting deeply between the os hyoides and thyroid cartilage partially divided the 
 external carotid artery on the right side just as it was given off; the flow of blood was 
 immense, and he was found dead within ten minutes of the infliction of the wound " 
 (Fothergillian prize essay for 1836, by my father, the late Mr. T. E. Bryant). In Guy's 
 Museum (Prep. 1711'*) the left interinil jugular vein may be seen divided, the cut being 
 between the thyroid and cricoid cartilages and proving speedily fatal. Prep. 171 P shows 
 division of the inferior thyroid artery. 
 
 Blood may flow into the trachea and suddenly or slowly cause asphyxia ; it may 
 coagulate over the orifice of the larynx with the same result. Mr. Le Gros Clark has also 
 shown (Surg. Diag.. 1870) how air may enter the circulation through a partially-divided 
 vein a-nd destroy life in twenty-four hours. 
 
 When the incision is above the hyoid bone and deep, the tongue may be divided, and 
 the loosened portion, by falling over the orifice of the larynx, may cause sudden death 
 by suffocation. In wounds of this description the surgeon should consequently guard 
 
woiWDs OF TIIJ-: 'niiioAT. 599 
 
 n<;ainst tlu* )tossil)ilil y i)f' tlii^^ ('(mtiiiirciicy by pas.sitiL!; a thread throufrh the ton«]^ue and 
 ilrawiiiir it forwartl. 
 
 Whi'ii the eiit is jnat iiliurr titr tliijroiti niiillitif)-, the e|ti<rhjttis may he »livi(hMj, and 
 this, t'allinir into the hiryiix. may eause fatal (lys|»n<L'a. To jtrevcnt tliis u stiteh should 
 he iiisiTted into the divided ]i(irlioii and the parts adjusted. 'J'he same result may take 
 plaee when any portiun of the oritiee of tlu- larynx lias heen detaehed. Indeed, all loose 
 bodies likely to obstruct respiration should be tixed. Emphysema is by no means an 
 uneommon eomplicration of eut throat when the respiratory traet has been opened, and is 
 not, as a rule, a dauji,erous oeeurrencc. It is more common when the external wound is 
 small. 
 
 liitlamniatiiiM of tiic air-tulifs aii<l lunu's i.> tin- .^rciindary <laiiL't'r of wounds of the 
 throat involvinu: the air-|)assai;cs : and when the jdiarynx or (esopha<:us has been opened, 
 this risk is airtrravated l>y the ])ossibh' iiitroduetion oi' f(»od into the trachea. It '' was 
 the eause of death in 17 out of 21 fatal eases of eut throat ei^nsecutively treated at 
 Ouy's Hospital in whieh tlie more immediate effects oi' the injury had Vjeen survived" 
 (Durham). Purulent inKltration of the cellular tissue of the neck may also ensue, or 
 avlenui of the glottis, and at a later date the air-pas.saires may be obstructed V^y the cica- 
 trization of the wound or the contraction of the trachea. In excejttional cases a perma- 
 nent fistulous openin«>- may be left. 
 
 The immediate danger of a wound in the throat con.sequently depends (1) on the 
 quantity of blood lost; (2) on the risk of suffocation from blood flowing into the air- 
 tube ; (;}) the danger of suffocation by tissues divided and partially separated from their 
 connections obstructing the larynx. The secondary dangers are those of oedema of the 
 larynx and inflammation of the air-passages, and later on from sub.setjuent obstruction of 
 the divided tube l)y the contraction of new tissue around it or the growtli of exuberant 
 granulations round the wound. 
 
 Treatment. — The first duty of the surgeon under all circumstances is to arrest Jiem- 
 orrJid;/'. Arteries ought to be ligatured or twisted, .so also all deep veins when moderate 
 pressure fails to check the flow of blood. A wounded artery or vein should be ligatured 
 above and below the wound. To tie up an opening in a large vein with a lateral ligature 
 is bad practice. 
 
 To find the bleeding vessel, the wound may have to be enlarged. The internal jugu- 
 lar vein may be ligatured with a good prospect of a successful result. Durham states 
 that out of 72 cases, 48 recovered. Gross has demonstrated the .soundness of the prac- 
 tice ( Amer. Journ. of MetL Sci., 1867). 
 
 The second duty of the surgeon is to prevenf suffocutuju. He should see that the 
 respiratory orifice is kept clear of blood or of any divided structure, such as the tongue or 
 epiglottis. Coagula ought to be speedily removed and respiration encouraged by artificial 
 means when natural processes have failed. 
 
 When the larynx or trachea has been wounded, the aim of the surgeon should be to 
 keep the divided ])ieces of the tube in continuity, and not to allow the upper portion to 
 overlap the lower and thus obstruct the resi)iration ; at the same time, care must be 
 taken to keep the wounded parts sufiiciently open to allow of the escape of the uiucus, 
 which is always profuse, and to permit the free ingress of air. 
 
 If the wound is very extensive and difficulties arise in carrying out the above indica- 
 tions, sutures may be introduced ; but it mu.st be left to the surgeons judgment to decide 
 when they may be necessary, according to the exigences of the individual case. In large 
 wounds, where the parts cannot be kept together, a suture is often of immense benefit ; 
 and sutures, when applied, should be put in firmly, including often the whole thickness 
 of the tissues. Their object can only be to fix the divided parts in position and prevent 
 any mechanical obstruction to the I'cspiratory act by their sudden movement. To do 
 this effectually, the measures employed should be boldly executed. The head should be 
 kept forward b\' the application of bandages, and water dressing applied to the wound 
 itself; constant attention is demanded of the nurse to keep the wound clear of discharge 
 and to see that no obstruction to the breathing take place. The atmosphere the patient 
 breathes should be kept warm and made moist by the introduction of steam, and the 
 wound covered with muslin. The clo.sest attention should be paid to the patient by a 
 skilful nurse, and every mental and bodily want or weakness cared for. As regards 
 nourishment, abundance .should always be provided, although it is not such an easy task 
 for the patient to take it. 
 
 When the pharynx or oesophagus is extensively' opened, the patient should never be 
 allowed to swallow, but be fed by means of a tube passed through either the nose or the 
 
600 SURGICAL AFFECTIONS OF THE LARYXX AXD TRACHEA. 
 
 mouth (and not through the wound) and directed with the fingers carefully down the throat 
 into the lower portion of the oesophagus. Through this beef tea, eggs, brandy, and other 
 liquid nourishment such as the symptoms indicate may be periodically administered. I 
 have an instance before me of this kind, and where the patient was kept alive by such 
 means for nearly six weeks, the tube having been passed through the nose. At the end 
 of this time he was able to swallow, and recovery ensued. When acting as dresser to the 
 late Mr. Aston Key, I had a case where the wound was inflicted through the trachea, 
 dividing the cesopliagus. In this instance the man was fed twice daily through a tube 
 passed through the mouth and directed with care into the lower oesophageal opening ; 
 this practice, being carried on for many weeks, was rewarded by recovery. The plan of 
 treatment just indicated, however, is only rational, and is such as any surgeon would 
 naturally suggest. All complications, such as suppuration in the cellular tissues around 
 the wound, bronchitis, or broncho-pneumonia, ai'e to be dealt with as they arise. Some 
 have suggested the propriety of tracheotomy in severe cases of cut throat, so as to allow 
 the wound to be closed. I am unable, however, to see the advantages offered by this 
 practice in ordinary cases, although in wounds involving the epiglottis or upper part of 
 the larynx, when inflammatory oedema appears as a secondary result, causing obstruction 
 to respiration and threatening life, there is no doubt as to the wisdom of the practice. 
 These cases, however, are uncommon. 
 
 Among the most remote dangers of such wounds the mechanical ob.struction of 
 exuberant granulations ought to be mentioned, likewise some narrowing of the air-pas- 
 sage from contraction of the cicatrix, and tracheal fistula. These results are common to 
 traumatic and surgical wounds of the part. In Prep. 1711". Guy^> Hosp. Museum, 
 taken from a patient who had lived for many years after a wound which had involved 
 both the trachea and oesophagus, both the trachea and oesophagus are much contracted 
 above the opening and in a less degree below. In 1873 I was called upon to perform 
 tracheotomy on a man get. 57 who had cut his throat through the thyroid cartilage .six- 
 teen months previously ; for eight or ten months he had been suffering from gradually- 
 increasing difficulty of breathing due to the contraction of the air-passage, and this 
 patient has ever since been obliged to wear the canula. In the seventh volume of the 
 Clin. Soc. Trans, an interesting case of the kind has been recorded by Mr. H. Lee. 
 
 Foreign Bodies in the Windpipe. 
 
 There are few accidents which excite more anxiety and alarm to a looker-on than the 
 passage of a foreign body into the larynx or trachea, since the unfortunate subject, in the 
 midst of appai'ent health or happiness, is suddenly forced to make violent .struggles for 
 life. To the spectator death seems imminent, and in the surgeon no less painful feelings 
 are excited ; for unless by his ail timely relief can be afforded, the danger which is 
 apparent becomes real and death is almost a certainty. 
 
 The majority of the victims of such an accident are children, although adults are not 
 exempt from such a contingency. 
 
 A foreign body may be inhaled at any moment, a sudden inspii'ation being sufficient 
 when the mouth is full or holds a foreign body which is smooth, light, or small, such as 
 a seed, fruit-stone, bead, bean, nut, or coin. Vomited matter may likewi.se be drawn by 
 inspiration into the air-tubes by patients in a state of unconsciousness, as when drunk, 
 under an anaesthetic, or in an epileptic fit. Foreign matter may likewise find an entry into 
 the respiratory tract through a fistulous opening between the oesophagus and trachea the 
 result of simple or cancerous ulceration. The body may be lodged at the orifice of the 
 larynx (Fig. 345). and thus cause sudden asphyxia, or pass into the rima or ventricle, 
 where it may be arrested and give rise to spasm or cause oedema, and. as a consequence, 
 more or less gradual obstruction. It may likewise pass into the trachea or bronchi, the 
 right bronchus being its most common seat, and become either impacted or remain mova- 
 ble. The size and the shape of the foreign body determine many of these points ; for, 
 whilst a large one will naturally be arrested at the orifice of the larynx, a small one will 
 probably pass through. A jagged and light bod}- such as a seed or piece of nutshell 
 would be more likely to be caught in the rima than a small round body such as a bean. 
 A light body will remain movable, whereas a heavier one may become impacted. 
 
 A piece of meat may become impacted in the rima glottidis and cause instantaneous 
 death (Prep. Guy's Hosp. Mus. 1710). 
 
 In the case of a child set. 2? on whom I unsuccessfully operated in 1864, a date-stone 
 was found impacted in the right bronchus, while its upper end was pressing against the 
 
FftnEiax nnniF.s is riii: wisin'iri':. 
 
 GO] 
 
 Vu.. :;10. 
 
 J. 
 
 uiising Death. 
 (Taken Irom a child eleven 
 months old. Prep. 1710^.) 
 
 Date-Stone Impacted in 
 Right Bronchus, i I'rep. 
 1717'*.) 
 
 leftside (if the traclica ;iii(l «'xritinf: ulccnitidii ( Fijr. iilti). Tlic child livccl four days. 
 In aiKttlicr case. rciMirdt'd in my Clliiicul Snnji n/. I'art TT m Ihhii \v:i< firtnly itiipaoted in 
 the riijht hroiicliiis, (•aii.^iiii'; ctunplt'tc 
 obstnicticin ti> the ri,Ldit \n\\]i. 
 
 Till' fact, |Miiiited out by Ooodall 
 of Duldiii. that tlic septum at the 
 divisidu of the tracliea is somewhat 
 to the left of the median line, is jiroh- 
 ably the ex|ilaiiati(in of the riirht 
 bronchus beinj; UKire fre(|iictitly the 
 peat of the foreiirn body than tin- 
 left. The hiitrer size of the ri<rht 
 bronclius doubtless favors this tend- 
 ency. 
 
 The sv.Ml'Tci.Ms which attend the 
 entrance of a foreign body into the 
 air-passajrres are somewhat character- 
 istic, although those that follow are 
 often ob.scure. The most typical is 
 a violent convulsive cough coming on pone in i.arvnx, 
 ahnipf/i/, followed by difficult respira- 
 tion and a feeling of suffocation, this 
 spasmodic cough being likely to recur at intervals on any movement and as long as the 
 foreign body is loose. 
 
 AV'hen the foreign. body is lodged near the rima and impacted, the voice is altered in 
 character, ichistling or sfri'/ii/oiia, and there may be some tenderness of the larynx on 
 manipulation, or pain. When an extraneous body is in the ventricles, the spasmodic 
 deVangement to which it gives rise too often proves speedily fatal. In children rapid 
 suffocation is a common result of such a cause, death being more frequent from spasm 
 of the glottis than from mechanical obstruction by the foreign body, though when the 
 body is fixed in the larynx chronic obstruction often comes on from the oedema of the 
 larynx excited by its presence. 
 
 When the breathing of the patient is at times natural and at others disturbed by a 
 paroxysm of cough or dyspnoea, and when these symptoms are brought on by any move- 
 ment or violent respiratory effort, it is probable that the foreign body is loose in the 
 trachea or in one of its divisions ; indeed, patients are conscious occasionally of the 
 movement of the body. When by auscultation it can be made out that air enters one 
 lung freely and the other feebly, the exact seat of impaction of the foreign body is indi- 
 cated, and the amount of dyspncea present will depend upon the tightness of the impaction. 
 
 When the extraneous body has passed through the larynx into the trachea, there may 
 be long intervals of repose between the attacks of laryngeal spasm, but any spa.sm may 
 prove fatal. 
 
 Many cases are now on record in which foreign bodies, particularly coins, have been 
 impacted in a bronchus and have given rise to no urgent symptoms for years. Dupuy- 
 tren in one of his lectures given in 1833 relates a case where a coin was known to have 
 been in the air-passage for ten years without producing any very distressing effects, and 
 was found after death to occupy a tubercular excavation. Professor Gross gives a case 
 in which a portion of bone is said to have been coughed up after having been retained 
 for sixty years. Cases such as the.se. however, should never allow the surgeon to rest 
 satisfied or permit a foreign body to remain in the air-passages, for so long as it does 
 death may at any moment be suddenly produced by convulsive laryngeal spa.sm. or more 
 slowly by broncho-pneumonia. 
 
 Difficulty of breathing is not uncommon as a consequence of the arrest of food in the 
 oesophagus or lower part of the pharynx, and at first sight the surgeon might think that 
 the symptoms are due to the presence of some foreign body in the air-passage. When 
 doubt exists, the patient should be made to swallow; in laryngeal obstruction no difficulty 
 will be experienced by the act. whereas in pharyngeal it will be impossible. Under other 
 circumstances a probang may be carefully introduced into the oesophagus, and in every 
 case a careful exploration of the throat and pharynx with the finger should be made. 
 When the foreign body is impacted in the pharynx and cannot be removed, and laryngeal 
 spasm threatens life, the windpipe may require to be opened. The surgeon should always 
 hesitate to employ force in pressing a foreign Ijody downward. 
 
602 SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. 
 
 Treatment. — Given the diagnosis of" a foreign body in the windpipe, the duty of the 
 surgeon plainly is to endeavor to remove it. There should be no deviation from this res- 
 olution, because so long as a foreign body remains in the air-passage sudden death from 
 spasm of the larynx is imminent, and the first spasm may prove fatal, the spasm being 
 produced by any movement of the foreign body. The surgeon should never allow him- 
 self to be misled by the mildness of the symptoms nor by the knowledge that in rare 
 instances foreign bodies have remained in the passage for years, and even then been 
 expelled, since such cases are exceptional. The accident is one that will inevitably 
 destroy life, although it must be doubtful at what time or in what form danger may 
 appear. 
 
 In all urgent cases in which spasm of the larynx threatens life tracheotomy should be 
 performed, because with an opening in the trachea fatal spasm is impossible, and the sur- 
 geon may then proceed to investigate the case. In cases in which life appears to be 
 extinguished the same practice should be adopted, artificial respiration being subse- 
 quently maintained. Should the symptoms point to the larynx as the seat of the 
 impaction, the upper orifice should be closely examined by the finger introduced 
 through the mouth, and a full-sized bougie or catheter — or, what is better, a small 
 piece of sponge held by forceps or fixed on a handle — introduced from below through 
 the wound into the larynx. By these measures most foreign bodies caught and impacted 
 in the larynx itself may be removed. In exceptional cases where these measures fail the 
 surgeon may be called upon to lay open the larynx. The laryngoscope at times will be 
 an invaluable aid in guiding to the position of the foreign body and in eft'ecting its extrac- 
 tion. It is only applicable, however, in adults. When the position of the foreign body 
 is known, its removal may be facilitated by curved forceps. 
 
 Laryngotomy is scarcely applicable to these cases, the majority being found in chil- 
 dren. In children the opening in the trachea should always be as high as possible, and 
 there is no objection to dividing the cricoid cartilage {larynijo-tracheotomy^ to reach the 
 larynx. When the foreign body is so fixed in the larynx as to be immovable by tlie 
 means suggested, the thyroid caitilage must be laid open by increasing the incision 
 upward. In doing this the larynx will be fully exposed and the removal of the body 
 facilitated. When the foreign body has passed the larynx and is in the trachea, a free 
 opening should be made tow down in the passage ; and when this is done, it not unfre- 
 (jucntly happens that the foreign body is expelled. Should this not happen and the. 
 foreign Ijody is heavy and smooth, the patient may be inverted and succussion employed 
 — that is, the patient should be patted sharply on the back or shaken with the view of 
 dislodging it. But this proceeding should not be employed until the trachea has been 
 opened. Should the foreign body be light, it may possibly be extracted by means of the 
 " sucker" figured 352 at page 609. The rubber tube for this purpose should be long. 
 
 Some surgeons advise the introduction of forceps or other instrument through the wound 
 into the trachea for the removal of the foreign body, and in recent times success has follow- 
 ed the practice. Thus in May, 1876, Mr. Maunder extracted by means of a loop of silver 
 wire through an opening made in the trachea a glass sleeve-link from the left bronchus 
 of a boy a3t. 13. Mr. Hulke in August, 1876, hooked out of the right bronchus of a 
 woman aet. 37 the outer tube of a tracheotomy canula by means of a piece of German 
 silver wire bent into a hook, and Mr. Lucas on November 16, 1877, removed by means 
 of forceps the same kind of thing from the left bronchus of a man aet. 57, the tube hav- 
 ing been in the bronchus for seven weeks. 
 
 Fig. 347 represents an excellent pair of forceps for this purpose. It was made for 
 Dr. S. D. Gross of Louisville before 1854, and is taken from his book on Foreign Bodies 
 
 Fig. 347. 
 
 Gross's Trachea Forceps 
 
 in the Air-Passages. "They," as described by him, "are composed of silver, and are a 
 little upward of eight inches in length. The handle is considerably curved on the flat 
 and has two rings for the thumb and finger. The blades, which are rounded and very 
 slender, are five inches long and terminate each in a fenestrated extremity nine lines in 
 
SCALD OF rUK LAUYSX. (103 
 
 len^tli l»y tliriT lines in width, tlit; milt;r siirt'iicc! heiiii: siiiouth uiid coiivox, tlii; iiiiicr Hut 
 anil sliiilitly serrated. Tlie blades when shut sli;<htly overhip eaeh other. The weight 
 of the instrunient is a little over five drachms. The instnini(!iit. hein<r long and slender, 
 may he used as a prohe ; heini; eomposi-d of silver, it may he hent at any point and in 
 any direetion ; and heing delieate, it eannot impede the jtassage of air durinj^ its u.se.' 
 
 When these means fail to remove the foreiirn l)ody. the jiatient must he lel"t, hut the 
 wound in the air-tuhe should l>e kept open. 
 
 If the foreij;ii hody be in the laryn.\, the eanula may be introduced; liut when in the 
 trachea or bronchus, its retention is injurious, as it prevents the escape of the substance. 
 Under tliese circumstances Hilton's suggesti(jn to form a transverse valvular openiiif^ in 
 the trachea is undoubtedly the best, since it readily allows the escape of tlie foreign body 
 when impelled against its surface. The cutting out of a portion of the trachea is (piite 
 unnecessary. A better practice consists in making some provision for the tracheal wound 
 to be held open by hooks, by some such apparatus as Golding-Bird's tracheal dilator. In 
 one case in which the trachea was deep 1 managed to keep the traclieal wound open by 
 means of a divided ring of strong wire embracing the neck, its two ends being made to 
 liook into the opening in the air-passage and acting as retractors. In anotlier I licld the 
 wound apart by means of a wire instrument made on the principle of the eye speculum. 
 When efforts fail at one time for the removal of the body, they nuiy be successful at 
 another. Mr. Urunel's well-known case is one in point. Mr. Durhaui informs us, from 
 an analysis of G3G cases <tf foreign bodies in the air-passages, that death resulted in 41 
 per cent, when no operation twas performed, and in 23 per cent, when operative measures 
 were resorted to, and lience the chances are greatly in favor of the latter practice. The 
 foreign body having been removed, the chief danger has passed. There may be some 
 inflammation of the air-passage as a result of the irritation of the foreign body, but this 
 usually subsides on the removal of its cause ; in exceptional instances it may prove 
 troublesome, if not fatal. The nature of the substance has also much influence in deter- 
 mining this result, smooth bodies being sliglitly irritating, while jagged are more so. The 
 operation of tracheotomy doubtless does something toward aggravating the tendency to 
 inflammation. Such a complication sliould be treated on rational principles, but in the 
 majority of instances the inflammation will subside spontaneously on the removal of the 
 oftending body. Water dressing to the wound and a warm, moist atmosphere are the 
 two essential points of practice to be attended to after the removal of the cause, and, as a 
 rule, convalescence speedily follows. Antcsthetics ought always to be administered in 
 these cases when operative interference is called for. 
 
 Scald of the Larynx. 
 
 This somewhat common accident is engendered amongst the poor from the habit of 
 feeding their children out of a teapot. The child, when thirsty and alone, being accus- 
 tomed to drink from the '• spout," tries the same experiment with the kettle of boiling 
 water, and scalds the pharynx and orifice of the larynx, so that anlenia of the part fol- 
 lows, in the same manner as a blister ari.ses by the application of boiling water or steam 
 to any other tissue. 
 
 The symptoms caused by such an accident appear, as a rule, very speedily, and the 
 small chink of the glottis soon closes ; as a consequence, a fatal result ensues unless early 
 relief can be obtained. 
 
 Sv.MPTOMS. — In some cases the mouth, with the soft palate, tongue, and fauces, will 
 be found swollen and vesicated. There will also be difficulty in swallowing, and also 
 alteration in the character of the voice. The respiration rajiidly becomes affected and a 
 spasmodic croupy cough appears, with .stridulous breathing. These symptoms may 
 become gradually or rapidly worse, and may be complicated with attacks o^ spasmodic 
 dyspnoea at long or short intervals ; but when these attacks appear, the condition is 
 extremely dangerous, as any spasm may prove fatal. A somewhat .similar result may- 
 arise from the intentional or accidental swallowing of any corrosive poison or acid or from 
 the inhalation of a flame. 
 
 Treatment. — In a fair proportion of these cases little other treatment than a warm 
 bed. the application of a hot sponge to the larynx, and the inhalation of warm moist air 
 is ever needed ; the symptoms sub.side as rapidly as they appear, three or four days see- 
 ing the worst of the ca.se : and in these mild cases the laryngeal symptoms are probably 
 never severe. When laryngeal symptoms exist, accompanied by spasm, the case assumes 
 a threatening aspect ; indeed, the first spa-sm may be the last. I have notes of the case 
 
604 SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. 
 
 -' of a child in whom the symptoms were so slight that no anxiety was felt, but a single 
 spasm took place two hours and a half after the accident and put an end to life. 
 
 When symptoms are severe, the operation of tracheotomy should be performed ; 
 indeed, I am disposed to recommend this operation in every case in Avhich the symptoms 
 are progressing and laryngeal spasms coexist. To postpone it too long, till the lungs 
 become gorged with blood, and consequently disposed to inflammatory action, and the 
 powers of the patient are depressed, is a timid, and certainly unsuccessful, practice. In 
 the opinion of many good surgeons, I know, it is thought desirable to pospone operative 
 interference as long as possible — "to watch and wait." In this I do not agree. When 
 laryngeal spasms exist with mechanical obstruction, nothing but opening the windpipe 
 places the patient in safety. Out of 9 cases consecutively treated by tracheotomy 5 
 recovered. The statistics, however, of my colleague, Mr. Durham, are less favorable, 35 
 out of 51 cases terminating fatally. 
 
 In some instances the scarification or puncturing of the oedematous opening of the 
 larynx and epiglottis gives great relief. I have been accustomed to do this by means of 
 an ordinary tenaculum or mounted needle. Mr. Tudor, formerly of the Dreadnaught, 
 has invented a useful instrument for the purpose, called an epiglottome. The puncture.^ 
 into the oedematous tissue may be free and never seem to do "harm. Drs. Wallace and 
 Bevan of Dublin have spoken very strongly in favor of the calomel treatment, two or 
 three grains being given every hour until the symptoms are relieved, and Dr. Croly uses 
 inunction at the same time. Other surgeons speak well of antimony, and doubtless it is 
 a drug that should always be given in doses of one, two, er three minims of the anti- 
 monial wine every quarter of an hour until some efi'ect has been made upon the disease, 
 and then at longer intervals. The best local application to the larynx is the hot sponge. 
 A blister over the upper part of the sternum sometimes does good, and in exceptional 
 cases leeches to the larynx may be used. The time required by all these remedies to pro- 
 duce their eff"ects is too long and their action is too uncertain to allow the surgeon to 
 depend upon them in acute cases; as accessories to the treatment they are of use," but as 
 means of preventing death when obstruction exists and spasms are frequent they are not 
 to be relied upon. When an operation is performed, it should be tracheotomy. Laryn- 
 gotomy is inapplicable and too near to the disease. Anaesthetics may be given without 
 fear. 
 
 Diseases of the Larynx requiring Tracheotomy. 
 
 Since the introduction of the laryngoscope our knowledge of the disease of the larynx 
 has so much increased, and the treatment of its diff'erent affections so much improved, 
 that the subject has become somewhat extensive — so extensive, indeed, that enterprising 
 members of our profession have contrived to turn it into a specialty. This is a subject 
 of regret in a certain sense, as it tends to make the bulk of the profession, and with it the 
 student, look upon laryngeal affections as difficult subjects of investigation and beyond 
 the reach of average skill. This is not, however, in any way correct, for the use of the 
 laryngoscope or throat speculum is no more difficult than that of any other iri.strument. 
 To use it neatly and efficiently requires skill and some practice, but the same efforts are 
 also essential to every other surgical investigation. 
 
 The first laryngoscope was introduced to the profession in 1829 by the late Dr. B. G. 
 Babington of Guy's Hospital, who under the term " glottiscope " invented an instrument 
 composed of a mirror fixed to a wire handle, which, being fixed against the palate whilst 
 the tongue was depressed, enabled him to view the upper part of the larynx. Garcia, 
 the singer, in 1855 gave an impulse to the idea by throwing the sun's rays into the back 
 of his mouth by means of a mirror held in his left hand, and so from a dentist's reflector 
 introduced into his mouth he could witness the movements of his larynx in the looking- 
 glass. But to Drs. Czermak and Turck is unquestionably due the credit of having applied 
 this mode of investigation in a scientific way to the diagnosis of laryngeal disease. They 
 employed, however, artificial illumination instead of solar, adopting the practice of Helm- 
 holtz in ophthalmoscopic operations. 
 
 The ordinary mode of application of the instrument is very simple. The patient sits 
 with his back to a good light ; that of the sun is the best, but a moderator, gas, or electric 
 lamp will suffice. The lamp should be in a line with the patient's face and on his right 
 side ; the surgeon, with the mirror fastened round his head, faces the light and reflects it 
 on the patient. The patient is then directed to open his mouth, protrude his tongue, and 
 hold it with a handkerchief; a warmed mirror is then introduced to the back of the 
 fauces, while the tongue at this time is depressed. The rays of light from the frontal 
 
/'//. I n y.\(;j:. il a I'lKcrioys unsrit iicrisu nil-: iu:si'ira tios. 
 
 005 
 
 HjiiTor aiv tlu'ii inailc tu fall upon tlic mirror in tlii' pliarynx, and with a litlh? arrange- 
 mont tlu' glottis anil all the parts arouml, ahovi; or hi'low, may be fari'lully examined. 
 
 The pharyntroal mirror may also he well illuminated hy simply projectint^ the rays of 
 light tVum a large retieetor fastened heind a gas or moderator lamp, as seen in Fig. 34b. 
 
 Fiu. 348. 
 
 Laryngoscopie Examination. 
 
 I have employed this method for many years, and found it more effectual than any 
 other. 
 
 It is impos.sible in the following chapter to give a full description of all the different 
 affections to which the larynx is liable, nor would it be consistent with the object I have 
 in view, since laryngeal affections come as much under the notice of the physician as of 
 the surgeon, and the latter is consulted only when medicine has failed to relieve symp- 
 toms and evidence exists of some progressive aflPection which, by causing obstruction to 
 the respiratory process, threatens life. In the following chapter I propose, therefore, to 
 consider the diseases of the larynx in their surgical aspect only, and to view them simply 
 in their relation to tracheotomy or other operative interference. 
 
 In a general way it may be asserted that tracheotomy may be called for under any 
 circumstances in which obstruction exists to the respiratory act. such as in pharyngeal 
 affections mechanically affecting the larynx; in laryngeal disease, acute or chronic, inflam- 
 matory or otherwise; or in tumors pressing from without upon the windpipe in some part 
 of its course. It may also be possibly required for some temporary purpose connected 
 with operative surgery, to ensure the maintenance of the respiratory act during the 
 removal of a large pharyngeal or maxillary tumor. 
 
 Pharyngeal Affections Obstructing the Respiration. 
 
 Abscesses about the pharynx or tonsils at times cause laryngeal obstruction, and 
 such a complication should be treated by puncturing the abscess with a guarded bistoury. 
 Inflammatory and ulcerating affections of the throat, more particularly those called diph- 
 theritic, are apt to spread to the larynx and set up a laryngitis. 
 
 Tumors of the pharynx or tonsils are occasionally met with pres.sing upon the 
 larynx and interfering with its functions ; a cyst may develop at the back of the tongue 
 in front of the epiglottis and by its size almost close the laryngeal orifice, or a naso-pha- 
 ryngeal tumor may so press downward as not only to threaten life by suffocation, but to 
 cause death. In a large naso-pharyngeal tumor I had to treat the former condition was 
 met with, but relief was given by the removal of the growth. In another case, one of 
 cancerous tumor of the pharynx above the soft palate, occurring in a boy aet. 18, and 
 which rapidly recurred after its removal, death ensued from suffocation, tracheotomy 
 having been rejected. Suffocation from simple enlargement of the tonsils I believe to be 
 unknown, although it has occurred from cancerous disease. 
 
606 SURGICAL AFFECTIOXS OF THE LARYXX AND TRACHEA. 
 
 Affections of the Larynx requiring Tracheotomy. 
 
 Inflammatory affections can never exist long without causing some closure of the 
 glottis, thereby endangering life. In acute laryngitis of catarrhal origin, in membranous 
 and in diphtheritic croup, a few hours may be sufficient to produce this effect, from either 
 oedema of the larynx, suppuration of the larynx, or the effusion of a false membrane. In 
 all the result is the same — mechanical closure of the glottis complicated with spasm — and 
 in all the important question presents itself as to whether medical treatment can be suf- 
 ficient to check the disease or surgical aid in the way of operative interference is required. 
 Trousseau, our great authority in this matter of tracheotomy in croup, maintained strongly 
 that the earlier the operation is performed the greater are the chances of success, that it 
 ought to be performed before death is imminent, and that, to whatever degree asphyxia 
 may have proceeded, it ought to be tried, for in the most desperate cases there is a chance 
 of success provided the local lesion, the croup, constitutes the chief danger of the disease. 
 In these views I entirely concur ; they are physiologically sound and clinically correct. 
 Indeed, the operation should be performed in all cases when the disease is steadily pro- 
 gressing and is unaffected by medical treatment, and it should be undertaken h^fore 
 asphyxia, carbonaemia, or severe blood poisoning has taken place. To operate before 
 any evidence of deficient oxygenation of the blood, as shown by lividity of the lips, etc., 
 exists would be bad practice, and to postpone operative interference when such lividity 
 is present is to throw away a chance. With retraction of the epigastrium and intercostal 
 spaces and supraclavicular depression in inspiration, with or without cyanosis, any delay 
 would be dangerous. It is a clinical fact that in a large number of cases the extension 
 of disease is arrested by the operation, though when the lungs have become gorged with 
 blood unfit for circulation by too protracted delay in operating a successful issue can 
 hardly be looked for. 
 
 In chronic laryngitis, whether tubercular, syphilitic, or otherwise, tracheotomy 
 may be required to prevent impending death or as a means of cure. For the first indi- 
 cation it should not be postponed too long, for ''too long ' often means "too late," .some 
 spasmodic attack carrying off the patient. When these attacks consequently appear and 
 recur, tracheotomy should be performed. 
 
 TracJieolomy as a means of cure in chronic inflammatory laryngeal affections is not 
 sufficiently practised. •' It has been hitherto generally performed in the class of cases to 
 which I have just alluded — to rescue patients from the danger of impending suffocation, 
 and to prolong life when threatened from laryngeal disease ; and yet it must have struck 
 most men, when watching cases which have been operated upon under these circum- 
 stances, how rapidly all laryngeal symptoms disappear and ulcerative action undergoes a 
 reparative process, both in the pharynx and larynx, after a new passage has been obtained 
 for the respiratory act and complete quiescence of the parts has been secured by means 
 of tracheotomy." I have a strong opinion, therefore, that it would be wise to perform 
 the operation in ulcerative laryngeal affections at an earlier period than has hitherto been 
 practised, witha view of arresting the progress of the disease, and probably of saving the 
 larynx as a respiratory and vocal organ, anticipating the time when the operation may be 
 demanded for the purpo.se of preventing impending suffocation. In the first volume of 
 the Clinical Society's Transactions I published some cases illustrative of these views, and 
 my more recent experience has confirmed them. It should not be performed in the very 
 early period of the disease, whilst any reasonable hope exists that by medical or local 
 treatment a successful result may be secured, but it should be undertaken in all cases of 
 progressive disea.se when local and general treatment have failed to make any impression 
 on the local affection. 
 
 Tumors of the larynx are not very uncommon. Children are liable to suffer 
 from warty growths of the rima or the surrounding parts, and in adults epithelial tumors , 
 are likewise met with. Cancerous growths involving the larynx are also on record. Mr. 
 Holmes, in his admirable work On Children's Diseases, informs us that out of twenty- 
 eight cases of tumor of the larynx which he tabulated from the Transactions of the Patho- 
 logical Society, seven were cancerous. He also points out the fact that in cases of tumors 
 of this region life is threatened by the occasional fits of spasmodic dyspnoea, the patient 
 being often well in the intervals ; and when these recur very severely, it becomes neces- 
 sary to perform tracheotomy. 
 
 When warty growths exist and it is impossible to remove them from above by means 
 of the forceps or snare, aided by the laryngoscope, the larynx may be laid open fearlessly 
 in the middle line and the tumor removed. I did this in 1871, in a child aet. 3, for exten- 
 
IU:()\ril()-l(i.][) \ rilACllF.o'l'oMW I.MiY\<;(>r()MY. f)07 
 
 sivc vviirtv (liscasc (if tlu' cpiirlultis and glottis with coinidctt! .siic-t;f.<.s, and my collcafriics, 
 Mr. Durliam and Mr. Davics-Collcy, Iiav(! dnnt- tlic .same. I Iiavo also hy tin- opcralidii 
 of tracdu'otomv iindnn^L'd for many niontlis tlic lil'c id' a man wlio had a cancerous hiryn- 
 peal tumor ohstrucliny: respiration. 
 
 Tracheotomy may also he recjuircd for tumors of the neck pressinj; upon the larynx. 
 I have hecn called u]ton to operate under tliese circumstances on three occasions. It may 
 likewise he demanded for intrathoracic tumors, ancurisnjal or otherwise, on account of 
 sudden larynireal spasm due either to pressure (»n the recurrent laryngeal nerve or to 
 compression (tf the traidica, Dr. Hristowe haviuir vvell sh<iwn {St. Thoiixis's JIosji. /i'<j>., 
 vol. iii., 1S72) ''that destruction of the functional activity of one recurrent laryn;rcal 
 nerve is marked }>y paralysis of tlx^ corresponding vocal cord, which can be recognized by 
 means of the laryngoscope, by impairment of the musical (piality of the voice, and (prob- 
 ably) by some difficulty of swallowing, owing to the tendency of fcjod to slip into the 
 laryn.x, but is not necessarily attended with stridor or dyspmea ; and, in the second jdace, 
 that compression of the trachea involves stridor and difficulty of breathing, which is often 
 paro.xysmal and liable to end in sudden death, but that it does not of itself interfere with 
 perfect intonation, excepting only in so far as it may render the voice weak by diminish- 
 ing the supply of wind to the vocal organs." 
 
 Excision of the Larynx. 
 
 This operation was first performed by P. H. Watson in 180(5, and later by Billroth of 
 Vienna in 1S73, for cancerous disease, Heine of Prague, Moriz Schmidt of Frankfort-on- 
 the-Maine, Langenbeck of Berlin, Caselli of Milan, and Gussenbauer of Prague, but the 
 success that has attended it is not such as to lead me to recommend the operation. The 
 operation can be performed by making a transverse inci.sion parallel to and above the 
 hyoid bone and a vertical one at a right angle to it over the larynx, the dissection of the 
 larynx being made from above. Dr. Foulis of Glasgow has, however, performed this 
 operatit)n upon a man set. 28 for recurrent papillary sarcoma with success. In the ope- 
 ration he left the epiglottis {Lancef, 1877, vol. ii., and 1878, vol. i.). 
 
 Bronchotomy, Tracheotomy, Laryngotomy. 
 
 Any opening made by the surgeon into the windpipe is called hroiwhotomi/ ; when 
 between the thyroid and cricoid cartilages, it is called hirijngotom]/ ; when below the cri- 
 coid into the trachea, trach<otom]i ; and when the incision includes the cricoid cartilage 
 and upper rings of the trachea it is called lari/ ago-tracheoto my . In all these operations 
 the object is the same — either to admit air into the lungs when some obstruction exi.sts 
 in or above the larynx, or to facilitate the removal of a foreign body or morbid growth. 
 Dismissing the general term '' bronchotomy " from our consideration, the latter two ope- 
 rations claim our notice and are applicable in two different classes of cases. When the 
 cause of obstruction is a I >f iva t\iG. larynx, laryngotomy may be performed ; when in the 
 larynx, tracheotomy or laryngo-tracheotomy should always be preferred. For the 
 removal of a foreign body or new growth tracheotomy is the better operation, the incis- 
 ion at times being extended either upward into the larynx, through the cricoid and thy- 
 roid cartilages, or downward as far as needed. For both operations anaesthetics may be 
 safely administered, unless asphyxia be profound, when it is not required. 
 
 Laryngotomy is not an operation to be performed on children, the crico-thyroid 
 space at an early period of life being too small to allow of a free opening being made into 
 it. It is only applicable in adults when obstruction to respiration exists above the rima 
 glottidis, such as that caused by an impacted mass of food or some pharyngeal growth. 
 For tetanus or any other spastnodic affection of the lar^^nx threatening life it may like- 
 wise be employed, as well as in operations on the palate, pharynx, etc.. in which it is 
 advisable to ensure the free passage of air into the lungs during manipulation, although 
 under these latter circumstances tracheotomy and the use of Dr. Trendelenburg's plug 
 are to be preferred (Fig. 228). 
 
 To perform the operation, the patient should be placed on the back with the thorax 
 raised, shoulders drawn down, and head extended. The operator should stand on the 
 patient's right side and feel for the thyroid cartilage, at the lower border of which the 
 windpipe is to be opened. To do this a vertical incision is to be made in the median 
 line, about one inch long, cutting through all the tissues covering in the crico-thyroid 
 membrane. The membrane should then be opened transversely with a knife. The crico- 
 
608 
 
 SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. 
 
 thyroid arteries cross this space, and may possibly be divided, giving rise to some little 
 hemorrhage. Sir W. Fergusson has recorded a case narrated to him by Professor Turner 
 of Edinburgh in which a fatal hemorrhage occurred from these vessels. Such a danger 
 i.'i. however, very remote. 
 
 Tracheotomy is by no means a simple operation, but under all circumstances is 
 delicate, requiring coolness and caution, and when performed hurriedly is too often made 
 
 Fig. 349. 
 
 Operation of Tracheotomy. 
 
 difficult, and even dangerous. In very young children it is always troublesome. The 
 surgeon may at times be called upon to be rapid in his movements, but never should be 
 hurried. As the result of hurry many are the mistakes that might be enumerated, such 
 as wounding of the innominate or carotid artery, the opening of the oesophagus through 
 the trachea, the puncturing of the spine through both these tubes, etc. 
 
 The patient should be placed as in laryngotomy. while the surgeon stands on the 
 right side. The different points in the neck must then be made out and the existence of 
 any large vein in the line of incision looked for, and, if present, avoided. The best 
 position for opening the trachea is half an inch below the cricoid cartilage or below the 
 isthmus of the thyroid gland ; but this is not a point of so much importance as some 
 surgeons would lead us to suppose. In infants it may be disregarded. An incision 
 about two inches long may then be made through all the soft parts covering the trachea. 
 This may be done rapidly when needed, deliberately when possible, care being taken at 
 the same time, by means of reti-actoi-s, not to displace the parts. During this step of the 
 operation the surgeon's left index finger should be his guide, and it should be steadily 
 kept over the trachea till the rings are felt, while it will also intimate the presence of any 
 arteries near the tube or in the line of incision. The rings once recognized, the trachea 
 may be opened with the knife, its edge being turned upward, and the opening made par- 
 allel with the nail of the left index finger, which is in the wound. When the windpipe 
 has been opened, air, blood, and mucus will at once bubble up. The canula with its 
 pilot should then be introduced into the trachea through the opening which the left index 
 finger has covered, this finger acting all through as a guide and director, and. lastly, as a 
 plug to the wound till the canula has been introduced. The eye of the operator should 
 be directed to the end of his left index finger. 
 
 In opening the trachea some prefer to use the hook to draw it forward, and in cases 
 in which much bleeding exists or the trachea is very deep it may be employed. I have, 
 however, rarely used it, having more confidence in the use of the left index finger as a 
 guide throughout. 
 
 Some employ, also, a dilator to keep the wound open till the tube is introduced, while 
 others prefer to open the trachea with a sharp trocar. The former practice is unnecessary 
 and the latter dangerous, as a sharp trocar ma}* perforate the trachea altogether and 
 enter the oesophagus — an accident I have known to occur, or, if it slip by the side of the 
 windpipe, the large vessels will be endangered. With respect to the canula. Fuller's 
 bivalve has hitherto met with general approval, and Durham's " lobstei'-tail " canula 
 (Fig. 350) has been much liked, though the best by far is the ball-and-socket instrument 
 
nnoyciioToM y, th.k iir.oro)! v, i..\i: vsaoroM v. 
 
 609 
 
 (Fij;. .'{')! ) I had iiiaiU' soiiu- years ap), its ^'n-at ailvantajrc ooiisistiii^' in tlic luuliility nf 
 the till)!' with the trachea, the neck jdate Ijeinj; fixed. 
 
 When this eanuhi is made ol" aliiininiuni, ^real advantaf^es are jraiiud, an aliiiiiininni 
 instrument \vei_t:hin,:; mdy sixty <:rains, when a Hilver one weighs tw<i Inindn-d and sixty. 
 
 F ui. 350. 
 
 Ifiirhain's riiniilii iiixl I'ilol. 
 
 Indeed, the aluminium is liiihter hy ten grains tlian the vuh-anite. Tlio rigid tuVjo. wlien 
 re(|uired t(» l)e w(trn lor h)Ug, too often excites ulceration by the pressure of its free end 
 on the trachea, which may extend into the innominate artery. Mr. Morant Baker has 
 
 i-i(i. :rji. 
 
 Fig. 352. 
 
 Hrvaiit's <,'amila 
 
 A, Full lenjith. 
 
 B, Shortened. 
 
 Tracheal Aspirator for the Removal of Mucus, 
 J>ynii)h, or possibly a Foreign Hotly, from the 
 Air-l'assages. 
 
 recently introduced into practice a tube made of vulcanized red india-rubber which seems 
 to answer well, and may be employed on the second or third day after the operation has 
 been performed. Every metal canula should be double, and every canula fixed in position 
 by a piece of silk or tape passed through the shield and fastened round the nape of the 
 neck. 
 
 After-Treatment. — After the operation the atmosphere of the room should be kept 
 warm and moist by the admission of steam, care being taken that the air is not saturated 
 with vapor. The wound ought to be kept clean ; strapping and sutures are rarely 
 required ; water dressing or sweet oil is probably the best local application. Great care 
 should be observed to keep the orifice of the canula free from mucus and the inner tube 
 clean, a " sucker " (Fig. 352) composed of a rubber bottle, glass tube, and rubber spout 
 small enough to enter the canula, and long enough to pass down the trachea if required, 
 being always at hand for the purpose. This instrument does away with the nasty and 
 dangerous practice of sucking by the mouth. After the operation a piece of muslin should 
 be placed over the tube, to prevent the entrance of foreign bodies. 
 
 Complications. — If the operation should be complicated by hemorrhage, the sur- 
 geon must not be alarmed. When arterial, it must be arrested before the trachea is 
 opened, either by the application of a ligature or by torsion ; if venous, the sooner the 
 trachea is opened, the better, for a few good inspirations do more to relieve the venous 
 congestion which is almost always present when tracheotomy is demanded than any other 
 attempt to check bleeding. As soon as the tube has been introduced the patient may be 
 rolled over on his side, to allow the blood to run away from the tracheal wound. A piece 
 of sponge applied with some pressure over the wound is generally enough to arrest all 
 venous bleeding, unless some large venous trunk has been opened. I have never known 
 hemorrhage of this kind to be so copious as to interfere with the operation, or to be so 
 persistent as not to cease readily on its completion. If the surgeon stops his operation 
 till bleeding has ceased, he will too often wait till, with the life of his patient, the neces- 
 sity of the operation has ]iassed away. 
 
 Opening of the Trachea. — There can be little doubt that in patients after 
 puberty the trachea should generally be opened below the isthmus of the thyroid gland, 
 but in infants and young children, where the trachea is deeply placed and the neck fat 
 39 
 
610 SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. 
 
 and short, the nearer the opening is to the cricoid cartihitre, the better. For several years 
 I have been in the habit of opening the trachea immediately below the cricoid ring, and 
 never have hesitated to divide the latter when more room is reqnired. In many instances 
 I have gone through the isthmus of the thyroid, and never had any reason to regret it ; 
 nay, I am almost tempted to believe that the dangers of its division are really theoretical, 
 and practically may be disregarded. Of this I am convinced — that the nearer the 
 tracheal opening is to the lower border of the cricoid ring, the better is the operation. 
 If the opening be too small at the first puncture, a second should be made rather than 
 grope about with retractors and instruments to find the original opening. The tracheal 
 tube need not be very large, for Mr. Marsh has demonstrated (*SV. Barth. Hasp. Repoi-t, 
 vol. iii.) that the rima glottidis is the smallest part of the air-tube. In dividing the soft 
 tissues and fascia on the trachea care should be taken to do so freely, to guard against 
 the mediastinal emphysema which Dr. Champneys has shown to be such a common cause 
 of death after tracheotomy (Med.-Chir. Trans., 1882 and 1883), from the escape of air 
 beneath the deep cervical fascia. 
 
 Under all cii'cumstances the operation should be completed, and even in apparently 
 hopeless cases artificial respiration should be kept up through the wound. Mr. Holmes 
 has recorded a case of Mr. Tatum's in which it was maintained for two hours with ulti- 
 mate success. 
 
 When tracheotomy has been performed for thyroidal tumors pressing upon the 
 trachea, the sui'geon should have at hand a long perforated tube small enough to be 
 introduced through the canula, as the tumor may so overlap the trachea as to cause 
 obstruction below the point at which the operation is performed. For the want of such 
 an instrument I lost a patient whom I saw with Sir Risdon Bennett, while by its aid I 
 was enabled to save another for several days, the elastic tube being pressed through the 
 canula, past the obstruction, into the lungs. I have had such a tube adapted to my 
 canula as a pilot to introduce it. It is almost needless to say that the canula should be 
 removed from the trachea as soon as respiration has been re-established by the natural 
 passage, and that it should on no account be left in more than three months. When 
 required longer, a new one should be substituted, since the canula rapidly undergoes 
 oxidization in the trachea and becomes liable to break. In a patient of my own, where 
 the tube had been worn six months, half its circumference close to the neck shield had 
 been destroyed, and the slightest violence would have broken the instrument in the 
 trachea. The vulcanite, and probably the aluminium, canula is good for constant use. 
 
 Mr. T. Smith in an excellent paper (Med.-Chir. Tnms., 1865) has given a good sum- 
 mary of the obstacles to the re-establishment of natural respiration after tracheotomy, 
 and he has shown that the chief causes are a narrowing of the passage of the larynx by 
 granulations around the canula, and the impairment or loss of those functions of the 
 muscles of the larynx which regulate the admission of air through the rima. There may 
 likewise be a persistence of the original cause which necessitated the performance of the 
 operation, the effects of the original disease, or the closure of the vocal cords from the 
 cicatrization of old ulceration. In three cases now under my observation in which trache- 
 otomy has been performed for chronic ulceration of the larynx the rima has so contracted 
 as to be impervious in two, and in one the opening is so small as to be insufficient for 
 respiration, although enough for speaking purposes. 
 
 To help the surgeon to judge of the patency of the glottis, Luer has invented a bullet 
 valve to be adapted to the orifice of the canula, and Mr. T. Smith an india-rubber one 
 which seems equally efficient and is a simpler instrument. Either may be employed, as 
 anything that helps to decide when the canula may be removed with safety is of value. 
 
FRACTrilKI) lllliS. <;il 
 
 CHAI^TKIl XTX. 
 
 SUKCKi; V OK Til K ('II KST. 
 Contusions. 
 
 The chest is liable to be contused, and severe contusions are not unfroquently fol- 
 lowed by extensive effusions of blood. The swelling under these circumstances occurs 
 suddenly after the injury and ajipears with the discoloration of a bruis(\ Those cases, as a 
 rule, do well if left aloiu', the e.xtravasated bhtod beconiin<; absorbed, but in exceptional 
 examples the blood may break down aiul give rise to supj)urati(»n. 
 
 Tkk.vtmknt. — When the contusion is slight, the apj)licatiou of a cold lead lotion is 
 all that is necessary, and in more severe examples, where extravasation is great, there is 
 nothing equal to the application of cold, in the form either of the metallic tube (Fig. 9) 
 or of ice. In obstinate cases the use of some stimulating liniment hastens recovery, and 
 the administration of tonics is always of value. 
 
 When the effused blood breaks down and suppuration ensues, the abscess must be 
 opened ; but the surgeon need be in no hurry to conclude that the effused blood is 
 incapable of being absorbed nor that pus has formed, since it is a familiar fact that 
 blood may remain fluid in the tissues for a long period and yet be eventually removed by 
 absorption. 
 
 Rupture of the Pectoral Muscle 
 
 is an accident which may take place from a forcible strain applied to the muscle when 
 unprepared for action or from external violence. I have seen a case in which the muscle, 
 from the forcible drawing back of the arm, was nearly torn across about its centre, in 
 which the fingers could be inserted between the divided ends of the torn muscle, and 
 there was much effusion of blood. In that case the arm was bound to the side by a 
 bandage and ice locally applied, and three months subsequently some power existed in 
 the muscle. The amount of repair which is to be expected in these cases depends upon 
 the severity of the injury and the care with which the parts are kept in position during 
 its progress. As a general rule, the two ends of the divided muscle should be kept in 
 contact for at least two months before movement is allowed. This accident is not rare in 
 children from forcible dragging of the arm. 
 
 Fractured Ribs 
 
 form about a tenth part of the cases of fracture admitted into a large hospital. This acci- 
 dent is less common in children and young adults than in subjects past middle age, on 
 account of the elasticity of the ribs. In the aged the ribs become so brittle that they 
 break under slight external violence, and in rare cases from the violence of a cough. I 
 have seen this occur in two patients between sixty and seventy years of age, the one a 
 male and the other a female ; in neither were there any signs of disease, and both of the 
 persons are now alive. 
 
 Fractured ribs are not uncommon accidents in lunatic asylums, and generally ari.se 
 from direct violence, though it would be wrong to assume that they are always the result 
 of ill-treatment, as patients, when much excited, will unconsciously inflict most serious 
 injuries on themselves; and it has been proved that the bones of many of the insane are 
 in an abnormally brittle state. This is especially true in the disease known as " general 
 paralysis of the insane." Dr. Campbell Brown of Liverpool has analyzed the ribs of 
 general paralytics, and states that '■ the ratio of organic constituents to earthv matters is 
 much greater, while the ratio of lime to phos]>horic acid is distinctly less, in the ribs of 
 paralytics than in those of healthy adults. There are the same differences between the 
 composition of healthy ribs and those of paralytics as between the composition of the 
 adult large bones and those of the fuetus. And generally the composition in cases of 
 paralysis approaches that observed in cases of osteo-malacia." Some striking cases bear- 
 ing on this subject are recorded by Dr. Hearder in the Jmini. of Mental Sci. for 1871. 
 
 In the majority of cases, the injury being the result of direct violence, the fracture 
 takes place at the part struck, and so the ribs are often driven in. In the minority, where 
 
612 SURGERY OF THE CHEST. 
 
 it is due to indirect violence such as that caused by a crush or squeeze, the ribs generally 
 give way about their middle and three or more become injured, both sides being not 
 unfrequently involved. When the bones are merely broken, it is called a simple fracture ; 
 but when complicated with a wound communicating with the fracture, compoinid. When 
 the ends of the broken ribs are driven inward, the pleura costalis or the lung itself may 
 be torn and the heart or pericardium or abdominal viscera injured. In an analysis of 136 
 consecutive cases which I made when registrar at Guy's, 108 were uncomplicated, and 
 of these 8 only had secondary inflammation ; 28 were complicated fractures : of these 6 
 died at once from fatal collapse, 16 were complicated with emphysema, 3 with emphy- 
 sema and haemoptysis, and 3 with extensive injury to the lung and secondary inflamma- 
 tory symptoms. Two of these cases subsequently died from old-standing disease. Frac- 
 tured ribs on the right side are often complicated with laceration of the liver. 
 
 When a rib is broken, the serous lining of the chest, the pleura costalis, is probably 
 injured, and the danger of the accident lies in the secondary inflammation — pleuritis — 
 which may follow ; and this occurred in 8 of the 108 cases just alluded to. In a case 
 recently seen, which proved fatal from other causes, the pleura was unimpaired, but a 
 quantity of blood was eff"used into the soft parts outside the pleura from laceration of an 
 intercostal artery. When the lung is injured, as indicated by emphysema or haemoptysis, 
 pneumonia, which happens in about 7 out of every 22 cases, is the danger to be feared. 
 Ca.ses that die from fatal collap.se offer the accident generally do so from hemorrhage due 
 to extensive laceration of the thoracic or abdominal viscera. In gunshot fractures a por- 
 tion of the ribs may be detached and driven into the lung. 
 
 Simple fracture is a serious accident only in subjects who are the victims of some 
 chronic chest aff"ection, when from the broken ribs the patients are unable to expectorate, 
 and asphyxia is favored. 
 
 Fractures complicated with injury to the lung are, however, more serious. When 
 severe, they are directly dangerous from the shock to the system and the hemorrhage that 
 frequently attends them, and indirecfhj so from the fact that the slightest lung wound is 
 liable to be followed by inflammation of the lung itself or of the pleura. 
 
 Fractured ribs generally unite in about a month, and where they have not been kept 
 quiet considerable callus may be thrown out or a false joint formed. 
 
 Diagnosis. — Pain at the seat of injury, aggravated by sternal pressure and associated 
 with a peculiar catch in the breath of the patient and the general avoidance of anything 
 like a full inspiration, is a somewhat characteri.stic symptom of a fractured rib, more espe- 
 cially when it .shows itself at once after direct or indirect violence. At times, too, the 
 patient will complain of a grating in the part, and on the application of the hand over the 
 seat of injury, if the patient be made to cough, crepitus will be felt, this crepitus being 
 caused by the friction of the ends of the broken bone. When the seat of fracture is 
 beneath a thick layer of muscles or fat, this symptom may, however, escape detection ; 
 nor should it be too closely sought after when others indicate the nature of the injury, as 
 the manipulation required to elicit this sign is sometimes considerable, and any approach 
 to violence or over-manipulation is always injurious. 
 
 When eniphysenia complicates the case, as indicated by a more or less diff"used 
 puflPy swelling which crackles on pressure, there will be no doubt as to the lung having 
 been injured, since this symptom is caused by the escape of air from the lung into the 
 cellular tissue about the seat of fracture. This may be either local or general ; when 
 associated with hftnvopfiji'is, it is fair to infer that the lung has been penetrated, the sever- 
 ity of the mischief being gauged by the extent of the emphysema and the amount of the 
 haemoptysis. 
 
 In rare cases the emphysema lasts for days. In a case under care in October, 1881, 
 it remained for seventeen days after the accident ; the patient recovered. 
 
 Emphysema may be met with as the result of chest injury without fracture of the ribs, 
 as evidenced by the case of a boy aet. 5 who, having had the wheel of a cart pass across 
 his shoulders, was admitted in 1883, within a few minutes after the accident, into my ward 
 at Guy's with universal emphysema and such difficulty of respiration that death appeared 
 imminent. The boy's body and neck appeared like a tight .sausage. To let out the air 
 I punctured the integuments over the child's body with a small knife an eighth of an inch 
 wide, and the air whistled out of the openings with enough force to blow out a lighted wax 
 taper. The relief aff"orded by the operation was marked, for the child steadily went on to 
 a complete recovery. There was no hjemopty.sis in this case or evidence of fracture of the 
 ribs. The child also cried naturally, the fact fairly proving that neither the larynx nor 
 the trachea was lacerated. Yet the opening into the air-passages must have been very 
 
riiAcrriii:!) in us. 613 
 
 free to ^^ive rise to sucli rapiil ami ticiicnil i'm|iliys<'iiiii. TIk- ri-licf jriven hy tlu; (ijn'ra- 
 tion *A' |»iiiic'turiii;^ the skin is a |niiiit in ri'inciiilicr (/inf. JAr/. ./'>»/•/*., Jamiarv 2tJ, 
 ISSl). 
 
 TitKAT.MKNT. — Tlin (iltjcct of the siir^M'oii in tilt" treat iiiciit ni' a .simple Tract lire nf tlie 
 thorax is to niaiiitaiii the rihs at rest, which sh(nihl he efl'ected l)y the u|)iilicati(jii of strips 
 of strmiir adhesive phister two iiich(!S l)roa<l, exteii(iiii<r from the 
 sternmii to the spine, and from at h-ast three iiicdies ahove to 
 thret' inches heh)W the seat of injury. 
 
 Till- )tfril>s s/i'iii/i/ III iijijilii (I frnni In loir ii/nnird nml nl tin i nd 
 of i.rjn'ntti(i>i^ and eacli one shouhl he made to cover half of tiiat 
 wliieii jireeeded it ( Kiir. ;};')!>). My this method the movements 
 of the broken rihs are restrained without thos(! of the o])positc 
 side lieint; interfi-red with. It is, moreover, in both comfort and 
 erticiency. far superior to the ohl method of encirclin<; tiie chest 
 with a Hannel roUer; indeed, it generally affords speedy relief to 
 all symptoms. When the case is complicated with emphysema, 
 or even with ha-moptysis, the same treatment should be carried ''^ e 
 
 out; tor in these more severe cases the necessity of maintaining strapping m Fracture of Kiiw. 
 the immol)ility of the ribs is just as necessary as in the less severe. 
 
 In rare casi's in which much displacement has occurred a sheet of felt or <rutta-percha 
 made soft by hot water and moulded to the part is of ,<rreat value, the mould being subse- 
 ([uentlv fixed liy stra])])iini' as described. 
 
 The patient should be ke])t (|uiet, though not necessarily in bed, and abundance of 
 bland, nutritious, but unstimulatiiig, I'ood given, with sedatives if re(|uired ; of the latter, 
 chloral in half-drachm doses is probably the best, though morphia or Dover's powder is 
 also good. When couirh or any symptoms of infiammation of the pleura or lungs appear, 
 antimonial wine in do.ses of thirty minims for an adult every four or six hours in .some 
 saline mixture is a most valuable remedy. When chest complications are .severe and 
 orthoi)n(.ea with a sense of suffocation from pulmonary congestion threatens life, venesec- 
 tion should be practised. Local treatment by it.self was sufficient in lOU of the 136 cases 
 above mentioned. 
 
 In a case of severe injury to the chest that came under my care some time ago, 
 caused by the passage over it of the wheels of a heavily-laden cart, fracture of five or 
 six ribs and dislocation of the clavicle occurred, associated with collapse, intense dyspnoea, 
 and lK\3moptysis ; I bled the patient twice in twelve hours, and each time with immediate 
 relief, the case going on to a good recovery. In it the severe dyspnoea and venous con- 
 gestion, the rapid and hard pulse that came on as soon as the collapse of the accident had 
 passed away and tlie circulation had been restored, too surely pointed to an excessive 
 engorgement of the lungs, and indicated that if relief were not afforded absolute suffoca- 
 tion would si)eedily ensue by the patient's own highly-carbonized blood. At such a crisis 
 antimony, however beneficial in simpler cases, could not be trusted, as there was no time 
 for it to take effect. Under these circumstances bleeding was performed, and as the blood 
 flowed life seemed gradually to return : the laborious breathing became quiet and sub- 
 dued ; the deadened and congested eye bright and natural ; the pulse, from being full and 
 hard, softer and less bounding ; and the boy's feelings, released from the impression that 
 death was nigh at hand, became more hopeful and resigned ; and as a spectator I felt 
 such a hope was valid and that success might crown our efforts. After the lapse of twelve 
 hours, however, the symptoms returned, and the repetitiiMi of the bleeding was followed 
 by a repetition of all its benefits. The antimony then came in to complete the cure ; by 
 the double venesection the pulmonary vessels had been relieved of their congestion, while 
 the antimony, in acting upon the circulation, perfected the cure by preventing a return 
 of the former threatening symptoms. The benefits arising from the treatment adopted in 
 this case have such a lasting liold on my memory that I cannot too strongly recommend 
 the practice thus pursued, and the more .so as I have seen it equally successful in other 
 cases. 
 
 Bleeding is now rarely performed, and at Guy's Hospital I believe it is rarer tlian any 
 capital operation. In the case of lacerated lung, however, when urgent dyspnoea makes 
 its appearance and the powers of the patient do not forbid it, I know of nothing which 
 gives greater relief to the patient or greater satisfaction to the practitioner. Bleed with 
 no sparing hand, letting it flow freely in a full stream, and as it flows the symptoms will 
 gradually disappear. When relief has been obtained, arrest the flow immediately, as 
 syncope can do only harm. The aim should be to make an impression through the sys- 
 
614 SURGERY OF THE CHEST. 
 
 temic circulation upon the pulmonary. The patient should be carefully watched and the 
 operation repeated if the symptoms return, and if necessary even for a third time. The 
 antimonial treatment, however, must not be neglected. The object of the bleeding is to 
 relieve immediate symptoms and to give time for the antimony to take effect, because, 
 when the patient has been brought fully under its influence, all danger may be said to 
 have disappeared ; few patients die from secondary inflammation of the lungs when once 
 fairly under the influence of antimony. 
 
 Fracture of the sterno-COStal cartilages is a rare accident. I have seen 
 but few cases ; in one of the seventh rib, which had resulted from a direct blow, a false 
 joint existed. In a recent case, in which the cartilage of the right second rib was driven 
 in by direct violence, no harm followed. These, which are said to unite generally by 
 bone, can be treated in the same way as fractured ribs. 
 
 Dislocation and fracture of the sternum are likewise rare accidents, and 
 the majority of them are complicated with other injuries, especially of the head and 
 spine; they were found in 4 out of 5G fatal cases of injury to the spine at Guy's Hos- 
 pital. The sternum yields, owing to the violent descent of i\\e chin against the manu- 
 brium. Fractured sternum is also occasionally met with as a complication of fractured 
 ribs. When fracture takes place, it is generally transverse and oblique from before back- 
 ward, the lower fragment being found projecting. Only rare examples exist of a vertical 
 fissure. When the upper portion of bone is displaced, it is generally displaced backward. 
 Kivington in an able paper {Med.-Chir. Trans., 1874) has fairly shown that displacement 
 occurs in preference to fracture when an arthrodial joint exists between the manubrium 
 and gladiolus. 
 
 Diagnosis. — When deformity is present from displacement of bones, the diagnosis is 
 easy ; and when this does not exist, pain in the part, aggravated by a full inspiration and 
 crepitus on the application of the hand, is the chief symptom. 
 
 Treatment. — The treatment must be the same as for fractured ribs — namely, the 
 recumbent position and strapping over the part, complications being dealt with as they 
 arise. I have lately had under care a man who fi-om a blow from the pole of a wagon 
 had the upper two inches of the body of the sternum displaced inward from the manu- 
 brium and costal cartilages ; the bones partially recovered their position in three weeks, 
 and the man got well. 
 
 Dislocation of the ribs requires notice, although little can be said about the 
 subject. It is rarely if ever an accident ^^er se ; and when it occurs, it is part of a more 
 severe injury, such as fracture of the spine or complicated fracture of the ribs. The same 
 remarks apply to dislocation of the ribs from the cartiha/es and of the cartilages from the 
 sternum. Practically, all these cases should be dealt with like fractures. 
 
 Wounds of the Chest. 
 
 The main point to be determined in such cases as these is whether the wound is super- 
 ficial or has penetrated the pleura ; for if the former obtains slight cause for anxiety 
 exists, but if the latter the accident is grave. 
 
 When the wound is penetrating, the extent of the penetration and the organ penetra- 
 ted have to be determined. Is the pleura alone wounded — a rare injury — or is the lung 
 involved? Is the heart injured or any of the great vessels — the intercostal or internal 
 mammary artery? Many of these points can be determined only by a knowledge of the 
 kind of weapon employed, its subsequent appearance, the direction of the force, and the 
 anatomical knowledge of the surgeon ; and even then the difficulties of these cases are 
 often great, as witnessed in a recent memorable trial (Flora Davy). When emphysema 
 and haemoptysis are present, they may be accepted as clear indications of a wounded lung. 
 Emphysema alone is always a suspicious symptom, though it may occur to a limited 
 extent in non-penetrating punctured wounds that traverse the soft tissues outside the 
 thorax ; while the absence of haemoptysis is no proof that the lung has escaped injury. 
 When blood and air bubble through the wound and air passes freely from it or a portion 
 of lung protrudes, there is no room for doubt as to the nature of the injury ; but these 
 cases are exceptional. In the majority the diagnosis is ever uncertain, since there are 
 no definite individual symptoms by which injury to the lung is to be diagnosed. The 
 surgeon in his anxiety to make out the point must never be induced to probe the wound 
 or to explore it with a finger, nor should he test the condition of the lung by making his 
 patient cough to expel air through the thoracic opening. Indeed, he should throw aside 
 all direct or manipulative modes of investigation and trust to the indirect. 
 
n'oiwns or Tin: cuhsr. <J15 
 
 Tilt' t/iiTit offi'cts of n jK'iu'tratiiii; wnuiid arc liciiKirrhajrc ii)ti» the chest or hjuino- 
 tliorax. ciMphyscnia, pnciiiiHi-tlinrax, ami hernia ot" the lllllL^ 'l'li«" s<ri,ii</iin/ results arc 
 those of iiiHaminatioii, sinli :i> |il(iirisv or ]iiieiiiiioiiia. li V'lio-l liorax. oi- eiii|iyciiia, with 
 tlu'ir coiise((iiciices. 
 
 l*K«»(iN()sis. — The prognosis is always imiavoraliie ami shoiiM he guardeil, more par- 
 ticularly when the wound is peuctratiug ; hut when a wtn-k has passed without any 
 unfavorahle symptoms appearing, a more ]»romising and decided tone may he assumed. 
 
 TuKATMKNT. — In all sus-^tccted or ohvious penetrating chest wounds the utnu>st gen- 
 tleness should he employed and complete (|uiet enforced, as any deviatifiu from this prac- 
 tice may disturh nature's reparative jiroeess, disarrantre clot, and excite overacti(»n or 
 iuHammation. The external wound should he carefully cit'aiifi/ tinil rloiit<f ainl all foreign 
 hodies rcmove(l. Tlie ))atient should he placed in the reciimhent position and on no 
 account allowed to stir. lie should he fed on the sini]»lest nutritious food, and for the 
 tirst two or three days this should he cold ; ice and milk I'orm, with(jut douht, the hest 
 mixture. The collajtse which often follows the injury need not excite alarm urdess it he 
 protracted or severe ; for when the result of hemorrhage, it is not only a salutary measure, 
 but the only means the surgeon looks to for the arrest of hemorrhage, as he himself is 
 powerless to interfere. If blood, however, accumulate in the chest and by its mechanical 
 pressure threaten life, .some means must be found for its evacuation, either through the 
 original wound or l)y the operation of tapping or by an incision of the thorax. The indi- 
 cations should he very decided before the surgeon interferes, as the extrava.satcd hlood 
 rajndlv coagulates, and consecjuently is difficult to remove. The same renuirks hold good 
 when air accumulates or is pent up in the pleural cavity. 
 
 The symptoms that attend reaction should l)e carefully watched, and anything like 
 excess of action, as indicated by increased difficulty in respiration, cough, or a rapid 
 pulse, ought to be met by the administrati(tn of antimony in half-drachm doses of the 
 wine with some saline every three or four hours. 
 
 If the lungs become gorged with blood and asphyxia threatens, venesection is as valu- 
 able a remedy in these cases as it has been shown to be in those of fractured ribs. Dr. 
 Macleod tells us that in the Crimea the cases of gunshot wounds of the chest that did 
 the best were tho.se in which early and repeated l)leedings were had recourse to. Pain 
 must be relieved by anodynes, chloral being better than opium. 
 
 Hernia of the lung, or pueumocele, is a rare consequence of a punctured wound 
 of the thorax. I have seen but one example, where the tumor was on the left side, 
 external to the nipple, and about the size of a walnut. The mass was left In sifii and 
 gradually withered. When the hernia is recent, however, and the lung healthy, its 
 reduction is generally considered to be the best practice ; but when of long standing and 
 diseased, it had better be left alone. Its removal by ligature or the knife has likewise 
 been recommended, successful cases having been recorded of all forms of practice. In a 
 case which came under my care at Guy's in 187(5, of fracture of the sternal ends of the 
 left third and foi.rth ribs by the man i'alling upon the blunt end of .some wooden palings, 
 in which the bones were driven in without wounding the integuments, a hernia of the 
 lung took place the size of a duck's egg ; but an excellent recovery followed the reduc- 
 tion of the hernia and the persistent application of pressure. A'elpeau has recorded an 
 instance of hernia of the lung following the healing of a wound. The tumor in such a 
 case is covered with integument, and is called " the consecutive variety of hernia."' In 
 such a ease all that can he done is to ]irotcct the lung from injury hv a shield. 
 
 Laceration of the lung without fracture of the ribs is an accident of 
 
 occasional occurrence, and 1 have recorded an instance in Gnij'x Reports for 1800 ari.sinir 
 from extreme pressure upon the ela.stic ribs of a boy ret. 7. I saw another ca.se in 180!), 
 in a child a;t. 4 who had been run over. The rent was on the lateral side of the right 
 lung and ran from its apex to base. The ribs of the same side were broken at their 
 angles far behind the seat of rupture. Poland also, in liis excellent article on the chest 
 in //o/we.-j'.s Sioycr//. has quoted several others. M. Grosselin's explanation of its cause is 
 probably correct — viz., '• that at the time of the injury when the chest su.stains the vio- 
 lence, the lungs are suddenly filled and distended with air by a full inspiration, and the 
 air, prevented from escaping by occlusion of the larynx, thus becomes pent up in the 
 lung tissue, and, the lung not being able to recede from the superincumbent pressure, its 
 tissue necessarily gives way." The symptoms of this injury are much the same as have 
 been mentioned in the paragraph on wounds of the lung, while the treatment must be 
 similar. 
 
 Severe compression of the chest may likewise cause laceration of the heart 
 
016 SURGERY OF THE CHEST. 
 
 or large vessels; also brain symptoms, such as uncoiiseiousness, epistaxis, and hemorrhage 
 into the orbit beneath the conjunctiva and eyelids ; and in a singular case which I recorded 
 in the same volume of the Gia/a Rep. as that of the boy just quoted paralysis of the mus- 
 cles of deglutition and of the larynx, which lasted for two days. 
 
 Abscesses are frequently found about the chest, and in rare instances may be due 
 to the discharge through the lung of a foreign body. Thus Dr. Wilks recorded at the 
 Pathological Society on November 1, 1881, a case of a child in which an ear of corn was 
 discharged from an abscess situated in the left suprascapular region. A recovery fol- 
 lowed. No history could be obtained as to how the foreign body entered the lung. It 
 was probably inhaled. 
 
 When abscesses are situated beneath the pectoral muscles, they are very obstinate. 
 They may be confined to the cellular tissue of the part and connected with the subpectoral 
 glands or associated with ruptured mu-scle or inflammation of the periosteum or bone. 
 
 When connected with the muscles, they must be opened and the parts kept quiet by 
 binding the arm to which the muscle belongs to the side, as each movement of the muscle 
 retards recovery. 
 
 When due to pe?-/o.sA?7?'s- or ostitu^ they are frequently syphilitic, and are more com- 
 monly situated over the sternum, though any of the ribs may be affected. Under these 
 circumstances constitutional treatment is essential, and the iodide of potassium, in grad- 
 ually-increasing doses, from five to ten grains, in some tonic such as bark, is the best 
 medicine. If the bone dies (necrosis), the dead portion must be removed when nature 
 proves herself incompetent to throw off the srqHesfrmji. 
 
 When sinuses exist about the thorax, the surgeon should always be alive to the fact 
 that they may be due either to an empyema which has naturally discharged itself or to a 
 snhstertidf absceas, which is making its way through the intercostal spaces. The history 
 of the case will be found to be the only correct clue to the diagnosis. In both instances 
 a free opening into the abscess and the washing out of its cavity are required. 
 
 Tumors of the chest are not uncommon, but come more under the notice of the 
 physician. Malignant and other tumors, however, may arise external to the ribs ; and I 
 have seen several cases of exostosis from the ribs, and one of enchondroma. No surgical 
 interference was called for. Exostosis from the first rib may press upon the branches of 
 the brachial plexus and give rise to some pain, or upon the subclavian artery or vein and 
 produce obstruction. In some cases these exostoses have been removed. 
 
 Deformities of the chest are mo.stly due to spinal curvatures, though the con- 
 tracted or compressed thorax with the projecting sternum of childhood (pigeon-breast) 
 is frequently found where some long-continued obstruction to natural respiration, such as 
 enlarged tonsils, exists. This is not, however, permanent in a large number of cases, 
 since children who are the subjects of it "grow out" of the deformity ; as their general 
 condition improves the cause is removed and their powers strengthen. It is commonly 
 found in rickety subjects, and is, without doubt, occasionally the result of enlarged tonsils. 
 
 Deformity of the chest may be due to an old pleurisy. 
 
 Tapping the Chest. 
 
 When air accumulates in the chest ( j^ncumo-fhora.r) as a consequence of either dis- 
 ea.se or accident, causes pressure on the lung, and interferes with the respiratory process 
 so as to create alarm, the tapping of the chest (paracentesis thoracis) with a small trocar 
 and canula fitted with a valve may be called for. When blood accumulates (Jiscmo-fhorax), 
 producing similar alarming symptoms, and the blood is mixed with air, and it is clear that 
 life will be extinguished if relief be not afforded, the blood and air must be let out ; and 
 for this purpose it is probably the best operation to make an incision into the thorax 
 where no wound previously existed, or to enlarge a small wound when present. To give 
 relief with a trocar and canula is always a difficult, and often an impossible, task, on 
 account of the coagulum. When s^crvm presses upon the thoracic contents (Jit/dro-fho- 
 ?Yf.x) and requires surgical interference, the trocar and canula with the aspirator are 
 beyond doubt the best instruments to employ, great care being observed to exclude air. 
 The object under all these circumstances is to remove the pressure from the lung in the 
 most effectual way by the withdrawal of the compressing material. When pus exists 
 (empi/emd), surgeons are not quite decided as to the best means to be employed, although 
 all are agreed as to the propriety of drawing it off. A generalized empyema rarely points 
 externally; a localized one does so frequently. For diagnostic ])urposes the aspirator may 
 be a valuable instrument, as it is for the first emptying of a localized empyema ; but for 
 
T.\i'i'iS(; rill-: ciiiisr. dlT 
 
 a coiicnil I'liipyiMiia tin* practice ol' as|»iratiiiLr is not to he advocated, siiico iiothiiif^ less 
 tliaii IVi'i' (lraiiiai.M' is likely tn siifcfcd. as a ircncral ruli'. Tu tap hy incaiis of the aspi- 
 rator iir the trocar and caiiula jrivt's temporary relief, Itiit docs not cure the disease, lor 
 which more eHicieiit measures are re<|Mired. For my own part, I helieve that when pus 
 80 presses upon the luntrs and interferes with the respiratory proeesH as to call for sur- 
 gical interference the pus must he let out hy nu'ans of a IVee opening, the opening ^jcing 
 hirge enough to ])ermit of the free escape of all fluid through a drainage-tube. The 
 introiluetion of drainage-tuhes hy M. Cliassaignae has heen of gnjat service in the treat- 
 ment of empyema. Hr. (Joodfellow and Mr. de Morgan — early advocates of their use in 
 this country — passed the ]»ertorated india-ruhher tuhe through the canula upon a long 
 iron prol)e, and hrought it out of a second opening in the lower and i»ost(?rior part of the 
 chest, this second opening heing made with a scalpel u|)on the cxtre-mity of the probe 
 pressed against the lower intercostal space. The perforated tulte conse(|U(.'ntly passed 
 as a seton through the chest and allowed the free csca|)e of any fluid in its cavity. 
 
 I have never adopted this |)ractice in the way here detailed, heing satisfied with a 
 free o])ening into the thora.x, with either a .scalpel or a large trocar and canula. and the 
 introduction of a drainage-tuht; into the thorax either through the canula or otherwise 
 and the subse(|uent daily washing out of the cavity with a solution of iodine. Sub- 
 aqueous drainage may lie employed. In May, LS""), I followed the former practice in 
 the case of a gentleman :ct. o7 whom I saw with Dr. Rowlands of Carmarthen, and drew 
 off tliree (juarts of pus from his left chest through a' free opening, and subsequently passed 
 a drainage-tube into the cavity. In three months convalescence ensued, and in another 
 month he was quite well, the lung on the aff"ected side having expar)ded. Itideed. I quite 
 coincide with Dr. (ioodhart (Gni/'s IIosj). R<p.^ 1877) that "if drainage is decided upon, 
 notliing short of perfect drainage is safe for the patient;" and to this end the opening 
 into tlie th(jrax must be free and the cavity of the chest kept well emptied, either by 
 irrigation or by wliat has been described as subaqueous drainage, which should be carried 
 out as follows: "Having determined on the spot at which i)uncture of the chest is to 
 be made, a trocar and canula are taken, the bore of which is alxiut five millimetres. A 
 length of several feet of black or red india-rubber tubing which will slip easily through 
 the canula is placed ready at hand; the chest is then tapped and the trochar withdrawn, 
 and as tlie fluid comes in full stream by the canula the india-rubber tubing is pushed 
 along the latter into the che.st as far as neces.sary — usually four or five inches. The 
 canula is then witlidrawn over the tube, leaving the one end of the latter in the chest, 
 while the other or free end is kept under water by the side of the bed. The tube then 
 acts as a syplion." 
 
 This plan of drainage is not. however, very complete; for out of 30 cases in which it 
 was employed, as reported by Dr. Goodhart, in 18 imperfect drainage had to be recorded, 
 and, as this is a method which professes to drain away pus, it cannot be said to have 
 proved successful. 
 
 In young people, where the ribs are elastic, good results may be looked for ; but in 
 the old, where the ri))s are rigid, no contraction can be expected. 
 
 The Operation. 
 
 In tapping the chest for air, serum, or pus the following points should be observed : 
 "Where the signs of disease are most marked, there the puncture should be made. When 
 the chest is full of fluid, the eighth or ninth intercostal space should be cho.sen. just in 
 front of the angle, or the seventh, midway between the sternum and spine. This latter 
 spot can always readily be found by drawing a line with a string round tlie body on the 
 level of the nipple, and midway between the sternum and spine this line will cut the 
 proper intercostal space. At this spot, close to the lower rib, a small incision should be 
 made through the skin and fascia with a lancet or scalpel, and through this the trocar and 
 canula. warmed and oiled, should be introduced ; the trocar, as .soon as it has jierforated 
 the chest, should be withdrawn, the canula being jiushcd more home. When the ojicra- 
 tion has been performed for air or serum, a small instrument should be employed and 
 great care used to prevent the admission of air. For this purpose there is no better 
 instrument than the pneumatic aspirator of Dr. Dieulafoy or one of its modifications, and 
 Dr. Bowditch of Boston, I'nited States — a staunch supporter of this practice — reports 
 (Pracfifioiin-. April, 1873) that during twenty-four years and in 270 operations he had 
 never seen any injury done by the aspirator. As a substitute one of the canulas may be 
 used fitted with a stop-cock or valve, to prevent the admission of air. 
 
618 SURGERY OF THE CHEST. 
 
 When the chest requires opening for the discharge of blood or pus, a free incision or 
 large canula should be resorted to. I prefer an incision, and make it large enough to 
 admit my little finger, and subsequently a large india-rubber drainage-tube. Trousseau 
 strongly advises the operation of tapping when serous effusion fills the cavity, as indicated 
 by auscultation and percussion ; when oppression of breathing also exists, it may be 
 urgently needed ; but this oppression, adds he, is one of the most deceitful of signs, and 
 its absence ought not to inspire too great a feeling of security, as by refraining from 
 interference we run the risk of losing patients whom the operation would assuredly have 
 saved. In empyema he fixes in the canula and draws off the fluid every twenty-four 
 hours, injecting the chest with a solution of iodine, one part of the tincture in six, "every 
 two, three, or four days. 
 
 It should, however, be recorded that sudden death has taken place after thoracentesis 
 for pleuritic effusion or empyema, although evidence is wanting to prove that any distinct 
 relation exists between the operation and death, since cases are on record in which sud- 
 den death ensued in the normal course of cases of pleuritic effusion. Trousseau has 
 recorded examples of the latter kind, and Drs. Cayley and Broadbent of the former {Clin. 
 Societi/^ 1877). 
 
 Apncea, or so-called Asphyxia. 
 
 Death from asphyxia, in the common acceptation of the term, means death from 
 either the cessation of the respiratory process or the want of the ordinary respiratory 
 medium (oxygen),, the heart ceasing to act after the cessation of the respiratory process. 
 Etymologically, it means an absence of pulse. The more correct term is " apncea." It 
 is caused by whatever interferes with the admission of the air into the lung — by such acts 
 as (iwwiiiiu/ and hanging, by diseases that mechanically block up the air-passages or excite 
 .spasm of the larynx, by any external or internal condition of the thorax that prevents 
 the admission of air into its cavity or interferes with its expansion, by the want of the 
 respiratory medium, or by the inhalation of toxic vapors. 
 
 Under some circumstances the asphyxia is rapid or acute ; in others, chronic. In 
 accidental cases it is chiefly the former ; in di.sease, the latter. In both, however, the 
 result is the same, the blood not being decarbonized as it should be, and what Dr. Cleve- 
 land has rightly called carbonaemia ensuing. Special symptoms may depend entirely 
 upon the nature of the asphyxiating cause, but the ultimate effects are the same in each. 
 In all, whether slow or rapid, there are congestion and lividity of the face. In all the 
 heart continues to beat, though laboriously, after respiration has ceased, the action becom- 
 ing gradually less distinct, till it stops altogether. It is possible for the heart to continue 
 its action from two to four minutes after the last respiratory effort. 
 
 After death, it has generally been thought the cerchral irxseia would be found gorged 
 with blood. Ackenian has shown, however, that this condition is present only when the 
 head of the subject has been kept lower than the rest of the body, and that death by 
 suffocation is always connected with an exsanguine state of the cerebral vessels. The 
 right side of the heart and great vessels will be full of black blood, whilst the Ir/t side will 
 be found empty ; and the whole arterial blood will be, as the venous, of a dark color. 
 All the abdominal viscera will be engorged with blood. 
 
 The lungs, in cases of hanging and mechanical obstruction, pi'esent no characteristic 
 appearance, but in those of drowning they will be njore or less filled with water or the 
 drowning medium and incapable of collapsing, and will feel heavy and doughy to the 
 touch. The air-tubes, moreover, will be choked with a sanious foam composed of blood, 
 water, mucus, ;<nd often foreign matter churned up with the air of the lungs. Frothy 
 water mixed with blood will also pour out of any section of the lung. These points were 
 clearly stated by the committee of the Roy. Med. and Chir. Society on suspending ani- 
 mation, and recorded in the Transactions for 1862. 
 
 Drowning. 
 
 Hoin long a Iniman bring mat/ he nndcr irater and i/et recover is an important question, 
 but the answer depends upon many considerations. Dr. Sanderson believes he has demon- 
 strated by experiments that in animals the duration of life turns upon the amount of air 
 confined in the chest at the time of immersion — that when the animal on immersion fills 
 its chest with water by an inspiratory effort, death is most rapid ; but if the chest be full 
 of air at the time, and no such inspiratory effort takes place, life may be prolonged for 
 several minutes. The occurrence of syncope at the moment of immersion, whether from 
 
Tni:ATMi:yT of M'S(t:.\, m: AsriivxiA. 
 
 »;i9 
 
 fright, sluK'k, or jtrcvious injury, is ciiiisiMjUi'iitly ii happy iifcidciit, the vospiratorv act 
 being niatt-rially diininislit'd l)y the jsyncupc. ■ If a pcrs<in he eoinph'tely .suhnierged," 
 writes Dr. \V. (J. Ilarh-y in llnlnutss Si/sfrm, ''and the entrance of water to, and exit of 
 air from, the lungs not prevented, we believe that recovery would he impossible after two 
 minutes. On the ctther hand, if the air-passages were closed against the entrance of 
 water and the chest kept i'ull of air, we see no reason for thinking that a human being 
 would perish either more slowly or more fjuickly than a dog placed under similar circum- 
 stances — namely, in iVom four to five minutes. " 
 
 Death by sfraiKfufn/inn is due to asphyxia alone, and. as a rule, is homicidal, being 
 consetjuently often complicated with other injuries. 
 
 Death by /idiiifin;/ is of a mixed form, since, in addition to the strangulation by the 
 Cord, there is the added traction on it by the weight of the falling body. 
 
 J/i(iii/iiii/ cau.ses death, according to Dr. A. Taylor, " commonly fnjin a})n<ea, but some- 
 times froui apoi)lexy, caused by pressure on the jugular vein, being preceded by c<^nvul- 
 sions, often lasting for many minutes, but in all jmtbability not accompanied by m(jre 
 than UKunentary pain. Occasionally there is found displacement or fracture of the first 
 or second of the vertebne, with com[(ression of the spinal marrow. This cause of death 
 is only likely to be ob.served in corpulent or heavy persons, when a long fall is allowed 
 by the cord, and is seldom met with in judicial executions." This latter fact is supported 
 by the observations of Dr. Barker of Melbourne, who informed Professor Haught(jn of 
 Dublin that in fifty-four post-mortem examinations of criminals hanged according to the 
 old or " short-drop " system, in not a single ca.se was there dislocation or fracture of the 
 neck. Tn the following plan, however, introduced by Dr. Barker, this dislocation was the 
 rule. Dr. llaughton (juotes his words (J/cW. TimcA and Guz.^ June 21, 1871) : " I have 
 the knot put about two inches from the spine, so that when it is tightened by the weight 
 of the body the knot comes on the vertebr;e ; by the fall the body has an impetus for- 
 ward, the resistance being at the beam to which the rope is fa.stened. The knot acts as 
 a fulcrum to i)ush the head forward. By this arrangement I have found in all ca.ses 
 there was a dislocation and fracture of the cervical .spine and pressure on the cord, lacer- 
 ation of the muscles of the larynx, and generally fracture of the hyoid bone, death being 
 always sudden and complete ; no long drop is required." To the Irish and American 
 long-drop system there are grave objections. When the cord is crushed, death is instan- 
 taneous ; when not so injured, life may be prolonged for some minutes — usually about 
 three ; but there is no evidence to believe that the period may be extended to ten. Con- 
 scious life, under both circumstances, probably is soon lost, rarely extending beyond the 
 thrte minutes. 
 
 When the cord is not injured, Taylor computes that life may be restored after five 
 minutes of suspension, and Tardieu, an eminent French writer, gives a similar period. 
 
 Treatment of Apncea, or Asphyxia. 
 
 All obstruction to the passage of fresh air to and from the lungs is to be at once, so 
 far as practicable, removed, all froth and mucus to be cleansed from the mouth and nos- 
 trils, and all tight articles of clothing to be 
 
 at once taken away from the neck and chest. Fig. .354. 
 
 In slight cases of temporary apnoea the treat- 
 ment is as in syncope, dropping the head, 
 which should be low in all cases, a dash of 
 cold, or alternately of cold and hot, water 
 to the face, or a smarting slap upon the epi- 
 gastrium, generally sufficing to revive the 
 patient. When this proves useless, artifi- 
 cial respiration should be instantly com- 
 menced. 
 
 The methods of artificial respiration 
 which have been successively in use are 
 those of the late Drs. Marshall Hall and 
 Silvester, but I believe the best method to 
 be the one more recently advocated by Dr. 
 Benjamin Howard of New York. This 
 
 " direct method." as the author calls it. was first published in the form of a prize essay 
 by the American Medical Association in 1871, and has since been adopted by the United 
 
620 
 
 SURGERY OF THE CHEST. 
 
 Fig. 355. 
 
 Artificial Respiration by Direct Method. 
 
 States Government Life-Saving Service, the Life-Saving Society of New York. etc. It is 
 eminently .simple and effective, and is to be applied in the treatment of the drowned as 
 follows, the rules having been drawn up for me by Dr. Howard : 
 
 Rule 1. For Ejection and Drainage of Fluids, etc. from the Stomach and 
 Lungs. Position of Faiient. — Face downward with forehead re.sting upon the fore-arm 
 or wrist, to keep the mouth from the ground, and a hard roll of clothing beneath the 
 epigastrium, which .should be the highest point, while the mouth is the lowest (Fig. 
 354). 
 
 Position and Action of Operator. — With the left hand well spread out upon the base 
 of the thorax, to the left of the spine, and the right hand upon the spine, a little above 
 
 the left and over the lower part of the 
 stomach, the operator should with a for- 
 ward motion throw upon them all the 
 weight and force the age and sex of the 
 patient will justify, ending this pressure 
 of two or three seconds with a sharp 
 push, which helps to jerk him back to 
 the upright position. And this move- 
 ment should Vje repeated two or three 
 times, according to the period of sub- 
 mersion and other indications. 
 
 Rule 2. Position of Operator. — ^^In 
 a kneeling posture, astride patient's 
 hips ; his hands upon the chest, so that 
 the ball of each thumb and little finirer 
 rests upon the inner margin of the free 
 border of the costal cartilages, the tip 
 of each thumb near or upon the zy- 
 phoid, and the fingers fitting into the corresponding intercostal spaces ; the elbows firmly 
 fixed, making them one with the sides and hips ; then — To Perform Artificial Respi- 
 ration. Position of Patif-nt. Rip or strip clothing from the waist and neck. Face 
 upward : shoulders slightly declining over. Hard roll of clothing placed beneath thorax ; 
 the head and neck bent back to the utmost, with the hands on the top of the head (one 
 twist of handkerchief around the crossed wrists keeping them there) (Fig. 355). 
 
 The operator, pressing upward and inward toward the diaphragm, using his knees as 
 a pivot and throwing his weight slowly forward two or three seconds until his face almost 
 touches that of the patient, should end with a sharp push, which helps to jerk him back 
 to the erect kneeling position. He should then rest three seconds and repeat this bellows- 
 blowing movement as before, continuing it at the rate of seven to ten times a minute, 
 taking the utmost care, on the occurrence of a natural gasp, gently to aid and deepen it 
 into a long breath until respiration becomes natural. When practicable, the tongue 
 •should be held firmly out of one corner of the mouth with the thumb and forefinger 
 armed with dry cotton rag. 
 
 Avoid all impatient vertical pushes ; the force upward and inward must be increased 
 gradually from zero to the maximum the age, sex, etc.. may indicate. Abandon no ca.se 
 as hopeless within an hour's useless effort. 
 
 In the application of this method to ca-^^es of stiUhirth the child lies along the left hand 
 of the operator, the ball of whose thumb takes the place of the hard roll of clothing .seen 
 in Fig. 355. Over this the shoulders decline, the head falling back, with the arms, if 
 convenient, on either side the face. The buttocks and thighs are supported by the 
 operator's fingers. 
 
 Thus the operator has the prominent little thorax completely within the grasp of his 
 right hand with firm counter-pressure behind, enabling him to apply, locate, distribute, 
 direct, or alternate his pressure as he pleases. 
 
 The advantages Dr. Howard claims for this method over other methods are: 1st. It pro- 
 vides for ejection and drainage of fluids, etc. from the stomach and lungs, and in such a 
 way that each motion for ejection induces an alternate inspiration. 2d. It excludes the 
 tongue from the pharynx without manipulation. 3d. It secures elevation of the epiglot- 
 tis and a post-oral air-way from the glottis to the nares. 4th. It includes a remedy 
 against syncope and cerebral ansemia. 5th. It obtains a more general expansion of the 
 thorax. 6th. It effects a thoracic compression which is more complete, better distributed, 
 directed, and regulated. 7th. It is done by one person and can be applied instantly on 
 
Tin:.\TMi:sT of ai\\(KA, on aspjivxia. 021 
 
 the spot wliorevor tlif patit-iit is fomul. Sth. It is more easily understoofl l)y the illiter- 
 ate, is less liiti^uiii^' to the tiperator, and is free from iiimeeessary motion or violenee. 
 
 When respiration is re-estahlished, maintain the; t«'m]teratnre ol" the hody hy friction, 
 warm Idankets, and when possible l»y warm water (1(M»° V.) or air hath, keeping: the head 
 where a eirculation of ])ure air niay he maintained. As soon as the patient can swalhiw 
 give warm milk, beef tea, tea, or eoff'ee, with a tahlespoonful of .some spirit; or these may 
 be injeeted by the stomach-pump. When respiration is restored, put the patient into a 
 warm bed witli hot bottles to his feet and encourage sleep, but let him be watched in ca.se 
 of secondary or '.elapsing apnwa ; at the slightest .symptoms of which, let friction, and 
 even artificial respiration, be re-employed. (Jive V(jlatile stimulants, such as tlie spiritus 
 amnion i:t> aromaticus. 
 
SURGERY OF THE URINOGENITAL SYSTEM. 
 
 CHAPTEK XX. 
 
 DISEASES OF THE KIDNEY.— STONE.— NEPHROTOMY. 
 
 Malformations of the kidney have more scientific than surgical interest, yet 
 they may have an important surgical bearing ; for when any accident from external 
 violence or internal irritation happens to a single or imperfect organ, the life of a patient 
 is more likely to be jeopardized than when it is normal. In a case recorded on page -189 
 this fact was illustrated. When a kidney is single, it is usually large and sometimes has 
 the form of a horseshoe ; when it assumes a central position, with the convexity of the 
 curve downward, it may be regarded as a double organ, the vessels entering from above 
 in their normal way. A kidney may also hold a position nearer the pelvis, or even lie in 
 the pelvis ; it may be "movable" or "floating." At times the adult kidney maintains the 
 lobulated character it possessed in foetal life. A kidney when loosely connected may 
 appear as a movable abdominal tumor, and in exceptional cases be the seat of much dis- 
 tress. In such operative surgery may be required. (Vide '" Nephrorraphy," page 031.) 
 
 The diseases of the kidney are generally regarded as belonging to the physi- 
 cian, but I need hardly add that a thorough knowledge of renal pathology is as requisite 
 to the surgeon as it is to the medical practitioner, for without such a knowledge he will 
 be able neither to recognize the different conditions of the urine with its deposits nor to 
 appreciate their significance. He will likewise be as unfit to decide upon the propriety 
 of an operation of expediency as to understand the risks of one of necessity ; for the 
 existence of kidney disease, as a rule, is enough to debar the surgeon from performing 
 any operation other than that required to save life, and in such operations it renders the 
 prognosis most unfavorable, since kidney disease is well known to be the chief cause of 
 death after operations. 
 
 As a rule of practice the condition of the kidney, as expressed by the character of the 
 urine, should be made out in all cases in which an operation is thought of, and more 
 particularly in operations upon the urinary organs. 
 
 Nephritis. 
 
 Inflammation of the kidney associated with suppuration of the organ has long been 
 recognized as a common consequence of obstructive disease of the urinary passages. But 
 it may occur as a consequence of local injury, or as an acute attack upon a chronically 
 diseased organ, or as a consequence of pyi^elnia or other cause. It is also very common 
 as a sequel to Bright's disease of the kidney — that is, to disease of the secreting structure 
 of the organ — in consequence of some local .source of irritation in any part of the urinary 
 passages. Bright's disease by itself is not a suppurative disease. 
 
 Suppurative nephritis may occur as an acute or as a chronic affection, though more 
 frequently as an acute upon a chronic disease. After death a kidney thus affected may 
 appear enlarged, with its substance more or less filled with suppurating cavities. When 
 the inflammatory action is confined to the mucous lining of the pelvis of the organ, it is 
 called pi/e/itis. At times the kidney is a mere cyst or shell containing pus and broken- 
 down tissue, and in extreme cases the kidney and parts around form one large suppurat- 
 ing cavity. This condition is not rare as a consequence of the breaking up of tubercu- 
 lous matter, and then it is usually symmetrical. 
 
 Symptoms and Diagnosis. — When after an injury in the loins, or in the course of 
 some obstructive vesical, urethral, or calculous affection, a patient is seized with rigors. 
 
 022 
 
m: I 'I I urns. 
 
 G2;J 
 
 Via. 3')f;. 
 
 severe pain and t»'ii<len)Oss in tlic linnltar rcjrioii, fcltrilc <listiirliaiipe, nausea, vomiting, 
 scanty. Iiiijli-folorcd, ami jiDs.silily lilctoily, urine, and irrital)lc liladilcr. ttcnfr iifjihrilin may 
 be suspected. When riiri>rs recur rrc(|uently and tliere is suppression of" urine with renal 
 casts or pus in the urini-. su|>puration ottlie oriran is to he diairnoscd ; and when to these 
 symptoms are added severe (h'pression, anasarca, and hrain .^yniptnms passing on to coma, 
 unuinic poi.sonintr may safely he expected. 
 
 Hut chronic nephritis is a more common afl'cction than the acute; indeed, unlcs.s 
 from accideiil, the acute is uenerally a se(|uel to the chronic. Kidney di.sea.se i.s a coiu- 
 luon eonsei|uence of long standing or neglected blad- 
 der or uretiiral mi.schief. When a stone has existed 
 for any period in the hladihr and has set up inflam- 
 mation of that (U'gan, when iVom prostatic disease the 
 same result ensues, or when from stricture the urin- 
 ary organs have been sul)jected to irritation and dis- 
 tension from retained urine, the ureters, and later on 
 the pelvis of the kidney, and subse(|uently the 'iecret- 
 ing structures of the kidneys tlu'mseives, becotne in- 
 flamed by extension from the blarlder. T'nder these 
 circumstances every gradation of dilatati(»n, inflam- 
 mation, or suppuration of the whole urinary pas.sages 
 may be found ; the bladder may be enormously thick- 
 ened and inflamed ; the ureters dilated, tortuous, 
 thickened, and stippurating ; the pelvis of the kidney 
 expanded and filled with pus — pijf.'Utis — and the kid- 
 ney itself more or less undergoing disorganizing 
 changes (Fig. o5'V). 
 
 Symptoms. — The symptoms of changes such as 
 these are not very definite. In all long stttudtHg 
 examples of obstructive urinary aifections some of 
 them may be suspected ; so also in all cases of 
 neglected stone, particularly when bladder symptoms 
 are marked ; in cases in which the urine is albumi- 
 nous, pale-colored, and smoky, or tinged with blood ; 
 when it contains pus in suspension, varying in quan- 
 tity at different times, or shreds of lymph ; when a Suppurative Disease of the Kidnevs, Dilata- 
 diill -ichino- min is nrpspnt in tbp Initio sbontintr tion of Ureters, Hypertrophy of Uie Bladder, 
 
 auii, acning pain is present in tne loins, snooting e,c_^ tjjg gtiect of Urethral obstruction, 
 round the hips into the groin and down to the testi- (Drawing ses^s, Guy's Hosp. Mus.) 
 cles ; when vomiting is constant and persistent, and the 
 
 digestive organs do their work badly ; and when sleep is diSicult to secure or superseded 
 by a general drowsiness. 
 
 Dla.(}N'osis. — Under these circumstances chronic kidney disea.se may ftiirly be diagnosed, 
 with or without suppuration in the organ or around it. 
 
 When anasarca .sets in or brain symptoms from uncmic poisoning a])pear, the diagnosis 
 is clear. 
 
 "When rigors are frequent, even when not well marked, when lumbar pain is constant 
 and increased on pressure, when on manipulation evidence exists of some deep-seated 
 lumbar swelling and fluctuation is distinctly or indistinctly to be made out, abscess of the 
 kidnnj is fairly indicated. W^hen with these a sudden discharge in the urine of large 
 quantities of pus takes place with relief to the local symptoms, it is probable that the 
 abscess has discharged itself through the ureter ; when the lumbar pain becomes more 
 intense, the swelling more marked and prominent, and fluctuation more distinct, it is 
 probable that the ureter has become obstructed and the renal abscess is making its way 
 through the loin externally ; and many cases are on record in which, after the di.scharge 
 of the abscess by natural or surgical means, a recovery has ensued. Indeed, stones have 
 been taken away from or discharged from the kidney in this way with a good result. 
 
 Kcnal, like perirenal, ab.seesses are, however, prone to make their way through the 
 diaphragm into the lung or into the colon : and cases are recorded where they burrowed 
 downward and appeared below Pouparts ligament or in the pelvis. In these ca.ses the 
 symptoms simulate spinal disease, the thigh being flexed upon the pelvis, this symptom 
 attended with lumbar pain or tenderness, being very constant in nephritic as in perine- 
 phritic abscess. Dr. Bowditch of Boston was the first to draw attention to the fact in 
 1869 and 1870. 
 
624 DISEASES OF THE KWyEY—STOyE—yEPHROTOMY. 
 
 Treatment. — When acute nephritis originates from a blow or from the irritation of a 
 renal calculus, complete rest in the horizontal posture in a warm bed is absolutely essen- 
 tial, with milk diet and the moderate use of simple diluents, as milk and water or barley 
 water. Poppy fomentations to the loins always give comfort, and when the pain is 
 severe leeching is beneficial ; cupping has been recommended and is of use. The bowels 
 should always be well cleared out by some .simple medicine, such as castor oil or an 
 enema. All medicines that act upon the kidney, as salines or turpentine, all external 
 applications, such as blasters, should be carefully avoided ; and for this same reason 
 stimulants ought not to be given. 
 
 The action of the skin should be encouraged by outside warmth, and the hot-air bath or 
 steam bath, applied to the patient in bed, is a valuable means to this end ; a hot bath is 
 a good substitute. Calomel and antimony cannot be recommended. 
 
 When the case passes into the chronic stage, counter-irritation becomes of value, and, 
 as this cannot be obtained by means of blisters, since cantharides act powerfully on the 
 kidneys, mustard may be employed, or a piece of lint saturated with a mixture of chloro- 
 form and alcohol should be applied to the loin and covered with oil silk. Dry cupping 
 also is of great value. 
 
 When acute nephritis supervenes upon the chronic form, the result of long-standing 
 disease of the urinary organs, or after operation, the whole aim of practice must be to 
 soothe, relieve pain, and keep life going. Nothing like mechanical interference with the 
 urinary passages must be thought of Retention of urine should, of cour.se, be 
 relieved, but the utmost gentleness ought to be employed in the manipulation. These 
 cases are, as a rule, very hopeless. 
 
 In chronic nephritic the result of local disease there can be little doubt that the best 
 practice is the removal of the cau.se. When a stone in the bladder has set up the mis- 
 chief, it should be removed, and by that mode which induces the least local irritation. 
 When a stricture of the urethra has been the cause, it should be dilated, for as long as 
 the local cause of the disease exists no recovery can be looked for. When calculus in 
 the kidney is the local irritant, the surgeon's aim must be to allay local irritation by 
 keeping the patient quiet and administering soothing remedies, the alkaline potash salts 
 being prescribed where the urine indicates uric-acid calculus, and the mineral acids when 
 the urine is phosphatic. The removal of the .stone by operation may also be entertained. 
 (Vide •' Nephro-Lithotomy," p. 628.) 
 
 When suppuration of the kidney takes place, with or without a calculus, and any 
 external evidence /jf the abscess exists, the kidney .should be cut down upon by a lumbar 
 incision, the abscess freely opened and drained after irrigation. ( Vide •■ Nephrotomy," 
 p. 628.) 
 
 When the urine is full of pus, the preparations of buchu are of undoubted value, 
 and the mineral acids or the preparations of iron of use. Warm baths and diaphoretics, 
 to induce free action of the skin, and by these means to relieve the kidney, with a sup- 
 ply of simple nutritious food, and stimulants only when absolutely required, make up the 
 treatment. 
 
 Perinephritis is an affection that must be recognized, and, although it may be 
 more frequently found in connection with suppuration of the kidney, it is at times inde- 
 pendent of it. It is indicated by a sudden pain in the loin, fever, and subsequently 
 lumbar sicdliuij^ with frequently cedema of the integuments of the loin. The pain is at 
 times constant and persistent, while at others it may appear and then disappear for an 
 uncertain interval, to recur spontaneously in all its severity. The urine in an uncompli- 
 cated case is generally natural, and if at all altered scanty, renal symptoms, so called, 
 being absent. When the case is left to nature, the inflammation may attack the chest 
 and induce a fatal plem-i.sy. or the abscess may burst into the bowel or externally, bur- 
 rowing beneath the fascia covering the psoas muscle and .showing itself in the thigh or 
 pointing to the loin. The surgeon should not. however, leave these cases to nature, but 
 cut down upon the abscess or lumbar swelling, as in colotomy, at the outer border of the 
 quadratus lumborum muscle, and evacuate the pus as soon as sufficient evidence exists 
 of its presence ; from this treatment a good result may be looked for. ( Vide paper by 
 Dr. Bowditch, Am. Journ. of Med. Science, 1871.) 
 
 HEMATURIA 
 
 is a symptom met with in many diver.se conditions, the hemorrhage being limited or 
 profuse. It may come from one or both the kidneys or any other part of the urinary 
 
ii.KM.\rri:i.\. 025 
 
 passage, eitli<>r as u result of S(»iim» coiistilutiDiuil cause, such as the lieuiorrlia^ie diatlie-' 
 sis, or stuue u»i»rl)i»l coiulitiiin of tlu- Mood, as in jMirpura, scurvy, smallpox, the |ila;iue, 
 or fever. It uiay likewise he parasitic. Profuse renal h.-eiuaturia takes jdace occasion- 
 ally »« all intennittent atVection. It may likewise follow an injury or ilisea.se of the 
 kiilney, ureter, hladder, prostate, vas deferens, or urethra. In surgical jiractice the 
 hoinorrhaire is more Jre(|Ucntly due to sonu- local cause, yet the practitioner should he 
 alive to the fact that it may orijrinate from a constitutiomd one or from the use of such 
 druf^s as turpentiiu' or eantharides. 
 
 |{kn.vI, IlKMtiKKIlACiK. — If the InniorriiaLie follow an aciidi lit. the diagnosis is .sel- 
 dom ditliciilt ; for when, after an injury to the loin, hlood is jiassed mixed with tlie urine, 
 it may he inferretl that the kidney has heeii injured ; and when slender, cylindrical, ]»ale 
 pieces of tihrin are .seen in the urine, the surj^eon may he sure that they come from the 
 kidney, these clots havintr hceii moulded in the uret(!r and washed down from the kidney 
 by the urine. Blood also, wiicii iiitiniately mixed with tiie urine, has jirohahiy ii renal 
 origin. 
 
 The jiassajxe of a stone down the ureter is also attended hy hemorrhajre. whicdi is rarely 
 profuse, and is, moreover, frenerally aecomjianicd hy severe colicky pain shooting down the 
 groin and scrotum of the affected side, with a retracted testicle. When blood comes from 
 a diseased kidney, it is mixed with the urine, as in cases of accident, and may be slight or 
 profuse in <|uantity ; but the nature of the affection or its being due to calculus will have 
 to be determined by the history of the case, the existence of lumbar pain or tenderness, 
 and a close examination of the urine. In cancer of the kidney pain rarely extends to the 
 testicle. 
 
 Parasitic HsBinaturia. — 'fhis is common in Egypt, Syria, and at the Cape, and is 
 now known to be due to the presence of a parasite first discovered l>y Bilharz in 1851. 
 Dr. Zancarol of Alexandria describes it as " Bilharzia lucmatobia." The disea.se is found 
 only in weakly subjects and those who drink foul water or the undistilled water of the 
 Nile. Its early symptoms are the appearance of blood at the end of micturition, its pas- 
 sage being acc(jmpaiiied and followed by pain, frequent micturition, and ana?mia. With 
 the parasite there is cystitis, whicli will go on, and at last give rise to dilated ureters and 
 diseased kidneys. 
 
 Dr. Zancarol ascribes the frequency of stone in the bladder in Egypt to the presence 
 of the parasite. 
 
 The urine of patients the subjects of this disease contains blood and mucus, but is of 
 norn^al specific gravity. The ova of the parasite itself are to be found in it in an active 
 condition for twenty-four hours after it has been pa.ssed. They are ovoid in shape, cili- 
 ated, and YT^ of an inch in diameter. The worm itself never passes with the urine. It 
 is filiform and three or four lines in length. A full description of the worm may be found 
 in the Trans, of the Path. Soc, December !), 1SS2. 
 
 Little can be said about treatment beyond that Dr. Wastobet of Beyrout, Syria, records 
 (^Lancet. December i>, 1882) a case cui'ed by one-drachm doses of the oil of turpentine in 
 milk three times a day in twenty-four days. 
 
 Vesical or prostatic hemorrhage, either from injury or disease, chiefly shows 
 itself as blood clots mixed with the urine, the former passing either before or after the 
 latter. The blood at first may fill the bladder, but after some days the urine will only be 
 stained with blood. When the clot has broken up. more or less discolored irregular coag- 
 ula with fimbriated edges will pass with the urine, these coagula being very characteristic 
 of blood clot. They may pa.ss ;>e/' urethrani as rolled-up masses, but when floated out in 
 water will present their natural shape ; blood that has been retained within the bladder 
 for any time will impart to the urine a porter-like aspect. 
 
 AVhen blood flows at the end of micturition in small quantities, squeezed out. as it 
 were, by the bladder, a calculus or prostatic disease may be suspected : but the same con- 
 dition is also occasionally met with in the irritable bladder of goiiorrha'a or after the pa.s- 
 sage of "gravel." 
 
 When a cancer of the bladder or prostate or a villous growth exists, pieces of broken-up 
 tissue may be detected by the microscope in the bloody urine. In these cases, too. the 
 hsematuria will be intermittent. 
 
 Urethral Hemorrhage. — When, after an injury to the periiKeum or pelvis or a 
 sudden muscular strain, pure blood flows from the urethra unmixed with urine, urethral 
 mischief may be suspected. 
 
 Urethral hemorrhage irrespective of injury, may proceed from a chancre, acute gonor- 
 rhoea, or an impacted stone. It may follow over-exertion or the straining associated with 
 
 40 
 
626 DISEASES OF THE KIDNEY.— STONE.— NEPHROTOMY. 
 
 the retention of urine or sexual intercourse. It may likewise take place after the forcible 
 bending of an erect penis in a chordee or during some sudden muscular exertion from a 
 rupture of the vas deferens, as pointed out by Hilton, and in rare cases it may occur with- 
 out any known cause, the blood flowing from the penis unaccompanied by any symptom 
 of disease. I have recorded two such cases {Clin. Sun/., Chapter 47). 
 
 Urethral hemorrhage as a result of catheteri,sm is also common, and it may be caused 
 by the introduction of some foreign body into the urethra. 
 
 It should also be remembered that bile when concentrated, indigo, or other rare con- 
 stituents of the urine, from diet or otherwise, may simulate the presence of blood, as may 
 the black urine which results from the external or internal use of carbolic acid when 
 ab.sorbed in poisonous doses. This symptom, however, soon disappears on the omission 
 of the remedy. In a case under my care in 1871, of a man who had a weak sore the size 
 ■of a crown piece, which had been dressed with an oily lotion of carbolic acid one part to 
 forty, the black urine appeared after the second dres.sing associated with brain symptoms 
 and collapse of the general powers which I thought must prove fatal. The symptoms, 
 however, speedily disappeared on withdrawing the drug, and a recovery ensued. In a 
 case under my care five years ago a boy xt. 9 was unintentionally kept in a semicomatose 
 state for two months by the application of a lotion of carbolic acid (one part to a hundred) 
 to a small sore, the brain recovering its healthy condition on the omission of the lotion. 
 The poisonous action of the carbolic acid was detected through the urine, which was occa- 
 sionally black. 
 
 Treatment. — The disease or condition that gives rise to the blood in the urine 
 requires treatment more than the .symptom itself, but at times the bleeding is so pro- 
 fuse as to threaten life. Renal hemorrhage, when profuse, may be checked by gallic acid 
 in full doses, gr. v to gr. x, three times a day, acetate of lead, tincture of ergot, or maticO; 
 opium being generally a valuable addition, and in extreme cases the spirit of turpentine, 
 absolute rest in the horizontal po.sition, and cold milk diet should be also adopted. 
 
 Hemorrhage from the bladder, when persistent, may be checked by the application of a 
 bag of ice over the pubes and to the perinaeum, by cold or astringent injections into the 
 rectum, with rest and opium. There is no neces.sity to pass a catheter or to interfere with 
 the clot so long as the urine flows and retention does not occur, the urine at the natural 
 temperature of the body being a good blood solvent. A clot of blood, when bathed with 
 urine, as a rule, disintegrates in the course of a few days, when it may be passed without 
 help. Any disturbance of the clot when first formed will probably tend rather to encour- 
 age than to .stop bleeding; consequently, no unnecessary catheterism should be employed. 
 When retention exists, the .symptoms become urgent, and opium administered either 
 by the mouth or, what is preferable, by the rectum fails to give relief, the passage of a 
 
 lartre-sized catheter and the use 
 Fig. 357. of an exhau.sting syringe, such as 
 
 Clover invented for use after lith- 
 otrity (Fig. 357), or the aspirator 
 may be called for ; yet these meas- 
 ures should be employed only 
 when an absolute necessity exists 
 and opium in full doses fails ta 
 give relief. 
 Clover's Syringe, as Improved bv Maunder. Urethral hemorrhage rarely 
 
 continues for any time or requires 
 for its treatment more than rest in the horizontal posture, unless caused by some lacera- 
 tion of the urethra or more severe injury. 
 
 Suppression op Urine 
 
 is the result of renal disease, from which, the kidneys ceasing to fulfil their functions, the 
 constituents of the urine are left in the blood and give rise to coma, and pos,sibly to con- 
 vulsions and death. Urtemia or uraemic poisoning is then said to be the cause of death. 
 It may occur at any stage of kidney disea.se, and not uncommonly follows an operation 
 performed on a patient the subject of such an affection ; it is a result to be taken into cal- 
 culation before undertaking any operation where albuminous urine exists. 
 
 In exceptional cases, however, suppression of urine occurs when no such chronic mis- 
 chief can be detected, coming on suddenly, as it often does, without cau.se, and leaving as 
 suddenly without any reason. I once saw a musician who secreted no urine for sixty 
 
SToxr: r\ riii: Kiitsi'V. c,27 
 
 hours, and tlicii jiassotl what sofiucil to ho a natural <juaiitity ; liis only other syiiijttom.s 
 wort' those of slijrht levcrishiicss aiul heailathc. In sucli cases the hot-air, vapor, or 
 warm liath is tho best remedy. 
 
 Stone in the Kidney 
 
 is not an iinconiinon artVotii>M. and is irenerally painful and often fatal. At times, how- 
 ever, lar<:e stones arc- found in tlie kidney after death which gave no .si<.'ns of their exist- 
 ence durini; life. When the stone hecnnies impacted in the oriran and ceases to be mov- 
 able, it does not trive rise to any marki-d symptoms, and, comparatively speakinir, ceases 
 to interfere with life; more fre»|uently. however, it often excites much local irritation, if 
 not suppuration, and usually kills by destntyinir the kidney by convertintr it into a sup- 
 puratiiiLT cyst. Small stones are constantly formed in the kidney and passed throu<rh the 
 ureter into the bladder. Large st<»nes may so increase as to form a cast of the pelvis of 
 the kidney (Fig. •i78i. and at times attain enormous dimensions. 
 
 The SYMPTo.Ms of stone in the kidney are a tendency to rigor, lumbar pain, increased 
 by riding or any jolting of the body, the pain passing dttwn the groin into the testicle of 
 the affected side and causing its retraction, irritable bladder, and blood in the urine. Irri- 
 tabilitv of the bladder may be the uu\\ symptom of renal disease. When the stone enters 
 the ureter, the inguinal and testicular pain becomes increased and a colicky pain appears, 
 attended often with sickness, and even collapse, the bladder becoming more irritable and 
 the urine more bloody. When the stone passes, all these symptoms suddeid}' cease, the 
 bladder irritation probably alone remaining. As time goes on and the local irritation 
 becomes worse some suppuration in the kidney may occur. As long as the ureter remains 
 open and pus makes its escape into the bladder the symptoms are not urgent; but .should 
 the ureter become closed by the stone or some inflammatory change, the pus will collect 
 and give rise to lumbar renal abscess. At times this lumbar swelling may be felt ; indeed, 
 in thin subjects, with one hand in the lumbar and the other in the hypochondriac region, 
 a calculus may by palpation even be made out in the kidney ; this examination will be 
 made occasionally with advantage when the patient is under an anaesthetic. The lumbar 
 swelling may so increase as to form a large cystic abdominal tumor. When the ureter is 
 obstructed, this result will take place more rapidly than when it is open, from the accu- 
 mulation of pus ; but when it is open, the pus flows into tlie bladder and passes with the 
 urine as turbid urine. When allowed to .settle in a porringer or glass, its presence will be 
 readily detected. Pus poured into the bladder from the kidney or elsewhere is mixed 
 with but little mucus, but when formed in the bladder is mixed with much. Pus and 
 mucus secreted from the bladder is constant in the urine ; when from the kidney, it may 
 be intermittent. Dr. Owen Rees has pointed out the value of the tincture of galls added 
 guttatim to the urine of patients who may be suspected to be suffering from renal cal- 
 culus, this tincture producing an immediate flocculent precipitate of a light-brown color 
 when any of the extractive matters of the blood are present (Bi-it. Med. Joitrn., October 
 21, 1876. p. 518). He also asserted that a heavy and continued pain over the sacrum 
 may be the only prominent clinical symptom of this affection. 
 
 Treatme.nt. — When a stone has formed in the kidney, the happiest result is its pas- 
 sage into the bladder; which end can be facilitated by the administration of diluents, 
 particularly water, as well as alkaline preparations of potash, such as the citrate, tartrate, 
 or bicarbonate. When strong evidence exists of local irritation, opium or henbane, 
 given by either the mouth or the rectum, is a valuable drug; while a subcutaneous injec- 
 tion of morphia over the affected kidney at times acts most beneficially. Fomentations 
 about the loin and groin or the warm bath also give much relief. 
 
 When the stone is passing down the ureter, the same practice is to be followed, a 
 warm bath and a full dose of opium often relaxing the parts and favoring the passage of 
 the stone. The administration of an anjesthetic by inhalation may, when the pain is 
 severe, under these circumstances, also be tried. In a case I was called upon to see, 
 where extreme agony existed, instantaneous and permanent relief followed the practice, 
 the stone having passed during the inhalation of the chloroform. 
 
 When the stone has become impacted in the kidney and gives rise to periodical 
 attacks of pain and constant unea-siness. each attack being worse than the last, important 
 questions occur to the surgeon : Is it to be allowed to remain, where it may in all prob- 
 ability set up irremediable disease if not destruction of the kidney ? or is an attempt to 
 be made to remove it by surgical operation ? The answer at the present day is very 
 decided : The surfreon should remove the stone. 
 
628 DISEASES OF THE KIDNEY.— STONE.— NEPHROTOMY. 
 
 RENAL SURGERY. 
 
 This branch of surgery has reached a definite position ; and if it rises in value as it 
 has risen in interest, a wide surgical field has indeed been opened. It is to Simon of 
 Heidelberg that we are indebted for its birth, in that he in ISGU first designedly reiuoved 
 a kidney with success. He did so for a urinary fistula of the ureter which had resulted 
 from an ovariotomy. 
 
 Since then, writes Clement Lucas in an able article (^British Med. Journ.. September 
 29. 1883), '•nephrectomy (removal of the kidney) has been performed upward of a hun- 
 dred times. Kejjhrotomy, or incision and drainage of the kidney, has become a much 
 more frequent operation, and renal lithotomy, }iephro-Ut]iotomy, has been successfully 
 extended to cases where no tumor or sinuses exist ;" and the credit of this last triumph 
 must be given to my friend 3Ir. Henrv ^lorris. (See Trans. Clinical Society, vol. xiv. 
 p. 30, 1881.) 
 
 A fourth operation, named neplirorrapliy . must also be mentioned — an operation first 
 performed by E. Hahn of Berlin ( Centralblatf fiir Chirurgie. July, 1881) — which consists 
 in cutting down upon and exposing a movable or floating kidney and stitching it to the 
 edges of the parietes of the lumbar wound. 
 
 Last, but not \e?L?,t. jiaracentesis of the kidney claims a notice. 
 
 Upon each and all of these surgical proceedings a few observations will be made. 
 
 Paracentesis of the KroNEY. 
 
 This operation is valuable for diagnostic as well as for curative purposes, and it may 
 be performed, either by way of aspiration or by means of a trocar, in cases in which it 
 is well to be assured of the presence or absence of fluid in any given dull lumbar 
 swelling. 
 
 In hvdronephrosis, or dropsy of the kidney, brought about by the retention of urine 
 in the pelvis of the kidney from obstruction of the ureter, in those rare examples of iso- 
 lated serous or blood cysts of the kidney, and hydatid cysts, this operation is particularly 
 valuable. 
 
 For the diagnosis of pyonephrosis it is equally of use. and even where the tumor may 
 turn out to be of a solid nature a fine aspirating needle is not likely to be followed by harm. 
 
 The best position for tapping the right kidney " is one halfway between the last rib 
 and the crest of the ilium, between two and two and a half inches behind the anterior 
 superior spine of the ilium" (Morris, Med.-Chir. Trans., vol. lix. p. 242), and for the left, 
 according to Mr. .J. Thomson of Nottingham, '-the interval between the last two ribs 
 near their anterior extremities" (^Patli. Soc. Trans., vol. xiii.). 
 
 Nephrotomy, or an incision into the pelvis or substance of the kidney, is called 
 for in cases of abscess of the organ, whether from stone or from tubercle, or of pyone- 
 phrosis from whatever cause, and for hydronephrosis and hydatid when the .simple opera- 
 tion of paracentesis has failed to bring about a cure. It essentially consists of exposing, 
 opening, irrigating, and draining the abscess cavity in the same way as any other abscess 
 cavity should be treated. 
 
 I have followed this in practice on many occasions, having in a man cut down upon a 
 suppurating kidney and evacuated several ounces of pus with marked benefit, and in 
 another opened and drained a large suppurating renal cyst through the left loin. 
 
 On August 31, 1876, I likewise cut down upon the right loin of a lady a?t. 27 whom 
 I saw in consultation with Dr. Moore and Mr. Pocock of Brighton, with a swelling which 
 we diagnosed as renal, and evacuated three pints of fetid pus. the lady making a good 
 recovery. In 1877 I cut into the left loin of a woman with a lumbar swelling and let 
 out a quart of pus with marked benefit, my finger readily passing into the dilated pelvis 
 of the kidney, and in 1883 I opened the right kidney of a man which twelve years before 
 had been seriously injured, and evacuated eighty-six ounces of fetid pus. subsequently 
 irrigating with iodine water and syringing the cavity. He was well in three months. 
 
 The operation in its several steps should be the same as that described for lumbar 
 colotomy, the kidney being readily reached and dealt with through such an incision as 
 was there indicated.- 
 
 NephrO-lithotomy, writes Henr}' Morris, who was the first surgeon who design- 
 edly cut down upon a kidney to remove a stone (see C'h'ji. Soc. Trim.'i.. vol. xiv. p. 30, 
 1881 j, '' should unhesitatingly be done in all cases in which .symptoms of renal calculus 
 continue uninfluenced by medical treatment and are sufficiently severe to interfere mate- 
 
I'AiiAChWTh'sis or Till: KinsEY. 029 
 
 riiilly with tlic (•(Hiifort and usoi'iiliicss ol" the |i!iticiit'.s lii'c If for scvcnil numtlis a jicrMon 
 has Itccii siiliji'ct t(» iiiKrc <tr less cdnstaiit |iairi in one loin and alon^' the ureter, and \n'.r 
 haps, also, in the tcsticU' of" thu sanu- side, it" then; have hcen rcicnrrinjr attacks oi" rnial 
 colic, and csjicciaUv it with tlicsi- symptoms there is occasional li:i>matiiria (»r the urine is 
 constantly char'red with a little pus or albumen, wc have the conditions not only justify- 
 ing, hut demandini;-. an explorati<ui. It", in addition to these symptoms, a small calculus 
 or a little ealeulous matter has heen j)asscd y>''/" /*/V7/;/v»///, there is almost absolute cer- 
 tainty of the presence ot" a stoiu' ; at the same time, it uiust be recognized that symptom!- 
 stronirlv suggestive of renal ealculus arise trom other causes than stone. " 
 
 ()l'KUATl(»N. — I give this in the words of Mr. .Morris: ''An incision is made four and 
 a half inches in length parallel with, and three-<|uarters of an iiudi below, the last rib. 
 The structures divided are the sanu' as in ne]ilMotoniy. If the r|Ua<lratus lumborum be 
 so wide as to contract the d«'ep jtart of the wound, its outer edge nuiy be incised to the 
 extent ot" half iw three-<|uarters of an incli. All bleeding ves.sels having been twi.sted 
 and hemorrhage (piite stayed, the assistant should stretch the edges of the wound widely 
 apart by suitable retractors, and the ojierator, with two jiairs of dissecting forceps, tears 
 through the perirenal fat. As he approaches the back of the kidney there will be some- 
 times noticed a difference in the character of this fat, that immediately in contact with 
 the kidney being finer in te.xture and of a delicate primrose color. If, from the presence 
 of the stone, there has been inflammation in the tissues around the kidney, thi.s appear- 
 ance will not be expected, and the whole of the tissue will probably be dense and tough. 
 
 '• When the kidney has been fairly reached, the index finger should be passed care- 
 fully over the whole of the posterior surface of the organ, including its pelvis, and any 
 inequality of surface or increased hardness or resistance at any particular spot should be 
 searched for. During this tactile exploration — indeed, throughout the whole of the 
 examination of the kidney — the abdominal walls of the patient should be well supported 
 by an assistant or well-arranged pillows, so that the kidney should not be pushed forward 
 by the exploring finger. If nothing suggestive of the presence of a .stone is thus felt, 
 the kidney .should be freely exposed to view by drawing aside the edges of the wound, 
 and a fine needle .should be passed into the renal substance. This should be done in a 
 systematic way and in several places, if the stone be not at once struck, introducing the 
 needle here and there, so as to puncture in succession the several calyces of the kidney, 
 in one or other of which experience tells us the stone usually rests. If in the course of 
 the digital exploration some one .spot gives more re,si.stanee than the rest, this should be 
 first punctured, but otherwise the puncturing should be done in a well-planned manner. 
 On this point I would lay great stress, as it is quite possible to puncture in a dozen places 
 and yet to miss the calculus. 
 
 " If by this means the calculus is not detected, the search should not be given up 
 until the fingers of the right hand are passed round the outer edge of the kidney, and 
 the front surface t"elt over in the same way as the posterior. Whilst doing this, in order 
 to give counter-resistance to the exploring finger, the kidney may be pressed against the 
 psoas muscle or be squeezed between the finger and thumb. Despite all these means, a 
 calculus may escape detection. I have recently removed by lumbar nephrectomy a healthy 
 kidney for a calculus the size of a marble imbedded in it, but which I could not localize. 
 The man recovered well, but the loss of a good kidney is a very regrettable feature in 
 the case. The kidney becomes very hard and tough under the prolonged irritation of a 
 stone, so that, whilst the whole organ feels firmer than natural, any slight difference in 
 the degree of resistance of one part is more difficult to appreciate. This hardness of the 
 renal substance should make the surgeon very sus]»icious of a calculus, and future experi- 
 ence will. I think, encourage him, when this condition is present, not to be satisfied either 
 that no stone exists or that nephrectomy must be performed until he has made such an 
 incision into the kidney as will open each of the calyces. Kidney wounds are known to 
 heal readily, aiul, whiLst the risk of such an incision would not ecjual that of nephrec- 
 tomy, the subsequent condition of the kidney would be preferable to the possession of 
 oidy one of these organs. 
 
 •• Having detected the stone by one or other of the methods above described, the over- 
 lying parts of the kidney should be cut into with a probe-ended straight bistoury, and 
 then with a scooping movement of the finger, introduced through the incision, the stone, 
 unless a branched or very large one, can be raised to the surface of the parietal wound 
 on the point of the finger ; or a pair of forceps might be passed into the kidney by the 
 side of the knife and the stone seized and withdrawn. The finger is, however, much to 
 be preferred ; and if the incision is small, as it ought to be. the finger serves the purpose 
 
630 DISEASES OF THE KIDSEY.— STONE.— XEPHREVTOMY. 
 
 of plugging the reiuil woiiiul, whilst it hicerates tlie renal tissue to the necessary extent. 
 By this plan the hemorrliage is minimized, and the rent made with the finger heals as 
 readily as the cut. When equally convenient to reach the stone, it is much best to opet 
 the secreting structure, and not the pelvis, of the kidney. The wound in the former 
 heals better than in the latter, and the chance of a urinary fistula is much less. If the cal- 
 culus be large and branched, it may possibly be requisite to break it up into two or more 
 fragments and remove the fragments separately. I have known this done in a suppurat- 
 ing kidney, but it is not probable that a stone will attain such a size as to require break- 
 ing before removal without having in its growth more or less destroyed the kidney 
 structure. A stone one ounce in weight has been removed entire from a kidney not 
 markedly enlarged nor the seat of advanced suppuration (Bennett May, Clhi. Soc. IVans., 
 1883). 
 
 AFTER-TREATMENT. — The after-treatment is very simple : a drainage-tube should be 
 left in the back part of the wound, and the rest should be closed by sutures. For a time, 
 of course, the whole or greater part of the urine secreted by the injured kidney Avill be 
 discharged through the loin, but after gradually diminishing this may be expected to 
 cease altogether in from three to four weeks. 
 
 '' These loin wounds usually heal very quickly. In nephrotomy, as in nephro-lithoto- 
 my, some simple dressing, such as lint soaked in terebene and oil or spread with boraeie 
 ointment, should be applied over the wound, and the drainage tube should pass through 
 this and be covered with a thick pad of absorbent cotton-wool, iodoform, or Lister's gauze, 
 retained in place by a light bandage. The dressings will require frequent changing, as 
 they soon become saturated with the urine. To keep the bedding dry, a large pad of 
 finely-powdered German moss peat should be placed beneath the loin to receive and absorb 
 the urine, Avhich it readily does. 
 
 Dangers of Operation. — The dangers of nephro-lithotomy are not great, so far 
 as we can judge from present experience. The operation hitherto has, it appears, been 
 uniformly successful, but the number of cases as yet recorded is but few. 1. Jleinorihar/e 
 from the wounded kidney is not likely to be serious if the plan suggested above be fol- 
 lowed. There may, perhaps, be a formidable-looking gush on fir.st dividing the tissue, 
 as in Mr. Beck's case, but compression with the finger or a sponge will soon check it. 
 2. Cellulitis may follow the operation, but with due jirecaution as to antiseptic cleanliness 
 and drainage this will almost certainly be escaped. It may, however, occur, and I am 
 aware of one case in which extensive suppurative cellulitis followed an exploratory incis- 
 ion in search of a renal calculus ; pus burrowed downward to the pelvis and upward 
 until the abscess burst into the lung, and, though the patient ultimately recovered, he 
 nearly lost his life. 3. Roial abxcess might possibly follow the operation as the result of 
 wounding an organ already long irritated by the presence of a calculus. I do not know 
 of its having occurred, and it is much more probable that any morbid change started by 
 the calculus would be checked and repaired by the removal of the cause — a result which 
 is pi'overbially known to occur in other tissues of the body. 4. A renal fistula or a mere 
 superficial purulent fi.stula may follow ; but, though the chances are against it, such a 
 result would be a welcome substitute for the ceaseless pain and chronic invalidism of the 
 condition which it replaces. 
 
 Nephrectomy. — This operation has been successfully performed at intervals for 
 years — in some cases on account of injury and in others b}' mistake, renal tumors having 
 been removed as ovarian ; but Simon of Heidelberg was the first surgeon who design- 
 edly performed it, and with success, by the lumbar operation. 
 
 Dr. Brant of Klausenburg on June 7, 1872, removed the left kidney of a man a?t. 27, 
 which had escaped from the loin through an opening caused by a stab four days before. 
 He tied its pedicle in two portions with a silken ligature, and recovery took place without 
 a bad symptom ( Wirner Med. Hoc//., November 29, 1873). 
 
 On December 2, 1873, Dr. A. Cam])bell of Dundee removed the kidney that was the 
 subject of cystic disease through an abdominal incision, having mistaken it for an ovarian 
 tumor, and the patient, who was a Avidow ost. 49, made a good recovery. The pedicle was 
 ligatured with carbolized catgut (Edin. Med. Jouni., July, 1874). 
 
 Nephrectomij may be performed by an abdominal or lumhnr incision, and there can be 
 no question that the latter is the right one to select in all ca.ses in which the kidney is 
 small and yet sufficiently diseased to justify its removal. 
 
 The abdominal incision should be reserved for large tumors which cannot be taken 
 away by the lumbar. 
 
 Lumbar ntphrectuiny is at all times a serious operation, and is only to be undertaken 
 
j'AJi.\cj:\Tj:sfs OF riir: kidshy. G."il 
 
 after inature corisidonitinii. " It is mily pennissiKh'," .says Siiiioii, 'Mvlien a patient's life 
 is sfrimisly tliivateiuMl hy tliseasi- ami all Dtlicr rciiicdirs have failed." It should, Iidw- 
 evor, he entertained when one oriran is seriously disorj:ani/ed fnjui ealeiiltis or other 
 cau.se.s, and when the minor operation of nephrotomy has failt'd or seem.s inapplicable; 
 when the ovfjau is the seat of a tumor otherwise incurahle or the subject of urethral 
 urinary fistula sericmsly interfering with life s duties. It .seems likewise applicable to 
 certain examples of ruptured or wounded kidney in which nature cannot be expected to 
 briuLT alioiit or has faili'd to secure repair. 
 
 It should never be undertaken uidess evidence exists as to tin- probaliilifv of the 
 other kidney being healthy, as evinced by the normal condition of the urine as to i|uan- 
 tity and t|uality, and the absence of albumen over and alxne what can be explaine<l by 
 tile presence of pus due to the disease of the atleeted organ. 
 
 It does not ajij)ear to be ap])licable to disorganization oi' the kiilnev from tuberculous 
 disease, such an aflection being usually double. 
 
 The operation itself should be made much upon the same lines as that of nepliro- 
 lithot(»my. 
 
 Should more room be rojuired in the incision, it can be gained by a vertical cut made 
 at right angles to the spinal end of the wound, thi.s incLsion not only facilitating the 
 removal of the kidney and the application of ligatures to its pedicle, but being very 
 favorable for drainage. 
 
 The kidney should be enucleated by the finger, and this is, as a rule, readily eflfected. 
 Where difficulty is felt the capsule may be left. 
 
 The pedicle should be secured ])y means of a double ligature of silk passed on a long 
 and strong aneurism uecdle, and it is well to tie the ureter and vessels separately. The 
 kidney should next be well dragged out of the wound, and to facilitate tliis the lower 
 ribs should be forcibly drawn upward. If the ligatures do not appear to he .securely 
 tied, a second one should be put on ; before the kidney is separated the pedicle should be 
 cut through with scissors. 
 
 All bleeding points should at once be .seized as they present themselves and secured 
 either by ligature or forceps. All the ligatures should be cut short. Any wound of the 
 peritoneum should be sutured. The wound should then be treated as any other deep 
 wound — that is, well washed out with iodine water and drained. Enough sutures should 
 be introduced into the wound to keep the parts together, but a free outlet should be left. 
 A large pad of ab.sorbent cotton and gauze may then be adjusted over the loin, to absorb 
 discharge, and the patient left alone for natures reparative powers to bring about a cure. 
 The simplest food is the best ; the nearer a milk diet can be maintained, the better. Con- 
 valescence has been generally secured in about four weeks. 
 
 Abdominal ncp/iircfoin// is to be entertained only when the lumbar is ina])plicable ; 
 and had I to do it, I should use the incision which approaches that illustrated in Fig, 
 UiO, the upper enil of the incision being made to pass more obli(|uely below the last rib. 
 Langenbuch of Berlin makes his along the outer border of the rectus abdominis, the mid- 
 point of the incision corresponding to the umbilicus. 
 
 All the details of the operation are to' be conducted with all the care observed in an 
 ovariotomy. 
 
 The statistics of the operation up to the present are : 
 
 Out of 90 cases well reported, 54 recovered and 42 died. Of these, 46 were made by 
 the abdominal incision, of which half died ; whereas of the 50 made by the lumbar, 31 
 recovered and 19 died. The result of the operation seems, however, to turn nujre upon 
 the disease denumding it. Thus, of IS ca,ses for cancer, 9 died ; of 10 ca.ses for floating 
 kidney. died ; of 7 for urethral fistula, all lumbar, recovered, 1 died. 
 
 Nephrorraphy is an operation undertaken for the relief and fixation of a kidney 
 which is freely mnn/h/r behind the peritoneum. It is clearly inapplicable to such rare 
 cases as are found to possess a mesonephron and are Jf'xitin;/ kidneys. It should, how- 
 ever, be undertaken only in exceptional cases. It consists in a lumbar incision as for 
 nephrotomy, after the exposure of the kidney, which is greatly aided by an assistant 
 pressing it well to the wound from the abdomen ; the ca])sule and cortex should be firmly 
 stitched by six or more sutures to the margins of the lumbar wound, the wound sub.se- 
 t|uently being left to granulate. The operation was first performed by Hahn of Berlin 
 in 1881, and it has been repeated by Langenbuch, Martin. Kiister, Esmarch. Weir. JN'ew- 
 man, and others with sufficient success to justify its adoption in such exceptionally trou- 
 blesome and painful cases of the aflection as are occasionally met with. 
 
 The OPERATION, up to the exposure of the kidney, is the same as that of nephrotomy, 
 
632 DISEASES OF THE BLADDER AND PROSTATE. 
 
 and later on consists in the application of strong catgut sutures between the renai capsule 
 and the margins of the lumbar wound. The kidney by this process is stitched back to 
 the loin, where it becomes ultimately fixed. The wound after this should be dressed so 
 as to heal by granulation. The operation of nephrectomy for this affection is hardly 
 justifiable. 
 
 For papers on this subject refer to Thomas Smith's, Mecl.-Chir. Trans, for 1869 ; to Lucas's, 
 British Med. Journal. September 29, 188-3 ; to Hexry Morris's, Aahhurst's Iniernatwnal EncyclopcBd. 
 of Surgery, vol. v.; CzERXY of Heidelberg, Tram. Internat. Med. Conrjress, 1881, vol. ii., p. 249; BAR- 
 KER, Trans, of Med.-Cfiir. Soc, vols. Ixiii. and Ixiv. ; Hahx, Centralhlattfur Chirurgie, July 23, 1881 ; 
 American Journal of Med. Science, January, 1873, July, 1874, also paper by Harris, 1882; David 
 Newman, M. B., Glasgow Med. Journal, August, 1883; Dr. Weir, Xew York Med. Gazette, 1884. 
 
 CHAPTER XXI. 
 
 DISEASES OF THE BLADDER AND PROSTATE. 
 
 Irritable Bladder. 
 
 Almost every disease of the urinary organs from the kidney downward manifests its 
 presence by some bladder symptom, and that symptom is usually what is called an irri- 
 table bkidder — that is, the patient passes urine more frequently than natural, with or 
 without pain. 
 
 Such a .symptom may indicate some slight deviation from the healthy relations that 
 ought normally to exist between the bladder and its contents, or the presence of a severe 
 if not fatal organic disease. It may be a result of some irritation of the glans penis asso- 
 ciated with retained subpreputial secretion or an adhesion between the glans and prepuce, 
 or it may be due to a serious cerebral or .spinal affection. It may indicate kidney, blad- 
 der, pro.static, or urethral disease, and. in many instances it is the one symptom that has 
 induced the patient to seek advice. The irrhaJtle hbiddcr. therefore, though only a symp- 
 tom, is clinically an important one, and demands elucidation at the commencement of a 
 chapter on bladder affections. 
 
 Irritability of Bladder in Children. — ^\'llen tliis symptom is well njarked in 
 a male child, the condition of the penis should first receive attention, since, if the prepuce 
 be long or adherent to the glans penis, and the secretion from Tyson's glands, from want 
 of cleanliness, have accumulated and become indurated, there will be strong reason to 
 believe that the irritability of bladder is the direct product of these apparently simple 
 causes ; for any of these conditions of the penis are sufficient to produce every degree of 
 bladder irritation, and a cure can be obtained only by their removal. To secure this end 
 all retained secretion .should be taken away, adhesions between the glans penis and pre- 
 puce carefully separated, and, if the prepuce be long, circumcision performed. If, how- 
 ever, on a careful examination, no such conditions are to be observed, the state of the 
 bladder should be inquired into, and for this purpose a sound passed Tan instrument with 
 a bulbous extremity being preferred) (Fig. 385) ; and if a stone be detected, the cause 
 of the symptom will be cleai'ly explained, as well as the practice to be followed. It must 
 be remarked, also, that if a calculus be the cause, a careful inquiry will probably detect 
 the pi-esence of other symptoms, such as pain after micturition. ha?maturia, and an occa- 
 sional interruption to the flow of urine, the intermitting urinal flow being very character- 
 istic of the presence of a .stone, although all these symptoms may be present in irritable 
 bladder from an adherent prepuce. When the .stone cannot be felt, it is not at once to 
 be assumed that no such cause exi.sts ; for on a .subsequent examination it may readily be 
 discovered, the calculus having been probably covered by one of the folds of mucous 
 membrane of a partially-contracted bladder. If, however, a second examination fail to 
 strike it, the condition of the bladder should receive attention ; and if to the sound its 
 mucous lining feels rough and the presence of the instrument cause more or less pain and 
 a desire to micturate, the urine will probably be found altered in character, and after 
 standing will show a cloudy deposit of mucus, if not of pus, the latter deposit being very 
 rare, however, in young subjects. 
 
 Treatment. — Under these circumstances the general health of the child will require 
 attention, as it may happen that some slight aperient or alterative or an alkaline mixture 
 
ii:i:ir\i:i.i: i:i..\i>i>er. r,,T{ 
 
 of potash. (»r perhaps a t mic, may he rt'(piin'tl, the ((lijoct Ix'iiig t<t make the miric as 
 uiiirritatiiig as possiliK-, ami thc'rel)y to aUow the vesical mucous iiR-mhraiu- tr» return to 
 its iioruial eoiidition. Rest, also, as fur as it is possihle to be secured, should he eulbreed. 
 The diet ought to he of the simplest uature and meat <riven in moderation, since it will 
 prohahlv he found that the urine is unnaturally loath-d with lithates, if not with lithie 
 acid; and this tendency to the deposition of such ingredients would he increased hy the 
 free administration of animal food. When, however, a case of irritahle bladder in a child 
 presents itself in which none of flic conditions alluded to are found, and in which the 
 penis, urethra, and Madder appear ])crfectly natural, the state of the rectum shruild be 
 in(|uired intti. tlu' presence of worms, and more particularly of ascarides, being (piite suf- 
 ficient to produce an irritable condition of the urinary organs. These may be removed 
 by a jalap purge or an enema of .some bitter vegetable infusion such as (piassia, but the 
 condition of the digestive a]iparatus will re(|uire attention, as influencing the presence of 
 worms. 
 
 Excluding tin- presence of a stone as a cause oi' irritable bladder in young children, 
 and in obstinate cases the probability of some villous growth, thi.s aftection is not (me of 
 serious importance if its true cau.se can be accurately recognized, since the conditions 
 upon which it depends are easily remediable, and the irritability of the bladder rapidly 
 disa]ipcars on their removal. 
 
 Irritability of Bladder in the Adult. — In adult life this symptom cannot be 
 
 regarded in such a favorable light as in a child, since it is too often as.sociated with con- 
 ditions which are of a very serious nature and are by no means readily removed, although 
 in the adult, as in the chifd. a congenital or an acquiri'd phimosis, with a contracted pre- 
 putial orifice or adhesions between the prepuce and the glans penis, is a sufficient condi- 
 tion to produce this symptom. 
 
 ,4s a siymptom of africfiire the irritable bladder is not without its value, and. as a rule, 
 it indicates considerable narrowing, as well as probably a contraction, which has been .so 
 gradual in its progress as to escape notice until this irritability of bladder enforced more 
 accurate observation and induced the patient to seek advice. It must be regarded as a 
 result, therefore, of a urethral stricture which can be relieved only by the removal of its 
 cause. Doubtless it is produced by some chronic inflammatory action of the vesical 
 mucous membrane, and as such requires treatment — viz., the dilatation of the stricture, 
 absolute rest, and the administration of alteratives. 
 
 As a symptom o^ enlarged proatnte (or of atony of the bladder in the aged in whom no 
 prostatic enlargement exists) this irritability of bladder is a complication of serious import, 
 for in both classes of cases it is due to a want of power on the part of the bladder to 
 empty its contents — in the one case from a mechanical obstruction caused by the pros- 
 tatic tumor, in the other from a loss of power in the parts, the residual urine under both, 
 partially decomposing, becomes ammoniacal, and in this way acting as an irritant to the 
 mucous membrane of the bladder, thereby giving rise to the irritability. 
 
 The treatment of these cases is not, therefore, a task of difficulty, the removal of the 
 residual urine and the prevention of its subsequent retention by the cautious emplovment 
 of a catheter being the most important, together with the frequent washing out of the 
 bladder with warm water or water medicated by some solution of morphia, opium, quinine, 
 boracic, or nitric acid. 
 
 The recognition of the cause of the symptom, however, is the main point to be remem- 
 bered, the practice to be followed readily suggesting itself when the cause is understood. 
 As a sign of gravel an irritable bladder is of importance, and a careful examination of the 
 urine will determine its true meaning. As a symptom of calculus in the bladder it is 
 constant and valuable, although in some cases of stone it is extraordinary how little irri- 
 tation the presence of a calculus wmII produce. As a sign, also, of organic disease of the 
 bladder, irritability must not be passed over. The obscurity of this class of cases is. how- 
 ever, very great, and the correctness of diagnosis must rest upon the combination of 
 many symptoms, none being of greater value than another. In women this .symptom is 
 a common accompaniment of uterine affections, while in both sexes it is often associated 
 with rectal disease. 
 
 Last, but not least, this irritability may be the product of a renal affection, the urethra 
 and bladder being perfectly sound. When, therefore, bladder .symptoms exist and a 
 careful examination fails to discover any disease in the bladder or urethra, it may fairly 
 be assumed that some renal affection is the cause. But a careful chemical and micro- 
 .scopical examination of the urine is alone sufficient to enable the surgeon to arrive at 
 anvthinc like a correct diagnosis. 
 
634 
 
 DISEASES OF THE BLADDER AND PROSTATE. 
 
 Irritability of bladder may also be produced by some cerebral or spinal disease, but 
 the fact can merely be alluded to in these pages. 
 
 The passage of a large quantity of urine, as in diabetes, should not be mistaken for 
 irritability of bladder. 
 
 Inflammation of the Bladder, 
 
 Cystitis is a common consequence of stone, prostatic disease, stricture, or gonorrhoea, 
 and is usually chronic or subacute, the more acute symptoms mostly supervening upon the 
 chronic. As an cicute idiopathic disease it has been described by authors, but clinically 
 such cases are very rare. The most acute are those occurring in gouty subjects as a 
 catarrhal affection. 
 
 The c/(ro»/c form is the direct consequence of local irritation produced by the- presence 
 of a tumor, stone, or other foreign body, although it is found whepever the flow of urine 
 is interfered with from either prostatic disease or urethral obstruction, the bladder in these 
 cases being irritated by the retained and decomposed urine as well as by its own ineffec- 
 tual attempts to evacuate its contents. A similar result likewise ensues when the bladder 
 is paralyzed and unable to expel its contents from overdistension, spinal injury, or disease. 
 It is under these circumstances the more acute forms of cystitis and the worst pathologi- 
 cal conditions are found. 
 
 Subacute cystitis is commonly the result of gonorrha?a, the inflammation of the 
 urethra spreading to the bladder. 
 
 The seat of the inflammation is the mucous membrane, which becomes rough, cov- 
 ered with flakes of adherent lymph and phosphatic secretion, thickened, and at times 
 ulcerated, and in the acute forms of the affection detached in fragments or as a whole 
 and thrown off as a slough. This latter condition is generally met with in the bladder 
 of the paralytic and in women who liave had their bladders much distended from retention. 
 It is probably as much due to the deficiency of nerve supply as to the intensity of the 
 inflammatory mischief, rough catheterism having often too much to do M'ith it. 
 
 In chronic cases the walls of the bladder become greatly hypertrophied from over- 
 action, thick muscular bands being visible, and where the obstruction to the exit of the 
 
 urine has been of long standing this thickening of 
 Fig. 358. the walls of the bladder is associated with its dila- 
 
 tation. Under these circumstances it is common 
 to meet with sacular dilatations of the mucous 
 membrane, the mucous lining of the bladder be- 
 coming pressed outward as a hernia between the 
 bands of muscular tissue forming the walls of the 
 organ. These pouches are usually small, though 
 in exceptional cases (as seen in Fig. 358) they 
 may be double the size of the bladder itself. Into 
 one of these pouches a stone may occasionally fall 
 and rest, thereby becoming encysted. At times 
 these sacculi are multiple. 
 
 Sacculi of the bladder are met with chiefly in 
 male subjects ; they were found in 20 out of 3000 
 post-mortem examinations made at Guy's; in 11 
 cases of stricture, 5 of stone, 1 of spinal disease, 1 of enlarged prostate. In 1 the cause 
 was not clear. My friend Dr. Hale "White recorded these facts with a case met with in 
 a woman at the Path. Society, March, 1883. 
 
 Symptoms. — When the disease is subacute, the symptoms are irritability of bladder 
 and inability to retain urine, the desire to pass water being often associated with its 
 uncontrollable passage. The act of micturition is attended with pain and followed by 
 straining, blood being frequently squeezed out by the forcible contraction of the oi'gan. 
 Pain is mostly present above the pubes, in the perinreum and penis, often over the sacrum 
 and in the groin. With these local symptoms there may be those of more or less severe 
 febrile disturbance. 
 
 The urine will be found to vary in character according to the cause of the disease. 
 When it has originated from the extension of a gonorrhoeal inflammation of the urethra, 
 it will be cloudy from the presence of mucus, or even of pus, and at times stained with 
 blood, this blood having been passed dui'ing the act of straining at the end of mictu- 
 rition. 
 
 Sac 
 
 Sacculated Bladder. 
 (Prep. 2087", Guy's Hosp. Mus.) 
 
IM'J.AMMATIUS OF 'J'] IK ni.AhDER. 
 
 G35 
 
 [n other cases of cliroiiic discasi; (nilnnhnl n/stlliH) the uriiit! will l)e inixcfj with 
 ^ravi.^h, viseid, r()|)y mueiis or niiicit-punili'iit fluid, whi(di so sticks to the hoituiu of tlie 
 diaiiilier-vessel ami toirether as to fall like a ^lutiimus mass when tiinieil out. 'I'he urine 
 will jtnd)ii]»ly, in ehmnie eases, he alkaline nr ammoniacal; in subacute, acid ; in ne;^lected 
 cases the diseharf^e of mucus hecoines (iiiirmnus. and |diips|diate of lime ollen becomes 
 mixed with the mucus and Ibrms stmie. 
 
 When ulceration of the bladder is present, all the symptoms are afrKravattvl and the 
 local pain is severe. Hleedinj; is a connnon accomjianiment, the blood being mixed with 
 the contents of the bladder and ])assed either as dark-colored urine or as clots of blood. 
 
 In the cystitis of <;onorrlnea it is pr(jbal)le that the mucous membrane about tlie neck 
 of the bladder is alone affected ; in the nnjre chronic cases of disease the whole surface 
 and submucous tissue are involved. 
 
 Tkk.VTMKNT. — Whatever may be the local cause of the cystitis, the local symptom.^ 
 re((uire attention, althoutrh in order to (tbtain a cure the removal of the cause is most 
 essential. 
 
 Rest in the horizontal posture, hot fomentations or the hot bath, simple diluents such 
 as barley water, linseed tea, milk and water, with alkalies, as the salicylate of soda, citrate, 
 or bicarbonate of potash, in ten-<?rain doses, three times a day. and, abtn'e all. sedatives, 
 are most essential. Of the sedatives hyoscyamus is the best, in half-drachni or drachm 
 doses of the tincture every two or three hours ; and where this is not enough opium may 
 be substituted, but where the kidneys are diseased opium should always be given with 
 great caution. The morphia suppo.sitory is an excellent remedy ; so is an enema of 
 starch with opium. The bowels should be relieved by enemata in preference to purga- 
 tives, although, when severe constipation is present, a good mercurial purge is often of 
 value ; leeches to the perin.'cum are sometimes serviceable. 
 
 AVhen retention of urine complicates the case, catheterism is called for : and an ela.stic 
 catheter should be used, with the utmost gentleness. 
 
 In clironic cases the infusions of buchu. uva ursi, pareira. or senega, and benzoic acid 
 in ten-grain doses are excellent remedies ; the tincture of cubebs or cijpaiba at times acts 
 also beneticially ; the triticum repens, in the form of a decoction, two ounces to the pint, 
 is also a valuable drug. When gout is the assignable cause, colchicum. with five-grain 
 doses of the carbonate of lithia, sometimes acts as a charm, and in some cases of gonor- 
 rhoea! cystitis the same good effect is often experi- 
 enced. AVhen stone is the cau.se, it should be re- 
 moved ; when stricture coexists, it must be dilated ; 
 when enlarged prostate or atony of the bladder in 
 the aged is the cause of the cystitis, it is . essential 
 to keep the bladder empty by the introduction of a 
 catheter once or twice daily ; in severe cases the blad- 
 der should be washed out by either a stream of tep- 
 id water or medicated solution. Boracic acid, ten 
 grains to the ounce of water, is the best form. Mr. 
 T. W^. Nunn speaks highly of a solution of two grains 
 of quinine in two and a half ounces of water wnth a 
 drop of diluted sulphuric acid. W^hen the urine is 
 fetid, Condy's fluid or a few drops of tincture of iodine, 
 carbolic acid, or of one part of thymol dissolved in 
 seven of glycerine may be added to the water. 
 
 In w'ashing the bladder the greatest gentleness 
 should be observed ; to force fluid into the l)ladder 
 by a syringe is dangerous, unless in skilled hands, 
 while to introduce more than three or four ounces of 
 ■fluid is unnecessary. The best method is by means 
 of the irrigating can or a piece of india-rubber tub- 
 ing, two or three feet long, fitted to the top of the 
 catheter after its introduction, and the gradual pour- 
 ing of the water or .solution made warm through a 
 glass funnel fitted to the other end. The tubing can 
 be raised to increase the pressure of the fluid, or de- 
 pressed, according to the necessities of the case, the 
 bladder resenting the slightest distension by its contraction and by the expulsion or ele- 
 vation of the fluid into the funnel. By these means no harm can possibly accrue to 
 
 Fig. 359. 
 
 Mode of Washing Out the Bladder. (^The irri- 
 gator can may be substituted for the jug 
 and hand.) 
 
636 DISEASES OF THE BLADDER AND PROSTATE. 
 
 an inflamed bladdei", and the most atonic bladder can be emptied as with a syphon (Fig. 
 359). 
 
 After the fluid has been inti'oduced and left for two or three minutes it should be 
 withdrawn, and fresh fluid poured in where necessary, the funnel being depressed below 
 the level of the bed for emptying the bladder. Anodyne solutions are said not to be of 
 much use in these cases, but I have been in the habit of introducing half a grain, more 
 or less, of morphia, with apparent advantage, after the washing out of the bladder. When 
 the washing out of the bladder increases the irritation, it should be discontinued. At times 
 a double catheter is of use, the injection flowing down one side and the contents of the 
 bladder out of the other. 
 
 In the inflamed bladder associated with atony the tincture of the perchloride of iron 
 is a valuable drug, or the dilute nitro-muriatic acid given in twenty-minim or half-drachm 
 doses three times a day ; but, in a general way, alkalies are called for, the urine naturally 
 secreted being acid, and so as it is poured into the inflamed bladder becomes an irritant. 
 The diet under all circumstances should be nutritious, but unstiuiulating, alcohol being 
 given carefully, according to the patient's powers. In all cases, however, of inflamed 
 bladder the surgeon ought to remember its cause, which is generally due to some obstruc- 
 tion to the flow of urine or local cause of irritation, and for a cure the removal of its 
 cause is essential. 
 
 Ulceration of the Bladder. 
 
 This is rarely the result of ordinary cystitis, though it may occur in the paralyzed 
 organ, and is met with after death where catheterism has been frequently employed and 
 in cases of stone. It is likewise' found in tuberculous subjects, from the breaking down 
 of tuberculous material, as well as in cancer. The disease is indicated by the same 
 symptoms as exist in inflamed bladder, with more local distress, more blood in the urine, 
 and greater pain after micturition. There is usually also much constitutional depression 
 and want of power. I have seen two cases in which extravasation of urine above the 
 pubes resulted from this disease, one of which recovered and the other died. 
 
 Treatment. — The indications for treatment are similar to those for cystitis, opium 
 being freely used as a suppository or an enema. All mechanical interference should be 
 avoided unless absolutely called for, and then it should be of the gentlest kind. It is a 
 question, however, whether in the severer forms median perineal cy.stotomy would not be 
 a sound practice ; the urine would then flow away as secreted and a chance given to the 
 bladder to recover itself; at any rate, the operation would give relief. I have done this 
 on several occasions with success. 
 
 Tubercular Disease of the Bladder. 
 
 This is a rare although a real aff"ection. and is confined to young middle age. It is 
 generally associated with the same disease of the kidneys, prostate, vesiculac seminales, 
 and testicles, and- shows itself as a deposit of tuberculous matter in the mucous and sub- 
 mucous tissue, which when it breaks down forms an ulcer. It is usually accompanied 
 with symptoms of irritable bladder and painful micturition, the latter symptom being 
 more common when ulceration has taken place. 
 
 Rest in the horizontal posture is essential in this as in all bladder affections, anodynes, 
 tonics, and nutritious food being of great value. My friend the late Mr. Poland told me 
 that in a case of tubercular disease of the bladder attended with ulceration (which was 
 under Mr. Aston Key's care when he was a dresser, about 1840), where the suffering was 
 severe, Mr. Key suggested the propriety of laying the bladder open as in lithotomy, and 
 thus allowing the urine to flow off" as soon as it reached the bladder. The patient, how- 
 ever, was too fiir exhausted from advanced lung disease to allow of its performance. 3Ir. 
 Key stated that in another case, where the disease had not made so much progress, he 
 should not hesitate in performing the operation. The bladder in this one was found 
 almost stripped of its mucous membrane, and what remained was studded with tubercu- 
 lar deposits. Mr. Key called it phthisis of the bladder. At the present day Mr. Aston 
 Key's suggestion of cystotomy would probably be performed. 
 
 Tumors of the Bladder. 
 
 A bladder, anatomically being constructed of mucous membrane, fibrous and muscu- 
 lar tissue, may be the seat of papillomata, the innocent villoits groxcth ; myxomata, or 
 
<:A\ci:iis. 
 
 (\:u 
 
 iiuiCDUs polypus ; i-'IHKomata, or liliiniis ;;ro\vtli ; MVOMATA, or niUHcular. ("<»iit;iiiiiiig, 
 likrwisi', as it tltu-s, (•])itlu'lial ami (M»iiiu'ctivi'-tissiU' I'lcinciits, it may he tlie sultji'i-t of 
 
 I'll ; aixl to this list i>kk.M(jII) 
 intraiiiiiral or polypoid. The 
 
 I'm. 360. 
 
 Thlckentd Mall of IHaJJrr 
 
 ' " ; ' Mir roscopic 
 
 Villous Growth in Bladder, with llyper- 
 irophied Walls of the Ur(,'aii. (From 
 drawing ;5()S''3, (Juy's Hosp. Mus.; 
 
 KlMTIIKMAl, CANCKIl, as Wi'll as of a SAKCOMATUIS «iK(»\V 
 
 tiiiiiors mav hi' adtli-d. Any one of these <xro\vths may he 
 papillomata are tiuiiul in ehihireii as well as in adnlts. 
 The other forms of tumor helonjr more to the iniddie-aLM-d 
 or old. (Irowths are as eonim<iM in the teinale as in the 
 male sex. 
 
 The papillomatous me mostly j»eduneulati;d. vil- 
 lous, and sinuli. Many are sessile and multiple. When 
 single, they are <;euerally attached to the hase of the hlad- 
 dor — that is, to the trig(»ne and orifices of the ureters, when 
 at times their long villous ends or |)rolongations of natural 
 villi are carried by the urine stream into the urethra, 
 where they may be broken off and exjielled or cause 
 obstruction. 
 
 In exeeptiiiiial eases the miicims surface of the bladder 
 may bi- nn)re or less covered with these villous or sessile 
 papillomatous growths ; indeed, instances are on record 
 where the ureters or calyces of kidneys were involved. 
 
 These growths are benign and of slow growth ; they 
 may last for six or more years. 
 
 Fig. 8G0 well illustrates the ordinary appearance of 
 this variety of tumor, with the changes brought about in 
 the bladdi'r from its presence. 
 
 The myxomata, fibromata, or myomata are 
 
 mostly single tumors and develop as pidypoid or irregular- 
 .shaped outgrowths, the expulsive action of the bladder doubtless doing much toward 
 making the growths polypoid. They affect both sexes equally, and are more frequent 
 during young than old life ; they may grow from any part of the bladder, but generally 
 from the trigone. 
 
 In Fig. 'M\\ the disease was extensive. It was described by Sir A. Cooper as '-tumor 
 of the mucous mem1)rane of the bladder everted, polypoid excre.scences producing .symp- 
 toms of stone." Fibrous and myomatous tumors are, however, rare. In 1883 I had a 
 man ;ct. 6(» under care with a fibrous growth springing from the fundus; it had caused 
 symptoms for four years. 
 
 Cancers. 
 
 These are generally of the epithelial form, but examples of the hard and soft varieties 
 have been recorded. They are generally sessile and infiltrating the walls of the bladder, 
 but they may assume the villous shape. The affections may be primary ; more commonly, 
 in women, the bladder becomes involved by the extension of 
 di.sease from the uterus, and in men from the rectum. Under 
 all circumstances the disease is one of middle or advanced age. 
 
 In the notes of a case before me, however, the disease 
 appeared in a man aet. 28; in ten others the ages varied from 
 48 to (J!t. 
 
 Symptoms. — All bladder tumors give rise to much the same 
 series of symptoms, which may be brought under three head- 
 ings — namely. irritahUily of bladder, passing on to incontinence, 
 hstmntnild, and puin. 
 
 The irritability may be very slow in its increase, intermittent 
 in its action, or rapidly progressive. In the majority of tumors 
 it is the earliest sign ; in the villous or papillomatous it rarely 
 appears till other evidence of bladder trouble, such as hajma- 
 turia, shows itself. When it has appeared, it usually steadily 
 increases in severity, till at last the bladder refuses to retain 
 urine and incontinence ensues. 
 
 The progress of villous disease is usually slow, but it may 
 be rapid. Thus, in one case of villous growth, the notes of which are before me. in a man 
 ret. 87, the irritability of bladder and h;vmaturia had been gradually increasing in severity 
 for eight yea r^. and after death the mucous lining of the bladder was found covered with 
 
 Fig. 361. 
 
 Polypoid Outfirnwtiis ifiin Mu- 
 cous Menihrane of Bladder. 
 (Preparation 21042^5, (iuy's Mu- 
 seum.) 
 
638 DISEASES OF THE BLADDER AXD PROSTATE. 
 
 a growth, and the walls of the bladder were so thickened that when removed, empty of 
 urine, it was as large as a coeoanut ; whilst in a second case, which occurred in a man a?t. 
 70. there had been symptoms for only tv;o months, and the first was haematuria. No pain 
 or difficulty in micturition had appeared till five days before his admission into Guy's. He 
 died from suppurating kidneys. In this case the disease was localized to the trigone of 
 the bladder. 
 
 It is to be remarked also that in villous disease there may be intervals of days, and 
 sometimes weeks, between the attacks of haematuria. the urine between-whiles being nor- 
 mal. In cancerous disease these intervals are rare. 
 
 It need hardly be said that the urine should be most carefully examined in all these 
 cases and its sediment and clots washed, for in one case a small fragment of villous growth 
 may often be found in it. and in another mas^e.f of epithelial or spindle-.shaped cells — not 
 isolated cells, however numerous — when the diagnosis will be complete. 
 
 With the same view, when a catheter has been passed, the contents of the instrument 
 should be well washed and examined. I have on several occasions found pieces of growth 
 in the instrument, and in the case of a female child who had .several attacks of haematuria 
 I caught in the eye of mv catheter a small villous growth, pulled it awav. and cured the 
 child. . . , ., 
 
 Ultzmann ( VilhHs-Ueher Hematuric, 1878) has described a condition of urine met with 
 in villous growths which he considers diagnostic. It consists of a coagulating of the urine, 
 which seems free from blood, into a glutinous mass soon after it has been passed, the mass 
 consisting, apparently, of fibrine. A. Stein of New York, in his able memoir on bladder 
 tumors (ISSlj. confirms the observation. It would .seem as if in some cases liquor san- 
 guinis exudes from the villi, and in others blood. 
 
 Hhf:maturia. or the passage of blood-stained urine, or blood in abundance or in clots, 
 is a constant .symptom, and in the villous growth it is usually the earliest. In such it is 
 also very intermittent — that is. it may appear to-day and not reappear for three or four 
 months. The same may be said of other growths, but. as a rule, when ha?maturia has 
 appeared with them, it is persistent. It is. however, usually a later symptom. 
 
 The blood generally shows itself toward the end of micturition, the stream of urine 
 being at first clear, and then toward the end red. In exceptional cases, however, the blood 
 may pass first. 
 
 The po.sition of the growth must have much to do with this symptom, growths about 
 the trigone being more liable to bleed when the bladder contracts than the same situated 
 nearer the fundus. 
 
 In exceptional cases of tumor of the bladder there is no hematuria. 
 
 Pain is not a constant symptom of this disease, although uneasiness from frequent 
 micturition may be troublesome ; pain becomes more marked as the irritability of bladder 
 increases and inflammation shows itself, and in the later stages of trouble it may become 
 intense. 
 
 The pain is usually felt in the penis after micturition, but a dull suprapubic pain is by 
 no means an uncommon symptom of bladder growth. 
 
 Pain over the sacrum and in the perinaeum and rectum, and pains shooting down the 
 thigh, are not rare. Lumbar pains are of frequent occurrence toward the close of the 
 case. 
 
 Diagnosis. — From what has been said as to .symptoms it will be gathered that it is 
 in exceptional cases alone a true diagnosis if any special vesical growth can be made out, 
 although when haematuria. steadily-increasing irritability of bladder, and pain are present,, 
 and these symptoms are unrelieved by treatment, the diagnosis of a local vesical cause 
 may fairly be made. A bimanual, vaginal, and suprapubic combined examination will 
 often prove of great value in aiding diagnosis in women and in men. The same method 
 applied through the rectum may be equally serviceable. 
 
 But for a completely satisfactory digital exploration of the bladder a full dilatation 
 of the female urethra is absolutely essential, and a central perineal urethral incision in 
 the male, by which the membranous portion of the urethra is opened to allow of direct 
 digital exploration, is equally called for. 
 
 Sounds and catheters are of use. but they are of uncertain value, and more particu- 
 larly when compared with '• direct digital bimanual exploration," as strongly advocated 
 by Sir H. Thompson. 
 
 Treatment. — Little more than palliative treatment has hitherto been generally 
 employed in these cases, as bladder tumors have been little understood. Yet an old 
 surgeon of Guy's (Warner) in 17-47 incised the urethra of a woman aet. 23 who was suf- 
 
CASrJJls. 
 
 iy.io 
 
 ferinj^ from a |)<ilyiHi.s ami put a ligatiiru nmiid the fuMluiiflc of a f:rowtIi the size of a 
 turkey's c'ltl; with comnlt'ic success; Dessault, after rcmoviiifr a stone from a male, suc- 
 cessfully twisted ort' a jiolyjtus that he iound in tiie Idaddcr ; ami Mr. Hirkett ( M'd.-Cliir. 
 Trails., 1S5S). in a strikinjr example of the disease occurring' in a female child :et. '>, 
 applied a liirature to the j:rowth, hut the patient died with suppuratin;.-^ kidney the effect 
 of the disease; anil in many eases the ])ractieahility of successful operative interference 
 is not diseourafiimr. 
 
 I also ill lSt)4 removed a villous <;rowtli from a woman s hladder with the ecraseur 
 with complete success. Other cases may also be found in .sur^'ical literature in which 
 operative interference has been emj)loyed, and niore particularly in women. In male sub- 
 jects the instances are very few. Civiale in 1^21 used to crush vesical growths with the 
 lithotrite with some success, and Covillard, according to Crosse {dinar// Fonudfions, 
 1885), was the first to perform designedly perineal cystotomy for a tumor with success. 
 Crosse ro])eated the o])eratioii in 1S;{4, Billroth. Volkman, and Kocher in 1874. Humphrey 
 in 1877, and Davies-Colley in 1S8(I. At the iire.><ent time Thompson has ably advocated 
 it. Suprapuliic cystotomy has been employed in still fewer cases. In considering the.se 
 operations it is always to be remembered that a case of bladder tumor when left to nature 
 can have but one ending, and that is death. Every rec(»very. therefore, aptly writes 
 Thompson, ''is a clear gain." In all cases of persistent Vjladdcr irritation and hit'inaturia 
 in which the cau.se is doubtful a full exploration of the bladder in the ways previou.sly 
 suggested, by urethral dilatation in the female and a perineal incision into the mem- 
 branous portion of the urethra in the male, should Vje undertaken. 
 
 Should no tumor be found, the injurious effects of the operation may be put down as 
 very slight ; should one be found to exist, its removal will probably be effected. Thomp- 
 son writes that out of 27 explorations he found and removed growths in 12 cases, and 
 that 5 of them were effectually cured. 
 
 The growth, when discovered, should be removed by scoop ecraseurs or forceps of 
 different shajtes and sizes. Thompson uses cutting as well as crushing forceps. The 
 latter are probably the safer and most efficient {vt>/f: Fig. 3(J2). 
 
 Fig. 362. 
 
 Thompson's Bladder Forceps. 
 
 When the whole growth can be removed, so much the better ; but should this not be 
 possible, the surgeon may console himself with Thompson's opinion that *• a complete 
 ablation of the growth is not absolutely essential to success ; that as cicatrization takes 
 place this process by degrees leads to solidification of the tissues at the point at which 
 evulsion was made." In female subjects the operation is far easier than it is in the male. 
 In both, however, it should be considered and adopted in an}" case of suspected tumor. 
 When any difficulty is experienced in finding or removing the growth, it may be well to 
 leave the case alone for twenty-four hours, as. from a case related to me by my friend 
 Mr. H. Morris, it .seems that when a bladder containing a growth is drained the growth 
 itself may be partially extruded through the wound by the natural expulsive action of 
 the bladder, when it can be readily seized and treated. 
 
 Under certain circumstances a suprapubic operation might be preferable to the per- 
 ineal ; for example, when the growth is at the fundus or very large. In a case of my 
 own of fibrous growth in the fundus I regretted that I had not chosen it. 
 
 The surgeon, when considering any operation upon the bladder, should remember that 
 its position is capable of undergoing great changes ; that in the adult, when flaccid, it lies 
 behind and below the level of the symphysis; and that when moderately distended it may 
 be uncovered with peritoneum for about one inch at its upper and anterior surface. He 
 should likewise be aware of what Dr. J. (t. Garson of the College of Surgeons has demon- 
 strated {Ellin. Med. Jiiurn.. October, 1878) when the rectum is di.stended with a rubber 
 oval bag measuring when full ten inches in circumference (the size of a man's hand) — 
 that the bladder is raised out of the pelvis into the position it occupies in the new-born 
 child, and that under such circumstances the bladder is uncovered above the symphysis 
 
640 
 
 DISEASES OF THE BLADDER AND PROSTATE. 
 
 for about three inches. It would seem by Garson's experiments that the bladder is raised 
 out of the pelvis by stretching the prostatic portion of the urethra to nearly double its 
 ordinary length, and that with the elevation of the bladder its posterior peritoneal cover- 
 ing is considerably raised, Douglas's pouch, which is normally about two and a half to 
 three inches from the anus, being raised to three, four, and even more, inches. My own 
 observations with the rectal dilator upon the cadaver support Dr. Garson's views. 
 
 The bearing of these facts upon suprapubic bladder operations is palpable. 
 
 For distending the rectum an oval india-rubber bag ten inches in circumference, with 
 a metal perforated tube for introducing and filling purposes, may be employed (Fig. 303). 
 
 Fig. 363. 
 
 Rectal Dilator. 
 
 Dermoid tumors of the bladder are of rare occurrence ; and when tliey 
 occur, they are probably ovarian in their origin, and are discharged through the bladder. 
 In exceptional cases they may have a bladder origin — that is, may have been developed 
 within the walls of the bladder and at a later stage broken down, ulcerated into it, and 
 been then discharged. 
 
 In the following ca.se this explanation seems to be the only reasonable one. 
 
 A married lady aet. 30, the mother of two children, came into my hands on June 30, 
 1883, to be operated upon for some hemorrhoidal trouble ; she then complained of slight 
 bladder irritability of a few days' standing. Previous to this she could hold her water 
 for hours ; indeed, on hunting-days she could do so for eight or ten. I regarded the blad- 
 der symptom as one associated with her rectal trouble. 
 
 After the operation the symptoms continued, and on July 10, without any apparent 
 cause, intense fever and constitutional disturbance appeared, and on the 11th her bladder 
 symptoms became intensified. 
 
 On the 12th some urethral obstruction occurred, and on examination with a view to 
 relieve it I removed a bundle, the size of a penholder, of fine hairs covered with phos- 
 phates from the urethra (Fig. 364, A), which bundle is now in the museum of the Eoyal 
 
 Dermoid Growth removed from the Bladder with hairs f A) covered with plio.s|)hatic; concretion. B, First part removed 
 C, Pedicle wiih ligature. D, Growth and pedicle finally removed. 
 
 College of Surgeons. With the removal of this all constitutional symptoms disappeared. 
 The bladder irritability, however, lasted, and for the next six weeks small phosphatic cal- 
 
i>i:nM()ii> TiMijiis or riii: iu.addiji. 
 
 <M1 
 
 illy assi.stiiijr nic- witli Mr, II. 
 
 mctlira raiiidly ililatc<l with 
 I tlifii introduced iiiv tinker 
 
 culi, t'oriiiftl i»ti li>iiL^ ami short hairs, were Ikmm^ fVc<|ii('iitly passed. Soiin- of thcsi- liairs 
 were a loot hxii; ; the majority were, however, short. 
 
 On several oeeasions I washeil the hladder <Mit with relict'. Karly in Septeinher the 
 ])atient was fairly eoinfortahh' ; she eoiild hold her urim- for hours and pass it without 
 pain. She then left liondon. Suddenly, however, towanl tin- en<l of the month, all her 
 severe symptoms ret urnecl. ami with aiz;.;ravation. The urine hrcame <diarL'»*d with mucuts, 
 and likewise with Mood. 
 
 Karlv in ()etid>cr I >:iw licr aizain. when >lic wa> pa^siuLi nia^^c* ol' ]diosphatie concre- 
 tion foniinl nil liairs. with urine riill nt' mucus and pu>. .\ hladder e.xpluration wa.s then 
 arraULjed. 
 
 On (Jetoher "Jit this was jierioriiied. Sir II. Tliomp-un ki 
 Morris. 
 
 For a lull examination an amesthetic wa.s given, and the 
 tlie small iustninu'iit 1 am in the habit of using (Fig. 4."{Sj. 
 into the hlaildcr, and at once came down upon a mass of phospatic concretion matted on 
 hair. This I removed, and, having done so, discovered hanging from the upper wall or 
 fuiulus of the bladder a polypoid outgrowth about one in(di and a half long, the pedicle 
 of which apjiareutly came out of a kind (d' annular depression in the walls of the bladder. 
 These facts were likewise recognized by Sir II. Thomp.stui. 1 then seized the growth with 
 a pair td' Thompsons fenestrated forceps (Fig. 'MVl) and drew it well down, and having 
 done .so, applied to its pedicle a ligature of chroniicized catgut. 
 
 Sir H. Thompson then, whilst I held the growth forward, cut oif its summit, whicli 
 measured three-quarters of an inch across (Fig. 304, B). This turned out to be what it 
 appeared at the time — a piece of coarse but perfect skin with sweat and .sebaceous glands 
 and hair follicles. A few hairs were on the 
 surface, but the bulk of them liad been re- 
 moved (Fig. 8(55). 
 
 After the operation all the liladder symp- 
 toms were relieved for a few days; they then 
 increased, but were again relieved when the 
 pedicle with its ligature came away on the 
 tenth day (Fig. 8()4, C). After this every- 
 thing went on well for a few days till the cat- 
 amenia ai)peared, when bladder troubles re- 
 turned and rapidly increased ; indeed, they 
 soon became as bad as ever. 
 
 On November 17 another exploration was 
 made of the bladder, when it was found that 
 the pedicle of the growth which had been left 
 had much increased, and had apparently jiro- 
 truded as far again as ever from the annular 
 ring in the bladder which was noticed at the 
 first operation. 
 
 The polypus was consecjuently again seized 
 and drawn down, and as Sir H. Thomp.son was 
 about to apply a ligature to its pedicle the 
 whole thing came away with the forceps in 
 my hands. The growth removed was as large 
 as that which existed at the first operation, 
 and it came away, pedicle and all (Fig. 304, D). 
 
 After the operation the annular ring no- 
 ticed was very distinct, and into this the finger was pas.sed with ease. I need, however, 
 hardly add that neither I nor Sir H. Thompson was too curious as to where it led. 
 
 With this operation all trouble ceased. The bladder in two days was well able to 
 retain its contents. In three days all blood and mucus disappeared from the urine. In 
 a week the urine was normal. At the end of two weeks from the operation, with the 
 exception of a little soreness, no bladder symptoms existed, and WMtliin one month the 
 patient was as well as she had ever been in her life. She is now as if she liad never had 
 a bladder trouble. 
 
 Remarks, — I believe this tumor to have originated from a dermoid cyst whicli had 
 been implanted in the walls of the bladder during the patient's foetal life : that it began 
 to undergo chansjes in its interior a few days before she came into my hands for rectal 
 41 " 
 
 7 Muscular 
 
 Microscopical .Appearances of a Section of the Skia 
 covering the I>eriuoid Tumor. 
 
642 DISEASES OF THE BLADDER AND PROSTATE. 
 
 mischief; that the tumor, then acutely inflamed, gave rise to the severe constitutional 
 symptoms mentioned and opened into the vesical cavity ; that at its opening it discharged, 
 firstly, the mass of fine long and short hairs covered with a very thin layer oi' ])hosphatic 
 deposit, and, secondly, the innumerable larger masses, or rather calculi, which were sub- 
 sequently passed or removed; that for a time, the cyst having partially discharged it- 
 self, the bladder trouble subsided, and when it reappeared it was from the formation of 
 almost a calculus upon the remaining hairs which the dermoid cyst then contained ; that 
 this cyst then began to turn inside out, and from the ex]>ulsive action of the bladder to 
 become polypoid; that at the first operation, when the bulk of the projecting growth was 
 removed, this process was not completed, such having taken place only at the second. 
 
 In support of these views Dr. Goodhart's following report of the preparation will be 
 read with interest : 
 
 " The specimens submitted to me were a rounded, knob-like piece with a truncated 
 end, which had been removed at the first operation, and an elongated, somewhat irregular- 
 shaped mass, presumably the stalk from which the first piece had been removed. Both 
 had long dark hairs growing from them in considerable numbers, and these were mostly 
 thickly covered with a shell of yellowish phosphatic matter. 
 
 "A section of the knob showed it to consist, apparently, of a layer of thickish skin, 
 with a quantity of tough fibrous tissue beneath it (Fig. HG5). The opinion furnished by 
 the naked eye was quite borne out by microscopical examination. No lengthy descrip- 
 tion need be given of it, as a very truthful drawing of a part of the section has been 
 made by Miss Boole, which will show at once that the growth is composed of perfect 
 skin. At <t I) c is the epidermal layer, with its horny layer at a, the intermediate layer 
 at b, and the mucous layer at c : below this comes a thick layer of fibrous tissue, </, which 
 has been reduced in the drawing to allow of the introduction of the deeper part. At e is 
 a sebaceous gland ; at / a section of a hair cut obliquely and surrounded by its cuticular 
 sheath ; while at ff are seen sections of sweat glands. 
 
 "The only question that arises from the appearances is as to the existence or not of 
 striped muscular fibres. 
 
 " In many parts of the section are broad bands (a piece of one is shown at /() which 
 look very much like muscular fibre, but the striati(Ui is nowhere distinct enough to pro- 
 nounce with any certainty. I am inclined to regard them as an embryonic form of mus- 
 cle midway between the striped and unstriped varieties. But, however this may be, the 
 nature of the growth is clearly similar to what upon the surface of the body would be 
 called molluscum fibrosum — that is to say, a polypoid overgrowth of the corium and sub- 
 cutaneous tissue, covered by the epidermal layers. 
 
 " In the urinary bladder, naturally, the first — and, indeed, the one — question is how 
 such an excrescence could get there, and I believe that only one answer to that question 
 has any degree of probability attached to it. 
 
 " It has been suggested that it is some congenital growth, like a hairy mole upon the 
 skin ; but taking into account the history, which conclusively establishes that the patient 
 was perfectly free from any vesical trouble of any kind until recent date, and knowing 
 that hair in the bladder always provokes a deposition of phosphates and causes extreme 
 worry and cystitis, it is inconceivable that this growth has been in the bladder any length 
 of time. It must, therefore, have come from the outside. The history, again, points 
 strongly toward this conclusion, for the first symptoms were those of high fever and sub- 
 sequent cystitis. I take it, therefore, as probable that at that time some inflammation 
 occurred around this growth, situated outside the bladder, that ulceration occurred in the 
 bladder and the polypus escaped into the cavity, and that when once there it immediately 
 provoked, as such a growth might be expected to do, the intense cystitis that then 
 happened. 
 
 " When we further have to decide whence the growth sprang, the facts of the case 
 are, I think, quite unmistakable ; for before the growth had been detected a mass of hair 
 had been discharged from the bladder, with a quantity of phosphatic matter (? fatty 
 matter). This surely indicates that a dermoid cyst had opened into the bladder, and the 
 growth in question was no doubt a .sprout from its wall. Whether the dermoid cyst 
 sprang from the ovary, as is naturally moxt probable, or came, as is not unknown, from 
 some other part of the pelvis, there is no evidence in the preparation to determine." — 
 James F. Ooodhart. 
 
 Atony of the bladder is a want of muscular power in the bladder to expel its 
 contents, as a result of overdistension from either compulsory retention or organic obstruc- 
 tion, or from some cerebral disturbance or from fever, etc. It has been often falsely 
 
yj:sj( '().L\Ti:sTi.\. i /. i isri 'la . vA.i 
 
 di'Hcribod as paralysis uf tin- Itladdcr ; Imt wlicrcas, in jtaralysis, tho |f)ss of j)r)WiT is due 
 to a want nt' iicrv*- supjily, in atuny it is the ri-sult of want of ninscular p(»W('r due to 
 exhaustion or overstretehinj:. It may he assoeiated with retention (jr witli ineontinetice, 
 the latt«'r eondition showin-; itself when tlie hladiler is overeharired. the drihhlinj: of 
 urine heini; a mere overflow. 
 
 TuKATMK.NT. — As the eaiise of atony of the bladder i> muscular exhaustion, so the 
 treatment «-onsists in jriving the or<;an muscular repose, which can be done by catheter- 
 ism. Where the atony is not very complete, the dra\vin<^ off of the urine twice a day 
 may suffice t<i allow the or^^an to recover its tone and to act naturally ; but when the 
 atony is extreme, it may be necessary to introduce a catheter into the bladder and to 
 fasten it there, the urine beiuLC allowed to run away as .secreted throuj!;h a tube fixed on 
 the eiul of the catheter. By this means the most complete rest can be. given t(» the 
 organ. Where the bladder is sluggish in resuming its functions, tonics such as ir(»n may 
 be given, with the local injection into the bladder of .some stimulant, as cold water, 
 diluted nitric acid, or tincture of iron in the proporti<»n of four to ten drops to the ounce; 
 but catheterism ahuie, as a rule, is enough, these cases generally reccjvering unless the 
 cause has been acting for too long a period. W^hen recovery is slow, an electric shock 
 through llif |iclvis is uftcii beneficial. 
 
 Paralysis of the bladder is a far more serious affection than atony, since the 
 want of power is due to deficiency in nerve supply ; which deficiency may be partial or 
 complete. It is met with whenever the spinal cord is injured or diseased, as in brain 
 shocks or disease, in reflected irritation from disea.se about the rectum, uterus, etc., and 
 after any operation upon these parts. It may be caused also by a severe mental shock or 
 the general depression from a fever. 
 
 Tre.\t.me.\t. — The cause of the paralysis in these cases must always have an import- 
 ant influence on the practice of the surgeon, but the necessity of keeping the bladder 
 empty is essential under all circumstances ; for this purpose a soft, full-sized elastic cath- 
 eter had better be passed two or three times a day, the greatest gentleness being observed 
 in the manipulation. When anything like cystitis is present, it should be locally treated 
 by washing out the bladder, etc., as already indicated. To leave a catheter in the blad- 
 der is not desirable. When professional aid is not always at hand, a nurse may at times 
 be entrusted with a full-sized vulcanized india-rubber catheter without a stylet and 
 allowed to pass it ; it has simply to be pushed down the penis, and can do no harm. In 
 fever cases the plan is a good one. 
 
 Hysterical retention is not rarely met with in women, and is difficult to treat. 
 Catheterism is to be resorted to only when necessity compels, hysterical patients usually 
 micturating when the pain of retention calls loudly for relief. The cold douche over the 
 lower part of the abdomen is a good local remedy for the affection, and not too plea.sant 
 for the patient to wish for its repetition. Moral treatment is always called for in these 
 cases, and is more needful than surgical interference. 
 
 Vesico-Intestinal. Fistula. 
 
 This is sometimes met with, and it is probable, in the majority of cases, that the 
 ulcerating process commences in the bowel and involves the bladder in a secondary 
 way. 
 
 Symptoms. — It usually first manifests its presence by the passage of wind with the 
 water, some little irritability of bladder having previously existed ; feces, liquid or solid, 
 soon follow, giving rise to fetid urine and severe bladder symptoms, the pain of foreign 
 material in the bladder being very marked when the large intestine or rectum is involved; 
 the liquid motion of the small intestine does not appear to give ri.se to the same local dis- 
 tress as the solid. 
 
 DlAGNOSLS. — There is no difiiculty in recognizing this mixture of urine and intestinal 
 contents. When flatus pas.ses per uref/iram, the ct)ndition may be suspected ; when the 
 urine has a fecal odor and color, the condition gives rise to something more than a sus- 
 picion; and when solid feces are visible, the diagnosis is certain. In doubtful cases the 
 microscoj)ical examination of the sediment of the urine will readily reveal its nature. At 
 times the feces may obstruct the ui'ethra and cause retention. 
 
 In looking into the history of these cases there will usually be found some bowel 
 symptoms, some diarrhoea or dysenteric affection, some symptoms of stricture or cancer 
 of the bowel ; and, although this afi'ection may be found associated with cancerous disease, 
 it seems more frequently to be the result of the simple perforating ulcer of the bowel. 
 
644 DISEASES OF THE BLADDER AND PROSTATE. 
 
 Treatment. — When a fecal fistula has once formed betw(;en the bowel and bladder, 
 the hopes of an unaided natural cure are very feeble ; when solid motions are mixed with 
 the urine, but little can be done except by an operation to palliate the suffering that is 
 produced. For a time the bladder may be emptied of its contents and by being washed 
 out freed of its local irritant, but the truce can be only for a limited period, another 
 action of the bowel being to a certainty followed by a fresh entry of feculent material 
 into the bladder, with all its evil effects. 
 
 When liquid motions or small intestine contents communicate with the bladder, the 
 symptoms are not nearly so distressing, and the necessity for interference is thereby 
 diminished. 
 
 The only means the surgeon has at his disposal by which relief can be afforded is 
 colotomy ; and when the rectum is the seat of the disease, whether cancerous or other- 
 wise, lumbar colotomy ought to be performed. By it the feces are diverted from their 
 unnatural channel and discharged through the loin, and all the miseries of bladder com- 
 plication are effectually relieved. When the ulceration is of a simple kind, there is some 
 prospect of its closing ; when of a cancerous nature, such a result cannot be expected ; 
 but under both circumstances a large amount of relief is immediately afforded and life 
 prolonged. 
 
 I have had four cases of vesico-intestinal fistula, in which this operation, lumbar colo- 
 tomy, has been performed with marked success ; one lived six years after the operation, 
 and died, aet. 70, from ruptured heart ; the second is still alive and well, eleven years 
 after the operation ; the third died four months after the operation, from kidney dis- 
 ease. Mr. Holmes, Mr. C. Heath, and Mr. Pennell of Rio have had similar cases. (For 
 further information vide Holmes's paper, Med.-Clrir. Trans., 18GG-67, and case, with 
 remarks, by author, Brif. and Foreign Qnarterly, January, 1869; and Clin. Soc. Trans., 
 1872.) 
 
 Incontinence of Urine 
 
 is met with under two very different conditions — in the one during sleep, when the will 
 of the patient is in abeyance, the neck of the bladder ceasing to act, from want of power, 
 and giving rise to nocturnal incontinence ; in the other the incontinence is only a result of 
 overdistension and is a mere overflow. The first form is common in children, the second 
 in adults. Incontinence, however, in both the child and the adult, may be due to bladder 
 irritation from the presence of a stone or other foreign body, and it will then exist during 
 the day rather than at night. It may also follow the operation of lithotomy from injury 
 to the sphincter of the neck of the bladder. 
 
 Incontinence in the child is a very troublesome, and often a very obstinate, 
 affection. It is, notwithstanding, generally curable, and even in very bad cases, as 
 puberty approaches, the symptom disappears, though in exceptional instances the infirm- 
 ity continues in after-life. The child is generally brought to the surgeon because he 
 " wets his bed," when too often the history reveals the painful fact that punishment has 
 been severely tried before professional advice was sought ; and it is needless to add that 
 by such a process no cure can be effected. In many instances the habit is in a measure 
 induced by a want of attention in the parents to take up the child during the long hours 
 of the night. 
 
 Tre.\t>ient. — When the prepuce is very long or adherent, circumcision should be 
 performed. 
 
 When the urine is chemically wrong in any of its constituents, remedies must be 
 given to correct the faults, and a limpid watery urine in a child, as in an adult, is always 
 an irritant. 
 
 With respect to medicines, the tincture of iron is doubtless the best, and next to it 
 belladonna in the form of either the tincture or the extract, but in some instances the 
 combination of the two is excellent. 
 
 I have tried and been disappointed with full doses of chloral given at bedtime. It 
 acts at times wonderfully well, but at others appears useless. When employed, it should 
 be given on an empty stomach. Tonics are the right medicines, one form often succeed- 
 ing where another fails, iron, quinine, nux vomica, and zinc being, as a rule, better than 
 belladonna. The tonics by day and a night-dose of belladonna have sometimes proved 
 of value. 
 
 The bowels should always be attended to and the presence of worms considered, and 
 it is well to have the bowels relieved at night before going to bed. When the child is 
 not too young, cold baths, with or without salt, should be used ; and every means should 
 
ryrLAMMATiox of riii: i'i:nsT.\Ti-:. 045 
 
 lu" I'liiplovftl to iiiaiiitaiii the <r«'iu'ral licaltli. altlnMij:li it must lie aiMcfl that cliiMrcii who 
 hibor under thi.s intirniity are rarely teilth- and caehcciic The chihl .should he eiieoura^ed 
 to sleep on his side in |»ret'erenee to his haek, and lor tliis end a handkerehief with a knot 
 in it may be fastened round the pelvis, the knot hein^' adjusted over the sacrum. 
 
 |)r. W. Steaven.son reeords (Ji/it. Mnl. Jnuni.. January (i, 1HH3) cases of lr('i|U('iit 
 micturition treated hy eU'etrieity with the most henefieial results. In these, one elec- 
 trode, in the form of a spinal disc, was connected with the positive pole of the battery 
 and ap])lied to the lumbar rei.non. and the other electrode was applied ab(»ve the pubes 
 or to the peri:!;tMim ; throuu:h lhe.se a weak current was passed for a few minutes daily. 
 Ivclicf of the symptoms from the C(»inmencement of tlu' trcatmi-iit and l>y coinpjctc cure, 
 usually within a furtniiilit. have been the results. 
 
 In cases of extreme obstinacy some surL^Mms ajijdy a solution of nitrate of silv«'r ten 
 <;rains to the ounce t<» the neck of the bladder, and, it is said, with advanta<:e. (Jthers 
 apply mechanical means to prevent the flow of urine, such as an india-ruliber rin<:r around 
 the penis, or cover up the urethral or preputial orifice by a layer of collodion, (iood 
 reports have been <riven of these practices. I cannot say that I think well of any such 
 means and have never adopted them, as they seem wrong in principle. 
 
 Xvcturuid incontinence in a child generally means atony of the sphincter, while incon- 
 tinence duriuLT the </"// suirirosts bladder irritation, generally a stone or urethral obstruction. 
 
 Incontinence in the adult, as already stated, means, as a rule, overfulness of 
 the bladder, the real condition being one of retention from some obstructive urethral or 
 prostatic disease, bladder atony, or paralysis. It may, however, be due to stone or to a 
 preceding lithotomy. In women it may be associated with some uterine displacement or 
 disturbance, some urethral disease or injury. In men and women severe spine disease 
 may cause it. 
 
 Treatment. — To treat it the cause mu-st be ascertained, and the introduction of a 
 catheter is probably a sound practice to follow as the first means of investigation, since it 
 settles at once the question of retention and often detects tlie true cause, thereby giving 
 a clue to the treatment to be adopted — viz., the removal of the cause. 
 
 True incontinence, however, is met with in severe cases of general or local paralysis, 
 in functional derangement of the cord from venereal exces.ses. and still more frequently 
 from self-abuse, such patients often complaining of '• inability to stop the flow of urine 
 when commenced.' It is. however, seen in old people with prostatic enlargement, the 
 tbii'd lobe being enlarged and pi'ojecting forward between the lateral lobes, so as to open 
 out the neck of the bladder and render it constantly patent, the incontinence being due 
 to overflow the result of retention. 
 
 In these ca.ses the use of a urinal is the only remedial means at the surgeons com- 
 mand, except in those caused by venereal excesses, when tonics, cold bathing, and abso- 
 lute abstinence from all injurious habits may effect a cure. 
 
 DISEASES OF THE PROSTATE. 
 
 The diseases of the prostate gland are of importance. Placed, as the gland is, at the 
 neck of the bladder and at the commencement of the urethra, on the one hand it may 
 suffer as a consequence of urethral disease, and on the other, when di.sea.«ed. it may give 
 rise to bladder symptoms of considerable severity. Thus, as a conseijuence of urethral 
 di.sease. gonorrh(jea, or stricture, it may inflame or suppurate and, mechanically interfering 
 with the flow of urine, cause retention. It may, indeed, undergo nearly complete destruc- 
 tion from supj)uratioii. the direct conse(|uence of stricture, and possibly of extravasation. 
 When enlarged from hypertrophy, stone, cancer, or any other cause, it may mechanically 
 interfere with the flow of urine, and so give rise to bladder symptoms or bladder disease 
 of no slight severity, and later on cause incontinence from overflow by the special direc- 
 tion of the growth. 
 
 Inflammation of the Prostate. 
 
 This is usually due to the extension backward of a gonorrhoeal inflammation or to the 
 presence of a stricture. It may arise, too. as a complication of cy.stitis from the irritation 
 of a calculus, the passage of a sound, or the application of caustics. It is also not 
 unknown as an idiopathic affection in gouty subjects and in those who indulge in sexual 
 excesses. 
 
 Symptoms. — It is generally ushered in with pain in the perinieum and bladder irrita- 
 
646 DISEASES OF THE BLADDER AXD PROSTATE. 
 
 tion, the act of micturition being attended and followed by pain, and often tenesmus. 
 Defecation eea.ses to be a painle-ss act, and is attended with uneasiness, sometimes 
 with difficulty, and at last with distress. On manipulating the perinaeum a deep-seated 
 fulness will be felt, and on passing the finger into the rectum the prostate will be found 
 enlarged, spongy, and painful : rigors probably will form one of the general symptoms, 
 with febrile disturbance, which will vary in severity according to the acuteness of the 
 aifection. 
 
 If the inflammation advances to abscess, a throbbing pain at the neelc of the bladder 
 will be felt, with a constant desire to go to stool, and retention of urine is almost .sure to 
 occur. 
 
 If left alone, the abscess will probably burst into the urethra and discharge itself 
 externally, with immediate and marked relief; while in other cases it may open into the 
 rectum. It sometimes happens that the abscess is ruptured during the passage of a 
 catheter to relieve retention or during a rectal examination. 
 
 When the disease is acute, the local as well as the general .symptoms will be severe ; 
 but when chronic, they will be less marked, though not less characteristic. 
 
 As a result of acute inflammation chronic disease is often left, as indicated by pain in 
 passing water, irritability of bladder, a thin urethral discharge, cloudy purulent urine, 
 and perineal, pelvic, and anal pain, which is increased on exercise or excitement. There 
 mav be at times some little loss of power in emptying the bladder, pain in sexual inter- 
 course, or frequent nocturnal emissions. 
 
 Treatment. — When the symptoms are acute, few remedies give more relief than the 
 application of fifteen or twenty leeches to the perina?nm. followed by a hot hip bath and 
 the subsequent application of a linseed poultice made with the decoction of poppies or 
 mixed with the extract of opium. A good purge should also be resorted to. and alkalies 
 given, with sedatives such as morphia or opium, allay pain. 
 
 When retention of urine complicates the case, a catheter must be passed, a catheter 
 coude being the best : but the warm bath and opium should first have been employed, as 
 the introduction of a catheter under such circumstances is always painful and may do 
 harm. When required, an elastic instrument which has been well softened and oiled 
 should be selected. Rest in the horizontal posture should be observed and liquid diet 
 given. 
 
 When an abscess has formed and there is evidence of deep-seated perineal suppura- 
 tion, an incision in the median line of the perinfeum should be made ; and, indeed, if 
 suppuration has not taken place, the operation, by lessening tension, will be followed by 
 relief to the .symptoms. 
 
 When the abscess has opened naturally, no surgical interference is usually required, 
 although in exceptional cases, where one abscess is followed by another and the deep parts 
 about the gland, instead of undergoing repair, are becoming more involved, a perineal 
 incision should be made. When the suppuration is the result of a stricture and has 
 probably been caused by extravasation, the propriety of dividing the stricture and laying 
 open the perineum down to the prostate cannot be questioned. 
 
 In chronic inflammation, whether the sequel of the acute or not. when attended with 
 suppuration, the practice already advised should be followed. When no suppuration 
 exists, but only enlargement, counter-irritation by means of small perineal blisters is of 
 great use, and the elevation of the pelvis with a pillow at night is also valuable. Tonics, 
 as a rule, are required, with the iodide of potassium. The bowels should never be allowed 
 to be confined, the best laxatives being some saline medicine or one of the natural mineral 
 waters, such as Vichy or Pullna. All mechanical interference with the prostate should 
 be avoided and the nocturnal emissions treated on general principles, and not as being 
 due to a local cause, tonics, generous living, and fresh air doing more toward hastening 
 recoverv than anything else. Over-exercise must be avoided and sexual excitement for- 
 bidden. 
 
 Abscesses occasionally occur around the prostate and give rise to very 
 
 many of the same symptoms as a prostatic abscess. They are more apt. however, to 
 make their way toward the po.sterior part of the perinseum into the ischio-reetal fossa. 
 As soon as they are recognized they should' be opened by one or two deep incisions in 
 front of the anus on either side of the median line. On one occasion I let out by two 
 incisions about a pint of pus that had accumulated in this part, and produced complete 
 retention of urine for several days. Immediate relief and a good recovery followed the 
 operation. 
 
nvriinTUnriiY m- riii: i'iiostati:. 047 
 
 Hypertrophy of the Prostate. 
 
 This is a giMieral ttTiii a|>|ili«'(I to a clinuiif fiilar<r<'iii»'iit nt" tlic; ^laiid which is not 
 iiitlamiiiati»ry. hut is <;fin'iallv hdifvctl to ht- a coniiiinii <oiisci|U(mic(' of" ohl a;r«; ; itidceil, 
 it has hi'i'ii reiranh'd as a part ol'a ^rciuTal sciiih- chaiiiro. l'athohi;_'iral iii\ i'sti;.'utio!is, how- 
 ever, havt' tauirht us tliat, altliouj^'h tliis is an atlV-ctioii of advanced lite, it is iti no way a 
 neeessary atteiichmt on ohl a^re, the vast majority of old men havin;^ nothing' of the kind. 
 
 When present, it is usually met witli in suhjeets over si.xly. I'lionipson has not met 
 witli an e.xamph^ under the aj^e (tf fifty-four, and after many dis.sections of the pro.states 
 of elderly men he found an appreciahle eidargement of the organ in one-tliird of the cuhch, 
 but only in one-third of tliese wa.s it enough to cause .symptom.s during life. 
 
 l'.VTii(»L(»(iY. — The di.sea.se i.s generally believed to be a hypertropliy or overgrowth 
 of natural tissues, and in a certain ])roportion of instances this is doubtless the case; but 
 in others the enlargi'nient is clearly caused by the development of 
 distinct glandular tumors embedded within the structure of tlie 
 gland, which may be si|ueezed out of the organ u]>on division of 
 the tissues covering them in. They are sometimes merely covered 
 by the capsule of the prostate, while at others they are well ])laced 
 within its structure ; at times they are single, at others multiple, 
 and rarely give rise to any otiier than mechanical symptoms. 
 When tliese growth.s are situated in what is called the third lobe 
 of the prostate, they give rise to .symptoms of obstruction and 
 bladder irritation ])reci.sely similar to those caused by the genuine 
 enlargement or hypertrophy of the gland itself. The.se fibrous (jr 
 glandular tumors are analogous to those found in the uterus. This 
 hypertrophy is now known to be, as shown by Ellis and others, a I 
 mere increase in the natural fibrous, muscular, and glandular struc- " 
 ture of the organ. The enlargement is mostly general, and as long 
 as the vesical or third lobe is not materially enlarged or the urethra 
 encroached upon it is extraordinary to what a size the prostate may 
 attain without giving rise to any special symptoms. It is. indeed, '^tbf ofX^olme'wIJh 
 only when the so-called third lobe increases bladder-ways and inter- Dilatation and Hypertro- 
 feres mechanically by its size or the direction of its growtb with ^ ^ ** 
 the act of micturition that any marked symptoms are produced. In the preparation from 
 which Fig. 36G was taken this condition is w'ell shown. 
 
 The effect of an enlargement of the prostate upon the urethra is very variable. At 
 one time the prostatic urethra will be elongated to twice or more its normal length, while 
 at another it will be tortuous, this condition being caused by an unequal enlargement 
 of the lateral lobes. In a third class the urethra will be more or less obstructed. In 
 the bladder other changes are found, and the sudden projection upward of the ve.sical 
 or third lobe is the most common ; yet when with this there is an enlargement of one or 
 other of the lateral lobes, a greaft irregularity of the urethra is the result. 
 
 This enlargement of the prostate may so derange the course of the muscular fibres 
 about the trigone of the bladder as to produce a bar or ridge that mechanically interferes 
 with micturition, (luthrie and Mercier have described such a bar as occurring independ- 
 ently of these changes, the bar consisting of the elastic structure and mucous meiubrane 
 of the neck of the bladder. Thomp.son also asserts that in '' very exceptional instances 
 the bar is undoubtedly to be met with." I have never known such a bar as that last 
 described, and give it onlj- on the authority of the names quoted. It is .said to occur 
 earlier in life than prostatic enlargements and to give rise to similar symptoms. Hyper- 
 trophied prostates are sometimes met with measuring four inches in diameter, and are 
 common at half that size. They have been found to weigh ten or twelve ounces, the 
 normal weight of the pro.state being four and a half drachms. 
 
 Symptoms. — So long as the vesical orifice of the urethra is not mechanically 
 encroached upon prostatic enlargement may proceed to an extreme degree without 
 giving rise to any definite symptoms, and retention of urine is very often the first 
 feature that attracts notice. But under these circumstances it generally will be found 
 that the patient has had for some time a difiiculty in micturition, that the bladder has 
 hesitated to contract when the desire to pass urine manifested itself, and that either there 
 has been less force in the expulsion of the fluid than formerly or the water has •flowed in 
 a more languid stream. 
 
 Irritability of the bladder will generally be present, the act of passing urine being 
 
648 DISEASES OF THE BLADDER AXD PROSTATE. 
 
 raj>idly followed by the desire to do so again, and the difficulty of the act gradually 
 increasing. 
 
 As the disease progresses a feeling of weight and fulness in the perinaeum and of 
 irritation about the rectum will soon appear, the rectal irritation and the irritability of 
 bladder increasing equally, till at last the two acts of defecation and micturition take 
 place together, the violent straining and tenesmus giving rise to prolapse of the rectum 
 or piles and leading the patient to believe that the bowel complication is the cause of his 
 disease, if not the disease itself. 
 
 At a still later period, and as the result of the bladder being unable to empty itself, a 
 residuum of urine remains behind, and the bladder consequently gradually expands from 
 its accumulation and becomes exhausted by its ineffectvial expulsive efforts. The urine, 
 moreover, at the same time decomposes and acts as a direct irritant to the mucous mem- 
 brane of the bladder. In this way inflammation of the bladder, and subsequently incon- 
 tinence from the overflow of a distended organ, is produced, this inconvenience existing 
 day and night. 
 
 The ultimate result of this aff"ection left to nature is the same as that of all obstructive 
 urethral diseases : from the pressure of retention the bladder sufters first, and subsequently 
 the ureters and kidneys ; oi'ganic renal disease is thus set up and the powers of life are 
 gradually sapped by exhaustion, death being often hastened by severe bladder symptoms, 
 haematuria, or ura?mic poisoning. 
 
 A physical examination of a patient laboring under this disease will probably reveal » 
 bladder more or less distended, and the passage of a catheter, even after the patient has, 
 to the best of his belief, emptied his bladder, will prove the presence of several ounces of 
 urine which may be ammoniacal, this change in the urine being produced by its partial 
 decomposition from its retention and admixture with the mucus of the bladder. In neg- 
 lected cases the urine will be fetid and may contain blood. The passage of the catheter 
 will also reveal the nature of the obstruction at the neck of the bladder. 
 
 On passing a finger into the rectum the enlarged prcstate will be felt, and in some 
 cases may nearly fill the pelvis. "When pus or fluid exists, fluctuation will be detected 
 and when inflammation, pain. To make this examination nicely the finger should be well 
 anointed, and at the moment of its introduction the patient should be told to bear down. 
 It should be remembered, however, that to appreciate any abnormal condition of the gland 
 it is necessary to be familiar with its normal state. 
 
 As a consequence of this afi'ection and of the change produced in the urine, a pho.s- 
 phatic calculus may form ; but its presence is often masked by the symptoms of the dis- 
 ease. When, however, there is increased pain after micturition, pus and blood in the 
 urine, and extreme pain in the penis, a calculus may be suspected ; and when fragments 
 of phosphatic deposit pass, the suspicion is confirmed. In all long-standing cases of pros- 
 tatic disease with bladder symptoms the presence of a stone should be suspected, although 
 when present it is often difficult of detection, from being protected by the enlarged i)ros- 
 tate, behind which it usually lies. 
 
 A patient with enlarged prostate is liable to retention from any sudden chill, overdis- 
 tension of the bladder, mental emotion, or fatigue; indeed, such accidents usually reveal 
 the presence of the afi'ection. 
 
 Treatment. — Medicine has no influence in checking the progress of this disease or 
 in causing absorption of the enlarged organ. l)ut surgery can do much in the way of pal- 
 liating the symptoms that are the direct result of the enlargement and neutralizing its 
 evil effects. 
 
 The most essential point is to secure the complete evacuation of the bladder's con- 
 tents, and also to see that no residuum of urine remains in the bladder to irritate the 
 organ and decompose, thereby setting up cystitis. This should be done by the passage 
 of a catheter. In early cases where but little bladder irritation exists the passage of the 
 instrument once a day may suffice ; but when the residual urine is in any quantity and 
 the bladder has lo.st some of its power of contraction, the introduction of an instrument 
 two or three times in the twenty-four hours may be necessary, and in woi'se cases, where 
 the bladder has lost all power of contraction on account of its overdistension from chronic 
 retention, it may be neces.sary or expedient to tie a catheter in the bladder and leave it 
 there for a time. The surgeon must remember, too. that instrumental aid. though valu- 
 able, is a necessary evil, and .should not be resorted to more frequently than the necessi- 
 ties of the case demand. 
 
 Where instruments are required, a flexible full-sized catheter is the best. When 
 silver instruments are employed, one with a large curve should be selected, the back of 
 
iiYi'Kirnioriiv <>/ riii: rnosTATi:. 649 
 
 the t-atlutfr lidiii;: iiiuiv readily ovor tliu ciilar^'cd vesical <ir third lobe of the prostate 
 than a shorter one. To assist in the introduction of any instrument into the bladder, the 
 pass-a<re id' the index tinker of the surfj^eon's left hand fully into the rectum is an excel- 
 lent aid, and under all circumstances the pelvis of the patient should be well raised on a 
 pillow. 
 
 W iicii an elastic iiist niMiciit i> used and sonic difliculty experienced in ridinj; over the 
 olistruction, success may (jften be achieved, as soon as the end of the instrument lias 
 reatdicd the vesical end of the urethra, by the withdrawal id" the stylet with one hand and 
 the pressure of the catheti'r into the bladder with the other. Force should never be 
 employed, <reiitlc manipulation and care almost always sufficing to secure success. 
 
 When the disease is chronic and the necessity of catlieterism is j»ro)iablv jiermanent, 
 the patient should be taiitrht to pass a gum elastic catheter for himself, a few lessons and 
 a little coiifiilence ])eing all required for the purpose. 
 
 AVheii the bladder, from overdistension, has lost all power and it is necessary that it 
 should have complete rest to allow it time to recover its tone, a catheter may be fastened 
 in ; and if the instrument sets up much bladder irritation, a good compromise may be 
 found in the practice of leaving it in at night and removing it during the dav. When 
 the introduction of the in.strument is attended with great difficulty, it may be expedient 
 to leave an instrument in for some days; but under these circumstances the bladder 
 should be washed out through the catheter daily. 
 
 The vulcanized india-rubber catheter is a good form to employ for this purpose, 
 although at times it cau.ses more urethral irritation than the gum elastic. A winged or 
 other self-retaining catheter may be employed when difficulties are experienced with keep- 
 ing in the simpler form. 
 
 When retention is present and catheterism impossible, the surgeon may be called upon 
 to puncture the bladder juey rectum or to aspirate it above the pubes in order to give 
 relief. When severe cystitis exists and the agony of catheterism becomes unendurable, 
 a clean perineal incision into the membranous portion of the urethra and the introduction 
 into the neck of the bladder of a soft catheter, to enable the urine to flow away as secreted, 
 is a desirable measure. 
 
 General Treatment. — With the local treatment of this aiFection the general must 
 not be neglected, although in importance it is quite .secondary. When cystitis exists, it 
 must be treated upon the principles previously laid down. The general condition of the 
 patient must be maintained by means of good diet and sufficient stimulants. The skin 
 should l»e kept warm and all sudden chills avoided ; the bowels kept open, but not loose ; 
 pain should be relieved by sedatives and sleep secured by hypnotics : tonics are often 
 called for. the preparations of iron being, as a rule, the best. 
 
 Exercise should be taken when there is no inflammation of the bladder or other reason 
 to forbid it, walking and driving being the best foi-ms ; and under these circumstances 
 the local distress from the affection may be rendered ver}' light and life prolonged for 
 many years with comfort. 
 
 Patients wuth this affection should once a day. as a matter of habit, pass urine on 
 their hands and knees, the bladder in this way having more power to evacuate its con- 
 tents ; and the mucus and other more solid contents, which otherwise would lie behind 
 the prostate, are got rid of with greater certainty. 
 
 Atrophy of the prostate is often found in the aged and in the young, and in 
 rare cases it is due to suiue arrest in its development. In the majority it is genuine 
 atrophy or fibroid degeneration, probably caused in some by syphilis. Such a condition, 
 however, does not give rise to any symptoms by which it can be recognized during life, 
 nor is it a cause of any distress. 
 
 Calcuh of the prostate are not rare, and may be found embedded in the organ 
 as small .stones varying in size from a grain of sand to bodies of much larger dimensions. 
 They are often very numerous, are sometimes amorphous, but are generally laminated. 
 Wollaston says they are composed of eighty-four per cent, of phosphate of lime, one-half 
 per cent, of carbonate of lime, and fifteen per cent, of animal matter. 
 
 •• The prostrate gland, like other glands, is liable to an inspissation of its secretion, 
 producing small yellow, sometimes red, pale or colorless bodies scattered throughout the 
 follicular structure. These at first are said to con.sist entirely of organic matter, which 
 Virchow believes to be derived from a peculiar insoluble protein substance mixed with 
 the semen, but sooner or later these formations ai"e believed to irritate the mucous mem- 
 brane, causing phosphatic depositions which beconu' encrusted upon the organic matter, 
 and thus the genuine prostatic calculi are formed '" {Pu/and). 
 
650 
 
 DISEASES OF THE BLADDER AND PROSTATE. 
 
 Fig. 367 
 
 Prostate 
 Prostate- Vesical Calculus. 
 
 Symptoms. — AVhen embedded in the organ and not interfering in any way with the 
 urethra, they cause no symptoms ; when encroaching upon the urinary passage, they may 
 cause obstruction, but certainly must give rise to urethral, and probablj' to bladder, 
 irritation. They are accompanied occasionally by ulceration and suppuration of the 
 surrounding parts. 
 
 A prostatic calculus may project into the urethra and increase the urethral portion, 
 subsequently extending backward into the bladder and forming a prostato-vesieal cal- 
 culus. In Guy s Hospital Refjorts^Y 1857 
 a case reported by Poland, with references 
 to others, will be found (Fig. 3G7). The 
 calculus has a dumb-bell shape. In all 
 these cases the urethra is usually per- 
 vious, the passage of a sound, however, 
 as a rule, detecting its presence, a grating 
 sensation being experienced in the passage 
 of the metal instrument over the stone, 
 but no ring will be heard. A large pros- 
 tatic calculus may also be felt per rectum. 
 Treatment. — When a prostatic calcu- 
 lus gives rise to sufficient symptoms to 
 indicate its presence and by its size is 
 likely to prove troublesome, it should be 
 removed by a perineal section, by such an 
 operation as median lithotomy, the incision 
 stopping short of the bladder when the stone does not involve it. In this way Dr. 
 Barker (vide Druit's Vocle Mecinn) removed a large stone nearly five inches in diameter 
 with success. When the stone or stones give rise to few symptoms of importance, they 
 should be left alone ; occasionally they pass nsitni-My per vrefh ram. The greatest argu- 
 ment against operation, unless absolutely essential, is found in the fact that these calculi 
 are mostly multiple and often exist in both lobes of the prostate. 
 
 Cancer of the prostate occurs but seldom, and is generally of the soft kind ; 
 indeed, as Dr. Walshe .stated in 1846. '• the evidence of the occurrence of true scirrhus 
 of the prostate is defective. ' 
 
 Symptoms.' — The symptoms are those of enlargement, and increase rapidly in severity, 
 the disease being attended with more frequent and profuse hemorrhage than the ordinary 
 hypertrophy. The blood follows the straining which attends the act of micturition, and 
 appears as pure blood : after catheterism it is often profuse. The disease may be pri- 
 mary, but is commonly secondary. It cannot exist for any time without giving rise to 
 glandular enlargements in the groin or along the iliac vessels, when, as a rule, the 
 patients powers rapidly yield. 
 
 Treatment. — The treatment is only palliative, the surgeon dealing with symptoms. 
 All instrumental interference should be of the gentlest kind and as little as possible. 
 Pain must be relieved by opium and the general powers maintained by good nourishment' 
 and stimulants. 
 
 Tubercle of the prostate probably, as a rule, only occurs as a part of a general 
 tuberculo.sis. and until the deposit is breaking up or by its presence is producing some 
 suppurative action it gives rise to no symptoms by which it can be recognized. It is too 
 often associated with renal or bladder disease, and the local pro.static mischief is lost in 
 the more general afiection. It is quite possible that some of the cases of so-called idio- 
 pathic abscess of the prostate are the result of the breaking down of this deposit, but 
 there are no clinical data to enable the surgeon to diagnose the presence of this disease, 
 and there are, consequently, none other than general rules of treatment to be mentioned. 
 
S'KJMC IS Tin: l',l.MHH:ii^ A. SI) ITS Tni:.\TMi:sT. 
 
 051 
 
 CII A V'VV: II XXII 
 
 STONK IN TlIK iJLADhKi;. AM» ITS TKKAT.M K.NT. 
 
 HkK(»i<k p:issiii<; til tlu; suhjoet of stoiu; in the hlatlder it aiipL'ur.s desirable to con.sider, 
 llioutrli hrii'Hy, tliat of urinary deposits, or<;anie and inorganic, as the value of a sound 
 kiiowled<;i' of what the urine may contain, either in snsj/fiisu/n, in Hfthit inn. or \u pr' fipi'fn- 
 fiuii, is to the surgeon as indispensable for successful practice as to the physician. 
 
 The student should reinenil)er that healthy urine is a clear acid, amber-color Huid 
 with a specific gravity of HtliO to lO.'^O; that in one thousand jiarts !)54.Hl consist of 
 water, 45.11) of .solid matters. These solid matters are made up as follows: I'rca. 21.57 ; 
 uric acid, 0.3(1 ; extractives, such as creatine, creatinine, .xanthine, hippuric acid, ammo- 
 nia, sarcine, pigment, unoxidizcd stuphur. jthosphorus. mucus, etc., (i.53 ; chlorine. 4.57; 
 sulphuric acid, l.))!; |diosphoric acid, 2.((!( ; ))Otash, 1.4(1; soda, 7.1!>: lime, 0.11 ; mag- 
 nesia, 0.12. lie should further remember that after drinking or after a meal the urine i.s 
 altered by the nature of the diet and probably diluted, and that the best sample of urine 
 to examine is that passed in the morning before breakfast — the " urina sanguinis " of 
 Prout ; when this urine contains any ingredient in excess or in deposit, some important 
 derangement of the system exists. When any of the constituents of the urine are in 
 excess, the balance which normally exists between them and that keeps them in solution 
 is disturbed, and, as a consequence, some depo.sit takes place. When this excess consist.s 
 of the safiiif matters of the urine, such as those of potash or soda, urinary deposits and 
 stone are less liable to form, on account of their solubility, than when the excess is found 
 in the alkaline earths; for the salts of lime and magnesia are most insoluble, and conse- 
 quently, when in excess, .soon show themselves as gravel or calculi. For the same reason, 
 uric acid, being very sparingly soluble, is a very common urinary deposit and is a con- 
 stituent of most stones. When blood or pus is found in the urine, the surgeon has to 
 discover its source. Is the origin of the blood urethral, prostatic, vesical, or renal ? Has 
 the pus been secreted by the bladder or been poured into it from the kidneys or other 
 part of the urinary tract ? Is the salt the result of some excessive supply of its chemi- 
 cal constituents, some deficiency in the working power of the machinery of the body, or 
 some accidental circumstance ? Are the kidneys themselves at fault ? or is it that they 
 are called upon to excrete morbid products which have accumulated in the blood from 
 organic or functional disturbance of other portions of the body upon which the existence 
 of healthy blood depends? All these points have to be determined in dealing with any 
 case of urinary deposit, and in the special works devoted to the subject can be found all 
 that is necessary to guide the student. 
 
 What I seek to impress here is that urinary deposits are not themselves diseases or to 
 
 Fig. 3GS. 
 
 Fig. 369. 
 
 Epithelium from Urinary Passages. 
 
 .Spermatozoa and Vaginal Epithelium. 
 
 be dealt with as such. They are always to be accepted as indications of disease, func- 
 tional or organic, in some of the working organs or other parts of the machinery of the 
 body. 
 
652 
 
 STONE IN THE BLADDER, AXD ITS TREATMEXT. 
 
 Fig. 370. 
 
 Oily Cads 
 
 The reader is referred for all special information on these points to the works of Bird, 
 Beale. Owen. Rees. Pavy, Bence Jones, William Roberts, Thudichum, \'oLrel, and Has- 
 sall. 
 
 Healthy urine ought to be quite clear. It may. however, be slightly hazy, from 
 mucus or frum tlie deposition of urates in cold weather, without being abnormal. When 
 any deposit has been merely suspended in the urine, it will commence subsiding as soon 
 as the urine has passed. These deposits are mostly organic and derived from the kidneys 
 themselves or the urinary passages. They may consist of epithelium cells, columnar 
 or tessellated, from those parts, with more or less mucus. ( IVrA- Fig. i^iis.j 
 
 Blood corpuscles or clots, crystals of hfematin, or pus cells, may be found. 
 Renal Casts. — -Waxy, granular, oily, bloody, or purulent (Fig. :^70). 
 The urine, under all the.se circumstances, is albuminous, and the best tests for albu. 
 men are the following : 
 
 Nitric Acid Test. — To test for albumen, the urine should be boiled and enough 
 strong nitric acid added to give the resulting liquid an acid reaction. 
 Any precipitate remaining after this treatment must be albumen. 
 A delicate mode of employing this te.st is to place a few drops of nitric acid in a tube 
 and then pour the urine carefully upon it, so that the two liquids do not mi.x ; or the 
 
 reverse process may be adopted. If albumen is 
 present, an opalescent zone will appear at the 
 plane of contact of the fluids. If the proportion 
 is small, several minutes may elapse before its 
 appearance. A quantitative estimate of the 
 amount of albumen sufiicient for clinical pur- 
 poses may be obtained by noting the amount of 
 precipitate to the liquid employed, but a more 
 accurate estimate may be formed by the use of 
 Roberts's dilution method, described in the Lan- 
 cet, vol. i., 1876, p. .313. 
 
 Picric Acid Test. — This test, as recom- 
 mended by Dr. (1. Johnson, is used as follows : 
 Fill a test-tube six inches long with four inches 
 of urine, and upon this pour an inch of the picric 
 acid solution (six or seven grains to the ounce), 
 so as to mix only with the upjier layer of the 
 urine. 
 
 If albumen is present, a cloud or coagulum 
 of albumen will appear as far as the yellow color of the test solution extends. 
 
 If the tube be allowed to stand, the precipitated albumen will gravitate and form a 
 film or deposit at the junction of the colored and unstained portion of the urine. The 
 
 turbid portion of the liquid must then be boiled ; and 
 if the precipitate is permanent, it must be albumen. 
 
 Dr. Pavy's Ferrocyanide of Potassium 
 Test, in -which the Spirit Lamp is not re- 
 quired. — Add to the susijected urine a sniull quan- 
 tity of a solution of citric acid. If this causes a pre- 
 cipitate of urates, add a little hot water, which will 
 redissolve it ; then add some solution of ferrocyanide 
 of potassium ; and if albumen is present, it will be 
 precipitated, and nothing else, as far as is known, 
 will. 
 
 It must be added that in all methods of testing 
 any initial turbidity of urine from the presence of 
 urates must be got rid of by heat. It should also be 
 ascertained that the patient is not taking cubebs or 
 copail)a. for all the oleo-resins are thrown down by 
 acids. Prior boiling of the liquid will also obviate 
 fallacy from this cause, 
 pellets and Oliver's test papers are trustworthy. 
 
 At times the dehria of kidney structure or cancer products may be found. 
 
 Spermatoza (Fig. 309), sarcinse, or hydatids may likewise be present, 
 these materials can be made out only by the microscope. 
 
 Urinarv Casts. 
 
 Fig. 371. 
 
 Urates. 
 
 For bedside purposes Pavy' 
 
 All 
 
yrtjsj-: /.v 77/a; iu.M>i)i:n, asd its thiiatmkst. 
 
 (>r);i 
 
 ITriiii' cniitaiiiiiij^ blood is i-ithcr it<l ur sinn/.y ; tliat coiitaiiiiii;.' bile, <liirk nr olive- 
 brown, lilttcli urine is cuninionly the result of tlie |iois<inoiis al(s<ir|itii(ri oi' carliolii- aeid. 
 
 Pus, wlien |)oure(l into the urinary passafxt', Ims usually little mucus with it ; that 
 seereted hv the Madder is j:;reatly mixed with it. {'undent urine is always alhundnous. 
 
 The urates generally appear as " hriek-dust " or " red jrravel deposits. Wiien they do 
 so, as soon as the urine has eoided down there is j^enerally some diminution in the watery 
 constituents of the urine with I'ehrile dist urhanee. When they are deposited some hours 
 al'ier mieturitiou, iiurea.sed acidity id' the urine is indicated, from ehanj^e.s in tlu; pif^ment 
 or extractives, the acids heinj; ]ir(d)ahly the lactic, acetic, and hutyrie. A drop of acid 
 jiddeil to such urine will cause the settlement of the deposit (\'\]i. -jTI). Urates are dis- 
 solved hy heat and alkalies. 
 
 Uric acid apjtears in transparent urine oi' a ycdlow color and is usually <le]»osited 
 shiwiv- Tilt' crystals are variously I'ormed, and (diiefiy rhomhie, with the an<rles routided 
 off or lo/.eniic-shaped (Fij^. 372). They are soluhle in potash or soda, hut insoluhle in 
 mineral acids. 
 
 Oxalate of lime is ]»rol)a])ly secreted under the same circumstances as the uric 
 acid and has tlu; same patlioloi;ieal siiiiiitication. ])r. Parkes held this view, and believed 
 tluvt it may he a substitution I'or the excretion of tlic carbolic acid of the lunjrs. It 
 appears as octahedral crystals or dumb-bell like bodies (Fig. 373) which are in.soluble in 
 
 Fig. 872. 
 
 Fig. 373. 
 
 Uric Acid. 
 
 Oxalate of Lime. 
 
 acetic acid and alkalies, though soluble in the mineral acids, such as the nitric, without 
 effc'rvesceiice. 
 
 The phosphates appear as the amraoniaco-magnesian phosphate, the phosphate of 
 magnesia, and the phosphate of lime. 
 
 The first occurs in the form of beautiful, colorless, transparent prisms or in foliaceous 
 or stellar prisms. It is supposed to be deposited as a consequence of the decomposition 
 
 Fig. 374. 
 
 Fig. 37-3. 
 
 Phosphates. 
 
 of urea, and is first .seen upon the surface of the urine as an iridescent pellicle (Fig. 374). 
 It is soluble in acetic acid, but not by heat. 
 
654 
 
 STONE IX THE BLADDER, AND ITS TREATMENT. 
 
 The phosphates of magnesia and lime occur as white gravel, usually amorphous, at 
 times crystalline. They are mostly found in alkaline urine mixed with pus or mucus 
 (Fig. 375). They are insoluble by heat, but soluble in acetic or the mineral acids. 
 
 Fig. 376. 
 
 Fig. 
 
 Tyrosine and Leucine. 
 
 Cystine. 
 
 Tyrosine appears in the form of fine needles or stars of a greenish-yellow color 
 (Fig. o76). When treated with nitric acid, urine containing it becomes of a deep-orange 
 color, and on evaporation of deep-yellow. A solution of soda dropped upon this flake 
 produces a red tinge. 
 
 Cystine occurs in colorless hexagonal plates (Fig. 377) or light fawn-colored amor- 
 phous depo.sit. and is soluble in ammonia and hydrochloric acid, insoluble in acetic acid. 
 
 Potash dissolves all deposits except the phosphates and oxalate of lime. 
 
 Heat dissolves only the urates of the urine. 
 
 Hydrochloric acid dissolves all except uric acid. 
 
 " Perfectly healthy urine should show no appreciable deposit ; when, however, it 
 becomes concentrated from deficiency of the watery excretion, then the uric acid is 
 thrown down in the form of a urate. This may occasionally occur within the body, but 
 far more frequently after the urine has been voided ; sometimes, however, this change 
 ensues so rapidly that the urine is erroneously supposed to have been passed in that con- 
 dition. The presence of a solid body in any part of the urinary tract favors deposition 
 very much, and hence urine which would otherwise remain clear may yield a deposit to 
 any substance previously present in the same tract, and may thus add considerably to an 
 already existing calculus. The appearance of the numerous layers so frequently seen 
 around a central nucleus, in both renal and vesical calculi, is thus easily explained. 
 When, however, the urine becomes further altered in composition — if, for example, a free 
 acid is either excreted with the urine or rapidly generated in it through the setting up of 
 the lactic fermentation — the uric acid becomes liberated from its state of combination, 
 and in a form more or less altered by the presence of colloid matters is deposited on a 
 previously existing calculus, or is passed as separate rhomboidal crystals or in aggregated 
 masses, constituting gravel or sand. I should feel disposed to confine the name of ' sand' 
 or ' gravel ' exclusively to such deposits, which, I believe, .seldom form the nucleus or 
 become the starting-point of any calculus. I may add that urine possessing these cha- 
 racters is frequently voided for months and years without the occurrence of any apprecia- 
 ble inconvenience to the patient. It is true that a calculus may be augmented by con- 
 tact with such urine, but, as I have said, it seldom originates in this way. Gravel or 
 sand consists of uric acid, previously in a state of solution, which has become precipitated 
 by the occurrence of some change in the urinary excretion." " It would, however, appear 
 probable that the initial step in the formation of a calculus is the exudation of some col- 
 loid mucus or some other albuminoid substance into the urinary passages. Into this 
 colloid urates or oxalate of lime, or both, are precipitated, and, combining with it. form 
 molecular aggregations of a globular character, which constitute the foundation of the 
 subsequent growth" (Garrod, LnmJeian Lectures, 1883). 
 
 When any of the inorganic deposits just described mass together either by themselves 
 upon any nucleus of organic matter, such as blood or a foreign body, a stone is the 
 result. This stone may form in the kidney and remain there ; it may pass into the blad- 
 der and be emitted with the urine or rest there and increase, or the calculus may have 
 
sT(K\j-: ly Tin: uladdj:!:, a.mj its tili:atmi:m\ tioo 
 
 its (iri;.'!!! ill the lilatKU-r. i-itluT fitun tin- jin-cipitutioii of tin- cartliy Cdiistitticnt* of the 
 uriiu' or tVoin tlu' irritjition of :i t'on*i;.'ii ImkIv introduced from with- 
 out. A st<iiie having' a n-iial origin aii*l nvtiiiir in thi* hhuhhr 
 seems to havf the power ot" extractiii": from the uriiif its iiior^'atiic 
 eleiiu'iits and thus ra|>i<lly iiu-rt'asiii<r, oxalate of lime, urate of am- 
 monia, urie aeid, phospliate of lime, or trijde jdiosphate bein<: firt'- 
 cijiitated hy its presence and a^irrejiatiiijr or crystallrzinjr upon it- 
 surface. It acts, too, after a time, as a foreifrn bmly. sets up Idad- 
 der irritation, and, a.s a con.seijuence, the phosphatic salts arc de- 
 posited, from the decomitositioii of the urine. Dr. Owen Kees has 
 shown ill his Crnoniau Lcrturcs (185()) that where irritation of tlie 
 bladder exists, from either a calculus, forei<rii body, or other cause, 
 the inucoiis membrane .secretes an alkaline fluid that tends to cause 
 a precipitation of the earthy phosphates and the formation of a plios- 
 phatic deposit upon a calculus. 
 
 Renal calculi are ■renerally compo.sed of uric acid, urate of 'nl!^p. MuJ^"l"ep. 2077*'^>' 
 amnmniii. or oxalate of lime, and Heale states that microscopic renal 
 
 calculi of phosphate of lime are by no means uncommon. These concretions may be 
 either impacted in the uriniferous ducts, lodtred in pouches connected with the ducts, 
 and increase in the structure of the kidney, or pass into the pelvis of the kidney. They 
 may be siii<rle or multiple and the size of a hemp-seed, nut, or walnut, or they may be 
 so moulded to the divisions of the pelvis of the organ as to assume an arborescent shape 
 such as that figured (Fijr. 378). Dr. Gee has lately recorded a case in which a renal 
 calculus weighed thirty-six and a quarter ounces {Med.-Chir. Trans., 1874). There is 
 rea.son also to believe that a renal, like a vesical, calculus may form upon a nucleus of 
 blood the result of an injury. 
 
 When the stone is tixed in the structure of the kidney, its presence may be indicated 
 by but few if any local symptoms. When it moves about in the pelvis of the kidney, it 
 gives rise to symptoms known as tho-se of nephrkic colic, paroxysmal lumbar pain, with 
 nausea, vomiting, or collapse, irritabilitj- of bladder, and at times painful micturition 
 and haMuaturia. being the chief symptoms. 
 
 When the stone passes into the ureter, all these are aggravated, pain shooting down 
 the groin, thigh, and scrotum of the affected side, with retraction of the testis; and these 
 continue till the stone reaches the bladder, when a sudden relief is felt. 
 
 When calculi accumulate in the kidney and increase in size, inflammation, suppura- 
 tion, and even the entire destruction, of the kidney may ensue, although it is remarkable 
 to what an extent one kidney may be destroyed without giving rise to any symptoms. On 
 the other hand, severe symptoms may appear for a time and subside, to reappear either 
 months or years later or not at all. In exceptionaJ cases a renal calculus may be dis- 
 charged externally through the loin with suppuration : Dr. Cayley showed such a speci- 
 men at the Pathological Society. 1874. A stone may V>e impacted in the ureter and not 
 rarely at its vesical orifice, when it will give rise to renal symptoms by obstruction, etc. 
 
 After a stone has reached the bladder it may be discharged with the urine or become 
 fixed in the urethra and cause obstruction, or it may rest in the bladder and increase and 
 reijuire .surgical treatment. 
 
 It is probable that most vesical calculi have a renal origin, and that some small 
 nucleus of either uric acic or oxalate of lime forms in the kidney and passes downward 
 into the bladder, where the urine, supersaturated with these constituents, deposits them 
 upon the renal calculus and increases its size. Stones thus formed have been called 
 priiiinri/ calcnloua fornmtloua. 
 
 When a foreign body has been introduced into the bladder or a stone has descended 
 into it and sets up much bladder irritation or cy.stitis. the phosphatic salts of the urine are 
 deposited upon its surface ; and stones thus formed are, therefore, phosphatic. When 
 urine is retained in the bladder and decomposes, as a consequence of either cystitis fol- 
 lowing paralysis, diseased prostate, urethra, or a new growth, its earthy constituents are 
 thrown down and phosphatic calculi or concretions are formed, such depo.sits being known 
 as secondary calculous forttiations. How far these latter may increase so as to form stones 
 is yet an open question. 
 
 All these chemical constituents, however, require to be held together by a kind of 
 cement. " Marcet referred it to the mucous secretion of the bladder ; Fourcroy and A au- 
 quelin to albumen, and .sometimes to gelatine with an admixture of urea: Berzelius. how- 
 ever, could not determine whether it was composed of fibrin, albumen, gaseous matter, or 
 
65(3 
 
 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 mucus ; Brande considered it to consist of a mixture of gelatine with urea ; Scharling 
 holds that the smaller calculi are always enveloped by a layer of mucus, albumen, or some 
 other organic matter, the flocculi of which entangle, and ultimately determine the crys- 
 tallization, of the more insoluble ingredients of the urine ; and Dr. Hoskins, as quoted by 
 Gross, extends this view to the minutest pai'ticle of the concretion " (Coulson). 
 
 Urinary calculi, says Poland, may be arranged, like the deposits, into two distinct 
 classes. The Jirst will include calculi of uric acid and the urates, with their modifications 
 the oxalates, xantJiic and cystic oxide (Dr. U. 0. Rees regarding the oxalate of lime as 
 uric acid or urates, altered after secretion) ; the second, the phosphatic calculi. A third 
 class may be added, consisting of the rare calculi of carbonate of lime, the fibrinous, the 
 uro-stealith, and the siliceous formations, other chemical ingredients being present, such 
 as organic matters, carbonate of magnesia, silica, oxide of iron, benzoate of ammonia, 
 oxalate of ammonia, phosphate of iron, urea, etc. The oxalates are the heaviest stones, 
 the phosphates the lightest and largest ; few exceed an ounce in weight. Coulson records 
 one, however, over six pounds. Recent calculi contain moisture, and consequently are 
 heavier than old. Stones vary in, shape according to their position. Thus, renal calculi 
 are generally irregular, often arborescent ; those in the ui'cfer, elongated, approaching a 
 cylindrical form. Bladder calculi, when single, are more ovoid and flattened ; when mul- 
 tiple, faceted. The mulberry stone or oxalate is always tuberculated, mostly globular, 
 and hard ; the uric acid and urate calculi, smooth and regular ; the phosphatic, irregular, 
 of odd shapes, and soft. The dumb-bell calculus is usually prostato-vesical or encysted. 
 The color of the layers of a calculus is due to the fact that the uric acid or urates in 
 their deposition take with them the coloring matter of the solution from which they are 
 deposited. All calculi, when associated with bladder irritation and ammoniacal urine, 
 become covered with a white coating of phosphatic deposit. A stone of uric acid is 
 usually fawn- or brown-colored ; of urate of ammonia, cinder-gray ; of oxalate of lime, 
 brown or blackish-green ; of xanthic or uric oxide, cinnamon-brown ; of cystic oxide, a 
 gray-greenish hue. 
 
 Phosphatic calculi, as are other forms when covered with a like deposit, are often 
 horribly fetid and ammoniacal. They are too commonly soft and friable. 
 
 The section of a calculus reveals its structure, and, while some are homogeneous, the 
 majority display concentric layers of diff"erent degrees of thickness, exceptional examples 
 displaying fine lines I'adiating from their centre, of a crystalline form, which may be seen 
 the cystine calculus (Fig. 'S82). 
 
 The dift'erent layers of a calculus may have the same composition or differ widely. 
 When the latter, the calculus is known as alternating ; but any single layer is generally 
 composed of several ingredients. '• It is probable," says Odling, " that if a very exact 
 analysis were made, each of the layers of nearly every calculus would be found to contain 
 uric acid, alkaline urates, phosphate of lime, and ammonio-phosphate of magnesia, with 
 or without the other constituents of calculi. Moreover, most calculi contain traces of all 
 the salts naturally existing in the urine, as well as coloring matter, mucus, etc." 
 
 Most calculi are divisible into a central portion, or nvclens, with an outer portion, or 
 hodi/ ; and occasionally there is an outside crvst of phosphate (Fig. B81). 
 
 The nucleus may be of the same nature or diftcr- 
 ent from the body. 
 
 It may be composed of some organic material, 
 such as blood, mucus, etc., or a foreign body intro- 
 duced from without (Fig. 080). 
 
 1. Uric acid calculus is by far the most fre- 
 quent, forming, according to Cadge, nine-tenths of all 
 primary formations {Address on Sirrgeri/, 1874). It 
 is usually derived from the kidney, and when re- 
 tained in the bladder becomes a flattened oval stone 
 of a fawn or yellow color, with a compact and occa- 
 sionally crystalline laminated structure (Fig. 379). 
 The uric acid is generally mixed with the alkaline 
 urates in variable proportions. 
 
 This form of stone is often found in gouty sub- 
 Uric Acid Calculus, with Nucleus uf o.xahite of j^^ts, and 2:enerallv in the middle period of life. It 
 
 Lime, a rep. 219.3.) .J ' ,, • ^' j vi • l • 1 1 " 
 
 IS usually assocuited with acid urine and such as is 
 prone to deposit the urates. The nuclei of most calculi are of this nature. In the cata- 
 logue of calculi of the Royal College of Surgeons of England (Plate lY. Fig. G) there 
 
 Fig. 379. 
 
SToyj-: L\ Tin: uladdi.i:, asi> its iiikatmicst. 057 
 
 is a (Iruwiiit: in wliidi ;i uric iicid ralculiis is sliuwii In have I'uniii'il routiil ii jiiccc; nf 
 
 StOfl. 
 
 '1. The urate of ammonia calculus is not rommon. In (iny's .MuMMnn tliLTi- arc 
 only 7 spt'cinicn^ <>r it out nf .I'.i I (alfiiri, .Most (•((ni|mnn(l calculi contain this sult.stancc in 
 aljuntlaiicc. 'I'licv are scliloni lai-jre, mostly smooth, ami of a gray-fawn c<)l(ir. On section 
 thev are lionio^renciuis or iiidistiiictly laminated and have an earthy fracture. They are 
 more commonly found in (diildren, althout^li they have ht.-en removed from adults. (luy'.s 
 Museum contains a hottle (No. 'I'lXW) in whicdi an; ]\'l calculi of this luiture. which Sir 
 A. Cooper removed from the Madder of one patient. They are of the color of pipe-clay 
 and in the form of cubes with the edges and angles rounded off. 
 
 The rarity of this form of calculus is pr<d)al)Iy due to the solubility of the salts. 
 
 :{. The oxalate of lime, or mulberry, calculus stands second in point of fre- 
 quencv to the uric acitl in Kuropean countries, though Dr. II. V. Carter tells us that the 
 oxalate of lime ingredient predominates in all urin- 
 ary calculi in Nortlu-rn India ( -SV. (ivDn/ri^ Ifiiajntdl Kio. 380. 
 Reports, 1871-72). These calculi vary in color '' 7 
 from gray to a rich brown or black and have an ^. 
 e.Kteriial form of a tubercular, angular, or spinous 
 character, being rarely perfectly smooth (Fig. 3S(I). 
 In some the surface is studded with spines so acute (^^ 
 and slender as to resemble thorns, while in others v^--- 
 there is a coating of acute octahedrons of transpar- 
 ent oxalate of lime, giving an extremely beautiful 
 
 appearance. Occasionally these crystals are opa(|ue Muiurry ( aicuius. its Section. 
 
 and the octahedron is flattened, when the calculus 
 appears as if studded with pearl-spar (Prep. 2139^ Guy's Museum). The intervals 
 between the spines are .sometimes filled with urates or pho.sphates, which give the stone 
 an ovoid form. 
 
 The section of a mulberry calculus is generally that of an imperfectly lamellated 
 structure, the consecutive layers forming waving lines which often resemble the knotted 
 heart of an oak (Fig. 38(1), but occasionally a layer of oxalate of lime is to be seen 
 arranged around the interior one with great regularity, having a remarkably radiated 
 appearance, like a series of infinitely minute needles placed side by side, and presenting a 
 perfectly porcellaneous structure. In compound calculi the oxalate of lime deposit gives 
 to the character of a stone a remarkably beautiful appearance resembling that of fortifi- 
 cation agate. 
 
 The oxalate of lime calculi that have their origin in the kidney (and pass soon after 
 their descent) are usually small, smooth, hemp-seed bodies. 
 
 The crystalline mulberry stone is of a pale-brown color, and, according -to Dr. Yelloly, 
 composed of nearly pure oxalate of lime. Poland had a case of this kind in which the 
 stone on extraction crumbled to pieces from the absence of any binding material of ani- 
 mal matter. He gives also, on the authority of Mr. C. Williams of Norwich, an account 
 of a pure white oxalate of lime calculus. '' This," he says, " is of a milk-white color, po.s- 
 sesses a highly-polished surface, is of extreme rarity, and is generally, if not always, found 
 in the kidney ; its external surfiice presents no crystals, but is perfectly smooth, though 
 it may be spinous. In the museum of the Norwich Hospital are three specimens.'" 
 
 The nucleus of a mulberry stone usually contains uric acid (Fig. 381), while the body 
 is often made up of alternate layers of uric acid and oxalate of lime. The urine is gen- 
 erally acid. Singular as it may appear, these rough mulberry stones rarely give rise to 
 so much bladder irritation as the smoother forius ; possibly they roll about less. 
 
 4. Cystine or cystic oxide calculus is of rare occurrence and is a formation of 
 the kidney. Wollaston discovered it in 1810, and the second calculus which he analyzed 
 is in Guys Museum, and is about an inch in diameter (Fig. 382) and contains sulphur in 
 large proportions. Poland points out its hereditary nature, since, out of 22 collected 
 cases, 10 occurred in four families, and in these the subjects of the complaint were 
 brothers. The calculi are generally rounded or smooth, but may be slightly tuberculated. 
 They have a waxlike lustre and appear semi-transparent and glistening. When recent, 
 they are of a pale yellowish-brown color, but when kept long assume a pea-green appear- 
 ance. Dr. Bird remarks u]»on this point. '' It has been suggested to me by Dr. Prout and 
 Dr. Willis that this alteration in tint may in some way depend upon changes produced ia 
 the sulphur." 
 
 They are soft in consistence and on section present a very imperfectly radiated strue- 
 42 
 
658 
 
 STOXE IX THE BLADDER, AXD ITS TREATMEXT. 
 
 ture, with no tendency to a development of concentric layers. They yield easily to the 
 knife when scraped and form a perfectly white powder, whether the calculus be green or 
 brown. The fracture is crystalline. 
 
 5. Phosphate of Lime Calculus. — There are two varieties of this form, the 
 one as described by Wollastnii. nf nual. origin, consisting of neutral phosphate of lime. 
 
 Fig. 381. 
 
 Fig. 382. 
 
 Mixed Calculus. 
 
 null mze 
 Cystic Oxide Calculus. (Guy's Mus., Xo. 2143.) 
 
 The 
 
 Fig. 383. 
 
 These usually have a smooth polished surface of a pale-brown color and are regularly 
 laminated, the lamina? being so slightly adherent as to be easily separable into concentric 
 crusts ; in some, lines are seen radiating in a direction perpendicular to the laminae. 
 These calculi contain a considerable proportion of animal matter. 
 
 The other form is of vesical origin and composed of phosphate of lime similar to that 
 of bones, and hence often called " bone-earth" calculi. They are more common than the 
 former and constitute irregular masses resembling mortar or a granular, semi-crystalline 
 powder enveloped in a tenacious mucus, these latter being more concretions than stones. 
 There ai*e three cases on record in which the phosphatic calculus has been followed by 
 other forms. Foreign bodies, as a rule (and vesical calculi of long standing are such), 
 have the earthy jdiosphates deposited upon them. 
 
 0. Triple phosphate, or ammoniaco-magnesian phosphate, calculus is rare. 
 e College of ^Surgeons possesses but three specimens, and Guy's only two. No. 2154 
 
 in Guy's 3Iuseum shows one which has no nucleus, but 
 a central cavity lined with delicate crystals of triple 
 phosphate, resembling the crystals of quartz in the 
 cavities of flints, while No. 2152 is a section of a large 
 calculus of the kind on a nucleus of a tobacco-pipe. 
 Fig. 383 represents such a calculus formed round a 
 piece of broken catheter, and occurred in the practice 
 of my friend Dr. Kitchener. 
 
 7. The fusible calculus, or the phosphate of lime 
 with phosphate of magnesia, and ammonia calculus, is 
 the most frequent of the phosphatic calculi. It is gen- 
 erally due to the presence of ammoniacal urine from 
 cystitis, and con.^titutes the crust that forms on other 
 calculi or on foreign bodies introduced into the bladder. These calculi increase to a large 
 size, are irregular, and mould themselves to the position in which they are placed, often 
 filling the bladder. Their color is white, gray, or dull yellow, their consistence friable 
 and more earthy than any other variety, sometimes so soft as to resemble moist chalk. 
 
 Their appearance on section is thus described by Mr. Taylor in the catalogue of the 
 calculi of the Hoyal College of Surgeons of England : " They are frequently composed 
 of concentric lamina?, which in general adhere but slightly to each other ; between the 
 lamina? shining crystals of the "triple phosphate are often observed ; or some of the 
 laminte are entirely wanting, and these form a white friable mass like chalk ; in others 
 they appear semi-crystalline, as if made up of numerous small crystals confusedly aggre- 
 gated together. In calculi that have a crystalline and glistening texture the triple phos- 
 phate is most abundant, while the calcareous phosphate is in excess in those which have 
 an amorphous earthy appearance." 
 
 8. The carbonate of lime calculus is a very rare form. Thudichum says that 
 prostatic calculi sometimes consist almost entirely of this substance. In Guy's Museum 
 
 Tripi 
 
 Phosi)hate Calculus with Nucleus 
 of a Piece of Catheter. 
 
STOSE IS Tin: 11 LAI) It nil, AM) ITS THE ATM EST. 659 
 
 (No. 21fS7^) such a vesical stimc exists, (if a siiow-wliile culnr. witli a nucleus of uric 
 aeid. Otlliuj^ says tliat calculi which have uuder^rone partial (h-cunipositiou in tlie Ijladiler 
 ot'toii etiiitaiu tiiis iii^^redieiit. 
 
 It. Tile uric (of I.'ielii',') or xanthiC oxide calculus, which hears a dose rela- 
 tion to uric acid, is as rare as the last. Dr. Marcet detected tlu? siihstancc in a stone ot" 
 eif^ht irrains' weij;ht, hut no remains of it are at Guy s. Stronieyer rediscovered it in a 
 stone weiirhintr tliree hundred and thirty-five grains, removed hy Langenbeck, which was 
 laminated and of a hriL'ht hrown color. A portion of this calculus is in <fuy's Mu.seum 
 (No. lM l.V"'). 
 
 10. The fibrinous calculus of Marcet and Prout re<|uires notice, although, 
 according to Bird, it must lie regarded as a portion of dried inspi.ssated alhuminou.s 
 matter exuded from an irritated kidney. Such pseudo-calculi present considerable lustre 
 and a vitreous fracture. 
 
 11. The Uro-Stealith calculus seems to be made up of fatty matter. It has 
 been described in llclK r"s Arc/iins ( IS44 — 17)) and by Moore in the Duhlln Qn/trf. Jonrn. 
 for ISol. In iluiitcr s collection there i.s likewi.se a fine sjtecimen of the kind. 
 
 1-. Blood, calculi have likewise been described by Marcet, and K(jberts lias 
 recorded one taken from a sheep by Mr. Lund of Manchester. All recorded ca.ses 
 have been connected with renal lucmaturia. Silica, and also the urates of soda and lime, 
 are occasional ingredients in a stone. 
 
 With this brief description of the varieties of stones — for much of which I am indebted 
 to Poland's article in Holmes's tSi/s/em — it may be well to consider if an}' diagnosis of their 
 nature can be made before their removal ; and for this purpose the character of the urine 
 is of great value. 
 
 If it be acid, the stone is either uric acid, oxalate of lime, or a mixture of the two; 
 and. as the uric is more common than the oxalate, the probabilities point to the former. 
 When the urine contains either ingredient, the nature of the layer that is being depo.sited 
 is established. 
 
 Gouty people are more prone to uric acid than to oxalate calculi. 
 
 If the urine be alkaline from /?.cet/ alkali, as indicated by the permanent change 
 in the test paper, the earthy phosphates or the carbonate of lime calculi are indicated ; if 
 from the carbonatr of ammonia the result of decomposition of the urine, the mixed phos- 
 phates — that is, a crust of these is being deposited upon an unknown nucleus. 
 
 When a small stone has been previously passed and examined, great help is given 
 towai'd the formation of an opinion, and also when gravel has been passed. 
 
 In England one person in one hundred thousand dies annually from stone, in Scotlanc) 
 one in fifty thousand, and in Ireland one in two hundred thousand. The proportion of 
 deaths varies greatly in diiferent districts. Cadge informing us in his very able address 
 given before the British Med. Assoc, for 1874 that in Norfolk the mortality from stone 
 is one in about forty-two thousand, and in Cheshire one in about four hundred and twenty- 
 five thousand. 
 
 The bills of mortality indicate that ten males die to one female from calculous disea.se, 
 and stone is said to be found in men twenty times more frequently than in women. It \9 
 probable, however, that stones form as readily in the one as in the other, but that in women, 
 owing to the shortness of the urethra and its capability of dilatation, they are more readily 
 discharged, large stones being not rarely discharged in the female sex by natural efforts. 
 ( Vide '" Stone in Female.'") The statistics of M. Civiale, Coulson. and Thompson indicate 
 that about sixty per cent, of the cases of calculi are found in subjects under twenty years 
 of age, ten or twelve per cent, in those between twenty and forty, twelve to fifteen per 
 cent, in those between forty and sixty, and about ten to twelve per cent, above sixty. 
 But in taking these absolute numbers and comparing them with the relative numbers of 
 persons living at the different periods of life named, it would appear that children and 
 young persons are less liable to calculous disorders than has been commonly supposed, 
 and that for twenty year.s and upward the tendency goes on increasing in a very remark- 
 able manner to the end of life ; or, as Sir II. Thompson puts it. that the '• proportion of 
 elderly calculous patients to the existing population at their own ages is larger than the 
 proportion of children afflicted is to the number of existing children." 
 
 Two-thirds of the cases of stone that have come under our notice in hospital practice 
 are in children, and half of these are under five years of age. These young ones are, 
 moreover, generally of a healthy and ruddy a.spect and form a contrast to those admitted 
 for other diseases, the formation and presence of a stone in young life being apparently 
 not incompatible with good health. 
 
660 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 Causes of Stone. — With respect to the causes of stone, I concur with Cadge that 
 " it is safer to attriVjute lithuria to dyspepsia and malassirailation, which probably concerns 
 all the digestive organs, than to fix the fault mainly on one,"' and that this condition arises 
 from the want of milk as an ordinary article of diet; for whilst, in tlie children of the 
 poor, stone in the bladder is so common as to constitute half the whole number of ca.ses 
 met with in jiractice, it is seldom seen in the more opulent classes. 
 
 STONE IN THE BLADDER. 
 
 When a stone has descended from the kidney into the bladder, it may give rise to no 
 more marked symptom than a slight urinary irritation ; and when it passes with the urin- 
 ary stream, this symptom will disappear. 
 
 When the calculus rests in the bladder and increases, it usually gives rise to more 
 characteristic symptoms, which differ widely in different subjects and apparently have 
 little to do with the nature of the stone. 
 
 In some — indeed, in the majority — of cases the symptoms are so slight as to be disre- 
 garded, whilst in the larger number the symptoms have frequently existed for many 
 months, if not for years, before advice is sought. Indifference or carelessness may occa- 
 sionally be the cause of this delay, but, as a rule, it is due to the uncertainty of the symp- 
 toms and the comparatively little inconvenience the patient suffers. It is a rare thing, 
 however, for a parent to seek professional advice for a child suffering with stone until 
 Tistmaturia has been observed, some prolapse of the rectum taken place, or the j)nin which 
 the child experiences after micturition become pronounced, although in such a case it will 
 generally, upon inquiry, be learnt that the child for many months had been observed to 
 play with or drag the penis after micturition, that the stream of urine had occasionally 
 been interrupted in its flow, and that a frequent call to make water had long existed. 
 
 These symptoms, therefore, with tolerable accuracy denote the presence of a calculus, 
 though its existence can be positively' affirmed only on its absolute detection by a sound. 
 Yet nearly all the symptoms which have been enumerated can be produced by other and 
 less important conditions, and more particularly by an elongated and adherent prepuce. 
 
 Retention of urine in an otherwise healthy child is almost always cau.sed by the impac- 
 tion of a .stone ; and when incontinence exists, it frequently indicates the presence of a 
 calculus which has been forming for a lengthened period, and which is often connected 
 with renal as well as vesical changes of an organic character. 
 
 In adult life indifference to early symptoms is not common, and a frequent desire to 
 pass water, when persistent, will soon induce a man to seek advice; and. as this may be 
 the only symptom of stone, it should be neither disregarded nor lightly treated. Indeed, 
 with such a symptom a sound .should at once be pa.ssed, this being the readie.'^t and best 
 means of proving w'hether a stone be the cause or not. The symptoms that indicate the 
 presence of a calculus will be found to vary from the slightest irritation of the bladder to 
 the severest agony, and those which have been described will be present in different degrees 
 of severity or in different combinations. The importance, however, of an early detection 
 of a calculus is so great that in every case of persi.stently irritable bladder which is not 
 clearly the product of some other affection it is better to suspect the existence of a stone 
 and examine with a sound than to run the slightest risk of overlooking it, and conse- 
 quently of increa.sing the dangers (which are alwa^'s great) of exciting or keeping up 
 organic disease in the bladder and kidney. It is to be remembered that the presence of a 
 calculus is dangerous to life chiefly from the organic renal changes it is liable to excite, 
 and that neither the operation of lithotrity nor that of lithotomy is commonly fatal if such 
 changes have not taken place. The early detection of a stone becomes, therefore, neces- 
 sarily a point of the highest importance. 
 
 The confirmed symptoms of vesical calculus in the adult are pain of different degrees 
 of intensity referred to the bladder and aggravated on any sudden movement, such as by 
 riding, jumping, or jolting of the bod)\ pain during, and particularly after, the act of 
 micturition, extending along the urethra to the penis, exhausting straining, and the pas- 
 sage of blood. During the flow of urine a sudden arrest of the stream will often be 
 observed, this arrest being followed after the lapse of a moment of time by the return of 
 the flow ; and this interruption maj- be repeated more than once in each act of micturi- 
 tion. Retention or incontinence of urine may complicate the case. Rectal irritation and 
 tenesmus, with or without prolapse, are also frequent symptoms, and reflected pains along 
 certain nerves are very constant. Thus, pain in the glans penis is most common, and 
 pain in the scrotum, perinaeum, and down the thighs is pretty constant. John Hunter 
 
STOSE i.\ Tin: ni.Ai)!)i:n. 
 
 661 
 
 relates a. Oiise of stoix- in wliitli ])ain in tin.! lel't lun'-arin was the only indication nf a 
 want to make watt-r. Sdint'tinies tiic Madder syi'ip^'""'^ "'•'} '"' seven; I'ur a time and 
 then cease, or suddenly appear after any extra exertion, in tlie former cu.se the .stone 
 probably becomes fixed in a .sacculus and cea.sos to irritate ; in tiie latter, it escapes from 
 a sacculus and makes its presence known. As lonjj; as the bladder remains healthy the 
 chani^es in the nrine will be but slight ; but when the stone, actinj; as a loreifjii body, 
 sets up cystitis, all the symptoms of that affection will appear, with the muco-purulent 
 discharire and ammoiiiacal urine. 
 
 When the symptoms have existetl fur :uiy IciiirtluMied jicriud. the jtroliabilities of 
 renal eompiicatinns are threat, as indicated by albuminous urine witli lunib.ir p.iiii and 
 anasarca. 
 
 In rare ca.ses a persistent erection (d' the ])enis is j)resent. 
 
 Hut these symptoms of stone are merely suhjictli-r : they are those ;^iven l)y the 
 patient ; and, however suii<;estive of the atfection they may be. they are not conclusive, 
 since all may be produced by other bladder affections. The oidy conclusive evidence to 
 be obtained is by the physical examination of the bladder, by the '' .sounding " of the 
 patient with a metallic sound or catheter, by the " ringing " of the stone against its end. 
 To sound a patient su.spected of stone, the horizontal position should be .selected and 
 the pelvis raised on a pillow. The bladder should contain a few ounces of urine if possi- 
 ble, three or four being enough and eight being ample, and the rectum should be empty. 
 When the bladder is empty, some few ounces of water should be injected. For a child 
 a small metallic bulbous catheter or sound with a short sharp curve should be used TFig. 
 
 385), the bulbous end being 
 one size larger than the stem, 
 and for the adult a similar in- 
 
 =__^ ^ strument suffices (Fig. oS4). 
 
 '-* -^ **^^.\^^ -^" instrument with a long 
 
 curve may glide over the stone, 
 Catheter Xo. 10. "%, % and will certainly fail to find 
 
 T> OD- % ^ one lodued behind the prostate; 
 
 Fig. 38o. \ _m •, • V , ,V rp, ' 
 
 It IS also less movable. Ihe 
 
 shortei'-curved catheter can be 
 made to turn downward to ex- 
 plore the base of the bladder 
 with the same fticility as it can 
 to explore the .sides. A hollow sound or cath- 
 eter is better than a solid, as a stone will often be 
 
 Fig. 384. 
 
 Child's Catheter. (Natural size) 
 
 detected on drawing off the urine, as the bladder, in the act of contracting, may throw 
 the stone upon the end of the instalment and thus make its presence known. The cath- 
 eter should not have a stylet. 
 
 The instrument should be warmed, freely oiled, and passed carefully and slowly into 
 the bladder ; nor ought its introduction to give pain. It should be at first pushed well 
 home toward the posterior part of the organ to search its base, and then turned first to 
 one side and then to the other to search its sides, the sound during the operation being 
 gradually withdrawn and again pushed back. When an enlarged i)rostate exists and a 
 stone is expected to lie in a pouch behind the so-called gland, the beak of the instrument 
 must be turned backward ; and in this way every corner of the bladder can be examined. 
 When no "ring" of the calculus is first obtained, the water may be partially drawn off, 
 and by this mananivre it may be heard. In children the introduction of a finger into 
 the rectum at times fticilitates the search, and the pressure of the hand above the pubes 
 often facilitates the detection of the stone. 
 
 A large stone is generally touched on the sound entering the neck of the bladder, and 
 a small one usually lies at the base of the bladder, to either the right or the left of the 
 median line. An encysted stone is a rarity. A stone may often be felt at one time and 
 not at another ; consequently, when well-nuirked symptoms exist, any hasty opinion as 
 to its absence is to be avoided. Mr. F. L' Estrange of Dublin has invented a sounding- 
 board to be fastened to the top of the .sound for intensifying the noi.se produced by the 
 instrument when it strikes a stone in the bladder. It is an ingenious instrument. 
 
 The late Mr. Napier invented a pewter sound, the surface of which, being oxidized 
 by nitric acid, is easily scratched when coming in contact with a stone. It seems to 
 be of use when the stone is otherwi.se difficult of detection. For the same purpose the 
 microphone may possibly prove of value. 
 
662 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 The operation of souiuling ought to reveal something more, however, than the pres- 
 ence of the stone, such as its size and nature and whether more than one is present. 
 The size is indicated by the extent of surface passed over by the point of the instru- 
 ment ; and the nature, by the noise emitted on the striking of the stone, such hard stones 
 as the uric acid or oxahite of lime giving a sharp, clear, ringing sound, while the light 
 and soft phosphatic calculi yield a dull one. The roughness of the oxalate of lime cal- 
 culus may also be generally felt. In children, with the finger in the rectum, the size 
 of the calculus can often be readily made out. The character of the urine, as already 
 pointed out, throws some light upon that of the calculus. The value of chloroform in 
 facilitating the search for a stone, more particularly in children, is so great that it should 
 almost always be employed. In sounding, the surgeon must not be misled by the sen- 
 sation given by the rugous or roughened bladder, the viscus feeling hard and uneven to 
 the end of the sound, and the examination giving pain. When this condition is made 
 out, all sounding should be given up ; for the existence of such with a stone is almost 
 unknown. 
 
 In children the instrument may strike against the sacrum or spine of i\\v ischium and 
 mislead, but in this case there is no sound emitted ; indeed, the surgeon must be careful 
 to hear as well as to feel the stone before he is satisfied as to its presence, as there are 
 many aifections of the bladder and prostate that in their clinical history and ph^'sical 
 symptoms simulate those of stone, but in none is any perceptible sound given when using 
 the metallic instrument, as in stone. The only unequivocal sign of calculus is the sound 
 produced on sti'iking the stone. 
 
 In forming a diagnosis the surgeon should always remember that when irritation at 
 the neck of the bladder arises from stone it is referred to the glans penis; when from dis- 
 ease of the bladder, to the organ itself; and when from disease of the prostate, to the 
 perineum or rectum. 
 
 When a calculus is suspected in the female, a vaginal examination will often enable 
 the surgeon to feel the foreign body. It will also remove all such sources of fallacy as 
 are prone to follow from uterine affections. In female children a rectal examination will 
 do as well. 
 
 Treatment. — A calculus having been detected in the bladder, there is only one form 
 of treatment which can be successful, and that is its removal ; for, with rare exceptions, 
 a stone, if allowed to remain, will set up, not only bladder disease, but kidney mischief, 
 ending in death. 
 
 A stone may be removed by a cutting operation — Jltltotomy ; or by a crushing one — 
 lithotrity ; the treatment by UfhontripticA and electrolysis has hitherto met with indifferent 
 success. 
 
 In former times small stones were removed from the bladder by forceps. Sir B. 
 Brodie, Sir AY. Blizard, Boyer, George Bell, and others, have recorded many such cases. 
 Sir A. Cooper's celebrated ca.se, in which he removed eighty small stones by this means, 
 is well known ; but the practice has been entirely superseded by the lithotrite. 
 
 Lithontriptics, or stone solvents, were used long before the composition of urinary 
 calculi had been made known, and were mostly alkaline remedies; and the most celebrated 
 nostrum of Joanna Stephens, for which the government of 1739 gave a reward of five 
 thou.sand pounds, was composed of burnt eggshells and snails, with Alicante soap. Prout 
 showed the value of fluid as a solvent in calculous affections ; Chevallier, of alkalies ; and 
 Ch. Petit, more particularly of the Yichy springs. There can be no little doubt, too, that 
 in the lithic-acid form of stone alkalies have an undeniable influence in checking their 
 increase, if not in aiding their solution. In other stones they have no such influence. 
 
 Dr. Roberts, who has in recent years paid much attention to this subject (Med.-Clnr. 
 Trans.. 1865), seems to think that " the results obtained by his experiments demand a 
 considerable modification of the prevailing opinion regarding the inutility of the .solvent 
 treatment : they suggest an essential improvement in the treatment of renal calculi ; they 
 indicate that uric acid and cystine, under certain circumstances, are capable of solution 
 in the bladder, by means of alkaline .salts administered by the mouth, at a rate which 
 admits of practical application, and that in picked cases a solvent treatment deserves to 
 be resolutely tried." He adds, however, " that the .solvent treatment is only applicable 
 in those cases of vesical calculi in which the urine is acid, the stone not large, its compo- 
 sition known to be uric acid, or .strongly su.spected to be such." The best solvents are 
 the acetate or citrate of potash, sufiicient doses being given to make the urine neutral, 
 not alkaline. 
 
 Garrod has suggested, as the results of experiment and experience, that as in herb- 
 
i.iTiioroMv ni: i.iriiorniTY is casks or stom:. {](\:\ 
 
 ivoroiis animals tlif presence (if lii|i]Miric acid in the urine linltls uric acid in Kuspcnsion, 
 so the administrution of hi|i|iuric or benzoic acid nii^ht \n'. oi' use. lie has t'ounil this to 
 be tlie case. lie jrives lienzoate of .so(hi in twenty-grain doses three times a dav, and con- 
 tinues it with some alkaline citrate if the urine he vt-ry acid. 1 have found this treatment 
 very efficacious in diminishinir the amount of uric acid in the urine. 
 
 lirodie -showed that the injection into the Madder ol' a solution oi' nitric acid two or 
 three minims to the ounce of water had the |M»wer of dissnlving ]dios|ihatic calculi, and 
 upon this su^Lrestinn other experimenters hav(- tried dihi-r fluids, such as weak alkaline 
 stdutions, fur uric acid calculi, carlxmate of lithia, hurax. and acetate of lead, etc. ; but 
 there is this «rreat disadvantajre in the jiractice — that the solutions are apt to irritate the 
 bladder and thus do more harm than <rood. In the uric a<Md and o\alat(; of lime calculi 
 they are almost useh-ss. In the phosphatic stones most surL'eons admit the value of the 
 practice, a solution of diluted nitric acid ^ij to a jiint of wat(;r. injected into ji bladder 
 where phosphates are being deposited, being of great value in many cases. Such a prac- 
 tice must, however, be carried out with great caution. 
 
 The aid of the galvanic battery ha.s been employed to break up stones by Dr. Bence 
 Jones, 8ir W. O Shaughiiessy, and others ; but the success attending the experiments 
 has not been sufficient to warrant the recommendation of the means. 
 
 Small stones may often be washed out of the bladder by means of the urine, and 
 jiatients who are prone to the j)a.ssagc of renal calculi into the bladder and to the forma- 
 tion of lithic acid or other gravel should be directed, once a day. when the full bladder is 
 ab«nit to di-scharge its contents, to arrest the flow of urine by holding the penis, and then 
 suddeidy to allow the stream to flow ; in this way the water, passing with a rush, carries 
 away any small stone or sand that might be resting in the bladder. I have known this 
 practice to be followed by good success. Old men should do this on their hands and 
 knees. When a stone is too large to pa.ss in this way, it must be removed, which is to 
 be done by means of lithotomy or lithotrity. 
 
 Lithotomy or Lithotrity in Cases of Stone. 
 Stone in the bladder in children may be safely treated by lithotomy, 
 
 which should be performed as soon as the stone has been detected in the bladder ; for 
 the dangers of any individual case can be fairly measured by the size of the stone and 
 the duration of the symptoms. The longer a calculus has existed, the greater are the 
 probabilities of renal disease complicating the case ; and the dangers of lithotomy, inde- 
 pendently of its own .special risks, are mostly due to the kidney affection. When the 
 stone is large, the neck of the bladder may be so injured by its removal as to set up a 
 fatal peritonitis, and hemorrhage may in exceptional cases cause death ; but in skilful 
 hands the operation of lithotomy in patients under puberty is most successful. 
 
 Sir W. Fergusson informs us in his College Lectures that out of fifty cases of lithot- 
 omy in children, he lost only two. In my own practice, out of the .same number of cases 
 under puberty, I have lost but two. In one the stone was two ounces in weight and two 
 inches in diameter, and the patient, ten years old, had had .symptoms all his life, and incon- 
 tinence of urine for four years. He died from peritonitis and extreme di.sorganization of 
 the kidney. In the other the child was three years old. The stone was removed without 
 difficulty and without bleeding, and convalescence seemed at hand, when on the seventh 
 day secondary hemorrhage occurred, and death took place from convulsions. 
 
 In children, therefore, it may be safely asserted that success may with .some confidence 
 be looked for after lithotomy when performed with care and .skill. " It nuiy reasonably be 
 doubted if better can be done before fifteen than cutting for stone" (Fergus.son). 
 
 Lithotrity in a child, with fine instruments, may be a justifiable operation in excep- 
 tional cases when the calculus is known to be very small, but. as a rule, in patients under 
 puberty lithotomy ought to be selected. In Great Britain this practice is generally fol- 
 lowed by surgeons, although in France lithotrity is more frequently .selected. 
 
 In stone in the bladder in adults its removal by lithotrity ought primarily 
 to be entertained, and lithotomy had rectiurse to only when lithotrity is inapplicable. 
 Lithotrity, as now practised, is, thanks to Bigelow, probably applicable to at least four- 
 fifths of all cases of stone in adult subjects. The danger of lithotomy rapidly increases 
 with age, the mortality being 1 in 8 between .seventeen and forty, 1 in 4 above that age. 
 I have cut 24 adult male subjects with G deaths, or 1 in 4 : and Thompson, out of 78 
 cases, lost 29, or 1 in '2%. 
 
 When renal disease can be made out as existing, lithotrity is no nn^re favorable an 
 
664 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 operation than lithotomy ; when with it there are bhidder complications, the cutting 
 operation is probably the right one to adopt, even if only as a means of giving relief, 
 although, when the stone is small and the renal symptoms are uncertain, lithotrity may 
 be undertaken with success. 
 
 When severe bladder mischief complicates the case, lithotrity is out of the question 
 and lithotomy should be selected, although experience confirms what C. Hawkins has 
 stated — that lithotrity may be performed with success when the bladder has been in a 
 very considerable state of irritation and secreting much ropy mucus. The irritation and 
 the secretion of mucus cease when the whole of the calculus has been removed. 
 
 Paralysis of the bladder does not preclude the practice of lithotrity, though it neces- 
 sitates extra care and gentleness in manipulation. An enlarged prostate, unless mechan- 
 ically interfering with the introduction of the instrument, is by no means an inseparable 
 bar to the operation. 
 
 When a severe organic urethral stricture exists, lithotrity may be impossible unless 
 the stricture can be fully dilated. When the stone is very large, the operation of crushing 
 may be out of question. I have, however, crushed a lithic-acid calculus one and a half 
 inches in diameter with success. 
 
 " Formerly," wrote Aston Key (1837, Gki/'s Reports), " patients laboring under cal- 
 culous disorders entertained a feeling of dread almost amounting to horror at the idea 
 of having a stone in the bladder, but since the introduction of lithotrity they no longer 
 entertain the dread of their symptoms depending on the presence of a stone ; and when 
 the stone is found, they cheerfully make up their minds to undergo an operation which 
 they regard as free from danger, and nearly so from pain. I have known a patient, and 
 more than one, to be pleased with the discovery of a stone in the bladder, convinced, as he 
 expressed it, that he could look for an easy cure from the new operation. The exagger- 
 ated statements of the advantages of lithotrity have thus not been unattended with good ; 
 they have been the means of inducing persons to come forward to obtain relief Avhen the 
 disease was incipient and the stone small. Since the introduction of lithotrity the sur- 
 geon examines the bladder with great care, knowing the importance of discovering the 
 calculus at the earliest period. The early symptoms of stone are thus watched with more 
 jealousy on the part of the surgeon, and are not so scrupulously concealed by the patient. 
 The advantages of an early knowledge of the existence of a stone and of prompt meas- 
 ures for its removal are known to both. The result of this is that patients apply for 
 advice when the stone is small, the bladder uninjured by its presence, and the kidneys 
 free from disease. In three persons out of four who apply for advice for symptoms of 
 calculus, the size of the stone and the conditions of the viscus render lithotrity an easy 
 and a safe operation." 
 
 These extracts, which I have given from Aston Key's paper written nearly fifty years 
 ago, might have been from the pen of a more recent writer, they so accurately represent 
 'the advantages of what was then called "the new operation," and prove how the great 
 surgeon who wrote them recognized its value. What Key would have said of Bigelow's 
 still newer method can easily be surmised. 
 
 Summary. — It would thus appear that in children lithotomy ought to be the rule and 
 lithotrity the exception, in achilts lithotrity ought to be the rule and lithotomy the excep- 
 tion, the latter operation being selected only when the former is impossible from some 
 urethral or prostatic irritability or mechanical obstruction, severe bladder disease, or a 
 large stone. Renal disease in all cases renders doubtful the prognosis of any operative 
 procedure, the weight of evidence tending in favor of a cutting rather than a crushing 
 operation under such circumstances, though, when the stone is small, lithotrity is not pre- 
 cluded. 
 
 In cases in which neither operation can be recommended or when both are rejected it 
 is wonderful how long patients the subjects of stone and organic disease by care and good 
 advice will live, and how little irritation a calculus sometimes causes ; and, though the 
 knowledge of this fact should not induce a surgeon to leave alone a patient who has a 
 stone, it is enough to enable him to give hope and encouragement to one whose life would 
 be endangered by any surgical attempt at its removal, for palliative treatment is, doubt- 
 less, a source of great comfort and a valuable means of prolonging life. 
 
 LITHOTRITY. 
 
 " In the whole of my professional experience," says Fergusson in his College Lectures 
 (1867), " I know not of a useful operation which has been so shamefully overpraised, and 
 
THE OPEIlATins. 6G5 
 
 thcrchy daiuairod in cliaractcr, as litliutrity. I know not any process in sur<rery requiring 
 luori! turotlioiijj;ht, knuwk'djio, manipulative skill, and aftLT-judj^inL-nt." '' Nor is it possi- 
 ble, " writes Thompson, " to t'ontluct all the manipulations with too much car*; ami jrentle- 
 ness." These o])inions, emanating; as they do IVom two such experienced lithotritists, 
 ouf;ht always to be remembered, since they are true to a degree that oidy surgeons who 
 have had s(»me exj)erience in the operation can appreciate. To Mr. Klderton, a North- 
 ampton surgi'on, is due the merit ol" hciMg the Hrst to construct an instrument for tiie 
 purpose ot" crushing a calculus and enaltling the patient to pass it by the urethra (Eiliii. 
 Mill, itnd Sitiy. Joiiniii/, April, ISl!)), 'out lithotrity was first realized as an operation and 
 successfully practised bv Civiale in 1S24, and to him the profession is chiefly indebted for 
 the operation, though Leroy d'Ktiolles, lleurteloup, Amussat, and others diil much towanl 
 favoring the practice. It is probably, however, to Ileurtelou]) that British surgeons are 
 mostly indebted, as he came over to Kngland about ISliU and fully exj)lained to the pro- 
 fession the mechanism of his improved instruments and the steps of the operation, and 
 on the invitation of Mr. Aston Key this instruction was given in the theatre of Gruy's 
 Hospital. Weiss, in 182!J, had previou.sly devised a screw lithotrite, and after lleurte- 
 loup's visit, and probably from information ac(|uired through him, so improved it that all 
 modern instruments are based upon that which he then introduced. A.ston Key, Brodie, 
 (\)stello, Hodgson, Fergusson, and others sub.sequently practised the operation, and 
 through the result of their experience, with that of Civiale, the operation has become a 
 recognized one, the instruments employed having been vastly improved and their use 
 better understood. 
 
 In 1829, Aston Key read a paper on lithotrity at the IFunterian Society, and the 
 report of a successful case, and in Guy's Riports for 18)J7 will be found a masterly' paper 
 upon the subject by the same surgeon. In 1834, Fergusson wrote on lithotrity in the 
 Ellin. Mill, mill Sitrq. Jouriiuf, in which he introduced his rack lithotrite, and to him, as 
 well as to Sir B. Brodie, Sir H. Thompson, and Charles Hawkins, mo.st of our modern 
 improvements are due. 
 
 The greatest improvement, however, was left for H. J. Bigelow of Harvard, United 
 States, who in 1878 introduced to the notice of surgeons his rapid method of crushing 
 stones and of evacuating their (Uhris, since which time, it may be said, with all truth, a 
 new starting-point for the operation has been supplied. It is true that the full credit of 
 this operation must not be given entirely to Bigelow, since something is due to the intro- 
 duction of anjusthetics, something to the principle embodied in Crampton's bladder evacu- 
 ator. introduced in 184G, and in Clover's, of a more recent period; something also to Otis, 
 who in 18T4 demonstrated the fact that the normal urethra will bear fuller dilatation 
 than it had hitherto been subjected to ; nevertheless, it was left to Bigelow to see fully 
 the bearing of all these points, and so to focus them, as it were, upon the ojieration of 
 lithotrity as to make the rapid method a po.sitive success, the method depending upon the 
 tolerance of the bladder, the use of large lithotrites, and, above all, the employment of 
 large cathetei's and of a more powerful evacuator than Clover's. " The new and essential 
 instrument of the operation," writes Bigelow, "is the large catheter, 25 to 31. This is 
 indispen.sable. The small size of the previous evacuating catheter delayed surgical prog- 
 ress for half a century." 
 
 The Operation. 
 
 The objects of lithotrity may now be defined as, fir.st, to reduce a stone to fragments 
 sufficiently small to pass through ushirqe an evacuating catheter as can be introduced into 
 the bladder without injury to the bladder and passages; and secondly, to remove the frag- 
 ments as speedily as possible. 
 
 Preliminary Treatment. — Starting with the assumption that our patient is fairly 
 healtliy, the stone of reasonalde dimensions — that is, not more than one or one and a half 
 indies in diameter — and not too hard, the urethra of normal size, the bladder capable of 
 retaining about four ounces of not unhealthy urine — conditions under which operative 
 interference ought to be most favorable — it is always well to keep the patient quiet for a 
 few days, and to test the urethra and bladder as to their capabilities of bearing the mechan- 
 ical irritation of large instruments by the introduction of a sound ; attention should be 
 paid at the same time to the condition of the secretions, etc. AVith every attention, 
 however, it is not uncommon to meet with cases in which the mere passage of a sound is 
 followed by severe local and constitutional disturbance, and in lithotrity such a complica- 
 tion is most detrimental. On the other hand, where irritability exists the occasional intro- 
 duction of an instrument is often followed bv relief. 
 
6Q6 
 
 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 When the bhxdder is inflamed and irritated by the presence of a stone, rest is most 
 essential, with the use of alkalies and the decoction of the tritieum repens or other drugs 
 suitable for cystitis. When the urine is ammoniacal, the bladder should be eni])tied and 
 washed out. 
 
 By these means the symptoms may subside and the bladder become capable of retain- 
 ing sufficient urine — four ounces — to allow of the operation being performed where i)re- 
 viously it would have been impossible. 
 
 Preparation for Operation. — The patient having been prepared for operation 
 by the treatment just laid down, the bowels cleared by a mild aperient or an enema the 
 day before, and the bladder sufficiently distended by the patient retaining his urine as 
 long as he conveniently can before the surgeon's visit, or by the injection into it of a 
 lotion of thymol or boracic acid, the operation may be proceeded with. 
 
 Position of Patient. — The patient should be placed upon a firm horsehair mat- 
 tress or sofa, with his right side near its edge ; his shoulders should be low, the pelvis 
 raised by means of a firm pillow, and the knees slightly flexed and separated, care being 
 taken that only such portions of the pelvis are exposed as are necessary to allow of the 
 surgeon's manipulation ; for a sudden chill often acts upon the bladder and induces it to 
 contract and expel its contents. 
 
 The object of raising the pelvis is to roll the stone backward from the neck of the 
 bladder, its most sensitive point. 
 
 An instrument with large teeth and a fene.strated female blade is the best for crush- 
 ing large stones (Fig. 388, A), and a less powerful instrument with finer teeth for small 
 stones or fragments (Fig. 388, B). 
 
 Introduction of Instrument. — The instrument, selected by the surgeon accord- 
 ing to the size of the stone to be crushed, having been previously well warmed and oiled, 
 is then to be cai'efully introduced, no force being employed ; indeed, it may almost be 
 allowed to slide into the bladder by its own weight, the surgeon simply guiding it. 
 
 When the instrument has reached the prostate, and not before, the handle of the 
 instrument is to be depressed toward the patient's thighs, when the blades rise up into 
 the bladder — "a movement which is rendered more easy," says Thompson, ''if a very 
 slight lateral rotary motion is given to the instrument at this part of its progress." 
 
 The bladder thus reached and the instrument pressed well into the organ, the object 
 is to seize the stone, which can be done either by so depressing the lithotrite with its 
 open blades as to allow of the stone falling between them or by turning the open instru- 
 ment to the stone and picking it up. The first is the older and the more usual method, 
 and the one I have commonly adopted ; the second is useful where the stone is not readily 
 found by the first method, where the prostate is enlarged, and the stone rests in a holloAV 
 behind it. In either method the movements of the instrument are to be gentle and quiet, 
 
 and care is to be observed that in opening 
 the instrument the male blade does not in- 
 jure the neck of the bladder. 
 
 Finding and Seizing the Stone. 
 
 " Let it be understood that the blades of the 
 lithotrite have entered the cavity of the blad- 
 der, and that the instrument slides easily 
 and smoothly down the trigone, which in 
 the living and healthy organ is an inclined 
 plane, although (juite otherwise in the 
 atonied and in the dead bladder. In many 
 cases the instrument in thus passing 
 grazes the stone, and the slightest lateral 
 movement of the blades, right or left, will 
 determine on which side it lies. Whether 
 the stone is felt or not, when the blades 
 have passed gently down in the middle 
 line until a very slight check to their 
 movement is perceived, the lithotrite 
 should rest there for three or four seconds, 
 and then the male blade should be slowly 
 withdrawn, without moving any other 
 part of the instrument, toward the neck 
 of the bladder, until a very slight check is perceived in that direction, followed by another 
 
 Fig. 386. 
 
 Ujjeratiou of Lithotiity. 
 
'/'///•; ()i'i:i:.\Tit)S. 
 
 0(17 
 
 Operation of Lithotrity. 
 
 tliri'f (ir tour scoonds' rest for currt'iits t(t sultsidc. Now tlio (iporiifor slioiiM r|uii'tly jircsH 
 Itack tilt' male hlinie without eliaiij^inj; the position of tlu,' lithotrite. and almost eertainly 
 the stone will he seized. In otiier words, open, pause, close;: tliat is all. 
 
 " It' no stone is thus found, the operator aj^ain withdraws the male hlarlc as hcfore, 
 but inelininir to the rijrht side ahout forty-tive def^rees, and (doses without disturhinj; tlie 
 central position of the instrument. If no stone is felt, he then turns them, opened, t(i 
 the left in a similar manner, and tlien closes tln'in. Thus, in almost all j)Ositions, the 
 stone is sci/cd sideways hy the hiades 
 (if the lithotrite, and very rarely hy 
 their extremities. Observe thai tin: 
 hln'h\< iir<' iiiirai/s to he opcnrd before 
 they are turneil^ for thin reason: If the 
 turn is first maile and the blades are siifi- 
 se(ji(nit/i/ opened, the ehanee is titat the 
 viah' blade, as it is withdrawn^ wdl more 
 th'' stone an-ai/ ; n^hereas, if the blaxbs 
 are inclined ivhile open, the stone, if 
 there, is almost certaiidi/ seizid. This is 
 one of the many apparently minute but 
 extremely important points of which 
 systematic lithotrity is made up. To 
 return : it is very rare that the stone 
 will elude the search thus far ; but if it 
 does, depress the handle of the lithotrite 
 half an inch or so, which raises the 
 blades very slightly from the floor of 
 the bladder, and turn them another 
 forty-five degrees to the left, bringinir, in f^iet, the blades horizontally to the left ; close. 
 If unsuccessful, turn them gently to horizontal on the right, and close. In all these 
 movements, if properly executed, thei'e has been barely contact of the lithotrite with the 
 vesical walls — at all events, no pressure, nothing to provoke undue pain or cause contrac- 
 tions of the bladder. If, however, there is an enlarged prostate, causing an eminence at 
 the neck of the bladder or depression behind it, or the stone is very small, or we are 
 exploring for some fragment at the close of the case which is suspected to have eluded 
 previous search, the blade may be reversed so as to point downward to the floor, and the 
 object sought may then often be secured with ease. If seeking for a small stone or for 
 fragments, we may employ a lithotrite with short blades, which can therefore be reversed 
 with much greater ease than one with long blades. 
 
 '' In order to do this properly, the handle of the lithotrite is depressed another inch or 
 so between the patients thighs, so that the shaft of the instrument, instead of being 
 directed a little upward, is level with or points below the horizon ; the blades, being still 
 closed, are cautiously brought round to the reversed position and the floor first lightly 
 swept in the manner of a sound in searching for stone. Then they may be carefully 
 opened and closed two or three times in slightly varied directions, but without injuring 
 the floor of the bladder. When the prostate is considerably enlarged and a stone or frag- 
 ments have to be sought behind it, the lithotrite is reversed without depressing the handle. 
 
 '• All these movements are to be executed at or beyond the centre of the vesical cavity, 
 the proper area for operating, without hurry, rapid movement, or any other which par- 
 takes of the nature of a jerk or concussion, and, if in a fairly healthy bladder, without 
 causing more than a very slight degree of pain to the patient. The operator's eye is also 
 to be so familiar with the scale marked on the sliding rod that he knows at a glance the 
 exact interval which it indicates as existing between the blades in the bladder. It is 
 essential to good practice, while manipulating the lithotrite, to maintain the axis of the 
 instrument as fiir as possible always in the same direction. The blades only are to be 
 moved; the shaft should occupy the same inclination, unless when this is intentionally 
 altered. In screwing home the small blade the operator is very apt to move the litho- 
 trite also at each turn of the screw, unless he is conscious of the care necessary to avoid 
 the evil. All lateral movements, all vibration and concussion, necessaril// fell on the neck of 
 the bladder and prostatic urethra, where the instrument is most closely embraced and its 
 mobility is most limited. To that part of the lithotrite which occupies the anterior por- 
 tion of the urethra much freedom of lateral movement is permitted, and in the blaclder 
 the instrument is free, although in a less degree ; but the axis or fixed point, as regards 
 
668 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 lateral movement, is at the part indicated, which is also the most sensitive spot of the 
 entire passage. Hence the aim of the operator should be to produce in this situation no 
 motion of the lithotrite except that on its own axis. Few of the details of the operation 
 require more practice to master than this. 
 
 " A rule has been laid down with reference to the situation of a calculus in the blad- 
 der. It is said that the larger the stone, the more certain is it to be found lying near to 
 the neck of the bladder in the ordinary recumbent position, while a small one is usually 
 detected at the back of the trigone. Without assenting to the accuracy of this reniark — 
 at all events, in relation to the small stone, which is often close to the vesical orifice — it 
 may be said here that the act of seizing a large stone in this position requires considera- 
 tion ; for if the operator commences by withdrawing the male blade according to the ordi- 
 nary custom, this blade is apt to be drawn against a large stone, which it therefore fails to 
 catch, and presses it back against the neck of the bladder, doing mischief and not succeed- 
 ing. As a general rule, it may be said that the most common cause of failure to seize a 
 large stone arises from its close proximity to the neck of the bladder (whatever position 
 is given to the patient) and from the male blade being drawn up against it at each open- 
 ing of the lithotrite in the manner just described. In these circumstances the operator 
 feels the contact of the stone without suspecting its precise locality each time he with- 
 draws the blade, and is apt to feel embarrassed on failing to seize it when he closes imme- 
 diately after. In these cases it is essential to draw the male blade gently, but closely, to 
 the neck of the bladder, and to slide the blade between the neck and the stone which lies 
 in contact with it." 
 
 '• The rules laid down for finding and seizing apply more or less to lithotrites of 
 moderate size, but this general rule may be borne in mind : viz., the more powerful the 
 lithotrite — that is, the larger and longer are its blades — the less readily are we to adopt 
 the reversed positions of the blades and the more fluid is it desirable to have in the blad- 
 der. As large and fenestrated blades are used chiefly for the initial act of breaking up a 
 large stone into fragments, it is obvious, also, that there is less occasion for the horizontal 
 and reversed movements, since a large stone may almost certainly be seized by the right 
 or left incline." 
 
 Crushing the Stone. — " Supposing that a hard stone of an Inch and a half in 
 diameter has fallen into the grasp of a powerful lithotrite, the screw is to be gradually 
 turned at first, to make the blades bite, since a sharp turn at this moment may drive the 
 stone out either right or left. As the power is increased the resistance is felt to relax, 
 sometimes by degrees, sometimes suddenly with a crack, and the stone is broken usually 
 into four or five large pieces, besides some small debris. This done, the male blade is 
 again drawn out, taking care not to shift the situation or alter the axis of the lithotrite, 
 and almost certainly one of the large fragments will be picked up. It is then only neces- 
 sary to screw home, release the screw, and open as before. This process may be repeated 
 several times at the same spot, for tlie area within which the larger fragments fall is very 
 limited and is unchanged if all remains quiet. The large and heavy pieces fall invariably 
 in the same place, and may be picked up again and again if this simple rule of keeping the 
 blades in one place is adhered to. Having now broken up the stone and crushed well the 
 largest fragments, and thus occupied perhaps from ten to fifteen minutes, it should be 
 time to employ the aspirator and remove the debris. Accordingly, the screw of the lith- 
 otrite is driven well home, to close the blades, between which some calculous matter prob- 
 ably is engaged, and the lithotrite is withdrawn." 
 
 Removal of Debris of Stone. — The stone, having been crushed, has to be 
 removed; and this is effected by means of a large catheter and powerful evacuation. 
 
 A No. 15 or 16 evacuating catheter for small, and a No. 17 or 18 for large, stones 
 should be selected and passed, the larger instruments, Nos. 25 to 30, as used by Bigelow, 
 being required in very exceptional instances, the size being determined by that of the 
 urethra. These are made of diiferent curves (Fig. 388, C). The urine should then be 
 withdrawn. 
 
 "An aspirator (Fig. 388, D), previously filled with tepid water, is then attached, the 
 connection tap opened, and a small portion of its contents pressed by the right hand into 
 the bladder, the left hand supporting and directing the evacuating catheter." 
 
 " On relaxing the pressure an immediate current outward follows, carrying with it, 
 very probably, a fair quantity of debris. Wait some three or four seconds after expan- 
 sion has finished and the current apparently ceased, as at that precise time it is quite 
 common for one or two of the larger fragments to drop into the receiver which would 
 have been driven back, perhaps, by too rapidly resuming the pressure. This process is 
 
Tiir: (ii'iniATios. 
 
 ^Wj 
 
 repeatiMl sovorul times, iiccdnliii^ to tin- aiiiomit ol' ililirla (ibscrved to enter the traji. 
 After a larj^e erusliiii;^ the eiitl <il" the evaeiiatiii^'^ eatheter sliouM nut rest (in the floor of 
 the lilachler, as it is tlien likely to })e ehoked witli di'luis ; hut after most of tlie fra^rments 
 liave heen removed it is ailvantaireoiis to htwer the end of the eatheter, in onh-r to eateh 
 tlie hist fra!j;meiits. 
 
 '• If tile outflow of the (iiii'eiit is felt to he suildenly eheekcil and tlie aspirator eeases 
 to distend, the operator may he almost certain that a fragment ol' a roiunled or cuhieal 
 
 Fjg. 388. 
 
 Reeeiuer 
 
 Lithotrites, Catheters, and Evacuator reciuireil for Bipelow's Rapid Lithotrity. 
 
 form or a small calculus, nearly fitting the interior of the catheter, hlocks the pa.s.sage 
 and prevents further egress. The piece must be expelled by making smart pressure 
 on the india-rubber bottle, after which the action of the aspirator will probably be 
 resumed. 
 
 " If, after crushing all the stone, so far as the operator is able to judge, and removing 
 the debris largely, nothing is heard or felt in contact with the end of the evacuating 
 catheters, notwithstanding that three or four successive pressures have been made, there 
 is ground for believing that all the fragments may now have been removed. Perhaps 
 there can be no better proof that the bladder has been emptied than is afforded by the 
 fact that a succession of outward and inward currents through the aspirator shows no 
 sign either to the eye or to the ear of the presence of another fragment. 
 
 " If all has not been removed, the sound of a large piece, perhajis making itself heard 
 and felt at each outward current against the end of the catheter, indicates that this must 
 be withdrawn and a lithotrite introduced. If the fragments are not of considerable size, 
 a lighter and handier lithotrite may succeed with advantage to the heavy fenestrated one 
 originally used, and the crushing continued. Of course, if more stone remains, the pro- 
 cess is repeated once or more. In from ten to forty or fifty minutes, however, a uric-acid 
 calculus of very considerable size may be thus broken up and removed.'" 
 
 After-Treatment. — When the patient has fully recovered from the ana?.sthetic, if 
 suffering severely say three or four hours after the operation — a condition, by the way, 
 which is very uncommon — a hot bath, as hot as he can have it, for fifteen minutes, gives 
 great relief. The treatment for the first three or four days in cases of large calculus is 
 that of a mild acute cystitis — recumbent position, external warmth. fre((uent hip baths, 
 and small but fre(|uent doses of solution of potash, just to neutralize the acidity of the 
 urine. If the urethra is overstretched or bruised, an india-rubber catheter may be tied 
 in for twenty-four hours or so, but this is not frequently necessary ; while if the bladder 
 had previously lost the power of emptying itself, such an inlying catheter for a day or 
 two is mostly better than frequent catheterism." 
 
 " As a general rule, we fiiul. during the three or four days immediately following the 
 operation, that the relief is considerable, that the urine is clear, that the bladder tolerates 
 a large quantity, and the aspect of the case is one of rapid and unchecked convalescence. 
 But on the fourth or fifth day a little excitement is not infrequently observed ; the blad- 
 
670 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 der becomes irritable, the urine is cloudy, and after twenty-four hours or so subacute 
 cystitis is established, often destined to be troublesome for a week or two. This liability 
 indicates that it is mo.st desirable to enforce the recumbent position, confinement to the 
 room, a warm temperature (in cold weather), and care in every particular of management 
 for at least some days after crushing a calculus, whatever its size." 
 
 Complications. — When a fragment becomes impacted in the urethra and produces 
 retention, it should either be gently pushed back into the bladder with a large catheter or 
 removed with urethral forceps. These fragments not only produce retention at times, 
 but epididymitis, from irritation of the caput gallinaginis. 
 
 Should fever follow the operation, ushered in with a rigor, there is probably some 
 slight lesion of the urethra. " In nine cases out of ten it is not of serious import, and 
 is treated by keeping the patient warm, wrapping him up well, applying hot bottles, and 
 giving some warm drink, as hot tea or warm wine and water."' A moderate dose of 
 opium is perhaps the most useful prophylactic. 
 
 Occasionally the attack of fever announces the onset of a cystitis, testitis, or some 
 renal complication. 
 
 Hemorrhage is a rare complication. When present, by rest and cold it usually 
 subsides. 
 
 Chronic retention of urine is a complication which is to be carefully looked for, since 
 it occurs very insiduously ; it is to be relieved by careful catheterism. 
 
 Sir H. Thompson reports that he has had 104 consecutive cases of rapid lithotrity in 
 men averaging sixty-two years of age, with only three deaths. This mortality, he adds, 
 "is a better achievement than I had ever ventured to hope for" (Holmes's System, 3d 
 edition, vol. iii.). 
 
 LITHOTOMY. 
 
 In children where lithotrity is inapplicable, and in adults when lithotrity, for reasons 
 already given, ought not or cannot be applied, lithotomy mnsf be employed; and lateral 
 lithotomy is doubtless the best, as it is the most usual, operation. " In children it is 
 difficult to mention any operation in surgery so uniformly successful as lithotomy is. 
 The incomplete development, and the consequently little susceptibility, of the parts 
 involved, the small size of the vessels and the little risk of hemorrhage, the yielding 
 nature of the textures, rendering force unnecessary in the extraction of the stone, are 
 circumstances that combine to divest the operation of much of the danger that surrounds 
 it when performed in the adult. From childhood to the age of puberty the dangers can 
 hardly be said to increase. Boys of thirteen years of age suffer scarcely more from the 
 operation than children, and for the same reason. Seeing, then, that so little risk and 
 suffering attends lithotomy in children, it is difficult for us to find an equally safe and 
 efficient substitute : it can .scarcely, indeed, be said to be required " fAston Key). 
 
 In the adult male lithotomj' is rarely resorted to until the surgeon becomes convinced 
 that the removal of the .stone by lithotrity is inapplicable or has failed ; at least such 
 has been the practice at Guy's Hospital for many years, and, taking the average of cases 
 of stone in the adult admitted, half only have been subjected to lithotomy. In private 
 practice the proportion of cases of lithotomy to lithotrity is much smaller, patients 
 applying for advice at an earlier period. From this fact the worst cases of stone are 
 alone submitted to the cutting operation, and, as a con.sequence, the mortality is high. 
 At Guy's lithotrity being the rule in adults and lithotomy the exception, the mortality 
 of the latter operation in adults is one in three, whereas in places where lithotrity is little 
 practised it is one in five. 
 
 •'It is probable." writes Birkett (Gnys Rep., 1867), "that the rate of mortality after 
 lithotomy must henceforth always appear higher than formerly, in consequence of so 
 many of the patients sufi"ering with stone who might have been cut successfully being 
 those now selected for the performance of lithotrity. In point of fact, the very cases 
 which swelled the li-st of succes.sful results no longer appear in the category of those 
 .submitted to the cutting operation ; but, on the contrary, those patients too ill to recover 
 from lithotrity frequently, as a last resource, submit to lithotomy and perish." 
 
 Lateral lithotomy, or the operation of Raw. Jaques. and Cheselden. is, without 
 doubt, the favorite means of extracting a stone from the bladder among modern surgeons, 
 assuming that lithotrity is inapplicable or inadvisable. As an operation it has been nobly 
 planned, and to see it performed with skill and precision is still a sight which affords 
 gratification to the youngest as well as to the oldest surgeon. In my student days to see 
 Aston Key cut for stone was an event which I now fondh' think over with pleasure and 
 
LITHOTOMY. 
 
 G71 
 
 adininition, and tliti niomory of t]»o skill uinl preci.sirm of lii.s acts in this as in all other 
 operations is still hcrnn- nio as a standard of perfection at which all shonld aim. 
 
 These remarks are not inapplicable ;js a prel'ace to tlie siiltjcet of lateral lithotomy, 
 for Key s use aiitl advocacy of the straight staff in that operation have s(» influenced all 
 his successors that up to the present day " Key's" operation is the one usually performed 
 at Guy's, the exceptions to this rule heinj^ so rare as not to he named. 'J'he success which 
 lias attended this practice has been very <^ooil ; when, indeed, compared with that I'lir- 
 nished from other sources, it seems so remarkable that it is difficult to arrive at any 
 other conclusion than that the mode of oj)eration has something to do with it, for, taking 
 the most reliable statistics — the Norwich 408 cases in sul^jects under puberty, and 
 Thompson's '^^\f^, eliminating the Guy's cases — the mortality was 1 in every 14 A cases; 
 whilst of Guy's eases and Key's operation during seventeen years it was 1 in 57 cases, 3 
 deaths only having occurred in 171 ca.scs, the success of Key's operation being four times 
 greater than that of others. 
 
 In children under five years of age these points are still more strongly marked, as, 
 out of 4U0 cases tabulated by Thompson, the mortality was 1 in every i:^i, the Norwich 
 not being quite so good ; whilst at Guy's after Key's operation, in my old table it was 1 
 in 23 A out of 73 cases, and more ncfntli/^ ditruKj seventeen i/ears^ enih'ng In 187^, 100 
 patients hure been cut consecutively witliout (t denth. 
 
 In the nine years ending 1882 the results were not (|uite so good, as one child, ajt. 3, 
 died on the fifth day from convulsions after secondary hemorrhage when he was thought 
 to have been convalescent, out of 15 cases operated upon. 
 
 This success is certainly more striking than I anticipated when I began the comparison, 
 and must in a measure, if not altogether, be ascribed to the greater safety of Key's 
 operation. 
 
 I propose now to describe the operation of lateral lithotomy, and I shall do .so after 
 what I believe to be the best method — that of " Key," giving also that with the curved 
 staff. But first of all as to the instruments required. 
 
 The staff, whether .straight, as in Key's operation, curved (Fig. 389). or rectangular, 
 as in others, must be regarded as a director. It is a means the surgeon employs to guide 
 
 Fig. 389. 
 
 J'ertjfusson's Ste^ 
 
 his knife into the bladder, and I may say with Key that "the advantage of a straight 
 over a curved line as a conductor to a cutting instrument is too obvious to require any 
 comment. Is it surprising that the. blind should err in a crooked path?" Key's staff is 
 blunt-pointed as a sound and more deeply 
 
 grooved than the common staff, to prevent 
 the risk of the knife slipping out ; the 
 groove is in the centre of the staff, not at 
 one side, as in the ordinary curved one, 
 and it runs to within half an inch of the 
 end. " Its chief superiority." writes Key, 
 "consists in allowing the surgeon to turn 
 the groove in any direction he may wish." 
 The staff must vary in lensth and size. 
 
 Fig. 390. 
 yrvm Fcrgussan 
 
 /{ey's Knife 
 
 according to the age of the patient and size of the urethra, it heing well to use as large 
 a one as will pass readily down the urethra. 
 
672 
 
 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 The knife varies much with the fancy of the operator. That employed by Key 
 (Fig. 390) and his successors resembles in form a common scalpel, but is longer in the 
 blade and slightly convex in the back near the point to enable it to run with more 
 facility in the groove of the director. Different sizes are required for a child and an 
 adult. 
 
 The knife as employed by Sir W. Fergusson (Fig. 390) is given as a type of that 
 required for the curved staif. 
 
 A probe-pointed, bistoury or blade with a round point is sometimes of use to 
 enlarge the vesical opening when not made free enough or to give vent to a large stone. 
 
 Lithotomy forceps should be made of several shapes and sizes, and a scoop 
 
 (Fig. 391) ought also to be at hand. It is used by passing it behind the stone and fix- 
 
 YiQ 391 iii,^ it there by the pressure of the 
 
 left index finger, the instrument with 
 the two hands being withdrawn with 
 mSIoBP II »-A w ^ tbe stone. 
 
 When the perinaeum is very deep 
 Lithotomy Scoop. ^^^^ ^^^^^^ ^^^^.^ ^^^-^^ j^ required by 
 
 the surgeon for the introduction of his forceps into the bladder and the extraction of the 
 
 stone, the blunt gOrget (Fig. 392) may be used, the instrument, guided by its beak. 
 
 Fig. 392. being passed into the bladder upon 
 
 the staff, and upon this the forceps 
 can readily be introduced. 
 
 The gorget is never needed in chil- 
 di'en, but in adults it is often of great 
 
 The Blunt Gorget. ^ 
 
 Preparation for Operation. — The bowels should be well cleared out by a dose 
 of castor oil, given some hours previously, and the rectum emptied by means of an ene- 
 ma the morning of the operation, care being taken that the enema has returned. The 
 perinaeum should likewise be shaved. 
 
 Fig. 393. 
 
 The Operation. 
 
 The surgeon, having decided upon his operation, selected his instruments, and seen 
 that he has at hand everything he may require, having also obtained the help of three, 
 if not four, assistants, besides the aufiesthetist, proceeds to place his patient. 
 
 A narrow but well-raised table should be employed, so that the patient's perina;um 
 and the surgeon's face should be nearly on the same level. The patient should be placed 
 
 on his back with his thighs flexed upon the pelvis and 
 the legs upon the thighs, the hands of the patient being 
 made to grasp his feet and fastened in such a position 
 by the figure-of-8 bandage, the padded bracelets and 
 anklets, as seen in Fig. 393, or Clover's crutch. Chil- 
 dren need not be fastened, but it is more prudent for 
 adults, although some surgeons, since the introduction 
 of anaesthetics, have given up the practice under all 
 circumstances. The shoulders should be well raised, 
 the knees separated, and the pelvis kept well down upon 
 the table by two assistants ; the surgeon should also see 
 that the patient is quite straight, the line of the umbili- 
 cus being the best guide to this position. The peii- 
 npcum should he perpendlcnlar. The surgeon may then 
 pass the staff, and, having introduced it well into the 
 bladder and felt as iveJl as heard the stone, he is to entrust it to the hands of an assistant 
 — one who can confidently be relied upon to hold it in the position in which the surgeon 
 has placed it and who will not draw it forward in any degree. This point is of import- 
 ance, for there is good reason to believe that many of the mishaps connected with the 
 operation are due to the staff having been partially withdrawn from the bladder by an 
 assistant, who perhaps in stooping forward tries to get a sight of the operator's movements. 
 When the straight staff is used, it is to be held well up, with the liandle slightly tilted 
 toward the operator ; and when the curved staff is employed, some surgeons like it to be 
 well hooked up against the symphysis ; but under all circumstances it is to be held 
 steadily. 
 
 Lithotomy Bracelets. 
 
THE OI'EllA TIDS. 
 
 G73 
 
 First Slip. — The surgeon, liaviiig ascertained the sizft of the prostate through an anal 
 examination, may tlieii proceed with tlie y'/>/ «/'/> of" the operation — viz., to hiy l>are the 
 staff <»r direct(»r that is to guide his knife into th(! bladder ; and the |)oint at wliich this 
 opening is (h'sired is nt llir iminhriiitoim [xtrtion hi liiml tlu; hnlh iiml In front of ihc ni<>slntf. 
 IJIi/.ard, Martineau, Stanley, Key. and Kergiisson all lay stress upon this important point. 
 Willi this view the pi-rineal incision is to Ite made, and in lateral lithotomy the line of inci.s- 
 ion lies IVom the left oi' the median line of the perinit'uni downward, hackwanl, and (jutward, 
 midway hetween the anus and the left tuher ischii. The incision is usually from three to 
 three and a half inches long. Some surgeons commence the cut an inch in front of the 
 anus, others tix it at one and a (juarter to one and three-((uarters ; hut this j)oint is not 
 one of primary importance. The object of the incision is to nuike a free external opening, 
 to enable the surgeon to reach the groove of the staff at the part indicated and allow 
 Hubse(|uently <if the removal of the stone ; a point midway betw(!en the scrotum and anus 
 is probably the best to start from, the length of the perineal region varying greatly in 
 difftrcMt subjects. 
 
 In making this ])eriiieal incision the left thumb of the operator should be firmly fixed 
 above the point at which the knife is to be introduced, and it is well for the surgeon with 
 the left fingers to hold the staff firmly at the root of the penis at the same time. The 
 point of the knife may be well introduced into the soft parts in the line of the director 
 and the tissues freely divided in the cut downward, a second or third touch of the knife 
 being made to complete the section. If these be made too low, the rectum is liable to be 
 wounded. In this incision the perineal triangle and ischio-rectal space are laid open, and 
 the skin and fascia with the transverse perineal muscle and its artery divided. 
 
 Second Step. — The surgeon, having exposed the groove of the director (staff) that is 
 to guide his knife into the bladder, should then proceed to the Rfcoud strp of the operation. 
 For this purpose, when the curved staff is used, he should introduce the forefinger of his 
 left hand into the wound and feel for the staff Itehiad and to the left of the bulb, and, liav- 
 inrj charlji made out the two edt/es of tlie groove and run hia nail betzveen them, he should 
 introduce the point of his knife upon the nail of the finger into the groove, and, having 
 clearly divided the tissues sufficiently to make him confident that the point of the knife 
 is well into the groove of the staff", complete his deep section by pushing the knife along 
 the groove of the .staff into the bladder, lateralizing it to divide the left lobe of the pros- 
 tate and neck of the bladder sufficiently (Fig. 394). " The point of the knife in Key's 
 
 Fig. 394. 
 
 Lateral Lithotomy with a Curved Staflf. 
 
 operation being kept steadily against the groove, the operator with his left hand takes the 
 handle of the director and lowers it till he brings the handle to the elevation described in 
 Fig. 8U5, keeping his right hand fixed ; then with an ea.sy, simultaneous movement of 
 both hands the groove of the director and the edge of the knife are to be turned obliquely 
 toward the patient's left side ; the knife, having the proper bearing, is now ready for the 
 section of the prostate ; at this time the operator should look to the exact line the director 
 takes, in order to carry the knife safely and slowly along the groove, which may now be 
 done without any risk of the point slipping out" (Key). 
 
 " In the majority of cases it will merely be necessary to pass the knife along the 
 4^ 
 
674 
 
 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 director, and, having cut the prostate, to withdraw it, without carrying it out of the 
 groove, varying the angle according to the age of the patient, the width of the pelvis, 
 and size of the stone. As the direction in which the prostate should be divided, in order 
 
 Fig. 395. 
 
 .^' 
 
 Lateral Lithotomy with Key's Straight Staff. (Taken froiii Key's works.) 
 
 to adhere to Cheselden's operation, is obliquely downward and outward, increasing the 
 angle at which the knife enters the bladder will incur no risk of wounding the pubic 
 artery. The knife may be conducted with deliberate care into the bladder ; the resistance 
 afforded by the prostate will be readily felt, and the hand of the operator should be 
 checked as soon as he feels the prostate has given way " (Key). 
 
 The surgeon knows when he has entered the bladder by the absence of resistance, and 
 occasionally by a rush of urine. He should remember, however, that some urine will 
 escape so soon as the urethra has been opened, and not be misled by the fact. The angle 
 which the knife makes with the staff regulates the size of the incision into the neck of 
 the bladder. When the knife is in a line with the staff, the incision will be limited ; the 
 larger the angle the knife makes with the staff, the larger will be the wound. 
 
 As a rule, a large wound can be of no advantage unless the stone is vei'y large. A 
 small wound, however, is a disadvantage when the stone is of medium size ; for. although 
 the neck of the bladder is capable of a good deal of dilatation under moderate force, any 
 severe laceration of the prostate is almost certain to be followed by bad results. Surgeons 
 differ much upon this point, some recommending dilatation in preference to free incisions 
 into the neck of the bladder, whilst others prefer free division of tissues rather than run 
 the risk of lacerating them. 
 
 Moderate dilatation is certainly free from risk, while severe dilatation is dangerous, 
 inasmuch as it necessitates great laceration. As a rule, the incision should never exceed 
 the limits of the prostate. 
 
 Third Step. — The bladder having been opened, the third step of the operation remains 
 to be performed, which consists in the removal of the stone. This is to be done by means 
 of forceps. 
 
 The knife having been withdrawn on the completion of the second step, the index 
 finger of the surgeon's left hand, guided by the staff, should be introduced through the 
 wound into the bladder ; and the operator ought always to remember that till the finger 
 has been fairly passed into the Madder vpon the staff, this insfnnnent is not to be ivifhdraicn, 
 although, when the bladder cannot be reached by the finger, the blunt gorget may be 
 passed along the staff, to act as a guide to the forceps. The forceps, held in the surgeon's 
 right hand, is then passed into the wound upon the left index finger, and, guided by it, 
 pushed into the opening, the forceps being introduced into the bladder at the moment the 
 finger is withdrawn. 
 
 " Having delivered his knife to the assistant, the operator, in ' Key's ' operation, takes 
 the staff in his right hand, and, passing the forefinger of his left along the director through 
 the opening in the prostate, withdraws the director, and, exchanging it for the forceps, 
 passes the latter upon his finger into the cavity of the bladder." 
 
 " In extracting the calculus, should the aperture in the prostate prove too small and a 
 great degree of violence be required to make it pass through the opening, it is advisable 
 always to dilate with the knife rather than expose the patient to the inevitable danger 
 consequent on laceration " (Key). 
 
 The forceps should be full-sized and introduced into the bladder closed fiat npon the 
 
SOi'n('J:s OF JUFFICULTY jy LITHOTOMY : lloW To AVOID THEM. (>7o 
 
 stone, and iinmediati'ly ofuMU'tl, the stone <renorally Ix'irif^ at once cauj:lit in tlic liladcs, the 
 rush (tf urine carrvinj:; it toward the wound. The stone sliouhl he ^rra.sjted hiddly, and 
 when seized lie sliiwly and deliherately extracted, the extractinj^ force beiiiir niaile in tlie 
 direction of the axis of the pelvis ihiwiiwanl an<l backward and then forward; a little 
 rotatory and side-to-side motion ol' the instrument at times facilitates the extraction of a 
 calculus, the sur<;enn at thi' same time, with his index fin^^er, pushini; the soft parts off 
 the stone. Before extracting;, the operator, by the sensation f;iven to the forceps, will 
 assuH' liiinsclf tliat the bladder is not caiif^ht. 
 
 It is in this third step of the opcjration that the surgeon frequently meets with his 
 difficulties, and much discretion and fertility of resource is often needed to overcome them, 
 since no definite rules can be laid down as a guide. The stone may elude the grasp oi' 
 his instrument : sometimes it clings to the bladder above the wound behind the .symj)hy- 
 sis, and is thus without the reach of the instrument; at others it is caught above, under 
 which circumstances the pressure of the hand of an assistant above the pubes Ijecomes of 
 value, or the injection of a stream of water is advantageous. Occasionally, although 
 rarely, the stone may be encysted. At times, when the stone is very small, it may be 
 washed out with the fir.st rush of urine, and consecjuently not felt. I have seen this hap- 
 pen in a child. At times a bladder may be opened and no stone found ; '• but from all 
 my experience," writes 8ir W. Fcrgusson, " I feel justified in stating my conviction that 
 most of the cases heretofore related as instances where the incisions for lithotomy have 
 been made, and a istone has not been present, have been examples where the surgeon has 
 failed to reach the bladder." In children this is particularly the ca.se, the surgeon push- 
 ing the bladder inward off the staff. This accident is liable to occur when the neck of 
 the bladder is not sufficiently opened. 
 
 After the removal of the stone the finger or sound should be introduced into the 
 bladder, to ascertain the existence or non-existence of a second stone. 
 
 Aftek-Trk.\tme\t. — As soon as the operation has been completed the patient should 
 be unbound and any bleeding vessels twisted. In children the introduction into the 
 wound of a piece of ice or the application to the wound of a cold sponge, with or without 
 ice, is usually enough to arrest any hemorrhage, and in the adult the same practice, a.^. a 
 rule, suffices. When, however, the hemorrhage is persistent, a piece of sponge or a 
 sponge tent .should be introduced into the wound up to the neck of the bladder ; such a 
 proceeding arrests bleeding, though not the flow of urine, which percolates through the 
 sponge. The sponge may be removed at the end of twenty-four hours. 
 
 Liston was in the habit of introducing a gum-elastic tube six inches long through the 
 wound into the bladder, to carry off the urine for the first two days, and fastening it in 
 with tapes. This practice is still followed by some. It is, however, quite unnecessary ; 
 and at Guy's we use the tube only in exceptional cases — that is, when severe hemorrhage 
 ensues, the wound being plugged around it. Dupuytren employed a tube to which was 
 attached a circular piece of oil silk at its centre, like an unribbed umbrella ; sponge or 
 charpie was introduced between the tube and silk when bleeding took place, after the 
 upper end of the tube had been introduced through the wound into the bladder. Mat- 
 thews has adapted an india-rubber bag around the tube, which can be introduced into 
 the bladder empty and then expanded with air and water. It answers the same purpose 
 as Dupuytren's cannle a chtmise, and is probably more efficient. 
 
 In exceptional cases, when the bulb is cut into, it may be necessary to apply pressure 
 with the finger on the pudic artery to arrest bleeding. 
 
 •The patient having been placed in a bed, a good draw sheet should be placed beneath 
 his hips and a pillow behind his knees, to keep them flexed, while the knees should not he 
 tvd together. A sedative may be employed to give rest, but beyond this little or no med- 
 ical treatment is required. The diet should be nutritious, but unstimulating, and wine 
 and meat given as soon as the appetite demands. The bowels, if not acting naturally on 
 the fifth or sixth day, should be cleared by an enema or mild aperient such as castor oil, 
 and the horizontal position should be maintained till the wound has closed. Key has 
 remarked that in children partial incontinence is apt to follow when this rule has not 
 been observed. 
 
 Sources of Difficulty in Lithotomy, and how to Avoid them. 
 
 The difficulties connected with the operation are too often due to carelessness and 
 too great speed ; consequently, they are mostly of the surgeon's own making. 
 
 If. however, he feels the stone and hears its ring before operating, he is sure of its 
 
676 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 presence, and knows also that the staft' is in tlic bladder, and that it has not passed 
 through any false passage in the urethra or between the bladder and rectum. If, more- 
 over, before, cutting, he assures himself by touching the staff that it has not been dis- 
 placed, he has a direct guide down to the calculus. 
 
 If when cutting after having exposed the groove of the staff, and then proceeding to 
 the second step of the operation, he feels the tico borders of the groove with the nail of 
 his left index finger, and with certainty cuts between them into the groove, he will be 
 still sure of his guide into the bladder, and not likely to fall into the not uncommon error 
 of mistaking the side of the staff for the groove, and thus going astray. 
 
 If, again, when running his knife down the director into the bladder, he pushes it 
 sufficiently far as to feel all resistance cease and for urine to flow, he may be certain that 
 the bladder has been opened. And if, on introducing his finger into the bladder, " he 
 never pushes the point of his forefinger onward unless he feels certain that he has it 
 between the stafi' and the wound," he is not likely to make a cavity with his finger in the 
 cellular tissue outside the bladder or to push the l)ladder off' the end of the staff; and if 
 he never removes the director or staff till his finger or gorget has been introduced into 
 the bladder as a guide to his forceps, he is still free from error. 
 
 In the last step he has only to handle his forceps boldly to grasp the stone fully, and 
 in extracting it alicai/s to draw doivnicard and backward, with some rotation, and he will 
 complete his operation without a mishap. 
 
 The external wound should always be free, the internal limited, moderate dilatation 
 of the neck of the bladder being free from harm. 
 
 If in operating the sui'geon lose his guide, from the end of the staff slipping out of 
 the bladder, and he be unable to effect its reintroduction, or if by some error he has 
 missed the staff and allowed his knife to travel by its side, and thus failed to find the 
 bladder, it is better to relinquish the operation, let the W'Ound heal, and operate again -. 
 for without the guide of the director the operation is an impossibility and all manipu- 
 lation hazardous. But so long as the staff is in the bladder errors may be corrected and 
 the operation completed, for by the reintroduction of the knife along the groove an open- 
 ing into the neck of the bladder that has been made so small as to forbid the introduction 
 of the finger may be enlarged, even when the neck of the bladder has been pushed back- 
 ward and the finger seems about to travel into an unknown region. 
 
 Should the rectum receive a .wiall wound during the operation, it may be disregarded, 
 as it is rarely followed by any injurious effect ; and even when the wound is large, it is 
 well, perhaps, to leave the case to nature. Should it not heal, the case may have to be 
 dealt with as one of fistula in ano, by division of the sphincter. 
 
 At times the walls of the rectum, after the operation, may slough from the injury 
 they sustained during the removal of the .stone, but such cases usually do w^ell when left 
 alone. In my own practice this sloughing took place after the extraction of a large mul- 
 berry calculus, but the case did very well, nor was the recovery tedious. 
 
 Prostatic enkayement may be a cause of difficulty in the operation in elderly patients ; 
 and when with this enlargement there is rigidity, the difficulties are increased, for the 
 surgeon, under these circumstances, in order to make a sufficient opening into the bladder, 
 may have to travel far into the pelvis upon the staff; and when the bladder is opened, he 
 may be unable, on account of its depth, to reach it with his finger. Under these circum- 
 stances the blunt gorget becomes of great value, as it can readily be run along the straight 
 or curved staff into the bladder and form a certain guide to the introduction of the for- 
 ceps. Martineau was very fond of the blunt gorget in most cases, and I am tempted to 
 think that in adult subjects it might now be used more frequently with advantage. I 
 have found the greatest benefit from its use in several cases. 
 
 When the prostatic enlargement encroaches on the bladder, the vesical lobe may 
 be lacerated by the blades of the forceps and torn away, and prostatic adenoid tumors 
 may likewise be enucleated. Key noticed this in 1837 ; Fergusson brought the subject 
 forward at the Pathological Society in 1848; Cadge exhibited two specimens in 1862; 
 and in 1878 I reported two others. I removed one in the fork of my forceps, an inch in 
 diameter, on January 19, 1875, when operating for stone upon a man ajt. 67, with a mul- 
 berry calculus one inch and a half in diameter, and the man made an excellent recovery. 
 The second was from a patient vet. 70 who was operated upon in February, 1876, the 
 prostatic tumor being enucleated during the extraction of a large stone with the forceps, 
 and the recovery was complete. 
 
 When the stone is soft, friable, and comes away piecemeal, it is wise to wash the blad- 
 der well out with a stream of tepid water ; and at times, when the stone is apparently 
 
or in: II (ipkiiatioss. crn 
 
 lifkl liy the Idaddcr in such a posit iim -aa torliitls its hciii^j caiij^ht hy the forceps, a stn-ain 
 ni" water thrmijih the bhulder may dixhidire it and allow (tf its removal. 
 
 Vvii/ tiii'iji stones should he erushed tiinuifjh the pi-ririeul wound before their removal, 
 and a short stront; lithotrite is tlu' best instrument for that purpose. 
 
 In moderately larj^e stones, when the wound in the neck (»f the bladder is not large 
 cnouirh. Liston's advice should be followed and an itu'ision made r)n the; opp(»site side of 
 the neck of the bladder by passing a blunt-pointed bistoury into the; wound, guided by 
 the linger, and turning its edge toward the rii//if tuber isehii. Martineau savs that he like- 
 wise often enhirgi'd the inner wouml two or three times to facilitate the escape of the stone. 
 
 When a sicoiul sfmir I'orms in the bladder and another operation is demanded, there is 
 no reason why it should not be jierforuied in the siiuw. ])osition and manner as the first, 
 and with ecjual success. At intervals of three and fifteen months I have had to cut a 
 patii'ut ;ot. (I<( three times for stone, removing nn the first occasion .seven calculi, on the 
 second two. aiul on the third two, with good results. The stones averaged on each occa- 
 sion more than an inch in diameter. The patient did as well after the second and third 
 operations as after the first, and is now quite well. The Norwich .statistics, as compiled 
 by Mr. C. Williams, show that a third operation uiay be performed with like succes.s 
 {Lancet, May 18, 1878). 
 
 Other Operations. 
 
 The median operation i^ the old Italian or Marian method. ba.sed upon the pre- 
 cept "A small incision, much dilatation," and has been revived by Allarton. It i.s per- 
 formed as follows : The operator fir.st introduces an ordinary grooved staft' into the bladder 
 and gives it to an assistant. He then passes his left forefinger into the rectum, with the 
 ]ialniar surface upward as fjir as the apex of the prostate, and holds it there as a guide to 
 the ne.xt step of the operation. He then takes a long .straight bistoury, and, with its 
 edge upward, introduces it about half an inch in front of the anus in the median line, 
 down to the membranous portion of the urethra or apex of the prostate, into the groove 
 of the staff, and presses it toward the bladder for about half an inch. He then cuts 
 upward, dividing the membranous portion of the urethra freely and the soft parts of the 
 perinjeum. making an external wound about an inch and a half long. Through this 
 wound he next introduces his finger into the bladder with a rotatory movement, the pros- 
 tatic piu'tion of the urethra and the neck of the bladder being dilated; the forceps are 
 then inserted into the bladder and the stone removed. 
 
 Where the .stone is large Allarton employs Weiss's three-bladed female dilator or 
 Arnott's hydraulic dilator. 
 
 This operation as described is precisely the one now generally performed for the digi- 
 tal exploration of the bladder and the removal of growths from the bladder. It is found 
 to give abundance of room for these purposes, and may therefore be said to be of value 
 for the removal of foreign bodies or stones of moderate size from the bladder. I have 
 employed it in several cases of stone during the last three years with success, and in one 
 case removed five calculi over half an inch in diameter with facility. I am indeed dis- 
 posed to think that this operation may prove to be better than the lateral in old subjects, 
 for it is certainly attended with less hemorrhage. In children the dilating process is dan- 
 gerous and apt to be attended by a tearing away of the neck of the bladder from its 
 perineal attachment. The experience of Norwich surgeons, however, in no way tends to 
 give it any support, the mortality of the median being nearly twice as great as that after 
 the lateral operation. 
 
 Dolbeau's operation must be mentioned as a modification of the median. A full 
 description ut' it can be fnunil in his work La Lithotritie Perineale (1872). In its first 
 step, where the membranous portion of the urethra is opened, it differs in no important 
 respect from Allartons. but in the second the neck of the bladder and parts external to it 
 are dilated, while in the third, unless the stone be very small, it is broken before removal. 
 
 The dilating process — an essential part of the operation — is effected by means of a 
 very ingenious six-bladed dilator, the blades of which are so arranged as to separate with- 
 out diverging by means of two balls which move upon a central stem. 
 
 The external parts down to the urethra are dilated first, then the membranous portion 
 of the urethra, and lastly the neck of the bladder, the passage into the bladder by these 
 successive dilatations being of uniform calibre and with smooth walls. The stone is 
 broken, not crushed, by the " cassepierre. ' an instrument that opens in the bladder with- 
 out divergence of its limbs. The fragments should then be removed with care and the 
 bladder washed out. 
 
678 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 Dolbcau claiin.s for tliis operation great advantages which are not yet proved. The 
 instrunient.s, liowever, are very ingenious. 
 
 Dupuytren's bilateral section of the prostate for the removal of hirge stones, 
 with tlie semilunar transverse perineal incision in front of the anus, meets with few sup- 
 porters at the present day. He made his first incision with a scalpel down to the mem- 
 branous portion of the urethra, and afterward introduced into the groove of the staff a 
 double-bladed curved lithotome, which was pushed, closed, down to the stone into the 
 bladder along the staff. The blades were then opened transversely and the instrument 
 withdrawn. 13y these means the neck of the bladder and the prostate were freely incLsed, 
 the prostatic section having an oblique direction downward. 
 
 Oiviale's Operation. — Civiale in 1836 suggested his medio-bilateral operation, 
 " being dissatisfied with the bilateral, and shunning the lateral method on account of the 
 anatomical objections." Having introduced a staff with a median groove, he made an 
 incision in the median line an inch and a half long in front of the anus down to the 
 membranous portion of the urethra. He made also a free opening into the urethra, and 
 then introduced art instrument similar to Dupuytren's lithotome, but straight, along the 
 groove of the staff into the bladder, opening the blades when the bladder had been 
 entered, and dividing the neck of the bladder on its withdrawal. The finger was then 
 introduced, the staff" removed, and the forceps inserted, the stone being removed as in 
 other operations. It differs little from Dupuytren's except in the form of perineal incis- 
 ion. Sir H. Thompson, who first described this operation in England, and Erichsen have 
 both successfully removed calculi by this operation. 
 
 Buchanan's Operation. — Dr. Andrew Buchanan's operation with the rectan- 
 gular staff, bent three inches from the point and deeply grooved laterally with a posterior 
 opening, is essentially a central operation. He suggested it in 1847. The staff is intro- 
 duced into the bladder and guided by the finger in the rectum ; the angle of the staff is 
 made to correspond to the apex of the prostate. The operator, still retaining his finger 
 in the rectum, inserts a long straight bistoury in front of the anus, with the blade hori- 
 zontal and the edge turning to the left down to the groove and angle of the staff, and 
 pushing it toward the bladder, to stop at the end of the staff. He then withdraws the 
 knife, and as he does so makes a curved incision through the soft parts around the left 
 side of the rectum toward the tuber ischii, the wound being about an inch and a half 
 long. Dr. Buchanan describes his operation as being half that of Dupuytren's. When 
 the stone is large, the right side of the prostate is cut, thus approaching it more nearly 
 as a whole. 
 
 The" recto-vesical operation was at one time a very favorite one. The late 
 Mr. Lloyd of St. Bartholomew's was about the last English surgeon who freely practised 
 it, whereas now it has been almost lost sight of. The operation consists in the introduc- 
 tion of the knife into the rectum, with the blade flat upon the palmar surface of the 
 right index finger, the turning of the edge of the knife upward, and the perforation of 
 the bowel and urethra at the apex of the prostate down to the groove of the staff", the 
 sphincter and soft parts being freely divided upward in the median line of the perina?um 
 for about one inch on the withdrawal of the knife. The left forefinger is next inserted 
 into the wound down to the groove of the staff, and the bistoury again introduced with 
 its edge downward and pushed into the bladder along the groove, the neck of the bladder 
 and prostate being freely divided when the stone is large. The finger is then jnxssed 
 into the bladder along the staff, the staff" removed and forceps passed, the calculus being 
 extracted in the usual way. As an ordinary operation this is greatly inferior to the lateral. 
 Kbnig's statistics, as quoted by Poland, show it to be very unsuccessful. When the stone 
 is very large, it may, however, be entertained. 
 
 Supra-Pubic Operation. — The high operation, or supra-pubic, is one of the 
 oldest, and was practised by Cheselden and Civiale. It was at one time supposed to be 
 the most direct and least dangerous operation, the only dangerous part involved in it 
 being the peritoneum, which can readily be avoided. For large stones it may be enter- 
 tained. 
 
 The operation consists of three stages : 
 
 The Jxraf consists in exposing the anterior wall of the bladder by a vertical incision 
 made in the median line above the pubes through the parietes, with the patient on his 
 back, his pelvis raised, and the bladder moderately distended with a one-per-cent. solution 
 of carbolic acid or thymol of the temperatur-e of the body, and well raised out of the pelvis 
 by the rubber rectal dilator (Fig. 363). 
 
 The second step is that of opening the bladder, and care should be observed that this 
 
stom: i.\ Tin: ri:MM.i: i:i.MH)i:n. ()70 
 
 opciiiiitr is made in the iin'tliaii liiu' ami r/osr tn tUr syiiii>lii/sis. Tliis is host dono by traits- 
 lixiiiir the MaddtT wIhtc it is fxpuscd and opcninjr it from liclow u|)\vard. can; heinj^ also 
 ohsiTVi'd that tho wound in tlic alxhunimil parictcs is cand'iilly kci»t open witli retractors. 
 
 The tltlnl step is tlie removal of the stone liy means of ioreeps. 
 
 After the operation the wound in the Madder should be brou^'ht tofrether carefully 
 with sutures ami the external wouml (dosed above, a space beiiifr left below for drainage, 
 and the ease lit'l to nature. Tlif urine should 8ubse(|uently be drawn off" at short 
 intervals. 
 
 The statistics of the operation are not (|uite satisfactory. (Jross J2;ives 1 death in 4 
 cases; Civiale, 1 in 2; Humphry of Cambridge and Dulles, 1 in :{. The latter author 
 speaks hij^hly (d' it (Aiiirn'rdii ./oiinia/ of Mail. Srlmrr, duly. 1S75; April. 1S7S). He 
 believes the o])eration to be (U'servinj,' of mr»re attention ami should receive a fairer trial 
 than it has yet had. 
 
 All theso varieties of operations have been detailed, as exceptional cases of stone may 
 be met with in which one or the other may be better than the lateral ; but as a general 
 operation lateral and median lithotomy are the best, and, of the modes of performing the 
 lateral operation, Key's is the simplest and mo.st successful. 
 
 Causes of Death after Lithotomy. 
 
 When ])atientsdie unrelieved with calculus, they generally do so from kidney disease ; 
 and in the majority of fatal cases of lithotomy the .same cause produces a like result. 
 When kidney disease is imt present, any of the operations described for the removal of 
 the stone, wiien performed with average skill, is likely to be successful. When kidney 
 disease exists, any operation is likely to prove unsuccessful. 
 
 These facts are fully illustrated in a paper I read in 1862 (Roy. Med. and Chir. 
 Society) on the causes of death after lithotomy. 
 
 Prognosis. — The longer a stone remains in the bladder, the greater are the probabili- 
 ties of renal disease ; and, consequently, the larger the stone, the greater the risk. 
 
 The duration of the symptoms and the size of the stone are, consequently, valuable 
 aids in forming a prognosis. 
 
 When death takes place from so-called shock, it is probably connected with organic 
 renal disease. 
 
 In a small proportion of cases death takes place from hemorrhage, such a result, how- 
 ever, when uncomplicated, being very exceptional. It does not probably occur once in a 
 hundred cases. 
 
 Pelvic cellulitis and peritonitis have usually been regarded as common causes of death. 
 Pelvic cellulitis is very insidious, and often only positively made known when some peri- 
 toneal complications make their appearance. Its cause has generally been assigned to a 
 too extensive incision of the neck of the bladder, but the careful investigation of a large 
 number of fatal cases suggests the probability that, although a fatal complication, it is 
 one which for the most part arises without urinary infiltration and as a result of continu- 
 ity with structures that have become inflamed from injury sustained during the operation 
 or from the prolonged presence of the stone. It is also commonly associated with renal dis- 
 ease, and it is now well known that under such circum.stances the inflammation of serous 
 membranes is very common. It is, consequently, an open question as to how far the 
 renal disease or the operation is the cause of the pelvic cellulitis and peritonitis. 
 
 Death from acute cystitis may occur, as it may from the hemorrhagic diathesis, 
 pyajmia. chloroform, or any accident. 
 
 Ursemia as a cause of death is classed with renal disease. 
 
 In children incontinence of urine is apt to follow the operation, particularly when the 
 horizontal position has not been rigidly enforced during the healing process. It is. how- 
 ever, a rare effect. 
 
 Wasting of a testis may likewise take place from some disease or wound of the vas 
 deferens. I have, however, known this to occur but once, but cases of it have been 
 recorded by Teevan and others. 
 
 STONE IN THE FEMALE BLADDER. ' 
 
 Calculi are doubtless formed as frequently in the kidney of the female as in that of 
 the male, and pass downward into the bladder, although, from the absence of the pros- 
 tate, as well as owing to the shortness and dilatability of the female urethra, they rarely 
 require surgical treatment. 
 
680 STONE IN THE BLADDER, AND ITS TREATMENT. 
 
 The records of surgery contain many instances in which hirge calculi have been passed 
 by natural efforts from the female bladder without any very injurious effect resulting, and 
 Mr. Clogg of Looe, Cornwall, has recorded a case in which a stone nearly four inches round 
 was thus passed (Brit. Med. Journ.., May 2, 1074). But the experience of every surgeon 
 will supply him with instances in which calculi of moderate dimensions have been readily 
 passed, and I have a specimen of mulberry stone nearly an inch in diameter which a young 
 woman thus got rid of. 
 
 In neglected cases of vesical calculi in women the stone may, however, excite ulcera- 
 tion of the bladder or be discharged per vaginam. 
 
 Symptoms. — The symptoms of stone in the bladder of the female are very similar to 
 those in the male, such as irritability of bladder, pain during and after the act of mictu- 
 rition, intermittent flow of urine, and hsematuria, a bearing-down pain and incontinence 
 of urine being common accompaniments. In the female sex uterine and vesical symp- 
 toms are so closely associated that surgeons cannot be too much aware of the fact, since 
 cases of stone in the bladder are frequently passed over as examples of uterine disease, 
 when a vaginal examination would reveal the true state of affairs ; a calculus can often 
 be felt by the finger through the vesico-vaginal septum, but where doubt exists the sound 
 will settle the point. 
 
 Treatment. — The treatment of stone in women is far less complicated than in men, 
 on account of the anatomical formation of the parts ; and the majority of calculi can be 
 readily removed either by urethral dilatation and extraction or by lithotrity. 
 
 The method by xirethral dilatation is based on the natural one of expulsion, and is 
 applicable in all cases of small calculi. In children a stone three-quarters of an inch in 
 diameter, and in adults of one inch in diameter, with the patient under the influence of 
 an anaesthetic, may be fearlessly removed from the bladder by rapid urethral dilatation 
 and extraction. Indeed, I have removed calculi two inches in diameter by this means 
 without any injurious after-effect; but it is probably wise not to make the attempt, the 
 surgeon possessing in lithotrity an efficient aid or substitute. 
 
 Slow dilatation of the urethra is almost certain to be followed by incontinence, while 
 after rapid proceedings it is rare to meet with this result. 
 
 The operation may be performed as follows: With the patient on her back, under the 
 influence of an anaesthetic, the urethra should be dilated by my urethral dilator (Fig. 
 438) sufficiently far to allow of the introduction of the left index-finger, or by Weiss's 
 three-pronged dilator, which should be introduced and rapidly expanded. The forceps 
 should then be introduced, when the stone, having been seized, can be rapidly removed. 
 I have on several occasions employed the lithotrite for this purpose, w^ith the view of 
 crushing the stone should any difficulties be experienced in its extraction, and therefore 
 recommend the practice. On four occasions I have not dilated the urethra at all, but 
 passed the lithotrite or forceps and extracted at once, and consider this plan is as good as 
 any other; for every surgeon must be struck with the facility with which a finger or any 
 moderate instrument can be introduced into the female bladder when the subject is under 
 the influence of an anaesthetic. 
 
 If any difficulty is felt in the extraction of the stone or it prove larger than can be safely 
 removed as a whole, it may be broken up and removed piecemeal. By these means I took 
 away at one operation without any difficulty or bad result, from a child only four years 
 old, a calculus an inch and a half in diameter, and in the year 18G9 I successfully removed 
 
 with facility three calculi from three patients by these 
 Fig. 396. means. In female subjects there can be no such hesita- 
 
 tion as to the wisdom of removing fragments after the 
 crushing operation as there is in males. 
 
 When the stone is too large for removal by rapid dila- 
 tation, or the bladder too contracted, inflamed, and ulcerated 
 to allow of lithotrity, the stone should be removed per 
 vaginam, the surgeon in this operation again imitating a 
 method sometimes resorted to by nature. To do this a 
 Extracted ihrou^Ji *^'^^ / clcan incision of sufficient length to admit the removal of 
 ''^"^'"JLctr^ throucyh L'reiAr/A the calculus has to be nnide into the bladder through the 
 Calculus removed ironi the Female vaginal Septum, guided by a director introduced through 
 naturaf size!*)"^ ^ agma. ( a ^jjj^ ^^j.g|^]^j.a. The wound should Subsequently be closed by 
 
 means of stitches, as in vesico-vaginal fistula. 
 In this way I have removed with good success a stone two inches long that formed a com- 
 plete cast of the contracted bladder (Fig. 396). Dr. Aveling and M. Vidal strongly recom- 
 
FouKicy iioDiEs ix Till-: i:i..\i>i)i:u. f;8l 
 
 nu'iul this ofitTiitidii, wliilc the lute .Mariuii Sims tlnni<rlit so well of it as t<» assert '"that 
 it is tin- (iiily jiistiHalilc (i|t('rati(tn fur stdtic in tlic t'ciiiak' bladder;" and if by the w<»rd 
 '' o|)erati(tn" he means a eiittinjr one. he is eertaiidy rif^ht. {'or where the urethra lias been 
 divided to aHow of the removal of stone ineontineiice is u eoinnioii conse(juence. 
 
 Urethral lithotomy is here mentioned only to be ef)ndeinned. as any ineision into 
 the neek of the leniale bladder is liable, as has just V>een said, to fie followed by incon- 
 tinence of urine, half the eases, as a rule, beinj^ so afleeted. 
 
 Hv way of summary, therefore, it may be concluded that a stone of m<iderat»! size 
 mav readily be removed from tlii' female bladder by immediate extraction. an<l one of 
 larjier dimensions by lithotrity and extraction, the patient beinjr JnHij under the influ- 
 ence of an ana'sthetic : that where. I'roin the size of the stmie. immediate extraction i.s 
 not atlvisable. or from the condition of the bladder lithotrity cannot be performed. va;:inal 
 lithotomy is the best operation, while all slow dilatati(»n of the urethra is to be avoided 
 and all urethral lithotomy condemned, (»n account of the fre<|Ucn(y of incontinence of 
 urine as the result of such treatment. 
 
 (For further information and statistics, cldc Dr. Aveling, Ohst. Trnnx.^ 18(J4 ; and paper 
 by author, Mtd.-Chir. Trans., 18G4.) 
 
 Foreign Bodies in the Bladder. 
 
 These are occasionally met with in both the male and the female suVjject. Broken 
 catheters and bougies are probably the most common, but a tobacco-pipe, pins, French 
 chalk, slate-pencil, straw, a silver toothpick, penholder, etc., are in the Guy s Museum 
 recorded as foreign bodies that have been removed from the male bladder, and a bone 
 bodkin-case, a cedar-pencil, and a stiletto from the female. 
 
 Foreign bodies may, however, obtain acce.ss to the bladder through wounds, gunshot 
 or otherwise, or through abscesses connected with bone. Brodie has related a case in 
 which he removed from a young lady a calculus which contained •' a small portion of 
 bone and two imperfectly formed human teeth," doubtless the remains of a blighted 
 ovum or contents of some dermoid cy.st ; and a second, in which a stone from the female 
 bladder had a hazel-nut as a nucleus. 
 
 When a foreign body remains long in the bladder, it acts as an irritant and usually 
 becomes rapidly covered with phosphates (Fig. 38;-)). In a specimen at the College of 
 Surgeons a foreign body is the nucleus of a uric acid calculus. 
 
 As soon as a foreign body is known to exist it ought to be removed. Where this can 
 be effected through the urethra, so much the better ; and as long as the substance is in 
 the pas.sage and not impacted, this may be done ; but when this cannot be effected and 
 the urethra is the seat of the offending body, a clean ineision should be made and the 
 foreign body removed, as incised wounds into the urethra usually heal well, and it is 
 better to make them than to lacerate the urethra by forcible internal manipulation. 
 
 I had a case some years ago in which a long hairpin had been impacted in the penis 
 and perinaeum with its points forward, one end being felt at the base of the penis imbed- 
 ded in the tissues beneath the skin. Under chloroform, I pressed the point through the 
 skin and gradually withdrew the pin, which came out nearly straight. A rapid recovery 
 followed, without a bad symptom. 
 
 When the foreign body is in the bladder and cannot be crushed by the lithotrite or 
 drawn out by the scoop, cystotomy must be performed, and in adults, when the foreign 
 body is not large, the median operation should be chosen. 
 
 The portion of catheter illustrated below (Fig. 397) I removed from the l)ladder of 
 
 Mr. B , ajt. (II. on August 23, 1875, by means of a .snjall lithotrite. thirteen days 
 
 after it had been broken off in the bladder. 
 I was fortunate enough to catch it at its 
 bulbous end and to withdraw it without 
 much difficulty, a rapid recovery following. 
 
 In icomeii under the influence of an ana>s- ^c***^ j\\,tJ- aize 
 
 thetic the body may usually be readilv ex- r, a t rv. . ^ <• x, i t>i i. .», 
 
 ^1, ' „•', .* , ,. • i-nd of Catheter removed from Male Bladder with 
 
 tractea by means of dressing or other forceps. . Lithotrite. 
 
 In the ca.se in which a lady's stiletto (Fig. 
 
 398) was in the bladder of a young woman, I found the point of the instrument present- 
 ing forward and upward and fixed in the .symphysis. With my left finger in the urethra, 
 I pressed it back, and after some little manipulation with the right index finger through 
 the rectum — for the patient was a virgin — I so placed the stiletto as to fix the point 
 
682 SURGERY OF THE URETHRA. 
 
 against the pulp of my left index finger, and with a pair of forceps introduced upon niy 
 finger extracted it. The patient recovered without any inconvenience. 
 
 Most cases may, indeed, be treated with a pair of forceps in the bladder and a finger 
 
 Fig. 398. 
 
 .stiletto leinoveil from Female Bladder. 
 
 in the vagina or rectum to mani])ulate and place the foreign body in a good position for 
 removal, the surgeon seizing the foreign body by one end. For the removal of such a 
 thing as a hairpin a blunt hook may possibly be serviceable. 
 
 CHAPTER XXIII. 
 SURGERY OF THE URETHRA. 
 
 A DIMINUTION in the calibre of the urethra the result of organic changes within its 
 walls gives rise to sfncfure ; any encroachment on the passage from without or within 
 causes obsfrvcfion. 
 
 Obstruction occurs when the urethra is narrowed from inflammatory engorgement 
 of its mucous and submucous tissue (the inflammatory stricture of some authors) or 
 from spasm of the urethral muscles (spasmodic stricture) ; when an abscess or tumor 
 outside or any prostatic enlargement encroaches on the urethra or when any fracture of 
 the pelvis presses upon it ; and lastly, when a calculus or foreign body is impacted in the 
 passage or a urethral polypus blocks it up. 
 
 Organic stricture is caused by the contraction of inflammatory deposit situated 
 upon, within, or beneath the mucous membrane of the canal, or from the contraction of 
 the cicatrix of a ruptured or injured urethra. The first form may be described as simple 
 organic' stn'cfnre ; the second, as traumatic or cicatricial stricture. The former is the more 
 common, my notes showing 603 examples of the former to 43 of the latter in consecutive 
 cases, or in the j)roportion of 14 to 1. 
 
 In the majority of cases the contraction of an organic stricture is of a chronic nature, 
 and in some may be readily traced to a more or less distinct chronic inflammation of the 
 passage ; but years will frequently pass before the obstruction to the flow of urine 
 becomes of sufficient importance to arrest attention, and a sudden attack of retention of 
 urine, induced by some act of irregularity or exposure to cold, will probably be the first 
 symptom to draw the patients attention to his condition. 
 
 The stricture may consist simply of a perforated membranous diaphragm stretched 
 across the canal ; of a narrow band of inflammatory product surrounding the passage, to 
 which the terms " whip-cord," "ring," or '-annular" stricture are attached; and in rarer 
 cases to bands of lymph stretching across the passage and forming what are known as 
 " bridle" strictures. It may be general or partial, and when the latter may have been 
 caused by some adhesion either of the natural rugae of the urethra or of some folds of 
 its mucous lining. When the stricture is more extensive, there is hardly a limit to the 
 extent of inflammatory deposit which nuiy exist, from the narrow band already alluded 
 to as forming the " annular " stricture, passing onward to the broader band which answers 
 to Sir A. Cooper's term of " ribbon " stricture, to the still severer cases in which the 
 urethra is f(juiid more or less contracted throughout its entire course. Between these 
 extremes numberless varie.ties and degrees of mischief may be observed, the urethra pre- 
 senting one single contraction or several independent ones. John Hunter mentioned a 
 case in which six strictures coexi.sted. 
 
 Lastly, the urethra may unijuestionably become " impermeable," the pathological 
 specimens in Guy's Museum being sufficient to demonstrate the fact. Such a condition, 
 liowever. cannot exist uncomplicated with other .symptoms, since it is obvious that the 
 
CAi'sK or sriiKTrRE. 083 
 
 urine must have some chiuinel for «>.scii|i»'. In iln;.st; casert, therefore, urinary fistula will 
 always he fnuiid. An nhUti rnilim of tin- urethra the result of injury from eieatrieial 
 stricture is also met witli. 
 
 Locality of Stricture. — I'or the only iletinite facts rclatin<^ to this suhject 1 must 
 refer — ami I ilo >" with idrasure — to the lahors of Sir II. Thompson; for, although 
 other writers have i^iven their '" im|iressioiis " u|ion the suhject and puhlisheiJ isolated 
 eases, it is to him that the profi-ssion is 
 
 indehteil for the analysis of two hundred I"i<i- •'!'•'•'■ 
 
 and seventy preparations contained in the ^i^'^^^^^K^SSjaffT'^^'^^^^im t'^- , - — 
 various museums, hy which in(|uiry alone L/- ^^^^^^^^^^ 
 this iiuestiou could have heen satisfactorily \ -.^^i^MBiBi^^Kv 
 determined. lie has most satisfaetordy ^*^^^^^^^^^5__^ 
 proved what is now irenerally received as 
 true — that in hy far the majority of ca.ses 
 of stricture the juncture of the spongy and 
 membranous portions of the urethra is its 
 most frequent seat (Fig. 39!h, and that the 
 
 1 -^^ ^ 1 • L' J^ o ^\- A. • ^\ .Stricture of the I'rethra, with iJilatatiini ol' I ruthia iHihind 
 
 inch situated m front ot this spot is the .stricture and Hypertrophy of Hla.l.l.r 
 
 ne.Kt jiosition in point of fre(|uency, while 
 
 exceptional cases may he found in the prostatic end of the membranous portion, at the 
 external orifice, or at the terminal two inches of the urethra ; but no specimen exi.sted in 
 which a stricture has been observed in the pro.static portion. 
 
 Looking over my own cases with a view to ir)(|uiring into the aiuaf)^ of i^fricfiire, I 
 find, omitting congenital narrowing of the urethra, that chronic gonorrhteal inflammation 
 had existed in 27H out of the G4(i instances, and that in 78 of these injections had been 
 employed in its cure ; that direct injury w^as the assigned cause of 43, while in ?>?>i) no 
 definite cause could be obtained. With these facts it seems, therefore, right to conclude 
 " that, although gonorrh(jea often precedes a stricture, at least half the ca.ses are found in 
 subjects who have not suffered from such a disease, and that when gonorrhoea might be 
 assigned as a cause the use of injections for its cure does not appear to have had any 
 positively injurious influence in producing a .stricture." I may add that these results can 
 be strictly relied on. as when noting the ca.ses considerable care was taken to .search out 
 this fact. It may. therefore, unquestionably be asserted that injections have not the 
 injurious influence in exciting stricture which some authors have ascribed to them. 
 
 Among the 330 eases in which no positive cause could be assigned were 3 in which 
 "gout "' existed, and several in which the contraction of chancres might fairly be ascribed 
 as the cause of the obstruction. 
 
 I have been unable to discover that the so-called phosphatic diathesis has any influ- 
 ence in exciting the formation of an organic stricture or any other urethral disea.se, 
 although this is a point upon which Sir. B. Brodie has largely dwelt ; but there can be 
 no doubt that any morbid condition of the urine has considerable power in exciting a 
 spasmodic contraction of the muscular walls of the urethra, more particularly when an 
 organic stricture exists, and of inducing retention of the urine. 
 
 Sy.mptoms. — In a large proportion of the cases of simple organic stricture an attack 
 of retention of urine is the first thing which attracts the attention of the patient, which 
 may have followed some indiscretion in diet, excess of drinking, or exposure to cold. It 
 is then, perhaps for the fir.st time, that the patient can bring to his recollection the fact 
 that other less marked, but not less certain, symptoms had previously existed for some 
 time. It may be that a chronic glf-et had been present for many months or that some 
 urethral pain or difficulty had attended the act of micturition, that the stream of urine 
 had been somewhat narrowed, divided, twisted, or of a screw shape, or that micturition 
 had been more frequent or prolonged ; yet these symptoms by themselves had failed to 
 make sufficient impression upon the mind of the sufferer as to lead him to suspect the 
 i^xistence of a stricture. 
 
 It mu.st not be thought, however, that the retention is usually caused by the gradual 
 contraction of the stricture, though in exceptional cases such a condition may exist ; yet 
 it is tolerably certain that in the majority the retention is due to some spasmodic action 
 of the urethral muscles at the seat of stricture, for very slight cau.ses appear capable of 
 exciting .spasmodic action of the canal in a disea.sed urethra, and consequently of giving 
 rise to retention, s])asniodic and organic stricture being generally combined. Indeed, out 
 of 483 cases of stricture con.secutively admitted into Guys. 120. or more than n fourth. 
 were suffering from retention. When the stricture is not discovered under these circum- 
 
684 SURGERY OF THE URETHRA. 
 
 stances, it will, if not detected early, soon give rise to other and more characteristic 
 symptoms. The stream of urine will gradually contract, so that it will at last cease to 
 exist, the urine passing only in drops. The bladder will become so irritable that the 
 patient will have to rise frequently in the night to micturate, and the effort will be 
 attended with pain ; a small quantity of urine, moreover, will probably also be ])assed ; 
 symptoms aft'ecting the rectum will soon appear, and the straining during the act of mic- 
 turition will be associated with tenesmus, these symptoms at times being so severe as to 
 necessitate, whenever natural relief is sought, the use of the stool in.stead of the chamber- 
 vessel. Prolapsus recti or piles also frequently complicate the case, while incontinence 
 of urine may follow. 
 
 Under these ciix'umstances it is clear that the bladder is never emptied, although some 
 small quantity of urine may be passed at each act of micturition. The retained urine, 
 undergoing partial decomposition, acts as an irritant and becomes cloudy and ammoniacal, 
 depositing more or less mucus and phosphates. The urine, collecting, gives rise to dis- 
 tension of the bladder, which, pressing on the rectum, excites tenesmus and prolapsus, 
 and, interfering with the retui'n of the venous blood, to piles. As the distension increases 
 the bladder loses its power of contraction, and consequently expands till it overflows, the 
 ovirflow of urine giving rise to incontinence^ which is a direct result of chronic retention. 
 A physical examination of the abdomen of a patient under these circumstances will 
 reveal the distended viscus as a central globular swelling giving a dull sound on per- 
 cussion. 
 
 During these changes others no less important are going on at the seat of stricture.: 
 the urethra behind the stricture dilates, this dilatation being mechanical and the direct 
 result of the ineifectual eiforts of the bladder to overcome the obstruction (Fig. 399). 
 As the pressure continues inflammation of the urethra and parts around appears ; the tis- 
 sues as they expand become indurated, and after a time ulcerate. A few drops of urine, 
 as a result, then percolate into the cellular tissue behind the stricture, and, setting up 
 suppuration, form a urinary abscess, which to the finger will appear as a deep-seated peri- 
 neal swelling. When the abscess is .slow in its formation it will be indolent and painless, 
 but if rapid very painful ; when opened or left to natural processes, it will, almost to a 
 certainty, be followed by 2i perineal urinary/ fis^tula. 
 
 If, however, the abscess and the urethral stricture be left unrelieved and the bladder 
 with the abdominal muscles still continues to act ineffectually to overcome the urethral 
 obstruction, the urine, by being forced into the dilated urethra behind the stricture and 
 into the perineal abscess communicating with it, will sooner or later cause rupture of the 
 abscess into the cellular tissue of the parts around, and as a result give rise to extravasa- 
 tion of urine. 
 
 When the parts thus gave way during the efforts of the patient to overcome the stric- 
 ture, or some uncontrollable spasmodic action of the bladder and abdominal muscles, a 
 sudden relief from the previous agony and a sensation that something has yielded may 
 for a time lull the apprehensions of the patient and mislead him into the idea that all is 
 well ; but the swelling of the perinseum, scrotum, penis, and supra-pubic region, which 
 must soon follow, with the absence of any flow of urine through the natural channel, will 
 reveal to the professional eye the true nature of the accident, and prove that the urethra 
 has given way behind the stricture and that exfravaxadon of urine has taken place. 
 
 Instruments for the Detection of a Stricture.— For the detection of a 
 
 stricture, as well as for its dilatation, metallic catheters, elastic catheters, or Jiliform 
 bougies may be employed. 
 
 The metallic catheter I prefer is that shown in Figs. 384, 385. The curve being 
 short and the end bulbous and a size larger than the shank, this form of catheter is very 
 perfect for mere examination purposes. The elastic instruments are upon the French 
 model and are made of the same material throughout, a groove in the top answering as a 
 substitute for the ivory head, which is never known to keep its place ; and when a catheter 
 has to be fastened into the bladder, the benefit of this arrangement is at once proved. 
 These catheters are made very small fFig. 400), even to. the half size. For dilating a 
 stricture they should always be pi'eferred. 
 
 The filiform bougies are made of the same material as the elastic catheter or of catgut 
 or whalebone. I prefer the first and last, as they are made very fine and smooth, with or 
 without olive tips ; some are of the same thickness throughout, whilst others have finer 
 points than shafts. They can often be insinuated through a narrow stricture when a 
 catheter cannot be introduced, and are consequently of great value for dilating purposes. 
 
 As guides into the bladder they are also of equal use, and particularly for internal or 
 
/•;.v. I u/.v I y/o.v inn sriin ti 'rk. 
 
 (J85 
 
 external urctlirotoiny. When these .small bougie.s are u.snJ. tin- un-thra .should he jin-- 
 vioii.sly tilltMl with nil. 
 
 I'ni'drliiiiatt'lv. the sizes ol" the Kreneh and Kn;_dish catheters are imt alike, the former 
 beiiij; inueh more jrradual in their increase. 1 a|t|ienil a table of the two scales: 
 
 N". 1 Kn«lish — No. 7 French. 
 
 .. o .. .. g .> 
 
 •• :{ •• .= " 9 •• 
 
 '•4 " : r " 11 '• 
 
 .. 5 « ^ .. \.> .. 
 
 " 6 " - '• l-> •' 
 
 " 7 " •• Ki " 
 
 .. ^ <> .. j7 u 
 
 .. „ .. ,. j^ >. 
 
 General Symptoms. — During the development of a .stricture, and more particu- 
 larly wlitii the >trietiiie has become a real cause of obstruction, a patient's general con- 
 dition is rarely good, and what are generally known as dyspeptic symptoms commonly 
 exist ; as a con.se(iuence, from the digestive organs failing to do their duty as in health, 
 
 Kio. 400. 
 
 N. 
 
 . 10 
 
 11 
 
 1'2 
 13 
 14 
 
 I'^nglisl 
 
 = 
 
 No. 
 
 19 
 20 
 2-2 
 Zi 
 2o 
 
 •reiieli. 
 
 
 15 
 
 
 = 
 
 
 20 
 
 •< 
 
 
 16 
 
 
 = 
 
 
 27 
 
 
 
 17 
 
 
 rz: 
 
 
 28 
 
 « 
 
 
 IH 
 
 
 ^ 
 
 
 30 
 
 '• 
 
 the patient often loses flesh and looks careworn and ill. As the disease progresses a con- 
 stant feeling of chilliness is very common, and rigors, followed by fever, are not unusual ; 
 these symptoms are at times intermittent, and are often regarded as being due to " ague." 
 AVhen a perineal abscess is forming, they are commonly present. 
 
 When the rigors are uncomplicated with abscess and are still frequent, there is good 
 reason to believe that they indicate some renal complication : for it cannot be too strongly 
 impressed upon the surgeon's mind that no stricture can long exist without producing 
 seciimlarilv iiiipdrtaut changes in the bladder and kidneys. 
 
 Results of Stricture. — When a stricture is neglected, renal di.sease is certain to 
 follow ; and when death takes place as a con.sequence of stricture, it will be from kidney 
 disease if it has not been suddenly brought about by one of the complications of stric- 
 ture, such as retention or extravasation of urine. Thus, out of 100 deaths from stricture 
 analyzed by Dr. Goodhart, the kidneys were suppurating in 41, wasted or inflamed in 18, 
 diseased in a less degree or cystic in 7, and liealthy in 34, or about one-third. 
 
 Organic strictures are not, however, all of the same character. 
 
 The simple stricture is the most usual, and beyond the mechanical eff'ects of its 
 existence has no special feature. The irritable stricture is comparatively rare, and 
 is characterized by excessive .sensibility on being touched by a catheter, with a disposition 
 to bleed. It is also prone to be associated with chilliness, and even rigors. The Con- 
 tractile stricture may belong to either of the former two groups, its peculiarity cdiisist- 
 ing in its tendency to recnntract after it>>. dihitation. The cicatricial Or traumatic 
 stricture has characters of its own, and. of these, its obstinacy is the most marked. 
 
 It is important to bear these divisions of organic stricture constantly in mind, for the 
 successful treatment of a case will often turn upon their recognition. 
 
 Examination for Stricture. — Before a surgeon can say with certainty that a 
 stricture exists a urethral examination is often a necessity, and this is an operation in 
 which difficulties are met w-ith by the inexperienced ; indeed, without some skill and con- 
 fidence the attempt to pass a full-sized catheter down even a healthy urethra constantly 
 fails. 
 
 To pass a catheter it is usually wise to place the patient in the recumbent position, 
 with the shoulders slightly raised and the knees separated : he should, too, be lying quite 
 straight, with the abdomen exposed to the navel, as the linea alba is the best guide as to 
 the line of the urethra. A large metallic instrument (No. 7 or 8 being the best) should be 
 selected for the examination, made moderately warm by being dipped in warm water or 
 rubbed by the hand, and thoroughly well oiled. The operator should stand on the hff 
 side of the patient, and. raising the penis with his left hand, should introduce the end of 
 the catheter into its urethral orifice, keeping its point during the introduction of the first 
 three or four inches well to the lou-er surface of the urethra, in order to avoid the lacunae 
 that exist in the roof of the passage. The handle of the instrument at this step of the 
 operation may be directed over the left thigh of the patient, or, what is preferable, main- 
 tained over the median line of the body in the direction of the umbilicus. With the left 
 
686 SURGERY OF THE URETHRA. 
 
 hand he may then gently draw the penis up the instrunient, while he allows the catheter 
 by its own weight to slip down the passage, simply directing it with a light hand. When 
 its end has reached the bulbous portion of the urethra, the handle of the catheter must 
 then be gently depressed in the central line of the body ; and if no obstruction exists, the 
 bladder will be entered, the point of the instrument during this movement being kept well 
 along the upper surface of the urethra. In a healthy urethra, indeed, the surgeon has 
 little more than to guide a metallic instrument into the bladder, the weight of the catheter 
 being alone nearly sufficient to allow it to pass down the passage. Half the errors com- 
 mitted in catheterism arise from a non-appreciation of this fact, the desire to ^>a.ss the 
 catheter originating efforts that interfere with the entry of the instrument into the blad- 
 der under proper guidance. 
 
 When a stricture exists, the catheter will be arrested in its course; and under these 
 circumstances it should be withdrawn an inch or so and passed on again, with the handle 
 slightly altered in direction. If the resistance is still felt, the instrument should be with- 
 drawn and one of a smaller size employed, and on this failing to glide by the obstruction 
 a yet smaller one should be tried ; and so on till the stricture is entered. 
 
 The seat of stricture or strictures, as well as the nature of the contraction, will be 
 made out by this process. If much pain attend the examination, either the surgeon has 
 employed too much force or an irritable stricture exists ; and if bleeding follows, this 
 latter probability is strengthened, particularly if no violence has been employed. Cathe- 
 terism, indeed, ought never to be attended with violence; and if gentle measures do not 
 succeed, no other should be attempted. 
 
 In passing a catheter some prefer the patient to be in the erect position, but I cannot 
 recommend it; there is more chance of inflicting injury in this position by the patient 
 moving, and the surgeon has not so complete a control over his instrument or patient as 
 when he is recumbent. When there is a stricture, the erect position is certainly wrong. 
 The mode known as the tour de maitre has to be named only to be condemned, though in 
 the hands of a skilled surgeon it may be used with impunity. The plan consists in intro- 
 ducing the catheter — the patient standing — with the handle presenting downward and the 
 convexity of its curve upward, passing it along the urethra down to the bulb, and then 
 onward into the bladder by describing a half circle toward the umbilicus, the handle of 
 the instrument, when it has reached the median line of the body above, being gradually 
 depressed, and the end of the instrument in this turn made to enter the bladder. 
 
 Treatment. — The treatment of stricture must be based on the pathology of the dis- 
 ease, and mild means should always be preferred to forcible or cutting measures. 
 
 The pathology of stricture is simple and consists either in the deposition of inflamma- 
 tory products in the mucous and submucous tissue, with their subsequent contraction, or 
 in the contraction of a cicatrix the result of an injury. 
 
 The principle of treatment is also simple, for it is primarily to dilate the contracted 
 canal, and secondarily to obtain the absorption or breaking up of the effused inflamma- 
 tory products. The more simple the means by which these ends can be secured, the 
 better. 
 
 Where the first end has been obtained without the second, temporary benefit may have 
 been effected, but no more. Where both ends can be gained by simple means, the treat- 
 ment must be pronounced good. In ordinary cases of organic stricture there is little doubt 
 that these ends are to be secured by dilatation of the stricture, and that by such local 
 treatment alone the majority of cases of organic stricture may be succes.sfully overcome., 
 
 Now, this treatment by dilatation may be continuous or intermittent. The former method 
 is to be preferred and should be carried out ; it is the most rapid and effectual the surgeon 
 has at his disposal, although it necessitates about a fortnight's rest. 
 
 The Continuous Method. — The size of the stricture having been gauged, an elastic con- 
 ical catheter with a bulbous end is to be taken and well oiled, and as large a one as can be 
 passed through the stricture introduced. Should the English catheter be preferred, it ought 
 to be made soft and flexible by being dipped in warm water or by friction with the finger, 
 and used without the stylet. The penis of the recumbent patient must then be raised by 
 the left hand and drawn forward as well as slightly downward, so as to make the urethra 
 as straight as possible. The catheter should then be introduced and passed gently down 
 the passage. If obstruction be felt, the catheter may be slightly withdrawn and then 
 pressed forward. The largest instrument the .stricture will admit without force should be 
 introduced, and, having passed the stricture and entered the bladder, it is to be fastened 
 in (Fig. 401). The end of the catheter up to its eye alone should rest in the bladder. 
 
 The orifice of the catheter may be either plugged with a peg of wood or the end 
 
TRKATMllST ni' STllK'TrnK. <j«7 
 
 capped V»y a y'\vvv of iii<lia-riiltJ)«'r tuliitijr. the fret- cikI nf which shDiild he dropju'd into 
 a urinal or tied in a kin»t tn prevent escupt- <»f' urine. 
 
 Alter twfiif y-toiir hniir.s. il' the catheter moves freely in the stricture, it may he 
 removed and a lartrt-r si/e introduced, the sur^'con hcinj: careful not to he tempted to 
 introduce one that fits th«' stricture too firndy. On the third 
 and following' days the same practice may he loilowed. and 
 in ahout ten days a comjtlete <lilatation of the stricture will 
 prohahly have heen perfected. If the catheter does not move 
 freely in the stricture, it must he left a few hours longer. 
 When the presence of the instrument in tlie hladder caus«'.s 
 irritation which is not remedied hy such alkalies as the citrate 
 or tartrate of potash with huchu and hyoscyatnus. it is wise to 
 have tin- catheter removed some few hours hefore a lar{:er size 
 is introduced, therehv <:ivinL' the hladder rest. When it is 
 impossihle for the patient to" maintain rest, a catheter may he-^''^^'^'' l ^-tenim.^ra.heter in the 
 passed in the evenint:. retaine<l all niirht, and removed in the 
 
 niorninir. At other times, where the symptoms are more severe, some slight intermi.ssion 
 of the treatment may he advi.sahle. the pas.sage of the catheter alone heing practised. 
 After the stricture has heen fully dilated tlie daily passage of an instrument for a few 
 days suli.sequently is all that is re<juired, the intervals hetween the introduction of the 
 catheter heing gradually lengthened. 
 
 The patient need not always V>e confined to bed during this treatment, but may lie on 
 a sofa or sit <|uietlv in a redining-chair. When movement, however, causes irritation of 
 the bladder, it must be forbidden. 
 
 In severe and neglected strictures this plan is one that ought always to Vje followed 
 when po.ssible. as it is sound in its princijde. safe in its practice, and as expeditious as is 
 consi.stent with the oVjject aimed at. 
 
 Iiiffrrniittaiit Dihitiitioii. — The intermittent method of dilatation is required in less 
 severe cases or where rest cannot be obtained, and it can be carried out by the introduc- 
 tion of an instrument on one day. and after the lapse of one or two more its reintroduc- 
 tion. followed immediately by the employment of a larger size, and then the next, and the 
 next size larger still, till complete dilatation of the stricture has been effected. It is the 
 second-best plan the surgeon lias at his command, and, although more tedious than the 
 former, is in the end successful : patients so treated, however, require, doubtless, the more 
 frequent introduction of a catheter to maintain the urethra in its dilated condition than 
 others treated by the former plan. For this method of treatment metallic instruments 
 are better than ela.stic. 
 
 When a stricture is so contracted that a catheter cannot be passed even after very 
 careful manipulation, the attempt should be given up and alkalies prescribed. AVhen the 
 urethra is irritable, opium, enforced rest, and the hip Vxith are of use. and after the lapse 
 of a day or more success may follow another attempt. When the stricture is reached by 
 the catheter, gentle pressure upon it may be employed ; indeed, pressure may be kept up 
 for two or three minutes, the parts often yielding under its influence and allowing the 
 instrument to pass. If this end be obtained, let the surgeon he .satisfied and leave the 
 catheter in. whether silver or elastic ; for should he remove it. he will in all probahtility 
 fail to pass a second. If the instrument be silver, an elastic one should be substituted 
 when it is removed. 
 
 When a catheter is grasped and '■ held " in the urethra, the operator may be tolerably 
 sure that he has entered the stricture ; and when its end is movable, he may be equally 
 sure that he is in a false passage. When the catheter has been held and passed forward 
 into the bladder, all is well ; when it .slips suddenly into a movable space, the urethra has 
 probably Vjeen perforated. Under these circumstances, when a false passage probably 
 exists, it is wise to give up local treatment for a few days, to allow the parts to heal. 
 
 A stricture should be dilated up to its fullest extent. 
 
 It i'.s important to hear in mind that aftn- the full (lilatation of a stricture contraction 
 xciU aijain take place after a time if the pasiiaije he not kept open, but the introduction of a 
 catheter once in every two. three, four, or more months, according to circumstances, is 
 generally sufficient to prevent such a result taking place. 
 
 On Splittin;j Strictures. — What in modern language is called fh^ rapid or immediate 
 treatmtnt of stricture is in reality its rupture or splitting, it being in all probability a rare 
 thing for a stricture to be suddenly, fully, and rapidly dilated without being lacerated. 
 The plan known by this name has certainly a taking title, and in practice has apparent 
 
688 SURGERY IN THE URETHRA. 
 
 advantages which, if supported by experience, would establish its claims on the attention 
 of surgeons. In our day it is known as that of Holt, but Holts instruments are mere 
 modifications of M. Perreve's made in 1847, and the same sort of practice has been 
 adopted by Mr. T. Wakley, Dr. Hutton of Dublin, Maisonneuve, Buchanan, and others. 
 
 Holt describes his instrument " as consisting of two grooved blades fixed in a divided 
 handle and containing between them a wire welded to their points, and on this wire a tube 
 (which when introduced between the blades corresponds to the natural caliVjre of the 
 urethra) is quickly passed, and thus ruptures or splits the obstruction.'" 
 
 The stricture having been split, the dilator should be rotated, to separate further the 
 sides of the rent, and then withdrawn, a catheter corresponding to the number of the tube 
 being substituted, for the purpose of removing the urine. This method, however, no 
 more effects a permanent cure of a stricture than the plan of dilatation, already referred 
 to, since every hospital surgeon has been called upon to treat cases of stricture that have 
 been subjected to this plan and then have relapsed. Indeed, there is reason to believe 
 that after tJie rapid metluxl an early relapse is more common than after others, and that 
 the cicatrices of these split structures contract faster than the original. Bad. and even 
 fatal, effects, moreover, are more common after the splitting operation than after gradual 
 dilatation. 
 
 The plan of treatment by dilatation I have laid down is safe and rarely followed by a 
 fatal result, but this cannot be said after the splitting of the stricture, although facts are 
 wanted to establi-sh the proportion of fatal to successful cases. 
 
 To narrow, ring or annular, subpubic, or penile strictures Holt's method is probably 
 well adapted, but for indurated, ribbon, tunnel, or complicated strictures it is dangerous 
 and unsuitable. 
 
 When a stricture is associated with a vesical calculus and it is a matter of necessity 
 to cure the one before lithotomy is employed, the immediate method may be used, but it 
 ought to be understood that a greater amount of danger attends its practice than follows 
 the more ordinary method. 
 
 The best instrument for this plan of treatment is that made by Weiss for 3Ir. B. W. 
 Richardson of Dublin (Fig. 402). 
 
 Fig. 402. 
 
 Richardson's liilator. 
 
 Other Forms of Treafnifut. — Yet all strictures cannot be treated by dilatation, for 
 " cases occur occasionally which are so exquisitely sensitive that the passage of a catheter, 
 however skilfully performed, is followed by such severe constitutional and local disturb- 
 ance as to produce more harm than good, and in which it is clear some other method of 
 cure must be employed ; whilst there are others which are relieved by means of the 
 catheter, and even fully dilated, but which have a tendency to recontract immediately 
 upon the omission of the treatment. In the former case the treatment aggravates instead 
 of relieves the symptoms ; in the latter it must be continued for life to preserve an open 
 passage. Under such circumstances some other plan of treatment must be adopted ;" 
 and I believe now, as when the above words were written. •• the most beneficial to be the 
 external division of the stricture from the perinfeum. and it is to the late Professor Syme 
 that we are here especially indebted for having so ably recalled our attention to the treat- 
 ment of such troublesome' and painful cases'' (^Guys Reports, 1858). 
 
 The surgeon must not, however, in all cases of irritable stricture come to the conclu- 
 sion that Syme's operation is required, as it is only in exceptional examples that it is 
 needed, for in some the irritability rapidly disappears under the use of the catheter, and 
 in others rest, alkalies, and opium have a mo.st beneficial influence. If these fail, the cut- 
 ting operation may be performed. 
 
 Recently the laminaria stalks have been employed for dilating stricture, but for peri- 
 neal strictm-es they are dangerous and are apt to break. For strictures at the orifice of 
 the urethra from the contraction of cicatrices they are most valuable, but for all other 
 forms they are ill adapted. A laminaria tent swells to at least twice its diameter and 
 may be introduced into the urethra dry and left there, a small shield being fixed to one 
 end. to prevent its slipping into the passage. 
 
 Caustics are not at the present day much employed in the treatment of stricture ; 
 indeed, few use them. The practice in theory is neither sound nor in its results certain ; 
 
URKTIIIIOTOMY. 
 
 <j«9 
 
 imlced, it is probably injurious, siiicf it is iuijxissibk' to iippiy sucb a oaustic as tho potassa 
 fusa to tbc si'at oi" stricture aloiic ; and when tissues an? tlcstroyed l)y its influiMice. tlioy 
 will subsi'tpu'utly i-icatrizK and coiitrat-t, and tliu> add In llic iiiisrliicl". 'I'bc i)ractict! is 
 not one tliat can in any way l>c rcconmii'iidcd. 
 
 Otis's method of treating stricture may Ik- described as a combination of 
 rupture and urelludloiny. lie a>serts it Id \)v. applicable to all cases of stricture situated 
 anterior to ti»e bulb, and that it is a radical cure in nine cases out ol" ten. 
 
 The operation is performed by tirst stretchinjj^ the stricture to the full ; second, slightly 
 cuttinj^ it by an instrument with a concealed blade ; and third, at once dilating the urethra 
 to a little more than its normal size. 
 
 Alter the operation the urethra is to be niaint;iiii(<l at its lull size by the daily pa.s- 
 sa;;c dT metal sounds until the incisions have healed. 
 
 Fig. 403. 
 
 Urethrotomy 
 
 is a comprehensive term, and includes the infmi'if d'wiAon of a stricture from the urethra 
 as well as the external through the ))erin;oum. 
 
 Internal urethrotomy has now many advocates, and in hard, old strictures it is 
 preferable to their rupture; lur strictures also at the orifice of the urethra and within the 
 penis it is a safe and valuable practice. In the hands of some surgeons it has been much 
 practised advantageously, and Mr. Lund of Manchester has lately advocated it. Many 
 instruments have been invented for the purpo.se, and Stafford's instrument, made in 1827, 
 is well known. Fergusson employed a long grooved director, which he 
 pas.sed through the stricture, and a very narrow-bladed knife, which can be 
 buried in the groove. Many ingenious instruments have been invented, but 
 the best is that which divides the strictures from behind forward on its with- 
 drawal, such as that represented in Fig. 403. It is one that I have had 
 made on Trelat's principle, perforated at its end for a guide bougie. In 
 strictures of the orifice a bistoury may be used. 
 
 After the division of the stricture it was a common custom to pass a 
 large catheter into the bladder and leave it in, but M. Gouley has fairly 
 shown that such a practice is not required. In orificial strictures after their 
 division the laminaria tent is the best to use, with a shield. 
 
 Maisonneuve employed a filiform gum-elastic bougie as a guide through 
 the stricture, as well as a grooved steel director, which is screwed to the 
 bougie and pushed into the bladder when the stricture has been divided. 
 
 Subcitfinti'ons perineal urethrotomy has been praetLsed, but my own expe- 
 rience of ir has not been favoraljle. 
 
 External urethrotomy is a valuable operation in .selected cases and 
 includes three very different measures — o)ic, in which the stricture is divided 
 through the periujeum upon a grooved director passed through the stricture 
 (extermd diri'sfoii or Syme's operation), the acconJ. in which the urethra is 
 opened in front of the stricture and a grooved probe passed through it into 
 the bladder previous to its division (Wheelhouse's operation ) ; and the third^ 
 in which the perinjxjum is laid open witlioat a urethral guide, the stricture 
 being impervious ; and to this the term piriiiecd section ought to be confined 
 (Cock's operation). 
 
 Syme's operation, as already stated, is valuable in the highly irrita- 
 ble as well as contractile stricture, in cases which Syme described as stric- 
 tures that " continue to present symptoms after being dilated " and that '' are 
 indomitable by the ordinary means of treatment." It is, moreover, usually 
 successful. 
 
 The operation is by no means one of difficulty. A grooved straight staff 
 as large as can be passed through the stricture is first introduced, the patient 
 having been placed upon his back, as if about to be cut for stone. The sur- 
 geon should then with perfect precision introduce his knife into the centre 
 of the periufpum, and at one stroke cut down upon the groove situated at 
 the lower border of the staff, and, using this as his guide, divide the perineal 
 portion of the urethra in which the stricture is situated. There are but two 
 important points to be observed in this the second step of the operation : the ^^ethr 
 first is to be certain that the knife occupies the groove of the staff, and sec- perforated at 
 ondly that the whole of the diseased or strictured portion of the urethra is Bougie. 
 
 44 
 
690 
 
 SURGERY OF THE URETHRA. 
 
 freely divided. Having succeeded in this the essential part of the operation, and after ;i 
 grooved probe or director has been introduced into the bladder through the perineal 
 wound, the sound may be removed, when either a full-sized elastic catheter can be readily 
 introduced through the penis into the bladder and fixed in, or Syme's catheter (Fig. 404) 
 may be introduced through the perineal wound for twenty-four hours. 
 
 Fig. 404. 
 
 Syme's Perineal Catheter. 
 
 After-Treatment. — The patient should then be sent to bed and a mild opiate given, 
 such as ten grains of Dover's powder, if much general or local vesical irritability exists. 
 The catheter may be left in for several days if it fiiil to cause pain, but if the bladder 
 resents its presence it may be removed ; indeed, more extensive experience has led me to 
 think that the presence of a catheter is scarcely required for three or four days after the 
 operation, when it should be passed and left in during the healing process. 
 
 After the wound has closed the occasional introduction of a catheter is essential, and 
 I cordially agree with Professor Syme in thinking '' prudence requires that every patient 
 who has had a stricture divided should learn to introduce bougies, since by doing so at 
 intervals of a week or a fortnight he will be perfectly secure from future trouble." The 
 division of a stricture no more effects a permanent cure than its dilatation or rupture, and 
 occasional dilatation is essential to maintain its patency. 
 
 WheelhOUSe's Operation. — Mr. C. G. Wheelhouse of Leeds has introduced an 
 operation for impermeable stricture which I believe deserves attention. He states that 
 in his hands and in those of his colleagues it has been most successful. 
 
 The instruments required for its performance are as follows : 
 
 " Lithotomy bandages ; a special staff fully grooved through the greater part, but not 
 through the whole, of its extent, the last half inch of the groove being ' stopped ' and 
 
 Fig. 40.5. 
 
 Grooved Staff, with Button-like tnd. 
 
 terminating in a rounded button-like end (Fig. 405) ; an ordinary scalpel ; two pairs of 
 straight-bladed forceps, nibbed at the points; ordinary artery forceps and ligatures; 
 
 Fig. 406. 
 
 Teale's Probe-Gorget. 
 
 sponge; a well-grooved and finely probe-pointed director; Teale's probe-gorget (Fig. 
 406); a straight probe-pointed bistoury; a short silver catheter (No. 10 or 11 gauge) 
 with elastic tube attached. 
 
 " The patient is placed in lithotomy position, with the pelvis a little elevated, so 
 as to permit the light to fall well upon it and into the wound to be made. The staff 
 is to be introduced with the groove looking toward the surface and brought gently into 
 contact with the stricture. It should not be pressed much against the stricture, 
 for fear of tearing the tissues of the urethra and causing it to leave the canal, 
 which would mar the whole after-proceedings, which depend upon the urethra being 
 opened a quarter of an inch in front of tlie stricture. Whilst an assistant holds the 
 
ri:i:riii:()T(iMY 
 
 091 
 
 Whuellioiise's Oiieration of Opeiiin); frethra. 
 
 etiiff ill tliis |)ositiiiii an iiicisioii is iiiiidc into tlio pciiiia'um, cxtorulin;; from opposite the 
 point of rt'flci'tinii ol" the siipcrliciiil prrinoal 
 fasciu to tlu' anterior nliri- nl' the spliiiictcr ani. 
 The tissues (if tlio periiiiiMiin arc to Itc steadily 
 divided until tlu' urethra is reached. This is 
 now to lie opened In thf ijriiinr kA' the stall, not 
 vpnii ifs ftiii'iit, so as eerrainly to seeiire a (|uart(!r 
 of an iiieli of healthy tiihe iniinediately in fniiit 
 of the strietiiri'. As soon as the urethra is open- 
 ed and the LM'oove in the staH' fully exposed the 
 edgi's of the healthy urethra are to he si'ized on 
 each side hy the straiirht-hladed iiihhed lorceps 
 and held apart. Tiie stall' is then to he jreiitly 
 withdrawn until the hiitton-poiiit appears in the 
 wound. It is then to he turned round, so that 
 the fjroove may look to the pubes, and the hut- 
 ton may he hooked into the upper angle of the 
 opened urethra, whieh is- then held stretched 
 open at three points; thus ( Fig. 407), and the 
 operator looks into it iniinediately in front oi' 
 the stricture. Whilst thus held open the probe-pointed director is inserted into the 
 urethra, and the operator, if he cannot see the opening of the stricture — which is often 
 po.ssible — generally succeeds in very quickly finding it, and passes the point onward 
 thnnKjIi the stricture toward the Idadder. The stricture is sometimes hidden amongst a 
 crop of granulations or warty growths, in the midst of which the probe-point easily finds 
 the true passage. This director having been passed on into the bhuhler (its entrance into 
 which is clearly denionstrated by the freedom of its movements), its groove is turned 
 dowmcard, the whole length of the .stricture is carefully and deliberately divided on its 
 under surface, and the passage is thus cleared. The director is still held in the same 
 position and the straight probe-pointed bistoury is run along the groove, to ensure com- 
 plete division of all bands or other obstructions. These being thoroughly cleared, the 
 old difficulty of directing the point of a catheter through the divided stricture and onward 
 into the bladder is to be overcome. To effect this the point of the probe-gorget is intro- 
 duced into the groove in the director, and, guided by it, is passed onward into the blad- 
 der, dilating the divided stricture and forming a metallic floor, along which the point. of 
 the catheter cannot fail to pass securely into the bladder. The entry of the gorget into 
 the latter viscus is signalized by an immediate gush of urine along it. 
 
 " The short catheter is now passed from the meatus down into the wound ; is made to 
 pass once or twice through the divided urethra, where it can be seen in the wound, to 
 render certain the fact that no obstructing bands have been left undivided ; and is then, 
 guided by the probe-dilator, passed easily and certainly along the posterior part of the 
 urethra into the bladder. 
 
 '' The gorget is now withdrawn, the catheter fastened in the urethra and allowed to 
 remain for three or four days, the elastic tube conveying the urine away to a vessel under 
 or by the side of the bed. 
 
 '•After three or four days the catheter is removed, and is then passed daily or every 
 second or third day, according to circumstances, until the wound in the perinjijum is 
 healed ; and after the parts have become consolidated it recjuires, of course, to be passed 
 still from time to time, to prevent recontractinn." 
 
 Perineal section, or Cock's operation, is a more difficult and dangerous 
 
 operation than Symes, and is called for in far more severe cases — that is, when the 
 urethra is impervious and no guide, to the urethra exists beyond that which the surgeons 
 knowledge of the anatomy of the parts affords. It should also be remembered that, as a 
 rule, the normal anatomy has been nearly destroyed, for impervious strictures requiring 
 urethrotomy are usually chronic, as well as complicated with extravasation, suppuration, 
 or urinary fistulre. 
 
 The operation I shall describe is that one suggested by Mr. Cock and known by his 
 name. " The objects aimed at in the operation can be accomplished, while I doubt if those 
 of any other have ever been fulfilled. However complicated may be the derangement of 
 the pcrinticum and however extensive the obstruction of the urethra, one portion of the 
 canal behind the stricture is alwa^'s healthy and often dilated, and is accessible to the 
 knife of the surgeon. I mean that portion of the urethra whieh emerges from the apex 
 
692 
 
 SURGERY OF THE URETHRA. 
 
 Mr. Cock's Operation of Tapping the Urethra at the Apex of 
 the Prostrate, or Perineal Section. 
 
 of tlie prostate — a part whicli is never the subject of stricture, and whose exact anatom- 
 ical position may be brought under the recognition of the linger of the operator. Thus, 
 when we cannot introduce a catheter by the ordinary method, and even when we cannot tap 
 the bladder through the rectum, it still remains to us to tap the unthraas it emerges from 
 the prostate, and thus to effect the desired communication." 
 
 The operation, which Mr. Cock has described as '• tapping the urethra at the apex of 
 the prostate, unassisted by a guide staff',' is illustrated in Fig. 408. I have seen Mr. 
 
 Cock frequently perform it, have done it 
 myself on many occasions, and have no 
 hesitation in strongly recommending it 
 as the operation for external urethrotomy 
 without a staff". The only instruments 
 retpiired ar€ a Lrood double-edged knife 
 with a very sharp point, a large silver 
 probe-pointed director with a handle, and 
 a catheter. 
 
 "The patient," writes Cock/ "is to 
 be placed in tfhe usual position for lithot- 
 omy ; and it is of the utmost importance 
 that the body and pelvis should be 
 straight, so that the median line may be 
 accurately preserved. The left forefin- 
 ger of the operator is then introduced 
 into the rectum, the bearings of the 
 prostate are carefully examined and 
 ascertained, and the tip of the finger is lodged on the apex of the gland ; the knife is 
 then plunged steadily but boldly into the median line of the perinjeum and carried on in 
 a direction toward the tip of the left forefinger, which lies in the rectum (Fig. 408). At 
 the same time, by an upward-and-downward movement, the vertical incision may be car- 
 ried in the median line to any extent that is considered desirable. The lower extremity 
 of the wound should come to within half an inch of the anus. 
 
 " The knife should never be withdrawn in its progress toward the apex of the pros- 
 tate, but its onward course must be steadily maintained until its point can be felt in close 
 proximity to the tip of the left forefinger. When the operator has fully assured himself 
 as. to the relative position of his finger, the apex of the prostate, and the point of his 
 knife, the latter is to be advanced with a motion somewhat obliquely either to the right 
 or the left, and it can hardly fail to pierce the urethra. If in this step of the operation 
 the anterior extremity of the prostate should be somewhat incised, it is a matter of no 
 consequence. 
 
 " In this operation it is of the utmost importance that the knife be not removed from 
 the wound and that no deviation be made from its original direction until the object is 
 accomplished. If the knife be prematurely removed, it will probably, when reinserted, 
 make a fresh incision and complicate the desired result. It will be seen that the wound, 
 when complicated, represents a triangle, the base being the external vertical incision 
 through the perin^eum, while the apex, and consequently the point of the knife, impinges on 
 the apex of the prostate. This shape of the wound facilitates the next step of the operation. 
 '* The knife is now withdrawn, but the left forefinger is still retained in the rectum. 
 The probe-pointed director is carried through the wound, and. guided by the left fore- 
 finger, enters the urethra and is passed into the bladder. The finger is now withdrawn 
 from the rectum, the left hand grasps the director, and along the groove of this instru- 
 ment the catheter is slid until it enters the bladder. 
 
 " The operation is now complete, and it oidy remains to secure the catheter in its 
 place with four pieces of tape, which are fastened to a girth round the loins. 
 
 " A direct communication with the bladder has now been obtained, and the relief to 
 the patient will be immediate; unless the kidneys have become irremediably disorganized, 
 we may confidently anticipate a favorable result; and the restoration of the urinary organs 
 will be more or less complete in proportion as the obstructed portion of the urethra is more 
 or less amenable to the ordinary judicious treatment of stricture. 
 
 " The catheter ma}' generally be retained in the bladder for a few days ; and if the 
 state of the urine renders ablution necessary, the viscus may be fi'equently washed out. 
 The catheter may then be removed, cleansed, and reintroduced. 
 
 I Guy\ Eosp. Rep., 1866. 
 
CdMi'LicATioss OF sTi'jcrriii:. 093 
 
 ■ It' tlif previous dcstructidii has not })C('m very ^reat. and if tin; ease progresses favor- 
 ably, tlic swellintr ol" the |ieriii:eiiiii and scrotiun frradiially sul)sitles, the induration dis- 
 appears, and the urinary sinuses become obliterated. The urethra may then be examined 
 in the i)rdinary way. to test its pernu'ability, and one may be agreeably surprised t<» find 
 that tlu' sound or catheter readily passes through the fnrnier stricture into the bla<Ider ; 
 its passage mav. il' necessary, be facilitated by passing a director through the periiueum 
 into tlie bhidiler and guiding tin- catheter along its groove. The urethra once restore<l to 
 its normal «'iiiidition and calibre, the artificial opening through the periujcum soon heals 
 up, and, barring the liability of stricture to return if not attt-ndcd to. the cure may be 
 said to be complete. 
 
 *' We must not. howcvt-r, always expect so favorable a result. I have operated in 
 several ca.ses where the obstruction of the canal was complete and impermeability per- 
 manent.' 
 
 •* In such cases the patient is condemned to pass his water through the artificial open- 
 ing in the perinteum unless a new pas.sage .should be bored to unite the upper and loM'er 
 portions of the patient's ui-ethra — an operation which I have seldom or never known to 
 be successful. 
 
 •' The necessity of micturating through the perinteum may seem to be a considerable 
 hardshij). but with a little arrangement the inconvenience is not very great; and be it 
 renu'nibered that the man's micturition is merely assimilated to that of the other sex. 
 
 " To keep the artificial passage in a permeable state, it is generally necessary to pass 
 a flexible bougie through the opening occasionally and to retain it in situ for a few hours. 
 The patient ver}' soon learns to do this for himself. 
 
 " I have now under my frequent observation two men, on one of whom I operated 
 twenty-five years ago, on the other twenty, and both are thankful for their condition. 
 
 •' I have not found this operation, with its result in a permanent factitious urethra, 
 at all interferes with the sexual function, although it is, of course, a complete bar to 
 procreation." 
 
 I have described fully this admirable operation in the words of its originator, and 
 believe it to be the only form of perineal section that ought to be performed in an 
 impervious urethra. It is not sufficiently known. In exceptional cases the surgeon may 
 examine the urethra itself with the view to find a passage through it, and for this purpose 
 use as a guide to its distal end a grooved staiF introduced through the penis down to the 
 obstruction, the two sides of the urethra being held weW apart by forceps, or. as suggested 
 by Avery, a loop of silk introduced through each edge of the divided urethra. If the 
 surgeon be fortunate enough to slip a fine grooved director through, the stricture will be 
 readily divided. Under these circumstances a catheter should be pas.sed through the 
 penis into the bladder and the one which had been introduced through the perinteum 
 withdrawn. I need hardly say, however, that it is very rare for the surgeon to be able 
 to trace the urethral passage through the stricture. 
 
 Complications of Stricture. 
 
 I have thus far dwelt upon pi rmeable and impermeable organic stricture and its treat- 
 ment, but have made only passing reference to its complications. I propo.se now to con- 
 sider these points more fully, including perineal abticeni^, extravasation of urine, and peri- 
 neal jistithi, all of which are the direct results of stricture and of local or diffused urinary 
 extravasation. 
 
 Extravasation of urine is a complication which will almost necessarily follow a neg- 
 lected stricture, and the pathological process by which it is produced has been already 
 described. It is one of the means which nature adopts to find an outlet for urine when 
 the natural passage has become so contracted as to forbid its flow. It is a complication 
 of great danger and requires in its treatment great decision on the part of the surgeon, 
 the effect of retained, and often putrid, urine upon any tissue of the body being generally 
 followed by sloughing. The early detection, therefore, of the beginning of an extrava- 
 sation is important and requires a few remarks. 
 
 Perineal Abscess. Sympto.ais. — If a patient the subject of a stricture appears 
 before a surgeon suflering from more or less severe febrile symptoms, a parched skin, dry 
 tongue, and a rapid irritable pulse, with or without an occasional rigor, a careful exam- 
 ination should be made of the perina?um and the parts around, and. whether there exist 
 any local symptoms sufficient to have attracted the notice of the patient or not. a circum- 
 scribed and almost solid mass will probably be discovered in the region of the bulb, which 
 
694 SURGERY OF THE URETHRA. 
 
 on firm pressure will be painful. The patient will frequently state that this has existed 
 for some weeks and cannot be the cause of all his symptoms. The surgeon, however, 
 must not be misled, since this circumscribed mass is in effect a urinary abscess the result 
 of a local and limited extravasation, and the symptoms will disappear only when its con- 
 tents have been evacuated. 
 
 Treatment. — If the urethra be examined, the stricture will almost to a certainty be 
 found much contracted and the stream of urine very small. Some discharge from the 
 urethra may perhaps be observed, a little of the pus contained within the abscess behind 
 the stricture making its way by the natural passage. If an instrument be made to pass 
 the stricture, it may then only enter the dilated, ulcerated, and suppurating cavity of the 
 abscess situated behind, and it will be a matter of difficulty to find the vesical end of the 
 urethra, and, as a consequence, the instrument will be passed onward into the bladder in 
 only exceptional cases. 
 
 The abscess itself must be opened and its contents evacuated ; for if this be not done, 
 it will to a certainty increase, and, being bound down by the perineal fascia, pass backward 
 and spread mischief around the neck of the bladder and in the cellular tissue of the pelvis 
 to the serious injury of the sufferer. 
 
 At the same time, the treatment of the stricture is to be remembered, as no treatment 
 can be regarded as scientific if it be not directed to remedy the stricture which is the cause 
 of the abscess. 
 
 I am well aware some surgeons are satisfied to open the abscess in the perinjeum and 
 leave the stricture to be subsequently treated by dilatation or other means, but such a 
 measure is temporizing ; and the soundest and most correct practice is to open the abscess 
 and at the same time to divide the stricture. This is readily done by passing a grooved 
 staff through the urethra into the abscess, if not into the bladder, and freely dividing all 
 the tissues by a scalpel introduced through the perinsBum. If the orifice of the vesical 
 end of the urethra can be detected with a probe, a large catheter may be passed and left 
 in ; but this point is not of any importance, as In' the operation the surgeon is certain that 
 the stricture has been divided, all pus freely evacuated, the possibility of further extrava- 
 sation taking place prevented, and a free outlet for the urine at the same time been obtained. 
 
 By adopting this practice much time is saved, the stricture being treated, and proba- 
 bly curedj by the same means that are absolutely essential for the treatment of the com- 
 plication. 
 
 When, however, perineal abscesses occur unconnected with strictui'e. they should be 
 opened early to prevent their breaking into the urethra and degenerating into urinary 
 fistula. External urethrotomy under these circumstances is not required. 
 
 Extravasation of Urine. — The complication of extravasation of urine does not 
 always appear as a local and confined extravasation or as a urinary abscess. It not rarely 
 shows itself as an extravasation of a severer nature — as one more sudden and marked in 
 its symptoms and more fatal in its effects, requiring also at the hands of the surgeon active 
 and energetic treatment. It occurs as the result of a sudden ruptiire of the urethra from 
 internal injury or giving way of the walls of an abscess communicating with it, the rup- 
 ture taking place suddenly during some effort of a patient the subject of a narrow and 
 contracted stricture to relieve his distended and overcharged Idadder. 
 
 Symptoms. — The symptoms by which the complication is manifested are very marked. 
 The patient will probably relate that during some sudden expulsive effort to pass his urine 
 he felt something give way. and that this sensation was attended with relief to the symp- 
 toms caused by the retention of urine. He will soon discover, however, that the relief 
 which he experienced was not the result of a flow of urine from the natural passage, and 
 from the rapid enlargement of the perinaeum, scrotum, and penis will be convinced that 
 something wrong has taken place. This swelling will be attended by a burning pain in 
 the parts thus gradually enlarging, and will be increased at each effort made to relieve 
 the distended bladder. The absence of pain on the fir.st onset of the extravasation may 
 delude the patient into a false idea of relief and safety. The surgeon, if now called to 
 see the patient, will find him laboring under retention of urine, with the perinaeum, penis, 
 and scrotum more or less swollen, and oedematous from tirinary infiltration, the extrava- 
 sated fluid, perhaps, having made or making its way upward over the abdominal parietes 
 even to the thorax. If the symptoms have existed long, a peculiar inflammation and 
 gangrene of the integuments will make its appearance, and all the constitutional symp- 
 toms described as typhoid will certainly be present. 
 
 Treatment. — Under these circumstances the surgeon in his treatment has three 
 objects to keep in mind: 
 
COMrLICATlOSS OF STJllCTL'Jth'. 
 
 005 
 
 First, to free the tissues alrcaily iiililtratccl tif tlicir extravasatfd uriru,', and thus pre- 
 vent their total (K'struetion. 
 
 S'VDiii/, to secure a tree ami ready outUft for the urine from tlie )>lail<ler. ami thus 
 relieve the reteutinii aixl prevent an extension of the mischief. 
 
 Thin! — which is no h-ss important — to cure the stricture, and thi-rehy n^move the 
 cause on whidi tlic complication orijiinally depended. 
 
 The first ol)ject is to he secured hy free incisions made throufrh the intejrumcnt into 
 the inliltrated cellular tissue; the second may perhaj)s l)e f<»rtunately .secured hy the pas- 
 sajre ol" a catheter, hut this success is exceptional ; and in the majority of cases the second 
 and thinl indications are carried out. either hy the external division of the .stricture or hy 
 the perineal section as just descrihed. A small grooved staff" may be pa.sscd in hy far the 
 niajoritv of ca.ses, tin- emplovnieiit of some force heini: perfectly justitiahle t<j make it 
 pass throuirh the strictured portion. 
 
 Urinary Fistulee. — These may be the result of a urinary abscess burstinjr in the 
 poriiKcuMi or scrotum or the conse<|uence of a nujre diffused urinary extravasation, the 
 fistuhe, under these latter circumstances, appearinj; in the perimeum. .scrotum, groin, 
 thighs, pubes, or nates (Fig. -lU'Jj. They are lieiierally the direct consequence of some 
 
 Fig. 409. 
 
 Urinary Fistuke the Result of Stricture. 
 
 urethral obstruction. Occasionally, however, they follow an accidental wound in the 
 perin.Bum or urethra or some such operation as lithotomy. 
 
 When the fistuhie are simple tracts communicating with a urethra behind a stricture 
 and the tissues through which they pass are healthy, they need not be regarded with any 
 anxiety, as in all possibility they will rapidly heal so soon as the urine flows readily the 
 natural way after the dilatation of the stricture. 
 
 When, however, the tistuhi3 pass through indurated and diseased tissues and are asso- 
 ciated with a contracted, if not impermeable, urethra, or are the result of some urinary 
 extravasation and sloughing of the parts, the .same success is not always secured. 
 
 Treatment. — It is true that in a large number of cases when the stricture is dilated 
 and cured the fistulse will close, but in exce])tional cases they refu.se to heal and re<|uirc 
 the local stimulation of some such escharotic as the nitrate of silver, liquor ammonias, 
 tincture of cantharides, the galvanic or actual cautery, to stimulate the indolent passage 
 and assi.st its contraction. 
 
 It should be remembered, however, that in all these cases it is the entrance of the 
 urine into the fistuhie which prevents their contraction and closure, and that any means 
 by which such an occurrence can be prevented will be followed by recovery. To allow 
 the patient to pass his urine is most injurious, and to pass a plugged catheter into the 
 urethra and leave it in will not suffice, as daily experience proves that urine .soon flows by 
 the side of the catheter and enters the fistula. The best plan is to have a catheter passed 
 whenever the bladder requires to be emptied: and if the surgeon has dilated the stricture 
 to its full size and in.structed the patient to pass an elastic catheter into the bladder, 
 there are very few in.stances of urinary fistulfc that require further treatment. ^^ here 
 this practice cannot be followed, the introduction of a soft catheter into the bladder, with 
 its end open to allow the urine to flow away as secreted, is to be advised. 
 
 When difficulty is experienced in dilating the stricture, Syme's operation may be per- 
 formed, the surgeon, when he can. laying open the fistula at the same time. 
 
69^ SURGERY OF THE URETHRA. 
 
 The urinary Ostala following litliotomy is best dealt with V)y the galvanic cautery and 
 catheterism. In these cases, however, the surgeon should always investigate the case 
 sufficiently to assure himself of the absence of a second stone or of a foreign body within 
 the wound, for I have known one case of a sponge, applied to arrest bleeding, being left 
 in the wound and preventing repair. In another a second calculus was overlooked and 
 prevented recovery ; the fistula healed when the stone had been expelled by natural 
 eiforts through the fistulous perineal opening. I have likewise seen two cases where some 
 calculous formations took place in the wound, and thus kept it open. 
 
 Urinary fistula the result of an abscess communicating with the rectum will generally 
 heal as soon as the urine is prevented from entering the passage. The use of the catheter 
 will sometimes efi"ect this ; at others, position will suffice. 8ir H. Thompson gives a case 
 in which recovei'y followed the practice of micturating in the prone position for a month. 
 But any means that for a time prevents the passage of urine into the fistula will probably 
 suffice to allow of its contraction. When this does not succeed, the passage may be stim- 
 ulated by the galvanic or other cauter}-, and in exceptional cases a plastic operation may 
 be called for. 
 
 The urinary fistulae associated with loss of tissue, whether in penis, scrotum, or peri- 
 naeum, require the greatest amount of ingenuity in the surgeon, as, besides the constric- 
 tion of the normal channel, some plastic operation is often necessary. 
 
 Cicatricial or Traumatic Stricture. 
 
 The difference in the cause, the permanency in the nature, and the difficulties in the 
 treatment of a so-called traumatic stricture have led me to separate the cases thus 
 denominated from that larger class which we have been just considering, the result of 
 local inflammations ; and from my notes of forty-three consecutive examples of this kind, 
 in all of which a distinct history could be obtained of some definite accident affecting the 
 perinjieum, the blow or fall was immediately followed by hemorrhage from the urethra, 
 with or without other symptoms, and at a later date by difficulty in micturition. 
 
 As a rule, these accidents take place in boyhood or in young adult life, though no age 
 is free from the dangers of such an injury ; and the kick of a man or a horse on the 
 perinfBum, a fall upon a pointed instrument or across a bar, beam, or rail, an injui-y from 
 a saddle when riding, a blow from a rope, and sloughing of the perineum after a violent 
 contusion, are the principal causes to which the stricture has been assigned in the cases 
 before me. In one and all there was clear evidence at the time of the injury that the 
 urethra was more or less involved, as hasmaturia in almost every case immediately fol- 
 lowed, while difficulty in micturition apppeared subsequently at variable intervals. In 
 some few cases several years had passed away before the attention of the patient was 
 called to the smallness of his stream of urine, when some sudden attack of retention was 
 the first symptom which attracted notice ; but in the majority of ca.ses the difficulty of 
 micturition appeared rapidly after the receipt of the primary injury, and w^ent on slowly 
 but surely to increase. 
 
 Pathology. — The pathology of these cases is not difficult to understand. The 
 urethra is either partially or wholly ruptured by the injury, the wound being irregularly 
 transverse ; union takes place, and subsequent contraction of the cicatricial tissue, with a 
 narrowing of the urethra and the formation of traumatic stricture follow. It is this path- 
 ological fact which enables us to explain the obstinacy of the symptoms and the difficulty 
 in the treatment. 
 
 Complications. — Traumatic stricture is as liable as any other organic stricture to 
 be followed by complications, these complications being the result of the obstruction to 
 the urethra, in whatever way that obstruction may primarily have been caused. Among 
 my 43 examples of traumatic stricture, 27 were admitted simply on account of their con- 
 tracted stream and difficulty in micturition ; in 8 retention of urine was the immediate 
 cause ; in 3, extravasation of urine ; and in five urinary fistula complicated the cases. 
 
 Treatment. — There are no cases of complicated or non-complicated organic stricture 
 more obstinate in their treatment than the traumatic, and the nature of the obstruction, 
 being cicatricial, is quite sufficient to account for this fact, since it is well known that all 
 cicatrices have a constant and almost perpetual tendency to contract. A traumatic stric- 
 ture the result of a contracting cicatrix is consequently in its nature essentially a con- 
 tractile stricture, and its treatment is therefore very troublesome. When treated by dila- 
 tation, it will recontract, and even if treated by perineal section or external division, it is 
 far more likely to return than any form of inflammatory stricture. 
 
CAFSrS OF DFA'lll I'lloM STIlK'Tilll-:. 697 
 
 All forms of trcatiiiciit arc t'»»iise<|iiciilly iinccrtaiii and unsatisfactory. If <lilatation 
 of tlio iiri'tlira is onci' sccunMl, tlic introdiictitm of a catluiti'r at short intervals is iintst 
 essential, or otherwise the canal is certain to reeontraet ; and if it is doiihtfiil whether any 
 case of simple inflammatory stricture is ever really cured, it may unr(uestional)ly be 
 usserted that a traumatic stricture will exist for life, and that it will rccjuire constant and 
 repeated treatment to preserve even a moderate patency of the narrowc^d passage. Tiie 
 princijjles of treatment in both varieties, however, are the same, althou<rh the practice 
 mav not he so successful. 
 
 If the urethra lie ])crmcal)lc, the treatment liy dilatation shouhl tie primarily employed, 
 and jpcrsevered in for some time if success is to be secured. If the stricture is so narrow 
 and indurated as to resist dilatation and a grooved stafl" can be passed through, the ripe- 
 ration of external division is the soundest jiractice and gives the surest hopes (»f imme- 
 diate aud future benefit. 
 
 If the stricture be impermeable and from its narrowness require imnx'fliate treatment, 
 or should its complications, either of extrava.sation or of urinary fistula, demand attention, 
 the perineal section must be carried out in the same matinctr as in the cases previously 
 referred to. 
 
 If extravasation of urine be present as a secondary result of this traumatic stricture, 
 the .same principles and practice which have been advocated in the treatment of simple 
 organic stricture are eciually applicable, as are also the recommendations which have been 
 made for the treatment of perineal fistula. 
 
 In cicatricial stricture where the urethra has so contracted as to render the passage of 
 a catheter impracticable, the establishment of a permanent perineal fistula is sometimes 
 demanded. 
 
 The permanent success, however, of the practice in these traumatic cases is not nearly 
 so great as in the inflammatory, although the practice in both is really the same. It is 
 hardly necessary to illustrate these facts, as the experience of all surgeons will bear 
 them out. 
 
 To show the greater severity of these cases and the difficulties of their treatment by 
 dilatation, it may be stated that out of the 43 examples of traumatic stricture which have 
 been tabulated, in G, or fourteen per cent, of the whole number, the operation of perineal 
 section or of external division was absolutely required ; whereas, amongst the cases of 
 simple organic stricture, only six per cent, required such operative interference, the simple 
 treatment by dilatation answering every other purpose. 
 
 Causes of Death from Stricture. 
 
 There are few local diseases which, if neglected, have a more fatal tendency than 
 urethral stricture, and there are none in which the progress toward evil can be so accu- 
 rately and clearly traced, from the portion of the urethra situated behind the stricture 
 which primarily experiences the evil influence of the obstruction to the bladder, which 
 becomes secondarily involved, and last, but not least, to the ureters and kidneys. The 
 importance of the kidneys in the animal economy as excretory organs receives thus a fresh 
 demonstration from the fatal effects of disease in their structure. 
 
 To assert that renal disea.se is the .sole cause of death from stricture would not, per- 
 haps, be strictly true : nevertheless, it is the principal one ; and if these glands are not 
 involved, .stricture and its complications are not fatal. 
 
 Simple uncomplicated stricture is not a fatal disease, few cases terminating in death. 
 
 Stricture and retention of urine form a more serious combination, and stricture with 
 extravasation of urine is .still more fatal. 
 
 It Avould thus appear that only when stricture has existed for a lengthened period and 
 become complicated does its fatal influence become apparent, the increase in the mortality 
 of the cases increasing with the severity of the complication. 
 
 The duration of the .stricture has necessarily a serious influence in producing a fatal 
 result : the longer the obstruction exists, the greater the probability, if not the certainty, 
 of the production of renal affection. 
 
 In 26 fatal cases, the notes of which are before me, the average duration of the stric- 
 ture was seventeen years; in 5 symptoms had existed under ten years, and in 10 for 
 upward of twenty years. 
 
 When stricture, therefore, has existed for a long period, and more particularly when 
 it has been neglected, it may be inferred with certainty that some disease of the kidneys 
 has been produced and that the slightest injury or accession of mischief is likely to ter- 
 
698 SURGERY OF THE URETHRA. 
 
 minate in death, for every subject of renal disease stands, as it were, continually on the 
 edge of a precipice over which the slightest adverse wind may send him ; and the fatal 
 results of many operation cases, whether upon the urinary organs or other parts, are to be 
 thus explained, for no subject of renal disease is able to resist the slightest tax upon his 
 powers, and his vital energy sinks irrecoverably upon the receipt of the most trifling injury. 
 By way of summary of the treatment of stricture, the following conclusions may be 
 drawn : 
 
 1. At least ninety-five out of every hundred cases of stricture are readily and safely 
 dilated by means of catheters, and every stricture might be so treated if recognized 
 before any complications appeared. 
 
 2. Of peinifable strictures, it is only in the obstinately irritable and contractile forms 
 that any other treatment is called for ; and in these external division by the plan recom- 
 mended by Syme is probably the best operation, though rapid dilatation, sjilitting, or 
 internal division of the stricture may be justifiable under exceptional conditions. 
 
 o. Strictures complicated with urinary abscess or extravasation in which perineal incis- 
 ions are called for should be treated by external division or Syme's operation when a staflF 
 can be passed through the stricture, and by perineal section, Wheelhouse's or Cock's ope- 
 ration, when no such guide can be employed. 
 
 4. In strictures complicated with nrinary fistidse, the stricture itself should be treated, 
 since the fistulje usually close as soon as the urethra has been fully dilated. When this 
 result does not take place, it is essential that all urine be prevented passing into the fis- 
 tulcTJ ; and the best means to ensure this is by the passage of the catheter whenever relief 
 is required. 
 
 5. The extermd division of the stricture is an excellent operation in obstinate cases of 
 permeable, contractile, and irritable strictures, in all cases of extravasation of urine in 
 which perineal incisions are called for, and also in long indurated strictures complicated 
 with urinary fistulae. 
 
 G. Perineal section, Wheelhouse's or Cock's operation, is good in all cases of imperme- 
 able stricture or obliterated urethra, complicated or not with urinary abscess or fistula, in 
 which a free outlet for the escape of urine is essential. 
 
 7. Internal urethrotomy, except in penile or in the obstinately irritable or contractile 
 strictures, is not often required, and the treatment by caustics is dangerous. 
 
 8. Ckatririal strictures should be treated as others, but they are far more obstinate and 
 require more frequently external urethrotomy. 
 
 Ruptured Urethra. 
 
 The secondary eifects of an injury to or a rupture of the urethra have already been 
 considered under the heading '• Traumatic Stricture," and it has been .shown that in at 
 least 6.65 per cent, of the cases of organic stricture an injury was the assigned cause. 
 It has also been shown that the worst and most intractable cases of stricture, as Avell as 
 the majority of examples of obliterated urethra, are of this kind. 
 
 I propose now to consider the subject of ruptured or injured urethra, with its imme- 
 diate effects and treatment. In the majority of instances the injury is caused by some 
 direct violence applied to the perinaeum, such as a fall against a post, plank, fence, or 
 chair, a blow or kick on the perinteum. In not a few instances the injury has been pro- 
 duced by the passage of a cart-wheel across the pelvis, although it may be somewhat 
 difiicult "to understan'd how such a result can be produced by this cause unless some frac- 
 ture of the pubic portion of the pelvis coexists ; but, explain it how we may, in practice 
 we meet with cases of ruptured urethra following the passage of a wheel across the pelvis 
 and unconnected with any other distinct evidence of fracture. 
 
 Symptoms. — The characteristic symptom of a rupture or laceration of the urethra is 
 the passage of blood from the penis unconnected with micturition. The blood appears 
 usually as an immediate result of the injury and may be little or profuse in quantity ; it 
 seldom endangers life, and. as a rule, subsides without treatment. If the injury has been 
 but a superficial tear in the mucous membrane, it is just possible that this is the only 
 symptom by which the laceration can be recognized ; and if some time has elapsed 
 between its receipt and the calls of nature to relieve the bladder, micturition may be 
 completed with little or no difficulty and convalescence re-established. 
 
 It is not often, however, that the subject of a lacerated or ruptured urethra escapes so 
 easilv, for in the majority of cases retention or extravasation of urine is the result; and 
 for the relief of this the advice of the surgeon is generally at once sought. 
 
RKTESTios or rnisi:. OUG 
 
 TkkaTMKNT. — Wlicii c:i1I(m1 to attond a itatii-iit wIid has been tlie subject of an injury 
 to the urethra sutterinf^ from siniph' retention, the first objeet of the surgeon is to utteuipt 
 tlie ita.s.sajre of a catheter; anil if the uretlira be ii<»t eoniph-tely torn away and there is 
 not much bh>ud h)cally efl'u.sed, there is a stnjii;; proljability that lie will succeed. A j.'uin 
 elustic instrunu'ut with a stronj; stylet should be ein])loyed. llaviiijr accomplished this, 
 the instrument should be fastened in and the urine allowed to flow away as secreted, 
 beini^ conducted at once by means of u tube into a vessel placed close at hand; for if the 
 catheter Ite |)lui:,ired. uriiu! is sure to find its way by its side into the |»erina'um. If the 
 attempt at catlifterism fail, some other means must be employed to provide an outlet for 
 the urine ; (ttherwise. extravasation, with all its dan;.cer. will necessarily f<»llow. Under 
 these circumstances an incision into the ])erinaMim on a <;rooved staff" jtassed down to the 
 ^eat of laceration in the ))erinaMim is un<|Uestionably the soundest practice to adopt, as 
 bv this means the extravasated blooil and urine Knd a ready outlet, and the bladder, 
 when it contracts, a vent fur its contents, the dauLcer of extravasation of urine being 
 thus prevented. 
 
 When the periiucuin has been laid open and the two ends of the divided urethra can 
 be made out, tliey may be brought together by a suture; and if the orifice of the vesical 
 end of the ruptured urethra can be found with a grooved probe, a catheter should be 
 passed, the instrument having been first introduced through the penis, and sub.sequently 
 guided upon the grooved probe into the bladder. If difficulty is experienced in finding 
 the orifice, there need be no alarm, as it s tjuite clear that the urine will readil}- find its 
 way externally through the artificial wound ; nevertheless, an early attempt to pass the 
 catheter should certainly be made, as it is mo.st important that the c<jntinuity of the 
 urethra should be restored as early as possible. 
 
 When a catheter has been introduced, it must be left, since the patency of the canal 
 should 1 i maintained iluriny the whole period of its repair and its subse<juent contraction 
 in a measure neutralized. 
 
 The frequent passage of an instrument afttr the repair has taken place is an import- 
 ant point to be observed, this practice being the best guarantee that a cicatricial stricture 
 cannot ensue. In the case of a man I treated seventeen years before for retention fol- 
 lowing a ruptured urethra by a perineal incision there has not since been any difficulty in 
 micturition. 
 
 RETENTION OF URINE. 
 
 When a patient is unable to pass his urine, he is said to be the subject of retention, 
 which may be due to the presence of organic or cicatricial stricture, spasm of the urethra, 
 urethral obstruction from inflammation of the urethra or prostate, urethral calculus, and 
 many other local and general causes. Amongst the latter must be placed brain disea.se, 
 and my friend Dr. Hess of Fiu-sbury Square told me in 1879 of the case of a gentleman 
 who had a bladder so dilated that it reached up to the ensiform cartilage and led the 
 medical man in attendance to believe that ascites existed. There was. at the same time, 
 very marked anasarca of the lower extremities up to the groins. All these symptoms, 
 however, disappeared when ten pints of urine were drawn off",- 
 
 I have already .stated that retention existed in 129 out of 608 cases of organic stric- 
 ture admitted into Guy's during seven years, and in S out of 43 cases of traumatic stric- 
 ture. It was also present in SO other cases, the result of varied general and local causes 
 unassociated with stricture. Spasmodic stricture was the assigned cause in half — /. e., it 
 was found in subjects in whom no permanent narrowing of the canal existed. In almost 
 all excess of drinking, with or without exposure to wet and cold, was the exciting cause, 
 and no complication aggravated the cases. One was in a bovfet. 10 who paid the penalty 
 of a drinking-bout by suffering the pain of a retention. Catheterism relieved him. In 
 all these 40 cases spasm of the muscles of the urethra was the assigned cause. 
 
 Retention in a child is generally from stone impacted in the urethra ; in an adult, 
 from stricture ; and in an old man. from prostatic disease. 
 
 Spasmodic Stricture as a Cause of Retention. 
 
 The existence of a trur sp'isniodic strictuiT is no longer a subject of doubt. That the 
 seat of the stricture is the membranous portion of the urethra, which is encircled by mus- 
 cles, is also now generally acknowledged, and that the usual exciting causes are exposure 
 to wet or cold and excess in drinking many cases before me clearly prove. Anything, 
 however, which can induce an altered or acid state of the urine is likelv to be followed 
 
700 SURGERY OF THE URETHRA. 
 
 "by this complication, gouty and rheumatic patients being particularly liable to such 
 attacks. 
 
 Treatment. — The treatment of such cases is not difficult, the simple passage of a 
 large metallic catheter being the most expeditious and certain practice. The instrument 
 should be well warmed and freely oiled, and then passed slowly, so as not to excite alarm 
 or increase the spasm of the muscles. In skilful hands its introduction is not an opera- 
 tion of difficulty. If, however, the operator be foiled in his endeavors, he must be 
 cautious not to employ force, which is never required and never justifiable. An anjes- 
 thetic should then be administered, and with a patient fully under its influence all obstruc- 
 tion ceases, while the instrument will pass into the bladder. If there be an objection to the 
 use of the anresthetic, the old remedy of a hot hath cannot be too highly extolled, few 
 patients suifering from simple retention failing to micturate when thus immersed ; by the 
 bath the introduction of a cathetre is likewise much facilitated. .1 faU oplnte is also an 
 invaluable remedy, relieving the involuntary contraction of the bladder which is so pain- 
 ful in cases of retention, and thus removing one of the most constant causes of spasmodic 
 stricture. The value of opium in these cases, according to .some, cannot be upheld too 
 strongly; indeed, they assert that there is no case of retention of urine which will not 
 yield to its benign influence, allowing either a natural relief or the introduction of a 
 catheter. The inhalation of an anaesthetic I believe to be a preferable remedy, its action 
 being more rapid and certain. If failure follow the application of these, other measures 
 must be adopted ; and without doubt the simplest, safest, and most expeditious practice 
 is puncturing the bladder. I prefer to do this through the rectum ; others, above the 
 pubes. In a simple spasmodic stricture, however, such a necessity can scarcely arise. 
 
 Inflammatory Stricture as a Cause of Retention. 
 
 It has been already shown that in spasmodic stricture exposure to wet or cold and an 
 altered condition of the urine, produced from either excess of drinking, gout, or rheuma- 
 tism, are the chief exciting causes of an attack of retention ; and if this be true, there 
 can be no difficulty in understanding that a like result may be brought about and is m.ore 
 liable to be experienced if the urethra itself should be the seat of an inflammatory action. 
 Retention of urine occasionally comes before our notice as a result and concomitant of 
 gonorrhoea. The causes of the retention are evidently compound — viz., spasmodic stricture, 
 and the mecbanical obstruction produced by the oedema of an acute inflammation combin- 
 ing to produce the result. 
 
 Treatment. — The treatment required to aff'ord relief must be based upon the appre- 
 ciation of these two conditions which have combined to cause the eff"ect. The retention 
 is in a measure mechanical, and must be met by mechanical treatment, but it is also func- 
 tional, and, as a consequence, must be so considered. 
 
 The symptoms being urgent, time is, therefore, a great object; and if called to a case 
 there are few surgeons who would not at once attempt to pass a catheter. Let the sur- 
 geon choose an instrument of medium size. No. 4 or 5, being the best, taking care that it 
 be well warmed and oiled, and then with gentleness, and yet with firmness, the obstruc- 
 tion may be overcome ; arte non vi must be the guide to action, as force is to be con- 
 demned as much in these cases as it was in the preceding. 
 
 If these means fail, a hot bath and a full opiate are the soundest remedies. They 
 relieve the local turuescence of the passage, and also the obstruction, and with it the 
 associated spasm, in some instances the introduction of a piece of ice into the rectum 
 serves a like purpose. The use of an anaesthetic in these cases cannot be recommended, 
 as it merely relieves the spasm, but does not alter the condition upon which the spasm 
 depends — viz., the inflammation. When these means fail — which is not commonly the 
 case — some operative measure may be required, which will be dwelt upon in another 
 page. 
 
 Retention of Urine following a Blow in the Perinaeum. — Under this 
 
 heading it is not my intention to allude to cases of ruptured urethra, as this condition has 
 already been con.sidered. But cases of retention occasionally come under notice which 
 follow a simple contusion in the perinaeum. I possess three such records — two in chil- 
 dren aged three and seven respectively, and one in an adult aged twenty-nine. In none 
 of these cases could hemorrhage or other symptom of ruptured urethra be made out. 
 The retention followed the contusion and was caused by some spasmodic condition of the 
 passage excited by the injury. In all the cases the simple passage of a catheter was the 
 only treatment, and with the relief of the symptoms convalescence followed. 
 
niynisrios or riii.sK. 701 
 
 Retention of urine from the pressure of an abscess in the perinseum 
 
 imist lie iiitiil ioiicd, :is cax's nl' rrtnitioii IVdim siicli ;i caii.-'C ipcc;i>i()iiall v i'miuc uimIit 
 iidtict', wliiln absci'ss aliuut tin- rt'rtiim is nut uiitVci|iU'iilly associatt'd with >ii(li a ilitli- 
 ciiltv. It slioiilil 1k' tivatoil hy oitcniiitr tlic al),sc(.'ss. 
 
 iParalysiS of the bladder IVmn any cause situated either in the or^'an itself <ir 
 assueiated witli spinal disease is a eitniniun eause ot" n^tentiitn. aiid the same ecjnijdieation 
 may he tV)und in lever or otiier e(Uistitutiunal eondition in wliieli the vital jxtwers of the 
 patient luive heen niucli reduced and the nervous system has. as a fonse<(uenee. become 
 unable to answer to its accustomed stimulus. Iletention of urine is also met witli as a 
 .svinptoni of peritonitis, loe.il or general, or as a result of some otlier abdr)minal disea.se. 
 It is well for the surj-eon In renieniber that this complication may be produced by the 
 causes enumerated. 
 
 It is not to treat retention of urine, however, that the surueon is usually called to 
 such cases, but for the incontinence of retention, the incontinence beinjr merely the over- 
 flow of an already overdistended and enfi-or<icd bladder. The symptom of incontinence i.s 
 a very positive one and should never mislead any practitioner. It is almost always a 
 concomitant and result of retention, and at any rate should be so regarded until the sur- 
 geon has convinced liimself by a carel'ul examinatifni that the bladder is not distended. 
 
 Retention of Urine as a Symptom of Enlarged Prostate, and in the 
 
 Aged. 
 
 It has been a coninion opinion, held by all surgeons for many generations, that an 
 enlarged prostate is a very general condition of old age, and retention of urine, as a con- 
 sequence and symptom of this affection, is of frequent occurrence. The investigations of 
 recent pathologists have shown, however, that such an opinion is b}^ no means correct ; 
 for although an eidargemeiit of the prostate, either as an hypertrophy or from the devel- 
 opment of independent prostatic glandular tumors, may take ])lace — and when it does, it 
 is most commonly met with in old people — yet such a condition is by no means to be con- 
 sidered as a necessary senile change. 
 
 Treatment. — When retention of urine takes place in old people in whom no stricture 
 exists, it is too frequently ascribed to this chronic enlargement of the prostate, and, as it 
 is really a rare thing to find such a condition in the bodies of tho.se that die, it is fair to 
 believe that this retention is due to other causes, such as atony of the bladder, which 
 may be relieved by the introduction of a large catheter. This operation .should always 
 be undertaken with great care, as an injury to the prostate or bladder in old people is of 
 consitlerable consequence. An elastic instrument with a full curve, in the bands of those 
 who are not in the constant habit of using instruments, is to be preferred, and this may 
 be passed slowly down to the neck of the bladder. It is at this point that the difficulty 
 in its introduction is always experienced ; but if the index finger of the left hand be intro- 
 duced into the rectum and the end of the instrument tilted upward by the slightest pres- 
 sure with the right hand, the catheter, as a rule, will be readily passed onward, and relief 
 will be .secured. The patient's pelvis should always be well raised before the catheter is 
 used. 
 
 Retention of urine may also be produced by an abscess situated in the prostate gland, 
 and the retention is relieved only when the abscess is opened. This treatment, therefore, 
 is that which should be followed. 
 
 Retention of Urine as a Result of an Elongated and Adherent 
 
 Prepuce. 
 
 It is a somewhat inexplicable fact that surgical writers have, with rare exceptions, omit- 
 ted to notice that an elongated prepuce and adhesion of the glans penis to its mucous 
 membrane covering is capable of producing retention of urine with every symptom of 
 vesical irritation ; yet few surgeons can have had much experience at any ho.spital or dis- 
 pensary, particularly in out-patient practice, without seeing many such examples. I 
 could quote cases in which an adherent prepuce had been the cause both of retention and 
 of incontinence of urine, and in which it had produced symptoms of irritable bladder and 
 every other symptom of vesical calculus, even haniiaturia. prolapsus recti, or constant 
 priapism. 
 
 All, or nearly all, these cases take place in early life, and I never see a case of vesical 
 irritation in a male child without first examining the condition of the penis. I have been 
 
702 SURGERY OF THE URETHRA. 
 
 in the habit of pointing out this fact to students for some years, and have advised them 
 to follow the practice suggested, under the conviction that in at least two-thirds of the 
 cases suffering from urinary irritation which pass under observation an adherent and elon- 
 gated prepuce is the sole cause. 
 
 Treatment. — Circumcision and the careful separation of the prepuce from the glans 
 penis, with the removal of the confined secretion of Tyson's glands, is the only remedy, 
 which is at once simple and complete. 
 
 Retention of Urine from Organic or Cicatricial Stricture. 
 
 Among the many contingencies to which a patient suffering from organic stricture is 
 continually exposed, none cause more agony and alarm or demand more prompt and deci- 
 sive action on the part of the surgeon than retention of urine. 
 
 The retention may be the result of a slowly-contracting organic stricture, but it will 
 probably be produced by some sudden accession of spasm of the muscles of the passage^ 
 and thus be compound in its nature, a spasmodic being grafted upon an organic stricture. 
 The symptoms, however, are necessarily urgent ; and it becomes an important question as 
 to what practice should be pursued. 
 
 Treatment. — With this object it will be of interest to inquire, first of all, what prac- 
 tice has been proved of value, and as a means to the solution of the difficulty I can show 
 that out of 224 examples of retention from simple oi'ganic stricture, 184 were successfully 
 treated by means of catheterism, warm baths, and opium. In 40 cases only, or 17.4 per 
 cent., were any other operative measures called into requisition, and in all of these 40 
 examples the bladder was punctured per rectum with complete success and without any 
 of the theoretical objections which have been adduced against the operation. 
 
 Out of 14 cases also of retention of urine produced by the gradual contraction of a 
 traumatic stricture, 8 were treated by means of catheterism and G by puncture of the 
 bladder, the proportion of cases requiring such an operation being much greater in trau- 
 matic strictures than in the preceding class of simple organic stricture, the cause of this 
 difference being very apparent. 
 
 If a surgeon is called to a patient suffering from retention of urine produced by either 
 a simple spasmodic or an inflammatory stricture, it has already been explained that relief 
 can be obtained by the cautious introduction of a catheter, aided, if required, by the use 
 of the warm bath or a full dose of opium, and in certain cases by the inhalation of an 
 anaesthetic. If these means fail, as experience proves may be the case, either from some 
 peculiarity of the stricture or from the manner in which the treatment has been carried 
 out, other measures will necessarily be called into requisition ; and it has been already 
 stated that the best and most expeditious practice is to puncture the bladder through the 
 rectum. It is true that this practice is rarely needed in .simple spasmodic or in inflamma- 
 tory, stricture, for in the majority of cases the means already suggested are amply 
 sufficient to secure relief; nevertheless, in exceptional instances this operation is of great 
 value. It must be remembered, also, that the practice is required only when simpler 
 means have failed. 
 
 Since the introduction of the " aspirator "" many surgeons have employed it with success 
 in cases of retention, but relief by such a measure does not commend itself to my mind- 
 being merely a temporizing operation and requiring frequent repetition in the .same case ; 
 it has no such influence for good upon the cause of the retention as the operation of 
 puncturing the bladder through the rectum. In exceptional cases of retention of urine 
 it may be a justifiable proceeding. 
 
 In the treatment of retention of urine with simple organic or traumatic stricture the 
 same principles of practice .should be applied as have been recommended in the former 
 class of cases, and in a large proportion of instances it has been already shown that suc- 
 cess by such treatment may be secured, since, out of 238 cases of retention admitted into 
 Guy's, operative measures were ref(uired in only 46, and the simple introduction of a 
 catheter, with the aid of warm baths and the internal administration of opium, proved 
 sufficient to carry out all the objects required in 192. If the surgeon is called, therefore, 
 to a case of retention of urine with organic stricture, the introduction of a catheter is 
 the primary means to be employed. If the history informs him that the retention is the 
 result of a gradually contracting passage, a medium-sized instrument should be selected, 
 and on this failing a second attempt, with a smaller one, may be followed by success. 
 Force, however, must not be employed, and too much time should not be expended in 
 making the attempt. If success is to follow the operation, it will readily be obtained; 
 
PuycTrni: or tin: r.i.M>i>i:ii r/.n iiEcrrM. 70;} 
 
 perseverance and repeati-d endeavors to pass an instrnnient, as a rule do harm. It" the 
 symptoms are not very nr-reiit aii<l some delay may he aMowed, the warm hath and a full 
 opiate, siieh as two, or evt-n three, {grains of opium, may he enqdoved, and under their 
 comhined influence it will he oidy in exceptional cases that reliei' will not suhsequently 
 be secured. 
 
 If the symptoms id" retention, however, are very urfrent and the ajronies of the suf- 
 ferer demand immediate relief, or if the means which have heen just described have been 
 fouml wantinjr after a fair trial, there is little doubt that the mo.st scientific and certain 
 practice is the puncturin<: of the bladder throu<rh the rectum ; for all experience has 
 correctly endorsed the opinion expressed l»y Mr. Cock wlien he recalled the attention of 
 the prcdessiou to this operation in his valuable paper published in 1S52 (vol. xxxv. of 
 the .I/t'/.-^VaV. Trans.) — "that the bladder nuiy be readied with tlie smallest amount of 
 pain, with the least risk of present or future danger, and with the greatest prospect of 
 ulterior good, by puncture through the rectum." 
 
 The records I possess of the cases of this operation positively prove the truth of this 
 opinion, and it is gratifying to find that in the.se days many surgeons recognize the value 
 of the practice. 
 
 The operation is as simple as it is safe, and as efficient as it is scientific. As a means 
 of relieving a patient from the agony of retention of urine which has been proved to be 
 irrenjediable by the rational use of catheters it .stands unrivalled. By its adoption all 
 forcible catheterism, with its dangers, is avoided. Perineal section and its difficulties as 
 a remedy for retention are done away with, and the operation for puncturing the bladder 
 above the pubes may nearly be forgotten. Puncturing the bladder through the rectum 
 embodies in itself all the advantages of these means, without any of their evils, and on 
 practical grounds commends itself for our adoption. 
 
 I would add. therefore, as a final conclusion, •• that in all cases of retention of urine 
 from stricture in which relief cannot be given by means of rational and not forciVjle 
 catheterism, and in which the use of the warm bath and opium have failed, the operation 
 of puncturing the bladder through the rectum should be performed. 
 
 Puncture of the Bladder per Rectum. 
 
 In all cases of retention of urine in which relief cannot be afforded by the introduc- 
 tion of a catheter, and the nature of the obstruction is not such as to require the opera- 
 tion of urethrotomy, puncturing the bladder through the rectum is the right operation to 
 perform, as by it relief can be given with rapidity, certainty, and safety. 
 
 In former times the bladder used to be punctured with a full-sized trocar and canula 
 from the perinaeum. but such a clumsy operation is not now recognized among surgical 
 proceedings, though with the aspirator the .same proceeding has been often undertaken. 
 At the present day some surgeons prefer tapping the bladder aVjove the pubes, but in 
 safety and efficiency the operation is not to be compared with that which I now recom- 
 mend, for. in the words of its modern advocate, Mr. Cock. " the operation is safe, easy of 
 accomplishment, and without danger as to its consequences. In cases of retention which 
 resist ordinary treatment it is greatly to be preferred to the long-continued attempts 
 at catheterism, which, whether successful or not, must be infiniteh' more injurious to the 
 urinary organs than the .simple and almo.st painless operation of tapping." 
 
 ''I consider." writes Cock, "that the benefit of the operation consists not merely in 
 the immediate relief given to the patient, but also in the opportunity which it affords, by 
 the retention of the canula in the bladder through an indefinite period, of diverting the 
 flow of urine from its ordinary channel, and thus giving quiet, freedom from pain, and 
 the natural means of restoration to the maimed, irritable, or diseased urethra. I conceive 
 also that the bladder might be tapped with advantage in cases of ob.stinate stricture in 
 which retention of urine does not actually exist." 
 
 These views, published by Mr. Cock in 1852 {M/d.-Chir. Tnms.. and 6-'«3/'.« Reporfis, 
 1866). I cordially endorse. The practice of Guy's Hospital, to my knowledge, has only- 
 confirmed their accuracy ; and the more I .see of the operation, the more I like it. The 
 objections rai.sed against it are theoretical, and not practical ; for absces.ses between the 
 bladder and rectum, persistent fistulous openings, injury to the seminal vesicles, and 
 wounds of the peritoneum do not commonh* occur. They are said to have done so in 
 exceptional instances, but such must indeed be very rare. Mr. Cock, in his large experi- 
 ence, has known but one bad result to follow the operation, and that was atrophy of the 
 testicle, from which he infers that the vas deferens was wounded. At Guv's, from the 
 
704 
 
 SURGERY OF THE URETHRA. 
 
 carelessness of a house-surgeon, a fatal peritonitis from the perforation of a coil of intes- 
 tine once followed the operation, the puncture having been made too far back ; but, elim- 
 inating carelessness — a ca,use of half the errors in surgery — the operation is very safe. 
 
 The only requisite is a moderately full bladder — a feature always present under the 
 circumstances which call for the operation. An enlarged prostate is no real obstacle to 
 its performance, since it may be perforated with impunity. 
 
 Operation. — The best instruments are those suggested by Mr. Cock. The long 
 curved trocar and canula, as originally employed, are inefficient instruments ; indeed, 
 many of the objections to the operation are probably traceable to their use. Cock's instru- 
 ments consist of a canula six and a half inches long, a blunt pilot trocar, and a sharp 
 trocar, a second tube Avith an expanding end to keep the canula in position, and a third 
 to maintain the second in position (Fig. 410). 
 
 The patient should be placed and held in the position for lithotomy and brought well 
 to the edge of the bed. The operator must then introduce the index finger of the left 
 hand into the rectum with the palm upward to feel for the prostate (Fig. 410), and, if 
 
 Fig. 410. 
 
 UnihUlc 
 
 Operation of Puncturing the Bladder per Rectum. 
 
 possible, for the bulging base of the tense bladder beyond. Some little pressure above 
 the pubes may help in this attempt. The pulpy point of the index finger is then to be 
 held in the median line, just below the spot at which the puncture is to be made. The 
 surgeon then with his right hand is to take from his assistant the canula, well oiled and 
 fitted with the hhmt pilot trocar, and to introduce it into the rectum upon his left index 
 finger, passing it well up to the point .selected for puncture. He should then steady the 
 canula and hold it firmly in position with the thumb and three outer fingers of his left 
 hand, and withdraw the blunt trocar. The i^liarp trocar can then be introduced through 
 the canula, and, having reached its end, the handle with the canula is to be depressed and 
 driven home, in a direction upward and forward, in a line toward the umhiUcm (dotted 
 line, Fig. 410). The bladder in this way will be entered, the free end of the instrument 
 moving freely, and all resistance ceasing. The trocar should then be withdrawn and the 
 canula pressed well home. Before the bladder is completely emptied it is well to insert 
 the two inner canulae and fasten the whole in by means of tapes, two passed in front and 
 two behind the thighs, to a girth round the waist. The canula may then be plugged with 
 a peg, to retain the urine, or with a hollow plug inserted into a piece of india-rubber tub- 
 ing, through which the water may drain away. 
 
 As soon as the urethral passage has become pervious to the catheter, hut not before. 
 
sri'liA-rriiic rrxcrrnh' or the uladd/:!:. 705 
 
 the canula should \>r witlMlrawn ; this cfinditioii usimlly takes |ilac(! within a week from 
 the iiitrodiictiou of the eatlictiT. In a casi- ol' iiiiiic the canula was h'ft in for seven 
 wt'(k> lit'foro a catheter eould be passed, when a rajtid cmr ensued. The stricture may 
 then he treated on rational prineiples by dilatation. It is very remarkable hr)w at times 
 a stricture which has thus been left alone and unirritated by catheterism or ineffectual 
 natural i-fforts at micturition, f.nves way under such treatment, and a thoroughly imper- 
 vimis indurated urethra becomes pervious and aincnabh! to sim|)le nteasures. 
 
 The wound into the bladder doses rapidly after the removal of the canula, even after 
 many weeks, and in a case of my own no urinary fistula followed the presence of the 
 canula for seven weeks. 
 
 In retention of urine from cidarjicd jirostate such an operation as this is rarely called i'ur, 
 yet at times it is necessary. It was performed at (iuy'.s in two out of twenty-four cases of 
 retention of urine from this cause, an(i with complete success. I have had recourse to it on 
 three occasions where the neck of the bladder and prostate gland had been seriously injured 
 from rough catheterism, and with such good success that I shall never hesitate to repeat 
 it when any difficulty exists in entering the bladder or in subse(|uently keeping an instru- 
 ment in the bladder. In two of the ca.ses mentioned the irritability of the bladder was 
 so great as to resent the presence of an instrument, and the pain and difficulty in its pas- 
 sage were .';o severe as to be nearly unendurable. In both the operation was followed by 
 speedy and permanent relief; the blad<ler recovered its healthy condition after the parts 
 had had rest for a few days, the urethra allowed of catheterism without distress, and con- 
 valescence was soon established. 
 
 I know of no operation attended with equal good that is so safe, satisfactory, or free 
 from danger. The surgeon may perform it without fear in all cases of retention where 
 any difficulty in catheterism exists. 
 
 In all cases of supposed retention of urine the surgeon should guard himself against 
 falling into the error of mistaking suppression for retention, as in all ca.ses of supposed 
 incontinence he should i-enieniber that it may be due to retention and overflow. 
 
 SuPRA-PuBic Puncture of the Bladder. 
 
 This operation has been growing in favor and claims description. Mr. T. Smirth^ 
 asserts '' that, while it is as safe as the rectal puncture, it is easier of performance," 
 and that " it is applicable to all cases of retention in which the bladder rises above the 
 pubes." 
 
 In corpulent subjects, and in such alone, the skin should be punctured with a knife, 
 to facilitate the entrance of the trocar. 
 
 Whilst the urine is in full flow it is wise to introduce through the canula a gum- 
 elastic catheter with a terminal as well as lateral orifice, the former allowing the passage 
 of a stylet into the bladder to serve as a guide for the introduction of a fresh instru- 
 ment. The catheter should be firmly secured in position by means of threads attached 
 to a belt of strapping and plugged, and for permanent wear fitted with a soft rubber 
 or vulcanite shield. Were I to perform this operation T should probably raise the blad- 
 der out of the pelvis by distending the rectum with the dilator as described at pacie 640, 
 Fig. 3G3. 
 
 Extravasation of Urine in Children, and Retention from Impacted 
 
 Urethral Calculus. 
 
 It has been already explained how retention and extravasation of urine in the aduh 
 may be produced by the mechanical obstruction of a urethral stricture. It remains to 
 show how in children the same effects ensue from a mechanical obstruction of a very dif- 
 ferent kind. I allude to the obstruction caused by a urethral calculus. 
 
 A vesical calculus, when small and ejected from the bladder, may become lodged or 
 impacted in any portion of the urethra, and as a consequence give rise to every degree 
 of difficulty of micturition, even to a retention of urine and extravasation. In adult life 
 I have seen complete retention, but I have never seen extravasation occur as a result of 
 impacted urethral calculus. In infancy and childhood, however, almost all the examples 
 of extravasation of urine that have passed under my observation have been the pi'oduct 
 of such a cause ; I have seen it in an infant fourteen months old, and in many others 
 older. When a case of retention in a child comes under notice, and there is no phimosis, 
 
 ' St. Earth. Hosp. Rep., 1881, p. 294. 
 45 
 
706 SURGERY OF THE URETHRA. 
 
 paraphimosis, or adherent prepuce by which this symptom may be produced, a strong 
 probability exists tliat a urethral calculus is the cause. 
 
 Treatment. — If the calculus can be removed by forceps carefully used, this practice 
 is the right one to adopt ; it is, however, rarely successful, and Avhere these means fail the 
 stone must be excised. When extravasation has taken place, the urethra must be opened 
 in the perinfcum by a free incision upon a grooved staff. The stone is sometimes lost in 
 the sloughing tissues. 
 
 Summary. — By -svay of summary of the causes of retention, it may be stated that 
 retention in a male child is usually due to a urethral calculus, phimosis, paraphimosis, 
 adherent prepuce, or the mechanical obstruction caused by a piece of string, etc. ; in a 
 female, to ulceration about the meatus or to adherent labia ; retention in the young adult., 
 to stricture, obstruction of the urethra from stone, gonorrhtjea, perineal, anal, prostatic 
 abscess, or rectal disease ; in the aged., from enlarged prostate or atony of the bladder. 
 
 Eetention from fever or general nerve shocks may occur at all periods. In women 
 hysterical retention may also occur, as well as retention from uterine causes. 
 
 Urethral or Urinary "Shock" and "Fever." 
 
 Surgeons have long been familiar with the fact that after the ])assage of a catheter 
 certain male patients experience symptoms which seem to be altogether irreconcilable 
 with the simplicity of the operation that apparently excites them. They have known that 
 immediately or soon after the easy passage of a catheter and micturition a man may 
 shiver and turn pale and cold, or perhaps faint, turn sick, or vomit — that he may even 
 have a slight epileptic convulsion and soon recover, the " shock"' either passing off or being 
 followed by a more or less severe febrile condition. 
 
 Mr. Banks and others have also pointed out how after the same simple exciting cause 
 a man may suffer from '• shock" of so severe a character as to terminate in death within 
 twenty-four hours, or become the subject of a "continuous" or "intermittent" attack of 
 fever which may or may not terminate in speedy death, the symptoms under these cir- 
 cum.stances assuming a shape of either urtemic or septicajmic poisoning ; and in these 
 cases, when suppiirative urethral or kidney disease in any of its forms is made out to 
 exist, there is no difficulty in finding an explanation of the " shock" or of the " fever." 
 
 Since the days of Richard Bright, and more particularly the publication of Dr. N. 
 Chever's valuable paper on the causes of death after injui'ies and surgical operations 
 (^Guya IIosp. Reports., 18-13), surgeons at Guy's have accepted as truisms " that an opera- 
 tion or injury in itself of a most trivial kind is liable to be followed by fatal results 
 should the subject of it be suffering at the time from either acute congestion or granular 
 degeneration of the kidneys ;" "that it is impossible to urire too strongly the necessity of 
 testing the urine for the presence of albumen in each patient before deciding upon the 
 performance of any surgical operation," however trivial it may appear; and that an 
 operation upon the urinary organs of the simplest character must always be regarded as 
 most dangerous when kidney trouble complicates the case, as well as when the patient has 
 been long under the influence of tropical malaria, as pointed out by Sir J. Fayrer. 
 
 But this explanation of the symptoms cannot be given for all cases, and we must 
 accept as true to a degree Sir A. Clark's recent assertion '• that in persons apparently 
 healthy catheterism is sonjetimes followed by fever neither distinctly uraemic nor dis- 
 tinctly pyaemie, that this fever sometimes ends in death, and that in such cases the 
 autopsy reveals no definite visible structural lesion adequate to account for death." ^ 
 
 Under these circumstances we of necessity go to the nervous system as the one at 
 fault, and recall the anatomical fact which " Miiller long ago demonstrated — that the 
 nervous supply of the penis, prostate, and neck of the bladder is almost purely sympa- 
 thetic, the nerves being traceable to the pelvic or inferior hypogastric plexuses,"'^ and 
 acknowledge that such plexuses are as susceptible to shock as are the abdominal. 
 
 Other points also in urethral or bladder troubles favor this view; for instance, medical 
 men must often have observed that with contraction of a distended bladder, on the expul- 
 sion of the last drops of urine a shudder constantly passes through the healthy frame, 
 and I well remember the case of a lady about thirty years of age who had the severest 
 rigor I ever witnessed as the direct and immediate effect of the bladder emptying itself 
 after a long enforced retention. 
 
 Again, in a case of rapid lithotrity I had in 1883 in a man aged fifty-nine, from whom 
 two hundred grains of uric acid calculus were removed without difficulty or the slightest 
 ^ Edin. Med. Journ., April, 1884. ^Mr. Banks's paper, Edin. Med. Jmirn., 1871. 
 
URETIIHM, on riUXAin' ''SHOCK" AM) ''FEVKR." 707 
 
 hitch ill forty-five iniiiutt-s, and where ii jroml result waH with cijiifideiice predicted, the 
 patit'iit ill forty lioiirs .sank collapsed, the coHapst? not folhiwiiii; the operatittn, hut show- 
 iiii; itself within the first Iwciity-lour hours. After death perfectly healthy kidneys were 
 found and an uiiiiijiircd empty lu aitliy liladdcr. In I'act, no j»atholoj;ical cause of death 
 was detected. 
 
 In all these cases ''shock" was manifested, and shock without fever, the "shock" in 
 its mildest form showini; it.self in the shudder of normal evacuation, in its more severe in 
 the evacuation <d' retention, and in its most severe and fatal funii in that followiiif^ a some- 
 what proloniretl, thoutrh apparently not violent, operation. 
 
 I hold, therefore, that " urethral shock" as well as " urethral fever" is met with in cer- 
 tain patients the sutijects of urethral and hladder aH"ecti(»ns, and that probably both shock 
 and lever are broiiLjJit about throiij^h the influence rjf the .sympathetic .system ; that the 
 shock may be only a passing shudder or faintne.ss, but that occasional rare cases occur 
 where the nervous shock is so profound, even after the simple introduction of a bougie or 
 catheter, that death may result within twenty-four liours ; that urethral fever may a.ssumc 
 any degree of intensity, from a slight rigor, and subsequent general malaise, to such seri- 
 ous prostration as may end fatally after some days; that a careful distinction must be 
 made between true urethral fever and py;oinia resulting from operative interference with 
 the urinary passages; that renal disease, with its resulting vitiated condition of the blood, 
 pndjably predisposes to death, as it unquestionably is one of its cau.ses in such ca.ses. 
 
 It will be seen that these conclusions coincide to a degree with those given bv Mr. 
 W. M. Banks in his able paper already referred to. 
 
 Trkatmkxt. — The surgeon should ever have before him the possibility of a jiatient 
 requiring the pas.sage of a catheter being prone to suffer from urethral "shock" or "fever." 
 He should, therefore, where possible, prepare liiin for the ordeal by clearing out the bowels 
 and keeping him warm and cjuiet for twenty-four hours, and, in many ca.ses, in bed. Where 
 any malarious fever has previously existed a good dose of quinine — say five grains — should 
 be given a few hours beforehand ; and even when no such history can be obtained, a like 
 practice has advantages. Should tlie patient have any external appearances of renal di.s- 
 ease and albumen be found in his urine, the surgeon should not pass a catheter without 
 these precautions unless under the pressure of urgency. 
 
 Under all circumstances the catheter must be clean, warm, and well anointed with 
 some anti.septic oil. It must be used carefully and tenderly, Should the bladder be 
 much distended, part of the urine should be drawn off at the time and the remainder at 
 a later period ; and if the contents of the bladder are fetid and the organ requires to be 
 washed out, some little of the injected antiseptic fluid should be left behind in the blad- 
 der. When a soft instrument can be used, it should be preferred. When " shock" is 
 caused by the manipulation, the warmth of a bed. with some external appliance to the 
 extremities, and the administration of a wineglas.sful of hot spirit and water, often acts 
 well. 
 
 When slight febrile disturbance takes place, a dose of Dover's powder or the bromide 
 of potassium is very useful. 
 
 In more chronic cases quinine and iron, combined or separately, are of great value, as 
 also are vapor or hot-air baths. When the symptoms are continuous or recurring, renal 
 disease is to be suspected, and the treatment must be conducted under such a Jight. The 
 prognosis of the.se cases always turns upon the persistency or frequent recurrence of the 
 symptoms and the elevation of the temperature, together with the indications afforded by 
 the dailv careful examination of the urine. 
 
708 AFFECTIONS OF THE GESITAL ORGANS. 
 
 CHAPTEE XXIV. 
 
 AFFECTIONS OF THE GENITAL ORGANS. 
 
 There is probably no peri oi the body which varies more in its conformation than the 
 penis, or one in which any congenital defect is more likely to be inherited. The elongated 
 and contracted prepuce is particularly hereditary, and all the male branches of a family 
 may be the subjects of it. I have known this to be the case in many instances, and in 
 one family five sons suffered from it, as well as their father. 
 
 Phimosis, or a condition of prepuce which, either from narrowness of the preputial 
 orifice or from adhesion, cannot be retracted behind the glans. is sometimes a congenital 
 affection, but as often as not it is an acquired one, the result of inflammatory thickening 
 and contraction sub.sequent to a preputial chancre or other trouble. 
 
 So long as the prepuce is only long and the glans can be uncovered for purposes of 
 cleanliness and during erection operative interference is not called for, though it is well 
 to impress upon nurses the necessity of paying attention to the infant's penis and of 
 cleaning it daily, since a want of such attention is frequently the source of urinary trou- 
 ble and penile irritation. From neglect the secretion of Tyson's glands collects behind 
 the corona and acts as an irritant ; the prepuce and glans penis as a result constantly 
 become adherent, and, as a consequence of the irritation, bladder symptoms, simulating 
 those of stone, appear. ( Vide page 632.) In some neglected cases an acute inflamma- 
 tion is induced, followed by oedema of the prepuce and the secretion of pus, which sus- 
 picious minds have too often interpreted as gonorrhoea, much to the injury of nursemaids 
 and otliers in whose charge the child rested. This disease is essentially a balanitis and is 
 easily cured by cleanliness. In the adult a long and narrow prepuce is injurious, as 
 being a bar to proper cleanliness and interfering with coitus or rendering it painful. It 
 is also, without doubt, an exciting cause of cancer of the organ where a disposition to 
 such an affection exists. In boyhood it may, by exciting an irritation in the parts, 
 induce a habit which ends in masturbation. It often gives rise, moreover, to inconti- 
 nence, and may produce retention of urine. Dr. Lewis Sayre of New York has also 
 pointed out in his work on Orthopedic Surgf-ry (1876) that as a direct result of this con- 
 dition of the prepuce talipes, paralysis, and other nervous affections may take place, the 
 talipes being due to muscular contraction of the lower extremities owing to i-eflex nerve 
 irritation, and paralysis as a consequence of nervous exhaustion caused by the undue 
 genital excitement which is often associated with this condition. 
 
 Treatment. — When the narrowing is not great, the daily retraction of the prepuce 
 over the glans for purposes of cleanliness is generally sufficient to dilate the orifice, care 
 being taken to replace it subsequently. Dr. Cruise's plan of dilating the orifice mechani- 
 cally is not satisfactory ; I have given it a trial and rejected it. The 
 Fig. 411. suggestion, also, of making two partial lateral sections of the mucous 
 
 membrane has in my hands met with the same fate. Neither of these 
 methods is so successful as to warrant its being recommended. 
 
 When phimosis exists, congenital or otherwise, it is, as a rule, best 
 treated by circumcision. In exceptional cases, where a narrowing of 
 the prepuce is more marked than an elongation, the prepuce may be 
 slit up (Fig. -411), but in children circumcision is the better operation. 
 ^-^ ' In some instances, however, where the penis is very short, the fault 
 //\^ resting more in the penis itself than its skin covering, circumcision 
 
 '\ should not be performed, for I have known, under these circum- 
 stances, the operation to fail, even when well done ; in such cases the 
 prepuce should rather be slit up to the corona, and its mucous cover- 
 ing turned well back and fixed to the skin. 
 
 In minor cases the sh'ffi)i(/ plan should be carried out, the .'^kin and 
 its mucous lining being divided in the middle line either by the intro- 
 duction of a bistoury guided by a director beneath the prepuce or by 
 inosis. means of a pair of .sharp scissors. The surgeon must be careful, in 
 doing this, to divide the mucous membrane rif/ht bade to the corona. 
 In the adult he should then turn the two flaps backward and ftisten the mucous to the 
 skin flap by means of some fine carbolized catgut sutures. In the infant there is no 
 
 \ 
 
( 7/.V 7 ■}/( /.s/O.V. /'. I l:.\riHMnsfS. 
 
 709 
 
 ri<i. 412. 
 
 Operation Tor I'hiiiiosis. fFirststep.) 
 
 ncct'ssitv to stitch. Wlicii tlu' ])rt'])ii('t; ri'i|iiirfs divi.-inii to expose a sore or .sonio warty 
 growth, the iihovt' phiii shniihl he sclfctcd. 
 
 Circurncision i>^ an operation that reijiiires frreat nicety, for it fails if .sufficient 
 skin is not tnketi away and the mucous covering; of tlie jrhms is not fully dividcil up to 
 the cnrona, and it does not turn out well when too much skin is removed. It is by no 
 means a danj;erous o|»eration, althouL'h in '' hieeders " it may he so, (iraiididier (/Jie 
 ILhnnphllr^ 1S55) rectirdinir seven cases of .Jewish children who dieil from preputial 
 hemiu"rha<jje after circumcision. The following is the plan I have lor years adopted ami 
 taujrhf. and have never known to lail if properly carried out : 
 
 The first point is to decich; how much skin is to he removed, which can .satisfactorily he 
 dcterminetl hv applyinj^ a pair of lont^ dressinj; forceps to the skin (»f the penis whilst it 
 rests in the natural ],ositioti. on a level with the 
 corona, and clnsiuix them as .soon as the glans penis 
 has heen allowed to slip hackward. The inteirunient 
 in front of the forceps may then he amputated with 
 a scalpel ( Ki-r. 412). 
 
 The force))s should now be taken away and the 
 mucous covering of the glans he divided in the mid- 
 dle line, well up to the corona (as in the slitting ope- 
 ration), and turned backward, the two flaps being 
 stitched to the skin by fine sutures. In adults a fine 
 uninterrupted suture is probably the best ; in infants 
 a strip of dry lint wrapped round the parts is all that 
 is necessary. 
 
 The glans penis, in this as in the former opera- 
 tion, should be comjiletely separated from its mu- 
 cous covering, all secretions removed, and the frajnum divided when short. 
 
 By adopting these suggestions the student has a definite guide to aid him in the 
 removal of the skin ; whereas, if the end of the foreskin be drawn out, as usually recom- 
 mended, he has none. 
 
 " Circumcision is practised amongst the Tongans (Friendly Islands), not as a religious 
 rite, but principally because the women won't have the men who are ^/^circumcised, and 
 they have to remain unmarried " (J. E. Moulton, Wiabijan MlsAlotiKiy, February 26, 188(J). 
 
 Paraphimosis is said to exist when a tight prepuce which has been retracted 
 behind the glans cannot be replaced, and as a consequence a .strangulation of the glans 
 and mucous lining of the prepuce with oedema takes place, and at a later period ulcera- 
 tion in the line of strangulation, and even sloughing. 
 
 In children it follows the accidental retraction of a narrow prepuce, and in adults the 
 mechanical retraction of the prepuce during coitus and the neglect to reduce it. It may 
 be associated or not with some venereal complication. 
 
 Treatment. — The object of the surgeon should be to reduce the glans behind the 
 narrow prepuce by which it is strangulated, and, failing this by simple means, he must 
 divide the constricting preputial orifice, so as to effect this end. 
 
 To carry out the first object an india-rubber band applied as an Esmarch's bandage 
 will sometimes answer, but if it does not an anajsthetic should be given and the patient 
 placed on his back ; the surgeon should take 
 the penis between the index and middle 
 fingers of his two interlocked hands, and 
 while thus pulling the prepuce forward for- 
 cibly press the glans backward with his two 
 thumbs, the pressure of the thumbs and 
 counter-pressure with traction of the inter- 
 locked fingers so displacing the fluid from 
 the (edematous tissues as to allow of the re- 
 duction of the paraphimosis. When the 
 oedema is very great, a few needle or lancet 
 punctures facilitate the operation. When 
 the affection has been of .some days' standing 
 and ulceration exists, and when failure has 
 
 followed all attempts at reduction, the Stric- .M„a> .,l Dividing Prepuce in Paraphimosis. 
 
 tured preputial orifice must be divided ; but 
 
 the band must not be looked for directly behind the glans, but behind the roll of cedema- 
 
 FiG. 413. 
 
710 AFFECTIONS OF THE GENITAL ORGANS. 
 
 tous prepuce that surrounds it. This is best done by a cut half an inch long, made with 
 a scalpel, in a vertical direction over the con:«triction, the thumb of the left hand forcibly 
 depressing the glans penis (Fig. 413). The prepuce at times yields audibly and the 
 wound gapes ; the whole constricting medium should be divided. Some antiseptic lotion 
 should be applied to the parts subsequently to assist recovery. After the paraphimosis 
 has been reduced and the oedema subsided, it is wise in the case of children to circumcise, 
 and in the adult the same practice is frequently desirable. In all cases of oedema of the 
 pi'iih in children the surgeon must remember that it may be due to mechanical strangu- 
 lation. 
 
 Warty growiihs are very common on the penis, and they may be found fringing 
 the oritice of the prepuce and the urethra or growing from any part of the mucous mem- 
 brane between these two points ; indeed, they may grow from within the urethra as well 
 as from the outside skin of the prepuce. In the bulk of cases they have a venereal 
 origin — that is, they have been caught by contagion, for warts are contagious — but they 
 at times occur without any such cause in men who have long prepuces and who are not 
 sufficiently careful in local cleanliness. 
 
 Treatment. — When they are numerous, their excision is the only successful treat- 
 ment, nitrate of silver being applied to their bases ; but in less severe examples the dry 
 oxide of zinc, freshly powdered savine, and calomel are good local applications, the warts 
 rapidly withering under their influenc. 
 
 Cancer of the Penis. — In the middle-aged and old it is sometimes difficult, if not 
 impossible, to distinguish simple warty from cancerous growths, although the greater 
 obstinacy of the cancerous and their disposition to bleed are probably the best points of 
 distinction. 
 
 When there is ulceration, the disease is probably cancer. If the cancer be left to take 
 its course, the glans penis and pi'epuce become infiltrated and the ulcer discharges a fetid 
 ichorous secretion, breaks down, and spreads ; the inguinal glands become involved, and 
 death takes place from exhaustion. At times the whole organ is destroyed and the scro- 
 tum involved. 
 
 Cancer of the penis is generally of the epithelial variety, true carcinoma being com- 
 paratively rare. 
 
 Treatment. — In all clear cases of this disease, unless the inguinal or lumbar glands 
 are extensively involved, amputation is the only sound practice to follow, and in the 
 doubtful it is the wisest. When the prepuce alone is involved, the excision of the growth 
 may be sufficient ; but nothing less than amputation is of any use when the glans is 
 affected. Under all circumstances the surgeon should cut quite free of the disease, for 
 the tissues about it are probably more or less infiltrated with cancerous products. I have 
 a patient alive and well now (1884) who.se penis I cut off for cancer seventeen years ago, 
 and a second from whom I excised a cancerous mass from the prepuce sixteen years ago. 
 Amputation of the Penis. — Since the galvanic cautery has been in use I have 
 employed nothing else fur amputation of the penis. A gum-elastic catheter should be 
 introduced into the urethra and the platinum wire passed with a 
 Fig. 414. needle between the spongy and cavernous bodies, and then round 
 
 the penis and made tight with the ecraseur screw. Connection with 
 the battery must then be made and the wire screwed i^loidy home ; 
 for if the ti.ssues are divided too rapidly, hemorrhage will take place. 
 The heat should not be too intense. The wire should then be made to 
 livide in the same way the spongy body and the urethra, half an inch 
 or more nearer the glans penis. Under ordinary circumstances the 
 operation is absolutely bloodless and the subsequent pain slight. 
 After the penis has been removed it is wise to slit the urethra open 
 for about half an inch, turn its two edges outward, and fasten them 
 to the skin with sutures. This step is good to prevent the contrac- 
 tion of the urethral orifice that may otherwise ensue. When the 
 ^^"'"o^ratVon.'^'^^^'^ Cautery is not to be had. the knife should be used. The old opera- 
 tion consisted in the removal of the organ by one clean sweep of 
 the bistoury, an assistant having steadied and compressed the base of the organ by a band 
 of tape. The modern improved operation — which, I believe, was suggested by Hilton — 
 consists in the introduction of a narrow bistoury between the spongy and cavernous bodies, 
 and after dividing the latter the spongy body with the urethra must be cut through about 
 half an inch more forward. The object of this is to make the urethra stand out from the 
 stunted oruan. and thus facilitate micturition. It is. without doubt, the best mode of 
 
MALF()li)IATI()\ or Tin: II!I\0-(;/:MTAL (fJ!(;AXS. 
 
 711 
 
 aniputatiii^ a \)v\\'\s witli tlu- kiiilV'. 'I'o pri'vont any tencK'ncy in th(! urethra to contract, 
 it may lu- slit itjim or stitclieil hark to the preputial .skin. Kijr. 414 illustrate.s tlie stump 
 after sueh an amputatinn. 
 
 To arrest liemorrhaL'e ilnrini: the upcratinn Chtver's clamp for compresHing the penis 
 is verv cxci'Ilciit. ami oui:lit to >iipcix(li' the tape. 
 
 Other Tumors of the Prepuce. — The prepuce may he the seat of f'lfh/, 
 sf/iiKioiis, or even jihioKs, tumors, though these are rare. It is not uncciinmonly the 
 suhject of what has heen tlescriheil as r/iii/uiufoisis, althou<;h when the penis is involved 
 the scr(»tuin is usually similarly attccted. I have, however, seen one case in a man ajred 
 tiiirtv-five where the penis was thus alone afleeted. The orjran was immense and fright- 
 ful to hiok at. When in rejio.se it measured eij^ht inches round and si.x long. The man 
 came to me with a gonorrlnea, admitting, however, that he had never been able to have 
 true coitus since the disease had existed, whicli was about four or five years. 
 
 The di.sease is a chronic hypertrophy of the skin and cellular ti.ssues. Nothing but 
 the excision of the redundant integument is beneficial. 
 
 Fig. 415. 
 
 Injuries to Penis. 
 
 These are not common, excepting such minor injuries as laceration of the frsenum or 
 prepuce produced in coitus. Inci-sed wounds, however, arc occasionally met with, the 
 products of insanity, jealousy, or malice ; the parts 
 require careful adaptation with sutures. Recently I 
 had a man under care who was lifted off a bench b}- a 
 Woman holding his penis. The accident was followed 
 by much urethral bleeding, which was stopped by ice, 
 and a good recovery took place. The body of the 
 penis at times, however becomes the seat of injury 
 from some rough bending of the organ during con- 
 nection or otherwise, and as a consequence, when the 
 immediate effects of the injury have passed away, 
 strange symptoms appear. Thus, some years ago I 
 was consulted by a gentleman whose penis, when 
 turgid, arched laterally, the cavernous body of one side 
 having atrophied and become a mere gristly mass. This 
 condition had followed an injury received in coitus many years before. Some great 
 induration had existed for months in the cavernous body that had sub.sequently atrophied. 
 More recently I have seen a married man about (50 who a year before '• missed his mark "' 
 in coitus and hurt his penis ; an induration followed, and at the present time, where this 
 existed, there is a deficiency of tissue and when the penis becomes turgid it is never 
 straight, but bent laterally. 
 
 A singular, ca.se of injury to the penis was seen at Guy's in 1867, in the practice of 
 Mr. Hilton. It was in a man aet. 50 who when nineteen had had his penis bitten by a 
 stallion ; after the accident some little bleeding occurred and a fleshy cylindrical body an 
 inch and a quarter long and one-third of an inch in diameter projected from the urethral 
 orifice. It was evidently the corpus spongiosum, which had been divided by the horse 
 behind the glans penis and had become everted. When the patient was admitted, the 
 corpus spongiosum urethn\i terminated abruptly about one inch behind the glans penis 
 and the urine flowed by the side of the protrusion (Fig 415). 
 
 Corpus s'pongiosMin projecting from Urethra 
 after Injury. 
 
 Malformation of the Urino-Genital Organs. 
 
 Malformations of the urino-genital organs are more common in the male than in the 
 female subject, and show themselves in many degrees of severity. Thus when the upper 
 surface of the urinary passage, from the orifice of the urethra to the fundus of the blad- 
 der, is deficient, a case of rxfrovcrxion of the Lhuhbr or ectopioii rrsicpc is said to exist ; when 
 the urethra alone is deficient at its upper part, epicpwlian is the term employed. Some 
 authors apply the latter also to the more complete condition. With this imperfect con- 
 dition a separation of the pubic bones frequently exists, as well as some malformation of 
 the scrotum, this sac being often bifid, though containing the testicles in proper position. 
 At times a hernia complicates the case. When no testes are present and the scrotum is 
 bifid, the question as to sex often arises ; for in the female the vagina is frequently 
 absent or so small as more nearly to represent a urethra than a vagina. 
 
712 AFFECTIONS OF THE GESITAL ORGANS. 
 
 In extroversion of the bladder tlie posterior wall of the bladder appears as a 
 red inucuus mass below the uiubilicus. which is lost in the upper border of the deformity 
 At the lower part of its surface the orifice of the ureters may be often seen as small nip- 
 ple-like projections, and in some instances these orifices are lost in the pelvic chink, 
 although they may be brought into view by depressing the fissured penis, or what repre- 
 sents the penis ; for this will probably appear only as an expanded glans penis and a 
 pendulous prepuce. The cleft urethra, as it becomes lost in the pelvic fissure, can be 
 made visible by pulling the parts down (Fig. 416). 
 
 In the female subject the exposed urethra will be seen between the two labia. When 
 the vagina is present, it will open at its upper border and appear continuous with the lower 
 labia (Fig. 417). At times, though very rarely, the epispadias involves only the urethra. 
 
 Fig. 416. Fig. 417. 
 
 \ 
 
 Ketopion Vesicie in Male. Ectopion Vesicae in Female. 
 
 I have seen but a few cases of this peculiarity, and in all the exposed mucous surface of 
 the urethra passed backward toward the pubes into a fissure, which was covered in by a 
 thin transverse fold of skin, from beneath which urine flowed. The scrotum was large, 
 but bifid, and contained the testes (Ouj/'s Hosp. R<?p., 1868). 
 
 Treat.mext. — The chief annoyance connected with this deformity being due to the 
 constant dribbling of the urine, Messrs. Simon and Lloyd were induced to carry out an 
 ingenious operation by which the urine might be carried into the rectum and the fissure 
 subsequently closed, but the attempt failed and has not been repeated. For particulars 
 the reader may refer to the Lancet (1851 and 1852). Holmes has suggested a modifica- 
 tion of Simon's plan, and it is probably in this direction that some good may eventually 
 be found. 
 
 In a case of epispadias in a boy recently under my care (September, 1875), in which 
 the whole of the urethra down to the neck of the bladder was fissured, and in which, 
 consequently, there was incontinence of urine, I tapped the urethra in the perinjeum in 
 front of the prostate and established an artificial urethral opening. By these means the 
 urine passed through the perinajum instead of above the pubes. and consequently could 
 be caught and retained in a urinal, greatly to the patient's comfort. In another case — 
 one of a boy ?et. 7 — I in May, 1880, after making a perineal incision, drew down the 
 penis, brought it out of the perineal wound, and fixed it there. Subsequently I com- 
 pletely closed the original fissure below the pubes. The case did well, and all the urine 
 flowed through the perinaeum and was readily caught in a urinal. 
 
 Other surgeons, however, have devised means by which the exposed mucous covering 
 of the bladder may be covered in, thereby adding to the comfort of the patient, and of 
 these Wood of King's College has been the most succes.sful. He has operated in ten 
 such cases, and Holmes in five. I have operated only in two. Four of Woods succeeded 
 completely, three of Holmes's, and one of mine, the others being partially succes.sful. 
 The operation consists in bringing up flaps of skin from either side of the fissure and 
 covering it in, fastening them together by sutures. (For full details viJf M<d.-Chir. 
 Trans., vol. Hi., and Holmes's Suiy. Bis. of Child., 1868.) In one case I destroyed the 
 mucous membrane with the cautery, and thus turned it into a cicatrix, avoiding the ureters. 
 
 Hypospadias is a term applied to any deficiency of the under surface of the 
 urethra, and in the larger number of cases the urethral orifice is placed below the glans 
 at a spot corresponding to the preputial frfenum. In some a depression exists in the 
 glans penis corresponding to the natural outlet, with several small depressions between 
 
MALI- OHM AT loS OF Till: llllS<J-(;ESITAI. OIK .ASS. 
 
 13 
 
 Vu;. 418. 
 
 the urethral orifice ami the cuiiliko ilcpressiDii at the extremity of the frhins, wliile iti 
 others one or imtre fnramiiia arc prt'seiit. situated hclow the true opening of the urethra, 
 throii'^h which urine eseape.s. Thi- urethral opunin;: in the.se euse.s is often small anil 
 re((uires eiilar^in^'. 
 
 In more e.vtreuje eases the urethral oritic<- appears at the hase of the jienis, when the 
 ileformitv is eouunonly associated with a hifid scrotum; under the.se circumstances, when 
 the testes are ahsent. the (juestion of sex is rai.sed. In a ea.se of tlii.s kind which I saw 
 in l.S()7 tlic sexual passion was so strong that a man eame to me to ask for <;astration, as 
 he was unable to copulate on account of the stuntefl condition of his penis, and the way 
 in which it was held dcnvn by a band winch caused it to arch downward under excite- 
 ment. The man at the tinu* had testitis from uiifrratitied passion. 
 
 Tkk.vtmknt — 'i'he operative measures that have been employed for the relief of this 
 deformity have hitherto not been very successful, althoufrh recently (M'</. Tlnvx (mil 
 
 (^/<»;., Januarv o*'. IST.") ) Mr. John Wood has recorded twrt cases of the 
 hahinir or prnllr varieties in which relief was f:iven. and M. Duplay 
 has published (Paris. lS74j full details of his method of dealin-r with 
 the more advanced form of malformation, called the perineo-.scrotal 
 (Fiir. 41S, A). I think so well of Duplay's ojieration that I will 
 describe it. It has for its object. ./?/>/. to separate the peni.s from 
 the scrotum and destroy its arching, in order to allow erection and 
 coition ; and. seconiV;/. to con.struct a new urethra from the abnormal 
 perineal openiiiir to the «rlans penis. 
 
 To carry out the first indication, a free division of the fibrous 
 bands conneetintr the penis with the .scrotum has to be made ; and 
 when this can be effected by a subcutaneous wound, as adopted by 
 
 Bouisson. so much the better. Dujtlay. however, incises transversely 
 
 the tissues from without inward, dividing, if necessary, the envelopes 
 
 and septum of the corpora cavernosa: this incision leaves a lozenge- ^'*^"°*^',^i'^s' "-'P**** 
 
 shaped wound TFig. 419, B), the edges of which may be brought 
 
 together by sutures (Fig. 419. C;. After this operation the penis is to be kept constantly 
 
 stretched, to guard against subsequent retraction, and six months later the second part 
 
 of the operation should be carred out. 
 
 The construction of a new urethra is a difiicult matter, and must be carried out in stages. 
 Duplays method is divided into three: 1st. the restoration of the urinary meatus ; 
 
 2d. the creation of the new urethra from the meatus down to the hypospadia perineal 
 
 opening ; and 3d. tlie reunion of the two portions of the urethra. 
 
 The first stage may be done at the same time as the correction of the arching of the 
 
 penis, and consists in simply paring the edges of the glans penis and bringing them 
 
 together by sutures round a catheter (Fig. 419, C). It is 
 
 almost always successful. 
 
 The s<rond stnge is to be effected in the following 
 
 manner : 
 
 The penis being held up. two longitudinal incisions are 
 
 made on its inferior surface parallel to the median line and 
 
 extending from the glans penis to the perineal urethral 
 
 opening, these inci.sions being bounded by two transverse 
 
 ones (Fig. 419. D). Two quadrilateral flaps are thus formed 
 
 (a ?>, a! b'), which should be large enough, when turned 
 
 back, to cover a catheter that has been previously intro- 
 duced into the urethra. 
 
 The cutaneous surface of these flaps .should next be 
 
 turned toward the catheter and the raw surface exposed to 
 
 view. 
 
 The .skin of the penis, in continuation of the transverse 
 
 incisions, is then by a little dissection made to furnish two 
 
 new flaps (c d. c <!' ) for covering the raw exposed surface of 
 
 the first flaps. 
 
 Lastly, the lower edge of the glans penis is vivified in 
 
 the part which corresponds to the new channel. 
 
 The flaps mu.st now be united, their sujierior edges being 
 
 stitched to the vivified glans, and the rwo flaps on each side of the urethra, the superficial 
 
 and deep, brought together with metallic or other sutures (Fig. 419, E). 
 
 Fig. 419. 
 
 Operations for Perineo-ScroUl 
 Hypijspadias. 
 
714 AFFECTIONS OF THE GENITAL ORGANS. 
 
 The thml stage of the operation consists in the reunion of the two portions of 
 urethra, and should be effected by paring the edges of the hypospadic orifice and bring- 
 ing them together by sutures, deep and superficial. 
 
 After the operation the urine must be drawn off by means of a catheter, and the 
 union of the parts is usually completed after three or four days. To render this result 
 more certain the membranous portion of the urethra might be opened in the perinji^um, 
 as in cystotomy or median lithotomy, and a catheter introduced into the bladder to divert 
 the urine from the seat of operation during the healing process. 
 
 Puberty is the best period, pi'obably, for the performance of this operation. 
 
 Occlusion of the urethra from some membrane or band sometimes exists, which if not 
 broken down in intra-uterine life leads to dilatation of the bladder, sacculation of the 
 ureters, distension of the pelvis of the kidney, and destruction of its secreting structure. 
 (Vide cases by Morris, Med.-Chir. Trans., 1876.) 
 
 ON LOCAL VENEREAL DISEASE. 
 
 GONORRHCEA. 
 
 Urethritis, gonorrhoea, and clap are terms applied to cases of inflammation of 
 the urethra of every degree of intensity and the product of a great variety of causes. 
 In some the affection is the consequence of the direct irritation of an instrument passed 
 into or left in the urethra, while in others it follows excessive or oi'dinary sexual inter- 
 course with unchaste women or with chaste women who are out of health and suffering from 
 acridity of the vaginal secretion. "A leucorrhcea," writes Diday, '• which would have 
 remained inoffensive after a single coitus, takes on, by redoubled excitement, irritant proper- 
 ties, and furnishes then a contagious fluid " (gonorrhoea). It is the direct product, most com- 
 monly, of contagion from the pus of an inflamed mucous membrane, Simon {^Holmes s Si/stem ., 
 vol. i.) having shown that " there is ample room to question the popular impression that 
 only specific inflammations are communicable ; much reason for suspecting it, on the con- 
 .trary, to be a generic and essential property of inflammation that its actions are always 
 in their kind, to some extent, contagious, pus from an acute inflammation producing its 
 kind on inoculation." 
 
 Lee states {Holnuss Si/sffm, vol. iii. ed. 3) the causes of urethritis to be the applica- 
 tion of a gonorrhoeal discharge to the sexual organs, and also certain irritating substances 
 applied to the mucous membranes, such as menstrual fluid, leucorrhoeal discharges, and 
 the injection of a solution of ammonia ; he does not exclude constitutional cause, such as 
 gout or rheumatism. 
 
 It is well to bear in mind also Ricord's observation, " that gonorrhoea often arises from 
 intercourse with women who themselves have not the disease ;" and Diday's, " that from 
 the very fact of a woman having a discharge, no matter what its origin, she is liable to 
 give a discharge to a man." Complaints closely resembling gonorrhoea sometimes appear 
 in persons the subjects of .stricture after sexual intercourse, a debauch, or other excite- 
 ment. 
 
 The disease may be acute and come on within a few hours of connection, or it may 
 fail to show itself for five or ten days ; and, in a general way, the sooner the symptoms 
 appear after the contagion, the acuter the disease. It may be subacute or chronic. 
 
 Symptoms. — It generally commences by an itching about the orifice of the urethra, 
 the mucous membrane of which will probably appear swollen and injected ; there will be 
 the sensation of heat on micturition, and after the lapse of a few hours some muco- 
 purulent fluid will be squeezed out of the urethra. In acute diseases the urethral 
 discharge will soon become abundant, and yellow, green, or blood-stained pus will flow 
 from a highly-injected and swollen urethra ; the whole glans and peiiis Avill become red, 
 swollen, and painful ; micturition will also probably be difiicult, painful, and scalding, the 
 passage being obstructed by the swelling of the mucous membrane. Chordee, or painful 
 erections, as the disease advances, will appear, and later on perineal pain, if not suppura- 
 tion. The groins, testicles, and perinaeum, too, become the seat of more or less tender- 
 ness, and constitutional symptoms show themselves, varying with the degree of the 
 inflammatory action ; in some subjects the febrile condition is well marked, but in most 
 it is absent. After the lapse of ten or fourteen days these acute symjjtoms partially sub- 
 side, the discharge becomes thinner and more muco-purulent, the external signsof inflam- 
 mation less marked, the pain on micturition less severe ; the perineal, inguinal, or scrotal 
 pain probably will have disappeared, a thin muco-purulent urethral discharge, with a 
 slight sensation of heat on micturition, alone remaining. 
 
c;oy(>J:J:J/<i:.i. Tlo 
 
 When these symptoms nre alldwed uneliecked to run their foiirse, I hoy will ^TiKlimlly 
 pass into tlie e()mliti(»ii kimwu as that tify/"7, in which a thin imico-iiuriilenl urclliral 
 discharj^e exists, uinittenth-d liy any litcal (»r f.M'ncral source ol" pain. G'/tr/, however, 
 luav he the result of some stricture or local urethra! disease, such as an ulcer. 
 
 The onlinarv seat of the afh^etion is the mucous memhrane of tin; urethra, the ori- 
 fices of the laeumi? hi'in^' chiefly involved. TIk; fossa riavicularis and parts around and 
 the mucous memhrane of the hull) are the most common s»;ats, the dissections of Sir A. 
 ('o<»per, Kie(U-d, Thomp.son, and others havin<^ proved this. At times, howtjver, ;.'oiior- 
 rlweal intlammatiou may, as Wallace pointed ont ( (Jii Vcmnnl Dijinist), involve at the 
 same time the whole of the urethra, tlie hiadder, the testicles, the f^lans, and the prepuce 
 in the male, ami in the female the nymphic, clitoris, vagina, etc., the disease, as it creeps 
 along to the posterior part of the urinary passage, decreasing in intensity in the anterior. 
 In severe cases the inflammation may extend to the submucous tissue and run on to 
 thickening, and even to suppuration. 
 
 I'rethritis the result of some mechanical irritation of the urethra is rarely acute; as 
 a rule it subsides as soon as the cause has been removed, Urethritis the consef|uence of 
 some gonorrha'al contagion is almost always acute, and, having once been started, is not 
 readily arrested. 
 
 (Jleet, whether tlie conse<(uence of an acute or of a subacute inflammation, when of 
 some standing, is almost always due to some urethral C(Uitraction r)r stricture. 
 
 Gonorrhoea in the Female. — Tn the female gonorrha-a is to be recognized as a 
 yellow purulent vaginal discharge accompanied by heat, pain, and signs of acute inflam- 
 mation. The less purulent it is, and the more the discharge is made up of mucus and 
 epithelium scales, the greater is the probability of the di.sease being due to vaginal 
 irritation other than gonorrhoeal — that is, to leucorrhuja ; and when the discharge is made 
 up of masses of glutinous, semi-transparent, albuminoid material like the white of e^:^, 
 the more certain is it that the discharge is uterine and comes from the glands in the neck 
 of the uterus. 
 
 It must be remembered, however, that in both sexes, as long as any purulent or semi- 
 purulent fluid is poured out by the mucous membrane of the genital passage (even the 
 slightest gleet), violent urethritis or inflammation of the vagina may arise in another 
 subject by contagion, and there is good reason to believe that sexual excitement is an 
 important element in aiding the propagation by contagion. Mr. J. Morgan of Dublin 
 believes that the vaginal discharges of constitutionally infected women are the cause of 
 the majority of sores in men. 
 
 TitEAT.MENT. — Gonorrhoea or urethritis is a local disease and may be treated locally 
 with success. When it is the result of local irritation from the passage of an in.stru- 
 ment, no treatment is called for, the discharge cea.sing naturally as soon as its cause has 
 been removed; but when from gonorrhoeal contagion, such a result is not met with. 
 
 In a very acute clap, wdien the urethra and penis are swollen from vascular turgescence, 
 free purgation with salines is the best practice, and in plethoric patients the addition of 
 antimony in quarter-grain doses, to excite nausea, is most valuable. 
 
 In less severe cases copaiba may be given in doses of twenty drops or half a drachm 
 three times a day with advantage, iDut this drug should not be continued for more than 
 three days. If it is to do good, it will show its influence within that time, and a huiger 
 continuance of the drug is useless and deleterious. The yellow oil of sandalwood may 
 also be employed in the same dose and under like circumstances, and at times it acts most 
 beneficially even when the copaiba has failed, but it is in no w^ay certain in its action. 
 
 For cleansing purposes an injection containing three or four drops of Condy's fluid 
 to the ounce of water is to be advocated. It may be used in all stages of the disease. 
 Astringent injections are always of value when they can be used frequently and efllicient- 
 ly, but strong injections are to be condemned. They may cure the disease suddenly, but 
 more commonly they fail and set up inflammation of the bladder and other mischief by 
 adding to the irritation. 
 
 The best injection in all stages of the disease is tannin in the proportion of three to 
 six grains to the ounce, and next to this is alum in the proportion of two or three grains 
 to the ounce, or the chloride of zinc one grain to the ounce. A solution of salicylic acid 
 is also good, half a drachm of the acid being dissolved in six ounces of water with a 
 scruple of borax. The perchloride of mercury, one grain to six ounces of distilled water, 
 as an occasional injection, has been recently advised. To be of use injections .should be 
 used from four to six times in the twenty-four hours. An ordinary glass syringe will answer 
 every purpose if the glans penis be well held, but there are special syringes which are 
 
716 AFFECTIONS OF THE GENITAL ORGANS. 
 
 supposed to have some advantages. During this treatment the use of such alkalies as 
 the citrate or tartrate of potash in twenty-grain doses, or ten grains of the bicarbonate, 
 may be given and good food allowed, but little or no .stimulant. 
 
 In the chronic stage I have found great benefit from the introduction into the urethra 
 of a large catheter covered with the glycerine of tannic acid, and at times the supposi- 
 torium acidi tannici rolled into sticks and passed into the urethra acts most beneficially. 
 
 The best way to give copaiba is as a bolus mixed with calcined magnesia and wrapped 
 in wafer paper, or as a mixture with gum and peppermint water. The capsules are 
 uncertain in their action. Copaiba is well known to produce in some patients a severe 
 rose urticarious eruption. Cubebs are less to be relied on than is copaiba. 
 
 In using injections the object is to make an impression upon the mucous membrane 
 by their astringent effects, and to keep it up. Weak astringents frequently employed are 
 far more valuable than strong ones used at longer intervals. When so used, they are as 
 beneficial in gonorrhoeal inflammations of the urethra as in that of the eye. When a 
 man can devote himself to the cure of his clap and throw into his urethra a weak astrin- 
 gent every hour, he will often check it within two or three days, in the same way as a 
 gonorrhoeal inflammation of the eye may be controlled under .similar treatment.' The 
 nitrate of silver injection is an uncertain, and at times a dangerous, remedy, often adding 
 to the disease instead of diminishing it. In all cases of long-continued clap or gleet in 
 the male the presence of a .stricture .should be suspected. It may often be made out by 
 the passage of a full-sized bougie a hoide when an ordinary catheter fails to detect it. 
 The gleet should only be satisfactorily treated by the cure of the .stricture — that is. its 
 full dilatation. 
 
 Tonics, particularly iron, are valuable adjuncts to the treatment. 
 
 All connection must be forbidden for some time after the apparent cure of a clap, for 
 any sexual excitement is likely to be followed by a relapse. Drinking and smoking to 
 excess are injurious. 
 
 In women a clap is readily cured by the frequent use of astringent injections of tan- 
 nin, alum, or sulphate of zinc ^ss to a pint ; the passage into the upper part of the vagina 
 of the tannic acid suppository is also excellent treatment. In the use of both these 
 means the patient should lie down with her hips raised, and the astringent should be 
 allowed to remain in the passage. To inject it sitting or standing is a useless, although 
 a too common, practice. 
 
 Complications. 
 
 In male subjects inflammation of the epididymis is the most common com- 
 plication, the disease doubtless spreading in a direct way from the urethra through the 
 vas deferens and cord to the epididymis. In .some cases it stops at the cord ; in others, 
 it goes on to affect the testicle itself. It is often associated with hydrocele, and from 
 this fact some surgeons have been led to bfelieve that inflammation of the testicle itself 
 is a common consequence of a clap. The treatment of this affection will be con.sidered in 
 a future page. 
 
 In the female inflammation of the ovary is said to occur, and even pelvic 
 
 peritonitis. 
 
 Abscesses in the cellular tissue external to the urethra, penile or perineal, are 
 often met with in acute gonorrhoea, and should be opened early. 
 
 Ohordee, or painful erection caused by the stretching of the corpora cavernosa, 
 into which inflammatory products have been infiltrated, is a common consequence, and a 
 vei-y painful one. Full doses of opium (gr. j) or ten grains of henbane, and a like dose 
 of camphor, are reliable remedies. Ricord used a suppository of ten grains of camphor 
 and one grain of the extract of opium ; I have sometimes thought the morphia supposi- 
 tory the most useful. Belladonna smeared over the urethra also gives relief at times. 
 
 Retention of urine may likewise occur from the mechanical closure of the urethra 
 through its swelling, from spasm of the urethra, or from both causes. The warm bath 
 and opium are the best remedies for the complication, a catheter being passed only when 
 an absolute neces.sity exists. 
 
 Inflammation of the prostate is likewise a complication, as is also inflam- 
 mation of the bladder. ( Vi'ie Chapter XXI.) 
 
 Inflammation of the inguinal glands, or sympathetic bubo, i? often 
 
 present, the glands occupying the upper part of the groin being usually involved, but 
 tho,se below Poupart's ligament are not seldom affected. In neglected cases these glands 
 
COMl'LIf'ATKfXS. 717 
 
 may suppurate. Fomontations and t<iiiics are the necessary treatment. The aVisorltcnts 
 of the penis are at times inHanied and suppurate. 
 
 Balanitis. — Wlien tlu- jrhms penis and jircpuee are involved in the inflammation and 
 this inllaniination is attended with protu.se discharge, hafdnifis or rxtenud ijouonlian is 
 said to be present. This att'eetion may be due to want (d cleaidiness a.s much as to gon- 
 orrha'al contact. When the ]>repuce becomes a'dematous and is long, phhnonn takes 
 place; when narrow and retracted behind the glands, so as to be irreducible, y>«r«yy/(/>/to«<» 
 exists. 
 
 Tkk.vt.mk.nt. — This balanitis should be treated locally by astringents, such as the 
 acetate of lead or the nitrate of silver lotion v-vj grs. to the ounce, painted on the inflamed 
 part. Phimosis and jiaraphiinosis should be treated on principle's already stated. 
 
 It should be remembered, too, tliat a balanitis associated with a rawness or erosion of 
 the gians or ju'epuce may be due to a syphilitic inoculation. 
 
 ^T^artS. — As a con.><e((uence of balanitis irarfs are very common, and may cover the 
 mucniis membrane of the glans and jtrepuce or invade tlie urethra it.self. They may 
 grow to a great size, putting on much the appearance of a cancerous penis. I have seen 
 them perforate the prepuce of a penis when phimosis was present. 
 
 Tkk.vt.me.nt. — They can be treated only by removal. When extensive, their excision 
 is the best plan, the operation being performed with the patient anaesthetized, nitrate of 
 silver or perchloride of iron or the galvanic cautery being freely applied to the base of 
 the warty growths. In less severe cases the warts will often wither if kept dry with the 
 oxide of zinc or the fresh powder of savin. 
 
 All warts are not, however, gonorrhijeal ; some may arise without any such cause, 
 even in clean sulijects. They are nevertheless contagious. In women they are often 
 found up the vauiiKi. l)ut more fr('<|uently at its orifice. 
 
 Gonorrhoeal Rheumatism. — An attection so called is an undoubted complica- 
 tion of the disease, explain it as we may. At the end of an attack of clap, patients, with- 
 out doubt, are often attacked with severe pain and tenderness of one or more joints, 
 attended with effusion and constitutional disturbance. It uiay occur with every fresh 
 attack of clap, and I have recorded a ca.se in my book on the joints in which it recurred 
 sixteen times after sixteen diff'erent attacks of gonorrhoea. Some authors look upon this 
 aff'ection as a .species of pyaemia due to the absorption of some morbid matter from the 
 inflamed urethra, but evidence is still wanting to prove the truth of the theory. It rarely 
 appears during the acute .stage of the affection, mostly in the chronic, but arrest of the 
 discharge cannot be associated with its appearance. The knees and ankles are the joints 
 mostly involved, yet those of the upper extren)ities are so at times. The fair-haired and 
 what are called strumous subjects are said to be more prone to the disease, but I cannot 
 say I have observed this. At times the rheumatic pains are more confined to the tendons, 
 fasciic. and muscles ; the heels and soles of the feet are also frequent seats ; as a result 
 of this inflainmaticm the parts involved, and particularly the fascia, may soften and yield. 
 The late Dr. liabbington used to say that this form of fascial rheumatism was found only 
 in those who had taken copaiba. 
 
 The disease may be nritte^ siihttcn'e, or chronic; and when acute, it may run on rapidly 
 to suppuration. The most acute example of suppuration of a knee-joint I have .seen was 
 of this nature ; it occurred in a man aet. 35 during the acute stage of gonorrhoea. It was 
 treated by free incisions into the joint, and followed by a good recovery with a stiff" joint. 
 This may well be called .acute f/onorr/taal i^T/iioi-i'fit!, to distinguish it from an acute gnnor- 
 rhoeal arthritis, upon which ray friend and colleague Mr. Davics-Colley has written an able 
 paper {Guys IIosj). R'p., vol. xli., 1883, p. 187). Gonorrhoeal arthritis " is as often found 
 in the female as the male — perhaps more often. It usually begins before the gonorrhoea 
 or discharge has existed for any considerable time, and the subjects are generally under 
 the middle age. The onset is like that of an attack of acute rheumatism. The patient 
 is feverish and has pain, tenderness, and swelling of several joints. These symptoms are 
 often so severe that he has to take to his bed. In a few days the inflammation leaves all 
 the joints save one. in which it concentrates itself with great severity. This may be any 
 one of the larger joints. Most frefjuently I have seen it in the elbow. The appearance 
 of the joint is not at all like that which is seen in acute synovitis. There may be eff"usion 
 within the synovial sac, but the most striking characteristic is the cedema of the soft parts 
 round the joint, accompanied, as a rule, during the height of the attack, by redness of the 
 skin. The swelling is in some cases very great ; and when the elbow has been aflfected. I 
 have seen the redness and oedema extending from the shoulder to the wrist-joint. I believe 
 that the superficial eff'usion is due to the inflammation having attacked especially the 
 
718 AFFECTIOXS OF THE GEyiTAL ORGANS. 
 
 fibrous tissues of the capsule ratlier than the synovial membrane by which it is lined. 
 The slight amount of eft'usion which occurs in the synovial sac is probably secondary to 
 the affection of the adjacent fibrous tissues, just as we sometimes see an acute periostitis 
 near the end of the diaphysis of a long bone accompanied by some effusion into the neigh- 
 borino' articulation. The joint is very tender, hot, and full of pain, and any attempt to 
 move it gives rise to excruciating pangs. The general temperature of the body is but 
 little elevated." From the great oedema which accompanies this aff"ection it may be mis- 
 taken for phlegmonous erysipelas, phlebitis, or lymphangitis, but a little care should pre- 
 vent an error in diagnosis from being made. Mr. Davies-Colley has pointed out that it 
 may be associated with cardiac complications. 
 
 Treatment. — Medicines seem to have but little influence on this disease. Local 
 treatment is. however, very necessary, such as immobility of the affected joint, with warm 
 fomentations, with or without the decoction of poppy-heads. The extract of belladonna 
 or opium diluted with vaseline is at times a valuable application. Opiates to relieve pain 
 are essential. 
 
 Should the joint suppurate, it must be dealt with by free incisions. In the arthritic 
 form this result is rare. When the acute symptoms have subsided, pressure is of great 
 value. 
 
 Under all circumstances the urethral or vaginal discharge must be cured. Passive 
 movement of the joint must be resorted to as soon as swelling and heat have gone, but 
 many joints become permanently stiff" after this aff"ection. 
 
 5lessrs. Duplay and Brun, who have written on the subject (Archives Generalcs de 
 Medecine, 1881), advocate the use of plaster of Paris splints. 
 
 Herpes Preputialis. — This is a simple affection which may be mistaken for chan- 
 cre, and i> known by the appearance of a crop of vesicles around the corona of the glans 
 or upon the external or internal surface of the prepuce. It is generally attended by much 
 local irritation and local evidence of inflammation, the vesicles when they burst often dis- 
 charging freely. The affection runs its course in a few days, and then the parts heal. A 
 zinc lotion of three or four grains to the ounce, or a solution of nitrate of silver gr. v to 
 the ounce, expedites recovery. 
 
 The number of vesicles and their grouping is generally sufficient to enable the surgeon 
 to diagnose this aff"ection from a venereal disease. 
 
 Chancre 
 
 -may be defined as a sore the result of venereal contact, and in a general way it is found 
 upon the penis of the male and the genitals of the female, but it may be seen upon other 
 parts of the body, such as the pubes, thighs, lips, tongue, nipples, fingers, etc. — in fact, 
 wherever the secretion from an infected subject may be applied to a raw surface. 
 
 In by far the larger number of cases this disease begins and ends as a local affection ; 
 in a smaller number it is a local inoculation of a constitutional disease and is followed by 
 syphilis. The sore is not syphilis, although it is the direct means of communicating syph- 
 ilis, any more than the inoculation of smallpox is smallpox, although the inoculation may 
 be the means of giving smallpox. 
 
 So long as the chancre is a local affection alone it is comparatively unimportant, how- 
 ever extensive and troublesome it may be in healing; but whenever it is the local inocu- 
 lation of a constitutional affection such as syphilis, it is of grave importance, however 
 apparently trivial may be the local sore. 
 
 It becomes, therefore, a vital question to make out from the appearances and conditions 
 of the sore whether it is likely to prove a local disease only or to be followed by constitu- 
 tional symptoms, and to a certain extent this diagnosis may be made — that is, a surgeon 
 may from the external appearance of a chancre go so far as to say that in all probability 
 this one will not be followed by syphilis and that one will, but he can do no more; to dogma- 
 tize upon the point and to speak with certainty are beyond his power. 
 
 The chancre which will not in all probability be followed by syphilis is the soft siijjj^u- 
 ratirig sore ; the chancre that will in all probability be followed by syphilis is the hard nov- 
 snpjvirntinff sore. 
 
 John Hunter thus described the indurated chancre : '• The sore is somewhat of a cir- 
 cular form, excavated, without granulations, with matter adhering to the surface, and with 
 a thickened edge and base. The hardness and thickening are very circumscribed, not dif- 
 fusing themselves gradually and imperceptibly into the surrounding parts, but terminating 
 abruptly." In this description we read the type of the hard infecting chancre — the chancre 
 
ciiAscni:. 719 
 
 of tilt' iriitcul:iti(»ii of syjiliilis. wherever ffuuul. Hunter aiMs. however, that "a cliancre- 
 has ciiiiiiiHtiily a thiekeiiftl base; ami althduirh tht; (•(iiiimnii iiitlaiiiiiiatioii spn-ads iiiueh 
 further, vi't the sju-eilie iiiflaniiiiatioii is ckiiHikmI t(» this hase. An infeetitijr <*liaii(ie may, 
 tno. appear only as a erack, i-xenriatifHi, nr iii(lurati'<l tiihercle, witlnmt abrasion. 
 
 This form of ehanere is e(immr)nly associate<l with some induration, not suppuration, 
 of the tirst row of the inguinal glands — the mnlliplr imlobni bnho. It.s secretion consists 
 of epithelial ifehris, of globules of lymj)!! more or less perfectly formed or disintegrating, 
 and of serum, »'>^ ;>»s, and not auto-inoculable. In debilitated and unliealthy subjects, 
 adds Lee, infecting sores will suppurate as any non-specific lesion would do, and in such 
 cases it is sometimes very difficult to distinguish the .secretion produced by the local dis- 
 ease from that which de])cnds upon constitutional peculiarity. 
 
 The soft siipinintfiiii/ c/iaiicrc is often multiple and has an excavated surface witli 
 neatly shaped and cut edges, as if the wouiul had been punched out. It has an irregular 
 and worm-eaten surface secreting abundance of pus. It is ])r(jne to spread rapidly and to 
 liecome phagedivnic. It has usually a soft base ; but if otherwise, it will have what 
 Kicord has described as a phlegmoinjus hardness, and not a defined one. as in the svphi- 
 litic chancre. It is commonly associated with a suppurating bubo, and secretes pus which 
 '• has the property of always reproducing its specific action when ajtplied to another part 
 of the same body or when inoculated upon another person " (H. Lee). 
 
 The experiments of Fournier and Kollet and Lee's observations led the latter surgeon 
 to '■ conclude that if a venereal sore yields a .secretion capable of being inoculated so as 
 to produce the specific pustule, the evidence, so far as it goes, is in favor of its being a 
 local disease and of its not requiring constitutional treatment. If, on the contrary, a dis- 
 ease which we believe to be primary syphilis yields a secretion which is not auto-inocula- 
 1)le. then the evidence is against the local character of the affection and indicates a con- 
 stitutional mode of treatment." In this we read the type of the simple local venereal 
 sore. 
 
 In a clinical point of view, however, this great distinction between the two forms of chan- 
 cre is not always definable ; and consequently an intermediate class of cases in which 
 syphilis occurs has to be recognized, in their clinical features more approaching the soft 
 sore. 
 
 There are, therefore, three forms of syphilitic sore, which the government committee 
 on syphilis has thus well described : One characterized by induration throughout its 
 entire course ; one soft in its early stage and becoming subsequently indurated ; and one 
 soft throughout the whole course, but which, unlike the simple local sore, is followed by 
 constitutional disease. 
 
 Hard sores do not of necessity give rise to syphilis, whilst soft .sores may. And it is 
 an undoubted fact that the question of induration or non-induration is greatly determined 
 by the position of the sore, chancres on the female genitals simple or syphilitic, and chan- 
 cres on the glans penis being rarely hard. 
 
 The point, therefore, resolves it.self into this — that the indurated chancre with a fair 
 amount of probability, although not certainty, may be the precursor of syphilis, and not 
 a merely local disease. The soft or non-indurated sore, in exceptional cases, may be due 
 to a syphilitic inoculation, although in the majority of cases it is a purely local affec- 
 tion. 
 
 A crop of soft sores fringing the prepuce or surrounding the corona is, in all proba- 
 bility, a simple and non-syphilitic disease. 
 
 A spreading chancre with a suppurating bubo is probably a local affection. 
 A small single chancre indurated from the beginning is the nio.st suspicious of syphi- 
 lii?, although even in this there is no certainty of its being so. In fact, it is not possible 
 to speak with any certainty as to a chancre being syphilitic or otherwise. Syphilis is a 
 constitutional disease which can be recognized only by its constitutional symptoms, and 
 not by the point of its inoculation. 
 
 With respect to the ])erio(/ of incubation of a simple or syphilitic chancre no definite 
 time can be given, since it varies from a few hours to a week, but the multiple suppurat- 
 ing simple chancres, as a rule, appear more rapidly after infection than an}- other ; the 
 syphilitic chancre often does not appear for a week at least, sometimes two or three, after 
 infection. Dr. Bumstead of New York says that " an interval of at least ten days will 
 be found to have existed between infection and the appearance of the sore " (edition of 
 Ciilleriers Atlas of Venereal Disease, 1868). 
 
 A chancre, like any ordinary sore, may present different appearances at different 
 times. It may be at its origin vesicular, papular, pustular, or an excoriation, and pass 
 
720 AFFECTIOXS OF THE GENITAL ORG ASS. 
 
 througli the ulceratlni/. fjranulatlug, and cicatrizing stages ; in one case the ulcerating stage 
 will be a long one. while in another it may be so brief as hardly to be recognized. 
 
 The action of the sore may vary with the condition of the patient, as well as with the 
 condition of the part upon which it is placed ; and it will probably be influenced by the 
 nature or the stage of the infecting sore from which the disease has been communicated. 
 
 A chancre, like an ordinary sore, when there is much local action and little con.stitu- 
 tional power, may become irritable, inflamed, or phagedaenic. more particularly when 
 drink, irregular living, and debauchery have so enervated the .system as to render the 
 patient unable to withstand the eifects of any local irritation. These various actions may 
 attack the chancre at any period of its progress. 
 
 When a chancre is sloughing or phagedaenic from the first and has originated from an 
 inoculation of syphilitic matter, there is every reason to believe that the sloughing pro- 
 cess may have a beneficial tendency, since the very intensity of the local eff"ects of the 
 poison may be the means of preventing its absorption, and thus, also, the outbreak of 
 syphilis. ^Yhen. however, the sloughing action appears during the ulcerating or later 
 period of the chancre's progress, it will have no such useful influence ; for when syphilis 
 is inoculated through a chancre, it is during its vesicular, papular, or pu.stular condition, 
 prior to its ulcerative stage, and no action of the sore that appears after this period can 
 have any eff"ect in checking the diff'usion of the poison. '• If the inflammation spreads 
 fast,'' writes Hunter, •• it shows a constitution more than naturally disposed to inflamma- 
 tion ; if the pain is great, it .shows a great disposition to irritation ; it also sometimes hap- 
 pens that they very early begin to form sloughs. When this is the case, they have a 
 strong tendency to mortification."' '• These three conditions of a sore,'" adds Aston Key, 
 commenting upon the above, •• distinct in their cause and in their operation from the 
 .syphilitic action, are adverted to as pointing out the distinction that is to be drawn 
 between the irritable, inflamed, and the sloughing chancre, and afl'ord a guide to the 
 pathological surgeon as safe and as intelligible as the more elaborate descriptions of mod- 
 ern writers" (6^»^'.s Hoi^p. Rep.. 1840). 
 
 Treatment. — The uncertainty that most surgeons entertain as to the nature of a 
 chancre, from the knowledge that any sore upon the penis, ranging from a simple excori- 
 ation to an indurated chancre, may be the inoculation of syphilis, renders it desirable and 
 expedient that all sores should be destroyed at the very earliest period ; and when this is 
 eff'ectually done before the ulcerative stage has set in, or during the vesicular, papular, 
 or pustular stages, there is good reason to believe that constitutional syphilis may often 
 be prevented. 
 
 When, however, the sore exists as an ulcer, this abortive practice is useless ; indeed, 
 in the majority of cases it makes a .small sore large, retards recovery, and in no way pre- 
 vents syphilitic symptoms appearing if the chancre had had a syphilitic origin. But, 
 taking all together, not one chancre out of four has a syphilitic origin. 
 
 For the destruction of a chancre on its first appearance, nitrate of silver, nitric acid, 
 potassa fusa, or chloride of zinc may be applied, so that the base of the sore is well 
 destroyed. 
 
 When this is not done, the chancre should be treated on ordinary principles : to the 
 inflamed sore, lead lotion, with or without opium, may be applied ; to the sloughing sore, 
 opium with tonics, internally, is indicated ; to the indolent sore, nitric acid lotion or black 
 wash is the best stimulant : while to ordinary sores, iodoform should be used. 
 
 A chancre requires no special treatment beyond its primary destruction from motives 
 of expediency or with the hope of preventing constitutional infection. The common prac- 
 tice of applying black wa.sh to all sores on the penis is not needed, and to cauterize all 
 chancres at everj' stage of their existence as soon as they come under notice is unneces- 
 sary. When the powers of the patient are feeble, tonics are called for. and any special 
 conditions are to be treated on common principles. 
 
 Medicines useful for syphilis should be given only when other evidence of syphilis 
 exists beyond that afforded by the local inoculation. To treat all chancres alike, as if 
 due to syphilis, is uncalled for and un.scientific ; by doing so many patients are materially 
 injured. 
 
 Complications. 
 
 Ptdmosis is one of the most common complications, and is found in at least a fourth 
 of all forms of chancre and at all stages of their progress. It is probably most frequent 
 with the sloughing sore. In the fringing preputial chancres, however, it is a common 
 complication. It is an accidental accompaniment of a chancre, and is due to the inflam- 
 
COM in. TC. I TToys. 72 1 
 
 luatnry infiltration of tin; propucf. WIh-ii imt severe, it is not a condition of much 
 inijiortance if local cleanliness he attended to. lor as the chancres heal the iiiHaniniatory 
 a-dftna will suhside and the parts will assume their natural condition. 
 
 When, however, aitinin is presrnf and a hlood-staitied discharge mi.\ed with the dthrix 
 of hroken-up tissues escapes from beneath the prepuce, and doubt, conse(juently, is felt 
 as to the nature, position, and character of the chancre; when evidence exists that the 
 parts beneath are undergoing a destructive process which demands direct local treat- 
 ment. — the prepuce must be slit up, the surgeon taking care to do this efl'ectually, since 
 through a want of due attention to this point the glans [»enis may be destroyed or the 
 prepuce pcrfurated. When the sore has been exposed, it ought to be treated on onlinary 
 principles. When a simple purulent discharge comes from the orifice of the pre|»U(;e. the 
 constant use of water and simple lead or other injeetioii will jtrobably siifiice. IMiimosis 
 witlmut iiifianimatory (cdema rarely calls for treatment. 
 
 PhagedSBna. — Venereal like other sores may slough, the suppurating chancre being 
 mure ])roiie to take on this action than the non-suppurating and indurated. When a .sore 
 sloughs from the first, it will probably prove to be non-infecting ; and even if .syphilitic 
 in its origin, it may lose its syphilitic nature, the sore, when the sloughing action has 
 cea.sed. becoming a simple one. This action is at times so intense that the penis rapidly 
 swells, inflames, and becomes gangrenous after infectifjn, the whole organ at times slough- 
 ing oft", while at others the action will be more partial. 
 
 In exceptional instances the mortification is of the dry kind. In the Peninsular war, 
 when the British troops were in Portugal, this sloughing of the penis from inflammation 
 was so severe that Inspector Fergus.son [ Mi'il.-Chir. Trans., vol. iv.) wrote: '• It is prob- 
 able more men have sustained the most melancholy of all mutilations during the four 
 years at war in Portugal through this disease — which was called the ' black lion — than 
 the registers of all the hospitals in England could produce in the last century." He 
 attributed the severity of tliis afi'ection to the free sexual intercourse of per.sons of dif- 
 ferent nations. 
 
 How far this phagednena depends upon some peculiar power of the infecting poison or 
 upon the constitution of the individual patient is difiicult to determine, although the latter 
 probably has the greater influence, aince, when any such depressing agency as that cau.sed 
 by drink, excess of venery, or illness is present, phagedaena is more likely to occur than 
 under other circumstances. 
 
 Treatment. — In the treatment, of all ca.ses of phagediena, opium, tonics, and good 
 living are the three essentials, while mercury and the iodide of potassium are inad- 
 missible. 
 
 Locally, the part must be kept clean by frerjueut ablution, and to this end the pre- 
 puce often requires to be .slit up. Lotions of nitric acid one drachm to five ounces of 
 water, of carbolic acid one part to thirty, of sulphate of copper five or ten grains to the 
 ounce, of potassio-tartrate of iron from ton to tw^enty grains to the ounce, are also useful, 
 and opium in solution is often a good addition. When the di.sease spreads, local mer- 
 curial fumigation is said to be of value, but change of air is mo.st beneficial. 
 
 Adenopathy, or bubo, is a common complication of the simple as well as of the 
 infecting chancre — that is, it is found in the local venereal sore as well as in the inocula- 
 tion of true syphilis, but in the former the gland, as a rule, suppurates, while in the latter 
 it rarely does so — at any rate, as a consequence of the local .sore. 
 
 '' Lymphatic absorption," writes Lee. '• from a suppurating syphilitic .sore (simple) 
 necessarily produces a suppurating bubo ; any attempt to jtrevent such an afi'ection from 
 suppurating is entirely futile. The disea.se within the lymphatic system is the same and 
 runs a similar course as that upon the surface of the body." 
 
 The bubo associated with -the simple non-infecting sore is the direct result of the 
 absorption of the specific pus, the matter in the interior of the gland retaining its specific 
 characters, whilst that outside the gland is ordinary non-specific pus. As the di.sease 
 advances, however, the two fluids mix, and the wdiole acquires the characters of the spe- 
 cific fluid, the surface of the sore about the glands becoming in this way inoculated. 
 
 In the infecting and syphilitic chancre the enlargement of the glands is usually indo- 
 lent and unconnected with suppuration. It appears within the first or second week of the 
 inoculation, and many glands are usually involved, forming hard, ind<dent, painless swell- 
 ings. In exceptional cases, however, where the sore is a source of local irritation, sup- 
 puration of the glands may take place, the suppurating bubo in the course of the consti- 
 tutional symptoms being no rare event. The presence or absence of suppuration in the 
 inguinal glands is not. therefore, evidence of any positive value as to the existence or 
 46 
 
722 AFFECTIONS OF THE GENITAL ORGANS. 
 
 non-existence of a syphilitic affection. It may, however, be .stated that a local sore on 
 the penis associated with an adenopathy which passes rapidly on to suppuration is in all 
 probability a local, and not a syphilitic, affection, while a local sore with a simple indura- 
 tion of the glands is in all probability a syphilitic inoculation. 
 
 In every form, therefore, of chancre, though more frequently in the local sore, simple 
 adenitis or sympathetic bubo may be met with as a result of local irritation which diflers 
 in no respect from the adenitis of any other local organ. One or more glands may be 
 involved in the action, and suppuration may be acute, subacute, or chronic. In the simple 
 local sore it is usually acute. As a rule, too. the sore formed by the venereal bubo, unlike 
 that resulting from simple adenitis, instead of healing kindly, often takes on very much 
 the appearance of the local disease : the edges ulcerate, the opening enlarges, and a large 
 sore is formed; indeed, from this action the sei-jn^iiK/vsi sore, to which allusion will be made, 
 often takes its origin. At times the bubo puts on a phagedasnic action and spreads fear- 
 fully. 
 
 In rare cases the glands are said to enlarge without any local lesion, this chronic 
 enlargement being followed by syphilis. I have, however, never seen a marked instance 
 of this, and in reputed cases have suspected the former existence of some overlooked 
 local sore or fissure. Mr. Cock does not recognize the affection. 
 
 Treatment. — There is nothing to be gained by suppuration of the inguinal glands, 
 for, even when associated with syphilis, the poison is not eliminated by such means, and 
 when due to some simple local source of irritation is only an additional cause of annoyance. 
 
 To endeavor to prevent suppuration is, consequently, a wise course ; this can best be 
 done by rest and the local application of cold in the form of ice or lotions of lead, muri- 
 ate of ammonia, or spirit. When suppuration is threatening or cannot be retarded, warm 
 fomentations are the best; and as soon as pus has formed a free incisio-n should be made, 
 followed by warm-water dressing or a p(uiltice. A vertical incision, as a rule, is the best; 
 but when the abscess is large, the opening should be made in the long axis. The appli- 
 cation of leeches or iodine to a bubo that threatens to suppurate seems a useless practice. 
 
 In the indolent bubo, or rather where indurated glands exist, local treatment it useless, 
 though care should be observed that no local source of irritation is added to that of the 
 sore and no excess of exercise taken by which the inflammation may be increased. 
 
 When the cellular tissue around the glands is infiltrated with inflammatory products, 
 as indicated by its brawniness, etc., the value of local pressure by means of a pad and the 
 spica bandage (Fig. 311, p. 5-42) is unquestioned, while tonics, rest, and other constitu- 
 tional treatment are beneficial. The local application of some mercurial ointment at times 
 appears to be of use, and a small blister or a strong solution of iodine or of nitrate of 
 silver is of value in hastening either the absorption of the inflammatory products or their 
 suppuration. As soon as suppuration appears the abscess should be opened. When a 
 hard gland is left at the bottom of a suppurating wound, the American practice of apply- 
 ing such a caustic as the potassa fusa to its centre, to cause its death and subsequent 
 sloughing, or Golding-Bird's electrolytic caustic, occasionally is of great use, this practice 
 being as useful in syphilitic glandular enlargements as in others. In some instances the 
 removal of the gland by the scalpel may be expedient. Sinuses must, if possible, always 
 be laid open. 
 
 If phagedaena attacks a bubo, the local application of nitric acid or the actual or gal- 
 vanic cautery is sometimes called for, more particularly when, in spite of general or other 
 local treatment, it spreads. Opium, tonics, and other internal remedies must not be 
 omitted. 
 
 HYDROCELE OF THE CORD AND OF THE TESTICLE. 
 
 Hydrocele, or a collection of serous fluid in close connection with the testicle or sper- 
 matic cord, is a term which has been applied to two classes of cases which differ in their 
 progress as well as in their pathology and agree only in the one marked and prominent 
 symptom, to which the term " hydrocele " is applicable. For clinical purposes, however, 
 the word has certain advantages, and with this view may still be employed. 
 
 Accepting the term, therefore, as signifying a collection of fluid in close contact with 
 the testicle or spermatic cord, two great divisions of the subject at once suggest them- 
 selves — namely, the vaginal 1ij/<lr(iceh or the collection of fluid into some portion of the 
 tunica vaginalis of either the cord or the testicle, and the encysted hydrocele, or spermato- 
 cele, which is an expanded and newly-formed cyst, as a rule, in connection with the epi- 
 didymis, and but rarely with the body of the testis. 
 
riiE iwTiKn.oi.Y or TrvDnnchL/:. 723 
 
 On the Formation of the Serous Sac. — Ii is well kti<»\vii t<i all wli.. havo 
 
 stiidirtl pliysidliiuv llial in its dcsri'iit IVoiu tin- loin duriii^r fa'tal liiV' the tt-sticle draws 
 with it into tlio scrotum two layers of poritoiR-uin with its attciidaii't nerves and vessels, 
 and that all pass tludui;h the internal and external alxloininal rin<^s in front of tlic! cord 
 into the serotuni, the posterior layer of peritoneum hein^ in close connection with the 
 tiiirous capsule of the body of the testicle — the tunica all)u;:inea — and the anterior in 
 coiMU'ction with the purse, or scrotum. In a perl'ectly normal conditiou it is jrenerally 
 suppitsi'il that at l)irth, or shortly alter, tlie two surfaces of this serous memhrane close 
 and l)ec(une a<lherent, the canal which was at one time present ceasing to exist fntm the 
 internal alidominal rinti' to the upper p(»rtion (d" tin; testicle, while in the scrotum the two 
 serous surfaci's remain permanently free, i'or the purpcse (d' allowing easy and ready middl- 
 ity of the testicle in its scrotal covering. It is now, however, well kn»nvn that the pro- 
 louiration of the serous membrane down the inguinal canal i/ito the srrotdl skc oi'ten 
 remains patent for a longer period than has generally been supposed, and that in .some 
 cases it continues as a pervious canal during the whole of life. It is likewise known that 
 the rdt/iiial fnucrss of the peritoneum may be closed at the upper part of the testicle, but 
 remain open above, during childhood, and even up to old age ; also that this naturally- 
 formed peritoneal tube and .sac may be closed at the internal or external abdominal rings, 
 or at any intermediate spot between these points, or at its junction with the te.stis. 
 
 As a conse((uence of these facts, it is tolerably clear that a collection of .serous fluid 
 may take place in any part of this prolonged .serous channel, and that a hydrocele of the 
 coi'd or testis of different kinds may be produced. 
 
 We thus find during infant and early life, from a want of closure of this tube at the 
 internal ring, that a serous exudation may take place either into the cord alone or through 
 the cord into the scrotal portion of this peritoneal .sac. Under the former circumstances 
 a vonr/enitaJ }ti/<Jrocde of the cord, and under the latter a congenital hydrocele of (he tistirle, 
 are said to exist. When the tubular portion of the canal is closed at the junction of the 
 cord and testicle and the testicular part is open, a simple vaginal hydrocele exists ; and 
 when the tubular portion of the canal is closed only at the internal ring, the hydrocele 
 may extend more or less up the canal, even as far as the internal ring. 
 
 In another class of cases the serous fluid may be confined between the internal and 
 external rings, giving rise to the so-caWed diffused hydrocele of the cord ; and when it occu- 
 pies a still more restricted space, it is usually described as an encysted hydrocele of the 
 same part. 
 
 The pathology of all these different conditions remains, however, the same, the differ- 
 ent position of the fluid being accidentally determined by the extent and lines of adhesion 
 or the closure of the peritoneal testicular prolongations. A congenital hydrocele may be 
 complicated with a hernia. A reference to Figs. 292, 293, 294 (p. 524), given to illus- 
 trate the subject of hernia, will assist the student in understanding these points. 
 
 The Pathology of Hydrocele. 
 
 Acquired Hydrocele. — It may with considerable confidence be asserted that, as 
 a general rule, the secretion of the .serous fluid which gives rise to the ordinary vaginal 
 hydrocele is due to an inflammatory affection of the tunica vaginalis, because in certain 
 cases flocculi of pure lymph may be .seen floating in the secretion, while in others spon- 
 taneous coagulation of the same may be observed. The thickening of the tunica vagi- 
 nalis, moreover, which .so fi'equently takes place in chronic cases, the presence of mem- 
 branous bands and septa in the cavity of the serous sac. and the fact that this f )rm of 
 hydrocele may W produced by extension of the inflammatory action from the epididymis 
 or the body of the testicle, jioint likewise to the same conclusion. 
 
 Congenital Hydrocele. — It is not, however, so clear that an inflammatory action 
 has any influence in the production of the serous effusion in the congenital form of hydro- 
 cele, in which a communication still exists between the abdominal peritoneal cavity and 
 the scrotal serous sac ; indeed, it would rather appear as if the exudation was of a passive 
 nature and merely an excess of the natural secretion of the serous membrane, since in 
 many of these cases the fluid rapidly disappears under tonic treatment, being reabsorbed 
 as the powers of the patient improve, and vice versa. 
 
 The fluid of a vaginal hydrocele is invariably albuminous, and under the influence 
 of an inflammatory action this is markedly increased ; hence, the amount of albumen in 
 the fluid of a hydrocele is determined by the nature and violence of the inflammatory 
 action. In the congenital variety it is a thin, serous, and saline fluid of a clear color, 
 
724 AFFECTIONS OF THE GENITAL ORGANS. 
 
 sliglitly tenacious and albuminous, the fluid differing in no single point liom the natural 
 serous fluid of the peritoneal cavity. In the acquired form it may present the sama cha- 
 racters, but it is usually more tenacious and varies from a pale amber to a deep straw 
 color. In some examples the fluid will be stained with blood, in others it will hold choles- 
 terin in suspension, at times being perfectly opaque and syrupy from the presence of 
 such matters. It is, however, in the old and chronic cases alone that these last conditions 
 are to be observed. 
 
 In the acute vaginal hydrocele more or less fibrin will be found, either in solu- 
 tion or in the form of false membrane or adhesions between the two surfaces of the serous 
 membrane ; in the chronic the walls of the cyst will be found to have undergone great 
 changes, the thin clear membrane having become thick and opaque, owing to the organi- 
 zation of the inflammatory product which had been poured out into its tissue, and in cer- 
 tain cases containing cartilaginous or ossific deposits, while on its surface it will present a 
 firm fibrous appearance. In rare cases suppuration may occur in the tunica vaginalis, 
 and even prove fatal. Thus, in 1883 a male child a?t. 8 days was brought to Guy's with 
 a red, swollen, glistening scrotum and the report that it had not passed urine for hours. 
 The penis and the perineeum were healthy. A catheter was passed without diftieulty and 
 a few drachms of urine drawn oiF, but the child died next day. After death the ui'inary 
 organs were found to be healthy, but the tunica vaginalis on both sides was full of pus, 
 and, as the vaginal process of the peritoneum on both sides was open and communicated 
 with the peritoneal cavity, there was evidence of peritonitis by extension. 
 
 Uncomplicated hydrocele, or a simple eff"usion into the tunica vaginalis, unas- 
 sociated with any disease of the testis or epididymis, is generally a painless and insidious 
 afiection •, it attracts attention mainly by its size, and demands treatment chiefly from the 
 mechanical inconvenience it causes. It is generally of slow progress, and. as a rule, will 
 be found to have existed for many months before being seen by the surgeon, the patient 
 seeking advice only when the organ has become cumbersome and from its weight has 
 excited some pain and dragging in the lumbar region. 
 
 The Clinical Examination of a Hydrocele of Testicle. 
 
 On examining a testicle the seat of this disease the enlargement will be found free 
 and readily movable and to occupy the positioli of that organ which it includes. On 
 inquiring into the history of the case it will be ascertained that the swelling appeared 
 primarily in connection with the testis and gradually enci'oached upon the upper portion 
 of the scrotum towai'd the external ring. On the surgeon grasping the neck of the 
 tumor below the external ring he will at once feel the cord clear and distinct above the 
 tumor. In exceptional cases, however, the fluid will be found to pass upward through 
 the external as far as the internal ring, and in such examples the peritoneal testicular pro- 
 cess has closed only at one point, and that is at its internal abdominal opening (Fig. 292). 
 On taking the tumor in the hand it will be found to be light, and on passing the fingers 
 over its surface it will be felt smooth and uniform. Fluctuation will also readily be 
 detected on the slightest and most delicate palpation. The position of the testicle should 
 then be looked for and made out, its natural site being somewhat posterior, and in large 
 tumors toward the upper part. But it must be borne in mine that in certain examples — 
 that is, in cases in which the organ is misplaced — the testicle may be in front of or below 
 the tumor. The best test of its presence is aff"orded by manipulation, the peculiar testic- 
 ular pain felt on the application of pressure affording a certain indication. The question 
 of translucency should next demand attention ; for when present, it is of peculiar import- 
 ance and indicative of the vaginal hydrocele. It must be remembered, however, that 
 such a symptom is not constant, since it is present neither in cases of hydrocele in which 
 the fluid is thick, bloody, or opaque, nor when the walls of the vaginal tumor have become 
 thickened by fibrinous deposit. 
 
 It should be added that for this translucency to be well observed the integuments of 
 the scrotum should be firmly stretched over the scrotal enlargement. 
 
 The tumor is generalh' described as being of a regular and pyriform shape, but this 
 condition is very variable, since the shape of the swelling depends upon the openness of 
 the tubular peritoneal membrane of the cord and the connection which exists between 
 the surfaces of the tunica vaginalis testis and tunica vaginalis scroti. When the canal 
 has closed and withered down to the body of the testis, the swelling will be more or less 
 globular ; and the higher the point of closure of the vaginal peritoneal sac toward the 
 internal ring, the more pyramidal will the watery swelling necessarily become. If adhe- 
 
ifVDiiocinj-: or Tiff: conn. 725 
 
 sions exist between the two layers (if serous incmliraiie at the lower portion of the testis, 
 the hydrocele will appear to he at tiie upper part; and when the natural contraction 
 between tlie tunica vaginalis of the cord and of the testicle is not completed (Fifr. 2'J4), 
 an irregular/or even an hour-glass, contraction may make its appearance. l\w outline of a 
 hydrocele dependinj: much upon the anatomical comlitions of tlu; part in which it is situ- 
 ated and the pathological changes which may have resulted from the aflection. The true 
 pyriform swelling is best seen in children, in whom the fluid will fre«|uently be found to 
 pass well up the cord ; in adults it is not, how(!Ver, unc<)mmon. 
 
 Hydrocele <»ccurs at all ages, but it is .somewhat common at birth and niid<lle age. and 
 in a large prnpnrtiiui of cas(>s ajtpears as a one-sided aflection and seems to aff'ect the right 
 or left testis indiscriminately, ('urling informs us that (»f 115 ca.ses, <J5 <»ccurred on the 
 right side, 44 on the left, ami (! were double; while out of 117, my own ca.ses. consecu- 
 tively ob.served. in which these facts were noted. 41 occurred on the right side. <i2 on the 
 left, and 14 were double — results coinciding with the opinions of Velpeau, Gerdy, and 
 others. 
 
 General Si'm.mary. — By way of summary, it may be said a chronic vaginal hydro- 
 cele appears as a painless enlargement of the testicle, of slow and unequal growth, and 
 tif variable size, with a .>«mooth and uniform surface and more or less ten.se ami fluctuat- 
 ing feel. It is invariably movalde within the scrotum, and, as a rule, appears to be dis- 
 tinct from any abdominal connections. The presence of the testis within the swelling 
 can generally be made out by the testicular pain which is produced by pressure at its 
 posterior and upper jiortion if the tumor be large, and at its lower if small, or by the 
 ab.senee of translucency at one spot, the tumor, as a rule, transmitting light when its 
 scrotal coverings have been well stretched. It has a tendency to remain tranquil for 
 many years, and by age simply increases in size. It occasiooilly grows to enormous 
 dimensions, when the penis may become buried within the swelling, but never proves 
 dangerous to life. It causes pain and requires treatment mainly from mechanical causes. 
 
 Hydrocele of the Cord. 
 
 Sv.MPTOM.-i .\xi» Diagnosis. — It has been already briefly explained how a hydrocele 
 of the cord may be produced, and under what circumstances it may appear as a diffused 
 or a .so-called ancysful tumor. It has likewi.se been shown how these two conditions are 
 but modifications of the .same disease, the diff"u.seness or isolation of the affections being 
 determined by the adhesion or more or less complete closure of the vaginal process of 
 peritoneum as it passes downward into the .•^crotum. Thus, a conjenit<d hyilroct^le of the 
 cord will be present when, from a want of closure at the abdominal orifice of the vaginal 
 peritoneal process, serous fluid can gravitate downward toward the testis. A diffused 
 hydrocelf of the cord will be .said to e.xist when, either at an early or a late period of life, 
 serous fluid collects in the vaginal peritoneal process, which is closed above at the inter- 
 nal ring and below at any point above the upper portion of the testis, while in a third 
 class of cases an eno/sted hydrocele of the cord may appear as a small isolated bag of 
 serous fluid movable with the cord and connected with it. 
 
 situated V»etween any of these points (Fig. 42<l). its cir- Fig. 420. 
 
 cumscribed nature having been determined by a more / ^^^ _— -^_"~^-^" ""~^ Ij/ 
 
 complete closure of the vaginal jieritoneal process and %' '^^; 
 the limited space into which the effusion has taken place. T "^ 
 
 PATHfiLftOY. — Under all these conditions, however, 
 the pathology of the affection is the .same, and the symp- 
 toms indicating its presence vary only according to the 
 size and tension of the .«ac which contains the fluid. In 
 the congenital form, in which a communication exi.sts 
 with the peritoneal cavity, the hydrocele will fluctuate 
 and have a smooth and uniform outline, but it can never 
 be tense. It will also disappear more or less readily 
 
 by pressure or by elevating the testicle on the patient Encrsted Hy.in.ceie of the rord. 
 
 assuming the recumbent position, when the fluid will 
 gravitate into the abdominal cavity with a rapidity which varies according to the size of 
 the peritoneal communication. 
 
 In the diffused hydrocele of the cord this disappearance of the swelling by rest or 
 pressure will not take place, for in such the opening of the vaginal process will have 
 closed naturally. The tumor will thus appear as a baggy or tense elastic swelling in 
 
 ;/ 
 
726 
 
 AFFECTIONS OF THE GESITAL ORGANS. 
 
 tlie inguinal canal, which it will more or less fill. It will give to the hand a sensation 
 of" fluctuation, and in certain instances may appear translucent. It will, moreover, on 
 any traction of the testicle, be found movable and painful in proporrtion to the amount 
 of tension of the cyst or of the inflamniatory action. 
 
 In the more localized or apparently cystic hydrocele of the cord the same symptoms 
 will present themselves. The tumor will be more isolated, probably more movable and 
 more tense, and it will be readily acted on also by any traction on the testis. It may 
 occur as a single cyst or as many cysts, but each will present the same symptoms. When 
 a single, tense, movable cyst exists, it may be mistaken for a distinct morbid growth ; 
 but the diagnosis of the case ought not to be diflBcult when care is observed. Fig. 420 
 well illustrates the ordinary appearance of the affection. 
 
 Treatment of Vaginal Hydrocele of the Testis. 
 
 In the conyenltul hijdrucelt of young life surgical treatment should be very sim- 
 ple, for the disease, as a rule, readily disappears with age and increasing strength. A 
 little cold lotion applied to the part, such as a solution of the hydrochlorate of ammonia, 
 and tonic medicine, is frequently sufficient to effect a cure ; for, as I have already stated, 
 the effusion into the vaginal sac in these instances seems to be often of a passive nature. 
 The hydrocele found in infancy is not, however, always of the congenital form. A hydro- 
 cele may exist in an infant in which there is no communication with the peritoneal 
 abdominal cavity through the neck of the vaginal process, and under the.se circum- 
 stances a different treatment may be required. Cold lotions and tonics may be of use, 
 and certainly should be primarily employed ; yet in many instances the treatment will 
 fail to cure the case. Acupuncture may be then employed and the fluid allowed to escape 
 into the cellular tissue around the sac, when it may be altogether removed by al)Sorption ; 
 but this treatment is not, as a rule, satisfactory, it being exceptional for a permanent 
 recover}' to be secured by such means, and I am disposed to think it better practice to 
 draw off the fluid by means of a fine trocar and canula. and to excite some fresh action 
 in the membrane lining the tunica vaginalis by stirring it up with the end of the canula. 
 This practice has been very successful in my experience. 
 
 In early examples^, when the hydrocele is still small and consequently of little incon- 
 venience, it is well, perhaps, to leave it alone ; for unless it causes anxiety to the patient 
 or proves troublesome or inconvenient from its size, there is no necessity for interference. 
 In vfTji old ]>f<ip1e it is as well not to interfere unless a strong necessity exists, as slough- 
 ing of the scrotum, suppuration of the sac, and other bad results occa.sionally occur in 
 these cases from slight causes. It must be added that the feelings of the patient as to 
 the amount of pain and inconvenience are the best guide to interference, verj- slight 
 enlargement causing as much pain in some patients as a greater increase in others. If, 
 then, some treatment be demanded, simple tapping should be performed as a primary 
 measure, the fluid being drawn off by means of a moderate-.sized trocar and canula. In 
 doing this some care is necessary, although the operation is really simple, as difficulties 
 are often made by the operator, while dangers result from want of caution. 
 
 The Tapping of a Hydrocele. 
 
 As a point of primary importance, the true position of the testicle should be defined. 
 
 In the majority of cases it will be found at the posterior part of the tumor and toward 
 
 its lower part, unless the hydro- 
 FiG. 421. 0g]g )}g very large. At times, 
 
 however, as has been ob.'jerved, 
 it will be found in front, from a 
 congenital malpo.sition. as well 
 as in certain other cases which 
 are difficult to explain. The 
 true position of the gland can 
 generally be made out by manip- 
 ulation, and further by the want 
 of transluceney in the tumor at 
 the part it occupies. Having 
 made out to a fair certainty the 
 
 position of the testis, the tumor .should be taken in the left hand and grasped firmly at 
 
 Tapping a Hydrocele. 
 
TREATMEST OF IIYDROCEIJ-: OF TlfE CORD. 727 
 
 its nock, tlic siir<ri'nii (iikiii>; care, at tlic saiiic time, tn stretcli tlic iMtc<;iiiiictit well over 
 the cvst uikI to niiilcr its wall teiist; and uiiyicMiii;; ( FifT. 421). Tlie trocar, with weli- 
 fittiiiLT eaimla (haviiiir hei'ii previoirsly well oileil ;. .should tlieri )»(! taken in the ri;;lit 
 lianil, with the index linger placed ahout three-((iiartcrs ol" an inch IVoni the extremity of 
 till' caniila, while the front ol" the tliumh rests on its flan<.'e. The oliject of this position 
 of the tin<;er is to prevent the instrument ^oinjr in t(jo far with a rush and therel)^' 
 endaiiirt'i'ini; the testicle; the ol)ject of that of tlnr thumh is to press home the caniila 
 as the trocar is l»ein<; withdrawn. The tumor should he punc-tured at its lower jtart.eare 
 l)eini; taken to avoid any larjjje vein. an<l the fluid allowed to run out. IIavin<r completely 
 emptied the cyst, the punctured intejiument should he firmly held and nipped up with 
 the thumh and finder of the left hand, and tlie cunulu should be withdrawn. A little 
 cold air or the irritation of the finjrer <;enerally cau.ses sufficient contraction of the darto.s 
 to close the wouiul and prevent hemorrhaire or any further escape of the remainintr fluid. 
 A jtiece of lint, however, may he ai»plied over the jMuicture for jmrposes of cleanliness 
 and to prevent friction. 
 
 In certain examples of this di.sea.se in the adult I have been induced to stir up the 
 cy.st as I have descrilted in the hydrocele of the young, and have met with some succe.s.s. 
 In no instance has any evil c()nse(|uenee resulted from the practice, and in several a cure 
 has taken place, evidently from inflammation. I would advise thi.s practice to be con- 
 fined, however, to young adults. As a palliative practice it is scarcely necessary to rec- 
 ommend any other than that described, as it is siinf)le. more efficacious than any other, 
 and not more dangerous. Acupuncture has been advised, but it has no practical advantage 
 over the simple tapping, and it is certainly less .successful in its result. In exceptional 
 cases it may be good, particularly in such a case as Mr. Curling has described, on the 
 authority of Mr. Luke, of a gentleman who was about to proceed to a part of the world 
 where surgical advice could not be secured, and where the patient could then perform 
 this simple operation on himself. I have more than once known a patient to tap 
 himself. 
 
 The period of relief which a patient experiences from a siiuple tapping varies exceed- 
 ingly from a few weeks to many years, and even in the same patient the interval will be 
 found to vary from time to time. In the young and middle-aged adult, when the general 
 health is sound and a return of the eftusion has taken place, unless any personal objection 
 should be made, it is generally advisable to adopt some plan for a more permanent cure. 
 In old men it is the soundest practice to rest .satisfied with the palliative treatment, and 
 in such the radical cure should Vje proposed only in exceptional cases. 
 
 Treatment of Hydrocele of the Cord. 
 
 The principles of treatment which have been laid down in ca.ses of hydrocele of the 
 testis are likewise applicable to those of hydrocele of the cord, their application requiring 
 only such modifications as may be demanded by the altered position of the affection. In 
 tlie c(>ii(fi)i!t<il hydrocele no special treatment is required, becau.se as .strength comes to 
 the child the fluid probably will be reabsorbed ; failing this result, tonics .should be given 
 to expedite the cure, and some cold lotion, such as the chloride of ammonium with vin- 
 egar 3J to Oj, should be applied. 
 
 In the diffused or enajstad hydrocele of the child or adult more active treatment is 
 frequently, though not in all cases, demanded ; the fluid will at times disappear without 
 treatment, though it may recur at a later date ; still, the aflfection cea.ses to trouble, and 
 unless some real inconvenience is produced by its presence it is as well to leave things 
 alone. When, however, pain or inconvenience is experienced, something must be done; 
 and no doubt the best practice is to evacuate the fluid. In small, tense, encysted hydro- 
 celes the practice of evacuating the fluid by acupuncture is certainly sound, since tapping 
 by the trocar and canula is an operation of some difficulty where the cyst is small. It 
 may be done with any needle, but those employed for cataract are probably the best, and 
 several openings .should be made. Tapping may be employed as in any other case of 
 ordinary hydrocele. I have on several occasions efl^ected the radical cure by injection, 
 and have not met with any bad results. "When this treatment fails and further ujcasures 
 are demanded, as a last resource an incision into the cyst may be made. 
 
 Radical Cure of Hydrocele. 
 
 It is not necessary to review all the various plans which have been, and are now, 
 employed for the permanent cure of a hydrocele of the tunica vaginalis. It will be 
 
728 AFFECTIONS OF THE GENITAL ORGANS. 
 
 more to the purpose to give the line of practice which is most successful, and which at 
 the same time is very simple — viz., the injection of the cyst with a solution of iodine. 
 It is not, perhaps, a question of much importance whether the fluid should be concen- 
 trated or diluted, or whether it should be permanently left in the cyst or withdrawn after 
 a few minutes have been allowed for it to act upon the secreting surface ; such minor 
 difl"erences may be left to the fancy of the operator. My own judgment leans toward 
 the practice of injecting from two to four drachms of a mixture of equal parts of the 
 tincture of iodine and water and allowing it to remain, care being taken that tlie canula 
 is previously well pushed home into the cyst, and that no iodine solution is allowed to 
 escape into the cellular tissue outside the sac. By this practice a radical cure is almost 
 certain to be secured, and only exceptionally does any failure or evil result follow. The 
 American surgeons are fond of injecting from half a drachm to a drachm of pure carbolic 
 acid liquefied with water or glycerin into the sac, and. Dr. Levis reports, with success. 
 In obstinate cases a free incision into the tunica vaginalis and the filling of the cavity with 
 carbolic or iodoform gauze, to make it fill up by granulation, is also to be recommended. 
 When a cure does not occur, it is generally due to the fact that a hydrocele has been 
 injected when some inflammation of the testicle coexists, and from which it has been 
 produced. In all examples of hydro-testitis the practice of injection must be looked 
 upon as injurious and as treating the result of a disease, and not the disease itself — the 
 effect, and not the cause. Within the last few years, where the iodine has failed, I have 
 often used warm water as an injection. It answered well, but set up more inflammatory 
 action than the iodine ; indeed, in several cases it excited suppuration. Some of the Dub- 
 lin surgeons speak highly of the practice of introducing into the sac of the tunica vag- 
 inalis a grain or more of the biniodide of mercury made into a paste with some grease, 
 and I have followed this practice in some cases with advantage. I prefer, however, 
 the iodine treatment. 
 
 Encysted Hydrocele of the Testis. 
 
 On examining the testis of the adult after death it is by no means an uncommon 
 occurrence to meet with small cysts connected with the epididymis. These may be sin- 
 gle or multiple, and in many instances are very numerous. These cysts are generally 
 more or less pedunculated, and, as a rule, are connected with the upper portion of the 
 epididymis. They are filled with a clear, watery fluid which contains, in certain cases, 
 some granules. 
 
 Pathology. — The pathology of the formation of these cysts is somewhat difficult to 
 understand, and surgically is of small importance, since they seldom, if ever, become of 
 sufficient size to cause inconvenience or to require any operative interference ; indeed, 
 they are rarely diagnosed during life, and are discovered oidy on post-mortem dissection. 
 
 Another kind of cyst is occasionally met with connected with the testis, and in close 
 contact, if not associated, with the epididymis. It has been described as the encysted 
 hydrocele. It springs from the same part as the smaller cyst, but grows to much larger 
 dimensions and generally contains a very different kind of fluid. Its origin is as obscure 
 as the former kind of cyst. It enlarges very slowly, does not give rise to any pain, nor 
 does it produce any inconvenience other than that caused by its size. It seldom requires 
 treatment in its early stage, and, as a rule, many years are allowed to pass before inter- 
 ference is demanded, the tumors frequently developing for twenty years or more before 
 advice is sought. These cases are by no means so common as the ordinary vaginal 
 hydrocele, not more than five per cent, of the cases of hydrocele being of this kind. 
 
 A cyst is occasionally developed between the tunica albuginea of the testis and the 
 tunica vaginalis testis, the pathology of which is very obscure. Mr. S. Osborne suggests 
 — and I think with good reason — that this is merely an enlargement of the corpus or 
 hydatid of Morgagni, a constant structure, existing as a pedunculated vesicle situated 
 between the summit of the globus major and the body of the testicle, between the visce- 
 ral layer of the tunica vaginalis and the tunica albuginea (>SV. Thomas s Ho^.'pital Report, 
 1874). Cases of this kind are described by Curling and Hutchinson. Guy's Museum 
 contains a specimen. I know of no means of diagnosing their existence. Their treat- 
 ment would be similar to that of other cysts. 
 
 Symptoms and Diagnosis. — In an early stage of encysted hydrocele the diagnosis 
 is not dfiicult, as the cyst usually appears as a kind of budding of the testis, or rather 
 of the upper portion of the epididymis ; as a tense, hard, globular, and in some cases 
 pendent, tumor more or less intimately connected with some portion of the spermatic 
 
ENCYSTKD IIYDIWVKLE OF THE TESTIS. 729 
 
 duct. It. is «;cii('rally disci ivi-red on tlic i»iirt of tlic patient \\y accident, and wlicii as 
 large as the natural testicle has Iteen (iccasimially set down as an extra nrj^an. 
 
 The surj^eon is not often c<insulted in such a case in its curly sta<re, the tumor usually 
 havin<: ln-eii allowed to j^row to an inconvenient size before advice is soufiht. in f'orniing 
 a diagnosis the history of the ease will ol'ten at (dice throw some light upon its nature, 
 and ill all prohahility it will he lound that the increase has heen extri.'mely slow, twenty 
 years or miu-e (d"ten intervening hel'ore the cyst attains anything like a large size. The.se 
 encysted hydroceles probahly never grow so fast nor accpiire such dimensions as the more 
 cummon vaginal species. 
 
 The next feature demanding attention in the development of these cysts is their shape 
 and outline, which are often rather striking. They never in their early stage, and rarely 
 at any time, assume the appearance (»f ordinary vaginal hydrocele, ami almost always 
 maintain a gloliular outline. 
 
 The position of the testis in its relation to the cyst next claims attention, and a marked 
 diftereiiee exists between the encysted and the vaginal hydrocele. In the vaginal, as a 
 rule, it is to be found at the }»osterior part of the sac when the tumor is small toward its 
 lower, when large toward its upper, part. In the eiicjsted it is to be found in front, to 
 one side, or below, and rarely at the posterior part. The reason for this is easily 
 exjilained. The cyst is usually connected with the epididymis, which normally lies at tlie 
 [•osterior part of the gland. 
 
 The nature of the cystic contents differs also in many points from the fluid of a vagi- 
 nal hydrocele, and is very characteristic. In the raginal hydrocele the fluid has been 
 described as being generally clear, like the serum of the blood, more or less albuminous, 
 of a straw color, and at times spontaneously coagulable, blood and cholesterin also being 
 occasional elements. In the fluid of an encysted hydrocele none of the.se elements are 
 generally present, but, as a rule, it is a limpid, feebly saline, watery liquid : at times it is 
 slightly opalescent, as if mixed with milk, and then it will be found to contain some 
 granules in suspe»ision. and fre({uently spermatozoa. Cystic hydrocele differs from the 
 vaginal in the slowness of its growth, its globular outline, the anterior position of the 
 testicle, and the nature of its cystic contents. 
 
 The origin of the spermatozoa in these cysts is a point of peculiar interest, and has 
 been a disputed point with pathologists for many years. Mr. Curlings investigations on 
 this subject have proved that in some instances their presence is certainly due to the 
 rupture of one of the spermatic tubes which pass over and are in close connection with 
 the walls of the cyst, this rupture generally taking place from an injury and being indi- 
 cated by some rapid increase in the .size of the cyst. Mr. Curling has shown that this 
 history was given in several of the cases in which spermatozoa were found, and in some 
 he was even able to demonstrate a distinct communication between the cyst and the 
 
 spermatic tube. The following case tends to support his views. Robert P , ast. tlO, 
 
 came under my care at Guy's Ho.spital on December 28, I860, with an encysted hydro- 
 cele of the left testicle of twenty years' growth. The increase had been very .slow until 
 the la.st month, when the tumor had doubled its normal size, this rapid growth having 
 followed an injury produced by a fall. When first under my observation, the scrotum 
 contained an irregular cystic tumor on its left side, evidently made up of several cysts, 
 of which three of large size could readily be distinguished, two being very tense, while 
 the third was baggy. The testis was found on the inner side of the tumor. Tapping 
 was at once resorted to and the lai'gest cyst emptied, many ounce.? of a milky fluid being 
 drawn off. The second tense cyst was then tapped through the same opening, with a 
 similar result, and the fluid collected in a distinct glass. The third cyst was also tapped, 
 but in this the fluid was quite watery. The fir.st two contained abundance of sperma- 
 tozoa, while the third did not contain any. A good recovery took place. 
 
 Trkat.mext of Encysted IIyi»rocele. — However interesting the two forms of 
 hydrocele which we have just been considering may be, both in their pathology and in 
 their points of difference, the treatment in the two cases is practically alike. When any- 
 thing is required to be done, simple tapping may suffice, and as a primary measure it 
 should always be preferred ; but, should the radical cure be required, the injection of 
 iodine may be carried out. The slow growth of these cysts, however, and the equally 
 slow reaccumulation of their contents after tapping, are points which indicate the pro- 
 priety of adopting the palliative treatment in the majority of. cases. 
 
730 AFFECTIONS OF THE GENITAL ORGANS. 
 
 Ruptured Hydroceles 
 
 It is well known that in children hydroceles, as a rule, disappear spontaneously with 
 little or no treatment, but in adults such a result is must uncommon. Messrs. Pott, 
 Cui'ling, and Sir B. Brodie relate cases of this kind, and attempt to explain the process 
 by which such a recovery takes place with more or less success. A single instance of the 
 kind has passed under my hands for treatment. 
 
 Charles C . aet. 04, came to Guys Hospital on January 29. 1863. with a hydro- 
 
 •cele of the left testis the size of a cocoanut. It was of two years" standing, and had been 
 tapped six times, under my care each time. He came under my notice, at length, when 
 I was about to leave the hospital, and I did no more than examine the parts, which were 
 tense and painful, telling the patient to return to me in the course of a few days to be 
 relieved. When he came the following week, all indication of swelling had completely 
 ■disappeared, the man assuring me that he had gone to bed the night of the second day 
 before his visit with a large tumor, and that when he awoke it had disappeared. He 
 added also that on the following morning he had passed a large quantity of thin urine. 
 The patient was a steady man and a widower, and told his tale with all the appearance 
 of truth and with some astonishment. In three months the fluid had again collected, and 
 he was tapped. This case was doubtless an example of subcutaneous rupture of the 
 tunica vaginalis. 
 
 In the following cases the rupture took place without hemorrhage. Rob. M , set. 
 
 ^Q^ came under my care in 1879 for a hydrocele of the right testis. It commenced six 
 years before and steadily increased up to one year and a half ago. when he accidentally 
 struck it, and in four or five hours the whole swelling had disappeared. He remained 
 well for three months, when it began to increase, and on admission the tumor was the 
 size of a fist. It was tapped and injected with iodine with success. ' 
 
 At times rupture of the tunica vaginalis is followed by a blood tumor, and this occurs 
 ■when any large vessel is ruptured. It took place in the following case. 
 
 R. B-^ ,?ei. 50, came under my care in July, 1879, with a large scrotal tumor. He 
 
 said that his right testicle had been large for years, but that he had never been tapped. 
 Four days before his admission, when sitting at his desk, he felt a pain in his scrotum, 
 and on putting his hand to it he found it enlarging, whilst the swelling of the testicle was 
 rapidly diminishing. The scrotum continued to increase for three days, when it ceased 
 to do so, and he came to Guy's. When admitted, the scrotum was very large and in cir- 
 cumference measured twenty-three by sixteen inches. It was uniformly smooth and but 
 slightly painful. The groin had an ecchymosed appearance and was brawny. Ice was 
 applied. On the fifth day I cut into the tumor and evacuated from the scrotal integu- 
 ments a mass of blood. Having done this, a rent about two inches long was clearly visi- 
 ble in the tunica vaginalis, and within this cavity was blood-stained serum and clot. On 
 turning this out the testicle was visible. The cavity was cleared out, washed with iodine 
 water.and drained ; and in the course of two weeks the patient was well, the cavity hav- 
 ing granulated. 
 
 The nature of these cases is not generally recognized. 
 
 HEMATOCELE. 
 
 As the term "hydrocele " is applied to the efi'usion of serous fluid into the sac of the 
 tunica vaginalis and of its tubular prolongation upward to the internal ring, as well as 
 into the c^'sts which have been already described as being connected with the testis, so 
 the term "" hfematocele " is employed to designate an effusion of blood into the same 
 parts. We thus have — 
 
 A vaginal and an encysted hematocele of the testis. 
 
 A diffused and an encysted hfematocele of the cord. 
 
 Haematocele may occur in an organ which had not previously shown any symptom of 
 disease, or it may be associated with a hydrocele. It may appear spontaneously without 
 an injury or as the result of a blow, strain, or the tapping of a hydrocele. It may attack 
 patients^ at any period of life, and in certain rare cases at a very early age. even in 
 infancy. I have the records of a case in which it was said to have made its appearance 
 at two years of age. 
 
 In the notes of my cases various cau.ses have been assigned for its production. In 
 more than one instance " it appeared gradually without any known cause." In another 
 " it occurred when hard at work pushing a wheelbarrow, something giving way with a 
 
ii.kmatockij:. 7:U 
 
 snap." In the majority it ''anK' on us an iniineiJiatc conseipu'rice of a hlow, and in 
 several as the result of tlie ta|>|iin;: of a liytlrorele. In all. however, the result was the 
 .sanie — a nmre or less rapid furniatioii of a tuiiiur in tin- po>itii»n or iici;.'Jil(()rhood of the 
 testiele. 
 
 Sy.mI'To.m.s ani> iM.viiNusi.s. — The symptoms of a lutMnatocele wiiieh lias made it.s 
 apjiearanee witiioiit any injury or assiirned cause are very ohseure. and are jiretty weli 
 summed up in the jtromiiient one of a LMailual and uniform eidar^rement of the orr;an. The 
 sweliinj; will vary in shape, as in a hydroeele. hut. like it also, may pre.sent a more or les.s 
 pyriform outline. The testiele will always, in the vaf^inal lufuiatoeele (on careful manipu- 
 lation hein<: matle), he detected somewhere in the sac. and usually at its jiosterior and 
 lower part, the peculiar testicular sensation heinj; jiroduced hy sliirht pressure. 
 
 When caused hy a sudden strain or injury, the enlar<:ement will he more .sudden as 
 well as rapid, and ho found to follow dose upon the receipt of the accident, while the rup- 
 ture fA' the hlood vessel may he announced liy the sensation of a >udden snap or jriving 
 way. 
 
 The local symptoms are similar to those already described. 
 
 The tumor, on its tirst appearance, may l»e somewhat soft and fihscure or clear fluctua- 
 tion may he detected in it ; hut if much time he allowed to pass before coming under 
 observation, this fluctuation will not, in all probability, be made out. for the eflfu.sed blood 
 rapidly coagulates and irive.s rise to the .sensation of a solid growth. The sac of the 
 haematocele, whether tunica vaginalis or cyst, rapidly alters in character and becomes 
 thick, and in certain eases fibrinous, or even cartilaginou^5. at first from the coagulation 
 of the fibrin of the blood u])on its inner surface and in ca.ses of longer standing from di.s- 
 tinct inflammatory changes brought about by the presence of the blood acting as foreign 
 matter. In some instances this thickening of the cyst is very great, even to the extent 
 of half an inch. 
 
 When a hiematocele has followed tipon a hydrocele, there will usually be a sudden 
 enlargement of the part after the strain or injury, accompanied with more or less pain, 
 this pain apparently depending upon the amount of distension to which the cyst ha.s been 
 subjected. If it follows the operation of tapping, it will, as a rule, be recognized by the 
 escape of more or less blood or bloody fluid at the time of operation and the rapid refill- 
 ing of the hydrocele sac or cyst with a more solid and opaque material. 
 
 To form a correct diagnosis of hj^matocele the history of the case is most important — 
 indeed, more so than the local symptoms ; for it is certainly true that by the latter alone, 
 in some instances, it is almost impossible to make out the true nature of the affection. 
 
 Sr.MMAKV. — By way of summary, it may be stated that a haematocele is usually a 
 uniformly smooth, tense, and HO?i-transparent tumor with an liuUstinct sen.sation of fluctu- 
 ation, but with iJUtinct evidence of testicular pain on pressure. It may be accompanied 
 with pain during the early period of the afl^'ection. from the distension of the cyst, but not 
 at a later date or during its chronic stage, unless softening down. As time passes, it will 
 become harder if no .symptoms of inflammation show them.selves, but on their manifesta- 
 tion evidence of suppuration will soon appear: for h:ematoceles have not, as a rule, a dis- 
 position to remain quiet, like hydroceles, but tend to open outward by the breaking up of 
 the coagulated blood which has been effused, and the inflammatory process. 
 
 The symptoms which indicate the presence of a Jtfnmotocrle of the spermatic cord a^re 
 somewhat similar to those already described for vaginal hfematocele, the difference in 
 locality being remembered. It is generally produced by a blow or strain, as in the ordi- 
 nary vaginal hiismatocele. It can be diagno.sed by the suddenness of its appearance or the 
 suddenness of the enlarged hydrocele sac. by the opacity of the swelling and tendency to 
 consolidation which it pos.ses.ses, also by the accompanying ecchymosis of the parts. 
 Cases are recorded by Bowman. Curling, and others in wliich this di-sease obtained enor- 
 mous dimensions, but such examples are very rare, the affection being very uncommon. 
 
 Source of the Blood. — A very common question with students is as to the origin 
 of the blood in these cases of lu^matocele. and in the spontaneous cases and those follow- 
 ing a strain or injury with an apparently sound testis this question is diflieult to answer 
 with certainty of accuracy. There can be little doubt, however, that a distinct rupture 
 of some of the vessels — probably veins — which ramify upon the body of the testis or on 
 the tunica vaginalis mu.st have taken place. 
 
 When occurring upon a hydrocele or after the operation of tapping, it is probably due 
 to the distinct rupture or perforation of one of the large veins which ramify outside the 
 tunica vaginalis, into its interior, or of one belonging to the body of the testis. 
 
 Scarpa relates a case of hjematocele in which the spermatic artery was wounded, find 
 
732 AFFECTIONS OF THE GENITAL ORGANS. 
 
 Sir A. Cooper another, in which a distinct rent in the tunica vaginalis was found on dis- 
 section. This latter condition is probably the most common. 
 
 Treatment. — The treatment of hemorrhage into the tunica vaginalis testis, or cord, 
 differs in no respect from the treatment of hemorrhage into any other part of the body. 
 In the very earliest* period of its occurrence rest in the horizontal posture with the testi- 
 cles well raised and the application of cold, either as ice in a bag or by means of the 
 metallic tube, are the most efficient means to arrest the flow of blood and relieve pain. 
 By such means the blood may also be reabsorbed and all future mischief prevented. 
 Should the blood, however, remain fluid for a long time and no symptoms of reabsorp- 
 tion or of inflammatory action manifest themselves, it is a sound practice to draw off' the 
 fluid contents with a trocar and canula. I have had a case in which this course was 
 adopted with good effect. 
 
 If signs of inflammation appear soon after its occurrence, cold lotions and leeches, 
 with the aid of saline purgatives, may occasionally be found efficient in arresting its prog- 
 ress and to allow of the subsequent reabsorption of the effused blood. But should symp- 
 toms of suppuration show themselves, or of the softening down of the coagula, a free 
 incision into the cyst or tunica vaginalis is the only sound practice, the whole semi-solid 
 contents being thoroughly turned out and the interior of the sac allowed to granulate. In 
 old and chronic cases with thickened sac walls the same treatment is also effectual. I 
 possess the records of many cases in which this plan was carried out with marked benefit 
 — in one case of only four months' duration, and in another of twenty-nine years', in which 
 the tunica vaginalis was at least half an inch thick, and in both a good recovery followed. 
 I need hardly add that excision is rarely called for in the treatment of these cases, 
 although, owing to difficulties in the diagnosis, recourse may occasionally have been 
 had to it. I have seen several such instances, but beyond the loss of the organ no evil 
 resulted. In old cases of haamatocele in aged subjects the practice of excision is probably 
 the best, but in the young and middle-aged it cannot be advised. The treatment of 
 haematocele of the cord is to be conducted on similar principles. 
 
 ON DISEASES OF THE TESTICLE. 
 
 Inflammation of the Testicle. 
 
 Under the term orchitis most authors have been in the habit of including the inflam- 
 mation of two distinct portions of the testicle and of mixing up the symptoms of two 
 affections, to the prevention of a sound and clear understanding of the subject. In this 
 chapter I shall separate the two and describe inflammation of the epididymis as one affec- 
 tion and inflammation of the true secreting gland as another, calling the former epiduly- 
 mitii> and the latter orchitis. In certain cases, it is true, both, structures are involved in 
 the inflammatory action, and to this state I shall apply the term tesfitis, the three words 
 accurately indicating the true seat of the malady, their use consequently tending to 
 facilitate its better study. 
 
 All surgeons will be ready to admit the distinctness of these two parts anatomically 
 and physiologically — viz., the epididymis and the gland. It is as well also to acknowledge 
 that pathologically they are constantly divided, and I am certain that to the student of 
 the affections of this organ such a division tends to a more ready discrimination and 
 appreciation of the several diseases of the testicle. 
 
 As a preliminary to the more special clinical and pathological consideration of these 
 diseases, the following observations of Sir* J. Paget, as given by Curling, upon the devel- 
 opment of the epididymis and testis may be read with interest and advantage. 
 
 Sir J. Paget observes '' that in the normal course of human development the proper 
 genital organs are in either sex developed in two distinct pieces — namely, the part for the 
 formation of the generative substance, the testicle or ovary ; and the part for the convey- 
 ance of that substance out of the body, the seminal duct or ovi-duct. The testicle or 
 ovary, as the case may be (and in their earliest periods they cannot be distinguished) is 
 formed on the inner concave side of the corpus Wolffianum, and the seminal or ovi-duct, 
 which is originally an isolated tube closed at both extremities, passes along the outer 
 border of that body from the level of the formative organ above to the cloaca or common 
 sinus of the urinary, genital, and digestive systems below. The perfection of develop- 
 ment is attained only by the conducting tube acquiring its just connections at once with 
 the formative organ, and through the medium of the cloaca with the exterior of the body. 
 The sexual character is first established when in the male the formative and conducting 
 
EI'IDIDYMITIS, on IM'LAMMATloy OF THE SEMIS A L DUCT. T-'i.'i 
 
 orj^ans bocoine coiiiu'ctcil hy tlic tlcvolopiiH'iit of iiiteniKMliatL- tubes wliidi con.stitute the 
 epiditlyiiiis, or wlioii in I ho I'euiah' a siiiiph; apcrtun- is fDinu'd at tin; upp»!r extreiiiities 
 of tlic i-iiii(Iiirtiiii; tube ami is placed elosely adjacent to the I'orinative urfraii. in both 
 sexes alike the lower extremities of the eonduetint^ tub(!S first open into the common 
 cloaca, and subseijuently, when that cavity is jiartitioned into the blailder and re(;tuni. or 
 bladder, vay;ina, and rectum, they ac(|uire in eacdi their just cf)nnections, and b(;conie in 
 the male the perfect vasa deferentia, and in the female Kallo|)ian tubes and uterus." 
 
 T will remind the student tliat the epididymis naturally forms the pijsterior and outer 
 ]).irt of the testicle, ami the secretins? portion or true f^land the anterior; that the ffjriner 
 in a j)erfectly healthy state is only indistinctly felt, the vas deferens, on being traced 
 downwanl from the cord, losiiiir itself, as it were, in this part. The body of the gland 
 can always be made out by its smooth ami elastic globular form. 
 
 Epididymitis, or Inflammation of the Seminal Duct. 
 
 Inflammation of the epididymis may be caused by some local inguinal injury or the 
 pressure of a truss, but, as a rule, it is a consecutive afiection and occurs in a.s.sociation 
 with a urethritis, gonorrhueal or otherwise, or as the result of some irritation of the pros- 
 tatic urethra, such as the presence of a calculus or the passage of a sound or lithotrite. 
 It is caused by an extension of inflaunnation from the urethra down the vas deferens to 
 the epididymis, and is an inflammation of the seminal (hirf, and not of the seminal gland. 
 It generally comes on suddenly and is attended with considerable pain, a marked enlarge- 
 ment of the epididjMuis or posterior part of the testicle forming its chief local .symptom. 
 It is constantly i)receded by severe pain in the anal and iliac fossjx; and accompanied by 
 special tenderness of the part, this tenderness being readily traceable up the cord, which 
 is occasionally swollen and (edematous. It is usually attended with uedenia and redness 
 of the scrotum over the inflamed tu])e. 
 
 The eidargement of the e])ididymis is very rapid, and in some instances very great. 
 It invariably assumes a special outline when uncomplicated — that is, when confined to 
 this special part — the epididymis appearing of a boat or truncated half-moon shape, hold- 
 ing the body of the testicle in its concavity. The lower portion of this body is usually 
 the most enlarged, being composed of the greater number of the convolutions of the 
 tubes, and consequently containing more connective tissue, since it is from the infiltration 
 with inflammatory eff'usion of this connective tissue around the inflamed seminal duct 
 that this enlargement is produced. 
 
 The affection generally is acute, comes on suddenly, runs a rapid cour.se, and is accom- 
 panied in most patients by some constitutional disturbance. In some subjects this is very 
 severe, while in others it is of a milder description, the sharpne.ss of the inflammation and 
 the peculiarity of the patients influencing the severity. 
 
 It is at times, however, complicated with other conditions, such as an inflammation of 
 the true secreting poj-tion of the testicle ; but this complication invariably occurs as a 
 secondary symptom, and is produced by the direct extension of the disease from the sem- 
 inal duct to the gland. I have never seen a genuine orchitis or inflammation of the sem- 
 inal gland as a result of gonorrhoea, except as an extension of the inflammation from the 
 epididymis, and it is in quite exceptional examples of this affection that the body of the 
 testicle is ever involved. 
 
 AVhen the inflammation has extended to the gland itself, the diagnosis is readily made, 
 the enlargement and great tenderness of the part clearly indicating what is the matter. 
 The whole organ presents an expanded biit flattened aspect, the swelling of the epididy- 
 mis posteriorly and of the body of the testis anteriorly producing this peculiar laterally 
 flattened outline. The two inflamed parts will, however, be always felt distinct from each 
 other and can be readily distinguished. There is, however, a second complication of 
 epididymitis more common than that just described, which is the effusion of fluid into the 
 tunica vaginalis, or the production of an acute hydrocele ; and I am disposed to think 
 that it is this apparent swelling of the organ which has given rise to the mistaken idea 
 that orchitis is a common affection after gonorrhoea. The enlargement of the organ from 
 such a condition is, however, very different from that already described as due to an 
 inflamed gland. It is more globular, tense, and ela.stic ; it is certainly equally painful 
 with that affection, but its true nature can be readily made out by its translucency and the 
 presence of fluctuation on palpation. It is the result of a direct extension of the inflam- 
 mation from the epididymis to the tunica vaginalis, and the following explanation of its 
 occurrence by Gendrin. as given by Curling, who assents to its soundness, seems most 
 
734 AFFECTIONS OF THE GENITAL OEGANS. 
 
 satisfactory, since it is certainly borne out by clinical observation. He says, '• When the 
 subserous cellular tissue, which always participates in the inflammation of a serous mem- 
 brane, penetrates into the interior of an organ, it becomes a ready means of communicat- 
 ing the inflammatory action ; but when the contiguous organ in subjacent parts is of a 
 different structure from that of the cellular tissue, the extension of inflammation inward 
 is checked. Thus, in the case of the inflamed tunica vaginalis the cellular tissue readily 
 transmitted the morbid action to the epididymis, but the tunica albuginea arrested its 
 progress to the body of the testicle ; and this explains the fact that after inflammation 
 of the tunica vaginalis excited by injection the body of the gland is rarely found to suffer. 
 On the other hand, the epididymis is seldom attacked with inflammation without the dis- 
 ease being quickly propagated to the tunica vaginalis. The hydrocele, as a rule, however, 
 disappears as the disease subsides in the epididymis, it being exceptional for the former 
 condition to remain when its cause has been removed. 
 
 As a consequence of this epididymitis, it is by no means uncommon for a considerable 
 thickening of the seminal ducts and of their surrounding cellular tissue to remain for 
 many weeks, or even months. In the majority of cases, however, this result does not 
 take place; for in the healthy subject there is every reason to believe that with the 
 inflammation all effusion disappears and the organ is left as sound as it was before. In 
 the cachectic patient this happy event does not, however, always take place, and more or 
 less thickening of the inflamed part will generally be observed, the epididymis feeling 
 indurated and enlarged and in parts nodulated and cordy. It has been a disputed point 
 by pathologists whether this condition ever leads to an atrophy or destruction of the tes- 
 ticles or whether it has any influence upon the true function of the organ in causing ster- 
 ility, and upon this point I have no positive facts to adduce, though I have certainly seen 
 a wasting of the glandular structure of the testicles after inflammation the result of an 
 epididymitis. In one instance I witnessed inflammation of the body of the testis in a 
 young man who married at a time when he had a marked induration of the epididymis 
 the result of an attack of inflammation some months previously. I entirely attributed 
 the inflammation in his case to the retention of seminal secretion from the obstruction to 
 the seminal duct the result of the old epididymitis, since we know that all ducts or canals, 
 when surrounded by organized inflammatory products, are liable to obstruction or stric- 
 ture, and it is only right to believe that the spermatic ducts are obedient to the same law, 
 although this result may not be very common. 
 
 On the dictum of Sir A. Cooper it has generally been asserted that the left testis is 
 more often attacked in cases of epididymitis than the right, but Curling's figures and my 
 own disprove the truth of this assertion, and show that in 202 cases of this affection the 
 right testis was the seat of the disease in 113 examples, the left in 74. and both glands in 
 15. The right organ is, therefore, more often affected than, the left, while in hydrocele the 
 left side is the most frequent seat of disease. 
 
 With respect to the cause of the disease, I took some pains during the eight years I 
 was registrar at Gruy's to find out the correctness of the general opinion that the epididy- 
 mitis usually supervened on the disappearance of the urethral discharge and was relieved 
 on its reappearance, or if it could be traced to any peculiarity in the treatment of the gon-. 
 orrhcea, to any neglect, or other cause. I have to confess that I was not able to connect 
 these phenomena in any way, as the epididymitis made its appearance during all stages 
 of the complaint and under every kind of condition — when injections were employed, and 
 when they were not; when copaiba and cubebs had been taken, and when they had not — 
 although in some cases the diminution of the discharge and appearance of the epididymitis 
 were coincident; but such a result is only consistent with the general rule that an inflam- 
 mation set up in one part tends to relieve an inflammation existing in another, and more 
 particularly in a neighboring tissue. The disease, however, appeared in the majority of 
 cases of neglected gonorrhoea, and in others in which strong injections had been recklessly 
 employed, but more particularly in the cachectic and irregularly living patients who had 
 been utterly regardless of their affection and taken no means to keep the testes well sus- 
 pended. 
 
 Treatment. — The treatment of this affection must depend upon the intensity of the 
 inflammation and the severity of the local and constitutional symptoms which it produces. 
 Eest in the horizontal posture, with elevation of the testes, or even of the pelvis, active 
 purgatives, with saline medicines, combined in acute cases with tartar emetic or colchicum 
 wine, are advantageous ; the local application of ice, hot poppy fomentations, or swathing 
 the parts in cotton-wool are often sufficient to check the disease at its onset and prevent 
 its passing into a chronic stage. It is also a wise measure to administer an opiate at night. 
 
Acrri: oiicurns, on isfi.ammatios or the skmisal oi.amis. 7;55 
 
 Wlu'ii till' liical sviii|>ii>iiis ami |tiiiii an- very si'Vciv, Iccclics may Jh' applitMl to tlu' ricrk 
 oftlu' tiiiijur, iir one nftlic tiirjri"! veins in tlic scrotnni (i|i('ni'»l. Tlic use of ini-rciiry ilucs 
 not a|t]t('ar tn lie til' much value except as a puTL^e. 
 
 If the patient. Imwever, I'nmi social reasons, olijeets or is unalile to keep at rest, tiie 
 parts must he well supported hy a suspenst»ry bandage; and a very 
 efficient suspeiisor is l'(inne<l hv a handkerehiel" folded crossways in 
 a triani:le. the apex of which is well hraeed up posteriorly hy a piece 
 of tape or handa^e and the haso attaclu'd firmly to a hand hroujrht 
 round the waist ( Kiir- \--). The same treatment must then lie jiur- 
 sued as we have already indicated. A hetter mode of sujiportinj; the 
 testicles is by attaehinu; two loops of tape three or four inches ajiart 
 to the central jiortion of the jiosterior fla|i of the shirt, and tw<» lon<^ 
 tapes to the bottom of the shirt front. On drawinj:' the jiosterior flap y* 
 between the leiis atid loopintr the front tapes throuiih the jiosterior 
 loops a most comfiu'table and efficient support is obtained. 
 
 Tlu' treatment by compression by means of strappinjr or an india- 
 rubber bail has also been strongly advocated. 1 have used it but 
 little ill the acute affection, although in the more chronic or sub- 
 acute, when the disease has passed into an inactive stage and little remains behind but 
 the product of the inflammatory process, the treatment by j)ressure appears very valu- 
 able — indeed, more so than any with which I am acquainted, nothing tending more to 
 hasten the absorjition of the iiiflatiimatory product (Fig. 420). 
 
 Vidal's plan of puncturing the tunica vaginalis, or even the testis itself, has been 
 freely practised by some Knglish surgeons, and Mr. II. Smith speaks highly of its value. 
 I have, however, never seen a case calling for so severe a measure. When tension exists, 
 an incision into the tunica vaginalis may be made with impunity; but I should hesitate 
 to puncture the testicle unless suppuration were present. 
 
 If mercui'y is ever needed in this affection, it is at the chronic stage ; as its power 
 doubtless lies in its tendency to produce disintegration of inflammatory products, so it 
 prevents the organization and subsequent contraction of such in and around the spermatic 
 ducts, and thus guards against the special evil effects of epididymitis. When I have had 
 occasion to use it, I have done so as an ointment applied wuth pressure to the part ; but 
 how far the good results which I have had from the practice have been due to the pres- 
 sure alone T am unable to say. Of late I have been accustomed to employ simple 
 pressure in these cases, an.d have no reason to believe my success has been le.ss fiivorable 
 than previously. 
 
 If suppuration takes place as a consequence of epididymitis — a result which occasion- 
 ally happens — it is well to open the abscess early and freely ; by such a practice the 
 discharge finds easy vent and the formation of sinuses is prevented. Simple dressing to 
 the part and the use of the suspen.sory bandage are the best subsequent local means, 
 while tonics and good living are generally required. 
 
 Acute Orchitis, or Inflammation of the Seminal Gland. 
 
 Orchitis or inflammation of the seminal gland as an acuh; affection, for the most part, 
 occurs as the result of an injury, but it appears at times .spontaneously without any such 
 cause, and more particularly in connection with parotiditis or mumps. It may. too, be 
 due to an extension of inflammation from the epididymis or spermatic duct, but it rarely 
 if ever takes place as a primary affection in connection with urethritis or gonorrhcea. 
 
 Acute orchitis may also attack the gland in its descent into the scrotum. The follow- 
 ing case illustrates this fact : Robert H , aet. 12, was brought to me at Guy's Hos- 
 pital on June 20, 1859, and as he walked into the room it w\is at once observed that his 
 body was bent unusually forward and his movement much restrained. The ricjlit testicle, 
 not having descended from the abdomen, could not be felt, and the left had first shown 
 itself at the external ring three days before the boy's application. Pain in the groin, 
 extended upward toward the loin, had been experienced for two weeks previously. The 
 testicle, which had pas.sed down the canal and partially through the external ring, was 
 about as big as an e^^ and remarkably tender. The horizontal posture was ordered to be 
 maintained, with the thigh flexed and cold lotion or ice applied. In three days the 
 symptoms had somewhat abated, and at the end of the week the swelling was much less. 
 On July 11, or the twenty-first dav after coming under observation, the testicle had 
 passed the external ring, although resting close to it in the scrotum. In another week 
 
736 AFFECTIOXS OF THE GEMTAL ORG ASS. 
 
 all pain had subsided : the testis was free, and the patient disappeared from observation, 
 being quite well. 
 
 On August 16. 1S71. I saw with Mr. Forman of Stoke Newington a boy aet. 14 with 
 acute inflaoimation of the left testis, which was at the internal ring. It was accompanied 
 with such severe local and abdominal pain, con.stipation. and vomiting as to lead Mr. 
 Forman to suspect the presence of a hernia. I saw the patient with these symptoms, 
 and. finding an inflamed painful inguinal swelling the size of an e^o^. I explored it with a 
 scalpel and discovered a tunica vaginalis filled with pus and a small undeveloped testis. 
 All the symptoms .speedily subsided after the operation, and a good recoverv en.sued. 
 
 Symptoms. — The symptoms of acute orchitis are very marked and its diagnosis is 
 ea.sy, for the rapid enlargement of the body of the gland, its flattened oval form and 
 extreme tenderness, are very characteristic. The patient will complain of its weight, 
 and. if standing, will probably as.sume a bent posture. The disease will be accompanied 
 by extreme local tenderness and pain of a dull aching character, which p»asses up the 
 loins, round the hips, and often down the thighs. The scrotum will probablv manife.st 
 some .symptoms of inflammation, such as swelling, redness, heat, and increased vascular- 
 ity. In exceptional examples there will be eff"usion of fluid into the tunica vaginalis, but 
 this complication is not so common after acute orchitis as after epididvmitis. for reasons 
 which have been already given. 
 
 The con.stitutional symptoms will be those of general irritative fever, and will vary 
 according to the .susceptibility of the subject of the disease ; in some cases they will be 
 very severe, and in others less so. 
 
 As a rule, it may also be asserted that acute orchitis tends toward recovery and seldom 
 terminates in suppuration, unless it be of the tubercular form or aflfecting very cachectic 
 patients. In one known example it ended in gangrene of the part. This case was 
 recorded by the late Mr. Harvey Ludlow in his unpublished Jacksonian prize es.say. It 
 was under the care of Mr. Stanley, who was induced to cut into the gland from the 
 .severity and obstinate character of the pain, and a black gangrenous cavity was exposed, 
 which was seen after death to have occupied half the organ. I have the records of a 
 case in which the patient stated that one testicle sloughed out after inflammation six 
 months previou.sly ; the man came under treatment for inflammation of the other. The 
 termination by suppuration, however. occa.sionally takes place, and numerous are the 
 examples of this condition which I possess. These cases may also at times end favorably, 
 the abscess healing without any evil result. }>ut too frequently the di.scharge of the 
 ab.s»ess ends in what has been variously described as benign fungus of the testis, granular 
 swelling, or hernia testis. The latter is the most correct and intelligible name, the affec- 
 tion being the result of rupture or ulceration of the tunica albuginea and the gradual 
 extrusion or hernia of the tubuli of the gland, the extruded gland being covered with 
 granulations. The true nature of this affection was first described by Sir W. Lawrence 
 in 1808 ( Edinhiirffh Med. and Surg. Joinnal. vol. iv. p. 257). 
 
 Acute orchitis as a consequence of parotiditis, or mumps, is a well- 
 recognized affection, althougli it may be difficult to explain the connection between the 
 two. It is described by some as a kind of meta.stasis. but there are no published facts 
 tending to support this view ; no one. however, is disposed to deny that the one affection 
 occurs in connection with the other. The disea.se is not usually very .severe : it com- 
 monly p»asses away with little treatment and leaves the testicle sound, few cases being on 
 record of atrophy of the glands attributable to this disease. The symptoms are precisely 
 similar to those already described, and need no further illustration. 
 
 Treatment. — The ordinary principles of treatment applicable to local inflammation 
 in general are to be acted on in the treatment of this aff"ection. Rest in the horizontal 
 posture, with elevation of the parts, and cold or warm fomentations according to the 
 relief they afford, are points to be attended to : leeching the groin or local venesection and 
 saline pnirgatives with sedatives are the chief remedies. The disea.se has a tendency to 
 get well by itself, and unless badly treated or neglected or attacking very cachectic sub- 
 jects this will generally be attained. In extremely severe examples, when the inflamma- 
 tion runs high, tartar emetic in full doses is a mo.st valuable drug, while colchicum in 
 half-drachm doses of the wine, with saline purgatives, often acts like a charm. Opium 
 in full doses may also be given where pain is severe and con.stitutional disturbance great. 
 A.n acute attack, however, generally runs its course in about ten days, and seldom ends 
 otherwise than well. 
 
cininsic (HK'iuTis. 7:57 
 
 Chronic Orchitis. 
 
 Clirutiii' iriflaniiiiatioii is the must comiiioii nl' the true diseases of tlie seminal ^'laiid, 
 and niav t'ulliiw the acute ancctinti or an injury, hut most t're((uetitly it is indueed hy 
 some special constitutional condition, such as ^'out. tuhi-rculosis, and more jiarticularly 
 syphilis. 
 
 Sympto.ms. — The jxeneral symptoms of chronic orchitis, from whatever cau.se. are 
 much alike, although they differ in some minor hut important jxdnts. In tlic sypiiilitic 
 affection the symptoms are somewhat peculiar, and, as its diajrnosis is important, it will 
 receive special consideration. The subject will conse(|uently l)e divided for consideration 
 into the ordinary fttrms of chronic orchitis and syphilitic orchitis. Chronic inflammation 
 of the testicle comes on most insidiously, and unless it follows an acute attack is so 
 unmarked hy any special symptom and unaccompanied hy pain that it is often oidy by 
 the increased size of the <rland that the jiatient is induced t«j seek advice. In .some ca.ses, 
 however, this swellinjr is acccunpanied by pain of a dull and achinjr character. In the 
 early stage of tlie disease the gland may be more or less painful on manipulation, but in 
 a more advanced condition or in a very chronic case no local pain will be experienced 
 even on somewhat rough manipulation ; and in these examples, on firm pressure, the 
 ordinary testicular sensation will fail to be excited. The general appearance also of the 
 testicle the subject of this affection is somewhat peculiar. It is not pyriform or globular, 
 as in hydrocele and many other affections of the gland, but has a peculiar flattened out- 
 line from side to .side, and a smooth, even surface. 'unless the disea.se be a.s.sociated with 
 some eff"usion into the tunica vaginalis, when the tumor will naturally assume more the 
 shape of a vaginal hydrocele. But the simple affection is rarely associated with such a 
 complicati(»n ; and when it is, the fluid, as a rule, is secreted in ver}' small quantities. 
 The epididymis, in exceptional examples, from the extension of the inflammation to its 
 tissue, may be slightly enlarged and thickened ; but this never occurs to any great extent. 
 
 There are also seldom any constitutional symptoms worthy of remark, except in 
 cachectic and irritable patients, when the dull aching pain of the part may give rise to 
 some general irritability of the patient's condition and an anxious expression of coun- 
 tenance. 
 
 Pathology. — The pathology of this affection is that of chronic inflammation of any 
 other part, and consists in a more or less general infiltration of the gland with an organ- 
 izable or organized material, the inflammatory effusion separating the secreting tubuli 
 and affecting them in ways determined by the amount of fibrin poured out between them 
 and the amount of pressure to which they are subjected, the inflammatory product in 
 some cases being very generally diffused between the tubuli, while in others it is deposited 
 in irregular masses. When the material poured out is very great and equally diffused 
 between the meshes of the testis — /. e.. when the disease is extensive or of long standing 
 — that condition of the gland is probably produced which is indicated by an utter absence 
 of the natural sensation of the organ on handling or on firm pressure, and under such 
 circumstances there is the greatest anxiety for the subse(|uent maintenance of the integ- 
 rity of the organ, tliough, .should the disease make a favorable progress toward recovery 
 and the inflammatory product be reabsorbed, the pressure will be proportionately removed 
 from the delicate tubuli of the organ and the natural testicular sensation be restored. 
 
 If the inflammatory product soften down, as it will in the delicate and cachectic sub- 
 ject, suppuration will take place ; and in proportion to its extent will be the liability to 
 a hernia testis. 
 
 Again, should this inflammatory product proceed to a more permanent organization 
 and contract, the delicate tubuli of the testicle will suffer in proportion to the extent of 
 the part involved, and an atrophy of the organ be the result as a consequence. 
 
 All these complications are met with in various degrees in practice, and with greater 
 or less frequency, the general condition of the patient having a more important influence 
 in determining the result even than the treatment ; but I nuiy add that there are few 
 affections which are more amenable to good treatment than that now under consideration. 
 
 When the disease is remarkably insidious in its advance, slow in its progress, and 
 painless in its character; when the patient is cachectic and irritable, with an anxious 
 countenance, a disposition to a hot skin, and to other symptoms of con.stitutional irri- 
 tation ; and, more particularly, when the disease ends in suppuration, as in all probability 
 it may when coming on and progressing in the manner just indicated. — it is reasonable 
 to believe that the organ is the seat of tubercular muchief, and that it disorganizes as a 
 result. It must be added, too, that in these cases the tubercular affection is probably of 
 
738 AFFECTIONS OF THE GENITAL ORGANS. 
 
 the infiltrating or miliary tubercular form, and not of that crude nature which runs a dif- 
 ferent course, and to which attention will subsequently be directed. 
 
 In gouty inflammation of the organ the symptoms, as a rule, are not so 
 chronic as in the class of cases to which we have just alluded. Indeed, they may more 
 rationally be described as being of a subacute nature ; for, though generally coming on 
 slowly, they are manifested by gi'eater local tendei'ness and pain, the pain being consider- 
 ably aggravated at certain periods, and most probably at night. The disease has, more- 
 over, a strong tendency toward recovery, and not toward disorganization of the testis. 
 Besides these symptoms, others indicating a gouty disposition will probably be present, 
 such as acidity of stomach, a loaded condition of the urine, and a more or less distinct 
 history of gout. There will also be frequent nocturnal pains of a darting character in 
 the opposite testicle, leading the patient to fear — what is by no means rare — a double 
 attack ; and when these pains occur, they are valuable in connection with others as diag- 
 nostic symptoms. 
 
 Symptoms and Diagnosis of Syphilitic Orchitis. 
 
 That syphilitic inflammatory disease may attack the testicle as any other gland or tex- 
 ture within or without the body is at the present day a well-recognized pathological fact, 
 and the credit of establishing this position is largely due to my colleague. Dr. Wilks. In 
 what way the syphilitic diifers from other forms of inflammation is a point worthy of 
 consideration, and, fortunately, the points of diff"erence are neither numerous nor deeply 
 seated. The main one is palpable and apparent, foe even by the most casual observer it 
 is readily seen that in syphilitic inflammations there is not only an infiltration of the part 
 aflfected with an organizable or organized material of a dense, firm, and fibrous structure, 
 but a mai'ked tendency of the deposit to undergo fibrous changes. We see this in every 
 tissue and in every stage of the disease. We see it primarily in the almost cartilaginous 
 hardness of the base of the true infecting chancre ; we see it in the early constitutional 
 symptoms of syphilis and in the greater permanency of skin-staining in the diff'erent 
 eruptions; in the diff'erent affections of the mucous membranes in all their parts; in the 
 inflammation of the eye, cellular tissue, periosteum, and bone. The pathologist sees it, 
 moreover, in the varied changes found after death in the internal organs of the syphilitic 
 subject, and the surgeon sees it, likewise, in the inflammation of the testes ; for in the 
 subject of hereditary or acquired syphilis the testicle may at some period of the disease — 
 and generally at a late one — become the seat of a syphilitic inflammation which manifests 
 all the peculiarities of this pathological condition. The aff"ection is essentially chronic — 
 as much so as the other forms of chronic orchitis — but is almost invariably confined to 
 the body of the gland, and rarely affects the spermatic duct. It is quite painless in its 
 nature, local and general, the patient bearing free manipulation without flinching and 
 often thinking little about his disease except from the increased size of the organ. The 
 special sensation of the gland usually disappears at a very early stage of the disease, and 
 there is rarely any constitutional disturbance accompanying its progress. It may or may 
 not be associated with other symptoms of constitutional syphilis, but usually appears 
 alone. 
 
 The disease manifests itself locally in a special manner which claims attention. It 
 usually affects the body of the testis and both testes at diflferent periods of its progress, 
 though rarely at the same time. It is almost always complicated by the presence of a 
 vaginal hydrocele, which at times increases to a considerable size, and much more so than 
 in other forms of chronic orchitis. The most characteristic point of all. however, is the 
 remarkable stony induration of the gland and its peculiar, irregular, nodular outline, small 
 fibrous projections from the body of the gland being distinctly visible in some cases, while 
 in others loose bodies are felt in the tunica vaginalis. 
 
 Prognosis. — In the majority of cases this disease terminates by resolution and appar- 
 ently leaves the gland intact, although in many a gradual wasting of the testicle is the 
 result, which ends in atrophy, and, as a consequence, in sterility. In exceptional cases 
 suppuration with or without hernia testis may take place. The disease, too, when appar- 
 ently cured, has a remarkable disposition to return on the slightest provocation. 
 
 Treatment. — There are few affections more amenable to treatment than chronic 
 orchitis, especially when taken early, and there are none which better prove the value of 
 pressure and mercurials in procuring the absorption and disintegration of inflammatory 
 products. In the common as well as in the syphilitic orchitis this statement holds good. 
 In a healthy subject with good powers and an unbroken constitution any form of mer- 
 
sv}rPTn}rs axd Di.i(;\ns/s of syriiii.rnc oik ii ins. 739 
 
 curial may In- adiiiiiiistcri-d, such as liliu' pill in fV)iir-<:ruiii doses or th(! [lorcliloridc, or 
 iiitTfurial iiiiinctioii with tlic nlcati- oi' incifiiry is likewise hc^iieficial. The object of the 
 sui'ijeon is neither to salivate iior to hriii<; the patient rapidly under the influence of the 
 remedy, but rather t(» ]troeure a leiij^thened and eijual action oi" the druj; ujton the local 
 disi'ase ; the close, therefore, should he carefully re;:uluted. In my hands the iodide of 
 mercury t:;iven in one-j;rain doses, with live L^rains ol" Dover's powder twici; a day. or tlie 
 uu'rcurial suppository, has proved eminently beneficial, the testicle b(Mn<r well strapped up 
 by common soap plaster. (See V'v^. 4liG.) Iri a more cachectic; patiiMit in whom mercury 
 may still be tolerated the same treatment may be employed, thoujrli in smaller doses; 
 and in others the mercurial may l)e locally ap]»lied iti tlie form of an ointment, or as 
 an oleate dissolved in oleic acid in the proportion of Kve per cent. I)urinfr this time 
 tonics such as (|uiMinc and iron may be administered an<l j^ood livin;^ and fresh air 
 enjoined. 
 
 In certain examples, however, occurring in cachectic patients it may not be desirable 
 to administer mercurials in any shape ; under such circumstances iodine may be substi- 
 tuted in the form of the iodide of potassium in three- or four-grain doses, gradually 
 increased to ten or twelve, combined with half-drachm doses of the syrup of the iodide 
 of iron in infusion of quassia, three times a day. Locally, strapping — or, rather, pres- 
 sure — should still be enforced. In hospital practice this treatment has been of great 
 value ; by it, steadily persevered in for six or eight weeks, even the worst of cases may 
 be expected to yield, the organ gradually becoming softer and more natural in sensation 
 and shape, and at last resuming its normal condition. 
 
 In the //""('/ form of orchitis, which can be recognized or suspected by the symptoms 
 already quoted, the administration of colchicum is very beneficial. It should be given 
 in small doses and continued for several weeks. The acetic extract in half-grain do.ses, 
 with Dover's powder, is tho best form ; and with it a cure may generally be guaranteed. 
 This form of disease is easily reduced when early recognized. It is more liable, however, 
 than other forms to relapses, but less so to disorganization and subsequent atrophy. 
 
 If there be sudden accessions of pain in the part, with other evidences of some fresh 
 inflammatory attack, the application of a few leeches with hot fomentations is very ser- 
 viceable ; but these conditions are uncommon. 
 
 When vaginal hydrocele coexists with the inflamed gland — a frequent complication 
 of the syphilitic variety — it is a good practice to draw off the fluid, to enable the surgeon 
 to apply his j»ressuve with more certainty and better effect. It is of no use to attempt to 
 cure the hydrocele itself, as it must be remembered that the hydrocele is the direct con- 
 5e(|uence of the diseased testis, and that it is of little use to treat the effect of a diseased 
 condition and not its cause. Remove the latter, and the former will probably disappear; 
 cure the orchitis, and the hydrocele will generall}' depart. 
 
 I have the records of a case which passed under my care for treatment where by 
 some oversight this attempt had been made, and the hydrocele was tapped and injected 
 with iodine on three different occasions without success. Under the subsequent treatment 
 the chronic orchitis disappeared, and with it the hydrocele. 
 
 It is not always desirable, nor is it possible in a large proportion of cases, to keep the 
 patient absolutely at rest during the process of treatment. In some it is advisable to do 
 so as much as possible, particularly when the patient experiences more pain and inconve- 
 nience when walking or moving about, but in the majority of cases it is suflScient to keep 
 the parts well supported. 
 
 In the consideration of the treatment of chronic orchitis it has been stated that a 
 good recovery may generally be secured by the means which have been suggested when 
 the disease has been taken in hand at an early period of its existence — that is, when not 
 niore than five or six weeks have been allowed to elapse. But in cases of longer standing 
 the prognosis is not so ftivorable, as regards either the removal of the disease or the sub- 
 se((uent integrity of the part as a seminal gland. These remarks apply more particularly 
 to the syphilitic form of the affection, for if of long standing the fibrinous matter has 
 generally become too well organized for future ab.sorption ; and when this is the case the 
 subsequent contraction of the organized product will almost to a certainty go on to the 
 destruction of the seminiferous tubuli and an atrophy of the gland. In Guy's Hospital 
 Museum are several admirable specimens exhibiting this result. 
 
 Again, in certain examples of chronic orchitis, whether syphilitic or otherwise, sup- 
 puration and disintegration of the gland structure will take place. This'termination may 
 be suspected when the disease is of a very torpid character, the pain of a constant aching 
 kind, and when all treatment fails to influence its course. 
 
740 AFFECTIONS OF THE GENITAL ORGANS. 
 
 When pus has formed, its early evacuation is the best practice, as a clean incision or 
 puncture into the part often prevents that destruction of the glandular structure and its 
 fibrous covering which usually precedes that troublesome affection, hernia testis. 
 
 Tubercular Disease of the Testicle. 
 
 Tubercular disease of the testicle may attack any part of the organ — that is, either 
 the seminal gland or its duct, or it may affect these parts separately or together. It may 
 show itself either in the form of an infiltration of the so-called miliary tubercles or in 
 the more distinct and usual condition of the yellow, cheesy, unorganizable material 
 described as crude tubercle. When it appears in the form of miliary tubercle, it is not 
 characterized by any very definite symptoms; indeed, the infiltration of a gland with 
 those small gray miliary bodies seldom makes itself known by any outward visible 
 signs, and their presence should be suspected only when a rapid disorganization of the 
 part takes place after an attack of acute or chronic inflammation. Organs thus infil- 
 trated have no power of resisting the inflammatory process, and, whether it be a lung or 
 a testicle which is the seat of this affection, active breaking up of tissue with suppuration 
 generally ensues. I shall exclude from present consideration those interesting cases, 
 remembering that, while pathologically they are cleai'ly to be recognized, practically 
 their presence can be suspected only when the riesult to which I have already alluded 
 takes place. 
 
 Symptoms. — The other form of tubercular testis is characterized by more special 
 symptoms and local conditions. It may involve, as already stated, either the body of 
 the gland or the epididymis, but doubtless the latter is the more frequently diseased. It is 
 generally discovered accidentally by the patient, and frequently not until some secondary 
 change in the structure is about to show itself. It appears primarily as an indolent, pain- 
 less enlargement of the epididymis and is usually described by the patient as a lump in 
 the testicle, this lump appearing generally at the upper part. This symptom, in all prob- 
 ability, is the only one to which attention can be drawn ; and the surgeon will recognize 
 it at once on manipulation, for the tubercular matter will feel as if some foreign body, as 
 a pea, bean, or nut, had been placed between the convolutions of the epididymis or in the 
 substance of the gland. The gland is not painful on pressure, nor in its inactive stage 
 does the disease seem to cause any injurious influence on the organ, which is otherwise 
 natural in its sensation and function. 
 
 In other cases the disease will appear as a general infiltration of the part involved ; 
 and should this be the epididymis, it will be enlarged, indurated, and nodular — painless, 
 perhaps, and inactive, the body of the testis, apparently sound, resting on the concavity 
 of the affected portion. If the body of the gland be the part affected, like symptoms 
 will be present, although the enlargement will show itself as a uniform or nodulated 
 expansion of the secreting structure, the epididymis or seminal duct being quite dis- 
 tinct. 
 
 This inactivity of the disease, however, does not always remain, though it may last 
 months, or even years ; but the time will come when the tubercular matter, in all prob- 
 ability, will soften down, and thus excite some increased action in the parts around. It 
 may be that this increased action in the part will first draw the patient's attention to his 
 affection, when the history of some previous thickening of the organ will for the first 
 time be obtained. When inflammatory symptoms are once developed, the di.sease will 
 certainly make rapid progress, and disintegration of this unorganizable tubercular matter 
 accompanied by suppuration will speedily follow. 
 
 In tubei'cular epididymitis — for such this disease may be named — local suppuration 
 will soon appear, with the discharge of ill-formed pus and dehria as a curdy, friable, and 
 granular material, and after this sinuses are apt to form, which may go on discharging 
 for a period depending on the extent of the disease and the amount of foreign material 
 existing to disintegrate and soften. 
 
 If the body of the testicle be the part implicated, the same gradual softening and 
 suppuration will take place ; but too often it will be followed by the formation of the 
 hernia testis, to which allusion has been already made. It is not, moreover, in every 
 case of this disease of the testis that disintegration of the tubercular material is to be 
 expected, with its accompanying suppuration and abscess ; for in many examples no such 
 result can be found, this tubercular matter undergoing a gradual change and showing 
 itself after death as an earthy concretion. The same changes take place in the testicle 
 as is seen in the absoi'bent glands, the lungs, and other parts. 
 
HKIIMA TESTIS. 741 
 
 TiiliiTciilar disease of the testis may neeur at any ajre, but is more commdii in ;'<lult 
 life. The hest eXiinipK- that I liave seen was in a cliiM ai^cl two years whdse tcstiele I 
 excised fur ilisease of six nnuiths" standing, which 
 
 had |»ni};ressed very sh»wly and ac(|uired a hirjre Kio. 423. 
 
 size hcinre su|)i)urati»in occurred. Convah'sceiice 
 f«)nowcd the operation ( Fij:. A'lW). The wh<dc ^ 
 oriran, with the epididymis, was nearly filled with ^<L 
 
 scrol'ulous deposit. It is in the testicle that we 
 have the hest opportunity of examining the true 
 tubercular disease in its diflerent stages, and oi" V 
 
 watching the various form of its deposition, its \ 
 
 clKniL,^es. ami decay. k 
 
 Tke.vt.mk.nt. — Wlu'u tultercular material has 
 been once deposited in the testicle, as in any other 
 tissue, there are no recognized means by which the /^ 
 
 absorption of this material can be procured. It is ,^^ 
 true that it may remain in an inactive or passive 
 
 !• . ,. ' • 1 12 •. • 1 1 c 11 1. Hernia of the Testicle followiii;; Tubercular I'is- 
 
 condition tor an indebnite period, and tinally, by ease. (Removed from iiiiant at. 2.) 
 
 undergoing an earthy degeneration, cease to trou- 
 ble ; nevertheless, it will still exist, ready, as it were, on the least disturbance to light up 
 some inflammatory action in the tissues around and to give ri.se to any or all of the 
 various conditions just described. 
 
 Looking also upon the deposition of turbecle in a te.sticle as only one of the local 
 manifestations of that general condition described as tuberculo.sis, it is dear that the 
 principles of treatment should be of a general character to improve the health and revive 
 the powers of the patient by tonics, good living, good air. regular habits, and — what is 
 of great importance — total abstinence from sexual excitement or gratification. Indeed, 
 the parts should be maintained as much as possible in a quiet condition, and for this pur- 
 pose cold sponging night and morning is of some service. 
 
 When inflammatory symptoms make their appearance, they will generally run their 
 cou-rse. in spite of treatment, for, as already shown, they are usually caused by the break- 
 ing down of the tubercular deposit, which may be looked upon as one of nature's means 
 for its elimination ; indeed, until this material has been discharged the sub.sidence of 
 inflammatory symptoms is not usually to be expected ; fomentations in this stage and the 
 application of water dressing to the part are, therefore, suitable, and the testes should be 
 supported in a suspensory bandage. When suppuration is nigh at hand or has mani- 
 fested itself, it is good practice to open the abscess freely with a lancet, as it saves time 
 and pain to the patient and often prevents the formation of the sinuses which prove so 
 troublesome. During all this time the health of the patient must be attended to by 
 ordinary measures. 
 
 When the gland has attained a large size and is evidently destroyed by abscesses and 
 disintegration of the infiltrating material, it may be excised, and more particularly if 
 hernia testis has appeared and the disorganized testis is a source of trouble and weak- 
 ness to an enfeebled patient. 
 
 Hernia Testis. 
 
 This affection, which has been variously described as '• granular swelling "' and 
 '' benign fungus of the testis," has also more correctly been called " hernia testis," for it 
 is essentially a gradual protru-sion of the substance of the gland through a rupture or 
 ulceration of its fibrous envelope, the tunica albuginea. It may follow upon suppuration 
 of the body of the gland the result of an injury or of an acute or chronic orchitis, or 
 from the softening down of tubercular deposit. It seems to be the result of pressure 
 produced by the natural elasticity of the fibrous tunica albuginea, the testicle, as it were, 
 being gradually squeezed out of its capsule and everted, the mass being eventually 
 increased by the free granulations which spring up on its surface. The whole organ or 
 only a portion of it may thus be extruded from its natural position, the extent varying 
 according to the amount of disease and the size of the opening in the tunica albuginea 
 and integuments. It must not be suppo.sed. however, that this hernia testis is the neces- 
 sary conseijuence of suppuration or of di.^organization of any portion of the gland, for 
 such is not the case ; indeed, in the majority of instances of suppuration it does not 
 occur. 
 
 Diagnosis. — The diagnosis is not difficult, and the disease, havicg been once seen, 
 
742 AFFECTIONS OF THE GENITAL ORGANS. 
 
 can be subsequently readily recognized. It is a peculiar fungating-looking growth with 
 everted edges and a sinus in its centre, generally secreting pus. It is of variable extent 
 and presents a more or less irregular surface and a pedunculated base, the pedicle pass- 
 ing through an opening in the scrotum to the remains of the testicle. The margin of 
 the opening in the scrotum is generally free, although in some cases adherent to the 
 growth. It may be slightly indurated, from inflammatory thickening, but will never pre- 
 sent the same aspect as a cancerous growth, for which, however, this affection may be 
 mistaken, the term "fungous testis" having doubtless been the means of encouraging 
 the great, error of regarding this simple disease as malignant. The natural sensation of 
 the gland remains, however, in these cases, and will be readily excited by manipulation, 
 whereas in cancerous disease no such natural sensation exists ; in doubtful cases this 
 point is one of primary importance. 
 
 Treatment. — It may safely be stated that the majority of cases of hernia testis can 
 be successfully treated by other less severe measures than castration, although this ope- 
 ration has been very generally performed for this affection. In exceptional instances it 
 may be demanded, and I have the records of many in which it has been successfully per- 
 formed. The surgeon's object, it may be briefly stated, is to restore the extruded testicle 
 to its natural place, which may frequently be done by simple pressure applied by fixing 
 a good firm pad over the surface of the growth and drawing the margin of the ulcerated 
 scrotum well forward, fixing the whole in position by strapping. In other cases, where 
 the granulations are very exuberant, caustics may be used to hasten their destruction ; 
 among the best is the red oxide of mercury ; pressure should be well maintained during 
 its use. All minor cases, and many of the severe, may certainly be cured by these 
 means if steadily pursued and well applied. In the more obstinate and severe examples 
 other measures must be adopted. The excision of the surface of the growth was for- 
 Dierly employed, and is occasionally resorted to in the present day, but at best the prac- 
 tice is a very doubtful one, for in the majority of cases to which it is applicable it would 
 be tantamount to castration, as the fungating mass is, as a rule, composed of the everted 
 tubules of the testis, covered with granulations, and consequently by this measure the 
 tubules would be cut off and the gland destroyed. 
 
 Mr. Syme described in the London and Edinhurgh Monthly Journal for January, 
 1845, a plan of treatment which in these cases is very serviceable. The operation con- 
 sists in the elevation of the margin of the scrotum from the protruding mass, the reduc- 
 tion of the hernia testis within the scrotum, and the retention of the part in its natural 
 position by stitching together the margins of the wound, careful bandaging and strapping 
 being also required in the treatment of these cases. The granulating organ becomes 
 attached to the inner surface of the scrotum, and a healthy action is subsequently 
 restored. It is almost needless to add that a local and constitutional treatment for the 
 original affection of the testis should at the same time be maintained. 
 
 Cystic Disease of the Testicle. 
 
 There is no affection of the testicle on the nature of which there has been a greater 
 diffei'ence of opinion than cystic disease, and, although modern pathologists have devoted 
 considerable attention to its investigation, the subject has not yet been brought out of its 
 obscurity and made plain to the profession. 
 
 Sir A. Cooper, one of its original inquirers, looked upon it as a distinct disease of the 
 secreting tid>nU of the organ, and upon his authority this view was for a time generally 
 received. More recently Mr. Curling's researches have tended to prove it to be an affec- 
 tion of the ducts of the testicle, and not of its secreting tubuli. " Why they alone," says 
 Mr. Curling, "are subject to the -morbid change I admit my inability to explain." 
 Whether this opinion be correct or not will be one of the subjects for present considera- 
 tion, since I am disposed to think that it is not quite consistent Avith observed facts, 
 although there can be no doubt that the rete testis appears to be the seat of the disease 
 in certain cases, while in exceptional examples cystic disease is undoubtedly formed inde- 
 pendent of this structure. 
 
 It has been my privilege to examine many examples of this rare affection with some 
 care, and I entirely concur in the main with Mr. Curling's conclusions, although I am 
 not so sure of the special seat of the disease as he appears to be. It is doubtless made 
 up of cysts, which are multilocular and of sizes varying from that of a mustard-seed to a 
 moderate-sized nut (Fig. 424). These cysts are filled with a thin, serous, blood-stained, 
 or glairy fluid, and at times with more or less pedunculated intracystic growths made up 
 
CYSTIC niSh'AS/': OF TllH TKSTK'LK. 
 
 743 
 
 .^ 
 
 
 L'j-itiC I)lJLU2C ul lllf ll 
 
 of :i (li'licate cclluliir struct mo or ol" u distiiict cl-W tissue. Tlioso cysts appear imbedded 
 ■^iii a fibrous strnuiu iA' dillcrciit deirrees of coiisisteucv and density- Tlie fibrous eleiueuts ia 
 some ari' much more iiumcnius than th«'y arc in 
 
 otliers,.\vliilst in some, apiiii. it will \w of a moie I'lo. 424. 
 
 delicate initure and more allied to the fibre struc- 
 ture found in the softer sarcounituus growth.s 
 of other ))arts. In certain examples the cysts 
 are clearly made up of dilated tubes with 
 pouches at their e.xtremities or as lateral dila- 
 tations, these tubes containinjr uranular matter 
 being occasionally lini'd, as .Mr. Curlini;- was the 
 first to observe, with tessellated epithelium. I 
 have failed, however, to find this in all the cases 
 1 have e.Kamined. and am disposi-d to look upon 
 the ])resenee of this tessellated epithelium as 
 specially eharacterizintr a certain growth. Sjier- 
 
 matozoa are invariably ab.sent in the cysts or . v 
 
 tubes of this affection, while cartilage or bone \^ i' / 
 
 elements will almost always be found to exist, 
 either as small isolated patches or as filling the 
 cyst, in which case the growth might be de- 
 scribed as an enchondromatous tumor ; the car- 
 tilage is deposited in separate mas.ses, and these ma.s.ses are divided by a fibrous stroma. 
 The true secreting ])ortion of the testicle will often be found pushed up into some corner 
 of the tumor, spread out over the cystic mass, or distributed between the cysts them- 
 selves, the tumor being invariably encysted in its own capsule; in rare cases tumors of 
 this nature will l)e found iipon the cord and body of the testicle. The above facts lead 
 me to conclude that the majority of these are new growths following the great law which 
 governs the development of all tumors by taking on the likeness of the part in which 
 they are developed, and that they are more or less built up as is the stricture of the 
 normal gland. The testis being essentially a tubular organ, all morbid growths developed 
 in or near it have a tendency to assume a tubular or cystic character, this character vary- 
 ing in extent in different cases, the cystic or tubular and fibrous or sarcomatous structure 
 being found in different degrees of perfection and quantity in different cases. 
 
 We may thus find in the testicle a tumor presenting all the elements of the fibrous oi 
 sarcomatous tumor without cysts, whilst in another, in which the cystic formation more 
 or less predominates, the same elements will exi.st in smaller proportions ; and in the 
 majority of these examples the true structure of the testicle will be found spread out in 
 a variable extent oyer the special capsule of the new growth. In other cases the new 
 growth will be altogether free from any connection w-itli the testis itself and be found 
 growing from the cord. All the.se .separate kinds of tumors, examples of which may be 
 seen in G-u.y's Mu.seum, appear to me merely modifications of one kind of growth, the 
 simple — or, perhaps more correctly, adenoid — growth of the testis. 
 
 We thus see a close analogy between these tumors of the testis and those of the mam- 
 mary gland, as well as of the ovary, and find in all the simple adenoid tumor partaking 
 more or less of the nature of the gland in which it is developed, and a true cystic disease 
 of the gland it.self, the latter being evidently a special affection of the tubes and ducts of 
 the mammary gland or testis, and not of the secreting structure. In both organs they 
 are new growths simulating more or less correctly the anatomical structure of the true 
 gland. 
 
 Symptoms and Diagnosis. — Having described the special pathology of this disease, 
 I pass on to consider its clinical aspect, as well as to point out the symptoms which indi- 
 cate its presence and help the formation of a correct diagnosis. In doing so I must pre- 
 mise that the several forms of this cystic disease are to be recognized more by negative 
 than by positive signs, since they appear usually as painless enlargements of the organ, 
 are of slow growth, and are unaccompanied by any such symptoms as attract attention, 
 the patient, indeed, seldom seeking advice until the organ has become troublesome from 
 its size, or the dragging pain in the loin, which always exists when the testicle has become 
 large and heavy from any cause, excites anxiety. The testis soon loses its natural shape 
 and assumes more the oval or pyriform outline of a vaginal hydrocele or hfematocele. It 
 will probably have a smooth and equal surface and be indistinctly fluctuating:, though not 
 translucent, while its natural sensation, experienced on manipulation, will most likely 
 
744 
 
 AFFECTIONS OF THE GENITAL ORGANS. 
 
 have disappeared at a very early stage of the disease. The general health of the patient 
 may probably be good, and there will be no evidence of any secondary glandular affection. 
 
 From hydrocele and haimatocele the disease may generally be recognized by the his- 
 tory of the case, the opacity of the tumor, and the loss of the natural testicular s£«isation. 
 When doubt exists, an exploratory puncture by the trocar and canula will decide the 
 point ; for in cystic disease a little bloody and glairy fluid will alone escape. 
 
 From the inflammatory aflections it may be diagnosed by the difterence in the shape 
 and feel of the tumor, the flattened compressed form of the organ, with its hard and 
 nodulated feel, as met with in the diflerent forms of orchitis, contrasting with the more 
 or less globular or pyriform shape, smooth outline, and elastic feel, without the peculiar 
 testicular sensation present in cystic disease. The inflammatory affections are also often 
 associated with a hydrocele ; the cystic, rarely. In the former, also, both organs are gen- 
 erally affected sooner or later, while in the latter the disease attacks only one. IMedical 
 treatment does not appear to have any influence in arresting the development of the 
 cystic, whilst in the inflammatory disease a good recovery may generally he secured by 
 the use of proper remedies. 
 
 Treatment. — There is but one remedy, which is the removal of the diseased organ. 
 No drugs seem to have the slightest effect in diminishing its size or arresting its growth. 
 Excision, therefore, should be performed, the operation being, as a rule, most successful. 
 
 Cancer of the Testicle. 
 
 The testicle, like all glands, may become the seat of cancerous disease, both of the 
 carcinoma fibrosum, or hard cancer, and of the carcinoma medullare, or soft cancer. It 
 is rare, however, for the hard cancer to attack the testis, the majority of examples being 
 of the soft or encephaloid form. For one example of the hard cancer it is probable that 
 at least twenty of the soft are met with in practice. In the different museums specimens 
 of the former kind may be seen, and at Guy's several exist. 
 
 Cancer may also attack this organ in one of two forms, either as the tuberous or as 
 the infiltrating cancer. In the former the disease appears either as an isolated growth or 
 as several distinct tumors separating the parts and then eventually coalescing into one 
 mass ; in the latter it appears from the beginning as the infiltrating kind, the cancerous 
 elements being more equally distributed between the tubes and ducts of the true secret- 
 ing gland tissue. 
 
 The malignant affections of the organ, as the simple, are accompanied by the develop- 
 ment of cysts, and these, in the malignant cases, ai'e filled with cancerous matter in lieu 
 
 of the glairy mucous or fibro-cellular intra- 
 FiG 425. cystic growths which are found in the sar- 
 
 comatous, adenoid, or cystic diseases. In 
 rare examples both conditions seem to co- 
 exist in the same organ, simple cysts, with 
 the clear or blood-stained glairy fluid, being 
 found in one portion, whilst in others these 
 cysts are filled with cancerous material, and 
 in a third enchondromatous masses may at 
 times be present (Fig. 425). 
 
 The part of the organ generally attacked 
 is the body of the gland, although the epi- 
 didymis may be the seat of the disease ; but 
 when the latter is involved, as a rule it is an 
 extension of the disease from the body of 
 the tumor. Rare examples, however, exist 
 which illustrate a primary affection of the 
 epididymis. 
 
 Cancer may attack the testis of the old 
 as well as of the young, and I have the 
 records of cases occurring in men aged fifty-six and sixty-two respectively. Instances 
 of this disease attacking infants even so young as seven months have likewise been 
 recorded by different aiithors, and I have excised a cancerous testicle from a boy only 
 two years old. The majority of cases occur, however, in young adult life, from twenty- 
 five to forty years of age, as is indicated by the following facts. 
 
 I possess the records of twenty-five cases, which I have added below to the fifty-one 
 
 ( ancer of the Testicle 
 
CAycr.R OF Tin: T/.srirrE. 7lo 
 
 examples orijxiiially talmlatcd Ky Mr. Harvey liiidlnw in liis Jacksonian prize essav. The 
 results are as follows ; 
 
 Before the ajre of 5 . .6 ea^cs. 
 
 From 1") to "Jd vears . . . 2 " 
 
 •• 1!-Jto30'" . . . . 17 " 
 
 " ;n to 4(1 " . . . . . .'U " 
 
 " 41 to .',()" . . . . . . 11 " 
 
 " ■■)1 to 70 " . . . . . . . 9 " 
 
 T.-tal .......... 7(; 
 
 Out of my 25 ea.ses the disease in 2<l had been frrowin<r for one year or less, and in the 
 remaininir 5 eases 2 were of three years'. 2 (d' four years', and 1 of five years' standing. 
 
 It is rare, if not unknown, for both testieles to be the seat of caneer at the same time. 
 I am not aware of any such example being on record. In IC out of the 25 ea.ses before 
 me the right organ was attacked, and in 9 the left. Malplaced testicles appear to be par- 
 ticularly prone to this di.sease. 
 
 Cancer of the testicle may come on as insidiously as the simple cystic di.sease. but in 
 general its growth is more rapid. It makes its appearance as a gradual enlargement of 
 the body of the organ, seldom attended by pain. There is also an early loss on pressure 
 or manipulation of the special testicular sensation. The outline of the tumor is smooth, 
 semi-elastic, and fluctuating, but as the disease progresses its surface may become some- 
 what uneven or irregularly bossy, thq tumor being harder in some parts than in others, 
 the softer parts projecting. In the carcinoma fibrosum, however, the whole tumor is hard 
 and at times nodular. The tumor is opaque from the beginning, and rarely, if ever, asso- 
 ciated with hydrocele ; and when it is so, it is by chance, the one affection having no direct 
 relation to the other. In this respect cancer differs from inflammation of the organ, which 
 is very frequently complicated by the presence of hydrocele. 
 
 The disease rarely extends beyond its fibrous covering or involves the scrotum, and 
 for a bleeding fungus to form the tumor must be very large. As the disease progresses 
 the health of the patient may suffer and a general aspect indicative of exhaustion and 
 Bome wasting disease appear, although it is not till a late period of this affection that any 
 such .symptoms are to be expected. When lumbar pain or a constant aching exists, a 
 suspicion of enlarged lumbar glands should be excited, and in certain examples a chain 
 of enlarged glands may be felt extending upward along the psoas muscle. 
 
 The inguinal glands are occasionally enlarged from infiltration, though it is believed 
 by some that this complication does not appear till the scrotum is involved in the disea.se. 
 This, however, is certainly not the ca.se, for large inguinal glands may appear at an early 
 stage of the affection. 
 
 Diagnosis. — The diagnosis of this di.sease is by no means easy, particularly in its 
 early stage ; indeed, in many instances it is almost impossible to be certain of its nature. 
 It is the size of the organ which generally first draws the attention of the patient to the 
 part, and the pain and inconvenience caused by its weight which prompt him to seek advice. 
 
 The hi.story of the case and the absence of translucency will prevent its being mis- 
 taken for a hydrocele, Haematocele, as a rule, has a distinct and special history of its 
 own. and the fact that the testis may be made out to exist in some portion of the tumor 
 is a material aid to the surgeon in forming a correct opinion as to the nature of the case. 
 
 The tenderness of the organ, the nature of the pain, and the shape of the swelling are 
 sufficient to indicate the inflammatory affection ; and when fluid exists the diagno.sis is 
 rendered more plain, since a vaginal hydrocele rarely coexists with any other disease than 
 the inflammatory, except to a very slight extent. 
 
 The simple cystic disease is of slower growth than the cancerous, and generally firmer 
 to the feel ; when punctured, it yields also a glairy fluid unlike the creamy material which 
 comes away from the cancerous disease. The subject of diagnosis of all these growths 
 will, however, be discussed hereafter. 
 
 Treatme.nt. — The only treatment which gives any comfort to the patient is excision 
 of the organ, and this .should be done as early as the diagn<»sis can be made, for there is 
 then less chance of the glands in the loin becoming involved. The general health must 
 also be attended to with great care at the .same time. 
 
 Diagnosis of Scrotal Tumors. 
 
 I propose now to consider the subject of the diagnosis of scrotal tumors as a whole, to 
 de.scribe the train of thought which passes through the surgeons mind when examining 
 
746 
 
 CHRONIC DISEASE OF THE TESTICLES. 
 
 Table of Diagnosis of Chronic 
 
 Symptoms. 
 
 Hydrocele. 
 
 Hsematocele. 
 
 Chronic orchitis. 
 
 Condition of tu- 
 mor. 
 
 Tense, usually transparent, 
 fluctuating. 
 
 Tense and elastic ; not 
 ti'ansparent ; obscure 
 fluctuation. 
 
 Firm, and not elastic ; not 
 transparent ; not fluc- 
 tuating unless comjili- 
 cated with hydrocele. 
 
 Outline. 
 
 Smooth and uniform. 
 
 Smooth and uniform. 
 
 Smootli and compressed 
 laterally. 
 
 Position of testis. 
 
 Posteriorly in vaginal; an- 
 teriorly at side or below 
 in encysted. 
 
 Posteriorly. 
 
 Evidently an enlarged 
 testis. 
 
 Testicular sensa- 
 tion. 
 
 Present on manipulation. 
 
 Present on manipula- 
 tion. 
 
 Present at first; absent 
 after long existence of 
 disease. 
 
 Rapidity of growth. 
 Size. 
 
 Gradual ; most so in en- 
 cyaled. 
 
 To great dimensions in vagi- 
 nal; moderate in encysted. 
 
 As a rule sudden, and 
 after accident at 
 times spontaneous 
 and gradual. 
 
 Moderate. 
 
 Slow. 
 
 Rarely more than three 
 or four times natural 
 
 Form. 
 
 Pyriform or oval in vaginal; 
 globular in encysted. 
 
 Pyriform or oval. 
 
 size. 
 Oval, with flattened sides. 
 
 Pain. 
 
 Manipular indica- 
 tions. 
 
 Very slight, if any, except 
 when complicated with in- 
 flamed testis, and in acute 
 hydrocele. Not increased 
 on pressure. 
 
 Like fluid, vibration on pal- 
 pation. 
 
 Painful at first and at 
 a later stage ; not 
 so during the inter- 
 mediate. 
 
 Firm and solid. 
 
 Dull pain, increased on 
 pressure, except in 
 very chronic disease. 
 
 Firm and solid unless as- 
 sociated with hydro- 
 cele. 
 
 Seat of its com- 
 mencement. 
 
 Cause. 
 
 In vaginal, at the lower part 
 of the tumor ; in encysted, 
 at the upper. 
 
 No recognized cause. 
 
 
 Evidently in body of 
 gland. 
 
 Injury, or idiopathic. 
 
 An injury or strain ; 
 rarely spontaneous. 
 
 Progress. 
 
 Has a tendency to remain 
 tranquil, and not to in- 
 flame unless injured. 
 
 Has tendency to in- 
 flame and suppu- 
 rate, and not to re- 
 main tranquil for 
 
 Slow growth ; rarely, but 
 at times, ends in sup- 
 puration. 
 
 Condition of cord. 
 
 Results of tapping, 
 exploratory or 
 otherwise. 
 
 Free and healthy. 
 
 Straw-colored, serous fluid 
 in vaginal; limpid, opal- 
 escent in encysted. 
 
 long. 
 Healthy. 
 
 Blood fresh or broken 
 up with pus. 
 
 Often full and tender on 
 manipulation. 
 
 
 Condition of in- 
 guinal and ab- 
 dominal glands. 
 Complications. 
 
 Organs involved. 
 
 Free and healthy. 
 Inflamed testicle. 
 Occasionally double. 
 
 Healthy. 
 
 None, unless hydro- 
 cele or injured tes- 
 ticle. 
 
 Never double. 
 
 Healthy. 
 
 Occasionally with hydro- 
 cele. 
 
 Generally both organs, 
 either separately or 
 together. 
 
CllJlOMC DISEASE OF THE TESTICLES. 
 Disease of the Testicles. 
 
 747 
 
 Sypliilitlc orchitis. 
 
 Tubercular ilUease. 
 
 Cystic or adenoid diHcase. 
 
 Carcinomatous disease. 
 
 Very snliil, Imt iidt 
 
 Indolfiu indurations in 
 
 Firm and elastic; in- 
 
 \ tense and firm en- 
 
 elastic or tiaiispai- 
 
 body of gland or epi- 
 
 sidious enlargement 
 
 largement of body 
 
 eiit mili'ss roiiipli- 
 
 didymis, like foreign 
 
 of gland; not trans- 
 
 of testis ; not trans- 
 
 I'ati'd willi liydro- 
 
 bodies. Toward the 
 
 lucent ; indistinct 
 
 lucent. Indistinct 
 
 cvk', wliicli is very 
 
 end these bodies .soft- 
 
 fluctuation. 
 
 fluctuation toward 
 
 general. 
 
 en and excite sup- 
 
 
 later stage ; bossy 
 
 
 puration. 
 
 
 outline; parts softer 
 than others. 
 
 Irregularly nodular 
 
 The epididymis the 
 
 Generally regular, 
 
 
 and very hard. 
 
 most frequently in- . 
 
 smooth, and elastic; 
 
 
 
 volved. 
 
 rarely bossy. 
 
 
 In tunu)r. 
 
 In natural jiosition, of- 
 ten half surrounded 
 by epididymis as a 
 half crescent. 
 
 In tumor. 
 
 In tumor. 
 
 Absent altogether, ex- 
 
 Present. 
 
 Present at first, but soon 
 
 Soon disapjiears. 
 
 cept in the very 
 
 
 lost. 
 
 
 early stage; returns 
 
 
 
 
 also toward conva- 
 
 
 
 
 lescence. 
 
 
 
 
 Slow in the extreme, 
 
 Slow at first; rapid 
 
 Unequal; slow at first. 
 
 Rapid, as a rule ; .slow 
 
 often hardly noticed. 
 
 afterward, when soft- 
 
 more rapid afterward. 
 
 only in the carcino- 
 
 
 ening and inflamed. 
 
 
 ma fibrosum, which 
 is very rare. 
 
 Moderate. 
 
 Moderate. 
 
 Rarely, but sometimes, 
 very large. 
 
 Sometimes very rare. 
 
 Irregularly oval and 
 
 Lumpy ; imeven in all 
 
 Oval, with flattened 
 
 Glol)ular or pyriform. 
 
 lumpy. 
 
 its stages. 
 
 sides. Smooth at first. 
 
 Smooth at first,subse- 
 
 
 
 subsequently bossy. 
 
 (piently lumpy, .soft- 
 est at these points. 
 
 Very slight ; allows 
 
 Very slight pain or ten- 
 
 Slight when present ; 
 
 Very slight, even on 
 
 rough handling. To- 
 
 derness, except when 
 
 generally painless, 
 
 free manipulation. 
 
 ward end of disease, 
 
 pressed hard or in- 
 
 even on manipula- 
 
 
 on recovery, pain on 
 
 flamed. 
 
 tion. 
 
 
 pressure returns. 
 
 
 
 
 \'ery hard and irreg- 
 
 At first as if foreign 
 
 Firm and elastic, more 
 
 Firm, but ela.stic ; softer 
 
 ular outline. Often 
 
 bodies existed in the 
 
 so in one spot than 
 
 on the bosses, when 
 
 hydrocele, with small 
 
 parts, lumpy ; at laal 
 
 another. 
 
 present. 
 
 fibrous bodies in tu- 
 
 soft before suppura- 
 
 
 
 nica albuginea. 
 
 tion. 
 
 
 
 Always in body of 
 
 Generally in epididy- 
 
 In body of gland. 
 
 Body of gland. 
 
 gland. 
 
 mis; occasionally in 
 body of gland. 
 
 
 
 Constitutional syplii- 
 
 Tuberculosis. 
 
 Unknown. 
 
 Unknown ; occasion- 
 
 lis, hereditary or ac- 
 
 
 
 ally from injury. 
 
 quired. 
 
 
 
 
 Essentially chronic ; 
 
 Very indolent and in- 
 
 Unequal ; never in- 
 
 Rapid as a rule ; rare- 
 
 rarely terminates by 
 
 sidious ; tends to in- 
 
 flamed. 
 
 ly slow. 
 
 suppuration. 
 
 flame and suppurate 
 after an uncertain 
 period. 
 
 
 
 Free. 
 
 Healthy. 
 
 Healthy. 
 
 Full ; veins enlarged. 
 
 
 
 Mucoid fiiiidy more or 
 less blood-stained. 
 
 Blood or creamy fluid, 
 with characteristic 
 
 
 
 
 
 
 cell-growth on micro- 
 
 
 
 
 scopical examination. 
 
 Generally indurated. 
 
 Generally indurated. 
 
 Rarely involved. 
 
 Generally involved. 
 
 Hydrocele, almost al- 
 
 Rarely with hydrocele. 
 
 Rarely with hydrocele. 
 
 Cancer in other parts ; 
 
 ways. Other syphi- 
 
 Tubercidar disease in 
 
 
 rarely with hydro- 
 
 litic affections. 
 
 other parts of body. 
 
 
 cele. 
 
 Often both organs. 
 
 Both organs, as a rule, 
 
 Always single. 
 
 Single as a rule. 
 
 
 involved. 
 
 
 
748 AFFECTIONS OF THE GENITAL ORGANS. 
 
 such a case with diagnostic intentions, and to point out the special symptoms or their 
 combination as they tend to indicate the presence of any special affection. In doing this 
 I believe that a near approximation to truth may generally be made when the history of 
 the case and its special symptoms are carefully weighed. Great difficulty may occasion- 
 ally be experienced in any given case, or it may be beyond our power to form anv posi- 
 tive opinion upon its jiature ; but I am not disposed on that account to place among 
 impossibilities the diagnosis of a scrotal tumor. There are gradations of probabilitv in 
 all our conclusions as to the diagnosis of an}' disease, and a certainty untainted by fal- 
 lacy or doubt is rarely obtained, but I take it we are as often correct in our judgment of 
 a scrotal tumor as of any other affection. To aid the student in this task the table on 
 pages 7-46, 747 has been drawn up. 
 
 The first point the surgeon has to decide on being consulted as to the nature of a 
 scrotal tumor has reference to the question of hernia. Is the tumor connected with the 
 testicle, or has it passed down the direction of the cord from the abdominal cavity ? If 
 the surgeon is able to isolate the growth at its neck from the abdominal cavity by the 
 thumb and finger, the question is at once decided ; for almost all scrotal tumors can be 
 so isolated, it being quite exceptional for any to pass up the cord so far as the internal 
 ring. Rare cases of vaginal hydrocele or haematoeele, however, in which the tunica 
 vaginalis is open up to the internal ring, form an exception. 
 
 It being determined that the swelling is not a hernia, the nature of the tumor next 
 claims attention. 
 
 Is it a hydrocele or ha?matocele ? Is it the product of inflammation or of tubercular 
 disease ? Is it a new growth altogether ? and if so. is it innocent or malignant in its nature ? 
 
 If the tumor prove translucent by tran.smitted light, the existence of a hydrocele is 
 fairly decided ; but, then, is it an ordinary vaginal hydrocele or encysted ? Should the 
 tumor be large, even, and pyriform, and the testis be found at the posterior part of the 
 tumor, either by means of manipulation or by the opacity displayed at one spot on trans- 
 mitting light, vaginal hydrocele may be suspected ; but should the testis exist in front or 
 at one side and tlie tumor have been of very slow growth, small, and more or less globu- 
 lar or evidently multilocular, a cystic hydrocele may probably be diagnosed. The tapping 
 of the tumor will, however, settle the diagnosis ; for in vaginal hydrocele the fluid will 
 be more or less straw-colored and albuminous, while in the encysted it will be watery, non- 
 albuminous, and occasionally, but not always, opalescent, and when opalescent containing, 
 on microscopical examination, granules and spermatozoa. 
 
 In examples of old hydrocele, however, the tumor may' be opaque, and under such 
 circumstances difficulties may be experienced, yet the history of these cases will tend to 
 throw much light upon the point, for to a certainty it will reveal a disease of very long 
 standing ; the tumor will be probably painless and fluctuating and the testis made out to 
 be in its usual position, at tbe posterior part of the sac. When a doubt exists, a punc- 
 ture with an exploring trocar and canula will decide the question, as in these cases fluid 
 of a dark color will be drawn off, loaded with chole.sterin. 
 
 "We will now pass on to the consideration of tumors which are not translucent and 
 not hydrocele : and it is here that the surgeon experiences true difficulty in his diagnosis, 
 as almost all the diseases of the testis are insidious in their growth and chiefly painless 
 in their development. The haematoeele, except in rare examples, usually follows upon 
 some strain or injury, increasing with tolerable rapidity up to a certain point and accom- 
 panied by pain, which soon subsides. It then becomes stationary as to size and remains 
 torpid for a variable period, when pain reappears, with other signs of inflammation. The 
 presence of the testis is also to be made out by manipulation toward the posterior part 
 of the organ. The surface of the tumor is always smooth, more or less oval or pyriform, 
 and semi-elastic or fluctuating. 
 
 The inflammator}' affections of the testis have a peculiar shape, being laterally flat- 
 tened, and are usualh- accompanied at some period of their course with tenderness and 
 pain, as well as often associated with fluid in the tunica vaginalis. In the syphilitic 
 inflammation this fluid is often copious. Both organs are also generally involved, either 
 together or at different times. The tumor is usually somewhat tender to the touch, and 
 has a firm fibrous feel unlike the semi-ela.stic and half-fluctuating sensations afforded by 
 cystic or carcinomatous disease. In very chronic cases the testis may. however, be per- 
 fectly painless and allow of any amount of manipulation without distress, the natural 
 testicular sensation, in fact, having disappeared. In syphilitic disease the surface of the 
 tumor will probably be irregular, with firm fibrous outgrowths in different parts and in 
 the tunica albuginea. 
 
CASTRATIOS. 719 
 
 In tilt' tiiUiTciilur afft'ctioii of the e|ii(li(lyiiiis or testis there should not he any (Jitti- 
 cillty ill the tliaj^iiosis, lor the tuhereular deposit, us u rule, takes place uiiaeeoinpaiiied Ijy 
 pain or any symptom lu-yoiid that produee<l hy its deposition. When dep(jsited in masses — 
 i.s usual form — it ieels like some foreitru hody introduced into the suhstanee of the frland 
 or id" the epididymis, and is at first (|uite painless and unprorluctive of any symptrjms ; 
 tlie>;e symptoms only appear when the material he^nns to soften down and excite some 
 infhimmat(»ry action in the parts around. The tuhereular material may he deposited in 
 one or nnu'e masses, these suhsecjuently, perhaps, coalescing into an irregular induration. 
 When suppuration takes place, the diagnosis is complete. 
 
 The cystic or simple tumors of the testis are painless throughout the whole course of 
 their growth and can he recognized by purely negative symptcjms. They attract the 
 patient's observation only from their size, can be handled withtuit exciting pain, and do 
 not usually give even the natural sensation of the organ upon pressure. They are sh>w 
 in their }»rogre.ss, uniform in their outline, and more or less globular, are always c(jnfini;d 
 to one gland, are rarely accompanietl with fluid in the tunica vaginalis, and on being 
 punctured emit only a more or less blood-stained glairy mucus. 
 
 The cancerous tumors of the organ are more rapid in their development than the cys- 
 tic, a year's growth, as a rule, giving a large tumor. They are likewise painless, and 
 readily allow of free manipulation. The natural sen.sation of the organ also .soon di.s- 
 appears. They are unaccomjjanied with a hydrocele, and also involve only one organ. 
 They have a more elastic and fluctuating feel than the cystic or inflammatory enlarge- 
 ments ; and when their outline is unequal or bos.sy, the projection is generally softer 
 than the other portion of the tumor. An exploring needle or trocar and canula rarely, 
 if ever, reveals the mucoid fluid so characteristic of the cystic or simple affection.s, but 
 usually lets out blood or the thin creamy fluid so characteristic of a cancer. In the pre- 
 ceding table the chief points of difference in the several chronic affections of the tes- 
 ticles are clearly sh(»wn. (See Table, pp. 740, 747.) 
 
 Castration. 
 
 The scrotum having been shaven and the skin over the testicle made tense, a free 
 incision is to be made through the scrotum and tunica vaginalis down to the tunica 
 vaginalis testis, and the body of the organ with the cord exposed. When any doubt as 
 to diagnosis exists, an incision should be made into the growth before its removal. A 
 strong double carbolized silk or catgut ligature should then be passed between the struc- 
 tures of the cord and firmly tied in halves ; the cord should be divided below the liga- 
 tures and the tumor turned out of its scrotal covering. There is no necessity to take 
 away any of the scrotum, however stretched, unless disea.sed, since it is sure to contract. 
 All vessels should be twisted, the wound washed out with some hot iodine water and 
 dried, and a few sutures put in at the upper part of the wound ; a drainage tube should 
 be intn^duced at the lower part of the WMjund and the patient put to bed with the pur.se 
 raised by a small pillow. No pain is caused when the ligature of the cord has been 
 tightly tied. Recovery is, as a rule, rapid after this operation. 
 
 To take the ves.sels of the cord up singly is a troublesome operation and has no 
 advantages. No assistant can hold the cord with his fingers after its division, as it is 
 sure to slip from his grasp. 
 
 To strap a testicle re(|uires some skill. The patient should be made to stand 
 against the edge of a table and separate his legs. The surgeon should then with his left 
 hand grasp the organ from behind and press it down 
 
 to the bottom of the scrotal sac, making the scrotum Fig. 426. 
 
 tense over its surface, the thumb and index finger , a^ ^ 
 
 of his left hand holding its neck. A piece of strap- v i^^*^' 
 ping spread on leather half an inch or more wide is /■ ' ' 
 next to be wound round the neck of the tumor 
 once, twioe, or even thrice, to hold it in positiim ; 
 for if this point be not attended to. all the subse- 
 quent steps will be useless (Fig. 426). Having 
 done this, pieces of stranpinir three-quarters of an c. • t .- i 
 
 • 11 i. v. 1- 1 .• 11 x- -1 strapping Testicle. 
 
 mcti fong are to be applied vertically irom one side 
 
 of the circular strip to the other, sufficient force being employed to compress the organ. 
 When the testis is completely covered in and compressed, another circular piece or so 
 should be applied, to keep the whole in position and to bind down the ends of the vertical 
 
750 
 
 AFFECTIONS OF THE GENITAL ORGANS. 
 
 Fig. 427 
 
 pieces. The strapping will probably require reapplication every second day, as the parts 
 soon yield and the strapping then forms a loose bag. The student must remember that 
 the object of the strapping is to compress the organ, and not to cover it. 
 
 For the purpose of compression a narrow rubber bandage nuiy be employed with 
 advantage. 
 
 Imperfect transition and malposition of the testicle are occasionally met 
 with, the organ being either arrested in some part of its course into its scrotal pouch or 
 misplaced. At times one testicle is found in the canal or it has failed to put in an appear- 
 ance, at all, while at others both are found to be out of place. Not uncommonly this 
 arrested descent of the testicle is complicated with a congenital hernia, the vaginal pro- 
 cess of peritoneum being still open, and in all cases of scrotal swelling in infants the 
 surgeon should examine the parts with care to discover whether the testicle is or is not 
 involved in the tumor. When the testes are thus placed, they are very commonly ill 
 developed. At times during their descent through the rings they are nipped by the 
 muscular structures and become inflamed. I have recorded such instances in a former 
 page. 
 
 Treatment. — Nothing can be done by way of treatment to expedite the descent of 
 the organ. When within the internal ring and complicated with hernia, it is well to 
 recommend a truss ; but when the testis is in the canal, such an instrument cannot be 
 worn, an extra element of danger, under these circumstances, being added to the case. 
 
 Testes so situated seem to be very prone to become the seat of cancerous disease. 
 Many such cases have been recorded. 
 
 In a case under my care, of a gentleman over fifty, an encysted hydrocele was found 
 with a small testicle situated in the centre of a congen- 
 ital hernia, the cyst on the reduction of the hernia appear- 
 ing as a tumor the size of a small orange, below . the 
 external ring and behind the hernia. I tapped it from 
 behind and drew off about two ounces of a milky fluid 
 containing many spermatoza, and injected it with iodine. 
 A good result followed. This gentleman was married and 
 had a fimily. 
 
 Malplaced testicles are less common than those 
 just described. I have, however, seen at least ten cases; 
 in five, one of which I have reported {Gui/s Hasp. Reports, 
 18G7), the right testicle was placed in the perinaBum in its 
 own separate scrotal pouch (Fig. 427), whilst in the other 
 five the right testicle was in the perinjcum, but outside the 
 scrotal sac, which was otherwise natural. There was in one 
 a hernia associated with the malplaced testicle, the bowel 
 clearly descending into the tunica vaginalis down to the 
 testicle. It would seem that the right testis is more prone to malposition than the 
 left. 
 
 Varicocele. 
 
 This signifies a varicose condition of the spermatic veins ; and when the disease is 
 well marked, their tortuosity and dilatations present the appearance (Fig. 428) and 
 impart the feeling of a " bag of worms" within the scrotum. It 
 is more common on the left than on the right side, the assigned 
 causes of this preponderance being the more dependent position 
 of the left organ and the liability of the vein to be pressed upon 
 by a loaded sigmoid flexure of the colon. It is a disease of 
 young adult life, and is the cause of the rejection in the British 
 army of about fifteen recruits in the thousand. It is doubtless 
 often, although not always, the product of masturbation or excess 
 of venery ; but anything that retards the return of the venous 
 blood from the organ aggravates, if it does not really cause it. 
 
 Symptoms. — The affection is generall}^ accompanied by a 
 dull aching pain in the part, as well as a sensation of weight 
 or fulness, but these symptoms are rarely complained of at an 
 early period of the affection. The pain often passes up the 
 groin, even to the loins, and is relieved if the patient assume the 
 
 Varicocele. (Taken from case i. ^ -i- t_ i x- xi i. 
 
 of Mr. jacobson.) recumbent position, or even by elevating the scrotum. 
 
 Right Testicle in the Perinoeum. 
 
 Fig. 428. 
 
AFFKCTIOSS Ob' TUE SLllOTI'M. 
 
 7.",! 
 
 Tkkatmknt. — If coiistijtatinn tix'iHts, tlio luiwcls must he n'jrulatcd. If tlio sornturii 
 .be lu'iidiilniis, cdld iKitliiiii.' ()iij.'lit to l»c rocoiniiiciiilcil and iIk- orf.'aii supportt-d hy woiiic 
 Buspciisory lianda;:f. Tonics are often of use. When this palliative treatment ^ive.s 
 relief and retanis the pro^'ress of the disease, nothing' more is needed ; hut when the dis- 
 ease is severe and these means are inefl'eetuiil. a more radieal treatment is ealled for. which 
 consists in the exeision, destruetion. or division of the veins. 
 
 Kirisinii is a practice which has heen reintroduced since antiseptic surj^ery has become 
 a fashion, and consists of the removal ol' ahout an inch of the diseased vein below the 
 external in<;uinal rinj^ after the application of a li^^ature of carbolized eatfrut above and 
 l)elow the part to Ite removed, (iood results, as a rule, follow this practice, hut I have 
 known of bad, and rejjard the operation as more dangerous than tliat now to be de.scril)ed. 
 
 Opnuition of Lii/dtinr. — This is a subcutaneous operation, and is most successful. 
 Some surgeons employ metallic wire for the purpose, others carbolized silk, catgut, or 
 kangaroo-tendon ligatures. Mr. Lee uses two pins to arrest the flow of blood through 
 the veins and performs subcutaneous division of the vessels between them ; I prefer, how- 
 ever, the ligature. Sir H. Hrodie u.sed to divide the veins subcutaneously and a|ij»ly_ 
 pressure. Mr. J. Wood of Kings subcutaneously surrounds the veins with a double 
 wire noose and keeps up pressure upon the wire by means of a metallic spring till the 
 division of the veins occurs. The operation I prefer is perffirmed as f(dlows : I'nder an 
 anivsthetie or not. the scrotum on the side of the varicocele is to be taken between the 
 fingers and thumb and the vas deferens (which may always be known by its cordy hard- 
 ness) allowed to escape ; so soon as this is done a needle armed with the ligature should 
 be passed through the scrotum beurath the bundle of spermatic veins and drawn through. 
 A Liston's needle on a handle should then be introduced through the same skin-opening 
 as was made by the first needle and. passed in front of the veins, and its point brought 
 out at the point of exit of the first needle. The ligature first passed is then to be threaded 
 through the eye of the needle, which should be drawn back. When this step has been 
 taken, the bundle of veins have been surrounded and may be occluded by firmly tying 
 the ends of the ligature. It is a good plan, before tying the ligature, to divide the skin 
 at its point of exit and entrance with a tenotomy knife, the loop of the ligature by this 
 Step being lost in the tissues and made subcutaneous. A second ligature is to be applied 
 in like manner, half an inch or more lower down or higher up, as the case may be ; and 
 after this the veins may or may not be divided subcutaneously between the two needles 
 by a tenotomy knife. Of late years I have left out this part of the operation with no 
 detriment. As a general rule, this operation is most successful, and not dangerous. It 
 is only to be done, however, when palliative treatment fails. 
 
 Mr. Morgan of DuVjlin has recently suggested an admirable suspender for varicocele 
 and other affections of the testis, which is illustrated in Fig. 429. It consists of a piece 
 of webbing four and a half inches long, three and a half 
 inches wide at one end, four inches at the other, and 
 gradually tapering to the narrower end. A piece of 
 thick lead wire is stitched in the rim of the smaller end, 
 two tapes sewn along the entire length of the webbing, 
 and the sides furnished with neat hooks, a lace, and a 
 good tongue of chamois leather. When the suspender 
 has been applied to the testicle, the tapes are to be 
 attached to an abdominal Vxdt. The size may vary more 
 or less. The lead wire encircling the lower end gives a 
 foundation to the general means of support and keeps 
 the testis within the bag ; the patient can mould it more 
 or less to his convenience, and it need not be worn at 
 night. 
 
 Fatty tumors are occasionally met with in the 
 cord — I have removed one the size of a walnut — and 
 fibrous or sarcomatous tumors have been met with on the testicle. I have seen one of 
 the latter, the size of an orange, excised by Mr. Hilton from the testicle with success. 
 
 Fig. 429. 
 
 Affections of the Scrotum. 
 
 The scrotal pouch is very frequently the seat of injury, while the testicle, from its 
 mobility, escapes. When the parts are bruised, the effusion of blood is at times very 
 great, the blood forming a large diffused scrotal haematocele, while at others it forms a 
 
752 
 
 AFFECTIONS OF THE GENITAL ORGANS. 
 
 Fig. 430. 
 
 distinct tumor. On January 29, 1871, I was consulted by T. B , 3et. 40, who sat 
 
 down on the broken arm of a chair, the stump of the arm brui.sing the perineal border 
 of the scrotum. A swelling at once appeared ; and when I saw him, twenty-six hours 
 after the accident, a well-defined blood tumor the size of a cocoanut existed in the median 
 line of the scrotum, the two testicles maintaining their position on either side. By rest, 
 cold lotion, and tonics the blood was absorbed in three months. 
 
 Lacerated wounds of the scrotum are also attended with blood extravasation, but they 
 usually heal readily, on account of the vascularity of the parts. 
 
 CEdema of the scrotum takes place when inflammation attacks neighboring 
 structures. It is seen in the inflammation of the epididymis associated with gonorrhcjea 
 and in acute orchitis ; in extravasation of urine and urinary perineal abscess ; in the reten- 
 tion of urine in childhood due to the obstruction of a calculus ; in phimosis or paraphi- 
 mosis ; in erysipelas. In all these cases it is present with more or less redness and exter- 
 nal signs of inflammation. 
 
 Simple cedema is one of the first indications of renal or cardiac dropsy. 
 Elephantiasis of Scrotum. — Not rarely the scrotum is the seat of elephantiasis 
 anibuin — solid cedema of the scrotum — and the disease generally attacks the penis as well. 
 In tropical countries, where this affection is common, the tumors attain an enormous size. 
 It is the same disease which attacks the female genitals and other parts of the body and 
 extremities, and in the West Indies is known as the " Barbadoes leg. ' By Mr. Dalton 
 of Guiana and other observers it is regarded as a constitutional disease. For its true 
 
 pathology refer to p. 178. It is occasionally associated with 
 ichthyosis of the tongue and is often attended with fever 
 and local erythema with oedema, which never subsides. 
 AVhen attacking the scrotum, nothing but its excision is of 
 any use. The historical case in which Mr. Key removed 
 from a Chinaman fet. 32 a tumor weighing fifty-six pounds 
 (Prep. 1620'''*, Guy's Museum), of ten years" growth (Fig. 
 430). is a good case in point ; but the growths attain a larger 
 size than this. Mr. "Wiblin in 1862 excised a growth equally 
 large, and in the Med.-Chir. Trans, for 1863 the report of hi.* 
 case will be found, with a reference to others. Such 
 growths are made up of the elements of ordinary connective 
 tissue. 
 
 Sir. J. Fayrer. who has operated on many cases, writes : 
 '• The operation for removal of a scrotal tumor is simple 
 enough, but it requires determination and expedition. It 
 also needs the aid of intelligent assistants. Before commen- 
 cing it is well to have the tumor raised and supported in a 
 vertical position for half an hour, to drain it of blood as 
 much as possible ; then, the patient having been placed in a recumbent position on an 
 ordinary table, with the nates brought near the end of it, he is to be put under the influ- 
 ence of an anfesthetic and the incisions are to be commenced. Several assistants are 
 re(|uired. to hold back the legs, raise the penis and testes, support the tumor, and rapidly 
 secure the bleeding points. These being provided, the operation nuiy be begun. The 
 director is to be introduced into the passage at the bottom of which lies the glans penis, 
 and that organ exposed by laying open, with either the long catlin or the sharp-pointed 
 bistoury, the dense tissue covering it. If the prepuce is healthy, it is well to reflect a 
 portion of it as a future covering to the penis. If the prepuce is involved, or even sus- 
 pected of being involved, it should be carefully dissected away, like the rest of the thick- 
 ened tissue. Having exposed the penis, it is to be raised and carefully dissected out, 
 with or without the prepuce, as the case may be. This is to be raised and held aside by 
 an assistant, care being taken in clearing it out of the morbid tissue not to divide the sus- 
 pensory ligament. 
 
 '" The next step is to make a deep and bold incision down to the tunica vaginalis on one 
 side. In a large tumor several incisions will be needed before the tunica vaginalis is exposed, 
 ■which probably will be found much thickened and distended with fluid, forming large 
 hydroceles. These should be laid open, and if the tunica vaginalis be much thickened it 
 shtjuld be removed ; if not so aff"ected and the testicle not enlarged, it need not be inter- 
 fered with. The testicle is then to be dissected out, reflected, and held upward with the 
 penis. A similar proceeding is to be carried out on the opposite side. The tumor is then 
 to be removed by connecting transversely the three vertical incisions already made, and 
 
 Elephantiasis <if the 
 (Key's case.) 
 
STi:iiii.iTY.~M.\Li: iMrnTi.sci-: AM) si'i:i:mai(iI'j:ii<i:a. 753 
 
 then, witli citluT tin- scalinl (ir tlic aiii|iiit:itiri;; kiiitV. the n'liiainin;.' porlion nf the neck 
 ol" thi" tuiiiur is to hi' cut thniti<:h. It is wi-ll licfoic scpariitiii^' it to mark out on the 
 perineal aspect hy an incision the line at wliich tlie removal is to he cimipleteil. During 
 the operation vessels are to he comniaiiile<l hy the fin^'ers of assistants and lar^re viins 
 contmllcd hy forceps. It is well that even the most ininutt; hleediii'.' point should he 
 lij:aturi'd (or twisted); otherwise, when reaction occurs, there may he hemorrha;:e. The 
 hleedini: haviiiu' heeii controlled, the testes with their elonj^ated cords are to he aj)plied to 
 the surface of the wound; the penis is to he enveloped in a fold of oiled lint and thus 
 kept apart from the tc-tes. which are also covered and supported in position hy oiled 
 cloths. " 
 
 The larL'cst tumor df this kind on record writrhcd two luindnd |i(iunds. 
 
 Dr. Turner of Samoa (^ii/asi/oir Mdl. .Jokih.. January, l.S.SiJj uses a clamp with a notch 
 in its centre for the urethra, to compress the hase of the scrotum after it has heen drained 
 of its hlood by elevation, lie likewi.se lays <rreat stress upon the propriety of dissecting 
 out the penis and the testicles hefore any attempt is made to remove the tumor. Other 
 surgeons have used a rulihcr tuhe to compress the hase of the tumor. 
 
 Cancer of the Scrotum. 
 
 This is a rare affection compared with what it was some years ago when .sweeps 
 ascended flues. It is still, however, met with in this country as a chunitn/siceep's cancer. 
 On the Continent it is well known in the tar and paraflline manufactories, the products of 
 distillation of coal, according to Volkmann, being more irritating to the human skin than 
 soot. The disease is in reality an epithelial cancer similar to that found in other parts of 
 the body ; at times it is very extensive and involves the whole scrotum. 
 
 Tkkat.ment. — Nothing but its removal can be recommended. Small tumors mav be 
 cauterized down or destroyed by caustics, but the larger should be excised. When the 
 growth can be isolated by pins passed through its base, the platinum wire ecraseur heated 
 by the galvanic battery is probably the best instrument to use ; otherwi.se, the knife is to 
 be employed. AVhen the whole scrotum is removed and the testes are left exposed, hang- 
 ing from their external rings, the surgeon need be under no alarm, for the parts will 
 granulate up in the course of time, and, what is more, the testicles may become movable. 
 I have seen this take place more than once. The earlier the disease is removed, the bet- 
 ter ; for by delay the glands of the groin may become involved. 
 
 Other Diseases of Scrotum. 
 
 The scrotum is occasionally, though rarely, the seat of tumors, sebaceous, fatty, fibrous, 
 or sarcomatous. It is likewise the seat of varicose veins, the small venous radicles appear- 
 ing as beaded dilatations of a peculiar aspect; the disease is, however, of little importance. 
 
 Tumors or swellings that encroach upon the scrotum from the perinivjum are j>robably 
 inflammatory, and are most frequently urinary ab.scesses a.ssociated with and dependent 
 upon some stricture; but occasionally an anal abscess may press forward, and I have seen 
 one occupying the whole perinajum up to the scrotum. These are to be treated by free 
 incisions. 
 
 STERILITY.— MALE IMPOTENCE AND SPERMATORRHCEA. 
 
 The influence of the sexual functions is so great in the economy (jf human life that 
 any impairment of the organs concerned is a matter of importance, not only in its effects 
 on the bodily health, but even more on the mental state of the person affected. 
 
 The sexual act is a compound one. physical and mental. The jdiysical organs maybe 
 perfect and capable in their way ; but if the mental are deficient in energy or weakened 
 by doubt of competency, or under the influence of some emotion such as shame or fear, 
 the sexual act will be spoilt, and failure to complete it must ensue. 
 
 It is, therefore, clear that impotence, real or imaginary, may be due to either physical 
 or mental causes. 
 
 Taylor defines tmpofcncy to be " an incapacity for sexual intercourse." This incapacity 
 may ensue from physical causes, remediable or irremediable. The latter includes loss of 
 penis and testicles, deformity of penis, including excess of and arrest of development, 
 maldevelopment in such cases as ectopia vesicae, etc. The remediable causes may be 
 some local afl!"ection of the penis or testes. 
 48 
 
754 AFFECTIONS OF THE GENITAL ORGANS. 
 
 Any condition that prevents the introduction of the organ into the female passage is 
 enough to cause impotence, whether such condition be connected with the penis or with 
 the testes. The same effect is produced by any disease or congenital malposition or devel- 
 opment of the testes attended with loss of sexual desire, as by old age. A man may, there- 
 fore, be impotent and virile or impotent and sterile. 
 
 A man may be capable of sexual intercourse and yet be sterile, sterility in the male 
 depending much upon the secretion of the testes, as well as upon the formation of the 
 penis ; for semen without spermatozoa is destitute of procreative power. A man may 
 have a penis the subject of epispadias or hypospadias; he may have sexual desire, and 
 even power, but if the urethral orifice be so low down as to prevent the semen from 
 being conveyed into the vagina he will be sterile, though all patients with hypospadias 
 are not so. I have known two men who had hypospadias — the orifice of the urethra in 
 each opening one inch behind the normal urethral opening — to be the fathers of three 
 and four children respectively, and a third, in whom the urethral orifice was one inch 
 behind the glans, whose wife died in childbirth. 
 
 When the urethral orifice is at the base of the penis, sterility must, however, exist. 
 When partial epispadias exists, there is no reason to believe that a man must be sterile. 
 
 When both testes are misplaced — that is, when they have not descended into the 
 scrotum — there is a strong probability that the organs are badly developed, that they do 
 not secrete healthy spermatic fluid, and that sterility is the result. Curling asserts this 
 very positively to be the fact, but he at the same time brings forward evidence from 
 Messrs. Cock's and Poland's practice that such is not always the case. In a general way 
 Mr. Curling may be right, but there are many exceptions to such a rule. When one testis 
 is in the scrotum and healthy, there is no reason to suspect sterility. 
 
 Sterility sometimes follows disease of the testes, inflammatory or otherwise ; for epi- 
 didymitis or inflammation of the duct of the testicle, as well as testitis or inflammation 
 of the gland, may be followed by atrophy of the organ. Gosselin, Godart, and Liegeois 
 have laid great stress upon this, and Curling ascribes these as common causes of sterility. 
 Sterility may also be produced by involuntai*y seminal emissions the result of excess of 
 venery or masturbation by producing either loss of sexual power or deterioration of 
 semen. Stricture or any impediment to the seminal discharge is also another cause. The 
 student must remember, too, that a man may be capable of sexual intercourse and be 
 sterile from other causes. He may even have emissions in connection without seminal 
 secretion, for the emissions may consist only of secretion from the seminal vesicles. I 
 have known this fact illustrated in a man who had lost both his testicles from a surgical 
 operation and yet had sexual power as strong as ever, attended with emission. The 
 removal of one testicle seems to interfere but little, if at all, with sexual power. Some 
 years ago I removed a testicle for cystic disease from a gentleman who had been married 
 many years and had no child. After the operation his wife soon conceived and gave birth 
 to a boy. 
 
 In the female subject impotency may be said to exist when the vagina is absent or 
 obliterated. It is for a time present when the orifice is occluded by some dense mem- 
 brane, or when the introduction of the male organ is prevented on account of the small- 
 ness of the orifice, by vaginismus, or from the presence of a bifid vagina. 
 
 Sterility is due to many causes, the occlusion of the os uteri being one, but morbid 
 conditions of the uterus and ovaries are probably the more frequent. 
 
 The student should remember that "Ithe functions of the testicle, like those of the 
 mammary gland and uterus, may be suspended for a long period — possibly for life — and 
 yet its structure may be sound and capable of being roused into activity" on any healthy 
 stimulus. Unlike other glands, it does not waste or atrophy for want of use, the physical 
 parts of man's nature being accurately adapted to the necessities of his position and to 
 his moral being. 
 
 Spermatorbhcea. 
 
 This doubtless exists as a disease, although rare. It consists in the discharge of sper- 
 matic fluid containing spermatozoa with the urine, without sexual desire or sexual excite- 
 ment. It is commonly associated with some derangement of the digestive organs, consti- 
 pation, and rectal irritation, spasmodic action of the levator ani acting on the vesiculae 
 seminales and prostate gland. In its most complete form it is associated with an absolute 
 loss of sensation about the veru montanum on the passage of a sound, a patient thus 
 affected allowing the introduction of an instrument without flinching, whilst the worst 
 cases are associated with wasting of the testicles and varicocele. It is at times, without 
 
SI'hn.MAToHL'IKKA. Too 
 
 (l()ul)t, (liic to excess of veiiory, l)ut inniv foimeioiily to nia.stiirl)ation. It coiimiii'im-cs 
 iiliiiitst alwiiys with iinctunial ciiiissioiis, whicli ^Tadiially l)i'c<mic iiioi-t' f"re<|Ut'rit. 'J'lie.se 
 are at tirst atti'iidcil with fiDtic .sensation, althoii^^li not mo suh.st;<|ui;ntly, and at hist occur 
 without erection. If cnpuhition he attenipteil, tlie ejacuhition takes place at once, often 
 before the intnxhiction of the orj^an. It (-ikIs in the total loss of ,s(!xual inclination and 
 power. Lalleniand says that ''seminal emissions supctrvening durinj.' micturition are the 
 njoat serious." 
 
 He holds that " spermatorrha'a is nearly always deptMident upon irritation olthe pro.s- 
 tate iiland and its ejaculatory ducts," and believes that " in most eases this irritation, 
 which also exists in the neck of the hhuhJer, is the result of chronic; inflammation of the 
 urethra in the prostatic portion of the verii montanum. An ohl attack (»f urethritis is 
 the most frecjuent cause of the seminal emissions, and tlie.se emissions are often related 
 to stricture of the un-thra. ' 
 
 Trousseau, however, whih; admittinj^ the force of these observations, believes that sper- 
 matorrh(oa or incontinence of semen is due to som(> inipcM-fection in the nervous system 
 of oriianic life, since it is so commonly found in men who have had incontinence of urine 
 in childhood. He looks upon the masturbation as an indirect proof that there is a h»ad 
 state of the nervous systen), and the subsequent impotence, insanity, or paralysis as an 
 aggravation of a nervous condition of which masturbation was oidy the first morbid 
 manifestation (Trous.seau, Clin. Med., vol. iii.). This latter view is supported by the fact 
 that in some cases of injury to or disease of the spinal column sjjermatorrlnea is a com- 
 mon associate. 
 
 False spermatorrhcsa is, however, a more common complaint. It is suppo.sed 
 to be present when nocturnal emissions are fre((uent, when diurnal emi.ssions take place 
 on any sexual thought and urethral discharge of a glairy fluid attends defecation, when 
 erections with discharge follow the slightest irritation, such as that produced by riding or 
 walking, from the friction of trousers, etc. Such cases are far from rare and are com- 
 monly due to masturliation, but are not cases of true spermatorrlnjea, although the)' often 
 precede it. Nocturnal emissions may be tot) frequent; but if associated with sexual feel- 
 ing, they are natural. They should, however, be checked, as they lead on to the true dis- 
 ease. The glairy fluid pressed out in defecation is rarely seminal, but is prostatic, of a 
 transparent, tenacious character, and not milky. The whole genital tract in this aflFection 
 is in a state of morbid sensibility, of hyperjvsthesia, and requires treatment, since the 
 false spermatorrhoea is often only the prelude to the true. 
 
 Treatment. — Trousseau, regarding masturbation as a manifestation of some disease 
 of the nervous centres, speaks strongly in favor of belladonna, and. so far as ni\- experi- 
 ence has gone, I am disposed to think it a valuable drug given in half-grain doses of the 
 extract twice a day, with some tonic such as iron, zinc, strychnine, or quinine. It seems 
 to act most beneficially, and in a marked manner to check the disposition to masturbate. 
 Of course this good can be met with only when there is in tlie patients mind a strong 
 wi.sh to overcome a repugnant habit. To aid this the application of a ring of blistering 
 fluid around the penis or painting the prepuce with iodine is n valuable adjunct. The 
 bowels, more particularly the rectum, under all circumstance, should be kept empty, and 
 the nightly injection of cold water into the bowel is a useful custom. The patient should 
 sleep upon a hard bed and be lightly covered. He should not rest on his back, and a 
 solid substance fastened in a handkerchief over the sacrum is a good mode of securing 
 this end. 
 
 AVhen evidence exists that the mucous membrane of the prostatic urethra is affected 
 near the orifices of the spermatic ducts, Lallemand's advice of applying a solution of • 
 nitrate of silver (gr. v to gr. x to the ounce) every other day should l)e followed. Some 
 surgeons use a stronger solution ; and when an absolute loss of .sensibility of these parts 
 is present, galvanism has been highly spoken of. For the application of the solution 
 Erichsen's syringe catheter is the best. Every means .should be employed to divert the 
 patient's mind from the seat of his affection by encouraging mental as well as physical 
 labor. Simple nutritious food should be allowed and cold bathing adopted. 
 
 In the cases of imaginary impotence of young married men all that the surgeon has 
 to do is to give confidence, for the failure is jirobably in the mind rather than in the body 
 of his patient. The best advice is to recommend abstention from coitus, when Nature in 
 her own time will have her way and assert her power. 
 
756 SURGICAL AFFECTIONS OF FEMALE GENITALS. 
 
 CHAPTER XXV. 
 SURGICAL AFFECTONS OF FEMALE GENITALS. 
 
 Wounds. 
 
 Wounds of the external genitals are met with in practice as the result of violence 
 intentionally committed or happening accidentally from falling or sitting on pointed or 
 cutting bodies. They are always serious, on account of the bleeding that attends them, 
 and wounds of the vagina are particularly so. However severe they are, they should be 
 carefully cleansed, adjusted, and stitched together ; for these tissues are very vascular 
 and heal well. 
 
 Severe lacerations at times takes place in the attempt at coitus. Some years ago I 
 was called to a young married woman for severe hemorrhage from these parts following 
 marital intercourse the night after marriage, and found two severe lacerations of the ori- 
 fice of the vagina and the hymen unruptured ; the membrane had been practically driven 
 in. Pressure arrested the bleeding. 
 
 Wounds of the vagina are apt to be followed by inconvenient cicatrices. 
 
 Foreign bodies are also at times introduced into the vagina for criminal or erotic pur- 
 poses. Mr. Hilton removed at Guy's a flat bone-netting me.sh ten inches long which had 
 pas.sed through the vaginal walls into the pelvis. Bottles and other foreign matters have 
 also been introduced. Sponges are not uncommonly found in the passage, and in a case 
 I knew of such a foreign body gave rise to the suspicions of cancerous disease. 
 
 Adherent Labia. 
 
 The labia during childhood are apt to adhere together from some local inflammatory 
 action, and so to close the labial orifice as to interfere with the act of micturition. The 
 urine in children thus afl'ected often squirts in a backward or forward direction, and for 
 this surgical attention is sought. In these cases the true condition of affairs will at once 
 be recognized on separating the genitals, for the labia will be found connected together 
 by a membranous adhesion which passes forward in some cases to the urethral orifice, 
 thereby affecting the urinary stream. This membrane is readily broken down by sepa- 
 rating the labia with the fingers or thumbs, or by means of a probe introduced behind it 
 from above. The application of a little cold cream will complete the cure if care be 
 taken to keep the parts clean. 
 
 Vulvitis. 
 
 This is a common complaint in children, and is almost always due to some rectal irri- 
 tation such as that caused by worms, scybala, etc., in the feeble and badly fed. It is 
 rarely the result of a gonorrhoeal aff"ection, as is too often suspected ; and it is well to be 
 aware of this fact, as it is not uncommon for a surgeon to be consulted about a child with 
 vulvitis under the suspicion that the aff"ection is the result of an impure criminal contact, 
 when it is due to some simple non-venereal cause. 
 
 Treatment. — It should be treated by local cleanliness and mild astringent lotions 
 such as lead, alum, etc. ; when worms are suspected, by the administration of a good 
 mercurial or jalap purge and attention to the digestive organs and general health; a 
 mixture of rhubarb and .soda for a few days, and subsequently a tonic, generally efl'ect a 
 cure. 
 
 Noma, or phagedaenic ulceration of the labia similar to the cancrum oris after the 
 exanthemata, is met with in cachectic children and is a disease of debility. It com- 
 mences as an inflammatory swelling of the parts similar to erysipelas, passing on to gan- 
 grene and ulceration, and is always attended with great prostration. 
 
 Treatment. — For its treatment such tonics as can be borne should be given, and 
 particularly iron, quinine, or bark. Wine and abundance of good liquid nouri.shment 
 should be given by the mouth, or by the rectum when the stomach rejects it, and milk 
 with chlorate of potash is a good drink. Locally, opium lotion with carbolic acid, nitric 
 acid, or nitrate of silver .should be used ; and when the ulceration spreads nitric acid in 
 its concentrated form may be applied, or the actual or galvanic cautery. 
 
iii:i:ma, etc. 7o7 
 
 Nsevi, wlu'ii foiinil involving tliof iiarts, are to be tri'utt'fl liko otiiors. 
 
 Hernia. — In wnmcii tlu- laliium may '>»' tin- seat of an iii;.'iiiiial /n ruin or of a ran'- 
 coct/i. Till" toniu-r is kiinwn l>v it> own syni|itoiiis. the latltT \)\ its wormy fV'«;l. It may 
 also l»r(Miiiu' tlu' scat of thrombuS, or Itlooil tumor on tlif receipt of an injury, wliit-li 
 is to l»e made out liy tlie history of the case, the smiih-n a|i|>earanee of the swcllin;^ al'ter 
 an injury, its external aspect an*l Huetuatinj; feel. Such hhnxl swellin;rs are to he treated 
 at first l»v the h>cal ap|)lication of cold, to arrest the flow of l>lood, and suh.stM|ueritly hy 
 lead lotions. If they tend to hreak up and form an altsccss, a free incision into the swell- 
 inj^ is the ritrht treatment to adopt. 
 
 Labial abscesses lorm at times as a result of a softened throm)»us, hut »n»re fre- 
 quently tVuni fulliciilar inflammation. They are very painful and ought to he opened 
 earlv. ( )(i a>iiiii;illv tiiey are the conse(|Uence of an inflamed cyst. 
 
 Labial cysts :ii-e very common, and are usually met with on the inner side of the 
 lahia. They are similar in their nature to the mucous cysts lound in the mouth or ahout 
 the tonj;ue and are lormeil in the same way. hy the obstruction of the <lucts of the mucous 
 L'lands of the jiarts. They ajipear as chronic painless swellinirs. jiroducinjL: ordy mechan- 
 ical inconvenience; but if ncirlectcd. they may inflame and su]tpurate. On manipulation 
 thev feel tense, globular, and semifluctuatinir. and contain a ulairy brown or blood-.stained 
 fluid, at times with eholesterin. 
 
 TuE.\T.MKNT. — They are to be treated by excision or the removal of the presenting; 
 surface of the cyst by a pair of forceps and .scissors, the removal of one wall exposing 
 the other, which contracts. Excision, however, is the .safe.st practice. When an opening 
 into the cyst is made, the cavity .should be plugged with lint or with lint .soaked in tinc- 
 ture of iodine, this fluid exciting adhesive action or suppuration in the cyst wall. When 
 the cyst suppurates, it is to be laid freely open and dealt with as an abscess. 
 
 Mucous cysts like the.se are also found in the vagina. 
 
 Sebaceous Tumors. — The internal labia may also be the seat of .sebaceous tumors 
 and of a solid (cdenia or liy]iertrophy similar to that .seen in the male scrotum, not unlike 
 clej>/i((iifi\tsisj and grow to a large size. Nothing but their removal can be entertained. 
 Some time since I removed with the galvanic ecraseur from a middle-aged woman both 
 labia, whicb had attained the size of a cocoanut, without tbe loss of a drop of blood, after 
 having isolated the growths by long pins inserted through their bases and passed the wire 
 round the pins. When this instrument cannot be obtained, the knife must be employed. 
 Such tumors are bighly vascular, and the surgeon requires good assistants in their removal. 
 
 Cancerous tumors, both epithelial and otherwise, of these parts are also met 
 with, and are known by their ordinary features; they should be treated by removal. It 
 seems that cancer is prone to appear in these regions at an earlier period of life than in 
 others. In 1809 I removed a well-marked cancerous tumor from the labium of a woman 
 only thirty-two years of age. 
 
 Epithelial disease of the clitoris occurs at times, and I have seen several 
 well-niark(<l ea.-es ; but more commonly it attacks the inner labia and orifice of the 
 vagina. In such ca.ses the benefit of the galvanic cautery is well ilhustrated. for the 
 removal of these growths by excision is very diflicult and always attended with copious 
 bleeding. When the whole growth cannot be isolated, as much as possible should be 
 excised or scraped off" and the cautery freely applied to the surface and base of what 
 remains. Where the growth can be isolated by the introduction of long pins beneath its 
 h»ase and a wire adjusted beneath the pins, the galvanic ecraseur. not made too hot and 
 slowly worked, is an admirable instrument to employ. By its means I have on several 
 occasions successfully removed, without the loss of a drop of blood, an epithelial cancer 
 occupying the fourchette of the vagina, encroaching on the passage and the perin.-euni. 
 The patients were under chloroform during the operation and felt no pain, the after-pain 
 in these cases being always slight, the cautery entirely destroying the sensibility of the 
 divided parts. Wounds so made heal kindly. 
 
 Lupus also attacks these parts like others, while ivarff/ i/roirfh<i are common. 
 
 Syphilis has received attention in another page. 
 
 Imperforate hymen is a condition to be recognized and not confused with the 
 adherent labia, already referred to. The hymen is more deeply placed, nearer the orifice 
 of the vagina. When imperforate, it causes retention of the menses, the accumulation 
 of the .secretions, and a pelvic tumor usually accompanied by periodic pain and constitu- 
 tional disturbance. 
 
 Tre.vtment. — The proper treatment of these cases is the division of the imperforate 
 membrane or its complete excision, the object being to allow of the free escape of the 
 
758 SURGICAL AFFECTIOyS OF FEMALE GENITALS. 
 
 retained secretion, which is usually black and treacle-like. Success usually attends this 
 practice, though a fatal peritonitis at times ensues. 
 
 A rigid hymen is occasionally an impediment to coitus in women who marry late 
 in life, and I have known one in which for two years after marriage the husband had 
 never had perfect connection on this account ; indeed, it was not till after his wife had 
 become pregnant and the vaginal membrane had been ruptured during the birth of the 
 child that a satisfactory coitus was effected. 
 
 I have also been called upon on one occasion to divide the hymen of a lady about 
 thirty who had been married for some months and had never had complete connection, 
 the husband's penis having been very large. 
 
 There are cases on record showing that when a vagina is occluded and the patient, 
 has been married, the urethra has been so enlarged as to admit the finger, and in all 
 probability the male organ. 
 
 A double vagina is another cause of difficult coitus. I was consulted in such a 
 case by a patient who had been married for several years and never had connection. The 
 woman came to me, as a divorce was under consideration. She complained of extreme 
 pain whenever an attempt at coitus was made, and the husband of inability to penetrate. 
 On making a careful examination a double vagina and uterus were discovered. I advised 
 the division of the septum with the galvanic wire by perforating the septum near the 
 uterus and gradually dividing it by means of steady traction upon the wire ; but whilst 
 the question was under the consideration of both parties the suspicion of pregnancy 
 occurred, and time proved its truth. A child was born prematurely after a tedious labor, 
 and I heard no more of the difficulties of the case. She became pregnant a second time. 
 
 Besides these deformities, others may occur, such as occlusion of the vagina or absence 
 of the uterus, or the opening of the rectum into the vagina, etc. 
 
 Enlarged Clitoris. — The clitoris is occasionally enlarged at birth, appearing as a 
 small jienis. I have seen an example of this, and at the end of the clitoris a depression 
 existed corresponding to the male urethra. The child in other respects was natural. 
 This organ, however, may in after-life become the subject of hypertrophy — indeed, of a 
 kind of elephas. as of the male penis — and require removal. 
 
 Clitoridectomy for epithelial cancer has already been alluded to. This operation 
 has been practised for epilepsy and supposed erotic complaints, but evidence is wanting to 
 justify this step. The operation for such purposes appears at present to be unjustifiable. 
 
 Vaginal tumors, besides the cystic and epithelial, are occasionally met with, and 
 vaginal polypi are found. I removed one the size of a nut from a child three years old, 
 and similar cases are on record. They should always be ligatured and excised. 
 
 Rupture of the Perineum. 
 
 This accident is not rare as a result of a rapid delivery, and to a small extent it is 
 
 somewhat common in first labors. When limited, it is not of much importance ; but when 
 
 p ^oi extensive the pelvic organs lose their natural support and are 
 
 liable to fall, giving rise to rectocelr., or prolapse of the pos- 
 
 . _ terior wall of the vagina, or cystocele, or prolapse of the an- 
 
 ^. ''^^^" ^ y^ terior wall of the vagina. 
 
 ^ ^' ^. When the sphincter ani or the rectum is implicated, the 
 
 accident becomes of grave importance. 
 
 At times the rupture is central, and in the ease from which 
 Fig. 4.31 was taken the child was born through the rupture B. 
 The incident took place in the practice of a medical friend, 
 who .sent the case to me. Dr. Wilson witnessed a like process 
 in a similar case (Udi'n. Med. Jonrn., April, 1875). 
 
 There is no rea-son to believe that rupture of the peri- 
 naeum is in all cases the fault of the accoucheur, although, 
 doubtless, it is so in some ; yet with a large child and rapid 
 labor it is often difficult to prevent. I have known it occur 
 in the practice of very good men. 
 
 Treatment. — Slight ruptures of the perinaeum need not 
 be regarded, but when a rupture into the body of the peri- 
 Central Rupture of the Perinfeum, naeum takes place during labor and the accident is recog- 
 through which Child was born. ^:^^^^ ^^^ y^^^^ practice IS to put in one or more sutures 
 
 at once. This practice is so sound that it cannot be too confidently recommended. 
 
liiTTiTj-: OF Till'. rrjiis.Ki:M. 
 
 759 
 
 Fig. 432. 
 
 When tho (t|»«'rati(iii is not |M'rfiirine(l at (tiicL', hut ]M).stp(»ri<'(l to tin- future, it iiiu.st Ijc 
 left (ill tlif jioritid nl' siickliii;.: lias passi-d and the ^.'cricral ln'altli of tin- patient been 
 restort'd ; the (i|)eratiuii, hein<: a plastie one, rei|uires j^ood power on the part of the 
 patient, and immediate union of the wound is wanted for siieeess. it is very sueeessful 
 when properly performed ; imleed, it rarely fails. 
 
 Ol'KKATKiN. — The huwels should he well cleared out hy an aperient ;:iv<ti two days 
 before and an entMua on the day <d' operation. An an;esthetie should he ^iven, the 
 patient placed in the position for lithotomy, with the buttocks brou^rht to the edfre of the 
 table, ami Clovers crutch applied, to keep the knees apart. The vagina should be well 
 wasluMl out with a carbolic acid or iodine lotion. An assistant should then well .separate 
 the labia, while the surtreon with his scalpel maps out the j»(»rtion of the intej^unient that 
 he proposes to raise (A, V, D, H, Kifr. -il>2), remembering that it is neces.sary to have a 
 broad surface to bring together as well as a cleanly cut one, since a thin membranous 
 union is u.sele.ss and a jagged surface will not unite. 
 
 At least an inch of raw surface should be provided on either side of the jierinjeuni for 
 union, the width of the bared surface diminishing slightly toward the anterior portion of 
 the labia and widening toward the anal end. No /i'sskc 
 IS to If s<icr!fi<-<(l . 
 
 The incisions should be carried along the outer bor- 
 der of the cicatricial tissue, and extend froni A to C and 
 from B to D, with a transverse cut from C to D, and thi.s 
 broad flap is to be raised toward the vagina and held up 
 by an assistant, two sutures inserted into the angles of 
 the flap helping this act (Fig. -iWl). 
 
 If bleeding follows, the larger arteries may be twisted, 
 while a little pressure .soon controls the smaller. 
 
 The Kccoud step of the operation, or the introduction 
 of the sutures, ren)ains to be performed ; and it is of no 
 less importance than the first. Four or five sutures are 
 required, and they should be of silkworm gut ; they 
 .sbould be introduced from a fjuarter to half an inch 
 from the margin of the wound, the one nearest the 
 rectum being first inserted. The introduction of the 
 first suture is of primary importance. It should be 
 passed deeply through the left side of the wound, rather 
 behind the level of the recto-vaginal septum, through the 
 tissues and the septum, and out at a corresponding point 
 on the right side; it should be completely buried in its ^ . , 
 
 II ° -^1 ^i I • ^ £• ^ '• .1 Operation for Ruptured Perinfeura. 
 
 whole course, with the obiect ot drawing the recto- . r- « i. — . . .i <• <■ ~ 
 
 1 / TT. , T1- ' ' ' ^' represents the surface from 
 
 vaginal septum well forward ( 1 <ae tig. 4!:>2). A sec- which the flap is raised, with the sutures 
 
 ond. third, and fourth may then be introduced, as indi- JheTwo'ider"'' '"'*'" approximation of 
 cated in the drawing. 
 
 A needle such as that seen in Fig. 432 is the one I employ. It is curved on the flat, 
 so as not to cut the recto-vaginal septum in its passage, and has an eye in its point to 
 admit the suture. The parts should be brought together carefully and pressed together 
 firmly after their apposition ; .several su])erficial sutures of fine carbolized gut may be 
 introduced should they be required. If thei'e be much spasm of the sphincter, the 
 muscle may be well stretched. 
 
 After-Treat.ment. — After the operation is completed the surgeon should satisfy 
 himself that the parts are in appo.sition, and the vagina should be well syringed. Some 
 iodoform gauze should be applied to the wound with some iodoform powder, and a 
 morphia suppository placed in the rectum to relieve pain and spasm. 
 
 The patient ought then to be removed to bed and her legs tied together and flexed 
 upon the abdomen. The urine should be drawn oft' every six hours for the first three or 
 four days and the parts kept clean. Iced milk and beef tea should be given for the first 
 day, but meat and wine subse({uently if the appetite allow. The patient may lie on her 
 side should .she wish. The sutures need not be removed till the fifth or sixth day. but 
 after the fourth day they should be taken away if suppuration appears in their track. 
 
 On withdrawing the sutures great care should be observed not to separate the thighs 
 or parts ; indeed, for quite ten days or more after the operation this point should be 
 observed. 
 
 After the first week the use of the catheter may be dispensed with, the patient mak- 
 
760 SURGICAL AFFECTIONS OF FEMALE GENITALS. 
 
 ing water on her hands and knees, the parts subsequently being carefully sponged. When 
 any oflensive vagina discharge appears, the passage may be syringed with an antiseptic 
 lotion. The bowels should be locked up for at least a week by small doses of opium twice 
 a day, and then relieved by a dose of castor oil after some warm oil has been injected into 
 the bowel ; but in some cases, where union is thought to be feeble, it is well to keep them 
 from acting for a longer period, care being always observed that no large indurated motion 
 be allowed to pass, warm water and oily enemata being used. 
 
 With this attention good success generally follows, and women may have subsequent 
 labors without any giving way of the parts. 
 
 AVhere much prolapse of the posterior wall of the vagina coexists, a strip of mucous 
 membrane running up the vagina from the anal end of the recto-vaginal septum may be 
 cut oif and the edges of the wound brought together. I have done this in many cases 
 with an excellent result ; indeed, in many cases of prolapse of the uterus following some 
 slight rupture Qf the perina3um, or even without, this operation is of great value. 
 
 In vaginal cystocele a like opei'ation is of benefit, the removal of a piece of vaginal 
 mucous membrane at its labial border being often followed by a good result. 
 
 Dr. Kaspozilo in this operation catches the fold of mucous membrane to be removed, 
 when drawn down, between the blades of a pair of long forceps, passes the sutures below 
 the forceps, and finally cuts the mucous membrane away, and then ties the sutures. 
 
 Operations for Prolapse of the Uterus 
 
 are of great value, and consist, with certain modifications, of the removal of vertical por- 
 tions of the posterior vaginal wall, though Marion Sims prefers the excision of an oval 
 portion of the anterior. 
 
 To do Sims's operation the patient should be placed in the position for lithotomy, and 
 the uterus or anterior vaginal wall near the uterus .should be seized with a vulsellum or 
 bullet forceps and drawn well downward. The surface of mucous membrane to be 
 removed should then be marked out with a scalpel, and a piece from the neck of the 
 uterus to the urethra, about three and a half inches long to two and a half wide, removed. 
 All bleeding vessels should be twisted or tied with catgut and the edges of this gaping 
 surface brought together by alternate deep and superficial sutures, these sutures being 
 introduced about a third of an inch apart. The wound should then be well washed with 
 an antiseptic lotion and the parts returned into the pelvis. 
 
 The stitches need not be removed for two or three weeks ; and when carbolized gut is 
 used, they may be left alone to come away. 
 
 When a portion of mucous membrane is removed from the posterior vaginal wall, 
 there is no necessity to draw the uterus or vagina down ; but a triangular (Hegar), five- 
 sided (Simon's), perpendicular, or other shaped portion of mucous membrane should be 
 removed and the cut edges brought together, as in Sims's operation, the lower border of 
 the flap under all circumstances corresponding to the junction of the vaginal mucous 
 membrane with the skin. 
 
 In all these operations it is of importance that the bared surfaces should be clean and 
 smooth and that there should be no blood beneath the flaps. 
 
 Vesico- and Recto- Vaginal Fistula. 
 
 Abnormal communications between the bladder or rectum and the vagina are usually 
 the result of long and tedious labor from sloughing of the tissues after too much pres- 
 sure, although at times they may be caused by the rough use of instruments, the reten- 
 tion of a pessary, or the presence of a stone. They are usually discovered a few days 
 after the delivery by urine, wind, or feces passing through the vaginal passage, these 
 symptoms appearing on the separation of the slough. 
 
 The surgeon is usually called upon to treat the case when the puerperal month has 
 passed and the patient's powers been restored ; till then it would be rash to think of 
 interference. 
 
 The operation for the cure of these aff"ections is a very good one and generally suc- 
 cessful, failure following only in exceptional instances — that is, when the subjects are 
 feeble, with small reparative power, or when the loss of tissues is too great to be 
 made up. 
 
 Recto-vaginal fistulas are more readily cured than vesico-vaginal, but both operations 
 are alike in principle. 
 
VKSICO. AM) lllUTD-VAdlSAL FlSTrL.K. 
 
 701 
 
 Ol'KllATloN. — Without yiin\\)i into its history, full dctiiils of which can \hi louml in 
 the s|)C<'ial works on tiic surLncul diseases of women, it may l»e saiil that it is l>v Sims ami 
 Hu/eman in America, and liy Simpson and Mrown in this count ry. that the modern opera- 
 tion has heen hrouji^ht to its present statt; of perfeclion, althouf.'h it is prohattly to tlitj 
 introduction of an.i'sthetics that its jijreat success is to he attrihuted. 
 
 \'cry small tistuhu may prohahly be cured by the actual or pilvanie cautery, but 
 every opening; aboye the size of a cruwcjuill demands some plastic operation. 
 
 In the operation the surjjeon has three main points to (d)serye : Ist. To brinj^ the 
 listuhi well into view and under control ; 2d, to jtare with nicety and accuracy its wlude 
 inaririn ; and .'Id, to brinLC into and maintain in apposition the raw and inci.sed surfaces. 
 
 For the first (tbject the duckbill speculum is uMd(»iibte<lly the; best; by some authors 
 it is sjxiken of as Hozemans, by others as Sims's. It is both a dilator of the vajrina and 
 a retractor. Some surj^eons. Jobert beinj^ amongst them, talk of e.\]»osin<^ the fistula by 
 dramrinj; the uterus externally and thus evertinj; tin; vajrina. I have never had the 
 bohlness to use sufficient force to do this, and cannot advise it. Such a measure would, 
 however, greatly facilitate the different steps of the operation. 
 
 Weiss has recently so arranned the duckbill speculum a.s to be seIf-suj»porting (Fig. 
 4i}4). 1 have used the instrument, and have been much struck Avith its value. 
 
 Fig. 434. 
 
 Fig. 435. 
 
 Position of Patient for Vesico-Vaginal Fistula. Self-Retaining Vaginal Speculum. 
 
 For recto-vaginal fistula the patient should be placed on her back, a.s in lithotomy, 
 and for ve.sico-vaginal fistula this position is at times the most convenient, though I 
 usually prefer the semi-prone position, the knees and thighs falling over the end of the 
 table, the surgeon looking down upon the fistula (Fig. 433). 
 When the uterus is dragged down sufficiently far to evert the 
 fistula, the lithotomy position is doubtless to be preferred. 
 
 The fistula having been brought well into view, the next step 
 is to pare its edges; and in doing this the operator must not be 
 too sparing of tissue, his aim being to obtain as broad and as 
 clean a surface as he can. AVhen this can be secured by means 
 of a knife and forceps, no better instruments are required, the 
 best knife being one that can be adjusted to any 
 angle with rapidity and ease. When the fistula 
 is high up in the vagina or large, the pronged 
 guide (a modification of that of Hilliard of Glas- 
 gow) made for me many years ago is an excel- 
 lent instrument (Fig. 435). It is readily applied 
 and ensures a clean-cut surface. Some surgeons 
 prefer the scissors (Fig. 436). 
 
 When this step of the operation has been 
 completed, the edges of the fistula must be 
 brought together ; and for this purpose numer- 
 ous devices have been employed. Splints of all 
 kinds have been suggested, but with experience 
 they have all been discarded, simple wire, silk- 
 worm-gut, or silk sutures, fastened with shot or 
 otherwise, being preferred. I have tried every form of splint, and have at last come to 
 gul sutures with or without shot fastenings, using occasionally a plaited fishing silk. 
 
 Paring Edgos of Vaginal Fistula. 
 
762 
 
 SURGICAL AFFECTIONS OF FEMALE GENVrALS. 
 
 Fig. 437 
 
 The sutures should be introduced tolerably close together and at a good distance — 
 say a third of an inch — from the margin of the wound, and should not be drawn too 
 tight. They should be fastened by running a perforated shot down over them, taking the 
 precaution subsequently to tie the gut over the shot to prevent its giving away. In this 
 step the operation is similar to that for fissured palate. In Fig. 437 may be seen the 
 needles employed, with the mode of introducing and securing the 
 sutures. 
 
 A good strong pair of forceps is required to nip the .shot after 
 they have been slipped into position. 
 
 When wire or gut is employed, Startin's hollow needles may be 
 used, but the ordinary curved needles with good eyes at their ends 
 are the best for silk. With wire, gut, or silk, the shot fastenings are 
 the best. 
 
 After-Treatment. — After the operation the vagina should be 
 well cleansed of blood and the bladder emptied. Ice or iced water 
 will generally arrest any bleeding that may ensue. An opiate sup- 
 positor}' should be administered after the operation, to give ease, and 
 the same practice should be followed with respect to the bladder and 
 diet as has been recommended after the operation for ruptured peri- 
 na?um. 
 
 To leave a catheter in the bladder after the operation for vesico- 
 vaginal fistula often adds to the irritation, its careful introduction at 
 stated periods being preferable. When from circumstances this can- 
 not be attended to, the introduction of a short catheter with an open 
 end, to allow of the urine passing as it is secreted, should be employed. 
 Dr. Meadows allows his patients to pass their urine in the natural 
 way after the operation, and I have dispensed with the catheter in 
 some cases without any bad result. 
 
 On the sixth or seventh day the sutures may be removed ; but if 
 good union has not taken place and they are not causing irritation, 
 they may be left in position for a longer period. 
 
 During convalescence the vagina should be kept well cleansed by 
 the daily use of some antiseptic lotion. 
 
 In recto-vaginal fistula the bowels should be kept locked up for 
 ten days or a fortnight, till the wound has firmly united, and then the 
 feces should be rendered .soft by enemata of oil and gruel. 
 
 When the tissues around the edges of the fistula are too thin to 
 allow of their being pared— and, indeed, under some other circum- 
 stances — they may be split ; that is. the vaginal mucous membrane 
 may be raised from its submucous bed for half or three-quarters of 
 an inch round the fistula and the under-surfaces of the raised mem- 
 brane brought together and held there by a quill suture. I have 
 adopted this method on many occasions and been most favorably 
 impressed with its advantages. I was led to do so some years ago in 
 a case of vesico-vaginal fistula where there was no tissue to spare, 
 and was pleased subsequently to see so good a surgeon as the late 
 Mr. CoUis of Dublin make the same siiggestion. When this plan is 
 adopted, the sutures mu.st be removed on the fourth day, otherwise, 
 the pressure of the bougie may cause ulceration. At times it is best 
 only to cut the sutures and leave the quills in position for a day or 
 so longer, the amount of irritation they cause being the surgeon's 
 guide. Dr. Kidd and Mr. Mapother of Dublin have adopted, how- 
 ever, what appears to be a better practice. They make a U-shaped cut round the fistula 
 through the mucous membrane of the vagina, raise the flap thus formed, and cut off" its 
 lower half, including the opening of the fistula into the vaginal mucous membrane. They 
 then draw down the shortened flap over the fistulous opening into the bladder and unite 
 it by sutures to the crescentic border of the mucous membrane forming the bed from 
 which the flap had been raised. The fistulous opening into the bladder is thus covered 
 over with a flap of sound mucous membrane (Brit. Med. Journ., June, 1872). 
 
 When the neck of the uterus is involved in the fi.stula. it may be necessary to lay it 
 open ; but when the uterus is involved, it is more frequently necessary to turn the neck 
 of the uterus into the bladder and close the vagina high up. In very extensive lacera- 
 
 Introduction of Sutures 
 in Vaginal Fistula. 
 
DISEASL'S AM> TCM'iUS OF Till:- lillEAST. 763 
 
 tions of the vosico-vajriiiiil septiini tlie surj^cdii may Ih- falli-cl iipdii tf) clone the vu^'ina 
 nearer its orifice. I have dom' so on several occasifuis with <ron(l succesH, two or more 
 operations liciiiLT refjiiired. 
 
 Wlieii tlie fistula is surroiimlcd hy cicatricial tissm-, and alter tlic; coaptation of its 
 ed^es there is found to he much tension, lateral incisions throu^di the tense mucous mcm- 
 brunc are of great use in allowinji the ed<res to fall rather than to \h: held tojrether. 
 
 In recto-vaf^inal fistula unconne<'ted with parturition, before an operation is attempted 
 the sur<;etm should satisfy himself by a digital examination of the rectum that no stric- 
 ture or disease (d" the rectum coexists to which the fistula is secon(hiry. 
 
 Vascular excrescences arc very common in the female urethra, and from their 
 great scii^iliilit v cause severe pain. They at times project from the meatus as a florid 
 outirrowtli and are often attended with a discharge of mucus, and at times of bl<»od. also 
 with irritability of the bladder. Their removal is the oidy sound treatment, and this can 
 be eftected l)y iiirce]is and scissors or by nn-ans of the galvanic cautery. Wlicn tlie former 
 practice is lollowed, the growth should be well drawn downward and excised, a stick of 
 nitrate of silver being ap[)lied to the base of the tumor, to prevent bleeding. When any 
 doubt exists as to its complete removal, chloride of zinc may be used. 
 
 When the urethra i.s the seat of more than one such growth, the introduction of a 
 stick of sul{»hate of zinc at intervals of two or three days may be followed by the wither- 
 ing of the growths; but when this result does not ensue, the pas.sage must be dilated and 
 the growths removed. Nitric acid in some cases is a good caustic to ensure their destruc- 
 tion when excision or the galvanic cautery cannot be employed, and Dr. A. Edis recom- 
 mends {Brif. M(d. Joitrii., April 4, 1874) the saturated solution of chromic acid, to be 
 applied by means of cotton-wool rolled round a stick to the growth until the surface 
 becomes shrivelled. 
 
 To facilitate the use of any of these means, but more particularly the destruction of 
 the growth with the galvanic cautery, I have found the use of the boxwood or ivory 
 speculum and dilator (depicted in Fig. 438) of great 
 
 iise. By it the urethra can be readily dilated, the Fig. 4:38. 
 
 urethral growth made to project through the aperture ^_ „_— _;^_,_^.^^^^^ ^^_ ^^^ 
 left in its side, and the whole tumor destroyed without ^^^^^ ^j^^^^ WBI^FI 
 doing any injury to the healthy tissues. ^^^^**^BMi|[| U|^^^^ ^ 
 
 Polypi of the female bladder may protrude ^ 
 
 through the urethra and put on the appearances of a speculum Dilator for Female Urethra. 
 
 urethral growth, but a complete examination of the 
 
 urinary organs will prevent the surgeon falling into any error of treatment. 
 
 Fibro-Cellular tumors at times grow in the urethra and cause much local dis- 
 tress. Some years ago I removed one which occupied the whole floor of the urethra to 
 the neck of the bladder from a lady with a good result. 
 
 Irritable bladder in women is a very common effect of uterine disturbance or dis- 
 placement, as well as of rectal disease. Such a symptom demands the closest investi- 
 gation to ascertain its cause. It is mostly .secondary to disease of the uterus, etc., and 
 not often dependent on bladder affections. When difficulty in diagnosis is experienced, 
 the surgeon should without hesitation make a digital exploration of the bladder. 
 
 CHAPTER XXYI. 
 
 DISEASES AND TUMORS OF THE BREAST. 
 
 Sore nipples are .sources of great distress and too often the precursors of mam- 
 mary abscess. They are doubtless often caused by some aphthous condition of the 
 childs mouth, but they as frequently result from some unusual .sensibility of the skin 
 of the part, and at times from want of care. In first pregnancies mothers should always 
 harden their nipples by the daily u.se of some spirit lotion or eau de cologne and water, 
 and where they are not sufficiently prominent a breast gla.ss or gutta-percha shield should 
 be worn, as nothing tends more than these means to prevent this troublesome affection. 
 
 Treatment. — When sore nipples occur at the time of suckling, the same shields 
 
764 DISEASES AND TUMORS OF THE BREAST. 
 
 should be worn, great care being observed to dry the nipples after use and never to leave 
 them in the child's mouth after the process has been completed. The application of the 
 glycerine of tannic acid, Richardson's styptic colloid, tincture of catechu, a solution of 
 nitrate of silver gr. v to the ounce of water, and an ointment of extract of rhatany gr. 
 viiij mixed with ^ij of the oil of theobroma, are good applications. Castor oil as an 
 external application, or collodion, is sometimes useful. When cracks exist, it is a good 
 plan for the mother to draw out the nipple by means of the old-fashioned feeding-bottle 
 before giving it to the infant, the mother's nipple being put into the central opening and 
 her mouth drawing the artificial one. Another ready method is the application to the 
 nipple of the mouth of a wide-necked empty bottle that has been heated by hot water, 
 the nipple, as the bottle cools, being pressed into the bottle and rendered prominent in a 
 painless way. 
 
 Engorgement of the breast takes place when from any cause a woman is 
 unable to give suck, either from defect or disease of the nipple or from the death of the 
 child. Under these circumstances the gland may become tense and distended, and if left 
 unrelieved for twenty-four or thirty-six hours will probably inflame. When the gland, 
 however, can be relieved by the application of an infant to the nipple, or, next best, by a 
 bottle in which a partial vacuum has been made by means of hot water, the mother's 
 mouth, or a very carefulli/ applied breast pump, the engorgement may subside and no 
 harm accrue. 
 
 Pressure should then be employed by means of strapping, which must be applied over 
 the gland, previously smeared with the extract of belladonna rendered liquid with an 
 equal part of glycerine. A saline or other purge is often of value, with some tonic medi- 
 cine as quinine, a mixture of two or three drachms of the sulphate of magnesia and one 
 or two grains of quinine two or three times a day being as good as any. 
 
 In lobular engorgement of the breast gentle friction is of great value, with or without 
 oil, and warm and moist applications are also most useful. 
 
 INFLAMMATION OF THE BREAST. 
 
 This may appear as either a subcutaneous more or less extensive periglandular abscess, 
 a local phlegmonous lobular inflammation, or a diffused abscess throughout the whole 
 gland. It may primarily involve the connective tissue which exists between the lobules, 
 as well as the true secreting structure of the gland ; it may likewise occur behind the 
 gland. 
 
 It may be acute or chronic in its nature ; it may run its course without any breaking 
 up of tissue or suppuration or be attended with most destructive local results, the extent 
 of destruction of tissue depending upon the severity of the inflammatory process and the 
 amount of constitutional power of the subject of the disease. As a rule, however, suppu- 
 ration takes place. 
 
 " When the mamma, in its state of full expansion and perfect functional activity, 
 becomes the subject of an interference, the result is very commonly a diff"use or nodular 
 inflammation and the formation of an abscess. A sudden stoppage of the milk soon after 
 the lactation has been established is apt to produce inflammation, and the same result, or 
 a degree of it, sometimes follows the weaning of the child after a long course of suckling. 
 The disturbing cause, whatever it may be, acts upon the mamma when its function 
 is at its greatest intensity, and the characteristic effect is inflammation and abscess " 
 (Creighton). 
 
 In a general way, inflammation attacks the breast gland when in a state of activity, 
 and it is exceptional for the passive organ to be the subject of this process. Out of 102 
 consecutive cases under my observation, 79 occurred during lactation, 2 during preg- 
 nancy, and 21 in patients who were neither suckling nor pregnant. Three-fourths of the 
 cases that occurred during lactation attacked patients during the first two months, and in 
 many of these a cracked nipple was the assigned cause; but I am disposed to think, with 
 Mr. Ballard, that abscess in the early months is due to the searching of the child after 
 milk before the gland is filled in patients who have not sufiicient power either to secrete 
 milk or to resist the inflammatory process when once originated. The aff"ection is more 
 common in primiparae, and the right breast is more frequently afl"ected than the left in 
 the proportion of 5 to 3. In some cases the rapidity of the process is very marked, an 
 abscess forming within a few days, while in others it is most insidious ; chronic abscesses 
 have been often mistaken for new growths, and amputation of the gland performed under 
 this false diagnosis. 
 
IyFLAM^fATl(^y OF Till: l: II EAST. TOo 
 
 Aliscossos occur in inhiitts iinasts, and tlicy arc t<i<i cniiunniily the conscijucticc of an 
 i{::ni)raiit nurse ajtplviiiLr prcssiirc to the jrlands in wliicli milk is fniiiul or friction to '• rnli 
 away the milk." 'I'lie milk appears to lie mure aluimlant in the male than in the tcjnalc 
 infant. 
 
 Tlu'v arc also met with in the male subject from injury or otlier causes. 
 
 Chronic mammitis in the boy or j^irl is hy no means a rare uflectioii, the umle- 
 vt'lojied Lrlaii'l heeominu indurated and very painl'ul ; such cases rarely suppurate. 
 
 TitK.VTMK.NT. — The activity of the treatment of the affection we are now considering 
 must he regulated by the acuteness or severity of the inflammatory process and the 
 nature of the constitutional and local symptoms to whidi it may give ri.se. As u broad 
 truth it may be contidently asserted that the inflammatory process is of a low type and 
 of a destructive nature, and that, as the constitutional powers are generally feeble, 
 nothing like lowering measures should be adopted, but. on the contrary, soothing local 
 applications and constitutional tonics with .sedatives are absolutely demanded. 
 
 In cases occurring during lactation no other principles of treatUKMit than those I have 
 just laid down should be entertained. Under such conditions soothing fomentations to 
 the breast, either of warm water or of some medicated solution such as the decoction of 
 poppies, give most relief, although a light linseed p(»ultice or some spongiopiline may be 
 well employed. In young, robust women, where suckling is impossiblcj the application 
 of laxatives and powerful purgatives may be called for. 
 
 Rest in the horizontal position affVirds striking comfort, and when it can be carried 
 out is of great practical advantage ; but if this desideratum cannot be secured, the whole 
 breast must be supported by a band or linen sling. During this time tonics in such a 
 form as can be borne and may be indicated should freely be given, quinine probably being 
 the best. Such stimulants as wine and beer must be cautiously administered, though the 
 cases are few which do not require such an addition to their diet, while plenty of nutri- 
 tious food should be allowed. A sedative at night is also very generally required, and 
 Dover's powder in ten-grain doses is the best f(trm ; for want of sleep from pain is a com- 
 mon accompaniment. A mild purgative in the early stages of the di.sease may be neces- 
 sary, but excessive purgation .should be avoided, since the object of the surgeon is to sup- 
 ]ily |)ower. and not to remove it — to soothe, and not to irritate. 
 
 Opening a Mammary Abscess. — There is a great difference of opinion among 
 surgeons about the propriety of opening a mammary abscess. Some think the best prac- 
 tice is to let the breast alone and leave the operation to nature, while others advocate an 
 early opening. But in neither am I disposed to coincide, for, while I regard it as a right 
 practice to postpone puncturing the organ as long as pos.sible and not to show any over- 
 anxiety in evacuating the pus, on the other hand I know that when the abscess is left to 
 itself much unnecessary suffering is endured and a considerable sacrifice of skin often fol- 
 lows, entailing a long convalescence and an ugly cicatrix. The practice I consequently 
 generally adopt is to leave the parts alone till pointing has taken ])lace and then to punc- 
 ture, making uiy incision in a line radiating from the nipple of the patient. By adopting 
 this practice any unnecessary pain is saved, for the appearance of jiointing is directly 
 under the observation of the surgeon, and it is not necessary to make frequent and care- 
 ful physical examinations. Of course some gentle manipulation is ab.solutely called for 
 to enable the surgeon to form an opinion, but the eye, not the finger, is the chief guide. 
 Much manipulation of the gland is both painful and injurious, and an absolute abandon- 
 ment of all local surgical treatment can only be condemned. 
 
 Warm fomentations in all stages of the disease are very grateful to the patient and 
 may be freely used ; and when early suppuration threatens, a light linseed poultice is 
 probably the best application. When the abscess has discharged, the poultice ma}- be 
 hiid aside and some antiseptic application employed, as constant poulticing soddens the 
 integument and retards the process of convalescence. 
 
 Treatment of Chronic Abscess. — The existence of a chronic abscess having 
 been made out — a point. Iiy the by, which will be returned to when the subject of the 
 diagnosis of a mammary tumor is discussed — it becomes an important question what 
 treatment should be pursued. 
 
 When the abscess is small, causing little or no annoyance, it may be left alone, and 
 under the influence of tonics and local pressure by means of strapping the fluid may be 
 absorbed, and such a result is occasionally brought about. In the majority of examples, 
 however, some more active treatment is neces.sary, and of these the evacuation of the pus 
 is the chief point. If the abscess is large and deeply seated — a common condition — the 
 drawing off of its contents by means of a trocar and canula is the usual practice and i.« 
 
766 DISEASES AND TUMORS OF THE BREAST. 
 
 generally believed to be the best ; but it has this disadvantage — that the wound gener- 
 ally soon closes and a second operation is required. The same treatment may be again 
 resorted to, with the same results, and this drawing off of the pus and the subsequent 
 closure of the wound may go on for many times. At last, however, the opening remains 
 patent and the ab.scess contracts, leaving a sinus in the majority of cases. Under these 
 circumstances a bolder plan of treatment seems absolutely demanded, as time is an 
 important element in the consideration of any plan of treatment. The best method 
 appears to be a free opening at the first operation, the surgeon subsequently inserting a 
 strip of oiled lint into the cavity of the abscess for a few hours, to prevent the wound closing. 
 Submaminary Abscess. — Abscesses occasionally form beliind the breast gland 
 over the pectoral muscle ; and when they do, the gland is pushed forward in a way that is 
 
 characteristic. The abscess (Fig. 439), as a rule, points 
 
 Fig. 439. below the breast. Such abscesses should be opened 
 
 • -s^ in the most dependent position as soon as any indica- 
 
 ^--,.^,^^ tion of fluctuation can be made out. This disease is 
 
 X very slow in its progress. 
 
 \ Treatment of Sinuses.— The treatment of 
 
 sinuses in the breast, as elsewhere, is always a task of 
 difficulty, and in certain cases all plans will fail. The 
 one principle of practice which seems to be the most 
 valuable is the establishment of a dependent outlet, 
 and for this purpose the introduction of a drainage 
 tube is a simple and successful practice. If there are 
 many sinuses, some pressure may be employed by 
 means of strapping, care being taken that the open- 
 ings are left uncovered, to ensure a free passage for 
 the discharge. Superficial sinuses may be slit up 
 (D.a\vin-40i''iTc"uy'sMifs'^B^^^^ wlien Other means fail, and in very chronic cases some 
 
 irritant such as iodine may be injected, to excite a 
 fresh action. The great principle of practice in these cases, however, appeal's to be that 
 to which I have already alluded, although other means may at times be demanded. 
 
 Chronic Induration of the Gland. 
 
 This affection occurs when, from some cause or other, the gland is morbidly excited. 
 It is chiefly found in unmarried women between the ages of thirty-eight and forty, though 
 it occurs in the married, and then, as a rule, in the sterile. It is usually associated with 
 some catamenial irregularity or some general disturbance, more particularly of the nerv- 
 ous system. 
 
 Symptoms. — The affection is known by the excessive sensibility of the indurated 
 gland on manipulation, the nervous excitement the examination causes, the total absence 
 of any local indications of a titmor when the fingers are placed fiat iqwn the part., and the 
 induration of the gland or lobe of the gland when the organ is raised from the pectoral 
 muscle and pinched. 
 
 Treatment. — The treatment consists in correcting what is wrong in the general con- 
 dition of the patient by means of iron, tonics, and alteratives, and soothing the affected 
 part. Cold lotions are at times grateful, while at others a belladonna plaster affords relief, 
 with or without pressure. Large breasts should be suspended, and all should be protected 
 by cotton-wool from the risks of injury. 
 
 The irritable marama of young girls is closely allied to the affection just described, 
 and is associated with a morbidly sensitive condition of the mammary gland and parts 
 around, and often with some induration. It is an affection closely connected with the 
 pelvic generative organs, which are mostly found to be not acting fairly, as indicated by 
 catamenial irregularity, etc. This condition is doubtless at times excited by depraved 
 habits. It should be treated on the same principle as the last affection. 
 
 TUMORS OF THE BREAST. 
 
 Tumors of the breast may rationally be accounted for by following out the functional 
 aberrations of the organ, and in proof of this the student should study carefully the 
 highly suggestive and valuable work of Dr. Charles Creighton.' who has shown that "the 
 ^ Contributions to the Physiology and Pathology of the Breast (1878). 
 
Ti'Moiis OF Tin: ni:i:.\sT. 707 
 
 lnvt'stiir:iti(iii nf Im'ast tunior.s ri'vcals iiicn-ly tin- woikinjr <if" the pliysiulijiricnl law of 
 lu'altliv iiiaiiiiiiarv artivity umlcr altcivd rirciiiiistaiiccs. tliat various ilf;_'ri'i'> of ilisordered 
 function niav result in various kinds oi' tumors.' and tiiat tumor fliscasu of tlic l»rea.st is 
 " I'ssi'iitiullv a disordi-r id' i'unctinii." 
 
 Tlio hrcast. in ))assin^ from its '• resting; " or inactive Htate to that of full activity, 
 iindcrj^ocs durini; the entire period of prej^nancy a process of "evolution, ' which is cha- 
 racterized in its dirt'ereiit stages hy certain cell chanj,'es within its acini and transport of 
 cells without, and in the return of the gland to its (|uiescent condition, on the subsidence 
 of lactation, a process of '• involution," in which a parallel series of changes acting in an 
 iiiversi' order is to 1)C ol)served, the fuiK-tioiial sul)sidence of the gland being s[)read over 
 a shiirter period of time than its gradual awakening duriiig pregnancy. 
 
 When the functional stimulus of the mamma is acting at its hunst point at the begin- 
 ning of " evolution " or the ending of '•involution," the secretory products arc large 
 granular yelhtw pigmented cells, which are found within the secreting acini, in the con- 
 nective-tissu(! s])aces outside the secreting structure, and likewise in the lymph sinuses of 
 the subjacent lymphatic glands, these cells being the waste products of a feeble degree 
 of secretory activity ; and if tiie mammary e.vcitation were always to act at that degree 
 of intensity, the secretion, it may be said, would always be in the lorm of large granular 
 pigmented cells. 
 
 At the m-xt apprednhle advunce in the intensity of the stimulu.s the product formed 
 in the gland may be described somewhat generally as a large granular nuclear cell, which 
 is nothing else than the crude epithelium of the middle period of the breast's unfolding, 
 in which an imperfect secretory force resides. 
 
 Coming sfi/l nearfr to the. full excitation, tlie cellular ingredients are fewer and the 
 mucous production much more abundant, and finally, when the stimulus is at its lieigld. the 
 mucous fluid has given place to a fatty fluid, and whatever cellular elements the secretion 
 contains are the woll-knowii colostrum cells, which approach most nearly the perfect secret- 
 ing cell. The periodical unfolding of the breasts, which is an obvious accompaniment of 
 each pregnancy, is thus characterized by a progressive series of immature secretory prod- 
 ucts, which necessarily run to waste. The epithelial cells are not transformed into milk 
 till the time of delivery and during the period of suckling following, but the functional 
 action of the breast has been at W'Ork all through the pregnancy, and has advanced in 
 intensity just as the secreting structure has advanced in its unfolding. The various 
 stages of unfolding have corresponding secretary products, becoming less and less crude, 
 and, as there is a similar series of more rapid but exactly parallel waste products in the 
 upfolding, it is a legitimate inference to ascribe " a special kind of secretorj- product to a 
 certain degree of intensity of the glandular force." 
 
 When the breast gland is disturbed from its resting state by a cause other than preg- 
 nancy, and in consequence of some morbid excitation is urged into a kind of evolution 
 process, the steps of its unfolding are less orderly than in the normal evolution, and the 
 '■spurious excitation" never carries the gland to the end of its unfolding or to the perfect 
 degree of its function. And. although the morbid excitation maybe said to correspond in 
 its intensity to a stage of the nornuil evolution, there is this fundamental difi'erence — that 
 the corresponding stage of the normal ])rocess is transient, giving place to a stronger force, 
 while the morbid process continues indefinitely at the same enfeebled level. As a conse- 
 quence the cell that should have been thrown ofi" from the acinus as waste almo.st as soon 
 as it was formed, remains in the place of its origin to multiply and with its progeny to 
 infest the glandular structure of the breast as either intra- or extra-acinous accumula- 
 tions. Indeed, according to Dr. Creighton, it is upon deviations from the physiological 
 track such as these that the existence of a tumor depends. 
 
 Thus, '' a circumscribed tumor arises at a particular part of the gland where the spu- 
 rious excitation has advanced to a certain stage of evolution or unfolding; in that partic- 
 ular region, probably a territory defined by the blood vessels, the functional force has 
 acted at a uniform imperfect level for a length of time, the inevitable cellular waste of 
 the crude secretion has accumulated within the acini or around them, and the foundation 
 of a tumor has been laid. 
 
 In the healthy action of the organ there is a provision for the disposal of the very 
 considerable amount of cellular waste material by means of the neighboring lymphatic 
 glands. In passing from the secreting acini and in traversing the .stroma of the gland 
 the waste cells often acquire a spindle form. and. although these cells are not always 
 distinguishable from the connective-tissue cells of the part, there is. especially in the 
 bitch, a class of pigmented epithelial cells in which such changes of form and position 
 
768 DISEASES AND TUMORS OF THE BREAST. 
 
 can be clearly traced. The spindle-shaped waste products are the type of the peri-aci' 
 nous cell collections in cystic or adeno-sarcoma. 
 
 So far as relates to the large nuclear cells, the wi^ra-acinous collections of them corre- 
 spond to the structure of medullary cancer, and the eW/-a-acinous infiltrations of the 
 same cells are a distinguishing feature of scirrhus. " The distinguishing feature of the 
 less malignant form of tumor is that the spurious functional activity comes nearer in the 
 degree of its intensity to that of the perfect secretory force^ the transformation of the 
 epithelium is a more real transformation, and the cellular waste is reduced — in part, at 
 least — to the class of fibre-like or crescentic elements that characterize the myxomatous 
 and more benign issues of the tumor process." 
 
 " The circumstance that the unknown diseased excitation most commonly befalls the 
 gland when it is in the state of rest is of the first importance in accounting for the for- 
 mation of a tumor. Whether the distubance be a mechanical injury or a sympathy with 
 excitement in the ovaries, or of a more general emotional nature, it comes upon the breast 
 in its re.sting state. The breast can react in no other way than by following the somewhat 
 slow process of its normal evolution ; without the intermediate stages of unfolding, it 
 cannot reach the perfect degree of its functions in which there would be immunity from 
 danger. The intermediate stages are necessarily associated with the formation of crude 
 cellular products ; it is at one or other of the intermediate stages that the morbid force 
 delays, and the corresponding cellular secretion of the gland thereupon assumes the cha- 
 racter of a formative or tumor process." 
 
 •' The circumstances of the functional disturbance are never exactly the same in any 
 two cases ; consequently, the respective modifications of structure — or, in other words, 
 the structure of the respective tumors — are never exactly the same." 
 
 When a tumor forms in the breast within the period when the function may still be 
 awakened to its full and healthy vigor — that is, during the period of its structural and 
 functional maturity — a resolution of the disease or a dispersion of the diseased products 
 may be looked for ; but when it appears at or near the climacteric years, when the gland 
 is suffering an effacement of its secreting mechani.sm and a withdrawal of its secretory 
 force, no such a result can be expected, and it is at this period that the greater number 
 of intractable tumors occur. 
 
 " It is the climacteric effacement of the bi'east that gives a peculiar character to the 
 disease in women, and there are well-marked structural differences in the tumors accord- 
 ing as they appear before or after that period. Those that develop after the climacteric 
 years are perhaps the most common, as they are certainly the most intractable, and they 
 have been the real source of ambiguity in the pathology of the organ. That ambiguity 
 depends upon the circumstance that they occur in an organ which is gradually losing or 
 has lost its characteristic structure." Where the normal it.self is vanishing, the departures 
 from the normal are elusive. 
 
 It seems probable, therefore, from Dr. Creighton's investigation, that the adenomata, 
 sarcomata, myxomata, and carcinomata have their type in a series of progressive changes 
 which the gland undergoes in its physiological evolution. The feebler the intensity of 
 the function, the more cancerous the disease ; the higher or more advanced the evolutiorx 
 from the re.sting state, the more benign the tumor. 
 
 Clinical Examination and Diagnosis of a Breast Tumor. 
 
 From a practical point of view, tumors of the breast may be divided into inflamma- 
 tory.! adenoid., or innocent, cystic., sarcomatous, and cancerous. Simple hypertrophy or 
 excess of growth of the gland can hardly be classed among the tumors. 
 
 The first point a surgeon has to determine when consulted by a patient who has " some- 
 thing the matter with her breast" is practically the exi.stence or non-existence of a tumor 
 — /. €., is there a new growth developed behind and in connection with the mammary gland 
 or is the di-sease from which the patient is suffering situated in the substance of the 
 glandular structure itself? This first and most important question ought to be solved 
 before a further step can with safety be taken, before the formation of a correct diagnosis 
 of the case can be made ; and it is quite impossible to magnify its importance. To do this, 
 however, considerable care is necessary, and some manipulative skill must be called into 
 requisition, as a careless examination will surely end in an uncertain diagnosis, and with 
 this a failure in treatment. In examining a breast, therefore, with diagnostic intentions 
 the surgeon, with the whole gland well in view, should place the palmar surfaces of his 
 fingers over the suspected .spot, and, taking the gland in his hand, manipulate it gently 
 
Tl'MOllS OF THE nUh'Asr. 
 
 7(11) 
 
 ami ill I'Vi-ry part with his Hiiirt'rs ami thuiiih. wlit-ii, if an isolated tumor ran Ik; foiinii, 
 lu: will in all prohahility di-trct its presence. If, however, he is uneertain upon this 
 point, he should make the j)atient lie down : lor • if a patient he sittiiifz; or stamlinj; and 
 the hreast is f^rasped l)y the finger and thumh, when induration of the jrland itself exists 
 a sensation is felt as if a tumor were present. If now the palmar surface of the linjrers 
 be pressed flatly a<;ainst the ehest in the same part, nothini; remarkahle will he distinguish- 
 able. If 11 tutnor or new growth exists, however, it is immediately jtereeptihle. lint if a 
 doubt arise in the matter, the patient should reeline when under exan)itiation, and then, 
 if there be a tumor, it is immediately manifest to the touch, and often to the eye (liir- 
 krtt). Having, then, detected the presence of a tumor — that is, an independent growth 
 developed in the neighborhood of the breast gland, and jirobably in connection with it — 
 the (|uestion arises as to its nature. Is it a simple or a malignant tumor? If the tumor 
 be movable ami bard, if (|uite free, or if it has liut a very uncertain connection with the 
 gland structure, there is a strong probal)ility that the tumor is of a simple nature; and 
 if it has existed for several months, this jtmliability becomes stronger, for the anwrnm 
 tumor has a tendency, even when primarily developed as a tuber or as an independent 
 structure, to as.sociate itself and become connected with the neighboring tissues by an 
 intiltrating process ; and if this has not taken place, the absence of these conditions 
 enhances the probability of the simple nature of the growth under examination. If the 
 patient is also young and healthy and no other abnormal conditions of either the brea.st 
 or the neighboring structures are to be detected, the probability becomes a certainty, and 
 the presence of an •• adenocele " may be determined on, this tumor being synonymous 
 with the chronic mammary tumor of Sir A. Cooper, the mammary glandular tumor of 
 Paget, the sero-cystic sarcoma of Brodie. the adenoma of Birkett. or the fibroma of 
 Gross. 
 
 These adenoceJe.'^ are found as a rule in the young and unmarried and in the apparently 
 healthy and robust, although occasionally they occur in the aged. They appear during 
 the period when the procreative organs, 
 and among them the mammary glands, 
 are in a state of " developmental per- 
 fection ;" and when they occur in mar- 
 ried women are most frequently de- 
 veloped during pregnancy or suck- 
 ling. They are never associated with 
 any other symptoms than such as can 
 be produced mechanically by their 
 presence, and never involve the integu- 
 ment except by distension, nor is the 
 skin ever infiltrated by any new ma- 
 terial. They are never accompanied 
 by any secondary enlargement of the 
 
 absorbent glands or associated with a .Succulent and Fibrous Mammary (ilaudular Tumor and Cysta 
 
 1 1 "f +1 n aa of ^ix Ycars' (irowth. (Taken from .S. A. P , a single woman 
 
 any SeCOnaary deposits; tney cause jgt 26. The drawing exhibits a section of the "new growth and a 
 no cachexia and do not undermine the pleceof mammary gland. The growth is enveloped by a fibrous 
 , , , , ~ , . ,1 capsule continuous with the suspensory ligaments ol the breast, 
 
 health, but aiiect the patient .solely Prep. 22925, Drawing 41U60, Guy's Museum. J. Birkett.) 
 
 through local influences, and demand 
 
 treatment chiefly from local considerations. They may be found in either breast, occa- 
 sionally in both,^ and are constantly multiple, two or more tumors being often found in 
 the same gland. In Fig. 440 the way the growth attacks the gland as an encapsuled 
 tumor is well illustrated. 
 
 From my notes of 81 cases consecutively observed — 
 
 Fig. 440. 
 
 iiya/iicnts 
 of 6t-ect.tt. 
 
 'I'l appeared under the age of 20. 
 28 between 21 and 30 years of age. 
 18 " 31 " 40" 
 11 " 41 " 50 " 
 
 2 above the age of 50. 
 37 were in suigle women. 
 31 in the married and prolific. 
 12 " " " sterile. 
 
 As long as these tumors remain small and quiescent they are of little importance, and, 
 being movable, are readily diagnosed ; but when j'ears have been allowed to elapse and 
 their growth has increased, and from their greater size they have become burdensome 
 and press on neighboring structures, they are neither of small importance nor readily 
 to be distinguished. But yet, if careful observations are taken, an error in diagnosis 
 should not be made : for. althouirh the breast itself may be much pressed on, or even 
 
 49 
 
770 
 
 DISEASES AND TUMORS OF THE BREAST. 
 
 expanded over, the tumor, it will still exist, and on careful examination its presence, as 
 a rule, will be made out. The nipple, although flattened from the extreme glandular 
 expansion-can still be seen (Fig. 442) and is rarely retracted. The integuments may be 
 stretched to an extreme point, yet they will still be movable and sound (Fig. 441), 
 
 Fig. 441. 
 
 Fig. 442. 
 
 ni^Jde 
 
 Cystic .Adenocele. 
 
 Solid very Lobulated Adenocele of Six Years' Growth. 
 -Taken from .\. S , set. 35.) 
 
 although some inflammation from overdistension may have made its appearance, and 
 large veins are always to be observed meandering in the healthy tissue. The tumor, if 
 solid, may appear lobulated (Fig. 442) ; and if containing cysts, fluctuation may be 
 detected. Still the disease is essentially a local one and aff"ects the patient through 
 purely local conditions. It is to be treated only by excision, and the gland, as a rule, 
 should be left unharmed, the tumor being turned out of its capsule. In extreme exam- 
 ples, however, the breast is so stretched out as to be useless, and then must be removed. 
 In the patient from which Fig. 442 was taken this was the case. She was a woman aet. 
 35, and the tumor was of six years' growth. 
 
 Diagnosis of a Tumor evidently caused by some Partial or Gen- 
 eral Enlargement or Infiltration of the Mammary Gland. 
 
 Let us suppose that the surgeon has a case of disease of the breast before him in 
 which the structure of the gland is itself involved, and there is no independent movable 
 
 tumor such as we have been considering, but in which on 
 manipulation it is evident the growth, whatever it may be, 
 is intimately connected with the gland structure. 
 
 What is the case? Have we an inflammatory affection 
 only of the organ, or some hypertrophy or innocent enlarge- 
 ment? Is it a simple or a malignant disease? When the 
 manipular indications of the mammary gland are tho.se only 
 of enlargement, is such a condition due to pregnancy or the 
 product of a simple hypertrophy, confining the meaning of 
 that term to an excess of growth ? 
 
 If the increase he (hie to hypertrophy — which is a some- 
 what rare condition — it will have been to a certainty of a 
 chronic nature, its increase slow and growth painless. The 
 gland will appear simply enlarged, with no increase in action 
 beyond that which growth demands, although this increase 
 in growth may be very great. It is found mostly in young 
 women, but I have seen it in the male ; at times it afi'ects 
 only one gland. In the case from which Fig. 443 was taken 
 each gland on removal weighed about fourteen pounds. I 
 saw the case some years ago with my friend Mr. Shipman 
 of Grantham. The breasts were subsequently removed by Sir W. Fergusson. 
 
 Hyperli 
 
CAL'ri.yn.MA nr Tin: j!i:i:.\s'i: on casceii. 771 
 
 That tlie a fleet ii 111 is suiiielliiii;; iimre tliaii a mere iiiereuse iit the irrowth of the plaiid 
 is priiveil hy the t'ael thai in a reiiiah' patient ol' mine ;ut. l."> whd had this disease, (d" 
 thirtecMi years' jrrowth. in her rij:;ht hreast, and imi in hn- hit. and had a eliihl, no 
 milk was seereted in tlie diseased j^laiid, while in the sctiind one there was uhiinduiice. 
 
 //' thr enhinjiiiii lit In dnv to prvijiuiiu-jf, there can he little ditlieulty in the diaj^noKis ; 
 for it is attended with an aetivity 'd' the ioeal eireuhitioii, a fjeneral f'nhiess of" the •rhuid, 
 an enlartremeiit <d' its veins, ami a darkenin;,' of the areola whieh will not fail to excite 
 suspicion. Besides this, hotli ijlniuh will he similarly affected — a crdncidence which is 
 rarelv sei'n in any morhid condition. The very suspicion of preirnancy, however, will he 
 eiioui^h to call attention toother points hy which a s(»lution of tlie difficulty can he ohtaiiurd. 
 
 U tin: I iiliiriiciiniit to hr r.ifilniiiril htj <ini/ iiifhniuniitori/ i-oiulitioii ? I do not mean an 
 acute inflammatory conditioji — for such an aflecti<tn has featun^s which are tot) character- 
 istic to allow any mistake in tliatrnosis lieintr made — hut is the infiltration of the f^land to 
 be explained hy some chronic inflamujatory chanj^e such as is so fre<(uently found in the 
 female hreast. or is it the early stauc of an infiltrating; cancer? The answer to this (|uery 
 is not always easy. In middle-atred patients, when cancerous affections may he looked 
 for, the presence of an indurated mammary gland, wholly or in part, must always be 
 regarded with suspicion ; and if the case be recent, I believe it to be an impossibility to 
 form any certain opinion as to its true nature. If the induration of the gland be the 
 only symptom and is associated with a sharp, or even a dull, pain, either a simple chronic 
 inflammation of the gland may be indicated or the early condition of a cancer. If, how- 
 ever, much time has already passed — say many months — and no other symptoms have 
 made their ai)]tearance. there is .some ground for tho hope that the enlargement may be 
 due to inflammation, since infiltrating cancers are not generally inactive — are not station- 
 ary, as a rule — and soon give rise to other symptoms, such as some, though it may be 
 slight, enlargement of the absorbent glands, some slight dimpling or puckering of the 
 skin — an important sign — or some more marked symptom, such as infiltration of the 
 intei:;ument or a retracted nipple. It should be remembered, however, that a retracted 
 nipple is only an accidental symptom such as may be caused by several co/iditions, and 
 is not by any means of itself characteristic of cancer. But if any or all of the.se symp- 
 toms show themselves soon after the first appearance of the lobular enlargement of the 
 mammary gland, an opinion as to the cancerous nature of the growth may be confidently 
 expres.sed. If, on the other hand, none of these symptoms make their appearance and 
 the induration or infiltration of the lobes of the gland remains stationary or shows some 
 tendency toward improvement, the probability of the .simple character of the disease 
 gains ground. When this induration of the mammary gland appears in 2l young siihject, 
 there will be no reason to suspect a cancer, and it should rather be regarded as the result 
 of some slight inflammatory effusirm. Under such circumstances there will generally be 
 some increase of pain after examination, but an absence of any other local .symptom. 
 There will probably be some irregularity of the catamenia and some signs of general 
 excitability of the patient. But, as a local affection, there will be only the one .symptom 
 of .induration of one or more lobes of the mammary gland, which, in the absence of nil 
 o'her Ki'ffns. may with safety be regarded as inflammatory. The same argument holds 
 good when the di.sease appears at a later period of life, although su.spicions of a cancer 
 should rightly be excited ; still, the positive diagnosis must be postponed till by the lapse 
 of time some other .symptoms, such as those already mentioned, make their appearance 
 to clear up all doubt, or by their absence prove the innocent nature of the affection. 
 
 Carcinoma of the Breast, or Cancer. 
 
 This affection is found either as an hijiltrttfion of the gland, wholly or in part (Fig. 
 444), or as an independent tumor or tuber within the meshes of the gland — tuberous 
 cancer (Fig. 445). It may likewise be met with associated with cysts — ci/stic cancer — 
 this being only a variety of the other forms. 
 
 In the infiltrating form the gland appears hard, inelastic, and incompressible ; as the 
 disease progresses it seems to contract and to draw all the parts around together, and 
 gradually to infiltrate them. In this way the nipple often becomes drawn in or to one 
 side. At times, after having been drawn in, it becomes infiltrated with the di.sease and 
 becomes again prominent ; at others, by the contraction of the gland, it may be strangu- 
 lated, become oedematous, and then slough ofl'. The skin is at first dimpled, then puck- 
 ered, and at last infiltrated. The breast also, from being a movable organ, becomes fixed 
 — so fixed, indeed, that it cannot be separated from the pectoral muscle. 
 
772 
 
 DISEASES AND TUMORS OF THE BREAST. 
 
 This form of cancer is the more common. The disease may appear in one lobe or in 
 all and be slow in its progress or rapid, but in all cases its progress is much alike. 
 
 Fig. 444. 
 
 Fig. 445. 
 
 Infiltrating Cancer of the Breast. 
 (Drawing 409i*, 'luy's Mus., Birkett's case.) 
 
 Tuberous cancer commences as a circumscribed independent growth within the 
 gland structure, with a well-defined capsule separating but not infiltrating the tissues 
 (Fig. 445). Sometimes two or more tubers appear together, and these may at la.st coalesce. 
 This form, unlike the infiltrating, does not contract, but grows in all directions, involving 
 all the parts which it touches, pushing the brea.st to one side, or drawing it to itself. It 
 often attains a large size, giving rise to an irregular lobulated tumor. It is at times 
 soft in consi.stence, when it is called medtdhiry cancer ; when firm, it is known ^% fihrous ; 
 when jelly-like, rjdatlnlform ; and more rarely it is black, or mehinotic. As it grows for- 
 ward it may involve the skin, break, and ulcerate, giving rise to the appearances formerly 
 called /ioir/«s hsematoiles, this form Vjeing always accompanied with hemorrhage. 
 
 In both forms the lymphatic glands in the axilla, above the clavicle, or on the side of 
 the neck will .sooner or later become involved : and when the skin is implicated, this 
 symptom soon appears. As the glands enlarge nerve pains down the arm appear and 
 oedema of the arm commences, from the mechanical obstruction to the venous circulation of 
 the extremity caused by the enlarged glands. At times a serous effusion takes place into 
 the pleural cavity of the affected side suflficient to destroy life. 
 
 In some rare cases of cancer the disease appears as a hrawvy infiltration of the breast 
 and integument over it, some erythematous redness and cedema being mixed with it at its 
 onset. The.se cancers are of the wor.st kind and speedily destroy life. 
 
 In other cases, mostly chronic, the disease is more cutaneous and shows itself as a 
 tubercular affection of the skin, which gradually spreads till at last the part affected 
 seems skin-bound. This condition ma}- be limited or extensive and occasionally involves 
 the whole of one side. I have recently had a case under observation in which both 
 brea.sts, the sternum, sides, and half the dorsal region of the back were thus involved. 
 At times this tubercular development is associated with acute or recurrent disease. ■ In 
 rare examples it occurs as a primary affection and is very chronic, the tubercles even dis- 
 appearing by atrophy. 
 
 A cancerovs tumor of the breast most frecjuently appears in middle life — that is, when 
 the procreative organs are verging toward their natural period of functional decline, such 
 a period taking place at an earlier date in the .single than in the fruitful woman. It 
 attacks married women more frequently than the unmarried, and when infiltrating or 
 involving the breast gland is seldom stationary. 
 
 As the disea.se progresses unchecked ulceration of the integument, preceded by a 
 softening down or breaking up of the tumor itself, will soon appear, and with this the 
 characteristic infiltration of the margin of the wound will occur and give rise to indura- 
 ted, everted edges (Fig. 449). A general cachexia, from the pain and wasting discharges, 
 will soon .show itself, and more or less distinct evidences of the complication of other 
 organs, become apparent. Under such circumstances the end is not far off. for the dis- 
 ease has run its course, and with it the powers of its victim have become undermined ; 
 for the victory remains with the strongest. In a general way, a cancer runs its course in 
 two or three years, though sometimes it is most chronic in its action. 
 
 To illustrate some of the points connected with this subject, the following analysis of 
 400 cases may be of value. The cases are taken from my own notes: 180 occurred in 
 Guy's during the period of ixiy registrarship, many years ago, and 220 are from my own 
 case-book .since. 
 
CYSTIC rcMoii OF Tin: i:i:i:.\ST. 773 
 
 The (/ist'dsc iiindi ifs /irsf iijiiirdinin i- — 
 
 111 17 liLsi's, or A pLT ((.'Mt., undtT .U) yciirs of iif^e. 
 " lOS " 27 " lii'lwft'ii ;{1 iiiid 10 vi'iirs of miv. 
 
 " H4 " ;i(i '• " -n " r,() ■ 
 
 '• KH " 'jf) " " r,i " IK) 
 
 " -J'J " 7 " " (il " 70 
 
 " 1 over 70 vrars of a;;o. 
 
 1 havi', however, seen a case ol' eaiiciT of the hreast in a patient Ufred 2H. and one of 
 i\ year's standintr in tlie hreast of an tthl hnly ;i't. !Mi. 
 
 C)f these K)() eases, Sl.'J were married, 77 single, and 1(» were widows. 
 
 Of till' !>1."> married, 2!5") wurv prolific and 7'S sterile. A hir<:(! proportion of the pro- 
 lific women were so to an extreme deirree. ten and more chihlren heiiij^ a common note to 
 find recorded. Married women and those in whom the ghiiid has been the most active 
 are apparently more liable to cancer of the breast when the jieriod of trhiml activity has 
 passed than the single. 
 
 (.)f these oxami>les, ]!t4 were in the ri<rht breast, 1(S7 in the left, and lit in botli. In 
 140 the di.sease had e.xisted a year or less; 
 
 111 \>[) lielween 1 and 2 years. I In 13 between 4 and 5 vears. 
 " 2;J " 2 " 3 " "9 " o " 7 ■ " 
 
 " 15 " 3 " 4 " I " 6 " 8 " 9 " 
 
 In 4 cases the disease had existed ten, twelve, fourteen, and twenty years respectively, 
 and the form of cancer in these of long standing was the atrophic. 
 
 With respect to any hcnditary hisforj/ of cancer in the 400 cases, although carefully 
 inquired into, I found it to exist in only 47, or nearly twelve i)er cent. In 35 of these 
 cancer was reported to have occurred in one member, in 11 in two members, and in 1 in 
 three, of the patient's family. 
 
 In 7 of the 47 cases the relative was on the father's side, in 23 on the mother's, and 
 in 7 it was found among the brothers or sisters. In 5 it had attacked the aunts, in 3 
 cousins, and in 1 a grandmother, although in these the point was not stated respecting 
 the paternal or maternal relation. These facts are enough to indicate that where an 
 hereditary tendency exists it is more powerful on the mother's than the father's side. 
 
 In a large proportion of the cases in which an hereditary history of cancer was traced 
 the cancer was of the breast. 
 
 A section of an infiltrating cancer is well slmwn in Fig. 444; a section of the tuberous 
 form in Fiu. 44."i. For the microscopical appearances of cancer, vide Fig. 45. 
 
 Colloid or alveolar cancer is occasionally seen in the mamma, although in a 
 clinical point of view the growth presents no such features as to enable the surireon to 
 recognize its presence. In Fig. 86, page 138, a cancer of the kind is illustnated. In it 
 the clinical features of the affection were those of the cystic disease. It is found in the 
 gland as an infiltrating and tuberous growth. 
 
 To the eye the colloid disease has a peculiar aspect, its jelly-like, semi-transparent 
 material, of all tints of pink and red, from degrees of blood-.staining, being divided by 
 thin meshes of fibre tissue into cells of different sizes. The way the jelly-like structure 
 oozes from its cells and the slight changes that take place in it after immersion in spirit 
 are its chief characteristics. 
 
 It ought to be treated by excision of the whole gland. 
 
 Cystic Tumor of the Breast. 
 
 The simple Sero-Cyst is usually found single in the mammary gland, and appears 
 as a small hard lump in one spot, which is at times, but not often, ]iainful. As it increases 
 it becomes more globular and dense, sometimes being of a stony hardness, wdiile at a still 
 later date it may afford the sensation of fluctuation. If left alone, it may so enlarge as 
 to come forward, and even burst, discharging a thin watery Ho»-albuminous fluid and then 
 collapsing. In rare cases the di.sease is thus cured, but more commonly the fluid 
 reaccumulatcs. 
 
 " The cyst wall of this tumor," writes Birkett, •• is very thin, composed of fibre tissue 
 firmly attached to the surrounding parts and lined with squamous epithelium. It is 
 always perfectly closed, and never communicates with a duct." 
 
 Trf.at.ment. — Such cysts should be punctured with a trocar and canula and some 
 cold lotion applied, for by this means many are permanently cured. Brodie employed 
 
774 
 
 DISEASES AND TUMORS OF THE BREAST. 
 
 Fig. 446. 
 
 alone, without puncture, a lotion made up of an ounce of the solution of the subacetate 
 of lead and thi'ee ounces and a half of both spirits of wine and camphor, which was to 
 be applied on a piece of folded flannel and renewed every three or four hours until the 
 skin over the tumor had become inflamed, the application to be reapplied after the lapse 
 of two or three days. 
 
 Spurious Cyst. — Besides the simple serous cyst, many examples of tumors of the 
 breast come under the observation of the surgeon the diagnosis of which is much obscured 
 by the presence of cysts — or, rather, of what Mr. Birkett describes as capsules — contain- 
 ing fluid of divers characters ; for the development of a cyst in the n)ajority of tumors 
 is a mere accident due to the eff'usion of fluid, probably serum, more or less blood-stained, 
 into the connective tissue of the part, the fluid separating the solid growth, and so forin- 
 ing an apparent cyst. Such a cyst, however, is' not a new development, like the more 
 solid portion of a tumor, nor is it in any way to be compared with the simple cystic for- 
 mations which are found in the neck or other portions of the body. The existence of the 
 false cysts, therefore, such as I have briefly sketched, in any of the breast tumors, 
 whether adenoid or malignant, is to be regarded as a mere accident, and ought to have no 
 weight in determining either the innocency or the malignancy of the growth under exam- 
 ination ; they are the product of a mechanical cause, may occur in either form, and are 
 not special growths or of any intrinsic importance. The diagnosis of the tumor contain- 
 ing such cysts rests, consequently, on other points, and more particularly on such as have 
 been already indicated. As a rule, these so-called cysts are found in the less firm and 
 
 solid forms of tumor, in such as contain less cellular or 
 connective tissue, and in the more rapidly developed 
 rather than in the slowly formed. We thus find in 
 one form of cystic adenoma a more or less solid tu- 
 mor, the growth being more lobulated and loosely con- 
 nected where the false cysts or capsules exist. In a 
 second class of cases loose pedunculated growths will 
 , r-..^j^' ■^^:i=^Jim» yw H M ^^ >^een lying within these capsules, with their float- 
 i lliflR ^"^"^ '^^1 f '\ ^"S extremities bathed with the so-called cyst contents 
 llll"il!'"^" ^ ffl _, i (Fig. 44(j), the different forms assumed by these 
 
 tumors depending upon the amount of connective 
 tis.sue which binds together the several lobes and 
 lobules, and the dimensions of the interspaces which 
 go to form the false cysts. In a third class, however, 
 the true cystic ndenoc.ele of the breast, the adenoid 
 Cystic Tuinoi ii. i,i,..M, uiih r.duiiciiiatea solid elements are developed within cysts composed 
 
 Adeuomatous (irowth ot One Yeai'.s Exi.s- p i.i . i i , t> ^ • ii i ^i. vi •„ r i „ 
 
 tence. (Removed bv T. Bryant from s. of dilated ducts. But in all, whether Within false 
 W-— , set. 43, in 1876 Three years later ^ .g^ ^j. j„ dilated ducts. the elementary structure of 
 
 patient was quite well.) ,•' , . - i i i i j 
 
 the growths is either dense and compact or loose and 
 
 pedunculated ; in all they simulate the structure of normal gland tis.sue. In some the 
 
 caecal terminations of the ducts are the most prominent, and in others the ducts and 
 
 sinuses, while in a few true milk or cream secretion exists, precisely similar to that 
 
 secreted by the breast. In all- probability, all adenomata are developed in cysts as intra- 
 
 cystic growths. Dr. Goodhart has supported this view in an able paper (Edin. Med. 
 
 Joiirn.^ 1872). 
 
 DiA(JNOSls OF True Cystic Adenocele. — This true cystic adenocele. however, is of 
 an innocent nature and pathologically allied to the genuine adenocele. It is the tumor 
 originally described by Sir B. Brodie as " arising by a dilatation of portions of some of 
 the lactiferous tubes," and by Mr. Birkett as duct cysts, distinctly referable to the dila- 
 tation of a duct or to a connection with one, and containing growths which appear to 
 spring from their walls ; and these two forms of cystic adenocele are strictly analogous 
 in their nature. In both the pedunculated or floating bodies possess a structure allied to 
 the breast gland, and are composed of more or less distinct caecal terminations of newly- 
 developed ducts, with variable quantities of true connective tissue. This affection is 
 more common in middle than in young life. Out of 12 ca.ses, G occurred in women under 
 thirty, 17 in women over forty, while 1 was as old as seventy-one (Path. Trans., vol. xvii. 
 p. 283). 
 
 Diagnosis of Cystic Adenoma. — How, then, is such a tumor to be made out? and 
 what are the special symptoms which characterize it from the other forms of mammary 
 tumor ? 
 
 First of all, being an innocent tumor, it will be found to aff"cct the patient in a purely 
 
s.mrnMATurs Ti'Muns or Tin-: i-.ueast. 
 
 i (O 
 
 Idoal niamicr. as do all otlii-r aik-ridul tiiiiinr.s. It is a local disease which at no period of 
 its growth and in no way will afl'cct the patient otherwise than throu^'h local causes. It 
 is never associatetl with secondary ^'laiidiilar etdarfreinents or with deposits in other tis- 
 sues, as the cancerous tumor, and it can, therefore, he by local syniptouis only that a cor- 
 rect diagnosis is to he luaile. 
 
 Tiu' tumor, heinjr a ijinit'inr tj/slic t/isxtsf, is always made uj) of cysts filled with intra 
 cystic growths in different degrees, and if us also u i/israse of /fit- (jlnnd ifs>//\ the cysts 
 having a distinct relation with the gland ducts. The cysts, having, therefore, in the 
 majority of cases, if not in all. some connuunication through the nipple with the external 
 surface' can he partially emptied of their contents by pressure through the nipple of the 
 affected organ. As a result, this discharge from the nipple must always materially tend 
 to confirm the impressions which may have been formed hy the careful ob.servation 
 of the case, and hy the presence of tho.se conditions to which attention has ju.st been 
 drawn. 
 
 Sr.MM.VKY. — Consequently, a n/sfir f>inii>r of the viitninKtri/ ijhinil in a healthy woman, 
 unattended by any other than local symptoms and as.sociated with the di.scharge of a clear 
 or coK>red viscid secretion from the nipi»le. which can be induced or materially increa.sed 
 by pressure, may with considerable confitlence be set down as the trui- ri/stlr mhuocde of 
 the breast. The I'alse adenoceles or other tumors, which have but little if any connection 
 with the true gland tissue, are new growths jjartaking of the nature of the breast gland, 
 according to the universal pathological law that all- new growths partake of the nature 
 and peculiarities of the structure in which they are developed. In Fig. 441 the external 
 appearances of one of the.se cystic adenoceles are well seen. 
 
 Fig. 447. 
 
 Galactocele. 
 
 This is a milk tumor found in the breast during lactation, the result of some retention 
 of milk in an obstructed or ruptured duct, the secretion being either fluid milk-like or 
 
 more solid and creamy, owing to the absorption of 
 the more fluid elements. Preps. 2290^, 2290^, and 
 2299*", Guy's Museum, illustrate these points. It 
 usually occurs somewhat suddenly during suckling, 
 and is indicated by a painless fluctuating swelling, 
 unaccompanied by any constitutional disturbance. 
 These cysts at times attain a large size. Scarpa has 
 recorded a case in which two pints of milk were re- 
 moved from the tumor. It .should be treated by an 
 incision into the cyst, leaving the walls of the cavity 
 to granulate. 
 
 X 
 
 ■ Cystic Cancer. 
 
 The pathology of cystic cancer is identical with 
 
 that of cv.stic adenoma, while the cysts in the one 
 
 instance contain the more or less solid characteristic 
 
 Cystic Carcinoma of Breast of Nine Months' lobules of the adenoid growth, and in the other are 
 
 oyThre.Jt^SvS axil- AHed with the less developed and more irregular, but 
 
 lary glands eniargfd. Three months after eouallv characteristic, material which goes to build 
 
 operation there was a large axillarv growth • » ,„. . >p,, ,. 
 
 and <rdema of arm. Mr. Birketts case. Up the CancerOUS tumor (rig. 44i). Ihe diagnosis 
 
 Drawing 40S12.) of these caucers rests, therefore, upon .such points as 
 
 have been alreadv described under a former headintr. 
 
 Sarcomatous Tumors of the Breast. 
 
 Sarcomatous tumors of the breast are met with in women of middle age. and they are 
 generally more succulent and less solid than the adenomata and more rapid in their 
 growth, while they have also a greater tendency to return after removal. They are 
 more closely connected with the breast than the adenomata, and are always encapsuled 
 (Fig. 448) ; they do not infiltrate the breast like the cancers. They run their course, 
 moreover, more rapidly than the former, and have a tendency to break down and give 
 rise to a bleeding mass of tissue which may be mistaken for a cancer. They are also 
 local, and are rarely associated with any secondary glandular enlargement. They should 
 
776 
 
 DISEASES AND TUMORS OF THE BREAST. 
 
 Fig. 448. 
 
 be dealt with as adenomata and removed, and the brea.st, as a rule, .should be removed 
 with them. I have the records of many interesting examples of this form of tumor, 
 and in the Fatli. Trans, for 1868, vol. xix., I recorded the case of a woman aet. 35 from 
 
 whom I removed a tumor weighing nearly five 
 pounds. The patient from whom Fig. 448 was 
 taken was thirty-three years of age, and in 
 her no return took place after operation — a 
 result which is not constant, since in a large 
 number of these cases the disease returns lo- 
 cally and acts in that point as badly as any 
 cancer. I have a patient now under care 
 from whose breast I have removed five tu- 
 mors at different intervals. When a return 
 takes place, the tumor should be excised at 
 once if the measure be practicable. 
 
 Hydatid cysts are found in the breasts, 
 but are not common. Only one example has 
 fallen into my hands, although I have seen 
 
 Sarcomatous Tumor of Nine Months' (Growth. (Removed fivp nthprs in thp Tirnr>(-ipp nf niv r-nllpflo-iips; 
 
 from M. T , at. 33, by T. Bryant in 1877. Good ^J*^ otners 111 ine practice 01 my coiicagues. 
 
 recovery.) My own patient was a woman aet. 30 who for 
 
 five years had had a jvnnless glohular swell- 
 ing in her left breast ; and when I saw her, it was as large as a cocoanut. I tapped the 
 cyst and evacuated sixteen ounces of a clear non-albuminous fluid, and, as it was evidently 
 the fluid of a hydatid, I made a free incision into the tumor and turned out a large acepha- 
 locyst. The patient made a good recovery. 
 
 NSBVUS, involving the whole mammary gland, may be met with. I have had under 
 my care a splendid example in a girl six years old in which the whole organ was like a 
 sponge and as large as half an orange. 
 
 Open, Ulcerating, and Discharging Tumor of the Breast. — In the 
 
 growth of any tumor situated in the mammary gland or its neighborhood there must be 
 a period when the integuments will become so involved as to ulcerate or give way, and 
 under these circumstances a discharging surface or cavity will present itself varying in 
 its aspect according to the innocency or malignancy of the growth with which it is asso- 
 ciated. If the tumor is cancerous, the open surface or discharging orifice will suggest its 
 nature, and the integument itself or the margins of the wound will be infiltrated with 
 cancerous material, the latter presenting the thickened, indurated, and everted margin so 
 characteristic of the cancerous ulcer, and which, when once seen and appreciated, can 
 hardly be mistaken (Fig. 449). But if the tumor be innocent, a very diff'erent condition 
 
 will present itself, for a clear understanding of which 
 it is essential to recall one or two points of difference 
 between the innocent and malignant tumors, although 
 attention may previousl}^ have been drawn to them in 
 former pages. It is the peculiar nature of the innocent 
 tumor to aff"ect the part in which it is developed simply 
 in a mechanical way ; it may separate or displace, but 
 never infiltrates, tissues. On the other hand, it is the 
 peculiar nature of the cancerous or malignant to infil- 
 trate and involve every tissue with which it comes in 
 contact. Applying, therefore, these two opposite fea- 
 tures of the innocent and malignant tumors to the class 
 of cases now under consideration, we shall readily un- 
 derstand how two very different local appearances may 
 be produced, and how in the cystic cancerous disease 
 the wound or surface will be characterized by all the 
 Open Caucer^of Breast ^w.u^^ peculiarities of the cancerous ulcer, and in the cystic 
 
 innocent tumor which may have ruptured from over- 
 distension the margin of the wound or discharging cavity will look healthy, free from all 
 appearance of infiltration, and as if mechanically cut or punched out rather than ulcer- 
 ated. In the ci/stic mhnoceles, in which it is not uncommon to find a sprouting and dis- 
 charging intracystic growth protruding from a wound through the ruptured integument, 
 and presenting a very doubtful, and sometimes cancerous, aspect, the importance of this 
 fcsymptom cannot be overrated; for if found projecting through an orifice of the integu- 
 
 Fig. 449. 
 
CJinosii DisicAsE or Tin: mammmly mieola. 777 
 
 liUMit wliifh is iitiinfiltratcd uimI ii|i|»an'iitly lu-altliy. such as wc liave alri-;i(ly (lescriljed, the 
 iniKici'iit iiatiiro ni" the tuiiior may with smiic iMiiitidnice hi' (h-rlariMl. 
 
 Value of the Retracted Nipple as a Symptom in Tumors of the 
 
 Breast. 
 
 There ran he litth- ihmlit that as a positive iiidieatitdi of cancenHis disease the iiiiport- 
 anee of a retracted iiipph' has heeii coiisiderahly overrated. Tlie syiu{»toin may be com- 
 mon ill intiltratiiijr cancer (d" the breast, but such a disease may exist without it; it may 
 be present, moreover, in simple non-cancerous afl'eetions. A retracted nipple may be 
 rep;arded as an accidental sYn)|)tom in the development of a tumor, as well as the product 
 of mechanical causes, its presence beiiifj; determined rather by the manner in wliich the 
 gland is involved than by the nature of the disease. If any tumor, simple or malignant 
 — any abscess, chronic or acuti — attack the centre of the mammary gland, a retracted 
 nipple will in all proliability be produced; for a di.sease so place<l necessarily cau.se.s sepa- 
 ration of the gland ducts, and, as a consei|uence, their extremities, terminating in the 
 nipple, will be drawn upon, and a retracted nipple must f(dlow. We thus tind this symp- 
 t<»m of freijucnt occurrence in the early stage of an iiitiltrating cancer of the organ, the 
 nipjde being always drawn toward the side of the gland wliich may be involved, while at 
 a later stage, when the infiltration is more complete, the nipple may again project. In a 
 central chronic abscess of the breast the retracted nipple is e<|ually common, and in the 
 true cystic adenocele it may be also present. In the ordinary adenocele, whether cystic 
 or otherwise, it is rarely met with, for the reason that this disease is not of the breast 
 gland itself, but only situated in its neighborhood. In rare ca.ses, however, such an asso- 
 ciation may coexist, and in one case in which I observed it some blow or injury had pre- 
 ceded the development of the adenoid tumor, and it was open to a doubt whether the 
 retracted nipple had not been brought about by a chronic inflammatory condition. It 
 should always be remembered, moreover, that a contracted nipple may be a natural con- 
 dition. 
 
 Value of a Discharge from the Nipple for Diaonostic Purposes. 
 
 When the discharge is slight or of a bloody nature, it does not indicate an}' special 
 affection, though it is well known that in cancerous affections a discharge from the nipple 
 is not unfrequent, the fluid having the appearance of blood-colored serum which is never 
 profuse and rarely amounts to more than a few drops. In the true cystic adenoceles this 
 symptom is of considerable value, for in all the eases which have passed under my obser- 
 vation, as well as in the majority of rec(jrded examples, this discharge from the nipple 
 was a prominent symptom, the fluid being generally of a mucoid nature and more or less 
 blood-stained ; and. although at times it occurred spontaneously and with relief to the 
 patient, at others it could readily be induced by some slight pressure upon the parts. In 
 the ontinnry adeaocde^ this symptom is seldom present. It exists, therefore, as a symp- 
 tom in the true disease of the breast structure, whether cancerous or adenoid, and. while 
 slight and uncertain in the former, it is more general and copious in the latter ; conse- 
 quently, as a means of diagnosis it is of some value. 
 
 Chronic Disease of the Mammary Areola preceding Cancer 
 
 (Paget's Disease). 
 
 Sir J. Paget has pointed out (.SV. Bo rtholomeic s Hasp. Rep., vol. x.. 1874) what my 
 own experience confirms — that cancer of the breast is sometimes preceded by a chronic 
 skin disease of the nipple and areola, the disease in the majority of the fifteen cases in which 
 he had observed it having •• the appearance of a florid, intensely red. raw surface, very 
 finely granular, as if nearly the whole thickness of the epidermis were removed, like the 
 surface of very acute diffused eczema or like that of an acute balanitis. From such a 
 surface there was always copious, clear, yellowish, viscid exudation."' In some cases the 
 eruption has presented the characters of an ordinary chronic eczema or psoriasis, the 
 eruption spreading beyond the areola in widening circles or with scattered blotches of 
 redness covering nearly the whole breast. 
 
 " The eruption has resisted all treatment, both local and general, and has continued 
 even after the affected part of the skin has been involved in the cancerous disease." 
 
 Mr. Henry Butlin has shown that these changes are due to an extension of the disease 
 from the surface of the nipple to the smaller ducts and acini of the gland, these parts 
 
778 DISEASES AND TUMORS OF THE BREAST. 
 
 being found, on microscopical examination, filled with proliferating epithelium, which at 
 times escapes from the ducts by rupture or growth into the surrounding tissues, thereby 
 producing the full formation of carcinoma (Med.-Chir. Trans., January, 1877), the 
 mechanical retention of the epithelial element within the gland and ducts evidently play- 
 in,o- an important part in the progress of this disease. Whether the disease be a true 
 eczema or a specific dermatitis — a question which has to be determined — the conclusion 
 is clear that the local disease is not to be disregarded. When much epidermis collects 
 upon the nipples, " Busch's practice in cases of epithelioma ought to be followed, and 
 such should be removed by the application of a lotion of soda from three to six grains to 
 an ounce ;" and if any suspicious hardness of the base of the sore exists, it should be 
 removed. 
 
 Importance of Enlargement of the Absorbent Glands as a Diag- 
 nostic Symptom. 
 
 When some enlargement of the axillary or clavicular glands exists with a chronic 
 tumor of the breast, the malignant nature of the disease is rendered probable ; for the 
 simple adenomata are generally unattended by such a complication, and with the cystic 
 affections it is also rare. Many months, however, may elapse in cases of cancer of the 
 breast before the appearance of this symptom, because enlargement of the absorbent 
 glands and infiltration of the skin have some connection. 
 
 In cancerous affections the enlargement of the glands is indolent and very painless. 
 In the inflammatory affections of the organ glandular enlargement and tenderness are 
 commonly present. 
 
 Value of the Tubercular and General Infiltration of the Integu- 
 ment over the Breast. 
 
 When the integument of a breast is sparsely or thickly studded with shot or pea-like 
 tubercular infiltrations, or is so infiltrated with new material as to present a brawn-like 
 feel and aspect, there can be no question as to the cancerous nature of the disease, since 
 such a symptom is never present in any inflammatory or simple disease of the mariimary 
 gland. The infiltration may be slight, from the mere shot- or pea-like affection of the 
 skin, to its more brawny infiltration, but in all stages it is equally characteristic and speaks 
 in positive language of the cancerous nature of the mammary growth, one tubercle tell- 
 ing as plain a tale as if many tubercles existed. 
 
 Cachexia. 
 
 I have no belief in the existence of a special cancerous cachexia. A cachexia may 
 be present in cancer as in any exhausting or .wasting disease, but that of cancer differs in 
 no single point from that of any other aftection. When a cachexia exists, it indicates 
 the presence of some affection which is undermining the patient's strength, which may be 
 cancer, but it may be any other form of disease. 
 
 Excision of the Breast. 
 
 There is no great danger attending excision of the breast beyond that which accom- 
 panies any operation, even the smallest. It is true that patients occasionally sink after 
 the operation, from pyaemia, erysipelas, or visceral diseases, but these contingencies attend 
 any operation or wound. From my notes of 133 cases of cancer in which excision was 
 carried out I find that 9 died, or about 6.7 per cent., while in 4 only, or 3 per cent., could 
 the death be ascribed to the operation. One died from pyasmia, on the thirty-fifth day ; 
 1 from erysipelas, contracted several months after the operation, when the wound had 
 healed ; 2 "from acute bronchitis, three weeks and a month respectively after the excision ; 
 l.from profuse diarrhoea, on the eighth day, probably pyasmic ; 1 from haemoptysis, in the 
 third week ; 2 from exhaustion after a return of the growth, in three and six months ; and 
 1 from actual sinking after the operation, on the third day. The 3 cases which died from 
 pyaemia and diarrhoea which was also probably pyaemic, and the 1 which sank on the 
 third day may. perhaps with justice, be directly assigned to the operation, but the fatal 
 termination in the remaining 5 examples had no reference whatever to the excision. In 
 the operations for innocent tumors of the breast no fatal instance occurred. 
 
/•;A'r/.s7o.v or rnr. i:iii:.\sr. 
 
 Ill iiporatitit; for cancer it is niit|iicsti()iial)ly tlic wisest course to excise the whole 
 gland. It is well not to he oier-aiixions ahoiit prt'servinjr too niueh integiinient ; and if" 
 anv douht exists as to its iterl'eet healthiness, the suspected jiortion had hetter he excised. 
 When enlarireil Lrhmds exist, they should he taken away ; and in any d<»ul)tl'ul case the 
 axilla should he ••xploreil. It is always important, when dissectiiifr out the tumor, to 
 keep dear of all diseased tissues, and in i'at suhjects to leave a fair covering; between the 
 incision and the tumor itself, as there is <;ood reason to believe that an early return of 
 the aHeetion is too often to he explained by want f)f attention to these jioints. In several 
 instant-es 1 have found small cancerous noduU's in the fascia over the pectoral muscle 
 which if left would have been the centre of ntnv jirowths. In the oj)eration for (tiinioceh- 
 it is (|uite exceptional for the removal of tin; breast to l)e necessary. In the majority of 
 instances such a practice would be clearly unjustifiabh!. As a rule, the tumor is readily 
 removed by makinti' a clean section throutrh its cyst wall and enuclcatin<; the frrowth ; 
 the breast is rarely injured, even by the operati(»n. In exceptional examples of this 
 afi'ection, however — that is, where a lar<;e tumor is closely connected with the mammary 
 «?land — as well as in \\\v irenuine or true cystic adenocele, it is absolutcdy necessary tliat 
 the breast <;land should be excised. In the removal of a .small tumor not involving the 
 breast the best practice is to make the incision in a liiie radiating from the nipple and to 
 manipulate the parts as little as possible, the surest plan being to cut well into the tumor 
 after having raised and made it prominent by gra.sping its base with the thumb and finger 
 of the opposite hand. 
 
 Ol'KH.VTioN. — In the removal of a breast the patient should be placed on her back 
 with the shoulder of the affected side raised by :v pillow and tlie arm drawn out at a right 
 angle to the })ody ( Fig. 450). 
 
 The incision should be elliptical and made in a line parallel with the fibres of the 
 
 pectoral muscle ; and when the skin is 
 Fig. 450. diseased, it should be removed. The 
 
 inner or sternal incision should first be 
 made, and bleeding is to be controlled 
 by the pressure of the fingers of an 
 assistant. The second or pectoral incis- 
 ion may then follow, and should be 
 made down to the free border of the 
 ])cctoral muscle, the definite form of 
 which is the best and surest guide to 
 the base of the gland. The whole tumor 
 by these means is thus readily excised, 
 a few touches of the scalpel dissecting 
 it off the pectoral muscle. The axillary 
 angle of the tumor should be divided 
 last, as it usually contains the chief 
 vessels that supply the gland. The 
 incision can be extended upward into 
 the axilla, to explore or remove the 
 glands. When this is done, an incision 
 at right angles to the wound backward 
 is good for drainage purposes. All bleeding vessels should be twisted, the surface of the 
 wound cleaned with iodine water, its edges well adju.sted, a drainage tube introduced at 
 the most dependent part, and steady pressure applied by means of pads of lint, gauze, or 
 cotton-wool. Adenoid or innocent tumors should be excised only if they are steadily 
 increasing and are sources of trouble. Conceravs tumors should be removed as soon as 
 the diagnosis of their existence is clear ; for accumulated evidence tends to .>^how that the 
 earlier a cancer is removed, the better are the prospects of a complete or lengthened 
 immunity from the disease, and that, whether the disease returns soon or late, the best 
 chance is thus afforded to the patient. 
 
 Excision of the Breast, with Incision Backward for Drainage: 
 
780 ON OVARIAN DISEASE AND OVARIOTOMY. 
 
 CHAPTEK XXVII. 
 ON OVARIAN DISEASE AND OVARIOTOMY. 
 
 The ovaries are glands and are developed as other glands, being composed of like 
 elements. In them, during infancy and childhood, although cell growth, and even cell 
 shedding, may go on, such processes take place silently, unattended by any external 
 manifestations of their action. At puberty, however, when the ovum has matured and 
 impregnation becomes possible, external signs of these changes appear with menstruation, 
 and with these changes functional disturbances of the ovaries and parts connected with 
 them occur and may require the attention of the physician. The surgeon's aid is called 
 for only when organic ovarian disease exists, and the nature of this aid varies with the 
 nature of the case. 
 
 Ovarian Disease. — Ovarian disease is a somewhat common affection, and, although 
 mostly met with during the active period of ovarian life, it occurs in childhood and mature 
 age. Two specimens now in the College of Surgeons were taken from twin children five 
 and eight weeks respectively by Dr. Leared, and a rare preparation at Prague shows a 
 cyst in the ovary of a child a year old. Roemer of Berlin in 1884 records a case in 
 which he successfully removed a dermoid ovarian tumor from an infant twenty months 
 old {Brit. Med. Jonrn., April 12, 1884). Kidd of Dublin has operated on a child aged 
 three. Spencer Wells has recorded a succes.sful case of ovariotomy in a child aged eight. 
 Dr. Barker of Philadelphia had another in one aged six years and eight months. I have 
 recorded two cases in which girls aged respectively fifteen and sixteen sank after tapping 
 from suppuration of the cyst; and in 18G9 I published in the Guys Hospital Reports a 
 case in which I successfully removed a polycystic ovarian tumor from a child aged four- 
 teen in whom no signs of puberty existed. But these instances are exceptional, and 
 ovarian disease is essentially an affection of mature adult life. In Spencer Wells's thou- 
 sand cases the age averaged thirty-nine. 
 
 Ovarian tumors may be ciinicall}' divided into four classes : Monocy&tic^ or unilocular 
 tumors ; poJi/(i/sf!(\ or multilocular tumors ; dermoid cysts ; fibrons and cancerous tumors. 
 The relative frequency of these difterent forms of tumors is well seen in the following 
 conclusions, which were di'awn up after a careful examination of the records of 88 fatal 
 cases of ovarian disease extracted for me by the late Dr. Phillips from the Guy's records, 
 and copied from my work On Ovariotomy published in 18G7. 
 
 Conclusions (h-awn from an analysis of 88 fatal cases of ovarian disease: 
 
 1. That 1) per cent, of the ovarian tumors are apparently monocystic, 9 per cent, der- 
 moid, 18 per cent, cancerous, and the remaining 64 -per cent, polycystic or more or less 
 solid. 
 
 2. That 53 per cent, of the cases are on the left side, 20 per cent, on the right, and 
 17 per cent, double. 
 
 3. That simple cystic disea.se of the ovary is rarely double, and that when double 
 ovarian disease exists the majority of the cases are cancerous, colloid, or of the solid 
 kind. 
 
 4. That about 70 per cent, of the cases are in married women, and that the disease is 
 most frequent between the age of twenty and forty, or during the vigor of sexual life. 
 
 5. That the disease runs its course in at least 75 per cent, of all cases within two 
 years, 30 per cent, dying from exhaustion, 20 per cent, from peritonitis, 17 per cent, from 
 suppuration of the cyst chiefly following tapping, 9 per cent, from the last two causes 
 combined, 10 per cent, from peritonitis caused by rupture of the cyst, 10 per cent, from 
 the cyst ulcerating into some viscus such as the intestine or bladder. Hemorrhage into 
 the abdomen and strangulation of the bowels by the pedicle caused death in one case. 
 
 6. That in the monocystic tumors there is a greater dispo.sition for the cyst to ulcerate 
 into the bowels than in other cases, and to suppurate after tapping. 
 
 7. That in 50 per cent, of the cases of cancerous di.sease both organs are involved. 
 
 8. That in the dermoid tumors there is a greater disposition for the cyst to rupture 
 than in all other forms of disease, death being directly due to this cause in 37 per cent. 
 
 9. That acute peritonitis and suppuration of the cy.st as a direct result of the opera- 
 tion of tapping are by no means unfrequent. 
 
 Cases of spontaneous recovery occur, but they are so rare that they must not be looked 
 
ni.Hi.snsi.s OF A.\ owiniAx ri'Mnn. 781 
 
 fbr. Wlit'ii they opi'ur, tlu'V takt; place by ni|>ture of the cyst : ami this ni|itiire i.s {gen- 
 erally the result of aeeideiit or violent lun.seiilar action. As a rule, however, when a cyst 
 ru|ttiires, death takes place from shock, jieritoiiitis, or hlood poisoninj^ {n'l/f Corieliisittn 5). 
 In exceptional eases, when the cy'^t has dischar^rcd itself into the lar^M! intestine, the 
 event may he sijrnified hy a copions discharge of the eyst's contents hy the reetuiu ; hut 
 when into the small howel, no such event may occur, the fluid heinj^ reahsorheil. Under 
 both eireumstances there is alway.s great danger to life from the entrance into the cyst 
 itself of fecal matter or fetid air. 
 
 Diagnosis of an Ovarian Tumor. 
 
 When an ovarian tutnitr has attained a considerahle size, ha.s risen well out of the 
 pelvis, and is unassoeiated with any complications, its diagnosis, as a rule, is not difficult, 
 more particularly if it can he made out to be comjto.scd (jf many eyst.s — /. t'., multilocular. 
 Hut when the tumor is small or very large, unilocular or very solid, central or of rapid 
 growth, difficulties of diagnosis are met with, and it may be ailmitted at once that under 
 any of these circumstances there are few surgical ca.ses that demand more care on the 
 part of the surgeon before he gives an opinion, and still more caution before he acts upon 
 it. In some few instances, indeed, a positive diagnosis cannot be made without the help 
 of some exploratory operative proceeding. Under all circumstances, however, " in the 
 diagnosis of a suspected ovarian case, every possibility of its nature .should be enter- 
 tained and a conclusion arrived at by a process of exclusion ; each possibility should be 
 separately considered and weighed and the most probable finally acee])ted." 
 
 The possibility of a solid or semi-solid tumor l)eing due to pregnancy and the proba- 
 bility of a cy.stic tumor being complicated with pregnancy or hydramnion ought always 
 to be before the mind of the surgeon, while the complete cessation of the menses for a 
 few months in connection with tlu; existence of an abdominal tumor ought also to suggest 
 in diagnosis caution and delay when for diagnostic or curative ends operative measures 
 are being considered, since, though catamenial irregularity is common in ovarian disease, 
 total arrest for any time is rare. 
 
 The early history of an ovarian case is always obscure, and the statements of patients 
 concerning its early growth must be accepted with caution. In a general way the tumor 
 is discovered by accident, or attention is first drawn to its presence by abdominal enlarge- 
 ment. 
 
 Pain is rarely present in the early stage of the disease, and when it exists is usually 
 the result of mechanical causes — that is, it is due to the impaction of a small ovarian 
 tumor in the pelvis or to the pressure of a larger one upon the viscera, vessels, or nerves. 
 
 When the tumor presses upon the bladder, incontinence of urine or dysuria will occur ; 
 but when it irritates the bowels, diarrlnea will l)e caused. When it drags upon the omen- 
 tum or pres.ses upon the stomach, nausea and vomiting may be jiresent ; and where it 
 encroaches upon the thorax, dyspnijea. Nerve pains will be produced according to the 
 nerves that are pressed upon, and wdema of the genitals, legs, or abdomen according to 
 the amount of interference to the return of venous blood is commonly caused by the 
 tumor. Oedema of the abdominal walls is said to be typical of cancerous di.sease of the 
 ovaries, but this is not the case, since I have seen this symptom ver}' frequently in 
 undoubted examples of simple ovarian disease. 
 
 Local pain, pyrexia, with a high temperature and ab<lominaI tenderness, associated 
 with a cystic abdominal tumor, generally indicate inflannnatory changes within an ova- 
 rian cyst. 
 
 Dermoid tumors are said to be more comnionly, and unilocular cysts least frequently, 
 attended with pain than any other. 
 
 In well-marked examples of ovarian disease the face becomes pinched and the peculiar 
 " ovarian exjiression "' manifests it.self, but after the removal of the tumor by ovariotomy 
 it is remarkal)le how soon this expression disappears. 
 
 The DIFFERENTIAI. DIAGNOSIS of an ovarian tumor will now occupy our attention, 
 and its physical signs will be first considered as made out by percussion and palpation, 
 .since it is by these more than any others that the surgeon is generally led to an approximate 
 opinion of the nature of the case. Too much confidence, however, must not be placed on 
 them, since they are of value only when taken in connection with other symptoms. 
 
 In all cases of suspected ovarian disease the patient to be examined .should be undressed 
 and then placed on her back with her shoulders and knees raised. The surgeim should 
 afterward so expose the abdomen as to be able to have a good look at it and ob.serve 
 
782 ON OVARJAN DISEASE AND OVARIOTOMY. 
 
 whether the abdominal enlarfrenient is central or lateral, smooth, irreirular, or nodular in 
 outline. Should the tumor move upward and downward during the respiratory act, the 
 tumor is probably free and non-adherent. The surgeon should then place his hand flat 
 upon the abdomen, and. having rested it there for a minute or so to test the points just 
 alluded to, should move it steadily over the whole surface of the tumor in all directions, 
 and at the same time, by palpation, ascertain something of the condition of the deeper parts. 
 
 By these means much will have been ascertained as to the nature of the case. It 
 will have been made out whether a tumor exists or not ; something will have been learnt, 
 too, concerning its size and mobility and whether it is solid, fluid, or the two combined. 
 Possibly by some sudden movement of the contents the question of pregnancy may be 
 raised or settled. 
 
 The surgeon should then proceed to percuss the parts, doing this at first superficially 
 and then deeply. He should also examine for fluctuation, asking himself during the 
 whole examination the following questions : Is this abdominal enlargement due to tym- 
 panitis, or is it some phantom — that is. muscular — tumor? Is it due to or complicated 
 with pregnane}', or is it uterine or ovarian disease ? Can it Ije a hydatid, pancreatic 
 (Lancet, February 11, 1882), or renal cyst, or an enlarged viscus, such as spleen or 
 kidney ? Is it a cancerous tumor ? 
 
 A fluctuating tumor rising from the pelvis in a central position, yielding a dull note 
 on superficial as well as on deep percussion, with epigastric and lumbar resonance, is 
 probably a cystic ovarian growth ; and when the tumor fluctuates in all directions, as is 
 proved by the peculiar thrill of the wave elicited on percussion, the growth is probably 
 unilocular or monocystic. When the tumor has an irregular or botryoidal outline and 
 fluctuation is confined to parts, it is certainly compound, the degrees of solidity in a com- 
 pound or multilocular tumor varying greatly. If the tumor seem to be a unilocular or 
 monocystic growth, the surgeon must remember that ovarian tumors of this kind are 
 comparatively rare, and that those which appear to be such often contain some intracystic 
 growths. He should also know that purely unilocular cysts are probably broad ligament 
 or parovarian cysts — that is, a cystic degeneration of the tubules of the Wolffian body — 
 although multilocular parovarian tumors have been recorded. 
 
 If the tumor be clearly cystic and multilrjcular. the probabilities are that it is ovarian ; 
 and if more solid than cystic, it will probably be dermoid or uterine. 
 
 Uterine and ovarian tumors yield a dull note on deep percussion, and as. in these cases, 
 the intestines are pushed upward and toward the loins, these regions are consequently 
 resonant, and no alteration in the position of the patient will alter this fact. In ascites, 
 with the shoulders of the patient raised, the lower portion of the abdomen may likewise 
 yield a dull sound, but with the shoulders depressed and the hips raised resonance will 
 be made out, the bowels naturally floating on the surface of the ascitic liquid. In ascites 
 the central portion of the abdomen is resonant and the sides are dull, whereas in ovarian 
 drops}- it is the reverse. " In ascites the greatest circular measurement is at the level 
 of the umbilicus; in ovarian dropsy it is often some inches lower down" (Wells). When 
 the intestines are matted together from cancerous or old peritoneal disease, diflSculties 
 occur, and errors in diagnosis can be avoided only by going carefully into the clinical his- 
 tory of the case and by a pelvic examination. In ovarian disease a friction sound may 
 be detected at times on auscultation or on the application of the hand, while in ascites no 
 such symptom will be present. 
 
 Diagnostic Value of a Pelvic Examination in Ovarian Disease. 
 
 The diagnosis of an ovarian tumor can hardly ever be said to be complete until a pel- 
 vic examination by means of the finger and uterine sound and the combined examination 
 between the abdominal wall and rectum have been made, for which purpose the patient 
 had better be placed on her side. 
 
 When the uterus is found to be in front of and distinct from the abdominal tumor 
 and movable without it, the growth is probably ovarian. When the tumor and uterus 
 move together, or if the uterus be drawn up out of the pelvis, difficulties in diagnosis 
 may be experienced. If the tumor be cystic, it may be ovarian with a short pedicle, a 
 broad ligament or parovarian cy.st, or a cystic disease of the uterus. W^hen it is solid, 
 it may still be ovarian, dermoid, fibrous, or cancerous, or it may be a fibrous tumor of 
 the uterus. 
 
 A fixed pelvic tumor is probably neither ovarian nor uterine ; but if either, it is can 
 cerous. 
 
VALl'L' OF TArriMl Foil lHA(JSOSTir riUFosFS. 783 
 
 III ail (tvariiiii tuiiiur tlic uti-riiic .s(»uik1 will ran-ly f^o bey<nid twi» inches, urik-ss coni- 
 pliratcd with |irt'^'iiaiicy or some uteriiK- discasi-. In cystic disease of the uterus it may 
 enter for six or more. 
 
 The uterine scuiiid should not he used tun hastily lor diagnostic purposes, because 
 wlieii prt'^naney and ovarian disease are eomljined evil may follow its use, althou<;h it 
 ought always to be employed before 0{»erative measures are resorted to. 
 
 \Vl»en ascites is present, a pelvic e.vainination will generally detect a vaginal rectocele 
 — that is, a bulging into the vagina of the posterior wall of the vaginal passage from tlie 
 pressure of the ascitic fluid into Douglas's poucli ; and this bulging is not met with in 
 uncomplicated ovarian di.sease, though it may occur when ovarian di.sea.se and ascites 
 coexist. I have found this point of great diagno.stic value for many years, and was 
 pleased to read that Dr. Peaslee had mentioned it as one of valua. 
 
 ''Solid uterine tumors," writes Tait, " besides the absence of fluctuation, have in 
 addition two vascular signs which I have never met with in ovarian tumor.s — viz., an 
 aortic impulse which may be seen and felt, and an enlargement of the uterine arteries to 
 be felt in the vagina." 
 
 [n pregnancy there is also to be seen the peculiar pur]ile livid condition of vagina 
 which does not exist in other pelvic tumors, the changed a]>[)earance of the nij»ple, 
 enlargement of the brea.sts, etc. 
 
 I have often found the value of rectal digital examination for diagnostic purposes to 
 be great, and particularly in young or old virgins, but I cannot speak from personal 
 experience of the value of the introduction of the hand. Professor Simon of Heidelberg, 
 however, speaks highl}' of it. 
 
 Value of Tapping for Diagnostic Purposes. 
 
 When there is any doubt as to the true nature of a cystic abdominal tumor, a pre- 
 liminary tapping ought to be performed and the physical nature of the fluid examined, 
 although in our present state of knowledge an ovarian fluid is not to be recognized by 
 any definite physical or chemical characters. Drs. Washington Atlee and Peaslee, how- 
 ever, inform us that the fluid of an ovarian cyst may be distingui.shed from all fluids by 
 the presence of a peculiar cell — which they call the ovarian granule cell — which is about 
 the size of a pus cell, round and full of granules, and Mr. Thornton has recently con- 
 firmed these ob.servations {Path. Soc, March IG, 1875;. adding, moreover, that large pear- 
 shaped, round, or oval cells containing a granular material with one or several large clear 
 nuclei, with nucleoli and a number of transparent globules or vacuoles, are characteristic 
 of malignant tumors. 
 
 When, from what appears to be a monocyst, the fluid drawn is clear, slightly opales- 
 cent, and limpid, of a low specific gravity, about lOOo, and non-eoagulable by heat or 
 nitric acid, or if coagulable by heat the coagulum is redissolved upon the addition of 
 boiling acetic acid, there is a strong reason to suspect that the tumor is a broad ligament 
 or parovarian cyst, and under such circumstances there is good reason to hope that a cure 
 may follow the operation of paracentesis, or. if not a cure, the lapse of a long interval of 
 time beiore the repetition of the operation is called for. This fact was pointed out bv the 
 late Dr. F. Bird (M'.l. TUnrn. July 19. 1851). 
 
 When the fluid drawn off is clearly albuminous, tenacious, dark, or light colored, 
 when it is even watery and like that contained in the cysts last described, and is found 
 microscopically to contain the compound cells or epithelial elements already referred to, 
 the tumor is probably ovarian and ought to be removed. 
 
 When the fluid drawn off" is highh' albuminous and coagulates spontaneously, the sus- 
 picion of the tumor being a fibro-cj'stic uterine one ought to be raised, though there is 
 little doubt that the true diagnosis of a fibro-cystic uterine tumor from a polycy.stic 
 ovarian can only be made out in the majority of ca.ses by an exploratory incision, 
 when the absence of the pearly appearance of the ovarian and the presence of the pink- 
 ish, vascular, and fleshy aspect of the fibro-cystic are enough to excite the surgeon's sus- 
 picion of the uterine nature of the growth. 
 
 When pregnancy and well-developed ovarian disease coexist, tapping ought to be 
 performed, though in eases where the operation is inadmissible, from the nature of the 
 tumor, ovariotomy is a justifiable proceeding, Spencer Wells and other surgeons having 
 performed the operation in many cases during pregnancy, and with success ; it should, 
 however, be undertaken before the fourth month. When the tumor is small, it should be 
 left alone. 
 
784 ON OVARIAN DISEASE AND OVARIOTOMY. 
 
 The Treatment of Ovarian Disease. 
 
 In the treatment of ovarian disease medicine is of little value and has no direct influ- 
 ence in arresting its progress. It does good only by improving the general condition of 
 the patient. The operation of tapping in unilocular cysts is, however, often of great 
 value, and at times essential. Injection of the cyst is applicable only to a small class of 
 cases. Ovariotomy, in a general way, is the only radical cure. 
 
 John Hunter clearly realized the truth of this in 1787, when he said, " In the early 
 stage of ovarian dropsy I would almost advise that they should be removed entirely if the 
 complaint can clearly be ascertained, as they otherwise will certainly kill the patient." 
 He adds, however, that " electricity has been serviceable lately in diminishing the progress 
 of the formation of the fluid in a patient I am acquainted with. How far it will be of 
 further service I cannot say" (MS. lectui'es). 
 
 At the present day the operation of ovariotomy is an accepted one by the profession, 
 and is as recognized and justifiable as any other grave operation. Surgeons and phy- 
 sicians diff"er only as to the class of cases in which it is applicable and the period at 
 which it should be performed. 
 
 British surgeons may probably claim the credit of having established this operation 
 in spite of early difficulties and blind opposition, and the names of Lizars of Edinburgh, 
 MacDowell of Kentucky, Jeaff'reson of Framlingham, Walne, Fred. Bird, Lane, Morgan, 
 Aston Key, Cooper, and Cajsar Hawkins of London, must ever be remembered as 
 amongst its earliest practical promoters. Charles Clay of Manchester, however, the first 
 great ovariotomist in this country. Brown, and particularly Spencer Wells, of London, 
 Keith of Edinburgh, Koeberle of Strasburg, Skbldberg of Stockholm, and Atlee of Amer- 
 ica, with Hutchinson, and possibly the present writer, have by their successes fairly 
 overcome all prejudices and rendered the operation an established and accepted one. 
 Without going into the details of statistics, which are now no more needed in this than 
 in other large operations, it may be confidently asserted that the operation is not placed 
 in too favorable a light when it is said to be successful in three out of every four cases, 
 good, bad, and indiff"erent, and in at least nine out of ten selected cases. Sir Spencer 
 Wells informs us, as the result of his unrivalled experience, that out of his 1000 cases, 
 "232, or 23.2 per cent., died, Avhilst T. Keith lost only 41 out of 381 cases, or 10.7 per 
 cent. Lawson Tait tells me that with the year ending 1883 he had 209 cases of removal 
 of one or both ovaries for cystic disease with but 7 deaths, or a mortality of 3.3 per 
 cent., and that of 36 cases of operation for cystic disease of the Fallopian tubes he had 
 no death. " If ovarian tumors," he adds, " are operated upon as soon as they are discov- 
 ered, and never tapped, there would be a mortality hardly perceptible." 
 
 " I have become," writes Spencer Wells, " more and more disposed to advise the 
 removal of an ovai-ian tumor as soon as its nature and connections can be clearly ascer- 
 tained and it is beginning in any way, physically or mentally, to do harm, since the risk 
 of the operation under such circumstances is certainly less, and the possible evils of 
 delay are eluded." 
 
 When delay must ensue, one of the minor methods of palliative surgical treatment 
 may be required, such as tapping, tapping and draining, incision, or tapping and iodine 
 injection. 
 
 Tapping. — This operation may be required for diagnostic purposes, and for relief 
 when other operative measures are necessarily or wisely po.stponed or have been rejected. 
 It should always be practised once in monocystic tumors, .since in such it may possibly 
 prove curative and probably postpone operative interference for years. It is not to be 
 recommended in compound or semi-solid tumors. Spencer Wells, however, maintains that 
 one or more tappings do not increase cousichrnhly the mortality of ovariotomy. 
 
 Injection of Iodine. — In the simple or monocystic ovarian tumors, when the diag- 
 no.sis is clear, the treatment by injection of iodine may be employed. M. Boinet says that 
 out of 45 patients suff"ering from this disease, 31 were cured, 5 had relapses, and 9 died. 
 Sir J. Simpson performed it in about 20 cases with good success, only 1 case dying, while 
 Dr. Tyler Smith found that out of 10 cases in which this practice was followed, 2 only 
 were satisfactory and 2 died. Dr. West in 8 cases had 1 cured. 
 
 The method at the best is uncertain. Spencer Wells does not advocate it. In the 
 majority of cases it does no good, and may even be followed by a fatal result. It is 
 applicable only to simple cases of ovarian or extra-ovarian cysts. 
 
 Incision. — This method is applicable only when the operation of ovariotomy is found 
 impossible from the adhesions or attachments of the tumor. Under these circumstances, 
 
THE <)J'i:j:.\ti().\ or ovmhotomy. 7h5 
 
 in certain oases, it is of iiiiiiu'iiso valiu'. In 1S77, I liatl tliis truth illustratcrl in the {icr- 
 
 8on ot Anii'lia It , ;i't. 20. whn liad recoLMiizfil the jirt'scMn'c <»f" an ahduniinal tumor 
 
 some months hetore slio bocanic i)rt.'_Lrnant. Al'tur the confinement, which was normal 
 and the child alive, the tumor grew rajtidly ; and when she eame under my care her 
 abdomen measured fifty-six inehos in circumference. 
 
 1 operated upon her. but. having found a moiiocyst universally adherent, I emjitied it 
 and evacuated manv ({uarts of a viscid fluid, washed the cyst well out witl> iodine water, 
 dried its cavity, and then drained it. For about a week there was some draining of serous 
 fluid, but there were no constitutional synijittuns. The cyst was irrigated daily with iodine 
 water. Uv the eleventh day the cavity had considerably shrunk. On the twenty-fifth it 
 would not hold an ounce of fluid. By two months it hail <|uite healed, and the woman 
 returned home. 
 
 I have jierformed a like operation to the above in three or lour other cases where 
 suppuration existed, and with success. 
 
 When Operation is Required. 
 
 Cases of the polycystic or dermoid kinds .should, as a rule, be operated upon a.s soon 
 as they become sources of local or constitutional distress. "Justice," says Wells, "in 
 these cases demands a most positive recommendation of excision, with a warning against 
 delay." " Every ovarian tumor." writes Schroder of Berlin, -'ought to be removed as 
 soon as it has been discovered. ' 
 
 It should not be entertainetl, however, when other organic disease is present or when 
 the local disease is clearly cancerous. The operation is a formidable one ; but if the gen- 
 eral condition of the patient be good, the prognosis is fiivorable even when the tuuKjr is 
 large and looking unfavorable for removal. 
 
 The size of a tumor has not appeared to have had much influence on the result, 
 although when it is solid and requires a large incision for its removal the dangers are 
 increased, small incisions, without doubt, being better than large. 
 
 Adhesions to the abdominal walls, parietes, or omentum have but little influence 
 upon the mortality, but pelvic adhesions are always grave and visceral dangerous. 
 
 The length, of the pedicle, when the clamp was used, was a matter of import- 
 ance, short pedicles adding to the danger of the case by necessitating dragging of the 
 uterus upward. At the present time, when clamps are abandoned and the intraperitoneal 
 method of ligating the pedicle and dropping it in is the common custom, the length or the 
 shortness of the pedicle is of small importance. 
 
 The breadth <ir thickness of the pedicle i^, however, a question of considera- 
 tion, since a broad pedicle of necessity requires many ligatures, and a thick one is diflScult 
 to ligate with safety. 
 
 The Operation' of Ovariotomy. 
 
 The preliminary treatment of a patient about to undergo the operation of ovariotomy 
 need not differ in any way from that which experience has taught us to be called for 
 previous to any other capital operation. AVe should do our best to raise the standard of 
 health by all those general hygienic and other influences which are well known to act 
 benefieially. such as good air, simple nutritious diet, a fair amount of .stimulants, and the 
 administration of some tonic. Let the patient take exercise, when she can without pain, 
 and be careful that it is kept within the limits of fatigue, that it be taken on level ground, 
 and that no shaking or straining be on any account allowed ; and when she is at rest, the 
 half-reclining position ought to be usually assumed. For a day or two before the opera- 
 tion, however, exercise, even when possible, is not to be advised, as quiet and repose are 
 then of some essential service. The urine should be carefully examined : and if .scanty 
 and concentrated, the operation must be delayed. Lithia water and alkalies are always 
 useful in exciting a free secretion of urine and in making it clearer. 
 
 As a tonic medicine iron appears to be of real and important value ; it has apparently 
 an influence for good which other tonics do not possess. It is no more useful, however, 
 before the operation of ovariotomy than before any other capital operation, though it is 
 as good, and I have often thought that in hospital practice wounds are less prone to 
 inflame and erysipelatous affections are less common under the influence of this medicine 
 than when no such preliminary treatment has been adopted. In peritoneal operations 
 this point is of primary importance, and, as a consequence, the adoption of this practice 
 
 50 
 
786 ON OVARIAN DISEASE AND OVARIOTOMY. 
 
 should be recommended. Tlie fonu of iron I prefer is the tincture of the perchloriue, 
 twenty drops combined with a like quantity of spirits of chlorofdrm or of syrup of lemons 
 or tola and a drachm of glycerine in water forming a pleasant draught. 
 
 The bowels of the patient should be gently opened two days previously by such a 
 mild aperient as castor oil or a draught composed of ten grains of rhubarb and twenty of 
 sulphate of potash in some aromatic water, and on the morning of operation the large 
 intestine should be washed out with a warm-water enema ; but nothing like powerful pur- 
 gation should be allowed under any consideration. Care should also be observed that the 
 catamenial period has passed for at least a week previous to the operation, as all ovarian 
 excitement is necessarily injurious at such a time and should be avoided. I have known 
 cases of ovariotomy, however, undertaken without any consideration of this point, and 
 believe that under such circumstances an untoward result is to be expected. 
 
 In hospital practice the patient should as much as possible be isolated from all others 
 and kept in a private room in which good ventilation exists ; a special nurse should also 
 be secured, who is not only entirely trustworthy, but understands how to use a female 
 catheter. Country patients should not be brought into town unless an urgent necessity 
 exists, as there is little doubt that the atmosphere of a large city is not so conducive to 
 the rapid reparation of a wound as fresh country air. In abdominal surgery this influ- 
 ence for good is of great value, and should not be thrown away unless from necessity. 
 
 The surgeon who is to operate, as well as his assistant, should not allow himself, for a 
 few days before the operation, to visit the post-mortem or dissecting room, nor should he 
 handle any morbid preparations. Erysipelatous affections and all contagious diseases 
 should also be shunned as much as possible ; indeed, the same rules which are observed 
 by the careful obstetric practitioner are necessary to the surgeon who undertakes the ope- 
 ration of ovariotomy, .since the same subtle poisons which are recognized by all to be 
 hurtful to the puerperal woman act with equal force upon the subject of ovarian as of 
 other diseases when submitted to operation, and, as a consequence, should be studiously 
 avoided. It follows, therefore, as regards the lookers-on at an operation and all who may 
 come in contact with the patient, that none who may bring infectious or contagious dis- 
 ease should on any account be admitted. The physician who is attending a case of puer- 
 peral fever is looked upon as a possible poisoner as far as concerns the puerperal woman. 
 The medical attendant of a scarlet-fever case, of erysipelas, or other contagious disease 
 should be regarded in the same light in the presence of an ovariotomy operation, and 
 should be excluded. Hence, in hospital practice, great care is needed to exclude all such 
 possible means of injury as have been briefly enumerated. 
 
 I need hardly allude to the necessity of all bed and bedding, blankets, sheets, and 
 hangings being perfectly fresh ; all sponges being iie>c, soft, well cleansed, scalded, and 
 free from soap and grit; and every instrument to be employed being scrupulously clean. 
 The hands of the operator should likewise be thoroughly cleansed from soap just previous 
 to the operation and be well warmed, for manipulation with a cold hand cannot but prove 
 injurious to an exposed peritoneum. 
 
 Temperature of the Room in which the Operation is Performed. — 
 
 There is still some difference of opinion on this point among operating surgeons, Dr. Clay 
 of Manchester, Peaslee of America, and others, advising that the operating room be heated 
 to 75° or 80° F. and a good supply of moisture engendered by the diffusion of steam, 
 while Wells and others make no such rule. Speaking from my own experience, I have 
 no faith in the adoption of such a practice. I would have the room heated to a comforta- 
 ble temperature, 65° being amply sufficient, since a greater heat acts as a powerful depres- 
 sant upon the patient and can do no good. A warm room with good ventilation is what 
 I always seek in preference to a hot one with closeness. A cold damp room is to be con- 
 demned under all circumstances. 
 
 Position of the Patient. — The horizontal position is that which patients suffer- 
 ing from ovarian disease can rarely assume ; and when the tumor is so large as to require 
 ovariotomy, this position becomes almost impossible. As a consequence, the half-reclin- 
 ing position is the most comfortable for the patient and convenient for the operating sur- 
 geon. It is the posture I have invariably adopted in the cases Avhich have fallen into my 
 hands, and I know of no good reason why it should be changed. 
 
 The semi-recumbent position affords all the advantages which have been claimed for 
 other postures without their evils; in it the tumor can readily be removed from the abdom- 
 inal cavity, and with care its fluid contents can without difficulty be prevented from 
 passing into the peritoneal cavity. There is also abundant room for every manipulative 
 act that can be required. 
 
Till: Ol'llllATIoS or oVMiloroMY. 7K7 
 
 Administration of Anaesthetics in the Operation. — Ammi;: ihc many 
 
 iiicitlcnl.il a(l\ aiitaizcs wliicli tlic iiil rnilncl iuii nl' aii;c>t licl ir.s |i.i> allurilcti licvoiitl iliat nl' 
 rclicviiiu pain, few arc j^rcatcr tliaii that <il" ohviatiii;.' Iiiirry — a poitit of critical iiiiport- 
 aiicc ill ovariotinnv ; ami tliciv can l»c little dmilit lliat the success of the <i|ierati<in has 
 thus hcen i:n'atly infiiicnce(l |>y their use. 
 
 It is true that (iterations for the removal of an ovarian tumor were iiinlertaken In-fore 
 the introduction of anv amost hetic. I)iit we all know how fatal were; their results and how 
 oxce|itional was n-coverv. Those who had an ojiport unity id' witnessiii}.' the j)erformance 
 of iin operation under sii<di unfavorahle eircuuistance.s can hardly wonder that so many 
 patients succunilu'd to the |)raetice, althoufrh they might he surprised that any were found 
 to convah'sce. To see a patient writhinj; under the agonies of an ahdominal section was 
 enough to make the hardest heart turn with horror, and to witness tlie surgeons hanrls 
 within the ahdonicn of a struggling woman in his endeavor to remove an adherent growth 
 was almost sufficient to make any professional spectator deciile that siudi an operation 
 was really uiijustitiahlc. 
 
 How. ill such a case, was it possilile for a surgeon to he (jiiiet in all his movements, 
 gentle in his mani])ulations. and thoughtful over the difficulties which of necessity pre- 
 sent themselves in an ovarian operation, when the cries of the patient's agony stimulated 
 him to expedition and her struggles forhade gentleness':' All surgeons who have ope- 
 rated ujton these ca.ses will agree that success, even under favorahle circumstances, is 
 only to be ae(|uired by attention to these points ; that hurry in any ojieration is always 
 bad and unjustifiable, while in ovariotomy it is destructive ; that force is never to be 
 employed in any case where art will answer ; that in ovariotomy all blind force and drag- 
 ging is to be strongly condemned ; and that in a proceeding in which steadiness in ope- 
 rating. gentlene.s3 in manipulating, and thoughtful attention to every detail are ab.soluteIy 
 essential to success the safety of the patient must depend upon her quietness and passive- 
 ness under the surgeons treatment. 
 
 Under these circumstances the value of some aiuesthetic cannot be too highly jiraised, 
 for by it the patient is not only rendered insensible to pain, but her perfect (Hiieseence 
 is guaranteed and her passiveness under the hands of the operating surgeon completely 
 ensured. 
 
 The vomiting that occasionally follows is the only argument against the inhalation 
 of an ana3sthetic, but this is an evil which must be endured for the .sake of the positive 
 good it affords. By the use of the nitrous-oxide gas followed up by ether, or of the 
 chloroform mixture, of alcohol one part, chloroform two. and ether three parts, as recom- 
 mended by the chloroform committee of the Royal Med. and Chir. Societ}', vomiting is 
 certainly less common than after the use of chloroform alone, and as a general anfesthetic 
 it should be employed. When chloroform or bichloride of methylene is used, it should 
 be given by '-Junker's" spray apparatus. 
 
 Extent of the Incision into the Abdominal Parietes. — The temjierature 
 
 of the room, the jmsition of the patient, and the propriety of tlie administration of anaes- 
 thetics having received our attention, the operation itself next claims consideration ; and 
 the first thought naturally is as to the extent of abdominal inci.sion re«|uired, as there is 
 still a want of uiianimitv in the practice of different surgeons upon this jioint. 
 
 Care to have the Bladder Empty. — Before commencing, the careful surgeon, 
 standing on the right hand of the patient, will .see that the bladder has been emptied by 
 means of a catheter, the linen of the patient well drawn up out of harm's way and freed 
 from the chance of becoming soiled by the use of waterproofing, the limbs of the patient 
 well protected and kept warm by a pair of drawers and covered by a clean sheet, either 
 with or witliout a blanket, the abdomen covered by a long piece of waterproofing with an 
 opening in the middle eight inches long by six wide, with its inner surface rendered adhe- 
 sive by a coating of plaster. He should also see that all his assistants are carefully 
 arranged and special duties assigned to each, and that every instrument that may be 
 re(|uired is clean and nigh at hand. He .should proceed to make his incision as soon as 
 tlie patient has been brought completely under the influence of an anaesthetic, though 
 previously he should determine as to its length. From Mr. Walne's. Sir J. Simpson's, and 
 Dr. Clay's practice it might be argued that the long incision should always be adopted, 
 since their success has been great and in their practice the long incision has been invari- 
 ably employed. From the practice of Dr. Keith. Sir Spencer Wells. Lawson Tait. and 
 others, the short incision would appear to be the better, for their success has at least 
 been as good as that of Dr. Clay and others, and as a rule the short incision has been the 
 one selected. I regard the truth as between the two extremes. When the tumor can 
 
788 
 
 ON OVARIAN DISEASE AND OVARIOTOMY. 
 
 be removed with facility by means of a short incision, a long one is clearly not required-, 
 and when the tumor is monocystic, or nearly so, and free from abdominal adhesions, it 
 may be so removed. But when the tumor is large and semi-solid, or when adhesions 
 exist which cannot be readily broken down by the employment of gentle traction upon 
 the growth, it is the best practice, doubtless, to make a long incision, as by so doing the 
 removal of the growth is much facilitated and the causes of its abdominal retention and 
 the connection of the adhesions are satisfactorily ascertained, and, as a consequence, can 
 be dealt with with greater safety. 
 
 My own practice has hitherto been influenced by such a conviction, and I have in all 
 cases commenced the operation by making a short abdominal incision, and in many have 
 been enabled to remove the tumor without further trouble. But in certain examples in 
 which difficulties appeared, and in which it was clear that adhesions existed for the break- 
 ing down of which some force would have been required and some working in the dark 
 called for, I have been induced to increase the length of the wound upward, even for an 
 inch or two beyond the umbilicus, regarding such an increase of the incision as unimport- 
 ant in comparison with the evil effects of violence and dragging upon the tumor for the 
 purpose of its removal, or the blind tearing down of the abdominal or visceral adhesions 
 which detain the growth. 
 
 I have never seen any evil effects from the long incision when ma Je under the cir- 
 cumstances I have just indicated, but have, beyond doubt, seen the bad results of an 
 opposite practice, of violence which has been employed in an attempt to remove a large 
 growth through a small opening, or to tear an adherent one from its abdominal or visceral 
 connections. 
 
 The incision should also always be made sufficiently low. If too high, considerable 
 traction upon the pedicle of the tumor must be made to bring it into sight, and with the 
 tumor the uterus will also be drawn out. This traction is always injurious, and should 
 be avoided. When the lower end of the wound is too high up, this traction of the parts 
 becomes unavoidable ; by extending the incision downward toward the pubes to a point 
 corresponding to the upper part of the healthy uterus, or about one inch above the pubes, 
 this evil can be prevented, and, consequently, the practice I have just advised should 
 invariably be adopted. 
 
 Tapping the Cyst. — The cyst, having been exposed, ought to be tapped, and for 
 this purpose the instrument represented in Fig. 451, as made for me by Mr. JMillikin in 
 
 1864, is the one I prefer. It 
 Fig. 451. includes not only a trocar and 
 
 canula, but a vulselluin forceps, 
 which slides upon the latter, and 
 by being made to grasp the cyst 
 walls holds the instrument firmly 
 in its position, thus enabling the 
 surgeon to make traction upon 
 the tumor for the purposes of its 
 removal. 
 
 Removal of Cyst. — When the cyst has been emptied and is of a simple nature, 
 its removal, unless adhesions exist, is readily effected; but when it is solid or very com- 
 pound, it may be necessary, to allow of its extraction, to lessen its size by breaking down 
 its contents, and for this purpose the surgeon must make a free opening into the cyst and 
 introduce his hand into its interior, the orifice of the opening into the cyst at the same 
 time being held well open and forward by forceps (Fig. 452) adapted for the purpose. 
 
 Fig. 452. 
 
 Trocar and Canula for Tapping, with Movable Forceps. 
 
 Nelaton's Cyst Forceps. 
 
 By these means the most compound cyst may be broken down and removed. When the 
 cyst is so adherent to the abdominal parietes as to render it difficult for the surgeon to 
 
Tin: <ti'i:i:.\ii().\ of niAn/oroMV. 
 
 789 
 
 distiiiLTuisli the cvst wall itM'li" lioiii llir |»:iri(lal layrr nf pcrildiK'imi, the plan a<l>i|iI<Ml 
 by Sir Spt'iifiT Wt-ils. ol" i-iiiptyiiij; tlii- i-yst ami seizing its posterior or u|)ptr wall from 
 within liv forceps ami inverting it, is a good one, the eyst then peeling oH on good trac- 
 tion lieing made. 
 
 Adhesions and their Treatment.— Winn the imisimi through the ahdominal 
 walls has heeii inatle and the smooth glistening surface of the visceral peritoneal covering 
 of the tninor recogni/ed. the surgeon may he satisfied that the uhdominul cavity lias heeii 
 fairly opened ami the tumor exposed; and when the ovarian eyst on ea(di respiratory act 
 is seen to move freelv within the ahdomeii, there is a strong prohahility, if not certainty, 
 that tlir tumor is free and the tomplieatioii of adhesions is not likely to be severe; for 
 wlien tlie tumor is fixed to the ahdominal walls, this mobility of the cyst is not present. 
 Fibrous or lil)ro-cvstic tumors of the ovary or uterus usually luive a fleshy or muscular 
 appearance. Adhesions may present themselves on the eomid(;tion of the abdominal 
 incision in three f(M'ms — Jirsf, as forming a complete and compact union between the peri- 
 toneal covering of the cyst and the abdominal peritoiieuni : .«'Y-o//f/, as loose and fibrous 
 connective bands; and /////•</. as visceral adhesions. When a firm atid compact union 
 exists between the cyst and tlie abdominal ))eritoiieal membrane, the surgeon will have 
 lost his chief guide as to the depth of his abdominal section, and under these circum- 
 stances he may experience .some difiiculty in deciding whether the abdominal cavity lias 
 been opened or not ; he must consequently be careful in his procedure, for he is not far 
 from the pos.sibility of perpetrating a fatal error — the separation of the parietal perito- 
 neum from its muscular connections; but this error, however, can be avoided by merely 
 extending the abdominal incision upward until the distinct line of separation between the 
 cyst wall and the abdominal peritoneal membrane is clearly seen. The next step of the 
 operation consists in tlie breaking down of adhesions, which may be done by the careful 
 introduction of the finger between the cyst walls and the parietal layer of peritoneum. 
 And here some force is perfectly justifiable; for if the adhesions are confined to the 
 abdominal parietes and can be torn through, there is rarely much subsequent danger to 
 be apprehended. Extreme care, however, is required at this stage of the operation. The 
 surgeon, by the introduction of his finger, should make out the extent of the adhesions 
 and test their strength. If they should be found numerous and too firm for separation, 
 the operation at this stage had better be abandoned and the wound closed; or should 
 many visceral adhesions of a firm character be present, it would be well to follow the 
 same practice, as the latter are much more dangerous than those merely attached to the 
 abdominal walls. It is, indeed, difficult, if not impossible, to describe with anything like 
 accuracy what extent or character of adhesions would justify the surgeon in abandoning 
 an operation once begun and then closing the wound. The careful study of reported 
 cases and experience alone will enable him to decide with certainty upon these points. 
 Yet. as a broad rule, it may be asserted that, while parietal adhesions may be fearlessly 
 treated when they can be divided, those connecting the cyst with the viscera and the 
 pelvis should always be regarded with alarm, and that the amount of force permissible in 
 the treatment of the former class of cases would be quite inexcusable when the viscera 
 are concerned. AVells's method of emptying the parent cyst, passing one hand into its 
 interior, grasping its back, and inverting it. the back part of the cy.st being withdrawn 
 through the opening made in its front, is an excellent one. 
 
 The fear of hemorrhage from the lacerated adhesions should always be present to the 
 surgeon, and the torn surface should be carefully examined with a view to the arrest of 
 any bleeding. 
 
 Omental adhesions should be particularly examined with care and torn through with 
 caution, for they are very vascular and cannot be treated with too much consideration. 
 As a rule, they should be divided and 
 
 secured with a fine ligature of silk or Fig. 453. 
 
 carbolized catgut. Their forcible sep- 
 aration is always bad. Spencer Wells's 
 forceps for holding the omentum ( Fig. 
 453) whilst the surgeon secures the ^; 
 
 vessels is invaluable. Firm band-like e i^- 
 
 adhesions may be similarly treated. 
 The ends of each ligature may' be cut 
 
 off and the knot left in. Omental Clamp Forceps. 
 
 When the incision has been made 
 and no adhesions exist between the cyst and the internal abdominal walls, it appears to be 
 
790 ox oy'ARLiy disease axb ovariotomy. 
 
 an unnecessary practice for the operator to introduce his hand into the abdominal cavity 
 with the view of learning whether, they exist or not. Adliesions in front must neces- 
 sarily be broken down, and this can generally be eifected hy the finger of the operator 
 introduced at th-e margin of the wound. As the cyst empties these adhesions are neces- 
 sarily brought forward ; but when they do n(jt exist, the peritoneum escapes even the 
 touch of the hand of the operator. In complicated and exceptional examples of this 
 operation it is clear that this practice cannot be followed, but in the more ordinary and 
 simple cases it is most applicable. In many examples Avhich have come into my hands 
 the value of this advice has been well proved, for in them the peritoneum was touched 
 only by the knife and needle. 
 
 As the tumor is being extracted care should be observed to guard against the pro- 
 trusion and exposure of the intestines and omentum, and this is best done by the intro- 
 duction of flat sponges, a sponge being tucked in and spread out beneath the parietes as 
 the process of extraction of the cyst and exposure of the pedicle is going on. 
 
 Treatment of the Pedicle. — At the present day the pedicle is, as a rule, tied in 
 two or more segments, according to its size, with carbolized silk, the ends of the ligatures 
 are cut ofi" close to the loop, and the pedicle with the ligatures is dropped back into the 
 pelvis. This method is doubtless a great improvement upon the clamp and dthcr fnrms 
 of practice. 
 
 In France, Maisonneuve twisted oft' the cyst by continued torsion, leaving the pedicle 
 to fall back into the abdomen, w^hilst Nelaton preferred to fix the pedicle externally 
 and secure it by means of a common clamp. In Germany, Martin and Langenbeck cut 
 through the peritoneal covering of the pedicle by a circular inci.sion, cut oft' the tumor, 
 tied each vessel separately, and fixed the pedicle to the walls of the abdomen by means 
 of a double ligature. Dr. C. Clay fastened the pedicle by a double ligature, cut oft' the 
 tumor, and, having allowed the pedicle to drop backward into the pelvis, brought the ends 
 of his ligatures out through the lower ends of the incision. Dr. Tyler Smith followed 
 the same treatment, but dropped both pedicle and ligatures, which are cut off' close, into 
 the pelvis, and then closed the wound. S. "Wells and T. Keith for years fixed the ped- 
 icle externally by means of a clamp, but Wells. Thornton, and most operators now use 
 the ligature, and Keith the cautery, as first employed by Mr. B. Brown and SkiJlberg, 
 dropping the cauterized end of the pedicle back into the pelvis. Atlee of America 
 employs the ecraseur. In my own practice I now always employ the ligature. 
 
 The plan of treatment now principally adopted, of drtipping in the pedicle with the 
 divided ligature, was first practised in 1829 by David Eodgers of New York. His patient 
 made a good recovery. The practice did not. however, meet with general approval. It 
 was too bold and inconsistent with all past experience and professional prejudices, and 
 fell to the ground. It was repeated at intervals bj' other surgeons with tolerable success ; 
 it has now gained a strong hold on the professional mind and become a general practice. 
 J may mention here that Sir B. Brodie had some confidence in this practice, for in 1843, 
 when discussing the case upon which Mr. Aston Key had operated without success at 
 Guy's Hospital, he expressed his belief that the right treatment of the pedicle was to 
 drop it in and close the wound, and that if success could be secured it would be by such 
 means. I make this statement on the authority of Dr. H. Oldham, who hoard the 
 remark. 
 
 What becomes of the ligated pedicle Avith the ligature or of the cauterized extremitj' 
 is a point of interest, and it may with some confidence be said that the ligated or cauter- 
 ized end does not slough, nor does the ligature act as a foreign body. In a case of my 
 own in which the pedicle was secured with carbolized catgut and dropped in with a good 
 result no traces of the ligature were visible a year later, when the patient died from 
 some cause other than the disease; indeed, there was not even an adhesion, for the fim- 
 briated end of the divided pedicle was free. 
 
 Dr. Doran' has also found, from a careful examination often cases at variable periods 
 after ovariotomy, that '' a communication between the distal and proximal parts of the 
 stump is established by inflammatory plastic eft'usion, and the ligature is unravelled by 
 granulation cells insinuating them.selves between its fibres.'" 
 
 Toilet of the Peritoneum. — When the pedicle has been secured, all bleeding 
 points should be carefully looked to. particularly at the seat of adhesions, and all vessels 
 should be twisted or ligatui-ed with fine carbolized .silk or catgut. 
 
 The second ovary, with the uterus, should then be examined, and the pelvis thor- 
 oughly cleaned with soft sponges. Indeed, the greatest care should be observed in what 
 ' St. Barlh. Hosp. Repa., vols. xiii. and xiv. 
 
Tin: ui'/:i:.\Ti').\ or ovmuoto.my. 7«jl 
 
 is culled the '• toilet til' llie iieritoiieiiiu, " so that Idotid cIhIh and fluid sliDuld be curerully 
 removed. In iiiy earlv days I. in cniimioii willi others, did not see the neeesxity of this 
 care. When this iniportant measure has heen completed, a flat spon;.'*- should he intro- 
 duced within the wound and left (ill the sutures have lieeu introduced. 
 
 Treatment of the Wound.— 'i'he operation completed, the ahdondnal cavity 
 cleansi'd, the opposite ovary examined, and all siyn.s of hcnnu'rha^M- ahscnt. the surjieon 
 may then ju'oeecd to the closure of the wound. He should do this l»y nicuris of deep 
 and superficial sutures; tho.se of silk plat, as sold hy fishiij'r-taekle makers, an.- the best. 
 These sutures should hi' inserted at intervals (jf an inch and maile to include tlu; museleit 
 and peritoneum, intermediate superficial sutures heinj.^ inserteil throujrh the skin. When 
 union has taken place — /. '., any time hetweeii three and si.x days — the sutures should he 
 reniovi'd. no nliject lieini; <rained hy leavinjj; them lon;;er in sifii. 
 
 Drainage Tubes. — In :ill complicated cases wliere tlie peritoneum has heen much 
 involved and there is a pndtahility of luunorrhatre or sennas exudation, a drainaj^e tube 
 should he introduced at the lower an^le of the wound. One made of <rlass is better than 
 the india-rul>l)er. 
 
 Aftkk-Tukat.MK.NT. — Whenever a iiatient has taken an an;e.->tlietic, it is wise to 
 keep the stomach as quiet as possible, and, as the benefit of an opiate after the ope- 
 ratittn is always frreat, it is wise to administer it by the rectum. In abdominal opera- 
 tions this practice is of great value, and for some years 1 have been accustomed to 
 •rive a half grain of morphia sup]iositorv after every ovarian operation, as well as 
 after others of hernia, ru])tured ])erin;vum. etc. The suppository should be adminis- 
 tered before the patient lias recovered from the efilects of the aiuosthetic, and care 
 should be taken that it be passed well into the rectum. If pain is felt, the supposi- 
 tory may be repeated; but it is rarely necessary to administer it more than once a day — 
 namely, at bedtime. The patient's room should be kept cool and airy, as in otiier cases 
 of operation. For the first two days milk or barley water forms generally tlie chief diet ; 
 but should sickness sujiervene as a result of the an:esthetic, ice and milk or ice and soda 
 water should be administered, and everything should be cold. If sickness continues, food 
 ought to be given two or three times a day by the rectum. As soon as the stomach will 
 admit, fresh meat, brandy, and wine ought carefully to be given, the object being in these 
 cases, as in all others of general surgery after the fir.st three days, to keep up the powers 
 of the patient, and so enable nature to complete the cure. The ai)plication of a Leiter's 
 coil to the abdomen I have found of great advantage, and an ice caj) to the head is bene- 
 ficial when the temperature rises above 102°. The urine ought to be drawn ofi" periodi- 
 cally ; and when the bowels rerjuire relief, their action should be rendered easy by the 
 use of enemata. The bladder should never be allowed to become distended or the bowels 
 be left loaded too long. 
 
 On the use of opium a few remarks remain to be made, for u])on this point the prac- 
 tice of surgeons appears to be uixlergoing a change. In the early operations of ovari- 
 otomy it was extensively employed, and at the present time some are still free with its 
 use ; but there is good rea.son to believe that in this operation, as in others, a very free 
 administration of the drug in every ca.se is not attended by such good results as could be 
 wished, and that in a ])atient under its full influence a wound does not repair .so rapidly 
 and favorably as in another where natural processes are allowed to progress without inter- 
 ference. Opium carefully given to allay pain and cause sleep is a drug concerning the 
 value of which there cannot be a doubt, but o])ium administered with sufficient freedom 
 to bring, and repeated often enough to maintain, a patient under its influence is a drug 
 against the use of which a surgeon should be on his guard. In ovarian cases it ought 
 not to be given in larger quantities than sufficient to allay pain and secure sleep. A 
 patient should not be kept under its full influence unless there are specific reasons for it. 
 It is best admini-stered by the bowel, being less liable to cause injurious effects and more 
 likely to produce good, since it is ab.sorbed as rapidly by the rectum as by the stomach ; 
 and in aV)doniinal operations it tends much to maintain that quietude of the bowels which 
 in all such cases is so desirable. In my own practice I have been accustomed for some 
 years to administer opium by the bowel in preference to the stomach in all cases of 
 abdominal surgery. 
 
 After the operation of ovariotomy jtatients may become jiregnant. Many of mine 
 have done .so, and in one case, recorded in the Gaz. Med. de Paris (1873), a patient had 
 twins — one male, and the other female. 
 
792 ON OVARIAN DISEASE AND ()\ ARIOTOMY. 
 
 Ovariotomy in Pregnancy. 
 
 Ovariotomy may even succeed when performed upon a pregnant woman. Sir Spencer 
 Wells has reported 9 such operations, with 8 recoveries. In 5 of the cases pregnancy 
 proceeded, and living children were born after natural labor ; and in all these the opera- 
 tion was performed within the fourth month. In the other cases a miscarriage occurred. 
 He lays it down as a rule that in cases of multilocular or solid tumor the tumor should be 
 removed in an early period of pregnancy ; and if an ovarian cyst should burst during 
 pregnancy, removal of the cyst and complete cleansing of the peritoneal cavity may save 
 the life of the mother, and pregnancy may go on to the full term. 
 
 Treatment of Slppurating Ovarian Cysts. 
 
 When an ovarian tumor is breaking down and undergoing disorganizing or suppura- 
 tive changes, whether spontaneously or after tapping, it has been already stated that it is 
 the surgeons duty to interfere and to remove what is a serious source of constitutional 
 irritation, and one which, if left to itself, must to an almost certainty destroy life. This 
 should be done by means of an exploratory operation. When the tumor can be removed 
 as a whole, so much the better ; but when it has contracted such adhesions with the parts 
 around as to be practically immovable, as much of the tumor should be turned out of the 
 parent cyst as possible and the cyst it,self stitched to the margins of the wound, the sup- 
 purating cavity being well washed out once or twice daily and a drainage tube left in. I 
 have recorded an excellent example of this practice in Gny'ii Ilu^p. Rep. for 1868, where 
 a woman a?t. 34 was successfully ti'eated by these means, and more recently, in 1874. I 
 removed a suppurating ovarian cy.st associated with acute peritonitis with a successful 
 result. 
 
 The strangulation of ovarian tumors by rotation is not rare. Rokitan- 
 
 sky in 18G5 published a paper upon it. It means that under certain circumstances the 
 movable ovarian tumor may rotate more or less upon its axis, and so twi.st the pedicle. 
 If the twist happens to be slight, no important interference with the circulation of the 
 vessels through it may be brought about ; but if it should be enough to prevent the 
 rettii'n of the venous blood from the ovary, congestion of the part strangulated, followed 
 by exudations of .serum, and possibl}' of blood, will follow, which give rise to symptoms 
 not unlike those of strangulated bowel. Indeed, cases of this kind have been regarded 
 
 as such. In Ann R , ^et. 28, under my care in February. 1884, the difficulties of 
 
 diagnosis were great, the onset of the symptoms having been sudden, the local pain severe, 
 and vomiting persistent. The symptoms had appeared after a railway journey. I ope- 
 rated at once, and removed a large polycystic tumor which was black from congestion and 
 with a Fallopian tube rigid with blood ; also some blood from the peritoneal cavity. The 
 pedicle was bloodless where twisted. Had relief not been given, the whole tumor would 
 have become gangrenous. As it was, the patient made a rapid recovery. 
 
 Wells reports two cases of sudden death from hemorrhage into the peritoneal cavity 
 from this cause. 
 
 Hysterectomy. 
 
 Operations upon the uterus have been gradually growing in favor, and the fact is 
 probably due to the experience which ovariotomists have accidentally acquired in the 
 removal of uterine tumors which have been mistaken for ovarian. They are now fre- 
 quently undertaken for cystic disease of the uterus and fibroid tumor, whether growing 
 as pedunculated, subperitoneal, or intramural growths, and much success has attended 
 the practice. 
 
 The operation has likewise been undertaken for cancer, but experience has not given 
 much support to the measure. 
 
 For fibro-cystic tumors the operation is a good one, for these growths steadily increase, 
 and do not, as the fibroids, cease to grow when menstruation has pas.sed away. 
 
 Fibro-cystic uterine tumors present all the external features of the more solid ovarian 
 and cannot be diagnosed, more particularly when a pelvic examination reveals but little. 
 When the uterus can be made out to form part of the tumor and to move with it, when 
 the uterine sound can be passed freely into the cavity of the uterus and be made to 
 extend far beyond its normal distance, when at each monthly period the flow is profuse, 
 when the tumor is fixed well in the pelvis and the abdominal veins, etc.. are turgid from 
 its mechanical pelvic pressure, — something more than a suspicion of its fibro-cystic nature 
 
iiYsTi'.in'.croMY. 
 
 7f».'J 
 
 may be foniKMl ; Imt when nm i tlnsc ^viiiiiliprii>. arr |irrsiiit, the ilia^'tuisis cariiKit he 
 
 inadi" with cfiMaiiit v. 
 
 Tilt' t)|»<'ratinii 111' cxtirii.-iliiiii of tin- nlrnis h:i> hccn ]mi riprmcd with HUcceHS hy Chiy 
 of MaiirhcsttT, Sturcr of |{(».stnii, KikIici li- ol" Stra.shiir;.', SchnnMh-r (jf Berlin, Keith of" 
 Ecliiihur^^h, Wells, 'riionitoii, Tait, Davies-Colley. ami iiiy.self. My own ca.se waH in the 
 
 person of Miss M , :ut. lid. Tlu- tumor ha<l ht-eri ".'rowiii;: for three years, aii<l for 
 
 this she had heeii mider the eare of l>r. Oldham, who helieved the ease to he om- of 
 ovarian disease. He .sent her to me for operation. On .Mav !!•, I'^Tl. I operated, and, 
 finding the uterus and hoth ovaries diseased, I removed the whole, ti.xinjr its hase with a 
 hirj;e elanip. An uninterrupted reeovery tnok |ilacc. l-'uli particulars will he Inund in 
 the Trxna. nf Obstif. Sar. ( 1S7I5). 
 
 I have operated on three other cases, hut not sueeessfullv. one patient dyin<r from 
 hemorrhage eau.sed hy the rupture ol' a pelvic vein and the others from the shock and 
 peritonitis. In two I removed the uterus and its tumors hy means of tlie chain ecra.seur 
 made by Meyer of (ireat Portland street. The chain should be passed well round the 
 base of the <;rowtli and >crewcd up .-Idwly. I wnuld, however, ti(»w use Lawson Tait'.s 
 clatnp (Fijr. 454). 
 
 Kk;. 4r,4. 
 
 "TT^ I^ mT^JaSJSvjSSSS^ ^^^ 
 
 Tail's (lanip. 
 
 Operations for uterine fibroids liave been more frequent than for cy.stic uterine disea.se, 
 and likewise more successful. They should not, however, be undertaken unless the 
 tumors form decided obstacles to the patient'.s progress through life, or give rise to trouble- 
 some hemorrhage. Many of these tumors cease to grow or to be a source of trouble after 
 the menopause, and many never interfere even with a woman's comfort. 
 
 In 1873 I removed a sessile fibrous tumor the size of a large cocoanut from the right 
 cornu of the uterus at the same time that I removed a large ovarian tumor from the left 
 ovary. The lady. set. 51, was a patient of Mr. Collambell of Lambeth, and recovered. 
 
 Mr. Thornton, who has had good experience of this operation, states " that large 
 pedunculated subperitoneal fibroids, when diagnosed, ishould be removed, even though 
 they may oidy cause inconvenience at the time.' He adds, however, that " operations 
 for intramural fibro-myomata are specially dangerous, since they naturally involve the 
 opening of the uterine cavity." The operations are far more formidable than ovarioto- 
 mies. " If you have to think twice," writes Keith, " before advising a woman to have 
 ovariotomy done, you must think fifty times ere you recommend her to have a uterine 
 tumor removed."' Neither Wells nor Thornton advocates their removal indiscriminately, 
 but rather the adoption of Batteys operation or the removal of the uterine appendages 
 to check the growth of the tumor when it gives rise to troublesome hemorrhage. 
 
 Thornton has performed Batteys operation fifteen times, and with success, ten of the 
 patients having lost their tumors ; in two the tumors are lessening, and the remaining 
 three are recent cases. 
 
 Lawson Tait has ably advocated this same measure, and has had much success. He 
 writes that the operation for the removal of the uterine appendages for uterine hemor- 
 rhage, when associated with uterine tumors, has been accepted. 
 
 Operation. — In a general sense the i«ame principles of practice are apjilical)le to 
 these cases as to those of ovarian disea.se. The one difficulty is the treatment of the 
 pedicle where such exists, or of the divided uterus. 
 
794 ' OX OVABIAX DISEASE AXB OVARIOTOMY. 
 
 When a fibroid tumor is pedunculated, there is no difficulty, as .the pedicle may be 
 tied in halves and dropped back, as in an ovarian tumor. When it is large and, thick, 
 possibly Thorntons method is very applicable, as described b}' him (Brit. Mtd. Journ., 
 October 13, I880) : 
 
 •• If the pedicle be transfixed, hemoiThage from the puncture is liable to occur and 
 very difficult to control. I therefore first secure the pedicle by a ligature tied firmly 
 round the whole of it. then, threading an end of this ligature through the needle again, 
 transfix the pedicle on the distal side of the first tie and proceed to ligature in halves or 
 smaller pieces if necessary. This method renders slipping of the ligature impossible.' 
 
 Under the above circumstances the pedicle may be dropped back and the abdominal 
 wound closed. 
 
 This practice must not. however, he adopted when the uterine cavity is exposed. 
 Under such circumstances the pedicle should be kept outside the abdominal walls. Sir 
 Spencer Wells uses for this purpose a stout pin about the size of a penholder, around 
 which he twists a figure-of-8 ligature, the two acting together as a clamp. Koeberle 
 employes his serre-noeud. and it is useful ; but Lawson Tait's clamp is probably better, 
 as it can secure a pedicle of any size and hold it securely. Indeed, when a clamp is 
 wanted for any operation, no better can be used (Fig. 454). Should there be any fear 
 of the clamp slipping, one or two pins may be passed through the distal side of the 
 pedicle to make it secure. 
 
 Hegar of Freiburg (Berlin l-Iiu. Woch.. No. 12, 1882) recommends the u.se of the 
 elastic ligature in the removal of abdominal tumors and organs. He has removed uter- 
 ine fibroids by this method without hemorrhage. From man}- experiments he thinks it 
 is evident that uterine pedicles can be treated without danger by the ela.stic ligature. 
 
 Carl Schroeder of Berlin, when removing his intramural fibroids, uses an india-rubber 
 ligature as a temporary clamp, enucleates the growth, and stitches together the capsule 
 of the growth with different layers of sutures, one suturing the mucous membrane of the 
 uterine cavity and the other the peritoneal layer, subsequently draining the cavity 
 through the vagina. 
 
 Out of 66 patients operated on by him. 20 died, or 30 per cent. Of his last 40, 
 he. however, lost but 9, or 22.5 per cent. 
 
 L. Tait has had 28 cases, with 6 deaths, or 21 per cent. Spencer Wells has had 39 
 cases, with 21 deaths, or 53 per cent. Keith has had 17 cases, with 1 death. 
 
 This operation of hy.sterectomy is the gravest the surgeon can undertake ; when com- 
 plicated, it tries him to the utmost. Let it not be undertaken rashly or without the 
 fullest consideration. 
 
THE SURGERY OF THE MUSCULAR AND 
 OSSEOUS SYSTEMS. 
 
 CHAPTEK XXXIII. 
 
 AFFECTIONS OF TIIK MUSCLES AND TENDONS. 
 
 Contusions. 
 
 Contusions of muscleis, as of other parts, may occur, and when severe may be fol- 
 lowad not only by want of power, but by absolute wasting. Thus, in ISti!^ I saw a man 
 .•vt. 44 who five months before received a severe contusion of the left deltoid mu^jcle from 
 a fall upon the shoulder, and as a consequence the muscle liad completely atrophied, 
 although there was no loss of sensation over the muscle and in all other respects the limb 
 was normal. 
 
 When wasting takes place, the muscle should be stimulated by galvanism before 
 degeneration has proceeded too far. When due to the want of nerve force, there is little 
 hope (if auv good rt'sult being ulitaiiicrl iin<ler any treatment. 
 
 Subcutaneous rupture of rauSCle to a slight degree is far from being uncom- 
 mon, particularly of the deltoid: but its complete rupture is very rare. In most ca.ses 
 of strains some rupture of a muscle takes place, which often shows itself by the effusion 
 of blood into the part. 
 
 At times a muscle is torn across by overaction, as in tetanus, the rectus abdominis 
 being that mo.st frequently affected ; but the psoas has been said by Mr. Earle to be .so 
 injured. Sedilhjt reports that out of 28 cases of ruptured muscle, 13 occurred at its point of 
 juncture with the tendon. He says, also, that rupture occurs only in some involuntary 
 action of the muscle or when it is taken unawares. In 1859 I attended a man aet. 21 who 
 ruptured the left rectus abdominis above the umbilicus when jumping with some bricks in his 
 hand. He was collapsed after the accident ; and when I saw him, the next day, the two ends 
 of the muscles were so far asunder as to allow the fingers to })e placed between them. In 
 1808 I also attended a man xt. 05 
 
 who, when lifting a cask with his Fig. 45.^. 
 
 body bent, felt an acute pain in the 
 posterior ])art of one thigh, " as if he 
 had been .struck with a potato ;" he 
 fell forward and was unable to walk. 
 When I saw him. two days after the 
 accident, the semi-membranosus mus- 
 cle had clearly been divided at its 
 origin from the tuber ischii ; the body 
 of the muscle could be felt as a loose, 
 fleshy mass, and below the tuberosity 
 of the ischium a marked deficiency was present. I have also the notes of a case of com- 
 plete laceration of the extensor triceps muscle of the thigh above the patella in a railway 
 inspector, who said that it gave way with a report on his attempting to start off suddenly 
 for a run. In this case there was great effusion of blood into the part within a few 
 hours, which had sub.sided after the application of ice. tlie separation of the muscle from 
 the patella being very distinct. In the drawing (Fig. 455\ rupture of the rectus femoris 
 is illustrated, and was taken from a male patient a^t. 42. 
 
 Minor degrees of laceration of muscles are of common occurrence, often followed for 
 
 795 
 
 Rupture of Rectus Femoris just above Patella in a Man set. 42. 
 
796 AFFECTIONS OF THE MUSCLES AND TENDONS. 
 
 many months by pain, stiffness, and want of power in the part, the pain disappearing for 
 a time to reappear on any overaction of the weakened muscle. These pains are often 
 called '' rheumatic." 
 
 In his Fothergillian prize essay Mr. Poland records two cases of complete rupture of 
 the rectus abdominis muscle in the hypogastric region, so that the finger could be laid in 
 the dents between the retracted ends. Both occurred in the wards of Gruy's Hospital and 
 in men of advanced years suffering under organic disease ; the one had an advanced stage 
 of bladder and kidney mischief the sequels of old stricture, the other was suffering from 
 a relapse after continued fever. In both the accident had been caused by a fall across 
 the iron rods of the bedstead in a vain attempt to rise and walk. Both died a few days 
 after the accident, when complete rupture of the rectus was found in the middle of the 
 hypogastric region, and coagulated blood existed between the divided ends, as if only just 
 poured out. No signs of repair were present. 
 
 Treatment. — In all cases of completely ruptured muscle the parts must be relaxed, 
 in order that the divided ends may be made to approximate as much as possible and 
 be fixed at rest, so that repair may not be interrupted. AVhen much effusion of blood or 
 serum follows, ice may be applied in a bag; and when absorption has somewhat advanced, 
 a stimulating liniment ha.stens recovery and gives comfort. When these are not attended 
 to. repair cannot go on ; indeed, as a consequence of neglect, suppuration is by no means 
 a rare result, as is seen in psoas abscess. When the laceration has been complete, perma- 
 nent weakness will remain ; and when the abdominal muscles are at fault, some hernial 
 protrusion of the abdominal contents will take place. In a man who fell from a ship's 
 ladder upon a blunt-pointed iron bar. and had severe rupture of the abdominal muscles 
 attached to the anterior half of the crest of the ilium, a large hernial protrusion existed 
 and I could press my fi.st into the opening through the muscles. In such cases some 
 artificial support is permanently needed. 
 
 Compound Laceration of Muscle. 
 
 When muscles are lacerated in connection with wounds of the soft parts covering 
 them, the injury is grave, and the primary danger of the case, as well as the prognosis as 
 to the future use of the part, turns upon the amount of laceration. In compound frac- 
 tures, etc.. this fact is well known. 
 
 But at times muscles are torn out through skin wounds or are ruptured at the time 
 of the accident, and may even hang out of the wound. When this is the case, the mus- 
 cle, unless much crushed or injured, must not be cut away, but replaced in position as 
 well as possible ; and to further this end the wound in the soft parts may be enlarged. 
 One of the worst cases of this kind I have ever seen I attended with Dr. Mason of the 
 Barbican. It was that of a gentleman fet. 22 who when sleep-walking fell a height of 
 forty feet out of a window on a glass skylight. Among other injuries, he sustained a 
 lacerated wound of his right thigh and complete division of the body of the inner ham- 
 string muscles. When I saw him a large mass of well-developed muscle protruded from 
 the skin wound. I enlarged the opening in the integument and carefully replaced the 
 muscle, keeping the limb on a splint. In five weeks he was convalescent. A year later 
 he had complete movement of his limb. Entire tendons are sometimes torn out of a 
 limb, and in Guy's Hospital Museum there is a preparation (1367) which includes the 
 last joint of the middle finger with its tendon of the flexor profundus attached. It was 
 torn by a threshing-machine, the accident being followed by tetanus ; yet the patient 
 recovered. In another preparation (1119^), figured below (Fig. 456), there is a portion 
 
 Fig. 456. 
 
 Sllorl 
 
 ThumVi. with Tendons, etc . Torn Out bv Machinerv. 
 
 of thumb with the long flexor and extensor and short exten.^or tendons, together with 
 the nerves, torn out by machinery. It was taken from a man aet. 17 who made a good 
 recovery. 
 
Ri'i'ir/U:' OF rhWDoys. 
 
 797 
 
 Dislocation of Muscles and Tendons. 
 
 TluTc is j^odd reason tti l)clievo tliiit iiiiisclcs. like tciitloris, iiiav he dislocate*!, altlnMij^h, 
 from the way the t'oniier are proteett'*! hy laseia ami the latter hy tihnms sheaths ami bony 
 •grooves, siieh aeeideiits are rare. When they occur, they are the result of some sudden and 
 une.xpeeted strain, rick, or twist. In the upper extremity the accid(Mit may occur to the 
 biceps tendon and thosi; al)out the wrist. 1 hav(; never seen a dislocated biceps tendon, 
 but must refer to an able article on the subject l)y Mr. J. W. White of Philadelphia, 
 published in the Aincr. Jiturti. <>/' Mnl. Sci., .January. 11S84. In the lower limli it may 
 occur to the peronei tendons and tendon <d' the posterior tibialis, a.s well as to the eon- 
 joined tendon <d' the extensors of the leg attached to tlie patella, and to that of the sar- 
 torius muscle. Other tendons may also, doubtless, be dislocated. 
 
 Whenever dislocation takes place, it can be recofrnizcd by the starting of the tendon 
 from its anatomical jtosition, as well as by the pain suffered on putting the muscle into 
 action, the muscle necessarily acting at a disadvantage. The temlon in most ca.ses may 
 be readily reduced, but the greatest difficulty will be ex[)erieneed in keeping it in ])osi- 
 tion ; indeed, it is a question whether the sheath of a tendon, when fairly ruptured, will 
 ever unite or repair ; yet the attempt to obtain it should be made. In a case of disloca- 
 tion of the peroneus longus tendon the only treatment that gave permanent relief was 
 its division, and, what is more, the foot was not visibly weakened by the operation. In 
 18t)!> I had under my care a woman ;et. 2!l with a well-marked example of dislocation of 
 the peroneus longus tendon. Some ten days before I saw her, when walking, she felt a 
 sudden pain behind the external malleolus which led her to think she had been struck 
 with a stone. She was at once disabled and experienced severe pain in the part, and on 
 rubbing her ankle at the time she felt a cord in front of the bone, which slipped in on 
 moving the foot. Since that time any movement of the ankle caused the same cord to 
 appear. When I saw her, by giving the foot the slightest twist the tendon of the pero- 
 neus longus muscle could be readily displaced from its groove behind the external mal- 
 leolus and made to appear upon the bone, where it could be rolled under the finger. Its 
 reduction was eff"ected by abducting the foot, but it was kept in its position with great 
 difficulty. For this purpose the best means were a good pad of lint fixed over and behind 
 the ankle by means of strapping. I saw her a month after the accident, when she could 
 walk witliout pain or stiffness; the tendon seemed fixed in its place, but the bandage 
 and pad were reap]ilied and directions given to retain them for a month. I have like- 
 wise seen the tendon of the tibialis posticus displaced from behind the inner malleolus. 
 
 Dislocations of muscles are probably more rare than those of tendons, and, if not, are 
 less recognized. They may be suspected to have taken place where, after a rick or strain, 
 pain is produced when the muscle is put into action and the pain is fixed to a spot, when 
 this pain is relieved by relaxing the affected muscles and kneading the part with the hand 
 when so relaxed, and when, moreover, there is no external evidence of a bruise to suggest 
 rupture of muscle. These cases should be treated by manipulation after relaxing the 
 muscles, the surgeon with a strong and firm pressure manipulating the part at the seat of 
 pain ; subsequently, pressure should be applied and the muscle kept at rest for a sufficient 
 time to allow the injured part to heal. 
 
 Fig. 457, 
 
 Rupture of Tendons. 
 
 This accident is more common than rupture of the body of a muscle, and a tendon 
 usually gives way at its muscular or bony origin. It occurs chiefly in subjects past mid- 
 dle life. The long biceps tendon not rarely gives 
 at its upper end ; and when it does, it imparts to 
 the biceps muscle, on contraction, a peculiar ap- 
 pearance, its inner or coracoid half contracting 
 into a hard knot (Fig. 457), while its outer re- 
 mains lax and but slightly altered. This swell- 
 ing has been mistaken for tumor of the muscle 
 of the arm. When the one tendon breaks, the 
 other usually follows at a later date, thereby 
 clearly indicating that they give way from some 
 disease. In a case I treated in 1858 the two 
 tendons gave way at the interval of four months, 
 Ruptured Long Teudon of Biceps. (Drawing 37^) and the arm became black and blue after the 
 
798 AFFECTIONS OF THE MUSCLES AND TENDONS. 
 
 accident. The tendo Achillis rarely snaps. The plantaris does so occasionally, and causes 
 a peculiar dragging of the foot and eversion. In the case of a man aet. 27 which I saw a 
 few hours aftfir the accident this symptom was so marked and peculiar as to make it 
 quite pathognomonic. The rupture was caused by taking an upward step of two and a 
 half feet into a vessel with a load on his back. The tendon gave way with a snap when 
 in the act of raising the posterior part of the heel from the ground. 
 
 I have likewise the notes of a case of rupture of the tendon of the hiceps femoris 
 which took place in a boy ?et. 8 who when hanging on behind a four-wheeled cab had 
 one of his legs entangled in the wheel. When admitted into Guy's, directly after the 
 accident, the tendon of the biceps femoris was made out to have been ruptured at its 
 insertion into the fibula ; there was a marked depression at this point, with ecchymosis. 
 The limb was flexed and fixed on an outside splint, and a good recovery ensued, although 
 there was some weakness of the muscles supplied by the external popliteal nerve, which 
 had apparently been injured at the same time. 
 
 Looking upon the ligamentum patellae as a tendon, the following example of its rup- 
 ture may be recorded. In 1867 I was called upon to treat a man ast. 31 for an injury he 
 had sustained to his right knee ten days previously while attempting to save himself from 
 falling backward. The knee swelled after the accident and became acutely painful ; and 
 when I saw him the patella was drawn up for at least an inch, the ligament having been 
 divided. I treated the case as for fractured patella, with a posterior splint, and employed 
 pressure to bring the patella downward : but I was unaVjle to alter its position to any 
 extent. The man recovered, however, with a useful limb. 
 
 Wounds of Tendons. 
 
 When tendons have been divided in incised wounds, they separate, and their separated 
 ends adhere to their sheaths, with the necessary consequence of impaired movements of 
 the parts to which the tendon is attached. To avoid this, as a primary treatment of 
 divided tendons the tendons should always be sutured with silk or catgut, the muscle 
 with which it is connected relaxed, and the wound dressed for quick union, the part being 
 kept in position by means of a splint. 
 
 In June, 1883, a woman aet. 34 had the extensor tendons of her ring and little fingers 
 divided above the wrist. My dres.ser enlarged the wound lengthways, found the separated 
 ends, and .stitched them together with carbolized catgut. He then washed the wound 
 with iodine water and dressed it with terebene oil. Good repair followed, with movement 
 of the fingers. 
 
 In June, 1883, a man ?et. 31 came under my care with a divided tendo Achillis from 
 a broken water-jug. The ends of the divided tendon were separated for about two inches. 
 My dres.ser, Mr. R. Knaggs, by my direction exposed the tendon fully by a vertical incis- 
 ion, wa.shed the wound with iodine water, and sutured the tendon with one central suture 
 of carbolized catgut and two lateral sutures of kangaroo tendon. He then extended the 
 foot and fixed it on a splint. The wound was dressed with terebene oil. Quick union 
 followed, and excellent repair, without suppuration. In two months the man had a sound 
 leg and strong tendon, with perfect movement of the foot. 
 
 This practice of stitching important tendons ought always to be adopted. 
 
 There is good reason to believe that a divided tendon may be successfully cut down 
 upon several weeks after its division and its ends sutured with a good result. 
 
 In wounds where muscles and tendons unite by granulations .some stiffness and want 
 of power in the part will remain for a long time, or even altogether. In healthy subjects 
 it is remarkable how tendons at one time fixed subsequently free themselves from their 
 surrounding attachments and become free again. This hope may always be held out to a 
 patient who takes a gloomy view of his own prospects. 
 
 Inflammation of Muscle 
 
 is a recognized affection, and occurs as a consequence of some strain or partial rupture 
 of its fibres, as well as independently of any such cause. It is the more common as a 
 result of injury, and is seen not seldom in the rectus abdominis as well as in the psoas 
 muscle, in which, as a cause of psoas abscess, I believe it to be not rare. As a result of 
 septicfemia it is frequently met with, and is found in every muscle, even the heart. It 
 appears as a more or less acute affection of the muscle, and is accompanied by swelling, 
 local pain, and constitutional disturbance; suppuration occurs in due time. The symp- 
 
IMLAMMATloy OF MfSCLK 
 
 09 
 
 toms nircly come on /lircclly af'ttT (lit- injury. JmiI pnihaMy afdr t.lic lafisi- of sLVt-ral 
 weeks, a.s a rorisecjiiciif*' nl' sdiiH' want of repair in tlic injured part, anil i'roin tin; non- 
 ohscrvance of the nceessarv rest wliieli an injured muscle so much reijuires in the process 
 of healinir. When an altseess forms in a njusele, the sooner it is opened the better, recov- 
 erv readily I'nllowinfr, even when the disease is in sueh a museular or^Mii as tin; tonjrue. 
 
 Intlammation of muscle as an independent afl'e<*tion is generally chronic, and in adults 
 is chieflv of syphilitic origin. In inl:int> it is met with most commonly as an affection 
 of the sterno-mastoid muscle, the hody oi" the muscle wholly or in jiart appearing as an 
 indurated mass. It is generally ol»served soon after birth, and may at times he traced to 
 some injury sustained at that time. I have seen it in the offspring of syphilitic parents, 
 hut more fre»|uentlv when no such history could he obtained. In fifteen consecutive ca.ses, 
 a syphilitic history was obtained oidy in one. These ea.se.s rarely if ever suppurate in 
 infants, but under the use of warm fomentations and .some simple tonic, such as cod- 
 liver oil, proceed to a natural recovery. I have never seen a ease fail to recover by these 
 means. 
 
 In the nirh/ period of the di.sease the inflammatory product is cellular; in the /ati r, 
 fibrous. These points are seen in Figs. 45S and 4.")It. which have been kindly made for 
 me by Pr. (Joodhart. Tlu-y were taken from a patient of Dr. F. Taylor jet. 5 weeks who 
 looked healthy, but had had '' snuffles," 
 slight fissuring of the anus, and superficial I'k;. 458. 
 
 ulceration of the .scrotum. There was no 
 history or other evidence of syphilis in the 
 parents. The child died from atelectasis. 
 The tumor in the l(/t muscle was only no- 
 ticed in the fifth week after birth, and the 
 rii//tt muscle was never noticed to be dis- 
 eased. The case is rej)orte(l in the /*<if/i. 
 Soc. Trans., 1875, vol. .xxvi. 
 
 The student .sluuild remember that this 
 affection appears as a simjile induration of 
 the muscle, and is, therefore, unlike any 
 glandular or other affection. 
 
 Chronic inflammation of the sterno-mas- 
 toid is likewise met with in adults, and, I 
 believe, chiefly as a consequence of syphil- 
 itic disease. It attacks the muscle in the 
 
 same way as it does others, such as those Showing the Early or Cellu- 
 n .1 . ii, 4. 1 • /• lar Stage. (I'roni the right 
 
 of the tongue, the e.Ktensor quadriceps of muscle ) 
 the thigh, the triceps of the arm. the tem- 
 poral, masseter, or other Uiuseles, the muscle or muscles becoming infiltrated more or less 
 dift'u.sely with the well-known syphilitic inflammatory products. These tumors, when their 
 nature is recognized and right treatment is employed, can be reabsorVjed ; but if neglected 
 and left alone, after attaining their full size, which is rarely great, they break up and sup- 
 purate, giving rise to deep-seated abscesses, which when they have discharged externally 
 leave deep, irregular, excavated sores. In the tongue they simulate closely cancerous 
 sores, many of the cases of supposed cured cancer of the tongue being, doubtless, of this 
 origin. In other parts they have much the aspect of the deep cellular membranous ulcers 
 which have been already described. As a part of syphilis they always appear late in its 
 course and remote from the primary inoculation. When they appear in the adult, in the 
 sterno-mastoid muscle, they more frequently attack its .sternal end than its body. 
 
 After the disease has ceased atrophy of the affected muscle is a common consequence. 
 Contraction occasionally follows, though I have never seen it. MM. Rieord and Notta 
 have, however, recorded examples. 
 
 Recognizing the syphilitic nature of this affection, the treatment should be conducted 
 on the usual principles; large doses of the iodide of potassium — say fifteen to thirty 
 grains — may be given three times a day with advantage, not in such full doses at first, 
 but by gradual increase from one to five grains. Mercury may also be given, the mer- 
 curial suppository once or twice a day being the best form. In the chapter on Syphilis 
 this practice will be found described in detail. 
 
 The Late or Fibrous stage. 
 (F'roiii the left iiitiscle.i 
 
800 AFFECTIONS OF THE MUSCLES AND TENDONS. 
 
 Atrophy of Muscle. 
 
 The surgeon can see this under a great variety of circumstances. He is the most 
 familiar with it as a consequence of want of use in disease of the joints or any other 
 aft'ection in which the limb is kept at rest, and under these circumstances the muscles 
 simply wa.ste ; they undergo no other change in structure and are capable of complete 
 restoration on reassuming their normal action. 
 
 In a large number of cases of infantile paralysis the same thing may also be said, for 
 under the stimulus of galvanism or the continuous current, persevered in for many 
 months, the thinnest limbs plump up and the feeblest muscles become capable of perform- 
 ing the work for which they were intended. Indeed, in those cases where deformity 
 does not complicate the case a good result may be looked for. 
 
 After fevers, lead poisoning, rheumatism, scrivener's palsv. and alcoholism the mus- 
 cles may undergo genuine degeneration, either granular, fatty, or waxy, and according to 
 Lockhart Clarke '• there is another form of this malady, which is known by the name of 
 proc/ressive muscular atrophy (Cruveilhier). atrop)liie muf.rnla'irK gralsKeuse progres!<ive 
 (Duehenne), and icastinij poh>j. This curious disease differs in several respects from the 
 other atrophies. It is always chronic, but of uncertain duration, is frequently hereditary, 
 capricious or irregular in its invasion, prone to spread from one part to another or become 
 general and thus go on to a fatal termination. The affected muscles suffer different 
 degrees of wasting and assume a variety of aspects. Even in the same muscle bundles in 
 different stages of atrophy and degeneration may be found at the side of others that have 
 retained their normal state. When the wasting is extreme in all the bundles, a long 
 muscle may be reduced to a mere fibrous and cylindrical cord or to a kind of tendon, and 
 a flat muscle may be reduced in the same manner to a kind of membrane. In some 
 instances the atrophy may be simple — that is, the muscular tissue may be wasted to a 
 considerable degree without any granular or fatty degeneration ; but generally one or both 
 of these alterations of structure are found to exist to a greater or less extent. The mus- 
 cle also changes and varies in color according to the nature and degree of the atrophy. 
 It is paler than natural ; occasionally it is quite colorless, like the flesh of fish, or it may 
 have a faint yellow or ochreous tint. Its consistence for the most part is increased in 
 consequence of the increase in the interfibrillar connective tissue. When examined under 
 the microscope, the affected muscles may be seen to have lost to a variable extent and 
 degree, or even entirely, the appearance of transverse and longitudinal .striation. while in 
 a corresponding proportion the sarcous or muscular element is transformed into granules, 
 which in some instances are too fine to be distinguished as separate particles. The gran- 
 ules are soluble in acetic acid. In this odd affection the granular, fatt}-, and waxy degen- 
 erations are found side by side "' (Holmes s Si/sf., 3d ed., vol. ii. p. 163). 
 
 Symptoms. — This disease is said to appear more commonly in t]ie hand and right 
 upper extremity, progressing upward to the trunk, and then ov^r it to the lower extremi- 
 ties. It rarely commences in the lower limbs. It begins with loss of power in the part, 
 this loss gradually increasing, but rarely with any loss of sensation. Want of muscular 
 co-ordination soon appears, as well as awkwardness in the patient's movements, and 
 cramps, twitches, and fibrillary tremors take place, occasionally with pain or some cuta- 
 neous anaesthesia. Cruveilhier believed that atrophy of the motor nerves was the start- 
 ing-point of this disease, but this theory is not now entertained. Lockhart Clarke says, 
 '• In 1861 I discovered in the spinal cord removed from a well-marked case of this disease 
 numerous lesions of the gray substance, consisting chieflv of areas of what I call granular 
 and fluid disintegration ; and I have seen the same in other cases since."' This view is 
 taught by Trousseau. Duehenne, 3Ieryon. Roberts, Cohn. and others. 
 
 This disease is generally hereditary, more common in males than in females, and is 
 excited by excessive muscular exertion, cold, and damp, as well as by injuries or disease 
 of the spine, syphilitic nr otherwise. 
 
 Treatment. — Removal of the cause is the primaVy object : and when syphilis is sus- 
 pected, special treatment should be employed. Tonics are always of use. and arsenic in 
 Dr. 3Ieryon's hands has met with good success. " but of all remedies hitherto employed 
 galvanism is undoubtedly the most useful when applied to the affected muscles." 
 while Clarke states that setons and blisters to the spine may be employed, in the early 
 stage. 
 
 Degeneration of muscles "with apparent hjrpertrophy — called 
 
 '■ Duchennes disease." after its first describer. in !>!")>! — is a strange affection which 
 attacks children, but continues to affect them for manv vears of their vouth. I have 
 
Tl'Mons I.\ MI'SCLI-:. HOI 
 
 pniuped it amongst tlie afl'octiims nl" tlic miisclt's, Imt the ohsorvatioiis of I)r. L. Clarke 
 ( Mri/.-C/iir. Tniiis.. vol. Ivii., 1^7 1) clearly jilaci' it aiiKiiigst tho neuroses. It In-gin-s 
 with wi-akni'ss of tlu' lowi-r liinhs, which is lasting and passes on to a progres.sive enlarge- 
 ment of the gastrocneniii, then of the glutei and luinltar muscles, anil occasionally of all 
 the mu.scles. These I'eel tirni and elastic, and hard on contraction. After a variable 
 period — at times years — the paralysis gradually increa.ses and becomes more general. 
 "The patient is no longer able to stand upright, the upper e.vtremities become affected, 
 the eidarged muscles rapidly decrease in volume, and the limbs and trunk become atro- 
 phied ni iiitissr. lu this state the patient may exist for a considerable time, but he ulti- 
 mately dies from inti-nurreut disease. Many of the children afi'ected with this singular 
 dis(U(ler have dull intellects and are more or less idiotic " (Clarke). I'atlmlugically. great 
 hyjiertropliy of the connective tissue of the muscle is to be found; the fibres themselves 
 show finer stri;c and are transparent, and large cnllectifjiis of fat cells also exist. Neither 
 medically nor surgically does any treatment seem to be of benefit. 
 
 Writer's Cramp, 
 
 or scrivener's palsy, is a good example of what Duchenne has called " functional impo- 
 tence," and it is doubtless due to overuse or exhaustion of the muscles employed. It 
 begins as an aching of the hand after prolonged writing, with diminished facility in the 
 act. After a time the pen is held in odd ways and with unusual tightness, but in spite 
 of this it often falls from the hand. The whole fore-arm or arm soon shares in the trou- 
 ble, and the difficulty in forming letters rapidly increases ; tremors of the hand at times 
 occur. At last the handwriting becomes illegible or the patient loses all power even of 
 making his mark. With these local symptoms there is often severe headache or back- 
 ache, and at times great mental distress. 
 
 In the nuijority (»f cases the inability to write is the sole trouble, but in many there 
 is equal difficulty in adapting the muscles of the hand to the pei'formance of any delicate 
 action. 
 
 The affection is to be treated by rest, as guaran- rio. 46 . 
 
 teed by a splint, and later on, when pain has passed, 
 by gentle galvanic stimulation. 
 
 As a help to sufferers the instrument figured (Fig. 
 460), and suggested by Xussbaum of Munich, seems 
 of use ; the eminence of its introducer is a guarantee 
 of its value. It is framed upon the opinion that, what- 
 ever the site of the malady, there is always spastic 
 contraction of the flexors and adductors, with a weak 
 condition of the extensors and abductors. With the ,. ^ , , „r . , 
 
 , , • 1 /> T 1 >ussbaum Instrument for Writer s Cramp. 
 
 bracelet put on as seen in the ngure, these last mus- 
 cles are strongly put into use, since the in.strument can be worked only by abduction of 
 the thuml) and the extension of the digital muscles. The patient may write with the 
 instrument as much as he likes. 
 
 Tumors in Muscle. 
 
 These are of rare occurrence and always of a serious nature. They are mostly of the 
 fibrous or fibro-cartilaginous kind. In 1866 I excised one of two years' growth from the 
 fleshy portion of the external oblique muscle of a woman a^t. 31 (Pafli. Soc. Trans., vol. 
 xviii.). The tumor se])arated the fibres of the muscle which it infiltrated, and micro- 
 scopically it had all the elements of the fibro-pla.stic tumors. It returned within the 
 year; and when I last saw the patient, in 1869. there was a .second growth, the size of a 
 cocoanut, occupying the place of the original tumor. In 1868, with Dr. Burchell of 
 Kingsland, I removed from tho abdominal muscles of a woman net. 33 a myxomatous 
 tumor eight or nine inches in diameter, of two years' growth. 
 
 Cancerous tumors may originate in, but more frequently infiltrate, muscles as 
 secondary growths or by cxten.sion from other parts. Surgeons see them in the pectoral 
 muscles in acute or neglected cases of cancer of the breast ; in the periosteal cancer of 
 bone, as well as in other parts. In the tongue and lip they may be regarded as new 
 growths. 
 
 Hydatids, likewise, are found in muscles, as in ever}- other tissue, as painless, ten.se, 
 globukr swellings. So also is that curious nematode worm the Trichina spiralis, which 
 "51 
 
802 AFFECTIOyS OF THE MUSCLES AXD TEXBOXS. 
 
 in man seems to be taken into the body through eating the insufficiently cooked flesh of 
 animals infested with it, particularly that of pigs. 
 
 " Trichinaj, as ordinarily observed in the human muscle, present the form of spirally- 
 coiled worms in the interior of small, globular, or lemon-shaped cysts ; which latter appear 
 as minute specks scarcely visible to the naked eye. These specks sometimes resemble 
 little particles of lime, and are more or less calcareous externally according to the degree 
 of degeneration which their walls have undergone ; these cysts are not, however, essen- 
 tial " (Cobbold). 
 
 When these worms are present in large numbers in the body, they give rise to a dis- 
 ease known as " trichiniasis," which is most fatal. Dr. Boehler and Konigsdbffer of 
 Central Saxony, who first saw this disease according to Leuchart. who described it. state 
 that '■ the aifection began with a sense of prostration, attended with extreme painfulness 
 of the limbs, and after these symptoms had lasted several days an enormous swelling of 
 the face very suddenly supervened. The pain occasioned by this swelling, and the fever, 
 troubled the patients night and day. In serious cases the patients could not voluntarily 
 extend their limbs, nor at any time could they do so without pain ; they laj' mostly with 
 their arms and legs half bent — heavilv'. as it were, and almost motionless, like logs. 
 Afterward, in the more serious cases, during the second and third week an extremely 
 painful and general swelling of the body took place. A large proportion of the cases 
 died. Dr. Thudichum has given an able report on this subject in the 3Ii-(Jic<il Officers' 
 Report to the Privy Councif (1SG4). 
 
 Vascular tumors of muscle have been made the subject of a special paper by 
 IVIr. C. de Morgan (Brit, and For. Med.-Chir. Rev., 1864), and Mr. Teevan has published 
 an able paper on tumors in muscle in the same review for 1874. These, however, are 
 very rare. The vascular tumors of erectile tissue attack a muscle either as a diffused or 
 encapsuled growth or as tumors having the appearance of varicose veins around the mus- 
 cle. They are chiefly, though not always, congenital, and are generally found in the 
 lower extremities. They have no definite clinical history beyond their gradual and pain- 
 less increase. My colleague. 3Ir. Howse. in 1872 exci-sed such a non-encapsuled growth 
 from the biceps muscle of the thigh of a woman aet. 2.3, which was made up of erectile 
 tissue and highly vascular and had been growing for eight years. He excised all the 
 muscle that was involved, but left its tendon. A good recovery ensued, with free move- 
 ment of the limb. 
 
 Ossification of muscle Tmyositis ossificans) is a condition which must be recog- 
 nized. At the College of Surgeons and St. George's Hospital preparations exist which 
 illu.strate how the muscles of the back may become plates of bone and the pelvis, ribs, 
 and scapuhie the seat of bony outgrowths. In a smaller way the " drill bone " of the 
 Prussian soldier — a plate of bone in the deltoid muscle — and in this country the " rider's 
 bone," in the origin of the adductor longus muscle of the thigh, are illustrations. 
 
 Some years ago one of my colleagues at Guy's excised from the body of the deltoid 
 muscle a piece of bone an inch long, the growth of some years. 
 
 The Rider's Bone. — What has been described as " the rider's bone " is probably 
 at first an inflammatory infiltration, and subsequently an ossification, of the tendon of 
 the pelvic origin of the adductor longus or magnus muscle. I had such a case under 
 ob.servation in the person of a medical friend set. 44, who while hunting in 18G9 made a 
 violent efi"ort to grip his horse when about to make a long jump. The eff"ort was not 
 attended with any pain, but was followed by much ecchymosis, extending down to the 
 knee, and loss of power in the muscles of the part. When these symptoms had subsided, 
 a dense induration was felt in the pubic origin of the right adductor longus muscle, 
 which was painful on manipulation. As time passed this induration not only lasted, but 
 became more dense ; and when I first saw him, about three months after the accident, it 
 was clearly in the sheath of the adductor longus and moved with it. It grew somewhat 
 during two years ; and when the tendon was rigid it appeared as an outgrowth from the 
 pubis, corresponding to the origin of the adductor longus, of about two inches in length. 
 When the muscle relaxed, it was clearly only in the tendon and had no bony origin. At 
 the present time this gentleman can take his exercise as usual. There is a distinct grat- 
 ing to be heard and felt on moving the tumor, which has not grown for the last three 
 years. The history of the case is identical with that given by Birkett (Gut/'s Hasp. Rep., 
 1868). Billroth has also described this afiection. 
 
 Fig. 461 represents a section of such a bone, kindly given to me by my friend Mr. 
 Gowlland, with a microscopical drawing of the same, made by my colleague, Mr. C. 
 J. Svmonds. 
 
TV M oils OF ThWDo.X. 
 
 .S(),3 
 
 'I'lic liDiic is irn-iiiilarly cciiiical in 'li:i|ii' and is tlircu iiiclies anil a lialC in lohL'th. The 
 base is sdiiu'wiiat Hatti'iicil and uu'asiiifs tlircc (|uartfrs ni" an in(di acrrjss. 
 
 Tho scctioii shows an uutor hiyor of" ciinipact Ixjnc, whicli, traced towanl the bone, 
 
 Fi(i. Kil. 
 
 a. Hyaline car- 
 tilage." 
 
 6. I'rolilVratiii^; 
 carlila^;!' with a 
 matrix staining 
 with I'lisiu. 
 
 r. Hoinains of 
 old matrix of 
 cartilage, with 
 enclose<l moilul- 
 la spaces. 
 
 (/. New hone 
 developed from 
 theeartilajjeand 
 arranged in ir- 
 regular trabec- 
 uiie. 
 
 n 
 
 
 'mww 
 
 a. Lacunteand 
 canaliculi. 
 
 b. Laiuellie. 
 
 c. Haversian 
 artery. 
 
 Rider's Bone seen in Section, with its Microscopical Appearance. 
 
 blends with an irregular bony and cartilaginous mass. Many trabeculfe divide the rest 
 of the surface into a cancellous tissue of rather dense character. 
 
 Microscopical sections were made from the base, to show the mode of growth, and on 
 reference to the figure it will be seen that a thick layer (only half is represented in the 
 drawing) of hyaline cartilage forms the surface. This contains more cells than that 
 ordinarily found in normal tissue. The deeper surface shows proliferation of cells and 
 an alteration of the matrix. Irregular cavities result as in normal ossification, though 
 less regularly, and upon the old calcified cartilage the new bone is laid down as in fo'tal 
 hone. As in normal ossification also, all the new material takes up the eosin. while the 
 cartiFage stains with logwood — a chemical difference apparently the result of growth. 
 
 The small figure, sketched from a piece that was ground down in the dry state, shows 
 the lacume and canaliculi as in true bone. The lamella? were irreg- 
 ularly arranged and the canaliculi and lacunae large, with a less Fig. 462. 
 perfect communication than in normal bone (Charters J. Symonds). 
 
 Tumors of Tendon. 
 
 Besides ganglion, other tumors are found connected with tendon, 
 and of these the cartilaginous and fibrous are the most common. I 
 removed from the long extensor tendon of the middle finger of a 
 boy <"et. 14 a fine example of the former. Some are said to ])egin 
 as ganglion, and subset^uently to con.solidate. I have seen one com- 
 posed of bone and cartilage of two years' growth, removed from the 
 extensor tendon of the hand, which was said to have such an origin. 
 Tumors with tendons passing through them are not rare, and on twn 
 occasions I have had to amputate the hand of a child for a cancer- 
 ous tumor occupying its palm, through which all the flexor tendons 
 passed (Fig. 462). In 1867 I removed from a boy aet. 3i a con- 
 genital tumor the size of a walnut, which evidently grew from the 
 theca of the tendon of the long extensor muscle of the thumb. Hand^ (Dorsal 
 
 r i.i' the 
 aspect.) 
 
804 AFFECTIONS OF THE MUSCLES AND TENDONS. 
 
 The tendon passed through the tumor which surrounded it. Dr. IMoxon examined the 
 growth, which was clearly composed of fat or condensed fibro-cellular tissue, with myself. 
 The majority of tumors connected with tendons, however, are of the nature of gang- 
 lion more or less indurated. 
 
 Inflammation of Tendons. 
 
 As an acute aflfection this is most serious and gives rise to severe local and constitu- 
 tional symptoms. It is met with as a consequence of a severe strain or laceration of 
 tendon, or of some punctured or other wound involving the sheath. It may begin in one 
 toe or finger and spread upward to the palm, and so on to other tendons, and even up the 
 fore-arm. The local symptoms are pain, with the external evidences of inflammation, 
 heat, redness, and swelling, the swelling being deep-seated, while the pain soon extends 
 up the arm beyond the seat of mischief. The constitutional symptoms are those of more 
 or less severe pyrexia. 
 
 If surgical interference is not brought to bear upon the ease at an early period, sup- 
 puration must soon appear, with symptoms of throbbing and aggravated local distress, as 
 well as the constitutional symptoms, rigors, excitement, and depression ; inflammation of 
 the absorbents and their glands will probably complicate the case. 
 
 Under still more neglect sloughing of the aff"ected tendons and diflFused inflammation, 
 with suppuration of all the parts involved in the disease, will ensue. A finger, hand, or 
 fore-arm may be jeopardized or sacrificed if the inflammation be very active or the treat- 
 ment with which it is met insufficient. 
 
 Absorbent inflammation and blood poisoning (septicaamia) are common accompani- 
 ments of this affection. 
 
 Treatment. — This affection is very amenable to surgical control, and a free incision 
 into the swollen part is the best means of arresting, its progress by relieving tension. 
 The operation not only relieves pain, which is caused by the tension of the fibrous tissues 
 from the effusion beneath, but arrests the progress of the afl'ection by preventing the 
 inflammatory effusion burrowing iip the theca of the tendon. 
 
 For these objects a clean cut down to the theca should be made as soon as hardness 
 of the parts, with external evidence of inflammation, appears. If pus escape, the prac- 
 tice must be good ; but if serum only, the operation will tend to arrest the progress of 
 the affection at its onset, prevent the formation of pus, and probably check the disease. 
 The incision should be vertical over the middle line of the finger and the centre of the 
 tendon, no vessel or nerve of importance being there in the way. 
 
 When suppuration exists, the surgeon must follow up with his lancet every line of 
 inflammation and suppuration ; for in no tissue does more harm ensue from retained 
 fluids than in the fibrous. 
 
 In the very earliest stage of the inflammation warm fomentations, and possibly leech- 
 ing, may be beneficial. Elevation of the limb, the hand being higher than the elbow and 
 the elbow than the shoulder, undoubtedly relieves pain. A saline purgative is* often 
 serviceable. But the surgeon must not lose time by such temporizing means, for tension 
 of the part means its death by strangulation if not mechanically relieved, and medicines 
 have no material influence upon the affection. When suppuration appears, tonics and 
 liberal diet are required, as well as stimulants carefully adjusted to the necessities of the 
 case. Sedatives are always wanted in some one of their forms. Morphia acts the most 
 rapidly in quarter- or half-grain doses given subcutaneously. Water dressing or poultices 
 should be applied. In very severe cases, when the powers of life are failing, amputation 
 may be justifiable, more particularly when the prospects are small of giving a useful hand 
 or arm. For the arrest of diffused inflammation in the hand and arm the occlusion of the 
 main artery of the limb has been suggested. Moore and Maunder have both adopted it 
 in the upper extremity, with enough success to justify the practice. Bleeding is apt to 
 take place at times during the progress of the sloughing of the tendon ; and if recurrent, 
 such a complication is likely to induce the surgeon to perform some operative act for its 
 control upon the main vessel of the extremity. Before doing this, however, he should 
 always remove any sloughing tendon, as I have known hemorrhage, even of a severe 
 kind, to be kept up by the presence of a sloughing tendon in a part, and to have been 
 arrested by its removal. 
 
AFFECTioss or liviis.i: Mi'cosj:, etc. 
 
 «U;j 
 
 Chronic Inflammation of Tendons. 
 
 The tlu'civ ol" tlic tfiidoiis oi' tlic extt-nsors of the tliiiinl). of tlic teinlo Afliilli.s, and tlio 
 loM" tt'iidoii of tilt' l)ic('])S, as of otlu-r iiiiisidt'.s, are lialde to inflame; and this action is 
 attended hv ]>ain and weakness on movinj; the niuscdes, and at times by s\v<dlin;i. More 
 fre((uentlv, however, the affection will show itstdf hy :i peculiar cracklinjr sensation, 
 which may be felt on ^'raspinj; the part when the muscles are in motion. This crepita- 
 tion, when it has i'ollowed an injury, has more than once been mistaken for that of frac- 
 ture ; yet it is distinct, and when once felt oujrht to be reco<^nized. The affection is 
 readily' cured by rest of the affected muscles through the application of splints, and by 
 counter-irritation by means of one or more blisters. The inflammation rarely goes on to 
 suppuration unless neglected. 
 
 AFFECTIONS OF BURS./E MUCOSA, SYNOVIAL CYSTS, 
 
 GANGLION, ETC. 
 
 Slnijtlr hiirsn are i)rotective synovial sacs found in the subcutaneous tissue wherever 
 pressure or friction is j)ersistcntly present. 
 
 Sj/Horidl hiirsiv. are of the same kind, and are formed in the same way, although situ- 
 ated between bone and muscle, tendon and bone, or between muscles, while some synovial 
 burs;\) are really xi/noviaf heniifv, or poucliings of an overdistended membrane of a joint 
 into the connective tissue between the muscles. A gaiKjUon is a bursal swelling directly 
 connected with the sheath of a tendon ; it may either involve one tendon and be local, or 
 many and be diffused. 
 
 When a bursa (simple or synovial) has an established anatomical position, it is called 
 normal ; and when it is a purely pathological production, accidental. Any of these bursas 
 are liable to inflanie, suppurate, or consolidate. 
 
 Simple Burs^. 
 
 The subcutaneous bursa over the patella or its ligament is more commonly enlarged 
 than any other, and when it is so is known as the " housemaid's knee.' When it acutely 
 inflames, suppuration rapidly takes place ; and if an external outlet for the pus is not 
 soon established, diffused suppuration around the knee and over the patella follows. 
 Indeed, most of the cases of diffused suppuration around the knee have their origin in 
 " bursitis." 
 
 When the inflammation is less acute and sliows itself by serous effusion into the 
 bursa, it may give rise to local pain on pressure and a peculiar crepitation, this crepitation 
 often exi.sting before any perceptible enlargement of the bursa has taken place. 
 
 In the more advanced stage, when the effusion has increased, an encysted fluctuating 
 swelling will have formed, which may be tense or flaccid, the degree of tension of the 
 bursa turning entirely upon the rapidity of the effusion. In more chronic examples the 
 bursa will appear harder, firmer, and less distinctly fluctuating, while in very neglected 
 or chronic cases it may have so consolidated as to appear as a solid tumor, although the 
 tumor will contain on section some cavity in its centre, the mass appearing to be made up 
 of concentric laminte of organized lymph (Fig. 463). In exceptional cases, however, the 
 
 Fig. 463. 
 
 Fig. 464. 
 
 Semi-solid lUirsa, laid Open. (Guy's Museum.) 
 
 Bursa sloughing from over Patella. 
 
 bursa may have completely consolidated. These bursa), as a rule, contain .simple serum, 
 although at times the serum is blood-stained, while in other cases rice-like bodies (organ- 
 ized fibrin) Or pedunculated fringe-like outgrowths like loose cartilages exist. When 
 
806 AFFECTIONS OF THE MUSCLES AND TENDONS. 
 
 injured, these burs^e may become filled with blood, their contents being grumous or like 
 coffee-grounds (ha>matocele). Bands of lymph cross the sac at times, but more fre- 
 quently they line it in regular, onion-like layers. In neglected cases this fibrin may die 
 and slough awa}', the bursa being cast out as a whole, as in an ordinary cellular mem- 
 branous ulcer and in the case from which Fig. 4CA was taken. In syphilitic subjects this 
 result is not unfrequent. 
 
 On the other hand, a bursa may increase by effusion, and by some external cause rup- 
 ture subcutaneously or externally, and thereby undergo a cure. In 1870 I had a case of 
 the former kind under my care in a man act. GO who had a bursa the size of a fist over his 
 patella, which ruptured on kneeling. When I saw him, the cellular tissue about the knee 
 was infiltrated with serum, which was subsequently absorbed, and the bursa did not 
 reappear. 
 
 What has been described as taking place in the bursa over the patella may occur in 
 other parts, and more particularly over the olecranon process, where an enlargement of the 
 bursa goes by the name of the " miner's elbow." I have, however, seen them over the 
 acromion process in men who carry timber ; over the tendon of the extensor quadriceps 
 muscle of the thigh in a woman who habitually started her sewing machine with ihe 
 knee ; over the tuberosity of the ischium in Spitalfields weavers (" weaver's bottom ") 
 and in Thames lightermen ; over the dorsum of the foot in extreme cases of talipes 
 equino-varus when the children walked upon the part; over the external malleolus in 
 tailors ; over the malleoli, and also the instep, from the pressure of a boot ; over the great 
 trochanter of the femur in a soldier, from pressure caused by sleeping on a board ; and 
 last, but not least, over the ball of the great toe in cases of " bunion," and in the sole of 
 the foot over the heads of the metatarsal bones in men who walk much with short shoes, 
 or with some who have contraction of the extensor tendons of the toes. 
 
 Bursfe will, however, enlarge or form wherever there is pressure, the enlargement 
 being in a measure compensatory to save deep tissues. Yet this rule does not hold good 
 always, for I have seen more than one instance in which enlarged bursas existed over 
 the knuckles of the first phalangeal joint of the hands without any such cause. 
 
 Treatment. — In the early crepitating stage of effusion the removal of all pressure 
 and the application of a blister are, probably, sufiicient to effect a cure, and in more 
 advanced stages the repeated application of blisters is often sufficient to excite absorp- 
 tion of the effused fluid and recovery. When these means fail and the walls of the bursa 
 are thin, the cavity may be tapped and the parietes of the cyst firmly pressed together by 
 means of a pad and strapping. When the walls are indurated, this treatment is useless ; 
 but a cure may generally be effected by the introduction of a seton, which should be kept 
 in till suppuration is freely established. In more solid cysts none of these means are of 
 use and excision is the only sound practice, the surgeon making his incision over the outer 
 border of the bursa in order that the cicatrix may be out of harm's way. In some few 
 instances where tapping has proved ineffectual, the cyst may be injected with thirty or 
 more drops of the compound tincture of iodine in a drachm of water, as in hydrocele. 
 When blood has been effused into the bursa from a blow, as indicated by its sudden 
 increase, a free incision into the cyst and the evacuation of the clots may be expected to 
 be followed by a recovery ; but this should be done only when its absorption does not 
 take place by natural processes. When loo.se or pedunculated bodies exist in a bursa and 
 cause distress, they may be removed by means of a free incision through its walls. 
 
 Synovial Burs^. 
 
 An enlargement of a sj-hovial bursa is a far more serious affection than that which 
 has been just described, as these bur.sas are situated about tendons or muscles, the articu- 
 lar extremities of bones and joints, and in many instances, indeed, have direct communi- 
 cation with joints. 
 
 T/irre is a ihrp Inrsa Lr-nrafh the (hitoid ?JH/.sc?e which when inflamed gives riscito 
 swelling around the shoulder-joint and pain and crepitation on movement, simulating 
 shoulder-joint mi.schief ; at times, too, this bursa communicates with the joint through 
 the bicipital groove in which the biceps tendon plays. It may be distended with serous 
 fluid or may contain loose bodies such as are found in other bursas or ganglia. They 
 should be dealt with cautiously, on account of the possibility of their communicating with 
 the joint. Hence, blistering and absolute rest of the arm are the best means to employ, 
 the bursas being opened only when obstinate and when pouching exLsts in front of the 
 deltoid tendon. From one of these bursas, on two occasions, I have evacuated within 
 
syynviM. i:ri:s.K. 807 
 
 three inuiichs more tliaii lialf a pint oi' hursul fluid, cuiituiniiig iiu'ldn-sccd-likc Ixulios, a 
 recDVory sub.stM|ueiitly taking place. Such an npcratioii shouhl, however, lie ihnie only 
 after j.'rave consiileration. 
 
 Another extensive hursa. .situated heneath the extenSOr mUSCleS of the thigh, 
 is not infVeijuentiy the scat of acute or subacute intlaniniat ion ; ami >iiili cases have lucii 
 nii>lakcn for inHainination of the knee-joint, 'i'lu; (lia;;nosis oii^'ht n<»t, however, to he 
 ditfifult. for in the luirsal enlarj^einent, however ^reat. the hul^in;: of the cavity will sel- 
 dom extend downward heyond the upper border of the patella, and will not, as in joint 
 disease, extend to cither side of that bone or below it. Fluctuation, moreover, will be 
 felt oidy above the joint, and not obli(|ucly tlirou;_'h it. When the patient stands, the 
 dirterence between the distension of the bursal and t^iat of the synovial sac will be also at 
 once manifested. With this eidarirement there may be s(»me stiflnes.s of the joint, liut 
 there will always be mobility. This bursa at times becomes the seat of supjturation. 
 when the necessity of a correct (lia<;nosis is more important on account of treatment. In 
 all cases it is necessary to maintain rest, and tlie absorption of the fluid should be pn*- 
 moted l)y blisters. In obstinate cases, when the bur.sa is very tense, the cavity may be 
 tapped, and when it sujtpurates freely opened ; but neither of these operations should be 
 uutlcrtaken without strong- necessity. Suppurative inflammation of the bur.sa may extend 
 to the joint with a fatal result. I have tapped such a bursa in a woman ait. o5 and drawn 
 off eifrht «»unces of a thick, g:rumoa.s-lor)kin<r. .semi-purulent fluid with success; in a .sec- 
 ond ca.-^c, a woman let. 50, I made a free incision into the bursa and evacuated many 
 ounces of pus and blood such as escapes from a luematocele ; a trood recovery took place. 
 
 The deep bursa between the Hgamentum patellae and the bone is very liable 
 to inflame and enlarj:e, which gives rise to pain that is often mistaken for joint disease. 
 The pain, however, is always local over the bursa and aggravated by the patient attempt- 
 ing to raise the extended leg. It is very troublesome, and when established can be treated 
 successfully oidy by means of blisters and rest with the leg on a posterior splint. 
 
 The bur.sa situated over the Upper part of the tuberosity of the os calcis, 
 
 between the bone and the tendo Achillis. is sometimes inflamed, and gives rise to a 
 marked projection in the part ; it causes pain and lameness. It is to be cured by absolute 
 rest (the foot and leg being fixed on a splint) and the application of blisters. 
 
 A bursa also naturally exists in connection with and beneath the tendon of the 
 psoas muscle as it passes over the arch of the pelvis; this may al.-o coiumunicate 
 with the hip-joint. When distended with fluid, it will give rise to a swelling in the 
 upper part of the thigh on the inner side of the femoral vessels, which will be soft and 
 fluctuating, but will not receive any impulse on coughing, like a psoas abscess, for which 
 it is apt to be mistaken. 
 
 The bursa between the tendon of the gluteus maximus and trochanter 
 
 may also inflame and suppurate; and when it does, it gives rise to a troublesome, and 
 often dangerous, aff'ection. When suppuration takes place, an opening may be made, 
 which should be free, but the thigh must be well fixed. When suppuration does not 
 occur naturally, the surgeon should be in no hurry to open the bursa, but be satisfied to 
 keep the limb at rest atid l»listcr the swellinc:. 
 
 Synovial bursas in the popliteal space require a rather longer notice than 
 the forms to which attention has already been directed, since they are, although common, 
 sometimes diflicult to diagnose and dangerous to treat. Their treatment, however, as a 
 rule, is successful. 
 
 The.se bursae may be divided, in a clinical point of view, into two classes, the /7/-.s< 
 including such as are connected with the sheaths of tendons or that encircle their in.ser- 
 tion, and have no communication with the knee-joint ; the second, those that directly or 
 indirectly communicate with the joint and are either synovial herniae pouching from it or 
 bursas originating about the tendons and communicating with it. 
 
 Among ihe Jirstt is the normal bur.sa which exists above the head of the fibula on the 
 outer border of the popliteal space between the insertion of the biceps muscle and the 
 external lateral ligament ; a second, which may be said to be on the outer border, although 
 it has a somewhat more central position, which separates the external lateral ligament 
 from the tendon of the popliteus mu.scle ; and a t/u'rd on the inner .side of the space which 
 lies between the tendon of the semi-membranosus muscle and the inner tuberosity of the 
 tibia, the whole of these bursje occupying the lon-rr half of the popliteal space. 
 
 In the S'cond division there is the smaller bursa which separates the outer head of the 
 ga.strocnemius muscle from the outer condyle of the femur, and the larger that normally 
 exists between the internal condvle of the femur and the inner head of the gastrocnemius 
 
808 AFFECTIONS OF THE MUSCLES AND TENDONS. 
 
 and semi-menibranosus muscles, and which generally sends a process between these mus- 
 cles, the smaller occasionally, and the larger generally, communicating with the knee-joint, 
 both of these occupying the upper half of the popliteal space. 
 
 The larger bursa may have its origin on the inner side of the popliteal space, but as 
 it grows invariably encroaches on it and becomes central, and is moi'e frequently enlarged 
 than any of the other popliteal bursas. 
 
 All these normal synovial burste may become enlarged under the influence of over- or 
 prolonged exertion or any sudden strain, the smaller ones increasing to the size of a wal- 
 nut and the larger to that of an orange. As they increase so they become central, and 
 as they assume a central position difficulties in their diagnosis may be experienced. They 
 may contain a thin, clear, or blood-stained serous fluid, a tenacious, synovial, or colloidal, 
 apple-jelly-like material, and, in exceptional instances may have consolidated. I have, 
 however, known this to occur but once. It is probable that the bursa? which have serous 
 contents do not communicate with a joint, while those that have synovia do. 
 
 Diagnosis. — In a general way, there ought not to be any difficulty in making these 
 cases out, more particularly when the different positions in which they may appear are 
 known, since their circumscribed and defined outline, their fluctuating feel and mobility 
 when the leg is flexed, and their hardness and elasticity Avhen fully stretched, fairly cha- 
 racterize them. When, however, the swelling pulsates and a bruit is heard over the 
 tumor, some difficulty in diagnosis may be felt, although I can hardly understand how 
 such a case could be mistaken for an aneurism, as on a careful examination the bursal 
 pulsatile swelling could not be emptied and refilled by the application and removal of 
 pressure upon the afi"erent artery, as would an aneurism ; neither would the pulsation be 
 so distinct nor the bruit so clear, for both the pulsation and the bruit would have been 
 simply communicated. The position of the bruit, moreover, would have a greater influ- 
 ence upon the symptoms in a case of bursa than in that of aneurism ; for whereas, in the 
 latter, by sl'ujhfli/ flexing the leg upon the thigh, the aneurism would become more 
 defined, its pulsations more marked and under control, in bursfe the swelling would 
 become more flaccid and less distinct. Extension makes the pulsation and the swelling 
 more distinct in the case of bursas, and less so in that of aneurism. 
 
 With respect to the diagnosis of a synovial bursa which communicates with the knee 
 and a true synovial hernia, I have not much to add beyond the fact that in the former 
 thei'e may be no symptons of knee-joint disease, whereas in the latter there will to a cer- 
 tainty be chronic eff"usion into the joint, which probably will be part of an osteo-arthritic 
 change. 
 
 When pressure upon the popliteal swelling causes it to diminish or disappear, while 
 the joint itself enlarges and becomes fluctuant, or more so under the pressure, it is a 
 fair inference that the joint and bursa communicate ; although, when these conditions do 
 not exist, it would be wrong to infer the opposite, for the opening from a bursa is at times 
 valvular and altered by position. 
 
 Treatment. — As an enlargement of these bursas always follows excessive muscular 
 action and strains, so by absolute rest of the limb, as guaranteed by a splint and the 
 application of repeated blisters, can the bulk of them be made to disappear. In obsti- 
 nate examples of the first division of cases tapping may be resorted to; whereas in the 
 second it should be undertaken only where other treatment has failed, and then with 
 extreme care by means of the aspirator. In still more obstinate cases, where the limb is 
 rendered useless, a free incision may be made into the cysts or they may be excised ; but 
 such desperate measui'es are applicable only in desperate cases. 
 
 The first division of cases may always be boldly dealt with, but the second should be 
 treated with extreme caution. 
 
 Thus, in a case which was under my care some years ago, where by repeated blister- 
 ing the tumor disappeared for a time only to recur, a surgeon was induced to tap, and 
 subsequently incise, the cyst ; after which acute suppuration of the part occurred, which 
 in the end compelled amputation. 
 
 The case of solid bursa already alluded to occurred in my own practice. I mistook 
 it for a tumor, having punctured it with a needle without obtaining any flow of fluid. It 
 was in a man of middle age, had been growing for about ten years, was the size of a fist, 
 filled the popliteal space, and was solid and movable. I found that it was connected 
 with the inner hamstring tendon only when making the attempt to remove it. On recog- 
 nizing its nature I took away a large portion of the mass down to its central cavity, 
 which was the size of a nut, but I left the deeper part. Suppuration, however, subse- 
 quently attacked the knee-joint, and amputation became necessary. I am unable to point 
 
GANdl.lnX. 809 
 
 out liiiw a corrcet (liairnosis rouM he iiiatlc in such a r-asc as this, hut tlif record of tlio 
 fact tliat a solid hiirsa may exist in this h>cality, as well as the uiilortuiiate result \vhi(di 
 accrued upon operatiiui in my case, may 1)0 of value. Holmes draws attention to a 
 valualilc paper hv M. I^'oudicr on this suKjecl in tlic Archlcfn (!riii'r(ilis dc Mid. fl.Sijtji. 
 
 Synovial Cysts. 
 
 In connection with tliis subject of synovial hernia it should he stated that at times 
 these hernijo rupture and the synovial fluid escapes into the connective tissue of the lef^, 
 forminj:; a synovial cyst ; and if Mr. Wornuild was ritjht when he taught that the thin- 
 nest point of the joint cajtsule was at the spot at which it partially encircles the tendon 
 of the poplitcus muscle, it is more than jirohahle that it is at this spot that the fluid 
 escapes. 
 
 The synovial cyst may occu]ty the popliteal space and upper part of the calf of tlie 
 leg or may be evident in the calf of tlie leg only, projecting most, as a rule, on the inner 
 aspect of the leg, or may be perceptible only at the upper and inner part of the leg as a 
 small defined swelling, not ap])roachiiig within three or four inches of any part of the 
 knee-joint. There need not of necessity be any communicable fluctuation between the 
 cyst and the joint. 
 
 These cysts are generally found in joints that are the seats of osteo-arthritis. and are 
 curable. They should not be punctured or otherwise subjected to operation unless there 
 ajipear strong reasons for so doing, inasmucli as interference may lead to acute inflamma- 
 tion and sup])uration of the knee-joint. 
 
 For this information I have to thank Mr. ^lorrant liaker, who has written a valuable 
 paper on the subject in the .SV. Bnrtholomp.wf. Hoap. Rrp. (1877). It recalled to my 
 recollection several cases which were doubtless of this afliiction, and which I did not 
 understand. 
 
 Ganglion. 
 
 This is met with in two forms — the one the more common as an encysted swelling con- 
 nected with the sheath of a tendon ; the second as a more diff"used swelling involving 
 the theca of one or of many tendons, those of the wrist being the most commonly affected 
 and the flexors more fre(|uently than the extensors. I have, however, seen it in the 
 extensors of the toes and mi the dorsal aspect of the foot beneath the annular ligament 
 of the ankle, but it may attack any tendon. Ganglion is always the result of strain or 
 overaction of the tendons. The local ganglion always contains colloidal apple-jelly-like 
 material, which is at times crystal-like in clearness, at others pinkish. In the diffused 
 the fluid is more like synovia, containing loose bodies. 
 
 " The bur.sae or ganglions which form about the sheaths of the tendons at the wrist 
 appear to be the cystic tran.sformations of the cells enclosed in the fringe-like processes 
 
 of the synovial membrane of the sheaths Sometimes they are distended with 
 
 serous fluid ; at other times their contents possess a gelatinous, or even a honey-like, con- 
 sistency, which constitute a form of meliceris. Under some circumstances free fibro- 
 cartilaginous-like bodies, irregularly shaped, composed of a compact connective substance, 
 form in consideral)le numlters, more especially in the ganglionic enlargement of the .syn- 
 ovial bursa which surrounds the flexor tendons of the finuers at the wrist" (Pasret, Surg. 
 Pnth). 
 
 The localized form of ganglion is more common on the dorsal aspect of the wrist 
 than anywhere else, although not rarely it is connected with the flexor tendons and 
 appears as a globular or irregularly cystic, tense swelling of the part. At times it is 
 very hard, at others fluctuating and soft. When of good size, it maj' be translucent. 
 Pressure upon it to any extent causes pain ; severe pressure, sickening pain — even faint- 
 ing and vomiting. Those in the palm of the hand about the head of the metacarpal 
 bones are the mo.st painful. At times ganglion is painless, causing only some weakness 
 of the wrist. 
 
 A large ganglion occasionally forms behind the external malleolus connected with the 
 peronei tendons. It should be touched with care. 
 
 The diflfused or compound ganglion varies in its symptoms according to the 
 number of t<'n(l<>iis involveil. When one only is affected, it may appear as a deep-seated, 
 fluctuating, irregular swelling in the course of the tendon, the amount of swelling and 
 defonuity depending entirely upon its size. The swelling, when many tendons are 
 involved, will be diff"used ; but when the whole of the flexor tendons are implicated, it 
 
810 AFFECTIOXS OF THE .MUSCLES ASD TESlJuyS. 
 
 will occupy both the palm of the hand and the fore-arm above the wrist. In the case 
 illustrated in Fig. -405. taken from a woman set. 49. sent to me by Dr. Lovegrove, now 
 of Hythe, all the flexor tendon.s were involved to an extreme degree. In such cases as 
 these the foreign bodies commonly called '■ melon-seed or rice-like " bodies are usually 
 present. They may frequently be made out to exist by the surgeon when ascertaining 
 the presence of fluctuation from above and below the annular ligament of the wrist by 
 firm pressure alternately applied in this direction, the pressure exciting a peculiar rough 
 scrooping sensation, caused by these loose bodies passing along the thecae of the tendons 
 beneath the ligament. 
 
 Fig. 465. 
 
 Ganglion involving all the Flexor Tendons of Hand and Wrist. 
 
 Treatment. — The local ganglion, when first formed, may often be cured by the appli- 
 cation of a blister and by securing rest to the tendon by means of some splint ; but when 
 it has existed for some time, such treatment is useless. When it can be ruptured by 
 pressure applied by grasping the flexed hand with both hands and by one thumb super- 
 posed upon the other over the ganglion, a cure may often be eff"ected. firm p)ressure being 
 subsequently kept up by means of a pad of lint and strapping. When this fails, the 
 ganglion should be punctured subcutaneou.sly b}* means of a spear-shaped needle or fine 
 tenotomy knife, its contents squeezed out, and pressure applied by lint and strapping as 
 before. When success does not follow this treatment, a .silk seton may be introduced, 
 the hand being kept quiet on a splint, but it should be removed .so .soon as suppuration 
 has been established. This treatment should not be employed, however, until all minor 
 means have failed ; for it is occasionally followed by difi'used inflammation of the theca 
 of the tendon with all its dangers. 
 
 The difl"used or compound ganglion is dangerous to deal with — that is. any inter- 
 ference with it may be followed by severe inflammation of all thecae involved, and thus 
 limb and life be jeopardized. But this result is not common when proper precautions 
 are taken to guard against it. The risk of such a thing should always, however, be laid 
 before the patient by the surgeon before any opteration is arranged. 
 
 The only eff"ectual way of dealing with it is by incision. To do this the surgeon 
 should for some five or six days before fix the hand and fore-arm upon a splint ; he 
 should then make a clean cut into the aff'ected theca, free enough to allow of the ready 
 escape of all the ganglion contents without any forciV)le manipulation. When many 
 thecae are involved, more incisions than one are called for. The incLsion should always 
 be made in a vertical direction over the tendons, and both above and below the annular 
 ligament when the disease extends up the arm. After the operation the whole cavity 
 should be well washed out with iodine water and the wound dressed with terebene oil or 
 iodoform gauze and powder. A splint should be kept on for a week, after which move- 
 ment of the finger should be allowed when the fear of difi'used suppurative inflammation 
 has passed away. In the severe example of the aff'ection illustrated in Fig. 405 this 
 practice was adopted with success, and in many others of a less severe character I could 
 record the same result. I have never had occasion to divide the annular ligament as 
 advised by Syme in the E'finfjxrgh Monthh/ Jovrn. (October, 1844). 
 
 The case illustrated in Fig. 4G6 was mi.«;taken for this aff'ection ; it occurred in a man 
 aet. 49. and had been of many years' duration. The swelling had the app)earance and 
 feel of the diffused ganglion with foreign bodies. Indeed, the sensation of the pre.senee 
 of foreign bodies was marked between the dorsal and palmar surface of the hand. The 
 swelling was, however, entirely confined to the hand and did not extend upward above 
 
MM.FnllMATlnSS. 
 
 HU 
 
 the aiiiiuhir liLrnliifiit (Luiicrt, 1SS4. j). SKI). M v IViriHl Mi'. II. MMi-ris t<-IIs iiic thai lio 
 lias seen two casrs (tl' latty t miior ciiinicctctl willi llic iiiciliaii iktvc with clinical >.yin|i- 
 tdiiis like tliusc (U'siTihrd. 
 
 I (i|i('iMtt'tl miuii it as for i.Mii^'^liuii, and to iiiy siirjirisc loiirul tin- wlmlc swclliii;: was 
 due to the iireseiice of u diHusctl li|M)iiiatoiis tuiiior situuled beneath the deep flexor ten- 
 
 Fui. 4G(;. 
 
 Lipoma, situated beneath tlie Flexor Tendons of tlie Hand, simulating (ianglion. 
 
 dons and coniplctely stirroundinjr tlieiu, dipping down ))et\veen the bones to appear upon 
 their dorsal ri'gioii. 1 removed the mass with much difficulty after a tedious dissection, 
 washed the whole palm out with iodine water, and puffed int<» the wounds some powdered 
 iodoform. 1 then fixed the hand upon a dorsal splint. Quick repair followed the o]>era- 
 tion without constitutional disturbance or suppuration. Within three weeks the man was 
 well, and returned home with a hand in no way impaired by the severe operation it had 
 been subjected to. In this case the fact that the swelling had not extended above the 
 annular ligament ought to have suggested that another cause than ganglion existed to 
 explain the symptoms. 
 
 CHAPTER XXIX. 
 
 DEFORMITIES, CLUB-FOOT, AND OKTHOP.EDIC SURGERY. 
 
 Malformations. 
 
 Malformations remain to be considered, those of special parts having already 
 received attention under other headings. 
 
 They may roughly be classed as being due either to excess, or hypertrophy, or to 
 deficinici/. 
 
 Unnatural adhesions between parts is not rare, and maldevelopment in some odd way 
 is occasionally met with. 
 
 As examples of excess of development supernumerary fingers or toes are the most 
 common, the supernumerary digits being more or less well formed or rudimentary, either 
 appearing as skin appendages (8, 9, Fig. 407) or being more like cleft phalanges with 
 common metacarpal or metatarsal bones (2, 6, 7, Fig. 467). The thumb is very com- 
 monly cleft. 
 
 Thus, out of 20 cases of supernumerary fingers and toes consecutively noted, 8 were 
 of the thumb and 4 of the fingers alone, 3 of the toes alone and 5 of the fingers and toes 
 together, the deformity being symmetrical in (> of the cases. Occasionally supernume- 
 rary fingers or toes have perfect metatarsal or metacarpal bones, and more rarely the 
 haiid mav be double. The late Jardine Murray of Brighton has recorded such a case 
 {MaJ.-Ch!r. Tram., vol. xlvi.). 
 
 Hypertrophy of extremities is met with, cither of whole limbs or of parts of limbs. 
 In drawing 10, Fig. 407. hypertrophy of one finger is shown associated with deficiency 
 of others, but hypertrophy "is a type of the aff"ection tljat is met with in practice, whether 
 of a digit or of an extremity. 
 
812 
 
 DEFORMITIES, CLUB-FOOT, AND ORTHOPAEDIC SURGERY. 
 
 Treatment. — Rudimentary fingers and toes may be fearlessly excised when they 
 appear as skin appendages ; but when they exist as bifid phalanges, great care is called 
 for in their treatment, on account of the frequency of there being a common joint to the 
 two digits. Under these circumstances the surgeon should carefully consider the ques- 
 
 FiG. 467. 
 
 Types of Different Kinds of Deformities of the Hands and Feet, witli a Drawing of a Child with a Caudal Appe 
 
 (Taken from life.) 
 
 tion of amputation ; and if he decide upon performing it, it will be wise to cut oiF the 
 supernumerary digit some little distance from the joint, leaving a stump, which, as a rule, 
 subsequently withers. 
 
 Hypertrophied extremities may be removed when they are sources of great inconve- 
 nience, but not otherwise. 
 
 Webbed fingers and toes are another common deformity. At times all the 
 digits of one or both hands or feet are webbed, but more commonly only two are involved. 
 Thus, I have seen the thumb and index finger webbed in one case (No. 3, Fig. 467), the 
 ring and middle fingers of both hands in another (No. 4), and again, in another, the 
 second and third toes of both feet. In one instance the toes of one foot were webbed 
 and the fingers of the hands more or less truncated. In another, with webbed toes on 
 both feet, there was a supernumerary right thumb. Indeed, where a disposition to 
 deformities shows itself, several varieties of deformity may coexist in the same subject. 
 
 Treatment. — For the hand, when the fingers are well formed, the surgeon, if possi- 
 ble, should divide the web, but under other circumstances it is more prudent to leave it 
 alone. When the web is very narrow, there is nothing left but to divide it ; but before 
 doing so a good opening at the base of the cleft ought to be established, to prevent the 
 subsequent closure of the wound. This can be eflSciently effected by means of the gal- 
 vanic cautery or otherwise and the subsequent introduction into the opening of a piece 
 of aluminium wire, the wire being kept in till the wourid has cicatrized and become as 
 thoroughly established as an ear-ring hole. When this step of the operation has been 
 effected, the cleft may be fearlessly divided. 
 
 When the web is broader and more material exists for the surgeon's manipulation, the 
 best plan to adopt is to split the web transversely between the fingers and to turn one flap 
 
MM.FOIIMATIOSS. 813 
 
 of skill nuiiid (irif Chilmt iiinl tlic i.ilicr flap rninni I lie .second, stitcliiiif: the edges of the 
 fl;i]p til ilir skill lit" till' liii<;i'r. 
 
 W^ebbed toes need no surgical iiiti li. nncc. 
 
 Absence of parts cuniiot sur;.Meally lie remedied. In No. i:5, Vx^i. ICT, there was 
 an aliseiiee of a tliiiiiili. Imt liy way <d" eonipeii.sation an extra tin<rer was given. In No. 
 14 the riiiir linger was aliseiit. Iml llie imh-x and iiii<ldle fingers were hyjuMirophit'd. 
 
 At other times linihs are triiiieated as if from intra-iiterine amputation, and in rarer 
 cases bones and joints seem to lie (h-Hcieiit. Tims, in a male siilijeet I had iiinler care 
 .some years ago the right arm was shortened, as if ampiitatecl aliove the elhow. and the 
 right lower e.vtreiiiity was represented hy one short lione, with a foot that would have 
 been called jierieet il" the little toe had not been ab.setit. 
 
 These eases are nientioiieil. however, only as curiosities, and are beyond the pale of 
 the surgeon's art. 
 
 Claw-like extremities, as represented in Nos. 1, II. and iL'. I'ig. HIT. are very 
 
 curious. No. 1 represents the hands of (ieorge N , act. 7 weeks, the third child of 
 
 well-made jiarcnts, the other children being natural. Very little power existed in the 
 claws, one finger alone being of use. The child in othc-r respects was well made and 
 intelligent. 
 
 Nos. 11 ami VI were taken IVom Edward K , ict. 4, one of eight children, three 
 
 being boys and five girls, one brother having preei.sely the same deformity. The jiarent.s 
 were well made. 
 
 The hands in No. 11 had apparently but tliree metacarpal bones, the wrist and carpal 
 joints being normal; the solitary digit had much power. The feet in No. 12 were .still 
 more oddly made. In both the tarsal bones seemed to be natural, but on the right foot 
 the metatarsal bones were confused together. The digits had good power. Nothing could 
 be suggested for the patient's benefit. 
 
 Hereditary Nature of Deformities. — The hereditary nature of deformities is 
 generally recognized, though in the history of such cases it is exceptional for such a tend- 
 ency to be traced. When, however, it is made out, it is, as a rule, remarkable. Deform- 
 ities, when inherited, are also generally of a like kind. Thus, deformities of the genital 
 organs are passed on to succeeding generations, as is the disposition to harelip or webbed 
 fingers, etc. 
 
 Exceptions to this rule are met with. Thus, in a family of twelve children, two out 
 of four boys had harelip and fissured palate, and one out of eight girls had hypertrophy 
 of the right lower extremity, with atrophy of the right great toe. The father of this 
 family had a supernumerary little finger on one hand. 
 
 A female child, one of five, the other four being well made, had hypertrophy of the 
 two inner toes of the left foot. They were at five weeks old as large as the toes of an 
 adult and as well made. The parents had no deformity, but the father's maternal grand- 
 father had a double thumb. 
 
 A boy had a double thumb on one hand and a web between the .second and third toes 
 of both feet. His father had webbed toes. 
 
 These exceptions to the rule above given are, however, rare. 
 
 As illustrations of the rule the following eases have been extracted from my note- 
 books. 
 
 A man had six perfect toes on each foot and six perfect fingers on each hand. He 
 was one of ten children, all of whom had the same kind of deformity. The parents of 
 these children were, however, well made. 
 
 A female child had left equino-varus. She was one of eight children, the other seven 
 being well made. The parents had no such deformity, but the mother had two brothers 
 and one sister so deformed, and her fiither had double talipes. 
 
 A man had scrotal hypospadiasis and was one of nine children. Both his parents 
 were w^ell formed and no history of deformity could be traced backward. One of his 
 sisters had harelip, while two of his brothers were deformed as he was, one having passed 
 as a female till he was eighteen years of age. Two other brothers and three sisters were 
 natural, but each of these brothers had a son a hypospadiac. 
 
 These cases are very striking. 
 
 Club-Foot. 
 
 When paralysis takes place of a single muscle or of a group of mu.scles functionally 
 associated, the opposing muscle or group, losing antagonism, acts uncontrolled, and. as a 
 
814 
 
 DEFORMITIES, CLUB-FOOT, AND ORTHOPEDIC SURGERY. 
 
 consequence, contraction or deformity is liable to be produced, the deformities resulting 
 from this class of cases being designated paralijtic distortions. 
 
 When a muscle or a group of muscles, from whatever cause, acts spasmodically with 
 an active tonic contraction or a slow and progressive one, quite irrespective of the will or 
 but slightly influenced by it, and in this way overcomes the opposing muscle or group of 
 muscles, deformities may likewise be produced, such cases being called sjjastic or !tj)as- 
 ■modic distortions. 
 
 In the first class the degree of deformity depends much upon the degree of paralysis 
 present, and in the second on the amount of spasm or contracting force of the muscles 
 involved. Some surgeons would class all deformities in the first group, but this view is 
 incorrect. 
 
 Both may be congenital or acquired. In the congenital greater changes take place in 
 the conformation of the bones than in the acquired, these changes depending much upon 
 the intensity of the muscular action, but more upon the period of life at which they com- 
 menced. 
 
 " It seems as if in congenital club-foot and analogous distortions a stimulus or irritant 
 were present in the medulla spinalis, acting upon certain ganglionic cells there, which 
 keeps the affected muscle in a state of chronic contraction, yet not sufficient to neutralize 
 the stimulus of the will within the limits of movement permitted by the structural short- 
 ening of the member. Many non-congenital spastic conti-actions appear allied to the con- 
 dition which prevails in some states of chorea, in which, Avhen the will would permit or 
 cause contraction or relaxation of a particular muscle, an involuntary influence excites 
 contraction, interferes with and frustrates the voluntary effort. In more intense spas- 
 modic contractions the will is entirely overpowered before structural shortening super- 
 venes to effect the same end " (Little). 
 
 As an extra argument in favor of this view the fact may be adduced that club-foot 
 often coexists with other deformities, such as spina bifida and club-hand, etc. '' Congeni- 
 tal and non-congenital club-foot spring from analogous causes." 
 
 When these muscular contractions are powerful enough or continue long enough to 
 alter the natural position of a part, deformity is said to exist, and according to its seat or 
 form a special name is given to it. 
 
 To Stromeyer abroad, as well as to Little in this country, we are chiefly indebted for 
 most of our knowledge on this matter, although in more recent times Tamplin, Lonsdale, 
 W. Adams, Brodhurst, and others have added much to the subject. 
 
 Stromeyer, however, in 1831, only followed Delpech in 1828, this great surgeon fol- 
 lowing a greater — John Hunter, who in 1794 established the principle of subcutaneous 
 sui'gery when he divided injuries to sound parts into two divisions and established this 
 principle — that "the injuries of the first division, in which the parts do not communicate 
 externally, seldom inflame, while those of the second commonly both inflame and sup- 
 purate." 
 
 Club-foot may be divided into four typical forms : 
 
 Talipes equinus, in which the heel is simply draw up by the contraction of the 
 muscles of the calf (Fig. 468) ; talipes varuS, in which the foot is drawn inward to 
 
 Fig. 468. 
 Talipes I^quiims 
 
 Fig. 469. 
 
 Conaenital Vaj'us. 
 
 ong 
 
 ■Oz 
 
 Three Grades of Severity. 
 
 different degrees (Fig. 460) ; talipes valgUS, in which the foot is turned out (Fig. 
 471) ; and talipes calcaneus, in which the foot is drawn up and the heel depressed 
 (Fig. 472). 
 
 Combinations of these forms are commonly seen. Thus, we have T. eqiimo-varus, 
 when the foot is turned in and heel drawn up (Fig. 470) ; T. equino-valgus. when the foot 
 
t'Ll'H-I-'OOT. 
 
 815 
 
 is turiH'J nitf ami the lu'ol drawn up, T. rdfrmno-ixinis and culrttnt'o-vift/us Ix-in^ tfrnis 
 applied when tlicheel is di-pressi-d and the toot turned in or out. 
 
 Talipes varus is the usual (•on;^enital form, hut any may exist, talipes eijuinns and 
 cquino-varus and valgus heing the more commcju acquired forms. 
 
 In I'lt/i/iis the ])eronei mu.scles are eliiefly involved ; in variix, tlie adductors, particu- 
 larly the two tiliials ; in ('(jkiuiis there is contraction of the muscles of the calf through 
 the teiulo Atdiillis ; and in rufrniii'iis, ])aralysis of the same group. 
 
 (Mul)-foot is often hereditary and more |)rone t(» attack the male branches of a family 
 than the female, and in this resp(!ct it seems to follow the ordinary law of all deformities. 
 In a rase uiuler my care of talipes varus the child's father, grandfather, and great-grand- 
 father on the father's side Juid congenital talij)es, while none of the feuiale branches of 
 the respective families were deformed. 
 
 •'It is convenient, for practical purposes, to divide congenital club-foot int(j three 
 degrees of .severity : the xh'(flitrnl^ that in which the position of the front of the foot, when 
 inverted, is such that the angle formed by it with the inside of the leg is greater than a 
 right angle, and in which the contraction is so moderate that the toes can easily be brought 
 temporarily by the hand of the surgeon into a straight line with the leg and the heel be 
 depressed to a natural position. The second class includes those in which the inversion 
 
 Fig. 470. 
 
 C'oaae/i 
 
 Acquired. 
 
 From Little. 
 
 of the foot and elevation of the heel appear the same or little greater than in those of 
 the first class, but in which no reasonable effort of the surgeon's hand will temporarily 
 extinguish the contraction and deformity. The tlilnJ class comprises those in which the 
 contraction of the soft parts and displacement of the hard parts reaches the highest 
 degree, so that the inner margin of the foot is situated at an acute angle with the inside 
 of the leg, sometimes, or even almost in contact with it. Cases of the first and second 
 grades may be respectively converted into the second and third grades by delay in the 
 application of remedies and by the effects of improper locomotion " (Little). 
 
 • Talipes rquinns is the most common form of the acquired talipes, although Little posi- 
 tively declares it is at times congenital. It is found in every degree, from the inability 
 to flex the foot beyond a right angle to a pointing of the toes, necessitating the patient 
 walking upon the heads of the metatarsal bones and phalanges, the head of the astragalus 
 projecting prominently on the dorsum of the'foot. Fig. 4G8 illustrates the medium and 
 extreme forms. 
 
 Talipes varus is the more common congenital form. Fig. 469 illustrates it in three 
 degrees of severity. 
 
 It is very frequently combined with T. equinus, as seen in Fig. 470. The arrows in 
 the figure indicate the direction of the convexity of the tarsus and metatarsus forward 
 and outward ; the perpendicular line through the axis of the limb shows the extent of 
 the inward deviation of the metatarsus, by which the base of the little toe, being brought 
 completely beneath the axis, has to support the entire weight of the body in walking. 
 
 Talipes i-afffUH may be of all degrees of severity and may be congenital or acquired, 
 these two varieties presenting very different appearances. Fig 471 illustrates the con- 
 genital form in two degrees of severity, and also the acquired. 
 
 Talipes calcaneus is illustrated in Fig. 472. 
 
 For a full detail of the anatomical changes of the foot under these different condi- 
 tions, vide Adams in Pat/i. Soc. Tnuis.^ vol. iii. 
 
816 DEFORMITIES, CLUB-FOOT, ASD ORTHOPAEDIC SURGERY. 
 
 Before considering the treatment of the.se affections it will be well to look into the 
 principle upon which all interference must be based and the process by which repair can 
 
 take place after the division of tendon. 
 
 To Pairet and W. Adams, in this country, we are 
 chiefly indebted for our knowledge of this subject, 
 and I shall as much as possible use Adams's descrip- 
 tion of this process, as published in 1860 in his 
 work on the Reparative Process af Human Tendons 
 after Divhiion, his investigations having confirmed 
 Acm/ircd \_ji^fc=^ those of the former, as well as added to our stock 
 
 Co„ffcnifal of knowledge. 
 
 Talipes Calcaneus When such a tendon as the tendo Achillis is di- 
 
 vided subcutaneously, the divided ends separate, in 
 an infant for half an inch and in an adult from one to two inches, the degree depending 
 much upon the healthy condition of the divided muscle and the amount of movement 
 subsequently permitted in the ankle-joint. 
 
 The reparative process begins by increased vascularity in the sheath of the tendon, 
 which is followed by the infiltration of a blastematous material into its meshes, or spaces 
 between its fibrous elements, exhibiting the development of innumerable small nuclei, a 
 few cells of large size and irregular form, with granular contents, or perhaps with one or 
 more nuclei, and .studded with minute molecules of oil, a blastematous material, in which 
 the cell forms do not develop beyond the stage of nuclei, appearing to be the proper 
 reparative material from which new tendon is developed. This nucleated blastema soon 
 becomes vascular, capillary vessels having been seen in it on the eighteenth day ; the 
 nuclei assume an elongated, spindle, or oat-shaped form, and are seen, after the addition 
 of acetic acid, to be arranged in parallel linear series. The tissue becomes gradually 
 more fibrillated, and at last fibrous, a solid bond of union subsequently forming betw^een 
 the divided extremities of the tendon, which is tough to the touch, but to the eye pre- 
 sents, even for at least three years, a grayish, translucent appearance, distinguishing it at 
 once from the glistening old tendon. This new tissue remains during life as permanent, 
 and has little tendency to contract subsequently. Adams's ob.servations rather led him to 
 the conclusion that the requi-red portion of new tendon is to be obtained during a length- 
 ened period of formation — that is, about two to three weeks, under the ordinary condi- 
 tions of health ; but in paralytic cases, as in others of feeble health, this period may be 
 doubled. 
 
 Adams informs us, also, that the divided extremities of the old tendon take no active 
 pai-t in the reparative process during its earlier .stages, although at the later the cut ends 
 become rounded and their structure softened. They become enlarged and exhibit a 
 tendency to split, and thin streaks of new material similar to that already described are 
 seen between the fibres ; the ends are joined by these means. At a later period the bulb- 
 ous enlargement gradually diminishes. 
 
 When a tendon is divided a second time, there is but little separation of its ends, and 
 this is probably due to adhesion of the new tendon to the neighboring fibro-cellular tis- 
 sue ; in which fact is found an explanation of the unsatisfactory results of second 
 operations. 
 
 There is no reason for believing that in the treatment of deformities by tenotomy 
 direct approximation and reunion of the divided extremities of the tendon must first be 
 obtained, and that the required elongation is afterward to be procured by gradual 
 mechanical extension of the new connecting medium, as we would stretch a piece of 
 india-rubber. 
 
 Gradual mechanical extension, however, is required in cases of long stahdiiuj, as in 
 those of conffenital origin, to forcibly overcome ligamentous resistance and to separate the 
 ends of the divided tendons, as it is in those of parnlyfic and non-co)ii/eiiitaI origin to pre- 
 vent the too rapid separation of the extremities of the tendon. The mechanical extension 
 should be carefully regulated according to the activity of the reparative process, as indi- 
 cated by the amount of eff"usion into the sheath. Blood poured out into the sheath, or 
 any inflammatory action, interferes much with the process of repair, any causes of gen- 
 eral feebleness, coldness of the limb, too early, too late, or too forcible extension, having 
 a like eff'ect. With these remarks the operation itself may be considered. 
 
 Treatment. — "The indications." writes Little, "are to overcome the shortening of 
 the muscles, ligaments, fascia?, and integuments on the contracted side of the member, to 
 direct the bones into their proper position, to educate the patient's voluntary use of the 
 
CLUIi-FOOT. 
 
 817 
 
 parts, to give strcnjjtli to tin' muscles ami li^raiiieiits in the <'/i»i^>iffff side of the incinlKir, 
 to I'omliat the tciKlciicy to rt'lapsc 
 
 To f'lilHl tiic first iiKliratiniis iiu'cliaiiical iiicaiis an- nl'tcii siitViciciit ; ami wln-n these 
 fail <»r arc iiia|i|ili(altU', the division of the toiitructcd stru(;tun;s is rt'<|iiirfd. To carry 
 out the other, luechanieal Jiieans are also rtf value, aided hy ireneral iiieasur<!s, ami ujore 
 }tartieularly l»y jralvariisuj of the wcakeiieil inusi'Ics. In a larj^e number of eases, how- 
 ever, instruments are not needed, much less temjtomy, since in any case of con<renital or 
 infantile tali))cs when the foot can he hrouL'ht int(j its normal position with hut little force 
 a cure without operation can with some conlidenee he pnunistMl. 
 
 In the very simplest ea.ses mere friction of the artected limh and the daily extension 
 of the contracted tendons are often enou<;;h to effect a cure, the nur.sc or parent iioldin<; 
 the crooked foot for some ten or fifteen minutes two or three times a day in the required 
 position. 
 
 In the next class of cases, which are slijihtly worse than the last, in which tlie fjot 
 can l)c hrouiiht with jiciitlc force into its natural ))lace. a cure can be effected by means 
 
 of strapping adjustcid in the fashion depicted below (Fig. 
 Fk;. 478. 473). The strapping must be of a firm nature, that spread 
 
 I on linen being the best, as u.sed at (jruy's. The first piece 
 
 acts as a kind of .splint, and the .second, on binding down 
 the first to tlie ankle, admits of any amount of force re- 
 
 Fio. 474. 
 
 Mode of Stretching Foot in Ta- 
 lipes Varus by Strapping. 
 
 Buchanan's Splint for Talipe.s. 
 
 quired to bring the foot in or out, according to the nature of the case. In a still more 
 severe form, where the former method is inapplicable, a small tin splint covered with 
 leather with a screw hinge at the ankle, such as that advised by Little or made for 
 my.self by Milikin may be employed, the foot being forcibly brought into the required 
 position and fixed there by strapping. Buchanan's splint, as seen in Fig. 474. is excel- 
 lent. 
 
 In the worst forms, where by no ordinary force the foot can be brought into the 
 required position, the division of the shortened tendon, tendons, or fascia should be per- 
 formed, no more structures being divided than is absolutely essential. 
 
 " When deciding on the necessity of operation, the surgeon must not be guided .solely 
 by the external configuration, but by the amount of firm resistance opposed to restoration, 
 by the depth of the furrows existing in the .sole and behind and above the heel, and by 
 the degree of tension of the integuments above the internal malleolus. The deep clefts 
 or furrows in question denote intensity of contraction of muscles and closer adhesion than 
 usual of integuments and fascia to the subjacent soft structures and bones. They prob- 
 ably denote, also, that the deformity dates from an early period of uterine existence " 
 (Little). 
 
 Sayre's law upon this point is very good. "Place the part contracted." he writes, "as 
 nearly as possible in its normal position by means of manual tension gradually applied, 
 and then carefully retain it in that position ; while the parts are thus placed upon the 
 stretch make additional point-pressure with the end of the finger or thumb upon the 
 parts thus rendered tense : and if such additional pressure produces r^fffx cont met ions, 
 that tendon, fascia, or muscle must be divided, and tlie point at which the reflex spasm is 
 excited is the point where the operation should be performed. If. on the contrary, the 
 additional point-pressure does not produce reflex contractions, the deformity can be over- 
 come by means of constant elastic tension ; and the more you cut. the greater will be the 
 amount of damage done" ( Orthnpffdic S'irg.. 1876). 
 
 In all cases treatment should be commenced as soon as posslhh'. and the foot of the 
 youngest infant ma}' be dealt with advantageously by manual extension a few days after 
 birth. "Within a week extension by strapping may be carefully employed, the foot being 
 52 
 
818 DEFORMITIES, CLUB-FOOT, AND ORTHOPAEDIC SURGERY. 
 
 looked to daily to see that no slougliing or cutting of the skin by the strai)ping takes 
 place. In infants the tendons yield far more readily than they do as months or years go 
 on, and with care no harm can accrue from simple mechanical extension. Kven splints, 
 carefully applied, can be used. 
 
 When tenotomy is clearly a necessity — that is, in grave deformities — there is no rea- 
 son, in a healthy well-developed babe, why it should not be performed within a month 
 after birth. I have divided the tendo Achillis for a talipes varus with an excellent result 
 at the end of the first week, and Mr. Little has operated successfully within twenty-four 
 hours of the child's birth. 
 
 The Operation. 
 
 In a large number of cases of congenital varus the division of the tendo Achillis is 
 enough, the foot, after division of the tendon, being generally capable of restoration to 
 the required position by mechanical means, but in severe examples the anterior or poste- 
 rior tibials, singl}^ or together, may require to be cut. These three tendons may be 
 divided at one operation in average cases, though in the severe Little's advice is good — 
 to deal with the tibial tendons first and overcome the inversion of the foot, and at a later 
 date to divide the tendo Achillis. The value of this proceeding consists in the fixed os 
 calcis offering a resisting point from which the surgeon is enabled to stretch out and 
 unfold the contracted inverted sole. 
 
 Division of the Tendo Achillis. — The patient should be turned on the abdo- 
 men and the tendon made tense by means of an assistant. The surgeon should then 
 insert a sharp-pointed or round knife flatwise from behind forward by the side of the 
 tendon as far as its anterior surface, when it should be turned laterally in front of the 
 tendon and its cutting edge directed backward toward the tendon, and with the slightest 
 sawing motion the tense cord may be divided, care being observed to do this completely ; 
 otherwise, failure will follow. During this procedure the surgeon should keep his finger 
 upon the tissue to be divided, and immediately on the withdrawal of his knife close the 
 opening with his finger or thumb, the assistant relaxing the parts at the moment he feels 
 resistance to cease. A dossil of lint should then be applied to the puncture and fixed by 
 strapping, this dressing being left for three days. If any suspicion exist of the posterior 
 tibial artery having been wounded, as indicated by arterial hemorrhage and blanching of 
 the foot, the dressing should be left on for at least a fortnight and all mechanical treat- 
 ment postponed. It is, however, an exceptional circumstance for any harm to follow the 
 puncture of the artery. Little, with all his experience, informs us that he has only once 
 seen any trouble from this circumstance. 
 
 After the operation the foot, in its deformed position, should be bound to a flexible 
 metal or other splint for three or four days, till the immediate eff'ects of the operation 
 have subsided, when the foot should be at once brought to the required position and 
 retained there by splints and bandages. 
 
 Division of the posterior tibial tendon should be performed with the child 
 upon its back, with the limb to be operated upon rotated well outward. The surgeon 
 should take charge of the foot, and his assistant of the knee. The tendon should be 
 divided about an inch or an inch and a half above the extremity of the inner malleolus. 
 In thin subjects, on abducting the foot, the tendon may be felt at the spot indicated ; but 
 in fat per.sons, and when the tendon cannot be made out, the surgeon knows it lies along 
 the inner edge of the tibia, " exactly midway between the anterior and posterior borders 
 of the leg on its inner aspect." 
 
 At this spot the knife should be inserted perpendicularly to the surface through the 
 fascia for about half an inch, an opening in the fascia being made sufficiently free to 
 admit of the introduction of the probe-pointed knife, which must next be inserted. This 
 knife can then be introduced perpendicularly, close to the bone, between it and the tendon 
 to be divided, when its edge should be turned toward the tendon and the operation com- 
 pleted by a slight sawing movement. It is not always necessary to change knives during 
 this operation ; some operators, indeed, never do so. It is safer, however, to adopt the 
 practice in fat subjects when some uncertainty exists as to the exact position of the ten- 
 don. As soon as the tendon has been divided a dossil of lint should be applied, as in the 
 former operation. 
 
 Some surgeons prefer to divide the tendon of the long flexor muscle at the same 
 time ; as a rule, this is unnecessary. 
 
 Division of the anterior tibial tendon can be performed with the patient 
 lying on his back and the foot extended, the tendon being in this way made prominent in 
 
CLVIl-FdOT. 
 
 819 
 
 fnnit (if the imuT inulleolus. Tlic knife sli<ml«l ))(• insertt'd at thiH jioiiit hehiiul the ten- 
 iliMi anil its c'djff turtu-d forward, when the U\:^\\X (••ml can he <lividt'd, tlio foot IjoIii^; at 
 once Ht'Xt'd and flu- |>iin(t iircd wouml ('((ViTt'd with lint and strapping. It might to he 
 ki'|it ill a splint for scvt-ral ilays alU-r diviHion (d" the tcmlo Arliillis. 
 
 Wlii'ii all tlii'Si' tt'iidons arc diviilcil at the same operation, the after-treatment must 
 he the same. 
 
 Division of the peronei tendons for talijieH valgus is eaHJly aecomplished hy 
 adduetiiitr the foot aiitl iiitrodueing the knil'e hehiml the external malleolus, hetween thi! 
 tendons and the lihiila, the tendons heing cut, on turning the edge of the knife toward 
 them, with a sawing movement. Some surgeons advocate a higher division of these tcndoiiH 
 to uhviate their retraction, union taking place lictweeii the teiidcjii and the .sheath. 
 
 It is unnecessary to describe the operation for division of the plnntar fnxcid or other 
 tendons, as the practice in all should be conducted on principles identical with those 
 already described. 
 
 Mkciia.nical Tre.\tment. — However necessary these operations may be in any 
 given case, it ought to be remembered that they are only preparatory to the mechanical 
 
 treatment which is subsequently to be carried out. That 
 Fig. 475. they are not always necessary has already been shown, 
 
 mechanical treatment generally being amply sufficient of 
 itself to effect all the surgeon desires. 
 
 In one case after the division of the rigid tendon or 
 tendons a cure may be effected by means of strapping, as 
 already illustrated (Fig. 47H) ; in a second a simple inside 
 or outside splint with strapping or bandages may be 
 
 Fig. 476. 
 
 Little's Modification of Scarpa's .Shoe 
 for Talipet^. 
 
 Mr. Davies-Col ley's Splint for Talipes Equino- Varus. 
 
 enough ; in a third the simple splint figured in Fig. 474 answers every pui-pose ; while in 
 a fourth Scarpa's shoe is required (Fig. 475), or some of its modifications. A shoe with 
 a ball-and-socket heel-joint which Messrs. Krohne made for me is .strongly to be recom- 
 mended, and in Fig. 476 is another, suggested by my colleague, Mr. Davies-Colley, which 
 for extreme examples of talipes is inexpensive and stands unrivalled. 
 
 In all the principle embodied is the same — the separation of the divided ends of the 
 tendon and the deposition of new material between them. The .splint invariably should 
 be applied and fixed to the foot in its deformed position and the separating process carried 
 out on the third or fourth day. In many I have brought the foot into position directly 
 after the division of the tendons with nothing but good results. 
 
 If failure follows the first operation, a second may be performed ; but the hope of a 
 succes.sful issue under these circumstances is far from good. 
 
 Barwell has recently revived the old practice of elastic bands to .stretch the tendons 
 in lieu of dividing them, and in some cases it is a valuable practice, but as a substitute 
 for tenotomy it cannot be recommended. 
 
 There are, however, cases of talipes equino-varus which are amenable neither to sub- 
 cutaneous tenotomy nor to mechanical appliances, as well as others which have been 
 treated by these measures and have failed, or which are so severe as to make it certain 
 that a long interval of time must of necessity be spent in the attempt to bring about a 
 cure, even if such a result were probable or possible ; and under these circumstances 
 surgeons have sought for more expeditious and efficient means of treatment. With such 
 a view, Dr. Little, the pioneer of tenotomy in this country, suggested, so long ago as 
 1854, ''that in inveterate varus the treatment might well be commenced in robu.st sub- 
 jects by ablation of the os cuboides." and the late Mr. S. Solly in 1857 carried the sug- 
 gestion into effect.' The case not proving very successful, the practice met with no 
 
 ^Med.-Chir. Trans., 1857. 
 
820 
 
 DEFORMITIES, CLUB-FOOT, AND ORTHOPEDIC SURGERY. 
 
 encouragement, and the operation was not repeated till Mr. Richard Davy, an old pupil 
 of my own, performed it at the Westminster Hospital in 1874 on a boy set. 15 with such 
 a " striking immediate result that the sole of the foot could with force be placed in a 
 natural position," and he repeated it in 1875-76. In 1872, Mr. Edward Lund went a 
 step farther and removed from a boy get. 7 both astragali in a case of severe double talipes 
 with some perceptible improvement. This measure he repeated in March, 1878.' 
 
 In October, 1875, however, my colleague, Mr. Davies-Colley, adopted a new method, 
 and on the suggestion of Mr. Howse removed from a boy aet. 12 a wedge-shaped piece 
 of the tarsus, without paying any regard to its articulations, by means of " an incision 
 three inches in length along the outer border of the left foot from the middle of the os 
 calcis to the middle of the fifth metatarsal bone, and a second across the dorsum of the 
 foot from the centre of this incision two inches long."'- Both feet were operated upon at 
 intervals of six weeks, and in less than ten weeks from the second operation the wounds 
 were quite healed and the boy could walk without assistance. In November, 1876, Mr. 
 Davy performed the same operation. 
 
 All these proceedings are sound in principle, and in cases of talipes in which minor 
 measures have been tried and have failed, or in which the probabilities of their success 
 are slight, and time and expense are questions of importance, they should be entertained. 
 I believe, however, that Mr. Davies-Colley's operation is the best for talipes equino-varus, 
 particularly when the varus is worse than the equinus, though Mr. Lund's operation is 
 probably of value under the reverse conditions. I say this after having had opportunities 
 of seeing several of Mr. Davy's and one of Mr. Lund's cases, and having carefully 
 watched throughout its treatment Mr. Davies-Colley's. Entertaining these opinions, I 
 performed Mr. Davies-Colley's operation on June 18, 1878, and with such a good result 
 that I now give drawings of the boy's foot before the operation (Figs. 477, 478) and 
 subsequent to it, with an outline of the portion of bones removed (Fig. 479). 
 
 Fio. 477. 
 
 Fig. 479. 
 
 Fig. 478. 
 
 Foot after 
 Operation. 
 
 The case was that of a boy fet. 12 who was born with talipes equino-varus of the right 
 foot and went under surgical treatment when eight months, and again when five years, 
 old, but with no permanent relief. On admission into Guy's, under my care, on June 
 12, 1878, the heel of the right foot was much drawn up and the foot so twisted inward 
 as to cause the sole of the foot to face the median line of the body, as in a complete sub- 
 astragaloid dislocation. The head of the astragalus was very prominent and the tip of the 
 inner malleolus approximated the base of the metatarsal bone of the gres^t toe, the tubercle 
 of the scaphoid being buried in the abnormal depression. By no force could the foot be 
 restored to a better position, although the teiido Achillis and tendon of the posterior tibial 
 muscles could be made tense. Under the circumstances described it was tolerably clear 
 
 ' Brit. Mt'fl. Jonvn., November 2, 1878. 
 ' Med.-Chir. Trans., 1877. 
 
KNOCK-KNEE. 821 
 
 that I'V im toiiotniiiy or Jiiccliaiiical iiiiaiis (•(nild any hope be entertained of restorinf; the 
 ioot to a >;ott(l jMisition, and I (•(ni.'«ct|u«iitly ih-tcniiiiHMl to pcrionii Mr. Davies-Colley's 
 ojHTUtion. 
 
 This I (litl on .hiiH' IS, 1S7S, l)y an olili<(iif T-iiicisioii ot'thi- soft parts ami the appli- 
 cation of a kfvholi' saw ln'iieath the tt'iidons and soil parts, niado alter Ksniarcdi l»anda;_'('.s 
 had lu'«'n applied as a toiiriii(|ii('t. 
 
 Tlu' wodu'i- of hone I took away is represented in Ki<_'. 471' and was removed entire, 
 fjreat eare hein;^ used to protect the tendons and soft tissues, and particularly those of the 
 sole, hy the introduction of a flat retractor duriny the sawin<^ process. 
 
 The day followin<^ the operation the temperature went up to 1M2.4°, but fell the next 
 day. On the third day, when the wound was dres.sed for the first time, it was !>'J.(i°, and 
 durinjr the projrress of tlie case it never deviated beyond a point or .so from that degree. 
 On July 11, the bones haviiii;- fairly united and the wound nearly closed, Davie.s-CoUey's 
 talijies splint was put on and the limb swuntr. 
 
 On Se)>tem]ier l(t the boy got up, and the sole of the foot was found, on his standing, 
 to be perfectly flat. An immovable splint was then applied, and the boy left for the 
 country. On C)ctober 20 he returned to have the tendo Achillis divided, with the view 
 of giving more movement to the ankle-joint, and .some success has followed the measure. 
 He can now (November 10) walk fairly well with his foot as flat to the ground as the 
 iinaft'ected one. I have had three other cases since, and seen about six more, which have 
 been eijually successful. 
 
 Spurious Valgus, or Flat-Foot, 
 
 is a common condition in feeble boys and girls who stand much or take too much exer- 
 tion. It is due to a giving way or yielding of the plantar arch and fibrous structures 
 of the sole of the foot, '• the keystone of the arch " — the navicular 
 bone — eventually .sinking with the astragalus and inner cuneiform 
 bones. ( Vide Fig. 480.) In some cases there is as a secondary con- 
 sequence contraction of the peronei muscles and impaired movements 
 of the ankle-joint. This stretching of the tissues gives ri.se to more 
 or less pain, and in extreme cases to inability to walk, or even to 
 stand. This affection is constantly associated with lateral curvature 
 of the spine. 
 
 Treatment. — In the milder form of cases, when the foot can read- 
 ily be restored to its normal position, a cure may be brought about by S[iurious\al»uii 
 periodical rest, gentle exercise, and mechanical support, by means of 
 strapping or the introduction of a firm pad or metal plate, to support the plantar arch, 
 into the hollow of a boot made with a straight inside edge and low heel. Tonics and 
 good air and living and the free movement of the joint are essential. 
 
 In a worse class of cases it is well forcibly to flex the foot and restore the parts to 
 their normal position, and then fix them so by means of a plaster-of-Paris bandage. 
 
 In more extreme cases some divisions of the tendons may be permissible, and in the 
 very worst operative interference may be justifiable. Dr. Ogston of Aberdeen has sug- 
 gested the union of Chopart's joint by pegging. 
 
 In examples in which much pain exists nothing but absolute rest will be of any use, 
 and in such the local signs of inflammation of the overstretched pai'ts are often evident, 
 and therefore fomentations, etc., may be employed. 
 
 Knock-Knee. 
 
 Knock-knee, like flat-foot, is primarily due to mechanical yielding of the internal liga- 
 ment of the knee-joint from want of power, and at a later date to the overgrowth of the 
 inner condyle of the femur with the low^er end of the diaphysis. from the want of the 
 controlling influence of pressure which normally is applied through the leg bones. It is 
 found in growing boys and girls who stand too much and carry heavy weights, and in 
 those of feeble power from either natural or acquired causes. It is not rarely seen with 
 rachitis. 
 
 Treatment. — It can be treated on principles based upon the facts just briefly stated, 
 and not purely by mechanical means. To put irons on the limb of a feeble subject is a 
 mistake ; for where the child is too weak to support his own frame without injury, to 
 give him more to carry must be hurtful. Young children should be taken off" their legs 
 
822 
 
 DEFORMITIES, CLUB-FOOT AND ORTHOPJEDIC SURGERY. 
 
 as much as po.s.«-ible and proviiU.'(l with proper food and such tmiie medicines as seem 
 requisite. Tlie weakened ligaments should have time given them to contract and become 
 strong. Older cliildren should be limited in the amount of exercise, rest and exercise 
 alternating at regular intervals. When walking half an hour causes pain or aching, 
 something less should be allowed, and so on. Exercise sufficient to get and keep the 
 muscles in order may be allowed, but not sufficient to tell upon the weakened ligaments. 
 In other cases, as an additional means, strapping the knees may be of great use. In 
 more severe cases splints or irons should be employed. These latter instruments should 
 extend from the pelvis to the foot and be well jointed. In very severe examples operative 
 interference may be justifiable, and the surgeon has a choice of three measures : 
 
 1st. Ogstons ojieration of obliquely sawing or chiselling off the inner coiuJyle of the 
 femur and forcibly straightening the bent limb, which is kept fixed by splints and band- 
 ages during the period of repair (Fig. 481). 
 
 2d. Mnceiven's uperufion of dividing with a saw or chisel the shaft of the femur uljove 
 the amdylesi. forcibly bringing the limb straight, and retaining it in its new position for 
 
 five or six weeks while the bone unites t Fig. 482), the cutan- 
 FiG. 4sl. eous incisions in both these operations being merely enough 
 
 to admit the cutting instrument or saw. 
 
 Fig. 482. 
 
 Prawing illustrating Dr. Ogston's Ope- 
 ration. I PJijId limb shows line of sec- 
 tion of the inner condyle of the fe- 
 mur. Z^//, inner condyle brought to 
 required position.) 
 
 Appearance of Limbs before and after Macewen's Operation in a 
 Patient set. 33. (The legs and feet rotated outward and ab- 
 ducted.) 
 
 3d. Tu.'i forcible str<Ai(jhfenin(j of the limb, as advocated by Delore. pressing it .straight, 
 and giving time for repair. 
 
 Of these three, the second, or Macewen's, is to be preferred, the results being as good 
 as, if not better than, Ogston's operation ; and the operation is attended with less risk, 
 tl.c knee-joint not being opened. My colleagues and I have performed it on many occa- 
 sions, and always with success. In the drawing above — one of the worst cases I have 
 undertaken, in an adult aet. 33 — the operation gave three inches to the patient's height 
 (Fig. 482 I. 
 
 Delore's operation is not to be advised, since it means not only the abruption of liga- 
 ments, but often the separation of epiphyses, and with such separation the dangers of 
 local disease .starting from the seat of injury, and the probable arre.st of growth in the 
 limb as a later consequence. Farabeuf and Mikulicza have fairly established this fact 
 (6V/.-:. Med. de Paris, January, 1880). 
 
 Tenotomy for Contracted Limb, etc. 
 
 Be.sides all these recognized affections, there are many other conditions in which 
 tenotomy is a valuable operation. Thus, in the contracted limbs which are associated 
 with hip, knee, or other joint disease, it is often necessary to divide the rigid and con- 
 tracted tendons or muscles that forbid the limb being .straightened by the application of 
 any ordinary or justifiable force, while mechanical means can then complete the object 
 the surgeon has in view. It is better to divide than to tear a tendon. 
 
 In 1871 I saw a boy set. 14 who for years had had repeated attacks of pain and inflam- 
 mation about his great toe. more particularly after overwalking. He had been under the 
 care of many medical men. who had treated him for gout. etc.. but who had never com- 
 pared the sound with the affected toe. When I did this, the source of the evil was very 
 apparent ; for the long extensor tendon was clearly contracted, and at its insertion into 
 
cosTiiAcTins nF Till-: r!S(;i:ns.—i:n!ii> Arnnrirv. h23 
 
 thf base of the extreme phalanx tlitie was iiuicli tliickeiiiiig. I diviiled the tendon, and 
 recovery at onee ensued. 
 
 The hicep.s muscle of tlie arm is also at times so contracted as to prevent extension ; 
 the adductor muscles of the tiiigh are so contracted as to cause j^reat apparent shorten- 
 ing of the lower extremity, and, as a result, limping. In both of these cases tenotomy 
 is of great service, lii fact, any tendon may contract under the influence of disease, and 
 ret|uire division. 
 
 Contraction of the Fingers. 
 
 In this curious affection, which generally ajipears in the little finger and subsequently 
 involves the ring finger, and in which the palmar fascia ciiietly, and the flexor tendons 
 secondarily, juotluce a jtcrmaiiciit contraction of first one and then the other linger, .so as 
 to draw them into the j)alm, some operation is called for. 
 
 It often attacks Ixtth hands, together or consecutively. It is said to be found more 
 frequently in gouty or rheumatic sul)jects than in others, but I have failed to verify this 
 statement. It is also difficult to trace the origin of the disea.se to any local injury. In 
 fact, this affection is somewhat obscure. It may attack the middle finger or any and all 
 of the fingers, but more commonly it is the two outer. From its .symmetry it has proba- 
 bly a constitutional and not a local, origin. It is often hereditary, but ])ossibly not more 
 so than any other deformity. 
 
 Treatmknt. — By fixing the contracted fingers in a flexible splint and gradually 
 stretching them much may be done, and in .several cases I have effected a complete cure 
 by these means. But it is diflicult for men-patients to submit to this inconvenience, and, 
 as a consequence, the surgeon is consulted only when the disease is severe and the finger 
 by its contraction has become u.seless, if not wor.se than u.seless. Under these circum- 
 stances the free division subcutaneou.sly of all the tense tissues may be called for. as 
 recently ably advocated by Mr. W. Adams (Bn't. Med. Journ., June 29, 1878). His opera- 
 tion and treatment are as follows : 
 
 1. The subcutaneous division of all the contracted bands of the palmar fascia and its 
 digital prolongations by as many punctures as might be necessary, cutting from above 
 downward with the smallest tenotomy knife. 
 
 2. Immediate extension of the contracted fingers, the fingers and hand to be bandaged 
 to a splint. 
 
 3. The bandage not to be removed until the fourth day, when the punctures will be 
 found to be healed. 
 
 4r. Extension splint to be worn night and day for two or three weeks, and afterward at 
 night for three or four weeks, motion being employed every day. 
 
 Dr. Madeliing of Bonn {BerUner Klinische Wochmschrift . No. 15, 1875) believes that 
 this condition of finger, known as " Dupuytren's contraction." is due to the absorption of 
 the numerous small deposits of fat which in healthy young and middle-aged subjects 
 exist between the connective-tissue bands of the palmar fa.scia and the short fibres which 
 connect this fascia with the superjacent integument. This fascia, consequently, under 
 the influence of pressure, falls into a state of chronic inflammation and becomes con- 
 tracted. He then describes how Busch of Bonn treats such cases with great success. In 
 a case, for example, of contraction of the little finger, he raises an angular skin flap from 
 the palm of the hand, its base being at the root of the finger, and then cuts away.. bit by 
 bit. the tense fa.scia beneath as the finger is being straightened. He then replaces the flap 
 and fixes it with sutures. The finger is left free for some days after this operation, but 
 as soon as granulations appear a cylinder of wood is placed in the palm for a few days, 
 and after this the finger is extended and kept so by means of a straight splint applied to 
 the back of the hand. This should be removed daily and the finger moved. At the end 
 of three or four weeks the hand is left free. Dr. Madeliing has never seen this operation 
 fail {Med. Rev., May 26, 1875). I have adopted this practice in several cases with excel- 
 lent results. In the same way one or more toes may be so affected, and tenotomy may 
 be called for. 
 
 Rigid Atrophy. 
 
 Muscles that atrophy occasionally contract and become rigid, but this rigidity must 
 not be mistaken for the spasmodic contraction of a muscle or group of muscles that is so 
 common in progressive disease, more particularly of joint disease, although it often follows 
 upon that form : indeed, it seems generally to be the consequence of some long-continued 
 
824 DEFORMITIES, CLUB-FOOT, AND ORTHOPEDIC SURGERY. 
 
 spasm, atrophy following from exhaustion, inflammation of the muscle, or what is called 
 " rheumatism."' It is seen more commonly in the flexor muscles of joints than in any 
 other, and. as a special afi"ection, in some cases of v:ry-neck, where the sterno-mastoid 
 muscle is at fault. 
 
 Treatment. — When the muscles are not too rigid, much may be done by rapid exten- 
 sion under the influence of an anaesthetic or gradually by means of splints, manipulation, 
 or india-rubber bands, etc., suited to the wants of the individual case. When these 
 means are ineffectual or the parts too rigid to allow of their application, the subcutaneous 
 division of the tendon of the muscle or muscles may be performed upon the same prin- 
 ciple under which tenotomy is practised in contracted tendons. 
 
 Wry-Neck is an example of this affection due to a contracted sterno-mastoid muscle. 
 It may be that the sternal or clavicular origin may be alone at fault, it being exceptional 
 to find both divisions of the muscle aff"ected. 
 
 Treatment. — Under such circumstances, when the muscle refuses to be stretched 
 by mechanical appliances, the half involved alone requires division, followed by extension 
 when union has taken place. In these difficult cases it seems wise, as a rule, not to bring 
 the divided ends of the muscle so closely into contact as the surgeon usually does after 
 division of a tendon. 
 
 One of the worst cases of the kind I ever had to treat was in a child fet. 7 in which 
 
 both origins of the muscle required division. I brought the head up to the required 
 
 position on the second day and kept it there, an excellent result 
 
 Fig. 488. en.suing. In another, which I treated in 1870, in a child aet. 6, 
 
 with Mr. Duke of Battle, the muscle of the left side was two 
 
 inches shorter than that of the right from contraction of its 
 
 sternal half. I applied extension on the third day, after the 
 
 division of the contracted portion, and brought the head into 
 
 its right place, keeping up the extension by means of a piece 
 
 ,,y , ~ .^.^ of india-rubber band an inch wide, which was fastened to a 
 
 Mm/i^ / / ^^ skull-cap on the opposite side of the head and passed backward 
 
 ^ ^ across the shoulders and beneath the axilla of the affected side 
 
 to fasten to a good thoracic belt (Fig. 483). 
 
 These cases of wrj'-neck due to contraction of muscles are 
 always associated with some arrest of growth in the upper and 
 lower jaws on the affected side. 
 
 3Ir. de Morgan informs us ( Mcd.-Cftir. Rev., 1866) that in a 
 ease that failed to 3'ield under such treatment he took away a piece 
 of the spinal accessory nerve with permanent benefit, the .sterno- 
 
 Cap and Band for Extension in ^-ii^ • ^ ^ • o -^ 1 j mi.- 
 
 Wry-N'tck. mastoid and trapezius muscles being 01 necessity paralyzed, ihis 
 
 operation has been repeated, but with only exceptional success. 
 
 The operation of dividing the sterno-mastoid muscle, either wholly or in part, at its 
 sternal or clavicular origin, must be subcutaneous and requires much care, for important 
 parts lie behind tKe muscle which may be injured. A punctured wound down to the 
 muscle should be made over the part to be divided with a sharp-pointed tenotomy knife ; 
 a blunt-pointed knife ought then to be introduced, with its edge turned toward the muscle, 
 close to its bony attachment, and all resisting fibres divided by turning the edge back- 
 ward, an assistant putting the muscles fully on the stretch ; the muscle usually gives way 
 with a distinct snap. The thumb or finger must then be applied to the part and a pad 
 adjusted, sufficient pressure being made to prevent bleeding, but no more. As already 
 stated, extension should be made early in the case, after the second or third day, and the 
 means adopted in the example quoted seems to be the best ; it succeeded, at any rate, 
 where the usual instruments failed. 
 
 When both insertions require division, it should be effected by two different punc- 
 tures. Some surgeons prefer to divide the muscle from behind forward, but there is 
 greater risk of injuring the deep parts by this practice than by the one advised. 
 
 I need scarcely add that where wry-neck is due to spinal disease no such treatment as 
 the above is applicable. 
 
coyrrsioys ar joiyjs. 825 
 
 CHA PTKIl X XX. 
 
 CONTUSIONS, 81'1{AL\S, WOl'MtS, IN.Jl lllKS OF .JOINTS, AND 
 
 DISLOCATIONS. 
 
 Sprains "lay l>i' vcrv slight or very sfiious iiidiit'ct injuries. Tliey iiielu(l»' iimre or 
 less severe overstreteliiii<;s, if not laeeratiuiis, of the ligaments that l»ind tlie bones of an 
 articulation tt»^etlier, some fracture (tr tearing away of the hone at the attachment of the 
 liL'aments — •• s])rain fractures." In ehihh'en untler ten. sjirains of joint.s are liable to be 
 comjilicated with some epijdiysial separation or incomplete fracture near the epiphy.sial 
 line, or some crushinir oi' compression of the spon*jy bone tissue. In the more severe 
 instances are inchuleil lacerations of the muscles, tendons, and soft parts that surround 
 the joint. All such accidents require rest and time in their treatment in order that 
 repair may be complete, since neglected sprains are often the cau.se of joint or bone 
 disease. 
 
 Contusions of joints «s direct injuries always ought to be regarded in a serious 
 aspect, for a large amount of internal mischief may often be su.stained with very slight 
 external evidence of injury, and under certain conditions of health a slight blow upon a 
 bone is often enough to set up seTere local action or to excite chronic changes which may 
 involve the integrity of the joint. During the period of the growth of bone in children 
 these observations have great force. The nature of the accident and the amount of force 
 concentrated on the joint form the best index to the case, and under all circumstances 
 the prognosis should be guarded and the treatment cautious. 
 
 Treatment. — •• In sprains of joints rest is the first principle,"' said John Hunter in 
 17S7 (MS. lectures), and at the present day the same words are as pregnant with truth 
 as when then spoken ; indeed, in simple cases of sprain by such treatment alone will con- 
 valescence be established. When swelling and effusion into the joint ensue in the course 
 of the second or third day after the accident, the evidence of internal injury is more 
 marked ; for such efi"usion means inflammation or synovitis, which is to be treated by abso- 
 lute rest, ensured by the application of a splint, the local use of cold or warmth, accord- 
 ing to the comfort afforded by either, and occasionall}' by leeches. 
 
 If swelling of the articulation follows immediately upon the injur}', eff'usion of blood 
 into the joint is indicated with or without fracture, but always with severe local mischief. 
 Such cases should be treated by the employment of a splint, to ensure immobility of the 
 articulation, elevation of the injured joint with the patient reclining, and the local appli- 
 cation of a bag of pounded ice or Leiter's metallic coil (Fig. 9), these means being main- 
 tained until the hemorrhage has ceased, all risks of inflammation of the joint are gone, 
 and repair appears to be going on satisfactorily. As soon as the primary eff'eets of the 
 sprain and all signs of inflammation have passed, the application of pressure to the joint 
 by means of a bandage or strapping with passive movement is very striking. When the 
 joint is rendered very tense from eff'used blood, it may be aspirated. 
 
 When the muscles over the shoulder-joint are severely bruised by a fall, much local 
 pain may be produced, as well as want of power in the arm. exciting a fear of either bone 
 or joint mischief; but a careful examination will show, if no roughness in the examina- 
 tion be used, that the joint can be passively moved without exciting pain, although if the 
 patient attempts to set the muscles in action pain is produced. This point is one of 
 clinical importance, indicating that the mischief is in the muscle, and not in the articula- 
 tion, the pain being excited by muscular action, and not by joint movement. 
 
 In delicate children all falls upon the hip followed by pain should be treated by rest 
 and extreme care, for a large number of cases of hip disease originate from some such 
 trifling cause ; and there is good reason to believe that the majorit}' of hip-joint affections 
 might be prevented by proper attention after .slight injury. 
 
 After-Treatment. — When the immediate eff'eets of the sprain have passed away, 
 the local use of a stimulating liniment and moderate friction of the part expedites the 
 cure, and at the .same time gives comfort to the patient. A local warm bath at intervals 
 likewise relieves the stiff"ness of the joint. Whenever movement excites more than a 
 momentary pain, rest should be observed; and if the pain continue, some chronic inflam- 
 matory change ought to be suspected and treated. When weakness of the joint alone 
 remains, a good bandage or strapping around the part, to give support, is of great benefit. 
 
826 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 Where much hiceration of ligament has taken place, it is at times necessary for the joint 
 to have some permanent artificial support, in the form of either a splint, felt, leather cas- 
 ing, or bandage ; fiM- no parts are repaired with less permanent power than ligaments. 
 
 In the wrist, when much swelling exists, a sprain may be mistaken for a fracture or a 
 fracture for a sprain, as fractures about the end of the radius are generally impacted, and 
 not, consequently, attended by crepitus. Much care is necessary in the diagnosis of such 
 cases. Man}- sprains of the ankle are also really cases of fracture of the fibula above 
 the malleolus. The popular notion that a severe sprain is worse than a fracture is in the 
 main true ; and when the sprain is neglected, the case is always more tedious than that 
 of a broken bone. 
 
 Wounds of Joints. 
 
 These are always serious accidents, yet as a whole, if treated with discretion and at 
 an early period of their existence, they are fairly successful in their issue. Lacerated, 
 incised, and punctured wounds are met with, and the symptoms that follow any one of 
 these accidents are by no means commensurate with the extent of the local injury ; for 
 a slight or punctured wound is often followed by severe and destructive local changes, 
 when an extensive one heals without giving rise to any mischief. 
 
 A joint is known to be wounded when its contents escape, the oily, glutinous nature 
 of synovia rendering its flow very manifest. In fat subjects, however, wounds over joints 
 give exit to an oily fluid simulating "joint oil," but such fluid is not sticky when rubbed 
 between the fingers, as is synovia. Joints are sometimes wounded without any evident 
 escape of their contents ; such doubtful cases are clinically to be treated as cases of 
 wound. In every case of wounded joint, however trivial, and in all doubtful eases of 
 wounded joints, the 2)ro(/)iosis must be very guarded and the treatment cautious. 
 
 Treatment. — A clean incised wound should be well cleansed with carbolic or iodine 
 water and its edges accurately adapted with sutures ; a contused or lacerated one .should 
 likewise be well washed and the joint syringed: and if the edges of the wound are 
 brought partially together, sufficient opening should be left for drainage. The wound in 
 both cases should be dressed with some absorbent antiseptic dressing such as iodoform or 
 carbolic gauze. Probing must be avoided, and the joint should be kept in absolute repose 
 by the application of a splint. Cold should then be applied, nothing checking pain or 
 subduing inflammation and efi'usion better. The cold, however, to be of value, must be 
 persistently maintained, as any intermission of its use is almost sure to be followed by 
 increase of pain and efi'usion. To seal hermetically a small wound with a piece of lint soaked 
 in the compound tincture of benzoin and at the same time apply cold is excellent prac- 
 tice. Should an interval have passed between the receipt of the accident and the appli- 
 cation of the cold, and much joint inflammation exist with con,stitutional symptoms, the 
 application of leeches to the joint, and subsequently of cold, is beneficial. £n exceptional 
 examples, where cold is not tolerated, warm fomentations must be substituted. Opium 
 is always of use. the patient being kept fairly under its influence by one grain two or 
 three times a day. Mercury is useless. In very sthenic cases antimony may be given, 
 and colchicum where gout is suspected. 
 
 When all acute symptoms have subsided and chronic efi'usion remains, the application 
 of a blister or of blisters expedites the absorption of the efi'used fluid, and the benefit of 
 pressure by the adjustment of well-applied strapping is very great. In feeble patients 
 tonics are required. Should suppuration appear, active treatment is called for, such as a 
 free incision into the joint, or other means which will be considered under the head of 
 " Suppurating Joints." 
 
 Extensive wounds of large joint-e complicated with other injuries had better be treated 
 by amputation or excision. 
 
 DISLOCATIONS. 
 
 A joint is said to be dislocated when the articular surface of one bone is displaced 
 from another. When the bone is wholly displaced, the dislocation is called complete ; but 
 when otherwise, partial or incomplete. 
 
 When a wound communicating with the joint complicates the case it is known as a 
 compound, and when not so as.sociated as a aimple. dislocation. 
 
 Congenital dislocations are cases of malformation, and the displacements of bones pro- 
 duced from disease are accidental complications of a more serious aff"ection. In the pres- 
 ent chapter neither of the.'se two conditions will receive attention. 
 
 Flower and Morris's ^liddlesex Hospital statistics (Holmes s System, vol. i.. 3d ed.) 
 
DisijxwTioys. 827 
 
 tell us that, out of 75(1 caaos of (lislocatinii of the upper extremity treated in twenty-six 
 years, 20 were of the elavicle, 1(J of tin; seapula, I)"') of the liuiuerus, 112 of the elhow. 
 1H7 of the thumb, aud 7S of the phalaii^'es. At (iuy's, during the ten years endiii;r with 
 1888, out of 4(j disloeatioiis of the lower extremity, 25 were of the hip, 7 of tlu; patella, 
 10 of the hones of the foot, and 4 partial of the knee. 
 
 Dislocations are mostly eaused hy external violenee, hut tht^y occasionally occur 
 fioni Miiisciilar action, as in dislocation of the lower jaw. [ have known, however, the 
 head of the Inimcrus to he displaced hy the exertion uscmI in the violent throwint: of a 
 stoni' and hv the spasm of muscles in an epileptic fit. I have likewise seen the hip-joint 
 dislocated 1)V mere muscular action. Scdioolboys are also familiar with the dishjcation of 
 the tlunul) at the carpal joint, which some young persons who jiossess relaxed liframents 
 are capahle of jjroducing at will. 
 
 Laceration of tlu^ liganients more or less complete, as well as of the capsular ligament, 
 is a usual accompaniment of all <lisli)cations, with more or less injury to the mu.scles and 
 soft parts that surround the injured articulation. In exceptional cases the capsule, 
 in.stead of being torn, may be simply stripped off the bone. At times the nerves are 
 pressed upon or lacerated and the main artery pressed upon, stretched, or divided. In 
 shoulder dislocations the circumflex nerve is frequently torn, and the popliteal artery is 
 injured in knee dislocations. In all joints, more particularly in the ankle, dislocation 
 may be complicated with fracture. 
 
 After a dislocation has been reduced most of these injuries are steadily repaired, 
 although some weakness of the joint often remains, and some impairment of mobility. 
 When nerves have been injured, more or less complete local paraly.sis or want of power 
 follows in the muscles supplied by the injured nerves. 
 
 When a dislocation has been overlooked or neglected, secondary and, in a measure, 
 reparative changes take place and a new joint is formed. To effect this, new products 
 are poured out around the bone in its new position, which organize and ossify (Fig. 484), 
 The cavity thus formed becomes lined with a dense layer 
 
 of fibrous tissue, putting on the external aspect and serv- Fk;. -484. 
 
 ing instead of cartilage. The head of the bone becomes 
 at the same time altered in shape and surrounded by the 
 condensed cellular tissue of the part, which answers for a 
 new capsule. A large amount of mobility is often se- 
 cured, particularly in the ball-and-socket joints. When, 
 however, the original articular cavity becomes gradually 
 filled in with fibrous tissue, the muscles, tendons, and 
 soft parts that have been torn or misplaced make fresh 
 attachments, and ossific matter is deposited in the ten- 
 dons. 
 
 How long these secondary changes take to form is 
 not vet decided. In some patients the\' doubtless occur 
 
 ■-„.^;^ll,, .,J : „4i II "D 11 i J XT' • False .Toiut iifter Dislocation of the Head 
 
 rapidly and in others slowly, as rJrodhurst and J^ournier of the Femur. (From .sir a. Cooper.) 
 both (*SV. Gi'orge's Hasp. Rep., 18G8) record a case in 
 
 which the cartilage of the acetabulum was found healthy and the cups unfilled three 
 years and ten years respectively after a dislocation. Cadge also records a singularly 
 instructive example (Med.-C/iit: Trans., vol. xxxviii.) of an unreduced dislocation of the 
 head of the femur upward between the two anterior spinous processes of the ilium of six- 
 teen years' standing, in which '' the new bone was deposited in such abundance that it 
 formed a new and complete acetabulum — so complete as, indeed, to hold the thigh bone 
 sus])ended after all the soft parts were removed and make it requisite to saw off a large 
 piece of the new bone in order to set the femur at liberty. The new cavity, thin at its 
 walls and smooth on its outside, was lined by a dense pearly white ti.ssue which resembled 
 fibro-cartilage. The head of the femur was still covered with cartilage. The old ace- 
 tabulum had disappeared, partly by the absorption of its cotyloid margin by a deposit of 
 new bone, and partly also by a mass of dense fibrous tissue." 
 
 Diagnosis and Symptoms. — Typical examples of dislocation, when seen at an early 
 period of their existence, are not difficult of diagnosis, although partial and even complete 
 dislocations .some days after the accident, when swelling of the parts has taken place, are 
 often obscure. The frequency with which such cases are overlooked, even by good men, 
 forbids our saying they can always be made out. 
 
 In evtri/ casf of xuspected disJoaition the surgeon ahoidd compare the sovnd tcith the 
 injured side, and in difficult cases, in young or sensitive subjects, he should make the 
 
828 CONTUSIOyS, SPRAINS, ASB WOUSm OF JOISTS. 
 
 examination with the patient anaesthetized. In doing tliis he will at once detect the 
 most obvious result of any dislocation — deformity — and be able to make out the direction 
 the displaced bone has taken : he. moreover, will see whether the limb is longer or shorter, 
 or more abducted or adducted, than its fellow. The patient will have lost all power of 
 voluntary movement ; the surgeon, by manipulation, will discover that where mobility 
 formerly existed such will be seriously impaired, and that the attempt to obtain it causes 
 severe pain. There will be an absence of crepitus, unless some days have passed since 
 the accident, when the crepitus of eflPu.sion into the joint or into the bursas about the joint 
 or tendons will often be felt. JJe/orniif^, loss of the power of voluntary motion, and 
 impaired mobility, coming on after an accident, are the three most marked symptoms of 
 dislocation. Indeed, these symptoms by themselves. With the absence of crepitus, are 
 usually enough to enable the surgeon to diagnose a dislocation from a fracture. They 
 are not enough, however, to distinguish it from the separation of an epiphvsis — an acci- 
 dent prone to aifect subjects under the age of twenty-one. 
 
 Treatment. — In all cases the reduction of the dislocation or displacement should be 
 effected as soon as pos.sible. delay being justifiable only when the appliances required for 
 the purpose are not at hand or the diagno.sis is uncertain. Most dislocations, not exclud- 
 ing those of the hip. may be readily reduced directly after their occurrence by extension 
 or manipulation without the aid of an anaesthetic ; but when any time has been allowed 
 to pass and the immediate constitutional effects of the accident have subsided, it is a fair 
 question whether it is advisable to attempt reduction before ana}sthetizing the patient, for 
 under the mo.st favorable circumstances, without this aid. much force will to a certainty 
 be called for, whilst with it the gentlest manipulation is often enough. Indeed, I believe 
 it to be wiser for the .surgeon to delay any attempt to reduce a dislocation till an anaes- 
 thetic can be obtained than to make it without, for the slight harm that ensues from the 
 delay is more than compensated by the great good secured b}' its use. In no department 
 of surgery is the benefit of anaesthetics better demonstrated than in this, for where force 
 formerly reigned gentleness now suffices, and where difficulty and pain were common 
 accompaniments facility of reduction and painlessness are now the rule. Their use has 
 superseded the old treatment by venesection, tartar emetic, the string of students, and 
 the pulleys. Under their influence all muscular spa.sm ceases to be a force which has to 
 be overcome, and the surgeon has .simply to replace the bone through the rent in its cap- 
 .sule by such gentle manipulative acts as the special requirements of each case appear to 
 indicate. The facility, however, with which a di.slocation is reduced by manipulation 
 turns much upon the surgeon's knowledge of the way the di.slocation was produced, for, 
 in a general sense, the best way to reduce a di.slocation is to make the head of the bone 
 retrace the course it followed after it had first bur.st through its capsule, the untorn parts 
 in the capsule being doubtless the main obstacle to reduction ; muscular spasm is elimi- 
 nated by the use of an anaesthetic. 
 
 In neglected cases of dislocation, where false joints and adhesions exist, force is called 
 for to break them down and pulleys may be wanted, but they mu-st always be employed 
 with the greate.st caution and under a healthy fear, for not only may the axillary artery 
 be torn and ligaments lacerated, but worse injuries may ensue ; thus, in Paris, in 1864, 
 the fore-arm of a woman aet. 64 was torn off at the elbow-joint in the attempt to reduce a 
 dislocation in the humerus, and in London, more recently, the same dreadful accident has 
 taken place. Agnew in his Surgery gives 24 cases of injury of the axillary artery brought 
 about in attempts at reduction of old dislocations of the humerus, and of these 15 were 
 fatal. 
 
 After-Treatmext. — After the reduction of a dislocation the limb should be kept at 
 rest and fixed by bandages on a splint ; Sedillot's rule of '• simply placing the joint in a 
 position the opposite of that in which it was when the dislocation occurred " is sound. 
 When any signs of inflammation .show themselves, cold, in the shape of ice in a bag, 
 should be employed ; leeches are seldom called for. 
 
 At lea.st three or four weeks are required for repair to take place before any useful 
 free movement of the joint can be allowed, although, when no inflammatory symptoms 
 appear, pas.sive movement may be permitted at the end of two weeks ; in dislocation of 
 the hip no walking or standing .should be permitted for a month. 
 
 When reduction cannot be accomplished after a reasonable attempt,' a second one may 
 be made at a subsequent period after the effects of the first have passed — that is, if any 
 sound hope exi.sts of success being secured — some modification of the means employed 
 probably suggesting themselves to the surgeon upon reflecting as to the peculiarity of 
 the case and the cause of his failure. 
 
DISLIKWTIOSS. K2t» 
 
 When tlic patient is ai» adult, the (lirticiiltics ami prospects of the rase should he laid 
 hi'fdif hiui and his npiuiiui taken — not, however, as to the desirahility or the reverse ol' 
 the attempt, lor such an opinion hehtngs to the surgeon and his collea^^ues oidy, hut as to 
 the risks that must he run ; lor in many cases failure of reduction — more particularly of 
 furcil)le reduction — is followed hy some destruction of the new joint that nature has par- 
 tially formed, hy some inflammatory chanp; that may end iti the dcstructinn of the joint 
 or in ri-ndcrinj; its usefulness still less pnunisinj;. 
 
 With respect to the propriety of atti-mptin;.' the reduction of an (d<l dislocatio?i no 
 definite rules can he laid down, and since an;esthetics have heeii introduced those orif^in- 
 ally jriven hy Sir A. Cooper and ireMcrally lollowed rei|uiri' modification. Sir A. Cooper 
 frave three months as a limit to the atti'inpt in the shoulder, and ei^ht weeks in the hip; 
 yet Seilillot reduced a dislocation (d" the shoulder more than a year after its rec<;ipt, 
 Hrodluirst on the one hundred and seventy-fifth day. Smith H-nited States) at the s(!venth 
 and tenth numtli, whilst Hreschet reduced a dislocated hip on the seventy-eifrhth day, 
 Travers and my colleauue, Mr. Durham, at the fifth month, lilackman (of Cirencester) at 
 the sixth month. Vet such ca.ses must be rare. Ball-and-socket joints are ahso more 
 readily replaced than others. The best guides the surgeon possesses for his decision are 
 found in the amount or the absence of repair that is present in the dislocated joint. When 
 the movement is good, there is small rea.son for making the attempt ; for, writes Fergus- 
 son, " after three months the use of the limb is not, when reduced, greater than that 
 which it would have ac((uired in its dislocated state." 
 
 When the movements are very limited, a cautious attempt to reduce the dislocation i.s 
 hardly likely to be followed by a bad result, at whatever period it is made ; but, as previ- 
 ously stated, the patient and the surgeon should take counsel together on the point and 
 share res])onsihility. 
 
 To facilitate the reduction of an old dislocation, it is needless to say, .some anaesthetic 
 should be em])loyed : ami as a primary step all adhesions should be bnjken down by free 
 rotation or forcil)le movements of the joint. W^hen this has been effected, the head of 
 the bone ought to be replaced by manipulation or by slight extension, forrible extension 
 being inadmissible. When tendons are very rigid and forbid movement, they should be 
 divided subcutaneously ; but this should be done some days before reduction is fully 
 attempted. 
 
 Compound dislocation is one of the most serious accidents that can befall a 
 limb, and in the larger joints is generally complicated with fracture or torn arteries. In 
 the knee-joint the popliteal artery is generally lacerated, and under such circumstances 
 amputation is the only resource. In the ankle-joint, where the accident is most commonly 
 seen, the case should be treated as one of fracture and wounded joint by immovable 
 splints after its reduction, and the persistent application of cold. In exceptional cases 
 only, when the soft parts are much injured, and in very feeble subjects, ought amputa- 
 tion to be thought of, excision of the articular surface being always a point for considera- 
 tion. In the elbow, where movement is of essential importance, excision had better be 
 performed when the wound is large, although recovery with movement of the joint may 
 take place without it in young adults. Under all circumstances the dislocation ought to 
 be reduced, the question of excision or amputation turning upon the amount of mischief 
 the soft parts or bones have sustained. 
 
 Compound dislocations and compound fractures into joints are clinically of very sim- 
 ilar import. 
 
 When dislocation and fracture coexist, difficulties are often inet with, but the reduction 
 of the dislocation is often possible by manipulation aided by anjiesthetics where without it 
 is impossible, and I have reduced with its aid, in one case, the head of a fractured humerus 
 from the subglenoid position, and in another a fore-arm displaced backward with fractured 
 arm-bone, and afterward in each case adjusted the fracture with facility; I have likewise 
 seen the head of the femur displaced upon the pubes pressed back into its socket, notwith- 
 standing that a fracture of the shaft existed. I believe that in the majority of these 
 cases the dislocation may be successfully treated before the fracture, the fractured bone 
 being at the same time moderately extended. It may be prudent in some to apply splints 
 before attempting the reduction of the dislocation, but such a step is not always necessary, 
 or, indeed, advi.sable. for with the limb encased in splints the surgeon has less influence 
 upon the di.slocated bone. When the dislocation cannot be reduced, the fracture must be 
 dealt with in the ordinary manner. In a case I recently had under care, of a woman aet. 
 6G, in which the head of the femur was dislocated into the .sciatic notch and an impacted 
 fracture of the neck of the thigh-bone coexi.sted, a good limb was secured. 
 
830 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 Separation of Epiphyses. 
 
 In all young patients, and in others under twenty, where a dislocation or fracture near 
 a joint is said to be present, the surgeon should suspect the injury to be one of partial or 
 complete separation, with or without fracture of an epiphysis, and particularly when any 
 of the joints of the upper extremity are involved; for, whilst dislocation of the shoulder- 
 joint in children is very rare, incomplete separation of the shaft of the humerus from 
 its upper epiphysis is not seldom met with (Fig. 543), and by far the majority of cases 
 of supposed dislocation at the elbow-joint in young subjects are examples of displacement 
 of the lower epiphysis of the humerus together with the fore-arm bones. The same 
 remarks are likewise applicable to the wrist-joint, dislocation of such in young people 
 being almost if not quite unknown, whilst separation of the lower epiphysis is probably 
 comparatively common. A pretty example of this kind is to be seen in Fig. 549. 
 
 In the lower extremity these cases are possibly rare. I have, however, seen, several 
 examples of displacement of the lower epiphysis of the femur with the tibia and fibula, 
 and give an example of this accident in Figs. 521 and 585, and I believe that what are 
 regarded as severe sprains of the ankle in children are often due to some displacement 
 of one or other of the malleolar epiphyses, since I have seen many examples of 
 arrest of growth in limbs that had been supposed to have been previously the seat of 
 sprains. 
 
 I have, moreover, certainly seen two cases of displacement of the foot outward with 
 the lower epiphysis of the tibia, one of which was compound, with the ends of the diaphy- 
 sis presenting through the wound. It occurred in March 21, 1884, in a boy £et. 15, from 
 the foot being caught between the spokes of a revolving wheel. The parts were readily 
 restored to their normal position, and a good recovery ensued. The epiphysial cartilage 
 in this case seemed to be attached to the diaphysis. How far arrest of growth in the bone 
 will ensue time must prove. 
 
 Again, there is good reason to believe that some examples of acute suppui'ation of 
 joints following injury have been brought about by this cause, and that a partial or com- 
 plete separation of an epiphysis in the hip, shoulder, elbow, wrist, or ankle-joint, associated 
 with a tearing away of the periosteum from the diaphysis with which the epiphysis is asso- 
 ciated, is occasionally followed by acute periosteal inflammation of the injured parts, com- 
 plicated with suppuration of the contiguous joint, and not rarely with acute articular 
 necrosis. 
 
 Dislocations of the Upper Extremity. 
 
 Dislocations of the spine and lower jaw have been considered in former chapters 
 (pages 237 and 449). Those of the upper extremity will now occupy our attention. 
 Dislocations of the Clavicle. — Dislocations of this bone at its sternal end are 
 rare accidents, though according to Flower they form about three per cent, of all disloca- 
 tions of the upper extremity. They are produced by violence applied to the shoulder 
 p, when the scapula is fixed, the clavicle being forcibly 
 
 thrown toward the mesial line. Dislocation downward is 
 an impossibility, the cartilage of the first rib preventing, 
 but it may take place ./brii-rf re?, upward, or backward, and 
 may be partial or complete. 
 
 Dislocation forward is usually caused by some 
 violent pressure of the shoulder backward, although Me- 
 lier (Archives Gen. de Med., tom. xix.) records a case in a 
 child where it was produced by simply pulling the arm. 
 The head of the bone in this accident forms a marked fea- 
 ture and cannot be mistaken for anything else (Fig. 485). 
 
 Dislocation of Sternal End of Clavicle ■\\T^ i t i i.- • j- / ' i - ; „^ 
 
 Forward. (Drawing 27-ii, Guy's Mus.) When the dislocation \s partial, some unusual prominence 
 
 of the end of the bone, on comparing it with its fellow, 
 will suggest its nature, the bone being only covered with skin and readily pressed back. 
 When complete, the nature of the accident will be still better marked, .and the end of the 
 bone will be usually found pointing downward. Inflammatory thickening of the joint 
 should not be mistaken for partial displacement. 
 
 Treatment. — There is usually little or no diflSculty in reducing this form of disloca- 
 tion by forcibly drawing back the shoulder and applying pressure to the displaced bone, 
 though there is great difficulty in keeping the bone in its normal position ; indeed, as a 
 
DisLocATfoxs or Tin-: rrrr:n rxriuiMirv. 831 
 
 riilf, it is (juitf iiii|i(issil»le to dd tliis satisfactorily. In dik- case I succeedcil Ity keep- 
 ing; the |»atii'iit 1)11 liis bai'k in licil fur tlni-*' weeks with his arm bound to liis side. A 
 pad in the axilhi, witli a tijruve-of'-S lianchijic to keep tlie shoulder outward, the elbow 
 bein^r bouiul to tlie .side, will do much towanl the desired end, and a j»ad f>f lint applied 
 outside the disjdaeed end of the elaviele and iirinly fixed in position by strappinj; carried 
 over the shoulder and scapula has a very beneficial tendency. Nelaton advises the use 
 of a conmiou hernia truss. The sur<;eon. however, must e.vpeet a certain amount of fail- 
 ure in the treatment of these eases, though he may safely assure his patient that the use- 
 fuliu'ss of the arm will be but little, if at all, imjiaireil. I have had one case of this 
 dislocation combini'd with fracture of the sternal end of the b<ine. in which the dislocation 
 was reduccil by manipulation and the arm bandaijcd with a fiootl result. 
 
 Dislocation upward is very rare. Mal<j;aii:ne has recorded four such cases, 
 ilaniiltoM another, (l(S(ril)C(l by Dr. Rochester of Buffalo, and Dr. K. \\. Smitli a sixth 
 (Ditbliii JoHiitnl of Ml ilicid Sell lice, 1S72). In 18G5 such a case came under my care. 
 It was in ii youn<:; woman, a milliner, ;et. 20, who two years before was violently crushed 
 in a crowd, the violence causing pain which was referred to the upper part of" her chest. 
 She was treated at home and got well, although with a deformity, for which .she consulted 
 me. On examining her chest the sternal ends of both clavicles were felt above the upper 
 border of the sternum, behind the sternal tendons of the sterno-mastoid muscles, and with 
 the slightest pressure upon the shoulders the two ends could be made to meet. By draw- 
 ing the .sh(uilders backward the bones could be separated and pressed back into wliat 
 appeared to be their normal position, but no apjiliance could keep them there. The 
 patient had good movement in her arms aiul followed her occupation. I have the notes 
 also of a second case that came under my care, in 18Gr>, in which one bone was displaced; 
 it occurred in a man j^t. 35, and was produced by a fiill on tlie shrtulder. 
 
 In the Guy's Museum (1292'-"') there is a specimen of dislocation of the clavicle at it.-j 
 sternal end upward and forward. It was taken from a man ret. 40 who fell from a height 
 and died nine days later from pneumonia. 
 
 Tkkat.ment. — In the treatment of this as of the last form of dislocation there is no 
 difficulty in reducing it by drawing outward the shoulders and applying pressure upon 
 the bone, but there is much in keeping the bone in po-sition. The best means, however, are 
 the application of a pad over the bone, the firm pressure of the .scapula against the ribs 
 by means of broad bands of strapping, and the supine position. Under all circumstances 
 the surgeon nuiy comfort the patient by the assurance that good and useful movement of 
 the arm will be secured. Ovrrlunul movements, however, will always be difficult. 
 
 Dislocation backward stands next in point of rarity to that of dislocation 
 upward, and is usually caused l)y violence, forcing the shoulder forw^ard. or by direct 
 force. I have seen but one such case, in a man aet. 52 who was crushed by falling bricks, 
 and in it the dislocation was self-reduced on the secend day, when the man was in bed. 
 
 The displaced clavicle so presses at times upon the trachea and oesophagus as to interfere 
 with respiration and deglutition. In 1845 a sailor aet. 17 was admitted into Guy's with 
 such an injury, the dislocation having been caused by a blow on the shoulder. It was 
 easily reduced by drawing the shoulders back, and maintained in situ without difficulty. 
 t]^a.ses of this kind have been recorded by Mr. Brown of Callington (Med. Gaz., 1845), 
 and M. Pellieux, 1834 (Revue Medicale). In one singular ca.se recorded by Sir A. 
 Cooper the dislocation was produced by curvatiire of the spine, and Mr. Davie of Bungay 
 excised the .sternal end of the displaced bone to prevent death from suffocation. Mr. C. 
 de Morgan has recorded a case in IToImes's S?/sfem in which, in a girl a?t. 10, the bone 
 was thus displaced and successfully treated by means of a splint across the shoulder, 
 with a pad between it and the spine, the shoulders being drawn to the splint by a bandage 
 and the child kept in bed. The splint was removed at the end of a fortnight, and the 
 articulation in fimr weeks became as firm as that on the other side ; the arm, moreover, 
 could be moved without causing any ])ain. 
 
 A separation of the sternal epiphysis of the clavicle niay take place and 
 
 be mistaken for dislocation. This can. however, occur only in voung life. Mr. C. Heath 
 brought forward an example of this kind in November, 1882, before the Clinical Society. 
 It occurred in a boy aet. 14 who was bowling a cricket-ball when he felt something give 
 way at his collar-bone. AVhen seen, the inner end of the clavicle was unduly prominent 
 and presented a sharp edge beneath the skin, between which and the suprasternal notch a 
 thin lamella of bone could be felt, ijuite unlike the smooth end of the bone covered with 
 cartilage. The bone fell into place on laying the patient down, and was kept in si((l by 
 means of a plaster-of-Paris bandage. 
 
832 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 Dislocation of the Scapula ^a- formerly called '• dislocation of the acromial 
 end of the clavicle." but. a.s the clavicle is a fixed point, it seems only consistent with 
 
 common sense, although not with custom, to follow Skey, 
 Fig. 486. Maclise, and Flower and call what have hitherto been 
 
 described as dislocations of the arromial end of the. clavicle 
 dislocations of the scapula. 
 
 In the more usual form of this accident the acromion 
 process of the scapula is forced heneath the clavicle. In rare 
 cases it may be received above it. Both are commonly 
 caused by direct violence to the shoulder. 
 
 Symptoms. — The symptoms are well marked in both 
 forms ; the falling of the .shoulder and projection upward 
 of the acromial end of the clavicle in one TFig. 48Gj, and 
 the projection upward of the acromion process of the scapula 
 ' \ in the other, prevent any mistake being made. 
 / Treatment. — In the dislocation of the scapula down- 
 
 ward the aim of the surgeon is to raise the scapula with the 
 
 dislocation of the .Scapula Down- ii .i i-i \.- x^ • -l ^ ^ ■\^ i 
 
 ward. fMr. Poland's ca.se.; ai"Di ^"d depre.ss the clavicle. which IS oest done by drawing 
 the elbow well backward and applying a pad over the clavi- 
 cle, the pad and ellxjw being fixed in position by means of a belt or plaster-of-Paris 
 bandage passed over the clavicle and round the elbow. The belt presses the clavicle 
 downward and raises the shoulder and arm upward. 
 
 The parts fall into position at times when the patient assumes the horizontal posture ; 
 and when this is the case and the position can be maintained for two or three weeks, it is 
 well to adopt it. At others a pad fixed over the clavicle by means of strapping or a 
 bandage passed between the axilla will suflBce, but the surgeon, recognizing the special 
 wants of the case, must adapt his means to meet them in the best possible way. Oood 
 mnveini-nts of the arm are. a< a rule acquired in time after either of these accidents. 
 
 Dislocations of the Humerus form at least half of all dislocations, and a suf- 
 ficient explanation of this fact is to be found in the globular form of the head of the humerus, 
 the .shallowness of the glenoid cavity, the free movement of the articulation, and its liabil- 
 ity to direct and indirect injury. 
 
 In 40 out of GO consecutive cases, or in two-thirds of them. I found a direct blow 
 upon the .shoulder was the cause of the accident, while in the exceptional cases a fall 
 upon the extended arm or elbow or a forcible dragging backward of the arm was the 
 assigned cau.se. The accident is rare in childhood, although I have seen an in.stance of it 
 at the age of thirteen, while Flower and Hulke have recorded a case in an infant four- 
 teen days old. Two-thirds of the cases are found in men between fifty and seventy years 
 of age, it being comparatively rare in women and in young adult life. I have, however, 
 treated one in a man act. 75. 
 
 Analysis of Sixty Consecutive Cases. 
 
 Out of 60 cases, 31 were described as suhglenoid. or downward. 25 sidjcoracoid, or 
 forward, and 4 svhspinons, or backward; 49 were in males, and 11 in females. I am dis- 
 posed to think that many of the cases called subglenoid were subcoracoid. 
 
 4 were in subjects under 20 years of age. 
 17 " " between 21 '" and 50. 
 
 38 " " " 51 " " 70. 
 
 1 aged 75. 
 
 The head of the humerus may be dislocated — 1. Dov:nv:ard — svhglenoid ; 2. Forward 
 — subcoracoid ; 3. Backuard — sidjspiootis. 
 
 When the coracoid process has been broken off. the head of the humerus may be 
 displaced over the root of the former, two or three such cases being on record. The 
 supracoracoid and subdavicular dislocations are very rare. 
 
 Subcoracoid. — This is without doubt the most common form of dislocation. 
 Flower has shown {Patlt. Hoc, vol. xii.) that thirty-one out of the forty-one specimens 
 of dislocation of the shoulder-joint found in the London museums belong to this class. 
 In it the head of the humerus rests on the anterior lip of the glenoid cavity beneath the 
 coracoid process, or even more forward, the completeness of this dislocation turning upon 
 the amount of laceration of the attachment of the posterior scapular mu.scles. "When they 
 are completely torn through at their insertion into the great tuberosity of the humerus or 
 
DISLOCATIOyS OF THE I'I'I'KIt KXTIIEMITY 
 
 833 
 
 the tuberosity is torn off, the lieud o\' the bone will be more forward than when they are only 
 stretched or iiartiallv divided. Many of the eases described by Sir A. Couper as dislucation 
 
 Fici. 487. 
 
 Fir;. 4«H. 
 
 Suhccracai/ 
 
 From Mr. Flower's Models, Middlesex Hosp. Mus. 
 
 Subcoracoi'l J'i-l.M;itii>ii of Head of 
 Humerus. (Drawing :i7*^.; 
 
 downward or as partial dislocation were doubtless of this kind, and many others recorded as 
 examples of subclavicular are nothin<r more than specimens of this variety (Fig. 487). 
 
 Symptoms. — The symptoms of this form of dislocation, in their general character, are 
 the same as in most others, such as inability to move the arm. immobility', and pain often 
 passing down some nerve-trunk and aggravated bj* movement. On looking at the part 
 and comparing the injured with the sound side before swelling has appeared, some .strik- 
 ing points will be observed, such as flattening of the deltoid, prominence of the acromion, 
 and a depression beneath it. Extra prominence will also be seen below the coracoid pro- 
 cess, from the head of the bone pushing forward the pectoral muscle (Fig. 488) : from 
 behind, too, there will be some flattening of the .shoulder. There will be little or no 
 lengthening of the limb, but the elbow will be found projecting more or less from the 
 side ; the movements of the fore-arm will Vje perfect. On manipulating the shoulder the 
 head of the bone will be felt beneath the pectoral muscle in front of the scapula, and from 
 the elbow it will be made to move. 
 
 Dislocation dowil"Ward, or subglenoid, although usually given as the most 
 common, is probably second in freijuency to the subcoracoid just described. Flower 
 asserts that nut one in ten of all dislocations of the humerus can properly be called sub- 
 glenoid. In it the head of the bone rests below the glenoid fossa (Fig. 487). the rent in 
 the capsule being at its inferior instead of its anterior border, and the soft parts mechani- 
 cally interfering with the natural tendency of the deltoid, coraco-brachialis. and biceps to 
 draw the head of the humerus upward toward the coracoid process. 
 
 Symptoms. — The most con.stant are immobility of the arm, as well as inability to 
 move it without pain, with a greater separation of the elbow from the side, a more marked 
 flattening of the shoulder, greater depression beneath 
 and extra prominence of the acromion than are met with 
 in the subcoracoid variety. The most typical, however, 
 are a depression of the anterior fold of the axilla, from a 
 drawing down of its attachment ; a falling of the breast, 
 as indicated by a lower position of the nipple ; the 
 marked presence of the head of the bone in the axilla ; 
 the separation of the coracoid process and the head of 
 the malplaced bone by a space of one to two inches (Fig. 
 489) ; and a clear elongation of the arm for one and a 
 half inches. 
 
 Hulke describes {flolmeiCs Si/sfem. vol. i. 3d ed. p. 
 '.•78) two rare examples of a variety of subglenoid dislo- 
 cation which he saw in the practice of the late Sir W. 
 Fergusson. In Ixith the arm was strongly abducted nud 
 raided, the elevation being so great as to make one patient 
 seek support of the arm by grasping the end of a stick 
 raised above his vertex, whilst the other rested his hand on 
 the top of his head. In neither could reduction be effected. 
 63 
 
 T^iG. 489. 
 
 SuI)u'lenoid TMslocation of .'Sixteen Weeks' 
 Standine. iTakt-u from a man aet. .Vj. 
 shiiwint; depression of the anterior fold 
 of the axilla, falling of the breast, and 
 elongation of arm.; 
 
834 
 
 CONTUSIOSS, SPBAIXS, AXD WOUyDS OF JOIXTS. 
 
 Dislocation Backward, or Subspinous. — This is next in rarity to the last, 
 
 and in it the head of the bone rests beneath the spine of the scapula or base of the 
 acromion (Fig. 490) ; the latter position being a less complete luxation than the former, 
 
 Fig. 490. 
 
 Fig. 491. 
 
 Sui~spLncus 
 
 Sf/h - cZar ■iri/Ia i 
 
 From Flower's Models, Middlesex Hospital. 
 
 Subspinous Dislocation of Head of 
 Humerus. (Taken from life.) 
 
 and more common. It corresponds to Malgaigne's '• subacromial " variety, this complete- 
 ness of the dislocation depending upon the amount of laceration of the muscles attached 
 to the bone, and more particularly of the subscapularis. 
 
 Symptoms. — The symptoms of this accident are very marked. Looking at the shoul- 
 der in front, there will be the flattening of the deltoid and prominence of the acromion 
 as usual, but there will be a marked flattening, if not depression, of the soft parts below 
 the coracoid and acromion processes. The elbow, instead of being fixed away from the 
 side, will be drawn to it and forward, the fore-arm generally pointing outward. The back 
 view, however, is the most typical, the head of the bone covered with muscles and soft 
 parts forming a prominent feature in the case (Fig. 491). I had under observation a 
 patient about thirty years of age who could at will dislocate her shoulder in this direc- 
 tion by muscular action. In this dislocation the limb is said to be slightly longer than 
 normal, but I have not found it so. 
 
 Subclavicular Dislocations, in which .the head of the humerus rests below the 
 clavicle on the sternal side of the coracoid process, are exceedingly rare (Fig. 490). I 
 have never seen a complete example. Malgaigne informs us that in it the arm is pressed 
 against the chest with the elbow slightly removed from the side, the head of the bone 
 beins: felt and seen in its abnormal position and the shaft instead of the head of the 
 humerus felt in the axilla. The bulk of cases recorded as of the subclavicular kind are 
 probably subcoracoid. 
 
 The SUpracoraCOid dislocation is a mixed form of accident, as it is secondary to a 
 fracture of the coracoid process. Malgaigne has recorded an example, and Holmes, in 
 the Med.-Chir. Tram., vol. xli.. a second, with an account of the dissection of the case, 
 the preparation being in St. George's Museum. He also describes a third, which occurred 
 in the practice of Sir P. Hewett. 
 
 Some points in diagnosis remain to be told, and the most important was pointed out 
 by the late Mr. T. Callaway in his excellent Jacksonian prize essay for 1849, which is 
 " that in taking the vertical circumference of any shoulder in which dislocation exists hy 
 means of a tape carried over the acromion and binder the axilla an increase of about tico 
 inches over the sound side is an invarifdAe concomitant.'" He .should iiave added, however, 
 that this test is applicable only to recent cases, and not to such as show muscular atrophy. 
 The same author also shows how elongation of the limb does not take place — at any rate, 
 to any extent — the different accounts given by authors on this point .depending upon the 
 fact that they are content with optical rather than actual mea.surement. Professor Dugas 
 of Georgia has also pointed out (Southern Jfd. and Sure/. Journal. 1856) a sign of dis- 
 location of the shoulder-joint that merits more notice than it has received, and I am 
 indebted to Dr. W. Briggs of Nashville for calling my attention to it. It is based upon the 
 physical fact that, in consequence of the rotundity of the thoracic walls, it is impossible for 
 
DISLOCATIONS OF TIIK UPPER EXTREMITY. 
 
 835 
 
 JiotJi eiiifs 1)/' (hr /limit nis tu laiirli (Id m n/ t/ir sniiu' linn . " li" ilic fiii^rrrSj therefore, of the 
 injured liiiili eaii he j)hi('eil hy the patient or l)y tlu; surj^eoii uj»on the souufl shoulder 
 while tlie ilhow touehes the thorax — a condition that ohtains in thi' normal condition of 
 the joint — there can he no dislocation. And il" this cann<it he done, there inniit he one; 
 for no other injury than a dislocation can induce this phy.sieal impossihility." Dr. V. 
 Hamilton has likewise shown ( Lmid. Mnl. AVc, April, ISTOj how in a dislocation a rule 
 will touch at the same time the acromion process and the clhow of the injured side — a 
 condition that cannot exist in health. 
 
 It .sometimes ha])pens that the head of the hone after its apjiarent reduction fails to 
 remain in position and falls out again ; and when this occurs, it becomes a question 
 whether some part of the glenoid cavity is fractured or some other fracture exists. I 
 have recently seen a case of dislocation of the head of the humerus forward and down- 
 ward in which a portion of the glenoid cavity was broken off' and displaced downward, 
 as.sociated with severe injury to the radio-spiral nerve. In children, or young persons 
 under twenty-one, the u])])er epiphysis of the humerus may be separated, or, rather, the 
 shaft of the humerus may be displaced oft' the epiphysis, which retains its normal position, 
 and under these circumstances the arm should be most carefully manipulated under chlo- 
 roform, to make the diagnosis sure. In exceptional cases, however, this slipping out 
 again is not to be explained by these complications, for in the case of a man ;ct. 75 who 
 had a dislocation backward the head of the bone could not be kept in position till the 
 muscles began to act after the eff'ects of the chloroform had subsided, and I had to hold 
 the bone in place till the patient recovered and the muscles acted naturally. 
 
 Treatment. — The use of anresthetics has completely revolutionized the treatment of 
 di-slocations, and at the present day nothing can usually be simpler than the reduction of 
 a dislocation of the shoulder, and what was formerly called reduction by stratagem is now 
 the rule. " If you can get a person off' his guard," wrote Abernethy, ''you have first to 
 put your hand up to the head of the bone, depress the elbow, and it will sometimes suc- 
 ceed in putting it in;" and the modern surgeon, in describing the reduction of dislocations 
 by mnnlpuhuion, might use the saine language. To reduce a dislocated humerus by manipu- 
 lation an anassthetic is essential ; and 
 
 when the patient is fully under its in- Fiu. 492. 
 
 flucnce, as well as in the horizontal po- 
 sition, the surgeon should grasp the 
 shoulder with one hand and the flexed 
 elbow with the other (Fig. 492, A). 
 When the dislocation is subglenoid or 
 subcoracoid, the thumb of the surgeon 
 may be placed over the head of the 
 bone and the fingers over the spine of 
 the scapula, the thumb acting as a ful- 
 crum ; Avith the other hand the flexed 
 elbow .should be drawn from the side 
 and extension made, some slight rotatory movement outward being emploj'ed. When 
 extension has been carried to its full extent, the elbow should then be raised and the arm 
 made to describe a semicircle in the direction of the sternum and the f\\ce, and then sud- 
 denly brought down to the side of the thorax, the head of the humerus at the same time 
 being rotated inward. The thumb of the opposite hand should give the right direction 
 to the head of the bone (Fig. -192, B). Should the first attempt fail, a second may suc- 
 ceed, or possibly a third. In the majority of dislocations of the shoulder this method 
 will succeed. In Philadelphia this practice is known as H. Smith's method. In the dis- 
 location backward, or subspinous, the same method will suffice, but in that ease the head 
 of the bone, being behind the glenoid cavity, refpiires pu.shing forward. Under such cir- 
 cumstances the surgeon .should stand slightly behind the patient, with one hand grasping 
 the axilla, with the thumb behind, and with the other the elbow, making extension ; 
 reduction may then be eflFected by drawing the elbow backward and rotating the bone. 
 By these means I easily reduced an interesting case of dislocation backward (subspinous) 
 complicated with fracture of the ribs of the same side and of the opposite clavicle. 
 When these moans fail or when chloroform is not at hand, reduction by means of exten- 
 sion with the heel in the axilla should be employed, the surgeon with his unbooted heel 
 pressing upon the head of the humerus or lower border of the axilla, and with his hana 
 grasping the fore-arm of the misplaced limb and making .steady extension ; .some slight 
 rotatory movement often facilitates reduction. The head of the bone usually slips into 
 
 Extension, Adduction, and Rotation Outward. 
 
836 
 
 CONTUSIONS, SPBAINS, AND WOUNDS OF JOINTS. 
 
 Clove-Hitch. 
 
 its place with a perceptible jerk, and the moment this is felt all extension should be 
 stopped. 
 
 To facilitate extension the clove-hitch (Fig. -493) may be employed, and instead of the 
 heel Mr. Skey's well-padded iron knob. 
 
 Mr. W. F. Teevan informs me that he has known the third rib to be fractured in the 
 attempt to reduce a dislocation of the head of the humerus with the foot in the axilla. 
 
 If the humerus still resists, the following plan, writes Hulke (^Hohnea's Surgery^ vol. 
 i., 3d ed.), '■ which I have never known to fail in a recent dislocation, may be tried. The 
 patient is seated in a high chair, which is placed about two feet from the 
 post of an open doorway ; the surgeon, having his back against the door- 
 post, places one foot upon the side of the chair and with his knee presses 
 into the axilla, and, with both hands upon the shoulder, steadies the pa- 
 tient's body ; a jack-towel is then fixed by a clove-hitch knot to the pa- 
 tient's arm, just above the elbow, and by its means two or three assistants, 
 placed on the other side of the doorway, make steady extension horizon- 
 tally outward." 
 
 This is only a modification of Sir A. Cooper's plan of bending the ex- 
 tended arm over the knee, placed in the axilla with the patient sitting, 
 using the humerus as a lever, and is doubtless a good one. 
 
 In 1870, Kocher of Bern (Berlin Klin. Woch., No. 9, 1870) introduced the following 
 new and simple method of reducing subcoracoid dislocations, which has been much and 
 successfully practised at Guy's : 
 
 With the patient sitting, the surgeon grasps the elbow of the affected limb with the 
 fore-arm flexed at a right angle, presses it firmly to the side of the patient's chest, and 
 rotates the flexed fore-arm and arm outward as far as they will go — that is. until firm 
 resistance is experienced. He then, with the arm still rotated outward, carries the elbow 
 forward and inward over, but away from, the chest, toward the median line of the body, 
 and suddenly rotates the arm inward, carrying the hand of the aff"eeted limb by this 
 movement toward the sound shoulder. By this last movement the head of the bone is 
 replaced in the glenoid cavity. 
 
 Mr. .J. E. Kelly of Dublin also recommends a method of reduction which in his and 
 his colleagues' hands has proved successful in twenty-seven cases. In it the patient 
 should be placed on his back at the edge of a couch, lower by three inches than the great 
 trochanter of the operator. •' The operator places the injured arm at right angles to the 
 body, and, standing again.st it with his side to the patient and his hip pressed firmly, but 
 not roughly, into the axilla, he folds the arm and hand of the patient closely round his 
 pelvis and fixes the hand firmly by pressing it against the crest of his ilium. The second 
 step, during which the reduction is aflfected. is ver}' simple, consisting merely of a rota- 
 tion or version of the surgeon's bodj' outward away from the patient with a force and 
 rapidity which necessarily vary with the peculiarity of the dislo- 
 cation, some yielding most readily to a sudden and powerful effort, 
 and others to gentle and irraduallv increasing traction '" (Utth/in Jour- 
 nal of Merl. Soc, September, 1882). 
 
 Should these means fail, success may be secured by drawing the 
 arm vertically upward, as practised by White of Manchester in 1704, 
 and recently advocated by Mr. Lowe of Burton-on-Trent (St. Barth. 
 Rep., 1870). In 1SG4 I succeeded by these means in the case of a 
 subglenoid dislocation of one month's standing in a man set. 64, the 
 method of manipulation and extension having failed, and again, 
 more recently, in a similar case of twenty-four hours' standing, in a 
 gentleman fet. 30. when every other means had proved unsuccess- 
 ful (Fig. 494). Mr. Lowe places his patient in a sitting posture on 
 the floor and then stands behind him on a sofa, forcibly extending 
 the dislocated arm upward, the scapula being kept fixed by the sur- 
 geon's foot. In all cases the extension should be gradual and 
 steady, the counter-extension effective; no jerking or great force 
 should be allowed ; pulleys are to be looked upon as dangerous ap- 
 pliances : with the use of anaesthetics they should be abandoned. 
 In recent dislocations they are never needed, and in the old adhesions should be broken 
 through by forcible rotation and flexion of a joint rather than by extension. 
 
 Extension forward is at times beneficial. It proved successful in my hands in a case 
 of subspinous dislocation of three weeks' standing in a man aet. 75. 
 
 Fig. 494. 
 
 Reduction by Extension of 
 Arm Upward. 
 
Disi.ocATioss I IF riir: rrr/:/: i-:xtremity. 
 
 837 
 
 III ii iKirlcctfd (lisli)rati(iii u|' t wriit y-fivr ilays' stiiii(liii<r .Mr. ("nek succefclcd in 1859 
 (rn/c author On Discasis nut/ /njurirs of ./(jt'nts, iKf)!!] l>y the followiiij^ plan, all other 
 means liavinj; failed : " An air-jiad made (if vulcanized in<lia-riilil)er was jiluced in the 
 axilla and the arm Hrnily l>andatred t<i the siile, the air-pad thus heinjj; made; to exert a 
 powerful out wan! pressiirr iipnii the head of tlie hone. Tpon removing the bandage 
 upon the third liay tlie head .if the hone was louml to have returned to its natural 
 position.' 
 
 Without ;iii;estheties olistaeles to the reduetimi of a (H.-loeatioii of the -houjder are 
 niuseular spasm and tlie ditlieiilty of replacing the head oi' the hone throtigii the rent in 
 its capsular ligament ; with them, the resistance of the muscles is an element which has 
 not to he considered, the second one alone existing. In old dislocations the presence of 
 adhesiiuis is an extra element of difficulty. 
 
 AFTKit-'ruK.VT.MKNT. — After the reduction of a dislocation the arm should he hound 
 to tlie side for a week and kept at rest for a fortnight or more, with the ohject of giving 
 time fiu- the lacerated or injured parts to repair and recover their power. All violent 
 e.xertion should he forhidden, and nothing more than passive motion should he sanctioned 
 for several months. 
 
 It happens at times that the trunks of the nerves are so injured a.s to give ri.se to 
 paralysis of the muscles supplied by them. I have seen, in one case, the parts supplied 
 by the ulnar nerve permanently paralyzed, and in another those supplied by the musculo- 
 spiral. It is by no means uncommon to find the circumflex nerve so injured as to be fol- 
 lowed by a most complete wasting of the deltoid muscle. In many cases, however, in 
 which paralysis follows dislocation, recovery may ensue ; and in a very marked example 
 I saw in lS7-t, in which paralysis of all the parts supplied by the radio-spiral nerve was 
 most complete, recovery took place in fifteen months. 
 
 In neglected dislocation of the shoulder it is always a difficult question to decide as 
 to the expediency of attempting reduction. Sir A. Cooper used to .say that after twelve 
 weeks' rest an attempt should not be made, and in a certain sense such an opinion is cor- 
 rect ; but there are many cases of less standing in which the attempt would be wrong, and 
 some few of much longer standing in which it would be right. 
 
 Where good movement exi.sts after twelve weeks there is little need for the attempt, 
 unless under exceptional conditions. When bad movement exi.sts, or none at all, the 
 attempt may be made ; for cases are on record in which reduction has been effected after 
 a year or more. 
 
 Fracture and Dislocation of the Head of the Humerus.— Dislocation 
 
 of the head of the humerus is sometimes associated with IVacture of the neck of the 
 bone. It is, as a rule, caused by a direct fall or blow 
 upon the shoulder, and it is probable that the dislocation 
 occurs first and the fracture follows. I have seen two 
 undoubted examples of the injury. In one, a boy act. 
 10, the head of the bone was dislocated backward be- 
 neath the spine of the scapula, and in the second, a man, 
 beneath the coracoid process. When the dislocation can 
 be reduced at once, as it may by means of an anajsthetic, 
 so much the better. When it cannot, the fracture must 
 be treated and the dislocation left alone, good movement 
 at times being the result. In Fig. -195 such a complica- 
 tion existed. The preparation was taken from a gentle- 
 man xt. 64, three months after the injury, before union 
 had taken place at the seat of fracture. 
 
 It must be remembered that cases of fracture of the 
 humerus about its tuberosities, when united, often sim- 
 ulate those of dislocation. 
 
 Compound dislocations of the shoulder 
 
 are grave accidents ; and when the soft parts have been 
 much injured, the best plan is probably to resect the head of the bone, although, when 
 the wound is limited or clean and reduction easy^ it may be right to treat the case as one 
 of wounded joint. 
 
 Dislocation of the Elbow. — This accident is most common in early life, and 
 according to the -^Iiddlesex Hospital table (Holmis'a Si/st., vol. i.) more than half the 
 cases occurred in boys between the ages of five and fifteen. Out of 33 cases. Dr. Ham- 
 ilton found 19 in children under fourteen years of age. At Guy's these proportions are 
 
 Fig. 495. 
 
 Corel roifi 
 
 drromion 
 
 Dislocation of the Head of the Humerus 
 associated with Fracture. (Prep. 1114*, 
 Guy's Hosp. Mus.) 
 
838 
 
 CONTUSIONS, SrEAINS, AND WOUNDS OF JOINTS. 
 
 not quite so large ; for out of 13 cases, G were in subjects between ten and twenty, 3 
 between twenty and thirty, 3 between thirty and forty, and 1 between forty and fifty. 
 In only one case was the subject a woman. 
 
 Both bones may be displaced backward, outward, inward, or forward, backward and 
 outward, or backward and inward. The aliia may be displaced backward alone, the radius 
 maintaining its natural position, and the head of the radius may be thrown forward or 
 backward. 
 
 These dislocations may be more or less complete, simple or compound, uncomplicated, 
 or complicated with fracture of one or more of the bones entering into the formation of 
 the joint; or with fracture or displacement of an epiphysis. 
 
 In point of frequency dislocation of both bones backward is the most common, the 
 other dislocations of both bones occurring in the order above given, dislocation forward 
 being so rare that without a fracture its existence was doubted by Sir A. Cooper ; but 
 Velpeau and Canton have each recorded undoubted examples. 
 
 The force required to produce any one of these injuries is severe. It is generally 
 exerted directly upon the elbow or indirectly upon the hand, by either a fall or a twist. 
 To admit of any dislocation, there must of necessity be much laceration of the ligaments. 
 Symptoms and Diagnosis. — These accidents are not difficult to diagnose when they 
 are seen at an early period of their existence, though after the lapse of some hours great 
 difficulty may be experienced, owing to the swelling masking the points of bone and ren- 
 dering it difficult to make out their relative positions. 
 
 The injured joint should always be carefully examined, each point of bone felt for, 
 and its relative position with other points compared with those of the sound limb. In 
 no cases can the surgeon derive greater assistance or feel more forcibly the value of this 
 rule than in dislocations of the elbow. The student should accustom himself to the 
 manipulation of healthy joints and learn where to place his finger upon the diff'erent 
 prominences and depressions, and, having learned the normal conditions, he will usually 
 find but little difficulty in discovering when a displacement has occurred. 
 
 When both bones are dislocated backward (Fig. 496), the forearm is partially flexed 
 and the hand slightly pronated ; the displaced bones project backward and make a prom- 
 inent swelling with the tendon of the triceps, while the con- 
 dyles of the humerus can readily be felt in front, pushing 
 the artery and soft parts forward, the inner condyle of the 
 humerus and the olecranon being far apart, and the great in- 
 crease in the antero-posterior diameter of the joint seen at 
 a glance. In thin subjects the olecranon and the head of 
 the radius can readily be felt in their abnormal position to 
 one another, and the head of the latter bone made through 
 the hand to rotate in its new situation. 
 
 In the dislocation of the bones outward the marked 
 prominence of the inner condyle of the humerus as seen from 
 behind is a typical feature (Fig. 497), and with luxation of the same bones inward the 
 external condyle is equally prominent. 
 
 In the rare form of disloca- 
 tion forivard (Fig. 498) the loss 
 of the olecranon from its right 
 position, the unusual prominence 
 of the condyles of the humerus, 
 and the marked elongation of the 
 fore-arm are the chief features. 
 In dislocation of the ulna 
 hackirard the pronation and 
 twisting inward of the hand, 
 the great shortening of the ul- 
 nar side of the fore-arm, and 
 projection liackward of the ole- 
 cranon mark the nature of the 
 accident. 
 
 When the head of the radius 
 is displaced alone forward (Fig. 
 499) or backward, its absence 
 from its natural position, as well 
 
 Fig. 496. 
 
 Dislocation of Radius and I'lna 
 Backward. (From Sir A. Cooi^er.) 
 
 Fig. 497. 
 
 Fig. 498. 
 
 Clferanan. 
 
 J/irirr 
 Cciit/i/le. 
 
 Dislocation of the Right Radius 
 and Ulna Outward. (Posterior 
 View. 1 
 
 Dislocation of Radius and Ulna For- 
 ward. (Canton's case, Duh. Quart., 
 August, 1860.) 
 
DISLOCATIONS OF Till-: ll'I'KJ: KXTIIKMITY. 
 
 839 
 
 ns its pn'Si'iiiT in ;iii iiniKiliiriil uiic, can usually In- uiafic out. In llic forward dislocation 
 till' rie'xion id" tlic joint is liujitcd. 
 
 In the liackward ( Fij;. 500) the Uiuvcnionts luiiy he couiidcle ; more coinuionly, huw- 
 fVi'T, tlu'V iirc limited. 
 
 Fio. 190. 
 
 Fio. 600. 
 
 Dislui'alioii i>r the Itmliiis I'diward. (I)r:iHiiiLC 'J7"", (Juy's IIos- 
 jiiial. I'"roiii dissecliou. Mr. Hilton s ease.) 
 
 Dislocaliou of tin.- Ilrail of tlif liadiua 
 ISackward. 
 
 TuKAT.MKNT. — Wlieii the nature of the dislocation bus been once reco<rnized, there is 
 little dirticiilty in its treatment; for, with tlie patient anjcsthetized. and the muscles con- 
 se(|ueiitly jiaralyzed. the reduction of any dislocation of the elbow by iitanipulatliju, or 
 rather by moulding the joint into its right form, is readily effected. This may usually be 
 d(uie by the surgeon's bands, pressure being applied according to tbe wants of tbe indi- 
 vidual ca.se, guided by the known anatomy of tbe part. Occa.sionally extension of the 
 fore-arm is required, or tlie forcible bending of the fore-arm over the surgeon's knee or 
 thumb ; ])ut in the majority of early cases the joint may be moulded into its normal posi- 
 tion. 
 
 Mr. J. E. Kelly of Dublin (^Dnhh'n Journ. of Med. S'-i., July, 1883) describes a method 
 of reduction in dislocations at the elbow-joint worthy of consideration, in which the sur- 
 geon, sitting on a table, fixes the patient's humerus beneath one thigh and extends with 
 his baiuls the fore-arm raised between them. 
 
 AVhen .some weeks have been allowed to pass without reduction, considerable force 
 may be rerpiired to break down the adhesions, forcible flexion and extension being then 
 applicable. 
 
 Up to two months any dislocation of the elbow may be reduced, or rather an attempt 
 at reducti(»n may be made. After that date, when useful movement has become possible, 
 the attempt had better not be entertained. When no movement exists, it is, however, jus- 
 tifiable, but no definite rule can be laid down on this point, since each case must be judged 
 xipon its own merits. I have reduced, after nine weeks, a dislocation of the bones of the 
 fore-arm backward with an excellent result, and have failed after five. What would be 
 justifiable under some circumstances would be unjustifiable in others, the age of the 
 patient, his position or occupation, and his necessities having as great an influence in 
 guiding the surgeon as the time that has elapsed after the accident and the amount of use- 
 ful movement in the joint. 
 
 When both bones are displaced, or the ulna alone, the surgeon should grasp the fore- 
 arm as a whole. When the radius is the bone displaced, the extending force should be 
 applied from the hand. 
 
 Aftkr-Trkatment. — After the reduction of the dislocation the arm should be kept 
 in a splint and cold lotion or ice applied, according to the amount of inflammation that 
 ensues. When little inflammation follows, passive movement may be allowed iu about 
 ten days or a fortnight. After the reduction of a dislocation of the head of the radius 
 forward there is usually great difficulty experienced in keeping the bone in its position. 
 To effect this I have found the forced flexion of the fore-arm the best, the wrist and fore- 
 arm being bound to the arm by means of a bandage. In a recent case the benefit of this 
 practice Avas well displayed. 
 
 When reduction of a neglected dislocation has been effected, it is wise to fix the elbow 
 on an angular splint for ten days or a fortnight and to apply cold water, and after all 
 inflammatory action has subsided to allow of passive or. ])ossiV)ly. forcible movements, 
 as a stiff elbow-joint is a misfortune of no mean importance, and to prevent it measures 
 may be employed which under other circumstances might be considered rash. In 
 neglected cases, where reduction is beyond all hope, the surgeon may use a consider- 
 able amount of force to flex the fore-arm to a right angle, in which position it should 
 be fixod. 
 
 In conipmmd dislocation of the elbow-joint, where reduction is possible and the wound 
 
840 
 
 CONTUSIONS, SPBAINS, AND WOUNDS OF JOINTS. 
 
 Fig. 501. 
 
 Displacement of the Lower Epiphysis 
 of the Humerus Backward. (Hutch- 
 inson's case.) 
 
 small, the case may be treated as one of wounded joint — viz. by splints and the applica- 
 tion of ice — good hopes existing of a sound recovery being 
 secured with movement. When the wound is large and the 
 soft parts are materially injured, excision of the joint should 
 be performed, the success attending this practice generally 
 being very satisfactory. When the vessels and nerves are 
 clearly so injured as to preclude the possibility of a useful 
 limb being secured, amputation may be required. 
 
 In all these dislocations of the elbow the surgeon should 
 be careful to ascertain that they are uncomplicated, that no 
 fracture coexists, or — what is more common in young sub- 
 jects — that no displacement of the lower epiphysis of the 
 humerus is present, such as is shown in Fig. 501. This can 
 be made out only by a careful comparison of the sound and 
 injured sides and the appreciation of the crepitus of fractvire, the crackling of eifu.sion, 
 and the semi-crepitating feel of a displaced epiphysis. 
 
 In June, 1881, I had under my care at (iuy's a boy set. 9 in whom the lower e])iphy- 
 sis of the humerus, with the bones of the fore-arm, was displaced backward, and in which 
 the anterior border of the diaphysis so injured the brachial artery as to occlude it. The 
 displaced bones were restored to their position and the arm was bound with splints. The 
 case did well, and in six weeks there was good movement in the joint and pulsation had 
 returned in the radial, though not in the brachial, artery. 
 
 Dislocations of the W^rist. — These are exceedingly rare accidents, the majority 
 of recorded cases of this nature being fractures of the lower end of the radius. What 
 is known as " Colles's fracture " is the more common form of accident. Dupuytren 
 pointed this out years ago, and the truth of the observation is now fairly recognized. 
 When dislocation does occur, the hand is displaced either forward or hackward^ the ends 
 of the radius and ulna forming prominent points in the opposite positions and the styloid 
 processes of the radius and ulna being recognizable points in a line with the shafts 
 of the bones of the fore-arm (Fig. 502). This feature is important ; for when the dis- 
 placement of the hand is due to a fracture of the lower ends of the radius and the ulna, 
 the styloid processes will be in connection with the hand instead of with the shafts of 
 the bones. 
 
 Treatment. — Reduction by manipulation is readily performed, extension of the hand 
 and direct pressure upon the displaced bones, as a rule, effecting the surgeon's purpose. 
 The parts should be kept in po.sition by an anterior and a posterior splint extending to 
 the flexure of the fingers. The splints should be removed, however, as soon as the parts 
 have become firm — that is, in about three weeks — and passive movement of the fingers 
 should be enforced. 
 
 Dislocation of the lower end of the radius with the hand may take place 
 whenever the hand is forciby pronated or supinated. When forcibly pronated, the ulna 
 projects backward and the radius and hand forward ; when .supinated, the reverse condi- 
 tions are found to exist. 
 
 I have seen the former accident but once, and that case is here figured (Fig. 503). It 
 was in a woman a^t. 56 who was admitted into my ward at Guy's for another affection. 
 The dislocation had taken place some months previously and had never been reduced. It 
 
 Fig. .502. 
 
 Fig. 503. 
 
 /^v_ 
 
 Dislocation of the Hand Forward. (Taken 
 from a cast of :Mr. Cadge's, copied from 
 Erichsen's work.) 
 
 Dislocation of the Hand and Iladiii.s Forward off the 
 Lower End of the Ulna. 
 
 was the result of a fall upon the dorsum of the hand. Pronation and supination of the 
 hand were limited, and the ulna was fixed in its new position. The hand, although more 
 pronated than natural, was very useful. 
 
DISLOCATIONS OF THE rPrEIl EXTREMITY. H41 
 
 Siicli (lisl(pc;iti<ms iirr readily rc(lucc(l l)y cxtciidiiij; tlic liaiid and ciiipluviii^^ jin-sMirc 
 to till' displaced lioiies. Alter their reductidii anterior and |)i)steri<ir splints sliouM be 
 applietl lor two or three weeks, to prevent the hones sli])piii;^ out of position and to allow 
 the liiranients time to unite. \\\ the ease liu'^ured no tri^atineiit was availahle. 
 
 Dislocation of the carpal bones is an oeeasional thou^rh rare aeeideiit, and the 
 displaeenu-nt (d' the <>s nitii/ninn haekward, from a fall upon the flexed liaiid, is tlie most 
 fre(jiient iorui. I have known this to tiecur in a woman during the efforts of parturition 
 in grasping a towel and loreihly bending tlie wrists, the bone lieing pressed out of its 
 conneetion. When the accident occurs, tlie prominent head of the bone on the dorsum 
 of the wrist in a line with the metacar]ial bone of the middle tinger is too marked a fea- 
 ture to allow of there being any difficulty in the diagnosis. The bone, as a rule, is easily 
 reduced by pressure and kept in position by means of a [tad. This pad must be main- 
 tained ill position for many weeks after the accident, to allow tiiiK- for the ligaments to 
 con.solidate. 
 
 South, in a note to his translati(»n of Chelius, records a case in which the j}isi/orm 
 hone was displaced, while Fergusson and Krichsen describe others caused bj- overaction 
 of the flexor carpi ulnaris. Krichsen also mentions a di.sloeation backward of the sfim'- 
 IiDiar bone, and in St. George's Hospital Museum there is a specimen of compound dislo- 
 cation of this bone on both sides, occasioned by a fiill from a height upon the hands, in 
 which the bones were pressed out of a wound in front of the wri.st. 
 
 Maisonneuve has recorded (^Mem. de la Soc. de Chir., tome ii. ) a case in which the 
 second row of carpal bones was di.splaced backward from the first, and Erichsen another, 
 in which the metacarpal bones were displaced backward from the carpus. These acci- 
 dents are very rare. 
 
 Dislocation of the thumb at any of its joints is not unusual. The metacnrprd 
 hone may be displaced backward or forward from the trapezium, the former being the 
 more common accident. This dislocation is frequently complicated with an oblique frac- 
 ture through the base of the metacarpal bone. Sir A. Cooper described a dislocation 
 inward, but gave no case. Dr. F. Hamilton questions its occurrence. 
 
 Reduction of these dislocations by extension and local pressure is usually readily 
 eflFected, the bones being kept in position b}' means of a pad and a good splint extending 
 some inches above and below the displaced bone. 
 
 Dislocation of the first phalanx from the metacarpal hone is a recognized accident, the 
 displacement backward being the usual form. Dislocation forioard is a rare one. The 
 first form is usually the result of a fall upon the distal end and palmar surface of the 
 thumb, the head of the metacarpal bone projecting forward, the base of the fir.st phalanx 
 backward, and the extreme phalanx being flexed upon the first. The head of the meta- 
 carpal bone in some cases may be thrust foi'ward through the capsule of the joint and 
 caught betw^een the two heads of the flexor brevis muscle, whilst in others, as in one I 
 have .seen — which w^as compound — the long extensor tendon of the thumb was hitched 
 round the ulnar side of the base of the first phalanx, and thus prevented I'cduction. which 
 was readily effected by forcible extension, adduction, and rotation. 
 
 Treatment. — In some cases the reduction of this form of dislocation is effected with 
 ease by simple extension or by the pressure of the surgeon's thumb upon the displaced 
 phalanx, and for the purpose of extension nothing 
 
 equals in -value the Indian toy called a " puzzle," Fig. 504. 
 
 or tube of plaited reed (Fig. 504). When this is 
 not at hand, .strips of strapping applied longitudi- 
 nally to the distal digit and fixed by a circular 
 piece will an.swer the purpose. In some instances 
 all these means fail and there is yet much obscurity 
 as to the cause of the difficulty. The numerous 
 
 muscles and tendons that surround the joint doubtless have a powerful influence, more 
 particularly the two heads of the short flexor with the sesamoid bones : and when the 
 wound in the capsule is small, the.se muscles act more powerfully, the base of the dis- 
 placed bone or the head of the metacarpal bone being held by these parts " as a button 
 is fastened into a button-hole."' Under these circumstances success may at times be 
 achieved by flexing the metacarpal bone of the thumb to an extreme degree, rotating, 
 and then suddenly extending the displaced phalanges, this manoeuvre, as it were, freeing 
 the displaced bone from the many tendons and ligaments that .surround the joint, and 
 that doubtless at times interfere with its reduction. I succeeded by this method in one 
 case where every other had failed. My friend the late Mr. Sells of Guildford informed 
 
842 
 
 CONTUSIO^'S, SPRAINS, AND WOUNDS OF JOINTS. 
 
 me that he had with facility reduced several dislocations of this form by forcibly bending 
 the thumb back, so as to tilt the base of the phalanx over the head of the flexed meta- 
 carpal bone, and then extending it. Both these means have the effect of relaxing the 
 short flexor muscle, as pointed out by Prof. Fabbri. When all such means as have been 
 mentioned have been unsuccessfully tried, the subcutaneous division of the tendons and 
 ligaments that appear to prevent reduction has been practised with variable success ; and 
 when this fails, excision of the part has been employed. In a case of this kind of six 
 months' standing, where the thumb was a useless member and the seat of pain, I excised 
 the joint with excellent success, a movable articulation being secured, with hardly any 
 deformity. 
 
 When the bone is displaced foncard, it seems probable, from the dissections of ]M. L. 
 H. Farabeuf (^Arch. GeneraJes de Medecme, September, 187G), that the extensor tendons 
 of the thumb being stretched on the inner or outer side of the metacarpal bone is the 
 cause of the difficulty in its reduction, and under such circumstances forced flexion of 
 the thumb upon the palm, aided by manipulation, is generally enough to replace it. 
 
 Dislocation of the migual phalanx of the thumb may take place in either direction, for- 
 ward or backward, the last being the more common ; and, the displaced bone being so 
 
 small, difiiculty is often felt in 
 applying extension to it. The 
 puzzle (Fig. 504) is the best 
 thing to employ for the pur- 
 pose, or Levis's apparatus (Fig; 
 505). At times pressure with 
 the thumb upon the displaced 
 bone or forcible flexion will suc- 
 ceed. Hamilton pithily advises " forced dorsal flexion in the case of the backward lux- 
 ation, and forced palmar flexion in the case of the forward dislocation " (8d ed., p. 634). 
 
 Dislocations of the phalanges of the fingers, like those of the thumb, may 
 
 occur in two directions, the backward being the more common. They are readily made 
 out, and are easily reduced by extension or by flexion and then extension. 
 
 Fig. 505. 
 
 Dislocations of the Lower Extremities. 
 
 Dislocations of the Hip. — These are grave accidents, and are found mostly in 
 male adults between fifteen and fiftv years of age, but occasionallv in the young or the 
 old. 
 
 The following analysis shows many of these points : 
 
 Out of 80 consecutive cases which have occurred at Guy's and in my own practice, 18 
 occurred in subjects under twenty years of age, the youngest being five ; 36 between the 
 ages of twenty-one and forty, and 26 had passed that period; 60 were males, and 11 
 females ; 41 were on the dorsum, 14 into the foramen ovale, 16 into the sciatic notch, and 
 9 on the OS pubis. 
 
 Mr. Powdrell {Lancet, 1868) has recorded a case 
 
 Fig. 506. 
 
 PuriFormis . ^ . 
 
 in which the head of the femur 
 was displaced into the foramen 
 Fig. 507. ovale at the age of six months ; 
 
 it was reduced by manipulation. 
 Erichsen has recorded another, 
 of dislocation on the pubes, in 
 a child a year and a half old. 
 I have treated three cases of 
 dislocation on the dorsum in 
 boys ast. 5 and in a girl set. Sj, 
 
 but these are exceptions. On 
 the other hand, dislocations may 
 occur in the aged. Malgaigne 
 has recorded five between the 
 ages of sixty and eighty-five, 
 and my notes contain cases 
 which occurred in men aged 
 
 sixty-one. sixty-four, sixty-five, and seventy-six ; but at this time of life fracture of the 
 
 neck of the femur is more common. 
 
 The accident is always the result of violence, no slight force being required to tear 
 
 Oi^.Hxi. 
 
 Recent Case of Dorsal Dislocation. Rent in Capsule, with Femur Flexed 
 (From Mr. Morris's paper.) 
 
DISLOCATIOyS OF Till-: LOW Ell KXTRKMITIES. 
 
 843 
 
 / 
 
 tliroimli till' liL'aiiitiits that Imld ami himl the IicimI of the ftiinir in its det'i) pelvic cup; 
 iiuloi'tl, wi'iv it not t'ur the ;j:rt'at k-vcia^'i- u[' the h)\V('r cxtremil). the accident wijiihl ])roh- 
 ahly he a rarity. In i-xceptinnal instances, however, tlic hone i.s disphiced witli the 
 slij^htest force. I have had uncK'r my care a youii;r man whose reniur had been dishtcated 
 a dozen times or more, the smaMest twist in the limh causin<.' its (hsiocation hackwanl. 
 
 t'onireiiital dishications and disjilacements from disease are not inehKh-cl in this ^'roiip. 
 
 l)ishications I'rom accident are ol" various forms, Imt the division made hy Sir A ('oopi;r 
 is ihdiKtless i)ractically tlie best, if we rememher that varieties u\' each form or jmrtiul 
 dislocations are met with in i)ractice, .since there is <.'ood reason to believe that the head 
 of the thiu:h-bone may rest at any jioint round its socket. 
 
 1. Dislocation /^^/ra/v/ and hdrkii^iini on the dorsum ilii is the most common. 
 
 2. Dislocation luu-h-uiitil, toward the i.^chiatic or sciatic notch — a variety of the latter — 
 stands third on the list as to fre(|uency. 
 
 o. Dislocation tfuicincfinf and ininnd into the foramen ovale stands .second. 
 
 4. Dislocation upvnril and /<>nrn id upon the ])ubes is about ecjual in frecjuency to that 
 toward the sciatic notch. 
 
 These several forms of dislocation depend much upon the degree of flexion or cxten- 
 f<ion and of inward or outward rotation of the thigh at the time of luxation. The head 
 of the femur under most, if not all, 
 
 circumstances, as demonstrated by .Mr. Fio. ^f^^. Fig. 609. 
 
 Henry Morris in an able paper (JA'/.- 
 Cfiii: TrcDis., 1ST7), leaves the ace- 
 tabulum, when the lower extremity is 
 ^//^ducted, through a rent in the cap- 
 sular ligament where it is the thinnest 
 — viz., at the inner and lower .side of 
 the joint (Fig. 5U7), the strong ilio- 
 and ischio-femoral ligaments situated 
 on the anterior, outer, and posterior 
 aspects of the joint and the shape of 
 the acetabulum preventing displace- 
 ment in any other position. With the 
 limb abducted, however, the head of 
 the femur is more than half out of the 
 acetabulum, the ligamentum teres is 
 quite loose, and all the strong portion 
 of the capsule is relaxed. Indeed, Mr. 
 Morris believes that it is only in ab- 
 duction of the lower extremity that a 
 simple dislocation of the head of the 
 femur can possibly occur, and that a dislocation on to the dorsum ilii or toward the sci- 
 atic notch is due to the amount of Ji'xion and rotation of the limb inward at the moment 
 of the accident, and dislocation on to the pubes to extension and rotation onticard ; al.so 
 that the degree of flexion and rotation of the limb inward determines in any particular 
 instance whether the dislocation .shall be dor.sal or ischiatic, the latter variety occurring 
 when flexion is carried to an extreme. 
 
 Direct dorsal dislocation can be produced onl\' by immense violence, and is often com- 
 plicated with fracture of the acetabulum. 
 
 In all ca.ses the round ligament and capsule are torn across, the muscles about the 
 joint being more or less lacerated. 
 
 Dislocation on the dorsum ilii, or backward and upward, forms about half of 
 all the cases of dislocation at this joint, and is usually produced by some twisting move- 
 ment of the body or limb when the latter is abducted or from a crushing weight received 
 when in a stooping posture. It can be recognized by the following signs — viz., the flexed 
 position of the thigh, the knee when the patient stands projecting in front of but above 
 the other ; the rotation inward of the limb, the great toe resting on the instep of the 
 opposite foot ; the projection of the great trochanter and its approximation to the anterior 
 superior spinous process of the ilium ; the elevation of the fold of the buttock ; the 
 immobility of the limb and the pain jiroduced by any attempt to abduct or to extend it ", 
 and the marked shortening of the limb — from an inch and a half to two and a half 
 inches (Fig. 510). 
 
 In thin subjects the head of the bone may be felt lying ujmiii the dorsum ilii. and in 
 
 Dislocation of the Head of the Dislocation of the Head of the 
 
 Femur on I)orsum Backward Femur Backward. 
 
 and rpward. 
 
 Takeu from specimens in the Middlesex Hospital Museum, and 
 prepared by Mr. Morris.) 
 
844 
 
 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 all there will be an unnatural fulness of this part. Slight flexion and adduction will 
 usually be borne, while patients may support the weight of the body on the injured limb, 
 or even walk upon it. 
 
 Dislocation backward toward the ischiatic notch forms about a seventh 
 
 of all cases and may be regarded as a variety of the one just described ; indeed, Erichsen 
 
 Fig. 510. 
 
 Fig. 511. 
 
 Fig. 513. 
 
 Dislocation Backward 
 on the Dorsum. 
 (Drawing 30&.) 
 
 Dislocation into 
 the Sciatic 
 
 Notch. (From 
 Bigelow.) 
 
 Position when the Limbs The Limbs Raised to a Riglit 
 
 are Extended, the Short- Angle with the Recum- 
 
 ening being Slight. bent Trunlc, the shorten- 
 
 ing being very striking. 
 
 (From paper by Dr. W. Dawson of Ohio, who subsequently wrote 
 that this test of dislocation had been suggested by O. H. Allis 
 in 1874, Philadelphia 3fed. Times.) 
 
 Fig. 514. 
 
 describes the two forms together as the ilio-sciatic. It is characterized by the same, 
 though less marked, symptoms. There is less shortening ; but if the patient be placed 
 upon his back and the thigh be flexed upon the trunk at a right angle, then the knee of 
 the dislocated limb will sink below that of the other side from one to two inches (Figs. 
 512, 513), the trochanter is drawn up and rotated forward, but not to the same extent, 
 and the head of the bone cannot be felt. To the eye the limb 
 assumes much the same position as in the last form, but, there being- 
 less shortening, the toes rest on the ball of the great toe of the 
 opposite limb instead of on the instep (Fig. 511). Bigelow believes 
 that this form of dislocation is due to the protrusion of the head of 
 the bone below the tendon of the obturator internus muscle, whereas 
 in the former kind the bone is protruded above the tendon. In this, 
 however, he is wrong, as Mr. Morris has shown that in afl forms of 
 dislocation the head of the femur makes its exit fi-om the acetabu- 
 lum lielow this tendon. 
 
 Dislocation upon the foramen ovale or obturator 
 
 foramen is a very striking accident. Sedillot as well as Boyer 
 believes that it is the most common of all forms, but British and 
 American surgeons usually place it third on the list. In my own 
 table it stands second. It is generally caused by some forced abduc- 
 tion of the knee or foot, the head of the bone being tilted inward. 
 In the case from which Fig. 514 was taken it was caused by abduc- 
 tion of the knee when the girl (aet. 14) was stepping out of an 
 omnibus. 
 
 Dislocation into the Fora- It is characterized by the bent position of the body and the 
 a gh-l*^8et ' 14 '7'^'^^" ^'"" pointing of the foot forward and slightly outward, the approxima- 
 tion of the trochanter toward the mesial line and consequent flatten- 
 ing of the hip, hoUowness below the anterior superior spinous process of the ilium, the 
 absence of the gluteal fold, and the elongation of the limb from one to two inches. Any 
 attempt at movement causes pain. The head of the bone can often be felt in its new 
 position beneath the adductors (Fig. 515). The patient can at times, however, walk with 
 such an injury. 
 
 Dislocation upon the OS pubis is the least common form of dislocation, and is 
 due to forced extension and rotation outward of the thigh after dislocation by abduction, 
 
DISLOCATIONS OF 'I'llh' I.OWEll EXTllEM ITIKS. 
 
 845 
 
 the pelvis l)i'iiij; thrown forwiinl :iii(l tlic hudy bent backward as the head of the feiiiur is 
 wrenched out of the ,sock(!t and then drawn upward. 
 
 It is marked by eversioii of the limb and loot and abduction, rotation backward of 
 the trochanter, and eonsecjueiit flattening of this region. The head of the bone can 
 usually also be I'elt, if nut seen, as a projection upon the os pubis (Fig. 51G) or on some 
 
 Fuj. ")lo. 
 
 Fio. 51G. 
 
 Fio. ol7. 
 
 Dislocation into Foramen Ovale. Dislocatiou upon Os Pubis. 
 
 (From Preparations.) 
 
 Dislocation upon Os Pubis. 
 (From Aslley Cooper.) 
 
 part of the lip uf the acetabulum. When thrown above the bone beneath Poupart's liga- 
 ment, it forms a very prominent projection beneath or to the outer side of the femoral 
 artery (Fig. 517). 
 
 When the head of the bone is thrown between the anterior superior and inferior 
 spines of the ilium or between the inferior spine and the acetabulum, the head of the 
 bone will be felt in that position. 
 
 Diagnosis. — With reasonable care and attention to the special symptoms which cha- 
 racterize the different forms of dislocation, these ought readily to be made out, although 
 certain fractures about the neck of the femur may present symptoms somewhat similar. 
 I have seen two cases of impacted fracture of the neck of the thigh-bone, with the foot 
 inverted and the thigh flexed, presenting symptoms so similar to those of dislocation into 
 the sciatic notch that the diagno.sis could not be made out till the patients were brought 
 under the influence of chloroform, when by gentle manipulation the nature of the accident 
 was discovered, the greater freedom with which the head of the bone could be made to 
 rotate in the acetabulum and the limp condition of the limb under chloroform in the case 
 of fracture forming a marked contrast to the immobility and permanent position of the 
 thigh in dislocation. The late Mr. K. W. Smith {On Fracture, 1850) records also a case 
 of fracture of the neck of the femur which had been mistaken for dislocation. 
 
 When, in the adult, the displacement recurs after the apparent reduction of the bone 
 and the extending force has been removed, the probabilities are that the lip of the ace- 
 tabulum has been broken off or the head of the femur fractured (r/VA Birkett, Med.-Chlr. 
 Trans., vol. Hi.), and when in a child the separation of the head of the bone or upper epi- 
 physis should be suspected, it being quite impossible, under both these circumstances, to 
 maintain the bone in position except by means of a long splint or weight to keep up 
 extension. In all cases of a doubtful nature chloroform should be given for purposes of 
 diagnosis, the surgeon using the gentlest manipulation. The sudden loss of mobility, the 
 rigidity of the limb, the absence of crepitus and other symptoms of fracture, with the 
 positive signs of the injuries themselves, are suflicient to indicate the nature of the case. 
 Nelaton's test for dislocation of the hip backward is. however, excellent, and consists of a 
 line drawn from the anterior superior spinous process of the ilium to the most prominent 
 part of the tuberosity of the ischium. In a normal joint the trochanter, in every position 
 of the limb, merely touches the lower border of this line, but in all dislocations where the 
 bone goes backward it is sometimes found an inch above it. 
 
 Tre.atme.nt. — Sir A. Cooper, with the surgeons of his day, considered the muscles 
 about a joint as the chief agents in drawing a displaced bone into its abnormal position 
 
846 
 
 CONTUSIONS, SPBAINS, AND WOUNDS OF JOINTS. 
 
 and as forming the main obstacle to its reduction, and, as a consequence they relied upon 
 physical force, in the form of pulleys and other complicated appliances, as the chief 
 means by which this obstacle could be neutralized. The modern surgeon, with anaesthet- 
 ics in his hands, knows that the muscular system has usually little or nothing to do with 
 the difficulties that are met with in the reduction of a dislocation, that these are found in 
 the ligaments and capsule, and that a large laceration in the capsule allows easy reduc- 
 tion, whereas difficulties must be experienced when the rent is small. With chloroform, 
 therefore, all pulleys and mechanical appliances can be done away with — certainly in 
 recent and probably in old cases. In my own opinion they are never required, for adhe- 
 sions are more readily broken down by forced flexion and rotation than by simple exten- 
 sion ; and if these fail, no extending force will succeed. In dislocations of the hip the 
 reduction by flexion becomes, therefore, a reality, and is one of the greatest improvements 
 in modern surgery. 
 
 In the dislocations backward — ilio-sciatic — the reduction by flexion is the correct 
 method, adduction, circumflexion, abduction, and extension of the limb being subse- 
 quently and successively employed (Fig. 519). In dislocation into the foramen ovale 
 the reduction by flexion is likewise good, with subsequent circumflexion inward and 
 extension (Fig. 518.) 
 
 In sub-pubic dislocations the reduction by extension outward and rotation is pref- 
 erable. 
 
 To carry out this reduction by flexion and manipulation, the patient should be placed 
 on his back on a hard couch and thoroughly ana?stheticized. The surgeon should then 
 grasp the ankle of the displaced limb with one hand and the ham with the other, flexing 
 the leg upon the thigh and the thigh upon the pelvis, at the same time lifting the limb and 
 adducting it toward the opposite side of the umbilicus. Having eff'ected this movement, 
 the surgeon should by a semicircular sweep outward suddenly extend the limb and bring 
 it into a straight line with the body (Fig. 519). If one attempt fail, a second may be 
 
 Fig. 518. 
 
 Fig. 519. 
 
 ^.s^J^ 
 
 In Dislocation into the Foramen Ovale. 
 (From Bigelow.) 
 
 Reduction by Manipulation. 
 
 In Ilio-Sciatic Dislocation. 
 
 made, and in by far the majority of recent cases success will attend the efl'ort. '■ If there 
 is any single and best rule for reducing a recent dislocation of the hip," writes Bigelow 
 {Lancet, June 15, 1878), '• it is to get the head of the femur directly below the socket by 
 flexing the thigh at about a right angle, and then to lift or jerk it forcibly up into its 
 place. This rule applies to all dislocations except the pubic. Flex and forcibly lift ; and 
 if this fail, flex and lift while abducting." No roughness should be used, gentle, well- 
 directed manipulation being all that is called for, the Teverage obtained through the femur 
 being enormous. Some slight rotation of the limb outward or inward, according to the 
 necessities of the case, at times facilitates reduction. Callender insists (Lancet, 1808) — 
 and wisely, I think — upon the importance of not fulhj ahducllng or rolling the limb out- 
 ward, as, if this be done, the head of the bone is almost certain to roll past the acetabu- 
 lum to its inner side ; or if an obturator dislocation is under treatment and the thigh is 
 rotated inward, the head of the femur will roll round to the ischiatic notch, just reversing 
 the movement which takes place when an ischiatic dislocation is improperly manipulated. 
 The object of the treatment is to use the femur as a lever to raise the head of the bone 
 from its backward position and allow the stretched muscles to act naturally and draw it 
 
DISLOCATIOSS OF Tin-: LOW Ell I'.XrilF.M ITIKS. 847 
 
 into ])laeo, the act of flexinii completely reluxiiij; the strorij^ ilio-feiiioral ligament, the 
 surgeon, with his knowledge u\' the way iti wliicii the head <if the bone was driven thnnigli 
 its eapsule, using his best endeavors to make it retraee its steps, and enipjoyirig his aiia- 
 toniieal knowledge to jtress, elevate, or guide flic nialplaced hone into its normal position. 
 The various nnivements adopted in reduetii)n hy manipulation, as well shown hy .Morris, 
 serve to bring the head of the displaced t'emur down to the notch in tin; acetabulum by 
 making it retrace the course it took in the process of dislocation, and then subse(|uently 
 turning it back through the rent in the eapsule by a rotation the rcver>e of that which 
 occurred during dislocation. This method of reducing dislocations of the hip is known 
 in France as Depres" method; in America, as Keid's. The former employed it in 1.SI55 
 {riilr Nelaton's I'lf/m/. C/iinin/., lS47j, but Dr. II. IJigelow has proved that the credit 
 of the method is really due to Nathan Smith of New Hampshire (see Mt niuirs, \H\\\). 
 In a case of dislocation into the foramen ovale in a man I failed in my first attempt by 
 manipulation, but in the second I succeeded by the application of the slightest pressure 
 u|ton the head of the bone ; and in the case of the girl fnuu whom Fig. 514 was taken 
 the head of the bone slipped into its position by simply fle.xing the leg on the thigh and 
 the thigh on the pelvis, with such gentle pressure as I was apjilying for a preliminary 
 diagnosis. 
 
 In one case of severe injury to the joint that came iiiuler my care, where the bone 
 was displaced on the dorsum, on attempting its reduction by manipulation the head of 
 the bone slipped with such facility round the acetabulum as to illustrate every typical 
 form of dislocation aiul several intermediate or partial foi'ms. In this case, however, 
 reduction was subsequently readily obtained by thoroughly flexing the thigh upon the 
 pelvis and Uflinij the head of the femur from its false position by extension forward. 
 
 When the rent in the capsule is small, difficulties may be felt in reducing tlie disloca- 
 tion ; but when lai'ge, little is usually experienced. 
 
 At times reduction is thought to have been accomplished when redislocation appears 
 after the limb has been left alone, and under these circumstances it is probable that the 
 head of the bone had only partially been replaced through the rent in the capsule. In 
 other cases of this kind which refuse to remain hi siftl there is reason to believe that the 
 lip of the acetabulum has been fractured, or, in young subjects, that the head of the 
 femur has separated at the epiphysial line of junction with the neck. Still, without these 
 explanations, cases are met with in which it is quite impossible to keep the limb in posi- 
 tion after its reduction. In some cases the reduction of the dislocation occurs by simple 
 muscular movement when the patient is in bed. I have seen several. When reduction 
 by flexit)n has failed or is inapplicable, that by extension should be employed, and in the 
 pubic form of dislocation no other should be used. It should be practised with the patient 
 under the influence of an anaesthetic and on his back, and as follows : The pelvis should be 
 fixed by a perineal band well padded and adjusted, and the limb extended in the line of 
 its position to draw the head of the bone out of its bed. The surgeon .should then either 
 elevate the bone, to allow the muscles to act upon it, or abduct, adduct, or rotate inward 
 or outward, according to the special want of the individual case. In some cases the 
 simple extension of the limb with the unbooted heel of the surgeon placed firndy in the 
 perinanim will answer every purpose. 
 
 After-Tkeatment. — After the reduction of a dislocation the legs should be fastened 
 together and no moven)ent allowed for three weeks, and then only gentle movement ; for 
 if this rule be not attended to, redislocation may occur. In a case under my care of dis- 
 location into the foramen ovale, in a young woman, after reduction had been effected, 
 redislocation occurred on the tenth day from crossing the leg over the opposite knee in 
 attempting to cut the toe-nails of the affected limb. 
 
 Splints are hardly called for in the majority of ca.ses, although, should secondary inflam- 
 mation follow or much local mischief complicate the case, they should be applied, with 
 either ice or hot fomentations, the surgeon selecting the application that gives most 
 relief. 
 
 Old dislocations, in a general sense, should be left alone, since in the hip difficul- 
 ties of reduction are always felt and danger is not rarely met with. During the first three 
 weeks reduction is rarely difficult and may always be tried ; indeed, within the month 
 good hopes attend the attempt. I have seen a dislocation on the dorsum reduced on the 
 thirty-fifth day with an excellent effect.- Dr. H. Croly of Dublin told me in 1879 of a 
 case of dislocation on to the pubis in which reduction was eff"ected on the thirty-ninth day 
 by manipulation after an attempt with pulleys had failed. Success has, however, been 
 recorded in exceptional cases up to the sixth or eighth week, or even after six months, 
 
848 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 but failure has more frequently followed the attempt. My colleague, Mr. Durham, in 
 1873 reduced one after the fifth month. Fergusson states that after three weeks he has 
 never seen a successful attempt. Sir A. Cooper fixed eight weeks as the limit of time up 
 to which the attempt should be made, and without the use of anaesthetics he was doubt- 
 less right. When reduction has failed, good movement may often be secured after the 
 lapse of time. The dangers attending attempts at reduction are not theoretical. Inflam- 
 mation and destruction of the joint are no infrequent consecjuences. and fracture of the 
 bone has been recorded by many surgeons. Dislocation of the knee or rupture of its 
 ligaments has likewise taken place from the extension employed, and with a fatal result. 
 
 When fracture of the femur is associated with (lislocation of the hone, the latter should, 
 when possible, be reduced by manipulation. In 1860 I saw my colleague, Mr. Birkett, 
 reduce with the greatest facility a dislocation of the head of the femur on the ramus of 
 the pubis in a boy aet. 12 when the femur was broken below the trochanter, the bone 
 slipping into place on the application of gentle well-directed force. Similar cases have 
 been recorded by Bloxam and M. Etene. 
 
 If the reduction of the dislocation by these means has failed, some hope remains that 
 when the fracture has united a better success may be secured. Sir A. Cooper has related 
 an example in which reduction by means of extension was effected five weeks after the 
 accident in a youth about seventeen. 
 
 Effects of Dislocation. — The sciatic nerve may be injured at times in a dislocation 
 of the hip, and as a conse(iuence paralysis may ensue. Morris shows in his paper how 
 this comjdication is caused, while Maclise in his illustrations gives a drawing illustrating 
 how the nerve may be stretched, and Hutchinson (^Med. Thnes, 1866) recorded a case in 
 which the paralysis was permanent. 
 
 Dislocations of tlie Patella. — These are not common accidents, but seven occurred 
 at Gruy's in ten years. When they occur, they are genei'ally caused by muscular action, 
 though at times by the application of direct force. They are most commonly met with 
 outward^ occasionally inward, and very rarely edgeways.. When the ligamentum patellae 
 has been torn across, the patella is drawn upward ; and authors have described this acci- 
 dent as dislocation upward. 
 
 The dislocation outicard is usually seen in women, in whom the femora have a more 
 oblique inward direction than in most men, or in knock-kneed subjects, the bone resting 
 flat on the outer condyle of the femur or on its outer edge ; in the former case the outer 
 edge of the patella, and in the latter the inner, tilts forward. The knee is usually slightly 
 flexed ; it looks broader and flatter, but the unnatural position of the cap marks the 
 nature of the accident. In 1868 I saw this accident in a male child ten months old ; the 
 patella rested on the outer side of the condyle of the femur and was readily reduced. 
 
 Dislocation iinrard is very rare and easily recognized. It is always due to direct vio- 
 lence to the outer border of the bone. 
 
 Both these accidents are attended with laceration of the synovial capsule. 
 
 Treatment. — Reduction is readily effected, usually by raising the heel of the limb, to 
 relax the extensor muscles of the thigh, and manipulating the displaced bone into its 
 position, the elevation of its depressed edge being generally enough to allow the muscles 
 to restore it to its right place. A splint should then be applied, as well as a bag of ice 
 for a few days till all inflammatory action has subsided, the knee being strapped up sub- 
 se(|uently for a month or more, to give time for the ligaments to unite firmly. These 
 dislocations, however, are very prone to recur on the slightest cause, and many patients 
 are obliged to wear for life a firm leather knee-cap to guard against such a contingency. 
 
 Dislocation of the bone edgeways is a very uncommon accident. I have seen 
 only one such instance, and in it the patella appeared to show its articular facet inward, 
 its inner edge presenting forward beneath the stretched skin. It was in a middle-aged 
 woman, and the displacement was produced by a direct blow upon the knee from a fall 
 off" a chair. Mayo has recorded an instance in which the bone had turned almost round. 
 
 This dislocation is readily known by the peculiar appearance of the joint. 
 
 Treatment. — In my own case reduction was effected with ease on raising the leg and 
 turning the patella into its right position with the fingers. Flower succeeded on bending 
 the knee only after chloroform had been given. Cases have been recorded where reduc- 
 tion was impossible, even after the subcutaneous division of the tendon and ligament that 
 is attached to it, and other rough means ; but these were employed before chloroform was 
 introduced, which must be their excuse. Under an anaesthetic it is probable that by 
 manipulation the bone will usually be reduced ; if not, it had better be left alone. Some 
 sudden muscular effort miijrht be of service. 
 
DISLOCATIOSS OF Tin: I.OWEIl KXTUEMITIES. 
 
 849 
 
 ¥u,. .")'J(i. 
 Pal tlln 
 
 Exfl ronHyle of femur 
 
 Partial Dislocation of the Left Tibia and Fibula For- 
 ward. (Taken from a man wt. 2:5.) 
 
 Dislocation of the Knee-Joint.- 'I'lii- arciilcnl run .ici'm- (.nlv Inim <:rciit viu- 
 li'iici', till' liiiaiiicnls that l)iiiil the hdiR-s to;j:cthi'r \n'\u<i very Htroii;^ ; yt-t it d<jes occur, 
 the tihiii hciiit; tlisjihici-d huc/i-irnni, fonrnnl. or litlrrnllij. Kuur (ixaiiiph's (jccurriMl at 
 (Juv s ill tell years. Wlieii jutr/id/, ii(t eoiniilieatidii, a.s a nil(!, exist.s, ami tlu? lateral i.s 
 iisiiallv of tlii.s nature; when cuin/tfitr, the snl"t pari ahitut the j(»int and the liljnm.s tis.sue.s 
 within are often .so injured as to render it a ;rreat ((uestion whether the joint, or even the 
 liiiili. can he saved. The hackward and forward dislocations are usually of this kiiul. 
 
 l)|.\iiNtisis. — When the |iopliteal artery or vein is injured or ruptured. aiii|)Utatioii 
 of the liiiil) inav he ealli'd for, this necessity beiiif^ rendered more than prohahle when 
 the circulation throu^di the vessels is not speedily restored after the reduction of the dis- 
 location or when a swollen ciuidition of the limb remains. 
 
 TuK.VT.MKNr. — The.se dislocations arc readily dia^nio.sed by the peculiar deformity they 
 display, and are easily reduced by extension and tlu; application of pressure where pres- 
 sure is needed. In the case from which Fiir- ;')-'• 
 was taken jiulsation in the ve.s.sels was arrested, 
 but it returiietl on the reduction of the dislo- 
 cation, and recovery with complete movement 
 of the joint was ohtaiiie(l. After the parts have 
 been replaced in tlieir normal positi(tn splints 
 should be adjusted and cold applied, for second- 
 ary inflammation is almost sure to follow. In 
 rare cases the displacement is permanent and the 
 limb is left u.seful. Thus, in a man xt. 20 under 
 my care the left tiltia and fibula were displaced 
 partially inward five years before I saw him from 
 a fall in wrestling. The inner condyle of the 
 femur rested on the outer articular facet of the tibia, and the head of the fibula seemed 
 to rest between the condyles of the femur. The man liad good though not complete 
 movement of the joint, could walk well and carry loads. 
 
 A displacement of the lower epiphysis of the femur with the leg-bones may be mis- 
 taken for dislocation of the knee, and in young subjects where this latter accident is sup- 
 posed to have taken place the surgeon should always consider 
 the probability of the injury being of the former kind. In 
 Fig. 521 this accident is well illustrated ; it was taken from a 
 boy ji3t. 10 who w'as under my care at Guy's some years ago. 
 The epiphysis had been displaced inward off the shaft of the 
 femur and rotated inward, and the lower end of the diaphy.sis 
 of the femur was nearly through the soft parts on the outer 
 side of the limb. The parts were restored to their normal 
 position by manipulation and extension and the limb was fas- 
 tened on a splint ; a good recovery with perfect movement of 
 the joint was the result. In some cases fracture coexists, and 
 in exceptional examples, where the end of the diaphysis ])ro- 
 jects through the soft parts, its resection may be required to 
 allow of its reduction. 
 
 Compound dislocations of the knee are generally so 
 serious as to necessitate the removal of the joint. The attempt 
 to save it should be made in exceptional cases only ; ampu- 
 tation or excision mav be selected. 
 
 Dislocation of "the head of the fibula is occasion- ^P'";«jio'j^and Rotation ^inward 
 
 all V met with. I have seen but three examples — one when Femur, with the Lcs Hones, from 
 dressing for the late Mr. A.ston Key, and two since. It is f!'om'atl.y*'it*'iar"''" ^'^'"^^'^ 
 generally caused by some violent adduction of the foot, with 
 
 abduction of the knee, the head of the fibula tearing through its ligamentous attach- 
 ments and becoming displaced outward. 
 
 DiACXOSis. — The accident can be readily recognized by the projection of the bone. 
 It should be treated by the application of a pad and pressure over the part suflicient to 
 keep the bone in its place, the limb being flexed when necessary, to relax the biceps 
 femoris. The pressure should be maintained for at least two months if good success is 
 to be looked for; as a rule, the bone never quite resumes its former position, the head 
 projecting more than usual. This deformity, however, does not appear to weaken the 
 limb to any great extent. 
 54 
 
 Fig. 521. 
 
850 
 
 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 Dislocation of the interarticular fibro- cartilages (.semilunar) is a recog- 
 nized accident. It is produced by some sudden twist of the knee with tlie foot everted, 
 and generally in subjects who have relaxed joints or such as have been the seat of some 
 chronic synovitis. The inner cartilage seems more liable to displacement than the outer. 
 Symptoms. — The symptoms of the accident are well marked. A patient, when walk- 
 ing, accidentally catches his foot against a stone or in rising from a kneeling position is 
 seized with a sudden sharp, sickening pain in the knee ; the joint becomes at once fixed 
 in a semiflexed position and any attempt to move it only excites some pain. When the 
 first agony has subsided, a painful spot is usually left, where the projecting cartilage 
 may be felt, or even seen ; and if the " internal derangement of the joint," as it was orig- 
 inally called, is left untreated, synovitis or effusion into the joint will soon show itself. 
 When these symptoms follow such an accident as has been described, the cartilage has 
 probably been torn from its attachment to the tibia and been doubled in or displaced. 
 
 Mr. J. F. Knott in an able paper (BhI>. Joiini. of Med. Sci., June, 1882, p. 479) has 
 shown that in " the combined twisting and lateral movement conveyed to the knee at a 
 moment when the ligaments are as lax as possible the margin of the condyle of the femur 
 is Jerked over the edge of the internal semilunar fibro-cartilage. The immediate result is 
 pressure of this structure, which is increased when the resulting pain brings about spas- 
 modic contraction of the surrounding muscles." 
 
 Treatment. — The best practice consists in the forced flexion of the joint, the slight 
 rotation of the leg outward, and sudden extension, pressure with the thumb upon the 
 cartilage above the edge of the inner condyle of the tibia during the flexion and extension 
 often being of use. When success attends this manoeuvre, the joint moves smoothly and 
 without pain, and the patient will at once be able to move the joint freely. At times the 
 reduction of the displaced cartilage is attended with a decided snap. After its reduction 
 the joint should be kept in a splint and such means employed as the symptoms that fol- 
 low indicate, for more or less inflammation often ensues, requiring ice, cold lotions, leech- 
 ing, and rest. When active symptoms have subsided, it is well to restrain the movements 
 of the joint by means of a knee-cap or strapping, as a recurrence of the accident is liable 
 to follow upon the least occasion. I have on several occasions thought that disease has 
 been excited when this measure has been omitted, and I once saw anchylosis follow. 
 Permanent lameness is by no means uncommon. When the surgeon fails to reduce the 
 displaced cartilage, the patient at times suddenly gains relief by its spontaneous reduc- 
 tion during some accidental movement. In other cases the cartilage resumes its normal 
 condition more slowly. In 1873 I saw a case of this kind where spontaneous reduction 
 always occurred after its displacement. It was in a gentleman a3t. 30, and the inner carti- 
 lage projected beyond the head of the tibia in a most marked manner. The patient should 
 be kept in bed and allowed only to move the limb, not to stand upon it. When this result 
 is not secured, the joint should be strapped up, to restrain movement. 
 
 Dislocations of the Ankle-Joint. — Such an accident uncomplicated with rup- 
 ture is rare ; that is, dislocation of the foot 
 ontvmrd is generally associated with frac- 
 ture of the fibula, and dislocation Invard 
 with fracture of the tibia, or both malleoli 
 may be broken. Pure dislocations of the 
 foot foricard or hachward^ however, may 
 occur. These dislocations are given in the 
 order of their frequency, and are usually 
 produced by some violent twist or bend- 
 ing of the foot when the patient is jump- 
 ing, or by some violent impulse of the body 
 with the foot fixed. 
 
 Dislocation of the foot o?'^;/-arf? is better 
 known as " Pott's fracture" (Fig. 522), the 
 fibula being usually broken two or three 
 inches above the external malleolus. It 
 is caused by a violent bending of the foot 
 outward with the foot everted, its outer 
 ward, with Fracture edffe beins raised and the inner turned 
 (lp."coopefr^"'- downward on the ground. At times the 
 extremity of the inner malleolus is broken 
 off" and displaced outward, with the foot and astragalus. Under all circumstances the 
 
 Fig. 522. 
 
 Fig. 523. 
 
 External Appearances of Foot in 
 Pott's Fracture. (Taken from 
 Pott's work.) 
 
 Dislocated Foot In- 
 
DISLOCATIOyS OF THE LOW'KIl IIXTIIIIMITIES. 
 
 851 
 
 Fig. 0-24. 
 
 IcnvtT I'lid *A' tlu' tihiii or imicr m:illtiiln< lniiiis a proiiiiiiciit prnjcctiDri iiiwanl. Iea<liii<: — 
 or »</,sl('a(liiit: — Sir A. Cuopor ami his copyists to iIi'slmmIjc this acci<lt'iit as (ii.shjcutioii of 
 tho tihia iiiwaril. At thi; scat of fracture of the Hlxila a depression exists. Wheii the 
 force is coiitimicil hcyoiid the point necessary to cause tlie ilisphu-cnicnt mentioned, the 
 h)\ver end of tlie tibia may he made to project throujiii the soft j»arts and tlius jrive rise 
 to ji compnuiiil lUslitciitinii. In still more severe cases tho e. \t rem i tics of both tibia and 
 fibula may be made to project, the foot being completely turned outward. Exceptional 
 cases occur in which the foot is turned out of its socket between the malleoli witliout 
 any accompanyinii: iVacture. 
 
 Dislocation of the foot inwunl (Fig. 523) is the counterpart of the last-described acci- 
 dent, and is caused by violence that turns the foot inward with its outer edge to the 
 ground. It is usually associated with an ol)li(|ue fracture of the inner malleolus and di.s- 
 plact'ment. The force n^quired to lu-oducc this dislocation is very great, the tibia being 
 a far stronger bone than tlie fibula ; the accidiuit. C(»nsc<|Mently, is less common. The end 
 of the fibula is often fractured and drawn outward with the astragalus. At times the 
 astragalus is also fractured. The accident is known by the in- 
 version of the foot, the sole looking inward, and by the projec- 
 tion of the external malleolus, this ))romincut symptom having 
 led Sir A. (^^oper to describe it as dislocation of the tibia out- 
 ward. 
 
 When the force is continued or more severe, either the fibula 
 or the fractured — or, rather, exposed — ends of both tibia and fib- 
 ula may be made to project through an external wound ; in still 
 uiore severe cases I have seen this more than once, and in one a 
 sound recovery ensued, with a movable joint. It was, however, 
 in a boy ivt. 12. I simply reduced the dislocation after washing 
 and dressing the wound, and fixed it in splints. 
 
 Dislocation of the foot fxakicurd (Fig. 52-1- ) was called by Sir 
 A. Cooper dislocation of the tibia and fibula forward. It is usu- 
 ally caused by the violent propulsion of the lower end of the 
 leg-bones forward when the foot is fixed, and is readily recog- 
 nized by the shortening of the anterior surface of the foot and 
 the proportionate elongation of the heel, with some pointing of 
 the toes as well as prominence of the lower end of the tibia. At 
 times the fibula is fractured and the point of bone carried backward with the astragalus. 
 
 This accident is rare, it being more common to meet with fracture of both malleoli 
 and displacement of the foot and broken fragments backward. 
 
 In 1802 I was called to treat a very marked case of this kind in a man aet. 32. The 
 astragalus with the foot seemed to have been shot eompleteh' out of its socket, and the 
 extremities of the tibia and fibula projected so far forward as almost to rupture the soft 
 parts covering them. The accident was caused by wrestling. The dislocation was 
 reduced by flexing the leg on the thigh and by manipulation, but no means could be 
 found to maintain the bones in position till the tendo Achillis was divided and the leg 
 placed on its side and fixed on an outside splint. 3Ir. Cock (G)ii/\< Rep., 1S55) has 
 recorded a case of the same accident in a boy xt. 16. where the same difficulty was expe- 
 rienced. He divided the tendo Achillis and bound the foot in splints, and a good result, 
 as in my case, was obtained. 
 
 Dislocation of the foot forward is probably more rare than the last, and is 
 generally only partial. It has been described as dislocation of the tibia backward, and is 
 known by ])recisely the opposite symptoms to those last described. The heel is shortened 
 and the foot lengthened, the upper surface of the astragalus being capable of recognition 
 by the fingers. Poland records such a case {Guys Rep., 1855) in which the whola foot 
 was much elongated, and the posterior part of the astragalus was caught in the anterior 
 part of the tibia and fibula and wedged in tightly. Reduction was efli'ected only after the 
 division of the tendo Achillis. 
 
 Tre.vt.mknt. — The lateral dis])lacements of the foot are not difficult of reduction by 
 extension and well-directed manipulative force. The flexion of the knee facilitates this 
 operation by relaxing the muscles of the calf. 
 
 To keep the bones in position a Macintyre or flat posterior splint extending up to the 
 popliteal space, with foot-piece and two side splints, all well padded, are sufficient as a 
 rule, the surgeon using his judgment as to the amount of pressure and padding that may 
 be demanded. In some cases where it is a very difficult matter to keep the parts quiet, 
 
 Dislocation of the Foot Rack- 
 ward. (Cast 165, Guy's Mus.) 
 
852 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 from the action of the gastrocnemii muscles, the tendo Achillis should be divided, the 
 foot after this simple operation being perfectly passive and entirely in the hands of the 
 surgeon to place and to keep in any required position. 
 
 The limb should subsequently be slung in a proper swing, Salter's being the best. In 
 hospital practice two or more pieces of bandage slinging the splints to the cradle answer 
 well. In the displacement of the foot forward or backward the same kind of treatment is 
 applicable, but in these accidents it is expedient, as a rule, to divide the tendo Achillis at 
 once. This should be done at any rate when the slightest disposition to displacement is 
 found to exist, the treatment of the case being by this operation rendered more simple 
 and certain. 
 
 The splints should be retained for at least six weeks, and afterward passive movement 
 should be allowed. The patient should not bear any weight on the limb for another 
 month. 
 
 The treatment of compound dislocation of the anJde-joint cannot be reduced to any 
 definite rules. Each ease must be treated on its own merits. In young and healthy sub- 
 jects more may be attempted in the way of saving the joint than in the old or cachectic. 
 When a small wound exists, operative interference is only exceptionally needed ; but 
 when a large one with projection of the bones, it is a question whether the better practice 
 lies in the reduction of the dislocation after cleansing the projecting bones or in their 
 resection. When the bones cannot be reduced by ordinary force, their resection becomes 
 a necessity. When the bones are much crushed, their resection should always be under- 
 taken ; indeed, it is a general feeling in my own mind that in compound dislocations, as in 
 compound fractures with a large wound, it is wiser to resect the ends of the projecting 
 bones than to reduce them. Amputation of the foot should be performed only when the 
 soft parts and the bones are much injured and the age of the patient or his want of power 
 forbids the hope that a recovery with a useful limb can be secured. Before any attempt 
 at reduction is made the parts should be thoroughly cleansed. After the reduction of 
 the dislocation, whether simple or compound, the application of ice or 
 Fig 525. cold is of great value, or the treatment by irrigation. In the suppura- 
 
 tive stage the latter practice is probably the better of the two. When 
 the wound is of only a limited nature, it may be sealed at once, either 
 by lint soaked in blood, or, what is better, by the compound tincture 
 of benzoin. The joint in such cases may be washed out with a weak 
 solution of carbolic acid (one part in forty) or iodine water before the 
 wound is sealed. Opposite the wound an interrupted splint should be 
 employed. 
 
 Secondary amputation may be called for in these cases, on account 
 of gangrene or a fiiilure in nature's efforts to effect repair, etc. 
 
 Dislocation of the tibia and fibula at their lower ar- 
 ticulation, with a forcing of the astragalus upward 
 
 between the two bones, is an accident which must be recog- 
 nized (Fig. 525), and is usually produced by a jump from a height on 
 the foot or feet. I saw a good example of it in 1869, in both feet of a 
 T.. , ,. f i , ,„ man fet. 55 who fell from a scaffold. The malleoli were widely sepa- 
 
 Dislocation ol Ankle — iinioipp i • • c Ix. 
 
 Astragalus between rated and projected, the depth of the toot from the extremities or the 
 O^ast 160, &iy's MusO malleoli was lessened, and the movements of the foot were almost gone. 
 No fracture could be made out. It was impossible to move the bones 
 from the position in which they were wedged, although all means were used. Yet a good 
 recovery took place, though with stiff joints. I have seen a like case since in a man who 
 jumped from a high window, but in it some fracture of the astragalus complicated the 
 injury; the man did well. 
 
 Dislocations at the tarsal joints are met with in practice, although but 
 rarely. They are difficult to diagnose, and still more difficult to classify, since they are 
 so variously described by different writers. The first to be noticed is snhastragaJoid dis- 
 location of the foot ^ in which the astragalus maintains its normal position with the tibia and 
 fibula, but loses it with respect to the rest of the foot. Mr. Arnott communicated to the 
 London Med. Gazette (vol. xv., 1837, p. 588) the report of a case in which he and Mr. A. 
 Shaw recognized the nature of the accident ; but the possibility of such an accident was 
 doubted till Mr. Pollock in 1859 (Med.-Chir. Trans., vol. xlii.) published two cases; one 
 occurred in Mr. Keate's practice in 1823, and in it the os calcis and scaphoid, with the 
 other foot-bones, were displaced outirard off the astragalus. In the other, which occurred 
 in his own practice, the same bones were dislocated inward. A dissection of this case is 
 
DISLUL'ATIOSS OF TlIK LOW'Kll hXmh'MJTIh'S. 
 
 853 
 
 Fi(i. 020. 
 
 given. Til Koiito'.s ca.se tlie foot wa.s everte<l and tin; head <tf the astra^alu.s projected on 
 tlie inner .side of the instej). In Polhicii'.s the loot was inverted, .so that the soh; tnrncd 
 inwuril as in varns ; thi' external inaUeoIns was very proniinent and the astra^^alns pm- 
 jeeted on the other sitK'. In sunie instances tlie snrfaees of tlie foot arc maintained in 
 their ri^^lit line. In Mr. I'uUock.s case reduction was found to In- inipossihh" till the 
 ten<h> Achillis had heen divided, wlien it was readily aeconi|tlislied. in an aide paper he 
 advocates this practice whenever difficulty of reduction of the inward or outward dislo- 
 cation, simple or compound, is experienced, and shows that the division of the j)osteri(*r 
 tihial tendon is occasionally called for in the outwanl. Mr. Turner of Manchester had 
 l)reviously advocated the same practice ( 7/7(/i.s. I*ror. Mi</. and Snrg. Jssoc, vol. ix.). 
 
 In 1882 a man ;ot. 3(i came under my care with disjtlacement of the foot outivard off 
 the astrairalus and slight eversion of the foot. The head of (he astragalus j>rojected 
 thnuijih a large wound in the soft parts above and within the 
 tu))ercle of the scaphoid and above the tendon of the ])osterior 
 tibial muscle. Keduction was found impossible until a portion of 
 the head of the bone was removed, wdien the parts were re|daced 
 and the case went on to a satisfactory conclusion, with movement 
 in the ankle-joint. 
 
 An atlmirable paper on this subject has been pul»lislied by Sir 
 W. .MacC'ormac (^V. Thomas s Hasp. Rep., 1872). The woodcut 
 produced (Fig. 526) is taken from it, from which it will be seen 
 that '' the foot was violently inverted and adducted, its position 
 being like that of talipes varus. The sole of the foot looked 
 inward and was nearly vertical ; the outer edge of the foot, with 
 the patient erect, would rest partially upon the ground. The great 
 toe pointed toward the arch of the opposite foot. The inner l)or- 
 der of the foot was somewhat shortened and more concave, while DLsiocation of Foot inward 
 
 ,, , ^1 ill 1 -p 1 ii otl'tho -Xstracalus. (After 
 
 the outer was more convex than natural and appeax'ed as it length- \v. MacCormac.) 
 ened. The outer malleolus was very prominent, while the inner 
 
 could not be perceived, so deeply was it buried. Neither malleolus was fractured, and 
 this would seem to be almost characteristic of this form of injury. The rounded head 
 of the astragalus, completely dislodged from the .scaphoid, was resting subcutaneously 
 over the calcaneo-cuboid articulation. The prominence cau.sed by the head was .somewhat 
 masked by swelling of the soft part just below it. The skin covering the head was so 
 tensely stretched that it seemed ready to burst, and a circular slough sub-sequently formed 
 at the spot. The outline of the head could, however, be ea.sily traced, and the finger, on 
 being passed upward beneath the external malleolus, readily felt the cartilaginous surface 
 of tlie large posterior articulating facet of the astragalus. Most of it was quite subcu- 
 taneous, and its external margin rendered the .skin very tense. The interos.seous ligament 
 had been ruptured. The tuberosity of the scaphoid stood out prominently and a depres- 
 sion could be felt behind it. The motions of the foot were very limited."' 3IacdonnelI 
 of Dublin {Diib. Jonm., 1839) published a case in which the same bones were displaced 
 backward, where the heel projected, and a marked prominence existed on the dorsum of 
 the foot, with an abrupt descent in front on the tarsus. 
 
 In 1862 I had to amputate the foot of a man fet. 24 for a compound dislocation of 
 the foot hackicard off the astragalus, with fracture of the calcis. When seen, the foot 
 was turned inward and much fore-shortened and there was a bony eminence in front of 
 the external malleolus, which turned out to be the displaced anterior third of the os calcis. 
 The accident was caused by the man's foot becoming wedged between the spring and the 
 step of a locomotive and his body falling outward. On dissection the astragalus was 
 found in its normal position, between the malleoli, but with its head resting on the 
 scaphoid bone, between the tendon of the tibialis anticus on its inner side and of the long 
 common extensor on the outer. On the outer side of the foot the displaced portion of 
 the OS calcis was resting on the dorsal surface of the cuboid bone : the rest of the calcis 
 was completely dislocated backward, its upper and posterior articular facet projecting 
 beyond the astragalus. The extreme end of the external malleolus was broken off. The 
 peronei tendons maintained their position behind the external malleolus, but were much 
 stretched. 
 
 M. Pari.se {Annahs de la Chintrf/., 1845) gives an instance — which is apparently 
 unique — of dislocation forward, in which marked elongation of the foot existed and the 
 projection of the heel was effiiced. 
 
 All these dislocations are rare. The first example of dislocation inward that I have 
 
85-1 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS. 
 
 seen was recorded b}" Mr. Cock in Guf/^s ffonp. Rep. for 1855. with a drawing; but in my 
 work On the Joints (1859) I published (Case 85) an example of dislocation of the foot 
 outward, with a description of the dissected extremity, which had occurred in the practice 
 of Mr. Aston Key in 1845. The foot was amputated, reduction being impossible. The 
 ankle-joint was perfect. The os calcis with the foot was displaced outward. The tendon 
 of the tibialis posticus was found in front of the tibia holding down the astragalus. The 
 posterior tibial nerve was violently stretched over the astragalus. The limb was removed 
 for tetanus, and the symptoms immediately disappeared after the amputation. A large 
 number of these cases are compound, and in some they are complicated with fracture of 
 the fibula. Broca (^Mem. de la Societe de Chirurg., tome iii.), out of thirteen examples 
 of dislocation outward, gives nine as compound. 
 
 This dislocation may be diagnosed from displacement at the ankle-joint and dislocation 
 of the astragalus itself by the fact that extension and flexion are present ; from fractures 
 about the ankle by the absence of crepitus, together with the positive signs of the inju- 
 ries themselves. 
 
 Treatment. — Reduction should be attempted only with the patient anaesthetized, and 
 under such an influence, by extension and manipulation, success may be looked for. When 
 difficulties are experienced, Turner and Pollock's suggestion of dividing the tendo Achillis, 
 and even the posterior tibial tendon, or any other tendon when it is clearly interfering with 
 the replacement of the bones, should be followed. "When these means fail and the stretched 
 skin gives way, the case must be treated as one of a compound nature and the astragalus 
 partially is excised, the foot being subsequently well confined in splints and ice applied.' 
 Occasionally amputation may be demanded, or Syme or Pirogoff's more partial operation. 
 Dislocations of the Astragalus alone are said to be more common than the 
 former accidents. I have seen several such, but I am disposed to think I have mistaken 
 some cases of sub-astragaloid dislocation for dislocation of the astragalus. Pollock believes 
 the pure dislocation of the astragalus to be very rare. 
 
 The bone may be shot out of its socket foricard, backward, and even latcralJi/. and in 
 rarer examples rotated on its axis. 
 
 In the dislocation /b/7carc/ the head of the bone projects from between the malleoli, in 
 some being shot inward so as to form a marked eminence beneath the internal malleolus, 
 in others outward. In such an accident the heel remains in its normal position and all 
 movement of the ankle-joint is lost. 
 
 The dislocation backward, of which Phillips (^Med. Gaz., 183-4) and Turner have cited 
 examples, is indicated by the remarkable projection which suddenly appears above the 
 heel, pressing out the tendo Achillis by the shortening of the foot and the prominence of 
 the tibia in front. 
 
 Dislocation of the astrar/a/us laternd// to be complete must be compound (Fig. 527), 
 and when incomplete at first will probably become complete at a later period through 
 
 sloughing of the soft parts. It is generally, but not 
 Fig. 527. always, complicated with fracture of one or other of 
 
 the malleoli. Boyer has recorded a case of dislocation 
 of the astragalus inward in which no such complica- 
 tion existed, and in Gni/'s Reports for 18G1 (p. 293) 
 I recorded an example of dislocation of the bone out- 
 tvard in a man ast. 51 in which both malleoli were 
 entire ; the astragalus had been fractured and turned 
 completely out of its bed and was found hanging to 
 the wound below the external malleolus. I removed 
 the broken fragments at once and brought the foot 
 Compound Disloc.itioiT^the Astragalus, into a good position ; a complete recovery w^ith a stiflf 
 
 joint ensued. Sixteen years after the accident the 
 man walked about without the aid of a stick and with no other inconvenience than that 
 occasioned by a stiff" joint, which he maintained was a very slight matter. Fig. 528 illus- 
 trates a case of dislocation of the bone outward, complicated with fracture of the fibula. 
 Rotation of the bone often coexists. Mr. Barwell has written (Med.-Chir. Trans., vol. 
 Ixvi.. 1883) an interesting paper upon this subject, and gives a case in which he resected 
 the astragalus with a good result. He tells us '• the bone may be turned either horizon- 
 tally, so that its long axis looks across the joint and at right angles to its normal posi- 
 tion," and this he would call version, "or it may turn over sideway upon its antero- 
 posterior axis, which might be termed torsion." That Mr. Barwell is right there can be 
 no doubt. In 1878 I removed from the inner side of the ankle-joint of a man the 
 
DTSLOCATTOyS OF Till-: I.oWKR F.XTI'J'.M ITIE.S. 
 
 855 
 
 Six 
 -ur- 
 
 l-io. 
 
 nocrosfil upjHT half of the astrii^alus tliat had its articuhir facet lookinj; inward, 
 nidiiths previously lie had received an injury to liis ankle which was rcfrartlcMl hy tin 
 ^leons who treated him as one of i'racture of the le^. 
 
 Tkf:at.mknt. — In simple dislocation of the astrajralus, when the l)OMe 
 can he re|>laced hy manipulatiun, iiothiiiji; more is neetlcd ; hut such a 
 result cannot always he secured. When it cannot, even under chhiro- 
 form. the tendo Achillis should he divided. In 1H(;2 I was called to 
 see a man ;et. liS who had fallen on his feet from a hciirht of four 
 yards, and whose riirht astra<;alus was shot forward completely out of 
 its socket and nearly hurst throuirh the skin. In this ca.se (dilortjform 
 had heen iriven and every kind of manipulation and e.vtension emploved 
 hy competent men to reduce the hone without effect. I divided the 
 tendo Achillis, extended the foot fully, and applied f^entle jiressure to 
 the projecting astragalus, when the bone slipped hack readily into its 
 place. Some crepitus was felt, however, and I believe a horizontal frac- 
 ture of the astragalus coexi.sted. the upper surface and head of the 
 bone having been displaced forward. The foot was fixed in side splints, 
 and a good recovery ensued with a movable joint. 
 
 When the displaced bone cannot be restored to its normal position Djsiwation of the As- 
 directly after the accident, it is now fairly a settled question that it traealus outward, 
 should not be removed till after the tissues have sloughed. 8ir A. Fibula. (Cast lei.j 
 Cooper strongly advocated this practice, and Broca has since supported 
 him. showing by an analysis of cases that in 3G examples of irreducible simple luxation 
 in which the bone was removed at once, one-fourth were fatal, while in A'i in wliich the 
 bone was left alone only '1 deaths took place; in 2 amputation was performed: in IG the 
 bone was removed after sloughing, and all recovered ; in 23 no operation was called for, 
 recovery taking place with a useful limb. 
 
 In all coTupound dislocations of the astragalus the removal of the bone .should always 
 be effected. 
 
 Dislocations of the other tarsal bones have been recorded. Malgaigne 
 relates two cases of (/islorafion of the calcic outward, the bone forming a projection 
 beneath the external malleolus and beyond the cuboid articulation. In 18G5 I saw a 
 case of Mr. Birkett's at Guys in which the left scaphoid hone was displaced inward and 
 formed a very marked projection. It was readily reduced by pressure under chloroform 
 at a moment when the distal end of the foot was drawn outward. I have the notes also 
 of a case of dislocation of the Internal cuneiform bone upward with the metatarsal bone 
 of the great toe in a man a:;t. 24 ; of a second, in a man jet. 80, in wliich the same bones 
 were displaced inward, the accident having been produced by a weight falling on the 
 outer ankle when the foot was resting on the great toe. In both reduction was readily 
 effected with a good result. 
 
 Holthou.se informs us that the internal cuneiform bone may be .separated from all 
 its articulations and thrown upward and inward. The three cuneiform bones are also 
 sometimes luxated together upward, and without much difficulty may be reduced by 
 pressure. 
 
 The scaphoid and cuboid bones may also be displaced. Malgaigne has described this 
 accident as a middle tarsal dislocation ; Liston has described it in his Prartical Snrrjery, 
 and Sir A. Cooper in his work On Dislocations. 
 
 Dislocations of the metatarsal bones may likewise occur. In 1854 I saw a case, 
 recorded by Mr. Cock (Gni/s Rep.. 1855), in which the entire metatarsus appeared to 
 have been .separated from its attachment to the cuneiform and cuboid bones and thrown 
 on the dorsal surface of the instep, where their bases could be seen and felt. The inter- 
 nal cuneiform and navicular bones appeai-ed to have been likewise injured. The injury 
 was the result of a crush from the wheel of a railway wagon. All Mr. Cock's efforts at 
 reduction failed, but a good foot was .secured, and the man subsequently returned to his 
 work as a laborer on the railway. 
 
 In March, 1884, a man jet. 36 came under my care with displacement of the three 
 inner metatarsal bones upward and outward, caused by the passage over the foot of the 
 wheel of a cart loaded with a ton and a half of bricks. Under chloroform and by manip- 
 ulation the bones were readily reduced, and a good result ensued. I suspected at the 
 time there was a fracture of the third bone. 
 
 Dr. Hetzig (Si/dtn. Soc. Bien. Rrp.. 18G5-66). who gives us an analysis of 29 cases 
 of these tarso-metatarsal dislocations, states that 13 were of single bones, 16 of the entire 
 
856 
 
 CONTUSIONS, SPRAINS, AND WOUNDS OF JOINTS 
 
 metatarsus, some of these being lateral and others vertical, as in Cock's case. In the 
 former greater inconvenience follows, from a failure in reduction. 
 
 Dislocations of the phalanges are less common than those of the finger and 
 chiefly occur upward, from direct violence to the ends of the toes, and, as a rule, are com- 
 pound. The great toe is the one usually injured, and, as in the thumb, considerable diffi- 
 culty is at times met with in its reduction, the ligaments and many tendons around the 
 joint aifording an explanation of this fact. Such a case should be treated in the same 
 way as dislocation of the thumb. Reduction must always be effected, when possible, by 
 extension and well-directed pressure ; forced flexion or extension sometimes facilitates the 
 process. 
 
 Congenital Malformations (Dislocation) of Joints. 
 
 It has been the habit of authors to describe cases included under the above heading 
 as examples of didocation, but it is clearly more correct to regard them as malformations, 
 for as met with in the shoulder, clavicle, wrist, and lower jaw they are ahvays associated 
 with a want of development in the bones and paralysis of the muscles of the part. 
 
 In Hip-Joint. — When seen in the hip, there is likewise good reason to believe that 
 congenital deficiencies are also present, as the anatomical facts which bear upon the point 
 support this view ; one such is given by Cruveilhier in the second plate of the second vol- 
 ume of his Pathological Anatomy, where an engraving of a skeleton in which this congen- 
 ital displacement existed shows it to be the result of a want of depth, from incomplete 
 formation, of the acetabulum, and another is furnished by a valuable preparation in the 
 Middlesex Hospital Museum (Prep. 12, Series 3), in which there is practically no acetab- 
 ulum, but a strong capsule and a well-developed head of the femur, without a ligamentum 
 teres. 
 
 Dr. A. G. Drachman (^London Med. Rfc, May 18, 1881) reports a case of a child born 
 of a mother with this deformity, who died on the seventh day, in which the left acetabu- 
 lum was considerably shallower than normal and the ring of cartilage was turned outward 
 at the superior, posterior, and outer part, forming an inclined plane over which the head 
 of the femur glided upward and backward on the ilium. The whole of the left side of the 
 pelvis was atrophied and the atrophy extended to the head of the femur, which, as well as 
 the head of the bone on the right side, was small. 
 
 Mr. Barker pointed out in a discussion at the Roy. Med. and Chir. Soc, November 
 17, 1883, that in the Musee Dupuytren the specimens .showed either absence of the liga- 
 mentum teres or its lengthening to a mere cord two and a half inches long. 
 
 This congenital displacement of the hip is by no means an uncommon affection, and is 
 often mistaken for hip or spinal disease, more particularly when one joint alone is impli- 
 cated. It aff"ects both joints in one-third of all cases, and occurs in female rather than in 
 male children in the proportion of 5 to 1. It is found also in those who are in all other 
 
 respects well in health and perfect in form, 
 
 Fig. 529. 
 
 Fig. 531. 
 
 and, although it has been boldly asserted 
 that " it is beyond doubt that this disloca- 
 tion is produced at birth through downward 
 force applied to the thigh in endeavoring to 
 hasten the birth in breech presentations," no 
 evidence has been published to support the 
 view. On reviewing my own experience I 
 must add that it does not in any Avay en- 
 courage such an opinion, for, whilst in no 
 case have I been able to learn that a breech 
 birth took place, I heard in the majority 
 that a natural birth occurred. 
 
 Symptoms. — The symptoms of the dis- 
 placement are very marked, and in its 
 double form are well shown in the forego- 
 ino- drawino-s, taken from life (Figs. 529, 
 
 Congenital Displace- e.i?,N ,, V, • i • i i 
 
 nient of Head of 530), the most conspicuous being lorclo- 
 Left Femur. gjg ^ peculiar breadth of hips, rounding 
 
 (Posterior view.) „ , K , . r. i i i 
 
 of the buttock, rotation of the whole ex- 
 tremity and foot inward, and slight flexion of the thigh — in fact, the symptoms of dorsal 
 dislocation of the hips. 
 
 Case of Congenital Di.splacement of 
 
 both Femora. 
 
 Anterior view. Side view. 
 
o.\ in.\c'rriu-:s. 
 
 857 
 
 I Ik- 
 
 liiiil) 
 once 
 
 h'V(,-l 
 
 Till- Ii»nl()sis is produced in llicsc cusi^s in tin- saiiio way a.s it is in tln' accidfiitul 
 dorsal dislocatinii or the accniiriMl (iis|ilact'iiiciit i\\' tlu; licad of tlii; fi;iiiur in hip disease, 
 and i-an 1)0 ofiact'd by cK-vatinn u\' tln' liiiil> uilli liir patient in tiie linrizuntal pdsitiun, as 
 in tliose cases ( Fij^s. (i(»!», (ill). 
 
 'Pile nniveinents of the joint are L'nod. at tinio peileit. and <rive rise to no pain, 
 head oi' the femur also rotates smoothly on the ilium. 
 
 When one joint <»nly is attected (Fig. Tiin), there will he shortcniiirr of tin- 
 tor alxiiit an iindi. and on coinjtarinj; the affected with the sound side it will he at 
 seen that ilii> >lii(rleiiinu is in tlu; tlii>rh and that the troclianter is drawn up to the 
 of tin' anterior superior spine of the ilium. 
 
 The walk of a patient witli a douhh; disjtlacenient is verv curious ; it is a kind of 
 ''roll." not unlike that of a woman who has some loosening of her sacro-iliac joints or 
 very liroad lii|)s, when going up stairs, wliile a ])atient with a single affected joint limps 
 and has an awkward gait wlii(di has often led parents ami others to susjtect hip or spinal 
 tlisease, more particularly when hy overuse of the malformed joint jtairis are exciteil. 
 C)ccasionally the muscles of the affectt'd limh or liinhs are weak, hut this is nn-t with only 
 in exce])ti<inal cases. 
 
 Tkkat.mk.n't. — Xothing can he recommended witli the view of cure, for art cannot 
 supply a natural deticiency or make up for a defect of structure in the bones of the joint. 
 Still, surgery can do much toward the prevention of additional trouble by exercising the 
 muscles of the limb and body without fatiguing them, forbidding excessive standing or 
 walking during the years of growth, and attending to the general health. 
 
 ^Mechanical ap])liances are to be condemned as useless, if not worse. They have been 
 employed on a wrong ))riuciple — or, rather, on a want of due appreciation of the conditions 
 of parts — and therefore with only a vague hope that they may do good. These observa- 
 tions ajiply as much to the use of an extension apparatus as to operative interference, 
 although with more force to the latter. 
 
 CHAPTER XXXI. 
 
 ox FRACTURES. 
 
 When a bone is broken, it is said to be fractured ; when the skin and soft parts cov- 
 ering in the broken bone are whole, the fracture is iiimple or subcutaneous ; when a 
 •wound exists commmu'cating icith the broken bone, whether the wound be caused directly 
 
 Fig. 532. 
 
 DeiitatL'il or CoiuiniiiuttMl. Oblique and Multiple. 
 
 Coinplete I'lactiires. (Prep. Guy's Hosp. Mus.) 
 
 by the same force that produced the fracture or indirectly by the bone perforating the 
 skin, the fracture is compound. A simple or compound fracture is said to be complete 
 when the solution of continuity is complete ; incomplete, when the bone is only cracked, 
 
858 
 
 ON FRACTURES. 
 
 fissured, or heiit, as in green-stick fracture, where the bone is spliiitered on its convex sur- 
 face, and not on its concave ; sjiliiiiered, when only a portion of the bone is cut off, either 
 by a sabre wound, in machinery, or by some local injury chippinj;- off the edge of a bone ; 
 fissur&d, when the line of fracture extends partially or wholly through the bone and no 
 separation of the fragments exists ; impacted, when one end of the broken bone is driven 
 into and fixed in the other. A bone may also he perforated by a gunshot or punctured 
 wound. 
 
 A complete fracture may be transverse, oblique, longitudinal, spiral, dentate, or 
 comminuted ; multiple of the same bones or of contiguous bones, of separate or distinct 
 bones {vide Fig. 532). All fractures may likewise be complicated with other injuries, 
 those into joints being the most important. Fractures and separations of epiphyses are 
 also intimately connected, but fractures may occur at any age, while separation of the 
 epiphyses is rarely found in subjects above twenty-one. 
 
 A fracture may be met with at every period of life ; indeed, it may occur in ntero from 
 some external violence ; and, when the accident has taken place some time antecedent to 
 
 birth, repair may have gone on to completion, al- 
 though in most cases Avith deformity, the vis medi- 
 catrix natnrse being, as Billroth well observes, a bet- 
 ter physician than surgeon. I have seen this in an 
 infant who was born with a humerus bent at right 
 angles, evidently from a repaired intra-uterine frac- 
 ture. During the delivery of a foetus, by turning 
 Incomplete Fraet^urej^f^^the Oavicle. (From t],^ g,,.^ft of a" femur, tibia, or fibula may be 'displaced 
 
 from one or both of its epiphyses. By liyperabduc- 
 tion of the femur the upper epiphysis of the bone is likely to suffer, and by traction on 
 the foot those of the lower end of the tibia and fibula (Dr. Alexander Simpson, Edinh. 
 Med. Journal, June, 1880 ; M. Delore, Diet. Encycloped. des Sciences 3IediraJes, iv. 201, 
 1879). The fractures of infancy are comparatively rare and are commonly incomplete, 
 or " green-stick." Fig. 533 illustrates this in the clavicle and Fig. 534 in the parietal 
 bone. The latter was taken from a child aet. 8 months who was thrown out of a peram- 
 bulator on the pavement. No symptoms of brain disturbance followed the accident at 
 any time. The drawing was taken on the second day following the accident. The case 
 
 Fig. 533. 
 
 Fig. 534. 
 
 Fig. 535. 
 
 yy 
 
 
 M 
 
 Incomplete Iraeture of the Parietal Bone of Infant. 
 
 Impacted I latliire of the Neck of the 
 Thigh-Hone. (Taken from a man jet. 
 G4, who recovered from the accident.) 
 
 occurred in the practice of Mr. Harris of South Hackney. In some such eases as these 
 the depression in the bone may, as time passes, be gradually pressed out, but in others it 
 is permanent. 
 
 Fractures in the adult are mostly complete, though an incomplete fracture may occur. 
 Impacted fractures (Fig. 535) are chiefly found in the aged, the bones at this period 
 of life being more brittle than they are in younger subjects. They are commoifh^ met 
 with in the neck of the femur and the lower end of the radius, although they occur in 
 the neck of the humerus and other parts. Thus, in Fig. 578 is illustrated an impacted 
 fracture of the shaft of the femur. Many comminuted fractures are doubtless due to 
 
CAUSES OF IRArrrRKS. 859 
 
 impaction of one frafjjniont of lume into the (itlicr. and t<i the subsequent splitting of the 
 latter. 
 
 Men are more exposed to fractures than women, on aeeount of thi-ir more eonstant lia- 
 liililvto injury, ami those hones suftt'r the most that are the m<ist exposed to external 
 vioh-nci- ; henee tlie fre((ueney of fracture of the lower extremities. 
 
 Hones in .scune suhjeets are very hrittle aiul break from slijrhi causes ; frnijUltus ossinm 
 is then said to exist. This condition miiy be hereditary. These btjiies, however, as a 
 rule, unite rapidly. In Auj;ust, ISrtli, I .saw a case of fracture of the neck of the thifrh- 
 bone which took place wlien a woman Jct. 83 was slowly walkin}^ from her bed to a chair. 
 
 Diseased bones are always predisposed to fracture from sli<rht causes, more particu- 
 larly the rickety and cancerous, aiul likewise bones that are weakened by the presence of 
 tumors or some svphilitic or other inflammatory affection. 
 
 In diseased or brittle bones muscular action may be enoufrh to cause fracture. Thus, 
 I have known a thiuh to be fractured in turninir in bed, in an epileptic attack, and in 
 swinging it over the side of a cart ; the humerus in the act of embracing a wife, an<l in a 
 man Jct. 2(! from throwing a stone; the clavicle, from lifting a heavy weight; the ribs, in 
 coughing; the radius, from wringing clothes; and every surgeon knows how fre<juently 
 the patella, and more rarely tlie olecranon, are broken from muscular spasm. Mr. Parker 
 records {Xew York Joiini. i>f Med., July, 1S52,) a case in whicli a dentist aet. 38 broke 
 his humerus while drawing a tooth. Mr. J. Anningson of Burnley has recorded a case 
 of a woman xt. A'l in which the upper three-fourths of the tubero.sity of the calcis was 
 fractured and displaced upward by niu.seular action (Brit. Med. Jo>trn., January 20, 1878). 
 Mr. Ball likewise records a similar case (Dublin Path. Societi/^ November, 1880). 
 
 Patients with disease of the nerve centres are very prone to suffer from fracture. 
 Davey in 1842 noted the fact that lunatics often so suffered, and the frequency of broken 
 ribs from slight causes in lunatic subjects can be explained by this liability. Weir Mitch- 
 ell in 1873 (American Journ. of Med. Science^ July) first called attention to the connec- 
 tion between fracture and locomotor ataxy and suggested impairment of nutrition as the 
 cause. Later on Charcot emphasized the fact, and at the same time noticed how rapidly 
 repair took place in the broken bones. 
 
 '' From a review of the observations made on the bones of two insane patients." writes 
 Dr. Omerod (.SV. Bart. Hasp. Rep.. 1870), "it may fairly be inferred that the brittleness 
 of the ribs depended on a morbid condition of the bones, and that this condition was 
 general, affecting different parts of the osseous system eoincidentally, though more marked 
 in the ribs than in some other more compact bones. The process was essentialU" one of 
 absorption of the internal structure of the bone, the osseous tissue being replaced by an 
 excessive deposit of the fatty matters normally existing in its interior. Thus the usually 
 invisible membrane lining the Haversian canals, and forming the coats of the vessels 
 lying there, was thickened into a membrane of cognizable structure and dimensions. The 
 space for this thickening was obtained by removal of the innermost concentric laminae, 
 and from this point a change was propagated which resulted in or tended to the removal 
 of each entire Haversian system. In the whole bone there was a loosening of the mutual 
 connection of the laminiv and an obscure disintegration of the osseous structure it.self, 
 and a general infiltration of oily matter into the substance which had intruded itself 
 within the Haversian canals, and into whatever part of the compact structure of a bone 
 could find room for it." 
 
 In confirmation of these views I may mention that I attended, with the late Dr. 
 Black of Canonbury, a middle-aged lady the subject of dementia and epilepsy who in 
 nine or ten fits, none of them having been violent, broke a bone, and on several occasions 
 two. The fractures took place by mere muscular action when the patient was in bed, and 
 rej)aired well — indeed, as well a.* if the subject of them had been quite healthy. 
 
 The immediate cause of fracture is usually some direct violence applied to 
 the part, or it may be indirect, the bone, under some bending force, giving way at its 
 weakest point — '' in the line of e.rte)t.'<i()n, not that of eanipresiiion " (Teevan). 
 
 Indirect fractures are. as a rule, of the simplest kind, unless complicated with 
 joint dislocation ; when compound, the soft parts are mostly injured by the protrusion of 
 the fractured bone. 
 
 Fractures the result of direct violence are always the most severe, the same vio- 
 lence that breaks the bone injuring the soft parts over it, and often Assuring and com- 
 minuting it. 
 
 The mode of production of a fracture is, consequently, a point of great practical 
 importance, alike for diagnosis, for prognosis, and for treatment. 
 
860 OX FRACTURES. 
 
 Symptoms. — The diagnosis of a fracture is usually easy, though in exceptional cases 
 it is difficult, if not impossible. It is easy when, after a blow or fall attended by the 
 sensation of something giving way, deformity is found, with inahiliti/ to move the limh, 
 and on manipulation abnormal mohUity of the injured limb exists, with crepifjis from the 
 rubbing of the broken fragments together ; when jx///i attends any attempt at movement 
 and siceUing rapidly follows the accident ; and when shortening exists, which is remedied 
 bv extension. 
 
 The diagnosis is difficult when, as in impacted fracture-^, abnormal mobility and crepi- 
 tus are absent and only slight but fixed deformity exists, when local pain and shortening 
 are the only symptom.s. and when the nature of the accident is the only guide ; when a 
 transverse fracture of such a bone as the tibia exists without displacement and with no 
 fracture of the fibula ; when the fracture is into or in the neighborhood of a joint 
 and there is much swelling of the injured part; and when a fracture and a dislocation 
 coexist. 
 
 It is always difficult, and at times impossible, to make out a simple fissure of a bone, 
 cranial or otherwise, and the same may be said of a fracture of the pelvis or thorax ; 
 such injuries as these can be made out only by the natural symptoms of fracture, as they 
 are called, and by such as are referred to the contents of the cranial, thoracic, or pelvic 
 
 cavities. 
 
 When a bone is broken near a joint and effusinn into it follows the injury, the sur- 
 geon should suspect the presence of a fissure of the bone into the articulation ; and when 
 a V-shaped fracture of the lower third of the tibia is present, the V occupying the internal 
 or suhcutaneovs mrfuce of the bone, and not the crest {vide Fig. 594). this complication 
 is to be looked for. 
 
 It is sometimes difficult to diagnose a fracture from a separated epiphysis. 
 
 When a fracture is transven^e (Fig. 532. A), there may be no or only some slight lat- 
 eral displacement ; when oblique (Fig. 532. D), there will probably be some shortening of 
 the limb, from the drawing up of the lower portion of the limb, or riding, as it is called, 
 of one end over the other. At times there will be rotation of the limb, and in com- 
 minuted fractures separation of the ends of the bone (Fig. 532. C). The.se points will 
 be greatly determined by the character of the fracture, the bone that is involved, and the 
 amount of muscular action that influences the fracture. 
 
 In parallel and conjoined bones of which only one is broken the deformity that exists 
 is likely to be less marked than where a single 'bone is broken, for under these circum- 
 stances' the non-fractured bone tends to neutralize the action of the muscles through 
 which deformity or contraction usually takes place. Muscular action is undoubtedly the 
 main cause of "deformitv. tonic action of the muscles existing under all circumstances, 
 and spasmodic action when the muscles are irritated by fragments and attempts at 
 reduction. 
 
 Muscular spasm being the main cause of deformity and shortening of the limb after 
 fracture, it becomes an important point to recollect in treatment that the peculiar deformity 
 associated with any .special form of fracture can be obviated by neutralizing the action of 
 the muscles that produce it. Thus, in fractures of the humerus above the insertion of 
 the deltoid, the action of the latter muscle will be to draw the lower fragment up and 
 outward, while the pectoral muscle has a direct influence in drawing in the upper frag- 
 ment. In fractures of the humerus heloic the insertion of the deltoid the tendency of 
 this muscle will be to draw the upper fragment outward, and the brachialis anticus has 
 an equally powerful tendency to draw the lower half forward. In fractures of the thigh- 
 bone below the minor trochanter, the psoas and iliacus muscles naturally draw the upper 
 fragment forward and rotate it outward, and in fracture of the condyles the gastrocnemii 
 have a powerful tendency to draw the lower end backward. 
 
 When a bone is fissured, and not displaced, the periosteum not being divided, there 
 will be but little displacement : in children this condition is often found. 
 
 Crepitus, or the grating sensation caused by the rubbing of the ends of the broken 
 bones together, is a most valuable sign of fracture, and when detected during the exam- 
 ination of a limb supposed to be fractured the diagnosis is made clear ; but when other 
 symptoms of fracture sufficient for a diagnosis are present, it need not be looked for. In 
 impacted fractures, as of the hip. it can be felt only on loosening the impacted fragments, 
 and consequentlv by doing irremediable harm ; this error is serious and should be avoided. 
 In incomplete fractures crepitus is also absent. In fact, every fracture or suspected frac- 
 ture should be manipulated with the utmost gentleness, in order that as little displace- 
 ment and local injury may be inflicted as possible, for the bulk of fractures can be made 
 
COMPOUND FRACTURES. 8(51 
 
 out with I'lTtiiiiity without crejiitus. As a syiuptKin. however, it is always of f:reut 
 value. 
 
 The erepitus of eft'usidii or of tin- thcc;e of tt-ndoiis must not he niistiikeii for that of 
 a hrokeu hone. It is a soft ert-jiitus rather than a hanl ouf. as in hone. liursal crepitu- 
 tion is jiartieularly liable to mislead. 
 
 When some swellintr follows immediately upon the aeeident, it means ruptured hlood 
 vessels, arterial or venous. When it oeeurs within a few hours, it is due t<i inflammatory 
 eflusion. 
 
 In all eases of supposed displacement the normal condition of the limb must he inijuired 
 into and the sound eompan-d with the affeeted, for in more cases than one I have known 
 a natural or old accjuired deformity in a liml> mistaken for one cau.sed by an accident, and 
 attempts have been made to restore — or, rather, to reduce — the parts to their supposed 
 normal condition. 
 
 pRtxJNosis. — Simple fractures, as a rule, do well. At Guy's, in six years, out of 469 
 cases of sim]>le fracture of the thigh, 17 died, or 8.5 per cent. ; of 888 examples of simple 
 fracture of the leg. 8 died, or not 1 per cent. ; of 123 cases of fractured patella, there was 
 no death. 
 
 The .same statistics inform us that one-tenth of all cases of fracture of the thigh are 
 com|Miiiiiil. as are also oiic-tiftli of all fractures of the leg. 
 
 Compound fractures are always serious accidents, those of the ujiper extremity 
 being less fatal than those of the leg. and these less so than those of the femur. Thus, 
 at (.iuys, in six years, out of iH cases of compound fractures of the arm and fore-arm, 16, 
 or 17 per cent., died, or 1 in 6 cases; out of 202 cases of compound fracture of the leg, 
 56, or 27.7 per cent., died, or 1 in 4 cases ; and out of 52 cases of compound fracture of 
 the thigh, 19, or 86.5 per cent., died, or 1 in 3, the mortality increasing by 10 per cent, 
 in each group. These statistics, however, but roughly indicate the risks of the different 
 accidents, as they include smashes of limbs with the compound fractures. 
 
 As a cause of death after fracture of the long bones Professor Czerny of Freiburg has 
 proved in an able paper (^BerUner Klinische Woc/ienschriff, Nos. 44 and 45) that " fat embo- 
 lism" is to be taken into account, the fluid fat of the bones being taken up by the veins 
 and carried to the central organs* — brain, lungs, and kidneys, etc. — and thus causing death. 
 This result, he states, is a common cause of death when a bone is much fissured and the 
 cancellous tissue laid open, as in the V-shaped fracture of the tibia, and more particularly 
 when this is compound. He does not inform us how this accident can be avoided. 
 
 Treatment. — The principles of the treatment of fractures are very .simple, though 
 the practice is often very difficult. To restore a bone to its normal position and to keep 
 it there by means of surgical appliances, or, as John Hunter expressed it in 1787, "to 
 place the parts in a proper position by art — that is, as near their natural position as possi- 
 ble — and to keep them so. ' are simple rules to be observed, but to carry them out often 
 demands the highest surgical skill and ingenuity ; and yet the whole treatment of frac- 
 tures is really comprised in these two indications. 
 
 In examining a fracture the greatest care is requisite, and only sufficient manipulation 
 should be allowed to ascertain the seat of the fracture, the li/ie of its direction, and the 
 tendency a fragment may have to ride in any direction, this special tendency being the 
 one point to be remembered in the treatment. These points, moreover, should be made 
 out at the single examination prior to treatment, for repeated examinations, Avhether liy 
 the responsible surgeon or by his assistants, are to be condemned, as they can only do 
 mischief by exciting more local irritation than is necessary and adding to the injury 
 which the muscles and soft parts have already sustained. For this reason when, after an 
 accident, a fracture is suspected to have taken place, the surgeon or bystanders should do 
 no more than bind the limb to some immovable apparatus, such as a wisp of straw, a 
 bundle of sticks, or two pieces of wood fixed by a handkerchief, till the sufferer has been 
 carried home and placed in the position in which he is to be treated. When the lower 
 extremity is the affected part, the injured limb may be bound to the sound one. the latter 
 acting as a splint. 
 
 In compound fracture the same precautions are necessary. Bleeding should be 
 arrested by the application over the wound of a pad or bandage kept in position by means 
 of pressure and the elevation of the limb, while in more severe cases the tourniquet or 
 some local pressure over the main artery may be called for. 
 
 If these precautions are not observed on the field, many lives may be lost from 
 hemorrhage, simple fractures may be turned into compound, while compound fractures 
 may be made worse. 
 
862 ON FRACTURES. 
 
 When a patient is placed in bed where he is to be treated, the fracture ought to be 
 manipulated and its position, nature, and peculiar tendency made out, and when made out 
 to be " set,' or put up, at once. The only exception to this rule is when time has been 
 allowed to pass before treatment is commenced and much oedema or swelling of the 
 injured extremity exists, then it is better to fix the injured limb raised upon a pillow, with 
 a long sand bag on either side, to act as a splint, and possibly a third round the foot, the 
 pillow and Side sand bags being firmly bound together by a strip of bandage and the 
 whole forming an immovable apparatus, Mr. Aston Key, indeed, was so fond of this 
 mode of putting up fracture of the leg that in my." dresser" days it was the usual mode 
 of treating them all through their course — that is, for the first month or five weeks, till 
 they could be put up in some starch or other immovable apparatus and the patient 
 allowed to get up. The method is comfortable and satisfactory to the patient, but it 
 wants closer attention on the part of the surgeon than can often be given. 
 
 In " setting " a fracture some care is needed, and the opposite and corresponding limb 
 should always be before the surgeon as a guide. Inquiries should also be made as to the 
 condition of the limb before the accident — whether it was deformed or shortened from 
 any previous fracture or disease, congenital or otherwise ; for I have known an injured 
 leg to have been likewise violently and unnecessarily manipulated to restore a supposed 
 fractured bone to a position that it could not be made to assume on account of some natu- 
 ral deformity, and likewise a fractured thigh subjected to like rough treatment to bring 
 it down to the level of its fellow, when an irremediable shortening existed from a former 
 fracture. 
 
 In extending a broken limb to restore the bones to their normal position, the upper 
 portion should be firmly held by an assistant to make counter-extension, and the muscles 
 attached to it relaxed by placing the limb in a slightly flexed position ; a second assistant 
 or the surgeon may then extend the fractured end, while the latter gently manipulates 
 the fracture, to make out its points. The extension should be steady and free from all 
 jerks and violent movements, gentle lateral, rotatory, or other movements being given as 
 required to restore the' displaced portion of bone, the pressure of the thumb or finger 
 being freely used to bring about an accurate coaptation or setting of the fragments ; for 
 the surgeon must remember that muscular contraction is better overcome by continued 
 extension than by temporary force, and that for the treatment of fractures generally mode- 
 rate extension continuously applied is preferable to forcible extension in any of its 
 forms. The inhalation of chloroform at times is a valuable aid in the reduction of a 
 fracture. * 
 
 If, when the fractured bones have been reduced, muscular spasm is so severe as to 
 render it impassible to keep them in situ — a condition which is not uncommon in fracture 
 of the leg — the tendon of the ofl^ending muscle may be divided. In otherwise intractable 
 fracture of the leg there is no operation of greater value and attended with less evil than 
 the division of the tendo Achillis. In a general way, however, the muscular spasm ceases 
 after the first three or four days. 
 
 When the fracture has been reduced and by manipulation coaptated or " set," splints 
 or other mechanical appliances are necessary to keep the bones in their normal position ; 
 and the simpler these appliances are, the better, so long as they fulfil their purpose. 
 These splints should always be well padded, and the pads so adju.sted as to fit into the 
 iaequalities of the limb and protect it from any local pressure. They should be firmly 
 and immovably fixed to the. limb by inelastic straps or bandages, and the seat of fracture, 
 as a rule, should be left exposed for the surgeon's examination, in order that the fracture 
 may be readjusted if displacement take place. To cover up a broken bone by bandages 
 or splints is a mistake. The position of the bone during the progress of repair should 
 always be open to view, the former practice being based on hope, the latter on certainty. 
 Pott's rule, that the splints should include the joint above as well as below the fracture, 
 is sound, though it cannot always be followed. Every joint, however, should be fixed 
 when by its action the broken bone is rendered movable. 
 
 When one bone is broken in a limb where double bones exist, the second acts as a 
 splint and keeps up extension. Under these circumstances a simpler apparatus is 
 required to keep the fractured bone quiet and restrain the action of the muscles that 
 move it than under other circumstances. 
 
 Extension is a valuable and necessary adjunct to other treatment, and should be kept 
 up by means of weights, pulleys, or such other appliances as the ingenuity of the sur- 
 geon may suggest. These means however, will be described in the treatment of special 
 fractures. 
 
TRKATMEyr OF Fli.K'TriiFS. 863 
 
 After the settinj? of the fracture, the CHseiituiI jMiint to be observed in its treatment 
 is thi' iuiuiobility of tlie brolieii bone; and next to this, its exposure U> observation dur- 
 ing; the prof^ress of repair to render certain that the ))one has maintained its right posi- 
 tion. 
 
 TliKATMKNT oK Cdmi^mmi FKACTriiES. — The tftat MU'iit of Compound, is similar to 
 that of sim|)le IVactures. ji/ns the treatment of the woujid with its complications ainl the 
 broken frairmeiits or jjrojectini; jiortions of bone, " but rixt of the bone is tlie great object 
 we have to aim at" (.John Hunter, 1787). 
 
 These fractures shnuM be ''set" in the .same way as the simple, great care bein<; 
 observed in the manipulation that tlie s(»ft |)arts are not more injured; lottse fragments of 
 broken bone must l)e taken away. ])rojectiiig porti<jns excised, and the Itone reduced, the 
 wound being enlarged when necessary to facilitate this act ; the injured parts, too, ought 
 to be thontughly cleansed and all wounded vessels twisted or ligatured ; the bones should 
 then be fixed immovably by means of splints, interrupted s]»lints often being rerjuired. 
 J When the wound is not very extensive, it should be .sealed by means of a piece of lint 
 saturated with blood, or, what is better, with the compound tincture of benzoin. If the 
 carbolic acid dressing is employed, the wound should be well washed with a weak solution 
 of one part in a hundred and dressed under the spray. The wound should be interfered 
 with as little as possible, since now, as when the following words were uttered. '■ the 
 great mischief and bad success arising in the treatment of compound fractures is the 
 dressing them every day and applying fresh poultices, which neces.sarily move the end.s 
 of the bones. The lioib, if possih/e, should iieirr be moved " (John Hunter. M.S. lect., 1787). 
 
 When the soft parts are much crushed and the large vessels and nerves injured, 
 amputation may be called for, more particularly in old subjects. 
 
 In compound fractures '' scarcely any amounnt or form of fractured bone alone," 
 writes Skey {Operative Snrtj.), " would justify the immediate resort to the knife if taken 
 singly, even supposing the bone fractured extensively into a large joint; for in such a 
 case, although anchylosis of the joint would probably occur, it would prove a lesser evil 
 than that of amputation. Superadded to a compound or comminuted fracture of bone, 
 the injury may be rendered yet more serious by extensive laceration of the muscles. In 
 considering this latter condition much will depend on the kind of laceration — whether the 
 muscles are merely cut asunder or whether contused or torn, and whether this injury 
 involves a few only or the majority of the muscles of the limb. Again, we must exam- 
 ine with great care the condition of the vessels. Is the main trunk whole ? we nnght 
 ask in the supposed case of fracture of the thigh, or in that of the leg. Is the posterior 
 tibial artery torn ? Is the limb colder than its fellow, or is the temperature considerably 
 lower than the rest of the body ? If .so, probably one or more arteries are divided. 
 What is the condition of the nerves? Does sensibility extend to the toes? If not, pro- 
 bably the nerve is divided also. If the evidence of the integrity of both artery and nerve 
 fail and the sinking temperature of the limb and the loss of sensibility continue to 
 increase, we have no alternative but amputation." 
 
 If a doubt exist in the mind of the surgeon as to the necessity of immediate amputation, 
 he should wait, unles,- the patient bo old, in which ease let him act promptly. 
 
 Simple fractures into joints require special treatment, as in a large number of 
 cases, although not in all, some impaired mobility of the joint will ensue ; for this reason 
 the joint itself should be placed at the most useful angle and so fixed. 
 
 Compound fractures into joints generally demand excision or amputation. In 
 the iipj» r extreniity. when there is any hiijie of saving the limb, excision is doubtless the 
 better operation. In the loicer the expectant treatment is certainly better than excision, 
 and probably better than amputation if the parts are not so injured as to render ampu- 
 tation at once a neces.sity, and if the age and general condition of the patient justify an 
 attempt to save the limb ; but the.se points will again have to be considered among the 
 special fractures. In gunshot wounds these views are now generally entertained. 
 
 The Fracture Bed. — The best is. without doubt, a good horsehair mattress placed 
 on a bedstead with a firm bottom ; buf where this does not exist, a board beneath the 
 mattress is a good substitute. A canvas bottom, however tightly corded, always yields, 
 and a feather or ordinary spring bed is not to be sanctioned. The woven wire mattress 
 is excellent. 
 
 The sheet covering the bed should be stretched and kept smooth several times daily, 
 so that no '• ruck " takes place, bedsores being more frequently caused by such than by 
 pressure. In fracture of the lower extremity the head of the patient should not be raised 
 too high, the use of one small pillow being ample. 
 
864 ON FRACTURES. 
 
 Splints made of wood, iron, felt, or perforated zinc may be employed, and the differ- 
 ent forms will be given when the special fractures are considered. As a rule, the simpler 
 in construction they are. the better ; and before adapting one to the broken limb it is well 
 to fit it to the sound. The splints should invariably be quite clean. 
 
 Pads. — All splints should be well padded and their edges carefully protected. The 
 pads should consequently be well fitted, broad, and overlapping the sides. The best 
 materials for these are tow or fine oakum, cotton or sheep's wool, or strips of thick flannel 
 enclosed in a casing of soft linen or lint. The pads should be first fixed to the splint by 
 tapes, or, what is better, by some pieces of strapping. 
 
 Besides wooden and iron splints, the "immovable apparatus" for fractures is a very 
 favorite one, and the material employed may be left to the fancy or convenience of the 
 surgeon. 
 
 In fractures of such single bones as the fibula or tibia, where no displacement exists, 
 their primary treatment by some immovable apparatus is very valuable, the limb being 
 either put up at once before swelling has appeared or as .soon as the swelling, etc.. has 
 sub.sided. In other cases it is inexpedient to employ it for at least ten or fourteen days, 
 until swelling has gone and a certain amount of repair taken place. In the fracture of 
 long bones, such as the femur, it is better to postpone its application until union is com- 
 plete. Some excellent surgeons — and among them Erichsen — employ the immovable 
 apparatus from the very first. The mode of its application is as follows: In all cases the 
 limb should be cleansed and carefully dried, the bone itself being well protected by cot- 
 ton-wool or a flannel bandage. The bandage, with the stiffening material, is then to be 
 prepared, and should be put on as smoothly as possible, no more " turns" being employed 
 than are absolutely necessar}'. 
 
 Splints of gutta-percha, millboard, leather, Cooking's poroplastic or hatter's felt, or 
 perforated zinc may be employed as additional supports when complete immobility is 
 demanded. The first five materials, after having been cut to pattern, should beforehand 
 be well softened by immersion in hot water or hot air and then moulded to the limb ; the 
 zinc should be carefully cut to fit it and well adjusted. These splints should be applied 
 over the cotton-wool or flannel bandage, and the prepared bandage then bound round. 
 When starch is used (Seutin's bandage), it should be exterior, two or three coats being 
 employed. The same may be said when the icJu'te of e<ig ov dextrine is employed. When 
 ffum and cliaJk are used, the same mode ought to be followed, the mixtVire consisting of 
 equal parts of finely-powdered gum and chalk made into the consistence of thick paste by 
 the addition of boiling water gradually stirred into it. This bandage is more solid than 
 the starch. 
 
 Mr. de Morgan prefers the glue bandage^ the best French glue, after having been 
 soaked in cold water and melted in a glue-pot, being applied like the starch ; the addition 
 of about one-fifth of methylated spirit to the solution of glue hastens the drying. 
 
 When plaster of Paris is employed, the bandage should be of some loose texture, and 
 that made of book muslin or crinoline is probably the best. It should be prepared be- 
 forehand by well rubbing fresh dry powder into its texture, and should be made ready 
 for use by being thoroughly wetted in a bowl of water for two or three minutes, some 
 additional plaster being rubbed with water into the bandage as it is unrolled, to strengthen 
 the whole. 
 
 When the surface is extensive, the setting of the plaster may be delayed by the addi- 
 tion of a little size or stale beer to the water with which it is mixed, while salt and the 
 use of warm water increase the rapidity with which the plaster sets. 
 
 The day following the application of this bandage a coating of flour paste, gum, or 
 even a coating of varnish, may be applied, to prevent chipping. 
 
 In the appendix to the Army Medical Report for 1869, Mr. Moffitt describes the 
 Bavarian mode of putting up a fracture in an immovable apparatus — a mode which 
 deserves to be more widely known than it is. I have tested it well, employing gum and 
 chalk instead of plaster of Paris, and can strongly recommend it ; being simple, it can be 
 applied very quickly, and is most effective. It is now in general use at Guy's, and is 
 applied as follows : The materials required to make it are a piece of stout, coarse " house- 
 flannel " which has been shrunk, some precipitated chalk, mucilage of gum acacia, a good- 
 sized cradle, and a stout needle and thread. When it is applied to the leg for fracture, 
 two equal-sized pieces of the flannel are first cut, long enough to reach from the lower 
 border of the patella to three inches below the heel, and in breadth about six inches 
 more than the circumference of the calf, so as to allow the edges to overlap for about 
 three inches when the flannel is folded round the leg. One of these pieces should now 
 
TUKATMI'yr OF FRACTURKS. 
 
 865 
 
 Bavarian, or Iniinovable. Splint. 
 
 a, First layer of llaiiiii-l, a|i|>lii-(l to liinli. fj, Second layer, 
 atiout to be applif'l. 
 
 lie ;i]iiilii'il to flic \o'^, its centru corrL'siMHnliiif^ with the ctMitro of tin; fall", and its two 
 
 flaps linnit;ht ti<,^htly toirctliiT over tlu; Hkiii ( Ki^. 5!{(i), where they shouhi be liniily 
 
 stitched toirether, the stitches lieiiij:; inserted 
 
 eluse ti» the hone. The stitches must he 
 
 hct;iin at the u])|»er ]>:irt, carried <h)wn to 
 
 the hollow of the instep, and then fastened 
 
 ort". Ilavinj; arrived at this point, the ne.\t 
 
 thinjr is to see that the fi»ot is at a riuht 
 
 anirle with the lei:;; if left alone, it will 
 
 jirohahly he at a very ohtu.se anji^le, and 
 
 eonsiderahle force is sometimes neees.sary 
 
 to bring tlie toes up, whieli must be done 
 
 jiow or not at all. The stitching must ne.xt 
 
 be begun on the sole of the foot, commencing 
 
 at the toes and ])roceeding toward the heel, 
 
 the flannel being tightly dragged downward. 
 
 The stitching along the sole of the foot being eomjdeted, the remaining piece along 
 tlie dorsum of the foot may next be stitched, and after this there can be no fear of the 
 foot changing its position. 
 
 The limb will now be tightly encased in a layer of flannel the edges of which are 
 Iving in adaptation in front of the leg. The flannel along the sole of the foot to within 
 an inch of the stitches should next be cut off and the edges turned l)ack. At present 
 the superfluous flannel along the front of the leg and dorsum of the foot should not be 
 interfered with, but the limb slung up to the cradle by three or four pieces of bandage 
 pinned or stitched to the adapted edges of flannel in front of the leg (Fig. 530). Thi.s 
 will have the effect of stretching the flannel and making it more closelj' adapt itself to 
 the shape of the calf, ankle-joint, etc., and allow the gum and chalk to be easily applied. 
 The ne.xt thing is to make a thick paste of the gum and chalk, the consistence of honey, 
 by stirring them together in a basin, which should be spread thickly over the surface of 
 the flannel with a brush or rubbed in with the palm of the hand, care being taken that 
 it enter all the little inecjualities of the flannel. Having done this, apply the outer layer 
 of flannel, placing it just as the first was placed, with its centre corresponding with the 
 median line of the calf, folding its edges closely around the leg and bringing them up 
 together in front over the edges of the previous layer. Keep them also in position in 
 front by about half a dozen stitches, put through at intervals down the leg close to the 
 shin. Along the sole of the foot this layer of flannel may at once be neatly finished ofi" 
 by turning in the edges and joining by stitches. The whole should now be left suspended 
 to the cradle for about twenty-four hours to dry. at the end of which time it may be taken 
 down and the splint removed from the leg by cutting up the stitches along the front of 
 the leg and dorsum of the foot with a pair of scissors, aided by forcibly separating the 
 adjacent edges of flannel. 
 
 It now only remains to trim up the splint by cutting off the superfluous edges, bind- 
 ing them with strips of leather made adhesive by being spread with resin plaster, and 
 inserting evelet-holes at equal distances all down, so as to lace the splint up the front 
 (Fig. 530, A). 
 
 If the splint is required for a hiee-joint. some modification of the above plan is neces- 
 sary. It will not do to suspend the limb to a cradle by the edges of the flannel, as in 
 the previous case, but the patient should be seated in a chair before a fire with the heel 
 resting on another chair. Then the fir-st layer of flannel should be tightly applied, its 
 edges being brought up together in front and stitches inserted close to the leg. The 
 gum-and-chalk paste may now be thickly spread over the surface of this flannel and 
 covered in by a second layer of flannel, exactly as in the previous case. This .second 
 layer may be fastened in front by a few stitches and the whole allowed to dry. When 
 quite dry, the adjacent edges of flannel may be forcibly separated and the stitches divided 
 with scissors. Lastly, the superfluous edges may be cut off", two semilunar pieces cut 
 out for the patella, the margins bound with leather, and eyelet-holes inserted for lacing 
 up in front. To apply the splint to the hip-joint it is necessary that the first layer of 
 flannel should surround the pelvis as high as the crests of the ilium, and also the aflfected 
 thigh. It should then be stitched along the outer side in one continuous seam and the 
 superfluous edges allowed to remain in apposition. The gum-and-chalk paste must then 
 be applied, some difficulty being probably experienced in applying it over the sacrum, 
 but the patient must be rolled first to one side and then to the other. While this is 
 
 55 
 
866 ON FRACTURES. 
 
 being done the second layer of flannel should be lying underneath (so as to protect Vw^ 
 bed), which may then be adapted and fastened closely by a few stitches along the line 
 of the previous sutures. When the whole is dry, it may or may not be found necessary 
 to rip it up and insert eyelet-holes. If the .splint fit closely, without causing any undue 
 pressure, the edges may be cut oft" close and the whole allowed to remain as it is ; but for 
 the sake of cleanliness, especially in children, it is generally better to cut up the stitches 
 along the outer side, bind the edges with leather, and lace it up, so as to allow the splint 
 to be removed as often as recjuisite. 
 
 When extra stiffness is required in any of these splints, the inner surface of the 
 second layer of flannel may be covered with the chalk paste before it is applied ; some 
 strips of tin or a piece of gutta-percha which has been moulded to the part should be 
 introduced between the two layers of flannel.' 
 
 Mr. Croft has suggested a very excellent modification of the Bavarian which is much 
 used. It is made as follows : 
 
 1. A piece of house-flannel or an old shrunk blanket, or any suitable substitute, is 
 selected. The pieces may be shaped by measurement, taking the circumference of the 
 limb above and below the knee, at the biggest part of the calf^ just above the ankle-joint, 
 from the front of the ankle-joint round the heel to the front again, and at the middle of 
 the metatarsus. The flannel of each splint should be in width half an inch less than 
 half the circumference at any of those points. The width of the two splints should be 
 one inch less than the circumference of the limb at any corresponding part ; it should be 
 long enough to extend from above the knee to the middle of the metatarsus. Four pieces 
 are required — two for each splint. 2. Two bandages of common mu.slin are prepared, each 
 five to six yards long and two inches and a half in width. 3. A handful or two of good 
 dry plaster is mixed with water to the consistence of thin cream. 4. The inside pieces 
 of flannel may be laid on the table or bed, the outer surface being upward. 5. The out- 
 side pieces are to be soaked in the pla.stei- .separately and laid out on their respective 
 in.side pieces. 
 
 Whilst traction is kept up and the ends of the broken bones are maintained in appo- 
 sition, the splints are to be applied and smoothed ; then the bandage is to be put on. 
 Traction is to be maintained during the hardening of the plaster. The latter takes place 
 in about three minutes. Next, the limb should be laid on a large, soft pillow, the toes 
 directed upward, and the knee a little bent. In the application of the bandage great 
 caution should be observed that it is not drawn tightly anywhere and that no one turn 
 of the bandage is tighter than another. The support is to be equal everywhere. The 
 two splints should not meet by about half an inch down either the front or the back. 
 The intervals are spanned by the dry porous muslin ; at the sides the bandage is fixed 
 to the splints by the plaster, which oozes into it from the outer layer of flannel. If it 
 become necessary next day, or later, to ease the splints or to inspect the limb at any spot. 
 the bandage can be slit up with scissors along the middle line in front. One or both of 
 the splints can then be eased from the limb and readjusted by the addition of another 
 bandage. It is undesirable wholl}" to remove the splints. They are hinged together at 
 the back by the muslin bandage which spans the interval there. The trimming of the 
 ap[>aratus may be done as soon as the plaster shall have hardened. Should the surgeon 
 be short-handed with regard to assistance, he may apply the outside splint first and lightly 
 bandage that on ; and when that splint has nearly hardened, he may put on the inside 
 one. As swelling subsides and the splints become more or less loose an additional band- 
 age should be put on. At the end of ten days, if the patient be convalescing, the out- 
 side bandage may be gummed or a fresh gummed bandage rolled on. That apparatus 
 will last until splints are no longer needed. At the end of a fortnight or three weeks, as 
 the case may be, the patient may leave the hospital for his own home. 
 
 This mode of treatment is admirably adapted to oblique fractures accompanied by dis- 
 placement of the tibia, to cases of Pott's fracture, and to comminuted fractures. 
 
 In cases of compound fracture an opening suitable to the wound may easily be made. 
 This splint is as good for joint cases as for those of fracture ; indeed, it is by far the best 
 immovable apparatus we possess. 
 
 Mr. Hyde has introduced a " leather-felt-splint " of great value which is readily 
 applied, is light and strong, and rarely requires to be used with starch. Cocking's poro- 
 plastic splint answers the same purpose, the splint becoming soft on immersion in hot air 
 or water, and hard again within a few minutes of its removal. If, when moulded, it fails 
 to fit exactly, it can be softened locally by the application of a hot-water sponge. 
 
 ' I am indebted to a valued pupil — ^Ir. W. H. Harsant — for the above description ff the splint. 
 
RF.i'Mii or rnirrrnKS. 867 
 
 Mr. L. Tail ( J/"/. Time*, IHtJ.j) has su]L'p-st«<l tin- use nf paraffin f(ir the Hanie jmr- 
 p(»>i'. the melted paraihii heinji kept licjuid hy the iiniiiersinii of the hnwl coiitainiti;: it in 
 hot water, the haiiihitre a.x it i.s hein^' applied liein;: made t<» pa.><.» through the rn|iiid paraffin, 
 inehint: at lM.'>° to lli(i° F. Two or more coats of paraffin may f>e paint<-d over tlie wliole. 
 
 Tfie liniiid f;las.s — si/imfe nf' fmftis/i — may als<i l)e u.sed. tlie .srdution f»ein;.' painted over 
 tlie Imndatre witli a Itnish. I have u.-ed it. and like it. hut not so miicli as tin- splint I 
 have de.serilteil. 
 
 By way of raiition it sfjouhl he state<l that all stareh. chalk. an<l plaster-of-I*aris splint.s 
 contraet on drvinL'. and from sueli contraetioiis I have known harm, and even ;.'anj:n-ne. 
 to follow. To LTUard airaiiist this eontini.'ei:cy wlieii f»anilaj:es are used eotton-wooj sliould 
 be applied fre<-Iy around the linil>. althoUL'h in the Bavarian .splint thi.s preeaution is not 
 called fiir. 
 
 On tliis aeeount the practice of usin<r these splints as a primary application in the 
 treatment cd" fractures is dan^'erous ; for when swelling to any extent takes place, the 
 pressure may he most harmful. 
 
 When pain or swelling of the limb follow.s the application of any r(f these splints, 
 tluv shfiuld be at once removed, the whole Ixdng cut up with .strong .sei.s.sors from end to 
 end. evelets being subse(|uently introduced for laces to draw them together again, or straps 
 and buckle- may be employed. 
 
 Repair of Fractures. — !» children broken Vjones repair rapidly, four weeks being 
 ample time for the whole process to be perfected, while in the aged ten weeks or more may 
 be needed. Kejiair goes on more rapidly when the broken ends of the bones are i)laced 
 and kept in position than when they. are apart or not kept at perfect rest. When bones 
 are maintained accurately in position or are impacted, direct union ensues, as in the .soft 
 parts; but when movement is allowed, reparative material is poured out around the broken 
 fragments and the provisional callus of authors or the ensheathing callus of Paget is formed, 
 which, acting as a temporary splint, keeps the Vjones in po.sition till they unite by means of 
 the permanent callus. The best repair of a fracture is the direct ; and when provisional 
 callus exists, some mobility of the broken bone has been allowed, to a certainty. This 
 addition to our knowledge is due to Sir J. Paget, for until his day a provisional callus 
 was always looked upon as a necessary means for the repair of every fracture. We now 
 know it is present only when mobility of the fragments interferes with direct repair, and in 
 proportion to the amount of provisional callus may the extent of mobility be estimated. 
 
 When a bone is broken, blood is effused, the amount depending upon the degree of 
 injury to the soft parts and the amount of comminution of the bone ; it is exceptional to 
 find f)lood between the broken bones. In simple fracture the periosteum may be oidy 
 torn across: in the comminuted it is more extensively injured, while in incomplete frac- 
 tures it is probably always entire. 
 
 After a simple fracture some slight inflammatory exudation may be poured out 
 around the broken bone, which in healthy subjects is very limited and unattended by any 
 constitutional symptoms. In more complicated cases or in cachectic subjects the effusion 
 mav be extensive and constitutional .symptoms with febrile disturbance severe. Under 
 favorable conditions this inflammatory material will be absorbed with the effused blood. 
 The true reparative material is poured out about the sixth or ninth day. and when no di-s- 
 placement exists it will be effused only between the ends of the V>roken bones ; when, 
 however, the bones are comminuted, it will be more diffused. When they are misplaced, 
 it will be still less defined : and when the periosteum is much separated or torn, it will be 
 poured out around the bones as a provisional callus. The true reparative products are 
 chieflv poured out by the periosteam and endosteum. though the soft parts around at 
 times add their quota. In the flat bones the ossification of this reparative material has a 
 preliminary fibrous-tissue stage, and in the long, after the blood has been absorbed, the 
 ceil infiltration passes on to the formation of connective tissue, or iteoplttsm. which subse- 
 (juently ossifies, in rare cases passing through the stage of fibro-cartilage. In chil- 
 dren it is probable that the cartilaginous stage always precedes the osseous, while in 
 adults the bone is poured out at once, which is probably always the ca.se in all rapidly- 
 repairing fractures. 
 
 Ossification may take place in the periosteal blastema or in the endosteal, or in both, 
 the.se points being greatly determined by the relative position of the broken ends of the 
 shaft of the bone and the comminution of the fragments, great displacement and separa- 
 tion of the fragments being bridged over or cemented together by irregular masses of 
 connecting bone ti.ssue. 
 
 When immobilitv of the broken bones has not been maintained, the bone cement or 
 
868 
 
 ON FRACTURES. 
 
 provisional callus will be very extensive. In the ribs, where it is impossible to prevent 
 movement, there is always some ensheathing callus; indeed, Dupuytren's ring of provis- 
 ional callus is constant. In the clavicle also it is common. In other bones it will vary 
 with the amount of movement that has been allowed in their treatment. When the 
 movement is very great, the process of ossification will not go on kindly and ligamentous 
 or fibrous union will remain, giving rise to an ununited fracture, and occasionally a false 
 joint is formed. (A splendid example of this is repre.sented in Fig. 537.) The rapidity 
 with which ossification or true bony union is obtained in fracture depends much on the 
 degree of immobility ensured to the broken bones and on the constitutional power of the 
 patient. 
 
 The periods in which the several parts of the reparative process are usually completed 
 after fractures of adult human bones are reckoned thus according to Paget : To the second 
 or third day after the injury, inflammation in and about the parts; thence to the eighth 
 or tenth, seeming inaction, with subsidence of inflammation ; thence to about the twen- 
 tieth, production of the reparative material and its gradual development to its fibrous 
 or cartilaginous condition ; thenceforward its gradual ossification — a part of the process 
 which is most variable as to both time of commencement and rate of progress, and which 
 is probably rarely completed before the ninth or tenth week. 
 
 In open or" compound fractures repair goes on very much in the same way as 
 in simple ; when they are made simple by sealing the wound, precisely the same process 
 goes on. When the wound is left open and suppuration takes place in the soft parts 
 around the broken fragments, repair goes on through granulation, the granulation tissue 
 subsequently ossifying and passing into bone cells ; the process of repair under these cir- 
 cumstances is thus more gradual than w^iere the reparative material is poured out between 
 the broken bones and proceeds directly to ossify. 
 
 At times after a simple fracture, but more commonly after a compound, the fractured 
 bone inflames, and as a result the broken fragments die wholly or in part ; repair is 
 retarded and cannot be perfected until the necrosed bone has been cast oif or renioved. 
 In comminuted compound fracture this result is more common than in less complicated 
 cases. In gunshot injuries of bones this comminution of the bone is the chief point of 
 diiference between them and other compound fractures. 
 
 Compound fractures, as a rule, require for their repair three or four times the period 
 required in simple. 
 
 Ununited fractures are met with when from any local or general cause ossific 
 union is delayed or does not take place between the broken ends of the bones, and in by 
 far the bulk of cases this is the result of a want of that complete rest and quiet which 
 is so essential for the ossific union of a broken bone. When the ends of the broken bone 
 are kept asunder, ossific union is likewise sure to be retarded or prevented, and also when 
 any muscle or fascia is placed between the broken fragments. In feeble, cachectic, and 
 syphilitic subjects the same want of repair may likewise be met with. 
 
 Failures in the reparative process depend, therefore, on some failure in the general 
 
 power of the patient, want of care in the local treatment 
 of the case, or on some local cause. The union, however, 
 is, as a rule, simply delayed. 
 
 Hamilton calculates that such delayed union occurs 
 once in 500 cases, but this average I believe to be too high. 
 It is chiefly found, according to Norris (Ainr-r. Jonrn. of 
 Med. Scinice.<i, 1842), in the thigh, leg, arm. fore-arm, and 
 lower jaw. I have seen it, however, in the clavicle and in 
 the ribs, and cases are recorded in which it was met with 
 in the spine. 
 
 In the majority of cases the union of the broken bones 
 is by fibrous tissue which has failed to ossify. In Prep. 
 1110*", Guy's Museum, this condition is well exemplified, 
 the ends of the bone being pointed and firmly joined by 
 ligamentous tissue. The length of this tissue varies in 
 difl"erent cases. In exceptional instances the ends of the 
 bone are rounded and enclosed by a strong capsular liga- 
 ment, and thus a false joint is formed, which is well exemplified in a specimen of frac- 
 ture of the fore-arm (Guy's Museum, 1119'"), but still better in that of the humerus 
 (Prep. 1110*^ Fig. 537), in which the ends of the bone are studded with fibro-cartilage 
 and complete movement existed. 
 
 Fig. 537. 
 
 inHumeruii 
 
 Prep. 1110«5, Guy's Mus. 
 
RESECTlny IS FRACTURES. 869 
 
 III iimrt' rare caM-s tlurt- i> a total absence ot' all iinititir^ medium. 
 
 Tkkatmknt. — Hc'jranliiig a larjre majority "f casi-s of ununited fracture as examples 
 of delav«^'d union due to a want of that alisolute immobility of the fractured limb which 
 is so necessary for its repair, the most essential point to be observed in treatment i.s the 
 application of an absolutely immoyable ajtparatus. which may be found in one of the forms 
 of splint described as immoyable. such as that of starch. e;.'j: and flour, chalk, plaster of 
 Paris, or lii|uid ^dass. with t:utta-percha. millboard, zinc, or felt, the joints abi»ve and 
 below the broken lione being included in the apparatus, while tonic treatment is at the 
 same time <d>seryed. 
 
 When the limb is thus firmly fixed, rest and tlie non-use of the limb is scarcely neces- 
 sary ; indeed, under certain circum.stances. the moderate use of the limb .seems to be 
 beneficial, and in seyeral cases under my care repair seems to have been ha.stened by such 
 a license. John Hunter saw the truth embodied in these remarks, having asserted in 
 17^17: "When the uniting process in fracture is backward, the parts should not be kept 
 at perfect rest. I have seen fractures of the lesr which would not otherwi.se unite do .so 
 after patients were up on their legs, the fractured bones being well supplied with iron 
 splints, etc." ( .^IS. lect.). When these means fail, the ends of the bone may be well 
 rubbed together to excite action before the reapf)lication of splints or subcutaneou.sly 
 scored with a tenotomy knife, while in still older cases the bones may be fastened together 
 by means of wire sutures or drilled and secured with ivory pegs, the credit of this latter 
 suggestion being due to Dieffenbach. Dr. Physick of New York years ago (1804) sug- 
 gested the introduction of a seton between the ends of the broken bones, and Xorris 
 reports that good success has followed the practice, 5-4 out of 72 ca.ses being succe.s.sful. 
 The object of the treatment is to excite local action between the fragments: and when 
 this is secured, the seton may be removed. With the same view Malgaigne introduced 
 acupuncture needles between the bones, and Miller and M. Blandin subcutaneously 
 scraped with a tenotomy knife the ends of the bones or the connective ti.ssue. 
 
 Resection has also been practised, and. according to Xorris. with success in 37 out 
 of tl-t ca.-es. The operation, however, is formidable, and should be undertaken only 
 where there is no hope of minor measures being successful, the ends of the fragments 
 being far apart and the condition of the limb such as to render some ri.sk justifiable to 
 gain the desir^ed end. I have performed this operation for ununited fractures of the 
 femur and humerus with excellent results, in some cases wiring the bone together. 
 
 Dr. H. J. Bigelow of Harvard has. however, met with considerable success in detach- 
 ing the periosteum for about half an incb from the extremities of the aflPected bone with 
 the muscles, taking off the ends of the bones and securing the resected portions together 
 by .strong wire p»assed through half the thickness of the shaft of either fragment ; the 
 periosteal flaps may also be united by sutures. The limb should then be fixed on a splint. 
 The wire can be left in place without fear from two to six months. He cured ten out of 
 eleven cases where this operation was performed (American Journ. of Med. Science.". 1867). 
 
 It occasionally happens that a fracture which had united becomes disunited after 
 fever, .scurvy, or other enfeebling cause, and I have had one very marked case of this in 
 the person of a young lady who had her thigh fractured abroad 
 and subse'iuently became the subject of tropical fever. In her Fig. 538. 
 
 case, although the bond of union completely gave way. she sub- 
 se^juently obtained a firm limb by means of local immobility and 
 constitutional tonics. These cases ought to be classed with others 
 in which the cicatrices of burns or old ulcers break down under 
 some enfeebling influence and heal under tonic and general hygi- 
 enic treatment. In the treatment of all the-e cases time ought 
 not to be estimated too closely. 
 
 The deformities that follow badly iinited frac- 
 tures at times reijuire surgical treatment : and when the sur- 
 geon is consulted during the first few weeks of the case, an 
 anaesthetic should be given and the bone refractured and set in 
 a good position, it being fjuite justifiable to employ considerable 
 force to attain this end. In young subjects this refracture is 
 rarely attended with difiiculty. though in the adult it is. CEster- 
 len and Skey were strong advocates for this practice, the former 
 having employed it up to the twenty-fourth week, and the latter Hyperostosis of the Tibia, 
 on a boy set. 15 thirteen months after the fracture. 
 
 When the bone has united too firmly, to permit of refracture, it should be divided by 
 
870 OS FRACTURES. 
 
 a subcutaneous section or by some cutting operation. Key Ji'l this latter operation in 
 the leg in 1839 (Gki/'s Hosp. Rep., Series 1, vol. iv). The subcutaneous section should 
 be performed in a similar way to that adopted by W. Adams in dividing the neck of 
 the thigh-bone with a saw or chisel. 
 
 These operations, however, are to be undertaken only when the local deformity f& 
 great and the limb useless. 
 
 In the incomplete or green-stick fractures of infancy, if the bone be not straightened, 
 strange deformities ensue. In the case depicted in Fig. 538 such a result was to be seen, 
 the bent tibia and fibula having been much thickened by the deposition of bone in the 
 concavity of the arch, the bone measuring across its centre six inches. It was taken 
 from a girl twelve years old. I am now disposed to think this case was really one of 
 hyperostosis of bone, which may or may not have followed a fracture. 
 
 SPECIAL FRACTURES. 
 Fractubes of the Upper Extremity. 
 
 Fractures of the cranium and spinal column have already received attention ; those 
 of the lower jaw have been described in page 450, and those of the nose and sternum in 
 Chapter XVII. 
 
 Fracture of the clavicle is generally the result of indirect violence, such as a 
 fall upon the shoulder; and vrhen of direct, it is usually compound or comminuted.. 
 Hamilton and Gurlt record examples from muscular action, and I have seen one in a man 
 fet. 44 (who had had syphilis nine years before) from simply lifting a heavy weight from 
 the ground. The bone broke near the sternal end with a snap, and a good recovery fol- 
 lowed. The case was brought under my notice by Mr. Couling. now of Brighton, when 
 house-surgeon at Guys. The statistics of the Middlesex Ho.spital. as compiled from the 
 experience of sixteen years by Messrs. Flower and Hulke (Boliins'.^ S^Kfem. vol. i. 3d 
 ed.). prove the clavicle to be more frequently broken than any other single bf»ne. the 
 radius standing next in order, although, including fracture of the radius with the ulna, 
 the fracture of the clavicle stands second. Half the recorded eases occurred in children 
 under five years of age. 
 
 The bone, as a rule, is broken about its centre, and the line of fracture, with rare 
 exceptions, is oblique from without inward and from before backward, the inner fragment 
 having commonly a tendency to ride over the outer, the outer falling downward and back- 
 ward. 
 
 Fractures at either extremity also occur, and one of the sternal end when vertical 
 may be mistaken for a separation of the body of the bone from its sternal epiphysis ; 
 when oblique, downward, or upward, such an error can hardly occur. 
 
 Symptoms. — The symptoms are generally well marked. There will be inability to 
 move the arm freely, with pain in the attempt, the patient supporting the arm of the 
 affected side. On comparing the shoulders of the two sides the joint on the aff'ected one 
 will be placed lower and more forward than on the sound side, and at the same time will 
 be drawn nearer to the median line of the body, even to the extent of an inch when the 
 di.splacement is great. On passing the finger over the broken bone some depression and 
 corresponding elevation of the broken fragments will be detected; and when the exami- 
 nation is made after the expiration of days, there will be also eff"u.sion of much solid mate- 
 rial. Crfpilus can sometimes be detected, but it need not be looked for. this symptom, 
 with the amount of displacement, depending much upon the line of the fracture and its 
 situation. 
 
 Dr. R. Smith of Dublin points out (Treatise on Fracture, 1850 i how in fractures of 
 the acromial end of the bone between the conoid and trapezoid ligaments there is scarcely 
 any displacement of either fragment, and under these circumstances the diagnosis has to 
 be made by the pain produced on pressure over the broken point, and by the crepitus 
 educed by the movement of the bones in opposite directions through the fingers. He 
 also shows how in fracture external to the trapezoid ligament, the inner fragment being 
 drawn upward by the trapezius muscle, the displacement is great. 
 
 In children incompJetf fractures of this bone may occur (Fig. 533). 
 
 Fractures of the clavicle are sometimes comminuted and compound, and occasionally 
 complicated with some severe injury to the vessels beneath. In the case of the late Sir 
 R. Peel the accident was followed bv a pulsating blood tumor which was supposed to 
 have been due to a rupture or laceration of some large vein, probably the subclavian, 
 
sriyiAi. ii:.\rTri:i:s. «7] 
 
 wliili', IVom tlu> scvfri' jiaiii that altfiidid the injury, soiih' of the norvo.s of the bnurhial 
 )iii'.\iis wiTc hflii'Vt'tl to liavc hccu iiijiircil. Mr. Krichs»;ii has n-conlcd {Brit. M^il. Jimni., 
 .Ill lie 7. 1S7M)' " •''"^'' '" which tlif Mihchiviaii vein was cornpn'sstMl hy a f'rajrnieiit of a 
 hroki'ii fhivic'le, and in which ainjuitation of the shoulder-joint was perforjncd on tlie six- 
 teenth day ; and I have seen one in whidi a hrokeii ehivicle was ioUoweil by arrest of 
 pulsation in the artery of the corresponding: arm. At St. (ieor^e's Hospital there is a speci- 
 men in which the i-nd of the fractured hone was driven throufrli the internal juj^ular vein. 
 
 Fractures nl'ljoth clavicles have also })een recorded. F have seen this inori' than once 
 ill children. 
 
 'I'kk.vTMK.NT. — -Daily experience proves that fractures (d" tin; clavicle unite without 
 anv treatment, and, moreover, palpable deformity too often shows tiiat where treatnit-nt 
 has been employed the union is neither perfect nor satisfactoi-y. Daily experience like- 
 wise proves that in most, if not all, cases of fractun* of the clavicle the bones I'all widl 
 into place on the ])atieiit assuminji tlie nicumbent jiosition. In yountr ladies, and in 
 others where it is a matter of importance to jireveiit deformity, the recumbent position 
 in bed niav be maintained for about three weeks, till union has fairly taken place; but 
 children and men will rarely be found willin<r to follow such a lin« of treatment, and 
 happily it is not recpiired, for nearly, if not quite, equally jrood results will be secured by 
 imitatinjr what takes place on the patient assuming the recumbent posititjn — viz.. by fix- 
 ing the lower blade of the scapula to the chest, binding down its angle to the thorax, and 
 thus )>reventing the tilting forward and rotation of the bone through which the deformity 
 takes place. 
 
 The ])lan I have ado])ted for some years is to place a pad over the blade of the scapula 
 below its spine, and to bind the bone firmly to the thorax by means of broad strips of 
 strapi)ing obliquely encircling half the chest from the spine to tlie sternum, at the same 
 time sup])orting the affected arm in a sling and drawing the hand upward toward the 
 op))osit(? shoulder. The same method is also advocated by Dr. E. Ilartshorne of }*enn- 
 sylvania. Whilst the strapping is being fixed the scapula should be well tilted backward 
 by elevating the arm. or the patient should be kept in the recumbent position. When 
 this practice cannot be followed, the elbow should be brought forward to a point ])elow 
 the nipple of the affected side and the hand drawn over the opposite shoulder. The old 
 plan of fixing the pad in the axilla and using a figure-of-8 bandage has no advantage, and, 
 moreover, causes much discomfort to the patient. 
 
 The axillary pad of Desault is at times serviceable and may be employed, being ea.sily 
 fixed by a broad piece of strapping made to encircle the shoulder. In addition to the pad. 
 Professor Gordon of Belfa.st (Dnh/iu Qunrf., 1859) recommends the injured arm to be 
 extended downward and firmly fixed to the body by a bandage, permanent extension 
 being kept up by means of a band fastened above to the fore-arm. flexed at right angles, 
 and below around the perinseum or upper part of the thigh. 
 
 Sayre's method, applied as follows, is cei'tainly valuable : 
 
 Take two strips of adhesive plaster, two and a half inches wide for an adult. Pass 
 one strip around the arm at the junction of the lower and middle third, one end of the 
 strip being united behind the arm to the same strip which is to be passed around the 
 body, making a loop and leaving an open space at the posterior part of the arm. This 
 loose loop arrangement prevents strangulation. Then draw the arm back, to bring the 
 pectoralis major muscle upon the stretch ; but the acromial end of the clavicle still rides 
 under the sternal fragment or end. Now secure the arm back by passing the long end 
 of the strip of' adhesive plaster around the body, bringing it two or three inches under 
 the arm of the opposite side, across the thorax, and fastening it to itself .somewhere about 
 the middle of the back. Care must be taken not to draw the arm too far back, but just 
 sufficient to put the ])ectoralis major on the stretch. Then take the other stri]) of adhe- 
 sive i)laster and make a slight longitudinal slit in the centre, to admit the point of the 
 elbow ; flex the arm at an acute angle over the chest, drawing it ujnvard. forward, and 
 inward, and thus reduce the fracture. After bringing both fragments of the bone into a 
 direct line, .secure the arm in this position by first placing the centre of the elbow in the 
 longitudinal slit in the adhesive plaster, passing one end of the strip across the back 
 diagonally to the opposite shoulder, then bringing the anterior end of the .strip up along 
 over the flexed arm and the hand, over the chest, and listening it to the posterior end of 
 the strip at the shoulder. If this plan be carried out carefully, it will yield a perfect 
 result without deformitv. 
 
 Fractures of the scapula are probably always the result of direct violence, 
 although a fracture of the neck of this bone may be produced by a fall upon the shoulder. 
 
872 
 
 ON FRACTURES. 
 
 Fig. 539. 
 
 Fracture of Scapula. 
 (Prep. 109/2", Guy's Mus.) 
 
 The ho<f^ of the bone may be fissured in any direction (Fig. 539), though much dis- 
 placement is rare. 
 
 In this accident mobility of the broken bone and crepitus may usually be made out 
 by manipulation, though in fat subjects and when effusion exi.sts the diatrnosis may be 
 difficult. 
 
 Treatment. — A broad pad carefully adju.sted and kept in 
 position by means of broad strips of plaster encircling half the 
 thorax, the arm being kept quiet and the elbow raised in a sling, 
 is usually sufficient treatment, although a good shield of gutta- 
 percha or felt may be sometimes beneficial. 
 
 The ((crom ion process may be fractured across its base or in 
 an}- other part ; and when it is so, the outer fragment is gener- 
 ally drawn downward with the arm, producing a dropping of the 
 shoulder. The accident can readily be made out. on tracing the 
 spine of the scapula outward, by the deformity, the break in the 
 normal line of the bone, and the local pain, if not by the separa- 
 tion of the fragments. There are also loss of power in the arm 
 and altei'ation in its outline. 
 
 Treatment. — It should be treated by raising the elbow 
 by means of a good sling or bandage, a small axillary pad and 
 a circular bandage binding the arm to the thorax. The union, 
 however, is often ligamentous, it being impossible to keep the 
 fragments of bone closeh* in apposition. 
 
 Fractures of the conicoid process are remarkably rare. I have seen but one decided 
 instance, and that in a girl fet. 15 or 16, the result of a blow. There were local pain and 
 crepitus to denote the injury, with displacement of the process, the point of which was 
 drawn downward by the biceps muscle, and its base projecting. Dr. Pauli of Luton 
 kindly gave me the notes of a case that occurred in a girl set. 14 from a fall on her 
 shoulder. There were marked mobility of the coracoid process and crepitus, but no 
 deformity. There was pain in the part, increased by any movement of the arm. This 
 accident is more commonly associated with dislocation of the humerus. 
 
 Treatment. — The mu.scles attached to the process must be relaxed, the biceps by 
 flexing the fore-arm, and the coraco-brachialis by drawing the arm forward and inward. 
 In this po.sition the arm should be bound by a bandage, the bone 
 itself, if possible, being restored to its normal position by manip- 
 ulation. 
 
 Fractures of the neck of the scapula or of the ijlenoid fossa 
 must be rare. Sir A. Cooper described such cases, but since 
 Malgaigne showed how the .symptoms described might be pro- 
 duced by dislocation of the shoulder with fracture of the glenoid 
 cavity, some doubt has been thrown upon the question of a sim- 
 ple fracture of the neck of the bone ever occurring. In Guys 
 Museum (Prep. 1097*^) there is a specimen of fracture of the 
 neck (Fig. 5-10), and in the Royal College of Surgeons there is a 
 second, .the third being recorded in Du Verney ( Truite <les 
 Maladies des Os, 1751). .Sir A. Cooper gives the flattening and 
 .sinking of the shoulder, the prominence of the acromion, the 
 elongation of the arm. and the presence of crepitus as the chief 
 symptoms, the head of the humerus being felt in the axilla. He also relates how the 
 arm may be replaced in its normal position and again displaced on allowing the arm to 
 drop, this symptom being the chief one of diagnosis between the supposed accident and 
 dislocation ; but when dislocation of the head of the humerus exists with fracture of the 
 glenoid fossa, the same symptoms are found. The subject, therefore, requires further 
 elucidation. In suspected ca.ses of this kind the elbow should be raised, in order to press 
 the head of the bone well upward into position, and kept there by sling and bandage. 
 
 I have seen a case of dislocation of the head of the humerus downward and for- 
 ward complicated with a fracture of the lower portion of the glenoid cavity, the broken 
 piece being drawn downward. 
 
 Fractures of the humerus form about one-seventh of all fractures, anxl are 
 about half as frequent as fractures of the clavicle and scapula together. They are com- 
 monly the result of direct violence, and occasionally of muscular action. They may be 
 divided into fractures of the head and tuberosities, shaft and condyles. 
 
 Fracture of tlie Neck of the 
 Scapula. 
 
SP1':( I A L /'AM ( TURKS. 
 
 873 
 
 Fifi. o42. 
 
 1/ 
 
 Greater TnhircsilV 
 Fracture of the Head 
 and Tul)fri>sitii-s of 
 the Humerus. I Viy- 
 hiiid's case.) 
 
 Iiii|>aoted I racture 
 of the Head of the 
 Humerus. (I'rep. 
 1113i",(iuy'8Mus.) 
 
 Krac-turo.'* iiiv(ilviii<; tlio hutil and tiiht roslliis are usually the result nt" a Idnw (»r 
 fall iiiMiu the shduldcr, altlioiijrii (ircasidually tlii-y f'<tlli»w falls on the elbow. In a 
 case that came iimler my <'ai"e in 1S77 ami <lieil from other iiijiiries the ;:reater tuherosity 
 was erushetl off and tlisplaeed upward IVoni a fall iipon the shoulder. This aeeident eouhl 
 never have l)een niiide out during life. In all eases the direction of the violence is an 
 ini|>ortant point to discover, as hy it the surjreon ohtains the he.st guide to tin; position of 
 the frairnients as well a.s to the nature of the injury. 
 
 When the line ol' fnicture follows that of the nniitmiilinl in(h% it is intracap.sular : and 
 when this occurs, the head of the hone may he completely separated and left as a foreif^n 
 liotly in the joint; yet such ca.ses are very rare. 
 In others, such as Fiir. 541 illustrates, the head is 
 separated and the tuherosity fractured ; more com- 
 monly, however, the fracture is iiti/tacOd. either 
 the lower fra.Lrment hein;z driven into the head 
 of the hone or the head driven into the neck, the 
 greater tuherosity. as a rule, being broken (Kig. 
 54:i). Dr. H. Smith of Dublin states that when 
 this accident exists the arm is shortened, the acm- 
 inion process projects, the shoulder loses its round- 
 ed form, the shat't of the humerus approaches the 
 acromion, and the head of the bone cannot be felt. 
 When the tuberosity is broken off, crepitus may 
 be detected. 
 
 In ISCiS I saw such a case in a woman ret. oD 
 who had fallen on the shoulder nineteen days previously, the ca.se having been treated as 
 one of contusion. Shortening in the arm of three-( quarters of an inch and a distinct 
 prominence of bone with thickening could be felt between the acromion and coractyid 
 processes, while the head of the bone rotated freely in the glenoid cavity. In it there 
 was some flattening of the deltoid. A good I'ecovery took place with permanent short- 
 ening. 
 
 I saw also a similar case in I8(Jo. in an old man jet. 82, in which good repair took 
 place. 
 
 More conunonly a fracture about the head of the bone means a/rucfure in the line or 
 a separation of the epiphysitis the epiphysis including the head and the tuberosities. This 
 accident is generally the result of a fall on the elbow, and the .symptoms of the accident 
 are tolerably distinct. The head of the bone can be felt in its normal position, but is not 
 movable on rotating the shaft, while the end of the displaced shaft is usually sent for- 
 ward. When fractured, the bone presents 
 
 a sharp edge and outline ; but when di.s- ^^'^- '^'^^■ 
 
 placed — an accident that can occur only in 
 suVjjects under twenty-one — the end of the 
 bone appears rounded and slightly convex. 
 It is, njoreover, drawn forward by the 
 action of the pectoral muscles and made 
 to project beneath the coracoid proce.ss in 
 a marked and characteristic manner. In 
 Fig. 543, taken from a male patient of 
 mine jet. IG. this position is well seen. 
 
 When the separation is complete, the 
 displacement will be very marked ; when 
 partial, it will be etiually characteristic; 
 
 ! . • ..:■ 1 T 1 J. £• ^\ IP... Separation of Shaft of Humerus from I nper Epiphrsis. 
 
 but in partial displacement oi the shait n r •- . 
 
 some molnlity of the head of the bone will exist. In this accident the shaft may be at 
 times replaced by manipulation. " but the moment the parts are abandoned to the uncon- 
 trolled action of the muscles the deformity recurs ' (R. Smith). 
 
 When, after a separation of the upper epiphysis or fracture through the tuberosities 
 or neck of the bone, the upper end of the diaphysis or the lower fragment of the broken 
 bone is drawn inward and forward by the pectoral muscles, the case may simulate that 
 of dislocation. The mistake, however, should not be made, as in the early period of the 
 accident increased mobility of the bone and crepitus should be enough to indicate its 
 nature, and in the later period, when the deformity produced by the end of the lower 
 fragment is visible, the accident is palpable. 
 
874 
 
 ON FRACTURES. 
 
 Fig. 544. 
 
 When, in fracture, impaction of either fragment exists, no crepitus will be felt unless 
 forcible movement be made, when it may b6 elicited. Care, however, should be observed 
 in seeking for this information, as a forcible separation of the impacted bones is a fatal 
 error. The accident is generally to be made out by the nature of the injury, the short- 
 ening of the limb, the absence of crepitus, and the movement of the head of the bone on 
 making gentle rotation of the shaft. 
 
 Treatment. — In fractures of the anatomical neck, when the head of the bone is 
 driven into the tuberosity and shaft, as in all other forms of impacted fracture, union 
 will go on if the impacted bones are not displaced by manipulation. The surgeon, there- 
 fore, has only to apply some simple splint, such as an anterior and posterior or lateral, or 
 iStrumeyer's cushion (Fig. 561), to maintain rest. The same treatment is applicable in 
 fracture or separation of the epiphyses when the bones have been replaced. In the case 
 illustrated in Fig. 5-43 a capital arm existed. 
 
 Fracture of the surgical neck of the humerus below the tuberosities is, however, prob- 
 ably the most common form of accident, and the line of fracture may be transverse or 
 oblique (Fig. 544). In it, when the bone is broken above the insertion of 
 the pectoral muscle — its usual seat — the lower fragment is drawn imcard 
 toward the chest, whilst the upper fragment is drawn upward and otit- 
 icani by the muscles that are inserted into the tuberosities. The bone 
 projects forward or backward according to the direction of the fracture, 
 the direction greatly depending upon that of the force. The more oblique 
 the line of fracture, the greater the deformity. Impaction of the broken 
 fragments may occur in this as in the last fracture, the lower usually 
 penetrating the upper. 
 
 Treatment.- — ^The nature of the accident having been ascertained and 
 the question of impaction or non-impaction decided, the treatment becomes 
 simple ; for in the impacted fracture, whether of the anatomical or the 
 surgical neck, the aim should be to keep the impacted bones in position 
 and to prevent their being loosened, so that natural processes may effect 
 a cure in a month or six weeks with a limited degree of deformity, and in 
 a non-imjiacted fracture the first aim is to bring the bones into as good 
 apposition as possible and to keep them there by means of splints and 
 position. In doing this the tendency of the fracture has to be considered, 
 which is that the lower fragment is drawn inward by the pectoral muscle and the upper 
 fragment outward by the scapular muscles. The best plan to carry out these objects is 
 to fix the arm between an inside right angular and an outside straight splint, the former 
 extending from the axilla to the wrist and the latter to the elbow, the two being well 
 bound together. It is a dangerous practice simply to place the fore-arm in a sling and 
 bind the arm to the side. When much injury to the soft parts or any wound exists, it is 
 an excellent plan to draw the arm outward from the body at half a right angle and to 
 rest it on the splint with the fore-arm partially flexed, care being taken that the lower 
 fragment is not drawn too far inward, or to bind it on Stromeyer's cushion. 
 
 At other times a good gutta-percha, felt, or leather casing moulded to the shoulder 
 and arm is very efficient, or a bent leather splint, the angle being well pressed into the 
 axilla, with one half fixed to the arm and the other to the thorax. 
 
 In all these cases the surgeon should explain to the patient that some impairment 
 of the mobility of the limb may be expected, and some shortening in impacted frac- 
 tures. 
 
 Fracture of the greater tuberosity is a recognized accident, and is usually 
 associated with dislocation of the humerus forward, the scapular muscles drawing the 
 tubero.sity backward. Dr. R. Smith, in his excellent work On Fractures, gives a descrip- 
 tion of two of these cases. He describes a remarkable increase in the breadth of the 
 articulation, the projection of the acromion and flattening of the deltoid, as the most 
 striking features of the injury. He also draws attention to the vertical sidciis correspond- 
 ing to the bicipital groove, formed by the head of the bone on the inner side and the dis- 
 placed tuberosity on the outer, as one of the eharacteri.stic symptoms. 
 
 Fractures of the shaft of the humerus are common, and more readily made 
 out, as well as more succes.sfully treated, than any other fracture. When oblique, they 
 are frequently followed by some degree of shortening ; but this result is of little practi- 
 cal importance, as it interferes but slightly with the functions of the hand. Such frac- 
 tures are as commonly the result of direct as of indirect violence, muscular action being 
 by no means an uncommon cause. I have already mentioned an instance in which it 
 
 Fracture of the Sur- 
 gkiil Neck of the 
 Humerus. (Prep. 
 
 11073:.) 
 
srKciM. I'liArrriiKS. 
 
 875 
 
 if tlic iililii|nity and it.s position. 
 
 splint for 1-ractiirt; at the Shaft of the 
 II1111K.T11.S. 
 
 opcmiiil ill ;i man iliirin;,' a marital ♦'inlirarc, ami a .second produced by throwiiifr a hall, 
 ijoiisdaii', .Mal^raij^nt'. Hamilton, and others have reeord»'d similar instances. 
 
 When the IVaetnre is transverse, there is no dis|)lacement ; when ohlii|UC, the tendency 
 of the lower fVairment to ridt; will depend upon the line 
 When the line fd" IVaetnre is helow the insertion ol" the 
 deltoid, the iippi'r rrairmeiit will have li tendency to he 
 drawn outward; when ahove this ]ioint,the upper I'ra^- 
 nient will he attracted inward hy the jiectoral muscles, 
 the lower I'rai^nnent hcinir «lrawn tipward and outward 
 hy the deltoid. 
 
 Loss of power in the arm, niohility ol' the lioin!, 
 crepitus, local pain, and deformity are ample symptoms 
 to indicate the accident. An error in diagnosis ouirht 
 not to occur. 
 
 TliK.VT.MK.NT. — This is not really difficult, althoujih, 
 from the fact that ununited fracture is more fre(|uently 
 found in this hone than in any other, it would appear 
 as if the practice were less successful. Agnew states 
 that out of 085 eases of non-union of hone, 21 !l, or 
 about )V1 jier cent., were of tlie humerus. 1 would ex- 
 plain the fact hy the want of a due appreciation of 
 Hoyer's rule of treatment — viz., to keep the joints 
 
 above and below the l)roken bone in absolute rest; for in fractures of the anu tlie com- 
 mon practice of ajiplyiiiLT sjdints to it and allowing perfect freedom to the action of the 
 fore-arm is to be condemned, because in moving tlie fore-ariu the triceps and brachiali.s 
 anticus, with the biceps, have as powerful an action upon the humerus as upon the bones 
 of the forearm. 
 
 In the primary treatment of all fractures of the arm it is a wise and scientific practice 
 to keep the fore-arm at rest, which is best done by the application of soiue angular splint 
 extending from the .shoulder or axilla to the wrist, associating with it a posterior or ante- 
 rior short splint reaching from the shoulder to the elbow (Fig. o-tS). After about two 
 or three weeks the angular splint may be removed and .some immovable one applied, the 
 fore-arm being left free. 
 
 Any s])lints that secure immobility of the broken bone after its ends have been coap- 
 tated by manipulation must be regarded as beneficial, and no splints can do this effectu- 
 ally that allow freedom of movement of the fore-arm. AVhen two lateral splints appear 
 the more adaptetl to keep the bones in position, they must be angular, to include the 
 elbow, and lient at a right angle. 
 
 The incomplete or green-stick fractures of children are well treated by milllioard. 
 gutta-percha, or felt splint after the bone has been restored to its normal position. 
 
 In putting up fractures of the arm care should be observed not to press upon the 
 musculo-.spiral nerve as it winds round the bone, especially when the line of fracture cor- 
 responds to its position. 
 
 Fractures involving the lower end of the humerus, whether transverse 
 
 above or vertical through the condyles, or both together, whether complicated with sepa- 
 ration of the epiphysis or some di.splacement of the bones of the fore-arm, are always dif- 
 ficult to a diagnose and to treat ; and when the joint is involved, either by the fracture 
 running into it or by disjilacement, there is usually some subsefjuent imperfection in its 
 movement. 
 
 Fractures above the condyles, where the bone is tliin and expanded, whether in the 
 child or in the adult, or separation of the lower epiphysis (an accident of early life), are 
 usually jiroduced by some fall upon the elbow. "When the line of fracture is oblique 
 from behind forward, the action of the biceps and brachialis anticus has a tendency to 
 draw the fore-arm with the lower fragment upward and forward. "When the line of frac- 
 ture is obli(|ue from before backward and upward, the lower fragment of bone, with. the 
 bones of the fore-arm. is apt to be drawn backward by the action of the triceps, thereby 
 giving ri.se to the external appearance of a di.<location of the bones of the fore-arm back- 
 ward, since there is the same projection of the olecranon process and hollowness above it. 
 the same projection of the lower end of the humerus forward, with the pressing forward 
 of the artery, in both accidents. There is, however, this great distinction between the 
 fracture and dislocation, so well expressed by 8ir. A. Cooper: In fracture there is " the 
 removal of all marks of dislocation on extension and their return as soon as extension is 
 
876 ON FRACTURES. 
 
 discontinued ;"' crepitus of a marked kind i.s felt where a fracture is present, and of a 
 suppressed kind where a displacement of tlie epiphysis exists, whereas in dislocation no 
 crepitus is present and there is marked immobility of the bones, the bones of the fore-arm 
 and the condyles of the humerus having lost their natural relative position. Malgaigne 
 also jiointed out that in fracture there will be a shortening between the acromion process 
 and the internal condyle, whereas in dislocation there will be none. In fracture the ante- 
 rior projection of the end of the humerus is aljove the fold of the elbow and not .so broad 
 or riiinnl a.< in ili-lncatimi. wlu've it is biloir it. 
 
 Fracture of the condyles into the joint is a grave accident and likely to be 
 
 followed by some stiffness of the joint. It may be oblique in any direction, the outer or 
 
 the inner condyle being fractured or associated with a transverse fracture of the bone 
 
 (Fig. 546). The existence of the fracture can be made out by manipulation, the amount 
 
 of displacement varying with the character of the injury. Crepi- 
 
 FiG. 546. tus can also be detected by grasping one or other condyle and 
 
 moving the broken fragment, while rotation of the radius often 
 
 gives rise to it when the external condyle is involved. Flexing 
 
 the ulna also produces it when the internal condyle is affected. 
 
 All these fractures into the elbow-joint are rapidly followed 
 by effusion, which often ma.sks the symptoms and renders the di- 
 agnosis difficult and uncertain. Under these circumstances no 
 diagnosis should be attempted until by rest and cold applications 
 the effusion has been absorbed and a full examination can be sat- 
 y?/ r/Z/T^"'''"^' ^ isfactorily made. A few days are usually enough for this change 
 
 Humtrus. to take place. In rare cases the inner condyle is simply chipped 
 
 Comminuted Fracture of the off. the joint not being implicated. I have recentlv had a case of 
 
 • ondvles of the Humerus, .ii-i- ■ i-ii i ".. -. 
 
 fPrep. iii2"5.) the kind in a woman in which the ulnar nerve was injured. 
 
 Treatment. — In all these cases of fractures involving the 
 condyles of the humerus, whether into the joint or not, the fragments .should be brought 
 into position by extension upon the fore-arm when needed, with manipulation, and an 
 anterior jointed rectangular splint applied, the upper half of the splint being well passed 
 up the arm and the lower to the wrist. In some cases a posterior arm splint projecting 
 down to the olecranon process is of use, the whole being well bound together and to the 
 limb. The joint, as a rule, may be left exposed for external applications. 8ome sur- 
 geons prefer from the first an immovable casing of gutta-percha or felt, while others 
 like lateral leather or pasteboard splints, but I think it preferable to leave the joint 
 exposed. 
 
 In children the bones unite in about three weeks, and in adults after a month ; con- 
 .sequently. all splints should be removed at the end of these periods and passive move- 
 ment allowed. Hamilton, however, in his great work On Fractures, states his belief that 
 passive movement ought to be commenced within seven days and perseveringly employed 
 until the cure is accomplished. He does not admit the use of splints after this period, 
 believing that the new material has steadied the fragments and that the danger of dis- 
 placement is but little, while the prevention of anchylosis demands early and continued 
 motion. 
 
 Fractures of one or other of the condyles of the humerus, complicated with dislocation 
 of the bones of the fore-arm, occasionally occur ; and when they do, they are difficult to 
 diagnose, and more difficult to treat. In the following case the cause of die difficulty of 
 reduction was explained by the fact that the external articular facet of the humerus had 
 been vertically displaced and the head of the radius was in contact with the inner artic- 
 ular facet, whilst the ulna worked upon the internal condyle. The case was that of a 
 boy aet. 10 who fell upon his hand, with his arm extended, from a horse's back, the force 
 having been carried through the radius to the outer condyle. The injury was regarded 
 at the time as one of T-fracture of the humerus. When I saw the boy, six weeks after 
 the accident, the injury seemed to be one of dislocation of the bones of the fore-arm 
 inward, with great thickening of the external condyle. The arm was much extended. 
 As reduction was impossible, resection was carried out with a good result. 
 
 The preparation and drawing (Fig. 547) show that the external condyle had been 
 broken and vertically displaced. The head of the radius and the ulna were both dis- 
 placed inward and well locked by processes of bone, explaining very clearly the difficulty 
 in reduction. The coronoid process of the ulna was in contact with the outer portion of 
 the internal condyle, and its outer edge with the inner margin of the trochlear surface of 
 the humerus. 
 
si'/yiAL i-i:.\'rin/:s. 
 
 H77 
 
 l'"i<i. .J47. 
 
 Till' licail of tln' rjHliuH rotatf<l oii tin- dis|tla(H'<l inntT half of the artii-iilur lacct <if 
 till- laiiiK'ni.s, witli its oiitcM- cdj^t' in c-oiitact with tlie di.sphiccMl 
 external iMOulylo. The oh-craiioii fossa was partially tilh-d up. 
 
 Aftt-r fraftiirc of the huiiieriis, as of other hoties. arrcjst of 
 urowth iiiav follow. I have seen such an arrest of jrrowth in 
 the humerus of a wouuin to the extent of three ami a half 
 inehes alter a fracture of the siialt which occurreil when she 
 was aliout eitrht years of ajje ( Kij;. O-lHj. I have alsit reconleil 
 [(t'lii/s //iisit. /'i/i., 1,S(>2) a ease of a woman iot. iJO in whiih. 
 with a stilV shouhler-joinf , the humerus was fivi; inches shorter 
 than its fellnw. the shorteninjr havinjr folhtwed som<! injury to 
 the upper part of the Ixuu' duriuj; infancy. In the first ease 
 the arrest of growth was jirohahly due to some injury to the 
 nutrient artery of the l>oMe ; in tlie second, to injury to the epi- 
 ]>hysial cartihiire at the upper part of the shaft. 
 
 Fractures of the Bones of the Fore-arm. — These 
 
 form aliout tw(»-tiftlis of all fractures, lialf the eases consisting:; 
 
 of fracture of the radius alone, a fourth of fracture of the ulna. iC c 
 
 inclinlinir the olecranon process, and the remaininjr fourth of the i'i-'i>iacedaii.i« ..ruiiiiinK.M hrac- 
 
 , ' , ,. ' ,. , ,. 1 I . ..1 1 tiireof tilt- l,..tt<r Kpiphysisof 
 
 two hones totretlier. traeture ot the radius and ulna together be- the Huiiktu.s, »iili Dislnatiou 
 
 ing alMMit ciiual in fn'(iii.>iii-y to that of the clavicle. ofthel{a.liu;*aM<l ru.alnwar.l. 
 
 Fracture of the radius niay take place at its head, neck, .shaft, or lower end. 
 
 When of the neck or shaft and transverse, the fragments of bone are usually loo.se, yield- 
 
 D'lSI-tiU'il 
 
 cvndifl' 
 
 Fig. 548. 
 
 Ki^hl IIUIIILTU:: 
 
 Arrest of Urowth in the Humerus after Fracture in earlv life. 
 
 Left Humerus. 
 
 ing on manipulation a distinct crepitus, the head of the bone being felt not to rotate in 
 its position ; but when the head of the bone is fissured longitudinally, no such symptoms 
 will be present. 
 
 In a case of injury to the right upper extremity in a man ret. 30, complicated with 
 brain mischief, which came under my care in 1877, there was an impacted Colles's frac- 
 ture of the right radius and a vertical fracture of the head of the same bone into the 
 joint. He had evidently fallen from a height upon his right hand and head. 
 
 Fractures of the foicfr cud of the bone are of a very variable nature. They are. as a 
 rule, caused by a fall upon the outspread liand with forcible extension backward, but they 
 may be due to a fall upon the back of the hand with the wrist flexed. Many of them are 
 impacted, the compact shaft of the bone being driven into the cancellated carpal extrem- 
 ity ; and when impaction does not exist, it is frequently from comminution of the lower 
 fragment. In possibly half of the cases of Colless fracture, however, there is no impao- 
 tion, the end of the radius being fractured and rotated backward. In young people a 
 separation of the epiphysis backward may occur (Fig. 540). 
 
 Fractures of the lower end have always been of special interest. Colles of Dublin 
 
878 
 
 OX FRACTURES. 
 
 first described them in 1814 (Edin. Med. and Surg. Jovrnol'), and such injuries are now 
 generally known as " Colles's fracture." Dr. K. W. Smith has done much to draw atten- 
 tion to their nature in hi.s work On 
 Fig. 549. Fracture, where he explains the cha- 
 
 FiG. 550. 
 
 Vertical Section of Radius, Kpiphysis, and .Soft Parts, showing 
 Separation and Backward Displacement of the Lower Epiphysis 
 of I be Radius. (Taken from a boy Kt. 10.) 
 
 Fracture and Backward Rotation of the Lower 
 End of the Radius, with Impaction of the 
 rpper Fragment. (From a patient of Mr. 
 Lucas. I 
 
 racteristic deformity by muscular action. Fius. 551, 552 show the appearance of the 
 wri.st. with displacement of the broken end and hand backward ; Fig. 553 shows fracture 
 with displacement forward. 
 
 Callender in an able paper (.SV. Bartli. Rep., 1865) showed that Voillemier, Malgaigne, 
 
 Fig. 551. 
 
 Fig. 552. 
 
 Colles's Fracture of Lower end of Rad- 
 ius and Displacement Backward. 
 (Dorsal view. From Dr. R. W. Smith.) 
 
 Fracture of Radius and Displacement Back- 
 ward. (Side view. From Dr. R. W. Smith.) 
 
 Fig. 
 
 Fracture of Radius and Displacement For- 
 ward. (From R. \\. Smith. j 
 
 and Nekton's views are often correct, and that impaction rather than muscular action i.s 
 the true explanation of the deformity. 
 
 '• The radius is first broken ; then, by the momentary continuance of the force in the 
 direction of the falling body, forward and outward, the shaft is driven into the carpal end. 
 
 burying itself chiefly from the dorsal surface toward 
 the palm, and toward the outer or the inner side. In 
 a great number of cases this impaction so fixes the 
 fragments that they cannot be unlocked, and the 
 deformity is permanent" (Callender). The thirty-six 
 specimens of fracture of the lower end of the radius 
 which the mu.seums connected with the London 
 schools of medicine contain clearly manifest that the 
 cause of each deformity is the impaction of the prox- 
 imal in the distal portion of the broken bone. 
 Gordon, however, has demonstrated from twenty-seven specimens in the Belfast 
 Museum that impaction is not constant. In nineteen of his examples there was oblique 
 fracture of the bone from before backward and upward, and in eight the fracture was 
 transverse. He believes Colles's fracture is "caused by the f;tll upon the palm of the 
 hand, the fall forcing the hand backward, putting the anterior carpal ligaments and flexor 
 tendons violently on the stretch, wrenching off by the •' cross-breaking strain' the lower 
 end of the radius, tilting it backward, with alteration of the aspect of its carpal surface, 
 and the bearing of the carpus upon it, leaving a gap between the fragments in front." 
 He likewise thinks that fractures produced by a fall on the back of the hand with the 
 wrist flexed are often impacted. 
 
 The fracture is usually placed about half an inch or an inch above the wrist-joint, and 
 the lower fragment or epiphysis is displaced backward. It is. moreover, so displaced that 
 the articular facet, in.stead of looking downward, forward, and inward, is made by rotation 
 to look downward, backward, and outward. The outer side of the fracture toward the 
 styloid process is rotated more than the inner, the strong ligaments uniting this with the 
 ulna holding the bone more in position. On this account the lower fragment is often also 
 broken vertically, giving rise to greater deformity as well as to shortening of the bone on 
 its outer border. In rare examples the fracture of the radius is complicated with disloca- 
 tion of the scaphoid bone forward. Dr. Cameron (GJas. Journ.. March. 1875) of Gla.sgow, 
 and Mr. Knott (Surg. Soc. of Ireland. January. 1881) of Dublin, both give examples of 
 
SPECIAL ri:.\<rri:/:s. 
 
 879 
 
 liu. O'-ll. 
 
 Fractured Knd of Hadius and Stvloid Process 
 of the riiia, (Prep. ]l}>^'.i 
 
 Fig. 5-35. 
 
 this. Ill sdiiu' iMM's the finl ul'ilie lioiie i.s cniiiiiiiniitcd ((iiiy s Mu.seuiu, lllll'-'j. and V'l^. 
 .'»."» I illustrates a i-a.»c ol" iVacture oi' liotli radii fVniii a fall on tlu- liaiid.-i. 
 
 hi Ati.vn.'Sls. — Till' dia-iiiusis of tlii.s aofitlciit i> imt diHicult ; iiiderti. tlie aspect of the 
 wrist may lu' .said to hi- charactiM-istic. " The jmstorior surface of the liiuh,' wrote Colics, 
 •• presents ii coiisidcralilt! dcforiiiity ; for a depression is to lie .»een in the fore-arm about 
 an inch and a half aliove the end of the Imiie. whilst 
 a eoiisideralile swelliiii;' occupies the wrist and meta- 
 carpus ; indeed, the carpus and ha.se of the metacar- 
 pus appear to he thrtiwn backward so much as on first 
 view to e.xcite a suspicion that the radius has been 
 dislocated forward. On viewinj; the anterior surface 
 of the limb we ob.serve a considerable fulness, as if 
 caused by the flexor tendons beinf; thrown forward ; 
 this fulness extends upward to about one-third of the 
 lenirth of the fore-anu. and tenniiuites below at the 
 upper edf^e of the annular lijrament of the wrist. The 
 extremity of the ulna is seen [irojectinfr toward the 
 palm and inner edjre of the limb." ( I'/V/r Fig. 5-49. j 
 The amount (}f deformity turns upon the amount of 
 displacement of the broken fra,<;inent.s. There will be pain in the part, increased by pres- 
 sure on the seat of fracture, and about the internal lateral ligament, the movement of the 
 joint being rendered impossible. On feeble movement of the hand the head of the radius 
 will be felt to rotate when the fracture is an impacted one ; crepitus will be either ab.sent 
 or very indistinct, and can only be well brought out by loosening the broken bones. In 
 rare cases these fractures are compound, the end of the shaft of the radius projecting for- 
 ward. More commonly, however, the ulna is made to protrude. Both these conditions 
 existed in the case from which Fig. 560 was taken. 
 
 Treatment. — In all fractures of the radius it is essential to keep the hand at rest, 
 and. as a consequence, all splints should extent! at any rate down to the base of the fin- 
 gers. In fractures of the neck or shaft the elbow should 
 be bent at right angles and the hand held midway 
 between pronation and supination, tw^o well-padded broad 
 splints extending down to the lingers being firmly fixed 
 on by strapping, broad bands, or a roller (Fig. 555). 
 When, as in fractures of the shaft, there is a disposi- 
 tion for the fragments to fall inward, some extra pad 
 may be employed. 
 
 The splints should be removed after three weeks and 
 freedom given to the hand, movement of the muscles 
 being encouraged ; shorter splints or some immovable apparatus should also be substitu- 
 ted down to the wrist whilst union is being consolidated. Lateral pressure of the bandages 
 must always be avoided. 
 
 In fractures of the lower extremity of the radius the old-fashioned jiistol-shaped splint 
 is still in favor -with some, its object being to keep the hand and wrist adducted. and 
 thereby to counteract the deformity that .so commonly attends this form of fracture. 
 Some surgeons, and more particularly the American, apply it to the palmar, and others, 
 including Nelaton, to the dor-sal. aspect, with a shorter second splint. I am no believer 
 \j) its virtues; for if the fracture be P ..„ 
 
 impacted and the fragments are not 
 loo.sened, it is u.seless. as union has only 
 to go on between the imjiacted fragments 
 for a cure to be efl'ected ; and when the 
 fragments are loosened and the bones 
 brought into apposition by extension and 
 manipulation, the pistol splint is not 
 wanted ; indeed, it is probably injurious, 
 causing displacement of the broken 
 bones. A well-padded broad anterior 
 splint reaching to the roots of the fin- 
 gers, with a dorsal splint, answers every arrs-pm . 
 purpose, the wants of the individual case determining the amount and position of the 
 extra padding. The best splint is without doubt that known as Carr's splint (Fig. 556). 
 
 Splints for Fracture of lore-Arm 
 
Dr. Goidon's Spliut for Colles's Fracture. 
 
 880 ON FRACTURES. 
 
 It is about eleven and a half inches long and two inches wide. The anterior portion has 
 an irregular convex surface, to fit into the concavity of the lower side of the radius, and 
 
 the posterior is flat ; connected with the 
 Fig. 55/. anterior an oblique cross-bar four inches 
 
 long is fixed for the patient to grasp. When 
 padded and nicely fixed with strapping or a 
 bandage, it is eflScient and comfortable. 
 
 Dr. Gordon of Belfast has introduced a 
 splint that has found favor. It " consists 
 of the body, the ulnar and bevelled portions, 
 with a curved back splint (Fig. 557). The 
 lower end of the ulnar portion is curved 
 forward and hollowed, to receive the inner 
 border of the flexed hand, with a slit for 
 the carpal strap. The bevelled portion is 
 secured to the body of the splint nearly half an inch internal to its margin ; it is cut oflF 
 obliquely from without inward and from below upward ; it is applied to the palmar sur- 
 face of the upper fragment, which it is its ofiice to fix. The lower end of the back splint 
 is much curved forward. This curve, with a thick pad, is necessary to enable it to press 
 the base of the metacarpus, the carpus, and the lower end of the lower fragment v:eU for- 
 ward for the restoration of the natural aspect of the carpal surface and the concavity of 
 the radius ' (^Gordon on Fractures of Baduis. etc.. p. 2-4, 1875). 
 The fore-arm should be well supported by a sling. 
 
 After this form of fracture the wrist-joint rarely recovers its normal movement, some 
 deformity permanently remaining ; and of this the patient ought to be warned. I have 
 recently, however, had under care (June, 1878) a case of double compound Colles's frac- 
 ture in which a recovery took place without any deformity. 
 
 Fractures of the ulna are almost always the result of direct violence, the mid- 
 dle and lower parts of the shaft — the thinfter portions — usually suflfei'ing. In these cases 
 there is. as a rule, little displacement ; and when it exists, it is of the lower fragment. 
 On manipulation crepitus is usually present, with local pain. Fracture of the oh-crnnon 
 process is a verv frequent accident fi'om a fall or blow upon the elbow or a sudden action 
 of the triceps. In it there is always more or less displacement of the end of the process ; 
 and the smaller the piece, the greater the displacement, the base of the process being held 
 well in position bv the fascia covering the bone and the periosteum. Fracture of the coru- 
 noid process (Guy's Museum, 1119'^^j, with or without dislocation of the ulna backward, 
 has also been described, though very rare. In the case from which Fig. 559 was taken 
 it coexisted with fracture of the head of the radius. The styloid process of the ulna 
 may likewise be broken and displaced forward or backward, and is generally caused 
 by a fall upon the hand ; it is, consequently, a frequent accompaniment of Colles's 
 fracture. 
 
 Treatment. — In fractures of the shaft the treatment is simple, the radius acting as 
 a splint and preventing shortening. The surgeon has only to see that the broken bone 
 is kept quiet and that the fragments are in position. This is well done by means of well- 
 padded anterior and posterior splints, the hands being fixed in a po.sition midway between 
 pronation and supination, Carr"s splint being the best. 
 
 In fractures of the coronotd process the fore-arm should be kept flexed, to relax the 
 brachialis anticus muscle, which is inserted in it, and in fractures of the olecranon nearly 
 sitraiglit. to relax the triceps, through which the separation of the fragments takes place. 
 The splint may be strapped on or fixed by strapping, and in severe cases an immovable 
 apparatus is advisable. 
 
 Some separation of the fragments very frequently remains after fracture of the ole- 
 cranon, which increases when the arm is used too soon, the power of the arm being con- 
 sequently weakened. Passive movement of the arm. however, should always be permitted 
 about five weeks after the accident, all violent effiijrts being condemned. 
 
 Fracture of both radius and ulna occurs about as frerjuently as fracture 
 of the ulna alone, but not a quarter so often as fracture of the radiu.s-. Direct violence 
 is the usual cause, a fall upon the hand being more commonly followed by fracture of the 
 radius than by that of the two bones. 
 
 Malgaigne has recorded instances of this accident from muscular action. In infants 
 the r/rern-i^tick or incomphte fracture of both bones is not infrequent. 
 
 The fracture may be transverse, oblique, or comminuted, and the displacement of the 
 
SPECI. \ L I'llA CTVllES. 
 
 881 
 
 Fig. .>j8. 
 
 Radius aud I'lna 
 (oiiMilidaled after 
 Fracture. i I'rep. 
 
 frujriiK'iit luav vary vastly aceoriliii;.' to the »linctii)ri and violence of the force which pro- 
 iluccil it. 
 
 Tlu'si' fractnri'.s arc readily made out and not often ilifficult to manage, although at 
 times the .siirgcon.s ingenuity i.s ta.xed to prevent deformity. 
 
 Tkk.vtmk.nt. — Tndcr all circumstances the fore-arm .should be flexed and the hand 
 kept in the scmi-pronc jiosition. Two vlih; splints should be employed, well jjadded, broad, 
 and coming down to the roots of the fingers, the surgeon so arranging his 
 jiads as to j»revent deformity and to neutralize the peculiar tendency of 
 the fracture. When the parts are bandaged too tightly, the bones may 
 be pres.scd together, and con.solidation takes place as a whole, with con- 
 se»|uent loss of moti«in,or the two bones may be braced together by some 
 bony isthmus (Fii;. 55S). Lmfir nil rirciimstunits t/ic j'r<icliii<- shoiilJ he 
 put ii/t with tltf hdinl .tupinotnl, the dorsal splint being first applied, and 
 then the |>almar, the fore-arm being semiflexed. When fracture of the 
 ratlins antl ulna takes place above the wrist-joint, the .symptoms may 
 simulate those of dislocation; but the greater mobility of the lower ends 
 of the bones, crepitus, and local pain ought to forbid the error being 
 acted upon. 
 
 Fracture of the carpal bones can occur only from direct vie- 
 lence. .snna' crushing force lieing the usual form. It may be difficult to 
 tliagnose, as the same force that produced the fracture will to a certainty 
 have injured the soft parts around the bones. Hapjdly, however, the 
 treatment of any severe injury to the wrist should be such as will serve 
 for all ; for the api)lication of an anterior sjdint, as well as cold lotions 
 and absolute rest of the injured part, ought always to be observed in all clear as in 
 doubtful cases, and with these a good result may generally be secured. 
 
 Fracture of the metacarpal bones i-> not rare. It is commonly caused by 
 some blow when fighting or otlicr furni of direct violence. Thus, it is most frequent 
 in the right first and fifth bones. Dr. E. H. Bennett of Dublin has shown (Dub. Joitrn, 
 *>/ Med. Sri., January. 1882) that in the commonest form the fracture passes obliquely 
 through the base of the bone, detaching the greater part of the articular facet and allow- 
 ing the body of the bone to be displaced with the thumb backward. It is rarely compli- 
 cated with much displacement. In young subjects the head of the bone or epiphysis 
 may be displaced. It should be treated, as all fractures. '• with brains," the pads and 
 splints being so applied as to fulfil the wants of the individual case. In the majority a 
 simple pad placed on the palm, with an ajiterior splint, may be sufficient. In one case 
 Malgaignes plan of placing a thick compress under the head of the bone and a second 
 over the dorsal projection, with two broad splints across the hand, may be called for; in 
 another Sir A. Cooper's, of binding the flexed fingers over a ball, may fulfil the necessary 
 requirements; but. as a rule, an anterior splint and jialmar pad carefully adjusted supplies 
 every want and is sufficient, the surgeon remembering that the palmar surfaces of these 
 metacarpal as well as phalangeal bones are concave. 
 
 Fracture of the phalanges is usually compound, although it may be simple, 
 and is easily diagnosed and readily treated. A simple anterior splint is all that is required, 
 a dorsal being rarely called for, a piece of wood .serving for the pur- 
 pose, though a thin. piece of perforated zinc is preferable. The splint 
 should be fixed on with strapping, a coating of the compound tincture 
 of benzoin rendering all firm and immovable. 
 
 In compound fracture into the elbo^w -joint, when the parts 
 
 are much injurLMl. excision is pmbablv the wisest step to adopt, as by it 
 convalescence is hastened and a good arm with a movable joint, as a 
 rule, given, whereas a recovery by natural processes without operation 
 will probably end with anchylosis after a tedious process of suppura- 
 tion. When the injury, however, is not severe and the patient young, 
 excision is not called for, a recovery with a movable joint being pos- 
 sible. I have had several excellent examples of this under my care 
 during the last few years. In aged sulijects, however, amputation 
 may be required, and in the one from which the preparation (Fig. 559^ 
 was taken such a. step was demanded. The drawing illustrates an 
 uncommon form of accident^ — comminuted fracture of the head of 
 the "radius and fracture of the coronoid process. 
 
 Coraponnd fractures of the arm and fore-arm ought to be treated upon 
 
 Fig. 559. 
 
 Fracture of the Coto- 
 noid Process and 
 Head of Radius, pro- 
 duce<l liy a Fall u|W)n 
 the IClb'ow. (Taken 
 from a woman xt. 
 To.) 
 
882 
 
 ON FRACTURES. 
 
 the same principles as the simple — that is. when the injury is not sufficient to necessitate 
 amputation or excision the bones should be brought into apposition and kept there by 
 means of splints, interrupted or not, the wounds being covered either by lint soaked in 
 blood, or, what is better, by the compound tincture of benzoin. It may be added that 
 the injury should indeed be great to necessitate amputation, it being justifiable to incur 
 some extra risk to save the hand. 
 
 In a severe case of compound comminuted fracture of the humerus caused by the 
 passage of a rifle bullet through the bone in a young man, which came under my care at 
 
 Fig. 560. Fig. 561. 
 
 Compound DiMocation of Ulna 
 and Shalt of Iladius I orward, 
 with Displacement of the 
 Lower Epiphysis of the Ra- 
 dius Backward. 
 
 Stromeyer's Cushion (from MacCormac). With straps applied. 
 
 Guy's, good success attended the immediate sealing of the 
 wound with benzoin and the application of the splint. The 
 man left the hospital in three months with a firmly-united bone 
 and a good sound arm. In such a ca.se as that represented in 
 Fig. 560; where displacement of the lower epiphysis of the radius 
 and dislocation of the ulna existed, amputation was demanded. 
 I have little to add to what has already been given in the way of treatment of com- 
 pound fractures of the humerus beyond an allusion to Stromeyer's cu.shion. which com- 
 mends itself to attention as much by the eminence of its advocate as by its usefulness. 
 It was introduced to our notice by Sir William MacCormac (Fig. 561). 
 
 The cushion may be described as triangular and wedge-shaped. At its thickest end 
 it measures four inches in depth, and from this point gradually thins down for a length 
 or fourteen or fifteen inches. The elbow rests on the thick end, while the thin rests on 
 the side of the chest. The cushion is readily fastened in its place by a tape round the 
 neck and the body ; and when this simple apparatus is applied the arm rests beautifully 
 supported and in excellent position. Whilst lying in bed nothing beyond the ordinary 
 dressings are required for the wound ; and if the patient has to be transported from one 
 place to another or is fit to walk about, this can be arranged with the utmost facility, as 
 cushion, arm, and all can be bound by a broad bandage to the body and thus form an 
 immovable whole. Stromeyer considered this cu.shion to be "the most valuable appliance 
 he had invented during his life." I have used it for fracture and dislocation of the 
 humerus and for shoulder-joint disease with great advantage, and have adapted straps to 
 it to hold the arm and fore-arm in position. 
 
 Compound dislocation and fracture of the phalangeal joints require 
 
 a distinct consideration, and the .slight constitutional svniptunis which such injuries induce 
 enable the surgeon to treat them on purely local considerations. 
 
 To dwell on the importance of the integrity of the hand as a whole or to adduce argu- 
 ments to show the necessity of saving as much as possible of the thumb and fingers is 
 unnecessary, since these rules of practice are now acknowledged ; yet such have their 
 limit, as anchylosis of some of these joints may prove an impediment rather than an 
 advantage to the free use of the hand, and a stifi" finger to a man in one business may 
 be most detrimental, while to one in another, if bent, it may be of service. 
 
 With the thumb, however, the above rule may be considered absolute, and an attempt 
 should invariably Vje made to save the joints and as much as possible of the injured parts, 
 it being often better in compound fractures to leave the bone to granulate than to remove 
 it ; for the use which may be made of the stump of a thumb or of one fixed by anchy- 
 losis can be appreciated only by those who have been fortunate enough to witness such 
 instances. 
 
 With the fingers this rule will not hold so good, since it often happens that the loss of 
 a finger will be found of less inconvenience than a stifi" one. In a general point of view, 
 a stiff metacarpo-phalangeal joint to a laboring-man is an impediment, while to a gentle- 
 man it may be of service and at the same time preserve the comeliness of the part. A 
 
FiiAcrriiEs or riii: ijt\\'i:n kxtiuimity. 883 
 
 8tifl' fir^l |i!i;il;iiiiri';il jniiit will Ik- iiiust iprcjinlicial in sniiic frailcs. wliilc in hIIkts it is (if 
 sliu'lit iin|Mirt;iiic('. A stifV joint lictwti-n tin- cxtninr iili;il:in;rcs is nin-ly oj' niu< li 
 nmniriii . 
 
 Till- pationt. liowfViT, slimild he consiiltiMl Ity tlir snrpNiti in all these cases and the 
 treatment ailapted ti> tlie wants nf the individual, since a fiositictti that may be f^ood fur 
 one may he had for aiinther. and nu one imsition is applicalth^ to all. It is too common 
 to find men applyiiiLr at liundun h(»s)iitals to have tin^n-rs remi»ve<l that have heen savetl, 
 but lixed at bad aiiiriis. the stiff lini:t r bein^ an iniprdiniint to the free performance of 
 their trade. 
 
 In compound fractures and dislocations cd' tlx; thumb htose frafrments of bone sh<»uld 
 be removed and joints excised ; as much us possible (»f the soft parts should be saved and 
 the wound left to natural processes for repair. To amputate a thumb for injury ought to 
 be a very rare ojieratiou. In those injuries to the fingers the same priticiples of practice 
 should be adojited, although modiKed by the wants of the individual case. To .save a 
 finger and to amputate it monthsafter on account of sfune stiffness of joint or malposition 
 is to waste time. When a joint has been oitened and anchylosis must be looked for after 
 a natural recovery, the propriety of making tlie attempt should be discussed before the 
 practice is decided upon, wlu-n, if the decision be in i'avor of a conservative practice, the 
 injured parts should In- adjusteil and fixed by means of a splint in the most favorable 
 position. 
 
 In most subjects the straight is a forced and inconvenient position, and not that ever 
 assumed hy nature with the hand at rest. The best is the slightly bent, when the thumb 
 and fingers can touch at their tips, or that wliich the hand naturally assumes when at rest. 
 In exceptional cases, however, exceptional positions may be required. I have for years 
 acted upon this principle, and always with advantage. 
 
 The best splint for fingers is a piece of perforated zinc. It i.s thin and can be bent to 
 the reiniired curve without trouble, as well as readily fixed on with strapping or lint 
 saturated in tincture of benzoin. 
 
 Fractures of the Lower Extremity. 
 
 Fractures of the pelvis, as of the cranium, spine, and thorax, are of importance, 
 inasmuch as tlie visceral contents are involved; but when no such complications exist, the 
 injury is, comparatively, not dangerous. 
 
 Fracture and dislocation of the bones commonly occur together and may be regarded 
 as alike in a clinical point of view. 
 
 The anterior portion of the crest of the ihum is not rarely broken from 
 direct violence, and the accident is not serious. Eest in bed, to keep the abdominal 
 muscles quiet, and the application of a pad with strapping, a mould of gutta-percha, or a 
 broad ])elvic belt when displacement exists, are the ordinary surgical means required. 
 
 Fracture of the pelvic basin itself is usually the result of some crushing force, 
 the weakest jtart ))reaking. such as the rami of the pubes. In other cases there will be 
 some si'iiaraiion of the pubic bones at the symphysis or other fracture of the brim. In 
 many the injury will be complicated with laceration of the urethra. In the ca.se of a 
 female jct. i^U, which I had under care, the bones were displaced on the right side for 
 more than an inch, when a curious deformity resulted, the pelvic bones with the adductor 
 muscles being curved out, leaving a hollow on the inner side of the thigh. 
 
 In another, sent to me by Dr. Bennett of Builth, in a female child, great separation of the 
 pelvic bones was present, the whole pelvic organs having been pres.sed out of the outlet of 
 the pelvis by the crushing force. The large intestine for about a foot, uterus, bladder, etc., 
 were all in view, the whole perin.ieum having been ruptured. The drawing (Fig. 562) 
 shows the child's condition when I saw her fourteen months after the accident. How 
 the child escaped with life was a mystery, the perinaeum being gone, the bowels protrud- 
 ing, and the bones of the pelvis widely apart. Such a case is enough to show how great 
 an injury tlie pelvis may occasionally sustain without causing death. As an example of 
 fractured jtelvis Fig. 563 may be referred to. 
 
 Di.\(iN(»sis. — The greatest care is necessary in examining the subject of a suspected 
 fracture of the pelvis, yet the diagnosis can generally be made from the nature of the 
 force employed, its direction, and the complications that exist. Urethral complication 
 is the most common in the male, and ought to be treated as already described at p. 
 698. As an illustration of the practice there recommended, in June, 1875, a boy aet. 
 7 was admitted under my care into Guy's Hospital with fracture of the pubic bones and 
 
884 
 
 ON FRACTURES. 
 
 laceration of the urethra, accompanied witli prol'use liemorrhage and retention, for which 
 catlieterisni was ineftectual, and death seemed imminent. I consequently made a free 
 incision into the periiu>jum down to the lacerated urethra upon a grooved staft', and a 
 rapid recovery took place after. Under all circumstances the utmost quiet must be 
 enforced ; for if the surgeon is unable to restore the fractured bones to their normal posi- 
 
 FiG. 562. 
 
 Fio. 503. 
 
 Fracture of the Pelvis in a Child, with Separation of 
 I'ubes, Prolapse of Rectum and Uterus. 
 
 Fracture of Pelvis. 
 (Prep. No. llo4, Guy's Hosp Mus.) 
 
 tion, at any rate he must do nothing to render their displacement greater or to increase the 
 risk of visceral injury. Where support by means of a bandage, strapping, or casing of gutta- 
 percha or some other substance gives comfort or seems called for, it should be applied ; 
 but in general "absolute rest and such treatment as the complication may require are all 
 that is necessary. In two cases I have seen obstruction of the iliac artery associated 
 with fractute of the brim of the pelvis. In one the vessel was so stretched as to cause 
 laceration of its inner and middle coats and obstruction, which were followed by gangrene 
 of the corresponding limb. In the other the obstruction lasted three weeks, when pulsa- 
 tion returned and the patient recovered. 
 
 Fracture of the acetabulum from the head of the femur being driven against 
 the bone has been recorded. Earle, in the nineteenth volume of the Mf'd.-Chir. Trans., 
 adduced a case in which the pelvis was broken into its three anatomical portions. Sir A. 
 Cooper and Travers have recorded others. Moore, also, in the thirty-fourth volume of 
 the same Transactions^ has given another, with a drawing, as figured here (Fig. 5G4). 
 When the head is driven into the pelvis, as illustrated in the drawing, there will be 
 deformity of the hip, inability to move the limb, with pain in the attempt, and crepitus. 
 Travers believed that acute pain on pressure upon the projecting spine of the pubes and 
 inability on the part of the patient to maintain the erect posture after pelvic injury are 
 diagnostic of fissure of the acetabulum. 
 
 A fracture of the Up of the acetaLu/inn is probably present in such cases of dislocation 
 of the hip as become displaced again after reduction, the head of the bone, having nothing 
 
 to restrain it, slipping out of its cup. In these cases the re- 
 duction of the dislocation is usually attended with crepitus, 
 followed by redislocation on the removal of the extending 
 force. It should be treated by fixed extension, as in frac- 
 ture of thigh-bone, and some circular pelvic pressure. This 
 accident is move frequently associated with dislocation of 
 the head of the femur backward than with any other. 
 
 Fracture of the sacrum may be regarded clinically like 
 tliat of the pelvis ; it is always the result of direct vio- 
 ence. 
 
 Fractures of the Loioer Extremitij. — From hospital sta- 
 tistics these fractures appear to be more common than those 
 of the upper extremity ; but, as the majority of cases of 
 fracture of the upper extremity are treated as out-patients, 
 of which no records are kept, the conclusion is weakened by 
 a fallacy. The Middlesex Hospital statistics, compiled by 
 Lonsdale and H. Morris for sixteen years, tell us that there 
 are 1206 examples of fracture of the lower extremity to 1932 of the upper, proving that 
 fractures of the upper extremity are twenty-three per cent, more frequent than those of 
 the lower. 
 
 Fig. 564. 
 
 Head of Femur driven through Ace- 
 tabulum. (Med.-Chir. Trans., vol 
 xxxiv.) 
 
FRACTl'Iih'S OF nil-: LOW Eli EXTREMITY. 885 
 
 Fractures of the femur lorm altout one-fourth of all fractures of the lower 
 extrcriiitv, and IVaetures of ihc neck ahout one-fifth of the fractures of the l)one. They 
 may !••' tliviiU'tl into those (1 j of the mrlc or nji/nr ni<i, (2) of the s/m/f, and (:{) of the 
 loici r or liuiili/ltir < ml . 
 
 Fracture of the neck or upper end existed in \ l out ..f li 17 consecutive cases 
 admitted into (Juy's, ur in one-lift h of all cases. It is more fre(|uent in the old than in 
 the yonn-,', proliahly iVom the impaired nutrition of the hone, tlic cortex in the ajjced heing 
 always thinner and the caiieeUi lartrer. I have, however, seen it in a boy set. 12 and a 
 munjut. liT. Staidey and Hamilton have recorded examples at even an earlier a<:e. In 
 Guy's Museum there is a specimen taken from a child ;ut. \) (l^rep. 11S4;. 
 
 When the fracture involv(!s the neck near tlu; head of the Itone, it has been called 
 iiifrd-vii/isiilar ( Fi<j;s. ')<!.') and .jTO) ; when the base of the neck near the trochanters, rxtra- 
 ciif>sit/iir ; but in these the joint is <ienerally involved, the line of 
 fracture, as a rule, being obli(|ue from the neck witliin to the Fi«- ^'C^^- 
 
 base of the neck without the ca])sule. Both ffjrnis may be ini- 
 paeteil ; the former is so fre<|uently, the latter frenerally. 
 
 In the fractures of the neck near the head of the bone the 
 neck of the bone is usually driven into the liead ( Fig. 570). In 
 the fractures of the base of the neck the neck is, as a rule, driven 
 into the shaft (Figs. "jlJo, 5(!(5, 5(i7). In exccptiomil cases the 
 impaction is double (Fig. 571). 
 
 Fractures of the narrow part of the neck of the femur are 
 generally caused by Indirect violence, such as tripping in the car- 
 pet ; fracture of the base of the neck by direct, such as a fall 
 upon the trochanter. When the posterior ridge of bone pene- 
 trates the trochanter, there will be eversion of the foot, the outer , ,, 
 surface of the trochanter looking backward, and the anterior .sur- L.'^ 
 face of the neck will be felt as a prominent projection beneath intra-Capswiar i-racmre of the 
 the rectus muscle. When the anterior ridge of bone penetrates Ligameiitous Kepair.*^ '''^""^ 
 the lower fragment, the foot will be straight or inverted, the sur- 
 face of the trochanter will look outward, and a great fulness will be felt behind the tro- 
 chanter. Should the limb be much addncted when the patient falls upon the trochanter, 
 the lower border of the neck may be driven into the trochanter, as seen in Figs. 535, 
 5GG ; and should the limb be much nhdncfed when the fall takes place, the fracture will 
 probably be in the narrow part of the neck, and therefore unimpacted and intra-capsular, 
 \Yhen the penetration of the neck is great, the trochanter will be broken off and there 
 will be no impaction, but the usual unimpacted fracture of the neck. 
 
 With these facts before us, the best division of fractures of the neck of the femur 
 for practical purposes seems to be into i\iQ impacted s^nA. unimpacted. 
 
 Sir A. Cooper recognized this fact of impaction to a degree, though he did not quite 
 see its importance, when, in describing fractures of the upper part of the thigh-bone he 
 wrote, " The fracture is placed at the root of the neck of the thigh-bone, the trochanter 
 is split, and the neck of the bone is received into its cleft. It fref(uently happens in this 
 injury that the fracture of the neck of the thigh-bone is complicated with an injury of 
 the trochanters, major and minor ; the neck of the thigh-bone is forced at times into the 
 cancelli of the major trochanter." To the late Professor R. W. Smith of Dublin the 
 thanks of the profession are unquestionably due for having given prominence to this class 
 of cases, and in his valuable work on fractures in the vicinity of joints, published in 
 1850, will be found nearly all that is known about the subject. 
 
 I am fully prepared to endorse his opinions and to agree with him '■ that all extra- 
 capsular fractures are in the first instance also impacted fractures." I believe, moreover, 
 that many so-called intra-capsular fractures and all mixed forms are primarily of a like 
 kind, and " that it depends principally upon the violence with which the injury has been 
 inflicted whether the neck of the bone shall remain implanted between the trochanters, 
 or whether these processes shall be so completely .separated from the shaft of the femur 
 as to allow of the escape of the cervix from the cavity which it had formed in the reticu- 
 lar ti.ssue of the lower fragment. If the force had not been very great, the neck of the 
 femur remains wedged in between the trochanters and one or both of these processes are 
 split off from the shaft ; and if the fibrous structures around the neck of the bone and 
 trochanters have not been injured, these broken portions of the trochanters are still held 
 firmly in their places and the cervix does not become loosened (Fig. 566) ; but if the 
 force has been considerable, the impulse prolonged, the bone in a state of senile atrophy. 
 
886 
 
 OX FRACTURES. 
 
 or if, as frequently liappens, the patient in endeavoring to rise falls a second time, then, 
 under these circumstances, the trochanters are not only broken from the shaft of the 
 femur, but are so far displaced and separated from their connection with the soft parts 
 that the cavity or socket, as it were, into which the superior fra,i>nients has been received, 
 is destroyed ; the impacted cervix thus set free no longer opposes the ascent of the 
 inferior fragment, and the case then presents the characters of the ordinary extra-cap- 
 
 FiG. 566. 
 
 Fig. 567. 
 
 Impacted Fracture of the Neck of the Thigh-Bone. 
 (From the museum of my father, the late Mr. T. E. 
 Bryant. Prep. Guy's Mus.", llSV^s.) 
 
 Comminuted Fracture of the Upper Fart of the Thigh- 
 Bone from the Neck being driven into the Shaft. (Prep. 
 119-), Guy's Mus., 
 
 sular fracture with great shortening of the limb "" (Fig. 567). In fact, the ordinary 
 fracture of the base of the neck of the thigh-bone is primarily an impacted fracture, the 
 impacted bones in some cases being loosened by a second fall, in others by excess of vio- 
 lence I'eceived in the original accident, and in too many by the manipulation of tlie surgeon 
 in his anxiety to make out the presence of a fracture hy the detection of crepitus. Indeed, 
 this seeking for crepitus in cases of fracture .is a practice fraught with danger. In frac- 
 tures of the neck of the thigh-bone it is not only unnecessary, because the diagnosis of 
 the case can be made out without it, but it is unjustifiable, as the attempt to find it in 
 every case of impacted fracture is often attended with irreparable mischief. 
 
 Symptoms. — The diagno.sis of fracture, impacted or otherwise, is a point of con- 
 siderable importance, but that of an impacted fracture is particularly so. since it is not to 
 be disputed that the recovery or degree of lameness of many a patient depends upon a 
 correct appreciation of the value of such symptoms as usually exist in this variety of 
 fracture, and that, too, in a very critical period of the case. Should an error in diagnosis 
 be made and the case being one of impacted fracture be overlooked, violent manipulative 
 efforts will probably be made to reduce the supposed dislocation or to set the supposed 
 
 fracture, or, what is equally probable. 
 Fig. 568. to decide the question between the pres- 
 
 ence of the two by the detection or 
 non-detection of crepitus. As a con- 
 sequence of this violence the impacted 
 bones will to a certainty be loosened, 
 if not woi-se disturbed, and the case 
 will be changed from one in which the 
 bones were placed favorably for union 
 and recovery into another in which a 
 very different set of circumstances has 
 to be encountered and a less favorable 
 progno.sis has to be given. 
 
 Happily, however, the diagnosis 
 of these cases is not difficult, and the 
 symptoms that indicate the presence 
 of an impacted or non-impacted frac- 
 Figure showing how the Trochanter of the Fractured Bone is ture are fairly characteristic. Those 
 Drawn Upward nearer the Anterior Superior ."^pine of the Ilium. „ ,. *^ . ^ ^ £■ ^ 
 
 A, Normal length of ba.se of ilio-femoral triangle (Fig. 569). B, ot an ordinary nou-impactecl tracture 
 Shortened base of ilio-femoral triangle. C, Horizontallevel of „f ^\.a rippl- nf tlio tliio-Ti Vinnp in anv 
 fractured bone. D, Horizontal level of sound bone. ^^ ^ .^ ^^^^ "' ^"^ , . ^ . ,. ^• 
 
 position are some slight indirect or 
 violent direct force ; a slxortenincj of the limb from one to two and a half inches ; rotation 
 outuyrrd of the limb, with eversion of the foot from mere gravity ; inability to ravie the 
 
I'liACTi'iiEs or Tin: i.owiai ExrnF.Mirv 
 
 887 
 
 llnth on tin* part of" tlu' |iali('iit, Itut jin-atcr iiiovi-iiifiit.s of tlic liiiili l»y the Mirj^tion's 
 haiul.s ; nin/Zin;/, ai-conliii;:; to tin; cliaraotcr of loicc t-inployc-il ami (iiiic after iiijurv ", j"tin 
 and oi'i-asioiial ntfiifus. In rafe ca.sfs of iioii-iiiipaclcil frartiin- of I lie m-ck the fo<it may 
 lie inverted and the thij;h even flexed. Those of an impaeled IVaeture are a hlow or 
 /</// itfiDii thr frnr/ninfrr, followed hy u more or less complete loss uf p<ni:cr in tin: limb; 
 sliDiti itimj to the extent of half an ineh or one inch ; a jLad, rctrttil, invirfrif, or Kfr<iii//tt 
 ]iosition of the foot, which moderate extension will nnf rectify: and when the impaction 
 is jfreat, an appnjxiination of the <j;reat trochanter to the median line of the Ixjdy (Fig. 
 5()S). The head of the hone will rotate in the aeetahnlnm. and the trochanter with it, 
 the rotation, however, of the trochanter taking place through an arc of a circh; of which 
 the head nf tlic hone is the centre, instead of ujion the axis of the shaft, as in detaclutd 
 fracture of the neck. There will he imlistinct or inj crepitus. ].,it(;al pain will always be 
 felt on pressure behind the trochanter, and local thickening within a few days of the acci- 
 dent. 
 
 When, iVnni the direction id' the I'orce applied to the troehaiitt-r. t\ie j>'js/r,i>/r wall of 
 the neck is driven into the inter-trochanteric line, the limb will Ix- rotated outward and 
 the foot rrt>rt>'<f ; and when the (inferior wall is driven into the bone, there will be invention 
 of the limb. The former I'orm of accident is far more common than the latter, on account 
 of the greater thinness of the ])osterior wall. 
 
 To make out the existence of shortening of the neck of the thigh-bone and its amount, 
 Nelaton's line is most inconvenient, since it necessitates the semi-rotation of the patient 
 over toward the sound side, and consequently it includes the risk of causing displacement 
 of the bones. My own test-line has no such objection and can be applied to the patient 
 in the horizontal posture. I have used it for many years and found it of great value ; 
 indeed, as a proof of its use I may add that forty-two consecutive cases of fracture of 
 the neck of the thigh-bone admitted into my wards to the end of 1883 (the average age 
 of tlie patients being seventy) left the hospital with union of the broken bones and use- 
 ful limbs. Only one patient, ;^t. 79, died, and she did so witli the fracture, though not 
 from it, but from sloughing of the skin in her lumbar region from injury sustained at the 
 time of the accident. In two oidy of the forty-two ca.ses was there any bedsore, and 
 these gave no trouble. All were treated with the double splint (Fig. 573). The diag- 
 nosis of all these cases had been made by means of the test-line I now describe, and with 
 the gentlest manipulation {Lancet^ January 22, 187G). 
 
 For purposes of demonstration I have described it as the base of the ilio-femoral 
 triangle (C B, Fig. 5G9), the two sides of the triangle being made up of two lines drawn 
 from the anterior superior spinous process 
 of the ilium, one of them, A C, being ver- 
 tical and traversing the outside of the hip 
 to the horizontal plane of the body, and the 
 second, A B, impinging on the tip of the 
 trochanter major and c(jrresponding in the 
 normal conditi(»n of the hip-joint to the an- 
 terior half of Nelaton's test-liue for dislo- 
 location of the head of the femur back- 
 ward. 
 
 The test-line C B for fracture or short- 
 ening of the neck joins the two at rlaht 
 
 „ 7° j.„xu„ *■ 1 r 1 i. J i? The Ilio-Femoral Rectangle, A B r. r B, test-line for frao- 
 
 anyles to the vertical line and extends from tare or shortening of the neck of the thigh-bone. 
 
 it to the trochanter. Any shortening of 
 
 this line, on comparing it with the same taken on the uninjured side, indicates with pre- 
 cision a shortening of the lu'ck of the thigh-bone ; and when the shortening has imme- 
 diately followed an injury, fracture of the neck of the thigh-bone, impacted or otherwise, 
 is certain. Compared with this line, all other measurements are uncertain. By its use 
 manipulations of the injured limb are rendered unneces.sary. For practical purposes the 
 vertical line A C and the test-line C B are alone reiiuired. To coni]iare the two sides of 
 the !)ody it is necessary to see tliat the pelvis is .straight. 
 
 -"^ly friend Mr. H. Morris has likewise a ready method of measuring those parts, 
 will -h he calls the bi-trochanteric measurement. (See Ilofnies's S^sf., vol. i. 3d ed. p. 
 1003). 
 
 The symptoms thus described, taken as a whole, may be looked upon as pathogno- 
 monic of an impacted fracture ; for, although there are other injuries to the hip-joint 
 which may give rise separately to manv of the symptoms detailed, there are none in 
 
 Fig. 569. 
 
888 
 
 ON FRACTURES. 
 
 which all or most are found combined. There is no injury to the hip-joint in which the 
 head of the femur rests and can be made to rotate in the acetabulum, and in which imme- 
 diate shortening is ever found, with the exception of a fracture, and there is no form of 
 fracture that occurs under like circumstances, with the exception of the impacted, that is 
 not accompanied by crepitus that can be readily detected, with complete ever.^ion of the 
 foot, marked shortening, and loss of power over the limb. 
 
 These points are well brought out in a paper in the Med. Times of 1869. in which I 
 gave a careful analysis of fourteen cases. 
 
 When sudden increase in the amount of shortening takes place some days after an 
 injury to the hip. the separation of the impacted bones and the drawing up of the lower 
 fragment should be suspected ; and when some gradual shortening follows, it signifies the 
 absorption of the injured neck of bone. 
 
 The eversion of the limb, as found in the non-impacted fracture, is due to the simple 
 weight of the broken limb, aided by the action of the powerful external rotator, and pos- 
 sibly of the adductor, muscles. The po.sition of the limb in the impacted fracture, whether 
 slightly everted, straight, or inverted, is determined by the impaction of the anterior or 
 posterior wall of the neck, and by the fact that the foot will be fixed by the impaction in 
 the position in which it existed at the time of the accident. 
 
 In non-impacted fracture of tc.3 narrow end of the neck, or true intra-capsular frac- 
 ture, there is usually less shortening than in the non-impacted fracture of the base, this 
 symptom depending in both of these cases upon the amount of separation of the fibrous 
 covering of the broken bone. In the former crepitus is also less distinct. In both these 
 forms the shortening will be made to disappear by extension, whilst in the impacted, in 
 any of its varieties, no such efiect will be produced by ordinary force. 
 
 It can only be by carelessness that a contused hip is mistaken for a fractured thigh, 
 impacted or otherwise. I have, however, known this error to be committed. 
 
 •■ The practical importance of readily identifying this fracture." writes Bigelow in his 
 valuable monograph on the hip, •• lies in' the fact that its progress, as regards both time 
 and good union, is in general more favorable than that of the unimpacted fractures: that, 
 though it is a comparatively common and disabling accident, it may exhibit little deform- 
 ity; and lastly, that the object of extension in its treatment is to steady the limb, and not 
 to draw it down." 
 
 Treatment. — If it were as distinctly understood as it should be by all students and 
 practitioners that a fracture of the neck of the thigh-bone can be diagnosed without seek- 
 ing for crepitus, that all but the gentlest manipulation of an injured hip is likely to prove 
 injurious, and that any attempt to elongate the limb by forcible extension, to flex it, or 
 to rotate it with the view of restoring it to its natural position is likely to be followed by 
 a breaking up of the impacted bones, and consequently by irreparable injury, the treat- 
 ment of these cases would be as satisfactory in its results as it is simple and our work- 
 houses would be occupied with fewer cripples. If. moreover, it was recognized, as it 
 should be. that many intra-capsular and all extra-capsular fractures unite when rightly 
 treated, every case of fracture of the neck of the femur, impacted or non-impacted, intra- 
 or extra-capsular, in the young, middle-aged, or old. would be treated as if repair and 
 union were sure to take place if the parts are kept at rest and in apposition, and in the 
 
 Fig. 570. 
 
 Fio. 571. 
 
 Impacted Intra-<"apsular Fracture of the Xeck of 
 1 enuir Repaired. (Ca-e of the late Mr. T. E. 
 Brvant. Prep. 118750, Guv's Mus.; 
 
 Doubly Impacted Fracture 
 of the Xeck of the Thigh- 
 Bone. 
 
 large proportion of cases the hopes of the surgeon will not be disappointed. ( Vide statis- 
 tics of my own cases, p. 887.) In the purely intra-capsular fracture union may take 
 place, osseous in many cases (Fig. 570), fibrous in more (Figs. 565 and 57-4). In a few 
 
riiAcrritEs of riii'. i.owi'.it f.xtiif.mity. 
 
 889 
 
 there will lie ruuie, owiiij; to a total sepunitioii of the liead of the bone from its attach- 
 iiieiits or to the feehh; piiwer or ape ol" the patient, or because the broken fragment 
 receives too little nourishment to allow of suDicieiit reparative material bein;r poun-il out. 
 or because the fractured bones have not been kept sufficiently at rest and in apposition. 
 I'ndcr these circumstances the head ol' the femur will be loose in the acetabulum, with 
 its broken surface smoothed into a cup-shaped cavity, where tlic r<»und(.'<l cud df the 
 broki'u neck (d' the femur plays as in a false joint. 
 
 In the impacti'd fractures union ought to be looked for if the broken frajrnient.s are 
 left aloiu' and not loosened by a caniless or too curious manipulation. 
 
 In the non-impacted extensi(»n is to l)e more thoroughly employed. The best splint 
 for tliese purpo.ses is my double one (Fig. 'u?,). By it, in the non-impacteddrac-turc. the 
 
 Fig. 572. 
 
 Gurdon Buck's Method of applying Exton.sion in a Case of Fracture of the Neck of the Thigh-Rone. 
 
 limb should be brought down to a level with its fellow and maintained there by means 
 of the elastic extension pulley ; by its means both limbs are kept parallel, no pressure is 
 applied over the trochanters, abduction or adduction of the limb is prevented, and exten- 
 sion is maintained. With this splint no perineal band is required if the foot of the bed 
 is raised two or three inches. 
 
 In the impacted fracture enough extension is required to neutralize muscular action, 
 but no more. 
 
 Gurdon Buck's method of applying extension to the limb by means of weights has 
 found great favor of late years in America and this country, and is doubtless very good 
 and simple, the counter-extending force being applied by means of a perineal band of 
 india-rubber tubing fastened to the head of the bedstead or splint, while the limb is 
 steadied by means of long sand-bags applied laterally, or short thigh-splints (Fig. 572). 
 This plan, however, has the disadvantage of not preserving sufficient immobility of the 
 broken bones, and ought, therefore, to be employed only in conjunction with the lone 
 splint. 
 
 Sir A. Cooper's plan of placing the patient on a double inclined plane has few advan- 
 tages when union is to be looked for, and even the broad well-padded belt which he 
 
 Fig. 573. 
 
 Double Splint for Fracture of the Shaft or Xeck of the Thigh-Rone and Hip Disease. 
 
 applied around the pelvis in order to keep the broken fragments closely together cannot 
 be recommended ; still where the long splint cannot be worn the inclined plane may be 
 substituted. 
 
 When the necessary confinement to the supine position cannot be tolerated and bed- 
 sores appear, it may be necessary to give up the long splint, and under these circum- 
 stances it is wise to fix the hip, pelvis, and thigh in some strong, immovable casing 
 similar to that employed in hip disease (Fig. 623), the limb being kept extended by 
 
890 
 
 Oy FRACTURES. 
 
 means ot 
 
 Fig. o74 
 
 weights attached to the foot during the setting of the material. The casing 
 
 mav be of plaster of Paris, leather, 
 
 Fig. 
 
 ».'• 
 
 - =^ 
 
 y 
 
 PYacture of the Xeek of the 
 Thigh-Bone within the Cap- 
 sule"; Repair of Fracture Vjy 
 Means of Bone. Fibrous Tis- 
 sue, and Fibro-Cartilage : Ab- 
 sorption of the Xeek of the 
 Bone. (Prep, removed from 
 woman aet. 60 who had re- 
 ceived the injury five years 
 before..! 
 
 Femur of the Opjjosite Side, 
 showing the -Amount of Bone 
 AbsorbSi. 
 
 felt, perforated zinc, or flannel, with 
 starch or gum and chalk. 
 
 To allow the patient to get up 
 without any apparatus is not only to 
 give up all hope of a cure by union, 
 but to add to the local irritation, as 
 the broken fragments will grate 
 ,, ,v - . :y/ against one another and irritate the 
 
 w ,', . ,1 '' ' " '■ soft parts around, often causing se- 
 
 > V V\L • ■' ' .'--f/ ygpg local and constitutional disturb- 
 
 ance. Under all circumstances, how- 
 ever, immobility of the broken bone 
 is to be ensured. 
 
 Interstitial absorption of 
 the neck of the bone is some- 
 times met with after fracture, and in 
 Fig. 574 the fact is well illustrated, 
 the neck of the bone having almost 
 entirely disappeared, as will be seen 
 at once on comparing a section of the injured bone with that 
 of the uninjured from the same subject (Fig. 275). It is said 
 also to take place after a contusion without any fracture in 
 osteo-arthritis : how far it may occur otherwise is an open ques- 
 tion. My own impression is that in all such cases some fracture existed, though it is diffi- 
 cult to prove the truth of such an opinion. The question requires further elucidation. 
 
 Fractures through the trochanter occasionally occur— Sir A. Cooper describes 
 them as oblique fractures not implicating the neck of the bone — and can be made out by 
 the immobility of the lower portion of the bone whilst the upper part is fixed, and by 
 the other signs of fracture, such as crepitus, etc. They should be treated like fractures 
 of the neck. 
 
 Separation of the epiphysis of the head of the bone has been described. 
 
 South has recorded such cases in his CIieh')is'.< Surgeri/. and Post of New York in the 
 Xiiv: York Journal (vol. iii.). but no preparation exists to deuion.strate the fact. It is 
 doubtless possible in the young, and would be known by some such symptoms as those 
 of fracture of the neck, crepitus being exchanged for what South calls a '• distinct dummy 
 sensation " on rotating and extending the limb. As a consequence of disease it will be 
 described in a later chapter. 
 
 Separation of the epiphysis of the trochanter major is a more definite 
 
 accident, and doubtless has occurred. Sir A. Cooper recorded a case which Mr. Aston 
 
 Key had observed, and the diagnosis was 
 Fig. 576. Fig. 577. verified after death. In it. however, the 
 
 '' detached fragment was not displaced, 
 
 but held in position by means of its 
 fibrous and tendinous coverings ; the 
 separation was the result of direct local 
 violence : abduction of the limb caused 
 great pain, but all other movements 
 were allowed. The preparation exists 
 in the Guy's Museum (1105) and is 
 here figui-ed (Fig. 576). A like case 
 occurred in the practice of the late Mr. 
 Poland, at Guy's, in 1871, which through 
 his kindness I saw. It occurred in a boy 
 fBt. 12 from a direct blow, and was cha- 
 racterized by a projection and thickening 
 
 of the trochanter (Fig. 577). Similar instances have also been published by Dr. Roddick 
 
 of Montreal (^Cannda Med. aud Surg. Jounial. November, 1875), Mr. McCarthy (Pafh. 
 
 Trans.. 1874). and Agnew in his Surgerr/. 
 
 Fracture of the Shaft of the Femur. — This may take place in any part, 
 
 but is more common in the centre than elsewhere, and as a consequence of indirect vio- 
 
 Fracture of the Epiphysis of the Major Trochanter. 
 Mr. Aston Key's case. Appearance during life. 
 
 (Prep. 1195. Guy's Mus.i (Mr. Poland's case.) 
 
rii.\rrriu:s or riii: L<i\\i:n i:\"nu:Mrry. 
 
 «91 
 
 leiit'i' ; it niay nccur. liiiwcvor, as a result nl" liiicct I'nrcc, and iiion; rarely of muscular 
 action. Kroin this cause I have seen it i'nnu the swiii;;iiijr ol" the linih ov<;r the side of a 
 cart ill the act of ilesceiidiiif^. and in an e|iilc|»tic |)atient from tiie .spasm of the muscles 
 with the patient in Itcd. 1 have known it also to take place IVoin the same cause when 
 t-ancer ol' the hone existed. 
 
 The fracture may he fr<insiersi\ i>//fi(/iir in any direction, rv77<Vv//, t/i'iifutnf, rniiimiinit' ,1^ 
 or iiiifiiiiftii, the nature of the force and its direction deterininin^ these points. A sharp 
 lilow is likclv to lie followt-d l»y a transverse fracture ; a crushin<^ force by a comminuted 
 one; an imlircct fracture prohahly will he nl)li(|ue, aceordin;: to the natural heiid in the 
 lower jiart of the limit. In the upper third the hone may he broken obliijut,' I'roin above 
 ami in front downward and outward, and from impaction id' the lower extremity into the 
 upper the latter fratiincnt mav be coniminutrd. the Ixme splitting .secondarily upward 
 
 l-'i(i. 57 «. 
 
 Impacted Fracture of the Shaft of the Femur produced by a Fall upon the Knee in a Man at. 83. 
 
 into the neck. Dr. E. II. Bennett of the Dublin I'niversity has written an intere.sting 
 paper on this form of fracture (Brif. Mxl. .Iniirn., June 2(), 1880). In the middle of the 
 bone a lateral obli(|uity is the most common ; in the lower third an oblit|uity from behind 
 forward. Fractures may also be double in the same bone, or compound. In the ca.se 
 illustrated (Fig. 578) the fracture was impacted, the upper fragment having been forced 
 into the hollow of the lower, which it split. It occurred in a patient under my care in 
 1S7G, ;i}t. 88, from a fall down an area upon his knee. The man died on the twenty- 
 ninth day, from kidney disease (Pafli. Soc. Traiix., vol. xxix., 1878). 
 
 The displacement that takes place turns much upon the line of the obliquity and the 
 position of the fracture. In fracture below the lesser trochanter the upper fragment is 
 prone to be drawn forward by the action of the psoas and iliacus muscles and outward by 
 the external rotators. In fractures above the condyles the lower fragment is apt to be 
 drawn backward Ity the unantagonized action of the gastrocnemii muscles. In fractures 
 of the centre of the shaft the deformity dej)ends on the line of oblitjuity. Rotation out- 
 ward of the lower fragment is found in nearly every case. 
 
 DiAONosLS. — There i.s usually no difficulty in diagnosing a fracture of the shaft, the 
 following symptoms being usually present: A fall or injury, followed by loss of power in 
 the limb; shortening, which extension can rectify; deformity, probably angular ; extra 
 mobility of the lower part of the injured limb; crepitus; and probably the projection of 
 one end of a fragment with eversion of the foot. When the fracture is transverse, the 
 shortening will rarely be marked ; when it is oblique, the direction of the angular deform- 
 ity often indicates the line of the obliquity. 
 
 In young children, where the fracture is incomplete, shortening with bowing of the 
 limb after an accident, and an indistinct .sensation of yielding on manipulation, with or 
 withotit a peculiar crackling sensation, indicate the nature of the accident. 
 
 Treat.mknt. — The fragments having been carefully adjusted by means of extension 
 and gentle manipulation, the mechanical treatment of these fractures consists in the main- 
 tenance of extension by means of some applied force and the complete rest of the coap- 
 tated bones, gentle compression of the aftected part sometimes being beneficial. To assist 
 the surgeon toward these ends some antvsthetic may be used if the pain be severe and it 
 is impossible by other means to keep the patient at rest and any spasmodic action of the 
 muscles interferes with the surgeon's aims. 
 
 For many years past I have used no other splint than the double one seen in Figs. 573 
 and 620, and mo.st surgeons who have employed it once adopt it. It does not shift from 
 its place, because the interruption over the trochanter renders it comfortable ; it keeps 
 the fractured limb still and maintains it parallel with its fellow : extension can be care- 
 fully and easily regulated by means of the extension elastic pulleys, and no perineal band 
 for counter-extension is needed ; the results, moreover, which have attended its u.se are 
 excellent. Thus, out of 100 cases consecutively treated in my wards with this sjdint, in 
 
892 
 
 ON FRACTURES. 
 
 52 there was no shortening, in SC there wa.s half an inch or under, and in 12 only was 
 there one inch. Four other cases died : 1, aet. 81, from senility ; 1, aet. 83, on the twenty- 
 ninth day, from kidney disease ; 1, set. 40, from abscess of the lung, on the twenty-third 
 day ; and 1, aet. 45, from delirium tremens, on the eighth day. 
 
 At other schools other iueans are adopted, according to the fancy of the surgeon and 
 the fashion of the school. Thus, in ho.-^pitals where the Scotch influence is great Listen's 
 long splint is the one usually employed, which should extend well up into the axilla and 
 several inches below the foot (Fig. 579), without foot-piece. It ought to be well padded 
 and supplied with a soft perineal band, such as a leather strap or a piece of india-rubber 
 tubing. The ankle and instep should be well protected from pressure by cotton-wool and 
 the retaining bandage applied with equal pressure. 
 
 Fig. 579. 
 
 Fig. 580. 
 
 Listen's Long Splint, with a Foot-Piece Attached, with Weights for Extension, in Fracture of the Neck of the 
 
 Thigh-Kone. 
 
 Where the long splint is employed. Desault's splint, with a foot-piece (Fig. 592), and 
 the addition of a cross-bar for steadiness, should be preferred. The splint may be of 
 .wood or metal and made with a slide, so as to be adjusted to different patients. All long 
 splints, however, without an interruption over the trochanter, as seen in Fig. 573, to 
 guard against pressure, are inefficient and most uncomfortable. 
 
 In fractures of the upper third, where the upper fragment is apt to tilt forward and 
 be rotated outward, the double inclined plane is often of great value. It should be 
 employed, however, only when the long splint fails to fulfil the objects the surgeon has 
 in view. It is daily dropping out of use. 
 
 A splint full of promise was introduced in 1875 into practice at Guy's Hospital fFig. 
 580) from the Marine Hospital, Greenwich, and is still used by some of my colleagues. 
 It is a modification of one invented by the late Dr. J. T. Hodgen of St. Louis. T'nited 
 States (Treat, on Mil. Sxrrj., hy F. H. Hamilton, 1865, p. 411). for gunshot fracture.?, 
 and is made of galvanized iron wire (No. 2). In it the injured limb may be supported 
 on a piece of flannel, which is slung to the iron rod, or upon pieces of bandage. Exten- 
 sion is kept up by means of the strapping attaching the foot of the injured limb to the 
 
 lower cross-bar of the splint, 
 and through the suspending 
 cords and pulleys. • The 
 counter-extension is main- 
 tained by the weight of the 
 limb above the fracture and 
 weight of the body. The 
 splint, as .seen in Fig. 580, 
 is most comfortable to the 
 patient, and an old house- 
 surgeon, Mr. J. F. Fry, 
 reports (Guy's Gazette.^ De- 
 cember 11, 1875) that out 
 of seventeen cases of frac- 
 ture of the thigh consecu- 
 tively treated with the 
 \ splint, the average amount 
 of shortening was less than 
 half an inch, and that in 
 six cases there was not any. 
 I have found, however, after _ 
 a lengthened trial of this 
 splint, that a much larger amount of callus is thrown out about the seat of fracture than 
 is met with when the bones are kept perfectly at rest, as they are by the double splint 
 
 Dr. J. Hodgen 's Suspension Splint, as used at Guy's. 
 
FiLirrnn.s <>]■■ jjij-: i.owkii kxtukmity. 
 
 893 
 
 (Fij;. f)";?), and cdiicIuiIi' fmin this fact that thuro is iiiori- mobility of the ends of the 
 })r()keii l)()iu' hy the oiu' form of tn>atm<-tit than liy tlie otlier. I'ndor such circumstuiiceit 
 I have discarded llodj^cii's splint in the treatment of fractures <jf tlie thifjh for the 
 doulih'. 
 
 Ilodiren's splint >liuiil(l nut he confonndiil with Natliaii Smiths, which is made of 
 wire applied to the niitrrior anrjucc of the lVaetiire<l linih. which is suspended to it hy 
 rollers ( KiL'. 'j'.tS). 
 
 When the fracture is compound, an interrupted splint may he employed. In addition 
 to the ion-: splint, short additional splints applied in front, or at the inner side r)f. or 
 behind, the thi<rh. as the want of the individual case may su<xjiest, are of frreat value to 
 ensure jrreater steadiness of the broken bone. In no case sliould the seat of fracture be 
 covered in. The bandage should stop brlow. and if nece.s.sary recommence above, it. 
 
 Fig. 581. 
 
 /■fj'.rtfti 1 1 mil 
 
 liiclifi riibirr 
 Accumulator 
 
 Rcji t with C, nt f nit en i r /•. r 
 ExCfnsion cf iiffected limb 
 
 Mr. Campbell de Morgan's .Splint, with Elastic Extension. 
 
 To prevent the bandage slippiiiir after it lias been applied, it is a good plan to give it one 
 coating of paste or glue. 
 
 Many modifications of the.se means might be mentioned. Thus. Paget has very 
 generally employed Busks long splint, in which a joint exists opposite the hip, which 
 enables tlie patient, after union has taken ])lace, to sit up without affecting the thigh- 
 bone. The late Mr. C. de Morgan of the Middlesex Hospital applied the extension to 
 the fractured limb by means of a force carried from the foot through a pedal cross-bar 
 to a long splint applied to the opposite limb (Fig. 581). 
 
 Sir W. Fergus.son was wont to apply his counter-extension from a strong stay of jean, 
 carefully fitted to the upper third of the opposite thigh, from which a band extended 
 in front and behind to the upper end of the splint, thus doing away with the perineal 
 pad. 
 
 During the application of the long splint steady traction .should be maintained on the 
 injured limb by a competent a.ssistant. When muscular spasm is severe, .some surgeons 
 have advised temporary pressure on the femoral artery in the groin. 
 It is said to .stop the spasm in all cases; and whenever I have tried it. 
 it answered well. 
 
 Vertical Extension. — In infants and children under three 
 years of age fractures of the thigh are treated with difficulty, for anv 
 immovable apparatus is constantly dirtied from urine, feces, etc., and 
 re(|uires to be changed, and the good that would otherwi.se be experi- 
 enced is thus neutralized. On this account Paget and Callender have 
 within the last few years treated many cases of fracture of the thigh 
 in children without splints, all apjiaratus being dispensed with. '■ the 
 child being laid on a firm bed, with the broken limb, after .setting it. 
 bent at the hip and knee, and laid on its outer side ' (Sf. Bnrtli. 
 Hosp. Rvp.. 18(57 '. I do not recommend this practice, but would 
 advise instead that the injured limb of the child, with the sound one. 
 be flexed at a right angle with the pelvis, fixed by some light splint 
 and hoisted upward to a cradle, hook, or bar above the bed TFig. 5S2). 
 By these means the weight of the body acts as a con.stant counter-extend- 
 ing force, the child can be well looked to for purpo.ses of cleanliness, and -t^ 
 a irood result may be expected. Kiimmell of Hamburg (BerUn Klin. Fracture of the Ftinui 
 Worh.. Xo. 4. 1882) holds this method of vertical extension in frac- veS/ixtSn." 
 tured thighs in infants to be the best. He .says, though wronglv. it 
 was first tried by Sehede of Berlin in 1S77. and publi.shes a list of twenty-eight cases so 
 treated in infants under two years. In justice to Guy's, however. I must state that I 
 began this form of practice at Guy's Ho.spital in 1870. and have before me a list of 
 twenty-eight cases so treated since in children varying from eight months of age up to 
 five years ; later than that age I prefer the double splint. 
 
894 
 
 ON FRACTURES. 
 
 Fig. 583. 
 
 Splints of gutta-percha, felt, or leather may he iised with the weight-s when they can 
 be applied, some immovable apparatus being adjusted after the second week ; indeed, in 
 some cases this immovable apparatus may be applied at once, care being taken that the 
 limb is kept well extended during its application and setting. The Bavarian flannel splint 
 is the best (Fig. 536). 
 
 In adults, also, after the fourth week, this same immovable apparatus may be 
 employed with advantage, the patient gaining greater freedom. Some surgeons think 
 so well of this plan as to advise its use in fracture of the thigh from the very first. 
 Erichsen, its ablest advocate, says (Science and Art of Surgeri/, p. 225) : " The starched 
 bandage may be employed in most cases. The limb should be evenly and thickly envel- 
 oped in a layer of cotton wadding ; a long piece of strong pasteboard about four inches 
 wide, soaked in starch, must next be applied to the posterior part of the limb from the 
 nates to the heel. If the patient be very muscular and the thigh 
 large, this mu.st be strengthened, especially at its upper part, by 
 having slips of bandage pasted upon it ; two narrower strips of 
 pasteboard are now placed, one along each side of the limb, from 
 the hip to the ankle, and another shorter piece on the fore part of 
 the thigh. A double layer of starched bandage should now be ap- 
 plied over the whole with a strong and well-starched spica (Fig. 
 583) ; it should be cut up and trimmed on the second or third day 
 and then reapplied." With such an apparatus Erichsen has treated 
 many fractured thighs, in both adults and children, without confine- 
 ment to bed for more than three or four days, and without the 
 slightest shortening or deformity being left. The points to be espe- 
 cially attended to are that the back splint be very strong, at the 
 upper part especially, and that the spica be well and firmly ap- 
 plied, .so that the hip and the whole of the pelvis be immovably 
 fixed. 
 
 Fractures of the condyles necessarily involve the joint, 
 and these may be transverse, oblique, or vertical (Fig. 584). In 
 subjects under twenty-one tlte loixrv epiphyaU mny he stepdra ted from 
 the shaft, thus simulating a transverse fracture (Fig. 585) or a dislo- 
 cation (Fig. 521). 
 
 These cases are serious on account of the joint complication, as some stiffness of the 
 Joint generally, but not always, follows this result, depending upon the amount of inflam- 
 matory action that takes place after the injnry. When the head of the tibia is fractured 
 
 into the joint, the same observations 
 are applicable. In these cases the pos- 
 terior splint, as suggested by Macln- 
 tyre (Fig. 597), is probably the best, 
 the knee being slightly flexed. When 
 joint complication exists, the applica- 
 tion of ice. or probably some leeches, 
 may be required. 
 
 In exceptional instances the upper 
 fragment of bone is driven into the 
 lower, thereby giving rise to an im- 
 pacted fracture. These cases, like 
 other impacted fractures, generally do 
 well by simple rest. 
 
 In' all eases involving joints passive motion should be 
 Fraftureof the >haft of the Femur, allowed at the end of five or .«ix weeks. 
 
 Nathan Smith of New York advocates the use of an an- 
 terior splint composed of a single piece of iron wire of the 
 thickness of a No. 11 catheter, which is carefully bent to 
 the inequalities of the limb and fastened to it by means of strapping and bandages, the 
 limb being subsequently suspended to the ceiling by a cord connected with the wire 
 above and"^ below the knee, extension being made through this cord, and the counter- 
 extension by so raising the foot of the bed as to tilt the body toward its head (Fig. 
 598). 
 
 In fractures of the lower third above the condyles, where the gastroc- 
 
 nemii muscles tend to draw the lower fragment backward into the popliteal space, some 
 
 From Erichsen. 
 
 Fig. 584. 
 
 Separation of the Ki)ii>hy- 
 >i> (Prep. llilU-i'', Guy's 
 Mus.j 
 
 with Longitudinal Fissure through 
 the Condyles into the Knee-joint. 
 (Prep. 12()0, (iuv'sMus.i 
 
rn.irrrnr.x of tiii: lower i'xtiiemity. 895 
 
 Pirjrc(nis jm-fi-r tlie use of the iiidiiifd jdaiu . ami wlit'ic the bones cannot he otliorwise 
 kejit in aji|Misiiion it is jnolcilily a sound |iraetice. liut what I Vjelieve to he a hetter one 
 is tlic (livi.-i<in (<1" ihe tendo Achillis and tlie suhseijuent use of the h»n<; ihjuhle splint. 
 The divisinii of the tendon jiaralyzcs the gastroeiieniii. and thus alhjws the surgeon to 
 hrin<; tiie hones into a jrood jiosition and t<» deal witli them as with an ordinary IVaeture. 
 I have tau'rht tliis for many years, and. havinir tested its value in three eases, ean pro- 
 nounee the ])raetiee to he j^ctod. My friend .^Ir. Treves of the Lotidon Hospital followed 
 the practiee in 1SS2 (lin'f. M<il. Jomn., Kehruary 17, 18H3),and it has likewise been prac- 
 tiseil hv Hr. Morris of Boston, in Anieriea. with sueeess (lioslun Mn/. uikI Siii</. Jomn.. 
 Noveniln'r li!*, 1S77). 
 
 Compound Fractures of the Thigh. — These are desperate accidents, and 
 take jilace in the jtroportion of one to every six or seven ca.ses of fracture of the femur; 
 and when they occur, hall" the ))atients die. They should be treated, where possible, on 
 conservative principles, and amputation should be performed oidy when the .soft parts, 
 with the vessels and nerves, are so injured as to forbid any reasonable hope of recovery. 
 Conservative practice should have full scope, in young subjects especially, and when any 
 doubt ujion the necessity of amputation exists, the surgeon had better decide upon trying 
 to save the limb, although in the aged an opposite practiee should be adopted. 
 
 Army surgeons, however, advise the propriety of practising conservatism for gunshot 
 fractures in the upper third of the thigh and amputati(tn for all fractures of the middle 
 and lower thirds, the nature of gunshot injuries to those parts precluding all hoj)e of a 
 natural recovery. All modern army surgeons — English. American. French, and (ierman 
 — agree upon this point, and endorse Dupuytrens. Hennen's, Larrey's, and Guthrie's 
 opinion that, in gunshot wounds of the thigh, •' in rejecting amputation we lo.se more lives 
 than we save limbs." and '' that in the exceptional cases which result in consolidation the 
 condition of the limb is not encouraging." 
 
 Amputation of the thigh for compound fracture is most fatal, two out of three dying. 
 In the upper third of the thigh the mortality is still greater. 
 
 It is from this fact alone that army surgeons have advised the conservative treatment 
 of ccjmpound fractures of the upper part of the femur, and Mr. Erichsen has been led to 
 assert that amputation in the upper third of the thigh for compound fracture is an unjusti- 
 fiable oiieration. 
 
 When amputation is not at once called for. the wound should be thoroughly cleansed 
 with some iodine or other antiseptic lotion, and all foreign bodies, with loose fragments 
 of bone, removed; the projecting portions of bone should be excised, bleeding arrested, 
 and the wound sealed with blood or the compound tincture of benzoin : a .splint should 
 be applied at once, moderate extension employed, and the case treated on general 
 principles. 
 
 Fractures of the Patella. — These are usually transverse, from a sudden action 
 of the quadriceps femnris under a violent effort to prevent the body falling backward, 
 the knee being at the time partially bent. ?^uch 
 
 fractures are met with chiefly near, though F'^- ■^'^"• 
 
 mostly below, the centre of the bone ; they ^--::-rv_ w;<<?v^^t^ y"^- ^,-^^te^^ 
 
 may. however, occur at any part, even in the \^^^^^^^^ ^ j>— ■' ■< g^^'^'^*^,^^i^ 
 extra-articular portion of bone. In some ca.ses „,., ,. ,„ ,, ^T. ,t^\ 
 
 , , 11 1 1 1 Multiple F racture of Patella, i Prep. r212SO.) 
 
 both pateliJB are broken, together or con.secu- 
 
 tively ; in rarer instances the same patella may be broken more than once. I have had 
 such a case in a man in whom one patella had been broken twice and the other three 
 times, and in the Guys Museum there is a preparation (Fig. 586) from my fathers mu- 
 seum in which the bone had been broken transversely into four fragments. proVjably 
 from different injuries or from some direct force, each fragment having a ligamentous 
 union. 
 
 These transverse fractures are at times, although rarely, the result of direct violence. 
 The French and American surgeons believe them to be so very frequently. Direct vio- 
 lence to the patella, however, is more commonly followed by what is called a starred or 
 vertical than by a transverse fracture, and in these cases there is rarely much separation 
 of the fragments. In transverse fracture the separation is sometimes very great, this fact 
 mainly depending upon the amount of muscular action at the time of fracture. It is, 
 however, greatly increased by the effusion of blood that follows the injury, and later on 
 of inflammatory exudation. At a still later period it is increased from a yielding of the 
 ligamentous tissue by flexing the leg before firm union has taken place. 
 
 Out of 2.'5 consecutive cases which passed under my care, in 7, on convalescence, the 
 
896 
 
 ON FRACTURES. 
 
 Fig. 587. 
 
 Fracture of the Patella. Separation of 
 Fragments. 
 
 1 IG 588 
 
 union was so close as to have been reported as bony ; in 9 there was separation of only a 
 quarter of an inch ; in 8, of half an inch ; in 1, of one inch. In all of these the move- 
 ments of the joint were perfect. 
 
 Dtagnosis. — The diagnosis of the transverse fracture is rarely difficult, the nature 
 
 of the violence, the sudden loss of power of the limb, 
 the distinct separation of the fragments, and the bulg- 
 ing of the synovial sac between the divided portions of 
 bone being characterteristic. In the stanrd fracture the 
 different pieces of bone may be made out. In the ver- 
 tical the diagnosis may be more difficult, and can be 
 made out only by manipulation. In exceptional cases 
 where either the ligamentum patellge or the tendon of the 
 extensors above the patella is broken some difficulty may 
 be felt, but such accidents are very rare. When the trans- 
 verse fracture is little more than a fissure, no separation will be found, the amount of 
 separation being determined by the extent of laceration of the fibrous and tendinous cov- 
 erings of the bone. When the laceration is partial and the separation slight, there is a 
 better hope of a bony or close union than when the laceration is complete and the separa- 
 tion great. It should be known, however, that union by bone may take place, although 
 probably but seldom ; that union by strong ligament, with about half an inch of separa- 
 tion, is more common ; and that non-union is exceptional. William Adams in the Path. 
 Trans, (vol. xiii.) informs us that out of 31 specimens he examined, 15 were examples of 
 ununited fracture, 12 of true ligamentous union, and -4 doubtful. In the ununited the 
 separation was very great ; in the ligamentous it was rarely beyond an inch and a half. 
 In the ununited the separated fragments were connected with each other by only a single 
 layer of fibrous tissue. 
 
 That bone union now takes place is generally recognized. In Prep. 1211", Guy's 
 Museum (Fig. 588), taken from my father's museum, the fact is well exemplified. The 
 specimen has been fully described, with remarks, by the late 
 Mr. W. King in the Gkt/'s Hasp. Rep. (Series i. vol. vi.) 
 
 In the starred or vertical fractures osseous union is gener- 
 ally secured, these cases being rarely attended with complete 
 laceration of the periosteal or fibrous coverings of the bone. 
 
 Treatment. — In all cases, as well as in every form, of 
 fractured patella, a long well-padded posterior splint with a 
 foot-piece extending from the tuberosity of the ischium to the 
 foot should at once be adjusted, the knee-joint being left un- 
 covered by the bandage. To the knee-joint cold should be 
 applied, for as a direct consequence of the accident blood is 
 very apt to be eff'used, and as a secondary efl"ect synovial 
 inflammation with eff"usion is almost sure to ensue. Should 
 Fracture of Patella United by the joint be hyper-distended with blood, such may be removed 
 
 Anterior surface. Vertical section, by the aspirator. 
 
 It has generally been the custom to raise the heel with a 
 view to destroy the action of the extensor muscles, but it is now more generally believed 
 that no good is derived from such a measure ; as a consequence, the horizontal position 
 of the limb is usually employed, the body being raised. The fragments should be brought 
 together at the same time as much as possible by the fingers of the surgeon, and later on 
 by some apparatus. To do so, however, while blood exists to any extent or the synovial 
 
 capsule is distended with inflammatory effusion 
 Fig. 589. is not wise, since any attempt to draw the bones 
 
 together under these circumstances can result 
 only in tilting forward the surfaces that are re- 
 quired to be brought into apposition, with no 
 good effect. 
 
 For a few days, therefore, until all in- 
 
 Accumulator. ^ r ,;•" ' "*■ - flaiumatory action has subsided, the surgeon 
 
 «..i;„f <•.,. !?-„„♦ „ (• ti r. * 11 ■.x^T'^ .■ o should rest satisfied by simply pressing the 
 
 splint for Fracture ot the Patella, with Elastic Com- , .,,■' n ii 
 
 pression. parts together witli his fanners : and when , 
 
 b; S^r'slrapprngSd t^f m "''""""• tliis result has been secured.^the two portions 
 
 may be drawn together by means of strips of 
 plaster diagonally applied, of india-rubber bands covered with wash-leather attached to 
 
FRAcrrnKs of tiif i.nwFi: FxriiFMrrv. h97 
 
 honks, which hiivc ht-cii iiiscrti'il at iiitcrviil.s of an inch on citlicr side of" tlic hplint. or, 
 wliat is Ix'ttcr, by means ol' clastic coni|trcssion as shown in Kijx. '>M1). 
 
 Maliraignc's hooks, whidi are composed of ibur ehiws drawn together hy a screw, liave 
 been much employed, and are doubtless efl'eetual, bnt from the fact that they jtenetrate 
 tlie soft parts and painfully and forcibly draw the broken fragments together they are 
 objectionable, (iood n-snlts have, however, been reported frouj their use. 
 
 As snoii as all inflammatory action of the joint has subsided and the bones are fairly 
 in ])usition such an immovable apparatus as the flannel I'avariaii splint may be ajiplied, 
 the patella being left exposed or not as the 
 
 surgeon may think fit. When the bone is Yu,.->'M). 
 
 bandaged over, care must lie taken not to 
 pn-ss upon it, as I luxve known secondary 
 suppuration with necrosis and joint complica- 
 tion of a serious nature thus ensue. Eriehseii 
 uses, as a rule, tlie starch liandage. and speaks 
 highly of it. lie applies it over a pad fixed 
 
 above the fractured Ikimc with a tigure-of-8 ,^^ ^ ,,, 
 
 , , /1II1 a • t ^ • the Middlesex Iio.->i)itaI Siilint for Fracture of the 
 
 bandage. C. Heath removes fluid by aspira- iWiia. 
 
 tion, applies a ]daster-of-Paris bandage over 
 
 cotton-wool, and allows liis patient to get up. Whatever apparatus is employed, it should 
 be kept on for five or six weeks at least ; and when removed, some light leather or felt 
 casing should be substituted. It is hazardous to allow the patient to flex the limb under 
 three months and to give it freedom under a year; for the united ligament is apt to be 
 stretched and ehmgated, and the limb weakened. An apparatus to limit the movement 
 of the joint should be w'orn after this accident. One made by Ilawksley and long used 
 at the Middlesex hosjiital is excellent (Fig. 590). " It is applied as soon as the patient 
 is allowed to get up, and the degree of flexion is gradually increased from time to time 
 by filing away the shoulder of ^he joint of the splint." 
 
 Within recent times surgeons have advocated the primary treatment of these frac- 
 tures by wiring the fractured bones together, and succes.ses have been obtained — .some 
 excellent, others indifferent, few better than the average obtained by the treatment above 
 described. Sir J. Lister has been amongst the most successful. So far as I can make 
 out, the first case recorded is by Dr. Uhde of Brunswick (^Deutsche Medicia nnd Woch<ns., 
 April 27, 1878). I cannot recommend this practice to be universally adopted. It is 
 eminently hazardous; and when we know that in the majority of cases of fractured 
 patella treated without operation results are obtained which in exceptional cases alone 
 interfere with life's duties, the treatment by operation stands condemned as a rule of 
 practice. 
 
 In 32 ca.ses of old fvacture of the bone Avhich have been admitted into Guy's for 
 other injuries, in 28 the limb was in all ways useful ; in 4 only was it weak, and in these 
 •4 the separation between the fragments was half an inch in 2, one inch in 1, and two 
 inches in the fourth ; whereas, in the patients with useful limbs, one man could go up a 
 ladder with two hundredweight on his shoulder, another acted as porter in a fish-market, 
 a third was a lighterman, two were coal porters, a sixth was a sailor, a seventh a carman, 
 an eighth a marine engineer. In one man with a perfectly useful limb the fragments 
 were three inches apart; in another, who could walk well, both bones were fractured and 
 the fragments two inches apart. In a cellarman who had good use of his leg the separa- 
 tion was four inches. In the majority of the good limbs the separation was about half 
 an inch. Upon the whole, the result of the accident was most satisfactory and enough 
 to justify the ordinary modes of treatment employed. 
 
 In examples of neglected cases of fracture where a great separation of the fragments 
 exists, and the knee is consequently so weak as to be useless, such an operation as has 
 been described may be justifiable, but under other circumstances I cannot, as a teacher, 
 regard it otherwise than as a rash and hazardous proceeding. 
 
 Compound Fractures of the Patella. — These are grave accidents, one-fourth 
 of the cuse.s dying. Poland in an able paper read before the Royal Med. and Chir. Society 
 (1870) gave an analysis of 85 such, and clearly proved that in all cases we should 
 attempt to .save the limb and adopt the ordinary treatment as for simple fractures of the 
 patella. To this end the wound should be well washed with iodine water or carbolic acid 
 lotion and accurately closed by sutures, and inflammation ought to be subdued by the 
 constant application of cold. If suppuration sets in, free incisions should be made into 
 57 
 
898 
 
 ON FRACTURES. 
 
 Fig. 591. 
 
 the joint, and amputation resorted to only when the powers of the patient fail to 
 repair the injured joint. Detached fragments of bone should, however, be removed at 
 once. 
 
 Out of the 85 cases collected by Poland, there were 20 deaths and 65 recoveries ; in 
 31 of these there was more or less complete anchylosis of the joint ; 20 recovered with 
 movement, -t were resected, and 5 amputated. The joint suppurated 
 in 43 out of the 65 cases of recovery, and in all the fatal cases. 
 
 In March, 1883, I saw a man set. 56 who after a compound com- 
 minuted fracture of the patella had necrosis of about a quarter of the 
 bone. He made a good recovery after the removal of the dead bone, 
 and had almost complete movement of the joint. The case occurred 
 in the practice of Mr. Wilson of Grantham. 
 
 Fractures of the Leg. — These are about twice as frequent as 
 those of the thigh. At Guy's. 1090 cases were admitted in six years, 
 against 541 of the thigh ; and of these 202, or one-fifth, were com- 
 pound. Of the simple cases not one per cent, died from all causes, 
 and of the compound twenty-seven per cent, succumbed. 
 
 Both bones, as a rule, are fractured, the fibula alone being broken in 
 about one case in six, and the tibia in about one in seven. Lonsdale's 
 statistics indicate the.se points. These fractures are more commonly 
 met with in adult than in child life. 
 
 In fractures of both bones those of the upper half are usually the. 
 
 Arrest of Growth i ^^^^^^ ^f direct violencc — fractures of the lower half of indirect, such 
 
 Shaft of Eight Tibia as the twistinsT of the foot or leir from a fall or a jump. 
 
 of'"Fib!;ir?onowin| In fractures of the tibia alone the line of fracture is fre- 
 
 injury to Upper Epi- quently transverse, and from this cause there is sometimes difficulty in 
 
 fore^ in Child tet' 8. making the diagnosis, the nearer the fracture to the knee, the more 
 
 transverse being the line. These fractures arise chiefly from direct 
 
 violence. They may so unite as to leave no external trace of injury ; indeed, they may 
 
 be attended with so little displacement that the line of the bone is never broken. I have 
 
 seen more than one patient walk upon the fractured limb directly after the accident, and 
 
 in one case the man went up a whole flight of stairs to his ward with but a slight limp. 
 
 In another, under my care in 1874, a woman with a fractured tibia and fibula went about 
 
 for a week. In a mouiuu-iegal point of view these facts are important. When the shaft 
 
 has been separated at its upper epiphysis, some arrest of growth may take place ; and 
 
 such a result is illustrated in Fig. 591. 
 
 Fracture of the fibula is more common than that of the tibia, particularly in 
 its lower third ; and I uelieve that in many examples of what are called bad sprains a 
 fracture exists. Fracture in the upper two-thirds is usually caused by direct violence, 
 but it may be by indirect, such as a wrench or twi.st of the ankle-joint ; under such con- 
 ditions the fracture will be oblique ; in the lower third the violence is commonly indirect, 
 such as a lateral twist or a forcible eversion of the foot. With pedal ('/(version, the extrem- 
 ity of the tibia is mostly broken off". When with this fracture the foot is displaced outward 
 and its outer edge raised, the accident is known as " Pott's fracture " (Fig. 522), and under 
 these circumstances the external ligament remains entire, the force being concentrated 
 against the fibula from two to three inches above the malleolus ; the internal ligament, 
 however, is ruptured or the inner malleolus is fractured. Displacement of the foot is 
 not necessarily an attendant upon the fracture. It seems to be the result of some con- 
 tinuation of the primary fracturing force or of some additional force, such as that of an 
 attempt to walk. In the indirect fracture the line of fracture is probably oblique, the 
 obliquity being determined by the direction of the force. 
 
 Dl.\GNOSis. — In fracture of either of the leg-bones alone the diagnosis may be .some- 
 what difficult, and more particularly when no displacement is present. Crepitus may .at 
 times be made out by a forcible attempt to move or bend the lower fragments, or by 
 some sudden inversion or eversion of the foot : but in trying for this the surgeon should 
 be careful not to do harm. Local pain, however, caused by pressure with the thumb over 
 the seat of fracture, and linear ecchymosis a few days after the accident, are valuable helps 
 to diagnosis in these as in all other kinds of fracture. 
 
 Protracted or repeated examinations of the injured limb should always be avoided-; 
 they only add to the mischief. 
 
 Treatment. — In fractures of either of these bones a natural splint is always found 
 
FRACTURES OF THE LOWER EXTREMITY. 
 
 899 
 
 Fig. 594. 
 
 in the saiiu' b<jne; consefjuently, shorteniiifr or deroriuity rarely follows the accident, 
 the surgeoM lias to do is simply to apply some sj)lii»t to ensure rest 
 to the broken bone and to tlie mu.seles that move the foot — to the 
 inside of the lejr when the fifrula is broken (Fig. 5!>3), and to the 
 outside when the tibia (Kijr. oH-); tiie splints should have a foot- 
 piece. In fraetures of the lower third of the fibula the foot may 
 be drawn inward, the bandaj_'e bein^r applied from without inward, 
 but in manv instances nothing more is called for than absolute 
 rest. In otlier cases a thiek jtad is often of use opposite the .seat 
 of fracture. In no ca.se should the banda<re cover the fracture. 
 After the lapse of a few days, or at most a week, when all swell- 
 intr, with other evidence of local injury, has subsided, the limb 
 mav with advanta<;e be put uj) in some immovable apparatus. 
 
 In cases of Pott's fracture, or dislocation of the foot outward with 
 fractured fibula. Pott used to place the patient on the affected side 
 with the injured limb flexed, fixing the leg upon an outside splint, 
 an inner splint being likewise very usually applied. A Vjetter plan, 
 however, is found in the posterior and two lateral splints, with a 
 swing, as seen in Fig. 596, this mode of swinging the limb being 
 a very good substitute for Salter's swing (Fig. 597). 
 
 Fractures of both bones occur in every variety, and the most common is the 
 transvoiM'. abuut throe inches above the ankle; but every form of oblifjue, dentated, 
 comminuted, and vertical fracture is met with (Fig. 532). When near the joints, the 
 vertical into the joint is by no means rare. The surgeon in his first examination of the 
 fractured limb should, if possible, make out the line of obliquity of the fracture and the 
 teiuhnci/ one or other of the fragments may have to ride in any one direction, always 
 observing the utmost gentleness in his manipulation. 
 
 When the tibia is broken at the junction of its middle and lower thirds, and the 
 extremity of its upper fragment on its inner or subcutaneous surface presents a V-shape 
 (Fig. 594), the surgeon may expect to find a fissure in the lower fragment 
 of bone starting from the apex of the V and running in a spiral direction 
 inward, backward, and outward round the inner edge of bone, across its 
 posterior surface toward the lower articular facet where the tibia and fibula 
 articulate, the fissure then passing horizontally inward across the lower ar- 
 ticular facet of the tibia to the posterior border of the inner malleolous to 
 join the one on the posterior aspect of the bone, thereby cutting off a tri- 
 angular fragment of the tibia at its lower extremity. 
 
 This variety of fracture is generally produced by some sudden twist of 
 the body when the foot is fixed. 
 
 It may be suspected during life when joint complications are associated 
 with the fracture. It was first described by M. Gosselin (^Gazette des Hopi- 
 taux, 1855). 
 
 When compound, it is generally of a serious nature, and. according to 
 Gosselin, should be treated by amputation. Dr. R. M. Hodges of America 
 goes so far as to say that by such a practice alone can the patients life be 
 saved (^Boston Med. (iiid Sitrff. Journcd. January. 1877). Death usually 
 takes place from pyjemia in cases that are left alone. 
 
 I am not disposed, however, to go so far in this direction, though I fully 
 recognize the serious nature of these cases and believe that they claim the 
 surgeon's anxious attention. 
 
 In transver.se fractures there is rarely deformity. In the oblique it is 
 a common result, the upper extremity of the lower portion of bone pro- 
 jecting,, as a rule, the lower fragment being rotated outward from the 
 great tendency the foot has toward eversion. 
 
 Symptoms. — The symptoms of fracture of the leg are too plain to be v-shaped Frac- 
 overlooked. The tibia being a superficial bone, any solution of continuity *"^tc^^ T'i^?*' 
 
 , . . o 1 f r. -^ ■ • 111" 1 /. 1 • with. "spiral Pis- 
 
 or deviation oi the line oi its spine is readily made out, the nature oi the sures. (Figure 
 accident, loss of power, deformity, and crepitus helping the diagnosis. In preparaflon* of 
 fractures near the joint it n;ay at times be difficult to make out whether <ios*eiin. now 
 the bone is fractured into the joint or not ; and when a doubt exists, cau- museum.^ 
 tion in prognosis and treatment should be ob.served. In fractures close to 
 the ankle accompanied with displacement dislocation may be roughly simulated, but the 
 
900 
 
 ON FRACTURES. 
 
 slightest care ought to detect the true nature of the case ; the facility with which the 
 displacement of the parts is rectified, the fact that the malleoli retain their normal rel- 
 ative position with the foot, and that the ankle-joint moves with facility, proves that the 
 displacement is due to broken bones, and not to dislocation of the joint. AVhen the 
 lower epiphysis of the tibia is displaced with the foot, there may be some difficulty in 
 making out the true state of the case, but such an accident can occur only in children ; 
 it will appear as a transverse fracture, but with no sharp edge of bone, as is usual in 
 fracture, while replacement of the displaced fragments wull not give rise to the ordinary 
 crepitus of broken bone, but to a more subdued sensation. 
 
 When a wound complicates the case, the diagnosis is readily made. 
 Treatment. — It is wise, in fractui-e of the leg as of other bones, to " set " the frac- 
 ture and to put the injured limb into the right position with good splints as soon as 
 possible. 
 
 . In a general way, for fractures of the lower two-thirds of the bones the best apparatus 
 is a straight, flat, and not too broad, metal or wooden posterior splint (Fig. 595j with a 
 
 Fig. 595. 
 
 Process of Setting a Fracture of the Leg. 
 
 rectangular foot-piece and two broad lateral splints (Fig. 596), all being well padded and 
 firmly fixed by broad strips of strapping, broad bands of inelastic webbing or bandages, 
 the seat of fracture being left exposed, if possible, for observation. In Fig. 596 the 
 whole apparatus is illustrated wuth an interrupted splint as for compound fracture. In 
 reducing a fracture of the leg the knee .should be partially flexed or held by an assistant, 
 the surgeon manipulating the lower portion (Fig. 595). 
 
 During the putting ap of the fracture the limb must be kept extended and the broken 
 bones maintained in position, it being a good plan to fix the foot and limb at first to the 
 
 posterior splint, and subsequently 
 Fig. 596. to apply the lateral. The leg after- 
 
 ward should be slung to a cradle by 
 bandages (Fig. 575), or Salter's 
 cradle may be used (Fig. 597). 
 When any wound in the soft parts 
 exists, as in compound fracture, the 
 corresponding lateral splint should 
 be interrupted, as shown in Fig. 
 596. 
 
 When the fracture is close to 
 the ankle-joint and any difiiculty is 
 experienced in keeping the broken 
 ^ bones in position from the spa.smodic 
 action of the tendo Achijlis, the 
 tendon should be divided. This 
 simple operation at once permits the 
 parts to be adjusted with admirable 
 facility and renders the retentive apparatus of real value, while it allows natural processes 
 of repair to go on uninterruptedly, the divided tendon and broken bones undergoing 
 repair together. 
 
 When the fracture is near or into the knee, a posterior splint such as that of Maclri- 
 tyre or Amesbury may be employed ; indeed, some employ this splint for most fractures 
 of the leg (Fig. 597). 
 
 Apparatus for Fixing and Swinging a Fracture of the Leg. 
 
FRACTURES OF TlIF LOWER EXTREMITY. 
 
 1)01 
 
 In setting ativ IVactnn' nf ilu- U-^ the opiiD.sitc liiiil» sliniiM be exposed as a guide and 
 an iii(|uirv made to prevent error a> to the existenee of any natural or aefjuired delormity. 
 The foot shouhl ^.'eiierally be phieed at rijrht an;zles with the h--:. with the sole flat to the 
 foot-pieee, i-are being observed that 
 till' heel d(H's not fall and the lower 
 fragment of bone etinset|Uently tilt 
 upward. The heel should also be 
 well protected from pressure and the 
 foot covered and protected with cot- 
 ton-wool. '• Take, therefore, " writes 
 Paget (Laiiof, February 27. ISOD), 
 "the foot-pieee of the splint as the 
 guide for the position of the foot ; 
 and if you but .see, in the manage- 
 ment of fractures of the leg. that 
 the foot of the ])atient and the foot- 
 pieee of the back si»lint fairly corre- 
 spond, it is hardly possible f<jr the 
 limb to fall into any defective meth- 
 od of repair. (_'orrespondence be- 
 tween the axis of the foot and of 
 
 Maclntyre's Si)Iiut and -Salter's Swinj;. 
 
 the foot-piece ensures that there shall be no rotation or version, either outward or inward. 
 Then, again, you should be careful that the foot touches the foot-piece by the three balLs 
 of the sole — the ball of the heel, the ball of the great toe. and the ball of the little toe." 
 Dr. Shrimpton of Paris, acting upon Dr. Nathan Smiths suggestion of an anterior wire 
 splint, has applied it to fractures of the leg with success. He employs a splint composed 
 of double wires an inch and a half apart, held together by four transverse bars and applied 
 by means of straps to the front of the leg, as illustrated in Fig. 59S (Luiicef, lS72j, the 
 
 Fig. 598 
 
 ^X 
 
 B 
 
 7 
 
 Nathan Smith's Anterior Wire Suspension Splint, with Dr. Shrinipton's Moditication of it below. 
 
 limb being subsequently slung in a vertical direction, as Esmarch slings his patient's leg 
 in disease of or after operations upon the ankle. After the limb has been kejjt in splints 
 for about a month some immovable apparatus, such as the flannel Bavarian (Fig. 536), 
 may be substituted and the patient allowed to get up, moving about with crutches for 
 another month. When there is little or no displacement and little swelling, as soon as 
 the immediate effects of the injury have passed away the immovable splint may be at 
 once applied — that is. after the first week — the wants of the individual ca.se being the 
 only guide to its treatment. When the bones are comminuted and some loose portion 
 has a tendency to ride or rise out of its position, the application of a pad. with sufficient 
 local pressure to keep the parts in position, may be employed. When much effusion of 
 blood or local action takes place, ice or cold lotion may be used as an application. Con- 
 stitutional symptoms can be treated as they arise. 
 
 Compound fractures of the leg ought to be adjusted in the same way as the 
 simple, care being taken to have an interruption in the splint corresponding to the wound 
 (Fig. 5l)tj). When the wounds are extensive, the posterior hollow splint of Maclntyrc or 
 any of its modifications may be used with advantage. 
 
 When the bones are comminuted, the loose pieces should be removed, the wound 
 
902 ON FRACTURES. 
 
 cleaned and sealed with a pad saturated with blood, the compound tincture of benzoin, or 
 carbolic acid, as already described ; at a later period of the case, when inflammation and 
 suppuration take place about the seat of fracture, a free incision should be made down to 
 the bone and any necrosed fragment removed. This operation gives. relief to pain and 
 expedites recovery. 
 
 When the injury to the soft parts is great and the large ve.s.sels or the joint are 
 involved, amputation may be called for. 
 
 About one in every three cases of fracture of the leg is compound, the average mor- 
 tality of the compound being also about one in three. Of those amputated, about sixty 
 per cent, are fatal. 
 
 When amputation is called for, a primary operation — /. c. one performed during tike 
 first three day.s — is better than a later one. 
 
 Fractures of the foot, commonly the result of some crushing force, are always 
 serious on account of the injury the soft parts have sustained in common with the bones. 
 When not so complicated, severe fractures of the bones of the foot as well as other bones 
 will recover by rest and the application of cold lotions, etc. 
 
 Fracture of the OS Calcis may occur by a fall from a height. It is seldom associ- 
 ated with any displacement and undergoes excellent repair when natui-al processes are 
 left to themselves. In exceptional cases the broken fragment may be drawn up by the 
 action of the gastrocnemii muscles, and under such circumstances the leg must be kept 
 flexed and the foot extended to keep the fragments in position by some outside splint. 
 Under these circumstances, however, the foot rarely recovers completely its natural use. 
 
 Fractures of the astragalus also occur from some fall or violence, and are often 
 compound. I had a case some years ago in which the upper surface of the bone with its 
 head was split off" and forced through the skin, and a second in which the bone was cru.shed 
 into fragments and extruded from below the external malleolus. In the former the soft 
 parts were so injured that amputation was performed, while in the latter recovery took 
 place by natural processes with a stiff but good limb. 
 
 Simple fracture may, however, occur, and I am disposed to think it is more common 
 than is supposed; but the injury is difficult to diagnose, particularly when no displace- 
 ment coexists. I have had occasion in two cases to remove from boys who had acute 
 inflammation of the bone and joint, following an injury, the whole of the necrosed upper 
 articular surface, with half the thickness of the astragalus, and in both good results fol- 
 lowed. The piece I removed in both instances looked as if it had been fractured, and 
 subsequently died. I have also recently (1878) removed from the inner aspect of the 
 ankle of a man the upper half of the astragalus that had been fractured six montlis pre- 
 viously, rotated, and so displaced as to present its upper articular facet inward. The case 
 had been reported at a sister-hospital as one of fracture of the tibia and fibula. The frac- 
 tured bone had subsequently inflamed and died. 
 
 Compound fracture of the metatarsal and phalangeal bones should be treated 
 on ordinary principles, the immediate dressing of the wounds with the compound tincture 
 of benzoin, to exclude all air and place the wound as much as possible under the condi- 
 tion of a subcutaneous one, being absolutely indicated. When parts irreparably injured 
 require to be taken away, no healthy structures ought to be sacrificed in order to perform 
 a named operation. 
 
 COMPLICATED FRACTURES. 
 
 Extravasation of Blood. 
 
 Fractures are very often complicated with rxfravasafion of hlood, and then difficulties 
 may be experienced in deciding whether the blood comes from an artery or from a vein. 
 In compound fracture, however, the difficulty of diagno.sis is less than in the simple, since 
 the florid character of the flowing blood, its pulsatile stream, and its capability of being 
 arrested by pressure on its cardiac side indicate its arterial source. In simple fractures the 
 difficulty is sometimes very great, particularly when the limb is distended with blood and 
 there is no pulsation in the swelling. When the vessels below the seat of injury pulsate 
 naturally, the blood has probably a venous origin ; but when pulsation is not felt, there 
 is no reason to jump to the conclusion that arterial laceration has taken place, as the 
 arteries may be simply pressed upon by the eff"used blood. When the swelling itself 
 pulsates, the diagnosis is simplified ; for such pulsation generally means that a traumatic 
 aneurism has formed and some large artery been ruptured. In a clinical point of view, 
 
COMl'Ll(ATi:n rilACTUHES. 903 
 
 however, tli<> (jucstion, liappily, is >i(tt very iiiiitcriul, as surpeons an; now tolcralily well 
 agreed as tit the |»rarti(M- tn !•<• |.urMi(<l. 
 
 Tkkatmknt. — 111 compound fractures the injured vessels shoultl Ik' tie<l or 
 twisted, and the wound should lie eiilar^H'd Inr this jiurjiose when neeessary ; and even 
 where such a praetiee is iinpossiltle, and fVoin the nature ^A' the t'raeture an<l eondition of 
 the soft parts it is prohahle that the liinli may he saved, the main artery .should he tied 
 hitrher up. as fractures heal well with a diminished supply u{' hlood. Vears aj^o, when a 
 student. I reini-inher a ease of Mr. liranshy Cooper in whieh a eotapound fraeture <jf the 
 lej; was e<»mplieated with a laceration of the femoral artery, and the artery was secure<l at 
 the .s«.'at of injurv- liejtair went on in the fraeture as well a.s in any ca.se I ever witnes.sed. 
 Mr. liranshv Cooper has also recorded in his SiDylnil J'Jssm/s a ease of fracture of tlie 
 femur where the femoral artery was lipitured for a ruptured popliteal artery, and recov- 
 ery took place in si.x weeks. 
 
 In the autumn of 1S7H a youth a't. l!^ came under my care with a compound fraeture 
 of the condyles of the humerus into the elhow-joint, and an injury to the brachial artery 
 about its centre sufficient to arrest all circulation throufrh it. The wound into the joint 
 was extensive, but. as my dresser had sealed it well with lint soaked in the compound 
 tincture of benzoin before I saw it, I thouL'ht it wise to leave the case to nature. The 
 youth went on well without one bad sym]itom,and left the hospital with a movable joint. 
 1 am disposed to attribute the well-doiuir of this case to the fact that the brachial artery 
 was obstructed. 
 
 When, however, the condition of the limb at the seat of fracture is such as to forbid 
 aiiv hope of its recovery being entertained, primary amputation ought to be performed ; 
 if a doubt e.\ists as to the probability of the limb being saved, the artery should be 
 secured in or above the wound, and amputation should be performed as a secondary 
 operation if the attempt fail to save the limb, the chances of a successful result in pri- 
 mary and secondary amputation being about e((ual. 
 
 In simple fracture, when there is great effusion of blood and Jio pulsation in the 
 swelling or vessels, the expectant treatment is the right one to adopt, the injured limb 
 being kept at rest and elevated and cold applied. When pulsation in the swelling is felt 
 and it is clear that arterial laceration has taken place, the same practice ought ahso pri- 
 marily to be adopted, since every hospital surgeon knows that these cases often do well 
 under such treatment. I can recall several where it was as clear as symptoms could define 
 that with fracture of the bones of the leg severe arterial laceration existed, and yet a good 
 recovery ensued. To cut down at the seat of injury and secure the wounded artery is 
 what no one at the present day advocates, although John Bell laid it down as a law that 
 such a rule should be followed ; but to do so above the seat of injury is one that com- 
 mends itself to the surgeon's attention when it is clear that some treatment is requi-site 
 for the wounded ves.sel, and that the fracture and parts around are progressing toward 
 recovery. When gangrene of the limb threatens, it would be as unscientific as it is use- 
 less to adopt this practice, amputation, under such circumstances, being alniic applica))le. 
 
 SuM.MARY. — By way of summary, it would appear that in compound fracture 
 complicated with arterial hemorrhage the vessel ought to be secured — if possible, in the 
 wound, if not, above it — and that primary or secondary amputation should he resorted to 
 only when the local injury forbids any hope of a natural recovery being entertained. 
 
 In simple fracture the expectant treatment should, as a rule, lie adopted. If, 
 from the progressive character of the hemorrhage, interference is absolutely demanded, 
 the artery should be secured above the fracture, and amputation had recourse to when 
 gangrene of the limb follows. Pressure upon the afferent artery is a practice that also 
 demands attention. 
 
 In exceptional cases it may be expedient to cut down upon the wounded vessel at the 
 seat of injury. 
 
 Fractures implicating Joints. 
 
 These are generally grave injuries, though in simpft' fractures the worst effect that is 
 usually to be looked for is some stiffness or anchylosis of the articulation. Yet this 
 result is not constant, and a movable joint is not rarely secured. As a matter of precau- 
 tion, however, the surgeon should warn the patient of the risk and be careful always to 
 adjust the fracture and limb in the most useful position for a stiff joint. Such cases 
 require very careful treatment, absolute immobility of the injured bone and articulation 
 being essential points to be observed ; the joint, if inflamed, must be treated upon ordi- 
 
904 OX FRACTURES. 
 
 nary principles. Passive movement of the joint should be commenced after the lapse of 
 four or five weeks. 
 
 Compound, fractures into joints are among the most serious cases the surgeon 
 has to treat, and in the lower extremity generally require amputation. In the knee- 
 joint this practice is the best when the wound is great and the fracture severe, though 
 exceptional cases are on record in which excision has been employed. In less severe 
 examples an attempt to save the member may be made, secondary amputation being per- 
 formed when ill-success follows. The same rules are applicable in these cases as in 
 wounds of joints, a simple fissure of bone adding but little to the danger, while severe 
 comminution reduces the prospects of success to a minimum. 
 
 In compound fracture into the ankle-joint without displacement no operation is usually 
 called for, since good results are obtainable by conservative treatment. 
 
 In compound fracture of the shoulder- and elbow-joints amputation is rarely required 
 unless the parts are irreparably crushed or the patient is so old as to forbid any hopes 
 of recovery being entertained. Yet in many cases excision should be undertaken, as it is 
 wiser to excise the articulation at once, with the view of securing movement, than to look 
 for a recovery by natural processes where anchylosis must be expected, unless, indeed, 
 the wound is small, the injury to the bones slight, and the patient young. 
 
 In compound fracture of the wrist no operation is required, as a general rule. 
 
 Summary. — By way of summary, compound fractures into joints should be regarded 
 as cases of wounded joint and treated accordingly, the amount of bone comminution and 
 displacement having an important influence in determining the question and nature of 
 operative interference when such may be called for. 
 
 In large joints, where excision is inexpedient or dangerous, amputation must be had 
 recourse to ; in others, where excision is a sound operation, it should be preferred. In 
 the ankle- or wrist-joint, where the articular ends of the bones project, they should, except 
 in young subjects, be removed. 
 
 Comminution of bones is a complication that requires a few observations, 
 although in shup/e fractures it does little more than render difiicult the treatment of the 
 case and increase the risk of some shortening or deformity. When, however, it is the 
 result of a direct force from a " spent ball " or other projectile, the comminution may be 
 very great ; the bone also may be fissured and with the soft parts contused, the danger 
 of the case under these circumstances being much aggravated, not only from the direct 
 effect of the injury, but from the ostitis that is so liable to follow. 
 
 In compound fracture bone comminution has. too. an important influence for harm, 
 adding greatly to the risks and dangers of suppuration and diminishing the probabil- 
 ities of a successful result, since each piece of bone often acts as an irritant and retards 
 recovery, and the fragments too often subsequently die. It is always well, therefore, in 
 these cases to remove the detached portions, and when the extremities of the bones are 
 ragged to excise them. Large pieces of bone, however, that are held by their periosteal 
 coverings must not be interfered with. This .splitting and comminution of bone is mo.st 
 frequently met with in gunshot wounds, the conoidal bullet of the present day splinter- 
 ing far more than the round one of former times. 
 
 In all cases of compound fracture where difficulty is experienced in reducing the pro- 
 jecting ends of the broken bone the best course is to remove them with a saw, particu- 
 larly when they are sharp ; comminuted fragments should also be taken away. When 
 much bone has, however, been removed, the surgeon should be careful not to separate 
 the parts too much, for fear of want of union. 
 
 The subject of dislocation and fracture has been discussed in the chapter on dislo- 
 cation. 
 
 Fracture from gunshot wounds will receive attention in the chapter devoted to gun- 
 shot injuries. 
 
DISEASES or THE JO [NTS. 905 
 
 CHAPTER XXXir. 
 
 DISKASKS OF TIIK JOINTS. 
 
 General Remarks. 
 
 To assert that safe and scientific surgery can only be based on sound pathology may 
 ap|H'ar to be a somewhat trite observation ; nevertheless, it is true — so true, indeed, that 
 it caiiiKit be impressed too forcibly on all who seek or profess to practise our profession. 
 Moreover, it should be the aim of every surgeon whose duty it is to practise and to teach 
 to dom(»nstrate the truth of the assertion and to establish his practice upon such a scien- 
 tific l)asis. It is with this feeling that I now pro])ose to consider the pathology of joint 
 disease and to explain iM-iefly the changes which the tissues undergo during infiammation 
 and the results to which those changes lead, setting aside for the present disputed points 
 of pathology and reserving for future consideration the suljject of tumors involving j<jints. 
 
 Diseases of a joint generally commence as an acute or chronic inflammation of the 
 bone or synovial membrane, although in the progress of any case, and particularly when 
 disorganization of a joint has taken place, both tissues become affected, the extent to 
 whicii either will be involved greatly depending upon the seat of the original disea.se. 
 When it has begun in the synovial membrane and gone on to produce disorganization of 
 the joint, the bones will in all probability be found to be affected only on their articular 
 facets ; the deeper structures will not have been involved. When the bones are the orig- 
 inal seat of the mischief, and the inflammatory process has spread from them to the .syn- 
 ovial membrane and disorganization of the joint taken place, the chief pathological changes 
 will be .seen in the osseous tissue, and either the whole or a part of the articular e])iphysi8, 
 if not a portion of the shaft, will be involved in the disease, lender both circumstances 
 the cartilage covering the articular facets will have disappeared. When the bones are 
 the primary seats of disease, the cartilages are shed more rapidly, as the articular carti- 
 lages derive most, if not all, of their nourishment through the bones ; and, as a conse- 
 (juen;ce, any perversion of nutrition and inflammatory changes of this tissue at once show 
 themselves in the cartilages. 
 
 Practically, there is no such thing as a primary di.sease of the articular cartilages, no 
 such process as so-called ulceration of cartilage, independently of disease of other tissues. 
 When the cartilages undergo a change, it is always secondary to some affection either of 
 the synovial membrane, when it is slow and partial in its action, or of the bone, when it 
 is rapid and complete. It should be remembered, however, that disease in the synovial 
 memVn-ane of a joint cannot exist for any time or be of any severity without involving 
 its ligaments or the cellular tissue with which it is surrounded. Nor can inflammatory 
 di.sease exist for any period in the ai'ticular extremity of a bone without more or less 
 affecting its periosteal covering. It should be added, too, that there is good reason to 
 believe that either bone or synovial disease may be .started by a severe sprain or laceration 
 of ligaments at their osseous or periosteal attachments. 
 
 Before proceeding to consider the changes the different tissues undergo from the inflam- 
 matory process, it will be well to ask whether there is such a disea.se as strumous disease 
 of a joint, strumous disease of the synovial membrane or bone. 
 
 If I were to answer this question according to custom, as indicated by the free appli- 
 cation of the term to joint disease, I should unquestionably say that it was a common 
 affection ; for there are few chronic changes of a joint that are not so designated, and it is 
 rare, in a delicate child, to meet with any chronic affection of a joint which is not regarded 
 by some as a strumous disease. Indeed, from the constant use of the phrase, it might be 
 thought that the term •• .strumous disease ' had .some definite meaning or conveyed some 
 definite idea — that the affection so designated was of a special kind, could be recognized 
 by special features, and possessed definite pathological characteristics. Yet it can hardly 
 be said that such is practically the ca.se ; for if we look for the points of difference 
 between the so-called strumous disease and the chronic inflammatory affections, we shall 
 fail to find them, since they are not clinicall}' to be distinguished or practically to be sepa- 
 rated. Indeed, I am more than satisfied that the so-called strumous disease of a joint is 
 nothing more than a chronic inflammation of the bones or the synovial membrane, or 
 both, that the pathological changes in the afiected tissues are such as are clearly traceable 
 
906 DISEASES OF THE JOINTS. 
 
 to a low form of inflammatory action, and that they difl"er in no single pathological point 
 from the inflammatory changes found in other parts. It is true that such afi'ections, 
 being of a low type, differ from other inflammatory actions of a more healthy charac- 
 ter, but that they are, nevertheless, inflammatory there can be no doubt. Practically, 
 therefore, it would be well to expunge this term " strumous " in respect to joints from our 
 vocabulary, as its use certainly misleads by making the student believe that the term has 
 a definite meaning when it has not. and by encouraging the idea that the disease to which 
 it is applied has a constitutional more than a local origin, and is consequently incurable. 
 Of this, however, I am sure— that so-called strumous disease of a joint is as curable and 
 as amenable to treatment as any other chronic inflammatory disease. In saying this, 
 however. I do not dispute the fact that pathologically we do at rare intervals find tuber- 
 cular deposit in some of the tissues building up a joint, and particularly in the bone ; but 
 I must repeat what I wrote many years ago in my work on diseases of the joints — that 
 " such preparations, being so rare, are to be regarded as pathological curiosities." They 
 are discovered also accidentally, and cannot be clinically recognized by any characteristic 
 features from other cases of chronic inflammation of the bone. It would be well, there- 
 fore, to give up the term in scientific discussion, or, if it be used at all, to use it in the 
 same sense as the words "tumors," rheumatism," and "fever" are now employed — as a 
 broad general term that includes many afi'ections and covers much ignorance. 
 
 With these general remarks, I now pass on to consider the changes the diflTerent tissues 
 entering into the formation of a joint undergo in the inflammatory process. 
 
 Pathological Changes which take Place in the Synovial Membrane 
 
 FROM Inflammation. 
 
 In a pathological point of view, inflammation of the synovial membrane may show 
 itself in two distinct ways — firstly, in change of function ; secondly, in change of struc- 
 ture. The first change may take place without the second, but the change of structure 
 necessarily includes an alteration in the function. The best examples of the first class 
 of cases, in which a change of function is the most prominent point, are seen in every-day 
 practice in cases of so-called chronic or subacute synovitis, where excess of secretion in 
 a joint is the main symptom, and in w^hich this secretion may be reabsorbed and leave no 
 trace of disease behind ; W'hilst the best illustrations of the second class, in which change 
 of structure is the main point of clinical as well as of pathological importance, are seen in 
 the pulpy disease of the synovial membrane. Between the two great classes of cases, 
 however, there are doubtless many links ; for example, in acute synovitis we have change 
 of structure even to more or less complete disorganization, and in chronic synovitis fre- 
 quently repeated we have change of structure such as gradually pases into the pulpy 
 synovial disease. It would thus appear that in acute inflammation of the synovial mem- 
 brane we have pathologically a series of changes that diff"er somewhat from those seen in 
 chronic inflammation, and that while the acute form, it is true, pas.ses into the chronic by 
 imperceptible gradations, the two classes of cases are, nevertheless, very distinct. Acute 
 inflammation of a synovial membrane in its early stage is pathologically represented by 
 what my notes of cases clearly illustrate — a more or less minute injection of the capillary 
 vessels, passing on to a velvety appearance of the synovial surface, a flocculent surface 
 or one covered with fine fringes of lymph, while in the more acute cases the synovial 
 membrane may have disappeared by ulceration or sloughing or have so softened down as 
 to be destroyed on the slightest touch. In the former class of cases there will be. clini- 
 call)% increase of secretion in the joint, severe local pain, and heat with surgical fever ; 
 while in the latter there will be acute suppuration and the synovial membrane may show 
 any one of the conditions already indicated, or they may have disappeared, pus and 
 broken-up membrane alone remaining to indicate the local severity of the action as well 
 as the destructive nature of the aff"ection. 
 
 In intermediate or less acute cases other changes may be seen, but they are not less 
 marked. In one, the notes of w^hich are before me, there was visible to the eye a local 
 patch of capillary injection, and beneath it could be made out a superficial granular 
 change of structure in the cartilage, In another an eff"usion of a firm fibrinous layer of 
 lymph over the surface of the synovial membrane and. articular cartilage showed itself, 
 and this membrane could be raised from its bed and peeled oflP — not only off" the synovial 
 capsule, but also off" the articular cartilage ; and beneath this membrane fine radiating 
 capillary vessels passing from the margin of the articular cartilage toward the centre 
 were clearly visible. In this case, moreover, after a section was made through the spot 
 
I'ATHOLOCy OF JOIST DISEASES. 907 
 
 of injected inembranc and cartilajri' down to tlic Itonr, tlu; .s\v<dl('n Iay«'r of membrane 
 jiassinj; over tin- eartilujre was clearly visible, as well as tlie granular degeneration of tlie 
 eartilage l)eneatli ; and this membrane eoiibl )»e separate*! from its cartilaginous connection 
 by means of needles. It occurred in a child, but it seems to me to be sufficient to prove 
 by means of pathology what aiiatfuny has hitherto failed to settle — viz., that a layer of 
 membrane passes over the articular cartilage. I have seen the.se <'hanges more than once. 
 
 The changes that take place in the synovial membrane in subacute and (dironic syno- 
 vitis remain tu be noticed, and tliey are (essentially of the .same jtathologieal character an 
 those we have been just considering, though they differ in this great point — that the 
 synovial membrane is not destroyed, but becomes thickened in various degrees by the 
 intiltration within its walls and upoji its surface of inflammatory product; and this thick- 
 ening may be so great that the synovial membrane may be represented by a tissue an inch 
 in diameter. It will, however, be found only in cases in which repciated attacks of 
 inflammation have taken place and many layers of lymph have been deposited upon and 
 in the affected tissue. The layi;rs may not be deposited rapidly one after another by con- 
 secutive attacks of chronic inflammatory action — for they may be the result of di.sease 
 which has sjiread over many years — but they will always represent an inflammatory action 
 of a chronic nature which at uncertain intervals has attacked the joint, and on each occa- 
 sion left l)ehind it pathological evidence of its presence by an inflammatory infiltration. 
 In delicate and so-called strumou.s subjects the product will be soft and pulpy, and in the 
 syphilitic firmer and fibrous. 
 
 It is with such changes as these tuat all cases of the gelatiniform or gelatinous dis- 
 ease of the .synovial membrane, as well as the pulpy disease of Sir B. Brodie, are uncjue.s- 
 tionably to be classed. Both are of the same nature pathologically and clinically — at 
 least, all my own investigations have led to this conclusion. I shall therefore employ the 
 phrase " pulpy disease of the synovial membrane " to designate the changes which ensue 
 in chronic inflammatory synovial disea.se. The term is short and as expressive as any- 
 other, besides being one with which the profession is familiar. 
 
 Pathological Changes which the Articular Cartilages undergo 
 
 FROM Disease. 
 
 The most important point the practical surgeon should recognize when considering the 
 pathology of the articular cartilages has reference to the fact that there is no primary 
 disease of its structure, since pathological anatomy teaches us that all the changes found 
 in it are secondary to some other affection, and, in the generality of cases, to disease in 
 the articular extremities of the bones. There is no such disease, therefore, as primary 
 " ulceration of the cartilages," and when the cartilages are diseased, they are so from 
 the extension of mischief from the bone beneath or from the synovial membrane around 
 or upon them. 
 
 Much has been written about the cartilages under the idea that they were liable to 
 special diseases, and much error has consequently crept into joint-pathology, the authority 
 of great names such as Brodie, Key, and others having helped to encoiirage this idea. 
 Modern investigation, as carried out by Redfern, Goodsir, and others, has. however, cor- 
 rected this erroneous notion, and an improved pathology has clearly .shown that the dis- 
 eases of the cartilages are secondary to diseases of other ti.ssues. 
 
 Some years ago, when describing the results of my own investigations, I divided 
 these affections into the fdttt/, the Jihroita, and the (jranular degenerations, and nothing 
 that has been observed since has led me to doubt the accuracy of this classification ; 
 indeed, additional experience has confirmed its truth. I am not about to enter, however, 
 into a minute description of the diff'erent changes, for they can be read elsewhere ; but it 
 may suffice for my present purpose to remind the reader that the fathj degnteraflon of 
 the articular cartilages is found in joints that have been deprived of their natural func- 
 tion.s from any cause — from non-use in the majority of cases, but in many from bad 
 nutrition ; that it is found in common with the same change in the bones or other tissues. 
 This fatty degeneration can be recognized with tolerable facility by the naked eye, for 
 the cartilage so aff"ected, instead of possessing its natural white pearly aspect, will appear 
 somewhat transparent, with an undulating, unef|ual, although smooth, surface. When 
 cut, it will feel softer than usual, and may be three or four times its natural thickness. 
 At times it may even be " pulped " by firm pressure with the finger, and be separated from 
 the bone with more than usual facility. Microscopically, also, it will present character- 
 istic features. The natural cartilage corpscules will have become changed into fat and 
 
908 DISEASES OF THE JOISTS 
 
 granule cells in various degrees, and the hyaline matrix will be filled with cavities vary- 
 ing from the healthy standard to large spaces. These spaces, moreover, will be filled with 
 the elements of fatty degeneration, into which the healthy corpuscles will have changed. 
 This fatty degeneration takes place in most joints that have not been used, but rarely 
 from disease of the joint itself. When, however, a joint so changed becomes the sub- 
 jecL of inflammation, disorganization of the articulation rapidly follows ; for such a degener- 
 ated tissue has no power of resisting disease and disappears when attacked by it rapidly. 
 
 The fibrous degeneration of the articular cartilage is a disease of a 
 
 peculiar character. I believe it to be associated with only one disease of a joint, which 
 is " osteo-arthritis." It is very gradual in its progress and is not characterized by any 
 definite symptoms. It can be recognized pathologically in its earliest stage by the loss 
 of the natural glistening aspect of the cartilage of a joint, the smooth surface of which 
 disappears and looks rough. Small fissures involving more or less of its thickness next 
 appear, which sometimes extend down to the bone, and, as a rule, are thicker in the cen- 
 tre ; they occasionally radiate outward. The cartilage seems gradually to become thin, 
 and after a time to disappear, exposing the articular surface of the bone, which probably 
 will have undergone the calcareous degeneration. Microscopically, the principal change 
 that is seen in tliis disease is the gradual alteration of the hyaline structure into fibre. 
 The cartilage corpuscles at the first will be found interspersed between these fibres, but 
 at a later date to have changed into granules. At the last stage nothing but fibres may 
 be found ; and when this condition exists, the total and rapid disappearance of the struc- 
 ture will not be far distant. 
 
 The granular degeneration of the articular cartilage is the most import- 
 ant afi"ection of this tissue. It is the one most commonly found in joint affection, and 
 seems to be the direct consecjuence of a perverted nutrition in the bone or synovial mem- 
 brane from disease of these structures. Though of a simple nature, it shows itself in 
 many ways, and without microscopical investigation it must have appeared unintelligible. 
 In its different forms it has doubtless led good observers to describe it as an ulceration 
 of cartilage, for under certain conditions the cartilage presents a worm-eaten, excavated 
 appearance not unlike that which ulceration might produce. 
 
 The disease is essentially a granular degeneration, first of the natural cartilage cells 
 imbedded in the hyaline mati-ix, and secondly of the hyaline matrix itself. Let a carti- 
 lage cell undergo this granular degeneration, and the granules by accumulation and mul- 
 tiplication form a cavity in the hyaline matrix. Let this cavity burst on the surface of 
 the cartilage into the joint, and an excavation is formed which can be seen by the naked 
 eye, and a so-called ulcer is produced. Let this change take place toward the margin of 
 the articular cartilage, and we find an explanation of Mr. Key's observations upon 
 so-called ulceration of this tissue in certain forms of inflammation of the synovial mem- 
 brane of the joint. Let this change take place near the bones as a result of disease in 
 their articular ends, and we find an explanation of the general condition of the cartilages 
 in the bulk of joint diseases ; for when the bones entering into the formation of a joint 
 are so affected as to interfere with the nutrition of the articular cartilages, the cartilage 
 may either present the worm-eaten appearance all over or in part, or it may have been 
 shed from its bony attachment, when it will be found to be lying upon the bone as a for- 
 eign body in the joint. In an early stage of disease this granular degeneration may be 
 detected only by a microscopical examination, although when it follows upon disease of 
 the bone the cartilage will always be found to peel from off its articular facet with unus- 
 ual facility. 
 
 In synovitis, also, the surface of the cartilage in contact with the inflamed membrane 
 will be found similarly involved. Should the disease be local, as is at times seen in cases 
 of injury to an internal ligament such as the ligamentum teres, the change in the carti- 
 lage will be local only ; but when general, the whole surface of the cartilage may be 
 involved. In acute disease acute degeneration follows, as is evidenced by daily practice. 
 
 Pathological Changes in the Bones the Result of Inflammation. 
 
 Inflammation of the articular extremities of a bone is a very common disease — proba- 
 bly the most common we have to deal with in connection with joints ; for it would appear 
 to be the cause of most, if not of all, of those cases of disease of the articulations which 
 we find in children and have been described as strumous or scrofulous disease of a joint. 
 Some years ago, when writing on this subject, I stated that " I cannot for one moment 
 doubt that the majority of the cases which are described by surgeons as strumous or scrof- 
 
IWTlloLoaV OF JOIST DISEASES. 
 
 909 
 
 Fig. 599. 
 
 ulous disease of a joint of the artieular extremities of the Vjones depend upon a chronic 
 infhininiation in the Ijoiic," and all the experience I have since {gained has tended to eon- 
 tirni nie in tiiis opininn. I lidieved then, as I believe now, that the disease in its origin 
 and projrress is iiifianiniatiM y. and tliat it is as cnralde as any other h)cal affection. It is 
 important to hear this invariahly in mind when examining; or treating a case of disease of 
 a joint, j)articiihirly when it is found in a .so-caMed strumous or cachectic sultject ; for if 
 we reiiard the diseasi' as a constitutional one, we are apt to think it ouglit to he treated 
 on "general principh's, antl to ncj^lect the local means hy which alone a f^ood recovery can 
 be secured. 
 
 Let us now in((uire into the changes that the lione undergoes during this inflammatory 
 or wrongly-called strumous atlection. 
 
 The most striking is probably the earliest, which is the expansion of the articular 
 extremity ; and iji some cases this will be very great, and generally uniform. The articu- 
 lar extremity of the aftected bone or the epiphyses of all the bones entering into the for- 
 mation of the joint will appear to be rounded and generally enlarged. Upon making a 
 section of a bone thus affected it will be found softer than natural ; indeed, it may be so 
 soft as to allow a knife to divide it, or even to break or crush it on firm pressure. To 
 the eye the section will appear more vascular than natural, the cancellated portions more 
 cancellated, the celFs enlarged, and the bony septa radiating from the shaft in a broad, 
 palm-like fashion. The cells will also be found filled with a pinkish serum. 
 
 If the disease continue and the inflammation be of a healthy type, parts of the bone 
 will ap))ear denser and more indurated than the remainder ; its cancelli will be filled with 
 inflammatory products which have organized, and the bone will appear on section as a 
 dense and ap]»arently bloodless mass surrounded by other vascular cancellated tissue. 
 Should the inflammation be of an unhealthy character, diffused suppuration within the 
 l;)one will take place, and death of the bone, wholly or in part, follow. Under these cir- 
 cumstances the disease will probably have become a genuine joint affection, and have 
 extended to the synovial membrane of the joint and set up disease within its substance. 
 This extension of disease will show itself by effusion within the joint, by pulpy thicken- 
 ing of the synovial membrane and of the cellular ti.ssue around 
 the articulation. Up to this point the disease has been local, in- 
 volving only the articular extremities of the bones, and has not at- 
 tacked the proper joint structures, and appears also to be perfectly 
 curable. But at this stage of the disease the articular cartilages 
 will have become affected ; for when the inflammatory action has 
 continued for any period and not shown any indications of subsi- 
 dence, but, on the contrary, has either assumed an unhealthy cha- 
 racter or interfered with the nutrition of the articular lamella of 
 bone upon which the cartilages rest, the articular cartilage will to a 
 certainty undergo a granular degeneration upon the surface in 
 apposition with the bone, become loosened from its attachment, 
 and be thrown off or shed (Fig. 599); or it may degenerate in patches 
 and present to the eye an irregular excavated surface. If the dis- 
 ease be chronic, the cartilage will degenerate slowly and be as slowly 
 loo.sened from its osseous base, when it may readily be lifted off the Drawing; ((;. >f. w-'m made 
 
 ■, , . ^ ^ -tf A ^• 1 • 1 .1 -1 to -show the.'>hed(liiiK0f llie 
 
 bone by any nistrument. it the disease be more rapid, the cartilage Articular cartilage in (Jsti- 
 will likewise be shed more rapidly, raised as a blister off the bone, **^" 
 or found l3'ing upon it as a foi'eign body. Under the microscope it will appear to have 
 undergone the granular degeneration. 
 
 When the disease is acute, the cartilage may disappear Fig. 600. 
 
 altogether, having Iteen shed from its osseous base and be- 
 come rapidly degenerated. 
 
 The articulating surface of the bone during this time 
 may appear in some cases, as in inflammation, only extra- 
 vascular ; in others it may be rough or so-called ulcerat- 
 ing ; while in a third class the articulating facets will have 
 
 been shed wholly or in part. In a still worse class pieces Transver.se section of the Humerus above 
 
 of necrosed bone involving more or less of the articular the(on(i.vies. siiowing New Bone de- 
 
 ... , 1 -i • 1 1 -ii posited Ipeiieatli Periosteum, undergo- 
 
 extremitv will be seen, while in the worst an abscess will ing Kareiactiun and thus simulating 
 have made its way into the joint from the diseased artic- Jpe^UeTorMfj.'Walid^f." ^™™ * 
 ular extremity. In all these conditions the cartilages 
 will have disappeared and the joint become disorganized. These pathological remarks 
 
910 ' DISEASES OF THE JOINTS. 
 
 are applicable to every articulation — to the hip as much as to the knee, and to the shoulder 
 as to the elbow. 
 
 In all chronic cases of ostitis there will be found more or less deposit upon the bone 
 underneath the periosteum, and some good surgeons believe that it is solely by such 
 deposit that the clinical symptoms of enlargement of bone are to be explained. My 
 friend Mr. C. Symonds has ably supported this view (Brit. Med. Journ., December 8, 
 1883). 
 
 The drawing (Fig. 600) shows how subperiosteal bony formations subsequently rar- 
 ify, so as to simulate true bony enlargement, the cancellous appearance being due to 
 the widening of the canals in the compact tissue thi'ough absorption of the bony 
 walls. 
 
 Clinical Symptoms associated with these Pathological Changes. 
 
 The symptoms by which these pathological changes which have been described can 
 be recognized vary according to the formation and surroundings of each joint, but in 
 their general character they are the same. 
 
 Any inflammation of the synovial membrane, of whatever kind, always 
 
 shows itself within a few hours or days of its origin by effusion, and consequently by 
 distension of the articulation, while in the knee, ankle, elbow, wrist, shoulder, and other 
 joints this clinical condition makes itself manifest in a way which cannot be misinter- 
 preted. The synovial sac becomes enlarged and distended by the effusion, so that it 
 bulges between the bones and gives an outline to the joint unlike that furnished by any 
 other condition. In the hip-joint similar changes take place, but they are not quite so 
 palpable, though they can be made out by careful examination, and particularly by a 
 comparison of the affected with the sound side — a point of practice which should never 
 be omitted in the examination of any injured or diseased joint; the soft parts in front 
 of the joint will be more prominent and full ; pain will be produced by gentle pressure 
 made upon the part, particularly behind the great trochanter, where a soft swelling, which 
 will be manifest to the eye, will also exist in lieu of the natural depression. Even fluc- 
 tuation may be detected through the joint on careful palpation. At any rate, to the eye 
 and hand there will be clearly some extra fulness of the soft parts sufficient to lead a 
 surgeon to suspect the true nature of the disease. 
 
 In disease of the articular extremities of the bones a different clinical 
 
 condition will be present. At the commencement of the disease, and sometimes for a 
 lengthened period, which varies in each case, an aching of the part is the only local 
 symptom. This aching may be of greater or less intensity, and depends much on the 
 severity of the disease. It is too often regarded as "growing pains" or rheumatism. 
 What I wish now to note is that local pain is the first clinical symptom, and not effusion, 
 and that there is no enlargement of the affected joint. As the disease progresses, how- 
 ever, an enlargement may be detected, which in the hip can be made out by manipula- 
 tion, whereas in the knee or other joints it may be visible to the eye. It will show itself 
 as an apparent enlargement of the bone, a thickening or expansion of the osseous, and 
 probably of the periosteal, structure unlike that existing in synovial disease ; there will 
 be no fluctuation, no soft yielding of the parts, but clearly a thickening of the osseous 
 structure of the articular extremity of the bone, while the soft parts covering in the 
 enlarged bone are quite natural. With this aching of the part there may also be increase 
 of heat as an early symptom, yet this symptom is not constant, although it is fairly 
 uniformly so ; it may, however, be intermittent. As a rule, it shows itself as a general 
 periodical flushing of the part. 
 
 In chronic synovitis which leads to joint changes the joint may probably 
 
 be gently moved without exciting pain or spasm of the muscles that move the articulation. 
 Pressure upon the part with the fingers will probably excite it, although moderate pres- 
 sure of one bone against the other may be made without giving rise to any indication of 
 distress. 
 
 In diseases of the bone entering into the formation of the joint 
 
 these clinical conditions do not all exist. The joint may be moved quietly without 
 exciting pain, but the attempt will, as a rule, excite spasm of one or more of the groups 
 of muscles which move the articulation. Moderate manipulation also will be well borne. 
 Firm pressure upon the bone, so as to bring the two articular surfaces in contact, will 
 always excite pain ; not the pressure produced by a jar, such as in the hip is caused by 
 a sudden blow upon the foot or trochanter — for such a mode of investigation must be 
 
nrsEASFs OF special joists. 911 
 
 looktMl upon iis niiiiih ami sniucwliat uiircrtaiii ; iiidi-cd, it is almost siiro to excite in the 
 ])atit'iit a start ami an i-xpressioii of pain — Itut tlio pntssuro which is ])ro(lufed by u stuady 
 i'oive ajiiilicd by the hand tn the trochanter toward the pelvis or through the tor»t to the 
 articular extremitiiis of the hones; a ))ressure which in synovial distnise rarely, if ever, 
 gives rise to j)ain, but in osteal disease invariably excites it. 
 
 These syniptoius in the two classes of casi-s ajtpear clearly to indicate the two distinct 
 aftections in tlieir early stage. They apply to all articulations, and may be thus sum- 
 marized : 
 
 Sr.M.MAHV. — In synovial disease >wclliMg is the earliest clinical symptom, with 
 more or less fluctuation, each joint showing this in its (nvn way. As a rule, this swelling 
 is unattended with much pain. Pressure on the joint causes ])ain, although gentle in<tve- 
 ment maybe made without increasing it or exciting spasm of the muscles which surround 
 the joint. Inter-articiilar pressure can generally l)e tolerated. 
 
 In articular ostitis pain is the earliest and most constant symptom — pain of an 
 aching character, varying in intensity and generally increased by firm local pressure. 
 Tiiere will be no visible enlargement of the part for .some weeks or months, and no fluc- 
 tuation. Gentle movement generally excites spasm of muscles about the joint, and inter- 
 articular pressure always increases this and cause.s pain. Increased heat also exists about 
 the parts and is of an intermittent character. 
 
 DISEASES OF SPECIAL JOINTS. 
 
 Disease of the Hip-Joint. 
 
 Authors have hitherto led their readers to look upon disease of the hip-joint as a 
 special or peculiar affection, and to regard it pathologically and clinically as distinct from 
 disea.ses of the other joints. Such, however, is not the case, for diseases of the hip-joint 
 differ in no single pathological point from those of any other articulation. 
 
 It has also with too much confidence been described as a ".strumous disease." as if 
 all diseases of the hip-joint or of any joint were generally of this nature or found in sub- 
 jects who are only of a strumous diathesis — as if all had a constitutional, and not a local, 
 origin. 
 
 Hip-joint disease is a local disease and is mostly set up by local causes. It is, more- 
 over, as amenable to local treatment as any other affection. " It occurs very frequently 
 in strumous children," says Mr. Holmes — " a circumstance which has led to its being 
 denominated 'strumous;' but it seems to have no necessary connection with struma, 
 unless so wide a signification be assigned to that somewhat vague term as would render 
 the designation itself unmeaning. If by struma be meant a state of the system which 
 renders the subject of it prone to the deposit of tubercle in the viscera. I think that there 
 is good reason for asserting that morbus coxarius often attacks children who are not 
 strumou.s — i e., who do not displa}' any such tendency to the deposit of tubercle — and 
 therefore that no decisive proof of any strumous tendency is afforded by the presence of 
 the affection. If, on the contrary, struma be defined as that condition of the system 
 which disposes its subjects to the development of low inflammations of various kinds, 
 then it is difficult to see what is the significance of the designation." It would, therefore, 
 be well to discard the erroneous notion that hip disease has its origin in a constitutional 
 cause, for till that is effected the local treatment is likely to be disregarded or looked 
 upon as of secondary importance, whereas all who have much experience in the treatment 
 of these cases will admit that local treatment cannot be made too prominent a feature. It 
 should, therefore, be looked upon clinically as a local affection and one to be treated by 
 local means, such constitutional treatment being employed as the general condition of the 
 patient may appear to warrant, the same principles of practice being applicable in these 
 cases as have been found of value in other joint affections. 
 
 Hip disease, unfortunately, is a very common affection, and my own statistics inform 
 me that it forms about thirty per cent, of the joint cases admitted into a metropolitan 
 hospital. It is also an affection of child-life, for out of 360 cases of which I have notes, 
 <)2 per cent, or nearly two-thirds, occurred in children under ten years of age. and four- 
 fifths in patients under twenty — that is, it occurred during the period of the growth and 
 development of the bone, and not during that of its full maturity. This point will be 
 seen on reference to the following; table : 
 
.::d « 
 97 
 
 :;as€ 
 
 * - 223 cases, or 61.9 per cent, 
 or 23.8 per cent. 
 
 86 
 
 
 27 
 
 
 or 7.5 " 
 
 13 
 
 
 or 3.6 
 
 11 
 
 
 or 3 
 
 912 DISEASES OF THE JOISTS. 
 
 Tahle showing the Agts at tchich Hip Disease commenced. 
 
 Four vears and under 
 
 Between 6 and 10 vears of age . 
 
 " 11 "20' 
 
 " 21 " 30 " . . 
 
 " 31 " 40 " . . 
 
 Above 40 years of age 
 
 Of these cases, 230 were collected by me when acting as registrar at Guy's from 1853 
 10 18G1, and 130 are from the notes of cases which have been under my own care. 
 
 It is found in the male and female subject in equal proportions, but appears to attack 
 the left more frequently than the right limb, sixty per cent, of my cases having occurred 
 on the left and forty on the right side ; and this proportion is very similar to that pub- 
 lished by Mr. Lonsdale in the Lancet for September 8. 1855. where, out of 112 cases of 
 deformity of the hip. 65 were of the left and 47 of the right side. 
 
 Pathology. — It has been already stated that in a pathological point of view hip dis- 
 ease differs in no respect from that of other joints and is not a strumous affection, 
 although it mav occur in strumous subjects. It may also be repeated that it is a very- 
 rare thing to find strumous or tubercular matter in a diseased hip-joint. Excluding new 
 growths, disease of the hip consequently means inflammation of the bones or soft parts 
 entering into the articulation, and in at least two-thirds of the cases inflammation and 
 necrosis of bone. 
 
 In the pathology of joints few points probably have been more disputed than the seat 
 of the disease in hip-joint affection, and I believe the difficulty has been entirely raised on 
 the mistaken notion that the nature of the affection was different from that of other joint 
 diseases. We have never heard much importance placed upon the point in diseases of 
 the knee-, shoulder-, or other joints. The question as to the origin or not of disease of 
 the knee in the crucial ligaments or of disease of the shoulder in the long tendon of the 
 biceps has never been very warmly discussed. And yet we find men gravely discussing 
 the question as to the origin of hip disease in the ligamentum teres. 3Iy much-respected 
 teacher, the late Mr. Aston Key. laid great stress on this point, and believed that it was 
 from that ligament and its attachments that disease of the hip-joint generally proceeded. 
 Pathologv has. however, made gi-eat advances since those days, and we now know that 
 •disease in a joint (hip or other) may have its origin in the bones which form the joint or 
 in the soft parts or ligaments that hold them together. Experience, moreover, has taught 
 us that we may have an acute inflammation of the synovial membrane rapidly going on 
 to complete disorganization of the ligaments, cartilages, and soft parts of the joints, and 
 even causing death of the bones entering into its formation. The inflammation may be 
 so acute as to render it difficult at the post-mortem examination to read the pathological 
 facts correctly ; for when such changes as these take place, it is fairly open to question 
 whether the iniSammation originated in the synovial membrane and spread to the bones, 
 :artilages. and ligaments, causing their destruction, or whether it began in an osseous 
 centre and extended to the joint. This difficulty is experienced when the disease has been 
 so severe as to cause a division of the pelvic bones into their original segments or a sep- 
 aration of the epiphysis of bone forming the head of the femur from its normal attach- 
 ment to the neck. 
 
 When the bones of the joint are equally involved in acute di.sease. it is probable that 
 the mischief began in the synovial membrane and spread to the bone. But when we find 
 one bone morediseased than another — e. g.. the femur than the acetabulum, or vice 
 irrsa — it is probable that acute inflammation originated in it and spread to the soft parts. 
 These points, however, are to be looked upon as only feeble indications, and not as definite 
 guides upon which an opinion may be formed. In chronic disease of the hip-joint the 
 question as to the seat of the original disease is not so easily answered, and yet. from 
 what I have observed, clinically and pathologically, the question is not one impossible to 
 answer. When a joint is disorganized, its ligaments and cartilages gone, and the articu- 
 lar surfaces of the bone exposed, or perhaps diseased, there may be some difficulty in 
 decidins as to the particular tissue in which the inflammation originated ; but when a sec- 
 tion of "the bone is made — e. g.. the head of a femur or the head of a tibia — and a cavity, 
 a sequestrum, or a suppurating bone is found communicating with the joint, probabilities 
 certainly point to the bone as being the original seat of the disea.se. But it may be 
 asserted that in such in.stances no one doubts the cause of the joint disease, since the 
 pathological conditions clearly prove it ; yet the clinical histories of such cases differ in 
 DO single point from those of others in which, perhaps, the same very marked evidence 
 
DISEASES OF SI'ECIM. .InlSTS. 
 
 013 
 
 of disease is not to be seen — that is, if the joint he cxuuiined on its surface only. Indeed, 
 tit examine a i>athoIo<;ieal specimen of" a hone or of a diseased joint, it is ahsohitely neces- 
 sary to make a vertical section through the h<ine, since to h>ok at it I'ronj the joint .surface 
 is most fallacious and an (i|iininii furnicd from the appearance thus aci|iiire(l is too likely 
 to he erroneous. 
 
 If \Vf make, then, a section of the hone in chronic disease of the joint, we shall find 
 in a larire uiimher of ca.ses, especially in the youn^'. hypenemia of its articular extremity 
 and condensation, if not suppurati(»n or necrosis, fronj chronic inflammatory action (V\^. 
 tlOl ) ; in fact, we shall Hud marked evidence of articular ostitis in <ine of its stapes, for 
 diiulitless (lurinir youiiLT lite this is the most common fnrni of disea.se which precedes joint 
 mischief and fntin which joint disease proceeds. This opinion is al.so corroborated hy tin* 
 fict that in our museums almost every s])ecimen of chronic joint di.sease reveals advanced 
 hunc mischief extendinj; heyond the surface and {generally involvinj; more or less of the 
 articjilar ends of the hone which enter into the formation of the joint. In our Guy's 
 Museum this point is very strongly displayed, and on lookinjr over other museums and 
 copious notes of joint ca.ses the .same truth is apparent. 
 
 At times, however, the disease may primarily commence in the epiphysial cartilage 
 situated between the head of the femur and its neck, the epiphysis as a con.sequence 
 being thrown off (Kig. (502). This jtathological observation must be looked upon as of 
 
 Fig. cm. Fig. 002. 
 
 Necrosis of the Head of the Femur, with Seques- 
 trum in it.s Xeck. (Prep. ISl.sS, (iuy's Mus.) 
 
 Separation of Epipliysis forming the Head 
 of Femur, ((iuy's Mus., Prep. ISI-t*".) 
 
 great clinical importance ; for if the majority of cases of joint disease is to be attributed 
 to the extension of an inflammatory action from the articular extremity of a bone to the 
 other tissues, it becomes a question of urgency to recognize the disease of the bone in its 
 early stage in order to prevent its progress to the tissues upon which the integrity of the 
 joint itself depends, and clinically there is good reason to believe that such can fre- 
 quently be done. In the hip-joint it may be difficult — po.s.sibly more difficult than it is 
 in disease of other articulations that are not so well covered in with soft parts, such as the 
 knee — but it can be made out with care and discrimination even in the hip. And here it may 
 be well to consider the clinical features upon which our diagnosis should be determined. 
 
 DlAGNCSis. — The neees.sity of making a correct and early diagnosis of hip disease 
 would scarcely require illustration did not daily experience indicate that it is not suffi- 
 ciently recognized. The early sym])toms of the affection, consequently, are important. 
 
 When a child, after injury to the hip. has joint pain, and possibly limps, and these 
 symptoms persist after all external evidence of injury has passed away, there is some rea- 
 son to suspect the presence of joint mischief. When this pain is increased by inter- 
 articular pressure, either by means of the hand applied over the trochanter or by the 
 patient standing or walking, the suspicion should be strengthened. When swelling of 
 the parts can be made out and .some bulging of the synovial membrane, as shown by a fulness 
 behind the trochanter and in the groin, is found to exist, combined with tenderness, syno- 
 vial inflammation is rendered probable; and when persistent pain without effusion is the more 
 prominent symptom, aggravated by firm inter-articular pressure, bone mischief is indicated. 
 When these symptoms appear after some fever or illnes.s — or, indeed, without any such cause 
 — they are of no less importance, although, probably, they are more liable to be overlooked. 
 
 As a clinical point of primary importance all joint pain claims attention, and particu- 
 larly in hip-joint cases: and when this is referred to the knee, the surgeon must not be 
 misled. Limping of any kind alwaj's indicates something wrong — probably very wrong 
 — more particularly when combined with joint pain aggravated by inter-articular pressure. 
 5S 
 
914 
 
 DISEASES OF THE JOINTS. 
 
 Spasm of the muscles arotind the joint is a symptom of great significance and a means that 
 nature adopts to ensure immobilit}- of the afiected articulation ; in some cases it will be 
 so severe as to forbid all movement, but in others it is less marked : at one time it will be 
 confined to one group of muscles, such as the flexors, when the position of the limb will 
 be determined, while at others the rotators or abductors will be afiected ; but whenever it 
 is met with, there is probably some afi"eetion of the joint itself or of the bones that enter 
 into its formation. When doubt exists as to muscular spasm being the cause of joint 
 immobility, an anaesthetic should be used, as all spasm ceases under its influence, and the 
 head of the bone, by manipulation, rotates with more or less facility and smoothness 
 according to the amount of joint mischief that is present. 
 
 Position of Limb as a Means of Diagnosis. — In the diagnosis or treatment of hip 
 disease there is no point which deserves closer attention than the position of the limb, and 
 I am disposed to think it has not received that attention, since experience has proved that 
 most of the cases of deformity met with after a natural cure of the disease are due to a 
 want of appreciation of its importance. 
 
 In one case the limb will appear elongated, but on measurement no real lengthening 
 will be detected, the apparent elongation being due to the tilting upward of the pelvis on 
 
 Fig. 605. 
 
 Fig. 606. 
 
 Apparent Shortening of the Limb in Hip Disease caused 
 liv .Adduction. 
 
 Fig. 603. 
 
 Fig. 604. 
 
 Fig. 607 
 
 Fig. 
 
 Fig. 6<J3. — Apparent Elonnaiion of the Left Lower Extremity in Hip Disease on the Left Side, due to .Induction of 
 the Limb and the necessary Tilting Upward of the Pelvis on the .Sound Side to allow the Abducted Limb being brought 
 Into a Line with the Body.' 
 
 Fig. 604. — .Itducted Position of the Diseased Left Limb when the Pelvis has been brought into its Natural Position 
 at Right Angles to the Spine. 
 
 Fig. 6<>o. — Position of Patient when Standing with Disease of the Left Hip-Joint and an Jdducted Limb. (The 
 pelvisis tilted up on the affected side and the limb thereby apparently shortened. 
 
 Fig. 606. — Position of the Adducted Limb when the Pelvis is brought Straight. 
 
 the sound side, either from the patient naturally throwing all the weight of the body on 
 that( side to take ofi" pressure from the aflfected one or from muscular spasm causing 
 abduction of the limbs i Figs. 603. GO-t >. In another case the 
 pelvis on the aff"ected side will be drawn up and tilted slightly 
 backward, the thigh becoming adducted and more or less 
 flexed upon the pelvis (Figs. 605. 606), or in some cases 
 rotated outward from the spasmodic contraction of the mus- 
 cles that move the hip. In other and more advanced cases 
 genuine shortening of the limb may take place from either real 
 loss of substance in the head or neck of the bone, or, in excep- 
 tional cases, from di.slocation of the head of the femur upward 
 and backward < ilio-ischiatie) : and in rarer examples the neck 
 and shaft of the femur may be separated and displaced up- 
 ward and backward, the epiphysial head of the bone being left 
 in the acetabulum. This probably occurred in the case from 
 which Figs. 607. 60S were taken. Where the joint is flexed, 
 some spinal deformitv (lordosis) will exist when the patient 
 Displacement oi Femur. ^Taken gt^uds or lies: but this apparent spinal curve will, however. 
 
 from »\ illiara D , set. H. lOl- ' rr f ., . 
 
 lowine disea-^ of five years' even in the worst cases, at once disappear when the patient 
 m«"emlitiIthe%inS) '^"'' is placed On his back and the limb raised (Figs. 609, 610) or 
 
DISEASES or SI-ECIAL .InlSTS. 
 
 915 
 
 wlu'ii lie stamls witli tin- k'j; flexed (Ki<j:. \\\'l). Aiiparciit el<)ii;:ati<iii oi" the liriih under 
 all "irciiiustaiires means it.s ff/>duetii»ii ; sliDrtciiiii^' ol" the liiiil) impliey //'/ductioii ; flexion 
 
 I'k.. ti(»<». 
 
 Fig. 609. — Lordosis of Spine, as seen with Patient tlie Subject of Hip Disease in Recumbent ^o^itloll, witii ?emur 
 flexed at Angle of V.V\ degrees. 
 
 Kig. 611). — Lordosis Kllaced by I'.levatiug tlie Fle.xed Limb. 
 
 gives rise to lordosis. These conditions necessarily follow any attempt of the patient to 
 bring the sole of the nialplaced limb down to the ground. 
 
 FlatleniiKi of the links, as seen in hip disea.se, is due to a wasting of the glutei mus- 
 cles from want of use, this symptom boeoniing more marked when the thigh is slightly 
 flexed, the trochanter rotated outward and the foot inward. 
 
 Disease of the Hip-Joint attended with Suppuration. — These are the 
 
 worst cases of joint disease. I'nr sujipiirariuii oi' a joint L;enerally means its disorgani- 
 zation ; and when the disea.se has its seat in the bone, necrosis or some serious inflam- 
 matory change is indicated. Under these circumstances all free movement of the head 
 of the bone will probably have long disappeared and more or less anchylosis or natural 
 repair have taken place, for in joint affections reparative and disea.sed actions run much 
 together. The limb may be found in any position, the flexed and adducted position of 
 
 the thigh being the most common, particularly 
 Fig. 611. Fig. 612, in neglected cases, as illu.strated in Fig. G13; 
 
 but at times the thigh will be rotated outward, 
 and even abducted. When sinuses exist, a 
 probe may detect diseased bone. When the 
 pelvis is involved in the disease, a finger 
 
 Fig. 613. 
 
 Lordosis of Spine in Hip Disease from Flexion of Thigh. 
 
 Flu. (ill. — Ancbylosis of Left Hip at VM°, jiroduciug Lordosis; when Patif.i i- •nik. 
 
 Fill. 612. — Lordosis remedied by raising limb. 
 
 Fig. 6i:?. — Disorganization of llip-.Ioint. (From patient, Sarah B , set. 22, July, 1870. Ejccision of the joint was 
 
 performed in this case, and a good result followed.; 
 
 pas.sed into the bowel will often detect any swelling about the floor of the acetabulum. 
 When dislocation is present, the symptoms will indicate its form. 
 
 All ca.ses, however, of suppuration about the joint, even when associated with disease 
 of the joint, are not to be regarded as a direct result of disorganization of the articu- 
 lation, since it is quite certain that inflammatory mischief may exist in the joint and sub- 
 side, and yet be followed b}' suppuration in the cellular tissue about the part ; and in this 
 opinion pathological does but confirm clinical observation. There may be some difficulty 
 
916 
 
 DISEASES OF THE JOINTS. 
 
 in making out such cases during life, but I have no doubt as to their existence. In the 
 hip they are the more common. 
 
 Prognosis. — When hip disease can be arrested in its early stage, a complete recovery 
 may take place, more particularly when it has its origin in synovial inflammation, although 
 when due to articular ostitis and the disease has been of long standing a recovery will 
 probably ensue with anchylosis. When the joint has suppurated and a natural recovery 
 follows, it must be, in the large majority of cases, with fibrous or soft anchylosis, and in 
 the minority with bony. In the 3Iedical Times and Gazette for 18G9 I illustrated all 
 these points fully by a series of cases. 
 
 A very beautiful example of bony anchylosis is represented in Fig. ()14. 
 
 It sometimes happens, when articular ostitis has attacked the head and neck of the 
 femur in childhood and recovery has taken place with either a movable or an anchylosed 
 joint, that some arrest of growth in the bone may be the result. I have seen this in a 
 
 Fig. 614. 
 
 Fig. 615. 
 
 Synostosis of Hip- Joint. (Taken by my father, the late Mr. 
 T. E. Bryant, from a man tet. 42 who had had a stitF joint 
 for thirty years. (Prep. 131S*8^ Guy's Mus.) 
 
 Arrest of Growth in the Neck 
 of Femur as a result of Artic- 
 ular Ostitis. 
 
 child who had been under my care when five years of age for articular ostitis, from which 
 she perfectly recovered ; the femur on the affected side at the age of eight was an inch 
 shorter than its fellow, the trochanter nearer the median line of the body and the anterior 
 superior spinous process of the ilium ; the seat of the shortening was clearly in the neck 
 of the femur, which had been arrested in its growth (Fig. 615). 
 
 Diagnosis. — The diagnosis of hip disease is to be made after a careful estimation of 
 the value of the symptoms as a whole, and not upon one or more supposed typical symp- 
 toms. The limping of a child with infantile paralysis of the leg has been confused with 
 that from disease of the hip, but the wasting of the limb and the absence of pain ought 
 to prevent such an error. The pain of spinal disease, of psoas abscess, of sub-iliac abscess, 
 of some glandular affection of the groin associated with limping, and nerve pain extend- 
 ing down the limb, may mislead, but the knowledge of these facts may prevent the repe- 
 tition of such mistakes. A congenital displacement of the head of the femur has been 
 frequently mistaken for the affection. ( Vide p. 850.) 
 
 Disease of the bursa connected with the psoas muscle in front of the joint, which at 
 times communicates with it, may render the diagnosis difiicult, but the pain on pressure 
 in front of the joint which exists in disease of the bursa, and the pain on pressure behind 
 the trochanter in hip disease, are enough to distinguish the two. Disease of the bursa 
 beneath the gluteus maximus muscle may also at times simulate hip affection, but with 
 care the two affections can be distinguished. 
 
 Diseases of the Knee-Joint. 
 
 This joint is probably more frequently the seat of disease than any other, and in hos- 
 pital practice my own statistics tell me that it forms forty per cent, of the joint cases 
 admitted into Guy's. The greater liability of the knee to injury, the thinness of its 
 
l>ISi:.lSi:s OF SI'ICCIAI. JOISTS. 
 
 917 
 
 Fig. (;if3. 
 
 iiiitiinil cnvcriiiL'. and tin- cinMiilicatiMl I'uriiiat ion >t\' ilic jnint tou-ctlicr inolmlil y afi'urd tlie 
 (riif fxplaiiatidii (if this I'act. It i> nirt with, iiiorcDvcr, in patients (if a inon; mature a<ro 
 tliaii hip disease, sixty-two per iiiil. nl" hip eases and oidy thirly-twn (d" knee disease licinf^ 
 I'niuid in ehildren iiuih'r ten. it must he admitteil. hnwever, that the knee wlien once 
 diseased is K-ss likidy to underj;o a natural cure, and muidi less a eure hy anchylosis, than 
 any »»ther articulation. This is jirohahly to he explaineil anatomically hy the existence 
 (d" the iiiter-arlicular tihro-cartilatres, which, while in a healthy joint they tend to keep it 
 healthy, in a diseased, hy iorhiddiii^' tlie contact (d' the two hom-s. render it difficult for 
 anchylosis to take place, since they must he at least partially ^'ot rid of by some suppu- 
 ration or other chanjje before anchylosis can be .secured. 
 
 When diseased, there is no joint, however, in which the (•han;_a'S can be better recog- 
 nized, or the clinical evidence of disease in the synovial im inbraiie or bones be made out 
 with irreater facility. 
 
 Ill synovitis, acute, subacute, or clironic, the synovial sac becomes distended; the 
 natural tlimples or do]>ressions which in health exist on either side of the patella soon dis- 
 appear, and in their places a bulging of the synovial mcndjrune will 
 be both seen and felt (Fig. Hid). The patella, too, becomes pressed 
 forward, and on palpation may be felt to float as upon a water-bed, ;/ 
 aiul readily made on pressure to dip upon the condyles of the femur u^ 
 which lie beneath. The extensor ujuscles above the patella likewi.se 
 will bo raised by the distended sac and the soft parts below the pa- 
 tella down to its ligament will pniject, distinct fluctuations being felt 
 not oidy across the joint from side to side, but in an ubli(|ue direction 
 from above downward. 
 
 Acute synovitis of the knee, except as a part of so-called rheu- 
 matic fever or pyjiemia, is rarely met with, unless as the result of a 
 wound or the extension of suppurating disease into the cavity. It 
 is a most sevei'e affection, and unless speedily arrested by ice, leech- 
 ing, or those means suggested in the chapter on wounds of joints, 
 ends in the destruction of the joint, and too often in the forfeiture 
 of the patient's life. 
 
 When, after suppuration, life is spared and the joint goes on to 
 repair, anchylosis may be secured ; and in puerperal, rheumatic, or pyaemic cases this 
 result is not rarely met with, the joint undergoing the whole series of changes in a few 
 months. This subject, however, will receive attention in the chapter on the suppuration 
 of joints. 
 
 In subacute synovitis — a far more common form than the acute — the local symptoms 
 are the same, but the constitutional are far less severe, whether the disea.se be caused by 
 some local injury or by some general cause, such as gout, gonorrhoea, rheumatism, or syph- 
 ilis ; it moreover almost always terminates in recovery. 
 
 To chronic synovitis the same remarks are applicable. This affection is often known as 
 " hydrops articuli,"' or simple dropsy of the joint, the chief symptom being an excess of 
 fluid. In many of these cases, however, this eff"usion into the joint is associated with 
 (tther changes, such as are known to exist in what is now recognized as a special affec- 
 tion — the chronic rhinmafic orthritis or osten-arthritis. In it the joint becomes so stretched 
 by the eff'usion, and the ligaments at last become so useless, that 
 the leg may be made to move about as a flail in every direction. 
 In a large number, however, plates of bones will be found in the 
 synovial membrane or about the articular ends of the bones, as 
 well as bony outgrowths or fringes of ossific matter from the mar- 
 gins of the articular fiicets, together with other changes, to which 
 attention will be directed in the proper place. It is well, however, 
 to remember here that a large number of the cases of chronic 
 synovitis or h3'drops articuli are really examples of the peculiar 
 disease known as rheumatic, or '' osteo-arthritis." 
 
 In the articular ostitis of the knee-joint the expanded 
 bones are .soon made out on comparing the sound with the affected 
 limb, for the articulation thus affected acquires a special shape 
 which is not to be misinterpreted, the condyles of the femur and Appearance of a Knee the 
 
 1 ' •-' Scat 01 Articul&r Ostitis 
 
 head of the tibia assuming a globular form, the soft parts covering 
 
 in the bones being healthy and movable and no eff'usion exi.sting in the joint (Fig. 617). 
 
 At times a joint so affected will become two inches larger than its fellow ; when eff'usion 
 
 Appearance of the Knee- 
 Joint in l^vnovitis. 
 
 Fig. (517. 
 
918 DISEASES OF THE JOIXTS. 
 
 is present, the extension of the inflammatory action from the bone to the joint itself is 
 indicated, the case being clearly a more severe one. 
 
 The condyles of the femur or head of the tibia alone may also be the seat of suppura- 
 tive disease, of an acute or chronic abscess, the.se local bone abscesses being probably 
 more common in the head of the tibia than elsewhere. Under these circumstances the 
 enlargement will be confined to the bone affected until the abscess burrows into the cavity 
 of the joint, when the joint becomes inflamed. This suppuration may occur with or with- 
 out necrosis. Fig. 634 illustrates a case in which diseased joint followed necrosis. 
 
 In the pulpy disease of the synovial membrane the local symptoms by which the 
 affection is tn lie diagiiused are likewise characteristic. In typical cases neither expanded 
 bones nor dilatation of the synovial sac with fluid is present, but the different points of 
 bone which are always to be made out in a healthy joint are obscured, if not undistin- 
 guishable ; they are covered in with a soft solid, yielding on palpation over the articular 
 ends of the bones, and more particularly around the patella, a doughy sensation. No 
 fluctuation is to be. detected, as a rule: and when fluid exists, it will clearly be in a thick- 
 ened capsule. At times this pulpy thickening of the synovial membrane is a secondary 
 affection due either to .some articular ostitis or to repeated attacks of synovitis. It may 
 also occur as part of a syphilitic disease, from the effusion of gummy material around the 
 joint. What Collis described as syphilitic joint I believe to be of this nature — viz., the 
 pulpy disease in a syphilitic subject, possibly complicated with periosteal thickening. 
 
 Diseases of the Ankle-Joint. 
 
 Nothing particular is to be noticed in the diseases of this joint ; their pathology is 
 identical with that of all other joints, synovial mischief being possibly more common than 
 affections of the bone. EffHision into the joint is readily detected by the swelling and 
 consequent pressing forward of the extensor muscles of the foot, by the fluctuation 
 between the malleoli in front, and at times behind, and along the borders of the tendo 
 Achillis. Bone enlargement is readily seen by the expanded malleolus or malleoli. Bone 
 abscess may occur in either malleolus or in the astragalus. 
 
 The pulpy disease makes itself known by some such swelling as is found in synovitis, 
 but the swelling will not be due to fluid, but to the presence of the lowly-organized tissue 
 found in the disease, showing itself in a doughy swelling around one or both of the mal- 
 leoli and beneath the extensor tendons. 
 
 Disease of the Tarsal and Metatarsal Joints 
 
 — or, rather, nf the liones and joints — is very common : for it is in the bones, as a rule, that 
 the disease begins, the joints becoming involved secondarily. Disease in tlie joint hfticeen 
 the astragalus and as calcis mny. however, be found alone, and I believe that such disease 
 is commonly the result of some lateral sprain of the ligaments that hold these bones 
 together, lateral sprains of the foot being more likely to be felt at this articulation than 
 at the ankle, as the astragalus is held so firmly between the malleoli. Disease in this 
 joint is to be recognized by the swelling being heneotli the malleoli, the pain produced by 
 any lateral movement of the heel or foot, and occasionally by the grating of roughened 
 bone. The movements of the ankle-joint will be uninvolved. 
 
 Disease of the other tarsal or metatarsal bones is indicated by the enlargement of the 
 bones, as well as by the position of the sinuses leading down to them. The scaphoid 
 
 bone and joints are frequently affected, this bone being the 
 keystone of the antero-po.sterior arch of the foot ; and when 
 the scaphoid is affected, the disease very commonly extends 
 to the cuneiform bones, there being but one synovial capsule 
 common to the scaphoid and the three cuneiform Vjones. 
 
 The form of the foot in these cases is very peculiar. •• It 
 
 assumes." writes Erichsen. " a remarkable bulbous or clubbed 
 
 appearance : the fore part and dorsum of the foot are greatly 
 
 swollen, glazed, and possibly perforated by sinu.ses discharging 
 
 thin unhealthy pus" (Science and Art of Surtieri/). When 
 
 Appearance of Foot after the Re- necrosed. these four bones mav be removed and a good foot 
 
 Td'^fh^eVcun^ff Bo?.e>^'^' left. As a single bone the cuboid is also not rarely diseased, 
 
 and may be taken away without any detriment. In the 
 
 case figured (Fig. 618) the scaphoid, three cuneiform, and cuboid bones were removed, 
 
DISEASES OF SPECIAL JOISTS. 919 
 
 ami an exci-llfiit loot rciiiaiiicd. I removed tlieiu t'ntni a boy act. 8 by simply enucleating 
 till' diseased and ilead hniics i'loiii their beds, and disturbinL' tlie periosteum and stif't part.s 
 as little as possible. 
 
 Of the metatarSO-phalangeal joints, that of the <:reat toe is the one most fre- 
 (|ueiitlv diseased, either iVuni iMJiirv <>r ntlnrw i.-e . and when so affeeted. it is troublesome to 
 deal with. There is some reason to believe that the burs;u about the .sesamoid IxMies at 
 tin- ball of the too are oeeasionally the .source of the evil. 
 
 When dead bone exists in these joints, it may be removed, and in some eases the joint 
 mav be excised with a trood result. 1 have done this on many occa.sions, and in several 
 a movable joint was seeureil. (ianti/ attections of this joint are very common, and may 
 ujo on to disori^anization. Disea.se of the joint as a result of a neglected bunion is not 
 rare, but such eases will be treated of in another page. 
 
 Disease of the Pelvic Joints 
 
 is often overlooked nr mistaken for hip or spina! disea.se, yet it has features of its own. 
 It is more eomnionly met with in adults than in children, and after parturition than as a 
 result of local injury. It is usually chronic. It may be secondary to disease of the bones 
 that form the joint. In its early stage it is characterized by pelvic or gluteal pains which 
 are aggravated by exercise, relieved by rest, and often put down as rheumatic. Lameness 
 is generally present, with a very peculiar unsteady, rolling gait. Local tenderness will 
 generally be manifested on digital pressure over the joint, and pain is excited by separat- 
 ing or pressing upon the iliac wings ; swelling along the line of joint may also be visible. 
 The thigh may or may not be flexed, but it will be made to move freely when the pelvis 
 is fixed. As the disease progresses suppuration will appear either in the gluteal region 
 over the* sacro-iliac joint or in the pelvic ; and when the thigh is permanently flexed, pel- 
 vic suppuration is indicated. It is to be di.stinguished from hip disease by the fact that 
 there is free movement of the femur in the acetabulum when the patient is recumbent, 
 and no spasm of pelvic muscles is experienced. There is, moreover, no swelling behind 
 the trochanter or pain on pressure in the part. In no stage of the disease will there be 
 any shortening of the limb. 
 
 Treatment. — In the treatment of this affection the same principles are applicable as 
 in that of other joints, rest, tonics, good food and air being essentials. As soon as sup- 
 puration can be made out an incision should be made, to prevent burrowing : and when 
 dead bone is present, it should be removed. I have taken awa}' large pieces of bone from 
 this joint with great benefit. 
 
 Disease of the Simphysis pubis is very rare, and I have seen it but twice. 
 One of the cases was in a man who some months before coming under my^ care was 
 believed to have fractured his pelvis and lacerated his urethra. When I saw him, 
 sinuses existed, running down to and into the joint, but no dead bone could be felt. 
 In Guy's Museum there is a preparation (1314^°) in which the synchondrosis is ossified 
 and carious, and a second (1314*") in which complete anchylosis is present, with new 
 bone. 
 
 Disease of the coccygeal joint is at least as rare as that of the pubic, although 
 well-marked cases have been recorded. It can readily be made out by thickening over 
 the joint and pain produced by any movement in the bone; in some cases a distinct grat- 
 ing can be felt with the finger in the rectum on attempting to move the part. 
 
 When the disease is clearly established and the joint disorganized, the best practice is 
 probably the removal of the bone ; and when this is not advisable or practicable, the coc- 
 cygeal muscles had better l)e divided by a subcutaneous inci.sion, to give rest to the joint, 
 but under these circumstances the cure must be slow. The pains of saero-coccygeal joint 
 disease are much .simulated by what Sir J. Simpson described (Med. Times. 1859) as coc- 
 cydj'nia, which is met with in women when any of the coccygeal muscles are brought into 
 action by walking, running, rising, defecating, or sneezing. This affection may be cured 
 by the subcutaneous section of the* coccygeal muscles. 
 
 Coccygeal anchylosis may occur between the .sacro-coccygeal articulation or between 
 any of the segments of the coccyx, or between all of them. The bones may retain their 
 normal position or be so misplaced as to cause the point to be directed forward or back- 
 ward, the former direction being more common. 
 
 When this forward condition is present, there may be some impediment to natural 
 labor, but not of necessity, since Smellie ( SyiL Sm-.^ vol. ii. p. 8) says, in the two cases 
 he had seen. " the women were as easily delivered as those in whom the coccvx is mova- 
 
920 DISEASES OF THE JOINTS. 
 
 ble." When difficulty is found, the bones should be fractured, the labor being aided by 
 forceps if necessary. 
 
 Diseases of the Joints of the Upper Extremity. 
 Diseases of the Sterno-Clavicular Joint. — Suppuration of this joint in 
 
 pyaemia is common, though as an independent disease it is very rare. I have seen but 
 two examples of it, which ended in disorganization. In syphilitic subjects, however, 
 inflammation about the joint is not unfrequent, but such cases rarely suppurate. The 
 disease, when it occurs, is easily recognized, the joint being superficial. 
 
 Disease between the sternal segments has been recorded by Hilton. I have seen but' 
 two examples of it, and both were complicated with substernal abscess and necrosis. 
 Local pain, increased on pressure, and the movement produced on coughing, with swell- 
 ing, indicate the disease. 
 
 Diseases of the shoulder-joint are comparatively rare and form a very small 
 proportion of the joint cases admitted into a hospital, the majority of such cases being 
 treated outside. Synovitis, however, in all its forms, is found in this joint, as well as 
 cases of articular ostitis, etc. The joint has no special disease. 
 
 When disorganization and suppuration take place, the matter burrows down the bicip- 
 ital groove and generally makes its appearance in front of the insertion of the deltoid 
 muscle ; at times, however, it bursts posteriorly or burrows beneath the pectoral muscle. 
 If recovery take place with anchylosis, a wonderfully useful limb is often secured, 
 the scapula allowing an amount of movement which is sufficient for most of the duties 
 of life, though it rarely admits of any action above the shoulder. When disease takes 
 place at the junction of the upper epiphysis and shaft and suppuration follows, the abscess 
 burrows in the same way, and much difficulty may be experienced in the diagnosis of the 
 case, although the thickening about the neck of bone under these circumstances is gene- 
 rally greater than in joint trouble. When inflammation of the bursa placed beneath the 
 deltoid muscles exists, some of the symptoms of shoulder-joint disease ai'e present ; but 
 the fact that the least action of the deltoid muscle excites pain in bursal disease when 
 the movement of the arm by the surgeon does not, and that the joint moves freely, 
 although possibly attended with a sense of crepitation, ought to suggest its nature. 
 
 Diseases of the elbow-joint are of great importance, as the value of the hand 
 is greatly dependent upon the integrity of the elbow, and a stifl" elbow-joint is a serious 
 detriment. In their general pathology they are the same as similar diseases in any other 
 joint. 
 
 Synovitis makes itself known by the general enlargement of the joint, as well as by 
 the sense of fluctuation on either side of the olecranon process. Pulpy disease is recog- 
 nized by the presence of the doughy, semi-fluctuating products that have been poured 
 out in the same position. Articular ostitis can be recognized by the expanded bones. 
 In a general way elbow-joint cases do well, recovery taking place with movement in 
 the majority, while in the minority a natural cure takes place by anchylosis, with or with- 
 out external suppuration. 
 
 The amount of movement that may at times be secured after a natural recovery from 
 a suppurating joint is very good. Fig. 619 was taken from a boy a3t. 19 who had had a 
 
 disorganized joint treated by free incisions when ten 
 Fig. 619. years of age. In it the head of the radius was dis- 
 
 placed outward. He had as much movement as the 
 drawing indicates. In many cases useful flexion and 
 extension are often secured, as well as pronation and 
 supination, and in some, while these latter movements 
 are preserved, the ulna and humerus are firmly fixed, 
 together ; and when so, the value of the hand is but 
 little diminished. In several of my own cases I have 
 found the rotation of the radius perfect after many 
 
 Drawing illustrating the Amount of Flexion 
 
 after Recovery from Suppuration. years. 
 
 But as these good results, which may follow a cure 
 by natural processes, cannot be calculated upon, it is doubtless a wiser course to submit 
 the majority of cases of disorganized elbow-joint to opei'ative interference — not so much, 
 probably, to remove a disease that is incurable by natural processes as to procure move- 
 ment and prevent anchylosis. 
 
 Disease of the wrist-joint is not so common as that of the carpal bones and 
 
o.v Tin: Tin: ATM EST ASi> criu: OF .inisr f>/si:.{si:. 9-21 
 
 i'ar|M)-|ilialaii^'i':il joiiit.s; Init when it has start«-(l in oik- i>\' tlii»si' jiarts. it is very prone 
 \o lit' |ini|ia;ratf(l tti otluTs. Wlu'ii siip|iuratitin takes jilacf, tlic pus iA'lvu burrows freely 
 betwei'ii the Icndons. but as lnu«; as necrosed bout- does not exist to prevent recovery a 
 >r{HH\ n-sult may be looked lor. althou<rli jimbably with some amount of stifliiess or even 
 aiichvlosis. When neemsed bone keeps up tlie irritation, it shoubl In- removed. To assist 
 reeoverv the hand shtuihl be se<'ured liy a splint in the position intermecliate between pro- 
 nation and su|iination. such a one beint; the liest. When the hand is left alone, it is too 
 apt to assuinr the prone position — ,i by no means <;ood one. 
 
 Disease of the raclio-ulnar joint is rarely met with. In a reeent ease of a 
 middh'-aired man tliat eame under my eare it appeared to follow overaetion ami jrave ri.se 
 to severe loeal jiain and <:eneral disturbance. It was fcdlowed by suppuration and relieved 
 by a free incision on the dorsal aspect of the wrist ilowii to the joint. The case terminated 
 by anchylosis. 
 
 Diseases of the phalangeal joints arc in their nature like those of other 
 joints and must be dealt with u|>on similar jirincijilcs, synovitis, pulpy disease, and bone 
 disease, with or without disorganizati<m, being found in all. When the disea.se is confined 
 to the synovial membrane and the joint has not disorganized, a recovery with movement 
 may be secured by good treatment. When a natural cure by anchylosis only can be 
 looked for. the ((uestion of the removal of the finger may be entertained as a matter of 
 expediency ; for a stiff nietacarpo-phalangeal joint is a serious detriment, while at the 
 proximal phalangeal joint anchylosis is less injurious, and least so at the terminal one. 
 
 In the thumii am]iutation is rarely to be thought of; for when recovery by anchylosis 
 from di.sease of the distal jilialangeal joint is [u-oltable. a good thumb may be secured, 
 though the same result in tlie metacarpo-phalangeal joint is so inconvenient that the 
 operati(m of excision is probably preferable. But every ca.se must be treated on its own 
 merits and according to its own special wants. 
 
 The position of the patient, his occupation, age, etc., should have a powerful influence 
 in guiding the surgeon to a decision. 
 
 ON THE TREATMENT AND CURE OF JOINT DISEASE. 
 
 In the treatment «f joint disease the most important point a surgeon has to bear in 
 mind is its curability, since clinical experience affords convincing evidence that under 
 judicious management a large proportion of joint cases can be guided succes-sfully to 
 a conjplete recovery with either movement of the joint or anchylosis. It is in exceptional 
 cases only that operative interference is required. 
 
 The recollection of these facts is a constant encouragement to the surgeon to perse- 
 vere with, and to the patient to submit to, the necessary means adapted to secure either 
 of these ends, while it in no way tends to discourage operative interference when the 
 course or the severity of the disease affords sufficient evidence that surgical interference 
 is expedient or necessary. 
 
 All pathological evidence likewise tends to the support of these conclusions, for no 
 one can have carefully examined joints that have been treated by either excision or 
 amputaticui. or others that have failed to go on toward a successful issue, without being 
 struck by the vast amount of repair that exists side by side with the disease and by the 
 apparently limited character of the latter, and also without feeling that in many cases 
 where a capital operation had been performed sim]>l('r operative interference would prob- 
 ably have been successful, or that none at all was really required. 
 
 At the .same time, it must be borne in mind that while in a pathological sense disease, 
 on account of its limited nature or reparable character, may need no interference, yet in 
 a clinical aspect a very opposite conclusion may reasonably have to be drawn, since the 
 disease, by its progressive and weakening tendency, may have demonstrated that the 
 powers of the patient were incompetent to provide, even in limited disease, the stimulus 
 needed for repair. 
 
 In the treatment of joint disease, however, it is not always a question as to the possi- 
 bility or the impossibility of securing a successful i.ssue by simply aiding natural efforts, 
 since questions of expediency come before the surgeon as to the wisdom of making the 
 attempt or as to whether better results might not be secured by surgical interference. 
 
 Surgeons, moreover, who look upon a stiff elbow- or .shoulder-joint as a serious incon- 
 venience and an unsatisfactory result of treatment, consequently advocate early excision 
 of a joint with the view of obtaining movement, and those who have little belief in 
 natural processes guided by art bringing about anchylosis in disease of the knee, or who 
 
922 
 
 DISEASES OF THE JOINTS. 
 
 think that the time occupied in the attempt is badly spent, advocate a like practice. 
 While some surgeons are always satisfied with a cure of the disease by natural efforts 
 assisted by art, and remove by operative measures joints or parts of joints when these 
 natural processes have proved themselves incompetent to effect a cure, others maintain 
 that in a large number of cases these natural processes lead only to an undesirable end, 
 and that it is not expedient to trust to them. Arguments of expediency also are used, 
 and in recent times have gained in importance, more particularly as brought to bear upon 
 the question of a cure with a stiff joint when a prolonged interval of time must of neces- 
 sity be required to secure the end. In some cases such arguments are of weight and 
 worthy of consideration, although as a broad rule of practice it is dangerous to adopt 
 them, for in the majority of cases natural processes guided by art are followed by results 
 which leave little to be desired, and are secured without the risks which are attached to 
 all operative interference. These points, however, will come out better when the treat- 
 ment of individual joints has to be considered, and to which attention will now be drawn. 
 
 Fig. 620. 
 
 Treatment of Disease of the Hip-Joint. 
 
 The average total duration of a case of hip disease in which recovery takes place 
 withrmt external suppuration is three years, and v-ith suppuration four. 
 
 So long as suppuration or other disorganizing change in the joint has not appeared a 
 good hope of a recovery with a useful articulation may be entertained, and so long as the 
 disease is in the synovial membrane the probabilities of a recovery with a movable joint 
 are great.' In a large number of cases where time has been allowed to pass and disease 
 has gone on to produce degenerative changes in the articular cartilages recovery with 
 anchylosis is to be looked for, anchylosis without suppuration being more common after 
 articular ostitis than after synovial disease (vide paper by author in Med. Tim en, July and 
 August, 1869). When, however, disease originates in the epiphysis of the head of the 
 bone or in the epiphysial connective cartilage betweeen the epiphysis and shaft, the pros- 
 pects of a recovery with movement are slight unless the mischief be checked in its early 
 stage ; for in the former case the articular cartilage which derives its nourishment mainly 
 from the bone soon undergoes degenerative changes that can be repaired only by pro- 
 cesses ending in anchylosis, and in the latter the epiphysis is often 
 cast off as a foreign body when recovery can take place only on 
 . its exfoliation or removal. 
 
 In both classes of cases, however, the treatment is in a measure 
 the same — that is, the joint is to be at rest and all inter-articular 
 pressure is to be avoided, for " in diseases of the joints rest cannot 
 be too much insisted upon" (John Hunter, 1787); and for these 
 ends the application of a splint is essential, 
 that form of splint being the best which 
 keeps the joint quiet, the pelvis at its nor- 
 mal angle to the spinal column, and the 
 affected limb from being either adducted 
 or abducted ; without doubt these points 
 are best preserved by the double splint fig- 
 ured in 573, 620. Children, with this splint 
 well adjusted, can be moved with the great- 
 est facility and, even when there is acute 
 joint disease, with very little suffering. 
 When the acute symptoms have subsided 
 and the disease is clearly going on to repair, 
 Thomas's splint is good. ( Vide Fig. 621.) 
 The hip splint consists, of a long 
 piece of malleable iron, one inch by a 
 quarter for an adult and three-quarters of 
 an inch by three-sixteenths for children, 
 extending from the lower angle of the 
 i.oubie Splint with Elastic sboulder-blade to the centre of the calf of 
 Extension, as appiieii in the leg, to which an iron oval chest hoop 
 
 Disease of the Paght Hip- ^^^^^^- f„^^j. ^^^^^ j^g, ^i,.^,^ ^j^^ ^^^ Thomas's Post^erior Splint ^ 
 ■'"'"'^- . o .... , applied lor Hip Disease. 
 
 Circumference is nrmly riveted at the upper 
 
 end, and two half hoops to support the thigh and calf, as seen in Fig. 621. 
 
 Fig. 621. 
 
Ti:i:.\rMi:sr a\i> crni-: of .kust disease. ;»2.3 
 
 Tlic vertical inni liaiwl is farcfiilly iiiihIcIIciI to tin- outliiii! of the trunk and Iiinl» ami 
 tlu' clifst lion|» fitted t(t till' sdiind side, liiit away tVuin tlic diseased. 'J'lie wlirdc sliould l»e 
 well padded and bound to the body, itassin-; in the direction ol' the sound side over tlie 
 |)(isteri(»r surf'aee ; and it" this is ettii-ieutly done, the diseased liinh will he well supported, 
 and the patient, il" a ehild. can readily he nioveil tVoin room to room. 
 
 The curve (d" the instrument may re(|uire alteration from time to time as the flexed 
 limh hccomcs extended and the curved spine straijrht. 
 
 Sir ('. i?ell clearly saw the necessity (»f rest, and was so impressed with it as to make 
 till' followini; ini^enious suir<i;estion : " I have ol)served that jiatients who have hip disease 
 recover when anidivlosis cd" the joint takes jdace, when the hones l)eeome fixed and imnmv- 
 alde. l"\»undini: upon this, I attempted Ity various contrivances to form an instrument which 
 mi^ht kee]i the l)ones at ))erfect resf, but so <ireat is the tendency in this joint to motion 
 that I have never yet succeeded. No instrument has ever been effectual in keepin;^ the 
 tliiii:h and trunk fixed. " '• I have been led to think that an operation mi^ht be j)erforined 
 here ; that ti cut niii/fif f>r iiuidf to ixposc f/ie iipin r iiart of tin- finnu- and tin; nedc he sinm 
 f/iri>in/h — not, you will ol)serve, to take away the head of the bone, as done by Mr. White 
 with success, f/i(f to jinnn't it to ninaiii at rest and to form an adhesion with the acetabulum. 
 In this case a joint will be formed where the bone has been divided " (Lond. Mid. (joz.. 
 January 12, 182S; " Hip Disease's." l)y Sir C. [then Mr.] Bell). 
 
 When suppuration has appeared, recovery with anchylosis can alone be looked 
 for, thoujjh where diseas(>d bone exists this result cannot be expected unless the disea.sed 
 bone is cast off or removed. AVhen, however, an abscess has been the result of clironic 
 changes in a pulpv synovial mem]»rane. the com])lete disorpuiization of the joint need not 
 as a necessary consequence be eoiitem])lated, althouirh where it has followed disease in 
 the articular extremities of the Itones (articular ostitis) it is more than probable that the 
 articular cartilajres, with the liuanients and synovial capsule, will have been completely 
 dei^troyed. Under the former circumstances, therefore, when the sup]iuration has taken 
 place as a conseijuence of synovial disea.se, recovery may ensue with soft or fibrous 
 anchylosis, or even with some degree of movement, whilst under the latter, though fibrous 
 anchylosis may supervene, osseous anchylosis can occur only after the cartilages with the 
 articular lamellfv; of bone have entirely gone and there is no necrosed bone left to keep 
 up the disea,se ; for with this complication a natural recovery cannot take place till the 
 source of irritation has been discharged by natural processes "or removed by art. 
 
 When suppuration occurs in a hij)-joint, though recovery may follow with partial 
 movement, there is but one result a surgeon can reasonably look for and strive to secure, 
 and this is anchylosis. If the history of the case and the clinical symptoms indicate that 
 the disease began in the synovial membrane and that the suppuration was the result of 
 pathological changes in that tissue alone, the hope of securing this result is very good, 
 since the di.sease in the joint, however extreme it may be, 
 under the.se circum,stances is probably only superficial and J' if-- ''--■ 
 
 does not involve the bones to any extent, .so that a good 
 recovery with a stiff joint may fairly be anticipated. If, how- 
 ever, the history of the ca.se and the clinical .symptoms indi- 
 cate disease of the bones, the probabilities of the same result 
 taking place will rest upon the amount of the disease. If the 
 disease in the bone be superficial, a natural cure by anchylo.sis 
 may be looked for, since dead bone, if not too large, and even V 
 
 the epiphysis, may be discharged externally and a good re- \ \ 
 
 covery follow. When, however, disea.se in the bone is exten- [^ - flj 
 
 sive (Fig. G22). or a seiiuestrum is so placed jn the centre of Head of Femur Altered by Di 
 the bone as to keep up irritatiim and interfere with repair, as e^se= Renioyed by Excision. 
 
 1 • T^- n,>i 1 ' . . o -11 1 Prep. 131839.) 
 
 IS shown in ing. hdl. the surgeon s active interference will be 
 
 imperatively demanded ; and it may be added that it is never practised with better results. 
 Fnder all circumstances, however, the first point in treatment is to secure the com- 
 plete immobility of the limb, which can be ensured by splints : extension should likewise 
 be kept up by lueans of weights or elastic forces. In one case a long outside splint may 
 be enough, while in another the weight is sufficient. In very chronic cases an immovable 
 casing of leather, gutta-percha, felt, wire, perforated zinc, or other appliance, such as the 
 fancy or ingenuity of the surgeon suggests, is the best, absolute immobility of the joint, 
 prevention of inter-articular pressure, tonic treatment, liberal regimen, good air, and time 
 being essential conditions for a successful issue. Fig. 62.3 represents a good apparatus 
 to ensure immobility when the patient is in bed. though the double splint figured 620 is 
 
924 
 
 DISEASES OF THE JOINTS. 
 
 better, for with it pressure over the trochanter is guarded against, abduction and adduc 
 tion of the affected limb are prevented, the pelvis is fixed at a right 
 angle to the spinal column, and the external malleolus of the affected 
 side is kept in a line with the hip ; elastic extension is likewise well main- 
 tained by means of an accumulator acting through a cord working over 
 a pulley inserted in the cross foot-piece. Mr. C. de Morgan's long splint 
 (Fig. 581) is also good applied to the side of the sound limb, through 
 which he likewise applied all counter-extension. 
 
 When malposition such as arises from flexion, abduction, or adduc- 
 tion of the thigh exists — a position which would be detrimental to the 
 patient's welfare — it is essential that it should be remedied before the 
 plan of treatment already laid down is carried out ; and so long as no 
 anchylosis has taken place or the union is soft there is a good prospect 
 of this being effected. For this pui'pose an anaesthetic should be given 
 and the thigh slowly but surely brought to a straight line with the body 
 and there fixed, any inflammation caused thereby being checked b}' the 
 local application of cold. At times, however, active disorganizing changes 
 and bad results follow. When displacement or dislocation of the joint 
 exi.sts, it is often in the surgeon's power to reduce the dislocation, and 
 then to treat the case as one of the ordinary kind. In the case from 
 which Fig. 624 was taken the boy was eleven years old ; the disease had 
 been acute, and the dislocation was on the ilium. Its reduction was 
 readily effected under chloroform, and a good result followed. A weight 
 of six or seven pounds was enough to keep the limb in position, and the counter-exten- 
 sion was well applied on the opposite side of the pelvis. If, however, I had now the treat- 
 ment of this case, I should employ the double splint with elastic extension. 
 
 When the displacement is of long standing and the natural cure of the disease has 
 gone on to its end, it is not wise to interfere and thus run the risk of undoing what 
 nature has well done, as many of these ca.ses of supposed dislocations are not of this kind, 
 but .simply a shortening of the neck of the bone from the absorption or destruction of 
 the head or epiphy.sis of the femur, or at times of the acetabulum. Drs. ^larch and 
 Sayre of New York deny the existence of a dislocation, but in this they are wrong. It 
 
 Immovable Casing 
 of Hip Disease. 
 
 Fig 624. 
 
 Fig. 625. 
 
 Fig. 626. 
 
 V -^ 
 
 Anchylosis of Hip-.Toint, 
 with Femur at Right An- 
 gles to Pelvis, before 
 Operation. iCase of Bov 
 set. 15.) 
 
 Position of Limb after Adams's 
 Operation as Performed by Au- 
 thor. 
 
 does occur, although rarely. In the case from which Fig. 624 was taken it was very 
 clear. 
 
 In exceptional in.stances the displacement of the limb is due to a separation of the 
 neck of the bone from the epiphysis, which is left fixed in the acetabulum or is cast off. 
 This condition is illustrated in Figs. 607, 608. 
 
 When anchylosis has taken place at a bad angle — at such an angle as seen in Fig. 625 
 — any attempt at forcible flexion with the view of breaking down the adhesions must be 
 
tiu:atmi:\t .\\n mii-: ur joist disicask. 
 
 925 
 
 P'iG. 02S. 
 
 looked u|)(»ri as fiitil.- ami iinjustiHahlf, altliniiirli it may Im- rifrlit to (•onsider tlie propriety 
 of iiiiproviiii,' tlif position of the liiiil) Ity s(Uiie snr;,Mcal procedure : and for this oltject 
 several snru'ical operations have heeii devised. Thus, in IS".'). M. Tillaux presented 
 before the Siirj^ieul Soeit-ty ol" I'aris a women ivX. '.VI the subject of bony anchylosis of 
 the hip-joint, with the limb tle.xed and rotated inward, for whom he had with suece.s.s 
 J'onihli/ f'ntrtitixt thv mil: uf tlif hnitf. He efl'ected this when the woman was und<-r chlo- 
 roform by usiiif^ considerable force, the bone j.'ivin;.' way with u hnnl crack. He subse- 
 <|Uentlv treatecl the case as one <tf fracture, and at tin; end of two months the jiatietit had 
 a strai^'ht limb. .M. Tillaux described the result as njilcHdltl, and considered the practice 
 infinitely preferable to the operation of .subcutaneous .section of the neck of the bone. 
 Tlu- operation is doubtless of value in certain ca.ses and worthy of consideration. 
 
 In lSt)!», Mr. W. Adams {lirit. Mnl. Joiinnil, iSTOj successfully treated a case of 
 this nature by subcutaneous division of the neck of the thiirh-bone by means of a fine 
 saw, and since then many operati(»ns 
 
 of the kind have been performed Fig. 027. 
 
 with irood success. 
 
 I have performed this operation 
 in a dozen cases, and with so much 
 success that I believe it to be the 
 best when the femur has a neck to 
 be divided. 
 
 The instruments re(|uired for the 
 operation are such as tho.se figured 
 (Fig. 627). The operation itself I 
 
 give in Mr. Adams's words : '" I entered the tenotomy knife a little above the top of the 
 great trochanter, and, carrying it straight down to the neck of the thigh-bone, divided 
 the mu.scles and opened the capsular ligament freely. Withdrawing the knife. I carried 
 the small saw along the track made — pursuing this by pressure of the fingers — .straight 
 down to the bone, and sawed through it from before backward, 
 in the direction represented in Fig. d'lS. which shows the saw 
 applied to the anterior surface of the neck of the bone. The 
 section of the bone was accomplished in four minutes. Xo 
 hemorrhage followed, and a good recovery took place with a 
 stiff limb." When the saw is used, it should be held at an an- 
 gle of 135° to the line of the shaft of the femur (Fig. ti28). 
 Some surgeons use a narrow chi.sel, but I prefer the saw. 
 
 In my cases the neck of the thigh-bone was readily divided 
 in less than five minutes and the wound above the trochanter 
 healed in a few days, the patients walking in eight weeks. I 
 have had one patient, a girl {\;t. 11, in whom both hips were 
 anchylosed in a flexed position against the abdomen, one being 
 adducted and the other rotated outward. On one side T divided 
 the neck of the femur and on the other the shaft below the tro- 
 chanters, and with such a good result that the patient can now, 
 six months after the second operation, walk by the aid of a 
 
 stick and sit with comfort. i 
 
 -J 
 
 I did not attempt to obtain movement in any of my cases, Drawing showing the Line of 
 having been well satisfied with the results secured, although I section of the Neck of the 
 am (juite alive to the fact that my friend Mr. Luiul of Man- mtioil. "'^ '" '''"** ^^ 
 Chester had operated with such success upon a man who had 
 
 both hip-joints anchylosed in a straight line with the body, and as a consequence could 
 not sit, that after the operation excellent motion was obtained in each hip-joint, and the 
 man could sit up in a chair with the body nearly perpendicular and the thighs comfort- 
 ably placed on the seat ; he could moreover support the weight of the body upon the legs 
 (Bn'f. Med. Joitnt., January 29. 1870). 
 
 When there is no neck of the femur to be divided, or when the muscles and soft parts 
 about the minor trochanter of the bone are so contracted and rigid as to render it proba- 
 ble that the shaft of the femur cannot be brought down to a right line, (rants operation 
 (Lnucef. December 1, 1S72) should be performed — that is, the femur should be divided 
 by a small valvular wound subcutaneously below the trochanter, by means of either the 
 saw. as emidoved by Adams, or the chisel, as suggested bv Volckmann and advocated by 
 Maunder, the same care to exclude air being employed in the operation as has been 
 
926 
 
 DISEASES OF THE JOINTS. 
 
 advi.sed in Adams's. Both these operations are superior to that of Barton, who divided 
 the femur between the trochanters, and to that of Sayre, who excised a wedge of bone 
 from between them. 
 
 Fig. 629. 
 
 Splint for Diseased Knee-Joiut. 
 
 Treatment of Diseases of the Knee-Joint. 
 
 This may be taken as a type of the treatment of all joint diseases. 
 Acute synovitis is usually the result of a wound and should be treated according to 
 the principles laid down in a former page — viz., by rest and ice locally and uiiium internally. 
 When disorganization of the joint ensues, free incision and irrigation are called for ; few cases 
 are more serious in their local as well as their general effects, as life is often endangered, and 
 recovery with a stiff joint must be regarded as favorable. Wlieii the disease is the result 
 of septicemia or rupture of an abscess into the joint, no better success can be expected. 
 In subacute and chronic forms of synovitis a good result may, as a rule, be 
 promised, and the treatment must be regulated by the cause of the disease. In traumatic 
 cases the local application of cold or warmth according to the amount of comfort one or 
 other affords, and immobility by means of splints, are the best means to use. When all 
 inflammation has subsided and a relaxed condition of joint remains, gentle support by 
 means of wtU-applied strapping is a valuable adjuvant. 
 
 In other cases the application of a blister to either side of the joint, as well as the 
 internal administration of the iodide of potassium, with or without bark or quinine, accord- 
 ing it the necessities of the patient, is of great use. When gout appears to be an element 
 in the affection, it is advisable to administer colchicum, lithia, and other remedies approved 
 
 in that disease. AVlien the case appears to have 
 a rheumatic origin, alkalies such as the bicar- 
 bonate or citrate of potash, etc., may prove 
 .serviceable ; and when there is any reason to 
 suspect syphilitic taint in the constitution, it is 
 necessary to employ such treatment as is pecu- 
 liar to such diseases — viz.. the iodide of potas- 
 sium or sodium, or some mercurial. 
 
 In very chronic and ob.stinate cases para- 
 centesis of the joint by means of the aspirator may be performed, and in the hands of 
 some has yielded marvellous success. Sir J. Fayrer was one of its strongest advocates; 
 having shown {Indian Med. Gaz., 1869) that in the chronic and subacute forms much 
 good is often obtained by the operation if care be taken to exclude the air by carefully 
 closing the puncture and fixing the joint on a splint, the drawing off of the fluid afford- 
 ing instantaneous relief. I have performed this operation 
 on many occa.sions with good results when the tension of 
 the joint was extreme ; it is a practice, however, that 
 ought to be followed with great caution. 
 
 The pulpy disease of the synovial membrane is a 
 very obstinate affection, and, though fairly curable with a 
 movable joint in its early stage, and occasionally so in a 
 later, is always tedious and unsatisfactory. 
 
 In its treatment the absolute immobility of the joint 
 is most es.sential. This may be guaranteed by the appli- 
 cation of a well-adapted splint (Fig. 629) reaching from 
 the foot two thirds up the thigh, or, what is far better, 
 Thomas's knee-splint (Fig. 630), composed of a padded 
 ovoid iron ring, three-eighths of an inch thick, to fit well 
 up in the groin, and two vertical iron rods, ending in a 
 patten about four inches below the foot, with an inter- 
 mediate foot-piece (Figs. 630, 631). An apron of basil 
 leather is stretched between the iron bars for the affected 
 limb to rest upon, in which slits are made for the inser- 
 tion of a bandage to keep the limb and s))lint together. 
 When the patient gets up, the splint is suspended by a 
 ■strap buckled to the ovoid thigh-ring and passed over the 
 shoulder of the sound side ; and when he walks upon the 
 
 Fig. 630. 
 
 Fig. 631. 
 
 Thomas's Knot 
 .Splint. 
 
 Knee-Splint as Ap- 
 plied 
 Liml 
 ten on 
 
 to Left splint, a patten has to be fitted to the foot of the opposite 
 ,'n Kight.''''*" limb, to maintain the level of the body (Fig. (J31). 
 
Ti:i:.\TMi:.\T ixn cn:i: of joist diskasi:. liiiT 
 
 When the kiH'f is imifli Hexed, a eiishioii or pad .should he placed In liind the knee, 
 which unfolds itself hy a frradual proeess of extension. 
 
 As the disease improves and ti»e dependent position of the limb becomes allowable the 
 patient can j^et about by means of a patten on the ojiposite limb. The introduction of 
 this patten for the above purposes is worthy of all prai.se. y^^, ,,.,., 
 
 As Ion;; as any heat (U* perioilic flushing of thf j<iint 
 exists the limb must be kept raised ami warm moist appli- 
 cations applied by strips o[' lint surrounding the joint. 
 After these symptoms have subsided and the [»njducts of 
 inflammation alone remain, well-appliecl pressure by moans 
 
 of Strapl.ini: is of ":reat value. Mr. Marshall \l.(liir,t^ bavarian Splint a^ complc-ted for 
 ..'',. 1111 <■ 1 /• 1 • ln.seai»e iif the Kiiet-. 
 
 May "J.). 1>^(_) speaks luglily oi the nve per cent. soluti(»n 
 
 of the tdeate of mercury in oleic acid as an ajjplication, and my experience of its use has 
 been satisfactory. Blisterinir and firing in this aficction seem to be of little value. In 
 the very chronic stage of the disease the Bavarian flannel splint (Figs. b'M'i, ^)?i'l) or 
 some other good casing may be employed. 
 
 The constitutional treatment in »11 stages of this affection is essentially tonic, as the 
 subjects of it are always feeble and often strumous ; iron, quinine, bark, cod-liver oil, 
 good food, and fresh or sea air are essential elements of succes.sful treatment. 
 
 By these means, so long as suppuration has not .set in, a cure may be affected, although 
 many months may be reijuired for its attainment. 
 
 When suppuration appears, the same principles of practice are applica})le. When 
 small deposits of pus form, from the breaking down of some portion of the pulpy ti.ssues. 
 and make their way externally toward the skin, and not into the joint, they may be 
 evacuated, and a good result still ensue. But when the joint becomes disorganized from 
 the same cause, ((uestious ari.se as to the expediency or possibility of saving the joint ; but 
 this subject will claim attention in the chapter on suppurating joints. 
 
 In articular ostitis — a di.sea.se readily made out in the knee when simple expan- 
 sion of the bones (Fig. <J17) and an aching pain and heat are the local symptom.s — all 
 walking or standing should be po.sitively interdicted, everything like inter-articular 
 pressure forbidden, and fomentations of warm water applied two or three times a day, or 
 strips of wet bandage covered by a handkerchief of elastic tissue or oil silk kept around 
 the joint. Some speak highly of blisters, moxas, and counter-irritants, which I rarely 
 employ, having long found the above practice preferable. 
 
 When heat has left the joint, the aching — miscalled " growing " — pains di.sappear, 
 and clinical evidence tends to show that all inflammatory action has subsided, the results 
 or products of inflammation alone remaining, local pressure as applied by strapping not 
 only gives comfort to the patient, but appears to help the absorption of the inflammatory 
 products and the subsequent cure of the disease. 
 
 Constitutional treatment, however, must not be forgotten, and tonics, as a rule, are 
 needed, cod-liver oil combined with the .syrup of the phosphate or iodide of iron being a 
 suitable prescription for children. W^hen the appetite is bad, quinine may be given ; at 
 other times, iron or other tonic. Good food and good air are as nece.ssary in this as in all 
 other joint cases. The use of the iodine-evaporating box should not be omitted. Mer- 
 cury is unnecessary. 
 
 In the early stage of articular ostitis splints are not required, as the joint is not itself 
 diseased and passive movement of the articulation will not do harm ; all inter-articular 
 pressure, however, .should be avoided, and for this purpose extension by means of weights 
 or elastic extension is very valuable. In a more advanced stage, however, when the 
 disease has .so progressed in the bones as to have set up some degenerating process in the 
 cartilages and the synovial membrane has become involved, as indicated by eff"usion or 
 the pulpy synovial thickening, the use of the splint is essential. 
 
 In neglected cases, when the joint has been allowed to assume an abnormal position — 
 the most common being that of flexion, with some amount of rotation inward or outward 
 — and in still worse cases, where dislocation of the tibia and fibula backward has taken 
 place, the deformity must, if possible, be remedied by gradual extension. This should be 
 employed by means of a posterior screw splint or the application of a constant gentle 
 force exerted through one of the many in.struments that have been made with the view 
 of pressing the femur backward and the head of the tibia forward. Manual extension 
 exerted under chloroform employed with care rarely does much harm ; forcible and sud- 
 den extension cannot be recommended, as it is followed at times by severe local action 
 and suppuration. In exceptional ca.ses it may be required. 
 
928 DISEASES OF THE JOINTS. 
 
 Anchylosis. — When a knee-joint has to he fixed, the hest position is one of sh'ght 
 flexion, or that which a man naturally assumes when he stands at ease. But anchylosis is 
 more difficult to secure in the knee- than in any other joint, on account of the presence of 
 the inter-articular fibro-cartilages. which prevent the bony surfaces from coming in contact. 
 Moreover, these cartilages, when diseased, are most difficult of repair, no tissue undergoing 
 a reparative process more slowly or imperfectly. It is doubtless from a knowledge of these 
 clinical truths that some surgeons despair of securing anchylosis in the knee, and even 
 doubt its occurrence, and are led to interfere by operation oftener than others. Anchylosis 
 of the knee — good solid ossific union of the bones as well as fibrous anchylosi.s — does, 
 however, occur, and when secured is of great value. It gives a limb which is far supe- 
 rior to any that follows excision, and is, as a rule, obtained without the dangers of an 
 operation, although possibly with the expenditure of more time. I have the notes of 
 many such eases, and in the Me'7. Times (187<») I published a series, in some of which 
 this resiilt took place with and in others without suppuration. 
 
 Diseases of the Ankle-Joint 
 
 should be treated on precisely the same principles as those laid down for the knee, the 
 best position of the foot being at an angle slightly exceeding that of a right angle. 
 
 Diseases of the Shoulder-Joint, 
 
 in their progress and treatment, are very similar to those of other joints. When the 
 shoulder has to be fixed, a leather casing including the scapula and humerus is a good 
 apparatus, the elbow being supported at the same time. The arm should be allowed to 
 hang parallel to the trunk, with the elbow slightly away from the chest ; and for this pur- 
 pose 8tromeyer"s cu.shion is of great value (Fig. 561). 
 
 Diseases of the Elbow-Joint 
 
 can usually be managed with greater ease than any other, a splint applied in the flexure 
 of the joint passing well down to the hand, to keep the radius in a position intermediate 
 between pronation and supination, being the be.«t. If the hand is left unsupported, it is 
 certain to assume the prone position, which, as a rule, is undesirable. Dislocation of this 
 joint, except at the head of the radius, which is often displaced backward and somewhat 
 outward, rarely takes place as a result of disease. 
 
 Before fixing the joint at an angle it is well in most cases to consult with the patient, 
 for in some the straight position is the more desirable. In the case of a painter I had 
 under care a flexed elbow would have lost him his occupation. In another, of a barge- 
 man, the joint was fixed at a right angle, with the hand pronated. to hold the oar. A 
 carpenter asked me to fix his left elbow at an obtuse angle, and a haycutter nearly 
 straight. In all these instances any other position would have been most detrimental. 
 
 In disease of the wrist and carpus the same position of the hand should be main- 
 tained as in disease about the elbow. 
 
 In disease of the phalangeal joints, when anchylo.sis is to be obtained. I have 
 of late years always fixed the diseased extremity at such an angle as will allow its point 
 to come in contact with the top of the thumb, having invariably found the straight posi- 
 tions of the finger vei-y inconvenient. In this position the fingers are more useful and 
 less in the way, and the deformity is less observed. In these cases the best material to 
 use as a splint is a piece of zinc or tin. which is firm. thin, and takes up little space. 
 
 ON OPERATIVE INTERFERENCE— EXCISION AND AMPUTA- 
 TION—IN JOINT DISEASE. 
 
 General Remarks. 
 
 In the treatment of joint disease, next to the preservation of life, the aim of the sur- 
 geon is to preserve the natural movements of the articulation, and. when that hope has 
 gone, to save the limb. If this end can be obtained with a stiff" joint, the result in dis- 
 ease of the lower extremity may be regarded as satisfactory, and even in the upper a stiff" 
 shoulder- or elbow-joint at a useful angle is not so bad a result as some would endeavor 
 to lead us to believe. 
 
<n'i:n.\'nvi: is'n:ni''i:iii:s<'i:~i:x<'isi<>s asi> ami'I'tation. !)29 
 
 Wlicii iKMtlii-r nf tlu'sc »'ii(ls apitears pmbahlL', pns.sihlu, or expediiMit fruin the extent 
 of the luciil disease, the <.'ein'ral want of power of (he patient, or the neeessities of the indi- 
 vidual ease, tlie <|uestion of operative interference eonies lielore the surgeon, and he has to 
 deeiih' on the expediency ol" an incision into thi- joint, the removal of dead bone iVoni <jr 
 excision of the joint, or amputation ; and to work out the many jioints involved in the 
 solution of these (|uestions is a task of dilhculty, since, from joints havin;r a ditferent value 
 in the human body, a iorm of practice which is applicable to one may be inexpedient to 
 anotlu-r. 'J'his diflicultv, moreover, is doubtless a^r^ravated by the different value which 
 surLji'ons jtlace on different forms of practice and the different estimation in which they 
 reirard natural processes. One who has j^reat I'aitli in natural processes in the cure <jf 
 disease, ami particularly (»f joint disease, will attempt to save a limb that another will 
 condemn, since he reirards as wroni;- any practice that interferes with a natural recovery 
 sti lon<r as any reasonable hope exists of securing such a result, and believes that a cure 
 by anchylosis, however ae(|uired and however long a time may be passed in securing it, 
 is worth the attempt. Another, who has stronger faith in surgical treatment, will exci.se 
 a joint, believing it to be inexpedient to attempt to obtain a natural cure, even if it may 
 be gained, when by excision an etjually good, if not a better, result can be .secured in a 
 shorter time ; and a third, looking upon both forms of practice as too protracted and 
 uncertain, will remove the diseased parts by amputatif)n, under tlie conviction that a 
 more certain as well as a more rapid recovery will be .secured by .such a process. 
 
 To lay down any definite rules upon operative interference in joint disea.se generally 
 is conse(|uently an impossibility, since each joint has its own .surgery. 
 
 It may. however, be stated as a starting-point that no surgical operative interference 
 is justifiable unless a joint has sujtpurated or become disorganized, and that amputation 
 should be thought of oidy when all minor measures are inapj)licable and it is necessary 
 to remove the disease to save life. The larger the joint, the greater the dangers of opera- 
 tive interference. 
 
 Treatment of Suppuration of the Hip-Joint. 
 
 In the treatment of a suppurating hip-, as of any other joint, it is important to ensure 
 a free vent for all discharge, as pent-up pus is always injurious ; with this view a free 
 incision into an ab.scess connected with the hip or the free opening of a sinus through 
 which pus slowly flows is sound practice. In the residual abscesses of repairing joint 
 disease it is well, however, not to incise unless they show a tendency to increase, since 
 many often spontaneously dry up. When these abscesses are interfered with, the pus 
 should be drawn off with the aspirator. 
 
 Removal of Necrosed Bone from and Excision of the Hip-Joint. 
 
 When the presence of dead bone can be made out in a suppurating hip-joint, there can 
 be no question about the propriety — nay, the necessity — for its removal, since it is certain 
 that so long as dead bone ren)ains to keep up irritation a cure by natural processes is impos- 
 sible. If this can be effected by means of a free incision, nothing more is needed; when 
 the OS innominatum is involved, there is a greater reason in favor of the removal of the 
 sequestrum. An operation undertaken upon the hip-joint under these circumstances is 
 scarcely more dangerous than an}' severe operation for necrosed bone, and in all proba- 
 bility is less so. The joint, as a joint, has to a certainty disappeared altogether, and a 
 free incision into it will hardly add to the dangers of the case. In a large number of 
 cases, however, this cannot be made, and under such circumstances, when a cure by nat- 
 ural processes cannot be looked for, the best practice lies in excision of the head of the 
 femur; and if the acetabulum is superficialh' affected or stripped of its cartilage (the dis- 
 ease being probably .secondary to that in the femur), it will undergo a natural repair as 
 soon as the cau.se of its di.sea.se has been removed. 
 
 When the presence of dead bone cannot be made out, or the weight of evidence tends 
 to show liiat there is no such complication to interfere with a natural recovery, the ques- 
 tion of exci.sion of the head and neck of the femur may have to be con.sidered. Those 
 who argue again,st its adoption assert, and with some truth, that while all these cases of 
 hip disease are capable of a natural repair in patients who have good, or even tolerably 
 good, reparative powers, yet in those who have not the operation of excision must natu- 
 rally fail, since as much power is probably needed to effect a cure after excision as is 
 demanded for the natural repair of an uncomplicated suppurating or disorganized joint. 
 5y 
 
930 DISEASES OF THE JOINTS. 
 
 To these latter remarks, however, I am disposed to demur ; and while ready to admit 
 that in all cases of disorganized hip-joint in which there is no disease of the bone to inter- 
 fere with recovery a natural cure may be fairly looked for so long as the powers of the 
 patient keep up and no signs of failure make their appearance, yet when these signs show 
 themselves, or evidence is adduced that in the battle of disease the reparative are "^^eaker 
 than the morbid processes, and treatment fails to turn the scale in their favor, the expe- 
 diency of performing excision cannot be disputed. The removal of the source of irrita- 
 tion acts beneficially upon the patient, and after the operation of excision many a case 
 has gone on to recovery which unoperated upon would eventually have proved fatal, the 
 patient being worn out by suppuration and exhaustive efforts to repair. 
 
 For the most reliable facts connected with the operation of excision of the hip-joint. I 
 must refer to the report of the committee of the London Clinical Society published in the 
 fourteenth volume of their Transactions (1881). In it, amongst much valuable material, 
 are certain conclusions based upon a careful analysis of 203 cases of excision, of 2(j<) 
 other cases in which suppuration existed, and of 124 in which no such complications 
 appeared, making a total of 587 cases. Where excision was performed the mortality was 
 40 per cent., against 33.5 per cent, treated by rest and extension, etc. A large propor- 
 tion of the deaths in both classes was from tubercular meningitis. I have lost but 5 out 
 of 30 eases- operated upon, arid, although I cannot say that in the 25 surviving all had 
 useful limbs, I am within the truth when I assert that the majority had. while without 
 the operation recovery was impossible. 
 
 Mr. Holmes, too, in his excellent work on ChlhJrens Diseasex, gives us 19 cases, of 
 which, in a general way, one-third died from the operation, another third recovered with 
 useful limbs, and the remaining third, although not cured, derived great benefit from the 
 operation. 
 
 On analyzing Hodges' and Good's cases as to the influence of age upon the operation, 
 some valuable facts may be recorded ; and out of 46 of Hodges' cases operated upon 
 under ten years of age, 15 died, or 33 per cent. ; of 37 cases between eleven and twenty 
 years of age, 21 died, or 57 per cent. ; of 12 cases operated upon between twenty-one 
 and thirty years of age, 7 died, or 60 per cent. ; and of 6 cases operated upon over 
 thirty years of age, 5 died, or 83 per cent. The analysis of Good's cases indicates the 
 same truths ; for of the cases operated upon under twelve years of age, 40.6 per cent, 
 died ; between twelve and twenty years of age, 60 per cent, died ; and between twenty 
 and fifty-eight years of age, 76 per cent. died. 
 
 Excision for hip disease in young life, therefore, is by no means a fatal operation, two 
 out of three recovering, while from ten to thirty years of age something less than half 
 recover, but after that period it is full of danger. The operation of excision, like ampu- 
 tation, lithotomy, or any other great operation, is more dangerous as age increases. The 
 important fact that children beyond infiincy bear severe operations well should ever be 
 before us, though it is of equal importance to remember that it is in young life we meet 
 with the best success in the expectant treatment of hip-joint as of other disease. 
 
 With the fact, therefore, before us — that in selected cases excision of the head of the 
 femur is not only a justifiable, but a good, operation — let us briefly consider under what 
 circumstances it should be performed ; and from the general facts, as learned from statis- 
 tics, we find two great results come out clearly : that in childhood the operation is 
 attended with success, two patients out of three recovering, while in adult life it is 
 attended with great danger, at least two out of three patients dying. In the former case, 
 consequently, the operation may be entertained under circumstances which in the latter 
 would render it unjustifiable. When, then, should excision of the hip be performed? 
 And, first of all, when should it not? 
 
 Excision is not required where suppuration or disorganization of the joint has not 
 taken place, because, so long as this condition is kept off by surgical as well as by medi- 
 cal skill, a solid hope exists that a cure of the disease may be secured, though by anchy- 
 losis. 
 
 It should not be performed when all evidence tends to show that the bones entering 
 into the formation of the joint are neither extensively involved nor wholly or in part 
 necrotic, and where the general condition of the patient, under proper treatment, is fairly 
 maintained. 
 
 It should not, moreover, be entertained for disorganization of the hip-joint the result 
 of synovial disease, unless very obstinate and extensive and the general health of the 
 patient is clearly yielding to the disease, nor should it ever be performed for acute sup- 
 purative disease. 
 
077.7;. 1 77 1 !■: iSTi:nFi:i'j:s( •h'^i:x( •is/n.\ . i sd . i mitt. i rins. 
 
 !):31 
 
 Fig. 633. 
 
 Kxcisinii >liniil(l always be entertained wIh-h it is clear that exten.sivo bone 
 iiii.scliici" fir pariial nccnisis i-xists, it l»i-iii^' tnlcraldy ccrtaiu utnlcr wiich circuiiiHtaiiccs 
 that a ciiri' l»v natural pritci'SHOs is liij^hly iiii|ir(ihalilc ; when siipiniratioii is jier.sistent in 
 spite dl" <^'(mm1 treatment ; when the <reneral heahh id" the patient is eh-arly l)cinjr sappeil 
 by the h>eal di.sease. wiiether that disease he in tlie Imnes (»r the synovial niemhranes, or 
 in hiith ; when intrapelvie ahseoss euniplicates the case; ami in the majority of eases in 
 which displacement of I lie head of the lemur exists. 
 
 Ol'KK.viio.v. — The opi-ration of excision is liest performed by a sli;.ditly-curved incis- 
 ion extendinii I'rom two to three inches almvc the trochanter alonjr its posterior border t(» 
 two to three inches below, more room bein<r obtained when ref|uircd in exceptii^nal cases 
 at the upjier angle of the wound V)y a cross-incision. By this incision tlierc is ample 
 room for the rapid exposure and enucleation of the head and neck oi" the bone, and .sub- 
 sequently for I'rce drainaire. 
 
 Some sur<;eons remove only the 1h ad and neck of the femur; others take itway the 
 trochanters as well. The amount (»f bone does not appear to be a point of much import- 
 ance, since excellent results havi' been obtained after both forms of practice. In the 
 removal of the bone the chain saw is often of great use, but I prefer to saw through the 
 bone before removing it with Adams's saw. For excisions of joints or bones generally 
 my friend and pujiil .Mr. (Jowan has invented a valuable and ingenious instrument; it is 
 composed of a pair of biting forceps for holding the bone, and a saw which works upon a 
 rotating .shield fixed to the forceps. By it a bone can be divided when seized with rapid- 
 ity ami safety. ( Vldr Fig. ()33.) The surgeon should preserve all the soft parts around 
 the bone as much as po.ssible ; and when the periosteum can be .saved, so much the better 
 Dr. 8ayre of New York, who has paid spe- 
 cial attention to these cases, describes his 
 operation as follows ( Brit. Med. Journ., 
 July, 1871 ) : " When the disease has gone 
 on to another stage where sinuses have oc- 
 curred and discharge pus, when a pi'obe 
 leads down to dead bone, there is nothing 
 to be done but to exsect it by making a 
 small incision above the trochanter major, 
 midway between it and the crest of the 
 ilium, over the top of the acetabulum — a 
 semilunar incision, the belly of the curve 
 covering the posterior part of the trochan- 
 ter major, going straight down to the bone 
 
 ^//,v.»y, the periosteum ; youthen pull the oowan-s Mon .Saw. (Can be worked on either side of 
 
 soft tissues on one side, and, taking a small the forceps.) 
 
 but strong curved bistoury, go as far round 
 
 the bone on each side as you can reach, at right angles to your first incision, .w as to 
 divide tlie periusteiim cnmplete.li/. You then take a strong, firm periosteal elevator with a 
 large handle and the end slightly curved, and go into this little triangle ; you peel off the 
 periosteum, and. as a matter of course, all the muscles with it ; by opening the joint thor- 
 oughly and turning the head of the bone out the periosteum is peeled off from the inner 
 portion ; you then saw off the bone above the trochanter minor, taking away the head 
 and neck of the bone with the trochanter major. After the operation, if you keep the leg 
 pulled out to its ])roper length by putting on a pair of wire breeches, you can send the 
 patient out into the air the next day." I have given this operation in Dr. Sayre's own 
 words, and am di.sposed to think as well of it as of his general treatment of hip disease. 
 His wire breeches, however, I have never used. 
 
 When the acetabulum is diseased — that is, necrosed — it may be removed. In many 
 of my own cases I removed large portions of the bone, and in one the whole floor, with 
 a good result ; indeed, there is reason to believe that when the bone can be removed the 
 case is not rendered more hopeless, for, as Holmes has well pointed out, there is always 
 a strong fascia which separates the floor of the acetabulum from the cavity of the pelvis 
 and prevents all contact with the viscera or their cellular connections. 
 
 After-Tre.\tmext. — After the operation the wound had better be left open to gran- 
 ulate, whilst good extension should be applied during the whole healing process and for 
 some weeks subsequently. My results since I have followed this practice have far 
 exceeded those I obtained previoush'. ]My own double interrupted splint is the best for 
 the purpose (Figs. 572, 620). As soon as the parts have thoroughly healed passive move- 
 
932 DISEASES OF THE JOINTS. 
 
 ment may be allowed, and it is remarkable to what an extent useful movement is often 
 secured, the patient being able not only to walk upon the limb, but to flex, abduct, and 
 adduct it nearly as well as he did before, shortening being the only fault. 
 
 xVniputation at the hip-joint may be entertained in hip disease when all hope of a 
 cure by natural processes, however ably assisted by art, has been abandoned, and when 
 the powers of the patient admit of a reasonable hope of recovery, also in cases where excis- 
 ion has been performed and failed. Under these circumstances it is often very successful. 
 
 Excision of the hip-joint for gunshot or other traumatic afl'ections of the joint cainiot 
 be recommended. The report of Dr. Otis, in the admirably got-up circulars of the War 
 Department of Washington (No. 2), proves this to demonstration ; for out of 85 cases, 
 only 8 recovered, 90 per cent, having proved fatal. At the same time he shows that 
 neither by the expectant treatment nor by amputation do better results ensue. He con- 
 cludes that excision of the hip may be performed in uncomplicated cases of gunshot frac- 
 tures of the joint — that if unsuccessful it relieves pain and is attended with less risk than 
 amputation, although life is probably prolonged for a longer period by the expectant treat- 
 ment. Professor Langenbeck, however, shows in his able essay on gunshot wounds of 
 the hip-joint, as translated by J. West of Birmingham, that, while of 88 cases in which 
 conservative treatment was employed 71 per cent, died, out of 31 cases treated by 
 resection 83 per cent. died. 
 
 Treatment op Suppuration of the Knee-Joint. 
 
 It may safely be asserted that in no case of inflammatory disease of the knee-joint in 
 which disorganization has not taken place should the idea of operative interference be 
 entertained, as, so long as this change is warded off", a reasonable hope of a cure with 
 either a movable or a stiff" joint, and consequently with a useful limb, exists. Excep- 
 tional cases may be seen in which this rule is inapplicable, but they are rare. 
 
 When, however, suppuration has taken place, the question of operative interference 
 naturally siiggests itself; and the surgeon considers whether natural processes are com- 
 petent to conduct the case to a successful issue, whether the local disease is of such a 
 nature as to be incurable unassisted by art, or the general powers of the patient are 
 sufficient to bear up against the demands that of necessity will be made upon them in the 
 progress of a natural cure, and last, but not least, if it is expedient to make the attempt. 
 
 These questions require for their solution much knowledge, thought, and judgment, a 
 careful weighing of the probabilities of the case and of the cause of the disease. When 
 the disease is in the synovial tissue alone and the powers of the patient are good, a cure 
 by natural processes assisted by art is generally to be secured, for pathologically in such 
 cases there is no reason why recovery should not take place, whereas, on the other hand, 
 when the disease has originated in the bone, spread to the synovial membrane, and been 
 followed by disorganization of the joint, a cure by natural processes is so improbable that 
 the removal of the diseased part by some operation is generally demanded, for patholog- 
 ically good reasons exist why recovery cannot take place, and clinically this observation 
 is borne out. 
 
 It is true that in suppuration of a joint from synovial disease, pulpy or otherwise, the 
 result of a so-called rheumatism settling in the knee, or of a puerperal synovitis, a trau- 
 matic synovitis, a gonorrhoeal synovitis, or any other, a cure with anchylosis is by no 
 means uncommon ; yet in all these, during their acute stage, the danger is always great, 
 and it often becomes a question whether an amputation is not needed to save life or to 
 give the patient a chance. Amputations, however, undertaken for acute suppurative dis- 
 ease are mostly fatal, and operations of excision are likewise equally unsuccessful. Indeed, 
 I hardly think either of these operations justiflable under such circumstances, and in this 
 opinion most are agreed. What I believe to be a better practice is making a free incision 
 into the joint — free enough to let out the pus that it contains, as well as to allow a free 
 escape of all as it forms — and the introduction of a drainage tube, together with the daily 
 washing out of the joint with iodine water. No retention of pus should be allowed under 
 any circumstances. 
 
 When suppuration has been set up in a joint from the degeneration of the pulpy 
 synovial disease, the benefit of a free incision is very great, and it should be practised 
 with a good hope of success before any other operative measure is undertaken. When, 
 however, suppuration in a joint has followed the extension of inflammatory mischief 
 from the bones, the hope of securing a good result v.athout operative interference is very 
 slender, since, as a rule, dead bone exists in the joint to keep up irritation, and as long a 
 
opr.iiATivi: isrinrr.iiKSCK—KXCvnoy asi> amittatios. 
 
 \y.v:\ 
 
 it remains a rccnvcrv is very iiii|in)liiililc. It is tnif iiatiin- <lncs inucli in many cases 
 toward (liis end. lint sin- is laiciy (•(iniiiett-nt to i-flcct tlif cure without sur;:icai aid. 
 In the l'i)lhiwinir eases these [mints arc W(dl seen: 
 
 Cask. — Diskask m- tiik KM:K-dniNT— Sii-imkatihn — Ukmov.m- ok Nkcro.skf) Bonk 
 i-iioM iiii: Joint — I{k<o\ki!V uiiii Anciivi.osis. 
 
 James W , :ct. 17, came unch-r my care in May, iStiti. fur disease in liis right 
 
 knee-joint, of one year's duration, which had Inllowed a lall upon the part. Swelliiif^ 
 appeared «lireetly after tiie accident, attended l>y severe constitutional (listury>ancc and 
 local pain. Suppuration also rapidly followed, and several lar<re openings made their 
 aitpearanee eight weeks after the accident. When I saw him, the joint was enlarged 
 from inflammatory thickening of the soft parts, and was clearly undergoing anchylosis. 
 The sinuses were discharging, and a probe passed into one readily detected dead bf)ne in 
 the joint. In Septemher the num was admitted into Guy's under my care, and on Octo- 
 ber IS, througli a mrtderate incision made on the inner side of the patella, two flat piece.s 
 of what were clearly the articular facets of tlie tibia were removed, liapid recovery and 
 firm anchylosis of the joint followed. 
 
 Cask. — Diskask ok tiik K.nkk-Joixt as a Co.vskquence ok Aktkilak Ostitis op 
 TiiUA — Hkmovai. ok Sequestrum from Bonk — Recovery with an Anciiylosed 
 Joint. 
 
 Henry \\ , ;et. 14, came under my care at Guy's Ilosjiital on May 17, 18(j7, for 
 
 extensive di,sease of the shaft of the right humerus and head of the left tibia, with sinuses 
 which had existed for several years. The left knee had been enlarged from eff'u.sion 
 for a year, but had never suppurated. When admitted, there was necrosis of the shaft 
 of the humerus, and likewise of the head of the tibia, while dead bone was readily felt 
 with a probe in both parts. In the tibia the bone was clearly near the joint, which was 
 enlarged from expanded bone and thickening of the soft parts around. There was no 
 eff'usion in the joint and hardly any movement in the articulation. In November, 1807, 
 I removed a mass of diseased bone from the tibia and fixed the leg upon a splint. In 
 January, 1808, I removed from the arm a sequestrum which included nearly the whole 
 shaft of the humerus, and a good recovery ensued. In six months the patient left the 
 hospital with a stiff knee and a sound arm. 
 
 Case. — Disease of the Knee-Joixt as a Result of Articular Ostitis endixg in 
 Necrosis — Amputation — Recovery. 
 
 Edward L , ;v>t. 14, came under my care at Guy's Hospital on September 8, 1868, 
 
 for disease in the left knee-joint of seven years' standing, which had been discharging for 
 many years. On admission the left knee-joint was completely dis- 
 organized and much enlarged ; it was also partially anehylosed. 
 Below the joint a sinus existed leading into the head of the tibia, 
 and through this sinus dead bone was felt. The boy's health was 
 very bad, and it was clear that nothing but amputation could be 
 entertained. His urine was albuminous. The operation was per- 
 formed on September 17, and a good recovery ensued. On ex- 
 amination of the joint w^hich was disorganized the head of the 
 tibia was found to be perforated with a channel which led from 
 the joint to a mass of necrosed bone, and the articular facet of the 
 tibia was likewi.«e necrosed. The disease in the joint clearly had 
 been secondary to the disease in the bone. The preparation is 
 depicted in Fig. 034, and the drawing well shows the condition of 
 the tibia. 
 
 Fifi. ()34. 
 
 f! 
 
 J 
 
 Remarks. 
 
 These three cases well show the results of articular ostitis 
 when passintr on to necrosis in the knee-joint and fairlv indicate Abscess of Tibia burrowing 
 
 . , , . ' 1 ^ •- . • , 111 1- ■ 1 T ^u £ ".L inlo Knee-.Toint, with >e- 
 
 the kind ot practice that should be applied, in the first case na- crosis. 
 
 ture had done her utmost toward obtaining a cure, the knee of 
 
 the patient being on admission partially anehylosed ; and had it not been for the presence 
 
934 DISEASES OF THE JOINTS. 
 
 of the necrosed articular facets of the tibia, a complete natural recovery would have 
 taken place. The surgeon's duty in this case was clearly to remove from the joint what 
 seemed to be the sole obstacle to a natural recovery — the necrosed bone ; and the com- 
 plete success of the treatment justified the step, for the boy ultimately had an admirable 
 limb. In the second case the disease was of precisely the same character, and natural 
 processes had also done their utmost toward the establishment of a cure, but the presence 
 of necrosed bone in this case, as in the former, interfered with the recovery and pre- 
 vented its realization. On the removal of the bone from outside the joint natural pro- 
 cesses went on without interruption toward the attainment of their end. and a complete 
 recovery with anchylosis was obtained. In the last case the same cause, articular ostitis, 
 and the same result, disorganization of the joint, were clearly present ; but the local dis- 
 ease in the bone was too extensive to allow of any hope of good being derived from its 
 removal, while the general condition of the patient was too precarious to allow of the 
 attempt. As a consequence, the only operative interference that seemed justifiable was 
 carried out. and the issue of the case was all that could be desired. In disorganization 
 of a knee-joint, therefore, the result of articular ostitis, of an ab.scess in the epiphysial 
 extremity of the bone bursting into the joint, of disease in the epiphysial cartilage 
 between the shaft and epiphysis, or of a .sequestrum in one or other of the bones entering 
 into its formation, some operative measure is usually required ; and when the diagnosis 
 of the case is tolerably clear, the practice ought to be decided, as delay cannot be of any 
 use. The disease must be removed. What ought that practice, then, to be? Should it 
 be excision or amputation ? Let us refer to facts to help us toward a solution of these 
 points. I have a table of 294 cases of nmputation of the tliigJi for chronic disease of the 
 knee-joint at various ages, and Sir W. MacCormac tabulates 137, the total making 431. 
 Of these. 96 died and .335 recovered, the mortality being 22 per cent., or 1 in 5. On 
 referring to Dr. Hodges work. I find 178 cases of excision of the knee undertaken solely 
 for chronic disease of the knee, of which 70 died and 108 recovered, the mortality of 
 excision being 39 per cent., or 1 in 2* cases. In this comparison the circumstances are 
 exactly similar, both operations being undertaken for chronic joint disease, and the mor- 
 tality is exactly double. In my table of amputations I have carefully guarded against 
 any fallacy and have included only my own statistics.' Mr. Callenders.- Sir W. MacCor- 
 mac's.' and Mr. Holmess.* all of which are equally indisputable ; and in the table of 
 excisions I have gone to Dr. Hodges' work, who. to make this point certain, states that, 
 with three exceptions performed for acute inflammation of the articulation, excision of 
 the knee has probably never been undertaken for any other than chronic disease or white 
 swelling. Mr. Swain, the author of the Jacksonian prize essay on •• Excision," and a 
 warm advocate of the operation, has given us .statistics on this subject, and from his book 
 (pp. 62 and 64) I have extracted the following facts : Up to 1865 there had been 316 
 cases of excision of the knee. Of this number. 85 died, or 26.8 per cent. ; 9 of these 
 died after amputation, which had been performed in 39 cases after excision. Since 1865, 
 74 cases are given. 25 of which died from the operation, or 33.7 per cent. ; 4 also died 
 out of 11 that underwent subsequent amputation; in all, 29 cases out of the 74 died, or 
 39 per cent. Mr. Swain gives us also a select list of cases numbering 82, of which 15 
 died from the effects of the operation, while 4 others recovered after amputation. We 
 have thus 472 ca.ses of excision of the knee, and 129 deaths, or 27.3 per cent., 13 of 
 these being after amputation : 41 other cases underwent amputation and recovered. Tak- 
 ing the whole number of 472 cases, 302. or 63.9 per cent., recovered after excision ; 41, 
 or 8.7 per cent., recovered after secondary amputation ; 129, or 27.3 per cent., died after 
 excision. The mortality from excision was thus greater than from amputation in the 
 same class of cases, the relative proportion being 27 to 22 per cent. '■ It is also," adds 
 Holmes. " a .somewhat suspicious feature in Mr. Swain's table that all the 302 recoveries 
 are claimed as being with useful limbs. If the information had been at all adequately 
 full, there would surely have been a category of recoveries with the limb more or less 
 useless."' since it is a well-known fact that in many cases in which it seemed perfect at 
 first the utility of the limb becomes destroyed by subsequent changes. In childhood 
 suspension of growth is not an unfrequent result : and when the whole epiphyses are 
 removed, it is to be looked for. It is true that Mr. Swain gives somewhat different results 
 from the same statistics, as he actually numbers amongst the recoveries after exci.<ion all 
 cases that subsequently underwent amputation, thus, of course, giving a far too favorable 
 coloring to the operation he is advocating. 
 
 ' Med.-Chtr. Tranx.. vol. xlii. ' Ibid., vol. xlvii. 
 
 3 Dub. Quart., August, 1868. * St. George's Hosp. Rep., 1866. 
 
<)]'i:i!.\'n\i-: isteiu'EIiesck-kxcisios .\m> ami'CTatios. \y.\h 
 
 If, lloweViT, we look to //"■ rrsiills nf Imtli iijhiiiIIoiis us pnfunittil nl dij]t'if'ii( jirriods 
 of 11 lift — a point ol" coiiiparisoii of iiuiuoiise iiiiportaiire, altlioii<:li «'iitir('ly i^'iiortMl by 
 Mr. Swaiii ami other ailvocati's of oxcisioii faiid I wisli its ailvot-atcs would (•(disider well 
 tlii'se points, and not pass tlit-ni by as of no iniportaiifc) — the loMowinfr striking result 
 eoines out : In my own tahle of amputations for chronic diseases of the knee in ])atients 
 under twenty years of ajre. out id' (ill eases, oidy \\ died, or 4.!r{ per eeiit.. or 1 in 21} cases. 
 In excision for the same class of ca.ses performed at the same period of life, out of D7 
 cases, 27 died, or 27. S per cent., or 1 in W'i, the difl'ereiit de;:rees of mortality of the two 
 operations under twenty years of ajre beinj; as 4.i> per cent, to 27. S per cent . minion 
 hi ill'/ iitiirlif sfviii fiinrs us /ntul as iinijnt/itfitjii ifiiriin/ /joiiiir/ lijr. It may thus fairly be 
 a.sked whether the advantayes of excision are so jrreat as to justify its performance in the 
 majority «d' cases (d" disease of the knee at that ajre. In amputations undertaken between 
 twi'uty-one and forty years of aire for chronic joint disease, out of 1 1'J cases. .'IS died, or 'A'l 
 per cent., or 1 in !> ; in excision, undertaken under similar circumstances, out of 74 cases, 
 'M died, (»r r)2.7 per cent., or more than 1 in every 2 cases, the difference between the 
 niiM'tality of the two o])erations. ■'!2 per cent, and r)2.7 per cent. resi)ectively, being 20 per 
 cent, against excision. 
 
 Summary. 
 
 It would thus appear that it is in young adult life that excisions, although always 
 more fatal than amputation, are the most justifiable ; that in childhood they are far too 
 dangerous ; while in patients j)ast middle age all admit their inapplicability. And yet it 
 must be admitte<l that excision of the knee-joint is a good operation, and that by it, when 
 successful, a far better limb is given than after amputation. The truth must be recog- 
 nized, however, that the o])eration, as hitherto practised, is much more fatal than ampu- 
 tation, although it may with confidence be asserted that the ca.ses in which amputation 
 has been performed are, as a rule, far more severe than tho.se in which excision has been 
 practised ; for the advocates of excision are disposed to operate at a somewhat earlier 
 period of disease than the advocates of amputation — that is, the former often remove a 
 disease they believe it is inexpedient to leave to be cured by natural processes, whilst the 
 latter remove a limb only when all hope of a natural cure has passed away and the opera- 
 tion is a necessity to save life. Are the advantages of excision, therefore, so great as to 
 justify a surgeon submitting a patient to an extra risk in order to secure them? As 
 hitherto practised, and as a general rule in surgery, I have no doubt in answering in the 
 negative. In exceptional cases the risk, it is true, may be run, but excision as a rule of 
 practice does not appear to be sound. Whether better results would not be .secured by 
 an earlier operation is an open question. Prof. Humphry's cases, recently published, and 
 those of my colleague, Mr. Howse, rather tend to .show they would ; for after excision 
 undertaken with a patient in good health, or at least not worn out by suppurative mis- 
 chief, a good result may fairly be expected. But is the risk of the operation when per- 
 formed under these favorable circumstances so slight as to justify the surgeon in throw- 
 ing aside the hope, and perhaps fair expectation, of securing a recovery by natural pro- 
 ce.sses ? Is excLsion of the knee to be an operation of expediency and not of necessity ? 
 AVe want facts to prove this fully, but as far as present experience goes it .seems to show 
 that if the operation is to be a successful as well as a general one in surgery it mu.st be 
 undertaken at a somewhat earlier period of disease than that at which the question of 
 amputation has to be mooted — that it should be performed before surgical fever has 
 reduced the powers of the patient and complete disorganization of the joint has taken 
 place. In fact, it should imt be practised when an operation is demanded to save the life 
 of a patient — for under such circum.stances a better chance is given by amputation — but 
 when the local disease is found to be steadily progressing in spite of treatment and dis- 
 organization is threatening. As a substitute for amputation undertaken in extreme dis- 
 ease to save life, facts tell against the practice ; as an operation of expediency to gain 
 time, the few facts we possess tell in its favor. From recent experience I am dispo.sed to 
 to think that under these circumstances excision is a successful and satisf\\ctorv ojteration. 
 In doubtful cases amputation is the more desirable, as it is the safer, operation : and, 
 since the great object of our profession is to prolong and save life, other objects ought 
 always to be subsidiary to this great aim. In acute suppuration of the knee excision is 
 never successful. Excision for gunshot wounds has been proved to be most unsatisfac- 
 tory ; indeed, as a practice in such cases it seem^; hardly justifiable. In compound dislo- 
 cation it has been succes.sful. Canton and M. Spillman have published such cases, but 
 upon the whole the evidence we possess is not much in its favor in traumatic cases. 
 
936 
 
 DISEASES OF THE JOINTS. 
 
 Resection in cases of deformity as a consequence of disease is probably a better field f r 
 the operation, and Drs. Barton and Buck of New York have demonstrated its value, 
 
 The Operation. 
 
 The best incision is that practised by Fergusson and suggested by Park — a straight 
 one across the joint below the patella from the posfen'or edge of one condyle to the cor- 
 responding part of the other. When the tissues over the knee are bad, the incision may 
 be curved, forming a flap. The old H-shaped incision is now rarely practised. Humphry 
 follows Mackenzie in making the semicircular incision with the convexity downward, and 
 Bickersteth of Liverpool mabss a vertical incision on the inner side of the patella. The 
 joint should be opened at once by dividing the ligamentum patellae and the capsule of 
 the joint, an assistant flexing the leg fully upon the thigh, thereby facilitating this part 
 of the operation. The soft parts ought then to be turned back off the patella and that 
 bone removed, there being no object in leaving it, but many reasons for its removal. The 
 joint having been fi'eely exposed by the division of the lateral and other ligaments and 
 by the forcible projection of the condyles, the lower two-thirds of the cartilaginous 
 extremity of the femur is to be excised, care being taken not to injure the popliteal 
 vessels which lie in close contact })ehind ; the whole of the epiphysis should not be 
 removed. This section is usually made at right angles to the shaft of the bones, but 
 lately it has been suggested that the surface of the femur should be made convex and 
 that of the tibia concave, or that of the femur should be made wedge-shaped to les-^en 
 the risk of any shifting of the bone. To make the section, the bow saw known as 
 •Butcher's is the best ; the section should be made from behind forward. In both bones, 
 when possible, it is well not to encroach upon the epiphysial cartilage. In dividing the bone 
 care is required not to strip off the periosteum above the line of section. When the sur- 
 faces are not healthy or do not come together well, another section may be made, it being 
 a point of primary importance that a perfect adjustment of the bones should be secured. 
 To aid this the osseous suture, as first employed by Gurdon Buck and practised by Nela- 
 ton and some English surgeons, is to be recommended. All bleeding ought to be arrested 
 by ligature or torsion of the vessels or by hot antiseptic sponges (a point much insisted 
 on by Prof. Humphry) and the parts brought well together by sutures, some immovable 
 apparatus being adjusted before the patient is taken from the operating-table. The splint 
 I prefer is the one figured below as used by my colleague, Mr. Howse. It is made of 
 
 Fig. 635. 
 
 Splint for Excision of TCnee. 
 1. Splint: Z, sliding bar; X, foot-piece. 2. Linib fixed in splint after operation: A, mattress; B, water-bed with pipe 
 (C); D, waxed bandage; K, longitudinal band to support heel fixed by strapping (E); H, band to support splint; 
 G, pillow. 
 
 tinned iron, and the limb is fixed in it by a waxed bandage. Dr. P. Heron Watson 
 employs with the plaster of Paris an anterior iron suspension rod. Salter's swing is 
 an invaluable adjunct. 
 
 Dr. Humphry first fixes the limb upon a posterior splint and foot-piece, then, uniting 
 the edges of the Avound by sutures, he applies well-padded long splints to the sides of the 
 
( ) I 'i:i: .1771 •/•; / .v ti:i! fi:ii i:s< 'ic—L'Xf 'isioy am> .\mitt.\ tios. 
 
 ■>i 
 
 Miiili, till- wiMiinI liriii:: li'lt t'.\|iiisc(l. 'I :iiii very pai-ticiilar, " lie writfs ( JAf/.-^ '////•. 
 Tidiix., V(il. Hi.), •to ailjiisl tilings well and liriiily in tlic first iiistaiic-f. ami am very 
 utiwilliii;,' to (listurl) tlic liinli artcrwanl. Indct'il, I rif(|iit'iitly (h) not n-imivt! any iif the 
 bamlaj^cs or splints I'm- live. six. <ir more weeks, and liy tliis care and jteriect (juiet I 
 endeavor to |>ronioie ininiediate union. This iierl'eet (|iiiet and ahstineiici! IVoin removal 
 of the hanihiLTes first ajijdied is. I eonsich-r, a very important item in the treatment. It is 
 0((Uallv important not to discontinue tiie splints till tlu! hones are (piite firmly united — 
 till tlu' patient can raise tlu' limit from the hed liy its own muscles without any move- 
 ment hcini; pcrceptihle hetweon the tihia and femur. It is neces.sary to make (|uit(! sure 
 of tliis." 
 
 Dr. Humphry adds that ''excision of the knee is not an operation oi' much dan<rer," 
 hut it must he rememhered that he has little or no faith in the cure l)y natural processes. 
 He helieves such a cure in the hulk of cases to he hardly wftrth the attempt, and advises 
 that excision should he employed early, so a.s to hrinj:- ahout hy operation tliat condition 
 which wt- would uladlv see attaiiie(l without such interference. 
 
 Foot iifier Ueiiioval of Xecrosed 
 Astragalus from a Child set. i'>. 
 
 Suppuration of the Ankle-Joint. 
 
 When the inihlc-joint has underjione disoriianization and is suppuratinfr, the benefit to 
 be gained by a free incision into the joint is very great, a cure with a movable articulation 
 being often obtained by these means. When this end is not 
 secured, a recovery by anchylosis may be looked for, it being Fifi. 63*!. 
 
 exceptional for any more active interference to be required 
 except when the bones are extensively involved. 
 
 When necrosis of one of the bones entering into the forma- 
 tion of the joint is present, recovery may be looked for on the 
 removal of the diseased bone. In the case illustrated in Fig. 
 63G I removed the necrosed upper lialf of the astragalus witb 
 an admirable result, and a good foot, with some amount of 
 movement, was secured. 
 
 Under these circumstances excision of the joint has been 
 practised, and with success. I have performed this operation 
 on three occasions, and in two with a good result ; in the 
 majority of cases of disorganized ankle-joints I have obtained 
 good results by the expectant treatment and free incision. 
 Excision may be expected to be successful when the disease 
 is limited to the articular surfiices of the bones, and it is in such that the treatment by 
 incisions and the expectant principle is so successful. When the disease is very exten- 
 sive, it is still a question whether amputation is not probably a better practice. Stokes, 
 however, has collected 51 cases of excision. 38 of which were successful, and in the 
 Dublin Quart, for 1870 an excellent example by Dr. Murney may be referred to. 
 
 In cases of injury, of compound dislocation, and fracture into the joint excision is 
 probably a sound operation. Mr. H. Lee has recently adopted it in two cases, and Lan- 
 genbeck has practised it freely with success. Hancock {Lancet., 18(57) gives nineteen 
 successful examples of the operation, quoting Heyfelder and Jaeger's practice in its sup- 
 port. In such cases, however, it seems well to practise it as a secondary operation. 
 
 With respect to the operation itself. I may quote Hancock's, as practised in 1851. and 
 given by Barwell with recent improvements. 
 
 The foot is first laid on its inside and an incision made over the lower three inches of 
 the posterior edge of the fibula. When it has reached the lower end of the malleolus, it 
 forms an angle and runs downward and forward to within about half an inch of the base 
 of the outer metatarsal bone. The angular flap is reflected forward ; the fibula, about 
 two inches above the malleolus, is thus sufficiently cleared of soft parts to allow cutting 
 forceps to be placed over it. when the bone then can be nipped in two and carefully dis- 
 sected out, leaving uncut the tendons of the peronei longus and brevis. The foot must 
 then be turned over. A similar incision should be made on the inner side, the portion in 
 the foot terminating over the projection of the inner cuneiform bone. The flap ought 
 then to be turned back and the sheaths of the flexor digitorum and posterior tibial ten- 
 dons exposed, the knife being kept close to the bone, avoiding the artery and nerve. The 
 internal lateral ligament should be severed carefully close to the bone : aiul the foot is 
 now twisted outward, when the astragalus and tibia will present at the inner wound. A 
 narrow-bladed saw inserted between the tendons into the inner wound will project through 
 
938 DISEASES OF THE JOINTS. 
 
 the outer. The lower end of the tibia, and then the top of the astragalus, should be sawn 
 ofl' in a proper direction. The only vessel that may require tying is one of the lower 
 branches of the peroneal artery. The wound can be closed with sutures, except that 
 part opposite the breach of osseous matter, and the leg and foot placed in a splint with a 
 foot-board and cold water applied. Mr. Hancock points out the superiority of total over 
 partial excision of the joint. Mr. Hey of Leeds in 1706 was the first surgeon who 
 resected the lower ends of the tibia and fibula for compound dislocation, and Moreau in 
 1792 for disease. Hancock, however, was the first to resect the joint as a whole. This 
 operation has grown in favor during the last few years, and in select cases is doubtless 
 beneficial. 
 
 Suppuration op the Shoulder-Joint. 
 
 Suppuration of the shoulder-joint is as successfully treated by free incisions into and 
 the removal of necrosed bone from the joint as the same affection of any other articula- 
 tion, and only when this treatment has failed or is inapplicable are more severe measures 
 required. 
 
 In the case from which Fig. 637 was taken the disease had evidently commenced as 
 an abscess in the head of the bone, which had made its way into the joint and downward 
 
 through the soft parts to a point below and behind the inser- 
 tion of the deltoid muscle. It had existed for a year before 
 I treated it, and nothing but excision was applicable, since 
 the abscess cavity contained a small sequestrum which could 
 not get out. After the operation the patient had a good 
 arm. 
 
 Excision of the shoulder-joint — or, rather, of the 
 head of tlie humerus— is an excellent operation in gunshot 
 wounds of the joint, in compound dislocation, or in cases of 
 disease where a cure by natural processes has failed after 
 judicious treatment, owing either to the extent of disease in 
 the bone or to the general feebleness of the patient's powers. 
 '■ The ultimate results of excision of this joint, whether for 
 injury or disease, are very satisfactory,"' says Hodges, but 
 Head of the Humerus removed by thev are uot more SO than the ultimate results of a cure by 
 
 Operation, sliowini; au Abscess .• , -.i i i • j? i. ^ 
 
 Cavity ut\ in its Centre, with natural processes, even with anchylosis; lor, whatever may 
 Small" se^iuestrum and ' Sinus j^g the capabilities of an arm after excision, thev are equalled 
 
 burrowing Downward. t tt t i n • • i 
 
 alter a natural cure. Under both circumstances, in the ma- 
 jority of cases, almost every movement can be effected except any overhand one, since 
 the arm cannot be rai.sed above the .shoulder. A man whose shoulder I excised fourteen 
 years ago was a coachman in 1872 and could drive a pair of horses with ease. A man 
 upon whom Mr. Key operated was subsequently able to carry on his occupation as a ham- 
 merman at a large engineer's, and another case, operated upon by the same surgeon 
 twenty-one years before, in June, 1869, could '• .shoe horses with any man." and as a 
 blacksmith felt no want in his arm. 
 
 In gunshot injuries to the shoulder excision is now a recognized operation, the experi- 
 ence acquired in the American war having decided the point. Dr. Otis (Circular 0) has 
 recorded that in 252 cases of primary excision, 23 per cent, died ; and in 323 secondary, 
 38 per cent. ; primary excisions being thus more successful than secondary. 
 
 In cases, also, of tumors involving the head of the bone, other than cancerous, excision 
 is an operation of value. 
 
 Operation. — The best incision is the vertical, from the acromion process through the 
 thickness of the deltoid down to its insertion. Some make an anterior in front of the 
 deltoid. N^laton used the transverse and Aston Key the deltoid flap. When the ver- 
 tical incision is made down to the bone, its head should be successively rotated outward 
 and then inward, the surgeon making a transverse cut across the tuberosities to divide 
 the insertions of the scapular muscles. The capsule may then be divided and the head 
 of the bone turned out of the wound and resected through the tuberosities. The long 
 tendon of the biceps needs no special attention, as in cases of disease it has probably long 
 gone or become fixed to the groove, and after resection of the joint is of no value. When 
 the glenoid cavity is diseased — that is, when dead bone is detected in it — it .should be 
 removed ; but. in a general way. it requires no treatment. AVhen the vertical incision is 
 employed.it is expedient to make an opening po.steriorly through the soft p.irts, at a point 
 
OPERA Tivi: isti:i:fi:}:i:sl'K-i:x< •isjox am> ampi'tatios. 
 
 !);i9 
 
 C'(»rri'S|»itiuliiii; to tlic upiKT end of tin- hiiinenis. Ii»r tlie purposes of (Jraiiia^c, this opeii- 
 iiii; buiiij; ki'pt piitiiit by mi'uiiK of u (Iniiiiu'ro tubt;. Whatever vessels art; divided should 
 Ite twisted, ami the |>osterior eireuuiflex artery at times pives trouble. After the ojxra- 
 tiou the arm should l)e ahdueted and placed on a pillow, the ed«;es of the wound earefully 
 hroutrht tojrether. and wafer dressinfr or dry lint aiijilied. As soon as repair has iairly 
 taken jilaee the patii-nt may -^et up. the arm Iteinj; well supjiorted in a slin<_'. Three or 
 four mnnths. however, are usually recjuireil before a useful arm is secured. 
 
 In this operatiiin .M. Oilier makes mueh of preservinir the ]»eriosteum, turnin;: it back 
 off the bone with all the soft parts by means of raspatories ; this is not so <liffi(ult in cases 
 of disease as mijrht be faneieil. A cut with a strong' knife down to the bone should .so 
 divide all the soft tissues over the bone as to <rive admission to the edire of a rasj»atory 
 for the jturpose of turninu: them back. Oilier has d(»ne this on four oecasi(tns with suc- 
 cess. In reseetini; the bone no more need V>e removed than is neces.xary beyond the head 
 and half the tuberosities; but when the section is not healtliy, ani>tl»er may be iiiaih.-. 
 Four or five inches of bone have been removed in some cases, and yet a useful limb 
 remained. 
 
 Suppuration of the Elbow-Joint. 
 
 Tliere is a irreat dit^erence amon<rst sur<reons as to the treatment of a suppurating 
 elbow-joint. In the Scotch school excision is emjdoyed very freely, under the belief that 
 a better arm more generally follows such a practice than results from a cure by natural 
 processes, and that a joint with better movement is secured in a shorter time. I cannot 
 say that 1 agree in this opinion, for in elbow-joint di.sease, where pus is let out by free 
 incisions and good reparative power is present, recovery with a movable joint, and one 
 admitting of jn-onation and supination of the hand, is by no means uncommon. In other 
 cases anchylosis of the humero-ulnar joint may take place at a good angle and pronation 
 and supination of the hand be retained — and when this is the case, the issue so far as the 
 usefulness of the hand is concerned is excellent — while in another class anchylosis of both 
 bones may take place with a very useful arm ; and this result is secured by no greater 
 expenditure of time than is required for repair after excision, and without the risks of an 
 operation. In synovial disease ending in disorganization this termination is far from being 
 uncommon. Indeed, in such cases exci.sion is rarely called for. In bone disease ending in 
 necrosis, however, the same rules do not apply, for under such circumstances no operation 
 is of greater value than excision (Fig. 638). In Fig. 638 the disease was necrosis of part 
 of the humerus ; in Fig. 639 necrosis of the head and neck of the radius. 
 
 Fig. 639. 
 
 Parts Removed after Disorganization of the 
 Elbow-Joint as a Result of Necrosis of 
 Humerus. 
 
 Necrosis of the Head and Neck of the Radius, fol- 
 lowed bv nisortranizatioti of the Elbow-JoiBt. 
 ^Removed by resection from a man set. 36.) 
 
 In all cases of disease of the elbow-joint in which natural processes are incompetent 
 to effect a cure excision should be performed, amputation being had recourse to only 
 when excision is inapplicable or has failed. In ca.ses of compound dislocation or fracture 
 
940 
 
 DISEASES OF THE JOINTS. 
 
 Fig. 610. 
 
 J 
 
 Vertical Incision for 
 Excision of the El- 
 bow-Joint. (From 
 Maunder.) 
 
 into the joint excision is an excellent operation, and to gunshot wounds the same observa- 
 tions apply. Amputation of the arm for injured elbow ought to be performed in qu'te 
 exceptional cases. Several inches of bone may be taken away in the operation. Mr. 
 Tudor of Dorchester removed five inches, the patient sub.se(|nently having an arm capable 
 of extensive motion in every direction, and with which he could lift a heavy chair ( J/er/.- 
 Chir. Trans., 1858). 
 
 Operation. — The best incision is the vertical one over the olecranon process, as prac- 
 tised by Langenbeck and the French surgeons, extending from three inches above to two 
 below the joint, the incision dividing all the tissues down to the bones. The soft parts 
 should then be carefully separated from the bones and drawn aside, the ulnar nerve being 
 raised from the inner condyle, with the inner half of the triceps tendon and fascia. i\o 
 frauiiverse incision across the triceps tendon should he made, it being 
 a vei*y important thing, as recommended by Dr. R. Hodges of Amer- 
 ica (^Hammond's Essays, 186-1) and demonstrated by Maunder (Brit. 
 M(d. Journal, 1871), to retain the triceps tendon and fascia 
 z:;^^^^^^ as it passes over the olecranon, with the fascia of the fore-arm and 
 
 ^ ^-^ ' anconeus muscle, a thick body of muscle and fascia being in this way 
 
 retained, extending from the arm above to the fore-arm below, which 
 adds materially to the extending power and subsequent value of the 
 limb (Fig. (J4()). The articular ends of the bones should then be 
 turned out and removed. The surgeon need not be too sparing in his 
 sections. In all cases the whole of the articular facets should be 
 resected ; and when the bone at the point of section is not quite 
 healthy, a second piece had better be removed. " If only the extreme 
 ends of the bones be sawn oflp. anchylosis will most likely take place ; 
 while if the amount above prescribed — viz., the whole condyloid 
 extremity of the humerus and all the sigmoid cavity of the ulna, with 
 the head of the radius, or even little more on both sides — be taken 
 away, free motion may. under favorable circum.stances. be expected " (Fig. 641 ) {Holmes s 
 System, vol. v.). I have at times regretted not having excised enough of bone, and par- 
 ticularly of the humerus ; indeed, I strongly advise the surgeon in all cases to be free in 
 
 his section of this bone, more particularly 
 in excisions for anchylosis. When pos- 
 sible, it is well to preserve the insertidus 
 of the biceps and brachialis anticus tendons 
 by pressing them back from the bones. To 
 preserve the periosteum in the operation, as 
 advocated by Oilier and Langenbeck, does 
 BMsosock^ joint -^ ^^^ appear from published facts or scien- 
 
 Splint for Excision of the Elbow, the .'Splint allowing everv ^.z. • .^i. ,. p • 
 
 movement. ' titic reasonings to be a matter or import- 
 
 ance. 
 After-Treatment. — After the operation, all hemorrhage having been arrested by 
 torsion and the application of cold or very hot water, or. what is preferable, iodine water 
 (gij ad Oj, this mixture checking capillary bleeding), the edges of the wound should be 
 brought together at their ends, a drainage tube introduced, and the arm fixed at an 
 obtuse angle upon such a screw .splint as that made for me and figured above (Fig. 641, 
 the splint allowing every movement), moderate pressure being applied and maintained 
 for a few hours by means of a bandage. Absolute rest should be maintained till the 
 wound has fairly healed and the powers of the patient have been restored, when passive 
 movement should be commenced with pronation and supination of the hand, the object 
 of this operation being not only to remove the disease, but to obtain a movable joint. 
 When anchylosis follows, the operation in a measure is unsuccessful, for it has failed in 
 one of its greatest advantages. In the most favorable cases the amount of movement 
 that is obtained is all that could be wished ; indeed, it is little less than that of the 
 healthy joint. In some cases, however, the joint is too loose, like a flail ; in others it is 
 stiff; whilst in another class flexion and extension are good, but pronation and supination 
 fail. In Mr. Syme's case of a man who had acted as a railway guard up to the time of 
 his death, nine years after the operation, when the joint was dissected, the ulna and 
 humerus were united by ligamentous union, and the end of the radius was polished oflf 
 and placed on the humerus and ulna upon a material much resembling cartilage. If the 
 ulnar nerve be injured, much wasting of the muscles must occur; if divided, union of the 
 ends may. however, take place. Syme has recorded such a case. When disease returns, 
 
 Fig. 041. 
 
(>ri:n.\rivF. i.\'n:nii:nKycK^h'xcisio\ .wd .\Mri"r.\T/o.\. 941 
 
 a st'fntid rt'si-rtioii imiv l>f |ii'rlnriin'i|, ami t-vt-n u tliinl. WIkmi «Ic!hI Imiii! follows, it may 
 In; miioVfd ; indeed, iiotliiii;^ sliould Ix- left iiiitrie<| liefore uiii|(iitii(i()ii is pructi.sed. I 
 have ju-rlnriiied the it|ierati<iii tweiit \ -live times, and liavu never had to resect a Hccoiid 
 tinn- or to am|iiitali', and i:i two-thinis of the eases ;;ood movement was «ihtaim'd. 
 
 Partial resections of tiie eihow have hithertfi heeii condemned, j)asl experience having 
 inilieatetl that thev almost always end in ani-hylosis of the joint. In iHtil, liowever, 
 my eolleairiie, Mr, Uirkett, excised the olecraimn for local disease followin<; an injury, 
 tile man re«'overinu: after many incmths' treatment with a slightly movahle articulation ; 
 and 1 have recently (1S77) done the same in a harrow-man ;t't. iJS. the patitMit recovering 
 with a joint tixed at a very ohtnse angle, with limited movement. I have likewise 
 removed the necrosed olecranon process from a disorganized elhow-joint of a woman with 
 a good result, the humerus and ulna suhsi'ijiiently anehylosing, while the radius and hand 
 retained all their movements. Fnuu the results of partial res(;ctions in other ji^iuts 
 as well as in the elhow I helieve, however, that with our proent improved methods of 
 treating wounds these partial operations are valuahle. 
 
 Suppuration of the Wrist and Carpal Joints. 
 
 In this affection o|>erative interference is rarely called for beyond free incisions for the 
 evacuation of ]ient-up j>us and renu)val of dead bone, recovery being aided by the ab.so- 
 lute immobility of the hand and fingers and such constitutional remedies a.s the wants of 
 the individual case .suggest. When, however, such means fail or the local disease is too 
 extensive or severe to allow of a natural rectjvery, excision of the joint should be j)er- 
 formed ; Lister, Hancock, and others have liad successful examples. The best method 
 of performing the operation is that of Langenbeck, by means of a single free incision 
 over the dorsum of the wrist extending along the centre of the metacarpal bone of the 
 index finger. IJy this incision the lower part of the radial artery is avoided and ample 
 room given for the completion of the operation. Through the opening made the carpal 
 bones can readily be turned out and the bases of the metacarpal bones, with the extremi- 
 ties of the radius and ulna, exci.sed, the tendons of the wrist being held aside with ea.se. 
 In performing this operation I have been struck with the facility with which it can be 
 effected, and believe it to be preferable to the comparatively difficult and complicated 
 method suggested by Lister, which is to be commenced by an incision made in front over 
 the second metacarpal bone internal to the tendon of the extensor secundi internodii pol- 
 licis and running along the back of the carpus, internal to the same tendon as high as to 
 the base of the styloid process of the radius ; the .soft parts, including the exten.sor 
 secundi internodii and the radial artery, being cautiously detached from the bone, exter- 
 nal to this incision, and the tendons of the radial extensors of the wrist being also severed 
 from their attachments, the external bones of the carpus will be ex])osed. When this 
 has been done sufficiently, the next step is to sever the trapezium from the other bones 
 with cutting pliers, in order to facilitate the removal of the latter, which should be done 
 as freely as is found convenient. The operator now turns to the ulnar side of the inci.s- 
 ion, and cleans the carpal and metacarpal bones as much as can easily be done. The 
 ulnar inci.sion is then made ; it should be very free, extending from about two inches 
 above the styloid proces.ss down to the middle of the fifth metacarpal bone and lying 
 near the anterior edge of the ulna. The dorsal line of this incision is then raised along 
 with the tendon of the extensor carpi ulnaris. which .should not be isolated from the .skin, 
 but cut as near its insertion as possible. Afterward the common exten.sor tendons should 
 be raised and the whole of the posterior aspect of the carpus denuded until the two 
 wounds communicate freely together, though the radius is not as yet cleaned. The next 
 step is to clean the anterior aspect of the ulna and carpus, in doing which the pisiform 
 bone and hooked process of the unciform are severed from the rest of the carpus, the 
 firmer with the knife, and the latter with the cutting pliers. In cleaning the anterior 
 aspect of the carpus care must be taken not to go so far forward as to endanger the 
 deep palmar arch. The ligaments of the internal carpal bones being now sufficiently 
 divided, they should be removed with blunt bone forceps; next, the end of the ulna is 
 made to protrude from the incision and .sawn off as low down as is consistent with its 
 condition, but in any case above its radial articulation. The end of the radius can then 
 be cleaned sufficiently to allow of its being protruded and removed. If this can be done 
 without disturbing the tendons from their grooves, it is far better. If the level of the 
 section is below tlie upper ])art of the cartilaginous facet for the ulna, the remainder of 
 the cartilage must be cut away with the pliers. The operator next attends to the meta- 
 
942 DISEASES OF THE JOINTS 
 
 carpal bones, which are pushed out from one or the otlier incision and cut off with tlie 
 pliers, so as to remove the whole of these cartilage-covered portions. The trapezium 
 bone, which was left in the early stage of the operation, can now be carefully dissected 
 out, so as to avoid any injury to the tendon of the flexor-carpi radialis or to the radial 
 artery, and the articular surface of the first metacarpal bone then becomes exposed and 
 removed. Lastly, the cartilaginous portion of the pisiform bone is taken away, but the 
 non-articular part is left, unless diseased, in which case it should be entirely removed. 
 This remark applies to the hooked process of the unciform. No tendons are divided in 
 this operation except the extensors of the wrist. 
 
 After-Treatment. — In order to ensure motion of the fingers passive movements 
 should be performed from a very early period after the operation. For this purpose Lis- 
 ter places the limb in a splint with the palm of the hand raised by a wedge of cork fixed 
 below it, so that the joints of the fingers can be moved without taking the limb off the 
 appar.atus. When the splint is removed, some flexible support is recjuired for some time. 
 ( Vide Lister's paper, Lancff, 1865.) 
 
 Excision of the joints of the thumb requires no description, and may be 
 made by a vertical dorsal incision that interferes but little with the tendons of the part. 
 The operation is very good, and should always be performed where possible for disease or 
 injury. I have done it on many occasions with a good result, and at times recovery has 
 been followed by movement. In the case of a man with neglected dislocation in which 
 I performed it, hermetically sealing the wound with lint and the compound tincture of 
 benzoin, rapid recovery followed with a movable joint. In a second case, in which I 
 excised the phalangeal joint of the thumb, a like result ensued. 
 
 Amputation in Joint Disease 
 
 ought never to be resorted to until all hope of a cure by natural processes has been given 
 up or failed — until incision into or the removal of necrosed bone from the joint has been 
 deemed unsuitable, excision of the joint inexpedient or inapplicable, or the progressive 
 nature of the disea.se and its sapping powers reveal the fact that if the disease be not 
 removed the life of the patient is likely to be sacrificed. In amputating for joint disease, 
 as for injuries, tutuors, or other causes, the principles of "the least sacrifice of parts" 
 should be followed, and no more of the body, under any circumstances, ought to be taken 
 away than the necessities of the case demand. To carry out this principle the surgeon 
 may, in pathological amputations, fearlessly divide tissues infiltrated with organized 
 inflammatory products, and even cut through the walls of suppurating cavities or dis- 
 eased joints, more pj^rticularly to save amputating above a joint. The value of this 
 practice I have fully illustrated (Laucef, January 23, 1875). 
 
 Amputation for disease of the hip, shoulder, and elbow-joint is performed only in 
 exceptional cases, and for the knee and ankle it is yearly becoming less common. Yet 
 it is a valuable operation in proper cases, as well as the means of saving many lives. The 
 mortality of amputation for chronic knee-joint diseases at Guy's Hospital is only 1 in 7, 
 and in young people under twenty years of age 1 in 20. In amputation for disease of 
 the knee, where the end of the femur is sound and the articular facet alone diseased, the 
 surgeon should sacrifice as little of the thigh as possible ; the amputation should be almost 
 at the joint, and the femur divided through its condyles, or just above, as in Stokes's ampu- 
 tation ; a higher section of bone should be made only when the necessity of the case 
 demands it. In disease of the ankle-joint, when excision and every smaller operation, 
 such as the removal of dead bone, has been put aside, Pirogoff 's operation should be 
 employed in preference to amputation, if the calcis with the integument over it be sound, 
 or Syme's amputation unless the disease of the articular end of the tibia is too extensive. 
 To amputate a sound foot for disease confined to the ankle-joint is a measure which can 
 be justified only by peculiar circumstances, and as a general practice it is to be con- 
 demned. Amputation of the arm for diseased elbow is still less justifiable, unless the 
 local disease is too extensive to allow of excision or the powers of the patient are t'oc 
 feeble to admit of the attempt. 
 
 LOOSE CARTILAGES IN THE JOINTS. 
 
 Loose bodies, ordinarily called loose cartilages, are found in joints and are most com- 
 mon in the knee, yet are met with in the elbow-, ankle-, and other joints. They are, 
 doubtless, generally developed in the sub-synovial cellular tissues, and as they increase 
 
ijxtsi: cAirni..i<;j:s i.\ riir: .lofx'rs. !>43 
 
 in size cncroacli u|m)u the i-iivity nf the iidiit liy |)U^llillJr the syimvial iiiemhraiie heforc 
 them, jiihI appear as warty or iiKire or h'ss peduiieiihitefl IViti^'ed frrowth.s liaii^'iiij: into 
 the eiivity. They may l»e siiiiiK- or multiple an<l of all nizes iip to that of a small walnut. 
 When one of tlfe masses lieeonu's detached, " a loose eartila^'e" is said to be present. Jcjliii 
 II (inter tautrht. and ivokitansky helieved. that they are formed by the orpinization ol' 
 fibrinous coaL'ula ; but evidence is wanting; to jtrove this view, for most, as pointe*! out 
 by Kainey, contain ill-furmed eartilatre cells, and ossitic matter and true bonc-lacuniu are 
 at limes present ( Ki-r. (ill'). I'ajret { .SV. Jin,//,, //osj,. Rrj,., iSTOj has 
 recently given fjood evidcnci" of the truth of Teales su<r<.^estion that Im.VA'l. 
 
 some of these bodies are really se<(uestra, and that "just as a blow on 
 bone or tooth may imluce lu'crosis and exl'oliation ^\''ithout sij:ns of 
 destructive inflammation, so may it with articular cartilage; and th' . v 
 
 characteristics of these eases wiil be that after injury to a previous! -. ■ . % 
 
 healthy joint a loose body is found in it, having the shape and general V^ttfcl^:; '^'l^/ 
 aspect and texture of a piece of articular cartilage, with or without Wii" u iiJ-=i->— ^ 
 some portion of subjacent bone, and with its cartilage corpuscles ""^fyi^y" rJ.,,J;,'"^';j' \-'/^^^^^^^ 
 arranged after the manner of the articular cartihiire." Dr. Adams Knee, d'rep. v.u.*", 
 of Dublin connects their presence with osteo-arthritis. 
 
 A report upon these bodies, with microscopical drawing kindly etched for me by 
 Dr. (Joodhart, will help to the solution of some of these points: 
 
 " The term ' loose cartilage' is applied to two conditions whicb are totally distinct — 
 the one where a portion of the normal articular cartilage has been detached by injury to 
 the joint and lies loo.se in its cavity ; the other where bodies of more or less consistence, 
 often cartilaginous or bony, are found, and which are new formations. 
 
 " Hecent observations seem to show that the former of the.se two is by no means of 
 infrequent occurrence, but it possesses no pathological interest whatever and needs no 
 description. A very good specimen of this form is to be found in the Guy's Hospital 
 Museum (1344*-). The latter, however, has frequently excited discussion among pathol- 
 ogists; so we will give in a few words what appears to be its usual composition and our 
 conclusions therefrom as to its mode of origin. Eoughly speaking, loose cartilages are 
 generally more or less smooth, of grayish color, and look, as their name suggests, like 
 pieces of cartilage ; but they may be nodulated and composed almost entirely of bony 
 material (Fig. ()42 and Prep. y5()B, Hunterian Mus.). Even in that case, however, they 
 have a thin film of filn-ous material over them still, obscuring the bone and rendering 
 them cartilaginous-looking on their external .surface. 
 
 '' The cases (five in all) that we have had an opportunity of examining have also 
 shown more or less calcareous matter ; they were never pure cartilage. One case in the 
 Guy's Museum (1344''"), while appearing cartilaginous, cut with a creaking sensation, and 
 \inder the microscope irregular deposits of calcareous matter and bone were found in all 
 directions in its sub.stance. In another (Hunterian Museum Cat., 957a) one surface is 
 tuberculated and composed of hard nodules of ivory-like bone, while in a concavity thus 
 formed is a cartilaginous mass. The bone on the surface in this specimen can only be 
 compared to the nodulated excrescences found at the margins of the articular cartilages 
 in cases of osteo-arthritis. 
 
 " The microscopical characteristics vary in each to a certain extent : some show fibro- 
 cartilage, calcareous matter, and bone ; others are entirely bony. The cartilage in the 
 specimens which we have examined was verv fibrous and the cartilage-cells small. The 
 calcareous matter had evidently not formed after any definite method or in any purposive 
 direction, as should occur in the building up of normal bone-tissue, and the bone had no 
 regular sy.stem of Haversian canals or bone corpuscles. The former occur as spaces of 
 irregular shape and position, and the corpuscles, with but few canaliculi, are often more 
 like calcified cartilage corpuscles and have no arrangement in relation to them. 
 
 '■ From this short description, and al.so from Fig. G43. it will be seen that the speci- 
 mens exhibit the formation of bone in its various stages : they show the primary cartilage 
 stage, the secondary calcareous stage, and its ultimate issue in true bone, the bone being, 
 as might be expected, of a somewhat irregular build. 
 
 " Having thus regard to their general structure, it would then seem most probable 
 that, since they are in their essence bony, loose cartilages must form in connection with 
 bone-forming tissue, and these, so far as is known, are found in the involutions of the 
 synovial membrane at the edges of the articular cartilages. This view is consistent also 
 with the appearances found in certain joints in cases of osteo-arthritis — such, for instance, 
 as a case recorded by Mr. Wagstaife in the Pat hob nj leal Society's Transactions (vol. xxiv., 
 
944 
 
 DISEASES OF THE JOINTS. 
 
 187o, p. 192), or specimens 954— 95Gb in the museum of the Koyal College of Surgeons. 
 In all these the formations may be seen in situ. It is also in accord with the gener- 
 ally-received opinion as to the more usual formation of loose cartilages at the present 
 time. 
 
 " But in connection witli this subject the so-called ■ melon-seed bodies found in joints 
 and in the synovial sheaths of tendons and on bursa; must be considered. As is well 
 
 Fig. 643. 
 
 ^%>~- 
 
 Microscopical Appeal ance of Loose Cartilage, a, Calcareous matter. 6, Small-celled cartilage, in parts more fibrous 
 
 than represented, c, Bone. 
 
 known, thev are generally abnormal developments of the synovial fringes, sometimes 
 inflammatory, sometimes, perhaps, as was suggested by Rokitansky. due to cystic dilata- 
 tion of the synovial folds, or perhaps to distension and coagulation within obstructed fol- 
 licles. But whether originating in one or all of these various ways, being all in common 
 due to changes in the synovial membrane and sub-synovial tissue, it is evident that they 
 are loose cartilages in miniature and only want size and the further change into cartilagi- 
 nous matter to be true loose cartilages. But I have lately had an opportunity of making 
 a very careful examination of some of these ' melon-seed bodies ' from one of the sheaths 
 of a tendon on the dorsum of the hand, which suggested the possibility, not to say proba- 
 bility, of another mode of origin. I failed to find in any of them an}' evidence of organ- 
 ized tissue whatever. They contained no nuclei or cell elements and were entirely com-- 
 posed of a faintly fibrillated hyaline substance characteristic of coagulated mucus or 
 fibrin. Hence it seems to be quite possible that loo.se cartilages may originate in a 
 nucleus of fibrin precipitated in the course of a chronic inflammation, and that they subse- 
 quently grow by accretion, becoming calcareous by central petrifaction. On this point 
 may be consulted a very interesting case of a loose body in the peritoneum recorded in the 
 Path. Soc. Trans, by Dr. Greenhow (vol. xxiii. p. 241). This specimen, in conjunction 
 with ' melon-seed bodies,' makes one reconsider whether the opinion formed originally by 
 John Hunter may not be correct — that loo.se bodies in the joints are sometimes formed 
 from the ' living pjrinciple of the blood.' " ' 
 
 Symptom.s. — Loose bodies, however formed, give rise to very similar symptoms, pro- 
 duced by the foreign body becoming fixed and pinched between the articular surfaces of 
 the bones. The presence of one of them is usually discovered, when the patient is walk- 
 ing or moving the joint, by some sudden inability to move the articulation and a severe 
 and sickening pain, which is relieved only by the cartilage slipping from between the 
 bones, which it usually does by a characteristic snap. 
 
 Some stiffness and slight inflammation of the joint may follow this injury, which by 
 rest and treatment will subside in a few days, to be renewed upon a recurrence of the 
 accident. In such a joint as the knee the cartilage may as often as not be felt on manip- 
 ulation, although readily slipping away under pressure. 
 
 Treatment. — The treatment may be described as palliative or operative. By the 
 former the cartilage is left untouched in the articulation, and by the latter it is removed 
 or fixed in an unoffending position. In a general way. the palliative treatment is the cor- 
 rect one to be enforced ; for. knowing how destructive inflammation of a joint following a 
 wound too often proves, few surgeons would venture upon an operation without an abso- 
 
 ' For further information vide Virchow's Krankhafien GeschwiilMe (vol. i.) ; Marsh, .Si. Earth. 
 Bo.'<p. Eeports. 
 
niihiMATic on ciinnxfc osriyjAirnrniTis. !M5 
 
 Into iieci'Msitv. uikI Mifh scldoin t-xists, for liy rrstrainiiifx the mnvciiifiits of the joint hy 
 soiiio k-atluT, felt, or otiier li;.'lit easing tlic! foreijrn body may Ixjconie tixetl, and eonse- 
 (|uentlv iiiMoeiioiis. Indeed, liy sueli treatment Hilton Iia.s .«hown ((tiii/it Rr/torfu, IHIJH) 
 that tliese eartiiaj^es may lieettme absorbed. He fixes the kmjhc body by means of a jtad 
 and strappin^i at the most convenient spot, and places the limb upon a splint. By this 
 practice pain is prevented ; the peduncle of the cartilage cannot be stretclied or the carti- 
 lage slip between the semi-flexed bones. In 1S77 I thus treated a woman who had a 
 liiiise cartilage the size of a large almond, and in three months, under observation, it 
 gradually lessened until it disappeared. When inflammation of the joint follows one of 
 the attacks of pain, it should be treated on ordinary principles. When, however, the car- 
 tilage by its presence produces such serious inconvenience as to destroy the value or use 
 of the joint, whether I'rom the IVe(|UtMicy of the attacks, the auutunt of inflammation that 
 follows, or the dread connecteil with the aflcction. some operative interference mav be jus- 
 tifiable, ami the cartilage should be rciiKivcd by either direct or subcutaneous incision ; no 
 ojieratiou .should be undertaken till all inflammatory action has ceased and the joint is in 
 a (juioscent state. With the view of removing the off'ending body by direct incision — a 
 practice which has gained ground in recent times — a splint should be applied and worn 
 for at least a week ; the loose body should then, by mani])ulation or by such niovemcnt 
 of the joint as the patient from experience knows will bring the cartilage under the sur- 
 geon's control, be brought up to one side of the joint (and in the knee its usual seat is on 
 one side of the patella), where it may be fixed with the finger. The surgeon may then 
 draw the skin over it to one side and cut down directly upon the cartilage, the incision 
 being large en<»ugh to allow of its escape. The wound, having been well washed with an 
 antisejttic lotion, should be closed by sutures dressed with iodoform or carVjolic gauze, and 
 the limb kept upon a splint till repair has been perfected. 
 
 The removal by subcutaneous incision consists in the fixing of the cartilage by means 
 of a grooved or harpoon-shaped needle inserted into its su)>stance through the skin ; of, 
 next, the introduction of a tenotomy knife beneath the skin down to the cartilage, and 
 the division, by a free sweep of the knife, of all the subcutaneous tissues covering it in ; 
 then of the dislodgment of the cartilage by the application of strong digital pressure or 
 tilting it by means of the grooved needle into the cellular tissue of the parts around, and 
 the application of a pad of lint over the spot where the cartilage escaped from the joint; 
 finally, absolute rest of the limb upon a splint must be subse(juently enforced and an ice- 
 bag applied over the joint. After this operation a small blister may be applied over the 
 cartilage in the cellular tissue, Synie having found that by such means the foreign body 
 becomes fixed in its new position and suksequently absorbed. To remove it by a subse- 
 quent operation is a recognized, though rarely a required, measure. Mr. W. J. Square of 
 Plymouth adojits the indirect operation, but. instead of s((ueezing the cartilage com]»letely 
 through the subcutaneous wound, he is satisfied by simply pressing the foreign body into 
 the subcutaneous opening and fixing it there by compress and strapping. At the Brit. 
 Med. Assoc, for 1871 he related twenty-four successful cases. The subcutaneous opera- 
 tion has hitherto been considered the safer of the two described, but with our improved 
 methods of treating wounds the operation by direct incision is said to be equally safe. 
 We, however, want facts to establish this point. 
 
 M. Larey's statistics (Gaz. chs JlOpitaux, No. G7) fairly support the indirect method: 
 Out of 129 cases operated upon by the direct method, 28 were fatal, and only 5 out of 
 the 38 by the indirect. He concludes, after a careful analysis of cases, that the opera- 
 tion is a serious one when practised by direct incision and a difficult one by the subcuta- 
 neous method, while extraction is more dangerous than the persistence of the affection. 
 He believes the operation is indicated by the complete mobility of the foreign body 
 within the joint ; the persistence of the accidents caused by its presence — viz.. pain, 
 arthritis, and lameness ; the failure of acupressure and other means for fixing the posi- 
 tion of the foreign body ; and the free con.sent of the patient after having been made 
 aware of its dangers. 
 
 RHEUMATIC OR CHRONIC OSTEO-ATHRITIS. 
 
 This affection, originally described by J. Haygarth ( Clinical Uisfonj of tlie Xodositi/ 
 of Joints, 1813), and accurately depicted by C'ruveilhier in his PdtiiolfHjicdl Amttomy 
 (1813), is now a well-recognized aflfection. thanks to the labors of the late Dr. R. Adams 
 of Dublin and his splendid monograph published in 1857, to Prof. Smith of Dublin, and 
 Canton of London. It is chieflv seen in the middle-aired or the old, though occasionally 
 60 ' ^ ■ J 
 
946 
 
 DISEASES OF THE JOINTS. 
 
 in young people. It may attack any joint, but is most common in the hip and shoulder, 
 and generally comes on without any definite cause ; yet in not a few I have known it fol- 
 low directly upon some injury. A large number of cases put up as unreduced dislocations 
 in the different mu.seums are doubtless examples of this affection, the displacement of the 
 head of the bones being the result of the disease. It is unfortunately called " rheumatic," 
 although it has no apparent connection with what is generally called '• rheumatism." It 
 has probably acquired the name from its chief local symptom of aching pain in the joint, 
 aggravated at night and in damp weather. The disease is at first associated with a dry- 
 ness of the joint, but subsequently with excess of secretion, even to a great extent ; with 
 some thickening and expansion of the head of the bones entering into its formation, some 
 eburnation of the articular lamella of bone with disappearance of its inter-articular carti- 
 lage after it has undergone the fibrous degeneration; and with what is still more peculiar 
 
 Fig. 644. 
 
 Fig. 645. 
 
 Si'iiiilunci 
 lailllaifc 
 
 Ost€o-Arthritis of Knee-joint. (Drawing 33«.) 
 
 Wearing away of tlie Head of the Tibia in Osteo-Artliriti 
 
 — the deposition of new crests (osteophytes, as they are called) or plates of bone around the 
 margins of the articular facets and in the ligaments and synovial membrane. These crests 
 often appear as ridges of bone which can readily be made out, and the plates may simuhite 
 a second patella when the knee is the joint involved. In the case from which Fig. 644 
 was taken all these conditions were readily distinguishable, the bones and synovial capsule 
 being enormously enlarged ; the ligaments were so stretched as to allow of .some lateral 
 movements in the joint, and the characteristic rough, crackling sensation which move- 
 ment of the joint always gives was most marked. 
 
 In still more extreme or neglected cases the end of one indurated bone will grind away 
 in time that of its contiguous bone, the condyle of the femur having in the case from 
 which Fig. 645 was taken ground down the head of the tibia for at lea.st an inch. The 
 preparation was made from the amputated limb of a man jet. 36, the leg having been 
 taken off" at the knee-joint, because the limb was a flail and the joint threatened to 
 become disorganized, and an excellent stump was left. 
 
 When the hip-joint is diseased, the head of the bone flattens down, the neck .shortens, 
 the cup of the acetabulum becomes saucer-like, and around its margin, as well as around 
 that of the head of the femur, an irregular crust of bony outgrowths forms (Fig. 646) ; 
 the cartilage likewise disappears, and the articular surface of the bones presents a dense 
 eburnated appearance. In the knee-joint one or both of the condyles of the femur 
 become elongated and expanded, the head of the tibia flattened, the patella enlarged, and 
 osteophytea of variable forms and dimensions fringe the margins of the bones. The syno- 
 vial membrane also will be thickened, and at a late stage of the affection expanded from 
 effusion, the ligaments in this way becoming elongated and the joint di.slocated. Adams's 
 " additamentary bones," or new plates of bone of different .sizes, are found within the 
 synovial membrane, with probably some pedunculated bodies upon its inner surface. 
 
 In its early stage the disease is characterized by local jiain. stiffness or rigidity of the 
 joint, and local thickening and development of bony outgrowths, every movement of the 
 joint giving rise to a characteristic crackling. In the later stage the same pain manifests 
 itself with thickening, bony outgrowths, effusion, greater mobility, and even dislocation, 
 and finally disorganization. 
 
 I have a lady under observation in whom this disease is so developed in both knee- 
 
JOIST IHSKASE ASSOC/. \TJ:1> with \h'R vol's AFI'l-J'TIOSS. 
 
 047 
 
 joints tliut the lejis ari' us fliiils, tlie hones being enormously expantlcd and the joints dis- 
 temh'd, additainentary hones and osteophytes existing. She can stand only hy means of 
 artiiit'ial su|>i>orts. 
 
 Tkkat.mknt — Little can he done hy means of medicine to ch(!<;k the jirogress of this 
 afl'ection beyond attention to the general condition of the j)atient. In the iodide of 
 
 Fi(i. (!4<j. 
 
 I"i(i. (i47. 
 
 Changes in the Ilia. I an.l Nick of the Femur and in the Acetahuhini in 
 Osteo-Arihiiiis. ^i'reparatiou 113l!>9, Guy's Hosp. Mus.) 
 
 External Appearances of the Ankle 
 the Seat of this Disease. 
 
 potassium we possess a drug that certainly relieves pain, and also, I believe, retards the 
 progress of the di.sease, the liquid extract of bark or other tonic being a valuable adjunct. 
 When pain is severe, anodynes may be given, such as Dover's powder, or the bromide of 
 potassium in doses of gr. x or gr. xv, this drug going well with the iodide. Profe.ssor 
 Smith, who has paid so much attention to this disease, thinks well of an electuary of 
 guaiacum, sulphur, the bitartrate and cai'bonate of potash, ginger, and rhubarb. Dr. 
 Adams prescribes the diluted phosphoric acid. Warm bathing is of use, as are also the 
 mineral springs of Germany. This disease, although locally a painful one, does not 
 appear to have a fatal tendency, and unless very neglected rarely goes on to the di.sor- 
 ganization of the joint. To maintain rest is not a recommendation to be attended to, as 
 it tends to make the joint stiffen in the early stage of the affection without arresting its 
 progress. In the more advanced stage, when " hydrops articuli " is present and the liga- 
 ments are so loose as to allow of the displacement of the joint, some mechanical appliance 
 is called for, such as that afforded by simple strapping, or of some firm leather, felt, or 
 other casing. In extreme cases excision or amputation may be required. 
 
 JOINT DISEASE ASSOCIATED WITH NERVOUS AFFECTIONS. 
 
 It has been known for some years that joint affections which simulate those called 
 rheumatic have been met with in the subjects of diseases of the nerve centres, as well as 
 in those who have had injuries to large nerve trunks. Indeed, from a recognition of 
 this connection. Dr. J. K. Mitchell of Philadelphia in 1831 originated the theory that 
 rheumatism was a spinal neurosis (^Amer. Jonni. of Med. Science, vol. viii.), and his argu- 
 ment had something in it. At the present day attention has been more particularly 
 drawn to the connection by Charcot, Weir Mitchell, Clifford Allbutt, Buzzard, and others, 
 and abundant evidence has been publi.shed to prove that in fabes (hrsa/ia or locomotor 
 ataxia there is a peculiar joint affection which approaches in some of its characters the 
 osteo-arthritis just described, and yet in others differs from it in a very marked manner. 
 
 Symptoms. — It may appear early in the progress of the nerve disease — that is, with 
 the characteristic '• lightning pains " — or it may not show itself till these pains have 
 become well marked. It usually first shows itself in one of the joints of the lower 
 extremity. 
 
 The joint trouble begins with effusion into the joint, some swelling of the limb, and 
 crackling of the joint on movement ; but with the.se symptoms there are usually no 
 increase in the temperature of the part, no pain, and no constitutional disturbances. 
 
 These sj'mptoms may last for a few days or weeks and then disappear, and leave 
 nothing behind except either some crackling of the articulation or a joint deformed from 
 relaxation of its ligaments, or even dislocated. In extreme cases an articular facet of 
 
948 DISEASES OF THE JOINTS. 
 
 bone becomes worn away and the head of the bone so altered in shape as to be unrecog- 
 nizable. There may be false bodies to the joint, and in some cases osteophytic outgrowths 
 from the articular surfaces ; but these are never so well marked as they are in osteo- 
 arthritis. There is never in this affection any eburnation of the articular surface of bone, 
 so constant in osteo-arthritis. 
 
 At the same time there is a strong analogy between the two affections, and I am dis- 
 posed to think that the differences between the two classes of cases are to be explained 
 by the fact that in the case of osteo-arthritis the disease invades tissues in which nerve 
 influence has its normal power, whereas in the other there is clearly a deficiency of such 
 power. 
 
 In osteo-arthritis there is more new bone thrown out in the shape of osteophytes and 
 plates than in the arthropathy of nervous disorders, because the action in the part is of 
 a more sthenic type, and for the same reason, in the arthropathies now under considera- 
 tion, the bone, from being ill-nourished and containing a diminished quantity of phos- 
 phate of lime and an excess of fat, is more readily worn down by attrition and made to 
 disappear than in the osteo-arthritis of the more sthenic kind, in which the bone, from its 
 hardness, becomes eburnated, and is only slowly ground down by attrition. More know- 
 ledge is, however, required respecting both these affections before they can find their right 
 place in pathology. 
 
 Treatment. — Little more can be done in these cases than to keep the joint quiet by 
 means of splints, and so to prevent movement, attrition, and displacement. In the state 
 of joint effusion well-applied pressure is of use, and that applied by means of an elastic 
 or rubber bandage over cotton-wool is to be recommended. When dislocation exists, some 
 immovable casing to the joint is of use. 
 
 ACUTE BURSITIS AND SUPPURATION AROUND JOINTS. 
 
 I have placed these two headings together, as there is good reason to believe that sup- 
 puration about the cellular tissue external to a joint is most frequently the consequence 
 of an acute inflammation of some superficial bursa, and that it is only in exceptional 
 instances such a connection cannot be traced. Over the knee- and elbow-joints, where 
 this suppuration is generally met with, some blow, fall, or punctured wound may origin- 
 ate an acute inflammation in the bursfe of these parts, while the thick integument cover- 
 ing them prevents the inflammatory products making their escape externally and favors 
 their lateral extension : the abscess, consequently, in one case, after covering the knee, 
 burrows backward into the popliteal space, or in the other comes forward in the arm into 
 its flexure ; more commonly, however, it shows itself as a painful phlegmonous inflam- 
 mation over and around the patella or olecranon process. In some examples the suppura- 
 tion is confined to the bursa, while in most the inflammation will be found to radiate from 
 these well-known points. In children, however, the connection between the suppuration 
 and bursitis is not so readily made out, and there can be little doubt that at times it does 
 not exist. 
 
 The severe cases of suppuration around a joint are most frequently met with in chil- 
 dren of delicate and feeble frames and in the badly fed, who are disposed to rapid exten- 
 sion of suppurative inflammation when started by any slight accident, blow, fall, or strain. 
 When these large abscesses appear around the shoulder — a joint that is less liable to di.s- 
 ease than any other — it has probably been caused by some strain or injury when the child 
 is dragged along by a careless or violent companion, or it may be that the muscles of the 
 parts are injured. At times it is the epiphysial cartilage placed between the epiphysis 
 and the shaft of the humerus which has suffered. 
 
 Diagnosis. — The diagno.sis of these cases of suppuration external to the joint is not 
 difiicult. On examination it will be seen that the swelling is external to the joint, cover- 
 ing in the well-known points of bone ; in the knee the soft parts probably will be raised 
 from the patella, and fluctuation will be felt above and around it. There will be much 
 local pain, but not so much constitutional disturbance as would exist with a suppurating 
 joint ; the joint, moreover, will be capable of some amount of movement without pain — 
 a condition which would be impossible if the seat of the disease were in and not around it. 
 
 Treat.ment. — There is only one form of treatment on which reliance can be placed 
 in these cases, and this consi.sts in giving free exit to the pws. A free incision, conse- 
 quently, should be made into the abscess over the seat of the bursa as soon as any pus 
 can be detected. The limb should be raised, the joint preserved at rest by splints, and 
 warm-water dressing or a poultice applied ; and the joint should be kept absolutely quiet 
 
ishi..\MM.\rii)S or liosi:. '.>40 
 
 till repair has \wv\\ fom|>lete<l. Wiicn tlie powers of tin? puticiit are feel)le, tonics should 
 he {^iveii. When tlic al»sress is not opt'iuMl early, it may o|m'Ii into the jtjint and produce 
 an acute sup|)uration. I have known this liappi-n in the kne»? with a fatal result. In the 
 knee it is often m-eessary to make a free incision on either side of the joint, as well as 
 over the patella, in order to prevent hurrowinj;. 
 
 CHAPTKU XXXITI. 
 DISEASES OF THE 1'. ( K\ E S 
 
 General Remarks. 
 
 In a pathological .sense diseases of the bone are identical with those of other tissues, 
 while such differences as exist are due to their anatomical and physiological peculiarities, 
 diseased action, under all circumstances, being materially modified by texture. In the 
 bones diseased action is thus modified by the presence of the inorganic material which 
 they contain, two-thirds of their constituents being earthy and one-third animal. This 
 animal texture includes a fibrous periosteal membrane with cellular tissue beneath, as well 
 as a finer endosteal membrane which lines the medullary canal. These two membranes are 
 intimately connected together by delicate vascular and membranous links permeating the 
 Haversian canals and canaliculi of the bone itself. The exterior of the bone is dense, and 
 derives most of its nourishment from ve.s.sels ramifying in the periosteum ; the intn-ior of 
 the bone is porous or cancellated, and derives its supply of blood from a distinct nutrient 
 artery which runs in the endosteum ; while the capillaries of both anastomose freely 
 through the bone canals. The long bones also are built up of shafts (diaphyses) and 
 epiphyses, the epiphyses being distinct from the .shafts during the early years of life and 
 having their own vascular supply. The shafts and epiphy.ses are connected together by 
 means of a layer of epiphysial cartilage, through which, as proved by Prof. Humphry, 
 the shafts mainly grow, though interstitial expansion has an influence in bone as in other 
 parts. The epiphyses themselves are covered with articular cartilage that derives its 
 nutritive supply from them. The.se anatomical points thus briefly sketched are import- 
 ant to remember when the pathological are considered, as most of the peculiarities 
 of bone disease are explicable by them. Thus, when a bone is inflamed, it can be so only 
 through its soft tissues, its inorganic matter being affected secondarily. The periosteal and 
 endosteal membranes being intimately connected, inflammation originating in one is very 
 liable to extend to the other; and in proportion to the nature or amount of this exten- 
 sion will the inflammation be periosteal or endosteal and the affection either periostitis or 
 ostitis. 
 
 In long bones, when disease attacks the .shaft, it may become arre.*<ted by the epiph- 
 ysis or epiphysial cartilage, the articular ends of the bones, and consequently the joints, 
 escaping. In periostitis, however, such a result is not always secured, for the .synovial 
 membrane of a joint, in a clinical point of view, may be regarded as a continuation of the 
 periosteum, and pus beneath this membrane may burrow into the neighboring articu- 
 lation, or the inflammation may spread by continuity. When the disease attacks the 
 epiphysis, the inflammation may spread into the joint. 
 
 \\ ith these remarks the diseases of bones may be considered, dividing them into the 
 inflammatory affections, tumors of bone, atrophy, hypertrophy, rickets, and mollities ossium. 
 
 INFLAMMATION OF BONE 
 
 may be divided into the acute and the chronic. 
 
 The acute uiay be idiopathic or the result of some injury, the division of a bone by 
 operation, or a compound fracture ; it may end in local abscess of bone, in diffused sup- 
 puration, or in the more or less complete death of the bone. When originating in the 
 periosteum and not wholly involving the endosteum or medullary membrane, the outer 
 surface of the bone alone may die ; when originating in the endosteum and not wholly 
 
950 
 
 DISEASES OF THE BOXES. 
 
 involving the periosteum, the inner portion of the bone may die and the shell escape, the 
 whole bone dying when both membranes have been equally involved, whether commen- 
 cing in one or the other. The extent and the depth of the destruction of bone, or its 
 '• necrosis." are determined by the extent and intensity of the inflammatory action and 
 the degree in which the membranes covering and lining the bone have been involved. 
 Thus, on the one hand, the superficial necrosis of the frontal bone of a child may ensue 
 after its exposure from a lacerated wound caused by the gnawing of a ferret (vide Fig. 
 648), in another case a large thin shell of bone may exfoliate from the tibia after an acute 
 periostitis (Fig. 649), in both of these cases the life of the bone having been sacrificed 
 
 Fk;. r,4,s. 
 
 Fir;. 649. 
 
 Superficial Xecrosis of Frontal Bone following Wound 
 
 caused by the Gnawing of a Ferret. (Delsey W , 
 
 St. 7 months, June, 1874.^ 
 
 Shell of Bone Exfoliated as a 
 Ilesult of Acute Periostitis. 
 (Periosteal Necrosis. 
 
 through the death of the periosteum alone. Fig. 650 represents a sequestrum the result 
 of an acute endostitis. osteomyelitis, or ostitis (for all these terms are synonymous) sur- 
 rounded by a reparative shell of bone newly formed by the uninjured periosteum ; while 
 
 Fig. 650. 
 firode fi/ue/iin^ ione tfyrei^f/7i Cloaca 
 
 Death of Bone the Piesult of Acute Ostitis, the Sequestrum, composed of the Shaft of the Tibia, 
 being surrounded by .Shell of New Bone. 
 
 Fig. 651 illustrates the appearance of the limb so aflfected, taken from life, with the 
 sinuses open leading from the surface of the limb through the soft parts of the shell of 
 
 Fi&. 6ol. 
 Jirohcs touching hone tlirnu^h. Cloacce 
 
 External Appearance of Limb the Seat of Acute > 
 leading down to 1 
 
 Shaft of tht libia, with Cloacje 
 
 new bone to the sequestrum. Fig. 652 represents a section of a bone which died, nearly 
 as a whole, from inflammation of both membranes, and upon the upper surface of which 
 no new bone formed, the periosteum having been completely destroyed, although at the 
 lower part, where the membrane was sound, bone has been renewed. 
 
isi'i.AMMATHis nr iiDSi:. 
 
 :>.jl 
 
 Vfif fKin' tfrifntfi /^riaatritm f/rri)l tout 
 
 In all tlii'se rases the iiifla)ii«'*l heme dit'il wludly <»r in part f'ntm an afiiti- infiaiiiiiiation, 
 the Ikmh- liy the iiiflaiiiiiialinii haviii;^ been deprived of its vascular supply tlir<iuj.'h a 
 hidckiu',' (»r its eapillari«'s. its death 
 resulting; I'mni hhxid stasis. These 
 ehaii;j:es, Imwevi'r. (hi not always 
 ensue, tor the aeut(> intlainMiatiiiii 
 ill some eases may terminate in an 
 aeiite ahscess of Imiie with or with 
 out necrosis, and in other cases iii 
 acute ahseesscs. I have in the 
 tiliia met with three centres 
 >ujipiiralion the r<>ult ol' aeute 
 inriaiiimatioii. When acute iiitlammatiou attacks an epiphysis, the same patlmhjgical 
 chanjres ensue. The whole ej»ipliysis may die and be cast off', or it may be the seat of 
 an abscess or (tf a local necrosis; and wlien the local necrosis is confined to the articular 
 
 if Necrosis of the 
 
 .■"huft of 111.- 'ril.ia 111" l;.-iill 
 rerioslitis. (I'rep. 1J4;J*'. i 
 
 >f .NciiK- (Kiitis and 
 
 Fio. 653. 
 
 
 'V^Hv^J^'j 
 
 Necrosis of tin- .Xniciihir Lamella of 
 Tone, Willi liegeiieration of Cartilage 
 covering il in. 
 
 lamella of bmie, the joint will become involved, as well illustrated in Fig. 653. In Fig. 
 W'.VJ the head ami neck of the radius necrosed and gave 
 rise to su]iiiiiratioii. 
 
 In chronic inflamni'ation of the articular extremities of 
 the long or spongy Itoiies other changes occur. They may 
 be described as tollows, <(Uoting my own words written in 
 185'J (on di.seases of joints) : Tn the earliest condition 
 simple vascularity will be the priiiciiial morbid appearance, 
 the cancelli containing more serum than natural ; but as 
 the disea.se advances the bone becomes larger than natural, 
 this enlargement in some cases being very great. Upon 
 making a section of the bone the saw will break through 
 its structure more easily than in a healthy specimen, its 
 earthy constituents having diminished ; and on comparing the structure of the di.seased 
 with a healthy bone it will be observed that its cancelli are much enlarged and the col- 
 umns radiate from the shaft in a palm-like fashion, as if they had been spread out from 
 downward pressure. When the inflammatory process is of a tolerably healthy character, 
 parts of the bone will appear denser and more indurated than the remainder, from the 
 organization of the inflammatory deposit, this deposit in bone always becoming osseous; 
 fref|uently, however, the death of the bone, with a small or large .sequestrum or a local 
 or difl"used abscess, is the result. If the denser portion of bone forming the shell is 
 examined, it will lie found thinner than natural and appear as if it had been dilated, in 
 .some cases crackling on firm pressure. Where the articular extremity joins the shaft 
 some new bone may be detected, thrown out, as it were to support its dilated body. The 
 articulating surfaces of the bones will in some parts appear more vascular than normal, 
 whilst in other more advanced cases portions having been thrown off like a .slough will 
 be found loo.se and lying in the joint, the denser portions of bone, as a result of articular 
 ostitis, dying more rapidly than the cancellated. 
 
 The cartilages at th.e same time undergo degenerative changes and separate from their 
 bony attachments more or less rapidly, in some cases being cast off as a slough or shed 
 as a nail or cuticle. T'nder these circumstances joint disease occurs. 
 
 In chronic inflammation of the shafts of bones changes similar to these are equally 
 manifest, the bone in the early stage first expanding, and in subjects of better power sub- 
 sequently thickening, from the organization of the inflammatory exudation, the bones 
 thus becomint; solid and dense and the subject of a condition known as sclerosis (Fig. 
 G54). ■ 
 
 In ca.ses of inflammation of bone when the periosteum is not morbidly involved a 
 layer of new tissue secreted from the pei-iosteum is poured out upon the bone, and at 
 first is soft and fibrinous, and subsequently hard and osseous, the new material being 
 reparative in its nature and that from which the new bone will be formed. It may be 
 only a few lines in thickness, though at times it is even half an inch (Fig. 656) ; and 
 before it becomes osseous it can readily be peeled off the bone by means of the handle of a 
 scalpel or perio.steal elevator. It is to this tissue M. Oilier alludes when he recommends 
 the sub-periosteal resection of the shaft or articular ends of bone, for it is mainly upon 
 .such that the regeneraticm of a bone or part of a bone depends. Changes analogous to 
 those described as going on in the periosteum occur in the endosteum or medullary mem- 
 brane of the bones, although not so well seen. The products, therefore, of a periostitis 
 
952 DISEASES OF THE BONES. 
 
 or endostitis vary with the character and intensity of the inflammatory process, precisely 
 in the same way and under the same conditions as the products of inflammation vary in 
 the softer tissues. In very intense inflammation the death of the inflamed part is the 
 result — death of the periosteum with the bone depending upon it for its nourishment, of 
 the endosteum with its bony fabric, or of the whole bone when both membranes are 
 
 Fig. 654. 
 
 Sclerosis of Bone the IJesult of rhrouic Inflammation. (From Prep. Guy's Mus.) 
 
 equally involved. When the bone does not die in mass, it may in detail, and as a result 
 of the inflammation local abscess of bone or diff'used suppuration may ensue, with or 
 without necrosis or a sequestrum ; when the suppuration is around the bone, it is seen 
 as a periosteal abscess — a condition which is mostly followed by a more or less extensive 
 necrosis. 
 
 The character of the pus in these cases of bone abscess is of diagnostic importance. 
 Pus the result of perio.stitis difibrs in no respect from that found in other tissues, but pus 
 the result of endostitis, ostitis, and o.steo-myelitis is freely mixed with oil globules. In a 
 striking case of this latter affection in a girl jet. 10, which was under my care, where a 
 free incision was made down to the tibia, the surface of the fluid evacuated was covered 
 with oil cells. Roser has made a like observation. 
 
 Acute Inflammation of Bone, 
 
 whether periosteal or endosteal, is chiefly found during the growing period of bone, before 
 puberty, and is a very grave affection. It occurs in the feeble and cachectic and in those 
 termed scrofulous, in the shafts of the long bones as well as in the epiphysis, and in such 
 as are most exposed, as the tibia and ulna, although it is almost as frequently seen in the 
 femur. The bones of the upper are probably more rarely affected than those of the lower 
 extremity. It is often the result of some local injury or exposure, though as often as not 
 no such exciting cause can be made out. 
 
 Symptoms. — The disease is generally ushered in with a deep aching pain in the bone, 
 with local tenderness, often a rigor, followed by intense constitutional disturbance and 
 increase of temperature. The pain in the limb is speedily followed by swelling, which at 
 first is deeply placed and not marked by any external evidence of inflammation, such as 
 redness ; as the swelling increases the soft parts covering it become tense and oedematous 
 and the veins of the part look full, such symptoms indicating deep-seated obstruction, 
 while any attempt at movement or pressure causes suffering. When the disease is situ- 
 ated in the articular end of a bone, it is constantly mistaken for rheumatic fever. 
 
 If the disease is pen'oateal in its origin, the skin soon becomes involved and local red- 
 ness appears, the slightest touch exciting pain. If endosfeal at the onset, gentle manipu- 
 lation will be allowed, and many days will pass before redness and other external signs 
 of inflammation show themselves, these appearing only when the disease has spread to the 
 periosteum and through it to the soft parts around. When suppuration ensues, the skin, 
 from being tense and oedematous, becomes inflamed, and the constitutional disturbance 
 worse ; rigors become more frequent, pain is more intense ; sleeplessness, and probably 
 delirium, with a feeble pulse, appear; and unless relief be afforded by a free incision 
 down to the bone, death by exhau.stion, and probably by blood-poisoning, is apt to occur, 
 since the connection between acute inflammation of bone and septicaemia is very close. 
 ( Virle Chapter I.) 
 
 When the inflammation is essentially ^enosto?/, more or less well-formed pus mixed 
 with blood will be effu.sed. though in feeble subjects it may be only a blood-stained serum 
 containing lymph. In some of the worst cases of this disease I have seen this effusion 
 was very copious. 
 
 Endostitis is particularly prone to be accompanied by blood-poisoning ; it is, therefore. 
 a far more serious disea.se than periostitis, whether as a primary affection or as consequent 
 upon the latter. 
 
 Acute periostitis, ostitis,' or endostitis may attack the cranial, carpal, and tarsal bones, 
 the shafts, articular ends of bones, or epiphyses ; and. according to its seat or extent, it 
 may terminate in recovery or in the complete death of either the centre or the shell of 
 
isi LAMM Arms or nosi:. 953 
 
 hone. Tlie host instance of death of the hone from periosteul infiaiiiination is seen in the 
 unL;ual phahmx of the tinirer. the hone dyin^' as a whoh- some five or six weeks after the 
 first onset of the inthiinmation, without any attempt at its re-lormation. Siieli eases are, 
 f^eiierally, hut wroii;;ly, hioketl upon as uliitlmrs. Of the tarsal liones. it is most common 
 in the os calcis, hirye set|uestra heinir ol'ten met with in this hone; peri(»steal necrosis is, 
 however, comparatively rare in the cah-is, except as a result of injury tr) its tuherositv. 
 
 When this disease attacks the articuhir ends of the hones, acute joint mischief is the 
 jreiieral result ; and when it follows the division r)f hone, hy either amputation or resec- 
 tion or after compountl fracture, jrunshot or otherwise, it is a common cause of death and 
 too fre<|uently is the preeursijr of septicjumia. Sir .J(jseph Kayrer. who has drawn atten- 
 tion to this fact in his Annnh nf Mi<l. Srii nc (ISt)')), looks upon the prominent fun<rous 
 mass of irranulations that is often .seen eoverin<r the end of an amputated bone as indica- 
 tive of the artection. and helieves that the facility with which the surgeon passes a probe 
 well into the medullary cavity throuirh these <;ranulations establishes the diafrnosis. He 
 gives the general symptoms as pain in the part, a'dema, and swelliiifr extending down the 
 limb, general fever, with <|uick pulse and increa.sed temperature, and more especially the 
 recession of the soft ]>arts. including the periosteum, from the bone, which is then left 
 denuded at the bottom of the wound. 
 
 Jules Koux of Toulon first drew attention to this affection, and gave it the name 
 " ostco-myelite." It is. however, essentially an endostitis, only of traumatic origin. 
 
 Trkatmknt. — In all cases of acute inflanunation of bone or periosteum, in which of 
 necessity there must be effusion beneath the dense fibrous periosteal layer, there is no 
 treatment eijual to that of a free incision down to the bone ; and if the di.sease is not 
 arresteil or modified by this practice, immense relief to pain is rapidly afforded. There i.s 
 good reason to believe, too. that by such treatment the disease is often limited, and even 
 arrested, as well as the death of the bone averted ; for bone, like other tissue, is very- 
 prone to die when subjected to the compressing influence of a confined effusion. When 
 the upper part of the shaft or the articular end of a bone is the seat of disease, this prac- 
 tice is very important. 
 
 Before making an incision there is no need for the surgeon to wait for the formation 
 of pus, as to do this is generally to wait too long. The object of the incision is to relieve 
 tension ; consequently, it should be carried out as soon as tension clearly exists. In cases 
 of acute disease of the tibia, with severe local pain and constitutional disturbance. I have 
 opened the periosteum on the third or fourth day, before any external evidences of inflam- 
 mation showed themselves, except turgid veins and bone enlargement. The incision gave 
 vent to blood-stained serum, but it was followed by immediate relief to all local and con- 
 stitutional disturbance and by a rapid recovery. If the incision does not save the life of 
 the bone, it relieves symptoms, and, what is more, it may limit the disease by preventing 
 the pus from burrowing beneath the periosteum covering the shaft of the bone into the 
 neighboring joint. This liability to joint complication is. indeed, one of the strongest 
 arguments in favor of the practice. The limb, at the same time, should be elevated and 
 hot fomentations applied ; pain should be relieved by opium, morphia, chloral, or any 
 other sedative, and the general powers kept up by abundance of nutritious food, such as 
 milk ; while stimulants .should be cautioush* administered. 
 
 When the inflammation ends in necrosis, it requires to be treated according to the 
 mode to be referreil to in a later page. 
 
 Occasionally, as an effect of acute inflammation of the periosteum, much blood is 
 effused between the membrane and the bone. I believe this result to be mechanical and 
 due to the rapid separation of the periosteum ; it is met with only in acute cases. 
 
 Acute Abscess in Bone. 
 
 Abscess in bone is the result of a local inflammation, and may or may not be associ- 
 ated with the death of a small piece of bone. In some cases it is acute, but more gene- 
 rally chronic. 
 
 In the acute some necrosis is generally associated with it ; in the chronic such an a.s.so- 
 ciation is more rare. 
 
 Not long ago I treated a boy aet. 17 who after intense pain in the head of his tibia for 
 three days had local swelling and severe con.stitutional disturbance that had been regarded 
 as due to rheumatism. At the en<l of a month, when I saw him. I made a free inci-sion 
 down to the bone, to relieve pain and give vent to any pus that might have found its way 
 externally. A week later pus appeared, evidently from the bone, for a probe could be 
 
954 DISEASES OF THE BONES. 
 
 passed through the wound into a cavity. Two weeks hiter, or six weeks from the com- 
 mencement of the symptoms, I enUxrged my opening, and through the aperture in the 
 head of the bone from which the pus had flowed I removed three pieces of bone, together 
 making one the size of a nut, which rested in a cavity lined with velvety granulations 
 such as are so characteristic of an abscess. A complete recovery ensued. In another 
 boy, aet. 10, in which severe local and constitutional symptoms had arisen early, I removed 
 a similar piece of bone from a like cavity in the end of the radius, and with a similar 
 good result. In both cases acute inflammation of bone had ended in the formation of a 
 local abscess with circumscribed necrosis, and recovery rapidly followed the surgical treat- 
 ment. 
 
 A few years ago a child was brought to me who had received, when asleep, an injury 
 to the tibia, from a playfellow having attempted to drive a pin into the bone. Nothing 
 beyond some slight local pain had followed the injury for a few days, when severe pain 
 and swelling appeared, with fever, etc. I cut down upon the part with a view of giving 
 relief, when the point of my knife went with a crackle through a thin layer of bone into 
 a cavity, which gave vent to a teaspoonful or more of pus. Immediate relief followed 
 the operation, and a good recovery took place. 
 
 These three cases sufl&ce to illustrate the fact that acute abscess in bone is met with, 
 and to show its symptoms and treatment. 
 
 Chronic Abscess in Bone. 
 
 In 1773, William Broomfield, surgeon to St. George's Hospital, in his CMrnrgical 
 Obst'Tvatioxs, wrote : " Whenever a patient complains of a dull, heavy pain deeply situ- 
 ated in the bone, possibly consequent to a violent blow received in the part some time 
 before, and, though at the time the patient complains of this uneasiness within the bone, 
 the integuments shall appear perfectly sound and the bone itself not in the least injured, 
 we have (jreat reason to susj^ect an abacess in the meduUay In 182-1, Sir B. Brodie ampu- 
 tated a limb for incurable pain in the tibia ; and in this case — which Sir W. Fergusson 
 has described "as one of the beacon-lights of surgery never to be forgotten" — "the 
 lower end of the tibia is enlarged and the surface presents marks of great vascularity; 
 the bone in the preparation is divided longitudinally, and just above the articulating sur- 
 face there is a cavity as large as a small chestnut. This cavity was 
 Fig. 655. filled with dark-colored pus. The inner surface of it is smooth. 
 
 The bone immediately surrounding it is harder than natural." 
 
 In these two extracts, written at an interval of fifty years, 
 are embodied the clinical and pathological facts connected with 
 this subject which are now recognized by surgeons. 
 
 Sir B. Brodie in 1846 published a valuable paper on this sub- 
 ject, and to him, oddly enough, the full credit of recognizing 
 these cas^s has been wrongly attributed. He probably first 
 Bji-hhusia/j^^xr^^mii • "ly heard of them from John Hunter. 
 
 CaHiiaje ''^vSi^pFJ If This chronic abscess is generally met with in the articular 
 
 ends of bones — that is, in their cancellous tissue — more particu- 
 larly in the two ends of the tibia. I have, however, seen it in 
 the condyle of the femur and the humerus and in the shafts of 
 the ulna, radius, and tibia. It may also occur in any bone. In 
 Fig. 655 the cavity of such an abscess is illustrated, and in Fig. 
 63-1 is seen its opening into the joint. The history of these cases 
 Abscess In Head^fTibia, follow- is generally obscure, an injury at times being its assigned cause, 
 ed by Disorganization and Dis- " SYMPTOMS. — The most characteristic symptoms are a fixed 
 
 location of the Joint. (Prep. , . ... ,, , . , • in ^1^.1 
 
 Guy's Hosp. Mus, i24.55<i) achuig pain in the part, '• the pam being a dull one, rather tend- 
 
 ing to produce sickness than to rouse '" (John Hunter) ; exacer- 
 bations occur in its progress, when the pain becomes acute, fixed, and of a burning pul- 
 sative kind — " like the falling of drops of molten lead," as a patient once described it to 
 me ; there will likewise be local circumscribed tenderness or pain on firm pressure, with 
 probably some evident enlargement of bone and the sense of local heat. 
 
 In more advanced cases the soft parts over the bone will be oedematous, and on firm 
 pressure over the painful spot a sensation of yielding will be given to the finger. In still 
 more neglected cases the abscess may make its way into a joint, while under fortunate cir- 
 cumstances it may advance forward and discharge itself externally. 
 
 Treatment. — " Abscess in bone may find its way to the surface," but " the crown of 
 
INFLAMMATlnS oF liOSK 
 
 955 
 
 the trephine is often necessary in Dnlcr to m*t at the seat of uVjscess," sai<l .Inlm llutitrr 
 in ITS" (MS. lectures). At the present (hiy si like treatment is to he advised, as iiothin}^ 
 less than the o|)eniii^ of the ahseess in tlie hone is of any nse ; and this is usually done 
 hy nu'aiis «>f a small trephine. The point to he .seleeted for the operation is the painful 
 spot, which should he marked hefore the patient is ansesthetieized ; the s(»ft parts should 
 then he divided hy a erueial ineision and turncfl hack and the hone itself freely peHor- 
 ated. with the ])eriosteum eoverinj; it. When the instrument has opened the ahseess, 
 pus will well up at onee ; the rinir fif hone raised hy the elevator oufrht then to he taken 
 away ; the eavity, whieh is j;enerally lined with smooth, velvety granulations, is rarely 
 very large and the (|uantity of pus .seldom ahove a drachm, althoujrli scjmetimes there 
 may he more. After the operation the parts have only to he left alone to heal, recovery 
 being very general. 
 
 It is not always necessary, however, to trephine a hone, as a less .severe operation is 
 at times all that is re<|uired, and that is its simple* puncture by means of a drill ; when 
 the .scat of the abscess is not very accurately defined, the drill is probably the better 
 instrument to use. In a .striking case I had in the spring of IHTO I carried out this oj)e- 
 ration and punctured the head of the tibia of a man who had all the external evidence of 
 local ostitis and su|)puration, such as pain, bone expansion, etc. I cut down upon the 
 painful expanded part and made two punctures with a drill, one of which clearly went 
 into a cavity in the bone, as evinced by the sudden loss of resi.stance. No pus, however, 
 was seen to well up in the wound at the time, though soon after the operation a free dis- 
 charge took place. The operation was followed by complete relief from all pain, and in a 
 month the man left (ruys (|uite restored, and three ijionths later he remained so. More 
 recently I arrested disease in the femur of a boy ajt. IS by trepliining the trochanter 
 major and puncturing the bone with a drill through the opening. 
 
 This operation of drilling the bone .*<eems to be good either for supposed suppuration 
 or for chronic ostitis. It is less formidable than trephining and may be done in cases 
 where the latter is inapplicable or not to be entertained ; indeed, the two means may be 
 employed together when the trephine has failed to open the ab.scess. Holmes's sugges- 
 tion is good — viz., to pierce the walls of the trephine-hole in several directions with a 
 sharp-pointed instrument, in order to remove the bone freely with a chisel if a drop of 
 pus follow any of these punctures. 
 
 Chronic Periostitis and Endostitis. 
 
 Chronic periostitis and ostitis are very common affections, more particularly involving 
 the shafts of the long bones. These affections may be modified by syphilis, scrofula, or 
 rheumatism and may originate from some local cau.se or injury, but in all their course is 
 the same, the disease varying only in the rapidity of its progress, extent of its influence, 
 and results. In one case complete recovery may take place, the effusion being reab- 
 sorbed ; in another the effusion may become organized as a superficial node or bony out- 
 growth (Fig. 656) or as an enlarged, elongated area of dense bone (Fig. 654). In excep- 
 
 FiG. ()o6. 
 
 iAellof done .- ^ __.-a :;::^^..t«gr--~— ^~^^^ 
 
 EfTects of Periostitis. 
 
 tional cases local suppuration may occur, giving rise to a chronic periosteal or endosteal 
 abscess ; in a large proportion of instances the bone dies, and thus gives rise to local necro- 
 sis ; whilst in some few the bone, either upon its surface or upon its interior, undergoes 
 a chronic disintegrating process known as caries. 
 
 In local perio.stitis a small portion of bone alone may die. and. as Sir James Paget 
 has shown ( C/in. Soc. Tnnis., 1870), remain quiescent under a puffy or suppurating 
 swelling. 
 
 Sy.mptoms. — The symptoms of chronic periostitis and ostitis (endostitis) are in their 
 nature very similar to, though less severe than, those of the acute, the most constant 
 being a dull, aching pain in the part, of a persistent kind, aggravated at intervals and 
 
956 DISEASES OF THE BOXES. 
 
 on hanging down the limb, tlie pain being almost always worse at night, more particu- 
 larly in syphilitic affections. The constitutional symptoms vary according to the severity 
 of the local condition, febrile disturbance and intensity of local action running hand in 
 hand. 
 
 In penmtitis the pain is generally local and attended with swelling at an early period 
 of the affection — indeed, within a few days of its onset. In endoAtitia the pain is gener- 
 ally more diffused through the whole bone, and will continue for weeks or months with- 
 out any external evidence of enlargement, being too often regarded as " rheumatic " or 
 '• growing pains." In periostitis tenderness on manipulation is an early and constant 
 symptom. In emlostitis the bone may be manipulated with gentleness without exciting 
 pain ; firm pressure, however, almost always causes suffering. In periostitis the enlarge- 
 ment generally shows itself as a boss}- or undulatory swelling on the surface of the bone, 
 with one, two, or more nodes upon the bone ; syphilitic periostitis is generally multiple 
 and undulatory, traumatic and other, forms of nodes usually single. In endostitis the 
 enlargement appears as a general expansion of the bone in all directions ; in rare ca.ses, 
 as a distinct elouejation. In periostitis, when suppuration is about to take place, external 
 evidence will appear in the form of increased swelling and tenderness, while redness of 
 the skin, cedema of the tissues covering in the node, and fluctuation will be present. In 
 endostitis terminating in abscess there will be a great aggravation of local pain, with con- 
 stitutional disturbance, and often rigors ; and when oedema of the soft parts over the 
 bone and external evidence of inflammation appear, the absce.ss is making its way exter- 
 nally through the periosteum. (Vide "Abscess in Bone.") 
 
 In necrosis of a long bone the result of periostitis and endostitis by extension the 
 hope of a new bone being formed is forlorn, as the periosteum — the chief bone-forming 
 membrane — has been destroyed, while in the necrosis of endo.stitis there is every hope 
 of a complete restoration of the bone through its perio.steal covering taking place on the 
 removal of the dead portion or sequestrum. 
 
 In necrosis of the skull, which is always periosteal, no new bone is formed, as the 
 perio.steum is destroj'ed. When following an injury to the skull, it is preceded by "the 
 puffy tumor of Pott." In .syphilis it follows a suppurating node. 
 
 In a rare, if not unique, preparation (Guy's Museum) of necrosis after amputation, 
 taken from a patient of my own, the end of the divided femur died, and at a later period 
 the periosteal sheath of new bone that formed around it also died, one sequestrum being 
 found within the other on their withdrawal from the stump. 
 
 Treatment. — In chrouic periostitis, when suppuration does not take place, fomenta- 
 tions, with the elevation of the limb, sedatives to allay pain, and the internal use of the 
 iodide or bromide of potassium, with or without tonics, according to the special require- 
 ments of the patient, are the most efficient means. In still more chronic cases the use 
 of a blister or the repeated application of the compound tincture of iodine is of value. 
 If rheumatism seem to influence the morbid action, colchicum has a beneficial tendency'. 
 When nocturnal pain is great, be.sides the internal administration of opium or other 
 sedatives, the external application of belladonna certainly gives relief. When pain is 
 severe and unrelieved by such treatment, a subcutaneous section of the periosteum with 
 a tenotomy knife is advisable. When suppuration threatens, the warmth of a poultice or 
 hot fomentation, with or without the application of leeches, may sometimes arrest it ; a 
 blister at times seems to check its progress. When pus has formed, it is wi.se, as a rule, 
 to let it out, but the surgeon should be in no hurry to do this unless the pain is great and 
 the abscess has a disposition to spread, as pus may be reabsorbed, and opening a perio.steal 
 abscess renders bone exfoliation more probable. 
 
 Chronic ostitis is an affection most troublesome to treat with any effect, and the same 
 means that have been recommended for periostitis may be tried in this. In a general way, 
 however, they do little more than give relief and have but slight effect on the progress of 
 the disease, it being far too common for a bone in a state of chronic inflammation to become 
 necrosed. When treated early, however, success is not unfrequent. When the disease is 
 steadily progressing and remedies appear to have no influence on its progress, the operation 
 of drilling the bone in one or more points, according to the extent of the disease, is an ope- 
 ration to be recommended; when this fails, that of trephining may be employed; for if 
 taking away a piece of bone or drilling it does not arrest the disease — which it undoubt- 
 edly often does — it at any rate gives relief to local pain. Pain in endostitis or periostitis 
 is due to tension caused by pent-up inflammatory effusion, whether fibrinous, purulent, or 
 serous, and relief can be afforded only by its removal. When a new growth, cystic or 
 otherwise, occupies the centre of a bone, a like pain is, however, experienced. 
 
SECROSIS. 057 
 
 NECROSIS 
 
 moans •■ tin- (loath of hono," and it is as a riilo the result of an acute periostitis or endoa- 
 titis. tlu- elironio action being shown in the process of exfoliation — /. «., in tlie separation of 
 the (U-ad from the living hone; for in this process a considerahle time is often expended, 
 no dcHiiite period having been hitherto recognized, as the rate of j»rogress differs in every 
 case. It niav Ix- of the sliaft of a hone or of an epiphysis; it may h»* of the shell or 
 Compact tissue, of the inside or cancellous tissue, or of both comhined. It may occur 
 idiopathically without known cause or as the result of fever, injury from sj»rain. concns- 
 sioii, contusion, fracture, or gunshot wound. I have alrea<ly related a case in which local 
 necrosis of the articular extremity of the tihia took place in six weeks, and it is well 
 known that jdialaiiges necrose and exloliate in five or six ; in fact, in acute necrosis, a 
 month or six weeks is full time for hone to die and he thrown off. This process is, how- 
 ever, at times very chronic. In the necrosis of the lower jaw from jihosphoriis the .same 
 truth is exemplified. 
 
 The process of exfoliation is a very beautiful one. and is the same in bone as in the 
 soft parts, only slower. 
 
 •• When a j»ortion of bone is to die," writes Holmes in an admirable article in his 
 Si/atnn (vol. ii. Hd ed. p. 294), "the first phenomenon is the cessation of circulation in it. 
 This leaves it hard, white, and sonorous when struck. It does not bleed when exposed 
 or cut into, and is insensible. Occasionally, when the dead heme is exposed to the air 
 and acted on by the presence of putrid pus. its c<»lor becomes nearly or quite black; large 
 surfaces of hard black necrosed bone are s(tmetimes left exposed by the sloughing of the 
 skin over the tibia. The dead bone at first retains its connection to the bone around, as 
 well as to the periosteum or whatever part of the nutrient membrane may belong to it ; 
 but the presence of a dead part is never long tolerated by the living tissues, and accord- 
 ingly the proccs.ses which are to eliminate it soon become perceptible in both these struc- 
 tures. The perio.steum or medullary membrane, as the ca.se may be, separates from the 
 dead bone and becomes inflamed ; a quantity of ossific deposit (more or less, according to 
 circumstances^ is poured out between it and the dead bone, and this deposit .soon becomes 
 converted into new bone, forming a .sheath over the dead portion, by which the latter is 
 enclosed, or incnginated^ as the technical term is. The dead part is now called a seques- 
 trum — a name only properly applied to it when loose and invaginated. though often incor- 
 rectly used of any piece of dead bone. While this sheath is being formed from the mem- 
 brane coating the dead bone changes are going on in the living bone to which it was 
 attached. When the latter has been previously diseased — /. e.. when the necrosis has 
 been of inflammatory origin — the inflammatory deposit which surrounds the sequestrum 
 softens, pus is formed, and a groove of ulceration is produced at the expense of the circle 
 of inflamed bone which forms the margin of the sequestrum. If the surrounding bone 
 has been previously healthy, the sequestrum acts as an irritant upon it, setting up first 
 inflamnuition and thickening to a variable distance, and then ulceration. Thus a groove 
 is traced round tke sequestrum, and the formation of the groove is accompanied by sup- 
 puration. • the pus containing much earthy matter from the disintegrated tissue, B. B. 
 Cooper stating two and a half per cent, of phosphate of lime.' The pus formed in the 
 neighborhood of the dead parts makes its way to the nearest surface, and in so doing 
 interrupts the formation of the periosteal sheath, leaving sinuses or chacse passing through 
 this sheath from the sequestrum to the surface of the body, or sometimes into a neigh- 
 boring joint or serous cavity. The presence of such sinuses leading through the shell of 
 bone to hard, smooth, sonorous bone at the bottom of the cavity is the distinguishing 
 mark of necrosis" (Fig. 651). 
 
 Where the periosteum has been destroyed, no investing sheath of bone will exist to 
 interfere with the separation and casting off of the sequestrum (Fig. (!52 ) : where it is 
 nearly perfect, the shell of new bone will be complete (Fig. 05U). Under these circum- 
 stances the casing thickens and Vjecomes den.se. The amount of thickening around the 
 se«|uestrum depends mueh upon the extent of new bone poured out by the periosteum 
 and the duration of the process: its density also turns upon the length of time the seques- 
 trum has been invaginated and the character of the inflammation. The bony shell in its 
 early condition is soft and readily cut, broken down, or peeled off; in its later stages it 
 becomes almost as hard as ivory and is most difiicult to cut. To reach the .sequestrum 
 in the thigh I have cut through a bony sheath upward of an inch in thickness. 
 
 The whole .shaft or any portion of a long bone may become necrosed, the epiphyses 
 often saving the joints (Fig. 652). but. as a rule, some portion of the shaft remains 
 
958 DISEASES OF THE BONES. 
 
 attached to one or other of the epiphyses. Occasionally the epiphyses themselves are 
 the seat of necrosis. In the tarsal bones, during infant life, the ossific centre of the 
 bones may die and exfoliate. There is also good reason to believe that necrosis of the 
 shaft of a bone often originates after a sprain from inflammation started by the injury in 
 the epiphysial cartilage connecting it with the epiphysis. The subperiosteal sheath is 
 never seen in necrosis of the skull or in short cancellous bones. 
 
 When the cloaca? of the bone case are large and fortunately placed toward the end 
 of the sequestrum, natural efforts may be sufficient of themselves to get uid of the foreign 
 
 body, the granulations filling the cavity gradu- 
 FiG. 657. ally pressing upon the dead bone and mechan- 
 
 ically extruding it from its bed. In this way 
 large masses of bone are sometimes discharged 
 by natural processes. After amputation this 
 result is frequently seen. Some years ago I 
 
 Upper Half of the Shaft of the Humerus thrown off saW witll Mr. Cock and Dr. Iliff of Kenuincirton 
 at its .Tuuetion with the t pper Epiphysis bv Katu- ■ i-i.i , n ^ too 
 
 rai Processes. (Prep. iiu4'>'.) ' a case in wliich the upper part of the shaft of 
 
 the humerus, which had separated at its upper 
 epiphysis, was gradually pressed out from below through the deltoid muscle and pro- 
 jected outside the acromion process for about an inch ; Mr. Cock had only to complete 
 the process which nature had so well commenced and draw out the bone, which was four 
 inches long (Fig. 057). 
 
 Every surgeon is familiar with a somewhat similar act in other cases where large 
 pieces of bone, and far more frequently small ones, are sometimes discharged by natural 
 processes, but such succe.s.sful natural efforts are rare in comparison with the failures ; 
 surgical art is demanded, as a rule, to assist in a cure. 
 
 When the dead bone has been .shed and the sequestrum extruded by natural efforts 
 or removed by surgical .skill, the bone granulates, and thus heals. When this process 
 takes place upon its surface, the steps are very visible ; and when the sequestrum has 
 been removed from a cavity, the same process goes on, but with it the gradual contrac- 
 tion of the periosteal shell of new bone that surrounds the se(iuestrum. A bone in this 
 way is re-formed and repaired. 
 
 Treatment. — When the presence of dead bone has been made out, its removal is the 
 only sound practice, since the longer it is left in its cavity, the thicker and denser will 
 become the periosteal bony sheath ; consequently, the probabilities of a natural cure are 
 lessened and the difficulties of a surgical operation greatly increased. The sequestrum, 
 however, cannot be taken away until it has been thrown off or loosened from the living 
 tissues, although as soon as this result has been effected the sooner the operation for its 
 removal is performed, the better. To interfere too soon before this process has been 
 completed is sometimes injurious and always futile ; to wait too long is simply to add to 
 the difficulties of the case and to postpone recovery. Bones that are not loose may, 
 however, often be detached by a good twist with a pair of forceps or raised by an 
 elevator. 
 
 When the dead bone is found to be loose by means of a probe, by being made to move 
 in its sheath, there should be no hesitation on the part of the surgeon as to interfering, 
 though when this movement cannot be made out the same treatment may be justifiable, 
 as the sequestrum may be so tightly impacted or shut in by granulations as to be 
 immovable, though still separated. Under these circumstances the history of the case, 
 and more particularly the duration of the disease, will be of great help as a guide ; for if 
 many months have passed since the inflammation that killed the bone set in, the proba- 
 bilities of the sequestrum being loose are gi-eat. as most sequestra are shed in four, five, 
 to ten months. I have seen a sequestrum in acute disease thrown off in six weeks, and 
 have removed a large portion of the shaft of the tibia three months after the first onset 
 of the symptoms, while, on the other hand, the dead bone may be found fixed at a far 
 more distant date than that named. All know that a necrosed phalanx is generally loose 
 and ready for removal at the end of five weeks, and in most cases the surgeon is justified 
 in performing the operation for necrosis (sequestrotomy) within the year. English sur- 
 geons, as a rule, are disposed to wait till the evidence of the sequestrum being quite loose 
 is clearly marked, whilst many continental surgeons, and particularly the German, excise 
 diseased bone within three months of the first manifestation of disease by what is called 
 a subperiosteal operation — that is, the peeling off of the periosteum and the resection of 
 the shaft of inflamed, dying, or dead bone. But in doing this, as nature has not yet indi- 
 cated the limit to the disease or separated the dead from the living bone, much good bone 
 
Ni-ynosrs. 
 
 909 
 
 must of m'cossity hv often rcinovcd with the diseased or iiiucli of the di>case<l liorie h*fl 
 liehiiid, hoth of whieh are iiii(h'sira))h' ohje<'ts. In Kiijilisii jiraetice tlie cure is often too 
 lonj;; |>ostpoiied. and the ditVieultics (»f the o|H'ration are iiu*reasf<l. In the coiititieiitul 
 more may l>e done l»y operative interference than is needed or less than is required, tlie 
 new formation of Ixme by the periosteum at the same time being necessarily interfered 
 witli. 
 
 The best practice, ])robably, is to be found between the two. ami that is sur<rical 
 interference about three to si.\ months after the first appearance of symptoms — in acute 
 disease and in small and narrow bones early, but in ehronie disease and in lartre and thick 
 bone- late, iuterlerenee. 
 
 The Operation of Sequestrotomy. — There is no (.peration in surgery more 
 satisfactory than this, as it is usually unattended with danger and followed by eompleti* 
 success. In many ca.ses it is simjile, while in others it is complicated, the ingenuity of 
 the surgeon being often ta.xed to devise nieans to carry out the oljject in view — viz.. the 
 removal of the se<|uestrum. Taking as a tyj)e of the affection the tibia in which the 
 whole shaft or diajdiysis is the seat of niisdiief. many cloacjc or fistuhe leading down to 
 the dead bone through the ])eriosteal bony case will probably be present, as is .shown in 
 Fig. t!51 ; and with a jirobe introduced through an opening at one end and a .second probe 
 at the other end the .surgeon may make his incision between the two down to the bone — 
 that is, down to the new case of bone that envelops the old ; and, having done this, he may 
 peel back the periosteum with a raspatory or periosteal retractor, cut tlirough the new 
 bone that prevents the dead from being seized, by means of cutting jjliers or chisel, and 
 thus expo.se tlie necrosed shaft. The dead piece may then be seized by a pair of seques- 
 trum f(n-cej)s, and, where practicable, withdrawn, f^hould it be too long to extract througli 
 the wound, or should the opening in the bony case correspond to its centre, the seques- 
 trum may be divided with a pair of cutting forceps and its two halves separately removed. 
 At times a good elevator is of u.se to raise the sequestrum from its bed or to pry it from 
 its attachment. Occasionally a good deal of the new casing of bone requires removal 
 before the surgeon can get at the dead portion, and in the femur, where the whole shaft 
 is necro.sed, the upper part being larger than the lower, it may be necessary to chisel off' 
 or remove nearly the whole surface of the new shell of bone to admit of the removal of 
 the sequestrum, it being impossible to withdraw through the lower orifice a piece of bone 
 of larger diameter. In one case the simple enlargement of one of the cloacje may be suf- 
 
 Fio. 658. 
 
 Instriimeuts L'sed in Sequestrotomy. 
 
 ficient to enable the surgeon to seize and remove the bone, while in another it is neces- 
 sary to lay two or more cloacfe into one. The operation should be done with as little 
 interference with the soft parts and bony .sheath as possible. The object having been 
 obtained, the parts have only to be kept clean, raised, and left alone to fill up and heal, 
 
960 
 
 DISEASES OF THE BONES. 
 
 Fig. 659. 
 
 when a good recovery will gciierally follow. The iiif^tnuiieiits employed for seques- 
 trotomy are illustrated in Fig. 058. In all cases Esmarch's elastic tourni(|uet should be 
 employed to prevent hemorrhage. 
 
 When the whole shaft of a bone has been removed in early life, some shortening of 
 tlie new bone or arrest of growth may be looked for, and in the case Fig. G59 such a 
 result took place. The drawing was taken from a young woman act. 25, 
 from whom, at the age of 11, I removed the whole shaft of the tibia. The 
 bowing of the limb was due to the bending of the fibula, which had grown 
 naturally and bent to adapt itself to the shortened tibia. 
 
 When the sequestrum cannot be raised from its bed, it had better be left 
 alone, the opening made not being lost, as through it the sequestrum may 
 subsequently be taken away or expelled naturally. 
 
 Dead bone the result of periosteal disease that is not covered in by new 
 bone regularly exfoliates and rarely requires more than its simple removal 
 by forceps, the soft parts covering it being divided ; in this way large por- 
 tions of the skull may be removed. I have taken away nearly half the 
 frontal bone in a child, and also in an adult after syphilitic periostitis, I 
 have removed large portions of all the cranial bones forming the vault. 
 In one case large portions of the parietal, occipital, and frontal bones 
 were removed. 
 
 When, after necrosis of a bone, the se((uestrum presses upon an artery, 
 
 fatal hemorrhage may ensue. Thus, Poland has recorded (Giri/>> Ilof^p. 
 
 Rep.) three cases where such a result took place in necrosis of the femur, 
 
 '^"'',p,"!^™f *"'* the popliteal artery in each having been wounded. Holmes has also 
 
 removal of Dead recorded a case where a fatal hemorrhage from the lingual artery followed 
 
 Shaft ^Vmrteen (jiggj^gg gf ^he jaw, and another in which bleeding from the aorta occurred 
 
 in caries of the spine. A preparation in the Guy's Museum (1243'^°) also 
 
 shows a piece of necrosed tibia that perforated the anterior tibial artery and set up 
 
 hemorrhage, necessitating the application of a ligature to the femoral artery. 
 
 When necrosis occurs in a joint, profuse suppuration and disorganization must ensue. 
 Where this does not prove fatal and repair goes on, recovery may be prevented by the 
 presence of diseased bone ; and when this can be detected, its removal is the best prac- 
 tice. I have done this in the knee in three cases, and in the hip-, ankle-, shoulder-, and 
 elbow-joints, with good result, having in each one removed large pieces of dead bone 
 through sufficiently large incision (Laiicef, Feb. 6, 1875). 
 
 Such cases as these must be looked upon as cases of necrosis, the joint having lost 
 its special features by previous disease. 
 
 Necrosis of the carpal and tarsal bones is a common affection, for these bones die like 
 the flat bones, no new sheath of bone preventing their exfoliation or removal. They may 
 be treated freely, such incisions being made as will allow of their removal. The os calcis 
 is the bone most commonly affected, and I have removed a large portion of it on many 
 occasions with complete success. The epiphysis of the heel is not rarely affected. The 
 scaphoid is sometimes involved, even at a very early period. The cuneiform and cuboid, 
 separately or together, are also found diseased. Not long ago I removed from a boy's 
 foot by two incisions the whole row of these bones, and an excellent foot was left — so 
 good, indeed, that it was difficult to believe that so much bone had been taken away 
 (Fig. (518). The same may be said of the carpal bones. Indeed, in these cases true con- 
 servative surgery is of great value. The removal of dead bone, however extensive, is a 
 very safe operation, and followed by results which are often startling by their success. 
 There is no limit to the removal of necrosed bone, wherever found, or to the amount of 
 natural repair. To amputate a limb, foot, or hand for necrosed bone until the surgeon 
 has proved that the removal of the- diseased partis impossible or the simple removal 
 proved unsucces.sful is scarcely a justifiable proceeding. 
 
 To gouge away bone that is inflamed and not dead or to excise inflamed bones that 
 may undergo repair is a proceeding which is practically bad and scientifically unrea- 
 sonable ; for all bone that is not dead is reparable, and to interfere with it mechanically 
 is bad surgery. 
 
 The great success of the operation for necrosis Tsequestrotomy) is unquestionably due 
 to the introduction of anaesthetics. Prior to their introduction the operation was dif- 
 ficult and dangerous ; indeed, it was rarely performed, amputation having been too often 
 substituted. 
 
CARIES. 961 
 
 CARIES. 
 
 N"> W(inl in Kurircry lias been used with L'lcattT carelessness and with a proater 
 variety nt" meanings than " carios, " nor is thiTc one that now ronveys a les« dfrinitc 
 idea. In this section it will lie apjilicd to an nnhculthy inflammation of bone, chiefly of 
 cancellous hone. When snjierticial. it appears as ulceration or molecuhir dt-ath of hone; 
 when deeply jdaced or central, it is often associated with necrosis or suppuration and may 
 or mav not he due to syphilis or struma. It is jHif/iolnt/icn/li/ remediable an<l rejiarable, 
 ami whenever fiiund i.s mixeil up with reparativi' jUftcesses. In jtatietits of feeble power 
 and some constitutional cachc.\ia. or where the disease is very extensive, it may. however. 
 cllniciilli/ he incurable. an<l thus re((uire surjrical interference. Nevertheles.-i. in its natun* 
 it is inflammatory, and should be looked upon as a curable afl\>ction depemling more upon 
 constitutional than upon local causes. In this respect it differs from necrosis. 
 
 A bone i.s said to be curi/nis on its sur/nci- when, Vjeing expo.sed,it presents an irregular 
 and worm-eaten appearance, is suppurating, and the .sore throws off" a .serous, more or less 
 (tft'ensive purulent discharge which contains excess of phosphate of lime mixed with 
 small fragments of bone tissue. This affection is generally as.^ociated with an ulcer or 
 open sore of the skin over the parts and more or less thickening of the perio.steum and 
 bone around and beneath tlie disea.sed ])ortion. It is always vascular and readily bleeds 
 on being touched. It is occasionally painful. At times the V»one is soft and yields to tHe 
 pressure (»f the probe ; in other cases it is hard. When it attacks the articular surface 
 of a bone, it often forms pits with sharp, well-defined edges ; and under these circum- 
 stances has been looked upon as scrofulous, but with what amount of truth it is difficult 
 to say. When it is a.ssociated with syphilis, it follows the suppuration of a node. At 
 times it is complicated with the tubercular thickening of the surface of the bone itself or 
 with what Paget has de.scril>ed as annular ulcers, in which a spot of ulceration is .seen 
 which goes on to form a circular trench round a worm-eaten surface. This trench 
 increases in width and depth and at last loo.sens a sequestrum, which separates and leaves 
 a circular depression. In bones of the skull this ulcer may involve one or both tables. 
 Thlx ulcer may subsequently heal, leaving a permanent depression. Oirits. in fact, is 
 inflammation and ulceration of ])one ; nrcro^o'a in its death en nmsse. 
 
 A bone carious in its interior is vascular, although softened sometimes almost to rot- 
 tenness, and ea.sily breaks down ; it discharges often a thin, sanguineous, fetid, .semi-puru- 
 lent fluid which contains fragments and elements of bone ; absces-ses which generally 
 communicate externally through the soft parts often coexist in and about the bone and 
 are occasionally combined with necro.sis. In the spine, where it is the more commonly 
 met with, it is often unassociated with any^ external suppuration or discharge, though the 
 bone, with the intervertebral substance, softens down and undergoes extensive molecular 
 death, much loss of bone taking place, the particles being apparently reabsorbed and car- 
 ried away, and complete recovery following without any external discharge. Around the 
 inflamed or carious bone the cancellous tissue is generally infiltrated with more or less 
 organizable inflammatory lymph, the nature of which depends much upon the character 
 of the inflammation. In feeble and strumous subjects the fluid will be of a serous, oily, 
 and non-plastic kind (Black On Tubt-rcnlous Bon' . Edinburgh. 1S59). the cancellous bone 
 becoming more cellular and lighter. In more healthy types the eff"u.sion will be plastic 
 and organizable, the bone becoming more compact. In one case no consolidation of the 
 surroumling bone will be present, while in another condensation of the bone to a greater 
 or less extent will be found. 
 
 Under all circumstances the nature of the inflammatory action turns much upon the 
 constitutional power of the patient, the disease tending in strumous and feeble subjects 
 to widen, but not to repair, while in more healthy subjects it inclines to a local action and 
 recovery. 
 
 In rare examples genuine tubercle may coexist with the inflammation. 
 
 Treatment. — Looking upon caries as an inflammatory affection, and consequently a.s 
 curable, it is to be treated on somewhat similar principles as inflammation of other parts. 
 When the general powers of the patient are feeble, they ought to be stimulated by tonic 
 medicine and regimen : local pain is to be soothed and torpid action stimulated, but all 
 mechanical and surgical interference should be avoided, except for the removal of dead 
 bone. In superficial caries or ulceration, when rest, elevation, soothing, or possibly stimu- 
 lating, applications, with tonics, fail to induce a healthy reparative action, local stimulants 
 are sometimes of use, and the local application of such acids as the acetic, nitric, or sul- 
 phuric, strong or diluted, has often a beneficial action. Mr. Le Gros-Clark strongly recom- 
 61 
 
962 
 
 DISEASES OF THE BONES. 
 
 mends acetic acid as the best solvent of the inorganic constituents. He uses as a dress- 
 ing one part of Beaufoy's No. 11 acid to five parts of water. George Pollock speaks 
 highly of the value of sulphuric acid, at first diluted with equal parts of water, and sub- 
 sequently pure. ^;he acid de.stroying the diseased bone to which it is applied and setting 
 up a more healthy action in the parts beneath, thus hastening recovery. Boinet advocates 
 the use of iodine, at first diluted, and then strong; others recommend phosphoric acid. 
 Dr. Fitzpatrick applies the Vienna paste or potassa cum calce to the surface of the 
 inflamed bone, as well as to its deeper parts after puncturing them. The actual or galvanic 
 cautery has also been employed, and in superficial caries it seems to be valuable. In deep- 
 seated or endosteal caries some speak highly of operative interference, either by the goug- 
 ing out of the diseased tissue or by the excision of the inflamed or carious bone ; but I 
 allude to this treatment only to condemn it. since I believe it to be both unnecessary and 
 injurious. It is unnecessary, as in the majority of cases recovery can be secured without it ; 
 it is injurious, since gouging, as a rule, adds to the irritation, and thus tends to the spread 
 of the disease, and often excites more general inflammation in the bone or endosteum. 
 
 Excision of the di-seased bone is not an operation that can be highl}- recommended, 
 yet it may be done, doubtless, with .success, as in the tarsus ; and many an inflamed or 
 carious os calcis has been successfully excised. There is however, a strong doubt as to 
 the necessity of the operation. When the bone dies, the necrosed bone may, and should, 
 be removed ; but in all other conditions it is reparable under constitutional treatment and 
 local applications. Surgeons who interfere surgically with carious bones usually jirefer 
 excision to any partial operation. Sui^erficial or perio.steal caries may be regarded and 
 treated as an indolent ulcer in other parts, the repair being more chronic in bones than in 
 soft tissues ; deep-seated caries or inflammation may be also considered much in the same 
 light. When syphilis complicates the case, iodine in full doses, in one of its forms, com- 
 bined with any tonic that may appear to be needed, and as a local application, is of 
 great use. 
 
 TUMORS OF BONE. 
 
 Tumors of bone vary but little in their pathology from tumors of other parts, and 
 whatever difiierences exist arise from the peculiarity of the tissue in or around which they 
 grow. Tumors of bone, as of .soft parts, partake of the nature of the tissue in which 
 they are developed ; thus, a tumor that in a fibrous organ would be more or less fibrous 
 when originating in or upon a bone is mixed with bone, and a carcinomatous tumor of soft 
 parts becomes a malignant osteoid cancer of a bone. In addition to these, there are 
 special tumors known as the myeloid and the cartilaginous. 
 
 Excluding, therefore, enlargements of bone due to inflammation, there are bony out- 
 growths or exostoses, cartitaginous and mydo'ul tumors, all being, as a rule, of an innocent 
 nature ; there are the osfeo-sarcomatous tumors, or fibrous tumors of bone, including 
 those that have a periosteal as well as an osteal origin, the fibrous and osseous elements 
 
 Fig. 660. 
 
 ^^ 
 
 .i^fe*'-^^ 
 
 ^. \ 
 
 
 Tumor as I>isfhart;til fr^'in ( a\ ity in Fig. 
 660. (Weight nearly l.i oz. ; circumfer- 
 ence 11 bv 9 inches." Mr. Hilton's case. 
 Prep. Guv's Mus. 1666«.) 
 
 predominating in various degrees ; and, lastly, there are the malignant tumors of honr^ 
 whether of the soft or the hard kind, osseous matter being mixed up largely with both, 
 the disease acquiring the name " osteoid cancer" when the bony elements predominate. 
 These tumors grow from the periosteum as well as from the bone. 
 
 Exostoses may grow from almost every bone ; from the cranium inside and out, 
 as well as from the bones of the trunk and extremities. Those of the cranium are usually 
 
TUMOIiS OF BOSK. 
 
 Fig. 002. 
 
 very cU-iisf and ol" ivory-Iikc hanliu-.x."* ; iiitlet'cl, they are oftt'ii called " ivory exostoses," 
 aiitr suiiutiiiies are .sii liaril that they eaiiiuit be ivinoved. They may have hroad buses, 
 but at times are pediiiieiilated, and in sin^^ular examples they occur as loose growths; 
 these latter havi- t^cnerally occurred in tin- frontal sinus and should be described as nton- 
 tosts. Mr. Hilton has recorded an interesting: ease {(Jnij'x liip., vol i.) in which .such a 
 bony tumor, of twenty-three years' staiidiii-: (Fig. tiUlj, fell out of a lar-.'e cavity in the 
 sujterinr maxillary boiie (Fiji. (»(>()). The man in IHC.'), thirty years after the operation, 
 was well, althoULtii distitrured by the hole in whi<'li the tiinior had rested ; and in a former 
 paj;e (')!•"> i I have recorded a ease of the .xamc afl'ection and ti<;ured it (Kigs. :541, VA'l). 
 These bony growths are nuire common about the orbit and air cells of the liead than else- 
 where. True ivory exostoses of these parts do, however, occur, and at times attain a 
 large size. Hirkett has related {Onyx Rrp.. IHIIH) such a case of Dr. V. Hruns, in which 
 an ivory tumor of seventy-four years' existence, weighing ten pounds, grew from I lie 
 oecipitai bone td" a man :et. SO. Exostcses fntm the jaws — or, rather, alveoli — are often 
 calleil •■ ejiulis." 
 
 Exostosis on the extremities are not uncommon, and arc apt to spring from the point 
 of junction of the shaft with the epiphysis (Virchow considering this as the usual seat) 
 ami at the attachment of mu.scles. They are mostly 
 outgrowths of bone capped with cartilage, by which 
 they grow (Kig. ••<»-) ; exostoses, however, of long 
 standing have an osseous shell. They have at times 
 broad bases, but more frequently narrow peduncles. 
 They are often curved or crested, assuming odd shapes, 
 and may grow to a large size. In exceptional instances 
 they may die or necrose without any known cau.se, and 
 as a result of accident they may be broken from their 
 attachment. I have seen this in an outgrowth from the 
 femur of a girl ret. 12 who received a kick from a 
 donkey, and a second case, in a patient of 3Ir. Birkett, 
 with an exostosis of the tibia. When bi'oken oif from 
 their bony attachments, they may in exceptional in- 
 stances wither, but, as a rule, they will again adhere. In a patient of Mr. Maunder, in 
 whom an exostosis of the femur was subcutaneously separated from the bone, adhesion 
 took place, although at a better angle. At times exostoses are multiple. In a girl aet. 
 16 I found exostoses of different sizes on both 
 tibiiv and both hands, one humerus, one radius, 
 and ilium, and in two patients, nine and six- 
 teen years of age respectively, five bones were 
 80 affected. 
 
 Some exostoses have & periosteal origin, the 
 result of organized inflammatory products, when 
 they are usually diffused. Fig. 663 .shows this 
 well and was taken from a patient of my father, the late Mr. T. E. Bryant. 
 
 Ungual exostoses deserve a special notice, since they are even now too often 
 mistaken for what is called "ingrowing toe-nail." They are generally found on the 
 distal phalanx of the great toe (Fig. 64, page 177), but Prep. 1287, Guy's Museum, 
 shows a specimen from the little toe. and I have had under care two cases in which an 
 exo.stosis grew from the ungual phalanx of the thumb, and one in which it was attached 
 to the index finger. Liston in 1825 first drew attention to the nature of these cases. 
 
 The osteophytes and the outgrowths of osteo-arthritis are not classed amongst the 
 exostoses. 
 
 Treatment. — When surgical interference is called for, nothing but the removal of 
 these growths can be entertained, their bases being well levelled down to the bone, or 
 even 'scooped out. When, however, they are placed near joints, this practice should be 
 well considered. In a case in which an exostosis projected from the inner condyle of the 
 knee I divided its base subcutaneously with a chisel and pres.sed it back into the popliteal 
 space, where it remained without giving trouble. In cranial exostosis this operation may 
 be not only difficult, but impossible ; still, the attempt, wherever it can. should be made, 
 for many successful attempts have ended in procuring the death of the exostosis and its 
 subsequent exfoliation. In such a ca.se. treated by Mr. Cock, where the removal of the 
 whole from the orbit was impossible from its hardness, a part was removed, and what 
 remained subsequently died and sloughed out. 
 
 Exostosis of the Femur. 
 
 Fig. 6G.3. 
 
 Periosteal Exostosis. (Prep. \\\V'\ Guy's Hosp. Mus.) 
 
964 
 
 DISEASES OF THE BONES. 
 
 Intracranial exostoses are rarely made out during life, and are at times associated with 
 epilepsy. 
 
 The following analysis of 1 20 cases of exostoses will show the seat of these growths. 
 45 were tabulated by my colleague, Mr. Birkett, in Guys Reports, and the remainder are 
 from my private notes. Cases of epulis are excluded. 
 
 Frontal bone 3 
 
 Upper jaw 1 
 
 Lower jaw 3 
 
 Bodies of cervical vertebrae 1 
 
 Sacrum 1 
 
 Kibs 3 
 
 Ilium 1 
 
 Scapula 10 
 
 Clavicle 3 
 
 Humerus lo 
 
 Ulna 1 
 
 Radius 2 
 
 Fingers 5 
 
 Ungual phalanx of thnmb . 2 
 
 Femur 18 
 
 Tibia . . .• 18 
 
 Fibula 4 
 
 Patella 1 
 
 Tarsal bone 1 
 
 Metatarsal 1 
 
 Ungual phalanx of great 
 
 toe .25 
 
 Sole of foot 1 
 
 Three of the cases tabulated were examples of multiple exostosis ; when the radius 
 was affected, it was in common with other bones. 
 
 Enchondromatous or cartilaginous tumors of bone are most commonly met with 
 in the phalanges and metacarpal bones. They are, however, seen surrounding bones hav- 
 ing a periosteal origin or growing from the bones of the upper jaw. A remarkable 
 instance of this has been recorded in Chapter XIII. and figured in Fig. 241. It would 
 appear that such cartilaginous tumors are more prone to attack the scapula than any 
 other bones, and I have seen several such cases. Mr. Birkett has recorded and figured a 
 fine specimen in the Guys Reports (1866). 
 
 The bones of the pelvis are at times the seat of such growths. I have the records of 
 a remarkable instance in which the pelvic surface of the ilium was the seat of the affec- 
 tion, and of another in which a middle-aged woman had an enormous cartilaginous out- 
 growth the size of a cocoanut springing from the pelvis and occupying the inner side of 
 the right thigh, beneath the adductor muscles. The case from which Fig. 664 was taken 
 
 FiG. 664. 
 
 Fig. 665. 
 
 Enchondroma of Pelvis. 
 
 Enchonflroiuatous Tumors. (From a 
 model in the Guy's Museum.) 
 
 occurred in the practice of my friend Mr. Knaggs of Huddersfield. It was of twenty 
 years' growth. Cartilaginous tumors of bone usually originate in it, and are found in 
 young subjects when the bone is growing. They are generally covered by a sliell of the 
 bone in which they originate ; the shell is at times expanded in all directions, but more 
 usually in one. In Fig. 665, taken from a model in Guy's Museum, this mode of growth 
 is seen. In Fig. 22 the section of such a growth is well illustrated. 
 
 These cases are occasionally multiple, congenital, and hereditary. Thus, in 1881 a 
 man fet. 53 came under my care for a fracture of his thigh. He had at least a dozen 
 outgrowths of bone or cartilage (ossifying enchondromata) upon his body, connected with 
 
Ti'Miijis or I to si:. 
 
 965 
 
 the shafts of his \^m\z honos. IK- was Ikitii with tht-iii. His fath(!r had three or four 
 /growths of (hf same kind as eon^'eiiital imiiors, and his son was literally eovereil witli 
 them from hirth. some ltein<^ iis hirj;e us <iran^es. My friend Or. Shuttlewortli nl' Lan- 
 caster has piildished a like ease in the lint. .!/»(/. Juitrn. (Deeemher 17, iSSlj. 
 
 (^irtthi<;inous tumors are usually of slow f;rowth and paiidess, with a smooth outline. 
 At times they un(h'r<;o deeay and soften down, diseharj^inj^ a hrown-colored sentus fluid 
 unlike any other tumor, and under such circiimstanees are proiu; to di.sseminate like can- 
 cer. At other times thev ossify antl turn into liony tumors, the " hullious exostosis" 
 bein<; often an ossified eneliondroma. 
 
 TuK.VTMKNT. — Where it can he dune a cartilaginous tumor .should be scooped out of 
 a hone, and in the j)lialan<j:es ami metacarpal hones this practice is usually successful. 
 I^xtreine example^ of the disease demand amjiutation or excision of the afl'ected hone. 
 
 Knchnndrcunatiius tumors are at times recurrent, and in rare examples return a.s 
 malignant tumors in uther jiarts of the hndy. Such ^Towths, havin<r a jieriosteal orifrin, 
 are usually r)«pid in their increase and diffused. True cartilajrinous tumors oi" hone are 
 usually circuuiscrilK'(l, and often multiple. The hones of the hand are at times niiuh 
 involved. 
 
 OsteO-SarCOma i>^ n term of broad signification, and is usually applied to the 
 fibrous tumor of lione in which fibre tissue and bone elements predominate in various 
 degrees. Wilks believes *• that they are altogether comparable to the fibrous tumors of 
 soft parts." They usually have a periosteal origin — ijcriosteid sdrcomn — and even in 
 exaggerated examples the shaft of the affected bone may be clearly traced through the 
 growth. The tumor is usually circumscribed, with a fibrous capsule and divided by 
 fibrous or ossitic rays into different portions; at times the fibrous elenient predominates, 
 at others the osseous. The disease is usually .seen attacking the ends of the shafts of 
 bone, and not the epiphy.ses. All these points are well seen in Fig. GOO. 
 
 Cartilage is often found to be mixed uj) with the fibrous and os.seous elements and in 
 proportion to the amount of bone matter entering into the formation of the tumoi it may 
 
 Fifi. r.nr,. 
 
 Fig. 667. 
 
 Periosteal Osleo->.tii..iiia. .Drawing 20, 
 Guy's IIosp. Mus. Key's case.) 
 
 Fig. 668. 
 
 Appearance of Limb affected 
 witli Osteo-Chondronia. 
 
 
 Osteo-Chondronia of remur. 
 (Drawing &•'.) 
 
 be regarded as innocent or otherwise ; bony periosteal growths are rarely cancerou.'i. 
 When fibrous tissue, and more jiarticularly the softer forms, pred<iminate, the tumor is 
 prone to recur at the same spot or in some other organ, as is the case with cancer. 
 
 Osteo-chondroma is applied to a tumor involving bone and made up of carti- 
 lage and bony elements in variable degrees, the cartilage taking the place of the fibrous 
 tissue of the osteo-sarcomatous tumor. In one case bone will predominate ; in another, 
 cartilage. The disease is usually of slow growth and simple in its nature. In the case 
 of a woman aet. 34, from which Fig. 667 was taken, the disease had cxi.<;ted for three 
 years. Fig. 668 represents the same tumor, taken during life. 
 
 Myeloid tumors of bone are probably innocent, exceptional instances being 
 
966 
 
 DISEASES OF THE BONES. 
 
 ou record in which a return in the part or in internal organs took place. They usually 
 attack also either the epiphyses or the epiphysial ends of the shafts of bones (Fig. G69). 
 
 Fig. 670. 
 
 Fig. CfiO. 
 
 Expansion of Condyles of Femur 
 from Myeloid Tumor. 
 
 Myeloid Tumors Expanding Bone. (Guy's IIosp Mus.) 
 
 I have seen the disease, however, involving the shaft of the radius and upper jaw, and 
 Paget has described it as attacking the breast. It begins commonly in the centre of the 
 bone, which it expands, forming a globular shell of bone — the spina ventosa of the older 
 writers (Fig. 670). The interior of this shell is made up of fibre tissue, or it may be 
 cystic, the cavity being divided by means of fibrous septa into more or less well-marked 
 cystic divisions. The spaces themselves, or loculi, contain the characteristic myeloid 
 material — " an opaque white, intermixed with a semi-transparent gelatinous-looking sub- 
 stance of a clierry-red color'' — and their substance is made up of the characteristic poly- 
 nucleated and irregular myeloid cells. 
 
 When the tumor encroaches on the joint, the cartilage is usually spread out over the 
 tumor, but intact. These tumors were originally mixed up with the cancerous or fibro- 
 plastic of Lebert. They are fouiul, likewise, in the gums as " epulis," and in other parts. 
 In a specimen of myeloid tumor of the upper jaw which I removed from a girl ret. 8 the 
 structure was very dense (^Guys Rep., 1873, 1874, 1877). 
 
 Cancers of bone, as of other parts, show their malignancy in effecting the utter 
 destruction of the bones in which they are developed. They may originate in the peri- 
 osteum or in the bone, but in either case both tissues will be eventually affected. When 
 they originate from the periosteum, the bone may be found in parts running through the 
 mass and with cancerous elements surrounding the shaft (Fig. 672) ; hut when the dis- 
 ease has existed for any period, the same 
 Fig. 671. cancerous elements will be found in the 
 
 shaft itself and destroying it. When the 
 disease begins in the bone, it is usually in 
 the medulla by one or more different cen- 
 tres, which by their increase expand the 
 bone and utterly destroy it (Fig. 671). 
 The bones under these circumstances are 
 very brittle and apt to break on the slight- 
 est force, even by ordinary muscular ac- 
 tion, the fracture probably being the first 
 indication of the presence of the cancer- 
 ous disease. I have known fracture to 
 occur under these circumstances by a patient turning in bed, crossing a street, or walking 
 down stairs. In the majority of eases of cancer of bone, bone elements have little to do 
 with the disease, though in what is called the true osteoid cancer masses of bone of a con- 
 densed kind appear in the medulla, and gradually grow until a large osseous mass of dis- 
 ease is formed. 
 
 In Fig. 673 this form of disease is well .seen, and was taken from a patient of Mr. 
 
 Fracture of the Femur from Muscular Action at the Seat of a 
 Local Cancer in a Man set. '2S. 
 
Tl Molts (iF HOSE. 
 
 1)G7 
 
 A.sliin Key iut. iJtl in whom inasst's ut" ImiK! iiiid ciirtiluj^iiKJUS tuln-rcltiM wt-ii; Iniiml in the 
 luii<;s. |ileuni. uiitl Ivniiiliatic ■;hiii(ls alUM- tli-ath. 
 
 'V\w. piiioHtnil liinii of caiic-or (^Kig. »J7-) ^rows more rapidly tliaii tlie ciulortteal or 
 intorstitiul, very ijuickly assumes a large size, and is not ol'teii aceompanieil hy pain ; the 
 
 Fi(i. 1)72. 
 
 Periosteal Cancer oi \iiv i una. 
 
 swelling is rarely srlobular in its outline, but loses itself both above and below in the sur- 
 rounding parts; and in the integument covering it large full veins, from obstruction to 
 the deep veins, will likewise be seen. It will possess a semi-elastic feel and often yield 
 to the touch an uneijual sensation as to density. Endostial cancer is commonly attended 
 with a dull aching pain due to the expansion of the bone. Its increase is at first slow ; 
 but wlien it has so destroyed the bone as to have reached the periosteum, pain will be 
 lessened, while the increase of the tumor will be more rapid. This form of cancer is more 
 frequently secoiulary than primary. 
 
 rriniarv cancer of bone or periosteum is more common in children than in adults. 
 
 Epithelial cancer niay attack a bone by the extension of the disease from the 
 soft parts, as seen when cancer of the lips spreads to the jaws, and skin cancer may also 
 
 Fig. <)7;;. 
 
 Fig. G74. 
 
 fvrneerOKjs.M',^"'' tn tibia 
 
 \:;fe^:^i 
 
 ( aiiLL-r AuuukiiiL; Xecrotseii TiWia. 
 
 extend downward into a bone of an extremity and cause 
 great destruction. At times a bone that has been the sub- 
 ject of necrosis may become the seat of cancer, and within 
 a short time I had three such cases under care, in two of 
 which the tibia was the seat of the disease, necrosis having 
 existed in both for upward of twenty years, and in the 
 third, although the femur apparently became necrosed 
 twenty-two years before the man came under my observa- 
 tion, the cancer evidently began in the skin over it and 
 extended down the sinuses into the bone. Fig. 675 was 
 taken from the limb of this patient during life ; Fig. 674 
 was taken from the limb after amputation at the knee-joint in another case. In a man I 
 treated years ago the os calcis and the soft parts over it were the seat of the disea.se. and 
 the bone after amputation was found infiltrated with cancerous epithelial elements : and 
 more recently (187'^) I amputated the foot of a woman which had been the seat of cancer 
 for twenty-five years, and of necrosis for ten. For other cases see Lnixet. February 23. 1 884. 
 Diagnosis of Timors of Bone. — In most cases only an approximation to truth can 
 be made. 
 
 A globular tumor situated in the articular end of a bone, and expanding it. but not 
 involving the joint, of slow, steady, and often painless growth in a young subject or 
 adult, is probably myeloid. 
 
 Osteoid (aiicer of Knee-joint. 
 (Prep. Guy's Hosp. Mus., 116)5o.) 
 
968 
 
 DISEASES OF THE BONES. 
 
 A more elongated or ovoid tumor situated in the shaft of a bone of more rapid growth, 
 with full veins in the soft parts covering it, and a semi-elastic, unequal feel, in a young 
 subject, is probably a periosteal cancer. 
 
 A jinu^JihroHs growth of a somewhat globular form, of gradual increase and unequal 
 surface, fibrous in one s})ot, bony in another, in an adult, is probably an osteo-sai'coma, 
 
 Fig. (i 
 
 6c/ie 
 
 I'af-dla 
 
 Cancer of the Skin .Spreading to the Bone. (From Edward Abrahams, set. 42.) 
 
 while a more indurated growth with a botryoidal outline and a similar clinical history is 
 probably an osteo-chondroma. 
 
 Pain, rapid and diffused growth, with unequal density, glandular enlargement, venous 
 obstruction, and wasting, generally indicate cancer. 
 
 Gradual, painless increase, a defined contour, globular, botryoidal, or in ridges, with 
 no venous obstruction, glandular enlargement, or disturbance of the general health, 
 usually indicate a benign tumor. The more globular the outline, the greater the prob- 
 ability of the growth being myeloid ; the older the patient and the more botryoidal the 
 growth, the greater the chance of its being enchondromatous ; the slower the growth, the 
 more local and divided into septa, the greater the chance of its being osteo-sarcoma. 
 
 When a tumor is periosteal, by making firm pressure below the tumor the bone will 
 be made out to be on a lower level than the growth ; when the tumor is endosteal and 
 the bone expanded, on making firm pressure below the surface of the bone the bone will 
 be felt to rise gradually from the unaffected part over the surface of the growth, so as to 
 form a shell for it. 
 
 Treatment. — A tumor of bone can be effectually treated only by excision ; and 
 when it involves the articular end of the bone and encroaches upon a joint, amputation is 
 too often necessary. When the whole bone is involved, as in a cancer, nothing but ampu- 
 tation can be entertained ; and it is usually well to amputate high above the disease. If 
 the tumor is placed in the head of the tibia, an amputation at the knee-joint may be per- 
 formed, or, where this is inexpedient, just above the condyles. If the condyles of the 
 femur are the seat of the disease, the amputation should be at the centre of the shaft, it 
 being justifiable to amputate at the hip-joint only when the disease is too extensive to 
 allow of an amputation through the bone, for the hip-joint operation is most fatal and 
 should be performed only when any less severe measure is impossible. In an evident 
 cancer of the lower half of the femur, where amputation is to be performed, it had better 
 be at the hip-joint, though in doubtful cases the limb may be removed just above the growth. 
 
 In the upper extremity, however, where amputation at any of the joints is, as a rule, 
 successful, it is wise in cancerous disease to remove the Avhole of the aff'ected bone and 
 amputate at the artictilation above. In periosteal cancers the whole bone should always 
 be removed. Amputation for myeloid and simple tumors is generally successful, and a 
 young woman for whom I amputated the thigh for myeloid disease in 1861 was still well 
 seventeen years after the operation. 
 
 If a tumor involve the shaft of a bone or the extremity of its diaphysis, but not the 
 epiphysis, and the growth appears to be local, and probably simple, an attempt should 
 first be made to deal with it locally, to scoop or to turn it out, the more severe measure 
 of excision or amputation being alone had recourse to should the minor fail. In the case 
 of the enchondromatous and fibrous tttmors of bone, the minor measure is usually suc- 
 cessful. In fact, in the treatment of tumors of bone, when the disease can be removed 
 without making any great sacrifice of other parts, the attempt sliould be made. Ampu- 
 tation as a primary measure should be reserved for clearly cancerous cases or diffused 
 growths, or for sucli as involve the articular ends of the bones, and, consequently, the 
 
TiMons or r.osi:. 
 
 9Gli 
 
 joint. Sciino iiiterestin*; cases illustrating' tlic !i(lviiiit;i;.'(' i»l' excising' portions of tlu- long 
 bdiu'S when tlu' scat of niV»'loi<l and otlicr tumors liavc hccn n-conliMl liy Mi-ssrs. Lucus 
 and .Moni< in tlic tenth vulninc ol' tlu- C/iin'raf Sucir/i/s Trniisttcliniis. 
 
 Pulsatile tumors of bone art- fanccrou.-. as a rule, thoiij^'h they niay 1»(; aneur- 
 isinal. t'ant-erous tumors id" the skull are fVe(|uenlly pulsatile, ami in one widl-marked 
 ease I had iintler care some time ajro. in whicdi the frontal hone was the seat of the <lis- 
 ease, this pulsatile condition was its early symptom, the swellin;.' hein^' eomparativdy 
 unnotieed. All jmlsatile hom- tumors have an interstitial ori^^iii ami expand the hone, 
 the new {growth reeeivinj;- its imjiulse from the lar;,;e arteries that supply it. firay ( Mnf.- 
 (^/lir. Trillin., vol. xxxix.) has recorded an example of pulsatiufj^ myeloid. True eases of 
 (istro-iiiinin'sni are rare. Mr. Hickersteth of liiverpool has recorded such a ease, and I 
 had the pleasurt- of exaniinin«i: it carefully with Mr. \V. Adams and rejiorting u[ion it to 
 the l'atholoL:ieal Soei»'ty (vol. xix.). It was undouhtedly a genuine case (»f this disease 
 involving the tihia. Mr. Mapother (DiiUIn Mid. Tnins.. isti."^,) has recorded anrtther. 
 These eases are made up o\' exjianded hone from aneurismal dilatation of the vessels of 
 the hone. 
 
 Tkk.vT.MF.NT. — Pulsatile caiK-erotis tvmiors of hone, like the iioii-piil.-atile, ought to he 
 treated by amputation ; true osteo-aneurisms of a limited size, when they can he made 
 out, should he dt^alt with by local extirpation or by destroying them by means of the 
 actual or galvanic cautery, and when very extensive by amjiutation. l>r. Mapother 
 cured his by the actual cautery, and Mr. Biekersteth by amjiutation. 
 
 Cysts in bone are occasionally met with, and may be serous, sanguineous, or 
 hvdatid. The ibrmer two are most comrnoidy met with in the jaws, and in Chapter 
 XI 11. attention has been directed to them. Whether they ever occur in the long bones 
 is an open ((uestion, though in 1870 I trephined the enormously enlarged and expanded 
 shaft of the tibia of a man aet. 30 for gradually progressive disease of fifteen years' stand- 
 ing, the bone having been the seat of a fixed pain in its centre. I did so under the 
 impression that the ca.<e was one of abscess, but. having perforated a dense shell of bone 
 an inch thick, I came upon a cavity the size of an egg which contained no pus. though it 
 was lined with the soft velvety material usually met with in abscess, and what escaped 
 from it was not to be distinguished from the blood that flowed during the operation. 
 The operation was ({uite successful, and a rapid cure ensued. I believe this case to have 
 been owe of cyst in the bone. 
 
 Hydatids are found in bone, and in Guy's 3Iuseum there is the head of a tiliia con- 
 taininu' a cvst or echinococcus which holds many smaller cysts within it ; ahso another 
 specimen illu.strating the existence of hydatids in the vertebra?. In 1869 I treated with 
 Dr. Freund a case in which a large hydatid escaped from the expanded condyle of the 
 humerus after a puncture in front of the joint. The hydatid had clearly made its way 
 from the bone into the elbow-joint and through this externally ; a good recovery with a 
 stift" joint ensued. 
 
 Hypertrophy and atrophy of bone are pathological realities, although during 
 life it may be a dithciilt. if not an impossible, task to recognize such conditions. Hyper- 
 trophies and chronic inflammatory changes are consequently often mistaken the one for 
 the other, although in the former the enlargement is gradual and painless and in the 
 latter as.sociated with local pain and other evidence of inflammation. In some cases the 
 bone is enlarged and its cancellous structure expanded (porous hyperostosis) : in another 
 it is enlarged, but at the same time more dense (sclerotic hyperostosis). The.se changes 
 are best seen in the calvaria (Fig. OTG). In Prep. 1068"'^ in Guy's Museum the bone is 
 at least double its normal thickness. In rare cases 
 the hypertrophy is clearl}' due to increase of func- 
 tion, as shown in another preparation in Guy's 
 Museum (1000'^), taken from a man who was a 
 paralytic and who had u.sed his arms for progression : 
 here the bones of the u])per extremity are larger than 
 those of the lower. In the majority of ca.ses. how- 
 ever, the sclei'osis of bone is due to inflammation, and 
 in the case which Sir P. Ilewett mentioned in his 
 well-known Coihge Lecture's^ where the mans skull 
 increased so imperceptibly year by year as to be 
 recognized only by the gradual increase in the size 
 of his hat, the disease was traced to an injury. 
 
 This aff"ection is pathologically interesting, though surgically nothing can be done for it. 
 
 Afropliy 
 
 Hypertroihy and Atrophy of the Bone. 
 (From preji. in (jiiy's Museum.) 
 
970 DISEASES OF THE BONES. 
 
 Atrophy is most commonly met with in the shafts of bones that have not been 
 used for many years, as in paralytic subjects and persons who 'have been the subject's of 
 joint disease, in the bones of the aged, and in those that have been injured. The bone 
 may become a mere shell, its cancellous tissue being expanded and its cells filled with a 
 fatty matter. 
 
 When atrophy follows injury, Curling's suggestion (Med.-Chir. Trans., vol. xx.) that 
 the causes may be found in injury to the medullary artery is probably right. This prob- 
 ably happened in the case of a man who came to me with an ununited" fracture of the 
 humerus, in whom I found the bone, on exposing its ends for operation, to be a mere 
 shell and not half its normal thickness. It, however, cannot be the only explanation, as 
 Norris has recorded {American Journ. of Med. Sri., 1842) a remarkable case in which, 
 after a double fracture of the humerus about its centre, the whole bone disappeared, the 
 fore-arm subsequently swinging as a thong, while the arm became shortened six inches ; 
 the bone disappeared •' by the gradual action of the absorbents." 
 
 In these eases spontaneous fracture or fracture from slight mu.scular action is very 
 prone to occur. 
 
 These cases of hypertrophy or atrophy must not be confused with the elongation of 
 the shaft of a bone which is due to inflammation, or to the shortening of a bone from 
 arrest of its growth following disease or the removal of the shaft, or to some injury to 
 the epiphysial cartilage that connects the shaft with the epiphysis ; for it cannot be too 
 strongly impressed upon the student's mind that any disease or injury which interferes 
 in any way with the nutrition of the epiphysial cartilage through which the long bones 
 mainly grow will be followed by arrest of the bone's "growth, and consequently by the 
 shortening of the limb — that is. when the disease or accident occurs in early life during 
 the period of growth. I have before me the notes of several cases where this result 
 ensued. In one in adult life the tibia was an inch shorter than its fellow after the 
 removal of a necrosed shaft in childhood {vide Fig. 659), in another nearly the same 
 amount of shortening followed an injury to the superior epiphysial line of the tibia, and 
 in a third the same result followed a displacement of the lower epiphysis. In all these 
 cases the fibula was curved outward, the shaft of the bone bent, and the outer malleolus 
 much lower than the inner, the bone having grown as the others. In one case the head 
 of the fibula was partially displaced outward. 
 
 Mollities OSSium, or OSteo-malacia, is a rare affection, and its cause is 
 wrapped in obscurity. It is found in men in about one ca.se in ten of the affection, and 
 in women is usually discovered during, even if it does not originate in. pregnancy. It 
 chiefly attacks subjects who from some cause or other have been subjected to prolonged 
 depressing influences, more particularly upon the nervous system. 
 
 My colleague, Mr. Durham, in an able paper on the subject {Gvy's Rep., 1864), writes 
 "that mollities ossium is to be regarded as a particular expression, as it were, of a general 
 morbid condition of the system, rather than as a special disease of the bones themselves;" 
 and I believe there can be little doubt as to the soundness of the opinion. It should 
 never be confounded with rickets or with the fragility of the bones met with in the aged 
 or demented. 
 
 Symptoms. — "The first symptom of the disease," writes Durham, "is pain, more or 
 less peculiar in character, always deep-seated, and greatly increased by pressure or motion, 
 sometimes coming on suddenly and with extreme severity, sometimes commencing vaguely 
 and insidiously, and gradually becoming almost insupportable; sometimes wandering, at 
 other times fixed for a period to some particular spot, and subsequently spreading to other 
 parts; sometimes intermitting, at other times unceasing. In the majority of cases the 
 pain appears to have been first felt in the lower half of the spine, the pelvis, and loins, 
 but in some it commenced in the feet, knees, or other parts of the lower extremities; the 
 pains are often looked upon as rheumatic. Associated with the pain there has always 
 been noticed on the part of the patient, at a very early period of the malady, a feeling 
 of general lassitude and disinclination to do anything. This feeling has increased more 
 or less uniformly, until it has ended in actual inability to make any exertion whatever ; 
 and with the early local changes are associated an uncertain, feeble gait and continual 
 fear of falling." 
 
 Symptoms that are more or less directly associated with the softening and absorption 
 of the bones are the next to appear, such as diminution of stature, deformity of the 
 spine or pelvis, some curvature or fracture of one or other of the long bones ; and as 
 time progresses these indications multiply. flexihiUty conjoined with fragility being the 
 distinguishing character of the bones in this disease. 
 
RICKETS. 
 
 !)71 
 
 TIu' urine altiiDst alvviiys contains a cuiisidijrahlc excess of lime salts. The (li>ease 
 is rarelv attciidfd with any ^'eneral or local symptoms of inflammation. The changes 
 ohservctl in the hones are carefully dcscrihed hy Durham. Increased vascularity appears 
 to he an early symptom, the lar^e irrooves seen in the cranial hones hein;; very striking; 
 next, the honv matter is seen to he more (»pa(jue and less uniform than natural ; some- 
 tinu's it is irregularly granular, "as if some disunion must have taken place hi-lween the 
 etmiponent idenu'Uts of the hony nuitter. 
 
 The lamiiuition of the hones next hec<uncs Ic.-s di.stinct ; the lamin:e of the Haversian 
 system appear more or less fused together; the hone corpuscles hecome wider, although 
 not with certainty more numerous. At a later date the earthy uuittcr hecomcs absorhed ; 
 the Haversian canals hecome surrounded hy a transjiarent ring of animal matter, which 
 ring then hecomes disintegrated and absorhed. By this process the Haversian system 
 ln'1'iunes destroyed, the bone assuming a hollowed-out, porous, or somewhat sponge-like 
 appearance. The contrast between the healthy and diseased bone is well seen in Fig.s. 
 (J77, 07S. 
 
 Fio. G77. Fig. 678. 
 
 
 ^'■^ 
 
 ^'pi'T-i^ 
 
 
 Section of Normal Occipital Hone. 
 
 Section Affected witli ^^<)llities 
 
 iDurhani, Guy's Rep., 1SG4.) 
 
 The same changes occur in the cancellated as in the compact tissue. In the more 
 advanced stage the bone disintegrates rapidly ; debrh of tissue, such as the remains of 
 blood vessels, shreds of membrane, fat and oil globules, with '-marrow cells." fill up the 
 large spaces. 
 
 ChemicaUi/, the inorganic constituents are greatly diminished and chemical disunion 
 and physical disunion coexist, the earthy matter being more readily dissolved out of the 
 diseased than out of normal bone. ''In healthy bone." writes Durham, '-the constituents 
 are combined ; in diseased bone they seem rather to be mixed. The animal constituents 
 are likewise more fatty and less nitrogenized than in normal bone ; the fat is more free. 
 In the mineral constituents the proportion of the carbonate of lime to the phosphate is 
 much diminished." 
 
 ProciXosis and Treatmext. — The prognosis in these cases is always bad. although 
 the possibility of a cure should not be doubted. Trousseau relates eases in which a good 
 result was obtained under the combined influence of rest, warmth, good food, and cod-liver 
 oil. the deformity, of course, remaining. Lime salts ought not to be given in these cases, 
 as they cannot be retained ; and to give them, adds Durham, is only to throw additional 
 work upon the excreting organs. 
 
 Rickets is an afllection of early childhood, or rather of young life, since it has been 
 kncnvn to att'ect animals, as proved by a skeleton of a West African baboon shown at the 
 Pathologica.1 Society of London in 1883 which exhibited the characteristic changes in the 
 epiphyses of the long bones, and by the head of a monkey which was a fine example of 
 craniotabes. In neither of these cases could syphilis be said to have had any influence. 
 It is more of an acquired than an hereditary affection, but it may attack a fa?tus in utero. 
 It is said by Sir W. Jenncr to be the commonest of the diathetic affections among the 
 London poor. It is, however, found in the families of the higher classes, and it is essen- 
 tially due to some malnutrition of the body, connected, proliably, with bad feeding and 
 the use of farinaceous in lieu of animal food, the bones during their period of growth 
 expanding at their epijihysial ends and bending in their shafts, and being very prone to 
 incomplete or green-stick fracture. 
 
 Symptoms. — •• Di.splacement and oblir|uity of the epiphyses may ensue, from softness 
 and flexibility of the layer of bone uniting it to the diaphysis, as is seen more especially 
 
972 DISEASES OF THE BOXES. 
 
 in the ribs, but a slighter degree of epiphysial obliquity is noticed in many of the joints 
 of the long bones, such as the knee or ankle ; the weight of the body is thus thrown 
 unequally, so that one set of ligaments has to bear more traction than another. These 
 ligaments then yield and the joints become loose, so that rachitic knock-knee {genu valgum) 
 or bow-legs {genu varum) is formed. 
 
 •• From sustaining the weight of the body the femur bends forward, the tibia usually 
 forward and either inward or outward, the greatest amount of yielding being where the 
 bone is thinnest and weakest. In many cases we find the os femoris bent forward, with 
 anterior and outward curvature of the tibia, knock-knee and flat-foot being coexistent in 
 the same individual. Just so far as the rachitic condition extends, so may we look for 
 abnormities of form ; thus, the 2)elc is may acquire some of those well-known contractions 
 of its outlet which are matters of such grievous moment to women at the period of par- 
 turition." the pelvis either retaining in adult life the small size and imperfect develop- 
 ment of infancy or becoming narrowed as to its cavity in one or other of its diameters. 
 
 The chest also undergoes allied changes, and Mr. Shaw has well pointed out (Holmes s 
 Si/sd-m, vol. iii. p. 820) how '' pigeon-brea.st " is one of the effects of the disease, atmo- 
 spheric pressure bending in the bones that have lost their elasticity and become softened, 
 and causing a projection of the sternum and lateral flattening of the che.st. 
 
 In the spine a general curving of the whole column is the more usual deformity, 
 "lordosis," or anterior projection of the lumbar vertebrae, as a compensating curve, being 
 found when pelvic obliquity is present. 
 
 In all cases of rickets Humphry has shown (J/<?'^7.-C//*V. Tram., 1862) that deficiency 
 of growth coexists with deformity, the lower limbs juore than the upper indicating this in 
 their proximal segment. In severe cases all the bones are more or less deformed, the 
 cranium — often large — presenting a quadrilateral aspect, with sutures widely open till a 
 late period of life, or even subsequently reopening, the bone either remaining thin or sub- 
 sequently thickening. The periosteum in these cases is also usually thickened, in the flat 
 as well as in the long bones. 
 
 The general symptoms of rickets are those of debility, muscular and general weakness 
 of the whole frame gradually passing into that of rickets ; dentition is retarded and teeth 
 decay or drop out. Sir W. Jenner lays great stress upon profuse per.spiration of the head 
 during the night, a tendency to kick off bedclothes, fetid stools, and general tenderness 
 of surface as constant symptoms of the early stage. 
 
 Pathology. — Tomes and De Morgan inform us that a rickety bone has the structural 
 arrangement of normal bone without the earthy salts. Jenner (Jlcd. Times, 1860), how- 
 ever, describes an enlargement of the lacunae generally, the effu.sion of a red pulpy sub- 
 .stance in the cancellous tissue, and a thickening of the periosteum, while Gee (<SV. Bart. 
 Rep., 1868). Dickinson (Jfed.-Chir. Trans., 1852). and others have pointed out how the 
 viscera undergo some " albuminoid " changes unlike the waxy or lardaceous disease. 
 
 In normal bone there is 37 per cent, of organic and 63 per cent, of inorganic matter. 
 In rickets the proportion is 79 per cent, of organic and 21 per cent, of inorganic matter. 
 Bones that have been solid may become pliable when this disease begins. 
 
 Rickets is a curable affection — that is, if taken before it has far advanced ; and it is 
 remarkable to what an extent the deformities are remediable under natural processes, and 
 how curved or bent shafts of bone recover their natural shape on taking off downward 
 pressure and improving the general powers of the child. In more severe cases, where the 
 curvature cannot be remedied, the bone consolidates and becomes strengthened by but- 
 tresses of bone along the concavity, and, although the stature may be diminished and the 
 limbs deformed, the general powers of the patient may be restored and a sound recovery 
 take place. 
 
 Treatment. — The medical treatment of rickets .should be conducted on reasonable 
 principles — fresh air and abundance of it, simple nutritious food such as may suit the 
 conditions of the digestive organs being essentials : milk and beef tea for young children 
 should be mo.stly relied upon, and meat in moderation for the older. Cod-liver oil. iron, 
 and quinine are also very valuable drugs. The bowels should be carefully attended to, 
 while all violent purgatives ought to be avoided. 
 
 The surgical treatment in the early stages is the prevention of deformity, and in the 
 later the remedying of it. By way of prevention, the child should be restrained from 
 any prolonged standing or sitting position ; the horizontal posture should be observed as 
 far as possible ; exercise should be allowed and followed by rest, the two alternating 
 according to the powers of the patient and the necessities of the case. As the general 
 health and powers improve more liberty may be sanctioned. In spinal cases these obser- 
 
OSTKITIS DEIOllMASS. 973 
 
 vatiiMis arc more especiiilly Idmliiiir, anil in tliiiii iiii)val)le couches and spinal chairs are 
 of ;;rcat .-.crvicc. 
 
 Where iuo«KTate deformity exists, more particularly in the lower extremities, it is 
 often interestinir to ohserve how, hy the above means, the bones recover their normal 
 sliape, and children " };row out " of their deformity us their health improves if otdy the 
 surgeon takes care it is not increased by nejilect. 
 
 in still worse cxam})les, and where exercise is es.sential and intertnittent rest will not 
 be (d)served, splints and instruments may be bound to the le;rs. Tw«j long side-splints 
 reachinj; to the <;roun<l. carefully boun<l to^rethcr and removed at nijrht, are as p»od as 
 unv. or an irnii splint with j(»iiits at the knee and ankle. Some surj^eons prefer an outer 
 splint for knock-knee and an inner one for bow lej;s. 
 
 When the curvature of the shafts of the lejr bones is very great or acute. Mr. II. 
 March has adoj)ted the ]ilan of' forcibly strai<:litenin<r the bones when the patients are 
 undt-r chloroform. He tliinks little of the risk of breaking the bone. knr»wing how rick- 
 etv bones unite (.SV. Ii<iilli. lu/i. for ISyOj. He believes the plan more adapted for acute 
 than for chronic ca.ses. In extreme cases an osteotomy niay be performed, or a wedge of 
 bone may be removed from the shaft. I performed this latter operation in IHJJH on the 
 leg of a child between four and five years of age, and Mr. Little has more recently 
 repeated the operation with advantage. It should be done only in extreme instances of 
 deformity an<l when no hope of improvement by other means can be entertained. 0.ste- 
 ottiuiy fcir this attection is now a common operation. 
 
 Acute rickets has been described, but Dr. Barlow in a very able paper (Mfil.-Chir. 
 Tr<in:i., vol. Ixvi.. iSSi^j has clearly .sliown that such cases are a combination of scurvy 
 and rickets, and that they should be called " infantile scurvy," the scurvy being an essen- 
 tial and the rickets a variable element. He carefully analyzes 31 cases. The invasion 
 of the disease may be gradual or abrupt, with more or less swelling of the legs, with pale, 
 tense, shining skin, but irif/iunf increase of heat. There may be some redness of the 
 part and s<ime cedema extending up the thigh. The tenderness on ])ressure is extreme, .so 
 that the child cries even in anticipation of being touched. In severe cases the child 
 moans constantly ; there is also some pseudo-paralysis of the affected limbs. When the 
 disease affects the thigh, all the local symptoms will be the same, only higher in the 
 limb. Other bones may become affected simultaneously or by subsequent involvement. 
 In most of the cases there is head-sweating, and in some the bones of the cranium appear 
 thickened near the sutures. In rare ca.ses purpuric symptoms appear. 
 
 There is rarely very great increase in bodily temperature, and this seems to turn 
 more upon the tension of the affected bone and soft parts over it than anything 
 else. 
 
 In almost all these ca.ses there is sponginess of the gums, and in many stomatitis. 
 
 The disease is a dangerous one. no less than 7 out of Barlow's 31 having died. 
 
 The pnfJio/oi/ic'il coiiih'fi'on of the affected bones is very marked. The perio.^teum is 
 separated from the bones, and the shafts of the bones from the epiphyses ; a layer of 
 uiaroon-colored blood-clots surrounds the bone. The bones affected may die in part, but 
 not wholly, as in inflammatory affections. It was this condition that induced Mr. T. 
 .Smith, who was the first to record a case of this disea.se (Fafh. Trans., 1876), to describe 
 it as one of hemorrhagic periostitis. The periosteum may be thus separated from the 
 cranial or any bone. 
 
 There is no reason to believe that syphilis has anything to do with this affection. 
 
 The disease tends spontaneously toward recovery under proper treatment. 
 
 Treatment. — The treatment recommended by Barlow is. hnnJly^ during the acute 
 stage, wet compresses and avoidance of movement, at a later period careful shampooing 
 and douches; internally.^ the use of raw-meat juice, fresh milk, and orange-juice or of 
 some fresh raw vegetable, and from the first the access of as much free air as is possible. 
 
 Osteitis Deformans. 
 
 This name has been given by Sir James Paget to a remarkable disease which he has 
 described in papers published in vol. Ix. of the Trans, of the Royal Medical tnnl Chirur- 
 gical Society (1877) and in vol. Ixv. (1882). I have recorded in the Guys Ilo.tp. Reports 
 for 1877 a good example of it, and have .seen three since. 
 
 It begins, writes Paget, in middle age or later, is very slow in progress, may continue 
 for many years without influence on the general health, and gives no other trouble than 
 that which is due to the changes of shape, size, and direction of the diseased bones. 
 
974 
 
 DISEASES OF THE BONES. 
 
 Even when the skull is hugely thickened and all its bones exceedingly aiicied in struc- 
 ture, the mind remains unaffected. 
 
 The disease affects most frequently the long bones of the lower extremities, the clavi- 
 
 The bones enlarge and soften, and those 
 bearing weight yield and become un- 
 
 cles, and the skull, and is usually symmetrical 
 Fig. G79. 
 
 naturally curved and misshapen, suj 
 gesting the proposed name, " osteitis 
 deformans." 
 
 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 and the necks 
 of the femora become nearl}^ horizontal. 
 But the limbs, however misshapen, re- 
 main strong and fit to support the trunk. 
 (Vif/e Fig. '679.) 
 
 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 noc- 
 turnal or periodical. It is unattended 
 
 Drawing of a Man suffering from Osteitis Deformans. (Taken „-i.i-. .p„„„,. \T„ „l,„^„^+^^;c.+i« «^v^/i; 
 
 from Author's case, G„y% Jie/,., 1877. This patient is now ^"th tever. JNo characteristic COndl- 
 
 (May, 1884) dying. He is blind and bloodless, and can hardly tions of Urine Or feces have been found 
 
 raise his limbs on account of their weight.) . ., ... . , ^ .,^ 
 
 in it, nor is it associated with any con- 
 stitutional disease, unless it be cancer. Three out of the twelve cases recorded by 
 Paget have ended in connection with this affection. 
 
 The bones examined after death show the consequences of an inflammation affecting 
 in the skull the whole thickness — in the long bones cliieflythe 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, bat it may be believed that they are inflammatory, for the softening 
 is associated with enlargement, with excessive production of imperfectly developed struc- 
 tures, 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 consecu- 
 tive hardening, is uncertain." 
 
 The disease does not apparently have any shortening influence on first life, for in Sir 
 J. Paget's case it had existed for twenty years, and in my own the man is now sixty-seven, 
 the symptoms having shown themselves about eleven years. The patient is now amauro- 
 tic and so feeble that he cannot raise his heavy limbs. He is anaemic, but shows no other 
 signs of disease. 
 
 In May, 1877, I saw a second example of this affection in the person of a married 
 lady aet. 54, who, although in the enjoyment of excellent health, was quite unable to walk 
 without crutches, on account of the weight and weakness of her legs. The disease had 
 been gradually coming on for six years, and the pains in the thighs had given her great 
 trouble. When I saw her. she came into my room on crutches and sat down with the 
 arched back so peculiar to this affection ; her thigh-bones were enormously thickened and 
 bent ; the necks of the femora were horizontal, as proved by the test line of the ilio- 
 femoral triangle (Fig. 569), and the knees were far apart, from the bowing of the legs. 
 The bones of the upper extremity were also clearly enlarged. I could not make out that 
 the cranial bones were involved. The lady informed me that she was at least an inch 
 shorter this year than she was last ; the changes in the necks of the femora would, how- 
 ever, account for this fact. 
 
 She had had two sisters ; one died from cancer of the breast, while the second was 
 an imbecile and had died in an asylum. 
 
 This case well supports the observations that have been made. 
 
 Sir J. Paget regards the disease as inflammatory. Dr. Goodhart brings forward 
 
ON aussiinr i.wjrnihx 97o 
 
 aiuitlicr liyiKitlii'sis. IIo doi's iint think the tiTin " iiiflaiiiniiitury " <iMi be coiisidcri'il as 
 piKpi'ilv tlcscrijitivi- (if this (list-asc, |iartly h»'<-ausf to jrivc • iiiHaiiiiiiatiori " ho wiile a 
 im-aiiinu: as wmihl i'iiil)raci' a <r»'iuTal hy|ifrtni|iliy <>f all the hutM^s as ((lie of its resultM 
 wnuhl be til (li'|irivo tlu' tiTiii (if all sij^niticaiicf, anil also because it is still less a|i|ilieable 
 t(i (ither diseases allied to the inie in (piestidn. 
 
 I>r. (Jdddhart ediisiders that hy|ier(istdsis is essentially a new frniwth — or. as he 
 expresses it. a jreneralizcd lidiie tunmr — and adduces in suppdrt (d" this view. 1st. The 
 ilinical histdry dt' the disease ; its cuexistencc with dtherwise jrodd health : the absence 
 id' pain; its intraetabilitv under treatun-nt ; its tVeijuenl assdciatidu tdward its chise with 
 siinie dther f'orni ut' ni:ilii:naiit tuiiKtr. lid. Its peculiar parallelism with nidlluscuni fibro- 
 suiu and a fdriu dt' elephantiasis, whiidi is a c(irrcspdiidiii;r disease in the subcutaneous 
 (ir Hlini-celliilar cunnective tissue td this in bune cdnnective tissue. There is certainly a 
 ^udd deal td be said in i'av(ir dt' this view. and. thdu^h Sir James I'a<:et does not see his 
 way td adiiptiiii: it as the more jirdbable. I am, (in a review dt" the whdle subject and 
 unl'ettered by any partiality for a theiiry (if my nwn. inclined td think with my cdlleairue. 
 
 No trciitiiitiit seems ti> have tlu; slitrhtest iiittiicnce (in the progress ot" this attection. 
 
 CHAPTER XXXIV. 
 ON GUNSHOT INJUKIES. 
 
 "GuNsiKiT injuries."' writes Professdr Ldn^iudre, "are the injuries which result from 
 the action (if missiles set in mutidn \ty a fdrce which is derived from the i<:;nitidn of explo.*'- 
 ive comjiounds. They comjireliend every kind and degree of liurt which is capable of 
 tieing produced on the human frame by the mechanical im|iulse of obtuse bodies."' He 
 informs us. moreover, that in every hundred casualties there are twenty killed to eighty 
 wounded, and that of the wounded one-third of the cases are .severe and two-thirds 
 .-light. 
 
 The wounds vary much in their character and nature, one caused by a rifle ball differ- 
 ing from that by a cannon ball or shell ; and the direct effect of a mis.sile upon a part 
 ditfej-s from that produced ImUrectly by the scattering of stones or any other hard sub- 
 stance caused by cannon shot or shell. Guns/iof contuduns of tissues, although apparently 
 trivial, are, as in civil life, often associated with severe deep-.seated injuries, and sujierticial 
 wounds apparently unimportant are often attended with or followed by serious accidents. 
 Gunshot Wounds are always of the coiituscil class; those of civil life, however severe, are 
 rarely, if ever, attended with that complete attrition and displacement, and even total 
 removal of substance, which are so con.stantly characteristic of wounds produced by gun- 
 shots, particularly in those of recent times. Gunshot wounds, moreover, are also prone 
 to be complicated by the introduction into the wound of some foreign bddy, such as some 
 portion of the soldier's dress pressed into the wound, or some part of the wadding, shot, 
 or shell itself. 
 
 It should also be known that " substances of very low degrees of density, such as 
 plugs of tallow, light wood, cork, wads of paper, and others, will serve to inflict penetrat- 
 ing wounds in the softer .structures of the body having all the characters of wounds 
 inflicted by denser projectiles if sufficient velocity be impressed upon them. But the 
 necessary force to accomplish this result can only be executed within very limited di.«- 
 tances" (Longmore). 
 
 "The external distinguishing signs of penetrating gunshot wounds are generally 
 manifest enough. The general dimensions of the opening made by the shot sufficiently 
 show whether it has been made by a small-arm bullet, a large grapeshot. or a still larger 
 gunshot; its shape, whether it has been made by a round projectile, by a fragment of a 
 shell, or an irregular splinter of some secondary missile ; while the aspect and condition 
 of the lips of the wound and of the structures immediately surrounding it sufliciently 
 mark it as not being one inflicted by a stabbing or cutting instrument." 
 
 Gunshot wounds differ considerably in appearance, these differences depending upon 
 the forms of the missiles causing the injury, and their speed, as well as the part of the 
 body struck and the position of the patient relative to the projectile at the time of injury. 
 When part of the body is carried away by a gunshot a.t/itfl speed, the surface of separa- 
 
976 
 
 ON GUNSHOT INJURIES. 
 
 tion will present a level yet contused and almost pulpified aspect ; when the speed is less 
 7-ajnd, the soft parts where the separation has taken place will be moi'e lacerated and the 
 bone comminuted ; and when the speed in sjient or the direction oblique, either the injured 
 parts will be crushed more or less deeply, or, with little or no evidence of external injury, 
 the deeper parts may be irreparably disorganized. 
 
 Again, bullets, "when at full speed, perforate or penetrate ; but when at less- 
 ened speed, they cru.sli and lacerate. When a gun is discharged near the body, the parts 
 around the wound of entrance will be blackened and burned, while the wound of entrance 
 appears as if punched out. When the discharge of the musket takes place a feu- inchfs 
 from the hody, the injured tissues will be more or less scorched, blackened, and studded 
 with grains of unexploded powder, and the wound of entrance large, ragged, and exca- 
 vated. 
 
 Wounds from bullets not at full speed, and fired at a distance of two or 
 three hundred yards, will present an opening the size of the projectile, or possibly smaller, 
 circular in shape, with serrated (inverted), undermined, puckered, and flabby edges ; at 
 times, however, a flap of skin is found at the opening. 
 
 The margin of the opening will appear as if contused, the evidences of bruising fad- 
 ing away into the surrounding tissues. 
 
 When the i^pced of the hidlet is mxch diminished, no skin may be carried away, the 
 diminished speed of the missile simply sti'etching and tearing asunder the tissues to allow 
 of entrance. 
 
 When wadding or other foreign substance has been carried into the wound of entrance, 
 this will of necessity be more lacerated and appear larger than it would otherwise be ; 
 and the same conditions may be found to exist when a ball enters the body where bone is 
 only covered with thin integument. 
 
 In modern warfare, where the rifle bullets are of a cylindro-conoidal form (Fig. 680), 
 soft parts are more readily penetrated and bones more generally split or splintered than 
 
 Fig. 680. 
 
 English and Foreign Bullets now ICnipluyed. (Natural Siz 
 
 was found of old from the impact of round balls. In the late Franco-German war these 
 points were generally observed, and, although the Prussian and Bavarian balls were said 
 to be larger than those of the French, the wounds produced by all were very much alike ; 
 if anything, however, the wound from the needle-gun produced the wider tract and larger 
 opening. 
 
 Indeed, in the " seton wounds," or wounds penetrating the soft parts alone, of all 
 these balls it was often difficult to make out the wound of entrance from the wound of 
 exit. When they traversed the soft parts alone, they often ran so cleanly through them 
 that only slight suppuration followed and repair was rapid, these modern balls causing 
 less severe lesions of the soft parts than the old spherical balls. Billroth asserts that 
 wounds with split-like exits were remarkable for the amount of suppuration that followed. 
 When bones were struck, no matter what the form of ball, the injury was alike: there 
 was comminution, vertical splintering, and at times almost pulverization. Indeed, in civil 
 life there is nothing like the splintering and comminution of bones seen in wounds from 
 rifle bullets. 
 
 The amount of alteration in form which the projectiles assume after striking a bone 
 
uy (n'ysjiuT j.\.ji'nij:s. 977 
 
 is verv rcniarkiildt', hoiiu' ItciiiL^ cimiplctcly llultciicil. nthcrs str:iiiL'<'ly cMntortccl. while 
 luuny are sjilit. 
 
 i)r. Ktifstt-r (if the Au.u'u.sta Hospital. Berlin, however, has ]trove<l l)y exi)eriiiieiit 
 (1S74) that the ainoiiiit of injury the hones and soft parts sustain in a ^'unshot wound 
 depends niueh upon the softness or hardness of tin- Itullet, a hard <»nc ^'oiiiir throu":!! a 
 part and leaviiij; a " seton wound." when- a soft one would prodiiei- fri;.ditful dfstru(ti«Mi 
 of tissue. He explains this fact hy the lead of the softer ))ull('ts heeoiniii^' heated hy col- 
 lision with hone and luoken up (not melted;. The Martini-Henry bullet is a hard one 
 and made of twelve parts hard lead and one tin. The bullet of the (iras rifle, the weajton 
 of the French army, is likewise liard. The C'ha.s.sepot and the others are all made of soft 
 lead, and conse«|ueiitly break up and flatten out aijainst bone, thereby causin<< large aper- 
 tures of exit and great laceration of tissue. 
 
 When the head of a b(»ne is struck, it is probaldy coniniinutt'd. When bones are not 
 bn»ken. but only bruised, acute periostitis and endoslitis are very common, the concussion 
 of the bone being generally so severe us to excite acute action. 
 
 With the rifle ball the course is more frequently direct than with tliat from the old 
 smooth-lmrcd musket. Tortuous courses are even now met with, but less frer|ucntly. the 
 weight of the ball and the extreme velocity with which it flitjs producing a more direct 
 route. It penetrates the soft tissues in a direct line, and when it strikes bone either runs 
 through or splinters it, entering it like a wedge. It will often ap])ear. writes hongmore, 
 that tlie track of a bullet, even at full speed, is widely removed from a straight line. But 
 it usually is not diflicult to reconcile the apparent irregularity in the course the projectile 
 has taken if the many varied positions in which the body and its parts are liable to be 
 placed are called to mind, and if, when making the examination, the surgeon takes care 
 to place the patient in a similar position to that which he was in when struck. 
 
 The injury imparted to soft parts by what are called spent balls or r ('a x.fict ahots is the 
 most destructive, and large projectiles roNin;/ ovn- the surface of a part or moving at low 
 rates of speed po.ssess a force which will cru.sh all parts, even whole extremities, with 
 which they happen to come in contact, and rupture internal organs in a way peculiar to 
 themselves. 
 
 A conical rifle ball, when partially spent, may lodge in a part, either in a bone or .some 
 soft tissue. It may take some unusual path and lodge where the surgeon cannot find it 
 or cannot remove it, and under these circumstances it may rest, become encysted, and 
 give but little trouble. But, on the other liand, it may set up a chronic inflammatory 
 action in the part and give rise to local suppuration. Bullets, however, rarely lodge in 
 the soft parts without giving rise to suppuration, although in bones they may do so. 
 Such ca.ses .should not, however, induce the surgeon to leave them alone when they can 
 be removed ; they should always be extracted if possible, unless they have penetrated 
 any of the great cavities of the body. Billroth speaks very strongly on this point. In 
 all blind tracks in the extremities the finger should be passed into the wound and the 
 foreign body looked for, the external wound being enlarged when needed for this purpose ; 
 and in nun-pciiclratiini wounds of the head, chest, abdf)men. and pelvis the same practice 
 may be observed. The removal of the ball as the cause of irritation has not only a bene- 
 ficial influence on the body of the patient, but it has an e(|ually beneficial influence upon 
 the mind ; for as long as the ball remains lost in the tissues the soldier naturally regards 
 it as a serious impediment to his recovery, and there is no eftoct e(jual to that caused by 
 its removal. Billroth has found much assistance from Nclaton's sound in doubtful cases, 
 but, as a rule, he says, projectiles that cannot be reached by the fingers can rarely be 
 extracted, the bullet-forceps, even the American, being of small value. 
 
 When a part of the body is carried away by a cnimou hall at full sppecf, the stump will 
 present a level surface of contused and almost pulpified tissues. The muscles and integu- 
 ment will not have retracted; the extremity of the broken bone will probably stand out, 
 small fragments of bone being scattered over the surface of the wound. 
 
 When the same result follows the contact of (t cainii») haU the force of ichich is par- 
 tially e.rprtithd^ there will l)e evidence of more dragging and laceration of the soft parts, 
 more irregularity of the wound, more hanging of the muscles, greater comminution of the 
 bone, and greater injury to the soft ])arts above the .seat of separation, and probably 
 greater splintering of the bone upward. 
 
 When the force of the cannon hall is still I'ss or spent, there may be no separation of 
 
 impaired parts, but a general contusion, cru.shing. or disorganization. In some cases, 
 
 where the force is obli(jue, there may be no external evidence of injury, this want of 
 
 external evidence being too coinuiuidv associated with broken bones or severe internal 
 
 fi2 
 
978 ON GUNSHOT INJUETES. 
 
 laceration of viscera or other soft parts. Such cases were formerly set down as due to 
 "wind contusions " or the "brush of a shot," but are now believed to be caused by con- 
 tusions of nearly-spent cannon balls or glancing blows from some projectile. 
 
 Shell wounds, as a rule, produce severe laceration of soft parts ; and though they may 
 penetrate tissues, yet they very rarely pass through them. 
 
 The ^founds produced hy rifle haJh at full speed at the point of entrance are often small, 
 circular, clean cut, and with inverted edges, but at the point of exit large, irregular, and 
 with everted edges. 
 
 As the distance from the weapon increases and the velocity of the ball diminishes, so 
 the wound of entrance becomes less circular and regular, larger and more contused, the 
 wound " sometimes consisting of three triangular flaps, which on being lifted up can be 
 made to meet at their apices in the centre of the opening " (Longmore). 
 
 When the ball has passed through the part, the wound of exit will probably be larger 
 than the projectile, more irregular, torn, and everted than that of entrance, the subcu- 
 taneous fat often projecting. At times, however, with the cylindro-conoidal bullet dis- 
 charged at full speed, it is difficult to distinguish by its appearance the wound of entrance 
 from that of exit. In the patient's clothing, when the wound of entrance is punctured, 
 that of exit will be lacerated. 
 
 The j)rn'« caused by a gunshot wound depends upon the parts that are injured. In a 
 general way it is not severe, and when so is evanescent. Writers tell us that it is often 
 described as being like the sudden stroke of a cane or the shock of a heavy blow. Some- 
 times soldiers are unaware of their wounds. When the trunks of nerves are pushed aside 
 and injured, intense pain may be felt, but not locally. Longmore relates the case of an 
 officer who from his sensations thought his arm was broken, but on examination no such 
 injury existed ; a ball had passed from right to left through his neck, which probably 
 injured some of the cervical or brachial plexus of nerves, thereby giving rise to his error. 
 More pain is occasionally felt at the wound of exit of a bullet than at that of entrance. 
 
 Shock. — " When a large bone is suddenly shattered, a cavity penetrated, an import- 
 ant viscus wounded, or a limb carried away by a round shot, the most prominent symptom 
 is the general perturbation and alarm which in most cases instantaneously supervenes on 
 the injury. This is generally described as the ' shock ' of the gunshot wound. The patient 
 trembles and totters, is pale, complains of being faint, perhaps vomits. His features 
 express extreme anxiety and distress. This emotion is in great measure instinctive and 
 seems to be sympathy of the whole frame with the part subjected to serious injury 
 expressed through the nervous system. This shock is more or less persistent according 
 to circumstances. Examples seem to show that it may occasionally be overpowered alto- 
 gether, even in most severe injuries, by moral and nervous action of another kind, by a 
 state of mental tension ; but this can rarely happen when the injury is a vital one. Panic 
 may lead to similar symptoms of shock, although the wound is of a less serious nature. 
 A soldier, having his thoughts carried away from himself, his whole frame stimulated to 
 the utmost height of excitement by the continued scenes and circumstances of the fight, 
 when he feels himself wounded is suddenly recalled to a sense of personal danger ; and 
 if he be .seized with doubt whether his wound is mortal, depression as low as his excite- 
 ment was high may immediately follow. This depression will vary in degree according 
 to individual character and intelligence, state of health, and other per.sonal peculiarities; 
 for while, on the one hand, in every action numerous examples occur of men walking to 
 the field hospital for as-si.stance almost unsupported after the loss of an arm or other such 
 severe injury, on the other men whose wounds are slight in proportion are cjuite over- 
 come and require to be carried. 
 
 "As a general rule, however, the graver the injury, the greater and more persistent is 
 the amount of ' shock.' A rifle bullet which splits up a long bone into many longitudinal 
 fragments inflicts a very much more serious injury than the ordinary fracture effected by 
 the ball from a smooth-bore musket, and the constitutional shock bears like proportion. 
 When a portion of one or both of the lower extremities is carried away by a cannon bnll, 
 the higher toward the trunk the injury is inflicted, the greater the shock, independent of 
 the loss of blood. When a ball has entered the body, though its course be not otherwise 
 indicated, the continuance of shock is a sufficient evidence that some organ essential to 
 life has been implicated in the injury '" (Longmore). 
 
 Hemorrhage. — The amount of hemorrhage attending a gunshot wound varies 
 according to the size and situation of the wounded vessels. When large vessels are 
 involved, death is rapid, and such cases do not come under the notice of the army 
 surseon. 
 
o.v I! r SSI Kit is.ni:ii:s. 979 
 
 Tn the (•a«i('s that coiiir into tlie Miri^'cun's liaiids in a jrcncral \vay tliere has hecn an 
 attack iif li('Miitrrlia;:<' dirrctly after the injury, l>ut little nmre ; po^^ilily some oozin;.'. but 
 rarely niueli, may exist. 
 
 When a limb is shot ofi", there is rarely more lilecdin;; than when it has betMi torn off 
 by machinery, as seen in civil life. liar^re vessels, wlieii torn or twisted, seldom bleed. 
 In these cases the jduj.'.ixe<l pulsatinir extremity of the lacerated artery will <:enerally bo 
 fouml projcctinjr from the wound. 
 
 In the wounds caused by rijh hitlls vessels escape in a marvellous manner, the ^'reat 
 resiliency (d" larire vessels and the freedom with which they slip away under pressure 
 from their loose cellular connections allowint; a ball to jiass alonj; or across their course 
 without wouiidinjr them. At times the ves.sel may be .«(» contused as to become obstructed 
 and obliterated. ( IVr/r I*rep. at N'etley.) Nevertheless, a rifle ball occasionally may 
 directly divide a larjre artery and cause instantaneous death. In the American war, 
 amon<; tin- cases of primary ;;unshot lesions of the arteries that came under treatment, 
 it was found that in most r»nly a ])ortion of the calibre of the vessel had been carried 
 away, and that ret ractimi had thu< been jirevented. 
 
 Secondary hemorrhage i^ common in <run.shot wounds, and is due, probably, a.s 
 a rule, to tin- reopeninir of a wound in a vessel temporarily closed, or to the .sloughing of 
 some part of its walls that had been injured. In the former case the new ti.s.sue that had 
 stopped for a time the flow of blood gives way under some sudden movement or local 
 mechanical force, such as some foreign body in the wound, or breaks down during the 
 suppurative or sloughing process ; in the latter^ the injured coats of the artery are ca.'^t 
 ofl^, having been destroyed by some ccmtusion or other violence. In either case the throm- 
 bus or clot in the vessel is not sufficiently well formed or organized to resist the force of 
 the blood current from behind. When such a clot organizes, there will, of course, be no 
 bleeding. ■■ The great fre(|uency of secondary hemorrhage has for its chief causes the 
 absence or faultiness of sanitary conditions and the debility of the patient due to priva- 
 tion of nourishing food and to exposure. The means calculated to remove or anticipate 
 such evils will, if applied, be of more value than is the ligature in coping with secondary 
 bleeding after gunshot iniur\ '" (MacCormac). 
 
 With respect to the treatment of secondary hemorrhage after gunshot wounds, it is 
 in principle similar to that which the civil surgeon follows. Styptics, where large vessels 
 are concerned, are worse than useless. Pressure is applicable only for temporary, not for 
 curative, purposes, and thus the surgeon is driven to cut down upon the wounded artery, 
 to tie or twist both ends, or to apply the .same practice to the vessel in its continuity 
 leading to the seat of bleeding -when the former operation is too difficult or dangerous. 
 Billroth advocates dealing with the main trunk of the bleeding vessel at an early period 
 of the hemorrhage, and not wasting time by delav'. He says that out of 23 cases in 
 which he applied a ligature to large arteries for hemorrhage, death took place in 7 from 
 bleeding on the .separation of the ligature, when no clot was found in the ves.sel ; in 
 12 from hemorrhage and p3aMnia, of which no examination was made; and 7 alone 
 recovered. 
 
 In the late continental war Stromeyer and MacCormac maintain that the result of 
 such operations was uniformly unfavorable. Out of 12 cases which Stromeyer saw, only 
 2 recovered. '• I think," he says. " we must decide to amputate oftener in cases of sec- 
 ondary hemorrhage." 
 
 Possibly a better result might have followed torsion of the arteries, for after such a 
 practice, when bleeding has been arrested, there is nothing to set up fresh mi.schief in the 
 artery, no foreign body like the ordinary ligature to excite anj' ulcerative or disorganiz- 
 ing process through which hemorrhage may take place, the thrombus that forms in the 
 vessels after torsion being allowed to go on undisturbed, to organize and become incor- 
 porated with the incurved middle arterial coat into one firm organized fibrinous mass. 
 The catgut ligature, however, may possibly be of use in these ca.ses. 
 
 Tre.\tment. — In the front of the battlefield little more can be done in the way of 
 treatment of gunshot wounds than the application of the ''first field dressing" some 
 pressure or tourniquet to arrest hemorrhage when the vessel cannot be at once secured, 
 some splint or other available support to prevent extra injury being inflicted by move- 
 ment to the field hospital. The wounds of the soldier must not be manipulated by the 
 surgeons in the front. No examination of the wound is to be made by probe or finger in 
 the battlefield or dressing station. '' The one line of treatment to be adopted by the sur- 
 geons in the front." writes Professor C. Reyher, " is to occlude the wound provisionally, 
 to lay the wounded part in a suitable position in the litter, and to render it provisionally 
 
980 ON GUNSHOT INJURIES. 
 
 immovable ;" for tlie surgeon is to remember tliat a proper and thorough examination of 
 the wound will take place at the field hospital. 
 
 The first field dressing was introduced during the Crimean war in 1853 by Professor 
 Longmore for the first time in any service ; '• and since that period," writes Longniore, 
 " it has been copied by every civilized power in the world — the principle of every man 
 carrying on his person the means of dressing his wound if he should eventually meet 
 with that calamity."' 
 
 What the first field dressing should be is not yet determined, but to carry out the 
 practice efficiently it is necessary that the bearer companies should be well organized, and 
 the men of which they should be composed must be expert dressers. The appliances at 
 hand for their use must also be effective, simple, portable, and last, but not least, cheap. 
 That they should be of an antiseptic nature all surgeons will now admit ; that they should 
 be absorbent is equally essential. Iodoform, absorbent antiseptic cotton, and gauze and 
 a bandage are probably the three best essentials ; and if a piece of protective or water- 
 proof material is added to the list, so much the better. Before examining a wound the 
 clothes that cover it should be carefully looked to. and more particularly the garment 
 next the skin ; for " it occasionally happens that a bullet will have sufficient force to pene- 
 trate the body to a limited distance, at the same time carrying a portion of the wounded 
 man's shirt before it, while, owing to the yielding nature of the material, it fails to tear 
 a piece out of it. The bullet will then lie. as it were, at the bottom of a pouch of the 
 shirt like the finger in a glove ; and when the shirt is taken out. the bullet will be brought 
 awav with it.'" Longmore, in his recent work on gunshot injuries, relates several instances 
 of the kind. 
 
 At the field hospital the wound should be thoroughly and carefully examined, and to 
 €ff"ect this the patient should be placed, when practicable, as near as possible in the posi- 
 tion he occupied when he received it. All foreign bodies must be taken away ; bleed- 
 ing vessels ought to be ligatured or twisted ; and when necessary the wound should be 
 enlarged for the purpose. No makeshift of pressure or other temporizing means should 
 be employed. When great collapse or " shock " exists, some gentle stimulant may be 
 given. The true condition of parts is to be made out at once and the plan of treatment 
 laid down, soft parts being adjusted, operative interference decided upon when necessary, 
 and right appliances employed. To clean the wound some antiseptic lotion should be 
 used. Iodine lotion made up to strength of a dark sherry color is the most available and 
 as good as any. and in this I have the support of Professor Lister ; but carbolic or sal- 
 icylic acid may be employed. The spray in military, if not in civil, surgery may fairly 
 be said to have been set aside by common consent. Brun. A'olkmann. and Billroth 
 amongst German surgeons have all abandoned it, and Sir J. Lister has said. " I do not 
 desire that the spray should be used in military practice : / heVuvf essentiidhj the same 
 results can he got icithout it.'' So now all surgeons are on the same platform as to prin- 
 ciples, and diff"er only in points of detail. 
 
 By far the best instrument with which to explore a wound is the finger, and for this 
 purpose the external opening through the fascia may always be enlarged. '• Probes 
 should seldom or never be used ; the finger is by far the best instrument if the wound 
 will admit it" (John Hunter, MS. lect., 1787). "No artificial instrument can give the 
 same amount of information or afford information so precise with regard to the lodgment 
 of foreign bodies and their nature as the surgeon's finger can give. The surgeon should 
 not withdraw the finger until the course the projectile has taken, the injury it has done, 
 the complications of the wound, such as the presence of foreign bodies, and in such a 
 case their kind and situation, have been decided by him: the exploration will then be 
 completed by one operation, and a second insertion of the finger for the purpose, which 
 is always irritating to a patient, will be avoided. The knowledge gained, moreover, will 
 be definite and of special utility in determining the proceedings to be afterward adopted. 
 The exploration is often as.sisted by pressing the soft parts, especially if the wound be in 
 one of the extremities, from an opposite direction toward the finger end." Sometimes, 
 when a lodged ball cannot otherwise be discovered, it may be found by passing the flat 
 palm of the hand down the limb. " Sometimes," writes Longmore, '• it may be detected 
 simply by relaxing the muscular tissues, so as to give a loose and pendulous condition to 
 the parts concerned, and then lightly tossing up the flesh at diff"erent points from below 
 with the tips of the fingers. When the finger passes through an opening in fascia or a 
 deep aponeurosis, the track will feel constricted ; when through muscles and connective, 
 expanded. 
 
 When sufficient information cannot be acquired through the finger, either from the 
 
ov r,r.v,s7/oy i.\.n-nn:s. 
 
 981 
 
 length of tin- wouinl or iVoiii its turtiidsitics, j»n»l)cs must he used. NV'laton'.s (Fig. 681). 
 with a small liall of |Mireflaiii at the cud, is frctinl, and .so also is Sayre's suak(i-joiuted 
 probe with a like cud. Louguiure pnl'crs a loug silver probe which can be bent to any 
 
 ^ntfi^rira 
 
 !• i(.. C.sl. 
 
 (^'Trffrsllallit f^xtmrlar. 
 
 Lccomle's Styli't-l'iiict': '/, ( iiniila iii.iviiiir cnir '/, < Nil >\v\ I rml with closed curettt's at end, (ixe<l in h:iii<llc r, the glid- 
 inH of tlie Limiilii lU'teriniiiiiiK' tlie oiK'iiing <pr ilo.>.ii^ of the curettes; </, curettes open, (.'nispini; hullet. 
 
 angle, but speaks highly of Hr. Lecon)te's stylet-pince. It responds as an indicator with 
 even more distinctness than the Xelaton probe in all cases in which the test would be of 
 service, while it answers for a variety of other ease.s in which Xelatons jirobe w<mld give 
 no indication at all. By it .small particles of the suVj.stance imbedded in the tissues can 
 be extracted for examination, and many foreign substances altogether removed. 
 
 In gunshot fractures of the .shafts of bones which are to be treated conservatively 
 Stromeyer advises that no probing ought to be performed, and in doubtful or in opera- 
 tion cases it ought only to be done just before the operation or under chloroform. 
 
 Electric indicators have been employed, and some are most ingenious and possibly 
 valuable, but they are not portable. The appliance of Mr. de Wilde, in which contact 
 with the metal of a ball is notified by the sound of a bell, is particularly taking, and a 
 very useful apparatus has also been made by Messrs. Krohne and Sesemann. Professor 
 Longmore speaks highly of both, but prefers the latter. It is designed to ascertain with 
 absolute certainty if a substance lodged in the body and admitting of being touched with 
 the probe or grasped with the forceps is a bullet, a fragment of a projectile, or other 
 metallic sub.stancc. The probe is elastic, and follows the track of any projectile more 
 readily than a stiff probe. In it are concealed two sharp needles, which when a hard 
 body is felt are pu.shed forward one after the other. This is done by pressing the small 
 buttons on the handles toward the probe. As soon as the two points touch the foreign 
 substance, if it be metal, the electric current passes through the instrument — a fact imme- 
 diately indicated by the hand on the dial. The hand moves actively toward either the 
 right or the left side. The forceps possess this principal advantage — that they can be 
 also used as a probe, thereby dispensing in many cases with the use of the elastic probe 
 altogether. The extremities are furnished with Assalini's points, with which particles 
 of clothing can be removed if such should l»e before the projectile. If a foreign body is 
 touched with the forceps, it should be gently grasped between both blades. If it be a 
 bullet or any piece of metallic projectile, the electric current passes through it. and the 
 hand on the dial moves again actively, as described above. It is. of course, necessary to 
 fix the connecting wires of the instrument into the brass heads on each side of the dial. 
 In the drawer below the dial there is a small battery charged with sulphate of mercury. 
 If the charge has become too dry and weak, it should be moistened with a few drops of 
 water, and a few pinches of sulphate of mercury should be added. It is to be observed 
 that the zinc plate touches the platinum points in the trough. 
 
 In exceptional and chronic ca.ses. where time has been allowed to pass, these instru- 
 ments are of greater use than in primary cases. 
 
 It need hardly be reasserted that when a ball has penetrated any of the cavities of the 
 body, such as the head, chest, or abdomen, it is not to be sought for on any account. 
 
 When a foreign body has been detected, it should be removed ; at 
 
 least, this is tlir rule. I'nxetrr's extractor. r<ini|ni>c(l of a scodji fnr liMldinf: and a pin for 
 fixing the bullet, has been highly praised (Fig. tiSl). Instruments with blades cannot be 
 recommended, as they necessitate the dilatation of the wound. 
 
 MacC'ormac writes. -'The bullet forceps I preferred was one with claw points at a right 
 angle with the handle and slightly overlapping, so as to admit of easy ingress. When 
 these catch the bullet, they rarely let it slip. The extraction of bullets, however, requires 
 
D82 
 
 OS GUXSHOT INJURIES. 
 
 fckill and patience; much injur\- may be inflicted on surrounding parts by the incautious 
 use of the bullet forcej^s." 
 
 When, from the smallness of the wound of entrance, force is required, it is better to 
 enlarge than to stretch the wound. When the foreign body rests beneath the skin, an 
 opening through it may be made. 
 
 When balls lodge in bone, they should be removed as from .soft parts ; when they can 
 be raised from their bed by an elevator, such an instrument should be employed. When 
 forceps are wanted for extraction, Luers '• sharp-pointed bullet forceps, which bite into 
 and secure a most firm grasp of the object, will best accomplish the extraction." To aid 
 extraction the gouging away of some part of the bone may be necessary. 
 
 As a rule, however, with rifle balls, the bone is splintered; and under these circum- 
 stances, when the epiphysis of the bone is involved, excision of the joint is called for 
 when the joints of the upper extremity or the head of the femur is involved, and ampu- 
 tation when the knee and ankle are injured. 
 
 After the removal of all foreign bodies from the wound, and when the parts have been 
 cleansed, they should be carefully adjusted, placed at rest in an easy position, and pro- 
 tected by wet or dry lint ; union by adhesion is out of all question, and that by granula- 
 tion alone can take place. 
 
 To hermetically seal a wound is not a practice to be generally recommended. Some 
 gentle support by means of a bandage not only gives comfort, but is beneficial. 
 
 When suppuration has taken place, the greatest care is needed to prevent burrowing. 
 As soon as abscesses form they should be lanced, and that freely. When the wounds of 
 entrance and exit are opened, the intervening sinus may be syringed with advantage, some 
 medicated lotion such as iodine water, Condys solution, or carbolic acid, one part to a 
 hundred, being used. 
 
 Under all circumstances thorough cleanliness should be observed and good food with 
 tonics and sedatives given, fresh air being allowed to circulate freely around the beds. 
 Stimulants should be administel-ed with great caution, enough only being allowed to assist 
 the digestion of solid food. 
 
 Gunshot wounds of soft parts usually suppurate about the third or fourth day, sloughs 
 mostly separate about the tenth or fourteenth, and recovery takes place in five or six 
 weeks, the wound of exit, as a rule, closius: before that of entrance. 
 
 Gunshot Wounds of the Head. 
 
 A gunshot wound of the head received from a rifle ball at full speed produces a dif- 
 fused injury to the skull and its contents; when caused by a spent ball or by a fragment 
 of shell, the injury may be localized. 
 
 In the former cases the external evidence of injury bears no comparison with the real 
 mischief the patient has sustained ; in the latter the external evidence may be greater 
 than the internal. Thus, the experience, says Pi'ofessor Longmore, of the military sur- 
 geon leads him always to hesitate in forming a prognosis, however limited a gunshot 
 injury ma}' appear to be at first observation. 
 
 Gunshot injuries are, moreover, .specially prone to be followed by diff'used meningitis, 
 encephalitis, and the formation of deep-seated abscesses, this proneness to traumatic inflam- 
 mation being clearly due to the injury the brain itself with its membranes has sustained, 
 
 for in head injuries with Avhich the 
 Fig. 682. Fig. 683. civilian is familiar this tendency to 
 
 traumatic encephalitis bears a direct 
 proportion to the injury of the cra- 
 nial contents. 
 
 The opening made into the skull 
 by a pistol ball when at full speed 
 is clean and defined ; that of exit, 
 larger and bevelled outward. They 
 are rarely complicated with fissures. 
 When, however, the velocity of the 
 ball is in a manner modified, there 
 may be the same amount of " star- 
 ring " at the wound as is seen by the 
 civil surgeon. 
 In military as in civil practice the inner table of the skull is always fractured to a 
 
 cf Ent. 
 
 Ji'ound cfJTxit. 
 
GuysifoT wor.sDs of nth: ui:m> 
 
 983 
 
 jrrfaltT i-xliiit than tlie oiittr wIumi tin- hull eiiurt from without (ri*«/«ir Fij^s. G82, GH3, 
 tuki'ii from I<<tti];mori>'.s uriifir in //o'mt/,'» Sj/Htnn). hiit the oppo-nito comlitioii exinti* when 
 till- hall |iu>.Hc> ihroii^'h tlu' xktill mi thr opposite .tide of the crutiiitm, the tuhle of the hLuU 
 i->irrf.Hpiiii{liii;; to the point of exit of the hull siifierin^ the mo>t in hoth ca.Het*. 
 
 In inilitury as in eivil pruetiee the ainonnt of external injury i^ no iniiieution of the 
 
 ml of internal mi.sehief. A >«|ient hall, u fragment (*f whell, a f*tone, may ••auM- what 
 
 ir«t to \h' only a eontiision itf the scalp, yet a frai-lure nuiy coexist with .sueh a eontu-> 
 
 >i.<ii, and a eonxiijeruhle amount of intrueranial miscdiief follow. "The amount of hruitt- 
 
 in^' ohvinus to ^i;:ht uinl the de;:ree of eoneu<««ion may have .seeme»l triflin;r. and yet the 
 
 remote eon>ei|Uenee.s may he serious enoui.di ( LoU'^niore i. 
 
 ('«uitu>ed j;un«>hot injurii-.s without any external ovideiiee of eranial mi^ehief are at 
 times a.t.soeiatetl with sueh intraeranial injury a> to }»«• followed hy a .»|ieedv death. 
 *• Contusiu'i and irlaneinjr .shot.s." say.s Dr. .\eudi»rfer of l'ra;:uf in his Mnmnil >,/ MUllini/ 
 Siiiytiy. " will either ocea.sion fissure.^, fraeture.'^, or depre.s.^ion.s or not interfere with the 
 inteirrity of the .skull at all, aecordiiif; to the velocity of the projectile and the elasticity 
 and power of resistance of tlie hoiu's." 
 
 Severe scalp wounds are jrenerally eau.se<l hy the impact of a projectile at an acute 
 anirle. I'nder such circumstances the hone i.s often left intact, and little or no injury to 
 the hrain results. 
 
 At a less acute anj;le the hone may l»c hruised. scratched, or furmwed. fissured, .starred, 
 or comminuted: and with these several conditions more or less .severe hrain svuiptoms may 
 be associated, the ^'ravity of the symi>toms dependiiiir on the severity of tlie concussion. 
 Concussion in military as in civil experience means either a temporary !4U.spension of 
 brain functions, a contusion or laceration of the hrain structure, or a more or less severe 
 extravasation of Ijlood upon or 
 
 into the brain itself, a severe con- ^'^' *''^^- ^^o. 685. 
 
 tusion of the skull without frac- 
 ture beini: <|uite i-apahle of ]>ro- 
 ducinsr a fatal laceration of a 
 villus. 
 
 '• A simple observation of the 
 injury to the outer table, whether 
 by sight or touch, will by no means 
 necessarily lead to a knowledire of 
 the amount of injury or chan>ri 
 of position in the injier table' 
 (LouLrmore). Indeed, it is <|uite 
 possible for a piece of the inner 
 taltle of the skull to be fractured 
 and detached without any fracture 
 of the external takin>: j)lace. This 
 is illustrated in Figs. 084, i'>'<7), 
 taken from the drawing of what is Ixdieved to be a unitjue specimen (2:]1.3 A. 31. AI)., 
 in the United States Museum, published in circular No. G. 
 
 When the external table has been ploughed off by the projectile, care should be taken 
 not to mistake such an injury for a fracture of both tables with depression. 
 
 In military as in civil practice, too. Jissureil /racfnna are nio.stly the result of bhiws 
 by heavy projectiles, and fissures of the inner table without external evidence of the 
 injury occasionally occur. 
 
 Contmiinif'd /ractiireii in both military and civil experience are also chieflv local 
 injuries, the fune <A' the 'ill ..r blow expending itself ..n tli.- injiin-d ^jM.t 
 
 Wounds complicated with fracture and depressed bone without 
 
 lodgment of the projectile are most serious. Of 7<i cases recorded after the 
 Ciiin.an .anq.aigii. .").") pr.pved tatal. and of the 21 survivors. 12 had to W invalided. 
 *• The .severe concussi(»n of the whole osseous sphere by the stroke of the projectile, the 
 bruising and injury to the bony texture immediately surrounding the spot against which 
 it has directly impinged, as well as the contusion of the external soft parts, so that the 
 Wound cannot clo.se by the adhesive process, constitute very important differences lietween 
 gunshot injuries on the one side and others" ( Lon;:more). 
 
 Fractures of the cranium from gunshot wonn<ls are not unfrei|uently »</my»/«V<f/'»/ irith 
 t/u rtftnfioii of f/i" pnjcch'h-. It may be that the ball has been flattened against the bone 
 and lodged in the wound, or it may be that it has been split against the fractured cranium, 
 
 Fiir. ' - 1 — I \;.ri..r \ i.-w of the inentione'l <ip«>oinh 
 Fig. (.8-">.— Fracture of the vitreou.s table of the frontal bone without 
 frnetiire of the external. 
 
 (Circular Nu. '"., Figs, i and •", Washineton.) 
 
984 ON GUNSHOT INJURIES. 
 
 one portion entering the skull and the other the integument. Under either circumstance 
 the segment that enters the skull may either lodge between the Vjone a)id the dura mater 
 or lacerate the membranes and enter the brain. Longmore gives a case in which there 
 ■was a fissured fracture with slight depression, but no hole in the skull, where, after death, 
 half the rifle bullet was found in the brain, the hole through which the half bullet had 
 forced admittance having closed as soon as it had entered the skull. He gives, also, 
 another precisely similar, which reflects great credit upon the surgeon, Dr. B. Howard 
 of the United States, in which, from the presence of a single hair protruding from within 
 the broken bone, it was inferred that a solid substance had entered the skull. Trephin- 
 ing was performed, a distorted Minie ball removed, and recovery ensued. 
 
 Rifle bullets at the usual speed, however, in the majority of cases enter the cerebral 
 mass, to make their exit, in some instances, at the opposite .side of the skull, in others to 
 rest beneath the opposite wall ; at times the ball takes a circuitous route. In all death 
 follows, as a rule, no exception to this fact having been reported from the Crimean war. 
 
 Treatment. — To do nothing active when death appears imminent is a duty the 
 student has to learn, but in the primary treatment of head injuries in the stage of col- 
 lapse, in military as in civil practice, there is no more stringent rule than to abstain fnan 
 interference — to wait and to watch. The patient should be relieved of all unnecessary 
 dress, no tight belts or garment being allowed to interfere with the respiration. He 
 should be placed in the horizontal position ; and when moved from necessity, it should be 
 done as gently as possible. When the extremities are cold, extra covering may be applied, 
 and artificial warmth when possible. 
 
 As the case develops its sui'gical treatment ought to be conducted on precisely similar 
 principles to those laid down in former chapters. Practice is to be established on the 
 preventive principle, to ward off intra-cephalic inflammation, perfect quiet, cold appli- 
 cations to the head, and liquid food being the three essentials. Foreign bodies are to be 
 searched after and removed with extreme caution. When they have entered the skull, 
 and still more the brain, all search is forbidden ; but when situated at the external orifice, 
 they should be taken away, and the sooner, the better. If a ball be so impacted as to lie 
 immovable, the wound in the broken bone may be enlarged to favor its extraction, but no 
 unnecessary interference with the cranium or its contents .should be entertained. All 
 foreign bodies in the integuments out.side the skull ought to be taken away as soon as 
 discovered. 
 
 The opinion of most surgeons is decidedly against the operation of trepln'nlng in gun- 
 shot wounds of the head. When the operation is entertained, it .should only be in com- 
 pound fractures with depression attended with brain symptoms. The experience of the 
 Crimean war, of our own as well as of French surgeons, of the Schleswig-Holstein and 
 Franco-Prussian wars as recorded by Stromeyer, of the Indian war as told us by Dr. 
 Williamson, is, without doubt, decidedly against this operation. In the Crimean cam- 
 paign the trephine was successfully employed in only 4 out of 28 cases in our own army, 
 and among the French it was for the mo.st part fatal. 
 
 The late American war, however, gives us a more favorable result — 85 recoveries to 
 115 deaths; but the report itself states that "the data are not sufficiently complete to 
 admit of fair comparative analysis," so judgment must be withheld. 
 
 In compound fracture loose fragments may always be removed. In all penetrating 
 wounds of the skull with lodgment of the projectile operative interference is out of all 
 question. 
 
 As a rule, writes MacCormac, '' the largest proportion of good results will obtain 
 amongst those cases where the amount of operative surgery has been at a minimum." 
 
 Summary. — By way of summary, it may be remembered that cerebral concussion, 
 rupture of one of the cerebral sinuses, and fatal intra-cranial hemorrhage may take place 
 from a gun.shot projectile without any external marks of injury, and that a gunshot injury 
 of the head followed by a scalp wound, without any cerebral symptom, may be followed 
 by inflammation of the bone and meningitis. 
 
 The vitreous or inner table of the skull may be fissured, depressed, and even detached, 
 without nvij fractvre of the external table. The drawings taken from Circular 6 of the 
 War Department at Wa.shington illustrate the fact (Figs. G84, 685), such accident being 
 probably the result of a small projectile striking the cranium very obliquely. Fissure 
 of the internal table may also coexist with a linear fissure of the external table. 
 
 A ball may gouge out a portion of the external table of the skull without injuring 
 the cranial contents. 
 
 A fragment or the whole of a ball may partially penetrate the skull and fall out or 
 
aussnnr wnrsits of rui-: <iii:st. imo 
 
 Ik' rctiiiiifd or pass tlir()ii;;li it, tlic wnmid of exit thnMij:h the tliickiu-ss nf Iikhc or 
 tlirou<;li tilt! two sides liciiij; lar;.M'r than tin- wound of entrance. 
 
 Penetratiiij; and perforatin;; fractures *A' liie cranium terminate favorahly in (|uitc 
 oxceittioiial instances. 
 
 Hernia or l'un;j:iis cercliri mav take |iiace alter ^'unsliof as alter otiier injuries, and 
 recovery in tliese cases may occur, tiie ex|ierience of surjreons in tlie American war 
 clearly sliowiiiij that this result is more likely to take jdace without than with compres- 
 sion or operative intttrference. 
 
 Trephining; may l>c undertaken only with a fair pros[iect of" success in local fractures 
 with depressiiin and hrain symptoms, lo(»se frairineuts of hone heiiit; always removed in 
 nil compound wouuils. 
 
 Gunshot Wounds of the Chest, 
 
 These arc returned as 1 in 10 amonji; the nfticers and 1 in IT amongst the men in the 
 Crimean war; ahout 80 per cent of these died; in the American war the mortalitv was 
 73 per cent. 
 
 Non-penetrating frunshot wounds jrenerally recover, althou<:h they are slow in healing, 
 on account of the natural movements of the rihs interrupting the process of repair. They 
 are, moret)ver, apt to be followed !iy jdeuritis, on account of the fre((uencv of the ball 
 taking a circuitous course beneath the skin round the walls of the chest. When the chest 
 has been severely contused from a spent ball or a heavy fragment of shell, abscesses, or 
 even necro.sis of the ribs, are prone to follow the accident ; and from the same character 
 of accident, where there is no fracture, the lungs may be injured, this result being like- 
 wise met with in young subjects in civil practice when the chest is stjueezed. Profe.s.sor 
 Longmore states that •• ecchyniosis, or at least congestion of the lung itself, to a partial 
 extent, in all probability follows every non-penetrating gunshot wound of the chest of 
 much severity."' The ribs may likewise be broken and "driven in, as in the direct blow.s 
 of civil life. 
 
 Pmetiiiting gunshot wounds are generally fatal, scarcely more than one in ten sur- 
 viving, while death generally results directly from hemorrhage or from the consequences 
 of secondary inflammation of the thoracic organs. The difficulties of diagnosis in the.se 
 cases are as great as they are in civil practice, especially if the bullet be small and has 
 entered obliquely near the scapula, or if the track of the bullet is covered by sound skin. 
 " It is only," says Longmore, " by a combination of symptoms, rather than by the pres- 
 ence of any one or other .symptom, that a lung wound can in many instances be diag- 
 nosed." Penetrating w^ounds w'ith lodgment of the ball are more fatal than perforating 
 wounds, and a fracture of the rib at the wound of entry renders a penetrating wound 
 more dangerous. When the lung has been wounded by a penetrating .shot, shock. C(d- 
 lapse, escape of air, hemorrhage from the external wound and from the lung, ha^mo- 
 thorax, and dyspnoea are characteristic symptoms. The shock is, however, frequently 
 less in penetrating than in non-penetrating wounds when the latter are attended with 
 general concussion. It is remarkable that a lung may at times be completely traversed 
 by a ball and beyond the haemoptysis and dy.spncca of the first few days be followed by 
 only the most trivial symptoms. 
 
 Extrrnal blee<J!tiif in chest injuries is also said to be more commonly due to laceration 
 of an intercostal or the internal mammary artery than to a wounded lung. 
 
 Internnl hieeduuj is the chief cause of death, but the surgeon has no means at his dis- 
 posal to make out the exact source of the hemorrhage. A gush of blood from the mouth 
 indicates the opening of a large vessel, but in more chronic cases the sources of the bleed- 
 ing may be pulmonary m- ]iarietal. "The situation of the wound of entrance or the 
 course the ball has taken, inferred from the relative positions of the wounds of entrance 
 and exit, will greatly help to determine the probable site of the bleeding, and to some 
 extent its probable dcfrrec of gravity. Internal bleeding from a wounded intercostal 
 artery is very rare."' 
 
 Gunshot wounds of the heart are always fatal, although not always immedi- 
 ately. In a case recorded in Circular No. ?> of the War Department at Washington the 
 patient survived fifty hours, the pistol ball having wounded the right auricle. 
 
 Treat.ment. — To arrest hemorrhage, to remove fragments of bone or foreign bodies, 
 and to do nothing that can interfere with nature's reparative processes, are the three 
 great principles of practice to be observed. They are. indeed, precisely similar to those 
 the civil surgeon follows. In bleeding from an intercostal artery the best plan is to plug 
 
986 OX GUNSHOT INJURIES. 
 
 the opening; at least, so says Professor Longmore. Tliis may be done in the following 
 way : "A large piece of linen is laid upon that part of the chest in which the wound is 
 placed, and the middle portion of this linen is pressed into the wound by the finger, so as 
 to form a kind of pouch. This pouch is then distended by sponge or lint pushed into it 
 until the pressure arrests the bleeding; on stretching out the corners of the cloth the pres- 
 sure of the plug will be increased.'" 
 
 If the wound is not attended with hemorrhage, it should be cleaned and lightly 
 closed, the side being strapped up to restrain movement. Hermetically sealing gunshot 
 wounds of the chest is reprehensible. The patient should be laid on the wounded side 
 with the wound downward, to allow of the escape of discharges. 
 
 In all other respects the treatment of gunshot wounds is similar to that of others, and 
 the remarks already made are applicable to them. Venesection is less commonly employed 
 now than it was by the surgeons of the Peninsular war, and in the American war 
 appears to have been abandoned. The dangers of inflammation of the contents of the 
 chest are the chief source of the surgeon's anxiety, and his aim ought to be to prevent 
 them if pos.sible, and when present to check them. Hemorrhage should be treated by 
 the application of cold, perfect rest, and the administration of opium. When empyema 
 follows as a secondary result, a free outlet may be made for the accumulated fluid. 
 
 Gunshot Wounds of the Abdomen. 
 
 These are mostly penetrating, and non-penetrating wounds ai'e often associated with 
 some injury of the abdominal viscera. Longmore informs us that in the Crimean cam- 
 paign, out of 115 non-penetrating wounds and contusions, 22 deaths occurred, these cases 
 including those of injured viscera. "When death follows a non-penetrating wound, it is, 
 as a rule, from sloughing of the abdominal walls. 
 
 Penetrating (jinishot ahdominal v:ovnih are generally fatal, 9 out of 10 of the Crimean 
 cases, French and English, having been so recorded. In the American campaign the 
 mortality was 74 per cent. Shock is always very great, and collapse from hemorrhage 
 the most striking symptom. This is, indeed, says Longmore, " sometimes the only symp- 
 tom which will enable the surgeon to diagnose that the viscera are perforated. The mind 
 remains clear, but the prostration, oppressive anxiety, and restlessness are intense. 
 Should life be prolonged, signs of peritonitis will soon appear. 
 
 In musket-shot wounds, it is exceptional for any of the abdominal contents to escape 
 from the opening ; but when they do, the nature of the wounded viscus will be indicated. 
 The swelling of the margins of the wound accounts for this fact. 
 
 Wounds of the Jiver are attended with a large mortality and are always complicated. 
 Shock and hemorrhage are the usual immediate causes of death ; but when life is pro- 
 longed, peritonitis. Longmore saw only 1 case of recovery in tlie Crimea, while Dr. Otis 
 records 4 recoveries in America out of 32 cases of this form of injury. In Circular No. 
 3 of the War Department at Washington, -1 cases of recovery out of 15 from this injury 
 are recorded, and in 1 the gall-bladder was wounded. Wounds of the spleen are almost 
 always fatal from hemorrhage, and are generally complicated with other injuries. ' 
 
 Grunshot wounds of the stomach are not always fatal. They are made out to exist 
 when the contents of the organ escape externally, or when, from the extent of wound, 
 the viscus can be seen. They are always a.ssociated with vomiting of blood. Hennen 
 records two good cases of recovery which occurred at Waterloo, and the well-known 
 American case of Alexis St, Martin, reported by Beaumont, is another. Dr. Peters of 
 the L^nited States army has also reported a case that occurred in the American war. 
 Guthrie and Cooper gives nine or ten others. 
 
 Treatment. — When the wound is incised, it should be stitched up. Opium should 
 be administered, with nutrient enemata. Nothing should be given by the mouth for 
 some days. 
 
 Gunshot wounds of the intestines are not necessarily fatal, although 
 instances of recovery are rare. Wounds of the large are not so bad as wounds of the 
 small intestines. Hemorrhage, and, if not, peritonitis, is the usual cause of death. 
 Longmore relates one case in which recovery took place. Dr. Hamilton of New York 
 (18G5) quotes eight cases of fecal fistula which terminated in recovery by natural pro- 
 cesses, all having taken place in the late American war, and in the older writers many 
 more might be found. Dr. Haber.shon has recorded a most interesting case of gunshot 
 wound of the colon through the right loin, the patient dying four years subsequently 
 from albuminuria (Gv>/'s Reports, 1859). 
 
aiwsii'i'r w'niwDs or ■nii: i:i..ii>i>i:i:, face, a.\i> .\j:(k. 5)87 
 
 TllHAT.MKNT. — AliMiliilr <|iiii't is the iiinsl csx-iit iiil point to Ik? oh.servcil in these as in 
 all (itlicr i"isfs lit" iil»<lnniinal injuiii's. 'I'lu- icciinilicnt positiiMi sliDiiid l»c cnlorci'd and 
 inaiiitainiHl imuUt all circiinistanft's. Opium or nmipliia slmuld alxi he ;_'ivi'n in repeated 
 (loses, no (Iru!; Iiavini; a lutter infiiience in peritoneal intlaniniatioii. Absolute cleanli- 
 ness of the wonnil shoiihl also he ohsi-rved, hut there should he no strappin;: or closing 
 of the orifice. Simple nutritious food may he allowed, and as the case proL^resses solids 
 uiuy firadnally he taken. 
 
 tWdl fistiihr appear to liave a tendency to c-lose hy theni.seivcs. In the American 
 cases thov ^uve, in tjeneral, hut little inuilile in lliiir mana;r<'nicnt (Circ. No. (I, S. (I. <)., 
 
 ist;.-)). 
 
 With reL:ard to explorini: the track nf tlic wound, the surp-on should never for^'ct, 
 .savs liidell {^Ann in itn (Jiimi., iSliT). "that in the manajrement ol" these cases Art, t<i he 
 useful, must he the servant of Nature, and must seek to do <::ood by assisting: licr ini.s- 
 tress in the elVorts to repair, and not hy the introduction of new and violent measures 
 which are liahle to airirravate the original injury." lie helievcs that neither the finger 
 iior any instrument should ])e used i'or exjiloratory purposes, except in special cases. Dr. 
 Otis, however, in Circular No. :> of the War J>epartment at Washington, issued in ISTI (p. 
 87), says that "the mortality of the.se cases is so great as to furnish an additional argu- 
 ment in hehalf of Legouest's proposition to incise the abdominal walls and exjtlore the 
 track of the ]>rojectiIe in certain ])enetrating wounds. Thus only can the patient exchange 
 the probability of inevitable death for the ])ossibility of recovery, either through the pre- 
 vention of extravasation by enterorrhapliy or the bringing of the wounded viscus into 
 ap]>osition with tlie abdominal walls. For one, I am free to assert that where there is 
 evidence that internal henuirrhage or fecal extravasation is going (jii, what may l)e termed 
 the ' ostrich plan " of giving opium and making the patient comff>rtable should he aban- 
 doned ; and I believe that prejudices similar to those that ovariotomy has successfully 
 overcome in the last (|uarter of a century will be dispelled by the results of exploratory 
 incisions in gunshot wounds of the abd(nnen liefore many years have elapsed." 
 
 Gunshot Wounds of the Bladder 
 
 do not appear to be so fatal as the cases of ruptured bladder met with in civil life. 
 Lidell reports two such cases where a good recovery followed, the projectile in both hav- 
 ing passed completely through the organ. Guthrie has related six, in all of which recov- 
 ery took place. MaeCormac records a case in which the ball pa.ssed through the rectum 
 and bladder, the feces for a time passing through the posterior opening and the urine 
 through the anterior. Both wounds closed by natural processes in seventeen days. In 
 all of these the urine escaped externally through the wound made by the projectile* and 
 thus prevented fatal peritonitis from taking place. Such instances as these indicate the 
 proper practice to be pursued in all cases of ruptured bladder — viz., cy.stotomy, as for 
 lateral lithotomy. When foreign bodies have been carried into the bladder, they should 
 be removed, as a ball may remain in tlje bladder and become the nucleus of a calculus. 
 Guthrie, llennen. Cheselden, and Garengeot have given such cases, and Ballingall has col- 
 lected in. In Circular No. o of the War l)e]iartmeut at Washington 8 cases are recorded 
 in which calculi were removed which had formed on bullets. 1 where a stone had concreted 
 upon an arrow-head, and 1 on necrosed bone. 
 
 Gunshot Wounds of the Face 
 
 are serious from the fact that they are so frequently followed by secondary hemorrhage ; 
 and, as the deep vessels are usually its source, the difficulties of controlling it are always 
 great. When this complication does not destroy life, good recoveries take place, wounds 
 of the face always healing kindly and with little scar. When there is much loss of tis- 
 sue, some secondary plastic operation may be required, and many are the instances of 
 success following this practice. 
 
 Gunshot Wounds of the Neck 
 
 are serious according to the nature of the parts involved. When the large vessels and 
 nerves are injured, a fatal result generally takes place ; and when the larN'ns or trachea 
 is implicated, the risks of suffocation are great — not only from the direct result of the 
 injur}', but from secondary oedema ; when this latter complication occurs, tracheotomy 
 
988 ON GUNSHOT INJURIES. 
 
 should at once be performed. Wounds of the neck are very liable to be followed by 
 septicaemia. 
 
 Wounds involving the vertehrse, are usually fatal, those cases alone recovering where 
 the spinous or transverse processes are the parts injured. 
 
 GUNSHOT WOUNDS OF THE EXTREMITIES 
 
 include flesh wounds and contusions, fractures which are rarely simple and compound 
 fractures, wounds of joints and compound fractures into joints. 
 
 All these may be complicated with some injury to the vessels and nerves of the part 
 and the lodgment of foreign bodies or projectiles. Grunshot flesh wounds usually do well 
 unless complicated with lesions of the vessels and nerves. 
 
 Fractures from Gunshot Wounds 
 
 are sometimes simple, but more commonly compound. When simph', they are generally 
 caused by blows from spent balls or other projectiles, the bones usually being split or 
 comminuted and contused, not rarely split vertically into a neighboring joint, the soft 
 parts equally suffering. When compound, the same comminution and splintering of the 
 bone is commonly present, associated with other complications, such as severe laceration 
 of the soft parts, involving arteries, veins, or nerves, with their attendant dangers, lodg- 
 ment of fragments or the whole of the foreign body in the bone or soft parts, and some 
 joint complication from the splitting of the bone into the joint or from direct injury to 
 the joint. 
 
 Military surgeons, however, writes Professor Longmore (in Holmes's Systevi), meet 
 with cases of partial fracture: " 1. Removal of portion of a bone by the projectile mak- 
 ing a furrow in its passage across its surface, grooving it. 2. Removal by splintering 
 olF longitudinal fragments from the external cylindrical part of a bone. 3. Removal of 
 part of the bone by completely punching out a portion, thus leaving a hole through the 
 entire substance of the bone. 4. Partial fracture by driving inward part of the external 
 cylinder and causing the fragment to lodge in the cancellated structure, with or without 
 lodgment of the projectile." 
 
 Of complete fractures, the peculiarity consists in the comminution and vertical splint- 
 ering of the bone, and of the complete removal of some part of the shaft of the bone, the 
 term "resecting fractures" being applied to such. One curious fact occasionally pro- 
 duced by the heavy conoidal ball is noticed in Circular No. 6 of the War Department at 
 Washington, in which the bone is fissured and comminuted, though less than is common, 
 at the point at which the ball impinges, while at two or three inches above or below this 
 point a nearly transverse fracture of the shaft is produced. In some of the specimens 
 the transverse fracture is not connected by fissures with the fracture produced by the 
 ball. These injuries, probably, are due to balls fired at short ranges. 
 
 When conoidal bullets, writes Longmore, happen to strike on or below the trochanters 
 of the femur, they usually leave the head and neck of the bone intact, but cause fissures, 
 which often extend to a long distance down the shaft ; when they pierce the head of the 
 bone, all the parts below usually escape fracture ; when the neck is perforated, the frac- 
 ture generally extends both upward and downward. The same rule holds good with 
 regard to the upper extremity of the humerus, although not in so marked a manner. 
 
 In all these fractures, from the comminution of the fragments and the concussion the 
 bone has sustained, o.steoniyelitis and septicaemia are liable to occur, as pointed out in 
 1860 by Jules Roux of Toulon (^BidJetin d^ r Academic Imperiale dc JIedcci)ie\ and by 
 Longmore (Med.-CJu'r. Trans., 1865). J. A. Lidell showed that gunshot contusions of 
 long bones are more fatal from this cause than comminuted gunshot fractures (^American 
 Journcd, vol. xlix.). 
 
 Fractures of the lower extremity are more liable to be followed by such blood poison- 
 ing than those of the upper, the susceptibility being much determined by the size of the 
 venous canals ; the larger and more numerous the veins of a part, the greater the danger 
 of septicaemia. 
 
 In gunshot wounds of the pelvic bones Stromeyer believes the liability to pysemia to 
 be very great, and that cold and exposure favor its development. 
 
GUNSHOT WolMfS (H- TIIK KXTliKMlTIES. 989 
 
 Gunshot Fractures of the Upper Extremity 
 
 are fur l(.'>> I'lital than tliitsi- of tin- luwi-r. " I'liles.s the hoxut he extensively iiijun.'il l»y a 
 luiissive pmjeetile or loii^itiiiliiial (•oimiiiinitinii exists tn a ^reut extent, espeeialiy il" also 
 iiivolvinj; a jdint, or the state (if the patient's hcaltli he very unfavdrahh', attempts should 
 always l»e made to save the limh " ( |jiin;/niore ). 
 
 TitKATMKNr. — When tlu' hone is niu(di splintered, an examination hy the Hn;:er for 
 foreii^n hndies or detacdied pieees of hone should he made ami their removal ert'eeled. 
 Sharp points of projeetitiir spieuhe shouhl he sawn off. the most dependent wound heing 
 extended when iieeessary, or u fresh incision made lor the jiurpose in a <lependent posi- 
 tion when only one wound exists, the ease heinir then treated as an ordinary eompound 
 fraeture. 
 
 If the shoulder and elhow-joint be opened and the condition of the soit parts, vessels, 
 etc., is not suidi as to neee.ssitate amputation, excision of the joint .should he performed, 
 the experience of the American war, as of all recent campaigns, very strongly indicating 
 this. 
 
 Gunshot Wounds ol'tlie wrist too often demand amputation : excision is not expedient, 
 hut where the major operation is not imperatively demanded attempts to save the limh 
 should he made. 
 
 The same remarks apply to injuries to the lingers and hand, and only such portions as 
 are irreparalily damaged should he removed ; for the value of a piece of thumh and one 
 finger, of whatever kind, is hardly to he overestimated, and every effort should he made 
 to preserve whatever parts can possihly he saved. 
 
 Gunshot Fractures of the Lower Extremity 
 
 are far more grave accidents than those of the upper. LongUK^'e lays it down as a gen- 
 eral rule that ordinary fractures below the knee from rifle balls -should never cause pri- 
 mary amputation, while, excepting in certain special cases, in fracture above the knee 
 amputation is held by most military surgeons to be a wcessun/ virfisure. 
 
 The special cases are gunshot fractures of the upper third of the femur, especially if 
 it be doubtful whether the liip-joint is implicated or not. as in these the danger attending 
 amputation is so great that the ([uestion is still open whether the i^afety of the patient is 
 best consulted hy excision of the injured portion of the femur, hy removal of detached 
 fragments and trusting to natural effects for union, or by resorting to amjnitation. 
 
 The decision of the surgeon must generally rest upon the extent of injury to the soft 
 parts, the age and the condition of the patient, and the surrounding circumstances. If 
 the femoral artery and vein have been divided, any attempt to preserve the limh will cer- 
 tainl)- prove fatal. 
 
 Amputation at the hip-joint for gunshot wounds is generally fatal — so fatal, indeed, 
 that it ought to be undertaken only when the lower limb is so mutilated as to render it a 
 necessity or when the great vessels have been injured. When any doubt exists as to the 
 probability of saving the limb, the operation should be postponed, and undertaken, if 
 neces.sary, as a secondary amputation. 
 
 The experience of all Uritish and continental surgeons fairly endorses Longmore's 
 conclusion.s — that while in gunshot fractures of the thigli the propriety of jtractising con- 
 servatism in the upper third is clearly indicated, amputation is the safest practice in gun- 
 shot fractures of the middle and lower third. 
 
 M. Legouest. in an essay jiublished in the Mtm. of the Society of Surgfona of Paris, 
 believes that amputation at the hip-joint should be reserved for compound fractures com- 
 plicated with injuries to the great vessels, and he advocates the postj>onement of the 
 operation as long as possible. 
 
 Ill gunshot fracture of the head of the femur, where the soft parts are not 
 greatly injured or the bone comminute<l. i.icision of the hone may be performed, the only 
 case of recovery in the American war from such an injury being where this practice was 
 adopted. In Circular Xo. 3 two such successful cases are recorded out of three, and they 
 induce Dr. Otis to " add that these instances must place excision at the hip for gunshot 
 injury amongst the established ojierations of surgery." Out of eighty-seven excisions at 
 the liip for injury in America, eight recovered. 
 
 In fracture of the thigh the evil of transporting a patient is so great that Stro- 
 meyer says, " 1 have during the last campaign lived to see what I expressed a desire for 
 some years ago when I wrote, ' Above all things it appears to me to be necessary that 
 
990 ON GUSSHOT ly JURIES. 
 
 cases of gunshot fracture of the thigh should not be transported to a distance, but should 
 be carried on a stretcher to the nearest house and the treatment carried out there.' " He 
 speaks most highly of the conservative treatment of all gunshot fractures. When opera- 
 tion is called for, primary measures should always be preferred for both amputation and 
 excision. 
 
 In fracture of the leg conservatism has even a better chance — that is, -nhere the 
 shaft of the bone alone is implicated ; for when the knee is involved, amputation is gener- 
 ally held to be the rule of treatment. Excision should not be entertained, the results of 
 experience condemning the attempt. Langenbeck recommends conservative treatment in 
 gunshot wounds of the knee, amputation being alone required when the soft parts are 
 severely injured and the bones shattered. He also lays the greatest stress upon the 
 necessity of fixing the limb in some immovable apparatus from the moment of the injviry 
 to its cure (the plaster-of-Paris splint being preferred), coupled with the application of ice 
 to the part. In gunshot fracture of the shaft of the leg bones not involving joints the 
 same rules of practice are applicable as have been laid down for the treatment of fracture 
 of the humerus, etc. 
 
 In gunshot wounds involving the ankle-jOint amputation is the best practice. In 
 exceptional instances where the injury is slight — that is, where the bone is simply split 
 into the joint — an attempt to save the limb may be justifiable. Excision as a primary 
 operation is not desirable ; as a secondary one, where an attempt to save the limb has 
 been made and failed, Langenbeck's experience is in favor of excision, nine out of eleven 
 cases in which he did it after the Bohemian war having recovered, but to obtain this 
 result he asserts that the complete immobility of the parts involved by means of the 
 plaster-of-Paris splint or one of its congeners is indispensable. 
 
 With respect to amputation in gunshot fractures, every surgeon since 
 Guthrie's time believes that the ji rim a /y should, as a rule, be preferred to the secondary. 
 This primary amputation should also be performed as soon after the accident as possible. 
 There is no necessity to wait for the effects of the shock of the accident to pass away, and 
 unless the collapse be very .severe the hand of the surgeon need not be stayed. When, 
 however, the collapse is great, some little delay had better be observed, for it is then 
 more than probable that some internal injury or other complication exists to prevent 
 reaction. 
 
 Chloroform or any other anaesthetic may be used in military as freely as in civil prac- 
 tice. It has a powerful influence in preventing shock and allowing prolonged or double 
 operations to be performed which could not otherwise be undertaken — at least, without 
 extra risk. In military practice it should be remembered that a limb must often be sac- 
 rificed when in civil practice it might be saved, and that amputation is often substituted 
 for excision on account of the impossibility of giving the part the necessary amount of 
 absolute rest and the patient the attention that can be found only in a civil hospital, " for 
 when active operations are proceeding and it is necessary to carry the wounded to any 
 distance, the advantage of early removal of shattered limbs is obvious, especially when 
 means of rendering the limbs immovable during the transport are defective or the trans- 
 port itself has to be conducted over rough roads or in unsuitable vehicles, and the hopes of 
 success from conservative treatment are thereby reduced almost to zero " (Longmore). 
 
 Dr. Gordon, the British commissioner accredited to the French army in the late war 
 between France and Prussia, informs us that the conclusions the bulk of surgeons arrived 
 at as regards amputation were that it was more suited than excision or resection when its 
 subject had to be carried on with the army ; that excision and resection were much more 
 likely to be successful when practised in the upper than in the lower extremity ; that 
 excision of the knee as a .substitute for amputation in case of gunshot wounds of that 
 articulation has sadly fixiled ; that the practice of conservative surgery in stationary hos- 
 pitals furnishes no criterion of its suitability in movable hospitals, its requirements 
 involving such attention from the surgeon as can alone be fully carried out when there 
 are comparatively few cases of .severity to attend to ; and that in many cases where the 
 limbs are saved they are relatively of little use. 
 
 MacCormac urges that the mortality after primary is so verj^ much .smaller than that 
 attendant on secondary amputation that this point cannot be too .strongly insisted upon. 
 
 The Surgical His^tory of the American War, as prepared by the late Surgeon Otis and 
 published by the American government, is a mine of practical information on gunshot 
 and other injuries incident to warfare. 
 
OSTi:<)Tn.M Y. iinsi:-si:iTis<;. OUl 
 
 OSTEOTOMY. 
 
 Wlii'ii. ill 1H70, Mr. W. Adams re|M)rtiMl his first Hucci;s.sfiil Cii.se of .subcutaiiuous 
 division of tin* neck of tlu' fciiiur for tlio ctiri.' of u deformity the result of .some old hip 
 disea.se, he iiitrodiun-d to the notice of IJrilish surgeons an operation (»f frreat value and 
 of wide application, and which, under the name of " «»steotomy, " has already won a hif:h 
 positidii in practical siir'rery. Mr. Adams, however, did not sufrjrest the operation, l»ut 
 followed lianjrenhcck, who in the winter of iSjIi first [>erformed it. and later on applied 
 it to eases of rachitic dct"iirniity of the lej^s and (tthers. At the present time Adains.s 
 o]»eration, as first dcscrihcd or with certain slight modifications, is the one emjdovfd for 
 the reclificatiiin iA' dcfurmitics in most liip cases. In ()gst(»irs and Maeeweiis operation 
 for the cure of" had cases of iiciiu valgum osteotomy is fully recognized. In the division 
 of curved or Kent hones the result of rickets it is constantly lieiiig performed, and as a 
 means of correcting the deformities due to badly united fractures or unreduced disloca- 
 tiidis it has a luight future. 
 
 Indeed, experience has fairly ]iroved that hones deformed by accident or disease may 
 be divided by the saw or chisel through a small skin W(Uind with an amount of safety 
 which is somewhat startling, and that the operation has apparently attached to it a smaller 
 number of risks than many others of a so-called minor character. 
 
 Whether the saw or chisel be used is a matter of .small importance, so long as either 
 instrument is used carefully. For my own part, I prefer the saw ; it was the one I origin- 
 ally employed in my early hip cases, and I have greater confidence in cleanly dividing 
 the bone I approach with the saw than with the chisel. When the saw is inapplicable, 
 as in the division of bones above the ankle for badly united fractures, the chisel may be 
 employed. 
 
 The wound must be kept clean during the operation, and for this purpose I hold wicli 
 my left hand, when grasping the bone operated upon, a sj)onge fiiirly filled with warm 
 iodine water, but carbolic lotion may be used instead. When the bone is divided and the 
 limb brought into the I'cijuired jiosition, the wound may be closed and covered with iodo- 
 form or carbolic gauz.e. The limb should then be at once fixed by some immovable splint, 
 such as Croft's or other pla.ster-of-Paris bandage, in the position in which it is eventually 
 to be brought. 
 
 In the majority of cases repair goes on quietly and quickly, and in five or .six weeks 
 the required result is brought about. In exceptional cases suppuration has taken place 
 In the line of bone section, and in a still fewer number one of the accidents appertaining 
 to wounds, however trivial, has brought about bad results. Accidents to deep vessels 
 have likewise been recorded, and in one a spiculum of the diseased bone perforated a 
 large artery and necessitated a series of operative proceedings which ended sadlv. Still, 
 all these evil results are very exceptional. They should, however, be rememl)ered as 
 warnings against surgeons being too strong in their assertions of the absolute safety of 
 the measure under consideration, and to remind them that interference with such tissues 
 as living flesh, bone, and blood has its ow'n dangers and risks, which exist in .spite of the 
 skill which may be brought to bear upon the case by the operating surgeon or the theory 
 under which the treatment of the wound may be carried out. 
 
 Osteotomy as an exten.sion of subcutaneous surgery to bones is a great advance, and 
 if not practised rashly is a valuable operation. Its special application to special cases 
 has received consideration in former chapters. 
 
 BONE-SETTING. 
 
 Bone-setters have acquired a position in this country, and the fact must be accepted 
 as conclusive evidence that surgeons have in a manner failed to give to the public the 
 relief that has unquestionably been given by their unqualified and so-called ignorant 
 fellow-workers, rather than as an additional testimony to the acknowledged preference 
 which a large number of the public undoubtedly have for the .strong assertions and pro- . 
 fessed power of charlatans and quacks over the calmer views and less dogmatic dicta of 
 the scientific school. 
 
 With this feeling I propose to con.sider briefly where it is that our faults lie and how 
 it is that they are to be remedied. And, first of all, where is it that surgeons have 
 failed? That the failure belongs more to the surgery of the joints than anywhere else 
 is a truism, for the f\^vorite expression of the bone-.setter that he has " put in ' what was 
 " out " before is a well-known phrase, and that the process of putting in is some sudden 
 
902 ON GUNSHOT INJURIES. 
 
 forcible movement of the joint in the way it sliould, hut would not, go, with free move- 
 ments of the joint in all possible directions, is a well-recognized form of practice. 
 
 The conclusion therefore is tolerably clear that where success follows the bone-setter's 
 effort movement is given to a joint in which little or but impaired movement previously 
 existed, and that this is effected by the breaking down of adhesions, either in the joint 
 itself or in the muscles and soft parts about the joint. In fact, his operation consists in 
 the sudden rupture or freedom of parts that forbade the free movement of the articulation. 
 
 Nothing need be said about the clicks, snaps, and sounds which are made to tickle the 
 ears of the patients and to make them understand how something that Avas out went into 
 place, since these are only "tricks of the trade," adjuncts to the empiric's art, employed 
 to secure the patient's belief in his assertions. 
 
 In one case a tendon, a rigid muscle, or a nerve is doubtless freed where it was before 
 fixed. In another an old adhesion which gave pain when extended is suddenly snapped. 
 In a third possibly some displaced tissue or slipped tendon is restored to its right place, 
 some fibro-cartilage in a joint is replaced. In rarer cases, after fracture, some osseous 
 union is broken through. In all, however, the result is the same : movement is given 
 where before it did not exist or free movement is acquired where painful movement was 
 previously experienced. 
 
 The experience of general surgeons could produce ample proof that there are evils 
 connected with the practice. The present writer has seen many ill results. In one an 
 impacted fracture of the neck of the femur undergoing natural repair was ruthlessly 
 broken up and comminvited and the man rendered an irremediable cripple. In another an 
 elbow which had been dislocated and reduced, and in which some stiffness followed, was 
 hoplessly disorganized by rough and needless manipulation. A hip-joint undergoing a 
 good cure with anchylosis, having been broken down, underwent suppuration, which ended 
 in the death of a valued life which would otherwise have been spared. 
 
 These, and more than these, speaking cases illustrate the dangers of a practice which 
 has much good in it if rightly directed, and likewise much evil if wrongly and recklessly 
 undertaken, especially if undertaken without knowledge of or care for a scientific diag- 
 nosis before treatment. 
 
 It is, however, the surgeon's duty, in these as in all other cases, to seize the good and 
 avoid the evils of a practice which — doubtless by chance — at times does much good, and 
 there is no doubt that for fear of doing harm surgeons often let the good go, and thus 
 allow their patients to pass into the hands of charlatans. 
 
 The surgeon ought, therefore, in cases of stiff joint, more particularly after sprains 
 and injuries, when all signs of overaction or inflammation have subsided, gave an anaes- 
 thetic and employ sudden forcible movement. He ought to guard against stiff joints in 
 the treatment of those injuries by employing passive movements earlier in the progress 
 of the case than he has been wont to do. In many obscure affections of joints and limbs 
 the result of twists, sprains, or injuries, he ought, for diagnostic as well as curative pur- 
 poses, to give an anajsthetic and so to manipulate the joint and limb as to discover if pos- 
 sible, and to dislodge or replace if present, what evidently interferes with motion at the 
 time and may continue to do so in the future. 
 
 In cases of limited disease of the joints there is no doubt, also, that much may be 
 done to prevent stiffness and to correct it when present, but in such cases a great appre- 
 ciation of the changes in and about the joint which preceded the stage of stiffness is all- 
 important — first, as a guide to know what prospects there may be of giving the move- 
 ment that is so desired ; and secondly as to the risks tJiat must be run to obtain it. 
 
 When the anchylosis or stiffness has been brought about by a long series of joint 
 changes, any attempt to break down united parts must of necessity be difficult, futile, 
 and dangerous in the extreme. 
 
 When it is probably due to some peri-articular inflammation, the prospects of obtain- 
 ing a good result are better. At the same time, it is to be admitted that the ultimate 
 results of breaking down adhesions about or in joints that are the result of disease with 
 the view of giving movement are not satisfactory. Movement for a time may be secured, 
 but the state of immobility is again soon reached. 
 
 On the whole, by way of summary, it may be said that the stiffness of a joint follow- 
 ing a sprain or injury may generally be treated with success by rapid manipulation, fol- 
 lowed up by passive movements through the entire range of joint movements, whereas 
 the stiffness of a joint due to disease can rarely be so treated without harm. 
 
 But in no case should forced flexion or movement be employed when any local signs 
 of inflammation are present. 
 
A y. ESTHETICS. li"J3 
 
 C'llAPTKK XXXV. 
 A.\ j:st II i;t I cs. 
 
 General Remarks. 
 
 WiiK.N Sir II. |);ivv's attfiitiuii was diawii in IT'.'S to Priestley's nitrou.s oxide f:as by 
 Ih". .Nliti-lu'll .-^ tliiMtry that this ;^as •* wa.s the |iriiici|»le of eoDta^'iuii and cajialde <if" yro- 
 dueinjj the must terrihle eHuets when resjiired liy aiiiiual.s in the minutest (juantities, or 
 even when upplii-d to the skin or museular tihre,'' and when he with Southey, the then 
 poet-hiureate, and Coleridjre, the ]diilusoi»her, inhaled it with suffieient l're<|uency "to 
 estahlish the t'aet that the ga.s i)osses.st'.s an into.vieating quality to whieh the enthusia.sm 
 of persons submitting to its ojieration ha.s imparted a eharacter of e.xtravajrance wholly 
 ineonsistrnt with truth" ( //('/'■ <>/ V'l'i/. by Paris, ISIJlj — he little thouj_'ht he was then 
 layini: the basis of experimental iuvestiLMtions that were t(» form an epoch in the hi.story 
 of the world — or, rather, of mankind — and to end in the introduction into jiractice of a 
 new ]>ower, which, being of inestimaliie value ty the general jiublic, is of nearly e(|ual 
 value to the medical jirofessiun, and has been the means of revolutionizing surgery to an 
 extent of which few are aware; for the -most terrible effects" with which thi.s gas wa.s 
 credited have been transformed into the beneticial effects brought about l»y anaesthetics. 
 
 In th.e ju'esent work I have neither .space nor inclination t(t go fully into the history 
 of the subject. To the works of Snow, Sir James Simi>.son. Saiisom, J)ruitt. Holmes. Dr. 
 Marion Sims, and MM. Perrin and Lallemand I must refer the reader for full [larticular.s 
 on this subject. I shall content my.self by recording the fact that Dr. Crawford W. Long 
 of Athens. Georgia, was the first surgeon who, in March, 1842, performed a surgical ope- 
 ration while the patient was completely anaesthetized by the inhalation of sulphuric ether. 
 Dr. Marion Sims ( Viiyinin Mediial MmitliJi/, May. 1877) remarks '"that the honor of the 
 first public and authentic trial of surgical amvsthesia by the aid of means newl}- dis- 
 covered belongs to an entirely obscure dentist, Horace Wells of Hartford. Connecticut " 
 (M. Perrin), this dentist having emjiloyed Davy's nitrous oxide gas in dentistry in 184tr 
 with an excellent result. In lS4(i. Morton, Wells's late partner, introduced into practice 
 at the Massachusetts Hospital the use of sulphuric ether, probably on the suggestion of 
 Dr. Jackson. In 1S47 our own Lawrence of St. Bartholomew's, on the suggestion of a 
 student — Mr. Furnell. now principal of ^Madras Medical College — used chloric ether for 
 the same purpose (Ilofi)irs's S^sf.. vol. v. 2d ed), and in the autumn of the same year Sir 
 James Simpson gave to the profession the active principle of the chloric of ether, the 
 chloroform, on the suggestion of Mr. Waldie of Liverpool, and since then this drug or 
 ether, separately or combined, has been in general use. 
 
 Other anaesthetics, however, have been introduced, the bichloride of methylene being 
 the most popular. 
 
 How aujvsthetics act upon the body is not yet determined, although it is tolerably 
 certain that the ultimate result is al>.solute paraly.sis of the nerve centres, cerebral and 
 spinal. To this end a patient pas.ses through, frsf, a stage of cerebral excitement ; »'.//, 
 cerebral insensibility and loss of sensation ; fhin////. loss of voluntary motion ; and Insf/i/, 
 loss of reflex action, the brain losing its power before the spinal cord, absolute paralvsis 
 and anaesthesia existing only when both nerve centres are completely under the influence 
 of the inhaled drug, the nerve supply of the respiratory and circulatorv .systems alone 
 excepted. Indeed, it is upon this fact that the practical value of all antvsthetics is based, 
 the surgeon aiming at producing paralysis of the mu.scles of the trunk and extremities 
 only, and not those of the respiratory or circulatory .sy.stems. In a general way. there is 
 a wide interval between the two effects. In exceptional instances this interval is abridged; 
 in such the heart and respiratory .system suddenly become affected, and it is under these 
 circumstances that sudden death takes place. 
 
 Chloroform, like many other drugs, does not act alike in all individuals, some beinir 
 very susceptible to its influence, whilst others are the reverse. Like all anfe.sthetics, it 
 at first increases the force of the heart's action, although this effect is slight and transient, 
 the heart acting with less than its natural force when complete anaesthesia is produced. 
 When a patient is brought quickly under the influence of an anaesthetic, the hearts 
 action may be suddenly arrested. Brown-Sequard believing that under such circumstances 
 63 
 
994 ANESTHETICS. 
 
 '•it is by the reflex influence due to the sudden irritation of the branches of the par 
 vagum in the lungs that chloroform has killed in the very rare cases in which the hearts 
 action had been stopped before the respiration" (Li^ct. on Phi/.-i. of Nerve Si/Hfem). 
 
 Moderate doses of chloroform tend to weaken the heart's action after their first stimu- 
 lating effects have passed away, the respiratory act usually ceasing before the circulatory 
 when death is the result. Thus, danger increases with the degree of stupor produced. 
 
 Ether is said not to depress the action of the heart to the same extent as chloroform. 
 Of late it has grown rapidly into favor, and it is said by its advocates to be more safe 
 than any other ansesthetic. It should be given with sufficient freedom to bring the 
 patient under its influence before the blood becomes saturated. 
 
 When the upper eyelid can be raised without muscular re.sistance and no muscular 
 contraction is caused by touching the cornea, the patient is. as a rule, sufficiently under 
 the influence of the anaesthetic for surgical purposes. 
 
 Respiration generally, but not invariably, ceases before the action of the heart, and 
 death may be due either to the failure of the heart's action or to that of the respiratory 
 function. 
 
 After death all the cavities of the heart are distended, the cases in which the left side 
 is empty being only exceptional. Chloroform is more commonly fatal in the struggling 
 stage than in any other. 
 
 Billroth asserts " that during the stage of excitement violent muscular efforts may 
 give rise to apoplexy, especially in individuals with disease of the heart, rigid arteries, or 
 emplrvsema. Of mo.st consequence in this stage, however, are the contractions of the 
 muscles of mastication and the posterior muscles of the tongue. By means of the 
 stylo-glossi and the glosso-pharyngei the tongue is drawn spasmodically backward, press- 
 ing the epiglottis down so as to close mechanically the aperture of the larynx. Such 
 patients become blue in the face and die suffocated — not through the direct action of the 
 chloroform, but from the mechanical privation of air." unless the tongue be well drawn 
 forward or the chin tilted upward. 
 
 Anaesthetics affect the brain of different people in as many ways as drunkenness. One 
 will be quarrelsome, a second violent, a third sentimental, and others maudlin, melan- 
 cholic, or merry. 
 
 In epileptic subjects I have seen patients pass through some epileptic convulsions 
 during their progress toward narcosis. 
 
 The best rules for the administi-ation of chloroform, ether, or any anaesthetic are those 
 given by the chloroform committee of the Royal Medical and Chirurgical Society of 
 London (1864). It was my privilege to act as one of the members of that body, and all 
 my subsequent experience has convinced me of the value of the suggestions then laid 
 down. I quote them in full, with only a few modifications. 
 
 Rules relating to the Administration of Anesthetics. 
 
 Anaesthetics .should on no account be given carelessly or by the inexperienced ; and 
 when complete insensibility is desired, the attention of the administrator should be exclu- 
 sively confined to the duty he has undertaken. 
 
 Under no circumstances is it desirable for a person to give an anjesthetic to himself. 
 
 It is not advisable to give an anfesthetic after a long fast or soon after a meal, the 
 best time for its administration being four or five hours after food has been taken. 
 
 If the patient is much depressed, there is no objection to his taking a small quantity 
 of brandy, wine, or ammonia before commencing the inhalation. 
 
 Provision for the free admission of air during the patient's narcotism is absolutely 
 necessary. 
 
 The recumbent position of the patient is preferable ; the prone position is inconvenient 
 to the administrator, but entails no extra danger. In the erect or .sitting po.sture there is 
 danger from syncope. Sudden elevation or turning of the body should be avoided. 
 
 An apparatus is not essential to safety if due care be taken in giving the anesthetic. 
 Free admixture of air with the anjesthetic is of the first importance, and. guaranteeing 
 this, any apparatus may be employed. If lint or a handkerchief or a napkin is used, it 
 should be folded as an open cone or held an inch or an inch and a half from the face. 
 
 Chloroform should invariably be given slowly. Sudden increase of the strength of 
 the anaesthetic is most dangerous. Three and a half per cent, is the average amount, 
 and four and a half per cent., with ninety-five and a half of atmospheric air, is the 
 maximum of the anaesthetic which can be required, given cautiously at first, the quantity 
 
A N.ESTIIKTICS. !»!»5 
 
 within tliis limit ln-iiiL.' >l<>\vly iiificuNfil acfonliii;; to tliu iit;i!L'.s>itii's of tlu; cum.', the 
 ailiiiiiii.stnitor h«-iii<; ^iiidt-d niori' hy its etf'ect on tliu patietit than by tlie amount cxliih- 
 itftl. KthtT may he jrivi-ii mori' Ixthlly. 
 
 'IMio aihiiinistrator .shwiihl watch tht* rusiiitutimi ot' hi> patient, ami iniist keep mie hand 
 free fur earefiil ohservatinn of the pulse. 
 
 When palient.s hohi their hreath, more air should he admitted; and when the move- 
 ment of swallowing is seen, it should hi- accepted as evidence that the an.esthetic i.s 
 .Htroni;er than necessary. On any soiiml of stertor IVesh air sliouhl he admitted. 
 
 The patient who apjtears likely to vomit whilst he^innin^ to inhale the an;i'sthetic 
 must at once he hroiijiht I'ully under its influence; tlu; tendency to sickness will then 
 
 ceas* 
 
 The occurrence duriuL' the ailministration of an aujosthetic of sudden pallor, lividity 
 of the patient's countenance, or sudih-n failure or flickeriuir of the ]»ulse, or fcehlo or 
 shallow respiratittns, indicates danger and necessitates immediate withdrawal «jf the an;es- 
 thotic until su(di svinptoms have disappeared. The chin should he raised as much as 
 possible fnun the sternum , and if this movement fail to open the larynx, tlie toiifjuc 
 »huuld he jniUeil forward and the head drawn back. 
 
 Nelaton and Marion Sims advise the inversion of tlie body, with the view of throwing 
 what blood there is wholly to the brain, on the theory that death IVoni chloroform is, as 
 a rule, due to syncope or to cerebral amvmia. In the more threateiiiii'.'' cases commence 
 instantly with- artificial respiration, whether the respiration has failed alone or the jiulse and 
 the res]>iration together. (Jalvanism may be used in addition to artificial res])iration, but 
 artificial respiration is on no account to be delayed or suspended in order tluit galvanism 
 may be tried. 
 
 In extreme cases larynj^otijmy may be re(|uired. 
 
 Few. if any. are insuscei)tible to the influence of anivstlietics. from two to ten minute.s 
 beiui; rei|uired to induce aiutsthesia. The time varies accordinir to atre, temperament, and 
 habits. 
 
 The mixture of alcohol (jne part, chloruform two ])arts, and ether three jiarts, which 
 should be mixed fresh before use, should be given in the same way as chloroform alone, 
 care being taken, when lint or a handkerchief is u.sed, to prevent the too free escape of 
 the vapor. 
 
 In Vienna the favorite mixture is three parts of ether to one of chloroform. Billroth 
 employs chloroform three parts, ether one part, and alcohol one part. 
 
 Use of Anesthetics in Surgical Operations. 
 
 Any person fit for a severe operation is a fit subject for an anaj.sthetic, but no one i.s 
 so free from danger that care in watching its effects can be dispensed with. The cases 
 rer|uiring the greatest vigilance are not the young and delicate, for whom a small dose 
 suffices, but the strong, who inhale deeply and struggle much. Ether is probablv better 
 for those suspected of fatty degeneration of the heart, although, as a rule, such cases are 
 eminently satisfactory under chloroform. 
 
 In phthisis, when an operation is unavoidable, antx^sthetics may be given with impunity. 
 
 For all iiperations upon the jaws and teeth, the lips, cheeks, and tongue, anaesthetics 
 may be inhaled with ordinary .safety. By care and good management the patient may be 
 kept under their influence to the completion of the operation. In these ca.ses blood, "as it 
 escapes, if not voided by the mouth, passes into the pharynx. If any small (|uaiitity 
 finds its way through the larynx, it is readily expelled by coughing. In ojierations u])on 
 the soft palate, fauces, pharynx, and posterior nares, if .sudden or severe hemorrhage is 
 likely to occur, it is not advisaltle to induce deep insensibility. In ca.'*es re((uiring larvn- 
 gotomy and tracheotomy anaesthetics may be employed with safety and advantatre. 
 
 For operations upon the eye involving the contents of the globe the use of an.fstheties 
 is open to objection, on account of the damage which the eye may sustain from muscular 
 straining or vomiting. If employed, profound in.sensibility should be induced. Keeent 
 experience tends rather to prove that ansesthetics may be used without fear in most eye 
 operations. 
 
 In operations for hernia and in the application of the taxis ansesthetics act most bene- 
 ficially. For most operations about the anus and perinwum profound anaesthesia is 
 positively demanded. 
 
 In the condition of shock or of great depression, as after hemorrhage, the careful 
 administration of ana;sthetics diminishes the risk of an operation. 
 
996 
 
 ANESTHETICS. 
 
 In all cases other than those sj^ecially referred to it is sufficient to state, so far as a 
 mere surgical operation is concerned, that anaesthetics may invariably be administered. 
 
 The continuous vomiting occasionally induced by and following upon the inhalation 
 of anaesthetics may be injurious by consequent exhaustion as well as by mechanically 
 disturbing the repair of a wound. With this reservation, they do not appear to inter- 
 fere with the recovery of patients from 
 surgical operations. 
 
 The results of 2586 capital operations 
 performed before, and of 1847 performed 
 since, the introduction of anaesthetics, which 
 I collected from all authentic available 
 sources, show that the rate of mortality 
 has not been increased, even though much 
 graver operations have been done under 
 the influence of anaesthetics. The risk 
 attending the inhalation of chloroform is 
 - very small, being about 1 in 3000 admin- 
 istrations. This is enough to forbid its use 
 in trivial cases, but not enough to do so in 
 cases of capital operation or where it is re- 
 quired for purposes of diagnosis. In chil- 
 dren it is very safe. 
 
 The best instrument for the administra- 
 tion of chloroform I believe to be that of Junker (Fig. 686). In it a drop of chloroform 
 vapor is vaporized by each full compression of the air-ball and a stronger vapor cannot 
 be given. It may be employed without the mouth-piece. If the ball is compressed 
 before each insi^iration, no vapor will be lost. I use nothing but this in my own practice. 
 The older instrument which I introduced at Gruy's in 1864 (Fig. 687) is, however, porta- 
 ble and good. It is not complicated by any valves, but is merely a mouth and nose-piece 
 lined with lint, with openings to admit air freely. Within the last few years Skinner's 
 inhaler, composed of a framework of wire covered with a layer of flannel, fastened to the 
 frame by a gusset and tape, and a handle, has found much favor and is very useful. 
 
 Clover's apparatus is, however, very good when it can be obtained. It is composed of 
 an india-rubber bag into which chloi'oform or any other anaesthetic is pumped, mixed with 
 atmospheric air. Clover employs three or four per cent, of chloroform. It is, however, 
 a cumbersome apparatus and cannot be at universal command. When he gives nitrous 
 
 Junker's Chloroform Inhaler. 
 
 Fig. 6S 
 
 Fig. 688. 
 
 Chloroform Inhaler. 
 
 Inhaler with Bottles and Perforated Inhaler as Ap- 
 
 Strap Complete. plied. (Rendle"slnlialer, 
 
 as improved by Morris.) 
 
 oxide gas at flrst and follows it up by ether, his apparatus is equally satisfactory. For 
 ether or the anfesthetic A. C. E. mixture the leather bottle-shaped apparatus, as sug- 
 gested by Dr. Golding Bird, or the one figured above as made for Mr. Eendle and 
 improved by 3Iorris (Fig. 688), is very valuable. 
 
 The bichloride of methylene is recommended to our notice as an anre.sthetic of 
 great power. Patients are said to be brought under the influence of the drug in twenty 
 or thirty seconds, and to recover from it rapidly with little inconvenience. No sickness 
 or headache is said to follow its use, unless the inhalation has been continued for many 
 minutes or a second dose is given to keep up the effect. Of course, if the inhalation be 
 prolonged, the after-eff"ects resemble, though in a less degree, those of chloroform, .save 
 the one — absence of muscular excitement. 
 
AS.r.sTiiiyriCS. 007 
 
 Dr. Bouchut ((itixittc (ha Ilnplttiiu) recuiuinciiils tlio use of chloral as an aiifi'sthctic 
 for i-liiltlrcii. lit' ^ivcs one dosi;, not fXCfiMJiii;,' rnrlv-live jrrain.s, in rliililrcn umlcr tiiree 
 yoars of aj^o. In half an hour the patient is ash'i'|i. anti in an hi»ur insfn.sihle. The anius- 
 thesia lusts fnnii three tn six hours and is l'i)ll()\vetJ hy no nM|ili'asant eonser|iienees. 
 Thirty j^rains may he t^iven without dan;;er, liouehut suys, tn cliililitn lietwcen twn and 
 five years id' ajre ( lin't. Mni. ,/inini., Novenilier HI, 1H7.S). 
 
 In ahdouiinal surjxery, such as ovariotuniy, Keith has said that ether is less prone to 
 he followed liy sickness than chloroform ; and if the success of an operation is any ar^ru- 
 inent in its I'avor, Keith's must he ((uoted. I have for some years emplr)yed the mixture 
 recommendetl hy the chloroform committee — of alcohol, chloroform, and ether — and think 
 wtdl of it. I helieve it to he as •rimd as chloroform, and less likely than any other t<j he 
 followed hy that hane of all amesthetics, vomitinLT. 
 
 In the operations of dentistry and all short measures the nitrous oxide gas is of great 
 value. 
 
 After the use of any an;esthetic everything should he given cold for twelve or tweiitv- 
 four hours, to prevent sickness; ice, indeed, may he sucked with advantage, ami ic(; and 
 milk form a very favorite mixture. If hot food he given, vomiting is far more likely to 
 appear or to he aggravated. 
 
 Secondary Uses of Anesthetics. 
 
 Anjesthetics, however, have other uses than tlie destruction of pain. As aids to diag- 
 nosis they are of priceless value, both to the jjhysician and to the surgeon. To the sur- 
 geon they have al.so opened up new fields for his scientific art which were formerly hut 
 little known. I shall point them out, liowever, but briefly, quoting from a lecture I had 
 the honor of delivering at the Ilunterian Society in 1<S70 : 
 
 " Chloroform as an aid to diagnosis stands second to no means which we have at our 
 disposal. T(t the physician who has a difficult case of abdominal tumor, what facilities it 
 gives him for its thorough investigation ! Suspected tumors become jdiantoms : so-called 
 movable kidneys slide away and indefinite conditions become clear and intelligible. With 
 how much greater certainty a physician can think over a doubtful case, decide upon its 
 nature, deliver his opinion, and treat it, when he has adopted this means of investigation ! 
 In hysterical subjects it renders a thorough abdominal examination a possibility when no 
 such otherwise existed, and in what class of cases, may I ask, is it more necessary to 
 make a positive diagnosis than in this ? In my own practice it enabled me on one occa- 
 sion to make out a pregnancy when an ovarian tumor had been diagnosed by men whose 
 authority was undoubted, and in a patient who.se position in life rendered the suspicion 
 of pregnancy almost a libel. Indeed, the ovarian nature of the disease was looked upon 
 as so decided that my aid was sought solely for the operation. In this ca.se an examina- 
 tion of the abdomen was impossible, from hysterical sensibility ; but under chloroform all 
 difficulties disappeared. To the physician-accoucheur may I not also assert it to be 
 e(|ually valuable for diagnostic ])urpo,ses? To answer this fully is out of my province, 
 but I have known a case of cystic disea.se of the uterus which was about to be operated 
 upon as an ovarian tumor made out ))y the use of the uterine .sound, with the patient 
 under chloroform, when an examination by the .same in.strument made before had failed 
 to yield any such evidence. In the surgical diseases of children is it possible to overesti- 
 mate its value ? With what gentleness can difficult examinations be now made of injured 
 limbs ! and with what certainty can we now apply our treatment ! In sounding for stone 
 what facilities it affords ! In general surgery what new fields has it not opened ? Would 
 nephrotomy or nephrectomy have been entertained ? Where would ovariotomy have 
 now been, may I ask, had not chloroform been in use? Would it have been an estab- 
 lished operation in surgery ? Could it have been so succes.sful ? The answers to the.'se 
 questions. I think, are plain : they must be in the negative. It is true the operation had 
 been performed before its introduction ; it had been succe.ssful in a few cases, but it had 
 almost fallen out of practice ; its revival was due, without doubt, to chlorofm-m, and its 
 present estal>lished position to the general use of that drug. Xo operation re(|uires more 
 gentleness and nicety, and how could these essential points of practice be apjilied with a 
 patient writhing under the agonies of an abdominal section? To all abdominal surgery 
 the same observations are applicable, although they may not tell, perhaps, with the same 
 force. Without anaesthetics could Bigelow have perfected his rapid lithotrity ? and 
 would Thompson have practised so boldly his operation of cystotomy for the removal of 
 bladder tumors ? 
 
998 ANJESTHETICS. 
 
 " Let us now refer to another class of cases — to that Large one. known as belonging to 
 plastic surgery. How many cases of vesico- or recto-vaginal fistula were successfully 
 treated by operation before chloroform was introduced ? At Guy's Hospital I can find 
 no record of such. The physician-accoucheur used to cauterize the margins of the fis- 
 tula, it is true, but, 1 fear, with poor success ; for I have never heard of a case of any 
 size being so cured. At the present day these cases are now to be cured by operation 
 with as much certainty as any other class. They have, in truth, been removed from the 
 incurable to curable affections. And yet these instances of plastic surgery are only a 
 portion of those which I might enumerate. 
 
 " In the treatment of deformities about the mouth, nose, and eye. in the division of 
 cicatrices after burns, in the ti'eatment of ruptured perineum with all its complications, 
 what innumerable cases might be quoted now, against the few of former times ! 
 
 " Again, in the operations on bones and joints, how many of the improvements in our 
 practice are there that may not be put down to the use of chloroform — operations for 
 necrosis in particular? How rare these were, and how unsatisfactory they must have 
 been, before its introduction ! I can recall a few which I saw in my student's days with 
 no pleasant feeling. How common they are now, and how successful ! Taking Guy's as 
 a type of the metropolitan hospitals, an operation for necrosis can always be found for 
 operating days, the operation is so frequent and so satisfactory. In the removal of bone 
 from joints, in the excision of joints, it is only fair to believe that a great part of the 
 success which now attends the practice is to be attributed to the use of an anaesthetic. 
 How many hands and feet which would formerly have been sacrificed are now saved by 
 the removal of diseased bone it is difficult to estimate. Would Sir W. Fergusson have 
 framed the phrase ' conservative surgery,' and could it have been adopted, before the 
 introduction of chloroform ? 
 
 " In the treatment of aneurisms have not like improvements to be recorded ? Has 
 not chloroform rendered possible the cure of aneurism by pressure ? Has it not also 
 rendered the practice of torsion of arteries for the arrest of hemorrhage a practical suc- 
 cess, thus simplifying surgery ? How many cases of strangulated hernia are now 
 reduced which in former times would have been submitted to strange treatment and to a 
 delayed operation ! How simple it has comparatively rendered the reduction of recent 
 dislocations ! Whei-e are now the pulleys, the ropes, and the other frightful mechanical 
 appliances that were used of old for the reduction of dislocations of the hip-, shoulder-, 
 and other joi«ts? Are they not decaying in the lumber-rooms of our hospitals? and 
 has not the use of chloroform made the reduction of dislocations by manipulation a 
 reality? On one occasion I reduced with ease, by manipulation, a dislocation of the 
 elbow-joint backward, complicated with fracture of the humerus, which would pi'obably 
 have been left unreduced before the introduction of the anjesthetic, and more recently 
 the head of the humerus dislocated on to the dorsum of the scapula, complicated with 
 fracture through the tuberosities. 
 
 " Let us contrast for one moment the operation of perineal section for stricture as it 
 was and is now performed. Do we not all remember it as one of the most unsatisfactory 
 and unsuccessful of surgical operations? Do not we know it to be one of the most satis- 
 factory and successful? Indeed, I might continue the contrast between the pre-an£es- 
 thetic period and the present, but I think I have said enough to show that to the 
 introduction of chloroform many of our best improvements in surgical practice are to be 
 attributed. For the surgeon it does away with all excuse, if any ever existed, for huriy 
 in an operation. He can take his steps in it with deliberation and make it a certainty. 
 We never s-ee now, happily, a theatre full of spectators observing the operation watch in 
 hand, and I trust there are few, if any, surgeons who at the present day sacrifice safety 
 and certainty in their operations for expedition and display. The use of anaesthetics has 
 rendered the practice of surgery safer, surer, and more scientific. It has removed dif- 
 ficulties from the practice of our art which before were insurmountable, and has rendered 
 possible innumerable things that could not in former times have been entertained." 
 
 Local anaesthesia may be brought about \)\ freezing a part, as suggested by Dr. 
 J. Arnott, or by means of the rapid evaporization of pure anhydrous ether, as practised 
 by Dr. B. W. Richardson. Both are valuable means of diminishing pain where anaes- 
 thesia by inhalation is forbidden or inapplicable. Arnott's plan is carried out by mixing 
 up finely-pounded ice in a gauze net or thin translucent india-rubber bag with half its 
 bulk of powdered salt, the net being placed over the part to be benumbed. If well 
 applied, it renders the skin at once pale and bloodless ; and if continued, of a tallowy, 
 death-like aspect. When too long applied, it may produce frost-bite or chilblain. 
 
AMi'CJ.irios. 999 
 
 |)r. Uirliiinlsdn's ttlicr spray is a iimrf t'Ir;:atit, as it is a more cflTi'Ctual, ni(»(k' of 
 ap|»lyiii;; Ideal aii:t'sllif>ia than icr. It is workcil l»y liis wctll-kiuiwii a|i])aratus, con- 
 sist iiii; of a tiilK' with iiulia-nililicr hall and .second sprinj; hall to make the current con- 
 tinuous, the air hein>; pumped in through 
 
 this tuhe into a hottle ennfainiuL: anhy- I'l'i- 'i^O. 
 
 (Irons ether of a sp. ;:r. ^K~'-'.\ and ot" a . 
 
 hoilinti-lioint of* '.>(i° Kalir. Throujih the /• 
 
 stopperi'tl neck ol" this hottle a ^lass tuhe ,i. "' 
 
 is ]>assed. whitdi rea(du'S at one end nearly ^"^"^Nv/l^ 
 t(t the hottom of the hottle and at the other 
 is fitted with a point with one or more per- 
 forations, throuuh which the ether is forced 
 in a fine spray, this spray lieinir directed 
 upon the ]»art to he Itenumhed ( Fi":. (iS9). 
 
 For openinir ahseesses. takin-- out snnill ,„ ,;i,.|,ar,i.so..'s Apparatus. 
 
 tumors, the removal of external )»ilcs, and 
 
 other minor o]>eratioiis. this local an;csthesia is of frrcat value, hut in graver surfrical 
 act.s it is inapplicahle, as it affects only, the surliice and is but skin-deep in its influence. 
 
 CHAPTER XXXVI. 
 
 AMPUTATION. 
 
 General Remarks. 
 
 When a limb is saved by the excision of a joint, and life prolonged by the application 
 of a ligature to or the torsion of a wounded or diseased artery, surgical science claims a 
 triumph ; and surely an ef(ual triumph ought to be accorded to her when, by the removal 
 of a part that interferes with its duties, life is rendered more valuable,; or by the amputa- 
 tion of a limb that is irreparably injured or diseased death is averted. To say that ampu- 
 tation is an opprobrium of our art is to take a. narrow view of its objects, since, as the first 
 object of the surgeon is (o save life, the necessary sacrifice of a limb becomes the truest 
 coiisorvadRm. To sacrifice a limb unnecessarily is an error which the surgical mind would 
 never willingly commit, although to sacrifice life in the feeble effort to save a limb is one 
 of far greater magnitude. It is an error, however, that timid surgeons are too likely to 
 fall into when inoculated with the narrow views of a spurious conservatism, since to leave 
 a limb alone with the hope of saving it is a passive act of the professional mind that 
 refjuires no effort, wliilc to make up the mind to act recjuires courage backed up with 
 knowledge and a full sense of responsibility. The operation of amputation itself re(|uires 
 nicety and well-a]iplied mechanical skill, but to determine upon its necessity or other- 
 wise requires a high order of knowledge, a careful lialancing of probabilities, and much 
 deci.sion. 
 
 It is not my intention to discuss in the present chapter the conditions under which 
 amputation may be called for, since these have been fully considered in the difierent 
 chapters devoted to such injuries and diseases as may require this treatment. I propose 
 simply to consider amputation as an operation, to point out the best modes of its perform- 
 ance under the different conditions in which it may be demanded, and to describe the 
 various forms of operation as applicable to different parts. 
 
 To supply the history of amputation would be an interesting but a too extended 
 process. In Cooper's Sun/irn/ Dictiovnn/ and Hohness Si/stein two able ax"ticles will be 
 found upon the subject which contain all that can be desired. For the present purpose 
 it will be enough to state that the first amputations were performed by the clrcuhtr method, 
 the soft parts being divided down to the l)one by a circular sweep of the knife {ri<h Cel- 
 sus), the hemorrhage being arrested by the red-hot iron and the bone divided by a .saw. 
 
 About 1718, J. L. Petit, the French surgeon who improved the tourniquet now known 
 by his name, as well as our own great surgeon, Cheselden, suggested that the skin and fat 
 
1 000 AMP UTA TIOX. 
 
 of the limb to be removed should be first cut throuuh and retracted and then the muscles 
 and bones divided as high as they were exposed. Still later, Louis of Paris adopted the 
 practice of dividing by the first cut the skin and superficial layer of muscles, by the second 
 the deeper muscles down to the bone at the line of the retracted superficial layer, and 
 lastly the bone itself. He also used a retractor. 
 
 In 1779, Alanson of Liverpool made a still further advance by cutting the integument 
 as usual and allowing it to retract and then dividing the muscles obliquely upward, cutting 
 from without down to the bone, more after the modern flap operation, the bone being sub- 
 sequently divided. The soft parts in this operation on being brought down formed a con- 
 ical cavity with the bone at the apex, Alanson's object having been to prevent the sugar- 
 loaf stump. Still later, Benjamin Bell of I']dinburgh and Hey of Leeds secured the same 
 end by first dividing the integument with a circular cut and dissecting it up, then the mus- 
 cles at a higher level, and lastly the bone, this being divided at a point considerably above 
 the line of the retracted muscles. Hey, moreover, in the thigh amputations suggested the 
 expediency of dividing the posterior muscles longer than the anterior, to compensate for 
 their greater retraction. 
 
 The flap operation is more modern than the circular, and to Mr. James Young 
 of Plymouth is due the credit of having first published, in 1G78, the method which he 
 informs us he had " from a very ingenious brother of ours," Mr. C. Lowdham of Exeter. 
 He made one flap only of skin, divided the muscles by the circular plan, and stitched the 
 parts together. Eighteen years later Verduin of Amsterdam made the first muscular and 
 skin flap by perforating the limb and cutting outward (tran.sfixion). 
 
 To Liston must be attributed the credit of having fully established the flap operation, 
 and in the pre-anas.sthetic period, when time was a point of consideration, the expedition 
 with which amputation could be performed by transfixion, compared with the tediousne.ss 
 of the circular operation, tended much toward this end. It was thought, moreover, that 
 a large mass of muscle formed a good covering to the bone and yielded a better stumj) 
 than that in the circular. Experience soon proved, however, that this opinion was not 
 supported by facts — that the supposed advantages were not real and did not compensate 
 for the larger extent of wound caused by the flap operation and for the evil of often hav- 
 ing to tuck in the projecting ends of the divided muscles before the integuments could be 
 adjusted. Liston saw this before he died, and was led with Syme to modify his operation, 
 making in muscular subjects two lateral crescentic skin flaps with their convexity down- 
 ward and dividing the muscles as in the circular method. This operation is by far the 
 best for all amputations of the leg and fore-arm. 
 
 In more modern times Lowdham and Young's practice has found expression in Car- 
 den's operation, while Teale's amputation must be regarded as a modification of the flap. 
 Both these gentlemen, however, advocated the long anterior flap in preference to all others, 
 Teale making two rectangular flaps of unequal length of skin and muscle (Fig. 695), and 
 Garden a rounded anterior flap of skin alone (Fig. 696) ; and under certain conditions 
 nothing can be better than the results obtained, the line of cicatrix being posterior to the 
 extremity of the stump and out of harm's way, thereby allowing the patient to rest part, 
 if not all, of his weight upon the stump. 
 
 The chief objections to the operation consist in the tendency there is for a long skin 
 flap to slough and the necessity of dividing the bone at a higher level than would be 
 required in the circular operation, when a long flap cannot otherwise be made. In mus- 
 cular subjects this last objection is serious and fatal to the operation in many thigh ampu- 
 tations, for it is a truth that cannot be too forcibly recognized that in the thigh the danger 
 to life is increased with every inch of bone removed. The surgeon who invariably prac- 
 tises Teale's amputation will often sacrifice a large portion of a limb that might otherwuse 
 be saved and have to amputate at a higher point than the necessities of the case demand, 
 thereby often adding to the danger of the case as well as performing a needless and unjus- 
 tifiable operation. The surgeoa who removes such portions of the body as require removal, 
 and no more, by such a flap as allows the cicatrix to be placed behind the stump and out 
 of harm's way, pei'forms a good and scientific operation. 
 
 LTnder all circumstances any form of amputation must be looked upon with favor that 
 takes away onlj/ what needs removal and provides sufficient integument to cover the end 
 of the stump, that ensures the cicatrix being out of harm's way, and that no nerves are 
 likely to be involved in the cicatrix or fixed to the end of the amputated bone. Any 
 forni of amputation must be regarded with disfavor that requires the removal of more 
 of the body than is essential to carry out the surgeon's primarv aim and increases the 
 risk of the operation, however good may be the .stump secured. To provide sufficient 
 
AMITTATIUS. KlOl 
 
 inte<;iiiiicnt to cover the stiiinii is !i \vi>c aixl ncces.'sary measure, and to fail in this wlien 
 circiinisianoes do not coni|Ml must l»e re^iarded as ha<l surpTV ; yet in eertain eases of 
 injury, disease, or ^'anirrene of the extremities, where it is advisal)le to take away tlie 
 diseased or injured |>art> and no sound skin is h-ft fnuu which to make a fla|). amputation 
 .shouhl lie |ierformed with<uit rejjanl to a eoverin;.' for the stump, as douhth-ss it is hetter 
 to remove tlie ilisi-aseil part tliat is hastening on the end and h-ave the stumji to ;rranulate 
 than to allow the tlisi-ase to have its way and saeritiee life. At the hip- and shoulder-joints, 
 where this eontin^eney is most likely to oeeur. the adoption id" this practice i.s not rarely 
 called for. ami at other parts is eijually appliealile. for. knowing what frood Htumpri are 
 often obtainetl when the skin and std't jiarts that at the time of tlie operation covered in 
 the hone suhse»juently slouirhed. I am convinced that in certain injuries to the arm and 
 le<; the surjreon had hetter amputate with a ])oor flap at the elhow- <»r knee-joints, leaving 
 the rest to nature, tlian risk life hy amputating higher up — /'.'.. thnmgh the shafts of the 
 humerus or femur. I have on many occasions acted on this principle, and to prevent the 
 necessity of amputating ahove a joint in order to make a goo<l >tump with a skin cover- 
 ing amputated at a joint or Itelow, utilizing even injured skin or hrui.<ed tissues, and 
 rarely have heeu disapj)ointed in the result, the stump suh.se(|uently granulatini: well 
 even when the flaps themselves sloughetl. In injuries to the leg this ]»oint is of great 
 importance, sitwe the mortality of am])utation of the thigh for injuries is very great. 
 As an admirable illustration of the value of this practice a case may be referred to 
 (Circ. No. 3. Depart, of War, Washington, page '2\\>) in which recovery ensued after all 
 four limbs of a man ji»t. 2(j were amputated on account of fro.st-bite. A month after the 
 injury, when the line of demarcation had exposed the bones, Dr. Muller, in order to .save 
 lo.ss of blood, which would have been serious in the patients weak condition, dissected as 
 much healthy flesh from the radius and ulna as the line of demarcation would admit with- 
 out cutting any blood vessels, and then sawed through the bone. This operation was per- 
 formed on both arms with hardly the loss of an}- blood. On the third day both legs were 
 amputated in the same manner. In this ca.se not one of the four stumps could be covered 
 with suflicieut skin, and much had to be left to self-reparation, which took place to an extra- 
 ordinary extent, the stumps healing over with healthy granulations, some little exfoliation 
 of bone taking place in two. 
 
 Again, is it always necessary to amputate through healthy tissues? or, to gain this 
 end. is it expedient to amputate higher up than would otherwise be nece.s.sary? I unhes- 
 itatingly answer that such practice is not called for. To amputate through tissues infil- 
 trated with cancer or other new growths would, of course, be futile and bad surgery, but 
 to cut through tissues that are merely infiltrated with inflammatory products, that are 
 pathologically reparable and of u.se, is a wise and conservative process. In di.sease of 
 the knee-joint, when suppuration has spread up the thigh into the soft parts, amputa- 
 tion may often be performed through the condyles or just above them and a good stump 
 secured when by following another practice a much higher amputation would be called 
 for, and con.serjuently increased risk to life incurred. Tissues infiltrated with inflamma- 
 tory lymph often unite rapidly and well ; indeed. I have seen ■• brawny flaps " unite by 
 primary uniim (juite as vf-aW as others not so infiltrated. 
 
 I am convinced, too. that however desirable it may be to obtain good. long, and healthy 
 flaps in all amputations, the advantages of such are not .so great as to justify the surgeon 
 in sacrificing more of the body than is e.s.sential. thereby adding to the risks of the case, 
 and more particularly in amputating above a joint. It is true that by one form ofampmta- 
 tion a better stump under most favorable circumstances is often secured than another, but 
 it is e({ually true that ijood stumps are often obtained under the most unftivorable condi- 
 tions and that bad stumps follow the amputation of a limb in which the state of the flaps 
 promised to bring about a favorable result. To as.sert that the form of amputation — or, 
 rather, that the shape of the flaps, etc. — has anything to do with the relative mortality of 
 different amputations is incorrect. What evidence exists points to a diflferent conclusion, 
 for the success of an amputation, as of any other operation, turns more upon what in 
 recent times seem to have been forgotten — viz.. the conditions of the visara, the ft^e, 
 and the general state of the subject, accepting the facts that the older the patient, the 
 greater the danger, and the more of the body that is removed, the greater the risk. My 
 own conviction is that, however desirable it mav be to obtain a model stump, the end is 
 not sufficiently certain or important to justify the surgeon in adding one tittle to the ri.sk 
 of the operation or in sacrificing more of the limb tlian the necessities of the ca.se demand. 
 I regard it as bad and unjustifiable surgery to perform a Syme's or a Pirogoflf's amputa- 
 tion when a Chopart's will suffice ; to amputate a leg when the removal of a foot at the 
 
1002 AMPUTATION. 
 
 joint will answer the purpose; to remove a leg or thigh an inch higher than is absolutely 
 called for, in order to execute what may be looked upon as a good operation or to gratify 
 a fancy ; to amputate through the condyles of the femur when an amputation at the 
 knee-joint can be performed, or through the shaft of the femur when the like end may 
 be secured by cutting thnuigh the condyles. The surgeon must ever look upon the ope- 
 ration of amputation as an unfortunate necessity, and should bear in mind that it is to be 
 undertaken only to save or to prolong life or to add to life's usefulness. With these ends 
 in view, he should not add one jot to its dangers or take away an inch more of the body 
 than is essential. The beauty of a stump may be something in itself, but is nothing if 
 it is to be obtained by increased danger, and the brilliancy of an operation is a snare that 
 should never be allowed to draw the surgeon away from the main object — the preserva- 
 tion of life — which alone gives the operation of amputation a high and scientific po.sition 
 in surgical practice. 
 
 The mortality of amputation is determined more by age than by anything else, and 
 the credit of having statistically proved this fact is dueto Mr. Holmes (,SV. Geonjcf. 
 Hof<p. Rep., 1866 and 1877;. In aiy own paper on the causes of death in amputation 
 (Med.-Chir. Tn(ii.'<., vol. xlii., 1859) this point was overlooked, but. following Mr. Holmes's 
 example, I reanalyzed the cases on which it was based, and have been somewhat startled 
 at the very definite conclusions brought out by my analysis. Thus, out of 103 cases 
 under twenty years of age, 10 died, or 1 in 10 : out of 111' cases between twenty-one and 
 forty years of age, 21 died, or 1 in 5 ; out of 74 eases over forty years of age. 22 died, or 
 1 in 3j, the mortality of amputation between the ages of twenty and forty being exactly 
 twice as great as before twenty years of age. 
 
 Mr. Callender {Med.-Chir. Trans., vol. xlvii., 1864) and Mr. Holmes's combined 
 statistics reveal the same results : 
 
 Cases under twenty years of age. Between twenty and forty Over forty years of age. 
 
 years of age. 
 
 Callender's 61 cases, 3 died. 92 cases, 20 died. 74 cases, 30 died. 
 
 Holmes's 130 '■ 22 " 215 " 68 " J^o " 6S " 
 
 191 cases, 25 died, 307 cases, 88 died, 229 ca.ses. 98 died, 
 < or 1 in 72. or 1 in 3h. or 1 in 2J. 
 
 Fifty-two deaths having occurred in 250 cases reported by Mr. Holmes in subjects under 
 thirty years, and 106 deaths in 250 cases operated upon after thirty years of age. 
 
 If the causes of amputation are looked at in the same light, the results become still 
 more marked ; for. dividing them into amputations for disease, for accident, and for 
 expediency, the latter term including amputations for tumors, deformity, etc., the follow- 
 ing facts are elicited : 
 
 Cases. 
 Under twenty years of age . . 68 
 Between twenty and forty . . 66 
 Over forty 33 
 
 Amputations for acute suppurative disease are most fatal and should be undertaken 
 only when a strong necessity exists. I pointed this out in 1859. but it is not a fact 
 sufficiently recognized. 
 
 Amputation in young life for chronic disease is mo.st successful, being three times 
 more so than at a later period, 1 only in ever}' 17 dying; amputation for accident increases 
 in fatality with age. and amputations of expediency are as dangerous at all periods of life 
 as traumatic amputations are in the aged. 
 
 Mr. Callender has also well shown ( Sf. Barth. Hoq). Rep.. 1869) that the mortality 
 of amputations is much alike, whether performed in country ho.spitals, in country private 
 practice, or in country cases in London. In amputations on London subjects, as in the 
 subjects of all large towns, the mortality is somewhat higher. 
 
 Dr. Steele has, however, gone farther and proved by figures that amputations per- 
 formed in London for injury on country patients are, as a rule, more favorable than when 
 performed in town cases, the diiFerence between the two classes being far less marked in 
 amputation for disease than in that for injury {Gvi/'ss Roup. Rfp.. 1869-70). 
 
 The causes of death after amputation are as follows, taking these conclusions from 
 my paper on the subject {Med.-Chir. Tram., 1859), to which the reader must be referred 
 for further details : Shock and exhaustion claim one-third of the fatal cases, and one- 
 twelfth of all amputations; ptyxmia was the cause of death in forty-two per cent, of the 
 
 )is< 
 
 jases. 
 
 
 Expediency. 
 
 
 Accident. 
 
 
 Died. 
 
 
 Cases. Died. 
 
 Ca.ses. 
 
 Died. 
 
 4, 
 
 or 1 in 
 
 17. 
 
 9 3, or 1 in 3. 
 
 26 
 
 3, or 1 in 9. 
 
 12, 
 
 or 1 in 
 
 5A. 
 
 15 4 or 1 in 4. 
 
 30 
 
 5. or 1 in 6. 
 
 5, 
 
 or 1 in 
 
 6J 
 
 9 3, or 1 in 3. 
 
 32 
 
 14, or 1 in 2^ 
 
DIFFKIIILST M<tl)i:s OF AMl'lJAll'J.W lOO.'i 
 
 filial cast's, and in niic-tiiitli ul" all aiii|iutatiuiiM ; iwrDiiilnn/ In ninrrlmifi in s(!Vcii per ccfit. 
 nt" til*' latal fasi's, or unc aiitl a liall" prr rent, of" the whole iiunihtT. Some riniijiliriitinn^ 
 crri'hral, tliorafic, or alKloininal, causes ileal li in about lour per (;ent. oi" all eases. I'va-iiiia 
 is nearly twiei' as fatal al'ter amputations of expedieiii-y as iifter tliose fur disease or pri- 
 niarv amputations, hut is less fatal after seeoiulary amputati(»ns than any others. In 
 amputation ol" the le^ it is twice as destructive as in that of the thi^'h, the larger section 
 of lion«f heinir the more dan;rerou.s. In primary amputation of the le;r it is more latal 
 than when performed for disease. 
 
 How far the «leaths from secondary hemorrhage will he dimini.>hed when the practice 
 of torsion of arteries is uiore f^eneral remains to he proved, althou<:h from the experience 
 we have had at (iuy's Hospital the promise of a better result is very jrreat. I'p to the 
 end of 1S74 we have had liOO consecutive cases of amputations of the thifrh, leg, arm, 
 and lore-arm in whi(di all the arteries had been twisted (11(( of them havinj: Ijeen of the 
 femoral artery), and no case of secondary liemorrhajrc? ; indeed, riur house-sur<reons never 
 expect to be called to cases of secondary heiiiorrhaL^i' now that torsion is the general 
 practice of the hospital. 
 
 Double amputations are of grave import and are very fatal. They are mostly 
 imdertakeM lor • sni.islics or bad com))ouud fractures. Out of 18 cases collected by my 
 dres.ser, Mr. W. Hlight, from the <iuy"s records, I can. however, record 5 successful cases, 
 or 27.7 per cent, of the whole number. One occurred in my own practice in a woman 
 ait. 3') who had a Symes amputation on one foot and a Iley s on the other. 1'wo i»ccurred 
 in the practice of Mr. Durham, and both in men — one, fct. 18, amputation of both thighs, 
 and the other, xi. 19, amputation in one thigh and fore-arm. Mr. Davies-Colley toiik off 
 both legs of a boy fet. 8 with a good result, and Mr. Jacob.son took off one leg in the thigh 
 and one below the knee in a man aet. 30 with a like result. Thirteen cases died soon after 
 the operation. 
 
 The operation of amputation may be called for on account of some incurable disea.se 
 or incurable injury. When performed for the fir.st cause, the operation has been described 
 as a patliolof/icdl amputation ; when for the second, traumatic. Both classes are also sub- 
 divided, the pathological into amputations for supjnirative disease of })ones and joints — 
 pure i>at]inh,(j'ical amputation ; and into tho.se for talipes, tumors, deformities, etc. — ampu- 
 tations of expediency. 
 
 Traumatic amputations performed during the first twentj'-four hours after the acci- 
 dent, before any inflammatory complications have set in, are called ^>//?>ja/y; the term 
 sccomlan/ is applied to the .same class of cases after suppuration has appeared, the word 
 intermediate being employed to designate amputations performed twenty-four hours after 
 the accident, but before suppuration has declared it.self. This distinction, however, is not 
 a satisfactory one. 
 
 Some statisticians have classed the secondary amputations with the pathological, but 
 this practice is clearly wrong. 
 
 The Different Modes of Amputation 
 
 may be divided into three great classes — 1st. the circular ; 2d. the /iap operation, whether 
 by transfixion or cutting from without inward — Teales amputation (consisting of one 
 long anterior skin and muscular flap, and short posterior) being looked upon as a modifi- 
 cation of the ordinary flap operation ; 3d. the mixed /arm of amputation — skin flap and 
 circular cut through muscles — Cardens operation being included in this series. Into one 
 or other of these classes almo.st every form of amputation may be brought, although prac- 
 tically there are innumerable modifications of each, more particularly of the flap. 
 
 The old circular operation, as already described, is now fairly abandoned. It has 
 no advantages over the more modern mixed form of amputation, and will not take the place 
 of the flap where the latter is applicable. In small limbs, where there is but little mus- 
 cular tissue and a single bone to divide, it may be performed, but cannot be recomiuended. 
 It is more practi.sed abroad than in this country. 
 
 The flap operation doubtless owes its popularity as much to Liston. Lisfranc. and 
 Velpeau. who were its strong suiiporters, as to the facility with which it is performed and 
 the satisfactory ajtpearance of the flaps at the time of the operation. Before anfe.sthetics 
 were introduced expedition was of importance, and it was the surgeons aim to remove a 
 limb as rapidly as possible. '• The surgeon, operating by the watch, took off a limb by 
 the flap operation in as many seconds as there were minutes occupied in the old circular 
 method" (Sir W. Fergusson). Since 1846, however, when ancBsthesia came into vogue, 
 
1 004 AMP VTA TlOy. 
 
 this necessity has ceased to exist, and surgeons hare been led away more from the flap 
 operation to what may now be described as the mixed. 
 
 In certain parts, however, the flap operation still holds its ground, and in a general 
 sense it may be said that in operations where the shafts of migU bones or some joints are 
 involved it is the best method, while in some localities, as at the shoulder- and hip-joints, 
 it is the only one open to the surgeon. 
 
 The objections to the flap operation are the large surface that is exposed, the danger 
 of puncturing or slitting the main artery of the part, the inconvenience of bleeding, the 
 leaving of the main artery and nerves in one of the flaps, and the disadvantage of a thick 
 mu.scular flap. 
 
 The flap amputation has. however, one great advantage, and that is its capability of 
 innumerable modifications. Thus, both flaps may be made by transfixing — the old plan ; 
 both may be made by cutting from without inward : one flap, the anterior, may be made 
 by the latter method, and the second, or po.sterior, by transfixion ; or lateral flaps, single, 
 or double, or oval flaps, may be made. 
 
 The advnntnges of transfixing the flap consist in the rapidity and cleanliness with 
 which the section of the mu.scles and the deeper parts is made ; its ilisodmntoges, in the 
 irregularity with which the skin is too often divided from the elastic integuments stretch- 
 ing before the knife. By the plan of cutting the flap from without inward this disad- 
 vantage is. however, neutralized, while an extra advantage is gained, for the .surgeon 
 can often cut a longer skin than muscular flap, which in large limbs is a matter of 
 importance. 
 
 In some amputations, as of single bones, the operation may be performed by cutting 
 the anterior flap from without inward, and the posterior by transfixing. In the arm and 
 thigh, when I select the flap amputation, this method is that which I usually adopt. In 
 cutting the flap by transfixion, particularly in the thigh, the surgeon should always sup- 
 port it with his left hand, and when a sufficient flap has been made cut sharplv outward 
 (Fig. 691). 
 
 Sir W. Fergusson says, with respect to the flap operation. '• If. in transfixing, the flaps 
 be made purposely short, and then, retraction being made, the knife be carried round the 
 expo.sed tissues which cover the bone, a cone will be formed resembling that in the ordi- 
 nary circular operation, and thus by a combination, a compromise, of the two methods 
 fthe circular and the flap), a covering to the end of the bone — in other words, a .stump — 
 will be left, superior, in my estimation, to any other." though he adds that •• cutting from 
 without inward is in manv instances followed bv the best results" (Ltct. on Prog, of 
 Surg.. 1867). 
 
 Besides the.se recognized forms of amputation, many others are performed, the surgeon 
 having too often "to cut the flap according to the tissues." particularly in cases of injury. 
 He has to utilize what skin there is left uninjured, in order to prevent the neces.sity of 
 amputating higher up ; it may be that one external or internal flap can be made, one 
 anterior or po.sterior ; in fact, any form or combination of flaps the surgeon maybe called 
 upon to make to carry out the object he has in hand — viz.. the removal of the part that 
 mu.st be removed, and no more, with the least sacrifice of parts. Indeed, as already 
 stated, under rare circumstances an amputation may best be performed without flaps or 
 with poor ones, it being a safer, and I believe a sounder, practice to take off a part that 
 mimt h^ removed to save life immediately above the seat of injury, even with bad. poor, 
 or no flaps, than for the sake of making flaps that may slough to amputate higher up, 
 possibly with the sacrifice of a joint, and by so doing to incur an unneces.sary danger to 
 the life we are operating to .save, Petits fundamental rule being far from true — that " as 
 little of the flesh should be cut away as possible ; but the more bone is removed, the 
 better" ( Traiti Jes Malad. Chir.. tom^ iii. p. 250). 
 
 As a variety of the antero-posterior flaps the surgeon may at times, by transfixion, 
 make the posterior one first, and then, taking between his fingers and thumb all the soft 
 parts not included in the posterior flap, complete the operation either by passing the end 
 of the knife beneath these tissues and cutting outward or by cutting from without inward, 
 as in the former case. This plan is most expeditious and was the one generally adopted 
 by the late Mr. Morgan of Guy's. 
 
 In some cases two lateral flaps may be made by either transfixion or cutting from 
 without inward. 
 
 The Flap Operation. — The surgeon, having decided upon the operation and 
 obtained the consent of the patient or of his friends to its performance, should see, 
 unless time presses, that any fecal accumulation is removed by either a mild aperient or 
 
Diri-KllllSr MohKS OF AMJ'LTATIuy. 
 
 KlOo 
 
 nn I'neina lulininistcrL'd thirty-six hours hi-ftirfhuiid. and that as ^rood a iin-al as the ]iatieiit 
 can takf hf jrivt'U lour or fivt! Iiours hrl'on- tlic liuic tixt-d lor llic o|ii-ratioii. Tlie meal 
 should hi' of lucat whrrr possihle, with souii' stiinuhiut, or. whni solids arc not acceptable, 
 of u mixturt' of uiilk. ejr^. and hrandy ; for, assuuiirijr that chlorcd'orni or souie aiwesthetic 
 is to he adujiiiistfrt'd. it is essential to ;;uard against sickness and to have the process of 
 di;ri-stion fairlv completed heforehand. since vomiting is more prone to take place with a 
 full than with an empty stomach. The ])art to he operute<l u]ion should be well washed 
 previously and when nundi hair is present also shaved before the patient is placed upon 
 the operatinj; table. 
 
 All instruments and drcssinir applian<"es should be arranj^ed rtut of the patients .sight 
 before the time of the operation, and a suflicielit number of assistants provided and spe- 
 cial duties allotted to them. 
 
 Thus, on one tray there should be a ttturiiitjuet or elastic bandage, to prevent hemor- 
 rhaire ; irood torsion forceps to twist, or ligatures to tie. the vessels; amputating knives 
 of sufficient length and size, with a bistoury or catlin to divide the .soft parts, and saw 
 and lione forceps for tlie treatment of the bone; a tenaculum should likowi.se be at liand, 
 to take up vessels tliat have retracted ; there should be also a pair of scissors and a linen 
 retractor. The torsion forceps I employ (Fig. 137) are as good for taking up an artery 
 to tie as for twisting. 
 
 On a second tray every api)liance for the dressing of a stump .should be arranged, 
 such as suture needles armed with waxed silk, wire, or carbolized catgut ; .strapy>ing cut 
 into sufficient lengths and breadths ; lint for pads or dressings, and .splints wlien applic- 
 able ; a can for hot water, to heat the strapping, should not be omitted ; hot and cold 
 water in abundance, c/cun sponges, supplied by the surgeon, well washed in iodine water 
 and .s<|ueezed dry. and soft towels, so arranged as to be always at the surgeons command 
 during the operation, must be jirovided. 
 
 With respect to a.ssi.stants, one to give the anaesthetic is a necessity ; and when po.ssi- 
 ble he should be an expert to whom the surgeon can resign his patient with confidence, 
 as it is trying and somewhat risky for the operator, when otherwise engaged, to have an 
 eye to the anaesthetist. A second is wanted, to hold the limb above and to command 
 
 Fig. 690. 
 
 Surgeon and his Assistants arranged for an Amputation. 
 
 the artery of the limb to be amputated ; a third, to hold the limb below till it is removed, 
 and subse(|uently to sponge and help to twist or tie the ves.sels : while a fourth is of 
 essential service in amputation of the thigh and leg to hand the instruments, sponge, or 
 to do what may be required, etc. They should be placed as .shown in Fig. 690. 
 
 The nurse should be near, to take away and clean all sponges as they are u.sed. and to 
 replace them with others squeezed quite dry. 
 
 When the operation has to be performed by daylight, the table should be placed where 
 the best light can be obtained ; and when by candlelight, sufficient provision nni.st be made. 
 A good operating lamp is of great use, as well as a hand-glass to throw light upon any 
 one part. 
 
1006 
 
 AMPUTATION. 
 
 Fig. 691. 
 
 The operating table should be narrow and steady, a kitchen table with flaps being the 
 best and always available. In hospitals there ought always to be a special table. 
 
 In amputations of the upper extremity the patient should be brought well to the side 
 of the table, and in amputations of the lower extremity well downward, the opposite 
 limb being secured by a turn of a bandage or strap to the leg of the table. 
 
 In amputating, the surgeon should always stand on the riffht-hand side of the part to 
 be amputated, in order with his left hand to keep full control of the flaps during the ope- 
 ration, and po.ssibly of the main arteries, and afterward of the stump. He should, more- 
 over, see that the tourniquet is so fixed as to control the vessel when tightened, which 
 should on no account be done until the operation is about to be commenced. Before fix- 
 ing the tourniquet the limb to be amputated should be emptied of its venous blood by 
 raising its end for one or two minutes and smoothing the veins from below upward by 
 pressure with the hand. The limb should then be constricted high up by a tourniquet or 
 Esmarch's elastic bandage. 
 
 In the flap operation, now being considered (and for the sake of illustration I will sup- 
 pose it to be a thigh), the surgeon should mark out with his eye the point at which he 
 
 proposes to divide the bone, and, with his 
 thumb on one side of the limb and his fingers 
 on the other, grasp it at a spot corresponding 
 to the base of the anterior flap he is about to 
 make, cutting from without inward, taking 
 care that the Lasr of this flap is at least an 
 inch lower down than the point at which the 
 bone is to be divided. The anterior flap, which 
 should be cut first and consist of skin, ought 
 to be as long as the soft parts below will allow 
 and large enough to cover half the stump, or 
 rather more than half the diameter of the 
 limb ; but when possible, it may be longer, 
 since it is now generally admitted that the 
 long anterior flap forms the best stump. The 
 skin flap should be broad and cut s({uare, with 
 the angles rounded off", but not pointed. The 
 muscles should then be divided down to the 
 bone with a clean cut of the knife, made from heel to point and reflected with the skin 
 flap. The anterior flap having thus been made, the point of the knife ought then to be 
 passed through the wound beneath the bone and the limb so transfixed as to include all 
 the tissues that remain undivided. The knife should then be made to run downward 
 parallel to the bone, far enough to make a flap of the required length, and then turned 
 backward, the outward cut being made sharply (Fig. 691). 
 
 During this stage of the operation the surgeon should with his left hand support the 
 under surface of the posterior flap. When the anterior flap has been made of only suffi- 
 cient length to cover half the face of the stump, the posterior must be cut long, to allow 
 the two to meet. When the anterior flap has been a long one — two-thirds of the length 
 required to cover the stump — the posterior flap need be only half the length of the ante- 
 rior. Long flaps always yield the most satisfactory results. 
 
 When the flaps have been made they should be carefully held away from the bone, 
 which is to be bared upward for about an inch above their base, where it is to be divided 
 and two periosteal flaps cut and pressed upward. The soft parts ought to be carefully 
 held awa}' from the bone, to escape injury, and for this purpose the linen retractor is of 
 great value. The saw must then be applied, the bow saw (Fig. G90) being probably bet- 
 ter than the flat. It should be used from heel to end with a firm, decided, free movement, 
 too much pressure upon it being likely to cause splintering of the bone. During these 
 steps of the operation the assistant who holds the limb must be careful neither to elevate 
 nor to depress it, for he will cause, by the former act, the surgeon's saw to become locked, 
 and by the latter splintering of the lower border of the bone. The best plan for the assist- 
 ant to adopt is to apply extension to the limb in the axis of the bone to be divided, as if 
 to draw the patient downward, though not Avith sufficient force to eff"ect this result. 
 
 When any splintering of the bone has taken place, the rough margin ought to be 
 carefully smoothed down with the cutting forceps, care being observed not to tear away 
 the periosteum. 
 
 Dr. McGill of the United States army has suggested the propriety of making the 
 
 Aniputatioii of the Thigh by Flap Operation. 
 
nirri:i:i:sr Mni>i:s of amitiaiios. 
 
 l(j()7 
 
 jtoriostoul flaps. US (IcsciilnMl almve.to i-ovcr in tin- eml fiftlie dividcfl Ixnic in ani|>ututioii, 
 and trivt's tliriT casrs in wliifli this was done with excollciit ctt'vct (Ciru. No. 'A). I liave 
 adii|itt>(| till' |dan on many occasions witli satisfactory results, tlic end of tin- divided lemur 
 bein^ in some eases capped with a ma>s of new Itone. 
 
 'hic bone beinj; sawn tliroULcli, the stump is to he raised and the main artery at once 
 .seized ; the vossid should be drawn out of its slieath, lirmly held with fon^eps (Fig. 1-^7 j, and 
 .sharply twisted sullicii'ntly often for the sur;.;eon to I'eel that resistance has gone. The end 
 ouiiht not to be twisteil ofl". The snniller arteries .should be treated in the same way ; it is 
 possibly the best practice to twist ofl' the ends of the small mu.scnlar and cutaneous branches. 
 
 When ligatures are preferred, they may Ix- used, the carb(»lizc(l catgut prolnibly Iteing 
 the b,.>t. 
 
 As soon as the chief ve.s.sels have been secured the tourni(|Uct should be taken away 
 and the stump i-levated, to assist tlie venous circulation, the assistant being ready with 
 his finger to compress the main artery of the lind) if any vessel remain unsecured. Any 
 nerve trunks that have been cut long in the flaps should be renioved to a level with the 
 bone. A stream of iodine water may then be made to pass over the end of the .stump, 
 to cleanse it of all blood and check ca]»illary bleeding, and the surface should ne.\t be 
 dried with a s])onge .s(|ueczed dry out of hot iodine water, the surgeon satisfying himself 
 that the vessels are all safely .secured. 1'he edges of the flaps may then be adjust eil, and 
 kept in apjjosition by sutures, which must not be put in too closely, but inserted about 
 half an inch from the margin of the wound and made to perforate the skin and fat 
 oblii|uely to the free border of the flap; the most dependent corner of the wound should 
 be left open for the introduction of a drainage tube. 
 
 A posterior splint ought then to be tixed on the stump (Fig. C!)2), with pads of lint 
 
 Fig. 093. 
 
 Fig. 692 
 
 Fig. 694. 
 
 Thigh Stuiap, with .Siiliut. Thigh Stump with Splint for Extension. 
 
 or sponge, to maintain steady pressure upon tlie ba.se of the flaps, though not on the 
 wound, and a piece of iodoform or carbolic gauze, through which a hole has been cut 
 for the end of the drainage tube, is to be applied to the surface of the wound. 
 
 A square of (janigee tissue should then be bound over the stump, or a good large 
 sponge, either of these materials forming a 
 firm elastic compress which keeps the flaps 
 well in apposition and checks bleeding, due 
 care being taken to keep the end of the drain- 
 age tube exposed. To seal a wound com- 
 pletely and not to leave a drainage opening 
 must always be regarded as bad practice. 
 With well-adjusted flaps, good drainage, 
 and rest, as secured by the application of 
 a splint, most stumps may be expected to 
 do well. 
 
 The stump may be raised, as in Fig. C02, 
 for the first day after the operation, but sub- 
 sequently placed in a horizontal position. 
 It should not be dressed for three or four 
 days unless it becomes uncomfortable or 
 there is any evidence of retained secretion, 
 for the le.ss the parts are disturbed during 
 the early days, the better, repair going on 
 much more satisfactorily when left alone 
 than when the dressings are too frequently 
 changed. To dross a stump, the trough, water-can, and tube, as illustrated in Fig. 694, 
 are to be recommended. 
 
 Vidcr can 
 Svsfiendeil to hook 
 of ied curtain hooji 
 
 Trough and Water-C.in for Dressing .Stuuip. 
 
1008 
 
 AMPUTATION. 
 
 Fig. 695, 
 
 contain 
 formed 
 
 When anything like retraction of the flaps exists, extension may be applied by means 
 of a splint of perforated zinc, as seen in Fig. 693. 
 
 Before chloroform was introduced it was the practice of the late Mr. Aston Key, as 
 well as that of JMr. Syme, to leave the stump open for a few hours before its flaps were 
 brought together ; and doubtless the measure was good, for in that time every bleeding 
 vessel showed itself and the surface of the wound became glazed, and therefore in a 
 state good for repair ; but since anaesthetics have been in use this practice has fallen 
 into desuetude. The application of the wet sponge, squeezed dry out of hot iodine lotion, 
 renders, moreover, such a practice unnecessary. 
 
 The stitches may be taken away on the third or fourth day, when the parts, if they 
 gape or if union is not solid, should be supported by strapping. The wound may be 
 dressed with the mixture of terebene one part and olive oil three parts, or iodoform gauze 
 and Gamgee tissue. 
 
 For the dressing of wounds the reader must refer to an early chapter. 
 
 Teale's Amputation, a Modification of the Skin and Muscular 
 
 Flap. — This was introduced " to procure a more useful stump and in the hope of some- 
 what diminishing the mortality of the operation. It is proposed to amputate by a long 
 and a short rectangular flap, the long flap folding over the end of the bone being formed of 
 parts generally devoid of large blood vessels and nerves, whilst those important structures 
 
 are contained in the short flap. The size of the 
 long flap is determined by the circumference of the 
 limb at the place of amputation, its length and its 
 breadth being each equal to half the circunifer-, 
 ence. The long flap is therefore a perfect square, 
 and is long enough to fall easily over the end of 
 the bone. In selecting the structures for its 
 formation such parts must be taken as do not 
 the larger blood vessels and nerves. A flap so 
 will be, for the most part, anterior in position, as 
 far as regards the general aspect of the body, but superior 
 when the patient is in the recumbent position, as during 
 the after-treatment. The short flap, containing the chief 
 vessels and nerves, is in length one-fourth of the other 
 (Fig. 695). The flaps being formed, the bone sawn, and 
 the arteries tied or twisted, the long flap is folded over the 
 end of the bone and each of its free angles fixed by sutures 
 to the corresponding free angle of the short flap. One or two more sutures may be 
 required to complete the transverse line of union of the flaps and to unite the side of the 
 short to the corresponding portion of the long, as well as the reflected portions of the 
 long flap to its unreflected. Thus, the transverse line of union is bounded at each end 
 by a short lateral line at right angles to it." 
 
 In making this long anterior flap the surgeon should be careful not to scarify it with 
 his knife, more particularly when it is chiefly skin, as in the leg, since, on account of its 
 length, it is very prone to slough, and if scarified this tendency is increased. Indeed, 
 this sloughing of the long flap is the great disadvantage of the operation, for in an ordi- 
 nary thigh, twelve inches in circumference, a flap of six inches would have to be made. 
 To secure a cicatrix away from the extremity of a stump is a point of great practical 
 value, and to do so by a long anterior flap is doubtless an advantage ; but this often 
 requires more soft parts than are generally at the surgeon's disposal, unless more of the 
 limb be taken away than requires removal. This object may, however, sometimes be 
 secured by making a shorter anterior flap than Teale suggests and dividing the bone one 
 or two inches above the line of the skin flaps. In fact, as long as the anterior flap, 
 whether rectangular or oval, is of sufiicient length to be drawn over the end of the stump 
 to its posterior aspect, the principle of Teale's operation is observed. 
 
 Mr. Spence in his Surgery (1871), p. 749, tells us that he acted much upon this prin- 
 ciple in 1858, making one long anterior skia and mnscular flap^ with a short posterior, 
 clearing the bone for nearly two inches before dividing it. 
 
 The Mixed Form of Amputation. — The mixed form of amputation as illus- 
 trated by Garden's operation will now claim attention. In principle it includes a combi- 
 nation of the circular and flap, already described. 
 
 " The operation consists in reflecting a rounded or semi-oval flap of skin and fat from 
 the front of the joint (knee), dividing everything else straight down to the bone, and 
 
 Teale's Amputation. 
 
hll'Fl.ni'.Si MnDKS OF AMITTATIOS. 
 
 1009 
 
 Yio. 696. 
 
 suwiiij; the Imhu- .sli;^litlv alinvc I lie iilaiif nl' tlic iiiiimIcs, thus lurmiii^' a liat-lacccl .siiuiip 
 witli II homii't (if iiitt'jriiiiu'iit (o full over it. 'I'lic i)p(;rati<>ii i.s .siiiipli;. 'J'lif opeiutor, 
 staiidiii;; oil tlu' /•/'//(/ .side nl" tlii' liiiil). seize."* it between liis left l'iire-jiiiji;er and tliuiiil) at 
 tlie .spot selected lor the lia.se of the Hap, and enters the; point of the knife eh>he to hi.s 
 tiii;{er, ljrinj;iiig it round lhrouj,'h skin and fat helow tlie patijlhi to the spot pressed by hi.s 
 thiinih ; then, turning the edjje downward at a ri^dit aiijrle with the line of the liiiih, he 
 j)asses it tlin»ut;h In tlu- spot where it first entered, eiitlin;: outward thioii;:h everything 
 behiinl the hone. The flap is then leHeeled and the rtmiaimler of the soft parts divided 
 .straight down to the hone; tlii' imiseles are then slightly cleared upward and the saw is 
 applied. Or. the linili being held as before, the hand and knife may be brought round 
 under the limb, as in the circiil.ir operation, and the blaile entered near the thumb and 
 drawn round to the op]»osite sidt,-, when the ham may be cut across by turning the edge 
 of the knife upward, and the operation comjdeted as before. In amputating through the 
 <M)iidvles the ])atella is <lrawii down by tle.xing the knee to a right angle before dividing 
 the soft parts in front of the bone ; or, if that be iiicoiiveiiient, the patella may be reflected 
 downward" {lirii. Mfd. Jonriinl^ April, iStilj. 
 
 This operation of Mr. Carden's is very valuable, not only a.s applicalde to the knee- 
 joint, to which it was originally apjilicd, but on account of the principle of practice it 
 embodies — that of making skin flajis and 
 the circular division of the muscles. The 
 practice, however, was not new ; for when 
 Mr. Cardeii began it, in 184G, Mr. 8yme 
 had puljlished in the Edin. Moufh. Jotirii. 
 of Med. Sci' nee of the same year his modi- 
 fication of the circular method of amjuita- 
 tion in the lower third of the thigh l»y mak- 
 ing two semilunar skin lateral flaj)s an<l ob- 
 lique .section of the muscles down to the 
 bone, dissecting the skin fla})S an inch or 
 more upward, and cutting the muscles on a 
 level with the retracted skin. Liston also, 
 in 1839, preferred skin flaps alone in mus- 
 cular subjects. 
 
 Accepting it as an operation for the re- 
 moval of a limb through the condyles of the 
 femur, I have, however, found it advisable 
 
 to make a slightly longer posterior flap than Carden advises (m/r Fig. GOG), making it 
 only of skin, and taking care to make the long anterior flap broad, with a base correspond- 
 ing to the ))osterior border of the lateral surfaces "of the condyles. 
 
 In this operation there is but a .slight section of the muscular tissue, and, beyond the 
 popliteal artery, few vessels of importance are divided. The stump that remains is like- 
 
 FiG. 697. 
 
 ("ardcn's Amputation, with Long Posterior Flap. 
 
 Amputation 
 
 liy the >rixed Method. 
 
 wise remarkably good, being long and broad. u]t(iti which patients can bear their weight 
 without pain. This operation is, I ])elieve, applicable to a far larger number of cases 
 than i^s generally thought, and, with Li.ster, I look upon it as a great advance in surgerv 
 It is, moreover, far safer than amputation through the .shaft of "the femur. 
 
 The object sought in all these long anterior flap operations is to procure a cicatrix 
 that is placed behind the stump out of harm's way. and .so long as this end can be secured 
 without .sacrificing more of the body than is ab.s'olutely required by the exigences of the 
 case the amputation is good, and it is a matter of small importance" whether the reetanjru' 
 lar and muscular flaps of Teale, the convex skin flaps of Carden, or the .skin and muscle 
 as practised by Spence, be employed. I prefer Carden's flap, with the modifications 
 fi4 
 
1010 
 
 SPECIAL AMPUTATIONS. 
 
 Fig. 698. 
 
 described, to any other, and when applied to the knee, where it is most applicaVjle, regard 
 it with high favor. 
 
 This " mixed method of amputation " has, however, a wider application than to 
 operations about the knee, and I believe it to be by far the best 
 operation in all amputations of the leg and fore-arm. It combines 
 the advantages of the circular and the flap without the disadvantages, 
 and rarely, if ever, calls for the sacrifice of more of the extremity than 
 is absolutely required. In its performance the two lateral skin flaps 
 should be made sufficiently long to meet over the stump without stretch- 
 ing, the surgeon by his eye judging their required length, while the 
 muscles should be divided by a circular sweep an inch below the base 
 of the retracted flaps, the bones being bared to this extent before they 
 are divided (Fig. GOT). Mr. Cock includes the muscles in the flap, but 
 I hardly think this necessary unless the skin is very thin. When the 
 flaps are brought together, a pretty stump is seen, and subsequently it 
 turns out to be a very good one (Fig. G98). 
 
 In amputation of the fore-arm the mixed form is the operation, the 
 
 putation of the skin flaps being made from, the anterior and posterior aspects of the limb, 
 
 jfe^hcKi.'^ ^^ ' '^^^' the flap amputation executed by transfixion being very unsatisfactory, on 
 
 account of the tendons of the fore-arm (Fig. 708). 
 
 In amputation at the wrist and elbow-joints nothing can be better than this mixed 
 
 method (Figs. 701, 702), the surgeon having it in his power, according to circumstances, 
 
 to make one long anterior, posterior, or lateral flap cover the stump, and thus to secure 
 
 the cicatrix being out of harm's way. One of the best stumps of this kind I ever obtained 
 
 was at the elbow-joint, in which I made a long skin posterior flap, the cicatrix sub.sequently 
 
 being placed above the condyles of the bone and in front (Fig. 702). 
 
 Stump after an Am- 
 
 SPECIAL AMPUTATIONS. 
 
 The subject of amputations as a whole having been considered, I propose now to 
 describe them in detail as applicable to diff'erent parts of the body, and begin with the 
 upper extremity. 
 
 Amputations at the Shoulder-Joint. 
 
 This operation may be called for in cases of injury when the arm has been so irrepar- 
 ably injured as to render amputation through the tuberosities impossible or excision inap- 
 plicable, or for disease when too extensive to be taken away by a less severe measure, the 
 surgeon always bearing in mind that large portions of the humerus may be resected with 
 advantage so long as the chief vessels and nerves of the arm are intact, and that amputa- 
 tion through the humerus, however high, leaves a far better .stump than at the joint. 
 
 After this operation, when performed for injury, 1 out of 3 cases die; but when for 
 disease, 1 in 2. 
 
 The operation is best performed by means of the double flap operation. A good 
 assistant is required, to compress the subclavian artery above the clavicle or to take 
 
 charge of the axillary in the lower 
 flap. When the right arm has to be 
 amputated the surgeon should stand 
 behind, and when the left in front, 
 of his patient (Fig. G99) ; under 
 both circumstances a deltoid flap 
 shoiild be fir.st made, cutting from 
 without inward between the poste- 
 rior part of the axilla and an inch 
 in front of the acromion process, 
 this incision including in its sweep 
 the whole deltoid muscle. Having 
 reflected this flap with a few bold 
 sweeps of the knife, the head of the 
 humerus should be disarticulated, 
 the knife being kept close to the 
 Amputation at the Shoulder-Joint. |,Qj,p ^,^j d^g lo^gj. fljjp made, three 
 
 or four inches long, by cutting from within outward. If this part of the operation is done 
 
 Fig. 699. 
 
SPECfA L A MrilTA TIOSS. 
 
 1011 
 
 with can', tin- main artory ••f tlif liiiil) will lie diviiled (Jiily on the cuiiiplction of the Kcoond 
 tlap, when the siirp'oii wi(h his h'ft hand can secure it between lii.s firi^'cr and thumb until 
 it fan In- either twisted or tied. 
 
 hurinj; the Hist step ol' tliis amputation tin- arm >hniil<l l»c held well out by an assist- 
 ant, liut durinir tlie seeond at first near th»; body ; and when the knife has jjassed beneath 
 the head cd" the binu', it sliouhl be abchieted. A very jrood stump usually follows this 
 ojnTation. At no joint of the body, however, is the surj:eon more compelled to form his 
 flaps aeeonlini: to the eireumstanees of tlu; ease than at the shoulder, sinei; the majority 
 t>f eases of amputation at this part are fur injury where the arm has been wholly or par- 
 tially torn olV. when the sur<;eon must make the best flap he can, and at times no flap at 
 all. As <;ooil a stump as any I have made at this joint was one in which a piece of intej^u- 
 inent from the posterior part of the arm was alone available. I have .seen many ca.ses in 
 whit h the flaps slouirhed and yet good cicatrices followed, the soft parts being readily 
 drawn forward by the cicatricial process. 
 
 In this amputation some surgeons prefer makitig an anterior and posterior flap by per- 
 forating in front of the posterior axillary fold to make the posterior flap, disarticulating 
 and dividing the axillary artery in the anterior flap ; but the operation, although good, is 
 not so eflicient as the former. 
 
 Amputation at the Arm. 
 
 Kxcision of the elbow-joint, even when three or lour inches of the humerus are taken 
 away, is such a very succes.sful operation that amputation at the arm is never called for 
 when excision can be entertained ; and this 
 observation applies as forcibly to cases of 
 injury of the elbow-joint as seen in civil 
 and military practice as it docs to cases of 
 disease. 
 
 When, however, the fore-arm and 
 elbow-joint are hopelessly injured, gan- 
 grenous, or diseased, amputation may be 
 demanded, and, therefore, as the very 
 worst eases are included in this category, 
 the mortality of the operation is great — 
 viz., 1 in 3 for injuries, and 1 in 10 for 
 disease. 
 
 The flap operation, as already de- 
 scribed, is the best in this region, the 
 anterior flap being made by cutting from 
 without i-nward toward the bone, excluding the brachial artery, and the posterior by 
 transfixing all that remains. In a very large, muscular arm the skin flap and circular cut 
 thro\igh muscle — I.e., the w/.rer/ operation — may be performed. Amputating by double 
 flaps and tran.sfixion is, however, excellent (Fig. 700). 
 
 Amputation of Ami by Flap Operation. 
 
 Fig. 701. 
 
 Fig. 702. 
 
 Amputation at the Elbow-Joint 
 
 is a capital operation, and ought always to be performed in preference to any higher 
 operation when amjiutation above the fore-arm 
 is imperative, if the condition of the soft parts 
 will allow. By this operation an excellent .stump 
 is obtained, and. as in other amputations at joints, 
 less constitutional disturbance, and probably less 
 risk to life, is incurred than after amputation 
 through the bones. I have had a patient up 
 and about on the seventh day after such an ope- 
 ration, the wound having united without any 
 traumatic fever or other disturbance. 
 
 It should be performed by the mixed metliod 
 of amputating, by anterior and posterior skin 
 semi-circular flaps, beginning and ending at the 
 lower extremities of the condyloid ridges, the 
 muscles being divided transversely on complet- 
 ing the disarticulation (Fig. 701) 
 
 -I- 1 Amputation at EII>ow-Joint 
 
 in tne by Mixed Method. 
 
 Stump after Amputa- 
 tion at Elbow-Joint. 
 
1012 AMPUTATIOX. 
 
 drawing of the stump (Fig. 702) the posterior flap was made longer than the anterior in order 
 that the cicatrix might be out of harms way. I have performed tliis operation on six 
 occasions, and the resuh in all was so good that I cannot too strongly advocate it when- 
 ever the injur}' or disease will allow ; in fact, it ought to be performed whenever enough 
 integument can be saved to cover the bone and the disease or injury for which amputa- 
 tion is called for has not attacked the humerus. 
 
 Amputation at the Fore-Arm. 
 
 This is comparatively a rare operation, modern surgeons doing their utmost to 
 save the hand. It is, consequently, performed only when the hand is hopelessly crushed 
 or so extensively diseased as to forbid any other treatment being entertained. At 
 Guy"s Hospital it was performed only 8-1 times in thirty years ending 1874 — on 44 
 occasions for injury, 9 patients dying, or 1 in 5, and on 40 occasions for disease, with 
 5 deaths, or 1 case in 8 — the operation being used in the ver}- worst cases. Amputa- 
 
 FiG. 703. 
 
 Amputation of Fore-Arm by Mixed Method. 
 
 tion of the fore-arm ought always to be performed by the mixed method, the one by 
 transfixing being very unsatisfactory, the many tendons, etc., of the part causing ragged 
 flaps, and thus favoring suppuration. Two well-cut and fairly-long semi-circular .skin 
 flaps and a clean circular section of the muscles are preferable to the flap operation and 
 yield a good stump (Fig. 703). The skin is usually too thin for one long skin flap, and 
 there are too many tendons for a Teale's. 
 
 Amputation at the Wrist-Joint. 
 
 I have never performed this operation or seen it done, but I have seen two cases in 
 which it had been performed years before for injury, and in both the stumps were con- 
 stant sources of trouble to their owners during the winter months, from their being the 
 seat of chilblains and ulcerations on account of the feebleness of the circulation through 
 the thin cutaneous covering, and in neither could a good hand be fitted with comfort. 
 Both patients likewise regretted that the amputation had not been performed higher up. 
 
 Under these circumstances I am disposed to follow the opinion of my patients, and 
 cannot advocate the operation. If. however, it be called for, it .should be performed 
 with skin flaps and the circular division of the deeper tissues or by the pure circular 
 operation. 
 
 Amputation of the Thumb and Fingers. 
 
 A knowledge of the shape of the articular ends of the bones and of the position of the 
 diflBrent articulations of the hand is of importance in all operations on these parts, and I 
 have, therefore, supplied a figure to illustrate these points as much as possible (Fig. 704). 
 
 The surgeon should remember that with the hand closed the knuckles are formed by 
 the heads of the metacarpal bones, the bases of the phalanges being in front, and that in 
 the second and third rows the same arrangement holds good. To open any of these joints, 
 consequently, the line of incision should be anterior to the knuckles on the dorsal aspect 
 and in the fold of the fingers on the palmar. In the figure it will be ob.served, also, that 
 the two distal joints are concave, with the concavity looking toward the ends of the fin- 
 gers, while at the metacarpal joints the concavity points the other way. the heads of the 
 metacarpal bones being round ; from the palmar surface the metacarpo-phalangeal joints 
 are more than half an inch behind the clefts of the fingers, corresponding pretty nearly 
 with the palmar furrow of the hand ; this furrow likewise corresponds with the upper 
 limit of the synovial sheaths of the flexor tendons and with the bifurcation of the digital 
 arteries. 
 
 In amputating at the phalangeal joints (Fig. 704, C) or through the bones, anterior 
 and posterior semicircular flaps are better than one long flap, although this may at times 
 
Sri.clAL AMi'l'TM'IOSS. 
 
 1013 
 
 Fig. 705. 
 
 bo iHTlun.M.l with a.lvantaire, ouo Uvz a..t<ri..r fl:ip (H). after opening the joint Iru.n its 
 .h.rUl asiu.rt ( .1 ), hcii.- tlu> !i.n>t .uiMinuu shapi- ; hut the surgeon must in these cum-s be 
 „,„,b .M.i.hMl by what skin he has tu utili/.e. As a rule, it l.s wise „ot to take ott the 
 heail ..?• the i.n.'xiinal b..iu-, thou^'h when there is iH.t suttieient tta). U> ever it the surgeon 
 niuv h.- iustilie.l in ivinoviug its li.-a.l witli b(.ne foreeps. , . . ^ . , 
 
 Amputation of the fingers at their metacarpal jomts requires mueh 
 
 nhvU ami in all the linp-rs th. su,-...,, shuuhl nnu.u.l..r that he is on no aeeount, 
 unle.ss absolutely required, to interfere with th.- palm of the hand his .m-,.s,..n ,n the 
 palmar surfaee must never go beyond the iold of the joint. In performing this opera- 
 Ib.n the surgeon is to take eliarge of the amputat.-d member, an assistant holding he 
 hand, separating the fingers, and eompressing the radial and ulnar ve.ssel.s. ^\ ith the 
 hand prl.nated^ivertieal ineision about one ineh long slim, d be made with a strong 
 ' ...ah,,.} over the dorsal aspeet of the head of the metacarpal 
 
 bone, and from its distal end over the joint the knife shc.uld 
 be made to pass u]. one cleft of the finger close to the bone to 
 be removed, round the palmar surface of the finger in the fold, 
 and through the sieoiid cleft to the point from 
 which the circular iiici.sion started, the tendons 
 and liiraments being divided as cleanly as pf>s- 
 sible (Fig. 7(»4). The joint can then be 0}.ened 
 and the finger removed. In a laboring-man it 
 is wise not to remove the head of the metacar- 
 pal bone unless diseased, although in the higher 
 classes it is sometimes expedient to take it away 
 with bone forceps, to allow the neighboring fin- 
 gers to be brought closer together, and thereby 
 To improve the aspect of the hand. With the 
 same object it is at times wise to take off the 
 head of the metacarpal bone of the little or in- 
 dex finger obliquely — /'. e., in a direction sloping 
 upward away from the median line of the hand. 
 In amputating either the little or the index fin- Hand after Ampu- 
 ger at this joint the same form of incision may Thuin^ index, 
 
 Outline Diagram for Amputation i:„ „,aflp the OUtcr flai) under both circumstances and two (Jiiter 
 of the Thuiiib and Fingers. uc iiirtuc, mc vm..- ' , i • • i Fingers. 
 
 "• ^ bein^ somewhat lar<rer than the inner, in order 
 
 that the cicatrix may be placed^'close to the adjoining finger and thus out of all harm's 
 way If the incision be so made as to allow the scar to fall over the exposed aspect of 
 the hand, the result is very inconvenient, and often painful, as the hand naturaUy rests 
 
 on its outer borders. „ , , , i i ^ i 
 
 The same arguments apply to the amputation of the thumb, «>"e long externa 
 skin flap adjusted to a shorter flap in the cleft being far superior to the palmar and dorsal 
 flaps usuall'y adopted. But it may here be .stated that amputation of the thumb ought to 
 be a very rare operation, as it is far better practice in all cases of injury to the thumb, 
 where there is no possibility of saving it. simply to cut off any .sharp point of bone, trim 
 UP the .soft parts, and allow the stump to granulate than to make what is sometimes called 
 a -ood job of it by amputating the organ higher up; for any stump of a thumb, how- 
 ever short or ugly, is of use. In the hand here figured (Fig. 70;>) the man was an 
 engineer, and he has been able for years to f.dlow his occupation with but little incon- 
 
 venience. „ , , i • \ „ lu 
 
 To describe other amputations of different parts of the hand is unnecessary As lit- 
 tle, as possible should be taken away, and this by making skin flaps only, care being 
 always observed to divide the tendons by a clean cut and as high up as possible, ihe 
 ingenuity of the surgeon and the wants of the individual case will suggest the best means 
 by whicii the latter can be supplied. 
 
 Amputations of the Lower Extremity. 
 
 These are of more importance than those of the upper, fron, their greater severity. 
 Tliev are. m.n-eover, larirer operations, more dangerous, and possibly more dithcult. 
 
 Amputation of the thigh at the hip-joint, is a formidable operation and is 
 ju.stma^l? only under desperate ?.nditio„s. wlu-n a limb is irreparably crushed or diseased 
 and resection of the head of the femur with more or less of its shaft is out of question. 
 
1014 
 
 AMPUTATTOy. 
 
 Fig. 706. 
 
 Lister's Abdominal Tonmiquet. 
 
 Fig 
 
 When performed for accident, it is almost always fatal, not ten per cent, recovering : for 
 
 disease, however, it is more successful, the risk being 
 about equal, although after resection of the head of the 
 femur which has failed it is somewhat better. The best 
 flaps where F. Jordan's method cannot be carried out 
 appear to be the external and internal. The patient 
 being brought to the edge of the table, with the tuber- 
 osities of the ischium in view and hemorrhage controlled 
 by Jordan Lloyd's method (]>. 1015^ or Listers tournifjuet 
 (Fig. TOGj, the surgeon should then make the extf-rnal 
 skin flap by means of a semicircular incision, starting 
 from the tuberosit}- of the i.schium, downward and out- 
 ward one hand's breadth Vjelow the great trochanter, and 
 then upward and forward to the centre of the groin (on 
 the outer side of the femoral vessels). This flap should then be reflected upward, so as 
 to expose the trochanter and allow the joint to be opened and disarticulation to be com- 
 pleted, the limb being forcibly adducted by an assistant to facilitate this .step. In doing 
 this no vessels of any importance are divided, while the most difficult part of the opera- 
 tion is performed. 
 
 The inner flap now remains to be made, which is readily done by transfixing the thigh 
 on the inner side, inserting the knife ^twelve inches long; in the anterior wound, passing 
 backward close to the inner side of the neck of the femur, and bringing it out near the 
 tuberosity of the ischium where the external incision was commenced, and then cut- 
 ting out through the .soft parts, including the adductors, etc. (Fig. 707). In doing this 
 
 all the pelvic muscles are separated from the thigh- 
 bone at one clean sweep, and a few touches of the 
 knife complete the amputation. Should there be 
 much cau.se to fear lo.ss of blood, the common 
 femoral artery may be ligatured in the wound 
 before the second flap is made, or it may be divided 
 and twLsted. The ve.s.sels can then be secured in 
 the way the surgeon proposes and the parts brought 
 together, the two flaps usually forming an excellent 
 covering to the acetabulum. Tlie wound being an 
 antero-f»osterior one. and therefore good for drain- 
 age, a good scar results. 
 
 This operation I Vjelieve to be better than the 
 anterior and posterior flap usually advised, and 
 which is thus described by Erichsen: "If the 
 operation be on the left side, the knife ^twelve 
 inches long) should be entered about two fingers' 
 breadth below the anterior spine of the ilium and 
 carried deeply in the limb behind the ve.s.sels directly 
 across the joint, its point being made to issue ju.st above the tuberosity of the ischium. 
 In transfixing on this side care must be taken not to wound the scrotum or the opposite 
 thigh ; the back of the knife must run parallel to, but not again.st. the pelvis, and the 
 point must not be held too high, le.st it enter the obturator foramen. The anterior flap 
 must then be rapidly cut downward and forward about five inches in length. The limb 
 mu.st now be forcibly ah»ducted and everted, the cap.sule of the joint opened. So soon as 
 this is done the head of the femur must be pushed up by forcibly depressing and abduct- 
 ing the limb, so that it may start out of the acetabulum : the heel of the knife is then 
 pas.sed behind it. the remainder of the capsule cut across, and the posterior flap rapidly 
 fashioned by carrying the knife downward and backward through the thick mu.scles in 
 this situation : the posterior flap may be about four inches long.'' The operation is then 
 to be completed as the former. In both these operations good as.sistants are needed to 
 compress the bleeding vessels as they are divided, for hemorrhage and the .shock of the 
 operation are the great evils to be feared. Lister's compressor, however, has rendered 
 this serious operation safer than it was. 
 
 Furneaux Jordan's Method.' — This excellent surgeon of Birmingham has 
 described a method of amputation at the hip-joint which must be regarded as a far better 
 operation than any that has been hitherto described, and it .seems to be generally appli- 
 
 ^ .Surgical Inquiries, 1880. 
 
 Ampntation at Hip-Joint by External and 
 Internal Flaps. 
 
SI'lK lAL AMl'l TA 770A.V. 
 
 1015 
 
 Fkj. tow 
 
 faiili', t'xcliiiliiij; only cases (»f new ^'mwtli in wliicli" the soft parts aroiiii)! the Itoiie are 
 iiivtilvcd in the dist-ast' It cimsists in an incision alon^r the outer side of the thi^h, exteiid- 
 ini; (hivvnwanl from the top of tiie trochanter lor six or more inclies. the enueleutioii of the 
 head of tlie femur from tlie acetal)nlum and tlie separation of part of the 
 shaft from its niuscuhir attachments, and tinally a circiihir divi>ion of 
 the soft parts (hiwn to the hone at any line thouu;ht desirahle. Tlie 
 suriretui may. if he choose, make the circular sweep tlirou<;ii the soft 
 jiarts hefore the shal't of the hone is turned out. 
 
 The periosteum should he saved from the shaft of the femur if prjs- 
 sihle, ami the attacdiments of the muscles thus saved, when, as shown hy 
 Mr. Shuter's case, a firni and movahle stump may he ohtained to fit into 
 the hucket of an artificial limh and assist iJroLM-essiiui. 
 
 It is hetter. says its autlnu\' to enucleate the femur where it is most 
 thinly cttvered, ami cut across the liinh where it is smaller and J'arther 
 removed from the trunk ; it is better, moreover, not to touch the hulky 
 soft jiarts at the inner an<l upper ]»arts of the thiLjh. 
 
 In this I (|uite concur, and from what I have seen of this operation — 
 and it has lieen performed at least five times at (ruy's — I cordially 
 recommend its adoption, aiul more particularly with the improvement, 
 as made hy Shuter, in ])reservint; the perio.steum as much as pcssihle. 
 
 Mr. Jordan Lloyd, also of Birmin<;liam. has suirjrested an excellent 
 method of eontrollin<r hemorrhatje in am])utation at the hip-joint which 
 deserves a notice. I have .seen it eni]doyed with marked success. It 
 is to be a])plied as follows : The limb to be amputated having been 
 emptied of its blood by elevation and friction toward the trunk, '' a strip of black 
 india-rublter bandage about two yards long is to be douV)led and passed between the 
 thighs, its centre lying hrtirecn tlic fnh/r lacJiit' of the aide to ln' openifed on and the 
 anus. A common calico thigh roller niu.st next be laid lengthways over the external 
 iliac artery. The ends of the rubber are now to be firmly and .steadily drawn in a 
 direction upward and outward, one in front and one behind, to a point above the centre 
 of the iliac crest of the same side. They must be pulled tight enough to check pulsation 
 in the femoral artery. The front part of the band, passing across the compress, occludes 
 the external iliac and runs parallel to and above Poupart's ligament. The back half of 
 the band runs across the great sacro-sciatic notch, and by compressing the vessels passing 
 through it prevents bleeding from the branches of the internal iliac artery. The ends of 
 the bandage, thus tightened, must be held by the hand of an a.ssistant placed just above 
 the centre of the iliac crest, the back of the hand being against the patient's body. To 
 prevent the bandage slippintr. it .><hould be fastened bv a safety-pin to the roller" (Laucet, 
 May 20, 1883). 
 
 Furiii-aux .Ionian's 
 M. thcd of Ainnu- 
 talion at the Hip- 
 Joint. 
 
 Amputation at the Thigh. 
 
 Primary amputations of the thigh, taken as a whole, are very serious, and. calculating 
 ca.'^es at all ages, more than half die. In subjects under twenty years of age. however, 
 better results can be recorded, the mortality being about half this amount, whilst in those 
 over forty the average is worse, age having here, as elsewhere, a striking influence on 
 results. Primary amputations, however, in the upper third of the thigh are more fatal 
 than those in the middle, and these;, again, are more fatal than amputations above the 
 knee, amputations through the condyles or at the knee-joint being better than all. The 
 nearer the operation ai)proaches the body, the greater is the risk. Still, even in the worst 
 cases of compound fracture of the thigh, when death seems inevitable, the surgeon should 
 operate when by so doing any reasonable ho])e of saving life can be entertained. 
 
 In amputations for diseases a better account can be given. 
 
 In am]nitation of the thigh for cliriDu'r joint di'srose at all ages the mortality is about 
 1 in 4, but under the age of twenty 1 in 17, while over that period it is 1 in 3. the differ- 
 ence in the mortality of the operation at the two periods being very great. Thus, taking 
 all cases of chronic disease toirether. out of 8f) of mv own, 13 died ; of 99 of rallender's, 
 28; of 54 of MacCormac's ( DnUn, Journal. 18()8), 10: and of 106 of Holmes's, 30; 
 making a total of 348 cases, of whicli 81 died, or 1 in 4. In subjects under twenty 
 years of age, out of G9 cases of Callender's and my own, 4 died, or 1 in 17: and of 
 119 cases over twenty years of age, 38 died, or 1 in 3; amputation of the thigh for 
 
 ' Clin. Soc. Trans., 18S3. 
 
1016 AMPUTATION. 
 
 chronic joint disease being nearly six times more successful in early than in middle 
 life. 
 
 This operation in the upper or middle third, when the muscles are thick, is best per- 
 formed by means of anterior and posterior skin flaps and the circular division of the 
 muscle, or by the flap operation as illustrated in Fig. (J91, the anterior flap being made by 
 cutting from without inward, and the posterior by perforating. The operation by lateral 
 flaps, whether made of skin or muscle, or skin alone and circular muscle, is not satisfac- 
 tory, the bones having a tendency to appear at the upper angles between the flaps. In 
 amputation at the lower third one long anterior flap may be made, and a short posterior, 
 as previously described under (larden's operation (Fig. GOG). 
 
 Mr. W. Stokes of Dublin advocates (Mrd.-Chir. Trans.\ ISTO ; Diib/in Joiirti. of Med. 
 Sci., 1875) the supra-coiidj/k/id ampufa/ion of the thigh, in which the femur is divided at 
 least half an inch above the antero-superior edge of the condyloid cartilage, and the 
 patella, deprived of its cartilaginous surface, is applied to the same surface and fixed 
 there with earbolized catgut sutures. The antei"ior skin flap is made oval, and the poste- 
 rior fully one-third of the length of the anterior. 
 
 I have performed this operation in one case with a good result, and have seen it per- 
 formed on several previous occasions by my colleagues with success. I think well of it, 
 and would suggest its wider trial. My colleague, Mr. Jacobson, has written an interest- 
 ing paper on it (Gin/s liosp. Reps., 1878). 
 
 This operation diff"ers from what is known as Gritti's in the section of the femur 
 being about one inch higher up. 
 
 Amputation at the Knee-Joint. 
 
 This is an excellent operation in all ways, and one that should always be performed in 
 preference to any higher amputation when the special circumstances of the case will 
 allow. It is apparently attended with less risk to life than when a section of the bone 
 is made, and yields an excellent and serviceable stump on which the weight of the body 
 can generally be sustained. Velpeau revived the operation in 1830, while Mr. Pollock 
 recalled the attention of London surgeons to the subject {Med.-Chir. Tram'., 1870). In 
 his paper he states that, up to 1870, 48 cases of the kind had taken place in England, 
 and that 12 died, or one-fourth, but since then the operation has been more common. 
 
 I have now performed it upward of 23 times — on 7 occasions for compound fracture 
 of the leg, 6 of which recovered ; in 13 cases for chronic disease of the knee-joint or leg, 
 11 of which recovered; and in 3 cases for gangrene of the leg 
 Fig. 709. from arterial obstruction. 1 of which alone recovered, the operation 
 
 in the other 2 having failed to save life. In only 2 or 3 of the 
 cases did I I'emove the patella. In all the successful cases excel- 
 lent stumps were obtained (Fig. 709). 
 
 In performing this operation a long, broad, anterior flap should 
 be made, which must of necessity be of skin, and also a tolerably 
 long posterior, for it is remarkable to what an extent the posterior 
 flap always retracts. I prefer to make my posterior flap about 
 two-thirds the length of the anterior and of skin only, and to 
 divide the muscles and deeper structures by cutting from behind 
 
 Ptuiiip ;ili('r Amputation ut „ , , • i i i xi • • j. j i? j.i a-x,- i j. 
 
 tii(> Lfit Knee-Joint. forward about an inch below the joint end oi the tibia, and not 
 after disarticulation, the popliteal artery being thus divided low 
 down, where it is readily secured. The patella should not be removed except when 
 diseased. 
 
 When the operation has been completed and the articular surface of the femur is 
 found not to be healthy or reparable, or the flaps too short, the condyles should be taken 
 away, a thin rounded section of bone being removed, or more if the necessities of the 
 case demand. 
 
 After the operation a troublesome suppuration occasionally takes place in the synovial 
 bursa beneath the extensor muscles of the thigh ; and when it occurs, it should be dealt 
 with by free incisions. 
 
 Stephen Smith of New York has suggested (Amer. Joinii. of Med. Sci., January, 
 1870) the formation of two lateral skin flaps for this amputation, each flap to be formed 
 by an incision commencing one inch below the tubercle of the tibia and carried down- 
 ward and forward over the side of the leg (vide Fig. 710) until it reaches the under sur- 
 face, when it is curved toward the median line. I have adopted this method on ten occa- 
 
.S7'AV 7.1/. A MIT T\ TfOXS. 1 1 7 
 
 sioiis witli cxcclltiit rt'siilts, aiitl iim di-pn-.i! lu tiiiiik it tin- liest. 'I'lic .«tinu|» li-ft is very 
 j^oud, the cicatrix liciii;.' vertical aii<l placnl well IkImikI tin- lowrr rii<l ol" the Iciiiiir 
 (Fig. 711). 
 
 Amputation at the Leo. 
 
 Aiiiputatitm of the leg tor (li.seiisc is a very successful o|terutioti, only about 1 case in 
 12 prnving iatal. in young life it is mure successful than at a later period. 
 
 Auiputatious for injury are, however, very unsuccessful, at least sixty per cent., or 
 
 Flo. 711. 
 
 Vui. 71(1. 
 
 ."^tt'phon Sinitli's Mcilii.il ol" .Aiiiimlating. Posterior Aspect of Stump aftfr S. Smith's Am- 
 
 putation at KiieL'-.Joint,sliowiii)j;<icatrix. 
 
 nitire than half the cases, dying. Pyjuniia i.s a more eummdii cause of death after this 
 form of amputation than oven after amputation of the thigh, it being fairly jiroved 
 that the larger the section of the shaft of a bone, the greater the liability to blood- 
 poisoning. 
 
 Amputations of ex}iediency in the leg are as dangerous as those for injury. 
 
 This operation in the upper two-thirds is doubtless best performed by the mixed 
 method, by two skin lateral flaps and the circular division of the muscles, as already 
 described (Fig. (.i97). When the condition of the soft parts forbids such an operation, 
 other flaps may be made, any form being allowable to avoid sacrificing more of the limb 
 than is necessary. In the lower third of the leg Teale's amputation is good, the long 
 anterior flap not being too long or so liable to slough. The long muscular flaps, and more 
 particularl}' the posterior calf flap, cannot be recommended. In the lateral flap opera- 
 tion, Mr. Cock, who always includes the muscles and makes the flaps long, turns out 
 excellent stumps. Some surgeons, in this mixed method, make anterior and posterior 
 skin flaps, but they possess no advantage over the lateral, while the anterior flap, falling 
 over the edge of the tibia, is apt to slough or to form unpleasant adhesions. In dividing 
 the tibia its anterior edge should be rounded oflf with the saw. 
 
 Amputations of the Foot. 
 
 In no part of the body has an improvement in surgery shown to greater advantage 
 than in the foot, for in none has so much been done in the way of conservatism. Whereas 
 formerly amputation of the whole foot was common, we have now Hey's, Chopart's. 
 Syrae's. Pirogoff"'s (the subastragaloid), and Hancock's operations, all based upon the well- 
 established position that governs, or oni/ht to ijaveni, all amputation.s — viz.. that no more 
 of the body sht»uld be removed than the necessities of the individual ca.se require, or. in 
 other words, upon the principle of •' the least sacrifice of parts." To amputate a foot 
 where anything less would suflice is in the present age regarded as almost criminal, and 
 surgeons generally accept Hancock's well-put ((uestion in his valuable lectures at the col- 
 lege in IStiO: " Can anything be more unphilosophical than to advocate the sacrifice of 
 any bone or joint of the foot for no other reason than that a particular operation should 
 be performed?" (^Lanat, 18()t)). Indeed, this principle of practice should be uppermo.st 
 in the mind of every surgeon called upon to treat any local disease, and in the hand and 
 foot it should be so pre-eminently. Accepting this teaching, Hancock's three other dicta 
 necessarily follow : 
 
 That we should perform our operation as close to the diseased or damaged structure 
 and preserve as much of the foot as we possibly can do with safety to our patient. 
 
 That where practicable we should cut through the tarsal bones with a saw in prefer- 
 ence to disarticulating them. 
 
 That we should avoid the destruction of parts whenever we can do so. 
 
 These views of Hancock accord so closely with those I have attempted to lay down 
 as guides to the surgeon in the surgery of other parts of the body that I have given 
 them in his own words and placed them as leading principles of practice to be observed 
 
1018 
 
 AMPUTATION. 
 
 Fig. 712. 
 
 Foot after Amputation of the Four Outer Toes 
 with their Metatarsal Bones, Two External 
 Cuneiform, and Cuboid Bones. (Key's case, 
 Guy's Hosp. Rep., 1836.; 
 
 in the surgery of the foot. I believe them to be of great practical value, and desire that 
 the student should have them always before him in the treatment of every case of local 
 injuryordisea.se. The principle embodied in the least 2>ossihle sacrifice of parts is one 
 upon which most of the operations of the foot should be undertaken ; and it is well to 
 remember that of the different amputations that have been recommended, while none of 
 them are called for until minor measures have altogether failed, each succeeding one is 
 
 only a degree more severe than the preceding. The 
 surgeon in the present day takes away di.^^eased bone 
 or bones without fear, and leaves nature to repair the 
 breach with every confidence. I have taken away, 
 in one case, the whole second row of tarsal bones, 
 and in another the three cuneiform, scaphoid, and 
 cuboid, with excellent results. I have i-emoved the 
 necrosed os calcis with so little deformity that the 
 loss could hai-dly be detected, and taken away on 
 several occasions the upper articulating surface of 
 the astragalus for disease with a result which has 
 a.stonished me, no extei-nal deformity remaining and 
 movement of the ankle being almost complete. Mr. 
 Key in 1836 took away the whole of the outer part of the foot for injury, leaving only 
 the OS calcis, astragalus, scaphoid, inner cuneiform bone, and great toe (^vlde Fig. 712; 
 Guys Rep.^ 18.36), from a boy fet. 17 who subsequently had a useful and sound foot. 
 More recently Mr. Birkett has done the same with a like success. Single metatarsal and 
 tarsal bones, when irreparably diseased, may be removed with some confidence of a good 
 result being obtained, and any of the operations I am about to describe should be under- 
 taken only w4ien less severe measures are inapplicable. 
 
 Upon this principle the amputations of Hey and of Lisfranc were hailed with satis- 
 faction, Hey's consisting of the disarticulation of the metatarsal bones from the tarsal, or 
 the section with the saw of the metatarsal or tarsal bones, Lisfranc suggesting their dis- 
 articulation. Chopart's amputation, again, at the medio-tarsal joints, Syme's amputation 
 at the ankle-joint, and Pirogoff's, which is a modification of Syme's, a part of the os cal- 
 cis being preserved, have all the same end in view. The sub- 
 astragaloid amputation, as recorded by Malgaigne, to save the 
 astragalus and ankle-joint, is based upon the same principle, 
 and Hancock's amputation to .save the posterior part of the 
 OS calcis with the astragalus goes still farther in the way of 
 conservatism. 
 
 All these operations have their own value and each is 
 applicable to its own class of cases. Where the minor measure 
 will suffice the major is out of all question, the principle of the 
 least possible sacrifice of parts being the one upon which they, 
 as all other amputations, should be based. 
 
 Before considering the different forms of ami)utation it will 
 be well to consider briefly the surgical guides to the foot as 
 expressed by its anatomy, for. although in cases of disease 
 these guides are greatly obscured, they are still of value, and 
 in cases of injury they are always reliable. The accompanying 
 figure will help the student. 
 
 On the inner side of the foot, not far from the inner mal- 
 leolus, the tubercle of the scaphoid {A) is to be felt as a 
 marked prominence ; about half an inch in fiont of this will 
 be found the articulation with the cuneiform bone (jB), and 
 one inch beyond this the joint which the surgeon will have to 
 open in Li.?franc's or Hey's operation (f): just above the tuber- 
 cle of the scaphoid will be found the articulation with the astrag- 
 alus, the line of Chopart's amputation (/)). 
 
 On the outer side of the foot, one inch below the external 
 malleolus, a sharply-defined projection will always be felt, which is the peroneal tubercle 
 (E'), and half an inch in front of this will be found the joint which separates the os calcis 
 from the cuboid, this joint forming the outer circle to Chopart's amputation. Half an 
 inch in front of this, again, or one inch from the tubercle, the prominence of the fifth 
 metatarsal bone is always to be felt (//), the line above this prominence indicating the 
 
 Fig. 713. 
 
 Surgical Guides to Foot as ex- 
 pressed by Anatomy. 
 
SrilClM. AMITTATIOSS. 
 
 lOlO 
 
 Fig. 71 1 
 
 nrtioulatinri with the cuhoid hmu- wliitli lnriii> the oiitir houiKhiry of tin- iiicisinn for 
 llov's or IjislVaiic'> i>|u'i-ati(iii. 
 
 All tlit'si' |M(iiit.s slmuhl lif hiiikoil i'ur in a licalthy I'lxit, ami learnt sn as to In- n*a<Jily 
 ri'coj;ni/AMl in the injnreil nr discasftl. 
 
 Hey's Amputation (Lisfranc's).— 'I'hc credit of introilucinj: this oj)eration 
 must he aeemded t(i lley, l(ir the date of the first case that he imhlisiied was 17!'7, 
 whereas liisfrane's ]ia|ier was oidy piihlished as a su<^^estioii in 1!S15. 
 
 The operation consists in tlie removal of all the toes with the metatarsal hones hy di.-r- 
 artieulatiun, althnuirh it seems, fmni readini: lley's ohservations (lH14j, that disarticula- 
 tion id' tlu' metatarsal ho?ies was nut essential, sinci' in one of the two cases recorded the 
 euhitid hone was reni(tved with smne part u\' the astrajralus, and in the second "the jiro- 
 jeetiniT j)art of the first eunt'iforni hone which supports the jrreat toe was divided with a 
 saw ;" and in others he stated that he sawed tliroui;h the metatarsal hones when the joints 
 were not removed. 
 
 •'The (tperatur." writes .Maliiaiune in dcscriliinL:- it. '' shouM use a small knife with a 
 .solid stron<r hack and only one edue. In o|»eratin;; on the ritrht foot the patient should 
 lie on his hack, and the surgeon, facing the foot, should frrasj) it 
 with his left hand, ti;e thumb and finger respectively resting on 
 the well-marked bony projection of the metatarsal bone of the 
 little toe, and the base of that of the great toe placed one inch 
 in front of the tubercle of the scaphoid. Half an inch in front 
 of these points an incision with its convexity downward is to be 
 made across the dorsal aspect of the foot, dividing all the soft 
 parts down to the bones liy a second cut. The ])lantar flajt is 
 then to be made by two lateral inci.sions carried from the liase 
 of the dor.sal flap 'along the metatar.sal bones, and joined bv a •'-tuiui. alter ii.-y^ .vmr-utation. 
 
 , . . . 11-1 1 1 1 11 i> 1 ■ (Iroin IKy > \\.,rk.i 
 
 curved incision made on a line heyonu the ball ot the great toe. 
 
 This flap is to be longer on the inner than on the outer side, because the internal cunei- 
 form bone is thicker than the cuboid, and it is to include all the tissues down to the bones. 
 l)isarticulation has next to be performed, and this is l)est done from the dor.sal region 
 when the parts are put firmly on the stretch l)y de])ressing the toes. The operator then 
 places the point of the knife on the outside of the joint, and, carrying its edge inward, he 
 opens it as far as the third metatarsal bone. Around here he carries the knife half a line 
 forward, incises almost transversely, and thus reaches the second metatarsal. Here he 
 must above all things remember the general precept not to engage his knife in the joint, 
 but to work only with its point and to confine himself to the division of the ligaments. 
 When this instrument has reached the second metatarsal bone, he quits this side of the 
 articulation to attack the inner side. This is well done by inserting the knife between the 
 shafts of the first and second metatarsal bones with its edge upward, and with a backward- 
 and-forward motion dividing the ligaments holding the second bone in place, this fact 
 being indicated by the sudden loss of resistance which the surgeon feels when pressing 
 the toes downward, and by the sudden separation of the tarsus from the metatarsus. 
 Disarticulation is then to be completed and the plantar flap .shajied by cutting forward 
 close to the bone. A long dorsal flaj) may be made when the plantar flap must be short." 
 
 The parts are then to be brought together by sutures, after securing the vessels by 
 torsion or the ligature and cutting oiF ragged tendons. The foot should be fixed upon a 
 splint, with the leg semiflexed upon its outer side, and treated on ordinary principles. 
 
 The stump left after this operation is good, and the operation one that ought to be 
 pcrfonncd when the toes and metatarsal bones alone require removal. 
 
 Chopart's amputation is an excellent and valuable operation, and should always 
 be ])erformeil in jirct'erence to any higher measure when disease or injury is confined to 
 the fore part of the foot. The great theoretical objection brought again.st it — the sub.se- 
 quent drawing up of the heel and the consequent pointing of the stump — has really little 
 weight, since it can be provided against by the division of the tendo Achillis at the time 
 of the operation, or sub-seijuently. should the difiiculty occur. In many cases of my own 
 the tendons have never been divided. My colleague. Mr. Cock, who has performed this 
 operation many times, thinks most highly <jf it. and never has had to amputate subse- 
 quently on account of the pointing of the stump. He believes that this can always be 
 prevented or cured by the division of the tendo Achillis on the first indication of such a 
 malformation. It was introduced into English practice in 1828 by the late Mr. James 
 of Exeter, and to the notice of Scotch surgeons by Professor 8yme. who subsequently, 
 however, renounced it in favor of his own operation at the ankle-joint. He did so on 
 
1020 
 
 AMPUTATION. 
 
 account of the objection already .stated, and because in such partial amputations the part 
 of the tarsus left behind, though apparently sound at the time, may become affected M'ith 
 the same disease at a later period. But such an argument may be brought against all 
 operations less than the removal of a diseased part far from the seat of mischief, and is 
 now fairly repudiated by modern surgeons. In fact, all excisional and conservative sur- 
 gery is based upon an opposite supposition, the local nature of disease becoming daily 
 more acknowledged and acted upon. 
 
 Operation. — The operation may be described as the amputation of the fore part of 
 the foot anterior to the astragalus and os calcis, or as the medio-tarsal amputation. On 
 the right foot it should be commenced by making a slightly 
 convex flap from the dorsal aspect of the foot, commencing Fig. 716. 
 
 half an inch behind the prominence of the metatarsal bone 
 of the little toe and terminating at the tubercle of the sca- 
 
 Fm. 71.".. 
 
 Chopart'.s Aiuputation. 
 
 Stump after Chopart's Amputation. 
 
 phoid, the surgeon grasping the foot with his index finger on one point and his thumb on 
 the other. The skin is the first part to be divided, and subsequently, on the level of its 
 retraction, all the tendons, etc., are cut through down to the bones or joints ; the articu- 
 lations are then opened, beginning at the scaphoid joint ; the foot should be forcibly bent 
 downward, to facilitate this part of the operation ; the plantar flap is to be made by cut- 
 ting forward, and in doing this care should be observed to keep the knife close to the 
 bones on the sole of the foot, in order that the soft parts may be divided with as clean a 
 cut as possible ; the flap should be long and extend as far as the balls of the toes, and 
 longer on its inner than on its outer aspect (Fig. 715). All ragged tendons may be cut 
 off" short and the parts brought together. If there be any difficulty in bringing up the 
 fore part of the stump or any retraction of the heel, the tendo Achillis should be divided 
 at once ; but if no such difficulty is experienced, such a measure is unnecessary. In 
 dressing the stump a good opening for drainage should be left. Fig. 71 (i illustrates the 
 condition of the stump a year after the operation, in which the tendo Achillis was not 
 divided. 
 
 On one occasion I performed this medio-tarsal operation for injury, making two lateral 
 flaps from the dorsum and sides of the foot, the integument of the sole having been 
 destroyed. A good stump resulted. 
 
 Tripier's Amputation.— The amputation of the foot devised by Tripier of Lyons 
 as a substitute for Chopart's claims a notice, since it professes to possess all the advan- 
 tages of the Chopart and none of its disadvantages. It includes a horizontal section of 
 the OS calcis on a level with the sustentaculum tali (Fig. 717, A), and gives a flat sur- 
 face to stand upon instead of the posterior part of the os calcis and the unsupported 
 anterior extremity of the bone. 
 
 The operation is described in the Bn'f. Med. Jonrn. (February 26, 1881), but I prefer 
 the description of it aiven by P. Hayes of Dublin in the Dublin Jovrnal (December 1, 
 1881). 
 
 Operation. — The surgeon's knife is caused to take the following course : Com- 
 mencing at the outer edge of the tendo Achillis, on a level with the external malleolus 
 (Fig. 717, C), a skin wound is to be made in a direction at first downward and forward, 
 and afterward forward, so as to pass two fingers' breadths below the malleolus, and then 
 to approach to wuthin a finger's breadth the upper part of the base of the fifth metatarsal 
 bone. From this point the incision is to be carried upward, forward, and inward, so as 
 
si'i.ciAL AMrriw'j'ioys. 
 
 021 
 
 tn rcai'li llu' iiiiuT iii!irL;iii of tin- tciiduii (.f ilu' rxt(!tis(ir lialluci.s prMpiiiis just h.-liiud tlic 
 first iiK'tutursal articulation. Tlie kiiilV- .sliuulJ now hi; made to cut downward and I'or- 
 ward, so a,s to t-ntiT tlu- solo ol" tin- loot a lini:fr's lnvadtli in iVont oi' tlu; dor>al wound. 
 The incision is then to l)o carried witli a L:«'iitli' I'orward curve; outward and backward 
 
 l'"iu. 717. 
 
 Tripier's Aniputatiidi of tlit- I'uot. 
 
 iintil it can be made continuous witli the first jiortion of the wound below the outer mal- 
 leolus (Fig.- 717, D). The divided integument having undergone some degree of retrac- 
 tion, the dorsal and plantar structures are to be divided hall" an inch behind tlie super- 
 ficial wound ; the soft parts are then to be separated from the bones, extreme care being 
 taken to preserve uninjured the vessels contained in the inner part of the plantar flaj). 
 
 The surgeon will find it convenient at this stage to disarticulate the cuboid and sca- 
 phoid from the os calcis and astragalus, just as in Ohopart's amputation. Having done 
 so, he will proceed to divide and separate the ])eriosteum from tlie under surface and pos- 
 terior extremity of the os calcis up to the level of the sustentaculum tali, where the bone 
 is to be sawn through in a direction from behiiul and within, forward and outward, so as 
 to leave a surface which will be at right angles with the axis of the tibia when the limb 
 is caused to assume the ordinary position for walking or standing (Fig. 717, A). 
 
 All sharp bone edges and angles should now be rounded off". The posterior tibial 
 nerve is to be exposed in the plantar flap and divided as high as possible, with a view to 
 prevent risk of neuroma. The vessels having been secured and drainage tubes having 
 been inserted, the flaps are to be brought together and the limbs so dressed as to secure 
 moderate flexion of the ankle-joint during the period of repair. M. Tripier attaches 
 importance to the preservation of the periosteum covering the under surface of the os 
 calcis when it is jiossible to do so. The stump yielded is a good one (Fisr. 717, B). 
 
 Subastragaloid amputation follows next in order amongst the amputations of 
 the foot, and is the removal of as much as is taken away in Chopart's amputation, with 
 the addition of the os calcis. It has been performed when the disease for which an ope- 
 ration is re(iuired involves these parts and yet leaves the astragalus and ankle-joint sound. 
 It seems, according to Velpeau (^Optratlvt> Surgeri/, 1839), to have been first performed 
 by M. de LigneroUes, and subsequently by Textor, although Malgaigne in 184G described 
 the operation as his own without mentioning these facts. 
 
 It is made by a heel flap, as in Syme's amputation, and a dorsal flap, as in Chopart's, 
 the foot being removed bv opening the joints between the scaphoid and astragalus, and 
 that between this latter bone and the calcis. 
 
 " The stumj) resulting from the subastragaloid amputation appears to me." writes 
 Hancock, " to be perfect ; it is round and of good form, the cicatrix is firm and well up 
 in front, and the bottom of the stump is perfectly covered by the natural heel tissue." 
 Nt^laton says this form of amputation ''has been found to surpass all amputations" 
 ((7//h. Siny.y 
 
 I am surprised at these opinions, for in the two cases I have had of it, though the 
 repair was good, the stumps were not to be compared with tlio.se of a Chopart, a Piro- 
 goff", or a Syme. I .shall never do it again. 
 
 Hancock's operation must be looked upon as a modification of the subastraga- 
 loid, in the same way as Pirogoff's is a modification of Syme's ; for Hancock saves the 
 tuberosity of the os calcis and turns it up, to be united to the lower surface of the astrag- 
 
1022 A MP UTA TION. 
 
 alu8, from which he takes a slice of bone. It ma}' be adopted when, in hi.s attempt to 
 perform the subastragaloid operation, the .surgeon finds the lower surface of the astraga- 
 lus diseased and the os calcis sound. Mr. Hancock performed it in ISG-t with an excel- 
 lent result. The incisions are very similar to those required in the suba.stragaloid, the 
 end of the os calcis being divided in a line corresponding to the heel flap, instead of the 
 flap being reflected. In the Lancet for 1866 full particulars of Hancock's operation may 
 be read, as described by him in a lecture at the College of Surgeons. 
 
 Syme's Operation. — This consists in the removal of the whole foot with the 
 articular surfaces of the bones of the leg just above the malleoli, a covering for the osse- 
 ous surfaces being provided from the integument of the heel, the result being, adds Lis- 
 ter, " a stump admirably fitted for bearing the weight of the body. At the same time, 
 the parts likeh' to originate carious disease are completely got rid of; so that this opera- 
 tion is calculated to super.sede entirely that of Chopart. besides taking the place of ampu- 
 tation of the leg in the majorit}- of cases formerly supposed to demand it" (Holmes's 
 Si/sf., vol. iii., 3d ed., p. 715). 
 
 This view of the operation, which was also held by its originator, emanating from one 
 who was so closely connected with Syme, professionally and otherwise, is doubtless far 
 too sanguine. 
 
 That the operation is good no surgeon will deny when amputation of the whole foot 
 is called for, but to say that it will supersede entirely Chopart's operation is to say what 
 I trust never will be true ; for when the bones of the ankle-joint and the joint itself are 
 sound, no surgeon ought to take away the whole foot if an}- minor measure will suffice. 
 AVhei'e Choparts amputation is applicable Syme's ought not to be entertained. As an 
 amputation of the foot where the whole foot must be sacrificed it is admirable, but under 
 no other circumstances can it be recommended ; that it is superior to amputation of the 
 leg mo.st surgeons will admit, upon the same principle that Chopart's is superior to it — 
 on the principle of the least possible .sacrifice of parts. 
 
 It is, however, a succes.sful operation, Hancock reporting (Lauaf. 1866) that out of 
 219 cases only 17 died, or 7? per cent. ; 181 were operations for disease, and of these 11 
 died, or 65 per cent. ; 32 for accidents, of which 6 died, or 13 per cent. The experience 
 of the American war speaks also in its favor, for out of 67 cases only 9 died, or 13^ 
 per cent. 
 
 Operation. — The operation is performed as follows (I give it in Syme's own words) : 
 "The foot being held at a right angle to the leg, the point of a common straight bistoury 
 should be introduced immediately below the fibula, at the centre of its malleolar projec- 
 tion, and then carried across the integuments of the sole in a straight line to the same 
 level on the opposite side. The operator, having next placed the fingers of his left hand 
 upon the heel and inserted the point of the thumb into the incision, pushes in the knife 
 with its blade parallel to the bone and cuts close to the osseous surface, at the same time 
 pressing the flap backward until the tuberosity is fairly turned, when, joining the two 
 extremities of the first incision by a transverse one across the instep, he opens the joint, 
 and, carrying his knife downward on each side of the astragalus, divides the lateral liga- 
 ments so as to complete the disarticulation. Lastly, the knife is drawn rovmd the extrem- 
 ities of the tibia and fibula, so as to expose them sufiiciently for being gra.sped in the hand 
 and removed by the saw. After the vessels have been tied (twisted), and before the edges 
 of the wound are stitched together, an opening should be made through the posterior part 
 of the flap where it is thinnest, to afford a dependent drain for the matter, as there must 
 always be too much blood retained in the cavity to permit of union by the first intention. 
 The dressings should be of the lightest description. That the flap may. and probably 
 will, still occasionally slough is unhappily too true, but this result is always owing to an 
 error in the mode of performance ; for as the integument, being detached from its sub- 
 jacent connections, can derive nourishment only from the anastomosing of vessels, it is 
 evident that if scored crossways, instead of being separated by cutting parallel to the sur- 
 face, the flap must lose its vitality." 
 
 Instead of dissecting the heel flap from the calcis at an early period of the operation, 
 it is a better and simpler practice to do this after the foot has been disarticulated, the sur- 
 geon, with the foot in his hand, readily separating the heel flap from above. 
 
 In Syme's first operation, in 1842 ( Obsn-vations in Clinkdl Surr/eri/. 1861). he simply 
 took away the malleolar projections and did not remove the articulating surface of the 
 tibia, as sub.sequently advLsed ; and it is still an open question whether any advantage is 
 gained by this extra section of bone. I have performed this operation b}' Syme's original 
 method with an excellent result. 
 
SPK( 7. 1 /. . 1 .1//' ^ "/I Tioys. 
 
 1(12; J 
 
 Fig. 718. 
 
 Anipiitutiiiii. 
 (From FergusjiOD.) 
 
 Tlie .stump I'lilldwiiig till' aiii|iiituti(iii is fxccllcnt. Fi;^. 71H, taken IVnin FergusKon's 
 lectures on the pntgreHs of surgery, illustrute.s it adiniralily : "The very Vjit of soft 
 material on whieh we naturally stand is still presi-rved for the future 
 basis <it" this support. J 
 
 Some surgeons, and I'irrie amongst tht-m, pfrfnrni the operation Ky 
 .siwing through the tiltia and Khula without disarticulating the font. 
 TIic innditicatinn is lt'i'mI. 
 
 Roux's amputation differs from Symes only in the flap being 
 made from the inner and under side of the heel. I have on one occasion 
 made a long anterinr flap — the oidy one the eimdition of the parts per- 
 mittt'd — witli siHcos. 
 
 PirOgofif 'S Amputation. — This operatif»n is to he regarded as a 
 niodifleaticm id' Symes. and was introduced by its distinguished originator 
 during the Crimean war. The merit he clainis for it is the novel osteo- 
 plastic principle that, a portion of one bone remaining naturally connected 
 with sdft parts, readily unites with another, and at the .same time .serves 
 to lengthen the limb and increase it.s utility. It differs from Synie's in 
 leaving the tuberosity of the os calcis in the heel flap instead of dis.secting stump afteTs} me's 
 it out and bringing up its exposed cut surface to unite to the divided 
 extremities of tlie tibia and fibula. I have fre(|uently performed it, and 
 in every instance with a good result. Busk was the first surgeon who did it in thi.s 
 country, in IX.u. 
 
 The limb is longer than after Syme'.s amputation, and the stump is not to be excelled 
 (Fig. 721), since a patient can walk upon it as well as if no amputation hail been per- 
 formed. The incisions are the same as in Syme's, 
 but no heel flap is dissected up. After disarticulat- 
 ing and dividing the lateral ligament sufficiently far 
 for the OS calcis to become visible behind the astrag- 
 alus, the surgeon has to saw through the os calcis 
 in the line of the heel and remove the foot, subse- 
 quently taking off the ends of the tibia and fibula. 
 
 Dr. Kben Watson, after having made the heel 
 flap, prefers, before going farther, to saw off as 
 much of the os calcis as he wants to save ; but there 
 is an objection to this practice, as I have known the 
 incision through the bone to be made too far for- 
 ward into the astragalo-calcanean joint, and a second 
 slice have to be removed. Dr. Watson also adopts 
 Pirrie's practice of dividing the tibia and fibula with- 
 out previous disarticulation of the foot (Figs. 720 PiroKoffs Amputation. (Heel flap with raids.) 
 
 and 721). 
 
 When this method is employed, the surgeon should make a more oblique section of 
 the OS calcis from below backward. 
 
 Fig. 720. 
 
 Pirogoflf's Amputation. (Division of malleoli. Takeu 
 from T. Smith's work.) 
 
 Stump after Pirogoffs Amputation. 
 
1024 
 
 AMPUTATION. 
 
 I regard Pirogoff's amputation as very good, and it yields an excellent stump (Fig. 
 721) ; it ought always to be preferred to Syme's when the os calcis is sound. If the bone 
 at the time of the operation be found to be bad, it must be removed, the operation 
 resolving itself into a Syme's ; but when the bone is good, it appears to be a grave error 
 to take away what makes so good a point of support to the body. 
 
 Hancock records 58 cases of this operation as performed by British surgeons ; 5 only, 
 or 9 per cent., died. 
 
 Amputation of the toes may be performed in the same way as amputation of 
 the fingers already described, equal care being observed not to interfere with the plantar 
 surface of the foot. In amputating the great or little toes the same oval flaps should be 
 made as were recommended in amputation of the thumb and little finger (page 1012). 
 They should always be large and as much skin saved as the case will allow. 
 
 Stumps, and their Morbid Conditions. 
 
 To secure a good stump is desirable, although to obtain it by taking away more of 
 the body than is required by the exigency of the case no increased risk to life should be 
 incurred. Many of the most promising stumps after an amputation often turn out badly, 
 while the least promising end well, the result depending more probably on their subse- 
 quent dressing than on the condition of the flaps at the time, it being quite certain that 
 bad dressing may destroy the best stumps and good dressing improve the bad. Still, the 
 character of the stump is much determined by the form of amputation that has been per- 
 formed. 
 
 The stump after a circular amputation (Fig. 722) is not so good as that obtained after 
 a flap (Fig. 723). The stump left after the mixed form of amputation of the leg leaves 
 
 Fig. 722. 
 
 Fig. 
 
 Fig. 724. 
 
 Thigh Stump after a Circular 
 Amputation of Thigh. 
 
 After a Flap. 
 
 Stump after Amputation at 
 the Knee-joint. 
 
 Fig. 725. 
 
 nothing to be desired (Fig. 698), and that which is met with after amputation at the 
 knee-joint when the patella is left is unexceptionable (Fig. 724). 
 
 A conical stump (Fig. 725) is always regarded as a bad one, and yet most thigh and 
 arm (single-bone) stumps after primary amputation become conical by time, the soft parts 
 and muscles wasting, except in very fat subjects. When double bones exist, this evil is 
 rarely seen, nor is it after amputation at the joints. Knee and elbow 
 stumps and Pirogoff"'s are the best we see. 
 
 A stump that looks well after an operation, with a mass of muscle 
 covering it, is sure to undergo a change ; the muscles will degenerate, 
 and after losing all their characteristic features turn into fibro-cellular 
 tissue, of which, and of fatty tissue, a good stump is formed. The 
 end of the bone will become rounded off" and its medullary canal filled 
 up ; the nerves of the stump also will become bulbous to a degree, but 
 painful only when they are involved in the cutaneous cicatrix or bound 
 down to the bone. 
 
 At times, however, stumps grow and become conical, and in the 
 amputations of childhood this condition must be expected. It is best 
 seen in the leg, as it so happen.^ that the shafts of bones grow most 
 where they come in contact with the larger epiphyses, and in the leg 
 the one entering into the knee-joint is the larger. In the case of a 
 boy xt. 7 whose leg I had to amputate, with some irregular skin flap, 
 for a compound fracture, just below the knee, I have had to take away on two occasions, 
 at intervals of three years, two pieces of bone at least an inch long, purely from the growth 
 of the bone during childhood; and it was interestina; to notice that the tibia on both occa- 
 
 Conical Stump. 
 
SVFA'I. I /. . 1 MITT. I 770.V.V. 
 
 1020 
 
 It'ast twice as niucli as the lili 
 111(1 an 
 
 my scciiikI (ppcratiiiii I m-vcr 
 
 sioiis had "_Mu\vii at 
 tuiii-lit'(l tlic liliiila. 
 
 Painful stumps iin- hk'sI llistI•('sslll^^ ami arc c((iiiiiiniily caused riy smiic increase 
 in the IiiiHmiiis cninlitiiiii nt' tlio (livi(h'il nerves, tlie nerve being incluiKMl in the cicatrix 
 tir prosetl ii|M(ii liy the Irone ; and nnihr sucli circuinstaiiCL'S a cure is readily effected by 
 the removal ol' the hulhous nerve. IJut in others the extreme jiaiii seems to he due to 
 hyjiera'sthesia \vhi(di is often called hysterical, the sli^rhtest tonch of tlie end of the 
 stump hein;^ suffii-ient to cause convulsive t\vitchinp;s of the limb and pain flyinjr up the 
 stump. Ill these cases operative interference cannot be recommcndcMl, althou;xh nerve 
 stretchiiiir has been advocateil. The {reiieral condition of the body usually associated 
 with this attectioii re(|uires attention ; tonics are always recjuired, with local soothin<r ano- 
 dyne ai(|ilicatinns such as lielladonna, ojiiiim, or stramonium ointments, etc. 
 
 Necrosis of the stump is a common condition, and it is often due to too great a 
 separation nl" the periosteum from the bone at the time of the operation by the forcible 
 traction of the flaps backward, and at times U) a distinct endostitis (»f the divided bone 
 (osteo-mvelitis). In the former case the necrosis is limited and will jirobably show it.self 
 only as a ring "if bone, which may come away by itself or 
 
 be removed. In the latter more or less of the shaft of Fjg. 726, 
 
 the bone dies and subse(|uently exfoliates, the i)erio,stenm 
 forming a new casing or sheath of bone to suj)ply the dead 
 bone's place, as in cases already described in the chapter 
 on ostitis. The largest seciuestrum I was ever called upon 
 to remove from a stump was from the femur of a man 
 who.se lower extremity I amputated for di.sease of the knee- 
 joint consecutive to acute necrosis of the tibia. The femur 
 became inflamed by endostitis after the amputation, and 
 ended in endosteal necrosis. The sequestrum was five 
 inches long. I drew it out of the end of the stump some Necrosis of a stump, 
 
 months after the amputation, and an excellent stump was 
 
 left. I have had also a similar case in a child about six years old, necrosis of the stump 
 following amputation for acute necrosis of the tibia extending into the knee-joint. The 
 stump united after the operation by primary union, but the bone subsequently appeared 
 in the wound as a necrosed mass, this change being attended with sligbt con.stitutional dis- 
 turbance. In exceptional cases the soft parts slip away from the bone and retract as 
 a whole, the stump bone suddenly protruding through them for some inches (Fig. 
 726). In these cases the periosteum covering the bone, having inflamed, retracts with 
 the soft parts, and so leaves the bone, which, deprived of its periosteum, projects from 
 between the flaps as a dead or dying portion, the result of periosteal necro.sis. ruder 
 these circumstances the .stump must be reopened and the end of the bone removed high 
 
 Sir Joseph Fayrer tells us (Clin. Surg., 1866) that in India this o.steo-myelitis of the 
 ends of stumps is a common affection, and often attended with severe constitutional symp- 
 toms such as are well known to accompany all cases of acute eiujoatitis with or without 
 amputation. He regards the aflrectit)n as so serious that he advocates the reamputation 
 of the limb above the next joint as soon as the earliest symptoms of systemic infection 
 appear, blood poisoning being the chief danger of the disease. '■ The proper time, " he 
 writes, '"for amputation in cases of diff'used osteo-myelitis is as soon as possible after you 
 have ascertained that the bone is affected, and the mode of arriving at this knowledge is 
 simply the passage of a long probe down the medulla. Should it impinge on healthy and 
 bleeding medulla near the surface, you may, if the con.stitutional s3'mptoms permit, wait 
 and see if nature is about to limit the suppuration and throw off" the diseased bone, which 
 is a rnre result. Should it pass well up the bone, its whole death is certain. In cases of 
 incipient inflammation the medulla will be found protruding like a fungus from the cen- 
 tral cavity and the bone surrounding it exposed to a greater or le.sser extent; at a later 
 period the end of the medulla is found already dead, blackened, and encrusted, but within 
 it is a putrid mass of bone, (fehris, and pus. In the former stage you can watch the 
 progress of the case. In the latter interference is immediately necessary ; and that. I fear, 
 can be nothing short of amputation, either about the next joint or perhaps, in a young 
 subject, at the epiphysis. The condition of the .soft parts must not deceive ; the condi- 
 tion of the bone and the constitutional .symptoms must be the guide as to the time and 
 necessity for operations."' I have made this long extract from Sir Joseph Fayrer's paper 
 
 63 
 
1026 
 
 AMPUTATION. 
 
 Fia. 
 
 because it is through him that in recent times the subject lias been brought prominently 
 
 under notice, though Longmore and Holmes in this country have ably dwelt upon it, 
 
 and lioux of Toulon made it the subject of" a special report. 
 
 In acute cases there can be little doubt as to the wisdom 
 of the practice suggested, but in English practice they are 
 not, however, of great fre(iuency, the cases of necrosis of 
 stumps met with being generally of a more chronic or sub- 
 acute kind, of either periosteal or endosteal origin, and not 
 requiring such active treatment. 
 
 Aneurismal enlargement of the arteries of a stump lias 
 been described by Erichsen on Cadge's authority, and is an 
 accidental association. 
 
 Cancer may also attack a stump. In December, 1871, I 
 removed the leg-stump of a man aet. 58 for extensive cancer- 
 ous disease of two years' standing, which attacked the cicatrix 
 
 that had been formed fifty-four years (vide Fig. 34, p. 13G). In this case amputation of 
 
 both legs had been performed for gangrene of the limb when the patient was a child 
 
 four years old. 
 
 When the end of the bone in a stump is not well covered and is subjected to pressure, 
 
 a bursa at times forms as a protective agent. This occurred in the case from which Fig. 
 
 727 was taken. I amputated the end of the humerus with the bursa, and a good stump 
 
 was left. 
 
 r-lionc 
 
 pet. ir,, 
 
 Removed from .John S 
 who had had his Arm Ampu 
 tated Four Years previously for 
 ail Accident. 
 
 To Prepare and Clean Sponges. 
 
 Having shaken them to get rid of sand, and washed them to remove dirt, place them 
 in water acidulated strongly with muriatic acid, and there let them remain until all effer- 
 vescence has ceased and chalk is removed. For this purpose it may be necessary to 
 renew the acid several times. 
 
 Let them then be well washed in plain water. 
 
 To bleach them, wash them repeatedly in a solution of binoxalate of potash ^j, ad Oj 
 of tepid water. 
 
 After an operation they should be washed in cold water free from bbxid, and then 
 placed in a solution of carbolic acid, one in eighty, and there left for twenty-four hours. 
 They are then, after another washing in pure water or carbolized water, ready for use. 
 When not at once required, they should be squeezed dry and suspended in a warm room 
 in a porous bag to dry. 
 
 Sponges should not be placed too near a fire, since dry heat hardens them, nor should 
 they be washed in a solution of soda unless they are very greasy, since alkalies dissolve 
 spongine or horny tissue and makes it soft and incapable of absorbing moisture. 
 
 ^' 
 
1 N D K X . 
 
 AllItOMFN. injuries of, 483 
 (liiij;iicisis in, -ISI 
 ciintiisioiis III', IS.'i 
 
 |)iMH'triUinK wdiinds of, |S| 
 
 gun.xlicit wounds of, ItSG 
 
 tii|.i)in;;, oL'l 
 Abdomiiiai jmriotos, wound:" of, 492 
 
 visooni, wounils of, 4'.M 
 
 j)rotrusion of, J'.l.'i 
 Alxluction of lu>r in liip disuuso, 914 
 AI>noi-uiiil iiiius, 49a 
 Absci'ss, ti7 
 
 chronic, t>S 
 
 niveoliir, 473 
 
 nun I, .i()S 
 
 in bone, 95.'{ 
 
 in bruin, 209 
 
 of brcHst, 7()6 
 
 f.-ciil. 49() 
 
 iiiiul)ar, 210 
 
 spinal, :j;59 
 
 l.erineal, 084, 094 
 
 of tongue, 42;i 
 
 of kidney, 0:50 
 
 of prostate, 040 
 
 of joints, 929 
 
 about joints, 948 
 
 opening, 09 
 
 Hilton's method, 70 
 Abscess knife, ()9 
 Abscission, .SI 4 
 Absorbent inflammation, 182 
 Accoininodation, 200 
 
 diseases of, 204 
 Acetabulum, fracture of, 884 
 
 impaction of femur in, 884 
 
 necrosis of, 931 
 Acromion, fracture of, 872 
 Actual cautery, 348 
 Acupressure, 340 
 Acute internal strangulation. 501 
 Adams's operation on hip, 92j 
 
 for deformed nose, 587 
 
 for contracted fingers, 823 
 Adduction of leg in hip disease, 914 
 Adenitis, ISl 
 
 sy|ihilitic, 721 
 Adenoma, 129 
 
 of breast, 770 
 cystic, 772 
 statistics of, 773 
 Adhesion, primary, 20 
 
 secondary, 29 
 
 repair by primary or second- 
 ary. 33 
 Adhesions of iris, 280 
 
 of labia, 750 . 
 
 peritoneal. 789 
 Adipose tumors, 126 
 Air in veins, 402 
 Air passages, foreign bodies in, 600 
 
 wounds of, 698 
 
 operations on, 605 
 Albuminuria, 052 
 
 with shock, 225 
 
 Alcoholic dressing of wounds, 51 
 Alimentation, rectal, 5S4 
 Ailnr!oii's o|ieration for stone, 077 
 Alveolar aliscess, 4 74 
 Amalgams, 409 
 Amaurosis, 285 
 Ametropia, 201 
 Amputation, 999 
 
 in collapse, 220 
 
 in joint disease, 929. 942 
 
 or excision of knee, 934 
 
 difl'ercnt varieties of, 1000 
 
 mortality, 1002 
 
 of the tliigh for diseases of the 
 knee, 1002 
 
 causes of death in, 1002 
 
 double, 1003 
 
 modes of, 1003 
 
 instruments required in, 1005 
 
 position of assistants in, lOOC 
 
 flap operation. 1005 
 
 its history, lOOIl 
 
 circular operation, 999 
 
 value of splints after, 1007 
 
 Teale's. lOOS 
 
 Garden's, 10119 
 
 mixed form, 1009 
 
 at shoulder-joint, 1009 
 
 arm, 1011 
 
 at elbow- joint, 1011 
 
 of fore-arm, 1012 
 
 of thumb and fingers, 1012 
 
 at wrist-joint, 1012 
 
 at hip-joint, 1013 
 
 by Furneau.\ .Jordan's method, 
 1015 
 
 of thigh, 1015 
 
 at knee-joint. 1010 
 
 of leg, l"ol7 
 
 of foot, 1017 
 
 in gangrene, SI 
 
 .in gunshot injuries, 989 
 
 in compound fractures. 836 
 
 dressing stunij) after, 1007 
 Amussat's operation, 512 
 Anal abscess. 508 
 Antesthesia, local, 999 
 Anassthetics, action of, 993 
 
 rules for the administration of, 
 994 
 
 value of, as aids to diagnosis, 
 997 
 
 improvements in practice due 
 to. 997 
 
 in eye surgery, 290 
 .Anastomosis, aneurism by, 376 
 Anatomical tubercle, 101 
 Anchylosis of spine, 246 
 
 oV hiji, 915, 924 
 
 of knee, 928 
 Anel's ojteration for aneurism, 369 
 Aneurism. ;157 
 
 pathology of, 357 
 
 diagnosis of. 300 
 
 diffused, 357, 373 
 
 Aneurism — 
 
 dissecting, 357 
 
 traumatic, 373 
 
 false, 357 
 
 true, 357 
 
 varicose, 375 
 
 rupture, 360 
 
 spontaneous cure of, 359 
 
 by anastomosis, 370 
 
 fusilorm, 357 
 
 arterio-venous, 374 
 
 cirsoid, .'170 
 
 special, 3sO 
 
 treatment of, 301 
 
 by ligature, 369 
 by compression, 303 
 by manipulation, 371 
 by injection, 372 
 Aneurism needle, 382 
 Aneurismal sac, relations of, to ar- 
 tery, 357 
 
 vari.\, 375 
 Angeio-lcucitis, 181 
 Angular curvature of spine, 245 
 Animal jioisons, 100 
 Ankle-joint, dislocations of, 850 
 
 diseases of. 918 
 
 siij)])uration of, 937 
 
 excision of, 937 
 
 amjiutation at, 1021 
 Ankyloglopsis. 418 
 Annular urethral stricture, 683 
 
 rectal, 581 
 Antiseptic irrigation, 33, 51 
 
 ligature, 342 
 Antrum, diseases of, 442 
 
 dropsy of, 442 
 
 suppuration of. 442 
 Antyllus, operation of, for aneur- 
 ism, 371 
 Anus, artificial, 495 
 
 abnormal. 495 
 
 imperforate, 500 
 
 diseases about, 565 
 
 fistula aI)out. 508 
 
 ])ainful ulcer of, 507 
 
 j)ruritus of, 578 
 Aorta, abdominal aneurism of, 383 
 
 ligature of, 383 
 
 compression of. 3S3 
 Aphasia after head injury, 200 
 Aphthous stomatitis, 415 
 Apiioea, 018 
 Arachnitis, 207 
 
 s])inal, 234 
 Arachnoid cysts, 203 
 Arch, |ialmar. wounds of. 393 
 Arm. amputation of. 1011 
 Arrest of growth after fracture. 876 
 
 of inflammation by obstruction 
 of artery. 71 
 Arrows, wounds from, 156 
 Arterial or anieraic gangrene, 81 
 
 pyivmia, 355 
 Arteries, diseases of, 352 
 1027 
 
1028 
 
 INDEX. 
 
 Arteries — 
 
 inflainuiiition of. 352 
 
 atheroma of, 3y,'i 
 
 injuries of, 340 
 
 contusion of, 341 
 
 torsion of, 341 
 
 statistics of, 34S 
 
 ligature of, 342 
 
 general rules for the ligature 
 of, 381 
 
 occlusion of, 341 
 
 subcutaneous rupture of, 341 
 
 hemorrhage from, 340, 343 
 Arterio-venous aneurism, ;!74 
 Arteritis and atheroma, 351 
 Artery constrictor, 34S 
 Arthritis, gonorrhceal, 717 
 
 osteo-, 946 
 Articular ends of bones, disease of, 
 908 
 
 necrosis of, 951 
 Artificial anus, 495 
 
 leech, 291 
 
 pupil, 305 
 
 respiration, (520 
 Asphyxia, 020 
 Aspirator in abscess, 69 
 Astragalo-calcanean joint, disease 
 of, 918 
 
 dislocation of, 852 
 Astragalus, dislocation of, 853 
 
 fracture of, 902 
 
 excision of, 855 
 Atheroma, 353 
 Atlas, disease of, 247 
 
 dislocation of, 239 
 Atrophy of bone, 969 
 
 of muscle, 800 
 Atropine in iritis, 280 
 Aural polypi, 330 
 Auricle, malformations of, 322 
 
 tumors of, 323 
 Axillary artery, ligature of, 390 
 
 BACK, injuries of, 232 
 sprains of, 242 
 Balanitis, 717 
 Bandage, spica, 542 
 suspensory, 735 
 immovable, 865 
 Barbadoes leg, 1 78 
 Base of skull, fractures of, 193 
 Basedow's disease, 185, 318 
 Bath, calomel, 1 13 
 Bavarian immovable flannel splint, 
 805 
 
 for knee, 927 
 Bedside experience, 19 
 Bed-sores, 79 
 Bellocq's instrument for plugging 
 
 nose. 5SS 
 Bending of bones. 971 
 Biceps tendon, rupture of, 797 
 Bigelow's lithotrity, 665 
 Bites, serpent, 102 
 Bladder, diseases of, 631 
 
 ruy)turc of, 490 
 
 irritable. 6:! I 
 
 in women. 763 
 
 inflammation of, 634 
 
 sacculated. 634 
 
 washing out, 635 
 
 ulceration of, 636 
 
 tumors of, 637 
 
 villous growths of, 637 
 
 cancer of, 637 
 
 atony of, 642 
 
 tubercular disease of, 636 
 
 paralysis of, 643 
 
 stone in, 660 
 
 Bladder- 
 foreign bodies in, 681 
 malformations of, 711 
 gunshot wounds of. 988 
 on bladder puncturing through 
 rectum, 703 
 
 above pubes, 705 
 Bleeding, arrest of. in wounds, 33 
 the operation of. 407 
 in he-.id injuries, 20S. 211 
 in wound of lung, 612 
 Blepharo-phymosis, 295 
 '• Block, reduction en." 543 
 Blood cysts in skull, 203 
 Blniid-i)oisoning, 91 
 
 prevention of. 98 
 Blood tumors of scalp, 189 
 Bodies, loose, in joints, 942 
 in bursa-, S06 
 in ganglia, SIO 
 Boils, 169 
 
 Delhi, 172 
 Bone, atroph.y of, 969 
 abscess of, 954 
 contusions of, of skull, 191 
 diseases of, 947 
 inflammation of, 950 
 elongation of. from inflamma 
 
 tion, 970 
 fractures of, 858 
 hypertrophy, 970 
 caries of, 961 
 necrosis of, 950 
 sclerosis of, 951 
 tumors of, 962 
 
 diagnosis of, 967 
 pulsatile tumors of, 969 
 cysts in, 969 
 hydatids in, 969 
 cancer of, 966 
 
 amputation in, 968 
 Bone-setting, 991 
 
 Bowel, internal strangulation of, 
 501 
 ruptured, 487 
 Brachial artery, ligature of, 391 
 Brain, bruised, 198 
 
 hemorrhage from, 198 
 
 from meningeal artery, 202 
 concussion of, 197, 210 
 compression of, 204, 210 
 hernia of, 207 
 inflammation of, 207 
 suppuration of, 210 
 wounds of, 206 
 Brain and its membranes, injuries 
 
 of, 201 
 Brasdor's operation, 369 
 Breast, diseases of, 763 
 
 Creighton's views of their pa- 
 thology, 767 
 hypertrophy of, 770 
 engorgement of, 764 
 inflammation of, 764 
 abscess of, 765 
 
 submammary abscess of, 766 
 chronic induration of, 766 
 irritable, 766 
 tumors of, 766 
 adenoma of, 767 
 
 statistics of, 766 
 cancer of, 771 
 open cancer of, 776 
 
 statistics of, 773 
 colloid cancer of, 774 
 cystic disease of, 773 
 cystic cancer, 776 
 sarcoma of, 776 
 milk tumor of, 775 
 hydatids of. 776 
 retracted nipple in, 777 
 
 Breast — 
 
 discharge from nipple in, 777 
 enlarged glands in, 778 
 infiltration of skin in. 778 
 chronic eczema of nipple pre- 
 ceding cancer, 777 
 
 excision of, 778 
 
 tumors of, diagnosis of, 768 
 Broad ligament, cysts of. 782 
 Bronchocele, 186 
 Bronchotomy, 60S 
 Bruise, 155 
 Bubo, in clap, 717 
 
 in chancre. 719 
 
 in syphilis. 721 
 Bubonocele. 527 
 Bullets, varieties of, 976 
 
 extractor, 981 
 Bunion, 174 
 Burns and scalds, 157 
 
 statistics of. 159 
 
 cause of death in, 158 
 
 pathology of. 159 
 
 of larynx, 603 > 
 
 Burrowing of abscess, 68 
 ]5ursa\ diseases (jf, S05 
 
 of svnovial, 806 
 
 of pojiliteal, 807 
 
 acute, inflammation of, Su5, 948 
 
 loose bodies in, 8II() 
 Button suture, 36 
 
 CACHEXIA, 21 
 Caecum, abscess about, 496 
 rupture of, 504 
 hernia of, 527 
 Calcis, fractures of, 902 
 
 necrosis of. 960 
 Calculus, nasal. 590 
 salivarj', 41 7 
 in tonsil. 438 
 renal, 626, 655 
 prostatic, 649 
 vesical. 655 
 urethral, 706 
 in female, 679 
 Callisen's operation, 512 
 Callous ulcers, 74 
 Callus, provisional, S67 
 Calomel bath in syphilis. 113 
 Canaliculi. obstruction of, 295 
 Cancer, 132. 153 
 structure, 153 
 causes, 138 
 heredity in, 138 
 clinical features, 133 
 treatment, 139 
 scirrhous. 134 
 medullary, 135 
 osteoid, 147 
 epithelial, 136 
 colloid, i;-18 
 villous, 139 
 of V\\K 412 
 of nose, 590 
 of cesophagus, 478 
 of tongue, 427 
 of tonsil, 433 
 of rectum, 579 
 of bladder, 638 
 of prostate, 650 
 of penis, 710 
 of breast, 771 
 of testicle, 744 
 of thyroid gland, 187 
 of bone, 966 
 of scrotum, 753 
 treatment by excision, 140 
 by caustics, 140 
 Cancrum oris, 415 
 
fM>r:x. 
 
 l(»J9 
 
 Cannon bnllt, blowi from, 077 
 Ciirboli/.cil li((atur«», :tl2 
 Carlmiiclu, Itlil 
 
 tiuiiil, 171. 116 
 (.'arcinitiiiii, i:t:i, Ijit 
 Cur<l(>ir« nnt|)utittii>n, inou 
 (.'artiinul poinis ( xix t l<> (»• oligorvod 
 ill (Ih< triMitiiiciii lit' wuiuutii, 
 
 ;u 
 
 Ciirio.«, IMU 
 
 i-iiiiMtif tiPiif iiiciil lit', '.M'l'J 
 
 of ti'ftti. H'lT 
 Cnrotiil iirliT.v, li-xiirnri' of, IJ84, 386 
 Car|ius. iliKliK-iitinii nf, S(0 
 
 (liM-UMts of, '.l-JI. <.l|l 
 Ciirr's Mpliiit for fnioture of foro- 
 
 nriii, Ss(» 
 C!irtili»;50, discrtdeg of, 907 
 
 tlislocutiiin.i of iiitcr-iirtiouliir, 
 Sj(» 
 
 tuiiiorx of. 127. I 17, '.'tU 
 
 fnioturp of CDstiil, t'l | 4 
 t'iivtiliijfe!!, loose, ill joints, ',H2 
 
 .sterno-oostnl. t'nu'turi' of, tH4 
 (.'nstration, "-I".' 
 Cuturnot, .iOtl 
 
 o|ii'rntioiis fur. .'ios 
 
 ai'i'iili'nts ilurinij. .'tI2 
 nfter-treatiiient, .112 
 
 glft8.««8, :{i;{ 
 Catarrh of tympanank ."JS-? 
 CiUarrlini coniiinotivitig, 2ftS 
 Catjrut siiiuri'.s, :'.7 
 
 li>;atui-e, earbolized, 342 
 Ciithcterti. OSj 
 
 on pas.sing. 685 
 
 tyiiii? in, tJSti 
 
 Eustachian, 334 
 Caustii-s, 141) 
 Cautery, actual. 34S 
 
 galvanic, in fi.^tula, 570 
 in piles, 574 
 in !-kin cancer, 141 
 in ovariotomy, 79U 
 Cell ilovi-lopiiient. 2f, 
 Cellular membranous sore, 74 
 Cellulitis. St) 
 Cervical cysts, 142 
 
 vertebra;, diseases of, 246, 
 2.ill 
 Cervi.x femoris, fracture of, 885 
 Chancre, 718 
 
 of li].. 414 
 
 infecting, 71 S 
 
 complieations of. 720 
 Charbon. or malignant pustule, 
 
 lliS 
 Charcot's disease of joints, 947 
 Cheiloplasiic operations, 412 
 Cheloid tumors. lt)3 
 
 of ear. 324 
 Chest, injuries of, 611 
 
 deformities of. 616 
 
 gunshot injuries of, 9S5 
 
 wounds iif. 614 
 
 of large vessels of, 339 
 
 tapping, 616 
 Chii^oe. 180 
 Chilblain, 167 
 Children, hydrocele in, 724 
 
 irritable bladder in, 632 
 
 incontinence in, 644 
 
 lithotomy in, 663 
 
 retention in, 699, 701 
 
 extravasation in, 640 
 Chiuiney-sweeji's cancer, 753 
 Chloroform, 993 
 
 value of, in strangulated her- 
 nia, 535 
 Choked disc, 289 
 Chopart's amputation, 1019 
 
 Chordee, 716 
 
 Choroid, hypuriviiiiu of, 281 
 
 injiirieK of. 2^2 
 Choroidiiiit. 2Sl 
 ('hrofiie aliitevnH, 6s 
 I lironie iiileHtinal obMtruction, A03 
 t'ieiilrioeH, ilii<eui<eH of. Kll 
 
 diviition of, 161 
 
 eongenitiil. Mil, 410 
 Cicatricial Ktrietiire of urethra, C96 
 
 of iL-iiipliagus, 4S0 
 Cieatrizatioli, 27 
 Cireiimeitiioii, 7it9 
 ("irooid aiieiiriKii), 15H 
 Civiale's litlmtrity, (i63 
 Clamp for ovariotomy, 790 
 
 for pile.M, 574 
 Clavicle, dislocation of. 830 
 
 fracture of, S70 
 Claw-liku extremities, sl3 
 Cleansing wounds, 32 
 Cleft palate, 4:;2 
 Clinical history, value of, 18 
 Clitorideetoiny, 75s 
 Clitoris, enlargement of, 758 
 
 cancer of, 75S 
 Cloaciv in bone, 950 
 Clots, ''active and passive," in 
 
 ancunsm, 359 
 Clover's lithotrity syringe, 626 
 Clovo-hitch. 836" 
 Clnh foot, .S14 
 t^oapfatiiin of wounds, 35 
 (/oeeyodynia, 919 
 Coccygeal joint, disease of, 919 
 
 tumors, 231 
 Cock's operation for stricture, 691 
 Cohnhcim's views on inflammation, 
 
 67 
 Cold as a local ajiplication, 50 
 
 as a styptic, 348 
 
 as an anaesthetic, 999 
 Cold ulcers, 77 
 Colectomy, 289 
 (^'ole's artery compressor, 364 
 Collapse, 224 
 
 amputation in. 226 
 Collateral circulation, 373 
 Colics* fracture. 877 
 Colloid canecr, l;!S 
 Coloboma, 278 
 Colon, ruj)ture of. 488 
 Colotomy, 511 
 
 for stricture. 583 
 
 ]tlug for, 513 
 Coma. 204 
 
 Comminuted fractures. 904 
 Compound fractures, 863 
 
 of skull, 191 
 
 dislocation, 829 
 
 of slioulder, 837 
 of elbow, 840 
 of knee, 849 
 of ankle, 852 
 Comjiress, Di.x's, wire, 346 
 Compression in aneurism, 363 
 
 of brain, 204 
 
 diagnosis of, 205 
 treatment of, 210 
 
 of chest. 615 
 Concussion of brain, 197 
 
 hemorrhage as the result 
 
 of,- 198 
 treatment of, 210 
 remote etfects of, 200 
 
 of spine, 232 
 Condylomata, 114, 577 
 Congenital anomalies of eyelids, 266 
 of lips. 409 
 
 malformations, 81 1 
 of joints, 856 
 
 Congoniinl — 
 
 liydro.-.dc. 724 
 
 tuiiiori*, 231 
 
 eii-atrices. 164, 410 
 
 hernia, 547 
 
 xyphiliN, I IH 
 
 m-baeeous cyi»t», 144 
 Conical cornea, 302 
 (.'oiijiiiictivn, diiieaBe of, 268 
 
 operation!* on, 297 
 
 injuries of, 27 1 
 Conjunctivitis, vnricticK of, 267 
 Cun.'ititutional eaiioeH of non-repair 
 in woundd, 31 
 
 sorcH, 73 
 Contagious ophthalmia, 270 
 Continuous suture, 35 
 Contraction of bowel, 505 
 
 after strangulation, 534 
 
 of Angers, 823 
 Contrecoup, 193, 199, 207 
 Contused Wounds, 41 
 Contusion, 155 
 
 of brain, 199 
 
 of scalj), 189 
 
 of bones of skull, 191 
 
 of chest, 611 
 
 of arteries, 34 I 
 Convulsions in head injuries, 193 
 
 202, 204, 208 
 Coracoid jirocess, fracture of, 872 
 Cord, 8|)erniatic, varicocele of, 750 
 tumors of, 751 
 hydrocele of, 722, 725 
 hivmatocele of, 730 
 
 spinal, injuries of, 232 
 Cornea, inflammation of, 272 
 
 ulcers of, 274 
 
 conical,. 302 
 
 opacities of, 275 
 
 tinting. 302 
 
 wounds of, 275 
 
 burns of, 276 
 
 operations on, 301 
 
 foreign bodies in, 303 
 Corns, 174 
 
 Coronoid process of jaw, fracture 
 of, 451 
 
 of ulna, fracture of. 882 
 Cortical cataract, 30" 
 Cranium, injuries of, 192 
 
 general propositions on, 192 
 
 contusion of, 191 
 
 fracture of. 192 
 
 compound, of. 194 
 
 fracture of base of, 193 
 diagnosis of. 194 
 
 ineomjilete fracture of, 858 
 
 gunshot injuries of. 982 
 Crepitus of fracture, 860 
 Croft's splint, 866 
 Croup, 606 
 Crushing ])iles, 575 
 Curvature of spine. 243. 245 
 
 Sayre's jacket in, 24S 
 Cutaneous cysts, 144 
 Cut throat, .598 
 Cutting teeth, 460 
 Cyclitis, 281 
 
 Cynanohe tonsillaris, 437 
 Cystic disease of breasts, 773 
 of antrum, 442 
 of testes. 742 
 of ovary, 780 
 Cvstine calculus, 657 
 Cystitis, 034 
 Cysts, as tumors. 142 
 
 serous. 185 
 
 simulating eneephalocele, 217 
 
 dentigerous, 443, 457, 463 
 
 thyroid, 143 
 
1030 
 
 IXDEX. 
 
 Cysts- 
 
 mucous, 143 
 oil. 145 
 
 sublingual, 416 
 sebaceous, 144 
 tarsal. 292 
 of orbit, 319 
 labial, 757 
 
 DAVIES-COLLEY'S talipes 
 
 splint, 819 
 
 operation for talipes equino- 
 varus, 819 
 Deaf-mutism, 337 
 Decay of teeth. 467 
 Deformities, 81 1 
 
 heredity of, 813 
 
 of nose, 5S6 
 
 of chest. 616 
 Delhi boil, 172 
 Delirium tremens, 222 
 Dental caries. 467 
 Dental irritation, 464 
 
 remote effects of, 465 
 
 surgery, remarks on, 453 
 Dentigerous cysts, 44.3, 457, 463 
 
 tumors, 444 
 Dentine, secondary. 466 
 Deposits, urinarv, 6.02 
 Depressed fracture of skull. 19.3, 204 
 
 trephining for, 212 
 Dermal or dermoid cvsts, 292 
 
 of bladder, 640 
 Diagnosis, 17 
 
 by exclusion, 17 
 Diaphragm, rupture of, 491 
 Diaphragmatic hernia, 558 
 Diathesis, 19 
 
 scrofulous. 20 
 
 hemorrhagic. 20 
 Dieulafoy's aspirator, 69 
 Diffuse cellular inflammation, 86 
 Diffused aneurism. 357 
 Digital compression of aneurism. 
 
 363 
 Dilatation of stricture, forcible. 687 
 Diphtheritic conjunctivitis, 271 
 Direct inguinal hernia. 548 
 
 ophthalmoscopic examination, 
 256 
 Dislocations, 826 
 
 of spine. 237 
 
 of jaw. 449 
 
 of ribs, 614 
 
 reduction of old. 828 
 compound, 828 
 
 of clavicle, 830 
 
 of scapula, 832 
 
 of humerus, S32 
 
 of elbow, 837 
 
 of wrist. 840 
 
 of radius, 840 
 
 of caijtal bones, 841 
 
 of thumb and phalanges, 841 
 
 of hip, s^i 
 old, 847 
 
 treatment of, 846 
 
 and fracture of hip, 847 
 
 of patella, 848 
 
 of knee-joint, 849 
 
 of fibula. S50 
 
 of foot at ankle. 850 
 
 of astragalus. S48 
 
 of foot off astragalus, 853 
 
 of tarsal joints, 855 
 
 unreduced, 828 
 
 reduction of, by manipulation 
 of hip. 846 
 
 of humerus. 835 
 Dislocation and fracture, 829 
 
 Dislocation and fracture — 
 
 of humerus, 837, 876 | 
 
 of hip, 848 I 
 
 Displaced hernia, 543 
 
 reduction en masge, 543 
 other varieties, 543 
 Displacement of femur in hip dis- 
 ease, 914 
 Dissecting aneurism. 357 
 Dissection wounds, 100 
 Distal ligature, 371 
 
 pressure, 367 
 Dix's wire compress, 346, 367 
 Dolbeau's perineal lithotrity, 677 
 Dorsalis pedis arterv. ligature of, 
 
 .398 
 Dorsum ilii. dislocation on, 843 
 Double splint for fracture of thigh, 
 889 
 
 statistics of results, 887, 892 
 for hip disease, 923 
 Douche, nasal, 587 
 Drainage of wounds, 38 
 tubes, 38 
 
 caution in their use, 38 
 in abscess, 70 
 after amputation, 1007 
 Dressing wounds. 32 
 second, 39 
 later. 41 
 Dropsy, diagnosis of ovarian, 781 
 Drowning, 618 
 
 recovery from, 619 
 Dry dressing of wounds, 51 
 
 gangrene, 80, 81 
 Duchenne's disease, 801 
 Dugas' guide to diagnosis of dis- 
 location of humerus. 834 
 Duodenum, ulceration of, 158 
 
 rupture of. 487 
 Dura mater, injuries of, 201 
 
 inflammation of, after ostitis, 
 
 207 
 blood outside, 202 
 within, 202 
 Durham's tracheotomy cannia, 608 
 Dyspeptic ulcer of tongue, 424 
 Dysphagia, 47S 
 
 E 
 
 AK, external, affections of, .322 
 malformations of, 322 
 cutaneous affections of, 323 
 injuries of, 323 
 tumors of, 323 
 cheloid tumors, 324 
 hfematoma, 323 
 foreign bodies in, 325 
 polypus in. 330 
 bleeding from, in fractured 
 
 skull, 195 
 middle, affections of, 330 
 catarrh of, 3;-'.3 
 Ear-ring holes, tumors of. 324 
 Earth-dressing of wounds, 51 
 Ecchymosis, 155 
 Echinococcus, 181 
 Ectopion vesicae, 711 
 Ectropion, 293 
 Eozematous ulcer, 76 
 Elastic extension. 891 
 
 ligature in fistula. 571 
 Elbow-joint, amputafion at, 1011 
 excision of, 940 
 dislocation of. 837 
 compound dislocations of, 
 
 840 
 compound' fractures into, 
 
 881 
 diseases of. 920, 928 
 Electric indicators, 981 
 
 Electrolysis in aneurism, 372 
 
 in stone, 663 
 in hydatid, 573 
 Electro-puncture of aneurism, 371 
 Elephantiasis Arabum, 177 
 
 Manson's views on, 178 
 
 ligature of main artery in, 178 
 
 of scrotum, 752 
 
 Graecorum, 177 
 Embolism, 354 
 
 pulmonary. 354 
 
 fat, in fracture, 861 
 Emigration of leucocytes, 26 
 Emissions, nocturnal, 755 
 Emmetropia, 261 
 Emphysema. 612 
 Empyema, 616 
 
 Encephalitis after injury, 207 
 Encephalocele, 216 
 Encephaloid cancer, 135 
 Enchondromata, 128, 148 
 
 of bone, 964 
 
 of jaw, 445 
 Encysted hernia, 54 7 
 
 hydrocele, 728 
 Endostitis, 955 
 Enostosis, 595 
 Enterocele, 527 
 Entero-epiplocele, 527 
 Enterotomy, 5li8 
 
 in malformations of rectum, 563 
 Entropion, 293 
 Enucleation of eyeball, 314 
 Epidirlymitis, 733 
 
 in gonorrboaa, 716 
 Epigastrium, blows on, 484 
 Epiglottis, wounds of. 599 
 Epilepsy, trephining in, 218 
 
 after injury. 212 
 Epiphysial cartilage, disease of, in 
 
 hip disease, 914 
 Epiphysis, inflammation of, 949 
 
 displacement of. 829 
 
 of humerus. 840, 873 
 
 of clavicle, 831 
 
 of radial, 877 
 
 of femur! 849 
 
 arrest of growth of bone from 
 injury of, 876 
 Epiplocele, 527 
 Episcleritis, 276 
 ; Epispadias, 711 
 Epistaxis. 587 
 
 plugging iKise in, 588 
 
 in head injuries, 196 
 Epithelioma, 136 
 
 of bone, 966 
 
 of nose, .''93 
 
 of lips. 412 
 
 of penis. 710 
 
 of scrotum, 753 
 
 of rectum, 579 
 
 of tongue, 427 
 
 of ceropbagus, 479 
 Epulis, 441, 475 
 Equinia, or glanders, 106 
 
 mitis, 107 
 Erectile tumor, 377 
 Erysipelas. 85 
 
 thermograjiby of, 85 
 
 phlegmonous. 86 
 
 pathological appearance; after 
 86 
 
 treatment of, 88 
 Erythema. 90 
 
 nodosum. 90 
 
 varieties of. 90 
 Esmarch's bandage, 344 
 
 in aneurism. 365 
 
 operation for closure of jaws, 
 448 
 
i.\ni:x. 
 
 1031 
 
 Ether upriiv. WJ 
 
 Eii!>itichiun out lifter, nuiiiiago of, 3,'S4 
 
 Exi'iKJon III" joint!!, Itis 
 
 uf tii|i, m:',\ 
 
 of kno«>, V'Mt 
 
 of II II kit", V'M 
 
 of !<houlil(>r. U38 
 
 of clliow. u:i9 
 
 of wrixl, U41 
 
 of larynx. ftUT 
 Exclufiioii, rt-iiDonin); by, 17 
 Kxfoliiition of bonf. D./n 
 Exo|ibibitlinii- bront-hocelc, 1S6 
 Exostosis '.til.J 
 
 pcrioHtenl. '.•('>:{ 
 
 ornnial. IM'.:', 
 
 of iinf^iinl jihiiliinx, 177, 9l'i.°< 
 stiitistic-s of. llt.l 
 
 frncliire of, iMi;; 
 
 of orbit, .'.IS 
 
 of inciilii^. .■{2S 
 External nientiis, exnininntion of, 
 324 
 
 affei-iions of, .".24 
 
 piles. ..71 
 
 urethrotomy. ('iS'.i 
 Extra-cii|isulHr fracture, SS5 
 Extraction of cataract, .'!••!• 
 
 after-treatment of, 312 
 
 of teeth, 4I>2, 47.J 
 Extra va.'iat ion of blood, 155 
 
 in fracture, 902 
 
 of urine, CiltS 
 
 in children. 705 
 Extroversion of blaclder, 71 1 
 Eye, injuries and disea.ses of, 255 
 Eyeball, exaiuination of. 255 
 
 operations on. 21(0 
 
 pfisitiun of patient in, 290 
 
 rupture of. 321 
 
 suppuration of. 321 
 
 extirpation of, 313 
 
 protrusion of, 314 
 
 tumors of. 320 
 
 vascular protrusion of, 316 
 Eyelashes, malposition of, 292 
 Eyelids, diseases of, 266 
 
 tumors of, 292 
 
 injuries of, 267 
 
 examination of, 255 
 
 formation of new, 294 
 
 FACIAL artery, ligature of, 387 
 carbuncle, 171 
 nerve, ]iaralysis of, 195,418 
 False joint after dislocation, 827 
 
 after fracture, 868 
 Farcy, 1<I6 
 
 Fascia of palm, contraction of, 823 
 Adams's operation for, 823 
 Fat embolism in fracture, 861 
 Fatty tumor, 126 
 Fauces, ulceration of, 436 
 Fecal abscess, 496 
 fistula. 495 
 impaction, 502 
 Feigned disease, 227 
 Female genital organs, affections of, 
 
 756 
 Female, stone in. 679 
 Femoral aneurism, 393 
 
 artery, ligature of, 395 
 hernia, 552 
 
 diagnosis, 553 
 str.ingulated, 553 
 Femur, dislocations of head of, 843 
 fractures of. *<85 
 of neck. SS5 
 of shaft, 891 
 of condyles, 894 
 
 Femur — 
 
 in cliildrcn, s'.i4 
 compound, of, SO,') 
 
 reparation of ejiiphjiii of 
 hea<l, SUO 
 
 ot tnichanter, 8110 
 ..f c.n.lyleH, siM 
 
 ahfiorption ot' neck, S90 
 Fever, intlnmiuatory, 6.'», 91 
 
 hectic, US 
 
 trnuniatic, 25, 92 
 Fibrin, execKs of, in iiillamination, 
 
 66 
 Fibromata, 126 
 Kibro-musciilar tumor, 126 
 Fibro-plastic tumor, K'.l 
 Fibrous )ioly)ius of jiharynx, 592 
 
 tumors, 127 
 
 of uterus, 792 
 Fibula, dislocation of head of, 849 
 
 fracture of, SOS 
 Fiel.l dressing, first, 9S(» 
 Fingers, compound fracture of, 882 
 
 am]iutalion of, 1012 
 
 contracteil, S23 
 
 dislocation of, 842 
 
 webbed, 812 
 First intention, union by, 26 
 Fissure of anus, 567 
 Fissured palate, 433 
 Fistula, 71 
 
 rectal, 568 
 
 fecal. 495 
 
 salivary, 417 
 
 urinary, 695 
 
 vaginal. 760 
 
 vcsico-intestinal, 643 
 Flap amputation, 1000 
 Flat foot. 821 
 Flexion in aneurism. 366 
 
 in reduction of dislocation of 
 hip, 846 
 Fluctuation, 68 
 Follicular tumors, 141 
 Foot, fractures of. 902 
 
 dislocation of. S50 
 
 perforating ulcer of. 171 
 
 amputations of. 1017 
 Forceps, artery, 345 
 
 bone, 960 
 
 bullet, 981 
 
 lion, 445 
 
 pharyngeal, 481 
 
 tooth, 476 
 
 tracheal, 603 
 
 omental clamp, 790 
 Forcible taxis. 536 
 Fore-arm, amputation of, 1012 
 
 fractures of, 877 
 compound. 8S2 
 Foreign boilies in conjunctiva, 271 
 
 in ear, 326 
 
 in nose, 590 
 
 in pharynx and cesophagus, 480 
 
 in air-passages, 600 
 
 in bladder, 6S1 
 
 in rectum, 565 
 
 in stomach and intestines-, 497 
 
 in gunshot injuries, 982 
 
 in wounds. 30 
 Fracture bed. 863 
 Fracture of exostoses, 963 
 
 with ruptured artery, 373 
 Fractures, 858 
 
 incomplete, 858 
 
 impacted, 858 
 
 diagnosis of. 859 
 
 prognosis. 861 
 
 treatment of simple, 861 
 
 in insane, 859 
 
 compound, 863 
 
 Fracture*— 
 
 from ({iiti'liot injuric", 988 
 
 rep'iir of. ,s67 
 
 compound, HS3 
 
 delayed union in, 868 
 of arm. Ks2 
 of ^kull. I9t 
 repair of. 868 
 
 ununiteil, sr.s 
 
 deformity after, 869 
 
 complicating joints, S63, 903 
 
 extravasation in, 902 
 
 comminution of bone in, 904 
 
 spontancou", H59 
 
 fat embolism in fracture, 861 
 
 sjiecial, of jaws, 450 
 
 of nose, jsf. 
 
 of skull. 192 
 
 of base of Rkull, 192 
 
 of spine. 237 
 
 of larvnx. 597 
 
 of ribs, r. 11 
 
 of clavicle, 870 
 
 of scapula, S71 
 
 of humerus, S72 
 
 of radius and ulna. 877 
 
 from gunshot injuries, 988 
 
 of metacarpal bones. 881 
 
 of yjhalanges. ssl 
 
 of lower extremity. 884 
 statistics of, 861, 884 
 
 of pelvis, 883 
 
 of femur. 885 
 
 of leg, 898 
 
 of patella. 895 
 
 of foot, 902 
 
 gunshot, 988 
 
 splints in, 864 
 
 immovable splints, 865 
 
 Colles's. 877 
 
 Pott's. 850 
 Frontal sinus, diseases of, 595 
 
 distension of. 595 
 
 fracture of, 587 
 
 enostosis of, 594 
 Frostbite, 80, 168 
 Fulminating glaucoma, 284 
 Fumigation, mercurial, 113 
 Fungous foot of India. 172 
 Furneaux Jordan's method of am- 
 putation at hip-joint, 1015 
 Furuncles of ear, 327 
 Furunculus. or boil. 169 
 Fusible calculus, 658 
 Fusiform aneurism, 357 
 
 GiAG, 432 
 r Galactocele, 775 
 (^all-bladder, rupture of, 489 
 Gall-duct, rupture of, 489 
 Galvanic cautery, in fistula, 570 
 in cancer, 140 
 in naevus, 379 
 in piles, 574 
 Galvano-puncture in aneurism, 372 
 Ganglion, s(i9 
 
 diffused, 809 
 Gangrene, anajmic or arterial, SO, 81 
 static or venous, 81, 82 
 from col.l, SO, 168 
 traumatic. 79 
 after ligature, 369 
 embolic, 354 
 hospital. 83 
 senile, 80 
 amputation in. S2 
 Gastrotomy and gastrostomy. 498 
 Genitals, female, affections of, 756 
 wounds of. 756 
 foreign bodies in, 756 
 
1032 
 
 INDEX. 
 
 Genitals, female — 
 
 adherent laliia, 75fi 
 vulvitis, 75f) 
 noma, 76fi 
 
 labial cysts, etc., 757 
 labial tumors, 757 
 imperforate hymen, 757 
 double vagina, 758 
 vaginal tumors, 758 
 
 Genito-urinary organs, injuries and 
 diseases of, 702 
 malformations of, 712 
 development of. 732 
 
 Genuflexion in popliteal aneurism, 
 .366 
 
 Glanders, 100 
 
 Glands, inflammation of, 181 
 in erysipelas, 88 
 
 Glandular tumors, 129 
 
 (ilaucoma, 283 
 
 Gleet, 715 
 
 Glioma, 320 
 
 Glossitis, 423 
 
 Glottis, foreign bodies in, 600 
 scalds of, 603 
 
 Gluteal aneurism, ligature of inter- 
 nal iliac in, 394 
 
 Goitre, 184 
 
 exophthalmic, 185, 318 
 
 Gonorrhoea. 714 
 in female. 715 
 complications of. 716 
 
 Gonorrhoeal rheumatism. 717 
 
 Gordon's splint for fracture of ra- 
 dius, 880 
 
 Gouty phlebitis. 401 
 testitis, 738 
 
 Gowan's excision saw, 931 
 
 Grafting skin, 164 
 
 Granular lids. 269 
 
 Granulating wounds, 28 
 
 treatment of, 42, 44 
 
 Granulation tumors, 713 
 
 Granulations, 28 
 diseases of, 62 
 
 Gravel, 655 
 
 Green-stick fracture, 858 
 
 Gritti's amputation, 1016 
 
 Gross's tracheal forceps 603 
 
 Growth, arrest of, after fracture, 876 
 after disease of hip, 916 
 
 Guinea-worm, 179 
 
 Gum and chalk splint, 865 
 
 Gum-boil, 489 
 
 Gummata, 112 
 
 Gums, afi"ections of, 489, 475 
 
 Gunpowder, burns from, 159 
 
 Gunshot injuries, 975 
 shock in, 978 
 hemorrhage in, 978 
 of head, 982 
 of chest, 985 
 of heart, 985 
 of abdomen, 986 
 of intestines, 936 
 of bladder, 987 
 fractures from, 988 
 of upper extremity, 989 
 of lower, 989 
 amputation in, 990 
 
 Gustatory nerve, division of, 429 
 
 H.I:MATOCELE,730 
 of the cord, 731 
 HaMiiatoma of scalp, 189 
 
 of ear, 323 
 Hasmaturia. 624, 638 
 Haemophilia, 20 
 Haemostatics, 340 
 surgical, 341 
 
 Haemothorax, 616 
 Hainsby's harelip truss, 411 
 Hammond's splint, for fracture of 
 
 jaw, 452 
 Hand, amputation of, 1012 
 
 dislocation of, 840 
 Hancock's operation on foot, 1021 
 Hanging, 619 
 Hard cataract, 307 
 Harelip, 410 
 
 suture, 36 
 Head, injuries of, 189 
 
 general propositions on, 
 
 192 
 trephining in, 212 
 conclusions on. 215 
 gunshot wounds of, 982 
 Headache after injury, 207 
 Healing process, 29 
 
 in wounds, 26 
 in muscle, 30 
 in nerve, 30 
 defects in, 61 
 Heart, wounds of. 338 
 
 gunshot wounds of, 985 
 Heat in inflammation, 64 
 Hectic fever, 98 
 Hemorrhage 343 
 consecutive, 59 
 secondary, 611, 349 
 summary of its treatment, 349 
 general treatment of, 350 
 in wounds, 30 
 in contused and lacerated 
 
 wounds, 42 
 urethral, 625 
 vesical, 625 
 renal. 625 
 
 in gunshot wounds. 978 
 after tooth extraction. 476 
 Hemorrhagic diathesis, 20 
 Hemorrhoids, 570 
 Hereditary syphilis. 155 
 Hernia, diagrams of, 524 
 abdominal, 525 
 anatomy of, 526 
 irreducible, 529 
 obstructed, 530 
 inflamed, 530 
 strangulated, 530 
 ])athological changes in, 532 
 treutuient of, 530 
 rupture of, 530 
 labial, 756 
 multij)le, 543 
 displaced, 543 
 inguinal, 547 , 
 femoral, 552 
 obturator, 554 
 umbilical, 556 
 other forms of, 557 
 congenital, 547 
 radical cure of, 549 
 cerebri. 207 
 testis, 741 
 Hernial sac, 526 
 
 changes in, 526 
 absence of, 527 
 hydrocele of. 528 
 reduction of, 543 
 rupture of, 545 
 Herniotomy, 544 
 Herpes preputialis, 718 
 Hey's am])utation, 1019 
 Hilton's method of opening an ab- 
 scess, 70 
 Hip-joint, amjmtation at, 1013 
 
 after gunshot injuries, 990 
 disease of, 911 
 diagnosis of, 913 
 pathology of, 912. 921 
 
 Hip-joint — 
 
 treatment of, 922 
 
 supjiuration of. 923 
 
 removal of necrosed bone from 
 030 
 
 excision of, 931 
 
 division of neck of femur in 
 disease of, 925 
 
 dislocation of, 842 
 
 old dislocations, S48 
 
 congenital malformation of, 856 
 Hodgen's suspension splint, 892 
 Hodgkin's disease of glands, 182 
 Holt's dilator, 688 
 Hornv growth beneath nail, 177 
 Horn's. 145 
 
 Hospital gangrene, 83 
 Housemaid's knee, 805 
 Howard's " direct method " of arti- 
 ficial respiration. 020 
 Humerus, dislocation of. 832 
 statistics of. 832 
 reduction of, 835 
 
 unreduced dislocations of, 837, 
 876 
 
 fracture and dislocation of, 837 
 
 compound dislocation of, 837 
 
 fracture of. 873 
 
 compound. 881 
 
 impacted fracture of neck. 872 
 Hunterinn chancre, 71 S 
 Hunter's operation for aneurism, 369 
 Hydatids, 180 
 
 abdominal, 522 
 
 diagnosis of, 522 
 
 of bone, 969 
 
 of breast, 776 
 
 of tongue. 423 
 
 of liver, 522 
 
 tapping, 523 
 Hydrocele of hernial sac, 528 
 
 of cord and testes, 722, 725 
 its pathology, 723 
 
 congenital. 723 
 
 encysted, 728 
 
 radical cure of, 727 
 
 on tapping, 726 
 
 spontaneous disappearance o^ 
 730 
 
 ruptured, 730 
 
 of neck, 142 
 Hvdro-nephrosis, 628 
 Hydrophobia, 103 
 Hydrops, antri, 442 
 
 articuli, 917 
 Hydro-sarcocele. 739 
 Hjdro-thorax, 616 
 Hygroma. 143 
 Hymen, imperforate, 757 
 
 rigid. 757 
 Hypermetrojtia, 262 
 
 as cause of squint. 298 
 Hypertrophy of extremities, 811 
 
 of bone, 969 
 
 of breast, 770 
 
 of lips. 414 
 
 of tongue. 419 
 
 of veins, 403 
 Hypopyon. 274 
 Hypos])adias. 713 
 Hysteria, 227 
 
 Hj-sterical retention of urine, 706 
 Hvsterectomv, 792 
 
 ICE in hernia, 530 
 poultice. 156 
 Ichthyosis linguae, 421 
 Ileum, rupture of, 487 
 Iliac arteries, ligature of, 393 
 Ilio-femoral triangle, 887 
 
isni.'X. 
 
 1033 
 
 Ilio-iuiRtio dialucation« of hip, 843 ! 
 Ilium. friK'tiirc of, sm{ | 
 
 Itllllluililllc Ulllnll, '.'7 
 
 Iuiiiii>l>ililv ill triMitiiiuiil <>r wiiuii>lii, 
 
 Iroiiiovnblo a|i|iiiriitiis in frui-turc, 
 
 KtU 
 Iin|iai.<ti'<l friii-turi', Sjl> 
 
 of llUIIKTUN. H72 
 
 of riidiuM, S77 
 of nook iif ilii({h bone, SH5 
 of uliaft of thij;li-bono, yUl 
 of t.'i>th, -It'C' 
 Iiii|iikc(i >ii of fci'i'.i, JO'J 
 Iiii|ii>rfMriitc itiiu.i, ^>lil 
 
 byiiieii. T.>7 
 liiiIKTiiu'iiblo strirtiire, r>S2 
 liii|n>lciu"e, 7-'>;! 
 liu'uroori»ti'<l liiTnia, ;'».'tO 
 Incised wounils, -';i 
 
 blreiling in, 24 
 |>iiin in, 2 t 
 lociii ertivts of, 24 
 Ini'i.siou of ini-iiibriinii t_vin|)uni, 3.'!1 
 Incoiii|ilote fnicturt', >S JS 
 hu>ontiiienee of urine. •544 
 Inilircet ophthulmosoo|iic examina- 
 tion. 2.JS 
 Indolent S'lrei", 75 
 Inf.intile hernia, 547 
 hydrocele, 72.S 
 jmialvsis, 8(10 
 s,v|iiiili!>, 115 
 Influiuination, (i4 
 
 as a ciiu!>e of non-repair, 30 
 absorbent, ]S1 
 asthenic <i5 
 ])henouu-na of, (U 
 ini.'reasc of temperature in, 65 
 local effects of, 00 
 InHaininatory fever, 65 
 Inilation of tyni|)anum. 322 
 Inirrown toe-nail, 175 
 Inguinal hernia, 547 
 
 direct and obliijue, 547 
 diagnosis of, 548 
 Inhaler, chloroform. '••90 
 Innominate artery, ligature of, 383 
 Inoculation, syphilitic, 118 
 vaccino-syphilitic. 119 
 Insanity after head injury, 201 
 Insect stings, 101 
 Intention, union by first, 26 
 
 by second, 28 
 Inter-arti'Milar cartilages of knee, 
 
 subluxation of, 850 
 Internal ear, diseases of, 336 
 Interruplcd suture, 35 
 Interstitial keratitis. 272 
 Intestinal obstruction, 500 
 diagnosis of, 500 
 causes of, 501 
 acute, 501 
 chronic. 503 
 from contractions. 504 
 from stricture, 504, 535 
 following hernia, 530 
 Intestines, rupture of. 486 
 protrusion of. 493 
 obstruction of. 500 
 tapping of. 520 
 gunshot wounds of, 986 
 Intra-capsular fracture of femur, 
 
 885 
 Intra-cranial suppuration. 207 
 Intra-parietal sac in hernia, 543 
 Intra-uterine fracture, 858 
 Intussusce])tion. 506 
 
 operative interference in, 507 
 Inversion of body in foreign body 
 in air-passages, 601 
 
 Iridectomy, 303 
 
 in glaucoma, 2h5 
 Irido rli..roidili». 2S| 
 Iridoloiny, :Wi\ 
 Iriit, congcniial uiioinaliuH of, 278 
 
 intliiiiimation of, 27''^ 
 
 wouihIh of, 2.sti 
 
 coloboma of, 278 
 Iritis 27H 
 
 Irreducible hernia, 529 
 Irrigation of wouiidx, 33, 49 
 Irritable blad<l<'r, 032 
 
 in Women, 763 
 
 mamma, 707 
 
 ulcer, 72 
 Ii<chiatic hernia, 558 
 Ischio-rectal abscess, 568 
 
 JA\V, deformities of, 449 
 fracture of, 450 
 
 treatment of, 450 
 rlislocalion of, 419 
 necrosis of, 4S9 
 excision of. 445 
 tumors of. 442. 444 
 closure of, 449 
 Jejunum, rupture of, 4S7 
 Joint allVctions after wounds of 
 nerves, 251 
 disease and nerv(jus affections, 
 947 
 Joints, contusions of, 825 
 
 compound fracture into, 863 
 dislocation of, 827 
 diseases of, 820 
 
 svniptonis of. 910 
 p"athology of, 906 
 treatment of, 921 
 amputation and excision of, 928 
 false. S09 
 wounds of, 826 
 neuralgia of, 229 
 sprains of, 825 
 anchylosis of, 916, 924, 928 
 loose cartilages in, 942 
 acute suj)puration round, 948 
 necrosis of, 913. 931, 938, 939 
 Jugular vein, wounds of, 399 
 opening, 399 
 
 t KELOID, 162 
 ^ of ear, 324 
 Kelotomy, 537 
 Keratitis, 272 
 Key's lithotomy, 671 
 Kidneys, injuries of, 489, 624 
 ta]>]iing. 028 
 stone in, 027 
 malformations of, 622 
 abscess in, 628 
 operations on, 627 
 Knee, amputation at, 1016 
 statistics of. 934 
 anchylosis of, 928 
 diseases of. 916 
 
 treatment of, 926 
 on tap]>ing, 926 
 mortality of amputation at, 
 
 1010 
 dislocation of. 849 
 wounds of. 826 
 suppuration of, 931 
 excision of. 934 
 
 operation of, 936 
 Knock-knee. 821 
 
 OgRton's operation for, 822 
 Macewen's, 822 
 Knot, rei'f, 345 
 granny, 345 
 
 LA HI A, adhcaion of, 756 
 tumorN of, 757 
 hypertrophy of, 757 
 Labyrinth, nnuctiomi of, 336 
 Iiitceruled woundx, 41 
 Lachrymal upparatui>, diiteaHe of, 
 
 295 
 Lachrymal nac, washing out, 297 
 
 obliteration of, 29j 
 Lamellar caturHct, 307 
 Laparotomy. 508 
 Laryngitiit, 605 
 Laryngoiicojiy, 604 
 Laryiigotomy, 007 
 Larynx, disease of, 004 
 
 rei{uiring tracheotomy. 604 
 
 excision of. 007 
 
 foreign bodies in, 600 
 
 wounds of, 597 
 
 tumors of, Omi 
 
 syphilitic >iisease of, 114, 604 
 
 s'calds of, 003 
 
 fracture of, 59" 
 Lateral curvature of spine, 243 
 Leech, artificial, 291 
 Leg, amputation of, 1008 
 
 fracture of bones of. 898 
 statistics of. 898 
 
 compound fracture of, 901 
 Leiler's merallic coil, 50 
 Lembert's suture, 494 
 Lens, affections of. 277 
 
 wounds of. 277 
 
 dislocation of, 277 
 
 diseases of, 277 
 Leucocytes. 26, 67 
 Leucorrhoea. 715 
 
 Ligature, the action of, on arterv, 
 342 
 
 of catgut, 342 
 
 of arteries, 345 
 
 rules to be observed in, 381 
 
 mode of applying. 345 
 
 carbolized catgut in. 342 
 
 in aneurism, .■!09 
 
 of abdominal aorta, 383 
 
 of innominate. 383 
 
 of carotids. 384 
 
 of lingual. 387 
 
 of facial, 38 
 
 of arteries of upper extremity, 
 .387 
 
 of iliac arteries, 393 
 
 of arteries of lower extremity, 
 393 
 Lightning, accidents from, 160 
 Lime in eyes. 271 
 Linear extraction of cataract. 310 
 Lingual artery, ligature of, 38" 
 
 in cancer of tongue, 429 
 Lip, congenital fissures of, 409 
 
 cancer of, 412 
 
 chancre of, 414 
 
 cysts of. 415 
 
 tumors of, 414 
 
 na?vus of. 415 
 
 wounds of. 409 
 
 restoration of, 413 
 
 hare, 4S0 
 
 phlegmonous inflammation of, 
 415 
 Lipoma, 126 
 
 of conjunctiva. 298 
 
 of nose, 5S9 
 
 of palm of hand. 810 
 Lisfranc's amputation, 1019 
 Listerian method of dressing 
 
 wounds, 54 
 Lithic acid deposits. 653 
 
 calculus. 656 
 Lithontriptics. 662 
 
1034 
 
 IXDEX. 
 
 Lithotomy, 670 
 
 when to be selected. 670 
 
 causes of death sifter. 679 
 
 sources of difficulty in, 675 
 
 Key's operation, 671 
 
 median, 677 
 
 bilateral, 678 
 
 Buchanan's, 678 
 
 recto-vesical. 678 
 
 high operation, 678 
 
 in female, 679 
 Lithotomy and lithotrity compared, 
 
 663 
 Lithotrity, 665 
 
 when to be selected, 665 
 
 perineal, 677 
 Littre's operation, 56.'? 
 Liver, hydatids in, 523 
 
 ruptured. 486 
 Lloyd's (Jordan) method of con- 
 trolling hemorrhage, 1015 
 Local anaesthetics, 998 
 Locked jaw, 219 
 Locomotor atax}', 800 
 Lodgment of balls, 977 
 Loose, cartilages, 942 
 
 bodies in bnrsae, 806 
 Lordosis, 243 
 
 in malformation of hip, 856 
 
 in hip disea.-'e, 915 
 
 in rickets, 971 
 Lower jaw, removal of, 447 
 
 tumors of, 446 
 Lumbar abscess. 245 
 
 colotomy, 51 1 
 Lunatics, fractures in, 859 
 
 fractured ribs in. 611 
 Lungs, condition of. in apnoea, 618 
 after drowning, 618 
 
 laceration of. 615 
 
 wounds of, 612 
 
 hernia of, 615 
 Lupus, 78 
 
 of nose, 589 
 Lymphatics, affections of, 181 
 
 wounds of, ISl 
 Lymphoma. 149, 183 
 Lyssi in hydrophobia, 106 
 
 MACEWEN'S operation for 
 knock-knee, ^22 
 Macintyre's splint, 900 
 Maeroglossia, 419 
 Malformations, Sll 
 
 of anus. 561 
 
 of ear, 322 
 
 of genitals, 710 
 
 of hip, 856 
 
 of kidnev, 631 
 
 of feet, S"l2 
 Malignant pustule, 108 
 
 tumors, 1.33, 153 
 Mamma, diseases of, 764 
 
 excision of, 779 
 Manipulation, treatment of aneur- 
 ism by, 371 
 
 reduction of dislocation of hu- 
 merus bv, 834 
 of hip, 846 
 Marriage after syphilis. 118 
 Masse, " reduction en." 543 
 Meatus, external, affections of, 324 
 Median lithotomy, 677 
 Medio-tarsal disease. 918 
 Medullary cancer, 135 
 Meibomian glands, obstruction of, 
 
 267 
 Melanosis. 131 
 
 of eyeball, 320 
 Membrana tympani, injury to, 330 
 
 Membrana tympani — 
 
 examination of, 331 
 
 perforation of, 331 
 Meningeal artery, rupture of, 201 
 Meningocele, 216 
 Metatarsal bones, amputation 
 
 through, 1019 
 Microscopical anatomy of tumors, 
 
 145 
 Milk cysts, 775 
 Mixed calculus, 656 
 Moles, 173 
 
 Moliities ossium. 970 
 Molluscous tumors of meatus, 328 
 Moluscum fibrosum, 127 
 Mortification, 79 
 Mosquito bites, 101 
 Mucous cysts, 143 
 
 of lips, 415 
 of tongue, 143 
 Mulberry calculus, 657 
 Multiple herniae, 543 
 Mumps, 418 
 
 orchitis in. 736 
 Muscles, injuries of, 795 
 
 tumors of, 801 
 
 vascular tumors of, 802 
 
 rupture of, 795 
 
 compound laceration of, 796 
 
 dislocation of, 797 
 
 degeneration of, 801 
 of pectoral, fill 
 
 inflammation of, 798 
 
 of sterno-mastoid, 799 
 
 division of. SIO 
 
 atrophy of. 800 
 
 rigid atrophy of, 823 
 
 ossification of, S02 
 
 hydatids in, 801 
 
 trichina in, 801 
 Mycetoma. 1 72 
 Myeloid tumor, 131, 966 
 Mvoma, 127 
 Mvopia. 262 
 Myxoma, 132, 152 
 
 Vf^VUS, 378 
 
 W degeneration of. 
 
 rS, 420 
 
 of scalp, 216 
 Xails. affections of, 175, 177 
 Nasal douche, 335, 587 
 Nasal duct, probing. 297 
 Naso-pharvngeal polypus, 592 
 Neck of femur, fracture of. 885 
 
 of humerus, fracture of, 872 
 
 of scapula, fracture of, 872 
 Necrosis, 957 
 
 operation for, 959 
 
 of jaws, 489 
 
 of stumps, 1025 
 
 phosphorus. 44ii 
 
 of bones of skull. 218 
 
 arrest of growth in bone after, 
 960 
 Needles, acupressure, 346 
 
 aneurism. 382 
 
 naevus, 380 
 
 palate, 433 
 N^laton's probe, 9S1 
 
 test line for dislocation of hip, 
 845 
 Nephrectomv, 630 
 Nephritis, 622 
 Nephro-lithotomy. 629 
 Nephrorraphj-, 631 
 Nephrotomy, 629 
 Nerves, influence of, in repair, 28 
 
 repair of. 30 
 
 injuries and disease of, 251 
 
 wounds of, 251 
 
 ' Nerves — 
 
 in head injuries, 199 
 Nerve-stretching. 253 
 Neuralgia. 253, 4r.6 
 Neuritis, optic, 289 
 Neuroma, 253 
 Nipples, sore, 763 
 
 chronic eczema of, 777 
 
 retracted, 777 
 Nitrous oxide, inhalation of, 993 
 Nodes, 956 
 Noma, 756 
 Nose, affections of, 586 
 
 bleeding from, 587 
 
 dislocation of cartibges of, 
 587 
 
 foreign bodies in, 590 
 
 new formation of, 596 
 
 fracture of, 5^6 
 
 obstructions of, 790 
 
 plugging the, 588 
 
 polypus of, 591 
 
 washing out, 587 
 
 wounds of, 586 
 Nuclear cataract, 307 
 Nystagmus, 272 
 
 OBLIQUE inguinal hernia, 547 
 Obstructed hernia, 530 
 Obstruction of intestine, 500 
 Obturator hernia. 554 
 Obturator foramen. 554 
 
 dislocation into, 844 
 Occipital artery, ligature of, 387 
 Occluded ears, 322 
 Occlusion, treatment of wounds by, 
 
 45 
 Odontalgia, 464 
 Odontoid process, displacement of, 
 
 239 
 Odontomes. 441, 455 
 (Edema glottidis. 603 
 (Esophageal forceps, 481 
 
 obstruction, 479 
 (Esophagotomy. 482 
 (Esophagus, foreign bodies in, 481 
 
 stricture of, 480 
 
 cancer of, 479 
 Ogston's operation for knock-knee, 
 
 822 
 Oil cysts, 145 
 Olecranon process, fracture of, 880 
 
 bursa over. 806 
 Omental sac in hernia, 527 
 
 hernia, strangulated, 532, 541 
 Omentum, protrusion of, 493 
 
 adhesions of, in ovarian dis- 
 ease. 789 
 Onychia, 175 
 
 maligna. 175 
 Open treatment of wounds, 47 
 Operative interference in joint dis- 
 ease. 928 
 Ophthalmia, varieties of, 268 
 
 sympathetic, 282 
 Ophthalmitis, 321 
 Ophthalmoscope, examination by, 
 
 256 
 Opisthotonos. 220 
 Optic disc, anomalies of, 260 
 
 nerve, atrophy of, 289 
 
 neuritis, 289 
 Orbit, affections of. 314 
 
 inflammation within. 315 
 
 tumors of, 319 
 
 hemorrhage into, 316 
 Orchitis, 735 
 
 chronic, 737 
 
 gouty, 738 
 
 syphilitic, 738 
 
iM)i:x. 
 
 l();i5 
 
 Orchitis— 
 
 tubtTouliir. 740 
 Oriciiiiil Kort', IT'i 
 Orth<>i'U<lic Mirncrv, SI I 
 OtttvitiK (lefuriniiii!'. UT^t 
 Osto.) uitliriliH, tlHi 
 Ofli'ii clnmilroiiia, 1»(56 
 0^tl•^l liiilllli'ill. UTII 
 Osteo-invclili", U.)-' 
 
 iit'liT iiiii)iutiiiii>n. 1025 
 Hl'tcr nuiinlmt injuries, 988 
 0!<tiMi-siiri'"iiiii, Olij 
 0?tt<>.i.l oiiiu'tT, 905 
 Osteotomy, 090 
 
 for bii.lly-uiiitfcl frncture, 863 
 in hip-joint (license, 925 
 in ilot'oiniiiy from ricitets, 973 
 in knock-knee, t*22 
 Ostilis. i».)0 
 
 of criinium, 217 
 Otitis. :i28 
 
 me<liu, XW) 
 Ovarian ovsfs. ."ujijturiUing, treat- 
 ment of, 702 
 Ovarian iln>|>sy, 7S0 
 
 (liaf^nosis of, 7S1 
 tapping;, diagnostic value 
 
 of. 7S;{ 
 pathology of. 780 
 statistics of, 780 
 tapjiing in. 784 
 treatment of, 784 
 Ovariotomy, selection of cases, 787 
 ojicration, 7S7 
 adlioions in, 780 
 treatment of pedicle, 700 
 on sponging out (lelvis, 790 
 treatment of wound, 791 
 after-treatment, 701 
 Oxalate of lime as gravel, 652 
 
 as calculus, 657 
 Ozajua, 503 
 
 PAliET'S ilisease of nipple, 777 
 Pain in inflammation, t)4 
 
 in wounds, 23, 59 
 Painful subcutaneous tumor, 254 
 Palate, cleft, 432 
 
 tumors of, 436 
 
 wounds of, 435 
 
 ulcerations of. 435 
 Palmar arch, wounds of, 593 
 Panniis, 270 
 Papillary tumors, 130 
 
 of rectum, 578 
 Paracentesis abdominis, 362 
 
 peru-ar^lii, 466 
 
 thoracis, 616 
 
 of joints, 026 
 
 in ovarian dropsy, 784 
 
 of cornea, 301 
 
 of kidney, 628 
 Paralysis, result of concussion, 205 
 
 spinal, 232 
 
 infantile, 800 
 
 of blad.ler, 643, 700 
 Paraphimosis. 709 
 Parasites, 17<J 
 Parasitic hivniaturia, 625 
 Parotid, inflammation of, 418 
 
 tumor of, 418 
 Patella, dislocation of, 848 
 
 fracture of, 805 
 
 compound, of, 897 
 
 enlarged bursa over, 806 
 Pathological tubercle. 101 
 Pectoral muscle, rupture of, 611 
 Pedicle in ovariotomv, treatment 
 
 of, 790 
 Pelvic joints, diseases of, 919 
 
 Pelvi», fracture of, KK.'J 
 
 urcthrni laceration in, 698, 
 
 ^h.■! 
 
 ob»trucled iliac artery in. 884 
 Penetrating wouniU ol abdnuien, 
 491 
 
 of chest, 614 
 of cranium, 195, 206 
 Penis, amputation of. 711 
 
 malformalions of, 7 10 
 
 injuries of, 7 I I 
 
 cancer of, 7 10 
 
 to fasten catheter in, 687 
 
 warts on. 710 
 Perforating ulcer of foot, 171 ' 
 
 of palate, 435 
 
 tumors of skull, 216 
 Pericardium, wounds of, 338 
 Perinieum, rupture of female, 758 
 
 operation for, 758 
 Perineal abscess, 694 
 
 hernia, 558 
 
 fistula, 695 
 
 section, 691 
 Perinephritis, 624 
 Periosteal exostosis, 963 
 
 cancer, 066 
 
 flaps in amputation, 1006 
 Periosteum, acute inflammation of, 
 952 
 
 chronic, 955 
 Periprostatic abscess, 646 
 Peritoneum, inflammation of, 485 
 
 wounds of, 491 
 Peroneal tendons, dislocation of, 797 
 I'liagedicna, 76 
 
 venereal, 721 
 Phalangeal joints, diseases of, 921 
 dislocations of, 842 
 fracture of, 882 
 Pharyngeal abscess, 246, 477, 605 
 
 tumors, 605 
 Pharynx, aff'ections of, 477 
 
 foreign bodies in, 480 
 
 wounds of, 480 
 
 tumors of, 477, 592 
 Phimosis, 709 
 
 with chancre, 720 
 Phlebitis, 399 
 
 and pyicmia, 94 
 Phlebolithes, 405 
 Phlegmasia doleus, 399 
 Phlegmonous erysipelas, 86 
 Phosphatic dejiosits, 653 
 
 calculus, 650 
 Phosphorus disease of jaws, 440 
 Phrenic hernia, 558 
 Phthiriasis, 266 
 Pigeon-breast, 616 
 Piles. 571 
 Pinguiculye. 298 
 Pirogoff's amputation, 1023 
 
 stump after, 1023 
 Pituitary membrane, thickening of, 
 
 592 
 Pivoting teeth, 470 
 Plaster-of- Paris splints, 864 
 Plugging nostrils. 588 
 Pneumatic occlusion of wounds, 52 
 Pneumocele, 615 
 Pneumothorax, 616 
 Poisoned wounds, 100 
 Politzer's nietho<l of inflating tym- 
 panum. 322 
 Polypus of antrum, 444 
 
 of bladder, 637 
 
 of ear, 330 
 
 of nose. 590 
 
 of palate, 436 
 
 of vagina. 758 
 
 of rectum, 577 
 
 Popliteal artery, ligation of, 396 
 Poiiition of lower extremity in hip 
 
 (liHeaiie, 013 
 Pott'H fracture, H50 
 Poultice, ice, 156 
 Prepuce, operations on, 708 
 
 tumor of, 7 1 1 
 Presbyopia, 277 
 
 Pressure in the treatment of wounds, 
 343 
 to Ktop bleeding, 343 
 in cure of aneurism, 362 
 Primary or epiick union, 26 
 how to help it, 34 
 Probang, 4K2 
 
 Projectiles, woumis caused by, 976 
 I'rola])RU8 of rectum, 57i» 
 Proptosis oculi, 1S4, .''.15 
 Prostate gland, affections of, 645 
 retention in, 701 
 inflammation and suppu- 
 ration of, 615 
 hypertrophy of, 647 
 calculi of, 640 
 cancer of, 650 
 Protection of wounds, 39 
 Pruritus ani, 57S 
 Psoas abscess, 246 
 Psoriasis of nails, 177 
 Pseudo-hypertrophic j>aralysi?, 801 
 Pterygium, 275, 207 
 Ptosis, 295 
 
 Pubes, dislocation of hip on, 844 
 Pubic symphysis, disease of, 910 
 Pulleys in dislocation, 82S 
 Pulmonary embolism, 355 
 Pulpy degeneration of synovial 
 
 membrane, 90'! 
 Pulsatile bone tumors, 969 
 Puncta lachrymalia, obstruction of, 
 
 295 
 Puncture of bladder from rectum, 
 
 703 
 Punctured wounds. 43 
 Pupil, artifleial, 3m5 
 Purulent ophthalmia, 270 
 
 catarrh of ear, 333 
 Pus, 67 
 
 absorption of, 68 
 Pustule, malignant, 108 
 Puzzle toy, value of, in dislocations, 
 
 841 
 Pyaemia. 91 
 
 analyses of cases of, 93 
 post-mortem appearances in, 
 
 93 
 not hospital disease, 96 
 arterial, 95 
 Pyelitis, 622 
 Pylorus, excision of, 520 
 
 Q 
 
 HILLED suture, 36 
 Quinsy, 437 
 
 RABIE.S, 103 
 Rachitic afifections of bones, 
 971 
 Radial artery, ligation of, 392 
 Radical cure of hernia, 549 
 
 of hydrocele, 728 
 Radicular odontonies. 456 
 Radio-ulnar joint, disease of. 921 
 Radius, dislocations of, 840 
 fractures of, 880 
 
 compound, of, 882 
 Ranula, 416 
 
 Rattlesnake, bites of. 102 
 Reaction after collapse, 25 
 Rectal alimentation, 584 
 
1036 
 
 IXDEX. 
 
 Rectal dilator, fi40 
 
 Rectangular staff in lithotomy, 678' 
 
 Recto-vaginal fistula, Ttil 
 
 Uectotou>_v, linear, 5s2 
 
 Rectum, affections of, 504 
 
 how to examine patient in, 
 565 
 
 injuries of, 564 
 
 rupture of, 564 
 
 prolapse of, 576 
 
 stricture of, 578, 580 
 
 excision of. 583 
 
 foreign bodies in, 565 
 
 malformations of, 561 
 
 painful ulcer of, 567 
 
 abscess of, 568 
 
 polypus of, 577 
 
 dilatation of, 584 
 Recurrent growths, 130 
 Redness in inflammation, 64 
 Reduction of dislocations, 823 
 
 of hernia, 535 
 Refraction, 261 
 Re-fracture of bone, 869 
 Regeneration of nerve, 30 
 Relaxed uvula, 436 
 Renal surgery, 628 
 
 calculus, 627 
 
 removal of, 629 
 
 hematuria, 625 
 Repair of wounds, 27 
 
 causes of failure in, 30 
 
 of subcutaneous wounds, 57 
 
 of wounded arteries, 340 
 
 of fractures, 867 
 Reporting eases, headings for, 21 
 Resection of joints, 'J'2S 
 
 of false joints, 869 
 Resolution of inflaminution, 66 
 Respiration, artificial, 619 
 Rest in treatment of aneurism, 359 
 
 in ununited fracture, 868 
 Retained testis. 749 
 Retention of urine, 700. 702 
 hysterical. 643 
 from adherent prepuce, 701 
 from cicatricial stricture, 
 702 
 Retina, hypersemia of, 2S6 
 
 atrophy of. 288 
 
 embolism of, 287 
 
 displacement of, 288 
 Retinitis, 286 
 Retraction of nii)ple, 777 
 Rheumatic arthritis, 946 
 
 iritis, 279 
 Rheumatism, gonorrhoea!, 717 
 Rhinoplasty, 596 
 Rhinoscopy, 589 
 Ribs, fracture of. 611 
 
 dislocation of, 614 
 Richardson's sprav-producer, 999 
 Rickets. 971 
 
 acute. 973 
 
 operative treatment in, 973 
 Rider's bone. 802 
 Rifle-ball wounds, 976 
 Rigg's disease, 473 
 Rodent ulcer, 137 
 Roussel's method of transfusion, 
 
 350 
 Roux's amputation, 1023 
 Rudimentary fingers and toes, 812 
 Rupia. syphilitic, 1 10 
 Rupture, abdominal, 525 
 
 of abdominal viscera, 483 
 
 of aneurism, 373 
 
 of artery, 341 
 
 of bladder, 489 
 
 of eyeball, 313 
 
 of muscle, 795 
 
 Rupture — 
 
 of rectum, 564 
 of urethra, 698 
 
 SAC, aneurismal, 357 
 suppuration of, 370 
 hernial, 526 
 omental, 527 
 
 kelotomy external to, 538 
 Sacculated bladder, 634 
 Sacral tumors, 231 
 Sacro-coccvgeal joint, disease of, 
 
 919" 
 Sacro-iliac joint disease, 919 
 .Salivary calculus, 417, 474 
 
 fistula, 417 
 Salter's swing, 900 
 Sarcoma, 13(1 
 
 melanotic, 131, 511 
 Sayre's jacket, 248 
 Scab, union under, 29 
 Scalds, 157 
 
 of the glottis, 603 
 Scalp, affections of, 216 
 contusion of. 189 
 wounds of, 190 
 sebaceous cysts of, 144 
 Scapula, dislocation of, 832 
 fracture of, 872 
 
 of neck of, 872 
 Sciatic notch, dislocation of hip 
 into, 844 
 
 hernia through, 558 
 Scirrhus, 134 
 
 Scissors for skin-grafting, 164 
 Sclerosis of bone, 951 
 Sclerotic, inflamed, 276 
 
 injuries of, 276 
 Sclerotomy. 303 
 Scorbutic ulcers, 77 
 Scoop extraction. 311 
 Scrofula. 20 
 
 Scrotal tumors, diagnosis of, 748 
 Scrotum, affections of, 752 
 cancer of, 753 
 injuries of. 752 
 tumors of, 752 
 elephantiasis of, 752 
 Scurv}', 77 
 Sebaceous cysts, 144 
 on head. 145 
 fungating. 141 
 sublingual, 416 
 .Second intention, healing by, 28 
 Secondary adhesion, 29 
 
 treatment for, 45 
 Semi-lunar cartilages of knee, sub- 
 luxation of, 850 
 Seminal duct, inflammation of, 733 
 
 obstruction of, 733 
 Senile cataract, 307 
 gangrene, 80 
 
 amputation in, 82 
 Separation of epiphysis of femur, 
 849, 873, 890 " 
 of humerus, 840 . 
 of clavicle, 832 
 of radius, 877 
 Sef)ticjemia, 91 
 
 Septum of nose, malformations of, 
 592 
 
 injuries of, 587 
 diseases of, 592 
 Sequestrum, removal of, 959 
 Sero-cystic disease of breast, 773 
 
 of testicle, 742 
 Serous cysts, 142 
 Serpents' bites, 102 
 , ."Serpiginous chancre, 118 
 I Seton in temple, 291 
 
 staphy- 
 
 Setting fractures, 862 
 Sexual hypochondriasis, 754 
 Sharp-hook extraction, 311 
 Shock and collapse. 25, 224 
 
 operations during. 226 
 after gunshot injuries, 97!: 
 Shoulder, amputation at, lUlO 
 
 dislocations at, 832 
 
 excision of, 938 
 
 diseases of, 920, 938 
 Sickness, chloroform, 995 
 Silkworm-gut for sutures, 37 
 Sinus, 71 
 Skin, formation of new, 27 
 
 transplantation of. 164 
 SliuU. contusion of. 192 
 
 fissure of, 192 
 
 fracture of. 192 
 
 incomplete fracture of. 853 
 
 gunshot wounds of, 982 
 
 perforating tumors of, 216 
 .Sloughing phagedasna, 76, 79 
 
 chancre. 720 
 Smith's (Xathan) wire splint. 901 
 Smith's (Thomas) gag for 
 
 lorraphy, 432 
 Snake bites. 102 
 Smifflcs. 45, 590 
 Soft cntaract, 307 
 
 chancre, 718 
 Softening of bone (mollities), 970 
 Solution of cataract. 308 
 Solvents for stone. 663 
 Soot cancer, 137, 753 
 Sores, varieties of, 73 
 
 healing, 74 
 
 indolent, 75 
 
 inflamed, 76 
 Sore throat, syphilitic, 1 11 
 
 sloughiug. 11 1 
 Sounding for stone, 660 
 Spasmodic retention. 699 
 Spastic contractions, 814 
 Speculum, ear, 324 
 
 rectal, 567 
 
 laryngeal, 605 
 
 urethral, female, 763 
 
 vaginnl. 761 
 Speir's artery constrictor, 348 
 Spent balls. 977 
 Spermatic cord, hydrocele of, 725 
 
 yaricocele of, 750 
 Spermatocele, 728 
 Spermatorrhoea, 754 
 Spermatozoa in encysted hydrocele, 
 
 729 
 Sphacelus, 79 
 
 Sphincter ani, spasm of, 568 
 Spica bandage, 542 
 Spina bifida,' 229 
 
 tumors simulating, 229 
 Spinal abscess. 246 
 
 instruments, 248 
 
 cord, wounds of. 242 
 Spine, concussion of, 232 
 
 diseases of, 245 
 
 fracture and dislocation of, 237 
 
 curvature of. 243 
 
 railway injuries of. 234 
 Spleen, rupture of. 486 
 Splints in treatment of wounds, 37. 
 862 
 
 immovable, 865 
 
 for hip disease, 923 
 
 for disease of knee, 927 . 
 
 double thigh. 889 
 
 for excision of elbow, 940 
 of knee. 936 
 Sponge, grafting. 167 
 
 how to prepare and clean, 1026 
 Spontaneous cure of aneurism, 359 
 
iMn:x. 
 
 lo.j? 
 
 Spraii)!* of biiok. 213 
 
 of joiulf, H'.'.') 
 K(juiii(, o|)oniti"iii!i for, 21)5) 
 Stnfl' lilliotoiiiv. 07 1 
 Stu|ih,vli>inik. :III2 
 
 I'ciiiiiviil of, 275 
 Slii|>hvl»rru|.li.v. 4Xi 
 Stiirclifil lminlil>co. SCI 
 Stiitio or \ CM10II-' (fiiiiuiTiu'. SI 
 :^tntix(ic!< of iuii|iiitiilioiiH. |002 
 
 uf )<iibfliiviiin iiiM-ui'iniM, ,'{88 
 
 of coiniiioii enrol ill, .'18.') 
 
 of torsion. .'US, 1003 
 
 of ncorosis of jiiw, 481i 
 
 of caii!<cH of inle^'tinui obstnio- 
 tion, .'.(t| 
 
 of iinsi! nlisoesH, ii'iS 
 
 of exostosii'. i)(il 
 
 of burns, |.'>".l 
 
 of out thront, .'lilS 
 
 of artiliriiil anus after hornin, 
 J.'U 
 
 after i-olotoin v. .'>! I 
 
 of frnctuivil skull, I'.Ml 
 
 of fatal eases of pvii'uiia, 93 
 
 of |)vu'iiiia, ()(> 
 
 of spinal injuries', 239 
 
 of sjiiun biliiln, 2-'<>^ 
 
 of fractureil ribs, till 
 
 of nc|ilire('toiiiv, li.'ll 
 
 of epiiliilyinitis, 7.".4 
 
 of stricture, (')S3, fiS.i 
 
 of tetanus, 211) 
 
 of abiloiiiinal injuries, 485 
 
 of hernia, .T2t'). .").')'.t 
 
 of ftrieture of rectum, 581 
 
 of stone, 659 
 
 of lithotomy, fi70, fi"! 
 
 of retention of urine, 699, 702 
 
 of hyilrocele, 72.') 
 
 of cancer of testicles, 744 
 
 of ovilrian disease, 780 
 
 of abscess of breast, 7fi4 
 
 of cancer of breast, 773 
 
 of adenoma. 769 
 
 of fracture. 861, S85 
 
 of clislocations, S2(i 
 
 of dislocation of humerus, 832 
 of head of femur, 843 
 
 of fracture of neck of femur, 
 88.=), 887 
 
 of fracture of shaft. 891 
 
 of fractures of le-;. 898 
 
 of excision of heail of femur, 
 930 
 
 of excision of knee, 934 
 
 of wounded from gunshot in- 
 juries, 976 
 
 of disease of knee, 917 
 
 of hip disease, 912 
 
 of excision of hip. 930 
 
 of amputation at thi^h, 1015 
 at knee-joint, 101 
 at knee, 934 
 
 of ."Lyme's amputation, 1022 
 Steatoma, 126 
 Sterility, 753 
 
 Sterno-clavieular joint, diseases of, 
 920 
 
 dislocation of, 830 
 Sterno-mastoid muscle, contraction 
 of. 824 
 
 induration of, 798 
 division of, 824 
 Sternum, dislocation and fracture 
 
 of, 614 
 Stings, insect, 102 
 Stomach, foreign bodies in, 497 
 
 rupture of, 487 
 
 opening the, 498 
 Stomatitis, 415 
 
 Stuno in Maildir. t>5.'i, 66(1 
 ill. lr<M|Mcni'y, 659 
 in kidney, 627 
 in urethra. OSJ, 70j 
 in women, 67'.' 
 Stopping teeth, 468 
 .'^trubifmuH, 298 
 
 operation for. 299 
 .Strangulated hernia, .').'! I 
 
 inechunicm .of, ,^3I 
 omental, 532 
 treatment of, 535 
 .Strangulation, internal. 501 
 
 of ovarian tumor. 792 
 .•stricture and rctenlion. 701) 
 .•stricture of urethru, lis;', 
 results of, (is.) 
 inflammatory, 700 
 spasmodic, 700 
 its eomj)lications. 694 
 traumatic or cicatricial, 
 
 698 
 treatment of, 686 
 summary of. 686 
 causes of death in, 686, 
 697 
 of intestine after hernia, 535 
 of cesophagu.s, 479 
 of rectum, 578, 580 
 Stronieyer's cushion, 882 
 Stumps, affections of, 1024 
 dressing of, 1007 
 conical, 1024 
 bursie over, 1025 
 necrosis of, 1025 
 painful, 1024 ' 
 Styes. 267 
 Styptics, 348 
 Subastragaloid amputation, 1021 
 
 <lislocati<m. 8.^)3 
 Subclavian aneurism, 387 
 
 artery, ligation of, 389 
 Subclavicular dislocation of shoul- 
 der, 831 
 .Subcoracoiil dislocation of shoul- 
 ! der, 832 
 
 Subcutaneous contused wounds, 42 
 I wounds, 56 
 
 I operations, 57 
 
 treatment of, 58 
 ! haemorrhage. 341 
 
 ! ligation of n;evus, 379 
 
 .Subdiaphragmatic abscess, 486 
 Subglenoid dislocation of shoulder, 
 I 833 
 
 .Sublingual cysts, 416 
 .'Submammary abscess. 766 
 I Subpectoral abscess. 616 
 I Subspinous dislocation of shoulder, 
 I 833 
 
 I Suction, removal of cataract bv, 
 ' 311 
 
 ' Sulphuric acid, treatment of disease 
 
 of bone by. 962 
 j .Supplemental teeth. 458 
 
 ^•'I'l' 
 
 )f urine, 626 
 
 ."Suppuration, 66 
 
 Supracondvloid amputation of 
 
 thigh. 1016 
 Suprapubic puncture of bladder, 
 
 705 
 Surgical cases, how to investigate, 
 
 21 
 Suspensory bandage, 735 
 
 Morgan's. 751 
 Sutures, materials for, 36 
 button, 36 
 harelip, 411 
 dcef), 35 
 continuous, 35 
 interrupted, 35 
 
 Suture* — 
 
 <{uillei|, 35 
 
 twihled, '.'tj 
 
 of inteiitine, 37, 494 
 Swelling in inlluaimation, 61 
 ."^ymblepharon, 21)4 
 Kyme'x amputation of foot, 1022 
 
 operation for iineurii<iii, 371 
 for i<tricture, 6h9 
 Sympathetic oplithnlinia, 282 
 .SymphysiH pubi^, diiiea»eH uf, 919 
 Syncope, 34.'» 
 Synostofiix of hip, 916 
 Synovial cyKlf. Xo* 
 
 membrane, (tiacares of, 906 
 Syphili.-". los 
 
 ui'ijuired, 1 Id 
 
 sore throat in. 1 I I 
 
 afTections of tongue in. Ill, 425 
 
 aflections of bone in. 1 12 
 
 |)athology of, 112. 718 
 
 treatment of, 1 13 
 
 hereclitary, 115 
 
 teeth in, 1 17 
 
 serpiginous ulceration in. 117 
 
 marriage after. 1 18 
 
 inoculaticin in, 1 18 
 Syphilitic disease of rectum, 579 
 
 of iris, 279 
 
 of testicle, 738 
 
 of larynx, 114 
 
 sores, 73, 77 
 
 teeth, 458 
 Syphilization, 119 
 Syringing ear, 326 
 
 TAdlJACOTIAX operations, 596 
 Talipes, different forms of, 814 
 their treatment, 816 
 Tapping abdomen, 521 
 
 ovarian cysts, 784 
 
 h3'drocele, 726 
 
 intestines. 520 
 
 chest. 618 
 
 hydatid, 523 
 
 knee, 926 
 Tarsal cartilage, tumors of, 292 
 
 cysts, 292 
 Tarsus, operations on, 1017 
 
 diseases of. 918 
 
 dislocations of, 853 
 Taxis, 536 
 
 where inadmissible, 536 
 Teale's amputation, lOOS 
 
 probe gorget, 690 
 Tear passage, operations on. 296 
 Teeth, cvsts containing, 443, 457, 
 462 
 
 syphilitic. 117 
 
 diseases of. 44."!. 467 
 
 cutting of. 460 
 
 affections of pulp. 471 
 
 of alveolo-dental mem- 
 brane. 472 
 
 local dental periostitis, 473 
 
 fracture of, 471 
 
 supernumcr.ary, 458 
 
 su|)pleniental. 458 
 
 malformed, 458 
 
 irregularity of, 461 
 
 impaction of, 463 
 
 absence of, 463 
 
 extraction of, 475 
 Temperature in inflammation, 65 
 
 in traumatic fever. 25. 91 
 
 in spinal injury, 234 
 Temporal artery, ligation of. 387 
 Temporo-maxillary articulation, 
 diseases of, 234 
 dislocation of, 449 
 
1038 
 
 INDEX. 
 
 TenJo Achillis, division of, 798, 
 818 
 
 rupture of, 797 
 Tendons, inflammation of, 798, 803 
 
 rupture of, 797 
 
 wounds of, 798 
 
 tumors of, 808 
 
 repair of, after division, 81fi 
 
 dislocation of, 797 
 Tenotomy, 817 
 
 in contracted joints, 822 
 
 in fracture, 862, 894, 900 
 Testicle, its development, 732 
 
 malposition of, 749 
 
 disease of, 732 
 
 inflammation of, 732 
 acute, 735 
 chronic, 736 
 
 syphilitic, 738 
 
 gouty, 738 
 
 tubercular disease, 740 
 
 hernia, 741 
 
 cystic disease of, 742 
 
 cancer of, 744 
 
 excision of, 749 
 
 strapping. 749 
 Tetanus. 219 
 
 infantile, 219 
 
 patb.dogy of, 221 
 
 statistics of, 219 
 Thecal abscess, 804 
 Thermograph of ervsipelas, 86 
 
 of traumatic fever, 92 
 
 of enterotomy, 509 
 Thigh, amputation of, 1015 
 statistics of, 1015 
 
 fracture of, 885 
 
 compound, 895 
 Thomas' splints for knee, 926 
 
 for hip, 923 
 Thorax, injuries of, fill 
 
 tapping. 61 6 
 
 abscesses al)out, 616 
 Throat, wounds of, 598 
 Thrombosis, 400 
 Thumb, dislocations of, 798 
 
 compound fracture of, 883 
 
 amputation of, 1012 
 
 excision of joints of, 942 
 Thyroid, cysts of, 142, 186 
 
 diseases of, 185 
 
 extirpation of, 188 
 Thyroid foramen, dislocation into, 
 
 884 
 Tibia, dislocation of, 849 
 
 fracture of. 898 
 
 V-shaped fracture of, 899 
 
 arrest of growth after, 898 
 Tibial artery, anterior, ligation of, 
 397 
 
 posterior, ligation of, 396 
 Tic doloureux, 252 
 Tinea tarsi, 267 
 Toe-nail, ingrown, 175 ! 
 
 horny. 1 77 
 Toes, amputation of, 1024 I 
 
 Tongue, congenital afiFections of, 
 419. 421 
 
 diseases of, 419 
 
 hypertrophy of, 419 
 
 inflammation of, 423 
 
 extirpation of, 430 
 
 wounds of, 419 
 
 ulcers of, 424 
 cancers of, 427 
 ichthyosis of, 421 
 Tongue-tie. 418 
 Tonsil, disease of, 437 
 cancer of. 488 
 excision of. 488 
 Tooth, development of, 453 
 
 Toothache, 464 
 Tooth cysts, 443, 457, 463 
 tumors, 444 
 wounds, 44 
 Torsion on arteries, effects of, 342 
 mode of doing it, 347 
 statistics of, 348, 1003 
 Torticollis. 824 
 Tourniquet, 345 
 Towne's stereoscopic test for retina, 
 
 266 
 Trachea, foreign bodies in, 600 
 
 wounds of, 598 
 
 subcutaneous division of, 598 
 Tracheal aspirator, 609 
 Tracheotomy, 607 
 
 its complications, 60S 
 
 for disease of larynx. 604 
 
 for foreign bodies, 601 
 
 tubes, 608 
 
 in tetanus, 222 
 Transfusion, 350 
 Transplantation of skin, 164 
 Traumatic aneurism, 373 
 
 delirium, 222 
 
 fever, 26, 91 
 
 gangrene, 80, 81 
 
 stricture, 696 
 Trendelenburg's tracheal tampon, 
 
 436 
 Trephining skull, 212 
 
 spine. 241 
 
 long bones, 954 
 Trichiasis, 292 
 Trichiniasis, 801 
 Tripier's amputations of the font. 
 
 1020 
 Trismus infantum, 219 
 Troclianter, fracture of epiphysis 
 
 of, 825 
 Trusses. 558 
 
 fur irreducible hernia, 529 
 
 to measure for, 560 
 Tubercle, 20 
 
 mucous, 111 
 Tumors. 120 
 
 innocent, 125 
 
 semi-malignant, 130 
 
 cancerous, 132 
 
 sebaceous, of scalp, 144 
 
 follicular, 141 
 
 perforating, of skull, 216 
 
 congenital, of sacrum, 231 
 
 painful subcutaneous, 254 
 
 of jaws. 442 
 
 cystic, 142 
 
 fatty, 126 
 
 fibromata, 126 
 
 myxoma, 132, 151 
 
 fibrous, 127 
 
 cartilaginous, 128, 965 
 
 osseous, 129 
 
 myeloid, 131 
 
 glandular or .adenoid, 129 
 
 pa]iillary, 130 
 
 recurrent, 130 
 
 sarcomata, 130 
 
 melanotic, 131 
 
 hard, 134 
 
 soft, 135 
 
 rodent ulcer, 137 
 
 colloid cancer, 138 
 
 villous, 138 
 
 granulation, 141 
 
 ])ulsatile, 969 
 
 cancerous, 132 
 
 diagnosis of, 132 
 
 epithelioma. 136 
 
 osteoma. 147 
 
 sarcoma, 150 
 
 adenoma, 148 
 
 Tumors — 
 
 carcinoma, 151 
 
 lymphoma, 149 
 
 colloid, 138 
 
 thyroidal, 184 
 
 microscopical anatomy of, 145 
 
 of bladder. 637 
 
 of bone. 962 
 
 their diagnosis, 969 
 their enucleation, 968 
 exostosis. 963 
 ungual, 177. 963 
 cartilaginous, 965 
 osteo-sarcoma and chon- 
 droma, 965 
 myeloid, 966 
 cancers of, 966 
 epithelial, of, 967 
 ]>ulsatile, 969 
 hydatid, 969 
 Tunica vaginalis, hydrocele of, 
 
 722 
 Twisted suture. 35 
 Tymj)anuui, inflating. 322 
 
 ULCERATION, 73 
 of rectum, 566 
 Ulcers, 73 
 
 of cornea, 275 
 Ulna, dislocation of, 837 
 
 fractures of, 880 
 Ulnar artery, ligation of, 392 
 
 nerve, injuries to. 251 
 Umbilical hernia, 556 
 Umbilicus, tumors of. 523 
 Ungual exostosis, 177, 963 
 Union of wounds, 26 
 
 of broken bones, 867 
 
 of divided tendons, 798. 815 
 Unreduced dislocations, 828 
 Ununited fractures. 868 
 Up])er jaw, removal of, 445 
 Uraclius, open, 523 
 Urates as dejiosits, 653 
 Ureter, injuries of, 489 
 
 stone in, 627 
 Urethra, ruptured, 698 
 
 with fracture of pelvis, 
 883 
 
 obstruction of, 682 
 
 stricture of, 682 
 
 calculus in, 682, 705 
 
 inflammation of, 714 
 
 aftections of female. 763 
 
 tapping in perinivum, 691 
 Urethrotomy, internal, 689 
 
 external. 689 
 Urinary abscess, 694 
 
 fistula. 695 
 
 deposits, 652 
 Urine, albuuiinous, 652 
 
 healthy, 652 
 
 deposits in. 653 
 
 blood in, 624, 638 
 
 incontinence of. 644 
 
 overflow of, 644 
 
 retention of, 699 
 
 suppression of, 626 
 
 extravasation of, 695 
 Uterus, extirpation of, 793 
 
 prolapse of, 761! 
 Uvula, elongation of, 436 
 
 ■y'-SHAPED fracture of tibia, 899 
 V Vaccinators, instructions for, 
 
 119 
 Vaceino-syphilis, 119 
 Vagina, foreign bodies in. 756 
 malformations of, 758 
 
iM>/:\'. 
 
 mvj 
 
 Xng'uia — 
 
 injiiricd of, 750 
 Vu>;iiiiil fistulii*. o|ioratioo.4 for, 
 700 
 
 C.VKtoCl-lf. oti-.. 7iiii 
 
 litlio'iiiuv, f.si 
 Villous, SI j 
 Valnulva'.s treatment of ancuri.^iii, 
 
 ;i(i2 
 Vnricooele, 75(1 
 Varicose uiu-uri^'iu, 'Mb 
 
 uloer, 7(\ 
 
 voiii.s, 403 
 Vuri.\, lo:{ 
 
 uiioiirisiiiikl, .S75 
 Vaooular kerutiti*. 273 
 
 lirutru.^ion of eyebull, 184, 316 
 
 tumor. 37'.' 
 
 of gum.'<, 47;') 
 Vault of skull, fracture of. 11*2 
 Vein*, wouuils of. 3H8 
 
 inj«-ction into. 3.'>0 
 
 iDJuries iind ilisea?es of, 39S 
 
 operation? on. 40i5 
 
 licmorrhage from. ."•JO 
 
 entrance of air into, 402 
 
 varicose. 4(13 
 Velum palati, woun'ls of. 435 
 Venereal diseases, local, 714 
 Venesection, operation of, 4lt7 
 
 in chest injuries. fil3 
 
 in head injuries, 208 
 Venous or static ganjjrene. SI 
 Ventral hernia. 557 
 Veruca. 173 
 
 nei-rogenica. 101 
 Vertical extension in fracture of 
 
 thi^'h. S'.t3 
 Vesical hemorrhage, 625 
 Vesico-intestinal fistula. 514, 643 
 Vesico-prostatio calculus, 64t> 
 Vesico-vaginal fistula, 760 
 Vienna paste. 141 
 Villous growths. 130 
 
 of bladder. 637 
 of rectum. 577 
 
 Viscera, ahdominal, protrusion of, 
 
 rx.i 
 
 rupture ol, 4H6 
 
 woumls of. 494 
 Vision, field of. 265 
 
 anoinalieH of, 2H6 
 Vitreous humor, ufTectiuns of, 2.S3 
 Vol\ ulu... 500 
 Vulva, injuries of, 756 
 Vulvitis, 757 
 
 AVAKDIIOP.S operation for 
 \ 1 aneurism, 369 
 Wurts, 173 
 
 anal, 578 
 
 venereal, 173, 710 
 Water dri'ssing. 49 
 Wax in ear, 326 
 Weak sores, 75 
 Webbed fingers and toes, 812 
 Weight, extension by, 892 
 
 jiressure by, 363 
 Wens, 144 
 Wheelhouse's operation for stric-' 
 
 ture, 690 
 Wincl|»ipe. foreign bodies in, 600 
 Women, surgical diseases of geni- 
 tals in, 756 
 
 stone in, 679 
 Wounds. 23 
 
 local effects of, 24 
 
 constitutional effects of, 25 
 
 adhesion in primary, 26 
 
 secondary, 29 
 
 alcoholic dressing of, 51 
 
 antiseptic irrigation of, 52 
 
 arrest of bleeding in, 30 
 
 arrow. 156 
 
 cicatrization of. 27 
 
 granulation of, 23 
 
 dressing of. 32 
 
 second dressing of. 39 
 
 complications of, 59 
 
 coaptation of. 35 
 
 contused, 31, 41 
 
 Woiindu — 
 
 inciocd, 23 
 
 treatment of, 32 
 
 laceruled, 31, 4 1 
 
 ojien, 12 
 
 treatment of, 42, 44 
 
 poisoned. 100 
 
 punctured, 43 
 
 rubcutuneouK, 56 
 
 tooth. 44 
 
 repair in, 26 
 
 by primary or Kccondary ad- 
 hesion, 33 
 
 non-repair in, 30 
 
 hemorrhage in, 30 
 treatment of, 32 
 six cardinal points to be 
 ob-erved in. 33 
 
 Bpecial treatment of, 45 
 by occlusion, 45 
 open method, 47 
 by water dressing, 48 
 ilry dressing. 50 
 earth dressing. 51 
 alcoholic dressing. 51 
 by jineumatic occlusion, 52 
 antis<'ptic irrigation. 52 
 Listerian method. 53 
 
 of scalp, 19(1 
 
 of nerves. 251 
 Wrist, amputation at. 1012 
 
 dislocation at. 840 
 
 suppuration and excision of, 
 941 
 
 diseases of, 921 
 Writer's cramp, 801 
 Wrv-neck, 824 
 
 XANTHELASMA of lids, 292 
 Xanthic oxide calculus, 658 
 
 Z'^ 
 
 INC, chloride of, paste, 140 
 
 THE END. 
 
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 and Nose, and Associated Affections of the Ear. New (3d) 
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 trations in color and 235 woodcuts, designed and executed 
 by the author. Cloth, $6.50. (Just ready?) 
 
 COHEN on Throat and Nasal Passages. New edition. In 
 one octavo volume of 750 pages, with 200 illus. {Pi-eparing.) 
 
 SEILER'S Handbook of Diseases of the Throat, Nose and 
 Naso-Pharynx. New (3d) edition. In one ]2mo. volume 
 of 373 pages, with 101 engravings and 2 colored plates, con- 
 taining 10 figures. Cloth, $'2.'25. 
 
 FLINT'S Manual of Auscultation and Percussion; of the 
 Physical Diagnosis of Diseases of the Lungs and Heart 
 and of Thoracic Aneurism. New (5th) edition. Revised 
 and enlarged by James C. Wilson, M. D. In one hand- 
 some 12mo. volume of 274 pages, with 12 illustrations. 
 Clotli, $1.7-5. (Just ready.) 
 
 FLINT'S Practical Treatise on the Physical Exploration or 
 the Chest and the Diagnosis of Diseases Affecting the Re- 
 spiratory Organs. Second and revised edition. In one hand- 
 some octavo volume of .591 pages. Cloth, $4.-50. 
 
 FLINT on Phthisis; its Morbid Anatomy, Etiology, Symp- 
 tomatic Events and Complications, Fatality and Prognosis, 
 Treatment and Physical Diagnosis; in a series of Clinical 
 Studies. In one 8vo. volume of 442 pages. Cloth, $3.-50. 
 
 LEA BROTHERS & CO., PUBLISHERS, PHILADELPHIA. 
 
Condensed List of Lea Brothers & Co.'s Medical Works. 
 
 ORGANS OF RESPIRATION, etc.— continued. 
 
 H.^IITII (iiitDiisiiiiiiitloii: lis I'iiiilyiiriil Iti'miMllaljloHtiiKL'S. 
 
 In iiiic iiciuvd vuluiiii' u( 'S't^i |iiiK<''H. c'lotli, f--'<^>- 
 \VILIjIA.'>IM on I'ulntuniirv ConHuinption; its Nature, 
 
 ViirlcllcMuiKl Tri'iitnn-nt. With an AnalyMls of Onu Tliou- 
 
 HJind t'a.M<>s to Kvi-niiillf\- Its Duration. In one octavo vol- 
 
 UMH- of :ui:i |.aK..s. Cluih, fl.:*). 
 FriiljKK on I)lsfii.sr.Hof till" LuuKHanil Air I'lLs.saui'H ; tholr 
 
 I'atlioloKv, I'h.VMlful DIaKnoslH, .Syniploni.s anil Treat nienl. 
 
 SiHMinil eillllon. In one Hvo. vol. of li.') puKes. Cloth, ^i.V). 
 I>A IKM'IIK on I'neunionla. In one octavo volume of -liW 
 
 liaKCM. Cloth, S.I.1K). 
 (JllOSS" I'ractlcal Treatise on Foreign Rodle.s In the Alr- 
 
 1'a.HHaKes. I n one octavo vohinie of Mi'l pajfes, with .V.t lllua- 
 
 Irnlldiis. Cloth, fl~'y. 
 SI.. Mil'', nil niplitiicrla. In one rjnio. volume. Cloth, fl.i"). 
 AV.XI.SIIK on Ihe lilseuM-s iif the Heart mid Ureal VciselB. 
 
 Ill one iicluvo \iilllllle III' in; pHK'CS. Cldlh, ?;t.iK). 
 FLINT'.'^ Practical Treatise on the DlaKiioslM, Patliolojfy 
 
 and Treatment of DIseiuses of the Heart. .Second and 
 
 revised edition. In one octavo vol. of 550 pages. Cloth, |4.0U. 
 
 ORGANS OF DIGESTION. 
 
 STILTjK on Clicileru. Its Origin, Causation, Symptoms 
 Prevention ami Trealnieiit. In one I'.'mo. volume of 184 
 JiiiKes, uilh ii rliart. Cloth, Jl.'i'). 
 
 H.VIlKKSIKirii on Diseiuses of the Alimentary Canal. 
 Second .Vmeriiiin I'miii the third and enlarged Kngllsh edi- 
 tion. In one octavo volume of .Wl iiaijes. Cloth, ?;i..50. 
 
 CH.4.1HIKK.S' .Manual of Diet in Health and IJisease. In 
 one liHlidsome octavo volume. Cloth, $'2.7.5. 
 
 PAVV'.S Treatise on the Kunction of DiKe.stlon; its Dis- 
 orders and their Treatment. From the second London edi- 
 tion. In one handsome volume, small octavo. Cloth, $2.00. 
 
 VENEREAL AND SKIN DISEASES. 
 
 TA YIjOR'S Clinical Atlas of Venereal and .Skin DLsen-ses. 
 Including Dlai;nosis, Prognosis and Treatment. In eight 
 folio parts, measuring 14 x l>t inches and comprising 4:il 
 pages of te.vt, with s.') large woodcuts and '2ia ligures on 58 
 l\i 11-page colored plates. Price, per part, ?2.60. (Com- 
 plete work noic ready.) Bound in one volume, half Bussia, 
 y.'T.UO; half Turkey Morocco, f28.00. For sale by subscription 
 only. Specimen of plates, by mail, 10 cents. Address the 
 Publishers. 
 
 HYDE on the Skin. Xew C^d) edition. In one very hand- 
 some octavo volume of HTG pages, with 85 illustrations, 
 and two colored plates. Cloth, $1.50; leather, ?.5.50. 
 
 TAYLOR on the Pathology and Treatment of Venereal 
 DIsea.ses. Ueing the si.xth edition of Bum.stead <fc Tay- 
 lor, completely rewritten by Dr. T.wlor. In one very 
 handsome octavo vol., prnfuselv illustrated. {Prijjarlng.) 
 
 BIJ.1I.STK A I> «fc T.\YI.OR on the Pathology and Treat- 
 ment of Venereal Diseases, including the results of recent 
 investigations upon the subject. Si.xth edition, rewritten 
 bv Dr. T.vyliir. See Tdi/lor, above. 
 
 CORNIL on Svnhilis. Translated by J. Hexry C. Simes, 
 M. D., and J. William WiiiTK, M. D. In one very hand- 
 some octavo volume of 4GI pages, with 84 beautiful illustra- 
 tions. Cloth, »;}.7.i. 
 
 CULIiERIER'S Atlas of Venereal Disea-s&s. Translated 
 and edited by Frekmax J. Bumstead, M. D., LL. D. In 
 one large imperial 4to.volumeof 328 pages, double columns, 
 with '2() iilates, containing about 1.50 figures, beautifully 
 colore<l, many of them the size of life. Strongly bound in 
 cloth, $17.00. 
 
 HUTCHINSON on Syphilis. In one l2mo. volume of 542 
 
 Sages, with 8 chromo-lithographic plates. Cloth, $2.'25. 
 ee Series of Clinical Manuals, page 2. 
 LEE'S Lectures on Syphilis, and on Some Forms of Local 
 
 Disease AfTecting Principally the Organs of Generation. 
 
 In one handsome octavo volume of 24e pages. Cloth, ?2.2.5. 
 HILL on Syphilis and Local Contagious Disorders. In one 
 
 handsome 8vo. volume. Cloth, $.3.2.5. 
 FOX'.S Epitome of Skin Diseases, with Formulie. For 
 
 Students and Practitioners. Third edition, revised by T. C. 
 
 Fox M. R.C. S. Inonel2mo.volumeof'2.'ispages. Cloth, f 1.2.5. 
 WILSON'S Student's Book of Cutaneous Medicine and 
 
 Diseases of the Skin. In one 12mo. volume of 535 pages. 
 
 Cloth, S3..50. 
 HILLIER'S Handbook of Skin Diseases, for Students and 
 
 Practitioners. Second American edition. In one l2mo. 
 
 volume of 358 pages, with illustrations. Cloth, $2.25. 
 
 DISEASES OF THE URINARY ORGANS. 
 
 ROBERTS' Practical Treatise on Urinary and Renal Dis- 
 eiises, including Urinary Deposits. Fourth American from 
 the fourth revised London edition. In one large octavo 
 volume, of 600 pages, with 81 illustrations. Cloth, ?.3..50. 
 
 PURDY on Bright's Disea.se and Allied Affections of the 
 Kidneys. In one handsome 8vo. volume of 288 pages, with 
 illustrations. Cloth, $'2.00. 
 
 GROSS' Practical Treati.se on the Diseases, Injuries and 
 Malformations of the Urinarv Bladder, the Prostate Oland 
 and the Urethra. Third edition, thoroughlv revised by 
 SAJirKL W. GROS.S, A. M., M. D. In one handsome 8vo. 
 volume of .574 pages, with 170 illustrations. Cloth, f4.50. 
 
 THOMPSON'S Lectureson Disea-ses of the Urinary Organs. 
 Second American edition. In one octavo volume of 203 
 pages, with '2.5 woodcuts. Cloth, $2.'25. 
 
 THOIIP.SON on the Pathologj- and Treatment of Stricture 
 of the Urethra and Urinary Fistula. From the third Eng- 
 lish edition. In one octavo volume of ;J59 pages, with 2 
 plates and 47 woodcuts. Cloth, ?:S..50. 
 
 LI' CAS on Disea.ses of the Urethra. In one 12mo. volume. 
 ( Prrpnring.) See Series of Clinical ManuaU, page 2. 
 
 BIORllLS on Surgical Diseases of the Kidney. In one 12mo. 
 volume of 5-54 pages, with 40 woodcuts "and 6 colored 
 plates. Cloth, ?2.25. See Series of Clinical ^fanuat.1,pfigeZ 
 
 B.VSHAM on Renal Diseases: a Clinical Guide to their 
 Diagnosis and Treatment. In one roval 12mo. volume of 
 304 pages, with illustrations. Cloth, f2.i'iO. 
 
 DISEASES OF THE NERVES AND MIND. 
 
 RO.SS' Handbook of the Dlsiases of tin- Nervous System. 
 In one octavo volume of 72<J pugcH, with 1«4 lllu.stratlous. 
 Cloth, frl..VI: leather, |.5..Vi. 
 
 MITC'IIKLI/M Lectures on niHeoHCH of the XervouH Sys- 
 tem, I'>(p<-<'lallv In Woiiii-n, Secund edition. In one hand- 
 some l2mo. Vdliime of '2^1 pages, with 5 llllidgraplile charUi. 
 
 IIA.1IILTON on Nervous Dlseiusr-s: tlieir Desirlptlon and 
 Treatment. Seconil edllidii, tlidroiighlv revlne*! and re- 
 written. In one handsoiiie octavo volume of .5U8 paiCM, 
 with 72 Illustrations, cldih fl.oo. 
 
 CLOUSTON dii Insanity. With U. S. Laws on Cimtody of 
 Insane, by C. F. Foi.hom, M. D. In one 8vo. volume of Ml 
 nage,s,wlth 8 plates. Cloth, $-l.oo. Dr. Folsom's Atmtract of 
 Laws for sale separately, see below. 
 
 SAVAGE on In.sanlty and Alllerl Neuroses. In one 12ino. 
 volume of .551 pages, with Is tvplc-al illustrations. Clotb, 
 12.00. .See Series of flinicU MdHiinls. page 2. 
 
 TIIKE on the Influence of the .Mind Over the Body In 
 Health and Disease. Second edition. In one octavo vol- 
 ume of 598 pages, with 72 Illustrations. Clotb, |.3.00. 
 
 GRAY'S Practicjil Treatl.se on Diseases of the Nervoua 
 System. In one handsome octavo volume of about 000 
 pages. ( I'rciMiririfi.i 
 
 PLAYFAIR on Nerve Prostration and Hysteria. In one 
 small octavo volume of 97 pages. Cloth, ll.Ofj. 
 
 FOLSO.II'.S Abstract of Statutes of U. S. on Custody of 
 Insane. In one 8vo. volume of 108 pages. Cloth, |1..50. 
 Also bound with Clou.ston on /n.wnf<i/, above. 
 
 JONES' Clinical Observations on Functional Nervous Dis- 
 orders. In one 8vo. volume of 340 pages. Cloth, ?3.25. 
 
 GYNytCOLOGY. 
 
 THE AMERICAN SystemsoffJynajcology and Obstetrics. 
 In treatises by various authors. G viia.'cologV edited bv Mat- 
 thew D. Man-n, M. D., and Obstetrics edfted by Bartox 
 C. Hirst, M. D. In four very hand.some super-royal octavo 
 volumes. Complete work Is nou' reaily, containing 3612 
 pages, 1092 engravings and 8 plates. Per volume, cloth, 
 $.5.00 ; leather, $6.00 r half Russia, $7.00. /br sale by subscrip- 
 tion only. 
 
 THOMAS' Practical Treatise on the Disea-ses of Women. 
 Fifth edition rewritten and greativ enlarged. In one large 
 and handsome octavo volume of* 810 pages, with 266 illus. 
 Cloth, $.5.00; leather, $6.00; half Ru.ssia, rai.sed bands, $6..50. 
 
 EMMET'.S Principles and Practice of Gynaecologv. For 
 Students and Practitioners. Third edition, revised and en- 
 larged. In one large octavo vol. of 880 pji., with 1.50 illus. 
 Cloth, $.5: leather, $(i.OO; half Russia, raised bands, $6..50. 
 
 DAVENPORT on Dise;i,ses of Women. A Manual of 
 non-surgical Gynecology'. Hand.some 12mo., .306 pages, 105 
 engravings. Cloth, $l.-50. 
 
 EDIS on Diseases of Women. A Manual for .Students and 
 Practitioners. In one handsome 8vo. volume of .576 pages, 
 with 148 illustrations. Cloth, $3.00; leather, $4.00. 
 
 MAY'S JIanual of the Diseases of Women. Second edition, 
 edited by L. S. Rau. M. D, In one l'2mo. volume of 360 
 pages, with 31 illustrations. Cloth, $1.75. 
 
 TAIT (Lawson)on Diseases of Women and Abdominal Sur- 
 gery. In two octavo volumes. Volume I., 5.54 pages, 62 
 engravings and 3 plates, just ready. Volume IL pre- 
 pririnfj. 
 
 BARNES' Clinical Exposition of the Medical and Surgical 
 Diseases of Women. Third American from the third Eng- 
 lish edition. In one handsome octavo volume of about 8«0 
 pages, with about 200 illustrations. (Preparing.) 
 
 DUNCAN'S Clinical Lectures on the Diseases of Women. 
 In one octavo volume of 175 pages. Cloth, $1..50. 
 
 HODGE on Diseases Peculiar to Women; including Dis- 
 placements of the Uterus. Second edition, revised and 
 enlarged. In one beautifully-printed octavo volume of 519 
 pages, with original illustrations. Cloth, $4..5<). 
 
 A!^H\VELL'S Practical Treatise on the Diseases Peculiar 
 to Women. One volume, 8vo., 520 pages. Cloth, $3.50. 
 
 WEST'.S Lectures on the Disea-ses of Women. Third 
 American from the third London edition In one octavo 
 volume of 543 pages. Cloth, $3.75; leather, $4.75. 
 
 DISEASES OF CHILDREN. 
 
 SMITH'S Treatise on the Disea-ses of Infancy and Child- 
 hood. New (seventh) edition, thoroughly revised and re- 
 written. In one hand.some octavo volumeof 881 pages, with 
 51 illustrations. Cloth, $4..50; leather, $5.50. (Just ready.) 
 
 OWEN on Surgical Diseases of Children. In one 12mo. 
 volume of 525 pages, with 85 woodcuts and 4 chromo- 
 lithographic plates. Cloth, $-2.00. See Series of Clinical 
 Manuals, page 2. 
 
 WEST on Some Disorders of the Nervous System in Child- 
 hood. In one volume, small 12mo. Cloth, $1.00. 
 
 CONDIE'S Practical Treatise on Diseases of Children. 
 Sixth edition. In one octavo volume of 779 pages. Cloth 
 $5.25; leather, $6.2,5. 
 
 OBSTETRICS. 
 
 THE AMERICAN System of Obstetrics, see the American 
 Systems of Gvnwcolosry and Obstetrics, above. 
 
 Pli'AY FAIR'S Treatise on the Science and Practice of 
 Midwifery. New (fifth) American from theseventh English 
 edition. Edited, with additions, by Robert P. Harris, 
 M. D. In one8vo. volumeof 664 pages, with 'XT illustrations. 
 Cloth, $4.00; leather, $.5.00. 
 
 LEI.SIIM.4N'S System of Midwifery, including the Dis- 
 eases of Pregnancy and the Puerperal State. Third Ameri- 
 can from the third and revised English edition, with addi- 
 tions, by J. S. Parry, M.D. In one large and very handsome 
 8vo. volume of 740 pages, with 205 Illustrations. Cloth, f4.50; 
 leather. $.5..50. 
 
 PARVIN'.S Treatise on Obstetrics New (2d) edition. In 
 one very handsome octavo volume of 701 pages, with 239 
 illustrations. Cl<ith. $4.25: leather. $o.'2.5. (Jusl ready.) 
 
 BARNES' System of Obstetric Medicine and Surgery. In 
 one large octavo volume of 872 pages, with 231 illustrations. 
 Cloth, f5.0<3; leather, $6.00. 
 
 LEA BROTHERS & CO.. PUBLISHERS, PHILADELPHIA. 
 
Condensed List of Lea Brothers & Co.'s Medical Works. 
 
 OBSTETRICS— continued. 
 
 KING'S ilanual of Obstetrics. New ifourth) edition. In 
 one handsome l.mo. volume of -iiZ pages, witli 141 illus- 
 trations. Cloth, $•.; 50. (Just rtady.) 
 
 LANUI.S on the Management of Labor. In one 12mo. vol- 
 ume of 329 pages, with '2S illustrations. Cloth, 51.75. 
 
 HODGE'S Principles and Practice of Obstetrics. In one 
 large quarto volume of 542 double-columned pages, illus- 
 trated with large lithographic plates containing 159 ligures 
 from original photographs, and with numerous woodcuts. 
 Stronglv bound in cloth, $14.00. 
 
 RAMSIJOTHA]>rS Principles and Practice of Obstetric 
 Medicint' and Surgery, In Keference to the Process of Par- 
 turition. In one large imperial 8vo. volume of 640 pages, 
 with (i4 lieautilul plates, and 43 woodcuts. Leather, $7.00. 
 
 BARKElt'.S Obstetrical and Clinical Essays. Inonelimo. 
 volume of about 300 pages. (I^-eparing.) 
 
 TANNER On the Signs and Diseases of Pregnancy. From 
 the second English edition. In one Svo. volumeof 490 pages, 
 with 4 colored plates and 16 woodcuts. Cloth, $4.25. 
 
 WINt'KEIj on the Pathology and Treatment of Childbed. 
 A Treatise for Physicians and Students. From the second 
 German edition by Chadwick, with additions by the 
 Author. In one octavo volume of 484 pages. Cloth, ^.00. 
 
 MEIGS on the Nature, Signs and Treatment of Childbed 
 Fever. In one Svo. volume of 340 pages. Cloth, $2.00. 
 
 CHURCHIIiIi'S Essays on the Puerperal Fever, and other 
 Diseases Peculiar to Women. lu one Svo. volume of 464 
 pages. Cloth, $2.50. 
 
 PARRY on Extra-Uterine Pregnancy; its Clinical History, 
 Diagnosis, Prognosis and Treatment. In one handsome 
 octavo volume of 272 pages. Cloth, $2.50. 
 
 OTOLOGY AND OPHTHALMOLOGY. 
 
 BERRY on the Eye. A Practical Treatise for Students 
 of Ophthalmology. Handsome octavo, 6So pages, 144 
 illustrations, of which 62 are exquisitely colored, cloth, 
 |7.50. 
 
 JUliER'S Ophthalmic Science and Practice. In one Svo. 
 volume of 4ti0 pages, with 125 woodcuts, 25 colored plates, 
 and tests for color-blindness and sharpness of vision. Cloth, 
 $4.50; leather, $5.50. 
 
 NETTLESHIP'S Diseases of the E.ve. Fourth and revised 
 edition. With an appendix on the detection of color-blind- 
 ness, by William Thomsox, M. D. In one 12mo. volume 
 of 504 pages, with ICA illustrations. Cloth, $2.00. (Just ready.) 
 
 NORRIS «fc OLIVER'S Text-book of Ophthalmologj'. 
 In one octavo volume of about 500 pages. {In press.) 
 
 CARTER & FROST'S Ophthalmic Surgery. In one 
 12mo. volume of 559 pages, with 91 engravings. Cloth, $2.2?. 
 See S' rics of Clinical Jlamia/s, page 2. Color-blindness 
 test, test-tj'jies and dots, and appendix of formulae. 
 
 BURNETT on the Ear; its Anatomy, Physiology and Dis- 
 eases. A practical Treatise for the use of Medical Students 
 and Practitioners. New (second) edition. In one handsome 
 octavo volume of 5s0 pages, with 107 illustrations. Cloth, 
 p.OO; leather, $.5.00. 
 
 POIilTZER on the Ear. For Students and Practitioners. 
 In one octavo volume of 800 pages, with 257 original illus- 
 trations. Cloth. $5.50. 
 
 liAURENCE & MOON'S Hand.v-Book of Ophthalmic 
 Surgery. For the use of Practitioners. Second edition, 
 revised and enlarged. In one octavo volume of 227 pages, 
 with 66 illustrations. Cloth, $2.75. 
 
 liA^VSON on Injuries to the Eye, Orbit and Eyelids; their 
 Immetliate and Remote Effects. In one Svo. volume of 404 
 pages, with 92 illustrations. Cloth, $3.50. 
 
 SURGERY. 
 
 GROSS' System of Surgery; Pathological, Diagnostic- 
 Therapeutic and Ov>erative. Sixth edition, thoroughly re- 
 vised. In two beautifully-printed imperial octavo volumes of 
 23S2 pages, with 1623 engravings. Strongly bound in leather, 
 with raised bands, $ 15.00. 
 
 HOLiME.S' Principles and Practice of Surgery. New Am- 
 erican from fifth English edition. Edited by T. P. Pick, 
 F. K. C. S. Darge octavo, 997 pages, 428 engravings. Cloth, 
 §6.00; leather, $7.00. 
 
 HOLLIES' System of Surgery, Theoretical and Practical. 
 In Treatises by various Authors. First American from 
 second English edition. Thoroughlj' revised, with numer- 
 ous additions, by J. H. Packard, M. D., assisted by a corps 
 of thirty-three of the most eminent American Surgeons. 
 In three large and very handsome imperial octavo volumes 
 of 3137 pages, with 979 engravings and 13 colored plates. Per 
 volume in cloth, $6.00; leather, $7.00; half Kussia, raised 
 bands, $7.50; For sale by subscription only. 
 
 ERICHSEN'S Science and Art of Surgery ; being a Trea- 
 tise on Surgical Injuries, Diseases and Operations. New 
 American trom the eighth and enlarged English edition. 
 In two large and beautiful octavo volumes, containing 
 2316 pages, with 984 engravings on wood. Cloth, $9.00; 
 leather, $11.00. 
 
 ASHHURST'S Principles and Practice of Surgery. New I 
 (fifth) and revised edition. In one large octavo volume 
 of 1144 pages, with 642 illustrations. Cloth, $6.00; leather, 
 $7.00. ' 
 
 BRYANT'S Practice of Surgery. Fourth American from 
 the fourth English edition. In one imperial Svo. volume of 
 1040 pages, with 727 engravings. Cloth, $6.50; leather, $7.50. 
 
 DRUITT'S Principles and Practice of Modern Surgerj'. 
 From the twelfth London edition, thoroiighlj- revised by 
 Staxley Boyd, F.K.C. S. In one handsome octavo vol- 
 ume of 965 pages, with 373 illustrations. Cloth, $4.00; 
 leather, $.5.00. 
 
 GANT'S Student's Surgerj\ A Multum in Farvo. In one 
 octavo volume of 84S pages, with 159 illustrations. Cloth, I 
 $3.75. {Just ready.) ' 
 
 SURGERY— continued. 
 
 TREVES' Manual of Surgery. In treatises bv various 
 authors. Edited by Frederick Treves, F". R. C. S. 
 Three 12mo. volumes, containing 1866 pages, with 213 illus- 
 trations. Per volume, cloth, $2.00. See ^Students' Series of 
 Manuals, page 1. 
 
 ROBERTS' Manual of Modern Surgery. In one hand- 
 some octavo volume of 7^0 pages with 501 illustrations. 
 Cloth, $4.50: leather, $5.50 (Just ready.) 
 
 GROSS' Practical Treatise on Impotence, Sterility and 
 Allied Disorders of the Male Sexual Organs. New (fourth) 
 edition. In one handsome Svo. volume of 176 pages, with 
 16 illustrations. Cloth, $1.50. (Just ready.) 
 
 SENN'S Surgical Bacteriology. New isecond) edition. In 
 one octavo volume of about 2.50 pages, with colored plates. 
 (I'reparina.) 
 
 THE AMERICAN SYSTEM OF DENTISTRY. In 
 treatises by various authors. Edited by Wilbir F. Litch, 
 M. D., D. D. S. The complete work is now ready in three 
 very handsome, exti'a-sized octavo volumes, containing 3160 
 pases, with 1873 engravings and 9 fiiU-jiage plates. Per 
 volume, cloth, $6.00; leather, $7.00; half "Morocco, $8.00. 
 Ihr sale by siibscrijHion only. 
 
 COLEMAN'S Dental Surgery and Pathologj-. Revised by 
 Thomas C. Stellwagen, M. D., D. D. S. In one handsome 
 volume of 412 pages, with 331 illustrations. Cloth, $;j.25. 
 
 STIMSON'S Practical Treatise on Fractures and Disloca- 
 tions. In two octavo volumes. Volume I., Fractures, .582 
 pages, 360 illus. Volume II., Dislocations. .540 pages, 163 
 illus. Complete work, cloth, $.5.50; leather, $7.50. Either 
 volume separately, cloth, $;f.00; leather, $4.00. 
 
 STI3ISON'S Manual of Operative Surgery. New (second) 
 edition. In one 12mo. volume of 503 pages, with 342 illus- 
 trations. Cloth, $2.50. 
 
 SMITH'S (Stephen) Operative Surgery. New (second) 
 and thoroughly revised edition. In one verj' handsome 
 octavo volume of 892 pages, with 1005 illustrations. Cloth, 
 $4; leather, $5. 
 
 HAMILTON'S Practical Treatise on Fractures and Dislo- 
 cations. Seventh edition, thoroughly revised. In one large 
 and handsome octavo volume of 998 pages, with 379 
 woodcuts. Cloth, $5.50; leather, $6..50. 
 
 GIBNEY'S Orthopsedlc Surgery. In one Svo. volume, pro- 
 fusely illustrated. {Jr^-eiKirina.) 
 
 TREVES on Intestinal Obstruction. In one 12mo. volume 
 of 522 pages, with 60 illustrations. Cloth, $2.00. See .Series 
 of Clinical Jlfa;!i(«?s, page2. 
 
 PiCK. on Fractures and Dislocations. In one l2mo. volume 
 of 530 pages, with 93 illustrations. Cloth,. $2.00. See Series of 
 Clinical Maiiuals, page 2. 
 
 BALL on Diseases of the Rectum and Anus. In one 12mo. 
 volume of 417 pages, with 54 cuts and 4 colored plates. 
 Cloth, $2.2.5. See Series of Clinical Jfanuals,p.'2. 
 
 BIARSH on Diseases of the Joints. In one 12mo. volume 
 of 468 pages, with 64 woodcuts and one colored plate. Cloth. 
 $2.00. See Series of Clinical Mamials, page 2. 
 
 BtJTLIN on the Tongue. In one 12nio. volume of 45$ 
 pages, with 8 colored plates and 3 woodcuts. Cloth, $3.50. 
 See Series of Clinical Manuals, page 2. 
 
 GOULD'S Surgical Diagnosis. In one 12mo. volume of 589 
 pages. Cloth, $2.00. See StudeiUs' Series of JIanuals, page 1. 
 
 PIRRIE'S Principles and Practice of Surgery. In one 
 Svo. volume of 784 pages, with 316 illustrations. Cloth, $3.75. 
 
 MILIiER'S Principles of Surgery. In one large octavo 
 volume of 683 pages, with 240 illustrations. Cloth, $3.75. 
 
 MILLER'S Practice of Surgery. In one large octavo vol- 
 ume of 682 pages, with 364 illustrations. Cloth, $3.75. 
 
 MEDICAL JURISPRUDENCE. 
 
 TIDY'S Legal Medicine. Volumes I. and II. Imperial 
 octavos, containing 1193 pages. Price per volume, cloth, 
 $6.00; leather, $7.00. 
 
 TAYLOR'S Medical Jurisprudence. In one large octavo 
 volume. 
 
 TAYLOR on Poisons in Relation to Medical Jurisprudence 
 and Medicine. Third American from the third revised 
 English edition. In one large octavo volume of 788 pages, 
 with 1(H illustrations. Cloth, $.5.50; leather, $ti.50. 
 
 PEPPER'S Forensic Medicine. In one 12mo. volume. 
 {I^-ejMring.) See Students' Sej-ics of Manuals, page 1. 
 
 PERIODICALS. 
 
 THE AMERICAN JOURNAL of the Medical Sciences. 
 
 Monthly with ISss. Reduced to $4.00 per annum. 
 
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 in advance, $4.0(X 
 
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 THE MEDICAL NEWS VISITING LUST for 1S91. 
 32 pages of important data and 176 pages of ruled blanks 
 for all records of practice. Wallet form, pocket, pencil, rub- 
 ber, catheter scale and erasable tablet. Issued in 4 styles : 
 Weekly, dated, for 30 patients; Monthly, undated, for 120 
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 week per \ear. The 60- patient book consists of 256 pages of 
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 to above periodicals, 75 cents. Or, Journal, News, Year- 
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 index 25 cents extra. 
 
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 Contains 400 pages " ledger '' paper, size 9x14, conveniently 
 ruled. Patent flexible back, half Russia, $5.00. Also same 
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 CARPENTER'S Prize Essay on the Use and Abuse of 
 Alcoholic Liquors in Health and Disease. In one 12mo. vol- 
 ume of 178 pages. Cloth, 60 cents. 
 
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 octavo volume of 493 pages. Cloth, $3.50. 
 
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•/i 
 
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COLUMBIA UNIVERSITY LIBRARIES j 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as 
 provided by the library rules or by special arrangement with 
 the Librarian in charge. 
 
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 1885 
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 pry ant , Tiiojaas_ 
 
 A ninual for the practice of 
 surge] y . . . 4th ed. 
 
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